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What’s New in the Patient Safety World

November 2020

The Costs of Inappropriate Medications



Most of our columns on PIM’s (Potentially Inappropriate Medications) in the elderly have focused on the safety issues. But there is also a fiscal downside of such prescribing. Two recent articles in the Journal of the American Geriatrics Society have highlighted those costs.


Clark et al. (Clark 2020) used data from the 2011–2015 Medical Expenditure Panel Survey (MEPS) to estimate the prevalence of PIM prescribing in community‐dwelling U.S. adults aged 65 and older. According to the press release for this study (UB 2020), “among the 218 million-plus older adults surveyed, more than 34% were prescribed at least one potentially inappropriate medication. Those patients were, on average, prescribed twice as many drugs, were nearly twice as likely to be hospitalized or visit the emergency department, and were more likely to visit a primary care physician compared to older adults who were not prescribed potentially inappropriate medication.

Patients who received these medications also spent an additional $458 on health care, including an extra $128 on prescription drugs.”


In that study the crude rate of hospitalizations was higher in those prescribed PIM’s at 35.6 per 100 persons versus 19.3 per 100 persons in the non-PIM group. The rate of ED visits was 41.1 per 100 persons in the PIM group compared with 23.6 per 100 persons in the non-PIM group. In the crude data, the difference in average total expenditures was higher for those on PIM’s within the inpatient ($1,767), ED ($141), and outpatient ($1,568) settings. Prescription drug expenditures were also higher in those prescribed PIM’s ($2,263). Totaling expenditures across all types resulted in a difference of $5,168 for those exposed to PIM’s as compared with the non-PIM group.


The authors did note a small but significant decrease over the period studied in the use of specific inappropriate medications including antispasmodics, antidepressants, digoxin, non-benzodiazepine hypnotics, androgens, estrogens, and metoclopramide. But, notably, some of the agents most commonly targeted for deprescribing in older adults (eg, first generation antihistamines, antipsychotics, benzodiazepines, nonsteroidal anti-inflammatory drugs, PPI’s, and long-acting sulfonylureas) did not change over this time period.


They conclude that PIM’s continue to be prescribed at high rates among older adults and are associated with increased healthcare utilization and costs across the healthcare continuum. They note that deprescribing is “currently in its infancy” in the United States, and that further interventions are needed to target unnecessary and inappropriate medications in older adults and reduce unnecessary healthcare utilization.


In the other study, Fralick et al. (Fralick 2020) analyzed data from the Medicare Part D Prescription Drug Program data set (2014–2018). They found that, from 2014 to 2018, 43 billion doses of potentially inappropriate medications were dispensed, with a reported spending of $25.2 billion. In 2018, 7.3 billion doses of potentially inappropriate medications were dispensed. The most common medications by number of doses dispensed were proton pump inhibitors, benzodiazepines, and tricyclic antidepressants, and the top five unique medications by reported spending were dexlansoprazole, esomeprazole, omeprazole, dronedarone, and conjugated estrogens.


Speaking of proton pump inhibitors, another recent study (Patel 2020) confirmed a point we have made over and over – PPI’s (and other acid suppressing medications) are often inappropriately continued after patients are discharged from or transferred from the ICU. The researchers analyzed data on patients admitted to ICU’s from 13 hospitals within a health system over a 6-month period. The highest incidence of inappropriate medication continuation after ICU transfer or discharge occurred in patients receiving a PPI (26.78%), followed by H2 blockers (8.39%) They also found frequent inappropriate continuation of bronchodilators (5.9%). They conclude that inappropriate discharge of patients on these medications not only poses risk for long term effects on a patient’s body but also costs the patients money for a medication they may not require.


Those authors note that studies have shown no benefits of adding PPI/H2RA medications in decreasing morbidity and mortality in the ICU and that many studies on long-term PPI usage have shown adverse effects. That is in keeping with a just-released scientific statement from the American Heart Association “Prevention of Complications in the Cardiac Intensive Care Unit” (Fordyce 2020) noted in our November 2020 What's New in the Patient Safety World column “Prevention of Complications in the Cardiac Intensive Care Unit”. That statement says “Newer evidence suggests that stress ulcer prophylaxis may be associated with reduced gastrointestinal bleeding in high-risk patients but overall has no demonstrated mortality benefit, and the number needed to treat is high.” It goes on to say “Routine use of stress ulcer prophylaxis is not necessary for low-risk patients in the CICU (cardiac ICU), including all patients receiving MV (mechanical ventilation). Stress ulcer prophylaxis is reasonable for patients in the CICU with multiple risk factors for gastrointestinal bleeding (including patients with shock, acute kidney injury requiring renal replacement therapy, MV, liver disease, use of anticoagulants, and ongoing coagulopathy as defined by platelet count <50 000/m3, an international normalized ratio >1.5, or a partial thromboplastin time >2 times the control value or on dual antiplatelet therapy), although the data supporting this approach are weak.”


Based on their findings of inappropriate continuation of these categories of drugs, Patel et al. believe that a multidisciplinary approach to medication reconciliation during ICU downgrade would prove beneficial in preventing such occurrences.


Bottom line: Far too many patients continue to take medications that are likely to be inappropriate. This leads not only to adverse effects on the patients but also increases healthcare utilization and costs. Careful medication reconciliation is needed at all transitions of care and, for most older adults, the annual “brown bag” medication review is important. Evidence-based deprescribing is critical in reducing hazards to patients and costs to the healthcare system. It’s also worth noting our previous warnings that sometimes the drug you thought you discontinued is still being taken by your patients.



Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:




Some of our past columns on deprescribing:




Some of our previous columns on medication reconciliation:


October 23, 2007 “Medication Reconciliation Tools”

December 30, 2008 “Unintended Consequences: Is Medication Reconciliation Next?”

May 13, 2008 “Medication Reconciliation: Topical and Compounded Medications”

September 8, 2009 “Barriers to Medication Reconciliation”

August 2011 “The Approach to Medication Reconciliation”

January 2012 “AHRQ’s New Medication Reconciliation Tool Kit”

September 2012 “Good News on Medication Reconciliation”

October 1, 2019 “Electronic Medication Reconciliation: Glass Half Full or Half Empty?”

July 2020 “Not Following Medication Changes after Hospitalization?”



Some of our other columns on failed discontinuation of medications:


May 27, 2014              “A Gap in ePrescribing: Stopping Medications”

March 2017                 “Yes! Another Voice for Medication e-Discontinuation!”

February 2018             “10 Years on the Wrong Medication”

August 28, 2018         “Thought You Discontinued That Medication? Think Again”

December 18, 2018     “Great Recommendations for e-Prescribing”

August 2019               “Including Indications for Medications: We Are Failing”

August 6, 2019           “Repeat Adverse Drug Events”







Clark CM, Shaver AL, Aurelio LA, et al. Potentially Inappropriate Medications Are Associated with Increased Healthcare Utilization and Costs. J Am Geriatr Soc 2020; Published online 05 August 2020



UB (University at Buffalo). Study: 34% of older adults in the U.S. are prescribed potentially inappropriate drugs, raising health care costs by hundreds. (Press Release). Newswise 2020; October 21, 2020



Fralick, M., Bartsch, E., Ritchie, C.S. and Sacks, C.A. (2020), Estimating the Use of Potentially Inappropriate Medications Among Older Adults in the United States. J Am Geriatr Soc 2020; Early View



Patel J, Reddy P, Toa M, et al. Inappropriate Continuation of Acid-Suppression Medication and Bronchodilators on Discharge from ICU. Chest Annual Meeting 2020; October 18-21, 2020



Fordyce CB, Katz JN, Alviar CL, et al. Prevention of Complications in the Cardiac Intensive Care Unit: A Scientific Statement From the American Heart Association. Circulation 2020; Published online 29 October 2020







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