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Appropriate Drug Use and Prescription Drug Programs

Value of Appropriate Use

Presenter:

Wayne A. Ray, Ph.D., Professor and Director, Division of Pharmacoepidemiology, Vanderbilt University School of Medicine, Nashville, TN.


In his presentation, Dr. Ray:

  • Defined appropriate or "rational" drug use.
  • Gave examples of common suboptimal drug use.
  • Explained the limitations of knowing the true prevalence and cost of suboptimal use.
  • Provided pragmatic suggestions for policies that encourage appropriate or "rational" drug use.

Ray prefers the term "rational" drug use to "appropriate" drug use and defined it as:

"The use of pharmaceuticals in such a manner that the outcomes of therapy, both clinical and economic, are optimal given the present state of knowledge."

He explained that errors in achieving rational drug use can occur at the patient, physician, and pharmacy or dispensing levels. Pre-prescribing errors at the patient level can result from patients' attitudes, beliefs, or knowledge levels. For example, a patient may not understand or believe in the validity of the reasons a doctor prescribes a particular drug regimen, and therefore may not comply with it. Similarly, patients' access or lack of access to care are very important determinants of medication use. Compliance errors can also occur after the patient leaves the physician's office if the patient fails to:

  • Fill prescriptions.
  • Comply with the course of treatment.
  • Follow a recommended diet.
  • Monitor vital statistics such as glucose levels and blood pressure.

Physicians' contribution to inappropriate drug use can occur at the time of diagnosis. Underdiagnosis from physicians can create a foundation for inappropriate use. Pressure from managed care organizations on physicians to see more patients in less time could cause physicians to take inadequate histories. Treatment choice is another factor that physicians can control and, if not done carefully, inappropriate choices may result and patients may be at risk for serious adverse drug events (ADEs). Pharmacy level errors generally occur with the dispensing of the wrong drug or the wrong dosage. Ray suggested that better information systems might alleviate these types of errors.

While the true prevalence of suboptimal drug use is unknown, Ray provided the following data to estimate the scope of the problem:

Beers' Criteria: 15-30 percent of pharmaceutical use for people age 65 and over is possibly suboptimal (Beers, 1997).

The Institute of Medicine estimates the costs of the following types of medication errors (Institute of Medicine, 2000):

  • Inpatient: $40 billion total cost, $20 billion of which is possibly preventable.
  • Ambulatory: $80 billion total cost
  • Nursing home: $8 billion total cost, $4 billion of which is possibly preventable.

Ray estimated that the cost of prescription drug errors represents 10 percent of health care expenditures, or $100 billion out of the $1.3 trillion economy and is clearly a big problem.

The primary problem in determining the true scope of the problem is that there currently are no standards by which to accurately measure compliance. Screening tools such as Beers' Criteria substitute for such standards because standards development is extremely difficult and must be developed to be disease-specific and evidence-based.

Ray explained that an accurate cost assessment would require a full decision model, including the consequences of suboptimal drug use. Existing cost analyses attribute the need for additional medical care and increased inpatient utilization to poor drug use, but the post-hoc causality assessment is dubious and has many methodological problems.

To address the issue of suboptimal drug use and to promote rational drug use, Ray explained that it is important to understand both the big picture and the smaller pragmatic tactics to reach it. The bigger picture goals of achieving more rational drug use require:

  • More complete knowledge base (regarding interactions and ADEs).
  • More evidence-based, maintained guidelines.
  • Integrated, real-time, patient databases (current databases are more fragmented than the care given).
  • More descriptive studies.

Ray explained that though the true magnitude of the problem is unknown, clearly suboptimal drug use is common and expensive, and programs should focus on improving the quality of drug use. However, Ray warned to beware of simplistic and overly ambitious "solutions." He explained that currently there are few silver bullets that can solve the problem, and it is important for policymakers to critically evaluate programs. Ray offered the following pragmatic solutions for considering policies that encourage rational use and reduce suboptimal use.

  1. Start with the "lowest hanging fruit," such as:
    • Reducing incidents of fraud and abuse.
    • Encouraging practitioners to prescribe generic substitutes for brand name drugs.
  2. Focus on solving medication errors and clinical problems through strategies such as disease management, rather than solely focusing on drugs and drug use.
  3. Choose clinical problems with strong guidelines for improvement, such as guidelines that:
    • Are evidence-based rather than consensus-based (Peer Review Organizations).
    • Have been in use for some time.
    • Are well maintained and up to date.
  4. Be aware of database limitations.
  5. Account for the influence of over-the-counter drug use and consequent interactions.

References

Beers MH, Ouslander JG, Fingold SF, Morgenstern H, Reuben DB, Rogers W, et al. Inappropriate medication prescribing in skilled-nursing facilities. Ann Intern Med 1992;117:684-9.

Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. Arch Intern Med 1997;157:1531-6.

Beers M, Avorn J, Soumerai SB, Daniel EE, Sherman DS, Salem S. Psychoactive medication use in intermediate-care facility residents. JAMA 1988;260:3016-20.

Federman AD, Adams AS, Ross-Degnan D, Soumerai SB, Ayanian JZ. Supplemental insurance and use of effective cardiovascular drugs among elderly Medicare beneficiaries with coronary heart disease. JAMA 2001;286:1732-39.

Institute of Medicine. Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. 2000.

Meridith S, Feldman P, Frey D, Hall K, Arnold K, Brown NJ, Ray WA. Possible medication errors in home health care patients. J Am Geriatr Soc 2001;49:719-24.

Schneider ED, Cleary PD, Zaslavsky AM, Epstein AM. Racial disparity in influenza vaccine. JAMA 2001; 286:1455-60.

Shekelle PG, Ortiz E, Rhodes S, Morton SC, Eccles MP, Grimshaw JM, Woolf SH. Validity of the Agency for Healthcare Research and Quality clinical practice guidelines. JAMA 2001;286:1461-7.

Soumerai SB, Lipton HL. Computer-based drug-utilization review–risk, benefit, or boondoggle. N Engl J Med 1995; 332:1641-5.

Willcox SM, Himmelstein DU, Woolhandler S. Inappropriate drug prescribing for the community-dwelling elderly. JAMA 1994;272:292-6.


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