Access to Multiple Health Systems May Put Patients at Risk

Patients with dementia who received prescriptions through both the Veterans Affairs (VA) system and through Medicare Part D had double the odds of exposure to potentially unsafe medication prescribing, according to a recent study in Annals of Internal Medicine. 

The findings suggest prescribing safety may be compromised when national policies, such as the Medicare Part D prescription drug program, the Patient Protection and Affordable Care Act, and the Veterans Access, Choice, and Accountability Act, expand patient access to multiple health systems that are poorly coordinated.

Dementia care is particularly challenging, researchers explained, because patients, on average, have four comorbid conditions and receive care from five different providers. Furthermore, patients take an average five medications, and 69% take more than eight different drugs.

To investigate the effect of dual health system use on the risk of potentially unsafe prescribing in the population, researchers conducted a retrospective cohort study of 75,829 veterans diagnosed with dementia. Among the participants, 80% used the VA system exclusively and 20% used both the VA and providers outside the VA through Medicare Part D.

When researchers looked at veterans’ patient data, they found the prevalence of potentially unsafe medication prescribing was high overall (44%). However, it was much higher among users of both the VA and outside providers (59%) compared with patients who used the VA exclusively (39%).

“For the benefits of dual use (such as increased access) to outweigh the risks, careful comanagement of care between VA and non-VA providers is critical,” the researchers wrote. “Successful comanagement requires that health information exchange between systems—currently the responsibility of veterans and caregivers—needs to improve.”

The researchers also suggested additional medication therapy management services to better protect patients.

In an accompany editorial, David R Gifford, MD, MPH, of the Warrant Alpert Medical School of Brown University, said the findings are relevant to a wider population than veterans with dementia in the VA system.

“On the surface, the study... seems to be only about medication prescribing for dementia in the [VA] system, but it could serve as the basis for an entire medical school course on health policy,” he wrote. “It has far-reaching implications for health care system design, medication prescribing, and daily clinical practice, particularly for the care of patients with chronic disease.”—Jolynn Tumolo