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October 2019

Substantial variation in uptake of new prescribing guidance

Substantial variation exists between general practices in uptake of new prescribing guidance, with important implications for patient care and health expenditure, finds the largest analysis of its kind.

The findings, published in The BMJ show that most practices changed their behaviour, but some changed much later than others, leading to avoidable health service costs and poorer patient care.

While adopting new evidence into clinical practice is considered important, the speed of uptake is variable.

Researchers used data from, an open database of all primary care prescribing by more than 8,000 general practitioners in England, on two treatment switches over a five year period.

The first was a switch to generic oral contraceptive desogestrel from the branded form (Cerazette) in 2012, and the second was to change the first line antibiotic choice for treating uncomplicated urinary tract infection (UTI) from trimethoprim to nitrofurantoin at various time points after 2014.

While most practices eventually showed a substantial change in clinical practice, considerable variation was found between practices in both the timing of change and how rapidly change was implemented once it had begun.

For example, it took a quarter of practices 14 months to switch from Cerazette to a generic form, and for the slowest 10%, a further 6 months, representing significant extra cost to the NHS.

For antibiotics, a quarter of practices did not make their largest change until 29 months after the guidance was released and 10% did not change until at least 32 months after the release, exposing patients to suboptimal care.

This was an observational study, and as such, didn't establish cause, but the authors suggest that using automated change detection methods could help to improve clinical practice by better identifying, understanding, and reducing unwarranted variation in care, they conclude.

Walker AJ, et al. BMJ 2019;367:l5205