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A preliminary qualitative study of general practitioners’ views on malnutrition management and oral nutritional supplementation prescription in the community
- Patricia Domínguez Castro, Sharon Kennelly, Barbara Clyne, Gerard Bury, Catriona Bradley, Karen Finnigan, Laura McCullagh, Michael Barry, Celine Murrin, Carla Perrotta, Katherine Loayza Villaroel, Ciara Reynolds, Eileen Gibney, Clare Corish
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- Journal:
- Proceedings of the Nutrition Society / Volume 79 / Issue OCE2 / 2020
- Published online by Cambridge University Press:
- 10 June 2020, E332
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Malnutrition, arising from a deficiency of energy and protein intake, occurs commonly among community-dwelling individuals. Oral nutritional supplements (ONS) are an effective method of managing malnutrition if prescribed for patients who are malnourished or at risk of malnutrition. However, previous research indicates that inappropriate prescribing of ONS occurs frequently in the community setting (30–70% prevalence). Moreover, it has been previously shown that the management of patients ‘at risk’ of malnutrition in the primary care/community setting in Ireland is sub-optimal, with low awareness of the condition and its management among non-dietetic health care professionals (HCPs). In Ireland, general practitioners (GPs) are the main prescribers of ONS in primary care. They are also on many occasions the first point of contact for individuals in the community who are malnourished or at risk of malnutrition. Therefore, exploring their experiences and perceptions can provide insight into the complexities of managing malnutrition and ONS prescribing in the community. The aim of this qualitative study was to explore GPs’ experiences and opinions on the management of malnutrition and the prescription of ONS in the primary care/community setting in Ireland. Semi-structured interviews were conducted with nine GPs. The interview explored among others the following domains; Barriers and facilitators in the management of malnutrition, ONS prescribing in the primary care/community setting, and future directions in the management of malnutrition and ONS prescribing. Recorded interviews were transcribed and analysed using inductive thematic analysis. Three main themes were identified; i) Malnutrition a secondary concern, encapsulating the idea that malnutrition is not something that GPs screen for in isolation ii) Resources and support for managing malnutrition are needed in the community iii) Reluctance to prescribe ONS. GPs reported not screening for malnutrition, but viewed it as a consequence of other conditions and social factors. According to the GPs, they should not have sole responsibility for malnutrition management and more dietitians and trained community nurses would be desirable to support them to deal with malnutrition in the community. A preference to avoid supplementation and implement dietary changes first was expressed by GPs. As main prescribers, GPs thought that they should receive further independent trainingon the different ONS available in the market as currently they did not feel confident prescribing a range of them. Awareness of ONS cost and its misuse by certain patients were reported as reasons that made GPs reluctant to prescribe them, potentially leading to under prescribing.
A preliminary qualitative study of nurses’ and dietitians’ views on malnutrition management and oral nutritional supplementation prescription in the community
- Patricia Domínguez Castro, Sharon Kennelly, Celine Murrin, Catriona Bradley, Barbara Clyne, Gerard Bury, Karen Finnigan, Laura McCullagh, Michael Barry, Sarah Browne, Ciara Reynolds, Laura Bardon, Eileen Gibney, Clare Corish
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- Journal:
- Proceedings of the Nutrition Society / Volume 79 / Issue OCE2 / 2020
- Published online by Cambridge University Press:
- 10 June 2020, E108
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Protein-energy malnutrition, or undernutrition, arising from a deficiency of energy and protein intake, can occur in developed countries both in hospitalised patients and in the primary care/community setting. Oral nutritional supplements (ONS) are an effective method of managing malnutrition if prescribed for patients who are malnourished or at risk of malnutrition. Pooled data of older adults at risk of malnutrition indicate that ONS combined with dietary counselling is the most effective intervention. Previous Irish research has demonstrated that management of patients ‘at risk’ of malnutrition in the primary care/community setting is sub-optimal, with low awareness of the condition and its management among non-dietetic health care professionals. Therefore, the aim of this qualitative study is to explore community nurses’ and dietitians’ experiences and opinions on the management of malnutrition and the prescription of ONS in the primary care/community setting in Ireland. Three focus groups were conducted with primary care dietitians (n = 17) and one focus group with community nurses (n = 5), one of the nurses had prescribing rights. The focus groups explored the following domains; the term malnutrition and patient population presenting as malnourished or at risk of malnutrition, barriers and facilitators in the management of malnutrition, ONS prescribing in the primary care/community setting, and future directions in the management of malnutrition and ONS prescribing. Recorded focus groups were transcribed and analysed using inductive thematic analysis. Both professional groups showed similar perspectives, and three preliminary main themes were identified; i) Malnutrition is a misunderstood term, ii) Delayed treatment of malnutrition, iii) Challenges with ONS prescription in the primary care/community setting. Both dietitians and community nurses agreed that the term malnutrition had negative connotations for patients and preferred not to use it with them. Dietitians identified the need for a multidisciplinary approach to manage patients at risk of malnutrition in the community, and community nurses agreed on their pivotal role identifying the risk of malnutrition and providing first line advice to clients. However, community nurses expressed the urgent need for training to provide first line advice to patients to improve their nutritional status to prevent malnutrition. Both groups also agreed on the need for access to more dietitians in the community, and suggested that giving dietitians prescribing rights would improve appropriate ONS prescribing. Community nurses identified a gap in their knowledge of the different ONS products, and the need to receive independent generic education on nutritional supplements.
REDUCING POTENTIALLY INAPPROPRIATE PRESCRIBING FOR OLDER PEOPLE IN PRIMARY CARE: COST-EFFECTIVENESS OF THE OPTI-SCRIPT INTERVENTION
- Paddy Gillespie, Barbara Clyne, Adam Raymakers, Tom Fahey, Carmel M. Hughes, Susan M. Smith
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- Journal:
- International Journal of Technology Assessment in Health Care / Volume 33 / Issue 4 / 2017
- Published online by Cambridge University Press:
- 11 October 2017, pp. 494-503
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Objectives: This study examines the cost-effectiveness of the OPTI-SCRIPT intervention on potentially inappropriate prescribing in primary care.
Methods: Economic evaluation, using incremental cost-effectiveness and cost utility analyses, conducted alongside a cluster randomized controlled trial of twenty-one general practices and 196 patients, to compare a multifaceted intervention with usual practice in primary care in Ireland. Potentially inappropriate prescriptions (PIPs) were determined by a pharmacist. Incremental costs, PIPs, and quality-adjusted life-years (QALYs) at 12-month follow-up were estimated using multilevel regression. Uncertainty was explored using cost-effectiveness acceptability curves.
Results: The intervention was associated with a nonsignificant mean cost increase of €407 (95 percent CIs, −357–1170), a significant mean reduction in PIPs of 0.379 (95 percent CI, 0.092–0.666), and a nonsignificant mean increase in QALYs of 0.013 (95 percent CIs, −0.016–0.042). The incremental cost per PIP avoided was €1,269 (95 percent CI, −1400–6302) and the incremental cost per QALY gained was €30,535 (95 percent CI, −334,846–289,498). The probability of the intervention being cost-effective was 0.602 at a threshold value of €45,000 per QALY gained and was at least 0.845 at threshold values of €2,500 per PIP avoided and higher.
Conclusions: While the OPTI-SCRIPT intervention was effective in reducing potentially inappropriate prescribing in primary care in Ireland, our findings highlight the uncertainty with respect to its cost-effectiveness. Further studies are required to explore the health and economic implications of interventions targeting potentially inappropriate prescribing.