Prevalence of polypharmacy in a Scottish primary care population.

PURPOSE: Polypharmacy-the use of multiple medications by a single patient-is an important issue associated with various adverse clinical outcomes and rising costs. It is also a topic rarely addressed by clinical guidelines. We used routine Scottish health records to address the lack of data on the prevalence of polypharmacy in the broader, adult primary care population, particularly in relation to long-term conditions. METHODS: We conducted a cross-sectional analysis of adult electronic primary healthcare records and used linear regression models to examine the association between the number of medicines prescribed regularly and both multimorbidity and specific clinical conditions, adjusting for age, gender and socioeconomic deprivation. RESULTS: Overall, 16.9 % of the adults assessed were receiving four to nine medications, and 4.6 % were receiving ten or more medications, increasing with age (28.6 and 7.4 %, respectively, in those aged 60-69 years; 51.8 and 18.6 %, respectively, in those aged ≥ 80 years), but relatively unaffected by gender or deprivation. Of those patients with two clinical conditions, 20.8 % were receiving four to nine medications, and 1.1 % were receiving ten or more medications; in those patients with six or more comorbidities, these values were 47.7 and 41.7 %, respectively. The number of medications varied considerably between clinical conditions, with cardiovascular conditions associated with the greatest number of additional medications. The accumulation of additional medicines was less with concordant conditions. CONCLUSIONS: Polypharmacy is common in UK primary care. The main factor associated with this is multimorbidity, although considerable variation exists between different conditions. The impact of clinical conditions on the number of medicines is generally less in the presence of co-existing concordant conditions.

Evaluation of medication reviews conducted by community pharmacists: a quantitative analysis of documented issues and recommendations.

UNLABELLED: What is already known about this subject? There is conflicting evidence concerning the potential benefits of pharmacist-led medication review. Little work has been published on the completeness of medication reviews provided by community pharmacists. What this study adds. The 60 community pharmacists taking part in a large randomized controlled trial showed considerable variation in the completeness of the reviews they recorded for intervention patients. Overall, pharmacists recorded only a minority of the potential issues present in these patients. The frequency with which pharmacists recorded issues was not related to key characteristics or to the number of reviews completed. AIMS: To describe issues noted and recommendations made by community pharmacists during reviews of medicines and lifestyle relating to coronary heart disease (CHD), and to identify and quantify missed opportunities for making further recommendations and assess any relationships with demographic characteristics of the pharmacists providing the reviews. METHODS: All issues and recommendations noted by 60 community pharmacists during patient consultations were classified and quantified. Two independent reviewers studied a subsample of cases from every participating pharmacist and identified and classified potential issues from the available data. The findings of the pharmacists and the reviewers were compared. Relevant pharmacist characteristics were obtained from questionnaire data to determine relationships to the proportion of potential issues noted. RESULTS: A total of 2228 issues and 2337 recommendations were noted by the pharmacists in the 738 patients seen, a median of three per patient (interquartile range 2-4). The majority of the recommendations made (1719; 74%) related to CHD. In the subsample of 169 patients (23% of the total), the reviewers identified 1539 potential issues, of which pharmacists identified an average of 33.8% (95% confidence interval 30.1, 36.4). No relationship was found between the proportion of issues noted and potentially relevant factors such as pharmacists' characteristics and their experience of doing reviews. CONCLUSIONS: The majority of issues and recommendations noted by pharmacists related to CHD, although pharmacists recorded only a minority of the issues identified by reviewers. Variation between pharmacists in the completeness of reviews was not explained by review or other relevant experience.

Effectiveness and cost-effectiveness of salicylic acid and cryotherapy for cutaneous warts. An economic decision model.

OBJECTIVES: To estimate the costs of commonly used treatments for cutaneous warts, as well as their health benefits and risk. To create an economic decision model to evaluate the cost-effectiveness of these treatments, and, as a result, assess whether a randomised controlled trial (RCT) would be feasible and cost-effective. DATA SOURCES: Focus groups, structured interviews and observation of practice. Postal survey sent to 723 patients. A recently updated Cochrane systematic review and published cost and prescribing data. REVIEW METHODS: Primary and secondary data collection methods were used to inform the development of an economic decision model. Data from the postal survey provided estimates of the effectiveness of wart treatments in a primary care setting. These estimates were compared with outcomes reported in the Cochrane review of wart treatment, which were largely obtained from RCTs conducted in secondary care. A decision model was developed including a variety of over-the-counter (OTC) and GP-prescribed treatments. The model simulated 10,000 patients and adopted a societal perspective. RESULTS: OTC treatments were used by a substantial number of patients (57%) before attending the GP surgery. By far the most commonly used OTC preparation was salicylic acid (SA). The results of the economic model suggested that of the treatments prescribed by a GP, the most cost-effective treatment was SA, with an incremental cost-effectiveness ratio (ICER) of 2.20 pound/% cured. The ICERs for cryotherapy varied widely (from 1.95 to 7.06 pound/% cured) depending on the frequency of applications and the mode of delivery. The most cost-effective mode of delivery was through nurse-led cryotherapy clinics (ICER = 1.95 pound/% cured) and this could be a cost-effective alternative to GP-prescribed SA. Overall, the OTC therapies were the most cost-effective treatment options. ICERs ranged from 0.22 pound/% cured for OTC duct tape and 0.76 pound/% cured for OTC cryotherapy to 1.12 pound/% cured for OTC SA. However, evidence in support of OTC duct tape and OTC cryotherapy is very limited. Side-effects were commonly reported for both SA and cryotherapy, particularly a burning sensation, pain and blistering. CONCLUSIONS: Cryotherapy delivered by a doctor is an expensive option for the treatment of warts in primary care. Alternative options such as GP-prescribed SA and nurse-led cryotherapy clinics provide more cost-effective alternatives, but are still expensive compared with self-treatment. Given the minor nature of most cutaneous warts, coupled with the fact that the majority spontaneously resolve in time, it may be concluded that a shift towards self-treatment is warranted. Although both duct tape and OTC cryotherapy appear promising new self-treatment options from both a cost and an effectiveness perspective, more research is required to confirm the efficacy of these two methods of wart treatment. If these treatments are shown to be as cost-effective as or more cost-effective than conventional treatments, then a shift in service delivery away from primary care towards more OTC treatment is likely. A public awareness campaign would be useful to educate patients about the self-limiting nature of warts and the possible alternative OTC treatment options available. Two future RCTs are recommended for consideration: a trial of SA compared with nurse-led cryotherapy in primary care, and a trial of home treatments. Greater understanding of the efficacy of these home treatments will give doctors a wider choice of treatment options, and may help to reduce the overall demand for cryotherapy in primary care.

Supporting adherence for people starting a new medication for a long-term condition through community pharmacies: a pragmatic randomised controlled trial of the New Medicine Service.

OBJECTIVE: To examine the effectiveness of the New Medicine Service (NMS), a national community pharmacy service to support medicines-taking in people starting a new medicine for a long-term condition, compared with normal practice. METHODS: Pragmatic patient-level parallel randomised controlled trial, in 46 community pharmacies in England. Patients 1:1 block randomisation stratified by drug/disease group within each pharmacy. 504 participants (NMS: 251) aged 14 years and over, identified in the pharmacy on presentation of a prescription for asthma/chronic obstructive pulmonary disease, hypertension, type 2 diabetes or an anticoagulant/antiplatelet agent. NMS intervention: One consultation 7-14 days after presentation of prescription followed by another 14-21 days thereafter to identify problems with treatment and provide support if needed. Controls received normal practice. Adherence, defined as missing no doses without the advice of a medical professional in the previous 7 days, was assessed through patient self-report at 10 weeks. Intention-to-treat analysis was employed, with outcome adjusted for recruiting pharmacy, NMS disease category, age, sex and medication count. Cost to the National Health Service (NHS) was collected. RESULTS: At 10 weeks, 53 patients had withdrawn and 443 (85%) patients were contacted successfully by telephone. In the unadjusted analysis of 378 patients still taking the initial medicine, 61% (95% CI 54% to 67%) and 71% (95% CI 64% to 77%) patients were adherent in the normal practice and NMS arms, respectively (p=0.04 for difference). In the adjusted intention-to-treat analysis, the OR for increased adherence was 1.67 (95% CI 1.06 to 2.62; p=0.027) in favour of the NMS arm. There was a general trend to reduced NHS costs, albeit, statistically non-significant, for the NMS intervention: saving £21 (95% CI -£59 to £100, p=0.128) per patient. CONCLUSIONS: The NMS significantly increased the proportion of patients adhering to their new medicine by about 10%, compared with normal practice. TRIAL REGISTRATION NUMBERS: ClinicalTrials.gov trial reference number NCT01635361 (http://clinicaltrials.gov/ct2/show/NCT01635361). Current Controlled trials: trial reference number ISRCTN 23560818 (http://www.controlled-trials.com/ISRCTN23560818/; DOI 10.1186/ISRCTN23560818). UK Clinical Research Network (UKCRN) study 12494 (http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=12494).

Views of older people on cataract surgery options: an assessment of preferences by conjoint analysis.

BACKGROUND: Key issues in the quality of care for people with cataracts in the UK include hospital waiting lists, complication rates from surgery, and the use of junior surgeons. The main objective of this study was to investigate the relative importance that older people attach to these factors when given theoretical choices over options for cataract surgery. METHOD: A systematic sample of 194 individuals aged 60-84 years on a general practice register in Nottingham were invited to take part in an interview based survey. Respondents ranked 11 "cataract surgery packages" containing different waiting list lengths, complication risks, and surgeon grades. Conjoint analysis was performed to determine the relative importance of these factors for individuals and for the group as a whole. RESULTS: Of the 194 subjects invited to participate, 146 (72%) completed the interview. For the group as a whole the "averaged importance" of the factors was: complication risk 45.8%; waiting time 41.1%, surgeon grade 13.1%. Analysis of importance scores for individuals showed that some were particularly concerned about complication risk while others were more concerned about waiting times. There was a strong negative correlation between importance scores for these factors (Spearman's rho -0.78, p<0.001). CONCLUSIONS: Most respondents thought that either risk of damage to sight and/or waiting time were important, while surgeon grade was relatively unimportant. The findings show that some potential cataract patients prefer a greater risk of complication combined with a short wait than a low complication rate and a longer wait.

Investigation into the reasons for preventable drug related admissions to a medical admissions unit: observational study.

OBJECTIVE: To describe the drugs and types of medicine management problems most frequently associated with preventable drug related admissions to an acute medical admissions unit. DESIGN: Observation study. SETTING: Medical admissions unit in a teaching hospital in Nottingham, UK. PARTICIPANTS: 4093 patients seen by pharmacists on the medical admissions unit between 1 January and 30 June 2001. MAIN OUTCOME MEASURES: Proportion of admissions that were drug related and preventable, classification of the underlying causes of preventable drug related admissions, and identification of drugs most commonly associated with preventable drug related admissions. RESULTS: Of the admissions seen by pharmacists, 265 (6.5%) were judged to be drug related and 178 (67%) of these were judged to be preventable. Preventable admissions were mainly due to problems with prescribing (63 cases (35%)), monitoring (46 cases (26%)), and adherence to medication (53 cases (30%)). The drugs most commonly implicated were NSAIDs, antiplatelets, antiepileptics, hypoglycaemics, diuretics, inhaled corticosteroids, cardiac glycosides, and beta-blockers. CONCLUSIONS: Potentially preventable drug related morbidity was associated with 4.3% of admissions to a medical admissions unit. In 91% of cases these admissions were related to problems with either prescribing, monitoring, or adherence.

Indicators for preventable drug related morbidity: application in primary care.

AIM: To apply in practice a series of validated indicators for preventable drug related morbidity (PDRM). DESIGN: A pilot study to identify retrospectively potential PDRM events over a 2 year 3 month time frame using the MIQUEST computer software program. SUBJECTS AND SETTING: The electronic patient record of all patients aged 18 years and over in nine English general practices. OUTCOME MEASURES: The number of potential PDRM events identified, as defined by the indicators. RESULTS: Five hundred and seven potential PDRM events were identified from 49 658 electronic patient records, giving an overall incidence of 1.0%. A small number of the indicators (n = 4) accounted for approximately 60% of the events, while for many indicators few events were identified. The most common events related to the use of non-steroidal anti-inflammatory drugs in patients with congestive heart failure or hypertension, lack of monitoring in patients prescribed angiotensin converting enzyme inhibitors, and the use of hypnotic-anxiolytic agents. CONCLUSIONS: A small number of indicators contributed to the majority of the PDRM events. Interrogation of electronic patient records in primary care using computerised queries shows potential for detecting PDRM.

Asthmatic symptoms, airway responsiveness and recognition of bronchoconstriction.

During an epidemiological investigation of asthma in an occupational setting, 1126 subjects completed a modified Medical Research Council respiratory questionnaire, then underwent airway responsiveness measurements as PD20FEV1 to methacholine. Previous experience of bronchoconstriction was assessed in the 481 subjects with measurable airway responsiveness (PD20FEV1 < 6400 g) by asking 'have you ever felt like this before' at the end of their methacholine challenge tests, i.e. when the subjects were bronchoconstricted by FEV1 decrements of at least 20%. The responses to this question bore no relationship to the previously administered questionnaire responses about wheezing, chest tightness, coughing, or breathlessness. However, there was an inverse relationship with PD20FEV1 measurements (P < 0.001), the positive response rate to the question falling from 92% among those with PD20FEV1 < 50 micrograms to 27% among those with PD20FEV1 in the highest measurable range (3200-6400 micrograms). This suggests that airway responsiveness measurements are a more reliable guide to subjects' previous experience of substantial bronchoconstriction (i.e. asthma) than are the responses to respiratory questionnaires.

Poles apart? The views of general practitioners and family health services authority advisers on prescribing cost issues.

BACKGROUND: In 1994, an Audit Commission report estimated that Pounds 425 million could be saved from the national drug budget if general practitioners (GPs) altered their prescribing in various ways. AIM: To assess the views of GPs and family health services authority (FHSA) advisers on issues similar to those raised in the Audit Commission report. METHOD: A questionnaire was sent to a 1 in 20 sample of GPs from 33 randomly selected FHSA areas (n = 576) and all FHSA advisers (n = 285). RESULTS: A total of 419 (72.7%) GPs and 234 (82.1%) advisers replied. There were statistically significant differences (P < 0.01) between GPs and advisers on all but one of the statements. In particular, there were marked differences on some of the statements relating to substitution with cheaper similar drugs. Differences were smaller for statements on the use of drugs of limited therapeutic value, the range of drugs prescribed, and practice prescribing policies. Differences were noted between subgroups of GPs in response to some of the statements. CONCLUSION: The majority of GPs in this survey gave responses that were supportive of many of the types of suggestion made by the Audit Commission. However, it is suggested that differences of opinion between GPs and FHSA advisers may have implications for the development of strategies to control prescribing costs.

How much does self-reported health status, measured by the SF-36, vary between electoral wards with different Jarman and Townsend scores?

BACKGROUND: The best way for practices to determine the health status of patients living in areas with different socioeconomic characteristics is unclear. AIMS: To see how much SF-36 health status varies between electoral wards, how much of this variation can be explained by census-derived Jarman and Townsend scores, and compare the performance of census scores with direct socioeconomic information. METHOD: A postal questionnaire survey of 3000 randomly selected 18 to 75-year-olds residing in 15 electoral wards and registered with two urban practices. RESULTS: The response rate was 73%. Only two of the eight SF-36 domains were significantly associated with Jarman scores, whereas seven domains were associated with the Townsend score. Of the four socioeconomic variables derived directly from the survey, unemployment showed the weakest association, housing tenure was associated with seven domains, and car ownership and low income were associated with all eight. Income explained between 47% to 71% of the variation across the eight domains. CONCLUSION: The most accurate predictions about health status were made from direct socioeconomic information. Nonetheless, the association between Townsend score and health status was strong enough to be of practical importance. This study cautions against assuming the Jarman score of a population has a clear relationship with its health status.

Do GPs working in practice with high or low prescribing costs have different views on prescribing cost issues?

BACKGROUND: In a previous study we found that a minority of general practitioners (GPs) had different views to health authority advisers on a number of prescribing cost issues. However, there were few differences between subgroups of GPs. We hypothesised that subgroups that might show differences were GPs from practices with either high or low prescribing costs. AIM: To assess differences in views on prescribing cost issues between GPs working in practices with either high or low prescribing costs. METHOD: Using PACTLINE data, prescribing costs were obtained for general practices within the Trent Region for the financial year 1996 to 1997. A questionnaire was sent anonymously to 340 GPs working in those practices with high prescribing costs, and to 322 GPs working in practices with the lowest prescribing costs. RESULTS: A total of 216 (63.5%) GPs from high-cost practices and 194 (60.2%) from low-cost practices responded. There were statistically significant differences between the two groups on seven out of 22 statements. However, when the confounding effect of fundholding was taken into account, significant differences were found for just three statements and each of these related to substitution with comparable but cheaper drugs. CONCLUSIONS: GPs working in practices with either high or low prescribing costs had different views on a number of statements concerning substitution with comparable but cheaper drugs. When encouraging GPs to control their prescribing costs, a different approach may be required for doctors in some high-cost practices.

Do prescribing formularies help GPs prescribe from a narrower range of drugs? A controlled trial of the introduction of prescribing formularies for NSAIDs.

BACKGROUND: Previous studies have suggested that prescribing formularies may promote rational prescribing. The range of drugs prescribed may be one aspect of rational prescribing. AIM: To determine whether the introduction of prescribing formularies helps general practitioners (GPs) to prescribe from a narrower range of non-steroidal anti-inflammatory drugs (NSAIDs). METHOD: General practices in Lincolnshire were offered help in developing prescribing formularies. Ten practices decided to develop a formulary for NSAIDs. Level 3 PACT data were used to determine whether changes in prescribing had occurred with the introduction of the formulary. Matched controls were used to determine whether similar changes had occurred in other practices. RESULTS: Between April and June 1992, and during the same period in 1993, practices that introduced a formulary for NSAIDs reduced the mean number of different drugs used (14.3 versus 13.1, P = 0.04) and increased the percentage of NSAID-defined daily doses coming from the three most commonly used drugs (70.1% versus 74.8%, P = 0.02). Similar changes were not seen in control practices. CONCLUSION: Following the development of a formulary for NSAIDs, practices prescribed from a narrower range of drugs and focused a greater proportion of their prescribing on their three most commonly used drugs.

The impact of nursing home patients on general practitioners' workload.

BACKGROUND: Although the number of people in nursing homes has risen substantially in recent years, the shift of responsibility into general practice has rarely been accompanied by extra resources. These patients may be associated with a higher general practitioner (GP) workload than others of similar age and sex. AIM: To assess the GP workload associated with nursing home residents and its associated costs. METHOD: All nursing home residents aged over 65 years and registered with nine Nottinghamshire practices during one year were matched with patients living in the community for general practice, age, and sex. Data were collected retrospectively for both groups on key workload measures. Costs for the workload measures were calculated using published estimates. RESULTS: Data were collected for 270 pairs of patients. Nursing home patients had more face-to-face contacts in normal surgery hours, telephone calls, and out-of-hours visits. The mean workload cost per month of a nursing home patient (assuming that one patient was seen per visit) was estimated to be 18.21 Pounds (10.49 Pounds higher than the cost of controls). A sensitivity analysis demonstrated that potential savings in visiting costs associated with increasing the numbers of patients seen per visit were 27% for one extra patient seen per visit and 44% for four extra patients. CONCLUSION: Nursing home residents were associated with higher workload for GPs than other patients of the same age and sex living in the community. Our costings provide a basis for negotiating suitable reimbursement of GPs for their additional work.

Are child health surveillance reviews just routine examinations of normal children?

BACKGROUND: The provision and content of child health surveillance (CHS) has changed greatly since 1990. However, its value continues to be questioned. The introduction of the personal child health record (PCHR) has provided a new means of collecting data about CHS. AIM: To identify what problems are recorded at CHS reviews in the PCHR during the first year of life, and what follow-up/referrals result directly from these reviews. METHOD: A total of 28 practices were recruited from one health authority. All babies born to mothers registered with study practices during one year were followed up. Health visitors returned copies of CHS reviews recorded in children's PCHRs. Written comments on returned reviews were analysed. RESULTS: In all, 2308 babies were entered into the study and 2001 (87%) were followed up for one year. A total of 7848 (78%) CHS reviews were returned. Physical problems were recorded in 58% of children at the 10-14 day, 35% at the six to eight week, and 39% at the six to nine month review. Of physical problems recorded at CHS reviews, 30% required follow-up in primary care and 7% required referral to hospital. Other problems were recorded less frequently and health promotion was recorded at only 7.5% of CHS reviews. CONCLUSION: Child health surveillance provides important opportunities to discuss problems that may cause parental concern and to identify children requiring treatment or follow-up. The design and use of the PCHR needs to change to reflect increasing emphasis on health promotion.

Controlled trial of pharmacist intervention in general practice: the effect on prescribing costs.

BACKGROUND: It has been suggested that the employment of pharmacists in general practice might moderate the growth in prescribing costs. However, empirical evidence for this proposition has been lacking. We report the results of a controlled trial of pharmacist intervention in United Kingdom general practice. AIM: To determine whether intervention practices made savings relative to controls. METHOD: An evaluation of an initiative set up by Doncaster Health Authority. Eight practices agreed to take part and received intensive input from five pharmacists for one year (September 1996 to August 1997) at a cost of 163,000 Pounds. Changes in prescribing patterns were investigated by comparing these practices with eight individually matched controls for both the year of the intervention and the previous year. Prescribing data (PACTLINE) were used to assess these changes. The measures used to take account of differences in the populations of the practices included the ASTRO-PU for overall prescribing and the STAR-PU for prescribing in specific therapeutic areas. Differences between intervention and control practices were subjected to Wilcoxon matched-pairs, signed-ranks tests. RESULTS: The median (minimum to maximum) rise in prescribing costs per ASTRO-PU was 0.85 Pound (-1.95 Pounds to 2.05 Pounds) in the intervention practices compared with 2.55 Pounds (1.74 Pounds to 4.65 Pounds) in controls (P = 0.025). Had the cost growth of the intervention group been as high as that of the controls, their total prescribing expenditure would have been around 347,000 Pounds higher. CONCLUSION: This study suggests that the use of pharmacists did control prescribing expenditure sufficiently to offset their employment costs.

Relation of out of hours activity by general practice and accident and emergency services with deprivation in Nottingham: longitudinal survey.

OBJECTIVES: To investigate the relation between out of hours activity of general practice and accident and emergency services with deprivation and distance from accident and emergency department. DESIGN: Six month longitudinal study. SETTING: Six general practices and the sole accident and emergency department in Nottingham. SUBJECTS: 4745 out of hours contacts generated by 45,182 patients from 23 electoral wards registered with six practices. MAIN OUTCOME MEASURES: Rates of out of hours contacts for general practice and accident and emergency services calculated by electoral ward; Jarman and Townsend deprivation scores and distance from accident and emergency department of electoral wards. RESULTS: Distances of wards from accident and emergency department ranged from 0.8 to 9 km, and Jarman deprivation scores ranged from -23.4 to 51.8. Out of hours contacts varied by ward from 110 to 350 events/1000 patients/year, and 58% of this variation was explained by the Jarman score. General practice and accident and emergency rates were positively correlated (Pearson coefficient 0.50, P = 0.015). Proximity to accident and emergency department was not significantly associated with increased activity when deprivation was included in regression analysis. One practice had substantially higher out of hours activity (B coefficient 124 (95% confidence interval 67 to 181)) even when deprivation was included in regression analysis. CONCLUSIONS: A disproportionate amount of out of hours workload fell on deprived inner city practices. High general practice and high accident and emergency activity occurred in the same areas rather than one service substituting for the other.

A prescription for improvement? An observational study to identify how general practices vary in their growth in prescribing costs.

OBJECTIVE: To identify how some general practices have low growth in prescribing costs relative to other practices. DESIGN: Observational study. SETTING: Trent region of England. PARTICIPANTS: 162 general practices: 54 with low growth in prescribing costs, 54 with average increases in costs, and 54 with large increases in costs. MAIN OUTCOME MEASURES: Changes in prescribing costs in therapeutic categories in which it has been suggested that savings can be made. RESULTS: There were significant differences between the three groups of practices in terms of their changes in prescribing costs for almost all the variables studied. For the group of practices with lowest growth in costs the most important factors were reducing numbers of prescription items and costs per item; relatively low growth in the costs of "new and expensive" drugs; increasing generic prescribing; and reducing costs for modified release products. This group of practices did not increase costs as much as the others for lipid lowering drugs (P=0.012) and hormone replacement therapy (P=0. 007). The practices with the greatest increases in costs had particularly large increases for proton pump inhibitors, selective serotonin reuptake inhibitors, and modified release products. Compared with the other groups these practices had larger increases in costs for "expensive hospital initiated drugs" (P=0.009). CONCLUSION: General practices vary in their growth in prescribing costs in many ways, with growth in costs for "new and expensive" drugs being particularly important.

Attendance and weight outcomes in 4754 adults referred over 6 months to a primary care/commercial weight management partnership scheme.

WHAT IS ALREADY KNOWN ON THIS SUBJECT: • There is growing evidence of the effectiveness of commercial weight management programmes in the community. A recent randomized controlled trial has shown commercial providers to be more effective than NHS providers for weight management solutions in primary care. Some commercial weight management providers have established national slimming on referral schemes for weight management, which result on average in weight losses of 4-5% over a 12-week referral period. A recent randomized controlled trial of a similar scheme over 12 months yielded similar weight loses. Another RCT comparing commercial providers over 6 months showed average weight losses of ∼6.6% across providers. WHAT THIS STUDY ADDS: • The present study shows that when local primary care practitioners target resources to where they, as health professionals, felt they would have the most beneficial effect in their local communities, greater weight losses can be achieved. • Different NHS Trusts extended 12-week referrals by an additional 12 weeks in a total of 4754 patients. • Mean weight losses of 8.6% were achieved suggesting that local targeting of primary care resources can maximize returns for NHS investments in commissioning the services of commercial weight management organizations. SUMMARY: This project audited attendance and weight loss in a primary care/commercial weight management partnership scheme in patients who participated over 6 months. 4754 adult patients (575 men, 4179 women) were referred to Slimming World for 24 weekly sessions. Data were analysed using individual weekly weight records. Mean (standard deviation, SD) body mass index (BMI) change was -3.3 kg m(-2) (2.2), weight change -8.9 kg (6.0), percent weight change -8.6% (5.3) and number of sessions attended 21.3 (3.2) of 24. For patients attending at least 20 of 24 sessions (n = 3626 or 76.3%), mean (SD) BMI change was -3.6 kg m(-2) (2.2), weight change -9.6 kg (6.1), percent weight change -9.3% (5.3). Weight loss was greater in men than women (P < 0.001). 74.5% of all patients enrolled, and 79.3% of patients attending 20 or more sessions achieved at least 5% weight loss. 37.3% of the whole population lost ≥10% of their weight. Weight gain was prevented in 96.3% of all patients referred. Referral to a commercial organization for community-based lifestyle intervention is a practical option for longer-term National Health Service weight management strategies.

Evaluation of patient reporting of adverse drug reactions to the UK 'Yellow Card Scheme': literature review, descriptive and qualitative analyses, and questionnaire surveys.

BACKGROUND: The monitoring of adverse drug reactions (ADRs) through pharmacovigilance is vital to patient safety. Spontaneous reporting of ADRs is one method of pharmacovigilance, and in the UK this is undertaken through the Yellow Card Scheme (YCS). Yellow Card reports are submitted to the Medicines and Healthcare products Regulatory Agency (MHRA) by post, telephone or via the internet. The MHRA electronically records and reviews information submitted so that important safety issues can be detected. While previous studies have shown differences between patient and health-care professional (HCP) reports for the types of drugs and reactions reported, relatively little is known about the pharmacovigilance impact of patient reports. There have also been few studies on the views and experiences of patients/consumers on the reporting of suspected ADRs. OBJECTIVES: To evaluate the pharmacovigilance impact of patient reporting of ADRs by analysing reports of suspected ADRs from the UK YCS and comparing reports from patients and HCPs. To elicit the views and experiences of patients and the public about patient reporting of ADRs. DESIGN: (1) Literature review and survey of international experiences of consumer reporting of ADRs; (2) descriptive analysis of Yellow Card reports; (3) signal generation analysis of Yellow Card reports; (4) qualitative analysis of Yellow Card reports; (5) questionnaire survey of patients reporting on Yellow Cards; (6) qualitative analysis of telephone interviews with patient reporters to the scheme; (7) qualitative analysis of focus groups and usability testing of the patient YCS; and (8) national omnibus telephone survey of public awareness of the YCS. PARTICIPANTS: Patients (n = 5180) and HCPs (n = 20,949) submitting Yellow Card reports from October 2005 to September 2007. Respondents to questionnaire survey (n = 1362). Participants at focus groups and usability testing sessions (n = 40). National omnibus telephone survey (n = 2028). SETTING: The literature review included studies in English from across the world. All other components included populations from the UK; the omnibus survey was restricted to Great Britain. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Characteristics of patient reports: types of drug and suspected ADR reported; seriousness of reports; and content of reports. The relative contributions of patient reports and of HCP reports to signal generation. Views and experiences of patient reporters. Views of members of the public about the YCS, including user-friendliness and usability of different ways of patient reporting. Public awareness of the YCS. Suggestions for improving patient reporting to the YCS. RESULTS: Compared with HCPs, patient reports to the YCS contained a higher median number of suspected ADRs per report, and described reactions in more detail. The proportions of reports categorised as 'serious' were similar; the patterns of drugs and reactions reported differed. Patient reports were richer in their descriptions of reactions than those from HCPs, and more often noted the effects of ADRs on patients' lives. Combining patient and HCP reports generated more potential signals than HCP reports alone; some potential signals in the 'HCP-only' data set were lost when combined with patient reports, but fewer than those gained; the addition of patient reports to HCP reports identified 47 new 'serious' reactions not previously included in 'Summaries of Product Characteristics'. Most patient reporters found it fairly easy to make reports, although improvements to the scheme were suggested, including greater publicity and the redesign of web- and paper-based reporting systems. Among members of the public, 8.5% were aware of the YCS in 2009. CONCLUSIONS: Patient reporting of suspected ADRs has the potential to add value to pharmacovigilance by reporting types of drugs and reactions different from those reported by HCPs; generating new potential signals; and describing suspected ADRs in enough detail to provide useful information on likely causality and impact on patients' lives. These findings suggest that further promotion of patient reporting to the YCS is justified, along with improvements to existing reporting systems. In order of priority, future work should include further investigation of (1) the pharmacovigilance impact of patient reporting in a longer-term study; (2) the optimum approach to signal generation analysis of patient and HCP reports; (3) the burden of ADRs in terms of impact on patients' lives; (4) the knowledge and attitudes of HCPs towards patient reporting of ADRs; (5) the value of using patient reports of ADRs to help other patients and HCPs who are seeking information on patient experiences of ADRs; and (6) the impact of increasing publicity and/or enhancements to reporting systems on the numbers and types of Yellow Card reports from patients. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Community falls prevention for people who call an emergency ambulance after a fall: randomised controlled trial.

OBJECTIVE: To evaluate whether a service to prevent falls in the community would help reduce the rate of falls in older people who call an emergency ambulance when they fall but are not taken to hospital. DESIGN: Randomised controlled trial. SETTING: Community covered by four primary care trusts, England. PARTICIPANTS: 204 adults aged more than 60 living at home or in residential care who had fallen and called an emergency ambulance but were not taken to hospital. INTERVENTIONS: Referral to community fall prevention services or standard medical and social care. MAIN OUTCOME MEASURES: The primary outcome was the rate of falls over 12 months, ascertained from monthly diaries. Secondary outcomes were scores on the Barthel index, Nottingham extended activities of daily living scale, and falls efficacy scale at baseline and by postal questionnaire at 12 months. Analysis was by intention to treat. RESULTS: 102 people were allocated to each group. 99 (97%) participants in the intervention group received the intervention. Falls diaries were analysed for 88.6 person years in the intervention group and 84.5 person years in the control group. The incidence rates of falls per year were 3.46 in the intervention group and 7.68 in the control group (incidence rate ratio 0.45, 95% confidence interval 0.35 to 0.58, P<0.001). The intervention group achieved higher scores on the Barthel index and Nottingham extended activities of daily living and lower scores on the falls efficacy scale (all P<0.05) at the 12 month follow-up. The number of times an emergency ambulance was called because of a fall was significantly different during follow-up (incidence rate ratio 0.60, 95% confidence interval 0.40 to 0.92, P=0.018). CONCLUSION: A service to prevent falls in the community reduced the fall rate and improved clinical outcome in the high risk group of older people who call an emergency ambulance after a fall but are not taken to hospital. TRIAL REGISTRATION: Current Controlled Trials ISRCTN67535605.