Developing consensus on the principles and key actions for collaborative working between general practices and community pharmacies: a modified eDelphi study.

OBJECTIVES: To develop consensus on the principles and key actions for collaborative working in practice between general practice, community pharmacy and patients and their carers. DESIGN: Three-round modified eDelphi study, starting from an established conceptual model of collaboration between general practitioners (GPs) and community pharmacists. SETTING: Community pharmacies and general practices in England, UK. PARTICIPANTS: A panel of 123 experts: 43% from a community pharmacy background; 36% from a GP background; 13% patients, carers or patient representatives and 8% from academic or commissioner backgrounds. Panellist numbers reduced by approximately 30% in rounds 2 and 3. PRIMARY AND SECONDARY OUTCOME MEASURES: Consensus between expert panellists, defined as at least 75% agreement. RESULTS: A high level of consensus (>80%) was achieved on all components of a model of collaboration composed of Fundamental Principles of Collaboration and Key Activities for Action, supported by a series of aspirational statements and suggested practical actions. The fundamental principles and key activities are appended by contextual points. The findings indicate that collaboration in practice involves team members other than just GPs and community pharmacists and recognises that patients often want to know how each professional team is involved in their care. This study also provides insights into how collaboration between general practice and community pharmacy settings appears to have shifted during the COVID-19 pandemic, especially through opportunities for virtual collaboration and communication that can transcend the need for close geographical proximity. CONCLUSION: A consensus-based model of collaboration between general practice teams, community pharmacy teams, and patients and their carers has been developed. It is practically focused, values the patient voice and incorporates general practice and community pharmacy team members. While developed in England, the model is likely to also have applicability to other countries with similar health systems that include general practices and community pharmacies.

Evaluating associations between metabolic health, obesity and depressive symptoms: a prospective analysis of data from the English Longitudinal Study of Ageing (ELSA) with a 2­year follow­up.

OBJECTIVES: Conflicting results have been reported when the associations between metabolic health, obesity and depression were examined previously. The primary aim of this study was to determine whether metabolic health or obesity are independently associated with depressive symptoms, among a representative sample of older people living in England. Independent associations between covariates and depression were also examined. DESIGN: Prospective study with a 2-year follow-up. SETTING: The English Longitudinal Study of Ageing Wave 6 (2012-2013) and Wave 7 (2014-2015). PARTICIPANTS: 6804 participants aged older than 50 years. DATA ANALYSIS: Multivariate models were used to determine whether metabolic health or obesity are independently associated with depressive symptoms at 2-year follow-up. Unadjusted and adjusted ORs with corresponding 95% CI were calculated; the adjusted ORs took account of baseline depression, gender, age, wealth, obesity and poor metabolic health. RESULTS: Before adjusting for covariates, poor metabolic health was associated with depressive symptoms at 2-year follow-up (OR 1.24; 95% CI, 1.07 to 1.44, p<0.01). After adjusting for covariates, the association was no longer statistically significant (OR 1.17; 95% CI, 0.99 to 1.38, p=0.07). Similarly, obesity was associated with depressive symptoms at 2-year follow-up before adjusting for covariates (OR 1.54; 95% CI, 1.33 to 1.79, p<0.01). However, after adjusting for covariates the association between obesity and depressive symptoms at 2-year follow-up became statistically insignificant (OR 1.19; 95% CI, 1.00 to 1.41, p=0.06). The strongest predictors for future depression were baseline depression (OR 10.59; 95% CI, 8.90 to 12.53, p<0.01) and lower wealth (OR 3.23; 95% CI, 2.44 to 4.35, p<0.01). CONCLUSION: Neither poor metabolic health nor obesity were associated with a risk of depressive symptoms at 2-year follow-up, after adjusting for covariates. As wealth inequalities continue to rise across England, the risk of depressive symptoms at 2-year follow-up is likely to be elevated in individuals living in the lower wealth quintiles.

Factors associated with polypharmacy in primary care: a cross-sectional analysis of data from The English Longitudinal Study of Ageing (ELSA).

OBJECTIVES: While older age and ill health are known to be associated with polypharmacy, this paper aims to identify whether wealth, body mass index (BMI), smoking and alcohol consumption are also associated with polypharmacy (5-9 prescribed medications) and hyperpolypharmacy prevalence (≥10 prescribed medications), among older people living in England. DESIGN: Cross-sectional study. SETTING: The English Longitudinal Study of Ageing Wave 6 (2012-2013). PARTICIPANTS: 7730 participants aged over 50 years. DATA SYNTHESIS: Two multivariate models were created. HR with corresponding 95% CI, for polypharmacy and hyperpolypharmacy, were calculated after adjusting for gender, age, wealth, smoking, alcohol consumption, BMI, self-rated health and the presence of a chronic health condition. RESULTS: Lower wealth (lowest wealth quintile vs highest wealth quintile, adjusted HR 1.28; 95% CI 1.04 to 1.69, P=0.02) and obesity (adjusted HR 1.81; 95% CI 1.53 to 2.15, p<0.01) were significantly associated with polypharmacy. Increasing age (50-59 years vs 70-79 years, adjusted HR 3.42; 95% CI 2.81 to 4.77, p<0.01) and the presence of a chronic health condition (adjusted HR 2.94; 95% CI 2.55 to 3.39, p<0.01) were also associated with polypharmacy. No statistically significant association between smoking and polypharmacy (adjusted HR 1.06; 95% CI 0.86 to 1.29, P=0.56) was established; while, very frequent alcohol consumption (consuming alcohol >5 times per week) was inversely associated with polypharmacy (never drank alcohol vs very frequently, adjusted HR 0.64; 95% CI 0.52 to 0.78, p<0.01). The adjusted HR for hyperpolypharmacy was accentuated, compared with polypharmacy. CONCLUSION: This study has identified that lower wealth, obesity, increasing age and chronic health conditions are significantly associated with polypharmacy and hyperpolypharmacy prevalence. The effect of these factors, on polypharmacy and especially hyperpolypharmacy prevalence, is likely to become more pronounced with the widening gap in UK wealth inequalities, the current obesity epidemic and the growing population of older people. The alcohol findings contribute to the debate on the relationship between alcohol consumption and health.

Barriers to administering non-oral formulations in a paediatric population: A semi-structured interview study.

There is a paucity of research exploring barriers to non-oral medicines administration in paediatric patients; however, these undoubtedly influence medicines adherence. Studies conducted with healthcare professionals have identified various issues with the administration and acceptance of non-oral medicines and devices (Venables et al., 2012; Walsh et al., 2015). EMA (2014) guidelines specify that formulation teams should demonstrate 'acceptability' of paediatric formulations when developing pharmaceutical formulations. Semi-structured interviews exploring barriers to administering non-oral medicines were conducted with young persons and the parents/legal guardians of children (0-17 years) with chronic conditions at the University Hospital of Coventry and Warwickshire, UK. 90 children prescribed a total of 148 non-oral medicines were recruited to the study; 88 barriers to administering non-oral medicines were reported. The most commonly reported barriers were: poor acceptance of face mask/difficulties with spacer for inhaled formulations (38% of reports); disliking parenteral/preferring alternative formulations (38% of reports); greasy texture of topical preparations; difficulty with administering an ocular ointment and the large dose volume of a nasal preparation. Formulation teams should consider the use of child-friendly, age-appropriate designs to improve usability and acceptance, thus medicines adherence. These findings should be used to inform future development of non-oral formulations and devices, suitable in terms of safety, efficacy and acceptability to paediatric patients.

Problems with oral formulations prescribed to children: a focus group study of healthcare professionals.

BACKGROUND: There is evidence to suggest that adherence with prescribed medication is lower amongst adolescents and children than in adults. Medication adherence rates between 11 and 93 % in paediatric patients have been reported. More research needs to be carried out in order to understand why medicines adherence is low and how adherence can be improved in children with long-term conditions. Personal communication with paediatricians in secondary care has highlighted that problems are most likely to be encountered by parents, carers, nurses and children themselves when administering medicines for prevalent long-term childhood conditions. OBJECTIVE: To explore problems with oral medicines prescribed to paediatric patients from the perspectives of medical practitioners, pharmacists and nurses. Setting Two NHS trusts in the West Midlands, UK. METHODS: Four focus groups (FG) were conducted. Five nurses, eight medical practitioners and six pharmacists participated in focus groups. The themes explored were problems experienced when prescribing, dispensing and administering oral medicines for children. Main outcome measure Themes evolving from Healthcare professionals reports on problems with administering medicines to paediatric patients. RESULTS: Two main themes: sensory and non-sensory emerged from the data. Included within these were taste, texture, colour, smell, size, swallowing, quantity, volume and manipulation with food. Taste was the most commonly reported barrier to medicines administration. Texture was reported to be a significant problem for the learning disability population. Medicines manipulation techniques were revealed across the groups, yet there was limited knowledge regarding the evidence base for such activity. Problems surrounding the supply of Specials medicines were discussed in-depth by the pharmacists. CONCLUSION: Organoleptic and physical properties of medicines are key barriers to medicines administration. A robust scientific evidence-based approach is warranted to inform standardised protocols guiding healthcare professionals to support safe and effective medicines manipulation across all settings. Pharmacists' knowledge of Specials medicines needs to be recognised as a valuable resource for doctors. Findings of this study should help to optimise paediatric prescribing and direct future formulation work.

The application of tribology in assessing texture perception of oral liquid medicines.

The palatability of medicines is likely to have a significant impact on patient adherence and consequently, on the safety and efficacy of a medicinal product. Palatability encompasses properties of medicines not limited to taste including swallowability (e.g. size, shape, texture). However, there has been limited work undertaken to measure the texture of medicines and how this may affect palatability and subsequent adherence. Tribology offers an understanding of oral processes and can allow physical properties of materials to be linked to "mouthfeel". This paper describes a preliminary application of tribology to oral liquid medicines and demonstrates that this technique is useful in the development of future oral liquid medicines.

Determination of formulation factors that affect oral medicines acceptability in a domiciliary paediatric population.

UNLABELLED: Acceptability of medicines for children is a challenge, yet critical to ensure adherence to treatment. There is very little literature on formulation factors that influence acceptability of medicines, particularly in the domiciliary environment. This pragmatic study was conducted at University Hospital Coventry and Warwickshire (UHCW) with the aim of identifying the prevalence and nature of oral formulation-related barriers to medicines administration in children suffering from long-term conditions. This study used semi-structured face-to-face interviews with 221 parents/carers of children (0-18 years) and 57 young people (12-18 years). RESULT: showed significant medicines refusal and manipulation in the domiciliary environment. Nearly one-third (71/232) of respondents reported medicines refusal. This was associated significantly with the age of child (p=0.016), socioeconomic status (IMD 2010 score) (p=0.002), taste (p<0.001), texture (p=0.017), and volume (of liquid/powder) or quantity (of solid dosage form) (p<0.001). 29% (74/252) of respondents reported manipulating medicines. P-values are based on multivariable statistical analysis models. This study has indicated that formulations prescribed to children with chronic conditions are not meeting the needs of a significant number of patients based on self-report. Age-appropriate medicines are required to provide suitable dose units with an acceptable taste for children. This study should aid pharmaceutical companies to prioritise paediatric formulation work.