Navigating the choppy waters of polypharmacy: who is responsible?
There is a longstanding — and ongoing — debate about who is responsible for individuals’ healthcare. Over many years, policy-makers, commissioners, clinicians and patient advocacy groups have argued backwards and forwards about the role of a lead clinician, or whether patients should hold their own records, and the role of patient advocates.
Certainly patients have the strongest incentive to ensure that they get the right treatment. However, they are also often ignorant about their treatment options. The imbalance of knowledge between patients and healthcare providers creates an uneven playing field when it comes to informed decision-making. This is particularly true when it comes to medication.
Decoding the medication administration chain
Unfortunately, many patients do not really know much about the drugs prescribed to treat their conditions. One study among attendees at surgical and medical outpatient clinics in Sri Lanka found that at the study baseline, nearly half the patients had very poor knowledge of the drugs they had been prescribed. For 42% of drugs, they knew only the name. They knew about side effects and storage conditions for just 7% of prescribed drugs. This is concerning because, as the same study pointed out, patients are the “last link in the medication administration chain”. They are therefore the final people who can prevent incorrect medication use.
However, if patients are the last link, there are others further up the chain who could also prevent problems. The first is the prescriber, usually a healthcare professional. They should have access to a comprehensive medical history for each patient. This will ensure that patients get the right medication for their condition, and also that potential interactions with previous medications are avoided.
Sadly, however, notes are often incomplete, or provider-specific. Notes from one institution are often not accessible to healthcare professionals elsewhere. Additionally, few professionals have time to do more than skim the notes for each patient. They are unlikely to have time to take in all the nuances of all the medications that are already being prescribed. They may rely on the patients to tell them about other medications — but as we already know, patients are not very good at that.
Insurers or payers may also have a role in preventing incorrect medication prescribing, especially in a system that requires pre-approval of prescriptions. They too should have a complete record of any prescriptions for each patient. However, not all side effects or interactions between medications are known. Insurers are also unlikely to be staffed by people with the knowledge to detect problems, which means that it needs to be done by an algorithm. This has potential, but will only work where pre-approval is needed.
Pharmacists are the next link in the chain. They are responsible for dispensing the prescriptions, and often pick up errors in dose or drug. However, they also often play a far greater role in medication management. Many people always use the same pharmacy for their prescriptions, so the pharmacist has a record of what has been dispensed before. They can therefore see if any previous medications could be a problem, and suggest an alternative to the prescriber. They also have a role in educating patients about their medication. For example, the Sri Lankan study mentioned before found that when pharmacists gave patients information about their medication in their native language, the patients knowledge increased significantly. This was particularly true when the information was written rather than spoken.
There is one other link in the chain, and that is anyone who may help the patient to take their medication. This might be family members, or the staff in a long-term care facility, hospital or hospice, or even a home care provider. These people are unlikely to be registered healthcare professionals, but they can check the instructions on a medicine packet, and may therefore pick up errors or potential problems.
A complex picture
There are therefore many people involved in the medication management chain. They all have different roles and opportunities for preventing medication errors, and ensuring that polypharmacy is managed appropriately. There is no obvious way in which responsibility for this could be placed on one single person. However, there is also no question that patients have both the biggest incentive to ensure things are right, and the least specialist knowledge. I believe we therefore need to find ways to empower patients to understand what is happening, and enable them to take an intelligent part in the debate about their health.
