Introduction
Duplicate prescriptions are a general, yet little considered problem, not limited
to geographic regions, healthcare systems, electronic or manual prescribing, outpatient
or inpatient care. We found with the search term duplicate prescription some 140 publications
but just one paper according to the respiratory care [1] while most papers elucidate more frequently prescribed drugs, e. g. for hypertension,
diabetes or hypercholesterolemia [2]
[3]
[4]
[5]
[6].
The problem prescribing multiple bronchodilators from the same class was only addressed
in the article by Kern et al. [1].
It is some 40 years that in Germany the first fixed combination of two inhalative
drugs was launched on the market (the SABA/SAMA fixed dose inhaler Berodual®), and almost twenty years ago the first ICS/LABA fixed combination was introduced.
Marketing both, the same drugs as monotherapy as well as an ingredient in a fixed
dose combination inhaler already paved the way for duplicate prescriptions shortly
after the millennium. Until 2012 only a few numbers of new inhalative drugs were launched
(i. e. single LABA’s and LAMA’s).
In contrast, during the last few years many new inhalative fixed dose combination
brands emerged on the German market. In addition, after the patent of many brands
(e. g. Budesonide/Formoterol, Fluticasonpropionate/Salmeterol, Tiotropium) expired,
several new generics were introduced. Moreover, the constituents of the new fixed
dose combinations are not easily recognizable by color codes, as was in the past the
blue inhaler for short acting beta2 agonists, reddish for inhaled corticosteroids
or green for anticholinergics.
Most patients with airway disease are treated in primary care, but each primary care
physician treats only a few such patients. In Germany, Asthma and COPD patients are
frequently treated by both the family physician and the respiratory specialist without
good functioning platforms to prevent duplicate prescriptions. Also, patients can
consult more than a single general or respiratory physician.
Hence, the German Airway League published and updated working tables with color codes
and symbols showing the mode of action and the approved frequency of daily inhalations
to be used by prescribing physicians (see [Fig. 1]).
Fig. 1 Color coded table of the German Airway League with different classes of inhalative
drugs. Green: Antimuscarinic substances, Blue: Beta Adrenergics, Red: inhalative corticosteroids;
combined colors for fixed dose combinations.
Data from the DocMorris database (on file) show, that duplicate prescriptions of different
statins like Atorvastatin and Simvastatin are lower than 1‰. We hypothesized that
in contrast to well established cholesterol-lowering-therapy many duplicate prescriptions
of inhalative drugs will occur, e. g. LABA/LAMA together with ICS/LABA or triple therapy,
LABA/LAMA with single LAMA or LABA etc.
In 2015 the German Airway league did a survey among 185 respiratory physicians in
secondary outpatient care via questionnaire to assess duplicate prescriptions detected
in patients referred to specialist care. 69.73 % or 129 physicians stated having seen
duplicate prescriptions at all; roughly 60 % of these in less than 5 % of their patients,
some 29 % in 5 – 10 % of their patients and some 9 % in 10 – 20 %. (Data on file)
The Federal Association of Respiratory Physicians performed a similar survey. 152
respiratory physicians participated. 50 % saw duplicate prescriptions in less than
5 % of their patients (26.3 % in 5 – 10 %, 4.6 % in 10 – 20 % and 0.7 % in more than
20 %) (see [Table 1]).
Table 1
Two independent surveys on duplicate prescriptions.
|
Percentage of respiratory physicians reporting duplicate prescriptions
|
Percentage of patients
|
German Airway League (n = 185)
|
Federal Association of Respiratory Physicians (n = 152)
|
< 5 %
|
59.7
|
50
|
5 – 10 %
|
28.7
|
26.3
|
10 – 20 %
|
9.3
|
4.6
|
> 20 %
|
0.8
|
0.7
|
(data on file)
Methodology
The German Airway’s League cooperates with pharmacies to promote patient education
on inhaled therapy and inhalation technique.
DocMorris, a mail order pharmacy, that patients can choose to fill their prescriptions
with, is one of the cooperation partners. It maintains a large digital database containing
prescriptions of inhaled medication. We searched this digital database for duplicate
prescriptions of inhalative bronchodilator drugs fully respecting personal data protection
law. Hence, ethics commission approval was not deemed to be necessary.
The retrospective survey was done between January 1st and October 31st, 2018. DocMorris
fills prescriptions reimbursed by the German statutory health care system (GKV, gesetzliche
Krankenversicherung). We looked for duplicate prescriptions of bronchodilator drugs
in the context of the GKV patients.
In detail, we differentiated between duplicate prescriptions of long acting bronchodilator
inhalatives on the one hand and short acting ones on the other. We only considered
prescriptions by respiratory specialists and primary care physicians (i. e. GP’s and
internists working for family care).
We considered duplicate prescriptions from two different perspectives:
-
Same physician’s perspective: duplicate prescriptions for the same patient by the
same physician at the same day or
-
Different physician’s perspective: duplicate prescriptions for the same patient by
different physicians within 14 weeks, where the older prescription is a large package.
In case of the different physician’s perspective only large packages (usually a supply
for 90 daily doses) were considered in order to exclude consecutive prescriptions
of several 30 daily doses of different bronchodilators (supposedly representing rather
a change in medication than a true duplicate prescription). Thus, our definition of
duplicates was very conservative, since many patients have a lower than maximum adherence
and some patients might have been prescribed lower than average doses, e. g. MART
(maintenance and reliever treatment) regimen (half of the approved daily dose plus
prn [pro re nata] use).
For both perspectives we calculated the percentage of duplicate prescriptions within
the respective drug classes in relation to the overall number of prescriptions in
that class (irrespective of prescriber): one class being long acting bronchodilators
(i. e. LAMA- and/or LABA-containing inhalatives) the other one short acting bronchodilators
(i. e. SABA-containing inhalatives).
We additionally recorded whether the prescriber was a family physician, a respiratory
physician or other.
We restricted our analysis to prescriptions for adult patients (18 years and older)
listed in the statutory health insurance (GKV), comprising some 90 % of the German
population.
Duplicate prescriptions of long acting bronchodilators were defined as:
Prescribed drug 1 and prescribed drug 2 both containing LABA (possibly as part of
a combination product) but different product group numbers (“Warengruppenschlüssel”),
or/and: Prescribed drug 1 and prescribed drug 2 both containing LAMA (possibly as
part of a combination product) but different product group numbers (“Warengruppenschlüssel”).
To identify physicians, their lifelong doctor identifier number (“lebenslange Arztnummer
LANR”) was used. If not given, the doctorʼs office number (“Betriebstättennummer BSNR”)
was used instead, for example for clinics like medical care center, hospital, emergency
unit. The last two digits of the LANR specify the physician’s specialist field (“Facharztrichtung”).
When no LANR was available we chose the label “other specialist”.
For family physicians (FP) (“Hausarzt”) the last two digits are
01: “Allgemeinmediziner (Hausarzt)”
02: “Arzt/Praktischer Arzt (Hausarzt)”
03: “Internist (Hausarzt)”
For respiratory physicians (RP) the last two digits are 30 (“Pneumologie”).
Prescribed drug: pharmacy product identifier number (“Pharmazentralnummer PZN”). Product
group number (“Warengruppenschlüssel”), starting with an A and followed by the ATC
code (according to WHO). Package size: standardized size (“Normgröße”) and pack size
(“Packungsgröße”).
For the 90 days’ supply, package size N3 was taken for SABA containing drugs. For
LABA and LAMA containing inhalatives due to lack of standardized sizes in some cases,
the following pack sizes were taken: 180 St, 3 St, 3 × 1 St, 3 × 30 St, 3 × 4.0 ml;
3 × 4 ml, 3 × 60 St, 90 St (see [Table 2] and [Table 3]).
Table 2
Ingredients and product group numbers of LABA containing inhalatives.
LABA Mono
|
LABA + LAMA Combi (double)
|
LABA + LAMA Combi (triple)
|
LABA Combi (double)
|
LABA (ingredients and product group numbers)
|
LAMA + LABA (ingredients and product group numbers)
|
LAMA + LABA + ICS (ingredients and product group numbers)
|
LABA + ICS (ingredients and product group numbers)
|
Formoterol
|
Indacaterol
|
Olodaterol
|
Salmeterol
|
Aclidinium + Formoterol
|
Glycopyrronium + Indacaterol
|
Olodaterol + Tiotropium
|
Umeclidinium + Vilanterol
|
Glycopyrronium + Formoterol + Beclomethason
|
Umeclidinium + Vilanterol + Fluticasonfuroat
|
Formoterol + Beclomethason
|
Formoterol + Budesonid
|
Formoterol + Fluticasonpropionat
|
Salmeterol + Fluticasonpropionat
|
Vilanterol + Fluticasonfuroat
|
AR03AC13
|
AR03AC18
|
AR03AC19
|
AR03AC12
|
AR03AL05
|
AR03AL04
|
AR03AL06
|
AR03AL03
|
AR03AL09
|
AR03AL08
|
AR03AK08
|
AR03AK07
|
AR03AK11
|
AR03AK06
|
AR03AK10
|
Table 3
Ingredients and product group numbers of LAMA containing inhalatives.
LAMA Mono
|
LABA + LAMA Combi (double)
|
LABA + LAMA Combi (triple)
|
LAMA (ingredients and product group numbers)
|
LAMA + LABA (ingredients and product group numbers)
|
LAMA + LABA + ICS (ingredients and product group numbers)
|
Aclidinium
|
Gycopyrronium
|
Tiotropium
|
Umeclidinium
|
Aclidinium + Formoterol
|
Glycopyrronium + Indacaterol
|
Olodaterol + Tiotropium
|
Umeclidinium + Vilanterol
|
Glycopyrronium + Formoterol + Beclomethason
|
Umeclidinium + Vilanterol + Fluticasonfuroat
|
AR03BB05
|
AR03BB06
|
AR03BB04
|
AR03BB07
|
AR03AL05
|
AR03AL04
|
AR03AL06
|
AR03AL03
|
AR03AL09
|
AR03AL08
|
In particular, if one drug contained only LABA and another one only LAMA, this was
not considered to be a duplicate prescription.
An example: Following four inhalatives were prescribed by one physician for a patient
at the same day: [Fig. 2].
Fig. 2 Original prescription for a patient.
By our definition of duplicate prescriptions this generated a count of four individual
duplicates, one of them (Spiriva and Anoro) caused by duplicate LAMA components, and
three (Symbicort and FormoLich, FormoLich and Anoro and Anoro and Symbicort) by duplicate
LABA components as shown in [Table 4].
Table 4
Count of duplicates of different inhalatives in the “same physicians” perspective.
Name of the drug
|
Ingridients
|
Product group number
|
LABA
|
LAMA
|
Name of the drug
|
Ingridients
|
Product group number
|
LABA
|
LAMA
|
SPIRIVA 18 µg Kapseln m. Inhalationsplv.Nachfül
|
Tiotropium
|
AR03BB04
|
no
|
yes
|
ANORO 55 µg/22 µg 30 ED Plv. z. Inhalation
|
Vilanterol and Umeclidinium
|
AR03AL03
|
yes
|
yes
|
SYMBICORT Turbohaler 320/9 µg/Dosis 60 ED
|
Formoterol and Budesonid
|
AR03AK07
|
yes
|
no
|
FORMOLICH 12 Mikrogramm Hartkaps. m. Plv. z.Inhal.
|
Formoterol
|
AR03AC13
|
yes
|
no
|
FORMOLICH 12 Mikrogramm Hartkaps. m. Plv. z. Inhal.
|
Formoterol
|
AR03AC13
|
yes
|
no
|
ANORO 55 µg/22 µg 30 ED Plv. z. Inhalation
|
Umeclidinium and Vilanterol
|
AR03AL03
|
yes
|
yes
|
ANORO 55 µg/22 µg 30 ED Plv. z. Inhalation
|
Vilanterol and Umeclidinium
|
AR03AL03
|
yes
|
yes
|
SYMBICORT Turbohaler 320/9 µg/Dosis 60 ED
|
Formoterol and Budesonid
|
AR03AK07
|
yes
|
no
|
In contrast, drug pairings Spiriva (LAMA only) plus Symbicort (ICS/LABA) and Spiriva
plus FormoLich (LABA only) did not generate a duplicate.
Duplicate prescriptions of short acting inhalative bronchodilators were defined as:
Prescribed drug 1 and prescribed drug 2 both containing SABA but different product
group numbers (“Warengruppenschlüssel”). (For details see [Table 5])
Table 5
Ingredients and product group numbers of SABA containing inhalatives.
SABA Mono
|
SABA Combi (double)
|
SABA (ingredients and product group numbers)
|
SAMA + SABA (ingredients and product group numbers)
|
SABA + Cromoglicinic acid (ingredients and product group numbers)
|
Fenoterol
|
Salbutamol
|
Terbutalin
|
Ipratropium + Fenoterol
|
Reproterol + Cromoglicinsäure
|
AR03AC04
|
AR03AC02
|
AR03AC03
|
AR03AL01
|
AR03AK05
|
Out of scope were duplicate prescriptions of inhalative bronchodilators containing
the exact same composition of ingredients but differing only in brand name (called
also co-marketing).
Results (long acting bronchodilators)
Results (long acting bronchodilators)
Overall, in the 10-month review period there were 99 145 prescriptions containing long acting
bronchodilators such as LABA Mono, LAMA Mono, LABA/LAMA-combinations, LABA/ICS-combinations,
LAMA/LABA/ICS-combinations. 62 035 (62.57 %) of them were prescribed by family doctors,
31 183 (31.45 %) by respiratory physicians and 5927 (5.98 %) through other specialists
or clinics.
Same day duplicate prescriptions for long acting bronchodilators by one physician
for the same patient were seen 765 times, corresponding to 0.77 % of overall long
acting prescriptions (534 by family physicians, i. e. 0.86 % of the family physician
prescriptions. 178 by respiratory specialists i. e. 0.57 % of the respiratory physician
prescriptions, 53 by others, i. e. 0.89 % of the other specialists’ prescriptions).
Restricting to large package sizes (according to the 90 days’ supply) we had an overall of 61 394 prescriptions with 35 693 (58.14 %) by family doctors,
22 103 (36.02 %) by respiratory specialists and 3598 (5.86 %) by other specialists
or clinics.
We saw 724 duplicate prescriptions by different physicians for the same patient within
14 weeks with the older prescription being a large package size (equaling 1.18 % of
overall long acting prescriptions with large package size).
-
416 times (57.46 % of 724) the duplicate was caused by prescriptions by a family physician
for one of the drugs and a respiratory physician for the other one
-
24 times (3.32 % of 724) it was brought up by two different respiratory physicians
-
50 times (6.91 % of 724) by two different family physicians and
-
234 times (32.32 % of 724) by others including hospital outpatient or emergency departments.
[Table 6] and [Fig. 3] and [Fig. 4] show that duplicate prescriptions of mono-products with combination-products as
well as two different combination products (roundabout 50 % each) was a lot more common
than duplicates of different mono-products, no matter whether from the same day same
physicians’ or from the different physicians within 14 weeks period perspective.
Table 6
Results of the overall and duplicate prescriptions of long acting bronchodilators
(LABA and/or LAMA containing drugs)
Survey period January 1st 2018–October 31st 2018
|
Number of prescriptions
|
Percentage duplicate prescriptions of overall prescriptions
|
Number of prescriptions by FP, RP, OP
|
Percentage of overall prescriptions by FP, RP, OP
|
Number of duplicate prescriptions of the respective drug groups
|
Overall prescriptions long acting bronchodilators
|
|
|
|
|
|
A.) all package sizes
|
99 145
|
A.)
|
A.)
|
FP 62 035
|
FP 62.57
|
RP 31 183
|
RP 31.45
|
OP 5929
|
OP 5.98
|
B.) Large package sizes
|
61 394
|
B.)
|
B.)
|
FP 35 693
|
FP 58.14
|
RP 22 103
|
RP 36.02
|
OP 3598
|
OP 5.86
|
Duplicate long-acting bronchodilator prescriptions Same physician
|
765
|
0.77
|
FP 534
|
FP 0.86
|
Different LABA Mono: 1
|
RP 178
|
RP 0.57
|
LABA Mono + LABA Combi: 319
|
OP 53
|
OP 0.89
|
Different LABA Combi: 327
|
|
|
Different LABA/LAMA Combi: 17
|
|
|
Different LAMA Mono: 13
|
|
|
LAMA Mono + LAMA Combi: 88
|
Duplicate long-acting bronchodilator prescriptions Different physicians
|
724
|
1.18
|
FP + RP 416
|
FP + RP 57.46
|
Different LABA Mono: 0
|
RP + RP 24
|
RP + RP 3.32
|
LABA Mono + LAMA Combi: 177
|
FP + FP 50
|
FP + FP 6.91
|
Different LABA Combi: 272
|
other constellation 234
|
other constellation 32.32
|
Different LABA/LAMA Combi: 76
|
|
|
Different LAMA Mono: 12
|
|
|
LAMA Mono + LAMA Combi: 187
|
FP: family physician, RP: respiratory physician, OP: physician other than family physician
or respiratory specialist
Numbers in the table are either numbers or percentages of prescriptions or of duplicate
prescriptions by the respective physicians or numbers of duplicate precriptions of
the respective drug groups as outlined in the heading of the respective column of
the table.
For calculation of the respective percentages see explanation in brackets.
Explanation of the column “number of duplicate prescriptions of the respective drug
groups”: Example from the same physician perspective: there was 1 duplicate prescription
by the same physician of two different LABA Mono containing inhalatives, e. g. one
containing Formoterol and the other one Salmeterol. 319 duplicates were seen with
one of the inhalatives containing a LABA Mono ingredient the other one a LABA Combi
(LABA with LAMA and/or ICS). See [Table 2] and [Table 3] for details.
Fig. 3 Same day duplicate prescriptions (long acting bronchodilators).
Fig. 4 14 weeks duplicate prescriptions.
Results (short acting bronchodilators)
Results (short acting bronchodilators)
On the SABA side there were 43 503 overall prescriptions such as SABA Mono, SABA/SAMA-combinations
and SABA/sodium cromoglycate combinations. 27 888 (64.11 %) of them were prescribed
by family doctors, 12 827 (29.49 %) by respiratory specialists and 2788 (6.41 %) by
other specialists or hospital outpatient and emergency departments. The 90 days’ supply
perspective shows 16 427 prescriptions, of these 11 611 (70.68 %) by family doctors,
3839 (23.37 %) by respiratory specialists, 977 (5.95 %) by other specialists or clinics.
Same day duplicate prescriptions in SABA by one physician for the same patient were
seen 667 times corresponding to 1.47 % of overall SABA prescriptions (391 through
family physicians, i. e. 1.40 % of the family physician prescriptions. 229 by respiratory
specialists i. e. 1.79 % of the respiratory physician prescriptions, 47 through others,
i. e. 1.69 % of the other specialists’ prescriptions).
We saw 380 duplicate SABA prescriptions within 14 weeks with the respective older
one being a large package size. This means 2.31 % of the overall large package size
SABA prescriptions were duplicate prescriptions. 255 (67.11 %) of the SABA duplicates
were triggered by family physicians and respiratory specialists, 3 (0.79 %) by different
respiratory specialists, 53 (13.95 %) by different family practitioners and 69 (18.16 %)
by others.
Looking at the details of the respective drug groups (see [Table 7] and [Fig. 5] and [Fig. 6], respectively) involved in the SABA duplicate prescriptions, about 75 % of them
are caused by mono with combination drugs, whereas prescriptions of two different
mono-drugs account for about 20 %. This is true for both the one physician, same day
and the different physicians within 14 weeks perspective.
Table 7
Results of the overall and duplicate prescriptions of SABA.
Survey period January 1st 2018–October 31st 2018
|
Number of overall prescriptions
|
Percentage duplicate prescriptions of overall prescriptions
|
Number of overall prescriptions by FP, RP, OP
|
Percentage of overall prescriptions by FP, RP, OP
|
Overall prescriptions SABA
|
|
|
|
|
A.) all package sizes
|
43 503
|
A.)
|
A.)
|
FP 27 888
|
FP 64.11
|
RP 12 827
|
RP 29.49
|
OP 2788
|
OP 6.41
|
B.) large package size
|
16 427
|
B.)
|
B.)
|
FP 11 611
|
FP 70.68
|
RP 3839
|
RP 23.37
|
OP 977
|
OP 5.95
|
Duplicate SABA prescriptions Same physician
|
667
|
1.53
|
FP 391
|
FP 1.40
|
RP 229
|
RP 1.79
|
OP 47
|
OP 1.69
|
Duplicate SABA prescriptions Different physicians
|
380
|
2.31
|
FP + RP 255
|
FP + RP 67.11
|
RP + RP 3
|
RP + RP 0.79
|
FP + FP 53
|
FP + FP 13.95
|
other constellation 69
|
other constellation 18,16
|
FP: family physician, RP: respiratory physician, OP: physician other than family physician
or respiratory specialist
Numbers in the table are either numbers or percentages of prescriptions or of duplicate
prescriptions by the respective physicians or numbers of duplicate precriptions of
the respective drug groups as outlined in the heading of the respective column of
the table.
For calculation of the respective percentages see explanation in brackets
Explanation of the column “number of duplicate prescriptions of the respective drug
groups”: Example from the same physician perspective: there were 132 duplicate prescription
by the same physician of two different SABA Mono containing inhalatives, e. g. one
containing Fenoterol and the other one Salbutamol. 499 duplicates were seen with one
of the inhalatives containing a SABA Mono ingredient the other one a SABA Combi. See
table 5 for details of the respective drug groups.
Fig. 5 Number of same day duplicate prescriptions of SABA.
Fig. 6 Number of SABA duplicate prescriptions (within 14 weeks, different physicians, same
patient).
Discussion
Despite lack of control of prescriptions on a patient level in the German healthcare
system and the possibility of mistakes due to a vast number of old and new single
and combination brands on the market the proportion of duplicate prescriptions in
the database was only some 1 %. Duplicate prescriptions involving combination products
were found to be much more common than duplicate prescriptions of different mono-products
(see [Fig. 3 – 6]). This finding might be owed to the fact that during the last few years many new
inhalative fixed dose combination brands emerged on the German market as well as several
new generics were introduced.
In 2015 both the German Airway League and the Federal Association of Respiratory Physicians
performed a survey among respiratory physicians who roughly estimated frequency of
duplicate prescriptions in patients referred by family physicians (FPs): In both surveys
50 – 60 % of the RP’s reported duplicate prescriptions by family physicians in less
than 5 %, by another 26 – 29 % up to 10 % of the cases. However, this was just an
estimation, not a retrospective analysis. Yet in 2015, the FP’s might have been less
familiar with the newly launched brands than in 2018 at the time of our data analysis.
Nonetheless, according to the authors present clinical experience we also expected
a much higher duplicate prescription rate.
We decided to focus the research on the patient’s perspective regardless of whether
the prescriber was the FP, the respiratory physician (RP) or prescriptions came from
both. The database shows, that prescriptions by other specialists i. e. emergency
care, ENT, allergologists (dermatologists), gynecologists (for pregnant women) are infrequent,
comprising only about 6 % of all prescriptions. The German statutory health care system
discourages prescriptions for respiratory diseases by other than family physicians
and respiratory specialists. Therefore, we restricted the detailed analysis to those
two groups. Remaining prescriptions are summarized under “other physicians”.
Some 2/3 of all prescriptions arise from FP and 1/3 from RP for both long acting (62.51 %
vs. 31.45 %) and short acting (64.11 vs. 29.49 %) bronchodilators which could reflect
the proportion of patients with airway diseases cared for.
The average number of prescriptions for long acting bronchodilators was 2.47 per patient;
FP’s prescribed 2.25 and RP’s 2.09 pro patient; remaining prescriptions came from
other physicians. The respective numbers for short acting bronchodilators were an
average of 1.81 prescriptions per patient; 1.78 by FP and 1.48 by RP. These numbers
may indicate that patients referred by FP to RP were already pretreated.
It is surprising that the percentage of RP’s same day prescriptions of two different
short acting bronchodilators was 1.79 % of their total prescriptions versus 1.40 %
of FP’s total. However, SABA prescription and even duplicate prescription can also
reflect asthma control. More severe asthma patients in specialty care may ask usually
for a higher amount of SABA prescription.
It was expected and it is reassuring, that LABA/LAMA duplicates were 1/3 lower by
specialists if compared with FP.
In contrast, it is an unexpected finding that the overall rate of duplicate prescriptions
for short acting bronchodilators (1.53 and 2.31 % of all, same day and 14 weeks prescriptions,
respectively) is higher than the overall duplicate prescription rate for long acting
bronchodilators. Short acting substances including combinations were launched decades
ago, while LAMA/LABA combination just around the observation period. Thus, other factors
than mistakes and confusion may play an important role. A small number of nebulizer
solutions for the use at home and SABA metered dose aerosols as acute reliever were
counted as duplicate prescriptions. More likely however this may reflect over-reliance
on reliever use rather than guideline guided COPD or asthma care.
Duplicates by two different physicians in the 14 weeks period with first supply of
90 days (N3) package may also represent a different problem than mistake of the prescriber:
we suspect in many cases missing information of the second prescriber. In the German
statutory healthcare system in 14 weeks period patients can consult several FP’s and
specialists and can get new prescriptions. The prescriber is usually not informed
about former prescriptions. This can dramatically improve if in the next years digital
prescription will be introduced provided that the prescribers information of personal
health record on electronic patient files will not be limited by data protection rules.
It is important to note that it is the pharmacist who can immediately detect same-day
duplicate prescriptions. Usually, the pharmacists will fill the duplicate prescription.
DocMorris provides written notice that in such cases the patients should re-consult
the prescribing physician.
Limitations of the survey
Limitations of the survey
The most important limitation of the study is the possibility that patients can fill
their prescriptions in different pharmacies. Therefore, the captured data can be incomplete
and duplicate prescriptions may be underestimated. To check generalizability of our
data extracted from the database of a large mail-order pharmacy we would need comparable
centrally aggregated data from a large number of on-site pharmacies. To our knowledge,
there is no such database available. Another possible source for validation is data
from a health care provider database.
Duplicate prescriptions were found at an unexpectedly low level; any differences in
duplicate prescribing habits between FP and RF should be interpreted with caution.
Conversely, clinical aspects cannot be captured in the pharmacy database which may
lead to an overestimation of duplicate prescriptions. Some patients could stop their
medication due to side effects and get another prescription, e. g. in COPD an ICS/LABA
treatment can be changed to LABA/LAMA if oral candidiasis appears.
Some patients with escalation or de-escalation of their treatment can have a “duplicate”
prescription, e. g. if an ICS/LABA treatment was escalated to triple therapy.
Conclusions
Despite a confusingly high number of recently introduced branded and generic drugs
on the inhalative market and the inherent weakness of the current prescribing system
the surprisingly low number of duplicate prescriptions as detected in this study is
reassuring. Nonetheless, irrespective the low percentage number of all prescriptions
we saw in just one large mail order pharmacy several thousands of erroneous prescriptions.
Prescribers should be aware of the issue of duplicates – especially when prescribing
combination products. The pharmacist can also detect same time duplicate prescriptions.
Moreover, looking the filling history of the patient the pharmacist can detect duplicates
from different prescribers, provided that the individual patient fills his prescription
always in the same pharmacy.