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The Pharmaceutical Journal Vol 265 No 7114 p401
September 16, 2000 The Conference

Practice research award lecture

The many faces of prescribing

This year's Practice Research Award was presented by Mrs Christine Glover (President of the Royal Pharmaceutical Society) to Ms Judy Cantrill at the British Pharmaceutical Conference in Birmingham on September 10. Accepting the award, Ms Cantrill said that it was an enormous pleasure to receive such an acknowledgment of her work

In her lecture, Ms Cantrill discussed the measurement of the appropriateness of long-term prescribing in general practice, and explored the relationship between health services research and pharmacy practice research.
She said that rational prescribing had been defined as prescribing that was appropriate, safe, effective and economic. Since the inception of the National Health Service, general practitioners had been accused of inappropriate prescribing; Ms Cantrill's aim was to determine whether inappropriate prescribing occurred in long-term prescribing. Her first step had been to look at the research evidence by carrying out a systematic review for the period 1980 to 1995. This identified 62 relevant studies, of which only 22 met predefined methodological criteria. It was apparent from the studies identified that there was no clear definition of how to measure the appropriateness of prescribing. Also, the research that had been carried out was narrow, ie, it involved only specific drugs or specific conditions and did not take into account the whole patient view. Reviewing the literature had identified that there was a need to develop a measure for looking at the appropriateness of prescribing for individual patients.
This had led on to step two of the programme, which was to conceptualise appropriateness and develop research tools and methods that could be used in its investigation. For this, Ms Cantrill drew on the methods and experience of the Rand Corporation in the United States. The Rand process used consensus methods to measure the appropriateness of (usually) surgical interventions, such as coronary artery by-pass grafts. This sort of approach aimed to bridge the gap between science and clinical practice by combining literature evidence with experts' opinions to form a consensus. However, there were some criticisms of this approach, namely, that it ignored patient preferences and GPs' subjective opinions, ie, their "gut instinct".
Two methods were used - the nominal group technique (involving face-to-face interviews), and the Delphi technique (involving postal questionnaires) - both of which had their origins outside health care.
Ms Cantrill's work involved forming a nominal group of nine experts, which included doctors and pharmacists. The group had been provided with a conceptual framework for the appropriateness of prescribing, and asked to generate and then prioritise criteria for assessing the appropriateness of long-term (longer than three months) prescribing based on the medical records of 103 patients. These criteria were then used to develop a questionnaire which was sent to 100 GPs and 100 community pharmacists who had previously been involved with initiatives aimed at helping to manage prescribing. This step of the investigation led to a consensus on 19 criteria from which 13 indicators of appropriateness of prescribing were produced. According to Ms Cantrill, the Rand process was considered complete after consensus was reached, but her approach was to take the process further and to test the 13 indicators in terms of inter-rater reliability. This was done using two research pharmacists who applied the indicators to the medical records of 49 patients purposely selected for known health problems. This step resulted in nine reliable indicators, such as:

Judy Cantrill
Judy Cantrill: pharmacy has a great deal to offer

The final stage was to test the validity of the indicators. Ten GPs in each of five family health service authorities had been asked to apply the nine indicators to patients that were again selected by purposive sampling. One hundred and one patients had been identified with 227 examples of potentially inappropriate prescribing. These were then classified into:

Some of the qualitative findings of this research were GPs' comments about inappropriate prescribing. For example, GPs listed patient pressure for branded medicines, historical prescribing, hospital-led prescribing, and problems with repeat prescribing as reasons for inappropriate prescribing.

In summary, the outcome of this body of work had been the development of nine valid, reliable indicators to identify potential inappropriate long-term prescribing. Continuing, Ms Cantrill said that this was a useful research tool, but that it was "very labour intensive". The next stage, she said, was to develop the tool in terms of computerising the indicators. Funding for this had now been obtained from the NHS information technology bid, and her group was collaborating with people working in medical informatics and with GP software system producers to take the development forward.
Taking a look at the future for this area, Ms Cantrill said that it was important to seek the views of patients together with the view from secondary care. "The views of new breeds of prescribers, such as nurses and pharmacists, will also be important as we move forward," she said.
For the second part of her lecture, Ms Cantrill gave her reflections on the relationship between health services research and pharmacy practice research.
Health services research drew on a wide range of methods from several disciplines, and needed input from and an understanding of science, clinical and practice issues. It also acknowledged the society within which it was placed, and was often responsive to current policy. However, to be of value, health services research needed to be translated into action.
"Researchers should guard against too much research and not enough development, and practitioners should guard against too much development and not enough research," Ms Cantrill warned. To explain this statement, she drew an analogy with the drug development process where a drug might be intensively researched, but never reach clinical practice.
Pharmacy had a great deal to offer health services research. Pharmacists had not only clinical and scientific expertise, but also a wealth of practice experience, resulting in a combination of theoretical and applied research. And pharmacy stood to gain from health services research in that it puts pharmacy and pharmacists on the wider health agenda.
Concluding, Ms Cantrill said that she hoped that the work she was doing offers a tool to facilitate the management of repeat prescribing.