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Chiedozie C, Murphy ME, Fahey T, Moriarty F. How many medications do doctors in primary care use? An observational study of the DU90% indicator in primary care in England. BMJ Open 2021; 11:e043049. [PMID: 33653750 PMCID: PMC7929869 DOI: 10.1136/bmjopen-2020-043049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
AIM To apply the drug utilisation 90% (DU90%) indicator (the number of unique drugs which makes up 90% of a doctor's prescribing) to general practitioner (GP) practices prescribing in England to examine time trends, practice-level variation, and relationships with practice characteristics, prescribing costs and low-value prescribing. STUDY DESIGN Retrospective cohort study. SETTING Primary care in England, using publicly available prescribing data available from the National Health Service (NHS) digital platform for 2013-2017. PARTICIPANTS All general practices in England (n=7620). PRIMARY AND SECONDARY OUTCOME MEASURES The DU90% was calculated on an annual basis for each practice based on medication British National Formulary codes. Low-value prescribing was defined using NHS 2017 guidance (including lidocaine plasters, liothyronine, omega-3 supplements). Descriptive statistics were generated per year on time trends and practice-level variation in the DU90%. Multilevel linear regression was used to examine the practice characteristics (relating to staff, patients and deprivation of the practice area). RESULTS Among 7620 practices, mean DU90% ranged from 130.0 to 131.0 across study years, and regarding variation between practices, there was a 1.4-fold difference between the lowest and highest 5% of practices. A range of medications were included in the DU90% of virtually all practices, including atorvastatin, levothyroxine, omeprazole, ramipril, amlodipine, simvastatin and aspirin. A higher volume of prescribing was associated with a lower DU90%, while having more patients, higher proportions of patients who are women or aged ≥45 years, higher number of GPs working in the practice and being in a more deprived area were associated with a higher DU90%. Practices in higher quintiles of DU90% had higher levels of low-priority prescribing and prescribing costs. CONCLUSION GP practices typically use 130 different medications in the bulk of their prescribing. Higher DU90% was associated with higher levels of low-priority prescribing and prescribing costs. Increasing use of personal formularies may enhance prescribing quality and reduce costs.
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Affiliation(s)
- Chiamaka Chiedozie
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Mark E Murphy
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Frank Moriarty
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Schmidt-Mende K, Andersen M, Wettermark B, Hasselström J. Educational intervention on medication reviews aiming to reduce acute healthcare consumption in elderly patients with potentially inappropriate medicines-A pragmatic open-label cluster-randomized controlled trial in primary care. Pharmacoepidemiol Drug Saf 2017; 26:1347-1356. [PMID: 28799226 DOI: 10.1002/pds.4263] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 05/08/2017] [Accepted: 06/15/2017] [Indexed: 11/10/2022]
Abstract
PURPOSE Potentially inappropriate medicines (PIMs) may cause 10% of unplanned admissions in elderly people. We performed an educational intervention in primary care to reduce acute health care consumption and PIMs through the promotion of medication reviews (MRs) in elderly patients. METHODS This cluster-randomized controlled trial was conducted in the context of an official campaign promoting rational drug use in elderly people. Sixty-nine primary health care practices with 119,910 patients aged older than or equal to 65 were randomized, with 1 dropout in the intervention group. The intervention consisted of educational outreach visits with feedback on prescribing and the development of a working procedure on MRs. Follow-up was 9 months. Outcomes were assessed in an administrative health care database. The combined primary outcome was unplanned hospital admission and/or emergency department visit. Secondary outcomes were among other PIMs and rates of MRs. The risk differences in outcomes between intervention and control group were estimated by using regression models. RESULTS During follow-up, 22.8% of patients in the intervention and 22.0% in the control group were admitted unplanned to hospital and/or experienced at least 1 emergency department (nonsignificant risk difference 0.8%, 95% CI -0.7% to 2.4%). There were no significant differences regarding secondary outcomes such as PIMs or MRs. CONCLUSIONS No changes were seen in acute health care consumption, PIMs, and MRs in elderly patients after an educational intervention in primary care. The reasons for the lack of effect could be a suboptimal intervention, limitations in outcome measures, and the use of administrative data to monitor outcomes.
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Affiliation(s)
- K Schmidt-Mende
- Academic Primary Health Care Centre, Stockholm County Council and Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Huddinge, Sweden
| | - M Andersen
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Centre for Pharmacoepidemiology, Department of Medicine Solna, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.,Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - B Wettermark
- Centre for Pharmacoepidemiology, Department of Medicine Solna, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.,Public Healthcare Services Committee, Stockholm County Council, Stockholm, Sweden
| | - J Hasselström
- Academic Primary Health Care Centre, Stockholm County Council and Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Huddinge, Sweden
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Engqvist I, Wyss K, Asker-Hagelberg C, Bergman U, Odar-Cederlöf I, Stiller CO, Fryckstedt J. Which Medication Is the Patient Taking at Admission to the Emergency Ward? Still Unclear Despite the Swedish Prescribed Drug Register. PLoS One 2015; 10:e0128716. [PMID: 26068920 PMCID: PMC4466313 DOI: 10.1371/journal.pone.0128716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 04/29/2015] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Correct information on patients' medication is crucial for diagnosis and treatment in the Emergency Department. The aim of this study was to investigate the concordance between the admission chart and two other records of the patient's medication. METHODS This cohort study includes data on 168 patients over 18 years admitted to the Emergency Ward between September 1 and 30, 2008. The record kept by the general practitioner and the patient record of dispensed drugs in the Swedish Prescribed Drug Register were compared to the admission chart record. RESULTS Drug record discrepancies of potential clinical significance between the admission chart record and the Swedish Prescribed Drug Register or general practitioner record were present in 79 and 82 percent, respectively. For 63 percent of the studied patients the admission chart record did not include all drugs registered in the Swedish Prescribed Drug Register. For 62 percent the admission chart record did not include all drugs registered in the general practitioner record. In addition, for 32 percent of the patients the admission chart record included drugs not registered in the Swedish Prescribed Drug Register and for 52 percent the admission chart record included drugs not found in the general practitioner record. The most discordant drug classes were cardiovascular and CNS-active drugs. Clinically significant drug record discrepancies were more frequent in older patients with multiple medication and caregivers. CONCLUSION The apparent absence of an accurate record of the patient's drugs at admission to the Emergency Ward constitutes a potential patient safety hazard. The available sources in Sweden, containing information on the drugs a particular patient is taking, do not seem to be up to date. These results highlight the importance of an accurate list of currently used drugs that follows the patient and can be accessed upon acute admission to the hospital.
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Affiliation(s)
- Ida Engqvist
- Karolinska Institutet, Department of Medicine, Department of Emergency Medicine, Karolinska University Hospital Solna, SE 171 76, Stockholm, Sweden
| | - Katja Wyss
- Karolinska Institutet, Department of Medicine, Department of Emergency Medicine, Karolinska University Hospital Solna, SE 171 76, Stockholm, Sweden
| | - Charlotte Asker-Hagelberg
- Karolinska Institutet, Department of Medicine, Clinical Pharmacology Unit, Karolinska University Hospital, Stockholm, Solna, SE 171 76, Stockholm, Sweden
- Medical Products Agency, P.O. box 26, SE 751 03, Uppsala, Sweden
| | - Ulf Bergman
- Karolinska Institutet, Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska University Hospital, Huddinge, SE 141 86, Stockholm, Sweden
- Karolinska Institutet, Centre for Pharmacoepidemiology, Department of Medicine, Karolinska University Hospital Solna, SE 171 76, Stockholm, Sweden
| | - Ingegerd Odar-Cederlöf
- Karolinska Institutet, Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska University Hospital, Huddinge, SE 141 86, Stockholm, Sweden
| | - Carl-Olav Stiller
- Karolinska Institutet, Department of Medicine, Clinical Pharmacology Unit, Karolinska University Hospital, Stockholm, Solna, SE 171 76, Stockholm, Sweden
| | - Jessica Fryckstedt
- Karolinska Institutet, Department of Medicine, Department of Emergency Medicine, Karolinska University Hospital Solna, SE 171 76, Stockholm, Sweden
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Milos V, Westerlund T, Midlöv P, Strandberg EL. Swedish general practitioners' attitudes towards treatment guidelines - a qualitative study. BMC FAMILY PRACTICE 2014; 15:199. [PMID: 25511989 PMCID: PMC4276045 DOI: 10.1186/s12875-014-0199-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 11/17/2014] [Indexed: 11/21/2022]
Abstract
Background Drug therapy in primary care is a challenge for general practitioners (GPs) and the prescribing decision is influenced by several factors. GPs obtain drug information in different ways, from evidence-based sources, their own or others’ experiences, or interactions with opinion makers, patients or colleagues. The need for objective drug information sources instead of drug industry-provided information has led to the establishment of local drug and therapeutic committees. They annually produce and implement local treatment guidelines in order to promote rational drug use. This study describes Swedish GPs’ attitudes towards locally developed evidence-based treatment guidelines. Methods Three focus group interviews were performed with a total of 17 GPs working at both public and private primary health care centres in Skåne in southern Sweden. Transcripts were analysed by conventional content analysis. Codes, categories and themes were derived from data during the analysis. Results We found two main themes: GP-related influencing factors and External influencing factors. The first theme emerged when we put together four main categories: Expectations and perceptions about existing local guidelines, Knowledge about evidence-based prescribing, Trust in development of guidelines, and Beliefs about adherence to guidelines. The second theme included the categories Patient-related aspects, Drug industry-related aspects, and Health economic aspects. The time-saving aspect, trust in evidence-based market-neutral guidelines and patient safety were described as key motivating factors for adherence. Patient safety was reported to be more important than adherence to guidelines or maintaining a good patient-doctor relationship. Cost containment was perceived both as a motivating factor and a barrier for adherence to guidelines. GPs expressed concerns about difficulties with adherence to guidelines when managing patients with drugs from other prescribers. GPs experienced a lack of time to self-inform and difficulties managing direct-to-consumer drug industry information. Conclusions Patient safety, trust in development of evidence-based recommendations, the patient-doctor encounter and cost containment were found to be key factors in GPs’ prescribing. Future studies should explore the need for transparency in forming and implementing guidelines, which might potentially increase adherence to evidence-based treatment guidelines in primary care.
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Affiliation(s)
- Veronica Milos
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden. .,Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Clinical Research Centre (CRC), Skåne University Hospital, building 28, floor 11, Jan Waldenströms gata 35, 205 02, Malmö, Sweden.
| | - Tommy Westerlund
- Medical Products Agency, Department of Medicine Usage, Uppsala and Sahlgrenska Academy, Department of Public Health and Community Medicine, Unit of Social Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
| | - Patrik Midlöv
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden.
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The right drug, but from whose perspective? A framework for analysing the structure and activities of drug and therapeutics committees. Eur J Clin Pharmacol 2013; 69 Suppl 1:79-87. [PMID: 23640192 PMCID: PMC3642357 DOI: 10.1007/s00228-013-1491-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 02/19/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE During the last five decades drug and therapeutics committees (DTCs), have evolved from mainly hospital-based groups of experts in pharmacotherapy and drug logistics into an arena for healthcare professionals employing evidence-based methods of promoting rational drug use. The purpose of this study was to suggest a framework for analysing the structure and activities of DTCs. METHODS A literature search was carried out in the Medline, Cinahl and Web of Sciences databases for the period 1993-2012. RESULTS A total of 207 articles were included. Based on these articles a framework for the analysis of the DTCs based on the role of the DTC, target groups, budget perspective and type of economic decisions could be suggested. CONCLUSIONS In order to respond to future demands the DTCs will have to develop their skill in pharmacoeconomics. Their processes will have to be standardised and made more transparent in order to be better adapted to evidence-based decision-making. They will also have to embrace the possibilities created by electronic health records in both influencing the decisions of physicians, and in improving quality assurance programmes and longitudinal follow-up of drug therapy and outcomes. They will have to find new ways of interacting with the public and policy makers in order to get the resources needed for their work. Finally, they will have to handle the conflict among national, regional and local decision-making processes and the relationship between formularies and therapeutic guidelines.
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Rahmner PB, Gustafsson LL, Holmström I, Rosenqvist U, Tomson G. Whose job is it anyway? Swedish general practitioners' perception of their responsibility for the patient's drug list. Ann Fam Med 2010; 8:40-6. [PMID: 20065277 PMCID: PMC2807387 DOI: 10.1370/afm.1074] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Information about the patient's current drug list is a prerequisite for safe drug prescribing. The aim of this study was to explore general practitioners' (GPs) understandings of who is responsible for the patient's drug list so that drugs prescribed by different physicians do not interact negatively or even cause harm. The study also sought to clarify how this responsibility was managed. METHODS We conducted a descriptive qualitative study among 20 Swedish physicians. We recruited the informants purposively and captured their view on responsibility by semistructured interviews. Data were analyzed using a phenomenographic approach. RESULTS We found variation in understandings about who is responsible for the patient's drug list and, in particular, how the GPs use different strategies to manage this responsibility. Five categories emerged: (1) imposed responsibility, (2) responsible for own prescriptions, (3) responsible for all drugs, (4) different but shared responsibility, and (5) patient responsible for transferring drug information. The relation between categories is illustrated in an outcome space, which displays how the GPs reason in relation to managing drug lists. CONCLUSIONS The understanding of the GP's responsibility for the patient's drug list varied, which may be a threat to safe patient care. We propose that GPs are made aware of variations in understanding responsibility so that health care quality can be improved.
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Affiliation(s)
- Pia Bastholm Rahmner
- Department of Drug Management and Informatics, Stockholm County Council, Sweden.
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de Bakker DH, Coffie DSV, Heerdink ER, van Dijk L, Groenewegen PP. Determinants of the range of drugs prescribed in general practice: a cross-sectional analysis. BMC Health Serv Res 2007; 7:132. [PMID: 17711593 PMCID: PMC2045668 DOI: 10.1186/1472-6963-7-132] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2006] [Accepted: 08/22/2007] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Dinny H de Bakker
- NIVEL Netherlands institute for health services research, PO Box 1568, Utrecht, The Netherlands
| | - Dayline SV Coffie
- NIVEL Netherlands institute for health services research, PO Box 1568, Utrecht, The Netherlands
| | - Eibert R Heerdink
- Utrecht University, Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht, The Netherlands
| | - Liset van Dijk
- NIVEL Netherlands institute for health services research, PO Box 1568, Utrecht, The Netherlands
| | - Peter P Groenewegen
- NIVEL Netherlands institute for health services research, PO Box 1568, Utrecht, The Netherlands
- Utrecht University, Department of Human Geography and Department of Sociology, Utrecht, The Netherlands
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