Award-Winning Study of Veterans Finds Increased Risk for Unsafe Prescribing

When Medicare Part D — federal coverage for prescription drugs — went into effect in 2006, its goal was to increase access to affordable prescription medications for older Americans. It also allowed older patients under the Department of Veterans Affairs’ care to receive affordable prescriptions from both VA and Medicare providers.

While at first glance this had the desired effect of improving access, a University of Pittsburgh research team has found that policies that expand access to providers across health care systems may have unintended, negative consequences for veterans.

Joshua Thorpe, an associate professor in Pitt’s School of Pharmacy, and his colleagues used VA and Medicare data to identify nearly 76,000 veterans with dementia who were enrolled as “dual users” in both health care systems from 2007 through 2010.

They found that, compared with VA-users only, veterans who used both VA and Medicare had more than double the odds of exposure to potentially unsafe medication. For those over 65 years of age, Thorpe said this includes Benadryl or evening medicine containing diphenhydramine, an antihistamine mainly used to treat allergies.

“These are drugs that could make you sleepy and a little dizzy,” potentially leading to falls, Thorpe said. “These are things you really don’t want people with Alzheimer’s disease taking.”

More broadly, the team’s findings suggest that being prescribed medications across the unconnected care systems also increased the risk for unsafe prescribing. Thorpe said one of the biggest examples of this is antipsychotic medication for dementia patients, which can add more health problems and hasten death.

“The downside of this policy is that when veterans go outside of the VA, they’re no longer part of our integrated health care system,” said Thorpe. “Unfortunately, there is currently no electronic medical record exchange across systems, making it difficult to ensure highly coordinated health care.”

The project earned Thorpe the 2017 VA’s Best Research Paper of the Year Award.

Other School of Pharmacy contributors to this study are associate professor Carolyn Thorpe, Joshua Thorpe’s wife, and PhD candidate Loren Schleiden.

“With the current system, it is up to the veteran and their family members to coordinate and communicate complex health information across systems and providers,” Joshua Thorpe said. “It’s sometimes difficult for any of us to keep track of our medical history, current and past treatments, and changes to medication regimens. It is particularly difficult for patients with memory problems such as those with Alzheimer’s disease.”

The exact reasons why these patients become dual users are not yet known. The team is conducting further studies to find out why, but one possible reason, Thorpe suggests, is location.

“Most of these VA medical centers are in densely populated areas, so some people living in rural areas may rather drive five minutes to their community doctor than drive an hour to the VA,” he said.

Possible solutions to the prescribing problems, Thorpe said, include having a pharmacy management system to coordinate with and help patients who are dual users and thinking ahead when it comes to new policies.

Overall though, Thorpe said the key to preventing this problem is better communication on all fronts.

“There needs to be a system that communicates with each other and doesn’t rely on patients who have enough to worry about to communicate complex medical information across all these physicians and systems,” he said. “We want to make sure these patients get the medications they need or not get the medications they shouldn’t be on.”

Thorpe, who teaches in the Department of Pharmacy and Therapeutics, is also a Health Scientist in the VA’s Center for Health Equity Research and Promotion in Pittsburgh.

He hopes his research ultimately influences policy, and it appears to be on its way.

VA leaders in Geriatrics and Extended Care, Pharmacy Benefits Management Services and the Center for Medication Safety have reached out to Thorpe to discuss new federal approaches to reduce the risk for potentially unsafe prescribing for veterans.