INCREASE IN PRESCRIPTION DRUG DEATHS IS REPORTED

UCSD researchers tie results to managed care

Prescription drug errors kill thousands more Americans a year than they did
a decade ago, raising concerns that fast-growing managed care systems may
not be paying enough heed to how their patients respond to medication,
three UCSD researchers report.

"We need to ask whether changes in the way we deliver medical care may have
increased the risk of death" from prescription drug mistakes, said
sociologist David Phillips, lead author of a letter printed in tomorrow's
issue of the British medical journal The Lancet.

Phillips, psychologist Nicholas Christenfeld and graduate student Laura
Glynn, all of UCSD, drew their study from a federal database of death
certificates filed between 1983 and 1993 in every state.

They found that deaths attributed to medication errors -- mistakes in the
type of medication or the dosage level prescribed -- rose more than twofold
in that period, a greater rate of increase than any other cause of death
except AIDS.

What was surprising, however, was that the number of deaths attributed to
medication errors rose only twofold for hospital patients, but for
outpatients the increase was more than eightfold.

The rates of increase were much higher than the increases in prescription
drug sales or in the population of the United States in that period, they
said. The deaths occurred in all ages and races, although they found the
highest increases in black and white males.

Health officials in Sacramento were cautious, saying they doubted the
increases could be attributed to managed care's cost cutting.

Dr. David Werdegar, head of the statewide Office of Health Planning and
Development, which studies hospital costs and quality, wondered whether the
people who died were in any managed care system at all.

Perhaps, they weren't, "but would have gotten better follow-up care that
would have avoided that death if they had been. I have some skepticism,
particularly when they lay this at the feet of managed care," he said.

The authors said they pointed at managed care because patients in 1993 were
more likely to receive treatment in an outpatient setting, such as a
doctor's office or an emergency room, rather than in a hospital bed than
they were in 1983, a trend largely dictated by managed care's desire to cut
health costs.

In this 10-year period, they wrote, the number of outpatient visits
nationwide increased by 75 percent while the number of hospitalization days
fell by 21 percent, according to national hospital statistics.

"What we see is that an enormously increasing number of patients are being
put out earlier on their own to deal with the effects of potentially lethal
medications," said Christenfeld, one of the researchers. "What health
maintenance organizations are good at is saving money; what they're not
good at is having doctors spend a good amount of time with patients."

What's troubling is that a medication error is much more likely to go
unnoticed or uncorrected if the drug is administered in an outpatient
setting, they said.

The researchers emphasized that the death certificates did not specify who
caused the error -- the pharmacy, the prescribing physician, a nurse, the
patient's family or the patient.

But the researchers said they found one important clue that points a finger
to managed care rather than patient error. The largest increase in deaths
due to medication error involved anesthesia and narcotic painkillers.

"These are medicines that would not normally be taken by the patient
himself, but would more likely be administered by a physician or nurse in
an outpatient setting," such as an emergency room or doctor's office,
Phillips said. A decade ago, the patient would have been more likely to
receive those drugs as a hospital patient.

The researchers hypothesized that the increase in death may be due to
patients given prescriptions and then sent home, where they are the only
ones in control of their medication.

"It is thought to be increasingly difficult for physicians to maintain the
continuity and quality of their relationships with patients" today compared
with 1983, they wrote.

Other health officials were also skeptical of the study.

"Unless these researchers can demonstrate something about the managed care
system that is causing this, I don't think they have any grounds for
claiming this has something to do with managed care," said Maureen O'Haren,
executive vice president for the California Association for Health Plans,
which represents nearly all health maintenance organizations in the state.

Dr. Brian Blackbourne, medical examiner for San Diego County since 1990,
said he hadn't noticed any increase in death from medication errors and
also questioned the UCSD report.

Phillips acknowledged that the statistics could not tell whether the deaths
occurred in people who were enrolled in managed care plans.

"The nearest we can say is that this increase in deaths from medication
errors appears to be associated with a change in the way medical care is
delivered," he said. "And that may very well be associated to trends in
managed care."

The researchers said they plan more studies to focus on where these kinds
of errors occur. Phillips said they want to know which regions of the
country, what ages of patients and which illnesses and conditions are
likely to lead to these kinds of fatal mistakes.

Phillips emphasized that the initial findings "do not necessarily signal
that the health care system should immediately return to inpatient care.

Rather, it may be a signal that we should increase our careful monitoring
of medications for our patients."

He pointed to the eightfold increase in medication error deaths among
outpatients as the strongest finding.

"There's no chance of them happening by chance alone. This kind of an
increase is an enormous one."