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Research ArticleOriginal ResearchA

Legacy Drug-Prescribing Patterns in Primary Care

Dee Mangin, Jennifer Lawson, Jessica Cuppage, Elizabeth Shaw, Katalin Ivanyi, Amie Davis and Cathy Risdon
The Annals of Family Medicine November 2018, 16 (6) 515-520; DOI: https://doi.org/10.1370/afm.2315
Dee Mangin
1Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
2University of Otago, Christchurch, New Zealand
MBChB, DPH, FRNZCGP
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  • For correspondence: mangind@mcmaster.ca
Jennifer Lawson
1Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
MLIS
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Jessica Cuppage
3University of Toronto, Ontario, Canada
MD
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Elizabeth Shaw
1Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
MD, CCFP, CFPC, FCFP
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Katalin Ivanyi
1Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
4Stonechurch Family Health Centre, Hamilton, Ontario, Canada
MD, CCFP, FCFP
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Amie Davis
1Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
5Halton McMaster Family Health Centre, Burlington, Ontario, Canada
MD, CCFP
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Cathy Risdon
1Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
MD, DMan, CCFP, FCFP
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  • Journal Club Discussion: Legacy drug-prescribing patterns in primary care
    Amanda Johnson
    Published on: 31 January 2019
  • Journal Club Discussion: Legacy drug-prescribing patterns in primary care
    Kaitlin Weisshappel
    Published on: 10 December 2018
  • Important work
    Michael A Steinman
    Published on: 26 November 2018
  • Common primary care practice
    Ilan Heinrich
    Published on: 26 November 2018
  • Published on: (31 January 2019)
    Page navigation anchor for Journal Club Discussion: Legacy drug-prescribing patterns in primary care
    Journal Club Discussion: Legacy drug-prescribing patterns in primary care
    • Amanda Johnson, Medical Student
    • Other Contributors:

    Polypharmacy has many well-known negative implications including lack of adherence, expense, drug interactions, and cognitive impairment. Identifying the most commonly overprescribed drugs could raise awareness of the issue and decrease the use of drugs beyond their effective or recommended period. The purpose of this study was to analyze the prevalence of legacy in 3 commonly prescribed drugs- antidepressants, bisphosph...

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    Polypharmacy has many well-known negative implications including lack of adherence, expense, drug interactions, and cognitive impairment. Identifying the most commonly overprescribed drugs could raise awareness of the issue and decrease the use of drugs beyond their effective or recommended period. The purpose of this study was to analyze the prevalence of legacy in 3 commonly prescribed drugs- antidepressants, bisphosphonates, and proton pump inhibitors (PPIs) by using the electronic medical record prescribing data within the McMaster University Sentinel and Information Collaboration (MUSIC) primary care practice-based research network (PBRN).

    The MUSIC network encompasses a variety of socioeconomic statuses in Hamilton, Ontario that contains de-identified health record data pertaining to drug product, dose, duration, and dates prescribed. Parameters based on recommended effective durations to prescribe medications were set to classify drugs as legacy or nonlegacy; 15 months for antidepressants, 5.5 years for bisphosphonates, and 15 months for PPIs. Two methods were used to determine the amount of time patients were on these medications, sum duration and start-stop duration. For the start-stop method, gaps in prescription dates were taken into consideration when determining how long a patient had been prescribed a medication. For the sum duration method, the total amount of time a patient had been prescribed the medication from January 2010 to December 2016. Both criteria had to be met to qualify as a legacy drug. A total of 16,125 prescriptions were included in the study, with 6,879 qualifying as legacy drugs.

    The results showed the overall rate of legacy drugs was 43%, specifically 46% of antidepressants were legacy drugs, 45% of PPIs, and 14% of bisphosphonates. Interestingly, 17% of patients were prescribed both antidepressant and PPI legacy drugs. There were no other important correlations. At the conclusion of the study, the majority of patients still had active prescriptions for these legacy drugs; 61% of antidepressants, 65% of PPIs, and 77% of bisphosphonates. Also of note, more women were prescribed legacy antidepressants and PPIs, while more men were prescribed legacy PPIs. It is worth addressing that this study was completed in Canada, where a single national health care system is present and data is more easily gathered- this certainly made a study like this more feasible than in the United States.

    Nearly half of the prescriptions included in this study were legacy drugs prescribed past the effective duration. This data indicates that legacy prescribing is indeed a major contributor to inappropriate polypharmacy, especially since 61-77% of the prescriptions included in this study were still active. Raising awareness about the issue of polypharmacy was one of the major strengths of this study. It also described 2 standardized methods of calculating prescription durations from medical record databases. However, there were a number of limitations.

    Though the study identified 2 different methods for determining legacy drugs and both had to be positive to qualify, it is difficult to know if the drugs were actually appropriately prescribed secondary to clinical criteria. For example, perhaps some patients continued to meet criteria for PPI therapy or presented with a different pathology that required PPI therapy again. It is also unknown if patients were switched from drugs within the same class because one was not working for them. For example, several different antidepressants may have tried over the period of 1 year in order to control the patient's symptoms. If so, then this may skew the results of some of the legacy drug durations.

    This study assumed that everyone on an antidepressant was being treated for depression when in fact there are many other uses for this class of drugs such as migraines, anxiety, and chronic pain. It would be helpful to know what the diagnosis for prescribing was because perhaps this would have excluded several prescriptions from the study. In addition to diagnosis, some general information on patient demographics including age, gender, comorbidities, and race/ethnicity would have been helpful to investigate if there is a specific demographic of patients that is receiving legacy prescriptions more than others.

    It also appears that the bisphosphonates legacy data may be inaccurate. The recommended treatment period for bisphosphonates is 5.5 years, but this study was only conducted for 6 years. Therefore, it is possible that several prescription durations were underestimated given that there was only a 6 month period for the researchers to identify any patients who were given the bisphosphonates during that time inappropriately. Perhaps a 10 or 15-year study would identify more patients.

    One way to combat this issue of inappropriate polypharmacy is to have providers reconcile medications during each patient visit. This includes going through each medication, inquiring about how it is used, how long the patient has been on it, and why they are on it. Providers can also generate a message to themselves on the electronic medical record to remind them after 15 months, for example, that a patient is on a certain medication and should be taken off of it or re-evaluated. Pharmacists should also be better utilized as a part of the checks and balances system to notify physicians if a patient is trying to refill a prescription that has exceeded the recommended treatment time. Mid-level provider visits could further be utilized for medication reviews. Finally, one single electronic medical record system for the entire country would likely decrease the issue of polypharmacy and drug interactions, and it would help physicians know exactly what drugs another provider prescribed to their patient.

    Competing interests: None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (10 December 2018)
    Page navigation anchor for Journal Club Discussion: Legacy drug-prescribing patterns in primary care
    Journal Club Discussion: Legacy drug-prescribing patterns in primary care
    • Kaitlin Weisshappel, Medical Student
    • Other Contributors:

    The overall purpose of the study was to examine the prevalence of legacy pharmacy prescriptions for adult patients in a primary care setting. The authors explored prescription timelines for bisphosphonates, antidepressants and proton pump inhibitors (PPIs) and hypothesized that many of these medications have extended prescriptions (termed "legacy prescriptions) outside of their intended therapeutic duration. The authors...

    Show More

    The overall purpose of the study was to examine the prevalence of legacy pharmacy prescriptions for adult patients in a primary care setting. The authors explored prescription timelines for bisphosphonates, antidepressants and proton pump inhibitors (PPIs) and hypothesized that many of these medications have extended prescriptions (termed "legacy prescriptions) outside of their intended therapeutic duration. The authors claimed that the extended use of these drugs contribute to polypharmacy and prescribing cascades.

    This study uses a retrospective cohort design to analyze identified data on 50,813 patient demographics and prescriptions collected over 6 years from the McMaster University Sentinel and Information Collaboration network in Hamilton, Ontario, which encompassed a wide range of socioeconomic statuses. The group discussed that this was a benefit of doing this study in Canada, due to the same insurance provider. Patients were included if they had taken antidepressants, bisphosphonates, and PPIs, which was selected by Anatomic Therapeutic Council (ATC) coding. Use of antidepressants for 15 months, bisphosphonates for 5.5 years, or PPIs for 15 months minimum were designated legacy prescriptions.

    We found that the inclusion of bisphosphonates in this particular study to be inappropriate in comparison to the other two medications, given the researchers defined legacy prescription for bisphosphonates to be greater than 5.5 years (compared to PPIs and antidepressants greater than 1.5-year window) and data-collection for the study was just a 6-year window. The difference between legacy prescription qualifications and the timeframe for data collection was too narrow in the opinion of the group to appropriately assess legacy prescriptions involving bisphosphonates despite the researchers' reported conservative definitions for legacy status.

    The group also discussed that the grouping all of the antidepressants (with the exception of MAO-Is) is problematic since there are multiple types of antidepressants with different indications and side effects. Also, the fact that MAO-Is are excluded was interesting. In the next study the antidepressant classes should be stratified, and/or MAO-Is should be included for completeness of assessment. Each class of antidepressants used should also be categorized by the diagnoses associated with each antidepressant prescription. SSRI use for premenstrual syndrome should also be taken into account or event excluded from future studies as prescriptions in this case are for 1 to 2 weeks per month while symptoms persist. In addition, PPIs could be prescribed as PRN, but have a long prescribing date, and it is unknown if those prescriptions should be considered legacy.

    Since there were few methods of evaluating legacy prescriptions, the authors developed their own method of summing the difference as well as the stop-start duration. Summing the difference involved calculating the length of each prescription, and stop-start duration consisted of calculating the difference between the first-ever start date and last-ever stop date for each drug. Using both resulted in the most accurate selection of legacy prescriptions, and prescriptions that only fit one or the other method were excluded. The group found that this was an acceptable method of determining legacy prescribing.

    While the rate of legacy prescribing was about 40% for antidepressants and PPIs, the group found it interesting that bisphosphonates had 14% legacy and 73% non-legacy prescriptions, possibly due to the relatively short course of data collected vs threshold for legacy prescriptions. The group also found it interesting that the highest percentage (17%) of dual legacy prescribing consisted of both antidepressants and PPIs, likely due to the effects of antidepressants on the GI system. Patients, that had received legacy prescriptions at some point, were also much more likely to still be on the legacy prescription at the end of data collection, and the group discussed that this was most likely due to physicians unwilling to change medications when patients are stable.

    The group also felt that the study could have improved with more information about prescriptions, such as: age group (especially for antidepressants and bisphosphonates); gender (increased risk of osteoporosis and depression in women); and dosage to determine the necessity of the legacy prescription. However, this may not have been possible with a large data set. The group also considered the possibility that prescriptions are not updated on patient records or low patient compliance with regular visits, which could cause a higher legacy prescribing percentage. However, there is not enough information given by the authors to make this conclusion.

    Regardless of outlying and confounding factors, the exogenous amount of legacy prescriptions cannot be denied. We believe that this study will raise awareness and cause providers to review medication prescriptions and update medication lists within the hospital EMR. This study, although limited to only 3 drug groups, is pertinent when considering other chronically prescribed medications in which it is important to be mindful of adverse side effects associated with long-term use. Additionally, patients and providers should be educated and stay up-to-date on prescription recommendations, treatment timelines, and associated side effects at various time-points of treatment.

    Future studies can be conducted as clinical trials in different outpatient settings, with the primary outcome being the difference in legacy prescribing following the implementation of different policies, mainly in clinics with continuity of care which will have better compliance. Possible methods to decrease legacy prescribing include provider education, follow-up appointment notifications linked with long- term prescriptions in the computer system, or making long-term prescriptions with multiple refills more difficult to obtain. Physician education could entail reinforcing when to stop prescriptions or a more complete medication history. In addition, certain prescriptions may be needed to be taken over long periods of time, for example, patients with relapsing depression in a short time period may need to be on SSRIs for 15 months or more. Finally, when prescribing medications with higher percentages of legacy prescriptions, patients could be given educational materials about the long-term use of medications and when it is most often appropriate to discontinue the medications pending provider approval. These are possible approaches to decreasing legacy prescribing, but it is unknown if they will address the problem and will need to be further studied.

    References

    Cheung KS, Chan EW, Wong AYS, et al. Long-term proton pump inhibitors and risk of gastric cancer development after treatment for Helicobacter pylori: a population-based study. Gut. 2018;67(1):28-35. doi: 10.1136/gutjnl-2017-314605

    Hengartner MP, Angst J, Rossler W. Antidepressant use prospectively relates to a poorer long-term outcome of depression: results from a prospective community cohort study over 30 years. Psychother Psychosom. 2018;87(3):181-183. doi: 10.1159/000488802

    Mangin D, Lawson J, Cuppage J, et al. Legacy drug-prescribing patterns in primary care. Ann Fam Med. 2018; 16(6):515-520. doi: 10.1370/afm.2315

    Watts NB. Long-term risks of bisphosphonate therapy. Arq Bras Endocrinol Metab. 2014;58(5):523-529. doi: 10.1590/0004-2730000003308

    Competing interests: None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (26 November 2018)
    Page navigation anchor for Important work
    Important work
    • Michael A Steinman, Professor of Medicine

    Congratulations on this thoughtful piece - it is interesting, informative, and important. I have a few thoughts to share:

    The term "legacy prescribing" is great, although I wonder if it is not pointed enough to get the idea across compared to a more judgmental term such as "prescriptions of excessive duration" or something similar. On a related note, there is some emerging work around deprescribing that sugge...

    Show More

    Congratulations on this thoughtful piece - it is interesting, informative, and important. I have a few thoughts to share:

    The term "legacy prescribing" is great, although I wonder if it is not pointed enough to get the idea across compared to a more judgmental term such as "prescriptions of excessive duration" or something similar. On a related note, there is some emerging work around deprescribing that suggests that patients are put off by this term ("deprescribing"), and as the field moves forward it will be useful to ensure that the relevant actors understand and buy in to the concepts revealed through language.

    The validation work on methods was a highly useful addition, although I have one question: how were refills accounted for in the prescription data? For example, if I prescribed a 30-day supply of a PPI with 11 refills, and a month later told the patient to stop taking the medication, is there any way of accounting for this or would this patient be counted as taking the medication for the full year? And, are there fields for indicating whether a medication is discontinued? There are some companies that are working on ensuring that discontinuation orders are communicated to community pharmacies in the U.S. (for prescribers who don't work in closed health systems), and major gaps remain, but I don't know if there are better systems in Canada.

    The results are very interesting, although sadly not surprising. And, as the authors noted there was likely undercounting of bisphosphonate legacy prescriptions given the duration of available data. For next steps, it would be particularly interesting to dig deeper into the details of who has legacy prescribing, how many of these prescriptions are actually inappropriate, and what factors drive failure to discontinue these medications.

    Thanks for sharing this important work.

    Competing interests: None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (26 November 2018)
    Page navigation anchor for Common primary care practice
    Common primary care practice
    • Ilan Heinrich, Family phycisian

    This observational study touches one of the basic defaults in the EMR era of primary care - the routine performance by re issuing on and on medications that should have been omitted along the years on clinical grounds, but instead are being prescribed by the power of futile inertia. Many family physicians do not engage in the trivial task of periodic review of their patients' medical charts due to various reasons among w...

    Show More

    This observational study touches one of the basic defaults in the EMR era of primary care - the routine performance by re issuing on and on medications that should have been omitted along the years on clinical grounds, but instead are being prescribed by the power of futile inertia. Many family physicians do not engage in the trivial task of periodic review of their patients' medical charts due to various reasons among which lack of time and interest rank high. As a result many patients suffers from the overgrowing medication phenomena named "polypharmacy" or "optimized pharmacy" in it's milder definition. The authors very wisely addressed this issue in regard to three "Legacy medication groups" - AD, BIS, PPI very common nowadays all over the world. Use of those medications should be carefully monitored due to their potential long term interaction with other prescribed drugs (Clopidogrel, Diuretics, Aspirin, Analgesics etc.). The study design is rather simple taking into inclusion only those patients fulfilling both requirements. Results to my opinion and clinical experience could be verified for many practices worldwide as I do have a very similar impression based on practice management. The study aims at HMO's and medical insurance companies' supervision systems to postulate routine surveillance instructions for similar "legacy selected medications" prescriptions. It's seems that this might be one of the next trends in Family medicine.

    Competing interests: None declared

    Show Less
    Competing Interests: None declared.
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The Annals of Family Medicine: 16 (6)
The Annals of Family Medicine: 16 (6)
Vol. 16, Issue 6
November/December 2018
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Legacy Drug-Prescribing Patterns in Primary Care
Dee Mangin, Jennifer Lawson, Jessica Cuppage, Elizabeth Shaw, Katalin Ivanyi, Amie Davis, Cathy Risdon
The Annals of Family Medicine Nov 2018, 16 (6) 515-520; DOI: 10.1370/afm.2315

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Legacy Drug-Prescribing Patterns in Primary Care
Dee Mangin, Jennifer Lawson, Jessica Cuppage, Elizabeth Shaw, Katalin Ivanyi, Amie Davis, Cathy Risdon
The Annals of Family Medicine Nov 2018, 16 (6) 515-520; DOI: 10.1370/afm.2315
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Keywords

  • polypharmacy
  • bisphosphonates
  • antidepressive agents
  • proton pump inhibitors
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  • electronic health records
  • potentially inappropriate medication list
  • inappropriate prescribing
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