Number of consulting medical institutions and risk of polypharmacy in community-dwelling older people under a healthcare system with free access: a cross-sectional study in Japan

Abstract

Background: Under the Japanese free access healthcare system, patients are allowed to consult multiple medical institutions (including clinics and hospitals for general or specialist consultation) without primary care referral. This potentially increases the risk of polypharmacy. We examined the association between the number of consulting medical institutions and polypharmacy under a healthcare system with free access. Methods: Via a self-administered questionnaire, we identified people aged ≥65 years with ≥1 disease and ≥1 consulting medical institution in a Japanese city in 2016. The exposure of interest was the number of consulting medical institutions (1, 2, or ≥3) and the outcome was polypharmacy (use of ≥6 types of drugs). We performed a multivariate logistic regression analysis, adjusting for age, sex, household economy, and the number and type of comorbidities. To minimize confounding effects, we also performed propensity-score-matched analysis, categorizing patients into two groups: 1 and ≥2 consulting medical institutions. Results: Of 993 eligible individuals (mean (standard deviation) age: 75.1 (6.5) years, men: 52.6%), 15.7% (156/993) showed polypharmacy. Proportions of polypharmacy were 9.7% (50/516), 16.6% (55/332), and 35.2% (51/145) for people who consulted 1, 2, and ≥3 medical institutions, respectively. Relative to people who consulted 1 medical institution, adjusted odds ratios (95% confidence intervals) for polypharmacy were 1.50 (0.94-2.37) and 3.34 (1.98-5.65) for those who consulted 2 and ≥3 medical institutions, respectively. In propensity score matching, of 516 and 477 patients who consulted 1 and ≥2 medical institutions, 307 pairs were generated. The proportion of polypharmacy was 10.8% (33/307) and 17.3% (53/307), respectively (P = 0.020). The odds ratio for polypharmacy (≥2 vs. 1 consulting medical institution) was 1.73 (95% confidence interval 1.09-2.76).

Association of Self-Reported Medication Adherence with Potentially Inappropriate Medications in Elderly Patients: A Cross-Sectional Pilot Study

“…In addition, the number of consulting medical institutions was associated with PP and PIM use. Cross-sectional studies in Japan have reported that patients who were prescribed by two or more physicians or who consulted more medical institutions are more likely to have PP and PIM use [8,70], as shown in our study. Furthermore, our study demonstrated that there is also a significant association between PP and PIM use, which is supported by previous reports [8,[20][21][22][23][24][25][26][27].…”

A narrative review of evidence to guide deprescribing among older adults

“…Another disadvantage of free access is polydoctoring, that is, patients seeking care from multiple providers. Since polydoctoring is a known risk factor for polypharmacy, 15 it is necessary to establish an environment in the Japanese healthcare system that encourages people to utilize primary care physicians as the point of contact for care, as well as better multidisciplinary cooperation. As stated before, the recent reimbursement system for deprescribing may not been widely recognized.…”

“…The Japanese healthcare system includes free access to healthcare facilities, which could lead to fragmentation of care without coordination (“polydoctoring”) 14 . The prevalence of polypharmacy is exceptionally high among older adults who visit multiple healthcare providers 15 . The revised Japanese Geriatrics Society guidelines explicitly disclosed the risks associated with multidrug use and listed potentially inappropriate drugs 16 .…”

Association between the size of healthcare facilities and the intensity of hypertension therapy: a cross-sectional comparison of prescription data from insurance claims data

“…One possible interpretation for the aforementioned association is that spontaneous role sharing in healthcare facilities emerged even though the Japanese healthcare system has a “free-access” attribute (even though a special fee can be required when patients visit large hospitals without referral, the proportion of hospitals charging the fee was below 50% at that time [ 26 ], and the healthcare provision system in Japan was still regarded as having a “free-access” attribute [ 27 , 28 ]). Patients with refractory conditions could be referred from small, general practitioner-like facilities to large-scale facilities to seek more specialized treatment, which results in the aforementioned association.…”