Documentation of antibiotic prescribing controls in UK NHS hospitals

E. M. Woodford*, K. A. Wilson and J. F. Marriott

The Pharmacy Practice Research Group, The School of Pharmacy, Aston University, Birmingham B4 7ET, UK

Received 11 April 2003; returned 6 May 2003; revised 11 October 2003; accepted 19 January 2004


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results and discussion
 Conclusions
 References
 
Objectives: To identify the types, prevalence and nature of antibiotic prescribing control documents within NHS hospitals in the UK.

Methods: A self-completion postal questionnaire was sent to each Chief Pharmacist at 465 NHS hospitals in 2001/2002. This contained questions covering hospital demographics, and hospital antibiotic prescribing control documentation, including format, dissemination, approval and review processes.

Results: In total, 253 (54%) completed questionnaires were returned. Of these, 168 respondents’ hospitals had an antibiotic formulary, 107 had a policy for antibiotic prescribing and 216 had guidelines on antibiotic use. All three types of antibiotic prescribing documents were used by 82 hospitals but 18 did not have any documents; 44% of formularies, 45% of policies and 35% of guidelines were available electronically. The Drug and Therapeutics Committee was the most frequently cited body for document approval and approximately one-third of documents had been approved during the current year of the questionnaire. Only about one-half of responding hospitals had an annual review of documents.

Conclusions: Despite publication of high-profile national guidance in response to growing concerns regarding antimicrobial resistance, there has been little increase in the use of antibiotic prescribing control documents in NHS hospitals over the past decade. It is clear that appropriate controls for antibiotic prescribing are not yet universally applied in the UK and recommendations for action have been proposed.

Keywords: formularies, policies, guidelines, medicines management, antibiotics


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results and discussion
 Conclusions
 References
 
One strategy to address the problems of antibiotic overuse and misuse and the resultant consequences of escalating costs and antibiotic resistance is the use of antibiotic prescribing control documents which rationalize prescribing through cost-containment, conformity and quality.1 Antibiotic policies are general statements of hospital strategy whereas formularies specify available drugs and guidelines include reference to specific clinical conditions.

A survey identifying the use of antibiotic prescribing control documents by UK NHS hospitals was undertaken in 1990 by a Working Party of the British Society for Antimicrobial Chemotherapy (BSAC).2 However, subsequently a specialist Sub-group of the Standing Medical Advisory Committee has made recommendations with respect to documentation required for the control of antibiotic prescribing.3

The aim of this study was to identify the prevalence and nature of documentation currently used in UK NHS hospitals for antibiotic prescribing control. It is an independent study funded by a PhD research grant and is not constrained by sponsorship from the NHS or the pharmaceutical industry.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results and discussion
 Conclusions
 References
 
A self-completion postal questionnaire was designed to identify general antibiotic prescribing document issues in relation to the control of antibiotic prescribing. After piloting, it was mailed to the Chief Pharmacist at 465 UK NHS hospitals in 2001/2002. Two follow-ups of the questionnaire were mailed, and data analysed following coding and entry into the ‘Statistical Package for the Social Sciences’ Version 11.

The geographical distribution of responding hospitals was plotted using Microsoft MapPoint software. The continuity correction for Pearson’s {chi}2 test was employed to investigate whether there was a statistically significant association between a hospital’s type and size and antibiotic control documents used, with a P value of <=0.05 indicating statistical significance.

The following definitions were used in the questionnaire — formulary: a limited list of drugs available for prescription (it does not include guidance for use); policy: a general statement of hospital strategy; guidelines: a document offering guidance regarding what drug should be prescribed for a specific clinical condition. The definition of a formulary is based upon that used in the BSAC survey, whilst the definitions of a policy and guidelines are more explicit.


    Results and discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results and discussion
 Conclusions
 References
 
Response rate

An overall response rate of 77% was achieved, with 358 questionnaires returned. Of these, 253 were completed giving a completion rate of 54%.

Of the 253 respondents, the majority were from District General hospitals (58%, n = 147) and the remainder were from either teaching hospitals (20%, n = 50) or specialist units (22%, n = 56). The profile of hospitals when classified by bed numbers showed that 119 hospitals had up to 500 beds (47%), 105 hospitals had between 500 and 1000 beds (42%), and 24 (9%) hospitals had 1000+ beds, with the remaining five (2%) respondents not knowing how many beds their hospital contained.

The study is limited owing to the lack of response from 212 (46% of n = 465) hospitals. However, no geographical differences were identified in the responses received, and consequently, there is no reason to suggest that these responses were not representative.

Use of documents

Table 1 summarizes data on the possession of antibiotic prescribing control documents by responding hospitals.


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Table 1. Use of antibiotic prescribing control documents by UK hospitals (n = 253)
 
It can be seen from the Venn diagram (Figure 1) that 82 (32%) of respondent hospitals had all three antibiotic prescribing control documents, 92 (36%) had two documents, 61 (24%) had one and 18 (7%) did not have any documents.



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Figure 1. Use of antibiotic prescribing control documents by UK NHS hospitals (n = 253).

 
These findings are consistent with the results of the BSAC Working Party which identified that 79% of hospitals (n = 431) surveyed in 1990 used an antibiotic formulary or limited drug list whereas about three-fifths (62%, n = 342) had a policy for antibiotic therapy.2

It does not appear that national guidance issued within the intervening decade has had much success in increasing the use of documentation to control antibiotic prescribing within UK NHS hospitals.

The UK Antimicrobial Resistance Strategy and Action Plan (2000)4 recommended that tailored information, guidelines and prescribing support should be provided to promote optimal antimicrobial prescribing in clinical practice. It is therefore of particular concern that 18 hospitals (7%) did not have any antibiotic prescribing control documents. However, two-thirds of these hospitals were small specialist hospitals, and it is possible that they obtain prescribing information from another hospital in their locality.

Small specialist hospitals had less chance of having either formularies or guidelines (P < 0.01). Responses were received from all four constituent countries of the UK, and there appeared to be no association between the geographical distribution of hospitals and whether they had antibiotic prescribing control documents.

Overall possession of antibiotic prescribing control documents by NHS hospitals was considered to be fairly encouraging, with 93% (n = 235) having at least one document type. Nathwani has indicated the importance of continued audits of antibiotic prescribing documentation.5 Although beyond the scope of this paper, these elements are part of ongoing research by the authors.

Availability of documents electronically

Over one-third of antibiotic formularies (44%, n = 156), policies (45%, n = 96) and guidelines (35%, n = 207) were available in electronic form. However, in the majority of cases, these documents were also available in printed form. Electronic prescribing guidance is easier to update than paper formats, and automatic alerts can be incorporated into these systems to prompt review processes. Computer-assisted prescribing systems are one step removed from electronic prescribing which the NHS has proposed should be operational within every NHS hospital by 2004.6

Dissemination of documents

About one-half of respondent hospitals provided prescribers with a personal copy of each document: formulary (60%, n = 145), policy (47%, n = 93) and guidelines (58%, n = 198). The most frequent combination of methods used to distribute documents was by issue of personal copies to prescribers in adjunct to ward copy access; 36 (25%, n = 145) hospitals’ formularies, 16 (17%, n = 93) hospitals’ policies and 45 (23%, n = 198) hospitals’ guidelines were available in this way.

The most common method of distributing documents to pharmacists was by issue of personal copies, which accounted for 39 (26%, n = 148) hospitals’ formularies, 19 (20%, n = 93) hospitals’ policies and 43 (22%, n = 198) hospitals’ guidelines.

Approval of documents

In the majority of hospitals, the Drug and Therapeutics Committee (DTC) was involved in document approval. The World Health Organization, in its recognition of the importance of establishing treatment guidelines, encourages hospitals to form multi-disciplinary DTCs to fulfil this role.7

The most frequently cited combination of approval bodies was the triad of the DTC, Pharmacy Department and Microbiology Department representation together, which accounted for the approval of 73 (46%, n = 158) hospitals’ formularies, 44 (44%, n = 100) hospitals’ policies and 91 (45%, n = 203) hospitals’ guidelines. The majority of the other documents were approved by one or more of the bodies cited above.

Approval dates of documents

37% (n = 101) of formularies, 39% (n = 62) of policies and 35% (n = 133) of guidelines had been approved within the current year at the time of the questionnaire. In total, 66 (65%, n = 101) hospitals’ formularies, 37 (60%, n = 62) hospitals’ policies and 90 (68%, n = 133) hospitals’ guidelines had been approved either the year of the questionnaire or in the previous year.

Revision of documents

The majority of hospitals had a planned revision for formularies (83%, n = 156), policies (76%, n = 93) and guidelines (77%, n = 205). Of documents for which both approval and review dates were provided, 50% (n = 78) of formularies, 49% (n = 43) of policies and 56% (n = 97) of guidelines were reviewed within 1 year. Periodic revision of antibiotic prescribing control documents is important to ensure the use of the most current evidence-based medicine and knowledge regarding resistance patterns. The Government has requested NHS Trusts to ensure that systems exist for the review of documents on at least an annual basis.8

Documents within the context of medicines management

This study defines the number of hospitals in which medicines management tools were in place before the issue of the Audit Commission’s report ‘A Spoonful of Sugar’ (2001).9 It has identified that only 60% (n = 152) of hospitals had both an antibiotic formulary and guidelines, which has been highlighted as a cornerstone of medicines management by the Audit Commission’s report.9 That report9 also indicated that computer technology was an essential part of the modernization agenda but it was unlikely that ‘Information for Health’ (1998)10 targets, which include access to clinical guidance, would be met. This latter view has been confirmed by this study.


    Conclusions
 Top
 Abstract
 Introduction
 Materials and methods
 Results and discussion
 Conclusions
 References
 
This study shows that the use of antibiotic prescribing control documentation in UK hospitals has changed little since the last national survey in 1990. Furthermore, it provides evidence of incomplete compliance with a number of national4,8,10 recommendations. An NHS strategy should be implemented to ensure hospitals’ conformity regarding antibiotic prescribing control documentation, and the following recommendations are proposed.

1. Hospitals should have an evidence-based antibiotic formulary and associated guidelines, which should be contained within the same document.
2. Professional staff should have access to electronic versions of antibiotic prescribing control documents.
3. Multidisciplinary committees, which include Pharmacy and Microbiology Department representation, should be formed for the review of antibiotic prescribing control documents.
4. Antibiotic prescribing control documents should be reviewed on at least an annual basis.


    Footnotes
 
* Corresponding author. Fax: +44-121-3590733; E-mail: woodfoem{at}aston.ac.uk Back


    References
 Top
 Abstract
 Introduction
 Materials and methods
 Results and discussion
 Conclusions
 References
 
1 . Gould, I. M. (1999). A review of the role of antibiotic policies in the control of antibiotic resistance. Journal of Antimicrobial Chemotherapy 43, 459–65.[Abstract/Free Full Text]

2 . Working Party of the British Society for Antimicrobial Chemotherapy. (1994). Hospital antibiotic control measures in the UK. Journal of Antimicrobial Chemotherapy 34, 21–42.[Abstract]

3 . Standing Medical Advisory Committee Subgroup on Antimicrobial Resistance. (1998). The Path of Least Resistance. Department of Health, UK.

4 . Department of Health. (2000). UK Antimicrobial Resistance Strategy and Action Plan. Crown Copyright. Department of Health, UK.

5 . Nathwani, D. (2003). From evidence-based guideline methodology to quality of care standards. Journal of Antimicrobial Chemotherapy 51, 1103–7.[Free Full Text]

6 . National Health Service. (2000). The NHS Plan. The Stationery Office Limited, UK.

7 . World Health Organization. (2000). World Health Organization Report on Infectious Diseases 2000. Overcoming Antimicrobial Resistance. World Health Organization, Geneva, Switzerland.

8 . Department of Health. (1999). Health Service Circular. Resistance to Antibiotics and Other Antimicrobial agents. 1999/049. Department of Health, UK.

9 . The Audit Commission. (2001). A Spoonful of Sugar. Audit Commission Publications, UK.

10 . National Health Service Executive. (1998). Information for Health: An Information Strategy for the Modern NHS. Crown Copyright. NHS Executive, UK.