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Guthrie B, Yu N, Murphy D, et al. Measuring prevalence, reliability and variation in high-risk prescribing in general practice using multilevel modelling of observational data in a population database. Southampton (UK): NIHR Journals Library; 2015 Oct. (Health Services and Delivery Research, No. 3.42.)

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Measuring prevalence, reliability and variation in high-risk prescribing in general practice using multilevel modelling of observational data in a population database.

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Appendix 5Change over time in high-risk prescribing prevalence and variation between practices: detailed tables and figures

TABLE 28

TABLE 28

Fitted models of change over time for individual indicators 2004–9

TABLE 29

Fitted models of change over time for composite indicators 2004–9

IndicatorBaseline %Trend, % change per quarter (95% CI) (if present second line is quadratic term)
Composite 1: NSAIDs8.30–0.39 (–0.46 to –0.32)
0.011 (0.007 to 0.015)
Composite 2: NSAIDs and antiplatelets9.62–0.37 (–0.45 to –0.30)
0.009 (0.005 to 0.013)
Composite 3: drug–disease interactions3.85–0.042 (–0.049 to –0.036)
Composite 4: drug–drug interactions11.21–0.43 (–0.52 to –0.34)
0.011 (0.0026 to 0.016)
Composite 5: renal adverse effects10.18–0.16 (–0.21 to –0.11)
Composite 6: all indicators except CKD7.68–0.23 (–0.28 to –0.18)
0.006 (0.003 to 0.009)
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).
FIGURE 15. Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis).

FIGURE 15

Time series of variation between practices in high-risk prescribing 2004–9 for individual indicators (note varying scales on y-axis). Indicators involving gastroprotection, indicators 4, 5, 13, 14, 16 and 17, are shown for the numerator ‘prescribed a NSAID without prescription of gastroprotection’. (a) indicator 1: drugs to avoid in heart failure; (b) indicator 2: beta blockers in asthma; (c) indicator 3: LABA use without ICS use; (d) indicator 4: NSAID in peptic ulcer; (e) indicator 5: NSAID in over-75-year-olds; (f) indicator 6: methotrexate in mixed strengths; (g) indicator 7: COCP in previous thromboembolism; (h) indicator 8: oestrogens in previous breast cancer; (i) indicator 9: antipsychotics in dementia; (j) indicator 10: Parkinson’s disease; (k) indicator 11: NSAID in CKD 3–5; (l) indicator 12: drugs to avoid in CKD 4 and 5; (m) indicator 13: NSAID with oral anticoagulant (OAC); (n) indicator 14: NSAID with aspirin or clopidogrel; (o) indicator 15: NSAID with ACE inhibitors/ARB and diuretic; (p) indicator 16: aspirin/clopidogrel with OAC; (q) indicator 17: aspirin and clopidogrel; (r) indicator 18: high-risk drugs with coumarin OAC; and (s) indicator 19: PPDE-5 inhibitor with oral nitrate. COCP, combined oral contraceptive pill.

FIGURE 16. Time series of variation between practices in high-risk prescribing 2004–9 for composite indicators.
FIGURE 16. Time series of variation between practices in high-risk prescribing 2004–9 for composite indicators.
FIGURE 16. Time series of variation between practices in high-risk prescribing 2004–9 for composite indicators.
FIGURE 16. Time series of variation between practices in high-risk prescribing 2004–9 for composite indicators.
FIGURE 16. Time series of variation between practices in high-risk prescribing 2004–9 for composite indicators.
FIGURE 16. Time series of variation between practices in high-risk prescribing 2004–9 for composite indicators.

FIGURE 16

Time series of variation between practices in high-risk prescribing 2004–9 for composite indicators. (a) Composite 1: NSAIDs; (b) composite 2: NSAIDs and antiplatelets; (c) composite 3: drug–disease interactions; (d) composite 4: drug–drug interactions; (e) composite 5: renal adverse effects; and (f) composite 6: all indicators except CKD.

TABLE 30

Variation between practices in high-risk prescribing 2004–9 for individual indicators

IndicatorICC (95% CI), Q1 2005ICC (95% CI), Q1 2006ICC (95% CI), Q1 2007ICC (95% CI), Q1 2008ICC (95% CI), Q1 2009F-test for difference in variances, Q1 2009 vs. Q1 2005a
1: Drugs to avoid in heart failure0.016 (0.009 to 0.029)0.013 (0.006 to 0.025)0.013 (0.006 to 0.027)0.012 (0.005 to 0.025)0.008 (0.003 to 0.022)p-value < 0.0001
2: Beta blockers in asthma0.051 (0.034 to 0.075)0.048 (0.032 to 0.071)0.047 (0.031 to 0.071)0.039 (0.025 to 0.061)0.036 (0.023 to 0.056)p-value < 0.004
3: LABA use without ICS usea0.125 (0.085 to 0.180)0.131 (0.091 to 0.184)0.151 (0.107 to 0.210)0.200 (0.153 to 0.259)0.202 (0.149 to 0.268)p-value < 0.0001
4: NSAID in peptic ulcer0.041 (0.027 to 0.063)0.036 (0.022 to 0.057)0.049 (0.032 to 0.075)0.062 (0.040 to 0.095)0.041 (0.024 to 0.069)p-value = 0.142
5: NSAID in over-75-year-olds0.053 (0.041 to 0.069)0.065 (0.050 to 0.084)0.082 (0.063 to 0.106)0.079 (0.060 to 0.103)0.087 (0.067 to 0.114)p-value = 0.0004
6: Methotrexate in mixed strengths0.151 (0.085 to 0.254)0.139 (0.083 to 0.224)0.185 (0.118 to 0.278)0.227 (0.151 to 0.326)0.320 (0.239 to 0.415)p-value < 0.0001
7: COCP in previous thromboembolismb––––––
8: Oestrogens in previous breast cancerb––––––
9: Antipsychotics in dementia0.074 (0.048 to 0.113)0.065 (0.042 to 0.101)0.056 (0.034 to 0.089)0.069 (0.046 to 0.103)0.064 (0.041 to 0.100)p-value = 0.313
10: Parkinson’s diseaseb––––––
11: NSAID in CKD 3–5a––0.051 (0.033 to 0.076)0.049 (0.035 to 0.069)0.068 (0.050 to 0.091)p-value < 0.0001
12: Drugs to avoid in CKD 4 and 5a––0.053 (0.023 to 0.117)0.048 (0.023 to 0.098)0.009 (0.001 to 0.104)p-value < 0.0001
13: NSAID and OAC0.109 (0.053 to 0.213)0.132 (0.064 to 0.253)0.215 (0.131 to 0.334)0.211 (0.122 to 0.340)0.167 (0.086 to 0.300)p-value = 0.0016
14: NSAID with aspirin or clopidogrel0.057 (0.044 to 0.072)0.064 (0.050 to 0.082)0.069 (0.054 to 0.088)0.077 (0.060 to 0.098)0.071 (0.055 to 0.092)p-value = 0.180
15: NSAID with ACE inhibitor/ARB and diuretic0.057 (0.042 to 0.075)0.054 (0.040 to 0.072)0.054 (0.040 to 0.072)0.063 (0.048 to 0.083)0.069 (0.052 to 0.091)p-value = 0.063
16: Aspirin/clopidogrel with OAC0.062 (0.038 to 0.101)0.067 (0.041 to 0.106)0.046 (0.026 to 0.081)0.063 (0.039 to 0.102)0.052 (0.030 to 0.089)p-value = 0.019
17: Aspirin and clopidogrel0.036 (0.022 to 0.056)0.023 (0.013 to 0.038)0.048 (0.033 to 0.070)0.053 (0.036 to 0.078)0.038 (0.024 to 0.061)p-value = 0.997
18: High-risk drug and coumarin OAC0.056 (0.025 to 0.121)0.027 (0.007 to 0.097)0.033 (0.012 to 0.086)0.033 (0.013 to 0.081)0.023 (0.006 to 0.077)p-value < 0.0001
19: PPDE-5 inhibitor and oral nitrateb––––––

COCP, combined oral contraceptive pill; OAC, oral anticoagulant.

a

Q1 2009 vs. Q1 2007 for CKD indicators; degrees of freedom vary from 190,190 to 181,183 as some practices have no eligible patients for some indicators.

b

Models did not converge reliably and/or distribution of level 2 (practice-level) residuals was very non-normally distributed.

TABLE 31

Variation between practices in high-risk prescribing 2004–9 for composite indicators

IndicatorICC (95% CI), Q1 2005ICC (95% CI), Q1 2006ICC (95% CI), Q1 2007ICC (95% CI), Q1 2008ICC (95% CI), Q1 2009F-test for difference in variances, Q1 2009 vs. Q1 2005a
Composite 1: NSAIDs0.049 (0.039 to 0.061)0.050 (0.040 to 0.063)0.055 (0.044 to 0.069)0.058 (0.046 to 0.073)0.058 (0.046 to 0.073)p-value = 0.305
Composite 2: NSAIDs and antiplatelets0.038 (0.030 to 0.047)0.037 (0.029 to 0.046)0.042 (0.033 to 0.053)0.045 (0.036 to 0.057)0.043 (0.034 to 0.054)p-value = 0.465
Composite 3: drug–disease interactions0.032 (0.024 to 0.035)0.032 (0.024 to 0.043)0.026 (0.019 to 0.035)0.027 (0.020 to 0.036)0.025 (0.018 to 0.054)p-value = 0.018
Composite 4: drug–drug interactions0.028 (0.022 to 0.036)0.027 (0.021 to 0.035)0.029 (0.022 to 0.037)0.034 (0.027 to 0.045)0.030 (0.023 to 0.039)p-value = 0.730
Composite 5: Renal adverse effects––0.042 (0.032 to 0.056)0.044 (0.034 to 0.058)0.051 (0.039 to 0.066)p-value = 0.040
Composite 6: all indicators except CKD0.027 (0.021 to 0.035)0.027 (0.021 to 0.034)0.028 (0.022 to 0.035)0.029 (0.022 to 0.037)0.025 (0.020 to 0.033)p-value = 0.470
a

Q1 2009 vs. Q1 2007 for CKD indicators.

Copyright © Queen’s Printer and Controller of HMSO 2015. This work was produced by Guthrie et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

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