Management of antipsychotics in primary care: Insights from healthcare professionals and policy makers in the United Kingdom.

INTRODUCTION: Antipsychotic medication is increasingly prescribed to patients with serious mental illness. Patients with serious mental illness often have cardiovascular and metabolic comorbidities, and antipsychotics independently increase the risk of cardiometabolic disease. Despite this, many patients prescribed antipsychotics are discharged to primary care without planned psychiatric review. We explore perceptions of healthcare professionals and managers/directors of policy regarding reasons for increasing prevalence and management of antipsychotics in primary care. METHODS: Qualitative study using semi-structured interviews with 11 general practitioners (GPs), 8 psychiatrists, and 11 managers/directors of policy in the United Kingdom. Data was analysed using thematic analysis. RESULTS: Respondents reported competency gaps that impaired ability to manage patients prescribed antipsychotic medications, arising from inadequate postgraduate training and professional development. GPs lacked confidence to manage antipsychotic medications alone; psychiatrists lacked skills to address cardiometabolic risks and did not perceive this as their role. Communication barriers, lack of integrated care records, limited psychology provision, lowered expectation towards patients with serious mental illness by professionals, and pressure to discharge from hospital resulted in patients in primary care becoming 'trapped' on antipsychotics, inhibiting opportunities to deprescribe. Organisational and contractual barriers between services exacerbate this risk, with socioeconomic deprivation and lack of access to non-pharmacological interventions driving overprescribing. Professionals voiced fears of censure if a catastrophic event occurred after stopping an antipsychotic. Facilitators to overcome these barriers were suggested. CONCLUSIONS: People prescribed antipsychotics experience a fragmented health system and suboptimal care. Several interventions could be taken to improve care for this population, but inadequate availability of non-pharmacological interventions and socioeconomic factors increasing mental distress need policy change to improve outcomes. The role of professionals' fear of medicolegal or regulatory censure inhibiting antipsychotic deprescribing was a new finding in this study.

The DynAIRx Project Protocol: Artificial Intelligence for dynamic prescribing optimisation and care integration in multimorbidity.

Background: Structured Medication Reviews (SMRs) are intended to help deliver the NHS Long Term Plan for medicines optimisation in people living with multiple long-term conditions and polypharmacy. It is challenging to gather the information needed for these reviews due to poor integration of health records across providers and there is little guidance on how to identify those patients most urgently requiring review. Objective: To extract information from scattered clinical records on how health and medications change over time, apply interpretable artificial intelligence (AI) approaches to predict risks of poor outcomes and overlay this information on care records to inform SMRs. We will pilot this approach in primary care prescribing audit and feedback systems, and co-design future medicines optimisation decision support systems. Design: DynAIRx will target potentially problematic polypharmacy in three key multimorbidity groups, namely, people with (a) mental and physical health problems, (b) four or more long-term conditions taking ten or more drugs and (c) older age and frailty. Structured clinical data will be drawn from integrated care records (general practice, hospital, and social care) covering an ∼11m population supplemented with Natural Language Processing (NLP) of unstructured clinical text. AI systems will be trained to identify patterns of conditions, medications, tests, and clinical contacts preceding adverse events in order to identify individuals who might benefit most from an SMR. Discussion: By implementing and evaluating an AI-augmented visualisation of care records in an existing prescribing audit and feedback system we will create a learning system for medicines optimisation, co-designed throughout with end-users and patients.

Exploring the challenges to safer prescribing and medication monitoring in prisons: A qualitative study with health care staff.

INTRODUCTION: Research suggests that patients who are prisoners experience greater morbidity, increased health inequalities and frequent preventable harm, compared to the general population. Little is known about the process and influencing factors for safe prescribing in the unique prison environment, which may limit the development efforts to improve the quality of care in prisons. This study aimed to understand the process and challenges associated with prescribing in prisons, explore the causes and impact of these challenges, and explore approaches to improve prescribing safety in prisons. METHODS: Grounded theory informed data collection and analysis of a nominal group discussion by seven participants and semi-structured telephone interviews with twenty prison healthcare staff, including GPs, pharmacists, psychiatrists and nurses. FINDINGS: The underlying complexity of prescribing in prison settings increased the level of challenge and influenced the safety of this process. Multiple contributors to the challenges of safe prescribing were identified (comprising governance and policy; the prison structure; staff retention, training and skill mix; IT systems and interface; polypharmacy and co-morbidity; tradability and patient behaviour) with overarching constructs of variations in practice/policy and the influence of prison culture. Participants identified measures to address these challenges through multi-disciplinary collaborative working, increased consistency in processes, and the need for more innovation and education/training. CONCLUSIONS: Our study highlighted that healthcare provision in prisons is unique and needs to tailor the care provided to patients without enforcing a model focused on primary, secondary or tertiary care. Participants emphasised a necessary shift in workplace culture and behaviour change to support improvements. The COM-B model of behaviour change may be effectively applied to develop interventions in organisations that have in-depth understanding of their own unique challenges.

Implementing prescribing safety indicators in prisons: A mixed methods study.

AIMS: To examine the prevalence of potentially hazardous prescribing in the prison setting using prescribing safety indicators (PSIs) and explore their implementation and use in practice. METHODS: PSIs were identified and reviewed by the project team following a literature review and a nominal group discussion. Pharmacists at 2 prison sites deployed the PSIs using search protocols within their electronic health record. Prevalence rates and 95% confidence intervals (CIs) were generated for each indicator. Semi-structured interviews with 20 prison healthcare staff across England and Wales were conducted to explore the feasibility of deploying and using PSIs in prison settings. RESULTS: Thirteen PSIs were successfully deployed mostly comprising drug-drug interactions (n = 9). Five yielded elevated prevalence rates: use of anticholinergics if aged ≥65 years (Site B: 25.8% [95%CI: 10.4-41.2%]), lack of antipsychotic monitoring for >12 months (Site A: 39.1% [95%CI: 27.1-52.1%]; Site B: 28.6% [95%CI: 17.9-41.4%]), prolonged use of hypnotics (Site B: 46.3% [95%CI: 35.6-57.1%]), antiplatelets prescribed with nonsteroidal anti-inflammatory drugs without gastrointestinal protection (Site A: 12.5% [95%CI: 0.0-35.4%]; Site B: 16.7% [95%CI: 0.4-64.1%]), and selective serotonin/norepinephrine reuptake inhibitors prescribed with nonsteroidal anti-inflammatory drugs/antiplatelets without gastrointestinal protection (Site A: 39.6% [95%CI: 31.2-48.4%]; Site B: 33.3% [95%CI: 20.8-47.9%]). Prison healthcare staff supported the use of PSIs and identified key considerations to guide its successful implementation, including staff engagement and PSI 'champions'. To respond to PSI searches, stakeholders suggested contextualised patient support through intraprofessional collaboration. CONCLUSION: We successfully implemented a suite of PSIs into 2 prisons, identifying those with higher prevalence values as intervention targets. When appropriately resourced and integrated into staff workflow, PSI searches may support prescribing safety in prisons.

Development of the adult complexity tool for pharmaceutical care (ACTPC) in hospital: A modified Delphi study.

BACKGROUND: Hospital pharmacists play an essential role in patient care; however, a lack of resources means pharmacists are unable to review all patients daily. Consequently, there is a demand for reliable screening tools to allocate care to patients with urgent and/or complex pharmaceutical needs. Several tools have been developed, but no broad consensus exists on the design of a screening tool to be used in the adult hospital setting. OBJECTIVE: To obtain expert consensus on the design of a pharmaceutical care complexity screening tool for use on admission to hospital. METHODS: Two Delphi studies were conducted: the first sought to gain consensus from experts including pharmacists, academics and physicians on the components of a pharmaceutical complexity tool, the second to achieve consensus from UK chief pharmacists and clinical service pharmacy managers on the clinical appropriateness and practicality of the tool. Tool components and Delphi statements were identified and refined from our previous systematic review, UK survey and interview study of prioritisation tools. A valid definition for consensus was used. RESULTS: Over 300 components were extracted from the interview data and systematic review and then refined for inclusion in the first Delphi study. Thirty-three experts completed Delphi One and consensus was reached on 92 components. Components were grouped into demographic, clinical and medication components and condensed to 33 items, which were included in the first draft of the Adult Complexity Tool for Pharmaceutical Care (ACTPC). The tool stratified patients into highly, moderately or least complex. Forty expert panellists completed Delphi Two and consensus was reached on review frequency and experience of pharmacy practitioner at each level. These decisions were incorporated into the final version of the ACTPC. CONCLUSIONS: The ACTPC is the first systematically designed and internationally agreed tool for use on medical admission to hospital. It has potential to enable the delivery of targeted patient-centred pharmaceutical care.

Patient prioritisation for hospital pharmacy services: current approaches in the UK.

OBJECTIVES: To survey and explore current approaches to deployment of pharmaceutical care prioritisation tools in acute hospitals in the UK. METHODS: A national online survey was circulated electronically to chief pharmacists of hospitals to determine if they use a prioritisation tool or process. Where such mechanisms exist, respondents were invited to participate in a semistructured telephone interview to explore the development, evaluation and application of their tool and share relevant documentation. Interviews were transcribed and thematically analysed. RESULTS: Seventy hospitals (70/130) used a tool or process to prioritise clinical pharmacy services. Thirty-six interviews were conducted, and two were excluded. The majority of tools had been developed in-house. Few hospitals had undertaken formal evaluations of their prioritisation tool. Pharmacy prioritisation tools ranged in complexity and often included a combination of pharmacy service prioritisation, such as medicines reconciliation, and a section to assign an individual patient prioritisation level. Determining the priority of a patient based on the identification of set indicators instilled confidence in pharmacists by ensuring they were not missing high-risk patients. Electronic prioritisation tools were especially useful at retrieving real-time data to prioritise workload, improving workflow and ensuring continuity in patient care. Drawbacks of using prioritisation tools included lack of tool sensitivity across certain specialties and time spent using the tool if not all information was accessible. CONCLUSIONS: Prioritisation tools were seen to be useful for prioritising workload and ensuring the right patients are seen at the right time. As few hospitals had formally evaluated their tools, it is important to rigorously and systematically develop an evidence-based prioritisation tool that is both useable and acceptable. Further research to evaluate such tools would be needed to ensure it improves patient health outcomes and efficiency in pharmacy services.

Factors influencing secondary care pharmacist and nurse independent prescribers' clinical reasoning: An interprofessional analysis.

In the United Kingdom, pharmacist and nurse independent prescribers are responsible for both the clinical assessment of and prescribing for patients. Prescribing is a complex skill that entails the application of knowledge, skills, and clinical reasoning to arrive at a clinically appropriate decision. Decision-making is influenced and informed by many factors. This study, the first of its kind, explores what factors influence pharmacist and nurse independent prescribers during the process of clinical reasoning. A think-aloud methodology immediately followed by a semi-structured interview was conducted with 11 active nurse and 10 pharmacist independent prescribers working in secondary care. Each participant was presented with validated clinical vignettes for the think-aloud stage. Participants chose the clinical therapeutic areas for the vignettes, based on their self-perceived competencies. Data were audio-recorded, transcribed verbatim, and a constant-comparative approach was used for analysis. Influences on clinical reasoning were broadly categorised into themes: social interaction, intrinsic, and contextual factors. These themes showed that intrinsic, sociocultural, and contextual aspects heavily influenced the clinical reasoning processes of prescribers. For example, prescribers were aware of treatment pathways, but chose to refer patient cases to avoid making the final prescribing decision. Exploration of this behaviour in the interviews revealed that previous experience and attitudes such as confidence and cautiousness associated with responsibility were strong influencers within the decision-making process. In addition, strengthening the professional identity of prescribers could be achieved through collaborative work with interprofessional healthcare teams to orient their professional practice from within the profession. Findings from this study can be used to inform the education, training, and practice of independent prescribers to improve healthcare services by improving their professional and interprofessional development.

A qualitative study exploring how pharmacist and nurse independent prescribers make clinical decisions.

AIM: The aim of this study was to explore how secondary care pharmacist and nurse independent prescribers clinically reason when making prescribing decisions. BACKGROUND: Clinical reasoning is a central component of prescribers' competence and professional autonomy when reaching a clinically appropriate decision. Like doctors, pharmacist and nurse independent prescribers in the UK have extensive prescribing rights, but little is known about their clinical reasoning. DESIGN: A qualitative approach using a think-aloud methodology and semi-structured interviews. METHODS: Eleven nurse and 10 pharmacist independent prescribers were asked to think-aloud about validated clinical vignettes prior to interview, between March - December 2015. Data were analysed using a constant-comparative approach. RESULTS: A strong link between clinical knowledge, grounded in previous experience and clinical reasoning was found. Despite prescribers approaching the clinical vignettes holistically, their focus varied according to professional background and job role. Nurses were more likely to describe interacting with patients, compared with pharmacists who were more focused on medical notes and laboratory results. Think-aloud protocol analysis revealed a distinct pattern in the process undertaken to reach a clinical decision. This is presented as a decision-making model, encompassing case familiarization, generating hypotheses, case assessment, final hypotheses and decision-making stages, which oscillated throughout the model. CONCLUSION: This is the first study to explore the clinical reasoning processes of secondary care pharmacist and nurse independent prescribers. The resultant decision-making model shows clinical reasoning as a complex and dynamic process. This model can inform the training of independent prescribers to become accurate problem solvers and continue making clinically appropriate decisions.

Practice makes perfect: A systematic review of the expertise development of pharmacist and nurse independent prescribers in the United Kingdom.

BACKGROUND: Prescribing is a complex and error-prone task that demands expertise. McLellan et al.'s theory of expertise development model ("the model"), developed to assess medical literature on prescribing by medical students, proposes that in order to develop, individuals should deliberately engage their knowledge, skills and attitudes within a social context. Its applicability to independent prescribers (IP) is unknown. AIM: A systematic review was conducted to explore whether the model is applicable to non-medical independent prescribing and to assess the factors underpinning expertise development reported in the literature. METHOD: Six electronic databases (EMBASE, Medline, AMED, CINAHL, IPA and PsychInfo) were searched for articles published between 2006 and 2016, reporting empirical data on pharmacist and nurse IPs education or practice. Data were extracted using themes from the model and analysed using framework analysis. RESULTS: Thirty-four studies met the inclusion criteria. Knowledge, pre-registration education, experience, support and confidence were some of the intrinsic and extrinsic factors influencing IPs. Difficulty in transferring theory to practice was attributed to lack of basic pharmacology and bioscience content in pre-registration nursing rather than the prescribing programme. Students saw interventions using virtual learning or learning in practice as more useful with long-term benefits e.g. students were able to use their skills in history taking following the virtual learning intervention 6-months after the programme. All studies demonstrated how engaging knowledge and skills affected individuals' attitude by, for example, increasing professional dignity. IPs were able to develop their expertise when integrating their competencies in a workplace context with support from colleagues and adherence to guidelines. CONCLUSION: This is the first study to synthesize data systematically on expertise development from studies on IPs using the model. The model showed the need for stronger foundations in scientific knowledge amongst some IPs, where continuous workplace practice can improve skills and strengthen attitudes. This could facilitate a smoother transfer of learnt theory to practice, in order for IPs to be experts within their fields and not merely adequately competent.

Nonmedical prescribing: where are we now?

Nonmedical prescribing has been allowed in the United Kingdom (UK) since 1992. Its development over the past 24 years has been marked by changes in legislation, enabling the progression towards independent prescribing for nurses, pharmacists and a range of allied health professionals. Although the UK has led the way regarding the introduction of nonmedical prescribing, it is now seen in a number of other Western-European and Anglophone countries although the models of application vary widely between countries. The programme of study to become a nonmedical prescriber (NMP) within the UK is rigorous, and involves a combination of taught curricula and practice-based learning. Prescribing is a complex skill that is high risk and error prone, with many influencing factors. Literature reports regarding the impact of nonmedical prescribing are sparse, with the majority of prescribing research tending to focus instead on prescribing by doctors. The impact of nonmedical prescribing however is important to evaluate, and can be carried out from several perspectives. This review takes a brief look back at the history of nonmedical prescribing, and compares this with the international situation. It also describes the processes required to qualify as a NMP in the UK, potential influences on nonmedical prescribing and the impact of nonmedical prescribing on patient opinions and outcomes and the opinions of doctors and other healthcare professionals.