How increased nurse prescribing can improve stoma care practice

Stoma care nurse specialists have a comprehensive knowledge of the range and use of stoma-related products, yet few are actually nurse prescribers. This article looks at why stoma care nurse specialists should consider becoming nurse prescribers and also examines ways to assist prescribing decisions.     

Study on management of pediatric migraine by general practitioners in northern France

The study explored the awareness of the Haute Autorité de Santé (High Health Authority, HAS) guidelines for migraine management in children among a random sample of 100 general practitioners (GPs) dichotomised in an urban and a rural group. A questionnaire conducted by phone included questions on knowledge of pediatric migraine acute treatment and preventive therapy, referral to a child neurologist as well as GPs awareness of HAS recommendations in general. Although 45% of GPs argued they were prescribing ibuprofen as first-line abortive drug, only 3% were aware of the recommended dose. Only 48% of GPs were agreeing to initiate preventive therapy. Fifty percent of GPs stated that they knew HAS guidelines but only 24% stated that they had read them. The only significant difference between urban and rural GPs concerned the initiation of preventive therapy. Continuing educational programmes on the implementation of pediatric migraine guidelines is strongly needed. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Evidence‐based guidelines for the use of biochemical markers of bone turnover in the selection and monitoring of bisphosphonate treatment in osteoporosis: a consensus document of the Belgian Bone Club

Objectives: To review the clinical value of bone turnover markers (BTM), to initiate and/or monitor anti‐resorptive treatment for osteoporosis compared with bone mineral density (BMD) and to evaluate suitable BTM and changes in BTM levels for significance of treatment efficiency. Methodology: Consensus meeting generating guidelines for clinical practice after review and discussion of the randomised controlled trials or meta‐analyses on the management of osteoporosis in postmenopausal women. Results: Although the correlation between BMD and BTM is statistically significant, BTM cannot be used as predictive markers of BMD in an individual patient. Both are independent predictors of fracture risk, but BTM can only be used as an additional risk factor in the decision to treat. Current data do not support the use of BTM to select the optimal treatment. However, they can be used to monitor treatment efficiency before BMD changes can be evaluated. Early changes in BTM can be used to measure the clinical efficacy of an anti‐resorptive treatment and to reinforce patient compliance. Discussion: Determining a threshold of BTM reflecting an optimal long‐term effect is not obvious. The objective should be the return to the premenopausal range and/or a decrease at least equal to the least significant change (30%). Preanalytical and analytical variability of BTM is an important limitation to their use. Serum C‐terminal cross‐linked telopeptide of type I collagen (CTX), procollagen 1 N terminal extension peptide and bone specific alkaline phosphatase (BSALP) appear to be the most suitable. Conclusion: Consensus regarding the use of BTM resulted in guidelines for clinical practice. BMD determines the indication to treat osteoporosis. BTM reflect treatment efficiency and can be used to motivate patients to persist with their medication.     

Antibiotic prescribing in primary care: The need for interprofessional collaboration

Abstract

Patients with self-limiting respiratory tract infections (RTIs) are frequently seen in general practice. Although antibiotics are ineffective for these conditions, they are often prescribed by general practitioners (GPs), and perceived patient expectations for an antibiotic plays an important role in the decision to prescribe one. Superfluous use of antibiotics contributes to antimicrobial resistance. High numbers of nurse prescribers work alongside GPs and these prescribers see education and self-management advice as central to the care of these patients. Multi-faceted interventions, designed to reduce antibiotic prescribing, only exist for GPs. Such interventions should foster interprofessional collaboration and, as such, consider the needs and experiences of the different prescribers, and the views of patients. This paper outlines a research study in which a questionnaire will be distributed to patients who consult with a nurse prescriber to see whether their expectations influence their satisfaction with the consultation outcome. Findings will guide the development of an interprofessional intervention designed to promote collaborative practice and appropriate and responsible antibiotic prescribing in primary care.     

Explore the effectors of bone mineral density in community women

Epidemiological studies that involve Asian women have revealed that their bone mineral density (BMD) is lower than that of European and American women. Few studies have simultaneously investigated the cognition, beliefs and behavior that affect BMD. The first aim of this study was to elucidate the relationships between demographics, knowledge of osteoporosis, health beliefs about osteoporosis, health-related behavior and BMD. The secondary goal was to explore the major predictive factors that affect the BMD of women in Community. This was an exploratory, community-based, cross-sectional study. Participants (N = 98) completed the osteoporosis related questionnaire and were invited to undergo BMD examinations using quantitative ultrasound (QUS). Overall, 73.4% of the participants had heard of the disease but the proportion of correct responses to the questions that tested knowledge of osteoporosis was only 44.0%. The investigation into osteoporosis-related beliefs revealed that women held quite accurate beliefs regarding the prevention of osteoporosis, but only 23.6% of them had undergone a BMD examination. An adjusted odds ratio indicated that if women had normal BMD then they were 1.57 times (95% CI: 1.08-2.29), 1.10 times (95% CI: 1.00-1.12) and 2.74 (95% CI: 1.09-6.86) times than their counterparts, respectively. The results revealed that women with normal BMD were more likely to have positively self-rated health, knowledge of osteoporosis and preventive behavior than their counterparts. The findings indicated that BMD was subjectively determined by a combination of cognitive and behavioral factors. Early detection was the key to preventing osteoporosis.     

Attitudes of Slovene general practitioners towards generic drug prescribing and comparison with international studies

BACKGROUND: Over the recent years there has been a steady 7% yearly increase in prescribing costs, which accounts for 17% of the Slovene national health care budget. Substitution of branded products by generic equivalents can offer savings. General practitioners (GPs) are often concerned about the quality of generic products and possible legal liabilities associated with their use. OBJECTIVE: We wanted to examine the attitudes of GPs in Slovenia towards generic drug prescribing. METHODS: We conducted a postal survey of a random sample of 200 out of 800 GPs in Slovenia from the National Health Insurance Institute database. GPs were asked 21 questions regarding their knowledge on generic drugs, awareness of prescribing costs, prices of generic drugs relative to brand name drugs and their attitude towards use of generic drugs. RESULTS: The 117 (58.5%) replies we received represent 15% of the GP population in Slovenia. 66.1% of GPs considered rising costs of medicines to be a serious problem for the health care budget. Each week, over 50% of GPs experienced demands from patients for specific drugs and the majority of GPs usually met their patients' demands or requests from hospital consultants for branded products. 38.3% of GPs did not take price into consideration when prescribing drugs. The majority of GPs (88.9%) perceived generics to have the same effectiveness as branded drugs. One quarter of GPs would prescribe more generics if additional clinical trials were presented. 37.3% would follow advice of academic detailers and 30.3% expected the generics to be even cheaper than they were. Independent detailing was welcomed by 63.8% of GPs because of the big influence of the pharmaceutical industry on the prescribing habits. 15.5% thought that the industry had a tremendous impact on their prescribing patterns. CONCLUSIONS: Slovene GPs are aware of the cost of prescribed drugs. They are willing to accept independent academic detailing to improve their prescribing and are willing to increase generic drugs under certain conditions.     

Addressing the concerns of the trainee nurse prescriber

AIM: To identify the specialties from which trainee prescribers come and to determine their pre-training and post-training concerns about prescribing and how they are utilising their prescribing skills. METHOD: A self-report profile questionnaire including open and closed questions, some Likert-type scales and a 24-item, self-report follow-up questionnaire were used. RESULTS: Half of the nurses who took part in this study came from four disciplines--practice nursing, mental health nursing, district nursing and paediatric/neonatal nursing. Before the course they were concerned that they had insufficient pharmacological knowledge to prescribe. However, once they had qualified this changed to concerns regarding educational needs, formal support and the way their role would be perceived by colleagues. Most participants felt that nurse prescribing impacted positively on patient care. CONCLUSION: With the right support systems in place, nurse prescribers are utilising their prescribing skills in order to develop their role, increase their clinical autonomy and improve the care of patients.     

The information sources used by community nurse prescribers

A purposive sample of 22 community nurse prescribers and five prescribing leads were interviewed to determine how nurses both access and assess the reliability of pharmacological information. Prescribers used both printed material and other professionals to obtain pharmacological information. The most commonly mentioned sources of printed material were journals and the British National Formulary. Other people that nurses obtained information from included pharmaceutical company representatives, community pharmacists, nurse specialists, colleagues, and GPs. Nurses described the attributes that they associated with reliable information (previous vetting, up-to-date and used by other healthcare professionals) and unreliable information (produced by those with a vested interest). Much of the pharmacological information supporting prescribers is aimed at doctors and may not be accessible for nurse prescribers. Organizations seeking to influence evidence-based practice should consider the method of communication in addition to the message.     

Deciding if lifestyle is a problem: GP risk assessments or patient evaluations? A conversation analytic study of preventive consultations in general practice

Objective. The aim of this study is to analyse the interaction between patients and GPs in preventive consultations with an emphasis on how patients answer GPs’ questions about lifestyle, and the conditions these answers impose on the process of establishing agreement about lifestyle as a problem or not. Design. Six general practitioners (GPs) video-recorded 15 annual preventive consultations. From these, 32 excerpts of discussions about lifestyle were analysed using conversation analysis (CA). Results. GPs used an interview format to assess risk in patients’ lifestyles. In some cases patients adhered to this format and answered the GPs’ questions, but in many cases patients gave what we have termed “anticipatory answers”. These answers indicate that the patients anticipate a response from their GPs that would highlight problems with their lifestyle. Typically, in an anticipatory answer, patients bypass the interview format to give their own evaluation of their lifestyle and GPs accept this evaluation. In cases of “no-problem” answers from patients, GPs usually encouraged patients by adding support for current habits. Conclusion. Patients anticipated that GPs might assess their lifestyles as problematic and they incorporated this possibility into their responses. They thereby controlled the definition of their lifestyle as a problem or not. GPs generally did not use the information provided in these answers as a resource for further discussion, but rather relied on standard interview procedures. Staying within the patients’ frame of reference and using the patients’ anticipatory answers might provide GPs with a better point of departure for discussion regarding lifestyle.     

C‐reactive protein point of care testing and physician communication skills training for lower respiratory tract infections in general practice: economic evaluation of a cluster randomized trial

Rationale, aims and objectives An economic evaluation of general practitioner (GP) use of C‐reactive protein (CRP) point of care test, GP communication skills training, and both GP use of CRP and communication skills training on antibiotic use for lower respiratory tract infections (LRTIs) in general practice. Methods Cost‐effectiveness analysis with a time horizon of 28 days alongside a factorial, cluster randomized trial in 431 patients with LRTIs recruited by 40 GPs. Interventions: usual care (control group), GP use of CRP point of care test, GP communication skills training, and both CRP use and communication skills training. Main outcome measure: health care costs. Cost‐effectiveness, using the primary outcome measure antibiotic prescribing at index consultation, was assessed by incremental cost‐effectiveness ratios (ICER). To adjust for skewed data and clustering, we used non‐parametric bootstrapping re‐sampling to derive percentile intervals for the mean difference in total costs and the mean difference in effectiveness between the groups. Various implementation scenarios according to GP preference were modelled with corresponding net monetary benefit (NMB) curves based on a given willingness‐to‐pay (λ) for a 1% lower antibiotic prescribing rate. Results The total mean cost per patient in the usual care group was €35.96 with antibiotic prescribing of 68%, €37.58 per patient managed by GPs using CRP tests (antibiotic prescribing 39%, ICER €5.79), €25.61 per patient managed by GPs trained in enhanced communication skills (antibiotic prescribing 33%, dominant) and €37.78 per patient managed by GPs using both interventions (antibiotic prescribing 23%, ICER €4.15). The interventions are cost‐effective in any combination (yielding NMB at no willingness‐to‐pay), taking into account GPs' preferences where at least 15% of GPs chose to implement the communication skills training. Conclusions The two strategies, both singly and combined, are cost‐effective interventions to reduce antibiotic prescribing for LRTI, at no, or low willingness‐to‐pay. Taking GP preferences into account will optimize investment in strategies to reduce antibiotic prescribing for LRTI.     

Motivating general practitioners to change their prescribing: the incentive of working together

OBJECTIVE: To determine the extent to which GPs were motivated to change their prescribing upon joining a Primary Care Commissioning Group (PCCG) and how effective certain interventions planned by the PCCG might be as a means to change prescribing. To define the characteristics of GPs less motivated to change their prescribing. Design: A cross-sectional survey of participating general practitioners linked with current prescribing information derived from PACT data. Setting: General practice covering a geographical locality within inner-city south London. Subjects: All 72 general practitioners who had joined a GP Commissioning Group. Main outcome measures: questionnaire responses. RESULTS: 93% of GPs entering the GP Commissioning Group expected their prescribing to change but none expected substantial change. There was no difference between fundholders, singlehanders nor training practices in their expectation of change. GPs in practices with the lowest quality prescribing, as measured by a quality index, were least likely to expect change (Spearman's r = 0.25, P = 0.04). Those in practices with higher prescribing costs were not more likely to expect their prescribing to change, whereas expensive prescribers who were unaware of their practices' prescribing costs were associated with a reduced expectation of prescribing change (P = 0.05). Educational interventions were thought to be the most effective means by which prescribing could be changed, whereas formularies and financial factors were perceived as weaker influences. CONCLUSION: Acceptance of a cash-limited prescribing budget by GPs is accompanied by the expectation of personal prescribing change. The motivation to change prescribing may be related to a strongly developed collectivist perspective amongst GPs who are prepared to consider the prescribing implications for their fellow GPs. It is ironic that those with the least expectation of change should have the lowest quality prescribing, or be unaware of their high cost prescribing. Engendering greater commitment to the professional group may be one way of changing their prescribing.     

Knowledge of and support for cancer patient pathways among general practitioners and other physicians – a study from Sweden

ObjectiveTo investigate the expertise in and support of the implemented new method of cancer patient pathways (CPPs) among general practitioners (GPs) and other working physicians in Sweden.DesignA survey in the form of 10 knowledge-based multiple-choice questions (MCQs) and two general questions about CPPs.SettingPhysicians from two different regions in Sweden answered the survey between December 2018 and January 2019.SubjectsGPs in primary care compared to other physicians. 155 participants completed the survey and the response rate was 65%.Main outcome measuresPhysicians’ self-estimated knowledge of CPPs in general and opinion of CPPs effect on mortality and morbidity. Their scores on 10 different MCQs. Scores were analysed in subgroups related to the physicians medical specialty and experience.ResultsA majority of all physicians (63%) felt that they had insufficient knowledge regarding the procedure of CPPs, and the average score from the MCQs was 3.8 out of 10 correct answers. The results showed that GPs performed significantly better than specialists from other disciplines.ConclusionsThe low percentage of correctly answered MCQs shows that the information about the entry part of CPPs needs to be improved. The study demonstrates a support for the system with CPPs because the physicians believed in its’ positive effects on morbidity and mortality, however, it also reveals a lack of self-estimated knowledge about the system with CPPs.

Key points

• Cancer patient pathways (CPPs) is a newly implemented method in Sweden that aims to equalize cancer care and reduce the time to diagnosis and treatment.
• The proficiency of when to initiate an investigation according to a specific CPP seems low. General practitioners (GPs) performed significantly better on knowledge-based questions than other specialists did.
• Physicians rated their knowledge as insufficient regarding the procedure of CPPs.
• A clear majority of physicians believed that CPPs promotes a lower mortality and morbidity in cancer.

     

Experiences and attitudes of nurse specialists in primary care regarding their role in care for patients with urinary incontinence

Scand J Caring Sci; 2011; 25; 303–310
Experiences and attitudes of nurse specialists in primary care regarding their role in care for patients with urinary incontinence Aim: To explore experiences and attitudes of nurse specialists in primary care regarding their role in care for patients with urinary incontinence (UI), thereby identifying facilitators and barriers for wider implementation. Background: Currently, primary care for patients with UI lacks sufficient adherence to existing guidelines on UI and is far from optimal. Studies in various countries show that involving nurse specialists may offer a solution to the inadequate care for UI. As qualitative studies on experiences of nurses with this type of intervention are lacking, we performed this study with a qualitative approach and data collection method within the course of a randomized controlled trial (RCT). Method: A focus group study was conducted in 2007 with six nurse specialists who were trained in caring for patients with UI in our pragmatic RCT. The focus group interview was audio‐taped and transcribed verbatim. The data were analysed using qualitative content analysis to identify themes. To understand obstacles and incentives for change, we relied on an existing ‘implementation model’. Findings: Nurse specialists feel competent to provide advice and information, to offer possible solutions and to give attention and guidance to the process of care of people with UI. They feel appreciated by patients and feel they offer an added value to the usual care of general practitioners (GPs). Nurses sometimes notice that GPs lack interest in UI. Personal contact with the GPs, availability of enough time, adequate equipment and financial resources are important preconditions for effective nurse specialist care. Nurse specialists value continuous education and feedback in daily care for patients with UI. Conclusion: Trained nurse specialists appeared to feel competent and satisfied to support GPs in care for patients with UI. They feel highly appreciated by both patients and GPs.     

Osteoporosis risk assessment and management in primary care: focus on quantity and quality

Introduction and hypothesis Early identification of high‐risk patients by general practitioners (GPs) plays the key role in the management of osteoporosis (OP). Methods We conducted a postal questionnaire survey among 1500 Czech GPs to examine their behaviour related to OP. Results The overall questionnaire return rate was 38%. The respondents (mean age 52 years; 61.5% women) did not differ from non‐respondents. OP knowledge correlated negatively with age (P < 0.001). The most common reason for both suspicion of OP and referral for suspected OP is the patient's complaints. When the initial skeletal examination for suspected OP is conducted on the GP's initiative, it is most often X‐ray (76%) followed by osteodensitometry (61%). The respondents address five patients (median) per month about this issue. The number of referrals to a specialist for suspected OP during the last quarter was 5 (median). The most commonly reported barriers to OP management were financial limits set by the health insurance agency (71%) and lack of authorization to prescribe selected drugs (71%). Conclusions The GPs should pay greater attention to risk factors and be more active in the detection of at‐risk patients. It is necessary to motivate the GPs and to overcome the barriers to effective clinical practice.     

Prevention and treatment of osteoporosis in women with breast cancer

Women who have had breast cancer may be at higher risk for osteoporosis than other women. First, they are more likely to undergo early menopause, due to chemotherapy-induced ovarian failure or oopherectomy. In addition, chemotherapy may have a direct adverse effect on bone mineral density (BMD), and osteoclastic activity may increase from the breast cancer itself. While estrogen therapy is considered standard for the prevention and treatment of osteoporosis, use of estrogen in women with a history of breast cancer is usually contraindicated. The approach to osteoporosis in women with breast cancer is also affected by the use of tamoxifen in many, as this drug appears to have opposite effects on BMD in premenopausal and postmenopausal women. We have reviewed therapeutic alternatives for the prevention and treatment of osteoporosis, focusing on patients with a history of breast cancer. Alendronate and raloxifene are currently approved in the United States for the prevention of osteoporosis; alendronate, raloxifene, and calcitonin are approved for treatment. Alendronate has the greatest positive effect on BMD and reduces the incidence of vertebral and nonvertebral fractures. Raloxifene and calcitonin appear to reduce the incidence of vertebral fractures; their effects on the incidence of nonvertebral fractures are not yet proven. Although no published studies specifically address the use of these approved agents for osteoporosis in women with breast cancer, understanding their relative effects on BMD in postmenopausal women in general will facilitate therapy selection in this population. Postmenopausal women with a history of breast cancer should undergo bone mineral analysis. Normal results and absence of other risk factors ensure that calcium and vitamin D intake are adequate. If osteopenia or other risk factors are present, preventive therapy with alendronate or raloxifene should be considered. For osteoporosis, treatment with alendronate should be strongly considered. Raloxifene and calcitonin are alternatives when alendronate is contraindicated. Further studies are needed to evaluate the optimal timing of initial bone mineral analysis in premenopausal women after breast cancer diagnosis and to determine the value of preventive treatment in women scheduled to undergo chemotherapy.