Patterns of prescribing in general practice in the last year of life

Problem

Polypharmacy is widespread in primary care. Yet the evidence base for many long-term medications is often lacking, particularly as the end of life approaches where the intended gain from treatments may only be realised over several years. Little is known about patterns of medication use towards the end of life in the general practice setting, and understanding this is key to developing and targeting medication optimisation strategies in this population. This study describes the use of long-term preventative, disease-treatment, and palliative medications, during the last year of life.

Approach

We analysed prescribing over the last 12 months of life from UK GP records of a random sample of 118,571 patients in the Clinical Practice Research Datalink (CPRD), who died between September 2010 and August 2015. Date and cause of death were determined from linked national death records. Medications were grouped broadly into three categories: long-term disease prevention (e.g. statins, anticoagulants, bisphosphonates, antidementia), long-term disease treatment (e.g. antidepressants, antiepileptics, mucosal protectants, bronchodilators), and palliative care (e.g. strong opioids, antiemetics, benzodiazepines). We calculated the percentage of patients prescribed different medication classes at weekly intervals during the year before death. Mixed-effect logistic regression was used to model the association between age and cause of death on changes in prescribing over the last 12 months of life.

Findings

Overall , 62% of individuals received a long-term disease prevention drug 1-year before death, increasing slightly to a peak of 65% 12-weeks before death, before falling to 57% at death. Patterns were similar across the main drug classes examined. Decreases in usage were particular marked for cardiovascular preventative medications (occurring from ~6 months prior to death), and in older patients and those dying of cancer. Drugs classified as long-term disease treatment were prescribed to 72% of patients at 1-year before death, steadily increasing to a peak of 83% at 2-weeks prior to death. In general increases in prescribing over the last year of life were most marked for patients dying of cancer. Decreases in use occurred in the last 2-3 weeks of life. Use of palliative care medications was observed in 17% of patients at 1-year before death, rising increasingly rapidly to 40% at death. Increases in injectable medications were restricted to the last month of life. Increases in palliative prescribing were by far most marked for cancer, and were greatest in older persons.

Consequences

Prescribing of long-term medications is common in the last year of life, with reductions in use occurring relatively late. Changes in prescribing are most marked in those dying of cancer. This likely reflects clinicians’ better recognition of limited life expectancy for these individuals. Further work is required to fully understand why this is and improve prescribing for all persons irrespective of underlying clinical condition.