Power dynamics and interprofessional collaboration: How do community pharmacists position general practitioners, and how do general practitioners position themselves?

Power differentials and medical dominance can negatively affect collaboration between physicians and pharmacists. Norway is recognized as having a relatively egalitarian work sector, which could affect power differentials. In this qualitative study, we used positioning theory as a framework to explore the aspect of power dynamics between Norwegian general practitioners (GPs) and community pharmacists. We used the concepts of reflexive and interactive positioning to identify how GPs positioned themselves and how they were positioned by pharmacists in six focus groups. Data were analyzed using systematic text condensation. We found positioning theory to be a useful lens through which to study power dynamics in relation to collaboration between community pharmacists and GPs. Our findings imply that the presence of medical dominance poses challenges even in an egalitarian Norwegian setting. However, although both GPs and pharmacists draw on a ‘medical dominance’ storyline, we have also identified how both pharmacists and GPs draw on alternative and promising storylines of collaboration between the two professions.publishedVersio

The potential for deprescribing in care home residents with Type 2 diabetes

Background: Type 2 diabetes is a common diagnosis in care home residents that is associated with potentially inappropriate prescribing and thus risk of additional suffering. Previous studies found that diabetes medicines can be safely withdrawn in care home residents, encouraging further investigation of the potential for deprescribing amongst these patients. Objectives: Describe comorbidities and medicine use in care home residents with Type 2 diabetes; identify number of potentially inappropriate medicines prescribed for these residents using a medicines optimisation tool; assess clinical applicability of the tool. Setting Thirty care homes for older people, East Anglia, UK. Method: Data on diagnoses and medicines were extracted from medical records of 826 residents. Potentially inappropriate medicines were identified using the tool ‘Optimising Safe and Appropriate Medicines Use’. Twenty percent of results were validated by a care home physician. Main outcome measure: Number of potentially inappropriate medicines. Results: The 106 residents with Type 2 diabetes had more comorbidities and prescriptions than those without. Over 90 % of residents with Type 2 diabetes had at least one potentially inappropriate medication. The most common was absence of valid indication. The physician unreservedly endorsed 39 % of the suggested deprescribing, and would consider discontinuing all but one of the remaining medicines following access to additional information. Conclusion: UK care home residents with Type 2 diabetes had an increased burden of comorbidities and prescriptions. The majority of these patients were prescribed potentially inappropriate medicines. Validation by a care home physician supported the clinical applicability of the medicines optimisation tool

Changes in Dentists' Prescribing Patterns in Norway 2005-2015.

Background There is scant knowledge of dentists' total prescribing patterns, and little is published on this internationally. The Norwegian Prescription Database (NorPD) includes data on all dispensed prescription medication in Norway from 2004 and can be used to investigate how dentists' prescribing has changed over time. There are few Norwegian guidelines supporting dentists' prescribing, and Norwegian legislation on dentists' prescribing rights leaves room for interpretation. The aim of this study was therefore to give an overview of all prescribing from dentists in Norway in the period 2005 to 2015 and to identify trends in their prescribing pattern over this time span. We also give characteristics of the prescribing dentists. Methods The study had a retrospective pharmacoepidemiologic design. Data on all medication prescribed by dentists and dispensed from Norwegian pharmacies in the time period 2005 to 2015 were extracted from the NorPD. Changes over time in the prescribers, patients, and medications are reported. Results There was an increase of 50% in total number of prescriptions from dentists in Norway from 2005 to 2015; adjusted for the growth in population, there was a 33% increase. The majority of prescriptions from dentists were for antibiotics and analgesics; however, the data reveal that the dentists prescribed from all major therapeutic groups. Dentists increased antibiotic prescribing in a period when total antibiotic prescribing in Norway decreased. Conclusions Our study finds antibiotics and analgesics dominate prescriptions from Norwegian dentists and shows an increase in use over time. It highlights the need for creating evidence-based prescribing guidelines for dentists and for ensuring that existing guidelines are implemented.publishedVersio

Less is more: The impact of deprescribing psychotropic drugs on behavioral and psychological symptoms and daily functioning in nursing home patients. Results from the Cluster-Randomized Controlled COSMOS Trial

Objective: To investigate the impact of medication reviews using collegial mentoring and systematic clinical evaluation on psychotropic prescriptions, behavioral and psychological symptoms of dementia (BPSD), and activities of daily living (ADL). Design: Four-month multicenter, multicomponent, cluster-randomized, single-blinded controlled trial. Setting: Thirty-three Norwegian nursing homes including 67 nursing home wards (clusters). Participants: A total of 723 enrolled patients, of which 428 participated in the study; 217 were randomized to the intervention and 211 to care as usual (control). Intervention: The COSMOS intervention consisted of Communication, Systematic pain management, Medication reviews, Organization of activities, and Safety. During medication review, the nursing home physician evaluated treatment with colleagues systematically using the results from validated clinical assessments. Measurements: Mean changes from baseline to month 4 in the number of prescribed psychotropic drugs (antipsychotics, anxiolytics, hypnotics or sedatives, antidepressants, and antidementia drugs); Neuropsychiatric Inventory Nursing Home Version (NPI-NH) and Cornell Scale of Depression in Dementia (CSDD); Lawton and Brody's Physical Self Maintenance Scale (PSMS). Results: Compared to control, the mean change in prescribed psychotropic drugs was reduced both in total and regular number, while mean changes in NPI-NH and CSDD scores did not differ between the groups. Mean change in PSMS showed improvement in the intervention group, and deterioration in the control group. Conclusion: Medication reviews using collegial mentoring and systematic clinical evaluation led to safe deprescribing, as the reductions in psychotropic drug use did not negatively affect BPSD, while ADL improved.publishedVersio

Type 2-diabetes i fastlegepraksis – en fokusgruppestudie

BAKGRUNN Nasjonal diabetesplan 2017–21 har iverksatt tiltak for å bedre diagnostisering og oppfølging av personer med type 2-diabetes i primærhelsetjenesten. Formålet med denne studien var å undersøke norske fastlegers erfaringer og tanker rundt diagnostisering og oppfølging av pasientgruppen. MATERIALE OG METODE I denne kvalitative studien ble det gjennomført tre fokusgruppeintervjuer med totalt 17 fastleger. Intervjuene ble tatt opp på bånd, transkribert og analysert med systematisk tekstkondensering. RESULTATER Fastlegene fortalte om en travel arbeidshverdag der målrettet identifikasjon av pasienter i risikosonen for sykdommen sjelden ble prioritert. De beskrev en pasientsentrert diabetesomsorg, hvor motivering til livsstilsendring ble ansett som en nødvendig, men krevende arbeidsoppgave. Legene problematiserte balansegangen mellom å følge generelle kliniske retningslinjer og det å individtilpasse oppfølging til den enkelte pasient. Samtidig uttrykte deltakerne at de var mindre faglig oppdatert enn de ønsket, grunnet tidspress. FORTOLKNING Fastlegene i studien beskrev en pasientsentrert diabetesomsorg som drives av klinisk erfaring. Retningslinjer har en veiledende, men ikke førende funksjon. En slik tilpasning muliggjør individualisert og tilpasset behandling, men kan også være en medvirkende årsak til mangelfull oppfølging i henhold til nasjonale retningslinjer.publishedVersio

Dermatological cancer screening: Evaluation of a new community pharmacy service

Background: Skin cancer accounts for one third of all cancers. Prognosis is inversely related to identification stage. Objectives: To describe a novel service, mole scans, performed in community pharmacy, the findings from the first 3.5 years it was in place, and to explore patient acceptability of the service. Methods: Norwegian Boots' pharmacies offer a mole scanning service in cooperation with ScreenCancer. Scans are undertaken within pharmacy consultation rooms. Image interpretation is undertaken remotely by a specialist. Number and result of scans performed from 2010 to 2014 are reported. A satisfaction questionnaire was returned by 10% of participants. Results: A total of 25836 scans were performed on 15777 individuals. Of these, 83.6% had normal scans, 1% had melanoma, and 15.4% had another skin condition. In 2014 the service identified 4.1% of melanoma cases registered in the Norwegian Cancer Registry. Most responders (88%) would use a similar service again. Nearly all (99%) felt the pharmacy was a suitable venue, and 95% would recommend the service to others. In total, 99% of respondents scored their overall satisfaction as “good” or higher. Conclusions: This approach was acceptable among participants who provided feedback. Providing mole scanning through pharmacies enables individuals to obtain a rapid check of moles causing concern, in an acceptable environment with a high level of satisfaction

Perception of the Professional Knowledge of and Education on the Medical Technology Products among the Pharmacists in the Baltic and Nordic Countries—A Cross-Sectional Exploratory Study

With increased development of medical technology (MT), new challenges emerge related to education and training of pharmacists and other healthcare specialists. Currently, only a few universities in the EU promote MT education and research. Objectives: The aim of this study was to evaluate the current status, views on, and need for the education on MT for the pharmacy students and practicing pharmacists in the Baltic and Nordic countries. Methods: The representatives of higher education institutions and community/hospital pharmacists from six Baltic and Nordic countries participated in a qualitative cross-sectional exploratory internet-based study from May to October 2014. Results: Approximately two-third of the respondents considered professional knowledge about MT products important for pharmacists, but half of them had never participated in any MT courses. More practicing pharmacists than representatives of academia underlined the need for increased MT education for pharmacy students in the future. Conclusions: The pharmacists in the Baltic and Nordic countries consider the professional knowledge about MT as pertinent in their education and work. The limited number and status of MT courses available today, however, is a major concern among both pharmacy students and practicing pharmacists in these countries. In the future, increasing education combining theory and practice about MT products would be one possible solution to overcome this challenge.Peer reviewe

The Prevalence of Self-Monitoring of Blood Glucose and Costs of Glucometer Strips in a Nationwide Cohort

Abstract Objective: This study used nationwide data to determine the prevalence of self-monitoring of blood glucose (SMBG) among all non-institutionalized persons living in Norway and to estimate the prevalence of SMBG among diabetes patients, the frequency and cost of SMBG, and the use of different glucometers. Methods: This retrospective, descriptive study is based on data of sales of glucometer strips to noninstitutionalized persons in Norway in 2008. The data included gender, age group, month of purchase, sales place, type of strips, number of packages dispensed, and cost of strips. Additionally, statistics on sales of insulin and oral antidiabetes medications were obtained from the Norwegian Prescription Database. Results: A total of 96,999 persons purchased strips, a prevalence of 2%. Approximately 70% of diabetes patients practiced SMBG. An average patient used 1.7 strips per day, and younger patients purchased more strips than older patients. Fewer than 50% of patients performed glucose measurements daily. One percent of patients used more than 10 strips daily and was accountable for 8% of total costs. Most patients used only one type of strips, but the number of strips purchased increased with the number of different strips. The average annual cost of strips was 446 e per person. Conclusions: Two percent of all non-institutionalized inhabitants and an estimated 70% of patients using diabetes medication purchased SMBG strips. A small percentage of the patients incurred a substantial proportion of the costs. This, along with the fact that over half of the patients monitor less than once per day, calls for tighter follow-up of diabetes patients

Diabetes Care in Community Pharmacy - Focus on Self-monitoring of Blood Glucose

Diabetes is a growing concern worldwide. Ideal management of the disease requires extensive self-care and broad follow-up by health care professionals. Considerable research has been done on involving the pharmacist in the healthcare of patients with diabetes, arguing that community pharmacists’ high availability to patients and specialized medication-focused education makes them a valuable asset to the diabetes team. This thesis consists of four papers. The work for these papers was performed from 2004 to 2009. Paper I gives an overview over diabetes care provided by Norwegian pharmacies. It is based on a descriptive study where all Norwegian pharmacies were invited to participate by filling out an online questionnaire. We found that most pharmacists were interested in working diabetes services. Some pharmacies offered diabetes patients a wide range of Services, but quality control of these services was seldom established. Almost all pharmacies offered practical services related to self-monitoring of blood glucose (SMBG), while giving advice on diet and other lifestyle factors was rarely done. The pharmacists were motivated to work within diabetes care, in particular SMBG. In Paper II we demonstrate how one can assure the quality of a point-of-care test (POCT) at the community pharmacy, in our case a blood glucose test, and show that when given the correct follow-up the pharmacies are able to match the quality of the results achieved at general practitioners’ offices. In Paper III we tested a new pharmacy service, where patients brought their own glucometers to the pharmacies where the glucose method was established. Patients had both their performance and their glucometer tested against the pharmacy method. We found that this reduced the number of user errors. It had no effect on the analytical quality of the patients’ SMBG results, which was good throughout the study. The patients’ trust in their own measurements Increased after their visit to the pharmacy, and the patients expressed a wish for annual pharmacy controls. In Paper IV we report the sales of SMBG strips to all non-institutionalized patients in Norway in 2008. We found that 96 999 different patients purchased strips that year. This gave a prevalence of 2 % in the Norwegian population, and approximately 70 % among patients being treated pharmacologically for their diabetes. The mean number of strips per day was 1.7, however 53 % of the patients did not purchase enough strips to monitor their blood glucose daily. The one percent of the patients who bought the most strips was responsible for 8 % of the costs. Most patients used only one brand of glucometer, though three percent purchased from 3-7 different types of strips. Use of strips increased with number of different types of strips. The sum of this work suggests that Norwegian pharmacies can be more actively used in assisting diabetes patients with their SMBG. The employees are motivated, and already involved at a smaller scale. Given correct training and follow-up they are capable of performing services involving POCT of good analytical quality, and patients are happy to receive this type of service from their community pharmacy. A small number of patients use a disproportionate amount of resources spent on SMBG, while a large number of patients rarely perform SMBG, giving room for improvement in the way resources are being spent. Several challenges remain: reaching the patients most in need of SMBG assistance, attaining access for pharmacies to the quality control support from the Norwegian Quality Improvement of Primary Care Laboratories (NOKLUS), and ensuring remuneration for the service