Flora M. Haaijer-Ruskamp

European Surveillance of Antimicrobial Consumption (ESAC): quality indicators for outpatient antibiotic use in Europe

Background and objective: Indicators to measure the quality of healthcare are increasingly used by healthcare professionals and policy makers. In the context of increasing antimicrobial resistance, this study aimed to develop valid drug-specific quality indicators for outpatient antibiotic use in Europe, derived from European Surveillance of Antimicrobial Consumption (ESAC) data. Methods: 27 experts (15 countries), in a European Science Foundation workshop, built on the expertise within the European Drug Utilisation Research Group, the General Practice Respiratory Infections Network, the ESCMID Study Group on Primary Care Topics, the Belgian Antibiotic Policy Coordination Committee, the World Health Organization, ESAC, and other experts. A set of proposed indicators was developed using 1997–2003 ESAC data. Participants scored the relevance of each indicator to reducing antimicrobial resistance, patient health benefit, cost effectiveness and public health policy makers (scale: 1 (completely disagree) to 9 (completely agree)). The scores were processed according to the UCLA-RAND appropriateness method. Indicators were judged relevant if the median score was not in the 1–6 interval and if there was consensus (number of scores within the 1–3 interval was fewer than one third of the panel). From the relevant indicators providing overlapping information, the one with the highest scores was selected for the final set of quality indicators—values were updated with 2004 ESAC data. Results: 22 participants (12 countries) completed scoring of a set of 22 proposed indicators. Nine were rated as relevant antibiotic prescribing indicators on all four dimensions; five were rated as relevant if only relevance to reducing antimicrobial resistance and public health policy makers was taken into account. A final set of 12 indicators was selected. Conclusion: 12 of the proposed ESAC-based quality indicators for outpatient antibiotic use in Europe have face validity and are potentially applicable. These indicators could be used to better describe antibiotic use in ambulatory care and assess the quality of national antibiotic prescribing patterns in Europe.

How physicians choose drugs.

A drug choice model which includes the physicians attitudes, norms and personal experiences with drugs, was tested. One hundred and sixty-nine physicians were asked to estimate the models components for the treatment of irritable bowel syndrome (IBS) and of renal colic. Given three drugs for both indications, the physicians gave their expectancies about the treatment outcomes, professional acceptability, patient demand and their personal experiences with the drugs. They also stated the value they assign to each of these components when choosing a drug for IBS and for renal colic. The influence of patient demand on the choice of a specific drug appeared to be negligible. The combined effect of the other three elements of the model predicted the stated drug of first choice correctly in 74% (for IBS) and 78% (for renal colic) of the cases, but further analysis showed that only the drug choices for renal colic were as reasoned as the model assumed. Expectancies and values about treatment outcomes determined the drug choice only in part. For choosing a drug for renal colic, the professional environment was more important. Moreover it was found that drug preferences were more related to expectancies about efficacy than to expectancies about side effects for both disorders. The findings can be useful when trying to change prescribing behaviour. Only a limited effect can be expected from the provision of technical drug information. Especially information about costs is unlikely to change prescribing easily, unless values and norms are changed as well. The importance of the professional environment implies that educational programmes in groups might be more effective than individual approaches.

Adverse drug reactions and polypharmacy in the elderly in general practice.

AbstractObjectives: The risk of adverse drug reactions (ADRs) increases with the number of drugs used. Most studies refer to potential interactions; the results regarding the severity of occurring and registered ADRs are inconsistent. Therefore, we examined the relevance of drug-induced problems in the elderly in general practice and their association with polypharmacy.nn Design: Retrospective cross-sectional analysis of prospectively collected data.nn Setting: Three family practices participating in the medication and morbidity Registration Network Groningen (RNG).nn Methods: From 2185 elderly patients (>64u2009years) medication and morbidity data were collected over the period of 2u2009years (1994 and 1995). Polypharmacy was defined as the long-term simultaneous use of two or more drugs. Adverse reactions recognised as such were coded as a separate `diagnosis A85. The most risky drug groups and the most prevalent diseases in relation to ADRs were studied.nn Results: The incidence of ADRs in general practice was 5.7 per 100 elderly patients and the prevalence 6.1 per 100. Moderate polypharmacy was more frequent in the elderly who experienced adverse effects; no other differences in degree of polypharmacy could be found. The elderly who experienced adverse reactions used overall more different drugs (14.4u2009±u20097.6, of which 1.5u2009±u20091.5 were used long term) than the other elderly patients (8.1u2009±u20095.7, of which 1.0u2009±u20091.5 were long term). The incidence of ADRs increased non-significantly with the number of drugs used long term. Antibiotics, antihypertensives and non-steroidal anti-inflammatory drugs were mainly responsible for gastrointestinal complaints (nausea, diarrhoea and stomach pain) and rash. In the cases of treating urinary tract infections and sleeping disorders, there was a significantly high risk of ADRs. Slightly more at risk for adverse drug reactions were older patients with coronary heart disease or asthma/chronic obstructive pulmonary disease.nn Conclusion: Most of the ADRs observed in general practice turn out to be rather harmless. This is in agreement with outpatient studies, though not with hospital studies. An increased risk of adverse effects with the number of drugs used simultaneously, as reported in other studies, was not confirmed in our study. This study however is limited to actually registered effects.

Soft regulations in pharmaceutical policy making: an overview of current approaches and their consequences.

It is a challenge to improve public health within limited resources. Pharmaceutical policy making is a greater challenge due to conflicting interests between key stakeholder groups. This paper reviews current and future strategies to help improve the quality and efficiency of care, with special emphasis on demand-side controls for pharmaceutical prescribing.A large number of different educational, organizational, financial and regulatory strategies have been applied in pharmaceutical policy making. However, the effectiveness of most strategies has not been thoroughly evaluated and there is evidence that the behaviour of healthcare professionals is difficult to influence with traditional methods. During the last decades, new modes of governing and new governing constellations have also appeared in healthcare. However, relationships between those who regulate and those regulated are often unclear. New approaches have recently been introduced, including extensive dissemination strategies for guidelines and extensive quality assessment programmes where physicians’ performances are measured against agreed standards or against each other. The main components of these ’soft regulations’ are standardization, monitoring and agenda setting. However, the impact of these new modes on health provision and overall costs is often unknown, and the increased focus on monitoring may result in a higher conformity and uniformity that may not always benefit all key stakeholders. Alongside this, a substantial growth of auditing associations controlling a diminishing minority of people actually performing the tasks may be costly and counter-productive.As a result, new effective strategies are urgently needed to help maintain comprehensive healthcare without prohibitively raising taxes or insurance premiums. This is especially important where countries are faced with extreme financial problems. Healthcare researchers may benefit from researching other areas of society. However, any potential strategies initiated must be adequately researched, debated and evaluated to enhance implementation. We hope this opinion paper is the first step in the process to develop and implement new demand-side initiatives building on existing ’soft regulations’.

Prescription of beta-blockers in patients with advanced heart failure and preserved left ventricular ejection fraction. Clinical implications and survival

The effects of β‐blockers in patients with heart failure (HF) and preserved left ventricular ejection fraction (LVEF) are not well established.

Cross-cultural differences in lay attitudes and utilisation of antibiotics in a Belgian and a Dutch city

Cultural differences are probably an important factor in the considerable variation in antibiotic use between countries. The objective of this study was to explore local cultural differences in the lay perspective on coping with URTD and using antibiotics. We interviewed 30 persons in a Dutch and a Belgian city. Twenty-one were interviewed a second time after 3 months. Between the first and second interview, they noted in a diary all URTD episodes experienced by themselves and their family members (N=69) and how they coped with them. The Dutch participants labelled most URTD episodes as common cold or flu. The Flemish participants labelled most of their URTD episodes as bronchitis and used more antibiotics. Four categories of antibiotic users could be distinguished. Participants with a Protestant background were more sceptical about medicines than those with a Catholic background. A thorough understanding of the cultural context is necessary to design effective campaigns to promote rational antibiotic use.

JOURNALISTS AND THEIR SOURCES OF IDEAS AND INFORMATION ON MEDICINES

In this article we describe from which sources science writers who write about medicines in daily newspapers get their ideas and information. This study was undertaken because mass media, and therefore newspapers, can play an important role in the diffusion of information about medicines. Two approaches, interviews and a content analysis, were used to answer the research questions. Both methods show the importance of professional medical journals and information from universities and their hospitals as sources of ideas and information. Although the pharmaceutical industry did not seem to play a role as source of ideas and information according to the journalists, it is the third most frequently cited source of information in the newspaper articles. To gain a better insight in the role of the pharmaceutical industry as source of ideas and information for newspaper journalists further research is necessary.

Indicators of prescribing quality in drug utilisation research: report of a European meeting (DURQUIM, 13-15 May 2004)

An invitational expert meeting on indicators of prescribing quality was held on 13–15 May 2004, bringing together—from 19 European countries, the US, Canada, and Australia—40 researchers specialized in the development and application of indicators. The meeting was organized by the European Drug Utilization Research Group (EuroDURG), the Belgian National Health Insurance Institute (RIZIV-INAMI), and the World Health Organisation Regional Office for Europe (WHO-Euro). The field of prescribing quality was defined and delineated from the medical error field. A conceptual grid for classifying quality indicators was discussed, combining two axes (a drug/disease/patient axis and a structure/process/outcome axis). In addition, available databases were listed for continuous monitoring of drug utilization in Europe, with a description of the content and the richness of the collected data, as well as the impact on the potential and limitations to develop quality indicators. The importance of the origin of data for validity assessment was stressed, as data on drug utilization may originate from physician sources (prescribing data), from pharmacist or health insurer sources (distribution data), or directly from patient sources (compliance data). The different aspects of validity and their methods of assessment were listed. An overview of the (in)appropriate uses of indicators was given. The state of the art of the development and application of prescribing quality indicators in all represented countries was made, together with a first draft of a database of prescribing quality indicators, already subjected to validation procedures.

The cost of prescription medicines to patients.

The study compares the cost-sharing (co-payment) arrangements for prescribed medicines in a sample of EU countries. Through a set of typical prescription scenarios, the cost burden to individual patients of prescriptions are examined, in the context of drug price, and from the perspective of therapeutic need. The cost to patients of medicines is consistently lower in some, and higher in other, countries, regardless of the type of prescription charge system. Fixed charge systems, as opposed to graduated co-payment systems, are obviously more likely to lead to similar charges for the treatment of comparable clinical conditions, but depending on the level of the charge, can result in the patient paying a higher charge than the price of the drug to the health organisation. Exemption from charges for prescription medicines, commonly relate to clinical condition and level of income. Some systems also have age-related criteria and apply ceilings to the total prescription cost burden borne by the patient. The impact on patient costs of specific policy formulations is discussed and a proposal is made for cost convergence for comparable therapies. The method used in this study may also provide a route for investigating model systems prior to implementation.

Improving drug treatment in general practice

In the international Drug Education Project, an educational program involving auditing and feedback in peer groups to improve the treatment of asthma and urinary tract infections (UTI) was developed and tested in primary care. Individualized feedback was provided and discussed in 24 Dutch peer groups showing doctors their prescribing practices and underlying reasons for treatment. A parallel, randomized controlled design was used to test the effect on competence and actual prescribing; in one study arm doctors received feedback on asthma treatment and in the other on UTI treatment. Especially the messages to treat asthma exacerbations with oral corticosteroids (17% increase) and to prescribe short courses for UTI (decrease duration of 1.8 days) brought about large improvements. Both messages concerned acute situations, and were clear and relatively easy for GPs to implement. GPs will experience more barriers when changing maintenance treatment of an asthma patient, which could explain the more limited success of this part of the educational program: the proportion of patients treated with inhaled corticosteroids increased 5%. A ceiling effect was experienced regarding drug choice for UTI.