"Prescribing for the whole person": A qualitative study exploring prescribing pharmacist views on type 2 diabetes management in New Zealand.

BACKGROUND: Pharmacist prescribers have comprehensive pharmacotherapy knowledge that can be useful for management of complex health conditions such as type 2 diabetes, yet the number of pharmacist prescribers working in New Zealand primary care is low. AIM: To explore the experiences of pharmacist prescribers in supporting type 2 diabetes management in New Zealand primary care. METHODS: Qualitative research design using semi-structured interviews with six pharmacist prescribers working in NZ primary care. Thematic analysis guided this study and themes were finalised with the wider research team. RESULTS: Three major themes were identified: team approach, health inequity and the role of a pharmacist prescriber. This study found that pharmacist prescribers may improve health equity by providing advanced pharmacotherapy knowledge within a wider primary care team to support complex patient needs and understanding the wider social determinants of health that impact effective diabetes management. Participants reportedly had more time to spend with patients (than GPs or nurses) and could also contribute to improving health outcomes by directly educating and empowering patients. CONCLUSION: The views of pharmacist prescribers have seldom been explored and this study suggests that their role may be under-utilised in primary care. In particular, pharmacist prescribers can provide specialist prescribing (and often mobile) care, and may contribute to improving health outcomes and reducing inequity when used as part of a multi-disciplinary team.

Relationship between risk factor profile and prescription of low-dose aspirin for preeclampsia prevention.

OBJECTIVE: The purpose of this study was to assess obstetrician-gynecologist utilization of low-dose aspirin for women at increased risk for hypertensive disorders of pregnancy using guidelines developed by the American College of Obstetricians and Gynecologists and supported by the United States Preventive Services Task Force. Further, the study evaluated prescribing practices in relation to specific risk factor profiles to identify which women are at highest risk of not receiving recommended therapy. METHODS: This was a retrospective cohort study reviewed and approved by the local Institutional Review Board. Electronic health records of women with singleton pregnancies who delivered between February and August 2020 were reviewed to identify risk factors for preeclampsia. Women were eligible for aspirin prophylaxis if they had at least one "high" risk factor or multiple "moderate" risk factors, as defined by the United States Preventive Services Task Force guidelines. Associations of interest were addressed using Pearson Chi-squared tests and multinomial logistic regression. RESULTS: 970 patients were included and 301 pregnant persons (31%) met criteria for low-dose aspirin prophylaxis; of these, 92 (31%) were given this recommendation. Those eligible for prophylaxis by presence of multiple "moderate" risk factors alone are least likely (0-6%) to receive indicated aspirin prophylaxis. CONCLUSIONS FOR PRACTICE: Low-dose aspirin is an underutilized tool for preventing preeclampsia. Women with a combination of "moderate" risk factors are most likely to not receive indicated aspirin prophylaxis. Efforts should be made to encourage broader uptake of the recommendations for aspirin prophylaxis among obstetrician-gynecologists. SIGNIFICANCE: What is already known on this subject? Low-dose aspirin has been shown to reduce preeclampsia risk in pregnant persons. This preventive measure has been recommended by most national and international organizations including the American College of Obstetricians and Gynecologists and the United States Preventive Services Task Force. Yet despite widespread support of this recommendation, uptake is not universal among obstetric care providers. What this study adds? This study identifies those who are most likely to experience a missed opportunity for aspirin prophylaxis, thus providing a suggestion for where provider education or other efforts to increase adherence to this guideline may be most impactful.

Nurse prescribing practices across the globe for medication-assisted treatment of the opioid use disorder (MOUD): a scoping review.

BACKGROUND: Despite the dramatic increase in opioid-related deaths in recent years, global access to treatment remains poor. A major barrier to people accessing Medication-assisted treatment of the opioid use disorder (MOUD) is the lack of providers who can prescribe and monitor MOUD. According to the World Drug Report, more young people are using drugs compared with previous generations and people in need of treatment cannot get it, women most of all. Nurse prescribers have the potential to enhance both access and treatment outcomes. Nurse prescribing practices do, however, vary greatly internationally. The aim of this scoping review is to explore nurse prescribing practices for MOUD globally with a view to informing equitable access and policies for people seeking MOUD. METHODS: This scoping review was informed by the preferred reporting items for systematic reviews and meta-analysis extension for scoping reviews (PRISMA-ScR). Electronic searches from 2010 to date were conducted on the following databases: PsycInfo, PubMed, Embase, and CINAHL. Only studies that met the eligibility criteria and described nurse prescribing policies and/or behaviours for MOUD were included. RESULTS: A total of 22 articles were included in the review which found several barriers and enablers to nurse prescribing of MOUD. Barriers included legislation constraints, lack of professional education and training and the presence of stigmatizing attitudes. Enablers included the presence of existing supportive services, prosocial messaging, and nurse prescriber autonomy. CONCLUSION: The safety and efficacy of nurse prescribing of MOUD is well established, and its expansion can provide a range of advantages to people who are dependent on opiates. This includes increasing access to treatment. Nurse prescribing of MOUD can increase the numbers of people in treatment from 'hard to reach' cohorts such as rural settings, or those with less financial means. It holds significant potential to reduce a wide range of harms and costs associated with high-risk opiate use. To reduce drug-related death and the global burden of harm to individuals, families, and communities, there is an urgent need to address the two key priorities of nurse prescriber legislation and education. Both of which are possible given political and educational commitment.

Characteristics of prescribing activity within primary care in Scotland 2013-2022 of general practitioners, nurse, pharmacist and allied health prescribers: A retrospective cross-sectional study.

BACKGROUND: Independent prescribing by nurses, pharmacists and allied health professionals is diversifying into a variety of healthcare settings as pressures mount on existing resources. Primary care was an early adopter of prescribing by non-medical professionals with resulting improvements in accessibility and flexibility of services but also noted barriers. Exploring existing prescribing activity within primary care can support future initiatives that are cognisant of the needs of this specific population and targeted in the use of finite resources. AIM: To explore the characteristics of prescribing activity of common drugs dispensed by community pharmacies in Scotland by prescribing groups of general practitioners, nurses, pharmacist and allied health professionals. Specifically, to compare overall drug prescribing frequency by prescriber group and identify emergent prescribing patterns of individual drugs. DESIGN: A cross-sectional study. METHODS: The data from Public Health Scotland on frequency of the ten most common drugs prescribed and dispensed from community pharmacies between 2013 and 2022 by prescriber group were examined, applying descriptive statistics using secondary data analysis. RESULTS: Prescribing activity in non-medical prescribing groups accounted for 2%-3% of overall prescribing activity in primary care. There is a growing interprofessional approach to prescribing in chronic disease. Proton pump inhibitors were the most commonly prescribed medication overall with a 4-fold increase in nurse prescribing. The decline in prescribing frequency caused by COVID 19 restrictions has since returned to pre-pandemic levels. CONCLUSION: There is a growing contribution of nurse independent prescriber activity within primary care although still a relatively small proportion compared to medical practitioners. The pattern of increased prescribing of medications for long term and chronic conditions such as proton pump inhibitors by all prescribers is suggestive of multi-disciplinary professionals supporting increased patient demand. This study provides a baseline to evaluate current service provision in further research and enable professional, service and policy development.

Readmissions after appointments with nurse prescribers: A register-based study.

BACKGROUND: Increasing number of nurse prescribers could be part of a solution to the shortage of physicians, improve access to treatment and curb the rise in healthcare costs; however, readmissions after nurse prescribers' appointments are under-researched. AIMS: To describe and compare clients' initial appointments with nurse prescribers and physicians. In addition, client readmissions within 60 days in the target organisation after nurse prescribers' and physicians' appointments were investigated. DESIGN: Retrospective register-based follow-up study. METHODS: Data included client appointments (n = 3986) with nurse prescribers and physicians, and clients' readmissions (n = 9038) from 1 January 2018 to 31 December 2019 from one hospital district in Finland. Data were analysed statistically using frequencies, percentages, rate ratios and cross-tabulation. STROBE checklist was used. RESULTS: Initial appointments including trimethoprim, pivmecillinam, phenoxymethyl penicillin, chloramphenicol, fusidic acid and cephalexin prescriptions with nurse prescribers (n = 36) were 2131, and physicians (n = 140) 1855. On average, client readmissions (within 60 days) per initial appointment were 2.10 after appointments with nurse prescribers and 2.46 after physicians. After initial appointments, including phenoxymethyl penicillin prescriptions, with nurse prescribers, clients had more readmissions in all age groups than after initial appointments with physicians. However, in all, after initial appointments with physicians, clients had a higher proportion of readmissions. CONCLUSION: Clients have fewer readmissions after appointments with nurse prescribers than physicians, including the same prescriptions. Nurse prescribers' skills may not have been fully utilised. Physicians treated many patients whose diseases nurse prescribers might have been able to treat based on the nurse prescribers' rights. However, physician clients may have more demanding service requirements.

Non-medical prescribing in nursing: the history and evolution of independent and supplementary prescribing.

Non-medical prescribing has been shown to be beneficial to both service users and practitioners spanning all care sectors. Nurse prescribing has developed significantly in its short existence, and is set to continue to push the boundaries of practice as the role and education of nurses changes and adapts to current population healthcare needs. This article details the origins and evolution of non-medical prescribing, the variety of annotations found on the Nursing and Midwifery Council (NMC) register involved and how these affect nursing practice, as well as the expansion of roles. It also discusses supervision and assessment requirements in line with the NMC standards for prescribing programmes, and the Royal Pharmaceutical Society competence framework.

Who prescribes quetiapine in Denmark?

The second-generation antipsychotic quetiapine is commonly used off-label for its anxiolytic and hypnotic properties. However, quetiapine is associated with problematic side-effects. We used Danish Medicinal Product Statistics and a 20% random sample of the Danish population's prescription fills (2001-2020) to describe the utilization of quetiapine and proportion of various prescriber types (general practitioner [GP], specialist in private practice, hospital physician and other prescribers) both in connection to first-time and subsequent prescriptions. In 2020, 92% of all quetiapine was dispensed outside hospitals and the average daily dispensed quantity of quetiapine per user corresponded to 100 mg/user/d. A GP issued 53% of first-time prescriptions and 75% of subsequent prescriptions for quetiapine in 2020. The proportion of quetiapine prescriptions issued by GPs varied by age group-from 14% among 0-17-year-olds to 93% among the ≥80-year-olds. Future initiatives on the rational use of quetiapine and related drugs, especially among adults, should target GPs.

Regulatory authority and clinical acceptability: Physicians' responses to regulatory drug safety warnings.

AIMS: Medicines regulators issue post-market safety warnings to advise of newly uncovered risks, but with mixed impacts. We aimed to identify factors influencing the use of regulatory warnings by primary care and specialist physicians in the US and Australia. METHODS: Semi-structured qualitative interviews were carried out with 40 primary care physicians, endocrinologists and other generalist specialists in Boston (USA) and Australia. Coding and analysis were performed inductively and iteratively to identify and examine key factors. Analysis centred around four areas: physicians' awareness of drug safety information, preferred information sources, opinion-forming and sharing of information with patients. RESULTS: Uncertainty, trust and clinical authority emerged as factors influencing use of advisories. Although regulators were trusted as authoritative institutions, they appeared to lack clinical authority, and physicians validated regulatory information against other trusted sources including evidence, expert opinion and experience. Specialists became aware of drug safety issues through specialised literature, using evidence and clinical consensus to form opinions. Primary care physicians, fielding high volumes of information, relied on convenient, accessible information sources including the media and the "clinical grapevine" for awareness, and on clinical colleagues, specialists and experience for interpretation. Communicating risk to patients was complicated by uncertainty; physicians tailored information to patients' health literacy and information needs. US physicians were more aware of their national regulator's post-market safety role than Australian physicians of theirs. CONCLUSION: Drug safety warnings may not be optimally received or used. Regulators should consider strategies that increase trust, clinical relevance and accessibility, and address physicians' needs in communicating risk to patients.

The influence of prescriber and patient gender on the prescription of benzodiazepines: results from the Florida Medicaid Dataset.

BACKGROUND: Benzodiazepine (BZD) prescription rates have increased over the past decade in the United States. Available literature indicates that sociodemographic factors may influence diagnostic patterns and/or prescription behaviour. Herein, the aim of this study is to determine whether the gender of the prescriber and/or patient influences BZD prescription. METHODS: Cross-sectional study using data from the Florida Medicaid Managed Medical Assistance Program from January 1, 2018 to December 31, 2018. Eligible recipients ages 18 to 64, inclusive, enrolled in the Florida Medicaid plan for at least 1 day, and were dually eligible. Recipients either had a serious mental illness (SMI), or non-SMI and anxiety. RESULTS: Total 125 463 cases were identified (i.e., received BZD or non-BZD prescription). Main effect of patient and prescriber gender was significant F(1, 125 459) = 0.105, P = 0 .745, partial η2 < 0.001. Relative risk (RR) of male prescribers prescribing a BZD compared to female prescribers was 1.540, 95% confidence intervals (CI) [1.513, 1.567], whereas the RR of male patients being prescribed a BZD compared to female patients was 1.16, 95% CI [1.14, 1.18]. Main effects of patient and prescriber gender were statistically significant F(1, 125 459) = 188.232, P < 0.001, partial η2 = 0.001 and F(1, 125 459) = 349.704, P < 0.001, partial η2 = 0.013, respectively. CONCLUSIONS: Male prescribers are more likely to prescribe BZDs, and male patients are more likely to receive BZDs. Further studies are required to characterize factors that influence this gender-by-gender interaction.

Understanding State-Level Variations in Implementing Academic Detailing for Prescribing Opioids: Findings from 11 States Within the United States.

OBJECTIVE: Academic detailing is a clinical education technique characterized by targeted, one-on-one, interactive conversations between trained staff and the clinician. This study describes variations in implementing academic detailing among jurisdictions receiving funding from the U.S. Centers for Disease Control and Prevention (CDC) to prevent prescription drug overdoses. DESIGN: In 2015, CDC started the Prescription Drug Overdose Prevention for States (PfS) program. SUBJECTS: This study focuses on 11 of the 29 funded jurisdictions that implemented academic detailing as part of their PfS efforts. METHODS: Jurisdictions provided annual progress reports from 2016 to 2019. We conducted semistructured interviews in 2017 and 2018 with all funded jurisdictions and conducted follow-up interviews with three jurisdictions in 2020 to obtain additional context. We used an analytic matrix display to identify themes from annual progress report data, the coding report from the 2017/2018 interviews, and the three follow-up interviews from 2020. RESULTS: Two academic detailing models emerged: 1) one-on-one detailing, where centrally trained staff conducted all visits, and 2) a train-the-trainer model. Jurisdictions also described a hybrid model, which they referred to as academic detailing despite not meeting the definition of academic detailing. We identified variations in delivery strategies, staffing, and curriculum development within and between models. Despite these differences, common themes included the need to use data to focus academic detailing and the importance of partnerships. CONCLUSIONS: Adoption of academic detailing as a strategy for improving opioid prescribing behaviors has increased. However, there is limited guidance and standardization to guide and evaluate implementation and outcomes.

What patient assessment skills do pharmacist independent prescribers require to prescribe immunomodulators in myeloma?

AIM: To gain consensus on the patient assessment skills required by pharmacist independent prescribers prescribing immunomodulators in myeloma across National Health Service Scotland. METHODS: This was a two-phase study which used nominal group technique to gain local consensus followed by a two-round eDelphi questionnaire to gain national consensus across all cancer networks. SETTING: This project was conducted across the three cancer networks within NHS Scotland: South East Scotland Cancer Network; West of Scotland Cancer Network and North Cancer Alliance. SUBJECTS: Participants were invited from each cancer network (South East Scotland Cancer Network, West of Scotland Cancer Network and North Cancer Alliance) and included haematology consultants, haematology specialist registrars, haematology advanced nurse practitioners and haematology pharmacists. RESULTS: There were five participants in the nominal group technique. Twenty-two out of 31 patient assessment skills gained local consensus, seven patient assessment skills did not gain consensus and two patient assessment skills were deemed irrelevant. There were 12 and 14 participants in round one and two of the eDelphi questionnaire, respectively. Twenty-nine patient assessment skills were included in the first-round questionnaire and 21 gained consensus. The remaining eight patient assessment skills were included in round two where seven did not achieve consensus and one achieved disagreement consensus. CONCLUSION: This research outlines 21 patient assessment skills required for pharmacist independent prescribers to prescribe immunomodulators for myeloma patients according to haematology specialists in Scotland. Discussion on patient assessment skills without consensus showed that the pharmacist independent prescribers would have a shared responsibility with the consultant. This work should inform the development of a competency framework to allow training of pharmacist independent prescribers in Scotland. Some patient assessment skills could be transferrable for pharmacist independent prescribers prescribing systemic anti-cancer therapy for other haematological malignancies.

A Comparison of Attitudes, Comfort, and Knowledge of Clozapine Among Two Diverse Samples of US Psychiatrists.

Considerable variation in clozapine utilization exists across the United States, and little is known about the perspective of psychiatrists in states with low clozapine use. To better understand clozapine practices, attitudes, and barriers, a survey was administered to a group of southeastern state conference attendees (SSCA; N = 86). The same survey was administered to psychiatrists belonging to a national community psychiatry organization (AACP; N = 57), and differences were analyzed across the two samples. In comparison to the AACP, the SSCA group felt less comfortable, perceived clozapine as less safe and effective, had fewer patients on clozapine, and were more likely to prefer antipsychotic polypharmacy to clozapine use. Across the sample, use of a myocarditis screening protocol was rare (N = 14/76; 18%) and less than half used plasma antipsychotic levels to guide dosage (N = 60/129; 47%). Continuing professional education on clozapine are needed for psychiatrists who see individuals with psychotic disorders.

'She taught me': factors consumers find important in nurse practitioner and pharmacist prescriber services.

BACKGROUND: Advanced practitioner services, such as those nurse practitioners and pharmacist prescribers provide, are an opportunity to improve health care delivery. In New Zealand, these practitioners remain underutilised, despite research suggesting they offer safe and effective care, and considerable international literature recording patient satisfaction with these roles. This study aimed to explore factors underlying consumer satisfaction with primary health care nurse practitioner and pharmacist prescriber services. METHODS: As part of a larger realist evaluation, 21 individuals receiving advanced practitioner services participated in semi-structured interviews. These interviews were transcribed and coded against context-mechanism-outcome configurations tested and refined throughout the research. RESULTS: Study findings emphasise the importance of consumer confidence in the provider as a mechanism for establishing advanced practitioner roles. Underlying this confidence is a recognition that these practitioners work in a more accessible manner, engage at the individual's 'level', and operate with passion. CONCLUSIONS: This research offers learnings to re-engineer service delivery within primary health care to make best use of the entire health care team by including consumers in the design and introduction of new roles.

Perceptions of underlying practice hierarchies: Who is managing my care?

BACKGROUND: The introduction of new health professional roles, such as that of the nurse practitioner and pharmacist prescriber in primary health care can lead to changes in health service delivery. Consumers, having used these roles, often report high satisfaction. However, there is limited knowledge of how these individuals position nurse practitioner and pharmacist prescriber roles within existing practice structures. METHODS: Semi-structured interviews were conducted with 21 individuals receiving services from these practitioners in New Zealand primary health care. Interviews were recorded and transcribed verbatim for thematic analysis. RESULTS: Participant views reflect established practice hierarchies, placing advanced practitioners 'below' general practitioners. Participants are unable to articulate what it was about these practitioners that meant they operated at lower tiers and often considered practitioners to act as 'their doctor'. They also highlight structural barriers impairing the ability of these providers to operate within their full scope of practice. CONCLUSIONS: While seeing value in the services they receive, consumers are often unable to position nurse practitioner and pharmacist prescriber roles within health system contexts or to articulate how they value their practitioner's skills. Embedded structural barriers may be more visible to consumers than their interactions with the health system suggest. This may influence peoples' ability to receive intended or optimal health services. Consumer 'health professional literacy' around the functions of distinct health practitioners should be supported so that they may make informed service provision choices.

Changes in the management of urinary tract infections in women: impact of the new recommendations on antibiotic prescribing behavior in France, between 2014 and 2019.

BACKGROUND: Urinary tract infections (UTIs) are among the most common infections that require antibiotic therapy. In December 2015, new guidelines for UTI management were published in France with the aim of reducing antibiotic misuse and the risk of antimicrobial resistance. OBJECTIVES: To analyze changes in antibiotic prescribing behavior for acute uncomplicated UTI in women in France from 2014 to 2019. METHODS: Retrospective study using data extracted from the medico-administrative database 'OpenMedic' that is linked to the French National Health Data System and collects data on the reimbursement of prescribed drugs. The analyses focused on the number of boxes of antibiotics delivered by community pharmacies, the molecule class, and the prescriber's specialty. RESULTS: Overall, antibiotic dispensing by community pharmacies increased by 2% between 2014 and 2019, but with differences in function of the antibiotic class. The use of antibiotics recommended as first-line and second-line treatment increased (+ 41% for fosfomycin and + 7430% for pivmecillinam). Conversely, the dispensing of lomefloxacin and norfloxacin decreased by 80%, and that of ciprofloxacin by 26%. Some antibiotics were mostly prescribed by general practitioners (lomefloxacin, pivmecillinam) and others by secondary care physicians (ofloxacin). Dispensing increased for antibiotics prescribed by secondary care physicians (+ 13% between 2014 and 2019) and decreased for antibiotics prescribed by GPs (- 2% for the same period). CONCLUSION: These data suggest that the new recommendations are followed, as indicated by the increased prescription of fosfomycin and pivmecillinam and decreased prescription of fluoroquinolones. However, the efficient transmission and implementation of new recommendations by practitioners requires time, means and dedicated tools.

Opioid days' supply limits: an interrupted time-series analysis of opioid prescribing before and following a Massachusetts law.

Background: In 2016, Massachusetts passed the first-in-the-nation law limiting opioid naïve adults and all minors to a 7-day supply of opioids when prescribed in the outpatient setting.Objective: We hypothesized this policy would be associated with declines in the percent of opioid prescriptions with more than a 7-day supply among opioid naïve adults and minors for select prescriber groups.Methods: Interrupted time series analyses were conducted using measures from the Massachusetts Prescription Monitoring Program database for 2015 through 2017 (n = 13,672,325 opioid prescriptions; 54% to females). Outcomes were the monthly percent of opioid prescriptions greater than 7 days' supply in opioid naïve adults and in minors among select prescriber groups. Model estimates of the pre-policy trend, the average changes in the level pre/post-implementation, and the trend changes post-implementation were assessed.Results: Pre-policy trends showed significant monthly declines in the percent of opioid prescriptions greater than 7 days' supply for all prescriber groups. Policy implementation was associated with significant reduction in the level for opioid naïve adults among surgeons (-2.92%, p < .01), dentists (-0.23%, p < .01), and general medical providers (-2.22%, p = .04), and for minors among all-included prescribers (-2.97%, p < .01) and surgeons (-3.8%, p < .01). Post-implementation changes in trends were not significant except among opioid naïve adults for dentists (0.02%, p = .04).Conclusion: Within a context of significant reductions occurring in opioid prescriptions greater than 7 days' supply during this period, the Massachusetts policy was associated with further declines for opioid naïve adults and minors among select prescriber groups.

Pharmacy practice in hospital settings in GCC countries: Prescribing and transcribing.

PURPOSE: To outline hospital pharmacy practices across the Gulf Cooperation Councils (GCC) countries' hospitals. METHODS: A modified survey questionnaire was prepared from the original 2019 American Society of Health-System Pharmacist (ASHP) survey questions. Survey details were discussed with some pharmacy directors for clarity and relevance. A list of hospitals were obtained from the Ministry of Health of each of the targeted GCC countries. A secure invitation link containing a survey questionnaire was sent to the participants directly. RESULTS: Sixty four hospitals responded to this survey. The overall response rate was 52%. About 47% of the surveyed hospitals considered their drug formularies as closed, and strict. Additionally, only 44% of hospitals compare the effectiveness of products, when taking formulary decisions for drug inclusion. Forty-four percent of hospitals have computerized prescriber order entry (CPOE / EHR) system functionality for formulary system management. At about 39.1% hospitals, pharmacists have the responsibility for managing medication therapies, majority were engaged in providing anticoagulation therapies. About 61% of hospital pharmacies in GCC countries receive medication orders electronically, through CPOE/EHR. Majority (66%) of the hospitals in GCC countries have an active Antimicrobial Stewardship Program (ASP) while only 40% of pharmacists have a key role in providing clinical support. About 57.8% of hospital pharmacy directors reported that pharmacists do not provide ambulatory care clinical pharmacy services in their hospitals. CONCLUSION: In GCC countries' hospitals, there are major areas for improvement to patient care of which pharmacists are uniquely qualified as the medication experts to have the most meaningful outcomes in all of the domains of safe medication use, medication therapy management, antimicrobial stewardship program and participation in outpatient clinics.

Associations Between the Specialty of Opioid Prescribers and Opioid Addiction, Misuse, and Overdose Outcomes.

OBJECTIVE: To examine associations between opioid prescriber specialty and patient likelihood of opioid use disorder (OUD), opioid misuse, and opioid overdose. DESIGN: Longitudinal retrospective study using Pennsylvania Medicaid data (2007-2015). METHODS: We constructed an incident cohort of 432,110 enrollees initiating prescription opioid use without a history of OUD or overdose six months before opioid initiation. We attributed patients to one of 10 specialties using the first opioid prescriber's specialty or, alternatively, the specialty of the dominant prescriber writing the majority of the patient's opioid prescriptions. We estimated adjusted rates for OUD, misuse, and overdose, adjusting for demographic variables and medical (including pain) and psychiatric comorbidities. RESULTS: The unadjusted incidence rates of OUD, misuse, and overdose were 7.13, 4.73, and 0.69 per 100,000 person-days, respectively. Patients initiating a new episode of opioid treatment with Pain Medicine/Anesthesiology (6.7 events, 95% confidence interval [CI] = 5.5 to 8.2) or Physical Medicine and Rehabilitation (PM&R; 6.1 events, 95% CI = 5.1 to 7.2) had higher adjusted rates for OUD per 100,000 person-days compared with Primary Care practitioners (PCPs; 4.4 events, 95% CI = 4.1 to 4.7). Patients with index prescriptions from Pain Medicine/Anesthesiology (15.9 events, 95% CI = 13.2 to 19.3) or PM&R (15.8 events, 95% CI = 13.5 to 18.4) had higher adjusted rates for misuse per 100,000 person-days compared with PCPs (9.6 events, 95% CI = 8.8 to 10.6). Findings were largely similar when patients were attributed to specialty based on dominant prescriber. CONCLUSIONS: Differences in opioid-related risks by specialty of opioid prescriber may arise from differences in patient risk factors, provider behavior, or both. Our findings inform targeting of opioid risk mitigation strategies to specific practitioner specialties.

Communication Experiences of DATA-Waivered Physicians with Community Pharmacists: A Qualitative Study.

Background: Patients engaged in evidence-based opioid use disorder (OUD) treatment can obtain prescriptions for buprenorphine containing products from specially trained physicians that are subsequently dispensed by community pharmacists. Despite the involvement of physicians and community pharmacists in buprenorphine prescribing and dispensing, respectively, our understanding of their interactions in this context is limited. Objective: To qualitatively describe the communication and collaborative experiences between Drug Addiction Treatment Act 2000 (DATA)-waivered physicians and community pharmacists from the perspective of the physician. Methods: Ten key informant interviews were conducted with DATA-waivered physicians practicing in Northeast Tennessee. A semi-structured interview guide was used to explore communication and collaborative experiences between the physicians and community pharmacists. Interviews were audio recorded and transcribed verbatim. A coding frame was developed using concepts from the scientific literature and emerging codes from physician interviews. Interviews were coded using NVivo 11, with the data subsequently organized and evaluated for themes. Results: Four themes were identified: (1) mechanics of communication; (2) role specification and expectations; (3) education and understanding; and (4) climate of clinical practice. Physician-pharmacist communication primarily occurred indirectly through patients or staff and perceived challenges to collaboration included; lack of trust, stigma, and fear of regulatory oversight. Physicians also indicated the two professionals may lack clear roles and responsibilities as well as common expectations for treatment plans. Conclusions: Communication between DATA-waivered physicians and community pharmacists is influenced by multiple factors. Further research is warranted to improve physician-community pharmacist collaboration (PCPC) in the context of OUD pharmacotherapy and addiction treatment.

A nurse prescriber-led protocol for anaemia management in established haemodialysis patients: A retrospective study.

AIM AND OBJECTIVE: To evaluate the impact of a nurse prescriber-led protocol compared to a traditional physician-led nonprotocol-based approach had on maintaining targeted haemoglobin levels in patients on maintenance haemodialysis. BACKGROUND: Anaemia is a common complication of chronic kidney disease and has a profound impact on the patients' well-being. Current practices place a greater emphasis on the decision-making role of nurses in renal anaemia management. The introduction of nurse prescribing in this area is a relatively new concept. DESIGN: A retrospective cohort design, covering an eight-month period pre- and post introduction of a nurse prescriber-led anaemia protocol; study adheres to the STROBE Statement. METHODS: Using a nonprobability convenience sample, data extracted from the medical records and electronic patient records system (eMed) related to 74 patients at a single outpatient haemodialysis centre located within an acute general teaching hospital. The primary outcome was patients' haemoglobin level pre- and post introduction of the protocol. Secondary outcomes included erythropoietin-stimulating agent and iron dosage, and serum ferritin and transferrin saturation levels. RESULTS: There were no statistically significant differences between pre- and post protocol serum haemoglobin level and erythropoietin-stimulating agent dosage. Under the management of the nurse prescriber, patients experienced a significant improvement in serum ferritin and transferrin saturation levels and required significantly less intravenous iron dosage. CONCLUSIONS: This study, the first of its kind, found that patients receiving haemodialysis experience a significant improvement in iron indices while receiving a significantly lower amount of intravenous iron when managed by a nurse prescriber. Furthermore, the nurse prescribers' decision-making capacity is as effective as a physician-led nonprotocol-based approach in achieving haemoglobin target levels. RELEVANCE TO CLINICAL PRACTICE: Nurse prescribers have a role in implementing a safe, standardised and sustained approach to anaemia management in outpatient haemodialysis settings without compromising patient care.