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Choonara YM. Enhancing diabetic foot management: Advocating for independent prescribing rights for podiatrists in South Africa. Foot (Edinb) 2024; 60:102126. [PMID: 39178497 DOI: 10.1016/j.foot.2024.102126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/24/2024] [Accepted: 08/14/2024] [Indexed: 08/26/2024]
Abstract
Diabetic foot complications are serious issues resulting from uncontrolled diabetes, primarily affecting the feet. Common complications include diabetic neuropathy, ulcers, PAD, Charcot foot, and gangrene. Preventive measures include controlling blood glucose levels, regular foot inspections, proper foot care, wearing appropriate footwear, and seeking prompt medical attention. A holistic approach to diabetic foot management is crucial due to the complex interplay of physiological, psychological, and environmental factors. Glycaemic control is essential for mitigating neuropathy and vasculopathy, while cardiovascular risk factors like hypertension and dyslipidemia are crucial for preventing complications. In South Africa, podiatrists play a crucial role in diabetic foot care, offering specialized expertise in the assessment, management, and prevention of foot complications associated with diabetes mellitus. They collaborate closely with other healthcare professionals to ensure comprehensive and coordinated care.Pharmacological management is a crucial aspect of podiatric care in the UK, where podiatrists use various medications to treat foot conditions effectively. In South Africa, podiatrists lack prescribing authority, leading to limited treatment options, dependency on referrals, and disparities in access to care. This fragmented approach can compromise patient outcomes, especially in chronic conditions like diabetes. To improve patient outcomes and promote optimal foot condition management, policy reforms, interdisciplinary collaboration, and professional advocacy efforts are needed.Policy recommendations for expanding podiatrist prescribing privileges include legislative reforms, regulatory framework updates, and professional accreditation. Legislative reforms could involve amending existing healthcare laws or introducing new regulations that recognize podiatrists as authorized prescribers. Regulatory framework updates should involve working with regulatory bodies to establish prescribing standards, prescribing limitations, and mechanisms for ongoing oversight and accountability. Professional accreditation should ensure educational programs for podiatrists incorporate training in pharmacology, pharmacotherapy, and prescribing practices to prepare graduates for the expanded scope of practice.Stakeholders in South Africa can improve diabetes management by advocating for policy reforms, professional recognition, and patient empowerment initiatives. By aligning policy, practice, education, research, and advocacy efforts, stakeholders can create a supportive ecosystem that fosters innovation, collaboration, and continuous improvement in diabetic foot care.
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Almalki ZS, Alahmari AK, Alajlan SAA, Alqahtani A, Alshehri AM, Alghamdi SA, Alanezi AA, Alawaji BK, Alanazi TA, Almutairi RA, Aldosari S, Ahmed N. Continuity of care in primary healthcare settings among patients with chronic diseases in Saudi Arabia. SAGE Open Med 2023; 11:20503121231208648. [PMID: 37915839 PMCID: PMC10617268 DOI: 10.1177/20503121231208648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/03/2023] [Indexed: 11/03/2023] Open
Abstract
Introduction Maintaining continuity of care is one of the most critical components of providing great care in primary health care. This study aimed to explore continuity of care and its predictors in primary healthcare settings among patients with chronic diseases in Saudi Arabia. Method Face-to-face cross-sectional interviews were conducted with patients with chronic diseases who had at least four visits to primary care facilities in Riyadh, Saudi Arabia, between November 1, 2022 and March 3, 2023. We determined patients' continuity of care levels using the Bice-Boxerman continuity of care index. A Tobit regression model was used to determine the effects of several factors on the continuity of care index. Results The interviews were conducted with 193 respondents with chronic diseases of interest. The mean continuity of care index of the entire sample was 0.54. Those with asthma had the highest median continuity of care index at 0.75 (interquartile range, 0.62-0.75), whereas those diagnosed with thyroid disease had a much lower continuity of care index (0.47) (interquartile range, 0.3-0.62). Tobit regression model findings showed that employed respondents with poorer general health had a negative effect on continuity of care index levels. By contrast, a higher continuity of care index was significantly associated with elderly respondents, urban residents, and those diagnosed with dyslipidemia, diabetes, hypertension, or asthma. Conclusions According to our findings, the continuity of care level in Saudi Arabia's primary healthcare setting is low. The data demonstrate how continuity of care varies among study group characteristics and that improving continuity of care among chronic disease patients in Saudi Arabia is multifaceted and challenging, necessitating a coordinated and integrated healthcare delivery approach.
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Affiliation(s)
- Ziyad S Almalki
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Abdullah K Alahmari
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | | | - Abdulhadi Alqahtani
- Clinical Research Specialist, Clinical Research Department, Research Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ahmed M Alshehri
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Saleh A Alghamdi
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Adel A Alanezi
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Basil K Alawaji
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Tareq A Alanazi
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Rawan A Almutairi
- Collage of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Saad Aldosari
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Nehad Ahmed
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
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Lampe D, Grosser J, Gensorowsky D, Witte J, Muth C, van den Akker M, Dinh TS, Greiner W. The Relationship of Continuity of Care, Polypharmacy and Medication Appropriateness: A Systematic Review of Observational Studies. Drugs Aging 2023; 40:473-497. [DOI: 10.1007/s40266-023-01022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2023] [Indexed: 03/29/2023]
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Ramachandran S, Salkar M, Bhattacharya K, Bentley JP, Maharjan S, Eriator I, McGwin G, Mauney MJ, Yang Y. Continuity of opioid prescribing among older adults on long-term opioids. THE AMERICAN JOURNAL OF MANAGED CARE 2023; 29:88-94. [PMID: 36811983 PMCID: PMC10851930 DOI: 10.37765/ajmc.2023.89317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVES To describe the continuity of opioid prescribing and prescriber characteristics among older adults with chronic noncancer pain (CNCP) who are on long-term opioid therapy (LTOT) and to evaluate the association of continuity of opioid prescribing and prescriber characteristics with the risk of opioid-related adverse events. STUDY DESIGN Nested case-control design. METHODS This study employed a nested case-control design using a 5% random sample of the national Medicare administrative claims data for 2012-2016. Eligible individuals experiencing a composite outcome of opioid-related adverse events were defined as cases and matched to controls using incidence density sampling. Continuity of opioid prescribing (operationalized using the Continuity of Care Index) and prescriber specialty were assessed among all eligible individuals. Conditional logistic regression was conducted to assess the relationships of interest after accounting for known confounders. RESULTS Individuals with low (odds ratio [OR], 1.45; 95% CI, 1.08-1.94) and medium (OR, 1.37; 95% CI, 1.04-1.79) continuity of opioid prescribing were found to have greater odds of experiencing a composite outcome of opioid-related adverse events compared with individuals with high prescribing continuity. Fewer than 1 in 10 (9.2%) older adults starting a new LTOT episode received at least 1 prescription from a pain specialist. Receiving a prescription from a pain specialist was not significantly associated with the outcome in adjusted analyses. CONCLUSIONS We found that higher continuity of opioid prescribing, but not provider specialty, was significantly associated with fewer opioid-related adverse outcomes among older adults with CNCP.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Yi Yang
- University of Mississippi School of Pharmacy, Faser 225, University, MS 38655.
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Mohottige D, Manley HJ, Hall RK. Less is More: Deprescribing Medications in Older Adults with Kidney Disease: A Review. KIDNEY360 2021; 2:1510-1522. [PMID: 35373095 PMCID: PMC8786141 DOI: 10.34067/kid.0001942021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/08/2021] [Indexed: 02/04/2023]
Abstract
Due to age and impaired kidney function, older adults with kidney disease are at increased risk of medication-related problems and related hospitalizations. One proa ctive approach to minimize this risk is deprescribing. Deprescribing refers to the systematic process of reducing or stopping a medication. Aside from preventing harm, deprescribing can potentially optimize patients' quality of life by aligning medications with their goals of care. For some patients, deprescribing could involve less aggressive management of their diabetes and/or hypertension. In other instances, deprescribing targets may include potentially inappropriate medications that carry greater risk of harm than benefit in older adults, medications that have questionable efficacy, including medications that have varying efficacy by degree of kidney function, and that increase medication regimen complexity. We include a guide for clinicians to utilize in deprescribing, the List, Evaluate, Shared Decision-Making, Support (LESS) framework. The LESS framework provides key considerations at each step of the deprescribing process that can be tailored for the medications and context of individu al patients. Patient characteristics or clinical events that warrant consideration of deprescribing include limited life expectancy, cognitive impairment, and health status changes, such as dialysis initiation or recent hospitalization. We acknowledge patient-, clinician-, and system-level challenges to the depre scribing process. These include patient hesitancy and challenges to discussing goals of care, clinician time constraints and a lack of evidence-based guidelines, and system-level challenges of interoperable electronic health records and limited incentives for deprescribing. However, novel evidence-based tools designed to facilitate deprescribing and future evidence on effectiveness of deprescribing could help mitigate these barriers. This review provides foundational knowledge on deprescribing as an emerging component of clinical practice and research within nephrology.
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Affiliation(s)
- Dinushika Mohottige
- Renal Section, Durham Veterans Affairs Healthcare System, Durham, North Carolina,Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Rasheeda K. Hall
- Renal Section, Durham Veterans Affairs Healthcare System, Durham, North Carolina,Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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Maciejewski ML, Hammill BG, Voils CI, Ding L, Bayliss EA, Curtis LH, Wang V. Prescriber continuity and medication availability in older adults with cardiometabolic conditions. SAGE Open Med 2018; 6:2050312118757388. [PMID: 29449946 PMCID: PMC5808964 DOI: 10.1177/2050312118757388] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 01/11/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Many older adults have multiple conditions and see multiple providers, which may impact their use of essential medications. OBJECTIVE We examined whether the number of prescribers of these medications was associated with the availability of medications, a surrogate for adherence, to manage diabetes, hypertension or dyslipidemia. METHODS A retrospective cohort of 383,145 older adults with diabetes, hypertension or dyslipidemia in the US Medicare program living in 10 states. The association between the number of prescribers of cardiometabolic medications in 2010 and medication availability (proportion of days with medication on hand) in 2011 was estimated via logistic regression, controlling for patient demographic characteristics and chronic conditions. RESULTS Medicare beneficiaries with diabetes, hypertension and/or dyslipidemia had an average of five chronic conditions overall, obtained 10-12 medications for all conditions and most often had one prescriber of cardiometabolic medications. In adjusted analyses, the number of prescribers was not significantly associated with availability of oral diabetes agents but having more prescribers is associated with increased medication availability in older Medicare beneficiaries with dyslipidemia or hypertension. CONCLUSION The incremental addition of new prescribers may be clinically reasonable for complex patients but creates the potential for coordination problems and informational discontinuity over time. Health systems may want to identify complex patients with multiple prescribers to minimize care fragmentation.
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Affiliation(s)
- Matthew L Maciejewski
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Bradley G Hammill
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Corrine I Voils
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Laura Ding
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente, Denver, CO, USA
- Department of Family Medicine, University of Colorado, Denver, CO, USA
| | - Lesley H Curtis
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Virginia Wang
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Hansen RA, Hohmann N, Maciejewski ML, Domino ME, Ray N, Mahendraratnam N, Farley JF. Continuity of Medication Management among Adults with Schizophrenia and Comorbid Cardiometabolic Conditions. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2017; 9:13-20. [PMID: 29552104 DOI: 10.1111/jphs.12201] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objectives Adults with schizophrenia and cardiometabolic conditions may be good candidates for co-management by primary care prescribers and specialists. Associated risks for discontinuity in medication management have not been well-studied. This study examines whether medication adherence, inpatient admissions, and emergency department (ED) visits vary by the number and types of prescribers seen by adults with schizophrenia and cardiometabolic conditions. Methods This study used a retrospective cohort of 4,223 adult Medicaid enrollees with schizophrenia and hypertension, hyperlipidemia, and/or diabetes from three states in 2009-2010. Logistic regression models were run on outcome variables reflecting medication adherence, ED utilization, and inpatient admissions as a function of the number and types of prescribers. Key findings Increases in number of psychiatric specialists were associated with better antipsychotic adherence, but decreasing statin adherence. Increases in number of psychiatric specialists were also associated with a higher probability of inpatient admission and ED visits, while increases in number of primary care prescribers were associated with increases in the probability of ED visits. Conclusion Greater antipsychotic adherence for adults receiving prescriptions from multiple psychiatric specialists was counteracted by lower statin adherence and greater risk of ED and inpatient utilization. This may help inform optimal care models for these complex individuals.
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Affiliation(s)
| | | | - Matthew L Maciejewski
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center
| | - Marisa E Domino
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Neepa Ray
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill
- Center for Medication Optimization through Practice and Policy, UNC Eshelman School of Pharmacy
| | | | - Joel F Farley
- College of Pharmacy, University of Minnesota, Department of Pharmaceutical Care & Health Systems, Minneapolis, USA
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Farley JF, Hansen RA, Domino ME, Borse M, Mahendraratnam N, Ray N, Maciejewski ML. Continuity of medication management in Medicaid patients with chronic comorbid conditions: An examination by mental health status. Gen Hosp Psychiatry 2017; 45:25-31. [PMID: 28274335 PMCID: PMC5843714 DOI: 10.1016/j.genhosppsych.2016.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 11/28/2016] [Accepted: 12/01/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Patients with serious mental illness (SMI) often have comorbid cardiometabolic conditions (CMCs) that may increase the number of prescribers involved in treatment. This study examined whether patients with SMI (depression and schizophrenia) and comorbid CMCs experience greater discontinuity of prescribing than patients with CMCs alone. METHODS 2009 Medicaid data were used to compare number and types of prescribers (primary care, cardiometabolic, psychiatric, other) in individuals with 1-3 CMCs (diabetes, hypertension, dyslipidemia) alone (n=76.451); with CMC and schizophrenia (n=6507); and with CMC and depression (n=23.510) and the degree of prescribing within a provider's area of specialty. RESULTS 44%, 61%, and 71% of individuals with CMCs only, with CMCs and schizophrenia, and with CMCs and depression had medications from these classes prescribed by 5 or more providers respectively. >35% of patients with CMCs alone or CMCs and schizophrenia had prescriptions provided by 3 or more PCP providers, which increased to 49.1% for patients with CMCs and depression. In the schizophrenia cohort, 29% of antipsychotics were PCP-prescribed while psychiatrists prescribed 10%, 9%, and 9% of antihypertensive, antihyperlipidemic, and antidiabetic medications respectively. CONCLUSIONS The presence of SMI increases the number of prescribers treating individuals with CMCs. The impact of this fragmentation in medication management on health outcomes is unknown.
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Affiliation(s)
- Joel F. Farley
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, USA,Corresponding author: Joel F. Farley, UNC Eshelman School of Pharmacy, 2205 Kerr Hall, Campus, Box 7573, Chapel Hill, NC 27599, USA.
| | | | - Marisa E. Domino
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
| | - Mrudula Borse
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, USA
| | | | - Neepa Ray
- Center for Medication Optimization through Practice and Policy, University of North Carolina at Chapel Hill, USA
| | - Matthew L. Maciejewski
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, USA,Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, USA
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