Effect of fundholding and indicative prescribing schemes on general practitioners' prescribing costs.

OBJECTIVE--To compare general practitioners'' prescribing costs in fundholding and non-fundholding practices before and after implementation of the NHS reforms in April 1991. DESIGN--Analysis of prescribing and cost information (PACT data; levels 2 and 3) over two six month periods in 1991 and 1992. SETTING--Oxford region. PARTICIPANTS--Three dispensing fundholding practices; five non-dispensing fundholding practices; and seven non-dispensing, non-fundholding practices. MAIN OUTCOME MEASURES--Percentage change in net cost of ingredients, number of items prescribed, average cost per item, and proportion of generic drugs prescribed after NHS reforms. RESULTS--Prescribing costs increased in all practices in the six months after the reforms. The net costs of ingredients increased among dispensing fundholders by 10.2%, among non-dispensing fundholders by 13.2%, and among non-fundholders by 18.7%. The number of items prescribed also increased in all three groups (by 5.2%, 7.5%, and 6.1% respectively). The increase in average cost per item was 4.8% for dispensing fundholders, 5.3% for non-dispensing fundholders, and 11.9% for non-fundholders. Dispensing fundholders increased the proportion of generic drugs prescribed from 26.9% to 34.5% and non-dispensing fundholders from 44.5% to 48.7%; non-fundholders showed no change (47%). Five of the eight fundholding practices made savings in their drugs budgets at the end of the first year of fundholding (range 2.9-10.7%; the three other practices overspent by up to 3.6%). All non-fundholding practices exceeded their indicative prescribing amounts (range 3.2-20.0%). CONCLUSIONS--Fundholding has helped to curb increases in prescribing costs, even among dispensing general practitioners, for whom the incentives are different. Indicative prescribing amounts for non-fundholding practices do not seem to have had the same effect.     

Hospital formularies: need for continuous intervention.

The effects of introducing a hospital formulary alone and with active intervention were compared prospectively with regard to drug costs and the quality of prescribing. Intervention comprised feedback on prescribing habits, peer comparison, and information on drugs. Aspects of prescribing that were not subjected to intervention did not alter. In the year in which intervention occurred generic prescribing rose by 50%; inappropriate prescribing and overall use of third generation cephalosporins fell; and compliance with the recommended list of drugs was good. Overall, drug costs remained static, compared with a projected increase of 0.25 m pounds; in a comparative control hospital drug costs rose by 18%. During the next year, when no form of intervention took place, previous gains were eroded and drug costs rose. Continuous intervention, review, and feedback are required if a formulary is to continue to achieve its objectives.     

Improving benzodiazepine prescribing in family practice through review and education.

Indications for and dosages of four commonly prescribed benzodiazepines were recorded at a family medicine centre with the aid of a computerized data collection system. Four guidelines were then developed for appropriate prescribing of these drugs: (a) benzodiazepines should be used less frequently with increasing age; (b) short-acting drugs are preferable to long-acting drugs; (c) patients 65 years of age and over should receive half the daily dose prescribed for younger patients; and (d) use of these drugs for more than 1 month should be discouraged. After a year''s observation it was evident that none of the guidelines were being followed. The 30 physicians in the practice were then informed of the findings by an educational program. Another 6 months of observation showed a reduction in the prescribing of benzodiazepines to patients 65 years of age and over, a significant shift to the use of short-acting benzodiazepines, and some reduction in the daily dose and duration of administration of diazepam. Thus, such a review of drug prescribing in family practice can be a practical and effective method of improving prescribing patterns.     

A study of general practitioners' reasons for changing their prescribing behaviour.

OBJECTIVES--To explore general practitioners'' reasons for recent changes in their prescribing behaviour. DESIGN--Qualitative analysis of semistructured interviews. SETTING--General practice in south east London. SUBJECTS--A heterogeneous sample of 18 general practitioners. RESULTS--Interviewees were able to identify between two and five specific changes that had occurred in their prescribing in the preceding six months. The most frequently mentioned changes related to fluoxetine, angiotensin converting enzyme inhibitors, and the antibiotic treatment of Helicobacter pylori. Three models of change were identified: an accumulation model, in which the volume and authority of evidence were important; a challenge model, in which behaviour change followed a dramatic or conflictual clinical event; and a continuity model, in which change took place against a background of willingness to change, modulated by other factors such as cost pressures and the comprehensible therapeutic action of a drug. Behaviour change was reinforced and sustained by experiences with individual patients. CONCLUSIONS--Multiple factors are involved in general practitioners'' decisions to change their prescribing habits. Three models of change can be identified which have important implications for the design and evaluation of interventions aimed at behaviour change.     

Defining inappropriate practices in prescribing for elderly people: a national consensus panel

OBJECTIVE: To develop a consensus-based list of inappropriate practices in prescribing for elderly people. DESIGN: Mail survey of a 32-member national panel. SETTING: Academic medical centres across Canada. PARTICIPANTS: Thirty-two specialists selected arbitrarily, including 7 clinical pharmacologists, 9 geriatricians, 8 family practitioners and 8 pharmacists. OUTCOME MEASURES: Consensus that the practice would introduce a substantial and significant increase in the risk of serious adverse effect and is common enough that its curtailment would decrease morbidity among elderly people, ranking of clinical importance of the risk, and availability of equally or more effective and less risky alternative therapy. RESULTS: The 32-member national panel developed a list of 71 practices in prescribing for elderly people and rated the clinical significance of each on a scale of 1 (not significant) to 4 (highly significant). The practices in prescribing identified fell into 3 categories: drugs generally contraindicated for elderly people, drug-disease interactions and drug-drug interactions. The mean significance rating was greater than 3 for 39 practices. For each practice, alternative therapies were recommended. There was surprising congruence among the specialists on the significance rating and the suggested alternative therapies. CONCLUSION: The authors have developed a valid, relevant list of inappropriate practices in prescribing for elderly people, to be used in a practice-based intervention study.     

Gastroscopic evaluation of anti-inflammatory agents

Gastroscopy was performed in 164 patients with rheumatoid arthritis (RA) and 85 with osteoarthritis (OA) to assess the effects of anti-inflammatory agents on the stomach. The main criterion for entry into the trial was the absence of active gastric lesions on pretreatment endoscopy. The patients were divided into groups to receive one of 12 anti-inflammatory drugs or combinations of these. Gastroscopy repeated at three to six and at 12 months disclosed gastric lesions in 78 cases (31%), patients in both disease categories being similarly affected. Lesions occurred in 41 of the 177 patients (23%) receiving a single drug and in 37 of the 72 (51%) receiving combined treatment. All the anti-inflammatory drugs caused gastric damage, the greatest offender being aspirin (13 out of 26 patients) and the least sulindac and diflunisal (two out of 19 (11%) and two out of 20 (10%) patients respectively). Corticosteroids caused gastric damage in only three out of 21 patients (14%), a lower incidence than expected.The indiscriminate prescribing of anti-inflammatory drugs to patients with OA is to be deplored. A lack of correlation between the patients'' subjective complaints of gastric discomfort and the gastroscopic findings emphasises the unreliability of patients'' complaints and the importance of gastroscopy in assessing gastric tolerance. It was not possible to assess minimal prescribing doses or minimum periods of treatment below which gastric damage may be guaranteed not to occur.     

Clinical and economic consequences of a reimbursement restriction of nebulised respiratory therapy in adults: direct comparison of randomised and observational evaluations

Objective To compare the results of a randomised and an observational evaluation of the same policy that restricted reimbursement for nebulised respiratory medications in adult patients in a community setting.Designs Cluster randomised controlled trial and observational time series with historical controls.Setting Pharmacare, the government funded drug benefits plan for elderly people and patients receiving social assistance in British Columbia, Canada.Participants In the randomised controlled trial 104 clusters of medical practices, pair matched by geography and approximately by practice size, were randomised to the intervention group (449 patients affected by the policy on 1 March 1999), and the control group (offered a six month exemption, affecting 386 patients). The observational analysis included all Pharmacare beneficiaries (excluding the 386 exempt patients) who had used any nebulised drugs six months before the policy (4624 patients).Intervention Pharmacare restricted reimbursement for nebulised bronchodilators, steroids, and cromoglycate to patients whose doctors applied for an individual patient''s exemption, giving an appropriate clinical reason.Main outcome measures Number of contacts with doctors and services, emergency admissions to hospital, and utilisation of and expenditure for respiratory drugs in databases of British Columbia''s Ministry of Health.Results Contacts with doctors or emergency admissions to hospital did not increase in association with the restriction, regardless of the analytical approach. In the observational analysis, we found a reduction of $C24 per patient month in all nebulised drug use (95% confidence interval 19 to 29) and an increase of $C3 per patient month in all expenditure for inhalers (1.4 to 4.5). The randomised evaluation found savings of $C8 per patient month for nebulisers (P = 0.24) and no increase in spending on inhalers (P = 0.79). Correcting for 60% non-compliance by exempt doctors in a sensitivity analysis yielded similar results as the observational evaluation.Conclusions Observational as well as randomised analyses found moderate net savings and no increase in unintended healthcare outcomes after restricting reimbursement for nebulised respiratory drugs. Randomised policy trials are feasible and, if carefully implemented, likely to be concordant with observational evaluations.     

Market penetration of new drugs in one United Kingdom region: implications for general practitioners and administrators.

OBJECTIVE--To determine the use of new drugs in one United Kingdom region. DESIGN--Examination of data on prescribing of angiotensin converting enzyme inhibitors, new broad spectrum antibiotics, and H2 receptor antagonists. Calculation of number of defined daily doses prescribed each month. SETTING--All general practices in Northern Ireland. MAIN OUTCOME MEASURES--Drug use index and market share of each drug. RESULTS--During 1988-91 prescribing of angiotensin converting enzyme inhibitors increased by 126%, of H2 receptor antagonists by 46%, and of new antibiotics by 207%. The first drug on the market usually retained the largest market share. Use of oral antibiotics increased threefold irrespective of the reporting policy of the general practitioners'' local laboratory. CONCLUSIONS--The increase in prescribing of these drugs seems to be greater than can be accounted for by an increase in patients with specific indications for these drugs. This suggests that the profession has not instituted effective checks to ensure that the legitimate promotion of new products does not lead to inappropriate and wasteful use.     

Development of long term use of psychotropic drugs by general practice patients

From 1984 to 1986 a prospective study was conducted of 104 general practice patients who started treatment with a benzodiazepine or an antidepressant drug. The duration of reported use of the drugs was two months for 45% of patients, four months for 17% of patients, and six months for 15%. Type of drug, age, and level of education were found to be predictive of continuing use.General practitioners have a significant effect on their patients'' use of drugs and, with careful selection and review when prescribing, may help to prevent dependence on psychotropic drugs.     

Thyroid Suppressibility: Follow-up for Two Years after Antithyroid Treatment

In hyperthyroidism suppression and non-suppression of early radioiodine neck uptake by exogenous thyroid hormone after a course of antithyroid drugs does not indicate clearly those patients who will eventually relapse or have a remission. Sixty-four hyperthyroid patients have been followed up for two years after an 18 to 24 months'' course of carbimazole. Twenty-eight patients had suppressed at the end of the carbimazole course and 20 of these remained in remission for two years, and 36 were non-suppressed and 21 of these relapsed.Patients with the highest neck uptakes relapsed soonest after stopping treatment. Pronounced rebound occurred in neck uptakes at one month after stopping treatment, both in patients who relapsed and in those who remained in remission. By one year after stopping treatment those who remained in remission had shown a further fall in early neck uptake. In two patients who relapsed after exposure to stressful events no change in 20-minute radioiodine neck uptakes was found in relation to the supposed stress.     

Results of Psychotherapy

A controlled double blind study was made of 299 non-psychotic female psychiatric clinic patients divided into six groups, with members of each group dealt with in a different manner from those in other groups. Those in one group had one or two hour-long psychotherapy sessions a week. Four groups were limited to brief visits but were given one of three kinds of drugs or a placebo. One group was merely put on a waiting list and received no therapy. As determined by a variety of independent measures, there was a fairly uniform average improvement of all groups except the one that received no treatment. Follow-up 10 to 18 months after termination of treatment revealed that the average patient had maintained her improvement and that those who had received no treatment showed considerable improvement after they were removed from the waiting list.The findings suggested that the widespread preference for the traditional outpatient psychotherapy is based as much on the physician''s bias as on proven greater effectiveness over briefer treatment methods. There was some confirmation that many things other than the development of understanding enter into much of the so-called psychoanalytically oriented psychotherapy and may have profound effect on the outcome.     

Antifungal drugs effect adherence of Candida albicans to acrylic surfaces by changing the zeta-potential of fungal cells

The effect of sub-inhibitory concentrations of antifungal drugs on the adherence of Candida albicans to acrylic surfaces was investigated. Among five antifungals tested, azalomycin F and aculeacin A significantly enhanced the adherence. The zeta-potential of fungal cells was affected by antifungal drugs, whereas no significant change in cell surface hydrophobicity was observed. The relationship obtained between the change in the adherence and that in zeta-potential suggests that the enhanced adherence was caused by decreased electric repulsive forces.     

Early antibiotic treatment of reactive arthritis associated with enteric infections: clinical and serological study.

OBJECTIVE--To find out whether a 10-14 days'' course of antibiotics early in the course of reactive arthritis associated with enteric infections could reduce the severity and duration of the disease and whether the antibody response in patients with reactive arthritis associated with yersinia infection differed between those treated and those not treated with the antibiotics. DESIGN--Prospective multicentre trial in which patients were randomised to treatment or no treatment with antibiotics. Patients were seen at three and six weeks and three, six, nine, 12, and 18 months after their first visit. SETTING--Departments of infectious diseases in three hospitals in Linköping, Malmö, and Stockholm, Sweden. PATIENTS--40 Consecutive patients who had had symptoms of reactive arthritis associated with enteric infection for less than four weeks. INTERVENTIONS--20 Patients were allocated to treatment with antibiotics and 20 patients did not receive antibiotics. All patients received non-steroidal anti-inflammatory drugs, and four also received intra-articular steroid injections after at least six weeks'' observation. MAIN OUTCOME MEASURES--Arthritic symptoms assessed clinically and by using Ritchies'' index; blood measurements reflecting inflammatory activity; serum IgG, IgM, and IgA antibody titres; HLA tissue type. RESULTS--No difference was observed concerning duration of arthritis, grade of inflammation, and number of joints affected between patients treated and those not treated with antibiotics. Furthermore, there was no significant difference between the two groups in erythrocyte sedimentation rate and haptoglobin, IgG, and IgA concentrations. All values had returned to normal within three months. No patient developed chronic arthritis, but sustained slight arthralgia occurred in three patients. The HLA-B27 antigen was found in 23 (58%) of the patients, and its presence did not affect clinical outcome. The IgG, IgM, and IgA antibody responses were similar in patients treated with antibiotics and those not treated. CONCLUSION--Short term antibiotic treatment has no beneficial effect on the clinical outcome of reactive arthritis associated with enteric infection.     

Diazepam and Tests of Thyroid Function

The effect of diazepam on thyroid function tests was examined in 12 euthyroid patients requiring the drug for psychiatric reasons and in six patients with thyrotoxicosis. Assessment was made before and after four weeks'' therapy.There was no significant difference in results from tests of thyroid iodide trapping and binding (thyroid radioiodine uptake, thyroid clearance, and absolute iodine uptake) except in the one-hour thyroid uptake in the euthyroid group, which was increased after diazepam. This increase occurred without alteration in serum thyroid stimulating hormone levels. No change occurred in either group in tests of thyroid hormone release (protein-bound iodine, T-3 resin uptake, or Thyopac-3 and free thyroxine index).Patients with suspected thyroid disease who are taking diazepam do not need to stop therapy while their thyroid status is being determined.