Primary Care Pharmacy June 2000 Vol 1 No 3 p84-87

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Making prescribing changes - Tipton's WWWHAM

By Jenifer Harding, BPharm, MRPharmS

How one pharmacist went about changing prescribing habits in a PCG

March, 2000, and another day dawns in the life of a primary care group (PCG) pharmacist. It's cold, it's snowing, there are roadworks on the M5 and the PCG November monthly statement shows that the already horrific overspend has further increased. Is all doom and gloom? Well, no. Underneath the overspend is an indication that some things are improving and ideas conceived and set in motion some months previously, are starting to work.
Rowley Regis and Tipton PCG is in the heart of the Black Country. Tipton, part of the borough of Sandwell, with its long history of ill-health, is one of the most socially deprived areas in the country. Within the PCG is the Tipton Care Organisation (TCO), a personal medical services pilot.
The Tipton Care Organisation pilot aims to provide integrated healthcare from all agencies (both public and private, social services, the community and voluntary sectors) for all patients. By encouraging new ways of partnership working, it is hoped that the provision of more local services and improvement in the quality of service delivery will improve the health of Tipton's population. It includes all eight general practices in the area in a GP association. One GP from each practice sits on the board and it is here that prescribing decisions are discussed and approved.

Why change?

• Will patients accept the change?
• Is the efficacy of the two drugs or classes equal?
• Are the indications the same?
• Are the dose options comparable?
• Is there potential for cost saving?
• Can the change and saving be maintained?

Strengthen your case by highlighting that any cost savings made could be linked to other therapy areas. For example, appropriate use of proton pump inhibitors (PPIs) is important and, for most people with healed gastric ulcers and controlled gastroesophageal reflux disease, the evidence indicates that maintenance doses should be prescribed instead of higher treatment doses. There is also concern that safety issues surrounding long-term high dose acid suppression are unresolved. We have calculated that £80,000 could be saved at Tipton by the use of maintenance doses of PPIs, which could, for example, be used to treat 300 new patients requiring a statin.
As a final test of the validity of the change, ask yourself whether you would take your choice if you were a patient? If not, why should you expect other people to take it? Only change to drugs that you would take yourself.

Selling the idea of change

What works well? In my experience, the following:

• Visits
• Reminders - paper or computerised
• Interactive meetings
• Combinations - audit feedback/local consensus/reminders
• Ownership
• "Pats on the back"

These work less well:

• Local opinion leaders
• Patient pressure
• Educational materials - recommendations, clinical guidelines
• Didactic meetings

When to change?

To pharmacists, the change is simple and obvious, but not to GPs, who will always remember that one patient whose gastrointestinal tract rebelled when changed from omeprazole to lansoprazole.
Even having made the decision to change, GPs may not readily implement the switch and fear of extra work and problem patients is very real. However, members of one local practice that was recently involved in a change said: "The process does not impact on the practice that much and the vast majority of fears are not realised."
It is important to set a deadline for the change. It could be now, after the next practice meeting, the first of the next month, the start of the next school term. However, try to avoid Christmas and summer holidays. The risk of failure is highest when staff are fewest and/or patient demands greatest.
One of the most important things to remember is . . . be patient.3 Pushing too hard can be an obstacle to change.

Who to change

Everyone for whom it is appropriate should be considered in any change. However, remember that, with drug changes, brand loyalty among patients can be strong and reassurance may be necessary.

How to change

Once the GPs have agreed that a change is needed, a deadline can be chosen. So what happens next?
Prescribing changes can be made in four ways:

• When new patients are prescribed the drug. (Although this does not allow treatment review of existing patients)
• Opportunistically - as patients make appointments or request prescriptions. (This is cheap, builds up the GP/patient relationship, includes medication review but excludes many appropriate patients)
• Clinics - often used for PPI and asthma inhaler changes. (Clinics are the most successful of these, in terms of patient satisfaction but there are disadvantages to them, as they are slow and time consuming, expensive in staff costs and frustrating when patients do not attend)
• Computer switching - when making a computer switch, patients can be informed by a personal letter either before or at the point of change, or by a general letter attached to their first repeat prescription after the change. All letters should invite the patient to make an appointment to discuss the change with a nominated person if they wish.

Housekeeping changes, such as changing prescribing periods from 56 to 28 days, can be done in similar ways.

Action for change

The majority of large-scale change is done by computer switching. The process for this begins with collection of all evidence to support the change, the criteria are then considered and presentations of the findings and conclusions made. Options are considered and, following the decision to change, everybody involved is informed. This encourages ownership and understanding.
The letter to patients, which may be different for each practice, should include:

• Simple language without jargon
• A reason for the change (eg, current best practice, more suitable drug choice)
• A contact name and telephone number (and time if appropriate)

If the change is to medicines to be prescribed, the letter should include:

• A reassurance that patients should notice no difference after the change
• An indication, where appropriate, that the new medicine looks different (eg, a capsule rather than a tablet)
• An invitation to discuss the change

One word to avoid is "cheap". However, patients often do realise that GPs are concerned about cost and a simple explanation may be appropriate (eg, X is a cost-effective preparation, which will help GPs provide high quality treatment for more patients).
Appropriate patients are then selected and, depending upon the change and practice preference, letters are either posted to patients before or at the change, or are attached to the first prescription after the change. Patients are followed up and the practice is re-audited after an agreed interval to confirm a successful change.

Maintenance of change

Most drug or housekeeping changes are "one-off" processes. However, maintenance is crucial, as there is no point in going through the process if GPs forget as soon as the initial change is done. Reinforcement is also needed with prescribing behaviour changes to avoid an unconscious return to previous habits and the process may have to be repeated.

Outcomes

Recent prescribing revision processes in Tipton have included:

• Proton pump inhibitors - encouraging maintenance rather than healing doses
• Statins - considering cost-effective use
• Modified release preparations - brand prescribing is encouraged for clinical and cost accountability
• 28 day prescribing for those patient aged over 65
• Prescribing in multiples of 28
• Reducing prescribing of antibiotics, NSAIDs and analgesics

Prescription Pricing Authority data is currently five months behind. This means that quantifying any outcomes from work started since autumn, 1999, is difficult and often only best guesses from baseline measurements are possible. However, some outcome measurements from earlier work are as follows:

PPIs In January, 1999, most patients were taking omeprazole 20mg but by September, 25 per cent of all prescribing was for maintenance doses. This figure has now increased.

Statins Using Tipton evidence-based statin guidelines, one practice switched over 100 appropriate patients from simvastatin and pravastatin (doses up to 20mg daily) to fluvastatin 40mg daily. No major problems have been noticed and only two patients needed to be changed back. Average costs per prescription decreased by 25 per cent, while prescriptions issued increased by about 20 per cent. As the cost of fluvastatin 40mg is only £165 a year, this represents a huge potential for more cost-effective use of prescribing resources. Further changes have now been implemented.
It is worth noting that this work was done prior to the publication of the coronary heart disease national service framework. With more stringent targets, different statin guidelines may have to be issued but the process and evidence base remain valid.
Control of modified-release prescribing Prescribing of modified-release preparations can be a difficult area to understand. Generic prescribing has been strongly impressed upon GPs and the majority were prescribing modified-release drugs generically under the impression that their patients would be supplied with the same brand each time at the lowest possible cost to the GPs. This was not the case and patients were being supplied with many different brands, often at high cost.
In June, 1999, we decided to recommend brand prescribing of modified-release preparations to ensure that patients received a consistent supply. This would be at a lower cost to the GP than the brand leader, irrespective of where patients had their prescription dispensed. We chose quality products made by one company, which were widely available and were used in many hospitals.
So far, other outcomes are anecdotal. However, GPs are altering their prescribing behaviour as a result of the changes made and are verbally reporting less antibiotic, non-steroidal anti-inflammatory drug (NSAID) and analgesic prescribing. Prescribing in multiples of 28 is increasing, and the change from 56 to 28 day prescribing for patients aged over 65 has been noted by community pharmacists. All nursing homes now have 28 day prescriptions, which has resulted in an estimated annual cost saving of £300 per resident.

Why do changes fail?

Changes fail for a number of reasons. These include:

• Lack of communication
• Lack of motivation
• Lack of knowledge or skill
• Inadequate systems/procedures
• Inadequate resources

Communication is essential. Even the best planned operation will fail if one person does not know what is happening. It is important not to forget to inform receptionists and local community pharmacists and to make sure that all GPs in the practice know what is happening. Tell them several times, if necessary.
The local health authority and secondary care should also be informed of any changes. Hospitals have tended to take the lead on medication choices but, as members of one practice commented: "It must be remembered that primary care picks up the bill for the long-term prescription of expensive drugs, with possible detrimental effects on the care of the rest of the practice population".
"Why should we bother?" is a difficult to answer when busy GPs are being asked to change prescribing behaviour (which they currently perceive as adequate) and to add additional work to themselves and their already overstretched staff.
Peer pressure is a wonderful tool for modifying behaviour, as anyone with children will know. Suggest that GPs discuss their experiences among themselves. Anonymised "league" tables work well, provided each practice knows which one they are.
Involve other people, including pharmaceutical companies. They want to sell their products just as much as you want the GPs to use them, and they have useful resources. Good representatives can help ensure successful communication, especially within the community. Many companies also offer "value-added" services, support, stationary, IT skills, sandwiches (it is amazing how well food helps memory). However, make sure that that you lead any project and select the company, do not let them choose you.
Remember that however successful the overall transition and however appropriate you think the change is, there will always be patients who complain. Be prepared for this and do not think that the project has been a failure because of a few grumbles. Change is hard work. Not especially for the practices, for whom the fear of change is greater than the work involved, but for the primary care pharmacist, on whom much of the success of the change will depend.
Have a personal belief in any changes and make sure that your evidence and the rationale for change can be justified. Do not swap for the sake of swapping just to save pennies. We are all inundated by companies saying that their product is the cheapest. It may be, but is it worth it? All therapeutic areas are currently suffering from this "I am the cheapest" syndrome and your choice may be different from the next health authority or the neighbouring PCG. However, if you feel that a decision is right for your PCG and your patients, then go with it. After all, it is your money being spent on your patients.

Mrs Harding is the primary care pharmacist at Rowley Regis and Tipton primary care group

References

Further Reading