Medication-Related Factors Affecting Discharge to Home

Abstract

To assess the reasons for barriers to home discharge by determining whether they were predicted by medication, clinical variables, and patient characteristics, the retrospective cohort study of 282 patients discharged from Kanazawa Red Cross Hospital in Kanazawa, Japan from January 2011 to December 2012 was performed. The percentage of patients discharged was 67.4%. By multivariate logistic analysis, significant differences in home discharge destination were determined by six factors: the duration of hospitalization before discharge (odds ratio (OR) 0.993; 95% 95% confidence interval (CI) 0.988–0.999), the presence of excretion assistance (OR 0.115; 95% CI 0.043–0.308), individual payment of medical expense (OR 0.344; 95% CI 0.146–0.811), the degree of independent living for the demented elderly (OR4.570; 95% CI 1.969–10.604), presence of the primary caregiver (OR 8.638; 95% CI 3.121–23.906), and admission to a hospital from home (OR 5.483; 95% CI 2.589–11.613). This study suggests that necessity of excretion assistance, long duration of hospitalization, and high individual payment of medical expense were barriers to home discharge. In contrast, three factors i.e., admission to a hospital form home, low degree of independent living for the demented elderly, and presence of the primary caregiver, favored home discharge. The relation between a patient’s status (cognitive status and incontinence) and a caregiver has an important effect on the home discharge. However, medication characteristics appeared to have little effect on recuperation destination.

Currently, a proactive approach to home medical care is being conducted in Japan. Home medical care will play an important role in building an integrated community care system. The participation of pharmacists is expected for efficient provision of quality patient care in home medical care and regional comprehensive care. But pharmacist participation in home care has been minimal and has frequently been limited to delivering drugs to patients’ homes.¹⁾

Environmental improvement and understanding of discharge has become important. There is an increasing importance in discharge planning for smoothly migration to home. An intervention study on the effect of discharge planning showed that shorter length of stay, reduction of re-hospitalization, appropriate use of the service after discharge, improving the satisfaction of patients and family and cost reduction can be expected.^2–5)

Elderly patients, who are often characterized by physiological functional decline and polypharmacy, are susceptible to adverse drug reactions to pharmacotherapy.^6,7) Complexity of medications is known to be one of the problems that make home medical care difficult. It is important to evaluate a medication depending on the patient’s cognitive independence and develop drug-dosage forms suitable for home care.^7,8) Accordingly, verifying the need for medication of patients discharged from the hospital may be beneficial in considering the manner of pharmacist participation in home care.

The purpose of this study was to analyze the medication-related factors that influence destination (home, other hospitals, and nursing homes) following the discharge of hospital patients receiving discharge planning services.

MATERIALS AND METHODS

Study Design and Data Source

This was a single-center, retrospective cohort study conducted at Kanazawa Red Cross Hospital in Japan. The study population included patients who were assigned to undergo discharge planning between March 2011 and April 2012 in the medical welfare counselors office of Kanazawa Red Cross Hospital.

Variables in Patient Characteristics

Data on health status and discharge status were collected by reviewing clinical charts at discharge. The collecting data factors such as age, sex, residence prior to hospital admission, discharge destination (divided into two groups, discharge to home and to other hospitals or nursing homes), length of hospital stay, number of hospitalizations, caregiver’s characteristics (number of family and the primary caregiver), type of residence after discharge, type of medicare, medical self-pay rate, and insurance for medical expenses. In the long-term care insurance system in Japan, care levels are classified as Support and Care Levels 1–4.

To assess the activities of daily living (ADL) of the patients, data on status of communication, toileting, feeding oneself, and mobility were collected. Degree of dementia was assessed using a scale provided by the Ministry of Health, Labour and Welfare of Japan, which includes five categories: (normal) no dementia, (I) some dementia but almost independent in daily living, (II) dementia with some difficulty communicating but independent in daily living with minimal observation, (III) dementia with some difficulty in communicating and requiring partial care, and (IV) severe dementia with difficulty in communicating and requiring complete care. Physical disability based on guidelines by the Ministry of Health and Welfare is divided in the following categories: J, having some physical disability but capable of going out around the house without assistance; A, incapable of going out alone but capable of managing daily household activities; B, spending most of time in bed; and C, bedridden. The Japan Coma Scale consists of four consciousness levels.

To ascertain the necessity of medical/nursing care after discharge, data of medical practices such as home oxygen therapy, suction, tube feeding, infusion (including central vein infusion), insulin injection, urinary catheter, pain control, care for bowel control, and other practices after discharge were collected. Furthermore, data of symptoms such as pain, sleep disorders, and difficulty in breathing were collected.

Classification of Medication-Related Problems

Problems associated with medication use are common in elderly adults. In this study, patient problems such as practical drug administration problems and use of inappropriate medication were investigated.

Number of Prescription Drugs

Elderly adults are particularly susceptible to adverse drug reactions because they are usually on multiple drug regimens and age is associated with changes in pharmacokinetics and pharmacodynamics. In addition, there is risk in increasing the number of drugs used.^7,9–11)

Number of Dosage Forms

When multiple medications are required, regimen complexity increases the likelihood of poor compliance or confusion in dosage.¹²⁾ Elderly adults and particularly those with low medical literacy are unable to consolidate prescription regimens to optimize a dosing schedule. Therefore, they may require assistance in taking medicines at home.

Use of Inappropriate Medication

Adverse drug events result in four times as many hospitalizations in elderly than in younger adults.¹³⁾ Various criteria (high-risk drug, Beers Criteria) exist that identify medications that should not be prescribed or should be prescribed with caution.¹⁴⁾

High-Risk Drugs: The Ministry of Health, Labour and Welfare of Japan categorizes prescription drugs into eight classes (digoxin, calcium channel blockers, angiotensin-converting enzyme inhibitors, H2 receptor antagonists, NSAIDs, benzodiazepines, antipsychotics, and antidepressants) and focuses on four types of prescription problems (inappropriate dosage, inappropriate duration of therapy, duplication of therapies, and potential for drug–drug interactions).

Beers Criteria: This criterion is to be considered for elderly people over the age of 65. The panel produced a list of medications considered inappropriate for elderly patients because of either ineffectiveness or high risk for adverse events.

Data Analysis

Univariate analysis for each of these items was conducted comparing the home discharge and the other hospital or nursing home discharge groups. Variables that gave p<0.2 from univariate analyses were further evaluated using a multivariable logistic regression. Multivariate analysis was performed by logistic regression using the above-mentioned independent variables and discharge to home as the dependent variable. All statistical analyses were carried out with Ekuseru-Toukei 2012 (Social Survey Research Information Co., Ltd., Tokyo, Japan).

Ethical Considerations

Implementation of the survey followed the ethical guidelines for epidemiological research of the Ministry of Education, Culture, Sports, Science and Technology and the Ministry of Health, Labour and Welfare of Japan. The ethics committee of the Graduate School of Medicine in the University of Kanazawa also approved this study.

RESULTS

The characteristics of the 282 discharged patients who received discharge planning are summarized in Table 1. The home discharge group comprised 190 cases (67.4%) and the non-home discharge group comprised 92 cases (32.6%). The mean age of patients was 78.7±10 years and mean length of hospital stay was 77±61.1 d. The mean number of prescribed medications was 6.5±3.4 tablets. The major diseases were cerebrovascular disease (n=119, 42.2%), hypertension (n=97, 34.4%), diabetes (n=88, 31.2%), cardiac disease (n=81, 28.7%), and dementia (n=79, 28%).

Table 1. Patient Characteristics Discharged to Home or to Hospital and Nursing Home (n=282)

	Total (n=282)	Discharge destination
		Hospital and nursing home (n=92)	Home (n=190)
Gender
Men	120	35	85
Women	162	57	105
Age (year)	78.7±10	81.6±8.4	77.3±10.8
Length of hospital stay (d)	77.1±61.4	93±69.2	69.1±61.3
Place of residence before hospital admission
Hospital	75	31	44
Nursing home	23	23	0
Home	184	38	146
Number of family	1.46±1.39	1.03±1.32	1.66±1.32
Presence of main caregiver	218	58	159
Care level
No application	48	12	36
No application or support need	89	18	71
No application or support need or care need level 1	144	28	118
No application or support need or care need level 1 or 2	187	43	144
No application or support need or care need level 1 or 2 or 3	219	63	156
No application or support need or care need level 1 or 2 or 3 or 4	254	83	171
No application or support need or care need level 1 or 2 or 3 or 4 or 5	282	92	190
Medical self-pay rate
0% of medical fees	36	11	25
10% of medical fees	215	76	139
30% of medical fees	31	5	26
Degree of dementia
Normal	53	5	48
Normal & I level	142	15	127
Normal or I or II	193	41	152
Normal or I or II or III	226	59	167
Normal or I or II or III or IV	273	86	187
Normal or I or II or III IV or M	282	92	190
Physical disability
Normal	49	6	43
Normal or J	69	6	54
Normal or J or A	139	18	121
Normal or J or A or B	209	48	161
Normal or J or A or B or C	282	92	190
Difficulty of communication	126	62	65
Consciousness level	59	30	29
Toileting (need assistance)	154	80	74
Eating behavior (need assistance)	100	59	41
Transfer			97
Need assistance	181	84	97
Independent	55	2	53
With cane	79	6	74
With wheelchair	148	84	63
Disease (multiple answers)
Fracture	75	22	54
Cerebrovascular	119	47	72
Dementia	79	41	38
Cardiovascular	81	22	59
Psychiatry (non-dementia)	22	11	11
Incontinence	17	7	10
Diabetes	88	24	64
Hypertension	97	29	68
Malignant neoplasms	45	12	35
Eating disorder	33	17	16
Method of drug administration
Self-administration	87	42	75
Help by caregiver	110	48	149
Medical/Nursing care
Pain control	68	17	51
Sleep disorders	65	17	47
Difficulty in breathing	7	4	3
Medication
Mean number of drugs	6.5±3.4	6.4 ±3.3	6.6 ±3.4
Mean number of administration	3.4±1.6	3.2 ±1.5	3.5 ±1.6
High-risk drug	143	45	97
Beers criteria drug	95	31	64
Topical medications	80	29	52
Powders	109	45	64

Results of univariate analysis of 20 independent variables met the statistical significance level (Table 2). Three basic variables, i.e., age, length of hospital stay, and residence prior to hospital admission, reached the statistical significance level (p<0.05). In the nursing care and socioeconomic attributes, 12 independent variables that met statistical significance (p<0.05) were number of family members, presence of primary caregiver, level of care, cognitive independence, daily life independence, availability of services, failure of communication, level of consciousness, independence of excretion, self-reliance of diet, movement without support, and independence of ambulatory movement. In the univariate analysis, four variables, i.e., dementia, eating disorder, psychiatry, and method of drug administration, reached statistical significance (p<0.05). With respect to pharmaceutical attributes, consumption of the powdered drug is statistically significant (p<0.05).

Table 2. Univariate Logistic Regression Analysis of Determinants of Home Placement after Discharge from Hospital

	Odds ratio	95% Confidence interval	p-Value
Gender
Men	0.759	0.456–1.262	0.287
Women
Age (year)	0.954	0.928–0.981	0.001
Length of hospital stay (d)	0.994	0.990–0.998	0.003
Place of residence before hospital admission
Hospital	0.593	0.343–1.026	0.062
Nursing home	—	—	—
Home	4.715	2.763–8.048	<0.0001
Number of family	1.454	1.177–1.797	0.0005
Presence of main caregiver	3.007	1.697–5.328	0.0001
Care level
No application	3.0067	1.697–5.328	0.0002
No application or support need	4.193	1.714–10.257	0.0017
No application or support need or care need level 1	3.583	2.106–6.095	<0.0001
No application or support need or care need level 1 or 2	4.976	2.889–	8.569
No application or support need or care need level 1 or 2 or 3	2.112	1.188–3.755	0.0109
No application or support need or care need level 1 or 2 or 3 or 4	0.976	0.423–2.250	0.954
Medical self-pay rate
0% of medical fees	1.116	0.523–2.379	0.777
10% of medical fees	0.574	0.306–1.075	0.083
30% of medical fees	2.759	1.023–7.437	0.045
Degree of dementia
Normal	5.882	2.255–13.346	0.0003
Normal or I level	10.348	5.510–19.435	<0.0001
Normal or I or II	4.976	2.889–8.568	<0.0001
Normal or I or II or III	4.061	2.208–7.471	<0.0001
Normal or I or II or III or IV	4.349	1.063–17.799	0.041
Physical disability
Normal	4.193	1.714–10.257	0.002
Normal or J	5.691	2.347–13.798	0.0001
Normal or J or A	7.209	3.981–13.057	<0.0001
Normal or J or A or B	5.089	2.881–8.989	<0.0001
Difficulty of communication	0.252	0.148–0.427	<0.0001
Consciousness level	0.647	0.429–0.976	0.038
Toileting (need assistance)	0.096	0.049–0.188	<0.0001
Eating behavior (need assistance)	0.154	0.089–0.267	<0.0001
Transfer
Need assistance	17.409	4.139–73.231	0.0001
Independent
With cane	9.144	3.802–21.989	<0.0001
With wheelchair	0.047	0.022–0.104	<0.0001
Disease (multiple answers)
Fracture	1.263	0.712–0.242	0.424
Cerebrovascular	0.584	0.353–0.966	0.036
Dementia	0.311	0.181–0.536	<0.0001
Cardiovascular	1.433	0.811–2.532	0.215
Psychiatry (non-dementia)	0.453	0.189–1.087	0.076
Incontinence	0.675	0.248–1.833	0.440
Diabetes	1.439	0.827–2.505	0.198
Hypertension	1.211	0.712–2.058	0.480
Malignant neoplasms	1.505	0.741–3.059	0.258
Eating disorder	0.406	0.195–0.846	0.016
Method of drug administration
Self-administration	4.348	2.218–8.521	<0.0001
Help by caregiver	2.998	1.787–5.030	<0.0001
Medical/Nursing care
Pain control	1.619	0.874–2.999	0.126
Sleep disorders	1.450	0.779–2.699	0.241
Difficulty in breathing	0.353	0.077–1.611	0.179
Medication
Mean number of drugs	1.015	0.943–1.094	0.690
Mean number of administration	1.155	0.981–1.359	0.084
High-risk drug	1.138	0.691–1.873	0.612
Beers criteria drug	1.000	0.590–1.693	0.999
Topical medications	0.819	0.476–1.409	0.470
Powders	0.531	0.319–0.881	0.014

In a multivariate logistic regression analysis, assessing factors associated with home discharge, 20 variables, which were extracted by univariate analysis, were analyzed (Table 3). Six predictors were associated with home discharge: the duration of hospitalization before discharge (odds ratio (OR) 0.993; 95% confidence interval (CI) 0.988–0.999), the presence of excretion assistance (OR 0.115; 95% CI 0.043–0.308), individual payment of medical expense (OR 0.344; 95% CI 0.146–0.811), the degree of independent living for the demented elderly (OR4.570; 95% CI 1.969–10.604), presence of the primary caregiver (OR 8.638; 95% CI 3.121–23.906), and admission to a hospital from home (OR 5.483; 95% CI 2.589–11.613). The presence of drug management (such as dosage forms, number of medicines, and high-risk drugs) was not significant in the regression analysis controlling for other potential risk factors.

Table 3. Multivariate Logistic Regression Analysis of Determinants of Home Placement after Discharge from Hospital

	Odds ratio	95% Confidence interval	p-Value
Place of residence before hospital admission from home	5.483	2.589–11.613	<0.0001
Presence of the primary caregiver	8.638	3.121–23.906	<0.0001
Degree of dementia (normal or I level)	4.570	1.969–10.604	0.0004
Length of hospital stay	0.993	0.988–0.999	0.013
Self-pay medical expenses (10% of medical fees)	0.344	0.146–0.811	0.015
Toileting (need assistance)	0.115	0.043–0.308	<0.0001

DISCUSSION

The decision whether or not a hospitalized patient is appropriate for discharge requires evaluation of multiple factors involving medical as well as psychosocial, logistic, and economic considerations.¹⁵⁾ In the present study, determinants of discharge to home were the availability of family or companion support, financial support, patient’s cognitive status, and activities of daily living such as toileting, length of hospital stay, and residence prior to hospital admission from home. These findings indicate that setting of the care of dementia and incontinence is important for home discharge and the availability of caregiver support may be essential for home discharge. In order to promote the home discharge, the most suitable discharge plan and the appropriate follow-up care at home must be taken into account for patients having dementia and /or incontinence.

Although problems associated with drugs in the elderly, such as side effects and medication adherence, which may influence home discharge were considered,¹⁶⁾ these problems were not identified as determinants of home discharge in this study. Several studies have suggested medication parameters such as use of high-risk medication and polypharmacy (use of five or more medications) that may increase the risk of rehospitalization.¹⁷⁾ Given that elderly patients often take multiple medications and are more susceptible to adverse drug events, it is particularly important to ensure that a complete and accurate list of medications is obtained at discharge.^18,19) Age-related pharmacodynamic and pharmacokinetic changes increase the susceptibility of elderly patients to adverse reactions from medications.^20–22)

In Japan, pharmaceutical counseling at discharge is not common, which could be a reason why no factors in drug-related items were identified as determinants of home discharge in this study. Performing an accurate medication reconciliation is a critical element of a successful discharge transition. Discharges from the nursing facility to home provide an opportunity to review and optimize the medication regimen.²³⁾ Pharmacists can be helpful as a resource for medication reconciliation.^24,25) The process also provides an opportunity for clinicians to ensure that patients understand which medications they are consuming, how to consume them, and why they are consuming them.^26–30)

From this study, the importance of care for cognitive function and excretion in home care is clarified. Drug therapy for patients with impaired cognitive and/or excretion is applied.³¹⁾ It is reported that patients receiving high doses of donepezil, a medication for Alzheimer’s disease, developed urinary disturbance. Furthermore, concomitant medication of donepezil and anticholinergic medications used to treat constipation or urinary retention may worsen cognitive symptoms.^32,33) The involvement of pharmacists in the drug therapy of such patients would be beneficial and provide a better care environment for the patient.

A limitation of this study is that a single-site study performed in a regional hospital. A bias by type of the patient’s disease might be assumed.

Acknowledgment

The authors would like to thank, Mr. Kuriyama K., Muryoi K. and Ms. Hashimoto K. for their help in the data collecting.

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