PCGs and Prescribing AuditPresentation at

EMIS National User Group ConferenceNottingham September 17th 1999

DR Amrit Takhar

GP, Wansford, Peterboroughhttp://www.wansford.co.uk

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. “

Mulley, BMJ editorial 28 8 99

 

   

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 indicatorsUse 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 Excel Can analyse data from EMIS Miquest Current best tool to compare CHDGP Project – best method to improve

Data standards in practices

EMIS Search & StatisticsA Age/Sex Registers

B Patient Searches

C Practice Audit

D Prescription Statistics

Prescription statisticsCollect prescription information

Display prescription informationList all items between specified dates

List all issues of a specified an item between particular dates

Drug costsThis 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

:

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

35-44 45-54 55-64 65-74 75-84 85-89 90+

% of patients on lipid lowering rx

Series3

Series4

“Clinical indicators should be used to learn, not to judge “

Audit – keep ownership

Use the appropriate toolsDR Amrit Takhar amrit@btinternet.com

GP, Wansford, Peterborough• http://www.wansford.co.uk