The prevalence of polypharmacy in older Europeans: A multi-national database study of general practitioner prescribing.

AIMS: The aims of this study were to measure the prevalence of polypharmacy and describe the prescribing of selected medications known for overuse in older people with polypharmacy in primary care. METHODS: This was a multinational retrospective cohort study across six countries: Belgium, France, Germany, Italy, Spain and the UK. We used anonymized longitudinal patient-level information from general practice databases hosted by IQVIA. Patients ≥65 years were included. Polypharmacy was defined as having 5-9 and ≥10 distinct drug classes (ATC Level 3) prescribed during a 6-month period. Selected medications were: opioids, antipsychotics, proton pump inhibitors (PPI), benzodiazepines (ATC Level 5). We included country experts on the healthcare context to interpret findings. RESULTS: Age and gender distribution was similar across the six countries (mean age 75-76 years; 54-56% female). The prevalence of polypharmacy of 5-9 drugs was 22.8% (UK) to 58.3% (Germany); ≥10 drugs from 11.3% (UK) to 28.5% (Germany). In the polypharmacy population prescribed ≥5 drugs, opioid prescribing ranged from 11.5% (France) to 27.5% (Spain). Prescribing of PPI was highest with almost half of patients receiving a PPI, 42.3% (Germany) to 65.5% (Spain). Benzodiazepine prescribing showed a marked variation between countries, 2.7% (UK) to 34.9% (Spain). The healthcare context information explained possible underreporting for selected medications. CONCLUSIONS: We have found a high prevalence of polypharmacy with more than half of the older population being prescribed ≥5 drugs in four of the six countries. Whilst polypharmacy may be appropriate in many patients, worryingly high usage of PPIs and benzodiazepines supports current efforts to improve polypharmacy management across Europe.

Corrigendum to "Utilisation Trend of Long-Acting Insulin Analogues including Biosimilars across Europe: Findings and Implications".

[This corrects the article DOI: 10.1155/2021/9996193.].

Key Considerations From a Health Authority Perspective When Proton Pump Inhibitors Are Used to Treat Gastroesophageal Reflux Disease (GERD) and Their Implications.

The growing prevalence of gastroesophageal reflux disease (GERD) needs to be carefully managed to relieve the symptoms and prevent complications. Complications of GERD can include erosive esophagitis, Barrett's esophagus and gastrointestinal (GI) bleeding. Proton pump inhibitors (PPIs) are typically first-line treatment for GERD alongside lifestyle changes in view of their effectiveness and cost-effectiveness. However, there are concerns with adherence to dosing regimens and recommended lifestyle changes reducing their effectiveness. There are also concerns about potential complications from chronic high-dose PPIs. These include an increased risk of chronic kidney disease, cardiovascular events and infections. Recommendations to physicians include prescribing or dispensing the lowest dose of PPI for the shortest time, with ongoing patient monitoring. Activities among community pharmacists and others have resulted in increased dispensing of PPIs without a prescription, which can be a challenge. PPIs are among the most prescribed and dispensed medicines in view of their effectiveness in managing GERD. However, there are concerns with the doses prescribed and dispensed as well as adherence to lifestyle advice. These issues and challenges need to be addressed by health authorities to maximize the role and value of PPIs.

Feedback of actionable individual patient prescription data to improve asthma prescribing: pragmatic cluster randomised trial in 233 UK general practices.

BACKGROUND: Potentially inappropriate prescribing (PIP) of asthma bronchodilator inhalers is associated with increased morbidity and mortality. AIM: To evaluate the effectiveness of feedback on the PIP of bronchodilator inhalers. DESIGN AND SETTING: Pragmatic cluster randomised trial involving 235 of 244 (96.3%) GP practices in one Scottish health board. METHOD: Practices were randomly allocated (1:1 ratio) to individualised feedback (including visualised medication histories for each patient and action-oriented messages) on PIP of bronchodilator inhalers from prescription data; feedback reports were sent in July 2015, February 2016, and August 2016. Controls were sent feedback on an unrelated subject. The primary outcome was the change in the mean number of patients per practice with PIP of bronchodilator inhalers from the baseline period (August 2014-July 2015) until the post-feedback period (February 2016-January 2017), identified through a composite of five individual measures using prescription data. RESULTS: In the analysis of the primary outcome, the mean number of patients with PIP of bronchodilator inhalers fell in the 118 practices that were sent feedback from 21.8 per practice to 17.7 per practice. Numbers fell marginally in the 115 control practices, from 20.5 per practice to 20.2 per practice, with a statistically significant difference between the two groups. There were 3.7 fewer patients per practice with PIP of bronchodilator inhalers in the intervention practices versus the control practices (95% confidence interval = -5.3 to -2.0). CONCLUSION: Individualised feedback of PIP of asthma bronchodilators that included background information, visualised medication histories for each patient, and action-oriented messages was effective at reducing the number of patients exposed to excess or unsafe prescribing of bronchodilator inhalers.

Delivery of care, seizure control and medication adherence in women with epilepsy during pregnancy.

PURPOSE: To evaluate service access for women with epilepsy (WWE) during pregnancy; to determine seizure frequency and rates of adherence to anti-seizure medication (ASM). METHODS: Between June 2019-June 2020, pregnant WWE within NHS Greater Glasgow and Clyde health-board were identified from the National Obstetric Register. A manual review of electronic patient records was undertaken to ensure diagnostic accuracy, as well as determine contact with epilepsy services and documented seizures. Medication dispensing records were obtained six months before and six months after midwifery booking and measures of ASM adherence calculated. RESULTS: Between June 2019-June 2020, 4592 women were registered with a pregnancy. Eighty-five (1.9%) were identified as having active epilepsy (generalised- 40/85 (47.0%), focal- 35/85 (41.2%), unclassified- 10/85 (11.8%)). Preconceptually, 42/85 WWE (49.4%) had input from epilepsy services. Only 59/85 (69.4%) were reviewed during pregnancy (First trimester- 21/59 (35.6%), Second trimester- 25/59 (42.4%) and Third trimester- 13/59 (22.0%)). Seizure occurrence was documented in 37/85 WWE (43.5%) during the antenatal/postnatal period. 71/85 WWE (83.5%) were prescribed ASM. Poor adherence was noted in 50/85 (58.9%) and a documented seizure recorded in 26/50 (52.0%) of these women. CONCLUSION: Too many WWE do not receive input from epilepsy services during pregnancy, leaving some with poor ASM adherence and continued seizures. We aim to use "near-live" obstetric and dispensing data to facilitate early identification of WWE, promoting timely access to epilepsy specialists. This will also provide an opportunity to address concerns regarding ASM safety and allow medication dose changes to be considered.

New ways of working releasing general practitioner capacity with pharmacy prescribing support: a cost-consequence analysis.

BACKGROUND: General practice in the United Kingdom is experiencing a workforce crisis. Greater multidisciplinary working, including more general practice pharmacists, is seen as part of the solution. However, it is unknown what impact and cost-consequences that pharmacists may have in freeing general practitioner (GP) capacity. OBJECTIVE: To evaluate the cost-consequences of additional pharmacists in releasing GP capacity. METHODS: This cost-consequences evaluation of a prospective observational cohort study in 15 urban practices involving 69 GPs in 1 locality serving a population of 82,000 people. GPs recorded the time they spent addressing key targeted prescribing activities during 5 distinct 2-week audit periods. Pharmacists performed these key prescribing activities to release GP capacity. An additional 225 h of pharmacists' time per week was committed to the locality. Standardized staff costings were used to estimate the financial impact. Prescribing indicator performance was assessed against the other 7 localities within the health board. RESULTS: When compared with employing extra nonsalaried GPs this required an estimated additional investment of £16.73 (range £5.97-20.87) per h to free GP capacity. This achieved a sustainable 47% (73 h per week, F(4,56) = 16.05, P < 0.001) reduction in GP time spent on key prescribing activities; equating to 4.9 h (95% confidence interval 3.1-6.7) per practice per week. No significant step changes in locality safety and quality prescribing measures, and no negative effects on locality-level prescribing cost-efficiency work were observed. CONCLUSION: Appropriately resourced general practice pharmacy teams delivered prescribing cost-efficiencies as well as sustainably freeing GP capacity by performing key prescribing activities.

General practice in the United Kingdom is experiencing a workforce crisis, and is struggling to deliver services. Pharmacists have been shown to be effective in freeing general practitioner (GP) capacity. However, it is unknown how much it costs to do this. Therefore, we aimed to assess the cost-consequences of releasing GP capacity. All practices in 1 region took part. GPs recorded the time it routinely took them to address key prescribing activities, Spring 2016. Pharmacists then delivered the key prescribing activities. The region got an extra 225 h of pharmacists' time to do these activities. Then in Spring 2018, the GPs and pharmacists recorded the time took to do the key prescribing activities. Standard salary costs were used to estimate how much money was needed to free GP capacity with pharmacists. The impact on routine cost-effective work was also assessed. Pharmacists delivering key prescribing activities freed 73 h per week of GP time. This equalled an average of 5 h per week per practice. Freeing GP capacity was estimated to cost an extra £16.73 (range £5.97­20.87) per h. There were no negative effects on cost-efficiency work. Appropriately resourcing general practice with pharmacists delivers sustainable prescribing cost-efficiencies and frees GP capacity.

Utilisation Trend of Long-Acting Insulin Analogues including Biosimilars across Europe: Findings and Implications.

BACKGROUND: Diabetes mellitus rates and associated costs continue to rise across Europe enhancing health authority focus on its management. The risk of complications is enhanced by poor glycaemic control, with long-acting insulin analogues developed to reduce hypoglycaemia and improve patient convenience. There are concerns though with their considerably higher costs, but moderated by reductions in complications and associated costs. Biosimilars can help further reduce costs. However, to date, price reductions for biosimilar insulin glargine appear limited. In addition, the originator company has switched promotional efforts to more concentrated patented formulations to reduce the impact of biosimilars. There are also concerns with different devices between the manufacturers. As a result, there is a need to assess current utilisation rates for insulins, especially long-acting insulin analogues and biosimilars, and the rationale for patterns seen, among multiple European countries to provide future direction. Methodology. Health authority databases are examined to assess utilisation and expenditure patterns for insulins, including biosimilar insulin glargine. Explanations for patterns seen were provided by senior-level personnel. RESULTS: Typically increasing use of long-acting insulin analogues across Europe including both Western and Central and Eastern European countries reflects perceived patient benefits despite higher prices. However, activities by the originator company to switch patients to more concentrated insulin glargine coupled with lowering prices towards biosimilars have limited biosimilar uptake, with biosimilars not currently launched in a minority of European countries. A number of activities were identified to address this. Enhancing the attractiveness of the biosimilar insulin market is essential to encourage other biosimilar manufacturers to enter the market as more long-acting insulin analogues lose their patents to benefit all key stakeholder groups. CONCLUSIONS: There are concerns with the availability and use of insulin glargine biosimilars among European countries despite lower costs. This can be addressed.

Comparison of COVID-19 outcomes among shielded and non-shielded populations.

Many western countries used shielding (extended self-isolation) of people presumed to be at high-risk from COVID-19 to protect them and reduce healthcare demand. To investigate the effectiveness of this strategy, we linked family practitioner, prescribing, laboratory, hospital and death records and compared COVID-19 outcomes among shielded and non-shielded individuals in the West of Scotland. Of the 1.3 million population, 27,747 (2.03%) were advised to shield, and 353,085 (26.85%) were classified a priori as moderate risk. COVID-19 testing was more common in the shielded (7.01%) and moderate risk (2.03%) groups, than low risk (0.73%). Referent to low-risk, the shielded group had higher confirmed infections (RR 8.45, 95% 7.44-9.59), case-fatality (RR 5.62, 95% CI 4.47-7.07) and population mortality (RR 57.56, 95% 44.06-75.19). The moderate-risk had intermediate confirmed infections (RR 4.11, 95% CI 3.82-4.42) and population mortality (RR 25.41, 95% CI 20.36-31.71) but, due to their higher prevalence, made the largest contribution to deaths (PAF 75.30%). Age ≥ 70 years accounted for 49.55% of deaths. In conclusion, in spite of the shielding strategy, high risk individuals were at increased risk of death. Furthermore, to be effective as a population strategy, shielding criteria would have needed to be widely expanded to include other criteria, such as the elderly.

Medication safety in primary care-from measurement to action.

Topics for DTB review articles are selected by DTB's editorial board to provide concise overviews of medicines and other treatments to help patients get the best care. Articles include a summary of key points and a brief overview for patients. Articles may also have a series of multiple choice CME questions.

Real-world evaluation of the impact of statin intensity on adherence and persistence to therapy: A Scottish population-based study.

AIM: To assess associations between statin intensity and adherence, persistence and discontinuation of statin therapy in Scotland. METHOD: Retrospective cohort study, using linked electronic health records covering a period from January 2009 to December 2016. The study cohort included adult patients (≥18 years) newly initiating statins within Greater Glasgow and Clyde, Scotland. Study outcomes comprised adherence, discontinuation and persistence to treatment, stratified by three exposure groups (high, moderate and low intensity). Discontinuation and persistence were calculated using the refill-gap and anniversary methods, respectively. Proportion of days covered (PDC) was used as a proxy for adherence. Kaplan-Meier survival curves and Cox proportional hazard models were used to evaluate discontinuation, and associations between adherence/persistence and statin intensity were assessed using logistic regression. RESULTS: A total of 73 716 patients with a mean age of 61.4 ± 12.6 years were included; the majority (88.3%) received moderate intensity statins. Discontinuation rates differed between intensity levels, with high-intensity patients less likely to discontinue treatment compared to those on moderate intensity (prior cardiovascular disease [CVD]: HR 0.43 [95% CI 0.34-0.55]; no prior CVD: 0.80 [0.74-0.86]). Persistence declined over time, and high-intensity patients had the highest persistence rates. Overall, 52.6% of patients were adherent to treatment (PDC ≥ 80%), but adherence was considerably higher among high-intensity patients (63.7%). CONCLUSION: High-intensity statins were associated with better persistence and adherence to treatment, but overall long-term persistence and adherence remain a challenge, particularly among patients without prior CVD. This needs addressing.

Prescribing trends of inhaler treatments for asthma and chronic obstructive pulmonary disease within a resource-constrained environment in the Scottish national health service: findings and implications.

Background: There is an increasing prevalence of asthma and chronic obstructive pulmonary disease (COPD) worldwide, leading to increased inhaler use. However, there are concerns with inhaler compliance resulting in different patented inhalers and longer-acting formulations. As a result, inhalers are now among the highest expenditure items in ambulatory care in Scotland leading to multiple initiatives to keep within budget without compromising care. Method: This study assesses inhaler utilization and expenditure between 2001 and 2017 alongside health authority initiatives. Results: There was an increase by 137% in inhaler utilization between 2001 and 2017, and a two-fold increase in expenditure, driven by the increasing use of patented combination inhalers to address concerns. This is very different to the oral markets where expenditure on proton pump inhibitors, statins, and antihypertensives have fallen considerably recently despite increased volumes due to the increasing use of low-cost generics. However, inhaler expenditure has started to fall with an increasing use of lower cost combinations and initiatives to reduce the steroid burden alongside monitoring patient care. Conclusion: Challenges with using and changing inhalers has meant this market has not followed other high-volume drug classes following patent loss. This is starting to change, with the situation monitored to enhance efficient prescribing alongside continued good quality care.

Ongoing initiatives within the Scottish National Health Service to affect the prescribing of selective serotonin reuptake inhibitors and their influence.

Aim: Increasing use of selective serotonin-reuptake inhibitors (SSRIs) in Scotland, coupled with safety concerns with some SSRIs, and the increasing availability of generic SSRIs, have resulted in multiple initiatives to improve the quality and efficiency of their prescribing in Scotland. Our aim is to assess their influence to provide future direction. Materials & methods: The prescription costs analysis database was used to document utilization and expenditure on SSRIs between 2001 and 2017 alongside documenting the initiatives. Results: Multiple interventions over the years increased international nonproprietary name prescribing up to 99.9% lowering overall costs. This, coupled with initiatives to limit escitalopram prescribing due to concerns with its value, resulted in a 73.7% reduction in SSRI expenditure between 2001 and 2017 despite a 2.34-fold increase in utilization. Safety warnings resulted in a significant reduction in the prescribing of paroxetine, citalopram and escitalopram alongside a significant increase in sertraline Conclusion: Multiple initiatives have increased the quality and efficiency of SSRI prescribing in Scotland providing direction to others.

Insights into frequent asthma exacerbations from a primary care perspective and the implications of UK National Review of Asthma Deaths recommendations.

The United Kingdom National Review of Asthma Deaths (NRAD) recommends that patients who require ≥3 courses of oral corticosteroids (OCS) for exacerbations in the past year or those on British Thoracic Society (BTS) Step 4/5 treatment must be referred to a specialist asthma service. The aim of the study was to identify the proportion of asthma patients in primary care that fulfil NRAD criteria for specialist referral and factors associated with frequent exacerbations. A total of 2639 adult asthma patients from 10 primary care practices in Glasgow, UK were retrospectively studied between 2014 and 2015. Frequent exacerbators and short-acting ß2-agonist (SABA) over-users were identified if they received ≥2 confirmed OCS courses for asthma and ≥13 SABA inhalers in the past year, respectively. Community dispensing data were used to assess treatment adherence defined as taking ≥75% of prescribed inhaled corticosteroid (ICS) dose. The study population included 185 (7%) frequent exacerbators, 137 (5%) SABA over-users, and 319 (12%) patients on BTS Step 4/5 treatment. Among frequent exacerbators, 41% required BTS Step 4/5 treatment, 46% had suboptimal ICS adherence, 42% had not attended an asthma review in the past year and 42% had no previous input from a specialist asthma service. Older age, female gender, BTS Step 4/5, SABA over-use and co-existing COPD diagnosis increased the risk of frequent exacerbations independently. Fourteen per 100 asthma patients would fulfil the NRAD criteria for specialist referral. Better collaboration between primary and secondary care asthma services is needed to improve chronic asthma care.

Ongoing activities to optimize the quality and efficiency of lipid-lowering agents in the Scottish national health service: influence and implications.

BACKGROUND: Prescribing of lipid-lowering agents (LLAs) has increased worldwide including in Scotland with increasing prevalence of coronary heart disease, and higher dose statins have been advocated in recent years. There have also been initiatives to encourage prescribing of generic versus patented statins to save costs without compromising care. There is a need to document these initiatives and outcomes to provide future direction. METHOD: Assessment of utilization (items dispensed) and expenditure of key LLAs (mainly statins) between 2001 and 2015 in Scotland alongside initiatives. RESULTS: Multiple interventions over the years have increased international nonproprietary name prescribing (99% for statins) and preferential prescribing of generic versus patented statins, and reduced inappropriate prescribing of ezetimibe. This resulted in a 50% reduction in expenditure of LLAs between 2001 and 2015 despite a 412% increase in utilization, increased prescribing of higher dose statins (71% in 2015) especially atorvastatin following generic availability, and reduced prescribing of ezetimibe (reduced by 72% between 2010 and 2015). As a result, the quality of prescribing has improved. CONCLUSION: Generic availability coupled with multiple measures has resulted in appreciable shifts in statin prescribing behavior and reduced ezetimibe prescribing, resulting in improvements in both the quality and efficiency of prescribing.

Evaluation of a complex intervention to improve primary care prescribing: a phase IV segmented regression interrupted time series analysis.

BACKGROUND: It is uncertain whether improvements in primary care high-risk prescribing seen in research trials can be realised in the real-world setting. AIM: To evaluate the impact of a 1-year system-wide phase IV prescribing safety improvement initiative, which included education, feedback, support to identify patients to review, and small financial incentives. DESIGN AND SETTING: An interrupted time series analysis of targeted high-risk prescribing in all 56 general practices in NHS Forth Valley, Scotland, was performed. In 2013-2014, this focused on high-risk non-steroidal anti-inflammatory drugs (NSAIDs) in older people and NSAIDs with oral anticoagulants; in 2014-2015, it focused on antipsychotics in older people. METHOD: The primary analysis used segmented regression analysis to estimate impact at the end of the intervention, and 12 months later. The secondary analysis used difference-in-difference methods to compare Forth Valley changes with those in NHS Greater Glasgow and Clyde (GGC). RESULTS: In the primary analysis, downward trends for all three NSAID measures that were existent before the intervention statistically significantly steepened following implementation of the intervention. At the end of the intervention period, 1221 fewer patients than expected were prescribed a high-risk NSAID. In contrast, antipsychotic prescribing in older people increased slowly over time, with no intervention-associated change. In the secondary analysis, reductions at the end of the intervention period in all three NSAID measures were statistically significantly greater in NHS Forth Valley than in NHS GGC, but only significantly greater for two of these measures 12 months after the intervention finished. CONCLUSION: There were substantial and sustained reductions in the high-risk prescribing of NSAIDs, although with some waning of effect 12 months after the intervention ceased. The same intervention had no effect on antipsychotic prescribing in older people.

Quality indicators as a tool in improving the introduction of new medicines.

Quality indicators are increasingly used as a tool to achieve safe and quality clinical care, cost-effective therapy, for professional learning, remuneration, accreditation and financial incentives. A substantial number focus on drug therapy but few address the introduction of new medicines even though this is a burning issue. The objective was to describe the issues and challenges in designing and implementing a transparent indicator framework and evaluation protocol for the introduction of new medicines and to provide guidance on how to apply quality indicators in the managed entry of new medicines. Quality indicators need to be developed early to assess whether new medicines are introduced appropriately. A number of key factors need to be addressed when developing, applying and evaluating indicators including dimensions of quality, suggested testing protocols, potential data sources, key implementation factors such as intended and unintended consequences, budget impact and cost-effectiveness, assuring the involvement of the medical professions, patients and the public, and reliable and easy-to-use computerized tools for data collection and management. Transparent approaches include the need for any quality indicators developed to handle conflict of interests to enhance their validity and acceptance. The suggested framework and indicator testing protocol may be useful in assessing the applicability of indicators for new medicines and may be adapted to healthcare settings worldwide. The suggestions build on existing literature to create a field testing methodology that can be used to produce country-specific quality indicators for new medicines as well as a cross international approach to facilitate access to new medicines.

Do quality incentives change prescribing patterns in primary care? An observational study in Scotland.

BACKGROUND: The 2004 General Medical Services (GMS) contract introduced financial incentives for the management of chronic illnesses in 10 clinical areas. The effect of the scheme on prescribing is unknown. OBJECTIVES: To quantify the impact of the latest GMS contract, which incorporates additional payments for quality outcomes, on prescribing patterns in GP practices. METHODS: This retrospective observational study of prescribing compared the defined daily doses (DDDs) for drugs mentioned or implied within the Quality and Outcomes Framework (QOF) of the latest GMS contract (QOF drugs) to the DDDs for all other drugs listed within the first 10 chapters on the British National Formulary (non-QOF drugs) for four financial years; two before and two after the introduction of the latest GMS contract. These measures were calculated for 92 GP practices of 100 in the Lothian region of Scotland, and the rate of change of prescribing was calculated from regression slopes within the log-scale interrupted time series analyses. RESULTS: The prescribing of QOF drugs increased significantly faster than the non-QOF drugs both before and after the introduction of the latest GMS contract but the rate of increase for the QOF drugs slowed significantly after April 2005 unlike prescribing of non-QOF drugs. CONCLUSIONS: The prescribing of relevant drugs increased before the introduction of the 2004 GMS contract; the increase continued in the first 2 years of the new contract but at a significantly lower level.