Healthy Skepticism International News

April 2004

Review of recent studies of prescribing by Canadian physicians

Antibiotic Prescribing for Pneumonia and to Children

Single studies in Ontario and British Columbia on antibiotic prescribing in a community setting seem to show that family doctors are adhering to guidelines and using anti-infective therapy in a consistent manner (Karakashian et al. 2002) (Bryce et al. 1997). However, while the B.C. study surveyed a random sample of over 300 GPs, the study in Ontario was done in a family practice clinic in a teaching hospital and the authors note that a larger prospective study is necessary to confirm the findings.

Prescribing for pneumonia in the outpatient and hospital setting showed considerable variability. In one study cost of antibiotic therapy ranged from $183.70 to $315.60. Of note, patients treated at institutions with the lowest antimicrobial costs did not demonstrate worse medical outcomes and the rate of hospitalization for outpatients was lowest for the site with the lowest costs (Gilbert et al. 1998). In a second study involving a total of 20 hospitals (11 teaching and 9 community) the rate of compliance with guidelines from the American Thoracic Society ranged from just under 50% to 100% (Feagan et al. 2000).

There seems to be significant over prescribing of antibiotics to children for certain conditions and a lack of basic knowledge of the principles of antibiotic use among a substantial minority of Canadian physicians. One study in Saskatchewan in 1995 showed that 49% of children with an upper respiratory tract infection, almost always due to a viral infection, received a prescription for an antibiotic. Sixty-one percent of children with sinusitis received antibiotics and 24% with influenza. Influenza is a viral condition and antibiotics cannot be justified under any circumstances and sinusitis is usually a viral condition (Wang et al. 1999). In an Ontario study of 5 family practices, 3 pediatric practices and 2 urgent care centres, although antibiotics were appropriately withheld in a number of conditions, they were prescribed to nearly all children with bronchitis, a condition that is usually viral. Children with ear infections almost always received a 10 day course of antibiotics despite studies confirming that, if antibiotics are necessary at all, a 5 day course is sufficient (Pennie 1998). A survey of B.C. family physicians looked at antibiotic prescribing to children and unfortunately found that 25% did not believe that prior antibiotic use 21 increased the personal risk for acquiring drug-resistant infection and 23% did not believe that antibiotic use was an important factor in promoting resistance in their communities (Paluck et al. 2001). A final study of antibiotic prescribing by pediatricians in Toronto found a very encouraging 89.5% appropriate rate of use of these drugs (Arnold et al. 1999).

Prescribing for Hypertension

Prescribing for hypertension in primary care clinics and an internal medicine referral clinic in Edmonton was examined from 1993 to 1995. Only 23% of 969 patients received a first-line drug as recommended by Canadian guidelines and, of the remainder, less than half had a documented reason why one of the first-line drugs could not be used (McAlister et al. 1997). Prescribing of first-line agents varied in studies in Quebec ranging from 45% in the family medicine centre at the Université de Sherbrooke (Laplante et al. 1998) to 63% in a Montreal family medicine teaching centre (Beaulieu et al. 1998). In a Halifax study there was a shift seen to newer more expensive agents (average daily cost went from $0.48 to $0.85 per patient) without any improvement in the control of blood pressure (Wolf et al. 1999).

Prescribing of Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Two studies have looked at this aspect of prescribing. In one standardized patients (healthy people trained to simulate a particular condition) presented to family doctors with problems related to the use of NSAIDs. In 15% the presenting problem was managed optimally, in 58% acceptably, in 23% suboptimally and in 4% in an unsafe fashion (Jennett et al. 1996). The second study concluded that unnecessary NSAID-prescribing and suboptimal management of NSAID-related side effects were sufficiently common (42% unnecessary prescriptions and 23% suboptimal management) to raise questions about the appropriateness of NSAID use in the general population (Tamblyn et al. 1997).

Prescribing to the Elderly

An examination of the use of vitamin B12 injections among elderly patients attending family doctors found that almost 20% were receiving more than one injection a month despite the lack of any evidence that injections that frequently are needed (van Walraven and Naylor 1999). Out of 1423 community dwelling people ≥65 years of age in Quebec almost 20% were prescribed benzodiazepines continuously over a 12 month period. According to the authors and generally accepted practice, except in cases of disabling chronic anxiety which remains responsive to benzodiazepine therapy, long-term use of these agents is contraindicated (Egan et al. 2000). Prolonged use of these drugs puts elderly people at higher risk for hip fractures, confusion, falls, and motor vehicle accidents among other problems.

Recommendations:

Canadian doctors need ready access to up-to-date objective sources of prescribing information. One such bulletin is published in British Columbia, the Therapeutics Letter. Resources should be made available so that this publication can be distributed for free to all Canadian doctors similar to the free distribution of the Drug and Therapeutics Bulletin in the United Kingdom.
There must be much stronger regulation of promotion in order to neutralize its negative effects on prescribing behaviour.
Methods such as academic detailing (having trained personnel, usually clinical pharmacists visit doctors to discuss specific prescribing practices) have been shown to not only be effective in improving prescribing but also to save money. There is a fledgling network of academic detailing in Canada. This network should be provided with resources to expand its activities to cover the entire country.
Some studies have shown that doctors who are not paid on a fee-for-service basis are superior prescribers compared to those on fee-for-service. Given this finding, doctors should be encouraged to explore alternative payment methods.
In Australia the government has funded an independent National Prescribing Service at a rate of about $6 million per year. Canada should study this Australian model with a view to establishing a Canadian equivalent.

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