Prescribing indicators for UK general practice: Delphi consultation study
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7258.425 (Published 12 August 2000) Cite this as: BMJ 2000;321:425
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Sir,
Campbell et al suggest that patient centred indicators may be better
for assessing quality of prescribing. I agree with the authors but patient
centred indicators may have a number of practical difficulties. Such
indicators will need some sort of personal data to identify the patient
and then the patient's clinical notes may need to be studied to find out
the circumstances under which a particular drug was prescribed. Also a
number of such indicators may be required for different age groups and for
different diseases. Data collection should be carried out by trained
investigators to minimise errors. All this will prove time consuming and
expensive especially when applied at a national level. In the controlled
environment of hospital such indicators may be practical but at primary
care level collection of such data will prove difficult.
Although PACT based indicators are not robust in measuring quality of
prescribing, they are simple and interventions based on them will have a
widespread effect. Combining PACT indicators with disease prevalence
statistics for a given population may be a way forward. Indicators such as
total aspirin scripts: combined prevalence of IHD and cerebrovascular
disease, total steroid inhaler scripts: prevalence of asthma may be
practical and need to be tested.
Reference
Prescribing indicators for UK general practice: Delphi consultation study
Stephen M Campbell, Judy A Cantrill, and Dave Roberts
BMJ 2000; 321: 425-428
Competing interests: No competing interests
Campbell et al have identified 12 prescribing indicators that are
valid and reliable in general practice.1 Although these indicators can be
used to compare prescribing behaviour between groups of doctors, the
authors themselves acknowledge that at an individual level they lack the
power to determine whether GPs are poorly performing.
This finding is inevitable because general practitioners differ in
their approach to medical problems and many of these differences reflect
appropriate modifications of prescribing behaviour to meet patient
expectations and develop trust between the patient and practitioner.
Patients value a supportive, caring and empathic doctor who is
confident in his or her diagnosis and treatment.2 However, Barry et al
have also demonstrated in their qualitative study that an important
component of outcome is related to unvoiced needs and concerns.3 In their
study, only four of 35 patients voiced all their agendas in consultation.
Although patients commonly discussed their symptoms and requested a
diagnosis and a prescription, worries about possible diagnoses, patients'
views about what was wrong, concerns about side effects, and not wanting a
prescription were rarely discussed. These non-discussed items often led to
problem outcomes including non-compliance.
Patients’ fear of illness or pain may also limit their acceptance of
alternative therapeutic options, especially if they believe they are only
being offered a particular treatment in order to reduce cost.
By encouraging doctors to meet prescribing targets we risk limiting
the effort they can make to encourage the voicing of patients' agendas,
and their ability to deal appropriately with these agendae once they are
expressed.
Patients would like personalised care from an empathic doctor who is
free to treat him or her in the way he or she feels is best. It is also
important that standards of care should be maintained and costs
controlled. Nevertheless, there is still room to develop more patient-
centred prescribing indicators, which reflect all these aims.
1. Campbell, S.M., Cantrill, J.A., Roberts, D. Prescribing indicators
for UK general practice: Delphi consultation study. BMJ 2000; 321: 425-428
2. Crow, R., Gage, H., Hampson, S., Hart, J., Kimber A., Thomas, H.
The role of expectancies in the placebo effect and their use in the
delivery of health care: a systematic review. HTA 1999; 3 (3)
3. Barry, C.A., Bradley, C.P., Britten, N., Stevenson, F.A., Barber,
N. Patients' unvoiced agendas in general practice consultations:
qualitative study. BMJ 2000;320:1246-1250
Competing interests: No competing interests
Deceptive Information
Dear Sir
Campbell and colleagues suggest anecdotally that prescribing
indicators may be set to contain costs rather than improve quality.
As the prescribing lead in our practice, I receive regular
communications from our local pharmaceutical advisor amongst which are
graphical representations of our performance as a practice against all the
practices in our area for seven quality indicators of prescribing. There
is something quite motivating to find that you are at the wrong end of a
graph when compared to one’s colleagues. Certainly we have used this
information to good effect at a practice level and have converted a 7%
overspend on our prescribing budget to a 5% underspend (on a drug budget
in excess of £2 million this represents considerable savings).
However, in an environment in which we are encouraged to use evidence
based medicine (1) to assist clinical decision making it seems at best a
little deceptive to receive information that purports to support
improvement and quality whereas in fact its hidden agenda is to contain
costs.
Yours faithfully
Dr Alexander Williams
Refs:
(1) Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB. Evidence based
medicine: what it is and what it isn't. BMJ 1996:312:71-2.
Competing interests: No competing interests