Non-dispensing pharmacists integrated into general practices as a new interprofessional model: a qualitative evaluation of general practitioners' experiences and views.

BACKGROUND: A new interprofessional model incorporating non-dispensing pharmacists in general practice teams can improve the quality of pharmaceutical care. However, results of the model are dependent on the context. Understanding when, why and how the model works may increase chances of successful broader implementation in other general practices. Earlier theories suggested that the results of the model are achieved by bringing pharmacotherapeutic knowledge into general practices. This mechanism may not be enough for successful implementation of the model. We wanted to understand better how establishing new interprofessional models in existing healthcare organisations takes place. METHODS: An interview study, with a realist informed evaluation was conducted. This qualitative study was part of the Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in primary care Teams (POINT) project. We invited the general practitioners of the 9 general practices who (had) worked closely with a non-dispensing pharmacist for an interview. Interview data were analysed through discussions about the coding with the research team where themes were developed over time. RESULTS: We interviewed 2 general practitioners in each general practice (18 interviews in total). In a context where general practitioners acknowledge the need for improvement and are willing to work with a non-dispensing pharmacist as a new team member, the following mechanisms are triggered. Non-dispensing pharmacists add new knowledge to current general practice. Through everyday talk (discursive actions) both general practitioners and non-dispensing pharmacists evolve in what they consider appropriate, legitimate and imaginable in their work situations. They align their professional identities. CONCLUSIONS: Not only the addition of new knowledge of non-dispensing pharmacist to the general practice team is crucial for the success of this interprofessional healthcare model, but also alignment of the general practitioners' and non-dispensing pharmacists' professional identities. This is essentially different from traditional pharmaceutical care models, in which pharmacists and GPs work in separate organisations. To induce the process of identity alignment, general practitioners need to acknowledge the need to improve the quality of pharmaceutical care interprofessionally. By acknowledging the aspect of interprofessionality, both general practitioners and non-dispensing pharmacists will explore and reflect on what they consider appropriate, legitimate and imaginable in carrying out their professional roles. TRIAL REGISTRATION: The POINT project was pre-registered in The Netherlands National Trial Register, with Trial registration number NTR-4389.

Under careful construction: combining findings, arguments, and values into robust health care coverage decisions.

BACKGROUND: Health care coverage decisions deal with health care technology provision or reimbursement at a national level. The coverage decision report, i.e., the publicly available document giving reasons for the decision, may contain various elements: quantitative calculations like cost and clinical effectiveness analyses and formalised and non-formalised qualitative considerations. We know little about the process of combining these heterogeneous elements into robust decisions. METHODS: This study describes a model for combining different elements in coverage decisions. We build on two qualitative cases of coverage appraisals at the Dutch National Health Care Institute, for which we analysed observations at committee meetings (n = 2, with field notes taken) and the corresponding audio files (n = 3), interviews with appraisal committee members (n = 10 in seven interviews) and with Institute employees (n = 5 in three interviews), and relevant documents (n = 4). RESULTS: We conceptualise decisions as combinations of elements, specifically (quantitative) findings and (qualitative) arguments and values. Our model contains three steps: 1) identifying elements; 2) designing the combinations of elements, which entails articulating links, broadening the scope of designed combinations, and black-boxing links; and 3) testing these combinations and choosing one as the final decision. CONCLUSIONS: Based on the proposed model, we suggest actively identifying a wider variety of elements and stepping up in terms of engaging patients and the public, including facilitating appeals. Future research could explore how different actors perceive the robustness of decisions and how this relates to their perceived legitimacy.

Effects of non-dispensing pharmacists integrated in general practice on medication-related hospitalisations.

AIMS: To evaluate the effect of non-dispensing pharmacists (NDPs) integrated in general practice on medication-related hospitalisations, drug burden index and costs in patients at high risk of medication problems (being 65 years or older and using 5 or more chronic medications). METHODS: This was a multicentre, nonrandomised, controlled intervention study with pre-post comparison (2013 vs June 2014 to May 2015) in 25 general practices in the Netherlands, comparing NDP-led care (intervention) with 2 current pharmaceutical care models (usual care and usual care plus). In the intervention group, 10 specially trained NDPs were employed in general practices to take integral responsibility for the pharmaceutical care. They provided a broad range of medication therapy management services both on patient level (e.g. clinical medication review) and practice level (e.g. quality improvement projects). In the control groups, pharmaceutical care was provided as usual by general practitioners and community pharmacists, or as usual plus, when pharmacists were additionally trained in performing medication reviews. RESULTS: Overall, 822 medication-related hospitalisations were identified among 11 281 high-risk patients during the intervention period. After adjustment for clustering and potential confounders, the rate ratio of medication-related hospitalisations in the intervention group compared to usual care was 0.68 (95% confidence interval: 0.57-0.82) and 1.05 (95% confidence interval: 0.73-1.52) compared to usual care plus. No differences in drug burden index or costs were found. CONCLUSIONS: In general practices with an integrated NDP, the rate of medication-related hospitalisations is lower compared to usual care. No differences with usual care plus were found.

Costs and effects of new professional roles: Evidence from a literature review.

One way in which governments are seeking to improve the efficiency of the health care sector is by redesigning health services to contain labour costs. The aim of this study was to investigate the impact of new professional roles on a wide range of health service outcomes and costs. A systematic literature review was performed by searching in different databases for evaluation papers of new professional roles (published 1985-2013). The PRISMA checklist was used to conduct and report the systematic literature review and the EPHPP-Quality Assessment Tool to assess the quality of the studies. Forty-one studies of specialist nurses (SNs) and advanced nurse practitioners (ANPs) were selected for data extraction and analysis. The 25 SN studies evaluated most often quality of life (10 studies), clinical outcomes (8), and costs (8). Significant advantages were seen most frequently regarding health care utilization (in 3 of 3 studies), patient information (5 of 6), and patient satisfaction (4 of 6). The 16 ANP studies evaluated most often patient satisfaction (8), clinical outcomes (5), and costs (5). Significant advantages were seen most frequently regarding clinical outcomes (5 of 5), patient information (3 of 4), and patient satisfaction (5 of 8). Promoting new professional roles may help improve health care delivery and possibly contain costs. Exploring the optimal skill-mix deserves further attention from health care professionals, researchers and policy makers.

Tailor-made finance versus tailor-made care. Can the state strengthen consumer choice in healthcare by reforming the financial structure of long-term care?

BACKGROUND: Policy instruments based on the working of markets have been introduced to empower consumers of healthcare. However, it is still not easy to become a critical consumer of healthcare. OBJECTIVES: The aim of this study is to analyse the possibilities of the state to strengthen the position of patients with the aid of a new financial regime, such as personal health budgets. METHODS: Data were collected through in-depth interviews with executives, managers, professionals and client representatives of six long-term care institutions. RESULTS: With the introduction of individual budgets the responsibility for budgetary control has shifted from the organisational level to the individual level in the caregiver-client relationship. Having more luxurious care on offer necessitates a stronger demarcation of regular care because organisations cannot simultaneously offer extra care as part of the standard care package. New financial instruments have an impact on the culture of receiving and giving care. Distributive justice takes on new meaning with the introduction of financial market mechanisms in healthcare; the distributing principle of 'need' is transformed into the principle of 'economic demand'. CONCLUSION: Financial instruments not only act as a countervailing power against providers insufficiently client-oriented, but are also used by providers to reinforce their own positions vis-à-vis demanding clients. Tailor-made finance is not the same as tailor-made care.

Computerized provider order entry system--does it support the inter-professional medication process? Lessons from a Dutch academic hospital.

OBJECTIVES: To assess the effects of a CPOE system on inter-professional workflow in the medication process. METHODS: Twenty-three semi-structured interviews with physicians, nurses, and pharmacists were conducted in a Dutch academic hospital. In addition, the handwritten and system-generated documents used daily were collected for analysis. Data was analyzed on the basis of three conceptual themes in the inter-professional workflow: division of tasks, flow of information, and task coordination. RESULTS: The CPOE system reorganized the existing work procedures, affecting the workflow among the three professional groups both advantageously and disadvantageously. The system resulted in the reassignment of tasks and reallocation of areas of expertise in the medication process. Moreover, patients' medication-related information became fragmented in both the paper records and in the electronic records, as well as in different professional domains. The system provided limited support for professional groups to coordinate their tasks temporally. It also made it difficult to build mutual intelligibility upon new changes in the medication plan. To integrate tasks, the professional groups had to bypass the system or add new steps and extra coordinative tasks. CONCLUSION: We identified several workflow integration issues after the implementation of a CPOE system. Our insights into these issues can help ensure that the system design or redesign properly integrates all tasks, information, and areas of expertise of professional groups into those of the physicians.

Notions of reliability: considering the importance of difference in guiding patients to health care Web sites.

OBJECTIVES: This article analyzes the efforts of three organizations to provide a standard that guides Internet users to reliable health care sites. METHODS: Comparison of health Internet sites, interviews and document studies. RESULTS: In comparing these approaches, three different constructions of reliability are identified. CONCLUSIONS: The resulting possibilities and restrictions of these constructions for users that are searching for health information on the Internet are revealed.

[Limited control of information for work disability evaluation]. / De beperkte controle van de informatie voor de arbeidsongeschiktheidsbeoordeling.

OBJECTIVE: To investigate the information insurance physicians have at their disposal to assess employment disability and how they verify this information. DESIGN: Descriptive. METHOD: In the period January 1999-April 2000, data were collected by means of semi-structured interviews with 19 insurance physicians from the 5 social insurance companies and from observations of 73 consultations conducted by 6 experienced insurance physicians. RESULTS: The average duration of the consultations between the insurance physicians and the clients was 30 minutes. Within these consultations, several issues were briefly discussed. The information obtained by the insurance physicians was limited to the first day of illness, a general description of the complaints and a code for the diagnoses. In 23 cases (32%) the insurance physicians requested information from the attending physician, and in 2 cases (3%) an expert opinion was requested. CONCLUSION: For the insurance physicians, the client was often the most important or indeed sole source of information. Often there was no other information against which the patient's data could be verified and such information was mostly not requested.

[Area reduction in carotid stenosis of the internal carotid artery]. / Querschnittsflächenreduktion bei A.-carotis-interna-Stenose. Bestimmung mit intensitätsgewichteter farbkodierter Duplexonographie.

AIM: In patients with atherosclerotic extracranial internal carotid artery (ICA-) stenosis the diagnostic value of colour Doppler energy (CDE)-coded duplexsonography was compared to three other methods: continuous wave (cw) Doppler peak systolic frequency (pF), pulsed wave (pw) Doppler peak systolic velocity (pV), and intraarterial digital subtraction angiography. METHODS: In 58 patients who suffered from 60 moderate to severe ICA stenoses, B-mode sonography combined with CDE-coded duplex sonography was applied to measure the extent of the stenosis by determining the residual lumen width. Results were correlated to pF and pV and with various angiographic indices. RESULTS: The determined values of the degree of stenosis were correlated to the measurement of pV (r = 0.441, p < 0.01), but not to pF (r = 0.122, n.s.). The best correlation to angiography was obtained when the linear ICA diameter was compared to the distal common carotid artery (common carotid artery index) (r = 0.214, n.s.). Sensitivity, specificity and diagnostic accuracy were comparable to the different frequency-based measurements, but the positive predictive value was lower. CONCLUSIONS: Determination of the degree of stenosis based on CDE alone is not reliable enough to allow correct diagnosis of severe carotid artery stenosis. In combination with the peak frequency method is's diagnostic value could be improved. This requires verification in a separate study.

Transient radicular irritation after single subarachnoid injection of isobaric 2% lignocaine for spinal anaesthesia.

Several cases have been reported recently in which symptoms suggestive of transient radicular irritation occurred following the use of hyperbaric 5% lignocaine for spinal anaesthesia. We report on three patients in whom we observed similar symptoms attributable to this kind of radicular irritation following uneventful spinal anaesthesia using isobaric 2% lignocaine. All three patients underwent minor gynaecological procedures and developed burning pains in the buttocks within 24 h of surgery. The long-term outcome was not clear for all the patients, but in at least one the pain disappeared.

[Acute hepatic porphyria and its neurological syndrome]. / Die akuten hepatischen Porphyrien und ihre neurologischen Syndrome.

Certain of the hepatic porphyrias are classified as belonging to the acute hepatic prophyrias, namely acute intermittent porphyria (AIP), variegate porphyria (VP), hereditary coproporphyria (HCP) and ALA-dehydrase deficiency. The common feature of all acute hepatic porphyrias is the sudden onset of neurological symptoms. The whole syndrome consists of acute abdominal pain crises with autonomic dysfunction, global or focal central nervous system involvement and a predominantly motor polyneuropathy. Mono- or oligosymptomatic manifestations of acute porphyrias occur and are probably underestimated. The laboratory diagnosis of porphyria depends on the measurement of porphyrin precursors in urine, whereas the measurement of porphyrins in urine and feces is essential for evaluation of the porphyria type. Enzyme measurements are used to identify asymptomatic family members whose quantitative excretions of porphyrins are normal. At present the pathogenesis of neurological manifestations of acute porphyrias remains an unsettled question. The major hypotheses are discussed in this paper. The most important precipitating factor in acute hepatic porphyrias is drug ingestion. As many new drugs have not been in use for sufficiently long periods to assess their porphyrogenic activity, it is safer to avoid drugs in patients with porphyria. The most effective treatment of porphyria attacks is the administration of heme. Among the porphyria patients with epileptic seizures requiring antiepileptic medication, treatment with bromides should be taken into consideration.

[Acute vertigo]. / Akuter schwindel.

Among all patients presenting with acute vertigo, majority will be suffering from benign paroxysmal positional vertigo, vestibular neuritis or Meniere's disease. One of the most important central vestibular disorder that imitates labyrinthine dysfunction is vertebrobasilar artery disease. To differentiate this condition from peripheral vestibular lesions, particular attention should be directed to the type of nystagmus which is present. Additionally, duration of vertigo and further neurological symptoms and signs are crucial for correct localization and etiology of the underlying disorder.

[Superficial cerebral hemosiderosis: a rare cause of ataxia or hypoacusis]. / Haemosiderosis superficialis cerebri: seltene Ursache einer Ataxie und Hypakusis.

Superficial siderosis of the central nervous system (SSC) typically involves slowly progressive ataxia, hypoacusis and dementia, possibly with pyramidal signs and sphincter disturbances in combination with xanthochromic CSF with siderophages. However, there are also atypical oligosymptomatic forms. Before the era of magnetic resonance imaging (MRI), diagnosis was only possible at autopsy. Nowadays a firm diagnosis can be made during life by demonstrating the typical marginal hypointense signal in the T2-weighted images in the cerebrum, brain stem, cerebellum and spinal cord. Contrast-enhanced computed tomography may demonstrate widespread meningeal enhancement, but this sign is not specific for SSC. We present an oligosymptomatic case of SSC with slowly progressive ataxia and slight hypoacusis. The etiology, gross pathological and histopathological findings, differential diagnosis and therapy are discussed.

Fasting increases the susceptibility of rat hepatocytes to the cytotoxic effects of N-hydroxy-acetylaminofluorene. Effects on mitochondrial respiration and membrane potential.

Isolated rat hepatocytes were incubated with the carcinogen N-hydroxy-2-acetylaminofluorene (N-OH-AAF). Cells from fasted rats were much more susceptible to the cytotoxic effects of 1 mM N-OH-AAF than cells from fed rats: after approximately 90 min exposure the former were all dead but the latter still viable. Even after 240 min 25% of the "fed" cells were still viable. The loss of viability was preceded by a decrease in mitochondrial membrane potential (MMP) and inhibition of respiration; the mitochondrial respiration as measured in permeabilized cells appeared uncoupled. Addition of 15 mM fructose prevented cell death and the loss of MMP in cells both from fed and fasted rats to a large extent; however, uncoupling was not prevented. After incubation of hepatocytes from fasted rats with 1 mM [3H]N-OH-AAF for 120 min, 12 nmol [3H]N-OH-AAF became bound per mg cell protein. Addition of fructose decreased this to 7 nmol. In cells from fed animals 4 nmol [3H]N-OH-AAF became bound after 120 min, in this case fructose had no effect. Part of the protective effect of fructose might be explained by a decrease in intracellular ATP, which prevents the formation of reactive intermediates of N-OH-AAF resulting in a decrease of covalent binding, in addition, fructose protects via a yet to be determined mechanism.

[Herpes-simplex encephalitis: case example, diagnosis and therapy]. / Die Herpes-simplex-Enzephalitis: Fallbeispiel, Diagnose und Therapie.

Herpes simplex encephalitis (HSE) is the most common nonepidemic cause of acute viral encephalitis. Since successful therapy depends on a high level of suspicion that HSE is present and on the early administration of antiviral treatment, knowledge of clinical and laboratory findings of HSE is of great importance. The clinical hallmark of HSE are signs of both focal and diffuse neurologic involvement. Our case report exemplifies the diagnostic problems that can occur in HSE-patients. The validity of the different ancillary examinations is discussed. Up to the present time brain biopsy has been the method of choice for a reliable early diagnosis of HSE. In the foreseeable future early diagnosis is likely to become available in a non-invasive way by the polymerase-chain reaction. Immediate antiviral therapy with acyclovir in HSE has proved to be useful in rigorously controlled trials. The clinical picture of the acyclovir-induced encephalopathy represents a disorder that can be probably avoided by means of a sufficient hydration.

A field study on stress indices in the sea mussel, Mytilus edulis: application of the "stress approach" in biomonitoring.

Sea mussels, Mytilus edulis, collected from a relatively unpolluted area of the Eastern Scheldt, were transplanted along contaminated sites of the Western Scheldt for 2 1/2 and 5 months. Several established stress indices were determined such as accumulation of pollutants, adenylate energy charge (AEC), and condition index. Following field exposure, mussels were also subjected to an additional lethal or sublethal stress. The data show that environmental exposure alters the mussel's response to stress, viz., aerial exposure and increased temperature, at the organismal (anoxic survival time), biochemical (AEC), and molecular (heat shock protein synthesis) level. The "stress approach" to assessment of environmental contamination appears to be a promising method to disclose early changes in the organism at a stage when conventional parameters (condition index, AEC) remain still unchanged.

Metabolic clearance rate of rat prolactin in preweanling rat pups.

The metabolic clearance rate (MCR) of immunoreactive rat prolactin (rPRL) was determined in urethane-anaesthetized 14 to 16-day-old rat pups using the constant infusion to equilibrium method. Two different doses of rPRL were used, 329 and 472 ng/min each at a volume of 0.0025 ml/min for 30 min. The MCR was 0.216 ml/min following infusion of 329 ng PRL/min dose and 0.337 ml/min following infusion of the 472-ng/min dose. When calculated on the basis of metabolic body weight the MCR of rPRL in rat pups was comparable to that of adult rats.

A randomised controlled trial of the effect of low fat diet advice on dietary response in insulin independent diabetic women.

Type 2 (insulin independent) diabetic women were randomly allocated to receive advice for low fat diets or low carbohydrate diets. By 24 h weighted dietary intakes before and after a mean interval of six months, patients in the low fat group had reduced their fat intake from 41% to 31% of total energy, while carbohydrate percentage of total energy intake increased from 38% to 46%. Percentage energy intake from fat and carbohydrate in the control group remained unchanged. Body weight fell in both groups especially for patients in the low fat group who were obese (weight/height2 greater than or equal to 28 kg/m2). Mean plasma glucose, HbA1, and triglycerides were unchanged. Mean plasma total cholesterol fell significantly in the low fat group compared with the controls (p less than 0.001), but there was no significant difference in the small reduction of high density lipoprotein cholesterol observed in both groups. Thus, adherence to low fat diets occurred without deterioration of diabetes and with benefit for weight and total cholesterol.

[Comparison of pherograms (plasma proteins, hemoglobins) in three species of Textor Temminck (Aves Ploceidae from Kinshasa region, Republic of Zaïre)]. / Comparaison des phérogrammes (protéines plasmatiques, hémoglobines) de trois espèces du genre Textor Temminck (Aves Ploceidae de la région de Kinshass, République du Zaïre).

The plasmic proteinograms got in agar-gel with adult subjects of three species of weavers offer clear similitude to each other and allow only very unusually a separation of the three species. Intraspecific variations in the three species appear on the level of zones a-b-c-d (alpha-globulins). None of these variations could be referred to a particular physiologic state. In the young weavers, we don't meet the beta-gamma-globulins h-i again. In those, the proteins concentration is very low and the haematocrit not very high. The two haemoglobinic fractions are lowly concentrated. Their relative concentration are in relation inverse to the concentrations observed in the grown-up subjects.