Background
Methods
Context and study setting
Study population
Data collection
Broad questions | |
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Could you tell me a little about your experience of prescribing for your older patients Prompts: multimorbidity; polypharmacy; patient preference/demands Are you familiar with the concept of PIP or the criteria used to measure it, aside from this study? Could you tell me a little about your perspective on PIP / What’s your view on PIP in primary care? In your opinion, how is PIP important, relevant to practice? What is your opinion of the terminology used, PIP? |
Data analysis
Results
Characteristics of participants
Characteristic | OPTI-SCRIPT study N (%) | National estimatesa % |
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Number interviewed | 17 | 476 |
Male (%) | 13 (76.4) | 69.0 |
Urban practice location | 12 (70.6) | 43.0 |
Single handed practices | 3 (17.6) | 35.0 |
>10 years in practice | 14 (82.3) | No estimate |
Interview method: | ||
In person (%) | 12 (70.5) | N/A |
Telephone (%) | 5 (29.5) | |
Average interview length (minutes) | 14.5 (range 8.56 - 26.31) | N/A |
Complex prescribing environment
“Well polypharmacy is the main issue. It’s a huge fear of drug interactions and side effects you know, it’s always a challenge isn’t it? You end up adding more and more tablets to the list and do you take time to review and stop the other ones and all of that?” (GP3)
“Yes the eh, constant evolution of a person’s prescription, the lack of stability, there must be a formula somewhere, that would be a nice formula to write, that eh, you know, the complexity of managing your patient’s repeat prescription increases exponentially in relation to the number of specialists they are seeing or something like that.” (GP13)
• Mixed public and private funding • Mixed eligibility based on means-testing of income: ○ General Medical Scheme (GMS) card holders (approx. 40 % of population) entitled to free medical visits but pay a small levy for dispensed medications ■ All those aged ≥70 years are automatically eligible GMS since August 2015 ○ Doctor visit card (DVC) holders are entitled to free GP visits but pay for prescriptions in full ○ Private patients pay in full for GP visits and dispensed medications • GPs must transcribe hospital prescriptions to GMS scripts for patients to receive prescription medication for free (subject to prescribing levy) • GPs are self-employed and are contracted by the State to provide services to certain populations (e.g. GMS card holders) • No national register of GPs but it is estimated that there are roughly 2,500 • Routine auditing of prescribing activity does not take place as it does in countries such as the UK, where most prescribers are supported by pharmaceutical advisors |
“Well it limits you eh, very much, the one that stands out there was a lady with [chronic condition], so all of her medication, apart from current illness, was in the hand of the consultant. And of course I had to provide the script through her medical card system, otherwise I probably wouldn’t have seen her because it wasn’t really my prescribing.” (GP9)
“…the more complex their prescription, the harder it is for me to do my job, almost as if, the more specialist clinics that people are going to, the tighter the straitjacket I’m on. These elderly people who have a lot of symptomatic illnesses as well, you know, attend me, and I have less and less options. If all I had to do was just care about the person’s headache, or their back pain, or their pneumonia, I could just do what I would normally do. But because they are seeing 3 different specialists and because they are on 3 different suites of medicines, you know, I have to cognisant of… You know I’m not complaining about that, it’s just a fact that it does get difficult. You’ve less and less wiggle room you know.” (GP13)
“The complexity of prescribing for the elderly is a lonely game.” (GP5)
“The real difficulty that we have, ok, is that we are basically transcribing hospital prescriptions in a lot of cases onto GMS [General Medical Services Scheme] scripts, ok, and a lot of the time when we get the prescriptions, it’s from an outpatient clinic. It might be in good cases 2 weeks later, in other cases, 5 or 6 months later when we get a letter of explanation for why the changes were made, ok, so do we ignore the prescription until we get an explanation for it?” (GP21)
Paternalistic doctor-patient relationship
“I mean they will take my lead on this, of course. I mean if this is what I tell them, em, they will say ‘Yes doctor, of course’.” (GP9)“Generally the older patients do as I asked them to do, and what I mean by compliance is that they mix up their tablets, but luckily, our local pharmacy now vacuum pack them for them…I mean I know, it sounds like baby stuff but to be honest with you, we have actually gone back to as if you were telling children when they have to take everything, and it works really well.” (GP23)
“I mean it certainly amazes me how blindly they will take increases in their medications, it’s incredible you know, eh and you know, ‘Oh I’m going to increase your blood pressure tablet by one, I’m going to add another anti-cholesterol tablet, O you’re a little bit sleepless we’ll add another…’, you know, they could walk out of here with three new tablets on their eh, script, they just accept it.” (GP2)
“…sometimes, people are on tablets and they don’t know why and the reason that they are on them has long since passed” (GP22)
“Because sometimes, if a tablet is upsetting them, some of them [patients] can be embarrassed to tell you, and they just don’t take them, and they end up with a stock pile, so I ask them to bring everything in.” (GP23)
Perceived value of PIP concept
“I’ve no doubt that there is, that we do prescribe inappropriately. Or that patients are inappropriately kept on medications for long periods when, in fact, that medication may have only been prescribed, or intended for a shorter term, a shorter duration.” (GP26)
“I think in the age group we are prescribing for, my X plus patients who are over 70, are all individuals. They are individuals themselves, but in fact, they are all on different cohorts of medications. So I don’t think you can be, when you look at best practice in prescribing one agent, you really have to say best practice in prescribing one agent with maybe, anti-coagulants and maybe, anti-hypertensives, and maybe, eh, multiple inhalers, and analgesics at the same time.” (GP5)
“Sometimes, however, for example, in relation to benzodiazepine, em, you know, somebody might be on benzodiazepines and has been for 40 years, which one of the patients actually was, I don’t think it’s appropriate to stop that. If they’re stable and they can get on with their lives then I think it would cause more hassle for them and so on and so forth, so, what might be generally inappropriate might be specifically appropriate.” (GP1)
“Inappropriate connotes carelessness, and I think very few of us are careless…” (GP5)
“Potentially inappropriate prescribing, I think that’s quite good, actually, because it’s, it’s potentially. It’s not giving you an absolute.” (GP22)