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Dr Sally Lewis shares her thoughts on ‘prudent prescribing’ after chairing a workshop examining how the principles of prudent healthcare might apply to prescribing and medicines management.
None of us need reminding that as a society we face a growing burden of chronic disease. Increasingly we cohabit with chronic pain, diabetes, respiratory disease, and cancer and neuro-degenerative disorders. The evidence based medicine revolution continues to develop guidelines for us to follow and there is a steady stream of new innovations in healthcare, not least in prescribing. This therefore will lead to rapid growth in the amount and diversity of medicines we will prescribe for our patients.
Is this bad? Not necessarily, but only if we have assured ourselves that every time we prescribe a drug it is a valuable addition to an individual’s management and has done no harm. This is the basis for prudent prescribing and makes it imperative that we determine the true value of the medicines we prescribe to each of our patients.
Value-based healthcare is defined as ‘an approach to providing care that maintains or improves quality whilst restricting growth in cost’. I believe it is an essential approach if we are to preserve and maintain the central ethos of the Welsh NHS.
In order to decide if something has value we need to look at the outcomes an intervention delivers in relation to its cost. When we are considering a prescription, we need to get much better at shared goal-setting with our patients and not assume what it is that they want and need. This requires a more nuanced and individualised approach to evidence-base medicine. We must give clear advice at the outset about risk and benefits and manage expectations that we will be reassessing the effectiveness of the drug and its side effects at a given interval. We must be bolder in tackling polypharmacy to prevent the harm that this can cause.
As prescribers, we aim to relieve symptoms and prevent complications through treating disease. We do not set out to do harm. Experience tells us that when issues of quality and patient safety are at stake prescribers step up to the plate and quickly change prescribing patterns. This has been particularly evident with the prescribing of non-steroidal anti-inflammatory drugs in recent years following developing evidence on the relative safety of different agents.
So what do we need for ‘prudent’ or ‘value-based prescribing’ to be fully implemented?
We need defined outcome measures which are meaningful to our patients, backed up with reliable and regular data to enable us to assess ourselves against them. Benchmarking is not an adequate measure, as we currently don’t know what optimum prescribing in relation to prevalence looks like. Managing variation alone has its limitations.
Crucially, we need more time with our patients and better access to non-pharmacological interventions.
We need wider public engagement with these issues and more attention paid to the social determinants of health.
Finally, we should abandon the term ‘medicines management’ – it does not reflect the collaborative approach between clinicians, pharmacists and patients that is necessary to deliver high quality prescribing in the 21st century.
Dr Sally Lewis is a practising GP, Assistant Medical Director (Value-based care and commissioning) and Primary Care Clinical Director for Aneurin Bevan University Health Board. Twitter: @RslewisSally
PLEASE NOTE THIS BLOG FIRST APPEARED ON 1000 LIVES IMPROVEMENT BLOG SITE.
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These are the things I find myself prescribing antibiotics for:
acute exacerbation of COPD or bronchiectasisrecurrent UTIacnepainful tonsillitis
and once, because the patient's older brother screamed so continuously that I could not make myself heard to his mother. She told me that he had a diagnosis of asthma and was "breathless". I could see nothing about this in the notes but was gettin gnowhere an dhad six patients waiting.
And if not antibiotics, what then?
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