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Noblet T1,2,3, Graham Clarke E1, Shirley D4, Marriott J1, Rushton A1
1University of Birmingham, Birmingham, United Kingdom, 2Macquarie University, Sydney, Australia, 3St George's University Hospitals NHS Foundation Trust, London, United Kingdom, 4University of Sydney, Sydney, Australia
Background: Non-medical prescribing (NMP) contributes to the effective management of both acute and chronic conditions. Robust studies utilising survey designs have concluded that NMP is safe and appropriate, demonstrating good patient satisfaction. Despite this, implementation remains relatively slow. Although reasons for this are unclear, it is argued that this is caused by a lack of persuasive evidence demonstrating clinical and economic benefits when comparing NMP to current models of healthcare. Employing non-medical prescribers within health-services has the potential to provide savings, whilst promoting holistic care. The future development of NMP across professions is dependent on low risk-of-bias evidence regarding clinical and cost-effectiveness; without which, it is difficult to demonstrate quality care and patient safety. To date, no systematic review has synthesised the existing evidence.
Purpose: To evaluate the clinical and cost-effectiveness of non-medical prescribing (NMP).
Methods: A systematic review was conducted according to a pre-defined protocol informed by the Cochrane handbook, registered with PROSPERO (CRD42015017212), and is reported in accordance with the PRISMA statement. Two reviewers independently completed searches, eligibility assessment and assessment of risk-of-bias (Cochrane risk-of-bias tool). Pre-defined search terms/combinations were utilised to search electronic-databases (to 01.11.16). In addition, hand searches of reference lists, key journals and grey literature were employed alongside consultation with authors/experts. Randomised controlled trials (RCTs) evaluating clinical and/or cost-effectiveness of NMP were included. Each included trial's characteristics and outcome data were tabulated. Within and between studies analysis was undertaken in the context of risk of bias and Grading of Recommendations, Assessment, Development and Evaluations(GRADE).
Results: Searches identified 373 potentially relevant studies. Following screening, 3 RCTs from two countries (UK and Australia) were included (n=932 participants) across primary and tertiary care settings. RCTs compared pharmacist-prescribing only. One RCT assessed as low risk of bias evaluated both clinical and cost-effectiveness. Two RCTs evaluated clinical effectiveness (one high risk of bias, one unclear risk of bias). Clinical effectiveness was evaluated using a range of safety and patient-reported outcome measures. All RCTs demonstrated significant improvement in function, wellbeing and pain outcomes when receiving NMP compared to treatment as usual (TAU). One RCT assessing safety found significantly fewer prescribing errors (drug-selection, dose, frequency) in the NMP group compared to TAU(p 0.001). An associated cost-analysis showed NMP to be more expensive than TAU (regression coefficient p=0.0000), however NMP groups generated increased QALYs compared to TAU.
Conclusion(s): Limited and moderate quality evidence (GRADE) exists evaluating clinical and cost-effectiveness of NMP across professions and clinical settings. Evidence suggests that NMP is safe and can provide beneficial clinical outcomes. Benefits to the health-economy remain unclear, with the cost-effectiveness of NMP assessed by a single RCT of low risk of bias. Adequately powered low risk of bias RCTs evaluating clinical and cost-effectiveness are required to evaluate physiotherapy NMP across clinical specialities and settings.
Implications: Politicians, policy and healthcare managers, and clinical professionals internationally may use the evidence from this review when considering the introduction or use of physiotherapist prescribing in the future.
Keywords: Non-medical prescribing, clinical effectiveness, cost-effectiveness
Funding acknowledgements: None
Purpose: To evaluate the clinical and cost-effectiveness of non-medical prescribing (NMP).
Methods: A systematic review was conducted according to a pre-defined protocol informed by the Cochrane handbook, registered with PROSPERO (CRD42015017212), and is reported in accordance with the PRISMA statement. Two reviewers independently completed searches, eligibility assessment and assessment of risk-of-bias (Cochrane risk-of-bias tool). Pre-defined search terms/combinations were utilised to search electronic-databases (to 01.11.16). In addition, hand searches of reference lists, key journals and grey literature were employed alongside consultation with authors/experts. Randomised controlled trials (RCTs) evaluating clinical and/or cost-effectiveness of NMP were included. Each included trial's characteristics and outcome data were tabulated. Within and between studies analysis was undertaken in the context of risk of bias and Grading of Recommendations, Assessment, Development and Evaluations(GRADE).
Results: Searches identified 373 potentially relevant studies. Following screening, 3 RCTs from two countries (UK and Australia) were included (n=932 participants) across primary and tertiary care settings. RCTs compared pharmacist-prescribing only. One RCT assessed as low risk of bias evaluated both clinical and cost-effectiveness. Two RCTs evaluated clinical effectiveness (one high risk of bias, one unclear risk of bias). Clinical effectiveness was evaluated using a range of safety and patient-reported outcome measures. All RCTs demonstrated significant improvement in function, wellbeing and pain outcomes when receiving NMP compared to treatment as usual (TAU). One RCT assessing safety found significantly fewer prescribing errors (drug-selection, dose, frequency) in the NMP group compared to TAU(p 0.001). An associated cost-analysis showed NMP to be more expensive than TAU (regression coefficient p=0.0000), however NMP groups generated increased QALYs compared to TAU.
Conclusion(s): Limited and moderate quality evidence (GRADE) exists evaluating clinical and cost-effectiveness of NMP across professions and clinical settings. Evidence suggests that NMP is safe and can provide beneficial clinical outcomes. Benefits to the health-economy remain unclear, with the cost-effectiveness of NMP assessed by a single RCT of low risk of bias. Adequately powered low risk of bias RCTs evaluating clinical and cost-effectiveness are required to evaluate physiotherapy NMP across clinical specialities and settings.
Implications: Politicians, policy and healthcare managers, and clinical professionals internationally may use the evidence from this review when considering the introduction or use of physiotherapist prescribing in the future.
Keywords: Non-medical prescribing, clinical effectiveness, cost-effectiveness
Funding acknowledgements: None
Topic: Professional issues; Professional practice: other; Service delivery/emerging roles
Ethics approval required: No
Institution: University of Birmingham
Ethics committee: University of Birmingham
Reason not required: Systematic Review of the Literature
All authors, affiliations and abstracts have been published as submitted.
