Preventable sources of medication related morbidity and mortality at transitions in care for hospitalized patients

With the aging of the population and advances in medical care and public health, a growing proportion of individuals have multiple chronic conditions. Indeed, in Canada, almost half of those aged 65 years and older are living with multiple co-existing chronic conditions. The impact of multimorbidity is multifaceted, leading to lower quality of life, declines in functional status, higher rates of disability and increased mortality. For healthcare systems, multimorbidity leads to greater healthcare utilization, especially of high-cost services such as hospital stays and emergency department visits. One of the most complex aspects of providing optimal care to patients with multimorbidity is their use of many different medications. Approximately 60% of multimorbid patients use five or more medications which in turn increases their risk of drug-drug and drug-disease interactions, and adverse drug events (ADEs). Despite the clinical challenges associated with treating complex patients with many medications, evidence-based guidance for safe and effective prescribing in the context of multimorbidity remains limited. Patients with multiple chronic conditions are likely to require repeated admission to hospital, and once discharged, over one-third will be re-admitted to hospital within 90-days. However, reducing re-admissions in these complex patients has remained challenging since the reason for returning to hospital can include a number of interlinked patient-, provider- and healthcare system-level factors. The impact of patient medications is of significant interest since a large proportion of re-admissions are related to ADEs. When patients are hospitalized, they are often discharged on substantially different medications than those prior to admission. One might expect that discontinuations, additions or modifications to patient drug regimens during hospitalization would reduce the likelihood of adverse health outcomes after discharge. However, the extent to which patients actually adhere to hospital medication changes or the appropriateness of these changes is not known. The impact of these factors on short-term patient health outcomes after discharge is also unknown.The overarching goal of this thesis was to explore potentially preventable sources of medication-related morbidity and mortality in hospitalized patients in the transition between hospital and home. Three studies were completed to accomplish this goal.Objective Study 1: Estimate the incidence and determinants of non-adherence to hospital medication changes in the 30-days after hospitalizationObjective Study 2: Estimate the association between non-adherence to medication changes made at hospital discharge on the risk of re-admissions, emergency department visits and death in the 30-days post dischargeObjective Study 3: Estimate the incidence of potentially inappropriate medications prescribed at hospital discharge and their impact on re-admissions, emergency department visits and death as well as drug-related adverse events in the 30-days after discharge

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