Achieving optimal prescribing: what can physicians do?

Recognized issue Prescription drugs are the therapeutic backbone of clinical practice. In 2005, Canadians received 14 prescriptions per capita; that number rose to 74 for people 80 years and older.2 In 2009, the per capita cost of prescription drugs in Canada was $877. Whereas in 1985 drug expenditures accounted for less than a tenth of total health expenditures, by 2009 they amounted to almost 16.2%.3 Both the frequency with which drugs are prescribed and the cost borne by patients and the health system underscore the importance of ensuring that prescribing is of the highest calibre. Unfortunately, there is a growing body of evidence that suggests that prescribing is often suboptimal. Some drugs are prescribed more frequently than is appropriate. Antibiotics, for example, are often prescribed for children with minor respiratory illnesses that are likely viral in origin.4,5 The underuse of clinically indicated medication is another type of suboptimal prescribing. Canadian studies have shown underuse of lipid-lowering agents,6 blood pressure drugs,7 medications for congestive heart failure,8 and prescriptions for post–myocardial infarction care.9 Finally, practitioners might make incorrect drug choices that might result in harm to patients. For example, a study of hospitalized patients in 5 Canadian provinces found that a quarter of adverse events were related to drug and fluid therapy and that 37% of the events were highly preventable.10 Less is known about communitybased practice; however, the Canadian component of an international study reported that 26% of errors in family practice involved treatments, including medications, and almost 40% of errors were believed by reporting physicians to have harmed patients.11 Seniors12 and those given opioids13 appear to be groups particularly vulnerable to inappropriate prescribing. While suboptimal prescribing has long been recognized as an issue, it has attracted increased attention since 2004 when the First Ministers called for the creation of a National Pharmaceuticals Strategy. One of the strategy’s 9 objectives was “to influence the prescribing behaviour of health care professionals so that drugs are used only when needed and the right drug is used for the right problem.”14 However, the 2006 National Pharmaceuticals Strategy Progress Report14 included less than a page on appropriate drug prescribing. Although it mentioned the important establishment of the Canadian Optimal Medication Prescribing and Utilization Service, it indicated that the Ministerial Task Force’s next step was largely to “continue to monitor progress.” The following year the Health Council of Canada hosted the Safe and Sound: Optimizing Prescribing Behaviours symposium to assist in the continued development of the National Pharmaceuticals Strategy. In the conference report, the council stated that sound prescribing decisions required “targeted education and easier access to the right information” for practitioners.15 The key strategies identified were the following: expansion of existing provincial academic detailing programs; creation of trusted sources of objective information for patients; and enhancement of existing initiatives, such as the Canadian Optimal Medication Prescribing and Utilization Service, directed at optimizing prescribing.15