The last research roundup provided you with an overview of articles looking at respiratory disease and included articles discussing delayed prescribing in upper respiratory tract infections, testing and prescribing for lower respiratory tract infections and the association between pre-existing respiratory disease and COVID-19 (Robertson, 2021). This month we are going to be looking at articles related to prescribing in sexual and reproductive health. This is an area where many non-medical prescribers' practice and often sexual health services can be nurse or pharmacist led. The articles look at non-medical prescribing in general sexual health as well as a focus on prescribing in HIV pre-exposure prophylaxis alongside an exploration of trends in UK contraception prescribing.
Independent nurse medication provision: A mixed method study assessing impact on patients' experience, processes, and costs in sexual health clinics
This original research study, published in the Journal of Advanced Nursing in January 2022 aimed to compare the implications of using nurse prescribing and the use of patient group directions (PGDs) for the provision of medications in sexual health clinic settings (Black et al, 2022). The study wanted to examine the effects on clinic processes, patients' experiences, and the costs of using these provisions from the perspectives of service providers, sexual health nurses and the patients using these services. The authors contextualise the rationale for this work in the statement that in the UK many sexual and reproductive health services allow for ‘autonomous provision of medication by nurses’ and indeed many trusts and providers support individual nurses to gain prescribing qualifications or by introducing local patient group directions to enable the supply of medication without the need for a medical prescriber to be present.
The researchers employed a mixed-method, comparative case study approach, which was carried out in five urban sexual health services in the United Kingdom between July 2015 and December 2016. Data was collected in the form of nurse questionnaires and diaries, a review of patient notes and a patient questionnaire. Data collection was constant over each of the five sites. Data from sexual health nurses included those who were active prescribers and those who used the PGD route. Within the nurse questionnaire, issues explored included training (how and whether it was funded and method of training). Nurses recorded their consultation durations and any support needed or received from other professionals in the clinical diaries. Patient notes were reviewed to explore medication provision, medication appropriateness and safety, including errors. Patients completed satisfaction questionnaires about consultations and information they received about medication and supply.
In total twenty-eight nurse prescribers and 67 PGD users took part; records of 1682 consultations were reviewed, with 1357 medications prescribed and 98.5% were found to be clinically and therapeutically appropriate. Significantly, the majority of medication decisions were deemed safe in accordance with the criteria used (96.0% nurse prescribers, 98.7% PGDs). Errors that were identified were predominantly minor (55.6% nurse prescribers, 62.4% PGDs) and related mainly to documentation omissions (78.0%); no patient harm was uncovered. Consultation durations and unplanned re-consultations were similar for both groups examined. Nurse prescribers sought assistance from colleagues less frequently than those using PGDs but did spend longer discussing cases when the review was sought. Nurse prescribing training required more resources compared with PGDs. Patient satisfaction was found to be high in both groups providing medication (>96%).
The authors conclude that nurse medication provision by both nurse prescribers and PGD users is safe and associated with a very high level of patient satisfaction. The documented effects on clinic processes and costs are similar for both methods of medication access. Undertaking the prescribing qualification involves independent study but may bring longer-term career progression, with higher banding to nurses and an enhanced service to the patients and clinics in their care.
Challenges of providing HIV pre-exposure prophylaxis across Australian clinics: qualitative insights of clinicians
This article, published in the open access Journal of Sexual Health in 2021 aimed to explore, from a qualitative perspective, the challenges experienced by prescribing clinicians in the prescription and supply of HIV pre-exposure prophylaxis (PrEP) since the introduction of a public subsidy for PrEP provision in 2018 through the Australian Pharmaceuticals Benefits Scheme for patients who had Medicare Insurance (Smith et al, 2021). The study was conducted in two Australian States; Western Australia (WA) and New South Wales (NSW). The authors acknowledge that PrEP provision has been rapidly implemented in Australia. The initial prescribing occurred through restricted access in demonstration studies but was followed up with prescribing across sexual health clinics and general practice settings.
The researchers conducted 28 semi-structured interviews between October 2019 and July 20, by telephone, video call or face-to-face, with PrEP providers in both chosen states and analysed the collected data using reflexive thematic analysis. Participants included general practitioners (GPs), sexual health nurses and sexual health physicians. In total, 28 participants were interviewed with 26 of those interviews being by telephone. Of these 28, 18 were from NSW and 10 from WA. The professional demographic showed 12 GPs, nine sexual health nurses and seven sexual health physicians.
The findings showed that sexual health services have been reconfigured to meet changing patient demand, with an emphasis on ensuring equitable financial access to PrEP. Restrictions to nurse-led PrEP frustrated some participants, as nurses had demonstrated competence during trials. GPs were believed to be less effective at prescribing PrEP, but GP participants themselves indicated that PrEP was an easy intervention, but difficult to integrate into general practice.
The authors conclude that the findings suggest that supporting patients without health insurance to access PrEP inexpensively, advocating for nurse-led PrEP, and developing guidelines adapted to general practice consultations could ensure that PrEP is delivered more effectively and equitably.
Time trends in contraceptive prescribing in UK primary care 2000–2018: a repeated cross-sectional study
This article, published in the open access journal, BMJ Sexual and Reproductive Health in November 2021 explored time trends in UK contraceptive prescribing between 2000 and 2018 (Pasvol et al, 2021). The author's rationale for this centred around new contraceptive method availability and incentives to increase contraceptive uptake that were introduced over the last two decades. They aimed to describe temporal trends in non-barrier contraceptive prescribing in the UK primary care setting for the defined period
The research was conducted using a repeated cross-sectional study approach and accessing patient data obtained from the IQVIA Medical Research Data (IMRD) database. Using this database, the proportion of women prescribed non-barrier contraception per year could be ascertained.
In total, 2 705 638 women aged 15–49 years were included in the data captured. It was noted that between the years of 2000 and 2018, the proportion of women prescribed combined hormonal contraception (CHC) fell from 26.2% to 14.3% Prescriptions for progestogen-only pills (POPs) rose from 4.3% to 10.8% and the prescription of long-acting reversible contraception (LARC) rose from 4.2% to 6.5%.
The findings showed that when comparing 2018 data for most deprived areas versus least deprived areas, women from the most deprived areas were more likely to be prescribed LARC 7.7% vs 5.6% while women from the least deprived areas were more likely to be prescribed contraceptive pills 20.8% vs 26.2% Notably the data showed that in 2009, LARC prescriptions increased irrespective of age and social deprivation in line with a pay-for-performance incentive. However, following the incentive's withdrawal in 2014, LARC prescriptions for adolescents aged 15–19 years fell from 6.8% in 2013 to 5.6% in 2018. CHC prescribing fell by 46% while POP prescribing more than doubled.
The authors conclude that the type of contraception prescribed was influenced by social deprivation, which correlates with data from Canada and Ireland in the same period. Withdrawal of a pay-for-performance incentive may have adversely affected adolescent LARC uptake, highlighting the need for further intervention to target this at-risk group.
Conclusion
Within the UK, sexual and reproductive health services are an area where many non-medical prescribers practice, and increasingly sexual health services can be nurse or pharmacist led. The articles reviewed this month cover areas of interest to UK practising non medical prescribers and cover three differing areas, all of which are important areas of prescribing within the developed world.