About one-third of patients who leave the emergency department (ED) after treatment never have their prescriptions filled. Unfilled prescriptions include high-priority medications needed on a timely basis such as analgesics, antibiotics, bronchodilators and corticosteroids.
Filling prescriptions from the hospital’s outpatient pharmacy or dispensing them in the ED is convenient for families and increases the likelihood of medication adherence, according to an AAP technical report that reviews the evidence on this topic.
The updated report Dispensing Medications at the Hospital Upon Discharge from an Emergency Department, from the Committee on Pediatric Emergency Medicine (COPEM), is available at https://doi.org/10.1542/peds.2023-062144 and will be published in the June issue of Pediatrics.
Picking up or receiving medication in the hospital may not guarantee medication compliance but increases the chance the child will receive it, said COPEM Chair Gregory P. Conners, M.D., M.P.H., M.B.A., FACEP, FAAP.
He recalled a recent example when a family was provided with an albuterol inhaler after their preschooler was treated in the ED for an asthma exacerbation.
“The family told me that they wouldn’t be able to go to the store and get this (product) for various reasons. So we were able to just dispense it, and then I knew that the child was able to continue the asthma treatment,” said Dr. Conners, the Stanley A. August Professor and chair of pediatrics and executive director of Upstate Golisano Children’s Hospital at Upstate Medical University in Syracuse, N.Y.
Dr. Conners also has seen infections progress because the family never filled an antibiotic prescription.
Various factors jeopardize families’ ability to obtain their prescriptions, including cost, reduced access to community pharmacies, lack of understanding of the importance of the medications or disagreement with the treatment plan. Some parents also may be reluctant to disclose their inability to pay for the prescription.
Even without financial barriers, some families fail to pick up medications due to lack of transportation, language/cultural barriers, health literacy issues or because it’s inconvenient.
A common scenario is when a patient is released after being in the ED all day and the parents want to get their child home. In addition, pharmacies may be closed when the patient is released.
The report offers the following solutions to improve medication adherence after ED treatment as well as concerns with these solutions:
- Administer the first antibiotic dose in the ED. Clinicians can provide medication instructions and address any immediate adverse reactions. Families also will have more time to fill the prescription.
- Provide a few days’ supply of medication. This works best for pills (not suspensions). Parents still will have to fill the remainder of the prescription and make sure all doses are taken even if the child appears to have improved. Also, second prescriptions would be needed — increasing the potential for error — and the family may have two copayments.
- Require electronic prescribing. E-prescribing has been shown to improve quality and patient satisfaction and reduce harm and wait times. An advantage of e-prescribing from the ED to the outpatient hospital pharmacy is the ability to find out quickly whether the medication is available. However, e-prescribing has not been shown to increase medication adherence.
Barriers to ED prescribing
- Staffing demands would increase for inpatient hospital pharmacists.
- Some state regulations limit outpatient dispensing by an inpatient facility.
- Insurance payment might be denied for outpatient medications dispensed by an inpatient pharmacy. Also, payment for pediatricians with value-based contracts may be impacted if the medication costs depend on where the medication is dispensed.
Despite the advantages of dispensing medications from the ED, there are several downsides:
- The convenience of filling medications in the ED may encourage families to visit EDs for minor acute care or because they don’t have a primary care physician.
- If hospital pharmacies are obligated to dispense medications to the uninsured, hospital expenses could increase, with a higher cost burden on small rural hospitals.
- The system of providing medications could impede patient flow.
- This method might have financial repercussions for some local pharmacies.
The report concludes that if logically, legally and financially possible, providing necessary medications from the ED or the outpatient pharmacy can be more convenient and reliable, and improve patient outcomes.