What makes a multidisciplinary medication review and deprescribing intervention for older people work well in primary care? A realist review and synthesis.

BACKGROUND: A third of older people take five or more regular medications (polypharmacy). Conducting medication reviews in primary care is key to identify and reduce/ stop inappropriate medications (deprescribing). Recent recommendations for effective deprescribing include shared-decision making and a multidisciplinary approach. Our aim was to understand when, why, and how interventions for medication review and deprescribing in primary care involving multidisciplinary teams (MDTs) work (or do not work) for older people. METHODS: A realist synthesis following the Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidelines was completed. A scoping literature review informed the generation of an initial programme theory. Systematic searches of different databases were conducted, and documents screened for eligibility, with data extracted based on a Context, Mechanisms, Outcome (CMO) configuration to develop further our programme theory. Documents were appraised based on assessments of relevance and rigour. A Stakeholder consultation with 26 primary care health care professionals (HCPs), 10 patients and three informal carers was conducted to test and refine the programme theory. Data synthesis was underpinned by Normalisation Process Theory to identify key mechanisms to enhance the implementation of MDT medication review and deprescribing in primary care. FINDINGS: A total of 2821 abstracts and 175 full-text documents were assessed for eligibility, with 28 included. Analysis of documents alongside stakeholder consultation outlined 33 CMO configurations categorised under four themes: 1) HCPs roles, responsibilities and relationships; 2) HCPs training and education; 3) the format and process of the medication review 4) involvement and education of patients and informal carers. A number of key mechanisms were identified including clearly defined roles and good communication between MDT members, integration of pharmacists in the team, simulation-based training or team building training, targeting high-risk patients, using deprescribing tools and drawing on expertise of other HCPs (e.g., nurses and frailty practitioners), involving patents and carers in the process, starting with 'quick wins', offering deprescribing as 'drug holidays', and ensuring appropriate and tailored follow-up plans that allow continuity of care and management. CONCLUSION: We identified key mechanisms that could inform the design of future interventions and services that successfully embed deprescribing in primary care.

Carrying out embedded implementation research in humanitarian settings: A qualitative study in Cox's Bazar, Bangladesh.

BACKGROUND: Embedded implementation research (IR) promotes evidence-informed policy and practices by involving decision-makers and program implementers in research activities that focus on understanding and solving existing implementation challenges. Although embedded IR has been conducted in multiple settings by different organizations, there are limited experiences of embedded IR in humanitarian settings. This study highlights some of the key challenges of conducting embedded IR in a humanitarian setting based on our experience with the Rohingya refugee population in Cox's Bazar, Bangladesh. METHODS AND FINDINGS: We collected qualitative data in between January and July 2019. First, we visited Rohingya refugee camps and interviewed representatives from different humanitarian organizations. Second, we conducted interviews with researchers from BRAC University who were engaged with data collection and analysis in a broader embedded IR study on maternal, newborn, child, and adolescent health (MNCAH) program implementation challenges. Data were analyzed using a thematic analysis approach. Two researchers developed and agreed on codes and relevant themes based on the objectives of this study. The findings of this study highlight several challenges encountered while conducting embedded IR in the Rohingya emergency setting in Cox's Bazar, which may have implications for other humanitarian settings. The overall context of the camps was complex, with more than 100 organizations devoted to providing health services for approximately 1 million refugees. Despite the presence of the Bangladesh government, United Nations agencies and other international organizations played key roles in making programmatic and policy decisions for the Rohingya. Because health service delivery modalities and policies and related implementation challenges for MNCAH programs for the refugees changed rapidly, the embedded IR approach used was flexible and able to adapt to changes identified, with research questions and methods modified accordingly. Access to the camps, reaching Rohingya respondents, overcoming language barriers in order to get quality information, and the limited availability of local research collaborators were additional challenges. Working with researchers or research institutes that are familiar with the context and have experience in conducting implementation and health systems research can help with collection of quality data, identifying key stakeholders and bringing them on board to ensure the execution of the project, and ensuring utilization of the research findings. Study limitations include possible constraints in generalizing our conclusions to other humanitarian settings. Implementation research conducted in additional humanitarian settings can contribute to the evidence on this topic. CONCLUSIONS: Findings indicate that embedded IR can be done effectively in humanitarian settings if the challenges are anticipated, and appropriate strategies and in-country partners put in place to address or mitigate them, before commencing the funding or starting of the project. Understanding the context and analyzing the role of relevant stakeholders prior to conducting the research, considering a simple descriptive method appropriate to answering real-time IR questions, and working with local researchers or research institutes with specific skill sets and prior experience conducting research in humanization contexts may reduce costs and time spent, and ensure collection of quality data relevant for policy and practice.

Impact of pharmacy medicine information service advice on clinician and patient outcomes: an overview.

BACKGROUND: Pharmacy-led medicine information (MI) services are available in many countries to support clinicians and patients make decisions on use of medicines. OBJECTIVES: To establish what impact, if any, pharmacy-led MI services have on clinician and patient outcomes. METHODS: All published works indexed in Embase or PubMed, meeting this review's inclusion and exclusion criteria, that wholly or partially attempted to measure the effects of MI advice were retrieved and assessed. RESULTS: Twenty studies were reviewed. Five broad themes were identified describing study findings, three were specific to clinicians: their views on the effect MI answers had; actions they took; and influence on their decision making. A fourth theme centred on patient utilisation of advice, and the fifth on 'process measures' attempting to determine MI worth. DISCUSSION: Studies report on positive patient outcomes as a direct result of MI advice. Clinicians and patients acted upon the advice provided. Clinicians also reported using MI advice as a 'safety net', to check, reassure or confirm what to do. MI advice also demonstrated economic worth, although these studies are old. CONCLUSION: MI Service advice appears to affect clinician and patient outcomes. However, study design limitations require findings be viewed cautiously.

Transition Planning For After Polio Eradication.

The Global Polio Eradication Initiative (GPEI) has been in operation since 1988, now spends $1 billion annually, and operates through thousands of staff and millions of volunteers in dozens of countries. It has brought polio to the brink of eradication. After eradication is achieved, what should happen to the substantial assets, capabilities, and lessons of the GPEI? To answer this question, an extensive process of transition planning is underway. There is an absolute need to maintain and mainstream some of the functions, to keep the world polio-free. There is also considerable risk-and, if seized, substantial opportunity-for other health programs and priorities. And critical lessons have been learned that can be used to address other health priorities. Planning has started in the 16 countries where GPEI's footprint is the greatest and in the program's 5 core agencies. Even though poliovirus transmission has not yet been stopped globally, this planning process is gaining momentum, and some plans are taking early shape. This is a complex area of work-with difficult technical, financial, and political elements. There is no significant precedent. There is forward motion and a willingness on many sides to understand and address the risks and to explore the opportunities. Very substantial investments have been made, over 30 years, to eradicate a human pathogen from the world for the second time ever. Transition planning represents a serious intent to responsibly bring the world's largest global health effort to a close and to protect and build upon the investment in this effort, where appropriate, to benefit other national and global priorities. Further detailed technical work is now needed, supported by broad and engaged debate, for this undertaking to achieve its full potential.

Oversight role of the Independent Monitoring Board of the Global Polio Eradication Initiative.

The Global Polio Eradication Initiative (GPEI) established its Independent Monitoring Board (IMB) in 2010 to monitor and guide its progress toward stopping polio transmission globally. The concept of an IMB is innovative, with no clear analogue in the history of the GPEI or in any other global health program. The IMB meets with senior program officials every 3-6 months. Its reports provide analysis and recommendations about individual polio-affected countries. The IMB also examines issues affecting the global program as a whole. Its areas of focus have included escalating the level of priority afforded to polio eradication (particularly by recommending a World Health Assembly resolution to declare polio eradication a programmatic emergency, which was enacted in May 2012), placing greater emphasis on people factors in the delivery of the program, encouraging innovation, strengthening focus on the small number of so-called sanctuaries where polio persists, and continuous quality improvement to reach every missed child with vaccination. The IMB's true independence from the agencies and countries delivering the program has enabled it to raise difficult issues that others cannot. Other global health programs might benefit from establishing similar independent monitoring mechanisms.

Qualitative exploration of the relationship between HIV/AIDS patients' experiences of clinical services and treatment adherence at Maitama District Hospital, Abuja, Nigeria.

Nigeria has the third largest number of patients worldwide living with HIV/AIDs, and the Nigerian government has set ambitious targets to slow, halt and potentially reverse this number over the coming years. Clinical service provision has increased to meet this challenge, and yet it is unknown how services may affect patient anti-retroviral therapy (ART) adherence. The aim of this study was to learn from patients what factors influence their adherence, and how services could be changed to facilitate adherence. In-depth interviews were conducted with 35 HIV patients attending Maitama District Hospital in Abuja and supplemented with shadowing observations of additional 10 patients during their clinic day appointment. Faith, stigma and discrimination and the hospital care patients received all influenced their thinking in relation to ART. Faith was expressed not only through their religious beliefs but also in the effectiveness of ART. They feared disclosure, even to close family, due to the stigma associated with HIV, and the threat of discrimination. They felt that the hospital service was under-resourced to cope with the volume of patients which led to delays on clinic day, including limited ART availability. This necessitated repeated hospital visits, thus increasing the chance of their status being revealed to third parties. Shadowing confirmed lengthy procedural delays in the hospital systems.

Facilitating self-care through community pharmacy in England.

In England, almost all the population are within a short walk of a community pharmacy. This network of pharmacies provides a range of services, most of which are commissioned and remunerated through a nationally agreed contract with the National Health Service (NHS). Over time this contract has seen funding move from the traditional core service of dispensing medicines, toward patient-facing clinical services. All of these services have elements of self-care built in to the service specification, which pharmacists are mandated to deliver. These services significantly expand the role of the community pharmacist beyond facilitating self-care by supplying "over the counter" (OTC) medication. The increased public health role, where promotion of healthy living and prevention of disease is now seen as an essential activity by and for pharmacists. Changes to UK health policy, where the focus has been on delivering care closer to the patients' home, means community pharmacists have an increasing role in the effective management of acute and long-term conditions. The most recent contract afforded to pharmacy has now started to integrate pharmacy services with medical services, in both primary and secondary care, in attempt to provide greater continuity for the patient. It is very likely that self-care activities provided by community pharmacy will expand further, especially around the management of long-term conditions as the pharmacy workforce transitions in to having prescribing rights for medicines other than non-prescription medicines.

Non-pharmacological interventions for the reduction and maintenance of blood pressure in people with prehypertension: a systematic review protocol.

INTRODUCTION: Prehypertension is defined as blood pressure that is above the normal range but not high enough to be classed as hypertension. Prehypertension is a warning of development of hypertension as well as a risk for cardiovascular disease, heart attack and stroke. In the UK, non-pharmacological interventions are recommended for prehypertension management but no reviews have focused on the effectiveness of these types of interventions solely in people with prehypertension. Therefore, the proposed systematic review will assess the clinical effectiveness and cost-effectiveness of non-pharmacological interventions in reducing or maintaining blood pressure in prehypertensive people. METHODS AND ANALYSIS: This systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The databases/trial registries that will be searched to identify relevant randomised controlled trials (RCTs) and economic evaluations include Medline, EMBASE, CINAHL, PsycINFO, CENTRAL, the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, Cochrane Library, Scopus and the International HTA Database. Search terms have been identified by the team including an information specialist. Three reviewers will be involved in the study selection process. Risk of bias will be evaluated using the Cochrane risk-of-bias tool for RCTs and the Consensus Health Economic Criteria list for economic evaluations. Findings from the included studies will be tabulated and synthesised narratively. Heterogeneity will be assessed through visual inspection of forest plots and the calculation of the χ2 and I2 statistics and causes of heterogeneity will be assessed where sufficient data are available. If possible, we plan to investigate differential effects on specific subgroups and from different types of interventions using meta-regression. Where relevant, the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) will be used to assess the certainty of the evidence found. ETHICS AND DISSEMINATION: Ethical approval is not needed. Results will be published in a peer-reviewed journal, disseminated via the wider study website and shared with the study sites and participants. REGISTRATION DETAILS: The review is registered with PROSPERO (CRD420232433047).

Fidelity to and utility of a home blood pressure self-monitoring regime in people with pre-hypertension: results from the REVERSE study.

INTRODUCTION: Around 40% of adults have pre-hypertension (120-139/80-89mmHg) increasing their risk of developing hypertension and associated cardiovascular conditions. Guidance on pre-hypertension management focuses on improving lifestyle. Self-monitoring may improve awareness and understanding of blood pressure (BP) for people with pre-hypertension, allowing them to modify their lifestyle risks. AIM: To determine the fidelity to and utility of a home BP self-monitoring regime in people with pre-hypertension. METHOD: This sub-study is part of a larger prospective, non-randomised feasibility study. Individuals with pre-hypertension were identified via GP records and pharmacy NHS Health Checks in Northwest England. Participants received training for home BP self-monitoring. They were asked to complete two readings (leaving a 5-minute interval) on the first three days of the month for six months, colour-code their readings and take action using a simple algorithm, then send them to the research team within 7 days. RESULTS: Eighty participants (aged 40-79, mean=59) enrolled. The majority were female (n=45, 56%), White British (n=79, 99%), and had not previously monitored their BP (n=55, 69%). Seventy-five (94%) participants completed the training. Sixty-one (81%) received online training and 14 (19%) opted for a face-to-face session. Sixty-one (81%) completed all six months of readings, 51 (68%) also returned them on time. All in-person training participants completed all six months of readings on time. Reasons for non-compliance to the protocol included battery issues, forgetting, and struggling to find a consistent time for readings. CONCLUSION: Home BP self-monitoring can be feasible and easily implementable for people with pre-hypertension - however, some barriers were identified.

Strengthening the evidence-policy interface for patient safety: enhancing global health through hospital partnerships.

Strengthening the evidence-policy interface is a well-recognized health system challenge in both the developed and developing world. Brokerage inherent in hospital-to-hospital partnerships can boost relationships between "evidence" and "policy" communities and move developing countries towards evidence based patient safety policy. In particular, we use the experience of a global hospital partnership programme focused on patient safety in the African Region to explore how hospital partnerships can be instrumental in advancing responsive decision-making, and the translation of patient safety evidence into health policy and planning. A co-developed approach to evidence-policy strengthening with seven components is described, with reflections from early implementation. This rapidly expanding field of enquiry is ripe for shared learning across continents, in keeping with the principles and spirit of health systems development in a globalized world.

Automated search methods for identifying wrong patient order entry-a scoping review.

Objective: To investigate: (1) what automated search methods are used to identify wrong-patient order entry (WPOE), (2) what data are being captured and how they are being used, (3) the causes of WPOE, and (4) how providers identify their own errors. Materials and Methods: A systematic scoping review of the empirical literature was performed using the databases CINAHL, Embase, and MEDLINE, covering the period from database inception until 2021. Search terms were related to the use of automated searches for WPOE when using an electronic prescribing system. Data were extracted and thematic analysis was performed to identify patterns or themes within the data. Results: Fifteen papers were included in the review. Several automated search methods were identified, with the retract-and-reorder (RAR) method and the Void Alert Tool (VAT) the most prevalent. Included studies used automated search methods to identify background error rates in isolation, or in the context of an intervention. Risk factors for WPOE were identified, with technological factors and interruptions deemed the biggest risks. Minimal data on how providers identify their own errors were identified. Discussion: RAR is the most widely used method to identify WPOE, with a good positive predictive value (PPV) of 76.2%. However, it will not currently identify other error types. The VAT is nonspecific for WPOE, with a mean PPV of 78%-93.1%, but the voiding reason accuracy varies considerably. Conclusion: Automated search methods are powerful tools to identify WPOE that would otherwise go unnoticed. Further research is required around self-identification of errors.

Risk reduction intervention for raised blood pressure (REVERSE): protocol for a mixed-methods feasibility study.

INTRODUCTION: Around 40% of adults have pre-hypertension (blood pressure between 120-139/80-89), meaning they are at increased risk of developing hypertension and other cardiovascular disease-related conditions. There are limited studies on the management of pre-hypertension; however, guidance recommends that it should be focused on lifestyle modification rather than on medication. Self-monitoring of blood pressure could allow people to monitor and manage their risk status and may allow individuals to modify lifestyle factors. The purpose of this study is to determine the feasibility and acceptability, to both healthcare professionals and people with pre-hypertension, of blood pressure self-monitoring. METHODS AND ANALYSIS: A prospective, non-randomised feasibility study, with a mixed-methods approach will be employed. Eligible participants (n=114) will be recruited from general practices, pharmacies and community providers across Lancashire and South Cumbria. Participants will self-monitor their blood pressure at home for 6 months and will complete questionnaires at three timepoints (baseline, 6 and 12 months). Healthcare professionals and participants involved in the study will be invited to take part in follow-up interviews and a focus group. The primary outcomes include the willingness to engage with the concept of pre-hypertension, the acceptability of self-monitoring, and the study processes. Secondary outcomes will inform the design of a potential future trial. A cost-analysis and cost-benefit analysis will be conducted. ETHICS AND DISSEMINATION: Ethics approval has been obtained from London-Fulham NHS Research Ethics Committee, the University of Central Lancashire Health Ethics Review Panel and the HRA. The results of the study will be disseminated via peer-reviewed publications, feedback to service users and healthcare professionals, and to professional bodies in primary care and pharmacy. TRIAL REGISTRATION NUMBER: ISRCTN13649483.

Assessing the hidden burden and costs of COVID-19 pandemic in South Asia: Implications for health and well-being of women, children and adolescents.

The COVID-19 pandemic has disproportionately affected vulnerable populations. With its intensity expected to be cyclical over the foreseeable future, and much of the impact estimates still modeled, it is imperative that we accurately assess the impact to date, to help with the process of targeted rebuilding of services. We collected data from administrative health information systems in six South Asian countries (Afghanistan, Bangladesh, Nepal, India, Pakistan and Sri Lanka), to determine essential health services coverage disruptions between January-December 2020, and January-June 2021, compared to the same calendar months in 2019, and estimated the impact of this disruption on maternal and child mortality using the Lives Saved Tool. We also modelled impact of prolonged school closures on continued enrollment, as well as potential sequelae for the cohort of girls who have likely dropped out. Coverage of key maternal and child health interventions, including antenatal care and immunizations, decreased by up to 60%, with the largest disruptions observed between April and June 2020. This was followed by a period of recovery from July 2020 to March 2021, but a reversal of most of these gains in April/May 2021, likely due to the delta variant-fueled surge in South Asia at the same time. We estimated that disruption of essential health services between January 2020 and June 2021 potentially resulted in an additional 19,000 maternal and 317,000 child deaths, an increase of 19% and 13% respectively, compared to 2019. Extended school closures likely resulted in 9 million adolescents dropping out permanently, with 40% likely being from poorest households, resulting in decreased lifetime earnings. A projected increase in early marriages for girls who dropped out could result in an additional 500,000 adolescent pregnancies, 153,000 low birthweight births, and 27,000 additional children becoming stunted by age two years. To date, the increase in maternal and child mortality due to health services disruption has likely exceeded the overall number of COVID-19 deaths in South Asia. The indirect effects of the pandemic were disproportionately borne by the most vulnerable populations, and effects are likely to be long-lasting, permanent and in some cases inter-generational, unless policies aimed at alleviating these impacts are instituted at scale and targeted to reach the poorest of the poor. There are also implications for future pandemic preparedness.

Developed-developing country partnerships: benefits to developed countries?

Developing countries can generate effective solutions for today's global health challenges. This paper reviews relevant literature to construct the case for international cooperation, and in particular, developed-developing country partnerships. Standard database and web-based searches were conducted for publications in English between 1990 and 2010. Studies containing full or partial data relating to international cooperation between developed and developing countries were retained for further analysis. Of 227 articles retained through initial screening, 65 were included in the final analysis. The results were two-fold: some articles pointed to intangible benefits accrued by developed country partners, but the majority of information pointed to developing country innovations that can potentially inform health systems in developed countries. This information spanned all six WHO health system components. Ten key health areas where developed countries have the most to learn from the developing world were identified and include, rural health service delivery; skills substitution; decentralisation of management; creative problem-solving; education in communicable disease control; innovation in mobile phone use; low technology simulation training; local product manufacture; health financing; and social entrepreneurship. While there are no guarantees that innovations from developing country experiences can effectively transfer to developed countries, combined developed-developing country learning processes can potentially generate effective solutions for global health systems. However, the global pool of knowledge in this area is virgin and further work needs to be undertaken to advance understanding of health innovation diffusion. Even more urgently, a standardized method for reporting partnership benefits is needed--this is perhaps the single most immediate need in planning for, and realizing, the full potential of international cooperation between developed and developing countries.

Over-the-counter medicines: their place in self-care.

Over the last 20 years, there has been a shift in Western countries' healthcare policy to empower patients to exercise self-care by taking greater control in managing their own health, especially in cases where their conditions are deemed minor and self-limiting. In the UK, this has been facilitated by the Department of Health in making more medicines available to the public without the need for a prescription. This article highlights how policy is affecting practice, what attitudes the public and health professionals have toward greater medicine availability, and considers their place in patient management.

Price versus clinical guidelines in primary care statin prescribing: a retrospective cohort study and cost simulation model.

OBJECTIVE: To investigate the relative impact of generic entry and National Institute for Health and Care Excellence clinical guidelines on prescribing using statins as an exemplar. DESIGN: Retrospective analysis of statin prescribing in primary care and cost simulation model. SETTING: Royal College of General Practitioners Research and Surveillance Centre (RCGP R&SC) database and Prescription Cost Analysis (PCA) database. PARTICIPANTS: New patients prescribed statins for the first time between July 2003 and September 2018. MAIN OUTCOME MEASURES: Shares of new patients prescribed one of the five statins available in the British National Formulary, and cost of prescribing statins to new and existing patients in primary care in England. RESULTS: General trends of statin' prescriptions were largely driven by a decrease in acquisition costs triggered by patent expiration, preceding NICE guidelines which themselves did not seem to affect prescription trends. Significant heterogeneity is observed in the prescription of the most cost-effective statin acrossGPs. A cost simulation shows that, between 2004 and 2018, the NHS could have saved £2.8bn (around 40% of the £6.3bn spent on statins during this time) if all GP practices had prescribed only the most cost-effective treatment. CONCLUSIONS: There is potential for large savings for the NHS if new and, whenever possible, ongoing patients are promptly switched to the first medicine that becomes available as generic within a therapeutic class as long as it has similar efficacy to still-patented medicines.

Preventing erosion of oral polio vaccine acceptance: A role for vaccinator visits and social norms.

BACKGROUND: With continued challenges to the timeline for polio transmission interruption in Pakistan, including COVID-19, there is a risk of oral polio vaccine campaign fatigue among caregivers of young children. Renewed efforts to minimize oral polio vaccine acceptance erosion may be needed. This study examines the possible role of social norms in protecting against acceptance erosion and the role of vaccinators in promoting these social norms. METHODS: Data were analyzed from a poll conducted by local interview teams between February 23 and April 5, 2016, among 4,070 parents and other caregivers of children under age 5 living in areas at high-risk for polio transmission in Pakistan. The sample was drawn via a stratified multistage cluster design utilizing random route methods at the household level. We calculated the prevalence of subjective and descriptive social norms around vaccine acceptance; vaccine acceptance and commitment to vaccinate in future; and experiences and views of polio vaccinators across the population. We examined the relationship between these social norms and vaccination behaviors as well as the relationship between experiences with and views of vaccinators and social norms using uncontrolled comparisons (t-tests of proportion) and logistic repressions to control for demographics. RESULTS: Both descriptive and subjective positive social norms were associated with vaccine acceptance and future commitment. Positive experiences with and views of vaccinators (trust, perceived technical knowledge, compassion, and overall pleasantness of the interaction) were associated with both descriptive and subjective positive social norms. CONCLUSIONS: These data support the idea that positive social norms could be protective against erosion of oral polio vaccine acceptance and that positive experiences with, and views of, vaccinators could help promote these positive social norms. Creative community engagement efforts may be able to leverage positive experiences with vaccinators to help foster social norms and protect against the risk of acceptance erosion.

Persistently normal blood tests in patients taking methotrexate for RA or azathioprine for IBD: a retrospective cohort study.

BACKGROUND: Disease-modifying anti-rheumatic drugs (DMARDs), including methotrexate and azathioprine, are commonly used to treat rheumatoid arthritis (RA) and inflammatory bowel disease (IBD). Blood-test safety monitoring is mainly undertaken in primary care. Normal blood results are common. AIM: To determine the frequency and associations of persistently normal blood tests in patients with RA prescribed methotrexate, and patients with IBD prescribed azathioprine. DESIGN AND SETTING: Two-year retrospective study of a cohort taken from an electronic pseudonymised primary care/laboratory database covering >1.4 million patients across Hampshire, UK. METHOD: Patients with RA and IBD, and associated methotrexate and azathioprine prescriptions, respectively, were identified. Tests and test thresholds recommended by the National Institute for Health and Care Excellence were applied. Persistent normality was defined as no abnormalities of any tests nor alanine aminotransferase (ALT), white blood count (WBC), neutrophils, and estimated glomerular filtration rate (eGFR) individually. Logistic regression was used to identify associations with test normality. RESULTS: Of 702 265 adults, 7102 had RA and 8597 had IBD. In total, 3001 (42.3%) patients with RA were prescribed methotrexate and 1162 (13.5%) patients with IBD were prescribed azathioprine; persistently normal tests occurred in 1585 (52.8%) and 657 (56.5%) of the populations, respectively. In patients with RA on methotrexate, 585 (19.5%) had eGFR, 219 (7.3%) ALT, 217 (7.2%) WBC, and 202 (6.7%) neutrophil abnormalities. In patients with IBD on azathioprine, 138 (11.9%) had WBC, 88 (7.6%) eGFR, 72 (6.2%) ALT, and 65 (5.6%) neutrophil abnormalities. Those least likely to have persistent test normality were older and/or had comorbidities. CONCLUSION: Persistent test normality is common when monitoring these DMARDs, with few hepatic or haematological abnormalities. More stratified monitoring approaches should be explored.

Characterising risk of non-steroidal anti-inflammatory drug-related acute kidney injury: a retrospective cohort study.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for pain and inflammation. NSAID complications include acute kidney injury (AKI), causing burden to patients and health services through increased morbidity, mortality, and hospital admissions. AIM: To measure the extent of NSAID prescribing in an adult population, the degree to which patients with potential higher risk of AKI were exposed to NSAIDs, and to quantify their risk of AKI. DESIGN & SETTING: Retrospective 2-year closed-cohort study. METHOD: A retrospective cohort of adults was identified from a pseudonymised electronic primary care database in Hampshire, UK. The cohort had clinical information, prescribing data, and complete GP- and hospital-ordered biochemistry data. NSAID exposure (minimum one prescription in a 2-month period) was categorised as never, intermittent, and continuous, and first AKI using the national AKI e-alert algorithm. Descriptive statistics and logistic regression were used to explore NSAID prescribing patterns and AKI risk. RESULTS: The baseline population was 702 265. NSAID prescription fell from 19 364 (2.8%) to 16 251 (2.4%) over 2 years. NSAID prescribing was positively associated with older age, female sex, greater socioeconomic deprivation, and certain comorbidities (diabetes, hypertension, osteoarthritis, and rheumatoid arthritis) and negatively with cardiovascular disease (CVD) and heart failure. Among those prescribed NSAIDs, AKI was associated with older age, greater deprivation, chronic kidney disease (CKD), CVD, heart failure, diabetes, and hypertension. CONCLUSION: Despite generally good prescribing practice, NSAID prescribing was identified in some people at higher risk of AKI (for example, patients with CKD and older) for whom medication review and NSAID deprescribing should be considered.

The Wessex Dementia Friendly Pharmacy Framework.

OBJECTIVES: To develop and launch a dementia friendly framework for community pharmacies in the Wessex region of England. METHODS: A framework consisting of essential (mandatory) and additional (non-mandatory) criteria were devised by local stakeholders and external scrutiny from the Alzheimer's Society. The framework was designed to allow pharmacy teams to achieve essential criteria without the need for approval by others (e.g. authorisation from internal company management structures). In total, 38 essential criteria across seven domains were devised. All essential criteria had to be met for pharmacies to be awarded dementia friendly status. Engagement events were organised to launch the framework detailing what it was and how pharmacies could meet each criterion. Pharmacies self-certified compliance with the framework criteria via an online platform, and validation activity was subsequently undertaken to see if pharmacies had appropriately self-certified against all essential criteria. KEY FINDINGS: Three hundred and fifty-five pharmacies (n = 504, 70%) engaged with the initiative, of which 330 uploaded self-certifications met all essential criteria of the framework. Validation visits showed self-certification to be appropriate in all but one visit (n = 11/12). Staff comments revealed that engaging with the framework had allowed them to be more aware of how better to support people with dementia. CONCLUSIONS: A dementia friendly framework was devised and implemented with a subsequent high level of uptake by community pharmacy.