The perils of pill-splitting

Wide-scale pill-splitting as a cost-containing measure is practiced by such large healthcare systems as the West Coast VA, Kaiser, and United Healthcare. The practice may serve the bottom line. But does it serve the patients?

Key Points

Commonly what I saw in the pill containers was up to 200 split products of all sizes - large, medium, and small - down to crumbs and dust. A visual disaster. When I asked the patients what splitting pattern they used, they often said that they got their 100 pills and split them all at once into 200 pieces (including a few that they picked back up off the floor). Then, to make matters worse, many of these patients preferred to start with the largest fragments and work their way down to licking dust as the last dose.

How it got started

The practice spread quickly from West Coast VA units to Kaiser and on to United HealthCare. In each of these 3 systems the practice of splitting pills is now massive. I believe that over $1 billion a year in savings to the system (not to patients) would be at risk if splitting went back to its original and limited use: brief titration of dose.

For a 1998 study [McDevitt JT, Gurst HA, Chen Y. Accuracy of tablet splitting. Pharmacotherapy 1998;18:193-197], several researchers focused on weighing split pills with an analytical balance. That study has become the gold standard on pill-splitting and has never been surpassed. McDevitt's volunteer group analyzed 1,752 splits weighed with German Mettler scales and found that "41.3% deviated from ideal weight by more than 10% and 12.4% deviated by more than 20%." Deviation like this can commonly mean a greater than 40% difference between the largest and smallest fragments.