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.

From community pharmacy to healthy living pharmacy: positive early experiences from Portsmouth, England.

BACKGROUND: Research has shown the potential for community pharmacies to promote better health and prevent disease by providing individual services in a limited range of settings. In the UK, the healthy living pharmacy (HLP) framework has been developed to allow pharmacies to provide a portfolio of such services tailored to local need. This paper reports an evaluation of the uptake and success of HLP introduction in Portsmouth, the original pathfinder site for a national program. OBJECTIVES: To assesses the impact on service provision and staff engagement at an early stage in HLP program development. METHODS: Quantitative data, derived from pharmacy records, on service provision by HLPs (n = 17) and non-HLPs (n = 19) during April 2011-March 2012 was evaluated for trends and differences. Face-to-face interviews were conducted during November 2011 and February 2012, to gauge staff opinion on HLP development and sustainability, using interpretative phenomenological analysis. RESULTS: Significantly more clients per pharmacy were seen in HLPs than non-HLPs for the following services: targeted respiratory medicine use reviews (medians: 29 vs 11; P = 0.0167); smoking cessation at initiation (62 vs 18; P < 0.001) and at 4-week (26 vs 10; P < 0.001) and 12-week (5 vs 1; P = 0.023) follow-ups. Medians for alcohol awareness and weight management were appreciably higher in HLP pharmacies, but the differences did not reach statistical significance. Medians for clients seeking emergency hormonal contraception were comparable. Interviews with 38 staff from 32 pharmacies revealed a positive impact on service development in HLPs, largely engineered through revision of skill mix and additional training of non-pharmacist staff to become healthy living champions. Obstacles to HLP development were managing the increased workload, raising awareness of clients and other healthcare professionals of the services available, and receiving remuneration for service provision. CONCLUSIONS: These data point to a largely successful introduction of the HLP program in Portsmouth and the potential for improving client health. Staff interviews suggest that adoption and sustainability of the scheme depend on achieving the right skill mix, including the introduction of healthy living champions, motivation of the entire staff team and the provision of adequate funding for services offered.

Review of services provided by pharmacies that promote healthy living.

BACKGROUND: The recognition that community pharmacies have the potential to make a greater contribution to promoting public health has led to a new concept, called the Healthy Living Pharmacy (HLP). These are designed to meet public health needs through a tiered commissioning framework delivering health and well being services through community pharmacy, tailored to local requirements for tackling health inequalities. AIM: To search the literature for quality evidence to support the inclusion of services in the HLP portfolio and suggest areas where more evidence is required. METHOD: A systematic review of the research literature covering the period January 1990-August 2011 inclusive, using MEDLINE, EMBASE, Pharmline, NHS Evidence and the Cochrane databases. On-line searching of the grey literature (e.g. conference proceedings) was also carried out. Standard methods of assessing quality were employed. RESULTS: A total of 377 papers were included. Over time, there was a marked increase in frequency of publications reflecting a growing pharmacy interest in the public healthcare agenda; over a third (35 %) of papers appeared in the last three-year study period. The body of research had a wide geographical basis; contributions were as follows: UK (51.5 %), US (20.4 %), Australia/New Zealand (9.8 %), Europe (7.7 %) and Canada (7.2 %). The topics of contraception, cardiovascular disease prevention, diabetes and smoking cessation accounted for 40 % of included papers. The literature supports the introduction of specific community pharmacy services, targeted at customer groups, both with and without pre-existing diseases. Good evidence exists for smoking cessation, cardiovascular disease prevention, hypertension and diabetes. Some good evidence exists for interventions on asthma and heart failure. The evidence supporting weight management, sexual health, osteoporosis detection, substance abuse and chronic obstructive pulmonary disease is weak and needs development. CONCLUSION: There is strong evidence for the role of community pharmacy in a range of services, not only aimed at improving general health, but also maintaining the health of those with existing disease. In other areas, the evidence is less strong and further research is required to justify their inclusion in a HLP portfolio.

What have we learned about interventions to reduce medical errors?

Medical errors and adverse events are now recognized as major threats to both individual and public health worldwide. This review provides a broad perspective on major effective, established, or promising strategies to reduce medical errors and harm. Initiatives to improve safety can be conceptualized as a "safety onion" with layers of protection, depending on their degree of remove from the patient. Interventions discussed include those applied at the levels of the patient (patient engagement and disclosure), the caregiver (education, teamwork, and checklists), the local workplace (culture and workplace changes), and the system (information technology and incident reporting systems). Promising interventions include forcing functions, computerized prescriber order entry with decision support, checklists, standardized handoffs and simulation training. Many of the interventions described still lack strong evidence of benefit, but this should not hold back implementation. Rather, it should spur innovation accompanied by evaluation and publication to share the results.