A cross-sectional study examining the nature and extent of interprofessional education in schools of pharmacy in the United Kingdom.

BACKGROUND: Interprofessional education can prepare the workforce for collaborative practice in complex health and social care systems. AIM: To examine the nature and extent of interprofessional education in schools of pharmacy in the United Kingdom. METHOD: An online questionnaire was developed using systems theory, published literature and input from an interprofessional expert panel; it included closed and open-ended questions and a demographic section. Following piloting, it was distributed to 31 schools of pharmacy. Descriptive statistics were used for quantitative data, and a content analysis approach for qualitative data. RESULTS: Ten schools of pharmacy responded. All reported delivering compulsory interprofessional education. Most (80%) reported an interprofessional steering group overseeing development. Formative and/or summative assessment varied depending on year of study. Mechanism and purpose of evaluation varied with respondents reporting Kirkpatrick Evaluation Model Levels 1-3 (100%; 80%; 70%). Two themes were identified: "Variation in Interprofessional Education Approaches and Opportunities" and "Factors Influencing Development and Implementation of Interprofessional Education". Formal teaching was mainly integrated into other modules; various pedagogic approaches and topics were used for campus-based activities. Respondents referred to planned interprofessional education during practice-based placements; some still at pilot stage. Overall, respondents agreed that practice-based placements offered opportunistic interprofessional education, but a more focused approach is needed to maximise student pharmacists' learning potential. CONCLUSION: Most interprofessional education offered in undergraduate pharmacy curricula in the United Kingdom is campus-based; the nature and extent of which varies between programmes. Very few examples of practice-based activities were reported. Results may inform future interprofessional education curricular development.

Student pharmacist practice-based interprofessional education in Scotland: a qualitative study of stakeholders' views and experiences.

Scottish Government funding supports practice-based experiential learning (EL) for student pharmacists. We explored views and experiences of key stakeholders on current practice and future development of interprofessional education (IPE) in EL including barriers and enablers. A pre-piloted schedule was used for online qualitative semi-structured interviews. eMail invitations were sent to 37 stakeholders with an information sheet and consent process. Interviews were analyzed thematically by two researchers independently. Recruitment continued until data saturation and wide representation were achieved. Twenty interviews were conducted with eight EL facilitators, seven faculty and five policy stakeholders. "Nature and experience of current IPE in EL activities" and "Future developments" were the two main themes. Barriers and enablers were also identified at macro, meso, and micro socio-institutional levels. The essence of the analysis highlighted stakeholders' views of the importance of building on current IPE while challenging the ethos and culture of EL practices. All stakeholders should be involved in co-production, training, piloting, and evaluation of curricular developments to overcome logistic barriers and enhanced enablers. Finally, the importance of workload management strategies and continuity of funding for success was also stressed by those interviewed. Future research could include designing frameworks for developing and implementing IPE within EL.

Competency-Based Assessment in Experiential Learning in Undergraduate Pharmacy Programmes: Qualitative Exploration of Facilitators' Views and Needs (ACTp Study).

Newly registered pharmacists will need to possess higher-level competencies and, in Great Britain, there is an expectation that assessments are undertaken during experiential learning (EL). The aim of this study was to explore the perceptions and educational needs of practice-based EL facilitators of student pharmacists, undertaking competency-based assessments during EL. Semi-structured one-on-one interviews were conducted with EL facilitators working in the community, hospital, and primary-care pharmacies. Data were thematically analysed. Fifteen facilitators were interviewed, and there were five from each site. There was general support for this role, but also anxiety due to the lack of knowledge about assessments and the repercussions on students. Benefits were that students would receive real-time feedback from workplace-based practitioners and facilitators would benefit from self-development. Challenges included additional workload and lack of consistency in marking. The majority agreed that clinical, professional, and communication skills could be assessed; however, a consensus was not reached regarding the tools, methods, and grading of assessments. The need for training and support were highlighted. A co-design method was proposed to ensure that the assessment methods and processes are accepted by all stakeholders. Training and resources should be tailored to the needs of facilitators.

Student and pre-registration pharmacist performance in a UK Prescribing Assessment.

Student and pre-registration pharmacist performance in a UK Prescribing Assessment': room for improvement and need for curricular change Background Increasingly the global policy direction is for patient-facing pharmacist prescribers. The 'UK Prescribing Safety Assessment' (PSA) was developed for medical graduates to demonstrate prescribing competencies in relation to the safe and effective use of medicines. Objectives To determine PSA performance of final year undergraduate student pharmacists (year 4) and pre-registration pharmacy graduates (year 5) and explore their opinions on its suitability. Setting Scotland, UK Methods Final year undergraduates (n = 238) and pre-registration pharmacists (n = 167) were briefed and undertook the PSA. PSA questions were mapped to specific thematic areas with 30 questions over 60 min. Data was analysed using descriptive statistics. A questionnaire was completed to gauge opinions on appropriateness of the PSA. Main Outcome Measure PSA scores Results Mean total PSA score for pre-registration pharmacists (64.4, SD 10) was significantly higher than for undergraduates (51.2, SD 12.0,) (p < 0.001). Pre-registration pharmacists performed significantly better across all question areas (all p < 0.001 other than 'adverse drug reactions', p < 0.01). Hospital pre-registration pharmacists performed statistically significantly better than community with higher overall scores (67.4, SD 9.8 v 63.2, SD 9.8, p < 0.05). Positive views on the appropriateness of the approach and the usability of the online interface were obtained from participants. Conclusion Hospital pre-registration pharmacists performed better than the undergraduates, but there is a need to improve prescribing skills in all, most notably in diagnostic skills. The PSA is acceptable to the participants. These results will help inform pharmacy curricula development and provides a cross-disciplinary method of assessment of prescribing competence.

Competency-based assessment of practice-based experiential learning in undergraduate pharmacy programmes

Objective: To obtain feedback from experiential learning (EL) leads about how competency-based assessments could be undertaken by EL facilitators, and to scope existing EL assessment structures in undergraduate Masters in Pharmacy (MPharm) programmes across the United Kingdom (UK). Methods: A cross-sectional survey was conducted utilizing a nine-item on-line survey, consisting of five open-ended and four closed-ended question. All UK universities with MPharm programmes (n=30) were invited to participate in the survey. Variables of interest were perceptions on activities and competencies that could be assessed by EL facilitators. The survey utilised a 5-point Likert-type response ranging from strongly disagree to strongly agree. Other variables of interest were tools/methods that could be used to assess competency, and perceived advantages and disadvantages of the proposed methods, the latter two captured via open-ended questions. Results: Of the 21 universities that responded (Response rate: 70%), 17 were included in the final analysis. Fourteen of the 17 (82.4%) offered the 4-year programme, while 3 (17.6%) offered both the 4-year and 5-year integrated programme. Assessments were mainly undertaken by university staff (59%), with minimal amounts undertaken during EL (39%). There was unanimous agreement (100%) that facilitators could assess students’ communication skills and professionalism during EL. No consensus, however, was achieved with regard to the tool(s) or method(s) to be used to assess student’s competencies. There were 13 responses to the open-ended comments. An advantage noted was that EL facilitator assessment of students would allow for more accurate evaluation of students in the practice setting, while acknowledging barriers such as the burden of time and the lack of consistency in marking. To address this lack of consistency, the majority highlighted the need for facilitator training (AU)

Pharmaceutical care issues in lung cancer: can community pharmacists support patients receiving systemic anticancer therapy?

OBJECTIVES: Most patients receive systemic anticancer therapy (SACT) as day cases and toxicities, if they occur, are likely to appear first in primary care. Pharmaceutical care can be delivered by community pharmacists, but little is known about the epidemiology of SACT toxicities in the community and potential interventions to address these which raise the following questions: what are the typologies of SACT-associated toxicities experienced by community-based patients and what are the associated pharmaceutical care issues (PCIs)? The aim of this study was to identify toxicities and pharmaceutical care issues of patients prescribed SACT for lung cancer and understand the potential for community pharmacists to deliver aspects of cancer care including toxicity management. METHODS: Retrospective analysis of clinical records of patients prescribed oral and parenteral SACT in 2013-14, to describe patient characteristics; SACT toxicity; PCIs and episodes of unscheduled care. KEY FINDINGS: Twelve categories of toxicity and 13 categories of PCIs were identified from 50 patients. More PCIs were observed with oral SACT/oral-parenteral combinations than with parenteral regimens. The PCIs which could be managed by community pharmacists were mucositis; skin toxicity; gastrointestinal toxicity; reinforcing patient education and identification/prevention of drug interactions. CONCLUSIONS: Community pharmacists are ideally placed to provide pharmaceutical care to patients with lung cancer prescribed SACT. Cancer specialists in secondary care can signpost patients to community pharmacists for early management of low-grade SACT toxicity.

Public perceptions and experiences of the minor ailment service in community pharmacy in Scotland

BACKGROUND: The Minor Ailment Service (MAS) in Scottish community pharmacy allows eligible people to gain improved access to care by providing free treatment for self-limiting conditions. OBJECTIVE: To determine the perceptions and experiences of individuals using MAS and to quantify the potential impact on usage of other healthcare services. METHODS: A cross-sectional survey was conducted of patients accessing MAS across Scotland during June and July 2018. Questionnaire items included reasons for choosing treatment through MAS, which other services they may have accessed had MAS not been available, experiences of consultation, overall satisfaction, and perceived effectiveness of treatment. Those accessing MAS were given a study pack including an information sheet, pre-piloted questionnaire, and pre-paid return envelope. Participants had the option to consent to an optional one-week follow up questionnaire that focused on perceived effectiveness of treatment after seven days and any further access to healthcare services such as general practice, emergency departments or repeat pharmacy visits. RESULTS: There were 1,121 respondents to the initial questionnaire. Most reported 'convenient Location' as the main reason for their access to community pharmacy (n=748; 67.1%). If MAS had not been available, 59% (n=655) of participants reported that they would have accessed general practice for treatment of their minor ailment. Experience of consultations was also rated highly with all ten outcome measures scoring 'Excellent' overall. Satisfaction was reported positively with most participants reporting full satisfaction with the overall experience (n=960; 87.2%). At one-week follow up, 327 participants responded, over 85% (n=281) did not require further access to care to treat their minor ailment and 99.7% (n=326) said they would use MAS again. CONCLUSIONS: Positive perceptions and experiences of those using MAS demonstrate a highly regarded service in terms of satisfaction and experience of consultation. The capacity for MAS to impact on the use of higher-cost healthcare services is evidenced through the number of participants who reported these services as a point of access to care should community pharmacy not be available. This national evaluation demonstrates MAS to be a positively experienced service and outlines the factors determining access for treatment of minor ailments

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Public perceptions and experiences of the minor ailment service in community pharmacy in Scotland.

BACKGROUND: The Minor Ailment Service (MAS) in Scottish community pharmacy allows eligible people to gain improved access to care by providing free treatment for self-limiting conditions. OBJECTIVE: To determine the perceptions and experiences of individuals using MAS and to quantify the potential impact on usage of other healthcare services. METHODS: A cross-sectional survey was conducted of patients accessing MAS across Scotland during June and July 2018. Questionnaire items included reasons for choosing treatment through MAS, which other services they may have accessed had MAS not been available, experiences of consultation, overall satisfaction, and perceived effectiveness of treatment. Those accessing MAS were given a study pack including an information sheet, pre-piloted questionnaire, and pre-paid return envelope. Participants had the option to consent to an optional one-week follow up questionnaire that focused on perceived effectiveness of treatment after seven days and any further access to healthcare services such as general practice, emergency departments or repeat pharmacy visits. RESULTS: There were 1,121 respondents to the initial questionnaire. Most reported 'convenient Location' as the main reason for their access to community pharmacy (n=748; 67.1%). If MAS had not been available, 59% (n=655) of participants reported that they would have accessed general practice for treatment of their minor ailment. Experience of consultations was also rated highly with all ten outcome measures scoring 'Excellent' overall. Satisfaction was reported positively with most participants reporting full satisfaction with the overall experience (n=960; 87.2%). At one-week follow up, 327 participants responded, over 85% (n=281) did not require further access to care to treat their minor ailment and 99.7% (n=326) said they would use MAS again. CONCLUSIONS: Positive perceptions and experiences of those using MAS demonstrate a highly regarded service in terms of satisfaction and experience of consultation. The capacity for MAS to impact on the use of higher-cost healthcare services is evidenced through the number of participants who reported these services as a point of access to care should community pharmacy not be available. This national evaluation demonstrates MAS to be a positively experienced service and outlines the factors determining access for treatment of minor ailments.

Competency-based assessment of practice-based experiential learning in undergraduate pharmacy programmes.

Objective: To obtain feedback from experiential leaning (EL) leads about how competency-based assessments could be undertaken by EL facilitators, and to scope existing EL assessment structures in undergraduate Masters in Pharmacy (MPharm) programmes across the United Kingdom (UK). Methods: A cross-sectional survey was conducted utilizing a nine-item on-line survey, consisting of five open-ended and four closed-ended question. All UK universities with MPharm programmes (n=30) were invited to participate in the survey. Variables of interest were perceptions on activities and competencies that could be assessed by EL facilitators. The survey utilised a 5-point Likert-type response ranging from strongly disagree to strongly agree. Other variables of interest were tools/methods that could be used to assess competency, and perceived advantages and disadvantages of the proposed methods, the latter two captured via open-ended questions. Results: Of the 21 universities that responded (Response rate: 70%), 17 were included in the final analysis. Fourteen of the 17 (82.4%) offered the 4-year programme, while 3 (17.6%) offered both the 4-year and 5-year integrated programme. Assessments were mainly undertaken by university staff (59%), with minimal amounts undertaken during EL (39%). There was unanimous agreement (100%) that facilitators could assess students' communication skills and professionalism during EL. No consensus, however, was achieved with regard to the tool(s) or method(s) to be used to assess student's competencies. There were 13 responses to the open-ended comments. An advantage noted was that EL facilitator assessment of students would allow for more accurate evaluation of students in the practice setting, while acknowledging barriers such as the burden of time and the lack of consistency in marking. To address this lack of consistency, the majority highlighted the need for facilitator training. Conclusion: Minimal assessments are currently undertaken during EL, with students predominantly assessed on return to the university. No consensus could be achieved with regard to the tool(s) or method(s) to be used to assess students' competencies, suggesting that perhaps there is no one-size-fits-all, and that the tools and methods used should be informed by the competencies being assessed.

Patient experiences of pharmacist independent prescriber-led post-myocardial infarction left ventricular systolic dysfunction clinics.

OBJECTIVES: Left ventricular systolic dysfunction (LVSD) is common following myocardial infarction (MI). Pharmacological management of secondary prevention is known to be sub-optimal. Integration of pharmacists into clinical teams improves prescribing and quantitative outcomes. Few data have been published on patient views of pharmacist input. We aimed to explore patient experiences of attending a dedicated pharmacist independent prescriber (PIP)-led clinic. METHODS: Semi-structured face-to-face interviews. Participants were aged ≥18 years with new incident MI and echocardiographically confirmed LVSD. Patients were recruited from three pharmacist-led clinics at point of clinic discharge. Interviews were transcribed verbatim. Thematic analysis was undertaken. KEY FINDINGS: Twelve patients were recruited, median age 67.5 years and ten male. Six core themes were identified: multidisciplinary working; satisfaction; confidence in the pharmacist; comparative care; prescribing behaviours; and monitoring. Pharmacist clinics complemented other established post-MI services, and participants perceived benefits obtained through effective inter-professional working. Participants welcomed dedicated appointment time, the opportunity to ask questions and address problems. Pharmacist explanations of condition and medicines, prescribing at the point of care and monitoring were beneficial and reduced patient stress. CONCLUSIONS: This study demonstrates that a PIP-led post-MI LVSD clinic delivers a positive initial patient experience. More research is needed to understand the longer-term patient experiences, the impact of such models on medication taking behaviours and the experiences of carers and other members of the multidisciplinary team.

Survey of undergraduates' perceptions of experiential learning in the MPharm programme: The TELL Project.

OBJECTIVE: To determine the perception of undergraduate pharmacy students of their experiential learning (EL) placements both in the community and hospital settings. METHODS: A cross-sectional survey was conducted utilizing a six-item online survey consisting of one open-ended and five closed-ended questions, the latter utilising five-point Likert-type scales ranging from strongly disagree (1) to strongly agree (5). All undergraduate pharmacy students from the School of Pharmacy (N=496) were included in the study. Survey questions assessed students' perceptions on the effectiveness of the EL, tutors and placements sites, and organisation and structure of the EL. Thematic content analysis was performed on the open-ended comments, where relevant themes were generated. RESULTS: From the 139 responses (response rate: 28%), 121 responses were analysed, and of these, 72.5% already had part-time jobs in community pharmacies. Close to 85% felt that their part-time work should contribute to EL hours, which is currently not recognised by the university. Respondents were positive about the effectiveness of EL in developing their professionalism and communication (M=3.84, SD=1.05), clinical (M=3.42, SD=1.22), and technical skills (M=3.32, SD=1.25) Respondents provided favourable feedback about their experience in the hospital as it gave them a real-world exposure to the role of a hospital pharmacist. Community placements were not viewed favourably and this was mainly attributed to the poor experience with tutors whom they felt used them as an extra pair of hands. This was thought to impede their learning experience. They also felt that hospital placements were of insufficient duration, reported by 72.5% of respondents. Respondents also felt they should be sent to other sites such as primary care for placements. CONCLUSIONS: Tutor-training is key to ensure tutors are aware of the responsibilities and expectations. Similarly, quality assurance measures should be adopted to ensure tutors and placement sites are capable of providing students with an effective placement experience. While placement durations are a concern, the focus should be on the quality of the placement experience, and ensuring there is structure and flexibility. Content changes are also needed to include emerging placement sites such as primary care to prepare students for evolving pharmacist roles in the changing healthcare system.

Survey of undergraduates' perceptions of experiential learning in the MPharm programme: the TELL Project

OBJECTIVE: To determine the perception of undergraduate pharmacy students of their experiential learning (EL) placements both in the community and hospital settings. METHODS: A cross-sectional survey was conducted utilizing a six-item online survey consisting of one open-ended and five closed-ended questions, the latter utilising five-point Likert-type scales ranging from strongly disagree (1) to strongly agree (5). All undergraduate pharmacy students from the School of Pharmacy (N=496) were included in the study. Survey questions assessed students' perceptions on the effectiveness of the EL, tutors and placements sites, and organisation and structure of the EL. Thematic content analysis was performed on the open-ended comments, where relevant themes were generated. RESULTS: From the 139 responses (response rate: 28%), 121 responses were analysed, and of these, 72.5% already had part-time jobs in community pharmacies. Close to 85% felt that their part-time work should contribute to EL hours, which is currently not recognised by the university. Respondents were positive about the effectiveness of EL in developing their professionalism and communication (M=3.84, SD=1.05), clinical (M=3.42, SD=1.22), and technical skills (M=3.32, SD=1.25) Respondents provided favourable feedback about their experience in the hospital as it gave them a real-world exposure to the role of a hospital pharmacist. Community placements were not viewed favourably and this was mainly attributed to the poor experience with tutors whom they felt used them as an extra pair of hands. This was thought to impede their learning experience. They also felt that hospital placements were of insufficient duration, reported by 72.5% of respondents. Respondents also felt they should be sent to other sites such as primary care for placements. CONCLUSIONS: Tutor-training is key to ensure tutors are aware of the responsibilities and expectations. Similarly, quality assurance measures should be adopted to ensure tutors and placement sites are capable of providing students with an effective placement experience. While placement durations are a concern, the focus should be on the quality of the placement experience, and ensuring there is structure and flexibility. Content changes are also needed to include emerging placement sites such as primary care to prepare students for evolving pharmacist roles in the changing healthcare system

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Nationwide survey of experiential learning in MPharm programmes in UK Universities.

OBJECTIVES: To determine the current structure of experiential learning (EL) in Master of Pharmacy (MPharm) programmes in UK universities, and assess how they meet the standards specified by the General Pharmaceutical Council. METHODS: A cross-sectional survey of staff in charge of EL in MPharm programmes was conducted, utilising a 31-item online survey, consisting of both open-ended and close-ended questions. Variables of interest were administrative aspects and structure of the EL component, tutor issues and placement sites. To pinpoint the challenges faced with EL, the Relative Importance Index (RII) was calculated. KEY FINDINGS: Twenty (66.7%) universities responded. EL coordinators were mostly academic/teaching fellows (19) and spent 0.29 ± 0.31 full-time equivalents on coordination. Tutors completed training annually in 53.8% of universities, with topics focusing on placement structure (85.7%) and requirements (78.6%). Total placement hours in all practice sites over the 4 years of study ranged from 54 to 496 h, and included hospitals, community pharmacies, hospices, prisons and nursing homes. The three biggest challenges faced with regard to EL were in obtaining/retaining hospital placements (1st), financial support (2nd) and quality assurance (QA) of tutors (3rd). CONCLUSIONS: While there has been an increase in the variety of placement sites and hours since the last survey in 2003, universities face challenges in terms of staffing and obtaining placement sites. There are also gaps in tutor training. More standardisation and regulation of the QA of the EL programme, placement sites and tutors is needed to ensure students obtain the most out of their placements.

Using forum theatre to teach communication skills within an undergraduate pharmacy curriculum: A qualitative evaluation of students' feedback.

BACKGROUND AND PURPOSE: Pharmacists need to learn communication styles which adopt a more consultative model. The objectives of this paper are to describe the use of forum theatre facilitated by actors to teach communication skills to pharmacy students and to highlight perceptions of the workshops. EDUCATIONAL ACTIVITY AND SETTING: During the actor-led forum theatre, students redirected scenes depicting pharmacist-patient consultations. Students also learned about their own communication styles and role-played consultations and interview situations with actors. Pharmacy undergraduate students enrolled in years 2, 3, and 4 answered open-ended questions online at the end of workshops. All responses were coded to identify themes. FINDINGS: Five themes emerged from 752 comments: (1) workshops were useful in facilitating communication skills development, (2) workshops encouraged reflection, (3) appreciation of feedback provided, (4) the live, interactive nature of the workshop enhanced learning, and (5) suggestions for improvement. There were requests for more varied scenarios involving different patient groups and more opportunities to participate in the role-plays. Students also requested smaller groups, which would encourage participation from those who were reticent and allow more personal feedback. SUMMARY: The use of forum theatre employing role-play, small group coaching on consultation and interview skills, and emphasizing feedback was perceived as an effective and engaging method to teach communication skills.

Associations between obesity and cognition in the pre-school years.

OBJECTIVE: To test the hypothesis that obesity is associated with impaired cognitive outcomes in the pre-school years. METHODS: Associations were examined between weight status at age 3-5 years and cognitive performance at age 5 years. Cognitive outcome measures were tests of pattern construction (visuospatial skills), naming vocabulary (expressive language skills), and picture similarity (reasoning skills). The sample was the UK Millennium Cohort Study (n = 12,349 participants). RESULTS: Boys with obesity at 3 years had significantly lower performance in pattern construction at age 5 years compared to those of a healthy weight, even after controlling for confounders (ß = -0.029, P = 0.03). Controlling for confounders, boys who developed obesity between the ages of 3 and 5 years had lower scores in pattern construction (ß = -0.03, P = 0.03). "Growing out" of obesity had a positive association with picture similarity performance in girls (ß = 0.03, P = 0.04). CONCLUSIONS: Obesity in the pre-school years was associated with poorer outcomes for some cognitive measures in this study. Stronger relationships between obesity and cognition or educational attainment may emerge later in childhood.

Long-acting muscarinic antagonists (LAMA) added to inhaled corticosteroids (ICS) versus the same dose of ICS alone for adults with asthma.

BACKGROUND: Despite the availability of several evidence-based therapies and non-pharmacological strategies to improve control of symptoms and prevent exacerbations of asthma, patients with asthma continue to be at risk for mortality and morbidity.Previous trials have demonstrated the potentially beneficial effects of the long-acting muscarinic antagonist (LAMA) tiotropium on lung function in patients with asthma; however, a definitive conclusion on the benefit of LAMA in asthma is lacking, as is information on where in the current step-wise management strategy they would be most beneficial. OBJECTIVES: To assess the efficacy and safety of a LAMA added to any dose of an inhaled corticosteroid (ICS) compared with the same dose of ICS alone for adults whose asthma is not well controlled. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register (CAGR) from inception to April 2015, and we imposed no restriction on language of publication. We also searched clinicaltrials.gov, the World Health Organization (WHO) trials portal and drug company registries to identify unpublished studies. SELECTION CRITERIA: We searched for parallel and cross-over randomised controlled trials in which adults whose asthma was not well controlled by ICS alone were randomly assigned to receive LAMA add-on or placebo (both combined with ICS) for at least 12 weeks. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the searches and extracted data from study reports. We used Covidence for duplicate screening, extraction of study characteristics and numerical data and risk of bias ratings. Pre-specified primary outcomes included exacerbations requiring oral corticosteroids, quality of life and all-cause serious adverse events. MAIN RESULTS: We identified five studies that met the inclusion criteria. All studies applied a double-blind, double-dummy design, and the population of all studies totalled 2563 adult participants. Study duration ranged from 12 weeks to 52 weeks, and risk of bias across domains in all studies was low. Trials included more women than men (33% to 47% male), and mean age of participants ranged from 41 to 48 years. Participants generally had a long history of asthma, and mean baseline predicted forced expiratory volume in one second (FEV1) was between 72% and 75% in three studies reporting pre-bronchodilator values.The rate of exacerbations requiring oral corticosteroids (OCS) was lower in patients prescribed an LAMA add-on than in those receiving the same dose of ICS alone (odds ratio (OR) 0.65, 95% confidence interval (CI) 0.46 to 0.93; 2277 participants; four studies; I(2) = 0%; high-quality evidence), meaning that 27 fewer people per 1000 would have an exacerbation over 21 weeks requiring OCS with LAMA compared with ICS alone (95% CI 42 fewer to 6 fewer).All-cause serious adverse events (SAEs) and exacerbations requiring hospital admission were rare and the effects too imprecise to permit firm conclusions, but effects suggested that LAMA add-on may be associated with fewer of both compared with ICS alone (SAEs: OR 0.60, 95% CI 0.23 to 1.57; 2532 participants; four studies; low-quality evidence; exacerbations requiring hospital admission: OR 0.42, 95% CI 0.12 to 1.47; 2562 participants; five studies; moderate-quality evidence). Additional therapy with a LAMA showed no clear benefit in terms of quality of life compared with ICS given alone; high-quality evidence showed only a small mean improvement in quality of life as measured on the Asthma Quality of Life Questionnaire (AQLQ), which was not statistically significant. The same was true for asthma control as measured on the Asthma Control Questionnaire (ACQ), which was based on moderate-quality evidence. LAMA combined with ICS showed consistent benefit in a range of lung function measures compared with the same dose of ICS alone, and LAMA was not associated with significantly higher rates of adverse events than were reported with placebo. AUTHORS' CONCLUSIONS: For adults taking ICS for asthma without a long-acting beta2-agonist (LABA), LAMA given as add-on treatment reduces the likelihood of exacerbations requiring treatment with OCS and improves lung function. The benefits of LAMA combined with ICS for hospital admissions, all-cause serious adverse events, quality of life and asthma control remain unknown.Results of this review, along with findings of related reviews conducted to assess the use of LAMA in other clinical scenarios involving asthma, can help to define the role of LAMA in the management of asthma. Trials of longer duration (up to 52 weeks) would provide a better opportunity to observe rare events such as serious adverse events and exacerbations requiring hospital admission.

Long-acting muscarinic antagonists (LAMA) added to inhaled corticosteroids (ICS) versus higher dose ICS for adults with asthma.

BACKGROUND: Long-acting muscarinic antagonists (LAMA), a class of drugs with proven effectiveness in chronic obstructive pulmonary disease (COPD), are being considered as an add-on option for adults with asthma whose condition is uncontrolled on inhaled corticosteroids (ICS). It is important to assess the safety and efficacy of LAMA add-on as an alternative to the prolonged use of higher doses of ICS, which are known to cause undesirable side effects in some people. OBJECTIVES: To compare the effects of adding a LAMA to any dose of ICS versus increasing the dose of ICS, for uncontrolled asthma in adults. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register (CAGR) from its inception in 1995 to April 2015, imposing no restriction on language of publication. We also handsearched trial registries, reference lists of primary studies and existing reviews, as well as manufacturers' websites. SELECTION CRITERIA: We looked for parallel or cross-over randomised controlled trials lasting at least 12 weeks, in which adults whose asthma was not well controlled on ICS alone were randomised to treatment with LAMA add-on to ICS or with an increased dose of ICS. Trials were excluded if patients were taking long-acting beta2-agonists during the study period. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the searches and extracted data from studies meeting all the inclusion criteria. We used Covidence to manage duplicate screening, data extraction and risk of bias judgements, and to form a consensus where discrepancies arose. We used standard methods expected by The Cochrane Collaboration.The pre-specified primary outcomes were exacerbations requiring a course of oral corticosteroids (OCS), effects on quality of life and serious adverse events. MAIN RESULTS: One cross-over randomised controlled trial met the inclusion criteria. The trial was performed in 210 patients with moderate to severe asthma and compared the use of the LAMA tiotropium bromide with double dose beclomethasone (an ICS) using a cross-over design and 14-week treatment periods.Compared with people taking a double dose of ICS, fewer people taking a LAMA add-on had an exacerbation requiring treatment with OCS (odds ratio (OR) 0.57, 95% confidence interval (CI) 0.22 to 1.43) or an exacerbation resulting in emergency department admission (OR 0.49, 95% CI 0.09 to 2.77), but the confidence intervals for both outcomes did not exclude the possibility that double dose ICS was more effective. Serious adverse events and exacerbations requiring hospitalisation occurred in similarly low numbers of people taking each treatment, but confidence intervals were too wide to suggest that the two treatment options were equivalent.Asthma-related quality of life was similar in both treatment groups (mean difference (MD) in change from baseline 0.10, 95% CI - 0.07 to 0.27). Those taking LAMA add-on scored slightly better on a scale measuring asthma control than those increasing their ICS dose (MD in change from baseline - 0.18, 95% CI - 0.34 to - 0.02), although the difference was clinically small. Evidence was deemed low quality for both quality of life and asthma control.There was moderate-quality evidence that participants' trough forced expiratory volume in one second (FEV1) was 100 mL better when taking LAMA add-on than with increased ICS dose (MD in change from baseline 0.10, 95% CI 0.03 to 0.17). AUTHORS' CONCLUSIONS: Only one randomised trial was found, comparing tiotropium add-on to increased dose beclomethasone. Differences between the treatments were too small or imprecise to understand whether adding a LAMA to ICS is safer or more effective than increasing the dose of ICS, and there is a possibility of carry-over effects due to the study's cross-over design. LAMA add-on may lead to more improvement in lung function (FEV1) than an increased dose of ICS.The results of this review, alongside pending results from related reviews assessing the use of LAMA against other treatments, will help to define the role of these drugs in asthma management, and this review should be updated as results from future trials emerge. Studies assessing the role of LAMA add-on should be longer and include a double-ICS treatment arm so that the results can be interpreted in the context of the guideline-recommended treatment options that are available to physicians.

Long-acting muscarinic antagonists (LAMA) added to inhaled corticosteroids (ICS) versus addition of long-acting beta2-agonists (LABA) for adults with asthma.

BACKGROUND: Poorly controlled asthma and preventable exacerbations place a significant strain on healthcare, often requiring additional medications, hospital stays or treatment in the emergency department.Long-acting beta2-agonists (LABA) are the preferred add-on treatment for adults with asthma whose symptoms are not well controlled on inhaled corticosteroids (ICS), but have important safety concerns in asthma. Long-acting muscarinic antagonists (LAMA) have confirmed efficacy in chronic obstructive pulmonary disease and are now being considered as an alternative add-on therapy for people with uncontrolled asthma. OBJECTIVES: To assess the efficacy and safety of adding a LAMA to ICS compared with adding a LABA for adults whose asthma is not well controlled on ICS alone. SEARCH METHODS: We searched the Cochrane Airways Group's Specialised Register (CAGR) from inception to April 2015, and imposed no restriction on language of publication. We searched additional resources to pick up unpublished studies, including ClinicalTrials.gov, World Health Organization trials portal, reference lists of primary studies and existing reviews, and manufacturers' trial registries. The most recent search was conducted in April 2015. SELECTION CRITERIA: We searched for parallel and cross-over RCTs in which adults whose asthma was not well controlled with ICS alone were randomised to receive LAMA add-on or LABA add-on for at least 12 weeks. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the electronic and additional searches and extracted data from study reports. We used Covidence for duplicate screening, extraction of study characteristics and numerical data, and risk of bias ratings.The pre-specified primary outcomes were exacerbations requiring oral corticosteroids (OCS), quality of life and serious adverse events. MAIN RESULTS: We included eight studies meeting the inclusion criteria, but four double-blind, double-dummy studies of around 2000 people dominated the analyses. These four trials were between 14 and 24 weeks long, all comparing tiotropium (usually Respimat) with salmeterol on top of medium doses of ICS.Studies reporting exacerbations requiring OCS showed no difference between the two add-ons, but our confidence in the effect was low due to inconsistency between studies and because the confidence intervals (CI) included significant benefit of either treatment (odds ratio (OR) 1.05, 95% CI 0.50 to 2.18; 1753 participants; 3 studies); three more people per 1000 might have an exacerbation on LAMA, but the CIs ranged from 29 fewer to 61 more. Imprecision was also an issue for serious adverse events and exacerbations requiring hospital admission, rated low (serious adverse events) and very low quality (exacerbations requiring hospital admission), because there were so few events in the analyses.People taking LAMA scored slightly worse on two scales measuring quality of life (Asthma Quality of Life Questionnaire; AQLQ) and asthma control (Asthma Control Questionnaire; ACQ); the evidence was rated high quality but the effects were small and unlikely to be clinically significant (AQLQ: mean difference (MD) -0.12, 95% CI -0.18 to -0.05; 1745 participants; 1745; 4 studies; ACQ: MD 0.06, 95% CI 0.00 to 0.13; 1483 participants; 3 studies).There was some evidence to support small benefits of LAMA over LABA on lung function, including on our pre-specified preferred measure trough forced expiratory volume in one second (FEV1) (MD 0.05 L, 95% CI 0.01 to 0.09; 1745 participants, 4 studies). However, the effects on other measures varied, and it is not clear whether the magnitude of the differences were clinically significant.More people had adverse events on LAMA but the difference with LABA was not statistically significant. AUTHORS' CONCLUSIONS: Direct evidence of LAMA versus LABA as add-on therapy is currently limited to studies of less than six months comparing tiotropium (Respimat) to salmeterol, and we do not know how they compare in terms of exacerbations and serious adverse events. There was moderate quality evidence that LAMAs show small benefits over LABA on some measures of lung function, and high quality evidence that LABAs are slightly better for quality of life, but the differences were all small. Given the much larger evidence base for LABA versus placebo for people whose asthma is not well controlled on ICS, the current evidence is not strong enough to say that LAMA can be substituted for LABA as add-on therapy.The results of this review, alongside pending results from related reviews assessing the use of LAMA in other clinical scenarios, will help to define the role of these drugs in asthma and it is important that they be updated as results from ongoing and planned trials emerge.

Integration of an online simulated prescription analysis into undergraduate pharmacy teaching using supplemental and replacement models.

OBJECTIVE: To describe student use and perceptions of online simulated prescription analysis following integration of supplemental and replacement models into pharmacy practice teaching. METHODS: Strathclyde Computerized Randomized Interactive Prescription Tutor (SCRIPT) is a simulated prescription analysis tool designed to support a pharmacy practice competency class. In 2008-2009, SCRIPT scenarios were released to coincide with timetabled teaching as the supplemental model. In 2009-2010, SCRIPT also replaced one-sixth of the taught component of the class as the replacement model. Student use and performance were compared, and their perceptions were documented. RESULTS: In both cohorts, the majority of use (over 70%) occurred immediately before assessments. Remote access decreased from 6409 (supplemental) to 3782 (replacement) attempts per 100 students. There was no difference in student performance between the cohorts, Students reported group and individual use and 4 targeted approaches using SCRIPT. CONCLUSION: E-learning can reduce the staff time in pharmacy practice teaching without affecting student performance. SCRIPT permits flexible learning that suits student preferences.

Changes to inhaled corticosteroid dose when initiating combination inhaler therapy in long-acting ß agonist-naïve patients with asthma: a retrospective database analysis.

Retrospective prescribing data were obtained from 46 general practice surgeries in NHS Scotland. Patients with asthma who were naïve to previous long-acting ß agonist therapy and initiated combination inhaler therapy in 2008-2009 were classified according to the inhaled corticosteroid (ICS) dose in their combination inhaler compared with the highest dose of ICS they received before initiation. Among the 685 patients (541 (79.0%) who had been prescribed an ICS previously), those originally on low-, medium- or high-dose ICS were changed to high-dose combination therapy in 122/250 (48.8%), 94/151 (62.3%) or 85/113 (75.2%) cases in each ICS dose category, respectively. These results suggest that evaluation of appropriate high-dose ICS prescribing in general practice is needed.