Prescribing drugs of dependence in general practice, Part A


3. General practice systems of care
3.9 Quality improvement activities
☰ Table of contents


Activities such as audit and feedback, educational outreach visits, educational meetings and the provision of educational materials such as guidelines may have some clinically beneficial effect on improving the quality of prescribing. These initiatives are supported particularly if messages are tailored to those practitioners identified as over-prescribing and address individual barriers to change.5

Given the increasing problem of prescription drug abuse, it is relevant that all general practices consider undertaking quality improvement activities in this area. For example, after performing an audit of patients prescribed benzodiazepines, practices can send out a letter outlining the harms and risks, and inviting patients to have a consultation to explore alternative ways of managing their symptoms.40-42

Refer to Appendix E.1 of the PDF version for a sample letter to patients.

Quality improvement activities should be more frequent and extensive if the practice has higher levels of drugs of dependence prescribing, opioid substitution therapy and mental illness or pain issues.

Practices should consider appropriate monitoring systems to ensure early alert and sentinel systems are in place. This would include simple systems for reporting adverse events (eg staff abuse, patient overdose, misuse) or system failings (eg patient not getting appropriate continued medication), to more complex auditing of practice populations (eg patients above therapeutic dose ceilings).

A simple checklist to assist practices in examining their quality management of drugs of dependence is available in Appendix D14 of the PDF version.

 

3.9.1 Clinical audit

Clinical audit is a broad term that encompasses several of the other quality improvement strategies such as record reviews, peer review, standard reviews (to see if standards are being met, guidelines followed and/or evidence-based practice used) and patient satisfaction surveys.43 The purpose of clinical audits is to improve the quality of healthcare services by systematically reviewing the care provided against set criteria.43

The gap between the criteria and the assessed performance provides guidance for priority improvement strategies.43 Clinical audit of prescribing drugs of dependence (eg new patients prescribed drugs of dependence, repeat prescriptions without review), patients at risk of problematic use (eg prior or current substance misuse) and patients misusing drugs of dependence may help practices improve or monitor safety of prescribing.

Evidence suggests that in terms of improving professional practice, audit and feedback leads to small (but potentially important) improvements.44 The relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.44

There are several clinical audit tools available. However, there are broad limitations to the effectiveness of clinical audit which may be relevant to prescribing drugs of dependence, these include clarity and measurability of the criteria and standards chosen, data quality, engagement of practitioners, and translation of findings into quality improvement strategies.43

  1. Nicholas R, Lee N, Roche A. Pharmaceutical Drug Misuse in Australia: Complex Problems, Balanced Responses. Adelaide: National Centre for Education and Training on Addiction (NCETA), Flinders University; 2011.
  2. Gorgels WJ, Oude Voshaar RC, Mol AJ, et al. Discontinuation of long-term benzodiazepine use by sending a letter to users in family practice: a prospective controlled intervention study. Drug Alcohol Depend 2005;78(1):49–56.
  3. Mugunthan K, McGuire T, Glasziou P. Minimal interventions to decrease long-term use of benzodiazepines in primary care: a systematic review and meta-analysis. Br J Gen Pract 2011;61(590):e573–78.
  4. Department of Health (England) and the devolved administrations. Drug Misuse and Dependence: UK Guidelines on Clinical Management. London: Department of Health (England), the Scottish Government, Welsh Assembly Govenment and Northern Ireland Executive; 2007.
  5. Travaglia J, Debono D. Clinical audit: a comprehensive review of the literature. Sydney: Centre for Clinical Governance Research in Health, Faculty of Medicine, University of New South Wales; 2009.
  6. Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012;6:CD000259.