Access To Two Different Health Care Systems Can Lead To Dangerous Presciption Combinations Interview with:


Dr. Joshua Thorpe

Joshua M. Thorpe, PhD, MPH
From the Center for Health Equity Research and Promotion
Veterans Affairs Pittsburgh Healthcare System
Pittsburgh Pennsylvania, and
Center for Health Services Research in Primary Care
Department of Pharmacy and Therapeutics
University of Pittsburgh School of Pharmacy What is the background for this study?

Response: Care coordination for persons with dementia is challenging for health care systems under the best of circumstances. These coordination challenges are exacerbated in Medicare-eligible veterans who receive care through both Medicare and the Department of Veterans Affairs (VA). Recent Medicare and VA policy changes (e.g., Medicare Part D, Veteran’s Choice Act) expand veterans’ access to providers outside the VA. While access to care may be improved, seeking care across multiple health systems may disrupt care coordination and increase the risk of unsafe prescribing – particularly in veterans with dementia. To see how expanded access to care outside the VA might influence medication safety for veterans with dementia, we studied prescribing safety in Veterans who qualified for prescriptions through the VA as well as through the Medicare Part D drug benefit. What are the main findings?

Response: Of the 75,000 Veterans with dementia, 44% were exposed to at least 1 potentially unsafe medication (PUM). Compared with VA-only users, dual VA/Part D users were at more than double the risk for exposure to potentially harmful drugs. Dual VA/Part D users were exposed to an average of 44 additional days of potentially harmful drugs each year. What should readers take away from your report?

Response: Most assume that greater access to care and choice is better for patients. These results show that, despite good intentions, policies designed to expand access can have very significant negative consequences. This is especially true when policy makers and health care organizations fail to put safeguards in place to ensure care coordination and information exchange between providers and across systems. What recommendations do you have for future research as a result of this study?

Response: We studied a narrow range of potentially harmful drugs. Future research should expand the list of safety indicators to include duplication of therapies, drug–drug interactions, drug–disease interactions, and unsafe over-the-counter medications. Finally, future research should examine older, non-dementia patients to determine if the noted problems are systemic across all older adult populations. Thank you for your contribution to the community.


Thorpe JM, Thorpe CT, Gellad WF, Good CB, Hanlon JT, Mor MK, et al. Dual Health Care System Use and High-Risk Prescribing in Patients With Dementia: A National Cohort Study. Ann Intern Med. [Epub ahead of print 6 December 2016]doi: 10.7326/M16-0551

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on December 12, 2016 by Marie Benz MD FAAD