Prescribing Issues and Concordance

"We are heading towards Pharmageddon" - Paul Flynn, MP for Newport West.¹

Drug treatment is the most common form of treatment in primary care, with an estimated 60% to 75% of patients receiving a prescription on consulting their GP. Although prescribing is an important part of primary care, it has frequently been described as unnecessary and wasteful. Repeat prescribing has been highlighted as a particular problem area; 66% of prescriptions issued are repeats where no face-to-face contact between patient and GP occurs. The need for greater co-operation between community pharmacists and GPs to rationalise the use of drugs has frequently been highlighted. The interface between primary care, secondary care, out of hours care and social services is also important.²

In England in 2007, 796 million prescription items were dispensed; an increase of 5.9% on 2006 and 59.2% over 1997.³

Drug expenditure by GPs in England accounted for approximately £4.5 billion in 1998, representing about 50% of costs in primary care. This expenditure is currently rising at 9% per annum.The net ingredient cost of all prescriptions dispensed increased by 2.1% to £8,372.7 million; a decrease of 0.7% in real terms on 2006 but an increase of 49.5% in real terms over 1997.³

The average net ingredient cost per prescription item in 2007 was £10.51; a decrease of 3.5% or 6.3% in real terms on 2006. The net ingredient cost per item in 1997 was £8.73.

The leading BNF Chapter in terms of prescription items dispensed and net ingredient cost was the Cardiovascular System in 2007, as it was in 2005. The leading BNF Section in terms of prescription items dispensed is Hypertension and Heart Failure.

Other stastistics of interest are as follows:

• 82.6% of all prescription items were written generically in 2007; it was 57.5% in 1996.
• There were on average 15.6 prescription items per head of population compared to 14.8 in 2006 and 10.0 in 1996.
• The elderly received 42.4 items per head in 2007 compared to 40.8 in 2006 and 21.2 in 1996.
• 88.06% of all prescription items dispensed were free to patients in 2007; in 2006 this was 88.0% and 85.6% in 1996.

Some of the pressures to prescribe have come from unexpected sources.The drive to meet GP contract targets has encouraged GPs to prescribe increasing amounts of medicines and to chase patients who are 'non-compliant'. This might in part explain the comment in guidance recently released by NICE that between a third and a half of medicines that are prescribed for long-term conditions are not used as recommended.⁴

Another influential factor is the 'pill for every ill' culture which has been fuelled by the media and is now firmly embedded in the nation's psyche.

PACT (Prescribing Analysis and Cost) is a series of reports, which tells GPs what they have prescribed and how much their prescribing has cost. The data are produced by the Prescription Pricing Authority (PPA) and give information on both individual GPs’ and practices’ prescribing costs, comparing them with other doctors in the same HA and also nationally.³ Since January 2007, circulation of hard copies ceased and was replaced with an on-line system called ePFIP. This is available to practice users via the internet as well as via the NHS internal network.⁵

This is the use of additional professional input into one or more elements involved in the prescribing process. The aim of prescribing support is to improve the pharmaceutical care of patients by allowing GPs more time to spend with patients, for example:

• Extended formulary nurse prescribers
• Patient group direction (PGD) system⁶
• Bulk prescribing
• Prescribing in instalments: (use the FP10 MDA form, e.g. drug addicts)

In the year 2000, patients over the age of 60 received 52% of all prescriptions, the majority of which were repeats.⁷ A benefit of repeat prescriptions for this age group is that they reduce patient inconvenience as well as the professional workload. A major disadvantage is the reduction of patient-doctor contact, resulting in potential clinical problems.²

When reviewing each repeat prescription, consideration should be given to the following:⁸

• Is it effective?
• Is it necessary or still required?
• Will the patient take it?
• Is the present formulation appropriate?
• Does it provide the most cost-effective treatment available?
• Has the patient had a clinical review within the last 15 months (or shorter if clinically appropriate)?

In its guidance on Medicines Adherence, NICE also recommends considering the following at review:⁴

• Offer repeat information and review, especially when treating long-term conditions with multiple medicines.
• Review at agreed intervals patients’ knowledge, understanding and concerns about medicines and whether they think they still need the medicine.
• Ask about adherence when reviewing medicines. Clarify possible causes of non-adherence and agree any action with the patient (including a date for follow-up).
• Bear in mind that patients sometimes evaluate prescribed medicines in their own way (for example, by stopping and starting them and monitoring symptoms). Ask the patient if they have their own way of weighing up their medicine.

In recent years there has been a move away from compliance, which suggests an element of compulsion, to concordance, in which prescriber and patient enter into a partnership concerning the use of medication.¹⁰

The cornerstones of concordance include:

• The level of information given to patients
• Side-effects
• The costs of medication
• The effect on lifestyle

NICE refers to the term 'non-adherence' and identifies two types: intentional (the patient decides not to follow the treatment recommendations) and unintentional (the patient wants to follow the treatment recommendations but has practical problems). They advocate a non-judgemental discussion in which the patient's perceptions and preferences are explored. These two types can overlap.

The discussion should, where relevant, include:

• What will happen if they don’t take the medicine
• Non-pharmacological alternatives
• Reducing or stopping long-term medicines
• Fitting medicines into their routine
• Choosing between medicine

The patient should also be given adequate information covering:

• What the medicine is, how to use it and likely benefits
• Likely adverse effects and what to do if they think they are experiencing them
• What to do if they miss a dose
• Whether another prescription is needed and how to get further supplies

Although not evidence-based, NICE recommends considering the following interventions if there is a specific need:

• Suggesting patients record their medicine-taking
• Encouraging patients to monitor their condition
• Simplifying the dosing regimen
• Using alternative packaging
• Using a multi-compartment medicines' system
• Considering options to reduce prescribing costs if this is an issue

Special clinical scenarios

Children¹¹

• Parents are mainly responsible for the administration of medicines to their children, so both the concordance of parent and child should be considered
• Concordance in children is influenced by the formulation, taste, appearance and ease of administration of a preparation
• Prescribed regimens should be tailored to the child’s daily routine
• Treatment goals should be set in collaboration with the child/parent

The elderly⁷

Important principles include:

• Effective communication
• Keeping regimens simple
• Giving reminder charts, concordance aids and special written instructions
• Monitoring concordance by counting returned tablets or checking plasma drug levels

One study found that large quantities of medicines, confusion and lack of knowledge as to why a medicine had been prescribed contributed to non-compliance. Appropriate communication between the pharmacist and patient, patient education and aids such as medication cards and referral for medication review could improve compliance in this age group.⁸