Prescription Fixes: States calibrate drug-warning systems for maximum impact

If someone alerts you to a possible problem, do you do anything about it?

And if you are receiving dozens of alerts in any given day, are you less likely to take action with each subsequent alert? State prescription drug tracking programs are increasingly turning to what are known as “unsolicited reports,” which warn prescribers when there is suspicious prescribing behavior. For example, a patient may go to four different doctors in the same week for the same addictive painkillers. The system would send a report to all of those prescribers, if they were signed up in the system.

Let’s look at one state that took action to send unsolicited reports about problematic prescribing activity to prescribers and what happened as a result. Massachusetts started sending email alerts to drug prescribers in 2013, telling them when the state’s drug tracking system had found patterns of troubling behavior: patients getting a lot of drugs, patients getting a lot of drugs from multiple prescribers, drugs being prescribed in dangerous amounts, and so on.

The state had been mailing out alerts from 2010 to 2013. The alerts and other steps taken by the state appeared to be having an effect. According to a presentation from the state Department of Public Health, it found that the rates of very frequent doctor shopping — patients filling prescriptions from multiple prescribers at multiple pharmacies — were cut in half.

But mailing the alerts proved costly and cumbersome, according to a report by the Pew Charitable Trusts. In developing the new email alert system, the state made a couple of key decisions:

1. It decided to send the alerts monthly, to avoid overwhelming prescribers with notifications.

2. It limited the number of times a prescriber would hear about the same patient, something designed to mitigate what the Pew calls “alert fatigue.” (A debatable move, to be sure.)

3. And in setting up the criteria for what triggers an alert, it decide to keep the criteria confidential. The goal, Pew notes, was to “prevent individuals from intentionally avoiding detection.” The criteria are set up by the state’s Medical Review Group, made up of prescribers and pharmacists.

The alerts from Massachusetts include a patient identification number that prescribers can use to query the state’s drug tracking system. There, the prescriber can see the whole history of how many times that patient has had prescriptions, what types, and from whom.

As you might expect, the alerts had one immediate effect. They raised awareness among prescribers about the fact that their patients, in some cases, were also getting drug prescriptions from other prescribers. The state found that when prescribers were shown all the other prescribers who were writing prescriptions for their patients, only 8.4 percent were “aware of all or most other prescribers.”

The state conducted a case-control study to compare those patients who had been the subject of prescriber alerts and those who were not. There were 84 people in each group, roughly half women and half men, with an average age of about 42 years. According the state Department of Public Health, it found that:

1. “Sending unsolicited reports reduces key proxy measures of questionable activity.”

2. “All key measures declined more in the case group compared with the comparison group.” 

3. “There was a statistically significant difference, between the case and comparison group, in the decline in the number of pharmacies visited from the pre- and post-intervention period and in the average days supply.”

Let’s break that last one down a bit. On average, patients who just went about their business without any alerts being sent to their prescribers visited 11 different pharmacies before the alerts started being sent, and 5.5 on average after, a decrease of 50 percent. The control group also saw a decrease, from 11.7 to 7, meaning a 40.2 percent decline. The number of drugs that were secured with each prescription also fell faster in the group that was the subject of alerts. They went from having a 473-day supply on average to 326 days, 31.1 percent drop. The comparison group went from 475 days to 359, a 24.4 percent drop.

With multiple programs — both state and federal — increasingly focused on curbing the prescription drug addiction problem, it’s difficult to tease out how any one facet of those programs had an impact. And, as you can see, numbers are dropping both with and without unsolicited reports.

This is an area we’ll have to watch as more states gather more data, and I will provide my own unsolicited report on that data.

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