Studies: Underprescribing, overprescribing both common

Finding the right fit for the prescription drugs taken by patients -- especially those who are older and on multiple medications -- is a difficult balance, according to a pair of studies published in October.

One, appearing in Medical Care, was based on the results of researchers' interviews and reviews of the records of 3,457 adults across the United States. They found that nearly 17% were prescribed a drug they did not need, but more than 37% didn't receive what they should have.

"Overuse and underuse is a problem everywhere," said William Shrank, MD, MSHS, lead author and an instructor at Brigham and Women's Hospital and Harvard Medical School in Boston.

The second paper, this one in the Journal of the American Geriatrics Society, found that 65% of the 196 older patients studied were on a drug they shouldn't have been taking and 64% were missing an important medication from their regimen. Many were both lacking a drug and taking one that was unnecessary.

"It's an issue of quality," said Michael Steinman, MD, lead author on that study and a geriatrician at the San Francisco VA Medical Center. "We need to be attentive to both of these prescribing problems."

Experts say some of these deficiencies, though not all, may be accounted for by individual factors associated with either the patient or doctor. These include variables such as concern about side effects or the preference to be less aggressive with a patient with a shorter life expectancy.

"There may be some mitigating factors specific to the doctor-patient relationship," said Joseph Keenan, MD, professor in the Dept. of Family Medicine at the University of Minnesota Medical School, Minneapolis. "But this is a high percentage who are over- or undertreated. This is not all due to some unique situation."

Many are particularly concerned about this phenomenon in seniors, who tend to be on multiple medications and are likely to have more than one chronic medical condition. For them, taking unnecessary drugs can add to the already significant cost burden of their prescription medications. Also, elderly physiology can be more sensitive to a drug's effects -- adverse or otherwise -- making this age group more likely to be harmed by the wrong mix.

"It's concerning at any age," said Dr. Keenan, who represents the American Geriatrics Society at American Medical Association meetings. "But the problem we find with under- or overprescribing in the very young or old is that their body's resources for dealing with it are limited."

Labor-intensive solutions

But while the problem is increasingly recognized, a solution is not clear. Those who work with this patient population say a comprehensive electronic medical record would be an enormous help. Until that is a possibility, many talk of a periodic visit devoted to reviewing what a patient is taking and why.

"There's no easy answer, but what this article encourages us to do is set aside some time for a detailed review of the prescription list for appropriateness," said Jane F. Potter, MD, president of the American Geriatrics Society and chief of the geriatrics and gerontology section at the University of Nebraska Medical Center, Omaha.

This strategy gives physicians an opportunity to discontinue a patient's drugs that are duplicative or were once necessary to treat symptoms that have disappeared. Other drugs can be changed for options that may be better suited to a geriatric patient. For instance, some medications, such as tricyclic antidepressants, which were on Dr. Steinman's list of inappropriately prescribed drugs, are not usually recommended in this age group.

"Many elderly patients have so many things wrong with them," said John Piette, PhD, a career scientist with the Ann Arbor VA Medical Center and associate professor of internal medicine at the University of Michigan. "It's hard to keep track of everything that's been started. They were probably appropriate when they were put on that drug, but some conditions do resolve. Overuse creeps in."

This review also could allow doctors to add new drugs to the mix -- even though the patient might not request it. While many drugs on the overuse list treated symptoms that a patient once may have had, quite a few on the underuse list were for conditions such as hypertension and hyperlipidemia that often show no signs but have long-term implications.

"There's a lot of medications for silent diseases that don't provide immediately tangible benefit for the patient," Dr. Steinman said. "[They] are not being taken."

Experts note, however, that this type of review is easier said than done. It can be tough to fit into a visit when patients often want many other concerns addressed.

"It's an almost overwhelming problem for the 15- to 20-minute visit," Dr. Keenan said.

Also, no single record of the medications may exist because they may have been prescribed by numerous physicians working in several different health systems and come from a variety of sources. They may even be leftover from deceased relatives.

"Prescribing for the elderly is a really complicated business," Dr. Steinman said. "The potential for overuse and underuse is great, and there are no systems to help to minimize these kind of problems."