Abstracts of Papers Presented at the Health Services Research & Pharmacy Practice Conference, 16-17 April 2015, Riddel Hall, Queen's University Belfast.

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International Journal of Pharmacy Practice 2015; Supplement 1

International Journal of

Pharmacy Practice IJPP 2015, Supplement 1: 2–27 © 2015 The Authors. IJPP © 2015 Royal Pharmaceutical Society

Investigating the quality and safety of discharge prescriptions in mental health hospitals: a prospective multicentre study R.N. Keersa,b, S.D. Williamsa,c, J.J. Vattakatucheryd,e, P. Brownf, J. Millerg, L. Prescottd and D.M. Ashcrofta,b a Manchester Pharmacy School, University of Manchester, bNIHR Primary Care Patient Safety Translational Research Centre, Manchester, c University Hospital of South Manchester NHS Foundation Trust, d 5 Boroughs Partnership NHS Foundation Trust, Warrington, eUniversity of Liverpool, fManchester Mental Health and Social Care NHS Trust and g Greater Manchester West Mental Health NHS Foundation Trust [email protected]

While research suggests that miscommunication and medication errors associated with discharge communications place patients at risk of harm,[1] the frequency and nature of problems associated with writing discharge prescriptions in UK mental health hospitals have not been fully explored. This study aimed to investigate the safety and quality of inpatient discharge prescriptions in three mental health NHS trusts in the North West of England. Trained pharmacy teams at each study site prospectively screened discharge prescriptions for acute adult and elderly inpatients over a 6-week period between February–March 2014. Any errors in prescribing, clerical details (e.g. demographic information) and communication of medications stopped (that were prescribed prior to admission) were recorded on a standardised form. A multidisciplinary panel assessed each prescribing error (PE) to confirm its presence, nature and potential severity. Those PEs having potentially significant, serious or life-threatening consequences for patients were considered clinically relevant.[2] Logistic regression analyses were conducted using STATA® v13 software to determine the potential predictors of identified errors. The study was approved by the University of Manchester Research Ethics Committee (Ref. 13279) and audit committees at each study site. A total of 274 discharge prescriptions were screened during the study period, containing 1456 newly prescribed or omitted medication items. One fifth (20.8%) of discharges containing prescribed medications were affected by at least one PE, with an error rate per prescribed item of 5.08% (95% CI 4.07– 6.33%). Nearly three quarters (73%) of PEs were considered to have potentially clinically relevant consequences for patients. At whole discharge level, increasing polypharmacy was asso© 2015 The Authors. IJPP © 2015 Royal Pharmaceutical Society

ciated with an elevated risk of PEs (compared with 0–5 items, 6–10 items OR 2.50 (95% CI 1.18–5.30) p = 0.017, 11+ items OR 8.04 (95% CI 2.64–24.52) p < 0.01). General Practitioner Trainees and Core/Specialist Trainees (grouped together) were significantly more likely to make PEs when compared with their Foundation Year colleagues (whole discharge level OR 3.62 (95% CI 1.17–11.18) p = 0.025, individual medication item level OR 2.80 (95% CI 1.12–6.95) p = 0.027). One or more clerical errors affected 71.9% (95% CI 66.3–76.9%) of discharge prescriptions, and most frequently involved failing to or incorrectly specifying whether the patient’s GP or hospital services should continue prescribing medications (43.4%). In total, 67.2% of prescriptions requiring communication of medications stopped during admission contained errors, and most commonly involved central nervous system class medicines (83.8%). Errors associated with mental health hospital discharge prescriptions are a common and important threat to patient safety. Particular emphasis should be placed on correct documentation of clerical information and communication of changes to established medications as part of improvement efforts, as these errors each affected more than two thirds of discharges in this study. The finding that GP Trainee and Core/Specialist Trainee prescribers appeared more likely to make PEs on discharge prescriptions than their junior colleagues also merits further investigation. A potential limitation of this study was that the number of medication communication change errors may have been underestimated as they were limited to medicines taken prior to admission that were stopped during inpatient stay. 1. Kripalani S, LeFevre F, Phillips CO et al. Deficits in communication and information transfer between hospitalbased and primary care physicians. JAMA 2007; 297: 831– 841. 2. Keers RN, Williams SD, Vattakatuchery JJ et al. Prevalence, nature and predictors of prescribing errors in mental health hospitals: a prospective multicentre study. BMJ Open 2014; 4:e006084.

Identifying the challenges of maintaining a good safety culture in community pharmacy using the Manchester Patient Safety Assessment Framework C.E.L. Thomas, D.M. Ashcroft, D. Parker and D.L. Phipps [email protected]

Safety culture has become firmly established within organisational research and practice as a means for explaining and predicting safety-related behaviour (1). The aim of this study is to gain a deeper understanding of safety culture and how it is maintained in community pharmacy. Four community pharmacies, a total of 23 participants were recruited between May and July 2014 in Greater Manchester. International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

Oral abstracts

Participants were recruited through local contacts and pharmaceutical committees. In each pharmacy, focus groups were held in which participants assessed their pharmacy’s safety culture using the Manchester Patient Safety Assessment Framework (MaPSaF) and then discussed the outcomes of their assessment as a team. MaPSaF is based on the five-level model of safety culture developed by Parker and Hudson (2). At the highest level of safety culture, risk management is seen as an integral part of behaviour in the workplace. Researchers visited pharmacies on monthly follow-up visits for four months to observe and discuss their progress following the initial focus group. Verbatim transcripts from the focus groups were subjected to template analysis. This involved identifying a priori themes from the literature as well as themes emerging from the data to create a template that was then applied to each transcript. Ethical approval was obtained from the University of Manchester Research Ethics Committee. Seven common factors were identified as challenges to maintaining safety culture in community pharmacy: firstly, though error reporting was common, knowing how to learn from errors was often perceived as challenging; following rules was identified as integral, however they were sometimes shown to be difficult to follow due to lack of flexibility; latent factors, mainly differences in support offered by area management, led to variation in safety culture. Thirdly, the intense pressure to complete a large amount of tasks simultaneously within limited time made maintaining a good safety culture sometimes challenging. Communication was noted as a challenge, particularly for pharmacies that had varying shifts, especially when a lack of written communication existed among the team. Task management decisions such as delegation and prioritisation were highlighted as needing to be constantly balanced. Finally, keeping the importance of patient safety in mind at all times was seen as fundamental to maintain a good safety culture. Each factor was shown to vary between pharmacies, for example, flexibility of rules was not as problematic for the independent pharmacy when compared with the medium-sized chain. Overall participants felt that being able to discuss the pharmacy’s safety culture as a team to be a valuable experience. Our findings suggest a range of factors that need to be managed within a community pharmacy setting in order to maintain a good safety culture. We have found MaPSaF to be a helpful discussion tool and a useful framework for assessing safety culture in community pharmacy. 1. Choudhry RM, Fang D, Mohamed S. The nature of safety culture: A survey of the state-of-the-art. Safety Science 2007; 45(10): 993–1012. 2. Parker D, Hudson P. Understanding your culture. Manchester: Shell International Exploration and Production. 2001.

© 2015 The Authors. IJPP © 2015 Royal Pharmaceutical Society

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Modelling unplanned readmission risk in patients admitted to an acute medical unit R. Millera,b, P. McCaffreya, C. Darcya, N. Blacka, A. Friela and K.Burnettb a Altnagelvin Area Hospital, L’Derry and bUniversity of Ulster, Coleraine [email protected]

Integrated Medicines Management (IMM) is now an accepted standard of high quality pharmaceutical care on hospital wards [1]. However, patients admitted to the Acute Medical Unit (AMU) are often in the hospital for too short a time to enable full implementation of IMM to fully address their pharmaceutical care needs. This study aimed to develop a model identifying patients admitted to AMU at higher risk of unplanned readmissions (suggestive of requiring baseline preventative intensive pharmaceutical care); based on results the team aims to then develop new care pathways for these patients during their stay in AMU and post-discharge from hospital. Both research ethical and trust governance permission was sought and granted for this study. Retrospective medical, demographic and socioeconomic data, together with 12 month unplanned readmissions information, were collected for 500 patients via computer held and chart records for patients (aged ≥ 40 years) with non-elective admissions to the AMU of a 481-bed hospital, over a six-month period. Terminally ill patients in receipt of palliative care were excluded. Data were coded and entered directly into the Statistical Package for the Social Sciences® version 20. The potential relationship between dichotomised patient variables at baseline (affecting at least 5% of the population) and ≥1 unplanned readmissions over 12 months was initially explored using chi-squared analysis with p ≤ 0.25 indicative of requiring further exploration [2]. These variables were individually entered into logistic regression models. The odds ratio (95% CI, Expβ) for each variable was recorded. Those variables with a chi-squared p ≤ 0.05, and statistically significant (p ≤ 0.05) logistic regression 95% CI, Exp β lower limit ≥1 were selected and entered into a backward stepwise multivariate logistic regression to produce the final model. The 500 patients (249 female and 251 male, aged 65.0 ± 14.5 years) included in data collection stayed in hospital for an average of 7.3 days (range = 1–118 days); their 12 month nonelective readmission rate was 29.6%. Forty-seven variables had a chi-squared p ≤ 0.25, with 16 of these also having potentially significant predictive properties when entered individually into logistic regression models. The final predictive readmission risk model included: patient drinks more than 25 units of alcohol per day (95% CI, Exp β = 2.038– 12.926, p = 0.001); patient uses a compliance aid (95% CI, Exp β = 1.948–16.951, p = 0.002); and patient has a history of respiratory disease (95% CI, Exp β = 1.107–3.208, p = 0.020). This three-variable model had 58.2% specificity, 69.3% sensitivity and 65.1% accuracy when the cut point was set to 0.4. The Hosmer & Lemeshow goodness-of-fit test for this model yielded an acceptable p value of 0.667. International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

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The team were aware of issues with patients with alcohol dependence being repeatedly readmitted to the AMU; the final model confirms this anecdotal observation. The low figure in terms of specificity suggests further data and additional variables may need to be collected and explored. The model also requires validation via application to a further independent data-set. Future work will address this model refinement and validation in order to produce a meaningful and workable predictive model. 1. Scullin C, Hogg A, Luo R, Scott MG, McElnay JC. Integrated medicines management – can routine implementation improve quality? J Eval Clin Prac 2012; 18(4): 807–815. 2. Hosmer DW, Lemeshow S. Applied Logistic Regression. Wiley series in Probability and Mathematical Statistics. New York: John Wiley & Sons, 1989.

Where do they go? Destination unknown: an exploratory study of the disposal of transdermal drug patches in the private healthcare sector (UK) L. Breena, H. Zamanb, A. Mahmoodb, W. Nabib, F. Mansooralib, Z. Patelb, M. Aminb and A. Nasimb a Bradford University School of Management, University of Bradford, UK and bBradford School of Pharmacy, School of Life Sciences, University of Bradford, UK [email protected]

The effective disposal of medication and more specifically accidental exposure to fentanyl via transdermal patches has recently been highlighted in two key documents [1, 2]. While the volume of unused medicines cost the NHS over £300 million every year [1], the volume of transdermal patch waste is unknown. There is a need for greater pharmacy intervention in the effective disposal of medicines to resolve issues such as hospital (re)-admissions, stockpiling leading to patient self– prescribing/dosing, and land and water pollution. The aim of this study was to examine transdermal patch disposal systems and practice amongst private sector care providers in the UK. This was part of a larger study focusing on transdermal patch application. A semi-structured qualitative questionnaire was posted to respondents qualified to administer transdermal patches in care homes, hospice and private hospitals. This was initially piloted on three care home respondents. Post-alteration based on the pilot feedback, a final questionnaire with 21 questions was deployed focusing on: patch application and administration, training and advice, disposal methods and policies plus associated training and the impact of action taken. An audit was not considered appropriate at this stage until the scale of the disposal issue was known. Data were recorded from both open and closed form questions (Likert scale and yes/no answers). Descriptive statistics were used to analyse the data using SPSS.


Ethical approval was obtained from the University of Bradford Ethics Committee. A total of 488 questionnaires were deployed to staff in 34 healthcare settings (6 private hospitals, 7 hospices and 21 care homes). Sixty-one questionnaires (12.3%) were returned: 40 from hospices (65.6%), 10 from care homes (16.4%), 8 from independent hospitals (13.1%) and 3 from home carers (4.9%). When commenting on drug patch disposal 17% of respondents asserted that they always returned this waste to pharmacy while 54% of respondents stated that they either rarely or never did this. 74% of respondents stated that medicines disposal was part of their job but paradoxically only 30% of respondents stated that they had undergone training for this. Access and knowledge of governing policy was fragmented with 7 out of 61 respondents saying they had no knowledge of appropriate policies and only 11 respondents reported offering guidance on patch disposal to patients. While this study did not aim to investigate drug patch disposal in relation to any one institutional type, the outputs indicate that there are common issues such as lack of guidance and training in the private hospitals, hospices and care homes examined. Where there should be uniformity and consistency in practice across the sector the results indicate that there are mixed practices and disjointed knowledge concerning the disposal of transdermal patches and this is worrying. In conclusion, the issue of medicines disposal generally continues to exist on the improvement agenda of healthcare professionals in this era of austerity. To inform clear guidance and policy it is proposed that a multi-institutional in-depth audit of transdermal patch disposal practice be undertaken under the supervision of trained pharmacy staff. 1. The Leeds Teaching Hospitals NHS Trust. Help Us to Reduce Waste. http://www.bringyourmedicinesleeds.nhs .uk/help-us-to-reduce-waste/ (accessed 08 December 2014). 2. Medicines Health Regulatory Agency. Transdermal Fentanyl ‘Patches’: Reminder of Potential for LifeThreatening Harm from Accidental Exposure, Particularly in Children. http://www.mhra.gov.uk/Safetyinformation/ DrugSafetyUpdate/CON432900 (accessed 22 September 2014).

We push, pump and drip-drop, but what are our patients getting? Observation of intravenous medication preparation and administration practices M. Ronan and C. Kirke Pharmacy Department, Tallaght Hospital, Dublin [email protected]

Medication administration via the intravenous (IV) route is known to be hazardous1, with high preparation and administration error rates noted in observational studies2. This study aimed to determine:

International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

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1. if IV medicines are prepared and administered in accordance with hospital guidelines and 2. the proportion of the prescribed dose received by patients with current infusion practices. Robert Gordon University Research Ethics Committee (REC) approval and hospital REC Chairman’s approval were granted. A paper-based data collection form based on reported observational studies2,3 categories was piloted, adjusted and finalised. A single pharmacist observed a convenience sample of IV drug preparation and administration meeting study inclusion criteria during a two-hour data collection period per day on 14 adult medical/surgical in-patient wards over six weeks in February and March 2014. Participants were observed once only and gave informed consent prior to observation. Data (participant demographics, preparation and administration details) were recorded on the ward and observations subsequently checked against hospital guidelines. Data were analysed using SPSS and descriptive statistics compiled. 105 IV drug preparations and 66 IV drug administrations by nurses were observed. Hospital guidelines were referred to in 40% (42/105) of preparations. The volume or type of reconstitution or diluent fluid differed from guidelines in 21% of preparations (22/105). An incorrect dose was prepared on 3 occasions but identified by the checking nurse and corrected. 73% (48/66) of administrations were outside recommended rates. 65% of IV injections were more than 100% faster and 36% of gravity infusions more than 50% slower than recommended (Table 1). Table 1 Deviation from rate of infusion/injection recommended in hospital guidelines Deviation from recommended rate

No deviation 1–25% faster 1–25% slower 26–50% faster 26–50% slower 51–75% faster 51–75% slower 76–100% faster 76–100% slower >100% faster >100% slower

Gravity (n = 28)

8 2 1 5 2 4

Volumetric infusion pump (n = 6) 3

Volumetric pump with safety software (n = 6)

Slow injection (n = 26)

5

2 4

1 1

1 17 5

Medication remained in the giving set and/or infusion bag at the end of the infusion and was discarded, resulting in underdosing in 95% of observed infusions (Table 2). This was in line with hospital guidelines.


Table 2 Percentage of prescribed dose administered to patient Percentage of prescribed dose administered

Gravity (n = 28)

60–70% 70–80% 80–90% 90–95% 95–100% Greater than 100%

2 14 10 1 1

Volumetric pump (n = 6)

Volumetric pump with safety software (n = 6)

Slow injection (n = 26)

4 2

5 1

2 24

Medication was prepared and administered in line with guidelines in 21% of observations (8/66). Under-dosing due to medication remaining in the line and/or bag occurred with 95% of infusions. Changes to hospital policy, practice and training are required to ensure the entire IV giving set is flushed to administer of the full dose and to ensure administration at the recommended rate. 1. Berdot S, Sabatier B, Gillaizeau F, Caruba T, Prognon P, Durieux P. Evaluation of drug administration errors in a teaching hospital. BMC Health Services Research 2012; 12(1):60. 2. Taxis K, Barber N. Ethnographic study of incidence and severity of intravenous drug errors. BMJ 2003; 326(7391):684. 3. Allan E, Barker K. Fundamentals of medication error research. American Journal of Health-System Pharmacy 1990; 47(3):555–571.

Nurse perceptions of medicine administration in Parkinson’s disease K. Lefteria, F. Liua and M. Browna,b

2 2 1

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a University of Hertfordshire and bMedPharm Ltd. [email protected]

There are 376,250 older people living in care homes in England [1]. Drug therapy in this population is often challenging due to altered age-related physiological functions, the presence of several disease conditions, including Parkinson’s disease (PD) and decline in cognitive capacity. PD brings about its own unique challenges as it is characterised by symptoms including tremor, rigidity and dysphagia and the complexity of the dosing regimen involves patients taking an average of 8.6 tablets per day [2]. The aim of the research was to identify current issues with the administration of medicines to PD patients and to explore nurse perceptions on the development of appropriate drug delivery systems which could give tailored solutions to these issues. Local nursing homes (206) were identified using yell.com and a sample of 32 was created using a random number generator. Each home manager was telephoned and asked to nominate International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

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a registered nurse from their staff to participate in a 60-minute in-depth semi-structured face to face interview with the research team. Details of the nurse’s experience of administering medicines to PD patients and current methods used to overcome any issues experienced were explored. Current available formulations were discussed and features of their “ideal” PD formulation considered. The interviews were recorded and transcribed, coded and then analysed using inductive thematic analysis to identify key themes. Ethics approval for this study was obtained from the UH Research Ethics Committee. All nursing homes contacted agreed to participate in the study with thirty one female and one male nurses being interviewed. The average duration of experience as a registered nurse was 15.5 years (range 0.5–40 years). The average size nursing home in which they were employed was 46 patients (range 19–95). All interviewees had experience with administering medicines to PD patients and were currently caring for at least two PD patients. PD patients were mainly prescribed oral tablets with limited use of alternative formulations. Nurses reported that this caused issues for medicine administration and two-thirds had resorted to crushing tablets to increase compliance. Of those that had not done this in practice the majority said that they would consider doing this if necessary. Nurses considered that a lack of liquid formulations and the prescriber’s reluctance to change to more costly alternatives were major contributing factors to this problem. The inconvenient dosing regimens of PD medicines were also reported as an issue. Nurses considered an ideal solution to the issues would be the availability of more liquid formulations or by avoiding the oral route completely e.g. a transdermal patch. Preferences for a reduction in dosing frequency and the need for new preparations to be cost-effective were acknowledged. Overall, the study has shown that current oral formulations available for PD disease can cause issues and manipulation of these is required for administration. The alternatives are limited and many are not being prescribed due to cost issues. Nurses consider either liquid formulations or drug delivery by the transdermal route to be the most appropriate for PD patients. However, development of new drug delivery systems will need to consider both ease of administration to the patient and cost-effectiveness. [1] The Adult Social Care Market and the Quality of Services, Care Quality Commission, November 2010, Figure 7: Places in homes for older people by population aged 65 and over, 7. [2] Grosset KA, Bone I, Grosset DG. Suboptimal medication adherence in Parkinson’s disease. Mov Disord 2005; 20(11): 1502–1507.


Recently registered pharmacy technicians’ views on their education and training experiences in community and hospital pharmacy S.D. Jee, E.I. Schafheutle and S. Willis Manchester Pharmacy School, The University of Manchester [email protected]

Prior to registration, pharmacy technicians must complete level-3 knowledge- and competence-based qualifications over two years, using a Further Education (FE) college, distance provider or approved NHS education centre (competence qualification), and complete work-based training typically in hospital or community pharmacy.1 Given the paucity of research in the area, a programme of work was undertaken to better understand the quality of pharmacy technician education and training. This paper aims to examine differences between trainee experiences in the two main sectors of community and hospital. After piloting with six pharmacy technician trainees, a census survey was administered by post and electronically (using Qualtrics (Provo, UT)) to 1457 recently registered (02/ 13–02/14) pharmacy technicians with four reminders. The questionnaire was informed by salient findings from qualitative interviews with education providers and employers.2 It contained five sections requesting views/information on: knowledge qualification, competence qualification, workbased training experience, open comments, and about you. Specific questions asked about content and support trainees received from education providers and employers, how the qualifications were funded, satisfaction levels with qualifications and work experience, and time taken to complete these. Most questions used a forced-choice format, including Likerttype options. Comparative statistical analyses between sectors consisted of Mann–Whitney U, which compared mean ranks (MR), and chi-square tests using IBM SPSS v20. Manchester University ethics committee granted approval. Six hundred and thirty-two usable responses were received (43.4%). The majority of respondents (550; 88%) were female and the average age was 35.26 ± 10.22. The majority (79.3%) of respondents were white British. Four hundred and seventyfive respondents (75.9%) trained in community and 133 (21.3%) in hospital. Most of those that trained in community (93%) used distance providers for their knowledge and competence qualification; most hospital trainees used an FE college for their knowledge qualification (78%) and an approved NHS centre for their competence qualification (57%). Statistical analyses showed a number of differences between respondents that trained in community and hospital. Those that trained in community were significantly more likely to contribute or provide full funds for undertaking knowledge and competence qualifications than those in hospital (χ2 (4, N = 606) = 21.140, p < 0.001). Respondents that trained in hospital felt more supported by their employing organisation (MR = 349 vs. 291, p = 0.001) and colleagues (MR = 345 vs. 292, p = 0.001); those in community felt more isolated (MR = 320 vs. 246, p < 0.001). Those that trained in hospital also felt more International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

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satisfied, overall, with their experience in the workplace during training (MR = 363 vs. 288, p < 0.001). Trainees in hospital received more study time than those in community (MR = 387 vs. 280, p < 0.001) and were more likely to complete qualifications in two years or less, whereas those in community took longer (χ2 (3, N = 625) = 106.654, p < 0.001). Findings illustrate the views of recently registered pharmacy technicians and the differences in experiences that exist between those that trained in different sectors. It is important that the views of pharmacy technicians are heard when making any revisions to education and training standards and regulations in how pharmacy technician education and training is undertaken to ensure consistency across different settings. 1. General Pharmaceutical Council. Criteria for registration as a pharmacy technician. 2013. London: General Pharmaceutical Council. 2. Jee S, Willis S, Pritchard A, Schafheutle E. Insights into the provision of Pharmacy Technician qualifications in Great Britain. Presented at APTUK Annual Professional Conference & Exhibition 2014: Patients First. 2014. Aston University, Birmingham.

A pilot study of a multidisciplinary clinical pain programme provided by the Gold Coast Medicare Local M.A. Kinga, A. Sava and J. McSwanb a Griffith University and bGold Coast Medicare Local and PainWISE [email protected]

Chronic pain is experienced by almost 20% and interferes with the daily activities of over 10% of adults living in Australia.1 Access to specialist multidisciplinary hospital based pain management clinics is limited, resulting in long waits for all but the most severe cases. To assist patients who were likely to have long waits to access hospital clinics, the Gold Coast Medicare Local, a primary care organisation that coordinates healthcare delivery and addresses local healthcare priorities, piloted a multidisciplinary patient support, education and information programme. The programme aimed to help patients manage their pain with appropriate support in primary care. The aim of this study was to evaluate the impact of the programme. Patients were identified from Gold Coast University Hospital wait lists for Persistent Pain, Orthopaedics, Rheumatology and Neurology, or referred by their General Practitioner. 103 patients were telephoned to inform them of the programme, and then mailed further details and an invitation to enrol. The programme included individual discussions with patients to support them and guide them to relevant allied health services, and ten evidence based education and information sessions. The group sessions lasted two hours and were held monthly commencing September 2013. Up to five additional allied health services were also provided.


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Demographic information was collected on those who enrolled. The Pain Self-Efficacy Questionnaire,2 a measure of a person’s ability to manage, or cope despite pain, was used to assess changes at six (February 2014) and ten (June 2014) months. Patients were also asked to comment on the programme. University ethics approval was granted. The 48 patients that enrolled in the programme had an average age of 55 years, and pain duration of 12.9 years; 38 were female. Two individual discussions were held with all participants and most attended at least half the education and information sessions (median = 5). Improvements in Pain Self-Efficacy were observed between 0 and 6 months, and again between 6 and 10 months (p < 0.001). The effect size for the change between 0 and 10 months was 1.1, equating to a large clinically significant improvement. Patients commented that they felt better equipped, i.e. more motivated, knowledgeable and empowered, to self-manage their pain as a result of participating in the programme. For patients experiencing chronic pain the ability to selfmanage their condition is a key outcome of therapy. The focus on self-management with support from health professionals in primary care resulted in improvements that continued throughout the life of the programme which were able to be captured using the tools selected. While there was no control group in this pilot, it is unlikely that a chronic pain condition would improve without intervention. Future research aims to determine whether the improvements are maintained over time and to evaluate the programme in a randomised controlled trial. A programme of education and information in combination with support from health professionals in primary care aids self-management of chronic pain conditions and has the potential to reduce hospital wait lists. Thanks to Andrea Sanders, and Ruth Carey from the Gold Coast Medicare Local. 1. Blyth FM, March LM, Brnabic AJM, Jorm LR,Williamson M, Cousins MJ. Chronic pain in Australia: a prevalence study. Pain 2001; 89 (2–3): 127–134. 2. Nicholas MK. The pain self-efficacy questionnaire: taking pain into account. Eur J Pain 2007; 11 (2): 153–163.

Educational provision for improving the prescribing of junior doctors: a national survey P.J. Lewis, S. Midgley, R. Quilliam and M.P. Tully Manchester Pharmacy School, The University of Manchester, Oxford Road, Manchester M13 9PL

[email protected] Prescribing errors are a common problem in secondary care and can affect up to 50% of admissions [1]. Reducing harm from error is a priority for NHS hospital trusts and as such many interventions have been implemented locally in order to improve prescribing. Such interventions include e-learning


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packages, face-to-face teaching and prescribing assessment amongst others. However, there is no obligation or national guidance on the delivery of such interventions across hospital trusts. This study aims to describe the current status of educational provision on prescribing safety across acute trusts in England. An online questionnaire was developed, piloted and emailed to the Chief Pharmacist and Director of Medical Education in 164 teaching and non-teaching acute NHS hospital trusts in England. A reminder email was sent to non-respondents after a three-week period. The survey incorporated mainly closed questions regarding types of educational interventions provided within the hospital for foundation doctors and details of their delivery. Some open questions were included to obtain participants’ opinions of educational interventions and their perceived effectiveness. Responses to closed questions were entered into SPSS and analysed using descriptive statistics. Responses to open-ended questions were coded and similarly analysed. Eighty-five hospital trusts responded to the questionnaire (RR = 51.8%). Nearly all trusts offered some form of educational intervention (83/85) yet there was considerable variation in content and mode of delivery. Teaching sessions (small and large group face-to-face teaching, often delivered by pharmacists) were the most commonly provided intervention (94% of trusts, n = 78). E-learning was delivered in 70% (n = 58) of trusts study guides in 10% (n = 8) and assessment in 63% (n = 52). Three interventions together (E–learning, teaching sessions and assessment) was the most common combination provided (29%, n = 25). However, the content of interventions (e.g. completion of mock drug charts, practice drug calculations, patient scenarios etc.) also greatly varied across trusts. Some of those delivering educational interventions (20.5%, n = 17) also reported that they collected data on their effectiveness (e.g. via pharmacist intervention monitoring). Half (53%, n = 44) stated that they provided some form of feedback to doctors. This was commonly informal, ad hoc and initiated only when concerns were raised. The University Ethics Committee judged that this work did not require ethical approval. The findings demonstrate that there is no uniformity in the provision of interventions to improve junior doctors prescribing across NHS acute hospital trusts. This lack of uniformity is likely to continue in the absence of evidence to suggest which approach or combination of approaches work best. However, since few hospitals collect data on the effectiveness of their interventions, even local data on efficacy is lacking. There also appears to be little evidence of formal feedback to doctors. Future work should determine the effectiveness of educational interventions and identify practical approaches to formal feedback provision. 1. Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, Tully M, Wass V. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. 2009. London, General Medical Council.


Interventions to address potentially inappropriate prescribing in primary care: a systematic review of randomised control trials B. Clyne, C. Fitzgerald, A. Quinlan, C. Hardy, R. Galvin, T. Fahey and S. M Smith HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland [email protected]

Potentially inappropriate prescribing (PIP) is broadly defined as the use of medicines that introduce a greater risk of adverse drug-related events where a safer, as effective alternative is available. PIP can contribute to increased morbidity, adverse drug events and hospitalisations. PIP is common in older people with an estimated prevalence of between 20 and 50% in community dwelling older adults, and the most important risk factor of receiving a PIP is being on multiple drugs – polypharmacy. This systematic review aimed to assess the effectiveness of interventions designed to reduce PIP in primary care. A systematic review of randomised controlled trials (RCTs) was conducted, adhering to PRISMA guidelines. PubMed, Embase, Scopus and the Cochrane library databases were searched (June 2014). Search terms included inappropriate prescribing, inappropriate pharmacotherapy, RCT, and primary care. Studies were included where: the population was community dwelling older patients (≥65); the intervention targeted PIP as compared to usual care or other intervention; and the outcome was change in PIP. Changes in PIP were measured with explicit (criterion-based, e.g. Beers or STOPP criteria) or implicit (judgment-based) tools such as the Medicines Appropriateness Index (MAI) which measures appropriateness across ten domains (e.g. indication, duration, cost), summed to provide an overall score. Three reviewers independently assessed studies for eligibility, extracted data, and assessed methodological quality using the Cochrane Collaboration’s risk of bias tool. As meta-analysis of results was not possible owing to heterogeneity in interventions, a narrative synthesis was carried out. No ethical approval was required. Of 699 records reviewed, 14 RCTs met the inclusion criteria. A total of 157,334 patients were included across all studies. Prevalence of PIP ranged from 18% to 78% at baseline. Five intervention strategies were identified: pharmacist-led advice; multi-disciplinary team (MDT) meetings; multifaceted interventions (combining two or more techniques) computerised clinical decision support systems (CDSSs); and audit and feedback. Pharmacist-led advice in four RCTs was associated with improvement in PIP (mean MAI difference of 3.1). Significant improvement in diminishing PIP was also found in one out of three MDT studies, two out of three multifaceted interventions and the only audit and feedback study. Both CDSSs studies were effective in reducing new PIP, particularly in relation to amitriptyline, but not in the discontinuation of existing PIP. The methodological quality of included studies was often poor, particularly in reporting selection and attrition bias. There were small numbers of studies within each category and International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

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there was considerable heterogeneity in the types of interventions grouped together and PIP assessment used. This systematic review of RCTs has found that pharmacistled interventions appear effective in decreasing PIP in primary care, with other interventions such as MDTs, multifaceted approaches and CDSSs showing promise. However, the heterogeneity of the study interventions and the variable methodological quality of these RCTs mean that results require further confirmation in ongoing RCTs. Furthermore, the clinical significance of reductions in MAI score is difficult to determine. There is a need for better quality evidence upon which to base approaches to improving prescribing for these vulnerable patients.

Prevalence of potentially inappropriate prescribing (PIP) and potentially prescribing omissions (PPO) in older Irish adults: findings from a randomised placebo-controlled trial (TRUST) D. O’Riordana,b, K. Walsha,b, S. Byrnea and P. Kearneyb a

Pharmaceutical Care Research Group, School of Pharmacy, University College Cork and bDepartment of Epidemiology and Public Health, University College Cork [email protected]; [email protected]; [email protected]; [email protected]

Potentially inappropriate prescribing (PIP) is a well documented problem in older patients. It includes the practice of administering potentially adversely interacting medicines, medicines with relative and absolute contraindications and unnecessary medicines 1. The major adverse events associated with PIP include serious drug interactions, hospitalisations, morbidity and in some cases mortality1. The aim of the study was to identify PIP and PPO’s using a subset of the Screening Tool of Older Persons Prescriptions/ Screening Tool to Alert doctors to Right Treatment, (STOPP/ START) criteria version 1 and 22 based on 258 community dwelling Irish adults aged ≥65 years screened in an ongoing European clinical trial. Ethical approval was obtained for this study. A subset of the criteria was used as information relating to drug strength, dose and duration of prescriptions in the TRUST dataset was not available. Therefore 40 PIP indicators and 14 PPO indicators from the STOPP/START version 1 criteria and 51 PIP indicators and 22 PPO indicators from version 2 were applied. PIP/ PPO prevalence according to both sets of criteria was estimated. Two pharmacists each reviewed half of the data independently. Each reviewer then randomly sampled 10% of the other reviewer’s data for consistency. Finally, all the data was cleaned, this involved a three step cycle of screening, diagnosing and editing any suspected data irregularities. Data on 258 patients screened in the study were analysed. The mean age (± SD) of the patients was 73.2 ± 5.1 years, 133 (51.6%) were female. The most common morbidity recorded was hypertension (53.9%). The median number of drugs con© 2015 The Authors. IJPP © 2015 Royal Pharmaceutical Society

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sumed was 4 (IQR = 4). The overall prevalence of PIP was 14.7% (n = 38) considering all 40 STOPP version 1 criteria while the overall prevalence of PPO was 16.7% (n = 43) considering 14 START version 1 criteria. The overall prevalence of PIP and PPO using version 2 was 15.9% (n = 41) and 20.5% (n = 53) respectively. There was a significant association between PIP (in both STOPP/START version 1 and 2) and polypharmacy when adjusted for age, sex and multimorbidity (adjusted OR 4.39, p = 0.001, 95% CI 1.77–10.87 and adjusted OR 3.27, p = 0.009, 95% CI 1.35–7.93 respectively). The association between PPO (in both STOPP/START version 1 and 2) and polypharmacy when adjusted for age sex and multimorbidity (adjusted OR 0.49, p = 0.118, 95% CI 0.20– 1.20 and adjusted OR 1.07, p = 0.874, 95% CI 0.48–2.35 respectively) was not significant. These findings indicate that PIP and PPO’s are prevalent in older adults screened for a randomised control trial (RCT) using a subset of the STOPP/START version 1 and 2 criteria. Screening tools such as STOPP/START have the potential to identify inappropriate prescribing at the point of randomising patients to clinical trials. The use of a structured pharmacist review of medication (SPRM) supported by a computerised decision support system (CDSS) and STOPP/ START version 2 is currently underway. 1. Lindley CM, Tully MP, Paramsothy V, Tallis RC. Inappropriate medication is a major cause of adverse drug reactions in elderly patients. Age and Ageing 1992; 21: 294–300. 2. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age and Ageing 2014; 0: 1–6.

Prescribing appropriate polypharmacy for older people in primary care: a qualitative study of general practitioners’ perceptions and experiences C.A. Cadogana, C. Ryana, G.J. Gormleyb, P. Passmorec, J. Francisd, N. Kersee and C Hughesa a School of Pharmacy, Queen’s University Belfast, bDepartment of General Practice, Queen’s University Belfast, cCentre for Public Health, Queen’s University Belfast, dSchool of Health Sciences, City University London and eSchool of Population Health, University of Auckland [email protected]

Ensuring appropriate combinations of medications in older populations with multimorbidity is an ongoing and ever increasing challenge. Evidence to support the effectiveness of interventions to improve appropriate polypharmacy in older people is weak.[1] It has been proposed that future interventions should adopt a theory-based approach and involve key stakeholders, such as healthcare professionals (HCPs), during intervention design.[1] Theory-based qualitative interviews using the Theoretical Domains Framework (TDF) can be used to identify specific barriers and facilitators to achieving desired International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

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changes in HCPs’ clinical practice.[2] The aim of this study was to explore general practitioners’ (GPs) approaches to prescribing polypharmacy to older patients and to identify key theoretical domains that acted as barriers and facilitators to the prescribing of appropriate polypharmacy. This study forms part of an ongoing mixed methods project seeking to develop an intervention to improve appropriate polypharmacy for older people in primary care. The intervention will specifically target identified theoretical domains. A purposive sample of up to two general practices (urban, rural) from each Health and Social Care Trust area (n = 5) in Northern Ireland was recruited into the study by the Northern Ireland Clinical Research Network. Semi-structured interviews were conducted with recruited GPs (up to two per practice) using a TDF-based topic guide. The topic guide (piloted with two academic GPs) explored GPs’ views on the term ‘polypharmacy’. Questions covering each TDF domain were used to explore GPs’ perceptions of barriers and facilitators to ensuring the prescribing of appropriate polypharmacy for older people. A clinical scenario of inappropriate polypharmacy was included to stimulate discussion. Data were recorded and transcribed verbatim. Transcripts were independently checked for accuracy. Following data saturation, data were analysed using both content analysis and the framework method. Ethical approval was granted by the Office of Research Ethics Committees Northern Ireland. Fourteen GPs participated in the study. GPs’ definitions of the term ‘polypharmacy’ varied, with a primary focus on numbers of drugs prescribed. ‘Knowledge’, ‘Skills’, ‘Beliefs about consequences’, ‘Social influences’ and ‘Social/ professional role and identity’ were identified as key theoretical domains that facilitated the prescribing of appropriate polypharmacy to older patients. For example, GPs reported that their clinical knowledge and skills facilitated them in making the necessary prescribing changes to ensure that older people receive appropriate polypharmacy. ‘Environmental context and resources’ was the main theoretical domain that prevented GPs from prescribing appropriate polypharmacy to older people in primary care, particularly time needed to address polypharmacy. The study findings show that GPs believe they have the requisite knowledge and skills to ensure older people receive appropriate polypharmacy. However, time pressures and resource limitations are currently preventing GPs from optimising older people’s prescriptions more frequently in routine clinical practice. This analysis will be integrated with other project components (semi-structured interviews of community pharmacists, focus groups involving older patients receiving polypharmacy). Synthesis of all data will be used to develop an intervention to assist GPs and community pharmacists in achieving appropriate polypharmacy in older people in primary care. This work was supported by The Dunhill Medical Trust [grant number: R298/0513]. 1. Patterson SM, Cadogan CA, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2014; 10: CD008165. 2. Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A. Making psychological theory useful for imple© 2015 The Authors. IJPP © 2015 Royal Pharmaceutical Society

menting evidence based practice: a consensus approach. Qual Saf Health Care 2005; 14: 26–33.

Inpatient electronic prescribing – how involved are inpatients with their medication? S. Jheetaa, C. Lubranta, S. Garfielda,b and B. D. Franklina,b a Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK and bThe Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, London, UK [email protected]

It has been suggested that greater patient involvement in medication may improve medication safety. However, it is not known to what extent electronic prescribing (EP) may support inpatient involvement in UK hospitals. EP systems could potentially create a barrier to patient involvement if patients have limited access to their medication records. Conversely, EP could facilitate the production of patient-specific interfaces which could be used to support increased patient involvement. We aimed to 1) identify whether commercial EP systems available in England have features which support inpatient interaction with their electronic medication record; and 2) explore the extent to which inpatients are supported to interact with EP systems in a sample of English hospitals. First, websites of commercial EP systems used in England[1,2] were searched to identify any features that support inpatient access or interaction. Second, thirteen hospital trusts in England with well-established inpatient EP systems were identified[1,2]; in each trust, a relevant pharmacist was emailed in July 2014 and invited to answer questions about inpatient interactions with their EP system. Based on pilot work, we developed open questions, including brief prompts, to explore if and how inpatients view details of their prescribed medication or use the system when selfadministering medication. Recipients were invited to respond by email or telephone depending on their preference. Key points from the data were collated, tabulated for comparison and summarised descriptively. Ethical approval was not required as the work was considered a service evaluation. Of fourteen commercial EP systems identified, only one website referred to possible inpatient involvement; this was via an ‘interactive patient console’ which could provide access to medical information, educational materials and communication with healthcare professionals. It required additional hardware such as televisions, microphones and keyboards. A representative of nine (69%) trusts responded to our survey, most of whom used commercial EP systems. None reported that inpatients were able to access or interact directly with their electronic medication record, although two reported that their system had a ‘patient friendly’ medication record International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

Oral abstracts

screen which could be shown to the patient by a healthcare professional if requested. Seven reported that printouts of inpatient medication were possible if requested by the patient but these were not routinely used. Self-administration of medication was reported to be rarely used; four trusts provided a paper medication record to any self-administering patients as patients were unable to access their electronic medication record. This exploratory study suggests that inpatient EP systems do not seem designed to accommodate patient interaction. There is potential for inpatients to view ‘patient-friendly’ screens with some systems although these are not routinely used. This may partly be due to the requirement for additional hardware to support more widespread use. Although there is a shift towards paperless systems, currently the most common way to provide patients with information about their prescribed medication is through paper printouts. A limitation is that email responses were more limited. EP suppliers and healthcare providers should consider how inpatients could best be involved with their medication with EP systems. 1. Ahmed Z, McLeod MC, Barber N, Jacklin A, Franklin BD. The use and functionality of electronic prescribing systems in English acute NHS Trusts: a cross-sectional survey. PLoS ONE 2013; 8(11): e80378. doi:10.1371/journal.pone .0080378 2. Cresswell K, Coleman J, Slee A, Williams R, Sheikh A et al. Investigating and learning lessons from early experiences of implementing ePrescribing systems into NHS hospitals: a questionnaire study. PLoS ONE 2013; 8(1): e53369. doi:10.1371/journal.pone.0053369

Exploring the perceptions and experiences of people who use and those that provide a shared care clozapine service C. Sowerby and D.A. Taylor University of Bath [email protected]

No Health without Mental Health 2011[1] and Delivering Better Mental Health Outcomes for People of All Ages 2011[2] emphasise that: care should be driven by patients, there should be choice in how patients obtain their care, and care should be individualised and recovery focused in order to improve patients’ independence. Clozapine clinics, managed within secondary care mental health trusts, are commonly used to supply clozapine to those in the community. A clozapine shared care service is an alternative option, where people taking clozapine obtain it from their GP and community pharmacy; who are supported by secondary care mental health colleagues. The aim of this study was to explore the perceptions and experiences of people receiving/delivering this service to better understand its effectiveness and acceptability.


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Semi-structured interviews and focus group methodology were used to explore perceptions and experiences of study participants. Potential professional participant groups included clozapine service users (CSU), general practitioners; community psychiatric nurses, community and hospital pharmacy staff and responsible clinicians. Ethical approval was granted in July 2013. A phenomenological analytical approach was adopted using Interpretative Phenomenological Analysis (IPA) to enable exploration of how the phenomenon of a shared care clozapine service had been experienced by study participants, and what this phenomenon meant to the individual. A total of 38 participants were recruited; including 32 healthcare professionals (HCPs) and 6 CSUs. There were 13 HCPinterviews, 1 patient interview and 6 focus groups, resulting in 20 transcripts. As the primary concern of IPAis with the detailed account of individual experience, there is benefit from a concentrated focus on a smaller number of cases. All participant groups were similarly represented in number. Transcripts were analysed within and across participant groups as an iterative process and resulted in four superordinate themes shared across the participant groups studied. These were: Clozapine Process, Shared Care, The Provision of Care and Multiprofessional Relationships. Knowledge of the clozapine process, had a positive effect on the experience of shared care clozapine for HCPs and CSUs, supporting a sense of confidence. The clozapine process itself caused anxiety for HCPs and CSUs alike, due to the consequences of a delayed clozapine supply. Multiprofessional relationships with HCPs and CSUs developed over time and were facilitated through communication. These relationships enabled HCPs to feel valued and included within the MDT. Shared care enabled CSUs to take ownership of their health and develop independence through realisation of their capability and a change in relationship between CSUs, HCPs and their medicines. Barriers related to the uptake of Shared care were identified as clozapine-associated stigma, changes in ownership of responsibility and professionals’ level of involvement in CSUs’ care. HCPs and CSUs perceived clozapine as different in the provision of care, because of the process of supply and its beneficial effects on symptoms. Both CSUs and HCPs agreed the provision of care for physical health was just as important as mental health. Results demonstrate that shared care clozapine empowers people who take clozapine to gain ownership of their health and supports multi-professional relationships. 1. Department of Health. No Health Without Mental Health : A Cross Government Outcomes Strategy, 2011. 2. Department of Health. Delivering Better Mental Health Outcomes for People of All Ages, 2011.


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Illness and medication beliefs among elderly Kuwaiti patients with type 2 diabetes in primary health care setting in Kuwait: a qualitative study M. Alsaleh, M. Weiss and H.E. Family University of Bath [email protected]

Kuwait is ranked as one of the top ten countries in the world in regard to the incidence of adult diabetes mellitus (DM).[1] Although there are health services in Kuwait for DM it is important to understand the beliefs that impact on the healthrelated behaviours of Kuwaiti diabetics. This will help identify the triggers that prompt people to seek medical advice for their condition, to understand how people take their medications, and how/where they obtain medical information. This research aimed to explore the beliefs of older DM patients’ about their condition and use of medicines in Kuwait. Ethical approval was obtained from Kuwaiti Ministry of Health Ethics Committee to conduct semi-structured interviews with type two DM patients. A topic guide, developed from the objectives of the study was used to guide the interviews. Participants were recruited from the primary health care diabetic clinics pharmacy by the researcher (MA). A sampling frame was employed in the recruitment process, whereby every fifth patient who met the inclusion criteria was invited to participate in the study. The inclusion criteria were: type two DM for >6 months, living in Kuwait, age 50 and over, and receiving oral hypoglycaemic medications (but not insulin). Informed consent was obtained from all participants. Interviews were audio-recorded and conducted in Arabic. Interviews were transcribed verbatim and analysed using thematic analysis.[2] Interviews were conducted with 15 patients (7 males) and lasted between 20 and 40 minutes. Nine themes emerged from the data: causes of diabetes, behaviour toward medication, attitude to control diabetes, views about medicine, views about doctors and pharmacists, medication reminders, sources of information and support, social gatherings for men or women and social behaviour related to social gatherings. This paper reports the strongest theme “behaviour towards medication.” Within this theme participants described wanting only the best treatment which related to evaluating diabetic medications according to their trade name, preferences for medicines originating from western over middleeastern countries and the original medicines packaging over hospital packaging: ‘honestly, if the Glucophage wasn’t made in Germany I wouldn’t consider to take it’. Participants’ narratives revealed that patients trust the doctor’s but not the pharmacist’s medicines advice. Patients also described hoarding and stock piling medicines after the Iraqi invasion, during which time there had been no access to medicines, as well as sharing DM medicine between husband and wife or amongst neighbours and friends. This is the first qualitative study to explore the social and cultural beliefs of diabetic patients’ illness and medicinetaking behaviour in Kuwait. However, it is recognised that this © 2015 The Authors. IJPP © 2015 Royal Pharmaceutical Society

is a small study which cannot be generalised to the wider population. Future work will include investigating whether these views are prevalent amongst a wider diabetic population. An understanding of how the illness and medication beliefs held by Kuwaiti DM patients influences their health behaviours will be helpful in identifying ways of shaping their behaviour through targeted interventions to promote a healthier lifestyle and improved DM management. 1. International Diabetes Federation. IDF Diabetes Atlas, 6th edn. Brussels, Belgium: International Diabetes Federation, 2013. 2. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006; 3(2):77–101.

Investigating the impact of medicine information services on patient outcomes: a systematic review N. Alkhaldi, D. Wright and D. Bhattacharya University of East Anglia [email protected]

A 2002 systematic review of the impact of medicine information (MI) services on patient outcomes, comprising six studies, found limited evidence and recommended that more robust studies are required to demonstrate their effectiveness (1). In financially constrained healthcare systems it is becoming increasingly important to demonstrate the value of different healthcare services. It may therefore be the absence of rigorous evidence that is associated with the reported reduction in MI services in the USA over recent years (2). This study aims to update the previously performed systematic review and collate the evidence for the effects of MI services on patient outcomes. Published and unpublished studies were identified through electronic and manual searches. The following databases were searched from inception to December 2013: CINAHL, EMBASE, MEDLINE and the Centre of Reviews and Dissemination. The primary author(s) were contacted through email to identified unpublished studies. After scoping searches were conducted, the search strategy combining the terms medicine information, drug information and dial access was used in combination with truncations, wild cards ($), adjacent search options (adj2), and other relevant Boolean operators permitted by the database. Studies reported in English, of any design, assessing the impact of MI services in secondary care and reporting patient outcomes were included. Independent screening of titles and abstracts was performed by two reviewers using a bespoke abstract screening tool. Disagreements were resolved by consensus with referral to a third reviewer if necessary. The Cochrane risk of bias tool was used to assess the quality of included studies. Quality appraisal was independently performed by two reviewers; studies were not excluded based on quality. Ten relevant published articles were identified of which four were from the UK, three from USA, two from Canada and one from Norway. Single-centre studies accounted for eight and two were multi-centre. All studies were descriptive rather than International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

Oral abstracts

experimental and no comparison groups were used. Five were prospective and five were retrospective in design. In most studies the impact of MI services on patients’ outcome(s) was captured through using survey methods. Three studies used a multi-professional expert panel comprising clinical pharmacists and doctors in order to identify and evaluate the patient outcomes of the MI service. A positive impact on patient outcomes was reported for 40% to 76% of MI service users. One large scale multi-centre observational study reported 44 fewer deaths per hospital per year in the 1029 hospitals with an MI service when taking into account other related factors. To date, no randomised controlled trials have been performed to demonstrate the effectiveness of the provision of MI services. The research methodologies used to investigate the impact of MI services on patient outcome(s) tend to rely on users subjectively stating whether patients benefited from the advice or review panels predicting patient outcomes as a result of the advice provided. With MI centres disappearing within some hospitals in the USA, this may provide an opportunity for cluster randomised controlled trials to more accurately determine the effect of MI services on patient outcomes. 1. Hands S, Stephens M, Brown D. A systematic review of the clinical and economic impact of drug information services on patient outcome. Pharm World Sci 2002; 24: 132–138. 2. Rosenberg JM, Koumis T, Nathan JP et al. Current status of pharmacist-operated drug information centers in the United States. Am J Health Syst-Pharm 2004; 61: 2023–2032.

Economic evaluation of a software-supported structured pharmacist medication review in hospitalised older patients J. Gallaghera, S. McCarthya, D. O’Sullivana, D. O’Mahonyb, P. Gillespiec, N. Woodsd and S. Byrnea a

School of Pharmacy, University College Cork, bDepartment of Geriatric Medicine, Cork University Hospital, cSchool of Business and Economics, National University of Ireland, Galway and dCentre for Policy Studies, University College Cork, Ireland [email protected]

A recent randomised controlled trial (RCT) conducted in an Irish hospital applied a structured pharmacist review of medication (SPRM) supported by computerised decision support software (CDSS). This novel intervention was predominantly based on the application of the STOPP (Screening Tool of Older Persons Potentially Inappropriate Prescriptions)/ START (Screening Tool to Alert Doctors to the Right Treatment) criteria to patient medication records. The aim of this paper was to examine the cost-effectiveness of pharmacists applying the SPRM/CDSS intervention on elderly hospital inpatients in comparison with usual pharmaceutical care. This evaluation is a trial based cost-effectiveness analysis. Full details of the study method are detailed elsewhere[1]. Patients were recruited and cluster randomised (according to © 2015 The Authors. IJPP © 2015 Royal Pharmaceutical Society

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admitting consultant) to either intervention or control arms between June 2011 and June 2012. Time horizon for this evaluation was confined to patient discharge or 10 day follow-up and perspective was that of the healthcare provider. Cost data were informed by a combination of individual patient trial data, published healthcare salaries and Irish diagnosis-related group data for inpatient stays. Incremental analysis was undertaken using a multi-level mixed effect regression model. Uncertainty was addressed using 95% confidence intervals and costeffectiveness acceptability curves. The probability of the intervention being cost-effective was measured using hypothetical threshold levels which the healthcare provider would be willing to pay for the prevention of an adverse drug reaction (ADR) [2]. Ethical approval was obtained from all relevant bodies. Application of SPRM/CDSS in hospitalised older patients is the dominant strategy. It reduces the likelihood of a patient experiencing an ADR, in addition having a reduced cost in comparison with usual care (see Table 1). Application to intervention group of patients cost €19 000; this was predominantly composed of the cost of pharmacist time (€40 per patient). Table 1 Incremental cost-effectiveness analysis Incremental analysis Intervention (n = 361) versus Control (n = 376) Mean patient cost for hospital stay – € (Standard deviation) Incremental cost: total cost – € Difference in mean (95% CIs) (P-value) Incremental effect: ADR event Odds ratio (95% CIs) (P-value) Incremental effect: No. of ADR events Difference in mean (95% CIs) (P-value) Threshold value (λ) per ADR averted

€0 €250 €500 €1000

13242 (15530)

15465 (19310)

−815 (−3451, 1820) (0.544)

0.655 (0.431, 0.994) (0.047) −0.064 (−0.135, 0.008) (0.081)

Incremental costeffectiveness analysis (Probability that intervention is cost-effective) 0.721 0.724 0.730 0.737

Based on the evidence presented, SPRM/CDSS is likely to be determined to be cost-effective, even at a €0 willingness to pay. However, this cost-effectiveness analysis was based on the prevention of adverse drug reactions rather than a more recognised outcome e.g. QALY. Hence, there is still an element of uncertainty regarding the cost-effectiveness status of the intervention. 1. O’Sullivan D et al. A randomised controlled trial to assess prevention of adverse drug reactions in hospitalised older patients using a software-supported structured pharmacist International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

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intervention. Clinical Pharmacology and Therapeutics [in press]. 2. Gillespie P et al. The cost-effectiveness of a structured education pulmonary rehabilitation programme for chronic obstructive pulmonary disease in primary care: the PRINCE cluster randomised trial. BMJ Open 2013; 3(11): e003479.

Feasibility evaluation of an electronic method for documentation of clinical pharmacy interventions and activities in secondary care J. Pattersona, A. Campbella and S. Cunninghamb a Pharmacy Department, Ulster Hospital, Dundonald, Belfast BT16 1RH and bSchool of Pharmacy & Life Sciences, Robert Gordon University, Aberdeen [email protected]

The positive contribution and role of the clinical pharmacist in secondary care are well established in the UK1. The issue of how to effectively benchmark clinical pharmacy services in Northern Ireland (NI) has long been debated. Existing local paper-based documentation methods could not provide the data required. An alternative computer-based system, ‘Electronic Pharmacist Intervention Clinical System’ (epics©), developed and supported locally in NI, was selected for evaluation to standardize reporting. To evaluate the feasibility of using epics© to gather data for benchmarking clinical pharmacy activity and outcomes. The setting was a teaching hospital in NI. Quantitative intervention and workload activity data were collected for clinical pharmacy services provided to the Coronary Care Unit (CCU). The software developer provided training, and epics© was trialled during January 2014. Data were collected daily by the principal researcher using epics© for a 2-month period (February–March 2014). Each intervention was assigned a clinical significance grade, based on the Eadon scale2, to provide qualitative data on patient outcome. Ethical review was carried out by University Ethics Panel and local NHS approval was sought but deemed unnecessary. During the 2-month period, 1508 interventions were documented on CCU as shown in Table 1.


Table 1 Summary of clinical pharmacist intervention data for CCU, February–March 2014 February 2014 March 2014 Total n (% of total) n (% of total) n (% of total) General data for CCU No. of admissions No. of discharges Total interventions Clinical significance grade – Eadon scale 1 2 3 4 5 6 epics© category Admission Allergy Information Incorrect Missing Discharge Other epics© stage Admission Inpatient Transfer Discharge Med Rec on admission % of patients with Med Rec on admission Med Rec on discharge % of patients with Med Rec on discharge Average mean number of interventions per patient

145 79 727 n (% of total)

142 104 781 n (% of total)

287 183 1508 n (% of total)

0 (0%) 0 (0%) 144 (19.8%) 580 (79.8%) 3 (0.4%) 0 (0%) n (% of total) 222 (30.5%) 6 (0.8%) 42 (5.8%) 27 (3.7%) 49 (6.8%) 158 (21.7%) 223 (30.7%) n (% of total) 404 (55.6%) 119 (16.4%) 0 (0%) 204 (28.0%)

0 (0%) 13 (1.7%) 285 (36.5%) 481 (61.6%) 2 (0.3%) 0 (0%) n (% of total) 212 (27.2%) 10 (1.3%) 50 (6.4%) 36 (4.6%) 56 (7.2%) 146 (18.7%) 271 (34.7%) n (% of total) 422 (54.0%) 133 (17.0%) 6 (0.9%) 220 (28.2%)

0 (0%) 13 (0.9%) 429 (28.4%) 1061 (70.4%) 5 (0.3%) 0 (0%) n (% of total) 434 (28.8%) 16 (1.1%) 92 (6.1%) 63 (4.2%) 105 (7.0%) 304 (20.1%) 494 (32.7%) n (% of total) 826 (54.8%) 252 (16.7%) 6 (0.4%) 424 (28.1%)

109

103

212

75%

72.5%

74%

73 92.4%

65 62.5%

138 75.4%

4.6

5.4

5.0

Analysis of the characteristics and range of data for all recorded interventions (n = 1508) showed most interventions occurred at admission (n = 826) or discharge (n = 424) stages with drug history (n = 222) and medicines reconciliation at discharge (n = 138) being most common, respectively. Other interventions included: kardex review (n = 158); laboratory test reviewed (n = 189); patient education (n = 79); laboratory test required (n = 67), and missing frequency (n = 39). The majority (70%) were graded as having improved patient care. Epics© showed that 84% of time was spent on patient-focused work activities. The epics© software enabled daily collection of clinical pharmacy intervention and workload activity data that could be used for benchmarking service provision. It provided an exten-


Oral abstracts

sive database of quantitative and qualitative information and has the potential to meet local and regional demands for clinical pharmacy data. Epics© is not integrated with all other systems and in the future any pharmacy software should, ideally, be part of a single electronic patient record. 1. National Institute for Health and Clinical Excellence (2007). Technical Patient Safety Solutions for Medicines Reconciliation on Admission of Adults to Hospital. PSG001. www.nice.org.uk (Online). 2. Eadon, H. Assessing the quality of ward pharmacists’ interventions. The International Journal of Pharmacy Practice 1992; 1: 145–147.

General public expectations of a community pharmacy led weight management service offered during smoking cessation A.E. Weidmanna, B. Addisona, A. Browna and J. Youngb a Robert Gordon University, Aberdeen and bNorthumbria University, Newcastle upon Tyne [email protected]

The World Health Organization estimates obesity prevalence will double to 41% of the Scottish population by 2030.1 The government has placed a strong emphasis on community pharmacies to provide a wide range of easy-to-access weight management services to the general public.2 A programme of studies by this research team, establishing views, attitudes and awareness of pharmacists, counter assistants and the general public towards weight management services currently delivered by UK community pharmacies, has identified a desire for a person-centred nutrition programme, based on the structure of, and used in conjunction with, the successfully implemented nicotine replacement therapy (NRT) scheme. The aim of this research was to explore the expectations of the general public towards such a tailored service. A cross-sectional survey with a sampling frame of 1500 randomly selected members of the Scottish general public aged 18 years and over (obtained from the electoral register) was conducted during June–August 2013. Questionnaires, with a covering letter describing the study’s aim and assurance of confidentiality, were mailed to all participants. Nonresponders were mailed up to two reminder questionnaires at 4 weekly intervals. The questionnaire comprised information on: awareness of services available from community pharmacies, respondents’ attitudes towards and expectations of weight management services provided in the context of NRT, demographic data and a final open question inviting further comment. Five-point Likert scales, semantic differentials and open/closed questions were used as response options. Data was analysed using descriptive statistics and cross-tabulations in SPSS (vs 21). Content analysis was performed the open question responses. The study was approved by the Ethical Review © 2015 The Authors. IJPP © 2015 Royal Pharmaceutical Society

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Panel of the School of Pharmacy and Life Sciences at Robert Gordon University, Aberdeen. A total of 255 questionnaires were returned (response rate of 17%). Demographics: The majority of respondents were male (48.2%; n = 123), aged 18–29 years (47.1%; n = 115) and in full-time employment (60.8%; n = 155). The majority of respondents were ex-smokers (34.9%; n = 89) or smokers (18%; n = 46). 67.1% (n = 171) classed themselves as having a normal body weight with 24.4% (n = 59) being overweight or obese. The majority of respondents (87.5%; n = 223) were not currently actively participating in a weight loss programme. Awareness of services available from community pharmacies: Only 2% (n = 5) and 5.9% (n = 15) had previously made use of a pharmacy or GP led NRT service. The majority agreed or strongly agreed (51.7%; n = 132) that they were unaware of any weight management services offered by community pharmacies. Attitudes towards and expectations of weight management services provided in the context of NRT:73.9% (n = 34) of smokers and 78.6% (n = 70) of ex-smokers consider there to be a need for a pharmacy-based weight loss service specifically tailored to people who would like to stop smoking. 72.2% (n = 164) of respondents would consider using such a service. Findings of this study illustrate a somewhat mixed picture of the general public’s expectations regarding weight management support services and specifically for patients wishing to stop smoking. These warrant further investigation. We acknowledge potential study limitations of bias, size and transferability to other areas in the UK. 1. The Scottish Government (2010). Preventing Overweight and Obesity in Scotland. A Route Map Towards Healthy Weight. http://www.scotland.gov.uk/Resource/Doc/ 302783/0094795.pdf (accessed October 2013). 2. Scottish Public Health Network. SOAR2 Project Working Group. Scottish Obesity Action Resource – Update. September 2012.

Ebola virus disease: understanding how relevant health information is disseminated in Nigeria O.P. Adigwea, J. Alfab and A.B. Umorub a

Health Policy Research and Development Unit, National Assembly, Abuja, Nigeria and bDepartment of Pharmaceutical Services National Assembly, Abuja, Nigeria

The high mortality rate and rapid spread associated with the Ebola virus disease (Ebola) justify its classification as an international health emergency[1]. This is in addition to the fact that currently, no cure exists for the disease. As prevention remains a key factor in controlling the spread of the disease, providing accurate and reliable health information in a timely manner is of utmost importance. This study aimed at understanding how health information relating to the Ebola was disseminated in Nigeria. A cross-sectional survey was designed to collect the relevant data from a convenient sample in a government establishment International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

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that interfaces with international visitors and the Nigerian public. Face and content validation was undertaken by an expert panel. Piloting did not result in any changes. The data were collected between July and August 2014 and analysed using SPSS (version 17). Research ethics and governance approval were obtained from the National Assembly management. An 80% response rate was achieved (561/700). Majority knew of Ebola (93%; 520/561) and other important information regarding the disease, for example, that it is viral (91%; 473/520). Knowledge in other areas was, however, inaccurate or inadequate. For instance only 57% (296/520) knew that it did not have a cure and close to half (46%; 239/520) felt that everyone infected with the virus would certainly die within 21 days. Respondents accessed information about Ebola from various sources with television and radio emerging as the most relevant, and posters, the least.

Figure 1 Sources on information on Ebola

Healthcare decisions made in emergencies such as Ebola are underpinned by information that individuals have access to. It is therefore important that health information provision is safe and efficient [2].Our study identified electronic and print media as the most efficient means of disseminating relevant information. This is particularly important in resource scarce settings. Reliance on social media and religious leaders for information on Ebola is worrisome as the quality of information provided is unknown. Evidence emerging from this study can therefore help relevant bodies improve the provision of health information, as well as ensure that the information is valid and reliable. 1. WHO (2014). Statement on the Meeting of the International Health Regulations Emergency Committee regarding the 2014 Ebola Outbreak in West Africa [Online]. http://www .who.int/mediacentre/news/statements/2014/ebola20140808/en/ 2. Adigwe OP. Health literacy: patient involvement and engagement with healthcare. Reply to Raynor, DK. Health literacy. British Medical Journal 2012; 344:e2188 [Online]. http://www.bmj.com/content/344/bmj.e2188/rr/ 587175 © 2015 The Authors. IJPP © 2015 Royal Pharmaceutical Society

Outcomes from the Irish national hepatitis C prospective treatment registry E. Graya, A. O’Learya,b, C. Walsha,c, C. Bergina,d and S Norrisa,d a Irish Hepatitis C Outcomes Research Network, St. James’ Hospital, Dublin 8, bNational Centre for Pharmacoeconomics, St James’ Hospital, Dublin 8, cDepartment of Mathematics, University of Dublin, Trinity College and dSt James’ Hospital, Dublin 8 [email protected]

The Irish Hepatitis C Outcomes and Research network (ICORN) Treatment Registry is a prospective outcomes study that collects real-world clinical and economic outcomes for patients treated with direct acting antiviral agents (DAA) (telaprevir and boceprevir), when added to a dual regimen of pegylated interferon/ribavirin for patients with Genotype 1 hepatitis C (HCV). The aim of the study is to determine sustained virological response (SVR) rates, eligibility for response-guided therapy (RGT), discontinuation rates, tolerability and total costs of treatment. The national ICORN HCV treatment registry is a web-based tool hosted on an electronic platform developed by the Dublin Centre for Clinical Research in conjunction with ICORN. Ethical approval for the study was obtained from the St. James’s Hospital/Tallaght Research Ethics Committee. Patients selected for treatment are consented for participation in the study and clinical data are captured at each hospital site using ICORN data collection sheets for the duration of treatment, and during post-treatment follow-up to outcome assessment at SVR 12 weeks and SVR 24 weeks. Patient variables collected are determined by study outcomes and include both categorical and continuous variables, stratified according to baseline demographics, HCV characteristics, and on-treatment medication requirements, tolerability, patient admissions, laboratory and diagnostic data. Data are subsequently entered into the registry prior to report generation, systematic quality control procedures and data analysis. Analysis is undertaken using SPSS Version 21®. A total of n = 279 patients are registered (June 2012–August 2014) across 7 hospitals. The cohort is predominantly male (72%) with a median age of 45 (range 18–72) and the majority are Irish born (71%). 70% are treatment naive and 29% are cirrhotic. Genotype 1, 1a and 1b account for 27%, 45% and 28% of the cohort respectively. Telaprevir is the DAA of choice (68%). At baseline, 56% of patients satisfy the criteria for RGT. Outcome data are complete for n = 136 patients. The SVR rate was 51%. Discontinuation of therapy due to treatment futility rules, adverse events and intolerance occurred in n = 62 (46%) patients. Safety data has been analysed for a cohort of n = 110. 41% of the cohort required an intervention for the management of anaemia, 30% (n = 32) of patients had neutrophil levels consistent with grade 3/4 neutropenia (neutrophils < 0.75 x109/L) and grade 3/4 thrombocytopenia, as evidenced by platelets below 50 x 109/L, was reported in 18.7% (n = 20) of the cohort. For n = 74 who completed treatment, 81% (n = 68) achieved an SVR24, indicating a relapse rate of 19%. International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

Oral abstracts

The efficacy rates, of 65–85% obtained in phase III clinical trials are higher then that seen in the real world setting 1–2. This is due to higher discontinuation rates, which is attributed to a more frequent occurrence of virological treatment failures and adverse events, a direct outcome of greater patient heterogeneity than seen in clinical trials. 1. Trembling PM, Tanwar S, Dusheiko GM. Boceprevir: an oral protease inhibitor for the treatment of chronic HCV infection. Expert Rev Anti Infect Ther 2012; 10(3): 269– 279. 2. Chang MH, Gordon LA, Fung HB. Boceprevir: a protease inhibitor for the treatment of hepatitis C. Clin Ther 2012; 34(10): 2021–2038.

The impact of contextual factors on the prescribing of psychoactive drugs with older people: an analysis of treatment culture in nursing homes using an ethnographic approach C. Shawa, C. Hughesa and B. McCormackb a Queen’s University, Belfast and bQueen Margaret University, Edinburgh [email protected]

Prescribing of psychoactive medications for older residents in nursing homes has been a cause for concern and such medications have been described as ‘chemical restraints’[1]. One factor which may influence the prescribing of these medicines is treatment culture, defined as the way in which prescribing of psychoactive medication is undertaken[2]. Nursing homes have been defined as resident-centred (least likely to use psychoactive medication), traditional (most likely) or ambiguous in terms of treatment culture[2]. The aim of this research was to explore treatment culture in nursing homes in respect of the prescribing of psychoactive medications, using an ethnographic approach. A cross-sectional study carried out in 2008 used an adapted treatment culture questionnaire in Northern Ireland and New Zealand to determine the treatment culture of 179 nursing homes[2]. Following on from this, six nursing homes were recruited into the first phase of a three-phase study. The current phase (Phase 2) recruited three homes from the original six, one in each category of treatment culture. Data were collected via observations, in-depth interviews with nursing home staff and examination of residents’ nursing notes (demographics and prescribing details, focusing on psychoactive medicines). Observations of the day-to-day working activities of all consenting nursing home staff and GPs were undertaken over a period of approximately 100 hours at each site, on different days, and shifts. In-depth interviews sought to explore and explain observational data. Data were analysed using Schein’s Framework and thematic analysis. Ethical approval was granted by the relevant ethics committee. Observations took place during 94 hours in a traditional home, 104 hours in an ambiguous home and 101 hours in a resident-centred home. The traditional home showed © 2015 The Authors. IJPP © 2015 Royal Pharmaceutical Society

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strict routine, little interaction between staff and residents and the administration of psychoactive drugs without a nonpharmacological intervention. In the ambiguous and residentcentred homes, there was a greater focus on resident choice, individualised care and interaction between staff and residents, with more emphasis on non-pharmacological treatments such as distraction and one-on-one attention. In-depth interviews took place with 15 participants across all homes: three managers, six nurses and six care assistants. Interview data was consistent with these findings; a nurse from a traditional home emphasised the need for ‘specific routines’ while a care assistant from a resident centred home placed importance on resident ‘preference and choice’. Ten sets of residents’ nursing notes were examined. The traditional nursing home had a higher incidence of psychoactive prescribing, while ambiguous and resident-centred homes had less prescribing of these medications. The resident-centred home had a higher incidence of ‘when required’psychoactive medications as opposed to daily administration in the traditional home. Initial analysis has shown evidence of behaviours which are consistent with the treatment culture category to which each home had been assigned. Modification of these behaviours, although challenging, may be achieved through staff education and training. This may lead to a shift towards a more flexible, resident-centred culture and a reduction in the prescribing and use of psychoactive medication. 1. Inouye S, Marcantonio E, Metzger E. Doing damage in delirium: the hazards of antipsychotic treatment in elderly people. Lancet Psychiatry 2014; 1: 312–315. 2. Hughes CM, Donnelly A, Moyes SA, Peri K, Scahill S, Chen C, McCormack BG, Kerse N. ‘The way we do things around here’: an international comparison of treatment culture in nursing homes. JAMDA 2012; 13: 360–367.

Involving lay researchers in data collection: a descriptive study S. Garfielda,b, S. Jheetaa, A. Bischlerc, A. Jacklina, C. Nortona, F. Hussona and B.D. Franklina,b a

Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK, bThe Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, London, UK and cPharmacy Department, Chelsea and Westminster Healthcare NHS Foundation Trust, London, UK [email protected]

It is widely recognised that patients and the public should be involved in research in a meaningful, rather than tokenistic, way[1,2]. A recent systematic review[2] found that lay people have been mostly involved in agenda setting and protocol development. It was much less common for lay people to be involved in execution of the research, such as carrying out data collection. We here report on our experience in involving lay people in data collection as part of a study of inpatient involvement in medication safety. The first phase of the study involved International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

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observations of doctors’ ward rounds, pharmacists’ ward visits and nurses’ drug administration rounds, to determine if and how healthcare professionals facilitate patient involvement in medication safety. The study had a patient and clinical engagement group whose lay representatives suggested that lay people should be involved in these observations in parallel with our researchers, a suggestion we adopted. The aim of the work presented here was to describe the benefits and challenges of having lay people conduct these observations, in order to inform the future role of lay people conducting this type of research. Observations took place between January and June 2014. NHS ethics approval was obtained for the main study but not required to conduct these additional interviews as lay observers were not recruited via the NHS. We conducted semi-structured interviews with the 3 lay members involved in data collection and the 4 research team members involved in their recruitment, training or support on the wards. The topic guide explored lay observers’ and researchers’ views of the benefits and challenges of lay involvement in the observations; it was informed by preliminary discussions with our lay observers and researchers. The interviews were transcribed verbatim and coded openly, using NVivo 8 for assistance. A second researcher independently coded 30% of interviews. In addition, secondary qualitative analysis of the observational data was carried out to identify the specific input of lay observers into the study findings. The lay members and researchers reported that lay members added value to the data by bringing new perspectives. Some challenges were identified including the infrastructure not being in place to support this specialist lay research role, differing paradigms of research governance held by the public and healthcare professionals, and difficulties in recruitment of a diverse range of lay observers. The secondary analysis demonstrated that five codes were added to the framework as a result of the lay observations. In this study, including observations by lay members added value to the findings. There is a need to build infrastructure in NHS trusts to support this involvement. This study was limited to interviews with the small number of lay observers and researchers who were involved in one research project. It is therefore unclear whether theoretical saturation was reached or how generalisable the findings are. However the full relevant population was interviewed and, given the scarcity of studies addressing this issue, these findings can help inform future lay involvement in data collection. 1. Snape D, Britten N, Froggat K, Gradingre F, Lobban F, Popay J, Wyatt K, Jacoby A. Exploring perceived barriers, drivers, impacts and the need for evaluation of public involvement in health and social care research. A modified Delphi study. BMJ Open 2014; 4: e004943. doi:10.1136/ bmjopen-2014-004943. 2. Domecq JP, Prutsky G, Elariyah T, Wang Z, Nabhan M, Shippee N, Brito JP, Boehmer K, Hasan R, Firwana B, Erwin P, Eton D, Sloan J, Montori V, Noon A, Dabrh AMA, Murad MH. Patient engagement in research: a systematic review. BMC Health Services Research 2014; 14: 89. http:// www.biomedcentral.com/1472-6963/14/89.


Patients’ medicines management after hospital discharge – a social network analysis B. Fylan Gwynn, A. Blenkinsopp, G. Armitage and D. Naylor The University of Bradford [email protected]

Patients are at heightened risk of harm from their medicines when their care is transferred between providers, often because of poor information sharing and limited opportunities to discuss managing their medicines with healthcare professionals [1]. Patients may have a range of medicines contacts influencing how their discharge medicines are used. Using a social networks theoretical framework, this research aims to describe the structure of patients’ personal and professional medicines networks after they are discharged from hospital. It also aims to understand the functions provided by those networks. The study was conducted with patients discharged from the cardiology wards of two acute hospital trusts. A quota sample of 60 patients was constructed based on a range of demographic variables: age, gender, deprivation and ethnicity. Semistructured interviews were conducted six weeks after hospital discharge. The timing of the interview was designed to allow patients to interact with healthcare professionals about their medicines and to order new supplies. The topic guide was informed by a literature review and was critically assessed by a patient representative. Interviews were conducted between January and June 2014. Transcribed interview data were analysed by one researcher using thematic analysis; text was coded and codes were grouped together into themes describing the structure and function of patients’ networks, and the content (what flows between network members) within them. NHS Research Ethics committee approval was granted. Participants’ ages ranged from 35–80; 42 were male and 18 were female and 9 were from ethnic minorities. Patients were from areas of high, medium and low deprivation. Patients had between 1 and 15 individual medicines contacts in their networks. Four types of contact were identified: healthcare professionals; healthcare support staff; personal contacts; and personal healthcare contacts. Some patients did not report GPs and community pharmacists to be members of their medicines networks and others experienced isolation after they left hospital. Content in the network included information and advice, and attitudes and shared experiences about medicines. Patients’ networks were multifunctional: they provided practical and emotional support with medicines; provided, adjusted and monitored medicines; and offered education about medicines. Healthcare professionals performed duplicate functions and some patients experienced safety incidents as a function of their networks, for example they failed to receive new or changed medicines from their GP after their discharge. Some patients had limited views of the care each professional should provide, for example education and review by community pharmacy. Patients perceived limited contact between members of their medicines networks.


Oral abstracts

Other research has shown that patients’ experiences of care transition can be disorientating [2]. We found that patients’ networks included professionals and personal contacts supporting patients in their use of medicines after their discharge from hospital. While some benefit from practical and emotional support in the home, others experience limited personal support after leaving hospital. Organisation of services meant that functions – such as educating patients – were duplicated, yet patients’ networks sometimes failed to safely optimise their medicines. Patients often do not experience care from professionals, such as GPs, in the way they expect. 1. The Care Quality Commission. Managing Patients’ Medicines after Discharge from Hospital. London: The Care Quality Commission, 2009. CQC-039-500-ESP-102009. 2. Knight D, Thompson D, Mathie E, Dickinson A. ‘Seamless care? Just a list would have helped!’ Older people and their carer’s experiences of support with medication on discharge home from hospital. Health Expect 2013; 16(3): 277–291.

Are pharmacists ready for research? R Kayyalia, D Berkoa and N Patelb a Kingston University and bUniversity of Reading [email protected]

The pharmacist’s role has evolved over the years to suit an ever changing health system. The recent NHS restructure after the Health and Social Care Act 2012[1] publication resulting in pharmacy services commissioning that depends on quality, efficiency and performance has made the involvement in research important. Pharmacy research is necessary to unlock pharmacists’ potential as a research base to provide evidencebased knowledge.[2] The aim of this study was to examine community pharmacists (CPs) and hospital pharmacists (HPs) willingness to engage in research and what they would need in order to incorporate it in their practise. The study targeted all HPs in a large teaching hospital in London as well as randomly selected CPs within Greater London (due to convenience). From 2250 pharmacies listed in Greater London, the minimum sample size calculated based on 95% confidence interval and 5% margin error was 334. Structured questionnaires, exploring (Partaking in Research, Research Ready, Barriers and Facilitators and Future Engagement) were either posted or hand delivered to CPs in February 2014. No follow-up mailing was performed. An online questionnaire was developed and sent to HPs. Consent (indicated via the returned questionnaires) for face-to-face interviews to be undertaken in March 2014 was only obtained for eight CPs. Time did not permit interviews of HPs. The study was approved by Kingston University Ethics Committee. A response rate of 20.4% (n = 51) was obtained from CPs. Fourteen out of 40 HPs responded (35%). The modal age range of responding CPs was 30–39 and they were equally distributed by gender. The majority of HPs were females with a modal age range of 40–49. Thirty CPs (58.8%) and eleven (79%) HPs rated research as important in their practise. Audits © 2015 The Authors. IJPP © 2015 Royal Pharmaceutical Society

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and service evaluations (mandatory research) were the main research types undertaken. Engagement with clinical trials, applied health or clinical research was greater with HPs than CPs (85.7% versus 33.3%). Barriers to undertaking research were time (most common), lack of training, lack of infrastructure and support. The biggest incentive for research engagement was remuneration (76% (n = 39)) and time (85% (n = 12)) by CPs and HPs, respectively. CPs’ potential research roles included raising public awareness (most common; 40%), recruiting patients or providing support. In contrast, HPs saw a role in leading and generating research and applying for funding. The interviews highlighted that 5 out of the 8 CPs were not aware of the Research Ready tools and their potential involvement in research. HPs and CPs recognise the importance of research to their practice, but many are not aware of the push for involvement in research, or how they could go about doing this. Considerations for time, remuneration, training and support need to be made in order for CPs, in particular, to be more actively involved. 1. Health and Social Care Act (2012). http://www.legislation .gov.uk/ukpga/2012/7/contents/enacted (accessed November 2013). 2. Royal Pharmaceutical Society. What Is Research Ready? http://www.rpharms.com/science-and-research/researchready.asp (accessed November 2013).

Engaging the community pharmacy sector in research: lessons learned from a national study of clinical productivity D. Halsalla, S. Jacobsa, R. Elveya, F. Bradleya, T. Fegana, M. Hannb, E. Schafheutlea, A. Wagnerc and K. Hassella a

Centre for Pharmacy Workforce Studies, Manchester Pharmacy School, The University of Manchester, bCentre for Biostatistics, Institute of Population Health, The University of Manchester and cNIHR, Clinical Research Network Eastern [email protected]

A major study of organisational factors associated with variation in clinical productivity in community pharmacies in England was funded by the National Institute for Health Research (National Research Ethics Service approval [13/ WM/0137]). This multi-method study, conducted across nine geographical areas, involved a survey of community pharmacies, analysis of activity data, a patient survey and stakeholder interviews. It is not the aim of this paper to present research findings. Rather, in a study which touched upon commercial sensitivities, this paper aims to describe and make recommendations for successful engagement with the community pharmacy sector to achieve full study support and participation. No data were collected to address this aim, but the approach used to engage with the community pharmacy sector to encourage study participation is described. Representatives of the International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

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national negotiating committee, a community pharmacy multiple, and an independent pharmacy were approached and contributed to study design. On securing funding, this stakeholder group was expanded to include service commissioners and patient representatives to provide ongoing advice on all aspects of the study. Presentations were made to national and local pharmacy organisations (Company Chemists Association, Local Pharmaceutical Committees (LPCs) and Local Pharmacy Networks (LPNs)) to invite endorsement of the study. Individual owners, superintendent pharmacists and research governance leads as gatekeepers to larger multiples were also contacted. Telephone calls, e-mails and one-to-one meetings aimed to clarify the purpose and benefits of the study, address concerns and secure agreement to participate. This study encountered reactions from the community pharmacy sector ranging from enthusiasm and encouragement to deep mistrust and negativity which stemmed partly from commercial sensitivities and concurrent changes in commissioning arrangements during 2013. Engagement of stakeholders in project design and in an ongoing advisory capacity was invaluable in addressing the concerns of the sector and ensuring that early misunderstandings were overcome through improved communication. Early discussions, clarification and reassurance helped secure explicit endorsement from four of the nine LPCs approached, and four of the nine major pharmacy multiples agreed for their pharmacies to participate. Nonparticipation by five multiples necessitated expanding the number of geographical areas from five to nine to maintain sample size. Response rate to the pharmacy survey was low (34%) but sufficient to power the analysis. The process of recruitment of pharmacies to the second stage of the study (patient survey and stakeholder interviews) was greatly enhanced by already established relationships and earlier lessons learned. Engaging with the community pharmacy sector to secure participation in a major national study has presented several challenges and has achieved moderate success. While not all stakeholders endorsed the study, support from those who did helped boost study participation. Careful consideration must be given to forms of communication and terminology used, and the political and commercial landscape in which community pharmacy operates must be anticipated when costing bids and planning timescales. Early engagement with pharmacy leaders and national bodies during study design can promote support; face-to-face meetings with individual superintendent pharmacists and pharmacy owners remain crucial for creating rapport.

A diary study of community pharmacists’ mental workload H.E. Family, M. Weiss and J. Sutton University of Bath [email protected]

Mental Workload (MWL) is a widely studied concept within the human factors and patient safety fields. MWL is measured


to identify how busy employees are, the complexity of tasks being carried out and whether additional tasks can be added to their current workload without reducing task performance or safety. [1] To date, the MWL of community pharmacists (CPs) practising in the United Kingdom (UK) has not been measured. This study aimed to measure CPs’ MWL throughout a day in their usual practice. Following receipt of university ethics approval a convenience sample of 104 CPs who had participated in an earlier study were invited to participate. The 104 CPs were strategically recruited through superintendent pharmacists and social media to be demographically representative of UK CPs. Fifty CPs expressed interest in this follow-up study and were posted a diary containing questions on demographics, the enhanced and locally commissioned services offered and seven copies of the NASA Task Load Index (TLX).[2] The NASA-TLX is a self-report measure of MWL that measures six facets of MWL (time pressure, mental effort, mental demand, physical demand, task frustration and performance concern), each rated on an 11 point scale (0–10). The mean of the scores on the six items provides an overall MWL score. Participants were asked to complete between two and seven MWL ratings over one day and received a £5 highstreet voucher for their participation. MWL ratings were plotted against time of day. Bivariate correlations were produced between overall MWL and the demographic characteristics of participants. Potentially significant relationships were explored further with an independent t-test. Forty CPs (19 men) returned their diaries (response rate of 38%) and a total of 186 MWL ratings were made across the diaries, providing sufficient power to carry out the planned analyses. MWL ratings were plotted against time of day. Peaks in overall MWL were seen at 11 o’clock in the morning and five o’clock in the afternoon. Time pressure, mental and physical demand were the highest rated facets of MWL. Bivariate correlations revealed no relationship between participant sex, age, pharmacy experience, or the type of community pharmacy CPs worked in and overall MWL. However, the correlations indicated a relationship between overall MWL and whether the CP worked full time (>35 hours a week) or part-time (48 ratings were from part-time CPs). An independent t-test showed that part-time CPs reported significantly lower overall MWL (mean = 4.39) compared with full-time CPs (mean = 5.14) (t (184) = 2.29, p < 0.05, r = 0.17). These results suggest that MWL peaks for many CPs at specific times of the day and that part-time CPs experience significantly less MWL compared with their full-time colleagues. However, the effect size of this difference was small. The diary ratings also suggest that time pressure, mental and physical demands are the primary sources of MWL that CPs experience. This initial study highlights the impact working patterns have on MWL and has implications for the times of day that safety critical tasks are carried out by CPs. 1. Wickens CD, Hollands JG, Banbury S, Parasuraman R. Mental workload, stress, and individual differences: cognitive and neuroergonomic perspectives. Engineering Psychology and Human Performance (International Edition), 4th edn. Upper Saddle River, NJ: Pearson, 2013: 346–376.


Oral abstracts

2. Hart SG, Staveland LE. Development of the NASA-TLX (Task Load Index); results of empirical and theoretical research. In: Hancock PA, Meskkati N, eds. Human Mental Workload. Amsterdam, Netherlands: North-Esland, 1988.

An evaluation of compliance with medicine-related criteria mandated in a national standard for patient discharge summary information B. Bourkea,b, C. Keanea and S. Cunninghamb a Saint Vincent’s University Hospital, Dublin, Ireland and bSchool of Pharmacy & Life Sciences, Robert Gordon University, Aberdeen [email protected]

Transition of care between hospital and community is a vulnerable time for patient safety and medication management.1 It has been shown that failure to communicate or document stopping or withholding a medicine and failure to communicate or document omission of a pre-admission medicine are the most common types of non-reconciliation on discharge from Irish hospitals.2 The discharge summary is an important tool in communicating essential information about a patient’s hospitalisation to their primary care physician. At present, a standardised discharge summary template is not available in Ireland. However, the Health Information and Quality Authority (HIQA) recently published the “National Standard for Patient Discharge Summary Information” outlining mandatory information that should be documented in a discharge summary. The aim of this study was to establish the current level of compliance with the medicine-related criteria in National Standard for Patient Discharge Summary (PDS) Information by medical teams in an Irish hospital. A retrospective survey of 100 discharge episodes was carried out at St Vincent’s University Hospital (SVUH), Ireland over a 4-week period. Patients discharged from medical specialties were eligible for inclusion. Psychiatric and surgical patients were excluded due to the limited number of discharges from psychiatry teams and the lack of changes made to surgical patients’ medication regimens. Demographic and medication data were collected from multiple sources and compared to information in the PDS and discharge prescription. Data was collected within one week of discharge and ten percent of data collection forms were validated for data entry. Ethics approval was sought from RGU Research Ethics Committee and SVUH Clinical Audit Committee. All the data were entered into a database on SPSS® version 16.0 (SPSS Inc) and 95% confidence intervals were calculated. One hundred discharge episodes from 10 medical specialties incorporating 1011 medications were studied. Patient discharge summaries were available for all discharge episodes, but only 94 discharge prescriptions were available. Four discharge summaries did not have a “date completed” documented but the majority (n = 74, 77.1%, ± 8.41) of the remaining 96 were completed on the day of discharge. The majority of discharge summaries (n = 61, 61%, ± 9.56) and prescriptions (n = 51, 54%, ± 10.08) were completed by the © 2015 The Authors. IJPP © 2015 Royal Pharmaceutical Society

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most junior member of the medical team. Details on the allergy status were more likely to be documented on the prescription rather than the PDS. Discrepancies between the two documents occurred in 24.7% (n = 171, ± 3.21) of discharge medicines. There were 256 medicines newly commenced, only 10.9% (n = 28, ± 3.82) of which had the indication explicitly stated. The indication was implied for another 75.8% (n = 194, ± 5.25), leaving 13.3% (n = 34, ± 4.16) drugs where the indication would have been unclear to the GP. Rationale for changes to pre-admission medicines was also poorly documented. Discharge documentation was not in full compliance with the HIQA standard. Discharge summaries were completed in a timely manner, and prescriptions were found to be more accurate than the medication list in the discharge summary. The electronic system should be re-designed to prompt for the information required by the standard and to allow the automatic generation of the discharge prescription. 1. Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. Canadian Medical Association Journal 2005; 173(5): 510–515. 2. Grimes TC, Duggan CA, Delaney TP, Graham IM, Conlon KC, Deasy E et al. Medication details documented on hospital discharge: cross-sectional observational study of factors associated with medication non-reconciliation. British Journal of Clinical Pharmacology 2011; 71(3): 449–457.

An exploration of the views of key stakeholders on generic drug substitution in Ireland: a qualitative study P.J. McCaguea,b, M. Kantchevb, J. Careyb, A. Stauntonb and S. McCarthyb,c a School of Pharmacy, Liverpool John Moores University, bSchool of Pharmacy, University College Cork, Cork and cCork University Hospital, Cork

Ireland is acknowledged to be a country with one of the lowest use of generic medicines in Europe1. In an attempt to improve the use of generic medicines in Ireland, in May 2013, The Health (Pricing and Medical Goods) Act 2013 was introduced. This legislation requires pharmacists to dispense specified generic medicines to patients regardless of the brand prescribed. The aim of this study was to ascertain the views of general practitioners (GPs), pharmacists and patients on generic medicines and the impact of the new government policy. The study received full ethical approval from the Clinical Research Ethics Committee of the Cork Teaching Hospitals. Initially a convenience method of sampling was used to invite participants to take part with subsequent participants recruited by a ‘snowballing effect’. Interviews were carried out face-toInternational Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

22


face or by telephone depending on the availability and location of the participant. An interview schedule of open-ended questions was developed following a review of the literature. Interviews were recorded, transcribed verbatim and analysed using thematic analysis. Each of the three stakeholder groups were analysed separately. Fourteen GPs, 17 pharmacists and 12 patients participated in the interviews. Data saturation was achieved in all three groups. A number of recurring themes were identified including willingness to accept generics, concerns, and successful implementation of the legislation into practice. GPs were generally positive about the introduction of the legislation and appeared committed to the cost-effective use of generic medicines in their practice. Some older GPs had some concerns regarding quality of these products. The study identified an emerging group of young prescribers willing to use international non-proprietary names when prescribing. Although pharmacists themselves were positive about the introduction of this legislation, they believed that misconceptions held by patients could be a barrier to successful change in practice. A number of pharmacists felt frustrated that the burden of implementing the legislation was being placed on them. Pharmacists also raised the issue of safety, expressing concern with respect to appropriateness of potential generic prescribing for drugs with a narrow therapeutic index. Both groups of healthcare professionals discussed strategies for improving the implementation of this legislation. On the whole, patients held positive views on generic medicines and recognised the cost-saving benefit for both the health service and for patients who pay for their medication. The patients interviewed generally believed that there was not enough information or education available to them concerning generic medicines. They felt that the use of generics could cause confusion, particularly to elderly patients. This work has described, for the first-time, the views of key stakeholders on this major legislative change in Ireland. It is clear from our findings that improved educational interventions are required for both healthcare professionals and patients in order to alleviate concerns or misconceptions they may have. Policymakers now need to address this issue in order to improve the uptake of generic medicines with both prescribers and patients alike. Future work includes a questionnaire study in order to obtain more generalisable results for the stakeholders described. 1. Brick A, Gorecki P, Nolan A (2013). Ireland: Pharmaceutical Prices, Prescribing Practices and Usage of Generics in Comparative Context. [Online]. http://www.tara.tcd .ie/bitstream/handle/2262/67333/RS32.pdf?sequence=1& isAllowed=y (accessed September 2014).


An evaluation of NHS Health Checks in community pharmacy: changes in cardiovascular risk factors over one year in patients aged 40–74 S. Butterworth, S.C. Willis and P. Higginson University of Manchester [email protected]

NHS Health Checks are a national cardiovascular risk assessment service offered since 2012 to people aged 40–74 without recognised cardiovascular disease (CVD). The Health Check uses age, gender, weight, height, smoking, alcohol use, exercise, family history, blood pressure and cholesterol to calculate a 10-year CVD risk using QRisk2. The aim of the Health Check is to identify a person’s CVD risk, communicate it in a way that is understood, and manage it appropriately. The study reported here undertaken in a single rural community pharmacy evaluated all patients receiving the service from when first commissioned until data collection ended (December 2012–June 2014) against Public Health England (PHE) Standards and also investigated differences in risk between patients. A sample of patients was followed up after one year by repeating the Health Check to measure change over time. Eligible subjects were identified using pharmacy records or referred by a nearby general practice (GP). Data collection was completed within the pharmacy with CVD risk calculated using HealthOptions software. Comparisons between subgroups used Mann-Whitney test for unpaired data in StatsDirect. Follow-up Health Checks took place after one year with all patients who received an initial check invited to take part until a minimum sample of 50 was exceeded to increase statistical power. Wilcoxon’s signed rank test for paired data was used to determine change in risk over one year. Manchester University Research Ethics Committee granted ethical approval. 161 participants received a Health Check during the first round of data collection with a full data set recorded for each subject meeting PHE Standard 3. Mean 10-year CVD risk was 9.3% (95% CI 8.2–10.5). Risk in males was 12.9% compared with 7.1% in females (p = 0.0003). Seventy-eight patients (48.4%) were referred to their GP for further assessment. Of these 59 (36.6%) had blood pressure >140/ 90 mmHg, 7 had raised total cholesterol, 23 (14.3%) a body mass index >30 and 18 (11.1%) a QRisk of >20. Fifty-two patients received a repeat Health Check, with QRisk2 found to have increased over the year; female mean risk at increased from 5.6% to 6.0% (p = 0.1134); for males risk increased from11.0% to 11.8% (p = 0.0095). Findings demonstrate that community pharmacy can effectively perform NHS Health Checks that meet PHE standards, despite concerns that non-GP providers are not able to do so(1). While the increase in QRisk2 over one year appears disappointing, findings are consistent with the Rose hypothesis(2) for outcomes in low risk versus high risk populations as the mean risk of patients receiving the service was 9.3% and hence for most subjects additional treatment was International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

Oral abstracts

inappropriate. Despite this lack of reduction in risk, findings suggest that community pharmacy is able to identify and refer high risk patients – and, moreover, that a rural location is not a barrier to this. What remains unknown at this stage is the extent to which community pharmacy services can have a positive impact on longer term outcomes. 1. Research Works Ltd. Understanding the implementation of NHS Health Checks. 2013. 2. Rose G. Sick individuals and sick populations. Int J of Epidemiol 1985; 14(1): 32–38.

Improving the appropriateness of prescribing in older patients: a systematic review and meta-analysis of pharmacists’ interventions in secondary care settings K. Walsh, D. O’Riordan, P. Kearney, S. Timmons and S. Byrne University College Cork [email protected]

Older patients are at a much greater risk of potentially inappropriate prescribing (PIP) than the general population as a consequence of polypharmacy. PIP has been found to increase the risk of adverse drug events (ADEs). Such ADEs can potentially lead to increased morbidity, mortality and health resource utilisation.[1] Reduction of PIP is even more critical in persons with dementia who have a greater susceptibility to the deleterious effects of potentially inappropriate medications.[2] The objectives of this review were to determine from the literature whether there was sufficient evidence to support the claim that pharmacists’ interventions can improve the quality of prescribing in older persons or persons with dementia who are admitted to hospital. This systematic review and meta-analysis was undertaken in compliance with PRISMA guidelines. An electronic search of the literature was conducted using twelve databases from inception up to and including September 2014. The search terms included synonyms and various combinations of the following key words; “pharmacist” AND “inappropriate prescribing” AND “elderly” OR “dementia” AND “hospital” AND “pharmaceutical care” AND “randomised controlled trial.” Study selection and risk of bias assessments were conducted by two independent reviewers. Data extraction were performed by one reviewer and verified by another. Consensus on all decisions was reached by discussion. Quantitative analysis was performed where appropriate. A total of 1,752 records were found after duplications were removed. After two stages of review, five trials were included. One trial was excluded from quantitative analysis as it was deemed to be at a high risk of bias. In total, 1,164 patients were included (589 in intervention and 575 in control arms respectively). The mean number of prescribed medications ranged from 7.7 to 8.7 in the intervention arms (mean = 8.1) and 7.3 to 8.0 in the control arms (mean = 7.5). A key component of all included studies was inter-disciplinary teamwork. All trials © 2015 The Authors. IJPP © 2015 Royal Pharmaceutical Society

23

included patients with dementia however no study was found which dealt with dementia patients specifically in this context.A meta-analysis using random-effects inverse variance methods found there was a statistically significant difference in the mean in favour of the pharmacists’ intervention when the summated medication appropriateness index data were analysed at discharge (n = 4, mean difference = −5.27, 95% CI: −8.44, −2.11, I2 = 93%). Overall these results should be viewed with some caution as there were only a small number of included trials, there was considerable heterogeneity and the included studies were assessed to have a moderate risk of bias. The findings of this systematic review and meta-analysis support the hypothesis that pharmacists can improve the appropriateness of prescribing in older inpatients when they work as part of a team. Hospital managers and policy-makers have a key role to play in encouraging pharmacists to join ward based teams and to utilise their clinical skills in order to maximise pharmaceutical support of older people. More research is required to determine whether a pharmacist-led intervention can reduce PIP and consequently improve outcomes for persons with dementia. 1. Gallagher PF, Barry PJ, Ryan C, Hartigan I, O’Mahony D. Inappropriate prescribing in an acutely ill population of elderly patients as determined by Beers’ Criteria. Age and Ageing 2008; 37(1): 96–101. 2. Brandt NJ, Turner T. Potentially inappropriate medications in older adults: a review of the 2012 Beers Criteria and the Implications in Persons with Dementia. Ment Health Clin 2014; 4(4): 75. http://cpnp.org/resource/mhc/2014/07/ potentially-inappropriate-medications-older-adultsreview-2012-beers-criteria (accessed 25 September 2014).

Potentially inappropriate prescribing in a middle-aged population: a cross-sectional study in Northern Ireland using the Enhanced Prescribing Database J.A. Coopera,b, F. Moriartyb, C. Ryana, S.M. Smithb, E. Wallaceb, K. Bennettc, C. Cahirc, D. Williamsd, M. Teelingc, T. Faheyb and C.M. Hughesa,b a School of Pharmacy, Queen’s University Belfast, bHealth Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, c Department of Pharmacology & Therapeutics, Trinity Centre for Health Sciences and dDepartment of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland [email protected]

Traditionally, the focus of potentially inappropriate prescribing (PIP) has been on older people. However, there is evidence that multimorbidity is also prevalent in middle-aged people (defined as 45–64 years)[1], but as yet, there has been little consideration of the associated risk of PIP in this age group. PROMPT (PRescribing Optimally in Middle-aged People’s Treatments) represents a set of 22 explicit prescribing criteria which may be applied to prescribing datasets (in the absence of International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

24


clinical information) to determine the prevalence of PIP in middle-aged people.[2] In this study, we aimed to investigate the level of PIP in Northern Ireland using data from the Enhanced Prescribing Database (EPD). A retrospective cross-sectional study was conducted by applying PROMPT to population-based data from the EPD between 01/01/2012 and 31/12/2012. Patients (aged 45–64 years) were included if they had three months lead-in data prior to the study start date and continuous data collection during the study period. The prevalence for each PROMPT criterion, the overall prevalence and corresponding 95% confidence intervals (CIs) were calculated. Logistic regression was used to investigate the association between PIP and gender (male/ female), age group (45–49, 50–54, 55–59, 60–64 years) and polypharmacy (≥4 different drugs classes). Ethical approval was granted by the National Research Ethics Service (NRES) Committee. This study included 441,925 patients (49.4% female; 50.6% male). The overall prevalence of PIP in this population was 21.9% (95% CI 21.8–22.0). During the study period, 13.9% of patients received one potentially inappropriate prescription (n = 61,395), 4.9% received two potentially inappropriate prescriptions (n = 21,519) and 3.1% received three or more potentially inappropriate prescriptions (n = 13,819). The most common instances of PIP are shown in Table 1. Adjusting for age and gender, patients receiving ≥4 different drugs classes were 12 times more likely to receive at least one potentially inappropriate prescription during the study period compared with patients receiving 0–3 different drugs classes (OR 12.18, 95% CI 11.97–12.39, P < 0.01). Table 1 Most common instances of PIP in middle-aged people using data from the EPD Most PROMPT criterion common instances of PIP

Patients (N = 441,925) (%)

1st

33,809 (7.7)

2nd

3rd 4th

5th

Proton pump inhibitors (PPIs) should not be prescribed at doses above the recommended maintenance dosage for greater than eight weeks. Strong opioids should not be prescribed without the co-prescribing of at least one bulk-forming or osmotic laxative. Benzodiazepines should not be used long-term (greater than four weeks). First generation antihistamines should not be used as first-line agents for greater than seven days. Non-benzodiazepine hypnotics (zolpidem, zaleplon, zopiclone) should not be used long-term (greater than four weeks).

31,110 (7.0)

17,698 (4.0) 11,098 (2.5)

10,875 (2.5)

This study shows that during the study period, approximately one in five middle-aged adults received at least one potentially inappropriate prescription; with the risk of PIP increasing with polypharmacy. These findings may help to inform interventions to improve prescribing practices in this age group.


1. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012; 380: 37–43. 9. 2. Cooper JA, Ryan C, Smith SM, Wallace E, Bennett K, Cahir C, Williams D, Teeling M, Fahey T, Hughes CM (PROMPT Steering Group). The development of the PROMPT (PRescribing Optimally in Middle-aged People’s Treatments) criteria. (Article is under review).

Trends in polypharmacy and prescribing appropriateness from 1997 to 2012 F. Moriartya,b, C. Hardya, K. Bennetta,c, S. Smitha and T. Faheya a HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland, bHRB PhD Scholars Programme in Health Services Research, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland and cDepartment of Pharmacology & Therapeutics, Trinity Centre for Health Sciences, St James’s Hospital, Dublin 8, Republic of Ireland [email protected]

Medicines are one of the most common healthcare interventions and volumes prescribed have risen in recent years. It is unclear how this increase in prescriptions has impacted on patients and to what extent this reflects increased use of evidence-based treatments or rising inappropriate prescription of medicines. The aim of this study is to determine over a 15-year period (1997–2012) in Ireland how prescribing patterns and rates of polypharmacy (being prescribed ≥5 regular medications) have changed, and in older adults (aged ≥65 years) to determine how the prevalence of potentially inappropriate prescribing (PIP) has changed. This repeated cross-sectional study using the Primary Care Reimbursement Service administrative pharmacy claims database includes all people eligible for the General Medical Services scheme in the Eastern Health Board region of Ireland in the years 1997, 2002, 2007 and 2012 (data pre-1997 was unavailable). The number of regular (dispensed in ≥3 consecutive months) drug classes dispensed per participant during each study year was determined. Using a subset of 30 criteria from the Screening Tool for Older Persons’ Prescriptions (STOPP)[1], the PIP prevalence in those aged ≥65 years was also calculated. Negative binomial regression models were fitted to determine, after adjusting for known confounders, the association between study year and the outcomes of polypharmacy (≥5 regular medications) and major polypharmacy (≥10 regular medications) while logistic regression was used for the outcome of any PIP. Ethical approval was not required. The study population ranged from 338,025 in 1997 to 539,752 in 2012. There was a marked increase from 1997 to 2012 in the proportion of participants with polypharmacy, particularly among older age groups (8.3–30.2% and 17.8–60.4% for those aged 45–64 and ≥65 respectively). The incident rate ratio for having polypharmacy in 2012 compared with 1997 International Journal of Pharmacy Practice, 23 (Suppl. S1), pp. 2–27

Oral abstracts

was 4.16 (95% CI 3.23, 5.36) after adjusting for age group and gender, and for major polypharmacy was 10.53 (95% CI 8.58, 12.91). The proportion of older study participants with PIP decreased from 32.6% in 1997 to 28.6% in 2002 but has since risen to 32.8% and 37.3% in 2007 and 2012. Although prescribing of high doses of aspirin and digoxin has decreased since 1997, prevalence of other criteria increased substantially, such as long-term use of high dose proton pump inhibitors from 0.8% to 23.8%. The odds ratio for the presence of any PIP versus none in 2012 compared with 1997 was 0.39 (95% CI 0.39, 0.4) after adjusting for gender and polypharmacy levels. This study demonstrates the trend of rising numbers of medicines prescribed in the older-aged population over time. The large increase in those taking ≥10 medicines is particularly concerning from a health expenditure perspective and due to the risk of adverse events in these complex polypharmacy patients[2]. While STOPP criteria prevalence rose during the study, after controlling for increasing polypharmacy levels, older individuals are now less likely to have PIP. Although prescribing of some medicines has improved, a focus on PIP drug classes with high or increasing prevalence is important to improve prescribing appropriateness. 1. Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment): consensus validation. Int J Clin Pharm Ther 2008; 46(2): 72–83. 2. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother 2007; 5(4): 345–351.

Medicine-related services: do pharmacists see things the same way as the public? J. Krska, S.A. Corlett, S. Gammie, R.L. Loo and R.M. Rodgers Medway School of Pharmacy, The Universities of Greenwich and Kent [email protected]

For pharmacists to help optimise medicines, the services they provide must meet the expectations of people who use them. Relatively little is known about what the public expect and want from pharmacy services or whether pharmacists’ perceptions of expectations are accurate. This work aimed to compare the perceptions of pharmacists and the public on aspects of the Medicines Use Review (MUR) and New Medicines Service (NMS). Questionnaires focusing on medicines-related services were adapted from a previously validated instrument, using findings from focus groups with pharmacists and the public. The questionnaires were designed to overlap, enabling pharmacist and public views to be compared. Both were piloted before use. The pharmacist questionnaire was distributed to all 836 community pharmacies in Kent, Surrey and Sussex.


25

Non-responders received a second mailing and a telephone call with further questionnaire, if requested. (1) Interview-assisted questionnaires, a standard, cost-effective market research method, were completed with 1000 participants at High Street locations in ten towns across Kent. (2) Chi-square tests were used to assess differences between views (SPSS v20). University research ethics approval was granted. The valid pharmacist response rate was 40.8% (341); 53.0% (179) were female and 65.4% (223) from large multiples. General public response rate was 47.2%; 52.6% were female and 60.5% used regular prescribed medicines. Pharmacists considered that more people would know about the MUR service than actually did: 38.7% thought at least half the public would have heard of it, whereas the actual figure was 18.2%. The even lower lack of awareness of the NMS was however anticipated: 93.2% of pharmacists thought very few /less than half the public would know about it, and in fact only 8.6% did. There were significant differences in the proportions of pharmacists estimating and the public agreeing they would be willing to make an appointment for a medicine-related service (47.2% versus 71.1%; p < 0.001) and in willingness to wait to see the pharmacist: 56.0% of pharmacists thought people would wait no more than 5 minutes, but only 20.3% of the public agreed with this waiting time, with 71.4% selecting 10/15 minutes (p < 0.001). In contrast perceptions concerning discussion time with a pharmacist were more closely aligned, with just over half of both pharmacists and the public viewing no more than 15 minutes as acceptable. There were differences in the reasons people might give when considering using a service (all p < 0.001). Fewer pharmacists (57.5%) than members of the public (76.0%) thought people would use a service ‘because they had problems with their medicines’. Most pharmacists thought the main reason for using the service would be ‘because the pharmacist asked’ (93.0%) whereas fewer members of the public viewed this as likely (68.7%). Over half the public (53.2%) viewed ‘wanting to help the pharmacist’ as a reason for using a service, compared with 22.0% of pharmacists. Pharmacists’ and the public’s perceptions were not aligned. Pharmacists need greater awareness of what the public see as acceptable and desirable, particularly around waiting times and appointments, as these are essential aspects of medicinesrelated services. 1. Rodgers RM, Loo R-L, Krska J. Public perception of medicines-related advisory services provided by pharmacies. Int J Pharm Pract 2013; 21 (Suppl 2): 28–29. 2. Corlett SA, Dodds LJ, Gammie S. Do pharmacists think that medicines advisory services improve patient adherence? Int J Pharm Pract 2014; 22 (Suppl 1): 34–35.


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‘You just forget that the pharmacist is actually there . . .’: views of people with long-term conditions (LTCs) on using community pharmacy for self-care support O.J. Ogunbayoa, E.I. Schafheutlea, C. Cuttsb and P.R. Noycea a Centre for Pharmacy Workforce Studies (CPWS) and bCentre for Pharmacy Postgraduate Education (CPPE), Manchester Pharmacy School, The University of Manchester M13 9PT [email protected]

Self-care support by healthcare professionals (HCPs) is a distinct holistic, patient-centred approach to managing LTCs.1 People with LTCs are regular users of community pharmacies, and dispensing and other services provide opportunities for self-care support. This study aimed to explore the views of people with LTCs on self-care and how they utilise community pharmacy for support. Semi-structured, face-to-face interviews were conducted with people with LTCs between May 2013 and June 2014. Participants were approached via a convenient sample of one General Practice and four community pharmacies in Northwest England, and four pharmacists in two Health Boards in Scotland. Forty-four participants in England and twenty-three in Scotland were identified purposively; fifteen in England and nine in Scotland were recruited and interviewed to achieve maximal variation2 of LTC type and demographics. Interview topics were developed from the literature and used as a framework for the analysis. Topics covered living with LTCs and undertaking self-care, sources of self-care support, and use of community pharmacy. All interviews were audio-taped, transcribed verbatim and analysed thematically. Interviews and data analysis were undertaken simultaneously until data saturation was reached. NHS Research Ethics and R&D approvals were obtained. Participants’ mean age was 62 (range: 24–92) years and 16 were females. Most (80%) participants had multiple LTCs. Participants had at least one of asthma/COPD (46%), diabetes (30%) and cardiovascular diseases (24%). The main themes that emerged were structured using a predefined thematic framework based on the topic guide. Almost all participants agreed that self-care was an integral part of daily living, and that they were already engaging in self-care behaviours such as adhering to their medicines regimen. Many others suggested that they needed support in areas such as changing lifestyles, self-monitoring and access to self-care resources. Most participants indicated that support networks such as family/carers and friends were primary sources of information and support with self-care, although they also indicated that they relied on HCPs, particularly nurses in their GP practices. Almost all viewed community pharmacy as, primarily, the supplier of their prescribed medicines, and not as a resource where they could get support for self-care of their LTCs. Additionally, many were unaware of the established community pharmacy’s medicines use services; the few who had experience of these


services did not view them as a resource to improve their selfcare behaviours. While some participants recognised the support that community pharmacy provided to them such as with minor ailments and some public health services (e.g. stop smoking), most appeared reluctant to acknowledge community pharmacy’s role in supporting their LTCs needs, including self-care. While study participants with LTCs engaged in self-care supported by their family, friends and some HCPs, they did not view community pharmacy as playing much of a role in the management and self-care support of their LTCs. The perspectives and needs of people with LTCs need to be better understood, so that community pharmacy services can be designed so as to contribute to their self-care needs. 1. Kennedy A, Rogers A, Bower P. Support for self care for patients with chronic disease. BMJ 2007; 335(7627): 968–970. 2. Creswell JW. Qualitative Inquiry and Research Design: Choosing among Five Approaches. Thousand Oaks, California: SAGE Publications, Inc., 2006.

Economic evaluation of a randomised controlled trial of pharmacist-supervised patient self-testing of warfarin therapy J. Gallaghera, S. McCarthya, N. Woodsb, F. Ryanc, S. O’Shead and S. Byrnea a School of Pharmacy, University College Cork, bCentre for Policy Studies, University College Cork, cMcGee Pharma International and dDepartment of Haematology, Cork University Hospital [email protected]

Management of oral anti-coagulation therapy (OAT) in a hospital based setting is an unnecessary burden on tertiary care services. Alternative flexible systems of anti-coagulation management are available. One option is pharmacist led patient self-testing (PST) of international normalised ratio (INR) levels. PST has demonstrated improvements in anticoagulation control, but its cost-effectiveness is inconclusive. The aim of this study is to conduct a cost-effectiveness evaluation of an automated direct-to-patient expert system, enabling remote and effective management of patients on OAT. We conducted an economic evaluation alongside a randomised controlled trial investigating a pharmacist led PST method. Full results of clinical trial are published elsewhere [1]. Trial was conducted in an Irish university teaching hospital. Long term anticoagulation patients (n = 162), were recruited to a 6-month cross over study between PST and routine care in a hospital based anti-coagulation clinic. Costs were informed by individual patient resource use, published salary scales, data from suppliers of expert systems and in-house hospital data. The outcome measure of this economic evaluation was the incremental cost of patient management over a 6-month period. Economic evaluation was from the healthcare payer perspective. Ethical approval was obtained from all responsible committees.


Oral abstracts

On a per patient basis over a 6-month period, PST resulted in an incremental cost of €59.08 in comparison with routine care. Patients achieved a significantly higher time in therapeutic range (TTR) during the PST arm in comparison with routine care. Overall cost of managing a patient through pharmacist supervised PST for a 6-month period is €226.45. Additional analysis of strategies from a societal perspective indicated that PST was the dominant strategy. Table 1 Cost-effectiveness of 6 months of PST versus anticoagulation management service (usual care) Patient self-testing

Mean % TTR (95% CI) Median % TTR (IQR) Mean INR tests/patient ± SD (range) Cost of 6 months of patient management Incremental cost of 6 months of PST therapy versus AMS

Anticoagulation management service

72 (+/− 2.32%) 59 (+/− 3.36%) 74 (64.6–81) 58.6 (45.5–73.1) 41.7 +/− 6.6 (24–60) 10.7 +/− 5.2 (5–35) €226.45

27

PST is marginally more expensive in comparison with centralised laboratory testing. However, the associated increase in INR control for a modest increase in expenditure provides further evidence that optimally managed warfarin therapy remains a successful strategy for anticoagulation management. TTR levels demonstrated in the intervention arm of the study are associated with significantly improved patient outcomes in terms of death, major bleeding and stroke[2]. 1. Ryan F, Byrne S, O’Shea S. Randomized controlled trial of supervised patient self-testing of warfarin therapy using an internet-based expert system. J Thromb Haemost 2009; 7: 1284–1290. 2. White HD, Gruber M, Feyzi J, Kaatz S, Tse HF, Husted S. Comparison of outcomes among patients randomized to warfarin therapy according to anticoagulant control: results from SPORTIF III and V. Arch Intern Med 2007; 167: 239– 245.

€167.38

€59.08



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