Safe prescribing of medicines can be used as an indicator of healthcare quality, complementing information on consumption and expenditure on pharmaceuticals (see also Chapter 9 on “Pharmaceuticals, technologies and digital health”). The overuse, underuse or misuse of prescription medicines can lead to serious consequences for the health of the patient and wasteful expenditure. This is the case for opioids and antibiotics, for example.
Antibiotics are prescribed for the treatment of bacterial infection, but their overuse or inappropriate prescription can drive rates of antimicrobial resistance, which is associated with increased mortality and healthcare costs across OECD countries (OECD, 2018[1]). Guidelines recommend that antibiotics should only be prescribed where clearly supported by clinical evidence. The total volume of antibiotics prescribed in the community setting has been validated as an indicator of safe and effective care, and countries try to reduce antibiotic prescribing in primary care to tackle antimicrobial resistance.
On average, 16 defined daily doses (DDDs) of antibiotics per 1 000 population were prescribed across OECD countries in 2023 – a slight reduction from 17 DDDs per 1 000 in 2013 (Figure 6.6). Finland reported the largest reduction in antibiotic prescribing over time, followed by Canada, Austria, Israel and Australia. The total volume of prescribed antibiotics in 2023 varied three‑fold across OECD countries, with Sweden, the Netherlands and Austria reporting the lowest volumes per population per day, and Greece and Korea reporting the highest. The observed variation might be explained by differences in primary care prescribing guidelines and antimicrobial stewardship incentives, as well as attitudes and expectations regarding optimal treatment of infectious illness.
Opioids are used to treat acute pain, such as pain associated with cancer. However, over the last decade opioids have increasingly been used to treat chronic pain – despite the risk of dependence and addiction – leading to serious health risks. Opioid misuse accounted for an alarming epidemic of overdose deaths in some OECD countries, notably in the United States and Canada. Clinical prescribing guidelines are a stewardship effort aimed at reducing long-term opioid prescribing as a patient safety measure by promoting use of alternative pain medications and appropriate dosing strategies (OECD, 2019[2]).
Among 19 countries with available data, Iceland reported an overall volume of opioids prescribed twice the OECD average, at 33 DDDs per 1 000 adult population. Türkiye, Korea and Italy reported the lowest volumes, at 5 DDDs per 1 000 or lower (Figure 6.7). This wide variation can be explained in part by differences in clinical practice in pain management, as well as differences in regulation, legal frameworks for opioids, prescribing policies and treatment guidelines. The OECD average decreased by 4 DDDs per 1 000 population in 2023 compared to 2013. Estonia, Portugal and Spain all reported an increase of over 5 DDDs per 1 000.
Polypharmacy is the routine prescribing of multiple medications (often defined as more than five) for a patient. While polypharmacy may be justified for the management of multiple comorbidities, inappropriate polypharmacy – such as the use of inappropriate medications, overuse and duplication – is common (de Bienassis et al., 2022[3]). Risks associated with polypharmacy are substantial; they include medication-related harms, drug-drug or drug-disease interactions, falls, and cognitive impairment.
According to the OECD’s Patient-Reported Indicator Surveys (PaRIS), on average across OECD countries, one in four primary care patients aged 45 and over with chronic conditions reported taking five or more medications (Figure 6.8.). The proportion varied from 35% in Slovenia and 32% in Luxembourg and France to 18% in OECD accession country Romania and 14% in Wales (United Kingdom). In 8 of the 19 surveyed countries (Czechia, France, Luxembourg, Norway, Slovenia, Switzerland, the United States), 5% or more of patients were taking ten or more medications. Registry-based analyses of individuals aged 75 and older offer a valuable complement to self-reported data, revealing that up to half of this population is taking more than five medications concurrently (Section on “Safe long-term care” in Chapter 10). Rationalisation of polypharmacy in primary care can lead to more effective, patient-centred, safer prescribing, while reducing wasteful expenditure through deprescribing.
