Understanding adherence to therapeutic guidelines: a multilevel analysis of statin prescription in the Skaraborg Primary Care Database

Hjerpe, Per; Ohlsson, Henrik; Lindblad, Ulf; Boström, Kristina Bengtsson; Merlo, Juan

doi:10.1007/s00228-010-0973-4

Cited by 17 publications

(23 citation statements)

References 21 publications

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“…Moreover, as we did not have access to information at the physician level, parts of the variation at the practice level could actually be attributed to variation among physicians. While some previous studies have shown that the variation at the physician level accounted for about 50% of variation at the practice level [ 21 ], others suggest that the variation at the physician level is more prominent. [ 25 ]…”

Section: Discussionmentioning

confidence: 88%

Practice variation in a longitudinal perspective: a multilevel analysis of the prescription of simvastatin in general practices between 2003 and 2009

Vervloet

Dijk

2011

Eur J Clin Pharmacol

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Our results indicate that a combination of several intervention measures seems to have been successful. While it seems like the implementation of the guidelines alone had some effect, there was an additional effect when reimbursement measures were implemented. Furthermore, the practice seemed to have affected the adoption of the national CVRM guideline as the variation initially increased after the guideline implementation. By including information on both the proportion of simvastatin prescribed and interpractice variation, we achieved a more complete evaluation of how simvastatin prescription developed over time and how it was related to the different measures taken.

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Section: Discussionmentioning

confidence: 88%

Practice variation in a longitudinal perspective: a multilevel analysis of the prescription of simvastatin in general practices between 2003 and 2009

Vervloet

Dijk

2011

Eur J Clin Pharmacol

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“…Clinical practice guidelines and prescribing indicators have become a common feature in many healthcare systems in an attempt to reduce unwarranted physician variation in medical care, improve quality and control drug costs [1]. In particular, improving the quality of drug prescribing in older populations is a priority due to the association between potentially inappropriate prescribing (PIP) and increases in patient morbidity, mortality, adverse drug events (ADEs), hospitalisation and healthcare costs [2,3].…”

Section: Introductionmentioning

confidence: 99%

“…The focus to date has mainly been on variation in prescribing volumes and costs which can have low validity with prescribers [8]. Quantifying and understanding the variation in PIP is important for planning interventions and the development of guidelines and incentives to improve prescribing quality in older populations [1]. It can also provide information for performance management purposes by identifying prescribers with particularly high rates of PIP for further investigation [9].…”

Section: Introductionmentioning

confidence: 99%

Prescriber variation in potentially inappropriate prescribing in older populations in Ireland

et al. 2014

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BackgroundHealth care policy-makers look for prescribing indicators at the population level to evaluate the performance of prescribers, improve quality and control drug costs. The aim of this research was to; (i) estimate the level of variation in potentially inappropriate prescribing (PIP) across prescribers in the national Irish older population using the STOPP criteria; (ii) estimate how reliably the criteria could distinguish between prescribers in terms of their proportion of PIP and; (iii) examine how PIP varies between prescribers and by patient and prescriber characteristics in a multilevel regression model.Methods1,938 general practitioners (GPs) with 338,375 registered patients’ ≥70 years were extracted from the Health Service Executive Primary Care Reimbursement Service (HSE-PCRS) pharmacy claims database. HSE-PCRS prescriptions are WHO ATC coded. Demographic data for claimants’ and prescribers’ are available. Thirty STOPP indicators were applied to prescription claims in 2007. Multilevel logistic regression examined how PIP varied between prescribers and by individual patient and prescriber level variables.ResultsThe unadjusted variation in PIP between prescribers was considerable (median 35%, IQR 30-40%). The STOPP criteria were reliable measures of PIP (average >0.8 reliability). The multilevel regression models found that only the patient level variable, number of different repeat drug classes was strongly associated with PIP (>2 drugs v none; adjusted OR, 4.0; 95% CI 3.7, 4.3). After adjustment for patient level variables the proportion of PIP varied fourfold (0.5 to 2 times the expected proportion) between prescribers but the majority of this variation was not significant.ConclusionPIP is of concern for all prescribers. Interventions aimed at enhancing appropriateness of prescribing should target patients taking multiple medications.

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“…54,95 Neither of the UK studies examined variation between GPs as well as between practices, but a Swedish study examining variation in use of guideline-recommended statins found that there was equal variation between physicians and between health-care centres (median odds ratios 1.89 and 1.88 respectively), which reduced over the 3 years studied as guideline compliance generally increased. 96 Four studies (two USA and two Sweden) examined the impact of geographical area on prescribing patterns. Zhang et al 97 showed that antibiotic use among older adults varies considerable between geographical regions in the USA (ratios of the 75th percentile to the 25th percentile of adjusted annual antibiotic spending were 1.31 across states and 1.32 across regions) after adjusting for population characteristics.…”

Section: Variation At Different Levelsmentioning

confidence: 99%

Measuring prevalence, reliability and variation in high-risk prescribing in general practice using multilevel modelling of observational data in a population database

Guthrie

Murphy

et al. 2015

Health Serv Deliv Res

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BackgroundHigh-risk primary care prescribing is common and is known to vary considerably between practices, but the extent to which high-risk prescribing varies among individual general practitioners (GPs) is not known.ObjectivesTo create prescribing safety indicators usable in existing electronic clinical data and to examine (1) variation in high-risk prescribing between patients, GPs and practices including reliability of measurement and (2) changes over time in high-risk prescribing prevalence and variation between practices.DesignDescriptive analysis and multilevel logistic regression modelling of routine data.SettingUK general practice using routine electronic medical record data.Participants(1) For analysis of variation and reliability, 398 GPs and 26,539 patients in 38 Scottish practices. (2) For analysis of change in high-risk prescribing, ≈ 300,000 patients particularly vulnerable to adverse drug effects registered with 190 Scottish practices.Main outcome measuresFor the analysis of variation between practices and between GPs, five indicators of high-risk non-steroidal anti-inflammatory drug (NSAID) prescribing. For the analysis of change in high-risk prescribing, 19 previously validated indicators.ResultsMeasurement of high-risk prescribing at GP level was feasible only for newly initiated drugs and for drugs similar to NSAIDs which are usually initiated by GPs. There was moderate variation between practices in total high-risk NSAID prescribing [intraclass correlation coefficient (ICC) 0.034], but this indicator was highly reliable (> 0.8 for all practices) at distinguishing between practices because of the large number of patients being measured. There was moderate variation in initiation of high-risk NSAID prescribing between practices (ICC 0.055) and larger variation between GPs (ICC 0.166), but measurement did not reliably distinguish between practices and had reliability > 0.7 for only half of the GPs in the study. Between quarter (Q)2 2004 and Q1 2009, the percentage of patients exposed to high-risk prescribing measured by 17 indicators that could be examined over the whole period fell from 8.5% to 5.2%, which was largely driven by reductions in high-risk NSAID and antiplatelet use. Variation between practices increased for five indicators and decreased for five, with no relationship between change in the rate of high-risk prescribing and change in variation between practices.ConclusionsHigh-risk prescribing is common and varies moderately between practices. High-risk prescribing at GP level cannot be easily measured routinely because of the difficulties in accurately identifying which GP actually prescribed the drug and because drug initiation is often a shared responsibility with specialists. For NSAID initiation, there was approximately three times greater variation between GPs than between practices. Most GPs with above average high-risk prescribing worked in practices which were not themselves above average. The observed reductions in high-risk prescribing between 2004 and 2009 were largely driven by falls in NSAID and antiplatelet prescribing, and there was no relationship between change in rate and change in variation between practices. These results are consistent with improvement interventions in all practices being more appropriate than interventions targeted on practices or GPs with higher than average high-risk prescribing. There is a need for research to understand why high-risk prescribing varies and to design and evaluate interventions to reduce it.FundingFunding for this study was provided by the Health Services and Delivery Research programme of the National Institute for Health Research.

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Understanding adherence to therapeutic guidelines: a multilevel analysis of statin prescription in the Skaraborg Primary Care Database

Abstract: Conclusion:The decentralized budget seemed to increase adherence to guidelines and reduce inefficient variation in prescribing.3

Cited by 17 publications

References 21 publications

Practice variation in a longitudinal perspective: a multilevel analysis of the prescription of simvastatin in general practices between 2003 and 2009

Practice variation in a longitudinal perspective: a multilevel analysis of the prescription of simvastatin in general practices between 2003 and 2009

Prescriber variation in potentially inappropriate prescribing in older populations in Ireland

Measuring prevalence, reliability and variation in high-risk prescribing in general practice using multilevel modelling of observational data in a population database

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