Showing papers by "Mark Ashworth published in 2002"

Satisfaction with respite care: a pilot study.

Abstract: Satisfaction with respite care may be bound up with a variety of factors. The interaction of social support with ratings of a carer's satisfaction with respite care has not been explored in published work. The present authors postulated that social support, both during caring and during periods of relief from caring whilst in receipt of respite care, would be associated with greater satisfaction with respite care. They embarked upon a pilot study of carers who were looking after dependants with dementia, a particularly demanding form of care. Previously validated scales were used for determining levels of social support, and for assessing possible confounding factors such as carer depression or strain. One hundred and forty carers were contacted, but only 26 completed the questionnaires. In terms of perceived benefit to the carer, satisfaction was high (rating scale = 1-7, mean = 5.8, mode = 7) and correlated significantly with the numbers of people in the social support network (r = 0.57, P = 0.002), albeit not with any of the four measured types of support which they may have provided. Carer satisfaction was not significantly correlated with carer strain nor depression scores. Regression analysis demonstrated that 17% of the variance in this satisfaction score was accounted for by the numbers in the social support network. Other factors did not significantly explain the observed variation.

Prescribing indicators and their use by primary care groups to influence prescribing

Abstract: Summary Objective: To examine the prescribing incentive schemes used by primary care groups (PCGs); to determine the prescribing indicators used under these schemes; and to assess whether the schemes were seeking to improve the quality of prescribing as well as controlling prescribing costs. Design: Cross-sectional survey. Setting: A total of 145 PCGs in the London and South-East NHS regions. Participants: Prescribing advisers in each PCG. Methods: Descriptions of the prescribing indicators monitored by each PCG were obtained from a questionnaire survey of PCGs at the end of the 1999–2000 financial year. Financial information on prescribing and details about the implementation of prescribing incentive schemes for this period became available 6 months later and were obtained by a further questionnaire, follow-up telephone and E-mail surveys. Outcome measures: Prescribing indicators, prescribing budgets and spend. Results: One hundred and twenty-one out of 145 (83%) PCGs replied to the questionnaires about prescribing indicators and 129 out of 145 (89%) replied with details about their prescribing costs. The most frequently monitored prescribing indicator was generic prescribing, used by 106 out of 121 (88%) PCGs. The most frequently used clinical areas for prescribing indicators were antibiotics (76% of PCGs), gastro-intestinal prescribing (68%), non-steroidal anti-inflammatories (37%) and cardiovascular prescribing (32%). Seventy-six (63%) schemes also used non-prescribing analysis & cost (PACT) based data for their incentive schemes such as information from prescribing audits and reviews of repeat prescribing protocols. Only 33 (23%) had reached agreement with their practices enabling all prescribing indicator information to be disseminated on a named basis to allow practices to examine each others' prescribing data. Conclusions: Prescribing incentive schemes usually include targets for improvements in prescribing quality as well as cost. PACT-based data were used for cost control and quality improvement but non-PACT data were almost entirely used to promote prescribing quality improvements. The validity of non-PACT data was questioned as was the choice of some indicators that appeared to have been selected without full consideration of current expert opinion. Further work is needed on which indicators are most likely to act as catalysts to prescribing change.

Psychiatric referral rates and the influence of on-site mental health workers in general practice.

Abstract: Psychiatric referral rates vary widely between different general practices. To increase our understanding of this variation, we conducted a one-year prospective observational study of outpatient psychiatric referrals made by all general practices (622 referrals from 29 practices) within the catchment area of one inner-city psychiatric service. Contrary to our hypothesis, practices with higher allocations of on-site mental health workers did not have lower psychiatric referral rates. On the other hand, the highest referring practices had lower mental health worker allocations suggesting a possible influence upon referrals in this subgroup. A wide range of quantitative variables explained very little of the referral rate variation, implying that more subjective factors, such as general practitioner attitudes, may be influential in the decision to refer a patient to the psychiatrist.

Demand, appropriateness and prescribing of 'lifestyle drugs': a consultation survey in general practice.

Abstract: Method. We carried out an observational study in primary care conducted over a 6-week period during 1999. Twenty-seven GPs were recruited, each from a different practice. All GP consultations were recorded for the study period and the GP completed a structured questionnaire each time sildenafil or orlistat were discussed in a consultation. Results. Sildenafil was discussed in 0.5% (68/13 394) of consultations and orlistat in 0.3% (42/13 394). GPs thought that a corresponding NHS prescription would be highly appropriate in 57 and 74% of cases, respectively, although for both lifestyle drugs, nearly 20% of GPs thought such prescriptions were inappropriate. An NHS prescription was issued in 43% of consultations in which sildenafil had been discussed and 33% in which orlistat had been discussed. Five out of 29 NHS sildenafil prescriptions were issued to patients failing to fulfil the requirements of prescribing guidelines; similarly, one out of 14 orlistat prescriptions fell outside licensed indications. There were four examples of NHS prescriptions for sildenafil which were given even when the GP thought the drug to be inappropriate, whereas orlistat was never given when the GP thought it inappropriate. Conclusions. Levels of demand for the two lifestyle drugs, sildenafil and orlistat, were modest when compared with earlier media predictions. Neither was there evidence that GP was pitted against patient in their negotiation concerning a lifestyle drug NHS prescription since most GPs agreed with their patients that such a prescription was appropriate. Prescribing guidelines and licensed indications were generally adhered to, but the modest level of demand raises questions about expanding the guidelines for sildenafil.

Prescribing incentive schemes in two NHS regions: cross sectional survey.

Abstract: # Prescribing incentive schemes in two NHS regions: cross sectional survey {#article-title-2} The introduction of fundholding in primary care in the United Kingdom contained prescribing costs, although the effect was modest and seemingly not accompanied by parallel improvements in the quality of prescribing.1 With the advent of primary care groups in 1999 a new incentive scheme was devised to influence prescribing. Financial rewards to general practices could be linked more explicitly to improvements in the quality and appropriateness of prescribing than under fundholding schemes. The money had to be invested in improvements to services available to patients.2 We surveyed prescribing indicators and financial rewards associated with such schemes in two NHS regions in England. In 2000 we sent two questionnaires to the prescribing adviser of each primary care group in the 66 London and 79 South East regional offices of the NHS Executive. One hundred and twenty one (83%) responded with details about their incentive scheme, and 129 (89%) provided financial information on prescribing. The table shows the categories of indicator most often included in the schemes. Quality based indicators were reported by 83% (100) and cost based indicators by 78% (94) of primary care groups. Some categories were used to indicate both quality and cost. Sixty three per cent of schemes (76) required the collection of data not based on prescribing analysis and cost (PACT), such as data from prescribing audits or reviews of repeat prescribing. View this table: Categories of prescribing indicators used by primary care groups in two NHS regions in their prescribing incentive schemes Prescribing costs ranged from an underspend of 7% to an overspend of …

Re: GPs' views on computerized drug interaction alerts

Abstract: In this issue of the Journal, Magnus et al. report onthe frequent overriding of computer-generateddrug-interaction alerts by general practitioners(GPs) (1). The results have important implicationsfor all those who either work in primary care or areresponsible for the strategy of Primary Care Trusts.The danger of overriding drug-interaction alertsmight well strike a painful chord with some pri-mary care readers. Our own practice has the EMIS(Egton Medical Information System) computersystem described in the paper and as a result ofautomatically pressing the override button, weissued a prescription for a b-blocker to an asthmaticpatient. This event shook us badly although, for-tunately, the prescribing error was rapidly correc-ted and no harm befell the patient.The study is timely and in tune with increasedinterest in risk management and system failures(2). Although increasingly part of the managementagenda, risk barely surfaces in the general practiceresearch agenda and still rarely features in under-graduate medical training. The Department ofHealth report concerning risk management (3),devoted the whole of a chapter (chapter 5) toresearch needs about risk (4). Indeed, one of thespecific research questions identified in this reportwas the need to produce an evidence-base on themethods that can be used to reduce drug error.There is very little systematic research in this areaof prescribing and this paper highlights that moreis necessary.Comprehensive reporting of results is essential inan area as sensitive as error-reporting. Lowresponse rates would be likely to lead to selectionbias: those having the most favourable risk profileswould almost certainly be the initial responders.Increasingly, a literature is emerging that empha-sizes the importance of high response rates wherelower response rates might act to mask sociallyunacceptable responses (5, 6). It was gratifying thento see that Magnus et al. had achieved such a com-mendably large study with an excellent responserate (236 of 336 GPs surveyed gave a response) (1).Any survey into risk should not stop at uncov-ering potentially risky behaviour with the possi-bility of clinical error. It is a moot point, butresearchers have an ethical duty to consider thewider issue of protecting patients. There is a rela-tionship between research findings and resultantpolicy implications and Magnus et al. deal with thisaspect well in their discussion (1). In particular,they consider the issue of accreditation. At present,only accredited computer systems are eligible forsubsidies offered by Primary Care Organizations(PCOs). The size of such subsidies (currentlyaround 50% and expected to be 100% after April2003) means that considerable central control canbe brought to bear on the system requirements. Ifan error reporting system with appropriate safe-guards were part of accreditation, it would ensurethat drug interaction alerts were ignored less often.The authors suggest that ‘consultation workload’could be looked at ‘to see whether time could bemade for properly checking prescribing hazardalerts’. Many of us in primary care would see thisas somewhat unrealistic. There are too manycompeting factors (such as the centrally imposedagenda of National Service Frameworks, accesstargets, etc.). More realistic is to introduce mech-anisms for preventing computers from issuingpotentially dangerous drug combinations. Oneidea not mentioned in the paper would be forprescribers to take ‘named doctor’ responsibilityfor overriding an alert, such that their name wouldappear in the case notes.Some of the results displayed in the tables, butnot discussed by Magnus et al. are worthy of

The effects on GP prescribing of joining a commissioning group

Abstract: Summary Background: It is not known to what extent general practitioners (GP) can change their prescribing upon joining a commissioning group and what features of a commissioning group may promote prescribing change. The opportunity to study potential prescribing change arose with the formation of a limited number of Primary Care Commissioning Groups (PCCGs), a precursor of Primary Care Groups (PCGs) and Primary Care Trusts (PCTs). Methods: This was a controlled study of general practice prescribing costs. All practices (n=24) within one inner city PCCG were compared with matched controls that were not part of a PCCG. Cross sectional survey data was collected from the PCCG practices to determine possible reasons for prescribing change. Results: The total annual prescribing cost rose by 4ḃ0% in the PCCG practices and by 6˙9% in controls (P=0ḃ01). Significant cost containment was found for gastrointestinal prescribing (P=0ḃ03), attributable to differences in the cost of proton pump inhibitors (PPIs) which fell by 0ḃ7% in the PCCG but rose by 7ḃ3% in controls (P=0ḃ03). Total relative savings in the PCCG practices amounted to around £220 000. General practitioners making the greater savings in PPI costs within the PCCG, were more likely to report being influenced by information from the prescribing adviser. Conclusion: General practice prescribing costs were contained to a greater degree in practices participating in the PCCG. The differences in gastrointestinal prescribing were most marked for PPIs which were specifically targeted by the prescribing adviser. The GPs themselves attributed their own prescribing change to information provided by the prescribing adviser. Other factors operating within the PCCG may also have influenced prescribing such as a more locally based management system, different financial incentives and a greater degree of co-operative working amongst GPs.

Benzodiazepines: addiction and abuse

Abstract: Benzodiazepine prescribing continues to be of importance both in the context of substance abuse and as part of the management of primary care mental health problems. Since the publication in Britain of both the 'Orange Book' and the National Service Framework for Mental Health, there has been a shift toward boosting the role of primary care in the management of substance abuse and, more generally, in mental health. Both publications have sections devoted to benzodiazepine prescribing. Yet before primary care can effectively extend its activity, the full primary care team needs to be well grounded in the broader educational aspects raised by benzodiazepine prescribing. We have therefore summarized the current understanding about benzodiazepines with the intention of supporting primary care in its changing role.