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A shared approach to better prescribing

Collaboration between two practices in Exeter points the way to rational prescribing
Why was the initiative launched?
What was done?
Five key planning meetings
Was the away day a success?
Cardiovascular disease
Central Nervous System
Gastrointestinal
Action Plans
Tips for success
For more information contact
Information available

Why was the initiative launched?


Information presented at a meeting in November 1999 of the Prescribing Leads from the practices in the Exeter Primary Care Group showed widely different prescribing practice and costs. It raised questions in the minds of the Prescribing Leads from two practices (Dr Gill Stowell, Ide Lane Surgery and Dr Phil Evans, St Leonard's Medical Practice) about how practices similar in size and philosophy could have widely different prescribing costs. PACT data illustrated the differences but could not explain them.

At the time the North and East Devon Health Authority offered to arrange and fund away-days for individual practices to explore prescribing issues. The two Prescribing Leads suggested that a joint away-day might help understand their differing prescribing costs. They might learn about improving quality and decreasing costs of prescribing.

What was done?


To ensure maximum attendance and allow adequate time for preparation, a date six months ahead was chosen (June 2000). A series of meetings proved to be essential stepping stones towards a successful event.

Five key planning meetings


The first meeting (March 2000) was a brainstorming session to enable the Prescribing Leads to sketch a broad picture of the issues that might need addressing. Various practice characteristics, like demography and organisation, were identified as possible contributory factors and each practice assembled relevant data. In addition, the top 10 drugs for each practice, and costs for each BNF therapeutic group were compared with the Exeter PCG average.

The second meeting (April 2000) involved the pharmaceutical advisers from the Health Authority and the PCG. A review of the PACT data for the two practices made focus on the three highest cost BNF therapeutic groups (Cardiovascular, CNS and GI) sensible. Decisions were also taken about practical points such as venue, participants and who should chair the event. The discussion was informed by experience from other local prescribing away-days.

At the third meeting (May 2000) the Prescribing Leads were able to review preliminary data about general characteristics of the practices and about prescribing in each of the three highlighted groups. The diagnosis and management of disease as well as prescribing would need to be addressed. Progress would depend on the extent to which the practice would be willing to share detailed data about the quality of care: a potentially sensitive issue. It seemed wise at this stage to check that all the partners involved were willing to proceed. Concerns proved unfounded: all the partners agreed that the session and the sharing of data should go ahead.

A final preparatory meeting (May 2000) allowed the finishing touches to be made to the arrangements for the day, including the structure of the session, the agenda, and the scope of background information for each participant.

Was the away day a success?


The away day was held in June 2000. On the day each participant was given a detailed information pack prepared by the health authority, including PACT data, and relevant guidelines. (Subsequent comments suggested that it might have been better to send these out in advance!).

Most GP principals attended along with a strong representation of other disciplines, including nurses and clerical staff. Retained doctors were invited but were unable to attend; locums should probably have been involved. In total 19 participants from the two practices attended. To get the day off to a good start an informal opening session consisted of an ice-breaking activity to get people talking!

The Chairman, Dr Nick Bradley, a GP from Ide Lane Surgery, set the scene and the ground rules: open discussion about the issues would be encouraged. The product would be plans for action within the two practices: it was not simply a talking shop! The two Prescribing Leads illustrated the strengths and weaknesses of each practice. Participants then identified four sets of factors which influenced prescribing, ie those related to patients, to doctors, to the practice and external factors. Discussion then focused around the three chosen topic areas.

Cardiovascular disease


The opening presentation demonstrated the quantity and quality of hard evidence available. Participants agreed it was easier to be rational when the evidence was clear-cut. In several areas the practices' use of particular drugs was similar, like the use of statins and of ACE inhibitors in hypertension. There were also wide variations. One practice seemed to implement the findings from single studies (HOPE study) promptly whereas the other preferred to wait for consensus reviews before changing practice.

Central Nervous System


Comparisons of the use of traditional and atypical anti-psychotics and the use of tricyclics and SSRIs from the practices and health authority perspective stimulated this part of the discussion. Information was also presented about the advantages and disadvantages of tricyclics against SSRIs and guidelines about the management of depression.

Participants argued that evidence was not as strong in this area and what there was tended to come from secondary care: it didn't translate well to primary care. There was a lack of evidence directly relevant to primary care. Prescribing seemed to be guided by emotion and anecdote rather than evidence; for example the practices had reached different conclusions about the advantages and disadvantages of SSRIs in depression. The high number of psychotic patients in one practice had significant impact on prescribing costs and better dialogue with secondary care was needed.

Gastrointestinal


Role-play of a consultation, focused on an elderly patient insisting on long term PPI treatment with a high dose, introduced this part of the session. Information about current prescribing practice and work on new guidelines was also presented.

Participants agreed this was a high cost area where change may be required, but it was difficult to persuade patients to change once they were established on a PPI. Treatment often seemed to be focused on the symptoms rather than disease. One practice had always followed a step-up approach to dyspepsia. The other practice was more flexible and recognised that it needed to review its management of dyspepsia. Participants agreed that this was an area worthy of attention in both practices.

Action Plans


For the final part of the day each practice met as a team to review what they had learnt during the day and to draw up action plans. Each practice identified a range of issues they needed to address and take forward. The issues ranged from the need to update one of the practice's formulary to the review of prescribing for individual patients (Table 1). The plans were then shared with the other practice. Arrangements would be put in place to monitor progress and allow the practice to meet again to revisit the issues.

Table 1: Practice Action Plans - some typical commitments


1 To review all patients on more than 80 mg of frusemide and consider use of ACE inhibitors
2 To review statin prescribing and ensure use of 20 mg and 40 mg dose instead of multiples of 10 mg or 20 mg
3 To update practice formulary with treatment of choice: losartan becomes candesartan
4 Practice/district nurse to check dressing prescriptions before they are sent off.
5 Liaise with consultant psychiatrist with regard to atypical antipsychotics
6 Use fluoxetine as a first choice SSRI and explore non-drug treatment of depression.


At the end of the session participants said how pleased they were with the sessions. It had been a great success. On the three main dimensions - relevance, interest and usefulness - participants rated the session highly. Comments included:


Some participants suggested the need for other similar sessions to enable the two practices to meet and share information and ideas. There was confidence that the action plans would be honoured. A joint away-day had proved to be a valuable way of sharing information, debating the issues and identifying what needed to be done.

Tips for success



For more information contact


Dr Gill Stowell, Ide Lane Surgery, Alphington
EXETER EX2 8UP
Telephone 01392 439 868
Email Gill.Stowell@gp-L83079.nhs.uk

Dr Philip Evans
St Leonard's Medical Practice, 34 Denmark Road
EXETER EX1 1SF
Telephone 01392 201 790
Email p.h.evans@ex.ac.uk

Ruth Airdrie
Pharmaceutical Adviser to Exeter PCG
North and East Devon Health Authority
Dean Clarke House, Southernhay East
Exeter EX1 1PQ
Telephone 01392 207388
Fax 01392 207377
E-mail: Ruth.Airdrie@nedevon-ha.swest.nhs.uk

The following information is available


 

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