An overprescribing epidemic

Over the past two years, we’ve developed vaccines, treatments, and other standards of care for Covid-19 that reduce the risk of severe illness and death. But during the first waves of the pandemic, there was little evidence on the best treatments for the virus, leading many doctors to experiment with unproven therapies like malaria drugs, anti-parasitics, and blood thinners.

Antibiotics, which were commonly overused before Covid-19, became another treatment that was widely prescribed to Covid-19 patients with no evidence of benefit. In a recent research letter in JAMA, researchers from the Centers for Disease Control and Prevention (CDC) found that about 30% of Medicare beneficiaries with Covid-19 as the primary diagnosis received an antibiotic in outpatient settings such as the ED, urgent care, telehealth, and doctor’s offices, from April 2020-2021.

Rates of antibiotic prescribing were highest in the ED, with more than one third of Covid-19 patients receiving a prescription, followed by telehealth and urgent care. Rates of prescribing were highest in October 2020, leading up to the winter Covid-19 surge.

Comparing regional prescribing rates, antibiotics were most likely to be prescribed in outpatient settings in the South (37%) and least likely in the Northeast (22%). This pattern tracks with previous research showing greater rates of overuse in the South compared to other regions.

Drivers of antibiotics for Covid-19

Why did so many clinicians prescribe antibiotics for Covid-19 with no evidence to support it, especially given the harm of antibiotic resistance?

Many doctors likely prescribed antibiotics to Covid-19 patients because they feared the possibility of “secondary infections,” when damage caused to the nose or lungs from a virus leads to a bacterial infection. Early reports from China had warned about drug-resistant infections in Covid-19 patients, but doctors later found that these warnings turned out to be overly cautious.

For some doctors, using antibiotics was an act of desperation early in the pandemic, driven by a lack of effective treatments.”Many physicians were inappropriately giving antibiotics because, honestly, they had limited choices,” said Dr. Teena Chopra, director of epidemiology and antibiotic stewardship at Detroit Medical Center, in The New York Times.

Many clinicians do not see antibiotic resistance as a real threat, despite the fact that 2.8 million of these infections occur every year. Especially in the stress of a pandemic, the constant drive for clinicians to “do something” can be more powerful than the future potential threat of superbugs.

The ease of prescribing antibiotics through telehealth visits may also be a factor. Direct-to-consumer telehealth visits had high rates of antibiotic prescribing for children with upper respiratory viruses before Covid-19. The inability to do a close examination via telehealth as well as the need to keep patient satisfaction rates high may result in a “better safe than sorry” approach.

Unnecessary antibiotics and race

In the CDC study, the authors found that antibiotics were more often prescribed to non-Hispanic white Medicare patients with Covid-19 (31%) compared to Black (23%), Hispanic (29%), Asian American/Pacific Islander (27%), or American Indian/Alaska Native (24%) patients with Covid-19.

This result is counterintuitive because prior to Covid-19, Black and Hispanic patients were more likely to receive inappropriate antibiotics. A recent study from researchers at the University of Texas at Austin found between 2009 and 2016 in outpatient settings, almost 64% of antibiotic prescriptions written for Black patients and 58% for Hispanic patients were inappropriate, compared to 56% for white patients. The University of Texas researchers posited that lack of access to follow-up care in communities of color may drive overprescription of antibiotics; if providers feared patients may get an infection and that they wouldn’t be able to come back to receive medications, they would be more likely to prescribe antibiotics.

The opposite pattern found in the CDC study may reflect the inequality of resources available in white neighborhoods during Covid-19, compared to communities of color. Hospitals serving more people of color were overwhelmed during the pandemic and at times ran out of beds and supplies. Providers serving white communities may have been able to offer more in the way of Covid-19 treatments — both beneficial and non-beneficial ones. Throughout the pandemic, the most privileged Americans have received the “more is better” treatment, while the most marginalized are denied basic lifesaving care.

The overprescription of antibiotics for Covid-19 patients provides several lessons on overuse in general: 1) uncertainty and lack of evidence can be major drivers of overuse, 2) care setting and location matter (and “virtual” settings matter as well), and 3) structural racism can lead both to underuse and overuse for people of color.

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As the use of multiple medications has increased, millions of older adults are at risk of being overloaded by unnecessary or potentially harmful medications. Being able to identify and stop certain low-value prescribing practices would be helpful to reduce both patient harm and waste to the system. That’s where EVOLV-Rx comes in.

In a recent article in JAMA Network Open, researchers from the University of Pittsburgh School of Medicine and the RAND Corporation explain their new metric, EVOLV-Rx (Evaluating Opportunities to Decrease Low-Value Prescribing). They developed this metric by first looking for low-value prescribing practices in guidelines and literature, incorporating focus group studies with patients and caretakers. To measure the value of different prescribing practices, they adapted from the Lown Institute’s approach to characterizing medication appropriateness. Then they convened a panel of physicians and pharmacists to narrow down the final set of practices that would be most meaningful to measure.

The final metric includes 18 low-value prescribing practices. These range from prescribing a drug that has not been proven effective for that indication (eg. testosterone for normal aging), to prescribing a drug for too long (eg. using heartburn medications for many months), to inappropriate use of medications (eg. antibiotics for respiratory infections).

Among the prescribing practices in the “potentially unsafe” category, the panel called out benzodiazepines, muscle relaxants, and anticholinergic drugs as ones to watch out for, as well as overuse of antiplatelet and anticoagulant therapies concurrently.

“The metric developed in this study may enhance the detection of low-value prescribing practices, reduce polypharmacy, and enable older adults to receive high-value care,” the authors write.

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The Lown Institute identified “prescription checkups” – medication reviews that give patients and clinicians opportunities to deprescribe (stop or reduce the dose of a medication) appropriately – as a necessary intervention for reducing harmful polypharmacy. For prescription checkups to become mainstream, there is a need for public and commercial health insurers to make them a regular benefit for patients. 

One pharmacy benefit manager has already taken the lead on providing prescription checkups to members at risk of medication overload. Optum Rx is a pharmacy care services company that manages pharmacy benefits for clients including health plans, employers, unions and government entities. Their new prescription checkup program aims to keep members safe and healthy while reducing costs associated with drugs that are no longer providing benefit.  

I asked Sumit Dutta, MD, Chief Medical Officer at Optum Rx, some questions to find out how their program is working on the ground.

What is Optum Rx? How did you get involved in taking action against harmful polypharmacy?

Dr. Dutta: Optum Rx helps more than 60 million people achieve better health outcomes and lower costs through innovative prescription drug benefits, clinical programs, specialty services, and consumer-oriented solutions. My team of pharmacists and pharmacy technicians help people every day learn how to take their medications, avoid harmful drug interactions, and manage their chronic conditions. 

We have been hearing from our clients, including employers and health plans, about the importance of complex and high-cost member management. Included within that realm is polypharmacy, also known as the use of five or more chronic medications at one time. To understand more, we leveraged our data capabilities to efficiently identify opportunities to address medication overload – medications that are causing harm or are no longer providing benefit. Our systems look for certain medications, or combinations of medicines that are known to increase adverse events.

When we took a closer look, we identified potential medication overload in 7 to 12% of Commercial plan members. This was concerning because unnecessary medication use leads to waste and increases one’s risk of harm from the medications they are using. In response, we developed the Optum Rx Polypharmacy Value Management Program (PVMP), which provides prescription checkups to help ensure people are benefiting from their medication and minimizing risk. The program is available for employers or plan sponsors to adopt and ultimately helps members take more ownership of their own health, reduces risks associated with clinically unnecessary or unwarranted treatment, and potentially lowers medication costs.

Can you tell us more about this program, and how you involved pharmacists, doctors and members in the process?

We first use an algorithm to identify people who have a high risk of experiencing medication overload and are taking medications that could potentially be deprescribed. We found a number of people were looking to simplify their medications. In fact, 25% of the people we offered a prescription checkup participated in the consultation.   

Once identified as someone who may benefit from a prescription checkup, a person receives a letter, voicemail, or phone call that informs them about this free service. An Optum Rx pharmacist performs a comprehensive medication review and evaluates their response to each medication through a structured assessment. That may sound complex, but it really just involves asking patients important questions about each medication such as: Are you benefitting from this medication? Are you experiencing side effects? This shared decision process helps to identify safety concerns that would otherwise go unnoticed and identifies the medications that have the best chance for successful deprescribing.

Pharmacists also look for utilization patterns and combinations that are commonly associated with risky and potentially harmful polypharmacy. For example, pharmacists look for prescribing cascades where one drug is being used to treat the adverse effects from another (instead of stopping or changing the drug causing the problem).

The next step is to contact the primary care provider. With the person’s agreement, the pharmacist will reach out to the provider to share the results of the prescription checkup, including drugs they identified as good candidates for deprescribing. The provider then determines if it is clinically appropriate to stop, adjust or switch medications – or they might follow up with the patient to further discuss their medication regimen. In our prescription checkup pilot, 40% of providers adjusted medications following outreach from pharmacists.

Each person who participates in the prescription checkup also receives a Medication Action Plan and education about how to avoid harmful and wasteful polypharmacy.

What are some steps people can take to manage multiple medications safely?

During the prescription checkup, we give members education about the harms and waste associated with medication overload, as well as a list of questions they should ask their provider every time they receive a new prescription.

Keeping a full medication list on hand and updating it as prescriptions change helps people track and manage their medications too. Including the date the medication was prescribed and what it was originally prescribed to treat can be incredibly helpful. People may not know that simplifying or reducing their medications is an option; they should speak with their healthcare providers if they believe they are using too many medications or are experiencing adverse effects.

What have the results of the program looked like? How did participants react?

The goal of the program is to address medication overload and lower the risks and costs associated with clinically unnecessary or unwarranted treatment to enable people to lead a healthy life. So far, the results we have seen are encouraging: 25% of people offered a prescription check-up participated in the consultation and 40% of their providers adjusted medications following pharmacist outreach.

People reported they felt comfortable talking with our pharmacists about their medication experience and were more empowered and knowledgeable about what to share with their providers. Many participants proactively followed up with their provider directly following the consultation. What’s very clear is that many people are interested in simplifying their treatment and using less medications when appropriate and if their doctors agree. 

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However, deprescribing in the hospital can be difficult, since hospital clinicians are usually focused on patients’ acute care issues rather than long-term medication problems. They also may not have the training or support needed to prioritize medications for deprescribing or engage in a prescription checkup with patients.

That’s where clinical decision tools like Medsafer come in. Medsafer is an electronic tool developed by a team of Canadian researchers that helps guide physicians and pharmacists through the depresribing process. The software inputs information on patients’ medications, health conditions, and frailty, and gives clinical teams a set of medications that could be deprescribed for that patient. This goes a long way toward automating the deprescribing process.

To test how well this tool works on the ground, the Medsafer team conducted a randomized controlled trial with about 5,700 older adults at 11 hospitals in Canada. They found that compared to the control group, patients with clinical teams that used Medsafer were nearly twice as likely to have at least one medication deprescribed. About 30% of patients in the control group had a medication deprescribed, compared to 55% of patients in the intervention group.

Among the most commonly deprescribed drugs in the trial were sleep aids, pain relievers, stool softeners, diabetes medications, blood thinners, and antipsychotics. Patients in the intervention group had much higher rates of deprescribing for risky meds like benzodiazepines (40% vs 20%), codeine and tramadol (55% vs 34%), antipsychotics (34% vs 23%), and diabetes meds (50% vs 36%), compared to those in the control group.

Despite the impressive rate of deprescribing using Medsafer, the study found no significant difference in adverse drug events within 30 days of discharge between the intervention and control groups. This could be because many of the drugs deprescribed were not beneficial to patients but not particularly risky (stool softeners or cholesterol medications, for example).

However, that doesn’t mean that deprescribing these drugs has no benefit. “Deprescribing these medications is less likely to impact 30-day ADEs, but still has patient and societal value, such as avoiding excess cost, waste, and pill burden,” the authors of the study wrote.

The results also point to the need for measuring outcomes besides short-term ADEs in deprescribing research. As UCSF geriatrics professor Dr. Michael Steinman wrote on Twitter, “We need to move beyond ADEs as our main (& often only) way of addressing medication harms. People experience harms from meds in lots of other ways. Cost burdens. Medicalization of lifestyle. Fear of future harms. Impacts on social functioning.”

Reducing unnecessary meds can also help patients achieve their long-term health goals. In a recent research letter in JAMA Internal Medicine, researchers at Beth Israel Deaconess Medical Center found that nearly 20% of adults with hypertension take medications that raise their blood pressure, such as antidepressants, NSAIDS, steroids, and estrogens. Patients taking these medications were more likely to need to take antihypertensive drugs to counteract these effects. Finding opportunities to deprescribe could make it easier for these patients to get their blood pressure under control.

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There have been many attempts by the US government to solve this problem. As early as 1987, the Centers for Medicare and Medicaid Services (CMS) banned the use of “chemical restraints” in nursing homes that were not required to treat medical symptoms. In 2008, the US Food and Drug Administration put a black box warning on all antipsychotics to inform health care professionals that elderly patients with dementia taking antipsychotics are at an increased risk of death, and to clarify that these drugs are not supposed to be used to treat dementia.

In 2012, CMS created the National Partnership to Improve Dementia Care in Nursing Homes, with a central goal of reducing the use of antipsychotics for dementia in nursing homes. As part of this initiative, CMS started reporting nursing homes’ rates of antipsychotic drug use. However, nursing homes are not required to report use of antipsychotic drugs for patients diagnosed with schizophrenia, Huntington’s Disease, or Tourette’s Syndrome, giving these institutions a potential loophole to the rule.

Although the reported rate of antipsychotic use has declined since 2012, this decline is in part due to a rise in schizophrenia diagnoses. A recent New York Times investigation found that the proportion of nursing home residents diagnosed with schizophrenia increased by 70% since 2012. An estimated one-third of these patients diagnosed with schizophrenia in 2018 did not have a record in Medicare claims of being treated for the condition, indicating these may just be false diagnoses to justify use of antipsychotics. Typically, schizophrenia is diagnosed before age 40, not later in life.

“Today, one in nine residents has received a schizophrenia diagnosis. In the general population, the disorder, which has strong genetic roots, afflicts roughly one in 150 people.”

Katie Thomas, Robert Gebeloff and Jessica Silver-Greenberg, The New York Times

While CMS reports about 15% of nursing home residents taking antipsychotics, when including diagnoses of schizophrenia, Huntington’s Disease, or Tourette’s Syndrome, more than 21% of residents are taking them, The New York Times found.

Overdiagnosis of schizophrenia appears to be more prevalent than for Black nursing home residents. A recent study from researchers at the School of Public Health at Brown University found that after 2012, Black nursing home residents with dementia were 1.7 times as likely to be diagnosed with schizophrenia compared to nonblack residents.

One reason for this pattern may be differences in quality of care and staffing between nursing homes serving older adults of different race/ethnicities. Covid-19 made it even these disparities even more clear; nursing homes serving more Black and Latinx residents were more likely to have at least one Covid-19 case. In New York state for example, 84% of nursing homes with at least a quarter of Black and Latinx residents had at least one Covid-19 case, while only 33% of mostly-white nursing homes had a Covid-19 case.

Similarly, recent research on low-value care in US health systems by Dr. Ishani Ganguli and colleagues found that health systems caring for more patients of color had greater rates of overuse. Use of antipsychotics for dementia was one of the most prevalent overused services measured in this study, with 23.5% of Medicare beneficiaries with dementia (but without severe mental illness) receiving antipsychotic medications in 2016-2017. However, in some health systems, more than 50% of beneficiaries with dementia received antipsychotics.

The overuse of antipsychotics and overdiagnoses of severe mental illness make it clear that reporting requirements are not enough to fix the widespread quality and staffing issues at nursing homes. Although the 2012 policy did not single out nursing homes serving Black residents, the loophole created another racial divide– a disparity in overdiagnosis as well as overmedication. We need more oversight and resources for nursing homes, particularly those serving people of color, to get at the root of the problem. Otherwise the overuse of antipsychotics and other drugs chemical restraints will remain prevalent in these settings, putting the lives and health of nursing home residents at risk.

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In reality, EHRs have made clinicians’ jobs harder without improving quality of care. From the start, EHR development was privatized, leading to a fragmented system of records that don’t connect automatically across institutions. EHRs were built primarily as a tool for billing rather than for clinical care, so performing seemingly simple tasks like bringing up a patient’s medication list can take dozens of clicks.

The structure of EHRs creates another serious problem, which Dr. Saira Shervani at the University of Chicago Medicine and colleagues discuss in a recent “Teachable Moment” article in JAMA Internal Medicine. Shervani et al share a story of a woman with a history of epilepsy who was admitted to the hospital due to recurrent falls and instability. They eventually discovered that she was experiencing adverse events from a duplicate epilepsy drug that was deprescribed by her neurologist, but had continued to be dispensed by the pharmacy.

Why would the pharmacy keep giving the patient a drug that her clinician had discontinued? Because when the neurologist discontinued the drug in the EHR, neither the patient nor the pharmacy were notified of this change.

While EHRs have the ability to send deprescribing requests to pharmacies, health networks don’t always turn on this functionality, because that “would entail additional costs for health care professionals and networks, including costs for software licensing and integration, as well as ongoing network fees and maintenance costs,” Shervani and colleagues write. The result is that deprescribing orders in the EHR are not transmitted to pharmacies in the same way as orders to prescribe.

In an accompanying editorial in JAMA Internal Medicine, Vanderbilt University Medical Center pharmacist Scott D. Nelson and professor Dr. Yaa Kumah-Crystal explain more about how clinicians have to work around the lack of deprescribing functionality:

Because most EHRs are not configured to notify pharmacies of prescription cancellations electronically, clinicians and staff are required to call the pharmacy to communicate that a prescription has been discontinued or actively submit a fax communication to the pharmacy about the prescription discontinuation…At times, prescribers attempt to prevent subsequent pharmacy dispenses by modifying the medication order in the EHR and sending a new prescription with “stop” or “cancel” in a free-text field, again hoping that the pharmacists will see and understand the message.

Think about that for a second. Doctors can notify pharmacies when they want to prescribe a new drug, with just a few clicks. But to get them to stop a drug, they might have to submit a fax to the pharmacy or write a note in the EHR and hope the pharmacist gets it. It’s hard to believe that this is the state of affairs in health technology in 2021.

We know that EHRs need a complete overhaul — they should be interoperable across systems, there should be secure and fast information exchange, and they should be much more usable for clinicians. However, part of the problem with deprescribing electronically is not technical but political. As Nelson and Kumah-Crystal write, there already exists a program that can cancel prescriptions through the EHR called CancelRx, which was developed in 2006. However, there are no minimum use requirements for this program, like there are for other EHR programs, so it often goes unused. Clinicians at Johns Hopkins Medical Center and the University of Wisconsin have had success using CancelRx, but adoption nationwide remains slow. Nelson and Kumah-Crystal recommend that institutions engage prescribers, pharmacists, IT specialists, and training teams to make sure that questions about workflow and troubleshooting can be worked out for a successful implementation.

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Another potential consequence of social isolation is medication overload. Older adults who are lonely may report depression or pain to their doctors, which can result in a prescription for medications that have concerning side effects for older adults. Chronic health problems associated with multiple medication use can also make it difficult for older adults to be social, which can lead to loneliness.

In a recent study in JAMA Internal Medicine, researchers at the University of California, San Francisco School of Medicine examined the relationship between loneliness and use of medications that pose a high risk of adverse events for older adults.

Older adults who reported high levels of loneliness were more than twice as likely to be taking a benzodiazepine or sedative compared to those reporting no loneliness.

The researchers used data from the National Social Life, Health, and Aging Project (NSHAP), a nationally-representative survey of adults 65 and over living in the community (not in a nursing home or other institutional setting). The probability of medication was adjusted for age, sex, race/ethnicity, education, and multimorbidity (having more than one health condition).

They found that older adults who reported moderate or high levels of loneliness were more significantly more likely to be taking certain pain relievers, sedatives, and antidepressants. For some of these drugs, the difference was striking. Older adults who reported high levels of loneliness were more than twice as likely to be taking a benzodiazepine (11% vs 5%) or sedative (20% vs 9%) compared to those reporting no loneliness. Lonely older adults were about twice as likely to be prescribed an antidepressant compared to adults reporting no loneliness (27% vs 14%). High levels of loneliness was also associated with higher rates of polypharmacy; half of lonely older adults were taking five or more drugs, compared to 41% of adults not reporting loneliness.

The link between these medications and loneliness is concerning, because these medications have potentially dangerous side effects and are not recommended for older adults. Benzodiazepines and antidepressants increase the risk of falls, fracture, cognitive impairment, and other adverse events. And chronic use of NSAIDs (non-steroidal anti-inflammatory drugs, like high-dose aspirin or ibuprofen) increases the risk of kidney failure, cardiovascular events, and ulcers and bleeding, which can be life-threatening.

“It’s easier to prescribe a pill than to ask ‘Why are you lonely?’ and listen to the answer.”

Dr. Carla Perissinotto, geriatrician and Associate Professor of Medicine at the University of California, San Francisco

Further, there is little evidence that taking these medications reduces loneliness; these medications are used to treat the symptoms of loneliness while the underlying causes go unaddressed. “It’s easier to prescribe a pill than to ask ‘Why are you lonely?’ and listen to the answer,” said Dr. Carla Perissinotto, geriatrician and Associate Professor of Medicine at the University of California, San Francisco.

The study authors recommend “prescribing” social interventions for lonely older adults, by referring them to local community-based support programs. Not only would this help address the underlying causes of loneliness, but also would avoid prescription of high-risk medications. However, this requires clinicians to take the step of discussing such a personal topic with their patients, which requires time and a trusting relationship. “We see loneliness in our older patients every day, but we don’t have time to ask them about it, because we have to check off so many other boxes,” said Perissinotto.

In our current health system, clinicians have less time to spend with patients, and we expect to get a “pill for every ill.” Unfortunately these factors have led to the medicalization of loneliness, in which older adults are put at grave risk of harm from overmedication, while their underlying social isolation goes unaddressed. To tackle this problem, we need to give clinicians and patients the time and space to have difficult conversations, make “social prescribing” options more available to clinicians, and educate both clinicians and patients about the risks of certain medications for older adults.

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Fortunately, researchers have found that direct-to-patient advertising can help patients start the conversation about deprescribing. The EMPOWER trial in Quebec, Canada, found that sending informational brochures to older adults taking sedative-hypnotic medications (such as Xanax and Valium) led to a large 22 percent greater reduction in their use compared to a control group who did not receive brochures. Sixty-two percent of participants in the intervention group initiated a conversation about deprescribing with a clinician. A subsequent randomized trial in Quebec called D-PRESCRIBE showed that combining patient brochures with recommendations from pharmacists to primary care physicians had an even greater impact on deprescribing.

Can the examples from these trials be applied on a larger scale? How do we go from trial to real world? In a webinar hosted by the US Deprescribing Research Network, Dr. Justin Turner, assistant professor at the faculty of pharmacy at University of Montreal and co-director of the Canadian Deprescribing Network (CADEN) tackled these questions in detail.

Turner and CADEN have been using Implementation Science (IS) to understand what influences the behavior of doctors and patients, and what could make them change. IS is the study of methods to promote the systematic uptake of evidence-based research into routine health care practice. IS tries to bridge the gap between “What we know” to “What we do.” Turner explains how they used different theoretical IS models to scale up the EMPOWER and D-PRESCRIBE trials, and what they learned.

Watch the video above to see the full webinar and access the slides on the US Deprescribing Research Network website!

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“I am convinced when a single drug is prescribed, the doctor probably knows what to anticipate. When two drugs are prescribed, uncertainty prevails. When three drugs are prescribed, a doctor hasn’t the foggiest notion how a patient will react. When four drugs are prescribed, God doesn’t know what might ensue.”

Anyone who cares for older adults knows that medication overload has become an epidemic. Over the last decade, older people sought medical treatment more than 35 million times for adverse drug events, and there were more than 2 million hospital admissions. These adverse drug events are often a result of overprescribing– more than 40% of older adults take five or more prescription medications a day, and 20% take more than ten. 

The solution to medication overload is deprescribing — taking patients off, or reducing the dose of, medications that are unnecessary or harmful. Sounds simple, but deprescribing is rare because often clinicians don’t have the time, skills, or information they need to do a full Prescription Checkup (a visit in which the patient and clinician review all the medications the patient is taking and discuss which drugs can be safely deprescribed).

Can pharmacists be the key that unlocks the full power of deprescribing? They have specialized knowledge of drug interactions and risks, and know how to safely remove and taper drugs. Yet there are many barriers in the way — most significantly, Medicare and most other payers don’t recognize pharmacists as clinical care providers and don’t pay them for this work. In short, most pharmacists are only paid to dispense medications, not deprescribe them.

How can we remove the barriers and make pharmacists our deprescribing heroes? In their recent piece in Senior Care Pharmacist, Lown health policy fellow Judith Garber and professor at the University of Washington School of Pharmacy Don Downing create a roadmap for collaboration. The article is a summary of their lecture at the American Society of Consultant Pharmacists annual meeting from November 2020. Garber and Downing outline how changes in policy, perceptions, and partnerships can make pharmacists leaders for deprescribing, and help mitigate our epidemic of overprescribing.

The American Society of Consultant Pharmacists has made this piece free for non-members to download for 30 days! Download the article on their website.

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However, some clinicians have concerns about telehealth that should be addressed, including the potential for increasing inappropriate prescribing. A recent study in Pediatrics looked at antibiotic prescribing for acute respiratory infections for pediatric telehealth visits, compared to urgent care and primary care provider offices. Researchers matched patient visits based on age, health conditions, state, and other patient characteristics. Antibiotic prescribing for colds and ear infections in children is not recommended but still very common. More than half (52%) of telehealth visits resulted in an antibiotic prescription, compared to 42% of urgent care visits and 31% of primary care office visits), a difference that is concerning.

Why would video visits be more prone to unnecessary antibiotic descriptions? The authors of the study speculate that because “a physician can’t physically examine a child remotely, he or she may not be sure about the diagnosis and prescribes antibiotics under a ‘better safe than sorry’ approach.” Another reason might be because the study measured telemedicine visits “outside the medical home,” which is different from video visits with one’s usual primary care provider. These types of “direct-to-consumer” businesses may result in more antibiotic prescribing because companies are concerned with keeping patient satisfaction rates high, and therefore will go against the guidelines to give patients antibiotics that they don’t need.

The study authors warn in an op-ed in STAT that the combination of increasing Covid cases and telemedicine could exacerbate this trend. “With more anxiety, more people getting sick, more people getting care, and more telemedicine use, doctors may inappropriately prescribe more antibiotics,” they write.

Overprescribing is also a major issue for older adults, with an estimated 34% of adults over 65 receiving one or more potentially inappropriate medications. Could our newfound reliance on telehealth exacerbate medication overload?

Judy Benkeser, BSN, RN, a nurse and care navigator at a Michigan Medicine primary care practice in Ann Arbor, believes it might. Most of her patients have multiple complex medical issues or psychosocial barriers, and many are taking multiple medications. While telemedicine is more convenient for lots of patients, there are many challenges using telemedicine for elderly, complex patients and other vulnerable populations. “I see many articles extolling the benefits of telemedicine, but few pointing out that it may not be for everyone,” Benkeser said.

In an email correspondence, Benkeser pointed out that medication reconciliations are less likely to take place during a virtual appointment, because this task is generally deferred to medical assistants or nurses in clinics, and because patients’ hearing or vision issues (and technology glitches) make the process more difficult. When prescribing a new medication, or making a medication change, clinicians try to “teach back” — to provide verbal instruction to patients, and ask them to repeat the instructions back, to make sure they understand. Video visits offer less opportunity for these checks.

The lack of coordination between care sites during the pandemic provides another obstacle to deprescribing. Not all electronic health record systems are compatible at all care sites, making it hard to share documentation from visits with primary care doctors. The pandemic has led to a drop in staffing at many medical offices, which exacerbates the coordination problem.

Benkeser also notes that requests for antidepressants, anti-anxiety meds, and sleep aids have risen during the pandemic. These prescriptions require careful, gradual dosing and close monitoring to ensure patients avoid adverse events, which is tougher to do with virtual visits compared to in-person.

When patients have to do visits over the phone rather than video, clinicians lose the opportunity to recognize signs of medication overload. “Physical examination–especially in vulnerable, elderly, or clinically complex patient populations– encompasses more than simple taking of vital signs. I watch how someone gets out of their chair and walks across the waiting room when they are in our office. Can they get on and off our scale? Can they walk down the hallway to the exam room without showing signs of fatigue or having difficulty breathing?” Without these clues, overmedication may go unnoticed, and could lead to harm.

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