Женский роман в гендерной перспективе

В статье излагаются результаты анализа становления и развития англо- и немецкоязычного женского романа – от канонического, через эмансипированный, к постфеминистскому, – в связи с широким распространением идей феминизма и опирающихся на них гендерных исследований.У статті представлено результати аналізу становлення й розвитку англо- та німецько-мовного жіночого роману – від канонічного, через емансипований до постфеміністського, – у його зв'язку з широким розповсюдженням ідей фемінізму та породженими останнім гендерними дослідженнями.The article offers the results of the author's analysis of Romance in the USA, UK and Germany, following its development from the Canon, through the Emancipated, to the present-day Post-feminist, all stages connected with and influenced by the growth of the ideas of feminism and Gender Studies

Older people's attitudes towards deprescribing cardiometabolic medication

Abstract Background Overtreatment with cardiometabolic medication in older patients can lead to major adverse events. Timely deprescribing of these medications is therefore essential. Self-reported willingness to stop medication is usually high among older people, still overtreatment with cardiometabolic medication is common and deprescribing is rarely initiated. An important barrier for deprescribing reported by general practitioners is the patients’ unwillingness to stop the medication. More insights are needed into the influence of patients’ characteristics on their attitudes towards deprescribing and differences in these attitudes between cardiometabolic medication groups. Methods A survey in older people using cardiometabolic medication using the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire was performed. Participants completed the general rPATD and an adapted version for four medication groups. Linear and ordinal logistic regression were used to assess the influence of age, sex, therapeutic area and number of medications used on the patients’ general attitudes towards deprescribing. Univariate analysis was used to compare differences in deprescribing attitudes towards sulfonylureas, insulins, antihypertensive medication and statins. Results Overall, 314 out of 1143 invited participants completed the survey (median age 76 years, 54% female). Most participants (80%) were satisfied with their medication and willing to stop medications if their doctor said it was possible (88%). Age, sex and therapeutic area had no influence on the general attitudes towards deprescribing. Taking more than ten medicines was significantly associated with a higher perceived medication burden. Antihypertensive medication and insulin were considered more appropriate than statins, and insulin was considered more appropriate than sulfonylureas not favouring deprescribing. Conclusions The majority of older people using cardiometabolic medication are willing to stop one of their medicines if their doctor said it was possible. Health care providers should take into account that patients perceive some of their medication as more appropriate than other medication when discussing deprescribing

Barriers and Enablers of Healthcare Providers to Deprescribe Cardiometabolic Medication in Older Patients:A Focus Group Study

INTRODUCTION: Benefits and risks of preventive medication change over time for ageing patients and deprescribing of medication may be needed. Deprescribing of cardiovascular and antidiabetic drugs can be challenging and is not widely implemented in daily practice. OBJECTIVE: The aim of this study was to identify barriers and enablers of deprescribing cardiometabolic medication as seen by healthcare providers (HCPs) of different disciplines, and to explore their views on their specific roles in the process of deprescribing. METHODS: Three focus groups with five general practitioners, eight pharmacists, three nurse practitioners, two geriatricians, and two elder care physicians were conducted in three cities in The Netherlands. Interviews were recorded and transcribed verbatim. Directed content analysis was performed on the basis of the Theoretical Domains Framework. Two researchers independently coded the data. RESULTS: Most HCPs agreed that deprescribing of cardiometabolic medication is relevant but that barriers include lack of evidence and expertise, negative beliefs and fears, poor communication and collaboration between HCPs, and lack of resources. Having a guideline was considered an enabler for the process of deprescribing of cardiometabolic medication. Some HCPs feared the consequences of discontinuing cardiovascular or antidiabetic medication, while others were not motivated to deprescribe when the patients experienced no problems with their medication. HCPs of all disciplines stated that adequate patient communication and involving the patients and relatives in the decision making enables deprescribing. Barriers to deprescribing included the use of medication initiated by specialists, the poor exchange of information, and the amount of time it takes to deprescribe cardiometabolic medication. The HCPs were uncertain about each other's roles and responsibilities. A multidisciplinary approach including the pharmacist and nurse practitioner was seen as the best way to support the process of deprescribing and address barriers related to resources. CONCLUSION: HCPs recognized the importance of deprescribing cardiometabolic medication as a medical decision that can only be made in close cooperation with the patient. To successfully accomplish the process of deprescribing they strongly recommended a multidisciplinary approach

Preferences of patients and pharmacists with regard to the management of drug-drug interactions: A choice-based conjoint analysis

Background For the management of drug-drug interactions (DDI), a risk-benefit assessment should be combined with the patient's perspective. Objective To investigate patients' and pharmacists' preferences regarding DDI management Design and methods We conducted an online choice-based conjoint survey among patients and pharmacists. The choice task was about the management of a fictitious DDI: the combination of a cardiovascular drug and an antibiotic for pneumonia leading to a risk for developing muscle problems. Respondents answered twelve choice sets of two DDI-management options. The options were only described by their five characteristics (attributes) regarding risk for adverse events, benefit, and practical consequences. Each of the five attributes could have two different levels (e.g. low or high risk), which were varied over the 12 choice tasks. Data were analysed by latent class analysis in order to identify potential classes (subgroups) of respondents with similar preference patterns. Results The survey was completed by 298 patients and 178 pharmacists. The latent class model for both patients and pharmacists resulted in three classes. The first class of patients attached most importance to fewer adverse events (class probability 41%), the second class attached most importance to avoiding a medication switch (20%), and the third class attached most importance to blood sampling (39%). For pharmacists, the first class attached most importance to curing pneumonia (31%), the second class to avoiding a medication switch (31%), and the third class to avoiding blood sampling (38%). Conclusion Among patients and pharmacists diverging preferences regarding DDI management were observed. Some subgroups of respondents attached most value to risk or benefit while others attached more value to practical considerations. Awareness of existing variability in preferences among and between pharmacists and patients can contribute to shared decision making in DDI management

Clinical decision rules and measuring renal function in community pharmacy: what do we get out of it?

OBJECTIVE To investigate the frequency and management of drug therapy alerts about drug use in patients with (potential) renal impairment, to investigate the contribution of point- of-care testing (PoCT) of renal function in community pharmacy to the availability of information on renal function, and to investigate pharmacists' experiences with drug therapy alerts and PoCT. DESIGN AND METHODS A clinical decision support system with clinical decision rules for eleven drugs (seven antibiotics, sotalol, digoxin, allopurinol and spironolactone) and PoCT of renal function were implemented in community pharmacies. The clinical decision rules generated an alert when dose adjustment was advised based on a registered impaired renal function, and when information on the renal function was lacking for patients over 70 years of age with a prescription for one of the selected drugs. Data registered in the clinical decision support system regarding generated alerts, renal functions and alert management were analysed retrospectively. In addition, the participating pharmacists filled out a questionnaire about their experiences. RESULTS 336 pharmacists managed 27.307 alerts for 21.494 patients, leading to 362 dose adjustments and 65 drug replacements. For 16.208 of these patients, renal function has been registered in the clinical decision support system, including over 400 PoCT measurements. Based on PoCT, 25 cases of impaired renal function have been registered, leading to two therapy adjustments. The participating pharmacists were positive about the project. CONCLUSION Advanced clinical decision rules on renal function led to over 400 therapy adjustments. PoCT is a potentially useful source of information on renal function in a limited number of cases, when this information is urgently needed and not available from other sources

The CombiConsultation for patients with diabetes, COPD and cardiovascular diseases: Evaluation of interventions and personal health-related goals

Background: The CombiConsultation is a consultation with the community pharmacist for patients with diabetes, COPD and/or cardiovascular disease (CVD), aligned with the annual or quarterly consultation with the practice nurse (PN) or general practitioner (GP). The consultation is focused on the personal health-related goals of the patient. Objectives: To assess the number and types of personal health-related goals, drug-related problems (DRPs) and interventions identified by pharmacists during a CombiConsultation and to investigate which patients can benefit most from such consultation. Method: Twenty-one Dutch community pharmacies and associated GP practices were included in the CombiConsultation study. CombiConsultations were performed, involving patients with diabetes, COPD and/or (at risk of) CVD. The pharmacists set health-related goals together with the patients and identified DRPs. The number and types of personal health-related goals, DRPs and interventions were analysed. Associations between patient characteristics and the identification of at least one DRP were analysed by multivariate regression analysis. Results: In 834 patients (49% men, mean age: 70 years), 939 DRPs were identified, mostly (potential) side effects (33%), undertreatment (18%) and overtreatment (14%). In 71% of the patients, one or more DRPs were found, with a median of one DRP per patient. Pharmacists proposed 935 recommendations, of which 72% were implemented. DRPs were found more often in patients using a higher number of drugs for chronic conditions. A total of 425 personal health-related goals were set, of which 53% were (partially) attained. Conclusion: The CombiConsultation can be used as a compact health service contributing to safe and effective use of medication for patients with diabetes, COPD and/or (at risk of) CVD, also in patients under 65 or with less than 5 medications in use. The output of the CombiConsultation reflects its characteristics

Barriers and facilitators for the implementation of the CombiConsultation by general practitioners, pharmacists and practice nurses: a qualitative interview study

BACKGROUND: The CombiConsultation is a consultation with the pharmacist for patients with a chronic condition, aligned with the periodic consultation with the practice nurse or general practitioner. Implementation requires adjustments in the working methods of these healthcare providers and therefore behavioural changes. AIM: The aim of this study was to identify the barriers and facilitators that determine the behavioural changes by pharmacists, general practitioners and practice nurses required for the implementation of the CombiConsultation. METHOD: Ten community pharmacists, 5 practice nurses and 5 general practitioners were sampled from practices enrolled in the CombiConsultation study. Their views regarding the implementation of this clinical pharmacy service were explored using interviews based on the 14 domains of the Theoretical Domains Framework (TDF), which are linked to the Capability-Opportunity-Motivation-Behaviour-model. Barriers and facilitators in the domains were assessed by content analysis. RESULTS: Twelve barriers and 23 facilitators were found within 13 TDF domains with high agreement between the healthcare providers. Important facilitators for implementation were the pharmacists' expertise in pharmacotherapy (capability), access to medical data and physical proximity between professional practices (opportunity). Barriers were pharmacists' insufficient consultation- and clinical-reasoning skills (capability), insufficient staff (opportunity) and reimbursement and lack of coordination among all involved healthcare providers (motivation). CONCLUSION: All healthcare providers are motivated to implement the CombiConsultation. An existing collaborative practice, with a clear and accepted professional role of the pharmacist is essential. Training of pharmacists in consultation and clinical-reasoning skills can be beneficial, as well as arrangements on the consultation logistics, and reimbursement

Preferences of Patients and Pharmacists with Regard to the Management of Drug-Drug Interactions:A Choice-Based Conjoint Analysis

INTRODUCTION: The management of drug-drug interactions (DDIs) is a complex process in which risk-benefit assessments should be combined with the patient's perspective. OBJECTIVE: The aim of this study was to determine patients' and pharmacists' preferences regarding DDI management. METHODS: We conducted a choice-based conjoint survey about a fictitious DDI concerning the combination of a cardiovascular drug and an antibiotic for pneumonia. Patients and pharmacists had to choose 12 times between two management options. The options were described by five attributes, including risk, benefit and practical consequences. Each attribute could have two different levels, which were varied over the choice tasks. Latent class analysis was used to identify potential classes of respondents with distinct patterns of similar preferences. RESULTS: In total, 298 patients and 178 pharmacists completed the questionnaire. The latent class model for both patients and pharmacists resulted in three classes. For patients, in one class the most importance was attached to avoiding switch of medication (class probability 20%), in a second class to fewer adverse events (41%), and in a third class to blood sampling (39%). For pharmacists, again one class attached the highest importance to avoiding switch of medication (31%). The other classes gave priority to curing pneumonia (31%) and avoiding blood sampling (38%). CONCLUSION: The results showed diverging preferences regarding DDI management among both patients and pharmacists. Different groups attached different value to risk and benefit versus practical considerations. Awareness of existing variability in preferences among and between pharmacists and patients is a step towards shared decision making in DDI management

The CombiConsultation: a new concept of sequential consultation with the pharmacist and practice nurse/general practitioner for patients with a chronic condition

The primary health care system is generally well organized for dealing with chronic diseases, but comprehensive medication management is still a challenge. Studies suggest that pharmacists can contribute to effective and safe drug therapy by providing services like a clinical medication review (CMR). However, several factors limit the potential impact of a CMR. Therefore, we propose a new pharmaceutical care service for patients with a chronic condition: the CombiConsultation. The CombiConsultation is a medication evaluation service conducted by the (community) pharmacist and either the practice nurse or general practitioner. It consists of 3 steps: medication check, implementation and follow-up. The pharmacist primarily focusses on setting treatment goals for 1 or 2 drug-related problems in relation to a specific chronic condition. In this manuscript we describe the process and characteristics of the CombiConsultation. We compare the CombiConsultation with the CMR and explain the choices made and the implications for implementation