GEERT KOCKEN*

* Geert Kocken is a health consultant at Stichting Doelmatige Geneesmiddelen Voorzieninq (DGV) Dutch Institute for Effective Use of Medication, Postbus 3089, 3502 GB Utrecht, the Netherlands. Tel. + 31 24 360 6200, fax: + 31 24 360 6644, e-mail: berkldgv@wxs.nl

A FACT-FINDING study of pharmacotherapy discussion groups in the A Netherlands has highlighted a major shift towards establishing standards and guidelines for prescribing, coupled with a growing determination to monitor compliance by general practitioners (GPs).

The study, carried out by the Dutch Institute for Effective Use of Medication, reveals that the number of discussion groups has increased by a third to more than 800 over the past five years, and that up to 95% of the country’s GPs and pharmacists are now involved.

The nationwide network of local pharmacotherapy discussion groups was launched by the Institute in early 1992 (see EDM-20). The idea was to promote rational drug use by bringing together GPs and pharmacists to exchange information about pharmacotherapy and develop local guidelines.

Since then a team of 16 advisers (communications consultants) have helped establish regional networks as well as providing support to individual groups of GPs and local pharmacists which meet regularly. The aim is to draw on the expertise available within these two professions in order to improve the prescribing practice of individual GPs.

Latest findings...

The new survey was initiated in 1997 to update information about the organization and operation of pharmacotherapy discussion groups and to find out whether any changes had occurred since the 1992 study. The number of groups had increased from 629 in 1992 to 827 in 1997, and 83% of these took part in the latest survey.

The study found that an increasing number of both GPs and pharmacists played an active role in organizing group activities (up from 78% in 1992 to 88% in 1997). Most groups meet six times a year and about two-thirds of them are assisted by an adviser recognised by the Dutch Association of General Practitioners.

Contacts with specialists in hospitals - a need highlighted in the earlier study - have become more frequent (41% compared with 27% in 1992). The Institute for Effective Use of Medication is currently trying to improve communication between pharmacotherapy discussion groups and hospitals at the interface between primary and secondary care. The discussion group infrastructure offers a good opportunity for improving intermediate pharmaceutical care.

The study identified a major shift in the objectives of discussion group consultations since the previous survey. While information exchange and discussion on prescribing practices are still high on the agenda, there is an increasing emphasis on the need to reach agreement on standards, policies and guidelines. The survey found that 72% of groups were making efforts to draw up policies and guidelines, while 27% planned to monitor compliance with them (compared with 49% and 9% respectively in 1992).

In preparing activities groups rely heavily on the use of specially developed working materials. Most groups (82%) have, at some time, used the series of preparative booklets issued by the Institute for Effective Use of Medication. Both GPs and pharmacists were very positive about the booklets and the case studies. During 1995 - 96, the most frequently discussed topics were asthma, hypertension, the use of antibiotics in the treatment of respiratory infections, the use of antimicrobial drugs to treat urinary tract infections and the use of antidepressants (50% - 60% of groups).

Although the Institute advises groups not to discuss new medicines until these have been assessed by authoritative publications, such as the Dutch Pharmacotherapy Compendium (Farmacotherapeutisch Kompas), the Dutch Society of General Practice Standards, and the Dutch Drug Bulletin (Geneesmiddelenbulletin), 70% of groups reported having done so. Indeed, many groups have agreed not to prescribe new medicines before consultations within the pharmacotherapy discussion group.

These folders are used for preparing discussions at the local groups of doctors and pharmacists

Stichting DGV

Prescriptions watchdog...

The survey showed that 68% of groups were using relevant prescription data, due in part to efforts by the Dutch Pharmacological Society, health insurance companies and the Dutch Institute for Effective Use of Medication to ensure the availability and proper use of relevant data. At present, the figures are used mainly to gain an insight into existing prescribing patterns. For just over half the groups these data serve as a tool in policy development, while 44% of groups using the data do so to check adherence to the policies and guidelines agreed within the discussion group.

One of the conclusions of the 1992 survey was that regular monitoring of prescription data was essential in order to bring about effective change in prescribing practices. However, only a minority of groups currently monitor GPs’ prescription practices for compliance with agreed group guidelines and policies. More widespread monitoring of data would offer a way of comparing prescribing practices among colleagues, and of verifying compliance with agreed standards, policies and guidelines.

What GPs and pharmacists think...

Over 80% of GPs and pharmacists rate the pharmacotherapy discussion group process as “useful” or “very useful”, while two-thirds of them also said it was efficient. However, 8% of groups are less satisfied, complaining that the results are not specific enough.

The GPs said they had gained a better understanding of the scope of their prescription practices, partly as a result of participation in a group. In addition they report improved relations with other GPs and pharmacists. Meanwhile, the discussion group system has helped define the pharmacist’s role as an adviser to the GP. Pharmacists are now paying more attention to supervising medication schemes and giving advice to GPs, due in part to their participation in pharmacotherapy discussion groups. Pharmacists also say they are now more inclined to contact a GP when they have a query. Another improvement, noted by both GPs and pharmacists, is that both parties have a clearer understanding of how tasks should be shared between them.

On ways of improving the discussion group system, almost a third of the groups maintained that consultations need to become more efficient, while over 40% said the agreements reached should become less voluntary - a view expressed more frequently by pharmacists than GPs. Greater use of prescription data would not only help develop and clarify policies but, more importantly, also enable groups to more effectively monitor compliance with agreed policies and guidelines.

The way ahead...

Regular assessments of the effectiveness of the pharmacotherapy discussion group network remain essential in order to modify goals and develop fresh approaches, methods and content. Other challenges include the development and implementation of regional formularies - exploiting the full potential of computerized data - and an increase in international cooperation. In Eastern Europe, the Dutch Institute for Effective Use of Medication recently responded to a request from WHO to give presentations on rational drug use strategies. Elsewhere, collaboration is already underway, with similar discussion networks in Belgium, Canada, Germany and the UK. In November 1998 the Institute collaborated with the WHO Regional Office for Europe in organizing a consultative meeting to share problems experienced with guideline implementation and to discuss pharmacotherapeutic committees.

Meanwhile, Institute advisers are working on new programmes - generic prescribing, polypharmacy among the elderly, pharmaceutical care and transmural pharmacotherapy (where people are referred from hospital to have their prescription dispensed in a community pharmacy) - to ensure that all GPs, pharmacists and specialists have expertise in auditing and cost-effective use of medication. In addition, the Institute continues to offer a range of new working materials and support to pharmacotherapy discussion groups to boost their effectiveness. This can involve evaluation exercises, help in solving cooperation problems or in starting up compliance monitoring, or efforts to revitalise the discussion group process whenever it gets bogged down.

A patient information leaflet from the generic prescribing project. It says that you can have the same medicine in a different coat - generic drugs are just as good but cheaper

Stichting DGV