PCGs and Prescribing Audit Presentation at EMIS National User Group Conference Nottingham September 17th 1999

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PCGs and Prescribing AuditPresentation at EMIS
National User Group ConferenceNottingham
September 17th 1999

• DR Amrit Takhar
• GP, Wansford, Peterborough
• http//www.wansford.co.uk

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Presentation overview

• Context
• Audit
• Examples of prescribing indicators
• Tools for analysis

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Driving forces

• The New NHS
• Clinical governance
• Performance indicators
• Information for Health
• Strategic importance of data
• National Service Frameworks

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• identifies
• opportunities for improvement in patient care
• and the mechanisms for realising them

Clinical audit
Audit has developed in the UK as an educational
exercise designed for and by the user to
continually improve the standard of health care
and sense of professional self esteem
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Audit Cycle

• observing current practice
• setting standards of care
• comparing practice to standards and implementing
  change

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• Clinical indicators should be used to learn, not
  to judge
• We learn by making comparisons and trying to
  understand the sources of variation. 1 Yet too
  often variation is seen more as a challenge to
  authority and competence than as an opportunity
  to learn.
• Mulley, BMJ editorial 28 8 99

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Prescribing quality indicators

•  
•    

Quality knowledge Quality patient care Or
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Indicator types

• Þ      drug choice indicators
• Þ      cost indicators
• Þ      range limiting indicators
• Þ      Memphis indicators (or similar)
• Þ      other less specific indicators of quality

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Prescribing quality indicators - features

• Easily measurable and relevant
• Be reproducible and reliable
• Based on clinical evidence or established
  practice
• Be owned and understood by those being assessed

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Prescribing quality indicators - features

• Independent of demographics
• Should be able to set a standard against them and
  weight them for relative importance
• Data providing the indicator should be easy to
  obtain and manipulate
• Responsive and able to be used to monitor trends

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Popular indicators

•         Generic - overall rate (262)
•         Ratio of inhaled corticosteroids to
  inhaled bronchodilators (182)
•         Prescribing rate of statins for IHD
  (103)
•         Is there a repeat prescribing protocol
  and is it audited? (79)
•         Amitriptyline, dothiepin, imipramine and
  lofepramine as of BNF section 4.3 (70)

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Ratio of inhaled corticosteroids to inhaled
bronchodilators

• Easily measurable and relevant to general
  practice
• Be reproducible, relevant and reliable
• Based on clinical evidence or established
  practice
• Be owned and understood by those being assessed
• Independent of demographics
• Should be able to set a standard against them and
  weight them for relative importance
• Data providing the indicator should be easy to
  obtain and manipulate
• Responsive and able to be used to monitor trends

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Prescribing of statins in IHD

• Easily measurable and relevant to general
  practice
• Be reproducible, relevant and reliable
• Based on clinical evidence or established
  practice
• Be owned and understood by those being assessed
• Independent of demographics
• Should be able to set a standard against them and
  weight them for relative importance
• Data providing the indicator should be easy to
  obtain and manipulate
• Responsive and able to be used to monitor trends

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Generic prescribing as an indicator

• Easily measurable and relevant to general
  practice
• Be reproducible, relevant and reliable
• Based on clinical evidence or established
  practice
• Be owned and understood by those being assessed
• Independent of demographics
• Should be able to set a standard against them and
  weight them for relative importance
• Data providing the indicator should be easy to
  obtain and manipulate
• Responsive and able to be used to monitor trends

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Possible targets

• Overall generic rate gt70
• Ratio of inhaled corticosteroids to inhaled
  bronchodilators 12
• patients with a recorded diagnosis of IHD on
  statins 70

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Evidence based Medicine
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Evidence based indicators (McColl et al)
Use of aspirin for patients at high risk of coronary or ischaemic cerebrovascular events of patients with IHD taking aspirin
Flu vaccination in the over 65s of over 65s vaccinated
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Evidence based indicators

• Use of ACE inhibitors for patients with heart
  failure
• of population with diagnosis of heart failure
• of heart failure patients on ACE inhibitor
• Use of warfarin for stroke prevention in
  nonvalvular atrial fibrillation
• with NV AF on warfarin prophylaxis

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• Data collection Standards
• Agreed audit standards and interpretation

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Data collection to support the measurements of
indicators is obviously a big issue and this is
likely to be an area where a minimal agreed
standard needs to be agreed across a PCG and the
infrastructure to achieve this ( eg Appropriate
use of IT and training ) It is important to
recognise that indicators themselves do not
improve quality this will probably require
related activities such as educational
initiatives using adult learning principles,
spreading best practice and sometimes specific
financial support or incentives. Most of the
indictors discussed do not have specific agreed
standards but it is likely this may come from the
newly formed National Institute of Clinical
Excellence (NICE). Therefore the interpretation
of the indicators will be determined locally by
PCGs for the time being
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Inherent dangers
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Inherent dangers in the choices of performance
indicators as clinicians could respond to them in
unpredictable ways. The effects of introducing
these measures needs proper evaluation to ensure
that the changes that occur are positive. Items
being measured may be overemphasised at expense
of other aspects of care
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Tools for analysis

• PACT Pact mainly aimed at cost analysis
• ePACT
• EMIS Source of disease data
• Excel Can analyse data from EMIS
• Miquest Current best tool to compare
• CHDGP Project best method to improve
• Data standards in practices

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EMIS Search Statistics

• A Age/Sex Registers
• B Patient Searches
• C Practice Audit
• D Prescription Statistics

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Prescription statistics

• Collect prescription information
• Display prescription information
• List all items between specified dates
• List all issues of a specified an item between
  particular dates

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Drug costs

• This function displays individual drug costs
• ChooseHow many drugs do you wish displayed
• Display your most expensive drugs or patients
• Main advantage over Pact is that you can get data
  at least 2-3 months before Pact data
• Specify time period more flexibly
• Before/after intervention
• Can highlight most expensive patients review
  repeat items

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Age/sex distributions Prescribing

• Enter the BNF group to display (0 for all)
• For example. Section 2 - Cardiovascular System
  Drugs. Section 2.1 Cardiac
  Glycosides
• 
  
• 
  

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Lipid lowering agents
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• Clinical indicators should be used to learn, not
  to judge
• Audit keep ownership
• Use the appropriate tools
• DR Amrit Takhar amrit_at_btinternet.com
• GP, Wansford, Peterborough
• http//www.wansford.co.uk

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