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Prescribing Cascades: How to Detect Them, Prevent Them, and Use Them Appropriately

Tobias Dreischulte, Faiza Shahid, Christiane Muth, Sven Schmiedl, and Walter Emil Haefeli

Dtsch Arztebl Int. 2022 Nov; 119(44): 745–752.

Published online 2022 Nov 4. doi: 10.3238/arztebl.m2022.0306

"Conclusions

Implications for clinical practice

Numerous prescribing cascades have already been described in the literature. A differentiated consideration of these shows, on the one hand, that unintentional and avoidable prescription cascades must be prevented more effectively in order to reduce unnecessary polypharmacy and its associated risks. On the other hand, prescribing cascades may be part of good prescribing practice and necessary for a positive benefit–risk balance in the overall treatment approach. One can also assume that many prescribing cascades have yet to be detected and that with the use of novel drugs, new ADR profiles will emerge (for example, checkpoint inhibitors) that lead to new prescribing cascades.

Implications for research

It has been shown that it is important to further develop current approaches for the systematic identification of previously undetected prescribing cascades and enable a better distinction between clinically relevant prescription cascades and spurious signals in which the prescription of a second drug has no causal relationship to the prescription of the precipitating drug. A systematic review compiles currently known prescribing cascades (40).

The extended classification system for prescribing cascades proposed here can provide a theoretical framework to classify the identified prescribing cascades into appropriate, necessary, and potentially inappropriate prescribing cascades. This can be used to develop practically implementable, potentially electronic instruments, aiming to alert physicians to both potentially inappropriate and potentially omitted prescribing cascades."

Researching the prescribing cascade in the field of medicine is an important endeavor, as it can help identify instances where a new medication is prescribed to treat the side effects of a previously prescribed medication. This can have significant implications for patient safety and healthcare costs. Here are steps and methods you can consider for researching the prescribing cascade:

Review Relevant Literature: Start by conducting a thorough literature review on prescribing cascades for a foundational understanding of the subject.

Clearly define the scope and objectives of your research.

Data Collection: This can involve obtaining access to electronic health records (EHRs) or collaborating with healthcare institutions or pharmacies.

Data Analysis: If you have access to patient data, you can use statistical software like Excel, R, or Python to analyze the data. You can create Excel files to organize and clean the data, but more complex analyses may require specialized statistical tools.

Identify Prescribing Cascades: Develop criteria to identify prescribing cascades within the data. This typically involves examining the sequence of medications prescribed to determine if a new medication is likely a response to side effects of a previous one.

Ethical Considerations

Collaborate with Experts

Document Findings

Record your findings, including the medications involved in prescribing cascades, the frequency of occurrence, and any associated clinical outcomes or adverse events.

Statistical Analysis: This may involve regression analysis, correlation studies, or other relevant statistical methods.

Interpretation and Conclusion: Interpret your findings in the context of patient safety, healthcare quality, and cost implications. Draw conclusions and consider potential recommendations or interventions to mitigate prescribing cascades.