A Randomised Pilot Study of the REVISiT Intervention

Prescribing medication is integral to the role of a general practitioner (GP). Figures from 2017 show that an estimated 1,105.8 million prescription items were dispensed in England alone. However, in practice, sometimes prescribing errors occur and these have the potential to cause significant morbidity and mortality. The General Medical Council (GMC) funded PRACtICe study which set out to determine the prevalence and nature of prescribing and monitoring errors in general practices in England identified prescribing errors in around one in twenty prescriptions. The study also put forward explanations as to why some of the errors may have occurred and offered recommendations for strategies and areas of focus that could potentially be explored to improve prescribing. One of these areas highlighted for consideration was providing further support for prescribing, specifically for GPs in training. The study found that, as a group, GPs in training did not necessarily receive training in prescribing that was comprehensive and structured. GPs in training also reported feeling unprepared for managing patients with complex and long term health needs.

Further to the PRACtICe study, in line with recommendation from the Medical Research Council (MRC) for developing complex interventions4, a series of focus groups5 were convened with health care professionals and members of the public to explore in more details which ideas proposed as part of the PRACtICe study should be considered for further development. The results further highlighted the desire for GPs in training to receive further educational input in the area of prescribing practice and safety. Furthermore, an educational intervention considered that could potentially meet this training need, was an individualised, pharmacist-led retrospective review of GPs in training prescribing practice (REVISiT intervention).

Following on from the focus group study, a small pilot study was conducted in the East Midlands to explore the feasibility of using the REVISiT intervention in general practice.6 The REVISiT intervention itself started with a primary care pharmacist undertaking a retrospective review of approximately 100 consecutive prescription items prescribed by ten GPs in training (in total 1028 prescriptions were reviewed). This was then followed by each GP in training, and their trainer receiving individualised feedback in a form of a report. The report presented the GP with areas where errors were identified and examples of 'good prescribing'. The impact of the intervention on prescribing and the experience of participating in the pilot study was assessed qualitatively. For this, GPs in training and their trainers participated in two interviews, one was conducted within a month of receiving feedback and the second one within 3-months of receiving feedback. Results from this pilot study reported an error rate of 9%, which was higher than the 5% error rate recorded in the GMC PRACtICe study. Furthermore, the pharmacist review identified a high rate of 'suboptimal' prescribing (35% of prescriptions) which identified further areas where GPs in training could improve on their prescribing. The qualitative narratives revealed that the REVISiT intervention was positively received by GPs and was deemed a unique training opportunity to receive individualised feedback on prescribing skills and knowledge that had potential to improve their prescribing and subsequently patient safety. GPs in training gave examples of where their prescribing had changed as a result of the REVISiT intervention and some communicated their intention to change, or implement a prescribing behaviour when the next opportunity arose.

After the pilot study, we conducted a qualitative study involving interviews, focus groups and a stakeholder event with key stakeholders (practice, policy, legal and members of the public) to explore whether the REVISiT intervention, in its current or modified form, should be considered for wide spread adoption into GP training and general practice or whether an evaluation study to establish the effectiveness and cost-effectiveness of the intervention was first warranted. Some participants expressed their disbelief that an intervention such as REVISiT was not already in routine use in general practice. They mainly felt that with some modifications the intervention would be fit to recommend for use. On the contrary, some suggested that more robust evidence, generated from conducting a definitive randomised controlled trial, would be needed before directing already limited resources towards an intervention in its early stages of development and use such as REVISiT.

However, before we are able to conduct a definitive randomised controlled trial of the REVISiT intervention to assess its effectiveness in improving prescribing of GPs in training (increase in the proportion of prescriptions prescribed correctly / reduction of observed prescribing errors) and the cost-effectiveness, there are components of the intervention itself and the trial process that need to be further explored, tested and refined. This step is important because there is evidence in the literature pointing to the 'failure' of some interventions arising due to poor intervention and study design and description.4