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Mocini D, Di Fusco SA, De Luca L, Caldarola P, Cipriani M, Corda M, Di Lenarda A, De Nardo A, Francese GM, Napoletano C, Navazio A, Riccio C, Roncon L, Tizzani E, Nardi F, Urbinati S, Valente S, Gulizia MM, Gabrielli D, Oliva F, Colivicchi F. ANMCO position paper 'Appropriateness of prescribing direct oral anticoagulants in stroke and systemic thromboembolism prevention in adult patients with non-valvular atrial fibrillation'. Eur Heart J Suppl 2022; 24:C278-C288. [PMID: 35602254 PMCID: PMC9117907 DOI: 10.1093/eurheartj/suac015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The appropriateness of prescribing direct oral anticoagulants [dabigatran, rivaroxaban, apixaban, and edoxaban (DOACs)] is regulated on the criteria established in Phase III trials. These criteria are reported in the summary of the product characteristics of the four DOACs. In clinical practice, prescriptions are not always in compliance with established indications. In particular, the use of lower doses than those recommended in drug data sheets is not uncommon. Literature data show that the inappropriate prescription of reduced doses causes drug underexposure and up to a three-fold increase in the risk of stroke/ischaemic transient attack, systemic thromboembolism, and hospitalization. Possible causes of the deviation between the dose that should be prescribed and that prescribed in the real world include erroneous prescription, an overstated haemorrhagic risk perception, and the presence of frail and complex patients in clinical practice who were not included in pivotal trials, which makes it difficult to apply study results to the real world. For these reasons, we summarize DOAC indications and contraindications. We also suggest the appropriate use of DOACs in common clinical scenarios, in accordance with what international guidelines and national and international health regulatory bodies recommend.
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Affiliation(s)
- David Mocini
- Division of Clinical and Rehabilitation Cardiology, Emergency Department, P.O. San Filippo Neri - ASL Roma 1, Via G. Martinotti, 20, 00135, Roma, RM, Italy
| | - Stefania Angela Di Fusco
- Division of Clinical and Rehabilitation Cardiology, Emergency Department, P.O. San Filippo Neri - ASL Roma 1, Via G. Martinotti, 20, 00135, Roma, RM, Italy
| | - Leonardo De Luca
- Cardiology, Department of Cardio-Thoraco-Vascular, Ospedale San Camillo, Circonvallazione Gianicolense, 87, 00152, Roma, RM, Italy
| | - Pasquale Caldarola
- Cardiology-ICU Department, Ospedale San Paolo, Via Caposcardicchio, 1, 70123, Bari, BA, Italy
| | - Manlio Cipriani
- Cardiology 2-Heart Failure and Transplants, ASST Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162, Milano, MI, Italy
| | - Marco Corda
- Cardiology Department, Arnas G. Brotzu, Piazzale Alessandro Ricchi, 1, 09134, Cagliari, CA, Italy
| | - Andrea Di Lenarda
- Cardiovascolular and Sports Medicine Department, Asugi Trieste, Via Slataper, 9, 34125, Trieste, TS, Italy
| | - Alfredo De Nardo
- Cardiology-ICU Department Ospedale Civile G. Jazzolino Piazza Fleming 89900 Vibo Valentia, VV, Italy
| | - Giuseppina Maura Francese
- Cardiology Department, P.O. Garibaldi-Nesima - Arnas Garibaldi, Via Palermo, 636, 95122, Catania, CT, Italy
| | - Cosimo Napoletano
- Cardiology-ICU Department - Cath Lab, Ospedale Civile G. Mazzini, Piazza Italia, 64100, Teramo, TE, Italy
| | - Alessandro Navazio
- Hospital Cardiology Department, Po Santa Maria Nuova - Ausl RE IRCCS, Viale Risorgimento, 80, 42100, Reggio Emilia, RE, Italy
| | - Carmine Riccio
- Follow-up of the Post-Acute Patient, Cardio-Vascular Department, Azienda Ospedaliera S. Anna E S. Sebastiano, Via Palasciano, 1, 81100, Caserta, CE, Italy
| | - Loris Roncon
- Cardiology Department, Ospedale Santa Maria Della Misericordia, Viale Tre Martiri, 140, 45100, Rovigo, RO Italy
| | - Emanuele Tizzani
- Cardiology Department, Ospedale Degli Infermi, Strada Rivalta, 29, 10098, Rivoli, TO, Italy
| | - Federico Nardi
- Cardiology Department, Ospedale Santo Spirito, Casale Monferrato (AL), Italy
| | - Stefano Urbinati
- Cardiology Department, Ospedale Bellaria, Via Altura, 3, 40139, Bologna, BO, Italy
| | - Serafina Valente
- Cardio-Thoracic Department, AOU Senese Ospedale S. Maria Alle Scotte, Viale Mario Bracci, 13, 53100, Siena, SI, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, P.O. Garibaldi-Nesima - Arnas Garibaldi, Via Palermo, 636, 95122, Catania, CT, Italy.,Fondazione per il Tuo cuore - Heart Care Foundation, Via La Marmora, 36, 50121, Firenze, FI, Italy
| | - Domenico Gabrielli
- Cardiology, Department of Cardio-Thoraco-Vascular, Ospedale San Camillo, Circonvallazione Gianicolense, 87, 00152, Roma, RM, Italy
| | - Fabrizio Oliva
- Unit of Intensive Cardiological Care, Cardiology 1-Hemodynamics, Cardiothoracovascular Department, "A. De Gasperis" ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162, Milano, MI, Italy
| | - Furio Colivicchi
- Division of Clinical and Rehabilitation Cardiology, Emergency Department, P.O. San Filippo Neri - ASL Roma 1, Via G. Martinotti, 20, 00135, Roma, RM, Italy
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Carey N, Edwards J, Otter S, Gage H, Williams P, Courtenay M, Moore A, Stenner K. A comparative case study of prescribing and non-prescribing physiotherapists and podiatrists. BMC Health Serv Res 2020; 20:1074. [PMID: 33234141 PMCID: PMC7687831 DOI: 10.1186/s12913-020-05918-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 11/12/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Increasing numbers of nurses, pharmacists and allied health professionals across the world have prescribing rights for medicines: over 90,000 of the eligible United Kingdom workforce are qualified as non-doctor prescribers. In order to inform future developments, it is important to understand the benefits and impact of prescribing by allied health professionals including physiotherapists and podiatrists. AIM to compare outcomes of physiotherapist and podiatrist Independent Prescriber (PP- IP) patients with those of physiotherapist and podiatrist non-prescribers (PP-NPs). Outcome measures included patient satisfaction, ease of access to services, quality of life and cost implications. DESIGN a mixed method comparative case study. METHODS Using mixed methods of data collection, outcomes were compared between 7 sites where care was provided from a PP-IP (3 podiatrist and 4 physiotherapist IPs) and 7 sites from a PP-NP (3 podiatrist and 4 physiotherapist NPs). Patients were followed up for 2 months (2015-2016). RESULTS 489 patients were recruited: n = 243 IP sites, and n = 246 NP sites. Independent prescribing was found to be highly acceptable, and equivalent in terms of quality of life (p > 0.05) and patient satisfaction (p ≤ 0.05) compared to care provided by NPs. PP-IP care delivery was found to be more resource intensive than PP-NP, with longer consultation duration for IPs (around 6.5 mins), and a higher proportion of physiotherapy patients discussed with medical colleagues (around 9.5 min). CONCLUSION This study provides new knowledge that PP-IPs provide high levels of care. PP-IP care delivery was found to be more resource intensive. Further research is required to explore cost effectiveness. A more focussed exploration within each profession using targeted outcome measures would enable a more robust comparison, inform future developments around the world and help ensure non-doctor prescribing is recognised as an effective way to alleviate shortfalls in the global workforce.
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Affiliation(s)
- Nicola Carey
- School of Health Sciences, University of Surrey, Kate Granger Building, Guildford, GU2 7YH UK
| | - Judith Edwards
- School of Health Sciences, University of Surrey, Kate Granger Building, Guildford, GU2 7YH UK
| | - Simon Otter
- School of Health Science, University of Brighton, Brighton, UK
| | - Heather Gage
- Department of Clinical and Experimental Medicine, Surrey Health Economics, University of Surrey, Guildford, UK
| | - Peter Williams
- Department of Mathematics, Faculty of Engineering and Physical Sciences, University of Surrey, Guildford, UK
| | - Molly Courtenay
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Ann Moore
- School of Health Science, University of Brighton, Brighton, UK
| | - Karen Stenner
- School of Health Sciences, University of Surrey, Kate Granger Building, Guildford, GU2 7YH UK
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Comorbid Anxiety and Depression among Pregnant Pakistani Women: Higher Rates, Different Vulnerability Characteristics, and the Role of Perceived Stress. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17197295. [PMID: 33036215 PMCID: PMC7579342 DOI: 10.3390/ijerph17197295] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 12/27/2022]
Abstract
Anxiety and depression commonly co-occur during pregnancy and may increase risk of poor birth outcomes including preterm birth and low birth weight. Our understanding of rates, patterns, and predictors of comorbid anxiety and depression is hindered given the dearth of literature, particularly in low- and middle-income (LMI) countries. The aim of this study is (1) to explore the prevalence and patterns of comorbid antenatal anxiety and depressive symptoms in the mild-to-severe and moderate-to-severe categories among women in a LMI country like Pakistan and (2) to understand the risk factors for comorbid anxiety and depressive symptoms. Using a prospective cohort design, a diverse sample of 300 pregnant women from four centers of Aga Khan Hospital for Women and Children in Pakistan were enrolled in the study. Comorbid anxiety and depression during pregnancy were high and numerous factors predicted increased likelihood of comorbidity, including: (1) High level of perceived stress at any time point, (2) having 3 or more previous children, and (3) having one or more adverse childhood experiences. These risks were increased if the husband was employed in the private sector. Early identification and treatment of mental health comorbidities may contribute to decreased adverse birth outcomes in LMI countries.
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Identification of potentially inappropriate cardiovascular prescriptions in the elderly using Beers’ criteria. REVISTA COLOMBIANA DE CARDIOLOGÍA 2020. [DOI: 10.1016/j.rccar.2019.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Latter S, Maben J, Myall M, Young A, Baileff A. Evaluating prescribing competencies and standards used in nurse independent prescribers’ prescribing consultations. J Res Nurs 2016. [DOI: 10.1177/1744987106073949] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Independent prescribing of medicines by nurses is widely considered to be part of advanced nursing practice, and occurs within an episode of patient care that can be completed independently by a nurse. Nurse prescribers therefore require the competencies necessary to manage a consultation—such as history taking and diagnostic skills—and subsequently need to decide on any appropriate medicine to be prescribed. Safe prescribing should also involve an accurate, legible and comprehensive written prescription and documentation of the consultation in the patient’s records. However, the extent to which nurse independent prescribers use prescribing competencies and standards in practice had not been researched prior to this study. Aim To describe the frequency with which nurses use a range of prescribing competencies in their prescribing consultations, in order to provide a measure of the quality and safety of nurses’ independent prescribing practices. Design and methods Across 10 case study sites, 118 nurse independent prescribers’ prescribing consultations were analysed using non-participant observation and a structured checklist of prescribing competencies. Documentary analysis was also undertaken of a) prescriptions written ( n =132) by nurses and b) the record of the prescribing episode in patient records ( n =118). Sample and setting 118 prescribing consultations of 14 purposively selected nurse independent prescribers working in primary and secondary care trust case study sites in England. Findings Nurse independent prescribers were issuing a prescription every 2.82 consultations; nurses used a range of assessment and diagnosis competencies in prescribing consultations, but some were employed more consistently than others; nurses almost universally wrote full and accurate prescription scripts for their patients; nurses recorded each of their prescribing consultations, but some details of the consultation and the prescription issued were not always consistently recorded in the patient records. Conclusion The findings from this observation study provide evidence about the quality and safety of nurses’ prescribing consultations in England.
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Affiliation(s)
- Sue Latter
- School of Nursing and Midwifery, University of Southampton, Highfield, Southampton
| | - Jill Maben
- Health Services Research Unit, London School of Hygiene and Tropical Medicine
| | - Michelle Myall
- School of Nursing and Midwifery, University of Southampton, Highfield, Southampton
| | - Amanda Young
- School of Nursing and Midwifery, University of Southampton, Highfield, Southampton
| | - Anne Baileff
- Southampton City PCT/School of Nursing and Midwifery
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Ricci-Cabello I, Gonçalves DC, Rojas-García A, Valderas JM. Measuring experiences and outcomes of patient safety in primary care: a systematic review of available instruments. Fam Pract 2015; 32:106-19. [PMID: 25192905 DOI: 10.1093/fampra/cmu052] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite the enormous potential for adverse events in primary care, the knowledge base about patient safety in this context is still sparse. The lack of appropriate measurement methods is a key factor limiting the development of research in this field. OBJECTIVE To identify and characterize available patient reported instruments to measure patient safety in primary care. METHODS We conducted a systematic literature review. We searched in bibliographic sources for empirical studies describing the development, evaluation or use of patient reported instruments assessing patient safety in primary care. Study selection and data extraction were independently conducted by two researchers. RESULTS We identified 28 studies reporting on 23 different instruments. Fifteen instruments were designed for paper-based self-administration, six for phone interview and two consisted in electronic reporting systems. Most instruments focused on specific aspects of patient safety, most commonly on experiences of adverse drug reactions. Face validity was assessed for 10 instruments (43%), three reported construct validity (13%) and three described reliability (13%). Responsiveness was not ascertained. CONCLUSIONS Although there is evidence of good psychometric properties for a reduced number of patient reported instruments, currently available instruments do not offer a comprehensive set of resources to measure the effects of interventions to improve patient safety in primary care from a patient perspective. Future research in the field should prioritize (i) the evaluation of the performance of already available instruments and (ii) the development of new instruments that enable an comprehensive assessment of patient safety at general practices.
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Affiliation(s)
- Ignacio Ricci-Cabello
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK,
| | - Daniela C Gonçalves
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Antonio Rojas-García
- Consorcio de Investigación Biomédica de Epidemiología y Salud Pública, Barcelona, Spain and
| | - Jose M Valderas
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK, Health Services and Policy Research Group, University of Exeter Medical School, Exeter, UK
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Hassan L, Frisher M, Senior J, Tully M, Webb R, While D, Shaw J. A cross-sectional prevalence survey of psychotropic medication prescribing patterns in prisons in England. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02330] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundThe prevalence of mental illness is significantly higher among prisoners than among people in the wider community. Psychotropic prescribing in prisons is a complex and controversial area, where prescribers balance individual health needs against security and safety risks. However, there are no current data on prescribing patterns in prisons or how these compare with those in the wider community.AimsThe study aimed to determine the prevalence, appropriateness and acceptability of psychotropic prescribing in prisons. The objectives were to determine rates of prescribing for psychotropic medications, compared with those in the wider community; the appropriateness of psychotropic prescribing in prisons; and the perceived satisfaction and acceptability of prescribing decisions to patients and general practitioners (GPs).MethodEleven prisons, housing 6052 men and 785 women, participated in a cross-sectional survey of psychotropic prescribing. On census days, data were extracted from clinical records for all patients in receipt of hypnotics, anxiolytics, antipsychotics, antimanics, antidepressants and central nervous system stimulants. The Clinical Practice Research Datalink supplied an equivalent data set for a random sample of 30,602 patients prescribed psychotropic medicines in the community. To determine the acceptability of prescribing decisions, patients attending GP consultations at three prisons were surveyed (n = 156). Pre- and post-consultation questionnaires were administered, covering expectations and satisfaction with outcomes, including prescribing decisions. Doctors (n = 6) completed post-consultation questionnaires to explore their perspectives on consultations.ResultsOverall, 17% of men and 48% of women in prison were prescribed at least one psychotropic medicine. After adjusting for age differences, psychotropic prescribing rates were four times higher among men [prevalence ratio (PR) 4.02, 95% confidence interval (CI) 3.75 to 4.30] and six times higher among women (PR 5.95, 95% CI 5.36 to 6.61) than among community patients. There were significant preferences for certain antidepressant and antipsychotic drugs in prison, compared with in the community. In 65.3% of cases, indications for psychotropic drugs were recorded and upheld in theBritish National Formulary. Antipsychotic prescriptions were less likely than other psychotropics to be supported by a valid indication in the patient notes (PR 0.75, 95% CI 0.67 to 0.83). In the acceptability study, patients who identified mental health as their primary problem were more likely than individuals who identified other types of health problems to want to start, stop and/or change their medication (PR 1.46, 95% CI 1.23 to 1.74), and to report dissatisfaction following the consultation (PR 1.76, 95% CI 1.01 to 3.08). Doctors were more likely to issue prescriptions when they thought that the patient wanted a prescription (PR 4.2, 95% CI 2.41 to 7.28), they perceived pressure to prescribe (PR 1.66, 95% CI 1.26 to 2.19), and/or the problem related to mental health (PR 1.67, 95% CI 1.27 to 2.20).ConclusionsPsychotropic medicines were prescribed more frequently in prisons than in the community. Without current and robust data on comparative rates of mental illness, it is not possible to fully assess the appropriateness of psychotropic prescribing. Nonetheless, psychotropic medicines were prescribed for a wider range of clinical indications than currently recommended, with discernible differences in drug choice. Complex health and security concerns exist within prisons. Further research is necessary to determine the effect of psychotropic prescribing on physical health, and to determine the optimum balance between medicines and alternative treatments in prisons.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Lamiece Hassan
- Centre for Mental Health and Risk, Institute of Brain and Behaviour, The University of Manchester, Manchester, UK
| | - Martin Frisher
- School of Pharmacy and Medicines Management, Keele University, Keele, UK
| | - Jane Senior
- Centre for Mental Health and Risk, Institute of Brain and Behaviour, The University of Manchester, Manchester, UK
| | - Mary Tully
- Manchester Pharmacy School, The University of Manchester, Manchester, UK
| | - Roger Webb
- Centre for Mental Health and Risk, Institute of Brain and Behaviour, The University of Manchester, Manchester, UK
| | - David While
- Centre for Mental Health and Risk, Institute of Brain and Behaviour, The University of Manchester, Manchester, UK
| | - Jenny Shaw
- Centre for Mental Health and Risk, Institute of Brain and Behaviour, The University of Manchester, Manchester, UK
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Momin TG, Pandya RN, Rana DA, Patel VJ. Use of potentially inappropriate medications in hospitalized elderly at a teaching hospital: a comparison between Beers 2003 and 2012 criteria. Indian J Pharmacol 2014; 45:603-7. [PMID: 24347769 PMCID: PMC3847251 DOI: 10.4103/0253-7613.121372] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 07/23/2013] [Accepted: 08/13/2013] [Indexed: 11/18/2022] Open
Abstract
Objectives: To detect the prevalence and pattern of use of Potentially inappropriate medications (PIMs) in hospitalized elderly patients of a tertiary care teaching hospital using Beers 2012 criteria and to compare the same with Beers 2003 criteria. Materials and Methods: Prescriptions of the elderly patients aged 65 years and above were collected from the medicine ward and analyzed. PIMs were identified with help of Beers 2003 and Beers 2012 criteria and comparison was made between the two criteria. Predictors associated with use of PIM were identified using bivariate and multivariate logistic regression analysis. Results: A total of 210 patients received 2,267 drugs. According to Beers 2003 criteria, 60 (28.57%) elderly patients received at least one PIM and 2.9% drugs were prescribed inappropriately. According to Beers 2012 criteria, 84 (40%) elderly received at least one PIM while 22 (10.47%) received multiple PIMs and about 5% drugs were prescribed inappropriately. The most commonly prescribed PIM was mineral oil-liquid paraffin (30, 14.3%) followed by spironolactone (25, 11.9%), digoxin (19, 9%), and benzodiazepines (14, 6.7%). There was a significant association between the number of patients receiving more than six drugs and the use of PIMs (P < 0.01). Use of more than 10 drugs was a significant predictor for use of PIMs in the elderly. Conclusion: The study shows high prevalence of prescribing PIMs in hospitalized elderly patients. Beers 2012 criteria are more effective in identifying PIMs than Beers 2003 criteria.
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Affiliation(s)
- Taufik G Momin
- Department of Pharmacology, Smt. Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad, Gujarat, India
| | - Rushi N Pandya
- Department of Pharmacology, Smt. Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad, Gujarat, India
| | - Devang A Rana
- Department of Pharmacology, Smt. Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad, Gujarat, India
| | - Varsha J Patel
- Department of Pharmacology, Smt. Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad, Gujarat, India
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Magin P, Goode S, Pond D. GPs, medications and older people: A qualitative study of general practitioners' approaches to potentially inappropriate medications in older people. Australas J Ageing 2014; 34:134-9. [PMID: 24754489 DOI: 10.1111/ajag.12150] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To explore the prescribing, and the rationale for this prescribing, of potentially inappropriate medications (PIMs) in older persons by Australian general practitioners (GPs). METHODS This was a qualitative study employing semistructured interviews and thematic analysis. GPs who had patients taking at least one PIM were invited to participate. PIMs were defined by the Beers criteria. RESULTS Twenty-two GPs from four regions in three Australian states participated. While none were aware of the Beers criteria, participant GPs displayed good knowledge of the potential adverse effects of these medications. They were comfortable with the continued prescription of the medications. This was based on often quite complex harm-benefit considerations of the biopsychosocial contexts of individual patients. CONCLUSIONS The concept of 'appropriate' versus 'inappropriate' medications implicit in classification systems such as the Beers criteria is at odds with complex considerations informing decision-making prescribing PIMs in older persons.
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Affiliation(s)
- Parker Magin
- Discipline of General Practice, University of Newcastle, Newcastle, New South Wales, Australia
| | - Susan Goode
- Discipline of General Practice, University of Newcastle, Newcastle, New South Wales, Australia
| | - Dimity Pond
- Discipline of General Practice, University of Newcastle, Newcastle, New South Wales, Australia
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Joshua IB, Passmore PR, Parsons R, Sunderland VB. Appropriateness of prescribing in selected healthcare facilities in Papua New Guinea. Health Policy Plan 2013; 29:257-65. [DOI: 10.1093/heapol/czt012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Latter S, Smith A, Blenkinsopp A, Nicholls P, Little P, Chapman S. Are nurse and pharmacist independent prescribers making clinically appropriate prescribing decisions? An analysis of consultations. J Health Serv Res Policy 2012; 17:149-56. [PMID: 22734082 DOI: 10.1258/jhsrp.2012.011090] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Legislation and health policy enabling nurses and pharmacists to prescribe a comprehensive range of medicines has been in place in the UK since 2006. Our objective was to evaluate the clinical appropriateness of prescribing by these professionals. METHODS A modified version of the Medication Appropriateness Index (MAI) was used by 10 medical, seven pharmacist and three nurse independent raters to evaluate a sample of 100 audio-recorded consultations in which a medicine was prescribed by a nurse or pharmacist. Raters were current prescribers with recognized experience in prescribing. Consultations were recorded in nine clinical practice settings in England. RESULTS Raters' analysis indicated that, in the majority of instances, nurses and pharmacists were prescribing clinically appropriately on all of the ten MAI criteria (indication, effectiveness, dosage, directions, practicality, drug-drug interaction, drug-disease interaction, duplication, duration, cost). Highest mean 'inappropriate' ratings were given for correct directions (nurses 12%; pharmacists 11%) and the cost of the drug prescribed (nurses 16% pharmacists 22%). Analysis of raters' qualitative comments identified two main themes: positive views on the overall safety and effectiveness of prescribing episodes; and potential for improvement in nurses' and pharmacists' history-taking, assessment and diagnosis skills. CONCLUSIONS Nurses and pharmacists are generally making clinically appropriate prescribing decisions. Decisions about the cost of drugs prescribed and assessment and diagnostic skills are areas for quality improvement.
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Affiliation(s)
- Sue Latter
- Faculty of Health Sciences, University of Southampton, Southampton, UK.
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Rodríguez Ruitiña AI. Presión de prescripción en atención primaria. Aten Primaria 2010; 42:300-1. [DOI: 10.1016/j.aprim.2009.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Accepted: 06/15/2009] [Indexed: 11/17/2022] Open
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Lewis PJ, Tully MP. The discomfort caused by patient pressure on the prescribing decisions of hospital prescribers. Res Social Adm Pharm 2010; 7:4-15. [PMID: 21397877 DOI: 10.1016/j.sapharm.2010.02.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Revised: 02/18/2010] [Accepted: 02/18/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND 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. OBJECTIVES To investigate the influences on hospital prescribers' decisions by exploring what they found uncomfortable when prescribing. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Penny J Lewis
- School of Pharmacy & Pharmaceutical Sciences, University of Manchester, Stopford Building, Oxford Rd, Manchester M13 9PT, UK.
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Baumann M, Baumann C, Le Bihan E, Chau N. How patients perceive the therapeutic communications skills of their general practitioners, and how that perception affects adherence: use of the TCom-skill GP scale in a specific geographical area. BMC Health Serv Res 2008; 8:244. [PMID: 19046433 PMCID: PMC2612661 DOI: 10.1186/1472-6963-8-244] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Accepted: 12/01/2008] [Indexed: 12/02/2022] Open
Abstract
Background To study: (1) the structure and test-retest reliability of a measure of how patients perceive the therapeutic communications skills of their general practitioners (TCom-skill GP), and (2) the associations of that scale with socio-demographic and health-related characteristics, and adherence. Methods A total of 393 people who lived in the same geographic area and invited to attend a preventive medical centre for a check up were asked to complete a self-administered questionnaire concerning TCom-skill GP (15 items), socio-demographic and health-related characteristics, and to answer two questions on perceived adherence. Results The average age of respondents was 46.8 years (SD 14), and 50.4% were men. The TCom-skill GP score was one-dimensional, had high internal coherence (Cronbach α 0.92), and good test-retest reliability (intra-class correlation coefficient 0.74). The overall score was positively related to increasing age. Respondents aged 60+ were more likely to be adherent. The higher the score, the higher the probability of adherence. Multivariate analysis showed that the TCom-skill score was associated with advancing age and the number of consultations with the GP during the previous 3 months, but not with gender, living alone, being employed, job category or educational level. Multivariate analysis also showed that adherence was associated with TCom-skill GP score which concealed the association between adherence and advancing age observed in univariate analysis. Conclusion The TCom-skill GP scale probably has value in assessing the quality of doctor-patient relationships and therapeutic communications. The psychometric properties of the TCom-skill GP scale were appropriate for its use in this context. Adherence related to the TCom-skill GP and the latter related to the age of patients and the number of their previous consultations. The TCom-skill GP scale may be a useful way to assess, in a specific geographical location, the impact of medical professional training on therapeutic communication.
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Affiliation(s)
- Michèle Baumann
- INtegrative research unit on Social and Individual DEvelopment, University of Luxembourg, Luxembourg.
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15
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Evaluation of the antibiotic prescribing of nurse practitioners trained to prescribe in primary care. Prim Health Care Res Dev 2008. [DOI: 10.1017/s1463423608000728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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16
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Latter S, Maben J, Myall M, Young A. Evaluating the clinical appropriateness of nurses' prescribing practice: method development and findings from an expert panel analysis. Qual Saf Health Care 2007; 16:415-21. [PMID: 18055884 DOI: 10.1136/qshc.2005.017038] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The number of nurses independently prescribing medicines in England is rising steadily. There had been no attempt systematically to evaluate the clinical appropriateness of nurses' prescribing decisions. AIMS (i) To establish a method of assessing the clinical appropriateness of nurses' prescribing decisions; (ii) to evaluate the prescribing decisions of a sample of nurses, using this method. METHOD A modified version of the Medication Appropriateness Index (MAI) was developed, piloted and subsequently used by seven medical prescribing experts to rate transcripts of 12 nurse prescriber consultations selected from a larger database of 118 audio-recorded consultations collected as part of a national evaluation. Experts were also able to give written qualitative comments on each of the MAI dimensions applied to each of the consultations. ANALYSIS Experts' ratings were analysed using descriptive statistics. Qualitative comments were subjected to a process of content analysis to identify themes within and across both MAI items and consultations. RESULTS Experts' application of the modified MAI to transcripts of nurse prescriber consultations demonstrated validity and feasibility as a method of assessing the clinical appropriateness of nurses' prescribing decisions. In the majority of assessments made by the expert panel, nurses' prescribing decisions were rated as clinically appropriate on all nine items in the MAI. CONCLUSION A valid and feasible method of assessing the clinical appropriateness of nurses' prescribing practice has been developed using a modified MAI and transcripts of audio-recorded consultations sent to a panel of prescribing experts. Prescribing nurses in this study were generally considered to be making clinically appropriate prescribing decisions. This approach to measuring prescribing appropriateness could be used as part of quality assurance in routine practice, as a method of identifying continuing professional development needs, or in future research as the expansion of non-medical prescribing continues.
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Affiliation(s)
- Sue Latter
- School of Nursing and Midwifery, Building 67, University of Southampton, Highfield, Southampton SO17 1BJ, England.
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17
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De Smet PAGM, Denneboom W, Kramers C, Grol R. A composite screening tool for medication reviews of outpatients: general issues with specific examples. Drugs Aging 2007; 24:733-60. [PMID: 17727304 DOI: 10.2165/00002512-200724090-00003] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Regular performance of medication reviews is prominent among methods that have been advocated to reduce the extent and seriousness of drug-related problems, such as adverse drug reactions, drug-disease interactions, drug-drug interactions, drug ineffectiveness and cost ineffectiveness. Several screening tools have been developed to guide practising healthcare professionals and researchers in reviewing the medication patterns of elderly patients; however, each of these tools has its own limitations. This review discusses a wide range of general prescription-, treatment- and patient-related issues that should be taken into account when reviewing medication patterns by implicit screening. These include generic and therapeutic substitution; potentially superfluous or inappropriate medications; potentially inappropriate dosages or duration of treatment; drug-disease and drug-drug interactions; under-treatment; making use of laboratory test results; patient adherence, experiences and habits; appropriate dosage forms and packaging. A broad selection of specific examples and references that can be used as a basis for explicit screening of medication patterns in outpatients is also offered.
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Development of NSAIDs prescription indicators based on health outcomes. Eur J Clin Pharmacol 2007; 64:61-7. [DOI: 10.1007/s00228-007-0384-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2007] [Accepted: 09/12/2007] [Indexed: 10/22/2022]
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Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, Hanlon JT. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet 2007; 370:173-184. [PMID: 17630041 DOI: 10.1016/s0140-6736(07)61091-5] [Citation(s) in RCA: 713] [Impact Index Per Article: 41.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Prescription of medicines is a fundamental component of the care of elderly people, and optimisation of drug prescribing for this group of patients has become an important public-health issue worldwide. Several characteristics of ageing and geriatric medicine affect medication prescribing for elderly people and render the selection of appropriate pharmacotherapy a challenging and complex process. In the first paper in this series we aim to define and categorise appropriate prescribing in elderly people, critically review the instruments that are available to measure it and discuss their predictive validity, critically review recent randomised controlled intervention studies that assessed the effect of optimisation strategies on the appropriateness of prescribing in elderly people, and suggest directions for future research and practice.
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Affiliation(s)
- Anne Spinewine
- Center for Clinical Pharmacy, School of Pharmacy, Université catholique de Louvain, Brussels, Belgium.
| | - Kenneth E Schmader
- Aging Center and Department of Medicine (Geriatrics), School of Medicine, Duke University Medical Center, Durham, NC, USA; Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA
| | - Nick Barber
- Department of Practice and Policy, School of Pharmacy, University of London, London, UK
| | | | - Kate L Lapane
- Department of Community Health, Brown Medical School, Providence, RI, USA
| | - Christian Swine
- Department of Geriatric Medicine, Mont-Godinne University Hospital, Université catholique de Louvain, Brussels, Belgium
| | - Joseph T Hanlon
- Institute on Aging, and Department of Medicine (Geriatrics), School of Medicine and Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA; Center for Health Equity Research and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
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20
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Abstract
Several compounds to improve cognition in schizophrenia are being studied in clinical trials, but little is known about how clinicians conceptualize the cognitive deficits of schizophrenia. In a pilot study, the author asked 40 psychiatrists 3 brief questions about the clinical presentation of cognitive deficits. Descriptions of cognitive deficits show high variability. Informants describe phenomenology like follow-through, attention, and emptiness as indicative of cognitive impairment. Informants' concepts of cognitive deficits overlap substantially with positive, negative, and thought disorder symptoms. Clinicians' concepts are complex and contextualized, in contrast to the discrete skills measured by neuropsychological tests. Results suggest that appropriate prescribing of cognition-enhancing medications may be challenging.
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Affiliation(s)
- Elizabeth Bromley
- Semel Institute Health Services Research Center, University of California, Los Angeles, 10920 Wilshire Boulevard, Suite 300, Los Angeles, CA 90024-6505, USA.
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21
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De Smet PAGM. Clinical risk management of herb-drug interactions. Br J Clin Pharmacol 2007; 63:258-67. [PMID: 17116126 PMCID: PMC2000738 DOI: 10.1111/j.1365-2125.2006.02797.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2006] [Accepted: 08/21/2006] [Indexed: 11/29/2022] Open
Abstract
The concomitant use of conventional and herbal medicines can lead to clinically relevant herb-drug interactions. Clinical risk management offers a systematic approach to minimize the untoward consequences of these interactions by paying attention to: (i) risk identification and assessment; (ii) development and execution of risk reduction strategies; and (iii) evaluation of risk reduction strategies. This paper reviews which steps should be explored or taken in these domains to improve the clinical risk management of adverse herb-drug interactions.
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Affiliation(s)
- Peter A G M De Smet
- Scientific Institute of Dutch Pharmacists, The Hague and Department of Clinical Pharmacy, University Medical Centre St Radboud, Nijmegen, the Netherlands.
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22
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Morecroft C, Cantrill J, Tully MP. Patients' evaluation of the appropriateness of their hypertension management--a qualitative study. Res Social Adm Pharm 2006; 2:186-211. [PMID: 17138508 DOI: 10.1016/j.sapharm.2006.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Revised: 02/16/2006] [Accepted: 02/16/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND The existing appropriateness measures for prescribing used in the United States and the United Kingdom use clinical attributes. Treatment and care from a patient's perspective need to be evaluated in terms of whether they are more likely to lead to an outcome of a life worth living, in social, psychological, and physical terms. However, it is unclear whether patients specifically evaluate their prescribed medication and treatment. If so, do they use only clinical attributes or a combination of clinical and nonclinical attributes? OBJECTIVES The aim of this study was to explore if patients evaluated their hypertension management, and if they did, investigate what attributes were involved in the evaluation. METHODS Semistructured interviews, which focused on personal experiences of hypertension and its management were undertaken with patients (n=28). The aim of the interviews was to obtain, in a narrative format, the experiences, beliefs, and information that patients considered important when discussing the management of hypertension. Data analysis used a constant comparative method. RESULTS All patients considered their hypertension management regimen appropriate, but were able to mention only 2 categories of attributes to justify their decision (the relationship with their General Practitioner and lowering of their blood pressure). Further series attributes were mentioned by the patient during the course of their interview; these attributes were considered to be involved in their evaluation. These implicit attributes were categorized as anxieties and concerns regarding treatment and diagnosis, explanation of the consequences of treatment, choice of antihypertensives, and the side effects experienced. CONCLUSIONS Patient's evaluation of appropriateness was constructed from both explicit and implicit attributes. Implicit attributes, those not consciously known to the patient still, could be involved in the process of evaluating hypertension, its treatment, and care. Although the nonmedical attributes that are considered by patients can be categorized, it has to be remembered that it is the inherent meaning held by each individual patient involved when an evaluation is made.
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Affiliation(s)
- Charles Morecroft
- School of Pharmacy and Pharmaceutical Sciences, The University of Manchester, Manchester, UK.
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Bryan S, Gill P, Greenfield S, Gutridge K, Marshall T. The myth of agency and patient choice in health care? The case of drug treatments to prevent coronary disease. Soc Sci Med 2006; 63:2698-701. [PMID: 16920242 DOI: 10.1016/j.socscimed.2006.07.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Indexed: 11/29/2022]
Abstract
Patient choice is at the heart of health-care reform programmes in the UK and in many other countries. The success of patient choice initiatives is dependent on a well-functioning agency relationship in health care. We interviewed 197 patients from 13 general practices in the West Midlands, UK, both before and after coronary screening. Our study suggests that, for patients presenting for coronary risk screening in primary care, the agency relationship is not working well--patients' expressed preferences relating to decisions to commence drug treatments were largely over-ridden in the clinical consultation. Therefore, if choice is to be a real driver of change in health care it needs to encompass patient empowerment and be based on a more collaborative approach to decision making between patients and professionals.
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Affiliation(s)
- Stirling Bryan
- Health Services Management Centre, University of Birmingham, UK.
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Barber N, Bradley C, Barry C, Stevenson F, Britten N, Jenkins L. Measuring the appropriateness of prescribing in primary care: are current measures complete? J Clin Pharm Ther 2006; 30:533-9. [PMID: 16336285 DOI: 10.1111/j.1365-2710.2005.00681.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Appropriateness of prescribing is often assessed by standard instruments. We wished to establish whether judgements of appropriateness that included patients' perspectives and contextual factors could lead to different conclusions when compared with commonly used instruments. To explore the predictive accuracy of these instruments. METHODS The design was interviews of patients, audio recordings of the consultation and interviews of the doctors, in varied primary care practices in England. Participants were patients who were likely to discuss a medication issue. The outcome measures were judgements of appropriateness made by the researchers and by two instruments: the Prescribing Appropriateness Index and the Medication Appropriateness Index. Implications for the predictive accuracy of the measures was also investigated. RESULTS From 35 cases there was agreement between the judges and the instruments in 22 cases, 16 were appropriate and 6 inappropriate. Of 10 cases classified as inappropriate by the instruments the judges thought four were appropriate. Of 18 cases classified as appropriate by the instruments, two were considered inappropriate by the judges. In seven cases the prescribing decisions could not be classified by the instruments because the decision was to not prescribe. CONCLUSIONS Current measures of appropriateness of prescribing depend predominantly on pharmacological criteria, and so do not represent cases that would be judged appropriate when including the patient's views and contextual factors. If most prescribing is appropriate then use of these measures may lead to more false negatives than real negatives. The instruments should be renamed as measures of 'pharmacological appropriateness' and are useful where the incidence of this type of inappropriate prescribing is relatively high.
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Affiliation(s)
- N Barber
- Department of Practice and Policy, The School of Pharmacy, London, UK.
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25
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Tully MP, Cantrill JA. The validity of explicit indicators of prescribing appropriateness. Int J Qual Health Care 2005; 18:87-94. [PMID: 16234298 DOI: 10.1093/intqhc/mzi084] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess, from the perspective of UK hospital doctors, the content validity and operational validity of a set of 14 previously developed explicit indicators of the appropriateness of long-term prescribing started during a hospital admission. METHOD A combination of data extraction from medical records and qualitative interviews with a maximum variability sample of hospital doctors. PARTICIPANTS The indicators were applied to 132 new prescriptions, intended for long-term use, prescribed for 61 patients; 36 doctors, of various grades, were purposively selected for interview. RESULTS Appropriate prescribing was viewed as prescribing that was indicated, necessary, evidence based (using a broad meaning of 'evidence') and of acceptable cost and risk-benefit ratio. These concepts applied to individual drugs for individual patients, rather than at a more general, public health level. Where drugs had failed an indicator, rationales were explored. Often, it was missing data in the medical notes that had resulted in the drug failing the indicator. CONCLUSIONS The 14 indicators were considered to have content validity, reflecting all aspects of appropriate prescribing discussed by the doctors. Their operational validity was less clear-cut, due to the lack of necessary data in the medical notes. This has implications for the use of explicit indicators for assessing prescribing appropriateness, as these hospital doctors did not consider that the data required for objective, systematic assessment of prescribing would ever be recorded in hospital medical notes.
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Affiliation(s)
- Mary Patricia Tully
- School of Pharmacy & Pharmaceutical Sciences, University of Manchester, Manchester, UK.
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Tully MP, Javed N, Cantrill JA. Development and Face Validity of Explicit indicators of Appropriateness of Long Term Prescribing. ACTA ACUST UNITED AC 2005; 27:407-13. [PMID: 16341749 DOI: 10.1007/s11096-005-0340-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To develop a set of explicit and operationalisable indicators of appropriate prescribing and assess their face validity using clinical pharmacists practising in secondary and primary care. METHOD Appropriateness indicators were derived from the literature, applied to data in the hospital clinical records of all newly prescribed long-term drugs for 50 randomly selected patients, further refined and then applied to another 25 randomly selected patients. A pre-piloted postal questionnaire was sent to 200 hospitals and primary care pharmacists, asking them to assess the indicators as to their importance for the assessment of appropriateness of long-term prescribing initiated in hospitals. RESULTS Fourteen indicators were developed and piloted. Of the 16 original indicators, 5 were discarded, as they were unable to be operationalised, and 2 were subdivided to reflect the routinely available data. Eighty-six pharmacists with individual patient-focussed clinical duties took part in the assessment of the face validity (response rate 43%). Eleven indicators achieved a median importance rating of 1 (very important), and three indicators a median importance rating of 2 on a 5-point scale. The three most important indicators overall were "indication included in discharge summary", "questionable high-risk therapeutic combination" and "hazardous drug-drug combination". CONCLUSION It was possible to develop and operationalise 14 indicators of the appropriateness of long-term prescribing commenced in hospital practice, all of which were considered to have face validity by an expert panel of clinical pharmacists. The development of these explicit indicators highlighted the incompleteness of the patient's record. Further work is needed to assess their validity and reliability, before their use in research or audit can be recommended.
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Affiliation(s)
- Mary P Tully
- School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Oxford Road, Manchester M13 9PL, UK.
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Abstract
BACKGROUND Co-morbidity, or the presence of more than one clinical condition, is gaining increased attention in epidemiological and health services research. However, the clinical relevance of co-morbidity has yet to be defined. In general practice, few studies have been conducted into co-morbidity, either at a single health care encounter, an episode of care, or for a defined time period. AIMS To describe the major co-morbidity cluster profiles recorded by general practitioners. Another aim of this study is to describe the common clusters of co-prescribing. METHODS AND RESULTS Twelve month data from patients attending 156 GPs from 95 practices around a six month period of January to June 2003 were analysed. This represented 840,961 encounters from about 200,000 individual patients at these participating practices. Co-morbidity and co-prescribing cluster profiles are represented by problems managed and reasons for prescribing for the top 10 presentations and top 10 prescribed drugs in the study period. CONCLUSIONS By analysing the 10 most prevalent problems and 10 most prevalent drugs prescribed in consultations in a community sample, other co-morbidities that are particular to general practice, for example hypertension and lipid disorders, can be uncovered. Whether these clusters are causally related or occur by chance requires further analysis.
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Affiliation(s)
- D C Saltman
- University of Sydney, 37A Booth Street, Balmain 2041, NSW, Australia.
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