Indicators of prescribing quality in drug utilisation research: report of a European meeting (DURQUIM, 13-15 May 2004)

Performance of 3 Sets of Criteria for Potentially Inappropriate Prescribing in Older People to Identify Inadequate Drug Treatment

IMPORTANCE

Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are used in research to reflect the quality of drug treatment in older people and have been suggested for inclusion in core outcome sets for evaluation of interventions for improved prescribing. Their validation so far, however, is primarily restricted to expert opinion-based processes.

OBJECTIVE

To evaluate the performance of 3 explicit PIM/PPO criteria sets as diagnostic tools to identify inadequate drug treatment in older patients.

DESIGN, SETTING, AND PARTICIPANTS

This diagnostic study analyzed patients aged 65 years or older consecutively included from 2 primary health care centers from October to November 2017. Data were analyzed from February to August 2022.

EXPOSURES

The PIMs/PPOs were concordantly identified by 2 specialist physicians (2018-2019) retrospectively after a planned physician visit, using 3 European PIM/PPO criteria sets and without knowledge of this diagnostic study.

MAIN OUTCOMES AND MEASURES

Area under the receiver operating characteristic (ROC) curve, reflecting the ability of PIM/PPO criteria sets to identify the reference standard of inadequate drug treatment, determined by 2 specialist physicians in consensus. Inadequate drug treatment implied that additional action related to the medication could be medically justified before the next regular visit.

RESULTS

A total of 302 patients were analyzed (median age, 74 [IQR, 69-81] years; 178 women [59%]; median number of drugs in the medication list, 6 [IQR, 3-9]); 98 patients (32%) had inadequate drug treatment. A total of 0 to 8 PIMs/PPOs per patient were identified using the Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria, 0 to 6 with the European EU(7)-PIM list, and 0 to 12 with the Swedish set of indicators of prescribing quality. The areas under the ROC curve for the 3 sets to identify the reference standard for inadequate drug treatment were 0.60 (95% CI, 0.53-0.66) for the STOPP/START criteria, 0.69 (95% CI, 0.63-0.75) for the EU(7)-PIM list, and 0.73 (95% CI, 0.67-0.80) for the Swedish set. For comparison, the area under the ROC curve was 0.71 (95% CI, 0.65-0.78) using the number of drugs in the medication list.

CONCLUSIONS AND RELEVANCE

In this diagnostic study, the evaluated PIM/PPO sets had poor to fair performance as diagnostic tools to identify inadequate drug treatment, comparable with a simple count of the number of drugs in the medication list. These findings suggest that use of PIMs/PPOs as indicators of drug treatment quality in core outcome sets for the evaluation of interventions for improved prescribing may need reconsideration.

Examining patterns in opioid prescribing for non-cancer-related pain in Wales: preliminary data from a retrospective cross-sectional study using large datasets

Objectives

To examine trends in strong opioid prescribing in a primary care population in Wales and identify if factors such as age, deprivation and recorded diagnosis of depression or anxiety may have influenced any changes noted.

Design

Trend, cross-sectional and longitudinal analyses of routine data from the Primary Care General Practice database and accessed via the Secure Anonymised Information Linkage (SAIL) databank.

Setting

A total of 345 Primary Care practices in Wales.

Participants

Anonymised records of 1,223,503 people aged 18 or over, receiving at least one opioid prescription between 1 January 2005 and 31 December 2015 were analysed. People with a cancer diagnosis (10.1%) were excluded from the detailed analysis.

Results

During the study period, 26,180,200 opioid prescriptions were issued to 1,223,503 individuals (55.9% female, 89.9% non-cancer diagnoses). The greatest increase in annual prescribing was in the 18-24 age group (10,470%), from 0.08 to 8.3 prescriptions/1000 population, although the 85+ age group had the highest prescribing rates across the study period (from 149.9 to 288.5 prescriptions/1000 population). The number of people with recorded diagnoses of depression or anxiety and prescribed strong opioids increased from 1.2 to 5.1 people/1000 population (328%). The increase was 366.9% in areas of highest deprivation compared to 310.3 in the least. Areas of greatest deprivation had more than twice the rate of strong opioid prescribing than the least deprived areas of Wales.

Conclusion

The study highlights a large increase in strong opioid prescribing for non-cancer pain, in Wales between 2005 and 2015. Population groups of interest include the youngest and oldest adult age groups and people with depression or anxiety particularly if living in the most deprived communities. Based on this evidence, development of a Welsh national guidance on safe and rational prescribing of opioids in chronic pain would be advisable to prevent further escalation of these medicines.

Summary points

This is the first large-scale, observational study of opioid prescribing in Wales.Over 1 million individual, anonymised medical records have been searched in order to develop the study cohort, thus reducing recall bias.Diagnosis and intervention coding in the Primary Care General Practice database is limited at input and may lead to under-reporting of diagnoses.There are limitations to the data available through the Secure Anonymised Information Linkage databank because anonymously linked dispensing data (what people collect from the pharmacy) are not currently available. Consequently, the results presented here could be seen as an 'intention to treat' and may under- or overestimate what people in Wales actually consume.

Usefulness of quality indicators for antibiotic use: case study for the Netherlands

Quality problem

Inappropriate antibiotic use drives development of antimicrobial resistance. Worldwide, guideline adherence for antibiotic treatment of infectious disease is far from optimal. Insight in prescribing quality is pivotal for healthcare professionals and policy makers to intervene appropriately.

Initial assessments

European countries uniformly monitor antibiotic use, which is reported yearly by the European Centre for Disease Prevention and Control. Unfortunately, this has not had enough impact to decrease prescribing and resistance levels.

Choice of solution

Quality indicators (QIs) could provide better insight in prescribing quality and enable benchmarking to other countries; this could trigger action to improve antimicrobial prescribing. European Surveillance of Antimicrobial Consumption (ESAC) proposed 12 antibiotic QIs.

Implementation

Trends in use of antibiotic subgroups and the 12 ESAC QI values were determined for Dutch primary care (2004-2013); outcomes were compared to other European countries. Dutch antibiotic use is low within the European context. Nitrofurantoin use is higher than the European average, use of small-spectrum antibiotics lowers. Use of macrolides, quinolones and amoxicillin/clavulanate declined, which was not supported by the broad/narrow QI results.

Evaluation

QIs expressing antibiotic subgroup use in Defined Daily Doses/1000 inhabitants/day, particularly small-spectrum and non-first choices, provide proper insight in prescribing quality and are useful for benchmarking purposes. QIs measuring percentages were not considered useful. The broad/narrow ratio could be more informative when adjusted to national guidelines, or when more antibiotic subgroups are included based on better European consensus.

Lessons learnt

Benchmarking the above mentioned Dutch QI values to other countries provides direction for three specific strategies to further improve Dutch antibiotic prescribing practice.

Clinical relevance of the STOPP/START criteria in hip fracture patients

Purpose

The aim of this study was to investigate the clinical relevance of potentially inappropriate medications (PIMs), identified by the STOPP criteria, and potential prescribing omissions (PPOs), identified by the START criteria, and to identify predictors for clinically relevant PIMs and PPOs.

Methods

The STOPP and START criteria were applied on the medication lists of 200 older hip fracture patients, consecutively recruited to a randomized controlled study in 2009. For each identified PIM and/or PPO, the clinical relevance was assessed at the individual level, using medical records from both hospital and primary care as well as data collected in the original study.

Results

A total of 555 PIMs/PPOs were identified in 170 (85%) patients (median age: 85 years, 67% female), 298 (54%) of which, in 141 (71%) patients, were assessed as clinically relevant. A greater proportion of PIMs than PPOs were clinically relevant: 71% (95% CI: 66%; 76%) vs. 32% (27%; 38%). A greater proportion of PPOs than PIMs could not be assessed with available information: 38% (32%; 44%) vs. 22% (17%; 27%). Number of drugs and multidose drug dispensing, but not age, sex, cognition, or nursing home residence, were associated with ≥1 clinically relevant PIMs/PPOs.

Conclusions

The present study illustrates that one in two PIMs/PPOs identified by the STOPP/START criteria is clearly clinically relevant, PIMs being clinically relevant to a greater extent than PPOs. Based on available information, the clinical relevance could not be determined in a non-negligible proportion of PIMs/PPOs. Number of drugs and multidose drug dispensing were associated with ≥1 clinically relevant PIMs/PPOs.

Analysis of the influence of recent reforms in China: cardiovascular and cerebrovascular medicines as a case history to provide future direction

BACKGROUND

Pharmaceutical expenditure has grown by 16% per annum in China, enhanced by incentives for physicians and hospitals. Hospital pharmacies dispense 80% of medicines in China, accounting for 46% of total hospital expenditure. Principal measures to moderate drug expenditure growth include pricing initiatives as limited demand-side measures.

OBJECTIVE

Assess current utilization and expenditure including traditional Chinese medicines (TCMs) between 2006 and 2012.

METHODS

Uncontrolled retrospective study of medicines to treat cardiovascular and cerebrovascular diseases in one of the largest hospitals in southwest China.

RESULTS

Utilization increased 3.3-fold for cerebrovascular medicines, greatest for TCMs, with expenditure increasing 4.85-fold. Low prices for generics were seen, similar to Europe. However, there was variable utilization of generics at 29-31% of total product volumes in recent years. There continued to be irrationality in prescribing with high use of TCMs, and the utilization of different medicines dropping significantly once they achieved low prices.

CONCLUSION

Prices still have an appreciable impact on utilization in China. Potential measures similar to those implemented among western European countries could improve prescribing rationality and conserve resources.

Association between drug-specific indicators of prescribing quality and quality of drug treatment: a validation study

Purpose

To evaluate the concurrent validity of three European sets of drug‐specific indicators of prescribing quality

Methods

In 200 hip fracture patients (≥65 years), consecutively recruited to a randomized controlled study in Sahlgrenska University Hospital in 2009, quality of drug treatment at study entry was assessed according to a gold standard as well as to three drug‐specific indicator sets (Swedish National Board of Health and Welfare, French consensus panel list, and German PRISCUS list). As gold standard, two specialist physicians independently assessed and then agreed on the quality for each patient, after initial screening with STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) and START (Screening Tool to Alert to Right Treatment).

Results

According to the Swedish, French, and German indicator sets, 82 (41%), 54 (27%), and 43 (22%) patients had potentially inappropriate drug treatment. A total of 141 (71%) patients had suboptimal drug treatment according to the gold standard. The sensitivity for the indicator sets was 0.51 (95% confidence interval: 0.43; 0.59), 0.33 (0.26; 0.41), and 0.29 (0.22; 0.37), respectively. The specificity was 0.83 (0.72; 0.91), 0.88 (0.77; 0.94), and 0.97 (0.88; 0.99). Suboptimal drug treatment was 2.0 (0.8; 5.3), 1.9 (0.7; 5.1), and 6.1 (1.3; 28.6) times as common in patients with potentially inappropriate drug treatment according to the indicator sets, after adjustments for age, sex, cognition, residence, multi‐dose drug dispensing, and number of drugs.

Conclusions

In this setting, the indicator sets had high specificity and low sensitivity. This needs to be considered upon use and interpretation. Copyright © 2015 The Authors Pharmacoepidemiology and Drug Safety Published by John Wiley & Sons, Ltd.

Quality indicators as a tool in improving the introduction of new medicines

Quality indicators are increasingly used as a tool to achieve safe and quality clinical care, cost-effective therapy, for professional learning, remuneration, accreditation and financial incentives. A substantial number focus on drug therapy but few address the introduction of new medicines even though this is a burning issue. The objective was to describe the issues and challenges in designing and implementing a transparent indicator framework and evaluation protocol for the introduction of new medicines and to provide guidance on how to apply quality indicators in the managed entry of new medicines. Quality indicators need to be developed early to assess whether new medicines are introduced appropriately. A number of key factors need to be addressed when developing, applying and evaluating indicators including dimensions of quality, suggested testing protocols, potential data sources, key implementation factors such as intended and unintended consequences, budget impact and cost-effectiveness, assuring the involvement of the medical professions, patients and the public, and reliable and easy-to-use computerized tools for data collection and management. Transparent approaches include the need for any quality indicators developed to handle conflict of interests to enhance their validity and acceptance. The suggested framework and indicator testing protocol may be useful in assessing the applicability of indicators for new medicines and may be adapted to healthcare settings worldwide. The suggestions build on existing literature to create a field testing methodology that can be used to produce country-specific quality indicators for new medicines as well as a cross international approach to facilitate access to new medicines.

Prevalence of suboptimal drug treatment in patients with and without multidose drug dispensing--a cross-sectional study

PURPOSE

The aim of this study was to compare the prevalence of suboptimal drug treatment in older patients with and without multidose drug dispensing (MDD).

METHODS

In 200 hip fracture patients (≥65 years of age), originally recruited to a randomized controlled study in Sahlgrenska University Hospital in 2009, quality of drug treatment at study entry was compared between patients with and without MDD. Two specialist physicians independently assessed and then agreed on the quality of the drug treatment of each patient. Suboptimal drug treatment was defined as ≥1 STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) or ≥1 START (Screening Tool to Alert to Right Treatment) outcome assessed as clinically relevant after individual considerations had been made, i.e. over- or undertreatment (≥1 inappropriate and ≥1 missing drug, respectively).

RESULTS

Patients with MDD (n=100) differed from patients without MDD (n=100) in several ways, for example by being older (87.6 vs. 81.5 years) and using more drugs (8.4 vs. 5.9 drugs). The total number (±standard deviation) of inappropriate and/or missing drugs per person was greater in MDD patients compared with patients without MDD (1.92±1.52 vs. 1.06±1.29, P<0.0001); MDD patients had an additional 0.77 inappropriate drugs and an additional 0.09 missing drugs per person. The prevalence of suboptimal drug treatment was greater in patients with MDD than in those without MDD (86 vs. 55%, P<0.0001). Logistic regression revealed that suboptimal drug treatment was 8.0 times as common in MDD patients, after adjustments for age, sex, number of drugs, cognition, and residence (95% confidence interval 2.4; 26.9). Corresponding figures for over- and undertreatment were 2.9 (1.1; 7.4) and 1.8 (0.8; 4.3), respectively.

CONCLUSIONS

Suboptimal drug treatment, including over- and undertreatment, is more common in MDD patients than in patients who receive their drugs via ordinary prescriptions. The findings confirm safety concerns regarding quality of drug treatment in MDD patients.

Drug treatment in older people before and after the transition to a multi-dose drug dispensing system--a longitudinal analysis

Background

An association has been found between multi-dose drug dispensing (MDD) and use of many drugs. The aim of this study was to investigate the nature of this association, by performing a longitudinal analysis of the drug treatment before and after the transition to MDD.

Methods

Inclusion critera in this register-based study were inhabitants in Region Västra Götaland, Sweden, who, at ≥65 years of age and between 1^st July 2006 and 30^th June 2010, filled their first MDD prescription. For each individual, prescribed drugs were estimated at three month intervals before and after (maximum 3 years, respectively) the first date of filling an MDD prescription (index date).

Results

A total of 30,922 individuals matched the inclusion criteria (mean age: 83.2 years; 59.9% female). There was a temporal association between the transition to MDD and an increased number of drugs: 5.4±3.9 and 7.5±3.8 unique drugs three months before and after the index date, respectively, as well as worse outcomes on several indicators of prescribing quality. When either data before or after the index date were used, a multi-level regression analysis predicted the number of drugs at the index date at 5.76 (95% confidence limits: 5.71; 5.80) and 7.15 (7.10; 7.19), respectively, for an average female individual (83.2 years, 10.8 unique diagnoses, 2.4 healthcare contacts/three months). The predicted change in the number of drugs, from three months before the index date to the index date, was greater when data before this date was used as compared with data after this date: 0.12 (0.09; 0.14) versus 0.02 (−0.01; 0.05).

Conclusions

After the patients entered the MDD system, they had an increased number of drugs, more often potentially harmful drug treatment, and fewer changes in drug treatment. These findings support a causal relationship between such a system and safety concerns as regards prescribing practices.

Compliance with quality prescribing indicators in terms of their relationship to financial incentives

OBJECTIVE

To develop quality prescribing indicators for general practitioners (GPs) who are non-monitored and not included in pay-for-performance programs, and to determine compliance with incentivized and non-incentivized indicators.

STUDY DESIGN

Descriptive cross sectional study.

SETTING

Aljarafe Primary Health Care Area (Andalusian Public Health Care Service, Spain), a rural and suburban area with a population of 323,857 inhabitants. Health assistance in this area is provided by 176 GPs in 37 health centers. Prescribing indicators were developed by a multidisciplinary group using a qualitative technique based on consensus. The members of the consensus group searched for updated recommendations focused on clinical evidence. Prescribing data were obtained from the computerised pharmacy records of reimbursed drugs and clinical data from the electronic clinical databases and hospital admission records.

RESULTS

Fourteen indicators based on the selection of drugs of different therapeutic groups or linked to patient´s clinical information were designed. The compliance with indicators based on the selection of drugs linked to financial incentives was higher than that of indicators not linked to financial incentives. The compliance with indicators based on clinical information varied widely. Inappropriate prescribing ranged from 7 %, in the use of long-acting beta-agonists in asthma, to 86 % in the use of drugs for the prevention of osteoporotic fractures in young women.

CONCLUSIONS

This study shows better compliance by GPs with indirect and incentivized quality prescribing indicators, included in pay-for-performance programs, compared with not-incentivized indicators based on the relative use of drugs and on the appropriateness prescribing.

Development and validation of potential structure indicators for evaluating antimicrobial stewardship programmes in European hospitals

This study describes the development of structure indicators for hospital antimicrobial stewardship programmes and pilot validation across European hospitals. A multi-disciplinary panel from four European countries developed structure indicators in three steps: identification and listing of indicators, remote ranking of indicators using multi-criteria scoring, selection of indicators in a face-to-face consensus meeting. Additionally, the top-ten indicators were identified as a minimal set of key indicators. A survey was sent to the directors of antimicrobial stewardship programmes in European hospitals. The yes/no answers for the indicators were transformed into numbers in order to calculate the total scores. A list of 58 indicators was selected and categorised into the following topics: antimicrobial stewardship services (12 items), tools (16 items), human resources and mandate (6 items), health care personnel development (4 items), basic diagnostic capabilities (6 items), microbiological rapid tests (2 items), evaluation of microbiological drug resistance data (3 items), antibiotic consumption control (5 items) and drug use monitoring (4 items). The indicator scores, reported by 11 pilot hospitals from five European countries, ranged from 32 to 50 (maximum score = 58) and from 5 to 10 points (maximum score = 10) for, respectively, the complete and the top-ten list. An international panel selected 58 potential structure indicators, among which was a minimal set of ten key structure indicators, that could be useful for assessment of the comprehensiveness and resource-intensity of antimicrobial stewardship programmes. There was significant heterogeneity among participating centres with regard to their score for structural components of effective antimicrobial stewardship.

Association between prescribing patterns of anti-asthmatic drugs and clinically uncontrolled asthma: a cross-sectional study

OBJECTIVE

Studies based on prescription data have shown that many asthmatics tend to use large quantities of inhaled beta-2-agonists, suggesting poorly controlled disease. The aim of the present study was to investigate the association between clinically uncontrolled asthma and prescribing patterns of anti-asthmatic drugs with a primary focus on short-acting beta-2-agonists (SABA).

METHODS

In a cross-sectional study 357 subjects, selected by their prescriptions of inhaled beta-2-agonists in Odense Pharmaco-Epidemiological Database, underwent individual clinical assessment including the Asthma Control Questionnaire (ACQ) and spirometry. The associations between uncontrolled asthma (ACQ score ≥ 1.50) and individual anti-asthmatic prescribing were analysed by means of logistic regression.

RESULTS

Clinically uncontrolled asthma was positively associated with SABA use, the association becoming stronger with higher annual quantity of SABA use, odds ratio (OR) 11.1 (95% CI 4.4-28.0) for ≥400 DDD/year. This trend persisted after stratifying for gender, age, and controller treatment. Although subjects using ≥450 DDD/year were all uncontrolled, there was substantial overlap in SABA use between controlled and uncontrolled subjects below this limit. We found no effect modification by age and gender. Use of inhaled corticosteroids protected against uncontrolled asthma, OR 0.51 (95% CI 0.27-0.95).

CONCLUSION

Asthmatics with a high use of SABA frequently have problems with uncontrolled asthma, and users of ICS are protected against uncontrolled asthma. The associations we found were, however, to weak too allow firm conclusions about asthma control for most individual asthma patients.

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.

The utility of an electronic adherence assessment device in type 2 diabetes mellitus: a pilot study of single medication

OBJECTIVES

The primary objective of this pilot study was to determine if the Medication Event Monitoring System (MEMS) is capable of providing meaningful estimates of compliance within the indigenous Qatari population. The secondary objective was to highlight any specific problems which might be associated with the use of MEMS within this population.

METHOD

A sample of adult diabetic Qatari patients attending an outpatient diabetic clinic were administered a Knowledge, Attitude, and Practices (KAP) questionnaire and then dispensed one of their regular medications in a MEMS((R))-fitted bottle. Data contained in the MEMS((R)) were downloaded after the patients returned for a refill and adherence was estimated using 2 methods: pill count and MEMS((R)) data.

RESULTS

A total of 54 patients agreed to participate in this pilot study. Adherence to daily doses was 67.7% and with regimen 13.7%. No correlation was found between adherence assessed by pill count and MEMS((R)). The association between KAP and adherence was generally poor. A number of other issues and challenges in the use of MEMS((R)) that could affect its utility were noted and will be discussed.

CONCLUSIONS

Our results revealed problems associated with the use of MEMS((R)) that could affect its usefulness in assessing adherence in this part of the world. Some issues identified in this pilot study included retrieving the MEMS((R)), registering extra opening of MEMS((R)), desire to hoard medicine by taking doses at different frequency than recorded in MEMS((R)). All these issues could be closely associated with the attitudes and practices of the patients, as demonstrated by our KAP analysis and correlations.

Assessment of regional variation in polypharmacy

PURPOSE

To assess polypharmacy in a population with emphasis on regions.

METHODS

We studied the individual-based data of all dispensed prescription drugs (DP) during a 3-month study period in Sweden 2006. As an indicator of polypharmacy, five or more (DP > or = 5) different drugs (substances) dispensed were applied. For analysis, we used comparisons of prevalence, correlation of prevalence of polypharmacy with different socioeconomic variables, and a novel weighted polypharmacy index.

RESULTS

The national prevalence of polypharmacy, DP > or = 5, was 10.5% (inter-regional variation 9.1-12.1%). The regional variation in the prevalence of polypharmacy was largest for the age groups > or =90 (45.6-59.1%), 80-89 (46.1-53.4%) and 70-79 years (33.1-38.0%). The national prevalence of excessive polypharmacy, DP > or = 10, was 2.2% (inter-regional variation 1.9-2.6%). The regional variation in prevalence of excessive polypharmacy was largest for the age groups > or =90 (9.8-22.3%), 80-89 (11.4-17.1%) and 70-79 years (7.0-9.4%). We found a fairly strong positive correlation between polypharmacy and the age group > or =70 years (r = 0.84 for men and 0.71 for women). The novel weighted polypharmacy index indicated regional differences in the internal distribution of the prevalence of dispensed drugs for individuals with polypharmacy.

CONCLUSION

Our findings indicate that the observed regional differences in the prevalence of polypharmacy partly can be explained by the regional age distribution in Sweden. The use of the novel weighted polypharmacy index indicated regional differences in drug therapy for individuals with polypharmacy.

Methods to identify the target population: implications for prescribing quality indicators

Background

Information on prescribing quality is increasingly used by policy makers, insurance companies and health care providers. For reliable assessment of prescribing quality it is important to correctly identify the patients eligible for recommended treatment. Often either diagnostic codes or clinical measurements are used to identify such patients. We compared these two approaches regarding the outcome of the prescribing quality assessment and their ability to identify treated and undertreated patients.

Methods

The approaches were compared using electronic health records for 3214 diabetes patients from 70 general practitioners. We selected three existing prescribing quality indicators (PQI) assessing different aspects of treatment in patients with hypertension or who were overweight. We compared population level prescribing quality scores and proportions of identified patients using definitions of hypertension or being overweight based on diagnostic codes, clinical measurements or both.

Results

The prescribing quality score for prescribing any antihypertensive treatment was 93% (95% confidence interval 90-95%) using the diagnostic code-based approach, and 81% (78-83%) using the measurement-based approach. Patients receiving antihypertensive treatment had a better registration of their diagnosis compared to hypertensive patients in whom such treatment was not initiated. Scores on the other two PQI were similar for the different approaches, ranging from 64 to 66%. For all PQI, the clinical measurement -based approach identified higher proportions of both well treated and undertreated patients compared to the diagnostic code -based approach.

Conclusions

The use of clinical measurements is recommended when PQI are used to identify undertreated patients. Using diagnostic codes or clinical measurement values has little impact on the outcomes of proportion-based PQI when both numerator and denominator are equally affected. In situations when a diagnosis is better registered for treated than untreated patients, as we observed for hypertension, the diagnostic code-based approach results in overestimation of provided treatment.

Regional variation and adherence to guidelines for drug treatment of asthma

AIMS

To describe the utilization of antiasthmatic drugs in Sweden and to explore regional variations in drug utilization and adherence to guidelines for rational drug prescribing of antiasthmatics and their rationale.

METHODS

Data on antiasthmatic drugs dispensed between July 2005 and December 2008 to all Swedish citizens aged between 18 and 44 years were obtained from the Swedish National Prescribed Drug Register. The period prevalence was determined by analyzing the number of users/1000 inhabitants, and the incidence by analyzing the number of new users after an 18-month drug-free wash-out period. Three drug-related indicators were used to assess the adherence to guidelines. All measures were analyzed by gender and region.

RESULTS

A total of 161,000 patients were dispensed antiasthmatics in 2007, corresponding to a prevalence of 4 and 6% among men and women, respectively; the incidence rates were 2 and 3%, respectively. The total drug utilization and adherence to guidelines varied between regions. The total drug expenditures of antiastmatics were 258 million SEK (28 million euro), with fixed dose combinations accounting for 46% of the expenditure. No relation was found between models for allocating prescribing budgets or clear Drug and Therapeutics Committee recommendations and adherence to guidelines.

CONCLUSION

There are large regional variations in the utilization of antiasthmatics between Swedish regions, with substantial room for improvement in the adherence to guidelines. New methods of influencing physician behavior may be needed in the future to enhance adherence.

Potential savings without compromising the quality of care

AIMS

This study was designed to analyse the association between adherence to guidelines for rational drug use and surrogate outcome markers for hypertension, diabetes and hypercholesterolaemia.

METHODS

The study used a cross-sectional ecological design. Data from dispensed prescriptions and medical records were analysed from 24 primary healthcare centres with a combined registered population of 330,000 patients in 2006. Guideline adherence was determined calculating the proportion of the prescribed volume of antidiabetic agents, antihypertensives and lipid-lowering agents representing the 14 different drugs included in the guidelines for these three areas. Patient outcome was assessed using surrogate marker data on HbA1C, blood pressure (BP) and s-cholesterol. The association between the guidelines adherence and outcomes measures was analysed by logistic regression.

RESULTS

The proportion of guideline antidiabetic drugs in relation to all antidiabetic drugs prescribed varied between 80% and 97% among the practices, the ratio of angiotensin converting enzyme (ACE)-inhibitors to all renin-angiotensin drugs 40-77% and the ratio of simvastatin to all statins 58-90%. The proportion of patients reaching targets for HbA1C, BP and s-cholesterol varied between 34% and 66%, 36% and 57% and 46% and 71% respectively. No significant associations were found between adherence to the guidelines and outcome. The expenditures for antihypertensives and lipid-lowering drugs could potentially be reduced by 10% and 50% respectively if all practices adhered to the guidelines as the top performing practices.

CONCLUSION

A substantial amount of money can be saved in primary care without compromising the quality of care by using recommended first-line drugs for the treatment diabetes, hypertension and hypercholesterolaemia.

European Surveillance of Antimicrobial Consumption (ESAC): quality indicators for outpatient antibiotic use in Europe

BACKGROUND AND OBJECTIVE

Indicators to measure the quality of healthcare are increasingly used by healthcare professionals and policy makers. In the context of increasing antimicrobial resistance, this study aimed to develop valid drug-specific quality indicators for outpatient antibiotic use in Europe, derived from European Surveillance of Antimicrobial Consumption (ESAC) data.

METHODS

27 experts (15 countries), in a European Science Foundation workshop, built on the expertise within the European Drug Utilisation Research Group, the General Practice Respiratory Infections Network, the ESCMID Study Group on Primary Care Topics, the Belgian Antibiotic Policy Coordination Committee, the World Health Organization, ESAC, and other experts. A set of proposed indicators was developed using 1997-2003 ESAC data. Participants scored the relevance of each indicator to reducing antimicrobial resistance, patient health benefit, cost effectiveness and public health policy makers (scale: 1 (completely disagree) to 9 (completely agree)). The scores were processed according to the UCLA-RAND appropriateness method. Indicators were judged relevant if the median score was not in the 1-6 interval and if there was consensus (number of scores within the 1-3 interval was fewer than one third of the panel). From the relevant indicators providing overlapping information, the one with the highest scores was selected for the final set of quality indicators-values were updated with 2004 ESAC data.

RESULTS

22 participants (12 countries) completed scoring of a set of 22 proposed indicators. Nine were rated as relevant antibiotic prescribing indicators on all four dimensions; five were rated as relevant if only relevance to reducing antimicrobial resistance and public health policy makers was taken into account. A final set of 12 indicators was selected.

CONCLUSION

12 of the proposed ESAC-based quality indicators for outpatient antibiotic use in Europe have face validity and are potentially applicable. These indicators could be used to better describe antibiotic use in ambulatory care and assess the quality of national antibiotic prescribing patterns in Europe.

Polypharmacy in elderly hospitalised patients in Slovakia

OBJECTIVE

The aims of the present study were to: analyse the prevalence of polypharmacy in a group of older patients; evaluate the influence of hospital stay on the number of drugs taken; assess the most frequently prescribed pharmacological classes; identify risk factors that predisposed the patient to polypharmacy. Setting The study was carried out in the Department of Internal Medicine of a non-university general hospital.

METHOD

In the retrospective study, 600 patients aged 65 years or more were enrolled. They were hospitalised in the period from 1st December 2003 to 31st March 2005. Each person taking six or more medications per day was considered to be a patient with polypharmacy. Particular sociodemographic and clinical characteristics, as well as comorbid conditions, were evaluated as factors potentially influencing the prevalence of polypharmacy.

MAIN OUTCOME MEASURE

The number and type of medications taken at the time of hospital admission and discharge were recorded and compared for each patient.

RESULTS

Polypharmacy on admission and at discharge was observed in 362 (60.3%) and 374 (62.3%) patients, respectively. Hospitalisation led to a significant increase in the number of medications. The spectrum of medications used corresponded to the proportions of diagnoses in the evaluated group, in which cardiovascular diseases were most prevalent. According to the multivariate analysis using a logistic regression model, diabetes mellitus (odds ratio (OR) 2.40; 95% confidence interval (CI): 1.64-3.50), heart failure (OR 2.14; 95% CI: 1.46-3.14), dementia (OR 2.12; 95% CI: 1.26-3.57), living alone (OR 2.00; 95% CI: 1.28-3.10), arterial hypertension (OR 1.63; 95% CI: 1.08-2.44) and cerebrovascular disease (OR 1.58; 95% CI: 1.03-2.44) significantly increased the risk of the presence of polypharmacy.

CONCLUSION

Our study confirmed a relatively high prevalence of polypharmacy in Slovak elderly patients. Polypharmacy risk rose especially with the increased prevalence of diseases of advancing age (diabetes mellitus, heart failure, arterial hypertension, dementia and cerebrovascular diseases). The increasing numbers of medications in inpatients indicate the need for the careful re-evaluation of pharmacotherapy during the stay in hospital.

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.

Is it possible to measure prescribing quality using only prescription data?

A large number of prescribing quality indicators based on register data have been proposed and many are used routinely in quality management. Often the content and face validity of indicators have been assessed by consensus methods, but studies analysing other validity aspects are scarce. Prescription data are frequently used for indicators, but they do not provide any direct information about disease and patient factors important for judging the quality of prescribing. If register-based proxies for diagnoses, disease severity or risk factors are employed, validation is essential. The concurrent validity of indicators should be assessed by comparing to a "gold standard" quality assessment at the patient level using all available clinical information. The validity of frequently used quality indicators of asthma treatment has been questioned and should be further investigated. NSAID prescribing indicators are currently under evaluation. In the future, detailed clinical information from practice databases and computerised hospital records will be an important data source for indicators and for validation studies. Furthermore, the statistical and epidemiological properties of prescribing quality indicators need more attention.

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.

General practitioners' ranking of evidence-based prescribing quality indicators: a comparative study with a prescription database

BACKGROUND

To ensure that indicators for assessing prescribing quality are appropriate and relevant, physicians should be involved in their development. How general practitioners (GPs) rank these indicators is not fully understood.

AIMS

(i) To determine how GPs in Ireland rank a set of evidence-based prescribing quality indicators in order of importance and relevance to their practice, and (ii) to compare the GPs' ranking of the defined set of indicators with actual prescribing practice using a prescription database.

METHODS

A postal questionnaire was sent to 105 GPs, who were asked to rank a set of 11 prescribing quality indicators, identified from the literature from most to least important. The results were aggregated and a weighted score for each indicator determined. These same prescribing indicators were then applied to a prescription database to compare the ranking provided with actual prescribing practice.

RESULTS

Eighty-six GPs (82%) returned the completed questionnaire. The higher ranks were for quality issues-use of inhaled corticosteroids, statins and benzodiazepines. Actual prescribing data showed prolonged use of benzodiazepines in over half of the prescriptions dispensed (n = 18 171), 52.48% (95% confidence interval 51.95, 53.01) and low usage of generic drugs, 17.78% (17.70, 17.90) despite their high ranking by the GPs.

CONCLUSION

While GPs have diverse views about the value of different prescribing quality indicators, the results suggest that they do rank evidence-based guidelines on patient management highly, but those based on costs and less evidence the lowest. There was considerable divergence between theory and practice in the application of quality indices.

Using aggregate data on dispensed drugs to evaluate the quality of prescribing in urban primary health care in Sweden

BACKGROUND

Valuable evaluations of the quality of drug prescribing in routine health care are difficult to perform. It is even more difficult to study prescribing in a non-gatekeeping healthcare system with a variety of caregivers involved in patient care. Consequently, there is a need to develop methods for evaluation using data available in routine health care.

OBJECTIVES

The aim of this study was to analyse possibilities and limitations for evaluation of the quality of drug prescribing using routinely collected aggregate data on dispensed drugs and health care provision. A secondary aim was to study the effects of allocating more resources to primary health care (PHC) on the quality of drug prescribing.

METHODS

The study was performed with routinely collected data from 10 PHC centres in Stockholm, Sweden that were participating in an intervention project that aimed to decrease the number of inhabitants per PHC doctor. Time periods for analysis were October-December 1999, 2000 and 2001. Data on dispensed prescriptions were analysed by age using Anatomical Therapeutic Chemical (ATC) classification/defined daily dose (DDD) methodology. The general quality of prescribing was determined using DU90% methodology (identifying the number of drugs constituting 90% of the volume expressed in DDDs and the adherence to evidence-based recommendations) and ratios between different treatment alternatives. The total volume and cost of drugs prescribed to the population was also analysed.

RESULTS

In 2001, PHC centres accounted for, on average, 27% (range 14-36%) of all doctor consultations and 32% (range 22-43%) of all prescriptions to populations in the corresponding primary care districts. There was great variation between the different PHC centres with regard to the prescribing doctors' compliance with guidelines from the regional drug and therapeutics committee, and the utilization of health care and drugs among the population in the corresponding primary care districts. No clear improvement was observed over time.

CONCLUSION

Analysis of aggregated prescription and healthcare data at population level was feasible. However, the effects of allocation of increasing resources to PHC on the quality of drug prescribing need to be analysed in a broader context.

The history of the Drug Utilization Research Group in Europe

Following the recommendations from a World Health Organization (WHO)/Euro symposium Consumption of drugs in 1969, a common classification system for drugs was developed, the Anatomical Therapeutic Chemical (ATC), and a technical unit of comparison, the Defined Daily Dose (DDD), as a comparative unit of drug use. This was found to be robust across therapeutic classifications, dosing forms and diverse populations. To maintain and develop the ATC/DDD system a WHO-Collaborating Centre was established in Oslo. As this was found to be of global interest the centre now reports to the WHO headquarters in Geneva. An informal WHO Drug Utilization Research Group (WHO-DURG), later the EuroDURG, has by now met 28 times in Europe. Since 1994 in Stockholm all these meetings have been with ISPE (International Society for Pharmacoepidemiology) when meeting in Europe. The main focus was initially to improve drug utilization through cross-national drug utilization studies based on the ATC/DDD methodology as they revealed large differences between and within countries that could not easily be explained by morbidity differences alone. These observed differences have led to the expansion of the area to include social, economic and qualitative methods with a more generalized public health focus. One of the most recent contributions was the development of drug use quality indicators.

Interventions to improve antibiotic prescribing practices for hospital inpatients

BACKGROUND

Up to 50% of antibiotic usage in hospitals is inappropriate. In hospitals infections caused by antibiotic-resistant bacteria are associated with higher mortality, morbidity and prolonged hospital stay compared with infections caused by antibiotic-susceptible bacteria. Clostridium difficile associated diarrhoea (CDAD) is a hospital acquired infection that is caused by antibiotic prescribing.

OBJECTIVES

To estimate the effectiveness of professional interventions that alone, or in combination, are effective in promoting prudent antibiotic prescribing to hospital inpatients, to evaluate the impact of these interventions on reducing the incidence of antimicrobial resistant pathogens or CDAD and their impact on clinical outcome.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) specialized register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE from 1980 to November 2003. Additional studies were obtained from the bibliographies of retrieved articles

SELECTION CRITERIA

We included all randomised and controlled clinical trials (RCT/CCT), controlled before and after studies (CBA) and interrupted time series (ITS) studies of antibiotic prescribing to hospital inpatients. Interventions included any professional or structural interventions as defined by EPOC.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data and assessed quality.

MAIN RESULTS

Sixty six studies were included and 51 (77%) showed a significant improvement in at least one outcome. Six interventions only aimed to increase treatment, 57 interventions aimed to decrease treatment and three interventions aimed to both increase and decrease treatment. The intervention target was the decision to prescribe antibiotics (one study), timing of first dose (six studies), the regimen (drug, dosing interval etc, 61 studies) or the duration of treatment (10 studies); 12 studies had more than one target. Of the six interventions that aimed to increase treatment, five reported a significant improvement in drug outcomes and one a significant improvement in clinical outcome. Of the 60 interventions that aimed to decrease treatment 47 reported drug outcomes of which 38 (81%) significantly improved, 16 reported microbiological outcomes of which 12 (75%) significantly improved and nine reported clinical outcomes of which two (22%) significantly deteriorated and 3 (33%) significantly improved. Five studies aimed to reduce CDAD. Three showed a significant reduction in CDAD. Due to differences in study design and duration of follow up it was only possible to perform meta-regression on a few studies.

AUTHORS' CONCLUSIONS

The results show that interventions to improve antibiotic prescribing to hospital inpatients are successful, and can reduce antimicrobial resistance or hospital acquired infections.