Pilot and quantitative evaluation of the TARGET acne toolkit by UK pharmacy professionals working in general practice.

BACKGROUND: Acne vulgaris (acne) is a common skin condition sometimes needing topical or oral antibiotic treatment. Pharmacists and pharmacy technicians (together known as pharmacy professionals) working in general practice are well placed to ensure their appropriate use. OBJECTIVES: The objectives of this study are to pilot an evidence-based intervention ('How to…' tool) to review treatments in the management of acne and evaluate the capability, opportunity, motivation and behaviour (COM-B) of pharmacy professionals working in general practice before and after the use of this tool. DESIGN, SETTING AND PARTICIPANTS: A quantitative electronic survey was developed asking UK-based pharmacy professionals working in general practice to rate their agreement with 21 predefined statements related to the COM-B model. INTERVENTION: Participants were sent an initial survey, given time to access and use the 'How to…' acne resources and then sent a follow-up survey 2 weeks later. OUTCOME MEASURES: Primary outcome was change in 5-point Likert scale responses to statements on capability, opportunity and motivation in the management of acne. Secondary outcome was the perceived usefulness of the toolkit. RESULTS: 141 pharmacy professionals completed the initial survey; 19 completed the follow-up survey. Significant improvement in the 5-point Likert scale means that responses were observed after implementation of the acne 'How to' resource; capability 3.68 (SD 0.40) versus 4.11 (SD 0.29), t(189) =-5.10, p <0.001; opportunity 3.85 (SD 0.24) versus 4.07 (SD 0.29), t(94)=-2.50, p=0.007 and motivation 4.35 (SD 0.47) versus 4.51 (SD 0.32), t(113)=-2.51, p=0.007. The 'How to' resources were rated as being useful (4.06, SD 0.12) and supportive (4.08, SD 0.18) to help pharmacy professionals in all areas of managing acne. CONCLUSION: The acne 'How to' resources are useful to pharmacy professionals in managing acne in general practice and may improve their capability. Further work is needed with greater numbers of participants to demonstrate generalisability of this outcome.

Perspectives of community pharmacy staff on commonly encountered skin conditions and the key challenges towards enhancing their role in dermatology.

This research letter discusses the perspectives of community pharmacy staff on commonly encountered skin conditions and the key challenges towards enhancing their role in this area. A mixed methods online survey was created, and a total of 174 community pharmacy staff completed the survey. The results highlight the range of conditions currently encountered in community pharmacy and the breadth of challenges facing community pharmacy staff, in particular challenges surrounding providing a differential diagnosis. Community pharmacies are an integral part of the NHS and have a key role in managing skin conditions; however, in order to optimise this role, the perspectives of staff discussed in this letter need to be further explored and addressed.

How can community pharmacists be supported to manage skin conditions? A multistage stakeholder research prioritisation exercise.

OBJECTIVE: To establish research priorities which will support the development and delivery of community pharmacy initiatives for the management of skin conditions. DESIGN: An iterative, multistage stakeholder consultation consisting of online survey, participant workshops and prioritisation meeting. SETTING: All data collection took place online with participants completing a survey (delivered via the JISC Online Survey platform, between July 2021 and January 2022) and participating in online workshops and meetings (hosted on Microsoft Teams between April and July 2022). PARTICIPANTS: 174 community pharmacists and pharmacy staff completed the online survey.53 participants participated in the exploratory workshops (19 community pharmacists, 4 non-pharmacist members of pharmacy staff and 30 members of the public). 4 healthcare professionals who were unable to attend a workshop participated in a one-to-one interview.29 participants from the workshops took part in the prioritisation meeting (5 pharmacists/pharmacy staff, 1 other healthcare professional and 23 members of the public). RESULTS: Five broad areas of potential research need were identified in the online survey: (1) identifying and diagnosing skin conditions; (2) skin conditions in skin of colour; (3) when to refer skin conditions; (4) disease-specific concerns and (5) product-specific concerns.These were explored and refined in the workshops to establish 10 potential areas for research, which will support pharmacists in managing skin conditions. These were ranked in the prioritisation meeting. Among those prioritised were topics which consider how pharmacists work with other healthcare professionals to identify and manage skin conditions. CONCLUSIONS: Survey responses and stakeholder workshops all recognised the potential for community pharmacists to play an active role in the management of common skin conditions. Future research may support this in the generation of resources for pharmacists, in encouraging public take-up of pharmacy services, and in evaluating the most effective provision for dealing with skin conditions.

Perceived current and future roles of UK-based community pharmacy professionals in the long-term management of acne.

Introduction: Acne is a common skin condition treated in community pharmacy but moderate to severe cases may need referral to general practice for treatment that may include topical or oral antimicrobial treatments. Pharmacy teams working in the community are well-placed to manage acne treatments in line with NICE guidance. Objectives: To explore the perceived current and future roles of community pharmacy (CP) teams alongside needs to achieve potential future roles. Additionally, usefulness of the TARGET acne 'How to' toolkit to support these roles was sought. Methods: A mixed-methods electronic survey of UK-based CP professionals and stakeholders in March 2023. Results: 54 pharmacy professionals and stakeholders responded to the survey. The current confidence of pharmacy professionals in managing acne was rated as moderate and reviewing long-term medications for acne prescribed by another healthcare professional was seen as a future role. The needs identified to undertake such a role were: training, availability of prescribing or supply frameworks, and appropriate remuneration. The TARGET acne resources were thought of as being very useful for acne management. Conclusions: Potential future roles for CP have been identified, alongside additional needs to undertake these roles; the TARGET acne 'How to' resources could support pharmacy professionals in the management and review of antimicrobial treatment for acne.

Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: Multiple interrupted time series study.

BACKGROUND: We previously reported on a randomised trial demonstrating the effectiveness and cost-effectiveness of a pharmacist-led information technology intervention (PINCER). We sought to investigate whether PINCER was effective in reducing hazardous prescribing when rolled out at scale in UK general practices. METHODS AND FINDINGS: We used a multiple interrupted time series design whereby successive groups of general practices received the PINCER intervention between September 2015 and April 2017. We used 11 prescribing safety indicators to identify potentially hazardous prescribing and collected data over a maximum of 16 quarterly time periods. The primary outcome was a composite of all the indicators; a composite for indicators associated with gastrointestinal (GI) bleeding was also reported, along with 11 individual indicators of hazardous prescribing. Data were analysed using logistic mixed models for the quarterly event numbers with the appropriate denominator, and calendar time included as a covariate. PINCER was implemented in 370 (94.1%) of 393 general practices covering a population of almost 3 million patients in the East Midlands region of England; data were successfully extracted from 343 (92.7%) of these practices. For the primary composite outcome, the PINCER intervention was associated with a decrease in the rate of hazardous prescribing of 16.7% (adjusted odds ratio (aOR) 0.83, 95% confidence interval (CI) 0.80 to 0.86) at 6 months and 15.3% (aOR 0.85, 95% CI 0.80 to 0.90) at 12 months postintervention. The unadjusted rate of hazardous prescribing reduced from 26.4% (22,503 patients in the numerator/853,631 patients in the denominator) to 20.1% (11,901 patients in the numerator/591,364 patients in the denominator) at 6 months and 19.1% (3,868 patients in the numerator/201,992 patients in the denominator). The greatest reduction in hazardous prescribing associated with the intervention was observed for the indicators associated with GI bleeding; for the GI composite indicator, there was a decrease of 23.9% at both 6 months (aOR 0.76, 95% CI 0.73 to 0.80) and 12 months (aOR 0.76, 95% CI 0.70 to 0.82) postintervention. The unadjusted rate of hazardous prescribing reduced from 31.4 (16,185 patients in the numerator/515,879 patients in the denominator) to 21.2% (7,607 patients in the numerator/358,349 patients in the denominator) at 6 months and 19.5% (2,369 patients in the numerator/121,534 patients in the denominator). We adjusted for calendar time and practice, but since this was an observational study, the findings may have been influenced by unknown confounding factors or behavioural changes unrelated to the PINCER intervention. Data were also not collected for all practices at 6 months and 12 months postintervention. CONCLUSIONS: The PINCER intervention, when rolled out at scale in routine clinical practice, was associated with a reduction in hazardous prescribing by 17% and 15% at 6 and 12 months postintervention. The greatest reductions in hazardous prescribing were for indicators associated with risk of GI bleeding. These findings support the wider national rollout of PINCER in England.

The potential of multispectral imaging flow cytometry for environmental monitoring.

Environmental monitoring involves the quantification of microscopic cells and particles such as algae, plant cells, pollen, or fungal spores. Traditional methods using conventional microscopy require expert knowledge, are time-intensive and not well-suited for automated high throughput. Multispectral imaging flow cytometry (MIFC) allows measurement of up to 5000 particles per second from a fluid suspension and can simultaneously capture up to 12 images of every single particle for brightfield and different spectral ranges, with up to 60x magnification. The high throughput of MIFC has high potential for increasing the amount and accuracy of environmental monitoring, such as for plant-pollinator interactions, fossil samples, air, water or food quality that currently rely on manual microscopic methods. Automated recognition of particles and cells is also possible, when MIFC is combined with deep-learning computational techniques. Furthermore, various fluorescence dyes can be used to stain specific parts of the cell to highlight physiological and chemical features including: vitality of pollen or algae, allergen content of individual pollen, surface chemical composition (carbohydrate coating) of cells, DNA- or enzyme-activity staining. Here, we outline the great potential for MIFC in environmental research for a variety of research fields and focal organisms. In addition, we provide best practice recommendations.

An ethnographic evaluation of a speciality training pathway for general practice nursing in the UK.

AIMS: The aim of the study was to evaluate the implementation and impact of the General Practice Nurse - Specialty Training (GPN-ST) programme across seven sites in one geographical location in the UK. The objectives were to understand, describe and evaluate: 1) the implementation of the 'proof of concept' training scheme; 2) the learning undertaken during the training; and 3) the impact of the training scheme on individual nurses. These objectives offer the opportunity to describe the potential return on investment for General Practices supporting nurses new to General Practice through the programme. BACKGROUND: General Practice Nurses (GPNs) play a vital role in delivering primary and community care. In the UK there is a shortfall in the GPN workforce. Unlike training for other clinical professions there is currently no standardised training pathway or entry route for nurses wishing to work in General Practice. An ethnographic evaluation was undertaken of a one-year speciality training programme (GPN-ST). The programme, aimed at nurses new to General Practice, included formal higher education training and funded supported learning and mentoring whilst in practice. METHODS: A qualitative ethnographic evaluation was undertaken. Observations were conducted of programme implementation, network and education meetings in the scheme. In-depth, semi-structured, interviews and focus groups were conducted with a wide range of professionals (n = 40) including nurse mentors, nursing students, academic providers, commissioners and the programme managers. These data were supplemented by documentary analysis of meeting notes, learning materials, internal student feedback and locally collected evaluation material in line with ethnographic approaches to research. Kirkpatrick's model for course evaluation and complimentary inductive emergent thematic analysis was used. FINDINGS: There is evidence of learning at every level of the Kirkpatrick model from reaction through to changes in behaviour and results in practice for patients. The speciality training route offered opportunities for deep learning for GPNs. The scheme offered a comprehensive career pathway to General Practice nursing which in turn benefited General Practices. Practices benefitted from confident, independent nurses who were able to contribute to patient care, practice safely and also contributed widely in the long-term for example in research, workforce development and mentoring. CONCLUSIONS: General Practice needs to invest in developing a workforce of GPNs, there are significant benefits to investing in the development of GPNs through a training pathway. This scheme provides scope for application in other clinical settings as well in other countries where there is a gap in career progression into GP practices. TWEETABLE ABSTRACT: GPNs play a vital role in delivering primary and community care. Unlike training for other clinical professions there is currently no standardised training pathway or entry route for nurses wishing to work in General Practice. There are significant benefits to investing in the development of GPNs through a training pathway.

Astropharmacy: Pushing the boundaries of the pharmacists' role for sustainable space exploration.

BACKGROUND: Human physiology undergoes extensive changes in space potentially leading to alterations in the way a medication functions. Understanding the efficacy behind Pharmacological Countermeasures (PCMs) and deliverable pharmacy services is imperative for the future presence of humans in space. However, while the pharmacist plays an integral role for human health terrestrially, pharmacist input has been minimal for human health in the space sector. Here, we explore the pharmacist's potential role in larger medical teams for future missions. OBJECTIVE: To explore pharmacy and space sector stakeholder perspectives regarding the pharmacist's role in the space sector. METHODS: Semi-structured interviews and focus groups were conducted with pharmacy (n = 31) and human health-related space sector stakeholders (n = 26) across the globe from governmental, commercial, industry and academic sectors. Purposive and snowball sampling were used to identify stakeholders. Interviews and focus groups were audio recorded, transcribed verbatim and thematically analysed. RESULTS: Three themes - medication management, medication-related research and medication and health information - were generated. The importance of medication optimisation within commercial and federal spaceflight participant medication regimens was cited as necessary for sustainable space exploration. Both groups advocated for pharmacists' involvement with in-situ medication manufacturing and medication-related research, particularly regarding space-based pharmacokinetic and pharmacodynamic drug profiling. Other essential roles included the pharmacist's role in providing medication information to spaceflight participants and other healthcare professionals on their health status and medication use risk in the context of space. CONCLUSIONS: With the advancement of accessible, commercial space travel and humans becoming an inter-planetary species, the opportunity to tackle PCM needs via a more extensive and comprehensive collaborative effort between the space, medical and pharmacy sectors is essential for sustainable space exploration.

Perspectives of pharmacists in general practice from qualitative focus groups with patients during a pilot study.

BACKGROUND: Utilising skill mix in general practice is proposed as a solution to the demand-supply issue. Pharmacists can play an important role in this context, leading to an increase in training and funding for independent prescriber roles. A role for pharmacists in general practice was funded, piloted, and evaluated by NHS England (NHSE) from 2015. AIM: To answer the following question: what is the patient perspective of pharmacists in patient-facing roles in general practice in the UK? DESIGN & SETTING: Focus group interviews exploring patient perspectives on the pharmacist role in the UK. METHOD: Thirty-four patients were interviewed in five focus group (January-December 2016). Data were iteratively analysed using the one sheet of paper technique. RESULTS: While the public were aware of the primary care crisis, they were less well informed about potential solutions. Data showed patients primarily sought access to a clinician over expressing a preference for any type of clinician. Low awareness was shown about the pharmacist role and there was initial confusion about it. Acceptability levels were high. It was found that pharmacists added value and provided an expert medication-focused service, which had a positive impact on medicines use. Patients reported benefit from longer appointments, feeling they were not rushed, and that all their conditions were being considered holistically. They trusted pharmacists as experts in medication and trust was consolidated over time. Regular coaching from a pharmacist could lead to improved patient self-monitoring and self-care. CONCLUSION: Pharmacists can add value to the general practice team and this is recognised by patients.

Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review.

OBJECTIVE: To estimate the incidence of avoidable significant harm in primary care in England; describe and classify the associated patient safety incidents and generate suggestions to mitigate risks of ameliorable factors contributing to the incidents. DESIGN: Retrospective case note review. Patients with significant health problems were identified and clinical judgements were made on avoidability and severity of harm. Factors contributing to avoidable harm were identified and recorded. SETTING: Primary care. PARTICIPANTS: Thirteen general practitioners (GPs) undertook a retrospective case note review of a sample of 14 407 primary care patients registered with 12 randomly selected general practices from three regions in England (total list size: 92 255 patients). MAIN OUTCOME MEASURES: The incidence of significant harm considered at least 'probably avoidable' and the nature of the safety incidents. RESULTS: The rate of significant harm considered at least probably avoidable was 35.6 (95% CI 23.3 to 48.0) per 100 000 patient-years (57.9, 95% CI 42.2 to 73.7, per 100 000 based on a sensitivity analysis). Overall, 74 cases of avoidable harm were detected, involving 72 patients. Three types of incident accounted for more than 90% of the problems: problems with diagnosis accounted for 45/74 (60.8%) primary incidents, followed by medication-related problems (n=19, 25.7%) and delayed referrals (n=8, 10.8%). In 59 (79.7%) cases, the significant harm could have been identified sooner (n=48) or prevented (n=11) if the GP had taken actions aligned with evidence-based guidelines. CONCLUSION: There is likely to be a substantial burden of avoidable significant harm attributable to primary care in England with diagnostic error accounting for most harms. Based on the contributory factors we found, improvements could be made through more effective implementation of existing information technology, enhanced team coordination and communication, and greater personal and informational continuity of care.

Exploring barriers to the sustainability of an electronic administration system in long-term care facilities: A case study approach.

BACKGROUND: The safe provision of medicines administration is a fundamental challenge faced in long-term care facilities (LTCFs). Many residents of LTCFs are frail older persons with multiple morbidities, and in addition to polypharmacy, are particularly at risk of harm due to concomitant disease and disability. One potential method to optimise medication safety and facilitate medicines administration within LTCFs is the introduction of technology. OBJECTIVE: This paper explores the barriers to long-term sustainability concerning the use of an electronic administration system (eMAR) in LTCFs. METHODS: Fifteen in depth, semi-structured interviews were conducted with LTCF staff (9), eMAR service commissioners (2), members of the implementation team (2) and care home strategy managers (2) across three LTCF sites. The study participants were purposefully sampled and each interview audio-recorded, transcribed verbatim and analysed using Nvivo 11. In addition to interviews, observational notes were taken by the lead researcher from visits to the LCTFs as a form of data collection. The analysis process consisted of a two-stage process of thematic analysis then theoretical mapping. RESULTS: Barriers identified were split into four main overarching areas: structural, implementation team, system user and operational barriers. The adoption of eMAR within this setting was welcomed by top-level stakeholders, however, LTCF staff displayed concerns over its usability. The lack of co-development and on-going training need highlighted barriers to its sustainability, in addition to risks associated with current legislation. The themes identified throughout the framework highlight challenges faced when exploring the sustainability of eMAR in LTCF. CONCLUSIONS: The use of technology in health care is evolving. Awareness of actors relating to its introduction can have significant impact on success and service sustainability.

Validation analysis of Global Health Security Index (GHSI) scores 2019.

INTRODUCTION: The COVID-19 pandemic powerfully demonstrates the consequences of biothreats. Countries will want to know how to better prepare for future events. The Global Health Security Index (GHSI) is a broad, independent assessment of 195 countries' preparedness for biothreats that may aid this endeavour. However, to be useful, the GHSI's external validity must be demonstrated. We aimed to validate the GHSI against a range of external metrics to assess how it could be utilised by countries. METHODS: Global aggregate communicable disease outcomes were correlated with GHSI scores and linear regression models were examined to determine associations while controlling for a number of global macroindices. GHSI scores for countries previously exposed to severe acute respiratory syndrome (SARS), Middle East respiratory syndrome and Ebola and recipients of US Global Health Security Agenda (GHSA) investment were compared with matched control countries. Possible content omissions in light of the progressing COVID-19 pandemic were assessed. RESULTS: GHSI scores for countries had strong criterion validity against the Joint External Evaluation ReadyScore (rho=0.82, p<0.0001), and moderate external validity against deaths from communicable diseases (-0.56, p<0.0001). GHSI scores were associated with reduced deaths from communicable diseases (F(3, 172)=22.75, p<0.0001). The proportion of deaths from communicable diseases decreased 4.8% per 10-point rise in GHSI. Recipient countries of the GHSA (n=31) and SARS-affected countries (n=26), had GHSI scores 6.0 (p=0.0011) and 8.2 (p=0.0010) points higher than matched controls, respectively. Biosecurity and biosafety appear weak globally including in high-income countries, and health systems, particularly in Africa, are not prepared. Notably, the GHSI does not account for all factors important for health security. CONCLUSION: The GHSI shows promise as a valid tool to guide action on biosafety, biosecurity and systems preparedness. However, countries need to look beyond existing metrics to other factors moderating the impact of future pandemics and other biothreats. Consideration of anthropogenic and large catastrophic scenarios is also needed.

'New Medicine Service': supporting adherence in people starting a new medication for a long-term condition: 26-week follow-up of a pragmatic randomised controlled trial.

OBJECTIVE: To examine the effectiveness and cost-effectiveness of the community pharmacy New Medicine Service (NMS) at 26 weeks. METHODS: Pragmatic patient-level parallel randomised controlled trial in 46 English community pharmacies. 504 participants aged ≥14, identified in the pharmacy when presenting a prescription for a new medicine for predefined long-term conditions, randomised to receive NMS (n=251) or normal practice (n=253) (NMS intervention: 2 consultations 1 and 2 weeks after prescription presentation). Adherence assessed through patient self-report at 26-week follow-up. Intention-to-treat analysis employed. National Health Service (NHS) costs calculated. Disease-specific Markov models estimating impact of non-adherence combined with clinical trial data to calculate costs per extra quality-adjusted life-year (QALY; NHS England perspective). RESULTS: Unadjusted analysis: of 327 patients still taking the initial medicine, 97/170 (57.1%) and 103/157 (65.6%) (p=0.113) patients were adherent in normal practice and NMS arms, respectively. Adjusted intention-to-treat analysis: adherence OR 1.50 (95% CI 0.93 to 2.44, p=0.095), in favour of NMS. There was a non-significant reduction in 26-week NHS costs for NMS: -£104 (95% CI -£37 to £257, p=0.168) per patient. NMS generated a mean of 0.04 (95% CI -0.01 to 0.13) more QALYs per patient, with mean reduction in lifetime cost of -£113.9 (-1159.4, 683.7). The incremental cost-effectiveness ratio was -£2758/QALY (2.5% and 97.5%: -38 739.5, 34 024.2. NMS has an 89% probability of cost-effectiveness at a willingness to pay of £20 000 per QALY. CONCLUSIONS: At 26-week follow-up, NMS was unable to demonstrate a statistically significant increase in adherence or reduction in NHS costs, which may be attributable to patient attrition from the study. Long-term economic evaluation suggested NMS may deliver better patient outcomes and reduced overall healthcare costs than normal practice, but uncertainty around this finding is high. TRIAL REGISTRATION NUMBER: NCT01635361, ISRCTN23560818, ISRCTN23560818, UKCRN12494.

Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study.

BACKGROUND: Health care-related harm is an internationally recognized threat to public health. The United Kingdom's national health services demonstrate that upwards of 90% of health care encounters can be delivered in ambulatory settings. Other countries are transitioning to more family practice-based health care systems, and efforts to understand avoidable harm in these settings is needed. METHODS: We developed 100 scenarios reflecting a range of diseases and informed by the World Health Organization definition of 'significant harm'. Scenarios included different types of patient safety incidents occurring by commission and omission, demonstrated variation in timeliness of intervention, and conditions where evidence-based guidelines are available or absent. We conducted a two-round RAND / UCLA Appropriateness Method consensus study with a panel of family practitioners in England to define "avoidable harm" within family practice. Panelists rated their perceptions of avoidability for each scenario. We ran a k-means cluster analysis of avoidability ratings. RESULTS: Panelists reached consensus for 95 out of 100 scenarios. The panel agreed avoidable harm occurs when a patient safety incident could have been probably, or totally, avoided by the timely intervention of a health care professional in family practice (e.g. investigations, treatment) and / or an administrative process (e.g. referrals, alerts in electronic health records, procedures for following up results) in accordance with accepted evidence-based practice and clinical governance. Fifty-four scenarios were deemed avoidable, whilst 31 scenarios were rated unavoidable and reflected outcomes deemed inevitable regardless of family practice intervention. Scenarios with low avoidability ratings (1 s or 2 s) were not represented by the categories that were used to generate scenarios, whereas scenarios with high avoidability ratings (7 s 8 s or 9 s) were represented by these a priori categories. DISCUSSION: The findings from this RAND/UCLA Appropriateness Method study define the characteristics and conditions that can be used to standardize measurement of outcomes for primary care patient safety. CONCLUSION: We have developed a definition of avoidable harm that has potential for researchers and practitioners to apply across primary care settings, and bolster international efforts to design interventions to target avoidable patient safety incidents that cause the most significant harm to patients.

The role of pharmacists in general practice: A realist review.

BACKGROUND: The review was carried out to inform the evaluation of the clinical pharmacists in general practice pilot scheme, a world leading initiative to improve health care delivery in England. Around 500 pharmacists are already working in general practice as part of the pilot, launched in July 2015. OBJECTIVES: The review attempts to explain the how pharmacists working in general practice is being implemented in the UK and beyond, what works well, what does not work so well and everything in-between. METHODS: This realist review was conducted to the RAMESES standards. Studies were identified by searching three databases, Medline, Embase and Scopus. Additional papers were gathered from reference lists, Google searches and via the find similar citations feature. RESULTS: A total of 83 papers and articles were initially identified from Medline (19), Embase (31) and Scopus (32). With close reading, the final review consisted of 43 papers relating to 38 studies. Most of the research was undertaken in the field of pharmacy practice and over half of the studies investigated the perspectives of different stakeholders using questionnaires or qualitative methods. CONCLUSION: The pharmacist working in general practice is still a relatively new concept and further more in-depth research is still required. However, from this small number of studies, the common barriers and facilitators to the implementation can be identified. The review also lists mechanisms that will be needed to ensure the effective implementation of this initiative.

'I expected just to walk in, get my tablets and then walk out': on framing new community pharmacy services in the English healthcare system.

Reconfiguration of the healthcare division of labour is becoming increasingly attractive in the context of increased patient demand and resource constraints. One example is the introduction of extended roles for pharmacists to provide patients additional support to manage their medicines, while also reducing work pressures experienced by other health professionals. Understanding how such policies are framed by those delivering and receiving care has been under-theorised. Using Goffman's frame theory, we examine one newly introduced community pharmacy service (New Medicines Service (NMS)) to illustrate how a policy intended to support patient medicine-taking through the extended roles of pharmacists is framed and where this deviates from its proposed aims. Three themes emerged: (i) the spatial-material artefacts; (ii) existing discursive culture and practice around medicine-taking; and (iii) the NMS interactions that shape and govern framing and subsequent interpretation of the NMS. Our study offers an explanatory and dynamic view of the framing process with important lessons for reconfiguring medicine management policy and practice. As well as illustrating framing as being variegated, complementary or conflicting, it also shows how this plurality and fragility had consequences for patient engagement and sense-making. The consequences for engagement and recommendations for implementing future initiatives are discussed.

Comparative Performance and Model Agreement of Three Common Photovoltaic Array Configurations.

Three grid-connected monocrystalline silicon arrays on the National Institute of Standards and Technology (NIST) campus in Gaithersburg, MD have been instrumented and monitored for 1 yr, with only minimal gaps in the data sets. These arrays range from 73 kW to 271 kW, and all use the same module, but have different tilts, orientations, and configurations. One array is installed facing east and west over a parking lot, one in an open field, and one on a flat roof. Various measured relationships and calculated standard metrics have been used to compare the relative performance of these arrays in their different configurations. Comprehensive performance models have also been created in the modeling software pvsyst for each array, and its predictions using measured on-site weather data are compared to the arrays' measured outputs. The comparisons show that all three arrays typically have monthly performance ratios (PRs) above 0.75, but differ significantly in their relative output, strongly correlating to their operating temperature and to a lesser extent their orientation. The model predictions are within 5% of the monthly delivered energy values except during the winter months, when there was intermittent snow on the arrays, and during maintenance and other outages.

Impact of a novel interprofessional dental and pharmacy student tobacco cessation education programme on dental patient outcomes.

The dental setting presents a unique opportunity to assist patients with tobacco cessation. Many dental providers do not feel prepared to provide tobacco cessation, particularly with regard to education on pharmacological treatments. An interprofessional practice experience with dental and pharmacy students provides a novel approach to tobacco cessation in the dental setting, but it is not known whether such methods affect patient outcomes. The goal of the study was to examine the impact of a novel dental and pharmacy student tobacco cessation education programme on patient knowledge gained, barriers to utilising cessation medications, quit intentions, and quit behaviours as compared to standard care. Dental patients who were seen at the dental admissions clinic of a dental school on interprofessional care (IPC) days and received tobacco cessation education from the dental-pharmacy student team (N = 25) were compared with dental patients at the clinic seen on Standard Care (SC) days (N = 25). Patients completed a post-appointment survey and a 4-week follow-up survey. IPC patients reported greater perceived knowledge post-appointment and at follow-up regarding tobacco cessation compared with SC patients and had greater intentions to utilise medication to assist with tobacco cessation. At follow-up there were no differences between groups in terms of quit attempts. Among patients who made a quit attempt those in the IPC group were more likely to have set a quit date and contacted a provider for assistance regarding tobacco cessation. Dental-pharmacy student interprofessional tobacco cessation may be an innovative way to provide tobacco cessation education to dental patients and provide students with interprofessional practice experiences.

Cost Effectiveness of Support for People Starting a New Medication for a Long-Term Condition Through Community Pharmacies: An Economic Evaluation of the New Medicine Service (NMS) Compared with Normal Practice.

BACKGROUND: The English community pharmacy New Medicine Service (NMS) significantly increases patient adherence to medicines, compared with normal practice. We examined the cost effectiveness of NMS compared with normal practice by combining adherence improvement and intervention costs with the effect of increased adherence on patient outcomes and healthcare costs. METHODS: We developed Markov models for diseases targeted by the NMS (hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, asthma and antiplatelet regimens) to assess the impact of patients' non-adherence. Clinical event probability, treatment pathway, resource use and costs were extracted from literature and costing tariffs. Incremental costs and outcomes associated with each disease were incorporated additively into a composite probabilistic model and combined with adherence rates and intervention costs from the trial. Costs per extra quality-adjusted life-year (QALY) were calculated from the perspective of NHS England, using a lifetime horizon. RESULTS: NMS generated a mean of 0.05 (95% CI 0.00-0.13) more QALYs per patient, at a mean reduced cost of -£144 (95% CI -769 to 73). The NMS dominates normal practice with a probability of 0.78 [incremental cost-effectiveness ratio (ICER) -£3166 per QALY]. NMS has a 96.7% probability of cost effectiveness compared with normal practice at a willingness to pay of £20,000 per QALY. Sensitivity analysis demonstrated that targeting each disease with NMS has a probability over 0.90 of cost effectiveness compared with normal practice at a willingness to pay of £20,000 per QALY. CONCLUSIONS: Our study suggests that the NMS increased patient medicine adherence compared with normal practice, which translated into increased health gain at reduced overall cost. TRIAL REGISTRATION: ClinicalTrials.gov Trial reference number NCT01635361 ( http://clinicaltrials.gov/ct2/show/NCT01635361 ). Current Controlled trials: Trial reference number ISRCTN 23560818 ( http://www.controlled-trials.com/ISRCTN23560818/ ; DOI 10.1186/ISRCTN23560818 ). UK Clinical Research Network (UKCRN) study 12494 ( http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=12494 ). FUNDING: Department of Health Policy Research Programme.