Assessment of factors that influence physician decision making regarding medication use in patients with dementia at the end of life

Objective
This study aimed to evaluate the extent to which patient-related factors and physicians' country of practice (Northern Ireland [NI] and the Republic of Ireland [RoI]) influenced decision making regarding medication use in patients with end-stage dementia.

Methods
The study utilised a factorial survey design comprising four vignettes to evaluate initiating/withholding or continuing/discontinuing specific medications in patients with dementia nearing death. Questionnaires and vignettes were mailed to all hospital physicians in geriatric medicine and to all general practitioners (GPs) in NI (November 2010) and RoI (December 2010), with a second copy provided 3 weeks after the first mailing. Logistic regression models were constructed to examine the impact of patient-related factors and physicians' country of practice on decision making. Significance was set a priori at p ≤ 0.05. Free text responses to open questions were analysed qualitatively using content analysis.

Results
The response rate was 20.6% (N = 662) [21.1% (N = 245) for GPs and 52.1% (N = 38) for hospital physicians in NI, 18.3% (N = 348) for GPs and 36.0% (N = 31) for hospital physicians in RoI]. There was considerable variability in decision making about initiating/withholding antibiotics and continuing/discontinuing the acetylcholinesterase inhibitor and memantine hydrochloride, and less variability in decision making regarding statins and antipsychotics. Patient place of residence and physician's country of practice had the strongest and most consistent effects on decision making although effect sizes were small.

Conclusions
Further research is required into other factors that may impact upon physicians' prescribing decisions for these vulnerable patients and to clarify how the factors examined in this study influence prescribing decisions.

Dynamics of macronutrient self-medication and illness-induced anorexia in virally infected insects

Some animals change their feeding behaviour when infected with parasites, seeking out substances that enhance their ability to overcome infection. This 'self-medication' is typically considered to involve the consumption of toxins, minerals or secondary compounds. However, recent studies have shown that macronutrients can influence the immune response and that pathogen-challenged individuals can self-medicate by choosing a diet rich in protein and low in carbohydrates. Infected individuals might also reduce food intake when infected (i.e. illness-induced anorexia). Here, we examine macronutrient self-medication and illness-induced anorexia in caterpillars of the African armyworm (Spodoptera exempta) by asking how individuals change their feeding decisions over the time course of infection with a baculovirus. We measured self-medication behaviour across several full-sib families to evaluate the plasticity of diet choice and underlying genetic variation. Larvae restricted to diets high in protein (P) and low in carbohydrate (C) were more likely to survive a virus challenge than those restricted to diets with a low P : C ratio. When allowed free choice, virus-challenged individuals chose a higher protein diet than controls. Individuals challenged with either a lethal or sublethal dose of virus increased the P : C ratio of their chosen diets. This was mostly due to a sharp decline in carbohydrate intake, rather than an increased intake of protein, reducing overall food intake, consistent with an illness-induced anorexic response. Over time the P : C ratio of the diet decreased until it matched that of controls. Our study provides the clearest evidence yet for dietary self-medication using macronutrients and shows that the temporal dynamics of feeding behaviour depends on the severity and stage of the infection. The strikingly similar behaviour shown by different families suggests that self-medication is phenotypically plastic and not a consequence of genetically based differences in diet choice between families. © 2013 British Ecological Society.

What the newspapers say about medication adherence: a content analysis

Background: This study investigates the coverage of adherence to medicine by the UK and US newsprint media. Adherence to medicine is recognised as an important issue facing healthcare professionals and the newsprint media is a key source of health information, however, little is known about newspaper coverage of medication adherence.

Methods. A search of the newspaper database Nexis®UK from 2004-2011 was performed. Content analysis of newspaper articles which referenced medication adherence from the twelve highest circulating UK and US daily newspapers and their Sunday equivalents was carried out. A second researcher coded a 15% sample of newspaper articles to establish the inter-rater reliability of coding.

Results: Searches of newspaper coverage of medication adherence in the UK and US yielded 181 relevant articles for each country. There was a large increase in the number of scientific articles on medication adherence in PubMed® over the study period, however, this was not reflected in the frequency of newspaper articles published on medication adherence. UK newspaper articles were significantly more likely to report the benefits of adherence (p = 0.005), whereas US newspaper articles were significantly more likely to report adherence issues in the elderly population (p = 0.004) and adherence associated with diseases of the central nervous system (p = 0.046). The most commonly reported barriers to adherence were patient factors e.g. poor memory, beliefs and age, whereas, the most commonly reported facilitators to adherence were medication factors including simplified regimens, shorter treatment duration and combination tablets. HIV/AIDS was the single most frequently cited disease (reported in 20% of newspaper articles). Poor quality reporting of medication adherence was identified in 62% of newspaper articles.

Conclusion: Adherence is not well covered in the newspaper media despite a significant presence in the medical literature. The mass media have the potential to help educate and shape the public's knowledge regarding the importance of medication adherence; this potential is not being realised at present. © 2013 Goodfellow et al.; licensee BioMed Central Ltd.

The relationship between BMI and the prescription of anti-obesity medication according to social factors: a population cross sectional study

Background: Obesity is a global public health problem. There are a range of treatments available with varying short and long term success rates. One option is the use of anti-obesity medication the prescription of which has increased dramatically in recent years. Despite this, little is known about the individual and GP practice factors that influence the prescription of anti-obesity medication. Methods: Multi-level logistic regression analysis was used to investigate factors associated with the prescription of anti-obesity medication in Northern Ireland using a population primary care prescribing database (~1.5 million people aged 16+ years) during 2009/10. Results: While 25.0% of people are obese, only 1.3% (2.1% of females, 0.6% of males) received anti-obesity medication. The relationship between medication rates and age differed by gender (P < 0.001) with prescriptions higher in younger females and older males. Prescribing of anti-obesity medication reflected obesity prevalence across urban/rural areas and deprivation. There was an unexplained two-fold difference, between the 25th and 75th percentile, in the GP practice prescription of anti-obesity medication. Conclusions: There is evidence of relative under-prescribing in males compared to females despite a similar prevalence of obesity. While the prevalence (and presumably the health consequences) of obesity worsens with age, younger females are more likely to be prescribed anti-obesity medication. This suggests an element of patient demand. Educational material to improve the understanding of the role of anti-obesity medication, for patients and practitioners, is recommended. But further study is needed to understand the factors responsible for the variation in prescribing between GP practices.

Better together: Interprofessional Education in Medication Safety

Background: The importance of actively working with other professionals, as part of a single team, is well embedded in discussions relating to effective healthcare. The need for effective teamwork specifically in relation to patient safety is also widely acknowledged; however healthcare has traditionally been poor at building teams and professional groups tend to function semi-autonomously and autocratically.1
Objective: This study aims to gain the views and experiences of students from nursing, pharmacy and medicine involved in an interprofessional workshop in medication safety.
Setting and methods: Interprofessional workshops involving students from nursing, pharmacy and medicine were delivered using case studies involving medication incidents. Focus groups were used to investigate participant’s views and experiences of the workshop.
Results: Focus groups were completed with 22 students. Five main themes were identified from the focus group data relating to medication safety; these were increasing confidence, insight into roles, improving skills, culture of responsibility and application to future practice.
Conclusions: This study represents a model for delivery of training that has demonstrated improvement in the students’ attitudes towards team working and is a first step towards introducing team working into the medication safety program. The programme continues to run using live and virtual workshops.

1. Leape LL. A systems analysis approach to medical error. J Clin Eval Clin Pract. 1997. 3, 3, 213-222.

Medication use review in Qatar: Are community pharmacists prepared for the extended professional role?

Background
The incidence of chronic illnesses is increasing globally. Non-adherence to medications and other medication-related problems are common among patients receiving long-term medications. Medication use review (MUR) is a service provision with an accredited pharmacist undertaking structured, adherence-centered reviews with patients receiving multiple medications. MUR services are not yet available in community pharmacies in Qatar.

Objective
The current study aims to evaluate community pharmacists' knowledge, attitudes, and perception towards establishing MUR as an extended role in patient care.

Setting
Private community pharmacies in Qatar including chains and independent pharmacies.

Methodology
A cross-sectional survey using a self-administered questionnaire was conducted among licensed community pharmacists from December 2012 to January 2013. Data analysis was conducted using descriptive and inferential statistics.

Main outcome measures
Knowledge, attitudes, and practices related to MUR concept and services.

Results A total of 123 participants responded to the survey (response rate 56 %). The mean total knowledge score was 71.4 ± 14.7 %. An overwhelming proportion of the participants (97 %) were able to identify the scope of MUR in relation to chronic illnesses and at enhancing the quality of pharmaceutical care. Furthermore, 80 % of the respondents were able to identify patients of priority for inclusion in an MUR program. However, only 43 % of the participants knew that acute medical conditions were not the principal focus of an MUR service, while at least 97 % acknowledged that the provision of MUR services is a great opportunity for an extended role of community pharmacists and that MUR makes excellent use of the pharmacist's professional skills in the community. The participants generally reported concerns about time, dedicated consultation area, and support staff as significant barriers towards MUR implementation.

Conclusion
This study suggests that community pharmacists in Qatar had sufficient knowledge about the concept of MUR and its scope, but there were still important deficiencies that warrant further education. The findings have important implications on policy and practice pertaining to the implementation of MUR as an extended role of pharmacists and as part of Qatar's National Health Strategy to move primary health care forward.