Physician Factors Associated With Polypharmacy and Potentially Inappropriate Medication Use

Kenya Ie, MD, PhD, MPH; Maria Felton, PharmD, BCPS; Sydney Springer, PharmD, BCPS; Stephen A. Wilson, MD, MPH; Steven M. Albert, PhD

Disclosures

J Am Board Fam Med. 2017;30(4):528-536. 

In This Article

Abstract and Introduction

Abstract

Background: Despite accumulating evidence about the harm of polypharmacy in family medicine, few studies have investigated factors related to polypharmacy. The objective of this study was to explore factors related to physicians' prescribing behavior.

Methods: We conducted a survey of physicians at 5 family medicine residency practices and a linked health record review of their patients ≥65 years old. The determinants of physicians' mean number of prescriptions and potentially inappropriate medications (PIMs) were examined using a generalized linear model.

Results: A total of 61 physicians (38 residents, 23 fellows/faculty) completed the survey, and 2103 visits by 932 patients seen by these physicians were analyzed. The mean numbers of prescriptions and PIMs per visit per physician were 9.50 and 0.46, respectively. After controlling for patient race and age, low prescribers were more likely to consider the number of medications (P = .007) and benefit/risk information for deprescribing (P = .017) when making prescribing decisions. Use of the Beers List was marginally significant in lower PIM prescribing (P = .05). Physicians' sex, duration of experience, and perceived confidence were not associated with prescribing patterns.

Conclusions: Conscious consideration concerning the number of medications and benefit/risk information, as well as using the Beers List, were associated with less polypharmacy and fewer PIMs.

Introduction

Polypharmacy is the use of more drugs than are clinically indicated,[1,2] or, more descriptively, the use of more than a certain number of drugs (eg, ≥5).[1,3] Polypharmacy has become more common among the elderly[4] and is related to several problems, including increased risk of being prescribed potentially inappropriate medications (PIMs),[5] which are delineated in several drug lists, such as the American Geriatrics Society Beers criteria.[6] Both polypharmacy and PIMs increase adverse drug events, worsen physical function, and result in excess health care utilization.[5–7] In 2014, 20% of total National Health Expenditures were spent for Medicare, and nearly half of the Medicare expenditure involved prescription drug–related costs.[8] Medication misuse and polypharmacy cost the United States more than $177 billion every year.[9]

Family physicians need to be aware of these medication-related problems within their own practices, as geriatric care in family medicine practices (FMPs) is likely to become more prevalent and important with increasingly aged populations.[10] The first published data of PIM prevalence in the United States indicated PIM use by approximately 23% of patients ≥65 years of age who visited clinics at least twice over a 2-year period.[11] Polypharmacy prevalence in primary care in several countries has been reported.[12,13] To our knowledge, however, no report has been published with a focus on polypharmacy in US FMPs. Based on unpublished internal quality data of older adults who visited FMPs more than once a year and had ≥2 chronic conditions, 86.1% were prescribed ≥5 medications and 33.4% were prescribed ≥1 PIM. Among patients who met polypharmacy or PIM criteria, less than half experienced a reduction in the amount of prescription medications or PIMs during a year. Thus, polypharmacy and PIMs are important problems that should be addressed in family medicine.

Deprescribing refers to the process of tapering, stopping, discontinuing, or withdrawing drugs, with a goal of managing polypharmacy and improving outcomes.[14] Deprescribing with a focus on certain types of PIMs (eg, nonsteroidal anti-inflammatory drugs, benzodiazepines) has been shown to improve patient outcomes[15] and can be done safely.[16] However, evidence is inconclusive about the effect of deprescribing that focuses on reducing the number of overall medications. A 2014 Cochrane review found inconsistent results among deprescribing studies that used either the Beers List, a pharmacist-led approach, or a multidisciplinary deprescribing intervention.[17]

In addition to the lack of evidence, deprescribing entails many practical challenges. Qualitative studies found that physicians tend to avoid discussing deprescribing with their elderly patients.[18,19] Some reasons they highlighted were "preventive medication is not easy to reduce,"[18,19] "lack of benefit/risk information of deprescribing,"[18,19] "guideline pressure,"[18] "medications initiated by specialists,"[19] and "patients may feel it is a sign of giving up."[18] Furthermore, the appropriateness of prescribed medications is multifactorial in most cases. Previously known factors associated with physicians' attitudes toward deprescribing include patient age, life expectancy, functional and cognitive status, comorbidity, expected medication adherence, insurance coverage, budgetary concerns, and the wishes of the patient and family.[20] However, these studies did not address the association between potential factors and actual prescription behaviors.

The objectives of this study were to investigate variability in prescription patterns for multimorbid elderly patients across family physicians and to explore factors related to prescription pattern variation, with the goal of informing interventions to reduce potentially harmful prescription.

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