Do decision support systems influence variation in prescription?

BackgroundEvidence of effectiveness of mobile health (mHealth) apps as well as their usability as non-drug interventions in primary care are emerging around the globe.ObjectiveThis study aimed to explore the feasibility of mHealth app prescription by general practitioners (GPs) and to evaluate the effectiveness of an implementation intervention to increase app prescription.MethodsA single-group, before-and-after study was conducted in Australian general practice. GPs were given prescription pads for 6 mHealth apps and reported the number of prescriptions dispensed for 4 months. After the reporting of month 2, a 2-minute video of one of the apps was randomly selected and sent to each GP. Data were collected through a prestudy questionnaire, monthly electronic reporting, and end-of-study interviews. The primary outcome was the number of app prescriptions (total, monthly, per GP, and per GP per fortnight). Secondary outcomes included confidence in prescribing apps (0-5 scale), the impact of the intervention video on subsequent prescription numbers, and acceptability of the interventions.ResultsOf 40 GPs recruited, 39 commenced, and 36 completed the study. In total, 1324 app prescriptions were dispensed over 4 months. The median number of apps prescribed per GP was 30 (range 6-111 apps). The median number of apps prescribed per GP per fortnight increased from the pre-study level of 1.7 to 4.1. Confidence about prescribing apps doubled from a mean of 2 (not so confident) to 4 (very confident). App videos did not affect subsequent prescription rates substantially. Post-study interviews revealed that the intervention was highly acceptable.ConclusionsmHealth app prescription in general practice is feasible, and our implementation intervention was effective in increasing app prescription. GPs need more tailored education and training on the value of mHealth apps and knowledge of prescribable apps to be able to successfully change their prescribing habits to include apps. The future of sustainable and scalable app prescription requires a trustworthy electronic app repository of prescribable mHealth apps for GPs.

Objective The aim of this study was to investigate the use of streptococcal antigen tests and antibiotic prescription in general practice in Norway in relation to the national guidelines for sore throat. Design This study was based on a web-based survey. Setting Norwegian general practice. Subjects 4700 members of the Norwegian College of General Practice received the survey by E-mail. Main outcome measures General practitioner (GP) adherence to national guidelines. Results In total, 807 GPs responded and were included in the study. According to the guidelines, 20% and 30% of the GPs would perform unnecessary streptococcal antigen testing when presented with mild and severe infections respectively, while 52% would not perform the test at moderate infection. Phenoxymethylpenicillin was recommended by 95% of the GPs. Conclusion In this survey of self-selected GPs, we identified some non-adherence to National guidelines for streptococcal antigen testing and antibiotic prescribing. However, when antibiotic treatment was offered, the correct antibiotics were prescribed. Key points Norwegian guidelines for diagnosis and treatment of throat infections include the use of Centor criteria as a clinical tool to limit the unnecessary use of antibiotics. In this web-based survey, we investigated the use of streptococcal antigen tests and antibiotic prescription in general practice in relation to the national guidelines. •Streptococcal antigen tests were not always performed according to Norwegian guidelines, causing inappropriate antibiotic prescribing. •National guidelines were followed in the choice of antibiotics for sore throat.

Dental prescribing is a crucial component of general dental practices, enabling the management of pain, control of infection, and promotion of postoperative recovery. Analgesics, antibiotics, and antiseptic mouthwashes are frequently prescribed as short-term adjuncts to definitive dental treatments, such as extractions, endodontic, and periodontal therapies. These medications can significantly affect cardiovascular, renal, hepatic, metabolic, and the microbiome beyond the oral cavity. The aim of the present review was to summarize the systemic health effects of three medication classes frequently prescribed by general dental practitioners and discusses their mechanisms, clinical implications, and stewardship opportunities. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for dental pain, but even a brief course can affect renal function, blood pressure, and gastrointestinal integrity in susceptible patients. Acetaminophen is an important analgesic for mild to moderate dental pain though its cumulative dosing may increase the risk of hepatotoxicity. Opioids are historically prescribed after tooth extractions and endodontic and periodontal surgeries, but they offer no advantage over non-opioid analgesics and contribute to opioid misuse in the community. Gabapentinoids are emerging as lower-risk opioid alternatives in patients who cannot use NSAIDs or acetaminophen, but their use also requires caution. Antibiotics continue to be prescribed for conditions that are not clinically indicated but may increase the risks of antimicrobial resistance, gut microbiome dysbiosis, and Clostridioides difficile infection. Mislabeling of penicillin allergies is widespread and may promote the use of higher-risk alternatives such as clindamycin. Antiseptic mouth rinses, particularly chlorhexidine, can effectively reduce oral microbial load but may disrupt nitrate-reducing oral bacteria and alter nitric oxide-mediated vascular function. General dental practitioners should integrate systemic health awareness when prescribing these medications to ensure safety and advance antimicrobial and pharmacologic stewardship in daily practices.

Introduction Quality improvement (QI) clusters have been established in many countries to improve healthcare using the Breakthrough Series’ collaboration model. We investigated the effect of a novel QI approach based on this model of performed medication reviews and drug prescription in a Norwegian municipality. Methods All 27 General Practitioners (GPs) in a mid-size Norwegian municipality were invited to join the intervention, consisting of three peer group meetings during a period of 7–8 months. Participants learned practical QI skills by planning and following up QI projects within drug prescription practice. Evaluation forms were used to assess participants’ self-rated improvement, reported medication review reimbursement codes (MRRCs) were used as a process measure, and defined daily doses (DDDs) of potentially inappropriate drugs (PIDs) dispensed to patients aged 65 years or older were used as outcome measures. Results Of the invited GPs, 25 completed the intervention. Of these, 76% self-reported improved QI skills and 67% reported improved drug prescription practices. Statistical process control revealed a non-random increase in the number of MRRCs lasting at least 7 months after intervention end. Compared with national average data, we found a significant reduction in dispensed DDDs in the intervention municipality for benzodiazepine derivates, benzodiazepine-related drugs, drugs for urinary frequency and incontinence and non-steroid anti-inflammatory and antirheumatic medications. Conclusion Intervention increased the frequency of medication reviews, resulting in fewer potentially inappropriate prescriptions. Moreover, there was self-reported improvement in QI skills in general, which may affect other practice areas as well. Intervention required relatively little absence from clinical practice compared with more traditional QI interventions and could, therefore, be easier to implement. KEY POINT The current study investigated to what extent a novel model based on the Breakthrough Series’ collaborative model affects GP improvement skills in general practice and changes their drug prescription. KEY FINDINGS Most participants reported better improvement skills and improved prescription practice. The number of dispensed potentially inappropriate drugs decreased significantly in the intervention municipality compared with the national average. The model seemed to lead to sustained changes after the end of the intervention.

BackgroundSuicide is a global public health concern, but it is preventable. Increased contact with primary care before the suicide or attempted suicide raises opportunities for intervention and prevention. However, suicide assessment and management are areas that many general practitioners (GPs) find particularly challenging. Previous research has indicated significant variability in how GPs understand, operationalize, and assess suicide risk, which subsequently has an impact on clinical decision making. Clinical decision support systems (CDSS) have been widely implemented across different health care settings, including primary care to support practitioners in clinical decision making. A CDSS may reduce inconsistencies in the identification, assessment, and management of suicide risk by GPs by guiding them through the consultation and generating a risk assessment plan that can be shared with a service user or with specialized mental health services.ObjectiveOur aim is to co-develop and test with end users (eg, GPs, primary care attendees, mental health professionals) an electronic clinical decision support system (e-CDSS) to support GPs in the identification, assessment, and management of suicidality in primary care.MethodsOurs is an ongoing embedded mixed-methods study with four phases: (1) qualitative interviews with GPs to explore their views on the content, format, and use of the e-CDSS, as well as consultation with two service-user advisory groups (people aged ≤25 and people aged ≥25) to inform the content of the e-CDSS including phrasing of items and clarity; (2) participatory co-production workshops with GPs, service users, and clinical experts in suicidality to determine the content and format of the e-CDDS; gain consensus of the relevance of items; establish content validity and identify pathways to implementation, using the Consolidated Framework for Implementation Research; (3) building the e-CDSS so that it guides the GP through a consultation; and (4) usability testing of the e-CDSS with GPs and service users in one primary care practice involving a nonlive and a live stage.ResultsThe study was funded for four years, to take place between 2015 and 2019, and is currently completing phase 4 data collection. The first results are expected to be submitted for publication in June 2019. The findings will enable us to evaluate the feasibility, acceptability, and usability of a suicide-specific, electronic, guided decision support system in primary care.ConclusionsThis study will be the first to explore the feasibility, acceptability, and usability of an electronic, guided decision support system for use in primary care consultations for the improved assessment and management of suicidality.International Registered Report Identifier (IRRID)RR1-10.2196/11135

Consensus guidelines for the treatment of depression in general practice were published in 1992.1 We investigated whether the prescription of antidepressants in general practice had changed since these guidelines and related educational materials had become available through the Defeat Depression Campaign and the Royal College of General Practitioners' senior mental health education fellowship.2 Cross sectional data for two periods of 12 months ending June 1993 and June 1995 were obtained from the database of the doctors' independent network (DIN-LINK); this is maintained by the independent company Compufile (Woking, Surrey), which provides general practice data mainly to the pharmaceutical industry. It contains data from 100 general practices (377 general practitioners, 750 000 patient records) across the United Kingdom that use AAH Meditel practice computer systems. Prescriptions for antidepressants linked to a general practitioner's …

Objectives To investigate how a community pharmacist can affect the quality of repeat prescribing, and to develop a model for general practitioner (GP) and pharmacist co-operation. Methods Repeat prescriptions with three or more items were reviewed by a community pharmacist and randomly allocated to a trial or control group. Drug-related problems (DRPs) were discussed at joint meetings with the GP and the pharmacist. A modified Delphi technique was used to evaluate the clinical significance of the DRPs identified by the pharmacist. Setting The repeat prescription review and meetings took place in a GP surgery in an inner city location between November, 1995, and October, 1997. Key findings The pharmacist reviewed 511 repeat prescriptions, representing 3,018 prescribed items. Ninety repeat prescriptions (36.3 per cent) in the trial group and 86 repeat prescriptions (34.1 per cent) in the control group were identified as having DRPs. The GP agreed with 92.3 per cent of the interventions in the trial group, while only 12.8 per cent of the interventions in the control group were routinely resolved by the GP. The difference in interventions dealt with between the trial and the control group is statistically significant (X2=94.14, P<0.001). The absolute risk reduction (ARR) was 26 per cent, and the prescription number needed to treat (NNT) was 3.8. For every 19 prescriptions reviewed, an intervention that results, or potentially results, in clinical improvement in patient care was made by the pharmacist. Conclusion The pharmacist significantly reduced the number of DRPs associated with repeat prescriptions compared with routine surgery procedure. Pharmacist review of repeat prescriptions is an effective method of solving DRPs, reducing risk and making significant clinical improvements to patient care.

Background This study aimed to gain a comprehensive understanding of oral COVID-19 antiviral prescribing in Australian general practice. Methods The study was a retrospective observational cohort study. Routinely collected, de-identified, Australian general practice consultation and prescription data was used with permission from participating primary health networks, from 938 general practices between March 2022 and September 2023. Study cohorts were patients aged ≥15 encompassing (i) an 'antiviral cohort' comprising patient records with ≥1 oral COVID-19 antiviral prescription/s and (ii) a 'comparison cohort' of remaining records. Primary outcome measures were the frequency and type of oral COVID-19 antivirals prescribed, and sociodemographic and health characteristics of patients prescribed antivirals. Secondary measures were the frequency of antiviral repeat prescribing and consultation modality. Results Within the study population of 3,813,051 patients, oral COVID-19 antivirals were prescribed to 3.39% (129,267) of patients including 14.79% (82,215/555,757) of patients aged ≥70years. Molnupiravir prescribing exceeded nirmatrelvir-ritonavir across all study months. Proportionally, antiviral prescribing was higher in the female population (74,709/2,059,676: 3.63%), Victoria (81,184/2,222,837: 3.65%), residing in high socioeconomic advantage areas (87,530/2,224,501: 3.93%), and ages 80-84 years (16,419/100,911: 16.27%). Of patients prescribed COVID-19 antivirals, 7.27% (9402/129,267) had repeat prescribing. Cardiovascular and musculoskeletal conditions were the most prevalent chronic diagnoses, and telehealth (58,660/107,727: 54.45%) exceeded face-to-face consultations. Conclusions Oral COVID-19 antiviral prescribing volumes in general practice may serve as an indicator of periods of increased transmission of COVID-19, through increases in prescribing activity. Telehealth exceeding face-to-face for oral COVID-19 antiviral prescribing supports continued access to telehealth to reduce exposure to COVID-19 and provide time-critical access to treatment.

The use of multiple drugs by patients increases the risk of medical problems. Clinical decision support could assist general practitioners with prescribing but is underused. This article aims to investigate the attitudes of general practitioners towards using decision support systems. A survey was distributed among 500 Dutch general practitioners. Virtually all 184 respondents indicated having a clinical information system, while only 21 percent indicated having a decision support plug-in; this correlated with their use of medical formularies. Only use of one of the medical formularies correlated with the number of recognized underprescription problems. General practitioners' attitudes toward a newly proposed system aiding them with polypharmacy prescribing were mainly positive (57%); the perceived usefulness correlated with output quality (p = .000), time investment (p = .000), and financial stimuli (payability: p = .000 and reimbursement: p = .015) but not with job relevance. Dutch general practitioners are thus likely to adopt the proposed system under the conditions that it improves prescription quality and does not require extensive investments of time or money.

Objective: To investigate areas in need of quality improvement within the diagnostic process and antibiotic treatment of acute respiratory tract infections (RTIs) in Danish general practice by using quality indicators (QIs).Design and setting: During a 4-week period in winter 2017, a prospective registration of patients diagnosed with RTIs was conducted in general practice in two regions of Denmark.Subjects: Throughout the registration period each patient with symptoms of an RTI was registered. Information about age, symptoms and findings, duration of symptoms, the use and result of clinical tests, allergy towards penicillin, referral to secondary care and the antibiotic given were recorded.Main outcome measures: Values and acceptable ranges for QIs focusing on the diagnostic process, the decision to prescribe antibiotics and the choice of antibiotics for patients with RTIs.Results: Regarding the diagnostic process nearly all QIs for patients diagnosed with acute pharyngotonsillitis and pneumonia fell within the acceptable range. Contrarily, the diagnostic QIs for patients with acute otitis media and acute rhinosinusitis were outside the acceptable range. All indicators designed to measure overuse of antibiotics were outside the acceptable range and nearly all indicators assessing if patients were sufficiently treated fell within the acceptable range. QIs assessing use of the recommended type of antibiotic were only within the acceptable range for patients diagnosed with acute pharyngotonsillitis.Conclusion: The findings indicate an overuse of antibiotics for RTIs in Danish general practice. Especially management of acute rhinosinusitis and acute bronchitis should be targeted in future quality improvement projects.KEY POINTS:To improve antibiotic prescribing in general practice it is important to focus on both the diagnostic process and the prescribing patterns.The findings indicate an overuse of antibiotics for acute respiratory tract infections in Danish general practice.Especially the diagnostic process and antibiotic prescribing patterns for acute rhinosinusitis and acute bronchitis could benefit from future quality improvement interventions.

BackgroundAntipsychotic medications are the first-line pharmacological intervention for severe mental illnesses (SMI) such as schizophrenia and other psychoses, while also being used to relieve distress and treat neuropsychiatric symptoms in dementia.Our aim was to examine the factors relating to antipsychotic prescribing in general practices across England and how cost changes in recent years have impacted on antipsychotic prescribing.MethodsThe study examined over time the prescribing volume and prices paid for antipsychotic medication by agent in primary care.Monthly prescribing in primary care was consolidated over 5 years (2013–2018) and DDD amount from WHO/ATC for each agent was used to convert the amount to total DDD/practice.The defined Daily Dose (DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults.ResultsWe included 5750 general practices with practice population > 3000 and with > 30 people on their SMI register. In 2018/19 there were 10,360,865 prescriptions containing 136 million DDD with costs of £110 million at an average cost of £0.81/DDD issued in primary care.In 2017/18 there was a sharp increase in overall prices and they had not reduced to expected levels by the end of the 2018/19 evaluation year. There was a gradual increase in antipsychotic prescribing over 2013–2019 which was not perturbed by the increase in drug price in 2017/18.The strongest positive relation to increased prescribing of antipsychotics came from higher social disadvantage, higher population density (urban), and comorbidities e.g. chronic obstructive pulmonary disease (COPD). Higher % younger and % older populations, northerliness and non-white (Black and Minority Ethnic(BAME)) ethnicity were all independently associated with less antipsychotic prescribing.Higher DDD/general practice population was linked with higher proportion(%) injectable, higher %liquid, higher doses/prescription and higher %zuclopenthixol depot. Less DDD/population was linked with general practices using higher % risperidone and higher spending/dose of antipsychotic.ConclusionsThe levels of antipsychotic prescribing at general practice level are driven by social factors/comorbidities. We found a link between depot prescriptions with higher antipsychotic DDD and risperidone prescriptions with lower antipsychotic DDD. It is important that all prescribers are aware of these drivers / links.

BackgroundMore than half of all antibiotic prescriptions in general practice are issued for respiratory tract infections (RTIs), despite convincing evidence that many of these infections are caused by viruses. Frequent misuse of antimicrobial agents is of great global health concern, as we face an emerging worldwide threat of bacterial antibiotic resistance. There is an increasing need to identify determinants and patterns of antibiotic prescribing, in order to identify where clinical practice can be improved.Methods/DesignApproximately 80 peer continuing medical education (CME) groups in southern Norway will be recruited to a cluster randomized trial. Participating groups will be randomized either to an intervention- or a control group. A multifaceted intervention has been tailored, where key components are educational outreach visits to the CME-groups, work-shops, audit and feedback. Prescription Peer Academic Detailers (Rx-PADs), who are trained GPs, will conduct the educational outreach visits. During these visits, evidence-based recommendations of antibiotic prescriptions for RTIs will be presented and software will be handed out for installation in participants PCs, enabling collection of prescription data. These data will subsequently be linked to corresponding data from the Norwegian Prescription Database (NorPD). Individual feedback reports will be sent all participating GPs during and one year after the intervention. Main outcomes are baseline proportion of inappropriate antibiotic prescriptions for RTIs and change in prescription patterns compared to baseline one year after the initiation of the tailored pedagogic intervention.DiscussionImprovement of prescription patterns in medical practice is a challenging task. A thorough evaluation of guidelines for antibiotic treatment in RTIs may impose important benefits, whereas inappropriate prescribing entails substantial costs, as well as undesirable consequences like development of antibiotic resistance. Our hypothesis is that an educational intervention program will be effective in improving prescription patterns by reducing the total number of antibiotic prescriptions, as well as reducing the amount of broad-spectrum antibiotics, with special emphasis on macrolides.

(2001) BMJ 323, 1340; Zermansky AG, Petty DR, Raynor DK, et al. . Randomised controlled trial of clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in...

The quality and safety of prescribing in general practice is important, Clinical decision support (CDS) systems can be used which present alerts to health professionals when prescribing in order to identify patients at risk of potentially hazardous prescribing. It is known that such computerised alerts may improve the safety of prescribing in hospitals but their implementation and sustainable use in general practice is less well understood. We aimed to understand the factors that influenced the successful implementation and sustained use in primary care of a CDS system. Participants were purposively recruited from Clinical Commissioning Groups (CCGs) and general practices in the North West and East Midlands regions of England and from the CDS developers. We conducted face-to-face and telephone-based semi-structured qualitative interviews with staff stakeholders. A selection of participants was interviewed longitudinally to explore the further sustainability 1-2 years after implementation of the CDS system. The analysis, informed by Normalisation Process Theory (NPT), was thematic, iterative and conducted alongside data collection. Thirty-nine interviews were conducted either individually or in groups, with 33 stakeholders, including 11 follow-up interviews. Eight themes were interpreted in alignment with the four NPT constructs: Coherence (The purpose of the CDS: Enhancing medication safety and improving cost effectiveness; Relationship of users to the technology; Engagement and communication between different stakeholders); Cognitive Participation (Management of the profile of alerts); Collective Action (Prescribing in general practice, patient and population characteristics and engagement with patients; Knowledge);and Reflexive Monitoring (Sustaining the use of the CDS through maintenance and customisation; Learning and behaviour change. Participants saw that the CDS could have a role in enhancing medication safety and in the quality of care. Engagement through communication and support for local primary care providers and management leaders was considered important for successful implementation. Management of prescribing alert profiles for general practices was a dynamic process evolving over time. At regional management levels, work was required to adapt, and modify the system to optimise its use in practice and fulfil local priorities. Contextual factors, including patient and population characteristics, could impact upon the decision-making processes of prescribers influencing the response to alerts. The CDS could operate as a knowledge base allowing prescribers access to evidence-based information that they otherwise would not have. This qualitative evaluation utilised NPT to understand the implementation, use and sustainability of a widely deployed CDS system offering prescribing alerts in general practice. The system was understood as having a role in medication safety in providing relevant patient specific information to prescribers in a timely manner. Engagement between stakeholders was considered important for the intervention in ensuring prescribers continued to utilise its functionality. Sustained implementation might be enhanced by careful profile management of the suite of alerts in the system. Our findings suggest that the use and sustainability of the CDS was related to prescribers' perceptions of the relevance of alerts. Shared understanding of the purpose of the CDS between CCGS and general practices particularly in balancing cost saving and safety messages could be beneficial.

The health and economic burden of antimicrobial resistance (in Australia is significant. Interventions that help guide and improve appropriate prescribing for acute respiratory tract infections in the community represent an opportunity to slow the spread of resistant bacteria. Clinicians who work in primary care are potentially the most influential health care professionals to address the problem of antimicrobial resistance, because this is where most antibiotics are prescribed. A cluster randomised trial was conducted comparing two parallel groups of 27 urban general practices in Queensland, Australia: 13 intervention and 14 control practices, with 56 and 54 general practitioners (GPs), respectively. This study evaluated an integrated, multifaceted evidence-based package of interventions implemented over a 6-month period. The evaluation included quantitative and qualitative components, and an economic analysis. A multimodal package of interventions resulted in a reduction of 3.81 prescriptions per GP per month. This equates to 1280.16 prescriptions for the 56GPs in the intervention practices over the 6-month period. The cost per prescription avoided was A$148. The qualitative feedback showed that the interventions were well received by the GPs and did not impact on consultation time. Providing GPs with a choice of tools might enhance their uptake and support for antimicrobial stewardship in the community. A multimodal package of interventions to enhance rational prescribing of antibiotics is effective, feasible and acceptable in general practice. Investment in antimicrobial stewardship strategies in primary care may ultimately provide the important returns for public health into the future.