The decision-making processes of UK general practice nurse prescribers when managing acute illness in patients with multimorbidity and polypharmacy: a qualitative study using think aloud and staged vignettes.

ObjectivesDespite widespread availability of evidence-based guidelines to inform rational use of medicines, considerable unwarranted variation exists in prescribing. A greater understanding of key determinants of contemporary prescribing in UK general...

<h3>Objectives</h3> Despite widespread availability of evidence-based guidelines to inform rational use of medicines, considerable unwarranted variation exists in prescribing. A greater understanding of key determinants of contemporary prescribing in UK...

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.

<h3>Background</h3> Therapeutic interventions, including prescribing medication, was a nationally agreed element of the advanced role (Department of Health, 2010), a view supported by Help the Hospices (2013). Palliative care patients often present with multiple complex symptoms and the benefits of Nurse Independent Prescribers (NIP) include faster access to medicines and rapid symptom control (Quinn &amp; Lawrie, 2010; Dawson, 2013). However, increasing demands on Community Palliative Care Teams providing timely access to medicines and embracing seven-day working, highlight a need to evaluate the role of the NIP within this service, to determine their benefits and enhance planning. <h3>Aims</h3> This report's objective was to examine the prescribing practice of a NIP within the Community Specialist Palliative Care Team, examining the scope, appropriateness of prescribing and reviewing benefits to patients and carers. <h3>Methods</h3> Quantitative data was collected for one year from one NIP, collated according to the drug monographs in Palliative Care Formulary 6 (Twycross, Wilcock &amp; Howard, 2017) and evaluated according to the range of drugs and frequency of prescribing. Patient and carers' experience of NIP was gathered qualitatively via semi-structured interviews and written feedback. Thematic analysis was undertaken on these accounts to identify findings. <h3>Results</h3> Data analysis showed the range and frequency of prescribing were appropriate and within the NIP's scope of practice. Over one third of prescriptions involved analgesics. Patient and carer responses were overwhelmingly positive and related to the nurse/patient relationship and expertise in prescribing for complex symptoms. <h3>Conclusions</h3> The NIP demonstrated appropriate prescribing practice. Patients and carers reported receiving medications more promptly and having doses adjusted when Out of Hours services were reluctant to do so. This provides evidence of the value of NIP training within the team.

Evidence on the survival of different restorations in general practice is scarce and so to address this need, a study was designed to monitor the outcome of Class V restorations placed in UK general practices. Prospective longitudinal cohort multi-centre study. UK general dental practice. Ten UK dentists each placed 100 Class V restorations and recorded selected clinical information at placement and at recall visits on record cards. Dentists selected materials and techniques which they felt appropriate to each clinical situation. Data cards for 11 restorations were incorrectly completed or information was missing leaving 989 for analysis. The majority of restorations were placed in patients between 51 and 60 years of age, in canines or premolars (68.4%) and under private contract (63%). Composite (40.85%) and compomer (23.46%) were the most frequently placed materials overall but were not the most frequently placed restorative by some dentists. Different dentists use different methods to manage Class V lesions but each dentist tends to use one restorative material predominantly. There is a degree of overlap among practitioners in the materials which they employ, but clear preferences were displayed in the materials used and handling techniques.

Objective The aim of this study was to identify perceived barriers to appropriate antibiotic prescribing across different healthcare settings. Methods A cross-sectional survey of clinicians in Australian hospitals and primary care was undertaken between June and October 2019. The perceived barriers to appropriate antibiotic prescribing were considered as dependent variables, whereas age, sex, clinical experience, healthcare setting and the use of guidelines were considered independent variables. We used multivariate logistic regression to identify factors predictive of inappropriate antibiotic prescribing. Content analysis of free-text responses provided additional insights into the impediments to appropriate prescribing. Results In all, 180 clinicians completed the survey. Overall, diagnostic uncertainty and limited access to guidelines and prescribing information were significant barriers to appropriate antibiotic prescribing. Factors associated with these barriers were clinical experience, care setting (hospitals vs primary care) and the use of guidelines. Experienced clinicians (>11 years) were less likely to consider that limited access to information negatively affected prescribing practices (experience 11-20 years, odds ratio (OR) 0.66, 95% confidence interval (CI) 0.31-0.84; experience >20 years, OR 0.51, 95% CI 0.24-0.91). Conversely, general practitioners considered diagnostic uncertainty (OR 1.31, 95% CI 1.09-1.63) and patient expectations (OR 1.41, 95% CI 1.12-1.84) were more likely to be perceived barriers to appropriate prescribing. The use of guidelines and clinical experience may counteract this. Conclusion Years of experience, use of guidelines and type of setting were predictors of clinicians' perceptions regarding antibiotic prescribing. Our data highlight the importance of individual and setting characteristics in understanding variations in prescribing practices and designing targeted interventions for appropriate antibiotic prescribing. What is known about the topic? Inappropriate antibiotic prescribing is a significant health issue in Australia. Drivers of inappropriate prescribing are known, but how individual and setting characteristics contribute to variations in prescribing behaviour has not been fully understood. What does this paper add? Diagnostic uncertainty and limited access to prescribing information, including guidelines, formulary restrictions and antibiotic resistance patterns, can limit appropriate antibiotic prescribing. Clinicians' years of experience, the healthcare settings and clinician use of guidelines are important predictors of antibiotic prescribing behaviour. What are the implications for practitioners? The findings of this study can inform the design of tailored interventions to promote rational antibiotic prescribing practices in general practice and hospital settings.

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...

Objective: To quantify the relation between community based antibacterial prescribing and antibacterial resistance in community acquired disease.Design: Cross sectional study of antibacterial prescribing and antibacterial resistance of routine isolates within...

Background: The Misuse of Drugs Act non-medical prescribing legislation permits nurse independent prescribers (NIPs) to prescribe any controlled drug that is within their scope of professional practice. Continuing professional development (CPD) is essential for safe effective prescribing and is required for professional revalidation. This study was conducted to explore the educational requirements of non-medical opioid prescribers. Methods: Informed by a critical realism position, an electronic survey was distributed to 147 NIPs working in a Scottish NHS Health Board. The aim was to identify how many NIPs were prescribing opioids and to explore their CPD requirements regardless of whether they prescribed opioids or not, including preferred method of delivery of education and to explore whether the single competency framework was sufficient to facilitate safe and effective prescribing. Results: The response rate was 46% (n=68). The majority of respondents (69%, n=37) prescribed opioids. Ninety-four percent of respondents (n=64) stated they felt that ongoing education was necessary to ensure safe opioid prescribing practice. Face-to-face methods of learning in small group discussions were the preferred option. Two thirds of the respondents (66%, n=45) felt that there should be protected time for prescribing CPD and 64% (n=27) felt the single competency framework provided a good standard for prescribing CPD. Conclusions: The results from this study suggest that nurses are prescribing opioids in acute and community hospitals. Group opioid education is recommended and using a structured competency framework to inform clinical practice may ensure safe, effective prescribing practice.

Over the last three decades, Australian opioid-prescribing rates and related morbidity and mortality have dramatically increased. Opioids are frequently prescribed by general practitioners (GPs) to manage chronic non-cancer pain, despite evidence-based recommendations from the Centre for Disease Control, National Institute for Health and Care Excellence and World Health Organization widely cautioning their use. Little is known about the factors influencing the opioid prescribing decisions of Australian GPs, especially when not evidence based. To explore the opioid prescribing knowledge, attitudes and practices of Australian GPs. Semi-structured interviews with 20 GPs recruited from the Monash University practice-based research network in metropolitan, southeastern Melbourne. Thematic analysis was used to identify emergent themes. Data were managed using QSR NVivo. Ethics approval was granted by Monash University. Three key themes emerged. GP attitudes towards opioid use for chronic pain varied by age of patient and goals for therapy. Use of opioids for elderly patients was positively perceived. GPs were reluctant to use opioids in younger patients due to fears of addiction and difficulty weaning. GPs felt obliged to prescribe opioids recommended by specialists, even if they believed the opioids were unsafe. This study identified and described the patient-centred nature of GP opioid prescribing decisions. Patient age and perceived age-related opioid harm were important factors influencing prescribing decisions. Future work should inform interventions that value GP autonomy while still encouraging a collaborative inter-speciality approach to managing chronic pain patients with opioids.

In the United Kingdom, nurses and pharmacists who have undertaken additional post-registration training can prescribe medicines for any medical condition within their competence (non-medical prescribers, NMPs), but little is known about patients' experiences and perceptions of this service. to obtain feedback from primary care patients on the impact of prescribing by nurse independent prescribers (NIPs) and pharmacist independent prescribers (PIPs) on experiences of the consultation, the patient-professional relationship, access to medicines, quality of care, choice, knowledge, patient-reported adherence and control of their condition. Two cross-sectional postal surveys. Patients prescribed for by either NIPs or PIPs in six general practices from different regions in England. 30% of patients responded (294/975; 149/525 NIPs; 145/450 PIPs). Most said they were very satisfied with their last visit (94%; 87%), they were told as much as they wanted to know about their medicines (88%; 80%), and felt the independent prescriber really understood their point of view (87%; 75%). They had a good relationship with (89%; 79%) and confidence in (84%; 77%) their NMP. When comparing NMP and doctor prescribing services, most patients reported no difference in their experience of care provided, including access to it, control of condition, support for adherence, quality and safety of care. Patients had positive perceptions and experience from their NMP visit. NMPs were well received, and patients' responses indicated the establishment of rapport. They did not express a strong preference for care provided by either their non-medical or medical prescriber.

We previously reported on a randomised trial demonstrating the effectiveness and cost-effectiveness of a pharmacist-led information technology intervention (PINCER). We sought to investigate whether PINCER was effective in reducing hazardous prescribing when rolled out at scale in UK general practices. We used a multiple interrupted time series design whereby successive groups of general practices received the PINCER intervention between September 2015 and April 2017. We used 11 prescribing safety indicators to identify potentially hazardous prescribing and collected data over a maximum of 16 quarterly time periods. The primary outcome was a composite of all the indicators; a composite for indicators associated with gastrointestinal (GI) bleeding was also reported, along with 11 individual indicators of hazardous prescribing. Data were analysed using logistic mixed models for the quarterly event numbers with the appropriate denominator, and calendar time included as a covariate. PINCER was implemented in 370 (94.1%) of 393 general practices covering a population of almost 3 million patients in the East Midlands region of England; data were successfully extracted from 343 (92.7%) of these practices. For the primary composite outcome, the PINCER intervention was associated with a decrease in the rate of hazardous prescribing of 16.7% (adjusted odds ratio (aOR) 0.83, 95% confidence interval (CI) 0.80 to 0.86) at 6 months and 15.3% (aOR 0.85, 95% CI 0.80 to 0.90) at 12 months postintervention. The unadjusted rate of hazardous prescribing reduced from 26.4% (22,503 patients in the numerator/853,631 patients in the denominator) to 20.1% (11,901 patients in the numerator/591,364 patients in the denominator) at 6 months and 19.1% (3,868 patients in the numerator/201,992 patients in the denominator). The greatest reduction in hazardous prescribing associated with the intervention was observed for the indicators associated with GI bleeding; for the GI composite indicator, there was a decrease of 23.9% at both 6 months (aOR 0.76, 95% CI 0.73 to 0.80) and 12 months (aOR 0.76, 95% CI 0.70 to 0.82) postintervention. The unadjusted rate of hazardous prescribing reduced from 31.4 (16,185 patients in the numerator/515,879 patients in the denominator) to 21.2% (7,607 patients in the numerator/358,349 patients in the denominator) at 6 months and 19.5% (2,369 patients in the numerator/121,534 patients in the denominator). We adjusted for calendar time and practice, but since this was an observational study, the findings may have been influenced by unknown confounding factors or behavioural changes unrelated to the PINCER intervention. Data were also not collected for all practices at 6 months and 12 months postintervention. The PINCER intervention, when rolled out at scale in routine clinical practice, was associated with a reduction in hazardous prescribing by 17% and 15% at 6 and 12 months postintervention. The greatest reductions in hazardous prescribing were for indicators associated with risk of GI bleeding. These findings support the wider national rollout of PINCER in England.

Appropriate Prescribing for Older People: A New Tool for the General Practitioner.

To better understand the reasons for lack of impact of sending feedback on prescribing pattern to general practitioners (GPs). Semi-structured interviews with GPs who had all participated in intervention studies addressing effects of prescriber feedback. Interviews were audiotaped and fully transcribed. Transcripts were studied repeatedly and coded into categories in order to produce meaningful patterns. None of the GPs believed they altered prescribing practice after they received prescriber feedback. Unsolicited prescriber feedback was perceived as violating the GPs' autonomy. The GPs wanted to decide for themselves what data should be sent to them. Aggregated data were difficult to interpret, and GPs did not regard it as a problem that their practice pattern deviated from that of other practices. There was a mistrust of the validity of data, and the GPs wanted to be able to identify the patients with a need for optimised therapy directly from the information provided in the prescriber feedback. In addition they wanted advice on how to optimise therapy. Postal prescriber feedback (not revealing the patients' identities) is not effective because it does not motivate GPs to change nor does it address the barriers to change. Prescriber feedback requested by the GPs may be more effective, however, if it includes identities of inappropriately treated patients combined with relevant advice on how to optimise prescribing.

The irrational use of drugs is a major problem of present day medical practice and its consequences include the development of resistance to antibiotics, ineffective treatment, adverse effects and an economic burden on the patient and society. A study from Attock District of Pakistan assessed this problem in the formal allopathic health sector and compared prescribing practices of health care providers in the public and private sector. WHO recommended drug use indicators were used to study prescription practices. Prescriptions were collected from 60 public and 48 private health facilities. The mean (+/- SE) number of drugs per prescription was 4.1 +/- 0.06 for private and 2.7 +/- 0.04 for public providers (p < 0.0001). General practitioners (GPs) who represent the private sector prescribed at least one antibiotic in 62% of prescriptions compared with 54% for public sector providers. Over 48% of GP prescriptions had at least one injectable drug compared with 22.0% by public providers (p < 0.0001). Thirteen percent of GP prescriptions had two or more injections. More than 11% of GP prescriptions had an intravenous infusion compared with 1% for public providers (p < 0.001). GPs prescribed three or more oral drugs in 70% of prescriptions compared with 44% for public providers (p < 0.0001). Prescription practices were analysed for four health problems, acute respiratory infection (ARI), childhood diarrhoea (CD), fever in children and fever in adults. For these disorders, both groups prescribed antibiotics generously, however, GPs prescribed them more frequently in ARI, CD and fever in children (p < 0.01). GPs prescribed steroids more frequently, however, it was significantly higher in ARI cases (p < 0.001). For all the four health problems studied, GPs prescribed injections more frequently than public providers (p < 0.001). In CD cases GPs prescribed oral rehydration salt (ORS) less frequently (33.3%) than public providers (57.7%). GPs prescribed intravenous infusion in 12.3% cases of fever in adults compared with none by public providers (p < 0.001). A combination of non-regulatory and regulatory interventions, directed at providers as well as consumers, would need to be implemented to improve prescription practices of health care providers. Regulation alone would be ineffective unless it is supported by a well-established institutional mechanism which ensures effective implementation. The Federal Ministry of Health and the Provincial Departments of Health have to play a critical role in this respect, while the role of the Pakistan Medical Association in self-regulation of prescription practices can not be overemphasized. Improper prescription practices will not improve without consumer targeted interventions that educate and empower communities regarding the hazards of inappropriate drug use.