The use of technology to improve medication adherence in heart failure patients: a systematic review of randomised controlled trials.

BACKGROUND: Heart failure is an ever-growing contributor to morbidity and mortality in the ageing population. Medication adherence rates among the HF population vary widely in the literature, with a reported range of 10-98%. Technologies have been developed to improve adherence to therapies and other clinical outcomes. AIMS: This systematic review aims to investigate the effect of different technologies on medication adherence in patients with heart failure. It also aims to determine their impact on other clinical outcomes and examine the potential of these technologies in clinical practice. METHODS: This systematic review was conducted using the following databases: PubMed Central UK, Embase, MEDLINE, CINAHL Plus, PsycINFO and Cochrane Library until October 2022. Studies were included if they were randomised controlled trials that used technology to improve medication adherence as an outcome in heart failure patients. The Cochrane Collaboration's Risk of Bias tool was used to assess individual studies. This review was registered with PROSPERO (ID: CRD42022371865). RESULTS: A total of nine studies met the inclusion criteria. Two studies showed statistically significant improvement in medication adherence following their respective interventions. Eight studies had at least one statistically significant result in the other clinical outcomes it measured, including self-care, quality of life and hospitalisations. All studies that evaluated self-care management showed statistically significant improvement. Improvements in other outcomes, such as quality of life and hospitalisations, were inconsistent. CONCLUSION: It is observable that there is limited evidence for using technology to improve medication adherence in heart failure patients. Further studies with larger study populations and validated self-reporting methods for medication adherence are required.

Two-way Automated Text Messaging Support From Community Pharmacies for Medication Taking in Multiple Long-term Conditions: Human-Centered Design With Nominal Group Technique Development Study.

BACKGROUND: Reviews of digital communication technologies suggest that they can be effective in supporting medication use; however, their use alongside nondigital components is unclear. We also explored the delivery of a digital communication intervention in a relatively novel setting of community pharmacies and how such an intervention might be delivered to patients with multiple long-term conditions. This meant that despite the large number of intervention examples available in the literature, design questions remained, which we wanted to explore with key stakeholders. Examples of how to involve stakeholders in the design of complex health care interventions are lacking; however, human-centered design (HCD) has been suggested as a potential approach. OBJECTIVE: This study aimed to design a new community pharmacy text messaging intervention to support medication use for multiple long-term conditions, with patient and health care professional stakeholders in primary care. METHODS: HCD was used to map the intervention "journey" and identify design questions to explore with patients and health care professionals. Six prototypes were developed to communicate the intervention concept, and a modified version of the Nominal Group Technique was used to gather feedback. Nominal group meetings generated qualitative data using questions about the aspects that participants liked for each prototype and any suggested changes. The discussion was analyzed using a framework approach to transform feedback into statements. These statements were then ranked using a web-based questionnaire to establish a consensus about what elements of the design were valued by stakeholders and what changes to the design were most important. RESULTS: A total of 30 participants provided feedback on the intervention design concept over 5 nominal group meetings (21 health care professionals and 9 patients) with a 57% (17/30) response rate to the ranking questionnaire. Furthermore, 51 proposed changes in the intervention were generated from the framework analysis. Of these 51 changes, 27 (53%) were incorporated into the next design stage, focusing on changes that were ranked highest. These included suggestions for how text message content might be tailored, patient information materials, and the structure for pharmacist consultation. All aspects that the participants liked were retained in the future design and provided evidence that the proposed intervention concept had good acceptability. CONCLUSIONS: HCD incorporating the Nominal Group Technique is an appropriate and successful approach for obtaining feedback from key stakeholders as part of an iterative design process. This was particularly helpful for our intervention, which combined digital and nondigital components for delivery in the novel setting of a community pharmacy. This approach enabled the collection and prioritization of useful multiperspective feedback to inform further development and testing of our intervention. This model has the potential to minimize research waste by gathering feedback early in the complex intervention design process.

Influencing medication taking behaviors using automated two-way digital communication: A narrative synthesis systematic review informed by the Behavior Change Wheel.

PURPOSE: Around half of prescribed medications for long-term conditions are not taken as directed. Automated two-way digital communication, such as text messaging and interactive voice response technology, could deliver interventions to improve medication adherence, and subsequently health. However, exploration of how such interventions may improve medication adherence is limited. This review aimed to explore how automated two-way digital communication can improve medication taking with or without using non-digital intervention components, such as phone calls with healthcare professionals. METHODS: A theory-informed narrative synthesis systematic review. Several databases were searched including CINAHL, Embase, Medline, and Web of Science using key words relating to 'medication adherence' and digital communication technologies. The Behavior Change Technique (BCT) coding using the BCT Taxonomy V1 and the Behavior Change Wheel were used to identify BCTs delivered within the included interventions. RESULTS: A total of 3,018 records were screened with 43 study reports included in the review. Four medication-taking behaviors: taking medication, obtaining medication, self-testing, and asking for support were identified as targets for behavior change within the included interventions. Most BCTs within the digital communication component aimed to increase motivation for medication adherence, with non-digital intervention components included to address other medication taking barriers, such as physical and psychological capability. CONCLUSION: Automated two-way digital communication can detect barriers to medication adherence by monitoring performance of the taking medication behavior. Monitoring outcomes from taking medication may increase reflective motivation to take medicines. Addressing physical opportunity to taking medication by facilitating the behavior obtaining medication may also increase adherence.

Exploration of prescribing error reporting across primary care: a qualitative study.

OBJECTIVES: To explore barriers and facilitators to prescribing error reporting across primary care. DESIGN: Qualitative semi-structured face-to-face and telephone interviews were conducted to explore facilitators and barriers to reporting prescribing errors. Data collection and thematic analysis were informed by the COM-B model of behaviour change. Framework analysis was used for coding and charting the data with the assistance of NVivo software (V.12). General and context specific influences on prescribing error reporting were mapped to constructs from the COM-B model (ie, capability, opportunity and motivation). SETTING: Primary care organisations, including community pharmacy, general practice and community care from North East England. PARTICIPANTS: We interviewed a maximal variation purposive sample of 25 participants, including prescribers, community pharmacists and key stakeholders with primary care or medicines safety roles at local, regional and national levels. RESULTS: Our findings describe a range of factors that influence the capability, opportunity and motivation to report prescribing errors in primary care. Three key contextual factors are also highlighted that were found to underpin many of the behavioural influences on reporting in this setting: the nature of prescribing; heterogeneous priorities for error reporting across and within different primary care organisations; and the complex infrastructure of reporting and learning pathways across primary care. Findings suggest that there is a lack of consistency in how, when and by whom, prescribing errors are reported across primary care. CONCLUSIONS: Further research is needed to identify cross-organisational and interprofessional consensus on agreed reporting thresholds and how best to facilitate a more collaborative approach to reporting and learning, that is, sensitive to the needs and priorities of disparate organisations across primary care. Despite acknowledged challenges, there may be potential for an increased role of community pharmacy in prescribing error reporting to support future learning.

Supporting patients with unlicensed medicine use: Analysing the script schemas for prescribing, pharmaceutical assessment and supply.

Unlicensed medicines (ULMs) are those which have not received authorisation from a regulator, as such they do not have the same reassurances around safety and efficacy as licensed medicines. This study aimed to explore the use of ULMs from the perspectives of prescribers, pharmacists and patients within the UK National Health Service (NHS) setting. Grounded theory was used as a framework, conducting 28 semi-structured qualitative interviews with prescribers, pharmacists and patients across both primary and secondary care settings. Participants were identified from their known use of ULMs where possible and a theoretical sampling approach was used to support recruitment of participants based on the emergent analysis. Analysis followed a constructivist inductive approach, using constant comparison to develop initial themes. This was followed by two focus groups, one with patients and one with professionals where initial analytic findings were presented to participants to further support the development of themes. All interviews were audio recorded and transcribed verbatim. Three sequential schema scripts were identified and used as a framework to explain our findings: ULM prescribing, pharmaceutical assessment of an ULM and ULM supply. Common and divergent events within these scripts were identified and analysed in an attempt to explain similarities and differences across primary and secondary care and between actors. The analysis identified issues around healthcare professional awareness of using ULMs, perceptions of ULM safety, challenges around what information should be provided to patients and by whom and adds to the debate around the place of ULMs in treatment pathways. This study highlights the need for a multidisciplinary conversation about how ULMs should be used in the NHS.

Prescribing error reporting in primary care: a narrative synthesis systematic review.

Prescribing errors can cause avoidable harm to patients. Most prescriptions originate in primary care, where medications tend to be self-administered and errors have the most potential to cause harm. Reporting prescribing errors can identify trends and reduce the risk of the reoccurrence of incidents; however, under-reporting is common. The organisation of care and the movement of prescriptions from general practice to community pharmacy may create difficulties for professionals to effectively report errors. This review aims specifically to identify primary research studies that examine barriers and facilitators to prescription error reporting across primary care. A systematic research of the literature was completed in July 2019. Four databases (PubMed/Medline, Cochrane, CINAHL and Web of Science) were searched for relevant studies. No date or language limits were applied. Eligible studies were critically appraised using the Mixed Methods Appraisal Tool, and data were descriptively and narratively synthesised. Ten articles were included in the final analysis. Seven studies considered prescription errors and error reporting within general practice and three within a community pharmacy setting. Findings from the included studies are presented across five themes, including definition of an error, prescribing error reporting culture, reporting processes, communication and capacity. Healthcare professionals appreciate the value of prescription error reporting, but there are key barriers to implementation, including time, fear of reprisal and organisation separation within primary care.

Introducing pharmacy students to the structure and function of general practice through undergraduate placements.

BACKGROUND AND PURPOSE: The aim of this study was to design and evaluate the introduction of a sustainable and feasible structure of placements in general practice for third-year pharmacy students at the University of Sunderland. The national agenda in the United Kingdom (UK) calls for an increased presence of pharmacists within general practice; therefore, development of placements in this is setting is aligned to the development of these new roles. EDUCATIONAL ACTIVITY AND SETTING: The placements were located in general practice surgeries in the North East of England in the UK. Students engaged in activities which introduced them to the structure and function of general practice and familiarise them with the role of pharmacists and other practice staff. Two cohorts undertook the education activity during the development process. The first cohort was comprised of 213 students, with 193 students the following year. FINDINGS: An action research approach was taken to evaluate and revise the design of the placement. The final design and delivery have been shown to have a positive impact on student learning experience, be feasible and sustainable. The placement was also successful at introducing students to potential future roles in general practice for pharmacists. SUMMARY: This model of general practice placement provision was found to be a feasible and sustainable delivery model, which was well received by undergraduate students.

Attitudes and perceptions of health professionals towards management of hypothyroidism in general practice: a qualitative interview study.

OBJECTIVE: To explore the attitudes and perceptions of health professionals towards management of hypothyroidism that contributes to the suboptimal treatment of hypothyroidism in general practice. DESIGN: A qualitative interview study using semistructured interviews. PARTICIPANTS: Sixteen participants were interviewed between March and August 2016 comprising nine general practitioners (GPs), four pharmacists, two practice nurses and one nurse practitioner. SETTING: General practice and community pharmacies in the counties of Northumberland, Tyne and Wear, Stockton-on-Tees and North Cumbria, North of England, UK. METHOD: A grounded-theory approach was used to generate themes from interviews, which were underpinned by the theory of planned behaviour to give explanation to the data. RESULTS: Although health professionals felt that hypothyroidism was easy to manage, GPs and nurses generally revealed inadequate knowledge of medication interactions and levothyroxine pharmacokinetics. Pharmacists felt limited in the advice that they provide to patients due to lack of access to patient records. Most GPs and nurses followed local guidelines, and relied on blood tests over clinical symptoms to adjust levothyroxine dose. The information exchanged between professional and patient was usually restricted by time and often centred on symptoms rather than patient education. Health professionals felt that incorrect levothyroxine adherence was the main reason behind suboptimal treatment, although other factors such as comorbidity and concomitant medication were mentioned. Enablers perceived by health professionals to improve the management of hypothyroidism included continuity of care, blood test reminders, system alerts for interfering medications and prescription renewal, and accessible blood tests and levothyroxine prescriptions for patients. CONCLUSION: There is a significant health professional behavioural component to the management of hypothyroidism. Addressing the differences in patient and professional knowledge and perceptions could reduce the barriers to optimal treatment, while continuity of care and increased involvement of pharmacists and practice nurses would help to promote optimal thyroid replacement.

Unlicensed medicines use: a UK guideline analysis using AGREE II.

OBJECTIVES: There is widespread use of unlicensed medicines within primary and secondary care but little information is available around how these medicines are used. This analysis examines and evaluates the content and quality of relevant guidance documentation currently in use within the UK. METHODS: Guidance documents were identified through a literature search as well as email requests to pharmacy organisations throughout the UK. Unlicensed medicine documentation suitable for inclusion in the analysis underwent thematic analysis and quality assessment using the AGREE II tool. KEY FINDINGS: Thematic analysis of 52 guidelines revealed four parent themes: (1) Professional responsibility (2) Usage practicalities (3) Risk versus benefit (4) Controlling use. There was variability in scores across the AGREE II domains with areas covering Scope and Purpose and Clarity of Presentation scoring well. Conversely, an area needing attention was Rigour of Development. CONCLUSION: Healthcare organisations would benefit from agreeing a 'core content' for the development of unlicensed medicines guidelines to ensure consistency and the presence of robust operating systems to deliver safe, effective treatment to all NHS patients.

Patients' attitudes and perceptions towards treatment of hypothyroidism in general practice: an in-depth qualitative interview study.

BACKGROUND: Suboptimal thyroid hormone replacement is common in patients with hypothyroidism and the behavioural factors underlying this are poorly understood. AIM: To explore the attitudes and perceptions of patients to thyroid hormone replacement therapy. DESIGN & SETTING: An in-depth qualitative interview study with patients with hypothyroidism residing in Northumberland, and Tyne and Wear, UK. METHOD: Twenty-seven patients participated, of which 15 patients had thyroid stimulating hormone (TSH) levels within the reference range (0.4-4.0 mU/L) and 12 patients had TSH levels outside the reference range. A grounded theory approach was used to explore and develop emerging themes, which were mapped to the health belief model (HBM). RESULTS: Patients generally had a low understanding of their condition or of the consequences of suboptimal thyroid hormone replacement. Patients that had experienced hypothyroid symptoms at initial diagnosis had a better perception of disease susceptibility, and this was reflected in excellent adherence to levothyroxine in this group of patients. The main benefits of optimal thyroid replacement were improved wellbeing and performance. However, patients who remained unwell despite a normal serum TSH level felt that their normal result presented a barrier to further evaluation of their symptoms by their GP. CONCLUSION: Educating patients with hypothyroidism regarding the consequences of inadequate thyroid hormone replacement may reduce barriers and improve treatment outcomes. An over-reliance on TSH as a sole marker of wellbeing reduced opportunities for clinicians to address patient symptoms. Evaluating symptoms in combination with biochemical indices, may lead to better patient outcomes than relying on laboratory tests alone.