November 21, 2018
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Legacy Prescribing Appears Common in Primary Care

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Legacy prescribing — prescribing drugs past their usual effective or recommended period — seemed prevalent in primary care, according to findings recently published in Annals of Family Medicine.

“Primary care serves a coordinating function for patients with multimorbidity and is also the setting for most long-term prescribing, making this an appropriate setting to study and address inappropriate medicine use and polypharmacy,” Dee Mangin, MBChB, DPH, FRNZCGP, professor and associate chair in the department of family medicine, McMaster University, and colleagues wrote.

“We investigated the extent of legacy drug prescribing for three exemplar drug classes prescribed for different conditions — antidepressants, bisphosphonates, and proton pump inhibitors — using routinely collected electronic health record prescribing data within a primary care practice-based research network,” they added.

Researchers examined records of 50,813 patients older than 18 years in the McMaster University Sentinel and Information Collaboration data set.

Mangin and colleagues found that 46% of patients receiving antidepressants, 45% of those receiving proton pump inhibitors and 14% of those receiving bisphosphonates had a legacy prescription at some point from 2010 to 2016.

In addition, the mean duration of prescribing for all legacy prescriptions was significantly longer than that for non-legacy prescriptions (P < .001). Concurrent legacy prescriptions for both antidepressants and PPIs was common, signaling a possible prescribing cascade.

Researchers added that many of these findings suggest legacy prescribing was common and consistent among primary care providers and could be contributing to inappropriate polypharmacy.

In an interview with Healio Family Medicine, Mangin said she felt the findings could be duplicated among other medications, such as those for pain, anti-anxiety and ADHD, calling legacy prescribing a “system-level issue.”

She also offered some approaches to ending indefinite prescription writing.

“Potential solutions should be developed by consulting with the physicians and patients. These will likely be technological — rethinking our current prescribing systems to focus on supporting appropriate duration and stopping, or deprescribing, as well, as we focus on starting and re-prescribing,” Mangin said.

“Solutions will also likely involve rethinking conversations between prescriber and patient at the first prescription of a drug. Understanding what a usual course length [is] and when, why, and how it is planned to stop, means that there will be clear expectations and a shared understanding at the outset. Communication of reason for starting and expected course length between different for a patient is also important, since prescriptions may be started by specialists but then ongoing responsibility for prescribing sits with the family doctor,” she added. – by Janel Miller

Disclosure: The authors report no relevant financial disclosures.