Towards therapeutic drug monitoring of TNF inhibitors for children with juvenile idiopathic arthritis: a scoping review.

OBJECTIVES: Before a clinician decides whether treatment with TNF inhibition in children with JIA has failed, one should ensure adequate systemic exposure has been achieved. Therapeutic drug monitoring might allow for improved treatment outcome with lower treatment-associated costs. However, this requires understanding of the pharmacokinetic (PK) characteristics, and the pharmacokinetic/pharmacodynamic (PK/PD) relationship for children with JIA. We performed a scoping review to summarize the available literature and identify areas for future research. METHODS: A systematic search was conducted of the Medline, EMBASE, Web of Science and Cochrane databases as well as the clinicaltrials.gov registry. In total, 3959 records were screened and 130 publications were selected for full text assessment. RESULTS: Twenty publications were included and divided into three categories: PK (n = 9), PK/PD (n = 3) and anti-drug antibodies (n = 13). Industry involvement was significant in 14 publications. Although data are limited, systemic exposure to TNF inhibitors is generally lower in younger children but meta-analysis is not possible. The PK/PD relationship has had limited study but there is partial evidence for infliximab. Anti-drug antibodies are common, and are related to impaired clinical outcome with adalimumab and infliximab therapy. CONCLUSION: The current knowledge about the PK and PK/PD of TNF inhibitors in the treatment of children with JIA is limited, which prevents the introduction of TDM. Re-analysis of available data from previous trials, incorporation of pharmacologic assessments into existing biorepository studies as well as new prospective PK and PK/PD trials are required to obtain this knowledge.

Accessibility, feasibility and educational impact of a peer review process for general practitioner consultation skills.

BACKGROUND: External peer review of consultations has been available to general medical practitioners (GPs) in the west of Scotland for several years. This study aims to assess the feasibility, accessibility and educational impact of consultation peer review for GPs. METHOD: An interview guide was developed and an independent researcher used this to interview a sample of 10 GPs who had submitted consultations for peer review in the previous six months. RESULTS: All GPs interviewed felt that there had been educational impact as a result of consultation peer review, the majority had presented this material as part of their annual appraisal and thought that their appraisal had been enhanced as a result. The process was both acceptable and feasible for the majority of GPs interviewed. CONCLUSION: Consultation peer review appears to be an acceptable and feasible educational activity, resulting in behaviour change. It may be useful as an alternative to multisource feedback and patient questionnaires in provision of evidence of effective communication skills for annual appraisal.

Pilot study to develop and test a generic peer feedback instrument to review videotaped consultations in primary care.

BACKGROUND: The ability to consult effectively is key to the delivery of quality patient care. External peer review of consultations has been available to general medical practitioners (GPs) in the west of Scotland for several years. Pharmacists are expected to provide increasingly complex advice for patients. This study describes the development and first steps in the evaluation of a generic tool to be used to inform feedback about both GP and pharmacist consultations with patients. METHOD: The tool was developed by a small group of GPs and tested for validity using a content validity inventory. An item correlation pilot (ICP) was carried out. Three experienced reviewers reviewed and scored three consultations in each of six GP tapes, a further three reviewers reviewed and scored three consultations in each of four pharmacists' tapes. The results underwent statistical analysis. RESULTS: Pharmacists do not examine patients and so two similar instruments were developed, whereby two questions pertinent to patient examination were omitted from the pharmacist instrument. The content validity inventory demonstrated aspects of face validity and content validity of instruments. Statistical analysis of GP tapes suggested that the instrument could discriminate between GP consultations. Skills demonstrated by pharmacists were given lower scores, were less consistent than the GPs and the instrument did not discriminate between those performing at different levels. CONCLUSION: The results suggest that the instrument is useful only when applied to practitioners who have been taught how to consult in a patientcentred manner, and have led to the introduction of training in consultation skills for pharmacists throughout Scotland. Potential reliability in providing peer feedback for GP consultations is important in the context of the provision of consistent, meaningful evidence for GP appraisal and revalidation in the UK.

Verifying appraisal evidence using feedback from trained peers: views and experiences of Scottish GP appraisers.

BACKGROUND: GP appraisal is currently considered inadequate because it lacks robustness. Objective assessment of appraisal evidence is needed to enable judgements on professional performance to be made. AIM: To determine GP appraisers' views of the acceptability, feasibility, and educational impact of external peer feedback received on three core appraisal activities undertaken as part of this study. DESIGN OF STUDY: Independent peer review and cross-sectional postal questionnaire study. SETTING: NHS Scotland. METHOD: One of three core appraisal activities (criterion audit, significant event analysis, or video of consultations) was undertaken by GP appraisers and subjected to peer review by trained colleagues. A follow-up postal questionnaire elicited participants' views on the potential acceptability, feasibility, and educational impact of this approach. RESULTS: Of 164 appraisers, 80 agreed to participate; 67/80 (84%) submitted one of three appraisal materials for peer review and returned completed questionnaires. For significant event analyses (n = 44), most responders believed the peer feedback method was feasible (100%) and fair (92.5%) and would add value to appraisal (95.5%). Peer feedback on criterion audits (n = 15) was believed to be acceptable and fair (93.3%) and it was thought it would be a useful educational tool (100%). Completing a consultation video (n = 8) was perceived to be feasible as part of normal general practice (n = 5). It was unanimously agreed that assessment of videos by peers has educational impact and would help improve appraisal. CONCLUSION: This group of GP appraisers strongly supported the role of external and independent feedback by trained peers as one approach to strengthening the existing appraisal process.