Views of healthcare professionals on complementary and alternative medicine use by patients with diabetes: a qualitative study.

BACKGROUND: Recent estimates indicate that a significant proportion of diabetic patients globally, up to 51%, are utilizing complementary and alternative medicine (CAM). To improve patient-provider communication and optimize prescribed treatments, healthcare professionals (HCPs) must understand the factors associated with CAM use among diabetic patients. There is a dearth of literature on HCPs perspectives on CAM use by diabetic patients. This study explored HCPs knowledge, perspective, and views on their diabetic patients' use of CAM. METHODS: Qualitative study using one-to-one semi-structured interviews conducted with 22 HCPs involved in the care of diabetic patients (6 endocrinologists, 4 general practitioners, 4 nurses and 8 pharmacists). Participants were recruited through general practices, community pharmacies and a diabetic centre in Saudi Arabia. Data were analyzed using thematic analysis. RESULTS: Five key themes resulted from the analysis. HCPs generally demonstrated negative perceptions toward CAM, particularly regarding their evidence-based effectiveness and safety. Participants described having limited interactions with diabetic patients regarding CAM use due to HCPs' lack of knowledge about CAM, limited consultation time and strict consultation protocols. Participants perceived convenience as the reason why patients use CAM. They believed many users lacked patience with prescribed medications to deliver favourable clinical outcomes and resorted to CAM use. CONCLUSIONS: HCPs have noted inadequate engagement with diabetic patients regarding CAM due to a lack of knowledge and resources. To ensure the safe use of CAM in diabetes and optimize prescribed treatment outcomes, one must address the communication gap by implementing a flexible consultation protocol and duration. Additionally, culturally sensitive, and evidence-based information should be available to HCPs and diabetic patients.

Baseline characteristics of people experiencing homelessness with a recent drug overdose in the PHOENIx pilot randomised controlled trial.

BACKGROUND: Drug-related deaths in Scotland are the highest in Europe. Half of all deaths in people experiencing homelessness are drug related, yet we know little about the unmet health needs of people experiencing homelessness with recent non-fatal overdose, limiting a tailored practice and policy response to a public health crisis. METHODS: People experiencing homelessness with at least one non-fatal street drug overdose in the previous 6 months were recruited from 20 venues in Glasgow, Scotland, and randomised into PHOENIx plus usual care, or usual care. PHOENIx is a collaborative assertive outreach intervention by independent prescriber NHS Pharmacists and third sector homelessness workers, offering repeated integrated, holistic physical, mental and addictions health and social care support including prescribing. We describe comprehensive baseline characteristics of randomised participants. RESULTS: One hundred and twenty-eight participants had a mean age of 42 years (SD 8.4); 71% male, homelessness for a median of 24 years (IQR 12-30). One hundred and eighteen (92%) lived in large, congregate city centre temporary accommodation. A quarter (25%) were not registered with a General Practitioner. Participants had overdosed a mean of 3.2 (SD 3.2) times in the preceding 6 months, using a median of 3 (IQR 2-4) non-prescription drugs concurrently: 112 (87.5%) street valium (benzodiazepine-type new psychoactive substances); 77 (60%) heroin; and 76 (59%) cocaine. Half (50%) were injecting, 50% into their groins. 90% were receiving care from Alcohol and Drug Recovery Services (ADRS), and in addition to using street drugs, 90% received opioid substitution therapy (OST), 10% diazepam for street valium use and one participant received heroin-assisted treatment. Participants had a mean of 2.2 (SD 1.3) mental health problems and 5.4 (SD 2.5) physical health problems; 50% received treatment for physical or mental health problems. Ninety-one per cent had at least one mental health problem; 66% had no specialist mental health support. Participants were frail (70%) or pre-frail (28%), with maximal levels of psychological distress, 44% received one or no daily meal, and 58% had previously attempted suicide. CONCLUSIONS: People at high risk of drug-related death continue to overdose repeatedly despite receiving OST. High levels of frailty, multimorbidity, unsuitable accommodation and unmet mental and physical health care needs require a reorientation of services informed by evidence of effectiveness and cost-effectiveness. Trial registration UK Clinical Trials Registry identifier: ISRCTN 10585019.

Protocol for a pilot randomised controlled trial to evaluate integrated support from pharmacist independent prescriber and third sector worker for people experiencing homelessness: the PHOENIx community pharmacy study.

BACKGROUND: People experiencing homelessness (PEH) have complex health and social care needs and most die in their early 40 s. PEH frequently use community pharmacies; however, evaluation of the delivery of structured, integrated, holistic health and social care intervention has not been previously undertaken in community pharmacies for PEH. PHOENIx (Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx) has been delivered and tested in Glasgow, Scotland, by NHS pharmacist independent prescribers and third sector homelessness support workers offering health and social care intervention in low threshold homeless drop-in venues, emergency accommodation and emergency departments, to PEH. Building on this work, this study aims to test recruitment, retention, intervention adherence and fidelity of community pharmacy-based PHOENIx intervention. METHODS: Randomised, multi-centre, open, parallel-group external pilot trial. A total of 100 PEH aged 18 years and over will be recruited from community pharmacies in Glasgow and Birmingham. PHOENIx intervention includes structured assessment in the community pharmacy of health, housing, benefits and activities, in addition to usual care, through weekly visits lasting up to six months. A primary outcome is whether to proceed to a definitive trial based on pre-specified progression criteria. Secondary outcomes include drug/alcohol treatment uptake and treatment retention; overdose rates; mortality and time to death; prison/criminal justice encounters; healthcare utilisation; housing tenure; patient-reported measures and intervention acceptability. Analysis will include descriptive statistics of recruitment and retention rates. Process evaluation will be conducted using Normalisation Process Theory. Health, social care and personal resource use data will be identified, measured and valued. DISCUSSION: If the findings of this pilot study suggest progression to a definitive trial, and if the definitive trial offers positive outcomes, it is intended that PHOENIx will be a publicly funded free-to-access service in community pharmacy for PEH. The study results will be shared with wider stakeholders and patients in addition to dissemination through medical journals and scientific conferences. TRIAL REGISTRATION: International Clinical Trial Registration ISRCTN88146807. Approved protocol version 2.0 dated July 19, 2022.

Pharmacist and Homeless Outreach Engagement and Non-medical Independent prescribing Rx (PHOENIx): a study protocol for a pilot randomised controlled trial.

INTRODUCTION: The number of people experiencing homelessness (PEH) is increasing worldwide. Systematic reviews show high levels of multimorbidity and mortality. Integrated health and social care outreach interventions may improve outcomes. No previous studies have targeted PEH with recent drug overdose despite high levels of drug-related deaths and few data describe their health/social care problems. Feasibility work suggests a collaborative health and social care intervention (Pharmacist and Homeless Outreach Engagement and Non-medical Independent prescribing Rx, PHOENIx) is potentially beneficial. We describe the methods of a pilot randomised controlled trial (RCT) with parallel process and economic evaluation of PEH with recent overdose. METHODS AND ANALYSIS: Detailed health and social care information will be collected before randomisation to care-as-usual plus visits from a pharmacist and a homeless outreach worker (PHOENIx) for 6-9 months or to care-as-usual. The outcomes are the rates of presentations to emergency department for overdose or other causes and whether to progress to a definitive RCT: recruitment of ≥100 participants within 4 months, ≥60% of patients remaining in the study at 6 and 9 months, ≥60% of patients receiving the intervention, and ≥80% of patients with data collected. The secondary outcomes include health-related quality of life, hospitalisations, treatment uptake and patient-reported measures. Semistructured interviews will explore the future implementation of PHOENIx, the reasons for overdose and protective factors. We will assess the feasibility of conducting a cost-effectiveness analysis. ETHICS AND DISSEMINATION: The study was approved by South East Scotland National Health Service Research Ethics Committee 01. Results will be made available to PEH, the study funders and other researchers. TRIAL REGISTRATION NUMBER: ISRCTN10585019.

An umbrella review of systematic reviews on contributory factors to medication errors in health-care settings.

INTRODUCTION: Medication errors are common events that compromise patient safety and are prevalent in all health-care settings. This umbrella review aims to systematically evaluate the evidence on contributory factors to medication errors in health-care settings in terms of the nature of these factors, methodologies and theories used to identify and classify them, and the terminologies and definitions used to describe them. AREAS COVERED: Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, and Google Scholar were searched from inception to March 2022. The data extraction form was derived from the Joanna Briggs Institute (JBI) Reviewers' Manual, and critical appraisal was conducted using the JBI quality assessment tool. A narrative approach to data synthesis was adopted. EXPERT OPINION: Twenty-seven systematic reviews were included, most of which focused on a specific health-care setting or clinical area. Decision-making mistakes such as non-consideration of patient risk factors most commonly led to error, followed by organizational and environmental factors (e.g. understaffing and distractions). Only 10 studies had a pre-specified methodology to classify contributory factors, among which the use of theory, specifically Reason's theory was commonly used. None of the reviews evaluated the effectiveness of interventions in preventing errors. The collated contributory factors identified in this umbrella review can inform holistic theory-based intervention development.

Complementary and alternative medicine use in self-management of diabetes: A qualitative study of patient and user conversations in online forums.

BACKGROUND: An important part of diabetes self-management includes discussing and seeking informal advice from others. AIM: This study aimed to explore beliefs and experiences of patients in relation to their use of CAM in diabetes through the use of data from online patient forum discussions. METHOD: Google search engine was used to identify relevant web-based online discussion forums in English language focussing on CAM use (including herbal and other unorthodox therapies) in diabetes and posted by either patients or carers. No date limit was imposed. A qualitative content analysis was adopted for analysis. RESULTS: Twenty-two online forums containing 77 threads with 1156 posts and replies were identified. Seven major themes emerged from the data analysis including: patient beliefs regarding CAM use, perceived effectiveness and safety of CAM, evidence base and information seeking. Patients used online forums to seek information about the benefits, side effects and share positive and negative experiences of CAM use. Feeling stressed, frustrated or overwhelmed with diabetes and prescribed medications was often linked to their decisions to use CAM. They described that healthcare professionals were often unaware or unable to help in regards to their queries around CAMs. CONCLUSION: Patients with diabetes use online forums to share information regarding CAM use. There is a scope for professional societies, patient charities and health systems to offer such online platforms to promote rationale use of CAM, provide evidence-based information to patients and alleviate fears and concerns around diabetes and prescribed medicines.

Factors affecting complementary and alternative medicine (CAM) use by adult diabetic patients: A systematic review using the theoretical domains framework (TDF).

BACKGROUND: It is estimated that approximately 50% of patients with diabetes use some form of complementary and alternative medicine (CAM) to manage their condition. OBJECTIVES: The objective of this study was to undertake a systematic review to explore factors that influence the use of CAM by diabetic patients. METHODS: A systematic review of literature was conducted using Cochrane and PRISMA guidelines. Nine databases including MEDLINE and EMBASE were searched from 2010 to March 2021 using medical subject headings and natural language keywords. Data in relation to factors associated with use of CAM in diabetic patients 18 years of age and older were extracted and further categorised as per the theoretical domains framework (TDF). RESULTS: Forty-three studies from 28 countries were included. A total of 84 factors were identified. Key factors related to the 'intentions (to treat and relieve symptoms) and goals' domain of the TDF. Accessibility and affordability compared to physician visits and modern medicines (TDF- environmental context and resources), 'Social influences' from family members, friends, religious and spiritual scholars were amongst other factors reported to be important. Users also reported lack of trust in modern medicines and perceived CAMs to be safer and free from adverse effects. CONCLUSIONS: Decisions to use CAM in diabetes are multifactorial. Healthcare professionals' awareness of patients' CAM use and associated factors can inform counselling practices and promote treatment optimisation, adherence and patient safety through avoidance of drug-CAM interactions. Alleviating patients' concerns and reluctance to use prescribed treatments are imperative to achieve therapeutic goals. Improving access and affordability is imperative where high costs prevent use of prescribed medicines leading to many patients using CAM as a standalone therapy. [Systematic review registration: PROSPERO CRD42019125036].

Complementary and alternative medicines use in COVID-19: A global perspective on practice, policy and research.

The COVID-19 pandemic has met international health systems with a low level of preparedness and emergency response. While the emergence of effective vaccines has offered the Governments, scientific communities, and members of the public a possible way out of the pandemic, effective pharmacotherapy, including immunotherapy for COVID-19 prevention and treatment, are yet to be established. Internationally, this has led to a surge in the demand and supply of many complementary and alternative medicines (CAM) and practices. Recent studies have shown increasing CAM information requests made to pharmacists and other healthcare staff from members of public and patients aimed at prevention, symptoms relief or treatment of COVID-19. In this context, it is imperative that healthcare professionals, including pharmacists, are acquainted with current practices, policies, and research in relation to CAM use in COVID-19. This narrative commentary will provide an update on global practices, policies and research in regards to CAM use in the context of COVID-19. Healthcare professionals' understanding of popular CAMs and those tipped for potential benefits in COVID-19, patient and consumer behaviors in relation to CAM use; and healthcare professionals' awareness of cultural, religious, and self-care practices associated with CAM use are imperative to inform effective communication and counselling practices and promote evidence based self-care when patients present for advice. This narrative provides relevant discussions specific to different continents and regions historically linked to diverse CAM practices.

Global prevalence and types of complementary and alternative medicines use amongst adults with diabetes: systematic review and meta-analysis.

AIM: This study aimed to undertake a systematic review and meta-analysis of global prevalence and types of complementary and alternative medicine (CAM) use amongst adults with diabetes. METHODS: Nine databases, including MEDLINE and EMBASE, were searched for studies published between 2009 and 2019 which included extractable data for CAM use in adult patients with diabetes. Study characteristics, types of CAM, and overall and subgroup prevalence data in relation to CAM use were extracted. Meta-analysis of aggregate level data on prevalence and prevalence ratios (PRs) was performed using a random effects model. RESULTS: From the 38 studies included in the review, a total of 37 types of CAM and 223 types of herbs were identified. Pooled prevalence of CAM use was 51%. A wide variation in prevalence rates (predictive interval 8-93%) was observed. In the context of high heterogeneity, we found no evidence that CAM use was associated with gender, chronicity or type of diabetes. Approximately one third of patients did not disclose their use of CAM to healthcare professionals (95% PrI 25%, 97%). Herbal medicines, acupuncture, homoeopathy and spiritual healing were the common CAM types reported. CONCLUSIONS: A wide variation in prevalence of CAM use by patients with diabetes was identified. Healthcare professionals should be aware of their patients' use of CAM to ensure treatment optimization, avoid herb-drug interactions and promote medication adherence in diabetes. Diabetic reviews and clinical guidelines should incorporate exploration of patient use of CAM as many patients do not proactively disclose the use of CAM to their healthcare professionals. REGISTRATION: The protocol for this study was registered with the Centre for Review and Dissemination (CRD). Protocol registration number CRD42019125036.

Complementary and Alternative Medicines for the Treatment of Hepatitis C: Perspectives of Users and CAM Practitioners.

BACKGROUND: Despite substantial progress in the treatment of hepatitis C through the use of direct-acting antivirals which have been shown to cure the disease, complementary and alternative medicines (CAM) are popular among patients as a substitute or complement of allopathic medicines. This study aimed to explore the perspectives of patients and CAM practitioners on the use of CAM for the treatment of hepatitis C in Pakistan. METHODS: A cross-sectional design was adopted. Participants (CAM practitioners and patients) were recruited from the capital and two provinces: Khyber Pakhtunkhwa and Punjab of Pakistan. A survey using paper-based questionnaires, each specific for patients and CAM practitioners, was conducted to gather information pertaining to demography, disease status, treatment history, and participants' perspectives (about the disease, reasons to switch to CAM, and referring source). RESULTS: A total of 417 respondents (n = 284 patients, n = 133 practitioners) were recruited. Of the total patients, 170 (59.9%) had started CAM during the previous three months. There were 168 (59.2%) of the total patients who had used allopathic treatments for hepatitis C prior to their use of CAM. The confidence in CAM (24.6%), high cost (19%), and unbearable side effects (52.1%) of allopathic medicines were the main reasons to switch to CAM treatment. Majority (49.3%) of the patients were referred to CAM on the recommendations of relatives or care givers (17.3%) whereas only 9.5% were referred by health care professionals. Out of 133 practitioners, 48 (36.1%) were practicing herbal medicines. From practitioners' perspectives, club-moss (Lycopodium clavatum) was the best treatment option for hepatitis C. The majority, 73 (54.9%), of the patients had chosen to use CAM because of the side effects of allopathic medicines. Patients who had previous "good experience" with CAM were the most common referral source (56.4%) for CAM use in hepatitis C. CONCLUSIONS: Patients' beliefs in CAM, side effects of allopathic therapy, high cost of allopathic medicines, and referrals from previous CAM users are key factors in the switching of hepatitis C patients to CAM.

Clinical Pharmacy Intervention for Persons Experiencing Homelessness: Evaluation of Patient Perspectives in Service Design and Development.

Persons experiencing homelessness have a high prevalence of severe mental health problems, alcohol dependence, substance misuse and infectious hepatitis C, and face up to twelve times higher mortality rates compared to the general population. They also face barriers to accessing healthcare. However, clinical pharmacy services are currently not available to homeless populations in England. The aim of this study was to conduct public involvement sessions with persons experiencing homelessness with a view to inform the design of patient-centred clinical pharmacy healthcare services. Qualitative methodology was used, using a focus group with homeless persons from emergency shelters and one to one engagement with those sleeping rough, using a topic guide. A total of nine homeless persons took part-seven males and two females. The participants of the sessions said that patient-centred clinical pharmacy services delivered for homeless persons would address many of their unmet needs around access to medicines, their understanding of prescribed medicines and holistic management of their health. The service would be able to make a positive impact on their health outcomes by screening for health conditions, facilitating better integration across services, referral and liaison with other services, and minimising misuse of prescribed medicines. The findings of this study will be used to inform the development, implementation and evaluation of a patient-centred clinical pharmacy service tailored to meet the specific needs of the homeless population.

Are pharmacy-based minor ailment schemes a substitute for other service providers? A systematic review.

BACKGROUND: Pharmacy-based minor ailment schemes (PMASs) have been introduced throughout the UK to reduce the burden of minor ailments on high-cost settings, including general practice and emergency departments. AIM: This study aimed to explore the effect of PMASs on patient health- and cost-related outcomes; and their impact on general practices. DESIGN AND SETTING: Community pharmacy-based systematic review. METHOD: Standard systematic review methods were used, including searches of electronic databases, and grey literature from 2001 to 2011, imposing no restrictions on language or study design. Reporting was conducted in the form recommended in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and checklist. RESULTS: Thirty-one evaluations were included from 3308 titles identified. Reconsultation rates in general practice, following an index consultation with a PMAS, ranged from 2.4% to 23.4%. The proportion of patients reporting complete resolution of symptoms after an index PMAS consultation ranged from 68% to 94%. No study included a full economic evaluation. The mean cost per PMAS consultation ranged from £1.44 to £15.90. The total number of consultations and prescribing for minor ailments at general practices often declined following the introduction of PMAS. CONCLUSION: Low reconsultation and high symptom-resolution rates suggest that minor ailments are being dealt with appropriately by PMASs. PMAS consultations are less expensive than consultations with GPs. The extent to which these schemes shift demand for management of minor ailments away from high-cost settings has not been fully determined. This evidence suggests that PMASs provide a suitable alternative to general practice consultations. Evidence from economic evaluations is needed to inform the future delivery of PMASs.