General practice pharmacist-led antipsychotic physical health monitoring: a prospective intervention scoping study.

BACKGROUND: People with severe mental health illness die prematurely, often due to preventable cardiometabolic disease, which can be exacerbated by antipsychotic medicines that are effective for treating mental illness. Literature demonstrates that physical health monitoring, as recommended in guidelines, for people receiving antipsychotics is substandard. Therefore, we aimed to scope the potential of a general practice clinical pharmacist (GPCP)-led multidisciplinary intervention optimising adherence to cardiometabolic monitoring guidelines and delivering polypharmacy reviews. METHOD: Prospective intervention scoping study in three urban general practices; one usual care, two intervention. Patients 18-65 years old prescribed oral antipsychotics were identified from records, and invited for cardiometabolic monitoring and GPCP medication review, from January to December 2022. Interventions and onward referrals were recorded and collated. Anonymised pre- and post-review data were analysed, and actions were graded for clinical importance. RESULTS: In total 1.5% (210/14,159) of patients aged 18-65 years met inclusion criteria; usual care practice (n = 58); and intervention practices (n = 152). From baseline, the usual care practice achieved an absolute 7% increase in the cardiometabolic monitoring care bundle (glucose/glycosylated haemoglobin, lipids, blood pressure plus body mass index) versus 19-58% in the intervention practices. Two-thirds (92/152) of patients participated in medication reviews, requiring pharmacological and/or non-pharmacological clinical actions. The majority of actions were graded as moderate importance. Seven percentage of patients were identified as new pre-diabetic/diabetic and 6% were at high risk of cardiovascular disease requiring statin initiation. CONCLUSION: A pharmacist-led multidisciplinary general practice-based approach may be effective at optimising cardiometabolic monitoring; identifying and treating diabetic and cardiovascular risk factors.

People with severe mental illness die 15­20 years earlier than the general population, many due to preventable and/or treatable heart disease. While antipsychotic medicines are effective for treating mental illness they are associated with potential adverse effects; weight gain, increased blood pressure, blood sugar, and cholesterol. Therefore, guidelines advise regular physical health checks for people with severe mental illness, and those receiving antipsychotics, to reduce avoidable harms and optimise preventative treatments. However, routine monitoring is substandard. This study aimed to explore the potential of a general practice pharmacist-led intervention to optimise physical health monitoring and medication reviews, from January to December 2022. Three practices participated; one providing usual care, and two the pharmacist intervention. The usual care practice achieved a 7% increase in all monitoring parameters (weight, blood pressure, blood sugars plus cholesterol), whereas the pharmacist-led practices achieved a 19­58% increase in monitoring. Two in three patients (92/152) participated in a medication review with the pharmacists that addressed a range of mental and physical health issues. Of the 152 patients in the intervention practices 6% were identified as being at high risk of heart disease requiring preventative medicines, and 7% were identified as having new diabetes and/or pre-diabetes.

Identifying mental health training needs of general practice pharmacy workforce to advance practice: a training needs analysis survey.

BACKGROUND: Mental health problems are commonly treated in general practice. Pharmacy roles are evolving in general practice; however it is unknown what mental health training the pharmacy workforce needs. AIM: To identify and prioritise general practice clinical pharmacists' (GPCPs) and technicians' mental health and psychotropic prescribing learning needs within general practice. METHOD: All 353 GPCPs and technicians, in one health board, were invited to participate in an online survey, September 2021. The validated Hennessy-Hicks Training Needs Assessment Questionnaire, was embedded in the survey. Participants rated 26 tasks with regard to their confidence in performing the task, and importance to their role. Clinical knowledge was assessed against clinical guidelines and literature. RESULTS: Response rate was 26% (92/353); 27% (68/256) GPCPs and 25% (24/97) technicians. Respondents prioritised 'appraising own performance' and 'assessing suicide/deliberate self-harm risk' as high training needs. There were significant variations in prioritisation between GPCPs and technicians; substantial pharmacist agreement (inter-rater correlation 0.713, 95% CI 0.376-0.870, p = 0.001). Depression was a priority training need followed by anxiety, dementia, bipolar, attention deficit (hyperactivity) disorder and schizophrenia. For depression treatment, 2 in 3 respondents were unaware of early antidepressant response, dose-response effects for efficacy, and would wait 8-12 weeks before optimising treatment. The majority were aware of individual lithium and antipsychotic cardiometabolic monitoring parameters; 25% identifying the correct monitoring care-bundle. CONCLUSION: Respondents identified a range of training needs which varied between technicians and pharmacist, and staff banding. Addressing these learning needs may help pharmacy staff to better support practices and patients.

New ways of working releasing general practitioner capacity with pharmacy prescribing support: a cost-consequence analysis.

BACKGROUND: General practice in the United Kingdom is experiencing a workforce crisis. Greater multidisciplinary working, including more general practice pharmacists, is seen as part of the solution. However, it is unknown what impact and cost-consequences that pharmacists may have in freeing general practitioner (GP) capacity. OBJECTIVE: To evaluate the cost-consequences of additional pharmacists in releasing GP capacity. METHODS: This cost-consequences evaluation of a prospective observational cohort study in 15 urban practices involving 69 GPs in 1 locality serving a population of 82,000 people. GPs recorded the time they spent addressing key targeted prescribing activities during 5 distinct 2-week audit periods. Pharmacists performed these key prescribing activities to release GP capacity. An additional 225 h of pharmacists' time per week was committed to the locality. Standardized staff costings were used to estimate the financial impact. Prescribing indicator performance was assessed against the other 7 localities within the health board. RESULTS: When compared with employing extra nonsalaried GPs this required an estimated additional investment of £16.73 (range £5.97-20.87) per h to free GP capacity. This achieved a sustainable 47% (73 h per week, F(4,56) = 16.05, P < 0.001) reduction in GP time spent on key prescribing activities; equating to 4.9 h (95% confidence interval 3.1-6.7) per practice per week. No significant step changes in locality safety and quality prescribing measures, and no negative effects on locality-level prescribing cost-efficiency work were observed. CONCLUSION: Appropriately resourced general practice pharmacy teams delivered prescribing cost-efficiencies as well as sustainably freeing GP capacity by performing key prescribing activities.

General practice in the United Kingdom is experiencing a workforce crisis, and is struggling to deliver services. Pharmacists have been shown to be effective in freeing general practitioner (GP) capacity. However, it is unknown how much it costs to do this. Therefore, we aimed to assess the cost-consequences of releasing GP capacity. All practices in 1 region took part. GPs recorded the time it routinely took them to address key prescribing activities, Spring 2016. Pharmacists then delivered the key prescribing activities. The region got an extra 225 h of pharmacists' time to do these activities. Then in Spring 2018, the GPs and pharmacists recorded the time took to do the key prescribing activities. Standard salary costs were used to estimate how much money was needed to free GP capacity with pharmacists. The impact on routine cost-effective work was also assessed. Pharmacists delivering key prescribing activities freed 73 h per week of GP time. This equalled an average of 5 h per week per practice. Freeing GP capacity was estimated to cost an extra £16.73 (range £5.97­20.87) per h. There were no negative effects on cost-efficiency work. Appropriately resourcing general practice with pharmacists delivers sustainable prescribing cost-efficiencies and frees GP capacity.

A Digital Intervention for Primary Care Practitioners to Support Antidepressant Discontinuation (Advisor for Health Professionals): Development Study.

BACKGROUND: The number of people receiving antidepressants has increased in the past 3 decades, mainly because of people staying on them longer. However, in many cases long-term treatment is not evidence based and risks increasing side effects. Additionally, prompting general practitioners (GPs) to review medication does not improve the rate of appropriate discontinuation. Therefore, GPs and other health professionals may need help to support patients discontinuing antidepressants in primary care. OBJECTIVE: This study aims to develop a digital intervention to support practitioners in helping patients discontinue inappropriate long-term antidepressants (as part of a wider intervention package including a patient digital intervention and patient telephone support). METHODS: A prototype digital intervention called Advisor for Health Professionals (ADvisor HP) was planned and developed using theory, evidence, and a person-based approach. The following elements informed development: a literature review and qualitative synthesis, an in-depth qualitative study, the development of guiding principles for design elements, and theoretical behavioral analyses. The intervention was then optimized through think-aloud qualitative interviews with health professionals while they were using the prototype intervention. RESULTS: Think-aloud qualitative interviews with 19 health professionals suggested that the digital intervention contained useful information and was readily accessible to practitioners. The development work highlighted a need for further guidance on drug tapering schedules for practitioners and clarity about who is responsible for broaching the subject of discontinuation. Practitioners highlighted the need to have information in easily and quickly accessible formats because of time constraints in day-to-day practice. Some GPs felt that some information was already known to them but understood why this was included. Practitioners differed in their ideas about how they would use ADvisor HP in practice, with some preferring to read the resource in its entirety and others wanting to dip in and out as needed. Changes were made to the wording and structure of the intervention in response to the feedback provided. CONCLUSIONS: ADvisor HP is a digital intervention that has been developed using theory, evidence, and a person-based approach. The optimization work suggests that practitioners may find this tool to be useful in supporting the reduction of long-term antidepressant use. Further quantitative and qualitative evaluation through a randomized controlled trial is needed to examine the feasibility, effectiveness, and cost-effectiveness of the intervention.

Ongoing initiatives within the Scottish National Health Service to affect the prescribing of selective serotonin reuptake inhibitors and their influence.

Aim: Increasing use of selective serotonin-reuptake inhibitors (SSRIs) in Scotland, coupled with safety concerns with some SSRIs, and the increasing availability of generic SSRIs, have resulted in multiple initiatives to improve the quality and efficiency of their prescribing in Scotland. Our aim is to assess their influence to provide future direction. Materials & methods: The prescription costs analysis database was used to document utilization and expenditure on SSRIs between 2001 and 2017 alongside documenting the initiatives. Results: Multiple interventions over the years increased international nonproprietary name prescribing up to 99.9% lowering overall costs. This, coupled with initiatives to limit escitalopram prescribing due to concerns with its value, resulted in a 73.7% reduction in SSRI expenditure between 2001 and 2017 despite a 2.34-fold increase in utilization. Safety warnings resulted in a significant reduction in the prescribing of paroxetine, citalopram and escitalopram alongside a significant increase in sertraline Conclusion: Multiple initiatives have increased the quality and efficiency of SSRI prescribing in Scotland providing direction to others.

Benzodiazepine and z-hypnotic prescribing for older people in primary care: a cross-sectional population-based study.

BACKGROUND: Overall prescribing of benzodiazepines and z-hypnotics (B&Zs) has slowly reduced over the past 20 years. However, long-term prescribing still occurs, particularly among older people, and this is at odds with prescribing guidance. AIM: To compare prescribing of B&Zs between care home and non-care home residents ≥65 years old. DESIGN AND SETTING: Cross-sectional population-based study in primary care in Scotland. METHOD: National patient-level B&Z prescribing data, for all adults aged ≥65 years, were extracted from the Prescribing Information System (PIS) for the calendar year 2011. The PIS gives access to data for all NHS prescriptions dispensed in primary care in Scotland. Data were stratified by health board, residential status, sex, and age (65-74, 75-84, and ≥85 years). To minimise disclosure risk, data from smaller health boards were amalgamated according to geography, thereby reducing the number from 14 to 10 areas. RESULTS: A total of 17% (n = 879 492) of the Scottish population were aged ≥65 years, of which 3.7% (n = 32 368) were care home residents. In total, 12.1% (n = 106 412) of older people were prescribed one or more B&Z: 5.9% an anxiolytic, 7.5% a hypnotic, and 1.3% were prescribed both. B&Zs were prescribed to 28.4% (9199) of care home and 11.5% (97 213) of non-care home residents (relative risk = 2.88, 95% CI = 2.82 to 2.95, P<0.001). Estimated annual B&Z exposure reduced with increasing age of care home residents, whereas non-care home residents' exposure increased with age. CONCLUSION: B&Zs were commonly prescribed for older people, with care home residents approximately three times more likely to be prescribed B&Zs than non-care home residents. However, overall B&Z exposure among non-care home residents was found to rise with increasing age.