No / Purpose:¿ A follow up study to investigate whether UK optometrists partially prescribe significant changes in refractive correction to assist patient adaption and whether various aspects of practitioner profiles are linked to the nature of these prescribing decisions. Method:¿ A case scenario type questionnaire was distributed by post and via the internet to UK optometrists. Five case scenarios were described that included information on patient age, symptoms, habitual refractive correction (if any), subjective refraction and any other relevant clinical information. In each case respondents were asked to indicate and justify what refractive correction they would prescribe. Results:¿ A total of 592 questionnaires were completed. Between 41% and 84% prescribed the subjective refraction result depending on the scenario. The likelihood of partial prescribing increased by 34% for every 10 years following qualification and thus after a typical 40 year career, respondents were now over three times more likely to partially prescribe. There were no other links with the propensity to partially prescribe. Conclusion:¿ The subjective refraction result exerted a strong hold on the reported prescribing outcome, particularly for newly qualified optometrists. Partial prescribing was increasingly proposed the greater the number of years the respondent had been qualified. This suggests that with increasing exposure to patients who return dissatisfied with their spectacles, a greater appreciation of partial prescribing is gained. This link seems to be an important finding that provides significant support for the prescribing rules suggested by textbooks, which are not yet supported by research evidence.

Yes / Background Recently, primary care in the United Kingdom has undergone substantial changes in skill mix. Non-medical prescribing was introduced to improve patient access to medicines, make better use of different health practitioners’ skills and increase patient choice. There is little evidence about value-based patient preferences for ‘prescribing nurse’ in a general practice setting. Objective To quantify value-based patient preferences for the profession of prescriber and other factors that influence choice of consultation for managing a minor illness. Design Discrete choice experiment patient survey. Setting and participants Five general practices in England with non-medical prescribing services, questionnaires completed by 451 patients. Main outcome measure Stated choice of consultation. Main results There was a strong general preference for consulting ‘own doctor’ for minor illness. However, a consultation with a nurse prescriber with positive patient-focused attributes can be more acceptable to patients than a consultation provided by a doctor. Attributes ‘professional’s attention to patients’ views’ and extent of ‘help offered’ were pivotal. Past experience influenced preference. Discussion and conclusion Respondents demonstrated valid preferences. Preferences for consulting a doctor remained strong, but many were happy to consult with a nurse if other aspects of the consultation were improved. Findings show who to consult is not the only valued factor in choice of consultation for minor illness. The ‘prescribing nurse’ role has potential to offer consultation styles that patients value. Within the study’s limitations, these findings can inform delivery of primary care to enhance patient experience and substitute appropriate nurse prescribing consultations for medical prescribing consultations. / Department of Health, Project 016/0108. NIHR, CDF/01/2008/009.

Yes / Background: Kidney function reduces with age, increasing the risk of harm from increased blood levels of many medicines. Although estimated glomerular filtration rate (eGFR) is reported for prescribing decisions in those aged ≥65 years, creatinine clearance (Cockcroft–Gault) gives a more accurate estimate of kidney function. Aim: To explore the extent of prescribing outside recommendations for people aged ≥65 years with reduced kidney function in primary care and to assess the impact of using eGFR instead of creatinine clearance to calculate kidney function. Design and setting: A cross-sectional survey of anonymised prescribing data in people aged ≥65 years from all 80 general practices (70 900 patients) in a north of England former primary care trust. Method: The prevalence of prescribing outside recommendations was analysed for eight exemplar drugs. Data were collected for age, sex, actual weight, serum creatinine, and eGFR. Kidney function as creatinine clearance (Cockcroft–Gault) was calculated using actual body weight and estimated ideal body weight. Results: Kidney function was too low for recommended prescribing in 4–40% of people aged ≥65 years, and in 24–80% of people aged ≥85 years despite more than 90% of patients having recent recorded kidney function results. Using eGFR overestimated kidney function for 3–28% of those aged ≥65 years, and for 13–58% of those aged ≥85 years. Increased age predicted higher odds of having a kidney function estimate too low for recommended prescribing of the study drugs. Conclusion: Prescribing recommendations when kidney function is reduced are not applied for many people aged ≥65 years in primary care. Using eGFR considerably overestimates kidney function for prescribing and, therefore, creatinine clearance (Cockcroft–Gault) should be assessed when prescribing for these people. Interventions are needed to aid prescribers when kidney function is reduced.

Yes / Objectives: To examine trends in opioid prescribing in primary care, identify patient and general practice characteristics associated with long-term and stronger opioid prescribing, and identify associations with changes in opioid prescribing. Design: Trend, cross-sectional and longitudinal analyses of routinely recorded patient data. Setting: 111 primary care practices in Leeds and Bradford, UK. Participants: We observed 471 828 patient-years in which all patients represented had at least 1 opioid prescription between April 2005 and March 2012. A cross-sectional analysis included 99 847 patients prescribed opioids between April 2011 and March 2012. A longitudinal analysis included 49 065 patient-years between April 2008 and March 2012. We excluded patients with cancer or treated for substance misuse. Main outcome measures: Long-term opioid prescribing (4 or more prescriptions within 12 months), stronger opioid prescribing and stepping up to or down from stronger opioids. Results: Opioid prescribing in the adult population almost doubled for weaker opioids over 2005–2012 and rose over sixfold for stronger opioids. There was marked variation among general practices in the odds of patients stepping up to stronger opioids compared with those not stepping up (range 0.31–3.36), unexplained by practice-level variables. Stepping up to stronger opioids was most strongly associated with being underweight (adjusted OR 3.26, 1.49 to 7.17), increasing polypharmacy (4.15, 3.26 to 5.29 for 10 or more repeat prescriptions), increasing numbers of primary care appointments (3.04, 2.48 to 3.73 for over 12 appointments in the year) and referrals to specialist pain services (5.17, 4.37 to 6.12). Compared with women under 50 years, men under 50 were less likely to step down once prescribed stronger opioids (0.53, 0.37 to 0.75). Conclusions: While clinicians should be alert to patients at risk of escalated opioid prescribing, much prescribing variation may be attributable to clinical behaviour. Effective strategies targeting clinicians and patients are needed to curb rising prescribing, especially of stronger opioids. / e National Institute for Health Research (NIHR) under its Research for Patient Benefit Programme (Grant Reference Number PB-PG- 1010-23041).

Background: The cumulative effect of taking anticholinergic medicines (anticholinergic burden) is associated with adverse outcomes for older people. Prevalence of anticholinergic prescribing is increasing, and there is a need for tools to proactively identify at-risk patients for medication reviews. Aim: To explore the need for, and feasibility of, an integrated case-finding tool that predicts risks using electronic health records (EHRs), facilitating the review of anticholinergic medicines for frail older people. Methods: Mixed methods, adopting a pragmatic approach. A systematic review, prediction modelling of cohort study data, and qualitative interviews were undertaken. Results: The systematic review found anticholinergic exposure was associated with adverse outcomes for the frail; poorer physical function, falls, and mortality, indicating a need for a risk reducing intervention. In the prediction modelling study, predicting risks using composite measures of anticholinergic burden and frailty indicated limited feasibility. Neither enhanced the performance of best subset models using cohort study data. Their predictive utility needs to be investigated using EHR data, to determine their feasibility within primary care. The qualitative study found healthcare professionals needed a proactive tool, supporting risk prediction as a feasible approach. Factors influencing future implementation were; upskilling requirements, deprescribing confidence, patient reluctance, motivation, holistic care, interoperability, trust in risk prediction, remuneration, among other barriers and facilitators. Conclusions: Through identifying a need, and potential feasibility, foundations towards the future developments of a case-finding tool have been provided, informing an early tool prototype (AC-FRAIL). Recommendations for further work suggest a roadmap ahead, to maximise the potential for integrated solutions to proactively reduce anticholinergic risks. / NIHR Yorkshire and Humber Patient Safety Translational Research Centre (NIHR YHPSTRC)

During the last decade, electronic prescribing has been a point of focus in healthcare industry and is rapidly becoming a standard of practice. It has proven as an important element in improving the quality of patient care, mitigating or eliminating the phone calls back and forth from pharmacies to point of care/health centers. Many e-prescribing systems were developed and marketed but these usually were unsuccessful because of the lack of direct electronic connectivity to local pharmacies and the lack of up-to-date formulary information, clinical guidelines, health plans & services among other reasons. Despite their benefits, the adoption and usage of electronic prescribing systems has been low. In some of the developing countries like Uganda, the problem is even worst. Due to lack of essential resources and manpower, healthcare services have significantly impacted on the productivity and quality of patient care.In an effort to improve, promote and maintain the quality of health services in rural settings of developing countries like Uganda, a high level design for e-prescribing system has been proposed. Design specifications for Electronic Prescribing Management System (EPMS) along with functional prototype are built based on ICT4MPOWER project requirements and previous research and publications in this area.Initially research began with Drug and Stock Management System and EPMS emerged as one of its essential components. In order to strengthen and establish connection between ongoing electronic health record system and drug and stock management development, EPMS component came into lime light. Mare prescription management is not enough to serve patient centric needs. Hence, clinical decision support has been introduced into e- prescribing system to improve the quality of prescribing decisions. In order to develop a patient-centric e-prescribing system that is self-evolving and self sustaining, it is important to update the clinical decision-support system, formularies & guidelines on regular basis. In order to make it usable, it is required to formulate effective health plans and increase associations between pharmacies and other health organizational units. The principal benefit of introducing E-prescribing system into Electronic Health Record (EHR) System is to connect open ended systems to form a strong knowledge base for future. / ICT4MPOWER

Digitalis in one of the most frequently prescribed drugs, especially to elderly people. The prescription of cardiac glucosides (1978) was studied by using statistics from Apoteksbolaget (the National Corpora­tion of Swedish Pharmacies). There was a threefold difference in the sales of cardiac glucosides per 1000 inhabitants in the different primary care areas. Digoxin was prescribed to 90-98 per cent of the patients, with considerable variations in the dosages. Many other factors besides the cardio-vascular morbidity were likely to cause these differences. Maintenance digitalis therapy has lately been questioned. In a retro­spective study, digitalis was discontinued in 141 geriatric patients without contraindications to digitalis withdrawal. Digoxin treatment seemed to be unnecessary in 108 patients (81 per cent), followed up two months after digoxin withdrawal. A long-term study (mean: 20,5 months) was carried out in these 108 patients. Digitalis therapy was reinstituted in 30 of 99 patients, equally distributed on the basis of clear, possible or uncertain indications. Significantly more patients (p&lt; 0,001) with atrial fibrillation compared with sinus rhythm were restarted. A prospective, randomized, double-blind placebo- controlled study in 39 out of 66 geriatric patients confirmed the results of the retrospective study. During a two-month period 32 of 37 patients (86 per cent) managed without digitalis. Eighteen out of 66 patients (27 per cent) presented contraindications to digoxin with­drawal. Those who needed digitalis were restarted mainly during the first nonth (mean: 18 days) following digoxin withdrawal. Digitalis intoxication has been studied earlier, mainly in hospitalized patients. A clinical examination and ECG of a random sample of out­patients treated with digoxin shewed that about 5 per cent were certainly intoxicated and about 2 per cent suspected of being intoxi­cated. Elderly patients are said to be more sensitive to digitalis. Eleven per cent of 66 geriatric patients were found, without doubt, to be digitalis intoxicated. The mean serum digoxin concentration was significantly higher in eight toxic patients compared with non-toxic patients, but 75 per cent of the toxic patients had serum digoxin con­centrations within or below therapeutic range. Five of these intoxi­cated patients did not need maintenance digitalis therapy. A questionnaire of 361 patients in Skellefteå and Uppsala revealed that about 45 per cent had taken digitalis for more than five years. Approximately 85 per cent took one tablet daily and stated compliance. About one fifth did not know why they were taking digoxin and about half of the patients were uncertain if they were improved, by digitalis therapy. Although digitalis intoxication is such an important clinical problem, some 55 per cent did not know about digitalis's side-effects and some 50 per cent stated that no or insufficient information had been given. Only 15 per cent were satisfied with the information they had received. A significant negative correlation between digoxin dosages and the age of the patients was found. / <p>Diss. Umeå : Umeå universitet, 1983, härtill 7 uppsatser</p> / digitalisering@umu

About 30.00% of schizophrenic patients fail to respond to conventional antipsychotics. Clozapine shows superior efficacy, for both the positive and negative symptoms of schizophrenia, over conventional antipsychotics. The reputation of clozapine lies mainly with its repeated proven efficacy in the treatment of refractory schizophrenia. However, clozapine has quite a severe side effect profile. Patients receiving clozapine therapy may develop serious adverse effects such as agranulocytosis, neutropenia and metabolic syndrome. Therefore guidelines are required which recommend that regular haematological and metabolic monitoring be performed. These monitoring guidelines should assist medical practitioners in the early detection and reporting of serious adverse effects associated with clozapine therapy. South Africa lacks uniform provincial or national guidelines regulating practices in the treatment of mental disorders. International guidelines may be considered, which are not specifically adapted for the South African setting. These guidelines recommend both the haematological and metabolic monitoring of clozapine. At present there are no South African guidelines recommending the metabolic monitoring of clozapine. The general aim of the study was to determine the prescribing and monitoring patterns of clozapine at Elizabeth Donkin Hospital in the Nelson Mandela Metropole. Due to the absence of specific South African guidelines and the severe side effect profile of clozapine, some of the research objectives were to determine whether the initiation of clozapine, as well as the haematological and metabolic monitoring performed, was compliant with international clinical guidelines. In this pharmacoepidemiological study a retrospective drug utilisation review was performed. The study was observational in design and included quantitative data. Data were collected from the files of 65 patients (N=65) discharged on clozapine between 1 December 2010 and 29 February 2012. Follow-up investigations were performed at the clinics and long-term care centres both three months and six months after discharge. In 52.30% (n=34) of the cases clozapine was previously prescribed. Compliance with the National Institute for Health and Clinical Excellence (NICE) guidelines for the appropriate initiation of clozapine was 63.10% (n=41). Compliance with the Standard Treatment guidelines for the initiation of clozapine by a psychiatrist was 63.10% (n=41). Noncompliance with the recommended guidelines for haematological monitoring occurred in 77.40% of patients in the hospital setting (n=48) as well as in 95.70% of patients during the three-month follow-up at the clinics (n=44). Non-compliance with the guidelines for metabolic monitoring occurred in all the observed patients in the hospital setting (n=62) as well as in 45.70% of patients in the clinic setting (n=21). It was found that 71.00% (n=46) of patients were still on clozapine three months after discharge and 65.00% (n=42) were still on clozapine six months after discharge from hospital, resulting in discontinuation rates of 29.00% and 35.00% respectively. It was found that clozapine was inadequately monitored although in most cases the initiation of clozapine was compliant with the recommended guidelines. However, practitioners should be trained on the existing prescribing and monitoring guidelines to promote the rational use of clozapine in the public health sector of South Africa. / MPham (Pharmacy Practice), North-West University, Potchefstroom Campus, 2014

About 30.00% of schizophrenic patients fail to respond to conventional antipsychotics. Clozapine shows superior efficacy, for both the positive and negative symptoms of schizophrenia, over conventional antipsychotics. The reputation of clozapine lies mainly with its repeated proven efficacy in the treatment of refractory schizophrenia. However, clozapine has quite a severe side effect profile. Patients receiving clozapine therapy may develop serious adverse effects such as agranulocytosis, neutropenia and metabolic syndrome. Therefore guidelines are required which recommend that regular haematological and metabolic monitoring be performed. These monitoring guidelines should assist medical practitioners in the early detection and reporting of serious adverse effects associated with clozapine therapy. South Africa lacks uniform provincial or national guidelines regulating practices in the treatment of mental disorders. International guidelines may be considered, which are not specifically adapted for the South African setting. These guidelines recommend both the haematological and metabolic monitoring of clozapine. At present there are no South African guidelines recommending the metabolic monitoring of clozapine. The general aim of the study was to determine the prescribing and monitoring patterns of clozapine at Elizabeth Donkin Hospital in the Nelson Mandela Metropole. Due to the absence of specific South African guidelines and the severe side effect profile of clozapine, some of the research objectives were to determine whether the initiation of clozapine, as well as the haematological and metabolic monitoring performed, was compliant with international clinical guidelines. In this pharmacoepidemiological study a retrospective drug utilisation review was performed. The study was observational in design and included quantitative data. Data were collected from the files of 65 patients (N=65) discharged on clozapine between 1 December 2010 and 29 February 2012. Follow-up investigations were performed at the clinics and long-term care centres both three months and six months after discharge. In 52.30% (n=34) of the cases clozapine was previously prescribed. Compliance with the National Institute for Health and Clinical Excellence (NICE) guidelines for the appropriate initiation of clozapine was 63.10% (n=41). Compliance with the Standard Treatment guidelines for the initiation of clozapine by a psychiatrist was 63.10% (n=41). Noncompliance with the recommended guidelines for haematological monitoring occurred in 77.40% of patients in the hospital setting (n=48) as well as in 95.70% of patients during the three-month follow-up at the clinics (n=44). Non-compliance with the guidelines for metabolic monitoring occurred in all the observed patients in the hospital setting (n=62) as well as in 45.70% of patients in the clinic setting (n=21). It was found that 71.00% (n=46) of patients were still on clozapine three months after discharge and 65.00% (n=42) were still on clozapine six months after discharge from hospital, resulting in discontinuation rates of 29.00% and 35.00% respectively. It was found that clozapine was inadequately monitored although in most cases the initiation of clozapine was compliant with the recommended guidelines. However, practitioners should be trained on the existing prescribing and monitoring guidelines to promote the rational use of clozapine in the public health sector of South Africa. / MPham (Pharmacy Practice), North-West University, Potchefstroom Campus, 2014

Thesis (DMed (Psychiatry))--University of Stellenbosch, 2007. / This study reports on the effect of seminar education by studying changes in knowledge, attitude and behaviour to haloperidol prescribing patterns of psychiatrists who In summary, this study demonstrated a direct relationship between seminar attendance and changes to selected minimum effective haloperidol dose and duration of treatment. However, seminar attendance did not appear to be a significant factor in changes to antipsychotic class used for treatment and changes in optimal effective haloperidol dose: rather a change in the level of “background” knowledge of participants was most likely responsible. This study also found individual participant characteristic differences in those who did change treatment duration and minimum effective dose. In conclusion, this study showed that the successful integration of international treatment recommendations into daily psychiatric practise could be facilitated by the use of appropriate educational seminars. Not all attendees benefit i.e. “learn”, but those needing to “learn” most do - i.e. those who need to change their prescribing habits most to meet internationally accepted guidelines. The peer exposure provided allows a format for informed discussion and the practise of evidence-based medicine. The judicious use of such seminars should result in better treatment options and outcomes for patients.attended evidence-based schizophrenia seminars presented by the Lundbeck Institute in Denmark. The objectives of the study were two-fold. Firstly, it set out to determine whether changes actually occurred in the post-seminar haloperidol prescribing behaviour of participants. This was done by analysing changes in choice of optimal haloperidol dose (both in acute treatment i.e. most effective dose and maintenance treatment i.e. minimum effective dose), selected duration of treatment (for first- and multi-episode schizophrenia patients) and drug-class used (conventional versus new generation antipsychotic). The study then investigated whether these changes (if they occurred) could be ascribed wholly or in part to the effect of schizophrenia seminar attendance, or whether other factors e.g. scientific progress over time in understanding schizophrenia and its treatment (“background” knowledge) and differences between participant datasets studied (only paired pre- and post-seminar data were used in this study) also played a role. Secondly, it attempted to identify factors predictive of seminar participants changing their haloperidol prescribing behaviour post-seminar i.e. what were the factors that predisposed some attendees to change their prescribing behaviour? This was done by analysing the effect that pre-seminar prescribing behaviour, participant nationality, patient caseload, work experience and workplace environment had on post-seminar behaviour. Results show that changes did occur in post-seminar haloperidol prescribing behaviour, but that they were not always due to an effect of seminar attendance. Only the changes in the minimum effective haloperidol dose and duration of treatment for first- and multi-episode schizophrenia patients could validly be ascribed to the effects of schizophrenia seminar attendance. Furthermore, multivariate analysis of the factors relating to these changes found that a participant was most likely to change their selected minimum effective haloperidol dose to be more in line with internationally accepted standards if they i) selected above the target dose pre-seminar, ii) had a relatively low caseload comprised mainly of schizophrenia patients and iii) came from either Greece, Germany, Britain, Spain, Italy or some other Eastern European country. The single most important factor related to changes in duration of treatment was found to be pre-seminar behaviour: respondents below the recommended duration of treatment increased their duration of treatment significantly.