Applying preventable drug-related morbidity indicators to the electronic patient record in UK primary care: methodological development.

BACKGROUND AND OBJECTIVE: Measuring and assessing the quality of health care services is an issue of high international importance. Providing data can be reliably extracted, making use of the electronic patient record (EPR) could help practitioners fulfil clinical governance obligations and ultimately improve the quality of patient care. The objective of this paper is to describe (i) the process used to apply a series of clinical indicators for preventable drug-related morbidity (PDRM) in the EPR, (ii) problems encountered and (iii) our attempts to resolve them. METHOD: The PDRM indicators were applied retrospectively in the EPR of all patients aged 18 years and over in nine general practices using the Morbidity Information and Query Export Syntax (MIQUEST) computer software programme. RESULTS: Issues identified as requiring attention when attempting to extract data from the EPR include considering the ranges to be used for age and biochemical test results, accuracy of diagnosis and drug coding, the level of complexity of the information needed, and how best to manipulate the resulting data. Practical difficulties encountered were ensuring the query coding schemes were sufficiently robust and comprehensive to secure reliable data extraction, the number of MIQUEST queries required to express each indicator, the time-consuming nature of the stages involved in the data manipulation process. DISCUSSION: Despite some practical difficulties, we have successfully used MIQUEST to identify potential preventable drug-related morbidities from the EPR. The quality of information that can be extracted from the EPR is obviously limited by the accuracy and completeness of the data on the system and the ability of the enquirer to reliably extract and manipulate that data. CONCLUSION: Although some of the problems encountered were specific to the MIQUEST software, many, including considering appropriate ranges for age and biochemical test results and paying careful attention to the reliability of drug and diagnosis coding, are relevant whenever data are extracted from the EPR for any purpose.

Preventing drug related morbidity: a process for facilitating changes in practice.

AIM: To describe how quantitative data obtained from applying a series of indicators for preventable drug related morbidity (PDRM) in the electronic patient record in English general practice can be used to facilitate changes aimed at helping to improve medicines management. DESIGN: A multidisciplinary discussion forum held at each practice facilitated by a clinical researcher. SUBJECTS AND SETTING: Eight English general practices. OUTCOME MEASURES: Issues discussed at the multidisciplinary discussion forum and ideas generated by practices for tackling these issues. Progress made by practices after 1, 3, and 6 months. RESULTS: A number of clinical issues were raised by the practices and ideas for moving them forward were discussed. The issues that were easiest and most straightforward to deal with (for example, reviewing specific patient groups) were quickly addressed in most instances. Practices were less likely to have taken steps towards addressing issues at a systems level. CONCLUSIONS: Data generated from applying PDRM indicators can be used to facilitate practice-wide discussion on medicines management. Different practices place different priority levels on the issues they wish to pursue. Individual practice "ownership" of these, together with having a central committed figure at the practice, is key to the success of the process.

Patient safety features of clinical computer systems: questionnaire survey of GP views.

AIM: To investigate general practitioners' (GPs') stated knowledge, use and training needs related to the patient safety features of computerised clinical systems in England. DESIGN: Questionnaire survey. SUBJECTS AND SETTING: GPs from six English primary care trusts. OUTCOME MEASURES: GPs' views on the importance of specified patient safety features on their computer system; their knowledge of the presence of specified safety features; previous training and perceived future training needs. RESULTS: Three hundred and eighty one GPs (64.0%) completed and returned the questionnaire. Although patient safety features were considered to be an important part of their computer system by the vast majority of GPs, many were unsure as to whether the system they were currently using possessed some of the specified features. Some respondents erroneously believed that their computers would warn them about potential contraindications or if an abnormal dose frequency had been prescribed. Only a minority had received formal training on the use of their system's patient safety features. CONCLUSIONS: Patient safety was an issue high on the agenda of this GP sample. The importance of raising GPs' awareness of both the potential use and deficiencies of the patient safety features on their systems and ensuring that appropriate training is available should not be underestimated.

Indicators for preventable drug related morbidity: application in primary care.

AIM: To apply in practice a series of validated indicators for preventable drug related morbidity (PDRM). DESIGN: A pilot study to identify retrospectively potential PDRM events over a 2 year 3 month time frame using the MIQUEST computer software program. SUBJECTS AND SETTING: The electronic patient record of all patients aged 18 years and over in nine English general practices. OUTCOME MEASURES: The number of potential PDRM events identified, as defined by the indicators. RESULTS: Five hundred and seven potential PDRM events were identified from 49 658 electronic patient records, giving an overall incidence of 1.0%. A small number of the indicators (n = 4) accounted for approximately 60% of the events, while for many indicators few events were identified. The most common events related to the use of non-steroidal anti-inflammatory drugs in patients with congestive heart failure or hypertension, lack of monitoring in patients prescribed angiotensin converting enzyme inhibitors, and the use of hypnotic-anxiolytic agents. CONCLUSIONS: A small number of indicators contributed to the majority of the PDRM events. Interrogation of electronic patient records in primary care using computerised queries shows potential for detecting PDRM.

Preventing drug-related morbidity--the development of quality indicators.

OBJECTIVE: To describe the process that has been undertaken to (i) validate further UK indicators for preventable drug-related morbidity (PDRM) generated by a previous study and (ii) develop additional new indicators derived from UK clinical practice. DESIGN: A two-round Delphi questionnaire survey. SETTING: A UK study based in primary care. PARTICIPANTS: A purposively selected sample of primary care pharmacists (n = 9) and general practitioners (n = 8). OUTCOME MEASURES: The establishment of consensus among the panel as to whether an indicator represented a PDRM. RESULTS: The pre-defined level of consensus was achieved for 24 indicators (59%; 24 of 41). CONCLUSIONS: We have identified that although mechanisms exist for identifying 'the outcome' component of PDRM indicators, identifying the 'pattern of care' that is needed to prevent their occurrence is far more challenging. Nonetheless, we have taken considerable steps along the path of validating such indicators. Future operationalization in a general practice setting should help to facilitate improvements in medicine management in primary care and ultimately benefit patients.

Preventing drug-related morbidity--determining valid indicators.

OBJECTIVE: To describe the process that is being undertaken to validate a series of indicators for preventable drug-related morbidity - originally developed in the US - for application in the UK health care system. DESIGN: A two-round Delphi questionnaire survey after a preliminary validation of the indicators within the University of Manchester School of Pharmacy. SETTING: A primary care study set in the UK. STUDY PARTICIPANTS: A purposively selected sample of general practitioners with a specific responsibility for prescribing-related issues (n = 6) and pharmacists actively involved in medication review in primary care (n = 10). MAIN OUTCOME MEASURES: The establishment of consensus among the participants that an indicator reflected preventable drug-related morbidity in primary care. RESULTS: After preliminary validation, 37 of the original 57 US indicators were retained. The Delphi panel generated 16 additional new indicators in the first round. At the end of the second round, the pre-defined level of consensus was reached for 29 indicators (19 of the US generated indicators; 10 generated by the panel in the first round). CONCLUSIONS: The Delphi results highlighted differences in both the clinical perspective and, possibly, philosophical viewpoints of health professionals practising in the UK and US health care systems. Further work, located in both primary and secondary care, is now in progress to operationalize the indicators. This process will form a key part of the refining, and hence further validation, of the indicators. The future development of prospective medical-record-based indicators should facilitate a reduction in the human, clinical, and economic burden of drug-related morbidity.

GPs' attitudes to minor ailments.

BACKGROUND: It is generally considered that a significant proportion of 'inappropriate' demand for GP services is generated by consultations for minor ailments. How GPs manage minor ailments is likely to affect how patients perceive and handle similar illnesses in the future. Whilst this potentially has significant implications for general practice workload, research investigating GP' attitudes towards minor ailments and their management is sparse. OBJECTIVE: Our aim was to describe GP' experiences and perceptions of minor ailment consultations and their attitudes towards minor ailment management. METHODS: A questionnaire survey was conducted in 1999, derived from a series of 20 qualitative interviews with practising GPs. The survey was sent to one GP randomly selected from each practice (n = 759) in eight English health authorities. Attitudinal statements were analysed using factor analysis. RESULTS: Four hundred and fourteen GPs (54.5%) completed and returned the questionnaire. Respondents were consulted regularly about minor illness or symptoms, with almost all (95.6%) having experienced a minor ailment consultation in the previous week. Factor analysis suggested four issues to be of importance in determining GP' attitudes to minor ailment management. These were attitudes towards pharmacists, attitudes towards patient empowerment, frustration with minor ailment consultations and attitudes towards caution/risk. CONCLUSION: Although GPs are clearly frustrated by the level of minor ailment consultations, this study suggests that there may be complex factors which influence their attitudes. For the optimal management of minor ailments, inter-professional relationships potentially are of great importance. With increasing patient demand, it is essential that finite health care resources are accessible, appropriate and used in an optimal way.

GP survey response rate: a miscellany of influencing factors.

BACKGROUND: GP response to surveys is acknowledged to vary widely. The minimization of non-response bias and the generalizability of findings are fundamental research issues. OBJECTIVE: The aim of this study was to identify the factors that had influenced GPs' decisions to complete a questionnaire. METHODS: A short questionnaire eliciting GPs' views on minor ailment consultations was sent to 759 GPs from eight English health authorities. The response rate was 54.5%. Factors perceived by respondents to have influenced their decision to complete this questionnaire were also assessed. Subsequently, a feedback summary, together with a short evaluation form, was sent to those GPs requesting it. RESULTS: The response from GPs located in the London area was significantly lower than that from those elsewhere. Respondents identified questionnaire length and the originating institution as the two major factors influencing their decision to return the survey. A single mailing of the evaluation form yielded a response rate of >60% predominantly positive comments. CONCLUSION: Many factors influence a GP's decision to complete a survey. The effect of location has, to date, largely been ignored. Furthermore, this study suggested feedback to be an important issue. Within health services research, all possible factors need to be considered to maximize response, reduce non-response bias and ultimately facilitate the dissemination of findings.

Why is pain management suboptimal on surgical wards?

BACKGROUND: During a patient's stay on a surgical ward, nurses hold a great deal of responsibility for pain management, especially when analgesics are prescribed on a PRN ('as needed') basis. Despite the availability of effective analgesics and new technologies for drug administration, studies continue to demonstrate suboptimal pain management. AIM OF THE STUDY: To identify perceived barriers to effective pain management in nursing practice. METHODS: The data are drawn from six nurse interviews and a survey of 180 nurses in 14 United Kingdom (UK) hospitals, which built upon detailed observations of nurses on surgical wards. RESULTS: In a question about possible reasons for suboptimal pain management, nurses identified a number of barriers that concerned organizational aspects such as workload and lack of staff, and also legal or institutional constraints. Nurses further stated that analgesic prescribing was sometimes inadequate, or that doctors or the pain team were unavailable to review medication. Further barriers that nurses may be less aware of were identified in a question concerning nurses' reasons for not asking patients a pain-related question during drug rounds. Previous observations had shown this to be the predominant time for pain questioning. The most commonly mentioned reasons were that patients were asleep, on epidural or patient controlled analgesia (PCA), or had recently had an analgesic. Nurses' replies also revealed that they relied considerably on patients' nonverbal behaviour and used this to assess analgesia requirements. Nurses' views and judgements regarding pain management were further supported in replies to a number of attitude statements and a question about the aim of administering analgesia. CONCLUSION: The strength of this work is that it identified two types of potential barriers to effective pain management, recognized and more subconscious ones, and both need to be addressed before introducing systems aimed at improving pain management.

Measuring the appropriateness of long-term prescribing in United Kingdom general practice--is the British National Formulary the 'gold standard'?

BACKGROUND: The British National Formulary (BNF) is an independent professional publication which is highly respected and widely used by health care professionals in the U.K. In addition, it has been translated into several languages for use outside the U.K. A set of prescribing indicators has been developed to assess the appropriateness of long-term prescribing in U.K. general practice, using the BNF as the 'gold standard'. OBJECTIVES: The objective of this paper is to gain an understanding of why GPs may prescribe outside the recommendations given in the BNF. METHODS: Twenty-two GPs were interviewed about a range of instances of potentially inappropriate prescribing for 101 patients under their care. These cases had been identified through the application of a set of prescribing indicators to the medical records of individual patients. The interview transcripts were repeatedly reviewed to identify cases where the GP felt that his/her prescribing was appropriate, even though it did not adhere to the guidance in the BNF. RESULTS: The indicators which looked at total daily dose, recording of a valid indication, prescribing drugs of limited clinical value, generic prescribing and use of a potentially hazardous drug-drug combination all identified situations in which the GP would prescribe outside of the BNF guidance. In some cases they felt that the guidance was difficult to apply in clinical practice and in others they were either unaware of or did not believe it to be based on sound evidence. This may either be dictated by individual patient need or a consistent approach to prescribing a specific drug, based on their own clinical experience. CONCLUSION: This study has demonstrated that GPs will sometimes prescribe outside BNF guidance. With the continuing effort to improve prescribing in general practice, it is essential for those trying to influence prescribing behaviour to understand the complexity of this decision-making process. This should help inform the design and implementation of strategies to change behaviour in this area.

Prescribing indicators for UK general practice: Delphi consultation study.

OBJECTIVES: To identify prescribing indicators based on prescribing analysis and cost (PACT) data that have face validity for measuring quality or cost minimisation. DESIGN: Modified two round Delphi questionnaire requiring quantitative and qualitative answers. SETTING: Health authorities in England. PARTICIPANTS: All health authority medical and pharmaceutical advisers in the first round and lead prescribing advisers for each health authority in the second round. MAIN OUTCOME MEASURES: Face validity (median rating of 7-9 on a nine point scale without disagreement) and reliability (rating 8 or 9) of indicators for assessing quality and cost minimisation. RESULTS: Completed second round questionnaires were received from 79 respondents out of 99. The median rating was 7 for cost minimisation and 6 for quality, and in all except four cases individual respondents rated indicators significantly higher for cost than for quality. Of the 41 indicators tested, only seven were rated valid and reliable for cost minimisation and five for quality. CONCLUSION: The 12 indicators rated as valid by leading prescribing advisers had a narrow focus and would allow only a limited examination of prescribing at a general practice, primary care group, or health authority level.

The validity of the modified patient generated index--a quantitative and qualitative approach.

The purpose of this study was to determine the validity of the recently modified patient generated index (PGI) when used as a self-completed postal questionnaire by older people with arthritis. Two postal surveys were used, followed by interviews with a theoretically chosen sub-sample of respondents to both. Data from the self-completed modified PGI and the arthritis impact measurement scales (AIMS) and the interviews were assessed against 10 pre-defined validity criteria. A total number of 1027 people over 65 years old and with arthritis were surveyed and 53 were selected for interview. The response rates to the two-part survey were 78 and 83%. Complete data for the validity analysis were available from 47% of the respondents. The modified PGI met four and failed to meet six validity criteria. Pre-defined correlations were found with the AIMS and differentiation was possible between respondents with mild, moderate and severe arthritis and between those who had recently sought medical attention and those who had not. The areas that had been chosen for inclusion in the modified PGI were affected by arthritis but may not have been the 'most important' areas. The measurement method could not detect changes in health nor differentiate between respondents taking and not taking analgesics. There were several problems in the respondents' interpretation of the instructions, which were only revealed during the interviews. These data should help inform further modification of the PGI.

Development of review criteria for assessing the quality of management of stable angina, adult asthma, and non-insulin dependent diabetes mellitus in general practice.

OBJECTIVE: To develop review criteria to assess the quality of care for three major chronic diseases: adult asthma, stable angina, and non-insulin dependent diabetes mellitus. SUBJECTS AND METHODS: Modified panel process based upon the RAND/UCLA (University College of Los Angeles) appropriateness method. Three multiprofessional panels made up of general practitioners, hospital specialists, and practice nurses. RESULTS: The RAND/UCLA appropriateness method of augmenting evidence with expert opinion was used to develop criteria for the care of the three conditions. Of those aspects of care which were rated as necessary by the panels, only 26% (16% asthma, 10% non-insulin dependent diabetes, 40% angina) were subsequently rated by the panels as being based on strong scientific evidence. CONCLUSION: The results show the importance of a systematic approach to combining evidence with expert opinion to develop review criteria for assessing the quality of three chronic diseases in general practice. The evidence base for the criteria was often incomplete, and explicit methods need to be used to combine evidence with expert opinion where evidence is not available.

Subjective outcome measurement--a primer.

There is a growing recognition within both the practice and research communities in pharmacy that serious attention must be given to the systematic study of the outcomes of pharmacy services, especially those outcomes that are focused on the patient. Research has tended to focus too strongly on the measurement of structure and process, with the unspoken assumption that if these are of good quality, the outcome will automatically be similar. However, the literature on outcome measurement instruments is vast and practitioners moving into this area for the first time may find themselves lost in a morass of conflicting definitions and different methods of measurement. This review considers the outcome measures or 'measurement instruments' that are used to assess subjective health status. Two commonly used taxonomies are described that concern the conceptual content (functional status, general health perceptions, quality of life and health-related quality of life) and the breadth of coverage of the instruments (generic, disease specific, domain or dimensions specific and patient-centred instruments). Specific attention is paid to the newest of these groups, the patient-centred instruments, which are very different in style and content to the other three and reflect a change in direction in instrument development, to address limitations of commonly used 'fixed' outcome instruments. Detail is given on what makes a quality instrument in particular circumstances (validity, reliability, sensitivity to change, multidimensional construct, practicality and applicability), to help pharmacists develop the necessary skills to select appropriate instruments in the burgeoning field of outcomes measurement.

Indicators of the appropriateness of long-term prescribing in general practice in the United Kingdom: consensus development, face and content validity, feasibility, and reliability.

OBJECTIVES: To develop valid, reliable indicators of the appropriateness of long-term prescribing in general practice medical records in the United Kingdom. DESIGN: A nominal group was used to identify potential indicators of appropriateness of prescribing. Their face and content validity were subsequently assessed in a two round Delphi exercise. Feasibility and reliability between raters were evaluated for the indicators for which consensus was reached and were suitable for application. PARTICIPANTS: The nominal group comprised a disciplinary mix of nine opinion leaders and prominent academics in the field of prescribing. The Delphi panel was composed of 100 general practitioners and 100 community pharmacists. RESULTS: The nominal group resulted in 20 items which were refined to produce 34 statements for the Delphi exercise. Consensus was reached on 30, from which 13 indicators suitable for application were produced. These were applied by two independent raters to the records of 49 purposively sampled patients in one general practice. Nine indicators showed acceptable reliability between raters. CONCLUSIONS: 9 indicators of prescribing appropriateness were produced suitable for application to the medical record of any patient on long term medication in United Kingdom general practice. Although the use of the medical record has limitations, this is currently the only available method to assess a patient's drug regimen in its entirety.

Appropriateness in health care: application to prescribing.

To help account for and address observed variations in medical practice, evaluations of "appropriateness" have sought to supplement incomplete evidence with professional opinion. This article contributes to an understanding and refinement of the construct of appropriateness by discussing how it has been defined and applied in studies of health care in general and prescribing in particular. We suggest that appropriateness is the outcome of a process of decision-making that maximises net individual health gains within society's available resources. This definition distinguishes between (in)appropriate prescribing, as an outcome, and (ir)rational prescribing as a process. To assess appropriateness, we advocate combining explicit criteria with independent review in cases of uncertainty and disagreement. Refinements based on reviews using implicit criteria should draw on shared professional knowledge and post hoc state the process followed as explicitly as possible. The Medication Appropriateness Index is shown to provide a solid foundation for identifying dimensions of prescribing appropriateness.

Prevalence of potentially inappropriate long term prescribing in general practice in the United Kingdom, 1980-95: systematic literature review.

OBJECTIVE: To determine the prevalence of potentially inappropriate long term prescribing in general practice in the United Kingdom. DESIGN: Review of 62 studies of the appropriateness of prescribing identified from seven electronic databases, from reference lists, and by hand searching of journals. A nominal group of 10 experts helped to define the appropriateness of prescribing. SETTING: General practice in the United Kingdom. MAIN OUTCOME MEASURES: Prevalences of 19 indicators of inappropriate long term prescribing representing five dimensions: indication, choice of drug, drug administration, communication, and review. RESULTS: Prevalences of potentially inappropriate prescribing varied by indicator and chronic condition, but drug dosages outside the therapeutic range consistently recorded the highest rates. The lowest rates were generally associated with indicators of the choice of the drug, except cost minimisation. Communication is studied less frequently than other dimensions of prescribing appropriateness. CONCLUSIONS: The evidence base to support allegations of widespread inappropriate prescribing in general practice is unsound. Although inappropriate prescribing has occurred, the scale of the problem is unknown because of limitations associated with selection of a standard, publication bias, and uncertainty about the context of prescribing decisions. Opportunities for cost savings and effectiveness gains are thus unclear. Indicators applicable to individual patients could yield evidence of prescribing appropriateness.

Management of minor ailments in primary schoolchildren in rural and urban areas.

The concept of self-management in healthcare includes disease prevention, self-diagnosis, self-treatment and appropriate consultation with health care practitioners. Within the context of childrens' ailments the decision-maker will usually be a carer. The aim of this study was to examine carers' management of minor childhood ailments within urban and rural settings. The subjects were primary schoolchildren (4-12 years of age) and the respondents were their parents or carers. Data were gathered using a pre-piloted structured questionnaire. The questionnaires were distributed through and collected by the head teachers of the 13 participating schools. Of the 491 questionnaires distributed, 306 (62%) were returned and suitable for analysis. In total, 96 (31%) children had experienced a minor ailment in the preceding 2 weeks; the most commonly reported were cold, headache and gastrointestinal disturbance. Ninety-five respondents indicated how they managed this episode; the most common response was to treat the child with a medicine which they already had in the house (41%). A further 24 obtained a medicine specifically to manage the episode; 12 on prescription and 12 purchased an over-the-counter (OTC) medicine. The majority of respondents (86%) felt that they based their management decision on their own experience, only 10 felt their action was influenced by the advice of a pharmacist or doctor. Fifty children (16%) were reported to have a chronic illness. Several respondents volunteered comments suggesting that they would be cautious in their use of OTC medicines. This study indicates that in the majority of cases, carers manage children's minor ailments without recourse to professional advice.