A Prescription for Failure

We spend a lot of time reporting around the elderly/chronically ill. Taking care of that burgeoning swath of society has become a big priority for health providers and payers with accountable care, hospital readmissions and population health management ruling the day.

The technology is bulking up—at-home medical monitoring devices, talking pill-boxes, analytics-driven care coordination and predictive modeling, and dozens of other software and hardware solutions trying to keep geriatric populations out of trouble. But they’re not moving the chains far enough or fast enough, and I think one reason is that none straight-on address the problem of polypharmacy and the prescription for failure that it’s written for so many costly and well-intentioned I.T. efforts.

Polypharmacy by abridged definition means “the use of multiple medications by a patient, especially when too many forms of medication are used by a patient, when more drugs are prescribed than is clinically warranted, or even when all prescribed medications are clinically indicated but there are too many pills to take (pill burden).”

It sums up what everyone knows is a huge clinical problem that’s only getting worse—that the elderly are taking too many medications, and no big surprise they’re not taking them correctly, and that those stupendously complex regimens—made even more dangerous by seniors going off the reservation by taking OTC drugs, someone else’s drugs, etc.—are sending them back to the hospital, or to a graveyard.

I recently did a piece on hospital readmissions and spoke with a number of CIOs, clinicians, CMIOs and other experts. Every one of them mentioned perplexing problems with medication adherence and discussed the technology, workflow and case management solutions they’re applying—with limited success, as they’d freely admit.

Their local problems are a national problem. The American Society of Consultant Pharmacists compiled research that found:

• Adverse drug reactions are among the top five greatest threats to the health of seniors.
• 28 percent of hospitalizations among seniors are due to adverse drug reactions.
• 32,000 seniors suffer hip fractures each year due to falls caused by medication-related problems.
• The elderly account for 12.9 percent of the U.S. population, but consume approximately 34 percent of total prescriptions.
• On average, individuals 65 to 69 years old take nearly 14 prescriptions per year, individuals aged 80 to 84 take an average of 18 prescriptions per year.

Providers and payers are pouring money into intensive case management efforts and elaborate I.T. infrastructures to increase medication adherence, but tracking an 8- or 10- or 14-prescription drug regimen would be a full-time job for someone of sound mind and body, if they put in some overtime. It’s bound to fail when you’re asking an elderly patient to do so who has serious health issues coupled with the inevitable effects of aging. Anyone who deals on a personal level with an older friend or family member knows that they often mess drug regimens up, and get befuddled, or anxious, or light-headed, which leads to another appointment, which often leads to another tweak in medications, which starts another vicious circle.

The pharmaceutical industry has put numerous life-saving drugs on the market, and it’s understood that on whole they’re giving the elderly an opportunity to lead longer and healthier lives. But today’s drug regimens are potentially past the point of diminishing returns and into the realm of therapies that are doing more harm than good.

The American Geriatric Society maintains the Beers Criteria, which since 1991 has been used to identify medications considered potentially inappropriate independent of diseases/conditions and a list of medications considered potentially inappropriate when used in seniors with certain diseases or conditions.

While some of the criteria are considered controversial, it’s clinically vetted information that should at least give pause to clinicians piling onto an elderly patient’s drug load. But studies indicate that 20 percent to 25 percent of elderly patients are taking at least one medication on the Beers List. And this is occurring even though the list has been adopted by the Centers for Medicare and Medicaid Services as a benchmark for quality measures.

There’s no getting around the fact that our most vulnerable population is taking too many medications, and those medication in many cases are becoming cures worse than the potential diseases. And nothing in terms of information technology solutions and clinical interventions is being pointed directly at this underlying cause of a large number of adverse drug events, hospitalizations and deaths.

When it comes to medication adherence, the industry is not having a full conversation about the problem. It’s like health reform—there’s a lot of discussions about bending a cost curve via aligned incentives and technology and accountability, but there’s fewer about medical malpractice reform.

These and other blind-spots need to be addressed by the entire spectrum of stakeholders if serious headway is going to be made in improving the quality and safety of care in this country.