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Use of Nonpalliative Medications Following Burdensome Health Care Transitions in Hospice Patients

A Matched Cohort Analysis

Zueger, Patrick M., PharmD, PhD*; Holmes, Holly M., MD, MS; Qato, Dima M., PharmD, MPH, PhD*,‡; Pickard, A. Simon, PhD*,‡; Calip, Gregory S., PharmD, MPH, PhD*,‡,§; Lee, Todd A., PharmD, PhD*,‡

doi: 10.1097/MLR.0000000000001008
Original Articles

Background: Limited benefit medications (LBMs), those medications with questionable benefit at the end of life, are often recommended for discontinuation in hospice patients. Transitions in care are associated with inappropriate prescribing in older and terminally ill populations.

Objectives: To evaluate the association between burdensome health care transitions and subsequent receipt of LBMs in older hospice patients.

Methods: We conducted a matched cohort analysis of patients admitted to hospice between 2008 and 2013 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. The prevalence of post–health care transition LBM use was assessed. Adjusted incidence rate ratios (IRRs) were estimated for the association between transitions and subsequent receipt of LBMs.

Results: In total, 17.9% of 7064 hospice patients received at least 1 LBM following their first burdensome health care transition. Posttransition continuation of a medication class used before hospice admission was most common for antidementia medications (14.2%) and antihypertensives (11.2%). Transitions were associated with a 33% increase in the risk of receiving at least 1 LBM [IRR, 1.33; 95% confidence interval (CI), 1.25–1.42], increasing to 56% when evaluating only hospitalization transitions (IRR, 1.56; 95% CI, 1.39–1.76). Medication classes more likely to be dispensed after a transition included antihyperlipidemics (IRR, 1.38; 95% CI, 1.13–1.70), antihypertensives (IRR, 1.28; 95% CI, 1.16–1.40), and proton-pump inhibitors (IRR, 1.40; 95% CI, 1.20–1.63).

Conclusions: Burdensome health care transitions were associated with the receipt of nonpalliative medications in older hospice patients. Interventions aimed at improving provider communication and reducing fragmentation in care may help reduce unnecessary medication use in this vulnerable population.

*Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL

Division of Geriatric and Palliative Medicine, UTHealth McGovern Medical School, Houston, TX

Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL

§Division of Public Health Sciences, Epidemiology Program, Fred Hutchinson Cancer Research Center, Seattle, WA

P.M.Z. was supported by a Dean’s Scholar Fellowship and Paul D. Doolen Scholarship for the Study of Aging through the University of Illinois.

This study used the linked SEER-Medicare database. The collection of cancer incidence data used in this study was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885; the National Cancer Institute’s Surveillance, Epidemiology and End Results Program under contract HHSN261201000140C awarded to the Cancer Prevention Institute of California, contract HHSN261201000035C awarded to the University of Southern California, and contract HHSN261201000034C awarded to the Public Health Institute; and the Centers for Disease Control and Prevention’s National Program of Cancer Registries, under agreement #U58DP003862-01 awarded to the California Department of Public Health. The ideas and opinions expressed herein are those of the author(s) and endorsement by the State of California Department of Public Health, the National Cancer Institute, and the Centers for Disease Control and Prevention or their Contractors and Subcontractors is not intended nor should be inferred.

P.M.Z. was a doctoral candidate in the Department of Pharmacy Systems, Outcomes, and Policy at the University of Illinois-Chicago while the study was conducted and is a current employee of AbbVie Inc. The remaining authors declare no conflict of interest.

Reprints: Todd A. Lee, PharmD, PhD, Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, 833 South Wood Street, Room 287, M/C 871, Chicago, IL 60612. E-mail:

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