Diabetes risk assessments and HbA1c-measurements in community pharmacies.

OBJECTIVES: Due to a lack of clear symptoms, type 2 diabetes (T2D) can remain undetected for many years. The aim of the study was to explore if Norwegian community pharmacies could identify individuals with a high risk of developing T2D by offering a diabetes risk assessment service. This study also investigated if the service recruited individuals that the national guideline recommends for diabetes risk assessment, and the proportion of participants who had visited their GP at least once a year. METHODS: During the inclusion period (September 2016 to the middle of April 2017), pharmacy customers 45 years or older wishing to participate contacted the pharmacy staff. Included participants completed a diabetes risk test and participants with a high risk were offered an HbA1c measurement. At two months after intervention, all participants were followed up. KEY FINDINGS: Of the 245 participants, 27% had a high risk of developing T2D. Of these, 46%, 43% and 9% had HbA1c values corresponding to normal (<39 mmol/mol [5.7%]), prediabetes (39-47 mmol/mol [5.7-6.4%]) or above cut-off for diabetes (≥48 mmol/mol [≥6.5%]), respectively. A total of 86% of the participants were in at least one category that the guideline recommends for a diabetes risk assessment, and 88% had visited their GP at least once a year. CONCLUSIONS: Norwegian community pharmacies can identify individuals with a high risk of developing T2D by offering a diabetes risk assessment service. Individuals who sought out the service were within the relevant demographics for testing, and a high proportion visited their GP at least once a year.

Power dynamics and interprofessional collaboration: How do community pharmacists position general practitioners, and how do general practitioners position themselves?

Power differentials and medical dominance can negatively affect collaboration between physicians and pharmacists. Norway is recognized as having a relatively egalitarian work sector, which could affect power differentials. In this qualitative study, we used positioning theory as a framework to explore the aspect of power dynamics between Norwegian general practitioners (GPs) and community pharmacists. We used the concepts of reflexive and interactive positioning to identify how GPs positioned themselves and how they were positioned by pharmacists in six focus groups. Data were analyzed using systematic text condensation. We found positioning theory to be a useful lens through which to study power dynamics in relation to collaboration between community pharmacists and GPs. Our findings imply that the presence of medical dominance poses challenges even in an egalitarian Norwegian setting. However, although both GPs and pharmacists draw on a 'medical dominance' storyline, we have also identified how both pharmacists and GPs draw on alternative and promising storylines of collaboration between the two professions.

Changes in Dentists' Prescribing Patterns in Norway 2005-2015.

BACKGROUND: There is scant knowledge of dentists' total prescribing patterns, and little is published on this internationally. The Norwegian Prescription Database (NorPD) includes data on all dispensed prescription medication in Norway from 2004 and can be used to investigate how dentists' prescribing has changed over time. There are few Norwegian guidelines supporting dentists' prescribing, and Norwegian legislation on dentists' prescribing rights leaves room for interpretation. The aim of this study was therefore to give an overview of all prescribing from dentists in Norway in the period 2005 to 2015 and to identify trends in their prescribing pattern over this time span. We also give characteristics of the prescribing dentists. METHODS: The study had a retrospective pharmacoepidemiologic design. Data on all medication prescribed by dentists and dispensed from Norwegian pharmacies in the time period 2005 to 2015 were extracted from the NorPD. Changes over time in the prescribers, patients, and medications are reported. RESULTS: There was an increase of 50% in total number of prescriptions from dentists in Norway from 2005 to 2015; adjusted for the growth in population, there was a 33% increase. The majority of prescriptions from dentists were for antibiotics and analgesics; however, the data reveal that the dentists prescribed from all major therapeutic groups. Dentists increased antibiotic prescribing in a period when total antibiotic prescribing in Norway decreased. CONCLUSIONS: Our study finds antibiotics and analgesics dominate prescriptions from Norwegian dentists and shows an increase in use over time. It highlights the need for creating evidence-based prescribing guidelines for dentists and for ensuring that existing guidelines are implemented.

Type 2 diabetes in general practice - a focus-group study. / Type 2-diabetes i fastlegepraksis ­ en fokusgruppestudie.

BACKGROUND: The National Diabetes Plan 2017-21 has implemented measures to improve diagnosis and follow-up of persons with type 2 diabetes by the primary health services. The objective of this study was to explore the experiences and thoughts of Norwegian general practitioners (GPs) with regard to diagnosis and follow-up of this patient group. MATERIAL AND METHOD: In this qualitative study, three focus-group interviews were conducted with a total of 17 GPs. The interviews were recorded, transcribed and analysed using systematic text condensation. RESULTS: The GPs reported having a busy daily schedule that rarely allowed for targeted identification of patients in the risk zone to be prioritised. They described a patient-centred diabetes care, in which motivating for lifestyle change was considered a necessary but demanding task. The doctors identified the need to find a balance between following the general clinical guidelines on the one hand and individually adapting the follow-up to each patient on the other. Furthermore, the participants reported being less updated on current medical knowledge than they wanted, due to time constraints. INTERPRETATION: The GPs in the study described a patient-centred diabetes care that was driven by clinical experience. The guidelines have an advisory, but not mandatory function. This approach enables personalised and adapted treatment, but could also be a contributory cause of the failure to provide sufficient follow-up as required by the national guidelines.

Complementing or conflicting? How pharmacists and physicians position the community pharmacist

BACKGROUND: Interprofessional collaboration between pharmacists and physicians in primary care has been linked to improved patient outcomes. How professionals position themselves and each other can shed light upon their relationship, and positioning theory can be used as a tool to better understand intergroup relations. OBJECTIVES: 1) To identify how community pharmacists position themselves, and how they are positioned by general practitioners. 2) To assess how well these positions correspond, how the positions align with a proactive position for the pharmacists, and discuss how the positions could potentially impact collaboration. METHODS: In this qualitative study, data were collected through six focus group interviews held between June and October 2019, three with pharmacists and three with physicians. The focus group interviews were conducted using a semi-structured interview guide. Data were audio recorded, transcribed verbatim, and analyzed using the Systematic text condensation method. Positioning theory was used as a theoretical framework to identify the positions assigned to community pharmacists by the pharmacists themselves and by the physicians. RESULTS: Twelve pharmacists and ten physicians participated. The pharmacists positioned themselves as the "last line of defense", "bridge-builders", "outsiders" - with responsibility, but with a lack of information and authority - and "practical problem solvers". The physicians positioned pharmacists as "a useful checkpoint", "non-clinicians" and "unknown". CONCLUSIONS: The study revealed both commonalities and disagreements in how community pharmacists position themselves and are positioned by general practitioners. Few of the positions assigned to pharmacists by the physicians support an active role for the pharmacists, while the pharmacists' positioning of themselves is more diverse. The physicians' positioning of pharmacists as an unknown group represents a major challenge for collaboration. Increasing the two professions' knowledge of each other may help produce new positions that are more coordinated, and thus more supportive towards collaboration

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Risk assessment and HbA1c measurement in Norwegian community pharmacies to identify people with undiagnosed type 2 diabetes - A feasibility study.

OBJECTIVES: Determine the feasibility of using a diabetes risk assessment tool followed by HbA1c-measurement in a community-pharmacy setting in Norway. METHODS: In this longitudinal study two pharmacists in each of three community pharmacies were trained to perform risk assessments, HbA1c-measurements and counselling. Pharmacy customers who were > 18 years old and could understand and speak Norwegian or English were recruited in the pharmacies during a two-months-period. Information about the service was presented in local newspapers, social media, leaflets and posters at the pharmacy. Customers wishing to participate contacted the pharmacy staff. Participants completed a validated diabetes risk test and a background questionnaire including a validated instrument for self-rated health. A HbA1c measurement was performed for individuals with a moderate to high risk of developing diabetes. If HbA1c ≥ 6.5% they were recommended to visit their general practitioner for follow-up. The pharmacies performed internal and external quality control of the HbA1c instrument. RESULTS: Of the 211 included participants 97 (46%) were > 50 years old. HbA1c was measured for the 47 participants (22%) with high risk. Thirty-two (15%) had HbA1c values < 5.7%, twelve (5.4%) had values between 5.7%-6.4%, and three (1.4%) had an HbA1c ≥ 6.5%. Two participants with HbA1 ≥ 6.5% were diagnosed with diabetes by their general practitioner. The third was lost to follow-up. Results from internal and external quality control for HbA1c were within set limits. CONCLUSION: The pharmacists were able to perform the risk assessment and measurement of HbA1c, and pharmacy customers were willing to participate. The HbA1c measurements fulfilled the requirements for analytical quality. Thus, it is feasible to implement this service in community pharmacies in Norway. In a large-scale study the inclusion criteria should be increased to 45 years in accordance with the population the risk test has been validated for.

Dental providers and pharmacists: a call for enhanced interprofessional collaboration.

Reports concerning medication discrepancies in dental records indicate that the concept of interprofessional collaboration between the dental team and pharmacists should be considered at all educational levels in dentistry and pharmacy. Inclusion of oral health as a therapeutic area in didactic pharmacy curricula is needed. Early exposure of dental students and student pharmacists to collaborative practices through interprofessional educational experiences may create a higher degree of awareness of the role of each profession and the potential to improve patient outcomes. Furthermore, efforts are needed to develop a systematic approach for medication review and reconciliation in dental practice to obtain accurate medication lists, potentially by utilising health information technology.

The potential for deprescribing in care home residents with Type 2 diabetes.

Background Type 2 diabetes is a common diagnosis in care home residents that is associated with potentially inappropriate prescribing and thus risk of additional suffering. Previous studies found that diabetes medicines can be safely withdrawn in care home residents, encouraging further investigation of the potential for deprescribing amongst these patients. Objectives Describe comorbidities and medicine use in care home residents with Type 2 diabetes; identify number of potentially inappropriate medicines prescribed for these residents using a medicines optimisation tool; assess clinical applicability of the tool. Setting Thirty care homes for older people, East Anglia, UK. Method Data on diagnoses and medicines were extracted from medical records of 826 residents. Potentially inappropriate medicines were identified using the tool 'Optimising Safe and Appropriate Medicines Use'. Twenty percent of results were validated by a care home physician. Main outcome measure Number of potentially inappropriate medicines. Results The 106 residents with Type 2 diabetes had more comorbidities and prescriptions than those without. Over 90 % of residents with Type 2 diabetes had at least one potentially inappropriate medication. The most common was absence of valid indication. The physician unreservedly endorsed 39 % of the suggested deprescribing, and would consider discontinuing all but one of the remaining medicines following access to additional information. Conclusion UK care home residents with Type 2 diabetes had an increased burden of comorbidities and prescriptions. The majority of these patients were prescribed potentially inappropriate medicines. Validation by a care home physician supported the clinical applicability of the medicines optimisation tool.

'I try not to bother the residents too much' - the use of capillary blood glucose measurements in nursing homes.

BACKGROUND: Capillary blood glucose measurements are regularly used for nursing home residents with diabetes. The usefulness of these measurements relies on clear indications for use, correct measurement techniques, proper documentation and clinical use of the resulting blood glucose values. The use of a regular, invasive procedure may also entail additional challenges in a population of older, multimorbid patients who often suffer from cognitive impairment or dementia. The aim of this study was to explore the perspectives of physicians, registered nurses and auxiliary nurses on the use, usefulness and potential challenges of using capillary blood glucose measurements in nursing homes, and the procedures for doing so. METHODS: This was a qualitative study that used three profession-specific focus group interviews. Interviews were transcribed in modified verbatim form and analysed in accordance with Malterud's principles of systematic text condensation. Five physicians, four registered nurses and three auxiliary nurses participated in the focus groups. RESULTS: All professional groups regarded capillary blood glucose measurements as a necessity in the management of diabetes, the physicians to ensure that the treatment is appropriate, and the nurses to be certain and assured about their caring decisions. Strict glycaemic control and excessive measurements were avoided in order to promote the well-being and safety of the residents. Sufficient knowledge of diabetes symptoms, equivalent practices for glucose measurement, and unambiguous documentation and communication of results were determined to be most helpful. However, all professional groups seldom involved the residents in managing their own measurements and stated that guidelines and training had been inconsistent or lacking. CONCLUSION: Inadequate procedures and training in diabetes care may compromise the rationale for capillary blood glucose measurements in nursing homes, and hence the residents' safety. These concerns should be addressed together with the possibility of involving and empowering residents by exploring their ability and wish to manage their own disease.

Perception of the Professional Knowledge of and Education on the Medical Technology Products among the Pharmacists in the Baltic and Nordic Countries-A Cross-Sectional Exploratory Study.

With increased development of medical technology (MT), new challenges emerge related to education and training of pharmacists and other healthcare specialists. Currently, only a few universities in the EU promote MT education and research. OBJECTIVES: The aim of this study was to evaluate the current status, views on, and need for the education on MT for the pharmacy students and practicing pharmacists in the Baltic and Nordic countries. METHODS: The representatives of higher education institutions and community/hospital pharmacists from six Baltic and Nordic countries participated in a qualitative cross-sectional exploratory internet-based study from May to October 2014. RESULTS: Approximately two-third of the respondents considered professional knowledge about MT products important for pharmacists, but half of them had never participated in any MT courses. More practicing pharmacists than representatives of academia underlined the need for increased MT education for pharmacy students in the future. CONCLUSIONS: The pharmacists in the Baltic and Nordic countries consider the professional knowledge about MT as pertinent in their education and work. The limited number and status of MT courses available today, however, is a major concern among both pharmacy students and practicing pharmacists in these countries. In the future, increasing education combining theory and practice about MT products would be one possible solution to overcome this challenge.

Nursing home patients with diabetes: prevalence, drug treatment and glycemic control.

AIMS: Determine prevalence of diabetes, and describe use of blood glucose lowering (BGL) drugs and glycemic control in Norwegian nursing homes. METHODS: In this cross-sectional study we collected details of BGL drugs, capillary blood glucose measurements (CBGM) in the last four weeks and HbA1c measurements in the last 12 months from the medical records of patients with diabetes, within a population of 742 long-term care patients from 19 randomly selected nursing homes in Western Norway. Descriptive statistics were applied, and Pearson's chi-squared (P≤0.05) or non-overlapping 95% confidence intervals were interpreted as significant effects. RESULTS: 116 patients (16%) had diabetes, 100 of these gave informed consent and medical data were available. BGL treatment was as follows: (1) insulin only (32%), (2) insulin and oral antidiabetics (OADs) (15%), (3) OADs only (27%) and (4) no drugs (26%). Patients with cognitive impairment were less likely to receive medical treatment (P=0.04). CBGM and HbA1c measurements were performed for 73% and 77% of patients, respectively. Mean HbA1c was 7.3% (57 mmol/mol), 46% of patients had an HbA1c <7.0% (53 mmol/mol), and CBGM consistent with risk of hypoglycemia was found for 60% of these patients. CONCLUSIONS: Prevalence of diabetes and BGL treatment in Norwegian nursing homes is comparable to other European countries. Although special care seems to be taken when choosing treatment for patients with cognitive impairment, there are signs of overtreatment in the population as a whole. The strict glycemic control unveiled may negatively affect these frail patients' quality of life and increase the risk of early death.