Abstract and Introduction
Abstract
Study Objectives: To enhance physician and patient awareness of polypharmacy; to decrease the risks, drug costs, and waste resulting from polypharmacy; and to make the business case for reducing misuse, overuse, and underuse of drugs by reducing polypharmacy.
Design: Longitudinal, time series cohort.
Setting: Outpatient, managed care, integrated delivery system.
Patients: A total of 195,971 patients who received health care from the Henry Ford Medical Group and had health insurance coverage from the Health Alliance Plan.
Measurements and Main Results: Two identical interventions separated by 1 year were conducted in patients at high risk of harm from polypharmacy based on five categories of high-risk drug combinations (referred to as polypharmacy events). Six months of pharmacy claims data were reviewed before and after each intervention to identify these patients. The intervention program consisted of clinical pharmacists performing drug therapy reviews, educating physicians and patients about drug safety and polypharmacy, and working with physicians and patients to correct polypharmacy problems. Prescription cost/member/month, number of prescriptions/member/month, and rates of polypharmacy events/1000 members were measured before and after each of the two interventions. After the first intervention, the overall rate of polypharmacy events decreased from 29.01 to 9.43/1000 patients (67.5% reduction). The number of prescriptions/member/month decreased from 4.6 to 2.2 (52.2% reduction), prescription cost/member/month decreased from $222 to $113 (49.1% reduction), and overall institution drug cost was reduced by $4.8 million. Six months after the second intervention, the overall rate of polypharmacy events was reduced from 27.99 to 17.07/1000 (39% reduction), the number of prescriptions/member/month decreased from 4.5 to 4.0 (11.1% reduction), and prescription cost/member/month decreased from $264 to $239 (9.5% reduction). Overall institution drug costs were reduced by $1.3 million. Sustained effects were seen for all measures of polypharmacy (p=0.001).
Conclusions: These interventions reduced drug costs and numbers of prescriptions in a managed care cohort of patients at high risk for adverse drug events due to polypharmacy. By providing clinical information, decision support, patient self-management support, and care delivery redesign some of the problems resulting from polypharmacy can be solved.Introduction
A national survey of noninstitutionalized American adults indicated that more than 40% of persons aged 65 years or older take five or more different drugs/week, with 12% taking 10 or more.[1] Polypharmacy, however, may not only be appropriate but is often necessary to improve health outcomes and prevent disease progression in older persons with chronic conditions. However, overuse, underuse, and misuse of drugs have all been linked to serious health problems, disabilities, hospitalizations, and death.[2-4]
The term polypharmacy suggests that more drugs are prescribed and taken than are warranted clinically. Patients at greatest risk of polypharmacy consequences are the elderly, patients taking five or more concurrent drugs, those with multiple physicians and pharmacies, patients with concurrent comorbidities or impairments in vision or dexterity, and individuals who have recently been hospitalized.[5] According to one study, nearly one in four noninstitutionalized elderly Americans is taking potentially dangerous prescription drugs.[3]
Researchers who evaluated a cohort of older ambulatory persons estimated that as many as 27.6% of adverse drug events are preventable and occur most commonly with cardiovascular drugs, diuretics, nonopioid analgesics, antidiabetic agents, and anticoagulants.[6] Preventable drug-related morbidity is the fifth most costly health condition. In 2000, the United States spent $133 billion on drugs and an estimated $177 billion managing drug-related problems.[7] For every $1.00 spent on drug therapy, as much as $1.30 may be spent managing drug-related problems.[7] These concerns have prompted calls to action by numerous organizations, including the Centers for Medicare and Medical Services, the Institute for Health Care Improvement, the Institute for Health Care Quality, the National Committee for Quality Assurance, the National Quality Forum, and the Institute for Safe Medication Practices. Oversight of pharmaceutical care by clinical pharmacists has proven effective in improving quality and lowering cost of care in various venues.[8-14]
The goal of our longitudinal study was to improve drug safety through the reduction of polypharmacy in managed care patients. In patients receiving polypharmacy, we performed two identical interventions that consisted of clinical pharmacists performing drug therapy reviews, educating physicians and patients about drug safety and polypharmacy, and working with physicians and patients to correct polypharmacy problems. The intervention integrated the practice of pharmaceutical care with data extracted from pharmacy claims. Primary objectives were to enhance physician awareness of polypharmacy within our managed care network, decrease rates of selected high-risk polypharmacy combinations, and reduce drug costs resulting from polypharmacy.
Our secondary objective was to develop the business case for expanding the polypharmacy intervention program to all patients receiving health coverage from our institution. According to some authors, an intervention can be said to fulfill a business case for quality if it leads to a financial return on the investment needed to implement the intervention in a reasonable time and with a reasonable rate of discounting.[15] This return may consist of profit, reduced losses, or avoided costs. For a polypharmacy intervention to be sustainable, it must satisfy the business case for quality.