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Research article:
Examining variations in prescribing safety in UK general practice: a cross-sectional study using the Clinical Practice Research Datalink
Reference:
S Jill Stocks, Evangelos Kontopantelis, Artur Akbarov, Sarah Rodger, Anthony J Avery, Darren M Ashcroft(2015) Examining variations in prescribing safety in UK general practice: a cross-sectional study using the Clinical Practice Research Datalink. BMJ, doi: 10.1136/bmj.h5501
- Link to fulltext article
- Abstract
- Study question What is the prevalence of different types of potentially hazardous prescribing in general practice in the United Kingdom, and what is the variation between practices? Methods A cross sectional study included all adult patients potentially at risk of a prescribing or monitoring error defined by a combination of diagnoses and prescriptions in 526 general practices contributing to the Clinical Practice Research Datalink (CPRD) up to 1 April 2013. Primary outcomes were the prevalence of potentially hazardous prescriptions of anticoagulants, anti-platelets, NSAIDs, β blockers, glitazones, metformin, digoxin, antipsychotics, combined hormonal contraceptives, and oestrogens and monitoring by blood test less frequently than recommended for patients with repeated prescriptions of angiotensin converting enzyme inhibitors and loop diuretics, amiodarone, methotrexate, lithium, or warfarin. Study answer and limitations 49 927 of 949 552 patients at risk triggered at least one prescribing indicator (5.26%, 95% confidence interval 5.21% to 5.30%) and 21 501 of 182 721 (11.8%, 11.6% to 11.9%) triggered at least one monitoring indicator. The prevalence of different types of potentially hazardous prescribing ranged from almost zero to 10.2%, and for inadequate monitoring ranged from 10.4% to 41.9%. Older patients and those prescribed multiple repeat medications had significantly higher risks of triggering a prescribing indicator whereas younger patients with fewer repeat prescriptions had significantly higher risk of triggering a monitoring indicator. There was high variation between practices for some indicators.Though prescribing safety indicators describe prescribing patterns that can increase the risk of harm to the patient and should generally be avoided, there will always be exceptions where the indicator is clinically justified. Furthermore there is the possibility that some information is not captured by CPRD for some practices—for example, INR results in patients receiving warfarin. What this study adds The high prevalence for certain indicators emphasises existing prescribing risks and the need for their appropriate consideration within primary care, particularly for older patients and those taking multiple medications. The high variation between practices indicates potential for improvement through targeted practice level intervention.
- Author for correspondence
- Jill Stocks
- Email for correspondence
- jill.stocks@manchester.ac.uk
Code list: res25: M1_U&E
89 codes in list
| Code | Coding system | Description | Entity type | List name | medcode | UorE | |
|---|---|---|---|---|---|---|---|
| 4412000 | Read | Urea and electrolytes normal | test | res25: M1_U&E | 18356 | 2 | |
| 4412100 | Read | Urea and electrolytes abnormal | test | res25: M1_U&E | 18667 | 2 | |
| 44h..00 | Read | Blood electrolyte levels | test | res25: M1_U&E | 21332 | 2 | |
| 44h0.00 | Read | Blood potassium level | test | res25: M1_U&E | 17497 | 2 | |
| 44h1.00 | Read | Blood sodium level | test | res25: M1_U&E | 17883 | 2 | |
| 44h2.00 | Read | Blood chloride level | test | res25: M1_U&E | 26901 | 2 | |
| 44h3.00 | Read | Blood bicarbonate level | test | res25: M1_U&E | 19850 | 2 | |
| 44h4.00 | Read | Blood calcium level | test | res25: M1_U&E | 13729 | 2 | |
| 44h5.00 | Read | Blood inorganic phosphate level | test | res25: M1_U&E | 13784 | 2 | |
| 44h6.00 | Read | Plasma sodium level | test | res25: M1_U&E | 14137 | 2 | |
| 44h7.00 | Read | Plasma calcium level | test | res25: M1_U&E | 19757 | 2 | |
| 44h8.00 | Read | Plasma potassium level | test | res25: M1_U&E | 14138 | 2 | |
| 44h9.00 | Read | Plasma corrected calcium level | test | res25: M1_U&E | 19758 | 2 | |
| 44hA.00 | Read | Blood total carbon dioxide (calculated) | test | res25: M1_U&E | 27084 | 2 | |
| 44hB.00 | Read | Actual bicarbonate level | test | res25: M1_U&E | 27102 | 2 | |
| 44hC.00 | Read | Standard bicarbonate level | test | res25: M1_U&E | 58566 | 2 | |
| 44hD.00 | Read | Blood ionised calcium level | test | res25: M1_U&E | 101211 | 2 | |
| 44i..00 | Read | Plasma electrolyte levels | test | res25: M1_U&E | 47183 | 2 | |
| 44I..00 | Read | Serum electrolytes | test | res25: M1_U&E | 13909 | 2 | |
| 44i0.00 | Read | Plasma bicarbonate level | test | res25: M1_U&E | 14354 | 2 | |
| 44I0.00 | Read | test | res25: M1_U&E | 92323 | 2 | ||
| 44i1.00 | Read | Plasma chloride level | test | res25: M1_U&E | 19759 | 2 | |
| 44I1.00 | Read | Blood sent for electrolytes | test | res25: M1_U&E | 31528 | 2 | |
| 44i2.00 | Read | Plasma inorganic phosphate level | test | res25: M1_U&E | 19766 | 2 | |
| 44I2.00 | Read | Electrolytes normal | test | res25: M1_U&E | 4351 | 2 | |
| 44I3.00 | Read | Electrolytes abnormal | test | res25: M1_U&E | 15134 | 2 | |
| 44I4.00 | Read | Serum potassium | test | res25: M1_U&E | 8 | 2 | |
| 44I4000 | Read | Normal serum potassium level | test | res25: M1_U&E | 26928 | 2 | |
| 44I4100 | Read | Raised serum potassium level | test | res25: M1_U&E | 26929 | 2 | |
| 44I4200 | Read | Low serum potassium level | test | res25: M1_U&E | 26279 | 2 | |
| 44I5.00 | Read | Serum sodium | test | res25: M1_U&E | 9 | 2 | |
| 44I5000 | Read | Serum sodium level normal | test | res25: M1_U&E | 26935 | 2 | |
| 44I5100 | Read | Serum sodium level abnormal | test | res25: M1_U&E | 26934 | 2 | |
| 44I6.00 | Read | Serum chloride | test | res25: M1_U&E | 13732 | 2 | |
| 44I6000 | Read | Serum chloride level normal | test | res25: M1_U&E | 55154 | 2 | |
| 44I6100 | Read | Serum chloride level abnormal | test | res25: M1_U&E | 45661 | 2 | |
| 44I7.00 | Read | Serum bicarbonate | test | res25: M1_U&E | 14353 | 2 | |
| 44I7000 | Read | Serum bicarbonate level normal | test | res25: M1_U&E | 39193 | 2 | |
| 44I7100 | Read | Serum bicarbonate level abnormal | test | res25: M1_U&E | 40934 | 2 | |
| 44I8.00 | Read | Serum calcium | test | res25: M1_U&E | 77 | 2 | |
| 44I8000 | Read | Normal serum calcium level | test | res25: M1_U&E | 13728 | 2 | |
| 44I8100 | Read | Raised serum calcium level | test | res25: M1_U&E | 26900 | 2 | |
| 44I9.00 | Read | Serum inorganic phosphate | test | res25: M1_U&E | 13607 | 2 | |
| 44I9000 | Read | Serum phosphate level normal | test | res25: M1_U&E | 13783 | 2 | |
| 44I9100 | Read | Serum phosphate level abnormal | test | res25: M1_U&E | 13785 | 2 | |
| 44IA.00 | Read | Plasma anion gap | test | res25: M1_U&E | 19897 | 2 | |
| 44IB.00 | Read | Serum anion gap | test | res25: M1_U&E | 19896 | 2 | |
| 44IC.00 | Read | Corrected serum calcium level | test | res25: M1_U&E | 7578 | 2 | |
| 44IC.11 | Read | Adjusted serum calcium level | test | res25: M1_U&E | 98168 | 2 | |
| 44ID.00 | Read | Serum ionised calcium level | test | res25: M1_U&E | 41072 | 2 | |
| 44IE.00 | Read | Serum ionized calcium (pH 7.4) level | test | res25: M1_U&E | 57209 | 2 | |
| 44IF.00 | Read | Urine chromatography | test | res25: M1_U&E | 49311 | 2 | |
| 44IZ.00 | Read | Serum electrolytes NOS | test | res25: M1_U&E | 43037 | 2 | |
| 44J..00 | Read | Blood urea/renal function | test | res25: M1_U&E | 13812 | 1 | |
| 44J1.00 | Read | Blood urea normal | test | res25: M1_U&E | 26832 | 1 | |
| 44J..11 | Read | Urea - blood | test | res25: M1_U&E | 1097 | 1 | |
| 44J..12 | Read | Urea and electrolytes | test | res25: M1_U&E | 13589 | 1 | |
| 44J..13 | Read | Serum urea level | test | res25: M1_U&E | 26945 | 1 | |
| 44J2.00 | Read | Blood urea abnormal | test | res25: M1_U&E | 2072 | 1 | |
| 44J3.00 | Read | Serum creatinine | test | res25: M1_U&E | 5 | 1 | |
| 44J3000 | Read | Serum creatinine abnormal | test | res25: M1_U&E | 31277 | 1 | |
| 44J3100 | Read | Serum creatinine low | test | res25: M1_U&E | 35545 | 1 | |
| 44J3200 | Read | Serum creatinine normal | test | res25: M1_U&E | 26903 | 1 | |
| 44J3300 | Read | Serum creatinine raised | test | res25: M1_U&E | 3927 | 1 | |
| 44J3z00 | Read | Serum creatinine NOS | test | res25: M1_U&E | 42345 | 1 | |
| 44J4.00 | Read | Serum osmolality | test | res25: M1_U&E | 14355 | 1 | |
| 44J5.00 | Read | Renal profile | test | res25: M1_U&E | 17251 | 1 | |
| 44J6.00 | Read | Albumin excretion rate | test | res25: M1_U&E | 23281 | 1 | |
| 44J7.00 | Read | Albumin / creatinine ratio | test | res25: M1_U&E | 14113 | 1 | |
| 44J8.00 | Read | Blood urea | test | res25: M1_U&E | 13813 | 1 | |
| 44J8.11 | Read | Urea - blood | test | res25: M1_U&E | 26944 | 1 | |
| 44J9.00 | Read | Serum urea level | test | res25: M1_U&E | 32 | 1 | |
| 44JA.00 | Read | Plasma urea level | test | res25: M1_U&E | 13814 | 1 | |
| 44JB.00 | Read | Urea and electrolytes | test | res25: M1_U&E | 49 | 2 | |
| 44JC.00 | Read | Corrected plasma creatinine level | test | res25: M1_U&E | 62062 | 1 | |
| 44JD.00 | Read | Corrected serum creatinine level | test | res25: M1_U&E | 45096 | 1 | |
| 44JE.00 | Read | Peritoneal equilibration test | test | res25: M1_U&E | 99353 | 1 | |
| 44JF.00 | Read | Plasma creatinine level | test | res25: M1_U&E | 13736 | 1 | |
| 44JG.00 | Read | Overnight albumin excretion rate | test | res25: M1_U&E | 43524 | 1 | |
| 44JH.00 | Read | Plasma osmolality | test | res25: M1_U&E | 31301 | 1 | |
| 44JZ.00 | Read | Blood urea/renal function NOS | test | res25: M1_U&E | 26943 | 1 | |
| 4513 | Read | Creatinine clearance-glom filt | test | res25: M1_U&E | 13737 | 1 | |
| 4513.11 | Read | Creatinine clearance | test | res25: M1_U&E | 13738 | 1 | |
| 451E.00 | Read | GFR calculated abbreviated MDRD | test | res25: M1_U&E | 23250 | 1 | |
| 451F.00 | Read | Glomerular filtration rate | test | res25: M1_U&E | 19747 | 1 | |
| 451G.00 | Read | GFR calculated abbreviated MDRD adj for African Americ orign | test | res25: M1_U&E | 30898 | 1 | |
| 4Q40.00 | Read | Creatinine level | test | res25: M1_U&E | 27095 | 1 | |
| 4Q42.00 | Read | Potassium level | test | res25: M1_U&E | 44370 | 2 | |
| 4Q43.00 | Read | Sodium level | test | res25: M1_U&E | 67485 | 2 |
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