National primary care research & development centre




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MEDICINES MANAGEMENT


Agarwal G, et al. GPs' approach to insulin prescribing in older patients: a qualitative study. British Journal of General Practice 2008 58 (553) 569-75.

http://dx.doi.org/10.3399/bjgp08X319639

http://pmid.us/18682013

Background: Evidence suggests that insulin is under-prescribed in older people. Some reasons for this include physician's concerns about potential side-effects or patients' resistance to insulin. In general, however, little is known about how GPs make decisions related to insulin prescribing in older people. AIM: To explore the process and rationale for prescribing decisions of GPs when treating older patients with type 2 diabetes. Design of study: Qualitative individual interviews using a grounded theory approach. Setting: Primary care. METHOD: A thematic analysis was conducted to identify themes that reflected factors that influence the prescribing of insulin. Results: Twenty-one GPs in active practice in Ontario completed interviews. Seven factors influencing the prescribing of insulin for older patients were identified: GPs' beliefs about older people; GPs' beliefs about diabetes and its management; gauging the intensity of therapy required; need for preparation for insulin therapy; presence of support from informal or formal healthcare provider; frustration with management complexity; and GPs' experience with insulin administration. Although GPs indicated that they would prescribe insulin allowing for the above factors, there was a mismatch in intended approach to prescribing and self-reported prescribing. Conclusion: GPs' rationale for prescribing (or not prescribing) insulin is mediated by both practitioner-related and patient-related factors. GPs intended and actual prescribing varied depending on their assessment of each patient's situation. In order to improve prescribing for increasing numbers of older people with type 2 diabetes, more education for GPs, specialist support, and use of allied health professionals is needed

Nutall SE, Dobson CC, Mills R. Evaluation of the antibiotic prescribing of nurse practitioners trained to prescribe in primary care. Primary Health Care Research & Development 2008 9 (03) 199-204.


http://dx.doi.org/10.1017/S1463423608000728


Aim To evaluate the antibiotic prescribing of prescriber-trained nurse practitioners in a primary care setting. Background As of 1st May 2006, legislation was introduced extending the prescriptive powers of appropriately trained nurses and nurse practitioners to nearly equal that of fully registered doctors. Following this increase, we believe that it is important to ensure that these new powers are being used judiciously. In this paper, we focus on a particular aspect of prescribing: that of antibiotics in a primary care setting. We examine how the prescriber-trained nurse practitioners’ prescribing of antibiotics compares with the practice guidelines on prescribing .Methods An audit of all consultations for six months following 1st May 2006 by the three nurse practitioners trained to prescribe was conducted. Where an antibiotic was prescribed, the anonymous clinical detail was compared with the appropriate practice guideline. The antibiotic-prescribing habits of doctors were identified from a literature search using Medline, by using UK-wide data provided by the Prescriptions Pricing Authority and from the practice Primary Medical Services review. Findings The nurse practitioners were found to prescribe antibiotics in a total of 1296 out of 3211 consultations at an average monthly rate of 41 per 100 consultations. The most common antibiotics prescribed in descending order of frequency were as follows: amoxicillin; flucloxacillin; erythromycin; pencillin V; cefalexin and trimethoprim. Of the antibiotics prescribed during this period, 1065 were found to adhere to practice guidelines and 200 did not. A further 31 were deferred prescriptions. Off-guideline prescribing was accompanied by clear clinical indication as to the reason for the prescription identified in the medical record. Overall prescribing rates in this study of 80 per 100 consultations (including items other than antibiotics) are comparable with those published in the literature

Omar RZ, et al A model based on age, sex, and morbidity to explain variation in UK general practice prescribing: cohort study. British Medical Journal 2008 337:a238.

http://dx.doi.org/10.1136/bmj.a238

http://pmid.us/18625598


Objective: To examine whether patient level morbidity based measure of clinical case mix explains variations in prescribing in general practice. Design: Retrospective study of a cohort of patients followed for one year. Setting: UK General Practice Research Database. ParticipantS: 129 general practices, with a total list size of 1 032 072. Main outcome measures: Each patient was assigned a morbidity group on the bases of diagnoses, age, and sex using the Johns Hopkins adjusted clinical group case mix system. Multilevel regression models were used to explain variability in prescribing, with age, sex, and morbidity as predictors. Results: The median number of prescriptions issued annually to a patient is 2 (90% range 0 to 18). The number of prescriptions issued to a patient increases with age and morbidity. Age and sex explained only 10% of the total variation in prescribing compared with 80% after including morbidity. When variation in prescribing was split between practices and within practices, most of the variation was at the practice level. Morbidity explained both variations well. Conclusions: Inclusion of a diagnosis based patient morbidity measure in prescribing models can explain a large amount of variability, both between practices and within practices. The use of patient based case mix systems may prove useful in allocation of budgets and therefore should be investigated further when examining prescribing patterns in general practices in the UK, particularly for specific therapeutic areas
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