Cookies on this website
We use cookies to ensure that we give you the best experience on our website. If you click 'Continue' we'll assume that you are happy to receive all cookies and you won't see this message again. Click 'Find out more' for information on how to change your cookie settings.

Emergency hospital admissions are rising and, increasingly, policy-makers, clinicians, and patients are worried about their effect on cancellations of elective procedures, prolonged waiting times, in-hospital infection rates, and costs. However, identifying useful strategies for reducing admissions has proved problematic; interventions designed to reduce hospitalisations often achieve no real-world benefit, yet consume scarce health resources. 

One promising intervention that has received little attention is medications; those which help a patient to avoid hospitalisation represent high-value activity in a patient’s overall care. Medications can reduce admission rates by preventing illnesses or mitigating symptoms and exacerbations that would have otherwise required urgent health care.  

nb

Our new study in BMC Medicine, therefore, aimed to identify and prioritise medications that have been shown in systematic reviews to prevent patients from requiring emergency hospital care.

What did we do?

We searched for systematic reviews of randomised controlled trials in adults that reported hospital admissions as an outcome. We then assessed the quality of evidence using GRADE criteria. We cross referenced effective medications with high or moderate quality evidence with UK, USA, and European clinical guidelines to determine which had an acceptable overall balance of benefit to harm.

What did we find?

We found 140 systematic reviews, including 1,968 randomised controlled trials and 925,364 patients. We identified eleven medications that significantly reduced emergency hospital admissions, were supported by high or moderate quality evidence, and were endorsed in clinical guidelines.

 

Evidence-based, guideline-supported medications that reduce emergency admissions

 

heart 

Heart failure

  • Angiotensin-converting enzyme inhibitors
  • Angiotensin-ll receptor blockers
  • Aldosterone receptor antagonists
  • Digoxin

 

 

Stable coronary artery disease

  • Intensive statin therapy

 

 

 

 

 

 

 lungs

Acute asthma in the emergency department

  • Early inhaled corticosteroids
  • Anticholinergics

 

 

Chronic obstructive pulmonary disease

  • Long-acting muscarinic antagonists
  • Long-acting beta-2 adrenoceptor agonists

 

 

 

 

 

 

 brain

Schizophrenia

  • Second generation antipsychotics
  • Depot/maintenance antipsychotics

What does this mean?

Using the eleven medications that we identified is clinically appropriate and will significantly reduce emergency hospital admissions for patients with heart failure, coronary artery disease, asthma, chronic obstructive pulmonary disease, and schizophrenia.

In some health systems, these medications are already prescribed as part of routine clinical practice. However, there is evidence of significant variation in their use in the UK, USA, and Europe, including under-prescribing and under-dosing. Therefore, policy-makers and clinicians should consider monitoring and improving use of these medications as a strategy to alleviate pressures on secondary acute care.

Existing mechanisms for quality measurement and improvement could be utilised. For example, the UK Quality and Outcomes Framework is a pay for performance incentive program that has reduced prescribing gaps and improved prescribing efficiency. The medications we identified should be considered for inclusion in these types of quality assurance and incentive systems.

Our results may also be used to inform shared decision making. When communicating treatment options with eligible patients, clinicians could discuss the ability of these medications to reduce the risk of being hospitalised. Given that most patients prefer to stay out of hospitals, we hope that our findings will help to inform their decisions.

This blog first appeared in BMC Medicine.

The study, titled “Medications that reduce emergency hospital admissions: an overview of systematic reviews and prioritisation of treatments” can be accessed here: https://rdcu.be/3wFJ

Profile

Niklas Bobrovitz is a PhD candidate in the Nuffield Department of Primary Care Health Sciences at the University of Oxford. He is also an honorary fellow at the Oxford Centre for Evidence-Based Medicine. His research focuses on health care utilisation, quality of care, and improving the translation of evidence into practice. He can be contacted on twitter (@nikbobrovitz) or by email (niklas.bobrovitz@phc.ox.ac.uk). 

Acknowledgments: Niklas Bobrovitz was funded by a Clarendon Scholarship, a Goodger and Schorstein Medical Sciences Research Scholarship, and the National Institute for Health Research School for Primary Care Research