Polypharmacy composition and patient- and provider-related variation in patients with epilepsy

Abstract

Objective: To describe polypharmacy composition, and the degree to which patients versus providers contribute to variation in medication fills, in people with epilepsy. Methods: We performed a retrospective study of Medicare beneficiaries with epilepsy (antiseizure medication plus diagnostic codes) in 2014 (N = 78,048). We described total number of medications and prescribers, and specific medications. Multilevel models evaluated the percentage of variation in two outcomes (1. number of medications per patient-provider dyad, and 2. whether a medication was filled within thirty days of a visit) due to patient-to-patient differences versus provider-to-provider differences. Results: Patients filled a median of 12 (interquartile range [IQR] 8-17) medications, from median of 5 (IQR 3-7) prescribers. Twenty-two percent filled an opioid, and 61% filled at least three central nervous system medications. Levetiracetam was the most common medication (40%), followed by hydrocodone/ acetaminophen (27%). The strongest predictor of medications per patient was Charlson comorbidity index (7.5 [95% confidence interval (CI) 7.2-7.8] additional medications for index 8+ versus 0). Provider-to-provider variation explained 36% of variation in number of medications per patient, whereas patient-to-patient variation explained only 2% of variation. Provider-to-provider variation explained 57% of variation in whether a patient filled a medication within 30 days of a visit, whereas patient-to-patient variation explained only 30% of variation. Conclusion: Patients with epilepsy fill a large number of medications from a large number of providers, including high-risk medications. Variation in medication fills was substantially more related to provider-to-provider rather than patient-to-patient variation. The better understanding of drivers of high-prescribing practices may reduce avoidable medication-related harms.

Reappraisal of the Medical Research Council Antiepileptic Drug Withdrawal Study: Contamination‐adjusted and dose‐response re‐analysis

“…Second, given that the MRC study was conducted in the 1980s to 1990s, it lacks magnetic resonance imaging (MRI) data and newer‐generation ASMs. However, newer‐generation ASMs have not been shown to be more effective than older generation ASMs, 2 and these older‐generation ASMs remain in widespread use today 39,40 . Still, future studies including these more current practice elements would be beneficial.…”

“…However, newer-generation ASMs have not been shown to be more effective than older generation ASMs, 2 and these oldergeneration ASMs remain in widespread use today. 39,40 Still, future studies including these more current practice elements would be beneficial.…”

Antiseizure medication withdrawal risk estimation and recommendations: A survey of American Academy of Neurology and EpiCARE members

“…We recruited neurologists. This included epileptologists and nonepileptologists, to compare responses, and given many nonepileptologists care for epilepsy patients 19 . The first group included current US AAN members.…”

A polifarmácia para o tratamento da epilepsia na rede pública de saúde: uma revisão integrativa de literatura

“…À vista disso, por mais que a polifarmácia possa ser adequada clinicamente, ela também possui o risco de apresentar efeitos adversos, como hospitalização e óbito. Ademais, esse tipo de tratamento medicamentoso pode implicar na queda da qualidade de vida -em cerca de 25% -dos enfermos por sua capacidade de atacar o Sistema Nervoso Central (SNC) (Terman et al, 2020(Terman et al, , 2022.…”

“…Nesse viés, ainda comparada com a população geral, a epilepsia propicia, de três a cinco vezes mais, a autointoxicação por medicamentos, incluindo opióides e psicotrópicos. Não obstante, a prescrição da polifarmácia não é dependente apenas das características do paciente e da sua adesão ao tratamento, mas também do papel do médico nas decisões clínicas, o qual precisa encontrar um equilíbrio benéfico ao paciente (Alexander;Broshek;Quigg, 2018;Terman et al, 2020Terman et al, , 2022.…”