Discussing evidence with patients when prescribing

Introduction

The UK healthcare landscape is characterised by evolving pharmaceutical advancements, rigorous regulatory standards, and demands a vigilant and informed approach to prescribing practices^​1–3​. In this dynamic environment, prescribing pharmacists are entrusted with the critical task of comprehending, communicating and appraising the evidence supporting prescribing decisions, as well as the associated risks.

This article aims to support improved understanding of evidence-based prescribing and risk. It highlights the pivotal role that pharmacist prescribers have in translating complex medical information for patients. 

It also explores important principles of evidence-based practice and risk communication. Through a comprehensive understanding of UK-specific medications, adept communication skills and a commitment to patient education, pharmacists can empower individuals to actively participate in decisions concerning their health.  

It is recommended that you read this article in conjunction with these resources from The Pharmaceutical Journal:

• ‘Principles of person-centred practice for prescribing’;
• ‘Factors influencing effective communication when prescribing’;
• ‘Communicating risk: how pharmacists should use data in conversations with patients‘;
• ‘How to provide patients with the right information to make informed choices‘.

To help further expand your prescribing skills, additional related articles are linked throughout. You will also be able to test your knowledge by completing a short quiz at the end of the article.

Emergence and development of evidence-based practice

Both within the UK and globally, evidence-based practice has emerged in response to the ongoing need for, and the benefits derived from, a more rigorous approach to clinical decision-making and patient care. The use of medicines within healthcare is grounded in the application of the scientific method where a systematic approach is adopted to the acquisition of new knowledge through observation, experimentation and analysis^​4​. This approach ensures that treatments and guidance are informed by a robust, reliable evidence base built on rigorous processes such as clinical trials, systematic reviews and peer review. Clinical trials — especially randomised controlled trials (RCTs) — are considered the gold standard in evaluating the efficacy and safety of medicines, as they provide controlled environments to assess outcomes in large populations. These trials are then subjected to peer review to ensure the validity, reliability and transparency of the findings^​5​.  

In the UK, bodies such as the National Institute for Health and Care Excellence (NICE) and the Medicines and Healthcare products Regulatory Agency (MHRA) play a central role in regulating and synthesising evidence to provide guidelines for healthcare practitioners. NICE publishes evidence-based guidelines to standardise care, ensuring that treatments are both clinically effective and cost-efficient^​6​. This process, underpinned by continuous peer review and systematic evaluation, ensures that medication use is safe, effective and tailored to meet patient needs, providing the foundation for decision-making in healthcare practice. 

Pharmacist prescribers must integrate an evidence-based approach into their practice, stay informed about the latest research and apply it to patient care. They must ensure patients understand the evidence behind their treatment options to be able to make informed choices; however, evidence must also be critically assessed within the broader context of the patient’s unique circumstances. Prescribing pharmacists need to balance the application of evidence with patient preferences, comorbidities and individual responses to treatments, tailoring their advice to optimise patient outcomes^​7​. 

Empowering patients to make informed decisions 

Person-centred practice recognises the importance of considering patient values, preferences and priorities when making prescribing decisions. Prescribers should look to facilitate shared decision-making with patients where treatment options are discussed jointly with the relative benefits and risks considered in relation to the patient’s individual circumstances and the impact on their overall quality of life^​8​. Patient involvement has been shown to increase the likelihood an individual will remain adherent with the prescribed treatment and results in better outcomes^​8​. 

However, several barriers can undermine patient empowerment and medication adherence. These include^​9​:

• Patient specific factors: particular to each individual and may include lack of knowledge and understanding about their condition or low levels of health literacy;
• Illness specific factors: could include a lack of apparent symptoms resulting in the patient concluding they do not need to take medicines (e.g. an asthma patient who stops taking their inhaler daily because they have not had any recent exacerbations) or poor understanding of the progression of their illness (e.g. insidious or progressive diseases);
• Medication specific factors: examples include lack of information about what the medicine does, side effects (or fear of them), complex regimes, polypharmacy or a lack of trust in the medicine prescribed (e.g. a generic substitution);
• Health system barriers: such as poor communication, mistrust of professionals or paternalism, lack of support, structural health inequalities, poor access to care or pharmacy, multiple prescribers;
• Diagnostic uncertainty and complexity: some patient presentations will involve symptoms that are challenging to differentiate or there may be multimorbidities and polypharmacy issues that add significant complexity for the patient; 
• Social factors: including stigma, lack of support from family or carers, religious beliefs, use of alternative treatments (e.g. complementary therapies, herbal/traditional medicines, homeopathy);
• Logistical factors: the ability to order and collect medicines, medicines shortages, renewal of medicines, lack of resource, cost etc.

While some of these factors may be beyond the control of an individual prescriber, it is possible to explore and overcome many of these barriers through careful discussion of risk and evidence that incorporates the patient’s ideas, concerns and expectations and results in a shared decision^​10​.

The success of these discussions will be influenced by how well the prescriber is able to build trust and establish a therapeutic relationship. See ‘How to build and maintain trust with patients’ for more information. 

Providing information

Incorporating patient decision aids into consultations demonstrates pharmacists’ commitment to evidence-based practice and patient-centred care, enhancing the overall quality of pharmaceutical services^​9​. In terms of information, there are now many different resources available in a variety of formats ranging from leaflets in different languages and braille to web-based patient decision aids, such as ‘Choice and Medication‘ for illnesses and treatments (see Further resources for a selection of examples). Written materials allow patients to review information at their own pace, summarising essential information about the medication, including risks, benefits and evidence^​12​. 

When providing information, prescribers must tailor their approach to the individual ensuring that their communication approach aligns with the patient’s level of health literacy. Some patients may have low health literacy, requiring clear, simple explanations of their medication and treatment, while others, known as expert patients, will seek detailed knowledge about their condition and treatment options and it may be appropriate to direct them to medical journals, relevant sections of NICE guidance or the BNF^​6,13​.

In addition to validated and approved sources, there are also many other places to find information. The reliability of information sources will vary and patients should be supported and encouraged to critically appraise materials about their condition that they may come across. For example, social media is now widely accepted as a primary form of communication and a resource that members of the public turn to for information and news, but it remains largely unregulated in terms of the quality and validity of information published or shared. Prescribers can help patients to better understand the nature of the information and provide simple structures for appraising online information. The patient’s association have produced some guidance that members of the public can follow, summarised in Box 2^​14​.

NICE guidance on medicines optimisation recommends the use of patient decision aids in consultations involving medicines^​8​. This aligns with GPhC standards for pharmacists to communicate effectively and the requirement to maintain, develop and use professional knowledge and skills^​1​.

With increasing availability of information resources, it is important to be prepared when planning a consultation by:

• Finding information in different formats or languages, which is appropriate for different people who are older, younger or neurodiverse;
• Ascertaining what they know about their condition and where they have looked for information already;
• Arranging for a translator where available or asking a carer or family member along, provided this is agreed by the patient;
• Making use of available patient decision aids;
• Ensuring you are able to identify when patients may lack capacity and know how the Mental Capacity Act should be applied in these circumstances.

Discussing risk

In order to make informed choices about their treatment, it is vital that patients have a strong understanding of their health risk and how their use of prescribed medicines interacts with this. 

This requires prescribers to fully explain the potential risks and benefits of medications to patients compared with the status quo or alternatives. While this will be clear cut in many instances, there will also be complex cases — particularly when polypharmacy and multimorbidities feature — where the relative benefits of medicines use can be harder to judge. In these situations, it is necessary to consider a range of risk types and the nature of the underlying evidence and how well it translates to each patient. For example, clinical trial data and practice guidance tends to be generated with a focus on single conditions. Certain patient cohorts, such as pregnant women, frail older people and children, are also likely to be underrepresented in the trial data and evidence base, which can make individualised discussions of risk and benefits more challenging. It can also be helpful to consider some of the different statistical categories of risk and develop a suitable communication strategy to discuss this with patients (see Box 2^{​15–19​}). 

For more information on this topic, see ‘Communicating risk: how pharmacists should use data in conversations with patients’.

Consider the following case study, which explores some of these concepts within the context of a typical patient consultation.

Ethical considerations when discussing evidence

There are also ethical considerations when discussing evidence with patients, such as:

• Will explaining evidence and risk in a certain way influence a patient’s subsequent decision to accept a preventative treatment? 
• Is this positive or negative?  
• Should I be trying to change a patient’s mind or give my opinion on what course of action they should take? 

There may also be questions around the patient’s capacity to understand the information being provided and what is required for them to make an informed decision^​20,21​. Pharmacists in clinical practice work with nurses, doctors and other medical professionals and — as medicines experts — are required to give advice on the latest medications and answer wide ranging medicines-related questions^​1​. It is therefore appropriate to provide expert advice to patients when called upon, while respecting their individual preferences and working within the scope of practice and area of competence. The right to autonomy has primacy even if the patient’s decision may result in increased risk of harm or is contrary to public health priorities. 

Personal judgement will be required in these situations and the Medicines, Ethics and Practice (MEP), section 2.1.2 can provide helpful guidance^​22​. Ethical issues often arise in situations where acting in the patient’s best interests may fall outside the legal constraints of normal practice^​23,24​. It is entirely possible for two different pharmacists, faced with the same facts and circumstances, to choose two different courses of action.

In complex situations where clinical judgement is required, it is vital to remember that all pharmacist prescribers must only prescribe within their scope of practice and use professional codes as a guide. It would be difficult to defend your actions in a court of law or fitness-to-practice professional regulatory hearing if you could not demonstrate your expertise in a particular clinical area. 

Knowledge check