October 30, 2013
Prescribing Varies Widely Across Regions for
Medicare Patients

Lebanon, NH—How prescription drugs are used to treat Medicare patients varies widely across regions of the United States, and the trends often appear to have little to do with patients’ health status or spending constraints.

That’s according to a new report from the Dartmouth Atlas Project, which suggests that regional practice culture may be behind a lot of the difference in the quantity and quality of drug therapy around the country.

“There is no good reason why heart attack victims living in Ogden, Utah, are twice as likely to receive medicine to lower their cholesterol and their risk of another heart attack than those in Abilene, Texas, but this inconsistency reflects the current practice of medicine in the United States,” said Jeffrey C. Munson, MD, lead author of the report and assistant professor at The Dartmouth Institute for Health Policy & Clinical Practice.

Katherine Hempstead, PhD, MA, senior program officer at the Robert Wood Johnson Foundation, a longtime funder of the Dartmouth Atlas Project, added, “Instead of varying widely, patterns of care should be nearly uniform across the country for non- controversial drug therapies with a strong evidence for their use.”

The Dartmouth report separates the U.S. into 306 regional health care markets and documents variations in the quantity and quality of prescription drug use, spending, and use of brand name drugs. Prescription drug use is examined in three categories—those proven to be effective, discretionary medications, and risky medications.

The study found the following variations:

• While the average Medicare Part D patient filled 49 standardized 30-day prescriptions in 2010, those in Miami, at the high end, filled an average of 63 prescriptions, compared to patients at the low end, in Grand Junction, Colorado, who filled 39 prescriptions per year. Other high-use regions included Lexington, Kentucky, with 59 prescriptions and Huntington, West Virginia, with 58, compared to low-use areas such as Albuquerque, New Mexico, at 40 and San Mateo County, California, at 41.

Looking at the use of proven drug therapies, such as beta-blockers and statins in the months after a heart attack as well as the use of osteoporosis drugs after bone fractures, the study found more regional difference.

• In 2008 to 2009, 91.4% of San Angelo, Texas, patients filled at least one prescription for a beta-blocker in the 7 to 12 months following hospital discharge, compared to 62.5% in Salem, Oregon, and a 78.5% national average.

• Showing similar variation, 91.3% Medicare beneficiaries from Ogden, Utah, filled a statin prescription in the second 6 months after hospital discharge, but only 44.3% did so in Abilene, Texas, compared to a 72% national average.

• Also despite other guideline recommendations, only 14.3% of fragility fracture survivors nationally received a drug to combat osteoporosis within 6 months of their injury, ranging from 28% in Honolulu, Hawaii, to 6.8% in Newark, New Jersey.

No single region was in the top 10 for prescribing all of the drug therapies called for in the national guidelines, according to study authors.

In terms of high-risk drugs for patients over 65, the report finds that patients in Alexandria, Louisiana, at 43%, were more than three times as likely to receive at least one than the 14% of patients in Rochester, Minnesota.

Also varying widely by region was prescription spending per beneficiary in the Part D program, ranging from $4,738 in Miami to $1,770 in St. Cloud, Minnesota, with a national average of $2,670.

With substitution of generic medications a method to control costs, 26.3% of overall prescriptions were filled with brand-name products, according to the study. Patients in Manhattan, however, received brand-name prescriptions 36% of the time, compared to just 16.5% of the time for beneficiaries in La Crosse, Wisconsin.

“We need to learn from regions that consistently provide high-quality care, and focus attention on regions that appear to offer the worst of both worlds: high-risk and discretionary medications and, in relative terms, low use of effective drug therapies,” said coauthor Nancy Morden, MD, MPH. “This will help us understand and ultimately improve prescribing quality for all Medicare beneficiaries.”

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