New Prescriptions After Hospitalization: A Bitter Pill or Just What the Doctor Ordered?

There is a heightened focus in pediatric medicine on reducing unnecessary medical care, including inappropriate medications.1,2 Concurrently, there is growing research in the area of polypharmacy in the pediatric population and its association with drug-drug interactions, adverse drug reactions, and increased acute care use.3–5 Despite calls for responsible prescribing,6 few studies have been focused on discrete opportunities in the care continuum at which interventions would be most effective to combat polypharmacy and its untoward effects. In “Medications Reconciled at Discharge Versus Admission Among Inpatients at a Children’s Hospital” from this edition of Hospital Pediatrics, Emdin et al7 examined hospital discharge medications as an important area for responsible prescribing and embarked on the critical first step of understanding medications commonly prescribed at discharge to identify medications that have higher potential for discretionary, rather than necessary, use.In this single-center, retrospective study, the study team reviewed 2 years of medication reconciliation records from inpatient encounters to assess the relative change in number of medications from admission to discharge and identified the most frequently added prescription medications (excluding antibiotics). They also identified patient-level factors associated with increased number of medications or addition of specific medications (ie, opioids) at hospital discharge. They found an increase in the number of medications at discharge compared with admission and that the most common subclasses of new discharge medications identified were opioids, proton pump inhibitors (PPIs), bronchodilators, antiemetics, and steroids.Interestingly, the study team found that although patients with complex chronic conditions had more medications at admission, they were less likely to have additional medications added by time of hospital discharge. The authors attributed this to the hospital- affiliated outpatient complex care program, which includes comprehensive care coordination that may have made medication changes less likely to occur during those patients’ hospitalizations. However, because children with complex chronic conditions are at higher risk for complex medication regimens and related medication nonadherence and adverse drug events,8,9 they have been the subject of research and initiatives aimed at optimizing medication lists.10,11 It remains possible that this increased attention on ensuring optimal medication regimens in a complex population that suffers from high rates of polypharmacy may have influenced this study’s findings. There may also be more attention focused on discharge medication practice in this population, such as involvement of a pharmacist or dedicated meetings to complete medication reconciliation,12 and there may simply be fewer opportunities to feasibly add medications for patients already experiencing high degrees of polypharmacy.This study should be examined in the context of several important limitations. It was conducted at a single center, thus organizational culture and norms about discretionary prescribing may be distinct. In addition, Although the authors assert that the increase in medications aimed at symptom management is a harbinger for postdischarge medication overuse and polypharmacy, they were unable to assess appropriateness or intended duration of use of these prescriptions. Many of the commonly identified medications prescribed at discharge, including opioids, can play an important role in supporting symptom management at home until children are back to their baseline level of health. Discharging patients when medically safe to continue their recovery at home is beneficial to limiting hospital length of stay to maximize efficient care and capacity for other children13 and, more importantly, to returning families to their normal lives and ability to go to work and care for other children. Although clear evidence indicating that symptom-focused medications result in earlier discharge is lacking, it is reasonable to conclude that both clinicians and patients and families are more willing to consider expediting discharge if as-needed medications aimed at addressing a patient’s comfort can be safely administered in the home environment. Therefore, cost is a consideration because an extra night in the hospital with family-life disruption and lost wages14 may be less preferable than a limited supply of medications aimed at symptom relief to be taken at home.Although the authors rightly point out the potential for discretionary prescribing, it is important to consider the situations in which new prescribing may reflect a new diagnosis. Among the most commonly added medications identified, corticosteroids and bronchodilators may be indicated when discharging a patient with a new asthma diagnosis. Similarly, patients admitted with symptomatic gastritis may appropriately finish a limited course of PPIs as they recover from their acute illness. Patients admitted for treatment of sickle cell crisis, the most common nonsurgical reason for opioid prescription in the study, may require tailored opioid therapy to treat pain to continue into the outpatient setting after hospitalization.15 However, these medications also pose a risk, as the authors point out, for prescription in situations in which their utility or safety is less clear. For example, PPIs are overprescribed16 in many care settings, and opioid misuse and addiction has been declared a public health emergency in the United States.17 Therefore, these findings should prompt further study to assess how commonly the rationale for or length of prescriptions aligns with current evidence and best practices. Multicenter studies are also required to determine if these prescribing practices reflect trends beyond the single center in which this study occurred.Despite these limitations, in their findings, Emdin et al7 highlight hospital discharge as an opportunity to critically review medication lists and ensure appropriate prescribing practice. In this study, we also highlight the potential for polypharmacy to occur in the general pediatric hospital population, not only in patients with complex chronic conditions. This is an important contribution to the body of knowledge about polypharmacy in children and, if these findings are born out in larger studies, indicates an additional priority for hospitalists aiming to improve the quality and safety of care for admitted pediatric patients.