22 June 2011
60,000 Scots prescribed 'high risk' drugs
Around 60,000 patients in Scotland are being prescribed drugs with a high risk of side effects, according to new research carried out at the University of Dundee.
Preventable adverse drug events caused by drugs prescribed in primary care are a frequent cause of hospital admission and death. Underlying health problems and other factors mean some patients are more likely to experience side effects which can be serious and even fatal.
Although General Practitioners often have good reasons to prescribe high risk drugs because there may not be any other option to treat debilitating medical conditions, it has been unclear how commonly this happens or how much it varies across general practices.
Professor Bruce Guthrie and colleagues in the Centre for Primary Care and Population Research at the University of Dundee’s School of Medicine, examined the frequency of high-risk prescribing in primary medical care, and the patient and practice characteristics associated with it.
They analysed prescribing records and other data from 315 Scottish General Practices with 1.76 million registered patients and examined the proportion of patients receiving a high-risk prescription using a composite of 15 individual indicators. These included the use of antipsychotic drugs in people with dementia, prescription of non-steroidal anti-inflammatory drugs like ibuprofen to people with previous stomach ulcers or kidney problems, and prescription of drugs recommended to be avoided in people with heart failure.
The team found that high-risk prescribing is common, with 139,404 out of 1,760,223 (7.9%) registered patients defined as being ‘at risk’ of receiving selected high-risk drug due to their age, pre-existing disease or co-prescription. 19,308 of these at-risk patients had been prescribed at least one high-risk drug in the previous year. Rates of high-risk prescribing varied approximately four fold between general practices even after taking into account differences in the patients registered with them.
This study shows that high-risk prescribing associated with harm can be reliably measured using routine clinical data, that it is relatively common, and that rates of such prescribing vary greatly in different general practices. The resulting paper is published today in the British Medical Journal.
Professor Guthrie says that it is important to recognise that many high-risk prescriptions are appropriate because clinicians and patients are often trying to balance benefit and risk in complex situations where there is no clearly ‘correct’ course of action. However, the big differences between practices indicates that prescribing could be made safer.
'The implications are that our study looked at a sample of about a third of Scottish patients. If you take this across the whole of Scotland, then approximately 60,000 people particularly vulnerable to side effects might be being prescribed high risk drugs. This may be the correct course of action and bring benefits to the patient but it has to be balanced against the dangers.
'We're not saying that all this type of prescribing should not be happening, but that we have to be satisfied that it’s appropriate and ensure that doing so doesn’t put the patient at more risk. All prescribing is risky to some extent, but the drugs we examined are particularly risky in some patients and we have to balance the benefits derived from these drugs and with the risks of taking them.
'We identified those people who, due to their age or medical history, are more likely to experience side effects which can be serious. What we found was that this type of high risk prescribing was fairly common but that it varies a lot between practices, and this variation is largely unexplained. The variation was considerable, with a fourfold difference in high risk prescribing between those practices at either end of the scale.
'We can’t make sweeping statements about people routinely being put at risk because of inappropriate prescribing. We would need to know more about the individual circumstances of the patient, but the fact high risk prescribing varies between practices suggests that there is scope to make prescribing safer.'
The number of chronic drugs is the patient characteristic most associated with high-risk prescribing. Since all the prescribing examined is stated in national guidance to be contra-indicated or to be avoided in routine practice, the report concludes that the high rates and large variation between practices is consistent with there being significant opportunities for improvement.
Although fifteen indicators were examined, feasibility constraints meant that other important indicators could not be examined. Professor Guthrie says the study is therefore likely to under-estimate true rates of high-risk prescribing. The prescribing being measured is high-risk but will sometimes be appropriate, since prescribers and patients often have to make decisions in situations where there is no clearly correct course of action.
'It’s all about improving the quality of prescribing. At the moment, GP practices do not get this kind of information. The feedback they receive about their prescribing is focused on costs, and there is less attention paid to prescribing quality and safety.
'Practices may therefore not be aware they are doing something different from others, and may be surprised to see that they prescribe more high risk drugs than others. We feel it would be helpful to let practices know how they compare to others and think the number of vulnerable patients being prescribed high risk drugs can be reduced.'
The study was funded by NHS Quality Improvement Scotland and Scottish Government Chief Scientist Office. Professor Guthrie says the next stage is to carry out further research into the effectiveness of uniform guidelines to reduce the number of deaths and ill-health caused by high-risk prescribing.
He added, 'We are now recruiting general practices in Tayside and Fife to the DQIP study which will test the effectiveness of providing GP practices with prescribing guidelines and information about their rates of high risk prescribing to try and enhance patient safety.
'In the rest of Scotland, we will be carrying out another study in collaboration with NHS Scotland Information Services Division and University of Strathclyde, which will use new NHS Scotland datasets to feedback prescribing safety data to practices. We believe that these new interventions hold much promise for making prescribing safer.'
For media enquiries contact:
Grant Hill
Press Officer
University of Dundee
Nethergate, Dundee, DD1 4HN
TEL: 01382 384768
E-MAIL: g.hill@dundee.ac.uk
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