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Bo R. Weber et al
Table 4. Unadjusted and Adjusted Odds Ratios (ORs) and 95% Confidence Intervals (CIs) for the Association Between Receiving an Antibiotic Prescription Upon Discharge to a Long-Term Care Facility and 30-Day Hospital Readmission, 30-day Emergency Department (ED) Visits, or Clostridium difficile-Associated Readmission or ED visit at the Index Facility Within 60 Days of Discharge (n=6,701)a
Hospital Readmission Within 30 Days of Discharge
Variable
Age (Ref >85 y) <65 y
65–75 y 76–85 y
Male Single Length of stay>7 d
Charlson comorbidity index>7 Surgical MS-DRG Diabetes
Liver disease Renal disease Cancer
Heart failure Pulmonary disease Cerebrovascular disease
Unadjusted OR (95% CI)
ED Visit Within 30 Days of Discharge
Adjusted OR (95% CI) Unadjusted OR (95% CI)
Received antibiotics upon discharge 1.2 (1.02–1.4) 1.01 (0.9–1.2)
2.1 (1.6–2.7) 1.9 (1.5–2.5) 1.4 (1.6–2.7) 1.2 (1.04–1.2) 0.9 (0.8–1.1) 1.8 (1.6–2.1) 1.8 (1.4–2.1)
1.8 (1.4–2.4) 1.6 (1.2–2.2) 1.3 (0.9–1.7)
1.3 (1.1–1.6) 1.6 (1.4–1.9)
0.9 (0.8–1.02) 0.8 (0.7–0.96) 1.5 (1.3–1.7) 2.1 (1.7–2.7) 1.3 (1.1–1.5) 1.7 (1.5–2.0) 1.3 (1.1–1.5) 1.1 (0.96–1.3) 0.95 (0.8–1.1)
1.3 (1.1–1.5) 1.7 (1.4–2.2) 1.2 (1.04–2.2) 1.7 (1.5–2.0)
2.2 (1.6–3.0) 1.4 (0.97–1.9) 1.3 (0.9–1.8) 1.1 (0.9–1.3) 1.2 (1.02–1.4) 1.6 (1.3–1.9) 1.2 (0.96–1.6) 1.2 (0.99–1.4) 1.2 (1.0–1.4) 1.4 (1.1–2.0) 0.9 (0.8–1.2) 1.1 (0.9–1.3) 0.96 (0.8–1.2) 1.2 (1.01–1.4) 0.9 (0.8–1.1)
C. difficile-Associated Readmission or ED Visit Within 60 Days of Discharge
Adjusted OR (95% CI) Unadjusted OR (95% CI)
1.2 (1.02–1.5)
1.9 (1.4–2.7) 1.3 (0.90–1.8) 1.2 (0.8–1.7)
2.2 (1.2–3.3) 1.4 (1.2–1.7)
2.4 (0.8–6.8) 2.1 (0.7–6.1) 1.7 (0.5–5.2) 0.9 (0.5–1.4) 1.2 (0.7–2.0) 3.0 (1.7–5.1) 1.5 (0.7–2.9) 0.7 (0.4–1.1) 1.7 (1.03–2.7) 3.0 (1.6–5.8) 1.8 (1.1–3.0) 1.5 (0.9–2.5) 1.8 (1.1–2.9) 0.9 (0.5–1.5) 1.01 (0.6–1.7)
Note. OR, odds ratio; CI, confidence interval; MS-DRG, Medicare severity diagnosis-related group. aPotential confounders included in the model for each outcome are indicated by a point estimate in the column providing the adjusted odds ratio.
improve prescribing practices.24 Furthermore, a recent systematic review concluded that medication reconciliation upon discharge is unlikely to reduce postdischarge healthcare utilization in the absence of other transitions of care intervention components.25 We did not observe a significant association between receiving
an antibiotic prescription upon discharge and 30-day hospital readmissions, which would have provided a financial incentive for acute-care hospitals to improve antibiotic prescribing in this patient population. However, our incidence of 30-day read- missions (14.3%) was limited to the index facility and was markedly lower than has been reported nationally among Medi- care beneficiaries.26 Furthermore, despite the lack of an associa- tion with 30-day readmissions, we did observe a significant association between receiving an antibiotic prescription upon discharge to an LTCF and 30-day ED visits and CDI within 6 months. These outcomes are burdensome to residents, their family members, and healthcare providers in both hospitals and nursing homes and should provide sufficient rationale to improve prescribing practices upon discharge. Finally, our finding that the most frequent indication for antibiotic prescribing upon dis- charge was UTI is concerning considering an increasingly robust body of research suggesting that UTI diagnoses frequently lead to overtreatment with antibiotics, particularly among older adults.27 This study had several limitations. Our retrospective design utilizing a large cohort of existing clinical data limited our ability
to precisely determine indications for antibiotic prescribing and the appropriateness of antibiotic prescribing upon discharge. However, our observation that UTIs were the most prevalent potential antibiotic indication was consistent with the high pre- valence of fluoroquinolones prescribed upon discharge. The proportion of antibiotics prescribed upon discharge that were continued following admission to the LTCF is unknown. A pre- vious study reported that half of antibiotics prescribed in 7 LTCFs in Georgia were initiated in the hospital; however, those results require confirmation from both the hospital and LTCF perspec- tive. We were only able to identify ED visits and readmissions to the index discharging facility; which may have underestimated the true frequency of these events.28 In addition, associations between receiving an antibiotic prescription upon discharge and read- missions and ED visits may have been affected by confounding by indication. That is, the reason for the readmission or ED visit may have been related to the indication for antibiotics rather than the antibiotics themselves. Lastly, our data may not be generalizable to other settings because this was a single-center study. Despite these limitations, this study provides novel data on the
frequency and characteristics of antibiotics prescribed upon dis- charge to LTCFs. Future work should address the frequency of inappropriate antibiotic prescribing in this patient population, associations with outcomes beyond the index facility, and out- comes within the LTCF posttransition.
Adjusted OR (95% CI)
1.7 (1.02–2.8)
2.7 (1.6–4.7)
2.5 (1.3–4.8)
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