Considering formulation characteristics when prescribing and dispensing medicinal products for children: a qualitative study among GPs and pharmacists.

BACKGROUND: Finding appropriate medicinal product formulations and dosage forms for children can be challenging. Knowledge about considerations behind which medicinal product to prescribe or dispense for children is lacking. OBJECTIVE: To explore considerations of formulation characteristics of medicinal products made by GPs when prescribing and by pharmacists when dispensing medicines for children 0-6 years of age. METHOD: A qualitative study was performed by conducting three semi-structured focus groups with GPs and three with pharmacists, using nearly identical thematic interview guides. Analysis was performed using systematic text condensation. RESULTS: Both GPs and pharmacists considered whether children and parents were willing and able to use medicinal products such as tablets and poor-tasting liquids before prescribing and dispensing them. These considerations were commonly based on health care workers' prior experiences, although parents and sometimes children were asked about their experiences with solid formulations. For antibiotics, GPs primarily wanted to prescribe first-choice antibiotics according to guidelines. Parents' concerns about getting the child to take the medicinal product due to poor taste could lead to the prescription of second-choice antibiotics. The pharmacists sometimes changed the prescribed formulation at parents' request but never changed the type of antibiotic without contacting the prescriber. CONCLUSION: Formulation characteristics strongly influenced which medicinal product children were prescribed and dispensed. Individualizing formulation choices for children through an increased collaboration between physicians, pharmacists and parents is suggested.

Register-based study showed that the age when children were prescribed antibiotic tablets and capsules instead of liquids increased from 2004 to 2016.

AIM: We investigated the age when the prescriptions of oral antibiotic formulations for children from birth to 12 years of age changed from being mostly liquid to mostly solid and the associations between solid formulations and child, prescriber and medication characteristics. METHODS: This register-based study comprised data from the Norwegian Prescription Database on oral antibiotics dispensed between 2004 and 2016 when both solid and liquid dosage forms were available in appropriate doses. RESULTS: Just over 1.2 million prescriptions were studied, and the age when children were prescribed oral solid antibiotics gradually increased. The mean age of conversion from liquids to solid formulations was 6.9 years and ranged from 5.7 years in 2004/2005 to 7.9 years in 2015/2016. Patient factors associated with solid dosage forms were the children's increasing age and male gender. Practitioner factors were the prescribers' increasing age, male gender, being a general practitioner and issuing fewer than 23 paediatric antibiotic prescriptions per year. Medication factors were bad-tasting liquids and the size and shape of solid dosage forms. CONCLUSION: The age when children were prescribed antibiotic tablets and capsules increased from 2004 to 2016. The medicine characteristics were quite consistent, so this was probably caused by a shift in formulation preferences.

Requests for new oral antibiotic prescriptions in children within 2 days: a Norwegian population-based study.

Background: Children commonly refuse to take antibiotics, which may induce parents to request new antibiotic prescriptions with different pharmaceutical characteristics. Objectives: To investigate prescription changes for children 0-12 years receiving oral liquid or solid antibiotic formulations and to explore the relationships between prescription changes and characteristics related to the child, prescriber and antibiotic. Methods: A population-based registry study based on data from the Norwegian Prescription Database (NorPD) from 2004 to 2016. Antibiotic prescription changes were defined as the dispensing of subsequent antibiotics with different pharmaceutical characteristics to the same child within 2 days after initial prescriptions. Data were analysed using multivariable logistic regression and generalized estimating equations. Results: Requests for new prescriptions followed 3.0% of 2 691 483 initial antibiotic prescriptions for children. Young children who received solid formulations (10.9%) and certain poor-tasting antibiotics (8.6%) had the highest proportions of new prescriptions. Penicillin V was most commonly changed, while macrolides/lincosamides dominated subsequent prescriptions. In order of magnitude, the characteristics associated with requests for new prescriptions were the children's ages, poor taste and concentration of liquids, size and shape of solids, prescribers born in recent decades, and girl patients. Reimbursed prescriptions and scored solids were associated with fewer requests. Conclusions: While only 3% of the antibiotic prescriptions were changed, the preference of broad-spectrum over narrow-spectrum antibiotics for young children in this study mirrors international prescription patterns. Avoiding the costs of children's refusal and consequent changes may thus be a motivation for choosing more preferred antibiotics.

Nurses' and pharmacists' learning experiences from participating in interprofessional medication reviews for elderly in primary health care - a qualitative study.

BACKGROUND: Traditionally, drug prescription and follow up have been the sole responsibility of physicians. However, interprofessional medication reviews (IMRs) have been developed to prevent drug discrepancies and patient harm especially for elderly patients with polypharmacy and multimorbidity. What participating nurses and pharmacists learn from each other during IMR is poorly studied. The aim of this study was to investigate nurses' and pharmacists' perceived learning experience after participating in IMRs in primary health care for up to two years. METHODS: A qualitative study with semi-structured focus group interviews and telephone interviews with nurses and pharmacists with experience from IMRs in nursing homes and home based services. The data was analysed thematically by using systematic text condensation. RESULTS: Thirteen nurses and four pharmacists were interviewed. They described some challenges concerning how to ensure participation of all three professions and how to get thorough information about the patient. As expected, both professions talked of an increased awareness with time of the benefit of working as a team and the perception of contributing to better and more individual care. The nurses' perception of the pharmacist changed from being a controller of drug management routines towards being a source of pharmacotherapy knowledge and a discussant partner of appropriate drug therapy in the elderly. The pharmacists became more aware of the nurses' crucial role of providing clinical information about the patient to enable individual advice. Increasingly the nurses learned to link the patient's symptoms of effect and side effect to the drugs prescribed. CONCLUSIONS: Although experiencing challenges in conducting IMRs, the nurses and pharmacists had learning experiences they said improved both their own practice and the quality of drug management. There are some challenges concerning how to ensure participation of all three professions and how to get thorough information about the patient.

Twelve months effect of self-referral to inpatient treatment on patient activation, recovery, symptoms and functioning: A randomized controlled study.

OBJECTIVE: To investigate the effect of having a contract for self-referral to inpatient treatment (SRIT) in patients with severe mental disorders. METHODS: A randomized controlled trial with 53 adult patients; 26 participants received a SRIT contract, which they could use to refer themselves into a Community Mental Health Centre up to five days for each referral without contacting a doctor in advance. Outcomes were assessed after 12 months with the self-report questionnaires Patient Activation Measure (PAM-13), Recovery Assessment Scale (RAS), and the Behavior and Symptom Identification Scale (BASIS-32) and analyzed using linear mixed and regression models. RESULTS: There was no significant effect on PAM-13 (estimated mean difference (emd) -0.41, 95% CI (CI):-7.49-6.67), nor on the RAS (emd 0.02, CI:-0.27-0.31) or BASIS-32 (0.09, CI:-0.28-0.45). An exploratory post hoc analysis showed effect of SRIT in those with low PAM below ≤47 (p=0.049). CONCLUSION: There were no group differences after 12 months, but both groups maintained their baseline levels. PRACTICE IMPLICATIONS: SRIT contracts can be recommended as it supports the rights to self-determination, promote user participation in decision-making in own treatment without any indication of adverse effects.

Short-term effects of a peer co-led educational programme delivered before mental health treatment: A randomised controlled trial.

OBJECTIVE: To investigate the 1-month effects of an educational programme co-led by peers delivered before treatment on treatment preferences, self-management knowledge and motivation in comparison to usual care. METHODS: Adults referred to a community mental health centre were randomised to either a control group (n=48) or a peer co-led educational programme (intervention group, n=45). The programme consisted of an 8-hour group education session followed by an individual pretreatment planning session. The main topics of the educational programme were treatment options, patients' rights, self-management, the importance of patient activation and participation. RESULTS: At 1-month follow-up, a significantly larger proportion of the patients in the intervention group knew which type of treatment they preferred (76.7% vs. 32.5%, p<0.001). The intervention group had significantly higher self-management knowledge (p<0.001). There was no effect on treatment motivation (p=0.543). CONCLUSION: At 1-month following the delivery of a pretreatment educational programme, we found that participants' knowledge of treatment preferences and self-management had improved. PRACTICE IMPLICATIONS: Educational interventions co-led by peers can optimise the process of informing and educating outpatients, thereby helping patients to clarify their treatment preferences.

How do we deal with multiple goals for care within an individual patient trajectory? A document content analysis of health service research papers on goals for care.

OBJECTIVES: Patients with complex long-term needs experience multiple parallel care processes, which may have conflicting or competing goals, within their individual patient trajectory (iPT). The alignment of multiple goals is often implicit or non-existent, and has received little attention in the literature. RESEARCH QUESTIONS: (1) What goals for care relevant for the iPT can be identified from the literature? (2) What goal typology can be proposed based on goal characteristics? (3) How can professionals negotiate a consistent set of goals for the iPT? DESIGN: Document content analysis of health service research papers, on the topic of 'goals for care'. SETTING: With the increasing prevalence of multimorbidity, guidance regarding the identification and alignment of goals for care across organisations and disciplines is urgently needed. PARTICIPANTS: 70 papers that describe 'goals for care', 'health' or 'the good healthcare process' relevant to a general iPT, identified in a step-wise structured search of MEDLINE, Web of Science and Google Scholar. RESULTS: We developed a goal typology with four categories. Three categories are professionally defined: (1) Functional, (2) Biological/Disease and (3) Adaptive goals. The fourth category is the patient's personally defined goals. Professional and personal goals may conflict, in which case goal prioritisation by creation of a goal hierarchy can be useful. We argue that the patient has the moral and legal right to determine the goals at the top of such a goal hierarchy. Professionals can then translate personal goals into realistic professional goals such as standardised health outcomes linked to evidence-based guidelines. Thereby, when goals are aligned with one another, the iPT will be truly patient centred, while care follows professional guidelines. CONCLUSIONS: Personal goals direct professional goals and define the success criteria of the iPT. However, making personal goals count requires brave and wide-sweeping attitudinal, organisational and regulatory transformation of care delivery.

Complementary and alternative medicine practitioner consultations among those who have or have had cancer in a Norwegian total population (Nord-Trøndelag Health Study): prevalence, socio-demographics and health perceptions.

The aim of the study was to identify the use of complementary and alternative medicine (CAM) practitioners among current and previous cancer patients in a total population. A secondary analysis of data from the Nord-Trøndelag Health Study (otherwise known as the HUNT 2 Study) - a total population survey conducted in central Norway - was undertaken. Analysis focused upon the response of 1406 individuals who reported to have or have had cancer and who answered a question on visits to CAM practitioners. The study identified 16.1% of respondents had visited a CAM practitioner in the prior 12 months compared with 12.8% in the total population, and the likelihood of consulting a CAM practitioner was significantly increased among those who had a university degree, who reported a lower perceived global health and who had experienced a health complaint during the last 12 months. Complementary and alternative medicine practitioner consultations among individuals with a previous or current malignant disease were highest for those with poor self-reported health status and with a recent health complaint. From the socio-demographic variables studied only the reporting of a university degree was significantly associated with higher CAM practitioner use.

Three-year follow-up after a two-year comprehensive pulmonary rehabilitation program.

The main objective of this study is to investigate the long-term effects, 3 years after the end of a 2-year pulmonary rehabilitation program with three weekly 1-h exercise sessions and 32 h of education in patients with chronic obstructive pulmonary disease. The method consists of open prospective observational study with 30 patients. Outcome measures were quality of life (QoL) (St George's Respiratory Questionnaire, SGRQ), physical exercise performance (6-min walking test, 6MWT), self-management abilities, lung function, hospitalization, and self-reported exercise. FEV(1) at baseline was 40.1% of predicted. The participants had statistical and clinical significant decrease in SGRQ (improved QoL) and increase in 6MWT during the program. They maintained the level of health they achieved during the program in the next 3 years, with a stable SGRQ score (-0.5 points, 95% CI -3.8 to 2.6 P=1.000) and 6MWT (+10 m 95% CI 28 to -4, P=0.273). Eighty percent of the participants had exercised at least 30 min three times a week from the end of the program to year 5. In conclusion, the participants had maintained their achieved level of health, improved their lung function slightly, and continued to exercise regularly 3 years after the end of the program.

Characteristics of visitors to homeopaths in a total adult population study in Norway (HUNT 2).

OBJECTIVES: To study the characteristics of people visiting homeopaths in a total adult population in Norway. METHODS: Data from a total population cross sectional health survey conducted in 1995-1997 in Central Norway (HUNT 2) with 65,495 participants. Variables included in the analysis were age, marital status, education, being a social welfare recipient, lifestyle (daily smoker), Hospital Anxiety and Depression Scale (HADS-T), global health perception, self-reported health complaints and a variety of diseases. Significance level p<0.01. RESULTS: 40,027 persons over 20 years answered the question on visits to a homeopath. 4.3% had consulted a homeopath during the last 12 months. The likelihood of a person consulting a homeopath was most strongly associated with being female (adjusted odds ratio 2.3, 95% confidence interval 2.1-2.6) and having a lower perceived global health (increasing from 1.5, 1.2-1.8 for good global health to 2.9, 1.9-4.3 for poor global health). There was a weaker but significant association between increased likelihood of visiting a homeopath and being 30-39 years (1.3, 1.1-1.4), having a HADS-T score between 10-14 (1.3, 1.1-1.6) and 15-19 (1.6, 1.3-2.0), having a health complaint the last year (1.5, 1.2-1.7), hay fever (1.7, 1.5-2.0), consulted for a psychiatric complaint (1.5, 1.3-1.8) and another chronic disease than the ones asked about in this study (1.3, 1.1-1.6). Being a smoker was significantly associated with decreased likelihood of consulting a homeopath (0.7, 0.6-0.7). There was also a trend for increased likelihood of visits to homeopaths (p<0.1) for those 60 years and over, social welfare recipients, having a chronic complaint and HADS-T score of 20 or higher, and decreased likelihood for widow(er)s. CONCLUSIONS AND PROPOSALS: Being female and having a lower perceived global health were the variables most strongly associated with visits to a homeopath. More studies on visits to homeopaths from other populations (countries, children and adolescent) are needed.

Changes in patients visiting a homeopathic clinic in Norway from 1994 to 2004.

AIM: There are a few examining changes in patient groups seeking homeopathic care. This study describes changes in complaints and characteristics of patients visiting a homeopathic clinic in Norway from 1994/1995 to 2003/2004. METHODS: Two surveys were conducted, each including data for 700 patients who had visited the same homeopathic clinic, with five (1995) and seven (2004) homeopaths, respectively. Data on patients' gender, age, occupation, reason for encounter and where they had heard about homeopathy and the homeopathic clinic were registered by the homeopaths. In 2004, the patients also answered questions on the previous use of conventional treatment and how long it took them to decide to consult a homeopath. RESULTS: There are no changes in the reason for encounter and gender proportions between 1995 and 2004. Over 36% of patients were under the age of 16 in 2004, compared to 26% in 1995. Most patients still consult homeopaths through a lay referral network. In 2004, more than 60% made an appointment with a homeopath within the first month of first considering it. CONCLUSION: There are few changes in the characteristics of this homeopathic patient population. There is a need for studies that explore the 'why question'; Why an increasing percentage of patients are children? Why people with higher education and why certain age groups visit homeopaths more frequently than others?

Patients' assessments of the effectiveness of homeopathic care in Norway: a prospective observational multicentre outcome study.

OBJECTIVE: To evaluate the patient reported effects of homeopathic care 6 months after first consultations. METHODS: Prospective uncontrolled observational multicentre outcome study. All patients visiting 80 homeopaths all over Norway for the first time in eight different time periods from 1996 to 1998 were approached. Patients wrote down their main complaint and scored its impact on daily living on a 100 mm Visual Analogue Scale (VAS) at the first consultation. Six months later they were asked to score again. The homeopaths recorded treatments given for up to two follow-up consultations. MAIN OUTCOME MEASURE: Predefined as a reduction of at least 10 mm in the VAS score between the first consultation and follow-up. RESULT: Patients 1097 were recruited, 654 completed the follow-up questionnaire. The main complaint improved by at least 10mm on the VAS for 71% (95% confidence interval 67-74%) of patients. The average reduction was 32mm (95% CI 30-35 mm). Fifty-one per cent (95% CI 48-55%) of the patients had an improvement in their general well being of more than 10 mm. The mean reduction in the whole group was 14mm (95% CI 12-16 mm). The proportion of patients using conventional medication reduced from 39% to 16%. Regression analysis showed that lower age and higher baseline score were predictors of better outcome. CONCLUSION: In this study, seven out of ten patients visiting a Norwegian homeopath reported a meaningful improvement in their main complaint 6 months after the initial consultation.

Users of homeopaths in Norway in 1998, compared to previous users and GP patients.

AIM: Homeopathy is the form of complementary medicine most frequently used in Norway. This study describes complaints and characteristics of patients who visited Norwegian homeopaths in 1998, comparing them with those who visited homeopaths in 1985 and general practice patients. METHODS: We conducted a survey of 1097 patients visiting 80 Norwegian homeopaths in 1998 and compared them with a similar survey in 1985 (1072 consultations) and a 1989 survey of general practice patients (90,458 consultations). RESULTS: One in four of patients visiting homeopaths in 1998 were children between 0 and 9 years of age, compared to one in ten in 1985 and in general practice. Almost half of the patients in 1998 had used prescription drugs provided by a medical doctor the previous month for the same complaints they presented to the homeopath. In 1998 patients sought homeopathy most often because of respiratory and skin complaints. In 1985 the most common reasons were musculo-skeletal and digestive problems. Four of the five commonest reasons for encounter in homeopathic practice in 1998 were also found among the five commonest reasons for general practice consultations. CONCLUSION: Patients currently visiting homeopaths differ in age and to some extent in complaints compared to previous users of homeopathy and general practice patients.

Users of homeopaths in Norway in 1998, compared to previous users and GP patients

Homeopathy is the form of complementary medicine most frequently used in Norway. This study describes complaints and characteristics of patients who visited Norwegian homeopaths in 1998, comparing them with those who visited homeopaths in 1995 and general practice patients.(AU)