GP practices are being urged to standardise their approaches to routine testing and monitoring of drugs, after new data revealed a significant variance in compliance across key safety indicators both for high risk prescriptions and many routinely prescribed drugs.
The new figures, from analysis of usage of OptimiseRx, the prescribing decision support tool used by two thirds of Clinical Commissioning Groups, suggest the need for prescribers to increase essential routine testing of clinical markers for patient harm from medications, and for more robust recording of test results into the primary care clinical system.
OptimiseRx is used within 4,000 practices in England and Wales covering 35.5 million patients. It prompts prescribers to monitor patients if evidence of routine drug monitoring recommended by Royal College of General Practitioners (RCGP) safety indicators is not found in the patient record.
Initiatives such as the Quality and Outcomes Framework (QOF) and prescribing incentive schemes have led to improvements in the requesting, recording and evaluation of results for specific therapeutic areas.
But 2018/19 figures from FDB’s OptimiseRx show a concerning mixed picture on safety adherence. This underlines the need for all practices to have robust processes for drug monitoring and recording of results for patients on long term medications.
In the case of the mood stabiliser lithium, for instance, monitoring prompts through OptimiseRx arose for an average 3% of prescriptions against the relevant RCGP indicator where no evidence of test results were found in the previous six months.
However, prescribers in hundreds of practices using OptimiseRx had no prompts for lithium testing presented, indicating that it is possible to adopt successful protocols at practice-level for the ordering of tests and results recording, guarding against a range of side effects from potential drug toxicity.
Conversely for amiodarone prescriptions where its side effects are of continuing clinical concern, prescribers were alerted on more than one in five occasions to the absence of a thyroid function test being recorded.
Prompting for appropriate monitoring of liver function in the same patient group was lower, with 16% of prescriptions not having evidence of liver function tests recorded in the previous nine months. This could potentially be explained by other clinical reasons for routine liver function tests being initiated.
Prescribers of ACE inhibitors and ARB medication were prompted just under 3% of occasions where they were identified as not meeting monitoring test criteria in relation to kidney function, like urea and electrolytes, within the last fifteen months.
But in relation to diabetic patients taking metformin there was an 8.5% incidence of serum creatinine tests – a monitor for potential kidney impairment – being missed or not recorded within the necessary 12 month period.
The OptimiseRx technology helps GPs and other prescribers make decisions that comply with local and national prescribing priorities. This includes alerting them when more cost effective alternatives are available, and by providing patient-specific prescribing recommendations based on the patient’s record to ensure safe and effective prescribing.
Dr Simon Hendricks, Product Innovation Manager at FDB, said: “Our new analysis of drug prescribing patterns across practices in England and Wales shows quite dramatic differences in evidence that essential monitoring tests are being undertaken.
“This may be partly a reflection of the management of patients across care settings and shared care arrangements or simply a variation in how reliable systems are for practices entering on patient records when a test has been carried out. Further work, in partnership with other relevant organisations, will uncover whether the absence of routine ordering of tests for one medication correlates with an absence of processes relating to drug therapeutic monitoring and recording of results in general.”
“In highlighting to prescribers when there is no record of an essential test being carried out, within a specified timeframe, we are providing a valuable reminder that the prescriber is responsible for the ongoing safe management of patients’ long-term use of medications.”
