What was the aim of the evidence review?
It is well documented that older people with multiple chronic medical conditions are taking several different medications. However, only a small number of patients will benefit from the drugs they are treated with. The driver for this evidence review was to better communicate such information to GPs and provide them with clarity about the effectiveness of commonly prescribed drugs, to reduce unintended harm.
Who completed the evidence review?
Dr Julian Treadwell, Salaried GP, Hindon Surgery, Wiltshire and NIHR In-Practice Fellow, Nuffield Department of Primary Care Health Sciences, Oxford. This evidence review was undertaken when Julian was a GP Clinical Evidence Fellow with Wiltshire Clinical Commissioning Group (CCG) 2014 – 2015.
What did they do?
Julian drew on Cochrane reviews, related publications and clinical trials.
What did they find?
Julian found national documents recommending a more rational approach to prescribing. GPs are expected to use their clinical judgement when applying evidence to individuals, even though most guidelines are based on evidence from trials on middle-aged patients with single conditions.
Compiling ‘at a glance’ information about common treatments used in primary care could help GPs with their decision-making for patients with multiple chronic medical conditions by providing data on less effective treatment. The evidence was presented as a Rational Prescribing guide.
Who was the evidence shared with and why?
The Rational Prescribing guide was shared with the Medicines Management team, CCG Clinical Governance committee and each senior group of the three geographical localities in Wiltshire CCG, the CCG Chair and a regional Chair. Two education workshops were also held to share the evidence with GPs and Pharmacists.
How were the findings used in local decision-making?
Julian’s work put this topic ‘on the map’ and facilitated discussion. It has anecdotally led to reduced prescribing, although this has not been formally evaluated. The following factors were reported or observed at the workshops:
- GPs confidence in using ‘numbers to treat’ is not high. This is a measure of effectiveness of a medication treatment.
- GPs feel they should overprescribe as this is usually what guidelines recommend; there is a lack of guidelines for prescribing for individuals with multiple chronic medical conditions.
- Evidence-based information in the Rational Prescribing guide appeared to give GPs permission to make a confident clinical prescribing decision for a patient with multiple chronic medical conditions, which may go against the guidelines for single condition prescribing.
- The guide also presented efficacy of common treatments in an easily-accessible way, enabling GPs to discuss pros and cons of different treatments with their patients.
What has changed as a result?
Information from this work has spread through informal GP networks. The Rational Prescribing guide was downloaded 213 times from the Wiltshire CCG website over 2 years. This work has introduced a new way of thinking about prescribing.