For the first time in 20 years, QPIs have landed across seven therapeutic areas to improve prescribing and prevent adverse drug events.
With medication-related problems costing $1.4 billion and causing 250,000 hospital admissions each year – two-thirds of them preventable – a new study has proposed 23 prescribing indicators to guide gold-standard prescribing for common health conditions in Australian primary care.
The research was published this week in the journal BMJ Quality & Safety.
Approved quality prescribing indicators (QPIs) included two relating to proton pump inhibitors, two to vaccinations, five to antihypertensives, four to non-steroidal anti-inflammatory drugs, two to respiratory medicines, five to mental health treatments and three to analgesics.
None of the QPIs relating to lipids met selection criteria.
The indicators instructed on appropriate initiation of medicines, ongoing monitoring and avoiding high-risk combinations, but also deprescribing when medications were no longer necessary, including reviewing antidepressant therapy after one year of treatment.
The recommendations included avoiding prescribing opioid analgesics to patients for more than one week following surgery, as well as avoiding gabapentin or pregabalin for general pain, prescribing them only for neuropathic pain.
QPIs advised against regular benzodiazepines or Z-drugs for more than four weeks for patients 65 years and older, and antipsychotics to treat behavioural and psychological symptoms for more than 12 weeks unless non-pharmacological treatment had failed, or the patient presented a risk to themselves or others.
Senior author Associate Professor Johnson George from the Centre for Medicine Use and Safety at the Monash Institute of Pharmaceutical Sciences, told The Medical Republic it had been almost 20 years since a quality prescribing indicator project was undertaken.
The next phase of the research, part of a broader $4 million Medical Research Future Fund (MRFF) APRICOT project, would test the indicators in a randomised controlled trial in primary care clinics, alongside an educational audit and feedback.
“We’ll have both usual care clinics and intervention clinics, so we can see how the education intervention we’re proposing improves on current practice or how it compares with usual care,” he said.
The study’s second author, Anna Mackintosh – the project manager for the MRFF’s project APRICOT – said the research was an important first step towards establishing quality benchmarks as part of a broader five-year project.
She told TMR they’d be trialling the QPIs in approximately 100 clinics across Victoria, New South Wales and Tasmania.
Internationally, there were 1486 rules and criteria for prescribing in primary care, according to a recent scoping review. The challenge, researchers said, was deciding which were most applicable to Australia.
An initial research team of three pharmacists and two GPs were selected to determine the most applicable indicators and to provide specific examples of inappropriate prescribing they had observed in those therapeutic areas, resulting in a list of 137 QPIs.
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The final list of 37 QPIs was then assessed by an expert panel of 12 GPs, 29 pharmacists, and 1 nurse practitioner from regional and metropolitan areas across Victoria, New South Wales, and Tasmania – where these QPIs will eventually be implemented in primary care clinics.
A QPI was approved if more than 80% of panellists scored it a four or five for validity and importance on a five-point Likert scale.
A total of 23 of the 37 selected QPIs were approved; however, anonymous comments from the panellists indicated perceived difficulties in implementing some of the indicators, researchers reported.
Panellists said ambiguous wording, including “all” and “regular”, would make implementation difficult, leading the research team to develop a secondary “operational” definition for each of the 23 QPIs.
To ensure clarity on how QPIs could be measured in practice, the research team developed secondary “operational” definitions for each approved indicator.
The biggest methodological limitation was the QPIs’ limited capacity to address emerging issues, as the study was limited to assessing existing, previously used indicators, researchers acknowledged.
“If this research were to be repeated, an alternative approach would be to first identify common and emerging issues in prescribing quality, then assess whether existing QPIs adequately address these issues and develop new indicators where gaps remain,” the report read.
The research was conducted in collaboration with researchers from Monash University, the University of Tasmania, and the University of Sydney.
Read the full study here.
