Evaluation of a cardiovascular disease opportunistic risk assessment pilot ('Heart MOT' service) in community pharmacies.

BACKGROUND: Cardiovascular risk-based screening is proposed as a key intervention to reduce premature cardiovascular disease (CVD) in the UK and internationally. This study evaluated a targeted cardiovascular (CVD) assessment pilot in 23 community pharmacies in Birmingham, UK. METHODS: The CVD risk assessment service used near-patient testing and the Framingham risk equations administered by pharmacists to screen clients aged 40-70 without known CVD. Outcomes assessed included volume of activity, uptake by deprivation and ethnicity and onwards referral. RESULTS: Complete data were available for 1130 of 1141 clients; 679 (60%) male, 218 (19%) smokers and 124 (11%) had a family history of CVD. Overall, 792 (70%) of clients were referred to their general practice: 201 (18%) at CVD risk of 20% or more, remainder with individual risk factor(s). Greater representation from Black (7.4%) and Asian (24.8%) communities and from average and less deprived quintiles than the affluent and most deprived was observed. CONCLUSIONS: Community pharmacies can provide a CVD risk assessment service in a UK urban setting that can attract males and provide access for deprived communities and Black and Asian communities. A pharmacy service can support GP practices in identifying and managing the workload of around 30% of clients.

A systematic review of quantitative and qualitative research on the role and effectiveness of written information available to patients about individual medicines.

OBJECTIVES: To establish the role and value of written information available to patients about individual medicines from the perspective of patients, carers and professionals. To determine how effective this information is in improving patients' knowledge and understanding of treatment and health outcomes. DATA SOURCES: Electronic databases searched to late 2004, experts in information design, and stakeholder workshops (including patients and patient organisations). REVIEW METHODS: Data from selected studies were tabulated and the results were qualitatively synthesised along with findings from the information design and stakeholder workshop strands. RESULTS: Most people do not value the written information they receive. They had concerns about the use of complex language and poor visual presentation and in most cases the research showed that the information did not increase knowledge. The research showed that patients valued written information that was tailored to their individual circumstances and illness, and that contained a balance of harm and benefit information. Most patients wanted to know about any adverse effects that could arise. Patients require information to help decision-making about whether to take a medicine or not and (once taking a medicine) with ongoing decisions about the management of the medicine and interpreting symptoms. Patients did not want written information to be a substitute for spoken information from their prescriber. While not everyone wanted written information, those who did wanted sufficient detail to meet their need. Some health professionals thought that written information for patients should be brief and simple, with concerns about providing side-effect information. They saw increasing compliance as a prime function, in contrast to patients who saw an informed decision not to take a medicine as an acceptable outcome. CONCLUSIONS: The combination of a quantitative and qualitative review, an exploration of best practice in information design, plus the input of patients at stakeholder workshops, allowed this review to look at all perspectives. There is a gap between currently provided leaflets and information which patients would value and find more useful. The challenge is to develop methods of provision flexible enough to allow uptake of varying amounts and types of information, depending on needs at different times in an illness. This review has identified a number of areas where future research could be improved in terms of the robustness of its design and conduct, and the use of patient-focused outcomes. The scope for this research includes determining the content, delivery and layout of statutory leaflets that best meet patients' needs, and providing individualised information, which includes both benefit and harm information. In particular, studies of the effectiveness and role and value of Internet-based medicines information are needed.

Patient reporting of suspected adverse drug reactions: a review of published literature and international experience.

AIMS: To synthesize data from published studies and international experience to identify evidence of potential benefits and drawbacks of direct patient reporting of suspected adverse drug reactions (ADRs) by patients. METHODS: Structured search of MEDLINE, CINAHL and PsycINFO supplemented by internet searches and requests for information to key contacts. RESULTS: Seven studies (eight papers) were included in the review. None of the studies concerned spontaneous reporting by patients. Information on patient reporting systems was obtained for six countries, with summary data reported by four. Patient reports identified possible new ADRs that had not previously been reported by health professionals. The quality of patient reports appears to be similar to that of health professional reports. There is some evidence that patients report an ADR when they consider their health professional has not paid attention to their concerns. Patient reports may, at least initially, be more time consuming to process. CONCLUSIONS: Overall, the evidence indicates that patient reporting of suspected ADRs has more potential benefits than drawbacks. Evaluation of patient reporting systems is needed to provide further evidence.

Community pharmacy supply of emergency hormonal contraception: a structured literature review of international evidence.

BACKGROUND: We could find no previous published review of the evidence relating to pharmacy supply of emergency hormonal contraception (EHC). Our objectives were to review, summarize and evaluate the peer-reviewed evidence relating to community pharmacy supply of EHC both in the UK and internationally. METHODS: Systematic searches were conducted for peer-reviewed international research from January 1990 to January 2005. The UK Health Development Agency's Evidence Base 2000 standards and the evidence categories used by the UK Department of Health were applied to each paper. RESULTS: We included 24 peer-reviewed papers. There was one randomized controlled trial (RCT); the remainder of the studies were qualitative or observational studies. Pharmacy supply of EHC enables most women to receive it within 24 h of unprotected sexual intercourse. Services were highly rated by women. One RCT showed that improving access to EHC did not reduce the use of other contraceptives, lead to an increase in risky sexual behaviour or increase the incidence of sexually transmitted infections (STIs). Users expressed some concerns about the appropriateness of receiving additional pharmacist advice regarding future contraception use and STIs. One study found pharmacy supply had led to a decrease in attendances at accident and emergency departments. CONCLUSION: There is good evidence that community pharmacy EHC services provide timely access to treatment and are highly rated by women.

Proton pump inhibitors: perspectives of patients and their GPs.

BACKGROUND: There is growing concern with the rapid increase in prescribing proton pump inhibitor drugs (PPIs) for a variety of gastrointestinal disorders, and the escalating costs associated with this trend. Explanations have included that general practitioners (GPs) prescribe PPIs inappropriately and that patients demand PPIs and use them as a way of avoiding having to make lifestyle changes. AIM: To compare the perspectives of GPs and their patients on the need for PPIs, to examine the pressure to prescribe, and to examine the effect of PPIs on lifestyle. DESIGN OF STUDY: Qualitative comparative study based on semi-structured interviews. SETTING: Twenty-six GPs in seven practices in the West Midlands and 82 of their patients on repeat prescriptions for PPIs. METHOD: Interviews were conducted covering a wide range of topics, including: experience, cause, course, and outcome of stomach problems; effectiveness of PPIs; and role of lifestyle in controlling symptoms. The transcripts were studied repeatedly to look for the occurrence and distribution of material relating to these issues, as well as other responder-driven issues. Codebooks were devised to enable a simple categorisation and systematic comparison of cases. RESULTS: GPs and patients agreed about the severity and unpleasantness of stomach symptoms for which PPIs were prescribed. While GPs and patients regarded PPIs as a very effective treatment, GPs rated their efficacy more highly than patients. Half of the GP interviews reproduced the stereotype of the demanding patient and of patients using PPIs to support unhealthy lifestyles. There was little evidence from patient interviews to support either stereotype. Doctors underestimated patient concerns about side-effects, safety, and long-term use of PPIs, and the willingness of patients to achieve the minimum effective dose by experimenting with their treatment. GPs felt that the pressure to prescribe PPIs was outweighed by the pressure not to prescribe, and most GPs had responded to the call to cut the prescribing of PPIs. Different strategies were employed to cut prescribing, including the wholesale switching of patients on a treatment dose of one brand of PPI to a maintenance dose of a cheaper brand of PPI, known as 'double switching'. CONCLUSION: The stereotypes of 'profligate prescriber', 'demanding patient', and 'adverse lifestyle', as explanations for the increase in the prescribing of PPIs, were not upheld. The stereotype of patients demanding PPIs may arise from GPs' internal pressure to prescribe being externalised onto patients. The extent to which health behaviour contributes to gastric disorders needs to be established empirically. Labelling PPI patients as having a poor lifestyle may be used as a means of reducing legitimate need for PPIs. Current policy relating to switching of dose and brand of PPI should be reviewed.

The rise and rise of proton pump inhibitor drugs: patients' perspectives.

The prescribing of proton pump inhibitor (PPIs) drugs has increased by 456% in the past 4 yr, despite no evidence of increased morbidity for gastrointestinal conditions. There has been no full explanation for this dramatic increase. Doctors attribute the rapid and apparently unjustified increase in prescribing of this new and expensive drug to patients' demands and not to the extensive advertising campaign. This paper presents the findings from interviews with 20 patients who were taking PPIs. The results revealed that the prescribing of PPIs was mainly initiated in primary care, with little evidence of overt patient demand for PPIs, influenced by the media or social contacts. Patients' perceptions and beliefs about PPIs are explored and discussed. Patients modified the prescribed regimen to suit their perceived needs. Patients felt PPIs were more effective than other drugs they had tried previously and expressed their concerns about stopping PPIs, or changing to another drug. However, despite these reservations, the majority of patients interviewed said they would change if their general practitioner (GP) suggested it. PPIs led some patients to abandon, or not to attempt, lifestyle changes. The consequences of this and the implications of the continued prescribing of PPIs are discussed.

Primary care--opportunities and threats. Developing prescribing in primary care.

The latest white papers on the NHS focus on stimulating innovation in the delivery of primary care and removing barriers to further development. Some of this innovation relates directly to prescribing in primary care, and in this article the authors speculate on what might happen if the prescribing initiatives referred to in the white papers were extended and disseminated more widely. The initiatives which might have the biggest impact are those encouraging closer collaboration between general practitioners and community pharmacists and those aiding extension of the current nurse prescribing scheme in primary care. Both offer considerable opportunities to improve primary care, but both bear some potential risks.

Patients, society, and the increase in self medication.

Self medication with over the counter medicines has long been a feature of the lay health system. With the reclassification of certain drugs, the public can buy preparations that were previously available only prescription. Sales of over the counter medicines are now equivalent to a third of the NHS drugs bill; governments throughout the world see self medication as a way of shifting some of the cost of health care onto consumers. The trend towards increased self care and with it the increasing empowerment of patients has many potential benefits; collaboration between doctors and pharmacists will be critical.

Over the counter drugs. The future for self medication.

The increasing trend towards deregulation of more medicines to over the counter status has implications for the primary health care team as well as for consumers and patients. Better information for patients could improve the safety of over the counter medicines, but better systems need to be devised for reporting adverse reactions. "Collaborative care" could bring financial benefits. Doctors, nurses, and pharmacists need to discuss how they will respond to self medication practices, and ways of rewarding pharmacists for advising patients need to be found. Improved communication between doctors and pharmacists and the involvement of nurses could bring health care professionals into a new and more constructive interaction with each other and with the patient--or the changes required could split the professions as they each try to keep control of medicines.

Effects of computer generated reminder charts on patients' compliance with drug regimens.

OBJECTIVE: To investigate whether a reminder chart improved patients' compliance with their drug regimen after discharge from hospital. DESIGN: Patients were randomly allocated to one of four groups. Two groups received the reminder chart: one also received routine counselling from a nurse and the other received structured counselling from a pharmacist, which included an explanation of the reminder chart. The other two groups received only counseling, either from a nurse or from a pharmacist. Patients were visited about 10 days later: they were questioned about their drug regimen, and their compliance was measured by tablet counting. SETTING: The pharmacy in a district general hospital and patients' homes. PATIENTS: 197 patients being discharged from hospital who were regularly taking two or more drugs. INTERVENTION: An individualised reminder chart, which listed each person's medicines and when they were to be taken and was automatically generated by a medicine labelling computer. MAIN OUTCOME MEASURES: Patient's compliance with and knowledge of their drug regimen. MAIN RESULTS: Of the patients who received the reminder chart, 83% (95% confidence interval 74% to 90%) correctly described their dose regimen compared with 47% (37% to 58%) of those without the chart (p < 0.001). The mean compliance score was 86% (81% to 91%) in both groups not given the reminder chart; 91% (87% to 94%) in the group given the chart without an explanation; and 95% (93% to 98%) in the group given the chart and an explanation. A mean compliance score of > 85% was achieved by 63% (53% to 73%) of patients without a reminder chart and by 86% (78% to 93%) of those receiving the chart (p < 0.001). CONCLUSIONS: An automatically generated reminder chart is a practical and cost effective aid to compliance.

Using a notification card to improve communication between community pharmacists and general practitioners.

A pilot scheme was set up to evaluate a notification card to be used by community pharmacists when referring patients to their general practitioner, with the aim of improving communication. Six community pharmacists and 15 general practitioners took part in the study. During the 18 month study period 120 cards were issued by pharmacists. The majority of patients (71%) advised to see their general practitioner by the pharmacist did so. Fourteen cards (12%) were issued for suspected adverse drug reactions. The card was received positively by patients, doctors and pharmacists.