Cascade of decisions meet personal preferences in sciatica treatment decisions

STUDY DESIGN

An in-depth interview study including patients, general practitioners, neurologists and neurosurgeons.

OBJECTIVE

To gain insight in decision-making in sciatica care, by identifying patients' and physicians' preferences for treatment options, and the differences between and within both groups.

SUMMARY OF BACKGROUND DATA

Sciatica is a self-limiting condition, which can be treated both conservatively and surgically. The value of both options has been disputed, and the care pathway is known for a substantial amount of practice variation. Most Dutch patients are taken care of by general practitioners before they are referred to hospital-based neurologists, who might refer to a neurosurgeon, who can perform a surgical intervention. Dutch sciatica care thus follows the principles of stepped care, and a cascade of decisions precedes surgery. Better understanding of the decision-making within this cascade might reveal opportunities to improve shared decision-making and to reduce unwarranted practice variation.

METHODS

Interviews with 10 patients and 22 physicians were analysed thematically.

RESULTS

While physicians were confident of their clinical diagnosis, patients preferred confirmation trough imaging to exclude other possible explanations. Furthermore, many patients showed reluctance towards the use of (strong) opioids, while all physicians favoured this and underlined the benefits of opioids in the management of sciatica complaints, to buy time and to allow patients to recover naturally. Finally, individual physicians differed strongly in their opinion on benefits and optimal timing of surgical treatment and epidural injections.

CONCLUSIONS

Dutch sciatica care is characterised by a cascade of decisions preceding surgery. Preferences differ within and between patients and physicians, which adds to the practice variation. To improve decision-making, physicians and patients should invest not necessarily more in the exchange of options or preferences, but in making sure the other understands the rationale behind them.

Consumers' self-reported adherence to directions for non-prescription medicines and the role of risk perception

BACKGROUND

Non-prescription medicines (NPMs), while relatively safe, are responsible for a small but significant proportion of medication misadventure and inappropriate use may lead to avoidable healthcare cost. Some consumers vary their use of NPMs from the directions provided on packaging or advice from healthcare professionals. Consumers may use NPMs at lower doses or less frequently than directed because of the risk of side effects.

PURPOSE

This study aimed to develop and validate a self-report measure for the extent to which consumers' follow directions (FDs) for NPMs. Secondly, it aimed to explore the relationship between risk perception towards NPMs and following directions.

METHODS

A cross-sectional study was administered online to participants who belong to an Australian agency which conducts consumer research. Participants were Australian adults who had used NPMs within the last month. Items for the FD-NPM scale were developed and validated. Exploratory factor analysis and confirmatory factor analysis were used to validate the FD-NPM scale. Structural equation modelling (SEM) was employed to explore the relationships between risk perception, covariates, and FDs.

RESULTS

There were 403 participants recruited. Less than 20% "always" or "often" self-reported following directions for dose, frequency, or duration of use. Factor analyses confirmed that there are two moderately positively correlated dimensions of FD-NPM (r = 0.46), which were named underuse and overuse. That is, consumers who self-reported underuse of non-prescription medicines were also more likely to self-report overuse. Consumers with high-risk perception towards NPMs, those who were younger and those who were more educated had a greater tendency to not follow directions.

CONCLUSION

A new self-report measure, the FD-NPM scale was developed and validated. That people who perceives NPMs to be harmful, tend to underuse and more concerningly, overuse them, is of great interest to clinicians and policymakers who are required to manage risk communications.

Pediatric Outpatient Prescriptions in Countries With Advanced Economies in the 21st Century: A Systematic Review

Importance

An international comparison of pediatric outpatient prescriptions (POPs) is pivotal to investigate inadequate practices at the national scale and guide corrective actions.

Objective

To compare annual POP prevalence among Organisation for Economic Co-operation and Development (OECD) member countries.

Evidence Review

Two independent reviewers systematically searched PubMed, Embase, and institutes of public health or drug agency websites for studies published since 2000 and reporting POP prevalence (expressed as number of patients aged <20 years with ≥1 POP per 1000 pediatric patients per year) in OECD member countries or large geographic areas within them. Risk of bias was assessed for exhaustiveness and representativeness. Prevalence ratios (PRs) were used to compare the highest and lowest POP prevalence among countries overall, by levels of Anatomical Therapeutic Chemical (ATC) classification for the overall pediatric population, and by age group (ie, ages <5-6 vs ≥5-6 years), stratifying on prescription-only drug (POD) status.

Findings

Among 11 studies performed on 3 regional and 8 national medicoadministrative databases in 11 countries, 35 552 550 pediatric patients were included. The overall risk of bias was low (10 studies were representative [90.9%], and the prevalence denominator included nonusers of health care for 9 studies [81.8%]). Prevalence of 1 or more POP per year ranged from 480 to 857 pediatric patients per 1000 in Sweden and France, respectively (PR, 1.8 [95% CI, 1.8-1.8]). Overall, among 8 studies reporting ATC level 1 drugs, Denmark had the lowest POP prevalence (eg, systemic hormonal preparations: 9 pediatric patients per 1000 per year) and France the highest (eg, systemic hormonal preparation: 216 pediatric patients per 1000 per year). Among 8 studies reporting ATC level 2 drugs for PODs, the PR between France and Denmark was 108.2 (95% CI, 108.2-108.2) for systemic corticosteroids and 2.1 (95% CI, 2.1-2.1) for drugs for obstructive airway disease. The PR for antibiotics was 3.4 (95% CI, 3.4-3.4) between New Zealand and Sweden. For pediatric patients aged 5 to 6 years or older, the PR for sex hormones was 2.1 (95% CI, 2.1-2.1) between Denmark and France. Among 7 studies reporting ATC level 5 drugs, the prevalence of the 10 most prevalent PODs was less than 100 pediatric patients per 1000 per year in Scandinavian countries and the Netherlands and less than 300 pediatric patients per 1000 per year in France and New Zealand.

Conclusions and Relevance

This study found large between-country variations in POPs, which may suggest substantial inappropriate prescriptions. The findings may suggest guidance for educational campaigns and regulatory decisions in some OECD member countries.

Why are self-medication opportunities limited in Austria? An interview study and comparison with other countries

Background

Austria has high health resource use compared to similar countries. Reclassifying (switching) medicines from prescription to non-prescription can reduce pressure on health resources and aid timely access to medicines. Since Austria is less progressive in this area than many other countries, this research aimed to elucidate enablers and barriers to it reclassifying medicines and make recommendations for change in the context of similar research conducted elsewhere.

Methods

Qualitative research using a heuristic approach was conducted in Austria in 2018. Informed by their own “insider” and “outsider” knowledge, the authors identified themes from personal interviews with 24 participants, including reclassification committee members, government officials and stakeholders, before comparing these themes with earlier research findings.

Results

Significant barriers to reclassification included committee conservatism, minimal political support, medical negativity and few company applications. Insufficient transparency about committee decisions, expectations of adverse committee decisions and a limited market discouraged company applications. Austria’s ‘social partnership’ arrangement and consensus decision making aided a conservative approach, but the regulator and an alternative non-committee switch process were enabling. Pharmacy showed mixed interest in reclassification. Suggested improvements include increasing transparency, committee composition changes, encouraging a more evidence-based approach by the committee, more pharmacy undergraduate clinical training, and companies using scientific advisory meetings and submitting high quality applications.

Conclusion

Removing barriers to reclassification would facilitate non-prescription availability of medicines and encourage self-care, and could reduce pressure on healthcare resources.

Prescription and Non-Prescription Drug Classification Systems Across Countries: Lessons Learned for Thailand

Purpose

The drug classification system, as prescription or non-prescription drug category, has been utilized as a regulatory strategy to ensure patient safety. In Thailand, the same system has been used for decades, though the drug classification criteria were updated to accommodate drug re-classification in 2016. These new criteria, however, have not been applied retroactively. Inconsistency in drug classification has been observed leading to concerns regarding the drug classification system. This has prompted the need for a review of the drug classification system in Thailand. This study aims to explore Thailand and other selected countries’ regulatory management regarding the drug classification system, drug classification criteria, and drug classification itself.

Methods

The drug classification systems of the United States, the United Kingdom, Japan, Singapore, Malaysia, the Philippines, and Canada were selected to study alongside Thailand’s system. The regulatory review was conducted through each country’s drug regulatory agency website and available published research. Complementary interviews with drug regulatory authorities were conducted when written documentation was unclear and had limited access. Fifty-two common drugs were selected to compare their actual classifications across the different countries.

Results

All selected countries classified drugs into two major groups: prescription drugs and non-prescription drugs. The studied countries further sub-classified non-prescription drugs into 1–4 categories. Principles of drug classification criteria among countries are similar; they comprised of three themes: disease characteristics, drug safety profile, and other drug characteristics. Actual drug classification of antibiotics, dyslipidemia treatments, and hypertension treatments in Thailand are notedly different from other countries. Furthermore, 77.4% of drugs studied in Thailand fall into the behind-the-counter (dangerous) drug category, which varied from antihistamines to antibiotics, dyslipidemia treatments, and vaccines.

Conclusion

Thailand’s drug classification criteria are comparable with other nations; however, there is a need to review drug classification statuses as many drugs have been classified into improper drug categories.

Australian pharmacists: ready for increased non-prescription medicines reclassification

OBJECTIVES

Reclassification of medicines from prescription to non-prescription increases timely access to treatment, promotes self-management of minor ailments and relieves healthcare system burden. Previous research identified that Australia lagged behind the United Kingdom and New Zealand in medicines reclassification. This study aimed to identify Australian pharmacists' opinions on the current state of medicines reclassification; the prescription medicines consumers requested without prescription; the medicines pharmacists believed should and should not be considered for reclassification; and perceived barriers to reclassification.

METHODS

A 2016 national online survey that sought pharmacists' opinions on the state of reclassification, perceived barriers to reclassification and readiness of the profession for further reclassification. Pharmacists' comments were invited through open-ended questions.

KEY FINDINGS

Two hundred and thirty-five valid surveys were completed. Respondents practised in community, hospital, consultant and academic contexts, and the majority were female (58.7%, n = 138). More than two thirds (70.66%, n = 166) of pharmacists reported receiving daily or weekly requests for non-prescription access to prescription medicines. The majority of pharmacists (71.7%) agreed that the Australian pharmacy profession is ready for further medicines reclassification, guided by patient safety, harm minimisation and medication continuance. The most prominent barrier to further reclassification was opposition from other healthcare professionals.

CONCLUSIONS

Australian pharmacists believe that their profession has the capacity to safely and effectively manage a wider range of non-prescription medicines through increased reclassification in the contexts of patient safety and risk mitigation. This study has contributed to the global conversation on non-prescription medicines access, providing momentum for practice and policy change.

Analysing the landscape for prescription to non-prescription reclassification (switch) in Germany: an interview study of committee members and stakeholders

Background

Non-prescription medicines are increasingly used in Germany, aided by prescription-to-non-prescription reclassification (or switch). This study aimed to examine the barriers and enablers to reclassification of medicines in Germany and provide recommendations for change.

Methods

Face-to-face conversational interviews with purposively selected key informants in Germany were conducted in 2017 by a researcher informed in the area. Interviews were transcribed, coded in NVIVO and systematically analysed using a framework approach.

Results

Twenty-four interviews were conducted with 32 participants including members of the committee considering reclassifications, and representatives from government, industry, health insurance, academia, and pharmacy, medical, and patients’ organisations.

A range of enablers and barriers emerged that influence reclassification including effects on the committee and process, or the desire of pharmaceutical companies to pursue reclassifications. Enabling market factors included the large population and a culture of self-medication. Enabling health system factors include the pharmacy-only category. Some pharmacy factors appeared enabling (e.g. a positive experience after reclassifying emergency contraception) while others appeared to hinder reclassification (e.g. insufficient pharmacy practice research). Some medical factors were enabling (e.g. reported waiting times) and others limited reclassification (e.g. opposition to some reclassifications). Some committee and government openness to reclassification and self-medication reportedly enabled reclassification, while conservatism was considered a barrier, particularly for classifications with special conditions for supply such as initial doctor diagnosis or other complexities. Some improvements to the committee constitution and considerations were recommended. Some participants found the reclassification process after the committee recommendation opaque, with opportunity for delays and political interference.

Industry factors included both enablers such as capability in reclassification, and barriers, such as a perceived low market potential of some reclassifications, and doubt that some candidates would be approved.

A need for more data emerged strongly, both pre-reclassification in applications, and post-reclassification.

Many participants saw merit with reclassification in non-traditional areas such as hypertension, diabetes and oral contraception.

Conclusions

Many factors influence reclassification in Germany. Recommended improvements included aspects of the process and committee consideration, and more data collection. Sufficient market exclusivity linked to data collection could aid the generation of evidence to aid committee considerations and encourage more applications of high quality.

Medicines reclassification from a pharmaceutical industry perspective: An international qualitative study

BACKGROUND

Widening access to medicines through reclassification ('switching') of medicines from prescription to non-prescription is an international trend generally welcomed by community pharmacists. Research has focused on scheduling and committee deliberations affecting reclassification, rather than industry aspects, despite industry's role in driving reclassifications. The research aimed to identify how pharmaceutical industry and product-related factors influence reclassification, and to explore stakeholder acceptability of government or third-party driven reclassifications.

METHODS

Sixty-five in-depth, semi-structured interviews were conducted with 80 key informants (including representatives from regulatory bodies, industry, pharmacy and medicine) in developed countries including the United States, the United Kingdom, Japan, Australia, and New Zealand. The questions explored barriers and enablers to reclassification at the local (micro-), regional (meso-) and global (macro-) levels. Analysis of transcribed interviews entailed descriptive and thematic approaches.

RESULTS

Pharmaceutical industry decisions to drive medicine reclassification reflect characteristics of the company, product, and external environment at all levels. For the company, financial factors, company focus (e.g. on prescription business versus non-prescription business), and capability in non-prescription medicines and reclassification were common influences. Products with significant non-prescription market potential and a well-known prescription medicine brand name most suited reclassification, usually near patent expiry. Barriers included immediate generic entry post-reclassification, and a short-term profitability and/or prescription business focus. Some countries allow government or a third-party (including pharmacy) to drive reclassifications, with examples of successful reclassifications ensuing. Some industry and other participants held concerns about this practice, particularly in the United States. Concerns included insufficient resourcing, and the pharmaceutical company's business, potentially encouraging product withdrawal or legal challenge.

CONCLUSIONS

This study is the first to explore both pharmaceutical industry factors affecting reclassification and acceptability of alternate drivers of reclassification. Factors beyond clinical safety and efficacy and the local reclassification environment can influence reclassification. Pharmacy-driven reclassification might be one alternative.

Patient access to medicines in two countries with similar health systems and differing medicines policies: Implications from a comprehensive literature review

BACKGROUND

Countries with similar health systems but different medicines policies might result in substantial medicines usage differences and resultant outcomes. The literature is sparse in this area.

OBJECTIVE

To review pharmaceutical policy research in New Zealand and Australia and discuss differences between the two countries and the impact these differences may have on subsequent medicine access.

METHODS

A review of the literature (2008-2016) was performed to identify relevant, peer-reviewed articles. Systematic searches were conducted across the six databases MEDLINE, PubMed, Science Direct, Springer Links, Scopus and Google Scholar. A further search of journals of high relevance was also conducted. Using content analysis, a narrative synthesis of pharmaceutical policy research influencing access to medicines in Australia and New Zealand was conducted. The results were critically assessed in the context of policy material available via grey literature from the respective countries.

RESULTS

Key elements regarding pharmaceutical policy were identified from the 35 research papers identified for this review. Through a content analysis, three broad categories of pharmaceutical policy were found, which potentially could influence patient access to medicines in each country; the national health system, pricing and reimbursement. Within these three categories, 9 subcategories were identified: national health policy, pharmacy system, marketing authorization and regulation, prescription to non-prescription medicine switch, orphan drug policies, generic medicine substitution, national pharmaceutical schedule and health technology assessment, patient co-payment and managed entry agreements.

CONCLUSIONS

This review systematically evaluated the current literature and identified key areas of difference in policy between Australia and NZ. Australia appears to cover and reimburse a greater number of medicines, while New Zealand achieves much lower prices for medicines than their Australian counterparts and has been more successful in controlling national pharmaceutical expenditure. Delays in patient access to new therapies in New Zealand have considerable implications for overall patient access to medicines; however, higher patient co-payments and relative pharmaceutical expenditure in Australia and its effect upon patient access to medicines must also be considered.

Pharmacy student decision making in over-the-counter medicine supply: A critical incident study

BACKGROUND

Various factors influence decision making in over-the-counter (OTC) medicine consultations, yet limited studies have focused, in-depth, on the thought process of pharmacy staff. This includes pharmacy students as pharmacists-in-training.

AIM

To explore the factors that influence pharmacy students' decisions in relation to OTC consultations and choice of OTC medicine/s.

METHODS

Semi-structured interviews using the critical incident technique were undertaken with ten pharmacy students in Australia, who also worked as part-time pharmacy staff.

RESULTS

Nine key themes were identified to influence pharmacy student decision making in OTC consultations, including customer response, confidence and scope of practice. Product requests were reported as more challenging due to customer expectations and experiences in other pharmacies, states or countries. Although negative customer response influenced some students to supply medicines in contradiction of evidence, an overarching concern for safety meant that a medicine was only supplied if unlikely to cause harm. Students reported developing confidence in OTC decision making more from real-life practice than university training; greater confidence was identified for inquiries more frequently experienced in the pharmacy. Students perceived that customers had assumptions around support staff, and were happier to talk to students than assistants.

CONCLUSION

This study further identified that OTC decision making is a complex process for pharmacy students. Additional opportunities for experiential learning within this area are suggested, such as work-based placements or in-class activities such as role-plays with simulated patients.

Opioid analgesic use in Australia and The Netherlands: a cross-country comparison

Background Increasing use of opioid analgesics (OA) has been reported worldwide. Objective To compare the use of OA in two countries in order to better understand these trends. Setting Outpatient settings in Australia and The Netherlands. Method We analysed publicly available government data on outpatient OA dispensing over 15 years (2000-2014). We compared dispensing trends for specific OA and explored medical (national clinical guidelines), contextual and policy-related factors to explain differences in use between the two countries. Main outcome measure OA prescribing in Australia and The Netherlands, absolute volume of use, preferred types of opioids and changes over time. Results The average annual increase in OA prescribing was 10% in Australia and 8% in The Netherlands between 2000 and 2014. In 2014, the total use of OA was 10.0 daily defined doses (DDD)/1000 population/day in Australia and 9.4 DDD/1000 population/day in The Netherlands. In Australia, the most commonly prescribed opioids were oxycodone and tramadol, compared to fentanyl and tramadol in The Netherlands. We found differences in prescribing guidelines, culture of prescribing and regulatory frameworks that could explain some of the observed differences. Conclusion OA prescribing has increased remarkably in both countries between 2000 and 2014 but the types of prescribed OA vary. Differences in national evidence-based guidelines influenced the types of OA used. Prescribing culture as well as regulatory policies and costs, may also contribute to the different patterns of OA use.

Community pharmacy modifications to non-prescription medication requests: A simulated patient study

BACKGROUND

Self-care, and hence self-medication, is becoming an increasingly popular practice worldwide. Community pharmacies are an important destination for those seeking non-prescription medicines, and pharmacists and their staff are in a prime position to facilitate appropriate and safe self-medication.

PURPOSE

To determine what modifications (for example, a change in brand, change in drug, or non-supply) pharmacy staff make when presented with a request for a non-prescription medicine, and to determine what factors influence whether a modification is made.

METHODS

Sixty-one third year Bachelor of Pharmacy students from The University of Sydney were trained as mystery shoppers to make 9 visits once a week to 36 community pharmacies in the metropolitan region of Sydney, Australia from March-October 2015. Students presented to a different, pre-allocated pharmacy once a week with a direct product request for a non-prescription medicine relating to a common ailment (e.g. asthma, insomnia, allergic rhinitis) for 9 weeks. Student mystery shoppers audio-recorded each visit and collected the details of the interaction and product sold. Descriptive statistics, chi-squared analyses, and binary logistic regression were performed to find factors influencing modifications made by pharmacy staff to the simulated patient initial request.

RESULTS

Of 540 completed visits, 497 were eligible for analysis. Modification (change in brand, intra/interclass change, companion sale, or no product supplied) occurred in 49% (n = 245) of visits. Whether the product requested was deemed "not appropriate" given the scenario outline was the only significant predictor of whether a modification to the request occurred (42% modification, "appropriate" scenarios vs. 57% modification, "not appropriate" scenarios; χ² = 8.90; p < 0.01).

CONCLUSIONS

Modification from the original non-prescription medicine request occurred in approximately half the reported requests. A request for a product that was considered "not appropriate" was more likely to elicit a modification than a request for an "appropriate" non-prescription medicine.

Investigation of social, demographic and health variations in the usage of prescribed and over-the-counter medicines within a large cohort (South Yorkshire, UK)

OBJECTIVES

Prescribed and over-the-counter (non-prescribed) medicine usage has increased in recent years; however, there has been less investigation of the socioeconomic predictors of use. This has been due to a lack of data, especially for over-the-counter medicines. Our study aims to understand how prescribed and over-the-counter medicine patterns vary by demographic, social and health characteristics within a large population cohort.

DESIGN

Cross-sectional data analysis.

SETTING

South Yorkshire, UK.

PARTICIPANTS

27 806 individuals from wave 1 of the Yorkshire Health Study (2010-2012).

MEASURES

Individuals self-reported each medicine they were taking and whether each was prescribed or not. The medicines were grouped into 14 categories (eg, cardiovascular system, infection, contraception). Negative binomial regression models were used to analyse the count of medicine usage. We included demographic (age, gender, ethnicity), social (education), health-related (body mass index, smoking, alcohol consumption, physical activity) factors and chronic health conditions (eg, stroke, anxiety and heart disease) in our analyses.

RESULTS

49% of men and 62% of women were taking medicine with the majority of this prescribed (88% and 83%, respectively). Health conditions were found to be positively associated with prescribed medicine usage, but mixed in their associated with over-the-counter medicines. Educational attainment was negatively associated with prescribed and positively associated with over-the-counter usage.

CONCLUSIONS

Our study addresses a dearth of evidence to provide new insights into how behaviours in medicine usage vary by demographic, social and health-related factors. Differences in over-the-counter medicine usage by educational attainment may help our understanding of the determinants of health inequalities.