Medications that reduce emergency hospital admissions: an overview of systematic reviews and prioritisation of treatments

Bobrovitz, Niklas; Heneghan, Carl; Onakpoya, Igho; Fletcher, Benjamin; Collins, Dylan; Tompson, Alice; Lee, Joseph; Nunan, David; Fisher, Rebecca; Scott, Brittney; O’Sullivan, Jack; Van Hecke, Oliver; Nicholson, Brian D.; Stevens, Sarah; Roberts, Nia; Mahtani, Kamal R.

doi:10.1186/s12916-018-1104-9

Table 2 Evidence- and guideline-based medications that reduce emergency hospital admissions

From: Medications that reduce emergency hospital admissions: an overview of systematic reviews and prioritisation of treatments

Author, Year^{ID No.}	Patient population	Medication treatment	Control	Patients (RCTs)	Mean age^a	Outcome and mean follow-up^b	NNT (95% CI) RR (95% CI)	I²%	Quality of evidence^c	Clinical guideline support
Author, Year^{ID No.}	Patient population	Medication treatment	Control	Patients (RCTs)	Mean age^a	Outcome and mean follow-up^b	NNT (95% CI) RR (95% CI)	I²%	Quality of evidence^c	America	UK	Europe
Reduces hospital admissions from out-patient, day-procedure or community settings
Xie, 2016^8916a	Heart failure with reduced left ejection fraction or left ventricular dysfunction	ACE inhibitors	Placebo	12,763 (5)	62 ± 4	HF hospitalisation at 32 months	NNT: 19 (16 to 25) RR: 0.71 (0.66 to 0.78)	0	Moderate	AHA, ACC	NICE	ESC
Xie, 2016^8916b		Angiotensin-II receptor blockers	Placebo	9878 (4)	65 ± 2	HF hospitalisation at 26 months	NNT: 19 (14 to 30) RR: 0.77 (0.70 to 0.86)	30	Moderate	AHA, ACC	NICE	ESC
Xie, 2016^8916c		Aldosterone antagonists	Placebo	11,477 (4)	65 ± 3	HF hospitalisation at 18 months	NNT: 22 (15 to 55) RR: 0.71 (0.57 to 0.88	74	Moderate	AHA, ACC	NICE	ESC
Hood, 2014³⁴¹⁵		Digoxin^d	Placebo	7262 (4)	61 ± 3	Hospitalisation at 12 months	NNT: 28 (23 to 37) RR: 0.71 (0.64 to 0.77)	29	High	AHA, ACC	NICE	ESC
Le, 2016^8817a	Heart failure with prior MI	Aldosterone antagonists	Placebo	15,786 (13)	63 ± 6	Hospitalisation at 15 months	NNT: 67 (39 to 233) RR: 0.93 (0.88 to 0.98)	35	Moderate	AHA, ACC	NICE
Afilalo, 2007^100c	Stable coronary artery disease	Intensive statin therapy	Moderate statin therapy	27,547 (4)	61 ± 2	HF hospitalisation at 41 months	NNT: 115 (84 to 189) RR: 0.73 (0.63 to 0.83)	4	Moderate	AHA, ACC	NICE	ESC; EAS
Kew, 2013^4002h	Stable COPD	Long-acting beta 2 agonists	Placebo	3804 (7)	62 ± 2	COPD hospitalisation at 9 months	NNT: 77 (47 to 420) RR: 0.74 (0.57 to 0.95)	35	Moderate	ATS^e	NICE	ESR^e
Ni, 2014^8850a	Stable COPD	Long-acting muscarinic antagonists^f	Placebo	5624 (10)	64 ± 3	COPD hospitalisation at 9 months	NNT: 106 (70 to 321) RR: 0.65 (0.47 to 0.88)	0	High	ATS	NICE	ESR
Reduces hospital admissions from the emergency department
Edmonds, 2012²¹⁵⁹	Acute asthma exacerbation	Early use of inhaled corticosteroids	Placebo	377 (5)	38 ± 8	Hospitalisation, Follow-up unclear	NNT: 7 (5 to 12) RR: 0.42 (0.25 to 0.67)	0	Moderate	ATS	NICE
Rodrigo, 2005^6568a	Acute asthma exacerbation	Anticholinergics	Beta 2 agonists	1556 (9)	18 to 55	Hospitalisation at ED discharge	NNT: 12 (8 to 26) RR: 0.68 (0.53 to 0.86)	14	Moderate	ATS	NICE
Reduces readmissions after an index hospital admission
Leucht, 2012^4508a	Schizophrenia	Antipsychotic maintenance therapy	No maintenance or placebo	2090 (16)	38 ± 9	Rehospitalisation at 11 months	NNT: 5 (4 to 7) RR: 0.38 (0.27 to 0.55)	45	High	APA	NICE	EPA^g
Kishimoto, 2013^4065a	Schizophrenia	Second-generation antipsychotics	First-generation antipsychotics	2869 (12)	33 ± 6	Hospitalisation at 13 months	NNT: 17 (12 to 48) RR: 0.72 (0.58 to 0.90)	18	Moderate	APA	NICE	EPA^g

ID No. identification number, RCT randomised controlled trial, NNT number needed to treat to avoid one emergency hospital admission, RR risk ratio, CI confidence interval, ED emergency department, ACE angiotensin-converting enzyme, HF heart failure, COPD chronic obstructive pulmonary disease, MI myocardial infarction, NICE National Institute for Health and Care Excellence, ESC European Society of Cardiology, AHA American Heart Association, ACC American College of Cardiology, EAS European Atherosclerosis Society, ATS American Thoracic Society, ESR European Respiratory Society, APA American Psychiatric Association, EPA European Psychiatric Association
^aMeans and standard deviations for patient ages in years. Mean of means and median ages in trials contributing to the pooled estimate. Not all included trials reported age in a form that could be averaged
^bMean length of follow-up across trials, unless otherwise specified. Mean of means, medians and total study durations reported in trials contributing to the pooled estimate. Not all included trials reported follow-up in a form that could be averaged. Rounded to the nearest whole month
^cModerate- or high-quality evidence according to the Grading of Recommendations Assessment, Development and Evaluation working group criteria
^dFor patients with normal sinus rhythm
^eThe ESR/ATS suggested in their joint 2012 guideline that long-acting beta 2 agonists are a clinically acceptable treatment for stable COPD. However, in their 2017 guideline on preventing exacerbations, they recommended monotherapy with long-acting muscarinic antagonists in preference to long-acting beta 2 agonists if the treatment goal is to prevent a future exacerbation. They indicated that this recommendation places less emphasis on symptomatic relief and that the differential effect on mortality or adverse events is unknown
^fAclidinium bromide. Four other meta-analyses with moderate-quality evidence examined other long-acting muscarinic antagonists (e.g. tiotropium) and reported similar effects
^gThe European Psychiatric Association has not published a clinical guideline for schizophrenia but has published a review of national guidelines across Europe and found significant agreement with respect to use of antipsychotic maintenance therapy and of second-generation antipsychotics

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