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Guthrie, Bruce; Donnan, Peter T.; Murphy, Douglas J.; Makubate, Boikanyo; Dreischulte, Tobias (2015): Bad apples or spoiled barrels? Multilevel modelling analysis of variation in high-risk prescribing in Scotland between general practitioners and between the practices they work in. In: BMJ Open, Vol. 5, No. 11


Objectives: Primary care high-risk prescribing causes significant harm, but it is unclear if it is largely driven by individuals (a `bad apple' problem) or by practices having higher or lower risk prescribing cultures (a `spoiled barrel' problem). The study aimed to examine the extent of variation in high-risk prescribing between individual prescribers and between the practices they work in. Design, setting and participants: Multilevel logistic regression modelling of routine cross-sectional data from 38 Scottish general practices for 181 010 encounters between 398 general practitioners (GPs) and 26 539 patients particularly vulnerable to adverse drug events (ADEs) of non-steroidal anti-inflammatory drugs (NSAIDs) due to age, comorbidity or coprescribing. Outcome measure: Initiation of a new NSAID prescription in an encounter between GPs and eligible patients. Results: A new high-risk NSAID was initiated in 1953 encounters (1.1% of encounters, 7.4% of patients). Older patients, those with more vulnerabilities to NSAID ADEs and those with polypharmacy were less likely to have a high-risk NSAID initiated, consistent with GPs generally recognising the risk of NSAIDs in eligible patients. Male GPs were more likely to initiate a high-risk NSAID than female GPs (OR 1.73, 95% CI 1.39 to 2.16). After accounting for patient characteristics, 4.2% (95% CI 2.1 to 8.3) of the variation in high-risk NSAID prescribing was attributable to variation between practices, and 14.2% (95% CI 11.4 to 17.3) to variation between GPs. Three practices had statistically higher than average high-risk prescribing, but only 15.7% of GPs with higher than average high-risk prescribing and 18.5% of patients receiving such a prescription were in these practices. Conclusions: There was much more variation in high-risk prescribing between GPs than between practices, and only targeting practices with higher than average rates will miss most high-risk NSAID prescribing. Primary care prescribing safety improvement should ideally target all practices, but encourage practices to consider and act on variation between prescribers in the practice.