Martinez Kathryn A, Linfield Debra T, Gupta Niyati M, Alapati Mohana Vamsi, Moussa Daniel, Hu Bo, Kim Luke Dogyun, Lam Simon, Russo-Alvarez Giavanna, Rothberg Michael B
Cleveland Clinic Center for Value-Based Care Research, Cleveland, OH, USA.
Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH, USA.
Curr Med Res Opin. 2022 Jan;38(1):123-130. doi: 10.1080/03007995.2021.1982683. Epub 2021 Oct 6.
Polypharmacy, or use of multiple medications, is associated with patient factors. Less is known regarding variation in polypharmacy by individual physicians. The objective of this study was to assess patient and physician factors associated with polypharmacy among older patients.
This is a cross-sectional study of patients aged ≥65 years with a primary care visit at Cleveland Clinic Health System in 2015 and their physicians. We collected patient demographics, comorbidities and current medications from the electronic health record, including potentially inappropriate medications (PIMs). We used mixed effects linear regression to estimate adjusted differences in the number of medications by patient factors. We generated adjusted prescribing rates for individual physicians and assessed differences in physician performance on quality measures by their prescribing rate.
Our study included 44,570 patients who were prescribed an average of 6.8 medications (standard deviation: 4.0) by 701 physicians. Female sex, higher BMI, having Medicaid insurance, current or former smoking status, comorbidities and seeing a specialist were associated with number of medications. Age was not. Among 267 physicians who saw ≥20 study-eligible patients, the adjusted mean number of medications per patient ranged from 5.2 to 9.6. Compared to physicians who prescribed above the mean, lower prescribing physicians performed significantly better on medication reconciliation ( = .007) and hypertension control ( < .001) and prescribed fewer PIMs ( < .001).
Individual physicians varied in their prescribing practices, even after adjusting for patient demographic and clinical characteristics. Interventions to reduce polypharmacy in older adults should target high prescribing physicians, as physician behavior is more actionable than patient factors.
多重用药，即使用多种药物，与患者因素相关。而关于个体医生在多重用药方面的差异，我们了解得较少。本研究的目的是评估老年患者中与多重用药相关的患者和医生因素。
这是一项横断面研究，研究对象为2015年在克利夫兰诊所医疗系统进行初级保健就诊的65岁及以上患者及其医生。我们从电子健康记录中收集了患者的人口统计学信息、合并症和当前用药情况，包括潜在不适当用药（PIMs）。我们使用混合效应线性回归来估计患者因素导致的用药数量调整差异。我们计算了个体医生的调整处方率，并根据他们的处方率评估医生在质量指标方面的表现差异。
我们的研究纳入了44570名患者，这些患者由701名医生平均开出6.8种药物（标准差：4.0）。女性、较高的体重指数、拥有医疗补助保险、当前或以前的吸烟状况、合并症以及看专科医生与用药数量相关。年龄则无关。在看过≥20名符合研究条件患者的267名医生中，每位患者的调整后平均用药数量在5.2至9.6之间。与处方量高于平均水平的医生相比，处方量较低的医生在用药核对（P = 0.007）和高血压控制（P < 0.001）方面表现明显更好，且开出的PIMs较少（P < 0.001）。
即使在调整了患者的人口统计学和临床特征后，个体医生的处方行为仍存在差异。减少老年人多重用药的干预措施应针对高处方量医生，因为医生行为比患者因素更具可操作性。
