The humanistic and economic burden of juvenile idiopathic arthritis in the era of biologic medication.

Juvenile idiopathic arthritis (JIA) is a poorly understood, heterogeneous, incurable, inflammatory syndrome. Long-term outcomes are uncertain, and this painful condition can result in lifelong disability. JIA is associated with considerable financial and humanistic burden for those affected and the healthcare system. Early diagnosis and effective treatment are indicated to optimise outcomes. Modern treatment aims to achieve remission and preserve joint function by using disease-modifying antirheumatic drugs (DMARDs) early. DMARDs can be classified as conventional/traditional or biologic. Biologic medications may be more effective but cost approximately ten times more than traditional DMARDs. Decision-makers in healthcare are increasingly comparing the cost and consequences of alternative treatment strategies to guide resource allocation decisions. There have been few economic evaluations to date to guide medicines optimisation in JIA. This systematic review highlights the lack of existing evidence relating to the humanistic and economic burden of JIA in the era of biologic medication.

Delivering health care through community pharmacies: are working conditions deterring female pharmacists' participation?

OBJECTIVE: Recent UK government policy has placed community pharmacists at the frontline of health care delivery in order to improve patient access. Community pharmacy has been beset by recruitment and retention problems which potentially threaten health service delivery. This is largely a consequence of an increased demand for pharmacists. Additionally, the proportion of female pharmacists in the profession has risen. Consequently, interrupted career patterns and part-time working practices have increased, shrinking the pool of available workers. This study aimed to examine the importance of factors influencing female community pharmacists' work patterns. METHOD: Q methodology was used in a sample of 40 female UK-based community pharmacists. RESULTS: Nine distinct factors emerged from a factor analysis of Q sorts: fulfilled pharmacists; family first or pharmacy shelved; low stress altruist; permanent part-time employees; focused on free time and finances; pressurized modernizers; wandering wage slaves; overloaded and under resourced for the new contract; and pin money part-timers. Female community pharmacists often worked below their potential and part-time at a practitioner level in response to a combination of domestic commitments and intensifying work place pressures. CONCLUSIONS: Family-friendly flexible work environments, adequate staffing levels and improved management support, might be more effective in increasing workforce participation than enhanced salary levels in this group of workers.

Personal development planning: first-year Master of Pharmacy students' engagement with, and attitudes towards, reflective self-assessment.

OBJECTIVES: The aims of this study were to determine whether first-year Master of Pharmacy (MPharm) students would engage with an activity similar to pharmacists' continuing professional development, and to explore attitudes surrounding this task. METHODS: A paper version of the Royal Pharmaceutical Society of Great Britain's electronic template for recording continuing professional development was developed. Students were asked to use this paper version to record the planning, action and evaluation carried out while completing a written assignment. The records were assessed to determine any reflective self-assessment contained in the evaluation section, and whether this reflection related to the specified learning outcome and the planning and action stages. Six focus groups were run, during which the students discussed their reaction to completing these records. The study was carried out during the first semester with first-year undergraduate MPharm students in the School of Pharmacy and Pharmaceutical Sciences at the University of Central Lancashire in the UK. KEY FINDINGS: It was found that few students appeared to engage fully with the whole recording process. During focus-group sessions competence to self-assess was raised as an issue by students, and the value of the reflective process was questioned. Some students did recognize the value of undertaking and recording reflective self-assessment. CONCLUSIONS: It appears that undergraduate students need a more gradual introduction to the process of reflective self-assessment. We suggest that the findings are linked to students' previous education experience and conclude there is a need for students to be encouraged to take ownership of their undergraduate learning, to gain confidence in self-assessment and to increase the value they place on reflection.

Clinicians' Perspectives on Cure in Adult Patients with Acute Lymphoblastic Leukemia with Minimal Residual Disease: A Delphi Study.

Hematologic complete remission (CR) is achievable for most adults with B cell precursor acute lymphoblastic leukemia (BCP-ALL). However, minimal residual disease (MRD) in patients with hematologic CR is associated with increased risk of relapse, shorter survival, and poorer transplantation outcomes. This study explored the concept of cure in adults with Philadelphia chromosome-negative (Ph-) BCP-ALL by MRD status at first hematologic CR (CR1) to inform evaluation of the clinical and economic benefits of new agents, where the concept of cure is important but long-term data are not available. The study used modified Delphi methodology involving clinicians experienced in the treatment of adult ALL. Participants completed a questionnaire, which was followed by country-specific panel discussions to discuss results and identify consensus on concepts and definitions. Clinicians from France (n = 4), Germany (n = 4), and the UK (n = 5) took part. Participants described cure in terms of the probability of future relapse. Relapse-free survival (RFS) was the preferred outcome measure to describe cure for the three patient groups considered (patients with MRD at CR1; patients who become negative for MRD after further treatment; patients who continue to have MRD). Consensus was reached on definitions of cure: that cure would begin to be considered at 3 years' RFS and/or would be highly likely at 5 years' RFS. Participants agreed that patients with MRD should usually undergo hematopoietic stem cell transplantation to have the best chance of survival; consensus was reached that alternatives are required when transplantation is not an option. Panels agreed that patients who achieve cure have a higher mortality rate and lower health-related quality of life than the general population. This study provides quantitative and qualitative information on the concept of cure in Ph- BCP-ALL in CR by MRD status applicable to interpreting the value of new therapies.Funding: Amgen.Plain Language Summary: Plain language summary available for this article.

The impact of increasing workloads and role expansion on female community pharmacists in the United Kingdom.

BACKGROUND: Evidence from United Kingdom and the United States indicates that community pharmacists' workloads have increased in recent years for 2 reasons. First, because of social and demographic changes there has been a greater demand for pharmaceutical services. Second, the community pharmacists' role has expanded. This article explores the effect of increased workloads on female community pharmacists. METHODS: Face-to-face interviews (n=30) were conducted with women over the age of 30 years in the North West of England who worked as community pharmacists. The interview schedule was designed to explore factors underpinning female working patterns in community pharmacy. Specifically, interviewees were asked about perceptions of working conditions, positive and negative aspects of community pharmacy working, views of recent changes in pharmacy, and future career plans. RESULTS: Findings suggest that although community pharmacists enjoy aspects of their new roles, their work environment has become increasingly pressurized, resulting in decreased job satisfaction. Additionally, this study found some evidence that increasing workloads resulted in decreased health and well-being. CONCLUSIONS: The role of the community pharmacist has significantly altered in recent years, and this has occurred following a decade of increasing workloads. Consideration of the factors shaping community pharmacy points to high-pressure working environments becoming common place. This is likely to have a negative impact on pharmacists and conceivably the services they provide.

Contested space in the pharmacy: public attitudes to pharmacy harm reduction services in the West of Scotland.

BACKGROUND: Internationally, community pharmacies have become increasingly involved in providing harm reduction services and health advice to people who use illicit drugs. OBJECTIVE: This paper considers public opinion of community pharmacy services. It discusses attitudes to harm reduction services in the context of stigmatization of addiction and people who use drugs. METHODS: This exploratory study involved twenty-six purposively sampled members of the public, from the West of Scotland, participating in one of 5 focus groups. The groups were composed to represent known groups of users and non-users of community pharmacy, none of whom were problem drug users. RESULTS: Three thematic categories were identified: methadone service users in community pharmacies; attitudes to harm reduction policies; contested space. Harm reduction service expansion has resulted in a high volume of drug users in and around some Scottish pharmacies. Even if harm reduction services are provided discretely users' behavior can differentiate them from other pharmacy users. Drug users' behavior in this setting is commonly perceived to be unacceptable and can deter other consumers from using pharmacy services. The results of this study infer that negative public opinion is highly suggestive of stereotyping and stigmatization of people who use drugs. Participants considered that (1) community pharmacies were unsuitable environments for harm reduction service provision, as they are used by older people and those with children; (2) current drug policy is perceived as ineffective, as abstinence is seldom achieved and methadone was reported to be re-sold; (3) people who use drugs were avoided where possible in community pharmacies. CONCLUSIONS: Community pharmacy harm reduction services increasingly bring together the public and drug users. Study participants were reluctant to share pharmacy facilities with drug users. This paper concludes by suggesting mechanisms to minimize stigmatization.

A qualitative exploration of opinions on the community pharmacists' role amongst the general public in Scotland.

OBJECTIVE: To understand members of the public's opinions and experiences of pharmacy services. METHOD: This exploratory study employed qualitative methods. Five focus groups were conducted with 26 members of the public resident in Scotland in March 2010. The groups comprised those perceived to be users and non-users of community pharmacy. A topic guide was developed to prompt discussion. Each focus group was recorded, transcribed, anonymised and analysed using thematic analysis. KEY FINDINGS: Participants made positive comments about pharmacy services although many preferred to see a general practitioner (GP). Participants discussed using pharmacies for convenience, often because they were unable to access GPs. Pharmacists were perceived principally to be suppliers of medicine, although there was some recognition of roles in dealing with minor ailments and providing advice. For those with serious and long-standing health matters GPs were usually the professional of choice for most health needs. Community pharmacy was seen to offer incomplete services which did not co-ordinate well with other primary-care services. The pharmacy environment and retail setting were not considered to be ideal for private healthcare consultations. CONCLUSIONS: This study suggests that despite recent initiatives to extend the role of community pharmacists many members of the general public continue to prefer a GP-led service. Importantly GPs inspire public confidence as well as offering comprehensive services and private consultation facilities. Improved communication and information sharing between community pharmacists and general practice could support community pharmacist-role expansion.

Understanding public trust in services provided by community pharmacists relative to those provided by general practitioners: a qualitative study.

OBJECTIVES: To apply sociological theories to understand public trust in extended services provided by community pharmacists relative to those provided by general practitioners (GPs). DESIGN: Qualitative study involving focus groups with members of the public. SETTING: The West of Scotland. PARTICIPANTS: 26 purposively sampled members of the public were involved in one of five focus groups. The groups were composed to represent known groups of users and non-users of community pharmacy, namely mothers with young children, seniors and men. RESULTS: Trust was seen as being crucial in healthcare settings. Focus group discussions revealed that participants were inclined to draw unfavourable comparisons between pharmacists and GPs. Importantly, participants' trust in GPs was greater than that in pharmacists. Participants considered pharmacists to be primarily involved in medicine supply, and awareness of the pharmacist's extended role was low. Participants were often reluctant to trust pharmacists to deliver unfamiliar services, particularly those perceived to be 'high risk'. Numerous system-based factors were identified, which reinforce patient trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments. Our data indicate that the nature and context of public interactions with GPs fostered familiarity with a specific GP or practice, which allowed interpersonal trust to develop. By contrast, participants' exposure to community pharmacists was limited. Additionally, a good understanding of the GPs' level of training and role promoted confidence. CONCLUSION: Current UK initiatives, which aim to implement a range of pharmacist-led services, are undermined by lack of public trust. It seems improbable that the public will trust pharmacists to deliver unfamiliar services, which are perceived to be 'high risk', unless health systems change in a way that promotes trust in pharmacists. This may be achieved by increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services.

Increasing community pharmacy workloads in England: causes and consequences.

OBJECTIVE: To explore English community pharmacists experiences of workload increases. Setting North West of England. METHOD: Ninety-six women and 71 men replied (response rates = 40 and 31%, respectively). Thirty female pharmacists and 29 male pharmacists were interviewed between February 2005 and February 2008. The study involved semi-structured face-to-face interviews with theoretically sampled respondents. Interviews were recorded and transcribed verbatim and a thematic analysis conducted. MAIN OUTCOME MEASURES: English community pharmacists' opinions and experiences. This paper specifically considers the following themes, community pharmacists' accounts of workload, role expansion, skill mix, management support, coping strategies, perceptions of patient safety, and impact on pharmacists health and well-being. RESULTS: Respondents reported escalating workloads in community pharmacy, which most respondents linked to increased stress and decreased job satisfaction. There were striking differences in the work patterns described by the male and female community pharmacists. Male interviewees commonly worked full time, in senior positions in community pharmacy. Female interviewees commonly worked part time as employees. This study suggests that interviewees perceived that skill mix initiatives were not currently helped pharmacists deal with rising workload demands. Additionally, this study found some evidence that work intensification resulted in decreased health and well-being and prompted concerns about patient safety. Community pharmacists are more vulnerable to work intensification than other health care professions. The demand-control-support model was applied to understand causes of work related stress. Interviews described using problem based coping strategies to combat stressful working environments. CONCLUSIONS: Workloads have increased in community pharmacy and the work environment has become increasingly stressful. Consideration of the factors shaping community pharmacy point to continued workload increases. This is likely to have a negative impact on pharmacists and conceivably the services they provide. Skilled support staff, supportive management and appropriate resourcing are required to maintain high quality services.

A comparison of parents and pediatric anesthesiologists' preferences for attributes of child daycase surgery: a discrete choice experiment.

BACKGROUND: Currently, there is little evidence relating to which attributes of pediatric daycase surgery are most important to parents; therefore, it is difficult for policy-makers in the UK to incorporate parents' preferences into pediatric daycase service provision. Additionally, few studies have considered anesthesiologists' preferences in this area. Parents and anesthesiologists' preferences for perioperative care of children undergoing daycase surgery may differ and this could affect levels of satisfaction with service provision. This study aimed to elicit and compare the relative importance of attributes of pediatric daycase surgery provision to parents and anesthesiologists using an established stated preference method, the discrete choice experiment. The attributes considered were: parental involvement in medical decision making; parental presence at induction of anaesthesia; quality of recovery from anaesthesia; staff attitude; postoperative pain and cost to the parents. METHODS: A postal questionnaire including a discrete choice experiment was sent to (a) parents whose children had been admitted to hospital under a surgical consultant (n = 280) and (b) anesthesiologists who are resident in the UK and are members of the Association of Paediatric Anaesthetists (n = 193). RESULTS: All six attributes studied were statistically significant to both respondent groups, indicating that all attributes were important to respondents. The strength of anesthesiologists and parents' preferences was significantly different for all attributes other than parental presence at induction of anaesthesia. CONCLUSIONS: Parents and anesthesiologists had a significantly different order of priorities for service attributes.