Linking community pharmacy dispensing data to prescribing data of general practitioners

General practice variation in peptic ulcer prophylaxis: a nationwide register-based study

BACKGROUND

Incidence of peptic ulcer bleeding can be substantially reduced by prophylactic use of proton pump inhibitors (PPIs) in patients at risk, but use of PPI varies among risk patients, and substantial under-prescribing may exist. The variation in prophylactic prescribing among general practices remains unknown.

METHODS

A nationwide register-based cross-sectional study analyzing the proportion of patients at risk of ulcer bleeding receiving PPI treatment within Danish general practices. Using logistic regression, we analyze associations between general practice characteristics and prophylactic treatment among patients at risk of ulcer bleeding listed with the general practice.

RESULTS

In most general practices, less than 40% of the patients at increased risk of ulcer bleeding were covered by PPI. Geographical variation was present, where practice location outside the capital area was associated with higher odds of PPI coverage among their risk patients. Partnership practices with GPs with a mean age ≥65 years or with only female GPs were associated with higher odds of providing prophylaxis among their risk patients compared to practices with a mean GP age <45 years or with only male GPs. Similar associations were not found for single-handed practices.

CONCLUSIONS

A significant under-prescribing of ulcer prophylaxis is common across all general practice characteristics, and only few associations with practice characteristics were present. Most efforts to rationalize PPI prescribing have aimed at reducing overprescribing but the findings point to under-prescribing as a problem as well. Development of new methods to assist GPs in identifying individuals at risk of ulcer complications is needed.

Epidemiology of the zoonotic malaria Plasmodium knowlesi in changing landscapes

Within the past two decades, incidence of human cases of the zoonotic malaria Plasmodium knowlesi has increased markedly. P. knowlesi is now the most common cause of human malaria in Malaysia and threatens to undermine malaria control programmes across Southeast Asia. The emergence of zoonotic malaria corresponds to a period of rapid deforestation within this region. These environmental changes impact the distribution and behaviour of the simian hosts, mosquito vector species and human populations, creating new opportunities for P. knowlesi transmission. Here, we review how landscape changes can drive zoonotic disease emergence, examine the extent and causes of these changes across Southeast and identify how these mechanisms may be impacting P. knowlesi dynamics. We review the current spatial epidemiology of reported P. knowlesi infections in people and assess how these demographic and environmental changes may lead to changes in transmission patterns. Finally, we identify opportunities to improve P. knowlesi surveillance and develop targeted ecological interventions within these landscapes.

Linkage of primary care prescribing records and pharmacy dispensing Records in the Salford Lung Study: application in asthma

BACKGROUND

Records of medication prescriptions can be used in conjunction with pharmacy dispensing records to investigate the incidence of adherence, which is defined as observing the treatment plans agreed between a patient and their clinician. Using prescribing records alone fails to identify primary non-adherence; medications not being collected from the dispensary. Using dispensing records alone means that cases of conditions that resolve and/or treatments that are discontinued will be unaccounted for. While using a linked prescribing and dispensing dataset to measure medication non-adherence is optimal, this linkage is not routinely conducted. Furthermore, without a unique common event identifier, linkage between these two datasets is not straightforward.

METHODS

We undertook a secondary analysis of the Salford Lung Study dataset. A novel probabilistic record linkage methodology was developed matching asthma medication pharmacy dispensing records and primary care prescribing records, using semantic (meaning) and syntactic (structure) harmonization, domain knowledge integration, and natural language feature extraction. Cox survival analysis was conducted to assess factors associated with the time to medication dispensing after the prescription was written. Finally, we used a simplified record linkage algorithm in which only identical records were matched, for a naïve benchmarking to compare against the results of our proposed methodology.

RESULTS

We matched 83% of pharmacy dispensing records to primary care prescribing records. Missing data were prevalent in the dispensing records which were not matched - approximately 60% for both medication strength and quantity. A naïve benchmarking approach, requiring perfect matching, identified one-quarter as many matching prescribing records as our methodology. Factors associated with delay (or failure) to collect the prescribed medication from a pharmacy included season, quantity of medication prescribed, previous dispensing history and class of medication. Our findings indicate that over 30% of prescriptions issued were not collected from a dispensary (primary non-adherence).

CONCLUSIONS

We have developed a probabilistic record linkage methodology matching a large percentage of pharmacy dispensing records with primary care prescribing records for asthma medications. This will allow researchers to link datasets in order to extract information about asthma medication non-adherence.

A cooperation project between hospital pharmacists and general practitioners about drug interactions in clinical practice

Objectives

(1) To evaluate drug-drug interactions (DDIs) in general practitioners' (GPs) prescriptions; (2) to implement a cooperation project between pharmacists and GPs to improve DDI management and patient care.

Methods

In 2013, pharmacists from the Community Drug Assistance ASL TO1 launched a cooperation project involving 48 GPs. As a first step, GPs were asked to select, from a list, drug associations for which they recommended analysis of occurrence in their prescriptions. The pharmacists (1) analysed GPs' prescriptions dated 2012-2014, according to the list of DDIs selected (n= 9); (2) evaluated solutions for DDI management, using the Micromedex DDI checker database and literature analysis; they then (3) disseminated DDI-related information to GPs through training meetings and (4) assessed the efficacy of these actions through a questionnaire submitted to the GPs in 2013.

Results

(1) Prescriptions analysis: a reduction in the number of DDIs was observed (-14% in 2013 vs 2012, -9% in 2014 vs 2012); in some cases these reductions were statistically significant (calcium carbonate + proton pump inhibitors (PPIs) -50%, p<0.0041, amoxicillin+lansoprazole -42%, p<0.0088). (2) Questionnaire: this was completed by 75% of GPs. The literature analysis was considered interesting by 94% of GPs; solutions were adopted by 89% of GPs and 34% of GPs affirmed that clinical improvements after application of the measures were observed in their patients, even if they could not provide quantitative data for this outcome.

Conclusion

The cooperation project between pharmacists and GPs was effective because it established a professional exchange between the two health professionals. The pharmacist gave support to GPs, which benefited the patients, who gained clinical improvements and improved satisfaction with their medical care, as declared by the GPs in answers to the questionnaire.

The Effect of Pharmacotherapy Audit Meetings on Early New Drug Prescribing by General Practitioners

Background:

New drugs are cornerstones of clinical practice. However, when included in practice in an erratic fashion, there is valid concern about uncertain risk–benefit for patients and increased healthcare expenditures. In several countries, general practitioners (GPs) and pharmacists work closely together to ensure proper use of new drugs in clinical practice.

Objective:

To estimate the effect of pharmacotherapy audit meetings (PTAMs) between GPs and community pharmacists on prescribing of newly marketed drugs by GPs.

Methods:

We conducted an observational study of new drug prescribing in a cohort of 103 GPs, working in 59 practices, from 1999 until 2003. The main outcome measures were the decisions to start therapy with a new drug or with an existing older drug from the same therapeutic category within the first 6 months after market introduction. Multilevel modeling was used for analyses.

Results:

Overall, in 6.1% of the decisions to start drug therapy, GPs chose the drug that was most recently introduced into the market. The GPs attending lowquality PTAMs made 1861 decisions to start therapy; in 112 (6.0%) of those decisions, a new drug was preferred over an older alternative. GPs participating in high-quality PTAMs preferred a new drug in only 3.4% of the 3138 decisions made. Compared with GPs participating in PTAMs on the highest quality level (level 4), GPS attending level 1 or level 2 PTAMs were more than twice as likely to start therapy with new drugs than with older drugs (OR 2.24; 95% CI 1.04 to 4.81 vs OR 2.31; 95% CI 1.30 to 4.09, respectively).

Conclusions:

PTAMs may be an effective way to control early prescribing of new drugs in general practice. For PTAMs to be effective, it is vital that GPs and pharmacists set common goals on how to optimize pharmacotherapy. This concordance should be reflected in PTAMs that result in concrete decisions with auditing of GP prescribing behavior. Pharmacists should play an active role in organizing PTAMs to increase their influence on drug prescribing.

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.

Community pharmacy: an untapped patient data resource

As community pharmacy services become more patient centered, they will be increasingly reliant on access to good quality patient information. This review describes how the information that is currently available in community pharmacies can be used to enhance service delivery and patient care. With integration of community pharmacy and medical practice records on the horizon, the opportunities this will provide are also considered. The community pharmacy held patient medication record, which is the central information repository and has been used to identify non-adherence, prompts the pharmacist to clinically review prescriptions, identify patients for additional services, and identify those patients at greater risk of adverse drug events. While active recording of patient consultations for treatment over the counter may improve the quality of consultations and information held, the lost benefits of anonymity afforded by community pharmacies need to be considered. Recording of pharmacy staff activities enables the workload to be monitored, remuneration to be justified, critical incidents to be learned from, but is not routine practice. Centralization of records between community pharmacies enables practices to be compared and consistent problems to be identified. By integrating pharmacy and medical practice records, patient behavior with respect to medicines can be more closely monitored and should prevent duplication of effort. When using patient information stored in a community pharmacy, it is, however, important to consider the reason why the information was recorded in the first instance and whether it is appropriate to use it for a different purpose without additional patient consent. Currently, community pharmacies have access to large amounts of information, which, if stored and used appropriately, can significantly enhance the quality of provided services and patient care. Integrating the records increases opportunities to enhance patient care yet further. While community pharmacies have significant amounts of information available to them, this is frequently untapped.

Validation of three geolocation strategies for health-facility attendees for research and public health surveillance in a rural setting in western Kenya

Understanding the spatial distribution of disease is critical for effective disease control. Where formal address networks do not exist, tracking spatial patterns of clinical disease is difficult. Geolocation strategies were tested at rural health facilities in western Kenya. Methods included geocoding residence by head of compound, participatory mapping and recording the self-reported nearest landmark. Geocoding was able to locate 72·9% [95% confidence interval (CI) 67·7–77·6] of individuals to within 250 m of the true compound location. The participatory mapping exercise was able to correctly locate 82·0% of compounds (95% CI 78·9–84·8) to a 2 × 2·5 km area with a 500 m buffer. The self-reported nearest landmark was able to locate 78·1% (95% CI 73·8–82·1) of compounds to the correct catchment area. These strategies tested provide options for quickly obtaining spatial information on individuals presenting at health facilities.

Correspondence between general practitioner-reported medication use and timing of prescription dispensation

Epidemiologic studies often rely on drug dispensation records to measure medication intake. We aimed to estimate correspondence between general practitioner (GP)-reported treatment and timing of prescription dispensation. From seven GPs in northern Denmark, we obtained 317 prescription records for 286 patients treated with ten commonly prescribed medication types for chronic diseases. We linked the GP-reported information to the regional prescription database to retrieve patients’ prescription records both prospectively and retrospectively in relation to the GP-reported date of treatment (index date, August 20, 2008 for all patients). We computed overall and medication-specific correspondence between GP-reported treatment and the timing of dispensation. We computed correspondence based on both exact medication and therapeutic subgroup agreement. The correspondence for dispensation within ±90 days of GP-reported treatment was 0.81 (95% confidence interval = 0.76–0.85) with variation by medication type, ranging from 0.55 for ACE-inhibitors to 1.00 for oral glucose-lowering agents. The correspondence was greater when analyzed within therapeutic groups than when analyzed for exact medications within these groups.

What can primary care prescribing data tell us about individual adherence to long-term medication?-comparison to pharmacy dispensing data

PURPOSE

To assess the predictive value of general practice electronic prescribing records with respect to adherence to long-term medications as compared to claims-based pharmacy dispensing data.

METHODS

A total of 29772 electronic prescribing records relating to 2713 patients attending a New Zealand general medical practice were linked by national health identifier to 63 833 dispensing records used for community pharmacy reimbursement. Individual possession ratios-prescription possession ratio (PPR) for prescribing and medication possession ratio (MPR) for dispensing-were calculated for the 15-month period from 1 January 2006 to 30 March 2007 based on each data source for the common long-term medications simvastatin, metoprolol succinate, bendrofluazide, felodipine, cilazapril and metformin.

RESULTS

Out of 646 patients prescribed at least one of the six medications by the practice during the 15-month period, 50% of patients maintained high adherence (MPR > or = 80%) to all (out of the 6) medications that they were prescribed over the period, with rates of high adherence to individual medications ranging from 68 (felodopine) to 55% (metformin). In 93% of 4043 cases where there was a prescription in the general practice data, a subsequent dispensing record for the same patient and drug was present with a time-stamp no more than seven days later. PPR < 80% demonstrated a positive predictive value (PPV) of 81.4% (95%CI 78-85%) and negative predictive value (NPV) of 76.3% (95%CI 73-79%) for MPR < 80%.

CONCLUSION

There is potential for general practices to identify substantial levels of long-term medication adherence problems through their electronic prescribing records. Significant further adherence problems could be detected if an e-pharmacy network allowed practices to match dispensing against prescriptions.

Duration of antidepressant drug treatment and its influence on risk of relapse/recurrence: immortal and neglected time bias

Several observational studies have found a higher risk of recurrence/relapse of depression for patients who discontinue antidepressant use compared with those who continue. This study demonstrated that measurement of follow-up time can be subject to immortal and neglected time bias. Data were obtained from the 2001 Second Dutch National Survey of General Practice. The study population was composed of antidepressant users with a registered depression diagnosis, divided into early discontinuers and continuing users. Two methods were used to measure time to relapse/recurrence. Method 1, used in previously mentioned studies, measured the beginning of follow-up 6 months after starting antidepressant therapy. Method 2 constructed individual treatment episodes for each patient and measured follow-up from actual end-of-treatment episode. The Cox proportional hazards model produced a risk ratio of 1.58 (95% confidence interval: 1.02, 2.45) for method 1, suggesting a higher risk of relapse/recurrence for early discontinuers. In method 2, a statistically nonsignificant risk ratio of 0.77 (95% confidence interval: 0.49, 1.21) was produced, indicating no difference in risk of relapse/recurrence. The authors found the method used in previous studies subject to bias. Applying a different method, accounting for immortal and neglected time bias, eliminated the protective effects of longer treatments.

Initiation of antidepressant therapy: do patients follow the GP's prescription?

BACKGROUND

The question whether patients actually start drug taking after having received a first antidepressant prescription is often overlooked.

AIM

To determine the incidence of patients who do not fill or fill only a single antidepressant prescription at the pharmacy, and to identify associated patient characteristics.

DESIGN OF STUDY

Retrospective study linking a general practice to a pharmacy dispensing database.

SETTING

General practice in the Netherlands.

METHOD

STUDY POPULATION

patients who received a first-time antidepressant prescription from a GP. Three patient groups were identified: patients who did not fill the prescription (non-fillers); patients who filled only a single prescription (single Rx-fillers); and patients who filled at least two consecutive prescriptions. Non-fillers and single Rx-fillers were combined into a group of decliners.

RESULTS

Of all 965 patients, 41 (4.2%) did not fill the prescription, and 229 (23.7%) filled only a single prescription. Patients who consulted their GP for a non-specific indication, rather than for depression, anxiety, panic, or obsessive-compulsive disorder, were almost three times more likely (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.8 to 3.9) to decline treatment. Further, the risk of declining was almost fivefold higher (OR = 4.8, 95% CI = 2.1 to 11.3) in non-Western immigrants, and almost twofold higher (OR = 1.8, 95% CI = 1.2 to 2.8) in patients >60 years of age.

CONCLUSION

Over one in four patients who receive a first-time antidepressant prescription decline treatment; they either do not initiate drug taking or do not persist with antidepressant use for longer than 2 weeks.

Prescriber adoption of newly approved selective COX-2 inhibitors

INTRODUCTION

There is no consistent definition of prescribers who adopt new drug treatments early. This study examines if COX-2 inhibitors (coxibs) were prescribed by subsets of practitioners and describes GP adoption patterns of coxibs and existing NSAIDs over time.

METHODS

A population-based drug utilisation study using a Dutch medication claims database. Prescribers of patients (18+yrs) prescribed an NSAID January 1999-December 2003 were identified. Four NSAID categories were chosen reflecting selectivity (coxibs, preferential COX-2 inhibitors and non-selective (ns) NSAIDs (sub-categorised as first or second line treatment)). The characteristics of prescribers issuing>10 prescriptions examined were: Type (GP, Specialist, Other); GP NSAID prescribing preference ratio (nsNSAIDs/coxib first prescription); coxib (ratio<3); prescriber proportion responsible for 100%, 80% and 50% of initiations. Odds Ratios (95%CI) were calculated (first-line nsNSAIDs as reference). Plots of prescribing proportions by quarter year were examined.

RESULTS

NSAID cohorts comprised: first-line ns (N=38783); second-line ns (N=1459); COX-2 preferential (N=3107); coxib (N=4202) patients. For all four cohorts, GPs were the most common prescriber type (>67%); the most frequent prescribing preference was for first-line nsNSAIDs; 50% percentile prescribing proportions were low (<9%). GPs were equally as likely to prescribe coxibs as first-line nsNSAIDs [OR 1.0 (0.9, 1.1)]. Plots of 100% prescriber proportion for first-line nsNSAIDs and coxibs showed convergence; 50th percentile prescriber proportions plots were constant.

CONCLUSIONS

Small subsets of prescribers accounted for the majority of initiations regardless of NSAID type. Further studies are needed on such prescribers to inform healthcare policies and encourage participation in post-marketing safety studies.

The Long-Term Outcome of Medical Therapy for BPH

OBJECTIVES

The lack of cure with medical therapy implies life-long treatment emphasising the need for a thorough understanding of the long-term outcome. We review the natural history, markers for progression, placebo effect, efficacy, pharmacoeconomic aspects, and preventive measures.

METHODS

Literature review with particular reference to long-term controlled studies using plant extracts, alpha1-blockers, 5alpha-reductase inhibitors (5-ARIs), and combination therapy.

RESULTS

There is a long-lasting (>or=12 mo) placebo response of symptoms (20% decrease) and maximum flow rate (10% rise). The five long-term controlled trials of plant extracts are inconclusive and therefore their role in contemporary medical management is still controversial. The alpha1-blockers provide fast amelioration of symptoms yet have no relevant impact on the risk of acute urinary retention or surgery. Combination therapy should be reserved for moderately or severely symptomatic patients with a high risk of progression; in the majority of patients the alpha1-blocker can be safely stopped after 6-12 mo. The preventive use of 5-ARIs in men with no or mild symptoms at risk of progression is scientifically sound yet not generally accepted mainly for economic reasons.

CONCLUSIONS

A sharp contrast exists between the duration of the longest controlled trial (4.5 yr) and the situation in real life with treatment periods up to one or two decades of life. Real-life and registry data will be the only source of this important information in the future.

Patient risk profiles and practice variation in nonadherence to antidepressants, antihypertensives and oral hypoglycemics

BACKGROUND

Many patients experience difficulties in following treatment recommendations. This study's objective is to identify nonadherence risk profiles regarding medication (antidepressants, antihypertensives, and oral hypoglycemics) from a combination of patients' socio-demographic characteristics, morbidity presented within general practice and medication characteristics. An additional objective is to explore differences in nonadherence among patients from different general practices.

METHODS

Data were obtained by linkage of a Dutch general practice registration database to a dispensing registration database from the year 2001. Subjects included in the analyses were users of antidepressants (n = 4,877), antihypertensives (n = 14,219), or oral hypoglycemics (n = 2,428) and their GPs. Outcome variables were: 1) early dropout i.e., a maximum of two prescriptions and 2) refill nonadherence (in patients with 3+ prescriptions); refill adherence < 80% was considered as nonadherence. Multilevel modeling was used for analyses.

RESULTS

Both early dropout and refill nonadherence were highest for antidepressants, followed by antihypertensives. Risk factors appeared medication specific and included: 1) non-western immigrants being more vulnerable for nonadherence to antihypertensives and antidepressants; 2) type of medication influencing nonadherence in both antihypertensives and antidepressants, 3) GP consultations contributing positively to adherence to antihypertensives and 4) somatic co-morbidity influencing adherence to antidepressants negatively. There was a considerable range between general practices in the proportion of patients who were nonadherent.

CONCLUSION

No clear risk profiles for nonadherence could be constructed. Characteristics that are correlated with nonadherence vary across different types of medication. Moreover, both patient and prescriber influence adherence. Especially non-western immigrants need more attention with regard to nonadherence, for example by better monitoring or communication. Since it is not clear which prescriber characteristics influence adherence levels of their patients, there is need for further research into the role of the prescriber.

Prescription of benzodiazepines in general practice in the context of a man-made disaster: a longitudinal study

BACKGROUND

Mental health problems associated with benzodiazepine treatment are often highly prevalent in the aftermath of disasters. Nevertheless, not much is known about benzodiazepine use after disasters. Considering the negative effects associated with prolonged use and the adverse effects of benzodiazepines on recovery of patients with acute stress, the aim of the present study was to explore benzodiazepine use in the context of the Enschede fireworks disaster of 13 May 2000.

METHODS

A longitudinal study using electronic medical records of general practitioners. Subjects were patients aged 16 years and older, registered at one of the practices between 1999 and 2003 (1541 victims and 5370 references). Pre- and post-disaster data were available on benzodiazepine prescriptions, healthcare utilization and sociodemographic characteristics. Benzodiazepine use was defined using different criteria (e.g. any use, daily use, chronic use). Data were analysed using multivariate multilevel logistic regression analyses.

RESULTS

Compared with patients from a reference group, disaster victims were at increased risk of becoming an incident benzodiazepine user after the disaster. Benzodiazepine use also had a different time course among victims compared with references. However, daily or prolonged use of benzodiazepines was not often observed and did not show dramatic deviations among disaster victims compared with references.

CONCLUSION

There is no convincing evidence that general practitioners systematically deviated from clinical guidelines for benzodiazepines, which generally advocate their short time application.