Perioperative medication management: expanding the role of the preadmission clinic pharmacist in a single centre, randomised controlled trial of collaborative prescribing

Partnered pharmacist medication charting and prescribing in Australian hospitals

Medication charting and prescribing errors commonly occur at hospital admission and discharge. Pharmacist medication reconciliation, after medicines are ordered by a medical officer, can identify and resolve errors, but this often occurs after the errors have reached the patient. Partnered pharmacist medication charting and prescribing are interprofessional, collaborative models that are designed to prevent medication errors before they occur, by involving pharmacists directly in charting and prescribing processes. In the partnered charting model, a pharmacist and medical officer discuss the patient's current medical and medication-related problems and agree on a medication management plan. Agreed medicines are then charted by the pharmacist on the inpatient medication chart. A similar collaborative model can be used at other points in the patient journey, including at discharge. Studies conducted at multiple Australian health services, including rural and regional hospitals, have shown that partnered charting on admission, and partnered prescribing at discharge, significantly reduces the number of medication errors and shortens patients' length of stay in hospital. Junior medical officers report benefiting from enhanced interprofessional learning and reduced workload. Partnered pharmacist medication charting and prescribing models have the best prospect of success in environments with a strong culture of interprofessional collaboration and clinical governance, and a sufficiently resourced clinical pharmacist workforce.

Medication management in general surgical patients made nil by mouth perioperatively: A quality improvement study

Perioperative medication management in patients who are nil by mouth for surgery or endoscopy is often suboptimal. Inappropriate medication management can prolong postoperative recovery and increase morbidity and mortality. This quality improvement study, carried out in general surgical patients at an 800-bed general hospital, aimed to improve perioperative medication management in accordance with the recommendations of the UK Clinical Pharmacy Association Handbook of Perioperative Medicine. Increasing awareness and educating general surgical team members, including doctors and non-medical prescribers, about perioperative medication management led to a non-significant improvement in medication management. However, a statistically significant improvement was achieved when nursing staff were also included. This study highlights the importance of involving different members of the multidisciplinary team in perioperative medication management.

Assessment of the Prescribing Pharmacist's Role in Supporting Access to Prescription-Only Medicines-Metadata Analysis in Poland

In 2020, pharmacists in Poland received additional authority to prescribe drugs. In this study, we analyzed prescribing after the implementation of this new responsibility. We assessed how the new regulation works in practice and what it means for the healthcare system in the area of access to prescription-only medicines. Data analysis included information on the prescriptions written, the type of substance according to the ATC classification, and data on the prescribing pharmacists. The study used over 2.994 million e-prescriptions written by pharmacists in Poland, which were made available by the e-Health Center. The largest group of drugs prescribed were drugs used in the treatment of cardiovascular diseases, accounting for 25% of all prescribed medications during the time of the analysis. The next prescription groups were for drugs used in gastrointestinal diseases and metabolic disorders, and those acting on the central nervous system, the respiratory system, and the musculoskeletal system. Among pharmaceutical prescriptions, 73% were pharmaceutical prescriptions issued in pharmacies at full price to the patient. The results indicate that pharmacists are eager to use their permission to prescribe drugs in authority situations. Almost three million records showed improved patient access to medicines in the healthcare system (approximately 5% of repeat prescriptions for all patients during the study period). These data confirm the possibility of cooperation between physicians and pharmacists in strengthening the efficiency of the patient healthcare system. An important conclusion from this work is the need to create the possibility for the pharmacist to access the information resources of the implemented Internet Patient Account system, including therapeutic indications for the drugs used.

Introduction of a Multidisciplinary Preoperative Clinic at Juntendo University Hospital - A Retrospective Observational Study Focusing on Effects of Preoperative Interventions on Clinical Outcomes

Objectives

To investigate the effects of interventions provided by a multidisciplinary team consisting of anesthesiologists, dentists, pharmacists, and nurses at a Preoperative Clinic (POC) on postoperative outcomes.

Methods

We retrospectively investigated patients who underwent preoperative evaluation at the POC at Juntendo University Hospital between May and July, 2019. Patients were divided into intervention and non-intervention groups according to whether they received intervention(s) at the POC or not. Postoperative outcomes were compared between the groups, before and after propensity score (PS) matching.

Results

We investigated 909 patients who completed POC evaluation and underwent surgery. Patients in the intervention group (n = 455 [50.1%]) received at least one intervention delivered, in the order of higher delivery frequencies, by dentists, pharmacists, nurses, and anesthesiologists. Before PS matching, the intervention group was associated with older age, more frequent cardiovascular comorbidities, and higher ASA-PS grades than the non-intervention group, while neither frequencies nor severities of postoperative complications differed between the groups. These outcomes did not differ between 382 PS-matched pairs with comparable risk factors either.

Conclusions

Before PS matching, postoperative outcomes did not differ between the groups, although the intervention group was associated with higher risks. These suggested that POC interventions could have improved postoperative outcomes in the higher-risk intervention group to the same level as in the non-intervention group. However, such potential beneficial effects of interventions could not be proven after PS matching. Further studies are required to elucidate effects of POC interventions on postoperative outcomes.

Costs, consequences and value for money in non-medical prescribing: a scoping review

OBJECTIVES

Non-medical prescribing (NMP) is a key feature of the UK healthcare system that refers to the legal prescribing rights granted to nurses, pharmacists and other non-medical healthcare professionals who have completed an approved training programme. NMP is deemed to facilitate better patient care and timely access to medicine. The aim of this scoping review is to identify, synthesise and report the evidence on the costs, consequences and value for money of NMP provided by non-medical healthcare professionals.

DESIGN

Scoping review DATA SOURCES: MEDLINE, Cochrane Library, Scopus, PubMed, ISI Web of Science and Google Scholar were systematically searched from 1999 to 2021.

ELIGIBILITY CRITERIA

Peer-reviewed and grey literature written in English were included. The research was limited to original studies evaluating economic values only or both consequences and costs of NMP.

DATA EXTRACTION AND SYNTHESIS

The identified studies were screened independently by two reviewers for final inclusion. The results were reported in tabular form and descriptively.

RESULTS

A total of 420 records were identified. Of these, nine studies evaluating and comparing NMP with patient group discussions, general practitioner-led usual care or services provided by non-prescribing colleagues were included. All studies evaluated the costs and economic values of prescribing services by non-medical prescribers, and eight assessed patient, health or clinical outcomes. Three studies showed pharmacist prescribing was superior in all outcomes and cost saving at a large scale. Others reported similar results in most health and patient outcomes across other non-medical prescribers and control groups. NMP was deemed resource intensive for both providers and other groups of non-medical prescribers (eg, nurses, physiotherapists, podiatrists).

CONCLUSIONS

The review demonstrated the need for quality evidence from more rigorous methodological studies examining all relevant costs and consequences to show value for money in NMP and inform the commissioning of NMP for different groups of healthcare professionals.

Evaluation of the clinical pharmacist services at a gynaecological oncology preadmission clinic

Background

Pharmacists working in the multidisciplinary gynaecological oncology pre-admission clinic (PAC) are involved in the perioperative assessment of patients for a comprehensive medication history and information provision regarding withholding of medications before surgery.

Objective

To evaluate the current services provided by pharmacists to multidisciplinary staff and patients attending the PAC.

Methods

A staff and a patient feedback survey on the value and impact of PAC pharmacy services were distributed within the PAC. The impact of the PAC pharmacist was also assessed by analysing pharmacist interventions and key performance indicators documented.

Results

Fifteen staff responses were recorded, 5 nursing staff, 2 midwives and 8 anaesthetists. Eighty-seven percent (n = 13) strongly agreed or agreed that pharmacists at PAC help reduce medication errors on admission. Staff strongly agreed 73% (n = 11) pharmacists obtain a more accurate medication history. Staff reported benefits in having a pharmacist at the clinic to discuss medication related questions with 87% (n = 13) strongly agreeing or agreeing with the statement. A staff overall satisfaction rating of 4.87 out of 5 was recorded. In the patient survey, respondents (n = 6) gave a 4.83 out of 5 rating in confidence in making changes to their medication and their overall satisfaction with the service provided. In reviewing data from January to June 2022, the number of patients seen by the pharmacist were 178 of 681 patients (26.1%) who attended the clinic. The most common medications involved in the pharmacist intervention include those that were advised to be withheld and those that required other changes to therapy prior to their procedure.

Conclusion

The role of a PAC pharmacist can be greatly appreciated by the multidisciplinary team and patients. Pharmacist interventions and key performance indicators have demonstrated the important activities of clinical pharmacy services in the PAC in optimising patient care in medication management.

Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews

The influence of pharmacotherapy regimens on surgical patient outcomes is increasingly appreciated in the era of enhanced recovery protocols and institutional focus on reducing postoperative complications. Specifics related to medication selection, dosing, frequency of administration, and duration of therapy are evolving to optimize pharmacotherapeutic regimens for many enhanced recovery protocolized elements. This review provides a summary of recent pharmacotherapeutic strategies, including those configured within electronic health record (EHR) applications and functionalities, that are associated with the minimization of the frequency and severity of postoperative complications (POCs), shortened hospital length of stay (LOS), reduced readmission rates, and cost or revenue impacts. Further, it will highlight preventive pharmacotherapy regimens that are correlated with improved patient preparation, especially those related to surgical site infection (SSI), venous thromboembolism (VTE), nausea and vomiting (PONV), postoperative ileus (POI), and emergence delirium (PoD) as well as less commonly encountered POCs such as acute kidney injury (AKI) and atrial fibrillation (AF). The importance of interprofessional collaboration in all periprocedural phases, focusing on medication management through shared responsibilities for drug therapy outcomes, will be emphasized. Finally, examples of collaborative care through shared mental models of drug stewardship and non-medical practice agreements to improve operative throughput, reduce operative stress, and increase patient satisfaction are illustrated.

Impact of a policy to improve the management of oral medications when patients are fasting before a procedure: an interrupted time series analysis

Background

Managing medications inappropriately when patients have oral intake restrictions can cause patient harm. This study evaluated the impact of a medication policy separating fasting from nil by mouth with respect to giving oral medications in patients fasting before a diagnostic or interventional procedure.

Methods

The policy stipulated that ‘fasting’ means oral medications should be given with a sip of water up to 1 hour before a procedure, unless there is a clinical reason to withhold, while ‘nil by mouth’ means nothing to be given orally, including medications.

The policy was implemented in Surgical areas in February 2015 and Medical areas in March 2015 at a tertiary referral hospital in Melbourne, Australia, and included bedside signs, clinical champions and education sessions.

The study was conducted in 2020. Admission and medication records were matched for non-elective procedure patients from January 2014 to May 2016. The monthly proportion of doses omitted inappropriately and overall omissions pre/post-policy implementation were compared using segmented regression.

Results

Pre-implementation, the proportion of doses withheld inappropriately and total omissions in medical areas were 18.1% and 28.0%, respectively. Post-implementation, an absolute reduction of 13.4% (95% CI 9.0% to 17.7%) and 11.1% (95% CI 2.6% to 19.6%), respectively, was seen. Post-implementation linear trend showed a 0.3% (95% CI 0.0% to 0.6%) increase in inappropriate omissions but not overall omissions.

In Surgical areas, pre-implementation proportions for inappropriate and overall omissions were lower than Medical areas’. Post-implementation, there was an absolute decrease in doses withheld inappropriately (8.3%, 95% CI 0.8% to 15.7%, from 11.9% pre-implementation) but not total omissions.

Conclusions

Distinguishing fasting from nil by mouth appeared to provide clarity for some staff: a reduction in inappropriate omissions was seen post-implementation. Although the small increase in post-implementation linear trend for inappropriate omissions in Medical areas suggests sustainability issues, total omissions were sustained. The policy’s concepts require verification beyond our institution.

Pediatric surgical errors: A systematic scoping review

BACKGROUND

Medical errors were largely concealed prior to the landmark report "To Err Is Human". The purpose of this systematic scoping review was to determine the extent pediatric surgery defines and studies errors, and to explore themes among papers focused on errors in pediatric surgery.

METHODS

The methodological framework used to conduct this scoping study has been outlined by Arksey and O'Malley. In January 2020, PubMed, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. Oxford Level of Evidence was assigned to each study; only studies rated Level 3 or higher were included.

RESULTS

Of 3,064 initial studies, 12 were included in the final analysis: 4 cohort studies, and 8 outcome/audit studies. This data represented 5,442,000 aggregate patients and 8,893 errors. There were 6 different error definitions and 5 study methods. Common themes amongst the studies included a systems-focused approach, an increase in errors seen with increased complexity, and studies exploring the relationship between error and adverse events.

CONCLUSIONS

This study revealed multiple error definitions, multiple error study methods, and common themes described in the pediatric surgical literature. Opportunities exist to improve the safety of surgical care of children by reducing errors. Original Scientific Research Type of Study: Systematic Scoping Review Level of Evidence Rating: 1.

Measuring performance of professional role substitution models of care against traditional medical care in healthcare-A systematic review

OBJECTIVES

To identify outcome measures used to evaluate performance of healthcare professional role substitution against usual medical doctor or specialist medical doctor care to facilitate our understanding of the adequacy of these measures in assessing quality of healthcare delivery.

METHODS

Using a systematic approach, we searched Medline, Cochrane Central Register of Controlled Trials, Embase, CINAHL, and Web of Science from database inception until May 2020. Studies that presented original comparative data on at least one outcome measure were included following screening by two authors. Findings were synthesized, and outcome measures classified into six domains which included: effectiveness, safety, appropriateness, access, continuity of care, efficiency, and sustainability which were informed by the Institute of Medicine dimensions of healthcare quality, the Australian health performance framework, and Levesque and Sutherland's integrated performance measurement framework.

RESULTS

One thirty five articles met the inclusion criteria, describing 58 separate outcome measures. Safety of role substitution models of care was assessed in 80 studies, effectiveness (n = 60), appropriateness (n = 40), access (n = 36), continuity of care (n = 6), efficiency and productivity (n = 45). Two-thirds of the studies that assessed productivity and efficiency performed an economic analysis (n = 27). The quality and rigour of evaluations varied substantially across studies, with two-thirds of all studies measuring and reporting outcomes from only one or two of these domains.

CONCLUSIONS

There are a growing number of studies measuring the performance of non-medical healthcare professional substitution roles. Few have been subject to robust evaluations, and there is limited evidence on the scientific rigour and adequacy of outcomes measured. A systematic and coordinated approach is required to support healthcare settings in assessing the value of non-medical role substitution healthcare delivery models.

Efficacy of a Bariatric Surgery Clinic-Based Pharmacist

Purpose

To evaluate the impact of a bariatric clinic-based pharmacist on inpatient length of stay, medication errors, and patient experience.

Materials and Methods

This was a retrospective cohort study comparing patients who received a pre-operative pharmacist consultation to historical cases without pre-operative pharmacist consultation prior to admission for bariatric surgery. A patient experience survey was administered post-operatively to the intervention group. The primary outcome was hospital length of stay (LOS). Secondary outcomes included corrected medication errors on reconciliation, pharmacist interventions, adverse drug event (ADE) prevention, and patient satisfaction.

Results

With 68 patients in the intervention group and 67 patients in the control group, the majority were female (76%) and received either laparoscopic Roux-en-Y gastric bypass (53%) or sleeve gastrectomy (47%). The median LOS in the intervention group was 55.5 h, which did not significantly differ from the median 57.9 h in the control group (p = 0.56). The clinic-based pharmacist made an average of 13 interventions per patient. Surveys were distributed to 73 patients with a 60% response rate. High overall satisfaction with the pre-operative pharmacist consultation was reported by 97% of patients.

Conclusion

Although hospital LOS did not significantly differ between groups, pre-operative pharmacist consultation prevented potential ADEs, and provided strong patient satisfaction. Having pharmacists as part of a multidisciplinary approach to bariatric surgery patient care can prevent medication-related adverse events and improve patient satisfaction.

Graphic Abstract

Defining and Studying Errors in Surgical Care: A Systematic Review

OBJECTIVE

Our objective was to determine the extent surgical disciplines categorize, define, and study errors, then use this information to provide recommendations for both current practice and future study.

SUMMARY BACKGROUND DATA

The report "To Err is Human" brought the ubiquity of medical errors to public attention. Variability in subsequent literature suggests the true prevalence of error remains unknown.

METHODS

In January 2020, PubMed, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. Only studies with Oxford Level of Evidence Level 3 or higher were included.

RESULTS

Of 3,064 studies, 92 met inclusion criteria: 6 randomized controlled trials, 4 systematic reviews, 24 cohort, 10 before-after, 35 outcome/audit, 5 cross sectional and 8 case-control studies. Over 15,933,430 patients and 162,113 errors were represented. There were 6 broad error categories, 13 different definitions of error, and 14 study methods.

CONCLUSIONS

Reported prevalence of error varied widely due to a lack of standardized categorization, definitions, and study methods. Future research should focus on immediately recognizing errors to minimize harm.

Reducing medication errors for adults in hospital settings

BACKGROUND

Medication errors are preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. Medication errors in hospitalised adults may cause harm, additional costs, and even death.

OBJECTIVES

To determine the effectiveness of interventions to reduce medication errors in adults in hospital settings.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers on 16 January 2020.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) and interrupted time series (ITS) studies investigating interventions aimed at reducing medication errors in hospitalised adults, compared with usual care or other interventions. Outcome measures included adverse drug events (ADEs), potential ADEs, preventable ADEs, medication errors, mortality, morbidity, length of stay, quality of life and identified/solved discrepancies. We included any hospital setting, such as inpatient care units, outpatient care settings, and accident and emergency departments.

DATA COLLECTION AND ANALYSIS

We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. Where necessary, we extracted and reanalysed ITS study data using piecewise linear regression, corrected for autocorrelation and seasonality, where possible.  MAIN RESULTS: We included 65 studies: 51 RCTs and 14 ITS studies, involving 110,875 participants. About half of trials gave rise to 'some concerns' for risk of bias during the randomisation process and one-third lacked blinding of outcome assessment. Most ITS studies presented low risk of bias. Most studies came from high-income countries or high-resource settings. Medication reconciliation -the process of comparing a patient's medication orders to the medications that the patient has been taking- was the most common type of intervention studied. Electronic prescribing systems, barcoding for correct administering of medications, organisational changes, feedback on medication errors, education of professionals and improved medication dispensing systems were other interventions studied. Medication reconciliation Low-certainty evidence suggests that medication reconciliation (MR) versus no-MR may reduce medication errors (odds ratio [OR] 0.55, 95% confidence interval (CI) 0.17 to 1.74; 3 studies; n=379). Compared to no-MR, MR probably reduces ADEs (OR 0.38, 95%CI 0.18 to 0.80; 3 studies, n=1336 ; moderate-certainty evidence), but has little to no effect on length of stay (mean difference (MD) -0.30 days, 95%CI -1.93 to 1.33 days; 3 studies, n=527) and quality of life (MD -1.51, 95%CI -10.04 to 7.02; 1 study, n=131).  Low-certainty evidence suggests that, compared to MR by other professionals, MR by pharmacists may reduce medication errors (OR 0.21, 95%CI 0.09 to 0.48; 8 studies, n=2648) and may increase ADEs (OR 1.34, 95%CI 0.73 to 2.44; 3 studies, n=2873). Compared to MR by other professionals, MR by pharmacists may have little to no effect on length of stay (MD -0.25, 95%CI -1.05 to 0.56; 6 studies, 3983). Moderate-certainty evidence shows that this intervention probably has little to no effect on mortality during hospitalisation (risk ratio (RR) 0.99, 95%CI 0.57 to 1.7; 2 studies, n=1000), and on readmissions at one month (RR 0.93, 95%CI 0.76 to 1.14; 2 studies, n=997); and low-certainty evidence suggests that the intervention may have little to no effect on quality of life (MD 0.00, 95%CI -14.09 to 14.09; 1 study, n=724).  Low-certainty evidence suggests that database-assisted MR conducted by pharmacists, versus unassisted MR conducted by pharmacists, may reduce potential ADEs (OR 0.26, 95%CI 0.10 to 0.64; 2 studies, n=3326), and may have no effect on length of stay (MD 1.00, 95%CI -0.17 to 2.17; 1 study, n=311).  Low-certainty evidence suggests that MR performed by trained pharmacist technicians, versus pharmacists, may have little to no difference on length of stay (MD -0.30, 95%CI -2.12 to 1.52; 1 study, n=183). However, the CI is compatible with important beneficial and detrimental effects. Low-certainty evidence suggests that MR before admission may increase the identification of discrepancies compared with MR after admission (MD 1.27, 95%CI 0.46 to 2.08; 1 study, n=307). However, the CI is compatible with important beneficial and detrimental effects. Moderate-certainty evidence shows that multimodal interventions probably increase discrepancy resolutions compared to usual care (RR 2.14, 95%CI 1.81 to 2.53; 1 study, n=487). Computerised physician order entry (CPOE)/clinical decision support systems (CDSS) Moderate-certainty evidence shows that CPOE/CDSS probably reduce medication errors compared to paper-based systems (OR 0.74, 95%CI 0.31 to 1.79; 2 studies, n=88).  Moderate-certainty evidence shows that, compared with standard CPOE/CDSS, improved CPOE/CDSS probably reduce medication errors (OR 0.85, 95%CI 0.74 to 0.97; 2 studies, n=630). Low-certainty evidence suggests that prioritised alerts provided by CPOE/CDSS may prevent ADEs compared to non-prioritised (inconsequential) alerts (MD 1.98, 95%CI 1.65 to 2.31; 1 study; participant numbers unavailable). Barcode identification of participants/medications Low-certainty evidence suggests that barcoding may reduce medication errors (OR 0.69, 95%CI 0.59 to 0.79; 2 studies, n=50,545). Reduced working hours Low-certainty evidence suggests that reduced working hours may reduce serious medication errors (RR 0.83, 95%CI 0.63 to 1.09; 1 study, n=634). However, the CI is compatible with important beneficial and detrimental effects. Feedback on prescribing errors Low-certainty evidence suggests that feedback on prescribing errors may reduce medication errors (OR 0.47, 95%CI 0.33 to 0.67; 4 studies, n=384). Dispensing system Low-certainty evidence suggests that dispensing systems in surgical wards may reduce medication errors (OR 0.61, 95%CI 0.47 to 0.79; 2 studies, n=1775).

AUTHORS' CONCLUSIONS

Low- to moderate-certainty evidence suggests that, compared to usual care, medication reconciliation, CPOE/CDSS, barcoding, feedback and dispensing systems in surgical wards may reduce medication errors and ADEs. However, the results are imprecise for some outcomes related to medication reconciliation and CPOE/CDSS. The evidence for other interventions is very uncertain. Powered and methodologically sound studies are needed to address the identified evidence gaps. Innovative, synergistic strategies -including those that involve patients- should also be evaluated.

[Evaluation of the Usefulness of Postoperative Analgesic Solution Preparation by Pharmacists in the Surgical Department]

Pharmacists began preparing drug solutions intraoperatively for postoperative analgesia in the Department of Surgery at Chiba University Hospital from May 2014. To verify the usefulness of pharmacists preparing these drug solutions, we conducted a questionnaire survey among 51 anesthesiologists and received 44 responses (recovery rate 86.3%). Burden on the anesthesiologists was significantly reduced both temporally and mentally when the pharmacists prepared the drug solutions compared with when the anesthesiologists did (p<0.01). The anesthesiologists' degree of anxiety about sometimes having to prepare drug solutions alone without any confirmation was also significantly reduced when pharmacists prepared them (p<0.01), which implies the need for a double-check system. In addition, 88.6% of anesthesiologists said that they were reassured with preparations done by the pharmacists under a sterile environment using a clean bench. Overall, 88.6% of anesthesiologists responded that they were satisfied with the preparation of drug solutions by pharmacists. Based on the results of this survey, pharmacists' preparation of drug solutions for postoperative analgesia is considered to be useful in ensuring the quality and safety of medical care because it reduced anesthesiologists' work to prepare the drug solutions, allowing them to concentrate on anesthesia and related work, it established a double-check system between the two staff teams, and it was done under a sterile environment.

Evaluation of the association between presenteeism and perceived availability of social support among hospital doctors in Zhejiang, China

Background

This study investigated the association between presenteeism and the perceived availability of social support among hospital doctors in China.

Methods

A questionnaire was administered by doctors randomly selected from 13 hospital in Hangzhou China using stratified sampling. Logit model was used for data analysis.

Results

The overall response rate was 88.16%. Among hospital doctors, for each unit increase of the perceived availability of social support, the prevalence of presenteeism was decreased by 8.3% (OR = 0.91, P = 0.000). In particular, if the doctors perceived availability of appraisal support, belonging support and tangible support as sufficient, the act of presenteeism was reduced by 20.2% (OR = 0.806, P = 0.000) 20.4% (OR = 0.803, P = 0.000) and 21.0% (OR = 0.799, P = 0.000) respectively with statistical differences.

Conclusion

In China, appraisal support, belonging support and tangible support, compared to other social support, had a stronger negative correlation with presenteeism among hospital doctors. The benefits of social support in alleviating doctors’ presenteeism warrant further investigation.

Influences on surgical antimicrobial prophylaxis decision making by surgical craft groups, anaesthetists, pharmacists and nurses in public and private hospitals

Background

Surgical antimicrobial prophylaxis (SAP) is a leading indication for antibiotic use in the hospital setting, with demonstrated high rates of inappropriateness. Decision-making for SAP is complex and multifactorial. A greater understanding of these factors is needed to inform the design of targeted antimicrobial stewardship interventions and strategies to support the optimization of SAP and its impacts on patient care.

Methods

A qualitative case study exploring the phenomenon of SAP decision-making. Focus groups were conducted with surgeons, anaesthetists, theatre nurses and pharmacists across one private and two public hospitals in Australia. Thematic analysis was guided by the Theoretical Domains Framework (TDF) and the Capabilities, Opportunities, Motivators-Behaviour (COM-B) model.

Results

Fourteen focus groups and one paired interview were completed. Ten of the fourteen TDF domains were identified as relevant. Thematic analysis revealed six significant themes mapped to the COM-B model, and subthemes mapped to the relevant TDF domains in a combined framework. Key themes identified were: 1) Low priority for surgical antimicrobial prophylaxis prescribing skills; 2) Prescriber autonomy takes precedence over guideline compliance; 3) Social codes of prescribing reinforce established practices; 4) Need for improved communication, documentation and collection of data for action; 5) Fears and perceptions of risk hinder appropriate SAP prescribing; and 6) Lack of clarity regarding roles and accountability.

Conclusions

SAP prescribing is a complex process that involves multiple professions across the pre-, intra- and post-operative surgical settings. The utilisation of behaviour change frameworks to identify barriers and enablers to optimal SAP prescribing supports future development of theory-informed antimicrobial stewardship interventions. Interventions should aim to increase surgeon engagement, enhance the prioritisation of and accountability for SAP, and address the underlying social factors involved in SAP decision-making, such as professional hierarchy and varied perceptions or risks and fears.

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.

Pharmacist involvement to improve patient outcomes in lower gastrointestinal surgery: a prospective before and after study

Background Enhanced recovery pathways were first introduced in the UK in 2002 (Enhanced Recovery Partnership Programme in Delivering enhanced recovery-helping patients to get better sooner after surgery. Department of Health, London, 2010). The aims of such pathways are to reduce patient length of stay whilst still providing high quality of care. Objectives To evaluate the impact of pharmacist involvement in enhanced recovery pathways. Setting A large 1200 bed tertiary hospital in the North of England. Methods The pre-post study included all patients admitted for major colorectal surgery during the period 2013-2016. Baseline data were collected on all patients seen pre-operatively in a nurse-led pre-admission clinic. The intervention was introduced where a dedicated surgical pharmacist pre-operatively reviewed patients from the time they were listed for surgery until discharge with a focus on medicines optimisation. Main outcome measure The primary outcome measures were length of stay along with the type and number of post-operative complications. Results 100 patients were included in this study, with 50 patients in the baseline group and 50 patients in the intervention group. There was a significant reduction in the median length of stay (baseline group-10.5 days; intervention group-7.5 days; P < 0.001). The total number of complications was also less in the intervention group (baseline group-125; intervention group-75; P > 0.05) as was the number of patients whom had no complications (P > 0.05). Conclusions Active pharmacist involvement in enhanced recovery protocols is associated with a significantly reduced median length of stay as well as an overall reduction in the total number of post-operative complications.

Pharmacist-assisted electronic prescribing at the time of admission to an inpatient orthopaedic unit and its impact on medication errors: a pre- and postintervention study

BACKGROUND

Prescribing and administration errors related to pre-admission medications are common amongst orthopaedic inpatients. Postprescribing medication reconciliation by clinical pharmacists after hospital admission prevents some but not all errors from reaching the patient. Involving pharmacists at the prescribing stage may more effectively prevent errors. The aim of the study was to evaluate the effect of pharmacist-assisted electronic prescribing at the time of hospital admission on medication errors in orthopaedic inpatients.

METHODS

A pre- and postintervention study was conducted in the orthopaedic unit of a major metropolitan Australian hospital. During the 10-week intervention phase, a project pharmacist used electronic prescribing to assist with prescribing admission medications and postoperative venous thromboembolism (VTE) prophylaxis, in consultation with orthopaedic medical officers. The primary endpoint was the number of medication errors per patient within 72 h of admission. Secondary endpoints included the number and consequence of adverse events (AEs) associated with admission medication errors and the time delay in administering VTE prophylaxis after elective surgery (number of hours after recommended postoperative dose-time).

RESULTS

A total of 198 and 210 patients, pre- and postintervention, were evaluated, respectively. The median number of admission medication errors per patient declined from six pre-intervention to one postintervention (p < 0.01). A total of 17 AEs were related to admission medication errors during the pre-intervention period compared with 1 postintervention. There were 54 and 63 elective surgery patients pre- and postintervention, respectively. The median delay in administering VTE prophylaxis for these patients declined from 9 h pre-intervention to 2 h postintervention (p < 0.01).

CONCLUSIONS

Pharmacist-assisted electronic prescribing reduced the number of admission medication errors and associated AEs.

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.

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.

Improved Medication Management With Introduction of a Perioperative and Prescribing Pharmacist Service

BACKGROUND

The medication lists in pre-admission clinic (PAC) questionnaires completed by patients prior to surgery are often inaccurate, potentially leading to medication errors during hospitalization. Studies have shown pharmacists are more accurate when obtaining a medication history and transcribing prescription orders, thereby reducing errors.

OBJECTIVE

To evaluate the impact of a PeRiopErative and Prescribing (PREP) pharmacist on postoperative medication management.

METHODS

A randomized prospective interventional study enrolled elective surgery patients at high risk for medication misadventure to receive PREP pharmacy service or usual care (control group). A best possible medication history (BPMH) was obtained by the PREP pharmacist and was available to surgical staff on admission. The PREP pharmacist also prepared discharge prescriptions for their patients. The primary outcomes for the study were accuracy of BPMH and discharge prescriptions compared to usual care. The study was powered to 80% with 2-tailed significance α of .05.

RESULTS

The medication history in the PREP pharmacist group had fewer errors than the control group: 9% (5/53) versus 96% (49/51; P < .001). Discharge prescriptions prepared by the PREP pharmacist had fewer errors than control group: 25% versus 78% (P < .001). Significantly, more PREP pharmacist patients received a discharge summary with a complete medication list: 75% versus 33% (P = .001). Inpatient prescribing was more accurate in the PREP pharmacist patients: 0.64 versus 1.31 errors per patient (P = .047).

CONCLUSION

Inclusion of the PREP pharmacist role in the elective surgery multidisciplinary team improved the accuracy of medication histories, inpatient prescribing, and discharge prescriptions for patients at high risk of medication misadventure.

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.

The Prevalence and Nature of Medication Errors and Adverse Events Related to Preadmission Medications When Patients Are Admitted to an Orthopedic Inpatient Unit: An Observational Study

Background: Medication errors commonly occur when patients move from the community into hospital. Whereas medication reconciliation by pharmacists can detect errors, delays in undertaking this can increase the risk that patients receive incorrect admission medication regimens. Orthopedic patients are an at-risk group because they are often elderly and use multiple medications. Objective: To evaluate the prevalence and nature of medication errors when patients are admitted to an orthopedic unit where pharmacists routinely undertake postprescribing medication reconciliation. Methods: A 10-week retrospective observational study was conducted at a major metropolitan hospital in Australia. Medication records of orthopedic inpatients were evaluated to determine the number of prescribing and administration errors associated with patients’ preadmission medications and the number of related adverse events that occurred within 72 hours of admission. Results: Preadmission, 198 patients were taking at least 1 regular medication, of whom 176 (88.9%) experienced at least 1 medication error. The median number of errors per patient was 6 (interquartile range 3-10). Unintended omission of a preadmission medication was the most common prescribing error (87.4%). There were 17 adverse events involving 24 medications in 16 (8.1%) patients that were potentially related to medication errors; 6 events were deemed moderate consequence (moderate injury or harm, increased length of stay, or cancelled/delayed treatment), and the remainder were minor. Conclusion and Relevance: Medication errors were common when orthopedic patients were admitted to hospital, despite postprescribing pharmacist medication reconciliation. Some of these errors led to patient harm. Interventions that ensure that medications are prescribed correctly at admission are required.

Impact of medication reconciliation for improving transitions of care

BACKGROUND

Transitional care provides for the continuity of care as patients move between different stages and settings of care. Medication discrepancies arising at care transitions have been reported as prevalent and are linked with adverse drug events (ADEs) (e.g. rehospitalisation).Medication reconciliation is a process to prevent medication errors at transitions. Reconciliation involves building a complete list of a person's medications, checking them for accuracy, reconciling and documenting any changes. Despite reconciliation being recognised as a key aspect of patient safety, there remains a lack of consensus and evidence about the most effective methods of implementing reconciliation and calls have been made to strengthen the evidence base prior to widespread adoption.

OBJECTIVES

To assess the effect of medication reconciliation on medication discrepancies, patient-related outcomes and healthcare utilisation in people receiving this intervention during care transitions compared to people not receiving medication reconciliation.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, seven other databases and two trials registers on 18 January 2018 together with reference checking, citation searching, grey literature searches and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included only randomised trials. Eligible studies described interventions fulfilling the Institute for Healthcare Improvement definition of medication reconciliation aimed at all patients experiencing a transition of care as compared to standard care in that institution. Included studies had to report on medication discrepancies as an outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts, assessed studies for eligibility, assessed risk of bias and extracted data. Study-specific estimates were pooled, using a random-effects model to yield summary estimates of effect and 95% confidence intervals (CI). We used the GRADE approach to assess the overall certainty of evidence for each pooled outcome.

MAIN RESULTS

We identified 25 randomised trials involving 6995 participants. All studies were conducted in hospital or immediately related settings in eight countries. Twenty-three studies were provider orientated (pharmacist mediated) and two were structural (an electronic reconciliation tool and medical record changes). A pooled result of 20 studies comparing medication reconciliation interventions to standard care of participants with at least one medication discrepancy showed a risk ratio (RR) of 0.53 (95% CI 0.42 to 0.67; 4629 participants). The certainty of the evidence on this outcome was very low and therefore the effect of medication reconciliation to reduce discrepancies was uncertain. Similarly, reconciliation's effect on the number of reported discrepancies per participant was also uncertain (mean difference (MD) -1.18, 95% CI -2.58 to 0.23; 4 studies; 1963 participants), as well as its effect on the number of medication discrepancies per participant medication (RR 0.13, 95% CI 0.01 to 1.29; 2 studies; 3595 participants) as the certainty of the evidence for both outcomes was very low.Reconciliation may also have had little or no effect on preventable adverse drug events (PADEs) due to the very low certainty of the available evidence (RR 0.37. 95% CI 0.09 to 1.57; 3 studies; 1253 participants), with again uncertainty on its effect on ADE (RR 1.09, 95% CI 0.91 to 1.30; 4 studies; 1363 participants; low-certainty evidence). Evidence of the effect of the interventions on healthcare utilisation was conflicting; it probably made little or no difference on unplanned rehospitalisation when reported alone (RR 0.72, 95% CI 0.44 to 1.18; 5 studies; 1206 participants; moderate-certainty evidence), and had an uncertain effect on a composite measure of hospital utilisation (emergency department, rehospitalisation RR 0.78, 95% CI 0.50 to 1.22; 4 studies; 597 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The impact of medication reconciliation interventions, in particular pharmacist-mediated interventions, on medication discrepancies is uncertain due to the certainty of the evidence being very low. There was also no certainty of the effect of the interventions on the secondary clinical outcomes of ADEs, PADEs and healthcare utilisation.

Clinical and cost-effectiveness of non-medical prescribing: A systematic review of randomised controlled trials

Objective

To evaluate the clinical and cost-effectiveness of non-medical prescribing (NMP).

Design

Systematic review. Two reviewers independently completed searches, eligibility assessment and assessment of risk of bias.

Data sources

Pre-defined search terms/combinations were utilised to search electronic databases. In addition, hand searches of reference lists, key journals and grey literature were employed alongside consultation with authors/experts.

Eligibility criteria for included studies

Randomised controlled trials (RCTs) evaluating clinical or cost-effectiveness of NMP. Measurements reported on one or more outcome(s) of: pain, function, disability, health, social impact, patient-safety, costs-analysis, quality adjusted life years (QALYs), patient satisfaction, clinician perception of clinical and functional outcomes.

Results

Three RCTs from two countries were included (n = 932 participants) across primary and tertiary care settings. One RCT was assessed as low risk of bias, one as high risk of bias and one as unclear risk of bias. All RCTs evaluated clinical effectiveness with one also evaluating cost-effectiveness. Clinical effectiveness was evaluated using a range of safety and patient-reported outcome measures. Participants demonstrated significant improvement in outcomes when receiving NMP compared to treatment as usual (TAU) in all RCTs. An associated cost analysis showed NMP to be more expensive than TAU (regression coefficient p = 0.0000), however experimental groups generated increased QALYs compared to TAU.

Conclusion

Limited evidence with overall unclear risk of bias exists evaluating clinical and cost-effectiveness of NMP across all professions and clinical settings. GRADE assessment revealed moderate quality evidence. Evidence suggests that NMP is safe and can provide beneficial clinical outcomes. Benefits to the health economy remain unclear, with the cost-effectiveness of NMP assessed by a single pilot RCT of low risk of bias. Adequately powered low risk of bias RCTs evaluating clinical and cost effectiveness are required to evaluate NMP across clinical specialities, professions and settings.

Registration

PROSPERO (CRD42015017212).

Evaluating the role of clinical pharmacists in pre-procedural anticoagulation management

OBJECTIVES

While physicians are typically responsible for managing perioperative warfarin, clinic pharmacists may improve pre-procedural decision-making. We assessed the impact of pharmacist-driven care for chronic warfarin-treated patients undergoing outpatient right heart catheterization (RHC).

METHODS

200 warfarin patients who underwent RHC between January 2012 and September 2015 were analyzed. Pharmacist-care (n = 79) was compared to the usual care model (n = 121). The primary outcome was a composite of (1) documentation of anticoagulation plan, (2) holding warfarin at least 5 days prior to procedure, (3) guideline-congruent low molecular weight heparin (LMWH) bridging, and (4) correct LMWH dosing if bridging deemed necessary. Chi-squared test performed to assess the role of pharmacist. A multivariable logistic regression analysis was performed to the composite endpoint, adjusted for the month of procedure.

RESULTS

Compared to the usual care model, pharmacist-driven care (OR 4.69, 95% CI 1.73-12.71, p = 0.002) and date of the procedure (OR 1.06/month, 95% CI 1.01-1.10, p = 0.011) were independently associated with the primary composite outcome. Of the individual outcome components, pharmacist-driven care was only associated with documentation (96.2% vs. 67.8%, OR 9.19, 95% CI 2.19-38.62, p = 0.002). Remaining components including hold warfarin for at least 5 days, appropriate bridging and correct LMWH dosing were not significantly associated with pharmacist-care.

CONCLUSIONS

Pharmacist-care is associated with better guideline-based anticoagulation management, but this was primarily driven by improved documentation. The impact of pharmacist managed peri-procedural anticoagulation on clinical outcomes remains unknown.

Barriers to and facilitators of independent non-medical prescribing in clinical practice: a mixed-methods systematic review

QUESTION

What are the factors that affect the implementation or utilisation of independent non-medical prescribing (iNMP)?

DESIGN

Mixed-methods systematic review. Two reviewers independently completed searches, eligibility and quality assessments.

DATA SOURCES

Pre-defined search terms were utilised to search electronic databases. Reference lists, key journals and grey literature were searched alongside consultation with authors/experts.

ELIGIBILITY CRITERIA FOR INCLUDED STUDIES

Qualitative and quantitative studies investigating independent prescribing by any non-medical professional group. Study participants included any stakeholders involved in actual or proposed iNMP. Measurements reported on data describing stakeholders' perceptions and experiences of the barriers to/facilitators of iNMP.

RESULTS

A total of 43 qualitative and seven quantitative studies from three countries (n=12, 117 participants) were included. Quality scores varied from 9 to 35 (Quality Assessment Tool for Studies with Diverse Designs, 0 to 48). Qualitative data were synthesised into four themes (and subthemes): systems (government and political, organisational, formulary); education and support (non-medical prescribing (NMP) courses/continuous professional development (CPD)); personal and professional (medical profession, NMP professions, service users); and financial factors. Quantitative data corroborated the qualitative themes. Integration of the qualitative themes and quantitative data enabled the development of a NMP implementation framework.

CONCLUSION

Barriers to and facilitators of the implementation and utilisation of iNMP are evident, demonstrating multifactorial and context-specific variables within four explicit themes. Professional bodies, politicians, policy and healthcare managers and clinicians could use the resulting NMP implementation framework to ensure the safe and successful implementation and utilisation of NMP. Clinical physiotherapists and other clinicians should consider whether these variables have been adequately addressed prior to adopting NMP into their clinical practice.

REGISTRATION

PROSPERO CRD42015017212. [Noblet T, Marriott J, Graham-Clarke E, Rushton A (2017) Barriers to and facilitators of independent non-medical prescribing in clinical practice: a mixed-methods systematic review. Journal of Physiotherapy 63: 221-234].

Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care

BACKGROUND

A range of health workforce strategies are needed to address health service demands in low-, middle- and high-income countries. Non-medical prescribing involves nurses, pharmacists, allied health professionals, and physician assistants substituting for doctors in a prescribing role, and this is one approach to improve access to medicines.

OBJECTIVES

To assess clinical, patient-reported, and resource use outcomes of non-medical prescribing for managing acute and chronic health conditions in primary and secondary care settings compared with medical prescribing (usual care).

SEARCH METHODS

We searched databases including CENTRAL, MEDLINE, Embase, and five other databases on 19 July 2016. We also searched the grey literature and handsearched bibliographies of relevant papers and publications.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs, controlled before-and-after (CBA) studies (with at least two intervention and two control sites) and interrupted time series analysis (with at least three observations before and after the intervention) comparing: 1. non-medical prescribing versus medical prescribing in acute care; 2. non-medical prescribing versus medical prescribing in chronic care; 3. non-medical prescribing versus medical prescribing in secondary care; 4 non-medical prescribing versus medical prescribing in primary care; 5. comparisons between different non-medical prescriber groups; and 6. non-medical healthcare providers with formal prescribing training versus those without formal prescribing training.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed studies for inclusion, extracted data, and assessed study quality with discrepancies resolved by discussion. Two review authors independently assessed risk of bias for the included studies according to EPOC criteria. We undertook meta-analyses using the fixed-effect model where studies were examining the same treatment effect and to account for small sample sizes. We compared outcomes to a random-effects model where clinical or statistical heterogeneity existed.

MAIN RESULTS

We included 46 studies (37,337 participants); non-medical prescribing was undertaken by nurses in 26 studies and pharmacists in 20 studies. In 45 studies non-medical prescribing as a component of care was compared with usual care medical prescribing. A further study compared nurse prescribing supported by guidelines with usual nurse prescribing care. No studies were found with non-medical prescribing being undertaken by other health professionals. The education requirement for non-medical prescribing varied with country and location.A meta-analysis of surrogate markers of chronic disease (systolic blood pressure, glycated haemoglobin, and low-density lipoprotein) showed positive intervention group effects. There was a moderate-certainty of evidence for studies of blood pressure at 12 months (mean difference (MD) -5.31 mmHg, 95% confidence interval (CI) -6.46 to -4.16; 12 studies, 4229 participants) and low-density lipoprotein (MD -0.21, 95% CI -0.29 to -0.14; 7 studies, 1469 participants); we downgraded the certainty of evidence from high due to considerations of serious inconsistency (considerable heterogeneity), multifaceted interventions, and variable prescribing autonomy. A high-certainty of evidence existed for comparative studies of glycated haemoglobin management at 12 months (MD -0.62, 95% CI -0.85 to -0.38; 6 studies, 775 participants). While there appeared little difference in medication adherence across studies, a meta-analysis of continuous outcome data from four studies showed an effect favouring patient adherence in the non-medical prescribing group (MD 0.15, 95% CI 0.00 to 0.30; 4 studies, 700 participants). We downgraded the certainty of evidence for adherence to moderate due to the serious risk of performance bias. While little difference was seen in patient-related adverse events between treatment groups, we downgraded the certainty of evidence to low due to indirectness, as the range of adverse events may not be related to the intervention and selective reporting failed to adequately report adverse events in many studies.Patients were generally satisfied with non-medical prescriber care (14 studies, 7514 participants). We downgraded the certainty of evidence from high to moderate due to indirectness, in that satisfaction with the prescribing component of care was only addressed in one study, and there was variability of satisfaction measures with little use of validated tools. A meta-analysis of health-related quality of life scores (SF-12 and SF-36) found a difference favouring usual care for the physical component score (MD 1.17, 95% CI 0.16 to 2.17), but not the mental component score (MD 0.58, 95% CI -0.40 to 1.55). However, the quality of life measurement may more appropriately reflect composite care rather than the prescribing component of care, and for this reason we downgraded the certainty of evidence to moderate due to indirectness of the measure of effect. A wide variety of resource use measures were reported across studies with little difference between groups for hospitalisations, emergency department visits, and outpatient visits. In the majority of studies reporting medication use, non-medical prescribers prescribed more drugs, intensified drug doses, and used a greater variety of drugs compared to usual care medical prescribers.The risk of bias across studies was generally low for selection bias (random sequence generation), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), and reporting bias (selective reporting). There was an unclear risk of selection bias (allocation concealment) and for other biases. A high risk of performance bias (blinding of participants and personnel) existed.

AUTHORS' CONCLUSIONS

The findings suggest that non-medical prescribers, practising with varying but high levels of prescribing autonomy, in a range of settings, were as effective as usual care medical prescribers. Non-medical prescribers can deliver comparable outcomes for systolic blood pressure, glycated haemoglobin, low-density lipoprotein, medication adherence, patient satisfaction, and health-related quality of life. It was difficult to determine the impact of non-medical prescribing compared to medical prescribing for adverse events and resource use outcomes due to the inconsistency and variability in reporting across studies. Future efforts should be directed towards more rigorous studies that can clearly identify the clinical, patient-reported, resource use, and economic outcomes of non-medical prescribing, in both high-income and low-income countries.

Impact of the Collaborative Pharmaceutical Care at Tallaght Hospital (PACT) model on medication appropriateness of older patients

Objectives

A high prevalence of potentially inappropriate prescribing (PIP) has been identified in older patients in Ireland. The impact of the Collaborative Pharmaceutical Care at Tallaght Hospital (PACT) model on the medication appropriateness of acute hospitalised older patients during admission and at discharge is reported.

Methods

Uncontrolled before-after study. The study population for this study was medical patients aged ≥65 years, using ≥3 regular medicines at admission, taken from a previous before-after study. Standard care involved clinical pharmacists being ward-based, contributing to medication history taking and prescription review, but not involved at discharge. The innovative PACT model involved clinical pharmacists being physician team-based, leading admission and discharge medication reconciliation and undertaking prescription review, with authority to change the prescription during admission or at discharge. The primary outcome was the Medication Appropriateness Index (MAI) score applied pre-admission, during admission and at discharge.

Results

Some 108 patients were included (48 PACT, 60 standard). PACT significantly improved the MAI score from pre-admission to admission (mean difference 2.4, 95% CI 1.0 to 3.9, p<0.005), and from pre-admission to discharge (mean difference 4.0, 95 CI 1.7 to 6.4, p<0.005). PACT resulted in significantly fewer drugs with one or more inappropriate rating at discharge (PACT 15.0%, standard 30.5%, p<0.001). The MAI criteria responsible for most inappropriate ratings were 'correct directions' (4.8% PACT, 17.3% standard), expense (5.3% PACT, 5.7% standard) and dosage (0.6% PACT, 4.0% standard). PACT suggestions to optimise medication use were accepted more frequently, and earlier in the hospital episode, than standard care (96.7% PACT, 69.3% standard, p<0.05).

Conclusions

Collaborative pharmaceutical care between physicians and pharmacists from admission to discharge, with authority for pharmacists to amend the prescription, improves medication appropriateness in older hospitalised Irish patients.

Patient satisfaction from two studies of collaborative doctor-pharmacist prescribing in Australia

BACKGROUND

Pharmacist prescribing has been introduced in several countries and is a possible future role for pharmacy in Australia.

OBJECTIVE

To assess whether patient satisfaction with the pharmacist as a prescriber, and patient experiences in two settings of collaborative doctor-pharmacist prescribing may be barriers to implementation of pharmacist prescribing.

DESIGN

Surveys containing closed questions, and Likert scale responses, were completed in both settings to investigate patient satisfaction after each consultation. A further survey investigating attitudes towards pharmacist prescribing, after multiple consultations, was completed in the sexual health clinic.

SETTING AND PARTICIPANTS

A surgical pre-admission clinic (PAC) in a tertiary hospital and an outpatient sexual health clinic at a university hospital. Two hundred patients scheduled for elective surgery, and 17 patients diagnosed with HIV infection, respectively, recruited to the pharmacist prescribing arm of two collaborative doctor-pharmacist prescribing studies.

RESULTS

Consultation satisfaction response rates in PAC and the sexual health clinic were 182/200 (91%) and 29/34 (85%), respectively. In the sexual health clinic, the attitudes towards pharmacist prescribing survey response rate were 14/17 (82%). Consultation satisfaction was high in both studies, most patients (98% and 97%, respectively) agreed they were satisfied with the consultation. In the sexual health clinic, all patients (14/14) agreed that they trusted the pharmacist's ability to prescribe, care was as good as usual care, and they would recommend seeing a pharmacist prescriber to friends.

DISCUSSION AND CONCLUSION

Most of the patients had a high satisfaction with pharmacist prescriber consultations, and a positive outlook on the collaborative model of care in the sexual health clinic.

Using scenarios to test the appropriateness of pharmacist prescribing in asthma management

OBJECTIVE

To explore the potential for community pharmacist prescribing in terms of usefulness, pharmacists' confidence, and appropriateness, in the context of asthma management.

METHODS

Twenty community pharmacists were recruited using convenience sampling from a group of trained practitioners who had already delivered asthma services. These pharmacists were asked to complete a scenario-based questionnaire (9 scenarios) modelled on information from real patients. Pharmacist interventions were independently reviewed and rated on their appropriateness according to the Respiratory Therapeutic Guidelines (TG) by three expert researchers.

RESULTS

In seven of nine scenarios (78%), the most common prescribing intervention made by pharmacists agreed with TG recommendations. Although the prescribing intervention was appropriate in the majority of cases, the execution of such interventions was not in line with guidelines (i.e. dosage or frequency) in the majority of scenarios. Due to this, only 47% (76/162) of the interventions overall were considered appropriate. However, pharmacists were deemed to be often following common clinical practice for asthma prescribing. Therefore 81% (132/162) of prescribing interventions were consistent with clinical practice, which is often not guideline driven, indicating a need for specific training in prescribing according to guidelines. Pharmacists reported that they were confident in making prescribing interventions and that this would be very useful in their management of the patients in the scenarios.

CONCLUSIONS

Community pharmacists may be able to prescribe asthma medications appropriately to help achieve good outcomes for their patients. However, further training in the guidelines for prescribing are required if pharmacists are to support asthma management in this way.

Collaborative pharmaceutical care in an Irish hospital: uncontrolled before-after study

BACKGROUND

We investigated the benefits of the Collaborative Pharmaceutical Care in Tallaght Hospital (PACT) service versus standard ward-based clinical pharmacy in adult inpatients receiving acute medical care, particularly on prevalence of medication error and quality of prescribing.

METHODS

Uncontrolled before-after study, undertaken in consecutive adult medical inpatients admitted and discharged alive, using at least three medications. Standard care involved clinical pharmacists being ward-based, contributing to medication history taking and prescription review, but not involved at discharge. The innovative PACT intervention involved clinical pharmacists being team-based, leading admission and discharge medication reconciliation and undertaking prescription review. Primary outcome measures were prevalence per patient of medication error and potentially severe error. Secondary measures included quality of prescribing using the Medication Appropriateness Index (MAI) in patients aged ≥65 years.

FINDINGS

Some 233 patients (112 PACT, 121 standard) were included. PACT decreased the prevalence of any medication error at discharge (adjusted OR 0.07 (95% CI 0.03 to 0.15)); number needed to treat (NNT) 3 (95% CI 2 to 3) and no PACT patient experienced a potentially severe error (NNT 20, 95% CI 10 to 142). In patients aged ≥65 years (n=108), PACT improved the MAI score from preadmission to discharge (Mann-Whitney U p<0.05; PACT median -1, IQR -3.75 to 0; standard care median +1, IQR -1 to +6).

CONCLUSIONS

PACT, a collaborative model of pharmaceutical care involving medication reconciliation and review, delivered by clinical pharmacists and physicians, at admission, during inpatient care and at discharge was protective against potentially severe medication errors in acute medical patients and improved the quality of prescribing in older patients.