Explanations for variations in clopidogrel prescribing in England.

BACKGROUND: The National Audit Office (NAO) has produced prescribing indicators that Primary Care Trusts (PCTs) can use to judge their performance. One of the indicators is for the antiplatelet clopidogrel, measured as defined daily dose (DDD) per cardiovascular Specific Therapeutic Age Related Prescribing Unit (STAR-PU). Clopidogrel is used as an indicator because it is a more expensive medicine than the alternative (aspirin) and there may be scope for cost reduction. We aimed to establish if the NAO indicator for clopidogrel prescribing is a valid measure of prescribing performance. METHODS: Prescribing data for 152 PCTs and a range of explanatory variables were obtained. Correlation between variables was determined. A regression analysis was conducted to compare the dependent variable (prescribing) with the explanatory variables identified. RESULTS: The percentage of patients on the coronary heart disease register and Index of Multiple Deprivation explained 30% of the variation in prescribing (DDD/STAR-PU) between PCTs. Even though DDD/STAR-PU is adjusted for age and sex other measures of need still have an impact on prescribing. CONCLUSIONS: Using DDD/STAR-PU alone as a prescribing indicator might misidentify some PCTs, which are under- and over-using clopidogrel. Poor ranking against other PCTs using the NAO indicator should be fully explored taking into account other variables (cardiovascular morbidity and deprivation) before any corrective action is taken.

Randomised controlled trial of clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in general practice.

OBJECTIVE: To determine whether a pharmacist can effectively review repeat prescriptions through consultations with elderly patients in general practice. DESIGN: Randomised controlled trial of clinical medication review by a pharmacist against normal general practice review. SETTING: Four general practices. PARTICIPANTS: 1188 patients aged 65 or over who were receiving at least one repeat prescription and living in the community. INTERVENTION: Patients were invited to a consultation at which the pharmacist reviewed their medical conditions and current treatment. MAIN OUTCOME MEASURES: Number of changes to repeat prescriptions over one year, drug costs, and use of healthcare services. RESULTS: 590 (97%) patients in the intervention group were reviewed compared with 233 (44%) in the control group. Patients seen by the pharmacist were more likely to have changes made to their repeat prescriptions (mean number of changes per patient 2.2 v 1.9; difference=0.31, 95% confidence interval 0.06 to 0.57; P=0.02). Monthly drug costs rose in both groups over the year, but the rise was less in the intervention group (mean difference 4.72 pound sterling per 28 days, - 7.04 pound sterling to - 2.41 pound sterling); equivalent to 61 pound sterling per patient a year. Intervention patients had a smaller rise in the number of drugs prescribed (0.2 v 0.4; mean difference -0.2, -0.4 to -0.1). There was no evidence that review of treatment by the pharmacist affected practice consultation rates, outpatient consultations, hospital admissions, or death rate. CONCLUSIONS: A clinical pharmacist can conduct effective consultations with elderly patients in general practice to review their drugs. Such review results in significant changes in patients' drugs and saves more than the cost of the intervention without affecting the workload of general practitioners.

"No thank you": why elderly patients declined to participate in a research study.

OBJECTIVES: To compare the population consenting for a study of the effectiveness of a pharmacist-run medication review clinic with the population not consenting for patients aged over 65 years old with respect to age, sex and number of repeat medicines. To explore the reasons why some patients declined to consent to the study. METHODS: Letters were sent to 2,403 patients aged 65 and over and taking at least one repeat medicine from 4 general practices. If no reply was received to a second letter they were followed up by telephone. If they declined to consent they were asked for their reasons. Data for consenting and non-consenting patients was collected on the stratification factors: age, sex and number of repeat medicines. Multiple logistic regression was used to assess the association of each factor with consent rates. RESULTS: Consenting patients were dissimilar to non-consenting patients. Patients were less likely to consent if they were older, OR (95% CI) = 0.54 (0.46, 0.64), or female, OR (95% CI) = 0.74 (0.63, 0.88). Patients were more likely to consent if on 5 or more repeat medicines: OR (95% CI) = 1.3 (1.1, 1.5). Ten broad categories of reasons why patients did not wish to participate were identified from the patient interviews. CONCLUSIONS: Patients were less likely to give their consent if they were elderly, female and on fewer repeat medicines. A number of administrative and behavioural factors were identified which reduced the chances of informed consent being given. These factors need to be addressed to maximise numbers of consenting patients in medication review studies.

Development of a method for clinical medication review by a pharmacist in general practice.

Medication review of patients on long-term treatment in general practice in the UK has been reported to be inadequate. Proposals followed suggesting that pharmacists could use their expertise to lead such a medication review in conjunction with the general practitioner. This paper describes the concept of clinical medication review by a pharmacist based in general practice. We describe the development of a method for a structured and systematic process for undertaking such a review in clinics conducted by a pharmacist. The method was developed for a nationally funded study in the UK. We provide a definition of clinical medication review and suggests a structure for the process through data gathering, evaluation and implementation.