52
PRESCRIBING IN GENERAL PRACTICE
labelled may well feel that the DHSS has a tendency to view high-cost prescribing as bad prescribing and the DHSS may associate their high-cost prescription findings with bad prescribing without knowing whether some of their findings would occur amongst prescription samples from non-high-cost prescribers. Conversely, having been labelled or having a chance of being labelled a high-cost prescriber may affect the attitude of prescribing doctors toward the DHSS. Conclusions By monitoring prescribing costs some doctors are labelled as ' high-cost prescribers'. The findings of this study suggest that those doctors investigated for high-cost prescribing during their first few years as principals in general practice expressed a greater need for further training and information on drug prescribing than other prescribers. It is significant that they tended to be foreign-trained and to practise in small partnershipsfactors which could have contributed to their need for help.
10. SPECIALTY INTERESTS AND PRESCRIBING PATTERNS: AN EXAM[NATION OF PAEDIATRIC PRESCRIPTIONS JEAN CLEARY
Many doctors in general practice have trained and have an interest in one or more specialist areas of medicine and many have postgraduate qualifications in them. It would be interesting to discover whether the present organisation of general practice allows them to make use of their special knowledge. We know from the answers to our second questionnaire that more than 100 respondents expressed interest in paediatrics, while the prescription data available to us give information about prescriptions which were written for patients under 15 at the time of collection. It was decided to compare the prescriptions for children issued by a group of doctors with an interest in paediatrics with another group to see whether this interest was reflected in the nature of their prescribing. The subject was thought worthy of study, also, because little has been published about prescribing for children. The samples A sample was selected of those doctors in the cohort who practised in Lancashire and Cheshire, who held the Diploma in Child Health (DCH) and/or had described paediatrics as a particular interest in their responses to the 1972 questionnaire. There were 15 of these doctors (the paediatric doctors) and a further 15 respondents were randomly selected from the same area (the non-paediatric doctors). The Lancashire doctors' prescribing had been analysed in September 1972 and the Cheshire ones in February 1973. The two groups of doctors were of a similar age; those in the paediatric group had a mean age of 37 8 years (range 28-51 years), and those in the non-paediatric group had a mean age of 34 9 (range 27-53 years). The difference between the means is not significant (t= 1 * 158). Two of the paediatric doctors were women and one of the non-paediatric, an unexpectedly low proportion since nearly one quarter of the cohort are women, and slightly more (28 per cent) of those who expressed a special interest in paediatrics. In the paediatric group six doctors held a DCH, four of these also had other postgraduate qualifications, and two had postgraduate qualifications in fields other than paediatrics. Eight had qualified in the United Kingdom and seven elsewhere; ten worked in- Lancashire and five in Cheshire. The non-paediatric group included six with postgraduate qualifications, ten having qualified in the United Kingdom and five elsewhere;
PRESCRMING
53
IN GENERAL PRACnCE
eight worked in Lancashire and seven in Cheshire. The 12 overseas doctors held 12 of the 23 postgraduate qualifications of all the 30 doctors; they were slightly, but not significantly, older than the UK doctors, the mean age of the overseas doctors was 37 1 years (range 28-51 years) and the UK doctors 33 *3 years (range 27-53 years; t=0 * 196). Method
Prescriptions dispensed for each general practitioner in the cohort were recorded individually and then classified into 88 DHSS therapeutic classes which were further reduced into 14 broad groups. The number of prescriptions in these categories has formed the basis of this study of the two groups of doctors; where more detail was required the therapeutic classes or the individual prescription items have been used. Volume of prescribing We have no direct evidence of the number of prescription forms written for children, but if we assume that the number of prescription items per prescription form is the same for both adults and children, and adjust the totals for the greater length of September, we get an estimated total of 1,825 prescription forms for the paediatric group (range 40200, mean 122, mean prescriptions per form 1 77) and 1,173 for the non-paediatric, (range 43-180, mean 118, mean prescriptions per form 1 .62). There was great dispersion among doctors in the number of prescription items issued to children (paediatric prescriptions) both absolutely and as a proportion of the total, but we cannot yet say whether a large number of paediatric prescriptions issued reflected a larger proportion of children seen.
Pattern of prescribing There was a considerable variation among members of the samples in the number of paediatric prescriptions dispensed during the month analysed, ranging from 58-373 (paediatric, mean 211 13, s.d. 85 18, non-paediatric, mean 190 07, s.d. 60 14). This variation may have been caused by the presence or absence of the doctor during the month, variations in morbidity, as well as selection of a particular doctor by patients, or of patients by doctors within a practice. In general, therefore, percentages of total prescriptions or paediatric prescriptions have been used in order to demonstrate the pattern of prescribing. The proportion of paediatric prescriptions ranged from about ten per cent to 33 per cent in the paediatric group, and from ten per cent to 40 per cent in the non-paediatric group. How these were divided among the fourteen broad groups is given in table 1. Only one doctor in the paediatric group prescribed drugs in all the 14 therapeutic groups for children, none in the non-paediatric group did. The range for the rest of the paediatric group was 9-13, and 9-12 for the non-paediatric group. All the doctors, however, used all the groups in their prescribing for adults. Of the groups least used for children, one, the genitourinary system, was much the smallest for adults also, but the anti-rheumatic ranked eighth for adults with both samples of doctors. The patterns of prescribing for the paediatric and non-paediatric doctors are strikingly similar (Spearman rank order correlation-=0 985, no pair of ranks differing by more than one point), and only two categories vary by as much as two per cent. The same two therapeutic groups were much the largest for both sets of doctorsthe anti-infectives and the respiratory group. In both cases these accounted for about half the paediatric prescriptions and, if we use the estimated total of prescription forms for children, we find that more than half of them included an anti-infective (91 per cent of which were antibiotics) and more than a quarter a cough medicine or bronchodilator. The next two largest groups were preparations affecting the skin and the anti-allergics,
54
PPMCRIBING
IN GENERAL PRACTICE
TABLE 1 PAEDIATRIC PRESCRIPTIONS BY THERAPEUTIC GROUPS
Paediatric doctors Therapeutic group % of DHSS abbreviated classes' Rank Number items2 title
39-48 Anti-infective 17-21 Respiratory 76-81 Skin-topical 66-68 Anti-allergic Eye, ENT, topical 69-75 23,29-34 Analgesics 01-08 Alimentary Psychotropics 22,24-28 82-88 Others Haematopoietic 58-64 49-57 Metabolic CVS & diuretics 09-16 35-38 GU system 65 Anti-rheumatic
Total
1 2 3 4 5 6 7 8 9 10 11 12 13
14
1040 517 309 244 237 215 203 130 126 103 17 14 8
4
3167
32*84 16-32 9 76 7 70 7 48 6 79
6*41 4*1o 3*98 3 25 0*54 0*44 o025 0*13 99*99
% of total3
6*22 3*o9 1*85 146
1P42 1-29 121 0 78 -
0o75 0 62 0o10 0*08 005 0*02 18*95
Non-paediatric doctors _ % of % of Rank Number items items4 1 2 4 3 5 7 6 8 9 10 12 11 13
953 466 292 351 211 150 161 130 56 51 9 13 4
13
4
33*42 16*35 10424 12*31
5*41 2-64 1-66 1 99
7 40
1P20
s526
085 091 0 * 74
565 4 s6 1P96 1 79
0o32 0*46 0414 0414
2851 100*0
2*12 0-29 0*05 007 0*02 002 16 17
'Full DHSS class descriptions will be found in the appendix. 'Per cent of total prescription items for children. 'n=16,714, total items for adults and children. 4n= 17,627, total items for adults and children.
which together comprised 17 * 5 per cent of the paediatric group's items for children and 22 5 per cent of the non-paediatric. It might be argued that seasonal variation was responsible for differences in prescribing rather than any characteristic of the doctors involved, but when we considered this aspect of the material we again found few differences, that is, when we compared the figures for September (18 Lancashire doctors) with those for February (12 Cheshire doctors) the rank order correlation for the 14 broad therapeutic categories is 0 -938, very slightly less than that for the paediatric/non-paediatric comparison (0 985). The greatest difference was a preponderance of respiratory tract preparations in September. While none of them was very large the differences were, with one exception (anti-allergic), bigger than the differences between the paediatric and non-paediatric groups. The largest groups of prescribed drugs (1) Antibiotics The antibiotics are the most important feature of the prescribing of nearly all the 30 doctors under consideration ranking first for 24 of them, second for five and down to fourth (after the respiratory, allergic, and skin groups) for the remaining one. For only four doctors does the proportion of antibiotics prescribed for children form less than 20 per cent of prescribed items, while for six it is between 45 and 50 per cent: the mean is about 30 per cent. The category of antibiotics can be broken down into the six DHSS classes: penicillins, tetracyclines, streptomycins, chloramphenicol (which was not prescribed by any doctor in either group) antifungal antibiotics, and others (table 2). It is obvious that the penicillins are far more widely used than other antibiotics. All but three doctors used more penicillin than any other antibiotic, generally very considerably more.
55
PRESCRJBING IN GENERAL PRACTICE
TABLE 2 ANTIBIOTICS AS A PERCENTAGE OF PAEDLATRIC PRESCRIPTIONS
Non-paediatric doctors
DHSS class
Paediatric doctors
Penicillins Other Tetracyclines Streptomycins Antifungal
20*87 4 45 3 *85 0*47 0*32
18'66 6 59 4* 74
Total
29 *97
30 *66
O*67
One paediatric and two non-paediatric doctors were relatively heavy prescribers of tetracyclines which amounted to 13-19 per cent of their total prescriptions for children. It is generally agreed that these are best avoided for children under 12 years of age, but is difficult to comment on this particular use without an age analysis of the patients involved, who included the 12-14 year olds.* However, surveys have suggested that this age group is unlikely to form a large part of the family doctor's case load. Work done on material drawn from the General Household Survey showed that the older the child the less likely is an illness episode to be presented to the doctor (Dajda and Mapes, 1976). It seems improbable then, that tetracyclines were prescribed solely for the older children. Two doctors, one in each group, were heavy prescribers (17 and 27 per cent) of the lauryl sulphate ester of erythromycin ('Ilosone') in preference to the penicillins, of which they prescribed little. Because of the risk of cholestatic hepatitis with repeated courses of treatment, the use of this preparation would not normally be recommended as one of first choice. (2) Respiratory system This group is in the top three for 20 of the 30 doctors and for only one is it ranked as low as sixth. It appears that four out of five children treated by doctors in the paediatric group, and three out of four in the non-paediatric receiving treatment affecting the lower respiratory system, had prescriptions including expectorants and cough suppressants. ' Benylin with codeine ', ' Actifed ' linctus and syrup, and ' Sancos ' linctus were among the most frequently prescribed. If the paediatric group's prescribing is compared with the non-paediatric there is little difference (t=0 .760), but there is a significant difference between Lancashire/September and Cheshire/February (t=2 861; p
PRESCRIBING IN GENERAL PRACTICE
labelled may well feel that the DHSS has a tendency to view high-cost prescribing as bad prescribing and the DHSS may associate their high-cost prescription findings with bad prescribing without knowing whether some of their findings would occur amongst prescription samples from non-high-cost prescribers. Conversely, having been labelled or having a chance of being labelled a high-cost prescriber may affect the attitude of prescribing doctors toward the DHSS. Conclusions By monitoring prescribing costs some doctors are labelled as ' high-cost prescribers'. The findings of this study suggest that those doctors investigated for high-cost prescribing during their first few years as principals in general practice expressed a greater need for further training and information on drug prescribing than other prescribers. It is significant that they tended to be foreign-trained and to practise in small partnershipsfactors which could have contributed to their need for help.
10. SPECIALTY INTERESTS AND PRESCRIBING PATTERNS: AN EXAM[NATION OF PAEDIATRIC PRESCRIPTIONS JEAN CLEARY
Many doctors in general practice have trained and have an interest in one or more specialist areas of medicine and many have postgraduate qualifications in them. It would be interesting to discover whether the present organisation of general practice allows them to make use of their special knowledge. We know from the answers to our second questionnaire that more than 100 respondents expressed interest in paediatrics, while the prescription data available to us give information about prescriptions which were written for patients under 15 at the time of collection. It was decided to compare the prescriptions for children issued by a group of doctors with an interest in paediatrics with another group to see whether this interest was reflected in the nature of their prescribing. The subject was thought worthy of study, also, because little has been published about prescribing for children. The samples A sample was selected of those doctors in the cohort who practised in Lancashire and Cheshire, who held the Diploma in Child Health (DCH) and/or had described paediatrics as a particular interest in their responses to the 1972 questionnaire. There were 15 of these doctors (the paediatric doctors) and a further 15 respondents were randomly selected from the same area (the non-paediatric doctors). The Lancashire doctors' prescribing had been analysed in September 1972 and the Cheshire ones in February 1973. The two groups of doctors were of a similar age; those in the paediatric group had a mean age of 37 8 years (range 28-51 years), and those in the non-paediatric group had a mean age of 34 9 (range 27-53 years). The difference between the means is not significant (t= 1 * 158). Two of the paediatric doctors were women and one of the non-paediatric, an unexpectedly low proportion since nearly one quarter of the cohort are women, and slightly more (28 per cent) of those who expressed a special interest in paediatrics. In the paediatric group six doctors held a DCH, four of these also had other postgraduate qualifications, and two had postgraduate qualifications in fields other than paediatrics. Eight had qualified in the United Kingdom and seven elsewhere; ten worked in- Lancashire and five in Cheshire. The non-paediatric group included six with postgraduate qualifications, ten having qualified in the United Kingdom and five elsewhere;
PRESCRMING
53
IN GENERAL PRACnCE
eight worked in Lancashire and seven in Cheshire. The 12 overseas doctors held 12 of the 23 postgraduate qualifications of all the 30 doctors; they were slightly, but not significantly, older than the UK doctors, the mean age of the overseas doctors was 37 1 years (range 28-51 years) and the UK doctors 33 *3 years (range 27-53 years; t=0 * 196). Method
Prescriptions dispensed for each general practitioner in the cohort were recorded individually and then classified into 88 DHSS therapeutic classes which were further reduced into 14 broad groups. The number of prescriptions in these categories has formed the basis of this study of the two groups of doctors; where more detail was required the therapeutic classes or the individual prescription items have been used. Volume of prescribing We have no direct evidence of the number of prescription forms written for children, but if we assume that the number of prescription items per prescription form is the same for both adults and children, and adjust the totals for the greater length of September, we get an estimated total of 1,825 prescription forms for the paediatric group (range 40200, mean 122, mean prescriptions per form 1 77) and 1,173 for the non-paediatric, (range 43-180, mean 118, mean prescriptions per form 1 .62). There was great dispersion among doctors in the number of prescription items issued to children (paediatric prescriptions) both absolutely and as a proportion of the total, but we cannot yet say whether a large number of paediatric prescriptions issued reflected a larger proportion of children seen.
Pattern of prescribing There was a considerable variation among members of the samples in the number of paediatric prescriptions dispensed during the month analysed, ranging from 58-373 (paediatric, mean 211 13, s.d. 85 18, non-paediatric, mean 190 07, s.d. 60 14). This variation may have been caused by the presence or absence of the doctor during the month, variations in morbidity, as well as selection of a particular doctor by patients, or of patients by doctors within a practice. In general, therefore, percentages of total prescriptions or paediatric prescriptions have been used in order to demonstrate the pattern of prescribing. The proportion of paediatric prescriptions ranged from about ten per cent to 33 per cent in the paediatric group, and from ten per cent to 40 per cent in the non-paediatric group. How these were divided among the fourteen broad groups is given in table 1. Only one doctor in the paediatric group prescribed drugs in all the 14 therapeutic groups for children, none in the non-paediatric group did. The range for the rest of the paediatric group was 9-13, and 9-12 for the non-paediatric group. All the doctors, however, used all the groups in their prescribing for adults. Of the groups least used for children, one, the genitourinary system, was much the smallest for adults also, but the anti-rheumatic ranked eighth for adults with both samples of doctors. The patterns of prescribing for the paediatric and non-paediatric doctors are strikingly similar (Spearman rank order correlation-=0 985, no pair of ranks differing by more than one point), and only two categories vary by as much as two per cent. The same two therapeutic groups were much the largest for both sets of doctorsthe anti-infectives and the respiratory group. In both cases these accounted for about half the paediatric prescriptions and, if we use the estimated total of prescription forms for children, we find that more than half of them included an anti-infective (91 per cent of which were antibiotics) and more than a quarter a cough medicine or bronchodilator. The next two largest groups were preparations affecting the skin and the anti-allergics,
54
PPMCRIBING
IN GENERAL PRACTICE
TABLE 1 PAEDIATRIC PRESCRIPTIONS BY THERAPEUTIC GROUPS
Paediatric doctors Therapeutic group % of DHSS abbreviated classes' Rank Number items2 title
39-48 Anti-infective 17-21 Respiratory 76-81 Skin-topical 66-68 Anti-allergic Eye, ENT, topical 69-75 23,29-34 Analgesics 01-08 Alimentary Psychotropics 22,24-28 82-88 Others Haematopoietic 58-64 49-57 Metabolic CVS & diuretics 09-16 35-38 GU system 65 Anti-rheumatic
Total
1 2 3 4 5 6 7 8 9 10 11 12 13
14
1040 517 309 244 237 215 203 130 126 103 17 14 8
4
3167
32*84 16-32 9 76 7 70 7 48 6 79
6*41 4*1o 3*98 3 25 0*54 0*44 o025 0*13 99*99
% of total3
6*22 3*o9 1*85 146
1P42 1-29 121 0 78 -
0o75 0 62 0o10 0*08 005 0*02 18*95
Non-paediatric doctors _ % of % of Rank Number items items4 1 2 4 3 5 7 6 8 9 10 12 11 13
953 466 292 351 211 150 161 130 56 51 9 13 4
13
4
33*42 16*35 10424 12*31
5*41 2-64 1-66 1 99
7 40
1P20
s526
085 091 0 * 74
565 4 s6 1P96 1 79
0o32 0*46 0414 0414
2851 100*0
2*12 0-29 0*05 007 0*02 002 16 17
'Full DHSS class descriptions will be found in the appendix. 'Per cent of total prescription items for children. 'n=16,714, total items for adults and children. 4n= 17,627, total items for adults and children.
which together comprised 17 * 5 per cent of the paediatric group's items for children and 22 5 per cent of the non-paediatric. It might be argued that seasonal variation was responsible for differences in prescribing rather than any characteristic of the doctors involved, but when we considered this aspect of the material we again found few differences, that is, when we compared the figures for September (18 Lancashire doctors) with those for February (12 Cheshire doctors) the rank order correlation for the 14 broad therapeutic categories is 0 -938, very slightly less than that for the paediatric/non-paediatric comparison (0 985). The greatest difference was a preponderance of respiratory tract preparations in September. While none of them was very large the differences were, with one exception (anti-allergic), bigger than the differences between the paediatric and non-paediatric groups. The largest groups of prescribed drugs (1) Antibiotics The antibiotics are the most important feature of the prescribing of nearly all the 30 doctors under consideration ranking first for 24 of them, second for five and down to fourth (after the respiratory, allergic, and skin groups) for the remaining one. For only four doctors does the proportion of antibiotics prescribed for children form less than 20 per cent of prescribed items, while for six it is between 45 and 50 per cent: the mean is about 30 per cent. The category of antibiotics can be broken down into the six DHSS classes: penicillins, tetracyclines, streptomycins, chloramphenicol (which was not prescribed by any doctor in either group) antifungal antibiotics, and others (table 2). It is obvious that the penicillins are far more widely used than other antibiotics. All but three doctors used more penicillin than any other antibiotic, generally very considerably more.
55
PRESCRJBING IN GENERAL PRACTICE
TABLE 2 ANTIBIOTICS AS A PERCENTAGE OF PAEDLATRIC PRESCRIPTIONS
Non-paediatric doctors
DHSS class
Paediatric doctors
Penicillins Other Tetracyclines Streptomycins Antifungal
20*87 4 45 3 *85 0*47 0*32
18'66 6 59 4* 74
Total
29 *97
30 *66
O*67
One paediatric and two non-paediatric doctors were relatively heavy prescribers of tetracyclines which amounted to 13-19 per cent of their total prescriptions for children. It is generally agreed that these are best avoided for children under 12 years of age, but is difficult to comment on this particular use without an age analysis of the patients involved, who included the 12-14 year olds.* However, surveys have suggested that this age group is unlikely to form a large part of the family doctor's case load. Work done on material drawn from the General Household Survey showed that the older the child the less likely is an illness episode to be presented to the doctor (Dajda and Mapes, 1976). It seems improbable then, that tetracyclines were prescribed solely for the older children. Two doctors, one in each group, were heavy prescribers (17 and 27 per cent) of the lauryl sulphate ester of erythromycin ('Ilosone') in preference to the penicillins, of which they prescribed little. Because of the risk of cholestatic hepatitis with repeated courses of treatment, the use of this preparation would not normally be recommended as one of first choice. (2) Respiratory system This group is in the top three for 20 of the 30 doctors and for only one is it ranked as low as sixth. It appears that four out of five children treated by doctors in the paediatric group, and three out of four in the non-paediatric receiving treatment affecting the lower respiratory system, had prescriptions including expectorants and cough suppressants. ' Benylin with codeine ', ' Actifed ' linctus and syrup, and ' Sancos ' linctus were among the most frequently prescribed. If the paediatric group's prescribing is compared with the non-paediatric there is little difference (t=0 .760), but there is a significant difference between Lancashire/September and Cheshire/February (t=2 861; p
