Prescription data as a tool in pharmacotherapy audit (I). General considerations

Adherence to guideline recommendations for urinary tract infections in adult women: a cross-sectional study

AIM

To study whether changes in drug preferences in the Dutch guideline for the treatment of Urinary Tract Infection (UTI) for General Practitioners (GPs) in 2013, resulted in corresponding changes in antibiotic dispensing.

BACKGROUND

For the treatment of uncomplicated UTI, nitrofurantoin remained the first choice, while fosfomycin became the second choice and changed ranks with trimethoprim. For a subsequent febrile UTI, ciprofloxacin became the first choice and changed ranks with amoxicillin/clavulanic acid, co-trimoxazole remained the third choice.

METHODS

In this observational cross-sectional study, routinely collected dispensing data from the Dutch Foundation of Pharmaceutical Statistics from 2012 to 2017 were used. The number of women 18 years and older, treated with one of the guideline antibiotics for uncomplicated UTI and subsequent febrile UTI were analysed annually. Proportions were calculated. Data were stratified for age categories. Failure of uncomplicated UTI treatment was defined as the dispensing of an antibiotic for febrile UTI within 14 days after the dispensing of an antibiotic for uncomplicated UTI.

FINDINGS

Data were available from 81% of all pharmacies in 2012 to 89% in 2017. Percentages of women dispensed nitrofurantoin were relatively stable with 87.4% in 2012 and 84.4% in 2017. Percentages of women dispensed fosfomycin increased from 5.4% in 2012 to 21.8% in 2017, whereas percentages of women dispensed trimethoprim decreased from 17.8% to 8.0%. Within age categories, the percentage of women dispensed fosfomycin increased from 12.4% in women 18-30 years old to 36.7% in women above 80 years old. Percentages of women dispensed antibiotics for febrile UTI remained stable at 5% annually. Percentages of women receiving ciprofloxacin increased from 1.9% in 2012 to 3.3% in 2017, while those receiving amoxicillin/clavulanic acid decreased from 2.9% to 1.8%. New guideline recommendations resulted in corresponding changes in dispensed antibiotics for uncomplicated UTI and subsequent febrile UTI. Drug choices differed for age categories.

Systematic Reviews and Meta-analyses for Cardiology Fellows

Participating in a scholarly activity is one of the training requirements for cardiology fellows. However, it can be very challenging to complete a research project during such a busy period of clinical training. To help the cardiology fellows in choosing and starting off a research project, a light has been shed on the process of conducting a systematic review, and the importance of this research activity, as well as its limitations.

The nine-year sustained cost-containment impact of swiss pilot physicians-pharmacists quality circles

BACKGROUND

Six pioneer physicians-pharmacists quality circles (PPQCs) located in the Swiss canton of Fribourg (administratively corresponding to a state in the US) were under the responsibility of 6 trained community pharmacists moderating the prescribing process of 24 general practitioners (GPs). PPQCs are based on a multifaceted collaborative process mediated by community pharmacists for improving compliance with clinical guidelines within GPs' prescribing practices.

OBJECTIVE

To assess, over a 9-year period (1999-2007), the cost-containment impact of the PPQCs.

METHODS

The key elements of PPQCs are a structured continuous quality improvement and education process; local networking; feedback of comparative and detailed data regarding costs, drug choice, and frequency of prescribed drugs; and structured independent literature review for interdisciplinary continuing education. The data are issued from the community pharmacy invoices to the health insurance companies. The study analyzed the cost-containment impact of the PPQCs in comparison with GPs working in similar conditions of care without particular collaboration with pharmacists, the percentage of generic prescriptions for specific cardiovascular drug classes, and the percentage of drug costs or units prescribed for specific cardiovascular drugs.

RESULTS

For the 9-year period, there was a 42% decrease in the drug costs in the PPQC group as compared to the control group, representing a $225,000 (USD) savings per GP only in 2007. These results are explained by better compliance with clinical and pharmacovigilance guidelines, larger distribution of generic drugs, a more balanced attitude toward marketing strategies, and interdisciplinary continuing education on the rational use of drugs.

CONCLUSIONS

The PPQC work process has yielded sustainable results, such as significant cost savings, higher penetration of generics and reflection on patient safety, and the place of "new" drugs in therapy. The PPQCs may also constitute a solid basis for implementing more comprehensive collaborative programs, such as medication reviews, adherence-enhancing interventions, or disease management approaches.

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.

Prescribing indicators

BACKGROUND

Differences in prescribing behaviour among general practitioners (GPs).

AIM

To formulate and validate clinical prescribing indicators based on general practice guidelines.

DESIGN

Validatory study.

SETTING

Pharmacies and general practices in the Netherlands in 2003.

PARTICIPANTS

A total of 379 pharmacies, 947 general practices and 3.8 million patients.

METHODS

A total of 51 potential indicators were formulated, based on medicinal recommendations from the evidence-based guidelines of the Dutch College of General Practitioners and the corresponding recommendations from the Commission Pharmaceutical Help of the Health Care Insurance Board. These indicators were submitted to an expert panel to assess content validity. The panel assessment was analysed using the RAND-UCLA appropriateness method (RAM). Then, for the remaining indicators, it was assessed to what extent these could be used to determine the prescribing behaviour of GPs and the level to which this behaviour varies among GPs. This was done using a prescribing analyses and cost (PACT) database that was compiled from prescription databases from 379 pharmacies, with all prescriptions from 1,434 GPs over an entire year to 3.8 million patients.

RESULTS

The panel considered 34 of the 51 potential indicators to be valid with respect to providing an adequate reflection of the central recommendations in the guideline and in terms of relevance with respect to health gain and/or efficiency. Of these 34 indicators, 20 revealed considerable differences in the prescribing behaviour of GPs.

CONCLUSION

On the basis of existing general practice guidelines, 20 prescribing indicators could be formulated that were assessed by an expert panel to be sufficiently valid and which could also discriminate the prescribing behaviour of GPs as reflected in the prescription databases of pharmacies.

Drug utilisation 90% profiles--a useful tool for quality assessment of prescribing in primary health care in Stockholm

PURPOSE

To analyse strengths and weaknesses of a simple method for assessing the general quality of drug prescribing and to study the acceptance of the method among general practitioners (GPs).

METHODS

Prescriptions dispensed during October-December 1999 and 2000, respectively, were analysed for 38 Primary Health Care centres (PHC) in Stockholm participating in an intervention project with the aim of increasing cost-consciousness among GPs. Focus was on quality of prescribing rather than on costs. Prescribing profiles focusing on the number of drugs constituting 90% of the volume (= DU90%) and the adherence to local drug committee guideline within this segment were presented for the prescribers. The credibility and usefulness of the method was evaluated by a questionnaire.

RESULT

Among the PHCs, the total number of drugs prescribed varied between 358 and 674. The number of drugs in the DU90%-segment varied between 117 and 194. The adherence to guideline within this segment varied between 56% and 74% and increased over time. The prescribers found the DU90%-profiles clear and relevant and considered the method to be a useful tool for improving the quality of drug prescribing.

CONCLUSION

Providing DU90%-profiles with guideline adherence as feedback was shown to be a valuable tool in general practice for assessing the overall quality in prescribing and to form the basis for more disease- or patient-specific analyses.