12 years on: coproxamol revisited

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.

Usage of paracetamol-containing combination analgesics remains high in primary care

AIMS

Paracetamol-containing combination analgesics are widely prescribed but the use of paracetamol/dextropropoxyphene (co-proxamol) is particularly controversial. We aim to examine the prescribing patterns of the paracetamol-containing analgesics in Ireland.

METHODS

A national primary care prescribing database was used to investigate patterns of usage. Twenty-six thousand three hundred and eighteen patients who were new to therapy with paracetamol and paracetamol-containing analgesics between January and June 2002 were identified as follows: no previous analgesic medication in the 6 months prior to enrolment into the study, and followed up for at least 12 months from the time of enrolment. Duration of therapy and the number of prescriptions received post enrolment were analyzed according to age. Odds ratios for receiving long-term (>1 month) compared with short-term (1 month) prescriptions for co-proxamol, paracetamol only or a paracetamol combination-type analgesic were calculated for women vs. men, and in those aged over 65 vs. those aged under 65 years.

RESULTS

Co-proxamol was the most commonly prescribed analgesic, accounting for 42% of all prescriptions dispensed during 2003. Long-term use of paracetamol-containing analgesic preparations was uncommon, with 56.7% receiving only 1 month's prescription during the study period. However, women (OR = 1.18, 95% CI 1.07, 1.28, P < 0.0001) and those over 65 years (OR = 1.71, 95% CI 1.57, 1.86, P < 0.0001) were more likely to receive a follow-up prescription for co-proxamol, but also for paracetamol (women, OR = 1.28, 95% CI 1.16, 1.39; over 65 year olds, OR = 2.67, 95% CI 2.44, 2.93) and the paracetamol combinations (women, OR = 1.33, 95% CI 1.20, 1.47; over 65 year olds, OR = 1.69, 95% CI 1.53, 1.87).

CONCLUSIONS

Co-proxamol was the most commonly prescribed paracetamol-containing analgesic preparation in Ireland. The results may indicate inappropriate use in primary care.

Co-proxamol and suicide: a study of national mortality statistics and local non-fatal self poisonings

OBJECTIVES

To examine the incidence of suicides due to co-proxamol compared with tricyclic antidepressants and paracetamol, and to compare fatality rates for self poisonings with these drugs.

DESIGN

Analysis of routinely collected national and local data on suicides and self poisonings.

SETTING

Records of suicides in England and Wales 1997-9; non-fatal self poisonings in Oxford District 1997-9.

DATA SOURCES

Office for National Statistics and Oxford monitoring system for attempted suicide.

MAIN OUTCOME MEASURES

Incidence of suicides with co-proxamol or tricyclic antidepressants or paracetamol. Ratios of fatal to non-fatal self poisonings.

RESULTS

Co-proxamol alone accounted for 5% of all suicides. Of 4162 drug related suicides, 18% (766) involved co-proxamol alone, 22% (927) tricyclic antidepressants alone, and 9% (368) paracetamol alone. A higher proportion of suicides in the 10-24 year age group were due to co-proxamol than in the other age groups. The odds of dying after overdose with co-proxamol was 2.3 times (95% confidence interval 2.1 to 2.5) that for tricyclic antidepressants and 28.1 times (24.9 to 32.9) that for paracetamol.

CONCLUSIONS

Self poisoning with co-proxamol is particularly dangerous and contributes substantially to drug related suicides. Restricting availability of co-proxamol could have an important role in suicide prevention.