A Pharmacist Clinician Model as part of a collaborative clinical workforce: A philosophical critique.

The term 'clinician' is not reserved for any healthcare professional group. However, there is a general acceptance that a clinician would have the knowledge, skills and behaviours to enable them to clinically assess and manage a patient autonomously. The expectation, in a modern collaborative healthcare system, is that this work would be completed as a part of a planned and integrated multi-disciplinary care delivery structure, where any given clinician delivers a devolved element of that patient's care. Forthcoming changes to regulation and professional development pathways in the UK will have a profound impact on pharmacist professional identity and practice. From 2026, all new UK pharmacist registrants will have full independent prescribing rights. A paradigm shift is expected to enable the development of a Pharmacist Clinician Model, incorporating pharmaceutical care needs with wider clinical assessment, diagnostic, and clinical management responsibilities. Consideration is given to this model and its implications. Changes to regulation, policy, education, and the governance required to deliver safe and effective pharmacist clinicians are outlined. A philosophical critique on the nature of being a clinician, and the differentiation of pharmacist clinician roles compared to other healthcare professions, is given. A further examination of the projected risks and expected benefits of this transformative practice model are then explored.

Patterns of initial and first-intensifying antidiabetic drug utilization among patients with type 2 diabetes mellitus in Scotland, 2010-2020: A retrospective population-based cohort study.

AIM: To evaluate the utilization and prescribing patterns of antidiabetic drugs (ADDs) for patients with type 2 diabetes mellitus (T2DM) at treatment initiation and first intensification. METHODS: A retrospective cohort study was performed using linked routinely collected data of patients with T2DM who received ADDs between January 2010 and December 2020 in Scotland. The prescribing patterns were quantified using frequency/percentages, absolute/relative change, and trend tests. RESULTS: Overall, 145 909 new ADD users were identified, with approximately 91% (N = 132 382) of patients receiving a single ADD at first treatment initiation. Metformin was the most often prescribed monotherapy (N = 118 737, 89.69%). A total of 50 731 patients (39.40%) who were started on metformin (N = 46 730/118 737, 39.36%) or sulphonylurea (SU; N = 4001/10 029, 39.89%) monotherapy had their treatment intensified with one or more additional ADD. Most initial-metformin (45 963/46 730; 98.36%) and initial-SU users (3894/4001; 97.33%) who added further drugs were intensified with single ADDs. SUs (22 197/45 963; 48.29%) were the most common first-intensifying monotherapy after initial metformin use, but these were replaced by sodium-glucose cotransporter-2 (SGLT2) inhibitors in 2019 (SGLT2 inhibitors: 2039/6065, 33.62% vs. SUs: 1924/6065, 31.72%). Metformin was the most frequently added monotherapy to initial SU use (2924/3894, 75.09%). Although the majority of patients received a single ADD, the use of combination therapy significantly increased over time. Nevertheless, there was a significant increasing trend towards prescribing the newer ADD classes (SGLT2 inhibitors, dipeptidyl peptidase-4 inhibitors) as monotherapy or in combination compared with the older ones (SUs, insulin, thiazolidinediones) at both drug initiation and first intensification. CONCLUSIONS: An overall increasing trend in prescribing the newer ADD classes compared to older ADDs was observed. However, metformin remained the most commonly prescribed first-line ADD, while SGLT2 inhibitors replaced SUs as the most common add-on therapy to initial metformin use in 2019.

Meta-analysis of factors associated with antidiabetic drug prescribing for type 2 diabetes mellitus.

BACKGROUND: There is a lack of consensus on prescribing alternatives to initial metformin therapy and intensification therapy for type 2 diabetes mellitus (T2DM) management. This review aimed to identify/quantify factors associated with prescribing of specific antidiabetic drug classes for T2DM. METHODS: Five databases (Medline/PubMed, Embase, Scopus, Web of Science) were searched using the synonyms of each concept (patients with T2DM, antidiabetic drugs and factors influencing prescribing) in both free text and Medical Subject Heading (MeSH) forms. Quantitative observational studies evaluating factors associated with antidiabetic prescribing of metformin, sulfonylurea, thiazolidinedione, Dipeptidyl-peptidase 4 inhibitors (DPP4-I), sodium glucose transporter 2 inhibitors (SGLT2-I), Glucagon-Like peptide receptor agonist (GLP1-RA) and insulin in outpatient settings and published from January 2009 to January 2021 were included. Quality assessment was performed using a Newcastle-Ottawa scale. The validation was done for 20% of identified studies. The pooled estimate was measured using a three-level random-effect meta-analysis model based on odds ratio [95% confidence interval]. Age, sex, body mass index (BMI), glycaemic control (HbA1c) and kidney-related problems were quantified. RESULTS: Of 2331 identified studies, 40 met the selection criteria. Of which, 36 and 31 studies included sex and age, respectively, while 20 studies examined baseline BMI, HbA1c and kidney-related problems. The majority of studies (77.5%, 31/40) were rated as good and despite that the overall heterogeneity for each studied factor was more than 75%, it is mostly related to within-study variance. Older age was significantly associated with higher sulfonylurea prescription (1.51 [1.29-1.76]), yet lower prescribing of metformin (0.70 [0.60-0.82]), SGLT2-I (0.57 [0.42-0.79]) and GLP1-RA (0.52 [0.40-0.69]); while higher baseline BMI showed opposite significant results (sulfonylurea: 0.76 [0.62-0.93], metformin: 1.22 [1.08-1.37], SGLT2-I: 1.88 [1.33-2.68], and GLP1-RA: 2.35 [1.54-3.59]). Both higher baseline HbA1c and having kidney-related problems were significantly associated with lower metformin prescription (0.74 [0.57-0.97], 0.39 [0.25-0.61]), but more insulin prescriptions (2.41 [1.87-3.10], 1.52 [1.10-2.10]). Also, DPP4-I prescriptions were higher for patients with kidney-related problems (1.37 [1.06-1.79]) yet lower among patients with higher HbA1c (0.82 [0.68-0.99]). Sex was significantly associated with GLP1-RA and thiazolidinedione prescribing (F:M; 1.38 [1.19-1.60] and 0.91 [0.84-0.98]). CONCLUSION: Several factors were identified as potential determinants of antidiabetic drug prescribing. The magnitude and significance of each factor differed by antidiabetic class. Patient's age and baseline BMI had the most significant association with the choice of four out of the seven studied antidiabetic drugs followed by the baseline HbA1c and kidney-related problems which had an impact on three studied antidiabetic drugs, whereas sex had the least impact on prescribing decision as it was associated with GLP1-RA and thiazolidinedione only.

Using the theoretical domains framework to explore behavioural determinants for medication taking in patients following percutaneous coronary intervention.

OBJECTIVES: To investigate relationships between factors influencing medication taking and behavioural determinants in patients who have undergone percutaneous coronary intervention (PCI). METHODS: A cross-sectional survey using a postal questionnaire distributed to PCI patients. The questionnaire was iteratively developed by the research team with reference to the theoretical domains framework (TDF) of behavioural determinants, reviewed for face and content validity and piloted. Data were analysed using descriptive and principal component analysis (PCA). Inferential analysis explored relationships between PCA component scores and factors influencing medicating taking behaviour. KEY FINDINGS: Adjusted response rate was 62.4% (325/521). PCA gave three components: (C1) Self-perceptions of knowledge and abilities in relation to medication taking; (C2) Aspects relating to activities and support in medication taking; (C3) Emotional aspects in taking medication. Generally, respondents held very positive views. Statistically significant relationships between all three components and self-reported chest pain/discomfort indicated patients with ongoing chest pain/discomfort post-PCI are more likely to have behavioural determinants and beliefs which make medication taking challenging. Respondents who were on 10 or more medications had lower levels of agreement with the C2 and C3 statements indicating challenges associated with their activities/support and anxieties in medication taking. CONCLUSIONS: PCI patients show links between TDF behavioural determinants and factors influencing medication taking for those reporting chest pain or polypharmacy. Further research needs to explore the effective design and implementation of behavioural change interventions to reduce the challenge of medication taking.

The Collaborative Care Model: Realizing healthcare values and increasing responsiveness in the pharmacy workforce.

Healthcare values are fairly ubiquitous across the globe, focusing on caring and respect, patient health, excellence in care delivery, and multi-stakeholder collaboration. Many individual pharmacists embrace these core values. However, their ability to honor these values is significantly determined by the nature of the system in which they work. The paper starts by presenting the prevailing pharmacist workforce model, the 'Atomistic' Model, in Scotland, in which core roles are typically separated into hierarchically disaggregated jobs focused on one professional 'pillar': Clinician/Practice Provider; Educator; Leader/Manager; and Researcher. This skills-segregation yields a workforce of individuals working in isolation rather than collaborating, lacking a shared purpose. Key strategic flaws include suboptimal responsiveness to population needs, inconsistency/inequity of care, erosion of professional agency, and lower job satisfaction. It is conjectured that this results from a lack of congruence between values, professional ethos, and organizational structure. 'Atomism' culminates in a syndrome of widespread professional-level cognitive dissonance. The paper contrasts this with an emerging workforce vision, the Collaborative Care Model. This new model defines a systems-first-approach, built on the principle that all jobs must include all four professional 'pillars'. Vertical skills integration, involving education and task sharing, supports sustainability and succession planning. Horizontal skills integration (across practice, leadership/management, education, and research) is included to improve responsiveness to population need and individual professional agency. The working conditions, supportive ethos, and career structure needed to make the model work are described. Moral and workforce theory are used to justify why the model may be more effective for population health, delivering greater job satisfaction for individuals and ultimately helping systematically realize healthcare values. Finally, the paper sketches the first steps needed to implement the model at the national level, starting with the operationalization of new multi-'pillar' professional curricula across the career spectrum. Potential challenges also are discussed.

General practice pharmacists' implementation of advanced clinical assessment skills: a qualitative study of behavioural determinants.

BACKGROUND: The role of General Practice Clinical Pharmacists is becoming more clinically complex. Some are undertaking courses to develop their skillsets. AIM: To explore potential behavioural determinants influencing the implementation of skills gained from Advanced Clinical Examination and Assessment courses by General Practice Clinical Pharmacists. METHOD: This study used a qualitative methodology with theoretical underpinning. General Practice Clinical Pharmacists in the Scottish National Health Service, having completed an Advanced Clinical Examination and Assessment course, were invited for online dyadic (paired) interviews. Informed written consent was obtained. The interview schedule was developed using the Theoretical Domains Framework and piloted. Interviews were recorded, transcribed verbatim and analysed using a framework analysis. Ethics approval was obtained. RESULTS: Seven dyadic interviews were conducted. These included fourteen pharmacist participants from eight Health Boards. Three main themes were identified: 1. Factors influencing implementation of advanced clinical skills by pharmacists; 2. Social and environmental influences affecting opportunities for pharmacists in advanced clinical roles; 3. Perceptions of pharmacist professional identity for advanced practice roles. Nine sub-themes provided a depth of insight including; participants reporting courses allowed clinically autonomous practice; participants shared frustration around social and environmental factors limiting implementation opportunities; participants expressed a need for clarification of professional identify/roles within current contractual mechanisms to allow them to fully implement the skills gained. CONCLUSION: This work identified numerous behavioural determinants related to implementation of advanced clinical skills by pharmacists in general practice. Policy, and review of implementation strategies are urgently required to best utilise pharmacists with these skills.

Pharmacy and medical student interprofessional education placement week.

BACKGROUND: Developing collaborative practice through interprofessional education (IPE) activities in undergraduate healthcare curricula is advocated by the World Health Organisation and the regulatory bodies for Medicine and Pharmacy within the UK. APPROACH: Our local faculty, comprising educators from within the Highland Pharmacy Education and Research Centre (HPERC) and Highland Medical Education Centre (HMEC), developed a 5-day IPE placement for pharmacy and medical students on clinical placement within NHS Highland. EVALUATION: We collected qualitative evaluation data using face-to-face focus group discussions with five pharmacy and four medical students (January 2020 cohort). Three key categories and multiple themes within each category were identified from participant narratives: Category 1, overall perception of experience-(themes: better than previous IPE experience; greater exposure to clinical pharmacy); Category 2, student interactions-(themes: learning with a buddy; understanding of interprofessional roles); Category 3, suggestions for improvement-(themes: choice of relevant clinical rotation and content; increase learning from clinical pharmacists; better orientation to placement). Overall, students valued their participation during this week and reported many benefits of learning with students from another profession. Students also highlighted suggestions to improve their learning experience. IMPLICATIONS: This evaluation has indicated students' support for embedding interprofessional placements into their curricula. Clinical educators should consider designing similar placements, while further work should focus on inclusion of higher student numbers and look to include a range of professions and practice settings.

Advanced pharmacist practice: where is the United Kingdom in pursuit of this 'Brave New World'?

Pharmacy has developed many novel patient-facing roles across the globe, typically delivered through the lens of pharmaceutical care. The macro-level implementation of such interventions is, however, fraught with difficulty. At an individual-level, psychological barriers of pharmacists and their ability to deliver autonomous complex clinical care are key considerations. As the United Kingdom imminently plans to launch a new advanced pharmacist practice curriculum and credentialing process to support advanced skills development, this commentary discusses where progress to date has taken us and what other developmental, environmental and cultural changes are needed to support this. The commentary also challenges some of pharmacy's historic dogma, discusses a requirement for teaching to transcend simplistic concepts of medicines-harm, considers the need for the standardisation of clinical skills and discusses the necessity of formal advanced practice programmes and preceptorship models. It finally proposes the concept of Advanced Pharmacist Practitioners as the ultimate future vision of autonomous practice and the need for Government Policy to support their creation.

External Loop Recorders: Primary Care Placement Is Noninferior to Hospital-Based Cardiac Unit.

Introduction: External loop recorders (ELRs) are recommended for the investigation of syncope and palpitations. This study aimed to compare rates of arrhythmia detection between primary care (PC) and hospital-based cardiac unit (HBCU) fitted ELRs. Methods: Data were captured from January to December 2015. Twenty-eight general practitioner practices and 1 hospital took part. Patients were divided into those with ELR fitted in PC or HBCU. All ELR data were analyzed by a cardiac physiologist. Results: A total of 560 ELR recordings were analyzed; 219 (PC) versus 341 (HBCU). There was no difference between the baseline characteristics (all Ps > .05). The predominant indication for ELR in each group were palpitations; between-group variation was observed for syncope (P = .0004). There were no significant between-group differences in the number of recordings per patient; however, PC group wore the ELR for less time (median 7 days vs median 14 days; P < .0001). There were no differences in arrhythmia detection between PC- and HBCU-fitted ELRs (16.2% [n = 39] vs 21.7% [n = 74], respectively; P = .28). PC placement of ELRs was highest in very remote rural communities (P = .005) and correlated with distance from HBCU (r = 0.39; P = .04). Conclusions: This study showed no difference in detection of arrhythmias between PC and HBCU fitted ELRs. This suggests adequate ELR recording can be completed by suitably trained staff in PC. Furthermore, ELRs were fitted for less time in PC without an adverse effect on diagnostic yield. ELR usage increased with increasing distance from the specialist center and rurality suggesting improved local access to arrhythmia detection services.

Prescribers' perceptions of benefits and limitations of direct acting oral anticoagulants in non-valvular atrial fibrillation.

BACKGROUND: There is an acknowledged lack of robust and rigorous research focusing on the perspectives of those prescribing direct acting oral anticoagulants (DOACs) for non-valvular atrial fibrillation (AF). OBJECTIVE: The objective was to describe prescribers' experiences of using DOACs in the management of non-valvular AF, including perceptions of benefits and limitations. METHODS: A cross-sectional survey of prescribers in a remote and rural area of Scotland. Among other items, the questionnaire invited free-text description of positive and negative experiences of DOACs, and benefits and limitations. Responses were independently analysed by two researchers using a summative content analysis approach. This involved counting and comparison, via keywords and content, followed by interpretation and coding of the underlying context into themes. RESULTS: One hundred and fifty-four responses were received, 120 (77.9%) from physicians, 18 (11.7%) from nurse prescribers and 10 (6.4%) from pharmacist prescribers (6 unidentified professions). Not having to monitor INR was the most cited benefit, particularly for prescribers and patients in remote and rural settings, followed by potentially improved patient adherence. These benefits were reflected in respondents' descriptions of positive experiences and patient feedback. The main limitations were the lack of reversal agents, cost and inability to monitor anticoagulation status. Many described their experiences of adverse effects of DOACs including fatal and non-fatal bleeding, and upper gastrointestinal disturbances. CONCLUSIONS: While prescribers have positive experiences and perceive benefits of DOACs, issues such as adverse effects and inability to monitor anticoagulation status merit further monitoring and investigation. These issues are particularly relevant given the trajectory of increased prescribing of DOACs.

Longitudinal evaluation of the effects of illness perceptions and beliefs about cardiac rehabilitation on quality of life of patients with coronary artery disease and their caregivers.

BACKGROUND: Patients' negative illness perceptions and beliefs about cardiac rehabilitation (CR) can influence uptake and adherence to CR. Little is known about the interpartner influence of these antecedent variables on quality of life of patients with coronary artery disease (CAD) and their family caregivers. The aims of the study were: 1) to assess differences in illness perceptions, beliefs about CR and quality of life between patients with CAD and their family caregivers upon entry to a CR programme and at 6 months follow-up; and 2) to examine whether patients' and caregivers' perceptions of the patient's illness and beliefs about CR at baseline predict their own and their partner's quality of life at 6 months. METHODS: In this longitudinal study of 40 patient-caregiver dyads from one CR service, patients completed the Brief Illness Perception Questionnaire and Beliefs about Cardiac Rehabilitation Questionnaire at baseline and 6 months; and caregivers completed these questionnaires based on their views about the patient's illness and CR. The Short-Form 12 Health Survey was used to assess patients' and caregivers' perceived health status. Dyadic data were analysed using the Actor-Partner Interdependence Model. RESULTS: Most patients (70%) were men, mean age 62.45 years; and most caregivers (70%) were women, mean age 59.55 years. Caregivers were more concerned about the patient's illness than the patients themselves; although they had similar scores for beliefs about CR. Patients had poorer physical health than caregivers, but their level of mental health was similar. Caregivers' poorer mental health at 6 months was predicted by the patient's perceptions of timeline and illness concern (i.e. partner effects). Patient's and caregiver's illness perceptions and beliefs about CR were associated with their own physical and mental health at 6 months (i.e. actor effects). CONCLUSIONS: Overall, the patients and caregivers had similar scores for illness perceptions and beliefs about CR. The actor and partner effect results indicate a need to focus on specific illness perceptions and beliefs about CR, targeting both the individual and the dyad, early in the rehabilitation process to help improve patients and caregivers physical and mental health (outcomes).

Longitudinal study of the relationship between patients' medication adherence and quality of life outcomes and illness perceptions and beliefs about cardiac rehabilitation.

BACKGROUND: Adherence to medication regimens is essential for preventing and reducing adverse outcomes among patients with coronary artery disease (CAD). Greater understanding of the relation between negative illness perceptions, beliefs about cardiac rehabilitation (CR) and medication adherence may help inform future approaches to improving medication adherence and quality of life (QoL) outcomes. The aims of the study are: 1) to compare changes in illness perceptions, beliefs about CR, medication adherence and QoL on entry to a CR programme and 6 months later; 2) to examine associations between patients' illness perceptions and beliefs about CR at baseline and medication adherence and QoL at 6 months. METHODS: A longitudinal study of 40 patients with CAD recruited from one CR service in Scotland. Patients completed the Medication Adherence Report Scale, Brief Illness Perception Questionnaire, Beliefs about CR questionnaire and the Short-Form 12 Health Survey. Data were analysed using the Wilcoxon Signed Ranks test, Pearson Product Moment correlation and Bayesian multiple logistic regression. RESULTS: Most patients were men (70%), aged 62.3 mean (SD 7.84) years. Small improvements in 'perceived suitability' of CR at baseline increased the odds of being fully adherent to medication by approximately 60% at 6 months. Being fully adherent at baseline increased the odds of staying so at 6 months by 13.5 times. 'Perceived necessity, concerns for exercise and practical barriers' were negatively associated with reductions in the probability of full medication adherence of 50, 10, and 50%. Small increases in concerns about exercise decreased the odds of better physical health at 6 months by about 50%; and increases in practical barriers decreased the odds of better physical health by about 60%. Patients perceived fewer consequences of their cardiac disease at 6 months. CONCLUSIONS: Patients' beliefs on entry to a CR programme are especially important to medication adherence at 6 months. Negative beliefs about CR should be identified early in CR to counteract any negative effects on QoL. Interventions to improve medication adherence and QoL outcomes should focus on improving patients' negative beliefs about CR and increasing understanding of the role of medication adherence in preventing a future cardiac event.

An evaluation of mental health clinical pharmacist independent prescribers within general practice in remote and rural Scotland.

Background A 12-month pilot was implemented in two general practices in remote and rural Scotland, with patients referred by general practitioners to specialist mental health pharmacist independent prescribers. Objective The objective was to evaluate the pilot service from the perspectives of the patients and the care team. Methods The pharmacists routinely recorded patient-specific data of all clinical issues and their actions at the time of each consultation. Further datasets comprised baseline and follow-up Patient Health Questionnaire (PHQ-9) and/or Generalised Anxiety Disorder (GAD-7) rating scales, a patient survey and interviews with members of the care team. Results Of the 75 patients, two-thirds (n = 47, 62.7%) were referred with a diagnosis of mixed depression and anxiety. There were 324 consultations (median 3, IQR 2-5, range 1-14) and 181 prescribing actions. At pilot completion, 34 patients (45.3%) had PHQ-9 and/or GAD-7 scores reduced by 50%. Patient questionnaires and staff interviews generated positive responses. Conclusion This pilot has provided evidence that specialist mental health pharmacist independent prescribers delivered quality care to patients with diagnoses of moderate to severe depression and/or anxiety. Whilst accepting study limitations, there is potential to translate the pilot model of care to sustained services throughout general practice.

A theoretically informed survey of the views and experiences of practicing pharmacists on research conduct, dissemination and translation.

BACKGROUND: While studies have reported pharmacists' perspectives of research involvement, almost all are limited by sector, have little focus on research translation and have not incorporated behavior change theory. OBJECTIVE: To determine pharmacists' views and experiences of research conduct, dissemination and translation. METHODS: This was an electronic cross-sectional survey of pharmacists across six Scottish health board areas. Survey items were: demographics; research activities (e.g. conduct, dissemination) in the last two years; research interests, experience and confidence in research tasks (e.g. proposal writing, data collection); and Likert statements on research conduct and dissemination, and translating research findings to practice. Conduct/dissemination and translation items were based on the Theoretical Domains Framework (TDF). Data were analysed using descriptive and inferential statistics, and principal component analysis (PCA) of TDF items. Following determination of internal consistency, scores for each component were calculated. RESULTS: The response rate was 19.4% (136/701), with 17 (12.5%) currently involved in research. Responses were more positive for interest in research than experience or confidence. PCA of research conduct/dissemination items identified three internally reliable components of support/opportunities, motivation/outcomes, and roles/characteristics. Component scores for support/opportunities to participate in research were most negative. PCA of translation items identified three internally reliable components of current practices/abilities, consequences and support. Scores for all three components were positive, being most positive for consequences of research translation. Those in secondary care, with a postgraduate qualification and prescribers scored higher for interest, experience, confidence, and for most components (p < 0.05). CONCLUSION: A minority of pharmacists are involved in the research conduct/dissemination and these are more likely to be highly qualified individuals based in secondary care. Given the need to develop and evaluate new models of pharmaceutical care, involvement should be extended to all practice settings. Study findings could be used to develop behavior change interventions targeting individuals and organizations.

Comparing ST-segment elevation myocardial infarction care between patients residing in central and remote locations: a retrospective case series.

INTRODUCTION: People who experience an ST-elevation myocardial infarction (STEMI) due to an occluded coronary artery require prompt treatment. Treatments to open a blocked artery are called reperfusion therapies (RTs) and can include intravenous pharmacological thrombolysis (TL) or primary percutaneous coronary intervention (pPCI) in a cardiac catheterisation laboratory (cath lab). Optimal RT (ORT) with pPCI or TL reduces morbidity and mortality. In remote areas, a number of geographical and organisational barriers may influence access to ORT. These are not well understood and the exact proportion of patients who receive ORT and the relationship to time of day and remoteness from the cardiac cath lab is unknown. The aim of this retrospective study was to compare the characteristics of ORT delivery in central and remote locations in the north of Scotland and to identify potential barriers to optimal care with a view to service redesign. METHOD: The study was set in the north of Scotland. All patients who attended hospital with a STEMI between March 2014 and April 2015 were identified from national coding data. A data collection form was developed by the research team in several iterative stages. Clinical details were collected retrospectively from patients' discharge letters. Data included treatment location, date of admission, distance of patient from the cath lab, route of access to health care, left ventricular function and RT received. Distance of patients from the cath lab was described as remote if they were more than 90 minutes of driving time from the cardiac cath lab and central if they were 90 minutes or less of driving time from the regional centre. For patients who made contact in a pre-hospital setting, ORT was defined as pre-hospital TL (PHT) or pPCI. For patients who self-presented to the hospital first, ORT was defined as in-hospital TL or pPCI. Data were described as mean (standard deviation) as appropriate. Chi-squared and student's t-test were used as appropriate. Each case was reviewed to determine if ORT was received; if ORT was not received, the reasons for this were recorded to identify potentially modifiable barriers. RESULTS: Of 627 acute myocardial infarction patients initially identified, 131 had a STEMI, and the others were non-STEMI. From this STEMI cohort, 82 (62%) patients were classed as central and 49 (38%) were remote. In terms of initial therapy, 26 (20%) received pPCI, 19 (15%) received PHTs, 52 (40%) received in-hospital TL, while 33 (25%) received no initial RT. ORT was received by 53 (65%) central and 20 (41%) remote patients; χ²=7.05, degrees of freedom =130, p<0.01).Several recurring barriers were identified. CONCLUSION: This study has demonstrated a significant health inequality between the treatment of STEMI in remote compared to central locations. Potential barriers identified include staffing availability and training, public awareness and inter-hospital communication. This suggests that there remain significant opportunities to improve STEMI care for people living in the north of Scotland.

A systematic review of clinicians' views and experiences of direct-acting oral anticoagulants in the management of nonvalvular atrial fibrillation.

AIMS: While a plethora of systematic reviews have provided evidence of efficacy, effectiveness and safety of direct-acting oral anticoagulants (DOACs) in the management of nonvalvular atrial fibrillation, there has been little emphasis on clinicians' perspectives. This systematic review aimed to critically appraise, synthesize and present the available evidence of clinicians' views and experiences. METHODS: Studies published in English from January 2006 to July 2017 reporting the views and/or experiences of doctors, nurses or pharmacists on any individual DOAC or as a pharmacological group were included. Studies were assessed for quality by two researchers, data extracted and findings synthesized using a narrative approach. RESULTS: Following exclusion of duplicates, 777 titles, 394 abstracts and 196 studies were screened. Ten studies were included in the review, nine of which were quantitative (cross-sectional surveys) and one qualitative (semistructured interviews), with marked heterogeneity in outcomes reported. Studies were conducted exclusively in Europe and the USA. In those studies reporting clinician preference, DOACs were first choice over warfarin in naïve patients, based on perceptions of evidence of effectiveness equivalent or superior to warfarin and superior safety. Other advantageous factors were in those with an unstable International Normalized Ratio and likely to miss appointments. There were, however, concerns relating to management of over-anticoagulation and experiences of observed bleeding rates. CONCLUSION: There is a limited evidence base of clinicians' perspectives of DOACs, necessitating further research, particularly given the trajectory of increased use worldwide.

A cross-sectional survey of the access of older people in the Scottish Highlands to general medical practices, community pharmacies and prescription medicines.

BACKGROUND: Access to medicines and healthcare is more problematic in remote and rural areas. OBJECTIVES: To quantify issues of access to general practitioners (GPs), community pharmacies and prescribed medicines in older people resident in the Scottish Highlands. METHODS: Anonymized questionnaires were mailed to a random sample of 2000 older people (≥60 years) resident in the Scottish Highlands. Questionnaire items were: access and convenience to GP and pharmacy services (10 items); prescribed medicines (13 items); attitudinal statements based on the Theoretical Domains Framework (12 items); quality of life (SF8, 8 items); and demographics (12 items). Results were analysed using descriptive, inferential and spatial statistics, and principal component analysis (PCA) of attitudinal items. RESULTS: With a response rate of 54.2%, the majority reported convenient access to GPs (89.1%) and community pharmacies (84.3%). Older age respondents (p < 0.0001) were more likely to state that their access to GP services was not convenient and those in rural areas to community pharmacies (p < 0.01). For access to prescribed medicines, those in poorer health (p < 0.001) and taking five or more regular prescribed medicines (p = 0.002) were more likely to state access not convenient. PCA identified three components of beliefs of capabilities, emotions and memory. Those with poorer health had more negative scores for all (p < 0.001). Those reporting issues of access to prescribed medicines had more negative scores for beliefs of capabilities (p < 0.001) while those of older age, living alone, and taking five or more regular prescribed medicines (all p < 0.001) had more negative scores for emotions. CONCLUSION: While the majority of respondents have convenient access to their GP practice, pharmacy and prescribed medicines, there is a need for further review of the pharmaceutical care of those of older age with poorer health, living alone in the more remote and rural areas and taking five or more prescribed medicines.

Unexpected deaths in cardiology outpatients - what can we learn from case review?

OBJECTIVES: A proportion of cardiac patients managed at a cardiology outpatient clinic will die between clinic visits. This study aimed to identify the cause of death, to determine if case review occurred and if a formal review of such cases might be useful. DESIGN: Single-centre retrospective cohort study. SETTING: A remote regional centre in the North of Scotland. PARTICIPANTS: All patients who had been removed from the cardiology outpatient clinic due to death in the community. MAIN OUTCOME MEASURES: Cause of death, comorbidities and treatments were collected from hospital records and the national register of deaths. Chi-squared test and Student's t-test were used with significance taken at the 5% level. RESULTS: Of 10,606 patients who attended the cardiology outpatient clinic, 75 (0.7%) patients died in the community. The majority (57.0%) died from a non-cardiac cause. Eleven patients (14.9%) died due to an unexpected cardiac death. A detailed case note review was undertaken. In only two (18.2%) cases was any note made as to the cause of death in the hospital records and in only one was there details of post mortem discussion between primary and secondary care. CONCLUSIONS: A small proportion of patients attending a cardiology outpatient clinic died in the community. Documentation of the death in the hospital notes was very poor and evidence of post mortem communication between primary and secondary care was absent in all but one case. Better documentation and communication between primary and secondary care would seem desirable.

Nicorandil, Gastrointestinal Adverse Drug Reactions and Ulcerations: A Systematic Review.

INTRODUCTION: Nicorandil is a popular anti-anginal drug in Europe and Japan. Apart from some common adverse drug reactions (ADR), its safety is satisfactory. Several reports have suggested a link between nicorandil, gastrointestinal (GI) ulceration and fistulas. The review aims to critically appraise, synthesize and present the available evidence of all known GI ADR per anatomical location. METHODS: The study complied with the PRISMA statement. Literature and pharmacovigilance databases were used to provide rate and/or calculate parameters (median age, median dose, history of symptoms, length of therapy and healing time after withdrawal of the drug). Differences in distribution of quantitative variables were analyzed via Mann-Whitney test. Correlation between quantitative variables was assessed with a Spearman's correlation coefficient. A p value <0.05 was significant. RESULTS: Oral ulcerations occur in 0.2% of the subjects, anal ulcerations are present between 0.07% and 0.37% of patients. Oral and distal GI involvements are the most common ADR (28-29% and 27-31% of all GI ADR, respectively). The hepatobiliary system, the pancreas and salivary glands are not affected by nicorandil exposure. The time to develop oral ulcerations is 74 weeks among people on <30 mg/day compared to only 7.5 weeks in individuals on higher regimens (p = 0.47). There is a significant correlation between dose and ulcer healing time (Spearman's 0.525, p < 0.001). CONCLUSIONS: Ulcerative disease is a very commonly reported GI ADR. A delayed ulcerative tendency supports the hypothesis of an ulcerogenic metabolite. Nicorandil seems to act as a cause of the ulcerations, but appears to also work in synergy with other promoting factors. Whether the action of the metabolites relies on a specific mechanism or a simple chemical ulceration is still to be established.

General practitioner views of an electronic high-risk medicine proforma to facilitate information transfer.

BACKGROUND: The potential of warfarin related harm is increased if clinicians lack the full patient specific information to make informed decisions-an e-proforma has been developed to communicate this information on hospital discharge. OBJECTIVE: To determine the views of general practitioners (GPs) on a warfarin discharge e-proforma. METHOD: A cross-sectional survey of all GPs (n = 272) within the Raigmore Hospital catchment area of NHS Highland, Scotland. RESULTS: The response rate was 39.3 % (107/272). 84 (78.5 %) noticed recent changes to information supplied on discharge for warfarin patients. 64 (59.8 %) respondents thought this would result in more informed prescribing with regards to dosing, while 65 (60.7 %) felt this would improve safety. Accurate completion, timely receipt of the e-proforma and a realistic date for subsequent INR tests were considered important by GPs. CONCLUSION: This study suggests the use of an e-proforma to communicate information about a high-risk medication, warfarin, to GPs on discharge optimises safe, informed prescribing and monitoring in primary care. The development of a discharge e-proforma for other high-risk medication as a patient safety improvement measure should be explored.