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Rapid Responses: Rapid Responses published:
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Over simplistic view
- David Gill (28 July 2000)
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A prescription for improvement?
- David F Bird (8 August 2000)
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David Gill, Practice Pharmacist Castlegait Surgery, Montrose, Scotland
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This study appears to suggest that practices who follow a recipe handed down from the Audit Commission will produce a lower increase in prescription costs than practices who do not. This is a very simplistic observation of a complex subject. PACT data and prescribing cost indicators are an evolving area and are still crude indicators of quality prescribing. With no linkage to indication and no supporting data on deprivation, disease prevalence etc the data presented cannot be meaningfully interperated. There is no indication of practice characteristics (other than fundholding) which have been shown to influence prescribing costs and volume such as number of partners, teaching/non teaching practice. It is possible that all the practices in the "lowest increase" group were semi- rural, multipartner teaching practices. Of concern is the observation that practices showing a low increase in costs did so partly by conservative prescribing in the face of an increasing weight of evidence for the use of statins in coronary heart disease. This shows not only the tension between evidence based medicine and budgetary constraints but also that the definition of being a "good" or "bad" prescriber cannot be equated solely with budgetary indicators. |
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David F Bird
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Dear Sir, Avery et al (BMJ 2000;321:276-81) after a great deal of labour,involving high powered researchers and,presumably,a fair amount of research funds,succeed in telling us that practices with lower prescribing costs prescibe less,use cheaper items and avoid new and expensive drugs. Surprise,surprise.I suggest that a 5yr old managing their pocket money could have told us the same basic economic statement. Prescribing is not done just for fun.Without some look at clinical outcomes such studies are of little value.If in 10yrs Avery et al could tell us that the low prescribers have just the same rate of coronaries,bypass grafts,suicides,osteoporotic hip fractures and so forth as the high prescribers then they might have made a useful point.As it is, with more and more pressure from our paymasters to raise standards and follow clinical guidelines,some expensive prescribing is inevitable, unless we opt for therapeutic nihilism.That may simply shift the cost of our prescribing budgets into secondary care management.Its cheaper for us to avoid inhaled steroid prescribing,for example,when the cost of hospital admissions for status asthmaticus is borne by someone else,but its hardly in our patient's best interests or ethical. I suspect that,like many GPs,I have over the years since PACT data came in,endeavoured to keep prescribing costs down by following good practice guidelines.Until the last 12mths my figures have always been below national and local averages while during the last 20 yrs the average age at death for my male patients has risen from 70y to 75y and for women from 77y to 83y.Perhaps an indication of having done something right!But now,after the generic fiasco and with the increased use of drugs recommended in current clinical guidelines our practice budget is well into negative balance,with a threat of reducing our services to balance the books.This ,as you may imagine,is a source of considerable irritation,not helped by articles such as Avery's which contribute little to the debate,presumably take a lot of time and money and are pretty pointless. David F.Bird. French Weir Health Centre, Taunton.Somerset.TAI INW |
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