The Pharmaceutical Journal
Vol 278 No 7438 p168
10 February 2007

This article
Reprint   Photocopy

PDF 80K, Acrobat Reader

Drug Utilisation Research Group

“Gaming”: a loophole in the system

Some GPs may be excluding patients from their chronic disease registers in order to boost their incomes (a practice known as “gaming”), according to Tim Doran, clinical research fellow at the National Primary Care Research and Development Centre.

Under the general medical services contract, GPs are paid for performance measured by quality indicators that cover clinical areas, organisation, patient experience and additional services. When the contract was introduced in April 2004, the quality of clinical care for 10 chronic diseases was to be evaluated. For example, practices score points for producing a register of patients with hypertension, then there are additional points available if 90 per cent of those patients have had their blood pressure measured in the past nine months and if 90 per cent have blood pressure of 150/90mmHg or lower.

Dr Doran said that when the GMS contract was negotiated, it was accepted that quality targets would not always be appropriate (eg, for terminally ill patients) and so a provision was made for practices not to include certain patients on a chronic disease register, known as “exception reporting”. Although reported achievement is affected by a number of factors, such as practice and population characteristics, Dr Doran pointed out that exception reporting allows practices to manipulate their figures — removing patients from a chronic disease register can allow target percentages to be met. He noted that a few practices have “excepted” over 80 per cent of patients on their chronic disease registers.

Analysis of data from general practices in England in the first year of the pay-for-performance programme (2004/05) found that although exception reporting was not extensive, it was a strong predictor of achievement. One per cent of practices exclude more than 15 per cent of patients. More research is needed to determine whether these practices are excluding patients for sound clinical reasons or in order to increase income, Dr Doran said.

GP practices have achieved more than expected by the Department of Health. In year 1, median reported achievement was 83.5 per cent compared with the expected 70 per cent. Dr Doran said that in year 3 of the GMS contract there is every reason to believe achievement will be higher. “An already expensive scheme is going to be even more expensive,” he predicted. In the US, negative schemes, where GPs lose money for falling below targets, are used.

Drop in Welsh chloramphenicol prescribing since OTC switch

The number of chloramphenicol eye preparations prescribed in Wales since chloramphenicol eye drops became available over the counter has decreased, said Teerapon Dhippayom, PhD student at the Welsh School of Pharmacy, Cardiff University. Following a 2 per cent annual increase in prescribing rate in recent years, 46.9 items were prescribed per 1,000 population in 2005/06 compared with 49.8 items in 2004/05.

The research also looked at correlation between the number of OTC packs of chloramphenicol supplied to pharmacies and the deprivation score across 22 local health boards. As expected, more chloramphenicol is supplied OTC in less deprived areas.

Is dietary change worth the effort?

People are being encouraged to make healthier food choices and to achieve optimal weight in order to prevent cardiovascular disease although most dietary studies are short-lived and frequently unimpressive, according to Dennis Johnston, head of the department of therapeutics and pharmacology, Queen’s University Belfast. For example, there are no good studies of salt reduction over long periods and data must be extrapolated, he said. In addition, evidence for dietary modification is almost exclusively in high risk populations.

Another problem for both patients and health care professionals who advise them is misinformation and lack of knowledge. “Do we need a degree in food science? Does everyone know what a saturated fat or omega 3 fatty acid is,” Professor Johnston asked.

“Current food labelling is designed to mislead,” Professor Johnston added, giving examples of the use of phrases like “90 per cent fat free” (instead of 10 per cent fat) and “0.99g sodium” (instead of the higher weight of sodium chloride). “We assume that people know what the measurements mean,” he explained. Professor Johnston also blamed misinformation for the increased number of patients he sees with significant hyponatraemia: some magazines advise dieting readers to drink plenty of water so they feel full.

IT can cut incidence of drug-related deaths in the NHS

A £10,000 grant from Connecting for Health has allowed researchers to identify functions that should be incorporated into clinical decision support systems to reduce preventable drug-related morbidity in the NHS.

Researchers were able to draw up a list of 20 drug groups that were the most significant cause of drug-related morbidity. These included non steroidal anti-inflammatory drugs, warfarin and diuretics.

In addition, they say that the five categories that can benefit from clinical decision support are: dosing, cautions and contraindications, allergy, drug-drug interactions and monitoring problems.

Rachel Howard, a lecturer in pharmacy practice at the University of Reading and part of the research group, was the winner of this year’s McGavock bursary. Dr Howard told The Journal that the £500 would be put towards a future research project.