Repeat Prescribing System Research Articles

Patient-centred improvement to repeat prescribing using the Always Event concept.

Repeat prescriptions are prescriptions issued to a patient for a second or subsequent time without requiring a consultation with a doctor. Repeat prescribing is common and an efficient system is necessary to deliver a high-quality service. Always Events can be used to drive patient-centred improvements in healthcare delivery. Our aim was to use the Always Event concept to improve our repeat prescribing system. This quality improvement project was carried out in a deprived, inner-city general practice setting in Glasgow, UK. 51 patients taking repeat medications completed short questionnaires, and the Always Event ‘Repeat prescriptions should be ready and available to collect’ was generated. We used the Plan-Do-Study-Act cycles to elucidate how our system could be improved and check if our intervention was effective. Over a 3-day period in July 2016, 269 out of 292 prescriptions (92.1%) were ready. We mapped out the repeat prescribing process and discovered that sometimes reception staff graded a request as inappropriate, for example, requested too early, and these requests were therefore not processed. Patients would then attend to collect a prescription that was not there. This was both inconvenient for the patient and time-consuming for the reception staff to investigate the reason. Our system was changed so that any request that was not being processed was recorded and the patient informed. In September 260 out of 267 (97.4%) prescriptions were ready, in November 350 out of 364 (96.2%), and in February 2017 314 out of 323 (97.2%) were ready. In conclusion, the Always Event approach allowed us to elicit important feedback from patients to identify a weakness in our repeat prescribing system, which was simple to rectify and led to an improved, more efficient service.

Repeat prescribing of medications: A system-centred risk management model for primary care organisations.

Rationale, aims and objectivesReducing preventable harm from repeat medication prescriptions is a patient safety priority worldwide. In the United Kingdom, repeat prescriptions items issued has doubled in the last 20 years from 5.8 to 13.3 items per patient per annum. This has significant resource implications and consequences for avoidable patient harms. Consequently, we aimed to test a risk management model to identify, measure, and reduce repeat prescribing system risks in primary care.MethodsAll 48 general medical practices in National Health Service (NHS) Lambeth Clinical Commissioning Group (an inner city area of south London in England) were recruited. Multiple interventions were implemented, including educational workshops, a web‐based risk monitoring system, and external reviews of repeat prescribing system risks by clinicians. Data were collected via documentation reviews and interviews and subject to basic thematic and descriptive statistical analyses.ResultsAcross the 48 participating general practices, 62 unique repeat prescribing risks were identified on 505 occasions (eg, practices frequently experiencing difficulty interpreting medication changes on hospital discharge summaries), equating to a mean of 8.1 risks per practice (range: 1‐33; SD = 7.13). Seven hundred sixty‐seven system improvement actions were recommended across 96 categories (eg, alerting hospitals to illegible writing and delays with discharge summaries) with a mean of 15.6 actions per practice (range: 0‐34; SD = 8.0).ConclusionsThe risk management model tested uncovered important safety concerns and facilitated the development and communication of related improvement recommendations. System‐wide information on hazardous repeat prescribing and how this could be mitigated is very limited. The approach reported may have potential to close this gap and improve the reliability of general practice systems and patient safety, which should be of high interest to primary care organisations internationally.

Repeat prescribing: 10 tips to develop a safer system

AbstractFailure of repeat prescribing systems can contribute to patient harm. Here, the author suggests 10 tips to be incorporated into general practice systems to help prevent avoidable risks.

Pharmaceutical needs assessment in general practice

Abstract Objective To develop a method of prioritising the need for pharmaceutical input into a general practice. Method An adaptation of health needs assessment methodology was used to study areas of potential pharmacist input into a practice. Prescribing data, information from the practice's computer system and medical records were used to identify the practice's needs for pharmacist input and changes to practice. Interviews with practice staff and direct observation were used to obtain information on current systems and suggestions for change. A summary of the needs identified and suggestions for change were used in a prioritisation process. Setting One UK general medical practice. Key findings The study identified the need for improvements to the repeat prescribing system, a greater agreement between practice partners on the use of a practice formulary and treatment protocols, and regular review and improved monitoring of patients taking long-term medication. Among patients taking repeat medication, those aged 45 or over and those taking four or more medicines were found to be at greatest risk of having potential pharmaceutical care issues which needed to be addressed. The prioritisation process resulted in pharmacist input into maintaining registers of patients taking drugs with narrow therapeutic indexes, reviewing the practice's computer-based formulary and undertaking medication review being considered of highest priority by medical staff. Conclusion The method enabled the identification of many areas which could benefit from pharmacist input and the prioritisation of these to plan future work.

Patient satisfaction with a community pharmacist-managed system of repeat prescribing

Abstract Background A randomised controlled trial investigated a community pharmacist-managed system of repeat prescribing. Patients attended their general practitioner for a medication review at intervals of up to 12 months and were monitored on a monthly basis when collecting repeat medicines by a community pharmacist of their choice. Objective To establish patient satisfaction with the pharmacist-managed repeat prescribing system, ie, whether they preferred to continue with this new system. Method Questionnaires were sent to 2,667 subjects, 1,625 in the group who received their repeat medicines by the intervention method and 1,042 in the control group who continued to receive their medicines by the traditional system. Key findings The response rate was 73 per cent. The baseline patient satisfaction with the traditional system of repeat prescribing was 88 per cent. However, the pharmacist-managed repeat prescribing was preferred to the traditional system by 81 per cent of intervention subjects, many of whom felt that the new prescribing system saved time and provided increased convenience. Reduced time and financial costs of obtaining repeat prescriptions influenced satisfaction. Many patients felt reassured by the increased clinical input provided by the community pharmacist. Patients in non-city communities showed greater preference for the new system than their city counterparts. Conclusion Results indicate that this or a similar system of pharmacist-managed repeat prescribing may be preferred to the traditional method by many patients who are stabilised on regular medication obtained by repeat prescriptions.

Repeat prescribing processes in primary care: a qualitative study

Abstract Objective To investigate the characteristics, local agreements and changes regarding repeat prescribing processes in primary health care in Finland. Setting Twenty-eight municipal health centres nationwide. Method Twenty-eight physicians and 28 medical receptionists were given semi-structured telephone interviews about repeat prescribing practices. The repeat prescribing process of each health centre was displayed as a flow chart and the processes were classified according to the quality of the practical flow and the medication review. Key findings There are various ways of carrying out repeat prescribing in different health centres. In some centres, a review of the medications is recognised as part of the repeat prescribing process, but in others there is no systematic review of the patients' medication. Repeat prescribing is often performed in a busy atmosphere. Repeat prescribing systems have evolved over time without proper management, and few local guidelines exist. Conclusions There is a need to reorganise the repeat prescribing systems in primary health care. A regular review of long-term medications, in particular, needs to become a part of the repeat prescribing process. There is a need for both local and national guidelines.

Prescription writing for diabetes: compliance with good practice

This study aimed to explore the prescriptions issued to patients with diabetes by nurse independent and nurse supplementary prescribers working in general practice. A total of 19 prescriptions were collected and assessed from four case-study sites based in general practice between October 2007 and September 2008. Prescriptions were collected from patients with diabetes whose consultations were video recorded for the purposes of research. Prescriptions were consistently issued on an appropriate computer-generated prescription form, written legibly in ink, used the correct terminology, generic prescribing and contained an accurate/appropriate product dose and preparation. They were less consistent in stating the number of days, quantity of medicine to be supplied, and providing clear and accurate instructions on frequency and timing of treatment. Nurses in general practice are using computer based repeat prescribing systems to issue prescriptions to patients for the management of diabetes and its common complications, such as hypertension, hyperlipidaemia and cardiovascular disease. Whilst nurse prescribers were generally compliant with good practice in prescription writing, they need to ensure that they include ongoing information with respect to the number of days of treatment, quantity of medicine to be supplied, and clear and accurate instructions regarding the frequency and timing of medicines.

Testing for an experience endowment effect in health care

Preferences have been shown to be influenced by initial endowments of wealth in the valuation literature. This paper tested for the influence of initial endowments of experience on preferences, using a discrete choice experiment. The experiment was carried out within the context of a randomized controlled trial evaluating the introduction of a new repeat prescribing system. The ‘intervention group’ experienced the proposed new system and the ‘control group’ the existing system. Evidence of an experience endowment effect was found, with only the ‘intervention group’ valuing attributes of the new repeat prescribing system. The implications of these results for economic evaluations alongside randomized controlled trials are considered.

Clinical pharmacy in primary care.

Clinical Pharmacy in the secondary care sector began to develop in the 1970s and has evolved into a service known as pharmaceutical care. The developments of such services in the primary care sector have not occurred at the same pace because of a remuneration structure which, to this day, largely depends on the speed and accuracy of dispensing a prescription. A complete examination and re-arrangement of the dual roles of the professional and trader is required in order to provide a more effective, efficient and easily accessible pharmaceutical care service within primary care. It has been suggested that up to 11.4% of hospital admissions [1–3] are related to the patient’s drug therapy and that if corrected at the dispensing stage would save considerable primary care costs [4]. An analysis of adverse drug reaction (ADRs) rates from 49 hospitals published in 36 articles stated that ADRs were responsible for 0.2–21.7% of hospital admissions [5]. Overall 71.5% of these were related to side effects, 16.8% were excessive effects, 11.3% were hypersensitivity reactions and 0.4% idiosyncratic. In 1989 Neville et al. [6], from a General Practitioner (GP) survey, stated that 1.06% of prescriptions had therapeutic errors but this may now be greater due to the inadequate control of a computerised repeat prescribing system [7]. This analysis of the prescribing in 50 GP surgeries revealed that 72% of repeat drugs had not been reviewed by a doctor for 15 months. Harris [8] reported that 75% of all prescribed items were repeats. These accounted for 81% of prescribing costs and 48.4% of patients obtained their next medicine supply by this method. Thus up to three quarters of all prescriptions may be generated by a patient initiating a repeat prescription. There is therefore a need for involvement by a clinical pharmacist at the prescribing and dispensing stages. This paper will focus on the limited reports of pharmaceutical care in the primary healthcare sector during the dispensing process. Pharmaceutical care The term ‘pharmaceutical care’ to replace clinical pharmacy was introduced by Brodie et al. [9] in 1980, when they suggested a complete change in the delivery of pharmaceutical services. Further developments of ‘pharmaceutical care’ were described by Hepler [10], as a covenantal relationship between a patient and a pharmacist, suggesting that pharmacists should accept more responsibility for drug use control. These concepts were further developed in 1989 by Hepler & Strand [11] who provided the now widely accepted definition of ‘pharmaceutical care’ as ‘the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life’. In 1986 the Nuffield Report [12] suggested that community pharmacists must be more patient-orientated. It also indicated that Pharmacy Practice (within the primary healthcare system) is an ‘area of health services research in which the greatest weaknesses are to be found. There is too little information available, relatively weak structures and very little funding’ [12]. The next dozen years have seen little change, and much of the Government funding has been spent on developing pilot services rather than their evaluation. Consequently when the funding has run out many of the services have ceased. Working party reports between 1986 and 1994 [13–16] have encouraged community pharmacy to assess its level of practice and research. Value for money and health outcomes will play a major role in the future and studies need to highlight the added value of community pharmaceutical services during the dispensing process. These studies should be based on the principles of pharmaceutical care especially the responsible provision of drug therapy, definite outcomes and quality of life issues. They also need to highlight the possible advantages for the development of multi-disciplinary teamwork amongst providers of care.

Asthma and factory emissions in northern England: addressing public concern by combining geographical and epidemiological methods.

The prevalence of asthma was assessed to investigate respiratory health effects of airborne emissions from a factory. A geographical information system allowed flexible definition of study areas in terms of their size, distance, and location in relation to the factory. The value of the approach for this type of investigation is focussed on. The factory is located in the south western part of a small market town in County Durham. A total of 1573 asthma cases were identified from general practitioner computerised repeat prescribing systems. Population denominators were defined from family health services authority patient registers. The area within 1 km and immediately to the north east of the factory had an age and sex standardised asthma prevalence 24% (confidence interval 4, 44%) in excess of the expected rate (p = 0.01). The increased prevalence was confined to middle aged and elderly adults living in the area between 0.5 and 1 km to the north east of the factory. The value of combining the skills of geographers and epidemiologists in addressing public health issues is shown, particularly through the use of geographical information systems which proved powerful and effective.

Practice Research. Computerisation--the choice.

General practitioners all over Britain and world-wide' -* have shown great interest in computerisation. An open meeting for general practitioners in Nottingham area to discuss computers drew representatives of 41 practices. It has been predicted5 ? that most practices will have computers, but among other factors absence of financial incentives to install computers from Department of Health and Social Security (despite publicity to contrary') will delay this. We describe our experience over 18 months searching for and then installing a computer in our practice. We are a dispensing practice of three partners in a new purpose-built area health authority health centre. We have a practice manager, secretary, two full-time dispenser/receptionists, and five part-time receptionists. We have a close relationship with three district nurses and two part-time health visitors. Our list of 5200 patients covers 80 square miles. We had a common problem in our practice. A rapid turnover of partners had led to a partnership of young doctors but old practice tools. A 30-year-old patient register had become unintentionally loose leaf. We installed a manual repeat prescribing system to identify treatment groups, a system of patient recall for influenza vaccine and cervical cytology, a system to control drug stocks and ordering and for taxing salaries (PAYE), and sophisticated practice accounting systems. We then studied all means of collating information manually?age, sex, and disease card index systems; E books; and tagged notes?but were deterred by problems of using them, the major disadvantage being effort required to extract meaningful statistical analyses of even two most basic factors, age and sex. Problems exist with computer files too, not least in ensuring quality of data, but their strength lies in possibility of manipulat? ing information. We describe six somewhat artificial stages, which we feel reflect course that many practices will travel if they decide to install a computer.