Patient and physician factors contributing to polypharmacy among older patients

Abstract

Objective

Polypharmacy, or use of multiple medications, is associated with patient factors. Less is known regarding variation in polypharmacy by individual physicians. The objective of this study was to assess patient and physician factors associated with polypharmacy among older patients.

Methods

This is a cross-sectional study of patients aged ≥65 years with a primary care visit at Cleveland Clinic Health System in 2015 and their physicians. We collected patient demographics, comorbidities and current medications from the electronic health record, including potentially inappropriate medications (PIMs). We used mixed effects linear regression to estimate adjusted differences in the number of medications by patient factors. We generated adjusted prescribing rates for individual physicians and assessed differences in physician performance on quality measures by their prescribing rate.

Results

Our study included 44,570 patients who were prescribed an average of 6.8 medications (standard deviation: 4.0) by 701 physicians. Female sex, higher BMI, having Medicaid insurance, current or former smoking status, comorbidities and seeing a specialist were associated with number of medications. Age was not. Among 267 physicians who saw ≥20 study-eligible patients, the adjusted mean number of medications per patient ranged from 5.2 to 9.6. Compared to physicians who prescribed above the mean, lower prescribing physicians performed significantly better on medication reconciliation (p = .007) and hypertension control (p < .001) and prescribed fewer PIMs (p < .001).

Conclusions

Individual physicians varied in their prescribing practices, even after adjusting for patient demographic and clinical characteristics. Interventions to reduce polypharmacy in older adults should target high prescribing physicians, as physician behavior is more actionable than patient factors.

Keywords:

• Polypharmacy
• prescribing
• older adults
• patient factors
• physician factors

Transparency

Declaration of funding

There was no funding for this study and this study has no sponsor.

Declaration of financial/other relationships

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

All authors directly participated in the study. M.B.R. and N.M.G. conceived of and designed the study. K.A.M. and D.T.L. performed analyses and wrote the manuscript. D.T.L. and D.M. conducted the literature review. N.M.G. and M.V.A. extracted the data and performed preliminary analyses. B.H. performed advanced statistical analyses. S.L. and G.R.A. provided content expertise on polypharmacy and L.D.K. provided content expertise on prescribing for older adults. All authors contributed to discussions and reviewed and edited the manuscript. All authors agree to be accountable for all aspects of the work.

Acknowledgements

This study was presented as a poster at the 2018 Society of General Internal Medicine National Meeting in Washington, DC.