It is not known how much the duration of newly prescribed antidepressant treatment is influenced by patient characteristics or practice variation.
To describe the relationship between patient characteristics and the duration of new antidepressant treatment by general practices.
Design and setting
Large primary care database cohort study of all patients with a newly initiated course of eligible antidepressant treatment during 1 year, from a database of 237 Scottish practices.
Detailed prescription data were used to estimate the duration of new antidepressant treatment for each patient. Cox proportional hazards regression was used to estimate the influence of patient characteristics on continuation of treatment and, by multilevel modelling, the variation between practices.
A total of 28 027 (2.2%) patients commenced antidepressant treatment during the year; 75% continued beyond 30 days, 56% beyond 90 days, and 40% beyond 180 days. Treatment was less likely to be continued in patients from areas of high socioeconomic deprivation: hazard ratio 1.22 (95% confidence interval [CI] = 1.16 to 1.29); in patients under 35 years, 1.33 (95% CI = 1.28 to 1.37); and in those for whom the GP recorded no relevant diagnostic code, 1.16 (95% CI = 1.13 to 1.18). Models accounted for between 2.2% and 3.9% of the variation in treatment duration.
Patient demographic characteristics account for relatively little variation in the duration of new antidepressant treatment, though treatment was shorter in younger patients and those with greater socioeconomic deprivation. There is variation in treatment duration between practices and according to whether patients have a depression diagnosis coded in their records.
antidepressive agents; clinical practice variation; depressive disorder; primary care
Anticipatory care for older patients who are frail involves both case identification and proactive intervention to reduce hospitalisation.
To identify a population who were at risk of admission to hospital and to provide an anticipatory care plan (ACP) for them and to ascertain whether using primary and secondary care data to identify this population and then applying an ACP can help to reduce hospital admission rates.
Design and setting
Cohort study of a service intervention in a general practice and a primary care team in Scotland.
The ACP sets out patients’ wishes in the event of a sudden deterioration in health. If admitted, a proactive approach was taken to transfer and discharge patients into the community. Cohorts were selected using the Nairn Case Finder, which matched patients in two practices for age, sex, multiple morbidity indexes, and secondary care outpatient and inpatient activity; 96 patients in each practice were studied for admission rate, occupied bed days and survival.
Survivors from the ACP cohort (n = 80) had 510 fewer days in hospital than in the 12 months pre-intervention: a significant reduction of 52.0% (P = 0.020). There were 37 fewer admissions of the survivors from that cohort post-intervention than in the preceding 12 months, with a significant reduction of 42.5% (P = 0.002). Mortality rates in the two cohorts were similar, but the number of patients who died in hospital and the hospital bed days used in the last 3 months of life were significantly lower for the decedents with an ACP than for the controls who had died (P = 0.007 and P = 0.045 respectively).
This approach produced statistically significant reductions in unplanned hospitalisation for a cohort of patients with multiple morbidities. It demonstrates the potential for providing better care for patients as well as better value for health and social care services. It is of particular benefit in managing end-of-life care.
admission; advance care planning; end-of-life care; general practice; patient readmission