Nurse and pharmacist supplementary prescribing in the UK—A thematic review of the literature

Adjunctive Medication Management and Contingency Management to enhance adherence to acamprosate for alcohol dependence: the ADAM trial RCT

Background

Acamprosate is an effective and cost-effective medication for alcohol relapse prevention but poor adherence can limit its full benefit. Effective interventions to support adherence to acamprosate are therefore needed.

Objectives

To determine the effectiveness of Medication Management, with and without Contingency Management, compared to Standard Support alone in enhancing adherence to acamprosate and the impact of adherence to acamprosate on abstinence and reduced alcohol consumption.

Design

Multicentre, three-arm, parallel-group, randomised controlled clinical trial.

Setting

Specialist alcohol treatment services in five regions of England (South East London, Central and North West London, Wessex, Yorkshire and Humber and West Midlands).

Participants

Adults (aged 18 years or more), an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis of alcohol dependence, abstinent from alcohol at baseline assessment, in receipt of a prescription for acamprosate.

Interventions

(1) Standard Support, (2) Standard Support with adjunctive Medication Management provided by pharmacists via a clinical contact centre (12 sessions over 6 months), (3) Standard Support with adjunctive Medication Management plus Contingency Management that consisted of vouchers (up to £120) to reinforce participation in Medication Management. Consenting participants were randomised in a 2 : 1 : 1 ratio to one of the three groups using a stratified random permuted block method using a remote system. Participants and researchers were not blind to treatment allocation.

Main outcome measures

Primary outcome: self-reported percentage of medication taken in the previous 28 days at 6 months post randomisation. Economic outcome: EuroQol-5 Dimensions, a five-level version, used to calculate quality-adjusted life-years, with costs estimated using the Adult Service Use Schedule.

Results

Of the 1459 potential participants approached, 1019 (70%) were assessed and 739 (73 consented to participate in the study, 372 (50%) were allocated to Standard Support, 182 (25%) to Standard Support with Medication Management and 185 (25%) to Standard Support and Medication Management with Contingency Management. Data were available for 518 (70%) of participants at 6-month follow-up, 255 (68.5%) allocated to Standard Support, 122 (67.0%) to Standard Support and Medication Management and 141 (76.2%) to Standard Support and Medication Management with Contingency Management. The mean difference of per cent adherence to acamprosate was higher for those who received Standard Support and Medication Management with Contingency Management (10.6%, 95% confidence interval 19.6% to 1.6%) compared to Standard Support alone, at the primary end point (6-month follow-up). There was no significant difference in per cent days adherent when comparing Standard Support and Medication Management with Standard Support alone 3.1% (95% confidence interval 12.8% to -6.5%) or comparing Standard Support and Medication Management with Standard Support and Medication Management with Contingency Management 7.9% (95% confidence interval 18.7% to -2.8%). The primary economic analysis at 6 months found that Standard Support and Medication Management with Contingency Management was cost-effective compared to Standard Support alone, achieving small gains in quality-adjusted life-years at a lower cost per participant. Cost-effectiveness was not observed for adjunctive Medication Management compared to Standard Support alone. There were no serious adverse events related to the trial interventions reported.

Limitations

The trial's primary outcome measure changed substantially due to data collection difficulties and therefore relied on a measure of self-reported adherence. A lower than anticipated follow-up rate at 12 months may have lowered the statistical power to detect differences in the secondary analyses, although the primary analysis was not impacted.

Conclusions

Medication Management enhanced with Contingency Management is beneficial to patients for supporting them to take acamprosate.

Future work

Given our findings in relation to Contingency Management enhancing Medication Management adherence, future trials should be developed to explore its effectiveness and cost-effectiveness with other alcohol interventions where there is evidence of poor adherence.

Trial registration

This trial is registered as ISRCTN17083622 https://doi.org/10.1186/ISRCTN17083622.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 22. See the NIHR Journals Library website for further project information.

Development and Implementation of Workshops to Optimize the Delivery of Vaccination Services in Community Pharmacies: Thinking beyond COVID-19

Vaccines are widely recognized as the most economically efficient strategy to combat infectious diseases. Community pharmacists, being highly accessible healthcare professionals, have the potential to significantly contribute to the promotion and facilitation of vaccination uptake. In Canada, the jurisdiction of healthcare falls under provincial legislation, leading to variations in the extent of pharmacist practice throughout the country. While some pharmacists in Canada already functioned as immunizers, Québec pharmacists gained the authority to prescribe and administer vaccines in March 2020 amidst the COVID-19 pandemic. Our workshop aimed to equip pharmacists in Québec with the necessary guidance to optimize vaccinations, emphasizing the importance of maintaining and expanding immunization services beyond influenza and COVID-19 vaccines in the future. During the workshop, pharmacists had the opportunity to exchange valuable insights and best practices regarding workflow optimization, identifying areas for improvement in competency, effectively reaching vulnerable population groups, and integrating allied team members into their practice. Participants were also asked to develop a plan of action to help implement practice change beyond the workshop. Interactive workshops centered around discussions like these serve as catalysts for advancing the pharmacy profession, uniting professionals with a collective aim of enhancing patient care.

Nurses, physicians and patients' knowledge and attitudes about nurse prescribing

Background

One of the roles that nurses have acquired in recent years is the role of prescribing. This study aimed to investigate the knowledge and attitudes of critical care nurses, physicians and patients about nurse prescribing.

Methods

A descriptive cross-sectional study with the participation of 152 nurses, 53 physicians and 75 patients was carried out. Participants were selected by stratified random sampling from the critical care units of six hospitals in Tabriz, Iran. Demographics and participants’ knowledge and attitudes about nurse prescribing questionnaires were used to collect data. The collected data were analyzed using SPSS-22 software.

Results

The mean scores of total knowledge about nurse prescribing in nurses, patients and physicians’ were 15.41 ± 1.85,16.45 ± 2.31, 14.74 ± 1.7 respectively (from a range of 10 -20), and the mean score of knowledge by physicians was significantly higher than others (P = 0.000) and they had more knowledge about nurse prescribing. The mean scores of the attitudes towards nurse prescribing in nurses, physicians and patients were 40.62 ± 3.68, 37.98 ± 5.92 and 39.38 ± 4.39 respectively (from a range of 10 -50). However, the total mean score of attitudes among nurses was significantly higher than others (P = 0.000) and nurses had more positive attitudes toward prescribing.

Conclusion

The results showed that the participants have a good understanding and attitudes toward nurse prescribing. Nurse prescribing as a new duty and authority can be considered in providing more effective care by specialist nurses. The results of this study can also be used in the future planning of health policy for nurses to have the right to prescribe and ultimately improve the quality of patient care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-00888-0.

Pharmacist non-medical prescribing in primary care. A systematic review of views, opinions, and attitudes

BACKGROUND

Uptake of non-medical prescribing by pharmacists working in primary care has been slow. This is despite benefits such as quicker and more efficient access to medicines for patients, a reduction in doctor workload, and enhanced professional satisfaction. This systematic review explores the views, opinions, and attitudes of pharmacists and graduates towards non-medical prescribing.

METHODS

Medline, ScienceDirect, Embase, and the University of Reading Summon Service were searched to identify qualitative and mixed methods papers that examined the views, opinions, and attitudes of pharmacists and graduates towards non-medical prescribing. Papers published between January 2003 and September 2017 were included. Studies were quality assessed using the CASP checklist and then analysed using thematic synthesis.

RESULTS

After 85 full-text articles were assessed, a final 14 studies were eligible for inclusion. The included studies assessed pharmacists who currently prescribe, and other pharmacists and graduates with familiarity of non-medical prescribing. Thematic synthesis identified two themes: (1) practice environment, and (2) pharmacist's role. Non-medical prescribing was considered a natural extension to the role of a pharmacist despite difficulties in completing the required training. The ability to then prescribe was dependent on funding and access to medical records, time, and support staff. Pharmacists experienced professional rivalry with both support and resistance from members of the primary care team. The provision of training was frequently referred to as unsatisfactory. Pharmacists were motivated to prescribe, deriving increased job satisfaction and a sense of professionalism; however, they often felt underprepared for the reality of unsupervised practice. Furthermore, pharmacists reported a cautious approach with a fear of making errors frequently discussed.

CONCLUSIONS

This review has identified themes and subsequent barriers and facilitators to non-medical prescribing. Many of the barriers are more perceived than real and are diminishing. Consideration of these will assist and advance pharmacist prescribing in primary care, leading to positive outcomes for both patient care and the pharmacy profession.

Prescribing trends over time by non-medical independent prescribers in primary care settings across Wales (2011-2018): a secondary database analysis

INTRODUCTION

As of 2015, as part of the implementation of the Welsh Government primary care plan and primary care clusters, the Welsh Government has encouraged non-medical healthcare professionals working in primary care to train as independent prescribers (IPs).

OBJECTIVES

This research aimed to identify the number of NMIPs in primary care in Wales and describe their prescribing trend of items between 2011 and 2018, in order to compare their prescribing pattern before and after the implementation of primary care clusters for Wales.

DESIGN

Retrospective secondary data analysis and interrupted time series analysis in order to compare prescribing by non-medical independent prescribers (NMIPs) preimplementation and postimplementation of primary care clusters across Wales.

RESULTS

Over the study period, 600 NMIPs (nurses n=474 and pharmacists n=104) had prescribed at least one item. The number of nurse IPs increased by 108% and pharmacists by 325% (pharmacists had the largest increase between July 2015 and March 2018). The number of items prescribed by NMIPs increased over time by an average of 1380 per month (95% CI 904 to 1855, p<0.001) after the implementation of primary care clusters compared with 496 (95% CI 445 to 548, p<0.001) prior its implementation. Approximately one-third of the items prescribed by NMIPs was within Betsi Cadwaladr University Health Board (HB) with only 4% in Powys Teaching HB.

CONCLUSION

The number of NMIPs and their volume of prescribing in primary care in Wales has increased following the implementation of primary care clusters in 2015. This suggests that the Government's recommendations of using NMIPs in primary care have been implemented. Future studies should focus on efficiency and quality of prescribing by NMIPs in primary care.

Pharmacists' Prescribing in Saudi Arabia: Cross-Sectional Study Describing Current Practices and Future Perspectives

Pharmacist prescribing is being increasingly undertaken to better use their skills and reduce the workload of existing prescribers such as doctors, often using formal processes to legitimate these activities. In developing countries like Saudi Arabia, however, pharmacists' prescribing remains informal with no legislation or formal training and there is a lack of research and understanding into such practices. Therefore, we aimed to describe current pharmacist prescribing practices in Saudi Arabia and explore pharmacists' views about pharmacists' prescribing. This is a cross-sectional survey study using an online questionnaire of hospital pharmacists in Saudi Arabia about pharmacists' prescribing, and associated views about prescribing legislation and barriers to implementing pharmacist prescribing. Over a quarter (28.5%) of pharmacists reported themselves as prescribers, 49% were following a collaborative prescribing model, 18% independent prescribing, and 33% were doing both. Ninety percent of prescribers reported confidence in prescribing the appropriate treatment and 92.3% perceived they will benefit from more prescribing training. Healthcare practice culture and pharmacist's competency were identified as barriers. There is an overall support for pharmacists' prescribing in Saudi Arabia among this sample of hospital pharmacists, with limitations in resources and the absence of standardized prescribing training being perceived as key barriers to pharmacists' prescribing.

Pharmacist Prescribing in Pediatric and Neonatal Acute Care: An Observational Study

OBJECTIVE

The intent of this project was to objectively describe the frequency of pharmacist prescribing in acute care pediatrics and neonatology and to determine the medications most often prescribed by pharmacists practicing in a jurisdiction that permits pharmacists' prescribing.

METHODS

This was a subgroup analysis of a retrospective observational study using prescribing data from an electronic medical record system used in 5 acute care hospitals (1 pediatric, 4 primarily adult but with pediatric and neonatal units) within Calgary, Alberta, Canada.

RESULTS

Considering orders for pediatric or neonatal patients only, there was a mean (SD) of 126 (226) prescriptions per pharmacist per year, with a wide range (1–1101 per year). Considering only the 9 clinical pharmacist full-time equivalents (FTEs) assigned to pediatrics and/or neonatology (i.e., not including dispensary pharmacist FTE), this represents 572 prescriptions per clinical pharmacist FTE per year (726 in pediatrics and 380 in neonatology). The most common medication classes on pediatric units included anti-infective agents, central nervous system agents, and gastrointestinal agents. In NICUs, blood formation, coagulation and thrombosis agents (mainly iron), electrolytes, caloric and water balance agents (primarily sodium supplements), and vitamins were also commonly prescribed by pharmacists.

CONCLUSIONS

As the scope of pharmacy practice expands to include prescribing, health team leadership can use these data to support incorporation of this role into practice. Prescribing pharmacists can ensure appropriate use of many medications used in acutely ill infants and children, potentially improving efficiency and quality of care.

Pharmacists' readiness to adopt prescribing authority in Jordan

Objectives

The overall objective of this study is to assess the views and attitudes of Jordanian pharmacists on expanded pharmacist prescribing role.

Methods

A cross-sectional, questionnaire-based study was conducted using a web-based questionnaire. Pharmacists were invited to take part in this study through pharmacists' Facebook groups for pharmacists in Jordan. Descriptive statistics were used to analyze the data in addition to the t-test to compare the mean difference of support levels toward supplementary and independent prescribing.

Key findings

A total of 521 pharmacists took part in this study. The majority of respondents (n = 482; 92.5%) believe that pharmacists in Jordan should have an expanded prescribing role. Respondents were significantly in favour of supplementary prescribing (P &lt; 0.05) than independent prescribing for various medical condition (e.g. diabetes and asthma). Respondents identified securing more roles in healthcare (n = 464; 89%) and increasing pharmacy profits (n = 420; 80.7%) as key facilitators to adopt this new role. Whereas inadequate training in the diagnosis of disease (n = 457; 87.7%), and inadequate training in patient assessment and monitoring (n = 453; 86.9%) were reported as the most likely barriers.

Conclusion

Overall, Jordanian pharmacists strongly supported the expanded prescribing role and favoured supplementary prescribing for chronic conditions (e.g. diabetes). The study highlighted the need for additional training in various areas (e.g. diagnosing and managing some clinical conditions) to prepare Jordanian pharmacists for this new role.

Understanding ethical/unethical behavior in pharmaceutical companies: a literature review

Purpose

The purpose of this paper is to examine and review the available literature on ethical/unethical behaviour of pharmaceutical companies and to determine the ethical issues, unethical behaviour by analysing, summarising and categorising the factors related to these issues and unethical behaviour as were studied during the period 2008-2017. Essentially, this paper presents a critical analysis of the available literature on the subject and avenues for future research.

Design/methodology/approach

This paper adopted the systematic review approach to achieve the purpose of this study and examines the most relevant literature from online existing database sources, available between 2008-2017 by using the keyword search method. Then studies are categorised and summarised, using previously developed theories and frameworks, which have provided evidence to the universal consensus that ethical behavioural outcomes are dependent on the interplay of individual, organisational and environmental factors and have reordered to fulfil the purpose.

Findings

The findings identify that ethical issues related to pharmaceutical companies as were studied during the period 2008-2017 are drug pricing, drug safety and gift-giving. The organisational variables appeared to be the dominant cause of these ethical issues and unethical practices along with other determinants such as environmental and stakeholders. A large number of studies were in the western country context. Theoretical research has studied more comparatively empirical studies.

Research limitations/implications

This review provides insights for understanding the ethical issues, unethical behaviour and determinants related to these issues of pharmaceutical companies and provides insights where the literature is standing. This review only includes studies between 2008-2017, which are related to the ethical issue of pharmaceutical companies, therefore, the view is only of the past 10 years papers. This review provides gaps and insight into the source of ideas for future research and will help the researchers in guiding ethics-related information in the context of pharmaceutical companies.

Practical implications

This study will help the practitioners and policymakers in informing about the issues that required the urgent need to solve and will shed some light to focus and formulate strategies for successful competitive advantage. This study will help researchers who are seeking information related to ethics and ethical behaviour in pharmaceutical companies.

Originality/value

To the best of my knowledge, this review of understanding ethical/unethical behaviour in pharmaceutical companies of the past 10 years between 2008-2017 has not been done to date. This study is filling the gap by bringing all the information about ethics in pharmaceutical companies at one place, which works as an index of ethics-related study in this specific pharmaceutical company context.

Barriers to pharmacist prescribing: a scoping review comparing the UK, New Zealand, Canadian and Australian experiences

OBJECTIVES

Non-medical prescribers, including pharmacists, have been found to achieve comparable clinical outcomes with doctors for certain health conditions. Legislation supporting pharmacist prescribing (PP) has been implemented in the United Kingdom (UK), Canada and New Zealand (NZ); however, to date, Australian pharmacists have not been extended prescribing rights. The purpose of this review was to describe the barriers to PP found in the literature from the UK, Canada, NZ and Australia, and examine the implications of these for the development of PP in Australia.

METHODS

We conducted a scoping review, which included peer-reviewed and grey literature, and consultation with stakeholders. Sources - Scopus, PubMed and CINAHL; Google Scholar, OpenGrey and organisational websites from January 2003 to March 2018 in the UK, Canada, NZ and Australia. Inclusion criteria - articles published in English, related to implementation of PP and articulated barriers to PP.

KEY FINDINGS

Of 863 unique records, 120 were reviewed and 64 articles were eligible for inclusion. Three key themes emerged: (1) Socio-political context, (2) Resourcing issues and (3) Prescriber competence. The most common barriers were inadequate training regarding diagnostic knowledge and skills, inadequate support from authorities and stakeholders, and insufficient funding/reimbursement.

CONCLUSIONS

If implementation of PP is to occur, attention needs to be focused on addressing identified barriers to PP implementation, including fostering a favourable socio-political context and prescriber competence. As such, a concerted effort is required to develop clear policy pathways, including targeted training courses, raising stakeholder recognition of PP and identifying specific funding, infrastructure and resourcing needs to ensure the smooth integration of pharmacist prescribers within interprofessional clinical teams.

Effects of pharmacist prescribing on patient outcomes in the hospital setting: a systematic review

OBJECTIVE

The objective of the review was to synthesize the best available evidence on the safety and effectiveness of pharmacist prescribing on patient outcomes in patients who present to hospital.

INTRODUCTION

Pharmacist prescribing is legal in many countries. Different models of prescribing include dependent, collaborative and independent. Existing reviews of pharmacist prescribing focus on studies in the community setting, or both community and hospital settings. Other reviews focus on descriptions of current practice or perspectives of clinicians and patients on the practice of pharmacist prescribing. A systematic review on the effects of pharmacist prescribing on patient outcomes in the hospital has not been previously undertaken and is important as this practice can help ease the burden on the healthcare system.

INCLUSION CRITERIA

Studies with controlled experimental designs comparing pharmacist prescribing to medical prescribing in the hospital setting were included in the review. Primary outcomes of interest included clinical outcomes such as therapeutic failure or benefit, adverse effects, and morbidity or mortality. Secondary outcomes included error rates in prescriptions, medication omissions on the medication chart, time or proportion of International Normalized Ratios in therapeutic range, time to reach therapeutic range, and patient satisfaction.

METHODS

A comprehensive three-step search strategy was utilized. The search was conducted in January 2017 in eight major databases from database inception. Only studies in English were included. The recommended Joanna Briggs Institute approach to critical appraisal, study selection and data extraction was used. Narrative synthesis was performed due to heterogeneity of the studies included in the review.

RESULTS

The 15 included studies related to dependent and collaborative prescribing models. In four studies that measured clinical outcomes, there was no difference in blood pressure management between pharmacists and doctors while patients of pharmacist prescribers had better cholesterol levels (mean difference in low density lipoprotein of 0.4 mmol/L in one study and 1.1 mmol/L in another; mean difference in total cholesterol of 1.0 mmol/L) and blood sugar levels (mean difference of fasting blood sugar levels of 15 mg/dL, mean difference of glycosylated hemoglobin of 2.6%). In two studies, pharmacists were better at adhering to warfarin dosing nomograms than doctors (average of 100% versus 62% compliance). In six studies, when prescribing warfarin according to dosing nomograms, equivalent numbers or more patients were maintained in therapeutic range by pharmacist prescribers compared to doctors. The incidence of adverse effects related to anticoagulant prescribing was similar across arms but all six studies were underpowered to detect this outcome. Three studies found that pharmacist prescribers made less prescribing errors (20 to 25 times less errors) and omissions (three to 116 times less omissions) than doctors when prescribing patients' usual medications on admission to hospital or in the preoperative setting. Two studies reported that patients were as satisfied with the services provided by pharmacist prescribers as with doctors.

CONCLUSIONS

This review provides low to moderate evidence that pharmacists can prescribe to the same standards as doctors. Pharmacists are better at adhering to dosing guidelines when prescribing by protocol and make significantly less prescribing errors when charting patients' usual medications on admission to hospital.

CAPABLE: Calgary zone usage of Additional Prescribing Authorization By pharmacists in an inpatient setting: review of the prescribing Landscape and Environment

BACKGROUND

In Alberta, Canada, pharmacists have been granted the ability to prescribe most medications independently after completing an additional authorization process. While there are data to support the use of pharmacists' prescribing in the community setting, little is known about its use in the inpatient hospital setting.

OBJECTIVES

To describe the prescribing patterns of pharmacists in an inpatient setting including the percentage of pharmacists using their prescribing authority, the care areas where prescribing occurred, and the frequency of prescribing. Secondary objectives included describing the medications prescribed, and to determine if pharmacists are documenting their prescribing interventions.

METHODS

A descriptive, retrospective, cross-sectional study of medications ordered by pharmacists through the electronic order entry system in Calgary, Alberta, Canada. Prescriptions were examined in the context of how often each pharmacist prescribed, the medications prescribed, and an audit of documentation practices was performed using patient charts.

RESULTS

A total of 64,293 orders from 172 pharmacists were included in the analysis, of which 51% (n = 32,681) were discontinuation orders. It was found that 90% of pharmacists used their prescribing authority, ordering a median of 11.3 prescriptions monthly (interquartile range 4.3-32.8). Clinical areas with the most overall prescribing included critical care (854.8), oncology and palliative care (463.0), and surgery (409.3) prescriptions per pharmacist Full-Time Equivalent per year.

CONCLUSIONS

This study demonstrates a broad range of prescribing from pharmacists within acute care practice and a wide variety of medication prescribed. Future areas for research include barriers and enablers to pharmacist prescribing and examination of where prescribing pharmacists have the greatest value.

Rural and metropolitan South Australian mental health workers' views about nurse prescribing: A thematic analysis

Almost one third of the South Australian population reside in regional locations, which are serviced by just 8% of the State's total psychiatrist workforce. Consequently, access to psychotropic medications in regional South Australia (SA) can be challenging. Granting prescribing rights to mental health nurses (MHNs) located in regional settings presents an opportunity to increase consumer access to psychotropic medications. The aim of the study was to understand the perspectives of mental health workers (MHWs) practising in regional and metropolitan settings towards MHN prescribing. The study adopted a qualitative approach. Seventeen MHWs participated in three focus groups, including two in regional SA and one in a metropolitan site within the State of SA. Participants reported difficulties in accessing medicines in regional areas. The regional focus groups indicated that MHN prescribing may help to release psychiatrists' time and provide quicker assessment and diagnosis. By contrast, the metropolitan focus group expressed reservations about MHN prescribing. Participants indicated that suitable governance structures supported by appropriate education programmes were a necessary prerequisite for MHN prescribing of psychotropic medications. MHN prescribing may help to mitigate the impact of psychiatrist shortages in regional South Australia and possibly in other areas of the world where recruitment is a challenge. The provision of adequate education and the establishment of a suitable governance and support framework are considered necessary steps to progress MHN prescribing.

A mixed methods exploration of physiotherapist's approaches to analgesic use among patients with hip osteoarthritis

OBJECTIVE

To explore how physiotherapists currently address analgesic use among patients with hip osteoarthritis, and their beliefs about the acceptability of prescribing for these patients.

METHODS

A cross-sectional questionnaire was mailed to 3126 UK-based physiotherapists. Approaches to analgesic use among patients with hip osteoarthritis were explored using a case vignette. Semi-structured telephone interviews were undertaken with 21 questionnaire responders and analysed thematically.

SETTING

UK.

PARTICIPANTS

Physiotherapists who had treated a patient with hip osteoarthritis in the previous 6 months.

RESULTS

Questionnaire response: 53% (n=1646). One thousand one hundred forty eight physiotherapists reported treating a patient with hip osteoarthritis in the last 6 months (applicable responses), of whom nine (1%) were non-medical prescribers. Nearly all physiotherapists (98%) reported that they would address analgesic use for the patient with hip osteoarthritis, most commonly by signposting them to their GP (83%). Fifty six percent would discuss optimal use of current medication, and 33%, would discuss use of over-the-counter medications. Interviews revealed that variations in physiotherapists' approaches to analgesic use were influenced by personal confidence, patient safety concerns, and their perceived professional remit. Whilst many recognised the benefits of analgesia prescribing for both patients and GP workload, additional responsibility for patient safety was a perceived barrier.

CONCLUSIONS

How physiotherapists currently address analgesic use with patients with hip osteoarthritis is variable. Although the potential benefits of independent prescribing were recognised, not all physiotherapist want the additional responsibility. Further guidance supporting optimisation of analgesic use among patients with hip OA may help better align care with best practice guidelines and reduce GP referrals.

Cost-effectiveness analysis of doctor-pharmacist collaborative prescribing for venous thromboembolism in high risk surgical patients

Background

Current evidence to support cost effectiveness of doctor- pharmacist collaborative prescribing is limited. Our aim was to evaluate inpatient prescribing of venous thromboembolism (VTE) prophylaxis by a pharmacist in an elective surgery pre-admission clinic against usual care, to measure any benefits in cost to the healthcare system and quality adjusted life years (QALYs) of patients.

Method

A decision tree model was developed to assess cost effectiveness of pharmacist prescribing compared with usual care for VTE prophylaxis in high risk surgical patients. Data from the literature was used to inform decision-tree probabilities, utility, and cost outcomes. In the intervention arm, a pharmacist prescribed patient’s regular medications, documented a VTE risk assessment and prescribed VTE prophylaxis. In the usual care arm, resident medical officers were responsible for prescribing regular medications, and for risk assessment and prescribing of VTE prophylaxis. The base scenario assessed the cost effectiveness of a pre-existing pre-admission clinic pharmacy service that takes on a collaborative prescribing role. The alternative scenario assessed the benefits of introducing a pre-admission clinic pharmacy service where previously there had not been one. Probabilistic sensitivity analysis was conducted to explore uncertainty in the model.

Results

In both the base-case scenario and the alternative scenario pharmacist prescribing resulted in an increase in the proportion of patients adequately treated and a decrease in the incidence of VTE resulting in cost savings and improvement in quality of life. The cost savings were $31 (95% CI: -$97, $160) per patient in the base scenario and $12 (95% CI: -$131, $155) per patient in the alternative scenario. In both scenarios the pharmacist-doctor prescribing resulted in an increase in QALYs of 0.02 (95% CI: -0.01, 0.005) per patient. The probability of being cost effective at a willingness to pay off $40,000 was 95% in the base scenario and 94% in the alternative scenario.

Conclusion

Delegation of the prescribing of VTE prophylaxis for high risk surgical patients to a pharmacist prescriber in PAC, as part of a designated scope of practice, would result in fewer cases of VTE and associated lower costs to the healthcare system and increased QALYs gained by patients.

Trial registration

Pre admission clinic study registered with ANZCTR-ACTR Number ACTRN12609000426280.

Stakeholders' views and experiences of pharmacist prescribing: a systematic review

AIMS

The aims of this systematic review were to: (1) critically appraise, synthesize and present the available evidence on the views and experiences of stakeholders on pharmacist prescribing and; (2) present the perceived facilitators and barriers for its global implementation.

METHODS

Medline, CINAHL, International Pharmaceutical Abstracts, PsychArticles and Google Scholar databases were searched. Study selection, quality assessment and data extraction were conducted independently by two reviewers. A narrative approach to data synthesis was undertaken due to heterogeneity, the nature of study types and outcome measures.

RESULTS

Sixty-five studies were identified, mostly from the UK (n = 34), followed by Australia (n = 13), Canada (n = 6) and USA (n = 5). Twenty-seven studies reported pharmacists' perspectives, with fewer studies focusing on patients' (n = 12), doctors' (n = 6), the general public's (n = 4), nurses' (n = 1), policymakers' (n = 1) and multiple stakeholders' (n = 14) perspectives. Most reported positive experiences and views, regardless of stage of implementation. The main benefits described were: ease of patient access to healthcare services, improved patient outcomes, better use of pharmacists' skills and knowledge, improved pharmacist job satisfaction, and reduced physician workload. Any lack of support for pharmacist prescribing was largely in relation to: accountability for prescribing, limited pharmacist diagnosis skills, lack of access to patient clinical records, and issues concerning organizational and financial support.

CONCLUSION

There is an accumulation of global evidence of the positive views and experiences of diverse stakeholder groups and their perceptions of facilitators and barriers to pharmacist prescribing. There are, however, organizational issues to be tackled which may otherwise impede the implementation and sustainability of pharmacist prescribing.

Nurse-led hypertension management was well accepted and non-inferior to physician consultation in a Chinese population: a randomized controlled trial

The objective of this study is to evaluate if nurse-led repeated prescription (NRP) could ensure non-inferior disease control and would be accepted in Chinese patients with controlled hypertension (HT) in primary care clinics. A 12-month follow-up non-inferiority randomized trial was conducted. The non-inferior margins for systolic and diastolic blood pressure were 6.6 mmHg and 3.7 mmHg, respectively. Eligible patients (>18 years of age) with HT were randomized to the NRP and usual care (UC) groups for their regular clinical follow-up. We used ANCOVA to study the difference-of-difference of the blood pressures between the two groups. The levels of patient acceptance and experience of NRP were assessed by the observed opt-out rate and a qualitative analysis. We found no statistically significant differences in BP blood pressure between the NRP (N = 194) and UC (N = 199) groups. Only 4 of the participants in the NRP group opted out due to a preference for assessment by a physician. The interviewed participants (N = 12) felt positive about NRP, because they experienced more relaxed communication with the nurse and believed that the eligibility to join the NRP program was an indication of optimal BP control. We observed no adverse events. The findings show that NRP was well accepted and found to be non-inferior to physician consultation for HT management.

Facilitators and barriers to non-medical prescribing - A systematic review and thematic synthesis

Introduction

Non-medical prescribing has the potential to deliver innovative healthcare within limited finances. However, uptake has been slow, and a proportion of non-medical prescribers do not use the qualification. This systematic review aimed to describe the facilitators and barriers to non-medical prescribing in the United Kingdom.

Methods

The systematic review and thematic analysis included qualitative and mixed methods papers reporting facilitators and barriers to independent non-medical prescribing in the United Kingdom. The following databases were searched to identify relevant papers: AMED, ASSIA, BNI, CINAHL, EMBASE, ERIC, MEDLINE, Open Grey, Open access theses and dissertations, and Web of Science. Papers published between 2006 and March 2017 were included. Studies were quality assessed using a validated tool (QATSDD), then underwent thematic analysis. The protocol was registered with PROSPERO (CRD42015019786).

Results

Of 3991 potentially relevant identified studies, 42 were eligible for inclusion. The studies were generally of moderate quality (83%), and most (71%) were published 2007–2012. The nursing profession dominated the studies (30/42). Thematic analysis identified three overarching themes: non-medical prescriber, human factors, and organisational aspects. Each theme consisted of several sub-themes; the four most highly mentioned were ‘medical professionals’, ‘area of competence’, ‘impact on time’ and ‘service’. Sub-themes were frequently interdependent on each other, having the potential to act as a barrier or facilitator depending on circumstances.

Discussion

Addressing the identified themes and subthemes enables strategies to be developed to support and optimise non-medical prescribing. Further research is required to identify if similar themes are encountered by other non-medical prescribing groups than nurses and pharmacists.

Iran's health policymakers' views on barriers and facilitators of nurse prescribing in their context: A qualitative study

BACKGROUND

In most countries, one of the main reasons for developing more advanced roles for nurses is to improve access to care in the context of limited number of doctors. It is considered that the introduction of major policy initiatives, such as nurse prescribing, requires high-level discussion and policy development to ensure successful implementation. This study aimed to identify the barriers and facilitators of nurse prescribing based on policymakers' views in Iran.

MATERIALS AND METHODS

This qualitative study was based on conventional content analysis approach. A purposeful sample of 14 participants were recruited, including 6 members of the Nursing Board, 6 members of the Iranian Nursing Organization, and 2 senior employees of Iran's Ministry of Health and Medical Education. Data were gathered through in-depth semi-structured interviews. Interviews were audio-recorded and transcribed verbatim.

RESULTS

The four emerged categories as facilitators of nurse prescribing were labeled "positive views of health policymakers," "human resources capabilities," "non-medical prescribing experiences," and "governmental and non-governmental organizational activities." The four extracted categories as barriers of nurse prescribing were "socio-cultural factors," "organizational factors," "educational barriers," and "human barriers."

CONCLUSIONS

Barriers and facilitating factors should be considered in order to bring about organizational policy changes and improve perspectives. Nurse prescribing requires the efforts of involved managers and authorities for development and modernization. The results of this study can serve as a compressed resource for policymakers and managers to identify the effective issues on nurse prescribing and can help them to plan for the implementation of nurse prescribing.

A scoping review of research on the prescribing practice of Canadian pharmacists

BACKGROUND

Pharmacists in Canada have been prescribing since 2007. This review aims to explore the volume, array and nature of research activity on Canadian pharmacist prescribing and to identify gaps in the existing literature.

METHODS

We conducted a scoping review to examine the literature on prescribing by pharmacists in Canada according to methodological trends, research areas and key findings. We searched for peer-reviewed research articles and abstracts in the Ovid MEDLINE, Ovid EMBASE and International Pharmaceutical Abstracts databases without any date limitations. A standardized form was used to extract information.

RESULTS

We identified 156 articles; of these, 26 articles and 12 abstracts met inclusion criteria. One-half of the research studies (20) used quantitative methods, including surveys, trials and experimental designs; 11 studies used qualitative methods and 7 used other methods. Research on pharmacist prescribing demonstrated an improvement in patient outcomes (13 studies), varied stakeholder perceptions (10 studies) and factors that influence this practice change (11 studies). Pharmacist prescribing was adopted when pharmacists practised patient-centred care. Stakeholders held contrasting perceptions of pharmacist prescribing.

DISCUSSION

Canadian research has demonstrated the benefit of pharmacist prescribing on patient outcomes, which is not present in the international literature. Future research may consider a meta-analysis addressing the impact on patient health. Gaps in research include comparisons between provinces, effects on physicians' services, overall patient safety and access to health care systems and economic implications for society.

CONCLUSION

A growing body of research on pharmacist prescribing has captured the early impact of prescribing on patient outcomes, perceptions of practice and practice change. Opportunities exist for pan-Canadian research that examines the system impact.

Non-medical prescribing assessment - An evaluation of a nationally agreed multi method approach

In the United Kingdom, legislation permits nurses and allied health professionals to prescribe for patients within their care. Preparation for this role includes learning, teaching and assessment that is embedded in practice, supervised by a designated medical practitioner (DMP) and evidenced in a reflective learning in practice portfolio.

AIM

The objectives were to explore; (1) which assessment in the practice portfolio was ranked most valuable in terms of achieving safe, effective prescribing practice and, (2) whether a practice based assessment (SDEP) was an acceptable alternative to an Observed Simulated Clinical Examination (OSCE).

METHODS

Online surveys were conducted and follow up semi structured telephone interviews were conducted across 5 universities in Scotland with students, DMPs and line managers.

RESULTS

Students ranked the learning log most valuable and DMPs and line managers ranked the SDEP most valuable. Survey and follow up interviews suggested that the portfolio provided the opportunity to develop prescribing skills and knowledge relevant to their specific clinical speciality. There was agreement amongst all participants that clinical assessment in the practice portfolio effectively enable non-medical prescribing students to evidence prescribing competence.

SUMMARY

The novel use of the SDEP and reflective summary offers a viable alternative to an OSCE and was viewed as one of the most valued components of the assessment strategy.

An exploratory study of the patient experience of pharmacist supplementary prescribing in a secondary care mental health setting

BACKGROUND

Management of chronic disease has become an increasing challenge to the National Health Service in the United Kingdom. The introduction of supplementary prescribing was seen as a possible mechanism to address the needs of this patient group. Individuals with mental illness were considered particularly suitable for management in this way.

OBJECTIVE

To explore the views and experiences of patients with mental illness on being managed by a pharmacist supplementary prescriber in a secondary care outpatient setting.

METHODS

A study of patient experiences utilising semi-structured interviews and self-completion diaries was adopted. Eleven patients participated in the study. Data were analysed utilising code and retrieve, and content analysis respectively.

RESULTS

Patients valued the increased accessibility to, and continuity of, their prescriber compared with their experience of other healthcare professionals. Patients reported they were able to trust the pharmacist's knowledge of medication, were provided with sufficient information regarding reasons for treatment and side effects, and felt that they had an active role in decisions concerning their healthcare.

CONCLUSIONS

This exploratory study showed that patients had positive views of being managed by a supplementary prescriber. However, it should be noted that the number of participants was small. It is therefore important that further, more wide ranging research is conducted to evaluate pharmacist prescribing within mental health settings.

Medication decision making and patient outcomes in GP, nurse and pharmacist prescriber consultations

Aim The aims of this study were twofold: (a) to explore whether specific components of shared decision making were present in consultations involving nurse prescribers (NPs), pharmacist prescribers (PPs) and general practitioners (GPs) and (b) to relate these to self-reported patient outcomes including satisfaction, adherence and patient perceptions of practitioner empathy.

BACKGROUND

There are a range of ways for defining and measuring the process of concordance, or shared decision making as it relates to decisions about medicines. As a result, demonstrating a convincing link between shared decision making and patient benefit is challenging. In the United Kingdom, nurses and pharmacists can now take on a prescribing role, engaging in shared decision making. Given the different professional backgrounds of GPs, NPs and PPs, this study sought to explore the process of shared decision making across these three prescriber groups.

METHODS

Analysis of audio-recordings of consultations in primary care in South England between patients and GPs, NPs and PPs. Analysis of patient questionnaires completed post consultation. Findings A total of 532 consultations were audio-recorded with 20 GPs, 19 NPs and 12 PPs. Prescribing decisions occurred in 421 (79%). Patients were given treatment options in 21% (102/482) of decisions, the prescriber elicited the patient's treatment preference in 18% (88/482) and the patient expressed a treatment preference in 24% (118/482) of decisions. PPs were more likely to ask for the patient's preference about their treatment regimen (χ 2=6.6, P=0.036, Cramer's V=0.12) than either NPs or GPs. Of the 275 patient questionnaires, 192(70%) could be matched with a prescribing decision. NP patients had higher satisfaction levels than patients of GPs or PPs. More time describing treatment options was associated with increased satisfaction, adherence and greater perceived practitioner empathy. While defining, measuring and enabling the process of shared decision making remains challenging, it may have patient benefit.

Use and evaluation of a mentoring scheme to promote integration of non-medical prescribing in a clinical context

BACKGROUND

Growing numbers of non-medical health professionals are attaining prescribing rights through post-registration non-medical prescribing (NMP) courses in the UK. However, not all implement prescribing post-qualification. This study evaluated the uptake and perceived usefulness of a mentoring scheme for two cohorts of NMP students at the University of Nottingham. The scheme paired students with qualified mentors with whom they had an opportunity to discuss the integration of prescribing theory into practice.

METHODS

Mentors were allocated on days 2-5 of the course. Surveys were distributed to students who completed the NMP course [n = 63] and their mentors. Likert-scale and open-ended questions addressed: use, perceived usefulness, and positive and negative aspects of the mentoring scheme. Semi-structured interviews were conducted with both students (n = 6) and mentors (n = 3) to explore their experience of the mentoring scheme in more detail. Students were purposively selected for interview depending on their level of use of the mentoring system. Interviews were analysed using thematic analysis.

RESULTS

The response rates were 65.1% (n = 41) and 56.3% (n = 36) for students and mentors respectively. Just over half of students (57.1%) accessed their mentor. Having a sufficient support network was the key reason for not using the scheme. Students found mentors helpful for: moral support (68.2%); contextualising prescribing (71.4%); and helping them to think about implementing prescribing in practice (72.7%). Fewer mentors felt they helped in relation to contextualising (57.9%) or implementing prescribing (31.6%). Less than half the students and mentors surveyed agreed that they received/provided assistance related to the integration of prescribing theory into practice (38.1% and 42.2% respectively) and assistance with assignments (36.3% and 45.5% respectively).Interviews suggested that students found it difficult to focus on implementing prescribing because of the academic demands of their course, which impacted on uptake and use of the mentoring scheme. Students emphasised the importance of being paired with a prescriber who was successfully prescribing. Mentors benefited from sharing and refreshing their academic knowledge.

CONCLUSIONS

Students and mentors derived benefits from participation in this scheme. This intervention may be better as a post-qualification support resource when students are ready to consider their future prescribing practice.

Development of consensus guidance to facilitate service redesign around pharmacist prescribing in UK hospital practice

BACKGROUND

The last decade has seen a drive towards non-medical prescribing in the United Kingdom (UK). However, there is a dearth of any published literature on applying the principles of service redesign to support pharmacist prescribing in any sphere of practice.

OBJECTIVE

To develop consensus guidance to facilitate service redesign around pharmacist prescribing.

SETTING

UK hospital practice.

METHODS

The Delphi technique was used to measure consensus of a panel of expert opinion holders in Scotland. Individuals with key strategic and operational roles in implementing initiatives of pharmacy practice and medicines management were recruited as experts. An electronic questionnaire consisting of 30 statements related to pharmacist prescribing service redesign was developed. These were presented as five-point Likert scales with illustrative quotes.

MAIN OUTCOME MEASURES

Consensus, defined as 70 % of panel members agreeing (ranked strongly agree/agree) with each statement.

RESULTS

Responses were obtained from 35/40 (87.5 %) experts in round one and 29 (72.5 %) in round two. Consensus in round one was achieved for 27/30 of statements relating to aspects of generic 'service development' (e.g. succession planning, multidisciplinary working, quality evaluation, practice development and outcome measures) and 'pharmacist prescribing role development' (e.g. education and future orientation of service). Issues of disagreement were around targeting of pharmacist prescribing to clinical specialities and financial remuneration for prescribing in the hospital setting.

CONCLUSION

Consensus guidance has been developed to facilitate service redesign around hospital pharmacist prescribing.

Non-medical prescribing of chemotherapy: engaging stakeholders to maximise success?

AIM

This study report examines the views and experiences of professional stakeholders about non-medical prescribing (NMP) of chemotherapy.

BACKGROUND

The introduction of open formulary NMP has created opportunities to radically change health-care delivery. For chemotherapy services, the most recent advice from the National Chemotherapy Advisory Group [Department of Health (2009) Chemotherapy Services in England, ensuring quality and safety: a report from the National Chemotherapy Advisory Group, London Her Majesty's Stationary Office] clearly endorses the development of nurse- or pharmacist-led chemotherapy clinics. This is very much welcomed but is based on very limited evidence as to their effectiveness.

DESIGN

A fourth-generation evaluation study.

METHODS

A purposeful sample of 23 stakeholders connected with the chemotherapy service was used. A serial data collection technique with individual interviews followed by uni-professional focus groups was adopted. Finally, a multi-professional focus group was held to determine the strategic way forward. Data were collected in 2009-2010.

RESULTS

The study illuminated the key features necessary to maximise success of NMP in chemotherapy clinics and captures the importance of good working relationships. Whilst different practice models will emerge, fundamental and core to services is the need for good team working, established and effective communication strategies, and most importantly avoiding isolation in practice. This study additionally reinforced any evaluation takes place within preexisting political contexts and in particular medical dominance. Not all medical colleagues agreed with or wanted NMP for their patients, highlighting difficulties of developing new models of working within a resisting culture.

CONCLUSION

No objections to NMP of chemotherapy were found, but, clearly, the context of practice needs to be agreed and supportedby all professional stakeholders. What is already known about this topicOpen formulary non-medical prescribing has been rapidly introduced over the past decade.Little research has been conducted in acute care and none in the chemotherapy setting.Cancer policy recommends the introduction of nurse-led chemotherapy clinics.What this paper addsNon-medical prescribing (NMP) in chemotherapy is appropriate with the right model of practice.Well-established professional relationships are a key to success.NMP is not appropriate in isolation of the multidisciplinary team (MDT).Implications for practice and/or policyNurses need to demonstrate the value of non-medical prescribing in chemotherapy using available metrics.Models of practice need to ensure good communication channels, MDT working, and transparency of prescribing.

Patient attitudes towards a new role for pharmacists: continued dispensing

BACKGROUND

In Australia, "continued dispensing" (CD) is a new model for supply of prescription medications. Under specific circumstances, community pharmacists are allowed to dispense a further one month supply of prescription only medications without a valid prescription. It allows continuation and treatment adherence when patients run out of statin and/or oral contraceptive (OC) medications, when it is not practical or they fail to plan accordingly to get a new prescription.

OBJECTIVE

The aim of this study was to explore patient attitudes towards a CD model, including any perceived concerns or associated risks with CD prior to its introduction.

METHODS

An Australia-wide computer-assisted telephone interview survey of statin and OC users aged 18 years or older was conducted in July 2013 prior to implementation of the CD model. A telephone number list was generated via a random number generation function based on a broad breakdown of the Australian population as outlined in the June 2013 Australian Bureau of Statistics data. The sample target for the survey was 300, consisting of 150 statin users and 150 OC users.

RESULTS

There were a total of 301 respondents, comprising 151 statin users and 150 OC users. Approximately 37% of all respondents had experienced running out of their medications in the past 12 months, of whom 35.4% had temporarily stopped treatment and 33.6% requested their medication from a pharmacist without a valid prescription. OC users were more likely to run out of their medications (P=0.021). The majority of respondents had a regular pharmacy (86%) and therefore would be eligible for CD in the future. The majority of those surveyed had no concerns about CD or perceived it as posing no risks. Concerns raised included consultation privacy and the pharmacist's lack of access to their medical records.

CONCLUSION

Australian users of statin and OC medications showed a high level of support for CD. Given that a significant proportion of patients temporarily stopped treatment when they ran out of medications and had no valid prescription, implementation of CD may alleviate the negative consequences of therapy interruption in statin and OC users in the short term. Longer-term solutions and opportunities to expand CD require further exploration.

Educational interventions to improve prescribing competency: a systematic review

OBJECTIVE

To review the literature on educational interventions to improve prescribing and identify educational methods that improve prescribing competency in both medical and non-medical prescribers.

DESIGN

A systematic review was conducted. The databases Medline, International Pharmaceutical Abstracts (IPA), EMBASE and CINAHL were searched for articles in English published between January 1990 and July 2013.

SETTING

Primary and secondary care.

PARTICIPANTS

Medical and non-medical prescribers.

INTERVENTION

Education-based interventions to aid improvement in prescribing competency.

PRIMARY OUTCOME

Improvements in prescribing competency (knows how) or performance (shows how) as defined by Miller's competency model. This was primarily demonstrated through prescribing examinations, changes in prescribing habits or adherence to guidelines.

RESULTS

A total of 47 studies met the inclusion criteria and were included in the systematic review. Studies were categorised by their method of assessment, with 20 studies assessing prescribing competence and 27 assessing prescribing performance. A wide variety of educational interventions were employed, with different outcome measures and methods of assessments. In particular, six studies demonstrated that specific prescribing training using the WHO Guide to Good Prescribing increased prescribing competency in a wide variety of settings. Continuing medical education in the form of academic detailing and personalised prescriber feedback also yielded positive results. Only four studies evaluated educational interventions targeted at non-medical prescribers, highlighting that further research is needed in this area.

CONCLUSIONS

A broad range of educational interventions have been conducted to improve prescribing competency. The WHO Guide to Good Prescribing has the largest body of evidence to support its use and is a promising model for the design of targeted prescribing courses. There is a need for further development and evaluation of educational methods for non-medical prescribers.

People's attitudes, beliefs, and experiences regarding polypharmacy and willingness to Deprescribe

OBJECTIVES

To capture people's attitudes, beliefs, and experiences regarding the number of medications they are taking and their feelings about stopping medications.

DESIGN

Administration of a validated questionnaire.

SETTING

Multidisciplinary ambulatory consulting service at the Royal Adelaide Hospital.

PARTICIPANTS

Participants were individuals aged 18 and older (median 71.5) taking at least one regular prescription medication; 100 participants completed all items of the questionnaire, 65 of whom were aged 65 and older.

MEASUREMENTS

Participants were administered the 15-item Patients' Attitudes Towards Deprescribing (PATD) questionnaire.

RESULTS

Participants were taking an average of 10 different prescription and nonprescription (including complementary), regular and as-needed medications. More than 60% felt that they were taking a "large number" of medications, and 92% stated that they would be willing to stop one or more of their current medications if possible. Number of regular medications, age, and number of medical conditions were not found to be correlated with willingness to stop a medication. The findings were similar in older and younger participants.

CONCLUSION

This study has shown that a cohort of mostly older adults were largely accepting of a trial of cessation of medication(s) that their prescriber deemed to be no longer required. Because few factors were associated with willingness to cease medications, all patients should be individually evaluated for deprescribing.

Initial perceptions of key stakeholders in Ontario regarding independent prescriptive authority for pharmacists

BACKGROUND

A number of jurisdictions, both in Canada and internationally, have recently expanded pharmacists' scope of practice to allow prescriptive authority.

OBJECTIVE

To ascertain the initial perceptions of the Ontario government and health professional stakeholder groups regarding the prospect of prescriptive authority for pharmacists.

METHODS

Qualitative research methods were used; data sources were policy documents and semi-structured interviews with key informants from the Ontario government and pharmacy and medical professional organizations. Purposive and snowball sampling strategies were used to identify 17 key informants. Fifty-one relevant policy documents were retrieved through searches of organizational websites and interviewee suggestions. Interview transcripts and documents were content analyzed independently by 2 researchers; and once consensus was achieved on key themes, the primary investigator analyzed the remainder.

RESULTS

Pharmacy organizations and Ontario government representatives both expressed support for pharmacist prescriptive authority, suggesting that it would enhance patient access to primary care. Medical organizations were opposed to this expanded pharmacist role, arguing that pharmacists' lack of training and experience in diagnosis and prescribing would endanger patient safety. Other concerns were fragmentation of care and pharmacists' lack of access to patient clinical information. Some government and pharmacy informants felt that pharmacist prescribing would decrease health system costs through substitution of cheaper health professionals for physicians, while others felt that costs would increase due to increased utilization of services. Medical organizations preferred delegated medical authority as the policy alternative to pharmacist prescribing.

CONCLUSIONS

Widely different views were expressed by the Ontario government and pharmacy organizations on the one hand and medical professional organizations on the other hand, regarding the potential impact of pharmacist prescribing on patient safety and access to primary care. This is likely due, at least in part, to the lack of evidence on the expected impact of this expanded pharmacist role. More research is needed to help inform discussions regarding this issue.

Expanded prescribing: a comparison of the views of Australian hospital and community pharmacists

BACKGROUND

Community pharmacies and hospitals are the two main professional areas for pharmacists. There is currently a lack of comparison of pharmacists working in these two distinct settings in relation to an expanded prescribing role.

OBJECTIVE

To compare the attitudes of hospital and community pharmacists regarding an expanded prescribing role.

SETTING

Australian pharmacists.

METHODS

A self-administered postal survey was used to collect the data. Data analysis was performed using SPSS(®) v19. Kendall's tau-c test was used to compare the mean values between categorical variables (i.e. hospital or community pharmacists) and continuous variables measuring attitudes on a Likert scale (i.e. reasons in favour and barriers of pharmacist prescribing, preferred therapeutic areas of prescribing and prescribing models). A Chi square test was used to analyse categorical variables (i.e. demographics).

MAIN OUTCOME MEASURE

The opinion of hospital and community pharmacists regarding an expanded prescribing role.

RESULTS

A response rate of 40.4% was achieved (1,049/2,592). Where significant differences were located, community pharmacists were more supportive of all proffered potential reasons in favour of pharmacist prescribing (p < 0.05) whereas hospital pharmacists were more in agreement with all suggested barriers to such a role (p < 0.05). In a supplementary (collaborative) prescribing model, hospital pharmacists were more confident than community pharmacists in prescribing for heart failure (p < 0.001) and anticoagulant therapies (p = 0.004). In an independent prescribing model hospital pharmacists were more supportive of prescribing anticoagulant therapies (p = 0.002). Significant differences were found between the two groups in relation to their support for independent prescribing (p = 0.020) and extension of the emergency supply 3 days rule to 30 days (p = 0.011).

CONCLUSION

This study suggests that there are differences between hospital and community pharmacists in what they regard as potential reasons in favour of an expanded pharmacist prescribing role, perceived barriers to such a role and whether to prescribe independently of doctors. Hospital pharmacists' attitudinal differences in terms of support for certain therapeutic areas of prescribing reflects probably their existing active role in clinical decision making processes in patients who are often seriously ill.

Educating nonmedical prescribers

The last decade has seen developments in nonmedical prescribing, with the introduction of prescribing rights for healthcare professionals. In this article, we focus on the education, training and practice of nonmedical prescribers in the UK. There are around 20,000 nurse independent prescribers, 2400 pharmacist supplementary/independent prescribers, several hundred allied health professional supplementary prescribers and almost 100 optometrist supplementary/independent prescribers. Many are active prescribers, managing chronic conditions or acute episodes of infections and minor ailments. Key aims of nonmedical prescribing are as follows: to improve patient care; to increase patient choice in accessing medicines; and to make better use of the skills of health professionals. Education and training are provided by higher education institutions accredited by UK professional bodies/regulators,namely, the Nursing and Midwifery Council, General Pharmaceutical Council, Health Professions Council and General Optical Council. The programme comprises two main components: a university component equivalent to 26 days full-time education and a period of learning in practice of 12 days minimum under the supervision of a designated medical practitioner. Course content focuses on the following factors: consultation, decision making, assessment and review; psychology of prescribing; prescribing in team context; applied therapeutics; evidence-based practice and clinical governance; legal, policy, professional and ethical aspects; and prescribing in the public health context. Nonmedical prescribers must practise within their competence, demonstrating continuing professional development to maintain the quality engendered during training. Despite the substantial progress, there are several issues of strategy, capacity, sustainability and a research evidence base which require attention to fully integrate nonmedical prescribing within healthcare.

Preparing hospital pharmacists to prescribe: stakeholders' views of postgraduate courses

OBJECTIVES

To explore pharmacy stakeholders' views on developing a postgraduate course to prepare hospital pharmacists for collaborative prescribing in Australia.

METHODS

Semi-structured interviews were conducted with pharmacy stakeholders from universities, hospitals and professional organisations (n = 25) to gather views on the content, structure and delivery methods of a possible postgraduate prescribing course for pharmacists. Transcripts were analysed thematically and coded using NVivo software.

KEY FINDINGS

There was strong support for collaborative prescribing as an appropriate role for advanced pharmacist practitioners and acknowledgement that further training is needed to implement this new role. It was proposed that postgraduate training for hospital pharmacists should be based on a national prescribing competency framework and participants highlighted key aspects of the prescribing process in which pharmacists need particular up-skilling: diagnosis, physical assessments, clinical decision-making and consultations. The training model used in the UK was favoured, where candidates undertake university-based study combined with collaborative training with a doctor and a practical assessment of competency.

CONCLUSIONS

The findings from this study have provided valuable information which can provide a pathway for the development of a postgraduate course to prepare Australian hospital pharmacists for prescribing. Future research should focus on uncovering the perceptions of Australian doctors, nurses and policy makers on the training requirements needed for pharmacist prescribing in the hospital setting. Stakeholders' views on pharmacist prescribing training in the community setting could also be explored.

An evaluation framework for non-medical prescribing research

Without robust and credible evidence for the benefits in health outcomes of non-medical prescribing, widespread implementation will be challenging. Our aim is to develop a consistent evaluation framework that could be applied to non-medical prescribing research. An informal collaboration was initiated in 2008 by a group of pharmacists from Australia and New Zealand to assist in information sharing, pilot design, methodologies and evaluation for pharmacist prescribing. Different pilots used different models, methodologies and evaluation. It was agreed that the development of a consistent evaluation framework to be applied to future research on non-medical prescribing was required. The framework would help to align the outcomes of different research pilots and enable the comparison of endpoints to determine the effectiveness of a non-medical prescribing intervention.

Roles of the non-medical prescribing leads within organisations across a Strategic Health Authority: perceived functions and factors supporting the role

Objectives

Extending the roles of nurses, pharmacists and allied health professionals to include prescribing has been identified as one way of improving service provision. In the UK, over 50 000 non-medical healthcare professionals are now qualified to prescribe. Implementation of non-medical prescribing ( NMP) is crucial to realise the potential return on investment. The UK Department of Health recommends a NMP lead to be responsible for the implementation of NMP within organisations. The aim of this study was to explore the role of NMP leads in organisations across one Strategic Health Authority (SHA) and to inform future planning with regards to the criteria for those adopting this role, the scope of the role and factors enabling the successful execution of the role.

Methods

Thirty-nine NMP leads across one SHA were approached. Semi-structured telephone interviews were conducted. Issues explored included the perceived role of the NMP lead, safety and clinical governance procedures and facilitators to the role. Transcribed audiotapes were coded and analysed using thematic analytical techniques.

Key findings

In total, 27/39 (69.2%) NMP leads were interviewed. The findings highlight the key role that the NMP lead plays with regards to the support and development of NMP within National Health Service trusts. Processes used to appoint NMP leads lacked clarity and varied between trusts. Only two NMP leads had designated or protected time for their role. Strategic influence, operational management and clinical governance were identified as key functions. Factors that supported the role included organisational support, level of influence and dedicated time.

Conclusion

The NMP lead plays a significant role in the development and implementation of NMP. Clear national guidance is needed with regards to the functions of this role, the necessary attributes for individuals recruited into this post and the time that should be designated to it. This is important as prescribing is extended to include other groups of non-medical healthcare professionals.

A cross sectional survey of the views of newly registered pharmacists in Great Britain on their potential prescribing role: a cautious approach

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Pharmacists, along with certain other health professionals, may train and practice as supplementary or independent prescribers. The implementation and sustainability of pharmacist prescribing services throughout Britain will require a sizeable workforce. However, a survey of GB pharmacists highlighted that only a minority has taken any action to investigate prescribing training. Newly registered pharmacists may be keen to explore extended clinical roles and their engagement is likely to be key to the future success of this initiative.

WHAT THIS STUDY ADDS

Newly registered pharmacists are cautious in their approach to taking on prescribing training and roles. While almost all expressed interest in prescribing training, they acknowledged training needs in clinical examination, patient monitoring and medico-legal aspects of prescribing. Longitudinal research on a cohort of newly registered pharmacist prescribers is warranted, aiming to identify later prescribing training actions and subsequent impact on patient care. AIM To investigate newly registered pharmacists' awareness of pharmacist prescribing and views on potential future roles as prescribers.

METHODS

A mailed questionnaire was sent to all 1658 pharmacists joining the Pharmacist Register in 2009.

RESULTS

The response rate was 25.2% (n= 418). While most (86.4%) expressed interest in prescribing training, they acknowledged training needs in clinical examination, patient monitoring and medico-legal aspects of prescribing. Two thirds of respondents (66.3%) thought the current requirement of being registered as a pharmacist for 2 years prior to commencing prescribing training was appropriate.

CONCLUSION

Newly registered pharmacists are cautious in their approach to taking on prescribing training and roles.

Assessing the contribution of prescribing in primary care by nurses and professionals allied to medicine: a systematic review of literature

Background

Safe and timely access to effective and appropriate medication through primary care settings is a major concern for all countries addressing both acute and chronic disease burdens. Legislation for nurses and other professionals allied to medicine to prescribe exists in a minority of countries, with more considering introducing legislation. Although there is variation in the range of medicines permitted to be prescribed, questions remain as to the contribution prescribing by nurses and professionals allied to medicine makes to the care of patients in primary care and what is the evidence on which clinicians, commissioners of services and policy makers can consider this innovation.

Methods

A integrative review of literature on non-medical prescribing in primary care was undertaken guided by dimensions of health care quality: effectiveness, acceptability, efficiency and access.

Results

19 papers of 17 empirical studies were identified which provided evidence of patient outcome of non medical prescribing in primary care settings. The majority were undertaken in the UK with only one each from the USA, Canada, Botswana and Zimbabwe. Only two studies investigated clinical outcomes of non-medical prescribing. Seven papers reported on qualitative designs and four of these had fewer than ten participants. Most studies reported that non medical prescribing was widely accepted and viewed positively by patients and professionals.

Conclusions

Primary health care is the setting where timely access to safe and appropriate medicines is most critical for the well-being of any population. The gradual growth over time of legislative authority and in the numbers of non-medical prescribers, particularly nurses, in some countries suggests that the acceptability of non-medical prescribing is based on the perceived value to the health care system as a whole. Our review suggests that there are substantial gaps in the knowledge base to help evidence based policy making in this arena. We suggest that future studies of non-medical prescribing in primary care focus on the broad range of patient and health service outcomes and include economic dimensions.

Improving hypertension management through pharmacist prescribing; the rural Alberta clinical trial in optimizing hypertension (Rural RxACTION): trial design and methods

BACKGROUND

Patients with hypertension continue to have less than optimal blood pressure control, with nearly one in five Canadian adults having hypertension. Pharmacist prescribing is gaining favor as a potential clinically efficacious and cost-effective means to improve both access and quality of care. With Alberta being the first province in Canada to have independent prescribing by pharmacists, it offers a unique opportunity to evaluate outcomes in patients who are prescribed antihypertensive therapy by pharmacists.

METHODS

The study is a randomized controlled trial of enhanced pharmacist care, with the unit of randomization being the patient. Participants will be randomized to enhanced pharmacist care (patient identification, assessment, education, close follow-up, and prescribing/titration of antihypertensive medications) or usual care. Participants are patients in rural Alberta with undiagnosed/uncontrolled blood pressure, as defined by the Canadian Hypertension Education Program. The primary outcome is the change in systolic blood pressure between baseline and 24 weeks in the enhanced-care versus usual-care arms. There are also three substudies running in conjunction with the project examining different remuneration models, investigating patient knowledge, and assessing health-resource utilization amongst patients in each group.

DISCUSSION

To date, one-third of the required sample size has been recruited. There are 15 communities and 17 pharmacists actively screening, recruiting, and following patients. This study will provide high-level evidence regarding pharmacist prescribing.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00878566.

Family Physicians' Perceptions of Pharmacy Adaptation Services in British Columbia

Background:

In 2008, the BC provincial government introduced legislation that enabled pharmacists to adapt prescriptions. The purpose of this study was to examine the perceptions, attitudes and practices of family physicians as they relate to pharmacy adaptation services.

Methods:

Focus groups and interviews were conducted with physicians in 4 of the 5 regional health authorities of BC (Fraser, Interior, Vancouver Coastal and Vancouver Island) and transcripts were thematically coded and analyzed.

Results:

Forty physicians participated in the 4 focus groups and 4 physicians participated in supplementary interviews. Physicians perceived 6 key concerns arising from the initiative: compromised patient monitoring, physician liability, physician burden, pharmacists' ability to make appropriate adaptations, conflicts of interest and impact on physician-pharmacist relationships. Physicians also believed that communication about the adaptation initiative was inadequate and that they were not sufficiently included in its development.

Interpretation:

Most of the participating physicians had received very few, if any, prescription adaptations; hence their concerns about the potential impact of such adaptations are mostly speculative. They also indicated a lack of information concerning the details of the initiative and the scope of what pharmacists are permitted to adapt. However, whether or not their perceptions are accurate, physicians' beliefs about prescription adaptations will affect their acceptance of the initiative and thus their concerns need to be addressed.

Conclusions:

Physicians are essential stakeholders in the prescribing process. To ensure that physicians support pharmacy adaptation services, their concerns should be addressed in the adaptation guidelines and efforts should be made to include them in discussions and provide them with detailed communications.