Journals
Where is the evidence base: NMP in primary care?
January 3, 2012 by admin
A review of the literature on non-medical prescribing (NMP) in primary care that looked for evidence of patient outcomes has found that most such studies were undertaken in the UK, and that there are ’substantial gaps’ in the knowledge base that could inform evidence-based policy making.
The authors identified 17 empirical studies providing patient outcome evidence of NMP in primary care, with only two looking at clinical outcomes. Some papers were surveys, had qualitative designs, few participants, or reported on prescribing from limited formularies, and the authors comment that, ‘the strength of evidence they provide on the whole is limited’.
NMP in primary care does seem to improve: ‘patients’ understanding of treatment, condition and self-care and provides a better level of care’, was well accepted by patients and professionals, and improved access to medicines and healthcare professionals. Other indicators of effectiveness such as clinical outcomes or patient safety had very limited evidence, and papers on health economics and efficiency were also lacking.
Bhanbhro S et al. Assessing the contribution of prescribing in primary care by nurses and professionals allied to medicine: a systematic review of literature. BMC Health Services Research 2011; 11:330.
http://dx.doi.org/10.1186/1472-6963-11-330
Better job satisfaction but more stress: prescribing in general practice?
October 20, 2011 by admin
Independent prescribing increased job satisfaction for nurse practitioners working in general practice but also increased the levels of work-related stress, according to this small study involving interviews with six nurse practitioners working in a busy inner city general practice.
Cousins R and Donnell C. Nurse prescribing in general practice: a qualitative study indicates increased job satisfaction and work-related stress. Fam Pract 2011; published 28 September online ahead of print.
http://dx.doi.org/10.1093/fampra/cmr077.
Audit of non-medical prescribing in a mental health trust
September 28, 2011 by admin
A questionnaire survey of nurse and pharmacist prescribers within one mental health trust has concluded that although there is a high degree of compliance with the UK standards adopted by the trust, clinical supervision and training needs improving to meet them fully. Additional regular monitoring arrangements would ensure compliance.
Of the 24 non-medical prescribers included, 18 nurses and two pharmacists replied and their answers revealed two groups - high-frequency and lower-frequency prescribers (including the two pharmacists). The high-frequency prescribers were specialists, working in areas such as mental health services for older people, and were prescribing repeat or maintenance specialist medications whereas the lower-frequency prescribers started treatments themselves.
The authors say that the shortfall in supervision could be because of a lack or supervisors, lack of training for them or simply a lack of availability of supervision. Although the respondents were positive about the benefits of non-medical prescribing, 60% believed that training and supervision had shortfalls.
Some conflict with psychiatrists was reported but all respondents said they would seek advice from psychiatrists when necessary.
Gumber R, Khoosal D and Gajebasia N. Non-medical prescribing: audit, practice and views. J Psychiatr Men Health Nurs 2011; published online 18 July.
http://dx.doi.org/10.1111/j.1365-2850.2011.01779.x.
Pharmacist prescribing in Northern Ireland: some way to go
September 16, 2011 by admin
The number of qualified pharmacist prescribers in Northern Ireland is still relatively small and many of those qualified to do so are not actually prescribing, according to recent research. The story is familiar: although benefits for patient care and perceptions of pharmacists’ roles are recognised, barriers to prescribing remain.
McCann L et al. Pharmacist prescribing in Northern Ireland: a quantitative assessment. Int J Clin Pharm 2011; online first.
http://dx.doi.org/10.1007/s11096-011-9545-7.
Time to make prescribing safety a primary care priority?
July 15, 2011 by admin
There are ‘considerable’ opportunities to improve primary care prescribing safety and it is time that prescribing safety becomes a priority in primary care, according to the authors of this study. They analysed data from 315 Scottish general practices and found that nearly 14% of patients who were defined as being vulnerable to adverse drug events had received one or more high-risk prescriptions in the last year.
Vulnerability was assessed on the basis of age, pre-existing condition such as heart failure or chronic kidney disease, or existing prescription of a drug with potential for interaction such as warfarin or diuretics. Indicators for high-risk prescribing were defined on the basis of safety alerts, national clinical guidelines, the BNF and prescribing advice. What this means is that although few of these prescriptions were absolutely contraindicated and may have been appropriate, explicit guidance mostly underpinned by a solid evidence base existed that they carried significant risk of harm and should be avoided in most situations. Of those patients prescribed 11 or more drugs in the long term, more than a quarter received a high risk prescription, and increasing age also increased the risk, up to the age of about 80. There was wide variation in high-risk prescribing between practices, with none of the variables examined accounting for this.
The authors suggest that drug reviews could be targeted at those receiving high risk prescriptions defined using these indicators, so that their appropriateness can be the subject of clinical judgement. Despite the significant harm caused by prescribing, these results suggest that prescribing improvement activity does not focus enough on safety.
Guthrie B et al. High risk prescribing in primary care patients particularly vulnerable to adverse drug events: cross sectional population database analysis in Scottish general practice. BMJ 2011; 342:d3514.
http://dx.doi.org/10.1136/bmj.d3514.
Clarity needed about the role of non-medical prescribing leads
June 8, 2011 by admin
Non-medical prescribing leads (NMP leads) make a significant contribution to the development of NMP and its oversight within Trusts, despite lack of clarity about the role and workload and other issues, according to this report of an interview study with 28 NMP leads across one Strategic Health Authority.
The role of the NMP lead included: information and communication between the Trust and prescribers; promoting and co-ordinating NMP and integrating it into service planning; clinical governance; and support and training. There was inconsistency and lack of clarity about the functions and scope of the NMP lead, and dedicated time for the role was often insufficient. The authors conclude that there should be clear national guidelines about the responsibilities, role and workload of NMP leads, and that greater consistency is also needed in clinical governance systems as NMP expands. In particular, all NMPs should be able to review their prescribing data.
Conversely, where strategies for the development of NMP did exist, it was more likely to be embedded within organisations, and practitioners faced fewer barriers.
Courtenay M, Carey N and Stenner K. Non medical prescribing leads’ views on their role and the implementation of non medical prescribing from a multi-organisational perspective. BMC Health Services Research 2011; 11:142.
http://dx.doi.org/10.1186/1472-6963-11-142
Paracetamol prescribing in children
June 8, 2011 by admin
There are ‘relatively high levels of potential overdosing in the youngest children and potential underdosing in the oldest children’ in paracetamol prescribing in primary care, according to the conclusions of this study. It analysed a year’s data about paracetamol prescriptions in children aged 0-12 in general practices in Scotland.
About one-fifth of the paracetamol prescriptions were defined as off-label - being outside the BNF for Children age and dose recommendations - with incorrect doses being the most common reason. In addition, another 15% of prescriptions did not have dosage instructions.
The risk of over-dosing in young children carries a risk of toxicity, particularly as parents and carers often use paracetamol for children before they seek professional advice. For older children receiving doses that are too low, there is a risk of treatment failure and prescribing not being cost-effective.
Kazouini A et al. Paracetamol prescribing in primary care: too little and too much? Br J Clin Phamacol 2011; in press.
http://dx.doi.org/10.1111/j.1365-2125.2011.03993.x
Potential of nurse prescribing in dermatology
February 3, 2011 by admin
This commentary on a recent article (see here) argues that nurse prescribing has an important contribution to make to the development of dermatology services given its scale and its potential to improve treatment outcomes and access to care. As ways of improving treatment effectiveness develop and are evaluated, it is important that they take account of nursing activity.
Ersser SJ. Nurse prescribing, concordance and the therapeutic consultation. BJD 2011; 164(2): 236-237.
Pharmacist independent prescribing: a community-based mental health clinic
February 3, 2011 by admin
A pharmacist independent prescriber describes his experiences in a community-based clinic for secondary care patients, mostly with affective disorders. A nurse prescriber and a consultant psychiatrist run clinics in tandem: he says there is a niche for pharmacist prescribers to see more complicated cases where people are taking multiple medicines and that more pharmacists could do this kind of work - although seeing patients like this and being responsible for them as a prescriber is outside the traditional comfort zone for many pharmacists.
Kirk S. Independent prescribing for secondary care patients in a community-based clinic. Br J Clin Pharmacy 2010; 2(11): 347-348.
http://www.clinicalpharmacy.org.uk/2010/december.html
Evaluating nurse prescribing in acute care: a case study
February 3, 2011 by admin
Nurse prescribers and doctors were found to provide equivalent care in this small case study in an acute hospital. This is interesting because much research so far has focussed on community settings and also because this study sought views from a range of levels within the organisation, including managers and patients from a range of ethnic groups.
The researchers used semi-structured interviews with nurse prescribers, medical, nursing and pharmacy colleagues and senior hospital staff, observations of nurse and doctor consultations, and patient questionnaires.
Nurse prescribing was seen as a positive development: there were benefits for patients through better use of staff skills and improved service delivery and both the prescribers and their colleagues were positive about the changes and their impact. Patients were more likely to be satisfied with the medication information they had received if they had seen a nurse rather than a doctor. Patients from different ethnic groups appeared to have similar views about their experience and medication. The prescribing practice of the doctors and nurses were found to be similar. Shared vision, local championship, action learning and team, peer and buddy support were all identified as factors that actively enabled implementation.
Jones K, Edwards M and While A. Nurse prescribing roles in acute care: an evaluative case study. J Advanced Nursing 2010; 67(1): 117-126.
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