The Pharmaceutical Journal
Vol 273 No 7315 p324
4 September 2004

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IJPP focuses on UK — side effect risks, nurse prescribing and care homes

Research published in the September issue of the International Journal of Pharmacy Practice is highlighted by Helen Bond

A study from the University of Reading has identified the differences in the interpretation of labels concerning side effect incidence rates between and doctors and non-medically qualified people.

The move towards shared decision making between patient and doctor in treatment options results in the increasing importance of a common understanding of the language used to describe the risks of side effects. Risk can be described numerically as a percentage or verbally in terms such as “common” or “rare” as outlined by EU guidelines. Due to the wide variation in patient numeracy, doctors have been found to prefer using verbal terms of explanation. However, studies have shown that there is little consistency in how patients interpret these terms.

In the study, side effects were described and participants were asked to estimate the percentage of the population who would experience them. Doctors and lay persons both overestimated the risk of side effects: the small number of participants whose estimates fell within the EU assigned probability ranges was particularly striking. This is concerning since these descriptors are starting to be used in mandatory patient information leaflets and other communications about risks.

The degree of overestimation in the doctor’s responses was not as great as in the lay persons’, and doctors showed less variability in their interpretation of the terms (possibly because they had more experience of side effects and their likelihood of occurrence). Thus, it could be argued that verbal descriptors should be used for describing side effects, but that the EU has attached the wrong labels to the specified probability ranges.

The study suggests that we are still a long way from achieving a standardised language of risk, although there might be more potential for use of standardised terms among professionals than the general public. The EU and other regulatory bodies should be cautious about advocating the use of particular verbal labels for describing side effects of medicines.

Influence of PCT on nurse prescribing
The NHS in the UK has, in recent years, introduced a number of measures to influence prescribing. Most of these have been focused on doctors; however, nurses have been prescribing in the UK from the Nurse Prescriber’s Formulary since 1994, and can assume responsibility for managing the care of certain patients. Thus, they have a direct effect on treatment choice, patient outcomes and cost.

A study from the University of Manchester describes the methods that primary care trusts use to influence the prescribing practices of community nurses and explores the views of nurse prescribers regarding these methods.

The methods used by PCTs to influence the decision making of nurse prescribers include formularies and guidelines, continuing professional development and directives. However, there appears to be little consistency in their implementation across PCTs. For example, only two out of five PCTs had a local formulary that included items that nurses were able to prescribe.

PCT support of CPD included updating nurse prescribers regarding current issues, training and development, and provision of feedback. However, relevance and success appear varied; for example, several nurse prescribers mentioned receiving newsletters that were of little relevance to their practice. Each of the PCTs held educational meetings for nurse prescribers, although their nature and extent were diverse. Some prescribers received informal feedback on an ad hoc basis, although many nurses interviewed stated that they would like to receive feedback on their performance.

The study states that PCTs must provide support for their non-medical prescribers to allow them to prescribe appropriately, safely, effectively and economically. In order to do this, PCTs will need to monitor the prescribing of all their prescribers, even if prescribing rates are low, and assess which areas require support. Support strategies can be developed in association with the prescribers to ensure that they meet their needs.

Inspection of homes
Long-term care of older people has become a major issue in the UK, driven by the increasing proportion of older adults and, consequently, health care costs. Concern over quality of care has been raised and strategies are being developed to ensure a minimal standard of care is attained.

Regulation and inspection are central to promoting quality within long-term care
facilities. However, it has been recognised that there is a lack of a unified regulatory method.

A study from the Queen’s University of Belfast has highlighted issues currently being inspected in care homes in Northern Ireland.

In the UK, care homes must be registered under the Care Standards Act 2000, and national minimum standards for care homes have been introduced. Registered managers must seek information and advice from a pharmacist regarding medicines policies and medicines dispensed in the home. However, there is no requirement for clinical-based pharmaceutical services, such as medication reviews, to be provided.

The analysis of inspection reports from 415 homes highlighted issues relating to the safe and effective use of medicines. Over 60 per cent of homes were found to have problems with record keeping, for example, administration sheets or prescription records. Inspection of “ordering and receipt of medicines” resulted in recommendations to improve standards in over a quarter of homes, and another significant area highlighted “medication”, for example, incorrect administration times.

The study concludes that the development of common documentation that promotes better care and a more patient-centred approach to inspection in the UK may go some way to optimising medicines use in elderly residents and possibly provide a structured framework to meet the challenges of caring for older people in residential and nursing homes.