By Betty Tran, MD, MSc
Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago
SYNOPSIS: In this population-based cohort study of older intensive care unit survivors, one in 15 of them received a new prescription for a sedative within a week of discharge, and more than half had recurrent prescriptions.
SOURCE: Burry LD, Bell CM, Hill A, et al. New and persistent sedative prescriptions among older adults following a critical illness: A population-based cohort study. Chest 2023;163:1425-1436.
Sedative medications, including antipsychotics and benzodiazepines, often are used in the intensive care unit (ICU) to treat medically complex patients who require various interventions, including invasive mechanical ventilation and procedures, and/or develop delirium and anxiety. As these patients recover from their ICU stays, these medications likely no longer are needed, but recovery can involve longer-term cognitive, physical, and psychologic rehabilitation. This study sought to explore the frequency of and risk factors associated with a new and persistent sedative prescription post-ICU discharge.
Using health administrative and outpatient prescription data from 2003-2019 as part of Ontario’s universal healthcare for residents of all ages and outpatient prescription coverage for those aged > 65 years, a cohort of ICU survivors aged ≥ 66 years who was sedative-naïve (no sedative prescription within six months prior to index ICU hospitalization) was defined, with follow-up to 180 days post-discharge. Sedatives included benzodiazepines, non-benzodiazepine sedative-hypnotics, or antipsychotics. The primary outcome was the proportion of patients filling a sedative prescription within seven days of discharge. Secondary outcomes included prescriptions for each type of sedative subclass within seven days of discharge and persistent sedative prescriptions, defined as the proportion of new sedative users filling one or more prescriptions after one week up to six months post-discharge.
A total of 250,428 sedative-naïve adults aged ≥ 66 years were included in the study. At baseline, 85.5% came from the community, 61.0% were male, 63.6% had surgery during their hospital stay, 26.3% were mechanically ventilated, and 14.8% had sepsis/septic shock. In terms of the primary outcome, 15,277 (6.1%) filled a new sedative prescription within one week of discharge and of these, 8,458 (55%) had a persistent sedative prescription. The most common sedative class prescribed was benzodiazepines, followed by a non-benzodiazepine sedative, then antipsychotics.
Patients who filled a new sedative prescription had more comorbidity burden (i.e., higher Charlson Comorbidity Index [CCI] score) and were more likely to be frail, have diagnoses of sepsis or acute kidney injury, require invasive mechanical ventilation, and have longer ICU and hospital stays. Using multivariable, multilevel logistic regression incorporating a priori factors, factors associated with filling a new sedative prescription included discharge to a long-term care facility (adjusted odds ratio [aOR], 4.00; 95% confidence interval [CI], 3.72-4.31), inpatient geriatric (aOR, 1.95; 95% CI, 1.80-2.10) or psychiatric (aOR, 2.76; 95%CI, 2.62-2.91) consultation, invasive mechanical ventilation (aOR, 1.59; 95% CI, 1.53-1.66), ICU length of stay seven days or longer (aOR, 1.50; 95% CI, 1.42-1.58), or discharge from a community hospital (aOR, 1.40; 95% CI, 1.16-1.70) or from a rural hospital (aOR, 1.67; 95% CI, 1.36-2.05). Risk factors associated with filling persistent sedative prescriptions included discharge to a long-term care facility and female sex. Overall, there was a wide range in proportion of patients discharged with new sedative prescriptions across 153 hospitals (2.1% up to 44.0%), with residual heterogeneity between hospitals having a stronger association with new sedative prescriptions (aOR, 1.43; 95% CI, 1.35-1.49) compared to other factors, such as CCI score, pre-existing polypharmacy, or sepsis diagnosis.
COMMENTARY
This study highlights the important finding that older ICU survivors often are discharged with a new sedative prescription, with more than half continuing to fill these prescriptions up to six months after hospital discharge. Although factors such as discharge destination to a long-term care facility, severity of critical illness, and baseline comorbidities play some role, what is notable is the substantial variation in prescribing patterns that was found between hospitals, suggesting an area ripe for interventions to modify discharge prescribing practices.
Information that is lacking and would be helpful in planning future interventions includes the clinical indication for the new sedative prescription: Are these new prescriptions indicated for management of sequelae of critical illness or an oversight due to lack of sufficient discharge medication reconciliation? If the former, establishing a post-ICU survivorship clinic or close follow-up with the patient’s primary care provider may be helpful to address specific ongoing impairments and determine a taper plan. If the latter, more stringent medication reconciliation and standardized communication between inpatient and outpatient teams would facilitate close follow-up and reassessment of medication needs as patients continue their recovery. Furthermore, the answers to these questions may vary from hospital to hospital, and it may be helpful for each site to perform their own internal quality improvement regarding their discharge medication reconciliation and follow-up scheduling protocols.
