Prescribing Quality Indicators Research Articles

The effects of substitution of hospital ward care from medical doctors to physician assistants on non-adherence to guidelines on medication prescribing.

AimThis study determined the effect of substitution of inpatient care from medical doctors (MDs) to physician assistants (PAs) on non-adherence to guidelines on medication prescribing.MethodsA multicenter matched-controlled study was performed comparing wards on which PAs provide medical care in collaboration with MDs (PA/MD model), with wards on which only MDs provide medical care (MD model). A set of 17 quality indicators to measure non-adherence to guidelines on medication prescribing by PAs and MDs was composed by 14 experts in a modified Delphi procedure. The indicators covered different pharmacotherapeutic subjects, such as gastric protection in case of use of NSAID or prevention of obstipation in case of use of opioids. These indicators were expressed in proportions by dividing the number of patients in which the prescriber did not adhere to a guideline, by all patients that were applicable. Multivariable regression analysis was performed in order to adjust for potential confounders.Results1021 patients from 17 hospital wards in the ‘PA/MD model’ group and 1286 patients from 17 hospital wards in the ‘MD model’ group were included. Two of the 17 quality indicators showed significantly less non-adherence to guidelines for the PA/MD model; the indicators concerning prescribing gastric protection in case of use of NSAID in combination with corticosteroids (OR 0.42, 95% CI 0.19–0.90) and in case of use of NSAID in patients older than 70 years (OR 0.47, 95% 0.23–0.95). For none of the other quality indicators for prescribing of medication a difference between the MD model and the PA/MD model was found.ConclusionThis study suggests that the non-adherence to guidelines on medication prescribing on wards with the PA/MD model does not differ from wards with traditional house staffing by MDs only. Further research is needed to determine quality, efficiency and safety of prescribing behavior of PAs.

Evaluating inter-rater reliability of indicators to assess performance of medicines management in health facilities in Uganda

BackgroundTo build capacity in medicines management, the Uganda Ministry of Health introduced a nationwide supervision, performance assessment and recognition strategy (SPARS) in 2012. Medicines management supervisors (MMS) assess performance using 25 indicators to identify problems, focus supervision, and monitor improvement in medicines stock and storage management, ordering and reporting, and prescribing and dispensing. Although the indicators are well-recognized and used internationally, little was known about the reliability of these indicators. An initial assessment of inter-rater reliability (IRR), which measures agreement among raters (i.e., MMS), showed poor IRR; subsequently, we implemented efforts to improve IRR. The aim of this study was to assess IRR for SPARS indicators at two subsequent time points to determine whether IRR increased following efforts to improve reproducibility.MethodsIRR was assessed in 2011 and again after efforts to improve IRR in 2012 and 2013. Efforts included targeted training, providing detailed guidelines and job aids, and refining indicator definitions and response categories. In the assessments, teams of three MMS measured 24 SPARS indicators in 26 facilities. We calculated IRR as a team agreement score (i.e., percent of the MMS teams in which all three MMS had the same score). Two sample tests for proportions were used to compare IRR scores for each indicator, domain, and overall for the initial assessment and the following two assessments. We also compared the IRR scores for indicators classified as simple (binary) versus complex (multi-component). Logistic regression was used to identify supervisor group characteristics associated with domain-specific and overall IRR scores.ResultsInitially only five (21%) indicators had acceptable reproducibility, defined as an IRR score ≥ 75%. At the initial assessment, prescribing quality indicators had the lowest and stock management indicators had the highest IRR. By the third IRR assessment, 12 (50%) indicators had acceptable reproducibility, and the overall IRR score improved from 57% to 72%. The IRR of simple indicators was consistently higher than that of complex indicators in the three assessment periods. We found no correlation between IRR scores and MMS experience or professional background.ConclusionsAssessments of indicator reproducibility are needed to improve IRR. Using simple indicators is recommended.

Trends in the prescription of benzodiazepines for the elderly in Korea

BackgroundThis study examined trends in the prescription of benzodiazepines for the elderly (age over 65 years) in Korea, a country with a higher level of spending on pharmaceuticals compared to that in other Organization for Economic Cooperation and Development (OECD) countries, and identified factors related to the inappropriate use of such drugs.MethodsWe used the National Health Insurance Claims Data (NHICD) for the period 2009–2013, including all reimbursed drug-prescribing information. Following the OECD’s prescribing quality indicators (PQIs), we looked at the prevalence, quantities, durations, and inappropriate (long-term or high-quantity) use of benzodiazepines, some of the most widely prescribed, but potentially inappropriate, drugs for the elderly. We also performed multivariate logistic regression analyses to identify factors related to the inappropriate use of these drugs.ResultsThe annual prevalence of benzodiazepine prescribing for elderly subjects decreased slightly over time but remained high (37.9% in 2009 and 35.1% in 2013). There were also small decreases in the inappropriate long-term use of benzodiazepines over the five years, with a 0.6 decrease in the Defined Daily Dose and a 4.1 per 1,000 decreases in elderly user-days. The proportion of subjects using long-acting benzodiazepines also fell from 263.6 to 220.4 per 1,000 elderly patients. The regression analyses found that the inappropriate long-term use of benzodiazepines in the elderly was significantly related to the patients visiting several institutions and physicians prescribing more than 30 days’ worth of medication.ConclusionsThe prevalence of prescribing potentially inappropriate drugs, such as benzodiazepines, remains high in Korea. Policy efforts, such as a periodic assessment of prescribing, restricting prescribing days, and more practical guidelines, are needed to improve the quality of prescribing.

Differences in antimicrobial consumption, prescribing and isolation rate of multidrug resistant Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii on surgical and medical wards.

In order to provide guidance data for clinically rational use of an antibiotics consuption, prescribing and prevalence of multidrug resistant (MDR) Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii were monitored on the surgical (S) and medical (M) wards of the University Hospital Center “Dr. Dragisa Misovic-Dedinje” (Belgrade, Serbia), in the study period from 2012 to 2015. Appropriateness of antimicrobial use was evaluated using the Global-Prevalence Survey method designed by the University of Antwerp. The percentages of MDR pathogens relative to the total number of isolates of K. pneumoniae and P. aeruginosa were higher on the S (86.2% and 49.1%) than on the M (63.2% and 36.9%) wards. The percentage of MDR A. baumannii was not different between S (93.7%) and M (79.5%) wards. An overall antibiotics consumption (defined daily doses/100 bed-days) during study was 369.7 and 261.5 on the S and M wards, respectively. A total of 225 prescriptions of antimicrobials were evaluated in138 adults admitted to wards on the day of the survey. The percentage of antimicrobials prescribed for prophylaxis on the M and S wards were 0% and 25%, respectively. Therapies were more frequently empiric (S, 86.8% and M, 80%). The percentages of medical errors on the S and M wards were 74.6% and 27.3%, respectively. The quality indicators for antibiotic prescribing on the S and M wards were as follows: the incorrect choice of antimicrobials (35.6% vs. 20.0%), inappropriate dose interval (70.6% vs. 16.9%) or duration of therapy (72.5% vs. 23.1%), a non-documented stop/review data (73.6% vs. 16.9%) and divergence from guidelines (71.9% vs. 23.1%). Treatment based on biomarkers was more common on the M wards as compared to the S wards. The increasing prevalence of MDR pathogens, a very high consumption and incorrect prescribing of antimicrobials need special attention, particularly on the S wards.

Antibiotic prescribing in relation to diagnoses and consultation rates in Belgium, the Netherlands and Sweden: use of European quality indicators

Objective: To assess the quality of antibiotic prescribing in primary care in Belgium, the Netherlands and Sweden using European disease-specific antibiotic prescribing quality indicators (APQI) and taking into account the threshold to consult and national guidelines.Design: A retrospective observational database study.Setting: Routine primary health care registration networks in Belgium, the Netherlands and Sweden.Subjects: All consultations for one of seven acute infections [upper respiratory tract infection (URTI), sinusitis, tonsillitis, otitis media, bronchitis, pneumonia and cystitis] and the antibiotic prescriptions in 2012 corresponding to these diagnoses.Main outcome measures: Consultation incidences for these diagnoses and APQI values (a) the percentages of patients receiving an antibiotic per diagnosis, (b) the percentages prescribed first-choice antibiotics and (c) the percentages prescribed quinolones.Results: The consultation incidence for respiratory tract infection was much higher in Belgium than in the Netherlands and Sweden. Most of the prescribing percentage indicators (a) were outside the recommended ranges, with Belgium deviating the most for URTI and bronchitis, Sweden for tonsillitis and the Netherlands for cystitis. The Netherlands and Sweden prescribed the recommended antibiotics (b) to a higher degree and the prescribing of quinolones exceeded the proposed range for most diagnoses (c) in Belgium. The interpretation of APQI was found to be dependent on the consultation incidences. High consultation incidences were associated with high antibiotic prescription rates. Taking into account the recommended treatments from national guidelines improved the results of the APQI values for sinusitis in the Netherlands and cystitis in Sweden.Conclusion: Quality assessment using European disease-specific APQI was feasible and their inter-country comparison can identify opportunities for quality improvement. Their interpretation, however, should take consultation incidences and national guidelines into account. Differences in registration quality might limit the comparison of diagnosis-linked data between countries, especially for conditions such as cystitis where patients do not always see a clinician before treatment.Key pointsThe large variation in antibiotic use between European countries points towards quality differences in prescribing in primary care. • The European disease-specific antibiotic prescribing quality indicators (APQI) provide insight into antibiotic prescribing, but need further development, taking into account consultation incidences and country-specific guidelines. • The incidence of consultations for respiratory tract infections was almost twice as high in Belgium compared to the Netherlands and Sweden. • Comparison between countries of diagnosis-linked data were complicated by differences in data collection, especially for urinary tract infections.

Development and validation of prescribing quality indicators for patients with type 2 diabetes.

Quality indicators are used to measure whether healthcare professionals act according to guidelines, but few indicators focus on the quality of pharmacotherapy for diabetes. The aim of this study was to develop and validate a set of prescribing quality indicators (PQIs) for type 2 diabetes in primary care, and to apply this set in practice. To take into account the stepwise treatment of chronic disease, clinical action indicators were specifically considered. Potential PQIs were derived from clinical practice guidelines and evaluated using the RAND/UCLA Appropriateness Method, a modified Delphi panel. Thereafter, the feasibility of calculating the PQIs was tested in two large Dutch primary care databases including >80000 diabetes patients in 2012. 32 PQIs focusing on treatment with glucose, lipid, blood pressure and albuminuria lowering drugs, and on vaccination, medication safety and adherence were assessed by ten experts. After the Delphi panel, the final list of twenty PQIs was tested for feasibility. All PQIs definitions were feasible for measuring the quality of medication treatment using these databases. Indicator scores ranged from 18.8% to 90.8% for PQIs focusing on current medication use, clinical action and medication choice, and from 2.1% to 37.2% for PQIs focusing on medication safety. Twenty PQIs focusing on treatment with glucose, lipid, blood pressure and albuminuria lowering drugs, and on medication safety in type 2 diabetes were developed, considered valid and operationally feasible. Results showed room for improvement, especially in initiation and intensification of treatment as measured with clinical action indicators.

Using Prescription Patterns in Primary Care to Derive New Quality Indicators for Childhood Community Antibiotic Prescribing.

To describe patterns of antibiotic outpatient use in 3 European countries, including 2 new pediatric-specific quality indicators (QIs). A cohort study was conducted, 2001-2010, using electronic primary care records of 2,196,312 children up to 14 (Pedianet, Italy) or 18 years (The Health Improvement Network, United Kingdom; Integrated Primary Care Information database, The Netherlands) contributing 12,079,620 person-years. Prevalence rates of antibiotic prescribing per year were calculated and antibiotics accounting (drug utilization) for 90% of all antibiotic prescriptions were identified (drug utilization 90% method). The ratio between users of broad to narrow-spectrum penicillins, cephalosporins and macrolides (B/N ratio) and 2 pediatric-specific QIs: the proportion of amoxicillin users (amoxicillin index) and the ratio between users of amoxicillin to broad-spectrum penicillins, cephalosporins and macrolides (A/B ratio) were determined. The overall annual prevalence of antibiotic prescriptions was 18.0% in the Netherlands, 36.2% in the United Kingdom and 52.0% in Italy. Use was maximal in the first years of life. The number of antibiotics accounting for the drug utilization 90% was comparable. The B/N ratio varied widely from 0.3 to 74.7. The amoxicillin index was highest in the Netherlands and the United Kingdom (50-60%), lowest in Italy (30%) and worsened over time in the United Kingdom and Italy. The A/B ratio in 2010 was 0.3 in Italy, 1.7 in the Netherlands and 5.4 in the United Kingdom. The patterns of antibiotic prescribing varied highly with age and country. The pediatric-specific QIs combined with the total prevalence rate of use provide a clear picture of the trends of community childhood antibiotic prescribing, allowing monitoring of the impact of policy interventions.

Determinants of physician antibiotic prescribing behavior: a 3 year cohort study in Portugal

Objectives Antibiotic misprescription is a major driver of resistance, which is a worldwide public health problem. Therefore, our aim is to assess the influence of the determinants of physician prescribing on the quality of antibiotic use.Methods A 3 year cohort study including all primary-care physicians working in Portugal’s Central Regional Health Administration (n = 1094) was conducted. We assessed the determinants of prescribing using a pre-validated, personally addressed, reply-paid, self-administered questionnaire (sent four times to non-responders, between September 2011 and February 2012) designed to collect information on physicians’ attitudes to and knowledge of antibiotic prescribing as well as their socio-demographic and professional data. To evaluate antibiotic prescribing, we’ve calculated ESAC 12 quality indicators per physician per year, allowing us to stratify them as good or poor prescribers according to their performance on those indicators. Associations between determinants and outcomes were fitted with generalized linear mixed models.Results The overall response rate was 46.1%. Emergency activity (OR [95% CI] = 0.29 [0.16–0.54]; p < 0.05) and workload (number of patients seen per day: OR [95% CI] = 0.97 [0.94–1.00]; p < 0.05; number of patients seen per week in emergencies: OR [95% CI] = 0.98 [0.97–0.99]; p < 0.05) were both related to poor quality of antibiotic prescribing. Statistically significant odds ratios were also obtained for ignorance (IqOR [95% CI] = 2.14 [1.31–3.52]), complacency (1/IqOR [95% CI] = 1.19 [1.01–1.41]) and responsibility of others (1/IqOR [95% CI] = 1.78 [1.10–3.06]).Conclusions The above results serve to emphasize workload, working at emergency departments and physicians’ attitudes identified as critical factors affecting antibiotic prescribing. This provides new insights for clinicians, researchers and policy makers when it comes to developing and improving the clinical and economic outcomes of antibiotic use. Key limitations of the study included the difficulty of results extrapolation and the limitations of the stratification method based on the antibiotic prescribing quality indicators.

Development and initial validation of prescribing quality indicators for patients with chronic kidney disease

Quality assessment is a key element for improving the quality of care. Currently, a comprehensive indicator set for measuring the quality of medication treatment in patients with chronic kidney disease (CKD) is lacking. Our aim was to develop and validate a set of prescribing quality indicators (PQIs) for CKD care, and to test the feasibility of applying this set in practice. Potential indicators were based on clinical practice guidelines and evaluated using the RAND/UCLA Appropriateness Method. This is a structured process in which an expert panel assesses the validity of the indicators. Feasibility was tested in a Dutch primary care database including >4500 diabetes patients with CKD. An initial list of 22 PQIs was assessed by 12 experts. After changing 10 PQIs, adding 2 and rejecting 8, a final list of 16 indicators was accepted by the expert panel as valid. These PQIs focused on the treatment of hypertension, albuminuria, mineral and bone disorder, statin prescribing and possible unsafe medication. The indicators were successfully applied to measure treatment quality in the primary care database, but for some indicators the number of eligible patients was too small for reliable calculation. Results showed that there was room for improvement in the treatment quality of this population. We developed a set of 16 PQIs for measuring the quality of treatment in CKD patients, which had sufficient content and face validity as well as operational feasibility. These PQIs can be used to point out priority areas for improvement.

How public reporting of prescription quality indicators influence prescribing practices? A survey of general practitioners.

Public reporting of performance data is one of the most popular topics in health care field. The aim of this study was to investigate the transparency mechanism, that is, how public reporting influenced general practitioners' (GPs) prescribing practices. GPs who had the license to prescribe medicine of all 10 primary care institutions were surveyed. Data were collected by an instrument, which exhibited satisfactory reliability and validity (Cronbach's alpha > 0.7; average variance extracted > 0.5; composite reliability > 0.7). Data analysis was conducted by structural equation model. The results showed that GPs' perceived value (GP's overall assessment of the worth of the public reporting) and attitude (the psychological reaction to public reporting) had a significantly direct effect on behavioural intention (r = 0.28; r = 0.36), and were affected by information accessibility (r = 0.63; r = 0.32). Attitude had a significant effect on perceived value(r = 0.45). Perceived risk (the perceptions of the possible loss due to public reporting, e.g. decreasing their income) did not have a significant relationship with information accessibility, attitude and behavioural intention(r = -0.09; r = 0.01; r = -0.07). The information accessibility, perceived value and attitude have strong effects on prescribing practices of GPs, whereas perceived risk did not play a role in influencing the prescribing practices. Policymakers need to improve the accessibility of prescription quality indicators and pay attention to the perceived values and attitudes of GPs. Policymakers also need to strengthen the risk education of GPs and attach incentives to transparent regulation.

Evaluating medication-related quality of care in residential aged care: a systematic review.

Given the growing aged care population, the complexity of their medication-related needs and increased risk of adverse drug events, there is a necessity to systematically monitor and manage medication-related quality of care. The aim of this systematic review was to identify and synthesise medication-related quality of care indicators with respect to application to residential aged care. MEDLINE (Ovid), Psychinfo, CINAHL, Embase and Google® were searched from 2001 to 2013 for studies that were in English, focused on older people aged 65+ years and discussed the development, application or validation of original medication-related quality of care indicators. The quality of selected articles was appraised using the Critical Appraisal Skills Program and psychometric qualities extracted and synthesised using content analysis. Indicators were mapped to six medication-related quality of care attributes and a minimum indicator set derived. Thirty three articles describing 25 indicator sets met the inclusion criteria. Thirteen (52%) contained prescribing quality indicators only. Eight (32%) were developed specifically for aged care. Twenty three (92%) were validated and seven (28%) assessed for reliability. The most common attribute addressed was medication appropriateness (n = 24). There were no indicators for evaluating medication use in those with limited life expectancy, which resulted in only five of the six attributes being addressed. The developed minimum indicator set contains 28 indicators representing 22 of 25 identified indicator sets. Whilst a wide variety of validated indicator sets exist, none addressed all aspects of medication-related quality of care pertinent to residential aged care. The minimum indicator set is intended as a foundation for comprehensively evaluating medication-related quality of care in this setting. Future work should focus on bridging identified gaps.

Treatment practice of acute cystitis on the basis of national prescription data

Urinary tract infections are one of the common diseases in the primary health care. To analyse patterns of ambulatory antibiotic use in acute cystitis. Antibiotic use data was based on national-level prescription turnovers. Patterns of antibiotic use were evaluated by prescribing quality indicators. The content of different national guidelines for treatment of acute cystitis and adherence to these guidelines were also evaluated. For the treatment of acute cystitis quinolones were used predominantly. Norfloxacin (26%) and ciprofloxacin (19%) were prescribed most commonly. The use of internationally recommended agents such as sulphonamides, nitrofurans and fosfomycin shared 15%, 7% and 2%, respectively. The average adherence rate to national guidelines was 66% and certain weak points (e.g. controversial content) of the national guidelines were also identified. Antibiotic use in acute cystitis seems to be suboptimal in Hungary. Considering actual local antibiotic resistance patterns, a new national guideline should be worked out for acute cystitis treatment.

Selection of hospital antimicrobial prescribing quality indicators: a consensus among German antibiotic stewardship (ABS) networkers

Simple, valid, and evidence-based indicators to measure the quality of antimicrobial prescribing in acute-care hospitals are urgently needed and increasingly requested by policymakers. The aim of this study was to develop new consensus quality indicators (QIs) for hospital antibiotic stewardship (ABS) and infection management which will be further evaluated for internal quality management and external quality assessment in Germany. Based on an extensive literature review, the Austrian-German hospital ABS Guideline Committee and selected members of the German ABS Expert Network discussed and drafted a list of 99 potential indicators for hospitals that reflect structural prerequisites for ABS (35 items), ABS core activities (18 items), additional ABS measures (5 items), and process of care indicators (both generic and disease-specific-12 and 29 items, respectively). Questionnaires were mailed to German ABS experts and healthcare professionals with further education in ABS. Participants scored (on a nine-point Likert scale) relevance (clinical, ecological/resistance, economical/expenses) and presumed practicability (six categories: clarity of definition, effort to collect data, barrier to implementation, verifiability, suitability for external quality assessment, quality gap), taking into account their local work environment. The scores were processed according to the RAND/UCLA appropriateness method, and QIs were judged relevant if the median (clinical + ecological and/or economical) scores were >6. The indicators thus assessed to be potentially relevant were then filtered according to their practicability. Highly relevant QIs with borderline practicability scores and items with disagreements and overlapping areas were re-discussed in a final multidisciplinary panel consensus workshop convened in November 2012. Of the 340 questionnaires that were mailed, 75 questionnaires were completed and returned. Of 99 initially proposed items, 32 were excluded due to insufficient scores. Of the remaining 67 items, 21 structural and 21 process of care QIs were finally selected, including four QIs with high clinical and ecological but limited economical relevance, and three QIs with high clinical and economical but limited ecological relevance. Among the selected QIs, efforts to collect data and implementation barriers were scored as suboptimal in many cases. A catalog of consensus structural and process of care ABS-QIs was established. These should undergo further pilot and feasibility studies in the German hospital healthcare sector. The panelists were most critical regarding resource use/complexity issues and presumed implementation barriers. How this may limit applicability of QIs remains to be determined.

Quality of antibiotic prescription during office hours and out-of-hours in Flemish primary care, using European quality indicators

Background: European disease-specific antibiotic prescribing quality indicators (APQI) were proposed for seven acute indications (bronchitis, upper respiratory infection, cystitis, tonsillitis, sinusitis, otitis media and pneumonia): (a) the percentage of patients prescribed an antibiotic; (b) the percentage of patients receiving the guideline recommended antibiotic; (c) the percentage of patients receiving quinolones.Objectives: To assess the feasibility of calculating values for these 21 APQI using primary care databases; and to assess the quality of antibiotic prescribing in office hours and out-of-hours general practice.Methods: Data was extracted from a morbidity registration network (http://www.intego.be) and the out-of-hours service centre in Flanders. Within both databases diagnoses are labelled using the revised second edition of International Classification of Primary Care (ICPC-2-R) and antibiotic prescriptions using Anatomical Therapeutic Chemical (ATC) classification.Results: Both databases allow calculation of APQI values and results are similar. Only for cystitis was the percentage of patients prescribed an antibiotic within the proposed acceptable range. For all indications, the percentage of recommended antibiotics was below the proposed acceptable range (80–100%). The percentage of quinolones was within the proposed acceptable range (0–5%) for otitis media, upper respiratory infection and tonsillitis.Conclusion: Primary care databases can produce APQI values. These values revealed huge opportunities to improve the quality of antibiotic prescribing in office hours and out-of-hours Flemish general practice, especially the prescription of recommended antibiotics.

High Prevalence of Poor Quality Drug Prescribing in Older Individuals: A Nationwide Report From the Italian Medicines Agency (AIFA)

Poor quality of drug prescribing in older persons is often associated with increased drug-related adverse events, hospitalization, and mortality. The present study describes a set of prescribing quality indicators developed by the Geriatrics Working Group of the Italian Medicines Agency (AIFA) and estimates their prevalence in the entire elderly (≥ 65 years) population in Italy. We performed a cross-sectional study using 2011 data from the OsMed (Osservatorio dei Medicinali) database, which comprises all prescribed drugs that are reimbursed by the Italian National Healthcare System. Yearly prevalence of drug prescribing quality indicators in the Italian older population (n = 12,301,537) was determined. Overall, 13 quality indicators addressing polypharmacy, adherence to treatment of chronic diseases, prescribing cascade, undertreatment, drug-drug interactions, and drugs to be avoided were identified. Polypharmacy was common, with more than 1.3 million individuals taking greater than or equal to 10 drugs (11.3% of the study population). The prevalence of low adherence and undertreatment was also elevated and increased with advancing age, with highest prevalence occurring in individuals aged 85 years and older. Prevalence was less than 3% for quality indicators assessing the prescribing cascade, drug-drug interactions, and drugs to be avoided. These results confirm the high frequency of suboptimal drug prescribing in older adults, using a database that covers the whole Italian population. In general, this descriptive study may help in prioritizing strategies aimed at improving the quality of prescribing in elderly population.

An ethnographic exploration of influences on prescribing in general practice: why is there variation in prescribing practices?

BackgroundPrescribing is a core activity for general practitioners, yet significant variation in the quality of prescribing has been reported. This suggests there may be room for improvement in the application of the current best research evidence. There has been substantial investment in technologies and interventions to address this issue, but effect sizes so far have been small to moderate. This suggests that prescribing is a decision-making process that is not sufficiently understood. By understanding more about prescribing processes and the implementation of research evidence, variation may more easily be understood and more effective interventions proposed.MethodsAn ethnographic study in three Scottish general practices with diverse organizational characteristics. Practices were ranked by their performance against Audit Scotland prescribing quality indicators, incorporating established best research evidence. Two practices of high prescribing quality and one practice of low prescribing quality were recruited. Participant observation, formal and informal interviews, and a review of practice documentation were employed.ResultsPractices ranked as high prescribing quality consistently made and applied macro and micro prescribing decisions, whereas the low-ranking practice only made micro prescribing decisions. Macro prescribing decisions were collective, policy decisions made considering research evidence in light of the average patient, one disease, condition, or drug. Micro prescribing decisions were made in consultation with the patient considering their views, preferences, circumstances and other conditions (if necessary).Although micro prescribing can operate independently, the implementation of evidence-based, quality prescribing was attributable to an interdependent relationship. Macro prescribing policy enabled prescribing decisions to be based on scientific evidence and applied consistently where possible. Ultimately, this influenced prescribing decisions that occur at the micro level in consultation with patients.ConclusionGeneral practitioners in the higher prescribing quality practices made two different ‘types’ of prescribing decision; macro and micro. Macro prescribing informs micro prescribing and without a macro basis to draw upon the low-ranked practice had no effective mechanism to engage with, reflect on and implement relevant evidence. Practices that recognize these two levels of decision making about prescribing are more likely to be able to implement higher quality evidence.

Prescription Pattern and Its Influencing Factors in Chinese County Hospitals: A Retrospective Cross-Sectional Study

ObjectiveThis study aimed to investigate prescription patterns and influencing factors in Chinese county hospitals.MethodsPrescription quality was evaluated by five indicators proposed by WHO/INRUD. A questionnaire for doctors was designed by our research group. All internists, surgeons, obstetricians, gynecologists and pediatricians from 10 county hospitals in Anhui province were asked to fill the questionnaire. Their prescriptions from May 2011 to April 2012 were analyzed.ResultsThree-hundred and thirty-seven doctors completed valid questionnaires, and 5099 prescriptions were analyzed. The average number of drugs per prescription was 3.52±2.31; the average percentage of generic drugs, antibiotic usage, injection drug usage, and drugs prescribed from the national essential drug list were 96.12%, 29.90%, 20.02% and 48.85%, respectively. Differences in final academic degree and specialty led to differences in all of the five prescription quality indicators. The older doctors tended to use more antibiotics. Doctors with more education, more training on rational drug use, and better acquisition of medicine knowledge prescribe a lower percentage of generic drugs. Moreover, the more supportive the doctor’s attitude to national essential medicine policy, the higher the percentage of generic drugs were prescribed. A higher level of medical knowledge was associated with a higher percentage of drugs prescribed from the essential drugs list.ConclusionsPromoting the education of medical knowledge on doctors, reinforcing the publicity of rational drug use to doctors, and initiating the performance evaluation for doctors are effective ways for improving prescription quality in Chinese county hospitals.

Design of antimicrobial stewardship care bundles on the high dependency unit

Antimicrobial guidelines aim to optimise treatment and minimise development of resistance. Care bundles support the implementation of local guidelines. Pharmacist identification of where in the prescribing, monitoring and documentation process, the quality of antimicrobial management in a High Dependency Unit of a large teaching hospital could be improved and design of antimicrobial care bundles for initiation and de-escalation of therapy to standardise care and improve practice. This study was conducted in a 10-bed, mixed medical-surgical HDU in a large Scottish (UK) teaching hospital. Quality indicators (n = 30) were agreed through multidisciplinary team review with reference to the evidence base, national strategy and local policy. Adherence to these quality indicators was measured before and after the pharmacist's contributions. Areas of non-adherence to quality indicators were used to design the care bundles. Adherence to the quality indicators before and after the pharmacist's action. Categorisation of pharmaceutical care issues ('check', 'change in drug therapy' and 'change in drug therapy process') were quantified. From 134 prescriptions, the pharmacist undertook 1,447 actions to ensure adherence to the 30 indicators. Adherence was very good (85.3 % CI 83.5, 87.1), but would have been unsatisfactory (53.5 % CI 50.9, 56.1) without the pharmacist's action (p < 0.001). Change in drug therapy process or change in drug therapy initiated by the pharmacist accounted for 31.9 % (CI 29.5, 34.3) of adherence. Non-adherence was related to documentation of past allergic reactions, bacteriological specimen results, indication and length of course of treatment (both at initiation and de-escalation). Care bundles were designed to target areas of non-adherence to local guidelines. The pharmacist made a significant contribution to improving adherence to evidence based antimicrobial prescribing quality indicators agreed by the multidisciplinary team. Prompts have been identified from the pharmaceutical care process and applied in the design of two antimicrobial care bundles proposed to support adherence with antimicrobial prescribing policies and guidelines.

A pilot qualitative study to explore stakeholder opinions regarding prescribing quality indicators

BackgroundInformation on prescribing quality of diabetes care is required by health care providers, insurance companies, policy makers, and the public. Knowledge regarding the opinions and preferences of all involved parties regarding prescribing quality information is important for effective use of prescribing quality indicators.MethodsBetween June and December 2009 we conducted semi structured interviews with 16 key-informants representing eight different organizations in the Netherlands involved in healthcare quality measurement and improvement. The interview guide included topics on participants’ opinions and preferences regarding existing types of prescribing quality indicators in relation to their aim of using quality information. Content analysis methods were used to process the resulting transcripts following the framework of predetermined themes.ResultsFindings from this qualitative study of stakeholder preferences showed that indicators focusing on undertreatment are found important by all participants. Furthermore, health care providers and policy makers valued prescribing safety indicators, insurance companies prioritized indicators focusing on prescribing costs, and patients’ organization representatives valued indicators focusing on interpersonal side of prescribing. Representatives of all stakeholders preferred positive formulation of the indicators to motivate health care providers to participate in health improvement programs. A composite score was found to be most useful by all participants as a starting point of prescribing quality assessment. Lack of information on reasons for deviating from guidelines recommendations appeared to be the most important barrier for using prescribing quality indicators. According to the health care providers, there are many legitimate reasons for not prescribing the recommended treatment and these reasons are not always taken into account by external evaluators. The latter may cause mistrust of health care providers towards external stakeholders and limit the use of PQI in external quality improvement programs.ConclusionPrescribing quality indicators are considered to be an important tool for assessing quality of provided diabetes care by all participants, although the preferences for specific types of indicators may differ by stakeholder depending on their user aim. Introduction of information systems to register the reasons for deviating from the recommended drug treatment may contribute to a more widespread use of PQI for assessment of provided health care quality to diabetic patents. This study identified the potential preferences regarding quality indicators for diabetes care, and this could be used for development of questionnaires to conduct a survey among a larger group of participants.

The effect of actions to improve the quality and efficiency of prescribing in specialised care

BackgroundOne of the prescribing quality indicators (PQI) set by the program contract for specialised care (SC) in our sector is the prescription by active substance (AS) instead of prescribing by...