The Utilization of Discharge Prescriptions in Germany

An overview for the years 2018–2021

Gaps in the supply of medications on discharge from hospital are associated with the risks of non-adherence, side effects and re-hospitalization. Discharge prescriptions, especially of medications newly started in the inpatient setting, can help to close gaps in medication supply, increase adherence and reduce the risk of re-hospitalization (1). Since the end of 2017, hospital doctors in Germany are permitted to write statutory health insurance (SHI)-covered prescriptions on discharge. However, this option has not yet been evaluated systematically.

Methods

We applied the database of the German Institute for Drug Use Evaluation (Deutsches Arzneiprüfungsinstitut, DAPI) to determine the number of SHI-covered discharge prescriptions filled in community pharmacies between 1 January 2018 and 31 December 2021. The database holds fully anonymized billing data of medicines and medicinal products collected from community pharmacies in all German federal states. Our analysis is based on a representative sample which was extrapolated to 100% of SHI-covered medication dispensations, using regional extrapolation factors (2). In this study, we looked at the number of discharge prescriptions per year, the prescribed active substances (ATC code), the prescribed package sizes, the days of the week on which prescriptions were issued, and the number of days until the prescriptions were filled. In addition, we addressed specific questions by investigating whether the formal easing of regulations during the COVID-19 pandemic led to any changes. We focused in particular on the suspension of the package size restriction and the extension of the validity period of prescriptions from 3 to 6 working days during the period from 1 June 2020 to 31 December 2021 (3).

Results

The number of discharge prescriptions increased from 2018 to 2021 by 172% (from 0.73 to 1.98 millions). In contrast, the total number of prescriptions remained largely unchanged (−2%). In 2021, the share of discharge prescriptions in all prescriptions was 0.4%. In all years, prescriptions of metamizole (mean 11%), pantoprazole (10%), enoxaparin (6%), and ibuprofen (6%) were filled most frequently. Across all years, the 10 most frequently prescribed active substances accounted for about 44% of all prescriptions issued (Table). During the entire period analyzed, 80% of the packages dispensed were of the German standard small package size N1; after the introduction of the COVID-19 exemption regulations, this percentage was with 77% (3.94 millions) slightly lower. Before and after the introduction of the COVID-19 exemption regulations, prescriptions were mostly issued on Fridays (25%/24%) and frequently filled on the same day (59%/54%) and for the most part within a maximum of 3 days (94%/90%). During the entire period, 56% of prescriptions were filled on the same day and prescriptions issued during the period from Monday to Friday were filled no later than by the day following the day of prescription issuance (85%). This proportion was lower for prescriptions issued on Saturdays and Sundays (61% and 78%, respectively), because, while 59% of prescriptions issued on Saturdays were again filled on the same day, only 2% were filled on the following day (Sundays) and 28% on Mondays. With regard to prescriptions issued on Sundays, only 17% were filled on the same day and 61% on the following day.

Table

List of the TOP 10 active substances/TOP-10 active substance combinations, based on discharge prescriptions filled 2018–2021

Discussion

Our representative analysis shows an increasing utilization of discharge prescriptions. According to hospital discharge data published by the Federal Statistical Office of Germany (Statistisches Bundesamt), an estimated 12 discharge prescriptions/100 patient cases were issued (4). A small number of medications likely to be prescribed on discharge from hospital, such as analgesics and anticoagulants, accounted for the majority of prescriptions. The pandemic-related easing of regulations had no significant effect on the dispensing of medications predominantly in the small package size N1 or on the filling of prescriptions within a period of a maximum of 3 days. Thus, it appears to be worth discussing whether it would be advisable to abandon a general limitation of the package size permitted to be prescribed. This question is particularly relevant in view of cases known from clinical practice where the smallest package size, containing medication for about 24 hours (for example, a metamizole package with 10 film-coated tablets), was not sufficient to fully close gaps in medication supply. At the same time, smaller package sizes can help to limit overuse, but cannot completely prevent it. Another point to be discussed is that 44% of discharge prescriptions were not filled on the same day and that the time to filling of discharge prescriptions was longer at the weekend, as expected. It cannot be determined from the data whether these delays were associated with relevant gaps in medication supply and what the main reasons for these delays have been. It is conceivable that discharge prescriptions were only issued on an as-needed basis or that patients were still having some of the medication at home or that patients were provided with medication on the ward (possibly supplementary). Since an actual delay in the supply of medication, but also brief interruptions of treatment, can be critical in individual cases (5), the reasons for and effects of these delays should be further studied, taking into account all actually written prescriptions (and not only at the filled prescriptions). If, for example, a patient’s impaired mobility is the reason behind the delayed prescription filling, e-prescriptions could be digitally sent to the selected pharmacy where the prescribed medication would then be dispensed and delivered by courier. If inadequate patient awareness of the urgency of treatment is the issue, it would be necessary to better address this point in the discharge counselings. Deregulating the requirements for community pharmacies with regard to dealing with rebate contracts, supply bottlenecks or out-of-stock package sizes could help to ensure that treatment is administered more quickly. Extending the option to dispense medications in the hospital to all days of the week (currently, dispensing of medications is only permissible if the discharge takes place before and on weekends and public holidays) could also help to make the same-day filling less urgent.

Heike Hilgarth, Gabriele Gradl, Nadine M. Metzger, Frank Dörje, Martin Schulz, Carolin Wolf, Hanna M Seidling on behalf of the ADKA-DPhG Working Group on Discharge Management/Discharge Prescriptions (see collaborators)

Federal Association of German Hospital Pharmacists (Bundesverband Deutscher Krankenhausapotheker e. V., ADKA) Berlin, Germany (Hilgarth, Dörje, Wolf, Seidling), [e-mail]; German Institute for Drug Use Evaluations (Deutsches Arzneiprüfungsinstitut e. V.) (DAPI), Berlin (Gradl, Schulz); German Pharmaceutical Society (Deutsche Pharmazeutische Gesellschaft, DPhG), Frankfurt, Germany (Metzger); Drug Commission of German Pharmacists (Arzneimittelkommission der Deutschen Apotheker, AMK), Berlin (Schulz); Institute of Pharmacy, Freie Universität Berlin (FU), Berlin (Schulz); Pharmacy Department, Erlangen University Hospital, Germany (Dörje, Wolf); Internal Medicine IX – Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg/Medical Faculty – Heidelberg University Hospital, Heidelberg, Germany (Seidling); Cooperation Unit Clinical Pharmacy, University of Heidelberg (Seidling)

Collaborators (ADKA-DPhG Working Group on Discharge Management/Discharge Prescriptions): Maika Bester (Pharmacy of GPR-Klinikum Rüsselsheim), Saskia Berger (Pharmacy of University Hospital Dresden), Sophia Klasing (Cooperation Unit Clinical Pharmacy, University of Heidelberg), Paul Maurischat (Pharmacy of Klinikum Südstadt Rostock), Carmen Schönwiesner (Pharmacy of Klinikum Nürnberg), Thomas Vorwerk (Pharmacy of Klinikum Region Hannover)

Funding

The Department of Clinical Pharmacology and Pharmacoepidemiology received research funding for several projects in the context of discharge management from the Dr. August and Dr. Anni Lesmüller Foundation, which was also used for parts of this study.

Conflict of interest statement

HH is member of the DPhG and employed as a scientific consultant at ADKA. NMM received fees from ADKA. MS is active in the GF Drugs of ABDA e. V., the Federal Chamber of Pharmacists (Bundesapothekerkammer, BAK) and the German Pharmacists’ Association (Deutsche Apothekerverband, DAV e. V.). HMS states that she received personal fees/reimbursement of travel expenses from e.g. chambers and specialist societies for lectures on medication safety. The remaining authors declare that no conflict of interest exists.

Manuscript received on 10 November 2023, revised version accepted on 30 April 2024.

Cite this as:
Hilgarth H, Gradl G, Metzger NM, Dörje F, Schulz M, Wolf C, Seidling HM, on behalf of the ADKA-DPhG Working Group on Discharge Management/Discharge Prescriptions: The utilization of discharge prescriptions in Germany—an overview for the years 2018–2021. Dtsch Arztebl Int 2024; 121: 539–40. DOI: 10.3238/arztebl.m2024.0095

References

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3. SARS-CoV-2-Arzneimittelversorgungsverordnung: www.bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/Gesetze_und_Verordnungen/GuV/A/SARS-CoV-2-AMVersorgVO_Bgbl.PDF (last accessed on 24 June 2024).

4. Fallzahlen der Krankenhausaufnahmen pro Jahr abzüglich der Stunden und Sterbefälle gemäß der Meldungen an das statistische Bundesamt: www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Krankenhaeuser/Tabellen/entlassene-patienten-eckdaten.html (last accessed on: 24 June 2024).

5. Ho PM, Tsai TT, Maddox TM, et al.: Delays in filling clopidogrel prescription after hospital discharge and adverse outcomes after drug-eluting stent implantation: implications for transitions of care. Circ Cardiovasc Qual Outcomes 2010; 3: 261–6.