Shoshana J. Herzig

National use of prescription medications for insomnia: NHANES 1999-2010.

STUDY OBJECTIVES To determine current patterns and predictors of use of prescription medications commonly used for insomnia (MCUFI) in the U.S. DESIGN Cross-sectional study. SETTING National Health and Nutrition Examination Survey, 1999-2010. PARTICIPANTS 32,328 noninstitutionalized community-dwelling U.S. adults. INTERVENTIONS N/A. MEASUREMENTS AND RESULTS WE DEFINED MCUFI USE AS USE OF ANY OF THE FOLLOWING MEDICATIONS IN THE PRECEDING MONTH: benzodiazepine receptor agonists (eszopiclone, zaleplon, zolpidem, estazolam, flurazepam, quazepam, temazepam, triazolam), barbiturates (amobarbital, amobarbitalsecobarbital, chloral hydrate), doxepin, quetiapine, ramelteon, and trazodone. We estimated prevalence of MCUFI use and concurrent use of another sedating medication. We determined predictors of MCUFI use using multivariate logistic regression. Overall, 3% percent of adults used a MCUFI within the preceding month. Zolpidem and trazodone were used most commonly. Overall MCUFI use increased between 1999-2000 and 2009-2010 (P value for trend < 0.001). Concurrent use of other sedating medications was high, with 55% of MCUFI users taking at least one other sedating medication and 10% taking ≥ 3 other sedating medications. Concurrent use of MCUFIs with opioids (24.6%) and non-MCUFI benzodiazepines (19.5%) were most common. After adjustment, adults seeing a mental health provider (aOR 4.68, 95% C.I. 3.79, 5.77), using other sedating medications (aOR 4.18, 95% C.I. 3.36, 5.19), and age ≥ 80 years (aOR 2.55, 95% C.I. 1.63, 4.01) had highest likelihood of MCUFI use. CONCLUSION In this nationally representative sample, reported use of prescription medications commonly used for insomnia (MCUFIs) within the preceding month was common, particularly among older adults and those seeing a mental health provider, with high use of sedative polypharmacy among MCUFI users.

Opioid utilization and opioid-related adverse events in nonsurgical patients in US hospitals.

BACKGROUND Recent studies in the outpatient setting have demonstrated high rates of opioid prescribing and overdose-related deaths. Prescribing practices in hospitalized patients are unexamined. OBJECTIVE To investigate patterns and predictors of opioid utilization in nonsurgical admissions to US hospitals, variation in use, and the association between hospital-level use and rates of severe opioid-related adverse events. DESIGN, SETTING, AND PATIENTS Adult nonsurgical admissions to 286 US hospitals. MEASUREMENTS Opioid exposure and severe opioid-related adverse events during hospitalization, defined using hospital charges and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. RESULTS Of 1.14 million admissions, opioids were used in 51%. The mean ± standard deviation daily dose received in oral morphine equivalents was 68 ± 185 mg; 23% of exposed received a total daily dose of ≥100 mg oral morphine equivalents. Opioid-prescribing rates ranged from 5% in the lowest-prescribing hospital to 72% in the highest-prescribing hospital (mean, 51% ± 10%). After adjusting for patient characteristics, the adjusted opioid-prescribing rates ranged from 33% to 64% (mean, 50% ± standard deviation 4%). Among exposed, 0.60% experienced severe opioid-related adverse events. Hospitals with higher opioid-prescribing rates had higher adjusted relative risk of a severe opioid-related adverse event per patient exposed (relative risk: 1.23 [1.14-1.33] for highest-prescribing compared with lowest-prescribing quartile). CONCLUSIONS The majority of hospitalized nonsurgical patients were exposed to opioids, often at high doses. Hospitals that used opioids most frequently had increased adjusted risk of a severe opioid-related adverse event per patient exposed. Interventions to standardize and enhance the safety of opioid prescribing in hospitalized patients should be investigated.

Association Between Sedating Medications and Delirium in Older Inpatients

To examine the association between Beers criteria sedative medications and delirium in a large cohort of hospitalized elderly adults with common medical conditions.

Patient care transitions from the emergency department to the medicine ward: evaluation of a standardized electronic signout tool

OBJECTIVE To evaluate the impact of a new electronic handoff tool for emergency department to medicine ward patient transfers over a 1-year period. DESIGN Prospective mixed-methods analysis of data submitted by medicine residents following admitting shifts before and after eSignout implementation. SETTING University-based, tertiary-care hospital. PARTICIPANTS Internal medicine resident physicians admitting patients from the emergency department. INTERVENTION An electronic handoff tool (eSignout) utilizing automated paging communication and responsibility acceptance without mandatory verbal communication between emergency department and medicine ward providers. MAIN OUTCOME MEASURES (i) Incidence of reported near misses/adverse events, (ii) communication of key clinical information and quality of verbal communication and (iii) characterization of near misses/adverse events. RESULTS Seventy-eight of 80 surveys (98%) and 1058 of 1388 surveys (76%) were completed before and after eSignout implementation. Compared with pre-intervention, residents in the post-intervention period reported similar number of shifts with a near miss/adverse event (10.3 vs. 7.8%; P = 0.27), similar communication of key clinical information, and improved verbal signout quality, when it occurred. Compared with the former process requiring mandatory verbal communication, 93% believed the eSignout was more efficient and 61% preferred the eSignout. Patient safety issues related to perceived sufficiency/accuracy of diagnosis, treatment or disposition, and information quality. CONCLUSIONS The eSignout was perceived as more efficient and preferred over the mandatory verbal signout process. Rates of reported adverse events were similar before and after the intervention. Our experience suggests electronic platforms with optional verbal communication can be used to standardize and improve the perceived efficiency of patient handoffs.

Acid-Suppressive Medication Use and the Risk for Nosocomial Gastrointestinal Tract Bleeding

BACKGROUND Acid-suppressive medications are increasingly prescribed for noncritically ill hospitalized patients, although the incidence of nosocomial gastrointestinal (GI) tract bleeding (GI bleeding) and magnitude of potential benefit from this practice are unknown. We aimed to define the incidence of nosocomial GI bleeding outside of the intensive care unit and examine the association between acid-suppressive medication use and this complication. METHODS We conducted a pharmacoepidemiologic cohort study of patients admitted to an academic medical center from 2004 through 2007, at least 18 years of age, and hospitalized for 3 or more days. Admissions with a primary diagnosis of GI bleeding were excluded. Acid-suppressive medication use was defined as any order for a proton pump inhibitor or histamine-2-receptor antagonist. The main outcome measure was nosocomial GI bleeding. A propensity matched generalized estimating equation was used to control for confounders. RESULTS The final cohort included 78,394 admissions (median age, 56 years; 41% men). Acid-suppressive medication was ordered in 59% of admissions, and nosocomial GI bleeding occurred in 224 admissions (0.29%). After matching on the propensity score, the adjusted odds ratio for nosocomial GI bleeding in the group exposed to acid-suppressive medication relative to the unexposed group was 0.63 (95% confidence interval, 0.42-0.93). The number needed to treat to prevent 1 episode of nosocomial GI bleeding was 770. CONCLUSIONS Nosocomial GI bleeding outside of the intensive care unit was rare. Despite a protective effect of acid-suppressive medication, the number needed to treat to prevent 1 case of nosocomial GI bleeding was relatively high, supporting the recommendation against routine use of prophylactic acid-suppressive medication in noncritically ill hospitalized patients.

Acid‐suppressive medication use in acute stroke and hospital‐acquired pneumonia

Pneumonia is a morbid complication of stroke, but evidence‐based strategies for its prevention are lacking. Acid‐suppressive medications have been associated with increased risk for nosocomial pneumonia in hospitalized patients. It is unclear whether these results can be extrapolated to stroke patients, where other factors strongly modulate pneumonia risk. We investigated the association between acid‐suppressive medication and hospital‐acquired pneumonia in patients with acute stroke.

Antipsychotic Use in Hospitalized Adults: Rates, Indications, and Predictors

To investigate patterns and predictors of use of antipsychotics in hospitalized adults.

Interhospital transfer patients discharged by academic hospitalists and general internists: Characteristics and outcomes

BACKGROUND Prior work suggests interhospital transfer (IHT) may be a risky event. Outcomes for patients transferred from another acute care institution and discharged by hospitalists and general internists at academic health systems are not well described. OBJECTIVE Investigate the characteristics and outcomes of IHT patients compared with patients admitted from the emergency department (ED) to academic health systems. DESIGN Retrospective cohort study. SETTING/PATIENTS A total of 885,392 adult inpatients discharged by hospitalists or general internal medicine physicians from 158 academic medical centers and affiliated hospitals participating in the University HealthSystem Consortium Clinical Database and Resource Manager from April 1, 2011 to March 31, 2012. METHODS Patient cohorts were defined by admission source: those from another acute care institution were IHTs, and those coming through the ED whose source of origination was not another hospital or ambulatory surgery site were ED admissions. In-hospital mortality was our primary outcome. We analyzed our data using descriptive statistics, t tests, χ(2) tests, and logistic regression. RESULTS Compared with ED admissions, IHT patients had a longer average length of stay, higher proportion of time spent in the intensive care unit, higher costs per hospital day, lower frequency of discharges home, and higher inpatient mortality (4.1% vs 1.8%, P < 0.01). After adjusting for patient characteristics and risk of mortality measures, IHT patients had a higher risk of in-hospital death (odds ratio: 1.36, 95% confidence interval: 1.29-1.43). CONCLUSIONS In this large national sample, IHT status is independently associated with inpatient mortality.

Antipsychotic utilization in the intensive care unit and in transitions of care.

PURPOSE The objective of this study was to quantify the rate at which newly initiated antipsychotic therapy is continued on discharge from the intensive care unit (ICU) and describe risk factors for continuation post-ICU discharge. MATERIALS AND METHODS This is a retrospective cohort study of all patients receiving an antipsychotic in the ICUs of a large academic medical center from January 1, 2005, to October 31, 2011. Medical record review was conducted to ascertain whether a patient was newly started on antipsychotic therapy and whether therapy was continued post-ICU discharge. RESULTS A total of 39,248 ICU admissions over the 7-year period were evaluated. Of these, 4468 (11%) were exposed to antipsychotic therapy, of which 3119 (8%) were newly initiated. In the newly initiated cohort, 642 (21%) were continued on therapy on discharge from the hospital. Type of drug (use of quetiapine vs no use of quetiapine: odds ratio, 3.2; 95% confidence interval, 2.5-4.0; P < .0001 and use of olanzapine: odds ratio, 2.4, 95% confidence interval, 2.0-3.1; P ≤ .0001) was a significant risk factor for continuing antipsychotics on discharge despite adjustment for clinical factors. CONCLUSIONS Antipsychotic use is common in the ICU setting, and a significant number of newly initiated patients have therapy continued upon discharge from the hospital.

Interhospital transfer patients discharged by academic hospitalists and general internists

BACKGROUND Prior work suggests interhospital transfer (IHT) may be a risky event. Outcomes for patients transferred from another acute care institution and discharged by hospitalists and general internists at academic health systems are not well described. OBJECTIVE Investigate the characteristics and outcomes of IHT patients compared with patients admitted from the emergency department (ED) to academic health systems. DESIGN Retrospective cohort study. SETTING/PATIENTS A total of 885,392 adult inpatients discharged by hospitalists or general internal medicine physicians from 158 academic medical centers and affiliated hospitals participating in the University HealthSystem Consortium Clinical Database and Resource Manager from April 1, 2011 to March 31, 2012. METHODS Patient cohorts were defined by admission source: those from another acute care institution were IHTs, and those coming through the ED whose source of origination was not another hospital or ambulatory surgery site were ED admissions. In-hospital mortality was our primary outcome. We analyzed our data using descriptive statistics, t tests, χ(2) tests, and logistic regression. RESULTS Compared with ED admissions, IHT patients had a longer average length of stay, higher proportion of time spent in the intensive care unit, higher costs per hospital day, lower frequency of discharges home, and higher inpatient mortality (4.1% vs 1.8%, P < 0.01). After adjusting for patient characteristics and risk of mortality measures, IHT patients had a higher risk of in-hospital death (odds ratio: 1.36, 95% confidence interval: 1.29-1.43). CONCLUSIONS In this large national sample, IHT status is independently associated with inpatient mortality.