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Statin discontinuation and new antipsychotic use after an acute hospital stay vary by hospital.

ABSTRACT: INTRODUCTION:Patients are at risk for medication problems after hospital admissions, particularly those with critical illness. Medication problems include continuation of acute medications and discontinuation of chronic medications after discharge. Little is known across a national integrated health care system about the extent of these two medication problems. OBJECTIVE:To examine the extent of statin medication discontinuation and new antipsychotic medication use after hospital discharge. DESIGN:Retrospective cohort study. SETTING:Veterans Affairs healthcare system. PARTICIPANTS:Veterans with an inpatient hospitalization from January 1, 2014-December 31, 2016, survived at least 180 days post-discharge, and received at least one medication through the VA outpatient pharmacy within one year around admission were included. Hospitalizations were grouped into: 1) direct admission to the intensive care unit (ICU) and a diagnosis of sepsis, 2) direct admission to the ICU without sepsis diagnosis, and 3) no ICU stay during the hospitalization. MAIN OUTCOME MEASURES:Statin medication discontinuation and new antipsychotic use at six months post-hospital discharge. RESULTS:A total of 520,187 participants were included in the statin medication and 910,629 in the antipsychotic medication cohorts. Statin discontinuation ranged from 10-15% and new antipsychotic prescription fills from 2-4% across the three hospitalization groups, with highest rates in the ICU admission and sepsis diagnosis group. Statin discontinuation and new antipsychotic use after a hospitalization varied by hospital, with worse performing hospitals having 11% higher odds of discontinuing a statin (median odds ratio at hospital-level, adjusted for patient differences, aMOR: 1.11 (95% CI: 1.09, 1.13)) and 29% higher odds of new antipsychotic use (aMOR, 1.29 (95% CI: 1.24, 1.34)). Risk-adjusted hospital rates of these two medication changes were not correlated (p = 0.49). CONCLUSIONS:Systemic variation in the rates of statin medication continuation and new antipsychotic use were found.

SUBMITTER: Coe AB

PROVIDER: S-EPMC7209203 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Statin discontinuation and new antipsychotic use after an acute hospital stay vary by hospital.

Coe Antoinette B AB Vincent Brenda M BM Iwashyna Theodore J TJ

PloS one 20200508 5

<h4>Introduction</h4>Patients are at risk for medication problems after hospital admissions, particularly those with critical illness. Medication problems include continuation of acute medications and discontinuation of chronic medications after discharge. Little is known across a national integrated health care system about the extent of these two medication problems.<h4>Objective</h4>To examine the extent of statin medication discontinuation and new antipsychotic medication use after hospital ...[more]

PMID: 32384108

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Project description:ObjectivesTo estimate 30-day statin discontinuation among newly admitted nursing home residents overall and within categories of life-limiting illness.DesignRetrospective cohort using Minimum Data Set 3.0 nursing home admission assessments from 2015 to 2016 merged to Medicare administrative data files.SettingU.S. Medicare- and Medicaid-certified nursing home facilities (n = 13,092).ParticipantsMedicare fee-for-service beneficiaries, aged 65 years and older, newly admitted to nursing homes for non-skilled nursing facility stays on statin pharmacotherapy at the time of admission (n = 73,247).MeasurementsResidents were categorized using evidence-based criteria to identify progressive, terminal conditions or limited prognoses (<6 months). Discontinuation was defined as the absence of a new Medicare Part D claim for statin pharmacotherapy in the 30 days following nursing home admission.ResultsOverall, 19.9% discontinued statins within 30 days of nursing home admission, with rates that varied by life-limiting illness classification (no life-limiting illness: 20.5%; serious illness: 18.6%; receipt of palliative care consult: 34.5%; clinician designated as end-of-life: 45.0%). Relative to those with no life-limiting illness, risk of 30-day statin discontinuation increased with life-limiting illness severity (serious illness: adjusted risk ratio (aRR) = 1.06; 95% confidence interval (CI) = 1.02-1.10; palliative care index diagnosis: aRR = 1.15; 95% CI = 1.10-1.21; palliative care consultation: aRR = 1.58; 95% CI = 1.43-1.74; clinician designated as end of life: aRR = 1.59; 95% CI = 1.42-1.79). Nevertheless, most remained on statins after entering the nursing home regardless of life-limiting illness status.ConclusionStatin use continues in a large proportion of Medicare beneficiaries after admission to a nursing home. Additional deprescribing research, which identifies how to engage nursing home residents and healthcare providers in a process to safely and effectively discontinue medications with questionable benefits, is warranted.

Project description:Although clozapine treatment is often discontinued due to limited efficacy or low tolerability, there is a lack of guidelines and evidence on treatment options after discontinuation of clozapine in patients with schizophrenia. Persistence has proven to be an adequate indicator for treatment effectiveness in patients with schizophrenia. The aim of this study was, therefore, to compare persistence of antipsychotic use between antipsychotic treatment options in patients after stopping clozapine treatment. Registry data from a prescription database representative of the Dutch population (1996-2017) was collected to investigate persistence in patients with schizophrenia who had been using clozapine for ? 90 days. Persistence with antipsychotics after clozapine discontinuation was analyzed using Cox-proportional hazard regression models. Our study population consisted of 321 participants, of whom 138 re-initiated clozapine and 183 started some other antipsychotic in the year after clozapine discontinuation (N = 518 antipsychotic use periods, N = 9,178 months). Second-generation antipsychotics (SGAs) as a group were associated with better persistence compared to first-generation antipsychotics (adjusted hazard ratio (aHR), 0.73; 95% confidence interval (CI) 0.57-0.93; P = 0.011). Compared with other antipsychotics, the following oral monotherapy antipsychotics were associated with significantly better persistence: restarting clozapine (aHR 0.48; 95% CI 0.32-0.71; P < 0.001) and switching to risperidone (aHR 0.52; 95% CI 0.32-0.84; P = 0.008) or olanzapine (aHR 0.55; 95% CI 0.35-0.87; P = 0.010). Sensitivity analyses confirmed the results. In conclusion, oral SGAs are associated with better persistence than alternative antipsychotic treatment options in patients discontinuing clozapine for undefined reasons. Especially clozapine (except in those with previous serious adverse reactions to clozapine), olanzapine and risperidone should be considered as oral monotherapy for these patients.

Project description:ObjectivesTo evaluate the prevalence and factors associated with statin pharmacotherapy in long-stay nursing home residents with life-limiting illness.DesignCross-sectional.SettingUS Medicare- and Medicaid-certified nursing home facilities.ParticipantsLong-stay nursing home resident Medicare fee-for-service beneficiaries aged 65 years or older with life-limiting illness (n = 424 212).MeasurementsPrevalent statin use was estimated as any low-moderate intensity (daily dose low-density lipoprotein-cholesterol [LDL-C] reduction <30%-50%) and high-intensity (daily dose LDL-C reduction >50%) use via Medicare Part D claims for a prescription supply on September 30, 2016, with a 90-day look-back period. Life-limiting illness was operationally defined to capture those near the end of life using evidence-based criteria to identify progressive terminal conditions or limited prognoses (<6 mo). Poisson models provided estimates of adjusted prevalence ratios and 95% confidence intervals for resident factors.ResultsA total of 34% of residents with life-limiting illness were prescribed statins (65-75 y = 44.0%, high intensity = 11.1%; >75 y = 31.1%, high intensity = 5.4%). Prevalence of statins varied by life-limiting illness definition. Of those with a prognosis of less than 6 months, 23% of the 65 to 75 and 12% of the older than 75 age groups were on statins. Factors positively associated with statin use included minority race or ethnicity, use of more than five concurrent medications, and atherosclerotic cardiovascular disease or risk factors.ConclusionDespite having a life-limiting illness, more than one-third of clinically compromised long-stay nursing home residents remain on statins. Although recent national guidelines have expanded indications for statins, the benefit of continued therapy in an advanced age population near the end of life is questionable. Efforts to deprescribe statins in the nursing home setting may be warranted. J Am Geriatr Soc 68:708-716, 2020.

Project description:INTRODUCTION:Antipsychotic medication is effective in reducing acute symptoms of psychosis, but it has a range of potentially serious and debilitating adverse effects and is often disliked by patients. It is therefore essential it is only used when benefits outweigh harms. Although multiple trials conducted with people with schizophrenia indicate an increased risk of relapse in the short-term following abrupt antipsychotic discontinuation, there is little evidence about the long-term outcome of a gradual process of reduction and discontinuation on social functioning, relapse and other outcomes. METHODS AND ANALYSIS:This is a multicentre, randomised controlled trial involving people with schizophrenia and related disorders who have had more than one episode. Participants are randomised to have a clinically-supervised, gradual reduction of antipsychotic medication, leading to discontinuation when possible, or to continue with maintenance treatment. Blinded follow-up assessments are conducted at 6, 12 and 24 months and the primary outcome is social functioning, measured by the Social Functioning Scale at 24 months. A minimum of 134 evaluable participants provides 90% power to detect a five-point difference, and 206 to detect a four-point difference. Secondary outcomes include severe relapse (admission to hospital) and the study is also intended to detect a minimum 10% difference in severe relapse, which requires 402 participants, assuming a 15% loss to follow-up. Other secondary outcomes include all relapses, as identified by an independent and blinded endpoint committee, symptoms measured by the Positive and Negative Syndrome Scale, quality of life, adverse effects, self-rated recovery and neuropsychological measures. Enrolment started in 2016. The trial is scheduled to finish in June 2022. ETHICS AND DISSEMINATION:Ethical approval was initially obtained on 27 October 2016 (UK Research Ethics Committee reference 16/LO/1507). Results will be published in peer-reviewed journals and disseminated to the public. TRIAL REGISTRATION NUMBER:ISRCTN90298520. EudraCT: 2016-000709-36. Pre-results.

Project description:ImportanceStatin use is common in older persons. Given uncertainties in ongoing benefit, changes in health status, and shifting goals of care and preferences, statin discontinuation may be considered in some older persons, although there is currently little evidence to guide this decision.ObjectiveTo evaluate the association between statin discontinuation and the rate of major adverse cardiovascular events (MACE) among people aged 75 years or older who receive long-term statin treatment.Design, setting, and participantsThis cohort study included all persons in Denmark aged 75 years or older who were treated with statins for at least 5 consecutive years as of January 1, 2011. Participants were followed up until December 31, 2016. Data were analyzed from July to November, 2020.ExposureStatin discontinuation.Main outcomes and measuresRate of occurrence of MACE and its components (myocardial infarction, ischemic stroke or transient ischemic attack, coronary revascularization, and death due to myocardial infarction or ischemic stroke) in persons continuing statins compared with those discontinuing statins. Confounding adjustment was done using inverse probability of treatment weighting. Analyses were conducted separately for primary prevention (no history of cardiovascular disease) and secondary prevention (history of cardiovascular disease).ResultsThe study included 67 418 long-term statin users, including 27 463 in the primary prevention analysis (median age, 79 years [IQR, 77-83 years]; 18 134 [66%] female) and 39 955 in the secondary prevention analysis (median age, 80 years [IQR, 77-84 years]; 18 717 [47%] female). In both primary and secondary prevention analyses, the rate of MACE was higher among persons who discontinued statins compared with those who continued statins. In the primary prevention cohort, the weighted rate difference was 9 per 1000 person-years (95% CI, 5-12 per 1000 person-years) and the adjusted sub-hazard ratio was 1.32 (95% CI, 1.18-1.48), corresponding to 1 excess MACE per 112 persons who discontinued statins per year. In the secondary prevention cohort, the weighted rate difference was 13 per 1000 person-years (95% CI, 8-17 per 1000 person-years) and the adjusted sub-hazard ratio was 1.28 (95% CI, 1.18-1.39), corresponding to 1 excess MACE per 77 persons who discontinued statins per year.Conclusions and relevanceIn this cohort study, among older adults receiving long-term statin treatment, discontinuation of statins was associated with a higher rate of MACE compared with statin continuation in both the primary and the secondary prevention cohorts. These findings suggest a need for robust evidence from randomized clinical trials.

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Statin discontinuation and new antipsychotic use after an acute hospital stay vary by hospital.

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Statin discontinuation and new antipsychotic use after an acute hospital stay vary by hospital.

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