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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 Sources 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

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