Reduce Harm and Waste - Overprescribing/Pharmacy

The approach to Reducing Harm and Waste in Realistic Medicine is to focus on value. When resources are limited, interventions are offered to those who will benefit most and who are more willing to accept risk and in these conditions it is more likely that high value healthcare is delivered. However as resources increase, interventions are offered to those less likely to benefit while the likelihood and magnitude of harm stays the same and in these conditions it is more likely that low or negative value healthcare is delivered. A personalised approach to care can help communicate these concepts for patients and help understand what benefit and risk mean for a patient’s personal situation. Personalised care can also reduce the impact of adverse events. Being Open is a best practice framework used in Scotland which creates an environment where patients and families feel supported and healthcare professionals and managers have the confidence to act appropriately. “Psychological harm to families is reduced when they experience compassionate care, their perspective is valued and when they are central to the review of care.” Being Open has also been used to prevent future harm when staff participate with the learning and improvement generated from the adverse event review reports. [The Scottish Government. Personalising Realistic Medicine: Chief Medical Officer for Scotland’s Annual Report 2017-18. Published 2019. https://www.gov.scot/publications/personalising-realistic-medicine-chief-medical-officer-scotland-annual-report-2017-2018/pages/7/]

Value can be assessed in many different ways and can include cost-effectiveness analysis, economic analysis, disinvestment, and reducing overuse and overprescribing. Below is a selection of journal articles and reports which are about pharmaceuticals, prescribing, and overprescribing in healthcare.  If you are looking to answer a specific question please submit a literature search request at the link above.  If you would like to be alerted when new content is available here then please sign in and select Follow.  You are welcome to leave comments and suggestions below in the comments section.

Articles

Berdud, M., Chalkidou, K., Dean, E.  (2019)  The future of global health procurement: Issues around pricing transparency.  The Office of Health Economics This OHE Research Paper focuses on the role that price transparency may play in the efficient and effective procurement of medicines by middle and low income countries.  Will making prices publicly available make procurement more efficient and cost effective medicines more accessible?

BLACK, C.D., et al, 2019. The Health System Costs of Potentially Inappropriate Prescribing: A Population-Based, Retrospective Cohort Study Using Linked Health Administrative Databases in Ontario, Canada. PharmacoEconomics Open, Conclusions: Potentially inappropriate prescribing  (PIP) in older adults is a significant source of health system costs from healthcare service use beyond medication costs, with a significant portion of hospitalizations and ED visit costs attributable to PIP. Future work should focus on identifying strategies and priorities for intervention.

FAJARDO, M.A., et al, 2019. Availability and readability of patient education materials for deprescribing: An environmental scan. British journal of clinical pharmacology, 85(7), pp. 1396-1406. Conclusions: “Over 1/3 of deprescribing PEMs present potential benefits and harms of deprescribing indicating most of the freely available materials are not balanced. Most PEMs are pitched above average reading levels making them inaccessible for low health literacy populations.”

LE BOSQUET, K., et al, 2019. Deprescribing: Practical Ways to Support Person-Centred, Evidence-Based Deprescribing. Pharmacy : A Journal Of Pharmacy Education And Practice, 7(3),
Deprescribing is complex and multifactorial with multiple approaches described in the literature. Internationally, there are guidelines and tools available to aid clinicians and patients to identify and safely withdraw inappropriate medications, post a shared decision-making medicines optimisation review. The increase in available treatments and use of single disease model guidelines have led to a healthcare system geared towards prescribing, with deprescribing often seen as a separate activity. Deprescribing should be seen as part of prescribing, and is a key element in ensuring patients remain on the most appropriate medications at the correct doses for them. Due to the complex nature of polypharmacy, every patient experience and relationship with medications is unique. The individual's history must be incorporated into a patient-centred medication review, in order for medicines to remain optimal through changes in circumstance and health. Knowledge of the law and appropriate recording is important to ensure consent is adequately gained and recorded in line with processes followed when initiating a medication. In recent years, with the increase in interested clinicians globally, a number of prominent networks have grown, creating crucial links for both research and sharing of good practice.

Chalmers, D., Poole, C., Webster, S., et al (2018) Assessing the healthcare resource use associated with inappropriate prescribing of inhaled corticosteroids for people with chronic obstructive pulmonary disease (COPD) in GOLD groups A or B: an observational stidy using the Clinical Practice Research Datalink (CRPD).  Respiratory Research 19(1):63 Conclusion: The data suggests that ICS use in GOLD A and B COPD patients is not associated with a benefit in terms of healthcare resource use compared to non-ICS bronchodilator based therapy; using ICS according to GOLD recommendations may offer an opportunity for improving patient care and reducing resource use

Greise-Mammen, N., Heisberger, KE., Meeerlie, M., et al (2018) PCNE definition of medication review: reaching agreement. International Journal of Clinical Pharmacy 40(5): 1199-1208.

Conclusion:  Involvment of an international community from research and practice and use of a systematic process led to an afreement on the term medication review and on classification valide for all settings and professions.

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Reports

IHI Blog, Leslie Pelton, September 10 2018.  Deprescribing can mean fewer Opioids, more grateful patients  (last accessed 19/10/2018). 

Miani, C., Martin, A., Exley, J., et al. (2017)  Clinical effectiveness and cost-effectiveness of issuing longer versis shorter duration (3 months vrs 28 day) prescriptions in patients with chronic conditions: systematic review and economic modelling.  Health Technology Assessment 21 (78): 1-128.  Although the quality of evidence was poor, this study found that longer prescriptions may be less costly overall, and may be associated with better adherence than 28 day prescriptions in patients with chronic conditions in primary care.

McCarthy D. Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017.

A multidisciplinary team of clinical experts in Ottawa, Canada, created a credible, low-cost process for developing and implementing evidence-based deprescribing guidelines and tools for assessing, tapering, and stopping medications that may cause harm or no longer benefit patients. Although the guidelines led primary care teams to consider approaches for identifying such medications and engaging patients in conversations about discontinuing them, the intervention has thus far been more successful in long-term care settings, where it strengthened team-based medication reviews in fulfillment of routine quality improvement and reporting requirements.

For more information and to obtain the full text click here.

Public Health England, 2015. Prescribing of psychotropic drugs to people with learning disabilities and/or autism by general practitioners in England. Public Health England, July 2015  (last accessed 11/09/2015)

“Comparison with epidemiological studies of mental illness in adults with learning disabilities suggests that 13% of the population (roughly 23,800 people) are being prescribed antipsychotics in the absence of a psychotic illness, and 10% antidepressants in the absence of an affective illness

(roughly 19,500 people). Allowing for overlap, which is common, we estimate that between 30,000 and 35,000 adults with a learning disability in England are taking one or both of these types of drug

in the absence of the conditions for which they are indicated. Prescribing of antipsychotics and antidepressants to children and young people is much less common.” (page 6-7)