Assessing prescribing of NSAIDs, antiplatelets, and anticoagulants in Canadian family medicine using chart review
- 309 Downloads
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.
KeywordsAnticoagulant Antiplatelet Canada Chart review NSAID Potentially inappropriate prescriptions Primary care
We would like to thank the Winnipeg Regional Health Authority who granted access to the required electronic medical records through Manitoba eHealth, Family Medical Centre and Kildonan Medical Centre, the University of Manitoba, College of Pharmacy for their support, and the University of Manitoba Biostatistical Consulting Unit. Finally, we would like to acknowledge Dr. Sheryl Zelenitsky for her help in the development of this manuscript.
University of Manitoba.
Conflicts of interest
- 8.Vandvik PO, Lincoff AM, Gore JM, Gutterman DD, Sonnenberg FA, Alonso-Coello P, et al. Primary and secondary prevention of cardiovascular disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141:e637S–68S.CrossRefPubMedPubMedCentralGoogle Scholar
- 9.Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141:e419S–94S.CrossRefPubMedPubMedCentralGoogle Scholar
- 10.Avery AJ, Rodgers S, Cantrill JA, Armstrong S, Cresswell K, Eden M, et al. A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. Lancet. 2012;6736:1–10.Google Scholar
- 18.Patterson SM, Hughes C, Kerse N, Cardwell CR, Bradley MC. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2012;5:CD008165. doi: 10.1002/14651858.CD008165.pub2.
- 19.Nkansah N, Mostovetsky O, Yu C, Chheng T, Beney J, Bond CM, et al. Effect of outpatient pharmacists’ non-dispensing roles on patient outcomes and prescribing patterns. Cochrane Database Syst Rev. 2010;7:CD000336. doi: 10.1002/14651858.CD000336.pub2.
- 20.Cipolle R, Strand L, Morley P. Pharmaceutical care practice: the clinician’s guide. 2nd ed. New York: McGraw-Hill; 2004.Google Scholar
- 21.WHO Collaborating Centre for Drug Statistics Methodology, Guidelines for ATC classification and DDD assignment 2013. Oslo; 2012.Google Scholar
- 26.Warlé-van Herwaarden MF, Koffeman AR, Valkhoff VE, 't Jong GW, Kramers C, Sturkenboom MC, et al. Time-trends in the prescribing of gastroprotective agents to primary care patients initiating low-dose aspirin or non-steroidal anti-inflammatory drugs: a population-based cohort study. Br J Clin Pharmacol. 2015;80:589–98. doi: 10.1111/bcp.12626.CrossRefPubMedPubMedCentralGoogle Scholar
- 29.Silverstein FE, Graham DY, Senior JR, Davies HW, Struthers BJ, Bittman RM, et al. Misoprostol reduces serious gastrointestinal complications in patients with rheumatoid arthritis receiving nonsteroidal anti-inflammatory drugs. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 1995;123:241–9.CrossRefPubMedGoogle Scholar
- 30.Rostom A, Dube C, Wells G, Tugwell P, Welch V, Jolicoeur E, et al. Prevention of NSAID-induced gastroduodenal ulcers. Cochrane Database Syst Rev. 2002;4:CD002296.Google Scholar