Prescribing antidepressants and benzodiazepines in the Netherlands: is chronic physical illness involved?

In this study we assessed differences in new and repeat prescriptions of psycho-tropics between patients receiving prescriptions for drugs to treat a common chronic disease and people without such prescriptions. The study used the databases of two Dutch health insurance companies (3 million people). We selected all Dutch men and women aged 45 and older who were registered for six consecutive years (1999-2004). Our analyses both found a consistent relation between psycho-tropics on the one hand and physical illness on the other. People with multi-morbidity were prescribed these drugs most often, especially men and those younger than 65. Epidemiological studies showed a prevalence of depression among people with multi-morbidity to be twice as high as among people without such conditions. According to recent guidelines non-drug treatment may be the first therapy option for patients with non severe depression. If prescribed for a long time, benzodiazepine prescriptions are especially known to be addictive. Our data raise the question to what extent patients with a chronic physical disease suffering from co-occurring mental problems are prescribed psycho-tropics in accord with the guidelines that also advise mental support in case of non severe mental problems. Further research can answer this important question.

A cluster randomized controlled trial aimed at implementation of local quality improvement collaboratives to improve prescribing and test ordering performance of general practitioners: study protocol.

BACKGROUND: The use of guidelines in general practice is not optimal. Although evidence-based methods to improve guideline adherence are available, variation in physician adherence to general practice guidelines remains relatively high. The objective for this study is to transfer a quality improvement strategy based on audit, feedback, educational materials, and peer group discussion moderated by local opinion leaders to the field. The research questions are: is the multifaceted strategy implemented on a large scale as planned?; what is the effect on general practitioners' (GPs) test ordering and prescribing behaviour?; and what are the costs of implementing the strategy? METHODS: In order to evaluate the effects, costs and feasibility of this new strategy we plan a multi-centre cluster randomized controlled trial (RCT) with a balanced incomplete block design. Local GP groups in the south of the Netherlands already taking part in pharmacotherapeutic audit meeting groups, will be recruited by regional health officers. Approximately 50 groups of GPs will be randomly allocated to two arms. These GPs will be offered two different balanced sets of clinical topics. Each GP within a group will receive comparative feedback on test ordering and prescribing performance. The feedback will be discussed in the group and working agreements will be created after discussion of the guidelines and barriers to change. The data for the feedback will be collected from existing and newly formed databases, both at baseline and after one year. DISCUSSION: We are not aware of published studies on successes and failures of attempts to transfer to the stakeholders in the field a multifaceted strategy aimed at GPs' test ordering and prescribing behaviour. This pragmatic study will focus on compatibility with existing infrastructure, while permitting a certain degree of adaptation to local needs and routines.

Pharmaceutical care and its relationship to prescribing behaviour of general practitioners.

OBJECTIVE: To study the correlation between pharmaceutical care and prescribing routines of general practitioners (GPs). METHODS: Cross-sectional study; 201 pharmacies, 408 general practices, The Netherlands, 2000/2001. The variation in prescribing behaviour was characterised using 20 validated prescribing indicators based on general practice guidelines. The general construct 'adherence to guidelines' served as the dependent variable and was formed by summing the scores of the prescribing indicators. Four possible determinants of the variation were determined on the basis of survey questions: the construct 'the pharmacist's attitude towards pharmaceutical care', and three partial constructs derived from the pharmacist's care-providing function: the care for the individual patient, the cooperation with general practitioners and the registration of the care provided. A multiple linear regression analysis was then performed. MAIN OUTCOME MEASURE: The weighted score for the prescribing indicators. RESULTS: The weighted average score for the prescribing indicators was 65% (SD 3.7). The response rate to the survey was 71%. The pharmacist's attitude to pharmaceutical care, as well as the degree to which the pharmacist provided care for the individual patient, the degree to which he cooperated with the general practitioner and the degree to which he registered the care provided were not correlated with the 'adherence to guidelines' by the general practitioner with whom the pharmacist frequently cooperated. CONCLUSION: Variations between general practitioners in the quality of prescribing, as measured by their adherence to guidelines, were not correlated with pharmaceutical care by the pharmacist with whom they cooperated on a day-to-day basis.

Differences in prescribing between GPs: impact of the cooperation with pharmacists and impact of visits from pharmaceutical industry representatives.

BACKGROUND: Community pharmacists, pharmaceutical industry and differences in prescribing between GPs. OBJECTIVE: To explore the role of the pharmacists and pharmaceutical industry representatives. METHODS: A cross-sectional survey was undertaken of 1434 GPs in The Netherlands in 2001. Prescribing indicators based on general practice guidelines were used to assess the quality of prescribing. Three constructs, based on survey questions, were used as possible determinants for the quality of prescribing: cooperation with the pharmacist; quality of the Pharmacotherapeutic audit meeting (PTAM); and the GP's attitude towards the pharmacist's role. Data were collected about the frequency of visits by pharmaceutical industry representatives. Responses from 324 solo GPs were analysed using multiple linear regression. RESULTS: Response rate: 71%. For the 324 solo GPs the average score for the 20 prescribing indicators was 64% (SD 3.7). For the non-solo GPs this score was 65% (SD 3.8, P < 0.05). The differences between solo and group practices were: the number of visits from pharmaceutical industry representatives (5.7 versus 3.8 visits per month), full time GPs (93% versus 50%), the number of patients per GP (2151, SD 693 versus 1506, SD 742), and the presence of a GP trainer (21 versus 38%). Of the solo GPs, 4.6% are female, compared with 26% of the GPs in non-solo practices. The quality of prescribing in solo practices was not correlated with the GP's attitude towards the pharmacist's role, the way in which GPs cooperated with pharmacists or the quality of the PTAM. More frequent visits from pharmaceutical industry representatives was associated with a lower quality of prescribing. CONCLUSION: There was a negative correlation between quality of prescribing by solo GPs and frequency of visits by pharmaceutical industry representatives. In day-to-day practice, no measurable effects of the cooperation between solo GP and pharmacist on the quality of prescribing were observed.

Pharmacists in primary care. Determinants of the care-providing function of Dutch community pharmacists in primary care.

OBJECTIVE: To identify determinants of the care-providing function of the community pharmacists (CPs) to explain variations in professional practice. SETTING: The Netherlands 2001. PARTICIPANTS: 328 CPs. METHOD: A cross-sectional questionnaire survey was performed. Questionnaires were used to collect data about the care provided in pharmacies. As dependent variables three partial constructs: 'individual patient care', 'registration of the care', and 'cooperation with GPs', and one total construct: 'care function' were formed. Independent variables were: gender, work experience, attitude to the care-providing function, tenure, relationship with GPs, pharmacist trainer, frequency of postgraduate training, workload, part-time working, frequency of contact with pharmaceutical representatives, presence of technicians with a specialised caring duty, size of the pharmacy, urbanisation, competition, franchise pharmacy, presence of sufficient personnel. A multiple-regression analysis was performed. RESULTS: Respondents 71%; of the respondents 29% never enquired about the patient's experience when supplying a medication for the second time. The supply of self-care remedies was never registered by 11% of respondents. Ninety percent of pharmacists participate more than four times per year in Pharmacotherapy Audit Meetings. The attitude of the pharmacist, relationship with the GP, presence of specialised technicians, frequency of postgraduate training and the type of tenure are significantly positively correlated with a care-providing function. Being a pharmacist trainer is significantly positively related with 'individual patient care', the frequency of postgraduate training is significantly positively correlated with 'registration of the care' and the number of years in service is significantly negatively correlated with 'cooperation with GPs'. There is a negative correlation between the cooperation with GPs and the number of years a pharmacist has been in service. CONCLUSION: Based on this survey, the development of programmes focused on optimal attitude, and cooperation between pharmacists and GPs is recommended.

Prescribing indicators. Development and validation of guideline-based prescribing indicators as an instrument to measure the variation in the prescribing behaviour of general practitioners.

BACKGROUND: Differences in prescribing behaviour among general practitioners (GPs). AIM: To formulate and validate clinical prescribing indicators based on general practice guidelines. DESIGN: Validatory study. SETTING: Pharmacies and general practices in the Netherlands in 2003. PARTICIPANTS: A total of 379 pharmacies, 947 general practices and 3.8 million patients. METHODS: A total of 51 potential indicators were formulated, based on medicinal recommendations from the evidence-based guidelines of the Dutch College of General Practitioners and the corresponding recommendations from the Commission Pharmaceutical Help of the Health Care Insurance Board. These indicators were submitted to an expert panel to assess content validity. The panel assessment was analysed using the RAND-UCLA appropriateness method (RAM). Then, for the remaining indicators, it was assessed to what extent these could be used to determine the prescribing behaviour of GPs and the level to which this behaviour varies among GPs. This was done using a prescribing analyses and cost (PACT) database that was compiled from prescription databases from 379 pharmacies, with all prescriptions from 1,434 GPs over an entire year to 3.8 million patients. RESULTS: The panel considered 34 of the 51 potential indicators to be valid with respect to providing an adequate reflection of the central recommendations in the guideline and in terms of relevance with respect to health gain and/or efficiency. Of these 34 indicators, 20 revealed considerable differences in the prescribing behaviour of GPs. CONCLUSION: On the basis of existing general practice guidelines, 20 prescribing indicators could be formulated that were assessed by an expert panel to be sufficiently valid and which could also discriminate the prescribing behaviour of GPs as reflected in the prescription databases of pharmacies.

Changing relationships: attitudes and opinions of general practitioners and pharmacists regarding the role of the community pharmacist.

BACKGROUND: Relationship between general practitioners and pharmacists. AIM: To explore similarities and differences in opinions between general practitioners and pharmacists about the pharmacist's role. To identify factors which determine the attitude of the general practitioner towards the role of the pharmacist as a care provider. DESIGN: Cross-sectional questionnaire survey. SETTING: The Netherlands, 2001. PARTICIPANTS: 926 non-dispensing general practitioners, 93 dispensing general practitioners and 328 community pharmacists. METHODS: Statements about the pharmacist's position in primary care were formulated. The attitude towards the pharmacist's care-providing function was determined by adding the scores to the statements. Data were collected on age, gender, professional experience, trainership, type and size of practice, electronic communication, urbanisation level, part-time work, work pressure, postgraduate training, pharmacotherapy audit meetings (PTAMs), the mutual relationship and the desired role of the pharmacist in pharmacotherapy. RESULTS: No significant differences in opinions were found between pharmacists and non-dispending general practitioners with respect to a number of the pharmacist's signalling tasks. Eighty-six percent (CI 83-89) of non-dispensing general practitioners and eighty-two percent (CI 76-87) of pharmacists shared the opinion that pharmacists need to provide the general practitioner with feedback on prescription figures. Furthermore, 85% (CI 82-88) of the non-dispensing general practitioners and 80% (CI 75-86) of the pharmacists believed that pharmacists should suggest items for the PTAM agenda, based on prescription patterns they notice in their pharmacy. The attitude of general practitioners towards the care-providing function of the community pharmacist correlates significantly with the relationship between general practitioners and pharmacists (P < 0.001). There is also a significant difference (P < 0.001) in the attitude score between dispensing and non-dispensing general practitioners: dispensing general practitioners scored lower on the attitude scale. CONCLUSION: Pharmacists and general practitioners largely agree on the pharmacotherapeutic signalling role that a pharmacist should fulfill. A good relationship benefits the attitude of general practitioners towards the pharmacist's care-providing function.