Prescriber variation in potentially inappropriate prescribing in older populations in Ireland

Caitriona Cahir,Kathleen Bennett,Tom Fahey,Conor Teljeur

doi:10.1186/1471-2296-15-59

Abstract

BackgroundHealth care policy-makers look for prescribing indicators at the population level to evaluate the performance of prescribers, improve quality and control drug costs. The aim of this research was to; (i) estimate the level of variation in potentially inappropriate prescribing (PIP) across prescribers in the national Irish older population using the STOPP criteria; (ii) estimate how reliably the criteria could distinguish between prescribers in terms of their proportion of PIP and; (iii) examine how PIP varies between prescribers and by patient and prescriber characteristics in a multilevel regression model.Methods1,938 general practitioners (GPs) with 338,375 registered patients’ ≥70 years were extracted from the Health Service Executive Primary Care Reimbursement Service (HSE-PCRS) pharmacy claims database. HSE-PCRS prescriptions are WHO ATC coded. Demographic data for claimants’ and prescribers’ are available. Thirty STOPP indicators were applied to prescription claims in 2007. Multilevel logistic regression examined how PIP varied between prescribers and by individual patient and prescriber level variables.ResultsThe unadjusted variation in PIP between prescribers was considerable (median 35%, IQR 30-40%). The STOPP criteria were reliable measures of PIP (average >0.8 reliability). The multilevel regression models found that only the patient level variable, number of different repeat drug classes was strongly associated with PIP (>2 drugs v none; adjusted OR, 4.0; 95% CI 3.7, 4.3). After adjustment for patient level variables the proportion of PIP varied fourfold (0.5 to 2 times the expected proportion) between prescribers but the majority of this variation was not significant.ConclusionPIP is of concern for all prescribers. Interventions aimed at enhancing appropriateness of prescribing should target patients taking multiple medications.

Highlights

Health care policy-makers look for prescribing indicators at the population level to evaluate the performance of prescribers, improve quality and control drug costs
The variation between general practitioners (GPs) in the overall rate of potentially inappropriate prescribing (PIP) was considerable ranging from 13% at the 5th percentile to 65% at the 95th percentile
Common cause variation is when the values are within the 2 standard deviation (SD) and 3 SD lines and special cause variation is when the values are outside the 3 SD lines

Summary

Introduction

Health care policy-makers look for prescribing indicators at the population level to evaluate the performance of prescribers, improve quality and control drug costs. Clinical practice guidelines and prescribing indicators have become a common feature in many healthcare systems in an attempt to reduce unwarranted physician variation in medical care, improve quality and control drug costs [1]. Quantifying and understanding the variation in PIP is important for planning interventions and the development of guidelines and incentives to improve prescribing quality in older populations [1]. It can provide information for performance management purposes by identifying prescribers with high rates of PIP for further investigation [9]

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