A rapid review of interventions to improve medicine self-management for older people living at home.

BACKGROUND: As people age, they are more likely to develop multiple long-term conditions that require complicated medicine regimens. Safely self-managing multiple medicines at home is challenging and how older people can be better supported to do so has not been fully explored. AIM: This study aimed to identify interventions to improve medicine self-management for older people living at home and the aspects of medicine self-management that they address. DESIGN: A rapid review was undertaken of publications up to April 2022. Eight databases were searched. Inclusion criteria were as follows: interventions aimed at people 65 years of age or older and their informal carers, living at home. Interventions needed to include at least one component of medicine self-management. Study protocols, conference papers, literature reviews and articles not in the English language were not included. The results from the review were reported through narrative synthesis, underpinned by the Resilient Healthcare theory. RESULTS: Database searches returned 14,353 results. One hundred and sixty-seven articles were individually appraised (full-text screening) and 33 were included in the review. The majority of interventions identified were educational. In most cases, they aimed to improve older people's adherence and increase their knowledge of medicines. Only very few interventions addressed potential issues with medicine supply. Only a minority of interventions specifically targeted older people with either polypharmacy, multimorbidities or frailty. CONCLUSION: To date, the emphasis in supporting older people to manage their medicines has been on the ability to adhere to medicine regimens. Most interventions identify and target deficiencies within the patient, rather than preparing patients for problems inherent in the medicine management system. Medicine self-management requires a much wider range of skills than taking medicines as prescribed. Interventions supporting older people to anticipate and respond to problems with their medicines may reduce the risk of harm associated with polypharmacy and may contribute to increased resilience in the system. PATIENT OR PUBLIC CONTRIBUTION: A patient with lived experience of medicine self-management in older age contributed towards shaping the research question as well as the inclusion and exclusion criteria for this review. She is also the coauthor of this article. A patient advisory group oversaw the study.

Co-designing an intervention to improve the process of deprescribing for older people living with frailty in the United Kingdom.

BACKGROUND: In older people living with frailty, polypharmacy can lead to preventable harm like adverse drug reactions and hospitalization. Deprescribing is a strategy to reduce problematic polypharmacy. All stakeholders should be actively involved in developing a person-centred deprescribing process that involves shared decision-making. OBJECTIVE: To co-design an intervention, supported by a logic model, to increase the engagement of older people living with frailty in the process of deprescribing. DESIGN: Experience-based co-design is an approach to service improvement, which uses service users and providers to identify problems and design solutions. This was used to create a person-centred intervention with the potential to improve the quality and outcomes of the deprescribing process. A 'trigger film' showing older people talking about their healthcare experiences was created and facilitated discussions about current problems in the deprescribing process. Problems were then prioritized and appropriate solutions were developed. The review located the solutions in the context of current processes and procedures. An ideal care pathway and a complex intervention to deliver better care were developed. SETTING AND PARTICIPANTS: Older people living with frailty, their informal carers and professionals living and/or working in West Yorkshire, England, UK. Deprescribing was considered in the context of primary care. RESULTS: The current deprescribing process differed from an ideal pathway. A complex intervention containing seven elements was required to move towards the ideal pathway. Three of these elements were prototyped and four still need development. The complex intervention responded to priorities about (a) clarity for older people about what was happening at all stages in the deprescribing process and (b) the quality of one-to-one consultations. CONCLUSIONS: Priorities for improving the current deprescribing process were successfully identified. Solutions were developed and structured as a complex intervention. Further work is underway to (a) complete the prototyping of the intervention and (b) conduct feasibility testing. PATIENT OR PUBLIC CONTRIBUTION: Older people living with frailty (and their informal carers) have made a central contribution, as collaborators, to ensure that a complex intervention has the greatest possible potential to enhance the experience of deprescribing medicines.

Experiences of patients with heart failure with medicines at transition intervention: Findings from the process evaluation of the Improving the Safety and Continuity of Medicines management at Transitions of care (ISCOMAT) programme.

BACKGROUND: Medicines are often suboptimally managed for heart failure patients across the transition from hospital to home, potentially leading to poor patient outcomes. The Improving the Safety and Continuity Of Medicines management at Transitions of care programme included: understanding the problems faced by patients and healthcare professionals; developing and co-designing the Medicines at Transitions of care Intervention (MaTI); a cluster randomized controlled trial testing the effectiveness of a complex behavioural MaTI aimed at improving medicines management at the interface between hospitals discharge and community care for patients with heart failure; and a process evaluation. The MaTI included a patient-held My Medicines Toolkit; enhanced communication between the hospital and the patient's community pharmacist and increased engagement of the community pharmacist postdischarge. This paper reports on the patients' experiences of the MaTI and its implementation from the process evaluation. DESIGN: Twenty one-to-one semi-structured patient interviews from six intervention sites were conducted between November 2018 and January 2020. Data were analysed using the Framework method, involving patients as co-analysts. Interview data were triangulated with routine trial data, the Consolidated Framework for Implementation Research and a logic model. RESULTS: Within the hospital setting patients engaged with the toolkit according to whether staff raised awareness of the My Medicines Toolkit's importance and the time and place of its introduction. Patients' engagement with community pharmacy depended on their awareness of the community pharmacist's role, support sources and perceptions of involvement in medicines management. The toolkit's impact on patients' medicines management at home included reassurance during gaps in care, increased knowledge of medicines, enhanced ability to monitor health and seek support and supporting sharing medicines management between formal and informal care networks. CONCLUSION: Many patients perceived that the MaTI offered them support in their medicines management when transitioning from hospital into the community. Importantly, it can be incorporated into and built upon patients' lived experiences of heart failure. Key to its successful implementation is the quality of engagement of healthcare professionals in introducing the intervention. PATIENT OR PUBLIC CONTRIBUTION: Patients were involved in the study design, as qualitative data co-analysts and as co-authors.

Supporting medicines management for older people at care transitions - a theory-based analysis of a systematic review of 24 interventions.

BACKGROUND: Older patients are at severe risk of harm from medicines following a hospital to home transition. Interventions aiming to support successful care transitions by improving medicines management have been implemented. This study aimed to explore which behavioural constructs have previously been targeted by interventions, which individual behaviour change techniques have been included, and which are yet to be trialled. METHOD: This study mapped the behaviour change techniques used in 24 randomised controlled trials to the Behaviour Change Technique Taxonomy. Once elicited, techniques were further mapped to the Theoretical Domains Framework to explore which determinants of behaviour change had been targeted, and what gaps, if any existed. RESULTS: Common behaviour change techniques used were: goals and planning; feedback and monitoring; social support; instruction on behaviour performance; and prompts/cues. These may be valuable when combined in a complex intervention. Interventions mostly mapped to between eight and 10 domains of the Theoretical Domains Framework. Environmental context and resources was an underrepresented domain, which should be considered within future interventions. CONCLUSION: This study has identified behaviour change techniques that could be valuable when combined within a complex intervention aiming to support post-discharge medicines management for older people. Whilst many interventions mapped to eight or more determinants of behaviour change, as identified within the Theoretical Domains Framework, careful assessment of the barriers to behaviour change should be conducted prior to intervention design to ensure all appropriate domains are targeted.

Successful care transitions for older people: a systematic review and meta-analysis of the effects of interventions that support medication continuity.

BACKGROUND: medication-related problems occur frequently when older patients are discharged from hospital. Interventions to support medication use have been developed; however, their effectiveness in older populations are unknown. This review evaluates interventions that support successful transitions of care through enhanced medication continuity. METHODS: a database search for randomised controlled trials was conducted. Selection criteria included mean participant age of 65 years and older, intervention delivered during hospital stay or following recent discharge and including activities that support medication continuity. Primary outcome of interest was hospital readmission. Secondary outcomes related to the safe use of medication and quality of life. Outcomes were pooled by random-effects meta-analysis where possible. RESULTS: twenty-four studies (total participants = 17,664) describing activities delivered at multiple time points were included. Interventions that bridged the transition for up to 90 days were more likely to support successful transitions. The meta-analysis, stratified by intervention component, demonstrated that self-management activities (RR 0.81 [0.74, 0.89]), telephone follow-up (RR 0.84 [0.73, 0.97]) and medication reconciliation (RR 0.88 [0.81, 0.96]) were statistically associated with reduced hospital readmissions. CONCLUSION: our results suggest that interventions that best support older patients' medication continuity are those that bridge transitions; these also have the greatest impact on reducing hospital readmission. Interventions that included self-management, telephone follow-up and medication reconciliation activities were most likely to be effective; however, further research needs to identify how to meaningfully engage with patients and caregivers to best support post-discharge medication continuity. Limitations included high subjectivity of intervention coding, study heterogeneity and resource restrictions.

Post-discharge medicines management: the experiences, perceptions and roles of older people and their family carers.

BACKGROUND: Multiple changes are made to older patients' medicines during hospital admission, which can sometimes cause confusion and anxiety. This results in problems with post-discharge medicines management, for example medicines taken incorrectly, which can lead to harm, hospital readmission and reduced quality of life. AIM: To explore the experiences of older patients and their family carers as they enacted post-discharge medicines management. DESIGN: Semi-structured interviews took place in participants' homes, approximately two weeks after hospital discharge. Data analysis used the Framework method. SETTING AND PARTICIPANTS: Recruitment took place during admission to one of two large teaching hospitals in North England. Twenty-seven participants aged 75 plus who lived with long-term conditions and polypharmacy, and nine family carers, were interviewed. FINDINGS: Three core themes emerged: impact of the transition, safety strategies and medicines management role. Conversations between participants and health-care professionals about medicines changes often lacked detail, which disrupted some participants' knowledge and medicines management capabilities. Participants used multiple strategies to support post-discharge medicines management, such as creating administration checklists, seeking advice or supporting primary care through prompts to ensure medicines were supplied on time. The level to which they engaged with these activities varied. DISCUSSION AND CONCLUSION: Participants experienced gaps in their post-discharge medicines management, which they had to bridge through implementing their own strategies or by enlisting support from others. Areas for improvement were identified, mainly through better communication about medicines changes and wider involvement of patients and family carers in their medicines-related care during the hospital-to-home transition.

Experience-based co-design-Adapting the method for a researcher-initiated study in a multi-site setting.

BACKGROUND: Experience-based co-design (EBCD) brings patients and staff together to co-design services. It is normally conducted in one organization which initiates and implements the process. We used the traditional EBCD method with a number of adaptations as part of a larger research study in the British National Health Service. METHODS: The primary aim was to assess the feasibility and acceptability of conducting research-initiated EBCD, to enhance intervention development prior to testing. As well as embedding the method in a research study, there were 3 further key adaptations: (a) working across primary and secondary care sectors, (b) working on multiple sites and (c) incorporating theory-informed analysis. RESULTS: We recruited four sites (covering both primary and secondary care) and, on each site, conducted the initial traditional EBCD meetings, with separate staff and patient groups-followed by a single joint patient-staff event, where four priority areas for co-design were agreed. This event was driven by theory-informed analysis, as well as the traditional trigger film of patient experiences. Each site worked on one priority area, and the four co-design groups met over 2-3 months to design prototype tools. A second joint event was held (not usually undertaken in single-site EBCD) where they shared and compared outputs. The research team combined elements of these outputs to create an intervention, now being tested in a cluster randomized controlled trial. CONCLUSIONS: EBCD can be successfully adapted for use across an entire patient pathway with multiple organizations and as part of a research process to identify an intervention for subsequent testing in a randomized trial. Our pragmatic approach used the patient experience to identify areas for improvement and co-designed an intervention which directly reflected patient priorities.

Impact of Pharmacist-Led Interventions to Improve Clinical Outcomes for Adults With Type 2 Diabetes at Risk of Developing Cardiovascular Disease: A Systematic Review and Meta-analysis.

ObjectiveThe aim of this systematic review and meta-analysis of randomised controlled trials is to evaluate the impact of pharmacist-led interventions on cardiovascular disease (CVD) risk factors among patients with type 2 diabetes. Method: A literature review was conducted according to PRISMA guidelines using 4 electronic databases: Embase, MEDLINE, CINHAL and the Cochrane Central Register of Controlled Trials. We searched for pharmacist interventions among adults with type 2 diabetes and cardiovascular disease in randomised controlled trials from inception to May 2021 in primary care, diabetes clinics and hospitals. The clinical outcomes measured glycosylated haemoglobin (HbA1c), blood pressure (BP) and lipid profile. The non-clinical outcomes included medication adherence, smoking, health-related quality of life and the cost of the intervention. For the meta-analysis, clinical outcomes were pooled with the random effect model in RevMan 5.3. The Cochrane risk-of-bias tool was used to assess the quality of the included studies. Results: We retrieved 223 studies,141 of which were included in the review. Ten published articles met the inclusion criteria and were included in the meta-analysis. The pharmacists delivered the interventions alone or collaboratively with other healthcare professionals in hospitals or similar settings. The overall result showed a significant reduction in HbA1c (n = 10; standard deviation in mean value [SDM]: -.53%, 95% CI: -.84, -.23) and systolic BP (n = 10; [SDM]: -.35 mmHg, 95% CI: -.51, -.20) in pharmacist intervention groups. For the non-clinical outcomes, the review revealed variable results from pharmacist intervention compared with those standard care. Conclusion: Pharmacy interventions provide evidence for pharmacists' decisive role in diabetes care management and reducing cardiovascular risk factors among adults with type 2 diabetes.

Economic evaluations of adult critical care pharmacy services: a scoping review.

OBJECTIVES: To summarise the extent and type of evidence available regarding economic evaluations of adult critical care pharmacy services in the context of UK practice. METHODS: A literature search was conducted in eight electronic databases and hand searching of full-text reference lists. Of 2409 journal articles initially identified, 38 were included in the final review. Independent literature review was undertaken by two investigators in a two-step process against the inclusion and exclusion criteria; title and abstract screening were followed by full-text screening. Included studies were taken from high-income economy countries that contained economic data evaluating any key aspect of adult critical care pharmacy services. Grey literature and studies that could not be translated into the English language were excluded. RESULTS: The majority were before-and-after studies (18, 47%) or other observational studies (17, 45%), and conducted in North America (25, 66%). None of the included studies were undertaken in the UK. Seven studies (18%) included cost-benefit analysis; all demonstrated positive cost-benefit values for clinical pharmacist activities. CONCLUSIONS: Further high-quality primary research focussing on the economic evaluation of UK adult critical care pharmacy services is needed, before undertaking a future systematic review. There is an indication of a cost-benefit value for critical care pharmacist activities. The lack of UK-based economic evaluations is a limitation to further development and standardisation of critical care pharmacy services nationally.

Using routine healthcare data to evaluate the impact of the Medicines at Transitions Intervention (MaTI) on clinical outcomes of patients hospitalised with heart failure: protocol for the Improving the Safety and Continuity Of Medicines management at Transitions of care (ISCOMAT) cluster randomised controlled trial with embedded process evaluation, health economics evaluation and internal pilot.

INTRODUCTION: Heart failure affects 26 million people globally, approximately 900 thousand people in the UK, and is increasing in incidence. Appropriate management of medicines for heart failure at the time of hospital discharge reduces readmissions, improves quality of life and increases survival. The Improving the Safety and Continuity Of Medicines management at Transitions (ISCOMAT) trial tests the effectiveness of the Medicines at Transition Intervention (MaTI), which aims to enhance self-care and increase community pharmacy involvement in the medicines management of heart failure patients. METHODS AND ANALYSIS: ISCOMAT is a parallel-group cluster randomised controlled trial, randomising 42 National Health Service trusts with cardiology wards in England on a 1:1 basis to implement the MaTI or treatment as usual. Around 2100 patients over the age of 18 admitted to hospital with heart failure with at least moderate left ventricular systolic dysfunction within the last 5 years, and planned discharge to the geographical area of the cluster will be recruited. The MaTI consists of training for staff, a toolkit for participants, transfer of discharge information to community pharmacies and a medicines reconciliation/review. Treatment as usual is determined by local policy and practices. The primary outcome is a composite of all-cause mortality and heart failure-related hospitalisation at 12 months postregistration obtained from national electronic health records. The key secondary outcome is continued prescription of guideline-indicated therapies at 12 months measured via patient-reported data and Hospital Episode Statistics. The trial contains a parallel mixed-methods process evaluation and an embedded health economics study. ETHICS AND DISSEMINATION: The study obtained approval from the Yorkshire and the Humber-Bradford Leeds Research Ethics Committee; REC reference 18/YH/0017. Findings will be disseminated via academic and policy conferences, peer-reviewed publications and social media. Amendments to the protocol are disseminated to all relevant parties as required. TRIAL REGISTRATION NUMBER: ISRCTN66212970; Pre-results.

Can user testing of a clinical trial patient information sheet make it fit-for-purpose?--a randomized controlled trial.

BACKGROUND: The participant information sheet (PIS) provided to potential trial participants is a critical part of the process of valid consent. However, there is long-standing concern that these lengthy and complex documents are not fit-for-purpose. This has been supported recently through the application of a performance-based approach to testing and improving readability called user testing. This method is now widely used to improve patient medicine leaflets--determining whether people can find and understand key facts. This study applied for the first time a controlled design to determine whether a PIS developed through user testing had improved readability over the original, using a sheet from a UK trial in acute myeloid leukemia (AML16). METHODS: In the first phase the performance of the original PIS was tested on people in the target group for the trial. There were three rounds of testing including 50 people in total--with the information revised according to its performance after each of the first 2 rounds. In the second phase, the revised PIS was compared with the original in a parallel groups randomised controlled trial (RCT) A total of 123 participants were recruited and randomly allocated to read one version of the PIS to find and show understanding of 21 key facts. RESULTS: The first, developmental phase produced a revised PIS significantly altered in its wording and layout. In the second, trial phase 66% of participants who read the revised PIS were able to show understanding of all aspects of the trial, compared with 15% of those reading the original version (Odds Ratio 11.2; Chi-square = 31.5 p < .001). When asked to state a preference, 87.1% participants chose the revised PIS (Sign test p < .001). CONCLUSIONS: The original PIS for the AML16 trial may not have enabled valid consent. Combining performance-based user testing with expertise in writing for patients and information design led to a significantly improved and preferred information sheet. User testing is an efficient method for indicating strengths and weaknesses in trial information, and Research Ethics Committees and Institutional Review Boards should consider requesting such testing, to ensure that PIS are fit-for-purpose.

Using experience-based co-design with patients, carers and healthcare professionals to develop theory-based interventions for safer medicines use.

BACKGROUND: Experience-Based Co-Design (EBCD) is a participatory design method which was originally developed and is still primarily used as a healthcare quality improvement tool. Traditionally, EBCD has been sited within single services or settings and has yielded improvements grounded in the experiences of those delivering and receiving care. METHOD: In this article we present how EBCD can be adapted to develop complex interventions, underpinned by theory, to be tested more widely within the healthcare system as part of a multi-phase, multi-site research study. We begin with an outline of co-design and the stages of EBCD. We then provide an overview of how EBCD can be assimilated into an intervention development and evaluation study, giving examples of the adaptations and research tools and methods that can be deployed. We also suggest how to appraise the resulting intervention so it is realistic and tractable in multiple sites. We describe how EBCD can be combined with different behaviour change theories and methods for intervention development and finally, we make suggestions about the skills needed for successful intervention development using EBCD. CONCLUSION: EBCD has been recognised as being a collaborative approach to improving healthcare services that puts patients and healthcare staff at the heart of initiatives and potential changes. We have demonstrated how EBCD can be integrated into a research project and how existing research approaches can be assimilated into EBCD stages. We have also suggested where behaviour change theories can be used to better understand intervention change mechanisms.

A non-randomised feasibility study of an intervention to optimise medicines at transitions of care for patients with heart failure.

BACKGROUND: Heart failure affects 26 million people globally, and the optimal management of medicines is crucial for patients, particularly when their care is transferred between hospital and the community. Optimising clinical outcomes requires well-calibrated cross-organisational processes with staff and patients responding and adapting to medicines changes. The aim of this study was to assess the feasibility of implementing a complex intervention (the Medicines at Transitions Intervention; MaTI) co-designed by patients and healthcare staff. The purpose of the intervention was to optimise medicines management across the gaps between secondary and primary care when hospitals handover care. The study objectives were to (1) assess feasibility through meeting specified progression criteria to proceed to the trial, (2) assess if the intervention was acceptable to staff and patients, and (3) determine whether amendment or refinement would be needed to enhance the MaTI. METHODS: The feasibility of the MaTI was tested in three healthcare areas in the North of England between July and October 2017. Feasibility was measured and assessed through four agreed progression to trial criteria: (1) patient recruitment, (2) patient receipt of a medicines toolkit, (3) transfer of discharge information to community pharmacy, and (4) offer of a community pharmacy medicines review/discussion or medicines reconciliation. From the cardiology wards at each of the three NHS Acute Trusts (sites), 10 patients (aged ≥ 18 years) were recruited and introduced to the 'My Medicines Toolkit' (MMT). Patients were asked to identify their usual community pharmacy or nominate a pharmacy. Discharge information was transferred to the community pharmacy; pharmacists were asked to reconcile medicines and invited patients for a medicines use review (MUR) or discussion. At 1 month following discharge, all patients were sent three questionnaire sets: quality-of-life, healthcare utilisation, and a patient experience survey. In a purposive sample, 20 patients were invited to participate in a semi-structured interview about their experiences of the MaTI. Staff from hospital and primary care settings involved in patients' care were invited to participate in a semi-structured interview. Patient and staff interviews were analysed using Framework Analysis. Questionnaire completion rates were recorded and data were descriptively analysed. RESULTS: Thirty-one patients were recruited across three sites. Eighteen staff and 18 patients took part in interviews, and 19 patients returned questionnaire sets. All four progression to trial criteria were met. We identified barriers to patient engagement with the intervention in hospital, which were compounded by patients' focus on returning home. Some patients described not engaging in discussions with staff about medicines and lacking motivation to do so because they were preoccupied with returning home. Some patients were unable or unwilling to attend a community pharmacy in person for a medicines review. Roles and responsibilities for delivering the MaTI were different in the three sites, and staff reported variations in time spent on MaTI activities. Staff reported some work pressures and staff absences that limited the time they could spend talking to patients about their medicines. Clinical teams reported that recording a target dose for heart failure medicines in patient-held documentation was difficult as they did not always know the ideal or tolerable dose. The majority of patients reported receiving the patient-held documentation. More than two-thirds reported being offered a MUR by their community pharmacists. CONCLUSIONS: Delivery of the Medicines at Transitions Intervention (MaTI) was feasible at all three sites, and progression to trial criteria were met. Refinements were found to be necessary to overcome identified barriers and strengthen delivery of all steps of the intervention. Necessary changes to the MaTI were identified along with amendments to the implementation plan for the subsequent trial. Future implementation needs to take into account the complexity of medicines management and adaptation to local context.

Professional Identity Formation in Pharmacy Students During an Early Preregistration Training Placement.

Objective. To explore the lived experiences of pharmacy students undertaking an early preregistration training placement in the United Kingdom, particularly with respect to the development of different aspects of their professionalism. Methods. Fourteen students returning from an early preregistration placement (during the third year of their pharmacy degree) were interviewed, using a semi-structured approach. Grounded theory methods were used to analyze the transcripts and a theory was developed. Results. Developing a professional identity was the core process that occurred during the placement. This included four stages: reflection, selection of attributes, professional socialization, and perception of role. As a consequence of developing a professional identity, participants had a strong vision of the kind of pharmacist they wanted to be when qualified. They articulated an increased responsibility as students, and began to see themselves as a "trainee professional." Conclusion. The findings of this study strongly support having an early preregistration period for pharmacy students to develop a sense of professional identity and strengthen their motivation to learn.

Medication-related risk factors and its association with repeated hospital admissions in frail elderly: A case control study.

BACKGROUND: Repeated hospital admissions are prevalent in older people. The role of medication in repeated hospital admissions has not been widely studied. The hypothesis that medication-related risk factors for initial hospital admissions were also associated with repeated hospital admissions was generated. OBJECTIVES: To examine the association between medication-related risk factors and repeated hospital admissions in older people living with frailty. METHOD: A retrospective case-control study was carried out with 200 patients aged ≥75 years with unplanned medical admissions into a large teaching hospital in England between January and December 2015. Demographic, clinical, and medication-related data were obtained from review of discharge summaries. Statistical comparisons were made between patients with 3 or more hospital admissions during the study period (cases) and those with 2 or fewer admissions (controls). Regressions were performed to establish independent predictors of repeated hospital admissions. RESULTS: Participants had a mean age of 83.8 years (SD 5.68) and 65.5% were female. There were 561 admission episodes across the sample, with the main reasons for admissions recorded as respiratory problems (25%) and falls (17%). Univariate logistic regression revealed five medication-related risks to be associated with repeated hospital admissions: Hyper-polypharmacy (defined as taking ≥10 medications) (OR 2.50, p < 0.005); prescription of potentially inappropriate medications (PIMs) (OR 1.89; p < 0.05); prescription of a diuretic (OR 1.87; p < 0.05); number of high risk medication (OR 1.29; p < 0.05) and the number of 'when required' medication (OR 1.20; p < 0.05). However, the effects of these risk factors became insignificant when comorbid disease was adjusted for in a multivariable model. CONCLUSION: Medication-related risk factors may play an important role in future repeated admission risk prediction models. The modifiable nature of medication-related risks factors highlights a real opportunity to improve health outcomes.

Optimised patient information materials and recruitment to a study of behavioural activation in older adults: an embedded study within a trial.

Background: Printed participant information about randomised controlled trials is often long, technical and difficult to navigate. Improving information materials is possible through optimisation and user-testing, and may impact on participant understanding and rates of recruitment. Methods: A study within a trial (SWAT) was undertaken within the CASPER trial. Potential CASPER participants were randomised to receive either the standard trial information or revised information that had been optimised through information design and user testing. Results: A total of 11,531 patients were randomised in the SWAT. Rates of recruitment to the CASPER trial were 2.0% in the optimised information group and 1.9% in the standard information group (odds ratio 1.027; 95% CI 0.79 to 1.33; p=0.202). Conclusions: Participant information that had been optimised through information design and user testing did not result in any change to rate of recruitment to the host trial. Registration: ISRCTN ID ISRCTN02202951; registered on 3 June 2009.

Is medication review by primary-care pharmacists for older people cost effective?: a narrative review of the literature, focusing on costs and benefits.

The nature, definition and history of medication review of long-term conditions and treatment is discussed. A literature search for studies of medication review of older people in primary care by pharmacists yielded 16 reports of studies in English, and only ten of these were randomized controlled trials. Extracting meaningful conclusions from the data was problematic because of variations in the nature of the review described, the populations studied, the outcome data measured and the evaluation criteria used. There is a dearth of economic measurement and often inadequate descriptions of the interventions performed. Those interventions that were described in detail varied in the skills, training and approach of the pharmacists. Therefore, there was no possibility of aggregating results of studies, and the review conclusions are based on trends and impression rather than meta-analysis. There was no suggestion in any reports that patients were harmed by the interventions, and some consistency in suggesting that falls and hospital admissions might be reduced with modest cost savings, at least in terms of drug costs. No studies reported a benefit in terms of mortality, mental capacity or activities of daily living. The authors conclude that clinical medication review is probably of value and may be cost effective, but propose a large-scale, long-term, multicentre, collaborative clinical trial with carefully chosen (and clearly described) interventions and outcome measures to confirm this.

Do community pharmacists have the attitudes and knowledge to support evidence based self-management of low back pain?

BACKGROUND: In many countries, community pharmacists can be consulted without appointment in a large number of convenient locations. They are in an ideal position to give advice to patients at the onset of low back pain and also reinforce advice given by other healthcare professionals. There is little specific information about the quality of care provided in the pharmacy for people with back pain. The main objectives of this survey were to determine the attitudes, knowledge and reported practice of English pharmacists advising people who present with acute or chronic low back pain. METHODS: A questionnaire was designed for anonymous self-completion by pharmacists attending continuing education sessions. Demographic questions were designed to allow comparison with a national pharmacy workforce survey. Attitudes were measured with the Back Beliefs Questionnaire (BBQ) and questions based on the Working Backs Scotland campaign. Questions about the treatment of back pain in the community pharmacy were written (or adapted) to reflect and characterise the nature of practice. In response to two clinical vignettes, respondents were asked to select proposals that they would recommend in practice. RESULTS: 335 responses from community pharmacists were analysed. Middle aged pharmacists, women, pharmacy managers and locums were over-represented compared to registration and workforce data. The mean (SD) BBQ score for the pharmacists was 31.37 (5.75), which was slightly more positive than in similar surveys of other groups. Those who had suffered from back pain seem to demonstrate more confidence (fewer negative feelings, more advice opportunities and better advice provision) in their perception of advice given in the pharmacy. Awareness of written information that could help to support practice was low. Reponses to the clinical vignettes were generally in line with the evidence base. Pharmacists expressed some caution about recommending activity. Most respondents said they would benefit from more education about back pain. CONCLUSION: Those sampled generally expressed positive attitudes about back pain and were able to offer evidence based advice. Pharmacists may benefit from training to increase their ability and confidence to offer support for self-care in back pain. Further research would be useful to clarify the representativeness of the sample.

Consumer medication information in the United States, Europe, and Australia: a comparative evaluation.

OBJECTIVE: To evaluate the quality of patient information leaflets provided with dispensed medications in the United States, United Kingdom, and Australia. DESIGN: Quantitative survey by an expert panel. SETTING: United States, United Kingdom, and Australia. PARTICIPANTS: Not applicable. INTERVENTION: Patient information leaflets for atenolol, glyburide (glibenclamide), atorvastatin, and nitroglycerin (glyceryl trinitrate) from the United States, United Kingdom, and Australia. MAIN OUTCOME MEASURES: Leaflets were evaluated against U.S. consensus criteria for both clinical information and general criteria, including the design of the leaflets. RESULTS: Leaflets from Australia received a mean overall score of 90% (range 83%-94%) adherence with criteria, those from the United Kingdom a score of 81% (range 73%-84%), and those from the United States a score of 68% (range 65%-77%). The U.S. leaflets achieved 50% or less adherence for contraindication and precaution information. Omissions included warnings about preexisting allergy and illness and information about drug interactions. The U.S. leaflets also scored poorly (60%) for legibility and comprehensibility. The lower U.K. score reflected shortcomings in information about how to use and monitor the medications (46% adherence) and on adverse drug reactions (64%), largely due to the lack of clear advice about urgency of action in relation to adverse drug reactions. CONCLUSION: Leaflet quality varied more among the three countries than within each country, reflecting the regulatory context. The Australian leaflets performed well across all criteria, whereas the U.S. leaflets had significant shortcomings with the omission of vital information for the safe and effective use of the medications. A repeat survey is needed to assess whether new legislation and guidance in all three countries successfully addresses the shortcomings identified.

The organisation and development of primary care pharmacy in the United Kingdom.

Primary care pharmacists carry out clinical and administrative work directly for family doctors and primary care organisations. They are a relatively recent innovation and their role in the United Kingdom (UK)'s National Health Service (NHS) is still developing. The economic liberalization of the NHS in the 1990s seems to have provided a major stimulus for the growth of primary care pharmacy. The establishment of the new professional group was not linked to a deliberate plan or change in health policy with respect to pharmacist development. Primary care pharmacy practice is much more varied and flexible than traditional pharmacy practice in the community and hospitals. Standards and professional organisation for primary care pharmacy are slowly emerging. Modernization of the NHS is providing many new opportunities, which primary care pharmacists are well placed to take advantage of. Traditional community pharmacy faces many problems unless it can learn to develop alongside primacy care pharmacy. Pharmaceutical care is set to improve in the United Kingdom, but the precise nature of future services and providers remains uncertain.