gms | German Medical Science

At discharge from the hospital, a patient with chronic cardiovascular diseases will receive a discharge report to his GP which usually includes recommendations for ambulatory prescriptions. Little is known from Germany about the extent to which GPs follow these recommendations. Also, little is known about the knowledge of patients about their prescriptions and the "performance" of the medication under field conditions. Poly-pharmacotherapy and inappropriate drug use at one side, and under-use of established therapies on the other side are important issues which emerge especially in the elderly population.

At discharge from the hospital, patients > 65 years with at least 2 diagnoses from the cardiovascular field were asked to allow a visit at their home after 3 and 12 months. 4 visits were scheduled: visit 1 (V1, retrospectively) assessed medication and clinical data at time of the referral to the hospital, visit 2 (V2) covers clinical and medication data at discharge (i.e. the recommendations for therapy to the GP), visit 3 (V3, 3 months) and visit 4 (V4, 12 months) assessed data on actual drug use at home, including data on knowledge about the prescriptions and clinical data from the patients own records regarding INR, glucose and blood pressure (if applicable), together with a geriatric assessment. Purposely, the GP was not involved in this survey to avoid a bias on the adherence to the hospitals prescribing recommendations. All prescriptions at V2 to V4 were subject to a medical and clinical pharmacology review addressing several issues regarding the appropriateness of therapy, e.g. harmful interactions, dosing problems, contraindications, polypharmacotherapy, and withholding an established drug (e.g. statin in hypercholesterolemia and CAD).

The results presented in this abstract are selected from the interim analysis of the V3-visit. 425 Patients (median 75 y, range 63 - 89 y) were enrolled in the survey at V2. From these, 23 died before V3 was made, 52 further patients were not accessible for V3. 34 patients were readmitted to the hospital for at least one time in the interval between V2 and V3. Qualifying diagnoses were hypertension (N=330), CAD (169), atrial fibrillation (N=109), diabetes (N=168), hyperlipidaemia (N=204), CHF (N= 115), stroke (59). At V2, patients were discharged with a median of 6 prescriptions (range 1-16, without OTC), at V3 a median of 7 prescriptions (range 1-20, including OTC) were taken by the patients. 7% of all medications at V3 were OTC's, 102 of 350 patients at V3 were taking at least 1 OTC (range 1-5). 14% of all prescriptions at V2 were unchanged at V3 (same brand name) at V3, 11% of all prescriptions were substituted by a generic preparation, and in 4% a similar drug from the same drug class was given. For 74% of all prescriptions, a reason for the purpose of the medication could be given by the patient (most often rather cursory like „for the heart"), but for only 4% of all prescriptions, a quotation about possible risks and side effects were made. In patients with atrial fibrillation and receiving oral anticoagulation, 16% had sub-therapeutic (< 1.8) and 30% had supra-therapeutic (> 3.5) INR readings. In hypertensive patients, an increase in the diastolic blood pressure > 10 mmHg at V3 compared with V2 was seen in 20% and an increase in systolic blood pressure > 10 mmHg was recorded in 40%. In 58 % of all pts. eligible for statin therapy, no such therapy was given.

The interim analysis of this survey indicates a large proportion of changes in the ambulatory medication after discharge from hospital, a minor quality in the actual performance of the therapy, as seen e.g. by the INR deviations and the decline in blood pressure control, and only sketchy knowledge of elderly patients about their medication. The final results of our survey (the last patient will have his V4 in September 2003) should stimulate concepts to improve the communication between hospitals and GPs about their priorities in pharmacotherapy.