New, persistent sedative use after ICU high in older adults in long-term care facilities
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Key takeaways:
- More than half of older ICU survivors who filled a new sedative prescription filled it again within 6 months of discharge.
- New sedative prescriptions varied by hospital.
Older ICU survivors had a higher likelihood for filling new and persistent sedative prescriptions when placed in a long-term care facility following ICU discharge, according to results published in CHEST.
“One in 15 sedative-naive, older adult ICU survivors filled a new sedative within [7 days or less] of discharge; more than one-half of these survivors filled persistent prescriptions,” Lisa D. Burry, PharmD, FCCP, assistant professor in the Leslie Dan Faculty of Pharmacy at University of Toronto, and colleagues wrote. “New prescriptions at discharge varied widely across hospitals and represent the potential value of modifying prescription practices, including medication review and reconciliation.”
In a population-based cohort study in Canada, Burry and colleagues evaluated 250,428 (mean age, 75.8 years; 61% men) older ICU survivors who did not fill a sedative prescription 6 months prior to ICU admittance from 153 hospitals to determine the prevalence of new (given within a week of discharge) and persistent (≤ 6 months) sedative prescriptions filled among these patients.
Further, researchers assessed what demographic, clinical and hospital factors are linked to new prescriptions through multilevel logistic regression, as well as persistent prescriptions through a multivariable proportional hazards model.
Within this cohort, 15,277 (6.1%) patients filled a new sedative prescription (median time, 0 days), of which 8,458 (3.4%) then filled a persistent prescription (median time to first persistent prescription, 26 days). More than half of the new sedative prescriptions were for benzodiazepine (n = 8,824), whereas fewer patients received a non-benzodiazepine (n = 2,749), an antipsychotic (n = 2,745) or multiple sedative classes (n = 959).
Notably, researchers found that some hospitals had more patients who filled a new sedative prescription than others, ranging from 2.1% (95% CI, 1.2%-2.8%) to 44% (95% CI, 2%-57.8%).
When evaluating the clinical characteristics of patients who filled vs. did not fill a new sedative prescription, researchers observed a higher prevalence of poorer health outcomes among patients with a filled prescription, including comorbidity burden (Charlson Comorbidity Index score 3, 38.6% vs. 31.7%), frailty (12.9% vs. 8%), sepsis (25.9% vs. 14.1%), acute kidney injury (13.2% vs. 8.2%) and invasive mechanical ventilation (35.6% vs 25.6%).
Discharge to a long-term care facility (vs. community) was linked to the highest odds for new sedative use (adjusted OR = 4; 95% CI, 3.72-4.31). Researchers also observed increased odds for this prescription with:
- receipt of an inpatient psychiatry consultation (aOR = 2.76; 95% CI, 2.62-2.91);
- receipt of an inpatient geriatric consultation (aOR = 1.95; 95% CI, 1.8-2.1);
- discharge from a rural hospital (aOR = 1.67; 95% CI, 1.36-2.05);
- invasive ventilation (aOR = 1.59; 95% CI, 1.53-1.66);
- an ICU stay duration of 7 days or longer (aOR = 1.5; 95% CI, 1.42-1.58); and
- discharge from a community hospital (aOR = 1.4; 95% CI, 1.16-1.7).
During this assessment, residual heterogeneity among the different hospitals was apparent (median aOR = 1.43; 95% CI, 1.35-1.49) and is important to consider when interpreting these findings, according to researchers.
“We ... identified substantial variation between sites, even after adjusting for other factors, suggesting that hospital-level interventions may represent a target for quality improvement,” Burry and colleagues wrote.
In terms of persistent sedative use, researchers found a heightened likelihood for this outcome among those discharged to a long-term care facility (subdistribution HR [sHR] = 4.45; 95% CI, 4.08-4.87) and women (sHR = 1.07; 95% CI, 1.02-1.13); a lower likelihood was found with pre-existing polypharmacy (sHR = 0.88; 95% CI, 0.84-0.93).
Among the different sedative classes, the likelihood for filling a persistent prescription was higher among patients who initially received an antipsychotic (sHR = 1.45; 95% CI, 1.35-1.56), a non-benzodiazepine (sHR = 1.44; 95% CI, 1.34-1.53) or multiple sedative classes (sHR = 2.16; 95% CI 1.97-2.37) vs. a benzodiazepine.
“Detailed review of sedative pharmacotherapy following an ICU admission can enhance postdischarge pharmacotherapy regimens and communication for survivors, their families and multiple care teams to support recovery,” Burry and colleagues wrote. “Given the many critically ill patients discharged every year, even small changes in prescribing practices may yield large benefits across a health care system.”
This study by Burry and colleagues could potentially improve patient life after the ICU with its identification of factors linked to persistent sedative use; however, more studies are needed to address the lack of connection between discharge sedative prescription and in-ICU sedative administration in this study, according to an accompanying editorial by Jai Darvall, PhD, associate professor in the department of critical care at the University of Melbourne.
“Higher rates of discharge sedatives in certain hospitals could be explained by differences in case-mix requiring higher (and perhaps appropriate) rates of new prescriptions commenced in patients admitted to those hospitals,” Darvall wrote.
He added, “Further work is thus required to explore whether these findings do truly represent missed opportunities for sedative deprescribing, or instead perhaps indicate an at-risk population that may benefit from increased mental health or psychological long-term follow-up.”