Successful care transitions for older people: a systematic review and meta-analysis of the effects of interventions that support medication continuity.

BACKGROUND: medication-related problems occur frequently when older patients are discharged from hospital. Interventions to support medication use have been developed; however, their effectiveness in older populations are unknown. This review evaluates interventions that support successful transitions of care through enhanced medication continuity. METHODS: a database search for randomised controlled trials was conducted. Selection criteria included mean participant age of 65 years and older, intervention delivered during hospital stay or following recent discharge and including activities that support medication continuity. Primary outcome of interest was hospital readmission. Secondary outcomes related to the safe use of medication and quality of life. Outcomes were pooled by random-effects meta-analysis where possible. RESULTS: twenty-four studies (total participants = 17,664) describing activities delivered at multiple time points were included. Interventions that bridged the transition for up to 90 days were more likely to support successful transitions. The meta-analysis, stratified by intervention component, demonstrated that self-management activities (RR 0.81 [0.74, 0.89]), telephone follow-up (RR 0.84 [0.73, 0.97]) and medication reconciliation (RR 0.88 [0.81, 0.96]) were statistically associated with reduced hospital readmissions. CONCLUSION: our results suggest that interventions that best support older patients' medication continuity are those that bridge transitions; these also have the greatest impact on reducing hospital readmission. Interventions that included self-management, telephone follow-up and medication reconciliation activities were most likely to be effective; however, further research needs to identify how to meaningfully engage with patients and caregivers to best support post-discharge medication continuity. Limitations included high subjectivity of intervention coding, study heterogeneity and resource restrictions.

Experience-based co-design-Adapting the method for a researcher-initiated study in a multi-site setting.

BACKGROUND: Experience-based co-design (EBCD) brings patients and staff together to co-design services. It is normally conducted in one organization which initiates and implements the process. We used the traditional EBCD method with a number of adaptations as part of a larger research study in the British National Health Service. METHODS: The primary aim was to assess the feasibility and acceptability of conducting research-initiated EBCD, to enhance intervention development prior to testing. As well as embedding the method in a research study, there were 3 further key adaptations: (a) working across primary and secondary care sectors, (b) working on multiple sites and (c) incorporating theory-informed analysis. RESULTS: We recruited four sites (covering both primary and secondary care) and, on each site, conducted the initial traditional EBCD meetings, with separate staff and patient groups-followed by a single joint patient-staff event, where four priority areas for co-design were agreed. This event was driven by theory-informed analysis, as well as the traditional trigger film of patient experiences. Each site worked on one priority area, and the four co-design groups met over 2-3 months to design prototype tools. A second joint event was held (not usually undertaken in single-site EBCD) where they shared and compared outputs. The research team combined elements of these outputs to create an intervention, now being tested in a cluster randomized controlled trial. CONCLUSIONS: EBCD can be successfully adapted for use across an entire patient pathway with multiple organizations and as part of a research process to identify an intervention for subsequent testing in a randomized trial. Our pragmatic approach used the patient experience to identify areas for improvement and co-designed an intervention which directly reflected patient priorities.

How timely is access to palliative care medicines in the community? A mixed methods study in a UK city.

OBJECTIVE: To investigate timely access to palliative medicines/drugs (PMs) from community pharmacies to inform palliative care service delivery. DESIGN: Mixed methods in two sequential phases: (1) prospective audit of prescriptions and concurrent survey of patients/representatives collecting PMs from pharmacy and (2) interviews with community pharmacists (CPs) and other healthcare professionals (HCPs). SETTING: Five community pharmacies in Sheffield, UK and HCPs that deliver palliative care in that community. PARTICIPANTS: Phase 1: five CPs: two providing access to PMs within a locally commissioned service (LCS) and three not in the LCS; 55 patients/representatives who completed the survey when accessing PMs and phase 2: 16 HCPs, including five phase 1 CPs, were interviewed. RESULTS: The prescription audit collected information on 75 prescriptions (75 patients) with 271 individual PMs; 55 patients/representatives (73%) completed the survey. Patients/representatives reported 73% of PMs were needed urgently. In 80% of cases, patients/representatives received all PMs on the first pharmacy visit. One in five had to travel to more than one pharmacy to access PMs. The range of PMs stocked by pharmacies was the key facilitating factor. CPs reported practical issues causing difficulty keeping PMs in stock and playing a reactive role with palliative prescriptions. Confidentiality concerns were cited by other HCPs who were reluctant to share key patient information proactively with pharmacy teams. Inadequate information transfer, lack of CP integration into the care of palliative patients and poor HCP knowledge of which pharmacies stock PMs meant patients and their families were not always able to access PMs promptly. CONCLUSIONS: Consistent routine information transfer and integration of pharmacy teams in the care of palliative patients are needed to achieve timely access to PMs. Commissioners of PM access schemes should review and monitor access. HCPs need to be routinely made aware and reminded about the service and its locations.

Stakeholder perspectives of care for people living with dementia moving from hospital to care facilities in the community: a systematic review.

BACKGROUND: People living with dementia in care homes are regularly admitted to hospital. The transition between hospitals and care homes is an area of documented poor care leading to adverse outcomes including costly re-hospitalisation. This review aims to understand the experiences and outcomes of care for people living with dementia who undergo this transition from the perspectives of key stakeholders; people living with dementia, their families and health care professionals. METHODS: A systematic search was conducted on the CINAHL, ASSIA, EMBASE, MEDLINE, PsychINFO, and Scopus databases without any date restrictions. We hand searched reference lists of included papers. Papers were included if they focused on people living with dementia moving from hospital to a short or long term care setting in the community including sub-acute, rehabilitation, skilled nursing facilities or care homes. Titles, abstracts and full texts were screened. Two authors independently evaluated study quality using a checklist. Themes were identified and discussed to reach consensus. RESULTS: In total, nine papers reporting eight studies met the inclusion criteria for the systematic review. A total of 257 stakeholders participated; 37 people living with dementia, 95 family members, and 125 health and social care professionals. Studies took place in Australia, Canada, United Kingdom (UK), and the United States of America (US). Four themes were identified as factors influencing the experience and outcomes of the transition from the perspectives of stakeholders; preparing for transition; quality of communication; the quality of care; family engagement and roles. CONCLUSION: This systematic review presents a compelling case for the need for robust evidence to guide best practice in this important area of multi-disciplinary clinical practice. The evidence suggests this transition is challenging for all stakeholders and that people with dementia have specific needs which need attention during this period. TRIAL REGISTRATION: PROSPERO Registration Number: CRD42017082041 .

Evaluating recruitment methods of patients with advanced cancer: a pragmatic opportunistic comparison.

BACKGROUND: Recruitment of patients with advanced cancer into studies is challenging. OBJECTIVE: To evaluate recruitment methods in a study of pharmacist-led cancer pain medicine consultations and produce recommendations for future studies. METHOD: Two methods of recruitment were employed: (1) community-based (general practitioner computer search, identification by general practitioner, community pharmacist or district nurse and hospital outpatient list search) and (2) hospice-based (in and outpatient list search). Patients identified in method 1 were invited by post and in method 2 were invited face-to-face. Information was designed in collaboration with patients and carers. RESULTS: A total of 128 patients were identified (85 from the community and 43 from the hospice), and 47 met the inclusion criteria. Twenty-three agreed to take part and 19 completed the study, 17 of whom were already under specialist palliative care. Recruitment rates were 7% for community-based methods and 40% for hospice. The recruitment methods differed in intensity of resource use. Recruitment via letter and a lack of engagement by healthcare professionals were found to be barriers. Facilitators included the researcher having personal involvement in recruitment. CONCLUSION: The overall recruitment rate was in line with other studies for this patient cohort. Attempts to identify and engage patients through community-based postal contact were less effective than where personal contact with patients was both possible and occurred. Methods were less successful at recruiting patients who were not already engaged with hospice services.

A community pharmacist medicines optimisation service for patients with advanced cancer pain: a proof of concept study.

Background Patients with advanced cancer commonly experience pain and it is least controlled in community settings. Community pharmacists in the UK already offer medicines optimisation consultations although not for this patient group. Objective To determine whether medicines consultations for patients with advanced cancer pain are feasible and acceptable. Setting Community-dwelling patients with advanced cancer pain were recruited from primary, secondary and tertiary care using purposive sampling in one UK city. Methods One face-to-face or two telephone delivered medicines optimisation consultations by pharmacists were tested. These were based on services currently delivered in UK community pharmacies. Feedback was obtained from patients and healthcare professionals involved to assess feasibility and acceptability. Main outcome measure Recruitment, acceptability and drug related problems. Results Twenty-three patients, (range 33-88 years) were recruited, 19 completed consultation(s) of whom 17 were receiving palliative care services. Five received face-to-face consultations and 14 by telephone during which 47 drug related problems were identified from 33 consultations (mean 2.5). Advice was provided for 34 drug related problems in 17 patients and referral to other healthcare professionals for 13 in 8 patients, 2 patients had none. Eleven patients returned questionnaires of which 8 (73%) would recommend the consultations to others. Conclusion The consultations were feasible as patients were recruited, retained, consultations delivered, and data collected. Patients found the 20-30 min intervention acceptable, found a self-perceived increase in medicines knowledge and most would recommend it to others. Community pharmacists were willing to carry out these services however they had confidence issues in accessing working knowledge. Most drug related problems were resolved by the pharmacists and even among patients receiving palliative care services there were still issues concerning analgesic management. Pharmacist-conducted medicines consultations demonstrate potential which now needs to be evaluated within a larger study in the future.

Gaps, traps, bridges and props: a mixed-methods study of resilience in the medicines management system for patients with heart failure at hospital discharge.

INTRODUCTION: Poor medicines management places patients at risk, particularly during care transitions. For patients with heart failure (HF), optimal medicines management is crucial to control symptoms and prevent hospital readmission. This study explored the concept of resilience using HF as an example condition to understand how the system compensates for known and unknown weaknesses. METHODS: We explored resilience using a mixed-methods approach in four healthcare economies in the north of England. Data from hospital site observations, healthcare staff and patient interviews, and documentary analysis were collected between June 2016 and March 2017. Data were synthesised and analysed using framework analysis. RESULTS: Interviews were conducted with 45 healthcare professionals, with 20 patients at three time points and 189 hours of observation were undertaken. We identified four primary inter-related themes concerning organisational resilience. These were named as gaps, traps, bridges and props. Gaps were discontinuities in processes that had the potential to result in poorly optimised medicines. Traps were features of the system that could produce errors or unintended adverse medication events. Bridges were features of the medicines management system that promoted safety and continuity which ensured that, despite varying conditions, care could be delivered successfully. Props were informal, temporary or impromptu actions taken by patients or healthcare staff to avoid potential adverse events. CONCLUSION: The numerous opportunities for HF patient safety to be compromised and for suboptimal medicines management during this common care transition are mitigated by system resilience. Cross-organisational bridges and temporary fixes or 'props' put in place by patients and carers, healthcare teams and organisations are critical for safe and optimal care to be delivered in the face of continued system pressures.

Pharmacist educational interventions for cancer pain management: a systematic review and meta-analysis.

OBJECTIVES: Educational interventions by pharmacists for patients with cancer pain aim to improve pain management, but little is known about the different components of interventions and their effectiveness. Our aim was to assess the benefit of pharmacist delivered educational interventions for patients with cancer pain. A systematic review and meta-analysis of experimental trials testing pharmacist delivered educational interventions for cancer pain was carried out to identify the components of interventions and effectiveness at improving pain-related outcomes for patients with cancer. A literature review was conducted in EMBASE, MEDLINE, CINAHL, PsycINFO, ASSIA, Web of Science and CENTRAL from inception until January 2018 searching for educational interventions involving a pharmacist for patients with cancer pain. Four studies were included involving 944 patients. Meta-analysis was carried out where possible. KEY FINDINGS: Meta-analysis of three of the four studies found that mean pain intensity in the intervention group was reduced by 0.76 on a 0-10 scale (95% confidence interval), although only two of the studies used validated measures of pain. Improvements in knowledge, side effects and patient satisfaction were seen although with less reliable measures. SUMMARY: Pharmacist educational interventions for patients with cancer pain have been found to show promise in reducing pain intensity. Studies were few and of varying quality. Further, good quality studies should be carried out in this area and these should be comprehensively reported. Trials measuring patient self-efficacy and patient satisfaction are needed before the impact of the pharmacist delivered interventions on these outcomes can be established.

Cardiology patients' medicines management networks after hospital discharge: A mixed methods analysis of a complex adaptive system.

INTRODUCTION: The complex healthcare system that provides patients with medicines places them at risk when care is transferred between healthcare organisations, for example discharge from hospital. Consequently, understanding and improving medicines management, particularly at care transfers, is a priority. OBJECTIVES: This study aimed to explore the medicines management system as patients experience it and determine differences in the patient-perceived importance of people in the system. METHODS: We used a Social Network Analysis framework, collecting ego-net data about the importance of people patients had contact with concerning their medicines after hospital discharge. Single- and multi-level logistic regression models of patients' networks were constructed, and model residuals were explored at the patient level. This enabled us to identify patients' networks with support tie patterns different from the general patterns suggested by the model results. Qualitative data for those patients were then analysed to understand their differing experiences. RESULTS: Networks comprised clinical and administrative healthcare staff and friends and family members. Networks were highly individual and the perceived importance of alters varied both within and between patients. Ties to spouses were significantly more likely to be rated as highly important and ties to community pharmacy staff (other than pharmacists) and to GP receptionists were less likely to be highly rated. Patients with low-value medicines management networks described having limited information about their medicines and a lack of understanding or help. Patients with high-value networks described appreciating support and having confidence in staff. CONCLUSIONS: Patients experienced medicines management as individual systems within which they interacted with healthcare staff and informal support to manage their treatment. Multilevel models indicated that there are unexplained variables impacting on patients' assessments of their medicines management networks. Qualitative exploration of the model residuals can offer an understanding of networks that do not have the typical range of support ties.

How do patients with cancer pain view community pharmacy services? An interview study.

Pain experienced by many patients with advanced cancer is often not well controlled and community pharmacists are potentially well placed to provide support. The study objective was to explore the views and experiences of patients with advanced cancer about community pharmacies, their services and attitudes towards having a community pharmacist pain medicines consultation. Purposive sampling of GP clinical information systems was used to recruit patients with advanced cancer, living in the community and receiving opioid analgesics in one area of England, UK between January 2015 and July 2016. Thirteen patients had a semi-structured interview which was audio-recorded and transcribed verbatim. Data were analysed deductively and inductively using Framework analysis and incorporating new themes as they emerged. The framework comprised Pain management, Experiences and expectations, Access to care and Communication. All patients reported using one regular community pharmacy citing convenience, service and staff friendliness as influential factors. The idea of a community pharmacy medicines consultation was acceptable to most patients. The idea of telephone consultations was positively received but electronic media such as Skype was not feasible or acceptable for most. Patients perceived a hierarchy of health professionals with specialist palliative care nurses at the top (due to their combined knowledge of their condition and medicines) followed by GPs then pharmacists. Patients receiving specialist palliative care described pain that was better controlled than those who were not. They thought medicines consultations with a pharmacist could be useful for patients before referral for palliative care. There is a need for pain medicines support for patients with advanced cancer, and unmet need appears greater for those not under the care of specialist services. Medicines consultations, in principle, are acceptable to patients both in person and by telephone, and the latter was perceived to be of particular benefit to patients less able to leave the house.

Characterising the growth in palliative care prescribing 2011-2015: Analysis of national medical and non-medical activity.

BACKGROUND: The role of non-medical prescribers working in palliative care has been expanding in recent years and prescribers report improvements in patient care, patient safety, better use of health professionals' skills and more flexible team working. Despite this, there is a lack of empirical evidence to demonstrate its clinical and economic impact, limiting our understanding of the future role of non-medical prescribers within a healthcare system serving an increasing number of people with palliative care needs. AIM: We developed a unique methodology to establish the level of non-medical prescribers' activity in palliative care across England and consider the likely overall contribution these prescribers are making at a national level in this context in relation to medical prescribing. SETTING/PARTICIPANTS: All prescriptions for 10 core palliative care drugs prescribed by general practitioners, nurses and pharmacists in England and dispensed in the community between April 2011 and April 2015 were extracted from the Prescribing Analysis Cost Tool system. DESIGN: The data were broken down by prescriber and basic descriptive analysis of prescription frequencies by opioid, non-opioids and total prescriptions by year were undertaken. To evaluate the yearly growth of non-medical prescribers, the total number of prescriptions was compared by year for each prescribing group. RESULTS: Non-medical prescribers issued prescriptions rose by 28% per year compared to 9% in those issued by medical prescribers. Despite this, the annual growth in non-medical prescribers prescriptions was less than 1% a year in relation to total community palliative care prescribing activity in England. Impact on medical prescribing is therefore minimal.

A qualitative study of patient involvement in medicines management after hospital discharge: an under-recognised source of systems resilience.

INTRODUCTION: There are risks to the safety of medicines management when patient care is transferred between healthcare organisations, for example, when a patient is discharged from hospital. Using the theoretical concept of resilience in healthcare, this study aimed to better understand the proactive role that patients can play in creating safer, resilient medicines management at a common transition of care. METHODS: Qualitative interviews with 60 cardiology patients 6 weeks after their discharge from 2 UK hospitals explored patients' experiences with their discharge medicines. Data were initially subjected to an inductive thematic analysis and a subsequent theory-guided deductive analysis. RESULTS: During interviews 23 patients described medicines management resilience strategies in two main themes: identifying system vulnerabilities; and establishing self-management strategies. Patients could anticipate problems in the system that supplied them with medicines and took specific actions to prevent them. They also identified when errors had occurred both before and after medicines had been supplied and took corrective action to avoid harm. Some reported how they had not foreseen problems or experienced patient safety incidents. Patients recounted how they ensured information about medicines changes was correctly communicated and acted upon, and described their strategies to enhance their own reliability in adherence and resource management. CONCLUSION: Patients experience the impact of vulnerabilities in the medicines management system across the secondary-primary care transition but many are able to enhance system resilience through developing strategies to reduce the risk of medicines errors occurring. Consequently, there are opportunities-with caveats-to elicit, develop and formalise patients' capabilities which would contribute to safer patient care and more effective medicines management.

Pharmacist joint-working with general practices: evaluating the Sheffield Primary Care Pharmacy Programme. A mixed-methods study.

BACKGROUND: The NHS in the UK supports pharmacists' deployment into general practices. This article reports on the implementation and impact of the Primary Care Pharmacy Programme (PCPP). The programme is a care delivery model that was undertaken at scale across a city in which community pharmacists (CPs) were matched with general practices and performed clinical duties for one half-day per week. AIM: To investigate (a) challenges of integration of CPs in general practices, and (b) the perceived impact on care delivery and community pharmacy practice. DESIGN & SETTING: This mixed-methods study was conducted with CPs, community pharmacy employers (CPEs), scheme commissioners (SCs), and patients in Sheffield. METHOD: Semi-structured interviews (n = 22) took place with CPs (n = 12), CPEs (n = 2), SCs (n = 3), and patients (n = 5). A cross-sectional survey of PCPP pharmacists (n = 47, 66%) was also used. A descriptive analysis of patient feedback forms was undertaken and a database of pharmacist activities was created. RESULTS: Eighty-six of 88 practices deployed a pharmacist. Although community pharmacy contracting and backfill arrangements were sometimes complicated, timely deployment was achieved. Development of closer relationships appeared to facilitate extension of initially agreed roles, including transition from 'backroom' to patient-facing clinical work. CPs gained understanding of GP processes and patients' primary care pathway, allowing them to follow up work at the community pharmacy in a more timely way, positively impacting on patients' and healthcare professionals' perceived delivery of care. CONCLUSION: The PCPP scheme was the first of its kind to achieve almost universal uptake by GPs throughout a large city. The study findings reveal the potential for CP-GP joint-working in increasing perceived positive care delivery and reducing fragmented care, and can inform future implementation at scale and at practice level.

Self-management toolkit and delivery strategy for end-of-life pain: the mixed-methods feasibility study.

BACKGROUND: Pain affects most people approaching the end of life and can be severe for some. Opioid analgesia is effective, but evidence is needed about how best to support patients in managing these medicines. OBJECTIVES: To develop a self-management support toolkit (SMST) and delivery strategy and to test the feasibility of evaluating this intervention in a future definitive trial. DESIGN: Phase I - evidence synthesis and qualitative interviews with patients and carers. Phase II - qualitative semistructured focus groups and interviews with patients, carers and specialist palliative care health professionals. Phase III - multicentre mixed-methods single-arm pre-post observational feasibility study. PARTICIPANTS: Phase I - six patients and carers. Phase II - 15 patients, four carers and 19 professionals. Phase III - 19 patients recruited to intervention that experienced pain, living at home and were treated with strong opioid analgesia. Process evaluation interviews with 13 patients, seven carers and 11 study nurses. INTERVENTION: Self-Management of Analgesia and Related Treatments at the end of life (SMART) intervention comprising a SMST and a four-step educational delivery approach by clinical nurse specialists in palliative care over 6 weeks. MAIN OUTCOME MEASURES: Recruitment rate, treatment fidelity, treatment acceptability, patient-reported outcomes (such as scores on the Brief Pain Inventory, Self-Efficacy for Managing Chronic Disease Scale, Edmonton Symptom Assessment Scale, EuroQol-5 Dimensions, Satisfaction with Information about Medicines Scale, and feasibility of collecting data on health-care resource use for economic evaluation). RESULTS: Phase I - key themes on supported self-management were identified from evidence synthesis and qualitative interviews. Phase II - the SMST was developed and refined. The delivery approach was nested within a nurse-patient consultation. Phase III - intervention was delivered to 17 (89%) patients, follow-up data at 6 weeks were available on 15 patients. Overall, the intervention was viewed as acceptable and valued. Descriptive analysis of patient-reported outcomes suggested that interference from pain and self-efficacy were likely to be candidates for primary outcomes in a future trial. No adverse events related to the intervention were reported. The health economic analysis suggested that SMART could be cost-effective. We identified key limitations and considerations for a future trial: improve recruitment through widening eligibility criteria, refine the SMST resources content, enhance fidelity of intervention delivery, secure research nurse support at recruiting sites, refine trial procedures (including withdrawal process and data collection frequency), and consider a cluster randomised design with nurse as cluster unit. LIMITATIONS: (1) The recruitment rate was lower than anticipated. (2) The content of the intervention was focused on strong opioids only. (3) The fidelity of intervention delivery was limited by the need for ongoing training and support. (4) Recruitment sites where clinical research nurse support was not secured had lower recruitment rates. (5) The process for recording withdrawal was not sufficiently detailed. (6) The number of follow-up visits was considered burdensome for some participants. (7) The feasibility trial did not have a control arm or assess randomisation processes. CONCLUSIONS: A future randomised controlled trial is feasible and acceptable. STUDY AND TRIAL REGISTRATION: This study is registered as PROSPERO CRD42014013572; Current Controlled Trials ISRCTN35327119; and National Institute for Health Research (NIHR) Portfolio registration 162114. FUNDING: The NIHR Health Technology Assessment programme.

Patients' knowledge of new medicines after discharge from hospital: What are the effects of hospital-based discharge counseling and community-based medicines use reviews (MURs)?

BACKGROUND: Interventions to reduce medicines discontinuity at transitions during and reinforced after discharge are effective. However, few studies have linked hospital-based counseling with onward referral for community pharmacy-based follow-up to support patients' medicines use. OBJECTIVE: To determine the effects of targeted hospital pharmacist counseling on discharge or targeted community pharmacy medicines reviews post-discharge on patients' knowledge of newly started medication. METHODS: The study was a controlled trial of targeted medicines discharge counseling provided by hospital pharmacists or follow-up post-discharge medicines review provided by community pharmacists compared with usual care (nurse counseling). Outcomes measured using a structured telephone survey conducted at two and four weeks after patients were discharged from hospital. RESULTS: Patients who received hospital pharmacist counseling were significantly more likely to report being told the purpose of their new medicine and how to take it versus those receiving usual care. Fewer than half of the patients who were allocated to receive a community pharmacy medicines review received one. CONCLUSIONS: Patient knowledge of medicines newly prescribed in the hospital was increased by targeted counseling of hospital pharmacists. The findings suggest the need to improve the consistency of the information covered when providing counseling, perhaps by the implementation of a counseling checklist for use by all disciplines of staff involved in patient counseling. The potential of community pharmacy follow-up medicines review is currently undermined by several barriers to uptake.

Opioid prescribing for patients with cancer in the last year of life: a longitudinal population cohort study.

We linked UK cancer registry data with the corresponding electronic primary care medical records of 6080 patients who died of cancer over a 7-year period in a large United Kingdom city. We extracted all prescriptions for analgesics issued to each patient in the linked cohort during the 12 months before death and analysed the extent and duration of strong opioid treatment with clinical and patient characteristics. Strong opioids were prescribed for 48% of patients in the last year of life. Median interval between first prescription of a strong opioid and death was 9 weeks (interquartile range 3-23). Strong opioid prescribing was not influenced by cancer type, duration of illness, or gender but was adversely influenced by older age. Compared with patients who died in a hospice, those who died in a hospital were 60% less likely to receive a strong opioid in primary care before admission (relative risk ratio 0.4, CI 0.3-0.5, P < 0.01). The study provides the first detailed analysis of the relatively late onset and short duration of strong opioid treatment in patients with cancer before death in a representative UK cohort. This pattern of prescribing does not match epidemiological data which point to earlier onset of pain. Although persistent undertreatment of cancer pain is well documented, this study suggests that strategies for earlier pain assessment and initiation of strong opioid treatment in community-based patients with cancer could help to improve pain outcomes.

Community pharmacists' experience and perceptions of the New Medicines Service (NMS).

OBJECTIVES: The New Medicines Service (NMS) is provided by community pharmacists in England to support patient adherence after the initiation of a new treatment. It is provided as part of the National Health Service (NHS) pharmacy contractual framework and involves a three-stage process: patient engagement, intervention and follow-up. The study aims to explore community pharmacists' experiences and perceptions of NMS within one area of the United Kingdom. METHODS: In-depth semi-structured telephone interviews were conducted with 14 community pharmacists. Interviews were audio-recorded, independently transcribed and thematically analysed. KEY FINDINGS: Pharmacists gave a mixed response to the operationalisation, ranging from positive opportunities for improving adherence and enhancement of practice to difficulties in terms of its administration. Pharmacists generally welcomed opportunities to utilise their professional expertise to achieve better patient engagement and for pharmacy practice to develop as a patient resource. There was a perceived need for better publicity about the service. Different levels of collaborative working were reported. Some pharmacists were working closely with local general practices most were not. Collaboration with nurses in the management of long-term conditions was rarely reported but desired by pharmacists. Where relationships with general practitioners (GPs) and nurses were established, NMS was an opportunity for further collaboration; however, others reported a lack of feedback and recognition of their role. CONCLUSIONS: Community pharmacists perceived the NMS service as beneficial to patients by providing additional advice and reassurance, but perceptions of its operationalisation were mixed. Overall, our findings indicate that NMS provides an opportunity for patient benefit and the development of contemporary pharmacy practice, but better collaboration with GPs and practice nurses could enhance the service.

Non-medical prescribing in palliative care: a regional survey.

BACKGROUND: The United Kingdom is considered to be the world leader in nurse prescribing, no other country having the same extended non-medical prescribing rights. Arguably, this growth has outpaced research to evaluate the benefits, particularly in areas of clinical practice where patients have complex co-morbid conditions such as palliative care. This is the first study of non-medical prescribing in palliative care in almost a decade. AIM: To explore the current position of nurse prescribing in palliative care and establish the impact on practice of the 2012 legislative changes. DESIGN: An online survey circulated during May and June 2013. PARTICIPANTS: Nurse members (n = 37) of a regional cancer network palliative care group (61% response rate). RESULTS: While this survey found non-medical prescribers have embraced the 2012 legislative changes and prescribe a wide range of drugs for cancer pain, we also identified scope to improve the transition from qualified to active non-medical prescriber by reducing the time interval between the two. CONCLUSION: To maximise the economic and clinical benefit of non-medical prescribing, the delay between qualifying as a prescriber and becoming an active prescriber needs to be reduced. Nurses who may be considering training to be a non-medical prescriber may be encouraged by the provision of adequate study leave and support to cover clinical work. Further research should explore the patients' perspective of non-medical prescribing.

Survey of patients' experiences and perceptions of care provided by nurse and pharmacist independent prescribers in primary care.

BACKGROUND: In the United Kingdom, nurses and pharmacists who have undertaken additional post-registration training can prescribe medicines for any medical condition within their competence (non-medical prescribers, NMPs), but little is known about patients' experiences and perceptions of this service. OBJECTIVE: to obtain feedback from primary care patients on the impact of prescribing by nurse independent prescribers (NIPs) and pharmacist independent prescribers (PIPs) on experiences of the consultation, the patient-professional relationship, access to medicines, quality of care, choice, knowledge, patient-reported adherence and control of their condition. DESIGN: Two cross-sectional postal surveys. SETTING AND PARTICIPANTS: Patients prescribed for by either NIPs or PIPs in six general practices from different regions in England. RESULTS: 30% of patients responded (294/975; 149/525 NIPs; 145/450 PIPs). Most said they were very satisfied with their last visit (94%; 87%), they were told as much as they wanted to know about their medicines (88%; 80%), and felt the independent prescriber really understood their point of view (87%; 75%). They had a good relationship with (89%; 79%) and confidence in (84%; 77%) their NMP. When comparing NMP and doctor prescribing services, most patients reported no difference in their experience of care provided, including access to it, control of condition, support for adherence, quality and safety of care. DISCUSSION AND CONCLUSIONS: Patients had positive perceptions and experience from their NMP visit. NMPs were well received, and patients' responses indicated the establishment of rapport. They did not express a strong preference for care provided by either their non-medical or medical prescriber.

An evaluation of an intervention designed to improve the evidence-based supply of non-prescription medicines from community pharmacies.

OBJECTIVES: The aims of this study were to conduct the proof of concept study and to develop and evaluate an educational intervention that promotes the evidence-based supply of non-prescription medicines (NPMs). METHOD: An educational intervention was delivered to pharmacy assistants and pharmacists in three pharmacies in England. The intervention included the provision of summaries of evidence for the treatment of four minor ailments and resulted in the preparation of evidence-based portfolios for the treatment of the following ailments: athlete's foot, cough, nasal congestion and period pain. The effect of the intervention was evaluated using a combination of direct overt observation, vignettes, self-reported behaviour and interviews. KEY FINDINGS: Evaluation data were collected from the three pharmacies. Data were derived from 3 pharmacists and 13 assistants, of whom 10 (3 pharmacists; 7 assistants) attended the training event. Comparing pre- and post-intervention practice, 8/11 (pre-) versus 5/6 (post-) observed, 46/80 versus 62/80 vignette and 25/30 versus 39/40 self-reported recommendations were evidence based. Prior to the intervention, 3/16 participants understood the role of evidence regarding the supply of NPMs compared with 16/16 post-intervention. Participants reported relying upon experiential knowledge to inform their decision making prior to the educational intervention. Thereafter, the participants reported using evidence to a greater extent. Barriers and facilitators for evidence-based practice were also identified. CONCLUSION: A one-off educational intervention increased participants' self-reported awareness and potential application of evidence to inform their supply of NPMs. Further research is needed to assess the effectiveness, long-term impact, generalisability and cost-effectiveness of this intervention for a wider range of common conditions.