Strategies for Preventing Misprescribing in Healthcare

According to the World Health Organization, unsafe medication practices and medication errors are one of the main causes of avoidable harm in the healthcare system

In the U.S. alone, there was a 200% increase in polypharmacy in the past 20 years. 34% of older adults in the U.S. are prescribed a potentially inappropriate medication. Every day 750 older people are hospitalized due to serious medication-related side effects.

The Lown Institute estimates that the drive to prescribe will contribute to the premature death of 150,000 Americans in the next decade if nothing changes in prescribing practices.  Addressing misprescribing could save as much as $62 billion over the next decade by avoiding unnecessary hospitalizations of older adults alone.

In this article, we’ll explore some of the impacts of misprescribing and what evidence-based strategies can help prevent it.

• What is Misprescribing?
• What Causes Misprescribing? Risk Factors
• Impact of Misprescribing
• Strategies for Preventing Misprescribing in Healthcare
• Benefits of Reducing Misprescribing

What is Misprescribing?

Misprescribing can be described as the action of prescribing medications that significantly increase the risk of adverse effects.

For example, misprescribing includes prescribing medications that can cause significant drug-drug interactions with other medications the patient already takes or prescribing drugs that have a similar/duplicative mode of action. It can also be prescribing a medication that’s inappropriate or at the wrong dose considering the patient's age and condition, such as their renal function.

Misprescribing is also prescribing a medication at the incorrect frequency or for the wrong duration.

In a broader definition, misprescribing also refers to writing prescriptions without an appropriate medical reason or in quantities and dosages that are inappropriate based on the patient’s characteristics.

Examples of Misprescribing

For instance, in the case of antibiotics, misprescribing can occur when antibiotics are prescribed unnecessarily to patients who don’t need them, when the wrong antibiotic is prescribed, or when an antibiotic is prescribed at the wrong dose or for the wrong duration.

In the case of opioids, misprescribing can include co-prescribing opioids with benzodiazepines, prescribing high-dose opioids to older adults, and prescribing long-acting opioids to opioid-naive patients.

Specifically for older patients, NSAIDs (nonsteroid anti-inflammatory drugs), antihistamines, benzodiazepines, and antipsychotics are often misprescribed, some of which can put older patients at risk for falls.

What Causes Misprescribing? Risk factors

Different factors can lead to misprescribing.

It can happen due to prescriber-related factors, such as the knowledge gap of medication-related problems, clinical inertia, or lack of communication. For example, prescribers often do not have information regarding prescriptions being written by other clinicians. The prescriber can also prescribe a medication to fulfill what they believe is the patient’s expectations. Misprescribing can also occur when the prescriber is concerned about possible complications for the patient (that’s especially the case for antibiotic misprescribing).

Patient-related factors can also lead to misprescribing. These include patient non-adherence or patient limited understanding of the medication.

Misprescribing can occur when there’s a lack of integrated care, or when there are time constraints. Healthcare technology can also increase the risk of misprescribing. For example, inappropriate prescribing can occur when electronic health records (EHRs) are complex to navigate, when relevant guidelines are not easily accessible, or when clinical decision systems are poorly designed.

Impact of misprescribing

Health outcome

Misprescribing leads to poor health outcomes.

One review about misprescribing in chronic kidney disease found that it was associated with increased hospital stay and a high risk of mortality (40%).

A study looking at the impact of misprescribing in patients with dementia found that patients with dementia who experienced misprescribing were more likely to have adverse health outcomes. In the study, misprescribing was associated with:

• Increased all-cause mortality (hazard ratio: 1.14; CI: 1.02-1.26; P<0.02).
• Skin ulcer and pressure sores (hazard ratio: 1.66; CI: 1.12-2.46; P<0.01).
• Falls (hazard ratio: 1.37; CI: 1.15-1.63; P<0.01).
• Anemia (hazard ratio: 1.61; CI: 1.10-2.38; P<0.02).
• Osteoporosis (hazard ratio: 1.62; CI: 1.02-2.57; P<0.04).

Misprescribing antibiotics in adults was estimated to cause a nearly fourfold increased risk of adverse drug events (ADEs). Examples of these ADEs include nausea, vomiting, stomach pain, and diarrhea (C. difficile-related or not).

Another study looking at the impact of opioid misprescribing among Medicaid enrollees found that a higher proportion of opioid users with inappropriate prescription drugs died compared to those without inappropriate prescriptions (8.65% vs. 2.56%, p<0.001).

Financial impact of misprescribing/ inappropriate prescribing

In addition to poor patient outcomes, misprescribing also significantly impacts healthcare costs.

One study looking at the cost of inappropriate prescribing in older adults estimated the cost at about $25.2 billion between 2014 and 2018.

Another study published in the Journal of American Geriatric Society found that older adults who experienced misprescribing had higher healthcare spending than older adults who were not exposed to misprescribing. They had higher outpatient visits costs ($116; 95% CI = $105–$243; P < .001), higher cost of prescription medications $128; 95% CI = $72–$199; P < .001), and higher healthcare expenditures ($458; 95% CI = $295–$664; P < .001)

One review from the Journal of the American Pharmacist Association found that costs of ADEs related to misprescribing were most often related to hospitalizations, healthcare expenses, and emergency room visits.

Researchers found similar results in a study about the health system costs of inappropriate prescribing. Looking at a cohort of older adults from 2002 to 2015, they found that misprescribing was linked to almost 40% of the total healthcare spending in the 90 days following inappropriate prescribing. The cost associated with increased rates of hospitalization, emergency department visits, and newly prescribed medications resulting from inappropriate prescribing was estimated at $1.2 billion.

Strategies for Preventing Misprescribing in Healthcare

Medication Reconciliation

Many prescribing errors occur during transitions of care, such as post-hospital admission. Medication reconciliation is an important step in identifying and preventing misprescribing, particularly during these transitions.

Medication reconciliation enables the care team to establish the most current medication list the patient takes.

It should be done throughout the patient’s care journey to prevent prescribing errors such as duplication of therapy, drug interactions, or incorrect doses.

Medication reconciliation can help prevent prescribing errors in and outside of the hospital. The process has been designed to prevent the most common medication errors, and studies have shown that it can reduce prescribing errors.

Prescriber education.

Another evidence-based strategy to prevent misprescribing is prescribers’ education.

Different educational approaches that have been proven to produce a positive effect on prescribing include the distribution of clinical protocols and therapeutic guidelines, educational meetings, audits, and feedback; sharing of quarterly reports, and annual medical education actions.

Arine’s prescribers analytics solution enables clinical teams to evaluate prescribing patterns, identify prescribing gaps, and address them with low-cost, high-impact interventions.

These outreaches include patient-specific context, as well as detailed medication and dose recommendations.

Arine has found that more than 50% of their care plan recommendations are typically implemented by prescribers.

Multidisciplinary team including pharmacists

Having a multidisciplinary team that includes pharmacists is another effective strategy to prevent misprescribing.

Research has shown that a multidisciplinary team can reduce inappropriate or multiple prescribing, especially in elderly patients, and for antibiotic prescribing.

One study published in the JAMA Network, the D-PRESCRIBE trial, found that 43% of community patients who received pharmacist-led interventions stopped taking inappropriate high-risk medications compared to 12% of patients who didn’t receive the interventions (risk difference, 31% [95% CI, 23% to 38%]). Inappropriate medications targeted in the study were sedative-hypnotics, first-generation antihistamines, glyburide, or nonsteroidal anti-inflammatory drugs.

In a study about the impact of pharmacists’ interventions on medication appropriateness, researchers found that pharmacist-led medication reviews were effective in reducing inappropriate prescribing in older people.

Limiting polypharmacy

Polypharmacy increases the risk of misprescribing.

Patients at risk of polypharmacy include:

• Older patients
• Patients with multiple conditions who are seeing multiple physician specialists
• Patients with chronic mental health conditions
• Patients living in long-term care facilities.

Certain systems-related factors such as poorly updated medical records or automatic refills, can also increase the risk of polypharmacy and misprescribing.

To prevent misprescribing, it’s important to identify patients more at risk of polypharmacy and subsequent drug-related health problems. Once these patients have been identified, the care team can intervene early to simplify the medication regimen and avoid medication-related complications.

Benefits of Reducing Misprescribing

Clinical impact

Decreasing misprescribing can improve patient outcomes, especially for older and high-risk patients.

Research has shown that addressing misprescribing can improve medication appropriateness, lower medication costs, reduce falls, and decrease the rate of ADEs.

For example, one study showed that a pharmacist-driven transition of care program for oral antibiotics significantly decreased inappropriate prescribing by almost 20% (p=0.005) for patients discharged from the hospital.

In another study from the Journal of the American Society of Health-System Pharmacists, researchers found that a comprehensive approach to address opioid misprescribing in a patient-centered care home resulted in a lower percentage of patients receiving chronic opioids (67.2% decrease in four years). This comprehensive approach also led to fewer patients being prescribed benzodiazepines (65.6% in three years), and a 50% decline in premature deaths (defined as death before 60 years old).

In the long-term care setting, the HALT study demonstrated that care teams can reduce the inappropriate prescribing of antipsychotics without worsening behavioral and psychological symptoms of dementia.

Working with Arine’s artificial intelligence-powered platform to decrease misprescribing for its members, one health plan was able to close 75% of the behavioral health polypharmacy gaps in 6 months. The same health plan saw a 20% increase in its member adherence to antidepressants and antipsychotic medications.

Financial impact

In addition to clinical impact, addressing misprescribing can also lead to significant healthcare cost reduction.

In one systematic review, authors found that optimizing medications in polymedicated patients can lead to statistically significant cost savings. Studies in this review reported cost reductions between $193 and $4,966 per patient per year. Most cost reductions were linked to a decrease in emergency visits and hospitalizations.

When looking at the cost-effectiveness of the intervention in the D-PRESCRIBE study, the authors found that the intervention for discontinuing nonsteroidal anti-inflammatory drugs was less costly (-CAD 1008.61) and more effective than usual care. Similarly, the intervention to deprescribe inappropriate sedative-hypnotics (including participant education on the risks of sedatives and alternative strategies for insomnia and pharmacist-led provider education on the risks associated with chronic sedative use and safer alternative treatment options) was less costly (-CAD 1392.05) and more effective than usual care (routine care from pharmacists and providers with no education and continued prescription filling). The savings realized were largely associated with avoiding falls and/or fractures and the related healthcare costs.

In one study looking at the inappropriate use of proton-pump inhibitors (PPI), authors found that stopping inappropriate PPI use was a cost-saving strategy for all ages. For instance, for patients over 80 years old, discontinuing inappropriate PPI resulted in a cost saving of 553 euros.

Thanks to its medication intelligence platform, Arine enables clients to address misprescribing, along with other opportunities to optimize medications, for their members in a cost-effective way. One of Arine’s clients saw a 47% reduction in hospital readmission rate after implementing Arine’s medication management program. This resulted in a 15% reduction in total costs of care.

Conclusion

The US is experiencing a misprescribing epidemic, affecting especially its older and most vulnerable populations. Systematizing medication reconciliation, including pharmacists in multidisciplinary care teams, educating prescribers, and limiting polypharmacy are all strategies that have been proven to prevent misprescribing.

Click here to learn more about how Arine’s medication intelligence platform can help care teams prevent misprescribing and improve patients’ outcomes.

Learn about Arine’s Prescribing Physician Analytics solution.