How many medications do doctors in primary care use? An observational study of the DU90% indicator in primary care in England

AimTo apply the drug utilisation 90% (DU90%) indicator (the number of unique drugs which makes up 90% of a doctor’s prescribing) to general practitioner (GP) practices prescribing in England to examine time trends, practice-level variation, and relationships with practice characteristics, prescribing costs and low-value prescribing.Study designRetrospective cohort study.SettingPrimary care in England, using publicly available prescribing data available from the National Health Service (NHS) digital platform for 2013–2017.ParticipantsAll general practices in England (n=7620).Primary and secondary outcome measuresThe DU90% was calculated on an annual basis for each practice based on medication British National Formulary codes. Low-value prescribing was defined using NHS 2017 guidance (including lidocaine plasters, liothyronine, omega-3 supplements). Descriptive statistics were generated per year on time trends and practice-level variation in the DU90%. Multilevel linear regression was used to examine the practice characteristics (relating to staff, patients and deprivation of the practice area).ResultsAmong 7620 practices, mean DU90% ranged from 130.0 to 131.0 across study years, and regarding variation between practices, there was a 1.4-fold difference between the lowest and highest 5% of practices. A range of medications were included in the DU90% of virtually all practices, including atorvastatin, levothyroxine, omeprazole, ramipril, amlodipine, simvastatin and aspirin. A higher volume of prescribing was associated with a lower DU90%, while having more patients, higher proportions of patients who are women or aged ≥45 years, higher number of GPs working in the practice and being in a more deprived area were associated with a higher DU90%. Practices in higher quintiles of DU90% had higher levels of low-priority prescribing and prescribing costs.ConclusionGP practices typically use 130 different medications in the bulk of their prescribing. Higher DU90% was associated with higher levels of low-priority prescribing and prescribing costs. Increasing use of personal formularies may enhance prescribing quality and reduce costs.

Download Full-text

How many medications do doctors in primary care use? An observational study of the DU90% indicator in primary care in England.

10.1101/2020.06.16.20132654 ◽

2020 ◽

Author(s):

Chiamaka Chiedozie ◽

Mark Murphy ◽

Tom Fahey ◽

Frank Moriarty

Keyword(s):

Primary Care ◽

Time Trends ◽

Level Variation ◽

Practice Level ◽

Practice Characteristics ◽

Characteristics Method ◽

Prescribing Quality ◽

Observational Cohort ◽

General Practices ◽

The Mean

Aim: To apply the DU90% indicator (the number of unique drugs which make up 90% of a doctor's prescribing) to GP practices prescribing in England to examine time trends, practice-level variation, and relationships with practice characteristics Method: This is an observational cohort study of all general practices in England. It utilises publicly available prescribing data from the National Health Service (NHS) Digital platform for 2013-2017. The DU90% was calculated on an annual basis for each practice based on medication BNF codes. Descriptive statistics were generated per year on time trends and practice-level variation in the DU90%. Multi-level linear regression was used to examine the practice characteristics (relating to staff, patients, and deprivation of the practice area). Results: A total of 7,623 GP practices were included. The mean DU90% ranged from 130.1 to 133.4 across study years, and variation between practices was low (with a 1.4 fold difference between the lowest and highest 5% of practices). A range of medications were included in the DU90% of virtually all practices, including atorvastatin, levothyroxine, omeprazole, ramipril, amlodipine, simvastatin and aspirin. A higher volume of prescribing was associated with a lower DU90%, while having more patients, higher proportions of patients who are female or aged 65+, higher number of GPs working in the practice, and being in a more deprived area were associated with a higher DU90%. Conclusion: GP practices typically use 130 different medications in the bulk of their prescribing. Increasing use of personal formularies may enhance prescribing quality and reduce costs.

Download Full-text

Practice-Level Variation in Telemedicine Use in a Pediatric Primary Care Network During the COVID-19 Pandemic: Retrospective Analysis and Survey Study

Journal of Medical Internet Research ◽

10.2196/24345 ◽

2020 ◽

Vol 22 (12) ◽

pp. e24345

Author(s):

Kelsey Schweiberger ◽

Alejandro Hoberman ◽

Jennifer Iagnemma ◽

Pamela Schoemer ◽

Joseph Squire ◽

...

Keyword(s):

Primary Care ◽

Race And Ethnicity ◽

Pediatric Primary Care ◽

Office Visits ◽

Level Variation ◽

Practice Level ◽

Practice Characteristics ◽

Care Practices ◽

Primary Care Practices ◽

Clinician Attitudes

Background Telehealth, the delivery of health care through telecommunication technology, has potential to address multiple health system concerns. Despite this potential, only 15% of pediatric primary care clinicians reported using telemedicine as of 2016, with the majority identifying inadequate payment for these services as the largest barrier to their adoption. The COVID-19 pandemic led to rapid changes in payment and regulations surrounding telehealth, enabling its integration into primary care pediatrics. Objective Due to limited use of telemedicine in primary care pediatrics prior to the COVID-19 pandemic, much is unknown about the role of telemedicine in pediatric primary care. To address this gap in knowledge, we examined the association between practice-level telemedicine use within a large pediatric primary care network and practice characteristics, telemedicine visit diagnoses, in-person visit volumes, child-level variations in telemedicine use, and clinician attitudes toward telemedicine. Methods We analyzed electronic health record data from 45 primary care practices and administered a clinician survey to practice clinicians. Practices were stratified into tertiles based on rates of telemedicine use (low, intermediate, high) per 1000 patients per week during a two-week period (April 19 to May 2, 2020). By practice tertile, we compared (1) practice characteristics, (2) telemedicine visit diagnoses, (3) rates of in-person visits to the office, urgent care, and the emergency department, (4) child-level variation in telemedicine use, and (5) clinician attitudes toward telemedicine across these practices. Results Across pediatric primary care practices, telemedicine visit rates ranged from 5 to 23 telemedicine visits per 1000 patients per week. Across all tertiles, the most frequent telemedicine visit diagnoses were mental health (28%-36% of visits) and dermatologic (15%-28%). Compared to low telemedicine use practices, high telemedicine use practices had fewer in-person office visits (10 vs 16 visits per 1000 patients per week, P=.005) but more total encounters overall (in-office and telemedicine: 28 vs 22 visits per 1000 patients per week, P=.006). Telemedicine use varied with child age, race and ethnicity, and recent preventive care; however, no significant interactions existed between these characteristics and practice-level telemedicine use. Finally, clinician attitudes regarding the usability and impact of telemedicine did not vary significantly across tertiles. Conclusions Across a network of pediatric practices, we identified significant practice-level variation in telemedicine use, with increased use associated with more varied telemedicine diagnoses, fewer in-person office visits, and increased overall primary care encounter volume. Thus, in the context of the pandemic, when underutilization of primary care was prevalent, higher practice-level telemedicine use supported pediatric primary care encounter volume closer to usual rates. Child-level telemedicine use differed by child age, race and ethnicity, and recent preventive care, building upon prior concerns about differences in access to telemedicine. However, increased practice-level use of telemedicine services was not associated with reduced or increased differences in use, suggesting that further work is needed to promote equitable access to primary care telemedicine.

Download Full-text

Practice-Level Variation in Telemedicine Use in a Pediatric Primary Care Network During the COVID-19 Pandemic: Retrospective Analysis and Survey Study (Preprint)

10.2196/preprints.24345 ◽

2020 ◽

Author(s):

Kelsey Schweiberger ◽

Alejandro Hoberman ◽

Jennifer Iagnemma ◽

Pamela Schoemer ◽

Joseph Squire ◽

...

Keyword(s):

Primary Care ◽

Race And Ethnicity ◽

Pediatric Primary Care ◽

Office Visits ◽

Level Variation ◽

Practice Level ◽

Practice Characteristics ◽

Care Practices ◽

Primary Care Practices ◽

Clinician Attitudes

BACKGROUND Telehealth, the delivery of health care through telecommunication technology, has potential to address multiple health system concerns. Despite this potential, only 15% of pediatric primary care clinicians reported using telemedicine as of 2016, with the majority identifying inadequate payment for these services as the largest barrier to their adoption. The COVID-19 pandemic led to rapid changes in payment and regulations surrounding telehealth, enabling its integration into primary care pediatrics. OBJECTIVE Due to limited use of telemedicine in primary care pediatrics prior to the COVID-19 pandemic, much is unknown about the role of telemedicine in pediatric primary care. To address this gap in knowledge, we examined the association between practice-level telemedicine use within a large pediatric primary care network and practice characteristics, telemedicine visit diagnoses, in-person visit volumes, child-level variations in telemedicine use, and clinician attitudes toward telemedicine. METHODS We analyzed electronic health record data from 45 primary care practices and administered a clinician survey to practice clinicians. Practices were stratified into tertiles based on rates of telemedicine use (low, intermediate, high) per 1000 patients per week during a two-week period (April 19 to May 2, 2020). By practice tertile, we compared (1) practice characteristics, (2) telemedicine visit diagnoses, (3) rates of in-person visits to the office, urgent care, and the emergency department, (4) child-level variation in telemedicine use, and (5) clinician attitudes toward telemedicine across these practices. RESULTS Across pediatric primary care practices, telemedicine visit rates ranged from 5 to 23 telemedicine visits per 1000 patients per week. Across all tertiles, the most frequent telemedicine visit diagnoses were mental health (28%-36% of visits) and dermatologic (15%-28%). Compared to low telemedicine use practices, high telemedicine use practices had fewer in-person office visits (10 vs 16 visits per 1000 patients per week, <i>P</i>=.005) but more total encounters overall (in-office and telemedicine: 28 vs 22 visits per 1000 patients per week, <i>P</i>=.006). Telemedicine use varied with child age, race and ethnicity, and recent preventive care; however, no significant interactions existed between these characteristics and practice-level telemedicine use. Finally, clinician attitudes regarding the usability and impact of telemedicine did not vary significantly across tertiles. CONCLUSIONS Across a network of pediatric practices, we identified significant practice-level variation in telemedicine use, with increased use associated with more varied telemedicine diagnoses, fewer in-person office visits, and increased overall primary care encounter volume. Thus, in the context of the pandemic, when underutilization of primary care was prevalent, higher practice-level telemedicine use supported pediatric primary care encounter volume closer to usual rates. Child-level telemedicine use differed by child age, race and ethnicity, and recent preventive care, building upon prior concerns about differences in access to telemedicine. However, increased practice-level use of telemedicine services was not associated with reduced or increased differences in use, suggesting that further work is needed to promote equitable access to primary care telemedicine.

Download Full-text

Links between the amount of antipsychotic medication prescribed per population at general practice level, local demographic factors and medication selection

BMC Psychiatry ◽

10.1186/s12888-020-02915-3 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

A. H. Heald ◽

M. Stedman ◽

S. Farman ◽

C. Khine ◽

M. Davies ◽

...

Keyword(s):

Primary Care ◽

General Practice ◽

Antipsychotic Medication ◽

Mental Illnesses ◽

Pharmacological Intervention ◽

Defined Daily Dose ◽

Practice Level ◽

Practice Population ◽

General Practices ◽

Antipsychotic Prescribing

Abstract Background Antipsychotic medications are the first-line pharmacological intervention for severe mental illnesses (SMI) such as schizophrenia and other psychoses, while also being used to relieve distress and treat neuropsychiatric symptoms in dementia. Our aim was to examine the factors relating to antipsychotic prescribing in general practices across England and how cost changes in recent years have impacted on antipsychotic prescribing. Methods The study examined over time the prescribing volume and prices paid for antipsychotic medication by agent in primary care. Monthly prescribing in primary care was consolidated over 5 years (2013–2018) and DDD amount from WHO/ATC for each agent was used to convert the amount to total DDD/practice. The defined Daily Dose (DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults. Results We included 5750 general practices with practice population > 3000 and with > 30 people on their SMI register. In 2018/19 there were 10,360,865 prescriptions containing 136 million DDD with costs of £110 million at an average cost of £0.81/DDD issued in primary care. In 2017/18 there was a sharp increase in overall prices and they had not reduced to expected levels by the end of the 2018/19 evaluation year. There was a gradual increase in antipsychotic prescribing over 2013–2019 which was not perturbed by the increase in drug price in 2017/18. The strongest positive relation to increased prescribing of antipsychotics came from higher social disadvantage, higher population density (urban), and comorbidities e.g. chronic obstructive pulmonary disease (COPD). Higher % younger and % older populations, northerliness and non-white (Black and Minority Ethnic(BAME)) ethnicity were all independently associated with less antipsychotic prescribing. Higher DDD/general practice population was linked with higher proportion(%) injectable, higher %liquid, higher doses/prescription and higher %zuclopenthixol depot. Less DDD/population was linked with general practices using higher % risperidone and higher spending/dose of antipsychotic. Conclusions The levels of antipsychotic prescribing at general practice level are driven by social factors/comorbidities. We found a link between depot prescriptions with higher antipsychotic DDD and risperidone prescriptions with lower antipsychotic DDD. It is important that all prescribers are aware of these drivers / links.

Download Full-text

Is an opportunistic primary care-based intervention for non-responders to bowel screening feasible and acceptable? A mixed-methods feasibility study in Scotland

BMJ Open ◽

10.1136/bmjopen-2017-016307 ◽

2017 ◽

Vol 7 (10) ◽

pp. e016307 ◽

Cited By ~ 4

Author(s):

Natalia Calanzani ◽

Debbie Cavers ◽

Gabriele Vojt ◽

Sheina Orbell ◽

Robert J C Steele ◽

...

Keyword(s):

Primary Care ◽

Mixed Methods ◽

Feasibility Study ◽

Occult Blood ◽

Secondary Outcome ◽

Structured Interviews ◽

Framework Analysis ◽

Test Kit ◽

General Practices ◽

Primary Care Professionals

ObjectivesWe aimed to test whether a brief, opportunistic intervention in general practice was a feasible and acceptable way to engage with bowel screening non-responders.DesignThis was a feasibility study testing an intervention which comprised a brief conversation during routine consultation, provision of a patient leaflet and instructions to request a replacement faecal occult blood test kit. A mixed-methods approach to evaluation was adopted. Data were collected from proformas completed after each intervention, from the Bowel Screening Centre database and from questionnaires. Semi-structured interviews were carried out. We used descriptive statistics, content and framework analysis to determine intervention feasibility and acceptability.ParticipantsBowel screening non-responders (as defined by the Scottish Bowel Screening Centre) and primary care professionals working in five general practices in Lothian, Scotland.Primary and secondary outcome measuresSeveral predefined feasibility parameters were assessed, including numbers of patients engaging in conversation, requesting a replacement kit and returning it, and willingness of primary care professionals to deliver the intervention.ResultsThe intervention was offered to 258 patients in five general practices: 220 (87.0%) engaged with the intervention, 60 (23.3%) requested a new kit, 22 (8.5%) kits were completed and returned. Interviews and questionnaires suggest that the intervention was feasible, acceptable and consistent with an existing health prevention agenda. Reported challenges referred to work-related pressures, time constraints and practice priorities.ConclusionsThis intervention was acceptable and resulted in a modest increase in non-responders participating in bowel screening, although outlined challenges may affect sustained implementation. The strategy is also aligned with the increasing role of primary care in promoting bowel screening.

Download Full-text

GP- and practice-related variation in ambulatory sensitive hospitalisations of older primary care patients

BMC Family Practice ◽

10.1186/s12875-020-01285-9 ◽

2020 ◽

Vol 21 (1) ◽

Author(s):

Leah Palapar ◽

Laura Wilkinson-Meyers ◽

Thomas Lumley ◽

Ngaire Kerse

Keyword(s):

Primary Care ◽

New Zealand ◽

Older People ◽

Home Visiting ◽

Controlled Trial ◽

Community Dwelling ◽

Trial Registration ◽

Primary Care Redesign ◽

Practice Level ◽

Practice Characteristics

Abstract Background Reducing ambulatory sensitive hospitalisations (ASHs) is a strategy to control spending on hospital care and to improve quality of primary health care. This research investigated whether ASH rates in older people varied by GP and practice characteristics. Methods We identified ASHs from the national dataset of hospital events for 3755 community-dwelling participants aged 75+ enrolled in a cluster randomised controlled trial involving 60 randomly selected general practices in three regions in New Zealand. Poisson mixed models of 36-month ASH rates were fitted for the entire sample, for complex participants, and non-complex participants. We examined variation in ASH rates according to GP- and practice-level characteristics after adjusting for patient-level predictors of ASH. Results Lower rates of ASHs were observed in female GPs (IRR 0.83, CI 0.71 to 0.98). In non-complex participants, but not complex participants, practices in more deprived areas had lower ASH rates (4% lower per deprivation decile higher, IRR 0.96, CI 0.92 to 1.00), whereas main urban centre practices had higher rates (IRR 1.84, CI 1.15 to 2.96). Variance explained by these significant factors was small (0.4% of total variance for GP sex, 0.2% for deprivation, and 0.5% for area type). None of the modifiable practice-level characteristics such as home visiting and systematically contacting patients were significantly associated with ASH rates. Conclusions Only a few GP and non-modifiable practice characteristics were associated with variation in ASH rates in 60 New Zealand practices interested in a trial about care of older people. Where there were significant associations, the contribution to overall variance was minimal. It also remains unclear whether lower ASH rates in older people represents underservicing or less overuse of hospital services, particularly for the relatively well patient attending practices in less central, more disadvantaged communities. Thus, reducing ASHs through primary care redesign for older people should be approached carefully. Trial registration Australian and New Zealand Clinical Trials Register ACTRN12609000648224.

Download Full-text

Links between the amount of antipsychotic medication prescribed per population at general practice level, local demographic factors and medication selection

10.21203/rs.2.24127/v1 ◽

2020 ◽

Author(s):

Adrian Hugh Heald ◽

Mike Stedman ◽

Sanam Farman ◽

Chaw Khine ◽

Mark Davies ◽

...

Keyword(s):

Primary Care ◽

General Practice ◽

Antipsychotic Medication ◽

Demographic Factors ◽

Mental Illnesses ◽

Pharmacological Intervention ◽

Practice Level ◽

Practice Population ◽

General Practices ◽

Antipsychotic Prescribing

Abstract BACKGROUND Antipsychotic medications are the first-line pharmacological intervention for severe mental illnesses(SMI) such as schizophrenia and other psychoses, while also being used to relieve distress and treat neuropsychiatric symptoms in dementia. Since 2014 many antipsychotic agents have moved to generic provision. In 2017_18 supplies of certain generic agents were affected by substantial price increases. Our aim was to examine factors relating to antipsychotic prescribing in general practices across England and how cost changes in recent years have impacted. METHODS The study examined over time the prescribing volume/prices paid for antipsychotic medication by agent in primary care. The NHS in England/Wales publishes each month the prescribing in general practice by BNF code. This was aggregated for the year 2018_19 using Defined Daily doses (DDD). Cost of each agent year-on-year was determined. Monthly prescribing in primary care was consolidated over 5 years(2013-2018) and DDD amount from WHO/ATC for each agent was used to convert the amount to total DDD/practice. RESULTS Description We included 5,750 general practices with practice population >3000 and with >30 people on their SMI register. In 2018_19 there were 10,360,865 prescriptions containing 136 million DDD with costs of £110 million at an average cost of £0.81/DDD issued in primary care. Effect of price In 2017_18 there was a sharp increase in overall prices. There was a gradual increase in antipsychotic prescribing over 2013-2019 which was not perturbed by the drug price increase in 2017/18. Regression Demographic factors The strongest positive relation to increased prescribing of antipsychotics came from higher social disadvantage, higher population density(urban), and comorbidities e.g. chronic obstructive pulmonary disease(COPD). Higher %younger and %older populations, northerliness and non-white (Black and Minority Ethnic (BME)) ethnicity were all independently associated with less antipsychotic prescribing. Prescribing Factors Higher DDD/general practice population was linked with higher %injectable, higher %liquid, higher doses/prescription and higher %zuclopenthixol depot. Less DDD/population was linked with general practices using higher %risperidone and higher spending/dose of antipsychotic. CONCLUSIONS Levels of antipsychotic prescribing at general practice level are driven by social factors/comorbidities. We found a contrasting link between depot prescriptions with higher DDD and risperidone prescriptions with lower DDD.

Download Full-text

Variation and statistical reliability of publicly reported primary care diagnostic activity indicators for cancer: a cross-sectional ecological study of routine data

BMJ Quality & Safety ◽

10.1136/bmjqs-2017-006607 ◽

2017 ◽

Vol 27 (1) ◽

pp. 21-30 ◽

Cited By ~ 14

Author(s):

Gary Abel ◽

Catherine L Saunders ◽

Silvia C Mendonca ◽

Carolynn Gildea ◽

Sean McPhail ◽

...

Keyword(s):

Primary Care ◽

High Reliability ◽

Routine Data ◽

Practice Variation ◽

Diagnostic Process ◽

Cross Sectional ◽

Outcome Indicators ◽

Practice Level ◽

Process Indicators ◽

General Practices

ObjectivesRecent public reporting initiatives in England highlight general practice variation in indicators of diagnostic activity related to cancer. We aimed to quantify the size and sources of variation and the reliability of practice-level estimates of such indicators, to better inform how this information is interpreted and used for quality improvement purposes.DesignEcological cross-sectional study.SettingEnglish primary care.ParticipantsAll general practices in England with at least 1000 patients.Main outcome measuresSixteen diagnostic activity indicators from the Cancer Services Public Health Profiles.ResultsMixed-effects logistic and Poisson regression showed that substantial proportions of the observed variance in practice scores reflected chance, variably so for different indicators (between 7% and 85%). However, after accounting for the role of chance, there remained substantial variation between practices (typically up to twofold variation between the 75th and 25th centiles of practice scores, and up to fourfold variation between the 90th and 10th centiles). The age and sex profile of practice populations explained some of this variation, by different amounts across indicators. Generally, the reliability of diagnostic process indicators relating to broader populations of patients most of whom do not have cancer (eg, rate of endoscopic investigations, or urgent referrals for suspected cancer (also known as ‘two week wait referrals’)) was high (≥0.80) or very high (≥0.90). In contrast, the reliability of diagnostic outcome indicators relating to incident cancer cases (eg, per cent of all cancer cases detected after an emergency presentation) ranged from 0.24 to 0.54, which is well below recommended thresholds (≥0.70).ConclusionsUse of indicators of diagnostic activity in individual general practices should principally focus on process indicators which have adequate or high reliability and not outcome indicators which are unreliable at practice level.

Download Full-text

The clinician impact and financial cost to the NHS of litigation over pregabalin: a cohort study in English primary care

10.1101/266403 ◽

2018 ◽

Cited By ~ 1

Author(s):

Richard Croker ◽

Darren Smyth ◽

Alex J Walker ◽

Ben Goldacre

Keyword(s):

Primary Care ◽

Neuropathic Pain ◽

Secondary Outcome ◽

Median Proportion ◽

The Supreme Court ◽

Before And After ◽

Excess Costs ◽

General Practices ◽

Legal Judgments ◽

Second Use

AbstractObjectivesFollowing litigation over pregabalin’s second-use medical patent for neuropathic pain NHS England were required by the court to instruct GPs to prescribe the branded form (Lyrica) for pain. Pfizer’s patent was found invalid in 2015; a ruling subject to ongoing appeals. If the Supreme Court appeal in February 2018 is unsuccessful, the NHS can reclaim excess prescribing costs. We set out to describe the variation in prescribing of pregabalin as branded Lyrica, geographically and over time; to determine how clinicians responded to the NHS England instruction to GPs; and to model excess costs to the NHS attributable to the legal judgments.SettingEnglish primary careParticipantsEnglish general practicesPrimary and secondary outcome measuresVariation in prescribing of branded Lyrica across the country before and after the NHS England instruction, by practice and by Clinical Commissioning Group (CCG); excess prescribing costs.ResultsThe proportion of pregabalin prescribed as Lyrica increased, from 0.3% over six months before the NHS England instruction (September 2014-February 2015) to 25.7% afterwards (April - September 2015). Although 70% of pregabalin is estimated to be for neuropathic pain, only 11.6% of practices prescribed Lyrica at this level; the median proportion prescribed as Lyrica was 8.8% (IQR 1.1-41.9%). If pregabalin had come entirely off patent in September 2015, and Pfizer had not appealed, we estimate the NHS would have spent £502m less on pregabalin to July 2017.ConclusionNHS England instructions to GPs regarding branded prescription of pregabalin were widely ignored, and have created much debate around clinical independence in prescribing. Protecting revenue from “skinny labels” will pose a challenge. If Pfizer’s final appeal on the patent is unsuccessful the NHS can seek reimbursement of excess pregabalin prescribing costs, potentially £502m.

Download Full-text

Is use of homeopathy associated with poor prescribing in English primary care? A cross-sectional study

Journal of the Royal Society of Medicine ◽

10.1177/0141076818765779 ◽

2018 ◽

Vol 111 (5) ◽

pp. 167-174 ◽

Cited By ~ 5

Author(s):

Alex J Walker ◽

Richard Croker ◽

Seb Bacon ◽

Edzard Ernst ◽

Helen J Curtis ◽

...

Keyword(s):

Primary Care ◽

Confidence Interval ◽

Odds Ratio ◽

Unit Cost ◽

Cost Savings ◽

Poor Performance ◽

Cross Sectional ◽

Quality Outcomes ◽

Prescribing Quality ◽

General Practices

Objectives Prescribing of homeopathy still occurs in a small minority of English general practices. We hypothesised that practices that prescribe any homeopathic preparations might differ in their prescribing of other drugs. Design Cross-sectional analysis. Setting English primary care. Participants English general practices. Main outcome measures We identified practices that made any homeopathy prescriptions over six months of data. We measured associations with four prescribing and two practice quality indicators using multivariable logistic regression. Results Only 8.5% of practices (644) prescribed homeopathy between December 2016 and May 2017. Practices in the worst-scoring quartile for a composite measure of prescribing quality (>51.4 mean percentile) were 2.1 times more likely to prescribe homeopathy than those in the best category (<40.3) (95% confidence interval: 1.6–2.8). Aggregate savings from the subset of these measures where a cost saving could be calculated were also strongly associated (highest vs. lowest quartile multivariable odds ratio: 2.9, confidence interval: 2.1–4.1). Of practices spending the most on medicines identified as ‘low value’ by NHS England, 12.8% prescribed homeopathy, compared to 3.9% for lowest spenders (multivariable odds ratio: 2.6, confidence interval: 1.9–3.6). Of practices in the worst category for aggregated price-per-unit cost savings, 12.7% prescribed homeopathy, compared to 3.5% in the best category (multivariable odds ratio: 2.7, confidence interval: 1.9–3.9). Practice quality outcomes framework scores and patient recommendation rates were not associated with prescribing homeopathy (odds ratio range: 0.9–1.2). Conclusions Even infrequent homeopathy prescribing is strongly associated with poor performance on a range of prescribing quality measures, but not with overall patient recommendation or quality outcomes framework score. The association is unlikely to be a direct causal relationship, but may reflect underlying practice features, such as the extent of respect for evidence-based practice, or poorer stewardship of the prescribing budget.

Download Full-text