Risky Drug Prescriptions Cut by Multipronged Intervention

Diana Swift

March 18, 2016

A three-pronged intervention in physician-owned primary care practices decreased high-risk prescribing of antiplatelet agents and nonsteroidal anti-inflammatory drugs (NSAIDs), according to a randomized trial published in the March 17 issue of the New England Journal of Medicine.

Researchers led by Tobias Dreischulte, PhD, from the Medicines Governance Unit, National Health Service, Tayside, Scotland, reported a significant drop in high-risk prescribing after the intervention, which included professional education, informatics/feedback, and financial incentives. It fell from a rate of 3.7% (1102 of 29,537 at-risk patients) immediately before the intervention to 2.2% (674 of 30,187 patients) afterward, for an adjusted odds ratio of 0.63 (95% confidence interval [CI], 0.57 - 0.68; P < .001). Reductions continued in the year after financial incentives ended.

To combat unsafe prescribing (eg, NSAIDs for patients with chronic kidney disease or heart failure or coprescription of NSAID and oral anticoagulants without gastric protection), the researchers randomly assigned 34 practices to 10 different start dates during 2011 to 2012 for a 48-week experiment.

The intervention consisted of an hour-long educational visit from a pharmacist and follow-up newsletters, informatics to facilitate patient reviews, and financial incentives to review at-risk patients' charts for appropriate prescribing. Participating physicians received an initial fixed payment of about USD $600, and roughly $25 per patient reviewed.

Analyzing data on more than 33,000 at-risk patients both pre- and postintervention in 33 of the 34 practices, the researchers observed a slight uptick in the rate of high-risk prescribing in the preintervention period (mean absolute increase, 0.07 percentage points for every 8 weeks elapsed; 95% CI, 0.02 - 0.12). The rate of continuing high-risk prescribing dropped from 2.6% just before the intervention to 1.5% afterward (adjusted odds ratio, 0.60; 95% CI, 0.53 - 0.67; P < .001), whereas new high-risk prescribing decreased from 1.1% to 0.7% (adjusted odds ratio, 0.77; 95% CI, 0.68 - 0.87; P < .001).

Eight of nine measures of high-risk prescribing showed reductions (range of adjusted odds ratios, 0.27 - 0.78), but no significant reduction emerged in the rate of NSAID prescription for patients with heart failure.

Hospital admissions for gastrointestinal bleeding fell from 4.6 per 10,000 person-years to 0.4 per 10,000 person-years (rate ratio, 0.09; 95% CI, 0.00 - 0.52). In patients at risk for NSAID- and antiplatelet-related adverse events, the incidence of total hospitalizations for gastrointestinal ulcer or bleeding fell from 55.7 to 37.0 admissions per 10,000 person-years (rate ratio, 0.66; 95% CI, 0.51 - 0.86). Heart failure admissions dropped from 707.7 to 513.5 per 10,000 person-years (rate ratio, 0.73; 95% CI, 0.56 - 0.95).

Total admissions for acute kidney injury did not notably decrease with intervention (from 101.9 to 86.0 admissions per 10,000 person-years, for a rate ratio of 0.84; 95% CI, 0.68 - 1.09; P = .19).

The authors note that as much as 4% of emergency hospital admissions are a result of avoidable adverse drug events. In most cases, commonly prescribed drugs are to blame "with substantial contributions from [NSAIDs] and antiplatelet medications because of gastrointestinal, cardiovascular, and renal adverse drug events," they write.

In the United States, for example, NSAIDS are widely used by people with chronic kidney disease who are unaware of the associated risks.

In 2013, IMS Health estimated the cost of avoidable US drug-related hospital admissions and emergency department/outpatient visits at $19.6 billion.

The investigators note that similar primary care interventions could work elsewhere in physician-owned practices using electronic medical records, but they caution that such interventions must be customized to individual healthcare contexts. "For example, the size of the incentives that are required to prompt review is likely to vary according to primary care physician payment structures and incomes," they write.

The authors were supported by a research grant from the Scottish Government Chief Scientist Office, which had no role in any aspect of the study. One study author reported grants from industry outside the scope of this study.

N Engl J Med. 2016;374:1053-1064. Abstract

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