Background
Methods
Design and setting
Indicator selection
Indicator topic | Indicator details |
---|---|
Risky prescribing | Avoidance of the following prescribing combinations: |
• Prescribing of a traditional oral NSAID or low-dose aspirin in patients with a history of peptic ulceration WITHOUT co-prescription of a gastro-protective drug. | |
• Prescribing of a traditional oral NSAID in patients aged 75 or over WITHOUT co-prescription of a gastro-protective drug. | |
• Prescribing of a traditional oral NSAID and aspirin in patients aged 65 or over WITHOUT co-prescription of a gastro-protective drug. | |
• Prescribing of aspirin and clopidogrel in patients aged 65 or over WITHOUT co-prescription of a gastro-protective drug. | |
• Prescribing of warfarin and a traditional oral NSAID WITHOUT co-prescription of a gastro-protective drug. | |
• Prescribing of warfarin and low-dose aspirin or clopidogrel, WITHOUT co-prescription of a gastro-protective drug. | |
• Prescribing an oral NSAID in patients with heart failure. | |
• Prescribing an oral NSAID in patients prescribed both a diuretic and an ACE-inhibitor / ARB. | |
• Prescribing an oral NSAID in patients with chronic kidney disease (stages 3, 4 and 5) | |
Treatment targets in type 2 diabetes | Achievement of all three recommended levels: |
• Blood pressure below 140/80 mmHg (or 130/80 mmHg if there is kidney, eye or cerebrovascular damage). | |
• HbA1c value below or equal to 59 mmol/mol. | |
• Cholesterol level below or equal to ≤ 4.0 mmol/l in patients who are 40 or older. | |
Blood pressure targets in treated hypertension | Aim for a target clinic blood pressure below 140/90 mmHg in people aged under 80 years with treated hypertension. |
Aim for a target clinic blood pressure below 150/90 mmHg in people aged 80 years and over with treated hypertension. | |
Anticoagulation in atrial fibrillation | In patients with atrial fibrillation who are either post-stroke, or have had a transient ischaemic attack: |
• Warfarin should be administered as the most effective thromboprophylactic agent. | |
• Aspirin or dipyridamole should not be administered as thromboprophylactic agents unless indicated for the treatment of comorbidities or vascular disease. | |
Those patients with AF in whom there is a record of a CHADS2 (congestive heart failure, hypertension, age >75, diabetes mellitus, and prior stroke) score of 1 should be offered anticoagulation drug therapy or anti-platelet therapy. | |
Those patients with AF whose latest record of a CHADS2 score is greater than 1 should be offered anticoagulation therapy. |
Sample
Interview procedure
Data analysis
Results
Recommendations | GP | Practice manager | Nurse | Total |
---|---|---|---|---|
Risky prescribing | 8 | 3 | 4 | 15 |
Treatment targets in type 2 diabetes | 7 | 4 | 4 | 15 |
Blood pressure targets in treated hypertension | 7 | 4 | 4 | 15 |
Anticoagulation in atrial fibrillation | 7 | 3 | 5 | 15 |
Total | 29 | 14 | 17 | 60 |
Characteristic | Number | Percent | |
---|---|---|---|
Gender | Male | 18 | 30 |
Female | 42 | 70 | |
Age group (years) | 20–29 | 1 | 2 |
30–39 | 12 | 20 | |
40–49 | 23 | 38 | |
50–59 | 19 | 32 | |
60–69 | 5 | 8 | |
Role | GP | 29 | 48 |
Nurse | 17 | 28 | |
Practice manager | 14 | 23 | |
Years’ experience in general practice | Mean | 14 | |
Range | 1 to 33 |
Theoretical domain determinants by indicator
Risky prescribing | Treatment targets in type 2 diabetes | Anticoagulation in atrial fibrillation | Blood pressure targets in treated hypertension | |
---|---|---|---|---|
Knowledge | GPs more knowledgeable compared to other staff Awareness of drug interactions and patient history | Variable awareness of recommended HbA1c levels Important to know the rationale and evidence behind recommendations Guidance generally familiar as standard practice | Indicators familiar because of QOF Important to have access to specialist knowledge Treatment often initiated in secondary care Lack of staff experience in starting treatment given relatively infrequent clinical presentation in primary care | Indicators familiar because of QOF Indicators ingrained as ‘bread and butter’ of general practice |
Skills | Communication skills for effective patient counselling Limited time to use skills (e.g. communication) | Communication skills for effective patient counselling Having technical skills such as medication titration Skills for monitoring and managing blood pressure more common than those for HbA1c | Communication skills for effective patient counselling | Communication skills for effective patient counselling Technical skills such as using blood pressure machines, obtaining reliable readings and titrating treatment |
Social professional role and identity | Prescribing perceived to be mainly the role of GPs. Practice nurses viewed their input as restricted to reviewing medication if required GP autonomy to deviate from guidance Threat of litigation reinforces nurse prescribers’ adherence to guidance Recognition of role of pharmacist Prescribing practice driven by perceived patient needs and professional ethos rather than guidance | Refer to diabetic lead if patient taking multiple medications Clarity of roles and responsibilities Tailoring care to patient needs and professional ethos more important than achieving strict targets | Tailored patient care can both help and hinder adherence (e.g. in elderly patients and patients with multiple conditions) Role more focused on long-term rather than acute care as atrial fibrillation often initially presents to secondary care Hospitals not always as up to date with guidance as they should be, resulting in wrong or contradictory advice for primary care Clinicians with more cardiac expertise tend to be responsible for most patients Practice nurses viewed their input as restricted to reviewing medication if required | Clarity of roles and responsibilities Professional ethics and threat of litigation promote adherence Tailoring care to patient needs and professional ethos more important than achieving strict targets |
Beliefs about capabilities | Clear guidance and access to specialist knowledge and training Adequacy of information technology system support | Confidence in ability to achieve targets depends on patient factors such as attendance and motivation Many clinicians confident with blood pressure and cholesterol but less so with HbA1c and any associated medication changes Organised links between primary and secondary care Confidence in diabetes lead Information technology capability to identify patients not achieving targets | Confidence related to availability of specialist staff, training and updates Supportive, organised links between primary and secondary care | Confidence helped by relative simplicity of guidance and decision support Confidence hindered by patient factors and limited resources for referrals |
Beliefs about consequences | Ensuring quality of care, patient health and patient safety Reputation for following guidance reflects well on practice and professional Perceived threat of litigation to nurse prescribers if guidance not followed Immediate financial and time costs (prescribing budget, increased appointments, auditing) outweighed by the potential longer term NHS cost reduction | Achieving targets linked to quality of care and better patient outcomes Achieving targets associated with short term gains in QOF income and longer term NHS savings Job satisfaction in achieving targets Perceived pressure to achieve targets undermines rapport with patients Achieving targets requires time and increases workload Costs for patients and side effects from additional prescribing to achieve targets | Ensuring quality of care, patient health and patient safety Achieving targets associated with short term gains in QOF income and longer term NHS savings Strict adherence to guidance inappropriate for some patients (e.g. elderly and those on multiple medications) | Ensuring quality of care and patient health Achieving targets associated with short term gains in QOF income and longer term NHS savings Perceived increased workload associated with following guidance (e.g. consultation length) |
Motivation and goals | Adherence ensures quality of care, patient health and patient safety Promoting a positive reputation for the practice Guarding against litigation Incentivisation of good prescribing Generally high motivation to follow guidance | Achieving targets associated with short term gains in QOF income and longer term NHS savings Achieving targets linked to quality of care, better patient outcomes and job satisfaction | Ensuring quality of care, patient health, and patient safety Achieving targets associated with short term gains in QOF income and longer term NHS savings | Ensuring quality of care, better patient health and job satisfaction Achieving targets associated with short term gains in QOF income and longer term NHS savings Generally high motivation to follow guidance |
Memory, attention and decision processes | Information technology systems often not in line with intuitive cognitive processes Decision aids and prompts for drug interactions Patient history provides important information for decision making Automatic cognitive processes useful in high-risk situations | Awareness of patient characteristics such as older age can influence decision of whether or not to aim for targets System prompts useful for embedding targets into memory | Relatively infrequent presentation of atrial fibrillation hinders commitment of guidance to memory Prompts and the ability to view guidance support decision making | High prevalence of hypertension helps embed guidance into routine practice Patient characteristics (e.g. older age) can influence tailored care to meet patient’s needs Guidance considered easy to retain Prompts useful for supporting adherence to guidance |
Environmental context and resources | Practice nurses pick up medication issues during reviews but lack knowledge and suitable templates sometimes impede this Prescribing policies, support and advice available from CCG medicines management teams and pharmacists Lack of time (e.g. training and education) and decision support. Inadequate information technology systems and communications with secondary care | External support from CCG, information technology systems and training opportunities Low staffing levels and high workloads Communication between primary and secondary care could be improved to support achievement of targets | Communication systems and established lines of responsibility within the practice are needed in order to identify potential issues around professionals’ adherence Inadequate communication between primary and secondary care Time and workload, especially as current information technology systems do not support easy identification of eligible patients | Established lines of responsibility, clear templates and access to training and education (e.g. motivational interviewing and titration for nurses) Limited availability of home blood pressure machines, heavy workload and short duration of consultation makes it difficult to schedule a specific time to measure blood pressure which contributes to difficulties in achieving targets |
Social influences | Patient preferences General approach and support of practice team | Pressure from QOF to achieve targets Practice managers aware that achieving targets is linked to practice QOF performance Benchmarking performance against other practices Overall team approach in practice | Pressure from QOF to achieve targets General approach and support of practice team Patient preferences | Pressure from QOF to achieve targets Team factors and support within and outside the practice (e.g. network meetings Benchmarking performance against other practices Patient preferences |
Emotion | Emotion generally not considered an influence Discomfort when guidance conflicts with patient-centred care Feeling constrained by guidance Feelings of caution and worry when prescribing additional medication Workload-related fatigue restricted ability to have in-depth conversations with patients | Achieving targets lead to job satisfaction Adverse impacts of fatigue on achieving targets Frustration from patient factors (e.g. resistance, low motivation) and missing targets Perceived pressure from targets which can generate tension between clinicians and patients | Frustration caused by complicated guidance making treatment difficult to explain to patients Limited time, mood and fatigue result in deferring decisions to further consultations Discomfort with pushing adherence amongst elderly patients | Emotion generally not considered an influence Achieving targets lead to job satisfaction Fatigue and workload influence whether targets were considered at every consultation Unease created by patient reactions to additional prescribing |
Behavioural regulation | Computer prompts for drug interactions, templates, audit and medication reviews Problems associated with rapidly accessing and interpreting full patient records Computer prompts not always useful – can be overwhelming | Help from computer prompts, recall systems, clear protocols and templates Action sequences helpful (e.g. reviewing patient medical notes and setting electronic reminders for action to self within patient record) | Help from computer prompts, recall systems, clear protocols and templates Limited ability of current computer prompts to support adherence to guidance | Help from computer prompts, recall systems, clear protocols and templates Patient risk factors act as prompts Opportunistic reviews of patient records Computer prompts not always considered useful and potentially distract from main purpose of consultation |
Risky prescribing
Treatment targets in type 2 diabetes
Anticoagulation in atrial fibrillation
Blood pressure targets in treated hypertension
Meta-themes spanning multiple indicators
“I suppose it depends who you, what level you’re viewing it from, so from a GPs perspective, I would say this is bread and butter, so it’s an understanding of pharmacy, poly-pharmacy and individualising therapy.”
GP, Blood pressure targets in hypertension (P67) |
“Certainly the blood pressure, blood sugar and cholesterol are so kind of ingrained in general practice, so it would feel like second nature so I’d, you almost kind of go on auto-pilot because it’s very rare that I wouldn’t know what to do…” GP, Treatment targets in type 2 diabetes (P22) |
“…… for whatever reason nurses seem to like guidelines more than doctors, certainly here our nurses will work to templates, if they see a guideline they sort of see it as a rule, and something they’ve got to follow, whereas our doctors won’t work to templates for love nor money, and if they see a guideline they see it as something that 90 percent of the time you ignore but is handy to use now and again…”
Practice Manager, Treatment targets in type 2 diabetes (P30) |
“If the GPs want to do different that’s fine, that’s them, but I, as a nurse practitioner, stick to the recommendations, I wouldn’t have a leg, if I gave them out of the recommendations and I ended up in court I wouldn’t have a leg to stand on because I’m a nurse, right, and I would be judged that you’ve gone against regulations you’ve done this and this is the consequence the patient’s lost his life or gone in to heart failure and you’re to blame, you can’t do that, you’re putting your registration on line, you’re opening to be sued if you don’t follow them. GPs can do all sorts out of boxes, but I stick to boxes…” Nurse Practitioner, Risky prescribing (P5) |
“…but there’s always a risk with, when deploying technology such as that, is that patients, people often, doctors certainly just want to get past it cause they’ve already moved on and they’re thinking to something else, or it is totally irrelevant to what’s going on in that consultation, so you know, you’ve got a sick patient who’s got lots of pain and they’re blood pressures notched up as a consequence, and that’s totally irrelevant.”
GP, Blood pressure targets in hypertension (P67) |
“…..we will reduce our number of admissions and strokes, and they’re large strokes with atrial fibrillation, so it’s a benefit not only to reduce the number of admissions but to the patient, their quality of life and the long term burden on the NHS when you have a large stroke, with you know, on-going care, not only on their…the patient but their family, and if patients are taking aspirin and that’s carrying a risk of a bleed, then they’ve got risk with minimal difference in benefit there, so we should hopefully be, if we’re treating people effectively, then we should be reducing the number of strokes…..”
GP, Anticoagulation in atrial fibrillation (P52) |
“…our Warfarin lead is actually a prescribing lead. So I’m very comfortable that we have the right knowledge in the place…”
Practice Manager, Risky prescribing (P1) |
“Monitor more easily, and as a result of all the guidance that comes out there’s the system that we use, generally it’s either EMIS or SystmOne [brands of electronic patient records] but the computer systems being in place enables access as well to guidelines more readily more quickly, and we know when they’re going to be updated, we can see the review dates on them, so we can see you know is this guidance due for a renewal or is it due for updating, so all of that, I mean I think that kind of approach has had an impact.” Nurse Practitioner, Blood pressure targets in hypertension (P98) |
“What would make you feel more confident, is there anything that would increase your confidence to follow this recommendation? (Interviewer) … As I again said if there is an organised link between the primary and secondary care and if there is an external supporting agency like a, for a patient education and things like that, it would be relatively easy to carry on these thing, yeah….” GP, Treatment targets in type 2 diabetes (P8) |
“…..you’ve got to be able to understand it well enough yourself to explain it to the patient in terms of they understand that they can engage with and then they’re likely to understand why they should comply with something that then is quite a nuisance, potentially”
GP, Anticoagulation in atrial fibrillation (P66) |
“….yeah, communication skills is a big one, because if you can’t communicate as to why these are important you’re not going to get them to anywhere near, and obviously be aware of your actual knowledge of them…”
Practice Nurse, Treatment targets in type 2 diabetes (P51) |
“…. I had to write to cardiology who hadn’t, who had patients on aspirin or hadn’t recommended warfarin yet they had a CHADs score of two, and so it, I felt it was confusing for the patient if they’d been told at clinic that they didn’t need it, then they turned up to see a GP who said that they did, so I felt I needed clarity from secondary care, so I had to write to a relatively large proportion of patients who’d been seen by secondary care to ask and clarify the situation…”
GP, Anticoagulation in atrial fibrillation (P52) |
“….I think things are communicated much better now…….. I think we know about them sooner most practices, our practice does have a prescribing lead…….so it’s sent to one person and it’s that persons responsibility to then erm give the information to the other members of the, of the team. The use of a good clinical computer system always make it easy if you have the information there …….if you have a formulary then obviously things are added that are recommended, that again makes it easier…… because clinicians do have an awful lot to think about in a ten minute consultation ……. so yeah.”
Practice Manager, Risky prescribing (P23) |
“….I think you’re always looking for other options really, do the patients really need to go on an NSAID, you know, more so now than a few years ago, I think sometimes you do feel a little bit sorry for patients, I’m thinking of one particular chap that was riddled with arthritis that said you know he was willing to take his chances with NSAIDs taking them all the time because he felt so much better taking them than he did when he didn’t, everything else he’d tried didn’t help so for him on balance he was happier taking them and going, you know, taking his chances rather than not taking them at all, and I think sometimes you do feel a little bit sad, really, for the patients, but, yeah, I mean you’ve to try and do what’s right haven’t you..”
Nurse Practitioner, Risky prescribing (P28) |
“… it depends how complex the patient is, depends on what, what else they’ve got going on and if, if it’s a patient that’s quite happy to take a medication if you recommend it then it’s fine, but if they, if they’re quite resistive or they’ve had side effects to other medications then picking the best one is probably, it can be stressful”
GP, Treatment targets in type 2 diabetes (P13) |
“…And I think also for people who are quite elderly and frail, to be on warfarin, maybe when they’ve not go so many, you’re thinking they’ve not got so many years left of their life and they might be prone to falls and that sort of thing, maybe it’s not always appropriate for them…..”
GP, Anticoagulation in atrial fibrillation (P73) |
“… it’s a risk benefit thing so if there are no other painkilling options and someone has inflammatory arthritis where anti-inflammatories are known to be an effective painkilling treatment for them, there may be, you may just need to monitor them closer and, and accept that that’s a, a high risk, that balance of risks benefits needs to be taken but after discussing it with the patient”
GP, Risky prescribing (P11) |
“… I would imagine every surgery will get some patients who just refuse to come in! There’s not a lot we can do. We write out, we get in touch with them (yes), we document that, you know, at the end of the day if they’re not willing to come in we can’t do anything about it! If they’re housebound we will go to them! (Yes right) we will make sure we’ve done everything we can (ok) to get to see that patient….”
Practice Manager, Blood pressure targets in hypertension (P47) |
“… I keep going back to the patient education, again, because that’s the main thing here, if you have ruled out all of it which we are good at anyway, if we are ruling out other things which is affecting why this is not coming under control, so if we have covered all of that, if still, that case scenario, then it’s an individual kind of based on that particular patient what you need to do kind of thing….”
GP, Treatment targets in type 2 diabetes (P8) |
“… Identifying the patients getting the patients to come and see you, and then getting them to cooperate and comply with anything that you wanted to do for them…”
GP, Anticoagulation in atrial fibrillation (P66) |
“…Things that help, first of all is having the clear guidance as in what drug to choose when, so the guidance is very clear on what drugs you should use…”
Nurse practitioner, Blood pressure targets in hypertension (P44) |
“… Yeah I mean well as I say they seem to be just about the standard things that we do, and they’re all just getting lower and lower so…what is it going to be next year, you know, they’re all going to come down, but as I say that’s the hardest thing I think is then, cause you think you’ve got a patient as low as you can get and then they drop it again, you know, so it’s an on-going challenge really and, you know, a lot of people it’s fairly easy to do because they’re very compliant but, you know, 97 % of something is quite a high proportion isn’t it when you’ve got individuals involved….”
Practice Manager, Treatment targets in type 2 diabetes (P27) |
“…….. you would want to have a look at the recommendations and check that they’re done on sound evidence, erm that’s probably the first thing, if it… if it’s consistent with what everything else is, so is it a guideline that’s been developed purely for cost saving grounds or is it one that’s been developed cause of… there’s clinical concerns and the…and you do get a bit of both sometimes so either… and one combined together, so I think it’s making sure and checking that that’s appropriate and it’s transferrable to your patient population as well…”
GP, Risky prescribing (P11) |