Medications and Prescribing Patterns as Factors Associated with Hospitalizations from Long-Term Care Facilities: A Systematic Review
Residents of long-term care facilities (LTCFs) are at high risk of hospitalization. Medications are a potentially modifiable risk factor for hospitalizations.
Our objective was to systematically review the association between medications or prescribing patterns and hospitalizations from LTCFs.
We searched MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and International Pharmaceutical Abstracts (IPA) from inception to August 2017 for longitudinal studies reporting associations between medications or prescribing patterns and hospitalizations. Two independent investigators completed the study selection, data extraction and quality assessment using the Joanna Briggs Institute Critical Appraisal Tools.
Three randomized controlled trials (RCTs), 22 cohort studies, five case–control studies, one case-time-control study and one case-crossover study, investigating 13 different medication classes and two prescribing patterns were included. An RCT demonstrated that high-dose influenza vaccination reduced all-cause hospitalization compared with standard-dose vaccination (risk ratio [RR] 0.93; 95% confidence interval [CI] 0.88–0.98). Another RCT found no difference in hospitalization rates between oseltamivir as influenza treatment and oseltamivir as treatment plus prophylaxis (treatment = 4.7%, treatment and prophylaxis = 3.5%; p = 0.7). The third RCT found no difference between multivitamin/mineral supplementation and hospitalization (odds ratio [OR] 0.94; 95% CI 0.74–1.20) or emergency department visits (OR 1.05; 95% CI 0.76–1.47). Two cohort studies demonstrated influenza vaccination reduced hospitalization. Four studies suggested polypharmacy and potentially inappropriate medications (PIMs) increased all-cause hospitalization. However, associations between polypharmacy (two studies), PIMs (one study) and fall-related hospitalizations were inconsistent. Inconsistent associations were found between psychotropic medications with all-cause and cause-specific hospitalizations (11 studies). Warfarin, nonsteroidal anti-inflammatory drugs, pantoprazole and vinpocetine but not long-term acetylsalicylic acid (aspirin), statins, trimetazidine, digoxin or β-blockers were associated with all-cause or cause-specific hospitalizations in single studies of specific resident populations. Most cohort studies assessed prevalent rather than incident medication exposure, and no studies considered time-varying medication use.
High-quality evidence suggests influenza vaccination reduces hospitalization. Polypharmacy and PIMs are consistently associated with increased all-cause hospitalization.
Compliance with Ethical Standards
Kate Wang is supported by an Australian Government Research Training Program Scholarship. Esa Chen is supported by the National Health and Medical Research Council (NHMRC) Cognitive Decline Partnership Centre and the Faculty of Pharmacy and Pharmaceutical Sciences, Monash University. Julia Gilmartin-Thomas is an NHMRC-ARC Dementia Research Development Fellow. Jenni Ilomäki is funded through the NHMRC Early Career Fellowship. No other sources of funding were used to assist in the preparation of this review.
Conflict of interest
Kate Wang, J. Simon Bell, Esa Chen, Julia Gilmartin-Thomas and Jenni Ilomäki have no conflicts of interest relevant to the content of this review.
- 6.Torio CM, Moore BJ. National inpatient hospital costs: the most expensive conditions by payer 2013. In: Statistical brief 204. Agency for Healthcare Research and Quality, Rockville. 2016. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb204-Most-Expensive-Hospital-Conditions.jsp. Accessed 16 Sept 2017.
- 11.Roughead EE, Semple SJ. Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002–2008. Aust N Z Health Policy. 2009;6(18). https://doi.org/10.1186/1743-8462-6-18.
- 16.Critical appraisal tools. Joanna Briggs Institute. 2016. http://joannabriggs.org/research/critical-appraisal-tools.html. Accessed 26 Sept 2017.
- 32.Simoni-Wastila L, Ryder PT, Qian J, Zuckerman IH, Shaffer T, Zhao L. Association of antipsychotic use with hospital events and mortality among medicare beneficiaries residing in long-term care facilities. Am J Geriatr Psychiatry. 2009;17(5):417–27. https://doi.org/10.1097/JGP.0b013e31819b8936.CrossRefPubMedPubMedCentralGoogle Scholar
- 46.Gravenstein S, Davidson HE, Taljaard M, Ogarek J, Gozalo P, Han L, et al. Comparative effectiveness of high-dose versus standard-dose influenza vaccination on numbers of US nursing home residents admitted to hospital: a cluster-randomised trial. Lancet Respir Med. 2017;5(9):738–46.CrossRefPubMedGoogle Scholar
- 49.Lattanzio F, Mussi C, Scafato E, Ruggiero C, Dell’Aquila G, Pedone C, et al. Health care for older people in Italy: The U.L.I.S.S.E. project (Un Link Informatico sui Servizi Sanitari Esistenti per l’anziano—a computerized network on health care services for older people). J Nutr Health Aging. 2010;14(3):238–42.CrossRefPubMedGoogle Scholar
- 50.Bernabei R, Gambassi G, Lapane K, Sgadari A, Landi F, Gatsonis C, et al. Characteristics of the SAGE database: a new resource for research on outcomes in long-term care. SAGE (Systematic Assessment of Geriatric drug use via Epidemiology) Study Group. J Gerontol A Biol Sci Med Sci. 1999;54(1):25–33.CrossRefGoogle Scholar
- 55.Dose-response relationship. In: Pettygrove S, editor. Encyclopædia Britannica: Encyclopædia Britannica, inc.; 2016.Google Scholar
- 61.Grace AR, Briggs R, Kieran RE, Corcoran RM, Romero-Ortuno R, Coughlan TL, et al. A comparison of Beers and STOPP criteria in assessing potentially inappropriate medications in nursing home residents attending the emergency department. J Am Med Dir Assoc. 2014;15(11):830–4. https://doi.org/10.1016/j.jamda.2014.08.008.CrossRefPubMedGoogle Scholar
- 62.van der Stelt CA, Windsant-van Vermeulen, den Tweel AM, Egberts AC, van den Bemt PM, Leendertse AJ, Hermens WA, et al. The association between potentially inappropriate prescribing and medication-related hospital admissions in older patients: a nested case control study. Drug Saf. 2016;39(1):79–87. https://doi.org/10.1007/s40264-015-0361-1.CrossRefPubMedGoogle Scholar
- 65.Chan TC, Hung IF, Luk JK, Shea YF, Chan FH, Woo PC, et al. Prevention of mortality and pneumonia among nursing home older adults by dual pneumococcal and seasonal influenza vaccination during a pandemic caused by novel pandemic influenza A (H1N1). J Am Med Dir Assoc. 2012;13(8):698–703. https://doi.org/10.1016/j.jamda.2012.05.009.CrossRefPubMedGoogle Scholar
- 66.Chan TC, Fan-Ngai Hung I, Ka-Hay Luk J, Chu LW, Hon-Wai Chan F. Effectiveness of influenza vaccination in institutionalized older adults: a systematic review. J Am Med Dir Assoc. 2014;15(3):226.e1-6. https://doi.org/10.1016/j.jamda.2013.10.008.
- 68.van der Sande MA, Meijer A, Şen-Kerpiclik F, Enserink R, Cools HJ, Overduin P, et al. Effectiveness of post-exposition prophylaxis with oseltamivir in nursing homes: a randomised controlled trial over four seasons. Emerg Themes Epidemiol. 2014;11(1):13. https://doi.org/10.1186/1742-7622-11-13.CrossRefPubMedPubMedCentralGoogle Scholar
- 69.Jefferson T, Jones M, Doshi P, Spencer EA, Onakpoya I, Heneghan CJ. Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. BMJ. 2014;348(g2545). https://doi.org/10.1136/bmj.g2545.
- 71.Bleeding during antithrombotic therapy in patients with atrial fibrillation. The stroke prevention in atrial fibrillation investigators. Arch Intern Med. 1996;156(4):409–16.Google Scholar
- 73.Leor J, Reicher-Reiss H, Goldbourt U, Boyko V, Gottlieb S, Battler A, et al. Aspirin and mortality in patients treated with angiotensin-converting enzyme inhibitors: a cohort study of 11,575 patients with coronary artery disease. J Am Coll Cardiol. 1999;33(7):1920–5. https://doi.org/10.1016/S0735-1097(99)00129-1.CrossRefPubMedGoogle Scholar
- 77.Pedro-Botet J, Climent E, Chillarón JJ, Toro R, Benaiges D, Flores-Le Roux JA. Statins for primary cardiovascular prevention in the elderly. J Geriatr Cardiol. 2015;12(4):431–8. https://doi.org/10.11909/j.issn.1671-5411.2015.04.016.PubMedPubMedCentralGoogle Scholar
- 79.Di Napoli P, Di Giovanni P, Gaeta MA, Taccardi AA, Barsotti A. Trimetazidine and reduction in mortality and hospitalization in patients with ischemic dilated cardiomyopathy: a post hoc analysis of the Villa Pini d’Abruzzo Trimetazidine Trial. J Cardiovasc Pharmacol. 2007;50(5):585–9. https://doi.org/10.1097/FJC.0b013e31814fa9cb.CrossRefPubMedGoogle Scholar
- 82.Pello Lázaro AM, Cristóbal C, Franco-Peláez JA, Tarín N, Aceña Á, Carda R, et al. Use of proton-pump inhibitors predicts heart failure and death in patients with coronary artery disease. PLoS One. 2017;12(1):e0169826. https://doi.org/10.1371/journal.pone.0169826.CrossRefPubMedPubMedCentralGoogle Scholar
- 86.Cameron ID, Murray GR, Gillespie LD, Robertson MC, Hill KD, Cumming RG, et al. Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database Syst Rev. 2010;(1):CD005465. https://doi.org/10.1002/14651858.cd005465.pub2.
- 87.Marcum ZA, Perera S, Thorpe JM, Switzer GE, Gray SL, Castle NG, et al. Anticholinergic use and recurrent falls in community-dwelling older adults: findings from the health ABC study. Ann Pharmacother. 2015;49(11):1214–21. https://doi.org/10.1177/1060028015596998.CrossRefPubMedPubMedCentralGoogle Scholar