Development of indicators for assessing the quality of prescribing of lipid-lowering drugs: data from the pharmacotherapeutic quality circles in Hesse, Germany.

Objective: To develop indicators based on prescription analysis in order to assess adherence using guidelines and to monitor prescribing behavior. Setting and material: Eleven pharmacotherapeutic circles (PTC) of the Association of Statutory Health Insurance Physicians (KV Hesse; 10 PTCs including 155 GPs as participants, mostly high prescribers; one circle with 11 moderators trained in pharmacology). These provided a total of 183,997 drug prescriptions involving 54,970 patients (prescriptions reimbursed by the substitute fund - Ersatzkassen- II. quarter 2000); claims form from 151 GPs. On average, 5.1% of the patients with prescriptions received lipid-lowering drugs. Method: Development and application of indicators based on the guideline for the treatment of hypercholesterolemia developed by a GP's guideline group of the quality circles in Hesse (Hausarztliche Leitliniengruppe Hessen). The ratio of prescribing for primary and secondary prevention was chosen as a top indicator for measuring adherence to the guideline. Prescribing for secondary prevention was assessed by a set of special diagnoses. The second indicator relates to patient groups (here: older than 75 years) where the benefit of prescribing is not clear. Further indicators measure the prescribing of first choice drugs, avoidance of risk combinations and cost-conscious prescribing. The indicators are presented in the prescription analysis and will be discussed during the circle meeting. Results: On average, the moderators prescribed 34% of the lipid-lowering drugs for primary prevention, the GP circle participants 36.7%. On average, moderators and GP participants prescribed lipid-lowering drugs for 4.9% and 7.5% of patients older than 75 years, respectively (6% and 22% in primary prevention). Approximately, 28% of all lipid-lowering drugs issued by the participants involved simvastatin and pravastatin as first-choice drugs compared to 36.5% in the case of the moderators. The prescribing of statins with fibrates or macrolides in combination is seldom. Cost-conscious prescribing can be assessed for each GP by the percentage of generic prescribing and the number of different brands per active agent. Both, moderators and participants used generics when prescribing fibrates, bile acid sequestrants or other types of lipid-lowering drugs (moderators 53.8% and GP participants 78. 5%). Three months is too short a period for assessing compliance of lipid-lowering drug prescribing. Conclusion: It is possible to derive indicators from the guidelines and to integrate them into prescription analysis. The indicators reveal prescribing problems. The evaluation of PTCs in 2002 will involve the use of indicators as an instrument to assess the success in the implementation of guidelines.