Process evaluation for the Care Homes Independent Pharmacist Prescriber Study (CHIPPS).

BACKGROUND: Medicines management in care homes requires significant improvement. CHIPPS was a cluster randomised controlled trial to determine the effectiveness of integrating pharmacist independent prescribers into care homes to assume central responsibility for medicines management. This paper reports the parallel mixed-methods process evaluation. METHOD: Intervention arm consisted of 25 triads: Care homes (staff and up to 24 residents), General Practitioner (GP) and Pharmacist Independent Prescriber (PIP). Data sources were pharmaceutical care plans (PCPs), pharmacist activity logs, online questionnaires and semi-structured interviews. Quantitative data were analysed descriptively. Qualitative data were analysed thematically. Results were mapped to the process evaluation objectives following the Medical Research Council framework. RESULTS: PCPs and activity logs were available from 22 PIPs. Questionnaires were returned by 16 PIPs, eight GPs, and two care home managers. Interviews were completed with 14 PIPs, eight GPs, nine care home managers, six care home staff, and one resident. All stakeholders reported some benefits from PIPs having responsibility for medicine management and identified no safety concerns. PIPs reported an increase in their knowledge and identified the value of having time to engage with care home staff and residents during reviews. The research paperwork was identified as least useful by many PIPs. PIPs conducted medication reviews on residents, recording 566 clinical interventions, many involving deprescribing; 93.8% of changes were sustained at 6 months. For 284 (50.2%) residents a medicine was stopped, and for a quarter of residents, changes involved a medicine linked to increased falls risk. Qualitative data indicated participants noted increased medication safety and improved resident quality of life. Contextual barriers to implementation were apparent in the few triads where PIP was not known previously to the GP and care home before the trial. In three triads, PIPs did not deliver the intervention. CONCLUSIONS: The intervention was generally implemented as intended, and well-received by most stakeholders. Whilst there was widespread deprescribing, contextual factors effected opportunity for PIP engagement in care homes. Implementation was most effective when communication pathways between PIP and GP had been previously well-established. TRIAL REGISTRATION: The definitive RCT was registered with the ISRCTN registry (registration number  ISRCTN 17847169 ).

A mixed-methods evaluation of a community pharmacy signposting service to a commercial weight-loss provider.

OBJECTIVE: Community pharmacies could provide access for clients to commercial weight management organizations. We evaluated recruitment, referral and outcomes of adults provided with free vouchers by community pharmacies to attend Scottish Slimmers classes. DESIGN: Prospective cohort design with qualitative interviews with clients and pharmacy personnel. Scottish Slimmers collected weight and attendance data. SETTING: Pharmacies in Aberdeen City, Scotland. SUBJECTS: Clients aged ≥18 years with BMI≥30 kg/m2. RESULTS: Ten of twenty-three pharmacies were recruited; eight successfully recruited clients. Of 129 clients recruited, ninety-seven (75 %) attended at least one class and fifty-one (40 %) attended all twelve classes. At baseline, clients' mean weight was 99·4 (sd 17·5) kg, mean BMI was 37·8 (sd 6·0) kg/m2. After 12 weeks, mean weight change was -3·7 % (last observation carried forward) or -2·8 % (baseline observation carried forward) for all ninety-seven clients. Client interviews indicated that many individuals would have not addressed their weight problems if this referral service had not been available. They had positive attitudes towards the pharmacy signposting service, attributed to the use of consultation rooms for privacy, receiving professional service from personnel and ongoing support and encouragement. The free provision of 12-week access facilitated participation. Service providers had positive attitudes and indicated their willingness to provide this service in future. CONCLUSIONS: Community pharmacies could be used to increase access to weight management services, with pharmacy personnel providing additional support to clients. Future provision of pharmacy referral schemes should be evaluated on a larger scale with an economic evaluation.

Tele-pharmacy in rural Scotland: a proof of concept study.

INTRODUCTION: Technology enables medical services to be provided to rural communities. This proof of concept study assessed the feasibility and acceptability of delivering community pharmacy services (CPS; including advice, sale of over-the-counter products and dispensing of prescriptions) by tele-technology (the Telepharmacy Robotic Supply Service (TPRSS)) to a rural population in Scotland. METHODS: Data collection included the following: postal surveys to local residents; focus groups/ interviews with pharmacists, other healthcare professionals (HCPs) and service users, at baseline and follow-up; TPRSS logs. Interviews/focus groups were audio-recorded, transcribed and thematically analysed. Descriptive statistics were reported for survey data. RESULTS: Qualitative results: Pre-installation: residents expressed satisfaction with current pharmacy access. HCPs believed the TPRSS would improve pharmacy access and reduce pressure on GPs. Concerns included costs, confidentiality, patient safety and 'fear' of technology. Post-installation: residents and pharmacy staff were positive, finding the service easy to use. Quantitative results: Pre-installation: almost half the respondents received regular prescription medicines and a third used an over-the-counter (OTC) medicine at least monthly. More than 80% (124/156) reported they would use the TPRSS. There was low awareness of the minor ailment service (MAS; 38%; 59/156). Post-installation: prescription ordering and OTC medicine purchase were used most frequently; the video link was used infrequently. Reasons for non-use were lack of need (36%; 40/112) and linkage to only one pharmacy (31%; 35/112). DISCUSSION: Community pharmacy services delivered remotely using tele-technology are feasible and acceptable. A larger study should be undertaken to confirm the potential of the TPRSS to reduce health inequalities in rural areas.

It's not what you do it's the way that it's measured: quality assessment of minor ailment management in community pharmacies.

BACKGROUND: Effective management of minor ailments in community pharmacies could reduce the burden on alternative high-cost services (general practices, Emergency Departments). Evidence is needed regarding the appropriateness of management of these conditions in community pharmacies. OBJECTIVE: To explore the appropriateness of minor ailment management in community pharmacies. SETTING: Prospective, observational study of simulated patient (SP) visits to community pharmacies in Grampian (Scotland) and East Anglia (England). METHOD: Eighteen pharmacies (nine per centre) were recruited within a 25-mile radius of Aberdeen or Norwich. Consultations for four minor ailments were evaluated: back pain; vomiting/diarrhoea; sore throat; and eye discomfort. Each pharmacy received one SP visit per ailment (four visits/pharmacy; 72 visits total). Visits were audio-recorded and SPs completed a data collection form immediately after each visit. PRIMARY OUTCOME MEASURE: Each SP consultation was assessed for appropriateness against product licence, practice guidelines and study-specific consensus standards developed by a multi-disciplinary consensus panel. RESULTS: Evaluable data were available for 68/72 (94.4%) visits. Most (96%) visits resulted in the sale of a product; advice alone was the outcome of three visits. All product sales complied with the product licence, 52 (76%) visits complied with practice guidelines and seven visits achieved a 'basic' standard according to the consensus standard. CONCLUSION: Appropriateness of care varied according to the standard used. Pharmacy-specific quality standards are needed which are realistic and relevant to the pharmacy context and which reflect legal and clinical guidelines to promote the safe and effective management of minor ailments in this setting.

Patient versus healthcare professional spontaneous adverse drug reaction reporting: a systematic review.

BACKGROUND: Increasing numbers of national pharmacovigilance schemes are accepting adverse drug reaction (ADR) reports from patients. The extent to which patient ADR reports contribute to pharmacovigilance requires comparisons to be made with reports from healthcare professionals (HCPs). OBJECTIVE: This systematic review was conducted to identify all comparative studies of patient and HCP ADR reports to national pharmacovigilance schemes. METHODS: We conducted a systematic review (which complied with the PRISMA statement) and a narrative synthesis of the results. Electronic databases (1996-2011) were searched, including MEDLINE, EMBASE and PHARM-Line, and supplementary searching of reference lists of included studies, authors' personal reference lists and internet searches was carried out. Studies that compared patient and HCP ADR reports submitted to national reporting schemes were considered for inclusion. Independent, duplicate data extraction, quality assessment and risk of bias were undertaken. RESULTS: Of the 949 hits generated, three comparative studies were identified and included in this review. These studies were conducted on the national pharmacovigilance schemes in the Netherlands, Denmark and the UK. Considerable variation was observed across the national schemes in terms of the proportion of total ADR reports submitted by patients. Some of this variation may be explained by the duration that the schemes have been in operation. The number of serious ADR reports as a percentage of total reports was similar for patients compared with HCPs within each study, but varied across studies. Similarities were shown with the Netherlands and the UK in terms of drugs reported. Both studies featured statins and proton pump inhibitors in the top five drugs. Clear differences were shown between patients and HCPs in the body systems affected by ADRs as well as the therapeutic categories reported in both the UK and Danish studies. There was considerable similarity when considering the nature of ADRs reported. The Dutch study also showed similarities between patients and physicians in terms of the types of drugs for which ADRs were reported. CONCLUSIONS: Despite the large and increasing number of national pharmacovigilance schemes that accept ADR reports from patients, few comparative studies have been undertaken of patient and HCP reporting. Comparison across schemes is challenging because of differences in reporting processes, the inclusion criteria of schemes and different reporter types. The true value of patient ADR reports to pharmacovigilance will remain unknown unless more comparative evaluations are undertaken. This systematic review has highlighted both similarities and differences between reporter behaviour, the implications of which, in terms of signal generation, require further exploration.

Preferences of community pharmacists for extended roles in primary care: a survey and discrete choice experiment.

BACKGROUND: Major changes in the roles and responsibilities of pharmacists across the world are occurring. A new Scottish Community Pharmacy contract was introduced in April 2006, following the introduction of a similar contract in England in 2005. This contract encourages greater involvement in medicines management and other clinical cognitive roles, whilst retaining a supply function. OBJECTIVE: To use a discrete choice experiment (DCE) to examine the strength of preference of community pharmacists for existing and potential new roles, prior to the introduction of the new contract. STUDY DESIGN: The DCE was a component of a larger questionnaire, which assessed demography, workload, attitudes to, and satisfaction with, proposed new roles, and current levels of activity. Attributes and levels for the DCE were based on the recent policy document for Scotland, The Right Medicine, and informed consensus, respectively. Scenarios were organised into pairs, and pharmacists were asked "Which job would you prefer?" The questionnaire was mailed to all pharmacists working in the community setting in Scotland (n = 1621), as identified from a telephone survey. The questionnaire was totally anonymous, and two reminders were sent. RESULTS: There was an overall response rate of 56.4% (914/1621). Community pharmacists preferred to work in an extended pharmacy team, to have strong integration with secondary care, and to provide a minor illness advice service. In 2003, they would forgo an annual income of 3443 pounds, 2183 pounds and 2798 pounds, respectively to achieve this. However, overall, the pharmacists preferred more income to less. Repeat dispensing, chronic disease management, offering health promotion services, and the number of prescriptions dispensed per month were not significant predictors of job choice. CONCLUSION: Community pharmacists placed the highest value on organisational aspects of their work, and having a first contact primary care role. Although total income was important, there were indications that they would be prepared to forgo income to attain their preferred job.

Theory-based communication skills training for medicine counter assistants to improve consultations for non-prescription medicines.

CONTEXT: Medicine counter assistants (MCAs) supply the majority of non-prescription medicines (NPMs) to consumers. Suboptimal communication during consultations between consumers and MCAs has been identified as a major cause of inappropriate supply. Evidence from medical consultations suggests that training in specified communication skills can change professional behaviour. METHODS: A feasibility study was conducted to evaluate the effect of theory-based communication skills training for MCAs. Thirty MCAs were recruited from 21 community pharmacies in Grampian, Scotland. The intervention comprised 2 4-hour training sessions, held 1 month apart. The sessions were informed by results from previous studies and the Calgary-Cambridge evidence-based model of communication skills training. Strategies for guiding individuals through change were adopted from cognitive behavioural therapy techniques. The theory of planned behaviour was used to assess potential pathways to behaviour change. Recorded data were collected during covert visits to the pharmacies by simulated patients at baseline and 1 month after each training session. Communication performance was measured as the number and type of questions asked. RESULTS: Compared with baseline measures, the total number of questions asked increased in the intervention group at both time-points. No change was shown in the control group between baseline and follow-up 1, and a decrease was shown in the total number of questions from follow-up 1 to 2. The intervention appeared to have greater effect on consultations involving advice, compared with those concerning product requests. DISCUSSION: Communication performance improved following training. Increased information exchange is associated with guideline-compliant supply of NPMs. A substantive randomised, controlled trial is now planned to assess the intervention.