For many patients navigating the complexities of chronic disease, the medication list only grows. A drug is started for a specific symptom or acute event; months or years later, that drug remains on the daily regimen, often long after the original indication has vanished or a safer alternative has emerged. This phenomenon, known as prescribing inertia, creates a silent burden of polypharmacy that increases the risk of adverse drug events and complicates care for the most vulnerable populations.
While the healthcare industry has spent decades perfecting the art of measuring whether patients start the right medications, it has largely ignored whether they should continue them. This gap represents a critical failure in current quality frameworks, leaving a void where a measure of continuation appropriateness in managed care should exist to ensure that treatment remains necessary, safe, and effective over time.
The current obsession with medication adherence—the percentage of time a patient takes their prescribed dose—has created a perverse incentive. In many managed care models, success is defined by a patient staying on a drug, regardless of whether that drug still serves a clinical purpose. By focusing exclusively on the “gap in care” (the failure to start a drug), the system overlooks the “surplus of care” (the failure to stop one).
The Adherence Paradox and the Quality Gap
Most managed care organizations rely on standardized quality metrics to evaluate performance and secure reimbursement. The Healthcare Effectiveness Data and Information Set (HEDIS), maintained by the National Committee for Quality Assurance, and the CMS Star Ratings system, are the gold standards for these measurements. Both frameworks heavily emphasize adherence for conditions like diabetes, hypertension, and hyperlipidemia.
However, these metrics are binary: the patient is either adherent or they are not. There is no mechanism within these frameworks to penalize the continuation of a medication that is no longer clinically indicated. For example, a patient may be flagged as “adherent” for taking a proton pump inhibitor (PPI) for years after a short-term ulcer treatment was completed, despite the increased long-term risks of bone fractures or kidney disease associated with prolonged PPI use.
This creates a paradox where the metrics used to improve quality may actually inadvertently encourage the persistence of unnecessary medications. When the primary goal is to hit a percentage target for adherence, there is little systemic motivation for a provider to engage in the complex, time-consuming process of deprescribing.
The Clinical Pharmacist as the Missing Link
Closing this gap requires a shift in who is tasked with the oversight of medication therapy. While physicians are the primary prescribers, clinical pharmacists are uniquely positioned to deliver a continuation appropriateness measure because their expertise lies in the intersection of pharmacology, patient history, and therapeutic outcomes.
Unlike a traditional pharmacist who focuses on dispensing, a clinical pharmacist engaged in medication therapy management (MTM) looks at the patient’s entire medication profile holistically. They are trained to identify “prescribing cascades,” where a second medication is prescribed to treat the side effect of a first medication, which is then mistakenly viewed as a new medical condition.
By integrating clinical pharmacists into the managed care quality loop, organizations can move beyond simple adherence. Pharmacists can conduct comprehensive medication reviews (CMRs) to determine if a drug is still meeting its goal, if the patient is experiencing intolerable side effects, or if the drug’s risks now outweigh its benefits due to the patient’s aging or changing comorbidities.
| Measure Type | Primary Focus | Key Metric | Clinical Goal |
|---|---|---|---|
| Initiation | Gap Closure | Did the patient start the drug? | Ensure evidence-based start |
| Adherence | Persistence | Is the patient taking the drug? | Maintain therapeutic levels |
| Continuation | Appropriateness | Should the patient still be on it? | Optimize safety and reduce burden |
The Impact of Systematic Deprescribing
Implementing a measure for continuation appropriateness is not merely an academic exercise in quality reporting; it has profound implications for patient safety. Polypharmacy—typically defined as the use of five or more medications—is strongly associated with an increased risk of falls, cognitive impairment, and hospitalizations, particularly in older adults.
The American Geriatrics Society (AGS) Beers Criteria provides a framework for potentially inappropriate medication use in older adults, but these guidelines are often underutilized in the fast-paced environment of primary care. A formal continuation appropriateness measure would institutionalize the use of these guidelines, transforming deprescribing from an occasional clinical intuition into a mandatory quality standard.
From a managed care perspective, the financial incentives are also clear. Reducing unnecessary prescriptions lowers direct pharmacy spend and, more importantly, reduces the high cost of treating adverse drug reactions. When a patient is hospitalized due to a medication-induced fall or an acute kidney injury caused by an unnecessary diuretic, the cost to the payer far exceeds the savings of maintaining a high adherence score.
Overcoming Implementation Barriers
The transition to measuring continuation appropriateness faces several hurdles. First, deprescribing is often perceived as “doing less,” which can be uncomfortable for both providers and patients who equate more medication with more aggressive care. Second, current electronic health record (EHR) systems are designed to flag missing medications (gaps), not redundant ones.
To move forward, managed care organizations must redefine “quality” to include the successful cessation of inappropriate therapy. This would involve creating a metric that tracks the percentage of patients who undergo a formal appropriateness review and the subsequent rate of clinically justified medication reductions.
Disclaimer: This article is for informational purposes only and does not constitute medical advice. Patients should always consult with their prescribing physician or a licensed pharmacist before making changes to their medication regimen.
The next critical step in this evolution will likely arrive from the integration of real-world evidence (RWE) into CMS quality reporting. As payers begin to prioritize value-based care over volume, the pressure to reduce the risks and costs of polypharmacy will likely drive the adoption of a formal continuation appropriateness measure in the coming regulatory cycles.
We invite readers to share their experiences with medication management and deprescribing in the comments below.
