Hospitals can reduce deaths by reducing medication

More harm than good?
More harm than good?
Image: Reuters/John Sommers II
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At their best, hospitals are places where doctors bring babies safely into the world and bring gravely ill people back from the brink of death. But at their worst, they are dangerous places where patients are vulnerable to hospital-acquired infections and a host of harmful medical errors.

A recent analysis grading more than 2,500 US hospitals on safety gave more than 1,000 of them a C or worse.

One way to make hospital care much safer and somewhat less expensive is to reduce the number of medicines people are on when they are in the hospital.

The proposal is simple: Stop all home medications at the time of admission, unless there is a compelling medical reason to continue them during the hospitalization. At discharge, use a similar decision rule: don’t resume any home medicine unless there is a compelling reason to do so.

The Institute of Medicine estimates that the rate of medication errors in hospitals is one error per patient per day. Part of what makes hospital care dangerous is complexity. In the US, it is common for patients to be on nine or 10 medications when they are admitted to the hospital.

The more medicines a person is on, the more difficult it is to care for them safely and effectively. Not surprisingly, the risk of being harmed by a medicine increases as the number of medicines one is on increases since the risk of drug-drug interactions and drug-disease interactions increases. But it is also because each new medicine creates multiple opportunities for wrong drug errors, wrong dose errors, and so on.

Unless a process is perfect (and no process in a hospital is perfect), then each new step decreases the chance that the overall process will be carried out successfully. So simple logic (and a mountain of evidence from statistical quality control) suggests that simplifying a patient’s drug therapy regimen will make care safer.

Stopping all home medicines during hospitalizations will also increase the efficiency of hospital care, and save Americans (who eventually pay all medical bills either through insurance premiums or taxes) a large amount of money. Precisely who saves the money depends on whether the hospital is public or private, the mix of commercial versus government insurance, and a variety of other factors. But US hospitals spent about $30 billion on drugs in 2014, so even a 1% reduction in expenditures would produce $300 million in savings.

Savings will come from avoiding the cost of the drug product itself, saving labor costs associated with ordering, transcribing, dispensing, administering, and monitoring the drug, and avoiding the human and financial costs associated other medication-related harm.

It might sound reckless to stop someone’s medicines when they are so sick that they need to be hospitalized. Indeed, it would be reckless if all medicines had benefits that outweighed their risks and that this benefit-risk ratio was negated by briefly stopping the medication.

Yet it is not reckless because, in reality, many medications are unnecessary or inappropriate. Many have only marginal benefits, and many of these benefits are more or less unaffected by stopping them for a few days. (After all, the most common length of stay in a US hospital is only 4.5 days.)

In fact, a nationwide study looking at the prevalence of inappropriate drug use found that, among older adults taking medication, 42.6% were on at least one inappropriate medication.

The challenge is to establish a process and set of decision rules that would allow doctors to identify, relatively quickly at the time of admission, which medicines to stop and which to continue.

At all times, clinical judgment would trump any decision rule, and patients would be involved in these decisions as much as possible. But it seems possible to set some guidelines that would make the process work smoothly.

Here is how it might work.

Imagine two lists: a list of drugs that would almost never be stopped during a hospital stay and a separate list of drugs that would be strong candidates for stopping under most ordinary circumstances.

On the first list would be any drugs with a proven ability to affect people’s survival. This list would include, for example, drugs for diabetes, high blood pressure, cancer, seizures, HIV, heart failure, abnormal heart rhythms, and blood clots.

Also on the “do not stop” list would be many drugs that don’t have a short term effect on survival but, if stopped, are likely to cause harm that would exceed the benefit gained by simplifying the inpatient drug regimen, e.g., drugs for depression, psychosis, severe pain, and certain types of inflammation.

On the second, “stop most of the time,” list would be drugs that affect symptoms but not survival—the idea being that the benefit of these drugs is less than the harm they might cause by complicating hospital care. Included here would be, for example, over-the-counter products (medicines as well as vitamins and supplements), medicines for anxiety, heartburn, constipation, mild pain, and Alzheimer’s disease.

There would barriers to implementing this proposal. The change-resistant culture of medicine, with its “clinical inertia,” often makes continuing the home medicines the path of least resistance (with the least amount of critical thinking required).

Coming up with a credible list of “never stop” and “almost always stop” medicines will be time-consuming task, and the list would have to be endorsed by professional associations of physicians, nurses and pharmacists.

The process must be able to guide decision-making without disrupting workflow in an already overtaxed system. Computerized systems for ordering medicines, now nearly ubiquitous in US hospitals, make implementing our proposal more feasible than ever before. Already, physicians must, at the time of admission, choose whether or not to continue or discontinue every home medicine.

At present, this decision is made somewhat automatically, with a strong bias toward continuing home medications. One solution is to use computerized clinical decision support at the point of care, along with a well-constructed list, to help doctors make more thoughtful decisions, shifting the bias towards more conservative treatment with fewer medicines.

In doing so, we think care will be simpler, safer, and less expensive. And that is a very good thing.

Bruce L. Lambert, PhD is Professor in the Department of Communication Studies, Director of the Center for Communication and Health at Northwestern University, and a member of the NU Public Voices Fellowship of the OpEd Project.

William Galanter, MD, PhD is Associate Chief Health Information Officer, University of Illinois Hospital and Health Sciences System.

Robert McNutt, MD is Associate Editor at the Journal of the American Medical Association and Director of Outcomes Research and Strategy at ICLOPS.