Prescription Pricing Authority Research Articles

L’adhésion thérapeutique aux traitements oraux : enjeux en oncologie - l’exemple du cancer du sein

Today, over 40 different oral anticancer therapies are available in the French prescription pricing authority dictionary. Adherence to these therapies has become a major issue in the field of oncology. Most of the available research has focused on adherence to hormonal therapy for breast cancer (BC). The objective of this paper is to synthesize current knowledge on adherence and persistence to hormonal therapy for BC. Available studies display significant heterogeneity due to variability in the measurements and data sources used, as well as in the timing of the measurements. Adherence and persistence estimates have recently been summarized in a meta-regression analysis. For tamoxifen, adherence ranges from 79% at one year to 65% at five years, and for Aromatase Inhibitors (AI), from 80% at one year to 72% at five years. Persistence decreases with the increasing duration of treatment: from a high of 86% of patients persistent at 1 year to a low of 53% at five years for tamoxifen, and from 88% to 69% for AI. Some of the modifiable determinants of adherence are directly linked to the patient-physician relation, to information provided during consultations, or to the specialty of the physician involved in the patient follow-up. Non-modifiable determinants, such as age or comorbidities, can be used to identify sub-groups of patients at high risk of non-adherence in order to target interventions. Few trials have been conducted in oncology to evaluate the efficacy of interventions to improve adherence. Adherence directly impacts both the efficacy of treatment and long-term treatment costs. Interventions to improve adherence to oral therapies should be systematically promoted in oncology. Improving adherence should be considered a priority in the field, lest physicians continue writing inefficient prescriptions for highly efficacious treatments.

Diabetes: costs and cost-effectiveness

Diabetes: costs and cost-effectiveness

Is there an association between referral population deprivation and antibiotic prescribing in primary and secondary care?

AbstractObjectiveThe study was designed to explore the presence of any relationship between NHS secondary care antibiotic prescribing rates or primary care antibiotic prescribing rates and the levels of deprivation experienced within the referred primary care population. The study also aimed to determine whether the antibiotic prescribing rates for each care sector were correlated.MethodThe study was conducted in 12 English hospital trusts of mixed size and case-mix. Antibiotic usage data (Anatomical Therapeutic Chemical (ATC) category J01) for the financial year, ending March 2001/2002 were used to calculate hospital trust prescribing rates (using the defined daily dose/finished consultant episode indicator). Primary care antibiotic prescribing data were obtained from the Prescription Pricing Authority (antibiotic items prescribed per 1000 residents) for the year 2001/2002. Index of Multiple Deprivation (IMD) 2000 deprivation data were obtained from the regional public health observatory websites for each of the primary care trusts within the relevant study areas.Key findingsNo correlation could be established between the weighted index of multiple deprivation of the treated population and antibiotic prescribing rates at each hospital trust. Primary care antibiotic prescribing rates were not found to correlate with antibiotic prescribing rates in the geographically associated hospital trust. Data from all 12 sites showed that the IMD 2000 measures and primary care prescribing rates were weakly correlated, with higher antibiotic prescribing rates being generally observed in areas of primary care exhibiting the worst levels of deprivationConclusionsThe likely explanations for the present findings are that deprivation-related illnesses are principally treated within primary care, whereas hospital antibiotic prescribing principally results from procedures isolated within secondary care or through the additional influence of nosocomial infection. Therefore, medicines management measures geared to controlling antibiotic prescribing in secondary care should not focus upon the levels of deprivation in the referred population, whereas those in primary care should.

Dispensing activity in a community pharmacy-based repeat dispensing pilot project

Abstract Objective To measure changes in dispensing activity in a UK repeat dispensing pilot study and to estimate any associated cost savings. Method Patients were provided with two successive three-monthly repeat prescriptions containing all of the items on their “repeat medicines list” and valid at a study pharmacy. Pharmacists consulted with patients at the time of supply and completed a patient-monitoring form. Prescriptions with pricing data were returned by the UK Prescription Pricing Authority. These data were used to calculate dispensing activity, the cost of dispensed items and an estimate of cost savings on non-dispensed items. A retrospective identification of items prescribed during the six months prior to the project was used to provide a comparison with those dispensed during the project and thus a more realistic estimate of changes. Setting 350 patients from two medical practices in a large English City, with inner city and suburban locations, and served by seven pharmacies. Key findings There were methodological challenges in establishing a robust framework for calculating changes. Based on all of the items that patients could have obtained from their repeat list, 23.8% were not dispensed during the intervention period. A correction was then made to allow for a comparison with usage in the six months prior to the study. Based on the corrected data, there was an estimated 11.3% savings in drug costs compared with the pre-intervention period. There was a marked difference in changes between the two practices, the pharmacies and individual patients. The capitation-based remuneration method was acceptable to all but one of the community pharmacists. Conclusion The repeat dispensing system reduced dispensing volume in comparison with the control period. A repeat dispensing system with a focus on patients' needs and their use of medicines might be cost neutral.

Relative impact of clinical evidence and over-the-counter prescribing on topical antibiotic use for acute infective conjunctivitis

Acute infective conjunctivitis is a common presentation in general practice. In 2005, three placebo-controlled clinical trials showed that use of topical antibiotics had a small effect on time to clinical resolution. In the same year, chloramphenicol eye drops were made available for sale over the counter. To compare the relative impact of clinical trial evidence and a change to over-the-counter availability on community use of topical chloramphenicol. Observational study using mainly routinely collected data for England. National prescribing data for England and local data from general practices in Oxfordshire, England. Data were collated from three sources: GP prescriptions from the Prescription Pricing Authority, wholesale supply to pharmacists from IMS Health, and an audit of delayed prescribing and non-prescribing from electronic consultation records for acute conjunctivitis, in four general practices. The number of general practice prescriptions for topical chloramphenicol fell from 2.3 million in 2004 to 1.9 million in 2007, a reduction of 15.5%. In contrast, over-the-counter sales by pharmacists have increased steadily. The net effect of these changes has been a 47.8% increase in total chloramphenicol use during 2005-2007, with 1.1 million additional packs being used in 2007 compared to 2004. Making an antibiotic available over the counter increases its use substantially. This is in conflict with the important public health message that antibiotic use needs to be reduced to combat resistance. These findings support the views of the Chief Medical Officer that no more antibiotics should currently be made available over the counter.

Do General Practices Which Provide An Acupuncture Service Have Low Referral Rates and Prescription Costs? A Pilot Survey

Studies by individual acupuncture practitioners have given an indication that offering acupuncture in primary care may reduce the need for referral to secondary care and reduce the costs of prescriptions. It would be informative to find out whether these findings can be supported by data from other practices. The aim of this study was to test the feasibility of surveying national data on referrals and prescribing. Three primary care trusts (PCTs) were selected, and all practices within each trust were sent an email asking whether any member of the primary care team offered acupuncture, and if so how many appointments per week. Data on rates of referral to orthopaedic, physiotherapy, pain and rheumatology clinics were then sought from the PCT, both for the practices offering acupuncture and for the PCT as a whole. Similarly, data on costs of prescriptions for non-steroidal (NSAID) and non-opioid analgesic drugs were obtained from the Prescription Pricing Authority. Out of the 109 practices surveyed, a total of 14 (13%) offered acupuncture services to some extent. There was wide variation in provision between the different PCTs. The eight practices which offered at least one appointment per week for every 2000 registered patients were included in the analysis. The mean values (and SDs) for the three PCTs and for the eight acupuncture practices, respectively, were as follows: for referral to various clinics: orthopaedic 32.3 (16.2) and 27.4 (10.87); pain clinic 1.6 (1.3) and 2.8 (1.6); physiotherapy 13.4 (14.5) and 29.5 (10.0); and rheumatology 4.7 (2.3) and 6.4 (3.0). The mean values for costs of non-opioid analgesics were pound1820 ( pound442) and pound2008 ( pound762); and for NSAIDs were pound4148 ( pound269) and pound4476 ( pound1366), respectively. There were no trends towards a reduction of clinic referral or prescription costs. We have conducted the first survey of the effects of provision of acupuncture in UK general practice, using data provided by the NHS, and uncovered a wide variation in the availability of the service in different areas. We have been unable to demonstrate any consistent differences in the prescribing or referral rates that could be due to the use of acupuncture in these practices. The wide variation in the data means that if such a trend exists, a very large survey would be needed to identify it. However, we discovered inaccuracies and variations in presentation of data by the PCTs which have made the numerical input, and hence our results, unreliable. Thus the practicalities of access to data and the problems with data accuracy would preclude a nationwide survey.

Prescribing practices for Betahistine

Prescribing practices for Betahistine

Use of Acid-Suppressing Drugs and the Risk of Bacterial Gastroenteritis

Gastric acid is a defense mechanism against gastrointestinal infections caused by ingested bacteria. Studies have suggested that the use of acid-suppressing drugs may increase the risk of gastroenteritis (GE). Patients aged 20-74 years with an episode of acute bacterial GE (n = 6414) were identified. A control group from the same study population without a diagnosis of GE (n = 50,000) was frequency-matched by age, sex, and calendar year to the case group. Unconditional logistic regression was used to calculate the adjusted relative risk (RR) of GE in patients using proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs). Current use of PPIs was associated with an increased risk of bacterial GE compared with nonuse, regardless of the treatment duration (RR, 2.9; 95% confidence interval [CI], 2.5-3.5), whereas no association was observed with H2RA use (RR, 1.1; 95% CI, 0.9-1.4). Doubling the PPI dose further increased the risk of developing bacterial GE (RR, 5.0; 95% CI, 2.7-9.3). The effect of PPI use did not vary significantly with regard to treatment indication. The increased risk associated with PPI use was similar for both omeprazole (RR, 3.0; 95% CI, 2.5-3.7) and lansoprazole (RR, 2.1; 95% CI, 1.4-3.0), whereas neither cimetidine nor ranitidine showed any increased risk. Campylobacter (n = 4124) and Salmonella (n = 1885) were the 2 species most frequently responsible for GE episodes in the case group. When analyzed separately, both species reproduced the increased risk associated with PPI use and not H2RA use. Clostridium GE cases were rare (n = 31). This study suggests that gastric acid suppression induced by PPIs but not H2RAs is associated with an increased risk of Campylobacter and Salmonella GE.

Safety of Zafirlukast

A prescription event monitoring (PEM) postmarketing surveillance study was carried out to examine the safety of zafirlukast as used in general practice in England. Exposure data were obtained from the first National Health Service (NHS) prescription dispensed for patients whose prescription details were processed by the Prescription Pricing Authority between August 1998 and December 2000. Outcome data were obtained from 'green form' questionnaires sent to general practitioners (GPs) at least 6 months following the first prescription issued. Incidence densities (IDs) were calculated for events reported per 1000 months of patient exposure and ID differences between the first month of treatment and months 2-6 combined were analysed. Events of medical interest were followed up by postal questionnaire sent to GPs. 21 557 green forms were sent to 8051 doctors, of which 9124 (42.3%) were returned. Useful clinical data was obtained for 7976 patients of which 4664 (58.5%) were female and 3265 (40.9%) were male. The patient's sex was not specified in 47 (0.6%) forms. The median age of the cohort was 53 years (interquartile range 38-66 years). The most frequently reported primary indication was the licensed indication of asthma, but for a small proportion of the cohort it was prescribed 'off label'.A total of 152 events in 120 (1.5%) patients were reported as adverse drug reactions (ADRs) by GPs on the green forms. ADRs with the highest reported frequency were headache and nausea. There were 3514 reasons for stopping zafirlukast in 3148 (39.5%) patients, the most frequently reported of which was that the drug was 'ineffective' (2008 patients; 25.2%). The most frequently reported specified clinical reason for stopping was headache (82 patients; 1.0%). There were 28 pregnancies reported in this cohort, 20 of which were reported to have exposure to zafirlukast during the first trimester. Nine live births with no recorded congenital abnormalities were reported for pregnancies with exposure in the first trimester. There were 151 deaths reported during the study period (1.9%). The most frequently reported causes of death were related to the respiratory system (57; 37.7%), including chronic obstructive pulmonary disease, asthma and bronchopneumonia. This study showed that zafirlukast, as used in general practice in England, is a generally well tolerated drug with few associated adverse events.

Antibiotic prescribing in general practice and hospital admissions for peritonsillar abscess, mastoiditis, and rheumatic fever in children: time trend analysis

Antibiotic resistance is an increasing problem in paediatric practice. General practitioners in the United Kingdom have consequently been exhorted to minimise antibiotic prescribing for childhood upper respiratory infections.1 However, some data suggest an association between reduced prescribing and an increased incidence of rare complications of bacterial infection.2–4 We report national data on community prescribing of antibiotics and hospital admissions for peritonsillar abscess, mastoiditis, and rheumatic fever in children during 1993-2003 (community prescribing) and 1993-2002 (hospital admissions). ### Participants, methods, and results We took prescribing data from the Prescription Pricing Authority's database for England (which collates information on drugs issued by pharmacists) and from the IMS Disease Analyzer Mediplus UK database (which contains electronic consultation data from about 130 computerised practices). We extracted hospital admission data from the hospital episode statistics for England using coding from the international classification of diseases, ninth and 10th revisions (ICD-9, ICD-10): 475 and J36 (quinsy); 390-2 and I00-I02 (rheumatic fever); and 383 and H70 (mastoiditis). The operation codes (OPCS 3 and OPCS 4) that we used for identifying cases of simple or cortical mastoidectomy were 200, 201.2, 201.9, D10.3, and D10.4, but we excluded cases with …

The potential of UK clinical databases in enhancing paediatric medication research

The research potential of many UK clinical databases is not being realized. A recent report published by the Royal College of Paediatrics & Child Health stated that there is a need to build research capacity and support in the area of paediatric pharmacology, with specific emphasis on the use of clinical databases. This article presents the databases available in the UK for medication research and gives some examples of paediatric studies conducted. The databases discussed include the Prescription Pricing Authority database, the General Practice Research Database, IMS Health databases (Medical Data Index, MIDAS Prescribing Insights, Disease-Analyser-Mediplus) and the Yellow Card Scheme. Other databases such as the Medicines Monitoring Unit (MEMO) and the Scottish Primary Care Computer System also have research potential in paediatric pharmacoepidemiology, but their population sizes are relatively small.

Effects of the Committee on Safety of Medicines Advice on Antidepressant Prescribing to Children and Adolescents in the UK

Psychotropic medication prescribing for children and adolescents rose significantly between 2000 and 2002, including antidepressant prescribing. In 2003, the Committee on Safety of Medicines (CSM) advised against using venlafaxine or any selective serotonin receptor inhibitor (SSRI), with the exception of fluoxetine, for childhood and adolescent depression. The aim of this study was to compare the prevalence and incidence of children and adolescents who were prescribed antidepressants in UK primary care, before and after the CSM advice on antidepressant prescribing. We also compared paediatric antidepressant prescribing trends from Mediplus data with national antidepressant prescribing trends in England from the Prescription Pricing Authority (PPA). The Disease Analyzer-Mediplus database contains anonymised primary care records for about 3 million patients. Eligible patients were aged <or=18 years and received >or=1 antidepressant prescription between 2000 and 2004. Antidepressants were grouped according to the CSM advice and the British National Formulary. Prevalence and incidence were calculated. The prevalences of 2000, 2002 and 2004 were compared using a Chi-squared test. PPA data on antidepressant prescribing rates were compared with paediatric antidepressant prescribing rates from Mediplus. 5,718 children and adolescents received a total of 25,542 prescriptions between 2000 and 2004. The median number of prescriptions per patient was two (interquartile range 1-5). Common indications included depression and anxiety. Antidepressant prevalence increased from 2000 to 2002 (from 5.4 to 6.6 patients per 1,000 people), with a rise in the number of patients prescribed venlafaxine and SSRIs. However, between 2002 and 2004 there was a decrease in antidepressant prevalence (from 6.6 to 5.7 per 1,000). The prevalence of CSM-contraindicated antidepressants (citalopram, escitalopram, fluvoxamine, paroxetine, sertraline and venlafaxine) declined by a third (from 3.1 to 2.0 per 1,000), but there was no change in fluoxetine prevalence (from 2.1 to 2.3 per 1,000). The number of patients prescribed tricyclic antidepressants dropped marginally (from 2.0 to 1.7 per 1,000). Incidences followed the same trends as the prevalences, but there was a 48% reduction in the incidence of CSM-contraindicated antidepressants between 2002 and 2004. National antidepressant prescribing trends increased; paediatric prescribing trends were similar to national trends between 2000 and 2003; however, there was a 27% reduction in the paediatric prescribing rate of CSM-contraindicated antidepressants between 2002 and 2004. Since 2003, fewer children and adolescents have been prescribed antidepressants in primary care. However, fluoxetine and non-SSRI antidepressant prevalences have not risen, implying that they are not prescribed as alternative treatments. This study shows that the CSM advice has had a significant effect in reversing the rising prevalence of antidepressant prescribing to children and adolescents in primary care.

Observational cohort study to monitor the use and safety of carvedilol in the treatment of heart failure in clinical practice in England – 1st interim report

This is an interim report of a prospective observational cohort study to monitor the safety and tolerability of carvedilol in clinical practice when prescribed for heart failure in England. The utilization of carvedilol, management of adverse events in the community and the symptomatic progression of heart failure were examined. It is a non-interventional, observational cohort surveillance study using questionnaires sent to the patients' general practitioners. The general practitioners (GPs) of the patients identified by the Prescription Pricing Authority were sent an eligibility questionnaire if the patient had been newly prescribed carvedilol between September 1999 and July 2001. Further questionnaires requesting baseline clinical information about eligible patients (carvedilol indicated for cardiac failure) and subsequent event data were sent to consenting GPs at 12 months. The questionnaires also requested specific information about initiation and supervision of treatment, including severity of heart failure and treatment withdrawal. The data were analyzed by using descriptive statistics. In addition, the incidence densities (ID) of each event (per 1000 person-months of treatment) were calculated, ranked and the difference between the ID of each event in the first (ID1) and subsequent 5 months of exposure (ID2) was tested by constructing 99% confidence intervals (CI). Selected events of clinical interest would be followed-up for further information to enable causal association with carvedilol to be assessed. In this interim report we have data on a cohort of 847 eligible patients for whom we have received information from the first follow-up questionnaire. The treatment of carvedilol was initiated in a majority of cases by hospital specialists (87%, n = 735), however, for most of them, further supervision of treatment was done under shared care between GPs and hospitals (70%, n = 595). More than 90% of the patients were started on carvedilol in the recommended dose range for the management of cardiac failure. Amongst the patients where NYHA grade of cardiac failure was expressed, the majority of patients treated with carvedilol had NYHA II (37%, n = 281) and III (40%, n = 297) symptoms at the start of carvedilol treatment. On treatment with carvedilol, improvement in NYHA status was reported for 43% (n = 364) of this cohort, whilst less than 2.5% (n = 20) of the patients deteriorated. The events reported with the highest ID1 were malaise/lassitude (14.6), dizziness (12.2), cardiac failure (9.7), dyspnea (9.7) and hypotension (8.5). The most common events reported as reasons for stopping carvedilol were "drug not effective", "dyspnea", "dizziness" and "lassitude". No events were identified as new signals (according to the ID1-ID2 statistic) of adverse events associated with carvedilol. There have been no events identified in this cohort that have required specific follow-up at the time of writing this paper. In summary, the interim results show that there is effective cooperation between hospital specialists and GPs in the use of carvedilol in the management of patients with heart failure. It also shows that carvedilol was well-tolerated and that patients with mild and moderate heart failure benefit symptomatically when treated with carvedilol in routine clinical practice.

Integrated care and electronic transmission of prescriptions: experience of the evaluation of ETP pilots

The NHS Care Records Service will connect more than 30,000 GPs and 270 acute, community and mental health NHS trusts in a single, secure national system. This will support electronic transmission of prescriptions (ETP) to pharmacies linked to the NHS Care Records Service spine and also to the national Prescription Pricing Authority (PPA). This article reflects on the experience of evaluating three pilot implementations of ETP in England in 2002, and concludes that some evaluation findings may be relevant not only to ETP messaging but also to electronic health record (EHR) systems and hence to the broader implications of implementing the NHS Care Records Service.

Explaining variation in antidepressant prescribing rates in east London: a cross sectional study

Rates of depression and anxiety in south Asian populations are lower than expected. It remains uncertain whether this reflects a real difference in prevalence or differences in case recognition and management. To examine whether concordance of culture or ethnicity between doctors and patients affects the prescribing rates for antidepressant and anxiolytic medications in general practice populations, taking into account demography, practice size and organization. A cross-sectional general practice study, using practice and demographic data from primary care trusts, doctors' place of qualification from the General Medical Council, combined with practice level prescribing data from the prescription pricing authority (PACT) for the period 2000-2002. Set in 139 practices in the east London primary care trusts (PCTs) of Tower Hamlets, Hackney and Newham, multiethnic areas with large populations of south Asian residents and doctors. The main outcome measure was the annual prescribing rates for each group of drugs, calculated as the mean of two years average daily quantities (ADQs) for each medication, divided by the practice population. In east London the median prescribing rate (ADQs) for all antidepressants was 7.97 (inter-quartile range 4.91-10.76), for all anxiolytics and hypnotics 2.27 (interquartile range 1.11-3.96). There were significant differences in prescribing rates between practices with UK trained GPs and practices with south Asian trained GPs, with the highest rates of antidepressant prescribing in practices with UK trained GPs and low proportions of south Asian patients. No differences were found in anxiolytic and hypnotic prescribing rates between these practices. 57% of the variation in prescribing between practices could be explained by a model including the place of GP qualification, the proportion of registered women, older (>65) patients, and the list size per full time GP. Compared with previous studies prescribing rates for antidepressants have almost doubled over five years, the greatest increase being for selective serotonin re-uptake inhibitors (SSRIs). There is a modest fall in prescribing rates for anxiolytics and hypnotics. Concordance between south Asian practice populations and doctors from similar south Asian cultures is not associated with an increase in antidepressant prescribing. Lower rates of prescribing in practices with south Asian trained doctors occur regardless of the ethnic composition of the practice population. Reasons for these differences are uncertain, but may include differences in explanatory models for presenting symptoms, and management strategies which rely less on a biomedical paradigm.

Safety profile of raloxifene as used in general practice in England: results of a prescription-event monitoring study.

Raloxifene, a selective estrogen receptor modulator (SERM) licensed for the prevention of non-traumatic vertebral fractures in postmenopausal women at increased risk of osteoporosis, was launched in the UK in August 1998. The aim of the study was to monitor the safety of raloxifene prescribed in the primary care setting in England using prescription-event monitoring (PEM). Patients were identified by means of prescription data supplied by the Prescription Pricing Authority between September 1998 and November 2000. Demographic and clinical event data were collected from questionnaires posted to primary care physicians (GPs) at least 6 months after the date of the first prescription for each patient. Information on medical events, suspected adverse drug reactions (ADRs), reasons for stopping treatment, pregnancies, and causes of death was requested. Event rates [Incidence Densities (IDs): no. first reports /1000 patient-months of treatment] were calculated. Differences between IDs for events reported in month one (ID(1)) and months 2-6 (ID(2-6)) of treatment were examined. The cohort comprised 13,987 patients [median age 62 years (IQR 55,69); 99.8% female]. The major indication was osteoporosis (40.9%, n=5725). Flushing was the event with the highest ID in month 1 (22.8), reported most frequently by GPs as an ADR to raloxifene (67/461 reports) and as the reason for stopping (700/4592 reports). Events associated with starting treatment included flushing, malaise/lassitude, headache/migraine, nausea/vomiting, sweating, cramp, pain abdomen, dizziness, diarrhea, mastalgia and vaginal hemorrhage. Less common events reported during treatment included deep vein thrombosis (n=13), pulmonary embolism (n=13), thrombophlebitis (n=31) and visual disturbance (n=29). In this study, there were 122 (0.9%) confirmed deaths, of which 32 causes of death were unknown. This study shows that raloxifene is generally well tolerated when used in general practice in England. Potential signals of unrecognised ADRs requiring further evaluation included gastrointestinal adverse symptoms and vaginal hemorrhage. There were also a small number of reports of events associated with venous thromboembolism and visual disorders that require further investigation.

Safety profile of celecoxib as used in general practice in England: results of a prescription-event monitoring study.

A post-marketing surveillance study using the technique of Prescription Event Monitoring was undertaken to monitor the safety of celecoxib, a cyclo-oxygenase (COX)-2 inhibitor, as prescribed in primary care in England. Patients were identified from dispensed British National Health Service prescription data supplied in confidence by the Prescription Pricing Authority for celecoxib between May and December 2000. Simple questionnaires were sent to the prescribing general practitioner at least 6 months after the date of the first dispensed prescription for each individual patient. Event incidence densities (IDs) [the number of 1st reports per 1000 patient-months of exposure (pme)] were calculated. ID differences for events reported in month 1 (ID1) and months 2-6 (ID2) were examined for temporal changes in event rate. Information on suspected adverse drug reactions (ADRs), reasons for stopping treatment, outcome of pregnancies and cause of death were also requested. Data were gathered on potential gastrointestinal (GI) risk factors [recent use of other non-steroidal anti-inflammatory drugs (NSAIDs), past history of upper GI disorders and concomitant gastro-irritant agents or anti-ulcer drugs]. Crude IDs per 1000 pme and ID ratios were calculated according to potential risk factors, and age (> or = 65 years, < or = 64 years). The cohort comprised of 17,458 patients [median age 62 years (IQR 51,73); 68.3% female]. The most common specified indication was osteoarthritis (28.1%, n = 4905). Not effective was the event with the highest ID1 (139.9 per 1000 pme). The clinical events with the highest ID1 were dyspepsia (25.4 per 1000 pme) followed by abdominal pain (10.6). These were also given frequently as reasons for stopping (551 and 174 of 9126 reports). Of 436 events in 325 patients (1.9% of total cohort) that were reported as ADRs, the most frequent were events within the alimentary system (186 reports). Uncommon events reported during treatment (not necessarily as ADRs) included allergy (0.10%, n = 17), anaphylaxis (0.01%, n = 2), angioneurotic oedema (0.02%, n = 3) and bronchospasm (0.05%, n = 9). There were 103 reports of events associated with thromboembolism and 111 reports of serious GI events [90 GI bleeds (upper and lower); 21 peptic ulcers] received during treatment or within 1 month of stopping. A past history of dyspeptic/other upper GI conditions and use of concomitant gastro-protective drugs were each associated with a significantly increased risk of dyspepsia and abdominal pain. Frequently reported adverse events were those GI events commonly associated with treatment with other NSAIDS. Stratification by identified risk factors suggested that channelling of high-risk patients is likely. Serious upper and lower GI events, and thromboembolic events did occur during this study, although the incidence was low (< 1%). Doctors should continue to prescribe NSAIDs, including COX-2-specific inhibitors, with caution.

Determinants of prescribing costs amongst single-handed general practitioners.

To investigate the contribution of patient and doctor characteristics in explaining observed variations in prescribing costs between individual doctors. Secondary analysis of data collected from general practitioners, Family Health Services Authorities, 1991 Census data set and the Prescription Pricing Authority. A multiple regression model with four variables (social class, training status, generic prescribing and length of time in general practice) explained only 16.5% of the variation in costs/ASTRO-PU. This study highlights that very little of the variation in prescribing costs can readily be explained. Further research is needed to document contributing factors.

Reducing community dyspepsia drug costs: a controlled trial

BACKGROUNDDyspepsia drug costs account for nearly 0.5% of the National Health Service budget. We hypothesised that improved management of dyspepsia would lead to reduced drug costs.AIMTo determine whether a multifaceted...

An update on the use of influenza vaccination in Wales and the impact of changes in government policy

Background: Influenza vaccine uptake in the United Kingdom has been improving steadily during the 1990s. In late 1998 the government announced that it was revising its guidelines for vaccine use to include all those 75 years and above as well as those in the previous high-risk categories. The author and others have shown that these changes would increase the high-risk pool of individuals, in Wales (population 2.9 million), recommended for vaccination to 15%. This present study builds on previous work on vaccine usage by Welsh general medical practitioners and quantifies the response to the policy change at both a national and practice level. Methods: Using information from the prescription pricing authority for Wales and computerised medical practices, vaccine uptake rates were calculated nationally for Wales, by administrative health regions, with a population of 550,000 on average, and by individual practices in southeast Wales. This data has been available from the early 1990s to the present day and covers the winter of 1998/1999, when policy was changed. Results: Since the 1980s, the uptake of vaccine has risen marginally in Wales from 8.7% of the population being vaccinated in 1993 to 9% in 1998/1999. Despite the change in government policy, no significant increase in response to this was seen at any population level. Less than 50% of those recommended for vaccination received it, with a 10-fold variation in the percentage of the population vaccinated by individual general medical practices. Conclusions: This study demonstrates that changes in government vaccination policy have made little difference to the vaccination practices of individual doctors. There still exists a shortfall between 2% and 6% (assuming that all vaccine doses are given to those who require it) between the vaccine delivered and the pool of the population at risk. In the United Kingdom, a vaccination policy left to individual practices to organise, with little central coordination or funding, leads to wide-scale variation and a large percentage of the population left unprotected.