A retrospective UK study analyzed the additional healthcare costs attributable to inadequate prescribing practices. As data from Switzerland show, among other things, the prescription prevalence of benzodiazepines in patients in the age group ≥65 years must be critically questioned. Long-term use of such substances is addictive and associated with other undesirable side effects.
While primary prevention is concerned with maintaining health or preventing disease, secondary prevention deals with early detection or prevention of the progression of a disease, and tertiary prevention focuses on preventing the progression or occurrence of complications in an already manifest disease. Avoidance of unnecessary diagnostic and therapeutic interventions, including avoidance of overmedication, is at the quaternary prevention level. An estimate by the Department of Health and Social Care in the United Kingdom found that about 10% of prescriptions related to polypharmacy are unnecessary [1]. A health economic study estimated the costs incurred by the National Health Service (NHS) in the United Kingdom (UK) due to unnecessary, non-indicated or dispensable prescribing of drugs with high dependence potential [2]. These substances include antidepressants, opioids, gabapentinoids, benzodiazepines, and the so-called “Z-drugs” – a class of novel hypnotics whose active ingredients begin with the letter Z (non-benzodiazepine agonists such as zolpidem, zopiclone, and zaleplon) [3].
Study shows: unnecessary use of opioids & co. causes high costs
Evaluated prescribing in primary care in GB from April 2015 to March 2018 [2]. The following data were analyzed: Number of adults continuously prescribed drugs with high dependence potential, duration of prescriptions*, “Net Ingredient Cost” (factory selling prices excluding VAT and distribution costs) and dispensing costs for each drug#. Consultation costs were calculated based on guideline recommendations and the number of long-term medication monitoring consultations demonstrated in previous studies.
* Data source: Public Health England
# Data Source: NHS Business Service Authority
For opioids, gabapentinoids, benzodiazepines, and “Z-drugs,” the total estimated unnecessary costs over three years (April 2015 to March 2018) were GBP 1,367,661,104 to GBP 1,555,234,627. For antidepressants, the estimated total unnecessary costs for one year ranged from GBP 37,321,783 to GBP 45,765,504. These data suggest that the NHS in England could suffer a significant estimated average annual loss of GBP 455,887,035 to GBP 518,411,542 for opioids, gabapentinoids, benzodiazepines, and “Z-drugs” and an estimated annual loss of GBP 37,321,783 to GBP 45,765,504 for antidepressants. Together, this results in an estimated annual loss of GBP 493,208,818 to GBP 564,177,046 as a result of non-indicated or unnecessary prescribing of drugs with high dependence potential. The authors point out that these are conservative estimates and that the effective figures could be even higher.
Overmedication is also a problem in Switzerland: example of benzodiazepines
A research team investigated benzodiazepine prescribing practices in nine Swiss cantons among persons aged ≥65 years [10]. A total of 69 005 subjects were included in the study. Approximately 20% of participants received at least one benzodiazepine prescription in 2017. Prescription prevalence increased with age (65-69: 15.9%, 70-74: 18.4%, 75-80: 22.5%, >80: 25.8%) and was higher in women (25.1%) than in men (14.6%). Participants with the highest health insurance deductible (CHF 2500) were 70% less likely to receive a prescription than participants with the lowest deductible of CHF 300 (OR=0.29, 95% CI: 0.24-0.35).
Individuals with at least one prescription were more likely to be hospitalized for trauma (OR=1.31, 95% CI: 1.20-1.44) and had 70% higher health care expenditures. Insured persons in the canton of Valais were three times more likely to receive a prescription than insured persons from the canton of Aargau (OR=2.84, 95% CI: 2.51-3.21). The study authors note that the proportion of ≥65-year-olds prescribed at least one benzodiazepine is high. Those affected are more likely to be hospitalized due to trauma and have higher health care expenditures. There were large differences in prescription prevalence between different cantons, which is an indication of possible overuse. Further studies are needed to elucidate the underlying causes of the findings identified.
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Polypharmacy in old age: risk-benefit assessment Older patients in particular often take a veritable cocktail of drugs. But not everything is always necessary, some can even be harmful. Therefore, it may be useful to regularly review the therapy and adjust it if necessary ( Tab. 1). This applies, among other things, to the long-term use of benzodiazepines, as they can be highly addictive and have various side effects. Although the benefit for short-term use – for example, as psychiatric crisis intervention or for induction of anesthesia prior to surgical procedures – is undisputed [6]. For the individual assessment of individual potentially critical drugs, the STOPP list (Fig. 1) or the online tool “Medstopper” can be consulted [7–9]. The potential for interaction of prescribed medications can be seen at www.mediq.ch or |
Structured programs with countermeasures
Given the significant unnecessary costs incurred, which point to care practices in need of quality improvement, it is important to develop programs that counteract this, he said. A current project launched in the UK on this is the nhsE & I national Structured Medication Review (SMR) program, which aims to address unnecessary overmedication in the context of polymedicated patients.
Overmedication is also a problem in Switzerland. The guideline, created by a Swiss working group, is intended to provide guidance to improve the treatment of elderly and multimorbid patients. The procedure can be put into a logical flow of four steps [4,5].
Inventory and Medication Reconciliation: A necessary prerequisite for an analysis and optimization of medication therapy is the recording/reconciliation of all medications taken. It is recommended that this be systematically recorded once or twice a year or when problems arise or after hospitalization.
Medication Review: The necessity of medications should be critically evaluated as a matter of principle. For certain groups of drugs, it is particularly worthwhile to take a closer look and perform critical reviewing. In structured evaluation, the (modified) Medication Appropriateness Index can be used.
Decision making/prioritization: What is most important to the patient at this time? Which complaints particularly restrict him/her in everyday life at the moment? Consideration of life expectancy and frailty
Medication Schedule: The medication list should contain at least the following information: Name and age, medication (trade name) and dosage, intake (Mo-Mi-Ab-Na).
Literature:
- “Good for You, Good for Us, Good for Everybody,” DHSC, Sept 2021, https://assets. publishing.service.gov.uk/government/uploads/system/uploads/attach ment_data/file/1019475/good-for-you-good-for-us-good-for-everybody. pdf#page32.
- Davies J, et al: The costs incurred by the NHS in England due to the unnecessary prescribing of dependency-forming medications. Addict Behav. 2022 Feb; 125:107143. doi: 10.1016/j.addbeh.2021.107143
- Deutsche Hauptstelle für Suchtfragen: Die Sucht und ihre Stoffe www.dhs.de/fileadmin/user_upload/pdf/Broschueren/Sucht-und-ihre-Stoffe_BENZODIAZEPINE.pdf, (last accessed 02.03.2022)
- Neuner-Jehle S, Senn O: Polypharmacy, Last modified: 11/2021, www.medix.ch/wissen/guidelines/medikation/polypharmazie (last accessed 03/02/2022).
- Parekh N, et al: Incidence of Medication-Related Harm in Older Adults After Hospital Discharge: A Systematic Review. J Am Geriatr Soc 2018; 66(9): 1812-1822.
- Gallagher P and O’Mahony D: STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers criteria. Age and Ageing 2008; 37: 673-679.
- O’Mahony D, et al: STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age and Ageing 2015; 44: 213-218.
- Hill-Taylor B, et al: Application of the STOPP/START criteria: a systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact. Journal of Clinical Pharmacy and Therapeutics, 2013; 38: 360-372.
- Blozik E, et al: Polypharmacy and Potentially Inappropriate Medication in the Adult, Community-Dwelling Population in Switzerland. Drugs Aging 2013; 1-8.
- Luta X, et al: Patterns of benzodiazepine prescription among older adults in Switzerland: a cross-sectional analysis of claims data. BMJ Open 2020 Jan 6; 10(1): e031156.
- “Research suggests benzodiazepine use is high while use disorder rates are low,” National Institute of Drug Abuse (NIH), Oct. 18, 2018, www.drugabuse.gov/news-events/latest-science/research-suggests-benzodiazepine-use-high-while-use-disorder-rates-are-low (last accessed Mar. 02, 2022).
HAUSARZT PRAXIS 2022; 17(3): 42-43
