Factors affecting the patient journey and patient care when receiving an unlicensed medicine: A systematic review.

BACKGROUND: Unlicensed medicines are used across the UK to treat an individual's clinical needs when there are no appropriate licensed alternatives. Patients, carers and parents have reported facing challenges with unlicensed medicines at the points of transfer of care between settings, a key time when medication errors may occur. There is little known about the patient journey as a whole, or the factors affecting patient care when receiving an unlicensed medicine. OBJECTIVE: A systematic review of UK literature to better understand factors that affect the entire patient journey from the decision to initiate treatment with an unlicensed medicine to the point at which treatment is supplied through a community pharmacy or ends. METHODS: Scopus, OVID EMCARE, EMBASE, OVID Medline ALL, CINAHL, Web of Science and Joanna Briggs Institute were searched from 1968 (introduction of the Medicines Act) until November 2020, using the PRISMA guidelines. Narrative synthesis of UK studies was employed to analyse descriptive and qualitative data on any reported findings that would impact the patient journey or care related to the use of unlicensed medicines, and any described barriers or enablers. RESULTS: Forty-five studies met criteria for final inclusion, with high levels of heterogeneity in terms of designs and methods. Specific challenges that were seen to impact the continuity of care across care settings, patient safety and provision of patient-centred care included diversity of clinical needs and impact of patient population age; healthcare professional awareness and acceptability of the use of unlicensed medicines; the hierarchical structure of the NHS; inconsistent doses and formulations with varying bioequivalence; patient/parent/carer/public awareness of unlicensed medicines use and perceived acceptability. CONCLUSIONS: This review identified a clear need for consistent information to be provided to healthcare professional and patients alike to support the safe and effective use of unlicensed medicines across care settings.

Unlicensed "Special" Medicines: Understanding the Community Pharmacist Perspective.

OBJECTIVE: Community pharmacy staff are responsible for obtaining and supplying unlicensed "special" medicines to patients in primary care. Less well-defined parameters for safe and effective use of unlicensed compared to licensed medicines, along with issues around maintaining consistency between care settings or among manufacturers, have been associated with increased risks. This study aimed to explore the views and experiences of community pharmacy staff on accessing and supplying unlicensed "special" medicines to patients in Wales and the perceived impact of challenges faced on patient care. METHODS: A qualitative, phenomenological approach was employed, involving semi-structured interviews with pharmacists and pharmacy technicians working at one small chain of community pharmacies in Wales. The interview schedule focused on the personal experiences and perceptions of the participants on the processes involved in accessing and supplying unlicensed "special" medicines from a community pharmacy. Interviews were audio-recorded and transcribed verbatim. RESULTS: A total of six participants completed the interview. Three main themes were constructed from inductive thematic analysis of the transcribed interviews: requirement for additional patient responsibilities; influences on the confidence felt by pharmacy staff when accessing and supplying unlicensed "special" medicines; and continuity of supply. CONCLUSION: This study gives a preliminary insight into the views and experiences of community pharmacy staff in Wales when accessing and supplying unlicensed "special" medicines. Further research is required to see if these views and experiences are representative of community pharmacy staff across the country.

Displaying medication costs on dispensing labels as a strategy to reduce wastage: views of the Welsh general public.

INTRODUCTION: In 2015, the UK health secretary made public an intention to include the value of medicines costing over £20 on dispensing labels as an attempt to reduce wastage attributable to patient behavior. However, there is a lack of evidence investigating the potential effect or feasibility of this proposal, and concerns have been raised that it may introduce new problems in vulnerable groups. This pilot study aimed to gather views of the Welsh general public on this subject. METHODS: Six focus groups from within key population groups were conducted. A snowball sampling strategy was employed with participants recruited via a neutral gatekeeper. Focus groups session were audio recorded and transcribed verbatim and iterative thematic analysis was used to identify emergent themes. RESULTS: Six focus groups were conducted. Three key themes were identified: "influence of cost" - whereby participants expressed concern about cost linking to their perceived value, guilt for needing prescribed medication and irrelevance of cost if the medication was considered necessary; "knowledge is power" - whereby participants expressed a desire to know more about their medicines and engage with health care professionals about them, and felt information on dispensing labels alone would be insufficient to support this and "blame the system" - whereby participants felt responsibility for wastage should be shared by both system and patient and identified existing wasteful practices such as inappropriate prescribing, ordering and disposal of returned medicines. CONCLUSION: Findings were largely consistent with criticisms publicized by professional bodies that introducing cost may serve to make patients feel guilty or unworthy rather than encourage them to use their medicines appropriately. Similarly, providing cost information on labels alone was considered insufficient and therefore additional counseling or education would be necessary to prevent misunderstanding. The acknowledgment of system factors contributing to wastage highlights an important role for pharmacists to become involved in using medicines more cost-effectively. However, cost was considered irrelevant if the medicine was deemed necessary by the patient, and therefore more mindful prescribing of superfluous items should be promoted.

What constitutes a high quality discharge summary? A comparison between the views of secondary and primary care doctors.

OBJECTIVE: This study aimed to identify any differences in opinion between UK hospital junior doctors and community General Practitioners (GPs) with respect to the ideal content and characteristics of discharge summaries, and to explore junior doctors' training for and awareness of post-discharge requirements of GPs. METHODS: A piloted anonymous survey was posted to 74 junior doctors at a UK general hospital and 153 local GPs. Doctors were asked to rank discharge summary key content and characteristics in order of importance. GP discharge summary preferences and junior doctor training were also investigated. Non-respondents, identified by non-receipt of a separate participation card, were followed up once. RESULTS: Thirty-six (49%) junior doctors and 42 (28%) GPs returned completed questionnaires. Accuracy was a priority with 24 (72%) GPs and 28 (88%) junior doctors ranking it most important. Details of medication changes were considered most important by 13 (39%) GPs and 4 (12%) junior doctors. Inadequate training in discharge summary writing was reported by 13 (36%) junior doctors. CONCLUSIONS: Although based on small sample sizes from one location, the level and range of differences in perceived importance of reporting medication changes suggests that many discharge summaries may not currently fulfil GP requirements for managing continuity of care. Results indicate that over a third of junior doctors felt inadequately prepared for writing discharge summaries. There may therefore be both a need and professional support for further training in discharge summary writing, requiring confirmatory research.