12 responses to “Implementing Prescribing Portraits — Therapeutics Initiative”

  1. This was an amazing TCMP! I immediately used the link to sign up for TI Portraits and I look forward to using it to improve my standard of care for my patients!!! A huge thanks to Dr. Norris for writing this article.

  2. How do Ontario docs register?

  3. For Bill Watson: Portraits are limited to prescribers in BC only, so you would be unable to register. Portraits use prescribing data that is only available within our province and unfortunately Ontario doesn’t have as extensive a database. There are some feedback programs in Ontario, which you may already be familiar with, but if not you might start here: (https://www.hqontario.ca/quality-improvement/practice-reports/primary-care.

    You can view the sample Portraits of course at https://www.ti.ubc.ca/portrait/portrait-topics/ but would not be able to receive feedback on your specific practice.

    While the UBC Therapeutics Initiative is not involved with any feedback programs in Ontario, we are part of a research project called CANBuild-AMR that involves building a national framework for feedback on antibiotic prescribing.

  4. TI is super intrusive. I received an unsolicited “Prescribing Portrait” from TI out of the blue. So much for registering, as they clearly have all my details already. I’m not sure who gave TI the authority to access my personal prescribing data, reassurances regarding confidentiality notwithstanding, but it certainly wasn’t me.

    A good practice in medicine, as in life, is to obtain consent, particularly when it comes to professional matters.

  5. For Russell:

    Receiving feedback on prescribing can be uncomfortable, but it sounds like your concerns are not about the information regarding your practice but rather on the processes used to get that information to you. We take privacy and security extremely seriously and I hope that having more detail will be helpful:

    • The information used to address and mail a Portrait is the publicly available information from the CPSBC and other professional colleges
    • Before any Portrait was sent, we sent a letter explaining Portraits, our security and privacy measures, as well as information about how to opt out;
    • With each Portrait, we send the same letter and opportunity to opt out; there is also a link on our website to opt out
    • The content of the Portrait comes from Pharmanet, MSP, and hospital data, which we access with permission from our provincial government; as part of our agreement to access the data, we are never allowed to see individual physician or patient level data. We can access that in aggregate (eg. total number of patients who had a 595 billing code on their file in a year, and proportion of those who got nitrofurantoin or another antibiotic).
    • When Portraits are generated, the data presented in your Portrait is yours and yours alone; no one at the TI or anywhere else is privy to your individual prescribing data. It is de-identified and a random code is generated. The Portrait is sealed in a privacy envelope with the number put on the outside. A printing company matches the coded privacy envelope with the mailing envelope.

    Portraits were mailed to all eligible prescribers in British Columbia, but future Portraits will be distributed via the online-only process. The advantages of this are many, including lower environmental impact, less cost, and quicker turn-around time. Unless you opt in, you will not receive any further Portraits.

    The impact of this quality-improvement initiative is based on evidence that prescribing feedback improves practice; the effect of Portrait is also being studied via randomized controlled trial which is approved by the University of British Columbia Clinical Ethics Review Board.

    We are publicly funded and operate independently, doing this work on behalf of the residents of British Columbia in keeping with our mandate – to provide physicians, nurse practitioners, pharmacists, allied health professionals & the public with up-to-date, independent, evidence-based, practical information on healthcare interventions.

    Please send an email to portrait@ti.ubc.ca if you have any further questions or I have failed to adequately address your concerns. It sounds like the Portrait was an unwelcome surprise and I am sorry for that; if there was an error that led to your not receiving an introductory letter and opt-out information for the program, please reach out and we can try to look into what may have happened as we want to be sure it doesn’t recur.

    For those who prefer to see the evidence summary and BC averages but not your own data, you can periodically check https://www.ti.ubc.ca/portrait/portrait-topics/

  6. Any chance something like this may become available to dentists in the future?

  7. @Eha: Yes! Coming very soon. Feel free to email me Jessica.otte@ubc.ca to learn a bit more.

  8. How come pharmacists are unable to access the program? They have some prescribing authority as well.

  9. @Amrit: Thanks for your interest! Pharmacists have only recently been able to prescribe for minor ailments; right now we don’t have enough data to be able to share meaningful feedback with Pharmacists but this is something we are working toward in future!

  10. I am very careful with the newest innovation, treatments, medication, approach, etc. and usually wait before making my choice for more evidence-based info beyond the initial hysterical excitement of sensational medias.

    I have always practiced with up-to-date info, and tested newly legitimately adopted therapies before applying them all over. At times, I build my own database from trusted authors and institutions who use the best research methodologies. The BC database is another resource among others I wish I could access.

    However, we physicians are not always well trained to criticise or trust scientific publications, to select which one is trustworthy or not. Even the FDA falls into pharmaceutical companies’ publication traps and precipitates approval for meds with zero efficacy (Alzheimer for instance). We need to know who builds the reference bank of data, how regularly is it updated, on which criteria, etc before we should give it full trust.

    Unfortunately, Board of Physicians sometimes do not update their bank of data and fail their members based on outdated science during their investigations.

  11. In the description, the tool leads the author to believe that there is “room to improve on deprescribing for patients over 70 on a statin for primary prevention”.

    I think this is a misleading statement. I am not familiar with any RCT that indicates safety of deprescribing statin in patients over the age of 70 who were previously started on primary prevention. The only RCT that looks at this focused primarily on outcomes at 60 days in patients with a life expectancy of < 1 year (JAMA 2021;4(12). Multiple studies, though observational, indicate that in fact, deprescribing over the age of 75 is associated with increased risk of MACE outcomes, even in primary prevention (J Am Geriatr Soc. 2023;71:2685–2689). The only ongoing RCT that I am aware of that looks specifically at this is yet unpublished (SITE trial). This issue is also addressed in the Best Science Medicine Podcast by James McCormack who ran a recent podcast on statins in the elderly (episode #551) in which the presenters also agree interpreting the evidence of starting a statin in someone over the age of 75 is very different than systematically deprescribing one.

    I agree that polypharmacy should be addressed as patients age, but I think Thomas et al say it best in that “the decision to deprescribe must be tailored to the patient’s individual setting, functional status, comorbidities and personal values.”

  12. Response to Harjinder Parwana:
    Thank you for submitting your comments and questions. As a member of the UBC Therapeutics Initiative who was involved in developing the Portrait and Therapeutics Letter on statins (https://www.ti.ubc.ca/2021/06/13/130-evidence-for-statins-in-people-over-70/), I wanted to address some of your concerns. You noted that you felt misled by the statement that there is “room to improve on deprescribing for patients over 70 on a statin for primary prevention.”

    After explaining how the Portrait can be used in practice, Dr Norris wrote “Using the Portrait and my EMR, I identified patients who might benefit from starting a statin and those who weren’t likely to benefit from being on a statin. I made a note in their chart to discuss this at their next visit.”

    Using Portrait in this way, to identify patients who could consider starting and stopping, led to shared decision-making with the patient. This seems to be in alignment with your suggestion that “the decision to deprescribe must be tailored to the patient’s individual setting, functional status, comorbidities, and personal values.” We agree and continue to assert that Portrait is a valuable tool to reflect on prescribing and as a resource when engaging patients in discussions about their medications. The “room to improve on deprescribing” might involve a commitment to discuss the likelihood of benefit and harm with patients and offer deprescribing as one of several options (especially for interventions where the evidence is uncertain, mixed, or the risk-benefit likelihood might be unfavourable).

    It is true that the impact of deprescribing statins in elderly patients for primary prevention is unknown and that ongoing randomized trials will likely provide some clarity. It would be important for prescribers to note this uncertainty in discussions about the possibility of deprescribing statins as part of shared, informed [delete comma] decision-making.

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