1. Barriers to implementing COPD guidelines for non-medical prescribers: a qualitative interview study Alison Paterson1, Anne Kinnear1, Marion Bennie2, Moira Kinnear1,2 Caroline Souter1 1 NHS Lothian Pharmacy Services, Edinburgh, 2 University of Strathclyde, Glasgow
Background
Key Emergent Themes
Domain (TDF)
Identified barriers
Skills
Motivating patients to try smoking cessation or PR
Beliefs about capabilities
Lack of confidence in stopping ICS containing inhalers
Beliefs about consequences
Disengaging patients by over-mentioning smoking cessation; worsening of COPD symptoms by changing inhaled treatment
Motivation and goals
Conflicting priorities within the consultation
Social influences
Patient centred lack of motivation to engage with PR or smoking cessation; variable prescribing practices amongst the MDT; patient perception of prescriber hierarchy in the MDT
Emotion
Fear of negative outcomes from over-mentioning smoking cessation or changing inhaled treatment
Environmental context and resources
Time in consultation; limited local access to PR classes; lack of placebo inhalers
In primary care chronic obstructive pulmonary disease (COPD) consultations are increasingly carried out by non-medical prescribers (NMPs) including practice nurses and pharmacist independent prescribers rather than general practitioners (GPs)1.
The GOLD COPD guidelines are considered optimal practice2.
Barriers to medical prescribers in implementing COPD guidelines have been established and include resource provision, difficulties in changing patient behaviours and lack of familiarity with recommendations, 3 however, there are no published studies regarding NMP-led services.
Aim
To identify areas of poor adherence and explore barriers to NMPs implementing the guidelines
Methods
Audit
23 criteria applied to 135 patient records across 3 GP practices in NHS Lothian
1:1 interviews with NMPs
Semi-structured schedule based on areas of poorest adherence
Practice nurses (n=4)
Pharmacists (n=3)
Analysis
Identification and categorisation of main barriers using Theoretical Domains Framework4
Abbreviations: PR – pulmonary rehabilitation, ICS – inhaled corticosteroid,
MDT – multi-disciplinary team
Smoking Cessation:
“If they are a happy smoker I think you have got to get the balance right, I’ve got to keep chipping away at them, but I don’t want to stop them coming back. Because all I ever go on about is smoking.”
Pulmonary Rehabilitation:
“So many times I have talked about it and nobody, pretty much nobody is interested.”
Results
Inhaler Technique:
“It would be one of the things I think, and I know it’s wrong and I shouldn’t do it, one of the things that I possibly miss out on if time is getting short and I’m conscious that the next patient is sitting outside.”
Audit Results – Criteria met on fewest occasions
Group B treatment:
“If they have been put on it in hospital it is really hard to get people off, because “the doctor said I should be on that””
Smoking cessation advice to all smokers at every visit in 9 % (n=65)
13% eligible patients are referred to pulmonary rehabilitation (n=118)
58% group B patients are not prescribed inhaled corticosteroids (n=62)
Inhaler technique is checked at every review in 14% (n=129)
Conclusion
Barriers identified by NMPs to implementing COPD guideline were similar to those identified by medical prescribers in other studies.
The major barriers to implementing evidence based pharmacological treatment included differences in prescribing practices across the multi-disciplinary team (MDT), limited experience in stopping inhaled corticosteroids when not indicated and resistance from patients.
Collaboration by the MDT is required to ensure consistency in the provision of evidence based care. x
References
Information Services Division Scotland. Health Conditions. General Practice.  Chronic Obstructive Pulmonary Disease. Available from:
GOLD. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) Available from 
Sharif R, Cuevas CR, Wang Y, Arora M, Sharma G. Guideline adherence in management of stable chronic obstructive pulmonary disease. Respiratory Medicine. 2013;107(7):
Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A, et al. Making psychological theory useful for implementing evidence based practice: a consensus approach. Quality & safety in health care. 2005;14(1):26-33.