Tackling potentially inappropriate prescribingBMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4688 (Published 14 November 2018) Cite this as: BMJ 2018;363:k4688
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With an increasingly ageing and co-morbid population there remains an ongoing tendency to treat all diagnosed conditions. Evidence based guidelines are often used to support clinical decisions and add medications to the patient’s existing list of drugs. It is acknowledged that secondary care provides valuable opportunities to review and rationalise medications as well as deprescribe frequently prescribed potentially inappropriate medications. The short stay in a hospital admission however along with uncertainty and inexperience around the process and the lack of details around existing therapy makes deprescribing an arduous task that is frequently not effected. There are many benefits to deprescribing, including improved adherence to drugs, a greater understanding of reasons for treatment and improved efficacy of essential medications. In addition, overall healthcare benefits from reduced direct costs of fewer treatments and indirectly through reduction in hospitalisation related to adverse medication effects (1).
Much of prescribing happens in primary care as well as through fragmented care delivered by different specialists to treat multi-morbidity that is increasingly common in the elderly (2). Comprehensive integrated care models may hold the key to support secondary care services by bridging the gap with primary care. Through opportunities for continuous review of medications and attempts to prescribe the lowest effective doses of only essential medications, risks of adverse effects and drug interactions can be minimised. Patients’ attitude to de-prescribing can however be a powerful force and factors such as trust and the ongoing relationship with the primary care physician are important considerations.
Healthcare organisations worldwide continue to struggle for sustainability. It is well understood that polypharmacy and potentially inappropriate medications (PIMs) may be associated with adverse clinical outcomes and an increased risk of hospital re-admissions. Whilst acknowledging variability in classification of PIMs, the issue of polypharmacy needs to be a priority for both primary and secondary care (3). Involvement of pharmacists in medical reconciliation on admission and discharge and their partnering with clinical care teams can yield significant benefits in terms of reducing drug errors. However, it still requires knowledge, expertise and willingness on the part of the medical teams to challenge the status quo and commence the all-important process of de-prescribing. Various alerts can be triggered on paper and electronic health records to try and prompt medical staff to recognise polypharmacy and effect de-prescription. The greater problem however in trying to achieve the WHO’s goal of medication safety is how to sustain any changes that are made long term. The answers likely lie in integration of services and the use of electronic medication management to seamlessly and safely support patients through the care continuum (1).
1. Hume AL, Quilliam BJ, Goldman R, et al Alternatives to potentially inappropriate medications for use in e-prescribing software: triggers and treatment algorithms. BMJ Qual Saf 2011;20:875-884.
2. Holt S, Schmiedl S, Thürmann PA. Potentially inappropriate medications in the elderly: the PRISCUS list. Dtsch Arztebl Int. 2010;107(31-32):543-51.
3. Chang CB, Chen JH, Wen CJ, et al. Potentially inappropriate medications in geriatric outpatients with polypharmacy: application of six sets of published explicit criteria. Br J Clin Pharmacol. 2011;72(3):482-9.
Competing interests: No competing interests
The review article ends by stating that electronic health record interventions may provide a way forward to prevent inappropriate prescribing. I describe below the process of tidying up the electronic record and enhancing the medicines list with clinical indications.
I have been summarising the records of incoming UK NHS patients for over 30 years. Today it takes me 3 hours to check 10 sets of records, some of which are transmitted electronically and some on paper. This involves checking the problem / disease list which can be full of electronic administration detritis -- eg chat to patient / patient telephone encounter - making it difficult to see the important medical diagnoses relevant to prescribing. I then check that the adverse drug reaction listing is accurate, which is possibly the most useful 'deprescribing' tool - e.g. Cough from ACE inhibitors, muscle aches in statins, and other non-specific issues provided by patients. I then go to the prescribing list to check it aligns itself to the newly created problem list. I then add clinical indications (www.clinicalindications.com) to the prescribing information - eg allopurinol take one daily to prevent gout. This does alter the repeat prescription counter but the information is so useful to the patient and other health staff who care for the patient.
There is an assumption that all staff and doctors know what the listed drugs are for but I would not expect, for example, orthopaedic specialists to understand many of the drugs uses. Clinical indications provide justification of a drug use and clinical indication software could be created to enhance the delivery of medicines but at a price. Interestingly, I rarely find significant errors in appropriate prescribing in this part of the country.
Competing interests: Developer of clinical indications on prescription www.clinicalindications.com
To find out the appropriate prescription for a disease state, the following methods can be useful
1. Use of software to find out the proper drug prescriptions for a particular disease condition by scanning the prescription sheets at dispensing.
2. For this, proper diagnosis and other comorbid conditions must be in prescription sheets.
3. Writing the generic name of the drug in the prescription sheet can also be useful in assessing the appropriate drug prescription for the particular disease.
This type of information in prescription sheets for screening with the help of software can be very useful to find the appropriate prescribing in medical practice.
Competing interests: No competing interests