Perceived barriers to paracetamol (acetaminophen) prescribing, especially following rofecoxib withdrawal from the market

General practitioners' views on managing knee osteoarthritis: a thematic analysis of factors influencing clinical practice guideline implementation in primary care

Background

Osteoarthritis (OA) is diagnosed and managed primarily by general practitioners (GPs). OA guidelines recommend using clinical criteria, without x-ray, for diagnosis, and advising strengthening exercise, aerobic activity and, if appropriate, weight loss as first-line treatments. These recommendations are often not implemented by GPs. To facilitate GP uptake of guidelines, greater understanding of GP practice behaviour is required. This qualitative study identified key factors influencing implementation of these recommendations in the primary-care setting.

Methods

Semi-structured interviews with eleven GPs were conducted, transcribed verbatim, coded by two independent researchers and analysed with an interpretive thematic approach using the COM-B model (Capability/Opportunity/Motivation-Behaviour) as a framework.

Results

Eleven themes were identified. Psychological capability themes: knowledge gaps, confidence to effectively manage OA, and skills to facilitate lifestyle change. Physical opportunity themes: system-related factors including time limitations, and patient resources. Social opportunity theme: influences from patients. Reflective motivation themes: GP's perceived role, and assumptions about people with knee OA. Automatic motivation themes: optimism, habit, and unease discussing weight. The findings demonstrated diverse and interacting influences on GPs' practice.

Conclusion

The identified themes provide insight into potential interventions to improve OA management in primary-care settings. Key suggestions include: improvements to OA clinical guidelines; targeting GP education to focus on identified knowledge gaps, confidence, and communication skills; development and implementation of new models of service delivery; and utilising positive social influences to facilitate best-practice behaviours. Complex, multimodal interventions that address multiple factors (both barriers and facilitators) are likely to be necessary.

A systematic review and evidence synthesis of qualitative studies to identify primary care clinicians' barriers and enablers to the management of osteoarthritis

OBJECTIVE

Primary care management of osteoarthritis (OA) is variable and often inconsistent with clinical practice guidelines (CPGs). This study aimed to identify and synthesize available qualitative evidence on primary care clinicians' views on providing recommended management of OA.

DESIGN

Eligibility criteria included full reports published in peer-reviewed journals, with data collected directly from primary care clinicians using qualitative methods for collection and analysis. Five electronic databases (MEDLINE, Cochrane Central Register, EMBASE, CINAHL and PsychInfo) were searched to August 2016. Two independent reviewers identified eligible reports, conducted critical appraisal (based on Critical Appraisal Skills Programme (CASP) criteria), and extracted data. Three reviewers independently, then collaboratively, synthesized and interpreted data through an inductive and iterative process to derive new themes. The Confidence in Evidence from Reviews of Qualitative research (CERQual) approach was used to determine a confidence profile for each finding.

RESULTS

Eight studies involving approximately 83 general practitioners (GPs), 24 practice nurses, 12 pharmacists and 10 physical therapists, from Australia, France, United Kingdom, Germany and Mexico were included. Four barriers were identified as themes 1) OA is not that serious, 2) Clinicians are, or perceive they are, under-prepared, 3) Personal beliefs at odds with providing recommended practice, and 4) Dissonant patient expectations. No themes were enablers. Confidence ratings were moderate or low.

CONCLUSIONS

Synthesising available data revealed barriers that collectively point towards a need to address clinician knowledge gaps, and enhance clinician communication and behaviour change skills to facilitate patient adherence, enable effective conversations and manage dissonant patient expectations.

REGISTRATION

PROSPERO (http://www.crd.york.ac.uk/PROSPERO) [4/11/2015, CRD42015027543].

Effectiveness of diclofenac versus paracetamol in knee osteoarthritis: a randomised controlled trial in primary care

BACKGROUND

The effectiveness of diclofenac versus paracetamol in primary care patients with pain caused by knee osteoarthritis is unclear.

AIM

To assess the effectiveness of diclofenac compared with paracetamol over a period of 2, 4, and 12 weeks in patients with knee osteoarthritis.

DESIGN AND SETTING

Randomised controlled trial in general practice.

METHOD

There were 104 patients included in the study, they were aged ≥45 years consulting their GP with knee pain caused by knee osteoarthritis. Patients were randomly allocated to diclofenac (n = 52) or paracetamol (n = 52) for at least 2 weeks. Primary outcomes were daily knee pain severity, and knee pain and function measured with the Knee Injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

Over a period of 2- and 4-weeks follow-up, no significant difference in daily knee pain was found between the patient groups: estimated differences of 0.5 (95% CI = -0.2 to 1.3) and -0.2 (95% CI = -1.0 to 0.7), respectively. Over the 12-weeks follow-up, no significant differences were found between both groups for KOOS pain: estimated difference of -2.8 (95% CI = -10.7 to 5.1) and KOOS function of -2.7 (-10.6 to 5.0).

CONCLUSION

Over a period of 2- and 4-weeks follow-up no significant difference in daily measured knee pain severity was found between primary care patients with knee osteoarthritis taking paracetamol or diclofenac. Also, over a period of 12-weeks follow-up no significant differences were found regarding KOOS pain and KOOS function between both groups. Patients more frequently reported minor adverse events after taking diclofenac (64%) than paracetamol (46%).

Australians with osteoarthritis: satisfaction with health care providers and the perceived helpfulness of treatments and information sources

OBJECTIVE

The aim of this study was to evaluate the satisfaction of Australian patients who suffer from osteoarthritis (OA) with their health care providers and the perceived helpfulness of treatments and information sources.

METHODS

A self-administered questionnaire was conducted with a sample of 560 Australian patients who suffer from OA with questions about satisfaction with health care providers and the helpfulness of different treatment options and information sources. Logistic regression models were used to assess potential predictors of satisfaction. Thematic analysis was undertaken for attitudinal factors associated with satisfaction.

RESULTS

A total of 435 participants returned questionnaires (response rate 78%). Most respondents were highly satisfied with the care provided by their general practitioner (GP) (84%), communication with their GP (88%), time spent with their GP (84%), and their ability to talk freely with their GP about their medical problem (93%), but less satisfied with their ability to talk freely about associated emotional problems (77%). Satisfaction with pharmacists (80%), rheumatologists (76%), and orthopedic surgeons (72%) was high. Joint replacement surgery (91%), prescription anti-inflammatory medications (66%), aids and assistive devices (65%), intra-articular injections (63%), and prescription painkiller medications (62%) were perceived as effective treatments. Less highly rated treatments were exercise (48%), physiotherapy (43%), and complementary medicines (29%). A majority of patients were satisfied with the information to manage their OA (65%). From the multivariable logistic regression analysis, four GP satisfaction factors were found to be predictors of overall satisfaction with GP care: the amount of time that the GP spends with the patient (P=0.005), the information the GP provides about what to expect (P<0.001), the communication between patient and GP (P=0.001), and the information that the GP provides about medications (P=0.042).

CONCLUSION

The study showed that although patients with OA were generally satisfied with their health care providers, there was notable variation in the perceived helpfulness of therapeutic options. The importance to patients of having access to good quality information about their condition was emphasized.

Australian GP management of osteoarthritis following the release of the RACGP guideline for the non-surgical management of hip and knee osteoarthritis

BACKGROUND

Osteoarthritis (OA) is a highly disabling and costly condition with an escalating prevalence in Australia due to the ageing and increasing obesity of the population. The general practitioner (GP) plays a central role in the management of this condition. The aim of this study was to examine opinions about the management of OA by Australian GPs following the release of the Royal Australian College of General Practitioners Guideline for the non-surgical management of hip and knee OA (RACGP OA CPG), and to compare the results with an earlier survey administered by the National Prescribing Service.

METHODS

In January 2013, a self-administered questionnaire was sent to 228 GPs to determine their treatment approaches to OA management using a clinical vignette of a patient with OA. This was compared with results from a similar survey undertaken in 2006.

RESULTS

Seventy-nine GPs returned questionnaires (response rate 35%). GP recommendations for paracetamol, a paracetamol/codeine compound, and oral non-steroidal anti-inflammatory drugs (NSAIDs) were consistent with recommendations in the RACGP OA CPG, and varied little from the previous survey. Notably, there was a marked increase between surveys in GP recommendations for tramadol (p = 0.004) and more potent opioids (p < 0.001). Advice about the adverse effects of NSAIDs and codeine and how to manage them increased between surveys (p = 0.038 and 0.005, respectively). For all non-pharmacological treatments, there were only minor changes in the percentage of GP recommendations when compared with the previous survey, however they remain underutilised.

CONCLUSIONS

GPs generally demonstrated a conservative approach to the treatment of OA, however, the increased recommendations for more potent opioids warrants further investigation. Patients should be made aware of the risks of medications through the use of decision aids, which can provide structured guidance to treatment. Non-pharmacological interventions were not given the importance that is suggested by clinical practice guidelines.

Assessing appropriateness of osteoarthritis care using quality indicators: a systematic review

RATIONALE, AIMS AND OBJECTIVES

Quality indicators (QIs) derived from the review of medical records, administrative databases, and patient questionnaires and interviews have been frequently used to assess the quality of osteoarthritis (OA) care. The purpose of this review is to summarize studies that have assessed the quality of OA care using QIs.

METHOD

We systematically searched MEDLINE, EMBASE, CINAHL and PsycINFO for English-language studies indexed by October 2014. Articles were included if they used any QIs for assessing the quality of OA care. We summarized the results of these studies, and with meta-analysis, generated an overall conclusion about the quality of care as measured by QIs for each treatment domain for OA care.

RESULTS

Fourteen studies assessed as being of high-quality were included in the review, with the number of QIs ranging from 1 to 21. Four of the 14 studies solely assessed the quality of OA care, while the other studies assessed health care quality for a range of conditions that included OA. The quality of OA care as assessed by a meta-analysis of QI pass rates across studies was suboptimal for all treatment domains (pass rates: pain and functional status assessment – 48.5%, 95% CI 32.6-64.6%; non-drug treatment – 36.1%, 95% CI 27.8-44.7%; drug treatment – 37.5%, 95% CI 30.8-44.5%; surgical referral – 78.9%, 95% CI 57.4-94.2%).

CONCLUSION

Despite efforts made at improving care for patients with OA, the wide divergence between evidence and consensus-based recommended care and practice has been reaffirmed.

Population prevalence of high dose paracetamol in dispensed paracetamol/opioid prescription combinations: an observational study

Background

Paracetamol (acetaminophen) is generally considered a safe medication, but is associated with hepatotoxicity at doses above doses of 4.0 g/day, and even below this daily dose in certain populations.

Methods

The Nova Scotia Prescription Monitoring Program (NSPMP) in the Canadian province of Nova Scotia is a legislated organization that collects dispensing information on all out-of-hospital prescription controlled drugs dispensed for all Nova Scotia residents. The NSPMP provided data to track all paracetamol/opioids redeemed by adults in Nova Scotia, from July 1, 2005 to June 30, 2010. Trends in the number of adults dispensed these prescriptions and the numbers of prescriptions and tablets dispensed over this period were determined. The numbers and proportions of adults who filled prescriptions exceeding 4.0 g/day and 3.25 g/day were determined for the one-year period July 1, 2009 to June 30, 2010. Data were stratified by sex and age (<65 versus 65+).

Results

Both the number of prescriptions filled and the number of tablets dispensed increased over the study period, although the proportion of the adult population who filled at least one paracetamol/opioid prescription was lower in each successive one-year period. From July 2009 to June 2010, one in 12 adults (n = 59,197) filled prescriptions for over 13 million paracetamol/opioid tablets. Six percent (n = 3,786) filled prescriptions that exceeded 4.0 g/day and 18.6% (n = 11,008) exceeded 3.25 g/day of paracetamol at least once. These findings exclude non-prescription paracetamol and paracetamol–only prescribed medications.

Conclusions

A substantial number of individuals who redeem prescriptions for paracetamol/opioid combinations may be at risk of paracetamol-related hepatotoxicity. Healthcare professionals must be vigilant when prescribing and dispensing these medications in order to reduce the associated risks.

"It looks after me": how older patients make decisions about analgesics for osteoarthritis

OBJECTIVE

To explore the key motivators behind selection of analgesics (nonsteroidal antiinflammatory drugs [NSAIDs], acetaminophen, and complementary medications [CMs]) by patients with osteoarthritis (OA).

METHODS

We performed a qualitative study in which in-depth semistructured interviews were conducted with 15 OA patients recruited from 4 general practices in Sydney, Australia. Patients were ages ≥65 years, and were currently taking or had recently taken an NSAID for OA.

RESULTS

Three key themes emerged from the data: reliance, routine, and pill load. Patients were strongly reliant upon NSAIDs because they consistently satisfied their needs. By contrast, they were much less reliant upon acetaminophen because of uncertainty or skepticism about its effectiveness. They were not reliant upon CMs but were willing to take them indefinitely because they were perceived as being without risk. Many patients took an NSAID as well as CMs as part of a "daily routine." By contrast, patients had difficulty developing a routine around using acetaminophen at the recommended maximum dose because of the implicit frequency of dosing required and an aversion to the associated "pill load."

CONCLUSION

The results highlight the importance of exploring the perceptions and preferences of patients with regard to analgesics for OA. Clinician advice regarding analgesia for OA should take account of the possible reliance of the patient upon an NSAID, their medicine routines, and their potential concern about the pill load associated, in particular, with acetaminophen.