“Prescribing Inertia” and “Medication Reconciliation.” Familiar Terms?

The “Interesting Article of the Week” is:

Knowing how to stop: ceasing prescribing when the medicine is no longer required.

J Manag Care Pharm. 2012 Jan-Feb;18(1):68-72.  Ostini RHegney DJackson CTett SE.

Pubmed citation found here. Free full text!

Happy medicationThis is a great paper about “prescribing inertia,” which is the tendency for medications, once prescribed, to be continued indefinitely even when this is not good medical practice.  The easiest example that comes to mind is PPIs, like omeprazole.  Once a patient gets started on a PPI, it tends to be continued forever.  Other examples, however, are NSAIDS, anti-depressants and chronic benzodiazepines.  If the clinical indication for a medication has passed, the patient cannot get any benefit from the drug but still is susceptible to all of the medication’s side effects.

Let me give two examples that I am personally acquainted with.  A friend of mine began to take high dose Naproxen due to a minor athletic injury.  When the injury healed, he continued to take Naproxen every night before bed even though he did not hurt any more simply because it was his habit and because (as he put it) “Maybe I’ll wake up with pain during the night.”  Unfortunately, what he woke up with one morning was projectile vomiting of bright red blood from his NSAID-induced ulcer.

Another friend was started on blood pressure medications when he was overweight and out of shape.   Year or so later, he became quite fit and lost a substantial amount of weight.   However, nobody thought to see if he still needed antihypertensive drugs—despite the fact that every single blood pressure he had over the next four years was normal, and I mean like 108/66 normal.  Hypertension, of course, like Type 2 diabetes, is part of the “metabolic syndrome,” and often will improve or even go away entirely if patients lose weight.  This particular guy competes in Triathlons, for heaven’s sake!  So, his doctor finally stopped his blood pressure meds and–who’d a thunk it?—his blood pressures remained normal.

I see this frequently in my jails.  Patients come to jail taking medications that they clearly don’t need (in my opinion).  Doxycycline for invisible acne.  Metformin for patients without Type 2 diabetes (or even insulin resistance).  Two different  SSRIs in the same patient.

According to this weeks interesting article, the main obstacle to stopping unnecessary medications is the patient’s perception that taking these medications is the standard of care and that stopping them is substandard care.  “My doctor thinks I need this,” they will say.

I agree.  In order to effectively stop unnecessary medications, you need to have patient buy-in.  In my experience, the easiest way in correctional medicine to get patient buy-in is to call the patient’s outside physician, explain what medication changes you want to make, and ask if that is OK.  Almost always, the outside physician will agree.  Then you can approach the patient by saying, “I’ve been talking to your doctor and we both think we should make some changes in your medications.  Here are the changes and here is why we are doing it (with the emphasis on we).”  (see The Right Way to Deal with Outside Physicians).

There actually is a term for this process.  It is called “Medication Reconciliation” and is a term invented by JCAHO, which accredits hospitals.  JCAHO requires all hospitals to do a “Medication Reconciliation” for each and every patient being discharged from that hospital.  Even ER patients!

The process of Medication Reconciliation in hospitals involves going over each patient’s personal medication list, plus any new medications prescribed at the hospital, looking for unnecessary medications, unnecessary polypharmacy, drug interactions, etc.  Often in the hospital, this is done with the aid of a clinical pharmacist.

I think “Medication Reconciliation” is a great term and a great idea that we should adopt in Correctional Medicine.  But instead of doing our “Medication Reconciliation” when patients are discharged from our facilities, we should do it when patients come into the facility.  Input from a clinical pharmacist, especially for complicated cases or long drug lists, would be especially helpful.

Do you have any good stories about “Medication Reconciliation” at your facility?  Please comment!

Interesting Article of the Week Plus Price Check!

An acquaintance complained to me recently that he was struggling to afford his medications, which cost him a couple of hundred dollars a month.  I looked at his medication list and saw (among other examples) that he had been prescribed the statin Crestor, which costs $5.00 a pill, even though generic simvastatin costs just 3 cents a pill!  He was prescribed the Angiotensin Receptor Blocker (ARB) Benicar ($4.26 a pill) even though the generic ARB losartan costs 7 cents a pill.

When I called the prescribing doctor on behalf of this patient, the doctor readily changed his prescriptions to the more affordable brands.  But why would he prescribe expensive stuff his patient couldn’t afford in the first place?  That is the subject of our interesting article of the week.

Ann Pharmacother. 2012 Feb;46(2):200-7. Epub 2012 Feb 7.

Assessment of prescribers’ knowledge of the cost of medications.

Cogdill BNappi JM.

(Click here to go to the PubMed citation)

This study assessed physician and medical students’ knowledge of drug prices. The prescribers in the study did amazingly poorly on a test of their knowledge of drug prices.  That didn’t surprise me.  What did surprise me, however, that the prescribers seemed not to care that they did not know drug prices! They didn’t seem to think it was important.  These prescribers also routinely prescribed medications without knowing or checking whether their patients had insurance that would cover the drug.

This attitude may be common (common?  Almost universal!) in the outside world of medicine, but it has no place in Correctional Medicine.  We prescribers who work in correctional facilities need to have an idea of what drugs cost.

  1. Most of our patients will eventually get out of our jails and prisons.  Most of them will not have medical insurance.  We need to prescribe medications that they will be able to afford.
  2. Besides being medical practitioners, we also are stewards of the money the county or state spends on medical care within our facility.  Every dollar that we spend needlessly is a dollar that cannot be used for something else.
  3. Besides looking for effective medications, we also need to look for medications with high value.  Value is a concept that seems to have been forgotten in modern medicine, as practiced in the United States at least.

What is the Value of a Drug?

The “Value” of a drug can be defined as the benefit of that drug divided by its cost.  If medication A and medication B both achieve the same result, but medication A is 20 times more expensive than medication B, then medication B has 20 times more value.

Sometimes, new and expensive drugs are touted by drug reps as having, say, “17% improved relative benefit” over the old, generic drug.  Almost always, these claims are unfounded or the difference is clinically meaningless.  But even if it is true, the generic drug  will still usually have more Value.  Nexium versus omeprazole is a good example.  AstraZenica, the maker of Nexium, claims that Nexium provides slightly better stomach acid control than does omeprazole.  Most experts do not believe this, but even if it is true, omeprazole costs 10 cents a pill, whereas Nexium costs $6.15 a pill.  Is Nexium 61 times more effective than omeprazole?  The answer is, of course, no.  Instead, omeprazole is 60 times more Valuable than is Nexium.

So why is Nexium one of the best selling drugs in the world?  The Interesting Article of the Week has the answer:  Because U.S. doctors don’t know how much Nexium costs and they don’t care.  Sad.

Let’s make sure that we Correctional Medical Specialists know the basic price of the drugs we use.  To do this, we need a source.  Your pharmacy is one source.  Have your pharmacy do a price comparison for you on a different category of drug every month.  You can also find the acquisition cost of most medications online.  Here is the one I use:  The Idaho Average Acquisition Cost Drug List.  It is published by Idaho Medicaid and is updated every two weeks.  You can find it here.

Price Comparisons

Here is the Average Acquisition Cost Drug List price for the medication classes I discussed in today’s post:

Angiotensin Receptor Blockers

Generic Drugs Brand Name Drugs Price per Pill
Losartan (Cozaar)50mg $0.07
Irbesartan (Avapro)150mg $1.83
Atacand (candesartan) 4mg $2.79
Benicar (olmesartan) 40mg $4.26
Diovan (valsartan) 40mg $2.67
Micardis (telmisartan) 40mg $4.02

Comment:  If you have to use an ARB rather than an ACE inhibitor, why would you use anything other than losartan (at least until the price of irbesartan falls to comparable levels?)


Generic Drugs Brand Name Drugs Price per Pill
Atorvastatin (Lipitor) 20mg $0.22
Simvastatin (Zocor) 20mg $0.03
Pravastatin (Pravachol) 20mg $0.07
Crestor (rosuvastatin)20mg $4.99
Livalo (pitavastatin) $4.14

Comment:  Note that atorvastatin is rapidly falling in price and will soon be comparable to simvastatin and pravastatin.  Lipitor was once the top selling drug in the world!

Proton Pump Inhibitors

Generic Drugs Brand Name Drugs Price per Pill
Omeprazole (Prilosec) 20mg $0.10
Lansoprazole (Prevacid) 15mg $1.27
Pantoprazole (Protonix) 20mg $0.09
Nexium (esomeprazole) 20mg $6.15
Dexilant (dexlansoprazole) 30mg $4.67
Aciphex (rabeprazole) 20mg $8.61

Comment:  Note that pantoprazole (Protonix) is now even a little less expensive than is omeprazole!  And remember that omeprazole also has an OTC formulation, so you can put it on your commissary, so inmates won’t have to come to you to get it.

Do you track drug prices at your facility?  How do you do it?  Please Comment!

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The Right Way to Deal with Outside Physicians

Those of us who practice medicine in jails frequently (Frequently? Daily!) run into the thorny issue of our relationship to the doctors who care for our patients outside of the jail.

When patients are in our jails, we are responsible for them; they are our patients. But these patients also have doctors outside of the jail that perhaps they have been seeing for years. The inmate considers their outside physician to be their “real” doctor, not us. (Throughout this article, I am going to use the term “doctors” rather than the more generic “practitioners.” I do not mean to slight nurse practitioners or physician assistants. What I say applies to them, as well.)

What brought this topic to mind is a case that occurred in one of my jails recently. A patient came to jail with a prescription pad filled out by his outside physician authorizing him to have a double mattress, an extra blanket and an extra pillow. (There was no note requiring us to feed him pizza every Friday night—he must have forgotten to ask for that.) So I was left in a little dilemma. What should I do about this note? Ignore it? Allow the inmate to have the extra comfort items?

Dealing with inmates’ outside physicians can be tricky, but I have found (mostly through sad experience) that there is definitely a right way and a wrong way to handle these encounters. The right way involves recognizing three important points:

Continue reading