No / The National Audit Office (NAO) has produced prescribing indicators that Primary Care Trusts (PCTs) can use to judge their performance. One of the indicators is for the antiplatelet clopidogrel, measured as defined daily dose (DDD) per cardiovascular Specific Therapeutic Age Related Prescribing Unit (STAR-PU). Clopidogrel is used as an indicator because it is a more expensive medicine than the alternative (aspirin) and there may be scope for cost reduction. We aimed to establish if the NAO indicator for clopidogrel prescribing is a valid measure of prescribing performance. Methods Prescribing data for 152 PCTs and a range of explanatory variables were obtained. Correlation between variables was determined. A regression analysis was conducted to compare the dependent variable (prescribing) with the explanatory variables identified. Results The percentage of patients on the coronary heart disease register and Index of Multiple Deprivation explained 30% of the variation in prescribing (DDD/STAR-PU) between PCTs. Even though DDD/STAR-PU is adjusted for age and sex other measures of need still have an impact on prescribing. Conclusions Using DDD/STAR-PU alone as a prescribing indicator might misidentify some PCTs, which are under- and over-using clopidogrel. Poor ranking against other PCTs using the NAO indicator should be fully explored taking into account other variables (cardiovascular morbidity and deprivation) before any corrective action is taken.

Prescribing of drugs is an integral component of health care. In ideal situations drug prescribing constitute safe, effective, and inexpensive treatment alternatives for many conditions. However, poor and inappropriate prescribing is associated with illness and increased costs that can have an important impact at population level. Therefore, evaluation of the quality of drug prescribing is an important part of the process to improve quality in health care delivery. "Drug Utilisation 90%" (DU90) is an innovative approach to assess drug prescribing. Using this approach the drugs that represent 90% of the drug prescription/sales volume are identified. The rationale behind the development of DU90 rests on an assumption that a low number of products prescribed is associated with more rational prescribing practices. Furthermore, the approach can be used to asses what proportion of the drugs that represent 90% of the volume is made up by drugs recommended by local drug committees. In this essay, a feasibility study of DU90 is presented. Furthermore, the usefulness of DU90 as an indicator for quality assessment is discussed. It is concluded that DU90 does not directly reflect the quality of prescribing but it seems to be an useful tool in the quality assessment process through indicating areas that need to be analysed in more depth. The approach can be used for exploring drug prescribing data in a rapid, effective and inexpensive way / Läkemedelsförskrivningen är en viktig komponent inom sjukvården. Använd på rätt sätt är den en relativt säker, effektiv och mindre kostsam form av behandling jämförd med andra terapeutiska åtgärder. Utvärderingen av kvaliteten på läkemedelsförskrivningen är en viktig insats eftersom dålig läkemedelsförskrivning kan leda till onödig sjuklighet för patienten och ökade kostnader för samhället. Drug Utilisation 90 % (DU90) är en ny metod för utvärderingen av läkemedelsförskrivningen. Med hjälp av denna metod identifieras de läkemedel som utgör 90 % av förskrivnings/försäljningsvolymen. Konceptet har utvecklats baserat på antagandet att användning av få produkter är associerat med en mer rationell läkemedelsförskrivning. Baserad på DU90 kan även följsamheten till listan på rekommenderade läkemedel som utfärdas periodvis av Läkemedelskommittéerna, utvärderas inom 90 % av förskrivnings-/försäljningsvolymen. I denna uppsats presenteras en pilotstudie av användbarheten av DU90. Vidare diskuteras DU90 som indikator för kvalitetsutvärdering. Sammanfattningsvis dras slutsatsen att DU90 inte direkt reflekterar kvaliteten på läkemedelsförskrivningen men verkar vara ett användbart verktyg eftersom det kan ge värdefull indikation på terapiområden som behöver vidare analys. DU90 förefaller vara ett snabbt, effektivt och billigt instrument för utvärdering av förskrivningsdata. / <p>ISBN 91-7997-105-9</p>

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Introduction: The volume of antipsychotic medications prescribed to children and adolescents has risen sharply since second generation antipsychotics, also referred to as atypical antipsychotics, were introduced in the 1990’s. The concern surrounding the expanded use of antipsychotics was that the medications have significant adverse metabolic side effects and they were often prescribed to treat conditions in young children for which they have not been proven to be safe and effective. While it is not unlawful for health care providers to prescribe medications for uses beyond which they have been approved by the United States Food and Drug Administration, the lack of empirical evidence guiding much of the antipsychotic use in children had professional pediatric medical groups and policy makers concerned for the well-being of children receiving the medications. Several states, including Pennsylvania, enacted prior authorization policies in an attempt to restrict prescribing to children where a medical need has been established. However, the impact of the policies is largely unknown since published data on the topic is sparse. Methods: This retrospective, medical claims-based cohort study, used de-identified administrative Medicaid data from January 2008 to December 2010 to investigate the impact of Pennsylvania’s September 2008 antipsychotic prior authorization policy on antipsychotic prescribing prevalence in children targeted by the policy. Descriptive methods and segmented regression of the interrupted time series were used to assess the effects of the policy on monthly antipsychotic prescribing prevalence. A difference-in-difference analysis compared Pennsylvania’s prescribing to Ohio, a geographically proximate and demographically similar state without a prior authorization policy; and Delaware, a state that enacted a policy 3 years prior to Pennsylvania. The potential for compensatory prescribing was assessed by reporting the prevalence of other psychotropic medications over the study period. Results: An average of 99,074 Pennsylvania Medicaid enrollees ages 0-6 were identified as meeting the study criteria annually from 2008-10. Immediately following the policy intervention, an abrupt, significant reduction in monthly prescriptions of antipsychotics was observed (-51 prescriptions per 100,000; p=0.0052) and sustained over the observation period. The proportion of children filling prescriptions for antipsychotics dropped approximately 46% and the average number of antipsychotic prescriptions filled per month was reduced by 53% in 2010 compared to 2008. In Ohio, a state without such a policy, the proportion of children receiving an antipsychotic increased nearly 10% in 2010 compared to 2008 and the average number of monthly prescriptions increased 30%. Reductions in antipsychotic prescribing in Delaware, a state that had its antipsychotic policy in place since 2005, were comparable to Pennsylvania. There was no evidence that non-antipsychotic psychotropic medications were prescribed in place of the medications restricted by the policy. Conclusions: Pennsylvania’s 2008 prior authorization policy was associated with a significant decrease in annual and monthly antipsychotic prescribing prevalence in Medicaid-insured children targeted by the policy, those ages 0-6 years of age. Reductions in most other psychotropics was also observed, indicating changes in prescribing behavior may have extended beyond antipsychotics. While this analysis suggests the policy may have achieved its primary aim of reducing antipsychotic prescribing, more research is needed to better understand the complex array of factors influencing provider behavior and to explore potential unintended consequences of the policy. / Public Health

In recent years, a significant change in the pharmacist’s scope of practice is the expansion of prescriptive authority (PA). In Saskatchewan, pharmacists adopted an interdependent prescribing model to support interprofessional collaboration, public safety though the optimal use of drug therapy, and the optimization of pharmacy competencies. In acquiring this new prescriptive authority, the community pharmacist also assumes new responsibilities and obligations, as well as transforming their relationships with patients and physicians. The purpose of this research is to assess rates of adoption by pharmacists of PA (Level 1 and Minor Ailments Prescribing) within community pharmacy practice in Saskatchewan. To gain a better understanding of how pharmacists are responding to new and evolving models of practice, this study proposes to measure their experiences with PA services and how it is affected by aspects of their professional practice. To investigate the study’s research questions, a cross-sectional study using a mail-in questionnaire with an online option was initiated. All registered community pharmacists in Saskatchewan (998) were asked to participate in the study. Of the 998 distributed questionnaires, 501 were returned back by the respondents yielding a response rate of 51.3 percent. The results disclose that a vast majority of respondents agreed or strongly agreed that they were confident in their ability to provide Level 1 (94%) and Minor Ailment (75%) prescribing. Respondents indicated that 74.2 percent of the time they actually provide Level 1 (L1) prescribing services to their patients and slightly more than half (52.5%) of the time provided Minor Ailment (MA) prescribing services. The majority of respondents (81.4 %) indicated that on average it took twenty minutes or less to provide MA prescribing service to their patients. Most pharmacist respondents strongly supported the statement that the pharmacies they worked at consistently provided Prescriptive Authority services (L1- 90% Strongly Agreed or Agreed, MA- 52.9% Strongly Agreed or Agreed) and that they get full support from managers (L1- 95.6% Strongly Agreed or Agreed, MA- 88% Strongly Agreed or Agreed) for their involvement in PA services. Respondents indicated some concern regarding the limited knowledge of patients on what pharmacists can do for them as a prescriber. In terms of overall relationships with patients, respondents indicated that patients were satisfied with the services pharmacists provide as a prescriber. Respondents reported that they had a good relationship with physicians. However, they did express concerns about their limited interactions with physicians as MA prescribers. Respondents generally reported supportive environments and positive interactions with patients and physicians. However, while expressing confidence in their ability to provide all prescriptive authority services, Level 1 services that supported traditional dispensing services were generally more consistently provided, supported, and perceived as being valued by patients and physicians compared to Minor Ailment Prescribing. The results also support the notion that pharmacists are highly confident to provide PA services to the patients and their relationships with the patients and physician improved day by day. Nevertheless, there is little evidence to suggest that patient’s level of knowledge about pharmacist’s new role; pharmacist’s interaction with physicians and physicians’ knowledge on PA have affected the provision of Prescriptive Authority services.

Purpose: Drug-drug interactions (DDIs) place a burden on our nation and cause potential harm to patients. Awareness of potential DDIs is essential for safe prescribing. Nurse practitioners (NP) have prescriptive authority throughout the nation, however, little is known about NP prescribing habits. The purpose of this study was to identify NPs' demographic and practice characteristics, DDI knowledge and factors that influence this knowledge.Data Sources: A survey was administered to NP prescribers recruited from a national conference. Data was collected on demographics, practice and technological characteristics, and perceptions and knowledge of DDIs.Conclusions: Data from 305 questionnaires were analyzed. NPs correctly classified 31% of drug pairs. Nitroglycerin and Sildenafil (drug combination to avoid) was classified correctly by the most respondents (90.8%, n = 305); Warfarin and Gemfibrozil (drug combination to usually avoid) the fewest 15.7% (n = 302). A positive correlation was found between NPs in acute care hospital settings and DDI knowledge, indicating higher knowledge scores. Neither hierarchical linear regression model was significant at predicting NPs' DDI knowledge.Implications for Practice: Continuing education needs to be targeted to enhance NPs knowledge of potential clinically significant DDIs. The increased recognition of potential DDIs among NPs will enhance patient safety.

This aim of the research was to explore pharmacist prescribing (PP) with a focus on antimicrobials, in hospitals in Scotland. A mixed-methods approach was used to collect, generate and synthesise data. A systematic review of peer-reviewed published literature on evidence-based roles for the pharmacist as part of an antimicrobial multidisciplinary team, identified roles for pharmacists within the teams but limited evidence relating to outcomes associated with these roles. Six qualitative focus groups, with 37 hospital pharmacists in 5 Scottish Health Boards, contextualised perceptions of barriers to, and facilitators of, implementation of PP in hospitals. Key themes were: perceived lack of pharmacy management support to take on a prescribing role and little strategic attention paid to PP implementation and sustainability. These issues were discussed in relation to PP in general and not only for antimicrobials. Participants perceived successful implementation of PP to be associated with factors including ward type and patient’s clinical condition. None of the pharmacists were prescribing antimicrobials and consequently further studies focused on PP in general. A scoping exercise, utilising various sources of information, reinforced findings from Phase 1; it highlighted the absence of any national or Health Board frameworks to support implementation of PP in secondary care in Scotland. Consensus-based research was undertaken, therefore, to provide guidance to facilitate service redesign involving PP in secondary care in Scotland. A Delphi approach undertaken with 40 experts, mainly in strategic posts, resulted in a high level of agreement in areas relating to succession planning, rather than role development; more variability was obtained in areas relating to future orientation of service, competencies required by prescribers and potential development of non-medical prescribing teams. The guidance was developed into a self-assessment toolkit providing an analytical strategy for implementation and role development of PP in secondary care. While the results and conclusions generated through this research need to be interpreted with caution, the data generated is an original contribution to the evidence base relating to PP.

Prescribing medicines is the primary intervention that most doctors offer to influence their patients’ health; however concerns have been expressed about the extent to which graduates are prepared by medical schools to assume prescribing responsibility. Both students and clinical teachers have identified a gap between workplace prescribing demands placed on newly qualified doctors and their preparation for this complex activity during undergraduate training. This study explored the exit-level prescribing performance of final-year students in the Graduate Entry Medical Programme at the University of the Witwatersrand compared with students’ perceptions of their prescribing competence. The results indicated a disparity between students’ competence and confidence. Examination marks showed that 83.6% of students were competent to prescribe according to the graduating standards of the University; however, questionnaire data revealed that 66% of students did not feel that their training had enabled them to prescribe rationally. This inconsistency was explored by analysis of the examination papers according to Bloom’s Revised and the SOLO Taxonomies. It was concluded that students score well on questions which test recall and application of knowledge, but some do not manage questions involving evaluation. Since prescribing is a complex skill that requires evaluative competence, this may explain why, despite high examination scores, students remain insecure. Exploration of the structure of knowledge through a Bernsteinian lens revealed that curricular components including problem-based learning and horizontal integration constrain epistemic access to the structure of rational prescribing knowledge for some students. It is recommended that rational prescribing skills should be taught as a synchronous strand within the curriculum, rather than in the current integrated mode. Learning could also be improved by innovative pedagogies associated with active learning and improved feedback.

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Medicine cures and kills people. In some advanced nations, prescription transparency is achieved through the separation of prescribing and dispensing, which further leads to public examination of prescriptions. Such an operation results in a restriction mechanism to prevent misuse and abuse of drugs and to guarantee the safety of consumers. Taiwan initiated the separation of prescribing and dispensing on March 1, 1997; however, most people do not recognize the significance of the system and conclude the issue to be an interest dispute between doctors and pharmacists. In the separation of prescribing and dispensing, disputes over the right of dispensation between doctors and pharmacists are commonly seen, but literatures are rarely found to review from consumers' position. This study plans to investigate consumers' viewpoints in respect of prescription transparency and understand its effect on satisfaction. Consequently, this study would be the benchmark for the government and health care sectors in promoting the separation of prescribing and dispensing. The study found the followings: 1. The discrepancy between satisfaction and attention to drug information is 0.88. Most people are used to nontransparent prescriptions, so such non-transparency does not cause significant dissatisfaction. 2. Among the people interviewed, the prescription transparency service they receive is 100% in academic medical centers, 66% in hospitals, and 23% in clinics. 3. 52.3% of the interviewees pays strong attention to drug information, 31.8% pays attention, 11.4% pays little attention, 2.8% pays very little attention and 1.7% do not pay attention at all. 4. The results show the diversity of demand to prescription transparency. Public displays different recognition to the importance of the list of medications: 82.5% thinks listing medication titles for easy reference. 81.9% considers the list represents a sense of responsibility from doctors and their prescriptions. 65.0% keeps the list for later use or for resolving medical disputes. 35.6% uses the list to enrich knowledge in medication. And 1.1% considers the list insignificant in all aspects. 5. Under the condition of non-transparent prescriptions, the educational level will influence the newly-developed factor in satisfaction. In other words, highly educated people tend to care more about prescription transparency