Last month, the research round-up provided you with an overview of articles focusing on prescribing in countries outside of the UK to try and gain a more global perspective on nurse prescribing practices. This month, we will examine a range of articles looking at prescribing in various aspects of cancer care. The first is a systematic review of the impact of nurse and pharmacist clinics with patients on anti-cancer medication, their care and experience. The second is a quantitative piece looking at nurse prescribing of opioids in cancer pain. Finally, we conclude with a review of pancreatic enzyme prescribing in the form of a national audit.
Nurse and pharmacist systemic anti-cancer therapy review clinics and their impact on patient experience and care: A systematic review
This article, published in the Journal of Advanced Nursing, sought to review the evidence surrounding nurse and pharmacist review of patients undergoing systemic anti-cancer therapy (SACT).
This systematic review of the literature was carried out using a robust protocol and incorporating the population, exposure and outcome (PEO) framework to manage the search strategy. The review took place in April 2022 and searched seven appropriate and respected databases. No timescales were set to capture the progress of this intervention from early evidence to current day. The outcomes measured were patient experience and care from a pharmacist or nurse-led interventional review. Robust inclusion and exclusion criteria were applied, and the quantitative data extracted converted to textual description, with the qualitative data subjected to appropriate thematic analysis. In total, 15 studies met the criteria for inclusion and after quality appraisal and thematic analysis, three main themes emerged with some clear sub-themes.
The three main themes were advanced clinical practice (ACP) SACT service development; ACP skills and qualifications; and the impact of ACP SACT services on patient care and outcomes. It was acknowledged that there was a variation in tasks undertaken by nurses and pharmacists, and role integration is restricted by limited physician engagement. It was also noted that role titles used, and skills and qualifications acquired, differ and professional autonomy is variable. The authors conclude that the evidence they sought in relation to the advanced practice role is limited in this area, and that there is no clear definition of skills needed and how these roles are affecting patient experience and outcomes.
They suggest that more research is necessary and suggest a focus on role implementation, skills and academic qualifications required to elicit the extent of patient and physician experience of, and satisfaction with, multi-professional care, and to analyse this alongside further evaluation of clinical delivery models in SACT.
Predictors of nurse practitioner prescription of opioids for cancer pain: Quantitative results
This article, published in the Journal of the Advanced Practitioner in Oncology, sought to examine predictors of nurse practitioners prescribing of opioids in the area of cancer care. The article outlines the role and impact of nurse practitioners in the area of pain management. It alludes to the lack of research studies on the influences that exist on the complex decision-making process in prescribing opioids in this area of pain management, and identifies this as a gap in the literature.
The purpose of this study was to make inroads into addressing this gap. The researchers employed an internet-based, descriptive comparative study to gather their data. They used the Diffusion of Innovations theoretical framework to structure the study with the aim of evaluating whether dominant personality, dominant decision style, advanced specialty certification, and/or demographic factors influenced oncology NP opioid prescribing proficiency (termed opioid decision score, or ODS) according to the National Comprehensive Cancer Network (NCCN) Guidelines. The study was limited in its scope of practitioners to nurses as they have the widest legal scope in regard to prescribing controlled drugs in the USA, according to the authors.
Participants were recruited from trusted lists of nurse practitioners and a convenience sampling method was employed. The researchers used the NCCN Cancer Plan Guidelines as a measure of adherence to prescribing appropriate opioids. Appropriate statistical analysis was employed to analyse the qualitative data gleaned. Data was collected between June and August 2018, with 398 nurse practitioners responding, equating to a 33.1% response rate. After screening, 361 participants were included for analysis.
Nurse practitioners reporting advanced specialty certification in oncology and/or hospice or palliative care scored significantly higher on the ODS compared with those with no advanced specialty certification. This study provides preliminary findings regarding the decision-making of NPs working with oncology patients and prescribing opioids for cancer pain.
Nurse practitioners with a dominant personality characteristic of openness and those reporting an advanced specialty certification in oncology and/or hospice or palliative care were more likely to prescribe opioids for patients with cancer according to NCCN Guidelines. The authors suggest that further investigation is needed to determine additional factors affecting prescribing of controlled substances by NPs and other prescribers.
A national audit of pancreatic enzyme prescribing in pancreatic cancer from 2015 to 2023 in England using OpenSAFELY-TPP
This article, published in Seminars in Oncology Nursing, sought to conduct and report on a national audit of pancreatic enzyme replacement therapy (PERT) prescribing between 2015 and 2023 to investigate any variability and whether this was attributable to the Covid-19 pandemic disruptions to service.
The aim was to investigate the impact of the Covid-19 pandemic on PERT prescribing to people with unresectable pancreatic cancer and to investigate the national and regional rates from January 2015 to January 2023.
The study was conducted with proper ethical and legal approval using the 24 million electronic health records of people on the OpenSAFELY-TPP research platform. Of those on this database, 22 860 people were diagnosed with pancreatic cancer and eligible to be included in the study cohort. Trends over time were measured and analysed to model the effects of the Covid-19 pandemic using an interrupted time series analysis method. It was noted that over the time studied, Covid-19 did not affect the rates of pancreatic cancer diagnosis; however, there was a negative effect on rates of surgical treatment. Although the average trends in the pandemic period are slightly lower than predicted, the authors conclude that, overall, the pandemic did not affect PERT prescribing in people with unresectable pancreatic cancer.
A clear dip in treatment rates of about 3% (from 46% to 43%), was observed immediately at the start of the pandemic (from March to July 2020). This dip was small and transient, and the rates of prescribing recovered by September 2020 to rates that would be expected if the pandemic had not occurred therefore these trends cannot be directly interpreted as the effect of the pandemic.
The authors conclude that in pancreatic cancer, if PERT is prescribed, it is usually initiated in hospitals by clinical nurse specialists and continued after discharge by primary care practitioners. At just under 50% in early 2023, the rates were still below the recommended 100% standard.
The authors suggest more research in necessary to investigate barriers to prescribing of PERT and geographic variation to improve quality of care. Finally, they state that this is now easier to achieve as prior work relied on manual audits. With OpenSAFELY, they have developed an automated audit that allows for regular updates.
Conclusion
What is clear from looking at this topic is that there is a wide scope for non-medical prescribers to be utilised in the area of cancer care. Some areas have a good adoption of specialist nurse, pharmacist and AHP roles with a good use of advanced specialist practitioners. Other areas are yet to fully embrace the role and value of clinicians other than doctors, and it is clear that more research in some areas would be beneficial going forward.