What influences prescribing decisions in a multimorbidity and polypharmacy context on the acute medical unit? An interprofessional, qualitative study.

RATIONALE, AIMS AND OBJECTIVES: The primary aim of the study was to understand the mindset of doctors and pharmacists, as they embark upon prescribing in a multimorbidity and polypharmacy context during routine practice at a hospital acute admissions unit. The study also aimed to evaluate to what extent attitudes, embedded within real-life decision-making scenarios, relate to existing theory and models of prescribing decisions. METHODS: Anonymized case studies were identified from the medical notes of patients aged 65 and over with conditions likely to be associated with multimorbidity, medication issues and polypharmacy: namely: fall, urinary tract infection, confusion or lower respiratory tract infection. A total of 39 doctors based on the acute medical admissions unit and 9 pharmacists were recruited to one of three focus groups. Patient case-studies provided the context for discussion from which verbatim transcripts were thematically analyzed using an interpretative, qualitative approach. Sub-themes were matched to Murshid and Mohaidin's proposed model of physician prescribing decisions. RESULTS: Seven principal themes were identified that were associated with prescribing decisions on the acute medical unit, namely, "patient characteristics," "drug characteristics," "pharmacist factors," "trustworthiness," "reliability of medication history," "competing priorities" and "responsibilities of prescribers." CONCLUSION: Prescribing decisions on the acute medical admissions unit were influenced by a variety of factors, some of which have already been acknowledged within existing theories and models. The findings provisionally offer new insights, which, subject to confirmation by further research, bring to light three attitudinal characteristics that may impact negatively upon the quality of prescribing decisions. These include, first, how perceived poor reliability of medication history may result in information gaps that compromise prescribing decisions; second, how competing priorities restrict doctors' aptitude to conduct a review of medication and finally, how doctors may rationalize the assignment of medication review to the GP.

Personalised Warfarin Dosing in Children Post-cardiac Surgery.

Warfarin dosing is challenging due to a multitude of factors affecting its pharmacokinetics (PK) and pharmacodynamics (PD). A novel personalised dosing algorithm predicated on a warfarin PK/PD model and incorporating CYP2C9 and VKORC1 genotype information has been developed for children. The present prospective, observational study aimed to compare the model with conventional weight-based dosing. The study involved two groups of children post-cardiac surgery: Group 1 were warfarin naïve, in whom loading and maintenance doses were estimated using the model over a 6-month duration and compared to historical case-matched controls. Group 2 were already established on maintenance therapy and randomised into a crossover study comparing the model with conventional maintenance dosing, over a 12-month period. Five patients enrolled in Group 1. Compared to the control group, the median time to achieve the first therapeutic INR was longer (5 vs. 2 days), to stable anticoagulation was shorter (29.0 vs. 96.5 days), to over-anticoagulation was longer (15.0 vs. 4.0 days). In addition, median percentage of INRs within the target range (%ITR) and percentage of time in therapeutic range (%TTR) was higher; 70% versus 47.4% and 83.4% versus 62.3%, respectively. Group 2 included 26 patients. No significant differences in INR control were found between model and conventional dosing phases; mean %ITR was 68.82% versus 67.9% (p = 0.84) and mean %TTR was 85.47% versus 80.2% (p = 0.09), respectively. The results suggest model-based dosing can improve anticoagulation control, particularly when initiating and stabilising warfarin dosing. Larger studies are needed to confirm these findings.

Exploring the prevalence of and factors associated with advice on prescription medicines: A survey of community pharmacies in an English city.

Service users rely upon pharmacy staff to provide advice on prescription medicines. The purpose of this study was to compare the prevalence of advice-giving in pharmacies located across different areas within an inner-city population. A questionnaire was administered with service users outside 29 community pharmacies in an English Midlands city between February and July 2014. The primary outcome measure was the percentage who had received information or advice when collecting a prescription medicine. A total of 1206 service users took part, of whom 49.1% were female and 50.9% were of minority ethnicity (48.8% white British). The age ranges were: 17-30 years (21.0%), 31-60 years (55.0%) and 61-80+ years (24.1%). Sixty-nine per cent of participants had collected a prescription for themselves, and the proportions of new and repeat prescriptions were 22.1% and 77.6% respectively. A subset of 141 participants had requested advice, of whom 94% confirmed that they had received it. Overall, 28.6% of 1065 participants received unsolicited information or advice. The overall prevalence of unsolicited advice-giving varied per pharmacy from 14% to 63% and for new and repeat prescriptions was 41.9% and 25.5% respectively (p < .001, new vs repeat). In areas of greater deprivation, a higher proportion of service users of minority ethnicity received unsolicited repeat prescription advice, compared to that of white British (33.0% vs 17.3% respectively; p < .001). Thus, the low incidence and contrasting patterns of prescription advice-giving suggests that the training and expertise of pharmacy staff may not always be used effectively within the UK NHS. Therefore, the current challenge is how community pharmacies can work in partnership with colleagues across the wider healthcare system when optimising the use of medicines and reducing health inequalities. The research performed here provides new insights reflecting the low prevalence of advice-giving and potential inequity associated with delivery of this pharmacy service.

Continuing professional development needs of nursing and allied health professionals with responsibility for prescribing.

BACKGROUND: Continuing professional development (CPD) for non-medical prescribers is recognised as being pivotal in maintaining up -to -date knowledge and skills influencing prescribing competence. This study was, therefore, designed to ascertain the aspirations, priorities and preferred mode of CPD for non-medical prescribers. METHOD: Qualitative data were derived from semi-structured in-depth interviews and a focus group given by 16 allied health professionals working in primary and secondary care settings. A topic guide was used to cover clinical decision-making (including difficult decisions), legal aspects of prescribing and diagnostic issues. A content analysis of the verbatim transcripts enabled four key emerging themes to be identified, thus offering a basis for developing a greater understanding of the CPD needs of non-medical prescribers. RESULTS: The four key emerging themes identified are the following: Theme 1: "Personal anxiety undermining confidence to prescribe", Theme 2: "External barriers and other factors that exacerbate anxiety", Theme 3: "Need for support identified through coping strategies", and Theme 4: "Preferred mode or style of learning". DISCUSSION: The findings suggest that anxiety and lack of confidence in non-medical prescribing pose a significant challenge for CPD. Strategies that are most likely to improve prescribing confidence are through a blended learning approach. Local higher education and workplace employer collaboration is an appropriate step forward to achieve this.

The effectiveness of screening for diabetes and cardiovascular disease risk factors in a community pharmacy setting.

UNLABELLED: Risk factors for cardiovascular disease including diabetes have seen a large rise in prevalence in recent years. This has prompted interest in prevention through the identifying individuals at risk of both diabetes and cardiovascular disease and has seen increased investment in screening interventions taking place in primary care. Community pharmacies have become increasingly involved in the provision of such interventions and this systematic review and meta-analysis aims to gather and analyse the existing literature assessing community pharmacy based screening for risk factors for diabetes and those with a high cardiovascular disease risk. METHODS: We conducted systematic searches of electronic databases using MeSH and free text terms from 1950 to March 2012. For our analysis two outcomes were assessed. They were the percentage of those screened who were referred for further assessment by primary care and the uptake of this referral. RESULTS: Sixteen studies fulfilled our inclusion criteria comprising 108,414 participants screened. There was significant heterogeneity for all included outcomes. Consequently we have not presented summary statistics and present forest plots with I2 and p values to describe heterogeneity. We found that all included studies suffered from high rates of attrition between pharmacy screening and follow up. We have also identified a strong trend towards higher rates for referral in more recent studies. CONCLUSIONS: Our results show that pharmacies are feasible sites for screening for diabetes and those at risk of cardiovascular disease. A significant number of previously unknown cases of cardiovascular disease risk factors such as hypertension, hypercholesterolemia and diabetes are identified, however a significant number of referred participants at high risk do not attend their practitioner for follow up. Research priorities should include methods of increasing uptake to follow up testing and early intervention, to maximise the efficacy of screening interventions based in community pharmacies.

'It's the best of two evils': a study of patients' perceived information needs about oral steroids for asthma.

OBJECTIVES: To explore the sources of patients' knowledge about the potential side-effects of oral steroids prescribed to treat asthma. METHODS: Seventeen in-depth interviews were conducted with patients taking prescribed oral steroid medication (prednisolone) for asthma. The interviews were transcribed verbatim and the data organized according to common themes. RESULTS: All the respondents acknowledged they had no choice but to take oral steroids but they wanted to be informed about the potential side-effects. Respondents reported that they had not received sufficient information about side-effects from their general practitioner (GP). Information was sought from both medical sources (pharmacists and asthma nurses) and non-medical sources (friends and family, self-help groups and the media) to supplement their knowledge. The conclusions drawn about the risks of taking oral steroids were also influenced by respondents' existing beliefs. CONCLUSIONS: Respondents drew upon information about oral steroids from a variety of professional and lay sources. The findings add weight to calls for doctors and patients to share their respective knowledge in consultations. Developing an understanding of the views of GPs about the provision of information about side-effects would help to identify any perceived barriers to a more open exchange of information in the consultation.