Primary care physicians prescribe many different medications, with variation associated more with patient, physician and practice site characteristics than clinical necessity, according to a study that included records from close to five million patients. The study examined the size and use of physicians’ personal formularies — the core set of newly initiated drugs — to better understand opportunities to improve the safety and cost of medication practices.
The authors, including Gordon Schiff, M.D., Associate Director of Brigham and Women’s Center for Patient Safety Research and Practice and Director of Quality and Safety for the Harvard Medical School Center for Primary Care, advocate conservative prescribing, in which physicians simplify the core set of drugs they prescribe. “Physicians may be prone to prescribing a host of new expensive drugs, often before solid and longer term evidence is available to support their use,” says Dr. Schiff. “Sticking to a core set of tried-and-true medications, or even non-drug alternatives would often be better.”
The study examined the personal formularies of internal and family medicine physicians at Brigham and Women’s Hospital in Boston, Northwestern Medicine in Chicago, University of Illinois at Chicago and the entire Veterans Health Administration in 2017 and 2018. Researchers studied prescribing patterns and found more than one-third of the variation related to the prescribing habits of individual physicians. The size of personal formularies, with a mean range between 150 and 296 drugs, was associated with panel size, the volume of clinical encounters and the physician’s sex. Female doctors tend to prescribe fewer medications than male doctors.
Lead author William Galanter, M.D., Ph.D., Clinical Assistant Professor of Pharmacy Systems, Outcomes and Policy at the University of Illinois at Chicago, says, “We looked particularly at some important classes of medications and found that some doctors use many more different medications from a class than other doctors. This lack of focus on a smaller group of medications will potentially increase errors since doctors likely lack familiarity with all the different drugs in the class.” Schiff agrees, saying, “Prescribers who stick to a more limited number of drugs can develop a better understanding of their dosing and side effects.”
The research team is also studying prescribing practices related to other key principles of conservative prescribing, including limiting the number of new drugs started at the same time and avoiding medications where non-drug alternative may be safer or more effective.