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Research Letters | Health Care Reform

Reasons for Discontinuation of Medication During Hospitalization and Documentation Thereof: A Descriptive Study of 400 Geriatric and Internal Medicine Patients FREE

Carolien M. J. van der Linden, MD; Paul A. F. Jansen, MD, PhD; Eva V. van Geerenstein, MD; Rob J. van Marum, MD, PhD; René J. E. Grouls, PhD; Toine C. G. Egberts, PharmD, PhD; Erik H. M. Korsten, MD, PhD
[+] Author Affiliations

Author Affiliations: Department of Geriatrics (Dr van der Linden), Hospital Pharmacy (Dr Grouls), and Anesthesiology and Intensive Care (Dr Korsten), Catharina Hospital, Eindhoven, the Netherlands; Department of Geriatrics (Drs Jansen, van Geerenstein, and van Marum) and Hospital Pharmacy (Dr Egberts), University Medical Centre Utrecht, Utrecht, the Netherlands; Utrecht Institute for Pharmaceutical Sciences, Utrecht (Dr Egberts); and Signal Processing Systems, Eindhoven University of Technology, Eindhoven (Dr Korsten). Dr Marum is now with Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands.


Arch Intern Med. 2010;170(12):1081-1083. doi:10.1001/archinternmed.2010.159.
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Medication is often changed or discontinued during hospital admission, and this is especially true for medications prescribed to elderly patients.1 However, after discharge further changes to medication regimens are not always intentional and may be due to poor communication.2 For example, in an earlier study, we found that adverse drug reactions detected during hospitalization and requiring cessation of the causative drug were poorly communicated to primary care professionals (general practitioners and pharmacists), leading to a rate of represcription of withdrawn medication of 27% during the first 6 months after discharge.3 The study highlighted the need for better communication of reasons for discontinuation of medication. Adequate communication of these reasons can only exist on the condition that these reasons are well documented. Our experience in daily practice is that such documentation is often inadequate. The objectives of the present study were to evaluate the frequency of reasons for discontinuation of medication and the documentation thereof in hospitalized patients.

We studied the medical records (paper and/or electronic) of consecutive patients admitted to the geriatric and internal medicine wards of the University Medical Center Utrecht (n = 200) and the Catharina Hospital in Eindhoven (n = 200), the Netherlands, to determine which medications were used before hospitalization. Discontinuation was defined as stopping or switching to another drug within the same therapeutic range. Prescribed and discontinued medications and dates of discontinuation were extracted from electronic prescription programs, and then patient records were reviewed to determine whether the reasons for discontinuation of these medications at these dates had been recorded. Reasons for discontinuation were categorized as “adverse drug reaction,” “contraindication,” “no longer indicated,” “interaction,” “palliation,” “ineffective,” “no reason mentioned,” “at request of patient,” or “other.” Discontinuation of antibiotics after completion of a course and of potassium supplementation after normalization of serum potassium level was interpreted as “no longer indicated.”

The mean age of the 200 geriatric patients was 82 years, and of the 200 internal medicine patients, 57 years. The geriatric patients used a mean of 7.3 (range, 0-24) medications at admission, and the internal medicine patients used a mean of 4.8 (range, 0-20). The mean number of discontinued medications was 4.9 (range, 0-22) in geriatric patients and 2.8 (range, 0-26) in internal medicine patients. Of all the discontinued medications used in geriatric patients, 50% were prescribed before admission and 50% had been started during hospitalization. Among internal medicine patients, 35% of discontinued medications were prescribed before and 65% during hospitalization. The most frequently discontinued medications were cardiovascular drugs, antibiotics, and supplements (vitamins and minerals). In 39.8% of discontinued medications, no reason for discontinuation was documented (Table). Most frequently documented reasons for discontinuation were “no longer indicated” (27.5%), “palliation” (9.8%), “contraindication” (9.1%), and “adverse drug reactions” (5.2%). In geriatric patients “palliation” occurred more frequently as reason for discontinuation: 12.3% vs 5.5% in internal medicine patients. “No longer indicated” occurred more often in internal medicine patients (32.5% vs 24.5%). Frequencies of other reasons for discontinuation were not different between geriatric and internal medicine patients.

Table Graphic Jump LocationTable. Reasons for Discontinuation of Medication

To our knowledge, this is the first study of reasons for medication discontinuation during hospitalization. We found that in more than a third of the discontinued medications the reason was not documented in the patient records. Poor documentation and communication of reasons for discontinuing medication may result in the represcription of withdrawn medications, which could have adverse repercussions on the patients' health. Eguale et al4 reported that reasons for discontinuation can be accurately recorded in an electronic prescription program in primary care. We propose that reasons for discontinuation of medication should be recorded in electronic patient files, which are currently being introduced in the Netherlands and other countries.5,6 To facilitate this, we are developing an electronic clinical decision support module that forces physicians to document these reasons. In addition, this module will make the information available to other relevant health care providers, for example, general practitioners and pharmacies. A limitation of the present study is its small number of studied departments (internal medicine and geriatric wards) and hospitals (n = 2).

We believe that using an electronic prescription program with a clinical decision support module that incorporates reasons for discontinuation will improve documentation and communication of reasons why medication is withdrawn, leading to better pharmacovigilance at a patient level.

Correspondence: Dr van der Linden, Catharina Hospital, PO Box 1350, Eindhoven 5602 ZA, the Netherlands (carolien.vd.linden@cze.nl).

Author Contributions: Dr van der Linden had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: van der Linden, Jansen, van Marum, Grouls, Egberts, and Korsten. Acquisition of data: van der Linden and van Geerenstein. Analysis and interpretation of data: van der Linden, Jansen, van Geerenstein, van Marum, Grouls, and Korsten. Drafting of the manuscript: van der Linden. Critical revision of the manuscript for important intellectual content: Jansen, van Geerenstein, van Marum, Grouls, Egberts, and Korsten. Administrative, technical, and material support: van der Linden. Study supervision: van der Linden, Jansen, van Marum, Grouls, Egberts, and Korsten.

Financial Disclosure: None reported.

Funding/Support: Dr van der Linden was financially supported by Catharina Hospitals Science Fund.

Role of the Sponsors: The Catharina Hospitals Science Fund had no role in the design and conduct of the study; in the collection, management, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

Laroche  MLCharmes  JPNouaille  YFourrier  AMerle  L Impact of hospitalisation in an acute medical geriatric unit on potentially inappropriate medication use. Drugs Aging 2006;23 (1) 49- 59
PubMed Link to Article
Stuffken  RHeerdink  ERde Koning  FHSouverein  PCEgberts  AC Association between hospitalization and discontinuity of medication therapy used in the community setting in the Netherlands. Ann Pharmacother 2008;42 (7) 933- 939
PubMed Link to Article
van der Linden  CMKerskes  CHBijl  AMMaas  HAEgberts  ACJansen  PA Represcription after adverse drug reaction in the elderly: a descriptive study. Arch Intern Med 2006;166 (15) 1666- 1667
PubMed Link to Article
Eguale  TTamblyn  RWinslade  NBuckeridge  D Detection of adverse drug events and other treatment outcomes using an electronic prescribing system. Drug Saf 2008;31 (11) 1005- 1016
PubMed Link to Article
Schiff  GDRucker  TD Computerized prescribing, building the electronic infrastructure for better medication usage. JAMA 1998;279 (13) 1024- 1029
PubMed Link to Article
Bell  DSCretin  SMarken  RSLandman  AB A conceptual framework for evaluating outpatient electronic prescribing systems based on their functional capabilities. J Am Med Inform Assoc 2004;11 (1) 60- 70
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable. Reasons for Discontinuation of Medication

References

Laroche  MLCharmes  JPNouaille  YFourrier  AMerle  L Impact of hospitalisation in an acute medical geriatric unit on potentially inappropriate medication use. Drugs Aging 2006;23 (1) 49- 59
PubMed Link to Article
Stuffken  RHeerdink  ERde Koning  FHSouverein  PCEgberts  AC Association between hospitalization and discontinuity of medication therapy used in the community setting in the Netherlands. Ann Pharmacother 2008;42 (7) 933- 939
PubMed Link to Article
van der Linden  CMKerskes  CHBijl  AMMaas  HAEgberts  ACJansen  PA Represcription after adverse drug reaction in the elderly: a descriptive study. Arch Intern Med 2006;166 (15) 1666- 1667
PubMed Link to Article
Eguale  TTamblyn  RWinslade  NBuckeridge  D Detection of adverse drug events and other treatment outcomes using an electronic prescribing system. Drug Saf 2008;31 (11) 1005- 1016
PubMed Link to Article
Schiff  GDRucker  TD Computerized prescribing, building the electronic infrastructure for better medication usage. JAMA 1998;279 (13) 1024- 1029
PubMed Link to Article
Bell  DSCretin  SMarken  RSLandman  AB A conceptual framework for evaluating outpatient electronic prescribing systems based on their functional capabilities. J Am Med Inform Assoc 2004;11 (1) 60- 70
PubMed Link to Article

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