Prescription Items Research Articles

Identification and costs of prescriber-defined repeat prescribing

Abstract The use of different definitions of repeat prescribing has, understandably, resulted in different published values of both numbers of prescriptions and their costs. One possible way of determining the number of repeat prescriptions would be to allow prescribers to self-identify prescriptions at source. However, the cost of repeat prescription items only becomes a tangible cost if, and when, the patient has the prescription dispensed. The aim of this work was to allow prescribers from six general practices in one family health services authority to self-identify repeat prescriptions. Only those prescriptions presented for dispensing were analysed and costed. Out of a total of nearly 54,000 prescription items, 29.4 per cent were identified as repeats; they accounted for 32.2 per cent of the total cost of the prescriptions. Overall, the average cost of repeat prescription items was higher than that for new prescription items. The approach used in this work is a novel method of identifying, quantifying and determining the extent and costs of repeat prescribing in a study population. The limitations of the method are discussed.

Oral counselling on dispensed medication: a survey of its extent and associated factors in a random sample of community pharmacies

Abstract To establish the current rate of oral counselling on dispensed medications, a random sample of 50 community pharmacists from the greater London area was selected. A non-participant observational method was used to obtain the required information. It was found that most pharmacist characteristics, including age, experience and employment status (proprietor, manager or locum) did not affect the rate of provision of oral counselling. However, the rate varied according to sex, with female pharmacists advising more patients. The rate of counselling was also influenced by the patient's age, the type of prescription (National Health Service or private), whether the prescription was a repeat or for new medication and the therapeutic category of the medicine. During the study, the collection of 1,472 prescription items was observed. Overall, counselling was provided for 39 per cent of patients. Counselling was given for around 70 per cent of new prescription items and for 20 per cent of repeat items.

Non-dispensing of NHS prescriptions in community pharmacies

Abstract Objective To explore non-dispensing of National Health Service (NHS) prescriptions in community pharmacies. Method Prospective study on prescription items that were presented and not dispensed. Pharmacy staff recorded reasons for non-dispensing of NHS prescription items and process outcomes, including substitution through other means. Setting Sixteen community pharmacies in the North of England. Key findings Data are available on 587 items (514 patients). Two main reasons for non-dispensing were identified: those related to the cost of the prescription charge (n=308) and those unrelated to cost (n=279). The latter generally suggested a prescribing issue involving the general practitioner's (GP's) computer system. Cost-related reasons included cheaper availability of over-the-counter (OTC) products (78.6 per cent) and incidents where customers were unwilling or unable to pay the prescription charge (20.1 per cent). Unsurprisingly, cost-related reasons were encountered almost exclusively for patients who were non-exempt from prescription charges, while non-cost reasons were more commonly seen for exempt patients. As a result of non-dispensing because of cost, 242 OTC products were sold, 97.0 per cent of which contained the same active ingredient as had been prescribed by the doctor. There were 62 incidents where a prescribed item was not dispensed, or substituted, because of cost, and more than one-third of these items (n=22) could be considered to be clinically important. Conclusions In addition to issues of GP prescribing, the cost of the prescription charge was identified as a major factor in non-dispensing. Many of the items were substituted by cheaper OTC products, yet some clinically important drugs were not dispensed or substituted, suggesting that a review of the UK charge system is appropriate.

Validation of the Welsh general practice morbidity database

Abstract Focal points

Clinical evaluation of community pharmacists' interventions

AbstractPharmacists' clinical interventions with prescriptions listed on the Australian Pharmaceutical Benefits Scheme were investigated in a pilot study set up in 30 pharmacies — 10 each from the states of New South Wales, Queensland and Victoria — stratified by city or rural location. Clinical interventions were self-reported by the 29 participating pharmacies for a period of four weeks. A total of 89,326 prescription items was dispensed in the pharmacies over the 675 recording days. There were 1,273 clinical interventions recorded from 1,053 prescription forms. Clinical interventions were divided into two main categories: reactive and proactive. The mean of the total clinical intervention rate was 1.5 per cent (SD=1.4 per cent), comprising 1.2 per cent (SD=1.2 per cent) reactive interventions and 0.3 per cent (SD=0.3 per cent) proactive interventions. A random sample of 50 proactive interventions that resulted in a change in a patient's therapy was evaluated by a clinical expert panel to determine the most likely adverse outcome avoided as a result of the pharmacist's intervention. This study provides evidence of community pharmacists' interventions with prescriptions and demonstrates that pharmacists increase the efficiency and effectiveness of patients' drug regimens and also, potentially, their welfare and quality of life.

The changing face of pharmacy practice — evidence from 20 years of work sampling studies

Abstract Objectives To determine whether the professional policy shift away from dispensing towards patient-focused care is reflected in the way community pharmacists actually use their time. Method Retrospective comparison, using data from five observational work sampling studies employing the same methodology. The percentage of time spent on manipulative dispensing (defined as creating labels and physically preparing prescription items) and health-related customer communication was monitored. Setting Fifteen independent practices (8.7 prescriptions/hour; London, England, 1993); 40 urban/rural pharmacies (7.8 prescriptions/hour; Dublin, Eire, 1985); 28 independents (9.1 prescriptions/hour; Sydney, Australia, 1985); one traditional multiple (9.6 prescriptions/hour; Nova Scotia, Canada, 1980); 20 traditional multiples (8.1 prescriptions/hour; eastern United States, 1973). Key findings Despite full computerisation, English pharmacists in 1993 spent as much time creating dispensing labels (8.8 per cent) as they did on health-related customer talk (7.2 per cent), and twice as much time preparing prescription items (14.2 per cent). Of their total time, 6.5 per cent was spent on simple redispensing (mostly counting tablets, pouring liquids and cutting blister strips). The time spent on extemporaneous preparation was extremely low. In Eire, pharmacists spent nearly twice as much time (5.8 per cent) on health-related talk as on counting, pouring and compounding (3.8 per cent) and in Australia nearly three times as much time (6.6 per cent vs 2.3 per cent). In Eire, two-thirds of pharmacists had qualified dispensing help of a type not found in other countries. In Australia, most products were ready to issue. Conclusion The proportion of pharmacist time spent on customer communication has increased three-fold since 1973. However, this has not been mirrored by a decline in time spent on manipulative dispensing. Keeping the study limitations in mind, it is suggested that, in Britain, the reprofessionalisation process may be hampered by the continued need for redispensing and the limited availability and use of trained support staff.

Analysis of a “Medidump” campaign in Australia

Abstract The Australian Commonwealth Department of Health, Housing and Community Services organised a campaign to collect unwanted medicines on a national basis. A representative sample of the returned medicines was analysed. Of the 6,556 items examined, the majority were tablets or capsules. There was a high level of prescription items, with cardiovascular (17.0 per cent), central nervous system (15.7 per cent) and respiratory (14.0 per cent) medications the main therapeutic categories returned. Some individual items occurred in high frequency, more than 100 items each of salbutamol, glyceryl trinitrate, frusemide, theophylline, beclomethasone dipropionate and aspirin being returned. The date of dispensing was only recorded for 45.1 per cent of the sample, and of these 37.6 per cent had been dispensed in the past year. Of the 5,860 items that could be evaluated, 38.9 per cent were unopened and 55.7 per cent had 80 per cent or more of the medication unused. Of the 4,359 items bearing a pharmacy label, 36.4 per cent were unopened and 53.9 per cent had 80 per cent or more of the medication unused. Approximately 55 per cent of cardiac and respiratory drugs and antibiotics were more than three-quarters unused and 45 per cent, 38 per cent and 47 per cent, respectively, of items in these therapeutic groups were returned unopened. Although the number of labelled items returned in each of these categories was lower than the total items returned, the percentages of items returned unopened were substantially the same. Some caution must be adopted in interpreting these results as they are based on medications that have been disposed of, and do not represent total medication usage.

Medication wrong-route administrations in relation to medical prescriptions

This study analyzes the influence of medical prescriptions' writing on the occurrence of medication errors in the medical wards of five Brazilian hospitals. This descriptive study used data obtained from a multicenter study conducted in 2005. The population was composed of 1,425 medication errors and the sample included 92 routes through which medication was wrongly administered. The pharmacological classes most frequently involved in errors were cardiovascular agents (31.5%), medication that acts on the nervous system (23.9%), and on the digestive system and metabolism (13.0%). In relation to the prescription items that may have contributed to such errors, we verified that 91.3% of prescriptions contained acronyms and abbreviations; patient information was missing in 22.8%, and 4.3% did not include the date and were effaced. Medication wrong-route administrations are common in Brazilian hospitals and around the world. It is well established that these situations may result in severe adverse events for patients, including death.

CUSUM charts for monitoring clinical practice quality using primary care prescribing data: a case study of an initiative to encourage generic prescribing of proton pump inhibitors

Expectations on organizations to monitor quality of care are growing. Whilst relevant data are increasingly becoming available it is, in many cases, difficult to distinguish real effects from background variation. Here, the potential usefulness of cumulative sum (CUSUM) charts for monitoring the use of medicines is explored through a case study of an initiative to encourage the prescribing of lowest cost proton pump inhibitors (PPI) in the context of implementation of national guidelines for the management of dyspepsia. This was a longitudinal study involving analysis of routinely collected prescribing data, set in all 12 primary care trusts (PCT) in the North East Strategic Health Authority. In it, comparison (by subtraction) of the time-series of the percentage of generic PPI prescription items for Gateshead with the mean of the other 11 PCTs was used to reduce both variation and bias. This was followed by the construction of a CUSUM chart displaying the effect of the Gateshead initiative. The simple process of comparison was very successful both in removing extraneous trends and reducing background variation, and the CUSUM highly effective for displaying the evidence for the hypothesized step-change in prescribing behaviour consequent on the Gateshead initiative. The effectiveness of the CUSUM here is strongly linked to the success of the preliminary comparison step. CUSUM, a statistical process control technique, has already been tested as a tool for interpreting hospital and general practice mortality rates. Here, its potential for more general applications in quality monitoring is demonstrated using routinely collected prescribing data. Such data contain valuable information about changes in clinical practice and CUSUM charts, when coupled with the idea of removing time trends and extraneous variation by reference to average behaviour, can provide a simple but effective technique for extracting it.

Prescribing and sale of ophthalmic chloramphenicol following reclassification to over-the-counter availability

The impact of over-the-counter (OTC) availability of chloramphenicol eye drops and eye ointment was investigated on the prescribing and overall supply of ophthalmic chloramphenicol in primary care. Primary care prescription data for ophthalmic chloramphenicol and ophthalmic antibacterials in England and Wales were analysed from December 2003 (month 1) to September 2008 (month 58). OTC data were analysed from June 2005 when the first OTC product was launched (months 19 to 58). In the 40 months following reclassification more than 2.9 million packs (53.9 per 1000 population) of chloramphenicol were sold in England and 152024 (51.7 per 1000 population) in Wales. In the 12 months to September 2008 sales of the drops and ointment were 67 and 40% of their respective prescription volumes in England. In Wales sales of drops were 52% and ointment 26% of their respective prescription volumes. The number of chloramphenicol packs sold was 2.2 times greater than the calculated reduction in ophthalmic antibacterial prescription items in England and 2.9 times greater than the reduction seen in Wales. Following the reclassification of chloramphenicol there have been significant increases in the supply of the ophthalmic antibacterials in both England and Wales.

What is the price benchmark to replace average wholesale price (AWP)?

An article on the front page of the Wall Street Journal on October 6, 2006, thrust into the public media the otherwise esoteric controversy concerning the use of average wholesale price (AWP) as the primary basis for reimbursements to pharmacies for pharmaceuticals in the United States. Although used widely for nearly 40 years, AWP had been criticized prior to this investigative report as unreliable, subject to manipulation, and not representative of the actual purchase price for pharmaceuticals. The Wall Street Journal article, based on a tentative settlement of litigation in which First DataBank (San Francisco, CA) and the McKesson Corporation (San Francisco, CA) were accused of unilaterally increasing AWPs, included the findings that (a) at least since 2003, AWP was not based on calculation of an "average" wholesale price but instead reflected the pricing of McKesson Corporation, a single drug wholesaler; and (b) AWP had undergone a systematic change beginning in 2001 when First DataBank had converted its markups of wholesale acquisition cost (WAC) to a common multiplier of 1.25,1 effectively increasing the AWP by 4% for AWPs that were previously calculated using a multiplier of 1.20. In March 2009, the future of AWP became uncertain as a result of circumstances surrounding the court settlement of the litigation that had begun in 2005 against First DataBank. On March 17, 2009, U.S. District Court Judge Patti B. Saris approved the proposed settlement of 2 civil action lawsuits filed by private health plan payers of pharmaceuticals against the 2 largest publishers of AWP, First DataBank (along with wholesaler McKesson) and Medi-Span (Indianapolis, IN, subsidiary of Wolters Kluwer Health). On March 30, 2009, Judge Saris signed a final order and judgment certifying the class (of "Private Payor" purchasers) which settled 2 national class action lawsuits against the 2 largest publishers of AWP. As part of the formal settlement, Medi-Span and First DataBank agreed to adjust the markup factor used to calculate AWP downward to 1.20 times WAC "for any prescription pharmaceutical" that had "a mark up factor basis from WAC to AWP in excess of 1.20" for the 1,442 specific national drug code (NDC) numbers that were listed in the court complaint. The "rollback" of AWP as a result of reducing the WAC/DP (direct price) multiplier to no more than 1.20 was implemented by First DataBank and Medi-Span on September 26, 2009, 180 days from the date of the judgment, as ordered. At the same time, these AWP publishers voluntarily implemented price modifications to all products that had a WAC markup greater than 1.20. This decision expanded the list of NDC numbers from the 1,442 specified in the lawsuit to well over 50,000 items. The expanded list included both prescription and nonprescription (over-the-counter [OTC]) items, both active and inactive NDC numbers on the drug database, as well as a variety of markup factors. The adjusted AWPs had markup factors that ranged from 1.20 to 1.33. About two-thirds to three-fourths of the NDC numbers with adjusted AWPs had a pre-settlement WAC markup of 1.25. This U.S. District Court decision on March 30, 2009, was also accompanied by separate announcements from the defendants Medi-Span and First DataBank that they would voluntarily discontinue publication of AWP.

A nationwide study on generic medicines substitution practices of Australian community pharmacists and patient acceptance

This study evaluated Australian community pharmacists' rate of generic medicine substitution, patient acceptance of generic substitution and cost-savings achieved for patients from substitution. A national stratified sample of 500 Australian pharmacies was randomly selected from different geographical areas. The data of the first 25 original PBS prescription items dispensed on one working day eligible for generic substitution were collected from each pharmacy. Responses were received from 82 pharmacies with a response rate of 16.4%. The pharmacists recommended generics for 96.4% (1461/1515) of the prescription items which were eligible for substitution. The generic substitution recommendation rate in urban (98.7%) and rural areas (98.0%) was significantly higher than remote areas (91.6%). Conversely, patients' acceptance in remote areas (84.5%) was significantly higher than rural (78.6%) and urban areas (73.2%). Patients with chronic diseases demonstrated significantly lower acceptability (72.4%) than patients with acute conditions (81.6%). Through acceptance of substitution, the patients' medicines expenditure reduced by around 21%. Australian community pharmacists demonstrated a high rate of recommending generic substitution. However, to optimize the generic medicines utilization, patients' acceptance requires further improvement.

Dispensing patterns and financial costs of glucose‐lowering therapies in the UK from 2000 to 2008*

A variety of influences determine prescribing behaviour. The purpose of this study was to characterize the pattern of dispensing for glucose-lowering and monitoring in the UK from 2000 to 2008, inclusively. Open source data were used from the four UK prescription pricing agencies. Historical patterns of dispensing change were analysed in England, thus data are for England unless otherwise stated. Costs were adjusted for price inflation and reported in UK pound at 2008 prices. The total cost in the UK in 2008 was 702 239 000 UK pounds: 22 897 000 pounds (3.2%) for Northern Ireland, 37 681 000 pounds (5.3%) for Wales, 57 146 000 pounds (8.1%) for Scotland and 590 514 000 pounds (83.4%) for England. As a per cent of the overall primary care drug budget for each region, this represented 6.9% overall and then 5.8, 6.5, 5.9 and 7.1%, respectively. In England, diabetes-related dispensing costs increased from 290m to 591m UK pounds. All glucose-lowering drug classes increased in volume, except the alpha-glucoside inhibitors and the prandial glucose regulators. Insulin costs increased from 128m to 286m UK pounds. Insulin glargine metrics increased year-on-year, whereas neutral protamine Hagedorn (NPH) declined. Analogue insulin increased (2.6 million to 33.9 million prescription items), whereas human insulin declined (21.0 million to 10.3 million). The costs of dispensing for diabetes increased markedly between 2000 and 2008 to represent an annual cost to the NHS of 708m UK pounds, or 7% of budget. Costs increased at a higher rate than volume. Changes in prescribing appeared to reflect commercial factors more than clinical evidence. Diabetes dispensing patterns need to be better controlled and costs contained.

Ethnic differences in access to prescription medication because of cost in New Zealand

ObjectivesThis paper aims to examine ethnic differences in financial barriers to access to prescription medication in New Zealand.MethodsData from SoFIE-Health (wave 3), which is an add-on to the Statistics New...

Clinical intervention rates in community pharmacy: a randomised trial of the effect of education and a professional allowance

AbstractObjectivesTo quantify the rate of clinical interventions by community pharmacists, and to determine the effect of providing targeted education and/or fee-for-service professional remuneration on the rate of clinical interventions.MethodsA randomised trial involving four groups of 10 community pharmacies: group A served as a control and received neither education nor remuneration; group B received education and professional remuneration; group C received “advanced” education and professional remuneration; and group D received professional remuneration with no education. Pharmacists in all groups documented interventions for three one-week periods. Types of intervention were pre-specified by the researchers and logged as such by the pharmacists. Interventions were categorised as “reactive” or “proactive” by a panel comprising a community pharmacist and a hospital pharmacist. Logistic regression analysis was used to compare differences in intervention rates between the groups at baseline, between groups over time (six weeks), and within groups over time.Results87,130 prescription items were dispensed in the study period, and there were 762 clinical interventions, an intervention rate of 0.87%. Of the total, 375 (0.43%) were proactive and 387 (0.44%) were reactive. Groups B and C showed increases in clinical intervention rates immediately after the educational intervention, but these rates then decreased between week 1 and 2. Over the study period, group D had statistically significant reductions in intervention rates from baseline (total, reactive and proactive), and group A showed statistically significant reductions in reactive intervention rates.ConclusionsThe results from this study show that providing remuneration alone or maintaining the status quo (ie, neither remuneration nor education) did not lead to an increase in clinical interventions in community pharmacies. Increases in rates within the groups receiving education and remuneration were short lived. Developing and implementing educational programmes in addition to fee-for-service remuneration packages may have a positive impact on clinical intervention rates. Longitudinal work is required to investigate the sustainable effects of longer-term education strategies on clinical interventions in community pharmacy.

Comparison of medication-prescribing patterns for patients in different social groups by a group of doctors in a general practice

Abstract Objective This study was designed to compare medication-prescribing patterns of five general practitioners (GPs) who served patients living in two different communities, one of which is more economically deprived. Method The study focused on cardiovascular and antibiotic prescribing. Practice population data including history of cardiovascular disease and records of medication prescribed were considered with public health and socio-economic statistics for each community. Setting The study practice serves 8300 patients in two clinics, Tipton and Gornal, 4 miles apart. Each has similar numbers of registered patients. Tipton is in one of England's most deprived areas, ranked 16 out of 354 in the Indices of Multiple Deprivation 2004, compared with Gornal which is situated in an area ranked 109. Key findings For each Tipton patient, mean prescribing costs were 37% higher and mean number of prescription items were 16% higher over the study period compared with Gornal. Although a higher incidence might be expected in Tipton, little difference in identified cardiovascular disease (CVD) was found between Tipton and Gornal, and prescribing rates of aspirin and statins were similar. Tipton patients with CVD were less likely to be prescribed antihypertensives especially calcium channel blockers (P = 0.003) and diuretics (P = 0.02). Tipton patients received on average 3.27 different cardiovascular drugs compared with 3.80 in Gornal (P = 0.004). In those aged 65 years and over, this reduced to 3.08 in Tipton compared with 3.82 in Gornal (P = 0.001). Tipton patients generally, and children specifically, were significantly more likely to receive antibiotic prescriptions (P <0.0001). Conclusion This study suggested that some prescribing patterns differed at the two clinics, which may reflect different behaviours by the GPs when prescribing in the two communities of different population need.

POLYPHARMACY AND INAPPROPRIATE PRESCRIBING IN ELDERLY HONG KONG CHINESE PATIENTS

POLYPHARMACY AND INAPPROPRIATE PRESCRIBING IN ELDERLY HONG KONG CHINESE PATIENTS

Interventions performed by New Zealand community pharmacists while dispensing prescription medications

To investigate the number and type of interventions performed by New Zealand community pharmacists when dispensing new prescriptions. All community pharmacies in Dunedin, New Zealand (29) were asked to use a tally system to record the types of interventions performed, the time taken and the number of prescription items processed per day. Data was collected for one full week for 20 pharmacies. In total 24,059 prescription items were dispensed by the 20 pharmacies over one week. There were 1,551 separate interventions recorded with a recorded time of 1,684 min. These interventions occurred at a rate of 64 interventions per 1,000 prescription items. Of recorded interventions, bureaucratic and generic substitution problems accounted for 81%. These combined interventions occurred at a rate of 52 per 1,000 prescription items and totalled 50% of the time spent on prescription interventions. Whilst clinical interventions were recorded at a rate of 13 per 1,000 items, they accounted for the remaining 50% of time spent. Half of the time spent by community pharmacists in Dunedin, New Zealand on prescription interventions consists of correcting bureaucratic and legal issues, limiting the time pharmacists can spend on clinical services.

Effects of the National Institute for Health and Clinical Excellence's technology appraisals on prescribing and net ingredient costs of drugs in the National Health Service in England

The aim of this study was to examine the impact of the National Institute for Health and Clinical Excellence's (NICE's) negative and restricting technology appraisals on the number of prescription items dispensed and the corresponding total net ingredient costs for drugs from 2000 to 2004 in the ambulatory care of the National Health Service (NHS) in England and Wales. In addition, it is discussed whether the NICE approach could be a role model for Germany. The number of prescription items dispensed and the net ingredient costs of thirty-one drugs reimbursed by the NHS were analyzed, thereof thirteen drugs descriptively and twenty-one drugs with regression analyses. Data were extracted from the "Prescription-Costs-Analysis-Statistics" for the ambulatory care of the British Department of Health (England 1993-2005). In the case of the twenty-one drugs analyzed by regression analyses, predictions were established how the prescribing and the costs would have developed without NICE's drug appraisal. Finally, conclusions were drawn whether NICE's negative and restricting drug appraisals had a decreasing effect or not. For 97 percent of the drugs analyzed in this study, the publication of NICE's fourteen negative and restricting technology appraisals of drugs between 2000 and 2004 did not reduce the number of prescription items dispensed and net ingredient costs in the ambulatory care of the NHS in England and Wales. Cost-effectiveness appraisals as performed by NICE or the German Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWiG) are a useful and important tool to enhance the discussion about methods and acceptance of evidence-based medicine in general.

The Effects of Physicians’ Financial Incentives on the Effectiveness of Taiwan’s Outpatient Drug Copayment Policy

This study examines how physicians' financial incentives affect the effectiveness of the outpatient drug copayment policy in Taiwan under National Health Insurance (NHI). Our sample of 1,301,599 patients aged less than 65 years was drawn from 21 hospitals for the study. We use analysis of variance to better understand possible reasons for changes in drug costs. Regression analysis is invoked to investigate the effect of physicians' financial incentives on drug utilization after the implementation of the drug copayment policy.The results indicate that total drug costs increase after the implementation of the co-payment policy because of increases in average drug price per prescription and drug utilization. In addition, the results indicate that hospitals with physician fee programs that include drug revenue have longer duration per prescription and higher drug items per prescription. From Taiwan's experience, we infer that physicians' financial incentives could have an impact on the effectiveness of polici...