Self-administration of medications in inpatient postnatal women: an opportunity to empower self-care, improved medicines knowledge and adherence utilising clinical pharmacists and midwifery workforce and use of a midwife formulary.

OBJECTIVES: To assess the impact of self-administration of medicines (facilitated by a midwife formulary) on postnatal women's knowledge of certain post-delivery medications, awareness of the Green Bag Scheme, factors contributing to constipation, pain satisfaction, adherence, and time released to midwives plus feedback from these women and their midwives. METHODS: The study was conducted in consented postnatal women, who self-administered medications from their bedside lockers. The mode of delivery and parity were recorded. Data were compared in women who self-administered to those who did not. Midwives used our established midwife formulary to write their essential unprescribed medications. Direct interview questionnaires were used to obtain their knowledge on chosen post-delivery medicines, pain satisfaction, the Green Bag Scheme and factors contributing to constipation. Regular medicines counts were used to check adherence. Midwives' time not administering these self-administered medications was estimated. Self-reported questionnaires were used to obtain feedback from participants and midwives. Responses were analysed proportionately and where appropriate by simple statistics. RESULTS: Women (n=203) who self-administered were compared with those (n=401) who did not. Greater medicines' knowledge and better (96% vs 79%) pain satisfaction were found in self-administering women. Knowledge of each contributing factor to constipation varied. Mode of delivery and parity had no impact on these outcomes. Adherence seemed high 96% (195/203). Awareness of the Green Bag Scheme was poor (66/604). Most women, 94% (191/203) found the service helpful and 89% (178/200) would take part again. At least 224 hours were released to midwives by these self-administering women. 164/203 (81%) midwives felt the scheme was beneficial. CONCLUSIONS: Self-administering women had better pain satisfaction, medication knowledge and adherence. The need to improve engagement in the Green Bag Scheme was flagged. This service, supported by use of a midwife formulary, can release time to midwives to do other tasks including care for women with more complex issues. A business case for this service is under review.

A modified Delphi study to determine the level of consensus across the European Union on the structures, processes and desired outcomes of the management of polypharmacy in older people.

BACKGROUND: Inappropriate use of multiple medicines (inappropriate polypharmacy) is a major challenge in older people with consequences of increased prevalence and severity of adverse drug reactions and interactions, and reduced medicines adherence. The aim of this study was to determine the levels of consensus amongst key stakeholders in the European Union (EU) in relation to aspects of the management of polypharmacy in older people. METHODS: Forty-six statements were developed on aspects of healthcare structures, processes and desired outcomes, with consensus defined at ≥ 80% agreement. Panel members were strategists (e.g. directors, leading clinicians and commissioners) from each of the 28 EU member states, with a target recruitment of five per member state. Three Delphi rounds were conducted via email, with panel members being provided with summative results and collated, anonymised comments at the commencement of Rounds 2 and 3. RESULTS: Ninety panel members were recruited (64.3% of target), with high participation levels throughout the three Delphi rounds (91.1%, 83.3%, 72.2%). During Round 1, consensus was obtained for 27/46 statements (58.7%), with an additional two statements in Round 2 and none in Round 3. Consensus was obtained for statements relating to: potential gain arising from polypharmacy management (3/4 statements); strategic development (7/7); change management (5/7) indicator measures (4/6); legislation (0/3); awareness raising (5/5); polypharmacy reviews (5/7); and EU vision (0/7). Analysis of free text comments indicated that the vision statements were too ambitious and not achievable by the specified timeframe of 2025. CONCLUSION: Consensus was obtained amongst key EU strategists around many aspects of polypharmacy management in older people. Notably, no consensus was achieved in relation to statements relating to the need to alter legislation in areas of healthcare delivery, remuneration and practitioner scope of practice. While the vision for the EU by 2025 was considered rather ambitious, there is great potential and clear opportunity to advance polypharmacy management throughout the EU and beyond.

A pilot study to assess the practicality, acceptability and feasibility of a randomised controlled trial to evaluate the impact of a pharmacist complex intervention on patients with stroke in their own homes.

OBJECTIVE: To test the practicality, acceptability and feasibility of recruitment, data collection, blood pressure (BP) monitoring and pharmaceutical care processes, in order to inform the design of a definitive randomised controlled trial of a pharmacist complex intervention on patients with stroke in their own homes. METHODS: Patients with new stroke from acute, rehabilitation wards and a neurovascular clinic (NVC) were randomised to usual care or to an intervention group who received a home visit at 1, 3 and 6 months from a clinical pharmacist. Pharmaceutical care comprised medication review, medicines and lifestyle advice, pharmaceutical care issue (PCI) resolution and supply of individualised patient information. A pharmaceutical care plan was sent to the General Practitioner and Community Pharmacy. BP and lipids were measured for both groups at baseline and at 6 months. Questionnaires covering satisfaction, quality of life and medicine adherence were administered at 6 months. RESULTS: Of the 430 potentially eligible patients, 30 inpatients and 10 NVC outpatients were recruited. Only 33/364 NVC outpatients (9.1%) had new stroke. 35 patients completed the study (intervention=18, usual care=17). Questionnaire completion rates were 91.4% and 84.4%, respectively. BP and lipid measurement processes were unreliable. From 104 identified PCIs, 19/23 recommendations (83%) made to general practitioners were accepted. CONCLUSION: Modifications to recruitment is required to include patients with transient ischaemic attack. Questionnaire response rates met criteria but completion rates did not, which merits further analysis. Lipid measurements are not necessary as an outcome measure. A reliable BP-monitoring process is required.

A systematic review of electronic multi-compartment medication devices with reminder systems for improving adherence to self-administered medications.

BACKGROUND: Many patients experience difficulties adhering to medication regimes. For people who forget or get confused about medication, there are products to help them such as multi-compartment medication devices (MMDs). Some of these, known as electronic MMDs (eMMDs), use audible and/or visual signals to prompt the patient when to take medication, dispense medications, give instructions to the patient, and contact a caregiver (mobile Internet or text to a carer) as needed. AIM: To systematically review the literature on the use of eMMDs, to determine what evidence for their effectiveness is available. METHODS: A comprehensive literature search of 10 databases, plus an Internet search and hand searching was conducted, using the MeSH terms reminder systems/patient compliance/medication adherence. There were no date restrictions. Inclusion criteria were patients in any community setting, in any country and with no restrictions of age, gender, ethnicity or medical condition, using an eMMD. Peer-reviewed quantitative or qualitative studies of any design were included. RESULTS: Of 805 abstracts identified and 99 full text papers retrieved, six met the inclusion criteria. Five of the studies reported adherence to medication regimes; one reported design factors to improve adherence. Adherence varied by the context of the reminders, the target group and usability of the devices. The studies were small scale and only one was a well conducted randomised controlled trial. CONCLUSION: Overall methodological quality of the studies was poor. Although positive effects on adherence were reported further, rigorously conducted, studies are needed to inform the use of eMMDs.

Views of patients and professionals about electronic multicompartment medication devices: a qualitative study.

OBJECTIVES: To explore the perceived acceptability, advantages and disadvantages of electronic multicompartment medication devices. DESIGN: Qualitative study using 8 focus groups and 10 individual semistructured interviews. Recordings were transcribed and analysed thematically. Strategies were employed to ensure the findings were credible and trustworthy. PARTICIPANTS AND SETTING: Community pharmacists (n=11), general practitioners (n=9), community nurses (n=12) and social care managers (n=8) were recruited from the National Health Service (NHS) and local authority services. Patients (n=15) who were current conventional or electronic multicompartment medication device users or had medication adherence problems were recruited from community pharmacies. 3 informal carers participated. RESULTS: Electronic multicompartment medication devices which prompt the patient to take medication may be beneficial for selected individuals, particularly those with cognitive impairment, but who are not seriously impaired, provided they have a good level of dexterity. They may also assist individuals where it is important that medication is taken at fixed time intervals. These are likely to be people who are being supported to live alone. No single device suited everybody; smaller/lighter devices were preferred but their usefulness was limited by the small number/size of storage compartments. Removing medications was often challenging. Transportability was an important factor for patients and carers. A carer's alert if medication is not taken was problematic with multiple barriers to implementation and no consensus as to who should receive the alert. There was a lack of enthusiasm among professionals, particularly among pharmacists, due to concerns about responsibility and funding for devices as well as ensuring devices met regulatory standards for storage and labelling. CONCLUSIONS: This study provides indicators of which patients might benefit from an electronic multicompartment medication device as well as the kinds of features to consider when matching a patient with a device. It also highlights other considerations for successful implementation including issues of responsibility, regulation and funding.

EVALUATION OF AN ELECTRONIC PAEDIATRIC INTENSIVE CARE UNIT (PICU) MEDICATION RECONCILIATION (MR) FORM.

AIM: To gather opinions from doctors and pharmacists to improve the design of the PICU MR form generated by the electronic prescribing and clinical notes system to support transfer of care from PICU to downstream wards that use paper systems. METHOD: A purposive sample of 10 forms covering a comprehensive range of medication information common to PICU patients was selected from practice between March 2014 and May 2014. Pharmacists (n=7) and doctors (n=9) who received these forms on downstream wards were invited to participate in semi-structured one-to-one interviews (n=20) with the PICU pharmacist within 48 hrs of receipt to explore their views about the form. The interview schedule was informed from literature and peer review. Comments and suggestions about layout and the MR process were invited. Two pilot interviews (1 pharmacist, 1 doctor) were conducted to test a priori themes were covered and that the questioning style was open, avoided leading and the participant was given time to consider their response. Interviews were recorded using an encrypted digital recorder, transcribed and checked (10%) for accuracy and coding. Framework analysis focused on documentation and work processes. SETTING: A 110 bed paediatric hospital with critical care, medical, neurology, haematology, oncology and mixed speciality surgical services. The 8-bedded PICU uses the electronic clinical information system (CIS) MetaVision® provided by iMDsoft® and includes electronic prescribing and clinical notes. Downstream wards using paper systems are provided with a new paper drug chart and printed CIS documentation on transfer. KEY FINDINGS: New themes extracted during analysis included misunderstanding of the purpose of the form, barriers to use and accessibility of the form. Despite positive comments about the form "…just pull the sheet and you know the medication is confirmed…" (Pharmacist) and "…I think it's a really good system. I think it's quite user friendly and it prints it out in an easy to read way…" (Dr). Issues were identified including unfamiliar documentation "on a paper kardex you would see straight away [medication was discontinued]… you don't know that you need to look somewhere else until you've missed it and it's along with some other chart…" (Pharmacist). Suggestions were made to alter the layout of the form to follow the logical order of steps in the MR process. Non-standard terminology introduced by the computer system was considered ambiguous. Barriers to using the form included misunderstandings in relation to the stage of the patient's journey - was it referring to admission to hospital, admission to PICU, during PICU admission or transfer from PICU? Educational needs were identified during the interviews. Missing forms were a problem. "…our biggest issue is that they come down without having had the discharge printed off…" (Dr). CONCLUSION: User input informed recommendations for improvements such as clarity of wording and layout of the form, ensuring the MR form is available downstream and highlighted areas for user education. Further evaluation will be undertaken following implementation of these changes.

Optimisation of secondary prevention of stroke: a qualitative study of stroke patients' beliefs, concerns and difficulties with their medicines.

OBJECTIVES: The objectives of this study are to explore stroke patients' and carers' beliefs and concerns about medicines and identify the barriers to medication adherence for secondary stroke prevention. METHODS: Qualitative semistructured one-on-one interviews were conducted with 30 patients with diagnosis of stroke. Interviews were analysed using the framework approach. KEY FINDINGS: The study suggests that stroke patients' and carers' perceptions of their medicines may influence medicine-taking behaviour. In some cases when beliefs outweighed concerns, practical barriers prevented participants taking their medicines. Negative beliefs about a medicine were strong enough to prevent some participants starting a new medicine. Participants' actions were influenced by the perceived consequences of not taking the medicine and the impact of the adverse effect on their quality of life. Concerns lessened with time with no adverse effects. The importance of the role of the carer and of a medicine-taking routine was evident. Participants reported the inadequacy of information provision and the desire to have more written and verbal information. Some reported total lack of contact with their general practitioner or community pharmacist after hospital discharge. CONCLUSIONS: Many of the difficulties stroke patients have adhering to secondary prevention strategies are potentially preventable with tailored information provision and appropriate monitoring and follow-up by primary healthcare professionals. We have designed an intervention addressing the identified barriers to medicine taking, the impact of which is currently being measured in a randomised controlled trial of a pharmacist-led home-based clinical medication review in stroke patients.

Design of antimicrobial stewardship care bundles on the high dependency unit.

BACKGROUND: Antimicrobial guidelines aim to optimise treatment and minimise development of resistance. Care bundles support the implementation of local guidelines. OBJECTIVE: Pharmacist identification of where in the prescribing, monitoring and documentation process, the quality of antimicrobial management in a High Dependency Unit of a large teaching hospital could be improved and design of antimicrobial care bundles for initiation and de-escalation of therapy to standardise care and improve practice. SETTING: This study was conducted in a 10-bed, mixed medical-surgical HDU in a large Scottish (UK) teaching hospital. METHODS: Quality indicators (n = 30) were agreed through multidisciplinary team review with reference to the evidence base, national strategy and local policy. Adherence to these quality indicators was measured before and after the pharmacist's contributions. Areas of non-adherence to quality indicators were used to design the care bundles. MAIN OUTCOME MEASURE: Adherence to the quality indicators before and after the pharmacist's action. Categorisation of pharmaceutical care issues ('check', 'change in drug therapy' and 'change in drug therapy process') were quantified. RESULTS: From 134 prescriptions, the pharmacist undertook 1,447 actions to ensure adherence to the 30 indicators. Adherence was very good (85.3 % CI 83.5, 87.1), but would have been unsatisfactory (53.5 % CI 50.9, 56.1) without the pharmacist's action (p < 0.001). Change in drug therapy process or change in drug therapy initiated by the pharmacist accounted for 31.9 % (CI 29.5, 34.3) of adherence. Non-adherence was related to documentation of past allergic reactions, bacteriological specimen results, indication and length of course of treatment (both at initiation and de-escalation). Care bundles were designed to target areas of non-adherence to local guidelines. CONCLUSION: The pharmacist made a significant contribution to improving adherence to evidence based antimicrobial prescribing quality indicators agreed by the multidisciplinary team. Prompts have been identified from the pharmaceutical care process and applied in the design of two antimicrobial care bundles proposed to support adherence with antimicrobial prescribing policies and guidelines.

An examination of subgroup classification in irritable bowel syndrome patients over time: a prospective study.

BACKGROUND: Irritable bowel syndrome (IBS) is a complex functional gastrointestinal disorder which to date remains poorly understood. Therapies for irritable bowel syndrome (IBS) patients are usually aimed at relieving the predominant symptom; however, little evidence exists as to whether or not the predominant symptom changes with time. Nurses are becoming increasingly involved in the assessment and management of IBS patients. OBJECTIVES: To categorise IBS patients into one of three sub-types, namely diarrhoea-predominant, constipation-predominant and a third group who alternate between the two, and to investigate changes in patient sub-type classification over time. DESIGN: Observational cohort study. SETTING: The general population of the United Kingdom (UK). METHODS: A cohort of 494 IBS patients, with a confirmed Rome II classification diagnosis, was recruited in the UK. Patients' IBS symptoms were recorded throughout a 26-week period. Proportions of individuals in each IBS subgroup were calculated and probabilities of moving from one subgroup to another between consecutive weeks were estimated. RESULTS: The percentage of patients given an overall subgroup classification of diarrhoea-predominant IBD (D-IBS) is 40.9%; 58.1% and 1% were classified as belonging to the alternator (A-IBS) and constipation-predominant (C-IBS) subgroups, respectively. PATIENTS: classified as an alternator or as diarrhoea-predominant have a high probability (0.67 and 0.71, respectively) of remaining in the same subgroup; however this probability is lower for constipation-predominant patients (0.35). CONCLUSION: Although many patients remain in the same IBS subgroup classification over time, there are individuals whose subgroup classification varies. As such, patients' IBS subgroup classification should be reviewed regularly and treatment adjusted accordingly in order to optimise patient care.

Design of an algorithm to support community pharmacy dyspepsia management.

OBJECTIVES: To design a care pathway and referral documentation system to support dyspepsia management in the community pharmacy according to national guidelines. To explore attitudes of community pharmacists and general practitioners (GPs) towards the proposed model of care. SETTING: Focus group of four community pharmacists from one locality and one-to-one interviews with five GPs in each of their surgeries in different city localities. METHOD: Literature review; design of a care pathway and referral system; qualitative analysis of focus group discussion and one-to-one interviews. MAIN OUTCOME MEASURE: Modified design of documentation system; attitudes and barriers towards an extended role for pharmacists in a community pharmacy based model of individual care of patients with dyspepsia. RESULTS: The care pathway and documentation system was modified to make it simple to use and to assure appropriate referral and reporting to GPs. All participants agreed that the SIGN guideline for Dyspepsia and local dyspepsia guidelines provide an opportunity to extend the role of pharmacists to prescribe therapeutic doses of H2 receptor antagonists, test for Helicobacter pylori in the pharmacy and prescribe eradication therapy. Perceived advantages to patients included better convenience and reduced waiting times for H. pylori testing. Current barriers to this model identified were: medico-legal issues, budgetary issues, limited access to patient data, lack of privacy to talk to patients, inadequate time and remuneration, no patient registration, patients describing vague symptoms and patient confidence in pharmacists. CONCLUSION: The proposed model of care and documentation system for community pharmacy based dyspepsia management generated a favourable response and design contributions from community pharmacists and GPs. Barriers were identified which have to be overcome prior to implementation and evaluation of the model.

Factors that influence prescribers in their selection and use of COX-2 selective inhibitors as opposed to non-selective NSAIDs.

OBJECTIVE: To identify factors that influence prescribers in their selection and use of cyclo-oxygenase-2 (COX-2) selective inhibitors as opposed to non-selective non-steroidal anti-inflammatory drugs (NSAIDs) and report the tendency to co-prescribe gastro-protection with these agents. SETTING: All 579 general practitioners (GPs) in one geographical area, Lothian, Scotland, UK. METHOD: Postal questionnaires; simple and factorial designed case series questionnaire. MAIN OUTCOME MEASURES: Categorisation of responses to clinical and non-clinical factors into highly, partially or not influential. The quantitative influence of the most prominent clinical factors on prescribing choice and the tendency of co-prescription of gastro-protection with these agents. RESULTS: Responses from 229 (40%) GPs suggested the following as most influential: Drug Evaluation Panel recommendations, Lothian Joint Formulary, local practice formulary, history of peptic ulcer disease (PUD), history of gastro-intestinal (GI) adverse effects with NSAIDs and advanced age. Advice from other physicians, patient demand, history of alcohol gastritis, history of gastro-oesophageal reflux disease, history of functional dyspepsia, concomitant use of low dose aspirin and concomitant use of gastro-protective agents were regarded to have moderate influence. Information directly from pharmaceutical industry and regular smoking were regarded as having weak influence. An 18% response to the factorial designed questionnaire using the most prominent clinical factors suggested that history of either GI adverse effects associated with non-selective NSAIDs or PUD resulted in more pronounced increase in the frequency (15%) of decision to prescribe COX-2 selective inhibitors than advanced age (10%). Concomitant use of low dose aspirin had little effect on GPs' decisions. The mean percentage of GPs choosing to co-prescribe gastro-protection was higher with non-selective NSAIDs (64%) than with COX-2 selective inhibitors (22%). CONCLUSION: Local authoritative guidance and history of GI complications highly influenced the GPs in their use and choice of either COX-2 selective inhibitors or non-selective NSAIDs. As expected the use of gastro-protection was more frequently chosen with non-selective NSAIDs than COX-2 selective inhibitors.

A comparison of irritable bowel syndrome patients managed in primary and secondary care: the Episode IBS study.

BACKGROUND: It is thought that people with irritable bowel syndrome (IBS) who consult secondary care have more severe symptomatology than those treated mainly in primary care. AIMS: To describe the physical and psychological symptoms of IBS, and the health-related quality of life of patients managed in primary and secondary care. DESIGN OF STUDY: Cross-sectional observational survey. SETTING: The general population of the United Kingdom (UK). METHODS: A cohort of people with IBS symptoms was recruited via a UK-wide newspaper advertisement. Frequency, duration and severity of symptoms, and health-related quality of life data were collected by semi-structured telephone interviews. Descriptive analysis allowed the comparison of those managed in primary care with those consulting secondary care. Logistic regression was used to identify factors associated with patients consulting secondary care. RESULTS: Data on 486 participants with confirmed IBS (Rome II criteria) were examined. Similar patterns in symptom severity were found in primary and secondary care groups. Factors associated with IBS patients consulting secondary care were: male sex, a longer length of time since diagnosis, having frequent bowel motions, not having dyspepsia in the past 3 months, and having used medication and alternative therapies. Although patients managed in secondary care have greater impairment to their usual activities, both groups had similar health-related quality-of-life profiles. CONCLUSION: High levels of physical and psychological morbidity were present in population-based volunteers managed in both primary and secondary care. This study suggests that patients with IBS managed solely in primary care are affected as much as those attending secondary care.