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- Box 1. Thirteen explicit criteria for PIPs used for assessing the appropriateness of GPs’ prescriptions to older patients (≥70 years).
Single drugs Combination of drugs 1. Tricyclic antidepressants
Amitriptyline
Doxepine
Trimipramine
8. Combination of a beta-blocker with either
Verapamil or
Diltiazem
2. First generation antihistamines
Dexchlorpheniramine
Promethazine
Alimemazine
Hydroxycine
9. Combination of an NSAID and warfarin 3. First generation (low potency)
Chlorpromazine
Chlorprotixene
Levoprometazine
Prochlorperazine
10. Combination of an NSAID (or a Cox-2 inhibitor)
with an ACE-inhibitor (or an ARB)4. Long-acting benzodiazepines
Carisoprodol
11. Combination of an NSAID and a SSRI 5. Muscle relaxant
Carisoprodol
12. Combination of an NSAID and a diuretic 6. Strong analgesics
Propoxyphene
Pethidine
Opioids with spasmolytics
13. Concurrent use of ≥3 psychotropic drugs within classes:
Opioid analgesics
Hypnotics
Tranquillisers
Antipsychotics
Antidepressants
7. Theophylline tablets ACE = angiotensin converting enzyme. ARB = Angiotensin receptor blocker. COX = cyclooxygenase. NSAID = non-steroidal anti-inflammatory drug. PIP = potentially inappropriate prescription. SSRI = selective serotonin reuptake inhibitor.
- Table 1. Unadjusted summary data showing the prevalence of PIPs and estimates of RR with 95% CIs in different subgroups of GP and drug-related characteristics at pre- and post-intervention. The total number of prescriptions pre-intervention was 1 034 033 and in the post-intervention period there were 1 104 391 prescriptions.
GPs, n PIPs prevalence, % Relative riska (95% CI) Pre-intervention (n = 23 184) Post-intervention (n = 19 754) Overall group 449 2.24 1.79 0.80 (0.78 to 0.81) Intervention 250 1.32 0.99 0.75 (0.73 to 0.77) Control 199 0.92 0.80 0.87 (0.84 to 0.89) Sex Female 139 0.44 0.37 0.83 (0.80 to 0.87) Male 310 1.80 1.42 0.79 (0.77 to 0.81) Practice setting Rural 208 1.01 0.80 0.79 (0.77 to 0.81) Urban 241 1.23 0.99 0.80 (0.78 to 0.82) Type of practice Single-handed 38 0.25 0.20 0.80 (0.75 to 0.84) Group practice 411 1.99 1.59 0.80 (0.78 to 0.81) GP specialist No 63 0.20 0.18 0.89 (0.84 to 0.95) Yes 386 2.04 1.61 0.79 (0.77 to 0.80) Age group, yearsb 27–42 84 0.23 0.22 0.95 (0.90 to 1.01) 43–48 102 0.42 0.32 0.77 (0.74 to 0.81) 49–52 75 0.38 0.29 0.77 (0.73 to 0.80) 53–56 98 0.55 0.44 0.79 (0.77 to 0.83) 57–68 90 0.66 0.51 0.78 (0.75 to 0.80) Mean PIPs per 100 prescriptions
1-year pre-interventionb0.5–1.6 89 0.24 0.22 0.91 (0.86 to 0.96) 1.7–2.0 90 0.39 0.33 0.85 (0.81 to 0.89) 2.1 –2.3 90 0.49 0.38 0.77 (0.74 to 0.80) 2.4–2.9 90 0.57 0.44 0.77 (0.74 to 0.80) 3.0–6.3 90 0.55 0.43 0.77 (0.74 to 0.80) Prescriptions per patient in
the 1 year pre-intervention
periodb1.9–8.6 89 0.21 0.20 0.95 (0.90 to 1.01) 8.7–10.7 90 0.35 0.28 0.79 (0.76 to 0.83) 10.8–12.8 90 0.44 0.35 0.79 (0.76 to 0.83) 12.9–14.9 90 0.56 0.44 0.80 (0.77 to 0.83) 15.0–32.6 90 0.68 0.51 0.76 (0.73 to 0.79) aRelative risk indicates how large the prevalence of PIPs at post-intervention was relative to the prevalence at pre-intervention. Relative risk estimates <1 indicate a reduction of PIPs. bDivided into quintiles by number of GPs. PIP = potentially inappropriate prescription. RR = relative risk.
- Table 2. The rate of change in PIPs in the intervention group versus the control group after adjusting for the GP subgroup characteristics. Estimates of IRRs showing the changes in PIPs per 100 prescriptions at post-intervention relative to 1 year pre-intervention obtained from the Poisson cluster effects regression model.
IRR (95% CI) P-value PIPs at baseline (ref: control group) Intervention 1.10 (0.97 to 1.25) 0.15 Within-group reduction of PIPs relative to baseline Control 0.93 (0.90 to 0.96) <0.01 Intervention 0.80 (0.78 to 0.82) <0.01 aReduction of PIPs after intervention (ref: control group) Intervention 0.86 (0.83 to 0.90) <0.01 Subgroups: Age group, years (ref: 27–42 years) 43–48 0.85 (0.81 to 0.89) <0.01 49–52 0.92 (0.87 to 0.97) <0.01 53–56 1.00 (0.95 to 1.05) 0.94 57–68 1.21 (1.16 to 1.27) <0.01 Specialist (ref: non-specialist) Specialist 1.04 (0.99 to 1.08) 0.13 Type of practice (ref: single-handed) Group practice 1.04 (0.99 to 1.08) 0.07 Sex (ref: female) Male 1.40 (1.35 to 1.44) <0.01 Practice setting (ref: rural) Urban 1.15 (1.11 to 1.19) <0.01 Mean PIPs p 100 prescriptions at baseline (ref: ≤1.6) 1.7–2.0 1.40 (1.34 to 1.45) <0.01 2.1–2.3 1.77 (1.71 to 1.84) <0.01 2.4–2.9 2.10 (2.02 to 2.18) <0.01 >2.9 2.40 (2.30 to 2.50) <0.01 Prescriptions per patient at baseline (ref: <8.7) 8.7–10.7 1.44 (1.38 to 1.51) <0.01 10.8–12.8 1.96 (1.88 to 2.05) <0.01 12.9–14.9 2.31 (2.20 to 2.42) <0.01 ≥15 2.97 (2.83 to 3.12) <0.01 IRR = incidence rate ratio. PIP = potentially inappropriate prescription. Ref = reference. aPIPs were 14% (1.0 to 0.86) lower in the intervention arm compared to the control at after intervention.
- Table 3. Subgroup analyses comparing changes in prescription rates of PIPs by the seven GP-related characteristics. Unadjusted IRRs and their 95% CIs obtained from the Poisson regression model with cluster effects at CME group level showing the changes in PIPs within the subgroups, α = 0.007.
Subgroups Intervention group Control group IRR (95% CI) P-value IRR (95% CI) P-value Age group, years 27–42 0.92 (0.85 to 0.99) 0.043 1.12 (1.04 to 1.21) 0.004 43–48 0.78 (0.72 to 0.82) <0.007 0.89 (0.84 to 0.95) 0.001 49–52 0.81 (0.77 to 0.86) <0.007 0.83 (0.77 to 0.90) <0.007 53–56 0.81 (0.83 to 0.85) <0.007 0.92 (0.86 to 0.98) 0.006 57–68 0.77 (0.73 to 0.81) <0.007 0.92 (0.87 to 0.97) 0.003 Specialist Non-specialist 0.84 (0.77 to 0.93) <0.007 1.04 (0.96 to 1.13) 0.329 Specialist 0.80 (0.78 to 0.82) <0.007 0.91 (0.88 to 0.94) <0.007 Type of practice Single-handed 0.75 (0.68 to 0.83) <0.007 0.91 (0.83 to 0.99) 0.034 Group 0.80 (0.78 to 0.83) <0.007 0.93 (0.90 to 0.96) <0.007 Sex Female 0.85 (0.80 to 0.90) <0.007 0.93 (0.88 to 0.99) 0.027 Male 0.79 (0.77 to 0.81) <0.007 0.92 (0.89 to 0.95) <0.007 Practice setting Rural 0.80 (0.77 to 0.83) <0.007 0.92 (0.88 to 0.96) <0.007 Urban 0.80 (0.78 to 0.83) <0.007 0.93 (0.90 to 0.97) <0.007 Mean PIPs per 100 prescriptions 1 year pre-intervention ≤1.6 0.88 (0.81 to 0.95) 0.001 1.09 (1.00 to 1.18) 0.041 1.7–2.0 0.83 (0.78 to 0.88) <0.007 1.04 (0.97 to 1.12) 0.265 2.1–2.3 0.81 (0.76 to 0.85) <0.007 0.85 (0.80 to 0.90) <0.007 2.4–2.9 0.74 (0.70 to 0.78) <0.007 0.89 (0.84 to 0.93) <0.007 >2.9 0.80 (0.76 to 0.83) <0.007 0.89 (0.83 to 0.96) 0.004 Prescriptions per patient in the 1 year pre-intervention period <8.7 0.90 (0.83 to 0.98) 0.016 1.16 (1.06 to 1.27) 0.001 8.7–10.7 0.83 (0.77 to 0.88) <0.007 0.87 (0.81 to 0.93) <0.007 10.8–12.8 0.80 (0.76 to 0.84) <0.007 0.95 (0.88 to 1.02) 0.190 12.9–14.9 0.80 (0.76 to 0.84) <0.007 0.92 (0.87 to 0.97) 0.004 >14.9 0.77 (0.73 to 0.80) <0.007 0.88 (0.83 to 0.93) <0.007 IRR = incidence rate ratio.
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Characteristics of GPs responding to an educational intervention to minimise inappropriate prescriptions: subgroup analyses of the Rx-PAD study
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