Should we prescribe longer repeat prescriptions for patients with long-term conditions during a pandemic?
March 25, 2020
Kamal R. Mahtani, Brian MacKenna, Elizabeth Spencer
On behalf of the Oxford COVID-19 Evidence Service Team
Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences
University of Oxford
Correspondence to: firstname.lastname@example.org
Lay Summary by Mandy Payne, Health Watch
The evidence is very limited and there is currently no definitive answer to this question. This issue will be reviewed as new relevant evidence is identified, and the report amended accordingly. However, in the UK, NHS England has advised that longer duration prescriptions should not be issued by GPs at this time, in order to protect the supply chain.
For stable chronic conditions such as diabetes, hypertension, or asthma, patients often receive ‘repeat’ prescriptions and these are usually issued without additional consultation with the consulting physician, usually in the UK a general practitioner (GP).
In an epidemic, the capacity of the patient to travel to collect a prescription may be curtailed. The current COVID-19 pandemic sees large numbers of people, particularly the older population, advised to remain at home for up to 12 weeks, and the entire population subject to severe movement restrictions. Frequent prescribing takes up a patient’s time, GP’s time and uses pharmacists’ time. In England, for medicines commonly prescribed for long-term conditions, 45% of the total volume in 2019 was for one month duration, 41% prescribed for two months and 7% prescribed for three months. (EBM Datalab 2020)
During the current COVID-19 pandemic, the possible benefits of providing prescriptions for 3 months’ duration, as opposed to shorter durations, may include:
– reducing person to person contact in order to slow transmission rates
– reducing anxiety among patients with long-term conditions who require repeat prescriptions
– reducing health services burden and costs.
However, during a global pandemic it is possible that interruptions in manufacturing and other activities may exacerbate medicines shortages that have occurred in the UK over the last few years (BBC News 2019). Other considerations include potential medication wastage; the potential risk of holding large amounts of medication in the home; the cost of a longer duration prescription may be prohibitive for some patients.
This rapid review aimed to assess the evidence on the effects of prescribing longer duration repeat prescriptions during a pandemic.
We rapidly searched electronic databases and the online grey literature for evidence on this question and found one systematic review (King 2018) that reviewed 13 studies comparing prescribing of 2 to 4 months duration with 28 days/1 month duration; this systematic review was also published as a Health Technology Assessment report (Miani 2017).
The included studies were all conducted in one country (the USA) and the quality ranged from moderate to very low. The authors found no studies reporting on health outcomes or adverse events for longer versus shorter duration repeat prescriptions. Evidence from moderate quality studies suggested that longer duration prescriptions were associated with better medication adherence. There was also some evidence from very low quality studies that longer prescription duration increased medication waste.
We found a further retrospective cohort study by Doble et al 2018 conducted in NHS settings. This study found that shorter prescription lengths could potentially reduce medication wastage, but they may also increase dispensing fees and/or the time burden of issuing prescriptions.
EMERGING EVIDENCE IN COVID-19
The evidence base from which to draw conclusions is very limited; no studies were carried out during a pandemic period or assessed the impact of changes in duration of repeat prescriptions on the medicines supply chain.
However, we did identify guidance from the NHS England (UK) who note (on 19th March 2020):
“The DHSC is working closely with industry, the NHS and others in the supply chain to ensure patients can access the medicines they need, and precautions are in place to reduce the likelihood of future shortages.
It is essential that GPs do not issue prescriptions for a longer duration, pharmacies do not order larger quantities, and patients and the public do not seek to stockpile medicines as this behaviour could put the supply chain at risk.”
During a pandemic, a pragmatic approach incorporating clinical judgement is required, with consideration of both individual patient needs and the medicine supply chain capacity. In England the NHS advises the use of electronic repeat dispensing where a clinician authorises a prescription for up to twelve months, allowing the patient to collect repeat prescriptions directly from a pharmacy without the need for a new prescription. Importantly this does not increase the duration between each prescription collection for the patient so there will be limited changes on volumes expected in the medicines supply chain. This approach is suitable for patients with stable chronic conditions, enables access to a consultation on a monthly basis with a pharmacist that can facilitate a patient obtaining a medical consultation if their condition changes. This approach may help patients remain at home during periods of social distancing or quarantine; reduce anxiety for those needing repeat prescriptions; and may help reduce burden on the pressured general practices whilst maintaining adequate medicine supplies.
The evidence base on this is very limited and there is no definitive answer on this issue
Evidence on duration of repeat prescriptions is necessary, particularly on health outcomes, to facilitate best practice
Local guidance may dictate practice. For example, in the UK, NHS England have currently advised against longer prescriptions.
Disclaimer: the article has not been peer-reviewed; it should not replace individual clinical judgement and the sources cited should be checked. The views expressed in this commentary represent the views of the authors and not necessarily those of the host institution, the NHS, the NIHR, or the Department of Health and Social Care. The views are not a substitute for professional medical advice.
Kamal Mahtani, Brian MacKenna, Elizabeth Spencer
repeat prescription duration
1. https://www.bbc.co.uk/news/health-46843631 Accessed 20 March 2020
2. Doble B, Payne R, Harshfield A, Wilson ECF. Retrospective, multicohort analysis of the Clinical Practice Research Datalink (CPRD) to determine differences in the cost of medication wastage, dispensing fees and prescriber time of issuing either short (<60 days) or long (≥60 days) prescription lengths in primary care for common, chronic conditions in the UK. BMJ Open. 2017 Dec 4;7(12):e019382. doi: 10.1136/bmjopen-2017-019382.
3. EBM Datalab 2020 https://github.com/ebmdatalab/repeat-prescribing-pandemic-covid-notebook/blob/master/notebooks/pandemic-repeat-prescriptions.ipynb Accessed 21 March 2020
4. King S, Miani C, Exley J, Larkin J, Kirtley A, Payne RA. Impact of issuing longer- versus shorter-duration prescriptions: a systematic review. Br J Gen Pract. 2018 Apr;68(669):e286-e292. doi: 10.3399/bjgp18X695501.
5. Miani C, Martin A, Exley J, Doble B, Wilson E, Payne R, Avery A, Meads C, Kirtley A, Jones MM, King S. Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling. Health Technol Assess. 2017 Dec;21(78):1-128. doi: 10.3310/hta21780.
6. Second Chief Pharmaceutical Officer Community Pharmacy COVID-19 Letter. NHS England. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/preparedness-letter_primary-care_community-pharmacy-19-march-2020.pdf
7. Electronic Repeat Dispensing Handbook. Wessex Academic Health Science Network. https://wessexahsn.org.uk/img/projects/Electronic%20Dispensing%20Handbook_Digital_WEB_S.pdf