Clinical and cost-effectiveness of non-medical prescribing: A systematic review of randomised controlled trials

Abstract

ObjectiveTo evaluate the clinical and cost-effectiveness of non-medical prescribing (NMP).DesignSystematic review. Two reviewers independently completed searches, eligibility assessment and assessment of risk of bias.Data sourcesPre-defined search terms/combinations were utilised to search electronic databases. In addition, hand searches of reference lists, key journals and grey literature were employed alongside consultation with authors/experts.Eligibility criteria for included studiesRandomised controlled trials (RCTs) evaluating clinical or cost-effectiveness of NMP. Measurements reported on one or more outcome(s) of: pain, function, disability, health, social impact, patient-safety, costs-analysis, quality adjusted life years (QALYs), patient satisfaction, clinician perception of clinical and functional outcomes.ResultsThree RCTs from two countries were included (n = 932 participants) across primary and tertiary care settings. One RCT was assessed as low risk of bias, one as high risk of bias and one as unclear risk of bias. All RCTs evaluated clinical effectiveness with one also evaluating cost-effectiveness. Clinical effectiveness was evaluated using a range of safety and patient-reported outcome measures. Participants demonstrated significant improvement in outcomes when receiving NMP compared to treatment as usual (TAU) in all RCTs. An associated cost analysis showed NMP to be more expensive than TAU (regression coefficient p = 0.0000), however experimental groups generated increased QALYs compared to TAU.ConclusionLimited evidence with overall unclear risk of bias exists evaluating clinical and cost-effectiveness of NMP across all professions and clinical settings. GRADE assessment revealed moderate quality evidence. 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 pilot RCT of low risk of bias. Adequately powered low risk of bias RCTs evaluating clinical and cost effectiveness are required to evaluate NMP across clinical specialities, professions and settings.RegistrationPROSPERO (CRD42015017212).

A Comparative Case Study of Prescribing and Non-Prescribing Physiotherapists and Podiatrists

“…There is limited evidence available with which to compare our study ndings (32,41,51,52,85). Despite positive ndings that NMP is safe, and provides bene cial clinical outcomes (32,34,62), the impact on the health economy, as reported in two recent systematic reviews examining clinical and cost effectiveness, remains unclear (51,52,85). The authors, as in this study, highlight the di culty in separating NMP effects from the contributions of healthcare team members, and a lack of adequately powered randomised controlled trials examining NMP across clinical specialities, professions and settings (31,51).…”

“…Despite positive ndings that NMP is safe, and provides bene cial clinical outcomes (32,34,62), the impact on the health economy, as reported in two recent systematic reviews examining clinical and cost effectiveness, remains unclear (51,52,85). The authors, as in this study, highlight the di culty in separating NMP effects from the contributions of healthcare team members, and a lack of adequately powered randomised controlled trials examining NMP across clinical specialities, professions and settings (31,51). Given that extended prescribing rights to nurses, pharmacists and AHPs offers a sustainable approach to improving the global workforce de cit, there is an urgent need to establish economic bene ts, or otherwise of non-medical prescribing to inform future international policy developments.…”

“…Whilst PP-SP helps streamline service delivery (44,45), IP is expected to bring additional bene ts in line with nurse and pharmacist prescribing (46,47). Exploration of clinical and cost effectiveness in this area is however limited and has to date lead to inconclusive ndings (48)(49)(50)(51)(52)(53). As most evidence relates to nurses and pharmacists, it is important to evaluate the impact of prescribing by allied health professionals (AHPs) in order to inform commissioning and implementation of NMP services where they are bene cial.…”

A comparative case study of prescribing and non-prescribing physiotherapists and podiatrists

“…The study adopted a comparative case study methodology used in situations when no single outcome measure is available 51,52 . Outcomes were compared between 7 sites where patients received care from a PP-IP (3 podiatrist and 4 physiotherapist IPs) and 7 sites where care was provided by a PP-NP without a prescribing quali cation (3 podiatrist and 4 physiotherapist non-prescribers) 53 .…”

Independent prescribing by advanced Physiotherapists for patients with low back pain in primary care: feasibility trial with an embedded qualitative-component

“…A recent systematic review evaluating the clinical and costeffectiveness of iNMP across all professions internationally, identified limited evidence with unclear risk of bias. The systematic review demonstrates that no trials have evaluated the clinical and cost-effectiveness of physiotherapist independent prescribing in the context of LBP [22].…”