Do no harm: A case study on overprescribing

If a patient asks for a prescription for a drug you haven’t prescribed or that isn’t medically necessary, how would you respond?

That’s the dilemma posed to doctors of optometry in Case Study No. 21 by AOA Ethics and Values Committee member Satya Verma, O.D., professor at the Pennsylvania College of Optometry at Salus University and inductee into the National Optometry Hall of Fame in 2020.

Overprescribing, in general in health care, has been a subject of frequent study. For instance, research published in 2018 found that 46% of a half million outpatient antibiotic prescriptions were written by clinicians without diagnoses of infection.

Doctors of optometry are generally judicious in prescribing, but they are not immune from overprescribing, whether it’s medications or ophthalmic devices, Dr. Verma says.

“Doctors of optometry should be sensitive to this issue and be extra cautious while prescribing medications and ophthalmic materials,” Dr. Verma says. “For example, if a patient is clinically diagnosed with dry eye but has no real symptoms, then we should not hurry to prescribe medications to these patients.

“The bottom line is that every diagnosis does not need a medication,” he says, also citing conjunctivitis (viral vs. bacterial) as an example. “If we can raise awareness and concern, we can do more good than harm.”

Find the case study in the AOA’s EyeLearn Professional Development Hub.

The price of overprescribing

The case study defines overprescribing as “the use of more medicine than clinically necessary, and this can put the patient at risk of side effects and polypharmacy with limited potential to benefit.”

“Doctors of optometry generally are cautious and conservative prescribers, but they can certainly be persuaded by persistent patients or aggressive sales pitches,” Dr. Verma writes.

Dr. Verma describes “an explosion of medication overload,” borne out by a literature review. In the case study, he cites:

• 42% of older adults over age 65 take five or more medications, resulting in adverse drug events.
• Inappropriate use not only increases the cost of health care but also results in adverse drug reactions and the body’s resistance to antibiotics.
• According to the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report in 2009, approximately $10.7 billion was spent in the U.S. on antibiotic therapy. Antibiotic resistance costs the U.S. economy an estimated $20 billion in excess direct health care costs with another $35 billion in lost productivity.

“It is imperative that we remain more cautious in our prescribing habits,” Dr. Verma writes. “We should not be swayed by outside pressures from patients and sales pitches. We should adhere to our Standards of Professional Conduct (AOA) to ‘do no harm’ to the patient.

“By adhering to these principles, we can provide the best care and advice to our patients without increasing the likelihood of potential harm,” he says.

Access Ethics and Values case studies on EyeLearn.