Pharmaceutical Economics Column: Exploring the Economics of Medications (Part 142)Potentially Inappropriate Prescribing in Ireland

Tetsuya Tanimoto, M.D.

Medical Governance Research Institute, Tokyo, Japan

In spring 2023, our pharmaceutical conflicts of interest research group participated in an international conference in Bath, UK. There, we had the pleasure of meeting Professor Tom Fahey from the Royal College of Surgeons in Ireland.

While Ireland is a small nation with an estimated population of 5.28 million in 2023, it boasts a young demographic and impressive economic metrics. According to the IMF, its projected per capita nominal GDP for 2024 is $104,000, ranking third globally—far outperforming Japan, which ranks 36th at $33,000. The Irish economy is driven by IT, pharmaceuticals, and financial services, with multinational corporations establishing their European headquarters there. The pharmaceutical and biopharmaceutical industries, in particular, play pivotal roles in the economy.

The pharmaceutical industry accounts for approximately 50% of Ireland's exports, with pharmaceutical exports reaching around 100 billion euros in 2022. Major pharmaceutical companies like Pfizer, Merck, and Abbott maintain production facilities in Ireland. Biopharmaceutical production is especially significant—eight of the world's top 10 pharmaceuticals are manufactured in Ireland. The government actively supports the pharmaceutical industry, investing approximately 2.2% of GDP in research and development in 2022.

Professor Fahey is an internationally renowned expert in public health and general practice, particularly known for his primary care research. He has received multiple research awards from the Royal College of General Practitioners and delivered the prestigious James Mackenzie Lecture in 2019. Currently, he serves as a board member of Ireland's Health Research Board and as a committee member of the Irish Medicines Regulatory Authority. Despite his distinguished position, he remains approachable and modest, making time for several web conferences with us. In November 2023, he even visited Japan to speak at the 18th Medical Reform Promotion Council hosted by the Medical Governance Research Institute in Tokyo.

At the end of October 2024, he conducted a web seminar for our study group, where he presented research on potentially inappropriate prescribing in Ireland. This refers to prescriptions where risks potentially outweigh benefits, particularly for elderly patients or those with specific conditions. This is a common clinical challenge worldwide, including in Japan. Examples include long-term prescriptions of benzodiazepines or proton pump inhibitors, which, despite physicians' awareness of the risks, often prove difficult to discontinue due to patient demands.

Professor Fahey's research, published in the British Medical Journal in 2018, investigated whether hospitalization increased potentially inappropriate prescribing among patients aged 65 and older (https://www.bmj.com/content/363/bmj.k4524.long).  The study, conducted across 44 general practices in Ireland from 2012 to 2015, examined whether hospital admission increased risks and if these risks elevated post-discharge.

The findings revealed that 45-51% of patients received at least one inappropriate prescription. Patients with hospital experience showed increased inappropriate prescribing post-discharge compared to pre-admission levels. Hospitalized patients had 1.24 times higher risk, which further increased to 1.72 times post-discharge. Age, number of prescribed medications, and multiple comorbidities were identified as contributing risk factors.

The research demonstrated that hospitalization increased the likelihood of inappropriate prescribing for elderly patients, particularly when new medications were added during hospitalization or existing prescriptions weren't reviewed. This could lead to unnecessary long-term medication use and increased side effects post-discharge, highlighting the importance of post-hospitalization medication management. Based on these findings, measures such as adding cautionary notes to discharge summaries have been implemented, achieving some success in reducing inappropriate prescribing.

This research has practical applications for daily medical practice in Japan, and we look forward to continuing international exchanges to explore the relationship between society and pharmaceuticals.

Originally published in Iyakukeizai in November 1, 2024