Researchers for the Dartmouth Atlas Project inspired a lot of discussion on how to improve Medicare with their 2009 report on regional variation in Medicare spending, and now they have produced another provocative report. This new report examines regional variation in prescriptive medicine, and despite the innocuous title — "The Dartmouth Atlas of Medicare Prescription Drug Use" — the findings are alarming.

For reasons yet to be learned, many Medicare patients are not getting drugs that would be effective in their care, while another group of patients are filling prescriptions for drugs known to be risky and not necessarily effective. The authors found variation between regions in both categories of drugs, indicating that some regions are under-prescribing effective drugs and over-prescribing risky drugs.

"We have a lot of room to do better," says Jeffrey Munson, M.D., an assistant professor at the Dartmouth Institute for Health Policy & Clinical Practice and lead author of the report, which studied 2010 outpatient prescription data for Medicare Part D. "We're learning that prescription drugs have tremendous potential for benefit but they also have tremendous potential for harm," Munson says.

Hospitals and physicians may have a hand in this mismatch of medicines to maladies as a result of patient discharges that could be handled better in two primary ways, even though the data studied are outpatient related, he says.

Before a patient leaves the hospital is a good place to get a patient started on a drug that has benefits in the long-term. Some heart attack patients may not continue to take a recommended beta-blocker for even the first six months after discharge — three years is the recommendation — without intervention before they leave the hospital and follow-up after.

Similarly, some patients may be continuing to take risky drugs that were started as a short-term measure while in the hospital but that should be discontinued after they leave. Proton pump inhibitors, used to treat heartburn and ulcers, are an example of a medicine that the elderly are taking too much.

The percentage of patients taking a proton pump inhibitor varied from 15.8 percent in Grand Junction, Colo., to 45.5 percent in Miami. Despite the benefits of taking them to some, many would be better off on another drug, particularly given that studies are indicating there can be rare but serious side effects.

Sometimes they are initiated in the hospital. "Once those patients leave, they don’t have to take them anymore, but they continue to," Munson says.

The actual reasons why there is such variation are unknown at this point. "That's the million dollar question," Munson says, adding that it's not because of variations in health or income.

Dartmouth researchers would welcome further study of the issue to come up with some causes for the variation.

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