The effects on GP prescribing of joining a commissioning group

BACKGROUND: It is not known to what extent general practitioners (GP) can change their prescribing upon joining a commissioning group and what features of a commissioning group may promote prescribing change. The opportunity to study potential prescribing change arose with the formation of a limited number of Primary Care Commissioning Groups (PCCGs), a precursor of Primary Care Groups (PCGs) and Primary Care Trusts (PCTs). METHODS: This was a controlled study of general practice prescribing costs. All practices (n=24) within one inner city PCCG were compared with matched controls that were not part of a PCCG. Cross sectional survey data was collected from the PCCG practices to determine possible reasons for prescribing change. RESULTS: The total annual prescribing cost rose by 4.0% in the PCCG practices and by 6.9% in controls (P=0.01). Significant cost containment was found for gastrointestinal prescribing (P=0.03), attributable to differences in the cost of proton pump inhibitors (PPIs) which fell by 0.7% in the PCCG but rose by 7.3% in controls (P=0.03). Total relative savings in the PCCG practices amounted to around pound 220,000. General practitioners making the greater savings in PPI costs within the PCCG, were more likely to report being influenced by information from the prescribing adviser. CONCLUSION: General practice prescribing costs were contained to a greater degree in practices participating in the PCCG. The differences in gastrointestinal prescribing were most marked for PPIs which were specifically targeted by the prescribing adviser. The GPs themselves attributed their own prescribing change to information provided by the prescribing adviser. Other factors operating within the PCCG may also have influenced prescribing such as a more locally based management system, different financial incentives and a greater degree of co-operative working amongst GPs.     

Attitudes of Slovene general practitioners towards generic drug prescribing and comparison with international studies

BACKGROUND: Over the recent years there has been a steady 7% yearly increase in prescribing costs, which accounts for 17% of the Slovene national health care budget. Substitution of branded products by generic equivalents can offer savings. General practitioners (GPs) are often concerned about the quality of generic products and possible legal liabilities associated with their use. OBJECTIVE: We wanted to examine the attitudes of GPs in Slovenia towards generic drug prescribing. METHODS: We conducted a postal survey of a random sample of 200 out of 800 GPs in Slovenia from the National Health Insurance Institute database. GPs were asked 21 questions regarding their knowledge on generic drugs, awareness of prescribing costs, prices of generic drugs relative to brand name drugs and their attitude towards use of generic drugs. RESULTS: The 117 (58.5%) replies we received represent 15% of the GP population in Slovenia. 66.1% of GPs considered rising costs of medicines to be a serious problem for the health care budget. Each week, over 50% of GPs experienced demands from patients for specific drugs and the majority of GPs usually met their patients' demands or requests from hospital consultants for branded products. 38.3% of GPs did not take price into consideration when prescribing drugs. The majority of GPs (88.9%) perceived generics to have the same effectiveness as branded drugs. One quarter of GPs would prescribe more generics if additional clinical trials were presented. 37.3% would follow advice of academic detailers and 30.3% expected the generics to be even cheaper than they were. Independent detailing was welcomed by 63.8% of GPs because of the big influence of the pharmaceutical industry on the prescribing habits. 15.5% thought that the industry had a tremendous impact on their prescribing patterns. CONCLUSIONS: Slovene GPs are aware of the cost of prescribed drugs. They are willing to accept independent academic detailing to improve their prescribing and are willing to increase generic drugs under certain conditions.     

Caring pathways of terminal cancer patients: a retrospective survey

Caring pathways of terminal cancer patients: a retrospective survey. Introduction. The caring patways of terminal cancer patients of the Vallagarina district, dead in 2008, cared at home and/or by district services in the last 90 days of life of cancer patients, were retrospectively described. Aim. To describe the last 90 days of life of all patients dead for cancer. Methods. Data were collected from different sources: hospital discharge forms, local health unit informative systems, data bank of the palliative care service (PC), charts of PC and home care services and through interviews to caregivers, for patients cared by General practitioners (GPs). Results. Four caring pathways were identified: patients mainly cared by GPs, in nursing homes, in long term care or by the PC service. The rate of hospital admissions varies widely: 25% of potential days of care for GPs patients; 1.3% for PCs patients; same for length of hospital stay: mean duration 18.7 days for GPs and 5.6 days for PC patients. Only rarely the GPs activate other forms of care such as care by multidisciplinary teams (10.8% patients) or visits at home by GPs (12.7% patients). Caregivers would like more information on the clinical situation of the patient and on the different caring services, to be involved in the decision making process. Conclusions. Patients cared by GPs and PC Service experience different caring pathways. Lack of information to caregivers may profoundly impact the type of care received.     

General practitioners' perceptions of antimicrobial resistance: a qualitative study

OBJECTIVES: Interventions aimed at enhancing the quality of antibiotic prescribing often highlight the threat of antimicrobial resistance. Although most antibiotics are prescribed by general practitioners (GPs), little is known of their perceptions of this issue. The aim of this study was therefore to achieve a deeper understanding of GPs' perceptions of antimicrobial resistance. METHODS: A qualitative interview, grounded theory study. Forty GPs were interviewed, 26 from high fluoroquinolone prescribing practices and 14 from average fluoroquinolone prescribing practices. RESULTS: Most GPs were concerned about the broad issue of antimicrobial resistance and agreed that it was a growing problem. However, many said they infrequently encountered its consequences in their everyday practice and some questioned the evidence linking their prescribing decisions to resistance and poorer outcomes for their patients. They felt conflicted by their apparent inability to influence the problem in the face of many other competing demands. A number said they would welcome more information from their microbiological colleagues about resistance patterns locally, and felt that undergraduate and graduate education about antimicrobial prescribing and resistance should be enhanced. However, a few mentioned that a heightened awareness of antimicrobial resistance locally may cause them to prescribe more second line agents as empirical therapy. CONCLUSIONS: Antimicrobial resistance is only one of a range of important influences on GPs decisions whether or not to prescribe an antibiotic and is not the most immediate. These influences all need to be taken into account when promoting a more cautious use of antibiotics in primary care. More information from microbiologist colleagues about local resistance would be clinically useful, but on its own, may paradoxically influence some GPs to prescribe newer, broader spectrum agents more often.     

Are general practitioners characteristics associated with the quality of type 2 diabetes care in general practice? Results from the Norwegian ROSA4 study from 2014

Objective: To explore the associations between general practitioners (GPs) characteristics such as gender, specialist status, country of birth and country of graduation and the quality of care for patients with type 2 diabetes (T2DM).

Design: Cross-sectional survey.

Setting and subjects: The 277 GPs provided care for 10082 patients with T2DM in Norway in 2014. The GPs characteristics were self-reported: 55% were male, 68% were specialists in General Practice, 82% born in Norway and 87% had graduated in Western Europe. Of patients, 81% were born in Norway and 8% in South Asia. Data regarding diabetes care were obtained from electronic medical records and manually verified.

Main outcome measures: Performance of recommended screening procedures, prescribed medication and level of HbA1c, blood pressure and LDL-cholesterol stratified according to GPs characteristics, adjusted for patient and GP characteristics.

Result: Female GPs, specialists, GPs born in Norway and GPs who graduated in Western Europe performed recommended procedures more frequently than their counterparts. Specialists achieved lower mean HbA1c (7.14% vs. 7.25%, p?p?=?0.018) and lower mean systolic blood pressure (133.0?mmHg vs. 134.7?mmHg, p?p?Conclusion: Several quality indicators for type 2 diabetes care were better if the GPs were specialists in General Practice.

• Key Points

• Research on associations between General Practitioners (GPs) characteristics and quality of care for patients with type 2 diabetes is limited.

• Specialists in General Practice performed recommended procedures more frequently, achieved better HbA1c and blood pressure levels than non-specialists.

• GPs who graduated in Western Europe performed screening procedures more frequently and achieved lower diastolic blood pressure compared with their counterparts.

• There were few significant differences in the quality of care between GP groups according to their gender and country of birth.

     

Motivating general practitioners to change their prescribing: the incentive of working together

OBJECTIVE: To determine the extent to which GPs were motivated to change their prescribing upon joining a Primary Care Commissioning Group (PCCG) and how effective certain interventions planned by the PCCG might be as a means to change prescribing. To define the characteristics of GPs less motivated to change their prescribing. Design: A cross-sectional survey of participating general practitioners linked with current prescribing information derived from PACT data. Setting: General practice covering a geographical locality within inner-city south London. Subjects: All 72 general practitioners who had joined a GP Commissioning Group. Main outcome measures: questionnaire responses. RESULTS: 93% of GPs entering the GP Commissioning Group expected their prescribing to change but none expected substantial change. There was no difference between fundholders, singlehanders nor training practices in their expectation of change. GPs in practices with the lowest quality prescribing, as measured by a quality index, were least likely to expect change (Spearman's r = 0.25, P = 0.04). Those in practices with higher prescribing costs were not more likely to expect their prescribing to change, whereas expensive prescribers who were unaware of their practices' prescribing costs were associated with a reduced expectation of prescribing change (P = 0.05). Educational interventions were thought to be the most effective means by which prescribing could be changed, whereas formularies and financial factors were perceived as weaker influences. CONCLUSION: Acceptance of a cash-limited prescribing budget by GPs is accompanied by the expectation of personal prescribing change. The motivation to change prescribing may be related to a strongly developed collectivist perspective amongst GPs who are prepared to consider the prescribing implications for their fellow GPs. It is ironic that those with the least expectation of change should have the lowest quality prescribing, or be unaware of their high cost prescribing. Engendering greater commitment to the professional group may be one way of changing their prescribing.     

C‐reactive protein point of care testing and physician communication skills training for lower respiratory tract infections in general practice: economic evaluation of a cluster randomized trial

Rationale, aims and objectives An economic evaluation of general practitioner (GP) use of C‐reactive protein (CRP) point of care test, GP communication skills training, and both GP use of CRP and communication skills training on antibiotic use for lower respiratory tract infections (LRTIs) in general practice. Methods Cost‐effectiveness analysis with a time horizon of 28 days alongside a factorial, cluster randomized trial in 431 patients with LRTIs recruited by 40 GPs. Interventions: usual care (control group), GP use of CRP point of care test, GP communication skills training, and both CRP use and communication skills training. Main outcome measure: health care costs. Cost‐effectiveness, using the primary outcome measure antibiotic prescribing at index consultation, was assessed by incremental cost‐effectiveness ratios (ICER). To adjust for skewed data and clustering, we used non‐parametric bootstrapping re‐sampling to derive percentile intervals for the mean difference in total costs and the mean difference in effectiveness between the groups. Various implementation scenarios according to GP preference were modelled with corresponding net monetary benefit (NMB) curves based on a given willingness‐to‐pay (λ) for a 1% lower antibiotic prescribing rate. Results The total mean cost per patient in the usual care group was €35.96 with antibiotic prescribing of 68%, €37.58 per patient managed by GPs using CRP tests (antibiotic prescribing 39%, ICER €5.79), €25.61 per patient managed by GPs trained in enhanced communication skills (antibiotic prescribing 33%, dominant) and €37.78 per patient managed by GPs using both interventions (antibiotic prescribing 23%, ICER €4.15). The interventions are cost‐effective in any combination (yielding NMB at no willingness‐to‐pay), taking into account GPs' preferences where at least 15% of GPs chose to implement the communication skills training. Conclusions The two strategies, both singly and combined, are cost‐effective interventions to reduce antibiotic prescribing for LRTI, at no, or low willingness‐to‐pay. Taking GP preferences into account will optimize investment in strategies to reduce antibiotic prescribing for LRTI.     

Evaluating nurse prescribing behaviour using constipation as a case study

Non-medical nurse prescribing in the UK continues to evolve with new legislative frameworks. Studies evaluating patterns of prescribing by nurses remain scarce. This secondary data analysis of national prescribing data investigated the prescribing behaviours of community-based nurses and general practitioners (GPs), using constipation as a case study. Currently, 37 683 registered nurses, midwives and health visitors are qualified to independently prescribe in the UK; however, only 16.6% of nurses prescribed items for constipation. Prescribing practices differed between nurses employed by primary care trusts (PCTs) and general practice, between nurses and GPs, and across regions. PCT-employed nurses undertook 83% of nurse prescribing although activity increased steadily among general practice-employed nurses. Pharmacological treatment choices differed between nurses and GPs. Over 60% of all nurses predominantly prescribed from one class of laxative compared with a wider range prescribed by GPs. The extent, impact and outcomes of medical prescribing need further study.     

Interdisciplinary cooperation of GPs in palliative care at home: a nationwide survey in The Netherlands

OBJECTIVE: To investigate the occurrence and predictors of interdisciplinary cooperation of GPs with other caregivers in palliative care at home. DESIGN: In a prospective study among 96 general practices, the GPs involved identified all dying patients during the study period of 12 months. The GPs received an additional post-mortem questionnaire for each patient who died during the study period, and registered the healthcare providers with whom they cooperated. Multivariable logistic regression analysis was used to identify the predictors of GP cooperation with other caregivers. SETTING: Second Dutch National Survey in General Practice. SUBJECTS: A total of 743 patients who received palliative care according to their GP. MAIN OUTCOME MEASURES: Interdisciplinary cooperation between GP and other healthcare providers. RESULTS: During the study period, 2194 patients died. GPs returned 1771 (73%) of the questionnaires. According to the GPs, 743 (46%) of their patients received palliative care. In 98% of these palliative care patients, the GP cooperated with at least one other caregiver, with a mean number of four. Cooperation with informal caregivers (83%) was most prevalent, followed by cooperation with other GPs (71%) and district nurses (63%). The best predictors of cooperation between GPs and other caregivers were the patient's age, the underlying disease, and the importance of psychosocial care. CONCLUSION: In palliative care patients, GP interdisciplinary cooperation with other caregivers is highly prevalent, especially with informal caregivers and other primary care collaborators. Cooperation is most prevalent in younger patients, patients with cancer as underlying disease, and if psychosocial care is important.     

From emergency department to general practitioner: evaluating emergency department communication and service to general practitioners

Objective: To survey general practitioners' (GPs) opinions of communication and service received from the ED of a tertiary metropolitan hospital. Methods: Analysis of a postal survey form sent to 380 GPs in the hospital catchment area. Results: One hundred and forty‐seven completed questionnaires (39%, 95% confidence interval [CI] 34–44%) were returned. Seventy‐eight GPs (53%, 95% CI 45–61%) endorsed the current method of discharge letter delivery by patient; however, 43 (29%, 95% CI 22–37%) stated that letters were often not received. The most commonly proposed alternative to patient delivery was facsimile transmission. One hundred and thirty respondents (88%, 95% CI 83–94%) rated the overall standard of communication from ED as average or better; however, 64 (44%, 95% CI 36–52%) felt that important information was omitted from the discharge letter. One hundred and seventeen (79%, 95% CI 73–86%) GPs found the ED admitting officer role useful when referring patients. Fifty‐nine (40%, 95% CI 32–48%) respondents cited difficulties accessing investigation results. The predominant source of patient dissatisfaction reported by GPs was excess waiting times. Conclusions: Half of GPs surveyed supported the current system of patient delivered discharge letters and of those who did not the majority preferred faxed discharges. There was little support for email communication. GPs reported problems with the current communication system including discharge letters not reaching GPs and deficiencies in the discharge information. GP reported substantial difficulties in accessing outstanding investigation results. Most GPs felt that assessment and treatment of their patients in the ED was of above average quality, as was the overall service they received from the ED. There was GP support for the ED admitting officer role.     

Providing Complementary and Alternative Medicine in primary care: the primary care workers' perspective

BACKGROUND: The use of Complementary and Alternative Medicine (CAM) in primary care is growing, but still not widespread. Little is known about how CAM can/should be integrated into mainstream care. OBJECTIVES: To assess primary care health professionals' perceptions of need and of some ways to integrate CAM in primary care. METHOD: Questionnaire survey of primary health care workers in Northwest London. General Practitioners (GPs) were targeted in a postal survey, other members of the primary care team, such as district and practice nurses, were targeted via colleagues. The questionnaire assessed health care professionals' perspective on complementary medicine, referrals, ways to integrate complementary medicine into primary care and interest in research on CAM. RESULTS: Responses were obtained from 149 GPs (40% response rate after one reminder) and 24 nurses and 32 other primary care team members. One hundred and seventy-one (83%) respondents had previously referred (or influenced referral) for CAM treatments, the main reasons cited were: patients request (68%), conventional treatments failed (58%) and evidence (36%) (more than one reason could be given). Acupuncture and homoeopathy were the therapies for which patients were most frequently referred, followed by manual therapies. There was a significant interest in more training/information on CAM (66%). Only 12 respondents (6%) were against any integration of CAM in mainstream primary care. Most respondents felt that CAM therapies should be provided by doctors (66%) or other health professionals trained in CAM (82%). Twenty-six percent of respondents agreed with provision of CAM by non-state-registered practitioners. It was felt that the integration of CAM could lead to cost savings (70%), particularly in conditions involving pain, but also cost increases (55%) particularly in 'poorly defined conditions'. Fifty-six percent of respondents would consider participating in studies investigating CAM. The greatest interest was in acupuncture (41% of those who expressed an interest in research), homoeopathy (30%) and therapeutic massage/aromatherapy (26%). CONCLUSIONS: There is considerable interest in CAM among primary care professionals, and many are already referring or suggesting referral. Such referrals are driven mainly by patient demand and by dissatisfaction with the results of conventional medicine. Most of our respondents were in favour of integrating at least some types of CAM in mainstream primary care. There is an urgent need to further educate/inform primary care health professionals about CAM.     

Shared decision making: evaluation of German medical students' preferences

Rationale Current medical student perceptions of patient centredness and the priorities of students for a change in medical care were investigated. Methods We conducted an observational study using questionnaires at the University of Leipzig in Germany. In total, 188 consecutive medical students attending the Department of General Medicine participated in this study. We investigated students’ priorities for an improvement in medical care related to aspects of the patient–doctor relationship and to aspects of organization. Results Receiving more information and undergoing the process of shared decision making was the most important choice; selected by 43.2% as their first priority. The second choice was found to be consultation time (16.2%) which also refers to the patient–doctor relationship. Shorter queues for tests, also considered important for more patient autonomy, were ranked third (14.6%). Medical students participating in this study were least interested in access to specialists, cost of medications and continuity of care. Conclusion For the first time, it is shown that shared decision making, in addition to its many benefits, is not only a patients’, but also a prospective doctors’ top priority. Consequently, medical student training programmes might incorporate shared decision‐making training as an important element of patient centredness.     

Should nurses prescribe blood components?

AIM: To explore the feasibility of nurses prescribing blood components. METHOD: Using a convenience snowball sample, a UK-wide questionnaire survey was undertaken to identify transfusion practices and canvass the opinions of nurses and doctors. RESULTS: A total of 179 (59%) of 302 respondents were supportive of nurses prescribing blood components, saying it would have a positive effect on the quality of patient care, result in fewer treatment delays and help doctors and nurses to use their time more effectively. The remaining 123 (41%) respondents had reservations about time and resource constraints and worries about undermining medical care and responsibility. CONCLUSION: Development of non-medical prescribing to allow nurses to prescribe blood components has the potential to deliver a more patient-centred quality service.     

General practice and chiropractic in Norway: How well do they communicate and what do GPs want to know?

BACKGROUND: Some within the medical establishment believe that the education and training of chiropractors is grounded in orthodox medicine and that these professional groups share a common language allowing for close dialogue. However, levels of communication and collaboration often remain low. Furthermore, studies have shown chiropractors to be lax in providing written reports to referring clinicians, a practice important to both patient care and interprofessional relationships. OBJECTIVE: To investigate existing levels of communication between general practitioners (GPs) and chiropractors in Norway and to identify trends in GP preferences for future interprofessional communications. DESIGN AND SETTING: A postal survey was conducted on a random sample of 230 GPs in Norway. RESULTS: A response rate of 51% was achieved. All respondents reported having made at least one referral to a chiropractor. Most (63%) referred infrequently, and only 7% communicated often with a chiropractor. Of those who were in contact with a chiropractor, three fourths communicated by telephone. One fifth of the respondents negatively assessed the quality of written reports. Approximately one third of those GPs who had referred patients did not receive a report, despite this being obligatory in Norway. Twelve percent reported problems with terminology. A written report for future reporting was favored by 75% of the GPs, who wanted the report to contain information on examination findings, diagnosis, treatment, and advice given. CONCLUSION: In general, communications between GPs and chiropractors in Norway are not ideal, particularly with regard to frequency and written quality. However, this is not unique to Norway. With increasing emphasis on multidisciplinary health care, greater understanding and better communication is needed to optimize the benefits of such an approach to patient management. Relevant, timely, consistent reporting on a reciprocal basis, together with a shared vocabulary, should help this process.