Highfield Unit, Worcester Royal Infirmary, Newtown Branch, Newtown Road, Worcester WR5 IJG and
1 South Worcestershire PCT, Isaac Maddox House, Shrub Hill Road, Worcester WR4 9RW, UK
SIR, The Cambridgeshire Inquiry of 2000 highlighted shortcomings in methotrexate prescribing in both primary and secondary care which led ultimately to the death of a patient [1]. Specific recommendations stated that record-keeping and amendment should be rigorously maintained in general practitioner (GP) surgeries as well as in hospitals; that warning and safety prompts should be programmed into GP prescribing and pharmacy labelling software; and that doses of methotrexate on prescriptions should be explicit and the term as directed should not be used. The development of patient-held records was suggested in order to facilitate GPs' access to patient records during house calls and out-of-hours consultations. The Inquiry also judged that the community use of 10 mg tablets is questionable due to their close resemblance to 2.5 mg tablets.
As part of a review of prescribing and monitoring protocols for disease-modifying anti-rheumatic drugs (DMARDs) in Worcestershire, we undertook a study of methotrexate record-keeping in partnership with a primary care group comprising nine practices. Our primary aim was to compare record-keeping of methotrexate dosage by hospital specialists, GPs and community pharmacists in addition to establishing patients' own understanding of their correct dose. Secondary aims were to collect information on the prescription of 10 mg tablets and the carriage of patient-held records. In Worcestershire the latter take the form of shared-care monitoring booklets, which are given to patients starting DMARDs.
Eighty-seven patients taking methotrexate for rheumatological disease were identified from primary care group computer records. Methotrexate dose information was extracted simultaneously from four sources for each patient: (i) telephone interview with the patient; (ii) hospital notes and computer records of GP letters; (iii) GP computer prescribing records; and (iv) community pharmacy records. Interpretation of data took account of the timing of communications between record-keepers and the presence of hospital letters in GP notes. The dose of methotrexate recommended by the hospital specialist was taken as a reference, provided it was clearly specified in the hospital records.
Only 48 patients (55%) had identical methotrexate dose records in all four areas. Of patients with record-keeping errors, 32 (37%) had an error in only one area; however, six (7%) had errors in two areas, and for a single patient all four sources gave differing information. The percentage of patient records with errors by source of data is shown in Table 1. Of six patients (7%) who gave incorrect doses, four were self-regulating (adjusting their own dosage) and two were confused about their dose. Although hospital letters to GPs did not convey the methotrexate dose routinely, information about dose changes was indicated in all but two cases. GP computer prescribing records constituted the largest source of error, due to either failure to update computer records from changes specified in hospital letters (21 cases, 24%), or the use of the term as directed instead of explicit doses (15 cases, 17%). Community pharmacy records were available for 73 of the 87 patients and they followed GP prescriptions correctly in 96% of patients. The 10 mg tablets were prescribed to 15 patients, with 10 patients prescribed both strengths simultaneously. The 10 mg tablets contributed directly to record-keeping errors in four cases. At interview only 48 patients (55%) still possessed patient-held records. Of these records, only 31 (65%) were up to date. Overall only 16 patients (18%) carried up-to-date records at all times.
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We found that 4.6% of patients adjusted their own methotrexate dose. The method used may bias towards underestimation of such behaviour, but this low figure probably reflects the close monitoring of therapy and regular patient follow-up. Our study also demonstrates the potential dangers resulting from community prescription of 10 mg methotrexate tablets. While supplies in hospital are necessary for oncology purposes, we would question the requirement for continued availability of the 10 mg methotrexate tablet within the community. <@?twb=.3w>By restricting use to 2.5 mg tablets, a considerable number of potential prescribing errors would be avoided.
Change of local practice is already occurring following this study. Hospital letters will clearly specify the methotrexate dose at each consultation. In primary care all computer records will be updated with the removal of as prescribed instructions, and a policy to avoid the use of 10 mg tablets in the community will be introduced. The local patient-held record system is under review. This study reinforces in a different locality some of the concerns raised in Cambridgeshire and suggests that other units should audit their methotrexate prescribing records. Rheumatology units need to work closely in partnership with primary care to improve practice if methotrexate-related morbidity is to be avoided.
Notes
Correspondence to: I. Rowe. E-mail: a.filer{at}bham.ac.uk
References