Every day, 750 older Americans are hospitalized for a serious adverse drug event. While prescription drugs have improved the lives of individuals around the world, increasing use of multiple medications at the same time have put millions of older Americans at risk for adverse drug events. In 2018, people over age 65 sought medical care at a clinic or emergency room 5 million times for an adverse drug event, and were hospitalized 280,000 times. In a 2019 Lown Institute report, we estimated that if nothing is done, there will be 4.6 million hospitalizations and 150,000 preventable deaths among older Americans over the next decade.
To address the epidemic of medication overload, the Lown Institute convened a working group of 22 experts on medication use, including doctors, nurses, pharmacists, researchers, and patient advocates. Our work produced a national action plan, which provides key recommendations for cultural, educational, and policy changes that are needed to reduce medication harm and burden. The recommendations include:
Implement prescription checkups to facilitate deprescribing
Patients and clinicians need designated time to review all the drugs a patient is taking, and discuss which can be stopped, or deprescribed, or reduced in dose. Patients who feel overwhelmed by their medication burden should be able to request a prescription checkup -- a medication review with a focus on deprescribing.
The following policy changes would help facilitate prescription checkups and appropriate deprescribing:
- Create avenues for clinician reimbursement for prescription checkups, such as allowing primary care clinicians to “bundle” a prescription checkup with the annual Medicare Wellness Visit.
- Allow Medicare to recognize pharmacists as health providers so they can be incorporated into the care team and paid for their clinical services.
- Encourage development of value-based payment models that reward clinicians for reducing adverse drug events in older patients, to incentivize preventive prescription checkups.
- Establish a centralized list of every patient’s medications, or improve the usability and accuracy of electronic health records and make them interoperable across health systems, to ease the creation of a comprehensive medication list for patients.
Improve information and training on appropriate medication use
Too often, clinicians do not have all the information they need about the benefits and harms of medications when making treatment decisions. In addition, health professions education usually does not teach clinicians-in-training how to safely deprescribe, nor is information on how to deprescribe safely always available for clinicians at the point of care.
The following initiatives would help fill information and knowledge gaps that drive medication overload:
- Ensure that clinical practice guidelines include information on prescribing for older patients with multiple chronic conditions and how to safely stop drugs.
- Make deprescribing guidelines widely available so clinicians have them at the point of care.
- Enhance health professions education and continuing education to incorporate training on patient-centered prescribing and deprescribing.
- Address systemic problems with adverse drug event under-reporting, to improve the availability of information on drug side effects.
Push back against the culture of prescribing
Both patients and clinicians are steeped in a culture of prescribing, which promotes the notion that there’s a “pill for every ill.” Pharmaceutical industry marketing to clinicians, direct-to-consumer drug advertising, the increasing medicalization of normal aging, the hurried pace of medical care, and the urge among doctors and other clinicians to “do something” about medical conditions all contribute to the culture of prescribing.
The following actions would help reduce the power of this cultural bias:
- Create campaigns to increase awareness of medication overload among the general public, patients, and health care professionals.
- Empower patients and caregivers to talk to their clinician about deprescribing.
- Encourage clinicians and health care institutions to deny pharmaceutical sales rep visits.
- Require better regulation of drug samples and close the drug sample loophole for reporting pharma payments.
- Increase regulation of direct-to-consumer drug advertising with either an outright ban, limit on ads for two years after approval, or stricter content requirements to show a more accurate balance of drug benefits and harms.
Medication overload is a complex problem and therefore requires a multi-faceted set of solutions. Reducing harm from multiple medications will not be easy, but there are opportunities across the health care system for positive change. We owe it to our grandparents, our parents, and ourselves to take action now.