Differential associations between actual and expected GP practice prescribing rates for statins, ACE inhibitors, and beta-blockers: a cross-sectional study in England

AIM: To explore the relationship between actual and expected general medical practitioner (GP) practice prescribing rates for statins, angiotensin converting enzyme (ACE) inhibitors, and beta-blockers. BACKGROUND: There is a growing body of literature highlighting inequities in GP practice prescribing rates for many drug therapies. The equity of prescribing is of central importance in the area of therapeutics since it explores the interface between those patients who should and those who actually do receive a drug therapy. SETTING: Four primary care trusts (PCTs 1–4) in the North West of England, including 132 GP practices. METHODS: Actual and expected prescribing rates for statins, beta-blockers, and ACE inhibitors were specifically developed for each GP practice. RESULTS: There were no statistically significant correlations between actual and expected prescribing rates in PCT2 and PCT3, although in PCT1 there were statistically significant correlations for statins (0.286, p < 0.05) and ACE inhibitors (0.381, p < 0.01). In PCT4, correlations were moderate to high for beta-blockers (0.693, p < 0.01), and moderate for statins (0.541, p < 0.05) and ACE inhibitors (0.585, p < 0.01). Scatterplots highlighted large variations between individual GP practices (both within and between PCTs) in terms of the relationship between actual and expected prescribing rates. CONCLUSION: This paper highlights variability between PCTs and GP practices in terms of the relationship between actual and expected prescribing rates. The findings from this paper may further advance the suggestion of inequities in prescribing rates for coronary heart disease (CHD) drugs, and studies such as this may be repeated in different therapeutic areas, healthcare settings, and countries

The Attitudes about Complex Therapy Scale (ACTS) in Type 2 Diabetes and Cardiovascular Disease: Development, Validity and Reliability

Background: Type 2 diabetes is associated with cardiovascular disease, and patients with both conditions are prescribed complex medication regimens. Aim: The aim was to develop a reliable and valid measure of attitudes associated with the prescription and management of multiple medicines in patients with Type 2 diabetes and cardiovascular disease. Methods: Principal component analysis (PCA) and Cronbach alpha assessed the reliability of the Attitudes about Complex Therapy Scale (ACTS). Examinations of relationships with related measures inform concurrent validity. Questionnaires were sent to a cross-sectional sample of 480 people prescribed multiple medicines for co-morbid Type 2 diabetes. Results: Cronbach alpha was 0.76, indicating the scale had good internal reliability. PCA rotated a four factor model accounting for 37% of the variance. Four subscales identified; 1. Concerns about multiple medicines and increasing numbers of medicines; 2.Anxiety over missed medicines; 3. Desires to substitute medicines and reduce the number of medicines prescribed and; 4. Perceptions related to organising and managing complex therapy. The ACTS showed significant relationships with measures of anxiety, depression, general beliefs about medicines and self-efficacy. Also, the ACTS significantly correlated with adherence to medicines, showing good predictive validity. Conclusion: The ACTS was designed to assess negative attitudes towards complex therapy and multiple medication management. This tool could aid prescribing decisions and may identify people who are intentionally non-adherent to all or some of their medicines

Pharmacists subjected to disciplinary action: Characteristics and risk factors

Abstract Objective To establish whether there are any characteristics of pharmacists that predict their likelihood of being subjected to disciplinary action. Methods The setting was the Royal Pharmaceutical Society of Great Britain's Disciplinary Committee. One hundred and seventeen pharmacists, all of whom had been referred to the Disciplinary Committee, were matched with a quota sample of 580 pharmacists who had not been subjected to disciplinary action but that matched the disciplined pharmacists on a set of demographic factors (gender, country of residence, year of registration). Frequency analysis and regression analysis were used to compare the two groups of pharmacists in terms of sector of work, ethnicity, age and country of training. Descriptive statistics were also obtained from the disciplined pharmacists to further explore characteristics of disciplinary cases and those pharmacists who undergo them. Key findings While a number of characteristics appeared to increase the likelihood of a pharmacist being referred to the disciplinary committee, only one of these – working in a community pharmacy – was statistically significant. Professional misconduct accounted for a greater proportion of referrals than did clinical malpractice, and approximately one-fifth of pharmacists who went before the Disciplinary Committee had previously been disciplined by the Society. Conclusions This study provides initial evidence of pharmacist characteristics that are associated with an increased risk of being disciplined, based upon the data currently available. It is recommended that follow-up work is carried out using a more extensive dataset in order to confirm the statistical trends identified here. </jats:sec

Plant species determine tidal wetland methane response to sea level rise

Blue carbon (C) ecosystems are among the most effective C sinks of the biosphere, but methane (CH4) emissions can offset their climate cooling effect. Drivers of CH4 emissions from blue C ecosystems and effects of global change are poorly understood. Here we test for the effects of sea level rise (SLR) and its interactions with elevated atmospheric CO2, eutrophication, and plant community composition on CH4 emissions from an estuarine tidal wetland. Changes in CH4 emissions with SLR are primarily mediated by shifts in plant community composition and associated plant traits that determine both the direction and magnitude of SLR effects on CH4 emissions. We furthermore show strong stimulation of CH4 emissions by elevated atmospheric CO2, whereas effects of eutrophication are not significant. Overall, our findings demonstrate a high sensitivity of CH4 emissions to global change with important implications for modeling greenhouse-gas dynamics of blue C ecosystems

Plant species determine tidal wetland methane response to sea level rise

Blue carbon (C) ecosystems are among the most effective C sinks of the biosphere, but methane (CH4) emissions can offset their climate cooling effect. Drivers of CH4 emissions from blue C ecosystems and effects of global change are poorly understood. Here we test for the effects of sea level rise (SLR) and its interactions with elevated atmospheric CO2, eutrophication, and plant community composition on CH4 emissions from an estuarine tidal wetland. Changes in CH4 emissions with SLR are primarily mediated by shifts in plant community composition and associated plant traits that determine both the direction and magnitude of SLR effects on CH4 emissions. We furthermore show strong stimulation of CH4 emissions by elevated atmospheric CO2, whereas effects of eutrophication are not significant. Overall, our findings demonstrate a high sensitivity of CH4 emissions to global change with important implications for modeling greenhouse-gas dynamics of blue C ecosystems

Patient perceptions of treatment and illness when prescribed multiple medicines for co-morbid type 2 diabetes

Illness and treatment perceptions are vital for people self-managing co-morbid conditions with associated cardiovascular disease, such as type 2 diabetes (T2D). However, perceptions of a co-morbid condition and the use of multiple medicines have yet to be researched. This study investigated the illness and treatment perceptions of people with co-morbid T2D. The Brief Illness Perception Questionnaire (repeated for T2D, hypertension, and hyperlipidemia) and the Beliefs about Medicines Questionnaire Specific Concerns Scales (repeated for Oral hypoglycemic agents, anti-hypertensive medicines, and statins) were sent to 480 people managing co-morbid T2D. Data on the number of medicines prescribed were collected from medical records. Significantly different perceptions were found across the illnesses. The strongest effect was for personal control; the greatest control reported for T2D. Illness perceptions of T2D differed significantly from perceptions about hyperlipidemia. Furthermore, illness perceptions of T2D also differed from perceptions of hypertension with the exception of perceptions of illness severity. Hypertension and hyperlipidemia shared similar perceptions about comprehensibility, concerns, personal control, and timeline. Significant differences were found for beliefs about treatment necessity, but no difference was found for treatment concerns. When the number of medicines was taken as a between-subjects factor, only intentional non-adherence, treatment necessity beliefs, and perceptions of illness timeline were accounted for. Co-morbid illness and treatment perceptions are complex, often vary between illnesses, and can be influenced by the number of medicines prescribed. Further research should investigate relationships between co-morbid illness and treatment perception structures and self-management practices

Persistence with anti-tumour necrosis factor therapies in patients with psoriatic arthritis: observational study from the British Society of Rheumatology Biologics Register

Objectives. To evaluate the risk–benefit profile of anti-TNF therapies in PsA and to study the predictors of treatment response and disease remission [disease activity score (DAS)-28 < 2.6]. Methods. The study included PsA patients (n = 596) registered with the British Society for Rheumatology Biologics Register (BSRBR). Response was assessed using the European League against Rheumatism (EULAR) improvement criteria. Univariate and multivariate logistic regression models were developed to examine factors associated with EULAR response and disease remission using a range of covariates. Poisson regression was used to calculate incidence rate ratios (IRRs) for serious adverse events (SAEs) vs seronegative RA controls receiving DMARDs, adjusting for age, sex and baseline co-morbidity. Results. At baseline, the mean (s.d.) DAS-28 was 6.4 (5.6). Of the patients, 70.3% were EULAR responders at 12 months. At 6 months, older patients [adjusted odds ratio (OR) 0.97 per year; 95% CI 0.95, 0.99], females (adjusted OR 0.51; 95% CI 0.34, 0.78) and patients on corticosteroids (adjusted OR 0.45; 95% CI 0.28, 0.72) were less likely to achieve a EULAR response. Over 1776.2 person-years of follow-up (median 3.07 per person), the IRR of SAEs compared with controls was not increased (0.9; 95% CI 0.8, 1.3). Conclusions. Anti-TNF therapies have a good response rate in PsA, and have an adverse event profile similar to that seen in a control cohort of patients with seronegative arthritis receiving DMARD therapy

Exploring the equity of GP practice prescribing rates for selected coronary heart disease drugs: a multiple regression analysis with proxies of healthcare need

Background There is a small, but growing body of literature highlighting inequities in GP practice prescribing rates for many drug therapies. The aim of this paper is to further explore the equity of prescribing for five major CHD drug groups and to explain the amount of variation in GP practice prescribing rates that can be explained by a range of healthcare needs indicators (HCNIs). Methods The study involved a cross-sectional secondary analysis in four primary care trusts (PCTs 1–4) in the North West of England, including 132 GP practices. Prescribing rates (average daily quantities per registered patient aged over 35 years) and HCNIs were developed for all GP practices. Analysis was undertaken using multiple linear regression. Results Between 22–25% of the variation in prescribing rates for statins, beta-blockers and bendrofluazide was explained in the multiple regression models. Slightly more variation was explained for ACE inhibitors (31.6%) and considerably more for aspirin (51.2%). Prescribing rates were positively associated with CHD hospital diagnoses and procedures for all drug groups other than ACE inhibitors. The proportion of patients aged 55–74 years was positively related to all prescribing rates other than aspirin, where they were positively related to the proportion of patients aged >75 years. However, prescribing rates for statins and ACE inhibitors were negatively associated with the proportion of patients aged >75 years in addition to the proportion of patients from minority ethnic groups. Prescribing rates for aspirin, bendrofluazide and all CHD drugs combined were negatively associated with deprivation. Conclusion Although around 25–50% of the variation in prescribing rates was explained by HCNIs, this varied markedly between PCTs and drug groups. Prescribing rates were generally characterised by both positive and negative associations with HCNIs, suggesting possible inequities in prescribing rates on the basis of ethnicity, deprivation and the proportion of patients aged over 75 years (for statins and ACE inhibitors, but not for aspirin)

Additional rare variant analysis in Parkinson's Disease cases with and without known pathogenic mutations: evidence for oligogenic inheritance

Oligogenic inheritance implies a role for several genetic factors in disease etiology. We studied oligogenic inheritance in Parkinson’s (PD) by assessing the potential burden of additional rare variants in established Mendelian genes and/or GBA, in individuals with and without a primary pathogenic genetic cause in two large independent cohorts totaling 7,900 PD cases and 6,166 controls. An excess (≥30%) of cases with a recognized primary genetic cause had ≥1 additional rare variants in Mendelian PD genes, as compared with no known mutation PD cases (17%) and unaffected controls (16%), supporting our hypothesis. Carriers of additional Mendelian gene variants have younger ages at onset (AAO). The effect of additional Mendelian variants in LRRK2 G2019S mutation carriers, of which ATP13A2 variation is particularly common, may account for some of the variation in penetrance. About 10% of no known mutation PD cases harbor a rare GBA variant compared to known pathogenic mutation PD cases (8%) and controls (5%), with carriers having earlier AAOs. Together, the data suggest that the oligogenic inheritance of rare Mendelian variants may be important in patient with a primary pathogenic cause, whereas GBA increases risk across all forms of PD. This study highlights potential genetic complexity of Mendelian PD. The identification of potential modifying variants provides new insights into disease mechanisms by potentially separating relevant from benign variants and by the interaction between genes in specific pathways. In the future this may be relevant to genetic testing and counselling of PD patients and their families