Sarah Rodgers

GPs' views on computerized drug interaction alerts: questionnaire survey

Background: There is evidence that patients are being prescribed potentially hazardous drug–drug combinations in general practice despite the use of computerized drug interaction alert systems. One reason for this may be that general practitioners (GPs) are overriding these alerts without properly checking them.

Evaluation of the information needs of patients with chronic obstructive pulmonary disease following pulmonary rehabilitation: a focus group study

Aims: This study aimed to understand patient information needs and how best to meet them in order to improve rehabilitation provision and aid disease self-management by exploring experiences of people who had recently completed a pulmonary rehabilitation programme in a community hospital setting. Methods: Qualitative research using focus groups was undertaken with 23 patients who had completed pulmonary rehabilitation within the previous four months. The focus groups were tape-recorded and contemporaneous notes made. The tapes were transcribed verbatim and template analysis was used to develop themes. Findings: The key information needs were for a full understanding of the disease to be generated for patients, their families and the wider public much earlier in the disease process and preferably at the point of diagnosis. Patients perceived that they needed to come to terms with the condition. In order to improve disease self-management feelings of anxiety and frustration should to be addressed with the suggestion that individual counselling might be made available through the rehabilitation programme. The need for continued support was highlighted with an emphasis on peer group support activities. Conclusions: The findings have implications for primary care in terms of unmet needs in the early stages of the condition and pulmonary rehabilitation programmes in terms of providing individual counselling and ongoing peer group support to aid disease self-management. Chronic Respiratory Disease 2007; 4: 195—203

Examining variations in prescribing safety in UK general practice: cross sectional study using the Clinical Practice Research Datalink

Study question What is the prevalence of different types of potentially hazardous prescribing in general practice in the United Kingdom, and what is the variation between practices? Methods A cross sectional study included all adult patients potentially at risk of a prescribing or monitoring error defined by a combination of diagnoses and prescriptions in 526 general practices contributing to the Clinical Practice Research Datalink (CPRD) up to 1 April 2013. Primary outcomes were the prevalence of potentially hazardous prescriptions of anticoagulants, anti-platelets, NSAIDs, β blockers, glitazones, metformin, digoxin, antipsychotics, combined hormonal contraceptives, and oestrogens and monitoring by blood test less frequently than recommended for patients with repeated prescriptions of angiotensin converting enzyme inhibitors and loop diuretics, amiodarone, methotrexate, lithium, or warfarin. Study answer and limitations 49 927 of 949 552 patients at risk triggered at least one prescribing indicator (5.26%, 95% confidence interval 5.21% to 5.30%) and 21 501 of 182 721 (11.8%, 11.6% to 11.9%) triggered at least one monitoring indicator. The prevalence of different types of potentially hazardous prescribing ranged from almost zero to 10.2%, and for inadequate monitoring ranged from 10.4% to 41.9%. Older patients and those prescribed multiple repeat medications had significantly higher risks of triggering a prescribing indicator whereas younger patients with fewer repeat prescriptions had significantly higher risk of triggering a monitoring indicator. There was high variation between practices for some indicators. Though prescribing safety indicators describe prescribing patterns that can increase the risk of harm to the patient and should generally be avoided, there will always be exceptions where the indicator is clinically justified. Furthermore there is the possibility that some information is not captured by CPRD for some practices—for example, INR results in patients receiving warfarin. What this study adds The high prevalence for certain indicators emphasises existing prescribing risks and the need for their appropriate consideration within primary care, particularly for older patients and those taking multiple medications. The high variation between practices indicates potential for improvement through targeted practice level intervention. Funding, competing interests, data sharing National Institute for Health Research through the Greater Manchester Primary Care Patient Safety Translational Research Centre (grant No GMPSTRC-2012-1). Data from CPRD cannot be shared because of licensing restrictions.

To freeze or not to freeze: a cost-effectiveness analysis of wart treatment.

Background  Several general practitioner (GP)‐prescribed and over‐the‐counter therapies for warts and verrucae are available. However, the cost‐effectiveness of these treatments is unknown.

An embedded longitudinal multi-faceted qualitative evaluation of a complex cluster randomized controlled trial aiming to reduce clinically important errors in medicines management in general practice

BackgroundThere is a need to shed light on the pathways through which complex interventions mediate their effects in order to enable critical reflection on their transferability. We sought to explore and understand key stakeholder accounts of the acceptability, likely impact and strategies for optimizing and rolling-out a successful pharmacist-led information technology-enabled (PINCER) intervention, which substantially reduced the risk of clinically important errors in medicines management in primary care.MethodsData were collected at two geographical locations in central England through a combination of one-to-one longitudinal semi-structured telephone interviews (one at the beginning of the trial and another when the trial was well underway), relevant documents, and focus group discussions following delivery of the PINCER intervention. Participants included PINCER pharmacists, general practice staff, researchers involved in the running of the trial, and primary care trust staff. PINCER pharmacists were interviewed at three different time-points during the delivery of the PINCER intervention. Analysis was thematic with diffusion of innovation theory providing a theoretical framework.ResultsWe conducted 52 semi-structured telephone interviews and six focus group discussions with 30 additional participants. In addition, documentary data were collected from six pharmacist diaries, along with notes from four meetings of the PINCER pharmacists and feedback meetings from 34 practices. Key findings that helped to explain the success of the PINCER intervention included the perceived importance of focusing on prescribing errors to all stakeholders, and the credibility and appropriateness of a pharmacist-led intervention to address these shortcomings. Central to this was the face-to-face contact and relationship building between pharmacists and a range of practice staff, and pharmacists’ explicitly designated role as a change agent. However, important concerns were identified about the likely sustainability of this new model of delivering care, in the absence of an appropriate support network for pharmacists and career development pathways.ConclusionsThis embedded qualitative inquiry has helped to understand the complex organizational and social environment in which the trial was undertaken and the PINCER intervention was delivered. The longitudinal element has given insight into the dynamic changes and developments over time. Medication errors and ways to address these are high on stakeholders’ agendas. Our results further indicate that pharmacists were, because of their professional standing and skill-set, able to engage with the complex general practice environment and able to identify and manage many clinically important errors in medicines management. The transferability of the PINCER intervention approach, both in relation to other prescribing errors and to other practices, is likely to be high.

A prescription for improvement? An observational study to identify how general practices vary in their growth in prescribing costs

Abstract Objective: To identify how some general practices have low growth in prescribing costs relative to other practices. Design: Observational study. Setting: Trent region of England. Participants: 162 general practices: 54 with low growth in prescribing costs, 54 with average increases in costs, and 54 with large increases in costs. Main outcome measures: Changes in prescribing costs in therapeutic categories in which it has been suggested that savings can be made. Results: There were significant differences between the three groups of practices in terms of their changes in prescribing costs for almost all the variables studied. For the group of practices with lowest growth in costs the most important factors were reducing numbers of prescription items and costs per item; relatively low growth in the costs of “new and expensive” drugs; increasing generic prescribing; and reducing costs for modified release products. This group of practices did not increase costs as much as the others for lipid lowering drugs (P=0.012) and hormone replacement therapy (P=0.007). The practices with the greatest increases in costs had particularly large increases for proton pump inhibitors, selective serotonin reuptake inhibitors, and modified release products. Compared with the other groups these practices had larger increases in costs for “expensive hospital initiated drugs” (P=0.009). Conclusion: General practices vary in their growth in prescribing costs in many ways, with growth in costs for “new and expensive” drugs being particularly important.

Applying preventable drug-related morbidity indicators to the electronic patient record in UK primary care: methodological development

Background and objective:  Measuring and assessing the quality of health care services is an issue of high international importance. Providing data can be reliably extracted, making use of the electronic patient record (EPR) could help practitioners fulfil clinical governance obligations and ultimately improve the quality of patient care. The objective of this paper is to describe (i) the process used to apply a series of clinical indicators for preventable drug‐related morbidity (PDRM) in the EPR, (ii) problems encountered and (iii) our attempts to resolve them.

Use of Over the Counter Medicines in Children

Objective To assess the reasons for over‐the‐counter (OTC) medicine use in children and the sociodemographic factors influencing this choice of self‐care rather than GP consultation.

Drugs to support smoking cessation in UK general practice: are evidence based guidelines being followed?

Background: Prescribing drugs to support smoking cessation is one of the most cost effective interventions in primary care, but there is evidence they are underused. Little is known about how far guidelines have been adopted. Aims: To examine the context in which nicotine replacement therapy (NRT) and bupropion are prescribed in UK general practice and whether guidelines are being followed. Design: Patient questionnaire survey. Setting: Twenty five general practices from the Trent Focus Collaborative Research Network in South Yorkshire and East Midlands, UK. Methods: Participating practices posted a questionnaire to up to 40 patients prescribed NRT and bupropion respectively in the previous 3–9 months. Results: The response rate for people prescribed NRT was 44.7% (323/723) and for bupropion 42.5% (77/181). Patients reported initiating the prescription request in 258 cases (65%), whereas GPs were reported as suggesting it in 49 (12%), smoking cessation services (SCS) in 38 (10%), and practice nurses in 36 (9%). Of those who could recall the content of the consultation in which NRT or bupropion was prescribed, 191 (79%) reported receiving advice on treatment use and 209 (68%) were encouraged to set a quit date. Follow up by SCS was recommended to 186 (64%) and practice follow up was offered to 212 (63%), but 41 (15%) reported no offer of follow up support. Conclusions: The majority of patients reported receiving advice and follow up in line with guidelines. However, relatively few prescriptions were suggested by GPs or practice nurses and, in a significant minority of cases, neither follow up by the practice nor additional support from SCS was recommended. More active implementation of guidelines could increase the impact of general practice on the prevalence of smoking.

Understanding the epidemiology of avoidable significant harm in primary care: protocol for a retrospective cross-sectional study

Introduction Most patient safety research has focused on specialist-care settings where there is an appreciation of the frequency and causes of medical errors, and the resulting burden of adverse events. There have, however, been few large-scale robust studies that have investigated the extent and severity of avoidable harm in primary care. To address this, we will conduct a 12-month retrospective cross-sectional study involving case note review of primary care patients. Methods and analysis We will conduct electronic searches of general practice (GP) clinical computer systems to identify patients with avoidable significant harm. Up to 16 general practices from 3 areas of England (East Midlands, London and the North West) will be recruited based on practice size, to obtain a sample of around 100 000 patients. Our investigations will include an ‘enhanced sample’ of patients with the highest risk of avoidable significant harm. We will estimate the incidence of avoidable significant harm and express this as ‘per 100 000 patients per year’. Univariate and multivariate analysis will be conducted to identify the factors associated with avoidable significant harm. Ethics/Dissemination The decision regarding participation by general practices in the study is entirely voluntary; the consent to participate may be withdrawn at any time. We will not seek individual patient consent for the retrospective case note review, but if patients respond to publicity about the project and say they do not wish their records to be included, we will follow these instructions. We will produce a report for the Department of Healths Policy Research Programme and several high-quality peer-reviewed publications in scientific journals. The study has been granted a favourable opinion by the East Midlands Nottingham 2 Research Ethics Committee (reference 15/EM/0411) and Confidentiality Advisory Group approval for access to medical records without consent under section 251 of the NHS Act 2006 (reference 15/CAG/0182).