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ILLUSTRATIVE CASE
A 67-year-old man with hypertension that is well controlled on hydrochlorothiazide 25 mg po daily was admitted to the family medicine inpatient service for community-acquired pneumonia requiring antibiotic therapy and oxygen support. Despite improvement in his overall condition, his blood pressure was consistently > 160/90 mm Hg during his hospitalization. He was treated with lisinopril 10 mg po daily in addition to his home medications, which helped achieve recommended blood pressure goals.
Prior to discharge, his blood pressure was noted to be 108/62 mm Hg. He asks if it is necessary to continue this new blood pressure medicine, as his home blood pressure readings had been within the goal set by his primary care physician. Should you continue this new antihypertensive agent at discharge?
Outpatient antihypertensive medication regimens are commonly intensified at hospital discharge in response to transient short-term elevations in blood pressure during inpatient encounters for noncardiac conditions.1,2 This is typically a reflexive response during a hospitalization, despite the unknown long-term, patient-oriented clinical outcomes. These short-term, in-hospital blood pressure elevations may be due to numerous temporary causes, such as stress/anxiety, a pain response, agitation, a medication adverse effect, or volume overload.3
The transition from inpatient to outpatient care is a high-risk period, especially for older adults, as functional status is generally worse at hospital discharge than prehospitalization baseline.4 To compound this problem, adverse drug reactions are a common cause of hospitalization for older adults. Changing blood pressure medications in response to acute physiologic changes during illness may contribute to patient harm. Although observational studies of adverse drug reactions related to blood pressure medications are numerous, researchers have only evaluated adverse drug reactions pertaining to hospital admissions.5-8 This study sought to evaluate the clinical outcomes associated with intensification of antihypertensive regimens at discharge among older adults.
STUDY SUMMARY
Increased risk of readmission, adverse events after intensification at discharge
This retrospective cohort study, which was conducted across multiple
Antihypertensive medication changes at discharge were evaluated using information pulled from VHA pharmacies, combined with clinical data merged from VHA and Medicare claims. Intensification was defined as either adding a new blood pressure medication or a dose increase of more than 20% on a previously prescribed antihypertensive medication. Patients were excluded if they were discharged with a secondary diagnosis that required modifications to a blood pressure medication (such as atrial fibrillation, acute coronary syndrome, or stroke), were hospitalized in the previous 30 days, were admitted from a skilled nursing facility, or received more than 20% of their care (including filling prescriptions) outside the VHA system.
Primary outcomes included hospital readmission or SAEs (falls, syncope, hypotension, serious electrolyte abnormalities, or acute kidney injury) within 30 days or having a cardiovascular event within 1 year of hospital discharge. Secondary outcomes included the change in systolic blood pressure (SBP) within 1 year after discharge. Propensity score matching was used as a balancing factor to create a matched-pairs cohort to compare those receiving blood pressure medication intensification at hospital discharge with those who did not.
Continue to: Intensification of the blood pressure...
Intensification of the blood pressure regimen at hospital discharge was associated with an increased risk in 30-day hospital readmission (hazard ratio [HR] = 1.23; 95% CI, 1.07–1.42; number needed to harm [NNH] = 27) and SAEs (HR = 1.41; 95% CI, 1.06–1.88; NNH = 63). There was no associated reduction in cardiovascular events (HR = 1.18; 95% CI, 0.99–1.40) or change in mean SBP within 1 year after hospital discharge in those who received intensification vs those who did not (mean BP, 134.7 vs 134.4 mm Hg; difference-in-differences estimate = 0.2 mm Hg; 95% CI, −2.0 to 2.4 mm Hg).
WHAT’S NEW
First study on outcomes related to HTN med changes at hospital discharge
This well-designed, retrospective cohort study provides important clinical data to help guide inpatient blood pressure management decisions for patients with noncardiac conditions. No clinical trials up to that time had assessed patient-oriented outcomes when antihypertensive medication regimens were intensified at hospital discharge.
CAVEATS
Study population: Primarily older men with noncardiac conditions
Selected populations benefit from intensive blood pressure control based on specific risk factors and medical conditions. In patients at high risk for cardiovascular disease, without a history of stroke or diabetes, intensive blood pressure control (SBP < 120 mm Hg) improves cardiovascular outcomes and overall survival compared with standard therapy (SBP < 140 mm Hg).9 This retrospective cohort study involved mainly elderly male patients with noncardiac conditions. The study also excluded patients with a secondary diagnosis requiring modifications to an antihypertensive regimen, such as atrial fibrillation, acute coronary syndrome, or cerebrovascular accident. Thus, the findings may not be applicable to these patient populations.
CHALLENGES TO IMPLEMENTATION
Clinicians will need to address individual needs
Physicians have to balance various antihypertensive management strategies, as competing medical specialty society guidelines recommend differing targets for optimal blood pressure control. Given the concern for medicolegal liability and potential harms of therapeutic inertia, inpatient physicians must consider whether hospitalization is the best time to alter medications for long-term outpatient blood pressure control. Finally, the decision to leave blood pressure management to outpatient physicians assumes the patient has a continuity relationship with a primary care medical home.
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
1. Anderson TS, Jing B, Auerbach A, et al. Clinical outcomes after intensifying antihypertensive medication regimens among older adults at hospital discharge. JAMA Intern Med. 2019;179:1528-1536.
2. Harris CM, Sridharan A, Landis R, et al. What happens to the medication regimens of older adults during and after an acute hospitalization? J Patient Saf. 2013;9:150-153.
3. Aung WM, Menon SV, Materson BJ. Management of hypertension in hospitalized patients. Hosp Pract (1995). 2015;43:101-106.
4. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003;51:451-458.
5. Omer HMRB, Hodson J, Pontefract SK, et al. Inpatient falls in older adults: a cohort study of antihypertensive prescribing pre- and post-fall. BMC Geriatr. 2018;18:58.
6. Alhawassi TM, Krass I, Pont LG. Antihypertensive-related adverse drug reactions among older hospitalized adults. Int J Clin Pharm. 2018;40:428-435.
7. Passarelli MCG, Jacob-Filho W, Figueras A. Adverse drug reactions in an elderly hospitalised population: inappropriate prescription is a leading cause. Drugs Aging. 2005;22:767-777.
8. Beckett NS, Peters R, Fletcher AE, et al; HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887-1898.
9. SPRINT Research Group; Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103-2116. Published correction appears in N Engl J Med. 2017;377:2506.
ILLUSTRATIVE CASE
A 67-year-old man with hypertension that is well controlled on hydrochlorothiazide 25 mg po daily was admitted to the family medicine inpatient service for community-acquired pneumonia requiring antibiotic therapy and oxygen support. Despite improvement in his overall condition, his blood pressure was consistently > 160/90 mm Hg during his hospitalization. He was treated with lisinopril 10 mg po daily in addition to his home medications, which helped achieve recommended blood pressure goals.
Prior to discharge, his blood pressure was noted to be 108/62 mm Hg. He asks if it is necessary to continue this new blood pressure medicine, as his home blood pressure readings had been within the goal set by his primary care physician. Should you continue this new antihypertensive agent at discharge?
Outpatient antihypertensive medication regimens are commonly intensified at hospital discharge in response to transient short-term elevations in blood pressure during inpatient encounters for noncardiac conditions.1,2 This is typically a reflexive response during a hospitalization, despite the unknown long-term, patient-oriented clinical outcomes. These short-term, in-hospital blood pressure elevations may be due to numerous temporary causes, such as stress/anxiety, a pain response, agitation, a medication adverse effect, or volume overload.3
The transition from inpatient to outpatient care is a high-risk period, especially for older adults, as functional status is generally worse at hospital discharge than prehospitalization baseline.4 To compound this problem, adverse drug reactions are a common cause of hospitalization for older adults. Changing blood pressure medications in response to acute physiologic changes during illness may contribute to patient harm. Although observational studies of adverse drug reactions related to blood pressure medications are numerous, researchers have only evaluated adverse drug reactions pertaining to hospital admissions.5-8 This study sought to evaluate the clinical outcomes associated with intensification of antihypertensive regimens at discharge among older adults.
STUDY SUMMARY
Increased risk of readmission, adverse events after intensification at discharge
This retrospective cohort study, which was conducted across multiple
Antihypertensive medication changes at discharge were evaluated using information pulled from VHA pharmacies, combined with clinical data merged from VHA and Medicare claims. Intensification was defined as either adding a new blood pressure medication or a dose increase of more than 20% on a previously prescribed antihypertensive medication. Patients were excluded if they were discharged with a secondary diagnosis that required modifications to a blood pressure medication (such as atrial fibrillation, acute coronary syndrome, or stroke), were hospitalized in the previous 30 days, were admitted from a skilled nursing facility, or received more than 20% of their care (including filling prescriptions) outside the VHA system.
Primary outcomes included hospital readmission or SAEs (falls, syncope, hypotension, serious electrolyte abnormalities, or acute kidney injury) within 30 days or having a cardiovascular event within 1 year of hospital discharge. Secondary outcomes included the change in systolic blood pressure (SBP) within 1 year after discharge. Propensity score matching was used as a balancing factor to create a matched-pairs cohort to compare those receiving blood pressure medication intensification at hospital discharge with those who did not.
Continue to: Intensification of the blood pressure...
Intensification of the blood pressure regimen at hospital discharge was associated with an increased risk in 30-day hospital readmission (hazard ratio [HR] = 1.23; 95% CI, 1.07–1.42; number needed to harm [NNH] = 27) and SAEs (HR = 1.41; 95% CI, 1.06–1.88; NNH = 63). There was no associated reduction in cardiovascular events (HR = 1.18; 95% CI, 0.99–1.40) or change in mean SBP within 1 year after hospital discharge in those who received intensification vs those who did not (mean BP, 134.7 vs 134.4 mm Hg; difference-in-differences estimate = 0.2 mm Hg; 95% CI, −2.0 to 2.4 mm Hg).
WHAT’S NEW
First study on outcomes related to HTN med changes at hospital discharge
This well-designed, retrospective cohort study provides important clinical data to help guide inpatient blood pressure management decisions for patients with noncardiac conditions. No clinical trials up to that time had assessed patient-oriented outcomes when antihypertensive medication regimens were intensified at hospital discharge.
CAVEATS
Study population: Primarily older men with noncardiac conditions
Selected populations benefit from intensive blood pressure control based on specific risk factors and medical conditions. In patients at high risk for cardiovascular disease, without a history of stroke or diabetes, intensive blood pressure control (SBP < 120 mm Hg) improves cardiovascular outcomes and overall survival compared with standard therapy (SBP < 140 mm Hg).9 This retrospective cohort study involved mainly elderly male patients with noncardiac conditions. The study also excluded patients with a secondary diagnosis requiring modifications to an antihypertensive regimen, such as atrial fibrillation, acute coronary syndrome, or cerebrovascular accident. Thus, the findings may not be applicable to these patient populations.
CHALLENGES TO IMPLEMENTATION
Clinicians will need to address individual needs
Physicians have to balance various antihypertensive management strategies, as competing medical specialty society guidelines recommend differing targets for optimal blood pressure control. Given the concern for medicolegal liability and potential harms of therapeutic inertia, inpatient physicians must consider whether hospitalization is the best time to alter medications for long-term outpatient blood pressure control. Finally, the decision to leave blood pressure management to outpatient physicians assumes the patient has a continuity relationship with a primary care medical home.
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
ILLUSTRATIVE CASE
A 67-year-old man with hypertension that is well controlled on hydrochlorothiazide 25 mg po daily was admitted to the family medicine inpatient service for community-acquired pneumonia requiring antibiotic therapy and oxygen support. Despite improvement in his overall condition, his blood pressure was consistently > 160/90 mm Hg during his hospitalization. He was treated with lisinopril 10 mg po daily in addition to his home medications, which helped achieve recommended blood pressure goals.
Prior to discharge, his blood pressure was noted to be 108/62 mm Hg. He asks if it is necessary to continue this new blood pressure medicine, as his home blood pressure readings had been within the goal set by his primary care physician. Should you continue this new antihypertensive agent at discharge?
Outpatient antihypertensive medication regimens are commonly intensified at hospital discharge in response to transient short-term elevations in blood pressure during inpatient encounters for noncardiac conditions.1,2 This is typically a reflexive response during a hospitalization, despite the unknown long-term, patient-oriented clinical outcomes. These short-term, in-hospital blood pressure elevations may be due to numerous temporary causes, such as stress/anxiety, a pain response, agitation, a medication adverse effect, or volume overload.3
The transition from inpatient to outpatient care is a high-risk period, especially for older adults, as functional status is generally worse at hospital discharge than prehospitalization baseline.4 To compound this problem, adverse drug reactions are a common cause of hospitalization for older adults. Changing blood pressure medications in response to acute physiologic changes during illness may contribute to patient harm. Although observational studies of adverse drug reactions related to blood pressure medications are numerous, researchers have only evaluated adverse drug reactions pertaining to hospital admissions.5-8 This study sought to evaluate the clinical outcomes associated with intensification of antihypertensive regimens at discharge among older adults.
STUDY SUMMARY
Increased risk of readmission, adverse events after intensification at discharge
This retrospective cohort study, which was conducted across multiple
Antihypertensive medication changes at discharge were evaluated using information pulled from VHA pharmacies, combined with clinical data merged from VHA and Medicare claims. Intensification was defined as either adding a new blood pressure medication or a dose increase of more than 20% on a previously prescribed antihypertensive medication. Patients were excluded if they were discharged with a secondary diagnosis that required modifications to a blood pressure medication (such as atrial fibrillation, acute coronary syndrome, or stroke), were hospitalized in the previous 30 days, were admitted from a skilled nursing facility, or received more than 20% of their care (including filling prescriptions) outside the VHA system.
Primary outcomes included hospital readmission or SAEs (falls, syncope, hypotension, serious electrolyte abnormalities, or acute kidney injury) within 30 days or having a cardiovascular event within 1 year of hospital discharge. Secondary outcomes included the change in systolic blood pressure (SBP) within 1 year after discharge. Propensity score matching was used as a balancing factor to create a matched-pairs cohort to compare those receiving blood pressure medication intensification at hospital discharge with those who did not.
Continue to: Intensification of the blood pressure...
Intensification of the blood pressure regimen at hospital discharge was associated with an increased risk in 30-day hospital readmission (hazard ratio [HR] = 1.23; 95% CI, 1.07–1.42; number needed to harm [NNH] = 27) and SAEs (HR = 1.41; 95% CI, 1.06–1.88; NNH = 63). There was no associated reduction in cardiovascular events (HR = 1.18; 95% CI, 0.99–1.40) or change in mean SBP within 1 year after hospital discharge in those who received intensification vs those who did not (mean BP, 134.7 vs 134.4 mm Hg; difference-in-differences estimate = 0.2 mm Hg; 95% CI, −2.0 to 2.4 mm Hg).
WHAT’S NEW
First study on outcomes related to HTN med changes at hospital discharge
This well-designed, retrospective cohort study provides important clinical data to help guide inpatient blood pressure management decisions for patients with noncardiac conditions. No clinical trials up to that time had assessed patient-oriented outcomes when antihypertensive medication regimens were intensified at hospital discharge.
CAVEATS
Study population: Primarily older men with noncardiac conditions
Selected populations benefit from intensive blood pressure control based on specific risk factors and medical conditions. In patients at high risk for cardiovascular disease, without a history of stroke or diabetes, intensive blood pressure control (SBP < 120 mm Hg) improves cardiovascular outcomes and overall survival compared with standard therapy (SBP < 140 mm Hg).9 This retrospective cohort study involved mainly elderly male patients with noncardiac conditions. The study also excluded patients with a secondary diagnosis requiring modifications to an antihypertensive regimen, such as atrial fibrillation, acute coronary syndrome, or cerebrovascular accident. Thus, the findings may not be applicable to these patient populations.
CHALLENGES TO IMPLEMENTATION
Clinicians will need to address individual needs
Physicians have to balance various antihypertensive management strategies, as competing medical specialty society guidelines recommend differing targets for optimal blood pressure control. Given the concern for medicolegal liability and potential harms of therapeutic inertia, inpatient physicians must consider whether hospitalization is the best time to alter medications for long-term outpatient blood pressure control. Finally, the decision to leave blood pressure management to outpatient physicians assumes the patient has a continuity relationship with a primary care medical home.
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
1. Anderson TS, Jing B, Auerbach A, et al. Clinical outcomes after intensifying antihypertensive medication regimens among older adults at hospital discharge. JAMA Intern Med. 2019;179:1528-1536.
2. Harris CM, Sridharan A, Landis R, et al. What happens to the medication regimens of older adults during and after an acute hospitalization? J Patient Saf. 2013;9:150-153.
3. Aung WM, Menon SV, Materson BJ. Management of hypertension in hospitalized patients. Hosp Pract (1995). 2015;43:101-106.
4. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003;51:451-458.
5. Omer HMRB, Hodson J, Pontefract SK, et al. Inpatient falls in older adults: a cohort study of antihypertensive prescribing pre- and post-fall. BMC Geriatr. 2018;18:58.
6. Alhawassi TM, Krass I, Pont LG. Antihypertensive-related adverse drug reactions among older hospitalized adults. Int J Clin Pharm. 2018;40:428-435.
7. Passarelli MCG, Jacob-Filho W, Figueras A. Adverse drug reactions in an elderly hospitalised population: inappropriate prescription is a leading cause. Drugs Aging. 2005;22:767-777.
8. Beckett NS, Peters R, Fletcher AE, et al; HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887-1898.
9. SPRINT Research Group; Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103-2116. Published correction appears in N Engl J Med. 2017;377:2506.
1. Anderson TS, Jing B, Auerbach A, et al. Clinical outcomes after intensifying antihypertensive medication regimens among older adults at hospital discharge. JAMA Intern Med. 2019;179:1528-1536.
2. Harris CM, Sridharan A, Landis R, et al. What happens to the medication regimens of older adults during and after an acute hospitalization? J Patient Saf. 2013;9:150-153.
3. Aung WM, Menon SV, Materson BJ. Management of hypertension in hospitalized patients. Hosp Pract (1995). 2015;43:101-106.
4. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003;51:451-458.
5. Omer HMRB, Hodson J, Pontefract SK, et al. Inpatient falls in older adults: a cohort study of antihypertensive prescribing pre- and post-fall. BMC Geriatr. 2018;18:58.
6. Alhawassi TM, Krass I, Pont LG. Antihypertensive-related adverse drug reactions among older hospitalized adults. Int J Clin Pharm. 2018;40:428-435.
7. Passarelli MCG, Jacob-Filho W, Figueras A. Adverse drug reactions in an elderly hospitalised population: inappropriate prescription is a leading cause. Drugs Aging. 2005;22:767-777.
8. Beckett NS, Peters R, Fletcher AE, et al; HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887-1898.
9. SPRINT Research Group; Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103-2116. Published correction appears in N Engl J Med. 2017;377:2506.
PRACTICE CHANGER
Avoid intensifying antihypertensive medication regimens at hospital discharge in older adults; making such changes increases the risk of serious adverse events (SAEs) and hospital readmission within 30 days without reducing the risk of serious cardiovascular events at 1 year post discharge.
STRENGTH OF RECOMMENDATION
B: Based on a large retrospective cohort study evaluating patient-oriented outcomes.1
Anderson TS, Jing B, Auerbach A, et al. Clinical outcomes after intensifying antihypertensive medication regimens among older adults at hospital discharge. JAMA Intern Med. 2019;179:1528-1536.
