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Prescribing in Canada:
A Review of the Literature
September 1988
Executive Summary of Medical Reform Group of
Ontario
Brief to the Pharmaceutical Inquiry of Ontario
Note: The following is the Executive Summary of Prescribing
in Canada. The full 28-page report is available from the Medical
Reform Group.
Executive Summary
Prescribing is an essential feature of the work of almost every
physician engaged in clinical practice. However, despite the central
role that prescribing plays in medical practice there has been no
systematic exploration of this topic in Canada. Through a review
of the available literature the Medical Reform Group of Ontario
will describe the general characteristics of prescribing and then
focus on three main themes: factors affecting prescribing, the appropriateness
of prescribing and adverse consequences from prescribed medications.
Based on the analysis in these three sections our conclusion and
recommendations offer suggestions on approaches to improving prescribing.
Canadian general practitioners issue prescriptions on average to
48 percent of all patients seen in the office. Each prescription
is for 1.2 to 1.4 drugs. In general, doctors use only 100 to 200
of the 3500 prescription products available and over 50 percent
of all prescriptions are written for no more than 27 different medications.
The most commonly prescribed groups of drugs are antibiotics and
psychotropics. The elderly are the most heavily prescribed age group.
Studies in Canada have identified a number of factors that appear
to influence appropriate prescribing. Generic prescribing may promote
more rational prescribing since an awareness of the generic names
of drugs would mean that physicians would know the contents of drugs.
One anecdotal report showed that in the case of fixed dose combination
products doctors were largely ignorant of their contents.
Economic factors can influence a doctor's choice of drugs in provinces
with formularies. Excluding expensive irrational products from a
formulary leads to a marked decrease in the prescribing of those
drugs to people covered by a drug plan.
Doctors' attitudes and personal characteristics affect their prescribing.
Physicians' attitudes about the validity of using drugs for psychosocial
problems appears to be a determinant of how frequently prescriptions
are written. Attendance at continuing medical education courses
seems to promote more appropriate prescribing. Finally, there is
some evidence, although not conclusive, that male physicians may
overprescribe psychotropic drugs to women.
The type of practice doctors have influences their use of drugs.
Salaried physicians practising in government funded community health
centres in Montreal were superior prescribers compared to physicians
practising in fee-for-service group practices.
Physicians source of information about pharmaceuticals is a major
factor in how well they prescribe. Canadian physicians, both general
practitioners and specialists, often rely on commercial sources,
that is those originating with the drug companies. for information
about drugs. With only one exception all the studies done on the
relationship between prescribing appropriateness and the source
of information about drugs have reached the conclusion that the
more doctors rely on commercial sources the less rational they are
as prescribers.
A study of retarded residents in five institutions in Eastern Ontario
found that there was a striking lack of association between the
degree of subnormality of the patient and the use of psychotropic
medication. The use of multiple drugs, or polypharmacy, did not
seem to be related to either demographic factors or clinical diagnosis.
In another centre in Ontario, the rationalization of drug therapy
resulted in substantial drops in the number of patients on anxiolytics,
hypnotics and antiparkinson medication as well as a marked reduction
in the incidence of polypharmacy.
Those over 65 years of age receive in excess of 12 prescriptions
a year. These people often take 4 to 6 different drugs daily. Evidence
that there is general overprescribing to the elderly comes from
the results of five different studies. In every case, after either
an educational campaign or a prescribing review, there was a reduction
in drug use.
The bulk of the Canadian literature on prescribing for the elderly
deals with psychotropic drugs. Per capita, people in this age group
receive, by far, the largest number of psychotropic prescriptions
with elderly women running ahead of elderly men. Evidence from across
Canada shows that individual psychotropic agents or particular classes
of these drugs are prescribed irrationally, particularly benzodiazepines
and barbiturates.
A summary of the results of five surveys on cimetidine prescribing
shows that of a total of 396 patients studied exactly half received
cimetidine inappropriately.
Little is known about antibiotic prescribing in the ambulatory
care setting, but some evidence does exist to indicate that there
is excessive prescribing to people with upper respiratory infections.
Out of a total of 1478 drug courses reviewed in twelve surveys
of hospital antibiotic prescribing, antibiotics were prescribed
appropriately in only 52 percent of cases. For 13 percent of prescriptions
appropriateness could not be determined and prescribing was clearly
inappropriate 34 percent of the time.
There has been a reassuring decline in propoxyphene prescribing
in recent years. In Saskatchewan, from 1977 to 1982, propoxyphene
prescriptions declined from 16.4 percent of all analgesic prescriptions
to just 4.2 percent.
Currently, prescriptions for psychotropic drugs make up between
15 to 28 percent of all prescriptions written. The question of whether
or not psychotropic drugs, especially benzodiazepines, are being
rationally prescribed is a complex problem to which there is no
easy answer and probably depends on what group(s) of patients they
are considered appropriate for. Diazepam may only be effective for
patients with high levels of pre-treatment anxiety and it appears
to be better than placebo for relieving anxiety for only the first
out of six weeks of therapy.
Women are by far the major recipients of prescriptions for psychotropics.
Between 62-77 percent of all such prescriptions go to women. While
women tend to seek support and assistance during times of marked
stress more readily than men the high level of prescribing to women
does not seem to be explicable on the basis that women visit physicians
more often than men. As we mentioned earlier, there is also strong,
but not conclusive, evidence that male physicians overprescribe
to women.
Psychotropics, especially benzodiazepines, are often used in the
treatment of somatic disorders despite the lack of objective evidence
that they do any good. Finally, sedatives and hypnotics are routinely,
and probably inappropriately, prescribed to hospitalized patients.
All the Canadian research into acute drug overdoses has shown that
psychotropics, especially benzodiazepines, were the most commonly
used products. There is a highly significant correlation between
the number of prescriptions of different drugs and their selection
for overdose.
The elderly seem to be the group most likely to suffer an adverse
drug reaction. This may be a reflection of the decreased metabolism
of drugs, or more likely, of the number of drugs they are prescribed.
In one case 20 percent of hospital admissions to a geriatrics ward
were the result of adverse drug reactions.
Fifteen to 30 percent of hospital patients were reported to have
had adverse drug reactions. Adverse drug reactions, both in hospitals
and in ambulatory settings, are probably greatly under-reported.
The occurence of an adverse drug reaction does not necessarily imply
inappropriate prescribing. Furthermore, these reactions cannot always
be prevented by appropriate prescribing, but in adults 64 to 80
percent of reactions may be potentially avoidable without compromising
any therapeutic benefit.
To improve physicians' prescribing the Medical Reform Group makes
the following recommendations:
1. There is an acute need for additional research about all aspects
of prescribing.
2. Drugs included in formularies should not only meet strict scientific
criteria for efficacy, but they should be included in formularies
only if there is a demonstrable need for them. This latter criteria
may mean that only a limited number of drugs in any therapeutic
class, for example the nonsteroidal anti-inflammatories or the benzodiazepines,
would be listed in the formulary.
3. Medical students need to be made more critical in their evaluation
of the claims of the pharmaceutical industry through courses in
medical school.
4. The government in conjunction with the medical and pharmacy professions
and other interested groups should develop both a low cost Canadian
equivalent of the AMA Drug Evaluation book to replace the Compendium
of Pharmaceuticals and Specialties and a Canadian equivalent of
The Medical Letter.
5. Pharmaceutical promotion needs to be much more stringently controlled
than is now the case. The visits of detailers to hospitals should
be regulated in line with policies adopted by some Swedish hospitals.
6. Since physicians in non fee-for-service settings appear to be
better prescribers than those practising under the traditional method
of payment there should be widespread encouragement by government
of non fee-forservice practice settings.
7. Physicians practising in health service organizations should
receive prescribing incentive payments similar to the ambulatory
care ones currently offered. These payments would be made to HSO
doctors whose per capita prescribing costs for Drug Benefit recipients
were below the regional average costs.
8. The provincial government in cooperation with the medical and
pharmacy professions and consumer groups should encourage and develop
general practice formularies.
9. Physicians should receive quarterly reports comparing their prescribing
for patients covered by the Drug Benefit Plan with the prescribing
of other doctors in the same region and with all doctors in the
province.
10. Funding should be made available for the training and hiring
of drug educators to engage in face-to-face educational interventions
on prescribing with Ontario doctors.
Medical Reform Group of Ontario
September 1988
Subject Headings: Abortion
Rights – Community
Health – Community
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Care Cost Containment – Health
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Care in Canada – Health
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Care in the U.K. – Health
Care in the U.S. – Health
Care Myths – Health
Care Reform – Health
Care Resources – Health
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Care Workers – Health
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– Physician
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Health – Publications/Health
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