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.     

How practitioners view generic drugs: an opinion study from general practitioners in Maine-et-Loire (France)

INTRODUCTION: Generic drugs are copies of original drugs, hence their low cost. In France, expansion of the use of generic drugs is not significant and the support of practitioners is essential in increasing this. AIM: The purpose of this study was to survey the opinion and practical experience of physicians regarding generic drugs, in order to develop a proposal for the safer use of these drugs. METHODS: A form was sent to the 1235 general and specialist practitioners in the Maine-et-Loire "département" with assistance from the regional health insurance, in March 2002. The main topics studied were prescribing practices, risks associated with generic drugs and pharmacist substitutions. The chi2 test and Fisher's exact test were used in the data analysis. RESULTS: Four hundred and twenty-nine forms were returned (34.7%). Only 55% of practitioners considered generic drugs to be as safe and effective as original drugs. Fifty-nine percent prescribe generics rarely or never. The prescribing depends on many factors, linked to the practitioner, the patient or the drug. Many practitioners reported adverse events with generic medicines. With regard to the switch by the pharmacist, it was reported that 45% of prescribers would refuse it in some instances. Among the proposals, cooperation between practitioners and pharmacists in the choice of the generic drugs was approved by 57% of physicians. DISCUSSION: The main perception is that the vastness of the generic world and the fear of adverse events are somewhat bewildering for both patients and health professionals. Among the proposals made by practitioners, a decrease in the number of generics for a same molecule and the institution of a standard price are widely approved. CONCLUSION: Practitioners do not refuse to use generic drugs but are very concerned about the risks of adverse effects for their patients. They regard it as important that a patient receiving chronic treatment be given the same generic drug each time.     

Nurse prescribing in dermatology: doctors' and non-prescribing nurses' views

Title.  Nurse prescribing in dermatology: doctors' and non-prescribing nurses' views.
Aim.  This paper is a report of a study conducted to explore doctor and non-prescribing nurse views about nurse prescribing in the light of their experience in dermatology.
Background.  The cooperation of healthcare professionals and peers is of key importance in enabling and supporting nurse prescribing. Lack of understanding of and opposition to nurse prescribing are known barriers to its implementation. Given the important role they play, it is necessary to consider how the recent expansion of nurse prescribing rights in England impacts on the views of healthcare professionals.
Method.  Interviews with 12 doctors and six non-prescribing nurses were conducted in 10 case study sites across England between 2006 and 2007. Participants all worked with nurses who prescribed for patients with dermatological conditions in secondary or primary care. Thematic analysis was conducted on the interview data.
Results.  Participants were positive about their experiences of nurse prescribing having witnessed benefits from it, but had reservations about nurse prescribing in general. Acceptance was conditional upon the nurses' level of experience, awareness of their own limitations and the context in which they prescribed. Fears that nurses would prescribe beyond their level of competence were expected to reduce as understanding and experience of nurse prescribing increased.
Conclusion.  Indications are that nurse prescribing can be acceptable to doctors and nurses so long as it operates within recommended parameters. Greater promotion and assessment of standards and criteria are recommended to improve understanding and acceptance of nurse prescribing.     

Solution‐driven approaches to generic substitution challenges – a survey among international experts

The main objective of this study was to explore the perception and understanding of economic, legal, and social barriers that may restrain generic uptake among recognized international experts in health care, and to identify and verify recommendations on how to streamline generic substitution (GS) at no expense of therapeutic safety. A questionnaire survey was devised, and experts with world‐renowned expertise in the field of generic medicinal products were selected. Almost 3/4 of respondents claimed that all drugs that satisfy bioequivalence criteria represent similar efficacy and adverse effects, and 1/4 of respondents believed that some differences could be reported. The majority of experts supported (i) the right of patients to refuse GS, (ii) the right of physicians to veto GS, and (iii) the introduction of a statutory obligation to provide patients with access to the cheapest generics available on the market. The main obstacles to more general uptake of generics were as follows: (i) perception of generics as lower quality products, (ii) absence of a transparent policy governing GS, and (iii) disincentives to pharmacists and physicians. Among the most popular recommendations were as follows: (i) introduction of various measures to aid physicians in generic prescribing, (ii) setting clear guidelines specifying when GS is not advisable, (iii) supporting competition on the generic market. The views of experts and the resulting recommendations were strongly affected by their opinion on the bioequivalence of generics. From this analysis, we have selected several principal recommendations which could help shape successful healthcare policies regarding GS.     

Lessons Learned From China's Healthcare System and Nursing Profession

Purpose: To examine the healthcare policy and the nursing profession in China and to share insights learned from that country, which can be used to inform health-policy decision makers in the US.
Organizing Construct: Despite their significant cultural, political, and historical differences, many healthcare issues are the same for China and the US. Both countries face rising healthcare costs and widening disparities between wealthy and poor individuals, and between urban and rural sectors.
Conclusions: Some of the ideas that can be gleaned from China's healthcare system include rewarding physicians for prescribing preventive services; using trained laypeople as gatekeepers to the healthcare system in rural areas; communicating to the public and to health-policy decision makers the importance of nurses so that staffing, work conditions, and professional status can be improved; and including nurses in health-policy decisions.
Clinical Relevance: Lessons learned from China's healthcare policy and healthcare system have implications for public health policy change that could lead to improved patient outcomes in the US. The current changing global health environment calls for healthcare providers to learn from and work with our international neighbors to improve health outcomes for all patients.     

British Association of Critical Care Nurses position statement on prescribing in critical care

Background: Nurses in the UK are now one group of non-medical staff who can prescribe. This practice is evolving for critical care nursing staff who care for critically ill patients during their stay in hospital through ward and outpatient follow-up after admission to critical care.
Aim: The purposes of this paper were to present existing information regarding prescribing to support nurses in critical care currently prescribing and to inform those who are intending to prescribe.
Methods: To develop the position statement, a search of the literature was conducted using key databases. To ascertain the current level and type of prescribing in critical care, a short questionnaire was sent by email to British Association of Critical Care Nursing members, and the results of this are presented in Appendix A.
Outcomes/Results: Evidence was found in relation to the history, context in critical care, educational requirements and issues of consent related to non-medical prescribing.
Conclusions: The position statement is based upon evidence from the literature, National Health Service policy and the Nursing and Midwifery Council regulations. It takes account of the critical care patient pathway before, during and after an admission to critical care.     

Validation and test–retest reliability of the Risser patient satisfaction scale in Cyprus

charalambous a. (2010) Journal of Nursing Management   18 ,61–69
Validation and test–retest reliability of the Risser patient satisfaction scale in Cyprus
Aim  To describe the translation, adaptation and validation of the Risser Patient Satisfaction Scale (RPSS) questionnaire into Greek language and discuss possibilities of its use in cancer care settings.
Background  The translation and cultural adaptation of a widely accepted, psychometrically tested tool is regarded as an essential component of effective human resource management or quality monitoring and improvement in the healthcare arena.
Methods  The original version of the English self-administered questionnaire consisting of 25 items was translated and validated using the internationally accepted and recommended methodology. The validation process included: assessment of the item internal consistency, using the alpha coefficient of Cronbach. Reproducibility (test–retest reliability) was tested by the Kappa correlation coefficient.
Results  The psychometric properties of the Greek version of the PSS were good. The internal consistency of the instrument was very good, Cronbach's alpha was found to be 0.89 ( P  < 0.001) and Kappa coefficient for reproducibility was found to be 0.84 (95% CI: 0.83–0.85, P  < 0.0001).
Conclusions  The translated and adapted Greek version is comparable with the original instrument in terms of validity and reliability.
Implications for nursing management  Managers should use validated patient satisfaction scales such as the RPSS in order to evaluate the quality of care in cancer care departments. The findings should be also compared using a bench mark on national and international levels.     

Practice patterns and perceptions about parenteral hydration in the last weeks of life: a survey of palliative care physicians in Latin America

ContextParenteral hydration at the end of life is controversial and has generated considerable debate for decades.ObjectivesTo identify palliative care physician parenteral hydration prescribing patterns and factors that influence prescribing levels (PLs) for patients during their last weeks of life.MethodsA cross-sectional, representative online survey of Latin American palliative care physicians was conducted in 2010. Physicians were asked to report the percentage of their terminally ill patients for whom they prescribed parenteral hydration. Predictors of parenteral hydration PLs were identified using logistic regression analysis.ResultsTwo hundred thirty-eight of 320 physicians completed the survey (74% response rate). Sixty percent of physicians reported prescribing parenteral hydration to 40%–100% of their patients during the last weeks of life. Factors influencing moderate/high PLs were the following: agreeing that parenteral hydration is clinically and psychologically efficacious (odds ratio [OR] 3.5; 95% confidence interval [CI] 1.5–8.3), disagreeing that withholding parenteral hydration alleviates symptoms (OR 3.3, 95% CI 1.3–8.1), agreeing that parenteral hydration is essential for meeting the minimum standards of care (OR 3.2, 95% CI 1.4–7.5), preferring the subcutaneous route of parenteral hydration for patient comfort and home use (OR 2.9, 95% CI 1.3–6.5), and being younger than 45 years of age (OR 2.6, 95% CI 1.3–5.2).ConclusionThe strongest determinant of prescribing patterns was agreement with the clinical/psychological efficaciousness of parenteral hydration. Our results reflect parenteral hydration prescribing patterns and perceptions that substantially differ from the conventional/traditional hospice philosophy. These findings suggest that the decision to prescribe or withhold parenteral hydration is largely based on clinical perceptions and that most palliative care physicians from this region of the world individualize treatment decisions.     

Telenurses' experiences of working with computerized decision support: supporting, inhibiting and quality improving

Title.  Telenurses' experiences of working with computerized decision support: supporting, inhibiting and quality improving.
Aim.  This paper is a report of a study conducted to describe telenurses' experiences of working with computerized decision support systems and how such systems could influence their work.
Background.  Telenursing is an expanding service in many Western countries, and in recent years centralization of telenursing services has occurred in Sweden. In connection with this, the use of computerized decision support has increased.
Method.  Eight Registered Nurses from three telephone advice call centres in Sweden who were using computerized decision support took part in semi-structured interviews in 2006. The data were analysed using qualitative content analysis.
Findings.  The findings are presented as one theme and three categories. Telenurses experienced their work with a decision support system as supporting, inhibiting and quality improving. Based on two of the categories –'supporting' and 'inhibiting'– a theme was revealed: being strengthened, but simultaneously controlled and inhibited . This theme represents the individual level . The telenurses found that the decision support system simplified their work, complemented their knowledge, gave them security and enhanced their credibility. They also described experiencing the system as incomplete, sometimes in conflict with their own opinions and controlling. The third category referred to the organizational level: the decision support system ensured the quality of telenursing.
Conclusions.  Although the telenurses experienced computerized decision support as both supporting and inhibiting, they preferred working with it. They also described how a computerized decision support system cannot replace telenurses' knowledge and competence, and that it should be considered as complementary.     

A qualitative study of factors influencing antimicrobial prescribing by non-consultant hospital doctors

OBJECTIVES: To determine the factors that influence non-consultant hospital doctors (NCHDs) in their decision to prescribe antimicrobial agents. METHODS: A qualitative study using semi-structured interviews centred on a life grid tracking the medical career of 22 NCHDs employed by a university teaching hospital in the west of Ireland. RESULTS: Early in their careers NCHD prescribing is based primarily on the immediate influence of more senior colleagues. Recollection of formalized undergraduate teaching and hospital guidelines are a very minor influence. As their career progressed and they exercise greater autonomy, personal experience becomes the major influence on prescribing decisions. Hospital guidelines are a minor influence. Participants consider that undergraduate teaching needs to be more practical and taught in a way that is easier to apply to on-ward situations and that hospital prescribing guidelines need to be presented in a 'user-friendly' format and adherence to the guidelines needs to be promoted. CONCLUSIONS: The key influences on antimicrobial prescribing by NCHDs are informal. New approaches are required to ensure that formal training and hospital guidelines on antimicrobial prescribing are more influential in shaping antimicrobial prescribing practice.     

Appropriate prescribing in the elderly: an investigation of two screening tools, Beers criteria considering diagnosis and independent of diagnosis and improved prescribing in the elderly tool to identify inappropriate use of medicines in the elderly in primary care in Ireland

Background:  Elderly patients are particularly vulnerable to inappropriate prescribing, with increased risk of adverse drug reactions and consequently higher rates of morbidity and mortality. A large proportion of inappropriate prescribing is preventable by adherence to prescribing guidelines, suitable monitoring and regular medication review. As a result, screening tools have been developed to help clinicians improve their prescribing.
Objectives:  To compare identification rates of inappropriate prescribing in elderly patients in primary care using two validated screening tools: Beers' criteria and improved prescribing in the elderly tool (IPET); to calculate the net ingredient cost (NIC) per month (€) of the potentially inappropriate medicines in this population of patients.
Method:  A consecutive cohort of 500 patients 65 years of age and over were recruited prospectively from primary care over a 6 month period in a provincial town in Ireland. Patients' medical records (electronic and paper) were screened and all relevant information concerning current illnesses and medications was recorded on a standardized data collection form to which Beers' criteria [considering diagnosis (CD) and independent of diagnosis (ID)] and IPET tools were applied. The NIC was calculated from an edition of the Irish monthly index of medical specialities published concurrently with the data collection.
Results:  Beers' criteria identified a total of 69 medicines that were prescribed inappropriately (eight CD and 61 ID) in 65 patients (13%), costing €824·88 per month while IPET identified 63 potentially inappropriate medicines in 52 (10·4%) patients costing €381·28 per month.
Conclusions:  Potentially inappropriate medications are prescribed in a significant proportion of elderly people in primary care, with significant economic implications.     

Effectiveness of nurse prescribing: a review of the literature

Background. In the UK, the number of nurses able to prescribe medicines is rapidly increasing in line with Government policy directives. Whilst a number of research studies have been conducted on nurse prescribing, review and synthesis of the findings from these studies had not been undertaken. Aims and objectives. The literature review was conducted to identify key findings about the impact and effectiveness of nurse prescribing as well as under‐researched issues, in order to inform future research, education and practice in this area. Methods. A review of the literature on the first phase of nurse prescribing (1993–2002) in the UK was undertaken using electronic databases and specified search terms; some hand searching and identification of grey literature was also carried out. Results. Eighteen research‐based publications were included in the review. Findings indicate that patients are generally satisfied with district nurses’ and health visitors’ prescribing in the first phase of nurse prescribing. Nurses who prescribe are also generally satisfied with their role, although some concerns about the adequacy of their pharmacological knowledge have been raised. There is some variation in the prescribing patterns of district nurses’, health visitors’ and practice nurses, and the limitations of the original Nurse Prescribers’ Formulary (NPF) have been highlighted. Some preconditions for good nurse prescribing practice have begun to be identified. Some nurse prescribing outcomes – e.g. its impact on the prescribing practices of doctors, and the perspectives of certain patient groups – remain un‐evaluated. Research into the first phase of nurse prescribing is inevitably confined to those with a district nurse and/or health visitor qualification who were prescribing from the original NPF, thus limiting conclusions that can be drawn for the current policy context. Conclusions. The review highlights that nurse prescribing has generally been evaluated positively to date; however, there are both methodological weaknesses and under‐researched issues that point to the need for further research into this important policy initiative. Relevance to clinical practice. The review focuses on a clinical issue central to current and future forms of health care practice. Findings from the review highlight both the impact of nurse prescribing and the prerequisites that require consideration by those responsible for the development of nurse prescribing in clinical practice.