Anticholinergic medicines in an older primary care population: a cross-sectional analysis of medicines' levels of anticholinergic activity and clinical indications

WHAT IS KNOWN AND OBJECTIVES

Adverse clinical outcomes have been associated with cumulative anticholinergic burden (to which low-potency as well as high-potency anticholinergic medicines contribute). The clinical indications for which anticholinergic medicines are prescribed (and thus the 'phenotype' of patients with anticholinergic burden) have not been established. We sought to establish the overall prevalence of prescribing of anticholinergic medicines, the prevalence of prescribing of low-, medium- and high-potency anticholinergic medicines, and the clinical indications for which the medicines were prescribed in an older primary care population.

METHODS

This was a cross-sectional analysis of a cohort study of Australian early-career general practitioners' (GPs') clinical consultations - the Registrar Clinical Encounters in Training (ReCEnT) study. In ReCEnT, GPs collect detailed data (including medicines prescribed and their clinical indication) for 60 consecutive patients, on up to three occasions 6 months apart. Anticholinergic medicines were categorized as levels 1 (low-potency) to 3 (high-potency) using the Anticholinergic Drug Scale (ADS).

RESULTS

During 2010-2014, 879 early-career GPs (across five of Australia's six states) conducted 20 555 consultations with patients aged 65 years or older, representing 35 506 problems/diagnoses. Anticholinergic medicines were prescribed in 10·4% [95% CIs 9·5-10·5] of consultations. Of the total anticholinergic load of prescribed medicines ('community anticholinergic load') 72·7% [95% CIs 71·0-74·3] was contributed by Level 1 medicines, 0·8% [95% CIs 0·5-1·3] by Level 2 medicines and 26·5% [95% CIs 24·8-28·1] by Level 3 medicines. Cardiac (40·0%), Musculoskeletal (16·9%) and Respiratory (10·6%) were the most common indications associated with Level 1 anticholinergic prescription. For Level 2 and 3 medicines (combined data), Psychological (16·1%), Neurological (16·1%), Musculoskeletal (15·7%) and Urological (11·1%) indications were most common.

WHAT IS NEW AND CONCLUSION

Anticholinergic medicines are frequently prescribed in Australian general practice, and the majority of the 'community' anticholinergic burden is contributed by 'low'-anticholinergic potency medicines whose anticholinergic effects may be largely 'invisible' to prescribing GPs. Furthermore, the clinical 'phenotype' of the patient with high anticholinergic burden may be very different to common stereotypes (patients with urological, psychological or neurological problems), potentially making recognition of risk of anticholinergic adverse effects additionally problematic for GPs.

Analysis by training status of performance in the certification examination for Australian family doctors

OBJECTIVES

Following recent changes to eligibility requirements for recognition as a general practitioner in Australia, an increasing proportion of candidates select the non-training, or practice-eligible, route to the RACGP Fellowship Examination, without the benefit of formal general practice training.

DESIGN

Pass rates for the training and practice-eligible cohorts from the 1996 and 1997 examinations were determined and compared.

SETTING

Royal Australian College of General Practitioners (RACGP).

SUBJECTS

General practitioner candidates for the RACGP.

RESULTS

The analysis of the 1996 and 1997 examinations showed that the overall pass rate and individual examination segment scores of the practice-eligible route candidates were lower than those for candidates from the training route.

CONCLUSIONS

The observed difference in performance is more probably due to different preparation for the examination than any systematic bias against particular groups of candidates. All candidates for the examination would benefit from exposure to the general practice curriculum and supervised experience in Australian general practice.

Longitudinal reliability of the Royal Australian College of General Practitioners certification examination

The examination for Fellowship of the Royal Australian College of General Practitioners is a long-standing examination that is regarded as a valid and comprehensive assessment of competence for general practice in Australia. Income and employment opportunities now depend on passing this battery of eight subtests. This paper describes the structures of the examination and reports an analysis of the reliability and efficiency of the examinations, based on data from five consecutive examinations. Results indicate that the examination achieves acceptable overall reliability, although suggestions for changes to improve reliability are made. A decision on implementing any changes must take into consideration any consequent changes in validity.

General practice procedural skills

In 1988 a self reported competency survey of Queensland interns was undertaken in the final months of their pre-registration year. The survey revealed that 24 of 46 essential procedural skills for general practice had been performed alone by 80 per cent or more of interns. Eleven of the remaining 22 procedures had been performed under supervision by at least 80 per cent of the respondents. There were four procedures that had been performed by fewer than half the respondents.

Competency of medical students in general practice procedural skills

A self-reported competency survey of 1988 sixth year medical students in Queensland revealed that only 2 of 47 procedural skills considered essential for general practice had been performed alone by 80 per cent or more of students. Six of the essential skills had not been performed by more than 80 per cent of students. Consideration needs to be given to the content and effectiveness of undergraduate general practice procedural skills training.

Analysis of the RACGP Fellowship examination results

The FRACGP examination assesses a candidate's performance in five behavioural attributes--knowledge, interpretation, problem solving, affective behaviour and psychomotor skills. These attributes were used as the basis for comparing the performance of various groups of candidates in the examination.