Assessing prescribing of NSAIDs, antiplatelets, and anticoagulants in Canadian family medicine using chart review

Abstract

Background Drug-related problems have been identified as a major contributor to emergency room visits, hospitalizations, and death. The most commonly implicated medications are nonsteroidal anti-inflammatory drugs (NSAIDs), antiplatelets, and anticoagulants. Considering a significant proportion of these harms are preventable, indicators to identify risky prescribing before they lead to harm have been developed. Objective To examine the prevalence and patterns of potentially inappropriate prescriptions (PIPs) in a primary care population who are using high-risk medications. Setting This study was performed within two multi-disciplinary family medicine teaching clinics in Winnipeg, Canada. Method A cross-sectional electronic/paper chart audit was conducted within two multi-disciplinary family medicine teaching clinics to evaluate the prevalence of 13 evidence-based high-risk prescriptions. Patients were included if they were prescribed an oral NSAID, antiplatelet, or an anticoagulant within the 12 month period between June 2012 and June 2013. Main outcome measure The proportion of PIPs associated with an increased bleeding risk for NSAIDs, antiplatelets, and anticoagulants. Results Of the 567 patients included in the review, 198 (35 %) patients had received at least 1 PIP in the past year. The most common PIP was the use of an oral NSAID with one or more GI risk factors without adequate gastro-protection. Only 34 (6 %) of these patients received a full medication review performed by a pharmacist. Although not statistically significant, patients who received a medication review had fewer inappropriate prescriptions (27 % with review, 35 % without). Conclusion Over one-third of the patients who were using high-risk medications were using them potentially inappropriately. Although pharmacists have been shown to reduce the amount of inappropriate prescribing, very few patients using these medications were referred to the pharmacist for a full medication review. These data suggest that there is opportunity for the identification and assessment of these patients when prescribing or dispensing these high-risk medications.

Impact of a Prescription Support Tool to Improve Adherence to the Guidelines for the Prescription of Oral Antithrombotics: The Combi-AT Randomized Controlled Trial Using Clinical Vignettes

“…However, inappropriate doses of oral anticoagulant and an inappropriate duration of oral AT combinations were the main errors of physicians in the control arm, which is consistent with the literature [4,6,7,8]. Therefore, failure to consider all components of oral AT prescriptions in the previous study [9] may have overestimated the appropriate oral AT prescription rate. To our knowledge, Combi-AT is the first study evaluating the rate of appropriate oral AT prescriptions considering all components of the prescription (i.e., the number of drugs, drug class, dosage and duration of prescription), regardless of the indication, in outpatient setting.…”

“…Overall, one-third of oral AT prescriptions were fully appropriate without access to the prescription support tool. This proportion is much lower than the 85% estimated rate from literature data [9] based on a single real-life Canadian study, where the dosage and the duration were not taken into account. However, inappropriate doses of oral anticoagulant and an inappropriate duration of oral AT combinations were the main errors of physicians in the control arm, which is consistent with the literature [4,6,7,8].…”

“…The unit of measurement was the prescription (clinical vignettes). Considering that 85% of oral AT prescriptions would comply with guidelines in the control arm [9] and that each physician would complete 3 clinical vignettes, to demonstrate an increase in this proportion up to 90% in the experimental arm, with a power of 80%, an alpha risk of 5% and a two-tailed test, we needed to include a minimum of 230 physicians per arm.…”

“…Several studies have reported the inappropriate use of oral ATs in patients with non-valvular atrial fibrillation (concomitant use of drugs increasing the risk of bleeding, insufficient dose of anticoagulant or use of antiplatelet agents instead of anticoagulants) [4,6,7,8]. Regardless of the indication, approximately 15% of patients with AT combinations had inappropriate dual or triple oral AT therapy according to a Canadian survey [9]. However, the appropriateness of the prescribing was limited to the type of drugs combined and did not cover the dosage and duration of prescription.…”

A prescription support-tool for chronic management of oral antithrombotic combinations in adults based on a systematic review of international guidelines

“…Improving their prescriptions by avoiding their inappropriate combinations (in terms of indication, dosage, type of drugs combined and duration of prescription) is a major concern. In a Canadian primary care cohort, approximately 15% of patients who were prescribed ATs had inappropriate dual or triple oral AT therapies (type of drugs combined only),[7] which suggests an important room for improvement for prescription of oral AT combinations. Actually, most clinical practice guidelines focus on a single disease and applying single-disease guidelines for multimorbidity increases the risk of inappropriate prescriptions (among other things inappropriate combinations).…”