Narrative review of primary care point-of-care testing (POCT) and antibacterial use in respiratory tract infection (RTI)

Antimicrobial resistance is a global problem and is being addressed through national strategies to improve diagnostics, develop new antimicrobials and promote antimicrobial stewardship. A narrative review of the literature was undertaken to ascertain the value of C reactive protein (CRP) and procalcitonin, measurements to guide antibacterial prescribing in adult patients presenting to GP practices with symptoms of respiratory tract infection (RTI). Studies that were included were randomised controlled trials,controlled before and after studies, cohort studies and economic evaluations. Many studies demonstrated that the use of CRP tests in patients presenting with RTI symptoms reduces antibiotic prescribing by 23.3% to36.16%. Procalcitonin is not currently available as a point-of-care testing (POCT), but has shown value for patients with RTI admitted to hospital. GPs and patients report a good acceptability for a CRP POCT and economic evaluations show cost-effectiveness of CRP POCT over existing RTI management in primary care. POCTs increase diagnostic precision for GPs in the better management of patients with RTI. CRP POCT can better target antibacterial prescribing by GPs and contribute to national antimicrobial resistance strategies. Health services need to develop ways to ensure funding is transferred in order for POCT to be implemented

Optimizing quality and efficiency of respiratory medicines in Scotland

Increasing prevalence of asthma and COPD has increased use of long acting inhalers. Different inhalers with patented delivery systems have kept costs high and inhalers among the highest expenditure items in ambulatory care in Scotland. There was a 136.8% increase in their utilisation between 2001 - 2017 alongside a 195.7% increase in expenditure. This is being addressed with brande

Sustainable Implementation of Polypharmacy reviews as part of integrated care at Scale

Medication is the most common form of intervention to prevent disease or slow disease progression, with guidelines for single diseases recommending evidence based drug treatments. There remains the mismatch between prescribing guidelines for specific medical conditions and the range of clinical complexity found in individual adults with multiple morbidities. The resulting polypharmacy (use of multiple medicines) can be both appropriate and inappropriate and the key healthcare aim for individual patients is to ensure the on-going safe and effective use of their multiple medicines.NHS Scotland developed, designed and implemented national policy to consider the patient pathway and the flow of work needed to be undertaken in clinical practice to address appropriate management of Polypharmacy. Implementation across all 14 health boards serving a population of 5.5 million people in Scotland utilised Kotter’s 8 steps[1] for implementation of change supported by clinical and policy leadership, economic data and clinical outcome data. NHS Scotland have provided leadership for a European work plan. SIMPATHY , Stimulating Innovation in Managment of Polypharmacy and Adherence in the Elderly, (www.simpathy.eu) has benchmarked European strategies to address polypharmacy and through in-depth case studies in 10 EU countries, is developing strategies and tools to support innovation in polypharmacy and adherence management across Europe.Synthesis of the findings from application of change management tools such as Kotter, PESTEL (Political, Economic, Social,Technological, Environmental and Legal) and SWOT ( Strenghts Weaknesses, Opportunities and Threats), together with the case studies serve to inform further innovation. Comparison was made to other EU countries, that had started to implement a programme..Work undertaken in the Scottish programme has been used to develop an economic tool that may be used by other countries to explore the economic benefits of a national polypharmacy management programme. Transferability of innovation will be supported through publication of a reference book based on the findings of SIMPATHY.Synthesis of findings confirmed that key principles of Kotter influenced the successful implementation of national policy for management of polypharmacy in Scotland. It was identified that policy and clinical leadership were essential drivers along with a policy change that supported implementation in the service together with contractual arrangements . Lessons learned from national policy implementation in Scotland and from local programmes in other EU countries, including facilitators and barriers, together with key features of an economic tool will inform innovation of integrated care at a policy level

Ongoing initiatives within the Scottish National Health Service to affect the prescribing of selective serotonin reuptake inhibitors and their influence

Aim: Increasing use of selective serotonin-reuptake inhibitors (SSRIs) in Scotland, coupled with safety concerns with some SSRIs, and the increasing availability of generic SSRIs, have resulted in multiple initiatives to improve the quality and efficiency of their prescribing in Scotland. Our aim is to assess their influence to provide future direction. Materials & methods: The prescription costs analysis database was used to document utilization and expenditure on SSRIs between 2001 and 2017 alongside documenting the initiatives. Results: Multiple interventions over the years increased international nonproprietary name prescribing up to 99.9% lowering overall costs. This, coupled with initiatives to limit escitalopram prescribing due to concerns with its value, resulted in a 73.7% reduction in SSRI expenditure between 2001 and 2017 despite a 2.34-fold increase in utilization. Safety warnings resulted in a significant reduction in the prescribing of paroxetine, citalopram and escitalopram alongside a significant increase in sertraline Conclusion: Multiple initiatives have increased the quality and efficiency of SSRI prescribing in Scotland providing direction to others

Recent initiatives in Scotland to improve the quality and efficiency of prescribing : findings and implications

Background: Changing demographics with an increase in chronic disease prevalence coupled with more aggressive management targets, and the continued launch of new premium priced products, has put considerable strain on healthcare systems to continue providing universal, high quality healthcare. High appropriate use of generics in a class where care is not compromised by prescribing generics versus patented products, combined with quality measures, can help with providing quality healthcare. Objective: Assess the utilisation and costs of lipid lowering therapies (C10), Proton-Pump Inhibitors (PPIs) (A02BC), and Selective Serotonin Reuptake Inhibitors (SSRIs) (N06AB) in ambulatory care in Scotland between 2001 and 2015 alongside reforms to provide future guidance. Methods: Utilisation measured in the number of items dispensed to assess prescriptions and reimbursed expenditure captured in GB pounds from NHS Scotland national database. National and regional initiatives to improve the quality and efficiency of prescribing were captured using standard methodologies (4Es - education, engineering, economics and enforcement). No time series analyses analysis was conducted as multiple interventions over time. Results: Lipid lowering therapies (statins predominantly): multiple initiatives including identifying patients with CHD, encouraging preferential prescribing of generics, reducing ezetimibe prescribing as little evidence of benefit, and encouraging the prescribing of higher dose statins in line with recommendations, resulted in statin expenditure falling by 56% in 2015 vs. 2001 despite a 4.03 fold increase in utilisation. High dose statins now account for 71.3% of total prescriptions, up from 17.3% in 2001. PPIs: similar multiple initiatives resulted in a 68% reduction in expenditure despite a 2.91 fold increase in utilisation. High dose prescribing reduced to 20.3% of all PPIs in 2015, down from 25.8% in 2009, following concerns. SSRIs: similar initiatives and encouraging citalopram vs. escitalopram resulted in expenditure falling by 60.1% despite a 2.12 fold increase in utilisation. Concerns with citalopram in 2012 saw its prescribing fall in recent years whilst the prescribing of sertraline has grown. The prescribing of paroxetine continually fell from 2002 onwards as a result of concerns. Conclusion: Multiple strategies have been successful with improving the quality and efficiency of prescribing in Scotland. These will continue

Ongoing activities to influence the prescribing of proton pump inhibitors within the Scottish National Health Service : their effect and implications

Introduction: There has been a considerable increase in the use of proton pump inhibitors (PPIs) in recent years due to their effectiveness versus H2 antagonists. This includes reducing GI bleeds in patients at risk. However, there are concerns with their long term use and potential costs. Costs can be reduced with increased prescribing of low cost generic PPIs. Aims: To analyse the influence of multiple demand-side measures in Scotland in recent years to increase the prescribing of low cost generic PPIs as well as encourage the prescribing of lower strength PPIs. Methods: Documenting utilization (mainly items dispensed) and expenditure in Scotland from 2001 to 2017 using health authority databases combined with documenting the multiple initiatives and measures both nationally and regionally. Results: The multiple measures in Scotland ensured high International non-proprietary name prescribing (up to 100% for some PPIs) as well as the prescribing of generic versus patented PPIs, with costs of generic PPIs as low as 8.5% of their pre-patent loss prices. Overall, total expenditure on PPIs in Scotland was 66.7% lower in 2017 at GB£18.83million compared to 2001 levels. This was despite a 3.06-fold increase in PPI utilization during this period. The savings were driven by the increasing use of generic omeprazole and lansoprazole versus patent protected PPIs. There was also a reduction in the prescribing of high strength PPIs during this period. Conclusion: Multiple initiatives in Scotland in recent years have reduced expenditure on PPIs despite appreciably increased utilisation. Multiple initiatives have also helped to reduce the prescribing of higher strength PPIs. This is an exemplar to other countries seeking to enhance their prescribing efficienc

Activities to optimize quality and efficiency of medicines in Scotland

Introduction: The growing prevalence of non-communicable diseases, combined with greater recognition of the effectiveness of lipid lowering agents (LLAs), has fueled their increasing use in recent years. Similarly, increasing recognition of mental health and, arguably, societal expectations and pressures has driven appreciable growth in antidepressant prescribing in recent years. Concurrent with this, growing resource pressures enhanced by the continual launch of new premium priced medicines necessitates reforms and initiatives within finite budgets. Scotland has introduced multiple measures in recent years to improve both the quality and efficiency of prescribing. There is a need to document these initiatives and outcomes to provide future direction. Method: Assessment of the utilization (items dispensed) and expenditure of key LLAs (mainly statins) and SSRIs between 2001 and 2017 in Scotland alongside initiatives. Results: Multiple interventions have increased international non-proprietary name (INN) prescribing (99% for statins and up to 99.9% for SSRIs). They have also increased preferential prescribing of generic versus patented statins with low costs for generics, reduced inappropriate prescribing of ezetimibe due to effectiveness concerns, and increased the prescribing of higher dose statins (71% in 2015). These measures have resulted in a 50% reduction in LLA expenditure between 2001 and 2015 despite a 412% increase in utilization. Initiatives to reduce the prescribing of escitalopram as lack of evidence demonstrating cost-benefits over generic citalopram, along with high INN prescribing, achieved a 73.7% reduction in SSRI expenditure between 2001 and 2017 despite a 2.34-fold increase in utilisation. Concerns with paroxetine, and more recently citalopram and escitalopram following safety warnings, resulted in a considerable reduction in their use alongside a significant increase in sertraline. Conclusion: Generic availability coupled with multiple measures has resulted in appreciable shifts in statin and SSRI prescribing behavior and reduced ezetimibe prescribing, resulting in improvements in both the quality and efficiency of prescribing to provide future direction

Ongoing activities to influence the prescribing of proton pump inhibitors within the Scottish National Health Service : their effect and implications

Introduction: There has been a considerable increase in the use of proton pump inhibitors (PPIs) in recent years due to their effectiveness versus H2 antagonists. This includes reducing GI bleeds in patients at risk. However, there are concerns with their long term use and potential costs. Costs can be reduced with increased prescribing of low cost generic PPIs. Aims: To analyse the influence of multiple demand-side measures in Scotland in recent years to increase the prescribing of low cost generic PPIs as well as encourage the prescribing of lower strength PPIs. Methods: Documenting utilization (mainly items dispensed) and expenditure in Scotland from 2001 to 2017 using health authority databases combined with documenting the multiple initiatives and measures both nationally and regionally. Results: The multiple measures in Scotland ensured high International non-proprietary name prescribing (up to 100% for some PPIs) as well as the prescribing of generic versus patented PPIs, with costs of generic PPIs as low as 8.5% of their pre-patent loss prices. Overall, total expenditure on PPIs in Scotland was 66.7% lower in 2017 at GB£18.83million compared to 2001 levels. This was despite a 3.06-fold increase in PPI utilization during this period. The savings were driven by the increasing use of generic omeprazole and lansoprazole versus patent protected PPIs. There was also a reduction in the prescribing of high strength PPIs during this period. Conclusion: Multiple initiatives in Scotland in recent years have reduced expenditure on PPIs despite appreciably increased utilisation. Multiple initiatives have also helped to reduce the prescribing of higher strength PPIs. This is an exemplar to other countries seeking to enhance their prescribing efficienc

Real-world evaluation of the impact of statin intensity on adherence and persistence to therapy : a Scottish population-based study

Aim: To assess associations between statin intensity and adherence, persistence and discontinuation of statin therapy in Scotland. Method: Retrospective cohort study, using linked electronic health records covering a period from January 2009 to December 2016. The study cohort included adult patients (≥18 years) newly initiating statins within Greater Glasgow and Clyde, Scotland. Study outcomes comprised adherence, discontinuation and persistence to treatment, stratified by three exposure groups (high, moderate and low intensity). Discontinuation and persistence were calculated using the refill-gap and anniversary methods, respectively. Proportion of days covered (PDC) was used as a proxy for adherence. Kaplan-Meier survival curves and Cox proportional hazard models were used to evaluate discontinuation, and associations between adherence/persistence and statin intensity were assessed using logistic regression. Results: A total of 73 716 patients with a mean age of 61.4 ± 12.6 years were included; the majority (88.3%) received moderate intensity statins. Discontinuation rates differed between intensity levels, with high-intensity patients less likely to discontinue treatment compared to those on moderate intensity (prior cardiovascular disease [CVD]: HR 0.43 [95% CI 0.34-0.55]; no prior CVD: 0.80 [0.74-0.86]). Persistence declined over time, and high-intensity patients had the highest persistence rates. Overall, 52.6% of patients were adherent to treatment (PDC ≥ 80%), but adherence was considerably higher among high-intensity patients (63.7%). Conclusion: High-intensity statins were associated with better persistence and adherence to treatment, but overall long-term persistence and adherence remain a challenge, particularly among patients without prior CVD. This needs addressing

Ongoing activities to optimize the quality and efficiency of lipid-lowering agents in the Scottish National Health System : influence and implications

Introduction and aims: Prescribing of lipid lowering agents (LLAs) has increased worldwide including in Scotland with increasing prevalence of coronary heart disease, and higher dose statins have been advocated in recent years. There have also been initiatives to encourage prescribing of generic versus patented statins to save costs without compromising care. There is a need to document these initiatives and outcomes to provide future direction. Method: Assessment of utilization (items dispensed) and expenditure of key LLAs (mainly statins) and expenditure between 2001 and 2015 in Scotland alongside initiatives. Results: Multiple interventions have increased international non-proprietary name (INN) prescribing (99% for statins) and preferential prescribing of generic versus patented statins, and reduced inappropriate prescribing of ezetimibe. This resulted in a 50% reduction in LLA expenditure between 2001 and 2015 despite a 412% increase in utilization, increased prescribing of higher dose statins (71% in 2015) especially atorvastatin following generic availability, and reduced prescribing of ezetimibe (reduced by 72% between 2010 and 2015). As a result, the quality of prescribing has improved. Conclusion: Generic availability coupled with multiple measures has resulted in appreciable shifts in statin prescribing behavior and reducing ezetimibe prescribing, resulting in improvements in both the quality and efficiency of prescribing