Elderly Americans are prescribed
medications in inexplicably different ways depending on where they live,
according to a new
report from Dartmouth researchers.

The
most
depressed older patients—or at least the ones being medicated — live
in parts of Louisiana and Florida. There’s a
cluster with dementia
around Miami. And the seniors who have the most trouble sleeping? They
live, perhaps unsurprisingly, in Manhattan.

The
study by the Dartmouth Institute for Health Policy and Clinical Practice
examined geographic variations in the drugs elderly Medicare patients received
in 2010. Researchers mapped where patients got medications they clearly needed
and where they got drugs deemed risky for the elderly. They also looked at differences
in the use of so-called discretionary drugs, which they say are widely
prescribed but of uncertain benefits.

The report’s findings underscore
those of a ProPublica
investigation in May, which found that some doctors who treat Medicare
patients often prescribe drugs that are dangerous or inappropriate for certain
patients. ProPublica also found that the federal officials who run Medicare
have done little to scrutinize prescribing patterns in their drug program,
known as Part D, or question doctors whose practices differ from their peers.

Officials from the Centers for
Medicare and Medicaid Services could not be reached to answer questions about
the study. They have previously said that the primary responsibility for
overseeing prescribing belongs to private insurers that administer the program.
Still, they have acknowledged that Medicare should and will do more to track
prescribing in Part D and follow up on unusual patterns.

The Dartmouth researchers did
not look at the habits of individual doctors, as ProPublica did, but instead
looked at the percent of patients in each region who received certain types of
medications. Regionals boundaries were based on where patients would be
referred for hospital care.

For example, 17 percent of
elderly patients in Miami received a prescription for a dementia drug in 2010,
while less than 4 percent of patients in Rochester, Minn., and Grand Junction,
Colo., got one. Nationally, the average was 7 percent, according to the report,
titled the Dartmouth Atlas of Medicare Prescription Drug Use.

There were similar differences by
location for antidepressants. In Miami, almost one-third of elderly Medicare
enrollees received at least one prescription for such drugs and about one-quarter
of those in a swath of Louisiana did. In Honolulu, just 7 percent got one.

The report does not address
whether the patients had diagnoses that would warrant the use of these
medications. It also does not include disabled patients under 65 who are also
covered by Part D.

Researchers examined whether
patients in different regions had been given widely accepted drug treatments
following health emergencies, for instance a beta
blocker after a heart attack or an osteoporosis
drug after certain fractures. 
And they calculated the percentage
of seniors who were given drugs labeled risky
by the American Geriatrics Society because they are known to affect their
cognition and balance.

“We see that some clinicians are
not achieving a level of effective medication use” compared to their peers, said
Dr. Nancy Morden, a lead author of the report.
“Conversely, some clinicians are putting their patients at much higher risk by
using hazardous medications at a much higher rate than their peers.”

The report does not tackle two
of the most fraught issues in prescribing today: the use of narcotic
painkillers and anti-psychotics, especially to treat dementia in the elderly.

Morden
said she was surprised to find that, in some regions, large percentages of
patients were getting discretionary drugs that were moderately beneficial, like
those for acid reflux — and not getting the ones that could save their lives,
like the beta blockers or cholesterol-lowering drugs.

 “What are we doing?” she said. “It’s surprising
to me that we can use so much of our energy to pursue medications that give us
far less in terms of health. I worry that it’s coming at the cost of getting
the effective medications.”

People in some regions of the
country are healthier than in others. But Morden said
that does not explain the wide variations her group found in so many different categories
of drugs. That may be a signal that patients are not
being adequately informed about the risks, benefits and costs of the drugs, she
said. Doctors also may be unaware of how different their practices are from the
peers in other parts of the country.

Overall, researchers found
that the elderly
in Miami fill more prescriptions than anywhere else. On
average Miami area patients got nearly 63 per person, including refills, in
2010, compared to a national average of 49. Seniors in Miami also had the highest
average spending on prescriptions that year, $4,738
compared to $2,670 nationally.

In the report, Morden and her co-authors encourage policymakers to seek
ways of reducing geographic variation in the way medications are prescribed.
They also urge patients to ask their doctors about whether a drug is truly
needed for them.

The Dartmouth group has
previously examined how costs and use of services in the Medicare program
differ markedly across the country. They note that some of the highest-spending
regions in terms of drug costs were also among the highest users of other types
of medical services.