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

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Patients prescribed antidepressants: inclusion and exclusion for comparative analysis.

    aPatients designated with an active status in their patient record as of December 31, 2016.

    bPatients had both an active status and a current prescription for the drug associated with legacy prescribing status (stop date after December 31, 2016).

Tables

  • Table 1

    Legacy Prescriptions Among Patients Prescribed Each Index Drug Class During 2010-2016

    MeasureAntidepressant Prescriptions
    (n = 8,119)    		Bisphosphonate Prescriptions
    (n = 1,592)    		PPI Prescriptions
    (n = 6,414)    		Total Prescriptions
    (N = 16,125)
    Total included in comparative analysis, No. (%)6,999 (86)1,387 (87)5,660 (88)14,046 (87)
     Legacy, No. (%)3,766 (46)228 (14)2,885 (45)6,879 (43)
     Nonlegacy, No. (%)3,233 (40)1,159 (73)2,775 (43)7,167 (44)
    Mean (SD) prescription duration
     Legacy prescriptions, ya4.8 (2.0)b6.7 (0.6)b4.9 (1.9)b–
     Nonlegacy prescriptions, yc0.4 (0.3)2.0 (1.4)0.4 (0.3)–
    Total excluded from comparative analysis, No. (%)1,120 (14)205 (13)754 (12)2,079 (13)
     Only start-stop legacy criteria met, No. (%)904 (11)123 (8)625 (10)1,652 (10)
     Only sum legacy criteria met, No. (%)216 (3)82 (5)129 (2)427 (3)

    • MUSIC = McMaster University Sentinel and Information Collaboration; PPI = proton pump inhibitor.

      Note: Data represent counts of individual prescriptions among 50,813 patients (population N) in the MUSIC data set.

    • a Calculated for patients with an active status and limited to start-stop duration values that were less than 8 years.

    • ↵b Difference between legacy and nonlegacy groups was significant (P <.001).

    • ↵c Calculated for patients with an active status and limited to start-stop duration values that were greater than 0 days.

  • Table 2

    Legacy Prescription and Coprescription: Unique Patients With Single- or Multiple-Drug Legacy Prescriptions, 2010-2016

    Drug Class/ClassesUnique Patients, No. (%)
    (n = 5,806)
    Single-drug legacy prescription4,745 (82)
     PPI1,850 (32)
     Antidepressant2,759 (48)
     Bisphosphonate136 (2)
    Multiple-drug legacy prescriptions1,061 (18)
     Antidepressant, bisphosphonate, and PPI12 (0.2)
     Antidepressant and PPI969 (17)
     Antidepressant and bisphosphonate26 (0.4)
     PPI and bisphosphonate54 (0.9)

    • PPI = proton pump inhibitor.

      Note: Data represent prescribing patterns among the 5,806 unique patients receiving the 6,879 legacy prescriptions in the second row of Table 1.

Additional Files

  • Supplemental Appendix

    Supplemental Appendix

    Files in this Data Supplement:

  • The Article in Brief

    Legacy Drug-Prescribing Patterns in Primary Care

    Dee Mangin , and colleagues

    Background Inappropriate prescribing of medications is often thought of in terms of the number, types or combinations of drugs prescribed at the same time, but it can also be considered in terms of the duration of prescriptions. This study evaluates the proportion of "legacy prescribing" (medications that are not appropriately discontinued when their usefulness has diminished) and when the risk of side-effects, interactions with other drugs, and ongoing costs remain) within 3 drug classes and associated patient characteristics.

    What This Study Found The continuation of drugs that are not intended to be taken indefinitely is a substantial and common problem that could contribute to over-medication, particularly in the elderly. In (n = 50,813). The study of adults in and around Hamilton, Ontario, Canada calculated rates of legacy prescribing for three types of drugs: antidepressants (continuous prescribing of more than 15 months), bisphosphonates (continuous prescribing of more than 5.5 years), and proton pump inhibitors (continuous prescribing of more than15 months). The proportion of patients having a legacy prescription at some time during the study period was 46 percent (3,766 of 8,119) for antidepressants, 14 percent (228 of 1,592) for bisphosphonates, and 45 percent (2,885 of 6,414) for proton pump inhibitors.

    Implications

    • The authors point out that prescribing systems are largely geared towards starting and continuing medicines; most have no controls to flag the end of an intermediate-term prescription, while routine re-prescribing systems and software features are common. These results are therefore not surprising and indicate a need for system-oriented change that encompasses prescribing systems, education and patient-pharmacist-physician communication on appropriate stopping of drug therapy.
    • The authors also suggest that legacy prescribing could be explored as a quality measure to incentivize restraint in a system where there are currently few, if any, indicators of the adverse effects of too much medicine.

  • Annals Journal Club

    Nov/Dec 2018: Legacy Drug Prescribing Patterns in Primary Care: A Cohort Study


    Paula P. Amin, MD, Grant Family Medicine Residency, and Michael E. Johansen, MD, MS, Associate Editor

    The Annals of Family Medicine encourages readers to develop a learning community to improve health care and health through enhanced primary care. Participate by conducting a RADICAL journal club. RADICAL stands for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. We encourage diverse participants to think critically about important issues affecting primary care and act on those discussions.1

    HOW IT WORKS

    In each issue, the Annals selects an article and provides discussion tips and questions. Take a RADICAL approach to these materials and post a summary of your conversation in our online discussion. (Open the article and click on "TRACK Discussion/ Submit a comment.") Discussion questions and information are online at: http://www.AnnFamMed.org/site/AJC/.

    CURRENT SELECTION

    Article for Discussion

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

    Discussion Tips

    Cohort studies allow researchers to explore associations and trends in how medical care is provided, which can lead to important insights about improving care such as continuing medications longer than is frequently recommended. This retrospective cohort study evaluated over 50,000 patients from a variety of clinicians to describe longitudinal prescribing patterns of antidepressants, bisphosphonates, and PPIs to identify and describe the phenomenon of "legacy prescribing."

    Discussion Questions

    • What question is asked and why does it matter?
    • What is a retrospective cohort study? How does this differ from a prospective cohort study and a case-control study?
    • How does this study advance beyond previous research and clinical practice on this topic?
    • How strong is the study design for answering the question and what are the weaknesses?
    • How does the sum duration calculation differ from the start-stop calculation? What insight can be gained from looking at the supplementary appendix?
    • To what degree can the findings be accounted for by: how patients were selected or excluded; how the main variables were measured; confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a 3rd factor); chance; or how the findings were interpreted?
    • What are the main study findings?
    • How do the findings of legacy prescribing of bisphosphonates compare with the findings of PPIs and antidepressants? Why might these rates differ?
    • Have you talked with a patient about stopping any of these medications? How are the conversations different than those about starting medication?
    • How strong is the evidence against long-term use of the included drug classes? Are these cases of lack of evidence or strong evidence against?
    • How comparable is the study sample to similar patients in your practice? What is your judgment about the transportability of the findings?
    • What other medication classes more commonly prescribed in primary care may have similar legacy prescribing trends?
    • How might this study change your practice? Policy? Education? Research?
    • What are the next steps in interpreting or applying the findings?
    • What researchable questions remain? How might a qualitative component improve your understanding of this phenomenon?

    References

    1. Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: It's time to get RADICAL. Ann Fam Med. 2006;4(3):196-197.

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