Physician Factors Associated with Inappropriate Vitamin B12 Prescribing in Ontario, Canada
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J Gen Intern Med DOI: 10.1007/s11606-020-06185-3 © Society of General Internal Medicine 2020
INTRODUCTION
Nearly two-thirds of Ontarians over the age of 65 are prescribed parenteral vitamin B12 without biochemical evidence of B12 deficiency in the year preceding their first prescription, costing an estimated $46 million CAD.1 To our knowledge, there is no published literature characterizing physician factors associated with inappropriate B12 prescribing. We assessed this using population-based databases.
METHODS
We undertook a retrospective cohort study using health system administrative databases available within ICES, in Ontario, Canada. Data sets were linked using unique, encoded identifiers and analyzed at ICES. All persons 65 years or older who received at least 1 intramuscular B12 prescription from January 1, 2011, to September 30, 2015, were included. Data were analyzed from July 26, 2018, to November 22, 2018. The primary outcome was inappropriate B12 supplementation, identified when persons with either a normal serum B12 level (> 221 pmol/L, consistent with the National Health and Nutritional Examination Survey upper limit of normal for marginal B12 deficiency) 2or without a documented B12 level in the 12 months prior, received their first intramuscular B12 prescription. We performed univariate and multivariable analyses using multilevel logistic regressions (adjusting for clustering within prescribing physician groups) to identify physician factors associated with inappropriate prescribing of vitamin B12. Physician factors included age, sex, years in practice, prescription volume, specialty, and medical school location (Canadian versus International). Patient variables included in the multivariable analysis were age, gender, rurality, income status, and comorbidities (Table 1). The use of data for this project is authorised under Section 45 of Ontario’s Personal Health Information Protection Act. Dr. Yulia Lin and Dr. Matthew C Cheung contributed equally as co-senior authors to this study. Received June 2, 2020 Accepted August 24, 2020
RESULTS
A total of 12,978 physicians prescribed 405,469 intramuscular B12 prescriptions to 146,850 persons, of which 93,615 were deemed inappropriate (Table 1).1 Physician factors (Table 2) associated with inappropriate B12 supplementation included higher volume of parenteral B12 prescribing (multivariable OR, 1.03 per 10 additional patients prescribed B12; 95% CI, 1.02–1.05), or having practiced for more years (OR, 1.15; 95% CI, 1.12–1.18). Female physicians were less likely (OR, 0.87; 95% CI, 0.81–0.93) to prescribe intramuscular B12 inappropriately compared with their male counterparts. When compared with primary care providers, internal medicine subspecialists were more likely to prescribe B12 inappropriately (OR 1.24; 95% CI 1.01–1.54), whereas geriatricians were less likely (OR, 0.35; 95% CI, 0.24–0.52). International medical graduates (OR, 0.83; 95% CI, 0.77–0.89) were less likely to prescribe parenteral B12 inappropriately when compared with Canadian medical g
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