3109 — Suboptimal pharmacotherapy and adverse outcomes among older veterans discharged from the emergency department

Hastings SN (COE/GRECC - Durham), Schmader KE (GRECC - Durham), Sloane RJ (Duke Aging Center), Weinberger M (COE - Durham), Goldberg KC (COE - Durham), Oddone EZ (COE - Durham)

Objectives:
Suboptimal pharmacotherapy is an important patient safety concern for older adults, yet this issue has not been adequately studied in the emergency department (ED) setting. The goal of this study was to determine whether suboptimal pharmacotherapy increases the risk of adverse outcomes among older veterans discharged from the ED.

Methods:
Patients were included in the sample if they were: 1) discharged home from the Durham VAMC ED between 7/1/2003 and 9/30/2003, 2) > = 65 years, and 3) followed in VA primary care (N=942). The primary independent variable, suboptimal pharmacotherapy, was a composite measure defined as one or more drug-related problems based on: 1) drugs-to-avoid criteria, 2) drug-drug interactions, 3) drug-disease interactions, or 4) failure to satisfy an explicit quality indicator for prescribing or medication monitoring. The primary dependent variable, adverse outcome, was time to first repeat ED visit, hospitalization, or death within 90 days of discharge from the index ED visit.

Results:
421 of 942 (44.7%) patients were prescribed a new medication at the time of ED discharge. Of these 421, 134 (31.8%) had suboptimal pharmacotherapy related to their discharge medications; 49/421 (11.6%) were prescribed a drug to avoid, 53/421 (12.6%) received a drug that introduced a new drug-drug interaction, 24/421 (5.7%) were given a drug that introduced a drug-disease interaction, and 74/421 (17.6%) did not have a quality indicator satisfied. 320 of 942 (34.0%) patients had a repeat ED visit, hospitalization or died within 90 days of the index ED visit. In multivariable analyses adjusted using propensity scores, risk of an adverse outcome was highest among patients with suboptimal pharmacotherapy (HR 1.32, 95% CI 0.95, 1.84; P=0.1) and lowest among patients who were not prescribed any new medications at ED discharge (HR 0.77, 95% CI 0.58, 1.03; P=0.08).

Implications:
A substantial number of older veterans discharged from the ED may be at risk for adverse events due to suboptimal prescribing and inadequate medication monitoring.

Impacts:
While further data on the relationship between ED discharge pharmacotherapy and patient outcomes are forthcoming, efforts to improve the quality of prescribing and medication monitoring in this vulnerable population are warranted.