Journals
Pharmacists and chronic pain prescribing: first RCT
May 17, 2013 by admin
In what they say is the first UK randomised controlled trial of pharmacist prescribing, UK researchers have concluded that there may be benefits for people with chronic pain from pharmacist prescribing, and that larger trials are now needed. The authors comment that despite the increasing number of pharmacists and other non-medical prescribers, rigorous outcome comparisons are lacking.
The trial assigned 196 patients from six practices with prescribing pharmacists in England and Scotland, all of whom used repeat prescriptions for pain medication (excluding certain groups such as those serious mental illness), to three groups at random - two groups received pharmacist medication review, with and without pharmacist prescribing (the former with a face to face consultation; the lattter with feedback to the GP), and one group received treatment as usual. One of the reasons for this exploratory trial was to select the best outcome measures for a larger multi-centre trial - four were used here, including both pain and generic health outcome measures.
The authors highlight the paucity of the evidence base for pharmacist prescribing using validated outcome measures, rather than the reported experiences of healthcare professionals and patients. The results suggest that pharmacist prescribing, and perhaps pharmacist medication review alone, is “feasible, acceptable and may lead to improvements in pain and other measures”, conclude the authors.
Bruhn H et al. Pharmacist-led management of chronic pain in primary care: results from a randomised controlled exploratory trial. BMJ Open 2013;3:e002361
http://dx.doi.org/10.1136/bmjopen-2012-002361
Comparing nurse prescribing and PGD use in a UK emergency department
May 17, 2013 by admin
Nurses in a London emergency department were providing appropriate medication under the different mechanisms of independent nurse prescribing and Patient Group Directions (PGDs), with some notable differences, according to this cross-sectional review.
The researchers reviewed notes from 617 episodes of care, 382 using independent nurse prescribing and 235 using PGDs. Analysis of the results revealed more frequent prescribing by the prescribing nurses, with appropriate medication given in all but one case (where penicillin was prescribed for an allergic patient, highlighting the importance of history-taking). All medications received by patients in the PGD group were appropriate, although documented less consistently, but over 10% were not covered within the PGD - it was not clear how a prescription was obtained for these from the patient notes. This highlights the limitations of PGDs. The nurses in this department managed a wide range of conditions, with pain relief being the most common type of medication supplied.
Black A and Dawood M. A comparison in independent nurse prescribing and patient group directions by nurse practitioners in the emergency department: A cross sectional review. Int. Emerg Nurs 2013; published online 6 May.
http:dx.doi.org/10.1016/j.ienj.2013.03.009
Prescribing errors: junior hospital doctors
March 22, 2013 by admin
It can be hard to identify why prescribing errors are made, never mind how to avoid those causes: the results of interviews with junior doctors in eight Scottish hospitals who made prescribing errors have now been published, shedding some useful light. Their perception was there were multiple causes for each type of error and the authors categorised the conditions that produce errors as: team, environment, individual, task or patient. The study included 40 prescribers, being interviewed about 100 errors.
Ross S. et al. Perceived causes of prescribing errors by junior doctors in hospital inpatients: a study from the PROTECT programme. BMJ Qual Saf 2013; 22:97-102.
http://dx.doi.org/10.1136/bmjqs-2012-001175
Responding to patients’ cues: nurse and pharmacist prescribers
February 4, 2013 by admin
Nurse and pharmacist prescribers responded positively to the emotional cues and concerns of their patients, according to the results of a study that involved audio recording more than 500 consultations in primary care in England. In total, 51 professionals were involved - a mix of GPs, nurse prescribers and pharmacist prescribers.
Riley R et al. A comparison of GP, pharmacist and nurse prescriber responses to patients’ emotional cues and concerns in primary care consultations. Patient Educ Couns 2012 Dec 11. pii: S0738-3991(12)00457-0, published online ahead of print.
Palliative care and independent prescribers: ‘off-label’ guidance
February 4, 2013 by admin
All prescribers should have consistent regulatory guidance for ‘off-label’ prescribing in palliative care, according to the conclusions of a survey of over 300 doctors, nurses and pharmacists who prescribe in this area.
The non-medical prescribers were less likely to follow the ‘must-dos’ of the relevant guidance, but this is partly because nurses’ and pharmacists’ guidance is based on an older, less pragmatic, version of the General Medical Council (GMC) guidance that doctors use. The proportion of doctors adhering to GMC guidance also compared favourably with a previous study.
Culshaw J, Kendall D and Wilcock A. Off-label prescribing in palliative care: A survey of independent prescribers. Palliat Med 2012; 21 November, published online ahead of print.
Pharmacist prescribing in a chronic pain management clinic
November 16, 2012 by admin
A multidisciplinary chronic pain management clinic involving a pharmacist independent prescriber has now been commissioned after a three-month pilot. It is estimated that £10,500 was saved in annualised drug expenditure for the 29 patients reviewed by the pharmacist during the pilot. This is a significant saving, achieved with an average of a 33% reduction in pain intensity for patients who previously were in uncontrolled chronic pain. The pharmacist independent prescriber played a key role in cost-effective and safe prescribing.
The clinic is in ‘Tier 2′ of the chronic pain management service in Gateshead and patients are usually referred to it by their GP if they have not responded to the ‘Tier 1′ GP-led service that offers standardised treatment protocols. ‘Tier 3′ is consultant-led, hospital-based care. The article describes how the clinic works, the specialist interventions that are available, and the role of the pain specialist pharmacist. Some patients referred to the service had experienced chronic pain for more than 40 years - often, symptoms had not improved in the face of a variety of pharmacological interventions, so the improvements in pain scores found are deemed clinically significant.
Thomas M. Is pharmacist prescribing a painless alternative in chronic pain management? Pharmacy Management 2012; 28(4).
Is interprofessional prescribing education feasible?
October 23, 2012 by admin
Joint prescribing courses for medical students and nurses could help overcome resistance from doctors to nurse prescribing and help mutual understanding of the different roles, according to this research which invited participants to share their experiences of interprofessional education. One issue was that medical students (third-years) had broad pharmaceutical knowledge whereas that of nurses was focussed on their specialist areas; this acted as a barrier to learning and teaching methods that encourage knowledge sharing should be considered.
Courtenay M. Interprofessional education between nurse prescribing and medical students: A qualitative study. J Interprof Care 2012; 1 October, published online ahead of print.
Prescribing decisions by non-medical prescribers
September 25, 2012 by admin
Nurse and pharmacist independent prescribers generally make prescribing decisions that are clinically appropriate, according to the results of this evaluation of nurse and pharmacist consultations, undertaken as past of a larger study. There is room for improvement in decisions about the costs of drugs and also history-taking, assessment and diagnostic skills.
A team of independent raters - pharmacists, doctors and nurses - used a version of the Medication Appropriateness Index (MAI) to rate 100 recorded consultations, and the data analysed. On the whole, pharmacist independent prescribers mostly prescribed for long-term conditions such as hypertension; nurse independent prescribers in a walk-in site and out-of-hours site prescribed for acute conditions such as infections and those in general practice for both acute and long-term conditions.
As other studies have commented, there has been a lack of evidence of safety and quality of non-medical prescribing, so this work adds to the evidence base, with its conclusion that both nurses and pharmacists were making clinically appropriate prescribing decisions: the MAI has not been used before to evaluate prescribing by pharmacists; for nurses it was used with the limited formulary, with similar results. Although the authors caution against direct comparison with research into doctors’ prescribing decisions, they say the results are broadly comparable. The consultations also provoked positive qualitative comments from raters.
On the issue of cost, it may be that the prescribers did not consider the costs of medicines to be particularly important, or that as many consultations were for long-term conditions, the prescribers may have been reluctant to change a medicine initially prescribed by someone else. The other area for improvement is history-taking, clinical assessment and diagnosis: the authors suggest that the prescribing training should deliver on these areas for pharmacists whereas organisations should ensure that nurses have these skills before taking up the training.
Latter S et al. Are nurse and pharmacist independent prescribers making clinically appropriate prescribing decisions? An analysis of consultations. J Health Serv Res Policy 2012; 17(3): 149-156.
http://dx.doi.org/10.1258/jhsrp.2012.011090
Nurse prescribing in secondary care
July 17, 2012 by admin
Nurses prescribing in secondary care believe that prescribing has clear benefits for patient care and that it is for experienced nurses, according to this study, which used a convenience sample of nurse prescribers. Those who are not prescribing have found finance arrangements between Trusts to be a barrier. Ongoing evaluation of nurse prescribing is needed, and the authors make recommendations about both education and practice.
Scrafton J, McKinnon J and Kane R. Exploring nurses’ experiences of prescribing in secondary care: informing future education and practice. J Clin Nurs 2012; 21(13-14):2044-53.
http://dx.doi.org/10.1111/j.1365-2702.2011.04050.x
Governance and support crucial for non-medical prescribing
July 16, 2012 by admin
In the current climate of changes to the commissioning process, and tight budgets, how can we be sure that the potential benefits of non-medical prescribing are being realised? ‘Robust governance and support from healthcare organisations’ are essential if non-medical prescribers (NMPs) are to make the maximum contribution to patient care and services, according to a large questionnaire study of non-medical prescribing across one strategic health authority in England. There is a question mark over the future of supplementary prescribing too.
This is the first study to look at how the different types of non-medical prescribing - including community practitioner prescribing, nurse, pharmacist and allied health professional prescribing - have been implemented in different settings within one geographical area, explain the authors. Detailed information about what the prescribing practice of different types of NMPs is, and what their governance arrangements are, in one large area is useful for planning and policy-making.
The study team emailed 1869 NMPs for whom email addresses were obtained from non-medical prescribing leads: of the 1585 invitations that were delivered, 883 resulted in responses (55.7%). More than 90% were nurses, including some who were community practitioner prescribers (although fewer than expected), with some pharmacists and allied health professionals (AHPs) also replying. The survey results showed that practitioners with more prior experience in the prescribing area made greater use of the prescribing qualification and prescribed more frequently. Although most respondents had the one year of prior experience in the prescribing area that is specified by guidance, 10.5% did not; in addition, nearly one-quarter had not undertaken specialist education in their practice area before starting prescribing.
The great majority of nurse independent/supplementary prescribers (more than 90%) said they were currently prescribing; in contrast, about one-third of pharmacist and AHP prescribers and community practitioner prescribers said they did not, often because their role had changed. Community practitioners did still seem to be facing barriers to do with prescription pad and IT issues as well. Interestingly, however, the authors have identified a number of other medicine management activities undertaken by these groups of prescribers, for example recommending over-the-counter medicines to patients, and highlight the importance of capturing all these activities and their impact on patient outcomes and service efficiency, given the budgetary pressures and NHS reforms under which services are being redesigned.
So, as well as experience, what influences prescribing rates and what could be done to ensure that non-medical prescribing delivers on its promise? The study team found that the level of support from non-medical prescribing leads affected prescribing rates - except that mental health nurses had low prescribing rates but the most support, so other factors may be at work here. Supplementary prescribing was not used often, and its use often resulted from organisational restrictions on independent prescribing. The authors suggest that its time may be past, and that this should be a consideration as policy for prescribing for other professionals develops.
On governance, the picture was largely reassuring, although there were still difficulties with obtaining prescribing data, and monitoring and audit of activity. However, community practitioner prescribers had fewer governance systems, and this group also reported that lack of infrastructure, confidence, and access to continuing professional development prevented them from prescribing.
Where does non-medical prescribing go now? Study leader, Professor Molly Courtenay of the University of Surrey, is optimistic about the contribution it could make. “Current reform within the NHS is likely to lead to significant changes in the delivery of care. Given the pressure on budgets and the drive to increase quality and efficiency, non-medical prescribing can make an important contribution. NMPs are extremely well qualified, and have a wealth of clinical experience. Their ability to prescribe enables better use of the skills of the clinical workforce, increasing service capacity and efficiency, and improving the quality of patient care”, she said.
Courtenay M, Carey N and Stenner K. An overview of non medical prescribing across one strategic health authority: a questionnaire survey. BMC Health Serv Res 2012; 12: 138; published in provisional form online ahead of print.
http://dx.doi.org/10.1186/1472-6963-12-138
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