General practitioners’ and nurses’ views on medication reviews and potentially inappropriate medicines in elderly patients – a qualitative study of reports by educating pharmacists

Objective: The aim with this study was to understand more about how general practitioners (GPs) and nurses in primary care experience their work with medication reviews in elderly patients. Design: This qualitative study was nested within a cluster randomised trial and analysed narrative and unstructured diaries written by two pharmacists who performed academic detailing, i.e. educational outreach visits in primary care. The educational sessions dealt with potentially inappropriate medicines, and stimulated interprofessional dialogue in relation to medication reviews. The purpose of the diaries was to document and structure the pedagogical process of academic detailing and contained quotes from 194 GP and 113 nurse participants in the sessions, and the pharmacists’ reflections. The data was explored using thematic analysis. Setting: Thirty-three primary care practices in Stockholm, Sweden. Subjects: GPs and nurses working in primary care. Main outcome measures: Thematic descriptions of academic detailing by pharmacists. Results: Five themes were identified: 1) Complexity in 3 ‘P’: patients, pharmacotherapy, and primary care; 2) What, when, who? Clash between GPs’ and nurses’ experiences and guidelines; 3) Real-world problems and less-than-ideal solutions; 4) Eureka? Experiences with different steps during a medication review; and 5) Threats to GP autonomy. Conclusion: GPs and nurses should participate in the construction and release of guidelines in order to increase their usability in clinical practice. Future research should analyse if alternative strategies such as condensed medical reviews and feedback on prescribing are easier to implement in primary care.Key points Complex medication reviews have been introduced on a large scale in Swedish primary care, but knowledge on GPs’ and nurses’ views on such reviews is lacking. In the context of primary care alternative strategies such as condensed medication reviews and feedback on prescribing may be more applicable than medication reviews according to guidelines. GPs and nurses should make contributions to the development of guidelines on medication reviews in order to increase their usability in clinical practice

The use of a Swedish telephone medical advice service by the elderly – a population-based study

Objective: The present study aimed to describe contact made by the elderly to Sweden’s nationwide medical helpline, Healthcare Guide 1177 by Phone (HGP). Other objectives were to study potential gender differences and the association between different HGP referral levels and acute visits to hospital-based emergency departments and acute visits to primary care centres. Design: De-identified data from recorded calls to HGP was extracted for analysis (n = 7477 for the oldest age group). Information about acute visits to emergency departments and to primary care reception was extracted from the patient administration system. Setting: Västerbotten County, Sweden. Subjects: Patients over 80 years. Main outcome measures: Calling and visiting frequencies for different age groups as well as reasons for contact and individual recommendations. Results: The utilisation rate of the telephone advice service for the oldest age group was high, with an incidence rate of 533 per 1000 person-years. Women had a 1.17 times higher incidence rate compared with men. The most common reason for contact was drug-related questions (17% of all contacts). Calls that were recommended to care by a medical specialist correlated with total emergency department visits (r = 0.30, p < 0.05) and calls that were given advice correlated with acute primary healthcare visits (r = 0.38, p = 0.005). Conclusion: The high utilisation of the telephone advice service by the elderly gives the telephone advice service a unique ability to function as a gatekeeper to further healthcare. Our data suggest that with the telephone advice service’s present guidelines, a significant proportion of all calls are being directed to further medical help. The high frequency of drug-related questions raises concerns about the elderly’s medication regimens.Key points Patients over 80 years of age had a high utilisation of the telephone medical advice service compared with other age groups. Drug-related questions were the most common reason for contact. A significant proportion of all calls made resulted in further heatlhcare contacts

Metrics for environmental compensation : A comparative analysis of Swedish municipalities

Environmental compensation (EC) aims at addressing environmental losses due to development projects and involves a need to compare development losses with compensation gains using relevant metrics. A conceptual procedure for computing no net loss is formulated and used as a point of departure for a comparative analysis of metrics used by five Swedish municipalities as a part of their EC implementation in the spatial planning context of detailed development plans. While Swedish law does not require EC in this context, these municipalities have still decided to introduce EC requirements for development projects that occur on municipality-owned land and to promote voluntary EC among private actors in development projects on private land. There is substantial variation across the municipalities studied with respect to both metrics and attributes subject to measurement, but there are also similarities: The attributes considered when assessing the need for EC in conjunction with development are not only about nature per se, but also about recreational opportunities and other types ecosystem services; semi-quantitative metrics such as scores are common while quantitative or monetary metrics are rare; and metrics are rarely applied to assess compensatory gains, focusing instead on losses from development. Streamlining across municipalities might be warranted for increasing predictability and transparency for developers and citizens, but it also introduces considerable challenges such as a need for developing consistent guidelines for semi-quantitative metrics, and to handle substitutability issues if metrics are not only applied on individual attributes but also on groups of attributes. The broad scope of attributes used by the municipalities is in line with an international tendency to broaden EC to include not only biodiversity aspects but also ecosystem services. Moreover, the EC systems applied by the municipalities are of particular importance for highlighting the crucial role of environmental management for maintaining and enhancing biodiversity and ecosystem services not only in areas having formal protection status but also in the everyday landscape. The municipalities’ experience and strengths and weaknesses associated with their EC systems are therefore relevant also in an international perspective.MuniCom

Ekologisk kompensation som styrmedel i kommunal planering

Projektet har undersökt erfarenheter av och förutsättningar för att tillämpa ekologisk kompensation inom ramen för den kommunala planeringen. Inom olika delstudier har projektet undersökt ekologisk kompensation som styrmedel, tillämpningen av skadelindringshierarkin, utformningen av kompensationsmodeller och rutiner, användningen av olika modeller för beräkning av förluster och vinster inom kompensationsprojekt, samt allmänhetens preferenser för olika kompensationsalternativ. Projektet har genomförts i nära samarbete med Helsingborgs och Lomma kommun, och Kommunförbundet Skåne har varit projektets kommunikationspartner och arrangör av flera större möten och workshopar med tjänstemän från många kommuner i Skåne. ...The project has investigated experiences of and prerequisites for applying environmental compensation within a municipal planning context. The project has examined environmental compensation as a policy instrument, the application of the mitigation hierarchy, the design of compensation models and procedures, the use of different frameworks for assessing losses and gains, and the public’s preferences for different compensation options. The project has been carried out in close co-operation with Helsingborg and Lomma municipalities. Kommunförbundet Skåne has been the project’s communication partner and organizer of several major meetings and workshops with officials from many municipalities in Skåne. ...Ekologisk kompensation som styrmedel – ett kommunperspektiv (MuniComp