Medication changes in patients transitioning between health care settings

Abstract

Pharmacotherapy is one the most commonly used medical interventions, and advances in pharmacotherapy have significantly contributed to the increase in life expectancy and quality of life that occurred during the last century. Many recent studies have revealed the impact of medication errors and the importance of continuity of care in medication management. A significant proportion of drug-related problems occur when patients transition from one healthcare setting to another. Care transitions are a natural occurrence in our healthcare system. With transitions across health care settings, nearly every patient is confronted with some form of medication discontinuity. During a single episode of an illness, patients may visit multiple care settings and be treated by different healthcare professionals. Transitions from one healthcare setting to another are associated with intentional and unintentional changes in drug use. Unintentional changes in drug therapy imply that the physician is unaware of these changes. During the short time of hospitalisation, the patient will be confronted with at least two transitions and at least three moments of (re)prescription and re-evaluation of drug therapy. First, upon admission, the preadmission medication regimen should be documented and evaluated. During this reconciliation process, intended but also unintended changes in prescribing and transcribing can occur. Second, during hospitalisation, a natural part of a patient treatment is the evaluation of any former drug treatment in the context of the patient’s (changing) clinical status and the prescription of new drugs. Finally, at discharge, the preadmission medication list will be compared with the current hospital medications to create a coherent set of discharge prescriptions. The aim of this thesis was to give more insight in the discontinuities in drug use seen around transitions between health care settings. Changes in drug use were quantitatively studied. We focused on hospitalisation as a determinant of medication changes and on medication changes as a determinant of hospitalisation. Two studies addressed that the reason for these changes was largely unknown i.e. that it was unknown whether changes in medication were the intention of the prescriber or whether it was unintended. This thesis confirms that transition into or out of the hospital are events associated with discontinuities in drug use. Patients transferred from the primary care setting to the hospital setting (or the reverse) may experience considerable (unintended) modifications to their drug regimen. We discussed the factors that were associated with the discontinuity of drug use and transitioning and factors that estimate the measurement of medication discontinuities. Recommendations for clinical practice and for future research are provided. In conclusion, transitions in care are periods when patients are vulnerable for discontinuities in drug use. Regardless of the patient’s movement through different healthcare settings, the prescribed medications should be consistent with his or her therapeutic needs. This thesis provides more insight regarding drug use and transitions between health care settings.