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1.
Dig Surg ; 37(1): 32-38, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-30943526

RESUMO

BACKGROUND: This study aimed to identify the burden and risk of venous thromboembolism (VTE) associated with cholecystectomy in England. METHODS: An historical cohort study of cholecystectomy patients from 2001 to 2011 was undertaken using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data. Crude rates and adjusted hazard ratios (HRs) were calculated for risk of VTE following cholecystectomy using Cox regression. RESULTS: 24,677 patients were identified with a rate of VTE in the first year following cholecystectomy of 2.80 per 1,000 person years (95% CI 2.18-3.59). Patients aged ≥70 vs. aged < 50 had 8.3-fold increase in risk of VTE (HR 8.27, 95% CI 3.72-18.35); patients with body mass index (BMI) > 30 vs. BMI < 30 had 2.4-fold increase in risk (HR 2.42, 95% CI 1.40-4.18); open vs. laparoscopic operation had 3-fold increase in risk (HR 2.94, 95% CI 1.55-5.55). Compared to general population, VTE risk was the highest in the first 30 days post-operatively with 9.9-fold risk following emergency cholecystectomy and 4.5-fold risk after inpatient cholecystectomy (HR 9.90, 95% CI 4.42-22.21; HR 4.54, 95% CI 2.85-7.21). CONCLUSIONS: Cholecystectomy is associated with a low absolute risk of VTE and we have identified high risk groups including the elderly, obese and those having open surgery.

2.
BMJ ; 367: l5205, 2019 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-31578187

RESUMO

OBJECTIVES: To determine how clinicians vary in their response to new guidance on existing or new interventions, by measuring the timing and magnitude of change at healthcare institutions. DESIGN: Automated change detection in longitudinal prescribing data. SETTING: Prescribing data in English primary care. PARTICIPANTS: English general practices. MAIN OUTCOME MEASURES: In each practice the following were measured: the timing of the largest changes, steepness of the change slope (change in proportion per month), and magnitude of the change for two example time series (expiry of the Cerazette patent in 2012, leading to cheaper generic desogestrel alternatives becoming available; and a change in antibiotic prescribing guidelines after 2014, favouring nitrofurantoin over trimethoprim for uncomplicated urinary tract infection (UTI)). RESULTS: Substantial heterogeneity was found between institutions in both timing and steepness of change. The range of time delay before a change was implemented was large (interquartile range 2-14 months (median 8) for Cerazette, and 5-29 months (18) for UTI). Substantial heterogeneity was also seen in slope following a detected change (interquartile range 2-28% absolute reduction per month (median 9%) for Cerazette, and 1-8% (2%) for UTI). When changes were implemented, the magnitude of change showed substantially less heterogeneity (interquartile range 44-85% (median 66%) for Cerazette and 28-47% (38%) for UTI). CONCLUSIONS: Substantial variation was observed in the speed with which individual NHS general practices responded to warranted changes in clinical practice. Changes in prescribing behaviour were detected automatically and robustly. Detection of structural breaks using indicator saturation methods opens up new opportunities to improve patient care through audit and feedback by moving away from cross sectional analyses, and automatically identifying institutions that respond rapidly, or slowly, to warranted changes in clinical practice.


Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Medicina Estatal/estatística & dados numéricos , Anti-Infecciosos/uso terapêutico , Conjuntos de Dados como Assunto , Substituição de Medicamentos/estatística & dados numéricos , Medicamentos Genéricos/uso terapêutico , Inglaterra , Medicina Geral/organização & administração , Medicina Geral/normas , Medicina Geral/estatística & dados numéricos , Humanos , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Medicina Estatal/normas , Fatores de Tempo , Infecções Urinárias/tratamento farmacológico
3.
BMJ Open Qual ; 8(1): e000349, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30997410

RESUMO

Monitoring of chronic conditions accounts for a significant proportion of blood testing in UK primary care; not all of this is based on evidence or guidelines. National benchmarking shows significant variation in testing rates for common blood tests. This project set out to standardise the blood tests used for monitoring of chronic conditions in primary care across North Devon, and to measure and reduce the harms of unwarranted testing. Chronic disease test groups were developed in line with current guidelines and implemented using one-click electronic test ordering systems. The main difference from previous general practitioner practice algorithms was removing the requirement for full blood count and liver function test monitoring for many conditions. Baseline harms of testing were measured and included significant costs, workload and patient anxiety. By defining the scale of the problem, we were able to leverage change across several cycles of quality improvement, using a pathology optimisation forum for peer-led improvement, and developing a framework focusing on what matters to patients. Overall primary care testing rates in North Devon fell by 14% for full blood count testing and 22% for liver function tests, but without a reduction in the number of tests showing possible significant pathology. We estimate that this has reduced testing costs by £200 000 across a population of around 180 000 people and has reduced downstream referral costs by a similar amount. Introduction of simple chronic disease test groups into primary care electronic ordering systems, when used alongside engagement with clinicians, leads to both quality improvement and reduction in system costs.

4.
BMJ Open ; 9(2): e026886, 2019 02 05.
Artigo em Inglês | MEDLINE | ID: mdl-30813120

RESUMO

OBJECTIVES: Approximately one in eight practices in primary care in England are 'dispensing practices' with an in-house dispensary providing medication directly to patients. These practices can generate additional income by negotiating lower prices on higher cost drugs, while being reimbursed at a standard rate. They, therefore, have a potential financial conflict of interest around prescribing choices. We aimed to determine whether dispensing practices are more likely to prescribe high-cost options for four commonly prescribed classes of drug where there is no evidence of superiority for high-cost options. DESIGN: A list was generated of drugs with high acquisition costs that were no more clinically effective than those with the lowest acquisition costs, for all four classes of drug examined. Data were obtained prescribing of statins, proton pump inhibitors (PPIs), angiotensin receptor blockers (ARBs) and ACE inhibitors (ACEis). Logistic regression was used to calculate ORs for prescribing high-cost options in dispensing practices, adjusting for Index of Multiple Deprivation score, practice list size and the number of doctors at each practice. SETTING: English primary care. PARTICIPANTS: All general practices in England. MAIN OUTCOME MEASURES: Mean cost per dose was calculated separately for dispensing and non-dispensing practices. Dispensing practices can vary in the number of patients they dispense to; we, therefore, additionally compared practices with no dispensing patients, low, medium and high proportions of dispensing patients. Total cost savings were modelled by applying the mean cost per dose from non-dispensing practices to the number of doses prescribed in dispensing practices. RESULTS: Dispensing practices were more likely to prescribe high-cost drugs across all classes: statins adjusted OR 1.51 (95% CI 1.49 to 1.53, p<0.0001), PPIs OR 1.11 (95% CI 1.09 to 1.13, p<0.0001), ACEi OR 2.58 (95% CI 2.46 to 2.70, p<0.0001), ARB OR 5.11 (95% CI 5.02 to 5.20, p<0.0001). Mean cost per dose in pence was higher in dispensing practices (statins 7.44 vs 6.27, PPIs 5.57 vs 5.46, ACEi 4.30 vs 4.24, ARB 11.09 vs 8.19). For all drug classes, the more dispensing patients a practice had, the more likely it was to issue a prescription for a high-cost option. Total cost savings in England available from all four classes are £628 875 per month or £7 546 502 per year. CONCLUSIONS: Doctors in dispensing practices are more likely to prescribe higher cost drugs. This is the largest study ever conducted on dispensing practices, and the first contemporary research suggesting some UK doctors respond to a financial conflict of interest in treatment decisions. The reimbursement system for dispensing practices may generate unintended consequences. Robust routine audit of practices prescribing higher volumes of unnecessarily expensive drugs may help reduce costs.

5.
J Med Internet Res ; 21(1): e10929, 2019 01 16.
Artigo em Inglês | MEDLINE | ID: mdl-30664459

RESUMO

BACKGROUND: OpenPrescribing is a freely accessible service that enables any user to view and analyze the National Health Service (NHS) primary care prescribing data at the level of individual practices. This tool is intended to improve the quality, safety, and cost-effectiveness of prescribing. OBJECTIVE: We aimed to measure the impact of OpenPrescribing being viewed on subsequent prescribing. METHODS: Having preregistered our protocol and code, we measured three different metrics of prescribing quality (mean percentile across 34 existing OpenPrescribing quality measures, available "price-per-unit" savings, and total "low-priority prescribing" spend) to see whether they changed after the viewing of Clinical Commissioning Group (CCG) and practice pages. We also measured whether practices whose data were viewed on OpenPrescribing differed in prescribing, prior to viewing, compared with those who were not. We used fixed-effects and between-effects linear panel regression to isolate change over time and differences between practices, respectively. We adjusted for the month of prescribing in the fixed-effects model to remove underlying trends in outcome measures. RESULTS: We found a reduction in available price-per-unit savings for both practices and CCGs after their pages were viewed. The saving was greater at practice level (-£40.42 per thousand patients per month; 95% CI -54.04 to -26.81) than at CCG level (-£14.70 per thousand patients per month; 95% CI -25.56 to -3.84). We estimate a total saving since launch of £243 thosand at practice level and £1.47 million at CCG level between the feature launch and end of follow-up (August to November 2017) among practices viewed. If the observed savings from practices viewed were extrapolated to all practices, this would generate £26.8 million in annual savings for the NHS, approximately 20% of the total possible savings from this method. The other two measures were not different after CCGs or practices were viewed. Practices that were viewed had worse prescribing quality scores overall prior to viewing. CONCLUSIONS: We found a positive impact from the use of OpenPrescribing, specifically for the class of savings opportunities that can only be identified by using this tool. Furthermore, we show that it is possible to conduct a robust analysis of the impact of such a Web-based service on clinical practice.


Assuntos
Análise Custo-Benefício/métodos , Análise de Dados , Estudos de Coortes , Inglaterra , Humanos , Internet , Segurança do Paciente
6.
J Antimicrob Chemother ; 74(4): 1133-1136, 2019 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-30689889

RESUMO

BACKGROUND: Antimicrobial resistance is a growing problem, with the need for 'strong action' highlighted by the Chief Medical Officer for England in 2013, along with a 5 year antimicrobial resistance strategy. OBJECTIVES: Five years on, we set out to determine if there was a measurable impact from the 5 year antimicrobial resistance strategy on overall antibiotic prescribing in NHS primary care in England. METHODS: We calculated the volume of antibiotic prescription items using annual prescription cost analysis data from 1998 to 2017 and monthly prescribing data from October 2010 to June 2018. Antibiotic prescribing rate was calculated using an age- and sex-adjusted denominator (Specific Therapeutic group Age-sex Related Prescribing Units, STAR-PU). We conducted interrupted time series analysis to measure any change in prescribing rate after the intervention. RESULTS: After several years with a stable rate of antibiotic prescribing, there was a downward change in gradient after 2013: -46.4 items per 1000 STAR-PU per year (95% CI = -61.4 to -31.3). The prescribing rate dropped from 1378 per 1000 STAR-PU per year in 2013 to 1184 in 2017, representing a 14.1% reduction. The reduction is similar for monthly data (16.4%). Assuming causality, when compared with predicted prescribing if the rate of prescribing had continued at the pre-2013 trend, we estimate that 9.7 million antibiotic prescriptions were prevented over the past year by the 5 year antimicrobial resistance strategy. CONCLUSIONS: Though we cannot firmly attribute causality for the reduction in prescribing to the 5 year antimicrobial resistance strategy, the magnitude and timing of the change are noteworthy; the substantial change followed a long period of relatively static antibiotic prescribing.

7.
J Antimicrob Chemother ; 74(1): 242-250, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30239809

RESUMO

Background: Reducing antibiotic overuse is a key NHS priority. The majority of antibiotics are prescribed in primary care. Objectives: To describe antibiotic prescribing trends in NHS England primary care for the years 1998-2017 using various measures. We investigated trends and variation between practices and geographical areas, out-of-hours prescribing, and seasonality. Methods: We used publicly available prescribing datasets and calculated antibiotic prescribing rates per 1000 age-sex-adjusted population units, percentage prescribed as broad-spectrum, and course length. We report national time trends for 1998-2016, geographical variation across 2017 and variation trends for 2010-17. We calculated percentiles and ranges, and plotted maps. Results: The overall rate of antibiotic prescribing has reduced by 18% since 2010, with the steepest decline since 2013. The percentage prescribed as broad-spectrum declined since 2006, from 18.0 to 8.4. Between the best and worst Clinical Commissioning Groups (CCGs) there was 2-fold variation for total antibiotic prescribing, but 7-fold variation for cephalosporins. Variation across general practices has declined. The CCG to which a practice belongs accounted for 12.6% of current variation (P < 0.0001). Higher antibiotic prescribing was associated with greater practice size, proportion of patients >65 years or <18 years, ruralness and deprivation. Seasonal increases have been declining for most antibiotics. If every practice prescribed antibiotics at the lowest decile rate in 2017, 10.8 million fewer prescriptions could have been issued (34%). Compared with standard practices, out-of-hours practices prescribed a greater proportion of broad-spectrum antibiotics. Conclusions: Despite a general trend towards more optimal antibiotic prescribing, considerable geographical variation persists across England's practices and CCGs.


Assuntos
Antibacterianos/uso terapêutico , Uso de Medicamentos/estatística & dados numéricos , Atenção Primária à Saúde/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Inglaterra , Feminino , Geografia , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Adulto Jovem
8.
J Antimicrob Chemother ; 74(4): 1125-1132, 2019 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-30590552

RESUMO

OBJECTIVES: To describe trends and geographical variation in prescribing of trimethoprim and nitrofurantoin to treat urinary tract infections, to describe variation in implementing guideline change and to compare actions taken to reduce trimethoprim use in high- and low-using Clinical Commissioning Groups (CCGs). METHODS: A retrospective cohort study and interrupted time series analysis of English NHS primary care prescribing data, complemented by information obtained through Freedom of Information Act requests to CCGs. The main outcome measures were variation in practice and CCG prescribing ratios geographically and over time, including an interrupted time series, and responses to Freedom of Information requests. RESULTS: The amount of trimethoprim prescribed, as a proportion of nitrofurantoin and trimethoprim combined, remained stable and high until 2014, then fell gradually to <50% in 2017; this reduction was more rapid following the introduction of the 'Quality Premium'. There was substantial variation in the speed of change between CCGs. As of April 2017, for the 10 CCGs with the lowest trimethoprim ratios, 9 had reported at least one of: formulary change, work plan or incentive scheme to change prescribing behaviour. None of the 10 highest-ratio CCGs did so. CONCLUSIONS: Many CCGs failed to implement an important change in antibiotic prescribing guidance, and there is strong evidence suggesting that CCGs with minimal prescribing change did little to implement the new guidance. We recommend: (i) a national programme of training and accreditation for medicines optimization pharmacists; and (ii) remedial action for CCGs that fail to implement guidance-with all materials and data shared publicly for both such activities.

9.
Lancet Psychiatry ; 6(2): 140-150, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30580987

RESUMO

BACKGROUND: There is a call for greater monitoring of opioid prescribing in the UK, particularly of strong opioids in chronic pain, for which there is little evidence of clinical benefit. We aimed to comprehensively assess trends and variation in opioid prescribing in primary care in England, from 1998 to 2018, and to assess factors associated with high-dose opioid prescribing behaviour in general practices. METHODS: We did a retrospective database study using open data sources on prescribing for all general practices in England. For all standard opioids we calculated the number of items prescribed, costs, and oral morphine equivalency to account for variation in strength. We assessed long-term prescribing trends from 1998 to 2017, patterns of geographical variation for 2018, and investigated practice factors associated with higher opioid prescribing. We also analysed prescriptions for long-acting opioids at high doses. FINDINGS: Between 1998 and 2016, opioid prescriptions increased by 34% in England (from 568 per 1000 patients to 761 per 1000). After correcting for total oral morphine equivalency, the increase was 127% (from 190 000 mg to 431 000 mg per 1000 population). There was a decline in prescriptions from 2016 to 2017. If every practice prescribed high-dose opioids at the lowest decile rate, 543 000 fewer high-dose prescriptions could have been issued over a period of 6 months. Larger practice list size, ruralness, and deprivation were associated with greater high-dose prescribing rates. The clinical commissioning group to which a practice belongs accounted for 11·7% of the variation in high-dose prescribing. We have developed a publicly available interactive online tool, OpenPrescribing.net, which displays all primary care opioid prescribing data in England down to the individual practice level. INTERPRETATION: Failing to account for opioid strength would substantially underestimate the true increase in opioid prescribing in the National Health Service (NHS) in England. Our findings support calls for greater action to promote best practice in chronic pain prescribing and to reduce geographical variation. This study provides a model for routine monitoring of opioid prescribing to aid targeting of interventions to reduce high-dose prescribing. FUNDING: National Institute for Health Research (NIHR) School of Primary Care Research, NIHR Biomedical Research Centre Oxford, NHS England.


Assuntos
Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/economia , Dor Crônica/tratamento farmacológico , Bases de Dados Factuais , Geografia Médica , Padrões de Prática Médica/tendências , Inglaterra , Humanos , Atenção Primária à Saúde , Estudos Retrospectivos
11.
BMC Med Inform Decis Mak ; 18(1): 62, 2018 07 09.
Artigo em Inglês | MEDLINE | ID: mdl-29986693

RESUMO

BACKGROUND: The widely used OpenPrescribing.net service provides standard measures which compare prescribing of Clinical Commissioning Groups (CCGs) and English General Practices against that of their peers. Detecting changes in prescribing behaviour compared with peers can help identify missed opportunities for medicines optimisation. Automating the process of detecting these changes is necessary due to the volume of data, but challenging due to variation in prescribing volume for different measures and locations. We set out to develop and implement a method of detecting change on all individual prescribing measures, in order to notify CCGs and practices of such changes in a timely manner. METHODS: We used the statistical process control method CUSUM to detect prescribing behaviour changes in relation to population trends for the individual standard measures on OpenPrescribing. Increases and decreases in percentile were detected separately, using a multiple of standard deviation as the threshold for detecting change. The algorithm was modified to continue re-triggering when trajectory persists. It was deployed, user-tested, and summary statistics generated on the number of alerts by CCG and practice. RESULTS: The algorithm detected changes in prescribing for 32 prespecified measures, across a wide range of CCG and practice sizes. Across the 209 English CCGs, a mean of 2.5 increase and 2.4 decrease alerts were triggered per CCG, per month. For the 7578 practices, a mean of 1.3 increase and 1.4 decrease alerts were triggered per practice, per month. CONCLUSIONS: The CUSUM method appears to effectively discriminate between random noise and sustained change in prescribing behaviour. This method aims to allow practices and CCGs to be informed of important changes quickly, with a view to improve their prescribing behaviour. The number of alerts triggered for CCGs and practices appears to be appropriate. Prescribing behaviour after users are alerted to changes will be monitored in order to assess the impact of these alerts.


Assuntos
Algoritmos , Prescrições de Medicamentos/estatística & dados numéricos , Sistemas de Registro de Ordens Médicas/estatística & dados numéricos , Programas Nacionais de Saúde/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Humanos , Grupo Associado , Reino Unido
12.
BMJ Open ; 8(6): e022416, 2018 06 07.
Artigo em Inglês | MEDLINE | ID: mdl-29880577

RESUMO

OBJECTIVES: Following litigation over pregabalin's second-use medical patent for neuropathic pain, National Health Service (NHS) England was required by the court to instruct general practitioners (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, whose judgement is awaited, is unsuccessful, the NHS can seek to 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 judgements. SETTING: English primary care. PARTICIPANTS: English general practices. PRIMARY AND SECONDARY OUTCOME MEASURES: Variation in prescribing of branded Lyrica across the country before and after the NHS England instruction, by practice and by Clinical Commissioning Group; excess prescribing costs. RESULTS: The proportion of pregabalin prescribed as Lyrica increased from 0.3% over 6 months before the NHS England instruction (September 2014 to February 2015) to 25.7% afterwards (April to September 2015). Although 70% of pregabalin is estimated to be for pain, including 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 £502 million less on pregabalin to July 2017. CONCLUSION: NHS 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 £502 million.


Assuntos
Custos de Medicamentos , Prescrições de Medicamentos/estatística & dados numéricos , Legislação de Medicamentos , Padrões de Prática Médica/tendências , Pregabalina/economia , Medicina Estatal/legislação & jurisprudência , Medicamentos Genéricos , Inglaterra , Medicina Geral/métodos , Humanos , Padrões de Prática Médica/legislação & jurisprudência , Atenção Primária à Saúde/métodos , Estudos Retrospectivos
13.
Diabetes Obes Metab ; 20(9): 2159-2168, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29732725

RESUMO

AIMS: To measure the variation in prescribing of second-line non-insulin diabetes drugs. MATERIALS AND METHODS: We evaluated time trends for the period 1998 to 2016, using England's publicly available prescribing datasets, and stratified these by the order in which they were prescribed to patients using the Clinical Practice Research Datalink. We calculated the proportion of each class of diabetes drug as a percentage of the total per year. We evaluated geographical variation in prescribing using general practice-level data for the latest 12 months (to August 2017), with aggregation to Clinical Commissioning Groups. We calculated percentiles and ranges, and plotted maps. RESULTS: Prescribing of therapy after metformin is changing rapidly. Dipeptidyl peptidase-4 (DPP-4) inhibitor use has increased markedly, with DPP-4 inhibitors now the most common second-line drug (43% prescriptions in 2016). The use of sodium-glucose co-transporter-2 (SGLT-2) inhibitors also increased rapidly (14% new second-line, 27% new third-line prescriptions in 2016). There was wide geographical variation in choice of therapies and average spend per patient. In contrast, metformin was consistently used as a first-line treatment in accordance with guidelines. CONCLUSIONS: In England there is extensive geographical variation in the prescribing of diabetes drugs after metformin, and increasing use of higher-cost DPP-4 inhibitors and SGLT-2 inhibitors compared with low-cost sulphonylureas. Our findings strongly support the case for comparative effectiveness trials of current diabetes drugs.


Assuntos
Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , Bases de Dados Factuais , Inibidores da Dipeptidil Peptidase IV/uso terapêutico , Inglaterra , Geografia Médica , Humanos , Hipoglicemiantes/provisão & distribução , Metformina/uso terapêutico , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico , Compostos de Sulfonilureia/uso terapêutico , Tempo
14.
J R Soc Med ; 111(6): 203-213, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29787684

RESUMO

Objectives NHS England recently announced a consultation seeking to discourage the use of treatments it considers to be low-value. We set out to produce an interactive data resource to show savings in each NHS general practice and to assess the current use of these treatments, their change in use over time, and the extent and reasons for variation in such prescribing. Design Cross-sectional analysis. Setting English primary care. Participants English general practices. Main outcome measures We determined the cost per 1000 patients for prescribing of each of 18 treatments identified by NHS England for each month from July 2012 to June 2017, and also aggregated over the most recent year to assess total cost and variation among practices. We used mixed effects linear regression to determine factors associated with cost of prescribing. Results Spend on low-value treatments was £153.5 m in the last year, across 5.8 m prescriptions (mean, £26 per prescription). Among individual treatments, liothyronine had the highest prescribing cost at £29.6 m, followed by trimipramine (£20.2 m). Over time, the overall total number of low-value prescriptions decreased, but the cost increased, although this varied greatly between treatments. Three treatment areas increased in cost and two increased in volume, all others reduced in cost and volume. Annual practice level spending varied widely (median, £2262 per thousand patients; interquartile range £1439 to £3298). Proportion of patients over 65 was strongly associated with low-value prescribing, as was Clinical Commissioning Group. Our interactive data tool was deployed to OpenPrescribing.net where monthly updated figures and graphs can be viewed. Conclusions Prescribing of low-value treatments is extensive but varies widely by treatment, geographic area and individual practice. Despite a fall in prescription numbers, the overall cost of prescribing for low-value items has risen. Prescribing behaviour is clustered by Clinical Commissioning Group, which may represent variation in the optimisation efficiency of medicines, or in some cases access inequality.


Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Padrões de Prática Médica , Atenção Primária à Saúde/métodos , Medicina Estatal , Redução de Custos , Estudos Transversais , Custos de Medicamentos , Inglaterra , Feminino , Seguimentos , Humanos , Masculino , Encaminhamento e Consulta , Estudos Retrospectivos
15.
BMJ Open ; 8(3): e021312, 2018 04 16.
Artigo em Inglês | MEDLINE | ID: mdl-29661914

RESUMO

OBJECTIVES: There is substantial disagreement about whether gluten-free foods should be prescribed on the National Health Service. We aim to describe time trends, variation and factors associated with prescribing gluten-free foods in England. SETTING: English primary care. PARTICIPANTS: English general practices. PRIMARY AND SECONDARY OUTCOME MEASURES: We described long-term national trends in gluten-free prescribing, and practice and Clinical Commissioning Group (CCG) level monthly variation in the rate of gluten-free prescribing (per 1000 patients) over time. We used a mixed-effect Poisson regression model to determine factors associated with gluten-free prescribing rate. RESULTS: There were 1.3 million gluten-free prescriptions between July 2016 and June 2017, down from 1.8 million in 2012/2013, with a corresponding cost reduction from £25.4 million to £18.7 million. There was substantial variation in prescribing rates among practices (range 0 to 148 prescriptions per 1000 patients, IQR 7.3-31.8), driven in part by substantial variation at the CCG level, likely due to differences in prescribing policy. Practices in the most deprived quintile of deprivation score had a lower prescribing rate than those in the highest quintile (incidence rate ratio 0.89, 95% CI 0.87 to 0.91). This is potentially a reflection of the lower rate of diagnosed coeliac disease in more deprived populations. CONCLUSION: Gluten-free prescribing is in a state of flux, with substantial clinically unwarranted variation between practices and CCGs.


Assuntos
Doença Celíaca/dietoterapia , Dieta Livre de Glúten/tendências , Padrões de Prática Médica/tendências , Atenção Primária à Saúde/tendências , Estudos Transversais , Inglaterra , Humanos , Programas Nacionais de Saúde , Estudos Retrospectivos
16.
J R Soc Med ; 111(5): 167-174, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29669216

RESUMO

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.


Assuntos
Homeopatia/estatística & dados numéricos , Padrões de Prática Médica , Atenção Primária à Saúde/métodos , Redução de Custos , Estudos Transversais , Custos de Medicamentos , Inglaterra , Humanos , Atenção Primária à Saúde/economia , Estudos Retrospectivos
17.
Br J Cancer ; 118(9): 1268-1275, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29681615

RESUMO

BACKGROUND: Tamoxifen was recommended by NICE in 2013 for chemoprevention of breast cancer, but a recent survey suggested only a quarter of GPs are aware of this. We set out to measure the uptake of tamoxifen, and the alternative raloxifene, in national prescribing data sets. METHODS: Tamoxifen and raloxifene data were extracted from England's monthly prescribing data sets, October 2010-October 2017. We used interrupted time series analysis to reveal national and local responses to guidelines. We investigated variation between practices by calculating percentiles for prescribing rates and ratios of change. RESULTS: We found an increase in monthly tamoxifen prescribing following release of the guidelines, with an increase in gradient (p = 0.001) but no step change (p = 0.342). Alongside a small change in raloxifene prescribing we estimate 8450 women took up chemoprevention between 2013 and 2016. We did not find evidence that this was limited to a small group of practices. CONCLUSIONS: Our results suggest that the uptake of new guidance on chemoprevention has been slow and has potentially left women exposed to avoidable risk. Improving dissemination of guidance to healthcare professionals and routinely monitoring implementation could help reduce this risk.


Assuntos
Neoplasias da Mama/prevenção & controle , Fidelidade a Diretrizes/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Tamoxifeno/uso terapêutico , Adulto , Antineoplásicos Hormonais/uso terapêutico , Neoplasias da Mama/epidemiologia , Quimioprevenção/métodos , Quimioprevenção/normas , Quimioprevenção/estatística & dados numéricos , Inglaterra/epidemiologia , Feminino , Fidelidade a Diretrizes/normas , Humanos , Análise de Séries Temporais Interrompida , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Cloridrato de Raloxifeno/uso terapêutico
18.
BMJ Open ; 8(2): e019643, 2018 02 08.
Artigo em Inglês | MEDLINE | ID: mdl-29439078

RESUMO

BACKGROUND: Minimising prescription costs while maintaining quality is a core element of delivering high-value healthcare. There are various strategies to achieve savings, but almost no research to date on determining the most effective approach. We describe a new method of identifying potential savings due to large national variations in drug cost, including variation in generic drug cost, and compare these with potential savings from an established method (generic prescribing). METHODS: We used English National Health Service (NHS) Digital prescribing data, from October 2015 to September 2016. Potential cost savings were calculated by determining the price per unit (eg, pill, millilitre) for each drug and dose within each general practice. This was compared against the same cost for the practice at the lowest cost decile to determine achievable savings. We compared these price-per-unit savings to the savings possible from generic switching and determined the chemicals with the highest savings nationally. A senior pharmacist manually assessed whether a random sample of savings were practically achievable. RESULTS: We identified a theoretical maximum of £410 million of savings over 12 months. £273 million of these savings were for individual prescribing changes worth over £50 per practice per month (mean annual saving £33 433 per practice); this compares favourably with generic switching, where only £35 million of achievable savings were identified. The biggest savings nationally were on glucose blood testing reagents (£12 million), fluticasone propionate (£9 million) and venlafaxine (£8 million). Approximately half of all savings were deemed practically achievable. DISCUSSION: We have developed a new method to identify and enable large potential cost savings within NHS community prescribing. Given the current pressures on the NHS, it is vital that these potential savings are realised. Our tool enabling doctors to achieve these savings is now launched in pilot form at OpenPrescribing.net. However, savings could potentially be achieved more simply through national policy change.


Assuntos
Redução de Custos , Custos de Medicamentos , Prescrições de Medicamentos/economia , Medicamentos Genéricos/economia , Estudos Transversais , Humanos , Medicina Estatal , Reino Unido
19.
BMC Cancer ; 17(1): 747, 2017 Nov 10.
Artigo em Inglês | MEDLINE | ID: mdl-29126386

RESUMO

BACKGROUND: Breast cancer patients are at an increased risk of venous thromboembolism (VTE). However, current evidence as to whether VTE increases the risk of mortality in breast cancer patients is conflicting. We present data from a large cohort of patients from the UK and pool these with previous data from a systematic review. METHODS: Using the Clinical Practice Research Datalink (CPRD) dataset, we identified a cohort of 13,202 breast cancer patients, of whom 611 were diagnosed with VTE between 1997 and 2006 and 12,591 did not develop VTE. Hazard ratios (HR) were used to compare mortality between the two groups. These were then pooled with existing data on this topic identified via a search of the MEDLINE and EMBASE databases (until January 2015) using a random-effects meta-analysis. RESULTS: Within the CPRD, VTE was associated with increased mortality when treated as a time-varying covariate (HR = 2.42; 95% CI, 2.13-2.75), however, when patients were permanently classed as having VTE based on presence of a VTE event within 6 months of cancer diagnosis, no increased risk was observed (HR = 1.22; 0.93-1.60). The pooled HR from seven studies using the second approach was 1.69 (1.12-2.55), with no effect seen when restricted to studies which adjusted for key covariates. CONCLUSION: A large HR for VTE in the time-varying covariate analysis reflects the known short-term mortality following a VTE. When breast cancer patients are fortunate to survive the initial VTE, the influence on longer-term mortality is less certain.


Assuntos
Anticoagulantes/uso terapêutico , Neoplasias da Mama/mortalidade , Tromboembolia Venosa/mortalidade , Neoplasias da Mama/complicações , Neoplasias da Mama/fisiopatologia , Estudos de Coortes , Feminino , Humanos , MEDLINE , Modelos de Riscos Proporcionais , Fatores de Risco , Tromboembolia Venosa/complicações , Tromboembolia Venosa/fisiopatologia
20.
J Med Virol ; 89(12): 2158-2164, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-28480974

RESUMO

Designing services with the capacity and expertise to meet the needs of the chronic hepatitis C (CHC) population in the era of direct acting antivirals (DAAs), and widening access to such treatments, requires detailed understanding of the characteristics and healthcare needs of the existing patient population. In this retrospective analysis of data from the National HCV Research UK Biobank between March 2012 and October 2014, the characteristics of the CHC population currently under specialist care in the UK were evaluated-with specific focus upon use of medications, adverse lifestyle choices, and comorbidities. Demographic data, risk factors for CHC acquisition, HCV genotype, liver disease status, lifestyle factors, comorbidities, and medication classes were collected. Data were analyzed by history of injecting drug use (IDU), age, and severity of liver disease. A total of 6278 patients (70.5% white; median age, 52 years) from 59 UK specialist centres were included; 59.1% of patients had acquired HCV through IDU. The prevalence of adverse lifestyle factors was significantly lower in non-IDU compared with previous IDU or recent IDU patients. Depression was common in the previous (50.8%) and recent IDU (68.1%) groups, compared with 27.6% in non-IDU patients. Cirrhosis was common (23.6%), and prevalence increased with age. We describe a heterogeneous, polymorbid, and aging population of CHC patients in secondary care, and demonstrate underrepresentation of injecting drug users within the current system. The implications of this present significant challenges to physicians and healthcare commissioners in designing services which are fit for purpose inthe DAA era.


Assuntos
Antivirais/uso terapêutico , Comorbidade , Hepatite C Crônica/tratamento farmacológico , Hepatite C Crônica/epidemiologia , Abuso de Substâncias por Via Intravenosa/epidemiologia , Adulto , Antivirais/administração & dosagem , Antivirais/efeitos adversos , Estudos de Coortes , Interações de Medicamentos , Feminino , Hepatite C Crônica/complicações , Hepatite C Crônica/virologia , Humanos , Estilo de Vida , Fígado/virologia , Cirrose Hepática/complicações , Cirrose Hepática/epidemiologia , Cirrose Hepática/virologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Polimedicação , Prevalência , Estudos Retrospectivos , Fatores de Risco , Especialização , Abuso de Substâncias por Via Intravenosa/complicações , Abuso de Substâncias por Via Intravenosa/virologia , Reino Unido/epidemiologia
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