Polypharmacy and the Triple Aim

May 4, 2016 / By Steve Delaronde

Nearly 60 percent of Americans have taken a prescription medication in the past month.  This does not include dietary supplements or over-the-counter (OTC) drugs.  The proportion of prescription drug users increases to nearly 90% among non-institutionalized persons 62 years and older according to an April 2016 JAMA Internal Medicine article.  More than one-third of older Americans concurrently use five or more prescription medications, and when supplements and OTC drugs are included, polypharmacy, or the excessive and unnecessary use of prescription and over-the-counter medications, increases to two-thirds of older adults.

Adverse drug events leading to emergency department visits and hospitalizations are often associated with inappropriate, excessive and uncoordinated prescribing of prescription medications.  Prescription drug use is increasing and shows no signs of abating.  Supplement and OTC drug use is also increasing. For example, one-third of Americans are diagnosed with high blood pressure and 28 percent of adults aged 40 and over are using a cholesterol-lowering medicine.  It is imperative that physicians have a comprehensive understanding of all types of drugs and supplements taken by their patients if adverse drug events and interactions are to be prevented.

Care coordination is the hallmark of successful implementation of the Triple Aim (lower costs, better outcomes, and a positive patient experience).  The role of primary care in coordinating the healthcare services received by patients may be most important when it comes to medication management. 

Prescription drugs taken for acute conditions such as infections, rashes and temporary pain are less likely to have long-term effects.  However, as more Americans are diagnosed with and treated for multiple chronic conditions such as hypertension, high cholesterol, depression, diabetes and asthma, the risk of polypharmacy and adverse events increases.

The following three approaches should be prioritized if polypharmacy is to be effectively addressed and the Triple Aim is to be realized.

1. Monitor the use of all drugs, including nutritional supplements and OTC drugs – Since it is estimated that one-quarter of patients do not report herb and supplement use to their primary care physicians, this type of questioning and data collection must become a routine part of the patient-physician encounter.
2. Deprescribing – The systematic process of identifying and discontinuing drugs in which potential harms may outweigh potential benefits. Ian Scott and colleagues recommend a five-step deprescribing protocol designed to minimize polypharmacy and improve patient outcomes.
3. Care coordination – Fragmented care leads to more prescriptions. Emergency rooms, hospital discharges and specialist care all increase the likelihood that a patient will receive a prescription – particularly one that is prescribed without the prescriber’s knowledge of all other medications that the patient is taking.

Ultimately, polypharmacy is just one aspect of uncoordinated, and often unnecessary, care that must be addressed by the U.S. healthcare system.  Adverse drug events can be avoided, lives can be saved, and the goals of the Triple Aim can be met by coordinating and reducing patient use of prescription medication, nutritional supplements and OTC drugs.

Steve Delaronde is director of consulting for populations and payment solutions at 3M Health Information Systems.