Variation in formulary adherence in general practice over time (2003-2007)

Adoption of new medicines in primary care: A comparison between the uptake of new oral anticoagulants and diabetes medicines

AIMS

To gain insight in the uptake and practice variation in the prescription of 2 new medicine groups for common conditions in primary care (direct-acting oral anticoagulants [DOACs] and incretin-based therapies) from introduction, around 2007, to 2019 and the correlation between the adoption of those medicines in primary care.

METHODS

Prescription data from general practices in the Dutch Nivel Primary Care Database from 2007 to 2019 were used. The percentage of patients with prescriptions for DOACs of all patients with prescriptions for DOACs and vitamin K antagonists was calculated per practice per year, as was the percentage of patients prescribed incretin-based therapies as a proportion of all patients with diabetes medication. Multilevel models were used to estimate practice variation for DOACs and incretin-based therapies, expressed as intraclass correlation coefficients. Linear regression analysis was used to study the association between the prescription of DOACs and incretin-based therapies.

RESULTS

Per year, 46-424 general practices and 179 933-1 654 376 patients were included. In 2019, the mean percentage of patients per practice using DOACs or incretin-based therapies was 54.9 and 9.7%, respectively. The intraclass correlation coefficient decreased from 0.75 to 0.024 for DOACs and from 0.33 to 0.074 for incretin-based medicines during the study period. No clear correlation was found between the prescription of DOACs and incretin-based therapies.

CONCLUSION

DOACs and incretin-based therapies have different adoption profiles and practice variation is large, especially in the years before these medicines were introduced in guidelines. Early adopters of both medicine classes differ.

Non-adherence to guideline recommendations for insulins: a qualitative study amongst primary care practitioners

Background

Guideline adherence is generally high in Dutch general practices. However, the prescription of insulins to type 2 diabetes mellitus patients is often not in line with the guideline, which recommends NPH insulin as first choice and discourages newer insulins. This qualitative study aimed to identify the reasons why primary care healthcare professionals prescribe insulins that are not recommended in guidelines.

Methods

Digital focus groups with primary care practitioners were organised. A topic list was developed, based on reasons for preferred insulins obtained from literature and a priori expert discussions. The discussions were video and audio-recorded, transcribed verbatim and coded with a combination of inductive and deductive codes. Codes were categorized into an existing knowledge, attitudes and behaviour model for guideline non-adherence.

Results

Four focus groups with eleven general practitioners, twelve practice nurses, six pharmacists, four diabetes nurses and two nurse practitioners were organised. The prescription of non-recommended insulins was largely driven by argumentation in the domain of attitudes. Lack of agreement with the guideline was the most prominent category. Most of those perspectives did not reflect disagreement with the guideline recommendations in general, but were about advantages of non-recommended insulins, which led, according to the healthcare professionals, to better applicability of those insulins to specific patients. The belief that guideline-recommended insulins were less effective, positive experience with other insulins and marketing from pharmaceutical companies were also identified as attitude-related barriers to prescribe guideline-recommended insulins. One additional category in the domain of attitudes was identified, namely the lack of uniformity in policy between healthcare professionals in the same practice. Only a small number of external barriers were identified, focusing on patient characteristics that prevented the use of recommended insulins, the availability of contradictory guidelines and other, mostly secondary care, healthcare providers initiating non-recommended insulins. No knowledge-related barriers were identified.

Conclusions

The prescription of non-recommended insulins in primary care is mostly driven by lack of agreement with the guideline recommendations and different interpretation of evidence. These insights can be used for the development of interventions to stimulate primary care practitioners to prescribe guideline-recommended insulins.

Incentivizing appropriate prescribing in primary care: Development and first results of an electronic health record-based pay-for-performance scheme

OBJECTIVE

Part of the funding of Dutch General Practitioners (GPs) care is based on pay-for-performance, including an incentive for appropriate prescribing according to guidelines in national formularies. Aim of this paper is to describe the development of an indicator and an infrastructure based on prescription data from GP Electronic Health Records (EHR), to assess the level of adherence to formularies and the effects of the pay-for-performance scheme, thereby assessing the usefulness of the infrastructure and the indicator.

METHODS

Adherence to formularies was calculated as the percentage of first prescriptions by the GP for medications that were included in one of the national formularies used by the GP, based on prescription data from EHRs. Adherence scores were collected quarterly for 2018 and 2019 and subsequently sent to health insurance companies for the pay-for-performance scheme. Adherence scores were used to monitor the effect of the pay-for-performance scheme.

RESULTS

75% (2018) and 83% (2019) of all GP practicesparticipated. Adherence to formularies was around 85% or 95%, depending on the formulary used. Adherence improved significantly, especially for practices that scored lowest in 2018.

DISCUSSION

We found high levels of adherence to national formularies, with small improvements after one year. The infrastructure will be used to further stimulate formulary-based prescribing by implementing more actionable and relevant indicators on adherence scores for GPs.

Newer long-acting insulin prescriptions to type 2 diabetes patients: prevalence and practice variation

Background Little is known about the prescription of expensive non-recommended newer long-acting insulins (glargine 300 U/ml and degludec) for type 2 diabetes mellitus (T2DM) patients. Aim To identify practice variation in and practice and patient-related characteristics associated with the prescription of newer long-acting insulins to T2DM patients in primary care. Design and Setting Retrospective cohort study in Dutch general practices (Nivel Primary Care Database). Method The first prescription for intermediate or long-acting insulins in 2018 was identified for patients aged ≥40 using other T2DM drugs. Per practice, the median percentage and interquartile range (IQR) of patients with newer insulin prescriptions were calculated. Multilevel logistic regression models were constructed to calculate intraclass correlation coefficients (ICC) and quantify the association of patient and practice characteristics with prescriptions for newer insulins (odds ratio’s (OR) and 95% confidence intervals (CI)). Results 7,757 patients with prescriptions for intermediate or long-acting insulins from 282 general practices were identified. A median percentage of 21.2% (IQR=12.5-36.4%) of all patients prescribed intermediate or long-acting insulins per practice received a prescription for newer insulins. After multilevel modelling, the ICC decreased from 20% to 19%. Female sex (OR=0.77;95%CI=0.69–0.87), age ≥86 years compared to 40-55 years (OR=0.22;95%CI=0.15-0.34), prescriptions for metformin (OR=0.66;95%CI=0.53-0.82), sulphonylurea (OR=0.58;95%CI=0.51-0.66) or other newer T2DM drugs (OR=3.10;95%CI=2.63-3.66) and dispensing practices (OR=1.78;95%CI=1.03-3.10) were associated with the prescription of newer insulins. Conclusion The interpractice variation in the prescription of newer insulins is large and could only be partially explained by patient and practice related differences. This indicates substantial opportunities for improvement.

Trends in polypharmacy and dispensed drugs among adults in the Netherlands as compared to the United States

BACKGROUND AND PURPOSE

Polypharmacy is becoming increasingly common owing to the ageing population, which can pose problems for patients and society. We investigated the trends in polypharmacy and underlying drug groups among adults in the Netherlands from 1999 to 2014 stratified by age, and compared these with findings from the United States (US).

METHODS

We conducted a repeated cross-sectional study using the Dutch IADB.nl prescription database. All patients aged 20 years and older in the period 1999 to 2014 were included. Polypharmacy was defined as the dispensing of five or more chronic drugs at the pharmacological subgroup level. Chi-square tests were applied to calculate the p-value for trends. Changes in prevalences were compared between the Netherlands and the US.

RESULTS

The prevalence of polypharmacy increased from 3.1% to 8.0% (p-value for trend <0.001) over 15 years, and increased in all age groups. The highest rates were observed in patients aged ≥65 years, but the relative increase over time was higher in the younger age groups. Overall, large increases were observed for angiotensin-II inhibitors, statins and proton-pump inhibitors. The relative increase in polypharmacy was larger in the Netherlands than in the US (ratio of polypharmacy prevalence 2.4 versus 1.8). The Netherlands showed larger relative increases for angiotensin-II inhibitors, statins, proton-pump inhibitors, biguanides and smaller relative increases for antidepressants, benzodiazepines and insulins.

CONCLUSIONS

Polypharmacy more than doubled from 1999 to 2014, and this increase was not limited to the elderly. The relative increase was larger in the Netherlands compared to the US, which was partly due to larger increases in several guideline-recommended preventive drugs.

Recent Initiatives in the Republic of Srpska to Enhance Appropriate Use of Antibiotics in Ambulatory Care; Their Influence and Implications

Introduction: There are increasing concerns world-wide with growing rates of antibiotic resistance necessitating urgent action. There have been a number of initiatives in the Republic of Srpska in recent years to address this and improve rational antibiotic prescribing and dispensing despite limited resources to fund multiple initiatives. Objective: Analyse antibiotic utilization patterns in the Republic of Srpska following these multiple initiatives as a basis for developing future programmes in the Republic if needed. Methods: Observational retrospective study of total outpatient antibiotic utilization from 2010 to 2015, based on data obtained from the Public Health Institute, alongside documentation of ongoing initiatives to influence utilization. The quality of antibiotic utilization principally assessed according to ESAC, ECDC, and WHO quality indicators and DU 90% (the drug utilization 90%) profile as well as vs. neighboring countries. Results: Following multiple initiatives, antibiotic utilization remained relatively stable in the Republic at 15.6 to 18.4 DIDs, with a decreasing trend in recent years, with rates comparable or lower than neighboring countries. Amoxicillin and the penicillins accounted for 29-40 and 50% of total utilization, respectively. Overall, limited utilization of co-amoxiclav (7-11%), cephalosporins, macrolides, and quinolones, as well as low use of third and fourth generation cephalosporins vs. first and second cephalosporins. However, increasing utilization of co-amoxiclav and azithromycin, as well as higher rates of quinolone utilization compared to some countries, was seen. Conclusions: Multiple interventions in the Republic of Srpska in recent years have resulted in one of the lowest utilization of antibiotics when compared with similar countries, acting as an exemplar to others. However, there are some concerns with current utilization of co-amoxiclav and azithromycin which are being addressed. This will be the subject of future research activities.

Is there a conflict between general practitioners applying guidelines for antibiotic prescribing and including their patients' preferences?

OBJECTIVES

One perceived barrier to guideline adherence is the existence of conflicting patient preferences. We examined whether patient preferences influence the prescription of antibiotics in general practice, and how this affects guideline adherence. We hypothesized that preferences play a larger role in prescribing antibiotics if the guideline allows for preferences to be taken into account, ie, if prescribing antibiotics is an option which can be considered rather than a clear recommendation to prescribe or not. We included three guidelines: acute cough, acute rhinosinusitis, and urinary tract infections.

METHODS

Data from NIVEL (the Netherlands Institute for Health Services Research) Primary Care Database (NIVEL-PCD) were used to assess antibiotic indications and prescriptions. These data were combined with a questionnaire among members of NIVEL's Dutch Health Care Consumer Panel to examine patient preferences. According to NIVEL-PCD, 286 of these members contacted their general practitioner (GP) in 2015 for acute cough, acute rhinosinusitis or urinary tract infections. A logistic multilevel regression analysis was performed to test our hypothesis.

RESULTS

Patient preferences do play a role in GPs' prescribing of antibiotics only in situations where, in accordance with the guideline, their use is an option which could be considered (interaction between indication and preference: p=0.049). If patients ask for antibiotics themselves in such situations, then GPs prescribe antibiotics more often.

CONCLUSION

Patient preferences only play a role if the guideline provides room to take preferences into account. Therefore, our results do not suggest a conflict between applying guidelines and including patient preferences. Further research is recommended to examine this possible conflict in other situations.

Assessment of prescribing practices at the primary healthcare facilities in Botswana with an emphasis on antibiotics: Findings and implications

BACKGROUND AND AIMS

Inappropriate drug prescribing has increased especially in developing countries where systems for monitoring medicine use are not well developed. This increases the rate of antimicrobial resistance. The study aim was to assess the prescribing patterns among urban primary health facilities in Botswana to provide future guidance including developing future quality indicators.

METHODS

Retrospective data from patients' records between January and December 2013 in 19 clinics were collected in a cross-sectional study. The WHO/International Network for Rational Use of Drugs indicators were used to assess prescribing patterns in the study clinics.

RESULTS

Average number of drugs per prescription was 2.8; 78.6% of the prescribed antibiotics were by International Non-proprietary Name and 96.1% complied with the Botswana Essential Drugs List. Overall rate of antibiotic prescribing was high (42.7%) with 14.7%, 5.9% and 1.3% of prescriptions having two, three and four antibiotics, respectively. Systemic antibiotics (JO1C) accounted for 45.4% of prescribed antibiotics of which amoxicillin accounted for 28.4% and metronidazole 14.4% of all antibiotic prescriptions. There was low use of co-amoxiclav (0.3% of all antibiotic prescriptions). Third generation cephalosporins and macrolides accounted for 9.8% and 6.2% of antibiotic prescriptions respectively, with no prescribing of fluoroquinolones. The majority of indications (87%) for antibiotic prescriptions were according to ICD classification.

CONCLUSIONS

While most indications for antibiotic prescriptions were based on signs and symptoms according to ICD, antibiotic prescribing rates were high with some conditions not requiring antibiotics because they are viral infections. There is a need to further improve prescribing practices through induction and training of in-service prescribers. An effective management tool for monitoring antibiotic prescribing practices at Primary Health Care facilities should be designed and implemented, including developing robust quality indicators.

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.

A multifaceted approach to decrease inappropriate antibiotic use in a pediatric outpatient clinic

BACKGROUND:

Inappropriate use of antimicrobial agents is the major cause for the development of resistance. Thus, it is important to include outpatient clinics in the development of antibiotic stewardship program.

METHODS:

We report a multifaceted approach to decrease inappropriate antibiotic use in upper respiratory tract infections (URTIs) in an outpatient pediatric clinic. The interventions included educational grand round, academic detailing, and prospective audit and feedback and peer comparison.

RESULTS:

During the study period, a total of 3677 outpatient clinic visits for URTIs were evaluated. Of all the included patients, 12% were <1 year of age, 42% were 1–5 years, and 46% were >5 years of age. Of the total patients, 684 (17.6%) received appropriate antibiotics, 2812 (76.4%) appropriately did not receive antibiotics, and 217 (6%) inappropriately received antibiotics. The monthly rate of prescription of inappropriate antibiotics significantly decreased from 12.3% at the beginning of the study to 3.8% at the end of the study (P < 0.0001). Antibiotic prescription among those who had rapid streptococcal antigen test (RSAT) was 40% compared with 78% among those who did not have RSAT (P < 0.0001).

CONCLUSIONS:

The combination of education and academic detailing is important to improve antibiotic use.

The Clinical and Economic Impact of Probiotics Consumption on Respiratory Tract Infections: Projections for Canada

INTRODUCTION

There is accumulating evidence supporting the use of probiotics, which are defined as "live micro-organisms which, when administered in adequate amounts, confer a health benefit on the host", as a preventive measure against respiratory tract infections (RTI). Two recent meta-analyses showed probiotic consumption (daily intake of 107 to 1010 CFU in any form for up to 3 months) significantly reduced RTI duration, frequency, antibiotic use and work absenteeism.

OBJECTIVES

The aim of this study was to assess the impact of probiotic use in terms of number of RTI episodes and days averted, and the number of antibiotic prescriptions and missed workdays averted, in the general population of Canada. In addition, the corresponding economic impact from both a healthcare payer and a productivity perspective was estimated.

METHODS

A microsimulation model was developed to reproduce the Canadian population (sample rate of 1/1000 = 35 540 individuals) employing age and gender. RTI incidence was taken from FluWatch consultation rates for influenza-like illness (2013-14) and StatCan all-cause consultations statistics. The model was calibrated on a 2.1% RTI annual incidence in the general population (5.2 million RTI days) and included known risk factors (smoking status, shared living conditions and vaccination status). RTI-related antibiotic prescriptions and work absenteeism were obtained from the literature.

RESULTS

The results indicate that probiotic use saved 573 000-2.3 million RTI-days, according to the YHEC-Cochrane scenarios respectively. These reductions were associated with an avoidance of 52 000-84 000 antibiotic courses and 330 000-500 000 sick-leave days. A projection of corresponding costs reductions amounted to Can$1.3-8.9 million from the healthcare payer perspective and Can$61.2-99.7 million when adding productivity losses.

CONCLUSION

The analysis shows that the potential of probiotics to reduce RTI-related events may have a substantial clinical and economic impact in Canada.

Inter-practice variation in polypharmacy prevalence amongst older patients in primary care

PURPOSE

Complex medication management in older people with multiple chronic conditions can introduce practice variation in polypharmacy prevalence. This study aimed to determine the inter-practice variation in polypharmacy prevalence and examine how this variation was influenced by patient and practice characteristics.

METHODS

This cohort study included 45,731 patients aged 55 years and older with at least one prescribed medication from 126 general practices that participated in NIVEL Primary Care Database in the Netherlands. Medication dispensing data of the year 2012 were used to determine polypharmacy. Polypharmacy was defined as the chronic and simultaneous use of at least five different medications. Multilevel logistic regression models were constructed to quantify the polypharmacy prevalence variation between practices. Patient characteristics (age, gender, socioeconomic status, number, and type of chronic conditions) and practice characteristics (practice location and practice population) were added to the models.

RESULTS

After accounting for differences in patient and practice characteristics, polypharmacy rates varied with a factor of 2.4 between practices (from 12.4% to 30.1%) and an overall mean of 19.8%. Age and type of conditions were highly positively associated with polypharmacy, and to a lesser extent a lower socioeconomic status.

CONCLUSIONS

Considerable variation in polypharmacy rates existed between general practices, even after accounting for patient and practice characteristics, which suggests that there is not much agreement concerning medication management in this complex patient group. Initiatives that could reduce inappropriate heterogeneity in medication management can add value to the care delivered to these patients. Copyright © 2016 John Wiley & Sons, Ltd.

Reducing antibiotic prescriptions for respiratory tract infections in family practice: results of a cluster randomized controlled trial evaluating a multifaceted peer-group-based intervention

Irrational antibiotic use for respiratory tract infections (RTI) is a major driver of bacterial resistance. The aim of this study was to evaluate the effect of a multifaceted peer-group based intervention aiming to reduce RTI-related antibiotic prescriptions in family practice. This was a cluster randomized controlled trial with pre- and follow-up measurement. The intervention was implemented through PharmacoTherapy Audit Meetings (PTAM) in which family physicians (FPs) and pharmacists collaborate. Four PTAM groups received the intervention consisting of: (1) FP communication skills training, including communication about delayed prescribing; (2) implementation of antibiotic prescribing agreements in FPs’ Electronic Prescribing Systems; (3) quarterly feedback figures for FPs. Four other PTAM groups were matched controls. Primary outcome measure was the number of RTI-related antibiotic prescriptions after the intervention, assessed with multilevel linear regression analyses. Total number and number of prescriptions stratified by age (under/over 12 years) were analysed. At baseline, the average total number of RTI-related antibiotic prescriptions per 1,000 patients was 207.9 and 176.7 in the intervention and control PTAM groups, respectively. At follow-up, FPs in both the intervention and control groups prescribed significantly less antibiotics. For adolescents and adults, the drop in number of antibiotic prescription was significantly larger in the intervention groups (−27.8 per 1,000 patients) than the control groups (−7.2 per 1,000 patients; P<0.05). This multifaceted peer-group-based intervention was effective in reducing the number of RTI-related antibiotic prescriptions for adolescents and adults. To affect antibiotic prescribing in children other methods are needed.