There is a delicate balance between prescribing new medications and identifying and eliminating unnecessary prescriptions to protect the overall care of a patient. As people age, multiple prescriptions are often prescribed to treat patients that have multiple conditions. However, if treatment regimens and medical history are not carefully reviewed by healthcare professionals and payors, a patient may inadvertently take multiple medications that may negatively interact with each other or that all treat the same condition. Eventually, polypharmacy can cause more harm than good!
Elderly Are Most at Risk for Polypharmacy
Polypharmacy is when a patient is prescribed five or more medications. This poses an increased risk to the patient without any intervention. Polypharmacy mainly affects the elderly (ages 65 years and older), since they are likely to have conditions that require prescription therapy.
One analysis reviewed over 35,000 Medicare beneficiaries of Maryland and West Virginia and found nearly half of them to be considered polypharmacy. Based on data from 2015 – 2016 from the Center for Disease Control (CDC), one in five patients used at least five prescription drugs (about 20%) in the past 30 days. The increase in number of medications for a patient has a direct correlation to the risk of an adverse drug event or a drug-drug interaction. Older adults are especially at risk for an adverse drug event due to their decreased metabolism and clearance of drugs as their bodies age. This risk is further exacerbated by the increasing number of drugs used. Additionally, patients may also experience a cascade effect in which a prescribed medication causes an adverse drug event (or side effect) which is often interpreted incorrectly as a new area for treatment, leading to yet additional prescribed medications.
Polypharmacy also has cost implications to both the payor and the patient. Besides the additional and wasteful cost of multiple medications, this population is also at a greater risk for a hospital admission due to an adverse drug event. Hospital admissions and multiple unnecessary drugs drive up costs for both the payor and healthcare system.
Ways to Combat Polypharmacy
There are several ways to combat polypharmacy. The healthcare system, payor and patient all play a major role in avoiding polypharmacy. During medical visits, the healthcare provider can perform a drug history evaluation to understand all of the patient’s medications, both prescription and over the counter. The provider can then make the decision to remove any medications deemed unnecessary. However, many clinicians are hesitant to stop a medication, especially if they were not the initial prescriber and the patient seems to be tolerating it appropriately. Coordination of care between healthcare providers needs to be improved to reduce polypharmacy and the potential risks. The decision to stop a medication is made between the clinician and patient which is based on factors such as indication, appropriateness of dosing/frequency, patient’s age and level of disability, adverse events versus clinical benefit of drug, and concurrent therapy.
The goal of eliminating prescriptions is to ensure a safe and effective use of medications. This method requires medication removal that is closely monitored by healthcare professionals to reduce the risk of adverse events and improve outcomes for the patient. The Beers Criteria developed by the American Geriatrics Society is a useful tool to aid in eliminating prescriptions that may harm the patient. It provides guidance on medications that should be avoided in elderly patients or in certain situations. There is also the STOPP (Screening Tool of Older Person’s Prescription) Criteria that identifies inappropriate medication use. These guidelines are aimed at improving the safety of medications for older adults by avoiding or minimizing exposure to medications with high risk for an adverse drug event. These methods can help reduce polypharmacy and can aid in reducing the risk of falls, improving or preserving cognitive function, and reducing the risk of hospitalization or death. While there is some overlap between the Beers Criteria and STOPP, the STOPP guidelines also account for drug-drug interactions and duplicative therapies within the same class.
There are ways to assess a patient’s medication use outside the medical office. The Centers for Medicare and Medicaid Services have developed drug utilization criteria that targets eight drug classes: digoxin, calcium channel blockers, ACE inhibitors, H2 receptor antagonists, non-steroidal anti-inflammatory drugs, benzodiazepines, antipsychotics, and antidepressants. These classes are also supported in the Beers Criteria, with the exception of the H2 receptor antagonists which were removed from the Beers Criteria in 2019 because there was weak evidence to support avoiding its use in the elderly. Medicare and Medicaid Services also focus on four types of prescribing issues: inappropriate dose, inappropriate duration of therapy, duplicative therapies and drug-drug interactions. This information can be pulled from claims data and assessed at the point of adjudication.
How Can Payors Help?
Payors can use technology to identify patients that are taking five or more medications and that are taking any of the medications listed in the Medicare-Medicaid targeted drug classes and in the Beers Criteria. This will help the payor to perform a drug utilization review of the patient based on claims data. Clinical appropriateness of each medication prescribed can also be factored into the claims review to ensure the patient is receiving the drug in a safe and effective manner.
As you can see, the goal of eliminating prescriptions that are not needed or cause harm to the patient, especially in the elderly population, must be achieved through open collaboration between patients, healthcare providers and payors. Employing drug utilization evaluations either in-person with the patient or on the backend with the payor can assist in achieving this goal. Outside of removing waste and inappropriate costs for both the patients and payors, decreasing the pill burden, removing unnecessary or unsafe medications, and education around deprescribing can aid in the patient’s longevity and quality of life.