The costs of anticipatory medications for patients approaching the end-of-life at home or in care homes are modest but most of the drugs are never used, suggests new research from the University of Cambridge’s Primary Care Unit.
The study is the first detailed analysis of the prescription, usage and wastage costs of these injectable end-of-life anticipatory medications.
When people are approaching the end of life at home and in residential care, injectable medications are often prescribed ahead of possible need, so that they are in place to help manage any distressing last-days-of-life symptoms that might occur.
In the UK, at least half of community-based patients approaching the end of their lives are thought to receive prescriptions of anticipatory medications. International guidance recommends individualised prescribing based on a patient’s likely needs, but most patients receive a standardised prescription of four medications, to treat common symptoms that might arise in the last days of life: pain, shortness of breath, nausea and vomiting, agitation and noisy respiratory secretions.
The new study looked at the electronic and paper clinical records of 164 patients living in two English counties, who had each been prescribed injectable anticipatory medications before they died. The cost of each prescribed medication was calculated and, from the records, the researchers could see which medications were used.
While 59% of the patients received some doses of medication, most of the medications in patients’ homes and care homes remained unused. In total, 85% of the prescription costs were spent on unused medications.
- The cost per patient of the medications that were prescribed in advance of need ranged from £8.76 to £229.82, with a median of £43.17 per patient, higher than was previously thought. The median cost for the medications used per patient was just £2.16 while the median cost of the unused medications was £41.47 per patient.
- Drugs for nausea and/or vomiting(predominantly Haloperidol and Cyclizine) and noisy respiratory secretions (predominantly Glycopyrronium Bromide) accounted for nearly two-thirds (64%) of total wastage costs.
The researchers suggest that fewer medication vials per patient might be a practical way to reduce costs. For example, it might be possible to reduce the number of vials of anti-emetics issued if nausea and vomiting is not anticipated for the individual patient. They suggest this could lead to significant savings at a population level, but caution that individualised prescribing and smooth access to medications must be enabled.
“The costs of anticipatory medications are a bit higher than previously reported but they remain modest.
Even so, it’s striking that so many drugs go unused. The data suggests that there may be scope to reduce the quantity of certain medication vials that are routinely prescribed without adversely affecting care, but we need to know a lot more about how anticipatory prescribing works and how people get on when they are prescribed these drugs before we can be sure that there are savings to be made. Further research is needed to explore this possibility”, said Dr Ben Bowers, researcher, Primary Care Unit and Dr Lloyd Morgan, Foundation Doctor, Primary Care Unit.
Read the research
Lloyd Morgan, Stephen Barclay, Kristian Pollock, Efthalia Massou, Ben Bowers: The financial costs of anticipatory prescribing. A retrospective observational study of prescribed, administered and wasted medications using community clinical records. Palliative Medicine. 10 October 2023. doi.org/10.1177/02692163231198372
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