Polypharmacy: Copious prescribing and lack of MTM drive challenges

Polypharmacy screening has significant potential to improve medication safety.

“Screening for polypharmacy becomes more significant than ever as patients seek treatment for various ailments from a variety of physicians and move from one care setting to another, exposing them to increasing risk of accumulating layers of drug therapy,” said Nasseer A. Masoodi, MD, MBA, associate professor clinical sciences, The Florida State University College of Medicine, Tallahassee, Fla. “Reconciling patient medications at every clinical encounter has a strong potential for decreasing risk of drug–drug interactions and adverse drug reactions [ADRs].”

A growing burden

Polypharmacy, the concomitant ingestion of four or more medications, also includes use of medications that are not clinically indicated or are inappropriate for a disease condition.

Many Americans use a disproportionate number of prescriptions and over-the-counter medications, said Masoodi, who is also vice president of health services and chief medical informatics officer at ACV Inc., a retirement community in Dowling Park, Fla. Data show that 31% of patients use more than one pharmacy and 50% receive prescriptions from more than one prescriber, increasing the complexity of their drug regimens and risk of drug–drug interactions.

“As more people seek healthcare services, we can expect polypharmacy to contribute significantly to the increasing number of hospitalizations, adverse drug reactions, and cost burden among likely consumers and service providers,” said Masoodi.

Several factors

Polypharmacy is driven by several factors, including multiple symptoms, multiple medical conditions, copious prescribing, multiple providers, lack of a primary provider to coordinate drug therapy, use of multiple pharmacies, drug-regimen changes, hoarding of medications, and self-treatment.

“However, the greatest driver of polypharmacy management challenges is predominantly from people over age 65 with multiple conditions and prescriptions from different physicians,” Masoodi said. “Elderly patients are prescribed twice as many medications as are younger patients, and nonprescription drug use among the elderly is sevenfold that of the general adult population.”

According to a study by Elinor C. Chumney and Leslie C. Robinson in Pharmacy Practice (2006), the frequency of ADRs increases with the number of drugs taken. It has been estimated that the frequency of ADRs is 6% when a patient takes two drugs, 50% when a patient takes five drugs, and almost 100% when a patient takes eight or more drugs.

“These data are very important for all stakeholders to focus on and improve health outcomes, cost-conscious healthcare, and quality of care,” Masoodi said.

Polypharmacy management challenges are also driven by adverse effects from other treatments and a minimal focus in most health systems to reassess treatment needs over time.

“Frequent physician visits add to the pill burden, as 75% of physician visits in the United States terminate in a written prescription,” he said.

A multipronged approach

Addressing polypharmacy requires a multipronged approach, ranging from financial incentives for providers and healthcare facilities to care-delivery improvements that address the root causes of these errors, said Masoodi.

Adoption of clinical IT tools - including electronic health records, e-prescribing, computerized physician order entry (CPOE), and electronic medication administration record (eMAR) - is one of the key components of any program to address the issue of polypharmacy, Masoodi said.

IT tools will also help providers and healthcare service providers to meet the Joint Commission’s requirements and recommendations for medication reconciliation, ensuring that medications are reconfirmed and reviewed with the patient at each transition in care, said Masoodi.

“Patient portals empower patients and family caregivers to manage their medications by keeping personal health records and personal medication lists, and informing them about medications’ purpose, effects, and side effects.”

In addition to computer technologies, coordination of care between patient, pharmacy, and clinical team and interdisciplinary teamwork can significantly reduce polypharmacy, he said.

Service providers and policy-makers should also invest in medical audits targeting elderly patients, who are more likely to be taking multiple drugs.

“A robust medical audit system identifies gaps between clinical practice and guidelines and provides feedback for health professionals to prompt incremental performance improvement,” Masoodi said.

James M. Wooten, PharmD, associate professor, department of medicine, University of Missouri-Kansas City School of Medicine, has written about polypharmacy and strategies to reduce the risk of adverse drug events in the elderly. He has suggested that elderly patients should be encouraged to bring all their medications to each appointment (“brown-bagging it”).

“This way, caregivers know exactly what is being taken by the patient,” Wooten wrote in a study published in the November 2010 issue of Southern Medical Journal.

Successful MTM programs

The literature cites many case studies of successful polypharmacy management programs, said Masoodi, including one at the Health Alliance Plan (HAP), the nonprofit managed care arm of Henry Ford Medical System in Detroit, to demonstrate polypharmacy control through medication therapy management (MTM).

HAP at Henry Ford Medical System developed its own methodology for MTM program data collection, data tracking, and outcome monitoring in 2006, and has refined it each year. It has pharmacists working in collaboration with physicians. From 2006 to 2011, improved outcomes have been demonstrated in many areas, including pharmacy efficiency, 55% improved drug therapy efficacy, 45% improved drug therapy safety, decreased adverse drug events from polypharmacy, and improved patient satisfaction.

Cost savings from 2006 to 2009 were about $4.4 million, a combination of $2.4 million from prescription cost savings (a 16% reduction) and $2 million from medical cost avoidance (a 21% reduction).

“Pharmacist-led interventions not only result in positive clinical outcomes, but can also result in substantial cost savings to institutions,” Masoodi said.