Does a feedback intervention support practices in improving prescribing for older people with reduced creatinine clearance? A feasibility study.

Problem

Kidney function reduces with age, increasing risk of harm from raised blood levels of many medicines. Prescribing recommendations when creatinine clearance is reduced are inconsistently implemented for older people in general practice, with 25% of patients aged ≥65yrs prescribed an average of two drugs where the kidney function was too low for recommended use, and 70 different drugs involved. It is not easy for prescribers to think about kidney function when prescribing, or to calculate and apply creatinine clearance when prescribing for older people and high-risk groups, or know which drugs are affected.We assessed the feasibility and acceptability of feedback to support safe prescribing of medicines for older people when kidney function is reduced.

Approach

We collected anonymous data on creatinine clearance from the seven general practices within two primary care networks (PCNs) to assess prescribing appropriateness for example drug groups (direct oral anticoagulants, anti-diabetics, and antibiotics) in patients aged ≥75yrs. We used these data in delivering bimonthly three evidence-based feedback reports to practices, and to assess change over time.We observed how PCNs and general practices received and used feedback. Semi-structured interviews explored experiences of feedback, guided by Clinical Performance Feedback Intervention Theory.

Findings

Initial findings indicate participants were interested in the feedback reports and saw them as important. In both PCNs the pharmacy teams were central to the response, undertaking all practice medication reviews.Scripts for prescribers, developed by our Public Patient Involvement group to help consultations with patients about their medicines and level of kidney function, and shared in the reports, were considered helpful.Interim analysis suggests an overall increase in recent creatinine clearance coding when key drugs are prescribed. However, getting the data to find patients at risk from their medicines because of their reduced kidney function is complex and challenging for prescribers.

Consequences

This feedback intervention engaged PCNs and practices. It raised awareness of the need to routinely calculate creatinine clearance, and of prescribing recommendations for many drugs when kidney function is reduced. Reducing risks associated with reduced creatinine clearance can decrease adverse drug reactions, hospitalisations, mortality and cost, especially for older patients.Routine calculation and coding of creatinine clearance would mean it is available for prescribing decisions and at-risk patients can be found by searches. This study provides evidence to improve functionality for timely calculation of creatinine clearance and coding at the time of kidney function test results coming into practice. Insights into feasibility of feedback on prescribing and kidney function within general practice will inform a future large-scale trial, and how best to help prescribers apply the recommendations for prescribing when kidney function is reduced, reducing the risk of harm.