Background: Excess prescription and use of short-acting beta-agonist (SABA) inhalers is associated with poor asthma control and increased risk of hospital admission. Aim: To quantify the prevalence, and identify the predictors of SABA overprescribing. Design and Setting: Cross-sectional study using anonymised clinical and prescribing data from the primary care records in three contiguous east London boroughs. Methods: Primary care medical record data for patients aged 5 – 80 years, with ‘active’ asthma were extracted in February 2020. Explanatory variables included demography, asthma management, co-morbidities and prescriptions for asthma medications. Results: In the study population of 30,694 people with asthma, 26% were prescribed ≥6 SABA inhalers in the previous year. A ten-fold variation between practices (<6% to 60%) was observed in the proportion of patients on ≥6 SABA inhalers/year. By converting both SABA and ICS to standard units we improved the accuracy of comparisons across different preparations. 25% of those taking ≥6 SABA/year were underusing ICS, this rose to 80% for those prescribed <6 SABA/year. Prescription modality was a strong predictor of SABA overprescribing, with repeat dispensing strongly linked to SABA overprescribing (OR 6.52, (95% CI 4.64 to 9.41)). Increasing severity of asthma and multimorbidity were also independent predictors of SABA overprescribing. Conclusion: In this multi-ethnic population a fifth of practices demonstrate an overprescribing rate of <20% a year. Based on previous data, supporting practices to enable the SABA≥12 group to reduce to 4-12 /year could potentially save up to 70% of asthma admissions a year within that group.
Organisational alignment, standardised data entry, peer-performance dashboards, and financial incentives rapidly and generally increased opportunistic screening with pulse regularity checks. This was associated with a significant increase in detection and prevalence of AF and is of public health importance.
Inhaled corticosteroids (ICS) are often prescribed for worsening breathlessness, exacerbation frequency or lung function in chronic obstructive pulmonary disease (COPD). In mild-moderate disease and infrequent exacerbations, treatment risks may outweigh benefits and ICS may be withdrawn safely under supervision. A systematic ICS deprescribing programme for patients with mildmoderate COPD was introduced in an east London Clinical Commissioning Group (CCG) in April 2017. Primary care patient record analysis found that prescribing fell from 34.9% (n = 701) in the 18 months pre-intervention to 26.9% (n = 538) by the second year of implementation, decreasing 0.84% per quarter post intervention (p = 0.006, linear regression). The relative decrease was greater than the comparison CCG (23.0% vs. 9.9%). Only South Asian ethnicity was associated with increased cessation (odds ratio 1.48, confidence interval (CI) 1.09-2.01), p = 0.013, logistic regression). Patient outcome data were not collected. A primary care-led programme comprising local education, financial incentivisation and consultant support led to a significant decrease in ICS prescribing.
BackgroundValproate is a known teratogen. In April 2018, the Medicines and Healthcare products Regulatory Agency (MHRA) restricted use in women and banned use in pregnancy, except for epilepsy with no other effective treatment. To date, there is limited information on valproate prescribing within primary care.AimTo characterise valproate prescribing to women of childbearing age, recorded advice or general practitioner prescribed contraception and recorded pregnancies.Design & settingA cross-sectional study of patients from all 141 general practices across three Clinical Commissioning Groups in East London.MethodWomen aged 15-44 years prescribed valproate between 1/10/2017-1/1/2020 were included. Exclusion criteria were early menopause, sterilisation procedures or hysterectomy. Pseudonymised data on valproate indication, pregnancy, pre-conception and contraception advice were retrospectively extracted from general practice consultation data. Data were analysed by quarter using univariate statistics.ResultsOf the total 1,042,463 registered patients, 344 women aged 15–44 years were prescribed valproate during the study period; 14 were excluded. There were 10 pregnancies during possible valproate exposure; one was terminated. During the study period, the number of women prescribed valproate significantly decreased (P=0.003). The pregnancy rate decreased from 9.9/1000 on valproate before the MHRA April 2018 warning, to an average of 2.8/1000 afterwards. Recorded pre-conception/contraception advice increased by 79%, from 24% to 43%, of women prescribed valproate.ConclusionWith continued pregnancies in women aged 15-44 years prescribed valproate, patient education and foetal outcomes remain ongoing concerns. Further improvements are needed to ensure women make informed reproductive choices and safeguard future pregnancies from valproate exposure.
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