Prescribing In The Community

25.9.06

Thanks to Marion for these.

Elderly are biggest consumer of drugs on prescription
• Less therapeutic variation (dose standard).
• Better evidence of effect - more obvious.
• Increasing elderly population.
• Defensive behaviour by doctor - in case they miss something.

Don't pay for prescriptions over 60/65?

40% take inappropriate drugs.
50% of hospital admissions due to adverse drug events are due to inappropriate prescribing.
Huge increase in prescribed drugs in over-65s since 1977.

Who prescribes?
• Doctors, mostly.
• Dentists - mostly antibiotics.
• Nurses - new act - antibiotics and fluids.
• Pharmacist.
• Patients/carers eg. paracetemol etc. - self-medication.

Process is flawed
• Prescriptions often written based purely on clinical acumen - presumptive diagnosis.
• Patient/carer often takes it to chemist - can be lost.
• Processed by hand - writing often hard to read.
• Renewal of prescription often without adequate counselling.
• Generation:
-not much else to think about;
-health is most crucial thing to them - drugs are exciting point of day.

Prescribing
• How to chose? Cost/industry reps/scientific evidence/efficacy/SE.
• Increasing availability of drugs - increasing complexity.
• Demand from patients - now well-informed.
• Increased volume of prescriptions - increasing risk of errors, less time for patient counselling.

Challenges
• Increased prescriptions and OTC meds - more mortality and morbidity associated.
• High financial costs due to morbidity (drug-related).
• Poorly-written prescription - pharmacists have to call prescriber, leading to another cost.

Patient safety
• Medication errors and adverse drug effects - result of interactions between prescribers, patients and medications.
• Need full picture of what's going on.
• High costs - financial and human - due to ADEs.
• Lack of access to patient information contributes to ADEs eg. in hospital and on discharge.
• Move to standardise NHS practices so information can be shared.

Barriers
• Lack of integration - this is changing slowly.
• Politics based on industry competition.
• Dave likes boys.
• Can the prescriber afford it? Economics - cost-effectiveness.
• There are fundamental changes to way prescribers operate - have to protect business interests.

Forward
• Promote access to accurate and complete patient information.
• Apply knowledge regarding drug therapy.
• Monitor drug therapy:
-effective?
-continuing indication? Has complaint been dealt with already?
-ADEs/SE (side-effects).
• Confirming tests before prescribing when possible.
• Standardise products for treating conditions - national guidelines from NICE, but remember: individual variation.
• Prescription not based on industry incentives.
• Improving patient education - explain medication changes - what to expect, written information.

Community pharmacists
• Review inappropriate drugs - check with prescriber.
• Check duplicate prescription eg. if they've been in hospital.
• Check drug/drug and drug/disease interactions.
• Advice on SEs/adverse effects.