The RISAP-study: a complex intervention in risk communication and shared decision-making in general practice

General practitioners (GPs) and patients find it difficult to talk about risk of future disease, especially when patients have asymptomatic conditions, and treatment options are unlikely to cause immediate perceptible improvements in well-being. Further studies in risk communication training are needed. Aim:1) to systematically develop, describe and evaluate a complex intervention comprising a training programme for GPs in risk communication and shared decision-making, 2) to evaluate the effect of the training programme on real-life consultations between GPs and patients with high cholesterol levels, and 3) to evaluate patients' reactions during and after the consultations. Methods/Design The effect of the complex intervention, based around a training programme, will be evaluated in a cluster-randomised controlled trial with an intervention group and an active control group with 40 GPs and 280 patients in each group. The GPs will receive a questionnaire at baseline and after 6 months about attitudes towards risk communication and cholesterol-reducing medication. After each consultation with a participating high cholesterol-patient, the GPs will complete a questionnaire about decision satisfaction (Provider Decision Process Assessment Instrument). The patients will receive a questionnaire at baseline and after 3 and 6 months. It includes questions about adherence to chosen treatment (Morisky Compliance Scale), self-rated health (SF-12), enablement (Patient Enablement Instrument), and risk communication and decision-making effectiveness (COMRADE Scale). Prescriptions, contacts to the health services, and cholesterol level will be drawn from the registers. In each group, 12 consultations will be observed and tape-recorded. The patients from these 24 consultations will be interviewed immediately after the consultation and re-interviewed after 6 months. Eight purposefully selected GPs from the intervention group will be interviewed in a focus group 6 months after participation in the training programme. The process and context of the RISAP-study will be investigated in detail using an action research approach, in order to analyse adaptation of the intervention model to the specific context. Discussion This study aims at providing GPs and patients with a firm basis for active deliberation about preventive treatment options, with a view to optimising adherence to chosen treatment. Trial registration ClinicalTrials.gov Protocol Registration System NCT0118705

Self-monitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data

Background: Uptake of self-testing and self-management of oral anticoagulation has remained inconsistent, despite good evidence of their effectiveness. To clarify the value of self-monitoring of oral anticoagulation, we did a meta-analysis of individual patient data addressing several important gaps in the evidence, including an estimate of the effect on time to death, first major haemorrhage, and thromboembolism. / Methods: We searched Ovid versions of Embase (1980–2009) and Medline (1966–2009), limiting searches to randomised trials with a maximally sensitive strategy. We approached all authors of included trials and requested individual patient data: primary outcomes were time to death, first major haemorrhage, and first thromboembolic event. We did prespecified subgroup analyses according to age, type of control-group care (anticoagulation-clinic care vs primary care), self-testing alone versus self-management, and sex. We analysed patients with mechanical heart valves or atrial fibrillation separately. We used a random-effect model method to calculate pooled hazard ratios and did tests for interaction and heterogeneity, and calculated a time-specific number needed to treat. / Findings: Of 1357 abstracts, we included 11 trials with data for 6417 participants and 12 800 person-years of follow-up. We reported a significant reduction in thromboembolic events in the self-monitoring group (hazard ratio 0·51; 95% CI 0·31–0·85) but not for major haemorrhagic events (0·88, 0·74–1·06) or death (0·82, 0·62–1·09). Participants younger than 55 years showed a striking reduction in thrombotic events (hazard ratio 0·33, 95% CI 0·17–0·66), as did participants with mechanical heart valve (0·52, 0·35–0·77). Analysis of major outcomes in the very elderly (age ≥85 years, n=99) showed no significant adverse effects of the intervention for all outcomes. Interpretation: Our analysis showed that self-monitoring and self-management of oral anticoagulation is a safe option for suitable patients of all ages. Patients should also be offered the option to self-manage their disease with suitable health-care support as back-up. / Funding: UK National Institute for Health Research (NIHR) Technology Assessment Programme, UK NIHR National School for Primary Care Research

N-acetylcysteine for prevention of radiocontrast induced nephrotoxicity: the importance of dose and route of administration

Dose and route of administration of N-acetylcysteine are key factors to consider when evaluating whether this agent is effective in preventing radiocontrast induced nephropath

Health Authority Pharmacists’ Perceptions of Independent Pharmacist Prescribing

ABSTRACTBackground: In many jurisdictions, the pharmacist’s role continues to evolve from drug distribution–based service delivery to expanded scopes of practice, including independent prescribing of medications. Objectives: To assess health authority–based pharmacists’ attitudes, be-liefs, and perceptions about independent prescribing, to determine how independent prescribing may affect their behaviour, and to identify perceived barriers and enablers to incorporating it into their practice.Methods: An anonymous, cross-sectional online survey of 677 health authority–based pharmacists employed by Lower Mainland Pharmacy Services in British Columbia collected information in the following domains: demographic characteristics; attitudes, beliefs, and perceptions regarding pharmacist prescribing; anticipated effect of pharmacist prescribing on behaviour; likelihood of applying for this authority, if granted; and barriers and enablers to applying for prescribing authority and incorporating prescribing into their practice. A multivariate regression analysis was performed.Results: A total of 266 pharmacists (39.3%) responded to the survey. Most respondents agreed that prescribing is important to the profession and relevant to their practice, and that it might enhance job satisfaction. Additionally, respondents agreed that they had the expertise to prescribe. Respondents perceived prescribing as having the potential to positively affect behaviour, including deprescribing, prescribing at time of discharge or transfer, and renewing medications. Enablers to applying for pharma-cist prescribing authority included perceived positive impact on patient care and the profession, level of support from management and coworkers, and personal ability. No barriers were identified. About two-thirds of phar-macists indicated they would likely apply for prescribing authority if it were granted through legislation. Pharmacists with a clinical practice or research role were significantly more likely to apply to be a prescriber, whereas those with more than 10 years of experience were less likely to apply.Conclusions: In this study, health authority–based pharmacists held positive attitudes and beliefs about the value and impact of independent prescribing of medications on their practice and the profession. There were no perceived barriers to applying for prescribing authority or to incorporating prescribing into practice.RÉSUMÉContexte : Dans bien des provinces, le rôle du pharmacien ne cesse d’évoluer, depuis la prestation de services fondée sur la distribution de médicaments à des champs de pratique élargis, comprenant le droit de prescription autonome des médicaments. Objectifs : Évaluer les attitudes, les croyances et les opinions des pharmaciens rattachés à des régies de santé concernant le droit de prescription autonome, déterminer l’influence de ce droit sur leurs habitudes et recenser les éléments qui, selon eux, entravent ou facilitent l’intégration de ce droit dans leur pratique.Méthodes : Une enquête transversale anonyme en ligne s’adressant à 677 pharmaciens rattachés à une régie de santé et employés par les services de pharmacie des basses-terres continentales en Colombie-Britannique a permis de recueillir de l’information sur les domaines suivants : caractéris-tiques démographiques; attitudes, croyances et opinions concernant le droit de prescrire des pharmaciens; effets envisagés sur les habitudes du droit de prescrire accordé aux pharmaciens; probabilité de demander ce droit, s’il existe; et les éléments entravant ou facilitant la demande du droit de prescrire et l’intégration de ce droit dans leur pratique. Une analyse de régression multivariée a été réalisée.Résultats : Au total, 266 pharmaciens (39,3 %) ont répondu au sondage. La plupart d’entre eux ont affirmé que le droit de prescrire est important pour la profession et pertinent dans le cadre de leur pratique et que cet acte pourrait accroître leur satisfaction au travail. De plus, les répondants affirmaient qu’ils possédaient l’expertise requise pour prescrire. Selon eux, le droit de prescrire pouvait influencer positivement leurs habitudes, notamment en ce qui concerne l’interruption de la prescription, la prescription au moment du congé ou d’un transfert et le renouvellement de médicaments. Parmi les éléments incitant les pharmaciens à solliciter le droit de prescrire, on comptait les effets positifs présumés sur les soins offerts aux patients et sur la profession, le soutien de la part de la direction et des collègues et les capacités personnelles. Aucun obstacle n’a été recensé. Environ deux tiers des pharmaciens ont indiqué qu’ils solliciteraient probablement le droit de prescrire s’il était accordé par la loi. Les pharmaciens en pratique clinique et ceux en recherche étaient beaucoup plus enclins à faire la demande pour devenir prescripteurs alors que ceux comptabilisant plus de dix ans d’expérience étaient moins enclins à faire la demande.Conclusions : Dans la présente étude, les pharmaciens rattachés à une régie de santé affichaient une attitude et des croyances positives à propos de la valeur du droit de prescription autonome des médicaments et des effets qu’il aurait sur leur pratique et la profession. On n’a recensé aucun élément perçu comme un obstacle à la formulation d’une demande du droit de prescrire ou à l’inclusion de ce rôle dans la pratique