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Prescribing in Canada: September 1988 Executive Summary of Medical Reform Group 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 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. 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. 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
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