Nurse practitioners and physicians are similarly likely to inappropriately prescribe medications to older patients

Embargoed for release until 5:00 p.m. ET on Monday 23 October 2023
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Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.
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1. Nurse practitioners and physicians are similarly likely to inappropriately prescribe medications to older patients

Abstract: https://www.acpjournals.org/doi/10.7326/M23-0827  

Editorial: https://www.acpjournals.org/doi/10.7326/M23-2556  

FREE Summary: https://www.acpjournals.org/doi/10.7326/P23-0008  

URL goes live when the embargo lifts 

A study of more than 73,000 primary care physicians (PCPs) and nurse practitioners (NPs) suggest that  both are similarly likely to inappropriately prescribe medications to older patients. According to the authors, this study adds to growing evidence indicating that when prescriptive authority is expanded to include NPs, these new prescribers do not perform worse than physicians. The study is published in Annals of Internal Medicine.

NPs, registered nurses with advanced degrees and more experience, are helping to solve the ongoing PCP shortage problem in the United States. Currently, state laws determine what type of medical care NPs can provide, such as practicing independently and prescribing medications without physician supervision.

Researchers from University of California, Los Angeles, Yale Law School, and Stanford University calculated inappropriate prescribing rates for 23,669 NPs and 50,060 PCPs prescribing medications to patients aged 65 years and older across 29 states that have granted NPs prescriptive authority. Inappropriate prescribing was defined using the American Geriatrics Society’s Beers Criteria. The researchers found that both PCPs and NPs averaged approximately 1.7 inappropriate prescriptions for every 100 prescriptions written. However, NPs were overrepresented among clinicians with the highest and the lowest rates of inappropriate prescribing. According to the authors, these findings provide useful lessons for policymakers, lawmakers, and regulators. Use of clinician-level performance measures, coupled with efforts to improve prescribing at the organizational and individual levels, could help to address deficient performance among all clinicians who prescribe. The authors say that technologic interventions, such as prescription drug monitoring, have a role to play, as do initiatives aimed at ensuring better adherence to trusted guidelines like the Beers Criteria.

An accompanying editorial from authors at University of California, Los Angeles suggests that rates of inappropriate prescribing are too high among clinicians of all stripes. The authors note that NPs are providing a greater proportion of care to older adults outside of large metropolitan areas, many of whom would likely have no other source of primary care. They also emphasize that NPs will continue to serve critical roles in ensuring that older adults in areas with inadequate numbers of health care providers receive primary care. The goal of clinicians should be to reduce variation and improve prescribing quality among all clinicians who care for older adults.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author David M. Studdert, LLB, ScD, please contact Beth Duff-Brown at bethduff@stanford.edu.

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2. Abortion rates remain lower compared with pre-pandemic rates

Abstract: https://www.acpjournals.org/doi/10.7326/M23-1609

Editorial: https://www.acpjournals.org/doi/10.7326/M23-2582

URL goes live when the embargo lifts 
An analysis of both medical and procedural abortions found that the overall incidence rate of abortions decreased by 14 percent during the early phase of the COVID-19 pandemic and did not return to pre-pandemic rates by June 2022. The analysis is published in Annals of Internal Medicine.

The in-person dispensing requirement that has been standard for mifepristone since the drug was approved was not enforced from July 2020 to January 2021 and after April 2021, creating an opportunity for increased patient access to medical abortions via telehealth. However, the extent to which these regulatory changes were communicated to abortion providers in the United States or resulted in changes in how abortion care was delivered is unknown.

Researchers from Brigham and Women’s Hospital and Harvard Medical School studied medical and procedural abortion rates among commercially-insured women, aged 15 to 44 years, from January 2018 to June 2022. The authors found that prior to the COVID-19 pandemic, the incidence rate of abortions was 151 per million women, with equal rates of medical and procedural abortions. After March 2020, there was an immediate 14 percent decrease in the monthly incidence rate of abortions. This decrease was driven by a 31 percent decline in procedural abortions, without a corresponding increase in the use of medical abortions. Fewer than 4 percent of medical abortions each month were administered via telehealth during each month of the study period.

These findings contrast with use of other procedures across many specialties, which returned to pre-pandemic levels by mid-2020 or 2021 after hospitals and clinics began resuming normal operations. According to the authors, their study suggests that regulatory changes designed to enhance abortion access during the pandemic did not result in a major shift from in-person visits to telehealth encounters, at least among abortions reimbursed by commercial insurance.

An accompanying editorial by authors from the University of Colorado and Warren Alpert Medical School of Brown University call for internal medicine physicians, regardless of specialty, to serve as resources for their patients’ reproductive health needs. The authors note that there is an opportunity for some internal medicine physicians to prescribe abortion pills in their practice, with the support of existing resources. They add that for those physicians who are restricted from prescribing because of state laws or employer regulations, awareness of reliable local and online resources where patients can access abortion services is paramount. Finally, they argue that internal medicine physicians and professional societies should consider ways to include access to abortion in their educational activities and to advocate for policy change regarding insurance coverage, especially given unequal access with self-pay abortion costs and regional barriers.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the lead author, Catherine Hwang, MD, MSPH, please contact Haley Bridger at hbridger@bwh.harvard.edu.

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3. ACP says ‘Enough is enough,’ vows to continue to fight for lower drug prices for patients

Abstract: https://www.acpjournals.org/doi/10.7326/M23-2447  
URL goes live when the embargo lifts 
ACP leaders have strong words for pharmaceutical and other health care companies that are challenging the implementation of the Medicare prescription drug price negotiation program. So far, these businesses have spent approximately $400 million challenging the program in U.S. courts. ACP, along with other medical societies, is pushing back.

In a new commentary published in Annals of Internal Medicine, ACP’s Executive Vice President and Chief Executive Officer Darilyn V. Moyer, MD, MACP and Senior Vice President and Chief Advocacy Officer Shari M. Erickson, MPH express strong support for the Inflation Reduction Act. The bill was signed into law last year, providing the U.S. Secretary of Health and Human Services with the authority to negotiate the prices for a set number of drugs, with implementation of those decreased prices in 2026. While the first 10 drugs in the Medicare Part D program were recently named, this is only a starting point and more needs to be done, ACP leaders say. Many patients still face what ACP calls a “Sophie’s choice,” or having to decide between purchasing their prescription medications or other life-sustaining necessities. For those patients, ACP vows to fight.

"ACP is resolute in its policy to put patients above pharmaceutical interests and will continue to work relentlessly to ensure that the program moves forward,” said Dr. Moyer. “Imagine how much of that pharmaceutical money could have gone to help persons who were so desperate to cover health care costs and the necessities of life that they went without or resorted to crowdsourcing campaigns. Enough is enough!”

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with someone from ACP, please contact Jacquelyn Blaser at jblaser@acponline.org. 

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