Hugh McGavock

How has fundholding in Northern Ireland affected prescribing patterns? A longitudinal study

Abstract Objective: To compare prescribing patterns in general practices before and after the introduction of fundholding in April 1993 to determine whether fundholding changed prescribing patterns among practices that joined the scheme. Design: Analysis of prescribing data from the Drug Utilisation Research Units database for all practices in Northern Ireland during April 1989 to March 1996. Setting: Northern Ireland. Subjects: 23 first wave fundholders, 34 second wave fundholders, 9 third wave fundholders, and 268 non-fundholders. Main outcome measures: Prescribing costs per 1000 patients, prescription items per 1000 patients, average cost per item, and rate of generic prescribing. Results: Prescribing costs and frequency increased in all groups throughout the study. Among the fundholders the rate of increase in costs after fundholding was significantly lower than among non-fundholders. The rate of increase in cost per item fell, coinciding with a significant increase in the rate of generic prescribing. However, with regard to first wave fundholders, their yearly increase in costs in their third year as fundholders (1995-6) was similar to that of the non-fundholders. The earlier practices that joined the scheme seemed to differ in some important respects from those that joined later. Conclusions: After fundholders joined the fundholding scheme their patterns of prescribing changed compared with those of non-fundholders: the rate of increase in costs fell and there was a significant rise in the rate of generic prescribing. Key messages The effects of fundholding on prescribing costs have been disputed Fundholders in Northern Ireland contained the rate of increase in prescribing costs more effectively than non-fundholders Fundholders increased their rate of generic prescribing by an average of 13% in the first year of fundholding The incentive to make further savings may have diminished after two years of fundholding

STRATEGIES TO IMPROVE THE COST EFFECTIVENESS OF GENERAL PRACTITIONER PRESCRIBING: AN INTERNATIONAL PERSPECTIVE

SummaryPrescribing costs are rising in all developed countries. The positive reasons for this are improved screening for diseases, aging populations and better drugs. The negative reason is prescribers’ failure to use drugs cost effectively, i.e. in a scientifically and economically rational manner. It is for the latter reason that health administrators and managers, faced with cutbacks of other essential health provisions such as elective surgery, have found it necessary to intervene to attempt modification of general practitioner prescribing. This article describes the range of interventions in 3 continents, from the extreme of an essential drugs list to financial incentives and/or penalties for the patient and/or physician, to independent academic, educational interventions. The impact of hospital-initiated prescribing on general practice is briefly considered, as is the need to educate patients not to expect a prescription except when absolutely necessary. Finally, the inadequacy of medical school training in pharmacology and therapeutics is described, together with the need for formal postgraduate education in these topics for all prescribers, both general practitioner and hospital specialist.

The use of angiotensin converting enzyme inhibitors in general practice—appropriate or inappropriate?

Aims—To evaluate the pattern of prescribing of angiotensin‐converting enzyme (ACE) inhibitors in general practice, related to the primary clinical diagnosis and concomitant medication.

Peripheral vasodilators and the management of peripheral vascular disease and Raynaud's syndrome in general practice.

There is no convincing evidence that peripheral vasodilators produce any significant improvement in exercise tolerance in patients with peripheral vascular disease, and these drugs may do more harm than good. In the treatment of severe Raynauds syndrome, however, thymoxamine, prazosin or nifedipine is recommended. A descriptive study was carried out, firstly, to determine why these drugs are prescribed in general practice, and secondly, to describe the drug choices in the treatment of both Raynauds syndrome and peripheral vascular disease in a representative sample of 22 practices in Northern Ireland. Of those patients prescribed peripheral vasodilators 69·6% were diagnosed as peripheral vascular disease, claudication or atherosclerosis. Over three‐quarters of peripheral vasodilators prescribed were repeat prescriptions. Of those with Raynauds syndrome only half were treated appropriately, and certainty of diagnosis did not guarantee appropriate treatment. Peripheral vasodilators accounted for the majority (51·5%) of items prescribed for peripheral vascular disease. A minority of patients with peripheral vascular disease (20·3%) were prescribed aspirin, and a smaller minority (4·4%) had undergone amputation. Peripheral vasodilators were prescribed unnecessarily and inappropriately. Measures to promote evidence‐based treatment of both Raynauds syndrome and peripheral vascular disease in general practice need to be taken.

Temporal trends in drug use in one UK region, revealed by chemical group matching.

(1) The pharmaceutical pricing data for Northern Ireland were amended to include defined daily dosages (DDD) for all single chemical entities. Eight therapeutic groups were studied: antiasthmatics, antidepressants, antimicrobials, benzodiazepines, hormone replacement therapy (HRT), hypoglycaemics, lipid‐lowering agents and ulcer‐healing drugs. Each group was then subdivided into its main chemical groups. The regional use of each chemical group was defined as the combined DDDs of its individual chemical entities per quarter year, from January 1989 until December 1994. (2) During this period, drug use increased in all eight therapeutic groups and in most of their constituent chemical groups. Increased use of newer drugs did not cause the expected decrease in use of established drugs. Use of all broad‐spectrum antimicrobials increased by 314%. Use of sedative benzodiazepines decreased slowly and steadily (16%) throughout the study period but use of all hypnotics increased inexplicably by 21% in 1992 reaching a plateau in 1993 and 1994. SSRI antidepressant use increased sharply (5333%) following their introduction in 1989, accompanied by a 24% increase in use of tricyclic antidepressants. There was a 23626% increase in the use of proton pump inhibitors and a smaller but steady increase of 38% in use of histamine H2 antagonists; it is unlikely that much of the prescribing of anti‐ulcer and antimicrobials was accurately targeted and rationally defensible. (3) More positively, use of β2‐agonist inhalers increased by 45% despite a 254% increase in the use of inhaled steroids. Use of HRT increased by 389% though evidence of under‐use is given. There was a steady increase in the use of both insulins (28%) and oral hypoglycaemics (34%). The use of ‘statins’ (690%) and fibrates (123%) increased. (4) The possible interpretations and implications of these patterns of drug use is discussed, together with their potential as proxies for morbidity incidence in the community.

Research methodology: Coding perceived morbidity in general practice--an evaluation of the Read Classification and the International Classification of Primary Care (ICPC).

Objectives—To evaluate the Read Classification and the International Classification of Primary Care (ICPC).

Predicting Prescribing Costs in General Practice using Practice Demography

Prescription and dispensing costs form a large part (c. 56%) of primary care expenditure in the NHS and concern has been expressed at its ever increasing total. Previous predictive models have either failed to account for a high proportion of costs or else have not been able to explain adequately the role practice list demography plays upon costs. Using prescription data and the practice demography, our model accounts for 91.4% of the variation in primary health care prescribing costs in Northern Ireland thus explaining them to a much greater extent than previous models and, in addition, explains a large part of the variation in total monthly consultations and numbers of prescriptions. In addition to comprehensiveness it has a high degree of parsimony, needing only three independent variables for each practice, namely, the number of children aged 0–4 years, the number of persons aged 60+ years and the number of partners in the practice, all of which are immediately comprehensible by GPs and their negotiators. Thus, it could form a valuable addition to the ‘evaluation kit’ of prescribing advisers and others concerned with auditing and containing costs. Previous studies have shown the importance of the age–sex structure of practice lists in relation to prescribing costs but none has been able to develop such a powerful, simple and comprehensible predictive model.