Corrick, Fenella J.
(2021)
Paediatric rational prescribing: a study of paediatric rational prescribing tools and development of a novel tool for the UK.
PhD thesis, University of Nottingham.
Abstract
Background
Children are vulnerable to inappropriate prescribing yet rational prescribing criteria, although widely used in adult medicine, are not well-established in paediatric research. Rational prescribing tools, criteria lists of potentially irrational prescribing, are used to study the use of medicines and can be used to detect and quantify inappropriate prescribing. This allows researchers to compare quality of prescribing across different populations, identify factors associated with irrational prescribing, and evaluate the effectiveness of interventions to improve prescribing.
Aims
The aims of this thesis were to identify and appraise all existing tools for studying irrational prescribing for children; to develop a rational prescribing tool that could be used across paediatric practice in the United Kingdom (UK); and to validate the novel tool for application in research and clinical practice in the UK.
Methods
A systematic review of paediatric rational prescribing tools was undertaken and identified two such tools. One of these, the POPI (Pediatrics: omissions of prescriptions and inappropriate prescriptions) tool, was designed for application to any paediatric practice setting but founded in French clinical practice. The second, PIPc (Indicators of potentially inappropriate prescribing in children) is a tool designed for use in primary care only, in Ireland and the UK.
In order to develop criteria applicable to any UK paediatric setting, the POPI tool was modified for use in the UK, resulting in the novel POPI UK tool. Each criterion was compared to relevant UK national guidelines, with three possible outcomes: no change; modification; or omission. Criteria concordant with UK guidelines were integrated into the new tool unchanged, criteria differing from guidelines were modified, and criteria with contradicting guidelines or no relevant UK guidelines were omitted.
Two validation studies were designed and carried out to evaluate POPI UK. Firstly, a prospective clinical validation study was designed to review the prescriptions of 600 children in a UK children’s hospital, in inpatient and emergency department settings. This study evaluated the relevance of the POPI UK criteria to the study population, assessed its ability to detect potentially inappropriate prescribing, and examined factors associated with any potentially inappropriate prescribing detected.
Secondly, the precision of the POPI UK tool was tested through an inter- and intra-rater reliability study. Cohen’s Kappa was calculated for agreement between two raters applying the criteria to twenty anonymised cases.
Results
The systematic review identified five articles meeting inclusion criteria. These related to three paediatric rational prescribing tools, POPI, PIPc, and POPI UK.
The POPI tool comprises 105 criteria and was designed for use in any paediatric practice setting, based on French standards of practice. The PIPc comprises twelve criteria, designed for use in primary care in Ireland and the UK. Due to the PIPc being specifically designed for use in primary care, the POPI tool was the focus of further study.
Modification of the POPI criteria was undertaken to develop the POPI UK tool. No change was made to 49 criteria., 29 were modified, four were reduced into two through combination with closely related criteria and 23 were omitted, including the omission of a category. The resulting POPI UK tool comprises 80 criteria divided into 21 clinical categories.
In the clinical validation study, the POPI UK criteria were relevant to the majority (96%) of the study population and the tool identified potentially irrational prescribing. In addition, several limitations were identified, including the detailed level of clinical information required to apply the criteria.
The inter- and intra-rater repeatability of POPI UK were rated as good, with Kappa values of 0.44 and 0.57 respectively. This was lower than the reliability of the original POPI tool. On examination of the studies, it appeared that methodological differences rather than the modification of the tool explained the observed difference in reliability of the criteria.
Conclusions
Two existing paediatric rational prescribing tools were identified and appraised, POPI and PIPc. In order to develop a tool applicable to children across UK paediatric settings a novel tool, POPI UK, was developed by modifying the POPI criteria. Validation studies demonstrated that POPI UK was relevant to a majority of the studied population and was able to identify potentially irrational prescribing with good reliability. This tool could be used in UK paediatric practice settings to evaluate rational prescribing. However, a number of significant limitations to all three paediatric rational prescribing tools have been identified and further research avenues are suggested including refinement of the POPI UK criteria.
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