Prescribing practices of Australian dispensing doctors

Background: In response to health workforce shortages policymakers have considered expanding the roles that a health professional may perform. A more traditional combination of health professional roles is that of a dispensing doctor (DD) who routinely prescribes and dispenses pharmaceuticals. A systematic review conducted on mainly overseas DDs’ practices found that DDs tended to prescribe more items per patients, less often generically, and showed poorer adherence to best practice. Convenience for patients was cited by both patients and DDs as the main reason for dispensing. In Australia, rural doctors are allowed to dispense Pharmaceutical Benefit Scheme (PBS) subsidised pharmaceutical benefits if there is no reasonable pharmacy coverage. Little was known about the practices of these Australian DDs. Objectives: To examine the PBS prescribing patterns of dispensing with matched non-dispensing doctors and identify factors that influence prescribing behaviour. Method: A sequential explanatory (QUAN-->qual) mixed methodology was utilised. Firstly, rurality-matched DDs’ and non-DDs’ PBS data for fiscal years 2005-7 were analysed against criteria distilled from a systematic review and stakeholder consultations. Secondly, structured interviews were conducted with a purposive sample of DDs to examine the quantitative findings. Key findings: DDs prescribed significantly fewer PBS prescriptions per patients but used Regulation 24 significantly more than non-DDs. Regulation 24 biased the prescribing data. DDs prescribed proportionally more penicillin type antibiotics, adrenergic inhalants and non-steroidal anti-inflammatories as compared to non-DDs. Reasons offered by DD-respondents highlighted that prescribing was influenced by an awareness of cost to the patients, peer pressure and confidential prescriber feedback provided on a regular basis. Implications: This innovative census study does not support international data that DDs are less judicious in their prescribing. There is some evidence that DDs might reduce health inequity between rural and urban Australian, and that the DD health model is valuable to patients in isolated communities.

Australian dispensing doctors' prescribing : quantitative and qualitative analysis

Objective: To evaluate the prescribing practices of Australian dispensing doctors (DDs) and to explore their interpretations of the findings. Design, participants and setting: Sequential explanatory mixed methods. The quantitative phase comprised analysis of Pharmaceutical Benefits Scheme (PBS) claims data of DDs and non-DDs, 1 July 2005 30 June 2007. The qualitative phase involved semi-structured interviews with DDs in rural and remote general practice across Australian states, August 2009 February 2010. Main outcome measures: The number of PBS prescriptions per 1000 patients and use of Regulation 24 of the National Health (Pharmaceutical Benefits) Regulations 1960 (r. 24); DDs' interpretation of the findings. Results: 72 DDs' and 1080 non-DDs' PBS claims data were analysed quantitatively. DDs issued fewer prescriptions per 1000 patients (9452 v 15057; P = 0.003), even with a similar proportion of concessional patients and patients aged >65 years in their populations. DDs issued significantly more r. 24 prescriptions per 1000 prescriptions than non-DDs (314 v 67; P=0.008). Interviews with 22 DDs explained that the fewer prescriptions were due to perceived expectation from their peers regarding prescribing norms and the need to generate less administrative paperwork in small practices. Conclusions: Contrary to overseas findings, we found no evidence that Australian DDs overprescribed because of their additional dispensing role. MJA 2011; 195: 172-175

Cholesterol-lowering management of stroke : inconsistencies of evidence and practice

Cholesterol-lowering treatment by statins is an important and costly issue; however, its role in stroke has not been well documented. The aim of the present study was to review literature and current practice regarding cholesterol-lowering treatment for stroke patients. A literature review was conducted on lipids in stroke and their management with both statins and diet, including the cost-effectiveness of medical nutrition therapy. Qualifying criteria and prescription procedures of the Pharmaceutical Benefits Scheme (PBS) were also reviewed. Data on lipid levels and statin prescriptions were analysed for 468 patients admitted to a stroke unit. The literature shows that management with both medication and diet can be effective, especially when combined; however, 60% of patients with an ischaemic event had fasting total cholesterol measures ≥4 mmol/L (n = 231), with only 52% prescribed statins on discharge (n = 120). Hypercholesterolaemia is an underdiagnosed and undertreated risk factor within the stroke population. It appears that the PBS has not kept pace with advances in the evidence in terms of statin use in the stroke population, and review is needed. The present review should address the qualifying criteria for the stroke population and recommendations on referral to dietitians for dietary advice. Cholesterol-lowering treatment for both stroke patients and the wider population is an area that needs awareness raising and review by the PBS, medical practitioners and dietitians. The role of dietary and pharmacological treatments needs to be clearly defined, including adjunct therapy, and the cost-effectiveness of medical nutrition therapy realised.

A snapshot of Australian nurse practitioners’ extended practice activities

Introduction The Australian Nurse Practitioner Project (AUSPRAC) was initiated to examine the introduction of nurse practitioners into the Australian health service environment. The nurse practitioner concept was introduced to Australia over two decades ago and has been evolving since. Today, however, the scope of practice, role and educational preparation of nurse practitioners is well defined (Gardner et al, 2006). Amendments to specific pre-existing legislation at a State level have permitted nurse practitioners to perform additional activities including some once in the domain of the medical profession. In the Australian Capital Territory, for example 13 diverse Acts and Regulations required amendments and three new Acts were established (ACT Health, 2006). Nurse practitioners are now legally authorized to diagnose, treat, refer and prescribe medications in all Australian states and territories. These extended practices differentiate nurse practitioners from other advanced practice roles in nursing (Gardner, Chang & Duffield, 2007). There are, however, obstacles for nurse practitioners wishing to use these extended practices. Restrictive access to Medicare funding via the Medicare Benefit Scheme (MBS) and the Pharmaceutical Benefit Scheme (PBS) limit the scope of nurse practitioner service in the private health sector and community settings. A recent survey of Australian nurse practitioners (n=202) found that two-thirds of respondents (66%) stated that lack of legislative support limited their practice. Specifically, 78% stated that lack of a Medicare provider number was ‘extremely limiting’ to their practice and 71% stated that no access to the PBS was ‘extremely limiting’ to their practice (Gardner et al, in press). Changes to Commonwealth legislation is needed to enable nurse practitioners to prescribe medication so that patients have access to PBS subsidies where they exist; currently patients with scripts which originated from nurse practitioners must pay in full for these prescriptions filled outside public hospitals. This report presents findings from a sub-study of Phase Two of AUSPRAC. Phase Two was designed to enable investigation of the process and activities of nurse practitioner service. Process measurements of nurse practitioner services are valuable to healthcare organisations and service providers (Middleton, 2007). Processes of practice can be evaluated through clinical audit, however as Middleton cautions, no direct relationship between these processes and patient outcomes can be assumed.

Prescriptions for reform of Australia's superannuation tax concessions

The highly controversial and often politicised issue of Australia’s retirement savings regime featured prominently throughout the two day Federal Government’s October 2011 Tax Forum. Calls for reform of this regime are by no means new. Reform debate over the years has focused on each of the three separate pillars: the age pension, compulsory superannuation, and voluntary saving, as well as the interaction of those three elements. However, recently there has been a significant shift away from reliance on the age pension, with its associated risks falling to the government, to a defined contributions scheme where the associated risks fall to the individual taxpayer. Consequently, Australia’s superannuation regime is predominantly subject to current debate, and, as such, the subject of this article. This article considers the history of Australia’s retirement savings regime, along with a framework for evaluating the superannuation tax concessions. It then discusses the recommendations of the Australian Future Tax System (AFTS) Review Panel and ensuing debate at the Tax Forum. Finally, it suggests two proposals to achieve the objectives of the AFTS Review in relation to retirement, those objectives being a system which is broad and adequate, acceptable to individuals, robust, simple and approachable, and finally sustainable. The first, whilst potentially requiring some tinkering’, is relatively simple and a blue print has already been provided to the Federal Government – the adoption of Recommendations 18 and 19 of the AFTS Review. The second is one of management. Superannuation concessions are fundamentally categorised as tax expenditures and the management of these tax expenditures, not just the reporting, should be undertaken.

Efficient Hg and Ag ion detection with luminescent PbS quantum dots grown in poly vinyl alcohol and capped with mercaptoethanol

PbS quantum dots capped with mercaptoethanol (C2H5OSH) have been synthesized in poly vinyl alcohol and used to investigate their photoluminescence (PL) response to various ions such as zinc (Zn), cadmium (Cd), mercury (Hg), silver (Ag), copper (Cu), iron (Fe), manganese (Mn), cobalt (Co), chromium (Cr) and nickel (Ni). The enhancement in the PL intensity was observed with specific ions namely Zn, Cd, Hg and Ag. Among these four ions, the PL response to Hg and Ag even at sub-micro-molar concentrations was quite high, compared to that of Zn and Cd. It was observed that the change in Pb and S molar ratio has profound effect on the sensitivity of these ions. These results indicate that the sensitivity of these QDs could be fine-tuned by controlling the S concentration at the surface. Contrary to the above, Cu quenched the photoluminescence. In Cd based QDs related ion probing, Hg and Cu was found to have quenching properties, however, our PbS QDs have quenching property only for Cu ions. This was attributed to the formation HgS at the surface that has bandgap higher than PbS. Another interesting property of PbS in PVA observed is photo-brightening mechanism due to the curing of the polymer with laser. However, the presence of excess ions at the surface changes its property to photo-darkening/brightening that depends on the direction of carrier transfer mechanism (from QDs to the surface adsorbed metal ions or vice-versa). which is an interesting feature for metal ion detectivity.

Shape-Dependent Confinement in Ultrasmall Zero-, One-, and Two-Dimensional PbS Nanostructures

Spatial dimensionality affects the degree of confinement when an electron-hole pair is squeezed from one or more dimensions approaching the bulk exciton Bohr radius (alpha(B)) limit. The etectron-hole interaction in zero-dimensional (0D) dots, one-dimensional (1D) rods/wires, and two-dimensional (2D) wells/sheets should be enhanced by the increase in confinement dimensions in the order 0D > 1D > 2D. We report the controlled synthesis of PbS nanomateriats with 0D, 1D, and 2D forms retaining at least one dimension in the strongly confined regime far below alpha(B) (similar to 10 nm for PbS) and provide evidence through varying the exciton-phonon coupling strength that the degree of confinement is systematically weakened by the loss of confinement dimension. Geometry variations show distinguishable far-field optical polarizations, which could find useful applications in polarization-sensitive devices.

Observation of persistent photoconductivity in flower shaped PbS dendrite structures

We report the observation of persistent photoconductivity (PPC) in flower shaped PbS dendrites grown by the hydrothermal method. Potential fluctuations, due to the presence of various confinement regimes in the branches of dendrites, and surface traps, are likely responsible for the PPC observed here. We also observed photocurrent quenching and decreased dark current in the PPC below 40 K, due to the presence of a metastable state, whereas positive PPC was observed in the temperature region 40-220 K. Dark conductivity measurements, time constant parameters obtained from the stretched exponential fittings of PPC, also showed the metastable state related transition around 50 K.

Elastic properties of PbS-As2S3 glasses

The temperature dependence of the longitudinal and shear ultrasound wave velocities in (As2S3)1-x(PbS)x glasses has been determined from 77 to 300K using a pulse echo interferometer. Elastic constants of the prepared glasses at room temperature have been computed from the experimental data. Both longitudinal and shear ultrasound wave velocities in these glasses show a linear temperature dependence with a negative temperature coefficient.

Ion probing with Luminescent PbS Quantum dots in PVA

The PbS quantum dots synthesized in PVA are used to investigate their photoluminescence (PL) response to various ions such as Zn, Cd, Hg, Ag, Cu, Fe, Mn, Co, Cr and Ni ions. The enhancement in the photoluminescence intensity is observed with specific ions namely Zn, Cd, Hg and Ag. Among these four ions, the PL response to Hg and Ag even at sub-micro-molar concentrations is quite high, approximately an order of magnitude higher than Zn and Cd. It is interesting to observe that the change in Pb and S molar ratio has profound effect on the selectivity of these ions. The samples prepared under excess of S are quite effective compared to Pb. Indeed, the later one has hardly any effect on the photoluminescence response. These results also indicate that the sensitivity of these QDs could be fine-tuned by controlling the S concentration at the surface. Contrary to the above, Cu, Fe and Co quenches the photoluminescence. Another interesting property of PbS in PVA observed is photo-brightening mechanism due to the curing of the polymer with laser. However, the presence of excess ions at the surface changes its property to photo-darkening/brightening that depends on the direction of carrier transfer mechanism (from QDs to the surface adsorbed metal ions or vice-versa), which is an interesting feature for metal ion detectivity.

Two beam photoluminescence of PbS quantum dots in polyvinyl alcohol

We report the effect of dual beam excitation on the photoluminescence (PL) from PbS quantum dots in polyvinyl alcohol by using two excitation lasers, namely Ar+ (514.5 nm) and He-Ne laser (670 nm). Both sources of excitation gave similar PL spectra around 1.67 eV (related to shallow traps) and 1.1 eV (related to deep traps). When both lasers were used at the same time, we found that the PL induced by each of the lasers was partly quenched by the illumination of the other laser. The proposed mechanism of this quenching effect involves traps that are populated by one specific laser excitation, being photo-ionized by the presence of the other laser. Temperature, laser intensity and modulation frequency dependent quenching efficiencies are presented in this paper. This reversible modulation has potential for optical switching and memory device applications. (C) 2010 Elsevier B.V. All rights reserved.

Synthesis and metallic probe induced conductance of Au tipped ultranarrow PbS rods

Au tipped ultranarrow PbS nanorods are synthesized. DFT electronic structure calculations and transport studies show that Au probes modify the nature and energies of PbS nanorod orbitals creating efficient electron conduction channels for enhanced conductance even at low applied bias.

A Bottom-Up Approach toward Fabrication of Ultrathin PbS Sheets

Two-dimensional (2D) sheets are currently in the spotlight of nanotechnology owing to high-performance device fabrication possibilities. Building a free-standing quantum sheet with controlled morphology is challenging when large planar geometry and ultranarrow thickness are simultaneously concerned. Coalescence of nanowires into large single-crystalline sheet is a promising approach leading to large, molecularly thick 2D sheets with controlled planar morphology. Here we report on a bottom-up approach to fabricate high-quality ultrathin 2D single crystalline sheets with well-defined rectangular morphology via collective coalescence of PbS nanowires. The ultrathin sheets are strictly rectangular with 1.8 nm thickness, 200-250 nm width, and 3-20 mu m length. The sheets show high electrical conductivity at room and cryogenic temperatures upon device fabrication. Density functional theory (DFT) calculations reveal that a single row of delocalized orbitals of a nanowire is gradually converted into several parallel conduction channels upon sheet formation, which enable superior in-plane carrier conduction.