Reducing short-acting beta-agonist overprescribing in general practice: evaluation of a quality improvement programme in East London

Problem

Initiatives to reduce overprescribing of short-acting beta-agonist (SABA) inhalers are implemented in UK and worldwide. Quality improvement (QI) programmes interact with other local strategies.Here we aimed to evaluate the impact of a system-wide QI programme on SABA overprescribing, and to identify the most effective strategies.

Approach

All general practices within an East London intervention borough compared with practices in two neighbouring, comparison boroughs, between October 2020 and March 2023.Study practices engaged in QI activities including: electronic alerts flagging patients prescribed ≥12 SABA inhalers/year; a tool using real-time prescribing data to generate lists of patients overprescribed SABA for review; a summary guideline for clinicians; patient and practitioner information leaflets, webinar coaching. Prescribing data were collected from electronic health records with SABA overprescription evaluated through interrupted times series analysis. Content analysis was applied to data collected through a survey and conversations with staff.

Findings

During the three-year study period all localities introduced incentivised activities aimed at reducing SABA prescribing. Despite this we observed a significant decrease in the prescription of SABA in the study practices, (≥12 SABA/year from 7.5% to 5.5%, ≥6 SABA/year from 27% to 21%, P=0.01), and a concurrent increase in ICS prescriptions/asthma patient. At the end of the study this was 2.5 times greater than in control localities. The estimated decrease in hospital admissions is 11%. The COVID pandemic gave rise to a temporary increase in patients on the asthma register, which persisted for 6 months and affected QI outcome measures. When used by practices the electronic alerts were effective: 50% of patients receiving an active response achieved a reduction to <12 SABA in the following year.

Consequences

A learning health system approach built on electronic prescription data from primary care was effective in reducing SABA overprescribing and increasing ICS prescribing, resulting in an estimated decrease of hospital admissions of 11%. Practices required coaching to use the electronic tools effectively, which was impacted by the COVID-19 pandemic.We found that a long-standing culture of primary care organisations working together were an important factor in implementing QI. Alerts integrated within the practice software to alert prescribing ≥12 SABA inhalers/year were associated with effective reduction overprescribing in the subsequent year. Our results highlight the importance of general practice teams working effectively with pharmacists to ensure a shared understanding of access to SABA medications. Introducing structural change to medicine management (i.e. practice pharmacists, strong medicine management teams and practices cohesion) can make effective contributions to reduce SABA overprescribing.