Prescribing indicators

The association of specific industry-related air pollution with occurrence of chronic diseases: A register-based study

Air pollution may contribute to onset and progression of chronic diseases such as cardiovascular and respiratory diseases. Most studies have focused on the contribution of traffic-related exposure to PM₁₀ or PM_2.5. Our aim was to investigate the association of different components of industry-related air pollution on the occurrence of chronic diseases. A register-based repeated cross-sectional study was conducted among 89,714 subjects (2012) with 536,599 annual observations (2012-2017) living in the vicinity of a large industrial area in the Netherlands. Information from the dispensed medication registration was linked with a dispersion model to characterize annual individual-level exposure of all subjects at place of residence. Associations between annual exposure (concentration and duration) to particulate matter (PM₁₀), nitrogen oxides (NO_X), sulphur dioxide (SO₂), and volatile organic compounds (VOC) with annual dispensed medication for cardiovascular diseases, respiratory diseases, diabetes mellitus, and inflammatory conditions were investigated by multivariate logistic regression analysis with generalized estimating equations (GEE) while controlling for confounders. Exposure to PM₁₀ and to NO_X (per μg/m³) were significantly associated with medication for cardiovascular diseases (OR 1.06, 95CI% 1.06-1.06 and OR 1.01, 95%CI 1.01-1.01 respectively). Exposures to PM₁₀ and SO₂ (per μg/m³) were significantly associated with medication for inflammatory conditions (OR 1.05, 95%CI 1.00-1.09 and OR 1.07, 95%CI 1.01-1.14 respectively). Exposure to SO₂ was inversely associated with respiratory diseases (OR 0.91, 95%CI 0.86-0.97). Except for inflammatory conditions, exposure duration (years) was significantly associated with the other three chronic diseases (OR varying from 1.01 to 1.03). This study indicates that specific air pollution components caused by industry may contribute to the occurrence of cardiovascular diseases, respiratory diseases, diabetes mellitus, and inflammatory conditions.

Quality indicators for responsible use of medicines: a systematic review

OBJECTIVE

All healthcare systems require valid ways to evaluate service delivery. The objective of this study was to identify existing content validated quality indicators (QIs) for responsible use of medicines (RUM) and classify them using multiple frameworks to identify gaps in current quality measurements.

DESIGN

Systematic review without meta-analysis.

SETTING

All care settings.

SEARCH STRATEGY

CINAHL, Embase, Global Health, International Pharmaceutical Abstract, MEDLINE, PubMed and Web of Science databases were searched up to April 2018. An internet search was also conducted. Articles were included if they described medication-related QIs developed using consensus methods. Government agency websites listing QIs for RUM were also included.

ANALYSIS

Several multidimensional frameworks were selected to assess the scope of QI coverage. These included Donabedian's framework (structure, process and outcome), the Anatomical Therapeutic Chemical (ATC) classification system and a validated classification for causes of drug-related problems (c-DRPs; drug selection, drug form, dose selection, treatment duration, drug use process, logistics, monitoring, adverse drug reactions and others).

RESULTS

2431 content validated QIs were identified from 131 articles and 5 websites. Using Donabedian's framework, the majority of QIs were process indicators. Based on the ATC code, the largest number of QIs pertained to medicines for nervous system (ATC code: N), followed by anti-infectives for systemic use (J) and cardiovascular system (C). The most common c-DRPs pertained to 'drug selection', followed by 'monitoring' and 'drug use process'.

CONCLUSIONS

This study was the first systematic review classifying QIs for RUM using multiple frameworks. The list of the identified QIs can be used as a database for evaluating the achievement of RUM. Although many QIs were identified, this approach allowed for the identification of gaps in quality measurement of RUM. In order to more effectively evaluate the extent to which RUM has been achieved, further development of QIs may be required.

Indicators for assessing quality of drug use: A systematic literature review

OBJECTIVE

We searched and described existing drug-related indicators, and provided helps for using indicators for quality assessment of drug use and developing new indicators.

METHODS

We searched 8 databases and 41 official WebPages of national pharmaceutical administration department or academic organizations to obtain literature on drug-related indicators. Researchers extracted data including basic information (countries, issue time et al.), target population, categories, and various characters of indicators. We finally conducted a descriptive analysis to summarize these indicators.

RESULTS

A total of 3598 literatures were retrieved, 39 of which were finally included. a) A total of 876 indicators were identified. Of which, 9.5% were structure indicator, 83.6% were process indicator and 6.9% were outcome indicator. b) Evaluation dimensions of indicators could be summarized as prescribing quality, patients' experience, pharmacy administration, drug-therapy process and cost. c) In included indicator sets, 9 were developed for specific drug, 7 were for specific disease and 6 were for specific population. d) Instructions of indicator sets were identified. 7 terms of instructions were included such as rationale, prerequisite and definition of indicators.

CONCLUSIONS

Most study suggest that prescribing quality is an essential dimension and process indicator was greatly considered in drug use evaluation. Drug-related indicators for general adults were relatively well-developed. There was an urgent need for investigation of drug use indicators for children and pregnant women.

How do physicians and trainers experience outcome-based education in "Rational prescribing"?

Background

Continuing medical education (CME) is compulsory in Iran, but has shown limitations in terms of educational style and format. Outcome-based education (OBE) has been proposed internationally to create links to physicians’ actual practices. We designed an outcome-based educational intervention for general physicians in primary care (GPs). Positive outcomes on GPs’ knowledge, skills and performance in the field of rational prescribing were found and have been reported.

The specific purpose of this study was to explore the perceptions of the GPs and trainers, who participated in the outcome-based education on rational prescribing.

Methods

All nine trainers in the educational programme and 12 general physicians (out of 58) were invited to individual interviews four months after participation in the CME program. Semi-structured open-ended interviews were carried out. Qualitative content analysis was used to explore the text and to interpret meaning and intention.

Results

There was a widespread agreement that the programme improved the participants’ knowledge and skills to a higher extent than previously attended programmes. Trainers emphasized the effect of outcome-based education on their educational planning, teaching and assessment methods, while the general physicians’ challenges were how to adapt their learning in the real work environment considering social and economical barriers. Self-described attitudes and reported practice changed towards more rational prescribing.

Conclusions

Outcome-based CME seems attractive and additionally useful for general physicians in Iran and could be an effective approach when creating CME programmes to improve general physicians’ performance. Similar approaches could be considered in other contexts both regionally and globally.

A pilot qualitative study to explore stakeholder opinions regarding prescribing quality indicators

Background

Information on prescribing quality of diabetes care is required by health care providers, insurance companies, policy makers, and the public. Knowledge regarding the opinions and preferences of all involved parties regarding prescribing quality information is important for effective use of prescribing quality indicators.

Methods

Between June and December 2009 we conducted semi structured interviews with 16 key-informants representing eight different organizations in the Netherlands involved in healthcare quality measurement and improvement. The interview guide included topics on participants’ opinions and preferences regarding existing types of prescribing quality indicators in relation to their aim of using quality information. Content analysis methods were used to process the resulting transcripts following the framework of predetermined themes.

Results

Findings from this qualitative study of stakeholder preferences showed that indicators focusing on undertreatment are found important by all participants. Furthermore, health care providers and policy makers valued prescribing safety indicators, insurance companies prioritized indicators focusing on prescribing costs, and patients’ organization representatives valued indicators focusing on interpersonal side of prescribing. Representatives of all stakeholders preferred positive formulation of the indicators to motivate health care providers to participate in health improvement programs. A composite score was found to be most useful by all participants as a starting point of prescribing quality assessment. Lack of information on reasons for deviating from guidelines recommendations appeared to be the most important barrier for using prescribing quality indicators. According to the health care providers, there are many legitimate reasons for not prescribing the recommended treatment and these reasons are not always taken into account by external evaluators. The latter may cause mistrust of health care providers towards external stakeholders and limit the use of PQI in external quality improvement programs.

Conclusion

Prescribing quality indicators are considered to be an important tool for assessing quality of provided diabetes care by all participants, although the preferences for specific types of indicators may differ by stakeholder depending on their user aim. Introduction of information systems to register the reasons for deviating from the recommended drug treatment may contribute to a more widespread use of PQI for assessment of provided health care quality to diabetic patents. This study identified the potential preferences regarding quality indicators for diabetes care, and this could be used for development of questionnaires to conduct a survey among a larger group of participants.

Change in antihypertensive drug prescribing after guideline implementation: a controlled before and after study

Background

Antihypertensive drug choices and treatment levels are not in accordance with the existing guidelines. We aimed to assess the impact of a guideline implementation intervention on antihypertensive drug prescribing.

Methods

In this controlled before and after study, the effects of a multifaceted (education, audit and feedback, local care pathway) quality programme was evaluated. The intervention was carried out in a health centre between 2002 and 2003. From each health care unit (n = 31), a doctor-nurse pair was trained to act as peer facilitators in the intervention.

All antihypertensive drugs prescribed by 25 facilitator general practitioners (intervention GPs) and 53 control GPs were retrieved from the nationwide Prescription Register for three-month periods in 2001 and 2003. The proportions of patients receiving specific antihypertensive drugs and multiple antihypertensive drugs were measured before and after the intervention for three subgroups of hypertension patients: hypertension only, with coronary heart disease, and with diabetes.

Results

In all subgroups, the use of multiple concurrent medications increased. For intervention patients with hypertension only, the odds ratio (OR) was 1.12 (95% CI 0.99, 1.25; p = 0.06) and for controls 1.13 (1.05, 1.21; p = 0.002). We observed no statistically significant differences in the change in the prescribing of specific antihypertensive agents between the intervention and control groups. The use of agents acting on the renin-angiotensin-aldosterone system increased in all subgroups (hypertension only intervention patients OR 1.19 (1.06, 1.34; p = 0.004) and controls OR 1.24 (1.15, 1.34; p < 0.0001).

Conclusions

A multifaceted guideline implementation intervention does not necessarily lead to significant changes in prescribing performance. Rigorous planning of the interventions and quality projects and their evaluation are essential.

Family doctors' views of pharmaceutical sales representatives: assessment scale development

BACKGROUND

The prescribing patterns depend on the physicians' attitudes and their subjective norms towards prescribing a particular drug, as well as on their personal experience with a particular drug. The physicians are affected by their interactions with pharmaceutical industry.

OBJECTIVE

The objectives were to develop a scale for assessment of pharmaceutical sales representatives (PSRs) by the family doctors (FDs) and to determine factors for their evaluation.

METHOD

Cross-sectional anonymous postal study. We included a random sample of 250 Slovenian FDs. Settings. Slovenian FDs' surgeries.

MAIN OUTCOME MEASURE

The score of various items regarding FDs' assessment of PSRs on a 7-point Likert scale.

RESULTS

We got 163 responses (65.2% response rate). The most important characteristic of PSRs, as rated by respondents on the scale from 1 to 7, was the fact that they did not mislead when presenting products' information. The second most important characteristic was the ability to provide objective information about the product. The first three most important characteristics, as rated by the respondents by themselves, were 'Shows good knowledge on the promoted subject', 'Provides objective product information' and 'Makes brief and exact visits'. Cronbach's alpha of the composite scale was 0.844. Factor analysis revealed three PSRs' factors: selling skills, communicating skills and sense of trustworthiness.

CONCLUSION

FDs evaluate PSRs mainly by their managerial skills and trustworthiness. The scale proved to be a reliable tool for assessing PSRs by FDs.

Defining antimicrobial prescribing quality indicators: what is a new prescription?

 

Since guidelines on antibiotic drug treatment often focus on appropriate first choice drugs, assessment of guideline adherence should only concentrate on the first drug prescribed, and not on subsequent antibiotics prescribed after failure of the first one.

Purpose

To determine a valid cut-off point for a definition of “first” or “new” prescription in indicators for the assessment of the quality of antibiotic drug treatment on the basis of pharmaceutical data.

Methods

Three possible definitions for the term “new prescription” were compared, based on three different periods of time, viz. more than 35, 28, or 21 days after starting a previous antibiotic. In an observational study, 1,225 antimicrobial prescriptions from the medical files of five family practices were audited (“clinical classification”) and compared with a classification based on the three definitions (“technical classification”). Agreement between these clinical and technical classifications was determined by calculating Cohen’s kappa. The technical classification was analyzed as a diagnostic test, using the clinical classification as the gold standard, and sensitivity, specificity, likelihood ratios, and post-test probabilities were calculated.

Results

Defining “new prescription” as “more than 35 days after a previous prescription was issued” resulted in a Cohen’s kappa of 0.93 (95% CI 0.92–0.98). The diagnostic value of this definition was extremely high, with a sensitivity of 0.976, specificity of 0.987, positive likelihood ratio of 77.7, and negative likelihood ratio of 0.02.

Conclusion

We recommend using a cut-off value of 35 days since the last antimicrobial prescription as the definition of a “new prescription” when no diagnostic information is available, i.e., when using pharmaceutical data to assess the quality of antibiotic prescribing behavior.

A systematic literature review: prescribing indicators related to type 2 diabetes mellitus and cardiovascular risk management

PURPOSE

Valid prescribing indicators (PI) are needed for reliable assessment of prescribing quality. The purpose of this study is to describe the validity of existing PI for type 2 diabetes mellitus and cardiovascular risk management.

METHODS

We conducted a systematic literature search for studies describing the development and assessment of relevant PIs between January 1990 and January 2009. We grouped identified PI as drug- or disease-oriented, and according to the aspects of prescribing addressed and the additional clinical information included. We reviewed the clinimetric characteristics of the different types of PI.

RESULTS

We identified 59 documents describing the clinimetrics of 16 types of PI covering relevant prescribing aspects, including first-choice treatment, safety issues, dosing, costs, sufficient and timely treatment. We identified three types of drug-oriented, and five types of disease-oriented PI with proven face and content validity as well as operational feasibility in different settings. PI focusing on treatment modifications were the only indicators that showed concurrent validity. Several solutions were proposed for dealing with case-mix and sample size problems, but their actual effect on PI scores was insufficiently assessed. Predictive validity of individual PI is not yet known.

CONCLUSION

We identified a range of existing PI that are valid for internal quality assessment as they are evidence-based, accepted by professionals, and reliable. For external use, problems of patient case-mix and sample size per PI should be better addressed. Further research is needed for selecting indicators that predict clinical outcomes.

Physicians' Views on Generic Medicines: A Narrative Review

Most countries are facing escalating health-care expenditures. A recent trend to control these staggering increases in costs is to encourage the use of generic medicines. Physicians are at the centerpiece of the medication use process as they are the dominant prescribers in all clinical settings. It is therefore prudent to examine what they perceive about generic medicines. The current study attempts to identify and review the literature on physicians' perceptions and practices on the use of generic medicines. Using subject-related keywords, an extensive literature search was undertaken through indexing services available in the authors' institution's library. Full text papers written in English language between 1980 and 2008 were retrieved and reviewed. Fourteen studies, majority ( n = 5) from the United States were reviewed and included. Most of the studies used quantitative methodology. Generally, physicians were neutral to slightly supportive on the use of generic medications. Most of the studies reviewed highlighted the factors that can influence physicians' views as policy-related issues, patient-related variables, drug characteristics and physician-related variables. Although physicians accept generic substitution under policy and economic pressures, they still have concerns about the overall quality and reliability of generic drugs as well as generic interchange of certain drug categories.

Can rational prescribing be improved by an outcome-based educational approach? A randomized trial completed in Iran

INTRODUCTION

An outcome-based education approach has been proposed to develop more effective continuing medical education (CME) programs. We have used this approach in developing an outcome-based educational intervention for general physicians working in primary care (GPs) and evaluated its effectiveness compared with a concurrent CME program in the field of rational prescribing.

METHODS

A cluster randomized controlled design was used. All 159 GPs working in 6 cities, in 2 regions in East Azerbaijan province in Iran, were invited to participate. The cities were matched and randomly divided into an intervention arm, for an outcome-based education on rational prescribing, and a control arm for a traditional CME program on the same topic. GPs' prescribing behavior was assessed 9 months before, and 3 months after the CME programs.

RESULTS

In total, 112 GPs participated. The GPs in the intervention arm significantly reduced the total number of prescribed drugs and the number of injections per prescription. The GPs in the intervention arm also increased their compliance with specific requirements for a correct prescription, such as explanation of specific time and manner of intake and precautions necessary when using drugs, with significant intervention effects of 13, 36, and 42 percentage units, respectively. Compared with the control arm, there was no significant improvement when prescribing antibiotics and anti-inflammatory agents.

DISCUSSION

Rational prescribing improved in some of the important outcome-based indicators, but several indicators were still suboptimal. The introduction of an outcome-based approach in CME seems promising when creating programs to improve GPs' prescribing behavior.

Does an outcome-based approach to continuing medical education improve physicians' competences in rational prescribing?

BACKGROUND

Continuing medical education (CME) is compulsory in Iran, and traditionally it is lecture-based, which is mostly not successful. Outcome-based education has been proposed for CME programs.

AIM

To evaluate the effectiveness of an outcome-based educational intervention with a new approach based on outcomes and aligned teaching methods, on knowledge and skills of general physicians (GPs) working in primary care compared with a concurrent CME program in the field of "Rational prescribing".

METHOD

The method used was cluster randomized controlled design. All GPs working in six cities in one province in Iran were invited to participate. The cities were matched and randomly divided into an intervention arm for education on rational prescribing with an outcome-based approach, and a control arm for a traditional program on the same topic. Knowledge and skills were assessed using a pre- and post-test, including case scenarios.

RESULTS

In total, 112 GPs participated. There were significant improvements in knowledge and prescribing skills after the training in the intervention arm as well as in comparison with the changes in the control arm. The overall intervention effect was 26 percentage units.

CONCLUSION

The introduction of an outcome-based approach in CME appears to be effective when creating programs to improve GPs' knowledge and skills.

[Review of the utilization of the RAND appropriateness method in the biomedical literature (1999-2004)]

OBJECTIVES

To identify and describe studies using the RAND/UCLA method to evaluate the appropriateness of health procedures. This method is a consensus technique that involves several phases to develop appropriateness criteria.

METHODS

We performed a literature search in 2005. OVIDMedline, ISI Web of Knowledge, IME and Highwire were consulted. Articles published between 1999 and 2004 and using the key words "appropriateness", "utilization review" and "physician practice patterns" were selected. Studies using the RAND method were included and those that did not explain the methodology in sufficient detail were excluded. Information on the procedure studied, the place and year of publication, and the characteristics of the journal were extracted from each article.

RESULTS AND DISCUSSION

A total of 5092 articles were identified and 205 were selected. Slightly more than half analyzed surgical or medical procedures, while 16.5% evaluated healthcare quality. More than 50% were published in journals of public health, general medicine, and gastroenterology and hepatology. The mean impact factor was 4.07. A quarter (25.4%) of the articles was published in 1999. CONCLUSIONS AND PERSPECTIVE: The RAND method is still widely used. Appropriateness criteria can be used to review utilization of procedures, to design guidelines, or to support for decision making. These tools should be reviewed to obtain evermore valid and reliable results.

How useful are prescribing indicators based on the DU90% method to distinguish the quality of prescribing between pharmacotherapy audit meetings with different levels of functioning?

Objectives

The objective of the study was to assess the association between the quality of drug prescribing based on three indicator types derived from the DU90% method and different levels of functioning in pharmacotherapy audit meetings (PTAMs).

Materials and methods

The level of functioning in PTAMs in 2004 was assessed by a standard questionnaire. Data on prescriptions in 2004 by the GPs participating in the included PTAMs were extracted from the database of the Foundation for Pharmaceutical Statistics. Three types of DU90% indicators were computed for the seven mostly prescribed drug classes. With univariate and multivariate analyses of variance, differences in the results of three types of indicators for each of the seven drug classes were assessed according to the levels of PTAMs.

Results

For 84 PTAMs with varying levels of functioning, we found no association between the level of PTAM and the quality of prescribing for any of the indicators within the seven drug classes. In general, results gained of all PTAMs seemed to be high in quality for the aspects measured.

Conclusions

It is difficult to define indicators based on the DU90% method, which can readily distinguish differences in the quality of drug prescribing between PTAMs with different levels of functioning. Indicators for prescribing should specifically meet relevant items in the quality of prescribing for certain drug classes. Items for classification of PTAM levels may need some reconsideration.

Determinants of the range of drugs prescribed in general practice: a cross-sectional analysis

Background

Current health policies assume that prescribing is more efficient and rational when general practitioners (GPs) work with a formulary or restricted drugs lists and thus with a limited range of drugs. Therefore we studied determinants of the range of drugs prescribed by general practitioners, distinguishing general GP-characteristics, characteristics of the practice setting, characteristics of the patient population and information sources used by GPs.

Methods

Secondary analysis was carried out on data from the Second Dutch Survey in General Practice. Data were available for 138 GPs working in 93 practices.

ATC-coded prescription data from electronic medical records, census data and data from GP/practice questionnaires were analyzed with multilevel techniques.

Results

The average GP writes prescriptions for 233 different drugs, i.e. 30% of the available drugs on the market within one year. There is considerable variation between ATC main groups and subgroups and between GPs. GPs with larger patient lists, GPs with higher prescribing volumes and GPs who frequently receive representatives from the pharmaceutical industry have a broader range when controlled for other variables.

Conclusion

The range of drugs prescribed is a useful instrument for analysing GPs' prescribing behaviour. It shows both variation between GPs and between therapeutic groups. Statistically significant relationships found were in line with the hypotheses formulated, like the one concerning the influence of the industry. Further research should be done into the relationship between the range and quality of prescribing and the reasons why some GPs prescribe a greater number of different drugs than others.

Attitudes of Slovene general practitioners towards generic drug prescribing and comparison with international studies

BACKGROUND

Over the recent years there has been a steady 7% yearly increase in prescribing costs, which accounts for 17% of the Slovene national health care budget. Substitution of branded products by generic equivalents can offer savings. General practitioners (GPs) are often concerned about the quality of generic products and possible legal liabilities associated with their use.

OBJECTIVE

We wanted to examine the attitudes of GPs in Slovenia towards generic drug prescribing.

METHODS

We conducted a postal survey of a random sample of 200 out of 800 GPs in Slovenia from the National Health Insurance Institute database. GPs were asked 21 questions regarding their knowledge on generic drugs, awareness of prescribing costs, prices of generic drugs relative to brand name drugs and their attitude towards use of generic drugs.

RESULTS

The 117 (58.5%) replies we received represent 15% of the GP population in Slovenia. 66.1% of GPs considered rising costs of medicines to be a serious problem for the health care budget. Each week, over 50% of GPs experienced demands from patients for specific drugs and the majority of GPs usually met their patients' demands or requests from hospital consultants for branded products. 38.3% of GPs did not take price into consideration when prescribing drugs. The majority of GPs (88.9%) perceived generics to have the same effectiveness as branded drugs. One quarter of GPs would prescribe more generics if additional clinical trials were presented. 37.3% would follow advice of academic detailers and 30.3% expected the generics to be even cheaper than they were. Independent detailing was welcomed by 63.8% of GPs because of the big influence of the pharmaceutical industry on the prescribing habits. 15.5% thought that the industry had a tremendous impact on their prescribing patterns.

CONCLUSIONS

Slovene GPs are aware of the cost of prescribed drugs. They are willing to accept independent academic detailing to improve their prescribing and are willing to increase generic drugs under certain conditions.

Pharmaceutical care and its relationship to prescribing behaviour of general practitioners

OBJECTIVE

To study the correlation between pharmaceutical care and prescribing routines of general practitioners (GPs).

METHODS

Cross-sectional study; 201 pharmacies, 408 general practices, The Netherlands, 2000/2001. The variation in prescribing behaviour was characterised using 20 validated prescribing indicators based on general practice guidelines. The general construct 'adherence to guidelines' served as the dependent variable and was formed by summing the scores of the prescribing indicators. Four possible determinants of the variation were determined on the basis of survey questions: the construct 'the pharmacist's attitude towards pharmaceutical care', and three partial constructs derived from the pharmacist's care-providing function: the care for the individual patient, the cooperation with general practitioners and the registration of the care provided. A multiple linear regression analysis was then performed.

MAIN OUTCOME MEASURE

The weighted score for the prescribing indicators.

RESULTS

The weighted average score for the prescribing indicators was 65% (SD 3.7). The response rate to the survey was 71%. The pharmacist's attitude to pharmaceutical care, as well as the degree to which the pharmacist provided care for the individual patient, the degree to which he cooperated with the general practitioner and the degree to which he registered the care provided were not correlated with the 'adherence to guidelines' by the general practitioner with whom the pharmacist frequently cooperated.

CONCLUSION

Variations between general practitioners in the quality of prescribing, as measured by their adherence to guidelines, were not correlated with pharmaceutical care by the pharmacist with whom they cooperated on a day-to-day basis.

Factor analysis improves the selection of prescribing indicators

OBJECTIVE

To test a method for improving the selection of indicators of general practitioners' prescribing.

METHODS

We conducted a prescription database study including all 180 general practices in the County of Funen, Denmark, approximately 472,000 inhabitants. Principal factor analysis was used to model correlation between 19 register-based indicators for the quality of non-steroidal anti-inflammatory drug (NSAID) prescribing.

RESULTS

The correlation between indicators ranged widely from 0 to 0.93. Factor analysis revealed three dimensions of quality: (1) "Coxib preference", comprising indicators directly quantifying choice of coxibs, indicators measuring expenditure per Defined Daily Dose, and indicators taking risk aspects into account, (2) "Frequent NSAID prescribing", comprising indicators quantifying prevalence or amount of NSAID prescribing, and (3) "Diverse NSAID choice", comprising indicators focusing on the width of GPs' formularies. The number of indicators for measuring the important aspects of quality in prescribing of NSAIDs could be reduced substantially by selecting the indicator in each dimension with the highest factor loading. A high preference for coxibs indicated both appropriate and inappropriate prescribing, as revealed by the correlation of the indicators in the first factor.

CONCLUSION

Correlation and factor analysis is a feasible method that assists the selection of indicators and gives better insight into prescribing patterns.

Differences in prescribing between GPs: impact of the cooperation with pharmacists and impact of visits from pharmaceutical industry representatives

BACKGROUND

Community pharmacists, pharmaceutical industry and differences in prescribing between GPs.

OBJECTIVE

To explore the role of the pharmacists and pharmaceutical industry representatives.

METHODS

A cross-sectional survey was undertaken of 1434 GPs in The Netherlands in 2001. Prescribing indicators based on general practice guidelines were used to assess the quality of prescribing. Three constructs, based on survey questions, were used as possible determinants for the quality of prescribing: cooperation with the pharmacist; quality of the Pharmacotherapeutic audit meeting (PTAM); and the GP's attitude towards the pharmacist's role. Data were collected about the frequency of visits by pharmaceutical industry representatives. Responses from 324 solo GPs were analysed using multiple linear regression.

RESULTS

Response rate: 71%. For the 324 solo GPs the average score for the 20 prescribing indicators was 64% (SD 3.7). For the non-solo GPs this score was 65% (SD 3.8, P < 0.05). The differences between solo and group practices were: the number of visits from pharmaceutical industry representatives (5.7 versus 3.8 visits per month), full time GPs (93% versus 50%), the number of patients per GP (2151, SD 693 versus 1506, SD 742), and the presence of a GP trainer (21 versus 38%). Of the solo GPs, 4.6% are female, compared with 26% of the GPs in non-solo practices. The quality of prescribing in solo practices was not correlated with the GP's attitude towards the pharmacist's role, the way in which GPs cooperated with pharmacists or the quality of the PTAM. More frequent visits from pharmaceutical industry representatives was associated with a lower quality of prescribing.

CONCLUSION

There was a negative correlation between quality of prescribing by solo GPs and frequency of visits by pharmaceutical industry representatives. In day-to-day practice, no measurable effects of the cooperation between solo GP and pharmacist on the quality of prescribing were observed.