PCGs and Prescribing Audit Presentation at EMIS National User Group Conference Nottingham September 17 th 1999 DR Amrit Takhar GP, Wansford, Peterborough

Presentation overview Context Audit Examples of prescribing indicators Tools for analysis

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

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

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

“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. “ 1 Mulley, BMJ editorial

Quality knowledge Quality patient care Or…

Indicator types  drug choice indicators  cost indicators  range limiting indicators  Memphis indicators (or similar)  other less specific indicators of quality

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

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

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)

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

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

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

Possible targets Overall generic rate >70% Ratio of inhaled corticosteroids to inhaled bronchodilators 1:2 % patients with a recorded diagnosis of IHD on statins 70%

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 65’s % of over 65s vaccinated

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

Data collection Standards Agreed audit standards and interpretation

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

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

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

EMIS Search & Statistics A Age/Sex Registers B Patient Searches C Practice Audit D Prescription Statistics

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

Drug costs This function displays individual drug costs Choose: How 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

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 :

“Clinical indicators should be used to learn, not to judge “ Audit – keep ownership Use the appropriate tools DR Amrit Takhar GP, Wansford, Peterborough