Prescribing In Primary Care Research Articles

Practice variation in opioid prescribing for non-cancer pain in Dutch primary care: A retrospective database study.

Prescription opioid use has increased steadily in many Western countries over the past two decades, most notably in the US, Canada, and most European countries, including the Netherlands. Especially the increasing use of prescription opioids for chronic non-cancer pain has raised concerns. Most opioids in the Netherlands are prescribed in general practices. However, little is known about variation in opioid prescribing between general practices. To better understand this, we investigated practice variation in opioid prescribing for non-cancer pain between Dutch general practices. Data from 2017-2019 of approximately 10% of all Dutch general practices was used. Each year included approximately 1000000 patients distributed over approximately 380 practices. The primary outcome was the proportion of patients with chronic (>90 days) high-dose (≥90 oral morphine equivalents) opioid prescriptions. The secondary outcome was the proportion of patients with chronic (<90 oral morphine equivalents) opioid prescriptions. Practice variation was expressed as the ratio of the 95th/5th percentiles and the ratio of mean top 10/bottom 10. Funnel plots were used to identify outliers. Potential factors associated with unwarranted variation were investigated by comparing outliers on practice size, patient neighbourhood socioeconomic status, and urbanicity. Results were similar across all years. The magnitude of variation for chronic high-dose opioid prescriptions in 2019 was 7.51-fold (95%/5% ratio), and 15.1-fold (top 10/bottom 10 ratio). The percentage of outliers in the funnel plots varied between 13.8% and 21.7%. Practices with high chronic high-dose opioid prescription proportions were larger, and had more patients from lower income and densely populated areas. There might be unwarranted practice variation in chronic high-dose opioid prescriptions in primary care, pointing at possible inappropriate use of opioids. This appears to be related to socioeconomic status, urbanicity, and practice size. Further investigation of the factors driving practice variation can provide target points for quality improvement and reduce inappropriate care and unwarranted variation.

Therapeutic inertia related to the injectable glucagon-like peptide-1 receptor agonists dulaglutide and semaglutide in patients with type 2 diabetes in UK primary care.

To determine the extent of therapeutic inertia related to the weekly injectable glucagon-like peptide-1 receptor agonists dulaglutide and semaglutide in patients with type 2 diabetes (T2D) in the United Kingdom. Adults with T2D who received their first primary care prescription of dulaglutide or semaglutide between January and July 2019 were identified from the UK Clinical Practice Research Datalink GOLD primary care database. Doses prescribed, glycated haemoglobin (HbA1c), body mass index (BMI) and concomitant T2D medications were assessed at first prescription and at 3, 6 and 9months. Of the patients prescribed dulaglutide (N=748; mean [SD] age 59.0 [11.2] years) and semaglutide (N=437; mean [SD] age 58.4 [10.6] years), 93.0% and 89.0%, respectively, had an HbA1c level ≥7.5%(≥58.46mmol/mol), and 56.4% and 54.9%, respectively, had an HbA1c level ≥9.0%(≥74.86mmol/mol), at first prescription. At 6 to 9 months, 75.0% of those on dulaglutide 0.75 mg and 57.6% of those on semaglutide 0.25 mg or 0.5 mg had an HbA1c level ≥7.5%(≥58.46mmol/mol). At 9 months, 21.9% of the dulaglutide cohort were on the suboptimal dose of 0.75 mg, and 46.1% of the semaglutide cohort were on the suboptimal doses of 0.25 mg or 0.5mg. Multiple examples of therapeutic inertia were identified, including first prescription at HbA1c levels considerably above target and failure to escalate to optimal doses even with evidence of suboptimal metabolic control. A substantial proportion of patients therefore did not achieve optimal HbA1c targets.

Effect of Antibiotic Prescription Audit and Feedback on Antibiotic Prescribing in Primary Care

Antibiotics are commonly prescribed in primary care, increasing the risk of antimicrobial resistance in the population. To investigate the effect of quarterly audit and feedback on antibiotic prescribing among primary care physicians in Switzerland with medium to high antibiotic prescription rates. This pragmatic randomized clinical trial was conducted from January 1, 2018, to December 31, 2019, among 3426 registered primary care physicians and pediatricians in single or small practices in Switzerland who were among the top 75% prescribers of antibiotics. Intention-to-treat analysis was performed using analysis of covariance models and conducted from September 1, 2021, to January 31, 2022. Primary care physicians were randomized in a 1:1 fashion to undergo quarterly antibiotic prescribing audit and feedback with peer benchmarking vs no intervention for 2 years, with 2017 used as the baseline year. Anonymized patient-level claims data from 3 health insurers serving roughly 50% of insurees in Switzerland were used for audit and feedback. The intervention group also received evidence-based guidelines for respiratory tract and urinary tract infection management and community antibiotic resistance information. Physicians in the intervention group were blinded regarding the nature of the trial, and physicians in the control group were not informed of the trial. The claims data used for audit and feedback were analyzed to assess outcomes. Primary outcome was the antibiotic prescribing rate per 100 consultations during the second year of the intervention. Secondary end points included overall antibiotic use in the first year and over 2 years, use of quinolones and oral cephalosporins, all-cause hospitalizations, and antibiotic use in 3 age groups. A total of 3426 physicians were randomized to the intervention (n = 1713) and control groups (n = 1713) serving 629 825 and 622 344 patients, respectively, with a total of 4 790 525 consultations in the baseline year of 2017. In the entire cohort, a 4.2% (95% CI, 3.9%-4.6%) relative increase in the antibiotic prescribing rate was noted during the second year of the intervention compared with 2017. In the intervention group, the median annual antibiotic prescribing rate per 100 consultations was 8.2 (IQR, 6.1-11.4) in the second year of the intervention and was 8.4 (IQR, 6.0-11.8) in the control group. Relative to the overall increase, a -0.1% (95% CI, -1.2% to 1.0%) lower antibiotic prescribing rate per 100 consultations was found in the intervention group compared with the control group. No relevant reductions in specific antibiotic prescribing rates were noted between groups except for quinolones in the second year of the intervention (-0.9% [95% CI, -1.5% to -0.4%]). This randomized clinical trial found that quarterly personalized antibiotic prescribing audit and feedback with peer benchmarking did not reduce antibiotic prescribing among primary care physicians in Switzerland with medium to high antibiotic prescription rates. ClinicalTrials.gov Identifier: NCT03379194.

Digitally deployed, GP remote consultation video intervention that aims to reduce opioid prescribing in primary care: protocol for a mixed-methods evaluation

IntroductionOpioid prescribing rates are disproportionately high in the North of England. In addition to patients’ complex health needs, clinician prescribing behaviour is also a key driver. Although strategies have been...

Improving antimicrobial stewardship in general practice

Reducing inappropriate antibiotic prescribing in primary care is a key element of antimicrobial stewardship. This study carried out in GP surgeries in Cornwall examined whether clarithromycin was being prescribed in accordance with NICE guidance, and whether allergy status and symptoms were correctly recorded in the case of patients who had penicillin allergy noted.

Project on exceptional dispensation in the Principality of Asturias

Community pharmacy (CF) is daily confronted with situations that prevent the proper dispensing of medication, putting at risk the continuity of treatment by patients, which causes medication-related problems (DRPs). In this pilot study, carried out in the Principality of Asturias, the aim was to quantify the number of incidents of this type related to those aspects of the prescription that could be easily corrected by the community pharmacist through simple interventions at the time of dispensing. It was carried out in ten pharmacies in this autonomous community during normal opening hours over fifteen working days. The sample included a total of 32,331 containers dispensed. A total of 406 incidences of exceptional dispensing were recorded. The total incidence rate reached 1.26% of the dispensations, which extrapolating to the total number of dispensations made in Asturias during the month of October 2020 would give us a figure of 27,030 total dispensations susceptible to exceptional dispensing.The total incidence rate was lower in urban pharmacies (1.03%) compared to semi-urban and rural pharmacies (1.37% and 1.39%). Most of the cases (59.4 %) involved patients with an individual contribution to the Health System corresponding to 10 % (TSI2) and the mean age of the patient was 60.8 years. Regarding the level of care, 79% of the cases corresponded to Primary Care (PC) prescriptions. The most common type of incidence is "potential interruption due to prescription not active at the time of dispensing (exceeding the 10-day margin)" with an incidence rate of 0.61 % of the dispensations, which would mean a total of 13,181 prescriptions susceptible to exceptional dispensing due to this type of incidence.In terms of economic savings, it was found that 63 of the 406 cases would have necessarily required a medical consultation and 30% of them would have been for active patients. Therefore, the remaining 343 cases, which could be resolved through exceptional dispensing by the community pharmacist, would mean a saving of more than 4,000 consultations and nearly 200,000 euros in direct and indirect costs if the pharmacist were allowed to intervene.

An audit of antibiotic prescribing in primary care 2019-2020 in Dunmanway Primary Care Centre.

Antibiotics are often the most common medication prescribed by general practitioners (GPs) and are often expected by patients despite campaigns such as Under the Weather. Antibiotic resistance is increasing in the community. The Health Service Executive (HSE) has issued 'Guidelines for Antimicrobial Prescribing in Primary Care in Ireland' aiming to optimise safe prescribing. This audit aims to analyse change in quality of prescribing after educational intervention. GP prescribing patterns were analysed over a week in October 2019 and re-audited in February 2020. Anonymous questionnaires detailed demographics, condition and antibiotic details. Educational intervention included texts, information and review of current guidelines. Data were analysed on a password protected spreadsheet. The HSE Guidelines for Antimicrobial Prescribing in Primary Care were taken as reference standard. A standard of 90% compliance for choice of antibiotic and 70% compliance for dose and course was agreed. FindingsAuditRe-AuditNumber prescriptions4024Number delayed scripts4/40=10%1/24=4.2%Adult37/40=92.5%19/24=79.2%Child3/40=7.5%5/24=20.8%IndicationURTI22.50%25%LRTI10%4%Other RTI37.50%42%UTI20%29%Skin12.50%0%Gynaecological2.50%0%2+ Infections 5%0%Co-amoxiclav17.50%12.50%AdherenceChoice37/40=92.5%22/24=91.7%Dose28/39=71.8%17/24=70.8%Course28/40=70%12/24=50%Discussion: Excellent antibiotic choice and dose concordance with guidelines was noted, with both phases meeting the set standards. Suboptimal course compliance with guidelines occurred in the re-audit. Potential causes include concerns regarding resistance and patient factors not included. This audit included unequal number of prescriptions in each phase but are still of significance and addresses a clinically relevant topic.

The Effectiveness of Interactive Dashboards to Optimise Antibiotic Prescribing in Primary Care: A Systematic Review.

Governments and healthcare organisations collect data on antibiotic prescribing (AP) for surveillance. This data can support tools for visualisations and feedback to GPs using dashboards that may prompt a change in prescribing behaviour. The objective of this systematic review was to assess the effectiveness of interactive dashboards to optimise AP in primary care. Six electronic databases were searched for relevant studies up to August 2022. A narrative synthesis of findings was conducted to evaluate the intervention processes and results. Two independent reviewers assessed the relevance, risk of bias and quality of the evidence. A total of ten studies were included (eight RCTs and two non-RCTs). Overall, seven studies showed a slight reduction in AP. However, this reduction in AP when offering a dashboard may not in itself result in reductions but only when combined with educational components, public commitment or behavioural strategies. Only one study recorded dashboard engagement and showed a difference of 10% (95% CI 5% to 15%) between intervention and control. None of the studies reported on the development, pilot or implementation of dashboards or the involvement of stakeholders in design and testing. Interactive dashboards may reduce AP in primary care but most likely only when combined with other educational or behavioural intervention strategies.

Team-based primary care reforms and older adults: a descriptive assessment of sociodemographic trends and prescribing endpoints in two Canadian provinces

BackgroundTeam-based primary care reforms aim to improve care coordination by involving multiple interdisciplinary health professionals in patient care. Team-based primary care may support improved medication management for older adults with polypharmacy and multiple points of contact with the healthcare system. However, little is known about this association. This study compares sociodemographic and prescribing trends among older adults in team-based vs. traditional primary care models in Ontario and Quebec.MethodsWe constructed two provincial cohorts using population-level health administrative data from 2006–2018. Our primary exposure was enrollment in a team-based model of care. Key endpoints included adverse drug events (ADEs), potentially inappropriate prescriptions (PIPs), and polypharmacy. We plotted prescribing trends across the observation period (stratified by model of care) in each province. We used standardized mean differences to compare characteristics of older adults and providers, as well as prescribing endpoints.ResultsFormal patient/physician enrollment increased in both provinces since the time of policy implementation; team-based enrollment among older adults was higher in Quebec (47%) than Ontario (33%) by the end of our observation period. The distribution of sociodemographic characteristics was reasonably comparable between team-based and non-team-based patients in both provinces, aside from a persistently higher share of rural patients in team-based care. Most PIPs assessed either declined or remained relatively steady over time, regardless of model of care and province. Several PIPs were more common among team-based patients than non-team-based patients, particularly in Quebec. We did not detect notable trends in ADEs or polypharmacy in either province.ConclusionsOur findings offer encouraging evidence that many PIPs are declining over time in this population, regardless of patients’ enrollment in team-based care. Rates of decline appear similar across models of care, suggesting these models may not meaningfully influence prescribing endpoints. Additional efforts are needed to understand the impact of team-based care among older adults and improve primary care prescribing practices.

Non-medical prescribing in primary care in the UK: an overview of the current literature

Background Non-medical prescribers are perceived as a complement to busy general practice in primary care. Aim To conduct an overview of the literature available on the role and impact of non-medical prescribers on primary care patients. Method A search was conducted using multiple databases to find articles published between January 2015-January 2021. Inclusion criteria: non-medical prescribers in primary care in the UK, written in the English language. Exclusion criteria: research conducted in secondary care or outside the UK. Findings 285 studies were identified; 15 were eligible for critical appraisal. The key themes were: non-medical prescriber's positive perceptions were autonomy, job satisfaction and colleague support. The negative perceptions included risk, lack of continuous professional development and organisational support. Conclusion By reviewing the perceptions of non-medical prescribing in primary care, organisations can ensure when employing new non-medical prescribers that adequate continued professional development and support is in place. Thereby reducing the concerns of non-medical prescribers about the ligation risk of prescribing.

Nudge interventions to reduce unnecessary antibiotic prescribing in primary care: a systematic review

ObjectivesAntibiotic prescribing in primary care contributes significantly to antibiotic overuse. Nudge interventions alter the decision-making environment to achieve behaviour change without restricting options. Our objectives were to conduct a systematic...

The experiences of physiotherapy independent prescribing in primary care: implications for practice.

To explore the experiences of musculoskeletal (MSk) physiotherapy independent prescribing in primary care from the perspectives of physiotherapists and General Practitioners (GPs) and identify the implications these have for contemporary physiotherapy practice in primary care. Legislative change in the United Kingdom (UK) in 2013 enabled physiotherapists holding a postgraduate non-medicalprescribing qualification to independently prescribe certain drugs that assist in patient management. Independent prescribing by physiotherapists is a relatively contemporary development in role change and purpose, occurring alongside the development of physiotherapy first contact practitioner (FCP) roles in primary care. A critical realist approach was used, with qualitative data collected via 15 semi-structured interviews with physiotherapists and GPs in primary care. Thematic analysis was applied. Fifteen participants were interviewed (13 physiotherapists, 2 GPs). Of the 13 physiotherapists, 8 were physiotherapy independent prescribers, 3 were MSk service leads, and 3 were physiotherapy consultants. Participants worked across 15 sites and 12 organisations. Whilst physiotherapists were empowered by their independent prescribing qualification, they were frustrated by current UK Controlled Drugs legislation. Physiotherapists reported vulnerability, isolation, and risk as potential challenges to independent prescribing, but noted clinical experience and 'patient mileage' as vital to mitigate these. Participants identified the need to establish prescribing impact, particularly around difficult to measure aspects such as more holistic conversations and enhanced practice directly attributed to prescribing knowledge. GPs were supportive of physiotherapists prescribing. Establishment of physiotherapy independent prescribing value and impact is required to evaluate the role of, and requirement for, physiotherapy independent prescribers within primary care physiotherapy FCP roles. Additionally, there is a need for a review of physiotherapy prescribing permitted formulary, and development of support mechanisms for physiotherapists at individual and system levels to build prescribing self-efficacy and autonomy, and to advance and sustain physiotherapy independent prescribing in primary care.

Assessing the Validity of Electronic Medical Records for Identifying High Antibiotic Prescribers in Primary Care.

Electronic medical record (EMR) prescription data may identify high antibiotic prescribers in primary care. However, practitioners doubt that population differences between providers and delayed antibiotic prescriptions are adequately accounted for in EMR-derived prescription rates. This study assessed the validity of using EMR prescription data to produce antibiotic prescription rates, accounting for these factors. The study was a secondary analysis of antimicrobial prescriptions collected from 4 primary care clinics from 2015 to 2017. For adults with selected respiratory and urinary infections, EMR diagnostic codes, prescription data, clinical diagnoses and demographics were abstracted. Overall and delayed prescription rates were produced for EMR diagnostic codes, clinical diagnoses, by clinic, and types of infection. Direct standardization was used to adjust for case mix differences by clinic. High antibiotic prescribers, above the 75th percentile for prescriptions, were compared with low antibiotic prescribers. Of 3108 EMR visits, there were 2577 (85.4%) eligible visits with a clinical diagnosis and prescription information. Overall antibiotic prescription rates were similar utilizing EMR records (31.6%) or clinical diagnoses (32.6%, P = .40). When delayed prescriptions were removed, prescribing rates were lower (22.4%, P < .01). EMR data overestimated prescribing rates for conditions where antibiotics are usually not indicated (17.7% EMR vs 7.6% clinical diagnoses, P < .001). High antibiotic prescribers saw more cases where antibiotics are usually indicated (23.4%) compared to low prescribers (16.8%; P = .001). Electronic medical record prescribing rates are similar to those using clinical diagnoses overall, but overestimate prescribing by clinicians for conditions usually not needing antibiotics. EMR prescription rates do not account for delayed antibiotic prescriptions or differences in infection case-mix.

Surfacing the causal assumptions and active ingredients of healthcare quality improvement interventions: An application to primary care opioid prescribing.

Efforts to maximize the impact of healthcare improvement interventions are hampered when intervention components are not well defined or described, precluding the ability to understand how and why interventions are expected to work. We partnered with two organizations delivering province-wide quality improvement interventions to establish how they envisaged their interventions lead to change (their underlying causal assumptions) and to identify active ingredients (behavior change techniques [BCTs]). The interventions assessed were an audit and feedback report and an academic detailing program. Both focused on supporting safer opioid prescribing in primary care in Ontario, Canada. Data collection involved semi-structured interviews with intervention developers (n = 8) and a content analysis of intervention documents. Analyses unpacked and articulated how the interventions were intended to achieve change and how this was operationalized. Developers anticipated that the feedback report would provide physicians with a clear understanding of their own prescribing patterns in comparison to others. In the feedback report, we found an emphasis on BCTs consistent with that assumption (feedback on behavior; social comparison). The detailing was designed to provide tailored support to enable physicians to overcome barriers to change and to gradually enact specific practice changes for patients based on improved communication. In the detailing materials, we found an emphasis on instructions on how to perform the behavior, for a range of behaviors (e.g., tapering opioids, treating opioid use disorder). The materials were supplemented by detailer-enacted BCTs (e.g., social support [practical]; goal setting [behavior]; review behavioral goal[s]). The interventions included a small range of BCTs addressing various clinical behaviors. This work provides a methodological example of how to apply a behavioral lens to surface the active ingredients, target clinical behaviors, and causal assumptions of existing large-scale improvement interventions that could be applied in other contexts to optimize effectiveness and facilitate scale and spread.

Migraine prevalence, migraine incidence and migraine drug prescriptions in primary care in the capital region of Iceland

The study aim was to describe migraine incidence over the ten-year periods, 2000-2009 and 2010-2019, in individuals aged 10-79 years in primary healthcare centre (PHCC) Sólvangur and Fjörður, Hafnarfirði. Another aim was to estimate migraine prevalence in primary care clinics in the capital area of Iceland over the period 2010-2019 and describe prescriptions for migraine specific drugs and other drugs used for migraine. This is a retrospective study based on data from medical records from the primary care clinics of the capital region of Iceland. The cohort consisted of individuals aged 10-79 years who were diagnosed with migraine, G43 according to the ICD-10 classification system. Migraine incidence at age 10-79 years over the ten-year period 2000-2009 at the primary care clinic Sólvangur was estimated 3.4 cases per 1000 person-years, during the period 2010-2019 in both Sólvangur and Fjörður clinics migraine incidence was estimated 2.9 cases per 1000 person-years. Increase was shown between the two periods in prescriptions of triptan drugs, opioids, and beta-blockers, where two-thirds of the migraineurs got prescription over the two periods. Women were three times more likely to be diagnosed with migraine than men, but men were diagnosed at younger age than women. Migraine prevalence at age 10-79 years in PHCCs in the capital area of Iceland was 4.4% over the period 2010-2019. Migraine prevalence in the PHCCs of the capital area of Iceland was only one third of migraine prevalence in the population-based cohort pilot study Heilsusaga Íslendinga. Increase in opioid drug prescriptions for individuals diagnosed with migraine is of concern and needs further study.

CLINICAL AND BEHAVIORAL PRACTICES OF PRIMARY HEALTHCARE PHYSICIANS IN ANTIBIOTICS PRESCRIBING IN GREECE.

Aim: To evaluate primary health physicians' clinical and behavioral practices towards antibiotics administration in a specific region in Greece. Materials and methods: A cross sectional study was conducted using a questionnaire in all structures of primary health care (PHC) of the Peloponnese Region. The study was conducted in May-October 2020. Results: In total, 306 out of 404 primary healthcare physicians completed the questionnaire (response rate of 75.8%). Our results showed that most of physicians used to prescribing antibiotics empirically in common diseases, except for the prevention of secondary respiratory tract infection. Overall, 66.3% answered that they do not feel diagnostic uncertainty that would lead them to prescribe antibiotics. Approximately 40% of the physicians stated an increase on antibiotics use and patients demand for antibiotic prescribing, however 71.4% "rarely/never" affected by this requirement. 51.9% of the sample used to prescribed brand name antibiotics. Statistically significant differences were found between demographic and professional characteristics, and physicians' clinical and behavioral practices (p≤ 0.05). Conclusions: Our findings could provide decision makers with information on how to manage antibiotic prescribing in primary health care in the country, focusing mainly on the use of specific diagnostic tests as well as relevant guidelines and protocols for changing prescription behavior.

Comparison of primary care prescriptions for old and very old hypertensive patients.

Elderly and very elderly individuals might be subject to different approaches for the treatment of hypertension. We aimed to compare drug utilization in hypertensive old patients and very old patients in primary care, along with the evaluation of potentially inappropriate drug prescribing. In this cross-sectional study, we compared prescriptions of 65-79-year-old (old patient prescriptions [OPP], n = 433,988) vs. ≥80-year-old (very old patient prescriptions [VOPP], n = 134,079) with "essential hypertension" diagnosis, issued by 3:1 systematically-sampled primary care physicians (n = 1431) in İstanbul throughout 2016. Drug utilization patterns and distribution of antihypertensives based on drug class and combination status were evaluated. Frequency of potentially inappropriate drugs per Beers Criteria were identified and compared. Antihypertensive monotherapy practice was less common in OPP than VOPP (43.3% vs. 45.3%; p < 0.001). In both groups,the most commonly prescribed drugs were beta-blockers for monotherapy (37.4% vs. 33.1%, p < 0.001) and thiazide diuretics for combined therapy (69.8% vs. 67.4%, p < 0.001). Metoprolol was the most commonly prescribed antihypertensive both in OPP and VOPP (15.3% vs. 14.8%). Furosemide was ranked 10th in OPP and 3rd in VOPP (2.7% vs. 5.5%). Cardiovascular system drugs were the most commonly encountered potentially inappropriate medications in both groups (263.9 vs. 283.4 per 10,000 prescriptions, p = 0.004). Regarding antihypertensive drugs, 2.2% of those in OPP and 2.4% of those in VOPP were identified as potentially inappropriate (p = 0.002). Prescribing preferences to old and very old patients mostly showed slight differences. Almost half of prescriptions comprising antihypertensive monotherapy might imply hesitancy to prescribe combinations. Overuse of risky drugs such as furosemide in both groups, especially in the very elderly, requires more attention.

Current management of gastro-oesophageal reflux disease-treatment costs, safety profile, and effectiveness: a narrative review.

The purpose of this study was to review the current management of gastro-oesophageal reflux disease (GORD), including treatment costs, safety profile and effectiveness. A literature review was performed of randomized-controlled trials, systematic reviews, Cochrane reports and National/Societal guidelines of the medical, endoscopic and surgical management of GORD. Proton pump inhibitor (PPI) prescribing patterns and expenditure were reviewed in different countries, including Australia, Canada, New Zealand, UK and USA. Proton pump inhibitors (PPIs) are primarily indicated for control of GORD, Helicobacter pylori eradication (combined with antibiotics), preventing NSAID-induced gastrointestinal bleeding and treating peptic ulcer disease. There is widespread overprescribing of PPIs in Western and Eastern nations in terms of indication and duration, with substantial expense for national health providers. Despite a favourable short-term safety profile, there are observational associations of adverse effects with long-term PPIs. These include nutrient malabsorption, enteric infections and cardiovascular events. The prevalence of PPI use makes their long-term safety profile clinically relevant. Cost-benefit, symptom control and quality-of-life outcomes favour laparoscopic fundoplication rather than chronic PPI treatment. Laparoscopic fundoplication in long-term management of PPI-responsive GORD is supported by SAGES, NICE and ACG, and PPI-refractory GORD by AGA and SAGES guidelines. The importance of establishing a definitive diagnosis prior to invasive management is emphasized, especially in PPI-refractory heartburn. We examined evidence-based guidelines for PPI prescribing and deprescribing in primary care and hospital settings and the need for PPI stewardship and education of health professionals. This narrative review presents the advantages and disadvantages of surgical, endoscopic and medical management of GORD, which may assist in shared decision making and treatment choice in individual patients.This paper was presented (GS020) at the 88th RACS Annual Scientific Conference, 6-10 May, 2019.

Computerized clinical decision support systems for prescribing in primary care: main characteristics and implementation impact—protocol of an evidence and gap map

BackgroundComputerized clinical decision support systems are used by clinicians at the point of care to improve quality of healthcare processes (prescribing error prevention, adherence to clinical guidelines, etc.) and clinical outcomes (preventive, therapeutic, and diagnostics). Attempts to summarize results of computerized clinical decision support systems to support prescription in primary care have been challenging, and most systematic reviews and meta-analyses failed due to an extremely high degree of heterogeneity present among the included primary studies. The aim of our study will be to synthesize the evidence, considering all methodological factors that could explain these differences, and build an evidence and gap map to identify important remaining research questions.MethodsA literature search will be conducted from January 2010 onwards in MEDLINE, Embase, the Cochrane Library, and Web of Science databases. Two reviewers will independently screen all citations, full text, and abstract data. The study methodological quality and risk of bias will be appraised using appropriate tools if applicable. A flow diagram with the screened studies will be presented, and all included studies will be displayed using interactive evidence and gap maps. Results will be reported in accordance with recommendations from the Campbell Collaboration on the development of evidence and gap maps.DiscussionEvidence behind computerized clinical decision support systems to support prescription use in primary care has so far been difficult to be synthesized. Evidence and gap maps represent an innovative approach that has emerged and is increasingly being used to address a broader research question, where multiple types of intervention and outcomes reported may be evaluated. Broad inclusion criteria have been chosen with regard to study designs, in order to collect all available information. Regarding the limitations, we will only include English and Spanish language studies from the last 10 years, we will not perform a grey literature search, and we will not carry out a meta-analysis due to the predictable heterogeneity of available studies.Systematic review registrationThis study is registered in Open Science Framework https://bit.ly/2RqKrWp

Observational UK cohort study to describe intermittent oral corticosteroid prescribing patterns and their association with adverse outcomes in asthma

IntroductionOral corticosteroids (OCS) for asthma are associated with increased risks of developing adverse outcomes (adverse outcomes); no previous study has focused exclusively on intermittent OCS use.MethodsThis historical (2008–2019) UK cohort...