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Gold, incentives and meh

Variation in uptake of new prescribing guidance by GPs, study finds

There is substantial variation in the speed at which GP practices adopt new prescribing guidance according to a large study which analysed two treatment switches. 

Analysis of OpenPrescribing.net data of the move from Cerazette to generic desogestrel in 2012, and from trimethoprim to nitrofurantoin as first-line antibiotic choice for UTI in 2014 showed while most practices did ultimately change their behaviour, some were much later to do so than others.

The study – thought to be the largest of its kind – also found a difference in how quickly practices fully moved to the new prescribing advice once they started to adopt it.

Writing in the BMJ, the researchers said the results had important implications for avoidable healthcare costs and improving patient care but also showed their technique could be used as an audit tool to boost uptake.

Using an automated technique which looked at both the magnitude and speed of uptake of the prescribing guidance month by month, the researchers showed that a large proportion of practices shifted away from prescribing branded Cerazette in early 2013, but a quarter did not show their most substantial change for 14 months, with the slowest 10% lagging a further six months behind.

On the antibiotic switch, a quarter of practices did not make their largest change for 29 months and 10% did not change until at least 32 months after the new guidance was issued.

The figures also showed a large variability in pace of change once practices had started to adopt the new rules, with the highest quarter of practices reducing Cerazette prescribing swiftly, by at least 26% in one month, while the lowest quarter of practices reducing it gradually, by less than 2% per month.

In their paper, the authors did point out that the antibiotic guidance was less clear, with some clinical judgment involved, compared with the ‘always prescribe the generic’ advice in the move to desogestrel.

Study leader Dr Ben Goldacre, director of the EBM Datalab at the University of Oxford – the team behind OpenPrescribing.net – said more work was now needed on the reason for the variation.

He said: ‘In lay terms, most practices changed their behaviour but some changed much later than others; and some practices showed rapid, coordinated change, while others changed only gradually.’

He concluded: ‘This method creates new opportunities to improve patient care through audit and feedback, by moving away from cross-sectional analyses and automatically identifying institutions who respond rapidly, or slowly, to warranted changes in clinical practice.’

Dr Samuel Finnikin, a GP in Sutton Coldfield and research fellow at the University of Birmingham said the implementation gap was not a new problem but there were more tools available to analyse the data.

He added that while incentivisation was one option, as had happened with trimethoprim to nitrofurantoin, money would be better spent on implementation teams who look at the data, identify practices that are behind the curve ‘and then visit them to understand why and help them change’.

‘We could also design our systems better to support decision making. But this has been an aspiration for a long time without any real change.’

He added: ‘At the moment, GPs are inundated with information from lots of sources, and it is difficult to keep up. We’re better as identifying the change laggards but no better at doing anything about it.’

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