Physicians’ orders to cancel standing prescriptions sometimes don’t get through to pharmacists, resulting in refills on prescriptions that are unneeded or even hazardous, researchers said.
Of every 200 instances when a physician ordered the discontinuation of a patient’s medication, the prescription was still refilled in about three cases, reported Adrienne Allen, MD, MPH, of North Shore Physicians Group in Danvers, Mass., and colleagues in the Nov. 20 issue of Annals of Internal Medicine.
Among a total of 1,218 inappropriately refilled prescriptions, in 50 instances there was a substantial risk of harm to patients. These included potential allergic reactions, dangerous interactions with other prescribed drugs, and evidence that patients were already suffering adverse effects from the drugs to be discontinued.
Allen and colleagues indicated that communication about stopped prescriptions may not always reach the pharmacist.
“Physician offices do not routinely communicate medication discontinuation orders to retail pharmacies,” they wrote.
Although pharmacies may receive prescriptions through electronic health record systems – in fact, it’s a requirement for “meaningful use” of electronic records, Allen and colleagues explained – those systems may not alert the pharmacies when a standing prescription is cancelled.
Patients also bear part of the blame, insofar as they apparently initiated the refill requests despite being told by their doctors to stop taking the medications.
Allen and colleagues concluded that “further work should focus on evaluating methods of improving communication between providers and pharmacies to better reconcile medication lists, as well as explore strategies to improve patient knowledge and awareness of their medication regimen.”
The researchers examined records maintained by Harvard Vanguard Medical Associates, a large group practice with 15 outpatient clinics in eastern Massachusetts, for a 1-year period in 2008 and 2009. They searched for orders to discontinue medications in five classes that would ordinarily be taken chronically, such that multiple refills would likely be authorized.
The drug classes included cholesterol-lowering statins, antihypertensive drugs, anti-diabetic agents, antiplatelet products, and oral anticoagulants.
Allen identified 83,902 orders to discontinue medications of these types before the prescription had been exhausted in 30,406 adult patients.
However, in 1,218 cases (1.5%), the records indicated refills were dispensed after the discontinuations orders were entered (95% CI 1.4% to 1.5%).
Drugs in all classes were subject to the inappropriate refills. Among the major individual drugs, the one most commonly refilled after a discontinuation order was metoprolol (refilled in 2.5% of discontinuations); the least common was metformin (0.9%).
The drugs most commonly subject to discontinuation orders were lisinopril and simvastatin.
Certain patient factors appeared to be associated with inappropriate refills. Older age, Medicare insurance, more than 10 active prescriptions, and comorbid cardiovascular disease, diabetes, or hypertension were all significantly more common in these cases (all P<0.001).
In the 1,218 cases of inappropriate refills, Allen and colleagues determined that 416 “met criteria for higher risk for potential adverse events” according to a standard algorithm.
Fifty of these were suggestive of actual harm from the putatively discontinued drugs. Charts for 18 noted a documented adverse drug reaction; 17 showed a laboratory abnormality; eight indicated that a drug of the same class was also prescribed; and seven recorded a documented allergy to the drug. In 22 cases, the reason for discontinuation was not given in the chart.
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