Statin prescription initiation and lifestyle behaviour: a primary care cohort study.

BACKGROUND: Statin prescribing and healthy lifestyles contribute to declining cardiovascular disease mortality. Recent guidelines emphasise the importance of giving lifestyle advice in association with prescribing statins but adherence to healthy lifestyle recommendations is sub-optimal. However, little is known about any change in patients' lifestyle behaviours when starting statins or of their recall of receiving advice. This study aimed to examine patients' diet and physical activity (PA) behaviours and their recall of lifestyle advice following initiation of statin prescribing in primary care. METHOD: In 12 general practices, patients with a recent initial prescription of statin therapy, were invited to participate. Those who agreed received a food diary by post, to record food consumed over 4 consecutive days and return to the researcher. We also telephoned participants to administer brief validated questionnaires to assess typical daily diet (DINE) and PA level (Godin). Using the same methods, food diaries and questionnaires were repeated 3 months later. At both times participants were asked if they had changed their behaviour or received advice about their diet or PA. RESULTS: Of 384 invited, 122 (32 %) participated; 109 (89.3 %) completed paired datasets; 50 (45.9 %) were male; their mean age was 64 years. 53.2 % (58/109) recalled receiving lifestyle advice. Of those who did, 69.0 % (40/58) reported having changed their diet or PA, compared to 31.4 % (16/51) of those who did not recall receiving advice. Initial mean daily saturated fat intake (12.9 % (SD3.5) of total energy) was higher than recommended; mean fibre intake (13.8 g/day (SD5.5)), fruit/vegetable consumption (2.7 portions/day (SD1.3)) and PA levels (Godin score 7.1 (SD13.9)) were low. Overall, although some individuals showed evidence of behaviour change, there were no significant changes in the proportions who reported high or medium fat intake (42.2 % v 49.5 %), low fibre (51.4 % v 55.0 %), or insufficient PA (80.7 % v 83.5 %) at 3-month follow-up. CONCLUSION: Whilst approximately half of our cohort recalled receiving lifestyle advice associated with statin prescribing this did not translate into significant changes in diet or PA. Further research is needed to explore gaps between people's knowledge and behaviours and determine how best to provide advice that supports behaviour change.

An investigation into the content validity of the Antimicrobial Self-Assessment Toolkit for NHS Trusts (ASAT v15a) using cognitive interviews with antimicrobial pharmacists.

WHAT IS KNOWN AND OBJECTIVE: The Antimicrobial Self-Assessment Toolkit for NHS Trusts (ASAT) was developed to evaluate the organizational strategies used to implement hospital-based antimicrobial stewardship programmes. An iterative approach was used to develop ASAT v15a, which has been previously investigated for face validity; however, further investigation into other types of validity was required. Therefore, the aim of this study was to investigate the content validity of ASAT v15a and hence modify and improve the content validity of the toolkit. METHODS: A purposive sample of eight antimicrobial pharmacists was interviewed using cognitive interviewing techniques from within the former North-west Strategic Health Authority in England. Respondents were asked to 'think aloud' and to verbally express their thought processes as they generated responses to each question with the ASAT. RESULTS: There were no cognitive difficulties reported by respondents in response to 26/83 (31·3%) questions within the ASAT. However, cognitive difficulties were reported by respondents at each stage of the cognitive processing pathway in response to 57/83 (68·7%) questions. These difficulties were comprehension/interpretation in 27/83 (32·5%) questions, information retrieval in 10/83 (12%) questions, judgment/decision in 6/83 (7·2%) questions and response generation/formatting in 13/83 (15·7%) questions. Other findings included disagreement with the weightings applied to 13/83 (15·7%) questions. Respondents recommended that these questions should be modified to reflect their impact on hospital-based antimicrobial stewardship programmes (ASPs). Based on these findings, modifications were made to ASAT v15a to produce the next iteration (ASAT v16). Furthermore, respondents indicated that the role of clinical microbiologists was underrepresented in the current version of the toolkit; therefore, seven proposed questions were drafted, based on a literature review. WHAT IS NEW AND CONCLUSION: Cognitive interviews were effectively able to detect problems encountered by respondents along the cognitive processing pathway by identifying words and/or phrases that required further modifications. Also, this method highlighted that there was a disparity between the respondents' interpretation and the ASAT developers' intent within some questions. Although respondents indicated that the toolkit evaluated the most pertinent components of ASPs, further modifications and testing would be required to improve its validity. These results highlight the importance of the inclusion of end-users in the development of reporting and/or evaluation tools or questionnaires.

Testing the validity of a translated pharmaceutical therapy-related quality of life instrument, using qualitative 'think aloud' methodology.

BACKGROUND AND OBJECTIVE: In pharmacy practice, there is a need for valid and reliable instruments to study patient-reported outcomes. One potential candidate is a pharmaceutical therapy-related quality of life (PTRQoL) instrument. This study explored the face and content validity, including cognitive aspects of question answering of a PTRQoL instrument, translated from English to Swedish. METHOD: A sample of 16 customers at Swedish community pharmacies, was asked to fill in the PTRQoL instrument while constantly reporting how they reasoned. The resulting interviews and concurrent probing, were audio-taped, transcribed verbatim and analysed using constant comparison method. RESULTS AND DISCUSSION: The relation between the measurement and its theoretical underpinning was challenged. Respondents neglected to read the instructions, used response options in an unpredictable way, and varied in their interpretations of the items. CONCLUSION: The combination of 'think-aloud', retrospective probing and qualitative analysis informed on the validity of the PTRQoL instrument and was valuable in questionnaire development. The study also identified specific problems that could be relevant for other instruments probing patients' medicines-related attitudes and behaviour.

Clinical and economic choices in the treatment of respiratory infections in cystic fibrosis: comparing hospital and home care.

BACKGROUND: A cost-effectiveness evaluation comparing home-based and hospital-based treatment with intravenous antibiotics for respiratory exacerbations in adults with cystic fibrosis (CF) has not been previously undertaken. METHODS: The study was conducted in a UK adult CF centre from a health service perspective. Clinical outcome and resource use data were obtained from a retrospective one-year study and combined with unit cost data in an incremental economic analysis. The primary outcome measure was percentage change in FEV(1); "effectiveness" was defined as maintenance of baseline average FEV(1) over the one-year study period. RESULTS: 116 patients received 454 courses of intravenous antibiotics. At the end of 1 year, there had been a mean percentage decline in FEV(1) compared with baseline average for home-treated patients but an improvement for hospital-treated patients (Tukey's HSD mean difference 10.1%, 95% CI 2.9 to 17.2, p = 0.003). Treatment was deemed "effective" in more hospital (58.8%) than home (42.6%) patients. The cost of hospital treatment was higher than home treatment (mean difference 9,005 pounds, 95% CI 3,507 to 14,700, p<0.001). The mean ICER was 46,098 pounds (2.5th and 97.5th percentiles -374,044 and 362,472). CONCLUSIONS: Hospital treatment was more effective but more expensive than home treatment. Potential methods to improve outcome at home should be considered but these may have resource implications.

Excelência em bancos de leite humano: uma visão do futuro--the First International Congress on Human Milk Banking.

The first International Congress of Human Milk Banks--Excellence in Human Milk Banking: A Vision of the Future, held in Brazil in June 2000 and sponsored by the Brazilian Association of Milk Banks, had representation from milk banks in Argentina, Chile, Costa Rica, Venezuela, France, the United Kingdom, and North America as well as Brazil. A recurring theme in the discussion of donor milk banking was the role of each country's milk banks in the promotion and support of breastfeeding. The Brazilian National Reference Milk Bank and the growth of donor milk banking in Brazil over the past 15 years were described, including federal regulation that all milk bank directors be trained and certified. Milk banking systems in France, the United Kingdom, Venezuela and the Caribbean, and North America were also discussed. Similarities and differences in the donor screening process and the regulation of milk banks in the countries is presented.

Impact of pharmacists providing a prescription review and monitoring service in ambulatory care or community practice.

OBJECTIVE: To systematically review the impact, on patient outcomes and costs to the healthcare system, of pharmacists reviewing and monitoring prescribing in ambulatory care or community practice. DATA SOURCES: We conducted a systematic search of published literature, up to and including 1998, on outcomes of prescription monitoring and review by pharmacists. Thirteen electronic databases were reviewed, along with a hand search of 11 journals known to publish pharmacy practice research. Fifty-five articles describing 50 comparative studies were identified. DATA EXTRACTION: Data were extracted including study design, clinical site, and results. A qualitative synthesis of the findings was conducted and methodological quality was appraised. DATA SYNTHESIS: Pharmacist-run services may be accompanied by improvements in clinical outcomes. Inconsistent definitions used in the research evaluated meant that an overall interpretation of a change in the incidence of compliance and adverse drug reactions was impossible. Other outcomes such as knowledge and satisfaction showed equivocal results overall. There was little or no change in quality of life where this was assessed. Savings in drug acquisition costs may have accrued, but it was impossible to calculate the magnitude. Pharmacist involvement produced a positive impact on cost-benefit and cost-effectiveness. CONCLUSIONS: The heterogeneity of the studies found and the variety in quality of much of the research design prevent the rigorous assessment of the direction and magnitude of any changes reviewed. Further studies are required, which must be rigorously designed, with blind and independent assessment of clearly defined outcomes. In particular, there is a need to investigate the effect of such services on the incidence of adverse drug reactions and quality of life and to conduct robust cost-benefit analyses.

The impact of information technology on the performance of clinical pharmacy services.

Electronic patient records are now being developed to assist in the clinical management of patients within secondary care. This paper reviews how various types of information technology used in these electronic patient records can improve the performance of clinical pharmacy services. The different levels of information technology support for some of the main aspects of clinical pharmacy services are described. How the impact and outcome of information technology support for these services should be evaluated are discussed. The human and technological factors that must be considered to ensure that the implementation succeeds and the potential benefits are realized are examined.

A memory clinic for the assessment of mild dementia.

The aims and experience of work in a specialist memory clinic' are described with reference to the first 200 patients attending the service. 93.5% of attenders were found to suffer from dementia. 67.9% of these fulfilled criteria for probable/possible Alzheimer's disease or other primary degenerative dementias and 8.6% fulfilled criteria for vascular dementia. In the remaining cases the aetiology of the dementia was considered to be multifactorial. The memory clinic proved to be an important resource for demented patients, their carers, and for research projects.

Extending community health nursing services. The Student Learning Center.

Faced with scarce resources, the Visiting Nurse Association of Omaha (VNA), Bishop Clarkson College, Creighton University, and University of Nebraska Medical Center collaborated to maintain services. Baccalaureate students learned to deliver community health nursing while serving a population in need of these services, but not coverable by funding sources. The Student Learning Center established by the VNA enabled 254 students to provide 5,035 home visits to families without funding sources.