Uncomfortable prescribing decisions: a critical incident study

Survey of potentially inappropriate prescriptions for common cold symptoms in Japan: A cross-sectional study

Background

Common cold is among the main reasons patients visit a medical facility. However, few studies have investigated whether prescriptions for common cold in Japan comply with domestic and international evidence.

Objective

To determine whether prescriptions for common cold complied with domestic and international evidence.

Methods

This cross-sectional study was conducted between October 22, 2020, and January 16, 2021. Patients with cold symptoms who visited the two dispensing pharmacies and met the eligibility criteria were interviewed.

Main outcome measure

The pharmacists at each store and a physician classified the patients into two groups: the potentially inappropriate prescribing group and the appropriate prescribing group.

Results

Of the 150 selected patients, 14 were excluded and 136 were included in the analysis. Males accounted for 44.9% of the total study population, and the median patient age was 34 years (interquartile range [IQR], 27–42). The prevalence rates of potentially inappropriate prescriptions and appropriate prescriptions were 89.0% and 11.0%, respectively and the median drug costs were 602.0 yen (IQR, 479.7–839.2) [$5.2 (IQR, 4.2–7.3)] and 406.7 yen (IQR, 194.5–537.2) [$3.5 (IQR, 1.7–4.7)], respectively. The most common potentially inappropriate prescriptions were the prescription of oral cephem antibacterial agents to patients who did not have symptoms of bacterial infections (50.4%) and β2 stimulants to those who did not have respiratory symptoms due to underlying disease or history (33.9%).

Conclusions

Approximately 90% of prescriptions for common cold symptoms in the area were potentially inappropriate. Our findings could contribute to the monitoring of the use of medicines for the treatment of common cold symptoms.

Behavioral determinants of antibiotic resistance: The role of social information

The increasing development of resistant pathogens is one of the greatest global health challenges. As antibiotic overuse amplifies antibiotic resistance, antibiotic intake poses a social dilemma in which individuals need to decide whether to prosocially reduce their intake in the collective interest versus to (over)use it even in case of mild diseases. We devise a novel behavioral game paradigm to model the social dilemma of antibiotic intake. Using this new method in an incentivized laboratory experiment (N = 272 German participants), we varied whether players had mutual knowledge about their antibiotic intake. The results indicate that there was substantial antibiotic overuse in the absence of social information. Overuse decreased when social information was present. Our postexperimental survey data further suggest that social information impacts people's behavioral motivation, evaluation of the other player, and positive affect. Taken together, providing social information about people's antibiotic intake may help in reducing antibiotic overuse. On a more general level, the novel behavioral game may be adapted to study other aspects of antibiotic intake to promote prudent use of antibiotics.

Understanding doctors' emergency department antibiotic prescribing decisions in children with respiratory symptoms in the UK: a qualitative study

OBJECTIVE

Exploration of the factors that influence hospital doctors' antibiotic prescribing decisions when treating children with respiratory symptoms in UK emergency departments.

METHODS

A qualitative study using semistructured interviews based on a critical incident technique with 21 physicians of different grades and specialties that treat children in the UK. Interviews were audio-recorded then transcribed verbatim and analysed using thematic analysis.

RESULTS

Four themes were identified. These themes illustrate factors which influence clinician prescribing. The three principal themes were authorities, pressures and risk. The fourth transcending theme that ran through all themes was clinician awareness and complicity ('knowing but still doing').

CONCLUSIONS

Hospital doctors prescribe antibiotics even when they know they should not. This appears to be due to the influence of those in charge or external pressures experienced while weighing up the immediate and longer term risks but clinicians do this with full insight into their actions. These findings have implications for invested parties seeking to develop future antimicrobial stewardship programmes. It is recommended that stewardship interventions acknowledge and target these themes which may in turn facilitate behaviour change and antimicrobial prescribing practice in emergency departments.

Effectiveness of honey for symptomatic relief in upper respiratory tract infections: a systematic review and meta-analysis

BACKGROUND

Antibiotic over prescription for upper respiratory tract infections (URTIs) in primary care exacerbates antimicrobial resistance. There is a need for effective alternatives to antibiotic prescribing. Honey is a lay remedy for URTIs, and has an emerging evidence base for its use. Honey has antimicrobial properties, and guidelines recommended honey for acute cough in children.

OBJECTIVES

To evaluate the effectiveness of honey for symptomatic relief in URTIs.

METHODS

A systematic review and meta-analysis. We searched Pubmed, Embase, Web of Science, AMED, Cab abstracts, Cochrane Library, LILACS, and CINAHL with a combination of keywords and MeSH terms.

RESULTS

We identified 1345 unique records, and 14 studies were included. Overall risk of bias was moderate. Compared with usual care, honey improved combined symptom score (three studies, mean difference -3.96, 95% CI -5.42 to -2.51, I²=0%), cough frequency (eight studies, standardised mean difference (SMD) -0.36, 95% CI -0.50 to -0.21, I²=0%) and cough severity (five studies, SMD -0.44, 95% CI -0.64 to -0.25, I²=20%). We combined two studies comparing honey with placebo for relieving combined symptoms (SMD -0.63, 95% CI -1.44 to 0.18, I²=91%).

CONCLUSIONS

Honey was superior to usual care for the improvement of symptoms of upper respiratory tract infections. It provides a widely available and cheap alternative to antibiotics. Honey could help efforts to slow the spread of antimicrobial resistance, but further high quality, placebo controlled trials are needed.

PROSPERO REGISTRATION NO

Study ID, CRD42017067582 on PROSPERO: International prospective register of systematic reviews (https://www.crd.york.ac.uk/prospero/).

How German general practitioners justify their provision of complementary and alternative medicine - a qualitative study

BACKGROUND

Many German general practitioners (GPs) use complementary and alternative medicine (CAM) in their daily work although most CAM procedures are controversial from an academic point of view.

OBJECTIVE

We aimed to investigate how GPs justify their use of CAM.

METHODS

We performed semi-structured, individual face-to-face interviews with 20 purposively sampled, experienced GPs providing primary care within the framework of the German statutory health insurance system. A grounded theory approach was used for data analysis.

RESULTS

All GPs participating in this study used at least some CAM in their clinical practice. Participants did not have any major conflicts when justifying their use of CAM therapies. Important arguments justifying CAM provision were: using it as a supplementary tool to conventional medicine; the feeling that evidence and science leave many problems in primary care unanswered; a strong focus on helping the individual patient, justifying the use of procedures not based on science for therapeutic and communicative purposes; a strong belief in one's own clinical experience; and appreciation of placebo effects. In general, participants preferred CAM therapies which seemed at least somewhat plausible to them and which they could provide in an authentic manner.

CONCLUSIONS

Our results suggest that many German GPs integrate CAM treatments in their routine primary care work without perceiving any major internal conflicts with professional ideals.

The role of real-world data in the development of treatment guidelines: a case study on guideline developers' opinions about using observational data on antibiotic prescribing in primary care

Background

Antimicrobial resistance (AMR) is a prominent threat to public health. Although many guidelines have been developed over the years to tackle this issue, their impact on health care practice varies. Guidelines are often based on evidence from clinical trials, but these have limitations, particularly in the breadth and generalisability of the evidence and evaluation of the guidelines’ uptake. The aim of this study was to investigate how national and local guidelines for managing common infections are developed and explore guideline committee members’ opinions about using real-world observational evidence in the guideline development process.

Methods

Six semi-structured interviews were completed with participants who had contributed to the development or adjustment of national or local guidelines on antimicrobial prescribing over the past 5 years (from the English National Institute for Health and Care Excellence (NICE)). Interviews were audio recorded and transcribed verbatim. Data was analysed thematically. This also included review of policy documents including guidelines, reports and minutes of guideline development group meetings that were available to the public.

Results

Three key themes emerged through our analysis: perception versus actual guideline development process, using other types of evidence in the guideline development process, and guidelines are not enough to change antibiotic prescribing behaviour. In addition, our study was able to provide some insight between the documented and actual guideline development process within NICE, as well as how local guidelines are developed, including differences in types of evidence used.

Conclusions

This case study indicates that there is the potential for a wider range of evidence to be included as part of the guideline development process at both the national and local levels. There was a general agreement that the inclusion of observational data would be appropriate in enhancing the guideline development process, as well providing a potential solution for monitoring guideline use in clinical practice, and improving the implementation of treatment guidelines in primary care.

Who is willing to stay sick for the collective? - Individual characteristics, experience, and trust

•

We study attitudes towards antibiotics and antibiotic resistance.

•

We analyze results from a novel web-survey of Swedish citizens (n = 1906).

•

Acceptability of doctor's decision not to prescribe antibiotics was found to be large.

•

Trust in the healthcare sector is linked to acceptability of doctor's decision.

•

Concern about antibiotic resistance is linked to willingness to limit antibiotic use.

Does medical training in Thailand prepare doctors for work in community hospitals? An analysis of critical incidents

BACKGROUND

Compulsory 3-year public service was implemented in 1967 as a measure to tackle the maldistribution of doctors in Thailand. Currently, therefore, most medical graduates work in rural community hospitals for their first jobs. This research explored doctors' perceptions of preparedness for practice using a critical incident technique.

METHODS

A self-administered critical incident questionnaire was developed. Convenient samples were used, i.e. Family Medicine residents at Ramathibodi Hospital who had worked in a community hospital after graduation before returning to residency training. Participants were asked to write about two incidents that had occurred while working in a community hospital, one in which they felt the knowledge and skills obtained in medical school had prepared them for managing the situation effectively and the other in which they felt ill-prepared. Data were thematically analysed.

RESULTS

Fifty-six critical incidents were reported from 28 participants. There were representatives from both normal and rural tracks of undergraduate training and community hospitals of all sizes and all regions. Doctors felt well-prepared to provide care for patients in emergency situations and as in-patients, but under-prepared for obstetric and paediatric emergencies, out-patient care, and palliative care. Moreover, they felt poorly prepared to deal with difficult patients, hospital administration and quality assurance.

CONCLUSIONS

Long-term solutions are needed to solve the rural doctor shortage. Medical graduates from both normal and rural tracks felt poorly prepared for working effectively in community hospitals. Medical training should prepare doctors for rural work, and they should be supported while in post.

Shared Goals, Different Barriers: A Qualitative Study of UK Veterinarians' and Farmers' Beliefs About Antimicrobial Resistance and Stewardship

Although much research has investigated the drivers of inappropriate antimicrobial prescribing in human medicine, equivalent research in veterinary medicine is in its infancy. This qualitative study used a critical incident approach to explore farm veterinarians' (vets) and farmers' beliefs about antimicrobial use and antimicrobial stewardship. Semi-structured interviews were conducted with 13 vets and 12 farmers in the UK, who worked mostly with beef cattle, dairy cattle and sheep, but a minority also worked with pigs or poultry. An inductive thematic analysis was conducted to explore how vets and farmers understood their responsibilities toward stewardship and antimicrobial resistance (AMR) and to identify key similarities and differences between the professions. The analysis generated four themes: "A shared conflict between ideals and behaviour," "Barriers to stewardship: the vets' perspective," "Barriers to stewardship: the farmers' perspective," and "A shared ambivalence: ownership vs. other-blaming." Vets and farmers demonstrated good understanding of stewardship but their treatment decisions are not always aligned to stewardship principles. Various barriers to improving antimicrobial stewardship were discussed by vets and farmers, but they placed differing emphasis on specific barriers. Faced with these barriers and an awareness that antimicrobial usage is not always aligned to stewardship principles, vets and farmers expressed frustration and a sense of ambivalence toward stewardship, and also engaged in other-blaming for the problem of AMR. In conclusion, vets and farmers in this study seem motivated to be antimicrobial stewards but feel challenged by the day-to-day reality of their jobs; they experience ambivalence toward their responsibilities for AMR, which may negatively impact their motivation to always act as antimicrobial stewards. Successfully tackling AMR will require change at the individual-, group-, and societal-level. Future interventions to improve antimicrobial usage in livestock farming could be situated within a social ecological framework, where other-blaming between professions is seen as a result of the interplay between psychological and contextual factors. Other-blaming could be reduced using a social identity approach; a common ingroup identity could be created by encouraging vets and farmers to focus on their common goal, namely a shared desire to promote animal welfare through optimal antimicrobial stewardship.

On the edges of medicine - a qualitative study on the function of complementary, alternative, and non-specific therapies in handling therapeutically indeterminate situations

Background

In routine practice, general practitioners (GPs) see many patients for whom treatment might not be necessary, or evidence-based treatments are not available, yet often a treatment is prescribed. We denote such situations as therapeutically indeterminate. We aimed to investigate 1) whether therapeutically indeterminate situations play a role in the accounts of GPs in their practical work; 2) the role of complementary and alternative medicine (CAM) modalities or non-specific therapies, and of other strategies used in handling therapeutically indeterminate situations; and 3) factors associated with preferences for specific strategies.

Methods

We performed semi-structured, individual face-to-face interviews with 20 purposively sampled, experienced GPs from Bavaria, Germany. A grounded theory approach was used for data analysis.

Results

Participants reported that therapeutically indeterminate situations recur often in their daily practice. Professionally legitimate strategies such as empathetic consultations without providing a treatment intervention did not seem to suffice for coping with all of these situations. CAM treatments were used frequently, but motives varied. While some participants were convinced that these treatments were active and effective, others were uncertain or had doubts and used them as a relational tool, as a non-specific treatment or as a beneficial placebo. Conventional drugs were also used in a non-specific manner or despite doubts regarding the risk-benefit ratio. The extent to which GPs felt responsible for offering solutions in therapeutically indeterminate situations seemed to influence their preference for specific strategies.

Conclusion

Our results demonstrate the important role of CAM and the somewhat smaller role of non-specific therapies for German general practitioners in dealing with therapeutically indeterminate situations. The concept of therapeutically indeterminate situations may be helpful in better understanding why many general practitioners treat patients in situations where treatment does not appear to be clearly indicated.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0945-4) contains supplementary material, which is available to authorized users.

'Damned one way or another': Bariatric surgeons' reflections on patients' suboptimal outcomes from weight loss surgery

OBJECTIVE

A minority of patients show sub-optimal outcomes after weight loss surgery. Research has identified predictors of poor outcomes focusing on the patients' perspective. No research has explored surgeons' accounts.

DESIGN

Ten Bariatric surgeons were interviewed using a critical incident approach to explore their explanations for sub-optimal outcomes in the context of a real-life case. Data were analysed using thematic analysis.

RESULTS

Three main themes were developed: 'Challenges to success' highlighting the role of psychosocial issues, poor adherence and patient non-disclosure; 'Ideal world solutions' describing who should identify and address psychosocial issues; and 'Real world compromise' reflecting the impact of limited resources and weighing up risk between carrying out versus not carrying out surgery. Transcending these themes was the notion of 'responsibility' with surgeons balancing the role of the patient, themselves and the health care system.

CONCLUSION

Some surgeons concluded that if they had known before surgery what they know now, they may not have operated. All emphasised that they could only know what was disclosed by the patient, that they were not convinced that not operating would have resulted in better outcomes in the longer term and many felt that they were 'damned one way or the other'.

Characteristics of the use of cold combination products among older ambulatory patients at the National Hospital Organization Tochigi Medical Center in Japan: a retrospective single-center observational study

Objective

Results

Perceptions of Legitimacy: The Influence on Medicine Taking and Prescribing

The terms non-compliance or non-adherence, in relation to medicine taking, contain the assumption that prescribers’ actions are legitimate and should be perceived as such by patients, and that non-adherence is deviant. Yet the high level of non-adherence suggests that patients do not necessarily perceive prescriptions in this way. We consider the relevance today of viewing non-adherence in terms of Weber’s concept of legitimacy. We also consider the more recent concept of concordance. Drawing on an analysis of interviews and consultations from a study of doctor–patient communication about drugs, we argue that decisions about prescribing and medicine taking are complex and take account of social as well as medical criteria. Moreover, any attempt to understand adherence needs to be flexible enough to encompass both a Weberian as well as a concordance approach to prescribing and medicine taking.

Factors influencing nurse and pharmacist willingness to take or not take responsibility for non-medical prescribing

BACKGROUND

In the UK, the majority of non-medical prescribers (NMPs) are nurses or pharmacists working in community or primary care. However, little is known about what influences their decisions to prescribe, unlike with medical prescribing. It is also unclear whether the medical findings can be extrapolated, given their very different prescribing training.

OBJECTIVES

To explore the factors influencing whether nurse and pharmacist NMPs in community and primary care settings take responsibility for prescribing.

METHODS

Initially, 20 NMPs (15 nurses and 5 pharmacists) were purposively selected and interviewed using the critical incident technique about situations where they felt it was inappropriate for them to take responsibility for prescribing or where they were uneasy about doing so. In addition, more general factors influencing their decision to take or not take prescribing responsibility were discussed. Subsequently, the themes from the interview analysis were validated in three focus groups with a total of 10 nurse NMPs. All data were analyzed using a constant comparison approach.

RESULTS

Fifty-two critical incidents were recorded--12 from pharmacist NMPs and 40 from nurse NMPs. Participants experienced situations where they were reluctant to accept responsibility for prescribing. Perceptions of competency, role and risk influenced their decision to prescribe. Workarounds such as delaying the prescribing decision or refer the patient to a doctor were used.

CONCLUSIONS

For NMPs to feel more confident about taking responsibility for prescribing, these issues of competency, role and perceived risk need to be addressed. Roles of NMPs must be clear to colleagues, doctors and patients. Training and support must be provided to enable professional development and increasing competence of NMPs.

Universal cures for idiosyncratic illnesses: A genealogy of therapeutic reasoning in the mental health field

Over the past decades, there has been a significant increase in prescriptions of psychotropic drugs for mental disorders. So far, most of the explanations of the phenomenon have focused on the process of medicalization, but little attention has been cast towards physicians’ day-to-day clinical reasoning, and the way it affects therapeutic decision-making. This article addresses the complex relationship between aetiology, diagnosis and drug treatment by examining the style of reasoning underlying prescribing practices through an historical lens. A genealogy of contemporary prescribing practices is proposed, that draws significant comparisons between 19th-century medicine and modern psychiatry. Tensions between specific, standardized cures and specific, idiosyncratic patients have been historically at play in clinical reasoning – and still are today. This inquiry into the epistemological foundations of contemporary drug prescription reveals an underlying search for scientific legitimacy.

The causes of prescribing errors in English general practices: a qualitative study

BACKGROUND

Few detailed studies exist of the underlying causes of prescribing errors in the UK.

AIM

To examine the causes of prescribing and monitoring errors in general practice and provide recommendations for how they may be overcome.

DESIGN AND SETTING

Qualitative interview and focus group study with purposive sampling of English general practices.

METHOD

General practice staff from 15 general practices across three PCTs in England participated in a combination of semi-structured interviews (n = 34) and six focus groups (n = 46). Thematic analysis informed by Reason's Accident Causation Model was used.

RESULTS

Seven categories of high-level error-producing conditions were identified: the prescriber, the patient, the team, the working environment, the task, the computer system, and the primary-secondary care interface. These were broken down to reveal various error-producing conditions: the prescriber's therapeutic training, drug knowledge and experience, knowledge of the patient, perception of risk, and their physical and emotional health; the patient's characteristics and the complexity of the individual clinical case; the importance of feeling comfortable within the practice team was highlighted, as well as the safety implications of GPs signing prescriptions generated by nurses when they had not seen the patient for themselves; the working environment with its extensive workload, time pressures, and interruptions; and computer-related issues associated with mis-selecting drugs from electronic pick-lists and overriding alerts were all highlighted as possible causes of prescribing errors and were often interconnected.

CONCLUSION

Complex underlying causes of prescribing and monitoring errors in general practices were highlighted, several of which are amenable to intervention.

The use of Ginkgo biloba in healthy elderly

To promote health-conscious behavior in the aging society and gain insight into the sources of knowledge on which preventive strategies are based, analyzing the behavior of elderly people who are recognized as highly health conscious may be useful. We focused on the use of Ginkgo biloba, which is commonly considered to be effective in preventing cognitive decline and dementia, among elderly adults. A total of 1,672 questionnaires were distributed among geriatric participants (60-94 years) who attended university lectures at 22 universities throughout Germany. Response rate was 36.1 %. We collected data on demographic characteristics, preventive strategies (use of Ginkgo and other supplements), health-conscious behavior, sources of knowledge concerning health behavior, and factors associated with the participants' concept of aging. The prevalence of Ginkgo use was 15.3 %. Ginkgo was assumed to be effective for cognitive enhancement and the treatment of cognitive decline by two thirds of the surveyed participants and one third believed Ginkgo to be effective for preventing dementia. Ginkgo use was significantly higher among participants using natural remedies and herbal and food supplements. The use of Ginkgo was recommended by physicians (57.3 %), chemists (16 %), and healthcare magazines (10.7 %). Food supplements were taken by 65.8 % of the sample: this percentage was significantly higher among subjects who exhibited health-conscious behavior. "Knowledge" about strategies to enhance cognition or prevent cognitive decline among the elderly do not appear to be evidence based. Thus, there is a need to establish reliable and independent sources of scientific information for healthcare professionals and the general public.

General practitioners' experiences and perceptions of benzodiazepine prescribing: systematic review and meta-synthesis

Background

Benzodiazepines are often prescribed long-term inappropriately. We aimed to systematically review and meta-synthesise qualitative studies exploring clinicians’ experiences and perceptions of benzodiazepine prescribing to build an explanatory model of processes underlying current prescribing practices.

Methods

We searched seven electronic databases for qualitative studies in Western primary care settings published in a European language between January 1990 and August 2011 analysing GP or practice nurse experiences of benzodiazepine prescribing. We assessed study quality using the Critical Appraisal Skills Programme Checklist. We analysed findings using thematic synthesis.

Results

We included eight studies from seven countries published between 1993 and 2010. Benzodiazepine prescribing decisions are complex, uncomfortable, and demanding, taken within the constraints of daily general practice. Different GPs varied in the extent to which they were willing to prescribe benzodiazepines, and individual GPs’ approaches also varied. GPs were ambivalent in their attitude towards prescribing benzodiazepines and inconsistently applied management strategies for their use. This was due to the changing context of prescribing, differing perceptions of the role and responsibility of the GP, variation in GPs’ attitudes to benzodiazepines, perceived lack of alternative treatment options, GPs’ perception of patient expectations and the doctor-patient relationship. GPs faced different challenges in managing initiation, continuation and withdrawal of benzodiazepines.

Conclusion

We have developed a model which could be used to inform future interventions to improve adherence to benzodiazepine prescribing guidance and improve prescribing through education and training of professionals on benzodiazepine use and withdrawal, greater provision of alternatives to drugs, reflective practice, and better communication with patients.

Influences on the decision to prescribe or administer anticholinergic drugs to treat death rattle: a focus group study

BACKGROUND

The evidence supporting pharmacological treatment of death rattle is poor; yet, anticholinergic drugs feature in end-of-life care pathways and guidelines worldwide as a treatment option.

AIM

This qualitative arm of a wider study aimed to explore important issues which health-care professionals associated with decision-making to prescribe or administer anticholinergics at the end of life.

DESIGN

After purposive sampling, five focus groups were conducted. Discussions were audiotaped and transcribed verbatim.

SETTING

Thirty medical and nursing personnel working in inpatient and community settings from two specialist palliative care units in the United Kingdom took part in the study.

RESULTS

Thematic analysis of transcripts from audiotapes revealed perceived pressures to prescribe and/or administer anticholinergics from colleagues and carers, and drugs were often prescribed or administered in order to be seen to 'do something', although the benefit in terms of therapeutic response was considered minimal. Familiarity with drug regimens and dosing was often based on personal experience. The monitoring of side effects of anticholinergics at the end of life was recognised as problematic and had little influence on prescribing and administration. There was also an indication that patients and carers in the community were more likely to receive timely verbal preparation and explanation around death rattle than those cared for in an inpatient setting.

CONCLUSION

The study raises questions about the routine inclusion of anticholinergic treatment in UK end of life care pathways for the treatment of death rattle.

Treatment choices of paediatric rheumatologists for juvenile idiopathic arthritis: etanercept or adalimumab?

OBJECTIVES

To evaluate differences in baseline characteristics between etanercept- and adalimumab-treated JIA patients and to reveal factors that influence the choice between these TNF inhibitors, which are considered equally effective in the recent ACR recommendations for JIA treatment.

METHODS

Biologic-naïve JIA patients with active arthritis who started treatment with adalimumab or etanercept between March 2008 and December 2011 were selected from the Dutch Arthritis and Biologicals in Children register. Baseline characteristics were compared. Focus group interviews with paediatric rheumatologists were performed to evaluate factors determining treatment choices.

RESULTS

A total of 193 patients started treatment with etanercept and 21 with adalimumab. Adalimumab-treated patients had longer disease duration prior to the start of biologics (median 5.7 vs 2.0 years) and more often a history of uveitis (71% vs 4%). Etanercept-treated patients had more disability at baseline (median Childhood Health Assessment Questionnaire score 1.1 vs 0.4) and more active arthritis (median number of active joints 6 vs 4). The presence of uveitis was the most important factor directing the choice towards adalimumab. Factors specific for the paediatric population-such as painful adalimumab injections-as well as the physician's familiarity with the drug accounted for the preference for etanercept.

CONCLUSION

Although the two TNF inhibitors are considered equally effective, in daily practice etanercept is most often prescribed; adalimumab is mainly preferred when uveitis is present. In choosing the most suitable biologic treatment, paediatric rheumatologists take into account drug and patient factors, considering newly published data and cautiously implementing this into daily care.

The Pattern of Drug Use in Acute Fever by General Practitioners (GPs) in Pune City, India

OBJECTIVES

1) To determine the WHO Prescribing Core Drug Use (PCDU) indicators in the management of acute fever (of less than 2 weeks duration) of the MBBS (allopathic) and BAMS (ayurvedic) General Practitioners (GPs) in Pune city. 2) To verify the appropriateness of the treatment. and 3) To compare the above parameters of the MBBS and the BAMS practitioners.

METHODS

Pune city was divided in five zones, north, south, east, west and central. A list of doctors was obtained from the Indian Medical Association and it was divided zone wise. 2 MBBS and 2 BAMS GPs. were selected per zone. An informed consent was obtained from the GPs. The sample size was 20 encounters per GP. The patients of all ages and both sexes, who suffered from fever of less than 2 weeks duration, were included in the study. The indicators which were studied were 1) the WHO Prescribing Core Drug Use indicators and 2) the complimentary drug use indicators for the appropriateness of the treatment.

RESULTS

1) The age, sex and diagnosis wise distribution of the patients was comparable in both the groups. 2) Among the WHO PCDU indicators, a highly significant difference was observed in the average number of drugs which was prescribed, the antibiotic usage and in the injections which were prescribed among the MBBS and the BAMS GPs 3) The use of the drugs from EDL and that of the generic drugs were comparable in both the groups.4) A marked irrationality was found in the injectable antimicrobials by the BAMS GPs.5) The selection of the antimicrobials was inappropriate in 64.14% and 17.5% of the encounters which were made by the BAMS and the MBBS GPs respectively.

CONCLUSION

Among the BAMS GPs: the WHO prescribing core drug use indicators were all significantly abnormal and the percentage of the inappropriate prescriptions was alarmingly high (92%). Among the MBBS GPs: There was more use of the antimicrobials but the proportion of the inappropriate prescriptions was less (42%).

Long term remission of anorexia nervosa: factors involved in the outcome of female patients

BACKGROUND

Anorexia nervosa (AN) is usually marked by difficult recovery.

OBJECTIVE

To elicit, describe and characterize factors involved in successful AN remission for at least five years and post-recovery life.

METHODS

A qualitative study design using semi-structured interviews according to grounded theory methodology was used. An intentional sample of 15 information rich AN patients was selected using two sampling procedures: the criterion and "snowball" techniques. Qualitative interviews were audiotaped, transcribed, and entered into a content analysis. Researchers coded transcripts and developed themes.

RESULTS

Four core parameters were found to be associated with remission: (i) 'motivation to change/stimuli'; (ii) 'empowerment/autonomy'; (iii) 'media related factors'; (iv) 'treatment factors'. Clinical remission can be associated with residual symptoms.

CONCLUSIONS

The recovery model involves not only one, but rather a set of inter-active variables, each one can partially explain remission. Media factors can take a new role on recovery. Remission, however, can be followed by remnants of the disease and functional limitations.

Work readiness of graduate health professionals

BACKGROUND AND AIM

The current exploratory study investigated work readiness among graduate health professionals.

DESIGN AND PARTICIPANTS

A critical incident technique was used to elicit perceptions regarding: strategies and skills that constitute work readiness among health professionals and the work readiness factors that help or hinder health graduates' transition and integration into the workplace. Fifteen medical graduates, 26 nursing graduates and five organisational representatives from a regional hospital in Victoria, Australia participated.

METHOD

Data were collected via qualitative interviews.

RESULTS

Participants discussed a total of 92 critical incidents; 52 related to helping and 40 to hindering work readiness factors that impacted graduates' transition and integration experiences. A follow-up thematic analysis indentified four critical work readiness factors: social intelligence, organisational acumen, work competence and personal characteristics. While graduates and organisational representatives considered each factor important, some differences between the groups emerged. Organisational representative's perceived social intelligence and clinical skills critical graduate competencies, yet graduates were unprepared in these areas.

CONCLUSION

The identified work readiness factors were consistent with past research and warrant further investigation of work readiness among a larger group of graduate health professionals in a range of contexts.

Repeat prescribing: which diagnoses, which drugs?

Background-Repeat prescribing should be limited to drugs which are to be prescribed on a long-term basis to patients whose conditions are stable. Early studies were based on small sample sizes. The definition of repeat prescribing has not been consistent and interpractice variation in repeat prescribing has not been described.Aims-To describe the diagnostic categories and anatomical groups associated with repeat prescriptions; to describe interpractice variation associated with repeat prescribing and to describe the repeat to consultation ratio for the most frequently prescribed diagnoses and drugs.Method-Doctors from a stratified quota sample of 22 Northern Ireland practices recorded their perceived diagnosis for every consultation and for every repeat prescription over a 2-week period.Results-The diagnostic categories significantly associated with repeat prescriptions were digestive, cardiovascular, neurological, psychiatric and metabolic ( p < 0.0001). The anatomical drug categories significantly associated with repeat prescriptions were gastrointestinal drugs, cardiovascular drugs, central nervous system drugs, dressings and appliances (p < 0.0001). There was wide interpractice variation in repeat prescribing (both overall and for individual anatomical groups) and associated diagnoses. High repeat to consultation ratios were recorded for ranitidine, temazepam and diazepan.Conclusions-Wide interpractice variation in repeat prescribing and associated diagnoses revealed poor consensus among practices. Therefore, the approach to the management of common conditions - whether to consult or issue a repeat prescription - was not uniform. The implications of these findings require further research. Commonly occurring diagnoses and drugs had unacceptably high repeat to consultation ratios. Copyright (c) 2000 John Wiley & Sons, Ltd.

"And mostly they have a need for sleeping pills": physicians' views on treatment of sleep disorders with drugs in nursing homes

The percentage of nursing home residents treated with hypnotic medications is high, as many authors report, despite the fact that such medications are almost always associated with undesirable effects for old people. This article takes a closer look at nursing home physicians' views of prescriptions when treating sleep disorders of nursing home residents. How do physicians characterize the treatment strategy for residents suffering from sleep disorders? How do they balance the benefits and risks of the hypnotic medication? Under what circumstances do they accept negative consequences? To answer these questions, N=20 physicians (aged 36 to 68 years) in 16 nursing homes in a German city were interviewed. The physicians were either employed by nursing homes or worked on a contract basis. Comparative categorization of the data produced a typology across cases. Three interpretative patterns concerning the use of drugs for treating sleep disorders were identified--"by request," "ambivalence," and "reflected prescription." Differences between them were determined by the significance of residents' wishes, neglect of risks, particularly that of addiction, and the attempt to balance benefits and disadvantages. The study showed deficits in professional management of sleep disorders in nursing homes.

Use and feasibility of delayed prescribing for respiratory tract infections: a questionnaire survey

BACKGROUND

Delayed prescribing of antibiotics for respiratory tract infections (RTIs) lowers the amount of antibiotics consumed. Several national treatment guidelines on RTIs recommend the strategy. When advocating treatment innovations, the feasibility and credibility of the innovation must be taken into account. The objective of this study was to explore GPs use and patients uptake of wait-and-see prescriptions for RTIs, and to investigate the feasibility of the strategy from GPs' and patients' perspectives.

METHODS

Questionnaire survey among Norwegian GPs issuing and patients receiving a wait-and-see-prescription for RTIs. Patients reported symptoms, confidence and antibiotics consumption, GPs reported diagnoses, reason for issuing a wait-and-see-prescription and their opinion about the method.

RESULTS

304 response pairs from consultations with 49 GPs were received. The patient response rate was 80%. The most common diagnosis for the GPs to issue a wait-and-see prescription was sinusitis (33%) and otitis (21%). 46% of the patients reported to consume the antibiotics. When adjusted for other factors, the diagnosis did not predict antibiotic consumption, but both being 16 years or more (p = 0,006) and reporting to have a fever (p = 0,012) doubled the odds of antibiotic consumption, while feeling very ill more than quadrupled the odds (p = 0,002). In 210 cases (69%), the GP found delayed prescribing a very reasonable strategy, and 270 patients (89%) would prefer to receive a wait-and-see prescription in a similar situation in the future. The GPs found delayed prescribing very reasonable most frequently in cases of sinusitis (79%, p = 0,007) and least frequently in cases of lower RTIs (49%, p = 0,002).

CONCLUSION

Most patients and GPs are satisfied with the delayed prescribing strategy. The patients' age, symptoms and malaise are more important than the diagnosis in predicting antibiotic consumption. The GP's view of the method as a reasonable approach depends on the patient's diagnosis. In our setting, delayed prescribing seems to be a feasible strategy, especially in cases of sinusitis and otitis. Educational efforts to promote delayed prescribing in similar settings should focus on these diagnoses.

Quality of drug prescribing in older patients: is there a problem and can we improve it?

Older patients are at high risk of suboptimal prescribing (overuse, underuse and misuse of drugs), which can lead to serious adverse drug reactions (ADR). About one in four patients admitted to hospital are prescribed at least one inappropriate medication and up to 20% of all inpatient deaths are attributed to potentially preventable ADR. Lists of drugs to avoid (unnecessary or where risks outweigh benefits) and drugs not to be omitted (strong indications if there are no contraindications) can assist in identifying suboptimal prescribing although, to date, no trials have established the ability of such screening, by itself, to improve prescribing quality. Remedial strategies proven to be effective in randomized trials include detailed appraisal of medication lists by multidisciplinary teams, which involve geriatricians and close liaison with specialist clinical pharmacists. A multifaceted quality improvement strategy is proposed that includes an aspirational target of no more than five different drugs be regularly prescribed to vulnerable older patients. Achieving this target involves prioritizing drug selection on the basis of strength of indication which may run counter to current disease-specific clinical guideline recommendations based on trials that have excluded most older patients. Such a strategy is worthy of further evaluation in a multicentre randomized trial.

Qualitative insights into general practitioners' views on the appropriateness of their long-term prescribing

Objective

To explore factors which may contribute to inappropriate long-term prescribing in United Kingdom general practice.

Methods

Nine previously validated indicators of the appropriateness of long-term prescribing were applied to a sample of patients, each under the care of one of 22 general practitioners from 10 practices. The GPs were then interviewed, using as the basis for the discussion specific examples of their prescribing that had been identified as potentially inappropriate. The interview transcripts were studied repeatedly to identify key themes in the reasons or explanations for apparently inappropriate prescribing.

Setting

General practices in three health authorities in England and one health board in Scotland.

Key findings

In total, 227 instances of potentially inappropriate prescribing, relating to 101 patients, were discussed with the 22 GPs. Four key themes emerged from the interview data. One common theme was that of perceived patient preference to continue with long-term therapy. A second theme was cases where the prescribing was “historical,” ie, the drug had been started a long time before, or by another doctor. Within this context, many doctors expressed great reluctance to change a drug when there was no obvious clinical need to do so, even though they would not initiate the drug regimen within their current practice. A third theme was that “hospital-led” prescribing was perceived to pose frequent and sometimes potentially difficult problems. Fourth, many GPs expressed their unease with the process of repeat prescribing which is operated in many UK practices.

Conclusions

This study has reinforced the fact that there are a number of internal and external factors which can impact on a GP's decision to continue apparently inappropriate long-term prescribing.

Prescription errors detected by Swedish pharmacists

Prescription errors identified and dealt with by personnel at 36 Swedish community and hospital pharmacies during March, 1992, were analysed. During the study period, the participating pharmacies handled 76,956 prescriptions for 41,908 patients. All prescription errors, even minor ones, were registered. In total 32,132 errors were detected and reported, corresponding to an overall rate of 42 per cent. The most common error was omission of the purpose of the therapy. This type of error was found in 20,517 prescriptions (64 per cent of all noted errors). Most detected errors did not require any special intervention by the dispensing pharmacist. Errors of commission, which are potentially harmful to the patient, totalled 338 or 1 per cent of the errors. The most common of these was that the dosage form stated was incorrect. The pharmacists were able to resolve almost three-quarters of the errors that required intervention and dispense the elucidated or amended prescription.

Diagnosis and management of pneumonia and bronchitis in outpatient primary care practices

AIMS

To understand which clinical criteria physicians use to diagnose pneumonia compared to bronchitis and upper respiratory tract infection (URTI).

METHODS

Retrospective chart review of adults diagnosed with pneumonia, bronchitis, or URTI.

RESULTS

Logistic regression analysis identified rales, a temperature > 100 degrees F (37.8 degrees C), chest pain, dyspnoea, rhonchi, heart rate, respiratory rate, and rhinorrhoea, as the best explanation for the variation in diagnosis of pneumonia compared to either of the alternative diagnoses (R2 = 59.3), with rales and a temperature > 100 degrees F explaining 30% of the variation. Rales, chest pain, and a temperature > 100 degrees F best predicted the ordering of a chest x-ray (R2 = 20.0). However, 35% (59/175) of patients diagnosed with pneumonia had a negative chest x-ray. Abnormal breath sounds were the best predictors for prescribing antibiotics (R2 = 38%). A significant number of patients with acute bronchitis (93% excluding sinusitis) and URTI (42%) were given antibiotics.

CONCLUSIONS

The presence of abnormal breath sounds and a temperature > 100 degrees F were the best predictors of a diagnosis of pneumonia.

GPs' and pharmacists' experiences of managing multimorbidity: a 'Pandora's box'

BACKGROUND

Multimorbidity is defined as the occurrence of two or more chronic diseases in one individual. Patients with multimorbidity generally have poorer health and functioning and higher rates of attendance in primary care and specialty settings.

AIM

To explore the views and attitudes of GPs and pharmacists managing patients with multimorbidity in primary care.

DESIGN OF STUDY

Qualitative study using focus groups.

SETTING

Primary care in Ireland.

METHOD

Three focus groups were held in total, involving 13 GPs and seven pharmacists. Focus groups were recorded, transcribed, and analysed using the 'framework' approach.

RESULTS

The predominant themes to emerge from the focus groups were: 1) the concept of multimorbidity and the link to polypharmacy and ageing; 2) health systems issues relating to lack to time, inter-professional communication difficulties, and fragmentation of care; 3) individual issues from clinicians relating to professional roles, clinical uncertainty, and avoidance; 4) patient issues; and 5) potential management solutions.

CONCLUSION

This study provides information on the significant impact of multimorbidity from a professional perspective. It highlights potential elements of an intervention that could be designed and tested to achieve improvements in the management of multimorbidity, outcomes for individuals affected, and the experiences of those providing healthcare.

Creation and validation of the PERFECT: a critical incident tool for evaluating change in the practices of health professionals

RATIONALE

The critical incident technique provides a means to better understand the reasons behind clinicians' practices and changes in practice. No standardized tool exists to elicit information using this technique.

OBJECTIVES

To create and validate a standardized tool that explores change and reasons for change in professional practice.

METHOD

Item generation was based on expert consultation and a review of the clinical practice and knowledge translation literature. The draft tool was pilot-tested with a convenience sample of 10 rehabilitation clinicians to receive feedback on its content, clarity, optimal cueing, omissions and ease of recall of critical incidents.

RESULTS

The tool was progressively refined and validated according to feedback from both the clinicians and expert reviewers. The final version of the tool includes 33 questions designed to elicit information on change and reasons for change in four areas: problem identification, assessment, treatment and referral practices. In addition, it elicits information on factors that facilitate or hinder change in practice. Cues are included when necessary to clarify questions and facilitate responses. Regarding ease of recall, all clinicians confirmed that beginning with a 6-month recall of practice change and working back to 1 year was a facilitator. All clinicians mentioned that the tool encouraged them to reflect about changes they made in their practice or lack thereof.

CONCLUSION

The newly created standardized critical incident tool, named the PERFECT (Professional Evaluation & Reflection on Change Tool) provides an opportunity for widespread applicability to explore change, reasons for change, as well as facilitators and barriers to change in the practices of health professionals.

The discomfort caused by patient pressure on the prescribing decisions of hospital prescribers

BACKGROUND

The influence of patient expectations and demands on the decisions of prescribers in general practice has been associated with irrational prescribing and lack of evidence-based practice. However, to our knowledge, no one has investigated patient pressure to prescribe in secondary care.

OBJECTIVES

To investigate the influences on hospital prescribers' decisions by exploring what they found uncomfortable when prescribing.

METHODS

Qualitative interviews with 48 prescribers of varying seniority from 4 hospitals were conducted. Interviews were based on the critical incident technique, and prescribers were asked, before an interview, to remember any uncomfortable prescribing decisions that they had made; these were then discussed in detail during an interview. This approach allowed the interviewer to explore the more general influences on the decision to prescribe. Interviews were tape recorded and transcribed verbatim. A grounded theory approach to data analysis was taken.

RESULTS

Prescribers discussed various factors that could provoke feelings of discomfort when prescribing. Pressure on the prescribing decision from patients, relatives, or carers was a major theme, and more than half of interviewees discussed discomfort caused by such perceived pressure on the prescribing decision. How prescribers dealt with this pressure varied with seniority and the type of relationship that they had fostered with the patient. Nearly half of all incidents of patient pressure resulted in the patient being prescribed the medication they requested. Yet, many of these requests were deemed inappropriate by the prescriber. Their reasons for capitulation varied but included maintaining a good prescriber-patient relationship and avoiding conflict in the wider health care team.

CONCLUSIONS

Pressure from patients, relatives, or carers was an uncomfortable influence on these hospital prescribers' prescribing decisions. Increasingly consumer-driven health care will intensify these issues in the future. We advocate further research, focusing on managing patient demands and improving prescribers' coping strategies.

GPs' decision-making when prescribing medicines for breastfeeding women: Content analysis of a survey

Background

Many breastfeeding women seek medical care from general practitioners (GPs) for various health problems and GPs may consider prescribing medicines in these consultations. Prescribing medicines to a breastfeeding mother may lead to untimely cessation of breastfeeding or a breastfeeding mother may be denied medicines due to the possible risk to her infant, both of which may lead to unwanted consequences. Information on factors governing GPs' decision-making and their views in such situations is limited.

Methods

GPs providing shared maternity care at the Royal Women's Hospital, Melbourne were surveyed using an anonymous postal survey to determine their knowledge, attitudes and practices on medicines and breastfeeding, in 2007/2008 (n = 640). Content analysis of their response to a question concerning decision-making about the use of medicine for a breastfeeding woman was conducted. A thematic network was constructed with basic, organising and global themes.

Results

335 (52%) GPs responded to the survey, and 253 (76%) provided information on the last time they had to decide about the use of medicine for a breastfeeding woman. Conditions reported were mastitis (24%), other infections (24%) and depressive disorders (21%). The global theme that emerged was "complexity of managing risk in prescribing for breastfeeding women". The organising themes were: certainty around decision-making; uncertainty around decision-making; need for drug information to be available, consistent and reliable; joint decision-making; the vulnerable "third party" and infant feeding decision. Decision-making is a spectrum from a straight forward decision, such as treatment of mastitis, to a complicated one requiring multiple inputs and consideration. GPs use more information seeking and collaboration in decision-making when they perceive the problem to be more complex, for example, in postnatal depression.

Conclusion

GPs feel that prescribing medicines for breastfeeding women is a contentious issue. They manage the risk of prescribing by gathering information and assessing the possible effects on the breastfed infant. Without evidence-based information, they sometimes recommend cessation of breastfeeding unnecessarily.

Development and use of the critical incident technique in evaluating causes of dispensing incidents

Aims and objectives

The study aimed to evaluate the causes of prevented dispensing incidents reported by hospitals using the critical incident technique developed by key-informant interviews, focus group and observation.

Setting

All Welsh NHS hospitals (n = 20) were invited to participate in the study. Sixteen hospitals agreed to take part; 10 hospitals reported incidents, four hospitals did not report any incidents and two hospitals withdrew from the study.

Method

In June 2005 three key-informant interviews and a focus group were conducted to determine dispensary workflow, which was then validated by a piloted non-participant observational study at three Welsh hospitals. Self-reported critical incident forms were then developed to collect dispensing-incident data involving drugs at high risk of dispensing incidents. Sixteen Welsh hospitals participated in the 4-month study (January-August 2006).

Key findings

Dispensary workflow encompassed the following events: prescription receipt, validating patient information, log of prescription, technical check, clinical check, label generation, stock selection, medicines assembly, product labelling, completion of registers, self-checking/endorsing and final accuracy check. Twenty-four incidents were reported by 10 hospitals involving paediatrics (n = 9, 38%), morphine sulphate (n = 5, 21%), insulin (n = 5, 21%), angiotensin-converting enzyme inhibitors (n = 3, 13%) and nifedipine (n = 2, 8%). Incidents commonly occurred at label generation (n = 9, 43%) and stock selection (n = 9, 43%), caused by error-producing conditions, active and latent failures. Active failures involved dispensing the wrong quantity of medication, interchanging different formulations, and computer and stock-selection errors. Error-producing conditions were reported as high workload, complex prescriptions and interruptions. Latent conditions were inadequate staffing/ skill mix, unclear drug computer selection lists and the storage of drugs on dispensary shelves.

Conclusion

The critical incident technique provided an in-depth understanding of the causes of dispensing incidents. Dispensing incidents arose because of organisational pathologies, error producing conditions and active failures such as inadequate staffing, high workload, interruptions, and computer and drug-selection errors.

The discomfort of an evidence-based prescribing decision

RATIONALE, AIMS AND OBJECTIVES

Prescribing decisions are not always based on published clinical research; social and environmental influences can sometimes drive such decisions. However, little is known about this topic in prescribing in secondary care. The aim of this study was to explore such influences by asking doctors to discuss their uncomfortable prescribing decisions in secondary care.

METHODS

Forty-eight doctors, of varying grades from four hospitals, were selected for in-depth qualitative interviews, which included the critical incident technique. Doctors were asked to remember any uncomfortable prescribing decisions and these 'incidents' were discussed, enabling the researcher to unpack the more subconscious influences on the decision to prescribe. Interviews were tape-recorded and transcribed verbatim. A grounded theory approach to data analysis was taken.

RESULTS

All doctors had previously been uncomfortable when attempting to practise in accordance with evidence-based medicine. Locating, critically appraising and applying the evidence to individual patients were frequent causes of discomfort. Many doctors struggled with uncomfortable decisions that were influenced by non-research evidence, such as prior experience or expert opinion. This appeared, in part, because of these doctors' skewed notions that EBM condemns clinical experience as illegitimate evidence.

CONCLUSIONS

Incorporating the research evidence into prescribing decisions was associated with much discomfort by secondary care doctors. Greater efforts should also be placed towards developing the model of EBM, so that it fits more explicitly with how medicine is currently practised. Perhaps more importantly, educators need to reinforce what EBM is and what it is not to all concerned in the delivery of health care.

How do district nurses choose which products to prescribe?

The aim of this study was to explore the influences on product selection by district nurses when they start to prescribe a product for the first time. Representatives from the pharmaceutical industry had the biggest impact on the prescribing of new products followed by the nurses' colleagues with specialists being viewed more positively than non-specialists. The primary care trust and patients appeared to have little impact on product selection. The challenge for primary and secondary care trusts is to promote safe cost-effective, evidence-based prescribing and to maximize consistency across the primary - secondary care interface. NHS organizations wishing to influence prescribing must convince prescribers that they are interested in more than just reducing costs and they could do well to take a lead from the pharmaceutical industry when they try to get their messages across to prescribers.