High-risk prescribing in an Irish primary care population: trends and variation

Br J Clin Pharmacol. 2017 Dec;83(12):2821-2830. doi: 10.1111/bcp.13373. Epub 2017 Aug 16.

Abstract

Aims: The aims of the present study were to examine the prevalence of high-risk prescribing (HRP) in community-dwelling adults in Ireland from 2011-2015 using consensus-validated indicators, factors associated with HRP, and the variation in HRP between general practitioners (GPs) and in the dispensing of high-risk prescriptions between pharmacies.

Methods: A repeated cross-sectional national pharmacy claims database study was conducted. Prescribing indicators were based on those developed in formal consensus studies and applicable to pharmacy claims data. Multilevel logistic regression was used to examine factors associated with HRP and dispensing.

Results: There were significant reductions in the rates of most indicators over time (P < 0.001). A total of 66 022 of 300 906 patients at risk in 2011 [21.9%, 95% confidence interval (CI) 21.8, 22.1%], and 42 109 of 278 469 in 2015 (15.1%, 95% CI 15.0, 15.3%), received ≥1 high-risk prescription (P < 0.001). In 2015, indicators with the highest rates of HRP were prescription of a nonsteroidal anti-inflammatory drug (NSAID) without gastroprotection in those ≥75 years (37.2% of those on NSAIDs), coprescription of warfarin and an antiplatelet agent or high-risk antibiotic (19.5% and 16.2% of those on warfarin, respectively) and prescription of digoxin ≥250 μg day-1 in those ≥65 years (14.0% of those on digoxin). Any HRP increased significantly with age and number of chronic medications (P < 0.001). a) After controlling for patient variables, the variation in the rate of HRP between GPs was significant (P < 0.05); and b) after controlling for patient variables and the prescribing GP, the variation in the rate of dispensing of high-risk prescriptions between pharmacies was significant (P < 0.05).

Conclusions: HRP in Ireland has declined over time, although some indicators persist. The variation between GPs and pharmacies suggests the potential for improvement in safe medicines use in community care, particularly in vulnerable older populations.

Keywords: general practice; high-risk prescribing; prescriber variation; prescribing safety; primary care.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Community Pharmacy Services / trends
  • Cross-Sectional Studies
  • Databases, Factual
  • Drug Interactions
  • Drug Prescriptions
  • Drug Utilization Review
  • Drug-Related Side Effects and Adverse Reactions / epidemiology
  • Drug-Related Side Effects and Adverse Reactions / prevention & control*
  • Female
  • General Practitioners / trends*
  • Humans
  • Ireland / epidemiology
  • Logistic Models
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Odds Ratio
  • Patient Safety
  • Physicians, Primary Care / trends*
  • Polypharmacy
  • Practice Patterns, Physicians' / trends*
  • Primary Health Care / trends*
  • Risk Assessment
  • Risk Factors
  • Time Factors