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Outpatient regimens

May 2014

Published in the May 2014 issue of Today’s Hospitalist

Regarding “Hands off outpatient regimens!” (November 2013), I disagree with the recommendation by Michael Steinman, MD, that hospitalists should avoid changing outpatient regimens unless those regimens directly affect the reason why a patient was hospitalized.

I frequently admit patients suffering from polypharmacy, older adults addicted to benzodiazepines, and many others with active medical problems that may be symptomatic or suboptimally managed but are not related to their admission. While earlier in my career, I would not change outpatient regimens, I realized I was doing a disservice to patients by not doing what was best medically.

Without knowing more about the case Dr. Steinman presented “what were the inpatient blood pressure values and was the patient symptomatic “it is difficult to say whether the hospitalist appropriately altered the patient’s antihypertensives. Treating numbers is frequently a mistake, and when changing chronic regimens, it is better to use longer-term markers such as outpatient symptoms and hemoglobin A1C, for example, than inpatient blood pressure or glucose values.

We have good evidence that hypertension is undertreated in the outpatient setting. The problems Dr. Steinman encountered are more likely due to hospitalists’ inexperience. Hospitalists should make changes to medication regimens, but only if they are keeping the patient’s big picture in mind.
Donald Misquitta, MD, MMSc

Dr. Steinman responds:
Dr. Misquitta makes some important points, perhaps none more central than his statement about keeping “the patient’s big picture in mind.”

When changing medications is likely to help a patient’s big-picture health status, it is appropriate. Pruning medications that are clearly unnecessary or harmful can be particularly useful. The caution is that in the short-term inpatient setting, it is difficult to know patients’ longstanding histories of medication adherence and their experience with and attitude toward medical interventions. For these reasons, medication changes that seem perfectly sensible may not produce the long-term benefits we seek.

Instead, we can often do the most good by communicating our thoughts and concerns to our patients and their outpatient clinicians so they may work together to implement those recommendations over the long term.
Michael Steinman, MD
San Francisco

Discharging delirium patients
Regarding “Discharging delirium patients on too many medications?” (February 2014): Because so many patients are discharged on multiple medications, it is critical that we understand patients’ capabilities. If individuals are not able to do the complex processing needed to take charge of their own care, we must identify someone who can.

I think that most of the evaluations we do in the hospital don’t adequately address the question of patients’ cognitive ability and that nationally, we don’t take enough time to truly evaluate patients’ capacity. That evaluation is the key to preventing readmissions and to finding out if patients can actively participate in their medical homes.
Napoleon Knight, MD
Urbana, Ill.