Development of patient-centred performance indicators to guide the delivery of pharmaceutical care in a district general hospital.

The aim of this study was to audit clinical pharmacy practice in an acute hospital setting against the individual patient care guidelines set out in the CRAG "Framework for Practice" document, and then to develop practical, patient-centred performance indicators that could be used locally to monitor the delivery of pharmaceutical care. A series of four audits were undertaken to establish key elements in the process of providing pharmaceutical care to patients. Four standard statements describing the performance of the pharmacy service in providing patient care were developed through peer discussion and formulation of ideas based around these data. The four standard statements were then used as performance indicators to evaluate service performance at PRI and tested by means of a further audit cycle. The use of this methodology facilitated operation of a structured service appraisal system and provided a forum that allowed problems with practice to be discussed and resolved.

New patients presenting to their GP with dyspepsia: does Helicobacter pylori eradication minimise the cost of managing these patients?

Fifty-seven patients newly presenting to their GP with dyspepsia agreed to take part in a pharmacist-led clinic which tested and treated for Helicobacter pylori. Of these patients, 63% (36/57) tested positive and received eradication therapy. For 78% (28/36), eradication was successful with the first course of treatment, 89% (25/28) remaining symptom-free over the six-month follow-up. Eradication was successful for a further 17% (6/36) after a second attempt; again, these patients remained free of symptoms over the follow-up period. Thus, of the initial patients, 54% (31/57) were successfully treated, with no further symptoms. Such results had significant consequences on the expected direct cost of management per patient from a GP viewpoint. Using decision analysis it was found that H. pylori eradication for patients presenting with dyspepsia for the first time could result in considerable cost savings per patient in the long term.

Integrating clinical pharmacists into the primary health care team: a framework for rational and cost-effective prescribing.

A recent Audit Commission report into general practice prescribing identifies areas where general practitioner and pharmacist collaboration could be beneficial. Two such areas are formulary development and repeat prescribing review. Increased generic prescribing is encouraged in the report and in central priorities for Scottish Health Boards. This study was designed to develop and assess the effects on prescribing, of a practice formulary and a procedure for change to generic name prescribing. A practice formulary, standards for generic name prescribing and an approach to prescribing review were agreed, developed and implemented. Formulary compliance and the extent of prescribing generically and of changes to generic prescriptions were assessed by prospective prescription monitoring. Consultations resulting in a prescription reduced from 69% to 59% and 80% of acute prescribing events were met from 144 formulary medicines. Rapid change to generic name prescriptions was achieved without patient complaints and the overall generic prescribing level increased from 57% to 68%. Eighty percent of all new prescriptions were generic.

Compliance with prescribed medicines in general medical and surgical wards.

A total of 6833 doses of medication were prescribed to 753 hospital inpatients in general wards over a 24-hour period (excluding medicines prescribed on an as-required basis and medicines prescribed for the first time during the 24-hour period). Of these, 574 (8.4%) doses were omitted, representing at least one omitted dose in 242 (32.1%) patients. Many of the omitted doses were of symptomatic treatments and in 43% of instances omission was deemed, retrospectively, to have been beneficial. Some omissions, however, were of a potentially life-threatening nature. The most common reasons for omission were that the patient refused the drug or that the nurse thought the drug unnecessary, the patient was on 'nil by mouth' or was too ill or unable to take the medicine. Thus, omission of prescribed medicines in general wards is common, often of little consequence or even beneficial, but of a potentially serious nature.

Side-effect 'tolerance' in elderly long-term recipients of benzodiazepine hypnotics.

The outcome of long-term benzodiazepine hypnotic therapy has been investigated in a group of elderly patients in the community; 220 receiving nitrazepam and 33 flurazepam. The estimated duration of therapy was as long as 15 years in some cases. More than half were taking doses greater than 5 mg and 15 mg, respectively, the majority on a regular nightly basis in accordance with the instructions on containers. The plasma concentrations of nitrazepam and the active desalkyl metabolite of flurazepam correlated positively with weight-related dose. In the case of desalkyl-flurazepam, but not nitrazepam, the levels were substantially higher than those previously reported in young individuals. There was sustained patient satisfaction with the effectiveness of the hypnotics and, despite the high plasma levels, little subjective or objective evidence of unwanted sedation, confusion or unsteadiness. The findings of the survey suggest the development of both pharmacodynamic tolerance to the unwanted sedative effects of these drugs and a degree of dependence in long-term recipients.

Postmarketing drug surveillance by record linkage in Tayside.

The feasibility of conducting postmarketing drug surveillance by record linkage in Tayside was assessed. The key feature of the method is that all hospital discharge data are already computerised by the area health board and may be accessed through the unique community health number (CHNo) which has been allocated to all Tayside residents. The 12 861 prescriptions for cimetidine dispensed in Tayside over a nine month period were collected and the CHNo identified for 76%. These corresponded to 3802 individuals and their discharge data, together with those for an equal number of controls matched by age, sex, and general practitioner were retrieved from the computer. The expected excess of those diseases for which cimetidine is prescribed (peptic ulcer and oesophagitis) was observed. Other drug-disease associations were observed but may have been due to confounding and emphasise the inadequacy of community based controls. The major advantages of record linkage are, firstly, the low cost of the method, the present study costing just over pounds 12 000, and, secondly, the duration of patient follow up which may may be extended for as many years as required simply by rerunning the computer programs. To assemble large patient cohorts the study would have to be extended to other area health boards that are currently developing similar computer systems. Record linkage may provide a cost effective method for the follow up of patients to identify serious adverse drug reactions, particularly those that take several years to develop.

Duplicate prescriptions: an aid to research and review.

We describe a method of studying patterns of prescribing and related morbidity in general practice. Prescribing data were automatically duplicated onto a ;no-carbon-required' prescription-pad. Additional information about diagnosis and indications for each drug, an indication of whether the drug was newly prescribed or a repeat, and a patient identification code were entered onto the bottom copy. A computer was used to process the data, which were gathered over a period of seven months.The method offers an efficient means of collecting data which can be applied by individuals or groups of doctors to improve patient care and help achieve rational prescribing.

Prescribing in general practice and the provision of drug information.

Duplicate prescriptions were used to monitor patient prescribing and morbidity data for 20 Tayside general practitioners during a two-year study. Each participant took part in two periods of active monitoring separated by a three-month gap. Prescribing statistics collected during the first period of monitoring formed the basis of drug information which was circulated to participants shortly after the start of the second period. Some of this information was purely statistical; other information included comments as well as statistics. Subsequent monitoring assessed any changes in prescribing. The results indicate that drug information of this kind can influence general practitioner prescribing but that there were no differences in response to information which was purely statistical and information which included comments.