Reducing Adverse Drug Events: The Need to Rethink Outpatient Prescribing.


Gains in life expectancy in theUnited States are being eroded at least in part due to the use and misuse of prescribed medications.1 Earlier this year, theUSCenters forDiseaseControl and Prevention reported that life expectancy for some groups in the United States continues to stagnate. Amongmiddle-agedwhitewomen, life expectancy decreased, in large part due to medication overdose, opioid use, and liver disease.2 In this issueof JAMA, the reportbyShehabandcolleagues3 suggests that the burden and patterns of adverse health outcomes due to prescribed medications are broader than previously thought. The authors examined data from visits to 58 emergency departments (EDs) included in the National Electronic Injury Surveillance System–Cooperative Adverse Drug EventSurveillance (NEISS-CADES)projectandidentified42585 cases of adverse drug events (ADEs) in 2013-2014. The authors estimated that there were 4 ED visits per 1000 individuals for ADEs annually in theUnited States, and that 27.3%of EDvisits for ADEs resulted in hospitalization. Persons aged 65 years or older accounted for an estimated 34.5% of ED visits for ADEs and experienced the highest hospitalization rates (43.6%). Among adults, the majority of ED visits for ADEs was attributed to anticoagulants, antibiotics,medications for diabetes, and opioids. Among children, antibiotics and neuropsychiatric agents were among the most common causes of ED visits for ADEs. Even though this study specifically excluded ED visits for drug withdrawal, therapeutic failure, occupational exposure, intentional overdose, and recreational drug use, Shehab et al3 still found an estimated 1.3 million ED visits forADEs,nearly a 10%increase from2005-2006.Thestudy wasdesigned to identifyEDvisits related toADEs; coderswere trained to transcribe rather than interpret clinical notes. The ADEs summarized in this study appear to only be a fraction of the total ADEs in the United States. EmergencydepartmentswithinVeteransHealthAdministration (VHA)medical centers andother integratedhealth care systems, suchasKaiserPermanente,werenoteligible for inclusionintheNEISS-CADESsurveyandwerethereforenot included in thestudybyShehabetal.3The typesofexcluded institutions arenoteworthybecauseEDsfromintegratedhealthsystemssuch asVHAmedicalcentersmayprovideuniqueopportunitiestoaddressADEs.More than2.3millionEDvisitsoccurredacrossEDs withinVHAmedicalcenters in2013,4manyofwhichwereforpatientsolder than65years,whowereprescribedmultiplemedications,orboth.TheVHAmedical centers andother integrated healthcaresystemsthat shareclinicaldataacross inpatientand outpatientclinical settingsmayprovidean ideal setting tostudy patientswithADEs in greater detail anddevelop interventions to prevent, identify, and address ADEs. According to Rydon-Grange, “When everyone is responsible, no one is responsible.”5 Patients often receive prescriptions frommultiple clinicians; for example, the hepatologist manages medications for cirrhosis, the cardiologist manages medications forbloodpressure, theorthopedistmanagesshorttermpainmedications, the primary care physician or chronic painspecialistmanageschronicpainmedications, and thepsychiatrist manages medications for depression. In this fragmented health care system, clinicians often hesitate to discontinue medications because of lack of familiarity with the medication or patient. Evenwhen clinicians are familiarwith patients, it is difficult to coordinate medications for multiple comorbid conditions (eg, managing diuresis in patients with heart failure and chronic kidney disease). In acute settings such as the ED, concerns about ADEs due to prescribed medications are often not fully addressed because of the limited scope and timewith patients and barriers to communication between physicians in the ED and a patient’s primary care team.Within large, integrated health care systemssuchas theVHA(whichhasa single,nationwidemedical record), communication between ED physicians and other clinicians ismore feasible,whichenhances the role that theED canplay in providing care for patients.Whether this translates into better health outcomes for patients in integrated systems isunknownbutshouldbecarefullystudied.Changesareneeded across the US health care system to assign the role of primary responsibility to a single clinician or a core group for each patient and ensure the means for easily and effectively communicatingwhat should be a deliberate process of starting,monitoring, and discontinuing prescribed medications across multiple clinicians, caregivers, and health care settings. Shehabetal3describetherealityanddauntingchallengesthat facemore thanhalfofpatients in theUnitedStateswhoareprescribedchronicmedicationswhentheystate, “[p]atients inambulatory care and some postacute care settings can have complexmedication regimens, at times prescribed bymultiple clinicians, with far less monitoring compared with hospitalized patients.”More than 10%of individuals in theUnitedStates are prescribed 5 ormoremedications,6 which perhaps not coincidentally isapproximatelythesameproportionofthosewhoseek care in theEDannually.7 It isvirtually impossible to take5medications exactly as directed,8 and only an estimated 50%of patientstaketheirmedicationsasprescribed,regardlessofthenumberofprescribedmedications.9,10Giventherisksofdruganddiet Related article page 2115 Opinion


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