Nurse prescribing in general practice: a qualitative study of job satisfaction and work-related stress.

PubMed

Cousins, Rosanna; Donnell, Christine

2012-04-01

Studies examining the impact nurse prescribing have largely focused on the efficacy of the service. It was suggested in pro-prescribing policy arguments that extending the nursing role to include prescribing would increase job satisfaction. This assertion has not been fully explored. To investigate the impact of independent prescribing for experienced nurse practitioners (NPs) working in general practice. In-depth interviews were conducted with six NPs who each had at least 3 years experience of independent prescribing in a busy inner city general practice. Analysis of interview data yielded two main themes: as independent prescribers NPs experienced increased levels of both job satisfaction and work-related stress. Increased satisfaction was associated with having greater autonomy and being able to provide more holistic care. Increased work-related stress emerged from greater job demands, perceived insufficient support and perceived effort-reward imbalance that centred upon the enhanced role not being recognized in terms of an increase in grade and pay. Independent prescribing increases job satisfaction for NPs in general practice, but there is also evidence of stressors associated with the role. It is important that NPs in general practice are encouraged and supported towards providing the effective patient-centred care in the community envisaged by current UK government. We acknowledge that the results presented in this paper are based on a sample limited to one city; however, it provides information that has important implications for the well being of NPs and ultimately patient care.

Personalized Medicine and Opioid Analgesic Prescribing for Chronic Pain: Opportunities and Challenges

PubMed Central

Bruehl, Stephen; Apkarian, A. Vania; Ballantyne, Jane C.; Berger, Ann; Borsook, David; Chen, Wen G.; Farrar, John T.; Haythornthwaite, Jennifer A.; Horn, Susan D.; Iadarola, Michael J.; Inturrisi, Charles E.; Lao, Lixing; Mackey, Sean; Mao, Jianren; Sawczuk, Andrea; Uhl, George R.; Witter, James; Woolf, Clifford J.; Zubieta, Jon-Kar; Lin, Yu

2013-01-01

Use of opioid analgesics for pain management has increased dramatically over the past decade, with corresponding increases in negative sequelae including overdose and death. There is currently no well-validated objective means of accurately identifying patients likely to experience good analgesia with low side effects and abuse risk prior to initiating opioid therapy. This paper discusses the concept of data-based personalized prescribing of opioid analgesics as a means to achieve this goal. Strengths, weaknesses, and potential synergism of traditional randomized placebo-controlled trial (RCT) and practice-based evidence (PBE) methodologies as means to acquire the clinical data necessary to develop validated personalized analgesic prescribing algorithms are overviewed. Several predictive factors that might be incorporated into such algorithms are briefly discussed, including genetic factors, differences in brain structure and function, differences in neurotransmitter pathways, and patient phenotypic variables such as negative affect, sex, and pain sensitivity. Currently available research is insufficient to inform development of quantitative analgesic prescribing algorithms. However, responder subtype analyses made practical by the large numbers of chronic pain patients in proposed collaborative PBE pain registries, in conjunction with follow-up validation RCTs, may eventually permit development of clinically useful analgesic prescribing algorithms. Perspective Current research is insufficient to base opioid analgesic prescribing on patient characteristics. Collaborative PBE studies in large, diverse pain patient samples in conjunction with follow-up RCTs may permit development of quantitative analgesic prescribing algorithms which could optimize opioid analgesic effectiveness, and mitigate risks of opioid-related abuse and mortality. PMID:23374939

Influences on the start, selection and duration of treatment with antibiotics in long-term care facilities

PubMed Central

Daneman, Nick; Campitelli, Michael A.; Giannakeas, Vasily; Morris, Andrew M.; Bell, Chaim M.; Maxwell, Colleen J.; Jeffs, Lianne; Austin, Peter C.; Bronskill, Susan E.

2017-01-01

BACKGROUND: Understanding the extent to which current antibiotic prescribing behaviour is influenced by clinicians’ historical patterns of practice will help target interventions to optimize antibiotic use in long-term care. Our objective was to evaluate whether clinicians’ historical prescribing behaviours influence the start, prolongation and class selection for treatment with antibiotics in residents of long-term care facilities. METHODS: We conducted a retrospective cohort study of all physicians who prescribed to residents in long-term care facilities in Ontario between Jan. 1 and Dec. 31, 2014. We examined variability in antibiotic prescribing among physicians for 3 measures: start of treatment with antibiotics, use of prolonged durations exceeding 7 days and selection of fluoroquinolones. Funnel plots with control limits were used to determine the extent of variation and characterize physicians as extreme low, low, average, high and extreme high prescribers for each tendency. Multivariable logistic regression was used to assess whether a clinician’s prescribing tendency in the previous year predicted current prescribing patterns, after accounting for residents’ demographics, comorbidity, functional status and indwelling devices. RESULTS: Among 1695 long-term care physicians, who prescribed for 93 132 residents, there was wide variability in the start of antibiotic treatment (median 45% of patients, interquartile range [IQR] 32%–55%), use of prolonged treatment durations (median 30% of antibiotic prescriptions, IQR 19%–46%) and selection of fluoroquinolones (median 27% of antibiotic prescriptions, IQR 18%–37%). Prescribing tendencies for antibiotics by physicians in 2014 correlated strongly with tendencies in the previous year. After controlling for individual resident characteristics, prior prescribing tendency was a significant predictor of current practice. INTERPRETATION: Physicians prescribing antibiotics exhibited individual, measurable and historical tendencies toward start of antibiotic treatment, use of prolonged treatment duration and class selection. Prescriber audit and feedback may be a promising tool to optimize antibiotic use in long-term care facilities. PMID:28652480

Influences on the start, selection and duration of treatment with antibiotics in long-term care facilities.

PubMed

Daneman, Nick; Campitelli, Michael A; Giannakeas, Vasily; Morris, Andrew M; Bell, Chaim M; Maxwell, Colleen J; Jeffs, Lianne; Austin, Peter C; Bronskill, Susan E

2017-06-26

Understanding the extent to which current antibiotic prescribing behaviour is influenced by clinicians' historical patterns of practice will help target interventions to optimize antibiotic use in long-term care. Our objective was to evaluate whether clinicians' historical prescribing behaviours influence the start, prolongation and class selection for treatment with antibiotics in residents of long-term care facilities. We conducted a retrospective cohort study of all physicians who prescribed to residents in long-term care facilities in Ontario between Jan. 1 and Dec. 31, 2014. We examined variability in antibiotic prescribing among physicians for 3 measures: start of treatment with antibiotics, use of prolonged durations exceeding 7 days and selection of fluoroquinolones. Funnel plots with control limits were used to determine the extent of variation and characterize physicians as extreme low, low, average, high and extreme high prescribers for each tendency. Multivariable logistic regression was used to assess whether a clinician's prescribing tendency in the previous year predicted current prescribing patterns, after accounting for residents' demographics, comorbidity, functional status and indwelling devices. Among 1695 long-term care physicians, who prescribed for 93 132 residents, there was wide variability in the start of antibiotic treatment (median 45% of patients, interquartile range [IQR] 32%-55%), use of prolonged treatment durations (median 30% of antibiotic prescriptions, IQR 19%-46%) and selection of fluoroquinolones (median 27% of antibiotic prescriptions, IQR 18%-37%). Prescribing tendencies for antibiotics by physicians in 2014 correlated strongly with tendencies in the previous year. After controlling for individual resident characteristics, prior prescribing tendency was a significant predictor of current practice. Physicians prescribing antibiotics exhibited individual, measurable and historical tendencies toward start of antibiotic treatment, use of prolonged treatment duration and class selection. Prescriber audit and feedback may be a promising tool to optimize antibiotic use in long-term care facilities. © 2017 Canadian Medical Association or its licensors.

National survey of fluid therapy in acute pancreatitis: current practice lacks a sound evidence base.

PubMed

Haydock, Matthew D; Mittal, Anubhav; van den Heever, Marc; Rossaak, Jeremy I; Connor, Saxon; Rodgers, Michael; Petrov, Maxim S; Windsor, John A

2013-10-01

Fluid therapy (FT) is a critical intervention in managing acute pancreatitis (AP). There is a paucity of evidence to guide FT and virtually no data on current prescribing practice. This survey aims to characterize current practice and opinion with regard to FT in AP throughout New Zealand. Information was collected on fluid selection, administration, and goal-directed FT. The survey was distributed online and in print to all doctors employed in General Surgery Departments in New Zealand on 1 May 2012. Monthly email reminders were sent for 6 months. The overall response rate was 47 % (n = 190/408). Crystalloids were the preferred initial fluid for all categories of severity; however, colloid use increased with severity (p < 0.001). Fluid volume also increased with severity (p = 0.001), with 74 % of respondents prescribing >4 L for AP with organ failure (OF). Clinicians treating 26-50 patients per year with AP were less likely to prescribe colloid for AP with OF (8 vs 43 %) (p = 0.001). Rate of fluid administration in AP with OF varied according to physicians' seniority (p = 0.004); consultants prescribed >4 L more than other groups (83 vs 68 %). Only 17 % of respondents reported the use of guidelines. This survey reveals significant variation in prescription of FT for AP, and aggressive FT is commonly prescribed for AP with OF. There is little adherence to published guidelines or best available evidence.

Prescribing benzodiazepines for noninstitutionalized elderly.

PubMed Central

Thomson, M.; Smith, W. A.

1995-01-01

OBJECTIVE: To describe benzodiazepine prescribing for elderly people living in the community in British Columbia, and to compare such prescribing with an indicator of current guidelines. DESIGN: Descriptive analysis of pharmacy billing data. SETTING: Province of British Columbia. PARTICIPANTS: All elderly persons (age 65 and older) dispensed benzodiazepines by community pharmacies in British Columbia during 1990. MAIN OUTCOME MEASURE: Potentially inappropriate prescriptions were defined by a maximum 2-month limit of 20 diazepam equivalents daily, as determined by the BC Drug Usage Review Program in consultation with experts in the field. Physicians' rates of potentially inappropriate prescribing were determined per 100 benzodiazepine prescriptions written. RESULTS: Almost 24% of elderly people in British Columbia were prescribed benzodiazepines at least once during 1990. Of these, 17.1% were given potentially inappropriate prescriptions. Physicians who prescribed benzodiazepines most frequently had the highest rates of potentially inappropriate prescriptions. CONCLUSION: Prescribing practice does not correspond with our indicator of current guidelines. PMID:7756916

The Hospitalist Perspective on Opioid Prescribing: A Qualitative Analysis

PubMed Central

Calcaterra, Susan L.; Drabkin, Anne D.; Leslie, Sarah E.; Doyle, Reina; Koester, Stephen; Frank, Joseph W.; Reich, Jennifer A.; Binswanger, Ingrid A.

2016-01-01

Background Pain is a frequent symptom among patients in the hospital. Pain management is a key quality indicator for hospitals and hospitalists are encouraged to frequently assess and treat pain. Optimal opioid prescribing, described as safe, patient-centered and informed opioid prescribing, may be at odds with the priorities of current hospital care, which focuses on patient-reported pain control rather than the potential long-term consequences of opioid use. Objective We aimed to understand physicians’ attitudes, beliefs and practices towards opioid prescribing during hospitalization and discharge. Design In-depth, semi-structured interviews Setting Two university hospitals, a safety-net hospital, a Veterans Affairs hospital, and a private hospital located in Denver, Colorado or Charleston, South Carolina. Participants Hospitalists (N=25) Measurements We systematically analyzed transcribed interviews and identified emerging themes using a team-based mixed inductive and deductive approach. Results Although hospitalists felt confident in their ability to control acute pain using opioid medications, they perceived limited success and satisfaction when managing acute exacerbations of chronic pain with opioids. Hospitalists recounted negative sentinel events which altered opioid prescribing practices in both the hospital setting and at the time of hospital discharge. Hospitalists described prescribing opioids as a pragmatic tool to facilitate hospital discharges or prevent readmissions. At times, this left them feeling conflicted about how this practice could impact the patient over the long term. Conclusions Strategies to provide adequate pain relief to hospitalized patients, which allow hospitalists to safely and optimally prescribe opioids while maintaining current standards of efficiency, are urgently needed. PMID:27157317

An Audit and Feedback Intervention for Reducing Antibiotic Prescribing in General Dental Practice: The RAPiD Cluster Randomised Controlled Trial.

PubMed

Elouafkaoui, Paula; Young, Linda; Newlands, Rumana; Duncan, Eilidh M; Elders, Andrew; Clarkson, Jan E; Ramsay, Craig R

2016-08-01

Dentists prescribe approximately 10% of antibiotics dispensed in UK community pharmacies. Despite clear clinical guidance, dentists often prescribe antibiotics inappropriately. This cluster-randomised controlled trial used routinely collected National Health Service (NHS) dental prescribing and treatment claim data to compare the impact of individualised audit and feedback (A&F) interventions on dentists' antibiotic prescribing rates. All 795 antibiotic prescribing NHS general dental practices in Scotland were included. Practices were randomised to the control (practices = 163; dentists = 567) or A&F intervention group (practices = 632; dentists = 1,999). A&F intervention practices were allocated to one of two A&F groups: (1) individualised graphical A&F comprising a line graph plotting an individual dentist's monthly antibiotic prescribing rate (practices = 316; dentists = 1,001); or (2) individualised graphical A&F plus a written behaviour change message synthesising and reiterating national guidance recommendations for dental antibiotic prescribing (practices = 316; dentists = 998). Intervention practices were also simultaneously randomised to receive A&F: (i) with or without a health board comparator comprising the addition of a line to the graphical A&F plotting the monthly antibiotic prescribing rate of all dentists in the health board; and (ii) delivered at 0 and 6 mo or at 0, 6, and 9 mo, giving a total of eight intervention groups. The primary outcome, measured by the trial statistician who was blinded to allocation, was the total number of antibiotic items dispensed per 100 NHS treatment claims over the 12 mo post-delivery of the baseline A&F. Primary outcome data was available for 152 control practices (dentists = 438) and 609 intervention practices (dentists = 1,550). At baseline, the number of antibiotic items prescribed per 100 NHS treatment claims was 8.3 in the control group and 8.5 in the intervention group. At follow-up, antibiotic prescribing had decreased by 0.4 antibiotic items per 100 NHS treatment claims in control practices and by 1.0 in intervention practices. This represents a significant reduction (-5.7%; 95% CI -10.2% to -1.1%; p = 0.01) in dentists' prescribing rate in the intervention group relative to the control group. Intervention subgroup analyses found a 6.1% reduction in the antibiotic prescribing rate of dentists who had received the written behaviour change message relative to dentists who had not (95% CI -10.4% to -1.9%; p = 0.01). There was no significant between-group difference in the prescribing rate of dentists who received a health board comparator relative to those who did not (-4.3%; 95% CI -8.6% to 0.1%; p = 0.06), nor between dentists who received A&F at 0 and 6 mo relative to those who received A&F at 0, 6, and 9 mo (0.02%; 95% CI -4.2% to 4.2%; p = 0.99). The key limitations relate to the use of routinely collected datasets which did not allow evaluation of any effects on inappropriate prescribing. A&F derived from routinely collected datasets led to a significant reduction in the antibiotic prescribing rate of dentists. Current Controlled Trials ISRCTN49204710.

Antihypertensive prescribing--a survey of general practice supervisors and registrars.

PubMed

Eastman, Peter

2008-11-01

Hypertension is a common problem in general practice. Prescribing guidelines vary, but generally favour thiazide diuretics as first line treatment for uncomplicated essential hypertension. This study looks at antihypertensive prescribing habits of primary care practitioners and their knowledge of prescribing guideline recommendations. General practitioner supervisors and registrars from the Sydney Institute of General Practice Education and Training completed an online survey between April and July 2007. In response to a clinical vignette, participants indicated which agent they would use as first line therapy. In addition, they described what they knew about existing prescribing guidelines for essential hypertension. One hundred and thirty-eight surveys were sent and 31 were returned completed. Angiotensin converting enzyme inhibitors were favoured as first line agents. Most believed current guidelines recommend more than one class of antihypertensive agent as appropriate for the initiation of single agent therapy. Angiotensin converting enzyme inhibitors were nominated most often as first line treatments recommended by guidelines. The study is limited by a small sample size, a low response rate and the fact that participants all came from a similar location. Prescribing habits in the study group were not consistent with two out of three Australian guidelines on management of hypertension. Further research may allow generalisation to the wider Australian general practice community and indicate underlying reasons for this inconsistency. Hypertension management is an important educational topic for general practice registrars and GPs.

Feedback on prescribing errors to junior doctors: exploring views, problems and preferred methods.

PubMed

Bertels, Jeroen; Almoudaris, Alex M; Cortoos, Pieter-Jan; Jacklin, Ann; Franklin, Bryony Dean

2013-06-01

Prescribing errors are common in hospital inpatients. However, the literature suggests that doctors are often unaware of their errors as they are not always informed of them. It has been suggested that providing more feedback to prescribers may reduce subsequent error rates. Only few studies have investigated the views of prescribers towards receiving such feedback, or the views of hospital pharmacists as potential feedback providers. Our aim was to explore the views of junior doctors and hospital pharmacists regarding feedback on individual doctors' prescribing errors. Objectives were to determine how feedback was currently provided and any associated problems, to explore views on other approaches to feedback, and to make recommendations for designing suitable feedback systems. A large London NHS hospital trust. To explore views on current and possible feedback mechanisms, self-administered questionnaires were given to all junior doctors and pharmacists, combining both 5-point Likert scale statements and open-ended questions. Agreement scores for statements regarding perceived prescribing error rates, opinions on feedback, barriers to feedback, and preferences for future practice. Response rates were 49% (37/75) for junior doctors and 57% (57/100) for pharmacists. In general, doctors did not feel threatened by feedback on their prescribing errors. They felt that feedback currently provided was constructive but often irregular and insufficient. Most pharmacists provided feedback in various ways; however some did not or were inconsistent. They were willing to provide more feedback, but did not feel it was always effective or feasible due to barriers such as communication problems and time constraints. Both professional groups preferred individual feedback with additional regular generic feedback on common or serious errors. Feedback on prescribing errors was valued and acceptable to both professional groups. From the results, several suggested methods of providing feedback on prescribing errors emerged. Addressing barriers such as the identification of individual prescribers would facilitate feedback in practice. Research investigating whether or not feedback reduces the subsequent error rate is now needed.

Prescribing Data in General Practice Demonstration (PDGPD) project--a cluster randomised controlled trial of a quality improvement intervention to achieve better prescribing for chronic heart failure and hypertension.

PubMed

Williamson, Margaret; Cardona-Morrell, Magnolia; Elliott, Jeffrey D; Reeve, James F; Stocks, Nigel P; Emery, Jon; Mackson, Judith M; Gunn, Jane M

2012-08-23

Research literature consistently documents that scientifically based therapeutic recommendations are not always followed in the hospital or in the primary care setting. Currently, there is evidence that some general practitioners in Australia are not prescribing appropriately for patients diagnosed with 1) hypertension (HT) and 2) chronic heart failure (CHF). The objectives of this study were to improve general practitioner's drug treatment management of these patients through feedback on their own prescribing and small group discussions with peers and a trained group facilitator. The impact evaluation includes quantitative assessment of prescribing changes at 6, 9, 12 and 18 months after the intervention. A pragmatic multi site cluster RCT began recruiting practices in October 2009 to evaluate the effects of a multi-faceted quality improvement (QI) intervention on prescribing practice among Australian general practitioners (GP) in relation to patients with CHF and HT. General practices were recruited nationally through General Practice Networks across Australia. Participating practices were randomly allocated to one of three groups: two groups received the QI intervention (the prescribing indicator feedback reports and small group discussion) with each group undertaking the clinical topics (CHF and HT) in reverse order to the other. The third group was waitlisted to receive the intervention 6 months later and acted as a "control" for the other two groups.De-identified data on practice, doctor and patient characteristics and their treatment for CHF and HT are extracted at six-monthly intervals before and after the intervention. Post-test comparisons will be conducted between the intervention and control arms using intention to treat analysis and models that account for clustering of practices in a Network and clustering of patients within practices and GPs. This paper describes the study protocol for a project that will contribute to the development of acceptable and sustainable methods to promote QI activities within routine general practice, enhance prescribing practices and improve patient outcomes in the context of CHF and HT. Australian New Zealand Clinical Trials Registry (ANZCTR), Trial # 320870.

Prescribing Data in General Practice Demonstration (PDGPD) project - a cluster randomised controlled trial of a quality improvement intervention to achieve better prescribing for chronic heart failure and hypertension

PubMed Central

2012-01-01

Background Research literature consistently documents that scientifically based therapeutic recommendations are not always followed in the hospital or in the primary care setting. Currently, there is evidence that some general practitioners in Australia are not prescribing appropriately for patients diagnosed with 1) hypertension (HT) and 2) chronic heart failure (CHF). The objectives of this study were to improve general practitioner’s drug treatment management of these patients through feedback on their own prescribing and small group discussions with peers and a trained group facilitator. The impact evaluation includes quantitative assessment of prescribing changes at 6, 9, 12 and 18 months after the intervention. Methods A pragmatic multi site cluster RCT began recruiting practices in October 2009 to evaluate the effects of a multi-faceted quality improvement (QI) intervention on prescribing practice among Australian general practitioners (GP) in relation to patients with CHF and HT. General practices were recruited nationally through General Practice Networks across Australia. Participating practices were randomly allocated to one of three groups: two groups received the QI intervention (the prescribing indicator feedback reports and small group discussion) with each group undertaking the clinical topics (CHF and HT) in reverse order to the other. The third group was waitlisted to receive the intervention 6 months later and acted as a “control” for the other two groups. De-identified data on practice, doctor and patient characteristics and their treatment for CHF and HT are extracted at six-monthly intervals before and after the intervention. Post-test comparisons will be conducted between the intervention and control arms using intention to treat analysis and models that account for clustering of practices in a Network and clustering of patients within practices and GPs. Discussion This paper describes the study protocol for a project that will contribute to the development of acceptable and sustainable methods to promote QI activities within routine general practice, enhance prescribing practices and improve patient outcomes in the context of CHF and HT. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR), Trial # 320870. PMID:22913571

Rational prescribing in paediatrics in a resource-limited setting.

PubMed

Risk, Rachel; Naismith, Hamish; Burnett, Alexander; Moore, Sophie E; Cham, Mamady; Unger, Stefan

2013-07-01

There is evidence of inappropriate medication use, causing unnecessary costs for health systems, particularly those with limited resources. Overprescription is commonly reported and can lead to antibiotic resistance. Prescribing patterns differ between countries; little is known about paediatric prescribing practices in Africa. To investigate prescribing practices in children in The Gambia, West Africa. A retrospective survey of prescribing practices in children under 5 years of age based on WHO protocol DAP/93.1 was conducted. Twenty government-run health centres across all six regions in The Gambia were assessed. The first 10 encounters each month in 2010 were recorded. For each encounter, patient demographics, diagnoses and medications were recorded as per protocol. Two thousand and four hundred patient encounters were included. The mean number of medications per encounter was 2.2 (median 2.0, IQR 2.0-3.0). Across different geographical regions within The Gambia antibiotics were prescribed in 63.4% (IQR 62.8-65.8%) and micronutrients in 21.7% (IQR 15.3-27.1%) of patient encounters. There was evidence of high antibiotic prescription in children with cough and coryzal symptoms (54.5%; IQR 35.8-59.0%) and simple diarrhoea without dehydration (44.8%; IQR 36.7-61.3%). 74.8% (IQR 71.8-76.1%) of medications were prescribed generically. The study showed an overprescription of antibiotics and substantial usage of micronutrients despite a lack of international evidence-based guidelines. Cost-effective interventions to improve prescribing practices are called for and more studies with a focus on rational prescribing in paediatrics in low-income settings are urgently required to fill the gap in current knowledge.

Nurse prescribing ethics and medical marketing.

PubMed

Adams, J

This article suggests that nurse prescribers require an awareness of key concepts in ethics, such as deontology and utilitarianism to reflect on current debates and contribute to them. The principles of biomedical ethics have also been influential in the development of professional codes of conduct. Attention is drawn to the importance of the Association of the British Pharmaceutical Industry's code of practice for the pharmaceutical industry in regulating marketing aimed at prescribers.

Neurologists' Views of Current Medications: Spasticity and Athetosis

ERIC Educational Resources Information Center

Obringer, S. John; Coffey, Kenneth

2008-01-01

Medications to treat individuals with cerebral palsy have increased significantly over the last few decades. The purpose of this article was to randomly survey practicing neurologists on a national level to determine prescribing patterns for both spasticity and athetosis. The results indicated that the most frequently prescribed medication for…

An Audit and Feedback Intervention for Reducing Antibiotic Prescribing in General Dental Practice: The RAPiD Cluster Randomised Controlled Trial

PubMed Central

Elouafkaoui, Paula; Young, Linda; Newlands, Rumana; Duncan, Eilidh M.; Elders, Andrew; Ramsay, Craig R.

2016-01-01

Background Dentists prescribe approximately 10% of antibiotics dispensed in UK community pharmacies. Despite clear clinical guidance, dentists often prescribe antibiotics inappropriately. This cluster-randomised controlled trial used routinely collected National Health Service (NHS) dental prescribing and treatment claim data to compare the impact of individualised audit and feedback (A&F) interventions on dentists’ antibiotic prescribing rates. Methods and Findings All 795 antibiotic prescribing NHS general dental practices in Scotland were included. Practices were randomised to the control (practices = 163; dentists = 567) or A&F intervention group (practices = 632; dentists = 1,999). A&F intervention practices were allocated to one of two A&F groups: (1) individualised graphical A&F comprising a line graph plotting an individual dentist’s monthly antibiotic prescribing rate (practices = 316; dentists = 1,001); or (2) individualised graphical A&F plus a written behaviour change message synthesising and reiterating national guidance recommendations for dental antibiotic prescribing (practices = 316; dentists = 998). Intervention practices were also simultaneously randomised to receive A&F: (i) with or without a health board comparator comprising the addition of a line to the graphical A&F plotting the monthly antibiotic prescribing rate of all dentists in the health board; and (ii) delivered at 0 and 6 mo or at 0, 6, and 9 mo, giving a total of eight intervention groups. The primary outcome, measured by the trial statistician who was blinded to allocation, was the total number of antibiotic items dispensed per 100 NHS treatment claims over the 12 mo post-delivery of the baseline A&F. Primary outcome data was available for 152 control practices (dentists = 438) and 609 intervention practices (dentists = 1,550). At baseline, the number of antibiotic items prescribed per 100 NHS treatment claims was 8.3 in the control group and 8.5 in the intervention group. At follow-up, antibiotic prescribing had decreased by 0.4 antibiotic items per 100 NHS treatment claims in control practices and by 1.0 in intervention practices. This represents a significant reduction (-5.7%; 95% CI -10.2% to -1.1%; p = 0.01) in dentists' prescribing rate in the intervention group relative to the control group. Intervention subgroup analyses found a 6.1% reduction in the antibiotic prescribing rate of dentists who had received the written behaviour change message relative to dentists who had not (95% CI -10.4% to -1.9%; p = 0.01). There was no significant between-group difference in the prescribing rate of dentists who received a health board comparator relative to those who did not (-4.3%; 95% CI -8.6% to 0.1%; p = 0.06), nor between dentists who received A&F at 0 and 6 mo relative to those who received A&F at 0, 6, and 9 mo (0.02%; 95% CI -4.2% to 4.2%; p = 0.99). The key limitations relate to the use of routinely collected datasets which did not allow evaluation of any effects on inappropriate prescribing. Conclusions A&F derived from routinely collected datasets led to a significant reduction in the antibiotic prescribing rate of dentists. Trial Registration Current Controlled Trials ISRCTN49204710 PMID:27575599

Enhancing the quality of antibiotic prescribing in Primary Care: Qualitative evaluation of a blended learning intervention

PubMed Central

2010-01-01

Background The Stemming the Tide of Antibiotic Resistance (STAR) Educational Program aims to enhance the quality of antibiotic prescribing and raise awareness about antibiotic resistance among general medical practitioners. It consists of a seven part, theory-based blended learning program that includes online reflection on clinicians' own practice, presentation of research evidence and guidelines, a practice-based seminar focusing on participants' own antibiotic prescribing and resistance rates in urine samples sent from their practice, communication skills training using videos of simulated patients in routine surgeries, and participation in a web forum. Effectiveness was evaluated in a randomised controlled trial in which 244 GPs and Nurse Practitioners and 68 general practices participated. This paper reports part of the process evaluation of that trial. Methods Semi-structured, digitally recorded, and transcribed telephone interviews with 31 purposively sampled trial participants analysed using thematic content analysis. Results The majority of participants reported increased awareness of antibiotic resistance, greater self-confidence in reducing antibiotic prescribing and at least some change in consultation style and antibiotic prescribing behaviour. Reported practical changes included adopting a practice-wide policy of antibiotic prescription reduction. Many GPs also reported increased insight into patients' expectations, ultimately contributing to improved doctor-patient rapport. The components of the intervention put forward as having the greatest influence on changing clinician behaviour were the up-to-date research evidence resources, simple and effective communication skills presented in on-line videos, and presentation of the practice's own antibiotic prescribing levels combined with an overview of local resistance data. Conclusion Participants regarded this complex blended learning intervention acceptable and feasible, and reported wide-ranging, positive changes in attitudes and clinical practice as a result of participating in the STAR Educational Program. Trial registration Current Controlled Trials ISRCTN63355948 PMID:20459655

Effectiveness of medicines review with web-based pharmaceutical treatment algorithms in reducing potentially inappropriate prescribing in older people in primary care: a cluster randomized trial (OPTI-SCRIPT study protocol).

PubMed

Clyne, Barbara; Bradley, Marie C; Smith, Susan M; Hughes, Carmel M; Motterlini, Nicola; Clear, Daniel; McDonnell, Ronan; Williams, David; Fahey, Tom

2013-03-13

Potentially inappropriate prescribing in older people is common in primary care and can result in increased morbidity, adverse drug events, hospitalizations and mortality. In Ireland, 36% of those aged 70 years or over received at least one potentially inappropriate medication, with an associated expenditure of over €45 million.The main objective of this study is to determine the effectiveness and acceptability of a complex, multifaceted intervention in reducing the level of potentially inappropriate prescribing in primary care. This study is a pragmatic cluster randomized controlled trial, conducted in primary care (OPTI-SCRIPT trial), involving 22 practices (clusters) and 220 patients. Practices will be allocated to intervention or control arms using minimization, with intervention participants receiving a complex multifaceted intervention incorporating academic detailing, medicines review with web-based pharmaceutical treatment algorithms that provide recommended alternative treatment options, and tailored patient information leaflets. Control practices will deliver usual care and receive simple patient-level feedback on potentially inappropriate prescribing. Routinely collected national prescribing data will also be analyzed for nonparticipating practices, acting as a contemporary national control. The primary outcomes are the proportion of participant patients with potentially inappropriate prescribing and the mean number of potentially inappropriate prescriptions per patient. In addition, economic and qualitative evaluations will be conducted. This study will establish the effectiveness of a multifaceted intervention in reducing potentially inappropriate prescribing in older people in Irish primary care that is generalizable to countries with similar prescribing challenges. Current controlled trials ISRCTN41694007.

Implementation in action: how Australian Exercise Physiologists approach exercise prescription for people with mental illness.

PubMed

Stanton, Robert; Rosenbaum, Simon; Lederman, Oscar; Happell, Brenda

2018-04-01

Accredited Exercise Physiologists (AEPs) are trained to deliver exercise and physical activity interventions for people with chronic and complex health conditions including those with mental illness. However, their views on exercise for mental illness, their exercise prescription practices, and need for further training are unknown. To examine the way in which Australian AEPs prescribe exercise for people with mental illness. Eighty-one AEPs (33.3 ± 10.4 years) completed an online version of the Exercise in Mental Illness Questionnaire. Findings are reported using descriptive statistics. AEPs report a high level of knowledge and confidence in prescribing exercise for people with mental illness. AEPs rate exercise to be at least of equal value to many established treatments for mental illness, and frequently prescribe exercise based on current best-practice principles. A need for additional training was identified. The response rate was low (2.4%) making generalisations from the findings difficult. Exercise prescription practices utilised by AEPs are consistent with current best-practice guidelines and there is frequent consultation with consumers to individualise exercise based on their preferences and available resources. Further training is deemed important.

Intravenous fluid prescription practices among pediatric residents in Korea.

PubMed

Lee, Jiwon M; Jung, Younghwa; Lee, Se Eun; Lee, Jun Ho; Kim, Kee Hyuck; Koo, Ja Wook; Park, Young Seo; Cheong, Hae Il; Ha, Il-Soo; Choi, Yong; Kang, Hee Gyung

2013-07-01

Recent studies have established the association between hypotonic fluids administration and hospital-acquired hyponatremia in children. The present paper investigated the pattern of current practice in intravenous fluid prescription among Korean pediatric residents, to underscore the need for updated education. A survey-based analysis was carried out. Pediatric residents at six university hospitals in Korea completed a survey consisting of four questions. Each question proposed a unique scenario in which the respondents had to prescribe either a hypotonic or an isotonic fluid for the patient. Ninety-one responses were collected and analyzed. In three of the four scenarios, a significant majority prescribed the hypotonic fluids (98.9%, 85.7%, and 69.2%, respectively). Notably, 69.2% of the respondents selected the hypotonic fluids for postoperative management. Almost all (96.7%) selected the isotonic fluids for hydration therapy. In the given scenarios, the majority of Korean pediatric residents would prescribe a hypotonic fluid, except for initial hydration. The current state of pediatric fluid management, notably, heightens the risk of hospital-acquired hyponatremia. Updated clinical practice education on intravenous fluid prescription, therefore, is urgently required.

The path of least resistance in oral surgery.

PubMed

Fee, Laura

2016-01-01

Antibiotic resistance is an imminent threat to worldwide public health. Dental professionals must demonstrate judicious use of antibiotics and educate their patients about the risks associated with their overuse. PURPOSE OF THE PAPER: To encourage the dental profession to prescribe responsibly in order to optimise the use of antibiotics in oral surgery. Antibiotic stewardship programmes are recommended to help reduce the emergence of infections that are multidrug-resistant. Clinical practice audits are encouraged to help dentists ensure conservative prescribing patterns. The dental profession has a duty of care to prescribe antibiotics in adherence with current best practice oral surgery guidelines. The dental profession must show leadership in slowing antibiotic resistance by pledgina to safeguard their appropriate use.

Prescribe to Prevent: Overdose Prevention and Naloxone Rescue Kits for Prescribers and Pharmacists

PubMed Central

Lim, Jamie K.; Bratberg, Jeffrey P.; Davis, Corey S.; Green, Traci C.; Walley, Alexander Y.

2016-01-01

In March of 2015, the United States Department of Health and Human Services identified 3 priority areas to reduce opioid use disorders and overdose, which are as follows: opioid-prescribing practices; expanded use and distribution of naloxone; and expansion of medication-assisted treatment. In this narrative review of overdose prevention and the role of prescribers and pharmacists in distributing naloxone, we address these priority areas and present a clinical scenario within the review involving a pharmacist, a patient with chronic pain and anxiety, and a primary care physician. We also discuss current laws related to naloxone prescribing and dispensing. This review was adapted from the Prescribe to Prevent online continuing medical education module created for prescribers and pharmacists (http://www.opioidprescribing.com/naloxone_module_1-landing). PMID:27261669

48 CFR 9905.501-50 - Techniques for application.

Code of Federal Regulations, 2010 CFR

2010-10-01

... of the date of final agreement on price, as shown on the signed certificate of current cost or... situation. Accordingly, it is neither appropriate nor practical to prescribe a single set of accounting practices which would be consistent in all situations with the practices of estimating costs. Therefore, the...

Implementing nurse prescribing: a case study in diabetes.

PubMed

Stenner, Karen; Carey, Nicola; Courtenay, Molly

2010-03-01

This paper is a report of a study exploring the views of nurses and team members on the implementation of nurse prescribing in diabetes services. Nurse prescribing is adopted as a means of improving service efficiency, particularly where demand outstretches resources. Although factors that support nurse prescribing have been identified, it is not known how these function within specific contexts. This is important as its uptake and use varies according to mode of prescribing and area of practice. A case study was undertaken in nine practice settings across England where nurses prescribed medicines for patients with diabetes. Thematic analysis was conducted on qualitative data from 31 semi-structured interviews undertaken between 2007 and 2008. Participants were qualified nurse prescribers, administrative staff, physicians and non-nurse prescribers. Nurses prescribed more often following the expansion of nurse independent prescribing rights in 2006. Initial implementation problems had been resolved and few current problems were reported. As nurses' roles were well-established, no major alterations to service provision were required to implement nurse prescribing. Access to formal and informal resources for support and training were available. Participants were accepting and supportive of this initiative to improve the efficiency of diabetes services. The main factors that promoted implementation of nurse prescribing in this setting were the ability to prescribe independently, acceptance of the prescribing role, good working relationships between doctors and nurses, and sound organizational and interpersonal support. The history of established nursing roles in diabetes care, and increasing service demand, meant that these diabetes services were primed to assimilate nurse prescribing.

Statin initiation by GPs in WA--a structured vignette study.

PubMed

Stafford, Leanne; Harmer, Nichola; Dhaliwal, Satvinder; Jiwa, Moyez

2009-09-01

Statins are recommended for all patients with known coronary heart disease. This pilot study investigated statin initiation by a Western Australian general practitioner cohort and the influence of prescriber and patient characteristics on prescribing. A structured vignette questionnaire was posted to members of the Fremantle GP Network. Respondents indicated their prescribing decisions for nine hypothetical patients who had recently suffered a myocardial infarction. Data analysis utilised logistic regression analyses and a generalised linear model with a logit link function. Fifty-five GPs responded (16.0% response rate). In over 20% of cases a statin was not prescribed. Male (OR 4.71; 95% CI: 1.24-17.87) and GPs with fewer years in practice (4.50; 1.21-16.77) were more likely to prescribe appropriately. Younger patients (2.21; 1.38-3.53), and those with diabetes (1.74; 1.09-2.76) or hypercholesterolaemia (4.81; 2.88-8.03) were more likely to receive therapy. Prescribing practices failed to comply with current guidelines in a significant number of cases. Further research to confirm these findings is warranted.

Trends and variation in prescribing of low-priority treatments identified by NHS England: a cross-sectional study and interactive data tool in English primary care.

PubMed

Walker, Alex J; Curtis, Helen J; Bacon, Seb; Croker, Richard; Goldacre, Ben

2018-06-01

Objectives NHS England recently announced a consultation seeking to discourage the use of treatments it considers to be low-value. We set out to produce an interactive data resource to show savings in each NHS general practice and to assess the current use of these treatments, their change in use over time, and the extent and reasons for variation in such prescribing. Design Cross-sectional analysis. Setting English primary care. Participants English general practices. Main outcome measures We determined the cost per 1000 patients for prescribing of each of 18 treatments identified by NHS England for each month from July 2012 to June 2017, and also aggregated over the most recent year to assess total cost and variation among practices. We used mixed effects linear regression to determine factors associated with cost of prescribing. Results Spend on low-value treatments was £153.5 m in the last year, across 5.8 m prescriptions (mean, £26 per prescription). Among individual treatments, liothyronine had the highest prescribing cost at £29.6 m, followed by trimipramine (£20.2 m). Over time, the overall total number of low-value prescriptions decreased, but the cost increased, although this varied greatly between treatments. Three treatment areas increased in cost and two increased in volume, all others reduced in cost and volume. Annual practice level spending varied widely (median, £2262 per thousand patients; interquartile range £1439 to £3298). Proportion of patients over 65 was strongly associated with low-value prescribing, as was Clinical Commissioning Group. Our interactive data tool was deployed to OpenPrescribing.net where monthly updated figures and graphs can be viewed. Conclusions Prescribing of low-value treatments is extensive but varies widely by treatment, geographic area and individual practice. Despite a fall in prescription numbers, the overall cost of prescribing for low-value items has risen. Prescribing behaviour is clustered by Clinical Commissioning Group, which may represent variation in the optimisation efficiency of medicines, or in some cases access inequality.

Off-Label Baclofen Prescribing Practices among French Alcohol Specialists: Results of a National Online Survey

PubMed Central

Rolland, Benjamin; Paille, François; Fleury, Benoit; Cottencin, Olivier; Benyamina, Amine; Aubin, Henri-Jean

2014-01-01

Objective To evaluate, among alcohol specialists belonging to the Société Française d’Alcoologie (SFA), i.e., the French Alcohol Society, the proportion of physicians who prescribed off-label baclofen for alcohol use disorders (AUDs). The secondary objective was to depict the features of individual prescribing and monitoring practices. Methods On-line survey among 484 French alcohol specialists. Physicians were asked whether they prescribed baclofen for AUDs. If they did not, the reasons for this choice were investigated. If they did, the features of the physician’s prescribing practice were explored, including the number of patients treated, the mean and maximum doses, the monitoring precautions and the pharmacovigilance reporting. Participants were also asked about their empirical findings on HDB’s efficacy and safety. Results In total, 302 physicians (response rate of 62.4%) participated in the survey. Data from 296 participants were analysed, representing 59.4% of all active prescribing physicians belonging to the SFA. HDB use was declared by 74.6% of participants (mean dose 109.5±43.6 mg/d; maximum dose 188±93.3 mg/d). However, 79.2% of prescribers had treated less than 30 patients, and 67.8% used HDB as a second-line medication. Although HDB was perceived as more efficacious than approved drugs by 54.3% of prescribers, it was also declared less safe by 62.8%. Nonetheless, 79.7% of prescribers had never filed any pharmacovigilance report. Non-prescribers (25.6%) were primarily deterred by the current lack of scientific data and official regulation. Conclusion A majority of French alcohol specialists reported using HDB, although often on a limited number of their patients. HDB was considered efficacious but also potentially hazardous. Despite this, physicians reported minimal safety data to the health security system. While French health authorities are planning to draft a specific regulatory measure for framing off-label HDB prescribing practices, the sustained education of prescribers on spontaneous pharmacovigilance reporting should be enhanced. PMID:24887094

Current trends in treatment of hypertension in Karachi and cost minimization possibilities.

PubMed

Hussain, Izhar M; Naqvi, Baqir S; Qasim, Rao M; Ali, Nasir

2015-01-01

This study finds out drug usage trends in Stage I Hypertensive Patients without any compelling indications in Karachi, deviations of current practices from evidence based antihypertensive therapeutic guidelines and looks for cost minimization opportunities. In the present study conducted during June 2012 to August 2012, two sets were used. Randomized stratified independent surveys were conducted in doctors and general population - including patients, using pretested questionnaires. Sample sizes for doctors and general population were 100 and 400 respectively. Statistical analysis was conducted on Statistical Package for Social Science (SPSS). Financial impact was also analyzed. On the basis of patients' doctors' feedback, Beta Blockers, and Angiotensin Converting Enzyme Inhibitors were used more frequently than other drugs. Thiazides and low-priced generics were hardly prescribed. Beta blockers were prescribed widely and considered cost effective. This trend increases cost by two to ten times. Feedbacks showed that therapeutic guidelines were not followed by the doctors practicing in the community and hospitals in Karachi. Thiazide diuretics were hardly used. Beta blockers were widely prescribed. High priced market leaders or expensive branded generics were commonly prescribed. Therefore, there are great opportunities for cost minimization by using evidence-based clinically effective and safe medicines.

Preserving the 'commons': addressing the sustainable use of antibiotics through an economic lens.

PubMed

Morel, C M; Edwards, S E; Harbarth, S

2017-10-01

As the growth of antibiotic resistance has resulted in large part from widespread use of antibiotics, every effort must be made to ensure their sustainable use. This narrative review aims to assess the potential contribution of health economic analyses to sustainable use efforts. The work draws on existing literature and experience with health economic tools. The study examines some of the weaknesses in the health, regulatory, and industry arenas that could contribute to inappropriate or suboptimal prescribing of antibiotics and describes how economic analysis could be used to improve current practice by comparing both costs and health outcomes to maximize societal wellbeing over the longer-term. It finds that economic considerations underpinning current antibiotic prescribing strategies are incomplete and short-termist, with the result that they may foster suboptimal use. It also stresses that perverse incentives that drive antibiotic sales and inappropriate prescribing practices must be dis-entangled for sustainable use policies to gain traction. Finally, payment structures can be used to re-align incentives and promote optimal prescribing and sustainable use more generally. In particular, eliminating or altering reimbursement differentials could help steer clinical practice more deliberately towards the minimization of selection pressure and the resulting levels of antibiotic resistance. This work highlights the need for appropriately designed cost-effectiveness analyses, incentives analysis, and novel remuneration systems to underpin sustainable use policies both within and beyond the health sector. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

Electronic information and clinical decision support for prescribing: state of play in Australian general practice

PubMed Central

Robertson, Jane; Moxey, Annette J; Newby, David A; Gillies, Malcolm B; Williamson, Margaret; Pearson, Sallie-Anne

2011-01-01

Background. Investments in eHealth worldwide have been mirrored in Australia, with >90% of general practices computerized. Recent eHealth incentives promote the use of up to date electronic information sources relevant to general practice with flexibility in mode of access. Objective. To determine GPs’ access to and use of electronic information sources and computerized clinical decision support systems (CDSSs) for prescribing. Methods. Semi-structured interviews were conducted with 18 experienced GPs and nine GP trainees in New South Wales, Australia in 2008. A thematic analysis of interview transcripts was undertaken. Results. Information needs varied with clinical experience, and people resources (specialists, GP peers and supervisors for trainees) were often preferred over written formats. Experienced GPs used a small number of electronic resources and accessed them infrequently. Familiarity from training and early clinical practice and easy access were dominant influences on resource use. Practice time constraints meant relevant information needed to be readily accessible during consultations, requiring integration or direct access from prescribing software. Quality of electronic resource content was assumed and cost a barrier for some GPs. Conclusions. The current Australian practice incentives do not prescribe which information resources GPs should use. Without integration into practice computing systems, uptake and routine use seem unlikely. CDSS developments must recognize the time pressures of practice, preference for integration and cost concerns. Minimum standards are required to ensure that high-quality information resources are integrated and regularly updated. Without standards, the anticipated benefits of computerization on patient safety and health outcomes will be uncertain. PMID:21109619

Impact of Antimicrobial Stewardship on Physician Practice in a Geriatric Facility

PubMed Central

Kassett, Nina; Sham, Rosalind; Aleong, Rosanne; Yang, Daisy; Kirzner, Michael; Craft, Aidlee

2016-01-01

Background There is a paucity of literature describing the implementation of antimicrobial stewardship programs (ASPs) in long-term care (LTC) facilities. The current study evaluated the impact of an ASP that was implemented across a geriatric facility, which included an inpatient specialty hospital and an LTC facility. The program included prospective audits with feedback, multidisciplinary education, information technology interventions, and guideline development. Objective To investigate the impact of the ASP on physicians’ prescribing practices in this geriatric facility. Methods Utilization data for antibiotics commonly used to treat urinary tract infections were retrieved for the period September 1, 2011, to August 31, 2013. The study examined whether there were significant changes in overall antibiotic use, ciprofloxacin use, and physician prescribing behaviour after program implementation in September 2012. Results There was no significant change in the total number of antibiotic prescriptions for urinary tract infections in the hospital or the LTC facility after ASP implementation. Significant reductions were seen in the average days of therapy initially prescribed and the actual days of therapy after ASP implementation in the LTC facility but not the hospital. Across both facilities, significant reductions were seen in the number of ciprofloxacin prescriptions. Conclusions The current study showed that an ASP can affect physicians’ antibiotic prescribing behaviour and antibiotic usage in an LTC environment. PMID:28123192

Is use of homeopathy associated with poor prescribing in English primary care? A cross-sectional study.

PubMed

Walker, Alex J; Croker, Richard; Bacon, Seb; Ernst, Edzard; Curtis, Helen J; Goldacre, Ben

2018-05-01

Objectives Prescribing of homeopathy still occurs in a small minority of English general practices. We hypothesised that practices that prescribe any homeopathic preparations might differ in their prescribing of other drugs. Design Cross-sectional analysis. Setting English primary care. Participants English general practices. Main outcome measures We identified practices that made any homeopathy prescriptions over six months of data. We measured associations with four prescribing and two practice quality indicators using multivariable logistic regression. Results Only 8.5% of practices (644) prescribed homeopathy between December 2016 and May 2017. Practices in the worst-scoring quartile for a composite measure of prescribing quality (>51.4 mean percentile) were 2.1 times more likely to prescribe homeopathy than those in the best category (<40.3) (95% confidence interval: 1.6-2.8). Aggregate savings from the subset of these measures where a cost saving could be calculated were also strongly associated (highest vs. lowest quartile multivariable odds ratio: 2.9, confidence interval: 2.1-4.1). Of practices spending the most on medicines identified as 'low value' by NHS England, 12.8% prescribed homeopathy, compared to 3.9% for lowest spenders (multivariable odds ratio: 2.6, confidence interval: 1.9-3.6). Of practices in the worst category for aggregated price-per-unit cost savings, 12.7% prescribed homeopathy, compared to 3.5% in the best category (multivariable odds ratio: 2.7, confidence interval: 1.9-3.9). Practice quality outcomes framework scores and patient recommendation rates were not associated with prescribing homeopathy (odds ratio range: 0.9-1.2). Conclusions Even infrequent homeopathy prescribing is strongly associated with poor performance on a range of prescribing quality measures, but not with overall patient recommendation or quality outcomes framework score. The association is unlikely to be a direct causal relationship, but may reflect underlying practice features, such as the extent of respect for evidence-based practice, or poorer stewardship of the prescribing budget.

Protocol for the New Medicine Service Study: a randomized controlled trial and economic evaluation with qualitative appraisal comparing the effectiveness and cost effectiveness of the New Medicine Service in community pharmacies in England

PubMed Central

2013-01-01

Background Medication non-adherence is considered an important cause of morbidity and mortality in primary care. This study aims to determine the effectiveness, cost effectiveness and acceptability of a complex intervention delivered by community pharmacists, the New Medicine Service (NMS), compared with current practice in reducing non-adherence to, and problems with, newly prescribed medicines for chronic conditions. Methods/design Research subject group: patients aged 14 years and above presenting in a community pharmacy for a newly prescribed medicine for asthma/chronic obstructive pulmonary disease (COPD); hypertension; type 2 diabetes or anticoagulant/antiplatelet agents in two geographical regions in England. Design: parallel group patient-level pragmatic randomized controlled trial. Interventions: patients randomized to either: (i) current practice; or (ii) NMS intervention comprising pharmacist-delivered support for a newly prescribed medicine. Primary outcomes: proportion of adherent patients at six, ten and 26 weeks from the date of presenting their prescriptions at the pharmacy; cost effectiveness of the intervention versus current practice at 10 weeks and 26 weeks; in-depth qualitative understanding of the operationalization of NMS in pharmacies. Secondary outcomes: impact of NMS on: patients’ understanding of their medicines, pharmacovigilance, interprofessional and patient-professional relationships and experiences of service users and stakeholders. Economic analysis: Trial-based economic analysis (cost per extra adherent patient) and long-term modeling of costs and health effects (cost per quality-adjusted-life-year) will be conducted from the perspective of National Health Service (NHS) England, comparing NMS with current practice. Qualitative analysis: a qualitative study of NMS implementation in different community settings, how organizational influences affect NMS delivery, patterns of NMS consultations and experiences of professionals and patients participating in NMS, and patients receiving current practice. Sample size: 250 patients in each treatment arm would provide at least 80% power (two-tailed alpha of 0.05) to demonstrate a reduction in patient-reported non-adherence from 20% to 10% in the NMS arm compared with current practice, assuming a 20% drop-out rate. Discussion At the time of submission of this article, 58 community pharmacies have been recruited and the interventions are being delivered. Analysis has not yet been undertaken. Trial registration Current controlled trials: ISRCTN23560818 Clinical Trials US (clinicaltrials.gov): NCT01635361 PMID:24289059

Protocol for the New Medicine Service Study: a randomized controlled trial and economic evaluation with qualitative appraisal comparing the effectiveness and cost effectiveness of the New Medicine Service in community pharmacies in England.

PubMed

Boyd, Matthew; Waring, Justin; Barber, Nick; Mehta, Rajnikant; Chuter, Antony; Avery, Anthony J; Salema, Nde-Eshimuni; Davies, James; Latif, Asam; Tanajewski, Lukasz; Elliott, Rachel A

2013-12-01

Medication non-adherence is considered an important cause of morbidity and mortality in primary care. This study aims to determine the effectiveness, cost effectiveness and acceptability of a complex intervention delivered by community pharmacists, the New Medicine Service (NMS), compared with current practice in reducing non-adherence to, and problems with, newly prescribed medicines for chronic conditions. Research subject group: patients aged 14 years and above presenting in a community pharmacy for a newly prescribed medicine for asthma/chronic obstructive pulmonary disease (COPD); hypertension; type 2 diabetes or anticoagulant/antiplatelet agents in two geographical regions in England. parallel group patient-level pragmatic randomized controlled trial. patients randomized to either: (i) current practice; or (ii) NMS intervention comprising pharmacist-delivered support for a newly prescribed medicine. proportion of adherent patients at six, ten and 26 weeks from the date of presenting their prescriptions at the pharmacy; cost effectiveness of the intervention versus current practice at 10 weeks and 26 weeks; in-depth qualitative understanding of the operationalization of NMS in pharmacies. impact of NMS on: patients' understanding of their medicines, pharmacovigilance, interprofessional and patient-professional relationships and experiences of service users and stakeholders.Economic analysis: Trial-based economic analysis (cost per extra adherent patient) and long-term modeling of costs and health effects (cost per quality-adjusted-life-year) will be conducted from the perspective of National Health Service (NHS) England, comparing NMS with current practice.Qualitative analysis: a qualitative study of NMS implementation in different community settings, how organizational influences affect NMS delivery, patterns of NMS consultations and experiences of professionals and patients participating in NMS, and patients receiving current practice. 250 patients in each treatment arm would provide at least 80% power (two-tailed alpha of 0.05) to demonstrate a reduction in patient-reported non-adherence from 20% to 10% in the NMS arm compared with current practice, assuming a 20% drop-out rate. At the time of submission of this article, 58 community pharmacies have been recruited and the interventions are being delivered. Analysis has not yet been undertaken. Current controlled trials: ISRCTN23560818. Clinical Trials US (clinicaltrials.gov): NCT01635361.

Implementing autonomous clinical nurse specialist prescriptive authority: a competency-based transition model.

PubMed

Klein, Tracy Ann

2012-01-01

The purpose of this study was to identify and implement a competency-based regulatory model that transitions clinical nurse specialists (CNSs) to autonomous prescriptive authority pursuant to change in state law. Prescriptive authority for CNSs may be optional or restricted under current state law. Implementation of the APRN Consensus Model includes full prescriptive authority for all advanced practice registered nurses. Clinical nurse specialists face barriers to establishing their prescribing authority when laws or practice change. Identification of transition models will assist CNSs who need to add prescriptive authority to their scope of practice. Identification and implementation of a competency-based transition model for expansion of CNS prescriptive authority. By January 1, 2012, 9 CNSs in the state exemplar have completed a practicum and been granted full prescriptive authority including scheduled drug prescribing. No complaints or board actions resulted from the transition to autonomous prescribing. Transition to prescribing may be facilitated through competency-based outcomes including practicum hours as appropriate to the individual CNS nursing specialty. Outcomes from this model can be used to develop and further validate educational and credentialing policies to reduce barriers for CNSs requiring prescriptive authority in other states.

The Ontario printed educational message (OPEM) trial to narrow the evidence-practice gap with respect to prescribing practices of general and family physicians: a cluster randomized controlled trial, targeting the care of individuals with diabetes and hypertension in Ontario, Canada

PubMed Central

Zwarenstein, Merrick; Hux, Janet E; Kelsall, Diane; Paterson, Michael; Grimshaw, Jeremy; Davis, Dave; Laupacis, Andreas; Evans, Michael; Austin, Peter C; Slaughter, Pamela M; Shiller, Susan K; Croxford, Ruth; Tu, Karen

2007-01-01

Background There are gaps between what family practitioners do in clinical practice and the evidence-based ideal. The most commonly used strategy to narrow these gaps is the printed educational message (PEM); however, the attributes of successful printed educational messages and their overall effectiveness in changing physician practice are not clear. The current endeavor aims to determine whether such messages change prescribing quality in primary care practice, and whether these effects differ with the format of the message. Methods/design The design is a large, simple, factorial, unblinded cluster-randomized controlled trial. PEMs will be distributed with informed, a quarterly evidence-based synopsis of current clinical information produced by the Institute for Clinical Evaluative Sciences, Toronto, Canada, and will be sent to all eligible general and family practitioners in Ontario. There will be three replicates of the trial, with three different educational messages, each aimed at narrowing a specific evidence-practice gap as follows: 1) angiotensin-converting enzyme inhibitors, hypertension treatment, and cholesterol lowering agents for diabetes; 2) retinal screening for diabetes; and 3) diuretics for hypertension. For each of the three replicates there will be three intervention groups. The first group will receive informed with an attached postcard-sized, short, directive "outsert." The second intervention group will receive informed with a two-page explanatory "insert" on the same topic. The third intervention group will receive informed, with both the above-mentioned outsert and insert. The control group will receive informed only, without either an outsert or insert. Routinely collected physician billing, prescription, and hospital data found in Ontario's administrative databases will be used to monitor pre-defined prescribing changes relevant and specific to each replicate, following delivery of the educational messages. Multi-level modeling will be used to study patterns in physician-prescribing quality over four quarters, before and after each of the three interventions. Subgroup analyses will be performed to assess the association between the characteristics of the physician's place of practice and target behaviours. A further analysis of the immediate and delayed impacts of the PEMs will be performed using time-series analysis and interventional, auto-regressive, integrated moving average modeling. Trial registration number Current controlled trial ISRCTN72772651. PMID:18039361

Red blood cell transfusion practices in two surgical intensive care units: a mixed methods assessment of barriers to evidence-based practice.

PubMed

Murphy, David J; Pronovost, Peter J; Lehmann, Christoph U; Gurses, Ayse P; Whitman, Glenn J R; Needham, Dale M; Berenholtz, Sean M

2014-10-01

Despite evidence supporting restrictive red blood cell (RBC) transfusion thresholds and the associated clinical practice guidelines, clinical practice has been slow to change in the intensive care unit (ICU). Our aim was to identify barriers to conservative transfusion practice adherence. A mixed-methods study involving observation of prescriber (i.e., physicians, physician assistants, nurse practitioners) and bedside nurse daily bedside rounds, provider survey, and medical record abstraction was conducted in one cardiac surgical ICU (CSICU) and one surgical ICU (SICU) in an academic hospital in Baltimore, Maryland. Of 52 patient encounters observed during bedside rounds, 38 (73%) involved patients without evidence of active bleeding or cardiac ischemia. Surveys were completed by 52 (93%) of the 56 providers participating in rounds. Prescribers in the CSICU and SICU (87 and 90%, respectively) indicated the ideal pretransfusion hemoglobin (Hb) to be not more than 7 g/dL in nonbleeding and/or nonischemic patients compared to a minority of nurses (8% [p = 0.002] and 42% [p = 0.015], respectively). Prescribers and nurses in both ICUs overestimated the typical pretransfusion Hb in their units (CSICU, p < 0.001; SICU, p = 0.019). During rounds, providers infrequently explicitly discussed Hb monitoring or transfusion thresholds (33%) despite most (60%) reporting significant variation in transfusion thresholds between individual prescribers. Our study identified several provider and system barriers to evidence-based transfusion practices including knowledge differences, overly optimistic estimates of current practice, and heterogeneous transfusion practice in each ICU. Further work is necessary to develop targeted interventions to improve evidence-based RBC transfusion practices. © 2014 AABB.

Reviewing long-term antidepressants can reduce drug burden: a prospective observational cohort study

PubMed Central

Johnson, Chris F; Macdonald, Hector J; Atkinson, Pauline; Buchanan, Alasdair I; Downes, Noreen; Dougall, Nadine

2012-01-01

Background Antidepressant prescribing continues to rise. Contributing factors are increased long-term prescribing and possibly the use of higher selective serotonin re-uptake inhibitor (SSRI) doses. Aim To review general practice patients prescribed the same antidepressant long-term (≥2 years) and evaluate prescribing and management pre and post-review. Design and setting Prospective observational cohort study using routine data from 78 urban general practices, Scotland. Method All patients prescribed antidepressants (excluding amitriptyline) for ≥2 years were identified from records November 2009 to March 2010. GPs selected patients for face-to-face review of clinical condition and medication, December 2009 to September 2010. Pre- and post-review data were collected; average antidepressant doses and changes in prescribed daily doses were calculated. Onward referral to support services was recorded. Results 8.6% (33 312/388 656) of all registered patients were prescribed an antidepressant, 47.1% (15 689) were defined as long-term users and 2849 (18.2%) were reviewed. 811 (28.5%) patients reviewed had a change in antidepressant therapy: 7.0% stopped, 12.8% reduced dose, 5.3% increased dose, and 3.4% changed antidepressant, resulting in 9.5% (95% CI = 9.1% to 9.8% P<0.001) reduction in prescribed daily dose and 8.1% reduction in prescribing costs. 6.3% were referred onwards, half to NHS Mental Health Services. Pre-review SSRI doses were 10–30% higher than previously reported. Conclusion Almost half of all people prescribed antidepressants were long-term users. Appropriate reductions in prescribing can be achieved by reviewing patients. Higher SSRI doses may be contributing to current antidepressant growth. PMID:23211181

Navigating Dilemmas in Transforming Assessment Practices: Experiences of Mathematics Teachers in Ontario, Canada

ERIC Educational Resources Information Center

Suurtamm, Christine; Koch, Martha J.

2014-01-01

Current thinking encourages teachers to incorporate a range of assessment practices that are responsive to student thinking and promote student learning. At the same time, teachers are situated in a landscape of accountability, where they are often seen as technicians who implement prescribed curriculum, policies, and procedures with success…

Is use of homeopathy associated with poor prescribing in English primary care? A cross-sectional study

PubMed Central

Croker, Richard; Bacon, Seb; Ernst, Edzard; Curtis, Helen J; Goldacre, Ben

2018-01-01

Objectives Prescribing of homeopathy still occurs in a small minority of English general practices. We hypothesised that practices that prescribe any homeopathic preparations might differ in their prescribing of other drugs. Design Cross-sectional analysis. Setting English primary care. Participants English general practices. Main outcome measures We identified practices that made any homeopathy prescriptions over six months of data. We measured associations with four prescribing and two practice quality indicators using multivariable logistic regression. Results Only 8.5% of practices (644) prescribed homeopathy between December 2016 and May 2017. Practices in the worst-scoring quartile for a composite measure of prescribing quality (>51.4 mean percentile) were 2.1 times more likely to prescribe homeopathy than those in the best category (<40.3) (95% confidence interval: 1.6–2.8). Aggregate savings from the subset of these measures where a cost saving could be calculated were also strongly associated (highest vs. lowest quartile multivariable odds ratio: 2.9, confidence interval: 2.1–4.1). Of practices spending the most on medicines identified as ‘low value’ by NHS England, 12.8% prescribed homeopathy, compared to 3.9% for lowest spenders (multivariable odds ratio: 2.6, confidence interval: 1.9–3.6). Of practices in the worst category for aggregated price-per-unit cost savings, 12.7% prescribed homeopathy, compared to 3.5% in the best category (multivariable odds ratio: 2.7, confidence interval: 1.9–3.9). Practice quality outcomes framework scores and patient recommendation rates were not associated with prescribing homeopathy (odds ratio range: 0.9–1.2). Conclusions Even infrequent homeopathy prescribing is strongly associated with poor performance on a range of prescribing quality measures, but not with overall patient recommendation or quality outcomes framework score. The association is unlikely to be a direct causal relationship, but may reflect underlying practice features, such as the extent of respect for evidence-based practice, or poorer stewardship of the prescribing budget. PMID:29669216

Attitudes and behaviour of general practitioners and their prescribing costs: a national cross sectional survey.

PubMed

Watkins, C; Harvey, I; Carthy, P; Moore, L; Robinson, E; Brawn, R

2003-02-01

General practitioner (GP) prescribing accounts for about 10% of NHS expenditure. GPs at the top of the range have annual prescribing costs that are almost twice as much as those at the bottom of the range. This variation cannot be accounted for purely in terms of differences in underlying need for health care. To describe the relationship between GPs' prescribing costs and their attitudes towards prescribing decisions and prescribing information sources, and to identify potentially modifiable attitudinal and behavioural factors associated with high cost prescribing. A postal questionnaire was designed on the basis of hypotheses developed from a literature search and an earlier qualitative survey. This questionnaire was sent to a national sample of GPs with equal numbers of practices in the upper, middle, and lowest quintile of prescribing costs. GP practices in England. 1714 GPs in NHS practice. GPs' self-reported practices, attitudes and personal characteristics. There was a 64% response rate. Responders were more likely to be from larger practices, in less deprived areas, and with lower prescribing costs than were non-responders. Multivariable analysis showed that GPs with high prescribing costs were significantly more likely to work in dispensing practices, in practices with low income populations, in single handed practices, and in practices without a GP trainer. They were also significantly more likely to see drug company representatives more frequently, to prescribe newly available drugs more freely, to prescribe more readily to patients who expect a prescription, to report high levels of frustration from lack of time in the consultation, to find unsatisfactory those consultations which ended in advice only, and to express dissatisfaction with their review methods for repeat prescribing. They were significantly less likely to find useful criticism of prescribing habits by colleagues, and to check the BNF rather than other sources when uncertain about an aspect of drug treatment. While they cannot be held to have a causal relationship, the pattern of attitudes towards prescribing of GPs in the highest quintile of prescribing costs provide the basis for developing an educational intervention which may be an acceptable method of modifying the attitudes of GPs and consequently reducing their prescribing costs.

Analysis of the prescribed burning practice in the pine forest of northwestern Portugal.

PubMed

Fernandes, P; Botelho, H

2004-01-01

The ignition of low-intensity fires in the dormant season in the pine stands of north-western Portugal seeks to reduce the existing fuel hazard without compromising site quality. The purpose of this study is to characterise this practice and assess its effectiveness, based on information resulting from the normal monitoring process at the management level, and using operational guidelines, fire behaviour models and a newly developed method to classify prescribed fire severity. Although the region's humid climate strongly constrains the activity of prescribed fire, 87% of the fires analysed were undertaken under acceptable meteorological and fuel moisture conditions. In fact, most operations achieved satisfactory results. On average, prescribed fire reduces by 96% the potential intensity of a wildfire occurring under extreme weather conditions, but 36% of the treated sites would still require heavy fire fighting resources to suppress such fire, and 17% would still carry it in the tree canopy. Only 10% of the prescribed burns have an excessive impact on trees or the forest floor, while 89% (normal fire weather) or 59% (extreme fire weather) comply with both ecological integrity maintenance and wildfire protection needs. Improved planning and monitoring procedures are recommended in order to overcome the current deficiencies.

Preface to an Ethics of Education as a Practice in Its Own Right

ERIC Educational Resources Information Center

Hogan, Padraig

2010-01-01

Education as a practice in its own right (or "sui generis" practice) invokes quite a different set of ethical considerations than does education understood as a subordinate activity--i.e. prescribed and controlled in its essentials by the current powers-that-be in a society. But the idea of education as a vehicle for the "values" of a particular…

Patterns of drugs prescribed for dental outpatients in Nigeria: findings and implications.

PubMed

Fadare, Joseph O; Oshikoya, Kazeem A; Obimakinde, Obitade S; Sijuade, Abayomi O; Afolayan, Jide M; Adeleke, Adeyinka A; Godman, Brian; Ojumu, Damilola O

2017-10-01

There are concerns with inappropriate prescribing of medicines among dentists especially antimicrobials. It is more concerning if this increases resistance rates. This study aimed to address this by assessing patterns of drugs prescribed for outpatients attending a hospital dental clinic in Nigeria. The findings will be used to plan future interventions, particularly around antimicrobial prescribing, where there are concerns. Medical records of patients attending the dental clinic of a leading teaching hospital in Nigeria were evaluated. Patients referred for admission, without a prescription, or prescribed medicines without a documented diagnosis were excluded. Overall, 607 prescriptions were analysed, 314 (51.7%) were for females. Periodontal and gum diseases (414; 68.1%) were the most frequent diagnoses, followed by pulpitis (49; 8.2%), and dentoalveolar abscess (43; 7.1%). A total of 1798 medicines were prescribed for all patients with a mean of 3.0 ± 0.48 medicines per prescription. Antimicrobials (1178; 65.5%) and analgesics (620; 34.5%) were the two drug classes prescribed. Ascorbic acid and vitamin B complex were prescribed for 361 (59.5%) patients. Among antimicrobials, amoxicillin (564; 95.1%) either alone or combined with clavulanic acid was the most frequently prescribed, followed by metronidazole (561; 94.6%). Brand name prescribing was also appreciably higher than WHO recommendations. Polypharmacy, brand name prescriptions, and the frequent prescription of antimicrobials were common practices at the dental clinic of this teaching hospital in Nigeria. We suggest a review of the current standard treatment guidelines in Nigeria to guide dentists on current knowledge- and evidence-based treatment of common oral diseases.

Evidence-based recommendations for the prescription of exercise for major depressive disorder.

PubMed

Rethorst, Chad D; Trivedi, Madhukar H

2013-05-01

Major depressive disorder (MDD) is a source of great disease burden, due in part to the limited accessibility and effectiveness of current treatments. Although current treatments are efficacious in a segment of the population with MDD, there is a clear need for alternative and augmentation treatment strategies. Exercise is one such alternative treatment option. Research has shown exercise to be efficacious as both a stand-alone and an augmentation therapy. As a result, exercise is now included in the American Psychiatric Association's treatment recommendations. The purpose of this article is to provide clinicians with a knowledge base to prescribe exercise to their patients. The authors describe the evidence supporting the use of exercise in the treatment of MDD, provide evidence-based recommendations for prescribing exercise, and address practical considerations related to prescribing exercise in real-world treatment settings.

Factors influencing pharmacists’ adoption of prescribing: qualitative application of the diffusion of innovations theory

PubMed Central

2013-01-01

Background In 2007, Alberta became the first Canadian jurisdiction to grant pharmacists a wide range of prescribing privileges. Our objective was to understand what factors influence pharmacists’ adoption of prescribing using a model for the Diffusion of Innovations in healthcare services. Methods Pharmacists participated in semi-structured telephone interviews to discuss their prescribing practices and explore the facilitators and barriers to implementation. Pharmacists working in community, hospital, PCN, or other settings were selected using a mix of random and purposive sampling. Two investigators independently analyzed each transcript using an Interpretive Description approach to identify themes. Analyses were informed by a model explaining the Diffusion of Innovations in health service organizations. Results Thirty-eight participants were interviewed. Prescribing behaviours varied from non-adoption through to product, disease, and patient focused use of prescribing. Pharmacists’ adoption of prescribing was dependent on the innovation itself, adopter, system readiness, and communication and influence. Adopting pharmacists viewed prescribing as a legitimization of previous practice and advantageous to instrumental daily tasks. The complexity of knowledge required for prescribing increased respectively in product, disease and patient focused prescribing scenarios. Individual adopters had higher levels of self-efficacy toward prescribing skills. At a system level, pharmacists who were in practice settings that were patient focused were more likely to adopt advanced prescribing practices, over those in product-focused settings. All pharmacists stated that physician relationships impacted their prescribing behaviours and individual pharmacists’ decisions to apply for independent prescribing privileges. Conclusions Diffusion of Innovations theory was helpful in understanding the multifaceted nature of pharmacists’ adoption of prescribing. The characteristics of the prescribing model itself which legitimized prior practices, the model of practice in a pharmacy setting, and relationships with physicians were prominent influences on pharmacists’ prescribing behaviours. PMID:24034176

Factors influencing pharmacists' adoption of prescribing: qualitative application of the diffusion of innovations theory.

PubMed

Makowsky, Mark J; Guirguis, Lisa M; Hughes, Christine A; Sadowski, Cheryl A; Yuksel, Nese

2013-09-14

In 2007, Alberta became the first Canadian jurisdiction to grant pharmacists a wide range of prescribing privileges. Our objective was to understand what factors influence pharmacists' adoption of prescribing using a model for the Diffusion of Innovations in healthcare services. Pharmacists participated in semi-structured telephone interviews to discuss their prescribing practices and explore the facilitators and barriers to implementation. Pharmacists working in community, hospital, PCN, or other settings were selected using a mix of random and purposive sampling. Two investigators independently analyzed each transcript using an Interpretive Description approach to identify themes. Analyses were informed by a model explaining the Diffusion of Innovations in health service organizations. Thirty-eight participants were interviewed. Prescribing behaviours varied from non-adoption through to product, disease, and patient focused use of prescribing. Pharmacists' adoption of prescribing was dependent on the innovation itself, adopter, system readiness, and communication and influence. Adopting pharmacists viewed prescribing as a legitimization of previous practice and advantageous to instrumental daily tasks. The complexity of knowledge required for prescribing increased respectively in product, disease and patient focused prescribing scenarios. Individual adopters had higher levels of self-efficacy toward prescribing skills. At a system level, pharmacists who were in practice settings that were patient focused were more likely to adopt advanced prescribing practices, over those in product-focused settings. All pharmacists stated that physician relationships impacted their prescribing behaviours and individual pharmacists' decisions to apply for independent prescribing privileges. Diffusion of Innovations theory was helpful in understanding the multifaceted nature of pharmacists' adoption of prescribing. The characteristics of the prescribing model itself which legitimized prior practices, the model of practice in a pharmacy setting, and relationships with physicians were prominent influences on pharmacists' prescribing behaviours.

Dental care resistance prevention and antibiotic prescribing modification—the cluster-randomised controlled DREAM trial

PubMed Central

2014-01-01

Background Bacterial resistance development is one of the most urgent problems in healthcare worldwide. In Europe, dentistry accounts for a comparatively high amount of antibiotic prescriptions. In light of increasing levels of bacterial resistance, this development is alarming. So far, very few interventional studies have been performed, and further research is urgently needed. By means of a complex educational intervention, the DREAM trial aims at optimising antibiotic prescribing behaviour of general dentists in Germany. Method This is a cluster-randomised controlled trial, where each cluster consists of one dental practice and all of its patients in a defined period. Participants are general dentists practicing in the German region of Mecklenburg-Western Pomerania. Randomisation takes place after baseline data collection (6 months) and will be stratified by the antibiotic prescribing rates of the participating dental practices. Dentists randomised into the intervention group will participate in a complex small group educational seminar that aims at: increasing knowledge on bacterial resistance, pharmacology, and prophylaxis of infectious endocarditis; increasing awareness of dentist-patient communication using video-taped vignettes of dentist-patient communication on antibiotic treatment; improving collaboration between general dentists, general practitioners, and practice-based cardiologists on the necessity of antibiotic prophylaxis; enhancing awareness of the dentists’ own prescribing habits by providing antibiotic prescribing feedback; and increasing patient knowledge on antibiotic treatment by providing patient-centred information material on antibiotic prophylaxis of endocarditis. The dentists randomised into the control group will not receive any educational programme and provide care as usual. Primary outcome is the overall antibiotic prescribing rate measured at T1 (period of six months after intervention). In a subgroup of adult patients affected by odontogenic infections, microbiological analyses for antibiotic resistance of oral streptococci are performed. Discussion Major aim of the study is to improve the process of decision making with regard to antibiotic prescribing. The approach is simple to implement and might be used rapidly in graduate and post-graduate medical education. We expect the results of this trial to have a major impact on antibiotic prescription strategies and practices in Germany. Trial registration Current Controlled Trials ISRCTN09576376 PMID:24559212

Dental care resistance prevention and antibiotic prescribing modification-the cluster-randomised controlled DREAM trial.

PubMed

Löffler, Christin; Böhmer, Femke; Hornung, Anne; Lang, Hermann; Burmeister, Ulrike; Podbielski, Andreas; Wollny, Anja; Kundt, Günther; Altiner, Attila

2014-02-22

Bacterial resistance development is one of the most urgent problems in healthcare worldwide. In Europe, dentistry accounts for a comparatively high amount of antibiotic prescriptions. In light of increasing levels of bacterial resistance, this development is alarming. So far, very few interventional studies have been performed, and further research is urgently needed. By means of a complex educational intervention, the DREAM trial aims at optimising antibiotic prescribing behaviour of general dentists in Germany. This is a cluster-randomised controlled trial, where each cluster consists of one dental practice and all of its patients in a defined period. Participants are general dentists practicing in the German region of Mecklenburg-Western Pomerania. Randomisation takes place after baseline data collection (6 months) and will be stratified by the antibiotic prescribing rates of the participating dental practices. Dentists randomised into the intervention group will participate in a complex small group educational seminar that aims at: increasing knowledge on bacterial resistance, pharmacology, and prophylaxis of infectious endocarditis; increasing awareness of dentist-patient communication using video-taped vignettes of dentist-patient communication on antibiotic treatment; improving collaboration between general dentists, general practitioners, and practice-based cardiologists on the necessity of antibiotic prophylaxis; enhancing awareness of the dentists' own prescribing habits by providing antibiotic prescribing feedback; and increasing patient knowledge on antibiotic treatment by providing patient-centred information material on antibiotic prophylaxis of endocarditis. The dentists randomised into the control group will not receive any educational programme and provide care as usual. Primary outcome is the overall antibiotic prescribing rate measured at T1 (period of six months after intervention). In a subgroup of adult patients affected by odontogenic infections, microbiological analyses for antibiotic resistance of oral streptococci are performed. Major aim of the study is to improve the process of decision making with regard to antibiotic prescribing. The approach is simple to implement and might be used rapidly in graduate and post-graduate medical education. We expect the results of this trial to have a major impact on antibiotic prescription strategies and practices in Germany. Current Controlled Trials ISRCTN09576376.

Prescribed fire in North American forests and woodlands: history, current practice, and challenges

Treesearch

Kevin C. Ryan; Eric E. Knapp; J. Morgan Varner

2013-01-01

Whether ignited by lightning or by Native Americans, fire once shaped many North American ecosystems. Euro-American settlement and 20th-century fire suppression practices drastically altered historic fire regimes, leading to excessive fuel accumulation and uncharacteristically severe wildfires in some areas and diminished flammability resulting from shifts to more fire...

The management of acute uncomplicated cystitis in adult women by family physicians in Canada

PubMed Central

McIsaac, Warren J; Prakash, Preeti; Ross, Susan

2008-01-01

INTRODUCTION There are few Canadian studies that have assessed prescribing patterns and antibiotic preferences of physicians for acute uncomplicated cystitis. A cross-Canada study of adult women with symptoms of acute cystitis seen by primary care physicians was conducted to determine current management practices and first-line antibiotic choices. METHODS A random sample of 2000 members of The College of Family Physicians of Canada were contacted in April 2002, and were asked to assess two women presenting with new urinary tract symptoms. Physicians completed a standardized checklist of symptoms and signs, indicated their diagnosis and antibiotics prescribed. A urine sample for culture was obtained. RESULTS Of the 418 responding physicians, 246 (58.6%) completed the study and assessed 446 women between April 2002 and March 2003. Most women (412 of 420, for whom clinical information about antibiotic prescriptions was available) reported either frequency, urgency or painful urination. Physicians would have usually ordered a urine culture for 77.0% of the women (95% CI 72.7 to 80.8) and prescribed an antibiotic for 86.9% of the women (95% CI 83.3 to 90.0). The urine culture was negative for 32.8% of these prescriptions. The most commonly prescribed antibiotic was trimethoprim/sulfamethoxazole (40.8%; 95% CI 35.7 to 46.1), followed by fluoroquinolones (27.4%; 95% CI 22.9 to 32.3) and nitrofurantoin (26.6%; 95% CI 22.1 to 31.4). CONCLUSION Empirical antibiotic prescribing is standard practice in the community, but is associated with high levels of unnecessary antibiotic use. While trimethoprim/sulfamethoxazole is the first-line empirical antibiotic choice, fluoroquinolone antibiotics have become the second most commonly prescribed empirical antibiotic for acute cystitis. The effect of current prescribing patterns on community levels of quinolone-resistant Escherichia coli may need to be monitored. PMID:19436509

Controlling pain and reducing misuse of opioids

PubMed Central

Kotalik, Jaro

2012-01-01

Abstract Objective To help family physicians achieve an ethical balance in their opioid prescribing practices. Quality of evidence MEDLINE was searched for English-language articles published between 1985 and 2011. Most available evidence was level III. Main message It is essential to follow practice guidelines when prescribing opioids, except when another course of action is demonstrably justified. In addition, when considering the appropriateness of an opioid prescription, with its many ethical implications, the decision can be usefully guided by the application of the ethical principles of beneficence, nonmaleficence, respect for autonomy, and justice. As well, it is essential to keep current about legal and regulatory changes and provincial electronic registries of opioid prescriptions. Conclusion Physicians need to ensure that their patients’ pain is properly assessed and managed. Reaching optimal pain control might necessitate prescribing opioids. But the obligation to provide pain relief needs to be balanced with an equally important responsibility not to expose patients to risk of addiction and not to create opportunities for drug diversion, trafficking, and the addiction of others. Basic ethical principles can provide a framework to help physicians make ethically appropriate decisions about opioid prescribing. PMID:22611604

Antimicrobial prescribing practice in UK equine veterinary practice.

PubMed

Hughes, L A; Pinchbeck, G; Callaby, R; Dawson, S; Clegg, P; Williams, N

2013-03-01

Antimicrobial use is known to select for the emergence of resistant strains of bacteria; therefore prudent use in both human and veterinary medicine is essential to preserve their efficacy. To characterise antimicrobial prescribing patterns in UK equine practice and evaluate factors associated with prescribing. A postal questionnaire including 4 clinical scenarios was sent to 740 veterinary surgeons that treat horses. Data were collected on the clinician, their practice and sources of information regarding antimicrobials and their use. Multivariable logistic regression analysis was used to ascertain factors associated with 5 outcomes; prescribing off-licence drugs; prescribing at incorrect doses; prescribing 3rd or 4th generation cephalosporins; prescribing fluoroquinolones and prescribing potentiated sulphonamides. Questionnaires were completed by 38% of veterinary surgeons who were sent questionnaires. Less than 1% of practices had antimicrobial use guidelines. Trimethoprim-sulphonamides were most commonly prescribed in each clinical scenario. Eleven percent of prescriptions were for antimicrobial drugs not licensed for use in horses in the UK. Five percent of prescriptions for licensed antimicrobials were under the recommended dose rate and 56% over the recommended dose rate. Fluoroquinolones and 3rd and 4th generation cephalosporins accounted for 1 and 3% of prescriptions, respectively. Veterinary surgeons working at referral practices were more likely to prescribe 3rd and 4th generation cephalosporins and fluoroquinolones and off-licence antimicrobials whereas those working in first-opinion practices were more likely to prescribe potentiated sulphonamides. Sources of information regarding antimicrobials also had an effect on prescribing. Prescription of antimicrobials at inappropriate doses was common even when provided with the weight of the animal. It is uncommon for UK equine veterinary practices to have guidelines for antimicrobial use. The introduction of such guidelines could lead to more prudent use of antimicrobials. © 2012 EVJ Ltd.

"Under the radar": nurse practitioner prescribers and pharmaceutical industry promotions.

PubMed

Ladd, Elissa C; Mahoney, Diane Feeney; Emani, Srinivas

2010-12-01

To assess nurse practitioners' interactions with pharmaceutical industry promotional activities and their perception of information reliability and self-reported prescribing behaviors. Self-administered online survey. A nationally randomized sample of nurse practitioner prescribers was surveyed. Eligibility criteria included current clinical practice and licensure to prescribe medications in their state of practice. A total of 263 responses were analyzed. Almost all respondents (96%) reported regular contact with pharmaceutical sales representatives, and most (71%) reported receiving information on new drugs directly from pharmaceutical sales representatives some or most of the time. A large portion (66%) dispensed drug samples regularly to their patients, and 73% believed that samples were somewhat or very helpful in learning about new drugs. Eighty-one percent of respondents thought that it was ethically acceptable to give out samples to anyone, and 90% believed that it was acceptable to attend lunch and dinner events sponsored by the pharmaceutical industry. Almost half (48%) stated that they were more likely to prescribe a drug that was highlighted during a lunch or dinner event. Most respondents stated that it was ethically acceptable for speakers to be paid by industry. Nurse practitioner prescribers had extensive contact with pharmaceutical industry promotional activities such as pharmaceutical representative contact, receipt of drug samples, and regular attendance at industry-sponsored meal events and continuing education programs. They reported that industry interface with nurse practitioner prescribers in the form of sponsored meals, education events, and paid speakers was ethically acceptable.

The effect of recent amblyopia research on current practice in the UK.

PubMed

Newsham, D

2010-10-01

Several studies have recently provided insights into how amblyopia may be most effectively managed. Despite the new evidence, a US study reported that a recent randomised controlled trial had made little influence on clinical practice. The aims of this research are to assess current practice of amblyopia management in the UK and to determine the comparability with the evidence-based recommendations. A questionnaire was constructed to assess current amblyopia management practice, particularly in relation to areas investigated by recent research and emailed to every head orthoptist within the UK. There was a great deal of variability in the amount of occlusion that was prescribed for moderate and severe amblyopia. Sixty per cent of clinicians indicated that the maximum they would prescribe was in excess of the 6 h recommended by research. Atropine was rarely recommended as a first-line treatment, with occlusion generally being considered to be more effective. Despite recommendations regarding education as a means of reducing non-compliance, only 39% of clinicians always gave written information, although various other methods of enhancing compliance were used. A period of refractive adaptation was allowed by most clinicians but often far less than recommended. The uptake of recent research evidence into clinical practice is sporadic and incomplete with one-third of respondents indicating that following the studies, they had made no changes whatsoever to their practice. This is similar to other areas of medicine; the reasons are likely to be varied, and is an area that would benefit from greater attention.

Time Trends and Geographical Variation in Prescribing of Drugs for Diabetes in England 1998-2017.

PubMed

Curtis, Helen J; Dennis, John M; Shields, Beverley M; Walker, Alex J; Bacon, Seb; Hattersley, Andrew T; Jones, Angus G; Goldacre, Ben

2018-05-07

UK guidelines for type II diabetes leave the choice of glucose lowering therapies after metformin largely to prescribers. They vary greatly in cost, and comparative effectiveness data is lacking. We set out to measure the variation in prescribing of these second-line non-insulin diabetes drugs. We evaluated time trends 1998-2016, using England's publicly available prescribing datasets, and stratified by the order prescribed to patients using the Clinical Practice Research Datalink (CPRD). We calculated the proportion of each class of diabetes drug as a percentage of the total per year. We evaluated geographical variation in prescribing using general practice-level data for the latest 12-months (to August 2017), with aggregation to Clinical Commissioning Groups (CCGs). We calculated percentiles, ranges and plotted maps. Prescribing of therapy after metformin is changing rapidly. DPP4-inhibitor use has increased markedly, now the most common second-line drug (43% prescriptions in 2016). Use of SGLT-2 inhibitors also increased rapidly (14% new second-line, 27% new third-line prescriptions in 2016). There is wide geographical variation in choice of therapies and average spend per patient. In contrast, metformin is consistently used first-line in accordance with guidelines. In England there is extensive geographical variation in the prescribing of diabetes drugs after metformin, and increasing use of higher-cost DPP4-inhibitors and SGLT-2 inhibitors over low-cost sulfonylureas. Our findings strongly support the case for comparative effectiveness trials of current diabetes drugs. This article is protected by copyright. All rights reserved.

Improving health visitor emollient prescribing using a CQUIN-based approach.

PubMed

Brooks, Christina; Khatau, Tejas

2015-12-01

Prescribing is an essential element of health visiting practice. This initiative used the payment framework of Commissioning for Quality and Innovation (CQUIN) to develop health visiting practice across a large health visiting workforce in the East Midlands. A focus on emollient prescribing practice was agreed and a guidance booklet regarding preferred emollient products was produced, based on the local formulary Each health visitor benefitted from receiving additional training and was given a guidance booklet to inform their practice. Targets were set for each quarter to demonstrate an improved prescribing adherence to the preferred product list.The targets were achieved for each quarter. Prescribing rates and confidence improved across the service. Therefore, it was demonstrated that specific guidance and ongoing support can improve prescribing practice within the health visiting service.

To what extent do prescribing practices for hypertension in the private sector in Zimbabwe follow the national treatment guidelines? An analysis of insurance medical claims.

PubMed

Basopo, Victor; Mujasi, Paschal N

2017-01-01

Hypertension is the most prevalent cardiovascular disease in Zimbabwe. The prevalence of Hypertension in the country is above 30% regardless of the cut off used. Currently, majority of patients in Zimbabwe seek health care from the private sector due to limited government funding for the public health sector. However, Standard treatment guidelines for hypertension are only available in the public sector and are optional in the private sector. This study assesses compliance of private sector prescribing to Standard Treatment guidelines for hypertension. We reviewed hypertension prescription claims to a private health insurance company in Zimbabwe for the period Jan 1-Dec 31 2015. We used the last prescription claimed in the year on the assumption that it represented the patient's current treatment. Prescription data was analyzed by comparing medicines prescribed to those recommended in the Zimbabwe 7th Essential Medicines List and Standard Treatment Guidelines 2015. We used Microsoft Excel© 2010 to conduct the analysis. A total of 1019 prescriptions were reviewed. Most patients were either on mono or dual therapy (76%). The mostly prescribed class of antihypertensive as first line were Angiotensin Converting Enzyme Inhibitors /Angiotensin Receptor Blockers. Regardless of whether they were being used as first, second or third line this class of antihypertensives emerged as the most prescribed (639 times). Only 358 (35%) prescriptions were compliant with standard treatment guidelines; the rest (661) did not meet several criteria. Areas of non-compliance included use of second line medicines as first line, failure to consider patient characteristics when prescribing, use of contraindicated medicines for certain patients, clinically significant interactions among prescribed medicines and illogical combinations that predispose patients to toxicity. The poor compliance to standard treatment guidelines observed in our study indicates need to improve prescription practices for Hypertension in the private sector in Zimbabwe for its cost-effective management among the covered patients. However, further investigation is needed to understand the drivers of the prescribing habits and the non-compliance to the Essential Medicines List and Standard Treatment guidelines observed. This will enable design of appropriate educational, managerial and economic interventions to improve compliance.

The missing link: family physician perspectives on barriers and enablers to prescribing a new Meningococcal B vaccine and other recommended, non-government funded vaccines.

PubMed

Taylor, Kathryn A; Stocks, Nigel; Marshall, Helen S

2014-07-16

To determine factors influencing Family Physician (FP) uptake of non government-funded vaccines, and to explore FP attitudes towards the introduction and use of a new vaccine to protect against serogroup B meningococcal disease to inform its future introduction into the Australian Immunisation Schedule. Quantitative, self-administered state-wide questionnaire mailed to all FPs in South Australia (n=1786). Results from 523 FP respondents in South Australia, collected between June and October 2013. Self-reported immunisation counselling practices; and knowledge, attitudes and barriers to prescribing of Meningococcal B (Men B) vaccine and other recommended, non-funded immunisations. The response rate was 30% (n=523). While most (59%) respondents had worked in general practice for over 20 years, only 39% of all respondents had ever had personal or professional experience with a case of invasive meningococcal disease (IMD). Most FPs (63%) were aware that a meningococcal B vaccine was being developed, and 93% of respondents agreed that this vaccine should be government-funded. FPs ranked Men B vaccine as the highest priority to receive funding of eight currently non-funded immunisation strategies. High vaccine cost and low patient socioeconomic status were identified as definite barriers to prescribing non-funded vaccines by 59% of respondents. Past IMD experience significantly affected attitudes and prescribing practices. IMD, while encountered rarely in clinical practice, is considered an important disease to vaccinate against by FPs. Cost and perceived low socioeconomic status of patients are substantial barriers to FPs prescribing Men B and other non-funded vaccines, and inclusion of such vaccines on the National Immunisation Program is likely to improve equity of access. Copyright © 2014 Elsevier Ltd. All rights reserved.

Recognition of pharmaceutical prescriptions across the European Union: a comparison of five Member States' policies and practices.

PubMed

Miguel, Lorena San; Augustin, Uta; Busse, Reinhard; Knai, Cécile; Rubert, Gloria; Sihvo, Sinikka; Baeten, Rita

2014-06-01

In 2011, the EU Directive on Patients' Rights in Cross Border Healthcare was approved, including a regulation on mutual recognition of prescriptions. To compare current national policies and practices on prescribing and dispensing, prescription-only medicines (POMs) in European countries in order to identify differences which could, challenge acceptance across borders. Semi-structured interviews with 37 national stakeholders were carried out. Furthermore, data on policies for prescribing and dispensing POMs were gathered based on desk research, and, contacts with relevant authorities via a purposely designed questionnaire. Important differences exist regarding: (1) information requirements for prescriptions to be, legally valid, (2) generic and international non-proprietary name (INN) policies and (3) professionals, legally allowed to prescribe POMs. Moreover, there is a lack of EU-wide access to key information for, validating prescriptions, recognizing the equivalence of products or identifying authorised prescribers. Differences in legislation and its application across Europe pose important challenges to be, addressed by policy makers with appropriate actions: (1) a prescribed product may not be dispensed, to a patient who needs it, (2) an inappropriate product (or inappropriate instructions) could be, provided and (3) POMs could be dispensed and consumed or sold, based on false prescriptions. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Current primary care management of children aged 1-36 months with urinary tract infections in Europe: large scale survey of paediatric practice.

PubMed

Hadjipanayis, Adamos; Grossman, Zachi; Del Torso, Stefano; van Esso, Diego; Dornbusch, Hans Juergen; Mazur, Artur; Drabik, Anna; Montini, Giovanni

2015-04-01

To describe current practice among European paediatricians regarding diagnosis and management of urinary tract infections in children aged 1-36 months and to compare these practices with recently published guidelines. Web-based large scale survey evaluating knowledge of, attitudes towards and the methods for diagnosing, treating and managing urinary tract infections in children. Primary and secondary care practices in Europe. 1129 paediatricians. A diagnosis of urinary tract infection is considered by 62% of the respondents in children aged 1-36 months with unexplained fever. The preferred method of urine collection is use of a bag (53% for infants <3 months and 59% for children 4-36 months of age). 60% of paediatricians agree that oral and parenteral antibiotics have equal efficacy. Co-amoxiclav is the antibiotic of choice for 41% of participants, while 9% prescribe amoxicillin. 80% of respondents prescribe ultrasound in all children with a confirmed urinary tract infection. 63% of respondents prescribe a cystography when abnormalities are revealed during ultrasound evaluation. A quarter of respondents recommend antibiotic prophylaxis for all children with any vesicoureteral reflux. The data among European countries are very heterogeneous. The three most recent urinary tract infection guidelines (the National Institute for Health and Care Excellence (NICE), the American Academy of Paediatrics and the Italian Society of Paediatric Nephrology) are not followed properly. Management of febrile urinary tract infections remains controversial and heterogeneous in Europe. Simple, short, practical and easy-to-remember guidelines and educational strategies to ensure their implementation should be developed. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Genetic screening for the predisposition to venous thromboembolism: a cost-utility analysis of clinical practice in the Italian health care system.

PubMed

Compagni, Amelia; Melegaro, Alessia; Tarricone, Rosanna

2013-01-01

In the Italian health care system, genetic tests for factor V Leiden and factor II are routinely prescribed to assess the predisposition to venous thromboembolism (VTE) of women who request oral contraception. With specific reference to two subpopulations of women already at risk (i.e., familial history or previous event of VTE), the study aimed to assess whether current screening practices in Italy are cost-effective. Two decisional models accrued costs and quality-adjusted life-years (QALY) annually from the perspective of the National Health Service. The two models were derived from a decision analysis exercise concerning testing practices and consequent prescribing behavior for oral contraception conducted with 250 Italian gynecologists. Health care costs were compiled on the basis of 10-year hospital discharge records and the activities of a thrombosis center. Whenever possible, input data were based on the Italian context; otherwise, the data were taken from the international literature. Current testing practices on women with a familial history of VTE generate an incremental cost-effectiveness ratio of €72,412/QALY, which is well above the acceptable threshold of cost-effectiveness of €40,000 to €50,000/QALY. In the case of women with a previous event of VTE, the most frequently used testing strategy is cost-ineffective and leads to an overall loss of QALY. This study represents the first attempt to conduct a cost-utility analysis of genetic screening practices for the predisposition to VTE in the Italian setting. The results indicate that there is an urgent need to better monitor the indications for which tests for factor V Leiden and factor II are prescribed. Copyright © 2013, International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc.

A survey of german physicians in private practice about contacts with pharmaceutical sales representatives.

PubMed

Lieb, Klaus; Brandtönies, Simone

2010-06-01

Physicians and pharmaceutical sales representatives (PSR) are in regular contact. The goal of the present study is systematically to assess the kind of contacts that take place and their quality with a survey of physicians in private practice. A further goal is to determine whether alternatives to current practices can be envisioned. 100 physicians in each of three specialties (neurology/psychiatry, general medicine, and cardiology) were surveyed with a questionnaire containing 37 questions. 208 (69.3%) questionnaires were anonymously filled out and returned. 77% (n = 160) of all physicians were visited by PSR at least once a week, and 19% (n = 39) every day. Pharmaceutical samples, items of office stationery and free lunches were the most commonly received gifts. 49% (n = 102) stated that they only occasionally, rarely, or never receive adequate information from PSR, and 76% (n = 158) stated that PSR often or always wanted to influence their prescribing patterns. Only 6% (n = 13) considered themselves to be often or always influenced, while 21% (n = 44) believed this of their colleagues. The physicians generally did not believe that PSR visits and drug company-sponsored educational events delivered objective information, in contrast to medical texts and non-sponsored educational events. Nonetheless, 52% (n = 108) of the physicians would regret the cessation of PSR visits, because PSRs give practical prescribing information, offer support for continuing medical education, and provide pharmaceutical samples. PSR visits and attempts to influence physicians' prescribing behavior are a part of everyday life in private medical practice, yet only a few physicians consider themselves to be susceptible to this kind of influence. A more critical attitude among physicians, and the creation of alternative educational events without drug company sponsoring, might lead to more independence and perhaps to more rational and less costly drug-prescribing practices.

Antibiotic prescribing practice and adherence to guidelines in primary care in the Cape Town Metro District, South Africa.

PubMed

Gasson, J; Blockman, M; Willems, B

2018-03-28

Knowledge of antibiotic prescribing practice in primary care in South Africa is limited. As 80% of human antibiotic use is in primary care, this knowledge is important in view of the global problem of antibiotic resistance. To assess antibiotic prescribing in primary care facilities in the Cape Town Metro District and compare it with current national guidelines, and to assess the reasons why prescriptions were not adherent to guidelines. A retrospective medical record review was performed in April/May 2016. Records of all patients seen over 2 days in each of eight representative primary care facilities in the Cape Town Metro District were reviewed. The treatment of any patient who raised a new complaint on either of those days was recorded. Prophylactic antibiotic courses, tuberculosis treatment and patients with a non-infection diagnosis were excluded. Treatment was compared with the Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare Level, 2014 edition. Of 654 records included, 68.7% indicated that an antibiotic had been prescribed. Overall guideline adherence was 45.1%. Adherence differed significantly between facilities and according to the physiological system being treated, whether the prescription was for an adult or paediatric patient, and the antibiotic prescribed. Healthcare professional type and patient gender had no significant effect on adherence. The main reasons for non-adherence were an undocumented diagnosis (30.5%), antibiotic not required (21.6%), incorrect dose (12.9%), incorrect drug (11.5%), and incorrect duration of therapy (9.5%). This study demonstrates poor adherence to guidelines. Irrational use of antibiotics is associated with increased antibiotic resistance. There is an urgent need to improve antibiotic prescribing practice in primary care in the Cape Town Metro District.

Drug promotional activities in Nigeria: impact on the prescribing patterns and practices of medical practitioners and the implications.

PubMed

Fadare, Joseph O; Oshikoya, Kazeem A; Ogunleye, Olayinka O; Desalu, Olufemi O; Ferrario, Alessandra; Enwere, Okezie O; Adeoti, Adekunle; Sunmonu, Taofiki A; Massele, Amos; Baker, Amanj; Godman, Brian

2018-04-01

Pharmaceutical companies spend significant amount of resources on promotion influencing the prescribing behavior of physicians. Drug promotion can negatively impact on rational prescribing, which may adversely affect the quality of patient care. However, little is known about these activities in Nigeria as the most populous country in Africa. We therefore aimed to explore the nature of encounters between Nigerian physicians and pharmaceutical sales representatives (PSRs), and how these encounters influence prescribing habits. Cross-sectional questionnaire-based study conducted among practicing physicians working in tertiary hospitals in four regions of Nigeria. 176 questionnaires were completed. 154 respondents (87.5%) had medicines promoted to them in the previous three months, with most encounters taking place in outpatients' clinics (60.2%), clinical meetings (46%) and new medicine launches (17.6%). Information about potential adverse effects and drug interactions was provided in 41.5%, and 27.3% of cases, respectively. Food, in the form of lunch or dinner, was the most common form of incentive (70.5%) given to physicians during promotional activities. 61% of physicians felt motivated to prescribe the drug promoted to them, with the quality of information provided being the driving factor. Most physicians (64.8%) would agree to some form of regulation of the relationship between medical doctors and the pharmaceutical industry. Interaction between PSRs and physicians is a regular occurrence in Nigeria, influencing prescribing practices. Meals and cheap gifts were the most common items offered to physicians during their encounters with PSRs. The need for some form of regulation by professional organizations and the government was expressed by most respondents to address current concerns.

Vitamin D Prescribing Practices in Primary Care Pediatrics: Underpinnings From the Health Belief Model and Use of Web-Based Delphi Technique for Instrument Validity.

PubMed

DelGiudice, Nancy J; Street, Nancy; Torchia, Ronald J; Sawyer, Susan S; Bernard, Sylvia Allison; Holick, Michael F

2018-05-24

Vitamin D deficiency and insufficiency is a pandemic problem in children and adolescents in the United States. The problem may be aggravated by the inconsistent implementation of current clinical practice guidelines for vitamin D management by pediatric primary care providers. This study examines the relationship between primary care providers' prescribing vitamin D to children ages 1 through 18 years and their practice actions and knowledge. A descriptive correlation design was used. Participants were recruited from a purposive sample of pediatricians and pediatric nurse practitioners through an online invitation to participate in a survey. Reliability and validity was established for the survey developed by the principal investigator using a web-based Delphi technique. Results from this study indicate that although most providers are aware that vitamin D insufficiency and deficiency are problems, fewer than half currently recommend 600- to 1,000-IU supplementation to their patients ages 1 through 18 years. Copyright © 2018 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.

Acute oxygen therapy: an audit of prescribing and delivery practices in a tertiary hospital in Perth, Western Australia.

PubMed

Kamran, Anam; Chia, Elisa; Tobin, Claire

2018-02-01

Oxygen is a widely used drug in the hospital setting. However, international audits suggest that oxygen administration practices are often not compliant with prescribed standards. This can place patients at risk and cause serious adverse events. To analyse data related to recent practices of oxygen prescription and administration at Royal Perth Hospital (RPH), Western Australia. The results of this audit aim to guide further research on possible interventional studies implementing key solutions. All patients who received care in the Acute Medical Unit at RPH between 1 September and 14 September 2015 were included in this audit. Patients who were given supplemental oxygen during their admission were selected for further review of records. Appropriate medically indicated target oxygen saturations for each patient were judged under consultation with a respiratory specialist. A total of 65 patients received oxygen supplementation within the study period; 36 of these patients (55.4%) had target oxygen saturations prescribed by doctors, and 25% of the prescribed targets were judged to be inappropriate. In total, 49 patients (75.4%) were exposed to a potential risk from oxygen therapy due to prescription error and/or delivery error. A real risk was identified in 19 patients (29.2%) as they received oxygen at levels outside their appropriate medically indicated target range. The current practices of oxygen prescription and administration within RPH are suboptimal. Patients are placed at risk of oxygen toxicity due to deviation from oxygen prescription guidelines. © 2017 Royal Australasian College of Physicians.

Nurse prescribing: reflections on safety in practice.

PubMed

Bradley, Eleanor; Hynam, Brian; Nolan, Peter

2007-08-01

This qualitative study explores how recently qualified nurse prescribers describe, and rate, the safety of their prescribing. Internationally, the costs of drug errors are enormous and they can have serious implications for staff and patients. Nurses are now undertaking extended prescribing practice throughout the UK. Nurse prescribers work across different work settings and although safe prescribing is a priority in all of them, it is essential to ascertain the conditions that foster the highest levels of safety and how nurses can be supported in practice. Thirty-one nurses form the West Midlands area of England agreed to participate in an in-depth interview which sought to elicit their responses to various aspects of their prescribing work. They came from a variety of specialities and from hospital, community and general practice backgrounds. On completion of their training nurses were acutely aware of the responsibility that prescribing imposed on them. Although this awareness was thought to encourage caution and safety, it may also account for the fact that 26% of the nurses (n=8) had not prescribed since qualifying. Nurses felt that the multidisciplinary team had a vital role to play in supporting their prescribing practice as did collaborative working. It is concluded that those working in specialty areas that are less well-defined in terms of scope of practice (e.g. older adult nursing and learning disability) would benefit in particular from ongoing mentoring relationships with experienced prescribers and the development of individual formularies.

Controlled trial of pharmacist intervention in general practice: the effect on prescribing costs.

PubMed

Rodgers, S; Avery, A J; Meechan, D; Briant, S; Geraghty, M; Doran, K; Whynes, D K

1999-09-01

It has been suggested that the employment of pharmacists in general practice might moderate the growth in prescribing costs. However, empirical evidence for this proposition has been lacking. We report the results of a controlled trial of pharmacist intervention in United Kingdom general practice. To determine whether intervention practices made savings relative to controls. An evaluation of an initiative set up by Doncaster Health Authority. Eight practices agreed to take part and received intensive input from five pharmacists for one year (September 1996 to August 1997) at a cost of 163,000 Pounds. Changes in prescribing patterns were investigated by comparing these practices with eight individually matched controls for both the year of the intervention and the previous year. Prescribing data (PACTLINE) were used to assess these changes. The measures used to take account of differences in the populations of the practices included the ASTRO-PU for overall prescribing and the STAR-PU for prescribing in specific therapeutic areas. Differences between intervention and control practices were subjected to Wilcoxon matched-pairs, signed-ranks tests. The median (minimum to maximum) rise in prescribing costs per ASTRO-PU was 0.85 Pound (-1.95 Pounds to 2.05 Pounds) in the intervention practices compared with 2.55 Pounds (1.74 Pounds to 4.65 Pounds) in controls (P = 0.025). Had the cost growth of the intervention group been as high as that of the controls, their total prescribing expenditure would have been around 347,000 Pounds higher. This study suggests that the use of pharmacists did control prescribing expenditure sufficiently to offset their employment costs.

Survey of Prophylactic Antiseizure Drug Use for Nontraumatic Intracerebral Hemorrhage

PubMed Central

Jensen, Matthew B.; Sattar, Ahsan; Sherbini, Khalid Al

2013-01-01

Objective Prophylactic antiseizure drugs (PAD) are commonly prescribed for nontraumatic intracerebral hemorrhage (ICH) despite limited evidence for this indication. We sought to determine the current prescribing patterns of the use of a PAD for ICH. Methods A 36-item survey was distributed to physicians that manage ICH patients soliciting details of PAD prescription in their practice. Results A total of 199 physicians responded to the survey, all of who manage between one and 50 or more ICH patients per year. The respondents were neurologists (32%), neurosurgeons (11%), and intensivists (57%) in academia (69%) and private practice (31%). PAD prescriptions were used: never (33%), 1–33% (35%), 34–66% (14%), 67–99% (9%) of the time, or always (9%). Most respondents performed electroencephalographic and serum level monitoring in at least some patients. Levetiracetam was used most often (60%), followed by fos/phenytoin (37%), for a usual duration of days (36%), weeks (47%), or months (17%). PAD prescription varied by patient characteristics and physician specialty. Perception of physician community consensus regarding PAD use for ICH among respondents ranged from strongly (7%) or weakly (23%) against the practice, to a fairly equal division of opinion (41%), to weakly (27%) or strongly (4%) in favor of the practice. Conclusions We found variability of multiple aspects of the current prescribing patterns and opinions regarding the use of a PAD for ICH. This variability is likely secondary to insufficient data. Clinical equipoise exists for this issue, and controlled trials would be both justified and useful. PMID:23582711

The use of psychotropic medication in patients with emotionally unstable personality disorder under the care of UK mental health services.

PubMed

Paton, Carol; Crawford, Michael J; Bhatti, Sumera F; Patel, Maxine X; Barnes, Thomas R E

2015-04-01

Guideline recommendations for the pharmacologic treatment of personality disorder lack consensus, particularly for emotionally unstable personality disorder (EUPD), and there is limited information on current prescribing practice in the United Kingdom. To characterize the nature and quality of current prescribing practice for personality disorder across the United Kingdom, as part of a quality improvement program. A cross-sectional survey of self-selected psychiatric services providing care for adults with personality disorder (ICD-10 criteria) was conducted. Data were collected during May 2012. Of 2,600 patients with a diagnosis of personality disorder, more than two-thirds (68%) had a diagnosis of EUPD. Almost all (92%) patients in the EUPD subgroup were prescribed psychotropic medication, most commonly an antidepressant or antipsychotic, principally for symptoms and behaviors that characterize EUPD, particularly affective dysregulation. Prescribing patterns were similar between those who had a diagnosed comorbid mental illness and those who had EUPD alone, but the latter group was less likely to have had their medication reviewed over the previous year, particularly with respect to tolerability (53% vs 43%). The use of psychotropic medication in EUPD in the United Kingdom is largely outside the licensed indications. Whether the treatment target is identified as intrinsic symptoms of EUPD or comorbid mental illness may depend on the diagnostic threshold of individual clinicians. Compared with prescribing for EUPD where there is judged to be a comorbid mental illness, the use of off-label medication for EUPD alone is less systematically reviewed and monitored, so opportunities for learning may be lost. Treatment may be continued long term by default. © Copyright 2015 Physicians Postgraduate Press, Inc.

A Technological Innovation to Reduce Prescribing Errors Based on Implementation Intentions: The Acceptability and Feasibility of MyPrescribe.

PubMed

Keyworth, Chris; Hart, Jo; Thoong, Hong; Ferguson, Jane; Tully, Mary

2017-08-01

Although prescribing of medication in hospitals is rarely an error-free process, prescribers receive little feedback on their mistakes and ways to change future practices. Audit and feedback interventions may be an effective approach to modifying the clinical practice of health professionals, but these may pose logistical challenges when used in hospitals. Moreover, such interventions are often labor intensive. Consequently, there is a need to develop effective and innovative interventions to overcome these challenges and to improve the delivery of feedback on prescribing. Implementation intentions, which have been shown to be effective in changing behavior, link critical situations with an appropriate response; however, these have rarely been used in the context of improving prescribing practices. Semistructured qualitative interviews were conducted to evaluate the acceptability and feasibility of providing feedback on prescribing errors via MyPrescribe, a mobile-compatible website informed by implementation intentions. Data relating to 200 prescribing errors made by 52 junior doctors were collected by 11 hospital pharmacists. These errors were populated into MyPrescribe, where prescribers were able to construct their own personalized action plans. Qualitative interviews with a subsample of 15 junior doctors were used to explore issues regarding feasibility and acceptability of MyPrescribe and their experiences of using implementation intentions to construct prescribing action plans. Framework analysis was used to identify prominent themes, with findings mapped to the behavioral components of the COM-B model (capability, opportunity, motivation, and behavior) to inform the development of future interventions. MyPrescribe was perceived to be effective in providing opportunities for critical reflection on prescribing errors and to complement existing training (such as junior doctors' e-portfolio). The participants were able to provide examples of how they would use "If-Then" plans for patient management. Technology, as opposed to other methods of learning (eg, traditional "paper based" learning), was seen as a positive advancement for continued learning. MyPrescribe was perceived as an acceptable and feasible learning tool for changing prescribing practices, with participants suggesting that it would make an important addition to medical prescribers' training in reflective practice. MyPrescribe is a novel theory-based technological innovation that provides the platform for doctors to create personalized implementation intentions. Applying the COM-B model allows for a more detailed understanding of the perceived mechanisms behind prescribing practices and the ways in which interventions aimed at changing professional practice can be implemented. ©Chris Keyworth, Jo Hart, Hong Thoong, Jane Ferguson, Mary Tully. Originally published in JMIR Human Factors (http://humanfactors.jmir.org), 01.08.2017.

Understanding long-term opioid prescribing for non-cancer pain in primary care: a qualitative study.

PubMed

McCrorie, Carolyn; Closs, S José; House, Allan; Petty, Duncan; Ziegler, Lucy; Glidewell, Liz; West, Robert; Foy, Robbie

2015-09-11

The place of opioids in the management of chronic, non-cancer pain is limited. Even so their use is escalating, leading to concerns that patients are prescribed strong opioids inappropriately and alternatives to medication are under-used. We aimed to understand the processes which bring about and perpetuate long-term prescribing of opioids for chronic, non-cancer pain. We held semi-structured interviews with patients and focus groups with general practitioners (GPs). Participants included 23 patients currently prescribed long-term opioids and 15 GPs from Leeds and Bradford, United Kingdom (UK). We used a grounded approach to the analysis of transcripts. Patients are driven by the needs for pain relief, explanation, and improvement or maintenance of quality of life. GPs' responses are shaped by how UK general practice is organised, available therapeutic choices and their expertise in managing chronic pain, especially when facing diagnostic uncertainty or when their own approach is at odds with the patient's wishes. Four features of the resulting transaction between patients and doctors influence prescribing: lack of clarity of strategy, including the risk of any plans being subverted by urgent demands; lack of certainty about locus of control in decision-making, especially in relation to prescribing; continuity in the doctor-patient relationship; and mutuality and trust. Problematic prescribing occurs when patients experience repeated consultations that do not meet their needs and GPs feel unable to negotiate alternative approaches to treatment. Therapeutic short-termism is perpetuated by inconsistent clinical encounters and the absence of mutually-agreed formulations of underlying problems and plans of action. Apart from commissioning improved access to appropriate specialist services, general practices should also consider how they manage problematic opioid prescribing and be prepared to set boundaries with patients.

Smartphone apps to support hospital prescribing and pharmacology education: a review of current provision

PubMed Central

Haffey, Faye; Brady, Richard R W; Maxwell, Simon

2014-01-01

Junior doctors write the majority of hospital prescriptions but many indicate they feel underprepared to assume this responsibility and around 10% of prescriptions contain errors. Medical smartphone apps are now widely used in clinical practice and present an opportunity to provide support to inexperienced prescribers. This study assesses the contemporary range of smartphone apps with prescribing or related content. Six smartphone app stores were searched for apps aimed at the healthcare professional with drug, pharmacology or prescribing content. Three hundred and six apps were identified. 34% appeared to be for use within the clinical environment in order to aid prescribing, 14% out with the clinical setting and 51% of apps were deemed appropriate for both clinical and non-clinical use. Apps with drug reference material, such as textbooks, manuals or medical apps with drug information were the commonest apps found (51%), followed by apps offering drug or infusion rate dose calculation (26%). 68% of apps charged for download, with a mean price of £14.25 per app and a range of £0.62–101.90. A diverse range of pharmacology-themed apps are available and there is further potential for the development of contemporary apps to improve prescribing performance. Personalized app stores may help universities/healthcare organizations offer high quality apps to students to aid in pharmacology education. Users of prescribing apps must be aware of the lack of information regarding the medical expertise of app developers. This will enable them to make informed choices about the use of such apps in their clinical practice. PMID:23488599

Antifungal prescribing pattern and attitude towards the treatment of oral candidiasis among dentists in Jordan.

PubMed

Al-Shayyab, Mohammad H; Abu-Hammad, Osama A; Al-Omiri, Mahmoud K; Dar-Odeh, Najla S

2015-08-01

The aim of this study was to evaluate the attitude of Jordanian dentists towards the treatment of oral candidiasis and their current antifungal prescribing habits, shedding more light on the possible influence of their socio-professional factors on the pattern of prescribing and practice. A structured validated questionnaire was developed and tested; it was then emailed to a random sample of 600 Jordanian dental practitioners during the period of this cross-sectional survey. The questionnaire recorded practitioners' personal details and their attitude and prescribing of antifungal therapy for oral candidiasis. Statistical significance was based on probability values of <0.05 and was measured using the chi-square and Fisher's exact tests. Multiple logistic regression analysis was used to analyse the influence of respondents' socio-professional factors on their attitude towards oral candidiasis. Of the 423 questionnaires returned, only 330 were included. The attitude of respondents was significantly influenced by their experience [odds ratio (OR) = 0.14; P < 0.001] and workplace (OR = 4.70; P < 0.001). Nystatin was the most commonly prescribed antifungal agent (78.2%), followed by miconazole (62.4%), which was prescribed for topical use. Systemic antifungals were prescribed by 21.2% of respondents, with a significant (P < 0.05) association with the country in which their qualification was obtained. The attitude towards the treatment of oral candidiasis is much better among the least-experienced dentists working in private practice. Nystatin and miconazole are the most popular choices of antifungal agents among Jordanian dentists. © 2015 FDI World Dental Federation.

Smartphone apps to support hospital prescribing and pharmacology education: a review of current provision.

PubMed

Haffey, Faye; Brady, Richard R W; Maxwell, Simon

2014-01-01

Junior doctors write the majority of hospital prescriptions but many indicate they feel underprepared to assume this responsibility and around 10% of prescriptions contain errors. Medical smartphone apps are now widely used in clinical practice and present an opportunity to provide support to inexperienced prescribers. This study assesses the contemporary range of smartphone apps with prescribing or related content. Six smartphone app stores were searched for apps aimed at the healthcare professional with drug, pharmacology or prescribing content. Three hundred and six apps were identified. 34% appeared to be for use within the clinical environment in order to aid prescribing, 14% out with the clinical setting and 51% of apps were deemed appropriate for both clinical and non-clinical use. Apps with drug reference material, such as textbooks, manuals or medical apps with drug information were the commonest apps found (51%), followed by apps offering drug or infusion rate dose calculation (26%). 68% of apps charged for download, with a mean price of £14.25 per app and a range of £0.62-101.90. A diverse range of pharmacology-themed apps are available and there is further potential for the development of contemporary apps to improve prescribing performance. Personalized app stores may help universities/healthcare organizations offer high quality apps to students to aid in pharmacology education. Users of prescribing apps must be aware of the lack of information regarding the medical expertise of app developers. This will enable them to make informed choices about the use of such apps in their clinical practice. © 2013 The British Pharmacological Society.

Perceptions and practices regarding herbal medicine prescriptions among physicians in Greater Beirut.

PubMed

Ala Aeddine, Nada; Khayat, Mohamed; Alawieh, Hanaa; Adibilly, Siham; Adib, Salim

2014-01-01

This survey aimed at assessing the perceptions of physicians regarding the appropriateness of prescribing herbal medicines (HM), their prescribing patterns and their knowledge regarding the interaction between HM and conventional drugs. No data are currently available in Lebanon concerning the frequency of HM prescription and indications. HM poorly prescribed can affect the overall quality of health among patients taking conventional drugs. This descriptive survey study was conducted in the Greater Beirut area in Lebanon during May-June 2009. All Primary Health Care (PHC) physicians in private community-based solo practice were identified from the Lebanese Order of Physicians listing, contacted and invited to participate. Those who agreed had to complete a pre-piloted face-to-face questionnaire. Of two hundred twelve participating physicians, 45% routinely prescribed HM to their patients. Between 64 to 67% prescribers believed that HM have more benefits, faster results and fewer side effects than conventional drugs. In addition, 58% thought that HM were less expensive, and 76% that they were easier to take than conventional drugs. More importantly, in a series of eight questions concerning the physicians' knowledge about the possible mechanism of drug-herb interactions, the general tendency was towards poor knowledge. A good percentage of PHC physicians who routinely prescribe HM do not know their mechanism of action or their possible interactions with the conventional drugs. Knowledge about mechanism of drug-herb interactions should be an integral part of the medical curriculum. The knowledge about HM should be an integral part of the medical curriculum as they are frequently prescribed by PHC physicians.

The impact of a general practice group intervention on prescribing costs and patterns.

PubMed Central

Walker, Jane; Mathers, Nigel

2002-01-01

BACKGROUND: The formation of primary care groups (PCGs) and trusts (PCTs) has shifted the emphasis from individual practice initiatives to group-based efforts to control rising prescribing costs. However, there is a paucity of literature describing such group initiatives. We report the results of a multilevel group initiative, involving input from a pharmaceutical adviser, practice comparison feedback, and peer review meetings. AIM: To determine the impact of a prescribing initiative on the prescribing patterns of a group of general practices. DESIGN OF STUDY: A comparative study with non-matched controls. SETTING: Nine semi-rural/rural practices forming a commissioning group pilot, later a PCG, in Southern Derbyshire with nine practices as controls. METHOD: Practice data were collated for overall prescribing and for therapeutic categories, between the years 1997/1998 and 1998/1999 and analysed statistically. Prescribing expenditure trends were also collated. RESULTS: Although both groups came well within their prescribing budgets, in the study group this was for the first time in five years. Their rate of increase in expenditure slowed significantly following the initiative compared with that of the comparison group, which continued to rise (median practice net ingredient cost/patient unit (nic/PU) increase: Pound Sterling0.69 and Pound Sterling3.80 respectively; P = 0.03). The study group's nic/PU dropped below, and stayed below, that of the comparison group one month after the start of the initiative. For most therapeutic categories the study group had lower increases in costs and higher increases in percentage of generic items than the comparison group. Quality markers were unaffected. CONCLUSION: We suggest that practices with diverse prescribing patterns can work together effectively within a PCT locality to control prescribing costs. PMID:12030659

Where to find information about drugs

PubMed Central

Day, Richard O; Snowden, Leone

2016-01-01

SUMMARY Good medicines information is critical to medical practice. Choose high-quality, pre-appraised sources first and make sure they are current. Select the information that is most relevant to the needs of your particular patient. Take the time to become familiar with the features of the resources you use. Australian Medicines Handbook, Therapeutic Guidelines, Australian Prescriber and NPS MedicineWise cover most routine clinical practice needs. PMID:27346917

Cost-effectiveness analysis of HLA-B*58: 01 genetic testing before initiation of allopurinol therapy to prevent allopurinol-induced Stevens-Johnson syndrome/toxic epidermal necrolysis in a Malaysian population.

PubMed

Chong, Huey Yi; Lim, Yi Heng; Prawjaeng, Juthamas; Tassaneeyakul, Wichittra; Mohamed, Zahurin; Chaiyakunapruk, Nathorn

2018-02-01

Studies found a strong association between allopurinol-induced Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) and the HLA-B*58:01 allele. HLA-B*58:01 screening-guided therapy may mitigate the risk of allopurinol-induced SJS/TEN. This study aimed to evaluate the cost-effectiveness of HLA-B*58:01 screening before allopurinol therapy initiation compared with the current practice of no screening for Malaysian patients with chronic gout in whom a hypouricemic agent is indicated. This cost-effectiveness analysis adopted a societal perspective with a lifetime horizon. A decision tree model coupled with Markov models were developed to estimate the costs and outcomes, represented by quality-adjusted life years (QALYs) gained, of three treatment strategies: (a) current practice (allopurinol initiation without HLA-B*58:01 screening); (b) HLA-B*58:01 screening before allopurinol initiation; and (c) alternative treatment (probenecid) without HLA-B*58:01 screening. The model was populated with data from literature review, meta-analysis, and published government documents. Cost values were adjusted for the year 2016, with costs and health outcomes discounted at 3% per annum. A series of sensitivity analysis including probabilistic sensitivity analysis were carried out to determine the robustness of the findings. Both HLA-B*58:01 screening and probenecid prescribing were dominated by current practice. Compared with current practice, HLA-B*58:01 screening resulted in 0.252 QALYs loss per patient at an additional cost of USD 322, whereas probenecid prescribing resulted in 1.928 QALYs loss per patient at an additional cost of USD 2203. One SJS/TEN case would be avoided for every 556 patients screened. At the cost-effectiveness threshold of USD 8695 per QALY, the probability of current practice being the best choice is 99.9%, in contrast with 0.1 and 0% in HLA-B*58:01 screening and probenecid prescribing, respectively. This is because of the low incidence of allopurinol-induced SJS/TEN in Malaysia and the lower efficacy of probenecid compared with allopurinol in gout control. This analysis showed that HLA-B*58:01 genetic testing before allopurinol initiation is unlikely to be a cost-effective intervention in Malaysia.

Integrating clinical pharmacists into the primary health care team: a framework for rational and cost-effective prescribing.

PubMed

Hamley, J H; MacGregor, S H; Dunbar, J A; Cromarty, J A

1997-02-01

A recent Audit Commission report into general practice prescribing identifies areas where general practitioner and pharmacist collaboration could be beneficial. Two such areas are formulary development and repeat prescribing review. Increased generic prescribing is encouraged in the report and in central priorities for Scottish Health Boards. This study was designed to develop and assess the effects on prescribing, of a practice formulary and a procedure for change to generic name prescribing. A practice formulary, standards for generic name prescribing and an approach to prescribing review were agreed, developed and implemented. Formulary compliance and the extent of prescribing generically and of changes to generic prescriptions were assessed by prospective prescription monitoring. Consultations resulting in a prescription reduced from 69% to 59% and 80% of acute prescribing events were met from 144 formulary medicines. Rapid change to generic name prescriptions was achieved without patient complaints and the overall generic prescribing level increased from 57% to 68%. Eighty percent of all new prescriptions were generic.

A Technological Innovation to Reduce Prescribing Errors Based on Implementation Intentions: The Acceptability and Feasibility of MyPrescribe

PubMed Central

Hart, Jo; Thoong, Hong; Ferguson, Jane; Tully, Mary

2017-01-01

Background Although prescribing of medication in hospitals is rarely an error-free process, prescribers receive little feedback on their mistakes and ways to change future practices. Audit and feedback interventions may be an effective approach to modifying the clinical practice of health professionals, but these may pose logistical challenges when used in hospitals. Moreover, such interventions are often labor intensive. Consequently, there is a need to develop effective and innovative interventions to overcome these challenges and to improve the delivery of feedback on prescribing. Implementation intentions, which have been shown to be effective in changing behavior, link critical situations with an appropriate response; however, these have rarely been used in the context of improving prescribing practices. Objective Semistructured qualitative interviews were conducted to evaluate the acceptability and feasibility of providing feedback on prescribing errors via MyPrescribe, a mobile-compatible website informed by implementation intentions. Methods Data relating to 200 prescribing errors made by 52 junior doctors were collected by 11 hospital pharmacists. These errors were populated into MyPrescribe, where prescribers were able to construct their own personalized action plans. Qualitative interviews with a subsample of 15 junior doctors were used to explore issues regarding feasibility and acceptability of MyPrescribe and their experiences of using implementation intentions to construct prescribing action plans. Framework analysis was used to identify prominent themes, with findings mapped to the behavioral components of the COM-B model (capability, opportunity, motivation, and behavior) to inform the development of future interventions. Results MyPrescribe was perceived to be effective in providing opportunities for critical reflection on prescribing errors and to complement existing training (such as junior doctors’ e-portfolio). The participants were able to provide examples of how they would use “If-Then” plans for patient management. Technology, as opposed to other methods of learning (eg, traditional “paper based” learning), was seen as a positive advancement for continued learning. Conclusions MyPrescribe was perceived as an acceptable and feasible learning tool for changing prescribing practices, with participants suggesting that it would make an important addition to medical prescribers’ training in reflective practice. MyPrescribe is a novel theory-based technological innovation that provides the platform for doctors to create personalized implementation intentions. Applying the COM-B model allows for a more detailed understanding of the perceived mechanisms behind prescribing practices and the ways in which interventions aimed at changing professional practice can be implemented. PMID:28765104

Treatment of gonorrhoea in Auckland, New Zealand: marked variation in prescriber adherence to treatment guidelines.

PubMed

Forster, Rose; Ng, Diana; Upton, Arlo; Franklin, Rick; Thomas, Mark

2017-06-01

The relentless emergence and spread of strains of Neisseria gonorrhoeae that are resistant to many antimicrobial agents has led to frequent changes in treatment guidelines, with a consequent risk that prescribers may not be aware of current guidelines. To determine the proportion of patients with gonorrhoea who were treated with a regimen consistent with the New Zealand Sexual Health Society (NZSHS) guidelines. We audited the treatment given to adult patients with laboratory-proven gonorrhoea in Auckland, New Zealand, during the first 6 months of 2015. Treatment compliant with the current NZSHS guidelines was administered in only 65% (458/706) episodes overall. Guideline-compliant treatment was much more likely to be prescribed for patients who presented to a sexual health clinic (89%) than for patients who presented to either a general practice or other community clinic (52%) or to a hospital (56%) (P < 0.0001). Overall, 52 of 706 (7%) episodes were not treated with any antimicrobial regimen by the service that diagnosed the patients' gonorrhoea, 13 of 62 (21%) episodes in patients who presented to a hospital, 34 of 403 (8%) episodes in patients who presented to a general practice or other community clinic and 5 of 241 (2%) episodes in patients who presented to a sexual health clinic (P < 0.0001). Low levels of compliance with treatment guidelines increase the risk that antibiotic-resistant strains of N. gonorrhoeae will spread within the Auckland region. Improved compliance with treatment guidelines, particularly in patients who present either to general practice or to hospitals, is necessary to maintain the efficacy of current treatment regimens. © 2017 Royal Australasian College of Physicians.

Effective Feedback to Improve Primary Care Prescribing Safety (EFIPPS) a pragmatic three-arm cluster randomised trial: designing the intervention (ClinicalTrials.gov registration NCT01602705).

PubMed

Barnett, Karen N; Bennie, Marion; Treweek, Shaun; Robertson, Christopher; Petrie, Dennis J; Ritchie, Lewis D; Guthrie, Bruce

2014-10-11

High-risk prescribing in primary care is common and causes considerable harm. Feedback interventions have small/moderate effects on clinical practice, but few trials explicitly compare different forms of feedback. There is growing recognition that intervention development should be theory-informed, and that comprehensive reporting of intervention design is required by potential users of trial findings. The paper describes intervention development for the Effective Feedback to Improve Primary Care Prescribing Safety (EFIPPS) study, a pragmatic three-arm cluster randomised trial in 262 Scottish general practices. The NHS chose to implement a feedback intervention to utilise a new resource, new Prescribing Information System (newPIS). The development phase required selection of high-risk prescribing outcome measures and design of intervention components: (1) educational material (the usual care comparison), (2) feedback of practice rates of high-risk prescribing received by both intervention arms and (3) a theory-informed behaviour change component to be received by one intervention arm. Outcome measures, educational material and feedback design, were developed with a National Health Service Advisory Group. The behaviour change component was informed by the Theory of Planned Behaviour and the Health Action Process Approach. A focus group elicitation study and an email Delphi study with general practitioners (GPs) identified key attitudes and barriers of responding to the prescribing feedback. Behaviour change techniques were mapped to the psychological constructs, and the content was informed by the results of the elicitation and Delphi study. Six high-risk prescribing measures were selected in a consensus process based on importance and feasibility. Educational material and feedback design were based on current NHS Scotland practice and Advisory Group recommendations. The behaviour change component was resource constrained in development, mirroring what is feasible in an NHS context. Four behaviour change interventions were developed and embedded in five quarterly rounds of feedback targeting attitudes, subjective norms, perceived behavioural control and action planning (2×). The paper describes a process which is feasible to use in the resource-constrained environment of NHS-led intervention development and documents the intervention to make its design and implementation explicit to potential users of the trial findings. ClinicalTrials.gov: NCT01602705.

Teaching Prescribing: Just What the Doctor Ordered? A Thematic Analysis of the Views of Newly Qualified Doctors

PubMed Central

Hansen, Christina R.; Walsh, Elaine K.; Bradley, Colin P.; Sahm, Laura J.

2017-01-01

Undergraduate medical education has been criticised for failing to adequately prepare doctors for the task of prescribing. Pharmacists have been shown to improve medication use in hospitals. This study aims to elicit the views of intern doctors on the challenges of prescribing, and to suggest changes in education to enhance prescribing practice and potential role of the pharmacist. Semi-structured, qualitative interviews were conducted with intern doctors in their first year post qualification in an Irish hospital. Data collection was conducted until no new themes emerged and thematic analysis was performed. Thirteen interviews took place. Interns described training in practical prescribing as limited and felt the curriculum failed to convey the reality of actual prescribing. Pharmacists were perceived to be a useful, but underutilised, information source in the prescribing process. They requested an earlier introduction, and repeated exposure, to prescribing, and suggested the involvement of peers and pharmacists in this teaching. Intern doctors reported difficulties in applying knowledge gained in medical school to clinical practice. New strategies are needed to enhance the clinical relevance of the medical curriculum by rethinking the learning outcomes regarding prescribing practice and the involvement of pharmacists in prescribing education. PMID:28970444

A transdisciplinary approach to understanding the health effects of wildfire and prescribed fire smoke regimes

NASA Astrophysics Data System (ADS)

Williamson, G. J.; Bowman, D. M. J. S.; Price, O. F.; Henderson, S. B.; Johnston, F. H.

2016-12-01

Prescribed burning is used to reduce the occurrence, extent and severity of uncontrolled fires in many flammable landscapes. However, epidemiologic evidence of the human health impacts of landscape fire smoke emissions is shaping fire management practice through increasingly stringent environmental regulation and public health policy. An unresolved question, critical for sustainable fire management, concerns the comparative human health effects of smoke from wild and prescribed fires. Here we review current knowledge of the health effects of landscape fire emissions and consider the similarities and differences in smoke from wild and prescribed fires with respect to the typical combustion conditions and fuel properties, the quality and magnitude of air pollution emissions, and the potential for dispersion to large populations. We further examine the interactions between these considerations, and how they may shape the longer term smoke regimes to which populations are exposed. We identify numerous knowledge gaps and propose a conceptual framework that describes pathways to better understanding of the health trade-offs of prescribed and wildfire smoke regimes.

Derivation of a needs based capitation formula for allocating prescribing budgets to health authorities and primary care groups in England: regression analysis

PubMed Central

Rice, Nigel; Dixon, Paul; Lloyd, David C E F; Roberts, David

2000-01-01

Objective To develop a weighted capitation formula for setting target allocations for prescribing expenditures for health authorities and primary care groups in England. Design Regression analysis relating prescribing costs to the demographic, morbidity, and mortality composition of practice lists. Setting 8500 general practices in England. Subjects Data from the 1991 census were attributed to practice lists on the basis of the place of residence of the practice population. Main outcome measures Variation in age, sex, and temporary resident originated prescribing units (ASTRO(97)-PUs) adjusted net ingredient cost of general practices in England for 1997-8 modelled for the impact of health and social needs after controlling for differences in supply. Results A needs gradient based on the four variables: permanent sickness, percentage of dependants in no carer households, percentage of students, and percentage of births on practice lists. These, together with supply characteristics, explained 41% of variation in prescribing costs per ASTRO(97)-PU adjusted capita across practices. The latter alone explained about 35% of variation in total costs per head across practices. Conclusions The model has good statistical specification and contains intuitively plausible needs drivers of prescribing expenditure. Together with adjustments made for differences in ASTRO(97)-PUs the model is capable of explaining 62% (35%+0.65% (41%)) of variation in prescribing expenditure at practice level. The results of the study have formed the basis for setting target budgets for 1999-2000 allocations for prescribing expenditure for health authorities and primary care groups. PMID:10650026

A multilevel analysis of trimethoprim and ciprofloxacin prescribing and resistance of uropathogenic Escherichia coli in general practice.

PubMed

Vellinga, Akke; Murphy, Andrew W; Hanahoe, Belinda; Bennett, Kathleen; Cormican, Martin

2010-07-01

A retrospective analysis of databases was performed to describe trimethoprim and ciprofloxacin prescribing and resistance in Escherichia coli within general practices in the West of Ireland from 2004 to 2008. Antimicrobial susceptibility testing was performed by disc diffusion methods according to the CLSI methods and criteria on significant E. coli isolates (colony count >10(5) cfu/mL) from urine samples submitted from general practice. Data were collected over a 4.5 year period and aggregated at practice level. Data on antimicrobial prescribing of practices were obtained from the national Irish prescribing database, which accounts for approximately 70% of all medicines prescribed in primary care. A multilevel model (MLwiN) was fitted with trimethoprim/ciprofloxacin resistance rates as outcome and practice prescribing as predictor. Practice and individual routinely collected variables were controlled for in the model. Seventy-two general practices sent between 13 and 720 (median 155) samples that turned out to be E. coli positive. Prescribing at practice level was significantly correlated with the probability of antimicrobial-resistant E. coli with an odds ratio of 1.02 [95% confidence interval (CI) 1.01-1.04] for every additional prescription of trimethoprim per 1000 patients per month in the practice and 1.08 (1.04-1.11) for ciprofloxacin. Age was a significant risk factor in both models. Higher variation between practices was found for ciprofloxacin as well as a yearly increase in resistance. Comparing a 'mean' practice with 1 prescription per month with one with 10 prescriptions per month showed an increase in predicted probability of a resistant E. coli for the 'mean' patient from 23.9% to 27.5% for trimethoprim and from 3.0% to 5.5% for ciprofloxacin. A higher level of antimicrobial prescribing in a practice is associated with a higher probability of a resistant E. coli for the patient. The variation in antimicrobial resistance levels between practices was relatively higher for ciprofloxacin than for trimethoprim.

Barriers to and enablers of implementing antimicrobial stewardship programs in veterinary practices.

PubMed

Hardefeldt, Laura Y; Gilkerson, J R; Billman-Jacobe, H; Stevenson, M A; Thursky, K; Bailey, K E; Browning, G F

2018-03-23

Antimicrobial stewardship (AMS) programs are yet to be widely implemented in veterinary practice and medical programs are unlikely to be directly applicable to veterinary settings. To gain an in-depth understanding of the factors that influence effective AMS in veterinary practices in Australia. A concurrent explanatory mixed methods design was used. The quantitative phase of the study consisted of an online questionnaire to assess veterinarians' attitudes to antimicrobial resistance (AMR) and antimicrobial use in animals, and the extent to which AMS currently is implemented (knowingly or unknowingly). The qualitative phase used semi-structured interviews to gain an understanding of the barriers to and enablers of AMS in veterinary practices. Data were collected and entered into NVivo v.11, openly coded and analyzed according to mixed methods data analysis principles. Companion animal, equine, and bovine veterinarians participated in the study. Veterinary practices rarely had antimicrobial prescribing policies. The key barriers were a lack of AMS governance structures, client expectations and competition between practices, cost of microbiological testing, and lack of access to education, training and AMS resources. The enablers were concern for the role of veterinary antimicrobial use in development of AMR in humans, a sense of pride in the service provided, and preparedness to change prescribing practices. Our study can guide development and establishment of AMS programs in veterinary practices by defining the major issues that influence the prescribing behavior of veterinarians. © 2018 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.

Variations in Mental Health Diagnosis and Prescribing Across Pediatric Primary Care Practices

PubMed Central

Mayne, Stephanie L.; Ross, Michelle E.; Song, Lihai; McCarn, Banita; Steffes, Jennifer; Liu, Weiwei; Margolis, Benyamin; Azuine, Romuladus; Gotlieb, Edward; Grundmeier, Robert W.; Leslie, Laurel K.; Localio, Russell; Wasserman, Richard

2016-01-01

BACKGROUND: Primary care pediatricians increasingly care for children’s mental health problems, but little is known about practice-level variation in diagnosis and psychotropic medication prescribing practices. METHODS: This retrospective review of electronic heath records from 43 US primary care practices included children aged 4 to 18 years with ≥1 office visit from January 1, 2009, to June 30, 2014. We examined variability in diagnosis and psychotropic prescribing across practices using logistic regression with practice fixed effects and evaluated associations of the availability of colocated or community-based mental health providers or the proportion of children in foster care with diagnosis and prescribing using generalized linear mixed models. RESULTS: Among 294 748 children, 40 932 (15%) received a mental health diagnosis and 39 695 (14%) were prescribed psychotropic medication. Attention deficit/hyperactivity disorder was most commonly diagnosed (1%–16% per practice). The proportion of children receiving any psychotropic medication (4%-26%) and the proportion receiving ≥2 medication classes (1%-12%) varied across practices. Prescribing of specific medication classes also varied (stimulants, 3%–18%; antidepressants, 1%–12%; α-agonists, 0%–8%; second-generation antipsychotics, 0%–5%). Variability was partially explained by community availability of psychiatrists (significantly higher odds of a diagnosis or prescription when not available) but not by colocation of mental health professionals or percentage of children in foster care. CONCLUSIONS: The prevalence of mental health diagnosis and psychotropic medication prescribing varies substantially across practices and is only partially explained by psychiatrist availability. Research is needed to better define the causes of variable practice-level diagnosis and prescribing and implications for child mental health outcomes. PMID:27244791

Improving specialist drug prescribing in primary care using task and error analysis: an observational study.

PubMed

Chana, Narinder; Porat, Talya; Whittlesea, Cate; Delaney, Brendan

2017-03-01

Electronic prescribing has benefited from computerised clinical decision support systems (CDSSs); however, no published studies have evaluated the potential for a CDSS to support GPs in prescribing specialist drugs. To identify potential weaknesses and errors in the existing process of prescribing specialist drugs that could be addressed in the development of a CDSS. Semi-structured interviews with key informants followed by an observational study involving GPs in the UK. Twelve key informants were interviewed to investigate the use of CDSSs in the UK. Nine GPs were observed while performing case scenarios depicting requests from hospitals or patients to prescribe a specialist drug. Activity diagrams, hierarchical task analysis, and systematic human error reduction and prediction approach analyses were performed. The current process of prescribing specialist drugs by GPs is prone to error. Errors of omission due to lack of information were the most common errors, which could potentially result in a GP prescribing a specialist drug that should only be prescribed in hospitals, or prescribing a specialist drug without reference to a shared care protocol. Half of all possible errors in the prescribing process had a high probability of occurrence. A CDSS supporting GPs during the process of prescribing specialist drugs is needed. This could, first, support the decision making of whether or not to undertake prescribing, and, second, provide drug-specific parameters linked to shared care protocols, which could reduce the errors identified and increase patient safety. © British Journal of General Practice 2017.

Risk Management for Opioid Prescribing in the Treatment of Patients With Pain From Cancer or Terminal Illness: Inadvertent Oversight or Taboo?

PubMed

Copenhaver, David J; Karvelas, Nicolas B; Fishman, Scott M

2017-11-01

As the United States experiences an epidemic of prescription drug abuse, and guidelines on safe practices in prescribing opioids in chronic pain have subsequently emerged from professional organizations and governmental agencies, limited guidance exists for prescribers of opioids to treat pain in patients with cancer or terminal illness. Patients with active cancer or terminal illness often have pain and are frequently prescribed opioids and other controlled substances. Current studies suggest that patients with cancer have similar rates of risk for misuse, abuse, and addiction as the general public. Moreover, palliative care and hospice programs appear poorly prepared for assessing or managing patients with aberrant behaviors or evidence of drug abuse. Further research and professional consensus are needed to help address the challenges associated with misuse, abuse, and addiction in patients with cancer and terminal illness.

A methodological protocol for selecting and quantifying low-value prescribing practices in routinely collected data: an Australian case study.

PubMed

Brett, Jonathan; Elshaug, Adam G; Bhatia, R Sacha; Chalmers, Kelsey; Badgery-Parker, Tim; Pearson, Sallie-Anne

2017-05-03

Growing imperatives for safety, quality and responsible resource allocation have prompted renewed efforts to identify and quantify harmful or wasteful (low-value) medical practices such as test ordering, procedures and prescribing. Quantifying these practices at a population level using routinely collected health data allows us to understand the scale of low-value medical practices, measure practice change following specific interventions and prioritise policy decisions. To date, almost all research examining health care through the low-value lens has focused on medical services (tests and procedures) rather than on prescribing. The protocol described herein outlines a program of research funded by Australia's National Health and Medical Research Council to select and quantify low-value prescribing practices within Australian routinely collected health data. We start by describing our process for identifying and cataloguing international low-value prescribing practices. We then outline our approach to translate these prescribing practices into indicators that can be applied to Australian routinely collected health data. Next, we detail methods of using Australian health data to quantify these prescribing practices (e.g. prevalence of low-value prescribing and related costs) and their downstream health consequences. We have approval from the necessary Australian state and commonwealth human research ethics and data access committees to undertake this work. The lack of systematic and transparent approaches to quantification of low-value practices in routinely collected data has been noted in recent reviews. Here, we present a methodology applied in the Australian context with the aim of demonstrating principles that can be applied across jurisdictions in order to harmonise international efforts to measure low-value prescribing. The outcomes of this research will be submitted to international peer-reviewed journals. Results will also be presented at national and international pharmacoepidemiology and health policy forums such that other jurisdictions have guidance to adapt this methodology.

Case Report: Activity Diagrams for Integrating Electronic Prescribing Tools into Clinical Workflow

PubMed Central

Johnson, Kevin B.; FitzHenry, Fern

2006-01-01

To facilitate the future implementation of an electronic prescribing system, this case study modeled prescription management processes in various primary care settings. The Vanderbilt e-prescribing design team conducted initial interviews with clinic managers, physicians and nurses, and then represented the sequences of steps carried out to complete prescriptions in activity diagrams. The diagrams covered outpatient prescribing for patients during a clinic visit and between clinic visits. Practice size, practice setting, and practice specialty type influenced the prescribing processes used. The model developed may be useful to others engaged in building or tailoring an e-prescribing system to meet the specific workflows of various clinic settings. PMID:16622168

Impacts of prescribed fire on ecosystem C and N cycles at Fort Benning Installation, Georgia

NASA Astrophysics Data System (ADS)

Zhao, S.; Liu, S.; Tieszen, L.

2007-12-01

A critical challenge for the land managers at military installation is to maintain the ecological sustainability of natural resources while meeting the needs of military training. Prescribed ground fire as a land management practice has been used to remove the ground layer plants at Fort Benning for two purposes: to facilitate access for military training, and to maintain and restore fire-adapted longleaf pine communities that are critical habitat for the federally endangered red-cockaded woodpecker (Picoides borealis). Nevertheless, the impacts of prescribed fire on ecosystem processes and health are not well-understood and quantified at the plot to regional scales. Frequent fire may result in ecosystem nitrogen (N) deficiency due to repeated N loss through combustion, volatilization, and leaching, threatening ecosystem sustainability at Fort Benning. On the other hand, N loss may be offset by enhanced symbiotic N2 fixation since fire favors herbaceous legumes by scarifying legume seeds and stimulating germination. Quantifying the impacts of prescribed fire on ecosystem carbon (C) and N cycles is further complicated by interactions and feedbacks among burning, nitrogen inputs, other land use practices (e.g. tree thinning or clear-cutting), and soil properties. In this study, we used the Erosion-Deposition-Carbon Model (EDCM), a process-based biogeochemical model, to simulate C and N dynamic at Fort Benning under different combinations of fire frequency, fire intensity, nitrogen deposition, legume nitrogen input, forest harvesting, and soil sand content. Model simulations indicated that prescribed fire led to nitrogen losses from ecosystems at Fort Benning, especially with high intensity and high frequency fires. Forest harvesting further intensified ecosystem nitrogen limitation, leading to reduced biophysical potential of C sequestration. The adverse impacts of prescribed fire and forest harvesting on C and N cycles were much higher in more sandy soil than in less sandy soil. N inputs from nitrogen deposition and legume N fixation helped replenish N losses to some extent. However, N losses due to fire and harvesting were not balanced or exceeded under current atmospheric N deposition and legume N input rates, suggesting additional N input (e.g., fertilization) may be needed to maintain the sustainability of current ecosystem states and management practices at Fort Benning.

Independent extended and supplementary nurse prescribing practice in the UK: a national questionnaire survey.

PubMed

Courtenay, Molly; Carey, Nicola; Burke, Joanna

2007-09-01

Nurses are able to prescribe independently from a list of nearly 250 prescription only medicines for a range of over 100 medical conditions or, from the whole British National Formulary as a supplementary prescriber. There is some evidence available on the prescribing practices of district nurses and health visitors and early independent extended prescribers. Little or no attention has focussed on supplementary nurse prescribing. To provide an overview of the prescribing practices of independent extended/supplementary nurse prescribers and the factors that facilitate or inhibit prescribing. National questionnaire survey. United Kingdom. A convenience sample of 868 qualified independent extended/supplementary nurse prescribers self-completed a written questionnaire. A total of 756 (87%) used independent extended prescribing; 304 (35%) used supplementary prescribing to treat a range of chronic conditions (including asthma, diabetes and hypertension); 710 (82%) nurses worked in primary care. Nurses in general practice reported the largest number of reasons preventing prescribing. Reasons included the inability to computer generate prescriptions and to implement the Clinical Management Plan. Nurses in primary care reported more continuing professional development needs. These needs included update on prescribing policy and the treatment management of conditions. A total of 277 (32%) nurses were unable to access continuing professional development. Independent extended/supplementary nurse prescribers work predominantly in primary care and do prescribe medicines. These nurses are highly qualified and have many years clinical experience. Supplementary prescribing is used by a minority of nurses. Implementing the Clinical Management Plan is a barrier preventing the use of this mode of prescribing. The continuing professional development needs of independent extended/supplementary nurse prescribers are frequently unmet. It will become increasingly important that these needs are met once nurses are able to prescribe the full range of medicines included in the British National Formulary, limited only by their area of competence.

Antibiotic prescribing for respiratory infections at retail clinics, physician practices, and emergency departments.

PubMed

Mehrotra, Ateev; Gidengil, Courtney A; Setodji, Claude M; Burns, Rachel M; Linder, Jeffrey A

2015-04-01

To compare antibiotic prescribing among retail clinics, primary care practices, and emergency departments (EDs) for acute respiratory infections (ARIs): antibiotics-may-be-appropriate ARIs (eg, sinusitis) and antibiotics-never-appropriate ARIs (eg, acute bronchitis). We analyzed retail clinic data from the electronic health records of the 3 largest retail clinic chains in the United States, and data on visits to primary care practices and EDs from the nationally representative National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Using multivariate models, we estimated an adjusted antibiotic prescribing rate for each site of care, controlling for differences in patient characteristics and diagnosis. From 2007 to 2009 in the United States, there were 3 million, 167 million, and 29 million ARI visits at retail clinics, primary care practices, and EDs, respectively. For all ARI visits, the adjusted antibiotic prescribing rate at retail clinics (58%) was similar to the rate at primary care practices (62%; P=.09) and EDs (59%; P=.48). For antibiotics-may-be-appropriate ARI visits, the adjusted antibiotic prescribing rate (95%) at retail clinics was higher than at primary care practices (85%; P<.01) and EDs (83%; P<.01). For antibiotics-never-appropriate ARI visits, the adjusted antibiotic prescribing rate (34%) at retail clinics was lower than at primary care practices (51%; P<.01) and EDs (48%; P<.01). Compared with primary care practices and EDs, there was no difference at retail clinics in overall ARI antibiotic prescribing. At retail clinics, antibiotic prescribing was more diagnosis-appropriate.

An audit of adherence to heart failure guidelines in an Australian hospital: A pharmacist perspective.

PubMed

Khalil, Viviane; Danninger, Melanie; Wang, Wei; Khalil, Hanan

2017-12-01

The Australian National Heart Foundation Guidelines have been developed to guide clinicians on how to best manage chronic heart failure (CHF) patients according to the current best available evidence. The primary aim of this study is to evaluate the proportion of patients prescribed evidence-based therapy (EBT) for CHF on discharge at this Australian metropolitan hospital and factors affecting its prescribing. The secondary aims are to examine the proportion of patients prescribed EBT on discharge on cardiac wards compared to medical wards and to explore the role of the pharmacist in the management of these patients. A retrospective audit of patients' medical notes who were admitted consecutively for CHF management was conducted over 6 months to examine their management. The results showed at discharge, a total of 52% of patients were discharged on angiotensin converting enzyme inhibitors/angiotensin receptor blockers, 49% were discharged on β-blockers, 15% were on Aldosterone receptor antagonists, 90% were discharged on diuretics, and 29% were discharged on Digoxin. The main determinants of prescribing EBT on discharge were the presence of prescribing contraindications and patients' comorbidities. Patients discharged from cardiac wards were more likely to be prescribed EBT than if discharged on medical wards. Furthermore, in the subset of the cohort who was reviewed by a pharmacist during admission, a higher percentage of patients were discharged on EBT compared with those who did not have a pharmaceutical input. This study highlighted existing gaps between the National CHF Guidelines and clinical prescribing practice in this hospital. Patients who were discharged from cardiac wards were more likely to be prescribed medications concordant with the guidelines, and there is further opportunity for pharmacists to assist in closing gaps in prescribing practice by the promotion of adherence to these guidelines. © 2017 John Wiley & Sons, Ltd.

Prescribing for pain--how do nurses contribute? A national questionnaire survey.

PubMed

Stenner, Karen; Carey, Nicola; Courtenay, Molly

2012-12-01

To provide information on the profile and practice of nurses in the UK who prescribe medication for pain. Pain is widely under-reported and under-treated and can have negative consequences for health and psychosocial well-being. Indications are that nurses can improve treatment and access to pain medications when they prescribe. Whilst nurses working in many practice areas treat patients with pain, little is known about the profile, prescribing practice or training needs of these nurses. A descriptive questionnaire survey. An online questionnaire was used to survey 214 nurses who prescribed for pain in the UK between May and July 2010. Data were analysed using descriptive statistics and non-parametric tests. Half the participants (50%) worked in primary care, 32% in secondary care and 14% worked across care settings. A range of services were provided, including general practice, palliative care, pain management, emergency care, walk-in-centres and out-of-hours. The majority (86%) independently prescribed 1-20 items per week. Non-opioid and weak opioids analgesics were prescribed by most (95%) nurses, whereas fewer (35%) prescribed strong opioids. Training in pain had been undertaken by 97% and 82% felt adequately trained, although 28% had problems accessing training. Those with specialist training prescribed a wider range of pain medications, were more likely to prescribe strong opioids and were more often in pain management roles. Nurses prescribe for pain in a range of settings with an emphasis on the treatment of minor ailments and acute pain. A range of medications are prescribed, and most nurses have access to training. The nursing contribution to pain treatment must be acknowledged within initiatives to improve pain management. Access to ongoing training is required to support nurse development in this area of practice to maximise benefits. © 2012 Blackwell Publishing Ltd.

Development of consensus guidance to facilitate service redesign around pharmacist prescribing in UK hospital practice.

PubMed

Tonna, Antonella; McCaig, Dorothy; Diack, Lesley; West, Bernice; Stewart, Derek

2014-10-01

The last decade has seen a drive towards non-medical prescribing in the United Kingdom (UK). However, there is a dearth of any published literature on applying the principles of service redesign to support pharmacist prescribing in any sphere of practice. To develop consensus guidance to facilitate service redesign around pharmacist prescribing. UK hospital practice. The Delphi technique was used to measure consensus of a panel of expert opinion holders in Scotland. Individuals with key strategic and operational roles in implementing initiatives of pharmacy practice and medicines management were recruited as experts. An electronic questionnaire consisting of 30 statements related to pharmacist prescribing service redesign was developed. These were presented as five-point Likert scales with illustrative quotes. Consensus, defined as 70 % of panel members agreeing (ranked strongly agree/agree) with each statement. Responses were obtained from 35/40 (87.5 %) experts in round one and 29 (72.5 %) in round two. Consensus in round one was achieved for 27/30 of statements relating to aspects of generic 'service development' (e.g. succession planning, multidisciplinary working, quality evaluation, practice development and outcome measures) and 'pharmacist prescribing role development' (e.g. education and future orientation of service). Issues of disagreement were around targeting of pharmacist prescribing to clinical specialities and financial remuneration for prescribing in the hospital setting. Consensus guidance has been developed to facilitate service redesign around hospital pharmacist prescribing.

Understanding the delayed prescribing of antibiotics for respiratory tract infection in primary care: a qualitative analysis.

PubMed

Ryves, R; Eyles, C; Moore, M; McDermott, L; Little, P; Leydon, G M

2016-11-18

To identify general practitioner (GP) views and understanding on the use of delayed prescribing in primary care. Qualitative semistructured telephone interview study. Primary care general practices in England. 32 GPs from identified high-prescribing and low-prescribing general practices in England. Semistructured telephone interviews were conducted with GPs identified from practices within clinical commissioning groups with the highest and lowest prescribing rates in England. A thematic analysis of the data was conducted to generate themes. All GPs had a good understanding of respiratory tract infection (RTI) management and how the delayed prescribing approach could be used in primary care. However, GPs highlighted factors that were influential as to whether delayed prescribing was successfully carried out during the consultation. These included the increase in evidence of antimicrobial resistance, and GPs' prior experiences of using delayed prescribing during the consultation. The patient-practitioner relationship could also influence treatment outcomes for RTI, and a lack of an agreed prescribing strategy within and between practices was considered to be of significance to GPs. Participants expressed that a lack of feedback on prescribing data at an individual and practice level made it difficult to know if delayed prescribing strategies were successful in reducing unnecessary consumption. GPs agreed that coherent and uniform training and guidelines would be of some benefit to ensure consistent prescribing throughout the UK. Delayed prescribing is encouraged in primary care, but is not always implemented successfully. Greater uniformity within and between practices in the UK is needed to operationalise delayed prescribing, as well as providing feedback on the uptake of antibiotics. Finally, GPs may need further guidance on how to answer the concerns of patients without interpreting these questions as a demand for antibiotics, as well as educating the patient about antimicrobial resistance and supporting a good patient-practitioner relationship. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Antibiotic prescribing in dental practice in Belgium.

PubMed

Mainjot, A; D'Hoore, W; Vanheusden, A; Van Nieuwenhuysen, J-P

2009-12-01

To assess the types and frequency of antibiotic prescriptions by Belgian dentists, the indications for antibiotic prescription, and dentists' knowledge about recommended practice in antibiotic use. In this cross-sectional survey, dental practitioners were asked to record information about all antibiotics prescribed to their patients during a 2-week period. The dental practitioners were also asked to complete a self-administered questionnaire regarding demographic data, prescribing practices, and knowledge about antibiotic use. A random sample of 268 Belgian dentists participated in the survey. During the 2-week period, 24 421 patient encounters were recorded; 1033 patients were prescribed an antibiotic (4.2%). The median number of prescriptions per dentist for the 2 weeks was 3. Broad spectrum antibiotics were most commonly prescribed: 82% of all prescriptions were for amoxycillin, amoxycillin-clavulanic acid and clindamycin. Antibiotics were often prescribed in the absence of fever (92.2%) and without any local treatment (54.2%). The most frequent diagnosis for which antibiotics were prescribed was periapical abscess (51.9%). Antibiotics were prescribed to 63.3% of patients with periapical abscess and 4.3% of patients with pulpitis. Patterns of prescriptions were confirmed by the data from the self-reported practice. Discrepancies between observed and recommended practice support the need for educational initiatives to promote rational use of antibiotics in dentistry in Belgium.

A qualitative study to explore influences on general practitioners' decisions to prescribe new drugs.

PubMed

Jacoby, Ann; Smith, Monica; Eccles, Martin

2003-02-01

Ensuring appropriate prescribing is an important challenge for the health service, and the need for research that takes account of the reasons behind individual general practitioners' (GPs) prescribing decisions has been highlighted. To explore differences among GPs in their decisions to prescribe new drugs. Qualitative approach, using in-depth semistructured interviews. Northern and Yorkshire Health Authority Region. Participants were identified from a random sample of 520 GPs in a quantitative study of patterns of uptake of eight recently introduced drugs. Purposeful sampling ensured inclusion of GPs prescribing any of the eight drugs and working in a range of practice settings. Fifty-six GPs were interviewed, using a topic guide. Interviews were recorded on audiotape. Transcribed text was methodically coded and data were analysed by constantly comparing emerging themes. Both low and high prescribers shared a view of themselves as conservative in their prescribing behaviour. Low prescribers appeared to conform more strongly to group norms and identified a consensus among practice partners in prescribing and cost-consciousness. Conformism to group norms was represented by a commitment to practice formularies. High prescribers more often expressed themselves to be indifferent to drug costs and a shared practice ethos. A shift in the attitudes of some GPs is required before cost-effectiveness is routinely incorporated in drug prescribing. The promotion of rational prescribing is likely to be more successful if efforts are focused on GPs' appreciation of cost issues and attitudes towards shared decision-making and responsibility.

Enfranchising the Profession through Evaluation: A Story from Australia

ERIC Educational Resources Information Center

Clinton, Janet; Dawson, Georgia

2018-01-01

Educational reform in Australia recognizes the need for an effective teacher evaluation system but has fallen short of actually prescribing one. Current practice does not align to policy intent, with teacher evaluation largely an exercise in compliance around performance management as opposed to a process that promotes evaluative thinking,…

Developing Accounting Students' Listening Skills: Barriers, Opportunities and an Integrated Stakeholder Approach

ERIC Educational Resources Information Center

Stone, Gerard; Lightbody, Margaret; Whait, Rob

2013-01-01

Accountants and employers of accounting graduates consider listening to be among the most important communication skills that graduates possess. However, accounting education practices that develop students' listening skills are uncommon. Further, in the case of listening development, the current approach of prescribing that educators do more to…

Principles of educational outreach ('academic detailing') to improve clinical decision making.

PubMed

Soumerai, S B; Avorn, J

1990-01-26

With the efficacy and costs of medications rising rapidly, it is increasingly important to ensure that drugs be prescribed as rationally as possible. Yet, physicians' choices of drugs frequently fall short of the ideal of precise and cost-effective decision making. Evidence indicates that such decisions can be improved in a variety of ways. A number of theories and principles of communication and behavior changes can be found that underlie the success of pharmaceutical manufacturers in influencing prescribing practices. Based on this behavioral science and several field trials, it is possible to define the theory and practice of methods to improve physicians' clinical decision making to enhance the quality and cost-effectiveness of care. Some of the most important techniques of such "academic detailing" include (1) conducting interviews to investigate baseline knowledge and motivations for current prescribing patterns, (2) focusing programs on specific categories of physicians as well as on their opinion leaders, (3) defining clear educational and behavioral objectives, (4) establishing credibility through a respected organizational identity, referencing authoritative and unbiased sources of information, and presenting both sides of controversial issues, (5) stimulating active physician participation in educational interactions, (6) using concise graphic educational materials, (7) highlighting and repeating the essential messages, and (8) providing positive reinforcement of improved practices in follow-up visits. Used by the nonprofit sector, the above techniques have been shown to reduce inappropriate prescribing as well as unnecessary health care expenditures.

A Canadian perspective on anterior cervical discectomies: practice patterns and preferences

PubMed Central

Bennardo, Michael; Farrokhyar, Forough; Martyniuk, Amanda; Reddy, Kesava

2018-01-01

Background The purpose of this study is to elucidate the current practice patterns of Canadian neurosurgeons with regards to anterior cervical discectomy (ACD). Methods A one-page questionnaire was sent out using SurveyMonkey to all neurosurgeon members of the Canadian Neurological Sciences Federation (CNSF). End points were surgeon preference for ACD surgical method, graft source, the length of collar usage and the recommended time before returning to work. Results Response rate was 74.0%. Of the responders, 75.0% performed single level ACD and 18.3% had completed spine fellowships. The majority (68.2%) chose ACD with fusion and plating (ACDFP) as their preferred method with allograft being the most popular choice of fusion material (44.3%). Most of the respondents did not prescribe collars (60.9%) and when they did, hard collar was prescribed most often (76.9%) and AspenTM collar was the most popular choice (67.7%). The majority of surgeons chose ‘other’ as their response for length of time for collar use (40.0%) while allowing them to take their collars off at night (78.1%). Most of the surgeons recommended physiotherapy post-operatively (58.1%) and time to physiotherapy was 6–8 weeks. Recommended back to work time was 6 weeks for 44.9% of respondents. In the cross analysis, surgeons who performed ACDF were more likely to prescribe collars (50%, P=0.01) versus surgeons who performed ACDFP (21.7%, P=0.01). Conclusions Our survey is an up to date description of current practice patterns for ACD amongst Canadian neurosurgeons. PMID:29732425

Management of Current Psychiatric Disorders

PubMed Central

Carbonnel, François; David, Michel; Norton, Joanna; Bourrel, Gérard; Boulenger, Jean-Philippe; Capdevielle, Delphine

2016-01-01

Objective: Describe and analyse the experience of family physicians in managing current psychiatric disorders to obtain a better understanding of the underlying reasons of under-detection and inadequate prescribing identified in studies. Methods: A qualitative study using in-depth interviews. Sample of 15 practicing family physicians, recruited by telephone from a precedent cohort (Sesame1) with a maximum variation: sex, age, single or group practice, urban or rural. Qualitative method is inspired by the completed grounded theory of a verbatim semiopragmatic analysis from 2 experts in this approach. Results: Family physicians found that current psychiatric disorders were related to psychological symptoms in reaction to life events. Their role was to make patients aware of a psychiatric symptom rather than establish a diagnosis. Their management responsibility was considered in contrasting ways: it was claimed or endured. They defined their position as facilitating compliance to psychiatrist consultations, while assuring a complementary psychotherapeutic approach. Prescribing medication was not a priority for them. Conclusions: The identified under-detection is essentially due to inherent frontline conditions and complexity of clinical forms. The family physician role, facilitating compliance to psychiatrist consultations while assuring a support psychotherapy is the main result of this study. More studies should be conducted to define more accurately the clinical reality, management and course of current psychiatric disorders in primary care.

Optometry Australia Scope of Practice Survey 2015.

PubMed

Kiely, Patricia M; Cappuccio, Skye; McIntyre, Ellen

2017-05-01

This paper presents results from the inaugural Scope of Practice Survey of Optometry Australia members conducted in October 2015. The survey gathered information related to confidence in detecting and diagnosing key ocular conditions, grading diabetic retinopathy, prescribing scheduled medicines, access to equipment, confidence using equipment, incidence of patients requiring therapeutic management, referral practices and services provided. The survey was developed, piloted, modified and administered to members of Optometry Australia (excluding student and retired members), who had a current email address. Results were collated and analysed using Microsoft Excel. Of the 587 optometrists in clinical practice who responded, 254 (43 per cent) had therapeutic endorsement of registration. The majority of respondents practised in a major city or surrounding suburbs (63 per cent). Independent practice was the most frequently cited practice type (58 per cent). The estimated average number of patients seen in a week was 48; there was a steady decrease in the number of patients per week with increasing age, from 53 for optometrists in their 20s to 27 for optometrists aged over 70. There was very high confidence (over 93 per cent) in ability to grade diabetic retinopathy and diagnose a range of ocular conditions. Confidence in performance of more advanced techniques was higher for endorsed than non-endorsed optometrists. Approximately 12 per cent of patients required a Schedule 4 therapeutic prescription. The most frequently recommended over-the-counter medications were for dry eye for both endorsed and non-endorsed optometrists. The most frequently prescribed Schedule 4 medications were anti-inflammatories. The most challenging conditions to prescribe for were glaucoma, microbial keratitis and uveitis. Approximately one in six therapeutically endorsed optometrists reported unexpected side effects of medications they had prescribed. Information from the survey will guide Optometry Australia in the design of continuing professional development programs and other materials. © 2017 Optometry Australia.

Sharing resources to create a district drug formulary: a countywide controlled trial.

PubMed Central

Hill-Smith, I

1996-01-01

BACKGROUND: Creating a drug formulary takes considerable time, but merely adopting one lacks local perspective and ownership. Sharing resources between several practices treads a middle path between these extremes, but is it effective? AIM: The aim of the study was to audit the influence of a district primary care drug formulary on prescribing by general practitioners. METHOD: A controlled trial was carried out to compare prescribing by 50 general practitioners from 11 urban and semirural practices in south Bedfordshire that participated in creating a district drug formulary with prescribing by all other general practitioners in the county. RESULTS: The proportion of prescription items that were for drugs listed in the formulary rose significantly in three therapeutics groups: cardiovascular (by 7-12% above control practice values); musculoskeletal (by 1-11% above control practice values); and obstetrics and gynaecology (by 6-9% above control practice values). The number of items prescribed per prescribing unit fell significantly in three therapeutic groups: musculoskeletal (by 1-7% below control practice values); nervous (by 7-12% below control practice values); and nutrition and blood (by 15-21% below control practice values). The estimated saving resulting from the creation of the formulary was 150,000 pounds (3000 pounds per doctor) per year. CONCLUSIONS: Sharing resources between practices to create a district-wide primary care drug formulary can lead to changes in prescribing and reduce costs sustained over 3 years. PMID:8762741

When human immunodeficiency virus (HIV) treatment goals conflict with guideline-based opioid prescribing: A qualitative study of HIV treatment providers.

PubMed

Starrels, Joanna L; Peyser, Deena; Haughton, Lorlette; Fox, Aaron; Merlin, Jessica S; Arnsten, Julia H; Cunningham, Chinazo O

2016-01-01

Human immunodeficiency virus (HIV)-infected patients have a high prevalence of chronic pain and opioid use, making HIV care a critical setting for improving the safety of opioid prescribing. Little is known about HIV treatment providers' perspectives about opioid prescribing to patients with chronic pain. The authors administered a questionnaire and conducted semistructured telephone interviews with 18 HIV treatment providers (infectious disease specialists, general internists, family medicine physicians, nurse practitioners, and physician assistants) in Bronx, NY. Open-ended interview questions focused on providers' experiences, beliefs, and attitudes about opioid prescribing and about the use of guideline-based opioid prescribing practices (conservative prescribing, and monitoring for and responding to misuse). Transcripts were thematically analyzed using a modified grounded theory approach. Eighteen HIV treatment providers included 13 physicians, four nurse practitioners, and one physician assistant. They were 62% female, 56% white, and practiced as HIV treatment providers for a mean of 14.6 years. Most reported always or almost always using opioid treatment agreements (56%) and urine drug testing (61%) with their patients on long-term opioid therapy. HIV treatment providers tended to view opioid prescribing for chronic pain within the "HIV paradigm," a set of priorities and principles defined by three key themes: (1) primacy of HIV goals, (2) familiarity with substance use, and (3) the clinician as ally. The HIV paradigm sometimes supported, and sometimes conflicted with, guideline-based opioid prescribing practices. For HIV treatment providers, perceived alignment with the HIV paradigm determined whether and how guideline-based opioid prescribing practices were adopted. For example, the primacy of HIV goals superseded conservative opioid prescribing when providers prescribed opioids with the goal of retaining patients in HIV care. These findings highlight unique factors in HIV care that influence adoption of guideline-based opioid prescribing practices. These factors should be considered in future research and initiatives to address opioid prescribing in HIV care.

Characterisation of antibiotic prescriptions for acute respiratory tract infections in Danish general practice: a retrospective registry based cohort study.

PubMed

Aabenhus, Rune; Hansen, Malene Plejdrup; Saust, Laura Trolle; Bjerrum, Lars

2017-05-19

Inappropriate use of antibiotics is contributing to the increasing rates of antimicrobial resistance. Several Danish guidelines on antibiotic prescribing for acute respiratory tract infections in general practice have been issued to promote rational prescribing of antibiotics, however it is unclear if these recommendations are followed. We aimed to characterise the pattern of antibiotic prescriptions for patients diagnosed with acute respiratory tract infections, by means of electronic prescriptions, labeled with clinical indications, from Danish general practice. Acute respiratory tract infections accounted for 456,532 antibiotic prescriptions issued between July 2012 and June 2013. Pneumonia was the most common indication with 178,354 prescriptions (39%), followed by acute tonsillitis (21%) and acute otitis media (19%). In total, penicillin V accounted for 58% of all prescriptions, followed by macrolides (18%) and amoxicillin (15%). The use of second-line agents increased with age for all indications, and comprised more than 40% of the prescriptions in patients aged >75 years. Women were more often prescribed antibiotics regardless of clinical indication. This is the first Danish study to characterise antibiotic prescription patterns for acute respiratory tract infections by data linkage of clinical indications. The findings confirm that penicillin V is the most commonly prescribed antibiotic agent for treatment of patients with an acute respiratory tract infection in Danish general practice. However, second-line agents like macrolides and amoxicillin with or without clavulanic acid are overused. Strategies to improve the quality of antibiotic prescribing especially for pneumonia, acute otitis media and acute rhinosinusitis are warranted. TRACKING THE OVERUSE OF ANTIBIOTICS: Better adherence to guidelines for prescribing antibiotics for different respiratory tract infections are warranted in Danish general practice. The over-use of antibiotics, particularly so-called 'second-line' agents such as amoxicillin, increases resistance and may lead to a potentially catastrophic scenario where antibiotics are no longer effective. Exactly how widespread the over-use of antibiotics is for different infections, however, is not clear. Rune Aabenhus at the University of Copenhagen and co-workers analyzed primary care data regarding antibiotic prescriptions for acute respiratory tract infections including pneumonia and ear infections in Denmark. They found that penicillin V-the current recommended first-line drug in Scandinavian countries-accounted for 58 per cent of prescriptions, a figure which should be improved. Amoxicillin and macrolides were over-prescribed, particularly in elderly patients. The team also call for further analysis of prescriptions given by out-of-hours clinics.

Improving opioid safety practices in primary care: protocol for the development and evaluation of a multifaceted, theory-informed pilot intervention for healthcare providers

PubMed Central

Leece, Pamela; Buchman, Daniel Z; Hamilton, Michael; Timmings, Caitlyn; Shantharam, Yalnee; Moore, Julia; Furlan, Andrea D

2017-01-01

Introduction In North America, drug overdose deaths are reaching unprecedented levels, largely driven by increasing prescription opioid-related deaths. Despite the development of several opioid guidelines, prescribing behaviours still contribute to poor patient outcomes and societal harm. Factors at the provider and system level may hinder or facilitate the application of evidence-based guidelines; interventions designed to address such factors are needed. Methods and analysis Using implementation science and behaviour change theory, we have planned the development and evaluation of a comprehensive Opioid Self-Assessment Package, designed to increase adherence to the Canadian Opioid Guideline among family physicians. The intervention uses practical educational and self-assessment tools to provide prescribers with feedback on their current knowledge and practices, and resources to improve their practice. The evaluation approach uses a pretest and post-test design and includes both quantitative and qualitative methods at baseline and 6 months. We will recruit a purposive sample of approximately 10 family physicians in Ontario from diverse practice settings, who currently treat patients with long-term opioid therapy for chronic pain. Quantitative data will be analysed using basic descriptive statistics, and qualitative data will be analysed using the Framework Method. Ethics and dissemination The University Health Network Research Ethics Board approved this study. Dissemination plan includes publications, conference presentations and brief stakeholder reports. This evidence-informed, theory-driven intervention has implications for national application of opioid quality improvement tools in primary care settings. We are engaging experts and end users in advisory and stakeholder roles throughout our project to increase its national relevance, application and sustainability. The performance measures could be used as the basis for health system quality improvement indicators to monitor opioid prescribing. Additionally, the methods and approach used in this study could be adapted for other opioid guidelines, or applied to other areas of preventive healthcare and clinical guideline implementation processes. PMID:28446522

Current practice of methylprednisolone administration for acute spinal cord injury in Germany: a national survey.

PubMed

Druschel, Claudia; Schaser, Klaus-Dieter; Schwab, Jan M

2013-05-15

Written mail-out survey. To determine current practice in high-dose methylprednisolone succinate (MPSS) administration for treatment of acute spinal cord injury (SCI) in Germany. Reanalysis of the National Acute Spinal Cord Injury Studies (NASCIS) resulted in criticism of the use of high-dose MPSS for treatment of acute SCI. Subsequently, SCI treatment guidelines were revised leading to a reduction in MPSS use across North America. The impact of these revisions on SCI treatment in Germany is not known. A questionnaire was sent to all trauma, orthopedic and neurosurgical departments of German university centers, affiliated teaching hospitals, and specialized SCI care centers. Survey included 6 questions about the administration of MPSS after acute SCI. Three hundred seventy-two respondents completed the survey (response rate: 51% overall, 76% university hospitals, 85% specialized SCI care centers). Overall, 55% of departments that treat SCI prescribe MPSS. Among them, 73% are "frequent" users administering MPSS to more than 50% of their patients. Ten percent prescribe according to NASCIS I, 43% NASCIS II, 33% NASCIS III, and 13% "generic protocols." As justification for MPSS treatment, "effectiveness" ranked before "common practice" and "medicolegal reasons." "Specialized" SCI care centers differ in that (1) MPSS is administered less frequently, (2) NASCIS I doses are not used, and (3) during the past several years, practice patterns are more likely to have shifted away from the treatment of SCI with MPSS. About one-half of the institutions continue to prescribe MPSS in the setting of acute SCI. A need for further education in almost one-fourth of German departments treating acute SCI is demonstrated through responses indicating use of the outdated NASCIS I protocol, a "legal need" or "unchanged MPSS application during the last years." "Specialized" SCI centers are more likely to change their practice in accordance with evolving literature. 3.

Prescription patterns and adequacy of blood pressure control among adult hypertensive patients in Kenya; findings and implications.

PubMed

Mbui, Jennifer M; Oluka, Margaret N; Guantai, Eric M; Sinei, Kipruto A; Achieng, Loice; Baker, Amanj; Jande, Mary; Massele, Amos; Godman, Brian

2017-11-01

Hypertension is a major cause of global morbidity and mortality, with high prevalence rates in Africa including Kenya. Consequently, it is imperative to understand current treatment approaches and their effectiveness in practice. Currently, there is paucity of such data in Kenya, which is a concern. The aim is to describe prescribing patterns and adequacy of blood pressure (BP) control in adult hypertensive patients to guide future practice. Retrospective study of patients attending a sub-county outpatient clinic combined with qualitative interviews. 247 hypertensive patients, predominantly female, mean age 55.8 years on antihypertensive therapy for 1-5 years, were analyzed. ACEIs and thiazide diuretics were the most commonly prescribed drugs, mainly as combination therapy. Treatment typically complied with guidelines, mainly for stage 2 hypertension (75%). BP control was observed in 46% of patients, with a significant reduction in mean systolic (155 to 144 mmHg) and diastolic (91 to 83 mmHg) BP (P < 0.001). Patients on ≥2 antihypertensive drugs were more likely to have uncontrolled BP (OR:1.9, p = 0.021). Encouragingly good adherence to guidelines was helped by training. Poor blood pressure control in the majority needs to be addressed. Additional training of prescribers and follow-up of measures to improve BP control will be introduced and followed up.

Characteristics of prescribers whose patients shop for opioids: results from a cohort study.

PubMed

Cepeda, M Soledad; Fife, Daniel; Berlin, Jesse A; Mastrogiovanni, Gregory; Yuan, Yingli

2012-01-01

Little is known about the prevalence of opioid shoppers in clinical practices and the relation between prescriber characteristics and the risk of having opioid shoppers. Describe the prevalence of opioid shoppers in prescribers' practices. Assess the relation between prescribers' characteristics and patient opioid shopping behavior. Retrospective cohort study using a large US retail prescription database. Patients with ≥1 opioid dispensing were followed 18 months. These patients' prescribers are the focus of the study. A patient was a "shopper" if he or she had opioid prescriptions written by ≥1 prescriber with ≥1 day of overlap filled at ≥3 pharmacies and a "heavy shopper" if he or she had ≥5 shopping episodes. The proportions of shoppers by prescriber and the proportion of prescribers with ≥1 shopper or heavy shopper were calculated. Among 858,290 opioid prescribers, most (87 percent) had no shoppers and 98 percent had no heavy shoppers. Prescribers who were aged 70-79 years, male, or who prescribed schedule II opioids had an increased likelihood of having shoppers. As the number of patients for whom a prescriber prescribed opioids increased, the proportion of shoppers also increased. Prescribers with 66 or more patients receiving opioids, who represented 25 percent of prescribers, prescribed for 82 percent of all shoppers. The great majority of opioid prescribers appear to have no shoppers in their practice. Any educational program will be more cost effective if targeted to prescribers of schedule II opioids with a large volume of patients requiring opioids.

Opioid Prescribing Education in Surgical Residencies: A Program Director Survey.

PubMed

Yorkgitis, Brian K; Bryant, Elizabeth; Raygor, Desiree; Brat, Gabriel; Smink, Douglas S; Crandall, Marie

Opioid abuse and misuse is a public health crisis. A national effort to reduce this phenomenon is ongoing. Residents represent a large pool of opioid prescribers but, are often not the target for opioid prescribing education (OPE). We developed a survey to assess current opioid prescribing practices and education among surgical residents. An Institutional Review Board and Association of Program Directors in Surgery approved survey was electronically mailed to surgical program directors (PDs). The survey included questions regarding residency type, location, number of graduates per year, perceived value of OPE, residency policy on prescribing outpatients controlled substances, presence of OPE, and preferred method of OPE. A total of 248 PDs were e-mailed the survey with 110 complete responses (44.4%). Of all 104 (94.5%) allow residents to prescribe outpatient opioids with 24 (23.1%) limiting the opioid class prescribed. A total of 29 (27.9%) programs require residents to obtain their own Drug Enforcement Administration registration. Only 22 (20.0%) programs had in place mandatory OPE, 7 (6.4%) PDs were unsure if OPE was a mandatory educational requirement. Furthermore, 70 (79.5%) of programs currently without OPE are considering adding it. Didactic lecture (18, 81.8%) is the most common modality for OPE. The mode time dedicated to OPE was 1 hour. When PDs were asked about which method would be best to deliver OPE, the most common response was case-based scenarios (39, 35.5%). Bivariate statistics were performed and no association was found between OPE and program characteristics'. Most surgical residency programs allow residents to prescribe outpatient opioids, very few require OPE. The most common method of OPE was didactic lectures. To enhance a resident's knowledge in prescribing opioids, programs should incorporate OPE into their curriculum. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

The identification of depression and the coverage of antidepressant drug prescriptions in Italian general practice.

PubMed

Bellantuono, Cesario; Mazzi, Maria Angela; Tansella, Michele; Rizzo, Raffaella; Goldberg, David

2002-10-01

Studies on antidepressant prescriptions in general practice need to assess the level of prescriptions relative to the need for them ('coverage'), and the variability among doctors. Two different cut-off scores on a screening test for depression (the Personal Health Questionnaire, PHQ) are used to predict rates for depression, and rates for depressive patients thought likely to benefit from antidepressants (according to a severity criterion) in primary care patients. These two rates are compared with assessments by 11 GPs of recognised depression, as well as with rates of drug prescribed. The rate for depression thought likely to be treated with antidepressants estimated with the PHQ is broadly comparable with the rate for conspicuous depressive illness, and much lower than that predicted by the PHQ for depression. There was great variability between GPs in their ability to detect depression, and their preparedness to prescribe antidepressants. Antidepressants were only prescribed for 3.5% of the patients, compared to the 8.9% thought to need them. However, antidepressants, mostly SSRIs, are much more likely to be prescribed than tranquillisers. The limitations of the study are that the PHQ is able to estimate 'coverage' but not 'focusing' (the proportion of those receiving antidepressants who needed them). Although the rate for conspicuous depression is similar to that for depressions thought to be treated with antidepressants, the 'coverage' of antidepressants was only 39.3%. The variability between physicians confirm the need of good practice guidelines and training packages for the identification and management of depression. Large epidemiological studies are needed to overcome the current lack of clinically relevant data on the quality of antidepressant prescriptions in general practice.

Misprescribing controlled substances: An evaluation of a professional development program.

PubMed

Dewey, Charlene M; Ghulyan, Marine V; Swiggart, William H

2016-01-01

Controlled prescription drug (CPD) abuse has reached epidemic proportions in the United States. Most physicians attending a 3-day continuing medical education (CME) professional development program (PDP) lack training in identifying risk and in managing patients who misuse CPDs. To address this issue, the authors conducted an evaluation of a PDP that trains physicians on proper prescribing, identifying substance abuse, utilizing screening, brief intervention, and referral to treatment (SBIRT), and implementing motivational interviewing (MI). The authors conducted a program evaluation to assess the efficacy and impact of the PDP on physicians' knowledge and prescribing behaviors. Participants (N = 174) were typically middle-aged (average age of 53 years), male (89%), and physicians (82%) and other health care professionals (18%). Many physicians practice in solo primary care settings (46%). Course evaluations were completed by n = 155 (89%) participants who rated the course and presenters highly (mean 4.8/5 respectively). Physicians' knowledge scores on pre/post assessments increased significantly: pretest (M = 58.7, SD = 13.12) and posttest (M = 78.28, SD = 9.83) (t(173) = 20.06, P ≤ .0001, 95% confidence interval, CI: [-21.51, -17.65]). Almost half of the participants, n = 83/174 (48%), completed the follow-up survey, and 93% agreed/strongly agreed (A/SA) they made professional practice changes. Of participants practicing with an active DEA (Drug Enforcement Administration) registration (n = 57), most agreed/strongly agreed they implemented changes to align their practices with current guidelines (89%), used CPD more appropriately (87%), implemented office policies on prescribing (81%), identified and referred more substance abuse patients to treatment (80%), shared new information/experience from course with other 25 health professionals (93%), and felt the course positively impacted their behaviors personally and professionally (90% and 96%, respectively). This is the first known study evaluating a PDP in this population. Results demonstrated participant satisfaction and improvement in prescribers' knowledge and self-reported prescribing behaviors. However, further study is needed to assess actual clinical practice changes, direct impact on patient outcomes, and rates of recidivism.

Opportunities and challenges to improving antibiotic prescribing practices through a One Health approach: results of a comparative survey of doctors, dentists and veterinarians in Australia

PubMed Central

Zhuo, Annie; Norris, Jacqueline M; Gilbert, Gwendolyn L; Ward, Michael P; Bajorek, Beata V; Degeling, Chris; Rowbotham, Samantha J; Dawson, Angus; Nguyen, Ky-Anh; Hill-Cawthorne, Grant A; Sorrell, Tania C; Govendir, Merran; Kesson, Alison M; Iredell, Jonathan R

2018-01-01

Objectives To explore and compare the knowledge, attitudes and experiences of doctors, dentists and veterinarians (as prescribers) in relation to antibiotic use and antibiotic resistance (AbR), and to consider the implications of these for policy-making that support a One Health approach. Design A cross-sectional survey conducted online. Setting Doctors, dentists and veterinarians practising in primary, secondary or tertiary care in Australia. Participants 547 doctors, 380 dentists and 403 veterinarians completed the survey. Main outcome measures Prescribers’ knowledge, attitudes and perceptions of AbR, the extent to which a range of factors are perceived as barriers to appropriate prescribing practices, and perceived helpfulness of potential strategies to improve antibiotic prescribing in practice. Results There was substantial agreement across prescriber groups that action on AbR is required by multiple sectors and stakeholders. However, prescribers externalised responsibility to some extent by seeing the roles of others as more important than their own in relation to AbR. There were common and context-specific barriers to optimal prescribing across the prescriber groups. Prescriber groups generally perceived restrictive policies as unhelpful to supporting appropriate prescribing in their practice. Conclusions The results have implications for implementing a One Health approach that involves doctors, dentists and veterinarians as key players to tackling the crisis of AbR. The findings are that (1) prescribers understand and are likely receptive to a One Health policy approach to AbR, (2) policy development should be sensitive to barriers that are specific to individual prescriber groups and (3) the development and introduction of interventions that might be perceived as reducing prescriber autonomy will need to be carefully designed and implemented. PMID:29602857

A 5-year retrospective audit of prescribing by a critical care outreach team.

PubMed

Wilson, Mark

2018-05-01

UK prescribing legislation changes made in 2006 and 2012 enabled appropriately qualified nurses to prescribe any licensed medication, and all controlled drugs in schedule 2-5 of the Misuse of Drugs Regulations 2001, for any medical condition within their clinical competence. Critical Care Outreach nurses who are independent nurse prescribers are ideally placed to ensure that acutely ill patients receive treatment without delay. The perceived challenge was how Critical Care Outreach nurses would be able to safely prescribe for a diverse patient group. This study informs this developing area of nurse prescribing in critical care practice. The aims of the audit were to: identify which medications were prescribed; develop a critical care outreach formulary; identify the frequency, timing and number of prescribing decisions being made; identify if prescribing practice changed over the years and provide information for our continuing professional development. This article reports on data collected from a 5-year retrospective audit; of prescribing activity undertaken by nine independent nurse prescribers working in a 24/7 Critical Care Outreach team of a 600-bedded district general hospital in the UK. In total, 8216 medication items were prescribed, with an average of 2·6 prescribed per shift. The most commonly prescribed items were intravenous fluids and analgesia, which were mostly prescribed at night and weekends. The audit has shown that Critical Care Outreach nurse prescribing is feasible in a whole hospital patient population. The majority of prescribing occurred after 16:00 and at night. Further research would be beneficial, particularly looking at patient outcomes following reviews from prescribing critical care outreach nurses. The audit is one of the only long-term studies that describes prescribing practice in Critical Care Outreach teams in the UK. © 2017 British Association of Critical Care Nurses.

The prescribing practices of nurses who care for patients with skin conditions: a questionnaire survey.

PubMed

Carey, Nicola; Courtenay, Molly; Stenner, Karen

2013-07-01

To explore the practice of nurses who prescribe medication for patients with skin conditions. Nurses have lead roles in dermatology services. In the United Kingdom, nurses in primary care frequently prescribe medicines for skin conditions, but there are concerns about role preparation and access to continuing professional development. The prescribing practices of nurse independent supplementary prescribers who care for patients with skin conditions are under-researched. Cross-sectional survey. An online questionnaire was used to survey 186 nurses who prescribed for skin conditions from May-July 2010. Data were analysed using descriptive statistics and nonparametric tests. The majority worked in primary care (78%) and general practice (111, 59.7%). Twenty (10.8%) had specialist modules (at diploma, degree or master's level), 104 (55.9%) had dermatology training (e.g. study days), 44 (23.7%) had no training, and a further 18 (9.6%) did not respond. Oral antibiotics, topical antifungal and antibacterial drugs were frequently prescribed. Nurses with specialist dermatology training used their qualification in a greater number of ways, prescribed the broadest range of products and prescribed more items per week. Over 70% reporting on continuing professional development had been able to access it. A large number of nurses in primary care prescribe medicines for skin conditions and are involved in medicines management activities. Lack of specialist dermatology training is a concern and associated with lower prescribing-related activities. Access to dermatology training and continuing professional development are required to support nurse development in this area of practice and maximise benefits. Nurse prescribers' involvement in medicines management activities has important implications in terms of improving access to services, efficiency and cost savings. To maximise their contribution, improved provision of specialist dermatology training is required. This will be of interest to education providers and service planners in the UK and countries around the world. © 2013 John Wiley & Sons Ltd.

Trends, geographical variation and factors associated with prescribing of gluten-free foods in English primary care: a cross-sectional study.

PubMed

Walker, Alex J; Curtis, Helen J; Bacon, Seb; Croker, Richard; Goldacre, Ben

2018-04-16

There is substantial disagreement about whether gluten-free foods should be prescribed on the National Health Service. We aim to describe time trends, variation and factors associated with prescribing gluten-free foods in England. English primary care. English general practices. We described long-term national trends in gluten-free prescribing, and practice and Clinical Commissioning Group (CCG) level monthly variation in the rate of gluten-free prescribing (per 1000 patients) over time. We used a mixed-effect Poisson regression model to determine factors associated with gluten-free prescribing rate. There were 1.3 million gluten-free prescriptions between July 2016 and June 2017, down from 1.8 million in 2012/2013, with a corresponding cost reduction from £25.4 million to £18.7 million. There was substantial variation in prescribing rates among practices (range 0 to 148 prescriptions per 1000 patients, IQR 7.3-31.8), driven in part by substantial variation at the CCG level, likely due to differences in prescribing policy. Practices in the most deprived quintile of deprivation score had a lower prescribing rate than those in the highest quintile (incidence rate ratio 0.89, 95% CI 0.87 to 0.91). This is potentially a reflection of the lower rate of diagnosed coeliac disease in more deprived populations. Gluten-free prescribing is in a state of flux, with substantial clinically unwarranted variation between practices and CCGs. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Evaluation of Health Plan Interventions to Influence Chronic Opioid Therapy Prescribing

PubMed Central

Saunders, Kathleen; Shortreed, Susan; Thielke, Stephen; Turner, Judith A.; LeResche, Linda; Beck, Randi; Von Korff, Michael

2015-01-01

Objectives Evaluate health plan interventions targeting physician chronic opioid therapy (COT) prescribing. Methods In 2006, Group Health’s (GH) integrated group practice (IGP) initiated diverse interventions targeting COT prescriber norms and practices. In 2010, the IGP implemented a COT guideline, including a mandated online course for physicians managing COT. These interventions were not implemented in GH’s network practices. We compared trends in GH-IGP and network practices for 2006–12 in the percent of patients receiving COT and their opioid dose. We compared physician beliefs before versus after the mandated course and pre- to post-course changes in COT dosing for IGP physicians who took the course. Results From 2006 to 2012, mean (SE) daily opioid dose among IGP COT patients (intervention setting) declined from 74.1 (1.9) mg. morphine equivalent dose (MED) to 48.3 (1.0) mg. MED. Dose changes among GH network COT patients (control setting) were modest—88.2 (5.0) mg. MED in 2006 to 75.7 (2.3) mg. MED in 2012. Among physicians taking the mandated course in 2011, we observed pre- to post-course changes toward more conservative opioid prescribing beliefs. However, COT dosing trends did not change pre- to post-course. Discussion Following initiatives implemented to alter physician prescribing practices and norms, mean opioid dose prescribed to COT patients declined more in intervention than control practices. Physicians reported more conservative beliefs regarding opioid prescribing immediately after completing an online course in 2011, but the course was not associated with additional reductions in mean daily opioid dose prescribed by physicians completing the course. PMID:25621426

Differential prescribing of opioid analgesics according to physician specialty for Medicaid patients with chronic noncancer pain diagnoses.

PubMed

Ringwalt, Chris; Gugelmann, Hallam; Garrettson, Mariana; Dasgupta, Nabarun; Chung, Arlene E; Proescholdbell, Scott K; Skinner, Asheley Cockrell

2014-01-01

Despite >20 years of studies investigating the characteristics of patients seeking or receiving opioid analgesics, research characterizing factors associated with physicians' opioid prescribing practices has been inconclusive, and the role of practitioner specialty in opioid prescribing practices remains largely unknown. To examine the relationships between physicians' and other providers' primary specialties and their opioid prescribing practices among patients with chronic noncancer pain (CNCP). Prescriptions for opioids filled by 81,459 Medicaid patients with CNCP in North Carolina (USA), 18 to 64 years of age, enrolled at any point during a one-year study period were examined. χ2<⁄span> statistics were used to examine bivariate differences in prescribing practices according to specialty. For multivariable analyses, maximum-likelihood logistic regression models were used to examine the effect of specialty on prescribing practices, controlling for patients' pain diagnoses and demographic characteristics. Of prescriptions filled by patients with CNCP, who constituted 6.4% of the total sample of 1.28 million individuals, 12.0% were for opioids. General practitioner⁄family medicine specialists and internists were least likely to prescribe opioids, and orthopedists were most likely. Across specialties, men were more likely to receive opioids than women, as were white individuals relative to other races⁄ethnicities. In multivariate analyses, all specialties except internal medicine had higher odds of prescribing an opioid than general practitioners: orthopedists, OR 7.1 (95% CI 6.7 to 7.5); dentists, OR 3.5 (95% CI 3.3 to 3.6); and emergency medicine physicians, OR 2.7 (95% CI 2.6 to 2.8). Significant differences in opioid prescribing practices across prescriber specialties may be reflective of differing norms concerning the appropriateness of opioids for the control of chronic pain. If so, sharing these norms across specialties may improve the care of patients with CNCP.

Prescribers prefer people: The sources of information used by doctors for prescribing suggest that the medium is more important than the message

PubMed Central

McGettigan, P; Golden, J; Fryer, J; Chan, R; Feely, J

2001-01-01

Aims The sources of prescribing information are legion but there is little knowledge about which are actually used in practice by doctors when prescribing. The aims of this study were to determine the sources of prescribing information considered important by doctors, establish which were used in practice, and investigate if hospital and primary care physicians differed in their use of the sources. Methods Two hundred general practitioners (GPs) and 230 hospital doctors were asked to rate information sources in terms of their importance for prescribing ‘old’ and ‘new’ drugs, and then to name the source from which information about the last new drug prescribed was actually derived. Results Among 108 GPs, the Drugs and Therapeutics Bulletin and medical journal articles were most frequently rated as important for information on both old and new drugs while pharmaceutical representatives and hospital/consultant recommendations were more important for information on new drugs, as opposed to old. In practice, information on the last new drug prescribed was derived from pharmaceutical representatives in 42% of cases and hospital/consultant recommendations in 36%, with other sources used infrequently. Among 118 hospital doctors, the British National Formulary (BNF) and senior colleagues were of greatest theoretical importance. In practice, information on the last new drug prescribed was derived from a broad range of sources: colleagues, 29%; pharmaceutical representatives, 18%; hospital clinical meetings, 15%; journal articles, 13%; lectures, 10%. GPs and hospital doctors differed significantly in their use of pharmaceutical representatives (42% vs 18%) and colleagues (7% vs 29%) as sources of prescribing information (P < 0.0001 for both). Conclusions The sources most frequently rated important in theory were not those most used in practice, especially among GPs. Both groups under-estimated the importance of pharmaceutical representatives. Most importantly, the sources of greatest practical importance were those involving the transfer of information through the medium of personal contact. PMID:11259994

Differential prescribing of opioid analgesics according to physician specialty for Medicaid patients with chronic noncancer pain diagnoses

PubMed Central

Ringwalt, Chris; Gugelmann, Hallam; Garrettson, Mariana; Dasgupta, Nabarun; Chung, Arlene E; Proescholdbell, Scott K; Skinner, Asheley Cockrell

2014-01-01

BACKGROUND: Despite >20 years of studies investigating the characteristics of patients seeking or receiving opioid analgesics, research characterizing factors associated with physicians’ opioid prescribing practices has been inconclusive, and the role of practitioner specialty in opioid prescribing practices remains largely unknown. OBJECTIVE: To examine the relationships between physicians’ and other providers’ primary specialties and their opioid prescribing practices among patients with chronic noncancer pain (CNCP). METHODS: Prescriptions for opioids filled by 81,459 Medicaid patients with CNCP in North Carolina (USA), 18 to 64 years of age, enrolled at any point during a one-year study period were examined. χ2 statistics were used to examine bivariate differences in prescribing practices according to specialty. For multivariable analyses, maximum-likelihood logistic regression models were used to examine the effect of specialty on prescribing practices, controlling for patients’ pain diagnoses and demographic characteristics. RESULTS: Of prescriptions filled by patients with CNCP, who constituted 6.4% of the total sample of 1.28 million individuals, 12.0% were for opioids. General practitioner/family medicine specialists and internists were least likely to prescribe opioids, and orthopedists were most likely. Across specialties, men were more likely to receive opioids than women, as were white individuals relative to other races/ethnicities. In multivariate analyses, all specialties except internal medicine had higher odds of prescribing an opioid than general practitioners: orthopedists, OR 7.1 (95% CI 6.7 to 7.5); dentists, OR 3.5 (95% CI 3.3 to 3.6); and emergency medicine physicians, OR 2.7 (95% CI 2.6 to 2.8). CONCLUSIONS: Significant differences in opioid prescribing practices across prescriber specialties may be reflective of differing norms concerning the appropriateness of opioids for the control of chronic pain. If so, sharing these norms across specialties may improve the care of patients with CNCP. PMID:24809067

A comparison of three methods of setting prescribing budgets, using data derived from defined daily dose analyses of historic patterns of use.

PubMed Central

Maxwell, M; Howie, J G; Pryde, C J

1998-01-01

BACKGROUND: Prescribing matters (particularly budget setting and research into prescribing variation between doctors) have been handicapped by the absence of credible measures of the volume of drugs prescribed. AIM: To use the defined daily dose (DDD) method to study variation in the volume and cost of drugs prescribed across the seven main British National Formulary (BNF) chapters with a view to comparing different methods of setting prescribing budgets. METHOD: Study of one year of prescribing statistics from all 129 general practices in Lothian, covering 808,059 patients: analyses of prescribing statistics for 1995 to define volume and cost/volume of prescribing for one year for 10 groups of practices defined by the age and deprivation status of their patients, for seven BNF chapters; creation of prescribing budgets for 1996 for each individual practice based on the use of target volume and cost statistics; comparison of 1996 DDD-based budgets with those set using the conventional historical approach; and comparison of DDD-based budgets with budgets set using a capitation-based formula derived from local cost/patient information. RESULTS: The volume of drugs prescribed was affected by the age structure of the practices in BNF Chapters 1 (gastrointestinal), 2 (cardiovascular), and 6 (endocrine), and by deprivation structure for BNF Chapters 3 (respiratory) and 4 (central nervous system). Costs per DDD in the major BNF chapters were largely independent of age, deprivation structure, or fundholding status. Capitation and DDD-based budgets were similar to each other, but both differed substantially from historic budgets. One practice in seven gained or lost more than 100,000 Pounds per annum using DDD or capitation budgets compared with historic budgets. The DDD-based budget, but not the capitation-based budget, can be used to set volume-specific prescribing targets. CONCLUSIONS: DDD-based and capitation-based prescribing budgets can be set using a simple explanatory model and generalizable methods. In this study, both differed substantially from historic budgets. DDD budgets could be created to accommodate new prescribing strategies and raised or lowered to reflect local intentions to alter overall prescribing volume or cost targets. We recommend that future work on setting budgets and researching prescribing variations should be based on DDD statistics. PMID:10024703

Investigation of the effect of a countywide protected learning time scheme on prescribing rates of ramipril: interrupted time series study.

PubMed

Siriwardena, A N; Fairchild, P; Gibson, S; Sach, T; Dewey, M

2007-02-01

Protected learning time (PLT) schemes have been set up in primary care across the UK. There is little published evidence of their effectiveness. To investigate the effect of a PLT intervention for general practice to increase prescribing of ramipril for prevention of cardiovascular outcomes. Quasi-experimental, interrupted time series. Lincolnshire, UK. Prescribing data were analysed one year before and after the education for change in rate of increase of prescribing of ramipril, whether change in prescribing was related to postulated explanatory variables and to determine intervention costs. The primary outcome was the rate of change of ramipril (10 mg) prescription items 12 months after compared with before the educational intervention. Secondary outcomes included cost. Ramipril prescribing at therapeutic dosage increased significantly (odds ratio 1.50, 95% CI 1.07-1.93) following education by 52,345 items (31,132 items at 10 mg) at a cost of pound 292k to pound 460k depending on formulation. This occurred despite a background of secular change. Most practices were represented by GPs, nurses or both during the education. Single-handed GPs were less likely to attend. Practices showed considerable variation in response to the educational intervention. The only predictor of whether practices increased in prescribing rate after the education was whether a practice nurse had undertaken specific diabetes training. Total list size, dispensing, training or single-handed status and GP attendance did not predict a change in prescribing. PLT schemes can contribute to beneficial changes in prescribing across a large geographical area.

Knowledge, attitude and practice of antibiotics prescribing among medical officers of public health care facilities in the state of Kedah, Malaysia.

PubMed

Tan, W L; Siti, R; Shahfini, I; Zuraidah, A

2015-10-01

Antibiotic resistance is a rising problem in Malaysia. For instance, high antibiotic prescribing rate for upper respiratory tract infection and inappropriate choice of antibiotic is a significant healthcare concern in Malaysia. Our main objective was to study knowledge, attitude and practice of antibiotic prescribing among medical officers in Kedah, Malaysia. A cross sectional study was conducted in outpatient departments of health clinics and hospitals in Kedah from June 2013 until December 2013. Sample size was 118 and systematic sampling was conducted. Research tool used was a validated questionnaire from studies conducted in Congo and Peru. Response rate was 84.8%. Majority of our respondents were female doctors (71.0%), local graduates (63.0%), and practiced for 4 years or less (61.0%). 52.0% of the respondents prescribed antibiotics more than once daily. Mean knowledge score on antibiotics was 5.31 ±1.19 (95% CI: 5.06; 5.54). More than half (62.0%) of our respondents were confident in antibiotic prescribing and there were merely 18.0% of them consulted any colleagues prior to prescription. There was a significant difference in frequency of antibiotic prescribing between junior doctors and senior doctors (P-value: 0.036). In addition, there was also a significant association between frequency of antibiotic prescribing and awareness of antibiotic resistance in their daily practice. (P-value: 0.002). Knowledge on antibiotic was moderate among our medical officers and antibiotic prescribing was frequent. Training and courses on appropriate antibiotic prescribing should be emphasized to ensure the best practice in antibiotic prescription.

Pharmacology and Therapeutics Education in the European Union Needs Harmonization and Modernization: A Cross‐sectional Survey Among 185 Medical Schools in 27 Countries

PubMed Central

Tichelaar, J; Okorie, M; Bissell, L; Christiaens, T; Likic, R; Mačìulaitis, R; Costa, J; Sanz, EJ; Tamba, BI; Maxwell, SR; Richir, MC; van Agtmael, MA

2017-01-01

Effective teaching in pharmacology and clinical pharmacology and therapeutics (CPT) is necessary to make medical students competent prescribers. However, the current structure, delivery, and assessment of CPT education in the European Union (EU) is unknown. We sent an online questionnaire to teachers with overall responsibility for CPT education in EU medical schools. Questions focused on undergraduate teaching and assessment of CPT, and students' preparedness for prescribing. In all, 185 medical schools (64%) from 27 EU countries responded. Traditional learning methods were mainly used. The majority of respondents did not provide students with the opportunity to practice real‐life prescribing and believed that their students were not well prepared for prescribing. There is a marked difference in the quality and quantity of CPT education within and between EU countries, suggesting that there is considerable scope for improvement. A collaborative approach should be adopted to harmonize and modernize the undergraduate CPT education across the EU. PMID:28295236

Predictors of noninvasive ventilation tolerance in patients with amyotrophic lateral sclerosis.

PubMed

Gruis, K L; Brown, D L; Schoennemann, A; Zebarah, V A; Feldman, E L

2005-12-01

Noninvasive ventilation (NIV) appears to improve survival and quality of life in patients with amyotrophic lateral sclerosis (ALS), but little is known about predictors of NIV tolerance. NIV use was assessed and clinical predictors of tolerance were investigated, using predictive modeling, in ALS patients diagnosed and followed in our clinic until death over a 4-year time period. Patients were prescribed NIV based on current practice parameters when respiratory symptoms were present or forced vital capacity was less than 50%. We prescribed NIV in 52% (72) of patients. For those prescribed NIV, information regarding tolerance was available for 50 patients, with 72% (36) tolerant to its use. Tolerance was six times more likely in limb-onset than bulbar-onset ALS patients, with a trend toward reduced tolerance in those with lower forced vital capacity at NIV initiation. Age, gender, and duration of disease were not predictors of NIV tolerance. We conclude that a majority of ALS patients who are prescribed NIV can successfully become tolerant to its use.

The Systematic Tool to Reduce Inappropriate Prescribing (STRIP): Combining implicit and explicit prescribing tools to improve appropriate prescribing.

PubMed

Drenth-van Maanen, A Clara; Leendertse, Anne J; Jansen, Paul A F; Knol, Wilma; Keijsers, Carolina J P W; Meulendijk, Michiel C; van Marum, Rob J

2018-04-01

Inappropriate prescribing is a major health care issue, especially regarding older patients on polypharmacy. Multiple implicit and explicit prescribing tools have been developed to improve prescribing, but these have hardly ever been used in combination. The Systematic Tool to Reduce Inappropriate Prescribing (STRIP) combines implicit prescribing tools with the explicit Screening Tool to Alert physicians to the Right Treatment and Screening Tool of Older People's potentially inappropriate Prescriptions criteria and has shared decision-making with the patient as a critical step. This article describes the STRIP and its ability to identify potentially inappropriate prescribing. The STRIP improved general practitioners' and final-year medical students' medication review skills. The Web-application STRIP Assistant was developed to enable health care providers to use the STRIP in daily practice and will be incorporated in clinical decision support systems. It is currently being used in the European Optimizing thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly (OPERAM) project, a multicentre randomized controlled trial involving patients aged 75 years and older using multiple medications for multiple medical conditions. In conclusion, the STRIP helps health care providers to systematically identify potentially inappropriate prescriptions and medication-related problems and to change the patient's medication regimen in accordance with the patient's needs and wishes. This article describes the STRIP and the available evidence so far. The OPERAM study is investigating the effect of STRIP use on clinical and economic outcomes. © 2017 John Wiley & Sons, Ltd.

Pediatricians' beliefs and prescribing patterns of adolescent contraception: a provider survey.

PubMed

Swanson, K J; Gossett, D R; Fournier, M

2013-12-01

Teen pregnancy and sexually transmitted infection (STI) rates continue to be significant public health problems in the United States. While general pediatricians are in a unique position to improve these issues by addressing contraception with their adolescent patients, there are no data describing their current prescribing patterns. This study sought to elucidate the beliefs and prescribing patterns of general pediatricians and pediatrics residents and to distinguish whether these were affected by practice setting, level of training, or gender. General pediatricians and pediatrics residents affiliated with Lurie Children's Hospital in Chicago, IL, were asked to complete a survey regarding adolescent contraception. Questions were related to obtaining information about contraception, contraceptive counseling, knowledge of contraceptive methods, prescribing patterns of contraceptives, and concerns about individual contraceptive methods. 120 physicians of an eligible 411 physicians participated in this study (29%). 79% of participants had prescribed at least 1 contraceptive method. The most commonly prescribed method was oral contraceptive pills at 72%. We noted few differences in prescribing patterns based on above criteria. Numerous misconceptions existed among participants, including a high rate of concern about infertility with IUD use (29% among physicians who prescribed at least 1 method of contraception). General pediatricians can improve their rates of prescribing contraception to adolescents, and could utilize more of the approved methods. One way to do so may be to implement educational interventions among general pediatricians. Copyright © 2013 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.

District nurses' prescribing practice and its link to structural conditions.

PubMed

Blanck, Susanne; Engström, Maria

2015-10-01

To describe district nurses' (DNs') prescribing practice and examine associations between DNs' self-reported prescribing frequency, opinions about prescribing, and structural conditions/empowerment. A cross-sectional and correlational design was employed. Data were collected during 2012 using questionnaires and a prescribing register. A random sample of 150 DNs from 32 primary care centers in Sweden was invited. DNs' ability to prescribe is used to a relatively small extent and access to "opportunities" and "informal power" seems to be the most important structural empowerment conditions for increased prescribing frequency and positive opinions about prescribing. The results support Kanter's theory of structural empowerment. This article regarding restricted prescribing shows how important structural conditions/empowerment is to DNs' prescribing and employers have to enhance nurses' access to especially the structures "opportunities" and "informal power" to increase nurse prescribing. More targeted support and training are needed in different prescribing areas to make use of DNs' prescription qualification to a greater extent. ©2015 American Association of Nurse Practitioners.

Opioid use following gynecologic and pelvic reconstructive surgery.

PubMed

Hota, Lekha S; Warda, Hussein A; Haviland, Miriam J; Searle, Frances M; Hacker, Michele R

2017-09-09

Opioid use, addiction, and overdose are a growing epidemic in the USA. Our objective was to determine whether the amount of opioid medication prescribed following gynecologic and pelvic reconstructive surgery is insufficient, adequate, or in excess. We hypothesized that we were overprescribing postoperative opioids. Participants who were at least 18 years old and underwent gynecologic and/or pelvic reconstructive surgery from April through August 2016 were eligible to participate. Routine practice for pain management is to prescribe 30 tablets of opioids for major procedures and ten to 15 tablets for minor procedures. At the 2-week postoperative visit, participants completed a questionnaire regarding the number of tablets prescribed and used, postoperative pain control, and relevant medical history. Fisher's exact test was used to compare data. Sixty-five participants completed questionnaires. Half (49.1%) reported being prescribed more opioids than needed, while two (3.5%) felt the amount was less than needed. Though not significant, participants who underwent major surgeries were more likely to report being prescribed more than needed (53.5%) compared with participants who underwent minor surgeries (35.7%; p = 0.47). Though not significant, participants with anxiety were less likely to report being prescribed more tablets than needed compared with participants without anxiety (44.4% vs. 57.1%; p = 0.38). This was also true of participants with depression compared with those without (37.5% vs. 58.3%; p = 0.17), and those with chronic pain compared with those without (33.3% vs. 60.0%; p = 0.10). Our current opioid prescription practice for postoperative pain management may exceed what patients need.

A Cluster Randomised Controlled Trial of a Pharmacist-Led Collaborative Intervention to Improve Statin Prescribing and Attainment of Cholesterol Targets in Primary Care

PubMed Central

Lowrie, Richard; Lloyd, Suzanne M.; McConnachie, Alex; Morrison, Jill

2014-01-01

Background Small trials with short term follow up suggest pharmacists’ interventions targeted at healthcare professionals can improve prescribing. In comparison with clinical guidance, contemporary statin prescribing is sub-optimal and achievement of cholesterol targets falls short of accepted standards, for patients with atherosclerotic vascular disease who are at highest absolute risk and who stand to obtain greatest benefit. We hypothesised that a pharmacist-led complex intervention delivered to doctors and nurses in primary care, would improve statin prescribing and achievement of cholesterol targets for incident and prevalent patients with vascular disease, beyond one year. Methods We allocated general practices to a 12-month Statin Outreach Support (SOS) intervention or usual care. SOS was delivered by one of 11 pharmacists who had received additional training. SOS comprised academic detailing and practical support to identify patients with vascular disease who were not prescribed a statin at optimal dose or did not have cholesterol at target, followed by individualised recommendations for changes to management. The primary outcome was the proportion of patients achieving cholesterol targets. Secondary outcomes were: the proportion of patients prescribed simvastatin 40 mg with target cholesterol achieved; cholesterol levels; prescribing of simvastatin 40 mg; prescribing of any statin and the proportion of patients with cholesterol tested. Outcomes were assessed after an average of 1.7 years (range 1.4–2.2 years), and practice level simvastatin 40 mg prescribing was assessed after 10 years. Findings We randomised 31 practices (72 General Practitioners (GPs), 40 nurses). Prior to randomisation a subset of eligible patients were identified to characterise practices; 40% had cholesterol levels below the target threshold. Improvements in data collection procedures allowed identification of all eligible patients (n = 7586) at follow up. Patients in practices allocated to SOS were significantly more likely to have cholesterol at target (69.5% vs 63.5%; OR 1.11, CI 1.00–1.23; p = 0.043) as a result of improved simvastatin prescribing. Subgroup analysis showed the primary outcome was achieved by prevalent but not incident patients. Statistically significant improvements occurred in all secondary outcomes for prevalent patients and all but one secondary outcome (the proportion of patients with cholesterol tested) for incident patients. SOS practices prescribed more simvastatin 40 mg than usual care practices, up to 10 years later. Interpretation Through a combination of educational and organisational support, a general practice based pharmacist led collaborative intervention can improve statin prescribing and achievement of cholesterol targets in a high-risk primary care based population. Trial Registration International Standard Randomised Controlled Trials Register ISRCTN61233866 PMID:25405478

Promoting sugar-free medicines: evaluation of a multi-faceted intervention.

PubMed

Weeks, Julie C; Dutt, Amalin; Robinson, Peter G

2003-12-01

To evaluate an intervention to increase the proportion of medicines prescribed as sugar-free formulations by general practitioners. Natural experiment. Interventions were set in Camden and Islington Health Authority with comparator data within that and adjacent health authorities. General medical practices. Two interventions were employed. A prescribing incentive scheme that used the proportion of medicines prescribed as sugar-free formulations as a quality marker for general practitioners and a publicity campaign for health care workers and members of the public. The proportions of amoxycillin mixture and all paracetamol liquid preparations that were prescribed in sugar-free formulations. Sugar-free prescribing in the practices participating in the incentive scheme increased from 27% to 45% whereas non-participating practices showed a decrease from 20% to 14%. The proportion of prescriptions for sugar-free formulations increased by approximately one half across the entire health authority so that after two years Camden and Islington had the highest level of prescribing of sugar-free paracetamol and amoxycillin in London. These data provide compelling evidence of the effectiveness of the prescribing incentive scheme whereas the publicity campaign did not change prescribing behaviour.

Off-label prescribing to children: attitudes and experience of general practitioners

PubMed Central

Ekins-Daukes, Suzie; Helms, Peter J; Taylor, Michael W; McLay, James S

2005-01-01

Aim To identify experience with and attitudes towards paediatric off-label prescribing in primary care. Method A prospective questionnaire survey was sent to a sample of Scottish primary care practices (346 doctors in 80 general practices located throughout Scotland). Results Two hundred and two (58%) completed questionnaires were returned. Over 70% of GPs admitted to being familiar with the concept, and 40% to knowingly prescribing off-label. The most important sources of paediatric prescribing information were the British National Formulary (81%), personal experience (71%) and previous prescription notes (45%). The most common reason given by GPs for off-label prescribing was prescribing for a younger age than recommended, although prescribing data confirm that age is the least important and dose the most important reason for such prescribing. When asked to comment upon different causes for off-label prescribing, 80% of respondents expressed appropriate awareness of and concern for the described scenarios. Over 97% of GPs ranked development of paediatric formulations and clearer dosage information more highly than clinical trials as a means to reducing off-label prescribing. Conclusions Despite high levels of off-label prescribing in primary care in the UK, the majority of GPs claimed to be familiar with the concept, although less than half were aware of this common practice. A clear disparity between perceived and actual reasons for off-label prescribing was noted, possibly due to a reliance on personal experience, colleague experience or previous patient prescription notes as a guide to prescribing. PMID:16042667

Antimicrobial prescribing behaviour in dogs and cats by Belgian veterinarians.

PubMed

Van Cleven, Alexia; Sarrazin, Steven; de Rooster, Hilde; Paepe, Dominique; Van der Meeren, Sofie; Dewulf, Jeroen

2018-03-17

The objective of this study is to survey general prescribing behaviour by Belgian companion animal veterinarians and to assess agreement of these practices with current treatment guidelines. Therefore an online survey was administered with five realistic and frequently occurring first-line cases to primary-care veterinary practitioners. For each case a predefined pattern of questions were asked about whether or not they would prescribe antimicrobials, if they would prescribe a non-antimicrobial treatment and if they would perform additional diagnostic steps. The responses were compared with recommendations in national guidelines and recent literature. The overall most prescribed antimicrobials were potentiated amoxicillin (43.0 per cent), fluoroquinolones (14.7 per cent), third-generation and fourth-generation cephalosporins (10.9 per cent) and tetracyclines (10.9 per cent). Only 48.3 per cent of the veterinarians complied with the guidelines in nearly all of the clinical scenarios (ie, prescribing antimicrobials when indicated, not prescribing antimicrobials when it is not indicated). Moreover, when prescribing highest priority critically important antimicrobials, susceptibility testing on bacterial cultures was performed in only 12.4 per cent of the prescriptions. The results showed that the prescribing behaviour of antimicrobial compounds by primary-care veterinary practitioners in dogs and cats is often not in agreement with national guidelines. Focus in improvement of this prescribing behaviour should be on performing the appropriate diagnostic steps and decreasing the use of highest priority critically important antimicrobials. © British Veterinary Association (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Incorporating assessment and prescribing for ambulatory ailments skills into practice: An environmental scan of continuing education for pharmacist prescribing in Canada

PubMed Central

Habicht, Dana; Ng, Sheila; Dunford, Drena; Shearer, Brenna; Kuo, I fan

2017-01-01

Objectives: Pharmacists in Canadian provinces are at different stages of applying prescribing legislation into practice. The purpose of this environmental scan was to examine differences in legislation, remuneration, professional uptake, continuing education requirements and continuing education resources relating to pharmacist prescribing for ambulatory ailments, with a focus on continuing education. Methods: Data were collected between May and December 2016 using websites and communication with provincial professional regulatory bodies, advocacy bodies, drug coverage programs and other organizations that offer continuing education for pharmacists. Results: Training requirements to prescribe for ambulatory ailments vary provincially, including no training requirements, online tutorials and a comprehensive application process. Government-funded remuneration for prescribing services is absent in most provinces. Pharmacist uptake of the training required to obtain prescribing authority ranges from 30% to 100% of pharmacists. Continuing education programs on the topic of prescribing across the country include online courses, in-person courses, webinars, panel discussions and preparation courses. Conclusion: Many aspects of pharmacist prescribing for ambulatory ailments, including the style and content of continuing education resources, vary from province to province. Further research on this topic would help to determine the effect of these differences on the success of incorporating pharmacist prescribing into practice. PMID:28894501

Incorporating assessment and prescribing for ambulatory ailments skills into practice: An environmental scan of continuing education for pharmacist prescribing in Canada.

PubMed

Habicht, Dana; Ng, Sheila; Dunford, Drena; Shearer, Brenna; Kuo, I Fan

2017-01-01

Pharmacists in Canadian provinces are at different stages of applying prescribing legislation into practice. The purpose of this environmental scan was to examine differences in legislation, remuneration, professional uptake, continuing education requirements and continuing education resources relating to pharmacist prescribing for ambulatory ailments, with a focus on continuing education. Data were collected between May and December 2016 using websites and communication with provincial professional regulatory bodies, advocacy bodies, drug coverage programs and other organizations that offer continuing education for pharmacists. Training requirements to prescribe for ambulatory ailments vary provincially, including no training requirements, online tutorials and a comprehensive application process. Government-funded remuneration for prescribing services is absent in most provinces. Pharmacist uptake of the training required to obtain prescribing authority ranges from 30% to 100% of pharmacists. Continuing education programs on the topic of prescribing across the country include online courses, in-person courses, webinars, panel discussions and preparation courses. Many aspects of pharmacist prescribing for ambulatory ailments, including the style and content of continuing education resources, vary from province to province. Further research on this topic would help to determine the effect of these differences on the success of incorporating pharmacist prescribing into practice.

Using E-Learning to Improve Prescribing Practice in Emerging Prescribers

ERIC Educational Resources Information Center

Baskett, Karen

2011-01-01

This paper reports on "The National Prescribing Curriculum" (NPC), a series of online, case-based modules designed to improve prescribing performance and confidence in emerging Australian prescribers. The modules mirror the decision-making process outlined in the "WHO Guide to Good Prescribing" (de Vries "et al.",…

Antibiotic prescribing during office hours and out-of-hours: a comparison of quality and quantity in primary care in the Netherlands

PubMed Central

Debets, Vera EC; Verheij, Theo JM; van der Velden, Alike W

2017-01-01

Background Unnecessary and non-first-choice antibiotic prescribing is a significant problem in primary care. It is often argued that irrational prescribing is higher during out-of-hours (OOH) consultations. Aim To obtain insight into the quantity and quality of OOH antibiotic prescribing for commonly presented infectious diseases. Design and setting Two two-way comparisons of 1) nationally dispensed antibiotics during office hours and OOH care, using data from the Dutch Foundation of Pharmaceutical Statistics, and 2) regional prescribing quality data from 45 primary care practices from Utrecht and its vicinity, and two large OOH services in Utrecht and Woerden. Method From the national data, yearly dispensed antibiotics were analysed per prescriber type, with respect to time (office hours or OOH) of prescription, types of antibiotics, and patients’ age group. Regional prescribing rates, choice of antibiotic, and appropriateness of prescribing were compared for otitis media, sinusitis, tonsillitis, bronchitis, cystitis, and impetigo. Appropriateness was assessed by comparing all relevant information from medical files with the guideline recommendations. Results Only 6% of GP-prescribed antibiotics were prescribed OOH. OOH, cystitis and acute otitis media presented most often. First-choice prescribing was comparable for the two settings, whereas prescribing rates were higher OOH, with comparatively more amoxicillin(/clavulanate). The appropriateness evaluation, however, revealed that overprescribing was comparable, or even lower than, for daily practice. Conclusion The suggestion that OOH antibiotic prescribing quality is worse than in daily practice does not seem founded. The higher OOH prescribing rates can be explained by a different population of presenting patients. The appropriateness of prescribing rather than prescribing rates, therefore, should be used to determine quality. PMID:28232364

Safer Prescribing and Care for the Elderly (SPACE): feasibility of audit and feedback plus practice mail-out to patients with high-risk prescribing.

PubMed

Wallis, Katharine; Tuckey, Rebecca

2017-06-01

INTRODUCTION High-risk prescribing in general practice is common and places patients at increased risk of adverse events. AIM The Safer Prescribing and Care for the Elderly (SPACE) intervention, comprising audit and feedback plus practice mail-out to patients with high-risk prescribing, was designed to promote medicines review and support safer prescribing. This study aims to test the SPACE intervention feasibility in general practice. METHODS This feasibility study involved an Auckland Primary Health Organisation (PHO), a clinical advisory pharmacist, two purposively sampled urban general practices, and seven GPs. The acceptability and utility of the SPACE intervention were assessed by semi- structured interviews involving study participants, including 11 patients with high-risk prescribing. Interviews were audio-recorded, transcribed verbatim and analysed using a general inductive approach to identify emergent themes. RESULTS The pharmacist said the SPACE intervention facilitated communication with GPs, and provided a platform for their clinical advisory role at no extra cost to the PHO. GPs said the feedback session with the pharmacist was educational but added to time pressures. GPs selected 29 patients for the mail-out. Some GPs were concerned the mail-out might upset patients, but patients said they felt cared for. Some patients intended to take the letter to their next appointment and discuss their medicines with their GP; others said there were already many things to discuss and not enough time. Some patients were confused by the medicines information brochure. DISCUSSION The SPACE intervention is feasible in general practice. The medicines information brochure needs simplification. Further research is needed to test the effect of SPACE on high-risk prescribing.

Influence of Qualification and Practice Settings of Dental Practitioners on Antimicrobial Prescribing in Delhi and National Capital Region, India

PubMed Central

Wasan, Himika; Gupta, Pooja; Mathur, Apoorva; Mutneja, Ekta; Mathur, Vijay Prakash; Gupta, Yogendra Kumar

2017-01-01

Background and Objectives: Inappropriate antimicrobial prescribing is highly reported in dentistry. The objective of the study was to see the effect of dental qualification and practice settings on antimicrobial prescribing practices among dental practitioners in Delhi and National Capital Region (NCR) of India. Materials and Methods: A self-designed and pretested questionnaire was given to 667 dental practitioners holding degrees of graduation, postgraduation, and those pursuing postgraduation, working in academic institutions and private clinics in NCR of India. Data were analyzed using statistical software Stata version 12.0. Chi-square and logistic regression tests were used for analysis. Results: Out of total 539 responded, 66.4% of the practitioners prescribed by brand name and 27.8% by generic name. Amoxicillin + clavulanic acid (27.4%) was the first choice. Only 26% of the practitioners asked for antimicrobial susceptibility testing. Space infections (91.9%), impacted third molar extractions (89.7%), and periodontal abscess (88.1%) were the conditions where antimicrobials were most frequently prescribed. However, 60.9% and 53.3% of the practitioners also prescribed antimicrobials for acute pulpitis and dry socket, respectively. For prophylaxis in medical conditions, amoxicillin was the first choice. In case of history of allergy to penicillin, 52.3% of the practitioners prescribe erythromycin whereas 14.6% prescribe amoxicillin. The adverse drug reporting culture was negligible, and only 14.3% of the practitioners were aware of the Pharmacovigilance Program of India. Level of qualification had a significant effect on prescribing (P < 0.05). Interpretation and Conclusion: Frequent irrational prescribing of antimicrobials used in odontogenic conditions warrants an urgent and continued need for guidelines as well as educational intervention programs in dentistry. This will improve the quality of antimicrobial prescribing practices in dentistry. PMID:28781493

Antimicrobial Use and Indication-based Prescribing Among General Practitioners in Eastern Croatia: Comparison with Data from the European Surveillance of Antimicrobial Consumption Project

PubMed Central

Vojvodić, Željko

2010-01-01

Aim To investigate antibiotic consumption in a sample of physicians from Osijek-Baranja county in Eastern Croatia and to determine the volume of prescribed antimicrobials and assess the appropriateness of prescribing practices. Methods Analysis of routine prescribing data was carried out in 30 primary care practices in both urban and rural communities of eastern Croatia, corresponding to a total population of 48 000 patients. Prescribing practices were studied over a period of 3 years, from 2003 to 2005. Both the quantity of antimicrobials and differences and similarities between individual practitioners were analyzed. Results Urban and rural practices did not significantly differ in regard to the volume of antimicrobials prescribed. However, significant differences were found between individual physicians. Total consumption was 17.73 defined daily doses per 1000 inhabitants per day or 6456.85 defined daily doses per 1000 inhabitants per year. The 10 most frequently used antimicrobials (93.70% of the total quantity) were amoxicillin, co-amoxiclav, co-trimoxazole, cephalexin, norfloxacin, penicillin V, azithromycin, cefuroxime, doxycycline, and nitrofurantoin. Sore throat was the most frequent reason for prescribing antibiotics. Conclusion Prescription of medicines in Osijek-Baranja county was characterized by high consumption of broad-spectrum penicillins, combined penicillins, combined sulfonamides and long-acting macrolides (azithromycin), together with disproportionately low use of doxycycline and erythromycin. The use of combined sulfonamides and azithromycin in this part of Croatia was among the highest in Europe. Great differences between prescribers in regard to indication-based prescribing have been found, and future studies should examine the factors behind these heterogeneous practices. PMID:21162165

Management system to a photovoltaic panel based on the measurement of short-circuit currents

NASA Astrophysics Data System (ADS)

Dordescu, M.

2016-12-01

This article is devoted to fundamental issues arising from operation in terms of increased energy efficiency for photovoltaic panel (PV). By measuring the current from functioning cage determine the current value prescribed amount corresponding to maximum power point results obtained by requiring proof of pregnancy with this method are the maximum energy possible, thus justifying the usefulness of this process very simple and inexpensive to implement in practice. The proposed adjustment method is much simpler and more economical than conventional methods that rely on measuring power cut.

Impact of new-generation agents on antiepileptic drug prescribing patterns in a residential ICF-MR facility.

PubMed

Smith, Stacey Allison; McKee, Jerry R

2004-06-01

Describe the impact of newer antiepileptic drugs (AEDs) on prescribing practices in a large, residential intermediate-care facility for the mentally retarded (ICF-MR), with onsite clinical pharmacist support services, over a 15-year period. All residents at the facility receiving AEDs for management of seizure disorder were included in this retrospective assessment. Number and type of AEDs used per individual were recorded and analyzed over the 15-year interval. Current prescribing practices were evaluated regarding rational polytherapy prescribing trends. 400-bed residential ICF-MR for the severe to profoundly mentally retarded. All individuals residing at the ICF-MR facility receiving AED therapy for a seizure disorder. Residents were primarily in the severe to profound range of developmental disability, with multiple medical comorbidities. Clinical pharmacists actively participate in all treatment teams and monthly neurology clinic to promote and encourage rational pharmacotherapy. Prescribing trends related to AED therapy were followed over a 15-year period. Comparisons were made regarding monotherapy and polytherapy at multiple-year intervals, with specific emphasis on how the newer generation AEDs have affected use of older medications. Overall trend from 1988 suggests more monotherapy and less use of barbiturates. Introduction of a new generation of AEDs has not affected the overall trend toward one- or two-drug regimens over the period in review. The relative stability of the number of AEDs per resident during the introduction of a new generation of AEDs suggests that as new drugs are added, ineffective or problem-prone drugs are discontinued.

Prescribing in prison: minimizing psychotropic drug diversion in correctional practice.

PubMed

Pilkinton, Patricia D; Pilkinton, James C

2014-04-01

Correctional facilities are a major provider of mental health care throughout the United States. In spite of the numerous benefits of providing care in this setting, clinicians are sometimes concerned about entering into correctional care because of uncertainty in prescribing practices. This article provides an introduction to prescription drug use, abuse, and diversion in the correctional setting, including systems issues in prescribing, commonly abused prescription medications, motivation for and detection of prescription drug abuse, and the use of laboratory monitoring. By understanding the personal and systemic factors that affect prescribing habits, the clinician can develop a more rewarding correctional practice and improve care for inmates with mental illness.

Process evaluation of the Data-driven Quality Improvement in Primary Care (DQIP) trial: quantitative examination of variation between practices in recruitment, implementation and effectiveness.

PubMed

Dreischulte, Tobias; Grant, Aileen; Hapca, Adrian; Guthrie, Bruce

2018-01-05

The cluster randomised trial of the Data-driven Quality Improvement in Primary Care (DQIP) intervention showed that education, informatics and financial incentives for general medical practices to review patients with ongoing high-risk prescribing of non-steroidal anti-inflammatory drugs and antiplatelets reduced the primary end point of high-risk prescribing by 37%, where both ongoing and new high-risk prescribing were significantly reduced. This quantitative process evaluation examined practice factors associated with (1) participation in the DQIP trial, (2) review activity (extent and nature of documented reviews) and (3) practice level effectiveness (relative reductions in the primary end point). Invited practices recruited (n=33) and not recruited (n=32) to the DQIP trial in Scotland, UK. (1) Characteristics of recruited versus non-recruited practices. Associations of (2) practice characteristics and 'adoption' (self-reported implementation work done by practices) with documented review activity and (3) of practice characteristics, DQIP adoption and review activity with effectiveness. (1) Recruited practices had lower performance in the quality and outcomes framework than those declining participation. (2) Not being an approved general practitioner training practice and higher self-reported adoption were significantly associated with higher review activity. (3) Effectiveness ranged from a relative increase in high-risk prescribing of 24.1% to a relative reduction of 77.2%. High-risk prescribing and DQIP adoption (but not documented review activity) were significantly associated with greater effectiveness in the final multivariate model, explaining 64.0% of variation in effectiveness. Intervention implementation and effectiveness of the DQIP intervention varied substantially between practices. Although the DQIP intervention primarily targeted review of ongoing high-risk prescribing, the finding that self-reported DQIP adoption was a stronger predictor of effectiveness than documented review activity supports that reducing initiation and/or re-initiation of high-risk prescribing is key to its effectiveness. NCT01425502; Post-results. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Assessing prescribing practices of clozapine before and after the implementation of an updated risk evaluation and mitigation strategy

PubMed Central

2018-01-01

Introduction: Clozapine is an atypical antipsychotic medication approved for treatment-resistant schizophrenia and suicidal behavior in schizophrenia or schizoaffective disorders. Despite its therapeutic efficacy, clozapine is associated with several adverse effects, including agranulocytosis. In late 2015, the Food and Drug Administration updated the risk evaluation and mitigation strategy (REMS) for clozapine with new requirements for monitoring, prescribing, and dispensing. The purpose of this study was to evaluate clozapine prescribing practices at a Kentucky state psychiatric hospital before and after the implementation of the updated REMS program. Methods: The primary outcome of this study was to evaluate clozapine prescribing practices by identifying the number of patients on clozapine therapy in the 6 months pre and post updated REMS implementation. Included in the study were patients at a Kentucky state psychiatric hospital on clozapine therapy for the 24 months before the updated REMS implementation and in the 6-month study period after the implementation. The secondary objective of this study examined psychiatrist comfort level of prescribing clozapine. Results: Since the implementation of the updated REMS program, there has been an increased percentage of patients that were prescribed clozapine at a Kentucky state psychiatric hospital. This increase was not statistically significant (P = .2610). Discussion: The prescribing practices of clozapine within this facility did not differ significantly comparing pre- and post-REMS change in terms of number of patients prescribed clozapine, patient's dose, and therapy duration. Data from this study contributes to the body of knowledge evaluating this new standard of practice under the updated REMS.

Atrial fibrillation in the elderly: physicians' attitudes to anticoagulation.

PubMed

King, D; Davies, K N; Slee, A; Silas, J H

1995-01-01

The use of warfarin and aspirin for the primary prevention of stroke in elderly patients with atrial fibrillation (AF) is controversial. To establish current practice we circulated a questionnaire to 300 geriatricians (G) and 300 cardiologists (C). The response rates were 47% G and 51% C. Most physicians prescribed warfarin in AF associated with mitral stenosis (G vs C, 86% vs 89%, NS). Cardiologists were more likely to prescribe warfarin in AF associated with dilated cardiomyopathy (G vs C, 52% vs 86%, P < 0.01). A minority would prescribe warfarin in aortic valve disease and AF (G vs C, 37% vs 24%, P < 0.05) and lone AF (G vs C, 10% vs 26%, P < 0.01). Aspirin was favoured in aortic valve disease and lone AF. The cardiologists were less reluctant to use warfarin in the young and more likely to electrically cardiovert the young with chronic AF.

Rationalising prescribing: Evidence, marketing and practice-relevant knowledge.

PubMed

Wadmann, Sarah; Bang, Lia E

2015-06-01

Initiatives in the name of 'rational pharmacotherapy' have been launched to alter what is seen as 'inappropriate' prescribing practices of physicians. Based on observations and interviews with 20 general practitioners (GPs) in 2009-2011, we explored how attempts to rationalise prescribing interact with chronic care management in Denmark. We demonstrate how attempts to rationalise prescribing by informing GPs about drug effects, adverse effects and price do not satisfy GPs' knowledge needs. We argue that, for GPs, 'rational' prescribing cannot be understood in separation from the processes that enable patients to use medication. Therefore, GPs do much more to obtain knowledge about medications than seek advice on 'rational pharmacotherapy'. For instance, GPs also seek opportunities to acquaint themselves with the material objects of medication and medical devices. We conceptualise the knowledge needs of GPs as a need for practice-relevant knowledge and argue that industry sales representatives are granted opportunity to access general practice because they understand this need of GPs. Copyright © 2015 Elsevier Ltd. All rights reserved.

A scoping review of research on the prescribing practice of Canadian pharmacists

PubMed Central

Faruquee, Chowdhury Farhana; Guirguis, Lisa M.

2015-01-01

Background: Pharmacists in Canada have been prescribing since 2007. This review aims to explore the volume, array and nature of research activity on Canadian pharmacist prescribing and to identify gaps in the existing literature. Methods: We conducted a scoping review to examine the literature on prescribing by pharmacists in Canada according to methodological trends, research areas and key findings. We searched for peer-reviewed research articles and abstracts in the Ovid MEDLINE, Ovid EMBASE and International Pharmaceutical Abstracts databases without any date limitations. A standardized form was used to extract information. Results: We identified 156 articles; of these, 26 articles and 12 abstracts met inclusion criteria. One-half of the research studies (20) used quantitative methods, including surveys, trials and experimental designs; 11 studies used qualitative methods and 7 used other methods. Research on pharmacist prescribing demonstrated an improvement in patient outcomes (13 studies), varied stakeholder perceptions (10 studies) and factors that influence this practice change (11 studies). Pharmacist prescribing was adopted when pharmacists practised patient-centred care. Stakeholders held contrasting perceptions of pharmacist prescribing. Discussion: Canadian research has demonstrated the benefit of pharmacist prescribing on patient outcomes, which is not present in the international literature. Future research may consider a meta-analysis addressing the impact on patient health. Gaps in research include comparisons between provinces, effects on physicians’ services, overall patient safety and access to health care systems and economic implications for society. Conclusion: A growing body of research on pharmacist prescribing has captured the early impact of prescribing on patient outcomes, perceptions of practice and practice change. Opportunities exist for pan-Canadian research that examines the system impact. PMID:26600824

Probiotic guidelines and physician practice: a cross-sectional survey and overview of the literature.

PubMed

Draper, K; Ley, C; Parsonnet, J

2017-08-24

Probiotic use by patients and physicians has dramatically increased over the last decade, although definitive evidence is often lacking for their use. We examined probiotic-prescribing practices among health care providers (HCP) at a tertiary medical centre and compared these practices to clinical guidelines. HCP at the Stanford Medical Center received a survey on probiotic prescribing practices including choice of probiotic and primary indications. A broad overview of the literature was performed. Among 2,331 HCP surveyed, 632 responded. Of the 582 of these who routinely prescribed medications, 61% had recommended probiotic foods or supplements to their patients. Women and gastroenterologists were more likely to prescribe probiotics (odds ratio (OR): 1.5, 95% confidence interval (CI): 1.0-2.1; OR: 3.9, 95% CI: 1.5-10.1, respectively). Among probiotic prescribers, 50% prescribed inconsistently or upon patient request, and 40% left probiotic choice to the patient. Common indications for probiotics, particularly Lactobacillus GG, were prevention and treatment of antibiotic-associated diarrhoea (79 and 66%, respectively). Probiotics were often prescribed for 'general bowel health' or at patient request (27 and 39% of responders, respectively). Most respondents (63%) thought an electronic medical record (EMR) pop-up would change probiotic prescribing patterns. However, a review of published guidelines and large trials found inconsistencies in probiotic indications, dosages and strain selection. Probiotic prescribing is common but lacks consistency, with choice of probiotic frequently left to the patient, even for indications with some strain-specific evidence. Implementation of EMR pop-ups/pocket guides may increase consistency in probiotic prescribing, although the lack of clear and consistent guidelines must first be addressed with large, well-designed clinical trials.

Use of behavioral economics and social psychology to improve treatment of acute respiratory infections (BEARI): rationale and design of a cluster randomized controlled trial [1RC4AG039115-01]--study protocol and baseline practice and provider characteristics.

PubMed

Persell, Stephen D; Friedberg, Mark W; Meeker, Daniella; Linder, Jeffrey A; Fox, Craig R; Goldstein, Noah J; Shah, Parth D; Knight, Tara K; Doctor, Jason N

2013-06-27

Inappropriate antibiotic prescribing for nonbacterial infections leads to increases in the costs of care, antibiotic resistance among bacteria, and adverse drug events. Acute respiratory infections (ARIs) are the most common reason for inappropriate antibiotic use. Most prior efforts to decrease inappropriate antibiotic prescribing for ARIs (e.g., educational or informational interventions) have relied on the implicit assumption that clinicians inappropriately prescribe antibiotics because they are unaware of guideline recommendations for ARIs. If lack of guideline awareness is not the reason for inappropriate prescribing, educational interventions may have limited impact on prescribing rates. Instead, interventions that apply social psychological and behavioral economic principles may be more effective in deterring inappropriate antibiotic prescribing for ARIs by well-informed clinicians. The Application of Behavioral Economics to Improve the Treatment of Acute Respiratory Infections (BEARI) Trial is a multisite, cluster-randomized controlled trial with practice as the unit of randomization. The primary aim is to test the ability of three interventions based on behavioral economic principles to reduce the rate of inappropriate antibiotic prescribing for ARIs. We randomized practices in a 2 × 2 × 2 factorial design to receive up to three interventions for non-antibiotic-appropriate diagnoses: 1) Accountable Justifications: When prescribing an antibiotic for an ARI, clinicians are prompted to record an explicit justification that appears in the patient electronic health record; 2) Suggested Alternatives: Through computerized clinical decision support, clinicians prescribing an antibiotic for an ARI receive a list of non-antibiotic treatment choices (including prescription options) prior to completing the antibiotic prescription; and 3) Peer Comparison: Each provider's rate of inappropriate antibiotic prescribing relative to top-performing peers is reported back to the provider periodically by email. We enrolled 269 clinicians (practicing attending physicians or advanced practice nurses) in 49 participating clinic sites and collected baseline data. The primary outcome is the antibiotic prescribing rate for office visits with non-antibiotic-appropriate ARI diagnoses. Secondary outcomes will examine antibiotic prescribing more broadly. The 18-month intervention period will be followed by a one year follow-up period to measure persistence of effects after interventions cease. The ongoing BEARI Trial will evaluate the effectiveness of behavioral economic strategies in reducing inappropriate prescribing of antibiotics. ClinicalTrials.gov: NCT01454947.

Assessment of prescribing practices among urban and rural general practitioners in Tamil Nadu.

PubMed

Gopalakrishnan, Sekharan; Ganeshkumar, Parasuraman; Katta, Ajitha

2013-01-01

Studying drug use pattern among medical practitioners is of vital importance in the present scenario where irrational drug use and development of drug resistance is becoming rampant. To assess, the pattern of prescribing practices among the general practitioners in a defined rural and urban area of Tamil Nadu. A community based descriptive study was conducted to collect 600 prescriptions from the catchment areas of rural and urban health training centers of a medical college using prescribing indicators as per the WHO "How to investigate drug use in health facilities" tool. This prescription study revealed that multivitamins (19.5%), antibiotics (19.3%), drugs for gastro-intestinal tract (GIT) (18%), analgesic non-steroidal anti-inflammatory drugs/ (NSAID's) (15.1%), and antihistaminic (12.5%) were prescribed frequently. Among the antibiotics, amoxicillin (49.2%) was the most commonly prescribed followed by gentamicin (31.7%). Percentage of prescriptions with an antibiotic was 55% and nearly 62% of the practitioners prescribed drugs by their generic names. As a practice of poly-pharmacy, it was observed that the average number of drugs prescribed in urban and rural area was nearly 5 and 4, respectively. Nearly 80% of the urban and rural practitioners were prescribing at least one injection. Study of the quality of prescriptions revealed that there was poor legibility, high usage of abbreviations, inadequate details of the drugs, and absence of signature by practitioners in the prescriptions. This study clearly highlights the practice of poly-pharmacy, low usage of generic drugs, injudicious usage of antibiotics and injections and low usage of drugs prescribed from essential drugs list.

Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study

PubMed Central

Greenhalgh, Trisha; Russell, Jill; Myall, Michelle

2011-01-01

Objective To describe, explore, and compare organisational routines for repeat prescribing in general practice to identify contributors and barriers to safety and quality. Design Ethnographic case study. Setting Four urban UK general practices with diverse organisational characteristics using electronic patient records that supported semi-automation of repeat prescribing. Participants 395 hours of ethnographic observation of staff (25 doctors, 16 nurses, 4 healthcare assistants, 6 managers, and 56 reception or administrative staff), and 28 documents and other artefacts relating to repeat prescribing locally and nationally. Main outcome measures Potential threats to patient safety and characteristics of good practice. Methods Observation of how doctors, receptionists, and other administrative staff contributed to, and collaborated on, the repeat prescribing routine. Analysis included mapping prescribing routines, building a rich description of organisational practices, and drawing these together through narrative synthesis. This was informed by a sociological model of how organisational routines shape and are shaped by information and communications technologies. Results Repeat prescribing was a complex, technology-supported social practice requiring collaboration between clinical and administrative staff, with important implications for patient safety. More than half of requests for repeat prescriptions were classed as “exceptions” by receptionists (most commonly because the drug, dose, or timing differed from what was on the electronic repeat list). They managed these exceptions by making situated judgments that enabled them (sometimes but not always) to bridge the gap between the idealised assumptions about tasks, roles, and interactions that were built into the electronic patient record and formal protocols, and the actual repeat prescribing routine as it played out in practice. This work was creative and demanded both explicit and tacit knowledge. Clinicians were often unaware of this input and it did not feature in policy documents or previous research. Yet it was sometimes critical to getting the job done and contributed in subtle ways to safeguarding patients. Conclusion Receptionists and administrative staff make important “hidden” contributions to quality and safety in repeat prescribing in general practice, regarding themselves accountable to patients for these contributions. Studying technology-supported work routines that seem mundane, standardised, and automated, but which in reality require a high degree of local tailoring and judgment from frontline staff, opens up a new agenda for the study of patient safety. PMID:22053317

Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study.

PubMed

Swinglehurst, Deborah; Greenhalgh, Trisha; Russell, Jill; Myall, Michelle

2011-11-03

To describe, explore, and compare organisational routines for repeat prescribing in general practice to identify contributors and barriers to safety and quality. Ethnographic case study. Four urban UK general practices with diverse organisational characteristics using electronic patient records that supported semi-automation of repeat prescribing. 395 hours of ethnographic observation of staff (25 doctors, 16 nurses, 4 healthcare assistants, 6 managers, and 56 reception or administrative staff), and 28 documents and other artefacts relating to repeat prescribing locally and nationally. Potential threats to patient safety and characteristics of good practice. Observation of how doctors, receptionists, and other administrative staff contributed to, and collaborated on, the repeat prescribing routine. Analysis included mapping prescribing routines, building a rich description of organisational practices, and drawing these together through narrative synthesis. This was informed by a sociological model of how organisational routines shape and are shaped by information and communications technologies. Results Repeat prescribing was a complex, technology-supported social practice requiring collaboration between clinical and administrative staff, with important implications for patient safety. More than half of requests for repeat prescriptions were classed as "exceptions" by receptionists (most commonly because the drug, dose, or timing differed from what was on the electronic repeat list). They managed these exceptions by making situated judgments that enabled them (sometimes but not always) to bridge the gap between the idealised assumptions about tasks, roles, and interactions that were built into the electronic patient record and formal protocols, and the actual repeat prescribing routine as it played out in practice. This work was creative and demanded both explicit and tacit knowledge. Clinicians were often unaware of this input and it did not feature in policy documents or previous research. Yet it was sometimes critical to getting the job done and contributed in subtle ways to safeguarding patients. Conclusion Receptionists and administrative staff make important "hidden" contributions to quality and safety in repeat prescribing in general practice, regarding themselves accountable to patients for these contributions. Studying technology-supported work routines that seem mundane, standardised, and automated, but which in reality require a high degree of local tailoring and judgment from frontline staff, opens up a new agenda for the study of patient safety.

Medication prescribing advice and drug utilization: a review from the United Kingdom.

PubMed

Law, J; Thompson, A

1996-01-01

General Medical Practitioners (GPs) in the United Kingdom are usually the first point of contact with the National Health Service (NHS) for patients. They provide the majority of ambulatory care for their practice population and act as 'gatekeepers' for referral onwards to other services. This article investigates the influence of the purchasing authority prescribing advisors (PAs), including pharmacists and GPs on the prescribing habits in Salford, England, an inner city area in the North of England, close to the city of Manchester. The PAs became known as the prescribing CIA, and used the strategy of Control, progressing to Influence and Autonomy, to develop a mature partnership between the GPs, PAs and other health care professionals. Information collated from prescribing (PACT) data, by the Prescription Pricing Authority, was used to make comparisons between different practices within an area. Savings made by making rational changes in prescribing, were used to enhance practice development for the benefit of patient care.

Pharmacist prescription of hormonal contraception in Oregon: Baseline knowledge and interest in provision.

PubMed

Rodriguez, Maria I; McConnell, K John; Swartz, Jonas; Edelman, Alison B

2016-01-01

Oregon has implemented legislation expanding the scope of pharmacists to directly prescribe short-acting hormonal contraception (pill and patch) without a medical prescription. Pharmacists are crucial to the success of the new law, but relatively little is known about their intentions to prescribe contraception, or the motivators or barriers in providing this service. With the use of a cross-sectional survey of pharmacists practicing in Oregon before the legislative implementation, we analyzed responses to assess contraceptive knowledge, motivation to participate in direct provision, and perception of barriers to pharmacist prescription of contraception. A logistic regression model was used to examine the association between years in pharmacy practice and intention to provide direct access to contraception. A total of 509 pharmacists responded (17%). If training and reimbursement were offered, more than one-half of pharmacists would potentially be interested in prescribing contraception, managing side-effects, or moving women to a different hormonal method (57%, 61%, and 54%, respectively). However, only 39.1% of pharmacists surveyed planned to actually prescribe hormonal contraception when the legislation took effect. Shortage of pharmacy staff to provide services, concerns about liability, and a need for additional training were the three largest barriers to participation. Pharmacists practicing in urban locations (odds ratio 1.73, 95% CI 1.11-2.70) or currently offering emergency contraception (odds ratio 2.23, 95% CI 1.47-3.40) were significantly more likely to be planning to participate. Preliminary data indicate a need to support pharmacists with education on contraceptive provision and development of interventions to facilitate counseling in the pharmacy setting. Copyright © 2016 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Prescribing injectable and oral methadone to opiate addicts: results from the 1995 national postal survey of community pharmacies in England and Wales.

PubMed Central

Strang, J.; Sheridan, J.; Barber, N.

1996-01-01

OBJECTIVE--To establish the extent of prescribing injectable and oral methadone to opiate addicts and the practice characteristics and dispensing arrangements attached to these prescriptions. DESIGN--National survey of 25% random sample of community (high street) pharmacies through postal questionnaire, with four mailings. SETTING--England and Wales. SUBJECTS--1 in 4 sample of all 10,616 community pharmacies, stratified by family health services authority. MAIN OUTCOME MEASURES--Data were collected on each prescription for controlled drugs currently being dispensed by pharmacies to misusers, describing the drug, form, dose, source (general practice or hospital; and NHS or private), and numbers of dispensing pick ups a week. RESULTS--Methadone was the opiate most commonly dispensed to misusers (96.0% of 3846 opiate prescriptions). 79.6% of methadone prescriptions were for the oral liquid form, 11.0% for tablet, and 9.3% for injectable ampoules. More than one third of all methadone prescriptions were for weekly or fortnightly pick up, with a further third being for daily pick up. Tablets and ampoules were even less likely to be dispensed on a daily basis. Private prescriptions were significantly more likely than NHS ones to be for tablets or ampoules, to be for substantially higher daily doses, and to be collected on a weekly or fortnightly basis. CONCLUSIONS--The distinctively British practice of prescribing injectable methadone was found to be widespread and, contrary to guidance, to be as prevalent in non-specialist as specialist settings. In view of the frequent crushing and injecting of methadone tablets, clearer more authoritative guidance is needed on the contexts in which injectable methadone (tablets as well as ampoules) should be prescribed and on the responsibilities for monitoring and supervision which should be attached. PMID:8704540

Patient information leaflets: informing or frightening? A focus group study exploring patients' emotional reactions and subsequent behavior towards package leaflets of commonly prescribed medications in family practices.

PubMed

Herber, Oliver Rudolf; Gies, Verena; Schwappach, David; Thürmann, Petra; Wilm, Stefan

2014-10-02

The purpose of patient information leaflets (PILs) is to inform patients about the administration, precautions and potential side effects of their prescribed medication. Despite European Commission guidelines aiming at increasing readability and comprehension of PILs little is known about the potential risk information has on patients. This article explores patients' reactions and subsequent behavior towards risk information conveyed in PILs of commonly prescribed drugs by general practitioners (GPs) for the treatment of Type 2 diabetes, hypertension or hypercholesterolemia; the most frequent cause for consultations in family practices in Germany. We conducted six focus groups comprising 35 patients which were recruited in GP practices. Transcripts were read and coded for themes; categories were created by abstracting data and further refined into a coding framework. Three interrelated categories are presented: (i) The vast amount of side effects and drug interactions commonly described in PILs provoke various emotional reactions in patients which (ii) lead to specific patient behavior of which (iii) consulting the GP for assistance is among the most common. Findings show that current description of potential risk information caused feelings of fear and anxiety in the reader resulting in undesirable behavioral reactions. Future PILs need to convey potential risk information in a language that is less frightening while retaining the information content required to make informed decisions about the prescribed medication. Thus, during the production process greater emphasis needs to be placed on testing the degree of emotional arousal provoked in patients when reading risk information to allow them to undertake a benefit-risk-assessment of their medication that is based on rational rather than emotional (fearful) reactions.

Supporting the improvement and management of prescribing for urinary tract infections (SIMPle): protocol for a cluster randomized trial

PubMed Central

2013-01-01

Background The overuse of antimicrobials is recognized as the main selective pressure driving the emergence and spread of antimicrobial resistance in human bacterial pathogens. Urinary tract infections (UTIs) are among the most common infections presented in primary care and empirical antimicrobial treatment is currently recommended. Previous research has identified that a substantial proportion of Irish general practitioners (GPs) prescribe antimicrobials for UTIs that are not in accordance with the Guidelines for Antimicrobial Prescribing in Primary Care in Ireland. The aim of this trial is to design, implement and evaluate the effectiveness of a complex intervention on GP antimicrobial prescribing and adult (18 years of age and over) patients’ antimicrobial consumption when presenting with a suspected UTI. Methods/design The Supporting the Improvement and Management of Prescribing for urinary tract infections (SIMPle) study is a three-armed intervention with practice-level randomization. Adult patients presenting with suspected UTIs in primary care will be included in the study. The intervention integrates components for both GPs and patients. For GPs the intervention includes interactive workshops, audit and feedback reports and automated electronic prompts summarizing recommended first-line antimicrobial treatment and, for one intervention arm, a recommendation to consider delayed antimicrobial treatment. For patients, multimedia applications and information leaflets are included. Thirty practices will be recruited to the study; laboratory data indicate that 2,038 patients will be prescribed an antimicrobial in the study. The primary outcome is a change in prescribing of first-line antimicrobials for UTIs in accordance with the Guidelines for Antimicrobial Prescribing in Primary Care in Ireland. The study will take place over 15 months with a six-month intervention period. Data will be collected through a remote electronic anonymized data-extraction system, a text-messaging system and GP and patient interviews and surveys. The intervention will be strengthened by the implementation of a social marketing framework and an economic evaluation. Trial registration This intervention is registered at ClinicalTrials.gov, ID NCT01913860. PMID:24359543

Accounting for medical variation: the case of prescribing activity in a New Zealand general practice sample.

PubMed

Davis, P B; Yee, R L; Millar, J

1994-08-01

Medical practice variation is extensive and well documented, particularly for surgical interventions, and raises important questions for health policy. To date, however, little work has been carried out on interpractitioner variation in prescribing activity in the primary care setting. An analytical model of medical variation is derived from the literature and relevant indicators are identified from a study of New Zealand general practice. The data are based on nearly 9,500 completed patient encounter records drawn from over a hundred practitioners in the Waikato region of the North Island, New Zealand. The data set represents a 1% sample of all weekday general practice office encounters in the Hamilton Health District recorded over a 12-month period. Overall levels of prescribing, and the distribution of drug mentions across diagnostic groupings, are broadly comparable to results drawn from international benchmark data. A multivariate analysis is carried out on seven measures of activity in the areas of prescribing volume, script detail, and therapeutic choice. The analysis indicates that patient, practitioner and practice attributes exert little systematic influence on the prescribing task. The principal influences are diagnosis, followed by practitioner identity. The pattern of findings suggests also that the prescribing task cannot be viewed as an undifferentiated activity. It is more usefully considered as a process of decision-making in which 'core' judgements--such as the decision to prescribe and the choice of drug--are highly predictable and strongly influenced by diagnosis, while 'peripheral' features of the task--such as choosing a combination drug or prescribing generically--are less determinate and more subject to the exercise of clinical discretion.(ABSTRACT TRUNCATED AT 250 WORDS)

Improving opioid safety practices in primary care: protocol for the development and evaluation of a multifaceted, theory-informed pilot intervention for healthcare providers.

PubMed

Leece, Pamela; Buchman, Daniel Z; Hamilton, Michael; Timmings, Caitlyn; Shantharam, Yalnee; Moore, Julia; Furlan, Andrea D

2017-04-26

In North America, drug overdose deaths are reaching unprecedented levels, largely driven by increasing prescription opioid-related deaths. Despite the development of several opioid guidelines, prescribing behaviours still contribute to poor patient outcomes and societal harm. Factors at the provider and system level may hinder or facilitate the application of evidence-based guidelines; interventions designed to address such factors are needed. Using implementation science and behaviour change theory, we have planned the development and evaluation of a comprehensive Opioid Self-Assessment Package, designed to increase adherence to the Canadian Opioid Guideline among family physicians. The intervention uses practical educational and self-assessment tools to provide prescribers with feedback on their current knowledge and practices, and resources to improve their practice. The evaluation approach uses a pretest and post-test design and includes both quantitative and qualitative methods at baseline and 6 months. We will recruit a purposive sample of approximately 10 family physicians in Ontario from diverse practice settings, who currently treat patients with long-term opioid therapy for chronic pain. Quantitative data will be analysed using basic descriptive statistics, and qualitative data will be analysed using the Framework Method. The University Health Network Research Ethics Board approved this study. Dissemination plan includes publications, conference presentations and brief stakeholder reports. This evidence-informed, theory-driven intervention has implications for national application of opioid quality improvement tools in primary care settings. We are engaging experts and end users in advisory and stakeholder roles throughout our project to increase its national relevance, application and sustainability. The performance measures could be used as the basis for health system quality improvement indicators to monitor opioid prescribing. Additionally, the methods and approach used in this study could be adapted for other opioid guidelines, or applied to other areas of preventive healthcare and clinical guideline implementation processes. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

How well are general practice trainees prepared for paediatric prescribing?

PubMed

Isa, N M; Taylor, Michael W; Helms, Peter J; McLay, James S

2009-03-01

We invited 232 General Practice Trainees to complete an on-line questionnaire to assess how they rated their training for the task of paediatric prescribing and therapeutics in the community. Of the 166 (71%) respondents who completed the questionnaire, 26.5% recalled specific teaching about paediatric prescribing and 59.6% covering one or more relevant topic during their undergraduate years. Undertaking a paediatric post during vocational training was associated with greater prescribing confidence (P < 0.001); however, 35% of respondents were not intending to undertake such a post. This study suggests that many GP trainees perceive their paediatric prescribing training as inadequate.

'It's showed me the skills that he has': pharmacists' and mentors' views on pharmacist supplementary prescribing.

PubMed

Lloyd, Fran; Parsons, Carole; Hughes, Carmel M

2010-02-01

Supplementary prescribing has seen pharmacists assume greater responsibility for prescribing in collaboration with doctors. This study explored the context and experiences, in relation to the practice of supplementary prescribing, of pharmacists and physicians (who acted as their training mentors) at least 12 months after pharmacists had qualified as supplementary prescribers. The setting was primary and secondary healthcare sectors in Northern Ireland. Pharmacists and mentors who had participated in a pre-training study were invited to take part. All pharmacists (n = 47) were invited to participate in focus groups, while mentors (n = 35) were asked to participate in face-to-face semi-structured interviews. The research took place between May 2005 and September 2007. All discussions and interviews were audiotaped, transcribed and analysed using constant comparison. Nine pharmacist focus groups were convened (number per group ranging from three to six; total n = 40) and 31 semi-structured interviews with mentors were conducted. The six main themes that emerged were optimal practice setting, professional progression for prescribing pharmacists, outcomes for prescribing pharmacists, mentors and patients, relationships, barriers to implementation and the future of pharmacist prescribing. Where practised, pharmacist prescribing had been accepted, worked best for chronic disease management, was perceived to have reduced doctors' workload and improved continuity of care for patients. However, three-quarters of pharmacists qualified to practise as supplementary prescribers were not actively prescribing, largely due to logistical and organisational barriers rather than inter-professional tensions. Independent prescribing was seen as contentious by mentors, particularly because of the diagnostic element. Supplementary prescribing has been successful where it has been implemented but a number of barriers remain which are preventing the wider acceptance of this practice innovation.

Current practice of emergency vagotomy and Helicobacter pylori eradication for complicated peptic ulcer in the United Kingdom.

PubMed

Gilliam, A D; Speake, W J; Lobo, D N; Beckingham, I J

2003-01-01

The aim was to assess the current opinion of surgeons, by subspecialty, towards vagotomy and the practice of Helicobacter pylori testing, treatment and follow-up, in patients with bleeding or perforated duodenal ulcer. A postal questionnaire was sent to 1073 Fellows of the Association of Surgeons of Great Britain and Ireland in 2001. Some 697 valid questionnaires were analysed (65.0 per cent). Most surgeons did not perform vagotomy for perforated or bleeding duodenal ulcer. There was no statistical difference between the responses of upper gastrointestinal surgeons and those of other specialists for perforated (P = 0.35) and bleeding (P = 0.45) ulcers. Respondents were more likely to perform a vagotomy for bleeding than for a perforated ulcer (P < 0.001). Although more than 80 per cent of surgeons prescribed H. pylori eradication treatment after operation, fewer than 60 per cent routinely tested patients for H. pylori eradication. Upper gastrointestinal surgeons were more likely to prescribe H. pylori treatment and test for eradication than other specialists (P < 0.01). Most surgeons in the UK no longer perform vagotomy for duodenal ulcer complications. Copyright 2002 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd

Pharmacology and Therapeutics Education in the European Union Needs Harmonization and Modernization: A Cross-sectional Survey Among 185 Medical Schools in 27 Countries.

PubMed

Brinkman, D J; Tichelaar, J; Okorie, M; Bissell, L; Christiaens, T; Likic, R; Mačìulaitis, R; Costa, J; Sanz, E J; Tamba, B I; Maxwell, S R; Richir, M C; van Agtmael, M A

2017-11-01

Effective teaching in pharmacology and clinical pharmacology and therapeutics (CPT) is necessary to make medical students competent prescribers. However, the current structure, delivery, and assessment of CPT education in the European Union (EU) is unknown. We sent an online questionnaire to teachers with overall responsibility for CPT education in EU medical schools. Questions focused on undergraduate teaching and assessment of CPT, and students' preparedness for prescribing. In all, 185 medical schools (64%) from 27 EU countries responded. Traditional learning methods were mainly used. The majority of respondents did not provide students with the opportunity to practice real-life prescribing and believed that their students were not well prepared for prescribing. There is a marked difference in the quality and quantity of CPT education within and between EU countries, suggesting that there is considerable scope for improvement. A collaborative approach should be adopted to harmonize and modernize the undergraduate CPT education across the EU. © 2017 The Authors Clinical Pharmacology & Therapeutics published by Wiley Periodicals, Inc. on behalf of American Society for Clinical Pharmacology and Therapeutics.

Strength and Conditioning and Concurrent Training Practices in Elite Rugby Union.

PubMed

Jones, Thomas W; Smith, Andrew; Macnaughton, Lindsay S; French, Duncan N

2016-12-01

Jones, TW, Smith, A, Macnaughton, LS, and French, DN. Strength and Conditioning and Concurrent Training Practices in Elite Rugby Union. J Strength Cond Res 30(12): 3354-3366, 2016-There is limited published research on strength and conditioning (S&C) practices in elite rugby union (RU). Information regarding testing batteries and programme design would provide valuable information to both applied practitioners and researchers investigating the influence of training interventions or preperformance strategies. The aim of this study was to detail the current practices of S&C coaches and sport scientists working in RU. A questionnaire was developed that comprised 7 sections: personal details, physical testing, strength and power development, concurrent training, flexibility development, unique aspects of the programme, and any further relevant information regarding prescribed training programmes. Forty-three (41 men, 2 women; age: 33.1 ± 5.3 years) of 52 (83%) coaches responded to the questionnaire. The majority of practitioners worked with international level and/or professional RU athletes. All respondents believed strength training benefits RU performance and reported that their athletes regularly performed strength training. The clean and back squat were rated the most important prescribed exercises. Forty-one (95%) respondents reported prescribing plyometric exercises and 38 (88%) indicated that periodization strategies were used. Forty-two (98%) practitioners reported conducting physical testing, with body composition being the most commonly tested phenotype. Thirty-three (77%) practitioners indicated that the potential muted strength development associated with concurrent training was considered when programming and 27 (63%) believed that strength before aerobic training was more favorable for strength development than vice versa. This research represents the only published survey to date of S&C practices in northern and southern hemisphere RU.

Cytotoxic drug use in treatment of dogs and cats with cancer by UK veterinary practices (2003 to 2004).

PubMed

Cave, T A; Norman, P; Mellor, D

2007-07-01

To describe the range and frequency of cytotoxic drugs prescribed within UK veterinary practices to treat dogs and cats with cancer, determine the effect of practice demographic variables on this practice and determine the frequency with which intravenous catheters were used during administration of parenteral cytotoxic drugs. A postal survey of 1838 veterinary practices providing care for dogs and cats within the UK. Prescription of cytotoxic drugs to treat dogs and cats with cancer during the preceding 12 months was reported by 70.8 per cent practices. The most widely prescribed agents were cyclophosphamide (65.4 per cent) and vincristine (63.5 per cent). Twenty-three per cent of responding practices had prescribed an antitumour antibiotic and 8.3 per cent had prescribed a platinum agent. The median frequency of prescription was between once a month and once every three months. Increasing frequency and range of cytotoxic drug prescription were associated with practice employment of higher numbers of veterinary surgeons and increased levels of pet insurance among practice clients. Almost a quarter of practices administering vesicant parenteral cytotoxic drugs failed to always use intravenous catheters to do so. Prescription of cytotoxic drugs, and therefore the potential for occupational exposure of staff, was widespread among UK veterinary practices providing care for dogs and cats.

Heterogeneity in the treatment of moderately severe scalp psoriasis in Scotland - results of a survey of Scottish health professionals.

PubMed

Smith, Douglas R W; Bottomley, Julia M; Auland, Merran; Jackson, Peter; Sharp, Judith

2011-01-01

Scalp psoriasis is a chronic recalcitrant condition. An aging literature for topical treatments used in clinical practice and no treatment guidelines means there is no current gold standard for its management in Scotland. There are no Scottish data on the resources and costs of treatment of the scalp psoriasis patient. Conduct a survey of Scottish healthcare professionals to understand how patients are typically managed to support the development of a model estimating the cost-effectiveness of a new treatment for moderately severe scalp psoriasis in Scotland. Experts from primary and secondary care were invited to participate in an interview programme to collect information on the management of scalp psoriasis in Scotland. This was further informed by Scottish prescribing statistics. Simple descriptive statistics were performed. Forty-three healthcare professionals (33 from primary care and ten in secondary care) completed the survey which illuminated national prescribing statistics. While an overall 72% response rate was achieved, representation from five of 14 Health Boards was not available. There was significant variation in stated patient pathways but some common themes. Most patients were treated initially with coal tar preparations and shampoos, then often progressing to topical potent corticosteroids. There was no consensus on the order patients might receive topicals thereafter although if referred for specialist review they would typically have been treated with three topicals in primary care first. Treatment in secondary care comprised application of topicals available in primary care or alternative preparations with nurse assistance to improve compliance. Phototherapy and systemic agents were not given to patients with scalp psoriasis alone. Study limitations are not considered to impact on the study observations. There was a large variety in first-, second- and third-line agents in primary care in scalp psoriasis although our interview programme and prescribing data confirmed which treatments were most frequently prescribed. Treatment heterogeneity reflects the limitations in current therapies, paucity of evidence-based effectiveness data and lack of clinical guidelines. Experts agreed 'current standard practice' in Scotland was best described as an average across five plausible treatment pathways.

Translating U-500R Randomized Clinical Trial Evidence to the Practice Setting: A Diabetes Educator/Expert Prescriber Team Approach

PubMed Central

Bergen, Paula M.; Kruger, Davida F.; Taylor, April D.; Eid, Wael E.; Bhan, Arti; Jackson, Jeffrey A.

2017-01-01

Purpose The purpose of this article is to provide recommendations to the diabetes educator/expert prescriber team for the use of human regular U-500 insulin (U-500R) in patients with severely insulin-resistant type 2 diabetes, including its initiation and titration, by utilizing dosing charts and teaching materials translated from a recent U-500R clinical trial. Conclusions Clinically relevant recommendations and teaching materials for the optimal use and management of U-500R in clinical practice are provided based on the efficacy and safety results of and lessons learned from the U-500R clinical trial by Hood et al, current standards of practice, and the authors’ clinical expertise. This trial was the first robustly powered, randomized, titration-to-target trial to compare twice-daily and three-times-daily U-500R dosing regimens. Modifications were made to the initiation and titration dosing algorithms used in this trial to simplify dosing strategies for the clinical setting and align with current glycemic targets recommended by the American Diabetes Association. Leveraging the expertise, resources, and patient interactions of the diabetes educator who can provide diabetes self-management education and support in collaboration with the multidisciplinary diabetes team is strongly recommended to ensure patients treated with U-500R receive the timely and comprehensive care required to safely and effectively use this highly concentrated insulin. PMID:28427304

Translating U-500R Randomized Clinical Trial Evidence to the Practice Setting: A Diabetes Educator/Expert Prescriber Team Approach.

PubMed

Bergen, Paula M; Kruger, Davida F; Taylor, April D; Eid, Wael E; Bhan, Arti; Jackson, Jeffrey A

2017-06-01

Purpose The purpose of this article is to provide recommendations to the diabetes educator/expert prescriber team for the use of human regular U-500 insulin (U-500R) in patients with severely insulin-resistant type 2 diabetes, including its initiation and titration, by utilizing dosing charts and teaching materials translated from a recent U-500R clinical trial. Conclusions Clinically relevant recommendations and teaching materials for the optimal use and management of U-500R in clinical practice are provided based on the efficacy and safety results of and lessons learned from the U-500R clinical trial by Hood et al, current standards of practice, and the authors' clinical expertise. This trial was the first robustly powered, randomized, titration-to-target trial to compare twice-daily and three-times-daily U-500R dosing regimens. Modifications were made to the initiation and titration dosing algorithms used in this trial to simplify dosing strategies for the clinical setting and align with current glycemic targets recommended by the American Diabetes Association. Leveraging the expertise, resources, and patient interactions of the diabetes educator who can provide diabetes self-management education and support in collaboration with the multidisciplinary diabetes team is strongly recommended to ensure patients treated with U-500R receive the timely and comprehensive care required to safely and effectively use this highly concentrated insulin.

Appraisal of antimicrobial prescribing practices of governmental and non-governmental dentists for hospitals in the western region of Saudi Arabia.

PubMed

Al-Harthi, Sameer E; Khan, Lateef M; Abed, Hassan H; Alkreathy, Huda M; Ali, Ahmed S

2013-12-01

To scrutinize the knowledge, attitude, and antimicrobial practices in Saudi Arabian Dentistry. In this cross-sectional survey of dentists, a self-administered questionnaire comprising of 61 questions was dispersed to the participants randomly, which included their professional profile, awareness of the current scope of antimicrobial resistance, prescribing practice, frequency of antimicrobial prescription, and sources of continuing education of antimicrobials. The study took place in the Faculty of Dentistry, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia between February and April 2013. Knowledge and awareness concerning specific antimicrobials, with specific oral cavity lesion was 78% for the students and interns, 80% for residents, and 95.3% for specialists. Approximately 89% of the students, interns and residents, and 98.4% of the specialists endorsed indiscriminate use of antibiotics. In addition, 93.4% of students, 90% of interns and residents, and 90.6% of specialists agreed that lack of health education is one of the contributors to overuse of antimicrobials. Moreover, 91.9% of the interns, 80% of residents, and 75.5% of specialists preferred amoxicillin + clavulanate as their first choice; however, a wide variation in the dosage frequency, and duration was observed. Participants are well aware of the significance of antimicrobial resistance, and considered that judicious use of antimicrobials is highly imperative to restrain this fiery predicament. Divergence was demonstrated between specialists and residents in prescribing practices. Institutional antimicrobial guideline was not interesting to all the respondents. This highlights the need for incessant instructive intervention in order to accomplish the prime objective of retreating antimicrobial resistance.

Evidence-based practice guidelines for prescribing home modifications for clients with bariatric care needs.

PubMed

de Lange, Laura; Coyle, Emma; Todd, Helen; Williams, Cylie

2018-04-01

Home modifications maintain people's functional independence and safety. No literature exists to guide the prescription of home modifications for clients with bariatric care needs. With Australia's increasing obesity rate, more evidence is needed to support home modification prescribers. This study aimed to map Australian home modification prescribing practices for clients with bariatric care needs and to establish and evaluate a clinical resource for this prescription process. The study included two phases. Phase 1 conducted a cross-sectional survey of therapists practicing in Australia, and Australian industry partners who prescribe or install home modifications for clients with bariatric care needs. Phase 2 included design, implementation and evaluation of a clinical resource. Data were analysed with means and frequencies; multivariable regression analysis was used to explore prescribing habits. Therapists surveyed (n = 347) reported 11 different bariatric weight definitions. Less than 3% constantly or regularly prescribed home modifications for these clients; rails were most commonly prescribed. Many therapists (n = 171, 58%) 'never' or 'rarely' knew rail load capacity. Therapists' knowledge of rail load capacity was associated with previous experience prescribing home modifications (P = 0.009); rail manufacturer's advice (P = 0.016) and not using advice from builders (P = 0.001). Clinical resources were used by 11% (n = 26) of therapists to support their prescription, and industry sporadically relied on therapists to specify modification design requirements (n = 5, 45%). Post-implementation of a clinical resource increased consensus regarding understanding of the term bariatric and increased consultation with builders and manufacturers. There was a lack of consistency in bariatric terminology, uncertainty of rail load capacities and minimal use of clinical practice guidelines. Additional resources will assist with consistency in prescribing practices to maximise occupational performance for clients with bariatric care needs. © 2018 Occupational Therapy Australia.

Generic medicines: Greek physicians' perceptions and prescribing practices.

PubMed

Tsiantou, V; Zavras, D; Kousoulakou, H; Geitona, M; Kyriopoulos, J

2009-10-01

The penetration of generic drugs in the Greek pharmaceutical market is placed among the weakest in the EU. The Greek regulatory framework does not systematically support the development of this subsector and physicians are not provided with incentives for prescribing generics. The aim of this study was to investigate the prescribing profile of physicians in Greece with a focus on the factors that influence their decision on generics prescribing. A structured questionnaire was sent by mail to a random national sample of 1463 physicians, stratified by sex, specialty and geographical region. The response rate was 82.3%. Greek physicians have a positive view on generics but they prefer to prescribe the original products. According to our analysis, physician's age and their opinion on generics' efficacy and effectiveness are identified as important determinants of their prescribing decision. The primary reason that could make them change their prescribing habits is the appearance of side-effects. Patients' insurance coverage and income, as well as the drug cost are also referred as factors that influence their prescribing decision. Despite the fact that they do not usually prescribe generics in their clinical practice, they are willing to substitute an original drug by a generic product. Our findings suggest that Greek physicians could be persuaded to prescribe generic medicines, if a generic promotion policy was introduced in the country. To develop such a policy, a set of supply side and demand-side measures should be implemented along with provision of information on generics to physicians during their education and clinical practice.

Provincial Comparison of Pharmacist Prescribing in Canada Using Alberta’s Model as the Reference Point

PubMed Central

Bhatia, Surya; Simpson, Scot H; Bungard, Tammy

2017-01-01

Background In the past decade, pharmacist practice has evolved tremendously in Canada, but the scope of practice varies substantially from one province to another. Objective To describe pharmacists’ scopes of practice relevant to prescribing within various jurisdictions of Canada, using the prescribing model in Alberta (authors’ province) as the reference point. Methods This cross-sectional survey consisted of clinical scenarios for emergency prescribing, adapting or renewing a prescription, and initial-access prescribing for a chronic disease. Pharmacists were asked about their ability to administer injections and to order or access the results of laboratory tests, as well as certification and training requirements and reimbursement models. Results Thirteen pharmacists representing Canadian provinces other than Alberta were surveyed in late 2015, for comparison with Alberta. With specific reference to the scenarios presented, pharmacists were able to prescribe in an emergency in 9 of the 10 provinces, renew prescriptions in all provinces, and adapt prescriptions in 6 provinces. Three provinces required that pharmacists have collaborative practice agreements identifying a specific practice area in order to initiate a prescription for a chronic disease (with 6–12 pharmacists per province having such agreements). Alberta required pharmacists to have authorization, based on a detailed application, in order to initiate any provincially regulated drug (with about 1150 pharmacists having this authorization). Pharmacists were allowed to administer vaccines in 9 provinces, and 5 provinces allowed pharmacists to administer drugs by injection. Three provinces had systems in place for pharmacists to access laboratory test results, and 2 allowed pharmacists to order laboratory tests. Five provinces had government-reimbursed programs in place for select prescribing services; however, all 9 provinces with public vaccination programs reimbursed pharmacists for this service. Conclusions Pharmacist prescribing differs among Canadian provinces. Although most provinces allow emergency prescribing and renewal or adaptation of prescriptions by pharmacists, only 4 provinces allow prescription initiation, with variable criteria and scope. Despite some progress to enhance patient flow through the health care system (e.g., by allowing pharmacists to extend prescriptions), further work should be pursued to harmonize clinical practices across Canada and to enable pharmacists to initiate and manage drug therapy. PMID:29109578

Contraception Delivery in Pediatric and Specialist Pediatric Practices.

PubMed

Kaskowitz, Alexa; Quint, Elisabeth; Zochowski, Melissa; Caldwell, Amy; Vinekar, Kavita; Dalton, Vanessa K

2017-04-01

To characterize pediatricians' knowledge, attitudes, and self-efficacy around contraception. Cross-sectional survey. United States. National sample of pediatricians. Assessment of behaviors of providing contraception. Reproductive health practice score. Two hundred twenty-three usable surveys were received, from 163 contraceptive prescribers and 60 nonprescribers. The mean reproductive health practice score was 43.1 (SD, 8.2; total possible score, 84). Prescribers differed in their mean reproductive health score (46.0; SD, 7.0) from nonprescribers (34.0; SD, 4.5; P < .001). Prescribers vs nonprescribers differed in their attitude and efficacy in providing contraception. More prescribers believed it was their responsibility to ask about patients' need for birth control, were confident in their ability to prescribe contraception options, and provided contraception to minors despite parental disapproval. Neither group was confident in their ability to place intrauterine devices or believed that the literature supports intrauterine device placement in adolescents. Only efficacy was related to prescribing contraception in a multivariate regression analysis (odds ratio, 1.7; P < .001). In this study, we showed that most pediatricians are contraception prescribers but the overall reproductive health score was low for prescribers and nonprescribers. The odds of prescribing contraception increased with higher self-efficacy scores rather than knowledge alone. Many prescribers and nonprescribers would not prescribe birth control if parents disapproved and do not believe it is their responsibility to assess patients' need for birth control. In addition very few pediatricians have training in long-acting reversible contraception, despite being the recommended method for adolescents. Copyright © 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.

Using antibiograms to improve antibiotic prescribing in skilled nursing facilities.

PubMed

Furuno, Jon P; Comer, Angela C; Johnson, J Kristie; Rosenberg, Joseph H; Moore, Susan L; MacKenzie, Thomas D; Hall, Kendall K; Hirshon, Jon Mark

2014-10-01

Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown. To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing. Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs. Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities. We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant ([Formula: see text]). Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs.

Influences on GPs' decision to prescribe new drugs-the importance of who says what.

PubMed

Prosser, Helen; Almond, Solomon; Walley, Tom

2003-02-01

The aim of this study was to understand the range of factors that influence GPs' uptake of new drugs A total of 107 GPs selected purposively from high, medium and low new drug prescribing practices in two health authorities in the north west of England were interviewed using the critical incident technique with semi-structured interviews. Interview topics included reasons for prescribing new drugs launched between January 1998 and May 1999; reasons for prescribing the new drug rather than alternatives; and sources of information used for each prescribed drug. Important biomedical influences were the failure of current therapy and adverse effect profile. More influential than these, however, was the pharmaceutical representative. Hospital consultants and observation of hospital prescribing was cited next most frequently. Patient request for a drug, and patient convenience and acceptability were also likely to influence new drug uptake. Written information was of limited importance except for local guidelines. GPs were largely reactive and opportunistic recipients of new drug information, rarely reporting an active information search. The decision to initiate a new drug is heavily influenced by 'who says what', in particular the pharmaceutical industry, hospital consultants and patients. The decision to 'adopt' a new drug is clinched by subsequent personal clinical experience. Prescribing of new drugs is not simply related to biomedical evaluation and critical appraisal but, more importantly, to the mode of exposure to pharmacological information and social influences on decision making. Viewed within this broad context, prescribing variation becomes more understandable. Findings have implications for the implementation of evidence-based medicine, which requires a multifaceted approach.

The impact of pharmacy services on opioid prescribing in dental practice.

PubMed

Stewart, Autumn; Zborovancik, Kelsey J; Stiely, Kara L

To compare rates of dental opioid prescribing between periods of full and partial integration of pharmacy services and periods of no integration. This observational study used a retrospective chart review of opioid prescriptions written by dental providers practicing in a free dental clinic for the medically underserved over a period of 74 months. Pharmacy services were fully integrated into the practice model for 48 of the 74 months under study. During this time frame, all dental opioid orders required review by the pharmacy department before prescribing. Outcomes related to prescribing rates and errors were compared between groups, which were defined by the level of integrated pharmacy services. Demographic and prescription-specific data (drug name, dose, quantity, directions, professional designation of individual entering order) and clinic appointment data were collected and analyzed with the use of descriptive and inferential statistics. A total of 102 opioids were prescribed to 89 patients; hydrocodone-acetaminophen combination products were the most frequently used. Opioid prescribing rates were 5 times greater when pharmacy services were not integrated (P <0.001); and dentists were 81% less likely to prescribe opioids when pharmacy was fully integrated (odds ratio 0.19, 95% confidence interval 0.124-0.293; P <0.001). Frequency of hydrocodone use compared with other opioids did not decrease after the rescheduling of hydrocodone to a Schedule II controlled substance. The frequency of prescribing errors was not statistically different between groups, although there were numerically fewer errors with integrated pharmacy services. The literature reports that dentists are the third most frequent prescribers of opioids. The findings from this study suggest that collaboration between pharmacists and dentists has the potential to decrease opioid utilization in primary dental practice. Copyright © 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Antibiotic Use in 2016 by Members of the American Association of Endodontists: Report of a National Survey.

PubMed

Germack, Mark; Sedgley, Christine M; Sabbah, Wael; Whitten, Brian

2017-10-01

This study surveyed the antibiotic prescribing practices of endodontists, and data were compared with previous surveys conducted in 1994 and 1999. A 17-question survey was sent via www.surveymonkey.com to 3000 active members of the American Association of Endodontists for responses about antibiotic prescribing practices and demographics. The data were analyzed using descriptive statistics, chi-square tests, and linear regression analyses. Six hundred eighty-six participants (22.86%) completed the survey. The most frequently prescribed antibiotics were amoxicillin (60.71%) followed by penicillin V (30.43%) and clindamycin for patients with allergies (95.4%). Respondents reported prescribing antibiotics for irreversible pulpitis with mild symptoms (1.75%), irreversible pulpitis with moderate symptoms (6.41%), necrotic pulp with symptomatic apical periodontitis (43.59%), chronic apical abscess without (10.50%) or with symptoms (29.74%), acute apical abscess (95.92%), avulsion (70.26%), endodontic surgery (41.69%), retreatment (silver point [23.76%] or gutta-percha [15.60%]), postoperative pain after instrumentation or obturation (12.39%), and perforation repair (5.98%). The type of practice (solo/group) and geographic region (Southeast) were significant predictors of increased antibiotic prescribing; 36.89% of respondents reported prescribing antibiotics that are not necessary, most commonly because of patient expectations. Since 1999, there has been a significant shift from prescribing penicillin V to amoxicillin as endodontists' first choice of antibiotic and a significant increase in the use of clindamycin for penicillin-allergic patients. Antibiotics continue to be prescribed in clinical situations for which they are typically not indicated, most commonly because of patient expectations. Regional differences in antibiotic prescribing practices by endodontists exist in the United States. Copyright © 2017 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.

Intervention studies on rational use of drugs in public and private sector in Nepal.

PubMed

Kafle, Kumud Kumar; Shrestha, Naveen; Karkee, Shiba Bahadur; Prasad, Radha Raman; Bhuju, Gajendra Bahadur; Das, Prabhakar Lal

2005-06-01

In developing countries, inappropriate, inefficient and ineffective use of pharmaceuticals have resulted into the poor health and medical cares for the community people. For improving the situation, various interventions have been tested and proved effective in different settings. In Nepal also, various strategies have been tested and found effective to improve the prescribing and dispensing practices. This paper has examined the process and results of different studies. The educational intervention, the training has not been effective in improving the prescribing practices but has limited effect on dispensing practices in the public sector. However, it becomes effective in improving prescribing practices if combined with a managerial intervention e.g. peer-group discussion. In private sector, training alone is effective in changing the drug recommendation practices of retailers. But none of interventions have been found to be effective in improving dispensing practices. After examining the effectiveness of different interventions, training combined with peer-group discussion is recommended for piloting in all Primary Health Care (PHC) outlets of a district to improve the prescribing practices. For improving the dispensing practices in both public and private sector, additional studies have to be carried out using different strategies.

Assessment of nonsteroidal anti-inflammatory drug use pattern using World Health Organization indicators: A cross-sectional study in a tertiary care teaching hospital of Chhattisgarh.

PubMed

R Vaishnavi, P R; Gaikwad, Nitin; Dhaneria, S P

2017-01-01

The objective of this study is to assess drug utilization pattern of nonsteroidal anti-inflammatory drugs (NSAIDs) in a tertiary care teaching hospital, Raipur, Chhattisgarh. A prospective, cross-sectional observational study was conducted in the outpatient department during 2-month period. After informed consent, the patients visiting pharmacy shop with a prescription were enrolled in the study. Their demographic details and prescription data were recorded in a case record form. The data were analyzed to determine the drug utilization pattern of NSAIDs, using the World Health Organization (WHO) prescribing indicators. A total of 600 prescriptions were analyzed. Of them, NSAIDs were prescribed in 30.83% encounters. In general, nonselective COX inhibitors were most commonly prescribed. The most commonly prescribed form of NSAID was paracetamol (39.45%). The percentage of NSAIDs prescribed with generic names were almost identical (91.15%), whereas the percentage of NSAIDs prescribed from the National List of Essential Medicine (India) - 2015 (49.72%) was not identical with the WHO standard (100%) which serves as an ideal. In 13.51% encounters, a fixed-dose combination (FDC) of NSAIDs was prescribed. Co-administration of gastroprotective agent with NSAIDs was observed in 24.32% encounters. The prescribing practices of NSAIDs indicate some deviation from the WHO standard. In addition, FDCs of NSAIDs with gastroprotective agents as well as other NSAIDs was also prescribed, which are irrational. This baseline data will be useful to plan further targeted research and to improve prescribing practices at the center. Various strategies such as face-to-face periodic training programs of prescribers, establishing drug and therapeutic committee; drug information centers; and drug bulletins can serve beneficial in improving prescribing practices.

Early experiences with E-prescribing.

PubMed

Halamka, John

2006-01-01

Most physicians understand that e-prescribing will reduce medical errors and will be perceived by patients as making the prescription process easier. However, they are skeptical about a number of things. They worry whether their office processes will be improved or streamlined; e-prescribing will interface seamlessly with their existing practice management software; training and support will be available; e-prescribing data will be seamlessly transferable to an electronic health record when they implement a more advanced clinical record system for their practice; and if they will achieve a return on investment. Early adopting clinicians in Massachusetts can convince the majority of clinicians to adopt e-prescribing by sharing their motivations for adopting e-prescribing, the challenges that they needed to overcome, the hardware and software requirements, and integration into their office workflow. Finally, interaction with the physicians and practice managers in the audience makes the adoption of e-prescribing seem both reasonable and exciting. Resources such as vendor lists, questions to ask, and hardware and software requirements also need to be readily available and in a form that non-technical staff can read and understand. Physicians who know the "why" would also like to know

Integration of vegetation community spatial data into a prescribed fire planning process at Shenandoah National Park, Virginia (USA)

USGS Publications Warehouse

Young, John A.; Mahan, Carolyn G.; Forder, Melissa

2017-01-01

Many eastern forest communities depend on fire for regeneration or are enhanced by fire as a restoration practice. However, the use of prescribed fire in the mesic forested environments and the densely populated regions of the eastern United States has been limited. The objective of our research was to develop a science-based approach to prioritizing the use of prescribed fire in appropriate forest types in the eastern United States based on a set of desired management outcomes. Through a process of expert elicitation and data analysis, we assessed and integrated recent vegetation community mapping results along with other available spatial data layers into a spatial prioritization tool for prescribed fire planning at Shenandoah National Park (Virginia, USA). The integration of vegetation spatial data allowed for development of per-pixel priority rankings and exclusion areas enabling precise targeting of fire management activities on the ground, as well as a park-wide ranking of fire planning compartments. We demonstrate the use and evaluation of this approach through implementation and monitoring of a prescribed burn and show that progress is being made toward desired conditions. Integration of spatial data into the fire planning process has served as a collaborative tool for the implementation of prescribed fire projects, which assures projects will be planned in the most appropriate areas to meet objectives that are supported by current science.

Emergency supply of prescription-only medicines to patients by community pharmacists: a mixed methods evaluation incorporating patient, pharmacist and GP perspectives

PubMed Central

Morecroft, Charles W; Mackridge, Adam J; Stokes, Elizabeth C; Gray, Nicola J; Wilson, Sarah E; Ashcroft, Darren M; Mensah, Noah; Pickup, Graham B

2015-01-01

Objective To evaluate and inform emergency supply of prescription-only medicines by community pharmacists (CPs), including how the service could form an integral component of established healthcare provision to maximise adherence. Design Mixed methods. 4 phases: prospective audit of emergency supply requests for prescribed medicines (October–November 2012 and April 2013); interviews with CPs (February–April 2013); follow-up interviews with patients (April–May 2013); interactive feedback sessions with general practice teams (October–November 2013). Setting 22 community pharmacies and 6 general practices in Northwest England. Participants 27 CPs with experience of dealing with requests for emergency supplies; 25 patients who received an emergency supply of a prescribed medicine; 58 staff at 6 general practices. Results Clinical audit in 22 pharmacies over two 4-week periods reported that 526 medicines were requested by 450 patients. Requests peaked over a bank holiday and around weekends. A significant number of supplies were made during practice opening hours. Most requests were for older patients and for medicines used in long-term conditions. Difficulty in renewing repeat medication (forgetting to order, or prescription delays) was the major reason for requests. The majority of medicines were ‘loaned’ in advance of a National Health Service (NHS) prescription. Interviews with CPs and patients indicated that continuous supply had a positive impact on medicines adherence, removing the need to access urgent care. General practice staff were surprised and concerned by the extent of emergency supply episodes. Conclusions CPs regularly provide emergency supplies to patients who run out of their repeat medication, including during practice opening hours. This may aid adherence. There is currently no feedback loop, however, to general practice. Patient care and interprofessional communication may be better served by the introduction of a formally structured and funded NHS emergency supply service from community pharmacies, with ongoing optimisation of repeat prescribing. PMID:26163029

Determinants associated with veterinary antimicrobial prescribing in farm animals in the Netherlands: a qualitative study.

PubMed

Speksnijder, D C; Jaarsma, A D C; van der Gugten, A C; Verheij, T J M; Wagenaar, J A

2015-04-01

Antimicrobial use in farm animals might contribute to the development of antimicrobial resistance in humans and animals, and there is an urgent need to reduce antimicrobial use in farm animals. Veterinarians are typically responsible for prescribing and overseeing antimicrobial use in animals. A thorough understanding of veterinarians' current prescribing practices and their reasons to prescribe antimicrobials might offer leads for interventions to reduce antimicrobial use in farm animals. This paper presents the results of a qualitative study of factors that influence prescribing behaviour of farm animal veterinarians. Semi-structured interviews with eleven farm animal veterinarians were conducted, which were taped, transcribed and iteratively analysed. This preliminary analysis was further discussed and refined in an expert meeting. A final conceptual model was derived from the analysis and sent to all the respondents for validation. Many conflicting interests are identifiable when it comes to antimicrobial prescribing by farm animal veterinarians. Belief in the professional obligation to alleviate animal suffering, financial dependency on clients, risk avoidance, shortcomings in advisory skills, financial barriers for structural veterinary herd health advisory services, lack of farmers' compliance to veterinary recommendations, public health interests, personal beliefs regarding the veterinary contribution to antimicrobial resistance and major economic powers are all influential determinants in antimicrobial prescribing behaviour of farm animal veterinarians. Interventions to change prescribing behaviour of farm animal veterinarians could address attitudes and advisory skills of veterinarians, as well as provide tools to deal with (perceived) pressure from farmers and advisors to prescribe antimicrobials. Additional (policy) measures could probably support farm animal veterinarians in acting as a more independent animal health consultant. © 2014 Blackwell Verlag GmbH.

Protocol for the PINCER trial: a cluster randomised trial comparing the effectiveness of a pharmacist-led IT-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices

PubMed Central

Avery, Anthony J; Rodgers, Sarah; Cantrill, Judith A; Armstrong, Sarah; Elliott, Rachel; Howard, Rachel; Kendrick, Denise; Morris, Caroline J; Murray, Scott A; Prescott, Robin J; Cresswell, Kathrin; Sheikh, Aziz

2009-01-01

Background Medication errors are an important cause of morbidity and mortality in primary care. The aims of this study are to determine the effectiveness, cost effectiveness and acceptability of a pharmacist-led information-technology-based complex intervention compared with simple feedback in reducing proportions of patients at risk from potentially hazardous prescribing and medicines management in general (family) practice. Methods Research subject group: "At-risk" patients registered with computerised general practices in two geographical regions in England. Design: Parallel group pragmatic cluster randomised trial. Interventions: Practices will be randomised to either: (i) Computer-generated feedback; or (ii) Pharmacist-led intervention comprising of computer-generated feedback, educational outreach and dedicated support. Primary outcome measures: The proportion of patients in each practice at six and 12 months post intervention: - with a computer-recorded history of peptic ulcer being prescribed non-selective non-steroidal anti-inflammatory drugs - with a computer-recorded diagnosis of asthma being prescribed beta-blockers - aged 75 years and older receiving long-term prescriptions for angiotensin converting enzyme inhibitors or loop diuretics without a recorded assessment of renal function and electrolytes in the preceding 15 months. Secondary outcome measures; These relate to a number of other examples of potentially hazardous prescribing and medicines management. Economic analysis: An economic evaluation will be done of the cost per error avoided, from the perspective of the UK National Health Service (NHS), comparing the pharmacist-led intervention with simple feedback. Qualitative analysis: A qualitative study will be conducted to explore the views and experiences of health care professionals and NHS managers concerning the interventions, and investigate possible reasons why the interventions prove effective, or conversely prove ineffective. Sample size: 34 practices in each of the two treatment arms would provide at least 80% power (two-tailed alpha of 0.05) to demonstrate a 50% reduction in error rates for each of the three primary outcome measures in the pharmacist-led intervention arm compared with a 11% reduction in the simple feedback arm. Discussion At the time of submission of this article, 72 general practices have been recruited (36 in each arm of the trial) and the interventions have been delivered. Analysis has not yet been undertaken. Trial registration Current controlled trials ISRCTN21785299 PMID:19409095

Use of behavioral economics and social psychology to improve treatment of acute respiratory infections (BEARI): rationale and design of a cluster randomized controlled trial [1RC4AG039115-01] - study protocol and baseline practice and provider characteristics

PubMed Central

2013-01-01

Background Inappropriate antibiotic prescribing for nonbacterial infections leads to increases in the costs of care, antibiotic resistance among bacteria, and adverse drug events. Acute respiratory infections (ARIs) are the most common reason for inappropriate antibiotic use. Most prior efforts to decrease inappropriate antibiotic prescribing for ARIs (e.g., educational or informational interventions) have relied on the implicit assumption that clinicians inappropriately prescribe antibiotics because they are unaware of guideline recommendations for ARIs. If lack of guideline awareness is not the reason for inappropriate prescribing, educational interventions may have limited impact on prescribing rates. Instead, interventions that apply social psychological and behavioral economic principles may be more effective in deterring inappropriate antibiotic prescribing for ARIs by well-informed clinicians. Methods/design The Application of Behavioral Economics to Improve the Treatment of Acute Respiratory Infections (BEARI) Trial is a multisite, cluster-randomized controlled trial with practice as the unit of randomization. The primary aim is to test the ability of three interventions based on behavioral economic principles to reduce the rate of inappropriate antibiotic prescribing for ARIs. We randomized practices in a 2 × 2 × 2 factorial design to receive up to three interventions for non-antibiotic-appropriate diagnoses: 1) Accountable Justifications: When prescribing an antibiotic for an ARI, clinicians are prompted to record an explicit justification that appears in the patient electronic health record; 2) Suggested Alternatives: Through computerized clinical decision support, clinicians prescribing an antibiotic for an ARI receive a list of non-antibiotic treatment choices (including prescription options) prior to completing the antibiotic prescription; and 3) Peer Comparison: Each provider’s rate of inappropriate antibiotic prescribing relative to top-performing peers is reported back to the provider periodically by email. We enrolled 269 clinicians (practicing attending physicians or advanced practice nurses) in 49 participating clinic sites and collected baseline data. The primary outcome is the antibiotic prescribing rate for office visits with non-antibiotic-appropriate ARI diagnoses. Secondary outcomes will examine antibiotic prescribing more broadly. The 18-month intervention period will be followed by a one year follow-up period to measure persistence of effects after interventions cease. Discussion The ongoing BEARI Trial will evaluate the effectiveness of behavioral economic strategies in reducing inappropriate prescribing of antibiotics. Trials registration ClinicalTrials.gov: NCT01454947 PMID:23806017

Developing health visitor prescribing.

PubMed

Brooks, Christina

2013-04-01

Prescribing is an essential element of the health visitor's role. However, in one inner-city locality prescribing in practice was evaluated to be at a low level. A number of barriers to prescribing were identified through a focus group. A project to support health visitors was planned and delivered. The project involved clinical updates and improvement to the registration process, thereby reducing delays for practitioners in getting prescribing pads. The result was that prescribing confidence improved and prescribing activity increased.

Data feedback and behavioural change intervention to improve primary care prescribing safety (EFIPPS): multicentre, three arm, cluster randomised controlled trial.

PubMed

Guthrie, Bruce; Kavanagh, Kimberley; Robertson, Chris; Barnett, Karen; Treweek, Shaun; Petrie, Dennis; Ritchie, Lewis; Bennie, Marion

2016-08-18

 To evaluate the effectiveness of feedback on safety of prescribing compared with moderately enhanced usual care.  Three arm, highly pragmatic cluster randomised trial.  262/278 (94%) primary care practices in three Scottish health boards.  Practices were randomised to: "usual care," consisting of emailed educational material with support for searching to identify patients (88 practices at baseline, 86 analysed); usual care plus feedback on practice's high risk prescribing sent quarterly on five occasions (87 practices, 86 analysed); or usual care plus the same feedback incorporating a behavioural change component (87 practices, 86 analysed).  The primary outcome was a patient level composite of six prescribing measures relating to high risk use of antipsychotics, non-steroidal anti-inflammatories, and antiplatelets. Secondary outcomes were the six individual measures. The primary analysis compared high risk prescribing in the two feedback arms against usual care at 15 months. Secondary analyses examined immediate change and change in trend of high risk prescribing associated with implementation of the intervention within each arm.  In the primary analysis, high risk prescribing as measured by the primary outcome fell from 6.0% (3332/55 896) to 5.1% (2845/55 872) in the usual care arm, compared with 5.9% (3341/56 194) to 4.6% (2587/56 478) in the feedback only arm (odds ratio 0.88 (95% confidence interval 0.80 to 0.96) compared with usual care; P=0.007) and 6.2% (3634/58 569) to 4.6% (2686/58 582) in the feedback plus behavioural change component arm (0.86 (0.78 to 0.95); P=0.002). In the pre-specified secondary analysis of change in trend within each arm, the usual care educational intervention had no effect on the existing declining trend in high risk prescribing. Both types of feedback were associated with significantly more rapid decline in high risk prescribing after the intervention compared with before.  Feedback of prescribing safety data was effective at reducing high risk prescribing. The intervention would be feasible to implement at scale in contexts where electronic health records are in general use.Trial registration Clinical trials NCT01602705. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Influencing prescribing in English primary care: the views of primary care organisations.

PubMed

Mason, Anne; Drummond, Michael; Towse, Adrian; Cooke, Jonathan

2004-07-01

The rapid rise of prescribing expenditure is a concern in many industrialised countries and methods to manage medicines are widely employed. The purpose of this study was to identify the approaches to improve primary care prescribing by primary care organisations (PCOs) in the National Health Service (NHS) in England. A questionnaire (Management of Medicines, MANMED) was mailed to prescribing advisers and prescribing leads in 332 PCOs. A response rate of 66% (220/332) was achieved. Most PCOs report the improvement of the quality of prescribing as their top priority, followed by budget adherence at both practice and PCO levels. Prescribing advisers typically offer several forms of support: practice visits, prescribing reviews, indicators of prescribing, prescribing newsletters, hands-on support, seminars and local formularies. PCOs are pursuing a wide range of prescribing initiatives, covering, on average, seven different therapeutic areas. National targets are the main driver for prescribing initiatives but other key influences include inappropriate prescribing and clinical governance. Although cost considerations are important, improving the quality of prescribing is perceived as the overriding principle on which PCO prescribing strategy is based. Multifaceted prescribing support is widespread and national targets are the largest single factor influencing choice of therapeutic area for prescribing initiatives. Diversity in approaches presents the opportunity to improve the evidence base for medicines management. Not only could such research inform PCOs in their central aim of improving the quality of prescribing within the NHS, but it may also offer insights of relevance to other countries if the influence of process and context upon the effectiveness of medicines management is systematically explored.

Heroin and methadone prescriptions from a London drug clinic over the first 15 years of operation (1968-1983): old records examined.

PubMed

Strang, John; Sheridan, Janie

2006-01-01

We charted changes in the prescriptions issued to opiate addicts in treatment at a London clinic over the first 15 years of operation of one of the new National Health Service (NHS) drug clinics established in 1968. Having located the original handwritten ledger records of prescriptions issued by the drug addict treatment clinic, an SPSS data file was created of the prescriptions given to each of the clinic patients each month over the period 1968-1983 to permit examination of changes over this 15-year period in the drugs prescribed (e.g., heroin, methadone), the form (e.g., injectable or oral), the daily doses, and the extent of multiple items for single patients (e.g., both injectable ampule and oral forms). For each month, a list was available of all current patients detailing which drug(s) they had received during that month, in what form(s) and what dose(s). These items were the basic units of study. We report changes over the 15-year period for which the data were available. For the first 5 years, more than half of the prescriptions were for heroin (diamorphine hydrochloride), with the remainder of the prescriptions mostly comprising oral methadone. After 1973, methadone ampules for injection were increasingly commonly prescribed and thereafter remained at about a quarter of the prescriptions for the remaining 10 years for which data are available, whereas heroin prescriptions declined over the mid-1970s to only 20%. From 1973 onward, oral methadone was increasingly prescribed, rising from approximately one third of prescriptions in the early 1970s to more than two thirds by the early 1980s. Individual patients often received more than one drug or form of drug: From 1969 onward, oral methadone was commonly prescribed as a supplement to heroin prescriptions. This same practice was widespread with prescriptions for methadone ampules prescribed as a supplement to heroin prescriptions. Daily doses of heroin were at a mean of from 160 to 540 mg, in contrast with means of 20 to 40 mg and 25 to 50 mg daily for the injectable methadone ampules and the oral methadone solution, respectively. Major changes occurred in the prescribing practices of this London drug clinic over the first 15 years of operation of the new NHS clinics. However, these changes did not occur overnight and can be seen to have been gradual evolutions of practice with the preservation of heroin prescription through the first 5 years and the subsequent move to increased prescribing of injectable methadone, with both these practices being overtaken by the subsequent increased prominence of oral methadone syrup as the main drug prescribed. Reference to the original records reveals a more interesting picture than might be evident from the potentially selective recall of contemporary or historical commentators.

Utility of routinely acquired primary care data for paediatric disease epidemiology and pharmacoepidemiology

PubMed Central

Helms, Peter J; Daukes, Suzie Ekins; Taylor, Michael W; Simpson, Colin R; McLay, James S

2005-01-01

Background The majority of medicines prescribed for children are prescribed in primary care for common acute and chronic conditions. This is in contrast to prescribing in secondary care where the population of children admitted is small but where a large number of different medicines are prescribed to treat more serious and less common conditions. Methods Data on prescribing was extracted from the General Practice Administration System for Scotland (GPASS) for the year November 1999 to October 2000 and prescribing patterns for children aged 0–16 years expressed as percentages. A comparison of age specific consultations for asthma, as an example of a common paediatric condition, was also made between two separate general practice data sets, the General Practice Research Database (GRPD) and the continuous morbidity recording (CMR) subset of GPASS. Results Of 214 medicines investigated for unlicensed and off-label prescribing no unlicensed prescribing was identified. Off-label prescribing due to age was most common among younger and older children. The most common reasons for off-label prescriptions were, in order of frequency, lower than recommended dose, higher than recommended dose, below the recommended age, and unlicensed formulation. Age and gender specific consultations for asthma were similar in the two representative databases, GPRD and CMR, both showing disappearance of the male predominance in the teenage years. Conclusions Large primary care data sets available within a unified health care system such as the UK National Health Service (NHS) are likely to be broadly compatible and produce similar results. The prescribing of off-label medicines to children is common in primary care, most commonly due to prescribing out with the recommended dosage regimen. PMID:15948933

Future perspectives on nonmedical prescribing

PubMed Central

Stewart, Derek; Jebara, Tesnime; Cunningham, Scott; Awaisu, Ahmed; Pallivalapila, Abdulrouf; MacLure, Katie

2017-01-01

Many countries have implemented nonmedical prescribing (NMP) and many others are scoping prescribing practices with a view to developing NMP. This paper provides a future perspective on NMP in light of findings of an umbrella review of aspects of NMP. This is followed by coverage of the Scottish Government strategy of pharmacist prescribing and finally, consideration of two key challenges. The review identified seven systematic reviews of influences on prescribing decision-making, processes of prescribing, and barriers and facilitators to implementation. Decision making was reported as complex with many, and often conflicting, influences. Facilitators of NMP included perceived improved patient care and professional autonomy, while barriers included lack of defined roles and resource pressures. Three systematic reviews explored patient outcomes that were noted to be equivalent or better to physician prescribing. In particular, a Cochrane review of 46 studies of clinical, patient-reported, and resource-use outcomes of NMP compared with medical prescribing showed positive intervention-group effects. Despite positive findings, authors highlighted high bias, poor definition and description of ‘prescribing’ and the ‘prescribing process’ and difficulty in separating NMP effects from the contributions of other healthcare team members. While evidence of benefit and safety is essential to inform practice, for NMP to be implemented and sustained on a large scale, there needs to be clear commitment at the highest level. The approach being taken by the Scottish Government to pharmacist prescribing implementation may inform developments in other professions and countries. The vision is that by 2023, all pharmacists providing pharmaceutical care will be pharmacist-independent prescribers. There are, however, challenges to implementing NMP into working practice; two key challenges are the need for sustainable models of care and evaluation research. These challenges could be met by considering the theoretical basis for implementation, and robust and rigorous evaluation. PMID:28607668

Evaluating nurse prescribers' education and continuing professional development for independent prescribing practice: findings from a national survey in England.

PubMed

Latter, Sue; Maben, Jill; Myall, Michelle; Young, Amanda

2007-10-01

The number of nurses able to independently prescribe medicines in England has risen steadily in recent years. To evaluate the adequacy of nurses' educational preparation for independent prescribing and to describe nurses' experiences of their continuing professional development as prescribers in practice. Postal questionnaire survey. Random sample of 246 nurses registered as nurse independent prescribers with the Nursing and Midwifery Council. The majority of nurses considered that the initial taught course element of their education programme met their needs, either to some extent (61% 151/246), or completely (22% 54/246). Most nurses (77% 190/246) received the specified 12 days support from their supervising medical practitioner and most were satisfied and positive about this experience. Nearly all of the nurses (>95%) reported that they were able to maintain a range of specified prescribing competencies in practice. Two thirds (62% 152/246) of the sample reported that they were receiving support/supervision for prescribing. Ninety five per cent (233/246) of the sample also reported that they engaged in self-directed informal continuing professional development, but only half of the sample had experience of formally provided professional development opportunities. Approximately half (52% 127/246) of the sample identified needs for continuing professional development. This first national survey of the education and professional development experiences of nurse independent prescribers in England provides evidence which highlights areas in which national policy is working well, and also points up issues which may need addressing as the roll out of nurse prescribing continues. The study also highlights characteristics and issues that health care policy makers and nurse educationalists internationally may wish to consider in developing and refining their own nurse prescriber education programmes.

The Great Boundary Crossing: Perceptions on Training Pharmacists as Supplementary Prescribers in the UK

ERIC Educational Resources Information Center

Tann, Jennifer; Blenkinsopp, Alison; Grime, Janet; Evans, Amanda

2010-01-01

Objective: To explore the perceptions of General Medical Practitioners and pharmacist supplementary prescribers of the training provided for qualification as a pharmacist supplementary prescriber, and the experience of pharmacist supplementary prescribers of subsequent continuing professional development in practice. Design: A qualitative study of…

Cluster-randomized, controlled trial of computer-based decision support for selecting long-term anti-thrombotic therapy after acute ischaemic stroke.

PubMed

Weir, C J; Lees, K R; MacWalter, R S; Muir, K W; Wallesch, C-W; McLelland, E V; Hendry, A

2003-02-01

Identifying the appropriate long-term anti-thrombotic therapy following acute ischaemic stroke is a challenging area in which computer-based decision support may provide assistance. To evaluate the influence on prescribing practice of a computer-based decision support system (CDSS) that provided patient-specific estimates of the expected ischaemic and haemorrhagic vascular event rates under each potential anti-thrombotic therapy. Cluster-randomized controlled trial. We recruited patients who presented for a first investigation of ischaemic stroke or TIA symptoms, excluding those with a poor prognosis or major contraindication to anticoagulation. After observation of routine prescribing practice (6 months) in each hospital, centres were randomized for 6 months to either control (routine practice observed) or intervention (practice observed while the CDSS provided patient-specific information). We compared, between control and intervention centres, the risk reduction (estimated by the CDSS) in ischaemic and haemorrhagic vascular events achieved by long-term anti-thrombotic therapy, and the proportions of subjects prescribed the optimal therapy identified by the CDSS. Sixteen hospitals recruited 1952 subjects. When the CDSS provided information, the mean relative risk reduction attained by prescribing increased by 2.7 percentage units (95%CI -0.3 to 5.7) and the odds ratio for the optimal therapy being prescribed was 1.32 (0.83 to 1.80). Some 55% (5/9) of clinicians believed the CDSS had influenced their prescribing. Cluster-randomized trials provide excellent frameworks for evaluating novel clinical management methods. Our CDSS was feasible to implement and acceptable to clinicians, but did not substantially influence prescribing practice for anti-thrombotic drugs after acute ischaemic stroke.

The peri-operative management of anti-platelet therapy in elective, non-cardiac surgery.

PubMed

Alcock, Richard F; Naoum, Chris; Aliprandi-Costa, Bernadette; Hillis, Graham S; Brieger, David B

2013-07-31

Cardiovascular complications are important causes of morbidity and mortality in patients undergoing elective non-cardiac surgery, with adverse cardiac outcomes estimated to occur in approximately 4% of all patients. Anti-platelet therapy withdrawal may precede up to 10% of acute cardiovascular syndromes, with withdrawal in the peri-operative setting incompletely appraised. The aims of our study were to determine the proportion of patients undergoing elective non-cardiac surgery currently prescribed anti-platelet therapy, and identify current practice in peri-operative management. In addition, the relationship between management of anti-platelet therapy and peri-operative cardiac risk was assessed. We evaluated consecutive patients attending elective non-cardiac surgery at a major tertiary referral centre. Clinical and biochemical data were collected and analysed on patients currently prescribed anti-platelet therapy. Peri-operative management of anti-platelet therapy was compared with estimated peri-operative cardiac risk. Included were 2950 consecutive patients, with 516 (17%) prescribed anti-platelet therapy, primarily for ischaemic heart disease. Two hundred and eighty nine (56%) patients had all anti-platelet therapy ceased in the peri-operative period, including 49% of patients with ischaemic heart disease and 46% of patients with previous coronary stenting. Peri-operative cardiac risk score did not influence anti-platelet therapy management. Approximately 17% of patients undergoing elective non-cardiac surgery are prescribed anti-platelet therapy, the predominant indication being for ischaemic heart disease. Almost half of all patients with previous coronary stenting had no anti-platelet therapy during the peri-operative period. The decision to cease anti-platelet therapy, which occurred commonly, did not appear to be guided by peri-operative cardiac risk stratification. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Learning to prescribe - pharmacists' experiences of supplementary prescribing training in England.

PubMed

Cooper, Richard J; Lymn, Joanne; Anderson, Claire; Avery, Anthony; Bissell, Paul; Guillaume, Louise; Hutchinson, Allen; Murphy, Elizabeth; Ratcliffe, Julie; Ward, Paul

2008-12-05

The introduction of non-medical prescribing for professions such as pharmacy and nursing in recent years offers additional responsibilities and opportunities but attendant training issues. In the UK and in contrast to some international models, becoming a non-medical prescriber involves the completion of an accredited training course offered by many higher education institutions, where the skills and knowledge necessary for prescribing are learnt. to explore pharmacists' perceptions and experiences of learning to prescribe on supplementary prescribing (SP) courses, particularly in relation to inter-professional learning, course content and subsequent use of prescribing in practice. A postal questionnaire survey was sent to all 808 SP registered pharmacists in England in April 2007, exploring demographic, training, prescribing, safety culture and general perceptions of SP. After one follow-up, 411 (51%) of pharmacists responded. 82% agreed SP training was useful, 58% agreed courses provided appropriate knowledge and 62% agreed that the necessary prescribing skills were gained. Clinical examination, consultation skills training and practical experience with doctors were valued highly; pharmacology training and some aspects of course delivery were criticised. Mixed views on inter-professional learning were reported - insights into other professions being valued but knowledge and skills differences considered problematic. 67% believed SP and recent independent prescribing (IP) should be taught together, with more diagnostic training wanted; few pharmacists trained in IP, but many were training or intending to train. There was no association between pharmacists' attitudes towards prescribing training and when they undertook training between 2004 and 2007 but earlier cohorts were more likely to be using supplementary prescribing in practice. Pharmacists appeared to value their SP training and suggested improvements that could inform future courses. The benefits of inter-professional learning, however, may conflict with providing profession-specific training. SP training may be perceived to be an instrumental 'stepping stone' in pharmacists' professional project of gaining full IP status.

Pharmaceutical company influences on medication prescribing and their potential impact on quality use of medicines.

PubMed

Kyle, G J; Nissen, L M; Tett, S E

2008-10-01

Pharmaceuticals are big business, reporting strong market growth year after year. The 'gatekeepers' of this market are prescribers of medicines, who are the major target of pharmaceutical companies, utilizing direct and indirect influences. This paper draws on previous research investigating pharmaceutical company prescribing influences to develop a qualitative model demonstrating the synergism between commercial influences on prescribing. The generic model was used to explore a realistic but hypothetical scenario to ascertain the applicability of the model. A generic influence model was developed. The model was readily able to be adapted to reflect a realistic practice scenario. Prescriber awareness of the linkages between various seemingly separate marketing techniques could potentially improve medicines usage in an evidence-based practice paradigm.

Non-steroidal anti-inflammatory drug prescribing patterns in general practice: comparison of a general practitioner-based survey and a pharmacy-based survey in France.

PubMed

Clinard, F; Sgro, C; Bardou, M; Dumas, M; Hillon, P; Bonithon-Kopp, C

2001-01-01

In order to assess biases occurring in primary care prescription studies, we compared non-steroidal anti-inflammatory drug (NSAID) prescribing patterns reported by general practitioners directly (GP-based survey) and from a pharmacy-based survey of general practitioner prescribing (pharmacy-based survey). Volunteer GPs of the administrative area of Côte d'Or (France) returned a mailed questionnaire on NSAID prescribing patterns for consecutive patients seen during a 2-month period. In order to obtain a reference basis, pharmacies of the same administrative area provided all prescriptions that included NSAIDs during a 1-week period originating in general practice. The rate of participation was 25% for the GPs and 40% for the pharmacies. Participant GPs were representative of GPs of the area with regard to sex, year of graduation and practice area but pharmacies from rural areas were over-represented. The GP-based survey and the pharmacy-based survey provided respectively 770 and 1050 prescriptions. There were no differences between either survey in the type of NSAIDs prescribed and in the most frequently associated drugs. GPs who volunteered in the GP survey prescribed NSAIDs more frequently orally and at higher doses than GPs involved in the pharmacy-based survey. They also prescribed more gastroprotective drugs, especially in the elderly. None of these results could be explained by differences in patient characteristics and GP practice areas. GPs who actively participate in prescription surveys exhibit prescribing patterns that fit better with official recommendations than the average. Although selection biases cannot be ruled out, it is suggested that some changes in GP prescription habits may have been induced by the survey itself.

The pattern of anxiolytic and hypnotic management by Australian general practice trainees.

PubMed

Holliday, Simon M; Morgan, Simon; Tapley, Amanda; Henderson, Kim M; Dunlop, Adrian J; van Driel, Mieke L; Spike, Neil A; McArthur, Lawrence A; Ball, Jean; Oldmeadow, Christopher J; Magin, Parker J

2017-03-01

Guidelines recommend anxiolytics and hypnotics (A/H) as second-line, short-term medications. We aimed to establish prevalence and associations of A/H prescribing by Australian general practice (GP) trainees. A cross-sectional analysis from a cohort study of vocational trainees from four GP Regional Training Providers during 2010-2013. General practice trainees act as independent practitioners (including for prescribing purposes) while having recourse to advice from a GP supervisor. Practice and trainee demographic data were collected as well as patient, clinical and educational data from 60 consecutive consultations of each trainee each training term. Analysis was at the level of individual problem managed, with the outcome factor being prescription of any anxiolytic or hypnotic. Overall, 645 registrars (response rate 94.0%) prescribed 68 582 medications in 69 621 consultations (with 112 890 problems managed). A/Hs were prescribed for 1.3% of problems managed and comprised 2.2% of all prescriptions. They were prescribed particularly for insomnia (28.2%) or anxiety (21.8%), but also for many 'off-label' indications. Significant associations of A/H prescriptions were: patient-level (greater age, Aboriginal and Torres Strait Islander status, English-speaking background, being new to the trainee but not to the practice); trainee-level (male) and consultation-level (longer duration, pre-existing problem, specialist referral not being made). Prescribing was significantly lower in one of the four Regional Training Providers. GP trainees, inconsistent with most guideline recommendations, prescribe A/Hs mainly as maintenance therapy to unfamiliar and older patients. Our results suggest that changes in management approaches are needed which may be facilitated by support for psychotherapeutic training. [Holliday SM, Morgan S, Tapley A, Henderson KM, Dunlop AJ, van Driel ML, Spike NA, McArthur LA, Ball J, Oldmeadow CJ, Magin PJ. The pattern of anxiolytic and hypnotic management by Australian general practice trainees. Drug Alcohol Rev 2017;36:261-269]. © 2016 Australasian Professional Society on Alcohol and other Drugs.

[Opinions and attitudes of Flemish pharmacists and general practitioners towards INN prescribing. A survery in Antwerp and East Flanders].

PubMed

Fraeyman, J; De Winter, J; De Loof, H; Van Hal, G; Beutels, P; Remmen, R; De Meyer, G R Y

2013-06-01

Since 2002 in Belgium, physicians are allowed to prescribe by International Non-proprietary Name (INN). In 2005, the conditions for this decree were set. Examples from other countries have shown that INN prescribing can significantly contribute to controlling pharmaceutical expenditures. The share of INN prescriptions remains low in Belgium (7% in 2011). To formulate an answer to the question: what are the opinions and attitudes of pharmacists and general practitioners [GP's] with regards to INN prescribing? In the winter of 2011-2012, a questionnaire with closed-ended questions was send to pharmacists and GP's in the provinces of Antwerp and East-Flanders, through training days and personal visits. Pharmacists and GP's scored a list of statements with a 5-point Likert scale. The themes of the statements related to: delivering INN prescriptions, legislation, impact on expenditures, choices regarding patient concerns and interprofessional relations. In total, 353 questionnaires were completed and returned of which 228 165%1 were by pharmacists and 125 (35%1 by GP's. Although both declared to be sufficiently up to date with regulations to prescribe (84%) or to deliver (95%] a INN prescription, only 13% of the pharmacists said all prescription they receive contain the correct information. Less GP's [36%) than pharmacists (82%] feel aided by their software program when prescribing or delivering an INN prescription. GP's rely mostly on NIHDI (National Institute for Health and Disability Insurance) as the main source for information on INN prescribing, pharmacists rely on the [Local) pharmacists association. The pharmacists and GP's in the study who relied on NIHDI as main information source, were less aware of legislation concerning INN [N2, p<0,05] than those who rely on the local professional association [N2, p<0,0001]. All pharmacists in the study said to consider the patients medication history when delivering an INN prescription for chronic treatment. However, 57% of the GP's preferred not to prescribe by INN for the reason that they are not sure whether the pharmacist will always consider the patients medication history in case of an INN prescription. Although the GP's showed certain motivation to prescribe by INN, it was no greater than for generic prescribing. And INN prescribing has no added value compared to generic prescribing, according to the GP's. For the pharmacists, INN prescribing does contain an opportunity. With the increase in numbers of dosages and sorts of packaging of generic products, it becomes more and more difficult for pharmacists to manage their stock. In case of an INN prescription, the pharmacist can choose between the different packages in his stock. This offers opportunities especially for acute conditions. INN prescribing is a good example of where the collaboration between pharmacists and GP's still contains a lot of opportunities, as well for the two professions, as the government and the patient in terms of controlling the pharmaceutical expenditures. Also the education for pharmacist or GP can further contribute to the sensitization of INN prescribing. In practice, there remain a number of issues and differences in opinions between pharmacists and general practitioners regarding INN prescribing. GP's feel few motivation to prescribe by INN and the government has put no imperative demands towards prescribers. Further evaluation of the practicaL feasibility of the current conditions for prescribing and delivering INN prescriptions is needed.

Nebulization of antimicrobial agents in mechanically ventilated adults in 2017: an international cross-sectional survey.

PubMed

Alves, Joana; Alp, Emine; Koulenti, Despoina; Zhang, Zhongheng; Ehrmann, Stephan; Blot, Stijn; Bassetti, Matteo; Conway-Morris, Andrew; Reina, Rosa; Teran, Enrique; Sole-Lleonart, Candela; Ruiz-Rodríguez, Maria; Rello, Jordi

2018-04-01

2017 ESCMID practice guidelines reported safety concerns and weak evidence of benefit supporting use of aerosolized antibiotics in mechanically ventilated patients. Our primary goal was to assess current patterns of aerosolized antibiotic prescription in mechanically ventilated patients. A sequential global survey was performed prior to the release of the ESCMID guidelines, from the 1st of February to the 30th of April 2017, using an electronic platform. Responses were analyzed comparing geographical regions. A total of 410 units responded, with 261 (177 from Europe) being eligible for the full survey. 26.8% of units reported not using aerosolized antibiotics. The two major indications amongst prescribing units were ventilator-associated pneumonia and ventilator-associated tracheobronchitis (74.3% and 49.4%, respectively). 63.6% of units indicated prescription solely in response to multi-drug resistant organisms. In comparison with a survey undertaken in 2014, there was a significant reduction in use of aerosolized antibiotics for prophylaxis (50.6% vs 7.7%, p < 0.05) and colonization (52.9% vs 25.3%, p < 0.05). The large majority of units (91.7%) reported only prescribing in patients with positive pulmonary cultures. Asia appeared to be an outlier, with 53.3% of units reporting empirical use. The most commonly used device was the jet nebulizer. The most commonly prescribed drugs were colistin methanesulfonate (57.6%), colistin base (41.9%) and amikacin (31.4%), although there was considerable heterogeneity across geographical areas. A significant gap exists between ESCMID clinical practice recommendations and the use of aerosolized antibiotics in clinical practice. Our findings indicate an urgent need for high-quality education to bring practice into line with evidence-based guidelines.

REVIEW OF INDEPENDENT NURSE PRESCRIBING IN A PAEDIATRIC CYSTIC FIBROSIS (CF) AND RESPIRATORY POPULATION.

PubMed

Chana, Gabis; Tabberner, Michelle; Nixon, Wendy; Frost, Sue; Barrett, Leslie; Desai, Maya; Paskin, Lucy

2016-09-01

With pressures on junior doctors' availability in the NHS, non-medical prescribing is topical. Independent Nurse Prescribers (INPs) can prescribe any licensed medicine for any medical condition within their level of competence.1 An audit was undertaken of the four INPs employed by the Respiratory Department evaluating current prescribing practices. The requirement for this audit was identified by the multidisciplinary team (MDT) and Trust approval was obtained. A data collection form was designed capturing patient demographics and full details of prescribed items.Over a 3 month period (August to October 2014) outpatient cystic fibrosis (CF) and respiratory prescriptions were studied using cluster sampling. Over a 6 week period prescription requests by CF INPs faxed to General Practitioners (GPs) were reviewed. INPs also prescribe via telephone, documenting advice on trust forms; these were preliminarily audited. All data was analysed using Microsoft Excel. Legality of prescriptions and adherence to national and local guidelines were evaluated. Reference keys were used to designate non-adherence post-application of exclusion criteria. A total of 77 outpatient prescriptions (45 CF and 32 respiratory) were completed by the 4 INPs, containing 122 items (72 CF and 50 respiratory). Of the CF prescribed items 21 were oral antibiotics (29%). Respiratory INPs mainly prescribed 14 inhaler devices (28%) and 12 inhaled bronchodilators (24%).All INP prescriptions met legal requirements. Basic details of medicinal products (drug name and dose) were documented for all items. A key finding was that duration/quantity was not indicated for 27 (54%) respiratory items.After applying exclusion criteria, of the CF prescribed items, 56/59 (95%) adhered to national guidelines and 47/66 (71%) followed local guidelines. The leading reason for not following local guidelines was not documenting allergy status. Of the respiratory prescribed items, 34 (100%) adhered to national guidelines and 31/32 (97%) followed local guidelines.A total of 33 faxes (with 38 items) were completed and 35 items (92%) were oral antibiotics. Drug name, dose and frequency were stated for all items. From the faxed items, 38 (100%) adhered to national guidelines and 32/33 (97%) followed local guidelines.Over 5 days, CF INPs provided telephone advice for 12 patients. Of these, 6 patients had respiratory exacerbation. Telephone advice led to faxes being sent to GPs for 9 patients. This was preliminary data with a re-audit planned after amendment of trust form. Overall INP prescribing was found to be safe and effective. This review enabled education of the respiratory team of prescribing practices via a local audit meeting. The positive contribution that INPs provide to patient care was highlighted as they improve the patient journey and support the MDT. The demand for INP prescribing in particular with CF has provided opportunity for a pharmacist prescriber to join the CF MDT. It is recommended medical and pharmacist prescribing to be reviewed. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Prescribed fire research in Pennsylvania

Treesearch

Patrick Brose

2009-01-01

Prescribed fire in Pennsylvania is a relatively new forestry practice because of the State's adverse experience with highly destructive wildfires in the early 1900s. The recent introduction of prescribed fire raises a myriad of questions regarding its correct and safe use. This poster briefly describes the prescribed fire research projects of the Forestry Sciences...

Introducing a drug formulary to general practice — effects on practice prescribing costs

PubMed Central

Beardon, P.H.G.; Brown, S.V.; Mowat, D.A.E.; Grant, J.A.; McDevitt, D.G.

1987-01-01

A drug formulary comprising 249 preparations of 132 drugs and drug combinations was prepared by the partners in a three-doctor general practice serving more than 5000 patients. No attempt was made to change to generic prescribing nor were repeat prescription drugs altered. Introduction of the formulary in September 1981 was followed by an increase in the proportion of prescriptions containing drugs from the formulary from about 55% to more than 60% for both repeat and non-repeat prescriptions. The proportion of formulary drugs on non-repeat prescriptions reached a maximum of 78% within the first year with the additional influence of information feedback. Over the first year the level of formulary drugs used for both repeat and nonrepeat prescribing levelled off at about 62%. Even with these modest changes, when compared with the costs of general practice prescribing in Scotland as a whole, the introduction of the formulary resulted in savings of approximately 10% within the practice for the mean ingredient costs both per patient and per prescription. PMID:3449632

A valuable approach to the use of electronic medical data in primary care research: Panning for gold.

PubMed

Barnett, Stephen; Henderson, Joan; Hodgkins, Adam; Harrison, Christopher; Ghosh, Abhijeet; Dijkmans-Hadley, Bridget; Britt, Helena; Bonney, Andrew

2017-05-01

Electronic medical data (EMD) from electronic health records of general practice computer systems have enormous research potential, yet many variables are unreliable. The aim of this study was to compare selected data variables from general practice EMD with a reliable, representative national dataset (Bettering the Evaluation and Care of Health (BEACH)) in order to validate their use for primary care research. EMD variables were compared with encounter data from the nationally representative BEACH program using χ 2 tests and robust 95% confidence intervals to test their validity (measure what they reportedly measure). The variables focused on for this study were patient age, sex, smoking status and medications prescribed at the visit. The EMD sample from six general practices in the Illawarra region of New South Wales, Australia, yielded data on 196,515 patient encounters. Details of 90,553 encounters were recorded in the 2013 BEACH dataset from 924 general practitioners. No significant differences in patient age ( p = 0.36) or sex ( p = 0.39) were found. EMD had a lower rate of current smokers and higher average scripts per visit, but similar prescribing distribution patterns. Validating EMD variables offers avenues for improving primary care delivery and measuring outcomes of care to inform clinical practice and health policy.

Electronic decision support in general practice. What's the hold up?

PubMed

Liaw, S T; Schattner, P

2003-11-01

The uptake of computers in Australian general practice has been for administrative use and prescribing, but the development of electronic decision support (EDS) has been particularly slow. Therefore, computers are not being used to their full potential in assisting general practitioners to care for their patients. This article examines current barriers to EDS in general practice and possible strategies to increase its uptake. Barriers to the uptake of EDS include a lack of a business case, shifting of costs for data collection and management to the clinician, uncertainty about the optimal level of decision support, lack of technical and semantic standards, and resistance to EDS use by the time conscious GP. There is a need for a more strategic and attractive incentives program, greater national coordination, and more effective collaboration between government, the computer industry and the medical profession if current inertia is to be overcome.

Effects of prescribed fire and fire surrogates on floral visiting insects of the blue ridge province in North Carolina

Treesearch

J.W. Campbell; J.L. Hanula; T.A. Waldrop

2007-01-01

Pollination by insects in forests is an extremely important process that should be conserved. Not only do pollinating insects help to maintain a diversity of plants within forests, but they also aid in pollinating crops found near forested land. Currently, the effects of various forest management practices on floral visiting insect abundance or diversity is unknown, so...

Changing the Antibiotic Prescribing of general practice registrars: the ChAP study protocol for a prospective controlled study of a multimodal educational intervention.

PubMed

van Driel, Mieke L; Morgan, Simon; Tapley, Amanda; McArthur, Lawrie; McElduff, Patrick; Yardley, Lucy; Dallas, Anthea; Deckx, Laura; Mulquiney, Katie; Davis, Joshua S; Davey, Andrew; Henderson, Kim; Little, Paul; Magin, Parker J

2016-06-06

Australian General Practitioners (GPs) are generous prescribers of antibiotics, prompting concerns including increasing antimicrobial resistance in the community. Recent data show that GPs in vocational training have prescribing patterns comparable with the high prescribing rate of their established GP supervisors. Evidence-based guidelines consistently advise that antibiotics are not indicated for uncomplicated upper respiratory tract infections (URTI) and are rarely indicated for acute bronchitis. A number of interventions have been trialled to promote rational antibiotic prescribing by established GPs (with variable effectiveness), but the impact of such interventions in a training setting is unclear. We hypothesise that intervening while early-career GPs are still developing their practice patterns and prescribing habits will result in better adherence to evidence-based guidelines as manifested by lower antibiotic prescribing rates for URTIs and acute bronchitis. The intervention consists of two online modules, a face-to-face workshop for GP trainees, a face-to-face workshop for their supervisors and encouragement for the trainee-supervisor dyad to include a case-based discussion of evidence-based antibiotic prescribing in their weekly one-on-one teaching meetings. We will use a non-randomised, non-equivalent control group design to assess the impact on antibiotic prescribing for acute upper respiratory infections and acute bronchitis by GP trainees in vocational training. Early-career GPs who are still developing their clinical practice and prescribing habits are an underutilized target-group for interventions to curb the growth of antimicrobial resistance in the community. Interventions that are embedded into existing training programs or are linked to continuing professional development have potential to increase the impact of existing interventions at limited additional cost. Australian New Zealand Clinical Trials Registry, ACTRN12614001209684 (registered 17/11/2014).

Respiratory pharmacotherapy use in patients newly diagnosed with chronic obstructive pulmonary disease in a primary care setting in the UK: a retrospective cohort study.

PubMed

Wurst, Keele E; Shukla, Amit; Muellerova, Hana; Davis, Kourtney J

2014-09-01

This retrospective cohort study aimed to analyze the prescribing practices of general practitioners treating patients with newly diagnosed chronic obstructive pulmonary disease (COPD), and to assess characteristics associated with initial pharmacotherapy. Patients were identified in the General Practice Research Database, a population-based UK electronic medical record (EMR) with data from January 1, 2008 to December 31, 2009. Patient characteristics, prescribed COPD pharmacotherapies (≤12 months before diagnosis and within 3 months following diagnosis), co-morbidities, hospitalizations, and events indicative of a possible COPD exacerbation (≤12 months before diagnosis) were analyzed in 7881 patients with newly diagnosed COPD. Most patients (64.4%) were prescribed COPD pharmacotherapy in the 12 months before diagnosis. Following diagnosis, COPD pharmacotherapy was prescribed within 3 months in 85.0% of patients. Short-acting bronchodilators alone (22.9%) or inhaled corticosteroids + long-acting beta-2 agonists (ICS+LABA, 22.1%) were prescribed most frequently. Compared with other pharmacotherapies, the prevalence of severe airflow limitation was highest in patients prescribed ICS+LABA+long-acting muscarinic antagonists (LAMA). Moderate-to-severe dyspnea was identified most frequently in patients prescribed a LAMA-containing regimen. Patients prescribed an ICS-containing regimen had a higher prevalence of asthma or possible exacerbations recorded in the EMR than those not prescribed ICS. In conclusion, pharmacotherapy prescribed at initial COPD diagnosis varied by disease severity indicators as assessed by airflow limitation, dyspnea, history of asthma, and possible exacerbations. Frequent prescription of COPD pharmacotherapies before the first-recorded COPD diagnosis indicates a delay between obstructive lung disease presentation in primary care practice and assignment of a medical diagnosis.

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

PubMed

Lewis, Penny J; Tully, Mary P

2011-03-01

The influence of patient expectations and demands on the decisions of prescribers in general practice has been associated with irrational prescribing and lack of evidence-based practice. However, to our knowledge, no one has investigated patient pressure to prescribe in secondary care. To investigate the influences on hospital prescribers' decisions by exploring what they found uncomfortable when prescribing. Qualitative interviews with 48 prescribers of varying seniority from 4 hospitals were conducted. Interviews were based on the critical incident technique, and prescribers were asked, before an interview, to remember any uncomfortable prescribing decisions that they had made; these were then discussed in detail during an interview. This approach allowed the interviewer to explore the more general influences on the decision to prescribe. Interviews were tape recorded and transcribed verbatim. A grounded theory approach to data analysis was taken. Prescribers discussed various factors that could provoke feelings of discomfort when prescribing. Pressure on the prescribing decision from patients, relatives, or carers was a major theme, and more than half of interviewees discussed discomfort caused by such perceived pressure on the prescribing decision. How prescribers dealt with this pressure varied with seniority and the type of relationship that they had fostered with the patient. Nearly half of all incidents of patient pressure resulted in the patient being prescribed the medication they requested. Yet, many of these requests were deemed inappropriate by the prescriber. Their reasons for capitulation varied but included maintaining a good prescriber-patient relationship and avoiding conflict in the wider health care team. Pressure from patients, relatives, or carers was an uncomfortable influence on these hospital prescribers' prescribing decisions. Increasingly consumer-driven health care will intensify these issues in the future. We advocate further research, focusing on managing patient demands and improving prescribers' coping strategies. Copyright © 2011 Elsevier Inc. All rights reserved.

US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011.

PubMed

Hicks, Lauri A; Bartoces, Monina G; Roberts, Rebecca M; Suda, Katie J; Hunkler, Robert J; Taylor, Thomas H; Schrag, Stephanie J

2015-05-01

Appropriate antibiotic prescribing is an essential strategy to reduce the spread of antibiotic resistance. US prescribing practices have not been thoroughly characterized. We analyzed outpatient antibiotic prescribing data to identify where appropriate antibiotic prescribing interventions could have the most impact. Oral antibiotic prescriptions dispensed during 2011 were extracted from the IMS Health Xponent database. The number of prescriptions and census denominators were used to calculate prescribing rates. Prescription totals were calculated for each provider specialty. Regression modeling was used to examine the association between socioeconomic and population health factors and prescribing rates. Healthcare providers prescribed 262.5 million courses of antibiotics in 2011(842 prescriptions per 1000 persons). Penicillins and macrolides were the most common antibiotic categories prescribed. The most commonly prescribed individual antibiotic agent was azithromycin. Family practitioners prescribed the most antibiotic courses (24%). The prescribing rate was higher in the South census region (931 prescriptions per 1000 persons) than in the West (647 prescriptions per 1000 persons; P < .001); this pattern was observed among all age groups, including children ≤ 2 and persons ≥ 65 years of age. Counties with a high proportion of obese persons, infants and children ≤ 2 years of age, prescribers per capita, and females were more likely to be high prescribing by multivariable analysis (adjusted odds ratio, >1.0). Efforts to characterize antibiotic prescribing practices should focus on the South census region and family practitioners. Further understanding of the factors leading to high prescribing among key target populations will inform appropriate prescribing interventions. Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.

ASSET (Age/Sex Standardised Estimates of Treatment): A Research Model to Improve the Governance of Prescribing Funds in Italy

PubMed Central

Favato, Giampiero; Mariani, Paolo; Mills, Roger W.; Capone, Alessandro; Pelagatti, Matteo; Pieri, Vasco; Marcobelli, Alberico; Trotta, Maria G.; Zucchi, Alberto; Catapano, Alberico L.

2007-01-01

Background The primary objective of this study was to make the first step in the modelling of pharmaceutical demand in Italy, by deriving a weighted capitation model to account for demographic differences among general practices. The experimental model was called ASSET (Age/Sex Standardised Estimates of Treatment). Methods and Major Findings Individual prescription costs and demographic data referred to 3,175,691 Italian subjects and were collected directly from three Regional Health Authorities over the 12-month period between October 2004 and September 2005. The mean annual prescription cost per individual was similar for males (196.13 euro) and females (195.12 euro). After 65 years of age, the mean prescribing costs for males were significantly higher than females. On average, costs for a 75-year-old subject would be 12 times the costs for a 25–34 year-old subject if male, 8 times if female. Subjects over 65 years of age (22% of total population) accounted for 56% of total prescribing costs. The weightings explained approximately 90% of the evolution of total prescribing costs, in spite of the pricing and reimbursement turbulences affecting Italy in the 2000–2005 period. The ASSET weightings were able to explain only about 25% of the variation in prescribing costs among individuals. Conclusions If mainly idiosyncratic prescribing by general practitioners causes the unexplained variations, the introduction of capitation-based budgets would gradually move practices with high prescribing costs towards the national average. It is also possible, though, that the unexplained individual variation in prescribing costs is the result of differences in the clinical characteristics or socio-economic conditions of practice populations. If this is the case, capitation-based budgets may lead to unfair distribution of resources. The ASSET age/sex weightings should be used as a guide, not as the ultimate determinant, for an equitable allocation of prescribing resources to regional authorities and general practices. PMID:17611624

ASSET (Age/Sex Standardised Estimates of Treatment): a research model to improve the governance of prescribing funds in Italy.

PubMed

Favato, Giampiero; Mariani, Paolo; Mills, Roger W; Capone, Alessandro; Pelagatti, Matteo; Pieri, Vasco; Marcobelli, Alberico; Trotta, Maria G; Zucchi, Alberto; Catapano, Alberico L

2007-07-04

The primary objective of this study was to make the first step in the modelling of pharmaceutical demand in Italy, by deriving a weighted capitation model to account for demographic differences among general practices. The experimental model was called ASSET (Age/Sex Standardised Estimates of Treatment). Individual prescription costs and demographic data referred to 3,175,691 Italian subjects and were collected directly from three Regional Health Authorities over the 12-month period between October 2004 and September 2005. The mean annual prescription cost per individual was similar for males (196.13 euro) and females (195.12 euro). After 65 years of age, the mean prescribing costs for males were significantly higher than females. On average, costs for a 75-year-old subject would be 12 times the costs for a 25-34 year-old subject if male, 8 times if female. Subjects over 65 years of age (22% of total population) accounted for 56% of total prescribing costs. The weightings explained approximately 90% of the evolution of total prescribing costs, in spite of the pricing and reimbursement turbulences affecting Italy in the 2000-2005 period. The ASSET weightings were able to explain only about 25% of the variation in prescribing costs among individuals. If mainly idiosyncratic prescribing by general practitioners causes the unexplained variations, the introduction of capitation-based budgets would gradually move practices with high prescribing costs towards the national average. It is also possible, though, that the unexplained individual variation in prescribing costs is the result of differences in the clinical characteristics or socio-economic conditions of practice populations. If this is the case, capitation-based budgets may lead to unfair distribution of resources. The ASSET age/sex weightings should be used as a guide, not as the ultimate determinant, for an equitable allocation of prescribing resources to regional authorities and general practices.

Using theory to explore facilitators and barriers to delayed prescribing in Australia: a qualitative study using the Theoretical Domains Framework and the Behaviour Change Wheel.

PubMed

Sargent, Lucy; McCullough, Amanda; Del Mar, Chris; Lowe, John

2017-02-13

Delayed antibiotic prescribing reduces antibiotic use for acute respiratory infections in trials in general practice, but the uptake in clinical practice is low. The aim of the study was to identify facilitators and barriers to general practitioners' (GPs') use of delayed prescribing and to gain pharmacists' and the public's views about delayed prescribing in Australia. This study used the Theoretical Domains Framework and the Behaviour Change Wheel to explore facilitators and barriers to delayed prescribing in Australia. Forty-three semi-structured, face-to-face interviews with general practitioners, pharmacists and patients were conducted. Responses were coded into domains of the Theoretical Domains Framework, and specific criteria from the Behaviour Change Wheel were used to identify which domains were relevant to increasing the use of delayed prescribing by GPs. The interviews revealed nine key domains that influence GPs' use of delayed prescribing: knowledge; cognitive and interpersonal skills; memory, attention and decision-making processes; optimism; beliefs about consequences; intentions; goals; emotion; and social influences: GPs knew about delayed prescribing; however, they did not use it consistently, preferring to bring patients back for review and only using it with patients in a highly selective way. Pharmacists would support GPs and the public in delayed prescribing but would fill the prescription if people insisted. The public said they would delay taking their antibiotics if asked by their GP and given the right information on managing symptoms and when to take antibiotics. Using a theory-driven approach, we identified nine key domains that influence GPs' willingness to provide a delayed prescription to patients with an acute respiratory infection presenting to general practice. These data can be used to develop a structured intervention to change this behaviour and thus reduce antibiotic use for acute respiratory infections in general practice.

Pattern of prescription drug use in Nigerian army hospitals.

PubMed

Adebayo, E T; Hussain, N A

2010-01-01

Most health expenditure of developing countries is on drugs and medical sundries but inappropriate use of such resources is common. To our knowledge, only few studies have been done in Africa on this issue , with inadequate consideration of the sociological context of the knowledge, attitude and practice of the prescribers especially doctors. This study presents the pooled data of the pattern of prescription drug use from three Nigerian Army hospitals using some WHO criteria, and the knowledge and attitude underlying doctors' prescribing practices in these hospitals. Retrospective cross-sectional survey of one year (March 2006-February 2007). Systematic random sample of general out patient case notes from three hospitals were collected using WHO criteria. The knowledge, attitude and practice survey of doctors at each study site towards the concept of rational drug use (RDU) were assessed using a self-administered questionnaire. Data collected from 660 case notes showed that average number of drugs per encounter was 2.8 while 49.3% of drugs were prescribed in the generic form. An average of 28.1% of patients encountered antibiotics. From the knowledge, attitude and practice survey, it is evident that 90.5% of 74 prescribers were aware of the existence of national essential drugs list but 58.1% of them did not use it as basis of prescriptions. In describing types of medicines preferred, 56.7% of prescribers claimed they prescribed a mixture of generic and branded drugs. Only 12.1% of prescribers could accurately detail the 5 steps of rational prescribing. The pattern of prescription drug use in Nigerian Army hospitals is unsatisfactory. It is characterised by high number of drugs per prescription, high rate of antibiotic usage and unscientific prescription by doctors. There is a need for further education and research on rational drug use among prescribers in Nigerian military health facilities.

A clustered randomized trial of the effects of feedback using academic detailing compared to postal bulletin on prescribing of preventative cardiovascular therapy.

PubMed

Naughton, Corina; Feely, John; Bennett, Kathleen

2007-10-01

Interventions to promote prescribing of preventive therapies in patients with cardiovascular disease (CVD) or diabetes have reported variable success. (i) To evaluate the effect of prescribing feedback on GP practice using academic detailing compared to postal bulletin on prescribing of CVD preventive therapies in patients with CVD or diabetes at 3 and 6 months post intervention and (ii) to evaluate the intervention from a GP's perspective. Volunteer GP practices (n = 98) were randomized to receive individualized prescribing feedback via academic detailing (postal bulletin plus outreach visit) (n = 48) or postal bulletin (n = 50). The proportion of CVD or diabetic patients on statins and antiplatelet agents/warfarin pre- and post-intervention was calculated for each GP practice. Multivariate regression with a random effects model was used to compare differences between the groups adjusting for GP clustering and confounding factors. beta-Coefficients and 95% confidence intervals (CIs) are presented. There was a 3% increase in statin prescribing in CVD patients at 6 months post-intervention for both randomized groups, but there was no statistical difference between the groups (beta = 0.004; 95% CI = -0.01 to 0.02). Statin and antiplatelet/warfarin prescribing also increased in the diabetic population; there was no significant differences between the groups. GPs participating in the project expressed a high level of satisfaction with both interventions. Prescribing of preventive therapies increased in both randomized groups over the study period. But academic detailing did not have an additional effect on changing prescribing over the postal bulletin alone.

Effect of Drug Sample Removal on Prescribing in a Family Practice Clinic

PubMed Central

Hartung, Daniel M.; Evans, David; Haxby, Dean G.; Kraemer, Dale F.; Andeen, Gabriel; Fagnan, Lyle J.

2010-01-01

PURPOSE Little is known about the impact of recent restrictions on pharmaceutical industry detailing and sampling on prescribing behavior, particularly within smaller, independent practices. The objective of this study was to evaluate the effect of a policy prohibiting prescription drug samples and pharmaceutical industry interaction on prescribing patterns in a rural family practice clinic in central Oregon. METHODS Segmented linear regression models were used to evaluate trends in prescribing using locally obtained pharmacy claims. Oregon Medicaid pharmacy claims were used to control for secular prescribing changes. Total and class-specific monthly trends in branded, promoted, and average prescription drug costs were analyzed 18 months before and after policy implementation. RESULTS Aggregate trends of brand name drug use did not change significantly after policy implementation. In aggregate, use of promoted agents decreased by 1.43% while nonpromoted branded agents increased by 3.04%. Branded drugs prescribed for respiratory disease declined significantly by 11.34% compared with a control group of prescribers. Relative to the control group, prescriptions of promoted cholesterol-lowering drugs and antidepressants were reduced by approximately 9.98% and 11.34%, respectively. The trend in average cost per prescription for lipid-lowering drugs was significantly reduced by $0.70 per prescription per month. Overall, average prescription drug costs increased by $5.18 immediately after policy implementation. CONCLUSIONS Restriction of pharmaceutical industry representatives and samples from a rural family practice clinic produced modest reductions in branded drug use that varied by class. Although aggregate average costs increased, prescriptions for branded and promoted lipid-lowering agents and antidepressants were reduced. PMID:20843881

Effect of drug sample removal on prescribing in a family practice clinic.

PubMed

Hartung, Daniel M; Evans, David; Haxby, Dean G; Kraemer, Dale F; Andeen, Gabriel; Fagnan, Lyle J

2010-01-01

Little is known about the impact of recent restrictions on pharmaceutical industry detailing and sampling on prescribing behavior, particularly within smaller, independent practices. The objective of this study was to evaluate the effect of a policy prohibiting prescription drug samples and pharmaceutical industry interaction on prescribing patterns in a rural family practice clinic in central Oregon. Segmented linear regression models were used to evaluate trends in prescribing using locally obtained pharmacy claims. Oregon Medicaid pharmacy claims were used to control for secular prescribing changes. Total and class-specific monthly trends in branded, promoted, and average prescription drug costs were analyzed 18 months before and after policy implementation. Aggregate trends of brand name drug use did not change significantly after policy implementation. In aggregate, use of promoted agents decreased by 1.43% while nonpromoted branded agents increased by 3.04%. Branded drugs prescribed for respiratory disease declined significantly by 11.34% compared with a control group of prescribers. Relative to the control group, prescriptions of promoted cholesterol-lowering drugs and antidepressants were reduced by approximately 9.98% and 11.34%, respectively. The trend in average cost per prescription for lipid-lowering drugs was significantly reduced by $0.70 per prescription per month. Overall, average prescription drug costs increased by $5.18 immediately after policy implementation. Restriction of pharmaceutical industry representatives and samples from a rural family practice clinic produced modest reductions in branded drug use that varied by class. Although aggregate average costs increased, prescriptions for branded and promoted lipid-lowering agents and antidepressants were reduced.

Quantitative analysis of antibiotic usage in British sheep flocks.

PubMed

Davies, Peers; Remnant, John G; Green, Martin J; Gascoigne, Emily; Gibbon, Nick; Hyde, Robert; Porteous, Jack R; Schubert, Kiera; Lovatt, Fiona; Corbishley, Alexander

2017-11-11

The aim of this study was to examine the variation in antibiotic usage between 207 commercial sheep flocks using their veterinary practice prescribing records. Mean and median prescribed mass per population corrected unit (mg/PCU) was 11.38 and 5.95, respectively and closely correlated with animal defined daily dose (ADDD) 1.47 (mean), 0.74 (median) (R 2 =0.84, P<0.001). This is low in comparison with the suggested target (an average across all the UK livestock sectors) of 50 mg/PCU. In total, 80 per cent of all antibiotic usage occurred in the 39 per cent of flocks where per animal usage was greater than 9.0 mg/PCU. Parenteral antibiotics, principally oxytetracycline, represented 82 per cent of the total prescribed mass, 65.5 per cent of antibiotics (mg/PCU) were prescribed for the treatment of lameness. Oral antibiotics were prescribed to 49 per cent of flocks, 64 per cent of predicted lamb crop/farm. Lowland flocks were prescribed significantly more antibiotics than hill flocks. Variance partitioning apportioned 79 per cent of variation in total antibiotic usage (mg/PCU) to the farm level and 21 per cent to the veterinary practice indicating that veterinary practices have a substantial impact on overall antimicrobial usage. Reducing antibiotic usage in the sheep sector should be possible with better understanding of the drivers of high usage in individual flocks and of veterinary prescribing practices. © British Veterinary Association (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Standardized Competencies for Parenteral Nutrition Prescribing: The American Society for Parenteral and Enteral Nutrition Model.

PubMed

Guenter, Peggi; Boullata, Joseph I; Ayers, Phil; Gervasio, Jane; Malone, Ainsley; Raymond, Erica; Holcombe, Beverly; Kraft, Michael; Sacks, Gordon; Seres, David

2015-08-01

Parenteral nutrition (PN) provision is complex, as it is a high-alert medication and prone to a variety of potential errors. With changes in clinical practice models and recent federal rulings, the number of PN prescribers may be increasing. Safe prescribing of this therapy requires that competency for prescribers from all disciplines be demonstrated using a standardized process. A standardized model for PN prescribing competency is proposed based on a competency framework, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)-published interdisciplinary core competencies, safe practice recommendations, and clinical guidelines. This framework will guide institutions and agencies in developing and maintaining competency for safe PN prescription by their staff. © 2015 American Society for Parenteral and Enteral Nutrition.

Recommendations for Establishing Policy for Electronic Prescribing in the State of Texas: Graduate Management Project

DTIC Science & Technology

2008-06-24

of electronic prescribing, but physicians hold concerns that electronic prescribing systems may produce a significant cost burden to their practices...edition number, etc. 14. ABSTRACT. A brief (approximately 200 words) factual summary of the most significant information. 15. SUBJECT TERMS. Key words...in favor of electronic prescribing, but physicians hold concerns that electronic prescribing systems may produce a significant cost burden to their

Current use of pharmacogenetic testing: a national survey of thiopurine methyltransferase testing prior to azathioprine prescription.

PubMed

Fargher, E A; Tricker, K; Newman, W; Elliott, R; Roberts, S A; Shaffer, J L; Bruce, I; Payne, K

2007-04-01

Azathioprine is an immunosuppressant prescribed for the treatment of inflammatory conditions and after organ transplantation. Risk of neutropaenia has limited the effective use of azathioprine (AZA) and driven requirements for careful monitoring and blood tests. Thiopurine methyltransferase (TPMT) is a genetically moderated key enzyme involved in the metabolism of AZA that can be used to stratify individuals into different levels of risk of developing neutropaenia. Two techniques can be used to measure TPMT status: enzyme-level testing (phenotype testing) and DNA based testing (genotype testing). To identify the current uptake of TPMT enzyme-level testing, TPMT genotype testing, and, the role of guidelines; to inform the prescribing and monitoring of AZA. A survey was mailed to a consultant dermatologist, gastroenterologist, and rheumatologist at every NHS Hospital Trust in England. The survey comprised mainly closed questions exploring: use of AZA and monitoring; use of TPMT enzyme-level testing and genotype testing; and, the role of guidelines to guide prescribing practice. A 70% (n=287) response rate was obtained. The majority of respondents reported prescribing AZA (99%, n=283). Prescribing and monitoring patterns differed between individual respondents and between the three disciplines. TPMT enzyme-level testing was reportedly used by 67% (n=189) of respondents, but this differed by discipline (dermatologists 94%, gastroenterologists 60%, rheumatologists 47%). In 91% of cases enzyme-level testing was carried out prior to prescribing AZA. Genotype testing is not typically available to NHS clinicians but 15 clinicians (six dermatologists, six gastroenterologists, three rheumatologists) reported using it. Most consultants (82%) reported using guidelines to inform their AZA prescribing and monitoring (dermatologists 81%, gastroenterologists 75%, rheumatologists 94%). Two-thirds of the consultants surveyed in England are using TPMT enzyme-level testing, prior to AZA treatment. Uptake differs between specialities. High uptake of TPMT enzyme-level testing by dermatologists, compared with gastroenterologists and rheumatologists, may reflect national guidelines advocating its use prior to AZA. Uptake of enzyme-level testing may alter in other specialties as other guidelines are developed.

Antibiotic prescribing for upper respiratory-tract infections in primary care.

PubMed

Patterson, Craig A; Mackson, Judith M; Weekes, Lynn M

2003-01-01

The use and overuse of antibiotics in humans is a major contributor to the selection of antibiotic resistance organisms. Recent evidence has shown that primary care prescribing selects for resistances of clinical importance. The National Prescribing Service runs both educational and audit activities. The latter provide some insight into general practice attitudes toward antibiotic prescribing.

Infection Prophylaxis in Peritoneal Dialysis Patients: Results from an Australia/New Zealand Survey.

PubMed

Campbell, Denise J; Mudge, David W; Gallagher, Martin P; Lim, Wai Hon; Ranganathan, Dwaraka; Saweirs, Walaa; Craig, Jonathan C

2017-01-01

♦ BACKGROUND: Clinical practice guidelines aim to reduce the rates of peritoneal dialysis (PD)-related infections, a common complication of PD in end-stage kidney disease patients. We describe the clinical practices used by Australian and New Zealand nephrologists to prevent PD-related infections in PD patients. ♦ METHODS: A survey of PD practices in relation to the use of antibiotic and antifungal prophylaxis in PD patients was conducted of practicing nephrologists identified via the Australia and New Zealand Society of Nephrology (ANZSN) membership in 2013. ♦ RESULTS: Of 333 nephrologists approached, 133 (39.9%) participated. Overall, 127 (95.5%) nephrologists prescribed antibiotics at the time of Tenckhoff catheter insertion, 85 (63.9%) routinely screened for nasal S. aureus carriage, with 76 (88.4%) reporting they treated S. aureus carriers with mupirocin ointment. Following Tenckhoff catheter insertion, 79 (59.4%) prescribed mupirocin ointment at the exit site or intranasally, and 93 (69.9%) nephrologists routinely prescribed a course of oral antifungal agent whenever their PD patients were given a course of antibiotics. ♦ CONCLUSIONS: Although the majority of nephrologists prescribe antibiotics at the time of Tenckhoff catheter insertion, less than 70% routinely prescribe mupirocin ointment and/or prophylactic antifungal therapy. This variation in practice in Australia and New Zealand may contribute to the disparity in PD-related infection rates that is seen between units. Copyright © 2017 International Society for Peritoneal Dialysis.

Dental consultations in UK general practice and antibiotic prescribing rates: a retrospective cohort study.

PubMed

Cope, Anwen L; Chestnutt, Ivor G; Wood, Fiona; Francis, Nick A

2016-05-01

The frequency of consulting for dental problems in general medical practice, and antibiotic prescribing associated with these consultations, is poorly described. To describe consultation rates and antibiotic use for dental problems in UK general medical practice, and explore factors associated with antibiotic prescribing for dental conditions. A retrospective cohort study using Clinical Practice Research Datalink, a database of general practice patient records in the UK. All dental consultations between 2004 and 2013 were identified. The main outcome was the prescription of an antibiotic during a dental consultation. Multilevel logistic regression was conducted to examine factors associated with antibiotic prescription. In all, 288 169 dental consultations were included in the cohort. The average rate of dental consultations was 6.06 consultations per 1000 patient-years. Rates of dental consultation decreased from 6.84 consultations per 1000 patient-years in 2008, to 4.23 consultations per 1000 patient-years in 2013. Consultation rates were higher among females than males and highest in patients aged 20-29 years. An antibiotic was prescribed in 57.1% of consultations. Significant predictors (P<0.001) of antibiotic prescribing included: patient middle age, male sex, and previous consultations for tooth-related problems. Antibiotics were more likely to be prescribed during consultations in December (odds ratio [OR] 1.18, 95% confidence interval [CI] = 1.13 to 1.24, P<0.001, reference month: June) and on a Monday (OR 1.10, 95% CI = 1.07 to 1.13, P<0.001) or a Friday (OR 1.15, 95% CI = 1.12 to 1.18, P<0.001, reference day: Wednesday). Consultation rates for dental problems in UK general practice are relatively low but more than half result in the prescription of an antibiotic. This raises concerns about patient morbidity and contributions to antimicrobial resistance. © British Journal of General Practice 2016.

A study of the management of erectile dysfunction in general practice.

PubMed

Griffiths, L; Bush, N; Mottram, D; Armstrong, D

2005-06-01

The Department of Health issued guidelines for the NHS treatment of erectile dysfunction (ED) with phosphodiesterase type 5 inhibitors (PDE 5 inhibitors) in 1999. There has been an increasing trend in the prescribing of PDE 5 inhibitors within Bebington and West Wirral Primary Care Trust (PCT) over the 3-year period from February 2001 to January 2004. The objective of the study was to investigate implementation of Government guidelines on prescribing of PDE 5 inhibitors for ED and the cost of prescribing outside these guidelines. Practice data were collected for all patients prescribed a PDE 5 inhibitor in 16 surgeries within Bebington and West Wirral Primary Care Trust, from November 2002 to December 2003. The data were evaluated with respect to adherence to UK Government guidelines. Analysis was made on the cost to the PCT with respect to treatment provided outside the guidelines. Prescribing for 78% of patients was within Government guidelines. With respect to frequency of prescribing, 89% of patients in the PCT received less than or equal to the recommended frequency of one tablet per week. The percentage range for practices was 67-100%. The cost to the PCT for PDE 5 inhibitor treatment provided outside the guidelines was 19,060 pounds sterling over the period of study. Prescribers generally follow Government guidelines, however, stricter adherence to guidelines could result in more efficient use of National Health Service resources.

Prescribing and deprescribing antihypertensive medication in older people by Dutch general practitioners: a qualitative study

PubMed Central

van Middelaar, Tessa; Ivens, Sophie D; van Peet, Petra G; Poortvliet, Rosalinde K E; Richard, Edo; Pols, A Jeannette; Moll van Charante, Eric P.

2018-01-01

Objectives To explore general practitioners’ (GPs) routines and considerations on (de)prescribing antihypertensive medication (AHM) in older patients, their judgement on usability of the current guideline and needs for future support. Design Semistructured interviews. Setting Dutch general practice. Participants Fifteen GPs were purposively sampled based on level of experience and practice characteristics until saturation was reached. Results GPs appeared reluctant to start AHM, especially in patient >80 years. High systolic blood pressure and history of cardiovascular disease or diabetes were enablers to start or intensify treatment. Reasons to refrain from this were frailty and patient preference. GPs described a tendency to continue AHM regimens unchanged, influenced by daily time constraints, automated prescription routines and anticipating discomfort when disturbing patients’ delicate balance. GPs were only inclined to deprescribe AHM in terminally ill patients or after prolonged achievement of target levels in combination with side effects or patient preference. Deprescription was facilitated when GPs had experience with patients showing increased quality of life after deprescription and was withheld by anticipated regret (ie, GPs’ fear of a stroke after deprescribing). GPs felt insufficient guidance from current guidelines, especially on deprescription. Conclusions GPs are reluctant to start or deprescribe AHM in older people and have a propensity to continue AHM within a daily routine that insufficiently supports critical medication review. (De)prescription is influenced by patient preferences and anticipated regret and current guidelines provide insufficient guidance. PMID:29678989

The prescription opioid epidemic: an overview for anesthesiologists.

PubMed

Alam, Asim; Juurlink, David N

2016-01-01

The objectives for preparing this article were to review the historical context and epidemiology surrounding the North American prescription opioid crisis, to summarize the evidence regarding the benefits and harms of long-term opioid therapy for non-cancer pain, and to outline ways in which anesthesiologists may help ameliorate the problem. We searched PubMed, Google Scholar, and EMBASE™ for relevant articles using various search terms, including pain, opioid epidemic, history of opioid use, perioperative care, and addiction. Related citations were further explored and searched depending on the specific subtopic of interest. In the 1980s and early 1990s, opioids were infrequently used for the treatment of chronic pain. Thereafter, however, physicians were gradually inculcated with the message that long-term opioid therapy was a safe and effective treatment option for patients with chronic non-cancer pain. Pharmaceutical companies supported this growing movement and employed aggressive and sometimes misleading marketing strategies for new opioid formulations. As a result, the practice of prescribing opioids flourished in the late 1990s. The surge in prescribing opioids was accompanied by a marked increase in opioid-related morbidity and mortality. This change in practice transpired despite the absence of randomized trials showing clinically significant benefit from the long-term use of opioids. Subsequently, however, a large and growing body of evidence has emerged quantifying the harms associated with long-term opioid therapy. Anesthesiologists widely prescribe opioids for acute and chronic pain; yet, as a group, they may be largely unaware of the current state of this growing epidemic and what role they can play to rectify this problem. Anesthesiologists are well positioned to take a leadership role in the management of postoperative discharge opioid therapy in an effort to curb the overutilization of opioids. Furthermore, anesthesiologists who regularly prescribe opioids for chronic pain patients should appreciate the limited evidence base for this practice and communicate the risks of opioid therapy to their patients.

Alliances of cooperation: negotiating New Hampshire nurse practitioners' prescribing practice.

PubMed

Sampson, Deborah A

2009-01-01

Nurse practitioner legislation varies among states, particularly in relation to practice without physician oversight, altering the legal environment within which nurse practitioners can use knowledge and skills to meet patient needs. Using New Hampshire as a case study, this historical analysis of nurse practitioners' negotiations over time for independent practice, defined in state practice acts, illuminates the complex social and economic factors affecting nurses' struggle to gain legal rights over their own professional practice without supervision and intervention from another profession. In New Hampshire, not only did organized medicine oppose nurses rights to practice, but pharmacists demanded the right to control all aspects of medication management, including who could prescribe and under what circumstances prescribing could occur. Shifting social and political terrain as well as changes in legislative and state professional board leadership affected the environment and negotiations of a small group of nurses who were ultimately successful in obtaining the right to define their own professional practice.

Evaluation of features to support safety and quality in general practice clinical software

PubMed Central

2011-01-01

Background Electronic prescribing is now the norm in many countries. We wished to find out if clinical software systems used by general practitioners in Australia include features (functional capabilities and other characteristics) that facilitate improved patient safety and care, with a focus on quality use of medicines. Methods Seven clinical software systems used in general practice were evaluated. Fifty software features that were previously rated as likely to have a high impact on safety and/or quality of care in general practice were tested and are reported here. Results The range of results for the implementation of 50 features across the 7 clinical software systems was as follows: 17-31 features (34-62%) were fully implemented, 9-13 (18-26%) partially implemented, and 9-20 (18-40%) not implemented. Key findings included: Access to evidence based drug and therapeutic information was limited. Decision support for prescribing was available but varied markedly between systems. During prescribing there was potential for medicine mis-selection in some systems, and linking a medicine with its indication was optional. The definition of 'current medicines' versus 'past medicines' was not always clear. There were limited resources for patients, and some medicines lists for patients were suboptimal. Results were provided to the software vendors, who were keen to improve their systems. Conclusions The clinical systems tested lack some of the features expected to support patient safety and quality of care. Standards and certification for clinical software would ensure that safety features are present and that there is a minimum level of clinical functionality that clinicians could expect to find in any system.

Recent migrants' perspectives on antibiotic use and prescribing in primary care: a qualitative study.

PubMed

Lindenmeyer, Antje; Redwood, Sabi; Griffith, Laura; Ahmed, Shazia; Phillimore, Jenny

2016-11-01

Currently there is great interest in antibiotic prescribing practices in the UK, but little is known about the experiences of the increasing numbers of recent migrants (those present in the UK for >1 year but <5 years) registered at GP practices. Qualitative research has suggested that reasons for not prescribing antibiotics may not be clearly communicated to migrants. This study aimed to explore the factors that shape migrants' experiences of and attitudes to antibiotics, and to suggest ways to improve effective communication around their use. A qualitative study on recent migrants' health beliefs, values, and experiences in a community setting in primary care. Twenty-three recent migrants were interviewed in their preferred language by trained community researchers. The research team conducted a thematic analysis, focusing on health beliefs, engaging with health services, transnational medicine, and concepts of fairness. Experiences around antibiotics were a strong emerging theme. Three reasons were identified for antibiotics seeking: first, holding an 'infectious model' of illness implying that antibiotics are required quickly to avoid illness becoming worse or spreading to others; second, reasoning that other medications will be less effective for people 'used to' antibiotics'; and third, perceiving antibiotic prescription as a sign of being taken seriously. Some participants obtained antibiotics from their country of origin or migrant networks in the UK; others changed their mind and accepted alternatives. Primary care professionals should aim to understand migrants' perspectives to improve communication with patients. Further research is needed to identify different strategies needed to respond to the varying understandings of antibiotics held by migrants. © British Journal of General Practice 2016.

Application of prescribing recommendations in older people with reduced kidney function: a cross-sectional study in general practice.

PubMed

Wood, Su; Petty, Duncan; Glidewell, Liz; Raynor, Dk Theo

2018-05-01

Kidney function reduces with age, increasing the risk of harm from increased blood levels of many medicines. Although estimated glomerular filtration rate (eGFR) is reported for prescribing decisions in those aged ≥65 years, creatinine clearance (Cockcroft-Gault) gives a more accurate estimate of kidney function. To explore the extent of prescribing outside recommendations for people aged ≥65 years with reduced kidney function in primary care and to assess the impact of using eGFR instead of creatinine clearance to calculate kidney function. A cross-sectional survey of anonymised prescribing data in people aged ≥65 years from all 80 general practices (70 900 patients) in a north of England former primary care trust. The prevalence of prescribing outside recommendations was analysed for eight exemplar drugs. Data were collected for age, sex, actual weight, serum creatinine, and eGFR. Kidney function as creatinine clearance (Cockcroft-Gault) was calculated using actual body weight and estimated ideal body weight. Kidney function was too low for recommended prescribing in 4-40% of people aged ≥65 years, and in 24-80% of people aged ≥85 years despite more than 90% of patients having recent recorded kidney function results. Using eGFR overestimated kidney function for 3-28% of those aged ≥65 years, and for 13-58% of those aged ≥85 years. Increased age predicted higher odds of having a kidney function estimate too low for recommended prescribing of the study drugs. Prescribing recommendations when kidney function is reduced are not applied for many people aged ≥65 years in primary care. Using eGFR considerably overestimates kidney function for prescribing and, therefore, creatinine clearance (Cockcroft-Gault) should be assessed when prescribing for these people. Interventions are needed to aid prescribers when kidney function is reduced. © British Journal of General Practice 2018.

Modeling of outpatient prescribing process in iran: a gateway toward electronic prescribing system.

PubMed

Ahmadi, Maryam; Samadbeik, Mahnaz; Sadoughi, Farahnaz

2014-01-01

Implementation of electronic prescribing system can overcome many problems of the paper prescribing system, and provide numerous opportunities of more effective and advantageous prescribing. Successful implementation of such a system requires complete and deep understanding of work content, human force, and workflow of paper prescribing. The current study was designed in order to model the current business process of outpatient prescribing in Iran and clarify different actions during this process. In order to describe the prescribing process and the system features in Iran, the methodology of business process modeling and analysis was used in the present study. The results of the process documentation were analyzed using a conceptual model of workflow elements and the technique of modeling "As-Is" business processes. Analysis of the current (as-is) prescribing process demonstrated that Iran stood at the first levels of sophistication in graduated levels of electronic prescribing, namely electronic prescription reference, and that there were problematic areas including bottlenecks, redundant and duplicated work, concentration of decision nodes, and communicative weaknesses among stakeholders of the process. Using information technology in some activities of medication prescription in Iran has not eliminated the dependence of the stakeholders on paper-based documents and prescriptions. Therefore, it is necessary to implement proper system programming in order to support change management and solve the problems in the existing prescribing process. To this end, a suitable basis should be provided for reorganization and improvement of the prescribing process for the future electronic systems.

Independent and supplementary prescribing and PGDs.

PubMed

Baird, A

Types of prescribing for non-medical staff are discussed and clarifications made regarding the current overlap in six forms of prescribing and administration of medication. Differences between independent and supplementary prescribing are explored and the distinction between patient group directions and extended formulary nurse prescribing outlined.

Use of buprenorphine for addiction treatment: perspectives of addiction specialists and general psychiatrists.

PubMed

Thomas, Cindy Parks; Reif, Sharon; Haq, Sayeda; Wallack, Stanley S; Hoyt, Alexander; Ritter, Grant A

2008-08-01

In 2002 buprenorphine (Suboxone or Subutex) was approved by the U.S. Food and Drug Administration for office-based treatment of opioid addiction. The goal of office-based pharmacotherapy is to bring more opiate-dependent people into treatment and to have more physicians address this problem. This study examined prescribing practices for buprenorphine, including facilitators and barriers, and the organizational settings that facilitate its being incorporated into treatment. Addiction specialists and other psychiatrists in four market areas were surveyed by mail and Internet in fall 2005 to examine prescribing practices for buprenorphine. Respondents included 271 addiction specialists (72% response rate) and 224 psychiatrists who were not listed as addiction specialists but who had patients with addictions in their practice (57% response rate). Three years after approval of buprenorphine for office-based addiction treatment, nearly 90% of addiction specialists had been approved to prescribe it and two-thirds treated patients with buprenorphine. However, fewer than 10% of non-addiction specialist psychiatrists prescribed it. Regression-adjusted factors predicting prescribing of buprenorphine included support of training and use of buprenorphine by the physician's main affiliated organization, less time in general psychiatry compared with addictions treatment, more time in group practice rather than solo, ten or more opiate-dependent patients, belief that drugs play a large role in addiction treatment, and patient demand. Office-based pharmacotherapy offers a promising path to improved access to addictions treatment, but prescribing has expanded little beyond the addiction specialist community.

Prophylactic antibiotic use in pediatric patients undergoing urinary tract catheterization: a survey of members of the Society for Pediatric Urology.

PubMed

Glaser, Alexander P; Rosoklija, Ilina; Johnson, Emilie K; Yerkes, Elizabeth B

2017-09-06

Current organizational guidelines regarding use of antibiotics during urinary tract catheterization are based on limited evidence and are not directly applicable to the pediatric urology population. We seek to improve understanding of this population by first evaluating current practices. This study aims to investigate practice patterns and attitudes of pediatric urologists regarding the use of antibiotics in the setting of urinary tract catheterization. An online survey was sent to members of the Society for Pediatric Urology. Questionnaire sections included demographics, general questions about antibiotic use with catheterization, and specific clinical scenarios. Descriptive statistics were used, and chi-square analysis was performed to examine associations between demographics and specific responses. Of 448 pediatric urologists surveyed, 154 (34%) responded to the survey. A majority of surveyed urologists (78%) prescribe daily prophylactic antibiotics with a hypospadias stent in place, but extensive variation in use of antibiotics was reported with other catheters and tubes. Extensive variation in practice patterns was also reported for three case scenarios regarding antibiotic prophylaxis with catheterization. Urologists > 50 years of age and fellowship-trained urologists were more likely to prescribe antibiotics for hypospadias stents (p = 0.02, p = 0.03), but no other significant associations between demographic characteristics and antibiotic use were found. There is substantial variation in practice patterns among surveyed pediatric urologists regarding prophylactic antibiotic use with urinary catheterization. This variation, combined with a lack of objective data and increasing pressure to decrease infectious complications and combat antibiotic resistance, highlights the need for development of management guidelines for this unique population.

Space-Time Cluster Analysis to Detect Innovative Clinical Practices: A Case Study of Aripiprazole in the Department of Veterans Affairs.

PubMed

Penfold, Robert B; Burgess, James F; Lee, Austin F; Li, Mingfei; Miller, Christopher J; Nealon Seibert, Marjorie; Semla, Todd P; Mohr, David C; Kazis, Lewis E; Bauer, Mark S

2018-02-01

To identify space-time clusters of changes in prescribing aripiprazole for bipolar disorder among providers in the VA. VA administrative data from 2002 to 2010 were used to identify prescriptions of aripiprazole for bipolar disorder. Prescriber characteristics were obtained using the Personnel and Accounting Integrated Database. We conducted a retrospective space-time cluster analysis using the space-time permutation statistic. All VA service users with a diagnosis of bipolar disorder were included in the patient population. Individuals with any schizophrenia spectrum diagnoses were excluded. We also identified all clinicians who wrote a prescription for any bipolar disorder medication. The study population included 32,630 prescribers. Of these, 8,643 wrote qualifying prescriptions. We identified three clusters of aripiprazole prescribing centered in Massachusetts, Ohio, and the Pacific Northwest. Clusters were associated with prescribing by VA-employed (vs. contracted) prescribers. Nurses with prescribing privileges were more likely to make a prescription for aripiprazole in cluster locations compared with psychiatrists. Primary care physicians were less likely. Early prescribing of aripiprazole for bipolar disorder clustered geographically and was associated with prescriber subgroups. These methods support prospective surveillance of practice changes and identification of associated health system characteristics. © Health Research and Educational Trust.

Self-Assessment of Antimicrobial Stewardship in Primary Care: Self-Reported Practice Using the TARGET Primary Care Self-Assessment Tool

PubMed Central

Owens, Rebecca; Moore, Michael; Pilat, Dirk; McNulty, Cliodna

2017-01-01

Multifaceted antimicrobial stewardship (AMS) interventions including: antibiotic guidance, reviews of antibiotic use using audits, education, patient facing materials, and self-assessment, are successful in improving antimicrobial use. We aimed to measure the self-reported AMS activity of staff completing a self-assessment tool (SAT). The Royal College of General Practitioners (RCGP)/Public Health England (PHE) SAT enables participants considering an AMS eLearning course to answer 12 short questions about their AMS activities. Questions cover guidance, audit, and reflection about antibiotic use, patient facing materials, and education. Responses are recorded digitally. Data were collated, anonymised, and exported into Microsoft Excel. Between November 2014 and June 2016, 1415 users completed the SAT. Ninety eight percent reported that they used antibiotic guidance for treating common infections and 63% knew this was available to all prescribers. Ninety four percent of GP respondents reported having used delayed prescribing when appropriate, 25% were not using Read codes, and 62% reported undertaking a practice-wide antibiotic audit in the last two years, of which, 77% developed an audit action plan. Twenty nine percent had undertaken other antibiotic-related clinical courses. Fifty six percent reported sharing patient leaflets covering infection. Many prescribers reported undertaking a range of AMS activities. GP practice managers should ensure that all clinicians have access to prescribing guidance. Antibiotic audits should be encouraged to enable GP staff to understand their prescribing behaviour and address gaps in good practice. Prescribers are not making full use of antibiotic prescribing-related training opportunities. Read coding facilitates more accurate auditing and its use by all clinicians should be encouraged. PMID:28813003

Self-Assessment of Antimicrobial Stewardship in Primary Care: Self-Reported Practice Using the TARGET Primary Care Self-Assessment Tool.

PubMed

Owens, Rebecca; Jones, Leah Ffion; Moore, Michael; Pilat, Dirk; McNulty, Cliodna

2017-08-16

Multifaceted antimicrobial stewardship (AMS) interventions including: antibiotic guidance, reviews of antibiotic use using audits, education, patient facing materials, and self-assessment, are successful in improving antimicrobial use. We aimed to measure the self-reported AMS activity of staff completing a self-assessment tool (SAT). The Royal College of General Practitioners (RCGP)/Public Health England (PHE) SAT enables participants considering an AMS eLearning course to answer 12 short questions about their AMS activities. Questions cover guidance, audit, and reflection about antibiotic use, patient facing materials, and education. Responses are recorded digitally. Data were collated, anonymised, and exported into Microsoft Excel. Between November 2014 and June 2016, 1415 users completed the SAT. Ninety eight percent reported that they used antibiotic guidance for treating common infections and 63% knew this was available to all prescribers. Ninety four percent of GP respondents reported having used delayed prescribing when appropriate, 25% were not using Read codes, and 62% reported undertaking a practice-wide antibiotic audit in the last two years, of which, 77% developed an audit action plan. Twenty nine percent had undertaken other antibiotic-related clinical courses. Fifty six percent reported sharing patient leaflets covering infection. Many prescribers reported undertaking a range of AMS activities. GP practice managers should ensure that all clinicians have access to prescribing guidance. Antibiotic audits should be encouraged to enable GP staff to understand their prescribing behaviour and address gaps in good practice. Prescribers are not making full use of antibiotic prescribing-related training opportunities. Read coding facilitates more accurate auditing and its use by all clinicians should be encouraged.

The efficiency of cardiovascular risk assessment: do the right patients get statin treatment?

PubMed Central

van Staa, Tjeerd-Pieter; Smeeth, Liam; Ng, Edmond S-W; Goldacre, Ben; Gulliford, Martin

2013-01-01

Objective To evaluate targeting of statin prescribing for primary prevention to those with high cardiovascular disease (CVD) risk. Design Two cohort studies including the general population and initiators of statins aged 35–74 years. Setting UK primary care records in the Clinical Practice Research Datalink. Patients 3.8 million general population patients and 300 914 statin users. Intervention Statin prescribing. Main outcome measures Statin prescribing by CVD risk; observed 5-year CVD risks; variability between practices. Results Statin prescribing increased substantially over time to patients with high 10-year CVD risk (≥20%): 7.0% of these received a statin prior to 2007, and 30.4% in 2007 onwards. Prescribing to patients with low risk (<15%) also increased (from 1.9% to 5.0%). Only about half the patients initiating statin treatment were high risk according to CVD risk score. The 5-year CVD risks, as observed during statin treatment, reduced over calendar time (from 17.0% to 7.1%). There was a large variation between general practices in the percentage of high-risk patients prescribed a statin in 2007 onwards, ranging from 8.2% to 61.5%. For low-risk patients, these varied from 2.1% to 29.1%. Conclusions There appeared to be substantive overuse in low CVD risk and underuse in high CVD risk (600 000 and 850 000 patients, respectively, in the UK since 2007). There is wide variation between practices in statin prescribing to patients at high CVD risk. There is a clear need for randomised trials for the best strategy to target statin treatment and manage CVD risk for primary prevention. PMID:23735939

Diffusion of new drugs in Danish general practice.

PubMed

Steffensen, F H; Sørensen, H T; Olesen, F

1999-08-01

There is a large variation in implementing research findings in clinical practice. We examined whether the concept of early or late adopters is universal for the diffusion of all new drugs, and whether it is associated with non-scientific factors in general practice. We identified all prescriptions for five new drugs from the population-based prescription database in North Jutland County, Denmark (490000 inhabitants) from 1993 to 1996, and calculated the period from release of the drugs to the issuing of the first prescription by each GP. Logistic regression was performed to predict early or late prescribing from physician characteristics, practice activity and the number of prescriptions, adjusted for age and sex. The distributions of the diffusion time of the drugs by 95 solo practitioners were asymmetrical, with a long upper tail representing the late prescribers. The shape and slope of the diffusion curve were highly drug dependent. There was poor agreement of the three adopter categories (early, intermediate and late prescribers) between the five drugs (kappa < 0.35), but being a late prescriber was the most consistent condition. Late prescribing of tramadol, compared with intermediate prescribing, was associated with female physicians (odds ratio (OR) 5.7; 95% CI 1.5-21.3), smaller list size (OR 0.1; 95% CI 0.0-0.8), a strong general restrictive attitude to pharmacotherapy (OR 0.07; 95% CI 0.01-0.68) and a tendency to lower diagnostic activity per patient (OR 0.4; 95% CI 0.1-1.9). The slope and shape of the diffusion curve are both dependent on physician and drug characteristics, but late prescribers share some common characteristics.

Focus on early-career GPs: qualitative evaluation of a multi-faceted educational intervention to improve antibiotic prescribing.

PubMed

Deckx, Laura; Anthierens, Sibyl; Magin, Parker J; Morgan, Simon; McArthur, Lawrie; Yardley, Lucy; Dallas, Anthea; Little, Paul; van Driel, Mieke L

2018-01-16

We conducted an educational intervention emphasizing rational antibiotic prescribing in early-career General Practitioners (GP) in vocational training (trainees). The intervention consisted of an online introduction module, an online communication training module, face-to-face workshops, and cases to be discussed one-on-one by the trainee-supervisor dyad during regular scheduled education sessions. To explore the participants' experiences with the intervention. A qualitative study of 14 GP trainees and supervisors. Interviews followed a semi-structured interview guide, were transcribed and analysed using concurrent thematic analysis. Overall, the intervention was well received. Resources were not often used in practice, but GP trainees used the information in communicating with patients. The intervention improved trainees' confidence and provided new communication strategies, e.g. explicitly asking about patients' expectations and talking patients through the examination to form an overall clinical picture. Trainees seemed eager to learn and adapt their practice, whereas GP supervisors rather commented that the intervention was reinforcing. None of the participants reported prescribing conflicts between trainee and supervisor. However, most participants identified conflicts within the GP practice or with specialists: other doctors who prescribe more antibiotics perpetuate patients' ideas that antibiotics will fix everything, which in turn causes conflict with the patient and undermines attempts to improve antibiotic prescribing. The educational intervention was received positively. Early-career GPs thought it influenced their prescribing behaviour and improved their confidence in non-prescribing. Interventions that target teams (e.g. entire practice) could minimize conflict, ensure consistency of messages and support overall antibiotic stewardship in primary care. © The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Rheumatologists lack confidence in their knowledge of cannabinoids pertaining to the management of rheumatic complaints.

PubMed

Fitzcharles, Mary-Ann; Ste-Marie, Peter A; Clauw, Daniel J; Jamal, Shahin; Karsh, Jacob; LeClercq, Sharon; McDougall, Jason J; Shir, Yoram; Shojania, Kam; Walsh, Zach

2014-07-30

Arthritis pain is reported as one of the most common reasons for persons using medical herbal cannabis in North America. "Severe arthritis" is the condition justifying legal use of cannabis in over half of all authorizations in Canada, where cannabis remains a controlled substance. As champions for the care of persons with arthritis, rheumatologists must be knowledgeable of treatment modalities both traditional and non-traditional, used by their patients. As study of cannabinoid molecules in medicine is recent, we have examined the confidence in the knowledge of cannabinoids expressed by Canadian rheumatologists. The confidence of rheumatologists in their knowledge of cannabinoid molecules and mechanisms relevant to rheumatology, and their ability to advise patients about cannabinoid treatments was recorded by an online questionnaire circulated via email to the entire Canadian Rheumatology Association membership. Over three quarters of the 128 respondents lacked confidence in their knowledge of cannabinoid molecules. While 45% of respondents believed there was no current role for cannabinoids in rheumatology patient care, only 25% supported any use of herbal cannabis. With 70% never having previously prescribed or recommended any cannabinoid treatment, uncertainty regarding good prescribing practices was prevalent. Concerns about risks of cannabis use were in line with the current literature. Rheumatologists lacked confidence in their knowledge of cannabinoid molecules in general and in their competence to prescribe any cannabinoid for rheumatic complaints. In line with this uncertainty, there is reticence to prescribe cannabinoid preparations for rheumatology patients. Guidance is required to inform rheumatologists on the evidence regarding cannabinoids.

Achievement of cholesterol targets and prescribing of higher-cost statins: a cross-sectional study in general practice.

PubMed

Fleetcroft, Robert; Schofield, Peter; Duerden, Martin; Ashworth, Mark

2012-12-01

There is conflicting evidence as to whether achievement of cholesterol targets at the population level is dependent on the choice and cost of statin. To investigate the practice-level relationship between cholesterol quality indicators in patients with heart disease, stroke, and diabetes and prescribing of low-cost statins. Correlations and linear regression modelling of retrospective cross-sectional practice-level data with potential explanatory variables in 7909 (96.4%) general practices in England in 2008-2009. Quality indicator data were obtained from the Information Centre and prescribing data from the NHS Business Authority. A 'cholesterol quality indicator' score was constructed by dividing the numbers of patients achieving the target for cholesterol control of ≤5 mmol/l in stroke, diabetes, and heart disease by the numbers on each register. A 'low-cost statin' ratio score was constructed by dividing the numbers of defined daily doses of simvastatin and pravastatin by the total numbers of defined daily doses of statins. Simvastatin accounted for 83.3% (standard deviation [SD] = 15.7%) of low-cost statins prescribed and atorvastatin accounted for 85.7% (SD = 14.8%) of high-cost statins prescribed. The mean cholesterol score was 73.7% (SD = 6.0%). Practices using a higher proportion of the low-cost statins were less successful in achieving cholesterol targets. An increase of 10% in the prescribing of low-cost statins was associated with a decrease of 0.46% in the cholesterol quality indicator score (95% confidence interval = -0.54% to -0.38%, P<0.001). Greater use of low-cost statins was associated with a small reduction in cholesterol control.

Extemporaneous formulations in Germany - relevance for everyday clinical practice.

PubMed

Staubach, Petra; Salzmann, Stefan; Peveling-Oberhag, Adriane; Weyer, Veronika; Zimmer, Sebastian; Gradl, Gabriele; Lang, Berenice M

2018-05-01

Extemporaneous formulations broaden the spectrum of therapeutic options for topical treatment in particular and thus improve patient care. The latest amendment to the Regulation on the Operation of Pharmacies issued in 2012 brought about changes in prescribing and manufacturing practices. The aim of the present study was to assess the relevance of extemporaneous formulations in everyday clinical practice. We used data from the German Institute for Drug Use Evaluation (DAPI) to analyze the prescribing practice for compounded preparations in Germany between the fourth quarter of 2011 and the third quarter of 2014. In doing so, we determined the total cost associated with extemporaneous formulations covered by statutory health insurance funds in the outpatient setting. Approximately three out of ten prescriptions (30.54 %) by German dermatologists during the observation period were extemporaneous formulations. While dermatologists make up only 2.7 % of physicians working in the statutory health care system in Germany, they prescribe more than half of all compounded preparations (53.6 %). Each dermatologist prescribed an average of 270.4 formulations per quarter; that number was 13.5 (1.3 %) for all other medical specialties. On average, 1,983,687 extemporaneous formulations overall (1.3 % of all prescriptions) were prescribed per quarter, corresponding to a total cost of € 40,944,982 (0.55 %). Apart from finished medicinal products, extemporaneous formulations play a key role in outpatient care. Based on the principles of evidence-based and patient-oriented medicine, the quality of compounded preparations and the prescribing practice of physicians (standardized vs. individual formulations) should be further investigated to optimize the quality of these preparations. © 2018 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd.

Prime Drug Interplay in Dental Practice

PubMed Central

Govila, Vivek; Saini, Ashish; Verma, Sunil Chandra

2016-01-01

Drug interaction is a negative representation of pharmacotherapy. In order to provide the best patient care possible, a thorough knowledge of how the drug interactions occur is needed for proper application in practice. Possible interactions among current medication and drugs being prescribed should be considered always. A thorough understanding of the mechanism of interactions among drugs is a must for the health care practitioner. Considering the astounding number of drugs patients may be taking, this task seems discouraging. The count of possible interactions in dental practice are less due to few number of drugs utilized and brief period of therapy, but still notable number are to be considered. The aim of present preview is to consider the manifold and multiplex nature of pharmacological drug-drug interaction in the general dental practice setting. PMID:27135021

Emergency supply of prescription-only medicines to patients by community pharmacists: a mixed methods evaluation incorporating patient, pharmacist and GP perspectives.

PubMed

Morecroft, Charles W; Mackridge, Adam J; Stokes, Elizabeth C; Gray, Nicola J; Wilson, Sarah E; Ashcroft, Darren M; Mensah, Noah; Pickup, Graham B

2015-07-10

To evaluate and inform emergency supply of prescription-only medicines by community pharmacists (CPs), including how the service could form an integral component of established healthcare provision to maximise adherence. Mixed methods. 4 phases: prospective audit of emergency supply requests for prescribed medicines (October-November 2012 and April 2013); interviews with CPs (February-April 2013); follow-up interviews with patients (April-May 2013); interactive feedback sessions with general practice teams (October-November 2013). 22 community pharmacies and 6 general practices in Northwest England. 27 CPs with experience of dealing with requests for emergency supplies; 25 patients who received an emergency supply of a prescribed medicine; 58 staff at 6 general practices. Clinical audit in 22 pharmacies over two 4-week periods reported that 526 medicines were requested by 450 patients. Requests peaked over a bank holiday and around weekends. A significant number of supplies were made during practice opening hours. Most requests were for older patients and for medicines used in long-term conditions. Difficulty in renewing repeat medication (forgetting to order, or prescription delays) was the major reason for requests. The majority of medicines were 'loaned' in advance of a National Health Service (NHS) prescription. Interviews with CPs and patients indicated that continuous supply had a positive impact on medicines adherence, removing the need to access urgent care. General practice staff were surprised and concerned by the extent of emergency supply episodes. CPs regularly provide emergency supplies to patients who run out of their repeat medication, including during practice opening hours. This may aid adherence. There is currently no feedback loop, however, to general practice. Patient care and interprofessional communication may be better served by the introduction of a formally structured and funded NHS emergency supply service from community pharmacies, with ongoing optimisation of repeat prescribing. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Multinational Comparison of Prophylactic Antibiotic Use for Eyelid Surgery.

PubMed

Fay, Aaron; Nallasamy, Nambi; Bernardini, Francesco; Wladis, Edward J; Durand, Marlene L; Devoto, Martin H; Meyer, Dale; Hartstein, Morris; Honavar, Santosh; Osaki, Midori H; Osaki, Tammy H; Santiago, Yvette M; Sales-Sanz, Marco; Vadala, Giuseppe; Verity, David

2015-07-01

Antibiotic stewardship is important in controlling resistance, adverse reactions, and cost. The literature regarding antibiotic use for eyelid surgery is lacking. To determine standard care and assess factors influencing antibiotic prescribing practices for eyelid surgery. A survey study was conducted from February 2, 2014, to March 24, 2014. The survey was distributed to 2397 oculoplastic surgeons in private and academic oculoplastic surgery practices in 43 countries. All surgeons were members of ophthalmic plastic and reconstructive surgery societies. Data were analyzed by geographic location. Linear regression was performed to quantify contributions to rates of prescribing postoperative antibiotics for routine eyelid surgical procedures. Rates of prescribing prophylactic intravenous, oral, and topical antibiotics as well as factors that influence surgeons' prescribing practices. A total of 782 responses were received from 2397 surgeons (average response rate, 36.7%; 2.5% margin of error) from 43 countries. Topical antibiotic use was common in all regions (85.2%). Perioperative intravenous antibiotic use was uncommon in all regions (13.5%). Geographic location was the greatest predictor of antibiotic prescribing practices (range, 2.9% in the United Kingdom to 86.7% in India; mean, 24%). Within Europe, Italy had the highest rate of antibiotic prescriptions for eyelid surgery (41.7%) and the United Kingdom had the lowest rate (2.9%.) In South America, Venezuela had the highest rate of antibiotic prescriptions for eyelid surgery (83.3%) and Chile had the lowest rate (0%). The practice locations that were associated with routinely prescribing postoperative oral antibiotics were India (odds ratio [OR], 15.83; 95% CI, 4.85-51.68; P < .001), Venezuela (OR, 13.47; 95% CI, 1.43-127.19; P = .02), and Southeast Asia (OR, 2.80; 95% CI, 1.15-6.84; P = .02). Conversely, practice location in the United Kingdom (OR, 0.048; 95% CI, 0.0063-0.37; P = .004), Australia and New Zealand (OR, 0.15; 95% CI, 0.033-0.67; P = .01), and the United States and Canada (OR, 0.41; 95% CI, 0.23-0.72; P = .002) were associated with decreased rates of postoperative oral antibiotic use. Surgeons' concern for allergic reactions was associated with decreased rates of prescribing antibiotics (OR, 0.34; 95% CI, 0.23-0.49; P < .001), while surgeons' concern for infection was associated with increased rates of prescribing antibiotics (OR 1.80; 95% CI, 1.45-2.23; P < .001). These results from members of ophthalmic plastic and reconstructive surgery societies confirm that antibiotic prescribing practices for routine eyelid surgical procedures vary widely throughout the world. No standard of care has been established that would require the routine use of postoperative prophylactic antibiotics following eyelid surgery.

Academic Detailing Has a Positive Effect on Prescribing and Decreasing Prescription Drug Costs: A Health Plan's Perspective

PubMed Central

Ndefo, Uche Anadu; Norman, Rolicia; Henry, Andrea

2017-01-01

Background When initiated by a health plan, academic detailing can be used to change prescribing practices, which can lead to increased safety and savings. Objective To evaluate the impact of academic detailing on prescribing and prescription drug costs of cefixime to a health plan. Methods A prospective intervention study was carried out that evaluated the prescribing practices and prescription drug costs of cefixime. A total of 11 prescribers were detailed by 1 pharmacist between August 2014 and March 2015. Two of the 11 prescribers did not respond to the academic detailing and were not followed up. The physicians' prescribing habits and prescription costs were compared before and after detailing to evaluate the effectiveness of the intervention. Data were collected for approximately 5 months before and after the intervention. Each prescriber served as his or her own control. Results Overall, an approximate 36% reduction in the number of cefixime prescriptions written and an approximate 20% decrease in prescription costs was seen with academic detailing compared with the year before the intervention. In 9 of 11 (82%) prescribers, intervention with academic detailing was successful and resulted in fewer prescriptions for cefixime during the study period. Conclusion Academic detailing had a positive impact on prescribing, by decreasing the number of cefixime prescriptions and lowering the drug costs to the health plan. PMID:28626509

The impact of nurse prescribing on the clinical setting.

PubMed

Creedon, Rena; Byrne, Stephen; Kennedy, Julia; McCarthy, Suzanne

To investigate the impact nurse prescribing has on the organisation, patient and health professional, and to identify factors associated with the growth of nurse prescribing. Systematic search and narrative review. Data obtained through CINAHL, PubMed, Science direct, Online Computer Library Centre (OCLC), databases/websites, and hand searching. English peer-reviewed quantitative, qualitative and mixed-method articles published from September 2009 through to August 2014 exploring nurse prescribing from the perspective of the organisation, health professional and patient were included. Following a systematic selection process, studies identified were also assessed for quality by applying Cardwell's framework. From the initial 443 citations 37 studies were included in the review. Most studies were descriptive in nature. Commonalities addressed were stakeholders' views, prescribing in practice, jurisdiction, education and benefits/barriers. Prescriptive authority for nurses continues to be a positive addition to clinical practice. However, concerns have emerged regarding appropriate support, relationships and jurisdictional issues. A more comprehensive understanding of nurse and midwife prescribing workloads is required to capture the true impact and cost-effectiveness of the initiative.

Academic Detailing with Provider Audit and Feedback Improve Prescribing Quality for Older Veterans.

PubMed

Vandenberg, Ann E; Echt, Katharina V; Kemp, Lawanda; McGwin, Gerald; Perkins, Molly M; Mirk, Anna K

2018-03-01

Suboptimal prescribing persists as a driver of poor quality care of older veterans and is associated with risk of hospitalization and emergency department visits. We adapted a successful medication management model, Integrated Management and Polypharmacy Review of Vulnerable Elders (IMPROVE), from an urban geriatric specialty clinic to rural community-based clinics that deliver primary care. The goals were to promote prescribing quality and safety for older adults, including reduced prescribing of potentially inappropriate medications (PIMs). We augmented the original model, which involved a pharmacist-led, one-on-one medication review with high-risk older veterans, to provide rural primary care providers (PCPs) and pharmacists with educational outreach through academic detailing and tools to support safe geriatric prescribing practices, as well as individual audit and feedback on prescribing practice and confidential peer benchmarking. Twenty PCPs and 4 pharmacists at 4 rural Georgia community-based outpatient clinics participated. More than 7,000 older veterans were seen in more than 20,000 PCP encounters during the 14-month intervention period. Implementation of the IMPROVE intervention reduced PIM prescribing incidence from 9.6 new medications per 100 encounters during baseline to 8.7 after the intervention (P = .009). IMPROVE reduced PIM prevalence (proportion of encounters involving veterans who were taking at least 1 PIM) from 22.6% to 16.7% (P < .001). These approaches were effective in reducing PIMs prescribed to older veterans in a rural setting and constitute a feasible model for disseminating geriatric best practices to the primary care setting. © 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.

Identification of an updated set of prescribing-safety indicators for GPs

PubMed Central

Spencer, Rachel; Bell, Brian; Avery, Anthony J; Gookey, Gill; Campbell, Stephen M

2014-01-01

Background Medication error is an important contributor to patient morbidity and mortality and is associated with inadequate patient safety measures. However, prescribing-safety tools specifically designed for use in general practice are lacking. Aim To identify and update a set of prescribing-safety indicators for assessing the safety of prescribing in general practice, and to estimate the risk of harm to patients associated with each indicator. Design and setting RAND/UCLA consensus development of indicators in UK general practice. Method Prescribing indicators were identified from a systematic review and previous consensus exercise. The RAND Appropriateness Method was used to further identify and develop the indicators with an electronic-Delphi method used to rate the risk associated with them. Twelve GPs from all the countries of the UK participated in the RAND exercise, with 11 GPs rating risk using the electronic-Delphi approach. Results Fifty-six prescribing-safety indicators were considered appropriate for inclusion (overall panel median rating of 7–9, with agreement). These indicators cover hazardous prescribing across a range of therapeutic indications, hazardous drug–drug combinations and inadequate laboratory test monitoring. Twenty-three (41%) of these indicators were considered high risk or extreme risk by 80% or more of the participants. Conclusion This study identified a set of 56 indicators that were considered, by a panel of GPs, to be appropriate for assessing the safety of GP prescribing. Twenty-three of these indicators were considered to be associated with high or extreme risk to patients and should be the focus of efforts to improve patient safety. PMID:24686882

Process evaluation of the data-driven quality improvement in primary care (DQIP) trial: active and less active ingredients of a multi-component complex intervention to reduce high-risk primary care prescribing.

PubMed

Grant, Aileen; Dreischulte, Tobias; Guthrie, Bruce

2017-01-07

Two to 4% of emergency hospital admissions are caused by preventable adverse drug events. The estimated costs of such avoidable admissions in England were £530 million in 2015. The data-driven quality improvement in primary care (DQIP) intervention was designed to prompt review of patients vulnerable from currently prescribed non-steroidal anti-inflammatory drugs (NSAIDs) and anti-platelets and was found to be effective at reducing this prescribing. A process evaluation was conducted parallel to the trial, and this paper reports the analysis which aimed to explore response to the intervention delivered to clusters in relation to participants' perceptions about which intervention elements were active in changing their practice. Data generation was by in-depth interview with key staff exploring participant's perceptions of the intervention components. Analysis was iterative using the framework technique and drawing on normalisation process theory. All the primary components of the intervention were perceived as active, but at different stages of implementation: financial incentives primarily supported recruitment; education motivated the GPs to initiate implementation; the informatics tool facilitated sustained implementation. Participants perceived the primary components as interdependent. Intervention subcomponents also varied in whether and when they were active. For example, run charts providing feedback of change in prescribing over time were ignored in the informatics tool, but were motivating in some practices in the regular e-mailed newsletter. The high-risk NSAID and anti-platelet prescribing targeted was accepted as important by all interviewees, and this shared understanding was a key wider context underlying intervention effectiveness. This was a novel use of process evaluation data which examined whether and how the individual intervention components were effective from the perspective of the professionals delivering changed care to patients. These findings are important for reproducibility and roll-out of the intervention. ClinicalTrials.gov, NCT01425502 .

Understanding flucloxacillin prescribing trends and treatment non-response in UK primary care: a Clinical Practice Research Datalink (CPRD) study

PubMed Central

Francis, Nick A.; Hood, Kerenza; Lyons, Ronan; Butler, Christopher C.

2016-01-01

Objectives The volume of prescribed antibiotics is associated with antimicrobial resistance and, unlike most other antibiotic classes, flucloxacillin prescribing has increased. We aimed to describe UK primary care flucloxacillin prescribing and factors associated with subsequent antibiotic prescribing as a proxy for non-response. Patients and methods Clinical Practice Research Datalink patients with acute prescriptions for oral flucloxacillin between January 2004 and December 2013, prescription details, associated Read codes and patient demographics were identified. Monthly prescribing rates were plotted and logistic regression identified factors associated with having a subsequent antibiotic prescription within 28 days. Results 3 031 179 acute prescriptions for 1 667 431 patients were included. Average monthly prescription rates increased from 4.74 prescriptions per 1000 patient-months in 2004 to 5.74 (increase of 21.1%) in 2013. The highest prescribing rates and the largest increases in rates were seen in older adults (70+ years), but the overall increase in prescribing was not accounted for by an ageing population. Prescribing 500 mg tablets/capsules rather than 250 mg became more common. Children were frequently prescribed low doses and small volumes (5 day course) and prescribing declined for children, including for impetigo. Only 4.2% of new prescriptions involved co-prescription of another antibiotic. Age (<5 and ≥60 years), diagnosis of ‘cellulitis or abscess’ or no associated code, and 500 mg dose were associated with a subsequent antibiotic prescription, which occurred after 17.6% of first prescriptions. Conclusions There is a need to understand better the reasons for increased prescribing of flucloxacillin in primary care, optimal dosing (and the need to co-prescribe other antibiotics) and the reasons why one in five patients are prescribed a further antibiotic within 4 weeks. PMID:27090629

Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: a multinational, cluster, randomised, factorial, controlled trial

PubMed Central

Little, Paul; Stuart, Beth; Francis, Nick; Douglas, Elaine; Tonkin-Crine, Sarah; Anthierens, Sibyl; Cals, Jochen WL; Melbye, Hasse; Santer, Miriam; Moore, Michael; Coenen, Samuel; Butler, Chris; Hood, Kerenza; Kelly, Mark; Godycki-Cwirko, Maciek; Mierzecki, Artur; Torres, Antoni; Llor, Carl; Davies, Melanie; Mullee, Mark; O'Reilly, Gilly; van der Velden, Alike; Geraghty, Adam WA; Goossens, Herman; Verheij, Theo; Yardley, Lucy

2013-01-01

Summary Background High-volume prescribing of antibiotics in primary care is a major driver of antibiotic resistance. Education of physicians and patients can lower prescribing levels, but it frequently relies on highly trained staff. We assessed whether internet-based training methods could alter prescribing practices in multiple health-care systems. Methods After a baseline audit in October to December, 2010, primary-care practices in six European countries were cluster randomised to usual care, training in the use of a C-reactive protein (CRP) test at point of care, in enhanced communication skills, or in both CRP and enhanced communication. Patients were recruited from February to May, 2011. This trial is registered, number ISRCTN99871214. Results The baseline audit, done in 259 practices, provided data for 6771 patients with lower-respiratory-tract infections (3742 [55·3%]) and upper-respiratory-tract infections (1416 [20·9%]), of whom 5355 (79·1%) were prescribed antibiotics. After randomisation, 246 practices were included and 4264 patients were recruited. The antibiotic prescribing rate was lower with CRP training than without (33% vs 48%, adjusted risk ratio 0·54, 95% CI 0·42–0·69) and with enhanced-communication training than without (36% vs 45%, 0·69, 0·54–0·87). The combined intervention was associated with the greatest reduction in prescribing rate (CRP risk ratio 0·53, 95% CI 0·36–0·74, p<0·0001; enhanced communication 0·68, 0·50–0·89, p=0·003; combined 0·38, 0·25–0·55, p<0·0001). Interpretation Internet training achieved important reductions in antibiotic prescribing for respiratory-tract infections across language and cultural boundaries. Funding European Commission Framework Programme 6, National Institute for Health Research, Research Foundation Flanders. PMID:23915885

A UK clinical audit addressing the quality of prescribing of sodium valproate for bipolar disorder in women of childbearing age.

PubMed

Paton, Carol; Cookson, John; Ferrier, I Nicol; Bhatti, Sumera; Fagan, Elizabeth; Barnes, Thomas R E

2018-04-12

To review prescribing practice concerning valproate, an established human teratogen, for the management of bipolar disorder in women of childbearing age. The Prescribing Observatory for Mental Health conducted a baseline clinical audit in the UK, as part of a quality improvement programme. Six hundred and forty-eight clinical teams from 55 mental health Trusts submitted retrospective treatment data relating to patients with a diagnosis of bipolar disorder. Of the audit sample of 6705 patients, 3854 were 50 years of age or younger. Valproate was prescribed for 24% of women and 43% men in this age group, and the mean dose of valproate was lower in women (1196 mg) than in men (1391 mg). For only half of such women was there documented evidence that information had been provided on the risks for the unborn child and the need for adequate contraception. Valproate was more often used in men to treat mania and aggression, while the most common treatment targets in women were hypomania and relapse prevention. Despite explicit recommendations in national treatment guidelines and published safety alerts and warnings regarding the use of valproate in women of childbearing age, current prescribing of this medication to such women in the context of the treatment of bipolar disorder falls short of best practice, particularly with regard to provision of information regarding the risks associated with exposure to valproate during pregnancy. While women younger than 50 years of age were less likely to be prescribed valproate than men in the same age group, and at a lower dosage, it is unclear to what extent this reflects clinicians' concerns about teratogenicity or is driven by perceptions of the indication for valproate, and the dosage required, for the treatment of different phases of the disorder in men and women. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Infective endocarditis prophylaxis: current practice trend among paediatric cardiologists: are we following the 2007 guidelines?

PubMed

Naik, Ronak J; Patel, Neil R; Wang, Ming; Shah, Nishant C

2016-08-01

In 2007, the American Heart Association modified the infective endocarditis prophylaxis guidelines by limiting the use of antibiotics in patients with cardiac conditions associated with the highest risk of adverse outcomes after infective endocarditis. Our objective was to evaluate current practice for infective endocarditis prophylaxis among paediatric cardiologists. A web-based survey focussing on current practice, describing the use of antibiotics for infective endocarditis prophylaxis in various congenital and acquired heart diseases, was distributed via e-mail to paediatric cardiologists. The survey was kept anonymous and was distributed twice. Data from 253 participants were analysed. Most paediatric cardiologists discontinued infective endocarditis prophylaxis in patients with simple lesions such as small ventricular septal defect, patent ductus arteriosus, and bicuspid aortic valve without stenosis or regurgitation; however, significant disagreement persists in prescribing infective endocarditis prophylaxis in certain conditions such as rheumatic heart disease, Fontan palliation without fenestration, and the Ross procedure. Use of antibiotic prophylaxis in certain selected conditions for which infective endocarditis prophylaxis has been indicated as per the current guidelines varies from 44 to 83%. Only 44% follow the current guidelines exclusively, and 34% regularly discuss the importance of oral hygiene with their patients at risk for infective endocarditis. Significant heterogeneity still persists in recommending infective endocarditis prophylaxis for several cardiac lesions among paediatric cardiologists. More than half of the participants (56%) do not follow the current guidelines exclusively in their practice. Counselling for optimal oral health in patients at risk for infective endocarditis needs to be optimised in the current practice.

Electronically delivered, multicomponent intervention to reduce unnecessary antibiotic prescribing for respiratory infections in primary care: a cluster randomised trial using electronic health records—REDUCE Trial study original protocol

PubMed Central

Juszczyk, Dorota; Charlton, Judith; McDermott, Lisa; Soames, Jamie; Sultana, Kirin; Ashworth, Mark; Fox, Robin; Hay, Alastair D; Little, Paul; Moore, Michael V; Yardley, Lucy; Prevost, A Toby; Gulliford, Martin C

2016-01-01

Introduction Respiratory tract infections (RTIs) account for about 60% of antibiotics prescribed in primary care. This study aims to test the effectiveness, in a cluster randomised controlled trial, of electronically delivered, multicomponent interventions to reduce unnecessary antibiotic prescribing when patients consult for RTIs in primary care. The research will specifically evaluate the effectiveness of feeding back electronic health records (EHRs) data to general practices. Methods and analysis 2-arm cluster randomised trial using the EHRs of the Clinical Practice Research Datalink (CPRD). General practices in England, Scotland, Wales and Northern Ireland are being recruited and the general population of all ages represents the target population. Control trial arm practices will continue with usual care. Practices in the intervention arm will receive complex multicomponent interventions, delivered remotely to information systems, including (1) feedback of each practice's antibiotic prescribing through monthly antibiotic prescribing reports estimated from CPRD data; (2) delivery of educational and decision support tools; (3) a webinar to explain and promote effective usage of the intervention. The intervention will continue for 12 months. Outcomes will be evaluated from CPRD EHRs. The primary outcome will be the number of antibiotic prescriptions for RTIs per 1000 patient years. Secondary outcomes will be: the RTI consultation rate; the proportion of consultations for RTI with an antibiotic prescribed; subgroups of age; different categories of RTI and quartiles of intervention usage. There will be more than 80% power to detect an absolute reduction in antibiotic prescription for RTI of 12 per 1000 registered patient years. Total healthcare usage will be estimated from CPRD data and compared between trial arms. Ethics and dissemination Trial protocol was approved by the National Research Ethics Service Committee (14/LO/1730). The pragmatic design of the trial will enable subsequent translation of effective interventions at scale in order to achieve population impact. Trial registration number ISRCTN95232781; Pre-results. PMID:27491663

An overiew of non medical prescribing across one strategic health authority: a questionnaire survey.

PubMed

Courtenay, Molly; Carey, Nicola; Stenner, Karen

2012-06-01

Over 50,000 non-medical healthcare professionals across the United Kingdom now have prescribing capabilities. However, there is no evidence available with regards to the extent to which non-medical prescribing (NMP) has been implemented within organisations across a strategic health authority (SHA). The aim of the study was to provide an overview of NMP across one SHA. NMP leads across one SHA were asked to supply the email addresses of NMPs within their organisation. One thousand five hundred and eighty five NMPs were contacted and invited to complete an on-line descriptive questionnaire survey, 883 (55.7%) participants responded. Data was collected between November 2010 and February 2011. The majority of NMPs were based in primary care and worked in a team of 2 or more. Nurse independent supplementary prescribers were the largest group (590 or 68.6%) compared to community practitioner prescribers (198 or 22.4%), pharmacist independent supplementary prescribers (35 or 4%), and allied health professionals and optometrist independent and/or supplementary prescribers (8 or 0.9%). Nearly all (over 90%) of nurse independent supplementary prescribers prescribed medicines. Approximately a third of pharmacist independent supplementary prescribers, allied health professionals, and community practitioner prescribers did not prescribe. Clinical governance procedures were largely in place, although fewer procedures were reported by community practitioner prescribers. General practice nurses prescribed the most items. Factors affecting prescribing practice were: employer, the level of experience prior to becoming a non-medical prescriber, existence of governance procedures and support for the prescribing role (p < 0.001). NMP in this strategic health authority reflects national development of this relatively new role in that the majority of non-medical prescribers were nurses based in primary care, with fewer pharmacist and allied health professional prescribers. This workforce is contributing to medicines management activities in a range of care settings. If non-medical prescibers are to maximise their contribution, robust governance and support from healthcare organisations is essential. The continued use of supplementary prescribing is questionable if maximum efficiency is sought. These are important points that need to be considered by those responsible for developing non-medical prescribing in the United Kingdom and other countries around the world.

The Use of Bloodstream Infection Mortality to Measure the Impact of Antimicrobial Stewardship Interventions: Assessing the Evidence.

PubMed

Coulter, Sonali; Roberts, Jason A; Hajkowicz, Krispin; Halton, Kate

2017-03-30

This review sets out to evaluate the current evidence on the impact of inappropriate therapy on bloodstream infections (BSI) and associated mortality. Based on the premise that better prescribing practices should result in better patient outcomes, BSI mortality may be a useful metric to evaluate antimicrobial stewardship (AMS) interventions. A systematic search was performed in key medical databases to identify papers published in English between 2005 and 2015 that examined the association between inappropriate prescribing and BSI mortality in adult patients. Only studies that included BSIs caused by ESKAPE ( Enterococcus faecium/faecalis , Staphylococcus aureus , Klebsiella pneumoniae , Acinetobacter baumannii , Pseudomonas aeruginosa and Enterobacter species ) organisms were included. Study quality was assessed using the GRADE criteria and results combined using a narrative synthesis. We included 46 studies. Inappropriate prescribing was associated with an overall increase in mortality in BSI. In BSI caused by resistant gram positive organisms, such as methicillin resistant S. aureus , inappropriate therapy resulted in up to a 3-fold increase in mortality. In BSI caused by gram negative (GN) resistant organisms a much greater impact ranging from 3 to 25 fold increase in the risk of mortality was observed. While the overall quality of the studies is limited by design and the variation in the definition of appropriate prescribing, there appears to be some evidence to suggest that inappropriate prescribing leads to increased mortality in patients due to GN BSI. The highest impact of inappropriate prescribing was seen in patients with GN BSI, which may be a useful metric to monitor the impact of AMS interventions.

The Use of Bloodstream Infection Mortality to Measure the Impact of Antimicrobial Stewardship Interventions: Assessing the Evidence

PubMed Central

Coulter, Sonali; Roberts, Jason A.; Hajkowicz, Krispin; Halton, Kate

2017-01-01

This review sets out to evaluate the current evidence on the impact of inappropriate therapy on bloodstream infections (BSI) and associated mortality. Based on the premise that better prescribing practices should result in better patient outcomes, BSI mortality may be a useful metric to evaluate antimicrobial stewardship (AMS) interventions. A systematic search was performed in key medical databases to identify papers published in English between 2005 and 2015 that examined the association between inappropriate prescribing and BSI mortality in adult patients. Only studies that included BSIs caused by ESKAPE (Enterococcus faecium/faecalis, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter species) organisms were included. Study quality was assessed using the GRADE criteria and results combined using a narrative synthesis. We included 46 studies. Inappropriate prescribing was associated with an overall increase in mortality in BSI. In BSI caused by resistant gram positive organisms, such as methicillin resistant S. aureus, inappropriate therapy resulted in up to a 3-fold increase in mortality. In BSI caused by gram negative (GN) resistant organisms a much greater impact ranging from 3 to 25 fold increase in the risk of mortality was observed. While the overall quality of the studies is limited by design and the variation in the definition of appropriate prescribing, there appears to be some evidence to suggest that inappropriate prescribing leads to increased mortality in patients due to GN BSI. The highest impact of inappropriate prescribing was seen in patients with GN BSI, which may be a useful metric to monitor the impact of AMS interventions. PMID:28458799

Physicians-in-training are not prepared to prescribe medical marijuana.

PubMed

Evanoff, Anastasia B; Quan, Tiffany; Dufault, Carolyn; Awad, Michael; Bierut, Laura Jean

2017-11-01

While medical marijuana use is legal in more than half of U.S. states, evidence is limited about the preparation of physicians-in-training to prescribe medical marijuana. We asked whether current medical school and graduate medical educational training prepare physicians to prescribe medical marijuana. We conducted a national survey of U.S. medical school curriculum deans, a similar survey of residents and fellows at Washington University in St. Louis, and a query of the Association of American Medical Colleges (AAMC) Curriculum Inventory database for keywords associated with medical marijuana. Surveys were obtained from 101 curriculum deans, and 258 residents and fellows. 145 schools were included in the curriculum search. The majority of deans (66.7%) reported that their graduates were not at all prepared to prescribe medical marijuana, and 25.0% reported that their graduates were not at all prepared to answer questions about medical marijuana. The vast majority of residents and fellows (89.5%) felt not at all prepared to prescribe medical marijuana, while 35.3% felt not at all prepared to answer questions, and 84.9% reported receiving no education in medical school or residency on medical marijuana. Finally, only 9% of medical school curriculums document in the AAMC Curriculum Inventory database content on medical marijuana. Our study highlights a fundamental mismatch between the state-level legalization of medical marijuana and the lack of preparation of physicians-in-training to prescribe it. With even more states on the cusp of legalizing medical marijuana, physician training should adapt to encompass this new reality of medical practice. Copyright © 2017 Elsevier B.V. All rights reserved.

Assessing the effectiveness and cost-effectiveness of audit and feedback on physician’s prescribing indicators: study protocol of a randomized controlled trial with economic evaluation

PubMed Central

2012-01-01

Background Physician prescribing is the most frequent medical intervention with a highest impact on healthcare costs and outcomes. Therefore improving and promoting rational drug use is a great interest. We aimed to assess the effectiveness and cost-effectiveness of two forms of conducting prescribing audit and feedback interventions and a printed educational material intervention in improving physician prescribing. Method/design A four-arm randomized trial with economic evaluation will be conducted in Tehran. Three interventions (routine feedback, revised feedback, and printed educational material) and a no intervention control arm will be compared. Physicians working in outpatient practices are randomly allocated to one of the four arms using stratified randomized sampling. The interventions are developed based on a review of literature, physician interviews, current experiences in Iran and with theoretical insights from the Theory of Planned Behavior. Effects of the interventions on improving antibiotics and corticosteroids prescribing will be assessed in regression analyses. Cost data will be assessed from a health care provider’s perspective and incremental cost-effectiveness ratios will be calculated. Discussion This study will determine the effectiveness and cost-effectiveness of three interventions and allow us to determine the most effective interventions in improving prescribing pattern. If the interventions are cost-effective, they will likely be applied nationwide. Trial registration Iranian Registry of Clinical Trials Registration Number: IRCT201106086740N1Pharmaceutical Sciences Research Center of TUMS Ethics Committee Registration Number: 90-02-27-07 PMID:23351564

A systematic review of educational interventions to change behaviour of prescribers in hospital settings, with a particular emphasis on new prescribers

PubMed Central

Brennan, Nicola; Mattick, Karen

2013-01-01

Aims Prescribing is a complex task and a high risk area of clinical practice. Poor prescribing occurs across staff grades and settings but new prescribers are attributed much of the blame. New prescribers may not be confident or even competent to prescribe and probably have different support and development needs than their more experienced colleagues. Unfortunately, little is known about what interventions are effective in this group. Previous systematic reviews have not distinguished between different grades of staff, have been narrow in scope and are now out of date. Therefore, to inform the design of educational interventions to change prescribing behaviour, particularly that of new prescibers, we conducted a systematic review of existing hospital-based interventions. Methods Embase, Medline, SIGLE, Cinahl and PsychINFO were searched for relevant studies published 1994–2010. Studies describing interventions to change the behaviour of prescribers in hospital settings were included, with an emphasis on new prescibers. The bibliographies of included papers were also searched for relevant studies. Interventions and effectiveness were classified using existing frameworks and the quality of studies was assessed using a validated instrument. Results Sixty-four studies were included in the review. Only 13% of interventions specifically targeted new prescribers. Most interventions (72%) were deemed effective in changing behaviour but no particular type stood out as most effective. Conclusion Very few studies have tailored educational interventions to meet needs of new prescribers, or distinguished between new and experienced prescribers. Educational development and research will be required to improve this important aspect of early clinical practice. PMID:22831632

Medication management policy, practice and research in Australian residential aged care: Current and future directions.

PubMed

Sluggett, Janet K; Ilomäki, Jenni; Seaman, Karla L; Corlis, Megan; Bell, J Simon

2017-02-01

Eight percent of Australians aged 65 years and over receive residential aged care each year. Residents are increasingly older, frailer and have complex care needs on entry to residential aged care. Up to 63% of Australian residents of aged care facilities take nine or more medications regularly. Together, these factors place residents at high risk of adverse drug events. This paper reviews medication-related policies, practices and research in Australian residential aged care. Complex processes underpin prescribing, supply and administration of medications in aged care facilities. A broad range of policies and resources are available to assist health professionals, aged care facilities and residents to optimise medication management. These include national guiding principles, a standardised national medication chart, clinical medication reviews and facility accreditation standards. Recent Australian interventions have improved medication use in residential aged care facilities. Generating evidence for prescribing and deprescribing that is specific to residential aged care, health workforce reform, medication-related quality indicators and inter-professional education in aged care are important steps toward optimising medication use in this setting. Copyright © 2016 Elsevier Ltd. All rights reserved.

A survey of the advertising of nine new drugs in the general practice literature.

PubMed

Jones, M; Greenfield, S; Bradley, C

1999-12-01

To undertake a survey of the advertising of new drugs in the general practice literature as part of a larger study investigating the factors which influence the introduction of new drugs into clinical practice. The advertisements for nine new drugs from a range of therapeutic groups were monitored for 30 months in 12 journals, which are received by most GPs. The amount of prescribing, in defined daily doses, of each new drug by 50 GPs, selected as regular users of a teaching hospital, was also recorded during this period. Of the journals, 798 issues were surveyed (93% of the total published). The total number of advertisements was almost 33 000, of which 2163 (6.6%) were for the study drugs. The pattern of advertising of each study drug was very complex and varied from month to month and between journals. There was no consistent pattern in the way the drugs were advertised, with large variations in the amount and timing of advertisements. The prescribing data showed wide variations in the number of GPs prescribing each drug and in the amount prescribed. There was no clear relationship between the extent of the advertising of a drug and the amount of prescribing by the GPs. This suggests that advertising in journals is only one of many factors which are important in influencing GPs to prescribe new drugs. However, the study may have been insufficiently comprehensive to capture complex relationships between advertising and prescribing.

Study of antibiotic prescribing among dental practitioners in Shiraz, Islamic Republic of Iran.

PubMed

Vessal, G; Khabiri, A; Mirkhani, H; Cookson, B D; Askarian, M

2011-10-01

Inappropriate prescribing of antibiotics by health care professionals is a worldwide concern. This study evaluated the knowledge and practices of dental practitioners in the city of Shiraz, Islamic Republic of Iran regarding their therapeutic use of antibiotics for patients with dentoalveolar infections. Of 219 (48.6%) dentists responding to the questionnaire more than 40% would prescribe antibiotics for localized fluctuant swelling and for problems for which antibiotics are not required according to good practice guidelines (acute pulpitis, chronic apical infection, periodontal abscess, chronic gingivitis, chronic periodontitis, pericoronitis and dry socket). A majority correctly prescribed antibiotics for acute periapical infection (77.2%), cellulitis (75.3%) and acute ulcerated gingivitis (63.0%). Amoxicillin was the most frequently prescribed antibiotic for all clinical conditions but there was a wide variation in dosage, frequency and duration for all antibiotics used. Guidelines on rational antibiotic use are needed for dental practitioners in the Islamic Republic of Iran.

Infant Reflux in the Primary Care Setting: A Brief Educational Intervention and Management Changes.

PubMed

Harris, Brendan Ryan; Bennett, William E

2018-07-01

There has been a significant increase in prescription of acid suppression therapy to infants despite limited support for efficacy and safety. Prior studies have shown that educational interventions can improve clinician practices. Our aim is to implement an educational module with high-yield evidence to decrease the rate of prescribing these medications. Chart review of infants seen by residents after completing module was performed. Twelve clinic sessions before and after intervention were examined. 28 residents completed the intervention and required clinics. Before implementation, 1.8% of infants seen were prescribed acid suppression with none receiving proton pump inhibitors (PPIs). After completion, 0.8% of infants were prescribed acid suppression and 1 patient received PPI. This was not a significant change. The study was unsuccessful in effecting changes in provider prescribing practices. Although, this is not the outcome expected, it is encouraging to have a low initial rate of PPI therapy prescribed patients.

An observational descriptive study of the epidemiology and treatment of neuropathic pain in a UK general population

PubMed Central

2013-01-01

Background This study updated our knowledge of UK primary care neuropathic pain incidence rates and prescribing practices. Methods Patients with a first diagnosis of post-herpetic neuralgia (PHN), painful diabetic neuropathy (PDN) or phantom limb pain (PLP) were identified from the General Practice Research Database (2006 – 2010) and incidence rates were calculated. Prescription records were searched for pain treatments from diagnosis of these conditions and the duration and daily dose estimated for first-line and subsequent treatment regimens. Recording of neuropathic back and post-operative pain was investigated. Results The study included 5,920 patients with PHN, 5,340 with PDN, and 185 with PLP. The incidence per 10,000 person-years was 3.4 (95% CI 3.4, 3.5) for PHN; and 0.11 (95% CI 0.09, 0.12) for PLP. Validation of the PDN case definition suggested that was not sensitive. Incident PHN increased over the study period. The most common first-line treatments were amitriptyline or gabapentin in the PDN and PLP cohorts, and amitriptyline or co-codamol (codeine-paracetamol) in PHN. Paracetamol, co-dydramol (paracetamol-dihydrocodeine) and capsaicin were also often prescribed in one or more condition. Most first-line treatments comprised only one therapeutic class. Use of antiepileptics licensed for neuropathic pain treatment had increased since 2002–2005. Amitriptyline was the only antidepressant prescribed commonly as a first-line treatment. Conclusion The UK incidence of diagnosed PHN has increased with the incidence of back-pain and post-operative pain unclear. While use of licenced antiepileptics increased, prescribing of therapy with little evidence of efficacy in neuropathic pain is still common and consequently treatment was often not in-line with current guidance. PMID:23442783

An observational descriptive study of the epidemiology and treatment of neuropathic pain in a UK general population.

PubMed

Hall, Gillian C; Morant, Steve V; Carroll, Dawn; Gabriel, Zahava L; McQuay, Henry J

2013-02-26

This study updated our knowledge of UK primary care neuropathic pain incidence rates and prescribing practices. Patients with a first diagnosis of post-herpetic neuralgia (PHN), painful diabetic neuropathy (PDN) or phantom limb pain (PLP) were identified from the General Practice Research Database (2006 - 2010) and incidence rates were calculated. Prescription records were searched for pain treatments from diagnosis of these conditions and the duration and daily dose estimated for first-line and subsequent treatment regimens. Recording of neuropathic back and post-operative pain was investigated. The study included 5,920 patients with PHN, 5,340 with PDN, and 185 with PLP. The incidence per 10,000 person-years was 3.4 (95% CI 3.4, 3.5) for PHN; and 0.11 (95% CI 0.09, 0.12) for PLP. Validation of the PDN case definition suggested that was not sensitive. Incident PHN increased over the study period. The most common first-line treatments were amitriptyline or gabapentin in the PDN and PLP cohorts, and amitriptyline or co-codamol (codeine-paracetamol) in PHN. Paracetamol, co-dydramol (paracetamol-dihydrocodeine) and capsaicin were also often prescribed in one or more condition. Most first-line treatments comprised only one therapeutic class. Use of antiepileptics licensed for neuropathic pain treatment had increased since 2002-2005. Amitriptyline was the only antidepressant prescribed commonly as a first-line treatment. The UK incidence of diagnosed PHN has increased with the incidence of back-pain and post-operative pain unclear. While use of licensed antiepileptics increased, prescribing of therapy with little evidence of efficacy in neuropathic pain is still common and consequently treatment was often not in-line with current guidance.

Long-term effect of a practice-based intervention (HAPPY AUDIT) aimed at reducing antibiotic prescribing in patients with respiratory tract infections.

PubMed

Llor, Carl; Bjerrum, Lars; Molero, José M; Moragas, Ana; González López-Valcárcel, Beatriz; Monedero, M José; Gómez, Manuel; Cid, Marina; Alcántara, Juan de Dios; Cots, Josep M; Ribas, Joana M; García, Guillermo; Ortega, Jesús; Pineda, Vicenta; Guerra, Gloria; Munuera, Susana

2018-04-27

Few studies have evaluated the long-term effects of educational interventions on antibiotic prescription and the results are controversial. This study was aimed at assessing the effect of a multifaceted practice-based intervention carried out 6 years earlier on current antibiotic prescription for respiratory tract infections (RTIs). The 210 general practitioners (GPs) who completed the first two registrations in 2008 and 2009 were invited to participate in a third registration. The intervention held before the second registration consisted of discussion about the first registration of results, appropriate use of antibiotics for RTIs, patient brochures, a workshop and the provision of rapid tests. As in the previous registrations, GPs were instructed to complete a template for all the patients with RTIs during 15 working days in 2015. A new group of GPs from the same areas was also invited to participate and acted as controls. A multilevel logistic regression analysis was performed considering the prescription of antibiotics as the dependent variable. A total of 121 GPs included in the 2009 intervention (57.6%) and 117 control GPs registered 22 247 RTIs. On adjustment for covariables, compared with the antibiotic prescription observed just after the intervention, GPs assigned to intervention prescribed slightly more antibiotics 6 years later albeit without statistically significant differences (OR 1.08, 95% CI 0.89-1.31, P = 0.46), while GPs in the control group prescribed significantly more antibiotics (OR 2.74, 95% CI 2.09-3.59, P < 0.001). This study shows that a single multifaceted intervention continues to reduce antibiotic prescribing 6 years later.

Nurse-led management of contraceptive services.

PubMed

Wilson, Emma

2014-07-01

This article discusses the role of the practice nurse (PN) in the provision of health assessment for contraceptive choices. PNs who have an extended role as an independent nurse prescriber must demonstrate the principles of safe prescribing practice, with appropriate and informed assessment of the patient's needs and risk within the limited time of a general practice appointment. With continued professional development, PNs are well placed to provide comprehensive, independent nurse-led contraceptive services.

Retrospective audit of antimicrobial prescribing practices for acute exacerbations of chronic obstructive pulmonary diseases in a large regional hospital.

PubMed

Brownridge, D J; Zaidi, S T R

2017-06-01

Chronic obstructive pulmonary disease (COPD) is associated with significant morbidity and mortality, and frequent exacerbations are associated with an increased risk of death, deterioration in lung function and reduced quality of life. Current Australian guidelines developed by the Lung Foundation of Australia (the COPD-X Plan) recommends the use of a short course of corticosteroids and oral antibiotics (amoxycillin or doxycycline) as part of the treatment of an AECOPD; however, it was noted that clinical practice at the study hospital had deviated from these guidelines. To evaluate the antibiotic prescribing practices in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients, and to compare the differences in clinical outcomes (primarily mean length of stay and the rate of unplanned readmissions) between patients who received broad- vs. narrow-spectrum antibiotics in a large regional hospital. Retrospective audit of medical records for patients admitted with uncomplicated AECOPD during January-September, 2014 in a 224 acute bed regional hospital in Victoria, Australia. Fifty-nine per cent of patients received broad-spectrum antibiotics (ceftriaxone), whereas only 10% of prescriptions were concordant with current Australian guideline recommendations. Patients receiving a broad-spectrum regimen were more likely to be older (74·9 vs. 69·9 years; P = 0·009), have a higher COPD severity score (i.e. BAP-65 score, 1·55 vs. 1·06; P = 0·002) and a higher CRP (59·2 vs. 25·5 mg/L; P = 0·003) on admission. The mean LOS was not significantly different between those who received ceftriaxone and those who did not (5·09 vs. 4·55 days; P = 0·47). There was no significant difference between the groups in rates of readmissions. The antibiotic prescribing patterns for AECOPD in rural and regional Australian hospitals have not previously been examined in the current literature. In the study hospital, the majority of patients received broad-spectrum antibiotics in the initial treatment of AECOPD. No differences in hospital length of stay, or rate of readmission for AECOPD were observed between those who received broad- and narrow-spectrum antibiotics. © 2017 John Wiley & Sons Ltd.

[Psychiatrists' decision making and monitoring of antipsychotic prescription for elderly schizophrenia patients].

PubMed

Jalenques, I; Ortega, V; Legrand, G; Auclair, C

2016-04-01

Advancing age entails specific treatment modalities for patients with schizophrenia. The choice of appropriate antipsychotic therapy (AP) and the monitoring of treatment is a major challenge. However, little is known about the real-world prescribing practices of psychiatrists for elderly schizophrenia patients. The aim of this study was to assess prescribing practices and treatment monitoring in elderly schizophrenia patients and whether socio-professional psychiatrists' characteristics are related to their practices. We contacted by mail 190 psychiatrists to take part in an observational survey of their AP prescribing practices for elderly (aged over 65) schizophrenia patients. The response rate was 44.2%, and of the psychiatrists who replied 75% were treating elderly schizophrenia patients. A second-generation AP (SGAP) was prescribed as first-line of treatment by 87.7% of the psychiatrists. The most frequently used SGAPs were risperidone and olanzapine (respectively preferred by 54.4% and 19.3% of the psychiatrists taking part). At the beginning of treatment, 91.1% of the psychiatrists prescribed a lower dose than for middle-aged patients. Of the psychiatrists taking part, 64.9% prescribed monotherapy; and among these psychiatrists, 65% cited insufficient control of the disease as the reason for their choice, while 48.7% of those who elected not to prescribe combined AP did so in order to limit the side-effects. Of the psychiatrists taking part, 54.4% prescribed long-acting injectable AP (LAAP); better therapeutic compliance and alliance was the main argument in the choice of LAAP given by the psychiatrists taking part who prescribed the drug, whereas the absence of indications and problems of tolerance were arguments against for those who did not. "Personal experience" emerged as the governing factor in the choice of AP. The AP side-effect profile was the main criterion of choice of the AP agent for 3.5% of the psychiatrists taking part, and the most frequently chosen secondary criterion (29.8%). Monitoring of treatment was partly performed according to professional recommendations: pre-treatment and post-prescription assessments of waist circumference and ophthalmological monitoring were very infrequent (8.8 to 18.5%) as were pre-treatment and early post-prescription assessments of prolactinaemia (14.8 to 20.4%); long-term cardiac monitoring was infrequent (43.9%). The psychiatrists taking part whose first-line drug was SGAP were more familiar with professional recommendations than those who prescribed first generation antipsychotic (FGA) drugs (72% as against 14.3%, P=0.006). Of the psychiatrists taking part in the study, 64.9% reported they commonly use professional recommendations. Psychiatrists who declared they commonly use professional recommendations measured pulse rate and blood pressure significantly more often over the long-term than those who did not (74.3% as against 41.2%, P=0.0315). They also measured waist circumference over the long-term significantly more often than psychiatrists who did not commonly use professional recommendations (22.9% as against 0%, P=0.0420). Psychiatrists treating more than ten of these patients yearly measured significantly more often over the long-term pulse rate and blood pressure than those treating fewer patients (80% as against 50%, P=0.0399). Over the long-term monitoring, psychiatrists with a larger number of elderly schizophrenia patients in their care also performed more often fasting blood glucose test, lipid profile and referral for cardiac consultation with ECG (respectively, 95.5% as against 70.8%, P=0.0489; 90.9% as against 58.3%, P=0.0182; 81.8% as against 29.2%, P<0.0001). The results of this survey need to be confirmed in a larger population sample. The antipsychotic prescribing practices were broadly in agreement with current recommendations except for the tolerance profile which was not the first element taken into account in the choice of the AP agent. Some clinical and paraclinical medical examinations were carried out infrequently, in particular cardiac monitoring over the long-term, which is essential in this elderly patient population. One important element to emerge from our results was that common use of professional recommendations is associated with better monitoring. Copyright © 2015 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.

Management of Type 2 diabetes in Ramadan: Low-ratio premix insulin working group practical advice

PubMed Central

Hassanein, Mohamed; Belhadj, Mohamed; Abdallah, Khalifa; Bhattacharya, Arpan D.; Singh, Awadhesh K.; Tayeb, Khaled; Al-Arouj, Monira; Elghweiry, Awad; Iraqi, Hinde; Nazeer, Mohamed; Jamoussi, Henda; Mnif, Mouna; Al-Madani, Abdulrazzaq; Al-Ali, Hossam; Ligthelm, Robert

2014-01-01

The challenge of insulin use during Ramadan could be minimized, if people with diabetes are metabolically stable and are provided with structured education for at least 2–3 months pre-Ramadan. Although, American diabetes association (ADA) recommendations 2010 and South Asian Consensus Guideline 2012 deal with management of diabetes in Ramadan and changes in insulin dosage, no specific guidance on widely prescribed low-ratio premix insulin is currently available. Hence, the working group for insulin therapy in Ramadan, after collective analysis, evaluation, and opinion from clinical practice, have formulated a practical advice to empower physicians with pre-Ramadan preparation, dose adjustment, and treatment algorithm for self-titration of low-ratio premix insulin. PMID:25364673

Drugs for the gynecologist to prescribe in the prevention of breast cancer: current status and future trends.

PubMed

Goldstein, S R

2000-05-01

Tamoxifen was approved for breast cancer prevention in October 1998. Thus, for the first time, we as gynecologists are being asked to prescribe this drug to healthy women. In the past each one of us has cared for women with breast cancer who have been treated with tamoxifen by oncologists or breast surgeons for the malignancy. Effects of tamoxifen on the uterus resulting in carcinomas, hyperplasia, and polyps are well known. Furthermore, tamoxifen has estrogenic properties in the venous system, increasing the incidence of deep vein thrombosis and pulmonary emboli. A new SERM (selective estrogen receptor modulator), raloxifene, has been approved for prevention and treatment of osteoporosis in postmenopausal women. It does not have stimulatory effects on the endometrium; however, it is estrogenic in the venous system. Preclinical data, as well as the breast cancer incidence reported in studies of the skeleton, seem to indicate that its effects in the breast are similar to those of tamoxifen. This article reviews tamoxifen and the new SERM, raloxifene, in an attempt to help gynecologists better understand each compound and what data are currently known, what we hope to learn from future studies, and what currently makes sense for clinical practice.

[Temporary recommendation for use on off-label baclofen: viewpoint of Prescribers of the CAMTEA system].

PubMed

Rolland, Benjamin; Deheul, Sylvie; Danel, Thierry; Bence, Camille; Blanquart, Marie-Christine; Bonord, Alexandre; Semal, Robin; Briand, Thierry; Sochala, Michel; Dubocage, Christelle; Dupriez, François; Duquesne, Damien; Gibour, Bernard; Loosfeld, Xavier; Henebelle, Dorothée; Henon, Michael; Vernalde, Elodie; Matton, Christian; Bacquet, Jean-Eudes; Molmy, Lucie; Sarasy, François; Simioni, Nicolas; Richez, Cécile; Gentil-Spinosi, Laure; Vosgien, Véronique; Yguel, Jacques; Ledent, Thierry; Auffret, Marine; Wilquin, Maroussia; Ziolkowski, Danièle; Sochala, Michel; Gautier, Sophie; Bordet, Régis; Cottencin, Olivier

2015-01-01

The use of high dose baclofen for alcohol-dependence emerged in France from 2008 based on empirical findings, and is still off-label. However, due to the rapid increase in this prescribing practice, the French health authorities have decided to frame it using an extraordinary regulatory measure named "temporary recommendation for use" (TRU). Baclofen prescribers from CAMTEA, a regional team-based off-label system for supervising baclofen prescribing, which was developed much prior to the TRU, discuss herein the pros and cons of this measure and the applicability of its different aspects in the daily clinical practice. © 2014 Société Française de Pharmacologie et de Thérapeutique.

Characteristics of methadone maintenance treatment patients prescribed opioid analgesics.

PubMed

Glenn, Matthew C; Sohler, Nancy L; Starrels, Joanna L; Maradiaga, Jeronimo; Jost, John J; Arnsten, Julia H; Cunningham, Chinazo O

2016-01-01

Opioid analgesic use and disorders have dramatically increased among the general American population and those receiving methadone maintenance treatment (MMT). Most research among MMT patients focuses on opioid analgesics misuse or disorders; few studies focus on MMT patients prescribed opioid analgesics. We describe demographic, clinical, and substance use characteristics of MMT patients prescribed opioid analgesics and compare them with MMT patients not prescribed opioid analgesics. We conducted a cross-sectional secondary data analysis using screening interviews from a parent study. From 2012 to 2015, we recruited adults from 3 MMT Bronx clinics. Questionnaire data included patterns of opioid analgesic use, substance use, comorbid illnesses, and demographic characteristics. Our main dependent variable was patients' report of currently taking prescribed opioid analgesics. To compare characteristics between MMT patients prescribed and not prescribed opioid analgesics, we conducted chi-square tests, t tests, and Mann-Whitney U tests. Of 611 MMT patients, most reported chronic pain (62.0%), hepatitis C virus (HCV) infection (52.1%), and current use of illicit substances (64.2%). Of the 29.8% who reported currently taking prescribed opioid analgesics, most misused their opioid analgesics (57.5%). Patients prescribed (versus not prescribed) opioid analgesics were more likely to report human immunodeficiency virus (HIV) infection (adjusted odds ratio [aOR] = 1.6, 95% confidence interval [CI]: 1.1-2.3) and chronic pain (aOR = 7.6, 95% CI: 4.6-12.6). Among MMT patients primarily in 3 Bronx clinics, nearly one third reported taking prescribed opioid analgesics. Compared with patients not prescribed opioid analgesics, those prescribed opioid analgesics were more likely to report chronic pain and HIV infection. However, between these patients, there was no difference in illicit substance use. These findings highlight the complexity of addressing chronic pain in MMT patients.

Characteristics of methadone maintenance treatment patients prescribed opioid analgesics

PubMed Central

Glenn, Matthew C.; Sohler, Nancy L.; Starrels, Joanna L.; Maradiaga, Jeronimo; Jost, John J.; Arnsten, Julia H.; Cunningham, Chinazo O.

2016-01-01

Background Opioid analgesic use and disorders have dramatically increased among the general American population and those receiving methadone maintenance treatment (MMT). Most research among MMT patients focuses on opioid analgesics misuse or disorders; few studies focus on MMT patients prescribed opioid analgesics. We describe demographic, clinical, and substance use characteristics of MMT patients prescribed opioid analgesics and compare them to MMT patients not prescribed opioid analgesics. Methods We conducted a cross-sectional secondary data analysis using screening interviews from a parent study. From 2012–2015, we recruited adults from 3 MMT Bronx clinics. Questionnaire data included: patterns of opioid analgesic use, substance use, comorbid illnesses, and demographic characteristics. Our main dependent variable was patients’ report of currently taking prescribed opioid analgesics. To compare characteristics between MMT patients prescribed and not prescribed opioid analgesics, we conducted chi-squared tests, t-tests, and Mann-Whitney U tests. Results Of 611 MMT patients, most reported chronic pain (62.0%), HCV infection (52.1%), and currently using illicit substances (64.2%). Of the 29.8% who reported currently taking prescribed opioid analgesics, most misused their opioid analgesics (57.5%). Patients prescribed (versus not prescribed) opioid analgesics were more likely to report HIV infection (aOR=1.6, 95% CI: 1.1–2.3) and chronic pain (aOR=7.6, 95% CI: 4.6–12.6). Conclusion Among MMT patients primarily in three Bronx clinics, nearly one-third reported taking prescribed opioid analgesics. Compared to patients not prescribed opioid analgesics, those prescribed opioid analgesics were more likely to report chronic pain and HIV infection. However, between these patients, there was no difference in illicit substance use. These findings highlight the complexity of addressing chronic pain in MMT patients. PMID:26731299

Effects of an e-Prescribing interface redesign on rates of generic drug prescribing: exploiting default options.

PubMed

Malhotra, Sameer; Cheriff, Adam D; Gossey, J Travis; Cole, Curtis L; Kaushal, Rainu; Ancker, Jessica S

2016-09-01

Increasing the use of generic medications could help control medical costs. However, educational interventions have limited impact on prescriber behavior, and e-prescribing alerts are associated with high override rates and alert fatigue. Our objective was to evaluate the effect of a less intrusive intervention, a redesign of an e-prescribing interface that provides default options intended to "nudge" prescribers towards prescribing generic drugs. This retrospective cohort study in an academic ambulatory multispecialty practice assessed the effects of customizing an e-prescribing interface to substitute generic equivalents for brand-name medications during order entry and allow a one-click override to order the brand-name medication. Among drugs with generic equivalents, the proportion of generic drugs prescribed more than doubled after the interface redesign, rising abruptly from 39.7% to 95.9% (a 56.2% increase; 95% confidence interval, 56.0-56.4%; P < .001). Before the redesign, generic drug prescribing rates varied by therapeutic class, with rates as low as 8.6% for genitourinary products and 15.7% for neuromuscular drugs. After the redesign, generic drug prescribing rates for all but four therapeutic classes were above 90%: endocrine drugs, neuromuscular drugs, nutritional products, and miscellaneous products. Changing the default option in an e-prescribing interface in an ambulatory care setting was followed by large and sustained increases in the proportion of generic drugs prescribed at the practice. Default options in health information technology exert a powerful effect on user behavior, an effect that can be leveraged to optimize decision making. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Nurse prescribing for inpatient pain in the United Kingdom: a national questionnaire survey.

PubMed

Stenner, Karen L; Courtenay, Molly; Cannons, Karin

2011-07-01

Nurses make a valuable contribution to pain services and have the potential to improve the safety and effectiveness of pain management. A recent addition to the role of the specialist pain nurse in the United Kingdom has been the introduction of prescribing rights, however there is a lack of literature about their role in prescribing pain medication. The aim of this study was to develop a profile of the experience, role and prescribing practice of these nurses. A descriptive questionnaire survey. 192 National Health Service public hospital inpatient pain services across the United Kingdom. 161 qualified nurse prescribers were invited to participate, representing 98% of known nurse prescribers contributing to inpatient pain services. The survey was completed in November 2009 by 137 nurses; a response rate of 85%. Compared with nurse prescribers in the United Kingdom in general, participants were highly qualified and experienced pain specialists. Fifty-six percent had qualified as a prescriber in the past 3 years and 22% reported that plans were underway for more nurses to undertake a nurse prescribing qualification. Although all participants worked in inpatient pain services, 35% also covered chronic pain (outpatient) services and 90% treated more than one pain type. A range of pain medications were prescribed, averaging 19.5 items per week. The role contained a strong educational component and contributed to informing organisational policy on pain management. Prescribing was said to improve nurses' ability to promote evidence-based practice but benefits were limited by legislation on prescribing controlled drugs. Findings demonstrate that pain nurses are increasingly adopting prescribing as part of their advanced nurse role. This has implications for the development needs of pain nurses in the United Kingdom and the future role development of nurses in other countries. Copyright © 2011 Elsevier Ltd. All rights reserved.

Modifying physician behavior to improve cost-efficiency in safety-net ambulatory settings.

PubMed

Borkowski, Nancy; Gumus, Gulcin; Deckard, Gloria J

2013-01-01

Change interventions in one form or another are viewed as important tools to reduce variation in medical services, reduce costs, and improve quality of care. With the current focus on efficient resource use, the successful design and implementation of change strategies are of utmost importance for health care managers. We present a case study in which macro and micro level change strategies were used to modify primary care physicians' practice patterns of prescribing diagnostic services in a safety-net's ambulatory clinics. The findings suggest that health care managers using evidence-based strategies can create a practice environment that reduces barriers and facilitates change.

An Analysis of 34,218 Pediatric Outpatient Controlled Substance Prescriptions.

PubMed

George, Jessica A; Park, Paul S; Hunsberger, Joanne; Shay, Joanne E; Lehmann, Christoph U; White, Elizabeth D; Lee, Benjamin H; Yaster, Myron

2016-03-01

Prescription errors are among the most common types of iatrogenic errors. Because of a previously reported 82% error rate in handwritten discharge narcotic prescriptions, we developed a computerized, web-based, controlled substance prescription writer that includes weight-based dosing logic and alerts to reduce the error rate to (virtually) zero. Over the past 7 years, >34,000 prescriptions have been created by hospital providers using this platform. We sought to determine the ongoing efficacy of the program in prescription error reduction and the patterns with which providers prescribe controlled substances for children and young adults (ages 0-21 years) at hospital discharge. We examined a database of 34,218 controlled substance discharge prescriptions written by our institutional providers from January 1, 2007 to February 14, 2014, for demographic information, including age and weight, type of medication prescribed based on patient age, formulation of dispensed medication, and amount of drug to be dispensed at hospital discharge. In addition, we randomly regenerated 2% (700) of prescriptions based on stored data and analyzed them for errors using previously established error criteria. Weights that were manually entered into the prescription writer by the prescriber were compared with the patient's weight in the hospital's electronic medical record. Patients in the database averaged 9 ± 6.1 (range, 0-21) years of age and 36.7 ± 24.9 (1-195) kg. Regardless of age, the most commonly prescribed opioid was oxycodone (73%), which was prescribed as a single agent uncombined with acetaminophen. Codeine was prescribed to 7% of patients and always in a formulation containing acetaminophen. Liquid formulations were prescribed to 98% of children <6 years of age and to 16% of children >12 years of age (the remaining 84% received tablet formulations). Regardless of opioid prescribed, the amount of liquid dispensed averaged 106 ± 125 (range, 2-3240) mL, and the number of tablets dispensed averaged 51 ± 51 (range, 1-1080). Of the subset of 700 regenerated prescriptions, all were legible (drug, amount dispensed, dose, patient demographics, and provider name) and used best prescribing practice (e.g., no trailing zero after a decimal point, leading zero for doses <1). Twenty-five of the 700 (3.6%) had incorrectly entered weights compared with the most recent weight in the chart. Of these, 14 varied by 10% or less and only 2 varied by >15%. Of these, 1 resulted in underdosing (true weight 80 kg prescribed for a weight of 50 kg) and the other in overdosing (true weight 10 kg prescribed for a weight of 30 kg). A computerized prescription writer eliminated most but not all the errors common to handwritten prescriptions. Oxycodone has supplanted codeine as the most commonly prescribed oral opioid in current pediatric pain practice and, independent of formulation, is dispensed in large quantities. This study underscores the need for liquid opioid formulations in the pediatric population and, because of their abuse potential, the urgent need to determine how much of the prescribed medication is actually used by patients.

Filgrastim use in patients receiving chemotherapy for early-stage breast cancer-a survey of physicians and patients.

PubMed

Hilton, John; Vandermeer, Lisa; Sienkiewicz, Marta; Mazzarello, Sasha; Hutton, Brian; Stober, Carol; Fergusson, Dean; Blanchette, Phillip; Joy, Anil A; Brianne Bota, A; Clemons, Mark

2018-07-01

Despite its widespread use as primary febrile neutropenia (FN) prophylaxis during chemotherapy for early-stage breast cancer, the optimal duration of daily filgrastim is unknown. Using the minimum effective duration may improve patient comfort and acceptability while reducing costs. Yet, suboptimal dosing may also negatively impact patient care. A survey was performed to obtain information regarding current practices for granulocyte colony-stimulating factor (G-CSF) use. Canadian oncologists involved in the treatment of breast cancer patients, as well as patients who had received neo/adjuvant chemotherapy for breast cancer, were surveyed. Standardized surveys were designed to collect information on perceived reasons for G-CSF use and current practices. The surveys were completed by 38/50 (76%) physicians and 95/97 (98%) patients. For physicians, there was variability in the choice of chemotherapy regimens that required G-CSF support, the dose of filgrastim prescribed and the number of days prescribed. The majority of physicians reported using 5 (31.6%), 7 (47.4%), or 10 (13.2%) days of therapy. Nearly half of the patients (46.3%) recalled having experienced at least one of the chemotherapy-related complications including chemotherapy delays, dose reductions, and FN. While on filgrastim, 66.3% of patients reported myalgia and bone pain. Both physicians and patients expressed interest in participating in clinical trials designed to optimize the duration of filgrastim administration. Significant variability in practice exists with respect to filgrastim administration. Definitive studies are therefore required to standardize and improve care, as this has the potential to impact treatment outcomes, patient quality of life, and cost savings.

Surgeon preferences regarding antibiotic prophylaxis for ballistic fractures.

PubMed

Marecek, Geoffrey S; Earhart, Jeffrey S; Gardner, Michael J; Davis, Jason; Merk, Bradley R

2016-06-01

Scant evidence exists to support antibiotic use for low velocity ballistic fractures (LVBF). We therefore sought to define current practice patterns. We hypothesized that most surgeons prescribe antibiotics for LVBF, prescribing is not driven by institutional protocols, and that decisions are based on protocols utilized for blunt trauma. A web-based questionnaire was emailed to the membership of the Orthopaedic Trauma Association (OTA). The questionnaire included demographic information and questions about LVBF treatment practices. Two hundred and twenty surgeons responded. One hundred and fifty-four (70 %) respondents worked at a Level-1 trauma center, 176 (80 %) had received fellowship education in orthopaedic trauma and 104 (47 %) treated at least 10 ballistic fractures annually. Responses were analyzed with SAS 9.3 for Windows (SAS Institute Inc, Cary, NC). One hundred eighty-six respondents (86 %) routinely provide antibiotics for LVBF. Those who did not were more apt to do so for intra-articular fractures (8/16, 50 %) and pelvic fractures with visceral injury (10/16, 63 %). Most surgeons (167, 76 %) do not believe the Gustilo-Anderson classification applies to ballistic fractures, and (20/29, 70 %) do not base their antibiotic choice on the classification system. Few institutions (58, 26 %) have protocols guiding antibiotic use for LVBF. Routine antibiotic use for LVBF is common; however, practice is not dictated by institutional protocol. Although antibiotic use generally follows current blunt trauma guidelines, surgeons do not base their treatment decisions the Gustilo-Anderson classification. Given the high rate of antibiotic use for LVBF, further study should focus on providing evidence-based treatment guidelines.

Current Management of Patients With Diverticulosis and Diverticular Disease: A Survey From the 2nd International Symposium on Diverticular Disease.

PubMed

Tursi, Antonio; Picchio, Marcello; Elisei, Walter; Di Mario, Francesco; Scarpignato, Carmelo; Brandimarte, Giovanni

2016-10-01

Management of diverticular disease (DD) remains a point of debate. To investigate the current opinion of participants of the 2nd International Symposium on Diverticular Disease, on real-life management of patients with DD of the colon. Twelve questions were aimed at the diagnosis, treatment, and management options for diverticulosis and symptomatic DD. In total, 115 surveys from 8 European Countries were filled out. High fiber diet was widely prescribed in diverticulosis (59.1%). Probiotics (25%) were the most frequent prescribed drug, whereas 29.8% of participants did not prescribe any treatment in diverticulosis. Colonoscopy was frequently prescribed in symptomatic patients (69.3%), whereas 72.9% of participants did not prescribe any instrumental tool in their follow-up. Rifaximin, probiotics, and mesalazine were the most frequent prescribed drugs both in symptomatic patients (28.1, 14.9%, and 11.4%, respectively) and to prevent recurrence of the disease (42.5%, 12.4%, and 28.2%, respectively). With respect to laboratory exams, 57.9% of participants prescribed them during follow-up. The majority of participants (64.9%) managed suspected acute diverticulitis at home. Rifaximin, probiotics, and mesalazine were the most frequent prescribed drugs to prevent recurrence of the disease (32.2%, 13.2%, and 11.4%, respectively), whereas 25.4% of participants did not prescribe any drugs. Finally, no differences were found among gastroenterologists, surgeons, and general practitioners in managing this disease. This surveys shows that current management of DD is similar between different medical specialities, generally in line with current literature.

Dental Students' Knowledge and Attitudes towards Antibiotic Prescribing Guidelines in Riyadh, Saudi Arabia.

PubMed

AboAlSamh, Abdulrahman; Alhussain, Abdulmalik; Alanazi, Nawaf; Alahmari, Rakan; Shaheen, Naila; Adlan, Abdallah

2018-05-07

Background: The use of antibiotics prophylactically and therapeutically in dentistry has become common practice. Inappropriate prescription may lead to adverse side effects and bacterial resistance. During clinical training, dental students in Saudi Arabia are authorized to prescribe antibiotics. Aim: To evaluate dental students’ knowledge and attitudes regarding antibiotic prescription in Riyadh, Saudi Arabia. Methods: A cross-sectional study based on a validated questionnaire consisting of 34 questions focusing on antibiotic indications in dentistry, antibiotic regimens, and knowledge regarding resistance was distributed amongst dental students in five leading dental colleges in Riyadh. Results: A large proportion of students (71.7%) were familiar with the concept of antibiotic resistance. When comparing junior and senior dental students’ knowledge with regards to indications of antibiotic use in commonly encountered conditions, it was found that there was no significant difference in antibiotic prescription frequency between these groups. Most dental students choose to prescribe amoxicillin as their first-choice of antibiotic (88.4%), and most also chose to use it for a duration of 3⁻5 days (69.2%). Conclusions: This study concludes that dental students may prescribe antibiotics inappropriately to manage various conditions when not indicated. This may indicate a defect in education of students with regards to current antibiotic guidelines.

Perceived Impacts of the Affordable Care Act: Perspectives of Buprenorphine Prescribers

PubMed Central

Knudsen, Hannah K.; Studts, Jamie L.

2017-01-01

The Affordable Care Act (ACA) has been heralded as a major policy change that is expected to transform the delivery of substance use disorder (SUD) treatment. Few studies have reported on the perceived impacts of ACA from the perspectives of SUD treatment providers, such as physicians who prescribe buprenorphine to patients with opioid use disorder. The present study describes buprenorphine prescribers’ perceptions regarding impacts of the ACA on the delivery of buprenorphine and examines whether state-level approaches to implementing ACA are associated with its perceived impacts. Data are drawn from a national sample of current buprenorphine prescribers (n=1,174) who were surveyed by mail. On average, buprenorphine prescribers reported ambivalence regarding the impacts of the ACA, as indicated by a mean of 2.75 (SD=0.69) on a scale that ranged from 1 (“strongly disagree”) to 5 (“strongly agree”). A multi-level mixed effects regression model indicated that physicians practicing in states that were supportive of ACA, as indicated by adopting both the Medicaid expansion and implementing a state-based health insurance exchange, had more positive perceptions of the ACA than physicians in states that had declined both of these policies. This study suggests that state approaches to ACA may be associated with varied impacts. PMID:28296579

High rate of systemic corticosteroid prescription among outpatient visits for psoriasis: A population-based epidemiological study using the Korean National Health Insurance database.

PubMed

Eun, Sang Jun; Jang, Sihyeok; Lee, Jin Yong; Do, Young Kyung; Jo, Seong Jin

2017-09-01

The use of systemic corticosteroids (SC) for the treatment of psoriasis is not recommended according to textbooks and guidelines. In clinical practise, however, many physicians frequently prescribe SC for patients with psoriasis. To determine the magnitude of SC prescription for outpatients with psoriasis in Korea and identify factors associated with the use of SC, we used the 2010-2014 nationwide claims data of the Health Insurance Review and Assessment Service of Korea. In frequency analysis for the full scale of prescribed SC, oral methylprednisolone was the most frequently prescribed SC, followed by dexamethasone and betamethasone injections. The prescription rate of SC was 26.4% in outpatient visit episodes for psoriasis. The prescription rate of SC was higher in older patients, Medical Aid recipients, patients who visited office-based physician practices and hospitals, and patients living in non-metropolitan areas. In multiple logistic regression analyses, the older age group and smaller health-care institutions were more associated with the SC prescription. In conclusion, SC were widely prescribed for patients with psoriasis in Korea despite the current guidelines. Both patients' individual and institutional characteristics were associated with the SC prescription. © 2017 Japanese Dermatological Association.

Has publication of the results of the ORACLE Children Study changed practice in the UK?

PubMed

Kenyon, S; Pike, K; Jones, D; Brocklehurst, P; Marlow, N; Salt, A; Taylor, D

2010-10-01

  To investigate whether publication of the results of the ORACLE Children's Study, a 7-year follow-up of the ORACLE trial, changed practice with regard to the routine prescription of antibiotics to women with preterm rupture of membranes or spontaneous preterm labour (intact membranes).   A comparative questionnaire survey of clinical practice in November 2007 (before publication) and March 2009 (after publication).   Lead obstetricians for labour wards of all maternity units in the UK.   Self-administered questionnaires requested information about the routine prescription of antibiotics to women with either preterm rupture of membranes or spontaneous preterm labour (intact membranes).   Change in practice for prescription of antibiotics.   The response rate was 166/214 (78%) in 2007 and 158/209 (76%) in 2009. In total, 120 maternity units responded on both occasions. For women with preterm rupture of membranes, 162/214 (98%) in 2007 and 151/158 (96%) in 2009 maternity units reported that they prescribed antibiotics, with the majority using erythromycin (98%). For women with spontaneous preterm labour (intact membranes), 35/166 (21%) in 2007 and 25/158 (16%) in 2009 maternity units reported that they routinely prescribed antibiotics. The findings from units who responded on both occasions are similar.   There has been little change in the reported prescription of antibiotics to women with either preterm rupture of membranes or spontaneous preterm labour following publication of the ORACLE Children's Study. This suggests that current practice may require updated guidance.

Forest management in the Blue Mountains: public perspectives on prescribed fire and mechanical thinning

Treesearch

Bruce Shindler; Michelle Reed

1996-01-01

Insect and disease epidemics have created unhealthy and overstocked conditions in national forests of the Blue Mountains. Two of the most important management tools for reducing fuel loads and restoring forest health are prescribed fire and mechanical thinning practices. Accurate information about public support for these practices is essential for implementing...

Undertaking clinical audit, with reference to a Prescribing Observatory for Mental Health audit of lithium monitoring.

PubMed

Paton, Carol; Barnes, Thomas R E

2014-06-01

Audit is an important tool for quality improvement. The collection of data on clinical performance against evidence-based and clinically relevant standards, which are considered by clinicians to be realistic in routine practice, can usefully prompt reflective practice and the implementation of change. Evidence of participation in clinical audit is required to achieve intended learning outcomes for trainees in psychiatry and revalidation for those who are members of the Royal College of Psychiatrists. This article addresses some of the practical steps involved in conducting an audit project, and, to illustrate key points, draws on lessons learnt from a national, audit-based, quality improvement programme of lithium prescribing and monitoring conducted through the Prescribing Observatory for Mental Health.

Optimizing medicines management: From compliance to concordance

PubMed Central

Cushing, Annie; Metcalfe, Richard

2007-01-01

Medication prescribed but not consumed represents a huge loss in drug and prescribing costs and an enormous waste of expensive medical time. In this article we discuss what is known about compliance and adherence, explore the concept of concordance and demonstrate its fundamental difference from both. Not all patients are ready or suitable for shared decision making in management of their condition, some still preferring a doctor-led decision but an increasing number want a partnership approach. By opening up and rebalancing the discussion about medication, we can expect a consultation which is more satisfying for both parties and flowing from this, more effective, focused prescribing of medication which is more likely to be adhered to by the patient. We examine the extent to which doctor and patient behaviors are currently compatible with this change of concept and practice, look at available consultation models which might be useful to the reflective practitioner and consider what actions on the part of the doctor and the healthcare system could promote medicine prescription and utilization in line with this new approach based on partnership. PMID:18516274

Multilevel analysis of the influence of patients' and general practitioners' characteristics on patented versus multiple-sourced statin prescribing in France.

PubMed

Pichetti, Sylvain; Sermet, Catherine; Godman, Brian; Campbell, Stephen M; Gustafsson, Lars L

2013-06-01

The French National Health Insurance and the Ministry of Health have introduced multiple reforms in recent years to increase prescribing efficiency. These include guidelines, academic detailing, financial incentives for the prescribing and dispensing of generics drugs as well as a voluntary pay-for-performance programme. However, the quality and efficiency of prescribing could be enhanced potentially if there was better understanding of the dynamics of prescribing behaviour in France. To analyse the patient and general practitioner characteristics that influence patented versus multiple-sourced statin prescribing in France. Statistical analysis was performed on the statin prescribing habits from 341 general practitioners (GPs) that were included in the IMS-Health Permanent Survey on Medical Prescription in France, which was conducted between 2009 and 2010 and involved 14,360 patients. Patient characteristics included their age and gender as well as five medical profiles that were constructed from the diagnoses obtained during consultations. These were (1) disorders of lipoprotein metabolism, (2) heart disease, (3) diabetes, (4) complex profiles and (5) profiles based on other diagnoses. Physician characteristics included their age, gender, solo or group practice, weekly workload and payment scheme. Patient age had a statistically significant impact on statin prescribing for patients in profile 1 (disorders of lipoprotein metabolism) and profile 3 (complex profiles) with a greater number of patented statins being prescribed for the youngest patients. For instance, patients older than 76 years with a complex profile were prescribed fewer patented statins than patients aged 68-76 years old with the same medical profile (coefficient: -0.225; p = 0.0008). By contrast, regardless of the patient's age, the medical profile did not affect the probability of prescribing a patented statin except in young patients with heart diseases who were prescribed a greater number of patented statins (coefficient: 0.3992; p = 0.0007). Prescribing was also statistically influenced by physician features, e.g., older male physicians were more likely to prescribe patented statins (coefficient: 0.245; p = 0.0417) and GPs practicing in groups were more likely to prescribe multiple sourced statins (coefficient: -0.178; p = 0.0338), which is an important finding of the study. GPs with a lower workload prescribed a greater number of patented statins. There is significant variability in the prescribing of different statins among patient and physician profiles as well as between solo and group practices. Consequently, there are opportunities to target demand-side measures to enhance the prescribing of multiple-sourced statins. Further studies are warranted, in particular in other therapeutic classes, to provide a counter-balance to the considerable marketing activities of pharmaceutical companies.

Does educational intervention improve doctors’ knowledge and perceptions of generic medicines and their generic prescribing rate? A study from Malaysia

PubMed Central

Wong, Zhi Yen; Alrasheedy, Alian A.; Saleem, Fahad; Mohamad Yahaya, Abdul Haniff; Aljadhey, Hisham

2014-01-01

Objectives: To investigate the impact of an educational intervention on doctors’ knowledge and perceptions towards generic medicines and their generic (international non-proprietary name) prescribing practice. Methods: This is a single-cohort pre-/post-intervention pilot study. The study was conducted in a tertiary care hospital in Perak, Malaysia. All doctors from the internal medicine department were invited to participate in the educational intervention. The intervention consisted of an interactive lecture, an educational booklet and a drug list. Doctors’ knowledge and perceptions were assessed by using a validated questionnaire, while the international non-proprietary name prescribing practice was assessed by screening the prescription before and after the intervention. Results: The intervention was effective in improving doctors’ knowledge towards bioequivalence, similarity of generic medicines and safety standards required for generic medicine registration (p = 0.034, p = 0.034 and p = 0.022, respectively). In terms of perceptions towards generic medicines, no significant changes were noted (p > 0.05). Similarly, no impact on international non-proprietary name prescribing practice was observed after the intervention (p > 0.05). Conclusion: Doctors had inadequate knowledge and misconceptions about generic medicines before the intervention. Moreover, international non-proprietary name prescribing was not a common practice. However, the educational intervention was only effective in improving doctors’ knowledge of generic medicines. PMID:26770747

Overprescription of postoperative narcotics: a look at postoperative pain medication delivery, consumption and disposal in urological practice.

PubMed

Bates, Cory; Laciak, Robert; Southwick, Andrew; Bishoff, Jay

2011-02-01

Prescription narcotic abuse is a significant social problem. Surplus medication following surgery is 1 source of prescription diversion. We assessed prescribing practices, consumption and disposal of prescribed narcotics after urological surgery. Surveys were administered to a 3-month consecutive sample of adult patients who underwent surgery performed by full and adjunct University of Utah Urology faculty. Surveys were performed 2 to 4 weeks postoperatively. With the exception of the investigators, prescribing physicians had no prior knowledge of the study. Data collected included perception of pain control, type and quantity of medication prescribed, quantity of leftover medication, refills needed, disposal instructions and surplus medication disposition. Overall 47% of 586 patients participated in the study. Hydrocodone was prescribed most commonly (63%), followed by oxycodone (35%), and 86% of the patients were satisfied with pain control. Of the dispensed narcotics 58% was consumed and 12% of patients requested refills. A total of 67% of patients had surplus medication from the initial prescription and 92% received no disposal instructions for surplus medication. Of those patients with leftover medication 91% kept the medication at home while 6% threw it in the trash, 2% flushed it down the toilet and less than 1% returned it to a pharmacy. Overprescription of narcotics is common and retained surplus medication presents a readily available source of opioid diversion. It appears that no entity on the prescribing or dispensing ends of prescription opioid delivery is fulfilling the responsibility to accurately educate patients on proper surplus medication disposal. Surgeons should analyze prescribing practices and consider decreasing the quantity of postoperative narcotics prescribed. Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

An evaluation of knowledge, attitude, and practice of adverse drug reaction reporting among prescribers at a tertiary care hospital.

PubMed

Desai, Chetna K; Iyer, Geetha; Panchal, Jigar; Shah, Samidh; Dikshit, R K

2011-10-01

Spontaneous reporting is an important tool in pharmacovigilance. However, its success depends on cooperative and motivated prescribers. Under-reporting of adverse drug reactions (ADRs) by prescribers is a common problem. The present study was undertaken to evaluate the knowledge, attitude, and practices (KAP) regarding ADR reporting among prescribers at the Civil Hospital, Ahmedabad, to get an insight into the causes of under-reporting of ADRs. A pretested KAP questionnaire comprising of 15 questions (knowledge 6, attitude 5, and practice 4) was administered to 436 prescribers. The questionnaires were assessed for their completeness (maximum score 20) and the type of responses regarding ADR reporting. Microsoft Excel worksheet (Microsoft Office 2007) and Chi-Square test were used for statistical analysis. A total of 260 (61%) prescribers completed the questionnaire (mean score of completion 18.04). The response rate of resident doctors (70.7%) was better than consultants (34.5%) (P < 0.001). ADR reporting was considered important by 97.3% of the respondents; primarily for improving patient safety (28.8%) and identifying new ADRs (24.6%). A majority of the respondents opined that they would like to report serious ADRs (56%). However, only 15% of the prescribers had reported ADRs previously. The reasons cited for this were lack of information on where (70%) and how (68%) to report and the lack of access to reporting forms (49.2%). Preferred methods for reporting were e-mail (56%) and personal communication (42%). The prescribers are aware of the ADRs and the importance of their reporting. However, under reporting and lack of knowledge about the reporting system are clearly evident. Creating awareness about ADR reporting and devising means to make it easy and convenient may aid in improving spontaneous reporting.

The social act of electronic medication prescribing.

PubMed

Aarts, Jos

2013-01-01

Prescribing medication is embedded in social norms and cultures. In modern Western health care professionals and policy makers have attempted to rationalize medicine by addressing cost-effectiveness of diagnostic and therapeutic treatments and the development of guidelines and protocols based on the outcomes of clinical studies. These notions of cost-effectiveness and evidence-based medicine have also been embedded in technology such as electronic prescribing systems. Such constraining systems may clash with the reality of clinical practice, where formal boundaries of responsibility and authorization are often blurred. Such systems may therefore even impede patient care. Medication is seen as the essence of medical practice. Prescribing is a social act. In a hospital medications may be aimed at treating a patient for a specific condition, in primary care the professional often meets the patient with her or his social and cultural notions of a health problem. The author argues that the design and implementation of electronic prescribing systems should address the social and cultural context of prescribing. Especially in primary care, where health problems are often ill defined and evidence-based medicine guidelines do not always work as intended, studies need to take into account the sociotechnical character of electronic prescribing systems.

Beneficial "halo effects" of surgical resident performance feedback.

PubMed

Lau, Brandyn D; Streiff, Michael B; Hobson, Deborah B; Kraus, Peggy S; Shaffer, Dauryne L; Popoola, Victor O; Farrow, Norma E; Efron, David T; Haut, Elliott R

2016-09-01

Venous thromboembolism (VTE) prevention is one of the most frequent measures of quality in hospital settings. In 2013, we began providing individualized feedback to general surgery residents about their VTE prophylaxis prescribing habits for general surgical patients. The purpose of this study was to investigate the indirect, or "halo effects" of providing individualized performance feedback to residents regarding prescription of appropriate VTE prophylaxis. This retrospective cohort study compared appropriate VTE prophylaxis prescription for all patients admitted to the adult trauma service from July 1, 2012 to May 31, 2015 at The Johns Hopkins Hospital, an academic hospital and Level 1 trauma center in Baltimore, Maryland. On October 1, 2013, we began providing monthly performance feedback to general surgery residents regarding their VTE prophylaxis prescribing habits for general surgery patients. Data were not provided about their prescription practice for trauma patients, or to any other prescribers within the hospital. During the study period, 931 adult trauma patients were admitted to the adult trauma service. After providing individualized feedback about general surgery patients, general surgery residents' prescribing practice for writing appropriate VTE prophylaxis orders for adult trauma patients significantly improved (93.9% versus 78.1%, P < 0.001). Prescription practice significantly improved among all other prescribers although they did not receive any specific individualized feedback, (84.9% versus 75.1%, P = 0.025); however, practice was significantly better among general surgery residents versus other providers (93.9% versus 84.9%, P = 0.003). There is a beneficial "halo effect" for patients treated by residents receiving individualized feedback about practice habits. Individualized feedback regarding practice habits for one patient type has both a direct and indirect effect on the quality of care patients receive and should be implemented for all providers. Copyright © 2016 Elsevier Inc. All rights reserved.

The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty.

PubMed

Dent, Elsa; Lien, Christopher; Lim, Wee Shiong; Wong, Wei Chin; Wong, Chek Hooi; Ng, Tze Pin; Woo, Jean; Dong, Birong; de la Vega, Shelley; Hua Poi, Philip Jun; Kamaruzzaman, Shahrul Bahyah Binti; Won, Chang; Chen, Liang-Kung; Rockwood, Kenneth; Arai, Hidenori; Rodriguez-Mañas, Leocadio; Cao, Li; Cesari, Matteo; Chan, Piu; Leung, Edward; Landi, Francesco; Fried, Linda P; Morley, John E; Vellas, Bruno; Flicker, Leon

2017-07-01

To develop Clinical Practice Guidelines for the screening, assessment and management of the geriatric condition of frailty. An adapted Grading of Recommendations, Assessment, Development, and Evaluation approach was used to develop the guidelines. This process involved detailed evaluation of the current scientific evidence paired with expert panel interpretation. Three categories of Clinical Practice Guidelines recommendations were developed: strong, conditional, and no recommendation. Strong recommendations were (1) use a validated measurement tool to identify frailty; (2) prescribe physical activity with a resistance training component; and (3) address polypharmacy by reducing or deprescribing any inappropriate/superfluous medications. Conditional recommendations were (1) screen for, and address modifiable causes of fatigue; (2) for persons exhibiting unintentional weight loss, screen for reversible causes and consider food fortification and protein/caloric supplementation; and (3) prescribe vitamin D for individuals deficient in vitamin D. No recommendation was given regarding the provision of a patient support and education plan. The recommendations provided herein are intended for use by healthcare providers in their management of older adults with frailty in the Asia Pacific region. It is proposed that regional guideline support committees be formed to help provide regular updates to these evidence-based guidelines. Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Clinical behavior of Japanese community pharmacists for preventing prescription drug overdose.

PubMed

Shimane, Takuya; Matsumoto, Toshihiko; Wada, Kiyoshi

2015-04-01

Prescription drug abuse, including benzodiazepines, is a growing health problem in Japan. This study examined the community pharmacist's clinical behavior regarding patients who overdose on prescribed drugs, and explored the possibility of overdose prevention by community pharmacists. We surveyed all registered community pharmacies with dispensing functions (n = 1867) in the Saitama Pharmaceutical Association. An anonymous self-administered questionnaire was mailed to each pharmacy. Respondents were asked about clinical behavior such as medication counseling and referral to the prescriber if prescription drug overdose was identified. Among respondents, 26% of community pharmacists reported clinical experience of working with patients who overdosed on prescribed drugs in the previous year. Half of respondents evaluated their practice such as medication counseling and referral to the prescriber as 'good'. On multivariate analysis, a 'poor' self-evaluation of referral to the prescriber was significantly associated with the following perceptions: 'insufficient confidence in communication with prescribers' (odds ratio [OR], 2.7; 95% confidence interval [95%CI]: 1.4-5.3), and 'to avoid trouble with prescribers' (OR, 1.7; 95%CI: 1.0-2.7). Japanese community pharmacists could prevent prescription drug abuse in their practice, but the pharmacists who have insufficient confidence in communication with prescribers and who are afraid of trouble with a prescriber, reported poor self-evaluation for referral to the prescribers. All prescribers should understand the importance of referral by community pharmacists, to assist community pharmacists in playing a critical role in prevention of prescription drug abuse. © 2014 The Authors. Psychiatry and Clinical Neurosciences © 2014 Japanese Society of Psychiatry and Neurology.

Survey on antimicrobial prescribing patterns in small animal veterinary practice in Emilia Romagna, Italy.

PubMed

Barbarossa, A; Rambaldi, J; Miraglia, V; Giunti, M; Diegoli, G; Zaghini, A

2017-07-15

This investigation provides for the first time a general view of the prescribing patterns of antimicrobials in small animal practice in Emilia Romagna, Italy. In the context of a project on antimicrobial resistance managed by the Regional Veterinary Service, veterinary clinicians were invited to voluntarily complete an online questionnaire. This was designed to gather information on antimicrobial prescribing practices and biosecurity measures and to understand the perception of the issue specific to this region of Italy. In total, 266 questionnaires correctly completed were collected. Although clinicians seemed to follow different approaches when using antimicrobials, the data analysis revealed a general awareness on resistance. Penicillins were the most commonly prescribed class, followed by (fluoro)quinolones and cephalosporins. Among those who use laboratory testing more or less frequently (microbiological analysis and susceptibility testing) to support their prescribing habits, only 7 per cent make a habit of always waiting for the results before starting the treatment. Seventy-eight per cent of the respondents declared the use of antimicrobials licensed for human beings. Biosecurity measures were carefully taken into account by the majority of the veterinarians. The results identified the antimicrobial classes that are commonly prescribed and highlighted that perioperative hygiene measures and the use of laboratory diagnosis are critical aspects that need to be emphasised in drawing up guidelines on the prudent use of these drugs in pets.

Why are patients prescribed proton pump inhibitors? Retrospective analysis of link between morbidity and prescribing in the General Practice Research Database

PubMed Central

Bashford, James N R; Norwood, Jeff; Chapman, Stephen R

1998-01-01

Objectives: To establish the relation between new prescriptions for proton pump inhibitors and recorded upper gastrointestinal morbidity within a large computerised general practitioner database. Design: Retrospective survey of morbidity and prescribing data linked to new prescriptions for proton pump inhibitors and comparison with licensed indications between 1991 and 1995. Setting: General Practice Research Database and prescribing analysis and cost (PACT) data for the former West Midlands region. Subjects: Information for 612 700 patients in the General Practice Research Database. Anonymous PACT data for all general practitioners in West Midlands region. Main outcome measures: Diagnostic codes linked to the first prescriptions issued for proton pump inhibitors; relation between new prescriptions and licensed indications; yearly change in ratio of new to repeat prescriptions and prescribing volumes measured as defined daily doses. Results: Oesophagitis was the commonest recorded indication in 1991, accounting for 31% of new prescriptions, but was third in 1995 (14%). During the study new prescriptions increased substantially, especially for duodenal disease (780%) and non-ulcer dyspepsia (690%). In 1995 non-specific morbidity accounted for 46% of new prescriptions. The total volume of prescribing rose 10-fold between 1991 and 1995, when repeat prescribing accounted for 77% of the total. Conclusions: Changes in recorded morbidity associated with new prescriptions of proton pump inhibitors did not necessarily reflect changes in licensed indications. Although general practitioners seemed to respond to changes in licensing, particularly for duodenal and gastric disease, prescribing for unlicensed indications non-ulcer dyspepsia and non-specific abdominal pain increased. Key messages There has been much speculation about the reasons behind the substantial rise in prescribing of proton pump inhibitors, especially their use for minor symptoms. We used the General Practitioner Research Database for the former West Midlands region to show that the volume of proton pump inhibitor prescribing rose 10-fold between 1992 and 1995 and repeat prescribing had risen to 77% of the volume by 1995 Prescribing for uncomplicated dyspepsia and non-specific abdominal symptoms, which were outside the licensed indications, accounted for 46% of new prescribing by 1995 The proportion of prescribing for the licensed indication of oesophagitis fell during the study, but that for duodenal ulceration increased in line with the expansion of licensed indications Analysis of PACT data showed similar prescribing trends to those found with the General Practitioner Research Database PMID:9703528

Part 1. Current prescribing trends of antibiotics by dentists in Australia from 2013 to 2016.

PubMed

Teoh, L; Stewart, K; Marino, R J; McCullough, M J

2018-05-13

Literature has shown dentists tend to overprescribe antibiotics and do not always prescribe in accordance with recommended guidelines. Unnecessary prescribing is one major factor that contributes to the development of antibiotic resistance. The aim of the present study was to assess the antibacterial prescribing patterns of dentists in Australia from 2013 to 2016. Data on dental antibacterial prescriptions dispensed under the Pharmaceutical Benefits Scheme (PBS) from 2013 to 2016 was accessed and prescribing trends analysed. The prescribing rates were standardised to the dose and population. There was a slight decrease in the dispensed use of most antibacterials from 2013-16, but there was a significant increase in the dispensed use of amoxicillin/clavulanic acid of 11.2%. Amoxicillin was the most commonly dispensed antibiotic, accounting for around 65% of all antibacterials from 2013-16, while phenoxymethylpenicillin accounted for only 1.4% of prescriptions in 2016. There were low but significant quantities of dispensed antibiotic prescriptions that do not fit with current guidelines. The data suggest that dentists in Australia are prescribing some antibiotics inappropriately and there is a preference for moderate to broad spectrum agents. The current PBS dental schedule is inconsistent with prescribing guidelines and may contribute to inappropriate prescribing. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Using nurses and office staff to report prescribing errors in primary care.

PubMed

Kennedy, Amanda G; Littenberg, Benjamin; Senders, John W

2008-08-01

To implement a prescribing-error reporting system in primary care offices and analyze the reports. Descriptive analysis of a voluntary prescribing-error-reporting system Seven primary care offices in Vermont, USA. One hundred and three prescribers, managers, nurses and office staff. Nurses and office staff were asked to report all communications with community pharmacists regarding prescription problems. All reports were classified by severity category, setting, error mode, prescription domain and error-producing conditions. All practices submitted reports, although reporting decreased by 3.6 reports per month (95% CI, -2.7 to -4.4, P<0.001, by linear regression analysis). Two hundred and sixteen reports were submitted. Nearly 90% (142/165) of errors were severity Category B (errors that did not reach the patient) according to the National Coordinating Council for Medication Error Reporting and Prevention Index for Categorizing Medication Errors. Nineteen errors reached the patient without causing harm (Category C); and 4 errors caused temporary harm requiring intervention (Category E). Errors involving strength were found in 30% of reports, including 23 prescriptions written for strengths not commercially available. Antidepressants, narcotics and antihypertensives were the most frequent drug classes reported. Participants completed an exit survey with a response rate of 84.5% (87/103). Nearly 90% (77/87) of respondents were willing to continue reporting after the study ended, however none of the participants currently submit reports. Nurses and office staff are a valuable resource for reporting prescribing errors. However, without ongoing reminders, the reporting system is not sustainable.

Clinical practice patterns in the assessment and management of low testosterone in men: an international survey of endocrinologists.

PubMed

Grossmann, Mathis; Anawalt, Bradley D; Wu, Frederick C W

2015-02-01

To document current practices in the approach to low testosterone in older men. Given that recommendations are based on low-level evidence, we hypothesized that there would be a wide variability in clinical practice patterns. Members of all major endocrine and andrological societies were invited to participate in a Web-based survey of the diagnostic work-up and management of a hypothetical index case of a 61-year old overweight man presenting with symptoms suggestive of androgen deficiency, without evidence of hypothalamic-pituitary-gonadal (HPT) axis disease. Nine hundred and forty-three respondents (91·2% adult endocrinologists) from Northern America (63·7%), Europe (12·7%), Oceania (8·2%), Latin America and Caribbean (7·6%), and the Middle East, Asia, or Africa (7·8%) completed the survey. Response rates among participating societies ranged from 4·1-20·0%. There was a wide variability in clinical practice patterns, especially regarding biochemical diagnosis of androgen deficiency, exclusion of HPT axis pathology, and monitoring for prostate cancer. In a man with suggestive symptoms, 42·4% of participants would offer testosterone treatment below a serum total testosterone of 10·4 nmol/l (300 ng/dl). A total of 46·0% of participants were, over the last five years, 'less inclined' to prescribe testosterone to men with nonspecific symptoms and borderline testosterone levels, compared to 'no change' (29·3%) or 'more inclined' (24·7%), P < 0·001. This large-scale international survey shows a wide variability in the management of lowered testosterone in older men, with deviations from current clinical practice guidelines, and a temporal trend towards increasing reluctance to prescribe testosterone to men without classical hypogonadism. These findings highlight the need for better evidence to guide clinicians regarding testosterone therapy. © 2014 John Wiley & Sons Ltd.

Software Development Standard Processes (SDSP)

NASA Technical Reports Server (NTRS)

Lavin, Milton L.; Wang, James J.; Morillo, Ronald; Mayer, John T.; Jamshidian, Barzia; Shimizu, Kenneth J.; Wilkinson, Belinda M.; Hihn, Jairus M.; Borgen, Rosana B.; Meyer, Kenneth N.;

An assessment of current clinical attitudes toward letrozole use in reproductive endocrinology practices.

PubMed

Malloch, Lindsay; Rhoton-Vlasak, Alice

2013-12-01

To assess the clinical use and practice attitudes among Society for Assisted Reproductive Technology (SART) members regarding the use of letrozole for ovulation induction and infertility treatment. The SART clinic physicians were mailed a cover letter and consent form, a two-page survey, and return envelope. The surveys were returned and analyzed using descriptive statistics. Not applicable. None. A 13-question survey. Reproductive endocrinology and infertility physicians use patterns and attitudes regarding letrozole. A total of 77.9% of physician prescribe letrozole. Of those who do not, 32.4% cited concern about the US Food and Drug Administration warning, 35.1% cited satisfaction with current medications, 25.7% cited both reasons, and 6.8% cited no experience with letrozole. Physicians (11.5%) were unaware of the US Food and Drug Administration warning. Physicians (99.7%) were aware that ovulation induction is an off-label use of letrozole. The most common use was for ovulation induction in patients with polycystic ovary syndrome (PCOS). Physicians (14.9%) prescribe letrozole as first-line ovulation therapy prior to clomid, 47.9% use for clomid failures, and 25.7% reported use in both situations. Most physicians surveyed use letrozole for ovulation induction despite the current US Food and Drug Administration warning. Even when accounting for nonrespondents, more than 25% of physicians indicated success with letrozole use. Questions regarding doses and clinical concerns about letrozole revealed no standardized manner of letrozole administration despite wide interest, therefore additional research is warranted. Copyright © 2013 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Prescribed Fire Education at Oklahoma State University: Training Our Future Pyros

Treesearch

John R. Weir

2008-01-01

The Rangeland Ecology and Management program at Oklahoma State University recognized the need for a practical, hands-on course designed for undergraduate and graduate students, with instruction on conducting prescribed fires for vegetation management, wildlife management, and livestock management. Two separate prescribed fire courses were initiated in the spring of...

Evidence and resources to implement Pharmacogenetic Knowledge for Precision Medicine

PubMed Central

Caudle, Kelly E.; Gammal, Roseann S.; Whirl-Carrillo, Michelle; Hoffman, James M.; Relling, Mary V.; Klein, Teri E.

2016-01-01

Purpose Implementation of pharmacogenetics into clinical practice has been relatively slow despite substantial scientific progress over the last decade. One barrier that inhibits uptake of pharmacogenetics into routine clinical practice is the lack of knowledge of how to translate a genetic test into a clinical action based on current evidence. The purpose of this paper is to describe the current state of pharmacogenetic evidence and evidence-based resources that facilitate the uptake of pharmacogenetics into clinical practice. Summary Controversy exists over the required evidence threshold needed for routine clinical implementation of pharmacogenetics. Large randomized controlled trials are not clinically feasible or necessary for many pharmacogenetic applications. Online resources exist like the Clinical Pharmacogenetics Implementation Consortium (CPIC) and the Pharmacogenomics Knowledgebase (PharmGKB) that provide freely available, evidence-based resources that facilitate the translation of genetic laboratory test results into actionable prescribing recommendations for specific drugs. Conclusion Resources provided by organizations such as CPIC and PharmGKB that use standardized approaches to evaluate the literature and provide clinical guidance are essential for the implementation of pharmacogenetics into routine clinical practice. PMID:27864205

A retrospective investigation of the clinical management of patients attending an out of hours dental clinic in Merseyside under the new NHS dental contract.

PubMed

Tulip, D E; Palmer, N O A

2008-12-20

To investigate the clinical management of patients attending for emergency dental treatment. A retrospective analysis of clinical record cards. Information was collected from patient record cards concerning the patient's reason for attendance and their management at an emergency dental clinic in South Sefton, Liverpool. Over a nine month period, 1,718 patients attended the clinic; 1,472 record cards were analysed. Over 80% of the patients attending the out of hours (OOH) clinic had pain associated with a localised dental infection or dental abscess. Where a diagnosis was recorded, only 67% of patients received appropriate treatment. Over 50% of patients received antibiotics alone with no other definitive treatment provided. The principal antibiotic prescribed for both adult and child patients was amoxicillin. The current study has highlighted that GDPs working within the OOH services are not adhering to current clinical and best practice guidelines with respect to patient examination, diagnosis, management, in particular the correct prescribing of antibiotics for dental infections, and clinical record keeping.

Coordination through databases can improve prescribed burning as a conservation tool to promote forest biodiversity.

PubMed

Ramberg, Ellinor; Strengbom, Joachim; Granath, Gustaf

2018-04-01

Prescribed fires are a common nature conservation practice. They are executed by several parties with limited coordination among them, and little consideration for wildfire occurrences and habitat requirements of fire-dependent species. Here, we gathered data on prescribed fires and wildfires in Sweden during 2011-2015 to (i) evaluate the importance and spatial extent of prescribed fires compared to wildfires and (ii) illustrate how a database can be used as a management tool for prescribed fires. We found that on average only 0.006% (prescribed 65%, wildfires 35%) of the Swedish forest burns per year, with 58% of the prescribed fires occurring on clearcuts. Also, both wildfires and prescribed fires seem to be important for the survival of fire-dependent species. A national fire database would simplify coordination and make planning and evaluation of prescribed fires more efficient. We propose an adaptive management strategy to improve the outcome of prescribed fires.

When is rational to order a diagnostic test, or prescribe treatment: the threshold model as an explanation of practice variation.

PubMed

Djulbegovic, Benjamin; van den Ende, Jef; Hamm, Robert M; Mayrhofer, Thomas; Hozo, Iztok; Pauker, Stephen G

2015-05-01

The threshold model represents an important advance in the field of medical decision-making. It is a linchpin between evidence (which exists on the continuum of credibility) and decision-making (which is a categorical exercise - we decide to act or not act). The threshold concept is closely related to the question of rational decision-making. When should the physician act, that is order a diagnostic test, or prescribe treatment? The threshold model embodies the decision theoretic rationality that says the most rational decision is to prescribe treatment when the expected treatment benefit outweighs its expected harms. However, the well-documented large variation in the way physicians order diagnostic tests or decide to administer treatments is consistent with a notion that physicians' individual action thresholds vary. We present a narrative review summarizing the existing literature on physicians' use of a threshold strategy for decision-making. We found that the observed variation in decision action thresholds is partially due to the way people integrate benefits and harms. That is, explanation of variation in clinical practice can be reduced to a consideration of thresholds. Limited evidence suggests that non-expected utility threshold (non-EUT) models, such as regret-based and dual-processing models, may explain current medical practice better. However, inclusion of costs and recognition of risk attitudes towards uncertain treatment effects and comorbidities may improve the explanatory and predictive value of the EUT-based threshold models. The decision when to act is closely related to the question of rational choice. We conclude that the medical community has not yet fully defined criteria for rational clinical decision-making. The traditional notion of rationality rooted in EUT may need to be supplemented by reflective rationality, which strives to integrate all aspects of medical practice - medical, humanistic and socio-economic - within a coherent reasoning system. © 2015 Stichting European Society for Clinical Investigation Journal Foundation.

Nurse prescribing as an aspect of future role expansion: the views of Irish clinical nurse specialists.

PubMed

Lockwood, Emily B; Fealy, Gerard M

2008-10-01

Nurses and midwives are expanding the scope of their professional practice, assuming additional responsibilities including the management and prescribing of medications. The aim of the study was to discover the attitudes of clinical nurse specialists (CNSs) in Ireland to nurse prescribing and to examine perceived barriers to engaging in this aspect of future role expansion. The expansion of the nursing role in relation to nurse prescribing is an ongoing process and is subject to incremental iterations of legislation and professional policy. Nurse prescribing as an expanded role function has become a reality in many countries. Ireland has addressed the matter in a formal and systematic way through legislation. A questionnaire was administered to a sample of 283 CNSs practising in a variety of care settings in Ireland. Attitudes were measured using Likert-type attitudinal scales, designed specifically for the study. Findings indicate that the majority of clinical nurse specialists were positively disposed toward nurse prescribing as a future role expansion. The fear of litigation was identified as the most significant barrier to nurse prescribing. The majority of respondents equated nurse prescribing with increased autonomy and holistic care. The findings indicate that there is a need for further examination of the educational requirements of the CNS in relation to nurse prescribing. The legislative implications for nurse prescribing and fear of legal consequences need to be considered prior to any implementation of nurse prescribing. While senior clinicians are willing to embrace future role expansion in the area of nurse prescribing, their Nurse Managers should recognize that facilitation of nurse prescribing needs to address the legal and educational requirements for such activity. Failure to address these requirements can represent a barrier to role expansion. This paper offers new understandings on the views of senior clinicians concerning nurse prescribing at a time of ongoing professional policy iteration and practice change in the area.

Variability of antibiotic prescribing in patients with chronic obstructive pulmonary disease exacerbations: a cohort study.

PubMed

Boggon, Rachael; Hubbard, Richard; Smeeth, Liam; Gulliford, Martin; Cassell, Jackie; Eaton, Susan; Pirmohamed, Munir; van Staa, Tjeerd-Pieter

2013-05-31

The role of antibiotics in treating mild or moderate exacerbations in patients with acute chronic obstructive pulmonary disease (COPD) is unclear. The aims were to: (i) describe patient characteristics associated with acute exacerbations amongst a representative COPD population, (ii) explore the relationship between COPD severity and outcomes amongst patients with exacerbations, and (iii) quantify variability by general practice in prescribing of antibiotics for COPD exacerbations. A cohort of 62,747 patients with COPD was identified from primary care general practices (GP) in England, and linked to hospital admission and death certificate data. Exacerbation cases were matched to three controls and characteristics compared using conditional logistic regression. Outcomes were compared using incidence rates and Cox regression, stratified by disease severity. Variability of prescribing at the GP level was evaluated graphically and by using multilevel models. COPD severity was found to be associated with exacerbation and subsequent mortality (very severe vs. mild, odds ratio for exacerbation 2.12 [95%CI 19.5-2.32]), hazard ratio for mortality 2.14 [95%CI 1.59-2.88]). Whilst 61% of exacerbation cases were prescribed antibiotics, this proportion varied considerably between GP practices (interquartile range, 48-73%). This variation is greater than can be explained by patient characteristics alone. There is significant variability between GP practices in the prescribing of antibiotics to COPD patients experiencing exacerbations. Combined with a lack of evidence on the effects of treatment, this supports the need and opportunity for a large scale pragmatic randomised trial of the prescribing of antibiotics for COPD patients with exacerbations, in order to clarify their effectiveness and long term outcomes whilst ensuring the representativeness of subjects.

Variability of antibiotic prescribing in patients with chronic obstructive pulmonary disease exacerbations: a cohort study

PubMed Central

2013-01-01

Background The role of antibiotics in treating mild or moderate exacerbations in patients with acute chronic obstructive pulmonary disease (COPD) is unclear. The aims were to: (i) describe patient characteristics associated with acute exacerbations amongst a representative COPD population, (ii) explore the relationship between COPD severity and outcomes amongst patients with exacerbations, and (iii) quantify variability by general practice in prescribing of antibiotics for COPD exacerbations. Method A cohort of 62,747 patients with COPD was identified from primary care general practices (GP) in England, and linked to hospital admission and death certificate data. Exacerbation cases were matched to three controls and characteristics compared using conditional logistic regression. Outcomes were compared using incidence rates and Cox regression, stratified by disease severity. Variability of prescribing at the GP level was evaluated graphically and by using multilevel models. Results COPD severity was found to be associated with exacerbation and subsequent mortality (very severe vs. mild, odds ratio for exacerbation 2.12 [95%CI 19.5–2.32]), hazard ratio for mortality 2.14 [95%CI 1.59–2.88]). Whilst 61% of exacerbation cases were prescribed antibiotics, this proportion varied considerably between GP practices (interquartile range, 48–73%). This variation is greater than can be explained by patient characteristics alone. Conclusions There is significant variability between GP practices in the prescribing of antibiotics to COPD patients experiencing exacerbations. Combined with a lack of evidence on the effects of treatment, this supports the need and opportunity for a large scale pragmatic randomised trial of the prescribing of antibiotics for COPD patients with exacerbations, in order to clarify their effectiveness and long term outcomes whilst ensuring the representativeness of subjects. PMID:23724907

Management of Helicobacter Pylori in the United States: Results from a national survey of gastroenterology physicians.

PubMed

Murakami, Traci T; Scranton, Rebecca A; Brown, Heidi E; Harris, Robin B; Chen, Zhao; Musuku, Sunitha; Oren, Eyal

2017-07-01

We sought to determine current knowledge and practices among gastroenterology physicians and assess adherence to current guidelines for H. pylori management. Online surveys were distributed in 2014 to practicing gastroenterology physicians for information related to the diagnosis and treatment of H. pylori infection. A total of 582 completed surveys were reviewed. The H. pylori screening test used "almost always" was gastric biopsy obtained during endoscopy (histology) (59%) followed by stool antigen test (20%). Standard triple therapy for 14days was commonly prescribed by 53% of respondents. The stool antigen test was most frequently chosen to confirm H. pylori eradication (51%), although only 58% of physicians checked for eradication in patients who underwent treatment. Adherence to current American College of Gastroenterology guidelines is low. Although more physicians treat patients with a positive H. pylori test, only half ensure eradication after treatment. Improving knowledge of the resistance patterns of H. pylori may be critical to ensure successful eradication. Copyright © 2017 Elsevier Inc. All rights reserved.

Avoidable Antibiotic Exposure for Uncomplicated Skin and Soft Tissue Infections in the Ambulatory Care Setting

PubMed Central

Hurley, Hermione J.; Knepper, Bryan C.; Price, Connie S.; Mehler, Philip S.; Burman, William J.; Jenkins, Timothy C.

2014-01-01

Background Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotics. A detailed understanding of current prescribing practices is necessary to optimize antibiotic use for these conditions. Methods This was a retrospective cohort study of children and adults treated in the ambulatory care setting for uncomplicated cellulitis, wound infection, or cutaneous abscess between March 1, 2010 and February 28, 2011. We assessed the frequency of avoidable antibiotic exposure, defined as: use of antibiotics with broad gram-negative activity, combination antibiotic therapy, or treatment for 10 or more days. Total antibiotic-days prescribed for the cohort were compared to antibiotic-days in four hypothetical short-course (5 – 7 days), single-antibiotic treatment models consistent with national guidelines. Results 364 cases were included for analysis (155 cellulitis, 41 wound infection, and 168 abscess). Antibiotics active against methicillin-resistant Staphylococcus aureus were prescribed in 61% of cases of cellulitis. Of 139 cases of abscess where drainage was performed, antibiotics were prescribed in 80% for a median of 10 (interquartile range 7 – 10) days. Of 292 total cases where complete prescribing data were available, avoidable antibiotic exposure occurred in 46%. This included use of antibiotics with broad gram-negative activity in 4%, combination therapy in 12%, and treatment for 10 or more days in 42%. Use of the short-course, single-antibiotic treatment strategies would have reduced prescribed antibiotic-days by 19 – 55%. Conclusions Nearly half of uncomplicated skin infections involved avoidable antibiotic exposure. Antibiotic use could be reduced through treatment approaches utilizing short courses of a single antibiotic. PMID:24262724

Nurse prescriber-patient consultations: a case study in dermatology.

PubMed

Courtenay, Molly; Carey, Nicola; Stenner, Karen

2009-06-01

This paper is a report of a study exploring the content and processes in consultations between nurse prescribers and patients with dermatological conditions. Communication skills, consultation time, information and follow-up are central to the treatment and management of patients with dermatological conditions. The contribution nurses make to the care of these patients has great potential. A multiple case study was conducted with 10 practice settings across England in which nurses prescribed medicines for patients with dermatological conditions. Data were collected between June 2006 and September 2007 using semi-structured interviews (n = 40), patient questionnaires (n = 165/200) and videotaped observations of nurse consultations (n = 40). Data analysis included thematic analysis, descriptive statistics, chi-square and non-parametric tests. Nurses believed that their holistic approach to assessment, combined with their prescribing knowledge, improved prescribing decisions. Listening and explanation of treatments were aspects of nurse communication that were rated highly by patients. Listening and dealing sensitively with emotions were also aspects of the videotaped consultations that were rated highly by assessors. Nurses were less consistent in providing information about medicines. Triangulated data from this study suggest that nurse prescribing enhances the care of patients with dermatological conditions through improved prescribing decisions. If patients are to be more involved in this decision-making, nurses must give them more information about their medicines. The benefits of prescribing were most evident in the practices of dermatology specialist nurses. Further evidence is required to identify whether prescribing by specialist nurses offers similar benefits in other therapeutic areas.

Geographic Variation in Opioid Prescribing in the U.S.

PubMed Central

McDonald, Douglas C.; Carlson, Kenneth; Izrael, David

2012-01-01

Estimates of geographic variation among states and counties in the prevalence of opioid prescribing are developed using data from a large (135M) representative national sample of opioid prescriptions dispensed during 2008 by 37,000 retail pharmacies. Statistical analyses are used to estimate the extent to which county variation is explained by characteristics of resident populations, their healthcare utilization, proxy measures of morbidity, availability of healthcare resources, and prescription monitoring laws. Geographic variation in prevalence of prescribed opioids is large, greater than variation observed for other healthcare services. Counties having the highest prescribing rates for opioids were disproportionately located in Appalachia and in Southern and Western states. The number of available physicians was by far the strongest predictor of amounts prescribed, but only one-third of county variation is explained by the combination of all measured factors. Wide variation in prescribing opioids reflects weak consensus regarding the appropriate use of opioids for treating pain, especially chronic non-cancer pain. Patients’ demands for treatment have increased, more potent opioids have become available, an epidemic of abuse has emerged, and calls for increased government regulation are growing. Greater guidance, education and training in opioid prescribing are needed for clinicians to support appropriate prescribing practices. Perspective Wide geographic variation that does not reflect differences in the prevalence of injuries, surgeries, or conditions requiring analgesics raises questions about opioid prescribing practices. Low prescription rates may indicate under-treatment, while high rates may indicate overprescribing and insufficient attention to risks of misuse. PMID:23031398

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

PubMed

Hanna, Tamer; Bajorek, Beata; Lemay, Kate; Armour, Carol L

2014-01-01

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

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

PubMed Central

Hanna, Tamer; Bajorek, Beata; LeMay, Kate; Armour, Carol L.

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. PMID:24644524

Dr. Biswell's influence on the development of prescribed burning in California

Treesearch

Jan W.\\t van Wagtendonk

1995-01-01

Prescribed burning in California has evolved from the original practices of the Native Americans, through years of experimentation and controversy, to finally become an accepted ecosystem management activity. When Dr. Harold Biswell arrived in California, he began research on improving game range by using prescribed fires and on understory burning in ponderosa pine (...

Antibiotic Prescribing Review as a Component of an Infectious Disease Course.

ERIC Educational Resources Information Center

Speedie, Marilyn K.; And Others

1979-01-01

The review of physician-prescribing is recognized as an important function for pharmacists. It is suggested that a course aimed at antibiotic drug prescribing review (DPR) would provide the opportunity to reinforce and apply the principles of DPR and to demonstrate how theoretical knowledge of antibiotics could be applied directly to practice.…

Spatio-temporal distribution of white-tailed deer (Odocioleus virginianus) relative to prescribed burns on rangeland in south Texas

Treesearch

Michael Glenn Meek

2007-01-01

Overgrazing and fire suppression has left much rangeland in poor condition for various wildlife species. Prescribed fire is one range improvement practice used to restore degraded wildlife habitat. I determined the effect of prescribed fire on whitetailed deer (Odocoileus virginianus) spatial and temporal distribution, in the presence of cattle...

Factors influencing secondary care pharmacist and nurse independent prescribers' clinical reasoning: An interprofessional analysis.

PubMed

Abuzour, Aseel S; Lewis, Penny J; Tully, Mary P

2018-03-01

In the United Kingdom, pharmacist and nurse independent prescribers are responsible for both the clinical assessment of and prescribing for patients. Prescribing is a complex skill that entails the application of knowledge, skills, and clinical reasoning to arrive at a clinically appropriate decision. Decision-making is influenced and informed by many factors. This study, the first of its kind, explores what factors influence pharmacist and nurse independent prescribers during the process of clinical reasoning. A think-aloud methodology immediately followed by a semi-structured interview was conducted with 11 active nurse and 10 pharmacist independent prescribers working in secondary care. Each participant was presented with validated clinical vignettes for the think-aloud stage. Participants chose the clinical therapeutic areas for the vignettes, based on their self-perceived competencies. Data were audio-recorded, transcribed verbatim, and a constant-comparative approach was used for analysis. Influences on clinical reasoning were broadly categorised into themes: social interaction, intrinsic, and contextual factors. These themes showed that intrinsic, sociocultural, and contextual aspects heavily influenced the clinical reasoning processes of prescribers. For example, prescribers were aware of treatment pathways, but chose to refer patient cases to avoid making the final prescribing decision. Exploration of this behaviour in the interviews revealed that previous experience and attitudes such as confidence and cautiousness associated with responsibility were strong influencers within the decision-making process. In addition, strengthening the professional identity of prescribers could be achieved through collaborative work with interprofessional healthcare teams to orient their professional practice from within the profession. Findings from this study can be used to inform the education, training, and practice of independent prescribers to improve healthcare services by improving their professional and interprofessional development.

Managing Opioid Addiction Risk in Plastic Surgery during the Perioperative Period.

PubMed

Demsey, Daniel; Carr, Nicholas J; Clarke, Hance; Vipler, Sharon

2017-10-01

Opioid addiction is a public health crisis that affects all areas of medicine. Large numbers of the population across all racial and economic demographics misuse prescription opioids and use illicit opioids. The current understanding is that opioid misuse is a disease that requires treatment, and is not an issue of choice or character. Use of opioid medication is a necessary part of postoperative analgesia, but many physicians are unsure of how to do this safely given the risk of patients developing an opioid misuse disorder. This review gives an update of the current state of the opioid crisis, explains how current surgeons' prescribing practices are contributing to it, and gives recommendations on how to use opioid medication safely in the perioperative period.

The clinician impact and financial cost to the NHS of litigation over pregabalin: a cohort study in English primary care.

PubMed

Croker, Richard; Smyth, Darren; Walker, Alex J; Goldacre, Ben

2018-06-07

Following litigation over pregabalin's second-use medical patent for neuropathic pain, National Health Service (NHS) England was required by the court to instruct general practitioners (GPs) to prescribe the branded form (Lyrica) for pain. Pfizer's patent was found invalid in 2015, a ruling subject to ongoing appeals. If the Supreme Court appeal in February 2018, whose judgement is awaited, is unsuccessful, the NHS can seek to reclaim excess prescribing costs. We set out to describe the variation in prescribing of pregabalin as branded Lyrica, geographically and over time; to determine how clinicians responded to the NHS England instruction to GPs; and to model excess costs to the NHS attributable to the legal judgements. English primary care. English general practices. Variation in prescribing of branded Lyrica across the country before and after the NHS England instruction, by practice and by Clinical Commissioning Group; excess prescribing costs. The proportion of pregabalin prescribed as Lyrica increased from 0.3% over 6 months before the NHS England instruction (September 2014 to February 2015) to 25.7% afterwards (April to September 2015). Although 70% of pregabalin is estimated to be for pain, including neuropathic pain, only 11.6% of practices prescribed Lyrica at this level; the median proportion prescribed as Lyrica was 8.8% (IQR 1.1%-41.9%). If pregabalin had come entirely off patent in September 2015, and Pfizer had not appealed, we estimate the NHS would have spent £502 million less on pregabalin to July 2017. NHS England instructions to GPs regarding branded prescription of pregabalin were widely ignored and have created much debate around clinical independence in prescribing. Protecting revenue from 'skinny labels' will pose a challenge. If Pfizer's final appeal on the patent is unsuccessful, the NHS can seek reimbursement of excess pregabalin prescribing costs, potentially £502 million. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Use of atropine penalization to treat amblyopia in UK orthoptic practice.

PubMed

Piano, Marianne; O'Connor, Anna R; Newsham, David

2014-01-01

To compare clinical practice patterns regarding atropine penalization use by UK orthoptists to the current evidence base and identify any existing barriers against use of AP as first-line treatment. An online survey was designed to assess current practice patterns of UK orthoptists using atropine penalization. They were asked to identify issues limiting their use of atropine penalization and give opinions on its effectiveness compared to occlusion. Descriptive statistics and content analysis were applied to the results. Responses were obtained from 151 orthoptists throughout the United Kingdom. The main perceived barriers to use of atropine penalization were inability to prescribe atropine and supply difficulties. However, respondents also did not consider atropine penalization as effective as occlusion in treating amblyopia, contrary to recent research findings. Patient selection criteria and treatment administration largely follow current evidence. More orthoptists use atropine penalization as first-line treatment than previously reported. Practitioners tend to closely follow the current evidence base when using atropine penalization, but reluctance in offering it as first-line treatment or providing a choice for parents between occlusion and atropine still remains. This may result from concerns regarding atropine's general efficacy, side effects, and risk of reverse amblyopia. Alternatively, as demonstrated in other areas of medicine, it may reflect the inherent delay of research findings translating to clinical practice changes. Copyright 2014, SLACK Incorporated.

Practice makes perfect: A systematic review of the expertise development of pharmacist and nurse independent prescribers in the United Kingdom.

PubMed

Abuzour, Aseel S; Lewis, Penny J; Tully, Mary P

2018-01-01

Prescribing is a complex and error-prone task that demands expertise. McLellan et al.'s theory of expertise development model ("the model"), developed to assess medical literature on prescribing by medical students, proposes that in order to develop, individuals should deliberately engage their knowledge, skills and attitudes within a social context. Its applicability to independent prescribers (IP) is unknown. A systematic review was conducted to explore whether the model is applicable to non-medical independent prescribing and to assess the factors underpinning expertise development reported in the literature. Six electronic databases (EMBASE, Medline, AMED, CINAHL, IPA and PsychInfo) were searched for articles published between 2006 and 2016, reporting empirical data on pharmacist and nurse IPs education or practice. Data were extracted using themes from the model and analysed using framework analysis. Thirty-four studies met the inclusion criteria. Knowledge, pre-registration education, experience, support and confidence were some of the intrinsic and extrinsic factors influencing IPs. Difficulty in transferring theory to practice was attributed to lack of basic pharmacology and bioscience content in pre-registration nursing rather than the prescribing programme. Students saw interventions using virtual learning or learning in practice as more useful with long-term benefits e.g. students were able to use their skills in history taking following the virtual learning intervention 6-months after the programme. All studies demonstrated how engaging knowledge and skills affected individuals' attitude by, for example, increasing professional dignity. IPs were able to develop their expertise when integrating their competencies in a workplace context with support from colleagues and adherence to guidelines. This is the first study to synthesize data systematically on expertise development from studies on IPs using the model. The model showed the need for stronger foundations in scientific knowledge amongst some IPs, where continuous workplace practice can improve skills and strengthen attitudes. This could facilitate a smoother transfer of learnt theory to practice, in order for IPs to be experts within their fields and not merely adequately competent. Copyright © 2017 Elsevier Inc. All rights reserved.

Electronically delivered, multicomponent intervention to reduce unnecessary antibiotic prescribing for respiratory infections in primary care: a cluster randomised trial using electronic health records-REDUCE Trial study original protocol.

PubMed

Juszczyk, Dorota; Charlton, Judith; McDermott, Lisa; Soames, Jamie; Sultana, Kirin; Ashworth, Mark; Fox, Robin; Hay, Alastair D; Little, Paul; Moore, Michael V; Yardley, Lucy; Prevost, A Toby; Gulliford, Martin C

2016-08-04

Respiratory tract infections (RTIs) account for about 60% of antibiotics prescribed in primary care. This study aims to test the effectiveness, in a cluster randomised controlled trial, of electronically delivered, multicomponent interventions to reduce unnecessary antibiotic prescribing when patients consult for RTIs in primary care. The research will specifically evaluate the effectiveness of feeding back electronic health records (EHRs) data to general practices. 2-arm cluster randomised trial using the EHRs of the Clinical Practice Research Datalink (CPRD). General practices in England, Scotland, Wales and Northern Ireland are being recruited and the general population of all ages represents the target population. Control trial arm practices will continue with usual care. Practices in the intervention arm will receive complex multicomponent interventions, delivered remotely to information systems, including (1) feedback of each practice's antibiotic prescribing through monthly antibiotic prescribing reports estimated from CPRD data; (2) delivery of educational and decision support tools; (3) a webinar to explain and promote effective usage of the intervention. The intervention will continue for 12 months. Outcomes will be evaluated from CPRD EHRs. The primary outcome will be the number of antibiotic prescriptions for RTIs per 1000 patient years. Secondary outcomes will be: the RTI consultation rate; the proportion of consultations for RTI with an antibiotic prescribed; subgroups of age; different categories of RTI and quartiles of intervention usage. There will be more than 80% power to detect an absolute reduction in antibiotic prescription for RTI of 12 per 1000 registered patient years. Total healthcare usage will be estimated from CPRD data and compared between trial arms. Trial protocol was approved by the National Research Ethics Service Committee (14/LO/1730). The pragmatic design of the trial will enable subsequent translation of effective interventions at scale in order to achieve population impact. ISRCTN95232781; Pre-results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Effects of viral respiratory disease education and surveillance on antibiotic prescribing.

PubMed

Temte, J L; Shult, P A; Kirk, C J; Amspaugh, J

1999-02-01

We describe a partnership between family practice residency clinics and a state public health virology laboratory that has produced comprehensive viral respiratory disease education and surveillance. Family practice residents have been provided with education on respiratory viruses and the results of ongoing viral surveillance. The preliminary effects of this program on antibiotic prescribing by senior residents are evaluated in this paper. We used a questionnaire to assess the acceptance by family practice residents of the educational component and the utility of ongoing viral surveillance. We used chart review to evaluate rates of antibiotic prescribing and the number of patients diagnosed per year with acute upper respiratory infection and acute bronchitis by senior residents in 1992 (preexposure) and 1996 (postexposure). By the third year of training, most residents (79%) reported receiving adequate training regarding common viral respiratory diseases. Moreover, residents reported that they were less likely to prescribe antibiotics to patients presenting with respiratory infections when provided with specific information on circulating viral pathogens. Antibiotic prescribing in the postexposure group was 68% lower for upper respiratory infection (URI) and 45% lower for a composite of URI and bronchitis. Education and monitoring of circulating respiratory viruses can result in familiarity with common disorders in primary care and reduce unnecessary antibiotic use.

Early pregnancy exposure to feto-toxic medications among out-patients in Malawi.

PubMed

Kabuluzi, Ezereth; Campbell, Malcolm; McGowan, Linda; Chirwa, Ellen; Brabin, Loretta

2014-08-01

To estimate the proportion of women in early pregnancy prescribed potentially feto-toxic medications at an out-patient clinic in Malawi. Over six-months the number of women of child-bearing age attending out-patient clinics and prescribed medicines at Mitundu Community Hospital was derived from the hospital's registry and pharmacy records. Women prescribed potentially feto-toxic medicines (using Food and Drug Administration classifications) by medical assessments were subsequently interviewed and pregnancy tested. Exposure to potentially feto-toxic medications was estimated and differences between pregnant and non-pregnant women were described. Of 8970 female outpatients, 1012 (11.3%; 95% CI: 10.6% to 12%) were prescribed potentially feto-toxic medicines. After excluding 740 as unlikely to be pregnant, 209 women had negative pregnancy tests and 63 were confirmed as pregnant, representing one in 16 of women prescribed contraindicated medicines or between 2.8% and 3.5% of all women attending in early pregnancy. Most medicines were FDA rated C or D. Only 152 (55.9%) of these women had been asked about pregnancy and prescribing practices did not discriminate between pregnant and non-pregnant patients. Assessment and prescribing practices for women attending out-patient clinics who might be in early pregnancy were inadequate, increasing the risk of exposure to potentially feto-toxic medicines.

Glad you brought it up: a patient-centred programme to reduce proton-pump inhibitor prescribing in general medical practice.

PubMed

Murie, Jill; Allen, Jane; Simmonds, Ray; de Wet, Carl

2012-01-01

Many patients unnecessarily receive proton-pump inhibitor (PPI) drugs long term with significant financial and safety implications. Educating, empowering and supporting patients to self-manage their symptoms can lead to significant and sustained reductions in PPI prescribing. We aimed to implement a programme to reduce inappropriate PPI prescribing. Eligible patients in one general medical practice in rural Scotland were invited for participation between November 2008 and February 2010. Patients attended special nurse advisor clinics, completed dyspepsia questionnaires, received information, formulated self-management plans and were offered flexible support. Of the study population, 437/2883 (15%) were prescribed PPIs. Of these, 166 (38%) were judged eligible for participation. After 12 months, 138/157 (83%) had reduced or stopped their PPIs, while 19/157 (11%) had reverted. The estimated annual net saving in the prescribing budget was ?3180.67. Self-reported understanding of symptom self-management increased from 6/20 (30%) to 18/20 (90%) patients after participation in the programme. A patient-centred programme delivered by a specialist nurse significantly reduced PPI prescribing with financial and potential therapeutic benefits. The vast majority of eligible patients were able to 'step down and off' or 'step off' PPI use after 12 months without any complications or deteriorating symptom control. Further research with larger cohorts of practices and patients is needed to develop a feasible, acceptable and effective programme if similar benefits are to be achieved for primary care in general.

[Evaluation of practices in the management of scabies in children].

PubMed

Lê, M-S; Richard, M-A; Baumstarck, K; Hesse, S; Gaudy-Marqueste, C; Grob, J-J; Mallet, S

2017-05-01

Scabies has been on the rise in France in recent years and has posed therapeutic problems, mainly due to the withdrawal of benzyl benzoate. The objective of this study was to describe prescribing practices for scabies in children. A national survey was conducted by means of a standardized questionnaire covering various clinical situations of scabies and the drugs used preferentially according to age, which was sent out between December 2014 and March 2015 to members of the clinical research group of the French Society of Paediatric Dermatology. Of the 38 experts contacted, 20 replied. For a typical case of scabies, 55% of the experts initially prescribed oral ivermectin for children aged 6 years, 15% prescribed ivermectin in children aged 2 years, and 5% in infants aged 3 months. Ivermectin was more widely prescribed after failure of prior treatment or recurrence of scabies, on skin lesions or impetigo, if precarious, especially for profuse hyperkeratotic scabies. A total of 35% of the experts reported no prescribing restrictions with regard to patient age or weight. Discrepancies were observed concerning the mode of administration and the time between consecutive doses. Esdepallethrin remained the preferred local treatment among the experts (38% of all topical prescriptions) except in asthmatic children, while permethrin was the least-prescribed topical agent. This study confirms the heterogeneity of our practices. Formal expert recommendations are awaited, particularly concerning the use of ivermectin in infants. Copyright © 2017. Published by Elsevier Masson SAS.

Evaluation of Statin Eligibility, Prescribing Practices, and Therapeutic Responses Using ATP III, ACC/AHA, and NLA Dyslipidemia Treatment Guidelines in a Large Urban Cohort of HIV-Infected Outpatients.

PubMed

Levy, Matthew E; Greenberg, Alan E; Magnus, Manya; Younes, Naji; Castel, Amanda

2018-02-01

Statin coverage has been examined among HIV-infected patients using Adult Treatment Panel III (ATP III) and American College of Cardiology/American Heart Association (ACC/AHA) guidelines, although not with newer National Lipid Association (NLA) guidelines. We investigated statin eligibility, prescribing practices, and therapeutic responses using these three guidelines. Sociodemographic, clinical, and laboratory data were collected between 2011 and 2016 for HIV-infected outpatients enrolled in the DC Cohort, a multi-center, prospective, observational study in Washington, DC. This analysis included patients aged ≥21 years receiving primary care at their HIV clinic site with ≥1 cholesterol result available. Of 3312 patients (median age 52; 79% black), 52% were eligible for statins based on ≥1 guideline, including 45% (NLA), 40% (ACC/AHA), and 30% (ATP III). Using each guideline, 49% (NLA), 56% (ACC/AHA), and 73% (ATP III) of eligible patients were prescribed statins. Predictors of new prescriptions included older age (aHR = 1.16 [1.08-1.26]/5 years), body mass index ≥30 (aHR = 1.50 [1.07-2.11]), and diabetes (aHR = 1.35 [1.03-1.79]). Hepatitis C coinfection was inversely associated with statin prescriptions (aHR = 0.67 [0.45-1.00]). Among 216 patients with available cholesterol results pre-/post-prescription, 53% achieved their NLA cholesterol goal after 6 months. Hepatitis C coinfection was positively associated (aHR = 1.87 [1.06-3.32]), and depression (aHR = 0.56 [0.35-0.92]) and protease inhibitor use (aHR = 0.61 [0.40-0.93]) were inversely associated, with NLA goal achievement. Half of patients were eligible for statins based on current US guidelines, with the highest proportion eligible based on NLA guidelines, yet, fewer received prescriptions and achieved treatment goals. Greater compliance with recommended statin prescribing practices may reduce cardiovascular disease risk among HIV-infected individuals.

The impact of a good practice manual on professional practice associated with psychotropic PRN in acute mental health wards: an exploratory study.

PubMed

Baker, J A; Lovell, K; Harris, N

2008-10-01

As required or pro re nata (PRN) psychotropic medicines are frequently used in acute mental health wards. PRN is known to contribute to polypharmacy and high doses of antipsychotic medication. Few studies have attempted to improve clinician's use of these potentially harmful drugs. The objectives of the study were to determine the impact and acceptability of a good practice manual on prescribing and administration practices of PRN psychotropic medication in acute mental health wards. The study used a pre-post exploratory design with two acute mental health wards in the NW of England. Over the total trial period of 10 weeks, 28 of 35 patients received 484 doses of PRN. Patients had a mean of 3.6 prescriptions of 14 different PRN medications in 34 different dose combinations prescribed. Medication errors beyond poor quality of prescribing occurred in 23 of the 35 patients (65.7%). Prescription quality improved following the introduction of the intervention but quality of nursing notes reduced. Acceptability of the manual to both nursing and medical staff was high. The introduction of the manual appeared to influence some of the practices associated with the prescribing and administration of PRN psychotropic medications. Further, larger, more robust studies are required in this area. In particular research is required to identify the reasons why professionals continue to rely so heavily on using PRN medication.

Referral Patterns, Diagnosis, and Disease Management of Patients With Axial Spondyloarthritis

PubMed Central

van der Heijde, Désirée; Sieper, Joachim; Elewaut, Dirk; Deodhar, Atul; Pangan, Aileen L.; Dorr, Alexander P.

2014-01-01

Background Recognition, diagnosis, and management of axial spondyloarthritis (axial SpA) continue to advance. Objectives The objectives of this study were to compare referrals, diagnosis, and management of axial SpA in Western Europe (WE), North America (US and Canada), and the rest of world (RoW) in academic and community rheumatology practices and to identify areas for further education. Methods Rheumatologists responded online to the MAXIMA (Management of Axial SpA International and Multicentric Approaches) survey. Questions pertained to referral, diagnosis, and management of axial SpA. Results Rheumatologists (N = 809) from 56 countries completed the survey about patients with chronic back pain (≥3 months) starting before age 45 years. Responses from academic and community practice rheumatologists were generally similar. Most referrals were from primary care providers. Symptom duration of 3 years or more at referral was reported more frequently by WE and RoW than US respondents. More WE and RoW than US rheumatologists referred to the Assessment of SpondyloArthritis International Society criteria for axial SpA in clinical practice. Rheumatologists reported prescribing disease-modifying antirheumatic drugs for the management of axial SpA. Sulfasalazine was frequently prescribed across regions; methotrexate was more commonly prescribed by US rheumatologists compared with other regions. Conclusions Referral patterns, diagnosis, and disease management for axial SpA were similar among WE, North America, and RoW rheumatologists and in academic/community practices, although more WE and RoW rheumatologists referred to Assessment of SpondyloArthritis International Society criteria in clinical practice. Disease-modifying antirheumatic drugs were commonly prescribed for axial SpA patients, although it was unclear whether these were prescribed for axial or peripheral symptoms. PMID:25417676

Referral patterns, diagnosis, and disease management of patients with axial spondyloarthritis: results of an international survey.

PubMed

van der Heijde, Désirée; Sieper, Joachim; Elewaut, Dirk; Deodhar, Atul; Pangan, Aileen L; Dorr, Alexander P

2014-12-01

Recognition, diagnosis, and management of axial spondyloarthritis (axial SpA) continue to advance. The objectives of this study were to compare referrals, diagnosis, and management of axial SpA in Western Europe (WE), North America (US and Canada), and the rest of world (RoW) in academic and community rheumatology practices and to identify areas for further education. Rheumatologists responded online to the MAXIMA (Management of Axial SpA International and Multicentric Approaches) survey. Questions pertained to referral, diagnosis, and management of axial SpA. Rheumatologists (N = 809) from 56 countries completed the survey about patients with chronic back pain (≥3 months) starting before age 45 years. Responses from academic and community practice rheumatologists were generally similar. Most referrals were from primary care providers. Symptom duration of 3 years or more at referral was reported more frequently by WE and RoW than US respondents. More WE and RoW than US rheumatologists referred to the Assessment of SpondyloArthritis International Society criteria for axial SpA in clinical practice. Rheumatologists reported prescribing disease-modifying antirheumatic drugs for the management of axial SpA. Sulfasalazine was frequently prescribed across regions; methotrexate was more commonly prescribed by US rheumatologists compared with other regions. Referral patterns, diagnosis, and disease management for axial SpA were similar among WE, North America, and RoW rheumatologists and in academic/community practices, although more WE and RoW rheumatologists referred to Assessment of SpondyloArthritis International Society criteria in clinical practice. Disease-modifying antirheumatic drugs were commonly prescribed for axial SpA patients, although it was unclear whether these were prescribed for axial or peripheral symptoms.

The pattern of prescribing of glucose modulating agents for type 2 diabetes in general practices in England 2016/17.

PubMed

Heald, Adrian H; Livingston, Mark; Bien, Zuzanna; Moreno, Gabriela Y C; Laing, Ian; Stedman, Mike

2018-03-14

In the financial year 2016/17 there were 52.0 million items prescribed for diabetes at a total net ingredient cost of £983.7 million - up from 28.9 million prescription items and £572.4 million in 2006/07. Anti-diabetes drugs (British National Formulary section 6.1.2) make up 45.1 per cent of the total £983.7 million net ingredient cost of drugs used in diabetes and account for 72.0 per cent of prescription items for all diabetes prescribing. We examined the way that agents licensed to treat type 2 diabetes were used across GP practices in England in the year 2016/2017. Analysis was at a GP practice level not at the level of patient data. Annual prescribing costs / patient / medication type for monotherapy varied considerable from £11/year for gliclazide and glimepiride to £885/year for Liraglutide. The use of SGLT-2i agents grew strongly at 70% per annum to around 100,000 DDD with prescriptions seen in 95% of GP practices. Liraglutide expenditure (11% of total) was high for a relatively small number of patients (1.3% of Defined Daily Doses), with still significant spend on exenatide. Liraglutide use significantly exceeded that of other glucagon-like peptide-1 (GLP-1) agonists. Our work demonstrates the significant cost of medication to modulate tissue glucose levels in type 2 diabetes and the dominance of some non-generic preparations in terms of number of prescriptions and overall spend. There are some older sulphonylureas in use, which should not generally be prescribed. Regular audit of patient treatment at a general practice level will ensure appropriate targeted use of licensed medications and of their cost effectiveness. © 2018 John Wiley & Sons Ltd.

Application of concentration ratios to analyze the phenomenon of "next-door" pharmacy in Taiwan.

PubMed

Ji Chen, Tzeng; Chou, Li-Fang; Hwang, Shinn Jang

2006-08-01

In Taiwan, a policy of separation of prescribing and dispensing practices of practitioners at Western medical and dental clinics was implemented on an incremental basis in 1997. The purpose of this policy was to promote pharmacists' autonomy and increase the transparency and safety of prescribing medications. To avoid profit loss from no longer being able to dispense prescription medications, some clinics opened pharmacies located under the same roof as the clinic ("next-door" pharmacies) or hired an on-site pharmacist. This practice might compromise pharmacists' professional autonomy and patients' benefit in pharmaceutical care. The aim of the current study was to clarify the relationship between practicing pharmacies and clinics that resulted from contracts between pharmacies and the Bureau of National Health Insurance from 1996 to 2004. The National Health Research Institutes database in Taiwan supplied the complete claims data sets of practicing pharmacies from 1997 to 2004. The prescribing source of every dispensed prescription was used to calculate the 1-firm concentration ratio (CR-1) (ie, the proportion of prescriptions issued by the largest prescribing clinic/hospital in the total number of dispensed prescriptions of a pharmacy in each year). Similar processing was applied to the clinics. We identified each clinic's largest cooperating pharmacy and compared their CR-1s. Pharmacies that dispensed >900 prescriptions/mo during the study period were considered thriving. Pharmacies with a CR-1 > or =0.99 and whose largest cooperating clinic had a CR-1 > or =0.99 were considered to have a close business relationship, possibly indicating a next-door pharmacy. The total number of prescriptions dispensed at all pharmacies in the database grew from 226,901 in 1996 to 59,785,039 in 2004, and the number of pharmacies, from 481 to 3529. An increasing number of pharmacies had a higher CR-1 after 1999. We found that most prescriptions could be dispensed at only 1 pharmacy during the study period. In 2004, 1429 clinics had >900 prescriptions/mo dispensed externally and a CR-1 > or =0.99. They had released 75.8% of all prescriptions to be dispensed at practicing pharmacies; 811 of these clinics had a cooperating pharmacy with a CR-1 > or =0.99. In this data analysis in Taiwan, most prescriptions from practitioners at Western medical and dental clinics could be dispensed at only 1 pharmacy during the study period, suggesting that pharmacists' professional autonomy and the patients' benefit in pharmaceutical care might be compromised in Taiwan.

Does non-medical prescribing make a difference to patients?

PubMed

Carey, Nicola; Stenner, Karen

This article examines the literature on non-medical prescribing to establish its impact on UK healthcare. It discusses how better access to medication through non-medical prescribing can improve patient safety and patient-centred care, and how nurse prescribing can help ensure quality of care in the NHS during the current financial crisis.

Developing resilient ponderosa pine forests with mechanical thinning and prescribed fire in central Oregon's pumice region

Treesearch

Matt D. Busse; P.H. Cochran; William E. Hopkins; William H. Johnson; Gregg M. Riegel; Gary O. Fiddler; Alice W. Ratcliff; Carol J. Shestak

2009-01-01

Thinning and prescribed burning are common management practices for reducing fuel buildup in ponderosa pine forests. However, it is not well understood if their combined use is required to lower wildfire risk and to help restore natural ecological function. We compared 16 treatment combinations of thinning, prescribed fire, and slash retention for two decades...

Impact of NICE guidance on tamoxifen prescribing in England 2011-2017: an interrupted time series analysis.

PubMed

Curtis, Helen J; Walker, Alex J; Goldacre, Ben

2018-05-01

Tamoxifen was recommended by NICE in 2013 for chemoprevention of breast cancer, but a recent survey suggested only a quarter of GPs are aware of this. We set out to measure the uptake of tamoxifen, and the alternative raloxifene, in national prescribing data sets. Tamoxifen and raloxifene data were extracted from England's monthly prescribing data sets, October 2010-October 2017. We used interrupted time series analysis to reveal national and local responses to guidelines. We investigated variation between practices by calculating percentiles for prescribing rates and ratios of change. We found an increase in monthly tamoxifen prescribing following release of the guidelines, with an increase in gradient (p = 0.001) but no step change (p = 0.342). Alongside a small change in raloxifene prescribing we estimate 8450 women took up chemoprevention between 2013 and 2016. We did not find evidence that this was limited to a small group of practices. Our results suggest that the uptake of new guidance on chemoprevention has been slow and has potentially left women exposed to avoidable risk. Improving dissemination of guidance to healthcare professionals and routinely monitoring implementation could help reduce this risk.

Implementing the EQUiPPED Medication Management Program at 5 VA Emergency Departments.

PubMed

Vandenberg, Ann E; Stevens, Melissa; Echt, Katharina V; Hastings, S Nicole; Powers, James; Markland, Alayne; Hwang, Ula; Hung, William; Belbis, Stephanie; Vaughan, Camille P

2016-04-01

The Enhancing Quality of Prescribing Practices for Older Veterans Discharged From the Emergency Department (EQUiPPED) program aimed to reduce potentially inappropriate medication prescribing to older adults at 5 VAMCs.

A closer look: decoupling the effects of prescribed fire and grazing on vegetation in a ponderosa pine forests

Treesearch

Marie Oliver; Becky K. Kerns; Michelle Buonopane

2012-01-01

Scientists have had little information about how prescribed fire and cattle grazing—common practices in many Western ponderosa pine forests—affects plant abundance and reproduction in the forest understory. Pacific Northwest Research Station scientists began to explore how these practices affect vegetation in a five-year study of postfire vegetation in eastern Oregon...

What are the similarities and differences in antimicrobial prescribing between Australian public and private hospitals?

PubMed

Cotta, M O; Chen, C; Tacey, M; James, R S; Buising, K L; Marshall, C; Thursky, K A

2016-10-01

Identifying themes associated with inappropriate prescribing in Australian public and private hospitals will help target future antimicrobial stewardship initiatives. To describe current antimicrobial prescribing practices, identify similarities and differences between hospital sectors and provide target areas for improvement specific to each hospital sector. All hospitals included in the study were part of the 2014 national antimicrobial prescribing survey and conducted one of the following: a whole hospital point prevalence survey, serial point prevalence surveys or a sample of randomly selected patients. Data on the types of antibiotics used, their indications for use and the quality of prescription based on compliance with national and local prescribing guidelines were collected. Two hundred and two hospitals (166 public and 36 private) comprising 10 882 patients and 15 967 antimicrobial prescriptions were included. Public hospitals had higher proportions of prescriptions for treatment (81.5% vs 48.4%) and medical prophylaxis (8.8% and 4.6%), whilst private hospitals had significantly higher surgical prophylaxis use (9.6% vs 46.9%) (P < 0.001). In public hospitals, the main reasons for non-compliance of treatment prescriptions were spectrum being too broad (30.5%) while in private it was incorrect dosing. Prolonged duration was the main reason for non-compliance among surgical prophylaxis prescriptions in both types of hospitals. Australian hospitals need to target specific areas to improve antimicrobial use. Specifically, unnecessary broad-spectrum therapy should be a priority area in public hospitals, whilst emphasis on curtailing antimicrobial overuse in surgical prophylaxis needs to be urgently addressed across in the private hospital sector. © 2016 Royal Australasian College of Physicians.

Diabetes management in an Australian primary care population.

PubMed

Krass, I; Hebing, R; Mitchell, B; Hughes, J; Peterson, G; Song, Y J C; Stewart, K; Armour, C L

2011-12-01

Worldwide studies have shown that significant proportions of patients with type 2 diabetes (T2DM) do not meet targets for glycaemic control, blood pressure (BP) and lipids, putting them at higher risk of developing complications. However, little is known about medicines management in Australian primary care populations with T2DM. The aim of this study was to (i) describe the management of a large group of patients in primary care, (ii) identify areas for improvement in management and (iii) determine any relationship between adherence and glycaemic, BP and lipid control. This was a retrospective, epidemiological study of primary care patients with T2DM diabetes, with HbA(1c) of >7%, recruited in 90 Australian community pharmacies. Data collected included demographic details, diabetes history, current medication regimen, height, weight, BP, physical activity and smoking status. Of the 430 patients, 98% used antidiabetics, 80% antihypertensives, 73% lipid lowering drugs and 38% aspirin. BP and all lipid targets were met by only 21% and 14% of the treated patients and 21% and 12% of the untreated patients respectively. Medication adherence was related to better glycaemic control (P = 0.04). An evidence-base prescribing practice gap was seen in this Australian primary care population of T2DM patients. Patients were undertreated with antihypertensive and lipid lowering medication, and several subgroups with co-morbidities were not receiving the recommended pharmacotherapy. Interventions are required to redress the current evidence-base prescribing practice gap in disease management in primary care. © 2011 Blackwell Publishing Ltd.

Antihypertensive medication prescription patterns and time trends for newly-diagnosed uncomplicated hypertension patients in Taiwan

PubMed Central

Liu, Pang-Hsiang; Wang, Jung-Der

2008-01-01

Background Knowledge of existing prescription patterns in the treatment of newly-diagnosed hypertension can provide useful information for improving clinical practice in this field. The aims of this study are to determine the prescription patterns and time trends for antihypertensive medication in newly-diagnosed cases of uncomplicated hypertension in Taiwan and to compare these with current clinical guidelines. Methods A total of 6,536 newly-diagnosed patients with uncomplicated hypertension, aged ≥30 years, were identified from the representative 200,000-person sample in the computerized reimbursement database of the National Health Insurance in Taiwan. These patients were followed from 1998 to 2004 with all diagnoses, prescription data and medication charges being retrieved for subsequent analysis. Results Prescription patterns varied by age, gender and clinical facilities, with mono-therapies being found to be dominant in the first year, albeit declining over time. Calcium channel blockers and beta-blockers were the most frequently prescribed antihypertensive drugs, either alone or in combinations. Although least expensive, the prescription rates of diuretics were low, at 8.3% for mono-therapies and 19.9% overall. The prescription rate for angiotensin receptor blockers (ARBs) was elevated considerably over time. After controlling for other related factors by multiple logistic regression analysis, ARBs were found to be prescribed mainly by medical centers or regional hospitals. Conclusion These findings indicate the existence of a gap between current clinical practice and the desired goal of cost-effectiveness in antihypertensive treatment in Taiwan, which should be corrected. PMID:18559115

Antihypertensive medication prescription patterns and time trends for newly-diagnosed uncomplicated hypertension patients in Taiwan.

PubMed

Liu, Pang-Hsiang; Wang, Jung-Der

2008-06-18

Knowledge of existing prescription patterns in the treatment of newly-diagnosed hypertension can provide useful information for improving clinical practice in this field. The aims of this study are to determine the prescription patterns and time trends for antihypertensive medication in newly-diagnosed cases of uncomplicated hypertension in Taiwan and to compare these with current clinical guidelines. A total of 6,536 newly-diagnosed patients with uncomplicated hypertension, aged >/=30 years, were identified from the representative 200,000-person sample in the computerized reimbursement database of the National Health Insurance in Taiwan. These patients were followed from 1998 to 2004 with all diagnoses, prescription data and medication charges being retrieved for subsequent analysis. Prescription patterns varied by age, gender and clinical facilities, with mono-therapies being found to be dominant in the first year, albeit declining over time. Calcium channel blockers and beta-blockers were the most frequently prescribed antihypertensive drugs, either alone or in combinations. Although least expensive, the prescription rates of diuretics were low, at 8.3% for mono-therapies and 19.9% overall. The prescription rate for angiotensin receptor blockers (ARBs) was elevated considerably over time. After controlling for other related factors by multiple logistic regression analysis, ARBs were found to be prescribed mainly by medical centers or regional hospitals. These findings indicate the existence of a gap between current clinical practice and the desired goal of cost-effectiveness in antihypertensive treatment in Taiwan, which should be corrected.

Developing standardised treatment for adults with myositis and different phenotypes: an international survey of current prescribing preferences.

PubMed

Tansley, Sarah; Shaddick, Gavin; Christopher-Stine, Lisa; Sharp, Charlotte; Dourmishev, Lyubomir; Maurer, Britta; Chinoy, Hector; McHugh, Neil

2016-01-01

The evidence base for treatment of the idiopathic inflammatory myopathies is extremely limited. The rarity and heterogeneity of these diseases has hampered the development of good quality clinical trials and while a range of immunomodulatory treatments are commonly used in clinical practice, as yet there are no clear guidelines directing their use. We aimed to establish current prescribing regimens used to treat adults with myositis internationally. An electronic survey based on different clinical scenarios was distributed internationally to clinicians involved in the treatment of patients with myositis. Participants were asked to select their first-line treatment preferences in each situation. A multinomial regression analysis was used to assess the influence of clinical scenario, respondent expertise and country of origin on first-line treatment choice. 107 survey responses were received. 57% of respondents considered themselves an expert in myositis and the majority of respondents were rheumatologists although responses from other specialities were also received. Pharmacological treatment with steroids and additional immunotherapy was the preference in most scenarios. First-line immunosuppressant choice was significantly influenced by the clinical scenario, the expertise of the treating physician and country of practice. Azathioprine, methotrexate and mycophenolate mofetil were the most commonly chosen agents. In the absence of available evidence, clinical experience and expert consensus often forms the basis of treatment guidelines. These results suggest that an international consensus approach would be possible in myositis and would overcome an urgent, yet unmet need for patients suffering with this difficult disease.

Ecological Assessment of Clinicians' Antipsychotic Prescription Habits in Psychiatric Inpatients: A Novel Web- and Mobile Phone-Based Prototype for a Dynamic Clinical Decision Support System.

PubMed

Berrouiguet, Sofian; Barrigón, Maria Luisa; Brandt, Sara A; Nitzburg, George C; Ovejero, Santiago; Alvarez-Garcia, Raquel; Carballo, Juan; Walter, Michel; Billot, Romain; Lenca, Philippe; Delgado-Gomez, David; Ropars, Juliette; de la Calle Gonzalez, Ivan; Courtet, Philippe; Baca-García, Enrique

2017-01-26

Electronic prescribing devices with clinical decision support systems (CDSSs) hold the potential to significantly improve pharmacological treatment management. The aim of our study was to develop a novel Web- and mobile phone-based application to provide a dynamic CDSS by monitoring and analyzing practitioners' antipsychotic prescription habits and simultaneously linking these data to inpatients' symptom changes. We recruited 353 psychiatric inpatients whose symptom levels and prescribed medications were inputted into the MEmind application. We standardized all medications in the MEmind database using the Anatomical Therapeutic Chemical (ATC) classification system and the defined daily dose (DDD). For each patient, MEmind calculated an average for the daily dose prescribed for antipsychotics (using the N05A ATC code), prescribed daily dose (PDD), and the PDD to DDD ratio. MEmind results found that antipsychotics were used by 61.5% (217/353) of inpatients, with the largest proportion being patients with schizophrenia spectrum disorders (33.4%, 118/353). Of the 217 patients, 137 (63.2%, 137/217) were administered pharmacological monotherapy and 80 (36.8%, 80/217) were administered polytherapy. Antipsychotics were used mostly in schizophrenia spectrum and related psychotic disorders, but they were also prescribed in other nonpsychotic diagnoses. Notably, we observed polypharmacy going against current antipsychotics guidelines. MEmind data indicated that antipsychotic polypharmacy and off-label use in inpatient units is commonly practiced. MEmind holds the potential to create a dynamic CDSS that provides real-time tracking of prescription practices and symptom change. Such feedback can help practitioners determine a maximally therapeutic drug treatment while avoiding unproductive overprescription and off-label use. ©Sofian Berrouiguet, Maria Luisa Barrigón, Sara A Brandt, George C Nitzburg, Santiago Ovejero, Raquel Alvarez-Garcia, Juan Carballo, Michel Walter, Romain Billot, Philippe Lenca, David Delgado-Gomez, Juliette Ropars, Ivan de la Calle Gonzalez, Philippe Courtet, Enrique Baca-García. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 26.01.2017.

Opioid prescribing patterns after Mohs micrographic surgery and standard excision: a survey of American Society for Dermatologic Surgery members and a chart review at a single institution.

PubMed

Harris, Kalynne; Calder, Scott; Larsen, Brooke; Duffy, Keith; Bowen, Glen; Tristani-Firouzi, Payam; Hadley, Michael; Endo, Justin

2014-08-01

Little is known about postoperative opioid prescribing patterns among dermatologic surgeons. To better understand postoperative opioid prescribing patterns among dermatologic surgeons in the United States. Two-part analysis consisting of a retrospective chart review of 233 dermatologic surgery patients at a single institution and an e-mail survey of American Society for Dermatologic Surgery (ASDS) members. (1) Retrospective review: 35% (82/233) of the patients received an opioid prescription. Larger defect size, repair of the defect, perioral and nasal site, and surgeon A or B performing surgery predicted opioid prescription. (2) E-mail survey: 556 ASDS members practicing within the United States responded. Sixty-four percent (357/556) reported prescribing opioids after ≤10% of cases. Surgeons younger than 55 years old, male surgeons, and surgeons in the southern and western United States were more likely to prescribe opioids after >10% of cases. Seventy-six percent (397/520) believed patients used ≤50% of the opioid pills prescribed. The retrospective review suggests that opioid prescribing is predicted by characteristics of the surgery (i.e., size, defect repair type, and anatomic location) and characteristics of the surgeon (i.e., age, sex, and practice location) with significant heterogeneity in prescribing habits. The national survey results raise the possibility that patients might not take all prescribed opioid pills after dermatologic surgery. Further investigation is warranted to determine how patients are actually using prescription pain pills to balance pain control with patient safety.

Repeat prescribing of medications: A system‐centred risk management model for primary care organisations

PubMed Central

Price, Julie; Man, Shu Ling; Bartlett, Stephen; Taylor, Kate; Dinwoodie, Mark

2017-01-01

Abstract Rationale, aims and objectives Reducing preventable harm from repeat medication prescriptions is a patient safety priority worldwide. In the United Kingdom, repeat prescriptions items issued has doubled in the last 20 years from 5.8 to 13.3 items per patient per annum. This has significant resource implications and consequences for avoidable patient harms. Consequently, we aimed to test a risk management model to identify, measure, and reduce repeat prescribing system risks in primary care. Methods All 48 general medical practices in National Health Service (NHS) Lambeth Clinical Commissioning Group (an inner city area of south London in England) were recruited. Multiple interventions were implemented, including educational workshops, a web‐based risk monitoring system, and external reviews of repeat prescribing system risks by clinicians. Data were collected via documentation reviews and interviews and subject to basic thematic and descriptive statistical analyses. Results Across the 48 participating general practices, 62 unique repeat prescribing risks were identified on 505 occasions (eg, practices frequently experiencing difficulty interpreting medication changes on hospital discharge summaries), equating to a mean of 8.1 risks per practice (range: 1‐33; SD = 7.13). Seven hundred sixty‐seven system improvement actions were recommended across 96 categories (eg, alerting hospitals to illegible writing and delays with discharge summaries) with a mean of 15.6 actions per practice (range: 0‐34; SD = 8.0). Conclusions The risk management model tested uncovered important safety concerns and facilitated the development and communication of related improvement recommendations. System‐wide information on hazardous repeat prescribing and how this could be mitigated is very limited. The approach reported may have potential to close this gap and improve the reliability of general practice systems and patient safety, which should be of high interest to primary care organisations internationally. PMID:28370904

Implementing the EQUiPPED Medication Management Program at 5 VA Emergency Departments

PubMed Central

Vandenberg, Ann E.; Stevens, Melissa; Echt, Katharina V.; Hastings, S. Nicole; Powers, James; Markland, Alayne; Hwang, Ula; Hung, William; Belbis, Stephanie; Vaughan, Camille P.

2016-01-01

The Enhancing Quality of Prescribing Practices for Older Veterans Discharged From the Emergency Department (EQUiPPED) program aimed to reduce potentially inappropriate medication prescribing to older adults at 5 VAMCs. PMID:27773986

Practical Approaches to Prescribing Physical Activity and Monitoring Exercise Intensity.

PubMed

Reed, Jennifer L; Pipe, Andrew L

2016-04-01

Regular physical activity helps to prevent heart disease, and reduces the risk of first or subsequent cardiovascular events. It is recommended that Canadian adults accumulate at least 150 minutes of moderate- to vigorous-intensity aerobic exercise per week, in bouts of 10 minutes or more, and perform muscle- and bone-strengthening activities at least 2 days per week. Individual exercise prescriptions can be developed using the frequency, intensity, time, and type principles. Increasing evidence suggests that high-intensity interval training is efficacious for a broad spectrum of heart health outcomes. Several practical approaches to prescribing and monitoring exercise intensity exist including: heart rate monitoring, the Borg rating of perceived exertion scale, the Talk Test, and, motion sensors. The Borg rating of perceived exertion scale matches a numerical value to an individual's perception of effort, and can also be used to estimate heart rate. The Talk Test, the level at which simple conversation is possible, can be used to monitor desired levels of moderate- to vigorous-intensity exercise. Motion sensors can provide users with practical and useful exercise training information to aid in meeting current exercise recommendations. These approaches can be used by the public, exercise scientists, and clinicians to easily and effectively guide physical activity in a variety of settings. Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Current sickle cell disease management practices in Nigeria.

PubMed

Galadanci, N; Wudil, B J; Balogun, T M; Ogunrinde, G O; Akinsulie, A; Hasan-Hanga, F; Mohammed, A S; Kehinde, M O; Olaniyi, J A; Diaku-Akinwumi, I N; Brown, B J; Adeleke, S; Nnodu, O E; Emodi, I; Ahmed, S; Osegbue, A O; Akinola, N; Opara, H I O; Adegoke, S A; Aneke, J; Adekile, A D

2014-03-01

Although Nigeria has the highest burden of sickle cell disease (SCD) worldwide, there is still variable and poor utilisation of standard-of-care practices for SCD patients in the country. This was a questionnaire survey of doctors in some dedicated SCD clinics in Nigeria in order to document the facilities available and common management practices. There were responses from 18 clinics based in 11 institutions. The number of patients being followed in each centre ranged from 15 to approximately 11 000. All clinics provided malaria prophylaxis and folic acid routinely to their patients. Only eight clinics prescribe penicillin prophylaxis. Eight prescribe hydroxyurea to patients who can afford it when indicated. All of the centres except three have electronic cell counters, but all had access to haemoglobin electrophoresis. Three had high-performance liquid chromatography machines installed but none was being routinely used. One institution had a functioning molecular biology laboratory. There is no official newborn screening programme in the country. All had access to microbiology and chemistry laboratories. Nine institutions had CT, six had MRI and three had transcranial Doppler facilities. The care available for SCD in Nigeria is still suboptimal and there is an urgent need for concerted effort to tackle the problem, but to make a significant impact on the burden of the disease would require more focus at the primary care level. Some steps to achieving this are outlined.

Factors associated with physicians' reliance on pharmaceutical sales representatives.

PubMed

Anderson, Britta L; Silverman, Gabriel K; Loewenstein, George F; Zinberg, Stanley; Schulkin, Jay

2009-08-01

To examine relationships between pharmaceutical representatives and obstetrician-gynecologists and identify factors associated with self-reported reliance on representatives when making prescribing decisions. In 2006-2007, questionnaires were mailed to 515 randomly selected physicians in the American College of Obstetricians and Gynecologists' Collaborative Ambulatory Research Network. Participants were asked about the information sources used when deciding to prescribe a new drug, interactions with sales representatives, views of representatives' value, and guidelines they had read on appropriate industry interactions. Two hundred fifty-one completed questionnaires (49%) were returned. Seventy-six percent of participants see sales representatives' information as at least somewhat valuable. Twenty-nine percent use representatives often or almost always when deciding whether to prescribe a new drug; 44% use them sometimes. Physicians in private practice are more likely than those in university hospitals to interact with, value, and rely on representatives; community hospital physicians tend to fall in the middle. Gender and age are not associated with industry interaction. Dispensing samples is associated with increased reliance on representatives when making prescribing decisions, beyond what is predicted by a physician's own beliefs about the value of representatives' information. Reading guidelines on physician-industry interaction is not associated with less reliance on representatives after controlling for practice setting. Physicians' interactions with industry and their familiarity with guidelines vary by practice setting, perhaps because of more restrictive policies in university settings, professional isolation of private practice, or differences in social norms. Prescribing samples may be associated with physicians' use of information from sales representatives more than is merited by the physicians' own beliefs about the value of pharmaceutical representatives.

Essential therapeutics skills required of junior doctors.

PubMed

Baldwin, Mathew J; Abouyannis, Michael; Butt, Tehreem F

2012-12-01

Junior doctors are responsible for the majority of in-hospital prescription errors. Little research has explored their confidence to prescribe, or practical therapeutics related tasks which they are required to perform in day-to-day practice. This survey aimed to explore these areas, gather feedback regarding therapeutics teaching at undergraduate level, and to apply findings to undergraduate training at University of Birmingham. Questionnaire-based survey of all first-year postgraduate doctors (PG1) attending teaching hospitals in the Birmingham and Worcester regions towards the end of the PG1 year. Doctors were asked about difficulties in prescribing, satisfaction with undergraduate training, and how frequently they undertook particular tasks pertaining to therapeutics. Qualitative data on suggestions for improving the curriculum were also collected. Difficulties were commonly encountered with prescribing warfarin, controlled drugs and syringe-driven drugs. Most (87.4 %) had been required to administer intravenous medications. Nearly all had prescribed to 'special groups' such as the elderly (100 %) and patients with renal disease (98.3 %). Thirty-seven percent were not satisfied with their undergraduate therapeutics teaching, and many (56.2 %) recommended making teaching more relevant to clinical practice. Many PG1s expressed difficulties in prescribing potentially dangerous medications. Although better than other UK surveys, significant numbers were not satisfied with undergraduate teaching. The strong opinion was for teaching to become more practical and more relevant. Prescriptions which PG1s are commonly asked to write have been described. Findings have guided improvements to undergraduate teaching and assessment in therapeutics at the University of Birmingham, and may offer guidance to other medical schools.

[Development of a pharmacological curriculum for general practice: Identifying and prescribing orally administered pharmacological substances with relevance for general practice].

PubMed

Straßner, Cornelia; Kaufmann-Kolle, Petra; Flum, Elisabeth; Schwill, Simon; Brandt, Bettina; Steinhäuser, Jost

2017-05-01

General practitioners (GPs) are among the specialists who prescribe the highest number of medication. Therefore the improvement of pharmacological competencies is an important part of the GP specialist training. The self-concept of general practice stating that GPs are the first contact persons for all health problems makes it challenging to define and acquire competencies for specialist training. While the "Competence-based Curriculum" developed by the German College of General Practitioners and Family Physicians defines diagnoses, reasons for counselling and competencies which are essential for general practice, a similar orientation guide is lacking for the pharmacological field. The aim of this study is to define and characterize pharmacological substances which every GP should know so well that he or she is able to conduct counselling and monitoring. We analysed private and public health insurance prescriptions of all general practices participating in the CONTENT project in the period from 2009 to 2014. The analysis was limited to substances with oral application which were prescribed at least once by at least 25 % (n = 11) of the practices. While the 100 most frequent prescriptions were included due to their frequency, less frequently prescribed substances were assessed concerning their relevance for general practice in a rating procedure. The substances included were classified by diagnoses and reasons for counselling. We analysed 1,912,896 prescriptions from 44 practices and 112,535 patients on the basis of the Anatomical Therapeutic Chemical (ATC) classification system. After applying the inclusion criteria, 453 substances were left, 302 of which were considered relevant for general practice and could be assigned to 45 diagnoses / reasons for counselling. The result of this study could be considered a working draft for a pharmacological curriculum for general practice, which may complement the "Competence-based Curriculum" in the medium term. Copyright © 2017. Published by Elsevier GmbH.

The assessment of pharmaceutical sales representatives by family physicians--does it affect the prescribing index?

PubMed

Klemenc-Ketis, Zalika; Kersnik, Janko

2013-06-01

Physicians' prescribing patterns depend on fixed and influence-sensitive factors. The latter include the influence of interactions with the pharmaceutical industry. To determine whether the assessment of pharmaceutical sales representatives (PSRs) by family physicians was associated with their actual prescribing index. Cross-sectional anonymous postal study. We included all family physicians working in practice settings in Slovenia in 2011. Slovenian family physicians' surgeries. Prescribing index of Slovenian family physicians. We received 247 responses (27.6% response rate). A prescribing index >100% was present in 57 (23.1%) of the respondents. Multivariate analysis revealed that working in regions of Slovenia other than the central region might be associated with a prescribing index >100%. Assessment of PSRs by family physicians was not significantly associated with a prescribing index >100%. The assessment of PSRs by family physicians does not have any substantial correlations with their prescribing index.

The primary care prescribing psychologist model: medical provider ratings of the safety, impact and utility of prescribing psychology in a primary care setting.

PubMed

Shearer, David S; Harmon, S Cory; Seavey, Brian M; Tiu, Alvin Y

2012-12-01

Family medicine providers at a large family medicine clinic were surveyed regarding their impression of the impact, utility and safety of the Primary Care Prescribing Psychologist (PCPP) model in which a prescribing psychologist is embedded in a primary care clinic. This article describes the model and provides indications of its strengths and weaknesses as reported by medical providers who have utilized the model for the past 2 years. A brief history of prescribing psychology and the challenges surrounding granting psychologists the authority to prescribe psychotropic medication is summarized. Results indicate family medicine providers agree that having a prescribing psychologist embedded in the family medicine clinic is helpful to their practice, safe for patients, convenient for providers and for patients, and improves patient care. Potential benefits of integrating prescribing psychology into primary care are considered and directions for future research are discussed.

Cluster randomized trials utilizing primary care electronic health records: methodological issues in design, conduct, and analysis (eCRT Study).

PubMed

Gulliford, Martin C; van Staa, Tjeerd P; McDermott, Lisa; McCann, Gerard; Charlton, Judith; Dregan, Alex

2014-06-11

There is growing interest in conducting clinical and cluster randomized trials through electronic health records. This paper reports on the methodological issues identified during the implementation of two cluster randomized trials using the electronic health records of the Clinical Practice Research Datalink (CPRD). Two trials were completed in primary care: one aimed to reduce inappropriate antibiotic prescribing for acute respiratory infection; the other aimed to increase physician adherence with secondary prevention interventions after first stroke. The paper draws on documentary records and trial datasets to report on the methodological experience with respect to research ethics and research governance approval, general practice recruitment and allocation, sample size calculation and power, intervention implementation, and trial analysis. We obtained research governance approvals from more than 150 primary care organizations in England, Wales, and Scotland. There were 104 CPRD general practices recruited to the antibiotic trial and 106 to the stroke trial, with the target number of practices being recruited within six months. Interventions were installed into practice information systems remotely over the internet. The mean number of participants per practice was 5,588 in the antibiotic trial and 110 in the stroke trial, with the coefficient of variation of practice sizes being 0.53 and 0.56 respectively. Outcome measures showed substantial correlations between the 12 months before, and after intervention, with coefficients ranging from 0.42 for diastolic blood pressure to 0.91 for proportion of consultations with antibiotics prescribed, defining practice and participant eligibility for analysis requires careful consideration. Cluster randomized trials may be performed efficiently in large samples from UK general practices using the electronic health records of a primary care database. The geographical dispersal of trial sites presents a difficulty for research governance approval and intervention implementation. Pretrial data analyses should inform trial design and analysis plans. Current Controlled Trials ISRCTN 47558792 and ISRCTN 35701810 (both registered on 17 March 2010).

Cluster randomized trials utilizing primary care electronic health records: methodological issues in design, conduct, and analysis (eCRT Study)

PubMed Central

2014-01-01

Background There is growing interest in conducting clinical and cluster randomized trials through electronic health records. This paper reports on the methodological issues identified during the implementation of two cluster randomized trials using the electronic health records of the Clinical Practice Research Datalink (CPRD). Methods Two trials were completed in primary care: one aimed to reduce inappropriate antibiotic prescribing for acute respiratory infection; the other aimed to increase physician adherence with secondary prevention interventions after first stroke. The paper draws on documentary records and trial datasets to report on the methodological experience with respect to research ethics and research governance approval, general practice recruitment and allocation, sample size calculation and power, intervention implementation, and trial analysis. Results We obtained research governance approvals from more than 150 primary care organizations in England, Wales, and Scotland. There were 104 CPRD general practices recruited to the antibiotic trial and 106 to the stroke trial, with the target number of practices being recruited within six months. Interventions were installed into practice information systems remotely over the internet. The mean number of participants per practice was 5,588 in the antibiotic trial and 110 in the stroke trial, with the coefficient of variation of practice sizes being 0.53 and 0.56 respectively. Outcome measures showed substantial correlations between the 12 months before, and after intervention, with coefficients ranging from 0.42 for diastolic blood pressure to 0.91 for proportion of consultations with antibiotics prescribed, defining practice and participant eligibility for analysis requires careful consideration. Conclusions Cluster randomized trials may be performed efficiently in large samples from UK general practices using the electronic health records of a primary care database. The geographical dispersal of trial sites presents a difficulty for research governance approval and intervention implementation. Pretrial data analyses should inform trial design and analysis plans. Trial registration Current Controlled Trials ISRCTN 47558792 and ISRCTN 35701810 (both registered on 17 March 2010). PMID:24919485

Effects of prescribed fire and fire surrogates on Saproxylic coleoptera in the Southern Appalachians of North Carolina

Treesearch

Joshua W. Campbell; James L. Hanula; Thomas A. Waldrop

2008-01-01

We examined the effects of forest management practices (prescribed burning, mechanical, and prescribed burn plus mechanical) on saproxylic forest Coleoptera in the southern Appalachian Mountains of North Carolina. During the 2-yr study, we captured 37,191 Coleoptera with baited multiple- unnel traps and pipe traps, comprising 20 families and 122 species that were used...

A comprehensive guide to fuel management practices for dry mixed conifer forests in the northwestern United States: Prescribed fire

Treesearch

Theresa B. Jain; Mike A. Battaglia; Han-Sup Han; Russell T. Graham; Christopher R. Keyes; Jeremy S. Fried; Jonathan E. Sandquist

2014-01-01

Fire has had a profound historical role in shaping dry mixed conifer forests in the western United States. However, the uncertainty and complexity of prescribed fires raises the question “Is fire always the best option for treating fuels?” The decision to use prescribed fire is dependent upon several factors.

Agile software development in an earned value world: a survival guide

NASA Astrophysics Data System (ADS)

Kantor, Jeffrey; Long, Kevin; Becla, Jacek; Economou, Frossie; Gelman, Margaret; Juric, Mario; Lambert, Ron; Krughoff, Simon; Swinbank, John D.; Wu, Xiuqin

2016-08-01

Agile methodologies are current best practice in software development. They are favored for, among other reasons, preventing premature optimization by taking a somewhat short-term focus, and allowing frequent replans/reprioritizations of upcoming development work based on recent results and current backlog. At the same time, funding agencies prescribe earned value management accounting for large projects which, these days, inevitably include substantial software components. Earned Value approaches emphasize a more comprehensive and typically longer-range plan, and tend to characterize frequent replans and reprioritizations as indicative of problems. Here we describe the planning, execution and reporting framework used by the LSST Data Management team, that navigates these opposite tensions.

Preparing medical students for clinical practice: easing the transition.

PubMed

Teagle, Alexandra R; George, Maria; Gainsborough, Nicola; Haq, Inam; Okorie, Michael

2017-08-01

The transition from medical student to junior doctor is a challenge; the UK General Medical Council has issued guidance emphasizing the importance of adequate preparation of medical students for clinical practice. This study aimed to determine whether a junior doctor-led simulation-based course is an effective way of preparing final year medical students for practice as a junior doctor.We piloted a new 'preparation for practice' course for final year medical students prior to beginning as Foundation Year 1 (first year of practice) doctors. The course ran over three days and consisted of four simulated stations: ward round, prescribing, handover, and lessons learnt. Quantitative and qualitative feedback was obtained.A total of 120 students attended (40 on each day) and feedback was collected from 95 of them. Using a scale of 1 (lowest) to 5 (highest), feedback was positive, with 99% and 96% rating 4 or 5 for the overall quality of the program and the relevance of the program content, respectively. A score of 5 was awarded by 67% of students for the ward round station; 58% for the handover station; 71% for the prescribing station, and 35% for the lessons learnt station. Following the prescribing station, students reported increased confidence in their prescribing.Preparation for practice courses and simulation are an effective and enjoyable way of easing the transition from medical student to junior doctor. Together with 'on-the-job' shadowing time, such programs can be used to improve students' confidence, competence, and ultimately patient safety and quality of care.

Knowledge, Practices, and Barriers to HIV Pre-Exposure Prophylaxis (PrEP) Prescribing Among Washington State Medical Providers.

PubMed

Wood, Brian R; McMahan, Vanessa M; Naismith, Kelly; Stockton, Jonathan B; Delaney, Lori A; Stekler, Joanne D

2018-01-04

We aimed to assess HIV pre-exposure prophylaxis (PrEP) awareness and prescribing practices among Washington State medical providers from diverse professional disciplines and practice types. In May 2016, we administered an anonymous online survey to licensed medical practitioners who provide primary, longitudinal, walk-in, emergency, obstetric, gynecologic, sexually transmitted infection (STI), or family planning care. Of 735 eligible providers, 64.8% had heard of PrEP. Younger providers and providers with a Doctor of Medicine (MD) degree were more likely to be aware of PrEP compared to older providers (p=0.0001) and providers of other training backgrounds (Advanced Registered Nurse Practitioner [ARNP], Doctor of Osteopathic Medicine [DO], or Physician Assistant [PA]) (p=0.04). Among providers aware of PrEP, most frequent reported concerns about prescribing were adherence (46.0%) and costs (42.9%). Providers felt very (20.1%) or somewhat (33.8%) comfortable discussing PrEP overall, but very (26.8%) or somewhat (44.7%) uncomfortable discussing cost and insurance issues. The 124 PrEP prescribers reported a median of 2 (range 1-175, total 1,142) patients prescribed PrEP. Prior authorizations and insurance denials had prevented prescriptions for 28.7% and 12.1% of prescribers, respectively. Interventions to improve PrEP access should include education to inform medical providers about PrEP, with particular attention to provider types less likely to be aware. Continued efforts to eliminate cost and insurance barriers and educate providers regarding financial resources would help improve PrEP access.

Antibiotics and Facial Fractures: Evidence-Based Recommendations Compared with Experience-Based Practice

PubMed Central

Mundinger, Gerhard S.; Borsuk, Daniel E.; Okhah, Zachary; Christy, Michael R.; Bojovic, Branko; Dorafshar, Amir H.; Rodriguez, Eduardo D.

2014-01-01

Efficacy of prophylactic antibiotics in craniofacial fracture management is controversial. The purpose of this study was to compare evidence-based literature recommendations regarding antibiotic prophylaxis in facial fracture management with expert-based practice. A systematic review of the literature was performed to identify published studies evaluating pre-, peri-, and postoperative efficacy of antibiotics in facial fracture management by facial third. Study level of evidence was assessed according to the American Society of Plastic Surgery criteria, and graded practice recommendations were made based on these assessments. Expert opinions were garnered during the Advanced Orbital Surgery Symposium in the form of surveys evaluating senior surgeon clinical antibiotic prescribing practices by time point and facial third. A total of 44 studies addressing antibiotic prophylaxis and facial fracture management were identified. Overall, studies were of poor quality, precluding formal quantitative analysis. Studies supported the use of perioperative antibiotics in all facial thirds, and preoperative antibiotics in comminuted mandible fractures. Postoperative antibiotics were not supported in any facial third. Survey respondents (n = 17) cumulatively reported their antibiotic prescribing practices over 286 practice years and 24,012 facial fracture cases. Percentages of prescribers administering pre-, intra-, and postoperative antibiotics, respectively, by facial third were as follows: upper face 47.1, 94.1, 70.6; midface 47.1, 100, 70.6%; and mandible 68.8, 94.1, 64.7%. Preoperative but not postoperative antibiotic use is recommended for comminuted mandible fractures. Frequent use of pre- and postoperative antibiotics in upper and midface fractures is not supported by literature recommendations, but with low-level evidence. Higher level studies may better guide clinical antibiotic prescribing practices. PMID:25709755

Prescription drug use and self-prescription among resident physicians.

PubMed

Christie, J D; Rosen, I M; Bellini, L M; Inglesby, T V; Lindsay, J; Alper, A; Asch, D A

1998-10-14

Self-prescription is common among practicing physicians, but little is known about the practice among resident physicians. To determine prescription drug use and self-prescription among US resident physicians. Anonymous mail survey of all resident physicians in 4 US categorical internal medicine training programs in February 1997. Self-reported use of health care services and prescription medications and how they were obtained. A total of 316 (83%) of 381 residents responded; 244 residents (78%) reported using at least 1 prescription medicine and 162 residents (52%) reported self-prescribing medications. Twenty-five percent of all medications and 42% of self-prescribed medications were obtained from a sample cabinet; 7% of all medications and 11% of self-prescribed medications were obtained directly from a pharmaceutical company representative. Self-prescription is common among resident physicians. Although self-prescription is difficult to evaluate, the source of these medications and the lack of oversight of medication use raise questions about the practice.

Patterns of methadone maintenance treatment provision in Ontario: Policy success or pendulum excess?

PubMed

Kurdyak, Paul; Jacob, Binu; Zaheer, Juveria; Fischer, Benedikt

2018-02-01

To describe recent trends and patterns in methadone maintenance treatment (MMT) practice regionally and over time in the province of Ontario. Population-based descriptive study using health administrative data between September 1, 2011, and December 31, 2014. Ontario. All active MMT-prescribing physicians and patients receiving MMT in the study period. Characteristics of MMT-prescribing physicians, including age, sex, specialty type, practice region, and practice volume; characteristics of patients receiving MMT, including age, sex, neighbourhood income, and region of residence. Between September 1, 2011, and December 31, 2014, the number of MMT-prescribing physicians and patients who received MMT increased by 26% and 42%, respectively. In 2014, there was a total of 312 MMT-prescribing physicians and 49 703 patients receiving MMT. In 2014 and on a per capita basis, patients receiving MMT were more prevalent in rural regions; and within rural regions, there were disproportionately large numbers of young female MMT patients residing in low-income neighbourhoods. The number of physicians prescribing MMT and patients receiving MMT has increased substantially between 2011 and 2014, with the largest per capita distribution occurring in rural regions and involving young adults. While availability of and access to MMT has improved considerably from before 2000 to levels of high use, these developments are likely influenced by recent trends in the proliferation of prescription opioid misuse across general populations. Copyright© the College of Family Physicians of Canada.

Factors affecting feasibility and acceptability of a practice-based educational intervention to support evidence-based prescribing: a qualitative study.

PubMed

Watkins, Chris; Timm, Anja; Gooberman-Hill, Rachael; Harvey, Ian; Haines, Andy; Donovan, Jenny

2004-12-01

Inappropriate and costly GP prescribing is a major problem facing Primary Care Trusts. Educational outreach into practices, alongside other measures, such as audit and feedback, have the potential to enable GP prescribing to become more evidence based. High GP prescribing costs are associated with GPs who see drug company representatives; tend to end consultations with prescriptions; and 'try out' new drugs on an 'ad hoc basis' and use this as evidence of the drug's effect. An educational intervention called 'reflective practice' was developed to meet these and other educational needs. The design of the intervention was informed by studies that have identified the pre-requisites of successful behaviour change in general practice. The study investigated the following: (i) Is it feasible for GPs to attend the sessions included in the educational intervention? (ii) Is the intervention acceptable to the participants and the session facilitators? (iii) What are the barriers to the group educational processes, and how can these be overcome? Four practices were recruited in South West England, all of them experiencing problems with prescribing appropriateness and cost. Reflective practice sessions (including a video-taped scenario) were run in each of these practices and qualitative methods were used to explore the complex attitudes and behaviour of the participants. A researcher observed and audio-taped sessions in each practice. At the end of the programme, a sample of doctors and all the facilitators were interviewed about their experiences. The recorded data were transcribed and analysed using standard qualitative methods. The doctors in the largest partnerships were those who had the greatest difficulty in attending the sessions. Elsewhere, doctors were also reluctant to become involved because of previous experience of top-down managerial initiatives about prescribing quality. Facilitators came from a broad range of professional backgrounds. While knowledge of prescribed drug management issues was important, the professional background of the facilitator was less important than group facilitation skills in creating a group process which participating GPs found satisfactory. The video-taped scenario was found to be useful to set the scene for the discussion. Preserving the anonymity of responses of the GPs in the initial stages of the sessions was important in ensuring honesty in the discussion. Reaching a consensus on management of common conditions was sometimes difficult, partly because the use of the term 'best buy' implies economic pressures, rather than benefits to patients, and partly because of the value with which GPs regard the concept of clinical autonomy. 'Reflective Practice' appeared to have the potential to make GPs aware of the link to be made between their clinical management decisions and the evidence provided by the British National Formulary and Clinical Evidence. The study indicates the importance of preparing the practice adequately, including providing protected time for all GPs to attend the educational intervention. Scenarios and the structure of the sessions need to make more explicit the links between everyday practice and published evidence of effectiveness. Emphasis on cost-effectiveness may be counterproductive and wider benefits need to be emphasized. We have also identified the skill profile of the facilitator role. Our study indicates a need for a clearer understanding of GPs' perception of clinical autonomy and how this conflicts with the goal of agreement on practice guidelines for treatment. The intervention is now ripe for further development, perhaps by integrating it with other interventions to change professional behaviour. The improved intervention should then be evaluated in a randomized controlled trial.

Prescribed fire as an alternative measure in European grassland conservation

NASA Astrophysics Data System (ADS)

Valkó, Orsolya; Deák, Balázs; Török, Péter; Tóthmérész, Béla

2015-04-01

There are contrasting opinions on the perspectives of prescribed burning management in European grasslands. One hand, prescribed burning can be effectively used with relatively low implementation costs for the management of open landscapes, the reduction of accumulated litter or for decreasing the chance of wildfires. On the other hand burning can also have serious detrimental impacts on grassland ecosystems by promoting the dominance of some problem species (e.g. some competitors or invasive species) and by threatening endangered plant and animal species, especially invertebrates, thus, inappropriate burning can result in a loss of biodiversity in the long run. Our goal was to review the publications on the application of prescribed burning in European grasslands considering general (e.g. timing, frequency and duration) and specific (e.g. types of grasslands, effects on endangered species) circumstances. Even prescribed burning forms an integral part of the North-American grassland management practice, it is rarely applied in Europe, despite the fact that uncontrolled burning occurs frequently in some regions. According to the North-American experiences prescribed burning can be a viable solution for biodiversity conservation and can be a feasible solution for several nature conservation problems. We reviewed prescribed burning studies from Europe and North-America to identify findings which might be adapted to the European grassland conservation strategy. We found that not only the application of fire management is scarce in Europe but there is also a lack of published studies on this topic. European studies - contrary to the North-American practice - usually used yearly dormant-season burning, and concluded that this burning type solely is not feasible to preserve and maintain species-rich grasslands. In North-American grasslands, application of burning has a stronger historical, practical and scientific background; it is fine-tuned in terms of timing, frequency and generally combined with other measures, such as grazing, seed sowing or herbicide application. By this complex approach several nature conservation goals can be fulfilled like increasing landscape-scale heterogeneity and invasion control. We emphasize that for establishing a fine-tuned prescribed burning management plan for the European grasslands the general findings of carefully designed case studies should be combined with the practical knowledge of conservation managers concerning the local application circumstances to reach specific management objectives.

An analysis of errors, discrepancies, and variation in opioid prescriptions for adult outpatients at a teaching hospital

PubMed Central

Bicket, Mark C.; Kattail, Deepa; Yaster, Myron; Wu, Christopher L.; Pronovost, Peter

2017-01-01

Objective To determine opioid prescribing patterns and rate of three types of errors, discrepancies, and variation from ideal practice. Design Retrospective review of opioid prescriptions processed at an outpatient pharmacy Setting Tertiary institutional medical center Patients We examined 510 consecutive opioid medication prescriptions for adult patients processed at an institutional outpatient pharmacy in June 2016 for patient, provider, and prescription characteristics. Main Outcome Measure(s) We analyzed prescriptions for deviation from best practice guidelines, lack of two patient identifiers, and noncompliance with Drug Enforcement Agency (DEA) rules. Results Mean patient age (SD) was 47.5 years (17.4). The most commonly prescribed opioid was oxycodone (71%), usually not combined with acetaminophen. Practitioners prescribed tablet formulation to 92% of the sample, averaging 57 (47) pills. We identified at least one error on 42% of prescriptions. Among all prescriptions, 9% deviated from best practice guidelines, 21% failed to include two patient identifiers, and 41% were noncompliant with DEA rules. Errors occurred in 89% of handwritten prescriptions, 0% of electronic health record (EHR) computer-generated prescriptions, and 12% of non-EHR computer-generated prescriptions. Inter-rater reliability by kappa was 0.993. Conclusions Inconsistencies in opioid prescribing remain common. Handwritten prescriptions continue to demonstrate higher associations of errors, discrepancies, and variation from ideal practice and government regulations. All computer-generated prescriptions adhered to best practice guidelines and contained two patient identifiers, and all EHR prescriptions were fully compliant with DEA rules. PMID:28345746

A survey of attitudes, practices, and knowledge regarding drug-drug interactions among medical residents in Iran.

PubMed

Nabovati, Ehsan; Vakili-Arki, Hasan; Taherzadeh, Zhila; Saberi, Mohammad Reza; Abu-Hanna, Ameen; Eslami, Saeid

2017-06-01

Background When prescribing medications, physicians should recognize clinically relevant potential drug-drug interactions (DDIs). To improve medication safety, it is important to understand prescribers' knowledge and opinions pertaining to DDIs. Objective To determine the current DDI information sources used by medical residents, their knowledge of DDIs, their opinions about performance feedback on co-prescription of interacting drugs. Setting Academic hospitals of Mashhad University of Medical Sciences (MUMS) in Iran. Methods A questionnaire containing questions regarding demographic and practice characteristics, DDI information sources, ability to recognize DDIs, and opinions about performance feedback was distributed to medical residents of 22 specialties in eight academic hospitals in Iran. We analyzed their perception pertaining to DDIs, their performance on classifying drug pairs, and we used a linear regression model to assess the association of potential determinants on their DDI knowledge. Main Outcome Measure prescribers' knowledge and opinions pertaining to DDIs. Results The overall response rate and completion rate for 315 distributed questionnaires were 90% (n = 295) and 86% (n = 281), respectively. Among DDI information sources, books, software on mobile phone or tablet, and Internet were the most commonly-used references. Residents could correctly classify only 41% (5.7/14) of the drug pairs. The regression model showed no significant association between residents' characteristics and their DDI knowledge. An overwhelming majority of the respondents (n = 268, 95.4%) wished to receive performance feedback on co-prescription of interacting drugs in their prescriptions. They mostly selected information technology-based tools (i.e. short text message and email) as their preferred method of receiving feedback. Conclusion Our findings indicate that prescribers may have poor ability to prevent clinically relevant potential DDI occurrence, and they perceive the need for performance feedback. These findings underline the importance of well-designed computerized alerting systems and delivering performance feedback to improve patient safety.

Do clinical practice education groups result in sustained change in GP prescribing?

PubMed

Richards, Dee; Toop, Les; Graham, Patrick

2003-04-01

Concern has been expressed at the poor uptake of evidence into clinical practice. This is despite the fact that continuing education is an embedded feature of quality assurance in general practice. There are a variety of clinical practice education methods available for dissemination of new evidence. Recent systematic reviews indicate that the effectiveness of these different strategies is extremely variable. Our aim was to determine whether a peer-led small group education pilot programme used to promote rational GP prescribing is an effective tool in changing practice when added to prescribing audit and feedback, academic detailing and educational bulletins, and to determine whether any effect seen decays over time. A retrospective analysis of a controlled trial of a small group education strategy with 24 month follow-up was carried out. The setting was an independent GPs association (IPA) of 230 GPs in the Christchurch New Zealand urban area. All intervention and control group GPs were already receiving prescribing audit and feedback, academic detailing and educational bulletins. The intervention group were the first 52 GPs to respond to an invitation to pilot the project. Two control groups were used, one group who joined the pilot later and a second group which included all other GPs in the IPA. The main outcome measures were targeted prescribing data for 12 months before and 24 months after each of four education sessions. An effect in the expected direction was seen in six of the eight key messages studied. This effect was statistically significant for five of the eight messages studied. The effect size varied between 7 and 40%. Where a positive effect was seen, the effect decayed with time but persisted to a significant level for 6-24 months of observation. The results support a positive effect of the education strategy on prescribing behaviour in the intervention group for most outcomes measured. The effect seen is statistically significant, sustained and is in addition to any effect of the other pharmaceutical educational initiatives already undertaken by the IPA.

Association of Industry Payments to Physicians With the Prescribing of Brand-name Statins in Massachusetts.

PubMed

Yeh, James S; Franklin, Jessica M; Avorn, Jerry; Landon, Joan; Kesselheim, Aaron S

2016-06-01

Pharmaceutical industry payments to physicians may affect prescribing practices and increase costs if more expensive medications are prescribed. Determine the association between industry payments to physicians and the prescribing of brand-name as compared with generic statins for lowering cholesterol. Cross-sectional linkage of the Part D Medicare prescriptions claims data with the Massachusetts physicians payment database including all licensed Massachusetts physicians who wrote prescriptions for statins paid for under the Medicare drug benefit in 2011. The exposure variable was a physician's industry payments as listed in the Massachusetts database. The outcome was the physician's rate of prescribing brand-name statins. We used linear regression to analyze the association between the intensity of physicians' industry relationships (as measured by total payments) and their prescribing practices, as well as the effects of specific types of payments. Among the 2444 Massachusetts physicians in the Medicare prescribing database in 2011, 899 (36.8%) received industry payments. The most frequent payment was for company-sponsored meals (n = 639 [71.1%]). Statins accounted for 1 559 003 prescription claims; 356 807 (22.8%) were for brand-name drugs. For physicians with no industry payments listed, the median brand-name statin prescribing rate was 17.8% (95% CI, 17.2%-18.4%). For every $1000 in total payments received, the brand-name statin prescribing rate increased by 0.1% (95% CI, 0.06%-0.13%; P < .001). Payments for educational training were associated with a 4.8% increase in the rate of brand-name prescribing (P = .004); other forms of payments were not. Industry payments to physicians are associated with higher rates of prescribing brand-name statins. As the United States seeks to rein in the costs of prescription drugs and make them less expensive for patients, our findings are concerning.

CE: Appropriate Use of Opioids in Managing Chronic Pain.

PubMed

Denenberg, Risa; Curtiss, Carol P

2016-07-01

: Over the past two decades, the use of opioids to manage chronic pain has increased substantially, primarily in response to the recognized functional, emotional, and financial burden associated with chronic pain. Within this same period, unintentional death related to prescription opioids has been identified as a public health crisis, owing in part to such factors as insufficient professional training and medication overprescription, misuse, and diversion. The authors discuss current best practices for prescribing opioids for chronic pain, emphasizing patient assessment and essential patient teaching points regarding safe medication use, storage, and disposal.

Non-medical prescribing of chemotherapy: engaging stakeholders to maximise success?

PubMed

Lennan, Elaine

2014-01-01

This study report examines the views and experiences of professional stakeholders about non-medical prescribing (NMP) of chemotherapy. The introduction of open formulary NMP has created opportunities to radically change health-care delivery. For chemotherapy services, the most recent advice from the National Chemotherapy Advisory Group [Department of Health (2009) Chemotherapy Services in England, ensuring quality and safety: a report from the National Chemotherapy Advisory Group, London Her Majesty's Stationary Office] clearly endorses the development of nurse- or pharmacist-led chemotherapy clinics. This is very much welcomed but is based on very limited evidence as to their effectiveness. A fourth-generation evaluation study. A purposeful sample of 23 stakeholders connected with the chemotherapy service was used. A serial data collection technique with individual interviews followed by uni-professional focus groups was adopted. Finally, a multi-professional focus group was held to determine the strategic way forward. Data were collected in 2009-2010. The study illuminated the key features necessary to maximise success of NMP in chemotherapy clinics and captures the importance of good working relationships. Whilst different practice models will emerge, fundamental and core to services is the need for good team working, established and effective communication strategies, and most importantly avoiding isolation in practice. This study additionally reinforced any evaluation takes place within preexisting political contexts and in particular medical dominance. Not all medical colleagues agreed with or wanted NMP for their patients, highlighting difficulties of developing new models of working within a resisting culture. No objections to NMP of chemotherapy were found, but, clearly, the context of practice needs to be agreed and supportedby all professional stakeholders. What is already known about this topicOpen formulary non-medical prescribing has been rapidly introduced over the past decade.Little research has been conducted in acute care and none in the chemotherapy setting.Cancer policy recommends the introduction of nurse-led chemotherapy clinics.What this paper addsNon-medical prescribing (NMP) in chemotherapy is appropriate with the right model of practice.Well-established professional relationships are a key to success.NMP is not appropriate in isolation of the multidisciplinary team (MDT).Implications for practice and/or policyNurses need to demonstrate the value of non-medical prescribing in chemotherapy using available metrics.Models of practice need to ensure good communication channels, MDT working, and transparency of prescribing.

The role of paediatric nurses in medication safety prior to the implementation of electronic prescribing: a qualitative case study.

PubMed

Farre, Albert; Heath, Gemma; Shaw, Karen; Jordan, Teresa; Cummins, Carole

2017-04-01

Objectives To explore paediatric nurses' experiences and perspectives of their role in the medication process and how this role is enacted in everyday practice. Methods A qualitative case study on a general surgical ward of a paediatric hospital in England, one year prior to the planned implementation of ePrescribing. Three focus groups and six individual semi-structured interviews were conducted, involving 24 nurses. Focus groups and interviews were audio-recorded, transcribed, anonymized and subjected to thematic analysis. Results Two overarching analytical themes were identified: the centrality of risk management in nurses' role in the medication process and the distributed nature of nurses' medication risk management practices. Nurses' contribution to medication safety was seen as an intrinsic feature of a role that extended beyond just preparing and administering medications as prescribed and placed nurses at the heart of a dynamic set of interactions, practices and situations through which medication risks were managed. These findings also illustrate the collective nature of patient safety. Conclusions Both the recognized and the unrecognized contributions of nurses to the management of medications needs to be considered in the design and implementation of ePrescribing systems.

Values Engagement in Evaluation: Ideas, Illustrations, and Implications

ERIC Educational Resources Information Center

Hall, Jori N.; Ahn, Jeehae; Greene, Jennifer C.

2012-01-01

Values-engagement in evaluation involves both describing stakeholder values and prescribing certain values. Describing stakeholder values is common practice in responsive evaluation traditions. Prescribing or advocating particular values is only "explicitly" part of democratic, culturally responsive, critical, and other openly…

Short- and long-term effects on fuels, forest structure, and wildfire potential from prescribed fire and resource benefit fire in southwestern forests, USA

Treesearch

Molly E. Hunter; Jose M. Iniguez; Leigh B. Lentile

2011-01-01

Prescribed and resource benefit fires are used to manage fuels in fire-prone landscapes in the Southwest. These practices, however, typically occur under different conditions, potentially leading to differences in fire behavior and effects. The objectives of this study were to investigate the effects of recent prescribed fires, resource benefit fires, and repeated...

Assessment of inappropriate antibiotic prescribing among a large cohort of general dentists in the United States.

PubMed

Durkin, Michael J; Feng, Qianxi; Warren, Kyle; Lockhart, Peter B; Thornhill, Martin H; Munshi, Kiraat D; Henderson, Rochelle R; Hsueh, Kevin; Fraser, Victoria J

2018-05-01

The purpose of this study was to assess dental antibiotic prescribing trends over time, to quantify the number and types of antibiotics dentists prescribe inappropriately, and to estimate the excess health care costs of inappropriate antibiotic prescribing with the use of a large cohort of general dentists in the United States. We used a quasi-Poisson regression model to analyze antibiotic prescriptions trends by general dentists between January 1, 2013, and December 31, 2015, with the use of data from Express Scripts Holding Company, a large pharmacy benefits manager. We evaluated antibiotic duration and appropriateness for general dentists. Appropriateness was evaluated by reviewing the antibiotic prescribed and the duration of the prescription. Overall, the number and rate of antibiotic prescriptions prescribed by general dentists remained stable in our cohort. During the 3-year study period, approximately 14% of antibiotic prescriptions were deemed inappropriate, based on the antibiotic prescribed, antibiotic treatment duration, or both indicators. The quasi-Poisson regression model, which adjusted for number of beneficiaries covered, revealed a small but statistically significant decrease in the monthly rate of inappropriate antibiotic prescriptions by 0.32% (95% confidence interval, 0.14% to 0.50%; P = .001). Overall antibiotic prescribing practices among general dentists in this cohort remained stable over time. The rate of inappropriate antibiotic prescriptions by general dentists decreased slightly over time. From these authors' definition of appropriate antibiotic prescription choice and duration, inappropriate antibiotic prescriptions are common (14% of all antibiotic prescriptions) among general dentists. Further analyses with the use of chart review, administrative data sets, or other approaches are needed to better evaluate antibiotic prescribing practices among dentists. Copyright © 2018 American Dental Association. Published by Elsevier Inc. All rights reserved.

Effectiveness of an educational feedback intervention on drug prescribing in dental practice.

PubMed

Rauniar, G P; Das, B P; Manandhar, T R; Bhattacharya, S K

2012-01-01

Irrational use of drugs as well as inappropriate and over drug prescribing leads to unnecessary expenditures and emergence of resistant bacterial strains. Feedback intervention on drug prescribing habits and face to face educational intervention of prescription audit would be effective in rationalizing prescribing practices. To measure the impact of educational feedback intervention on the prescribing behavior of dental surgeons. Prospective audit of twelve hundred outpatients prescriptions in dental OPD at BPKIHS of those dental surgeon who attended the educational intervention session was collected randomly by trained persons on customized data collection sheet before and after educational intervention. A total 1200 prescription were collected, 300 before and 300 after intervention period at the internal of one month, three months and six months. Majority of the prescriptions (39.33%) contained four drugs but after intervention, prescriptions contained mostly one drug, 73% in first month, 78.67% in third month and 65.34% in six month. Mean number of drugs per prescription after intervention were decreased. There was increased number of generic names of drugs after intervention. Amoxicillin, Metronidazole, Chlorhexidine, Povidone iodine gargle, Nimesulide, Ibuprofen, Ibuprofen + paracetamol, and Paracetamol were most commonly prescribed by dental prescribers before and after intervention. Selection of antimicrobial was done on empirical basis which was correct because Amoxicillin concentration reaches effectively in gingival crevicular fluid and Metronidazole covered effectively against anaerobic bacteria were found in orodental infection. The uses of topical anti-infective preparation as irrigants of choice that can kill majority of micro-organisms found is root canal and dental tubules and minimize systemic use of antimicrobials. Nimesulide prescribing needs to be rationalized. Feedback educational intervention of prescription audit is effective to improve their prescribing behaviors and rationalize drug utilization pattern for the benefit of the patients.

Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care - a mixed methods study in Sweden.

PubMed

Strandberg, Eva Lena; Brorsson, Annika; André, Malin; Gröndal, Hedvig; Mölstad, Sigvard; Hedin, Katarina

2016-07-18

Prescribing of antibiotics for common infections varies widely, and there is no medical explanation. Systematic reviews have highlighted factors that may influence antibiotic prescribing and that this is a complex process. It is unclear how factors interact and how the primary care organization affects diagnostic procedures and antibiotic prescribing. Therefore, we sought to explore and understand interactions between factors influencing antibiotic prescribing for respiratory tract infections in primary care. Our mixed methods design was guided by the Triangulation Design Model according to Creswell. Quantitative and qualitative data were collected in parallel. Quantitative data were collected by prescription statistics, questionnaires to patients, and general practitioners' audit registrations. Qualitative data were collected through observations and semi-structured interviews. From the analysis of the data from the different sources an overall theme emerged: A common practice in the primary health care centre is crucial for low antibiotic prescribing in line with guidelines. Several factors contribute to a common practice, such as promoting management and leadership, internalized guidelines including inter-professional discussions, the general practitioner's diagnostic process, nurse triage, and patient expectation. These factors were closely related and influenced each other. The results showed that knowledge must be internalized and guidelines need to be normative for the group as well as for every individual. Low prescribing is associated with adapted and transformed guidelines within all staff, not only general practitioners. Nurses' triage and self-care advice played an important role. Encouragement from the management level stimulated inter-professional discussions about antibiotic prescribing. Informal opinion moulders talking about antibiotic prescribing was supported by the managers. Finally, continuous professional development activities were encouraged for up-to-date knowledge.

A rational approach to the selection of useful drugs for clinical practice.

PubMed

Spector, Reynold; Vesell, Elliot S

2002-05-01

Confusion exists concerning optimal selection of drugs for clinical practice. Many reasons contribute to this confusion which derives from various sources including industry, the FDA and often less than ideal education of physicians in clinical pharmacology during medical school and thereafter. This presentation does not focus on allocating blame for the current unsatisfactory situation, but rather offers a solution to improve drug therapy. Our educational solution consists of a paradigm for rational drug therapy, specifically a checklist of eight criteria for physicians to review before prescribing drugs. Such a review would facilitate better estimation by physicians of risk/benefit ratios involving new, often expensive and, in some cases, questionably effective and safe drugs. Copyright 2002 S. Karger AG, Basel

Predictors of Treatment Response to Fluoxetine in PTSD Following a Recent History of War Zone Stress Exposure

DTIC Science & Technology

2010-07-01

routinely prescribed for acute stress disorder and early PTSD and recommended in the VA-DoD best practice guidelines, the efficacy of SSRIs as an early...selective serotonin reuptake inhibitors (SSRIs) are routinely prescribed for acute stress disorder and early PTSD and recommended in the VA-DoD best practice...1-0283 TITLE: Predictors of Treatment Response to Fluoxetine in PTSD Following a Recent History of War Zone Stress Exposure

The attitudes and beliefs of oncology nurse practitioners regarding direct-to-consumer advertising of prescription medications.

PubMed

Viale, Pamela Hallquist; Sanchez Yamamoto, Deanna

2004-07-01

To obtain information about the knowledge and attitudes of oncology nurse practitioners (ONPs) concerning the effect of direct-to-consumer (DTC) advertising of prescription medications on prescribing patterns. Exploratory survey. Oncology Nursing Society Nurse Practitioner Special Interest Group members in the United States. 221 of 376 ONPs completed the survey (58%). Researcher-developed 12-question postal survey. Knowledge and attitudes of ONPs on DTC advertising effects on prescribing patterns. The findings were similar to those of previous studies of physicians regarding the number of visits when patients requested DTC-advertised medications. Major differences were the positive attitudes of ONPs toward potentially longer patient visits to explain and educate patients regarding medication requests based on DTC advertising and smaller percentages of ONPs who felt "pressured" to prescribe requested medications. ONPs have mixed opinions regarding the practice of DTC advertising but do not believe that they are influenced heavily by advertising with regard to prescriptive practices. ONPs consider patient encounters for education purposes as appropriate and include information about requested DTC-advertised medications in their approach to patient care. This is an exploratory survey of a specialty group of ONPs. More research is needed to further explore the practice of DTC advertising and potential influences on the prescribing patterns of ONPs. DTC advertising of prescription medications is increasing; ONPs need to increase their knowledge base about the potential for influences of prescriptive practices.

Brand Name Statin Prescribing in a Resident Ambulatory Practice: Implications for Teaching Cost-Conscious Medicine.

PubMed

Ryskina, Kira L; Pesko, Michael F; Gossey, J Travis; Caesar, Erica Phillips; Bishop, Tara F

2014-09-01

Several national initiatives aim to teach high-value care to residents. While there is a growing body of literature on cost impact of physicians' therapeutic decisions, few studies have assessed factors that influence residents' prescribing practices. We studied factors associated with intensive health care utilization among internal medicine residents, using brand name statin prescribing as a proxy for higher-cost care. We conducted a retrospective, cross-sectional analysis of statin prescriptions by residents at an urban academic internal medicine program, using electronic health record data between July 1, 2010, and June 30, 2011. For 319 encounters by 90 residents, patients were given a brand name statin in 50% of cases. When categorized into quintiles, the bottom quintile of residents prescribed brand name statins in 2% of encounters, while the top quintile prescribed brand name statins in 98% of encounters. After adjusting for potential confounders, including patient characteristics and supervising attending, being in the primary care track was associated with lower odds (odds ratio [OR], 0.38; P  =  .02; 95% confidence interval [CI], 0.16-0.86), and graduating from a medical school with an above-average hospital care intensity index was associated with higher odds of prescribing brand name statins (OR, 1.70; P  =  .049; 95% CI, 1.003-2.88). We found considerable variation in brand name statin prescribing by residents. Medical school attended and residency program type were associated with resident prescribing behavior. Future interventions should raise awareness of these patterns in an effort to teach high-value, cost-conscious care to all residents.

Feasibility and impact of a computer-guided consultation on guideline-based management of COPD in general practice.

PubMed

Angus, Robert M; Thompson, Elizabeth B; Davies, Lisa; Trusdale, Ann; Hodgson, Chris; McKnight, Eddie; Davies, Andrew; Pearson, Mike G

2012-12-01

Applying guidelines is a universal challenge that is often not met. Intelligent software systems that facilitate real-time management during a clinical interaction may offer a solution. To determine if the use of a computer-guided consultation that facilitates the National Institute for Health and Clinical Excellence-based chronic obstructive pulmonary disease (COPD) guidance and prompts clinical decision-making is feasible in primary care and to assess its impact on diagnosis and management in reviews of COPD patients. Practice nurses, one-third of whom had no specific respiratory training, undertook a computer-guided review in the usual consulting room setting using a laptop computer with the screen visible to them and to the patient. A total of 293 patients (mean (SD) age 69.7 (10.1) years, 163 (55.6%) male) with a diagnosis of COPD were randomly selected from GP databases in 16 practices and assessed. Of 236 patients who had spirometry, 45 (19%) did not have airflow obstruction and the guided clinical history changed the primary diagnosis from COPD in a further 24 patients. In the 191 patients with confirmed COPD, the consultations prompted management changes including 169 recommendations for altered prescribing of inhalers (addition or discontinuation, inhaler dose or device). In addition, 47% of the 55 current smokers were referred for smoking cessation support, 12 (6%) for oxygen assessment, and 47 (24%) for pulmonary rehabilitation. Computer-guided consultations are practicable in general practice. Primary care COPD databases were confirmed to contain a significant proportion of incorrectly assigned patients. They resulted in interventions and the rationalisation of prescribing in line with recommendations. Only in 22 (12%) of those fully assessed was no management change suggested. The introduction of a computer-guided consultation offers the prospect of comprehensive guideline quality management.

Factors influencing physicians' prescribing behaviour in the treatment of childhood diarrhoea: knowledge may not be the clue.

PubMed

Paredes, P; de la Peña, M; Flores-Guerra, E; Diaz, J; Trostle, J

1996-04-01

Proper diarrhoea treatment has received greater attention during the last 10 years. However, the unjustified use of medicines to treat simple episodes of acute diarrhoea continues to divert attention and available resources away from appropriate treatment. A study to identify the factors determining prescribing practices for diarrhoea treatment was carried out in a peri-urban part of Lima, Peru in 1991. Physicians were interviewed, and then their practice was assessed by visits of confederates with healthy children described as ill, by interviews with mothers of sick children leaving the clinic, or by both of these methods. Physicians' reported practices in treating diarrhoea cases were compared to their actual practices. Although physicians' knowledge of drug management seemed to influence the low frequency of prescription of antidiarrhoeal drugs, it did not have the same influence on prescription of antimicrobials. Our results suggest that the diagnostic process and consequently the treatment decision do not follow a scientific rationale for this illness. The physicians' prescribing practices seemed to be more related to agreement with social expectations and the caretakers' perception of the physicians' role than they were to the standard biomedical rules of diarrhoea management.

Using qualitative insights to change practice: exploring the culture of antibiotic prescribing and consumption for urinary tract infections

PubMed Central

Duane, Sinead; Domegan, Christine; Callan, Aoife; Galvin, Sandra; Cormican, Martin; Bennett, Kathleen; Murphy, Andrew W

2016-01-01

Objectives The aim of this paper is to explore the culture of antibiotic prescribing and consumption in the community for urinary tract infections (UTI) from the perspective of the general practitioners (GPs) and community member. Design Indepth interviews were conducted with GPs, and focus groups were held with community members. Setting General practice and community setting. Participants 15 GPs practising in rural and urban locations in Ireland participated in the indepth interviews. 6 focus groups (n=42) with participants who had direct or indirect experiences with UTI were also undertaken. Results The decision to prescribe or consume an antibiotic for a UTI is a set of complex processes including need recognition, information search and evaluation processes governed by the relationship and interactions between the GP and the patient. Different GP and patient decision-making profiles emerged emphasising the diversity and variety of general practice in real-life settings. The GP findings showed a requirement for more microbiological information on antibiotic resistance patterns to inform prescribing decisions. Focus group participants wanted a conversation with the GP about their illness and the treatment options available. Conclusions Collectively, this research identified the consultation as a priority intervention environment for stimulating change in relation to antibiotics. This paper demonstrates how qualitative research can identify the interacting processes which are instrumental to the decision to prescribe or consume an antibiotic for a suspected UTI. Qualitative research empowers researchers to investigate the what, how and why of interventions in real-life setting. Qualitative research can play a critical and instrumental role in designing behavioural change strategies with high impact on practice. The results of this research were used to design a complex intervention informed by social marketing. Trial registration number NCT01913860; Pre-results. PMID:26754175

Nation-scale adoption of new medicines by doctors: an application of the Bass diffusion model

PubMed Central

2012-01-01

Background The adoption of new medicines is influenced by a complex set of social processes that have been widely examined in terms of individual prescribers’ information-seeking and decision-making behaviour. However, quantitative, population-wide analyses of how long it takes for new healthcare practices to become part of mainstream practice are rare. Methods We applied a Bass diffusion model to monthly prescription volumes of 103 often-prescribed drugs in Australia (monthly time series data totalling 803 million prescriptions between 1992 and 2010), to determine the distribution of adoption rates. Our aim was to test the utility of applying the Bass diffusion model to national-scale prescribing volumes. Results The Bass diffusion model was fitted to the adoption of a broad cross-section of drugs using national monthly prescription volumes from Australia (median R2 = 0.97, interquartile range 0.95 to 0.99). The median time to adoption was 8.2 years (IQR 4.9 to 12.1). The model distinguished two classes of prescribing patterns – those where adoption appeared to be driven mostly by external forces (19 drugs) and those driven mostly by social contagion (84 drugs). Those driven more prominently by internal forces were found to have shorter adoption times (p = 0.02 in a non-parametric analysis of variance by ranks). Conclusion The Bass diffusion model may be used to retrospectively represent the patterns of adoption exhibited in prescription volumes in Australia, and distinguishes between adoption driven primarily by external forces such as regulation, or internal forces such as social contagion. The eight-year delay between the introduction of a new medicine and the adoption of the prescribing practice suggests the presence of system inertia in Australian prescribing practices. PMID:22876867

How public reporting of prescription quality indicators influence prescribing practices? A survey of general practitioners.

PubMed

Du, Xin; Zhang, Xinping; Tang, Yuqing; Zhang, Xiaopeng; Wang, Lijun; Wang, Xuan

2015-10-01

Public reporting of performance data is one of the most popular topics in health care field. The aim of this study was to investigate the transparency mechanism, that is, how public reporting influenced general practitioners' (GPs) prescribing practices. GPs who had the license to prescribe medicine of all 10 primary care institutions were surveyed. Data were collected by an instrument, which exhibited satisfactory reliability and validity (Cronbach's alpha > 0.7; average variance extracted > 0.5; composite reliability > 0.7). Data analysis was conducted by structural equation model. The results showed that GPs' perceived value (GP's overall assessment of the worth of the public reporting) and attitude (the psychological reaction to public reporting) had a significantly direct effect on behavioural intention (r = 0.28; r = 0.36), and were affected by information accessibility (r = 0.63; r = 0.32). Attitude had a significant effect on perceived value(r = 0.45). Perceived risk (the perceptions of the possible loss due to public reporting, e.g. decreasing their income) did not have a significant relationship with information accessibility, attitude and behavioural intention(r = -0.09; r = 0.01; r = -0.07). The information accessibility, perceived value and attitude have strong effects on prescribing practices of GPs, whereas perceived risk did not play a role in influencing the prescribing practices. Policymakers need to improve the accessibility of prescription quality indicators and pay attention to the perceived values and attitudes of GPs. Policymakers also need to strengthen the risk education of GPs and attach incentives to transparent regulation. © 2015 John Wiley & Sons, Ltd.

Antibiotic prescriptions for outpatient acute rhinosinusitis in Canada, 2007-2013.

PubMed

Sharma, Prateek; Finley, Rita; Weese, Scott; Glass-Kaastra, Shiona; McIsaac, Warren

2017-01-01

Acute rhinosinusitis (ARS) is a respiratory disease commonly caused by viral infections. Physicians regularly prescribe antibiotics despite bacterial etiologies being uncommon. This is of concern, as this use adds to the selection pressure for resistance. Here we present the descriptive epidemiology of acute rhinosinusitis and corresponding antibiotic prescribing practices by Canadian outpatient physicians from 2007-2013. Diagnosis and antibiotic prescription data for ARS were extracted from the Canadian Disease and Therapeutic Index for 2007 to 2013, and population data were acquired from Statistics Canada. ARS diagnosis and antibiotic prescription rates and frequencies of antibiotic classes were calculated. Eighty-eight percent of patients diagnosed with ARS in 2013 were adults, with a greater rate of antibiotic prescriptions observed among the adults relative to the pediatric patients (1632.9 and 468.6 antibiotic prescriptions per 10,000 inhabitants). Between 2007 and 2013, the ARS diagnosis rate decreased from 596 to 464 diagnoses per 10,000 inhabitants, while the percentage of diagnoses with antibiotic prescriptions at the national level remained stable (87% to 84%). From 2007 to 2013, prescription rates for macrolides decreased from 203.5 to 105.4 prescriptions per 10,000 inhabitants. In 2013, penicillins with extended spectrum were more commonly prescribed compared to macrolides among adult patients (153.5 and 105.4 prescriptions per 10,000 inhabitants, respectively). This study is the first to describe physician antibiotic prescribing practices for treatment of ARS in Canada. Results show that antibiotic treatment for ARS represents an area for implementing antimicrobial stewardship, and through it, managing antibiotic resistance. Further work is required to better understand diagnosing practices and treatment criteria for ARS, and use this information to further assist physicians to limit unnecessary antibiotic prescribing practices.

Primary care clinicians' experiences prescribing HIV pre-exposure prophylaxis at a specialized community health centre in Boston: lessons from early adopters.

PubMed

Krakower, Douglas S; Maloney, Kevin M; Grasso, Chris; Melbourne, Katherine; Mayer, Kenneth H

2016-01-01

An estimated 1.2 million Americans have indications for using antiretroviral pre-exposure prophylaxis (PrEP) to prevent HIV acquisition. For many of these at-risk individuals, the best opportunity to learn about and receive PrEP will be during routine visits to their generalist primary care clinicians. However, few generalist clinicians have prescribed PrEP, primarily because of practical concerns about providing PrEP in primary care settings. The experiences of specialized primary care clinicians who have prescribed PrEP can inform the feasibility of PrEP provision by generalists. During January to February 2015, 35 primary care clinicians at a community health centre in Boston that specializes in the care of sexual and gender minorities completed anonymous surveys about their experiences and practices with PrEP provision. Responses were analyzed with descriptive statistics. Thirty-two clinicians (response rate=91%) completed the surveys. Nearly all clinicians (97%) had prescribed PrEP (median 20 patients, interquartile range 11-33). Most clinicians reported testing and risk-reduction counselling practices concordant with U.S. Centers for Disease Control and Prevention guidelines for PrEP. Clinicians indicated that patients using PrEP experienced medication toxicities infrequently and generally reported high adherence. However, some clinicians' practices differed from guideline recommendations, and some clinicians observed patients with increased risk behaviours. Most clinicians (79%) rated PrEP provision as easy to accomplish, and 97% considered themselves likely to prescribe PrEP in the future. In a primary care clinic with specialized expertise in HIV prevention, clinicians perceived that PrEP provision to large numbers of patients was safe, feasible and potentially effective. Efforts to engage generalist primary care clinicians in PrEP provision could facilitate scale-up of this efficacious intervention.

Antibiotic prescriptions for outpatient acute rhinosinusitis in Canada, 2007-2013

PubMed Central

Weese, Scott; Glass-Kaastra, Shiona; McIsaac, Warren

2017-01-01

Introduction Acute rhinosinusitis (ARS) is a respiratory disease commonly caused by viral infections. Physicians regularly prescribe antibiotics despite bacterial etiologies being uncommon. This is of concern, as this use adds to the selection pressure for resistance. Here we present the descriptive epidemiology of acute rhinosinusitis and corresponding antibiotic prescribing practices by Canadian outpatient physicians from 2007–2013. Materials/Methods Diagnosis and antibiotic prescription data for ARS were extracted from the Canadian Disease and Therapeutic Index for 2007 to 2013, and population data were acquired from Statistics Canada. ARS diagnosis and antibiotic prescription rates and frequencies of antibiotic classes were calculated. Results Eighty-eight percent of patients diagnosed with ARS in 2013 were adults, with a greater rate of antibiotic prescriptions observed among the adults relative to the pediatric patients (1632.9 and 468.6 antibiotic prescriptions per 10,000 inhabitants). Between 2007 and 2013, the ARS diagnosis rate decreased from 596 to 464 diagnoses per 10,000 inhabitants, while the percentage of diagnoses with antibiotic prescriptions at the national level remained stable (87% to 84%). From 2007 to 2013, prescription rates for macrolides decreased from 203.5 to 105.4 prescriptions per 10,000 inhabitants. In 2013, penicillins with extended spectrum were more commonly prescribed compared to macrolides among adult patients (153.5 and 105.4 prescriptions per 10,000 inhabitants, respectively). Conclusion This study is the first to describe physician antibiotic prescribing practices for treatment of ARS in Canada. Results show that antibiotic treatment for ARS represents an area for implementing antimicrobial stewardship, and through it, managing antibiotic resistance. Further work is required to better understand diagnosing practices and treatment criteria for ARS, and use this information to further assist physicians to limit unnecessary antibiotic prescribing practices. PMID:28750020

SCOPE of Pain: An Evaluation of an Opioid Risk Evaluation and Mitigation Strategy Continuing Education Program

PubMed Central

Zisblatt, Lara; Ng, Pamela; Hayes, Sean M.; Peloquin, Sophie; Hardesty, Ilana; White, Julie L.

2016-01-01

Objective. Due to the high prevalence of prescription opioid misuse, the US Food and Drug Administration (FDA) mandated a Risk Evaluation and Mitigation Strategy (REMS) requiring manufacturers of extended-release/long-acting (ER/LA) opioid analgesics to fund continuing education based on a FDA Blueprint. This article describes the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) program, an ER/LA opioid analgesic REMS program, and its impact on clinician knowledge, confidence, attitudes, and self-reported clinical practice. Method. Participants of the 3-h SCOPE of Pain training completed pre-, immediate post- and 2-month post-assessments. Subjects. The primary target group (n = 2,850), and a subset (n = 476) who completed a 2-month post-assessment, consisted of clinicians licensed to prescribe ER/LA opioid analgesics, who care for patients with chronic pain and who completed the 3-h training between February 28, 2013 and June 13, 2014. Results. Immediately post-program, there was a significant increase in correct responses to knowledge questions (60% to 84%, P ≤ 0.02) and 87% of participants planned to make practice changes. At 2-months post-program, there continued to be a significant increase in correct responses to knowledge questions (60% to 69%, P ≤ 0.03) and 67% reported increased confidence in applying safe opioid prescribing care and 86% reported implementing practice changes. There was also an improvement in alignment of desired attitudes toward safe opioid prescribing. Conclusions. The SCOPE of Pain program improved knowledge, attitudes, confidence, and self-reported clinical practice in safe opioid prescribing. This national REMS program holds potential to improve the safe use of opioids for the treatment of chronic pain. PMID:26304703

Antimicrobial stewardship activities: a survey of Queensland hospitals.

PubMed

Avent, Minyon L; Hall, Lisa; Davis, Louise; Allen, Michelle; Roberts, Jason A; Unwin, Sean; McIntosh, Kylie A; Thursky, Karin; Buising, Kirsty; Paterson, David L

2014-11-01

In 2011, the Australian Commission on Safety and Quality in Health Care (ACSQHC) recommended that all hospitals in Australia must have an Antimicrobial Stewardship (AMS) program by 2013. Nevertheless, little is known about current AMS activities. This study aimed to determine the AMS activities currently undertaken, and to identify gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. The AMS activities of 26 facilities from 15 hospital and health services in Queensland were surveyed during June 2012 to address strategies for effective AMS: implementing clinical guidelines, formulary restriction, reviewing antimicrobial prescribing, auditing antimicrobial use and selective reporting of susceptibility results. The response rate was 62%. Nineteen percent had an AMS team (a dedicated multidisciplinary team consisting of a medically trained staff member and a pharmacist). All facilities had access to an electronic version of Therapeutic Guidelines: Antibiotic, with a further 50% developing local guidelines for antimicrobials. One-third of facilities had additional restrictions. Eighty-eight percent had advice for restricted antimicrobials from in-house infectious disease physicians or clinical microbiologists. Antimicrobials were monitored with feedback given to prescribers at point of care by 76% of facilities. Deficiencies reported as barriers to establishing AMS programs included: pharmacy resources, financial support by hospital management, and training and education in antimicrobial use. Several areas for improvement were identified: reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use. There also appears to be a lack of resources to support AMS programs in some facilities. WHAT IS KNOWN ABOUT THE TOPIC?: The ACSQHC has recommended that all hospitals implement an AMS program by 2013 as a requirement of Standard 3 (Preventing and Controlling Healthcare-Associated Infections) of the National Safety and Quality Health Service Standards. The intent of AMS is to ensure appropriate prescribing of antimicrobials as part of the broader systems within a health service organisation to prevent and manage healthcare-associated infections, and improve patient safety and quality of care. This criterion also aligns closely with Standard 4: Medication Safety. Despite this recommendation, little is known about what AMS activities are undertaken in these facilities and what additional resources would be required in order to meet these national standards. WHAT DOES THE PAPER ADD?: This is the first survey that has been conducted of public hospital and health services in Queensland, a large decentralised state in Australia. This paper describes what AMS activities are currently being undertaken, identifies practice gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: Several areas for improvement such as reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use have been identified. In addition, there appears to be a lack of resources to support AMS programs in some facilities.

Uncertainties in prescribed fire emissions and their impact on smoke dispersion predictions

EPA Science Inventory

Prescribed burning (PB) is practiced throughout the Southeastern U.S. for its important ecological and safety benefits such as preparing for tree seeding and planting, controlling disease and tree competition, managing understory debris, perpetuating fire-dependent plant species,...

75 FR 2122 - Additional Guidance Regarding Application of Current Procedures for Testing Energy Consumption of...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-01-14

... prescribed or amended under this section shall be reasonably designed to produce test results which measure... Energy's (DOE) guidance to ensure the consistent application of DOE's current test procedure to...) to prescribe standardized test procedures to measure the energy consumption of certain consumer...

Use of antipsychotic medications for the management of delirium: an audit of current practice in the acute care setting.

PubMed

Tropea, J; Slee, J; Holmes, A C N; Gorelik, A; Brand, C A

2009-02-01

Despite delirium being common in older hospitalized people, little is known about its management. The aims of this study are (1) to describe the pharmacological management of delirium in an acute care setting as a baseline measure prior to the implementation of newly developed Australian guidelines; and (2) to determine what areas of delirium pharmacological management need to be targeted for future practical guideline implementation and quality improvement activities. A medical record audit was conducted using a structured audit form. All patients aged 65 years and over who were admitted to a general medical or orthopaedic unit of the Royal Melbourne Hospital between 1 March 2006 and 28 February 2007 and coded with delirium were included. Data on the use of antipsychotic medications for the management of delirium in relation to best practice recommendations were assessed. Overall 174 episodes of care were included in the analysis. Antipsychotic medications were used for the management of most patients with severe behavioral and or emotional disturbance associated with delirium. There was variation in the prescribing patterns of antipsychotic agents and the documentation of medication management plans. Less than a quarter of patients prescribed antipsychotic medication were started on a low dose and very few were reviewed on a regular basis. A wide range of practice is seen in the use of antipsychotic agents to manage older patients with severe symptoms associated with delirium. The findings highlight the need to implement evidence-based guideline recommendations with a focus on improving the consistency in the pharmacological management and documentation processes.

Consumer Satisfaction with Antipsychotic Medication Monitoring Appointments: The Role of Consumer-Prescriber Communication Patterns

PubMed Central

Reich, Catherine M.; Hack, Samantha M.; Klingaman, Elizabeth A.; Brown, Clayton H.; Fang, Li Juan; Dixon, Lisa B.; Jahn, Danielle R.; Kreyenbuhl, Julie A.

2017-01-01

Objective The study was designed to explore patterns of prescriber communication behaviors as they relate to consumer satisfaction among a serious mental illness sample. Methods Recordings from 175 antipsychotic medication-monitoring appointments between veterans with psychiatric disorders and their prescribers were coded using the Roter Interaction Analysis System (RIAS) for communication behavioral patterns. Results The frequency of prescriber communication behaviors (i.e., facilitation, rapport, procedural, psychosocial, biomedical, and total utterances) did not reliably predict consumer satisfaction. The ratio of prescriber to consumer utterances did predict consumer satisfaction. Conclusion Consistent with client-centered care theory, antipsychotic medication consumers were more satisfied with their encounters when their prescriber did not dominate the conversation. Practice Implications Therefore, one potential recommendation from these findings could be for medication prescribers to spend more of their time listening to, rather than speaking with, their SMI consumers. PMID:28920491

Variation in formulary adherence in general practice over time (2003-2007).

PubMed

van Dijk, Liset; de Jong, Judith D; Westert, Gert P; de Bakker, Dinny H

2011-12-01

To study trends and variation in adherence to the main national formulary for the 20 most prevalent health problems in Dutch general practice over a 5-year period (2003-07). Routine electronic medical records from a pool of 115 representative general practices were linked to the main national formulary. Analyses included over 2 million prescriptions for 246 391 patients. The outcome variable was whether or not the prescribed medication was congruent with recommendations in the national formulary. Trends and variation were analysed using three-level multilevel logistic regression analyses (general practice, patient, and prescription). The percentage of formulary adherent prescriptions for the 20 most prevalent health problems was 73-76% between 2003 and 2007. The percentage varied considerably between guidelines. Lowest adherence rates were found for acute bronchitis and acute upper respiratory infection. Interpractice variation was constant over time. General practice information networks are useful for monitoring general patterns of formulary on a year-to-year basis. Formulary adherence is stable over time but varies across diagnoses, patients and general practices. In the past decade, efforts have been made to increase the level of formulary adherent prescribing. These general efforts managed to stabilize (variation in) adherence in a field where many other initiatives (e.g. by pharmaceutical companies) are undertaken to influence prescribing behaviour.

The need for a prescribing competency framework to address the burden of complex polypharmacy among multiple long-term conditions.

PubMed

Picton, Catherine; Loughrey, Claire; Webb, Andrew

2016-10-01

The original requirement for a competency framework for prescribers was to identify the essential skills for non-medical prescribers. However, core prescribing competencies are relevant to any prescriber. The new, revised version is especially relevant for doctors/physicians. Doctors are the most frequent prescribers - prescribing is the most common therapeutic intervention. The quantity and complexity of medicine use is increasing through multiple treatment strategies/pathways for multiple comorbidities, resulting in polypharmacy - especially with long-term conditions. This is against a background of the ongoing introduction of new drugs with novel mechanisms of action with increased risks of adverse effects, compounded by drug-drug and disease-drug interactions. This has increased the need for monitoring and follow-up, including identification and management of poor adherence. It is challenging for doctors to maintain safe and effective prescribing and train other doctors and non-medical prescribers within the multidisciplinary team. The prescribing competency framework provides a systematic approach to support doctors to prescribe safely and effectively. It can be used by medical schools to teach prescribing, including preparation for the prescribing safety assessment; by F1/F2 doctors to support prescribing in early years; as part of prescribing quality improvement initiatives and as a continuing professional development framework in general practice or acute care settings. © Royal College of Physicians 2016. All rights reserved.

Antibiotic Prescribing Practices for Prevention of Surgical Site Infections in Australia: Increased Uptake of National Guidelines after Surveillance and Reporting and Impact on Infection Rates.

PubMed

Bull, Ann L; Worth, Leon J; Spelman, Tim; Richards, Michael J

2017-10-01

Antimicrobial prophylaxis is the single most effective intervention to reduce risk of surgical site infections (SSIs); however, prescribing practices should be aligned with accepted and recommended surgical antibiotic prophylaxis (SAP) regimens to be effective. As part of a comprehensive surveillance network, SAP data are collated and analyzed for compliance with recommendations. Results are reported to hospitals for quality improvement purposes. In this study, statewide results were analyzed to ascertain changes over time and whether improved compliance was associated with a reduction in risk for SSI. A standardized tool for monitoring SAP and SSIs was used in Victorian healthcare facilities. For the current study, data submitted for the period 2003-2015 were analyzed. Compliance with national recommendations (Australian Therapeutic Guidelines-Antibiotic) was used as the reference standard for antibiotic selection, timing, and duration Results: A total of 144,075 surgical procedures were surveyed during the study period. During this period, the proportion of patients receiving antibiotic agents according to national guidelines increased. Across all surgical groups, the odds ratio (OR) for appropriate SAP choice increased by 13%/year. Greatest improvement was seen for colorectal procedures (19%/year), with the smallest change observed for cholecystectomy and cardiac operations (9%/year). The OR for receiving an antibiotic agent at the recommended time increased by 12%/year and the odds of the antibiotic agent being discontinued within 24 hours by 27%/year. Non-compliance with a recommended SAP agent and timing was associated with an increased risk of SSI across all procedure groups (OR 1.33, 95% confidence interval 1.24-1.43). Sustained improvements in prescribing practices for SAP have been demonstrated through a comprehensive surveillance and reporting system. Non-compliance with SAP guidelines is associated with an increased risk for SSI. Quality improvement programs must focus on uptake and implementation of evidence-based guidelines.

Automated quality checks on repeat prescribing.

PubMed Central

Rogers, Jeremy E; Wroe, Christopher J; Roberts, Angus; Swallow, Angela; Stables, David; Cantrill, Judith A; Rector, Alan L

2003-01-01

BACKGROUND: Good clinical practice in primary care includes periodic review of repeat prescriptions. Markers of prescriptions that may need review have been described, but manually checking all repeat prescriptions against the markers would be impractical. AIM: To investigate the feasibility of computerising the application of repeat prescribing quality checks to electronic patient records in United Kingdom (UK) primary care. DESIGN OF STUDY: Software performance test against benchmark manual analysis of cross-sectional convenience sample of prescribing documentation. SETTING: Three general practices in Greater Manchester, in the north west of England, during a 4-month period in 2001. METHOD: A machine-readable drug information resource, based on the British National Formulary (BNF) as the 'gold standard' for valid drug indications, was installed in three practices. Software raised alerts for each repeat prescribed item where the electronic patient record contained no valid indication for the medication. Alerts raised by the software in two practices were analysed manually. Clinical reaction to the software was assessed by semi-structured interviews in three practices. RESULTS: There was no valid indication in the electronic medical records for 14.8% of repeat prescribed items. Sixty-two per cent of all alerts generated were incorrect. Forty-three per cent of all incorrect alerts were as a result of errors in the drug information resource, 44% to locally idiosyncratic clinical coding, 8% to the use of the BNF without adaptation as a gold standard, and 5% to the inability of the system to infer diagnoses that, although unrecorded, would be 'obvious' to a clinical reading the record. The interviewed clinicians supported the goals of the software. CONCLUSION: Using electronic records for secondary decision support purposes will benefit from (and may require) both more consistent electronic clinical data collection across multiple sites, and reconciling clinicians' willingness to infer unstated but 'obvious' diagnoses with the machine's inability to do the same. PMID:14702902

Prescription rates of adrenaline auto-injectors for children in UK general practice: a retrospective cohort study.

PubMed

Diwakar, Lavanya; Cummins, Carole; Ryan, Ronan; Marshall, Tom; Roberts, Tracy

2017-04-01

Adrenaline auto-injectors (AAI) should be provided to individuals considered to be at high risk of anaphylaxis. There is some evidence that the rate of AAI prescription is increasing, but the true extent has not been previously quantified. To estimate the trends in annual GP-issued prescriptions for AAI among UK children between 2000 and 2012. Retrospective cohort study using data from primary care practices that contributed to The Health Improvement Network (THIN) database. Children and young people aged between 0-17 years of age with a prescription for AAIs were identified, and annual AAI device prescription rates were estimated using Stata (version 12). A total of 1.06 million UK children were identified, providing 5.1 million person years of follow-up data. Overall, 23 837 children were deemed high risk by their GPs, and were prescribed 98 737 AAI devices. This equates to 4.67 children (95% confidence interval [CI] = 4.66 to 4.69), and 19.4 (95% CI = 19.2 to 19.5) devices per 1000 person years. Between 2000 and 2012, there has been a 355% increase in the number of children prescribed devices, and a 506% increase in the total number of AAI devices prescribed per 1000 person years in the UK. The number of devices issued per high-risk child during this period has also increased by 33%. The number of children being prescribed AAI devices and the number of devices being prescribed in UK primary care between 2000 and 2012 has significantly increased. A discussion to promote rational prescribing of AAIs in the NHS is needed. © British Journal of General Practice 2017.

Disclosure of industry payments to prescribers: industry payments might be a factor impacting generic drug prescribing.

PubMed

Qian, Jingjing; Hansen, Richard A; Surry, Daniel; Howard, Jennifer; Kiptanui, Zippora; Harris, Ilene

2017-07-01

Pharmaceutical companies paid at least $3.91bn to prescribers in 2013, yet evidence indicating whether industry payments shift prescribing away from generics is limited. This study examined the association between amount of industry payments to prescribers and generic drug prescribing rates among Medicare Part D prescribers. A cross-sectional analysis was conducted among 770 095 Medicare Part D prescribers after linking the 2013 national Open Payments data with 2013 Medicare Provider Utilization and Payment data. The exposure variable was the categorized amount of total industry payments to prescribers (i.e., meals, travel, research, and ownership). The outcome was prescriber's annual generic drug prescribing rate. Multivariable generalized linear regression models were used to examine the association between the amount of industry payments and prescriber's annual generic drug prescribing rates, controlling for prescriber's demographic and practice characteristics. In this sample, over one-third (38.0%) of Medicare Part D prescribers received industry payments in 2013. The mean annual generic drug prescribing rate was highest among prescribers receiving no payments and lowest among those receiving more than $500 of industry payments (77.5% vs. 71.3%, respectively; p < 0.001). The receipt of industry payments was independently associated with prescribers' generic drug prescribing rate; higher payments corresponded with lower generic drug prescribing rates. Other prescriber characteristics associated with higher annual generic drug prescribing rate included male sex, non-northeast region, specialty, and patient volume. Receipt of industry payments was associated with a decreased rate of generic drug prescribing. How this affects patient care and total medical costs warrants further study. Copyright © 2017 John Wiley & Sons, Ltd. Copyright © 2017 John Wiley & Sons, Ltd.

Association between physicians’ interaction with pharmaceutical companies and their clinical practices: A systematic review and meta-analysis

PubMed Central

Al-Khaled, Lina; Kahale, Lara A.; Nas, Hala; El-Jardali, Fadi

2017-01-01

Background Pharmaceutical company representatives likely influence the prescribing habits and professional behaviors of physicians. The objective of this study was to systematically review the association between physicians’ interactions with pharmaceutical companies and their clinical practices. Methods We used the standard systematic review methodology. Observational and experimental study designs examining any type of targeted interaction between practicing physicians and pharmaceutical companies were eligible. The search strategy included a search of MEDLINE and EMBASE databases up to July 2016. Two reviewers selected studies, abstracted data, and assessed risk of bias in duplicate and independently. We assessed the quality of evidence using the GRADE approach. Results Twenty articles reporting on 19 studies met our inclusion criteria. All of these studies were conducted in high-income countries and examined different types of interactions, including detailing, industry-funded continuing medical education, and receiving free gifts. While all included studies assessed prescribing behaviors, four studies also assessed financial outcomes, one assessed physicians’ knowledge, and one assessed their beliefs. None of the studies assessed clinical outcomes. Out of the 19 studies, 15 found a consistent association between interactions promoting a medication, and inappropriately increased prescribing rates, lower prescribing quality, and/or increased prescribing costs. The remaining four studies found both associations and lack of significant associations for the different types of exposures and drugs examined in the studies. A meta-analysis of six of these studies found a statistically significant association between exposure and physicians’ prescribing behaviors (OR = 2.52; 95% CI 1.82–3.50). The quality of evidence was downgraded to moderate for risk of bias and inconsistency. Sensitivity analysis excluding studies at high risk of bias did not substantially change these results. A subgroup analysis did not find a difference by type of exposure. Conclusion There is moderate quality evidence that physicians’ interactions with pharmaceutical companies are associated with their prescribing patterns and quality. PMID:28406971

Enhancing HIV Pre-exposure, Prophylaxis Practices via an Educational Intervention.

PubMed

Newman, Rebecca; Katchi, Tasleem; Karass, Michael; Gennarelli, Melissa; Goutis, Jason; Kifayat, Alina; Solanki, Shantanu; Yandrapalli, Srikanth; Forman, Leanne; Nabors, Christopher

2018-04-20

Pre-exposure prophylaxis (PrEP) for HIV involves using antiretroviral drugs to prevent individuals at high risk from acquiring HIV infection. Most practicing primary care providers believe PrEP to be safe and effective, but less than half have prescribed or referred for PrEP. Attitudes and prescribing patterns among house officers have not been well described previously. Can an educational intervention enhance HIV PrEP practices among internal medicine house officers? This study relied on a pretest/posttest design. All categorical trainees at a medium-sized internal medicine program were offered a baseline survey to assess their knowledge on PrEP. This was followed by a PrEP-focused educational intervention and a postintervention survey. Likert scales captured perceptions regarding safety, effectiveness, barriers, factors that would promote PrEP use, potential side effects, impact on risk-taking behavior, and provider comfort level in assessing behavioral risks and in PrEP prescribing. Data were analyzed using descriptive statistics, Wilcoxon signed rank test, and the Kruskal-Wallis test. Significance was accepted for P < 0.05. Forty-eight (100%) trainees participated in the educational session, 45 (94%) in a preintervention survey, and 36 (75%) in a postintervention survey. Before PrEP training, 22% of respondents were unaware of PrEP, 78% believed PrEP was effective, 66% believed PrEP was safe, 62% had fair or poor awareness of side effects; 18% of residents had referred for or prescribed PrEP, and 31% believed they were likely to prescribe PrEP in the next 6 months. After the intervention, 94% of trainees believed PrEP was effective (P < 0.001), 92% believed PrEP was safe (P < 0.001), and two-thirds believed they were likely to prescribe PrEP in the next 6 months. Brief, focused training on HIV prevention promotes awareness, acceptance, and likelihood of prescribing PrEP by internal medicine trainees.

Improving antibiotic prescribing by general practitioners: a protocol for a systematic review of interventions involving pharmacists

PubMed Central

Saha, Sajal K; Hawes, Lesley; Mazza, Danielle

2018-01-01

Introduction Effective antibiotic options in general practice for patients with infections are declining significantly due to antibiotic over-prescribing and emerging antibiotic resistance. To better improve antibiotic prescribing by general practitioner (GP), pharmacist–GP collaborations have been promoted under antibiotic stewardship programmes. However, there is insufficient information about whether and how pharmacists help GPs to more appropriately prescribe antibiotics. This systematic review aims to determine whether pharmacist-led or pharmacist-involved interventions are effective at improving antibiotic prescribing by GPs. Methods and analysis A systematic review of English language randomised controlled trials (RCTs), cluster RCTs, controlled before-and-after studies and interrupted time series studies cited in MEDLINE, EMBASE, EMCARE, CINAHL Plus, PubMed, PsycINFO, Cochrane Central Register of Controlled Trials and Web of Science databases will be conducted. Studies will be included if a pharmacist is involved as the intervention provider and GPs are the intervention recipients in general practice setting. Data extraction and management will be conducted using Effective Practice and Organisation of Care data abstraction tools and a template for intervention description and replication. The Cochrane and ROBINS-I risk of bias assessment tools will be used to assess the methodological quality of studies. Primary outcome measures include changes (overall, broad spectrum and guidelines concordance) of GP-prescribed antibiotics. Secondary outcomes include quality of antibiotic prescribing, delayed antibiotic use, acceptability and feasibility of interventions. Meta-analysis for combined effect and forest plots, χ2 test and I2 statistics for detailed heterogeneity and sensitivity analysis will be performed if data permit. Grading of Recommendations Assessment, Development and Evaluation and Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidance will be used to report findings. Ethics and dissemination No ethics approval is required as no primary, personal or confidential data are being collected in this study. The findings will be disseminated to national and international scientific sessions and published in a peer-reviewed journal. PROSPERO registration number CRD42017078478. PMID:29654036

The effect of sibutramine prescribing in routine clinical practice on cardiovascular outcomes: a cohort study in the United Kingdom

PubMed Central

Hayes, J F; Bhaskaran, K; Batterham, R; Smeeth, L; Douglas, I

2015-01-01

Background/Objectives: The marketing authorization for the weight loss drug sibutramine was suspended in 2010 following a major trial that showed increased rates of non-fatal myocardial infarction and cerebrovascular events in patients with pre-existing cardiovascular disease. In routine clinical practice, sibutramine was already contraindicated in patients with cardiovascular disease and so the relevance of these influential clinical trial findings to the ‘real World' population of patients receiving or eligible for the drug is questionable. We assessed rates of myocardial infarction and cerebrovascular events in a cohort of patients prescribed sibutramine or orlistat in the United Kingdom. Subjects/Methods: A cohort of patients prescribed weight loss medication was identified within the Clinical Practice Research Datalink. Rates of myocardial infarction or cerebrovascular event, and all-cause mortality were compared between patients prescribed sibutramine and similar patients prescribed orlistat, using both a multivariable Cox proportional hazard model, and propensity score-adjusted model. Possible effect modification by pre-existing cardiovascular disease and cardiovascular risk factors was assessed. Results: Patients prescribed sibutramine (N=23 927) appeared to have an elevated rate of myocardial infarction or cerebrovascular events compared with those taking orlistat (N=77 047; hazard ratio 1.69, 95% confidence interval 1.12–2.56). However, subgroup analysis showed the elevated rate was larger in those with pre-existing cardiovascular disease (hazard ratio 4.37, 95% confidence interval 2.21–8.64), compared with those with no cardiovascular disease (hazard ratio 1.52, 95% confidence interval 0.92–2.48, P-interaction=0.0076). All-cause mortality was not increased in those prescribed sibutramine (hazard ratio 0.67, 95% confidence interval 0.34–1.32). Conclusions: Sibutramine was associated with increased rates of acute cardiovascular events in people with pre-existing cardiovascular disease, but there was a low absolute risk in those without. Sibutramine's marketing authorization may have, therefore, been inappropriately withdrawn for people without cardiovascular disease. PMID:25971925

The effect of sibutramine prescribing in routine clinical practice on cardiovascular outcomes: a cohort study in the United Kingdom.

PubMed

Hayes, J F; Bhaskaran, K; Batterham, R; Smeeth, L; Douglas, I

2015-09-01

The marketing authorization for the weight loss drug sibutramine was suspended in 2010 following a major trial that showed increased rates of non-fatal myocardial infarction and cerebrovascular events in patients with pre-existing cardiovascular disease. In routine clinical practice, sibutramine was already contraindicated in patients with cardiovascular disease and so the relevance of these influential clinical trial findings to the 'real World' population of patients receiving or eligible for the drug is questionable. We assessed rates of myocardial infarction and cerebrovascular events in a cohort of patients prescribed sibutramine or orlistat in the United Kingdom. A cohort of patients prescribed weight loss medication was identified within the Clinical Practice Research Datalink. Rates of myocardial infarction or cerebrovascular event, and all-cause mortality were compared between patients prescribed sibutramine and similar patients prescribed orlistat, using both a multivariable Cox proportional hazard model, and propensity score-adjusted model. Possible effect modification by pre-existing cardiovascular disease and cardiovascular risk factors was assessed. Patients prescribed sibutramine (N=23,927) appeared to have an elevated rate of myocardial infarction or cerebrovascular events compared with those taking orlistat (N=77,047; hazard ratio 1.69, 95% confidence interval 1.12-2.56). However, subgroup analysis showed the elevated rate was larger in those with pre-existing cardiovascular disease (hazard ratio 4.37, 95% confidence interval 2.21-8.64), compared with those with no cardiovascular disease (hazard ratio 1.52, 95% confidence interval 0.92-2.48, P-interaction=0.0076). All-cause mortality was not increased in those prescribed sibutramine (hazard ratio 0.67, 95% confidence interval 0.34-1.32). Sibutramine was associated with increased rates of acute cardiovascular events in people with pre-existing cardiovascular disease, but there was a low absolute risk in those without. Sibutramine's marketing authorization may have, therefore, been inappropriately withdrawn for people without cardiovascular disease.

Optimising the quality of antibiotic prescribing in out-of-hours primary care in Belgium: a study protocol for an action research project.

PubMed

Colliers, Annelies; Coenen, Samuel; Philips, Hilde; Remmen, Roy; Anthierens, Sibyl

2017-10-15

Antimicrobial resistance is a major public health threat driven by inappropriate antibiotic use, mainly in general practice and for respiratory tract infections. In Belgium, the quality of general practitioners' (GPs) antibiotic prescribing is low. To improve antibiotic use, we need a better understanding of this quality problem and corresponding interventions. A general practitioners cooperative (GPC) for out-of-hours (OOH) care presents a unique opportunity to reach a large group of GPs and work on quality improvement. Participatory action research (PAR) is a bottom-up approach that focuses on implementing change into daily practice and has the potential to empower practitioners to produce their own solutions to optimise their antibiotic prescribing. This PAR study to improve antibiotic prescribing quality in OOH care uses a mixed methods approach. In a first exploratory phase, we will develop a partnership with a GPC and map the existing barriers and opportunities. In a second phase, we will focus on facilitating change and implementing interventions through PDSA (Plan-Do-Study-Act) cycles. In a third phase, antibiotic prescribing quality outside and antibiotic use during office hours will be evaluated. Equally important are the process evaluation and theory building on improving antibiotic prescribing. The study protocol was approved by the Ethics Committee of the Antwerp University Hospital/University of Antwerp. PAR unfolds in response to the needs and issues of the stakeholders, therefore new ethics approval will be obtained at each new stage of the research. Interventions to improve antibiotic prescribing are needed now more than ever and outcomes will be highly relevant for GPCs, GPs in daily practice, national policymakers and the international scientific community. NCT03082521; Pre-results. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Pharmaceutical Company Influence on Non-Steroidal Anti-inflammatory Drug Prescribing Behaviors

PubMed Central

Naik, Aanand D.; Woofter, Aaron L.; Skinner, Jessica M.; Abraham, Neena S.

2010-01-01

Objectives Adherence to safer nonsteroidal anti-inflammatory drug (NSAID) prescribing strategies remains low, despite their acceptance as markers of high-quality care and their aggressive dissemination. This study describes the taxonomy of methods used by pharmaceutical companies to influence physicians’ NSAID prescribing behaviors and elicits physicians’ perceptions of and counter-balances to these influences. Study Design In-depth interviews analyzed using the constant comparative method of qualitative data analysis. Methods Qualitative interviews were conducted with physicians representing various clinical specialties. Interviews were transcribed and coded inductively using grounded theory. Recruitment was stopped at 25 participants after the attainment of thematic saturation, when no new concepts emerged from ongoing analysis of consecutive interviews. Results Physicians described a variety of influences that shaped their NSAID prescribing behaviors, including detailing and direct contact with pharmaceutical representatives, requests from patients inspired by direct-to-consumer advertisements, and marketing during medical school and residency training. Physicians described practice guidelines, peer-reviewed evidence and opinions of local physician experts as important counterweights to pharmaceutical company influence. Local physician experts interpreted and provided context for new clinical evidence, practice guidelines and NSAID related marketing. Conclusions The social and communicative strategies used by pharmaceutical companies can be adapted to improve physicians’ adoption of guidelines for safer NSAID prescribing. The communicative interactions between local experts and other physicians who prescribe NSAIDs may be the critical target for future interventions to promote safer NSAID prescribing. PMID:19341315

Attitudes of physicians and pharmacists towards International Non-proprietary Name prescribing in Belgium.

PubMed

Van Bever, Elien; Elseviers, Monique; Plovie, Marijke; Vandeputte, Lieselot; Van Bortel, Luc; Vander Stichele, Robert

2015-03-01

International Non-proprietary Name (INN) prescribing is the use of the name of the active ingredient(s) instead of the brand name for prescribing. In Belgium, INN prescribing began in 2005 and a major policy change occurred in 2012. The aim was to explore the opinions of Dutch-speaking general practitioners (GPs) and pharmacists. An electronic questionnaire with 39 five-point Likert scale statements and one open question was administered in 2013. Multivariate analysis was performed with multiple linear regression on a sum score for benefit statements and for drawback statements. Answers to the open question were qualitatively analysed. We received 745 valid responses with a representable sample for both subgroups. Participants perceived the motives to introduce INN prescribing as purely economic (to reduce pharmaceutical expenditures for the government and the patient). Participants accepted the concept of INN prescribing, but 88% stressed the importance of guaranteed treatment continuity, especially in older, chronic patients, to prevent patient confusion, medication non-adherence and erroneous drug use. In conclusion, the current way in which INN prescribing is applied in Belgium leads to many concerns among primary health professionals about patient confusion and medication adherence. Slightly adapting the current concept of INN prescribing to these concerns can turn INN prescribing into one of the major policies in Belgium to reduce pharmaceutical expenditures and to stimulate rational drug prescribing. © 2014 Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society).

Scottish Keep Well health check programme: an interrupted time series analysis.

PubMed

Geue, Claudia; Lewsey, James D; MacKay, Daniel F; Antony, Grace; Fischbacher, Colin M; Muirie, Jill; McCartney, Gerard

2016-09-01

Effective interventions are available to reduce cardiovascular risk. Recently, health check programmes have been implemented to target those at high risk of cardiovascular disease (CVD), but there is much debate whether these are likely to be effective at population level. This paper evaluates the impact of wave 1 of Keep Well, a Scottish health check programme, on cardiovascular outcomes. Interrupted time series analyses were employed, comparing trends in outcomes in participating and non-participating practices before and after the introduction of health checks. Health outcomes are defined as CVD mortality, incident hospitalisations and prescribing of cardiovascular drugs. After accounting for secular trends and seasonal variation, coronary heart disease mortality and hospitalisations changed by 0.4% (95% CI -5.2% to 6.3%) and -1.1% (-3.4% to 1.3%) in Keep Well practices and by -0.3% (-2.7% to 2.2%) and -0.1% (-1.8% to 1.7%) in non-Keep Well practices, respectively, following the intervention. Adjusted changes in prescribing in Keep Well and non-Keep Well practices were 0.4% (-10.4% to 12.5%) and -1.5% (-9.4% to 7.2%) for statins; -2.5% (-12.3% to 8.4%) and -1.6% (-7.1% to 4.3%) for antihypertensive drugs; and -0.9% (-6.5% to 5.0%) and -2.4% (-10.1% to 6.0%) for antiplatelet drugs. Any impact of the Keep Well health check intervention on CVD outcomes and prescribing in Scotland was very small. Findings do not support the use of the screening approach used by current health check programmes to address CVD. We used an interrupted time series method, but evaluation methods based on randomisation are feasible and preferable and would have allowed more reliable conclusions. These should be considered more often by policymakers at an early stage in programme design when there is uncertainty regarding programme effectiveness. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

A comparison of cost effectiveness using data from randomized trials or actual clinical practice: selective cox-2 inhibitors as an example.

PubMed

van Staa, Tjeerd-Pieter; Leufkens, Hubert G; Zhang, Bill; Smeeth, Liam

2009-12-01

Data on absolute risks of outcomes and patterns of drug use in cost-effectiveness analyses are often based on randomised clinical trials (RCTs). The objective of this study was to evaluate the external validity of published cost-effectiveness studies by comparing the data used in these studies (typically based on RCTs) to observational data from actual clinical practice. Selective Cox-2 inhibitors (coxibs) were used as an example. The UK General Practice Research Database (GPRD) was used to estimate the exposure characteristics and individual probabilities of upper gastrointestinal (GI) events during current exposure to nonsteroidal anti-inflammatory drugs (NSAIDs) or coxibs. A basic cost-effectiveness model was developed evaluating two alternative strategies: prescription of a conventional NSAID or coxib. Outcomes included upper GI events as recorded in GPRD and hospitalisation for upper GI events recorded in the national registry of hospitalisations (Hospital Episode Statistics) linked to GPRD. Prescription costs were based on the prescribed number of tables as recorded in GPRD and the 2006 cost data from the British National Formulary. The study population included over 1 million patients prescribed conventional NSAIDs or coxibs. Only a minority of patients used the drugs long-term and daily (34.5% of conventional NSAIDs and 44.2% of coxibs), whereas coxib RCTs required daily use for at least 6-9 months. The mean cost of preventing one upper GI event as recorded in GPRD was US$104k (ranging from US$64k with long-term daily use to US$182k with intermittent use) and US$298k for hospitalizations. The mean costs (for GPRD events) over calendar time were US$58k during 1990-1993 and US$174k during 2002-2005. Using RCT data rather than GPRD data for event probabilities, the mean cost was US$16k with the VIGOR RCT and US$20k with the CLASS RCT. The published cost-effectiveness analyses of coxibs lacked external validity, did not represent patients in actual clinical practice, and should not have been used to inform prescribing policies. External validity should be an explicit requirement for cost-effectiveness analyses.

HL7 Structured Product Labeling - electronic prescribing information for provider order entry decision support.

PubMed

Schadow, Gunther

2005-01-01

Prescribing errors are an important cause of adverse events, and lack of knowledge of the drug is a root cause for prescribing errors. The FDA is issuing new regulations that will make the drug labels much more useful not only to physicians, but also to computerized order entry systems that support physicians to practice safe prescribing. For this purpose, FDA works with HL7 to create the Structured Product Label (SPL) standard that includes a document format as well as a drug knowledge representation, this poster introduces the basic concepts of SPL.

Ontario dentists: 3. Radiographs prescribed in general practice.

PubMed

Swan, E S; Lewis, D W

1993-01-01

In February 1991, a mail survey was used to poll a sample consisting of about 10 per cent of Ontario's general dentists. The data obtained provided information about the radiographs prescribed by dentists for five different patient types, which were described to the respondents. The per cent agreement between the radiographic procedures prescribed by Ontario dentists and the ADA-approved Center for Devices and Radiological Health (CDRH) guidelines ranged from three per cent to 79 per cent, depending on patient type and disease risk. For each patient and risk type, there was considerable variation in the radiographs prescribed.

Improving relapse prevention after successful electroconvulsive therapy for patients with severe depression: completed audit cycle involving 102 full electroconvulsive therapy courses in West Sussex, United kingdom.

PubMed

Atiku, Leonard; Gorst-Unsworth, Caroline; Khan, Barkath Ulla; Huq, Fuad; Gordon, Jackie

2015-03-01

The aim of this study was to determine whether current guidance or consensus regarding continuation pharmacotherapy after successful electroconvulsive therapy (ECT) was being followed by referring clinicians in West Sussex, United Kingdom. A complete audit cycle examining psychotropic medication after successful ECT for patients with severe depression was performed. Clinical and ECT records (electronic and paper) were reviewed, and relapse rates in the 4 commonly prescribed psychotropic medication groups were compared. The pattern of relapse in the 4 groups was similar for both audits 1 and 2. Taking the 102 patients as a whole, the lowest relapse rates were recorded for patients taking a combination of an antidepressant and lithium (16% relapsed within 6 months of successful ECT). Patients taking a combination of antipsychotic and antidepressants fared the worst with 75% relapse rate. This was followed by those taking a combination of antidepressant and a mood stabilizer (other than lithium) (69%). Patients taking antidepressant(s) only were associated with a relapse rate of 60%. Audit 2 demonstrated that clinicians did not change their prescribing practices for their patients after successful ECT despite the efforts made in widely disseminating the results of audit 1. In particular, there was no increase in the use of lithium. Not all psychotropic medication prescribing for patients receiving ECT for depression followed available and current guidance or consensus. More needs to be done to understand the reasons for the reluctance to use lithium if relapse rates after ECT are to improve.

75 FR 65663 - Gilbert Eugene Johnson, M.D.; Revocation of Registration

Federal Register 2010, 2011, 2012, 2013, 2014

2010-10-26

... administering of controlled or narcotic drugs''; and (3) Respondent ``prescribed, dispensed or administered controlled substances or narcotic drugs in excess of the amount considered good medical practice or prescribed, dispensed or administered controlled substances or narcotic drugs without medical need.'' Id. at...

Prescribed burning to affect a state transition in a shrub-encroached desert grassland

USDA-ARS?s Scientific Manuscript database

Prescribed burning is a commonly advocated and historical practice for control of woody species encroachment into grasslands on all continents. However, desert grasslands of the southwestern United States often lack needed herbaceous fuel loads for effective prescriptions, dominant perennial gramin...

Prescribed fire and its impacts on ecosystem services in the UK.

PubMed

Harper, Ashleigh R; Doerr, Stefan H; Santin, Cristina; Froyd, Cynthia A; Sinnadurai, Paul

2018-05-15

The impacts of vegetation fires on ecosystems are complex and varied affecting a range of important ecosystem services. Fire has the potential to affect the physicochemical and ecological status of water systems, alter several aspects of the carbon cycle (e.g. above- and below-ground carbon storage) and trigger changes in vegetation type and structure. Globally, fire is an essential part of land management in fire-prone regions in, e.g. Australia, the USA and some Mediterranean countries to mitigate the likelihood of catastrophic wildfires and sustain healthy ecosystems. In the less-fire prone UK, fire has a long history of usage in management for enhancing the productivity of heather, red grouse and sheep. This distinctly different socioeconomic tradition of burning underlies some of the controversy in recent decades in the UK around the use of fire. Negative public opinion and opposition from popular media have highlighted concerns around the detrimental impacts burning can have on the health and diversity of upland habitats. It is evident there are many gaps in the current knowledge around the environmental impacts of prescribed burning in less fire-prone regions (e.g. UK). Land owners and managers require a greater level of certainty on the advantages and disadvantages of prescribed burning in comparison to other techniques to better inform management practices. This paper addresses this gap by providing a critical review of published work and future research directions related to the impacts of prescribed fire on three key aspects of ecosystem services: (i) water quality, (ii) carbon dynamics and (iii) habitat composition and structure (biodiversity). Its overall aims are to provide guidance based on the current state-of-the-art for researchers, land owners, managers and policy makers on the potential effects of the use of burning and to inform the wider debate about the place of fire in modern conservation and land management in humid temperate ecosystems. Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.

Prescription opioid use and misuse: piloting an educational strategy for rural primary care physicians.

PubMed

Srivastava, Anita; Kahan, Meldon; Jiwa, Ashifa

2012-04-01

To evaluate the feasibility and effectiveness of a multifaceted educational intervention to improve the opioid prescribing practices of rural family physicians in a remote First Nations community. Prospective cohort study. Sioux Lookout, Ont. Family physicians. Eighteen family physicians participated in a 1-year study of a series of educational interventions on safe opioid prescribing. Interventions included a main workshop with a lecture and interactive case discussions, an online chat room, video case conferencing, and consultant support. Responses to questionnaires at baseline and after 1 year on knowledge, attitudes, and practices related to opioid prescribing. The main workshop was feasible and was well received by primary care physicians in remote communities. At 1 year, physicians were less concerned about getting patients addicted to opioids and more comfortable with opioid dosing. Multifaceted education and consultant support might play an important role in improving family physician comfort with opioid prescribing, and could improve the treatment of chronic pain while minimizing the risk of addiction.

Evaluation and optimisation of current milrinone prescribing for the treatment and prevention of low cardiac output syndrome in paediatric patients after open heart surgery using a physiology-based pharmacokinetic drug-disease model.

PubMed

Vogt, Winnie

2014-01-01

Milrinone is the drug of choice for the treatment and prevention of low cardiac output syndrome (LCOS) in paediatric patients after open heart surgery across Europe. Discrepancies, however, among prescribing guidance, clinical studies and practice pattern require clarification to ensure safe and effective prescribing. However, the clearance prediction equations derived from classical pharmacokinetic modelling provide limited support as they have recently failed a clinical practice evaluation. Therefore, the objective of this study was to evaluate current milrinone dosing using physiology-based pharmacokinetic (PBPK) modelling and simulation to complement the existing pharmacokinetic knowledge and propose optimised dosing regimens as a basis for improving the standard of care for paediatric patients. A PBPK drug-disease model using a population approach was developed in three steps from healthy young adults to adult patients and paediatric patients with and without LCOS after open heart surgery. Pre- and postoperative organ function values from adult and paediatric patients were collected from literature and integrated into a disease model as factorial changes from the reference values in healthy adults aged 20-40 years. The disease model was combined with the PBPK drug model and evaluated against existing pharmacokinetic data. Model robustness was assessed by parametric sensitivity analysis. In the next step, virtual patient populations were created, each with 1,000 subjects reflecting the average adult and paediatric patient characteristics with regard to age, sex, bodyweight and height. They were integrated into the PBPK drug-disease model to evaluate the effectiveness of current milrinone dosing in achieving the therapeutic target range of 100-300 ng/mL milrinone in plasma. Optimised dosing regimens were subsequently developed. The pharmacokinetics of milrinone in healthy young adults as well as adult and paediatric patients were accurately described with an average fold error of 1.1 ± 0.1 (mean ± standard deviation) and mean relative deviation of 1.5 ± 0.3 as measures of bias and precision, respectively. Normalised maximum sensitivity coefficients for model input parameters ranged from -0.84 to 0.71, which indicated model robustness. The evaluation of milrinone dosing across different paediatric age groups showed a non-linear age dependence of total plasma clearance and exposure differences of a factor 1.4 between patients with and without LCOS for a fixed dosing regimen. None of the currently used dosing regimens for milrinone achieved the therapeutic target range across all paediatric age groups and adult patients, so optimised dosing regimens were developed that considered the age-dependent and pathophysiological differences. The PBPK drug-disease model for milrinone in paediatric patients with and without LCOS after open heart surgery highlights that age, disease and surgery differently impact the pharmacokinetics of milrinone, and that current milrinone dosing for LCOS is suboptimal to maintain the therapeutic target range across the entire paediatric age range. Thus, optimised dosing strategies are proposed to ensure safe and effective prescribing.

Children's medicines in Tanzania: a national survey of administration practices and preferences.

PubMed

Adams, Lisa V; Craig, Sienna R; Mmbaga, Elia John; Naburi, Helga; Lahey, Timothy; Nutt, Cameron T; Kisenge, Rodrick; Noel, Gary J; Spielberg, Stephen P

2013-01-01

The dearth of age-appropriate formulations of many medicines for children poses a major challenge to pediatric therapeutic practice, adherence, and health care delivery worldwide. We provide information on current administration practices of pediatric medicines and describe key stakeholder preferences for new formulation characteristics. We surveyed children aged 6-12 years, parents/caregivers over age 18 with children under age 12, and healthcare workers in 10 regions of Tanzania to determine current pediatric medicine prescription and administration practices as well as preferences for new formulations. Analyses were stratified by setting, pediatric age group, parent/caregiver education, and healthcare worker cadre. Complete data were available for 206 children, 202 parents/caregivers, and 202 healthcare workers. Swallowing oral solid dosage forms whole or crushing/dissolving them and mixing with water were the two most frequently reported methods of administration. Children frequently reported disliking medication taste, and many had vomited doses. Healthcare workers reported medicine availability most significantly influences prescribing practices. Most parents/caregivers and children prefer sweet-tasting medicine. Parents/caregivers and healthcare workers prefer oral liquid dosage forms for young children, and had similar thresholds for the maximum number of oral solid dosage forms children at different ages can take. There are many impediments to acceptable and accurate administration of medicines to children. Current practices are associated with poor tolerability and the potential for under- or over-dosing. Children, parents/caregivers, and healthcare workers in Tanzania have clear preferences for tastes and formulations, which should inform the development, manufacturing, and marketing of pediatric medications for resource-limited settings.

Specialty training and the personal use of benzodiazepines by physicians affect their proneness to prescribe tranquilizers.

PubMed

Linden, M; Gothe, H

1998-03-01

The decision on how to treat a patient does not depend on clinical matters or illness characteristics alone, but also on patient, physician and setting variables such as personality, training, or reimbursement. No research has yet been carried out to answer the question whether personal experience with medications also influences prescribing behavior. In this study, 124 physicians stratified according to specialty (neuropsychiatrists vs. general practitioners), type of institution (private practice vs. hospital), years of professional experience (young vs. old), and region (rural vs. urban) participated in a structured interview to evaluate their proneness to prescribe benzodiazepines for sleep disorders as well as their personal experience in taking benzodiazepines for their own sleep problems. Both specialty and personal experience were significantly related to proneness to prescribe. Other variables tested (region, institution, age, gender) did not help to explain the variance in benzodiazepine prescribing practice. Thus physician variables and, importantly, their own personal experience in taking the medication significantly influence treatment choice. Rational medical decision making and treatment guidelines must therefore take into account medical knowledge as well as knowledge of personal treatment preferences and professional biases.

Race- and gender-related differences in clinical characteristics and quality of life among outpatients with psychotic disorders.

PubMed

Nejtek, Vicki A; Allison, Nanette; Hilburn, Craig

2012-09-01

Historically, the literature suggests that African Americans with mental illness are diagnosed with psychotic disorders at a higher rate and receive higher doses of antipsychotic medications than other racial groups. However, few studies have compared clinical characteristics and quality of life among African-American (AA) and white men and women. Thus, research is needed to examine potential race and gender differences in clinical characteristics, prescribing practices, and quality of life. This exploratory, hypothesis-generating study examined current and past diagnoses, current pharmacotherapy, failed psychotropic medications, and quality of life among 23 AA and 31 white men and women receiving outpatient treatment for psychosis. Depression and psychotic depression were common complaints in the sample, yet only a third of the patients received antidepressants. We found that AA men received an antidepressant for depression symptoms less often, received higher antipsychotic doses, and rated their overall quality of life as poorer than any other group. White men and AA women had a history of more years of mental illness and had experienced 57% and 69% more psychotropic medication failures, respectively, than AA men or white women. Quality of life scores were significantly related to years of mental illness, number of past diagnoses, and number of failed medications. Our data suggest that clinicians could significantly enhance prognostic outcomes in outpatients with psychotic disorders by routinely re-evaluating depressive symptomatology and prescribing practices and considering adding psychosocial interventions to avert deterioration in quality of life. Further investigation of race and gender differences in quality of life and satisfaction as a function of diagnoses and treatment is warranted.

Opioid Use Disorder in Pregnancy: Health Policy and Practice in the Midst of an Epidemic

PubMed Central

Krans, Elizabeth E.; Patrick, Stephen W.

2016-01-01

Opioid abuse among pregnant women has reached epidemic proportions and has influenced maternal and child health policy at the federal, state and local levels. As a result, we review the current state of opioid use in pregnancy and evaluate recent legislative and health policy initiatives designed to combat opioid addiction in pregnancy. We emphasize the importance of safe and responsible opioid prescribing practices, expanding the availability and accessibility of medication-assisted treatment and standardizing care for infants at risk of neonatal abstinence syndrome. Efforts to penalize pregnant women and negative consequences for disclosing substance use to providers are harmful and may prevent women from seeking prenatal care and other beneficial health care services during pregnancy. Instead, providers should advocate for health policy informed by scientific research and evidence-based practice to reduce the burden of prenatal opioid abuse and optimize outcomes for mothers and their infants. PMID:27275812

Practical outpatient pharmacotherapy for alcohol use disorder

PubMed Central

Kim, Youngjung; Hack, Laura M; Ahn, Elizabeth S

2018-01-01

Alcohol use disorder (AUD) is commonly encountered in clinical practice. A combination of psychosocial intervention and pharmacotherapy is the cornerstone of AUD treatment. Despite their efficacy, safety and cost-effectiveness, clinicians are reluctant to prescribe medications to treat individuals with AUD. Given the high rate of relapse with psychosocial intervention alone, increasing patient access to this underutilized treatment has the potential to improve clinical outcome in this difficult-to-treat population. Herein, we provide practical pharmacotherapy strategies to improve treatment outcome for AUD. We review the efficacy and side effects of both on- and off-label agents with a particular focus on clinical applicability. Recommendations are supported by findings from randomized controlled trials (RCT) and meta-analyses selected to be representative, where possible, of current treatment guidelines. The goal of this paper is to help readers use pharmacotherapy with greater confidence when treating patients with AUD. PMID:29445407

Non-medical prescribing in New Zealand: an overview of prescribing rights, service delivery models and training.

PubMed

Raghunandan, Rakhee; Tordoff, June; Smith, Alesha

2017-11-01

In this paper, we aim to provide an updated source of information for nonmedical prescribing (NMP) in New Zealand (NZ). A variety of NZ sources were used to collect data: legislation, policy documents and information from professional and regulatory organizations, and education providers. In NZ, the legal categories for prescribers include authorized, designated, and delegated prescribers. Authorized prescribers include dentists, midwives, nurse practitioners, and optometrist prescribers. Designated prescribers include pharmacist prescribers, registered nurse prescribers, and dietitian prescribers. There are no delegated prescribers in NZ at this time. There is variation in the regulation, educational programmes and prescribing competencies used by the different prescribing health professionals involved in NMP in NZ. This update collates relevant information relating to NMP in NZ into one consolidated document and provides policy makers with a current overview of prescribing rights, service delivery models, training requirements, and prescribing competencies used for NMP in NZ. As NMP in NZ continues to expand and evolve, this paper will form a baseline for future NMP research in NZ. NZ needs to develop overarching NMP policy to enable consistency in the various aspects of NMP, thereby delivering a safe and sustainable NMP service in NZ.

The current evidence base for the feasibility of 48-hour continuous subcutaneous infusions (CSCIs): A systematically-structured review.

PubMed

Baker, James; Dickman, Andrew; Mason, Stephen; Ellershaw, John

2018-01-01

A continuous subcutaneous infusion (CSCI) is an effective method of multiple drug administration commonly encountered in end of life care when the oral route is compromised. At present, current practice is to limit syringe driver infusion time to a maximum of 24 hours as dictated by available chemical stability data. However, the ability to deliver prescribed medication by a CSCI over 48 hours may have numerous benefits in both patient care and health service resource utilisation. To examine and present the current evidence base for the stability of 48-hour multiple-drug CSCIs in current clinical practice. A systematically-structured review following PRISMA guidelines. Three electronic databases and the grey literature were searched with no time limits. Empirical studies reporting data on the chemical stability of continuous subcutaneous infusions or solutions stored in polypropylene syringes were included. Twenty-one empirical studies were included in this review reporting chemical compatibility and stability of 32 discrete combinations of twenty-four drugs tested at a variety of different drug concentrations. The majority of combinations reported were assessed as being chemically compatible. The greatest risk of clinically significant chemical degradation was observed with midazolam. Only one study reported the microbiological stability of the solution examined. There is currently limited evidence for the physical, chemical and microbiological stability of solutions for continuous subcutaneous infusion over a period of 48 hours. More stability data is required before the use of 48-hour CSCIs can be evaluated for use within clinical practice.

An uncommon skin condition illustrates the need for caution when prescribing for friends.

PubMed

Ares, Ella

2008-08-01

A dual-focused case study written to discuss the legal and medical hazards of informally writing prescriptions for friends or family members and to provide knowledge of early-stage mycosis fungoides (MF), its course, and treatment. A review of the prescribing practices of clinicians, the cognitive processes needed in diagnosis and treatment, the current ethical guidelines, and a review of MF, its course, and treatments. Treating acquaintances and family informally places clinicians at risk for liability and patients at risk for inaccurate diagnosis and treatment. This case illustrates the potential hazard of casually treating a friend for what looks like a benign condition. Resembling atopic dermatitis in its early stages, MF is the most common of a rare group of skin lymphomas. Early diagnosis and treatment are crucial for a better prognosis. Had this clinician complied with the request of her friend, his diagnosis would have been missed and timely treatment delayed. No matter what the prior relationship may have been, once a clinician treats a patient, a legally binding relationship begins, requiring the due standard of care. Nurse practitioners (NPs) need to be aware of the potential for error when treating acquaintances. Available NP standards of practice and ethical guidelines should address informal treatment situations.

Economic prescribing of corticosteroid nasal sprays in Germany: comparison of mometasone and budesonide nasal sprays on the basis of the DDD, the PDD and reference prices.

PubMed

Becker, Beril; Kruppert, Silvia; Kostev, Karel

2013-01-01

According to the German Social Security Code (SGB V), drugs should be prescribed on a cost-effective basis. An attempt is made to achieve this in Germany with the help of the DDD system and reference prices. Taking the example of the most frequently prescribed corticosteroid nasal sprays containing the active substances budesonide (BNS) or mometasone (MNS), we will show here that the DDD system is not necessarily suitable for tapping economic reserves. Despite the pharmacologic differences between the two substances, a uniformly defined daily dose (DDD) is assumed for both. Moreover, since 2006 they have formed a reference-price group of nasally administered medication with other active substances. Products were compared with regard to potential differences in patient populations and resulting treatment costs. The extent to which the two instruments are suitable for tapping economic reserves were estimated. We analyzed longitudinal diagnostic and prescription data in the IMS® Disease Analyzer Database from the period 2006 to July 2010. In total we analyzed data from 16,163 MNS and 4,218 BNS patients from GP practices plus 11,103 MNS and 2,521 BNS patients from ENT practices. The average quantity prescribed per patient differed in favor of MNS by -111.5 (for first prescriptions) to -260.1 puffs (after 730 days) in GP practices and by -137.3 to -488.3 puffs in ENT practices (p < 0.001). The mean calculated treatment cost per year from the point of view of the statutory health insurer was 20.40 € (GP practices) and 30.50 € (ENT practices) for MNS compared to 22.40 € (GP practices) and 32.10 € (ENT practices) for BNS. Based on the price level after the 2011 referenceprice adjustment, the treatment costs are 16.40 € (GP practices) and 24.20 € (ENT practices) for MNS versus 21.20 € (GP practices) and 32.30 € (ENT practices) for BNS. The volumes of MNS actually prescribed are significantly lower than those of BNS in the compared patient populations. Based on the actual consumption of the substances, there is no treatment-cost advantage for BNS in comparison to MNS from the statutory health insurer's point of view. By contrast, the reference-price adjustment results in a greater reduction of treatment costs for mometasone, so that in this case the statutory health insurer is able to tap economic reserves. Both the comparative parameters used for calculating the reference price and the DDD system are only conditionally suitable for tapping economic reserves for drugs.

Use of Smoking Cessation Interventions by Physicians in Argentina

PubMed Central

Schoj, Veronica; Mejia, Raul; Alderete, Mariela; Kaplan, Celia P.; Peña, Lorena; Gregorich, Steven E.; Alderete, Ethel; Pérez-Stable, Eliseo J.

2015-01-01

Background Physician-implemented interventions for smoking cessation are effective but infrequently used. We evaluated smoking cessation practices among physicians in Argentina. Methods A self-administered survey of physicians from six clinical systems asked about smoking cessation counselling practices, barriers to tobacco use counselling and perceived quality of training received in smoking cessation practices. Results Of 254 physicians, 52.3% were women, 11.8% were current smokers and 52% never smoked. Perceived quality of training in tobacco cessation counselling was rated as very good or good by 41.8% and as poor/very poor by 58.2%. Most physicians (90%) reported asking and recording smoking status, 89% advised patients to quit smoking but only 37% asked them to set a quit date and 44% prescribed medications. Multivariate analyses showed that Physicians’ perceived quality of their training in smoking cessation methods was associated with greater use of evidence-based cessation interventions. (OR = 6.5; 95% CI = 2.2–19.1); motivating patients to quit (OR: 7.9 CI 3.44–18.5), assisting patients to quit (OR = 9.9; 95% CI = 4.0–24.2) prescribing medications (OR = 9.6; 95% CI = 3.5–26.7), and setting up follow-up (OR = 13.0; 95% CI = 4.4–38.5). Conclusions Perceived quality of training in smoking cessation was associated with using evidence-based interventions and among physicians from Argentina. Medical training programs should enhance the quality of this curriculum. PMID:27594922

Prescribed fire and air quality in the American South: a review of conflicting interests and a technique for incorporating the land manager into regional air quality modeling

Treesearch

Gary L. Achtemeier

2013-01-01

In this paper, conflicting interests in prescribed burn practice and improving air quality in the South are reviewed. Conflicting societal interests and legislative actions threaten to curtail the use of prescribed fire to manage for endangered species and for other land management objectives in the South. This comes at a time when efforts are being made to increase...

Prescribing by pharmacists in Alberta and its relation to culture and personality traits.

PubMed

Rosenthal, Meagen M; Houle, Sherilyn K D; Eberhart, Greg; Tsuyuki, Ross T

2015-01-01

As evidence for the efficacy of pharmacists' interventions, governments worldwide are developing legislation to formalize new practice approaches, including independent prescribing by pharmacists. Pharmacists in Alberta became the first in Canada availed of this opportunity; however, uptake of such has been slow. One approach to understanding this problem is through an examination of pharmacists who have already gained this ability. The primary objective of this study was to gain descriptive insight into the culture and personality traits of innovator, and early adopter, Alberta pharmacists with Additional Prescribing Authorization using the Organizational Culture Profile and Big Five Inventory. The study was a cross-sectional online survey of Alberta pharmacists who obtained Additional Prescribing Authorization (independent prescribing authority), in the fall of 2012. The survey contained three sections; the first contained basic demographic, background and practice questions; the second section contained the Organizational Culture Profile; and the third section contained the Big Five Inventory. Sixty-five survey instruments were returned, for a response rate of 39%. Respondents' mean age was 40 (SD 10) years. The top reason cited by respondents for applying for prescribing authority was to improve patient care. The majority of respondents perceived greater value in the cultural factors of competitiveness, social responsibility, supportiveness, performance orientation and stability, and may be more likely to exhibit behavior in line with the personality traits of extraversion, agreeableness, conscientiousness and openness. Inferential statistical analysis revealed a significant linear relationship between Organizational Culture Profile responses to cultural factors of social responsibility and competitiveness and the number of prescription adaptations provided. This insight into the experiences of innovators and early adopter pharmacist prescribers can be used to develop more specific and targeted knowledge implementation studies to improve the uptake and integration of prescribing by pharmacists. Copyright © 2015 Elsevier Inc. All rights reserved.

The management of acne vulgaris in primary care: a cohort study of consulting and prescribing patterns using the Clinical Practice Research Datalink.

PubMed

Francis, N A; Entwistle, K; Santer, M; Layton, A M; Eady, E A; Butler, C C

2017-01-01

Effective management of acne vulgaris in primary care involves support (usually provided over a number of consultations) and prescription of effective treatments. However, consulting and prescribing patterns for acne in primary care are not well described. To describe the rate of primary-care consultations and follow-up consultations; prescribing patterns, including overall use of acne-related medications (ARMs); and initial and follow-up prescription for acne vulgaris in the U.K. U.K. primary-care acne consultations and prescriptions for ARMs were identified in the Clinical Practice Research Datalink. Annual consultation rates (between 2004 and 2013) by age and sex, new consultations and consultations in the subsequent year were calculated, along with prescribing trends - during a new consultation and over the subsequent 90 days and year - using the number of registered patients as the denominator. Two-thirds (66·1%) of patients who had a new acne consultation had no further acne consultations in the subsequent year. Overall 26·7%, 24·9%, and 23·6% and 2·8% of patients were prescribed no ARM, an oral antibiotic, a topical antibiotic or an oral plus topical antibiotic, respectively, during a new acne consultation. In total 60·1% and 38·6% of patients prescribed an ARM received no further ARM prescriptions in the following 90 days and 1 year, respectively, despite most prescriptions being for 2 months or less. Prescribing rates for lymecycline and topical combined clindamycin and benzoyl peroxide increased substantially between 2004 and 2013. There were no important changes in consultation rates between 2004 and 2013. These data suggest that patients with acne are receiving a suboptimal initial choice of ARMs, longitudinal care and prescribing. © 2016 British Association of Dermatologists.

Perceptions of prescribed burning in a local forest community in Victoria, Australia.

PubMed

Bell, Tina; Oliveras, Immaculada

2006-11-01

The general perceptions of prescribed burning were elicited from forest users for an area that has been subject to this form of land management for at least 20 years. The largest group consisted of local residents living in and around the Wombat State Forest with two smaller groups of students from a nearby university campus and local professional land managers. A questionnaire was given to each participant in order to explore how the forest was used, to determine the level of knowledge of burning in the targeted forest and Victoria and the perception of the appearance, effectiveness of protection, and accessibility to the forest after prescribed burning. Generally all groups had similar responses with community members having stronger views on the effectiveness and practicalities of prescribed burning, whereas students were more neutral in their opinions. All participants claimed knowledge of prescribed burning activities within Victoria, but fewer had experience of planned fires in the Wombat State Forest. All groups agreed that areas that had not been recently burned had a better appearance than those that had, but this result may have included a range of value judgments. Land managers had a greater understanding of the ecological importance of season and timing of burning; however, some students and community members were equally knowledgeable. Prescribed burning did not impede access to the forest, nor did smoke from prescribed burns pose any great problem. The majority of the participants felt that the amount of prescribed burning done in the forest was adequate for engendering a feeling of protection to life and property, yet many were still suspicious of this management practice. These initial findings indicate several areas in which further research would be useful including the efficacy of education programs for community members and improved communication of burn plans by land managers.

Advantages and disadvantages of interdisciplinary consultation in the prescription of assistive technologies for mobility limitations.

PubMed

de Laat, Fred A; van Heerebeek, Bart; van Netten, Jaap J

2018-03-28

To explore the advantages and disadvantages experienced by professionals in interdisciplinary consultation involving the user, prescriber and technician in the prescription of assistive technologies for mobility limitations. Cross-sectional study. Prescribers (N = 39) and orthopaedic technicians (N = 50), who were regularly involved in an interdisciplinary consultation completed a questionnaire about advantages and disadvantages of the interdisciplinary consultation. Advantages of the interdisciplinary consultation were mentioned within all CanMEDS areas of medical practice, including better and quicker prescription of the assistive technology, shared knowledge of medical diagnosis and device possibilities, shared decision making of the device prescription and clear communication rules. Disadvantages were mentioned in the CanMEDS areas management and collaboration, including planning problems (financial) reimbursement of this type of consultation, and time efficiency. On a 10-point scale, mean (standard deviation) rates of interdisciplinary consultations were 7.9 (0.6) according to prescribers, and 7.8 (0.9) by technicians. All participants wanted to continue the interdisciplinary consultation. Prescribers and technicians in the field of assistive technologies for walking mobility limitations appreciate an interdisciplinary consultation. Advantages are found in all CanMEDS areas, whereas disadvantages only concern coordination. It should be encouraged to realize this kind of consultation in all situations where such technologies are prescribed. Implications for rehabilitation Interdisciplinary consultation involving the user, prescriber and technician to prescribe assistive technologies for mobility limitations has many advantages in all CanMEDS areas of medical practice, and few disadvantages, related to management and collaboration only. The disadvantages of interdisciplinary consultation, such as (financial) reimbursement by health insurance companies, have to be taken into account. Professionals in the field of ankle-foot-orthoses and orthopaedic shoes (medical specialist as prescriber and orthopaedic technician) who are involved in interdisciplinary consultation appreciate it and want to continue.

Addiction liability of pharmacotherapeutic interventions in obesity.

PubMed

Greene, William M; Sylvester, Mark; Abraham, Joel

2011-01-01

Obesity and substance use disorders are rapidly growing problems throughout the world. Of the current mainstay therapies of diet, exercise, behavioral modification, surgery, and medications, drugs have the greatest risk for abuse and dependence. As each of these disorders share similar underpinnings mediated by the dopaminergic brain reward pathways, clinicians must seriously consider the safety of both the patient's physical and mental health when prescribing treatments. Specifically, balance and awareness of the factors involved in the variable abuse potentials of these prescribed medications is paramount. A cursory review of weight loss medications commonly used is performed with attention to FDA status, mechanism of action, and abuse potential. Concurrent strategies to minimize risk such as drug screening, ruling out doctor shopping, temporal considerations, monitoring for signs and symptoms of abuse and/or dependency, and a safety-tiered prescribing approach is also discussed in order to optimize best treatment practice. As the understanding of these disorders progresses along with the evolution of agreed nomenclature and awareness of compulsive behavioral disorders in general, greater safety and more appropriate interventions may be achieved. Further areas of research will help to elucidate nuances of the coocurrance and treatment of these disorders and perhaps guide drug research and development in the area of drug treatments of obesity.

Perceptions and knowledge regarding antimicrobial stewardship among clinicians in Jeddah, Saudi Arabia

PubMed Central

Al-Harthi, Sameer E.; Khan, Lateef M.; Osman, Abdel-Moneim M.; Alim, Mai A.; Saadah, Omar I.; Almohammadi, Abdulrehman A.; Khan, Faheem M.; Kamel, Fatemah O.

2015-01-01

Objectives: To understand the perceptions, attitude, and prescribing practices of clinicians regarding antimicrobial resistance (AMR). Methods: A multidisciplinary cross-sectional study comprising 447 clinicians of university, public, and private hospitals of Jeddah, Saudi Arabia was carried out from August to October 2014 using a self-administered questionnaire. Results: Interestingly, 33% of the general physicians yielded to patient/parent’s demand for the choice of antimicrobials (AMs) as compared with only 13.2% of the residents, and 4.3% of the specialists. In addition, expensive AMs are more often prescribed by the general physician (70.4%) in comparison with 26.4% residents and 30.4% of the specialists. However, no significant differences were observed between the knowledge and perceptions regarding the current scope of AM agents, as well as their use and misuse. Furthermore, dependability of specialist and residents seems to be significantly higher than general physicians on pocketbooks and smartphone for AM education sources. Conclusion: This study revealed that despite a clear concept of AMR, general physicians lacks consistency in prescribing aptitude and use of effective educational resources, while all respondents lacks dedication to follow the guidelines of AM use. This highlights the requirement of AM stewardship with decisive objective of reduction in AMR. PMID:26108585

Thromboprophylaxis among Australasian colorectal surgeons.

PubMed

Smart, Philip; Burbury, Kate; Lingaratnam, Senthil; Lynch, A Craig; Mackay, John; Heriot, Alexander

2013-09-01

Thromboembolism is a common cause of morbidity and mortality in patients with colorectal cancer, but thromboprophylaxis (TP) is underutilized. Current guidelines do not make specific recommendations for colorectal cancer patients and provide minimal guidance for the ambulatory setting, although emerging evidence suggests TP may be warranted during chemoradiotherapy or in the extended post-operative phase. A survey of Australasian colorectal surgeons was therefore performed to assess current TP practice and attitudes. An online survey was sent to 204 surgeons who were members of the Colorectal Surgical Society of Australia and New Zealand. One hundred twenty-eight surgeons (63%) completed the survey. Most surgeons consult available guidelines, and where recommendations are made, current practice is in line with them. Lack of data, lack of ownership, logistical issues and an absence of guideline recommendations currently prevent surgeons from instituting TP in the neoadjuvant treatment period. Fifty-four per cent of surgeons currently prescribe TP after hospital discharge; those that do not, cite logistical issues as the main constraint. More data on thromboembolism risk during various treatment phases are required and should be promulgated in tumour-specific guidelines. Logistical barriers to adopting TP in the ambulatory setting should be addressed. © 2012 The Authors. ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons.

Public Health Detailing—A Successful Strategy to Promote Judicious Opioid Analgesic Prescribing

PubMed Central

Tuazon, Ellenie; Paone, Denise; Dowell, Deborah; Vo, Linda; Starrels, Joanna L.; Jones, Christopher M.; Kunins, Hillary V.

2016-01-01

Objectives. To evaluate knowledge and prescribing changes following a 2-month public health detailing campaign (one-to-one educational visits) about judicious opioid analgesic prescribing conducted among health care providers in Staten Island, New York City, in 2013. Methods. Three detailing campaign recommendations were (1) a 3-day supply of opioids is usually sufficient for acute pain, (2) avoid prescribing opioids for chronic noncancer pain, and (3) avoid high-dose opioid prescriptions. Evaluation consisted of a knowledge survey, and assessing prescribing rates and median day supply per prescription. Prescribing data from the 3-month period before the campaign were compared with 2 sequential 3-month periods after the campaign. Results. Among 866 health care providers visited, knowledge increased for all 3 recommendations (P < .01). After the campaign, the overall prescribing rate decreased similarly in Staten Island and other New York City counties (boroughs), but the high-dose prescribing rate decreased more in Staten Island than in other boroughs (P < .01). Median day supply remained stable in Staten Island and increased in other boroughs. Conclusions. The public health detailing campaign improved knowledge and likely prescribing practices and could be considered by other jurisdictions to promote judicious opioid prescribing. PMID:27400353

40 CFR 792.1 - Scope.

Code of Federal Regulations, 2010 CFR

2010-07-01

...) GOOD LABORATORY PRACTICE STANDARDS General Provisions § 792.1 Scope. (a) This part prescribes good laboratory practices for conducting studies relating to health effects, environmental effects, and chemical...

40 CFR 792.1 - Scope.

Code of Federal Regulations, 2011 CFR

2011-07-01

...) GOOD LABORATORY PRACTICE STANDARDS General Provisions § 792.1 Scope. (a) This part prescribes good laboratory practices for conducting studies relating to health effects, environmental effects, and chemical...

Air quality impacts from prescribed forest fires under different management practices.

PubMed

Tian, Di; Wang, Yuhang; Bergin, Michelle; Hu, Yongtao; Liu, Yongqiang; Russell, Armistead G

2008-04-15

Large amounts of air pollutants are emitted during prescribed forest fires. Such emissions and corresponding air quality impacts can be modulated by different forest management practices. The impacts of changing burning seasons and frequencies and of controlling emissions during smoldering on regional air quality in Georgia are quantified using source-oriented air quality modeling, with modified emissions from prescribed fires reflecting effects of each practice. Equivalent fires in the spring and winter are found to have a greater impact on PM2.5 than those in summer, though ozone impacts are larger from spring and summer fires. If prescribed fires are less frequent more biofuel is burnt in each fire, leading to larger emissions and air quality impacts per fire. For example, emissions from a fire with a 5-year fire return interval (FRI) are 72% larger than those from a fire of the same acreage with a 2-year FRI. However, corresponding long-term regional impacts are reduced with the longer FRI since the annual burned area is reduced. Total emissions for fires in Georgia with a 5-year FRI are 32% less than those with a 2-year FRI. Smoldering emissions can lead to approximately 1.0 or 1.9 microg/m3 of PM2.5 in the Atlanta PM2.5 nonattainment area during March 2002.

Engaging healthcare providers to implement HIV pre-exposure prophylaxis.

PubMed

Krakower, Douglas; Mayer, Kenneth H

2012-11-01

Recent randomized controlled trials have demonstrated that HIV pre-exposure prophylaxis (PrEP) can decrease HIV incidence among several at-risk populations, including men who have sex with men, serodiscordant couples, and heterosexual men and women. As PrEP is a biomedical intervention that requires clinical monitoring and a high level of medication adherence, maximizing the public health effectiveness of PrEP in real-world settings will require the training of a cadre of healthcare providers to prescribe PrEP. Therefore it is critical to understand provider knowledge, practices, and attitudes towards PrEP prescribing, and to develop strategies for engaging and training providers to provide PrEP. Limited numbers of studies have focused on PrEP implementation by healthcare providers. These studies suggest that some providers are knowledgeable about PrEP, but many are not, or express misgivings. Although many clinicians report willingness to provide PrEP, few have prescribed PrEP in clinical practice. Provider comfort and skills in HIV risk assessment are suboptimal, which could limit identification of individuals who are most likely to benefit from PrEP use. Further studies to understand facilitators and barriers to HIV-risk assessment and PrEP prescribing by practicing clinicians are needed. Innovative training strategies and decision-support interventions for providers could optimize PrEP implementation and therefore merit additional research.

Using Health Information Technology to Improve Adherence to Opioid Prescribing Guidelines in Primary Care

PubMed Central

Zlateva, Ianita; Khatri, Khushbu; Ciaburri, Nicholas

2015-01-01

Objective: To evaluate the impact of a clinical dashboard for opioid analgesic management on opioid prescribing and adherence to opioid practice guidelines in primary care. Methods: A pre/postimplementation evaluation using electronic health record (EHR) data from patients receiving chronic opioid therapy (COT) between April 1, 2011 and March 31, 2013. Measures include annual proportions of COT patients who received urine drug testing, signed an opioid treatment agreement, had a documented assessment of pain-related functional status, and had at least 1 visit with a behavioral health provider. Results: Adherence to several opioid prescribing guidelines improved in the postimplementation year compared with the preimplementation year: (1) the proportions of COT patients with a signed opioid treatment agreement and urine drug testing increased from 49% to 63% and 66% to 86%, respectively. The proportion of COT patients with a documented assessment of functional status increased from 33% to 46% and those with a behavioral health visit increased from 24% to 28%. However, there was a small decline in the proportion of patients prescribed COT from 3.4% to 3.1%. Discussion: Implementation of an opioid dashboard led to increased adherence to certain opioid practice guidelines and a decline in COT. This may be attributable to more efficient team-based pain management facilitated by the dashboard and increased transparency of opioid prescription practices. Health Information Technology solutions such as clinical dashboards can increase adherence to practice guidelines. PMID:25411860

Therapies most frequently used for the management of bruxism by a sample of German dentists.

PubMed

Ommerborn, Michelle A; Taghavi, Jalleh; Singh, Preeti; Handschel, Joerg; Depprich, Rita A; Raab, Wolfgang H M

2011-03-01

At present, there is little information available on how practicing dentists manage bruxism patients with respect to conservative, reversible techniques as compared to irreversible techniques. The purpose of this study was to determine the most commonly applied therapies used for the management of bruxism by German general dentists (GDs) and dental specialists. In addition, efforts were made to gather information on the knowledge and opinion of GDs and specialists regarding the role of occlusal interferences, in particular, on the development of sleep bruxism. A 13-item questionnaire was developed and mailed to all active members of the statutory dental insurance providers of the German North Rhine (n=5500; 2006 roster) and the German Westphalia-Lippe area (n=4984; 2006 roster). Group differences were statistically analyzed using chi-square tests for the qualitative variables and Mann-Whitney U tests for the quantitative variables (α=.05). Occlusal splints were by far the most frequently prescribed therapy for the management of bruxism, followed by relaxation techniques, occlusal equilibration, physiotherapy, and prosthodontic reconstruction. The occlusal stabilization splint with canine protected articulation was the splint type most often prescribed, whereas respondents used unadjusted soft splints for approximately 8% of their bruxism patients. Comparison of the opinions of all responding practicing dentists with that of experts in regard to the statement that "sleep bruxism is caused by occlusal interferences" showed a significant difference between the 2 groups (P=.021). Eighty-five percent of the experts disagreed with this statement, and only 47.7% of the practicing dentists had the same opinion as the experts. Most practicing dentists seem to concur with current scientific recommendations, and express the opinion that the management of bruxism should predominantly be conservative and reversible; however, the findings of the present survey reveal diverse differences between GDs and dental specialists concerning the most frequently prescribed therapies. Moreover, the discrepancies detected in some areas, such as the use of irreversible techniques or the use of unadjusted soft splints, emphasize the need to more promptly transfer new knowledge in the field of bruxism from researchers to practicing dentists. Copyright © 2011 The Editorial Council of the Journal of Prosthetic Dentistry. Published by Mosby, Inc. All rights reserved.

[COPD routine management in France: are guidelines used in clinical practice?].

PubMed

Jebrak, G

2010-01-01

COPD management guidelines have been proposed to improve the major outcomes for COPD patients. In clinical practice, COPD treatment is only partially consistent with current guidelines and recommendations. Global initiative for chronic obstructive lung disease (GOLD) guidelines are based on a COPD severity scale and are subject to change as the evidence based evolves. The main purpose of our study was to access whether the treatments prescribed to patients with COPD were consistent with these guidelines. Treatments prescribed by French physicians to 542 patients with COPD in stable conditions were recorded according to the severity of obstruction, using GOLD classification. We compared our prescription data base with the GOLD guidelines. Forty percent of the initial physicians were chest specialists. 78.3 % men, (64.8+/-10.8years) and 25 % were still smokers at inclusion. We found an important discrepancy between recommended treatment and COPD severity. Bronchodilators were commonly prescribed, but 11 % in severe COPD (stages III and IV) did not receive them. Inhaled steroids (ICS) were used respectively in 55.2 %, 59.4 % of patients in stages I, II (FEV1>50 %) (for whom they are not recommended) and 77.4 and 85.3 % in stages III and IV. Only 30 % of patients used ICS+beta2 agonists in the same device. Influenza vaccination had been performed in only half of patients whatever the severity of COPD. Pulmonary rehabilitation had been used by 10 % of patients, (stage II: 6.4 %, stage III: 9.6 %, stage IV: 20.6 %). We confirmed that there are discrepancies between COPD guidelines and routine treatments. Some treatments such as ICS were overused in mild phenotypes, whereas in a high proportion of cases influenza immunisation and rehabilitation were omitted.

Pharmacist prescribing: a cross-sectional survey of the views of pharmacists in Nigeria.

PubMed

Auta, Asa; Strickland-Hodge, Barry; Maz, Julia; David, Shalkur

2018-04-01

This study was carried out to: (1) explore the views of pharmacists in Nigeria on the extension of prescribing authority to them and determine their willingness to be prescribers and (2) identify the potential facilitators and barriers to introducing pharmacist prescribing in Nigeria. An online cross-sectional survey was conducted from August to October 2014 among 775 pharmacists recruited from the Facebook group of the Pharmaceutical Society of Nigeria using a simple random technique. The questionnaire used for the survey was developed based on the review of the literature and previous qualitative studies conducted in Nigeria. The instrument was evaluated for content validity by two external pharmacy practice researchers and the reliability of items assessed using internal consistency tests. Data obtained from the survey were entered into SPSS v.22, and descriptive statistics were generated. Relationships between variables were evaluated using the chi-square test, and P < 0.05 was considered statistically significant. The response rate was 40.6% (315/775). Three hundred and six (97.1%) respondents agreed that pharmacists should be given prescribing authority. Of these 306, 295 (96.4%) were willing to be prescribers, and just over half of them (148/295; 50.2%) would prefer to prescribe in collaboration with medical doctors. Of those willing to be prescribers, 285 (96.6%) reported that they would need additional training. The most perceived areas of training needed were in the principles of differential diagnosis (81.4%), pathophysiology of diseases (74.0%) and interpretation of laboratory results (68.1%). Respondents identified increasing patients' access to care (308/315; 97.8%) and better utilisation of pharmacists' skills (307/315; 97.5%) as the most likely facilitators to pharmacist prescribing in Nigeria. On the other hand, resistance from the medical doctors (299/315; 94.9%) and pharmacists' inadequate skills in diagnosis (255/315; 81.0%) were perceived as the most likely barriers. Pharmacist prescribing represents an opportunity to promote patients' access to care and the utilisation of pharmacists' skills in Nigeria. The majority of pharmacists showed a positive attitude towards pharmacist prescribing and were willing to be prescribers. The findings of this study could potentially contribute to future medicine prescribing policy and pharmacy practice in Nigeria. © 2017 Royal Pharmaceutical Society.

High-Dose Opioid Prescribing and Opioid-Related Hospitalization: A Population-Based Study.

PubMed

Fernandes, Kimberly; Martins, Diana; Juurlink, David; Mamdani, Muhammad; Paterson, J Michael; Spooner, Luke; Singh, Samantha; Gomes, Tara

2016-01-01

To examine the impact of national clinical practice guidelines and provincial drug policy interventions on prevalence of high-dose opioid prescribing and rates of hospitalization for opioid toxicity. Interventional time-series analysis. Ontario, Canada, from 2003 to 2014. Ontario Drug Benefit (ODB) beneficiaries aged 15 to 64 years from 2003 to 2014. Publication of Canadian clinical practice guidelines for use of opioids in chronic non-cancer pain (May 2010) and implementation of Ontario's Narcotics Safety and Awareness Act (NSAA; November 2011). Three outcomes were explored: the rate of opioid use among ODB beneficiaries, the prevalence of opioid prescriptions exceeding 200 mg and 400 mg morphine equivalents per day, and rates of opioid-related emergency department visits and hospital admissions. Over the 12 year study period, the rate of opioid use declined 15.2%, from 2764 to 2342 users per 10,000 ODB eligible persons. The rate of opioid use was significantly impacted by the Canadian clinical practice guidelines (p-value = .03) which led to a decline in use, but no impact was observed by the enactment of the NSAA (p-value = .43). Among opioid users, the prevalence of high-dose prescribing doubled (from 4.2% to 8.7%) over the study period. By 2014, 40.9% of recipients of long-acting opioids exceeded daily doses of 200 mg morphine or equivalent, including 55.8% of long-acting oxycodone users and 76.3% of transdermal fentanyl users. Moreover, in the last period, 18.7% of long-acting opioid users exceeded daily doses of 400 mg morphine or equivalent. Rates of opioid-related emergency department visits and hospital admissions increased 55.0% over the study period from 9.0 to 14.0 per 10,000 ODB beneficiaries from 2003 to 2013. This rate was not significantly impacted by the Canadian clinical practice guidelines (p-value = .68) or enactment of the NSAA (p-value = .59). Although the Canadian clinical practice guidelines for use of opioids in chronic non-cancer pain led to a decline in opioid prescribing rates among ODB beneficiaries these guidelines and subsequent Ontario legislation did not result in a significant change in rates of opioid-related hospitalizations. Given the prevalence of high dose opioid prescribing in this population, this suggests that improved strategies and programs for the safe prescribing of long-acting opioids are needed.

Primary prevention of cardiovascular diseases: a cost study in family practices.

PubMed

de Bekker-Grob, Esther W; van Dulmen, Sandra; van den Berg, Matthijs; Verheij, Robert A; Slobbe, Laurentius C J

2011-07-06

Considering the scarcity of health care resources and the high costs associated with cardiovascular diseases, we investigated the spending on cardiovascular primary preventive activities and the prescribing behaviour of primary preventive cardiovascular medication (PPCM) in Dutch family practices (FPs). A mixed methods design was used, which consisted of a questionnaire (n = 80 FPs), video recordings of hypertension- or cholesterol-related general practitioner visits (n = 56), and the database of Netherlands Information Network of General Practice (n = 45 FPs; n = 157,137 patients). The questionnaire and video recordings were used to determine the average frequency and time spent on cardiovascular primary preventive activities per FP respectively. Taking into account the annual income and full time equivalents of general practitioners, health care assistants, and practice nurses as well as the practice costs, the total spending on cardiovascular primary preventive activities in Dutch FPs was calculated. The database of Netherlands Information Network of General Practice was used to determine the prescribing behaviour in Dutch FPs by conducting multilevel regression models and adjusting for patient and practice characteristics. Total expenditure on cardiovascular primary preventive activities in FPs in 2009 was €38.8 million (€2.35 per capita), of which 47% was spent on blood pressure measurements, 26% on cardiovascular risk profiling, and 11% on lifestyle counselling. Fifteen percent (€11 per capita) of all cardiovascular medication prescribed in FPs was a PPCM. FPs differed greatly on prescription of PPCM (odds ratio of 3.1). Total costs of cardiovascular primary preventive activities in FPs such as blood pressure measurements and lifestyle counselling are relatively low compared to the costs of PPCM. There is considerable heterogeneity in prescribing behaviour of PPCM between FPs. Further research is needed to determine whether such large differences in prescription rates are justified. Striving for an optimal use of cardiovascular primary preventive activities might lead to similar health outcomes, but may achieve important cost savings.

Impact of smoke from prescribed burning: Is it a public health concern?

PubMed

Haikerwal, Anjali; Reisen, Fabienne; Sim, Malcolm R; Abramson, Michael J; Meyer, Carl P; Johnston, Fay H; Dennekamp, Martine

2015-05-01

Given the increase in wildfire intensity and frequency worldwide, prescribed burning is becoming a more common and widespread practice. Prescribed burning is a fire management tool used to reduce fuel loads for wildfire suppression purposes and occurs on an annual basis in many parts of the world. Smoke from prescribed burning can have a substantial impact on air quality and the environment. Prescribed burning is a significant source of fine particulate matter (PM2.5 aerodynamic diameter<2.5µm) and these particulates are found to be consistently elevated during smoke events. Due to their fine nature PM2.5 are particularly harmful to human health. Here we discuss the impact of prescribed burning on air quality particularly focussing on PM2.5. We have summarised available case studies from Australia including a recent study we conducted in regional Victoria, Australia during the prescribed burning season in 2013. The studies reported very high short-term (hourly) concentrations of PM2.5 during prescribed burning. Given the increase in PM2.5 concentrations during smoke events, there is a need to understand the influence of prescribed burning smoke exposure on human health. This is important especially since adverse health impacts have been observed during wildfire events when PM2.5 concentrations were similar to those observed during prescribed burning events. Robust research is required to quantify and determine health impacts from prescribed burning smoke exposure and derive evidence based interventions for managing the risk. Given the increase in PM2.5 concentrations during PB smoke events and its impact on the local air quality, the need to understand the influence of PB smoke exposure on human health is important. This knowledge will be important to inform policy and practice of the integrated, consistent, and adaptive approach to the appropriate planning and implementation of public health strategies during PB events. This will also have important implications for land management and public health organizations in developing evidence based objectives to minimize the risk of PB smoke exposure.

Prescribed burning and mechanical thinning effects on belowground conditions and soil respiration in a mixed-conifer forest, California

Treesearch

Soung-Ryoul Ryu; Amy Concilio; Jiquan Chen; Malcolm North; Siyan Ma

2009-01-01

Soil respiration (RS) is a major carbon pathway from terrestrial ecosystems to the atmosphere and is sensitive to environmental changes. Although commonly used mechanical thinning and prescribed burning can significantly alter the soil environment, the effect of these practices on RS...

47 CFR 1.1151 - Authority to prescribe and collect regulatory fees.

Code of Federal Regulations, 2010 CFR

2010-10-01

... regulatory activities in the private radio, mass media, common carrier, and cable television services. [59 FR... fees. 1.1151 Section 1.1151 Telecommunication FEDERAL COMMUNICATIONS COMMISSION GENERAL PRACTICE AND... section 9 of the Communications Act, 47 U.S.C. 159, which directs the Commission to prescribe and collect...

Preparing to Prescribe: How Do Clerkship Students Learn in the Midst of Complexity?

ERIC Educational Resources Information Center

McLellan, Lucy; Yardley, Sarah; Norris, Ben; de Bruin, Anique; Tully, Mary P.; Dornan, Tim

2015-01-01

Prescribing tasks, which involve pharmacological knowledge, clinical decision-making and practical skill, take place within unpredictable social environments and involve interactions within and between endlessly changing health care teams. Despite this, curriculum designers commonly assume them to be simple to learn and perform. This research used…

7 CFR 75.7 - Inspection in accordance with methods prescribed or approved.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 7 Agriculture 3 2012-01-01 2012-01-01 false Inspection in accordance with methods prescribed or approved. 75.7 Section 75.7 Agriculture Regulations of the Department of Agriculture (Continued) AGRICULTURAL MARKETING SERVICE (Standards, Inspections, Marketing Practices), DEPARTMENT OF AGRICULTURE (CONTINUED) REGULATIONS AND STANDARDS UNDER THE...

7 CFR 75.7 - Inspection in accordance with methods prescribed or approved.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 7 Agriculture 3 2014-01-01 2014-01-01 false Inspection in accordance with methods prescribed or approved. 75.7 Section 75.7 Agriculture Regulations of the Department of Agriculture (Continued) AGRICULTURAL MARKETING SERVICE (Standards, Inspections, Marketing Practices), DEPARTMENT OF AGRICULTURE (CONTINUED) REGULATIONS AND STANDARDS UNDER THE...

7 CFR 75.7 - Inspection in accordance with methods prescribed or approved.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 7 Agriculture 3 2013-01-01 2013-01-01 false Inspection in accordance with methods prescribed or approved. 75.7 Section 75.7 Agriculture Regulations of the Department of Agriculture (Continued) AGRICULTURAL MARKETING SERVICE (Standards, Inspections, Marketing Practices), DEPARTMENT OF AGRICULTURE (CONTINUED) REGULATIONS AND STANDARDS UNDER THE...

7 CFR 75.7 - Inspection in accordance with methods prescribed or approved.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 7 Agriculture 3 2011-01-01 2011-01-01 false Inspection in accordance with methods prescribed or approved. 75.7 Section 75.7 Agriculture Regulations of the Department of Agriculture (Continued) AGRICULTURAL MARKETING SERVICE (Standards, Inspections, Marketing Practices), DEPARTMENT OF AGRICULTURE (CONTINUED) REGULATIONS AND STANDARDS UNDER THE...

7 CFR 75.7 - Inspection in accordance with methods prescribed or approved.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 7 Agriculture 3 2010-01-01 2010-01-01 false Inspection in accordance with methods prescribed or approved. 75.7 Section 75.7 Agriculture Regulations of the Department of Agriculture (Continued) AGRICULTURAL MARKETING SERVICE (Standards, Inspections, Marketing Practices), DEPARTMENT OF AGRICULTURE (CONTINUED) REGULATIONS AND STANDARDS UNDER THE...

38 CFR 21.9725 - Progress and conduct.

Code of Federal Regulations, 2010 CFR

2010-07-01

... to the regularly prescribed standards of the institution of higher learning he or she is attending... to the regularly prescribed standards and practices of the institution of higher learning in which he... readmitted as a student by the institution of higher learning in which he or she is enrolled, VA will...

Prescribed fire effects on resource selection by cattle in mesic sagebrush steppe. Part 1: Spring grazing

USDA-ARS?s Scientific Manuscript database

Prescribed fire is commonly applied world wide as tool for enhancing habitats and altering resource selection patterns of grazing animals. A scientific basic for this management practice has been established in some rangeland ecosystems (e.g montane grasslands, tall grass prairie, mixed prairie, ...

Antibiotic use and knowledge in the community in Kalamoon, Syrian Arab Republic: a cross-sectional study.

PubMed

Barah, F; Gonçalves, V

2010-05-01

Antibiotic misuse contributes to the growing problem of microbial resistance. To understand the current knowledge and practices regarding antibiotic use among Syrians, we conducted a cross-sectional study of 430 randomly selected adult residents of Kalamoon in the Syrian Arab Republic using a questionnaire. A high proportion (85%) had taken antibiotics in the past 4 weeks and 34% were not aware of the dangers of antibiotics. Of 365 participants, only 43% were prescribed the antibiotic by a physician to treat the condition, while 57% used an old prescription or took someone else's advice. Males, younger individuals, and those with low and medium income and lower educational status showed poorer practice and lower knowledge towards antibiotics. Educational efforts are needed to reduce patient demand for antibiotics.

[Psychiatric medication as restraint: between autonomy and protection, is there place for a legal framework?].

PubMed

Bernheim, Emmanuelle

2010-01-01

The use of chemical restraint has been regulated for the past ten years in Quebec. However, clinical, ethical and legal issues, sometimes contradictory, have not really been considered during the legislative process leading to consolidation in its current form. The author supports that, because of the absence of consent and the effects of medication, a specific legal framework to the use of medication is necessary in a context of unplanned intervention to protect both patients and medical staff. This framework would prescribe good practice, take into account the non-medical aspects of consent to care and formalize the practice as an exception to the rule. In addition, the symbolism of law, through which social solidarity can be expressed, must not be underestimated.

Chapter 21: Estimating Net Savings - Common Practices. The Uniform Methods Project: Methods for Determining Energy Efficiency Savings for Specific Measures

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kurnik, Charles W; Violette, Daniel M.; Rathbun, Pamela

This chapter focuses on the methods used to estimate net energy savings in evaluation, measurement, and verification (EM and V) studies for energy efficiency (EE) programs. The chapter provides a definition of net savings, which remains an unsettled topic both within the EE evaluation community and across the broader public policy evaluation community, particularly in the context of attribution of savings to a program. The chapter differs from the measure-specific Uniform Methods Project (UMP) chapters in both its approach and work product. Unlike other UMP resources that provide recommended protocols for determining gross energy savings, this chapter describes and comparesmore » the current industry practices for determining net energy savings but does not prescribe methods.« less

The incommensurability of nursing as a practice and the customer service model: an evolutionary threat to the discipline.

PubMed

Austin, Wendy J

2011-07-01

Corporate and commercial values are inducing some healthcare organizations to prescribe a customer service model that reframes the provision of nursing care. In this paper it is argued that such a model is incommensurable with nursing conceived as a moral practice and ultimately places nurses at risk. Based upon understanding from ongoing research on compassion fatigue, it is proposed that compassion fatigue as currently experienced by nurses may not arise predominantly from too great a demand for compassion, but rather from barriers to enacting compassionate care. These barriers are often systemic. The paradigm shift in which healthcare environments are viewed as marketplaces rather than moral communities has the potential to radically affect the evolution of nursing as a discipline. © 2011 Blackwell Publishing Ltd.