How Medication Management Can Cut Admissions, ICU Stays

CMOs need their physicians to be addressing prescription overload.

For patients on multiple medications, deprescribing is a key strategy to promote patient safety and care quality.

The primary risk with multiple medications is medication interactions. This risk can lead to an increase or decrease in the effects of medications as well as undesired effects and side effects.

Cost and waste are other considerations, according to Karna Patel, MD, MPH, vice president at Tampa General Hospital and president of Tampa General Medical Group.

"As you add more medications, there is more cost to pay for those medicines," Patel says. "Globally, prescribing multiple medications can lead to waste of pharmaceuticals."

When assessing patients on multiple medications, clinic visits and visits in other healthcare settings are an opportunity to go over a patient's medication list, according to Patel.

"At that time, we want to make sure all the medications the patient is taking are appropriate for their conditions," Patel says. "We also check for interactions. That is a great time to try to deprescribe or consolidate medications."

For example, there may be three medications for three conditions, but there are medications that can be used for treating more than one condition, according to Patel.

"We want to look for an opportunity to use one medication rather than three medications," Patel says. "Deprescribing is one way to move forward when a medication is not needed and you can consolidate medications, so you are prescribing only the medications that are absolutely needed for patients."

Cymbalta is an example of a medication that clinicians can use to deprescribe and consolidate medications, according to Patel.

"Cymbalta is a medicine that is approved for anxiety, depression, neuropathy, and chronic pain," Patel says. "In many cases, patients take multiple medications to address those problems, and there is an opportunity to discontinue those medications and switch to Cymbalta, which can help with all of those conditions."

At Tampa General Hospital, referrals to pharmacists are also an opportunity to assess patients on multiple medications, according to Maja Gift, MHA, BS Pharm, senior director of pharmacy services at the academic medical center.

"We may have a physician who is concerned that a patient is on a lot of medications, and they will issue a referral to a pharmacist to conduct a review," Gift says. "Pharmacists have a lot of training, and they know a lot of details about medications, so it makes sense to pull them into a situation where a medication review is required."

Deprescribing best practices

The first step in deprescribing is looking at the current clinical status of the patient and their list of conditions, according to Patel. Then, clinicians should look at the medications and the evidence-based guidelines to see which medications are necessary and aligned with the evidence-based guidelines, and which medications are well tolerated by the patient, he says.

"Keeping all those things in mind, you go down the list of medications and make the decision of which ones to keep and which ones to discontinue," Patel says. "In addition, you want to look at which medications can be consolidated to address multiple problems."

Medication therapy management is the process for deprescribing, according to Gift.

"That process includes having a pharmacist review every medication a patient is on, evaluate for drug interactions, and evaluate for duplication of therapy because one medication can be enough instead of multiple medications," Gift says.

Medication therapy management is reimbursed by the Centers for Medicare & Medicaid Services as well as most commercial payers, according to Gift.

Best practices for deprescribing include allotting time to do the job, according to Patel.

"If there is a long list of medications, it can take 30 minutes to go through everything and make sure that you can consolidate and deprescribe," Patel says.

Another best practice for deprescribing is knowing when a medication should not be discontinued abruptly, according to Patel.

"Some medications require tapering, especially medications that have the risk of withdrawal," Patel says. "Other medications that do not require tapering can be stopped without being concerned about withdrawal symptoms."

Why multiple medications should concern CMOs

Multiple medications for patients should be on a CMO's radar because medication management is a component of value-based care, according to Patel.

"We are focused more on patient experience, quality, outcomes, and cost of care," Patel says. "Medication management is an important area for CMOs and health systems because if we are aiming for all of those things, we want to make sure patients are getting the medications that are needed—not multiple medications that are duplicated or are interacting."

There are other reasons CMOs should be concerned about patients with multiple medications, according to Patel.

"The side effects that can result from multiple medications can lead to increases in healthcare utilization, risk of going to the emergency department, hospital admissions, or ICU stays," Patel says. "There are other risks such as impacting the quality of life from falls or other injuries."