Process evaluation for the Care Homes Independent Pharmacist Prescriber Study (CHIPPS).

BACKGROUND: Medicines management in care homes requires significant improvement. CHIPPS was a cluster randomised controlled trial to determine the effectiveness of integrating pharmacist independent prescribers into care homes to assume central responsibility for medicines management. This paper reports the parallel mixed-methods process evaluation. METHOD: Intervention arm consisted of 25 triads: Care homes (staff and up to 24 residents), General Practitioner (GP) and Pharmacist Independent Prescriber (PIP). Data sources were pharmaceutical care plans (PCPs), pharmacist activity logs, online questionnaires and semi-structured interviews. Quantitative data were analysed descriptively. Qualitative data were analysed thematically. Results were mapped to the process evaluation objectives following the Medical Research Council framework. RESULTS: PCPs and activity logs were available from 22 PIPs. Questionnaires were returned by 16 PIPs, eight GPs, and two care home managers. Interviews were completed with 14 PIPs, eight GPs, nine care home managers, six care home staff, and one resident. All stakeholders reported some benefits from PIPs having responsibility for medicine management and identified no safety concerns. PIPs reported an increase in their knowledge and identified the value of having time to engage with care home staff and residents during reviews. The research paperwork was identified as least useful by many PIPs. PIPs conducted medication reviews on residents, recording 566 clinical interventions, many involving deprescribing; 93.8% of changes were sustained at 6 months. For 284 (50.2%) residents a medicine was stopped, and for a quarter of residents, changes involved a medicine linked to increased falls risk. Qualitative data indicated participants noted increased medication safety and improved resident quality of life. Contextual barriers to implementation were apparent in the few triads where PIP was not known previously to the GP and care home before the trial. In three triads, PIPs did not deliver the intervention. CONCLUSIONS: The intervention was generally implemented as intended, and well-received by most stakeholders. Whilst there was widespread deprescribing, contextual factors effected opportunity for PIP engagement in care homes. Implementation was most effective when communication pathways between PIP and GP had been previously well-established. TRIAL REGISTRATION: The definitive RCT was registered with the ISRCTN registry (registration number  ISRCTN 17847169 ).

Development and feasibility testing of an evidence-based training programme for pharmacist independent prescribers responsible for the medicines-related activities within care homes.

INTRODUCTION: The UK pharmacists with independent prescribing rights (pharmacist independent prescribers [PIPs]) are authorised to prescribe within their areas of competence. To enable PIPs to provide pharmaceutical care to residents in care homes and assume responsibility for medicines management, a process for development and assessment of competence is required. The aim of this research was to develop a training and accreditation process (training programme) to enable PIPs to operate safely and effectively within care homes. METHODS: Located in England, Scotland and Northern Ireland across four sites and based on a systematic review, it consisted of four phases: (1) initial stakeholder engagement, (2) uni-professional focus groups and interviews, (3) expert panel consensus and (4) feasibility testing. Four PIPs were trained each to provide pharmaceutical care to 10 care home residents. An expert panel synthesised the evidence at each stage to develop each iteration of the training programme. Content analysis was used throughout. RESULTS: Differences in baseline knowledge of PIPs required inclusion of a Personal Development Framework and the provision of a mentor. Face-to-face training focussed on managing medicines for a complex older person, minimising prescribing costs and supporting people without capacity. Provision of time to understand local context and develop relationships with care homes and general practitioners was identified as a central requirement. PIPs were assessed for competency via viva. Feasibility testing demonstrated that the derived training programme was acceptable, practical and effective. DISCUSSION: The model seemed to work, but due to small numbers, larger-scale testing of the training programme is now required.

Clinical and cost effectiveness of a multi-professional medication reviews in care homes (CAREMED).

OBJECTIVES: With 70% of care home residents experiencing a medication error every day in the UK, better multi-professional working between medical practitioners, pharmacists and care homes was recommended. The aim of this study was to determine the effectiveness (falls reduction) and cost-effectiveness, of a multi-professional medication review (MPMR) service in care homes for older people. METHOD: A total of care homes in the East of England were cluster randomised to 'usual care' or two multi-professional (General practitioner, clinical pharmacist and care homes staff) medication reviews during the 12-month trial period. Target recruitment was 900 residents with 10% assumed loss to follow-up. Co-primary outcome measures were number of falls and potentially inappropriate prescribing assessed by the Screening Tool of Older Persons Prescriptions. KEY FINDINGS: A total of 826 care home residents were recruited with 324 lost to follow-up for at least one primary outcome measure. The mean number of falls per resident per annum was 3.3 for intervention and 3.0 for control (P = 0.947). Each resident was found to be prescribed 0.69 (intervention) and 0.85 (control) potentially inappropriate medicines after 12 months (P = 0.046). No significant difference identified in emergency hospital admissions or deaths. Estimated unadjusted incremental mean cost per resident was £374.26 higher in the intervention group. CONCLUSIONS: In line with other medication review based interventions in care homes, two MPMRs improved medication appropriateness but failed to demonstrate improvements in clinical outcomes. From a health system perspective costs where estimated to increase overall and therefore a different model of medicines management is required.

A cost-consequences analysis of an adherence focused pharmacist-led medication review service.

OBJECTIVES: The aim of this project was to conduct an economic evaluation of the Norfolk Medicines Support Service (NMSS), a pharmacist-led medication review service for patients identified in primary care as non-adherent. METHODS: The cost-consequences analysis was based on a before and after evaluation of the NMSS. Participants completed a self-reported adherence and health-related quality of life questionnaire prior to the review, at 6 weeks and 6 months. Service provision, prescribing and secondary care costs were considered and the mean cost before and after the intervention was calculated. KEY FINDINGS: One-hundred and seventeen patients were included in the evaluation. The mean cost per patient of prescribing and hospital admissions in the 6 months prior to the intervention was £2190 and in the 6 months after intervention £1883. This equates to a mean cost saving of £307 per patient (parametric 95% confidence interval: £1269 to £655). The intervention reduced emergency hospital admissions and increased medication adherence but no significant change in health-related quality of life was observed. CONCLUSION: The costs of providing this medication review service were offset by the reduction in emergency hospital admissions and savings in medication cost, assuming the findings of the evaluation were real and the regression to the mean phenomenon was not involved. This cost-consequences approach provides a transparent descriptive summary for decision-makers to use as the basis for resource allocation decisions.

Does it matter whether the recipient of patient questionnaires in general practice is the general practitioner or an independent researcher? The REPLY randomised trial.

BACKGROUND: Self-administered questionnaires are becoming increasingly common in general practice. Much research has explored methods to increase response rates but comparatively few studies have explored the effect of questionnaire administration on reported answers. METHODS: The aim of this study was to determine the effect on responses of returning patient questionnaires to the respondents' medical practice or an independent researcher to questions relating to adherence and satisfaction with a GP consultation. One medical practice in Waveney primary care trust, Suffolk, England participated in this randomised trial. Patients over 18 years initiated on a new long-term medication during a consultation with a GP were randomly allocated to return a survey from their medical practice to either their medical practice or an independent researcher. The main outcome measures were self reported adherence, satisfaction with information about the newly prescribed medicine, the consultation and involvement in discussions. RESULTS: 274 (47%) patients responded to the questionnaire (45% medical practice, 48% independent researcher (95% CI -5 to 11%, p = 0.46)) and the groups appeared demographically comparable, although the high level of non-response limits the ability to assess this. There were no significant differences between the groups with respect to total adherence or any of the satisfaction scales. Five (4%) patients reported altering doses of medication in the medical practice group compared with 18 (13%) in the researcher group (P = 0.009, Fisher's exact test). More patients in the medical practice group reported difficulties using their medication compared to the researcher group (46 (35%) v 30 (21%); p = 0.015, Fisher's exact test). CONCLUSION: Postal satisfaction questionnaires do not appear to be affected by whether they are returned to the patient's own medical practice or an independent researcher. However, returning postal questionnaires relating to detailed patient behaviours may be subject to response biases and further work is needed to explore this phenomena.

DengueInfo: A web portal to dengue information resources.

DengueInfo (http://www.dengueinfo.org) is a web portal and database that brings clarity to dengue research by integrating the growing number of complete genome sequences of dengue virus with relevant literature and curated epidemiological information. Additionally, it represents a repository of on-going prospective and retrospective studies of dengue disease severity. We intend the database to be a flagship resource for the dengue community, providing standardized and high quality information and facilitating research into key aspects of dengue biology and assisting in its control. To aid this process we also introduce a standard nomenclature for dengue isolates inspired by globally accepted system used for influenza virus.