Imagine a scenario when a medication's long-term use is linked to serious adverse drug reactions or another case where ...
Medication therapy is among the most common therapies to treat medical conditions but can lead to negative outcomes, especially when overused.
Let’s look at the following example. A 68-year-old male, we’ll call him Joe, has a history of chronic obstructive pulmonary disease (COPD) and takes two inhalers on a daily basis. Joe visits his primary care physician for a COPD exacerbation. His healthcare providers have prescribed levofloxacin and some steroids. Joe experiences diarrhea and neuropathy from the antibiotic as well as insomnia from the steroids. He’s prescribed an anti-diarrheal, gabapentin, and Ambien to manage these side effects. Taking all these medications affects the patient’s kidney function which leads to an increase in his blood pressure. His care team decides to start him on a blood pressure medication. Joe is now taking six additional medications. He has lost his independence due to the pain caused by the neuropathy and now experiences some cognitive impairment due to the side effects of Ambien.
Scenarios similar to Joe’s happen all too often. Polypharmacy can lead to poor patient outcomes, increased health expenditures, and devastating social outcomes, especially for older patients.
In this article we discuss
- What is Polypharmacy?
- Factors Contributing to Polypharmacy
- What are the Impacts of Polypharmacy?
- Economic Implications of Polypharmacy
- Strategies for Reducing the Negative Impact of Polypharmacy
- How Medication Optimization Reduces the Negative Impact of Polypharmacy
- A Solution to the Polypharmacy Epidemic
What is Polypharmacy?
The definition of polypharmacy is the use of five medications or more. These medications can include prescribed and over-the-counter medications as well as complementary medicine therapies.
According to the World Health Organization (WHO), there are two different types of polypharmacy:
- Appropriate polypharmacy —when all medications are prescribed for a specific therapeutic objective that’s being attained, when medications are optimized, and when the patient is fully engaged and takes their medication as intended.
- Inappropriate polypharmacy — when some of the medicines prescribed are no longer needed, when these medications didn’t achieve their therapeutic objectives, when medications have a risk of ADRs, or when the patient isn’t willing to take them as intended.
In this article, we will focus on inappropriate polypharmacy.
The overall prevalence of polypharmacy is unclear, but research has found that it tends to be higher in older adults, especially those in nursing homes. One study from the Centers for Disease Control and Prevention (CDC) found that 65% of older adults seen in physician offices experienced some polypharmacy. Another study published in the Journal of the American Board of Family Medicine reported that up to 86% of older adults with two or more chronic health conditions were prescribed five or more medications.
Factors Contributing to Polypharmacy
Besides age and health conditions, other factors contribute to polypharmacy.
One study found that physicians who look at the number of medications the patient takes are likely to prescribe fewer medications—including potentially inappropriate medications—than other physicians. Physicians using the Beers List were also less likely to prescribe unnecessary medications.
Other barriers to deprescribing are the lack of time for physicians, the belief of the patient that the medication might help, and scenarios when medication was started by another physician.
Adults living in long-term care facilities have a higher risk of polypharmacy. Up to 91% of these patients take five or more medications daily. Conditions associated with polypharmacy in young patients include fibromyalgia, developmental disabilities, diabetes, heart disease, stroke, and cancer.
People with mental health conditions are another group of people that are at risk of polypharmacy because there are often prescribed additional medications to manage adverse drug reactions caused by most behavioral medications. This group is also at a higher risk of polypharmacy due to the non-optimization of their medication therapy.
Healthcare system factors
At the health system level, polypharmacy can be caused by poor health record keeping, poor transition of care processes, and the use of automated-refill systems. Patients seen in outpatient care settings and hospitals are more likely to have polypharmacy than those in the community (37% and 52% respectively compared to 20%).In homebound adults, the period after hospitalization is associated with a higher prevalence of polypharmacy.
A European study found that people with a migration background have a significantly higher probability of polypharmacy (P = 0.045). Low education attainment and low income are also associated with higher odds of polypharmacy, especially in African-Americans.
It’s important to understand the factors driving polypharmacy since it’s a growing phenomenon. The world’s older population is growing and the World Health Organization (WHO) projects the older population to reach 16% in 2050. This shift will lead to an increase in polypharmacy and its negative impacts.
What are the Impacts of Polypharmacy?
- Polypharmacy is associated with an increased risk of adverse drug reactions (ADE). Patients taking five or more medications have a 88% higher risk of experiencing an ADE than those taking less than five medications. The risk of experiencing an ADE increases by 7% to 10% with each additional medication taken.
- Those living in a nursing home and taking nine or more medications have a risk of adverse drug events twice as high compared to those taking fewer medications.
- Polypharmacy can also increase the risk of cognitive impairment and functional decline, due to the numerous DDI and drug-diseases interactions it causes. Especially in older people, these interactions can result in decreased strength, increased frailty, and increased risk of falls. In its “Medication overload” report, the Lown Institute found that patients taking four or more medications were linked to an 18% higher risk of falls while people taking 10 or more medications had a 50% increased risk of falls. In one Italian study about mild cognitive impairment (MCI), researchers noted that 50% of people with MCI were taking three or more medications daily. At the end of the year-long study, the risk of developing dementia was six-fold higher in that group than in the group taking less than three medications daily.
- Polypharmacy is also linked to increased mortality. Taking six to nine medications has been linked to a 59% greater chance of death in older adults compared to taking no medications. When the number of medications increased to ten, the risk of death increased by 96% compared to older adults taking no medication.
In addition to worse patient outcomes, polypharmacy also has a serious impact on the cost of care. In a report from the IMS Institute of Health Informatics, called Advancing the Responsible Use of Medicines: Applying Levers for Change, researchers estimated that mismanaged polypharmacy was responsible for 4% of the world’s total avoidable costs due to suboptimal medication use. Specifically in the US, medication misuse and polypharmacy are estimated to cost $177 billion every year.
At the patient level, elevated costs can be explained by increased monthly copays that come from a high number of medications. A 2015 survey found that 40% of adults over 50 years old were concerned about being able to pay for their medications. High medication costs can cause patients to ration their medications which can lead to additional medical problems.
Patients, health care plans, and hospitals also spend more on medical costs—outpatient visits and hospitalizations— due to polypharmacy-related duplication of therapy, ADEs, and DDIs. With an estimated cost per ADE-related hospitalization of $13,308, it’s not surprising to see that the US could potentially save $60 billion over a decade in unnecessary hospitalizations for older adults alone reducing inappropriate or unnecessary medications.
A study published in the American Journal of Cardiology found that in older adults with cardiovascular disease polypharmacy nearly doubled their total health expenditures ($19,068 vs $8,815) and tripled their pharmacy spending ($1,286 vs $488) compared to people without polypharmacy.
The increased costs and poor patient health outcomes caused by polypharmacy can in turn lead to negative social outcomes.
People taking five or more medicines are three times more likely to be frail. Frailty alone was found to double the risk of death, dementia, and persistent physical disability which can lead to individual isolation and caregiver burden.
One Belgian study published in the CDC’s publication Preventing Chronic Diseases found that people with chronic conditions and multimorbidity who take five or more medications reported worse health-related quality of life (HRQoL). People with polypharmacy had significantly more difficulty with mobility and usual activity. They also reported worse anxiety and depression scores although those differences were not significant when compared with people without polypharmacy.
Let’s look at the following example. A 68-year-old male, we’ll call him Joe, has a history of chronic obstructive pulmonary disease (COPD) and takes two inhalers on a daily basis. Joe visits his primary care physician for a COPD exacerbation. His healthcare providers have prescribed levofloxacin and some steroids. Joe experiences diarrhea and neuropathy from the antibiotic as well as insomnia from the steroids. He’s prescribed an anti-diarrheal medication, gabapentin, and Ambien to manage these side effects. Taking all these medications affects the patient’s kidney function which leads to an increase in his blood pressure. His care team decides to start him on a blood pressure medication. Joe is now taking six additional medications. He has lost his independence due to the pain caused by the neuropathy and now experiences some cognitive impairment due to the side effects of Ambien.
Medications reported worse health-related quality of life (HRQoL). People with polypharmacy had significantly more difficulty with mobility and usual activity. They also reported worse anxiety and depression scores although those differences were not significant when compared with people without polypharmacy.
Strategies for Reducing the Negative Impact of Polypharmacy
Strategies have been proposed to mitigate the impact of polypharmacy although to this day it’s not clear if these interventions to reduce inappropriate polypharmacy improve clinical outcomes.
One strategy, deprescribing, is the process of identifying and stopping medications when their potential harms outweigh their potential benefits based on the patient’s therapy goals, level of functioning, values, and preferences.
Deprescribing tools include:
- The STOPP/START criteria. Screening Tool of Older Persons potentially inappropriate Prescriptions and Screening Tool to Alert to Right Treatment.
- The Beers Criteria List, which is a list of medications that should be avoided by older adults.
- The iMAP (individualized Medication Assessment and Planning) program, a tool developed by clinical pharmacists to identify and resolve medication-related problems.
These tools allow prescribers to compare and check a person’s medication list against a list of potentially inappropriate medications to uncover possible medication duplications; medication and disease interactions; and medication adjustments. Although these tools may be useful to review patient medication lists, they don’t take into account each patient’s complexity.
Other methods to decrease inappropriate polypharmacy include carefully considering the patient’s treatment goal before prescribing any new medications, discussing the medication benefits and risks with the patient and/or their caregivers, and talking about alternative non-pharmacological therapies. Medication affordability, patient compliance, and life expectancy should also be considered.
Transitions of care represent crucial points when inappropriate prescribing can happen. Improving these processes by using integrated health systems and team-based models of care can go a long way to decrease the incidence of polypharmacy.
How Medication Optimization Reduces the Negative Impact of Polypharmacy
Traditional strategies to reduce the impact of polypharmacy have yielded mixed results. Achieving this goal requires a comprehensive/holistic medication optimization approach that takes into account the whole patient/ the patient in all their complexity. Medication optimization helps care teams ensure that patients take medications that are indicated, safe, and effective for their goal of care. Beyond just looking at a patient’s medication list, medication optimization takes into account the patient’s clinical, socio-economical, and behavioral status to determine the best medication therapy for the patient. Arine’s platform integrates patients’ demographic data as well as data from prescription claims and hospitalization history to identify polypharmacy gaps.
Arine’s medication intelligence platform uses this data to generate personalized care plans that overcome the exact barriers to medication optimization.
In addition to reducing the impact of polypharmacy at the patient level, medication optimization can also be designed to intervene at the prescriber level.
Using prescriber analytics, Arine’s platform uncovers prescribing patterns and allows fast and effective prescriber education and communication. Using the platform, one of Arine’s clients was able to proactively identify, educate, and intervene with prescribers who were over-prescribing behavioral health medications. As a result, this health plan achieved annual savings of $1,400 to $4,300 per engaged member per year.
Conclusion: A Solution to the Polypharmacy Epidemic
Inappropriate polypharmacy costs patient lives, leads to poor health and social outcomes, and costs the US health system billions every year. Medication optimization powered by artificial intelligence can help care teams intervene in a timely manner and reduce the devastating adverse effects of this medication overload epidemic.
Learn how medication optimization improves health and economic outcomes. Register for Medication Optimization: The Missing Link in Value-Based Care today.