Impacts of Antipsychotic Medication Prescribing Practices in Critically Ill Adult Patients on Health Resource Utilization and New Psychoactive Medication Prescriptions
Natalia Jaworska, Andrea Soo, Henry T. Stelfox, Lisa D. Burry, Kirsten M. Fiest
Antipsychotic medications are commonly prescribed to critically ill adult patients and initiation of new antipsychotic prescriptions in the intensive care unit (ICU) increases the proportion of patients discharged home on antipsychotics. Critically ill adult patients are also frequently exposed to multiple psychoactive medications during ICU admission and hospitalization including benzodiazepines and opioid medications which may increase the risk of psychoactive polypharmacy following hospital discharge. The associated impact on health resource utilization and risk of new benzodiazepine and opioid prescriptions is unknown.
Antipsychotic medication prescribing frequently occurs among critically ill patients to manage symptoms related to delirium, anxiety, or insomnia . Several large randomized control studies have shown antipsychotic medication use in critically ill adult patients does not reduce incidence and duration of delirium, leading current guidelines to recommend against the routine use of antipsychotic medication for the prevention or treatment of delirium [2–6]. Antipsychotics are also commonly continued at hospital discharge. Previous observational studies estimate 21 to 24% of antipsychotic naïve critically ill patients who receive an antipsychotic in the intensive care unit (ICU) are discharged from hospital with an ongoing antipsychotic prescription [7,8]. Patients with critical illness are exposed to a number of psychoactive medications in addition to antipsychotics during their ICU admission and may be at risk of psychoactive polypharmacy (i.e., simultaneous use of at least two classes of psychoactive medications) following hospital discharge [9–11]. Benzodiazepine and opioid use in critical illness may contribute to negative clinical outcomes following critical illness including delirium, post-traumatic stress disorder, depression, anxiety, and cognitive dysfunction [12–14].
Materials and method
This multi-center, propensity-score matched retrospective cohort study is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement  (S1 File). Adult patients at least 18 years of age admitted to one of four medical-surgical ICUs with electronic medical records in Calgary, Alberta, Canada (catchment population 1.5 million) from January 1, 2014 to June 30, 2016 were included in the study cohort. Patients were excluded if they had an antipsychotic medication prescription three months prior to hospital admission, length of ICU admission of <24 hours, ICU admission diagnosis of overdose, or if they died in the ICU or in hospital following ICU admission. Patients were further excluded if patient data did not link to a Discharge Abstract Database (DAD) admission or if they were non-Alberta residents. If patients had more than one admission to the ICU during the study period, only the first admission with a length of stay >24 hours was included. The primary study cohort was comprised of patients who survived to hospital discharge with follow-up on antipsychotic medication prescriptions up to 1-year following hospital discharge.
There were 6,050 eligible patients admitted to one of four medical-surgical ICUs with at least one ICU admission between January 1, 2014 and June 30, 2016. After exclusion of ineligible patients, the overall study cohort for analysis consisted of 3,506 patients who survived to hospital discharge. (Fig 1) Due to missing admission reason for one patient who received antipsychotic medications and eight patients who did not receive antipsychotic medications from the overall cohort, propensity-scores were calculated for 988 patients who received antipsychotic medications in the ICU (99.9%) and 2,509 patients who did not receive antipsychotic medications in the ICU (99.7%). Of those patients with complete data, 294 patients who received antipsychotic medications in ICU and 1,815 patients who did not receive antipsychotic medications in ICU could not be matched with outcome data within the specified caliper width equal to 0.05.
In this multi-center propensity-matched retrospective study, we identified that one in five antipsychotic naïve ICU patients who received an antipsychotic medication in ICU were subsequently prescribed an antipsychotic medication at hospital discharge. Being prescribed an antipsychotic medication during hospitalization was associated with both an increased odds of being co-prescribed a benzodiazepine and opioid medication during hospitalization and in the 1-year following a patient’s hospital discharge.
Among ICU patients surviving to hospital discharge who continue new antipsychotic medication prescriptions at hospital discharge, there was an association with new additional prescriptions of benzodiazepines and opioids in-hospital and up to 1-year following hospital discharge. There was no association between health resource utilization or 30-day mortality following hospital discharge and ongoing antipsychotic medication use at hospital discharge in this patient cohort. This ICU patient population may benefit from additional medication reconciliation prior to or following hospital discharge.
Citation: Jaworska N, Soo A, Stelfox HT, Burry LD, Fiest KM (2023) Impacts of antipsychotic medication prescribing practices in critically ill adult patients on health resource utilization and new psychoactive medication prescriptions. PLoS ONE 18(6): e0287929. https://doi.org/10.1371/journal.pone.0287929
Editor: Ashish Sarangi, University of Missouri Columbia, UNITED STATES
Received: March 17, 2023; Accepted: June 15, 2023; Published: June 29, 2023
Copyright: © 2023 Jaworska et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data may only be available upon reasonable request. The custodian of the data, Alberta Health Services, limits sharing of data to ensure patient confidentiality. Alberta Health Services can be contacted at firstname.lastname@example.org to make a data request directly from the custodian to replicate the data used in the study.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.