Non-pharmacological interventions for the reduction and maintenance of blood pressure in people with prehypertension: a systematic review protocol.

INTRODUCTION: Prehypertension is defined as blood pressure that is above the normal range but not high enough to be classed as hypertension. Prehypertension is a warning of development of hypertension as well as a risk for cardiovascular disease, heart attack and stroke. In the UK, non-pharmacological interventions are recommended for prehypertension management but no reviews have focused on the effectiveness of these types of interventions solely in people with prehypertension. Therefore, the proposed systematic review will assess the clinical effectiveness and cost-effectiveness of non-pharmacological interventions in reducing or maintaining blood pressure in prehypertensive people. METHODS AND ANALYSIS: This systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The databases/trial registries that will be searched to identify relevant randomised controlled trials (RCTs) and economic evaluations include Medline, EMBASE, CINAHL, PsycINFO, CENTRAL, the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, Cochrane Library, Scopus and the International HTA Database. Search terms have been identified by the team including an information specialist. Three reviewers will be involved in the study selection process. Risk of bias will be evaluated using the Cochrane risk-of-bias tool for RCTs and the Consensus Health Economic Criteria list for economic evaluations. Findings from the included studies will be tabulated and synthesised narratively. Heterogeneity will be assessed through visual inspection of forest plots and the calculation of the χ2 and I2 statistics and causes of heterogeneity will be assessed where sufficient data are available. If possible, we plan to investigate differential effects on specific subgroups and from different types of interventions using meta-regression. Where relevant, the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) will be used to assess the certainty of the evidence found. ETHICS AND DISSEMINATION: Ethical approval is not needed. Results will be published in a peer-reviewed journal, disseminated via the wider study website and shared with the study sites and participants. REGISTRATION DETAILS: The review is registered with PROSPERO (CRD420232433047).

Facilitating self-care through community pharmacy in England.

In England, almost all the population are within a short walk of a community pharmacy. This network of pharmacies provides a range of services, most of which are commissioned and remunerated through a nationally agreed contract with the National Health Service (NHS). Over time this contract has seen funding move from the traditional core service of dispensing medicines, toward patient-facing clinical services. All of these services have elements of self-care built in to the service specification, which pharmacists are mandated to deliver. These services significantly expand the role of the community pharmacist beyond facilitating self-care by supplying "over the counter" (OTC) medication. The increased public health role, where promotion of healthy living and prevention of disease is now seen as an essential activity by and for pharmacists. Changes to UK health policy, where the focus has been on delivering care closer to the patients' home, means community pharmacists have an increasing role in the effective management of acute and long-term conditions. The most recent contract afforded to pharmacy has now started to integrate pharmacy services with medical services, in both primary and secondary care, in attempt to provide greater continuity for the patient. It is very likely that self-care activities provided by community pharmacy will expand further, especially around the management of long-term conditions as the pharmacy workforce transitions in to having prescribing rights for medicines other than non-prescription medicines.

What makes a multidisciplinary medication review and deprescribing intervention for older people work well in primary care? A realist review and synthesis.

BACKGROUND: A third of older people take five or more regular medications (polypharmacy). Conducting medication reviews in primary care is key to identify and reduce/ stop inappropriate medications (deprescribing). Recent recommendations for effective deprescribing include shared-decision making and a multidisciplinary approach. Our aim was to understand when, why, and how interventions for medication review and deprescribing in primary care involving multidisciplinary teams (MDTs) work (or do not work) for older people. METHODS: A realist synthesis following the Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidelines was completed. A scoping literature review informed the generation of an initial programme theory. Systematic searches of different databases were conducted, and documents screened for eligibility, with data extracted based on a Context, Mechanisms, Outcome (CMO) configuration to develop further our programme theory. Documents were appraised based on assessments of relevance and rigour. A Stakeholder consultation with 26 primary care health care professionals (HCPs), 10 patients and three informal carers was conducted to test and refine the programme theory. Data synthesis was underpinned by Normalisation Process Theory to identify key mechanisms to enhance the implementation of MDT medication review and deprescribing in primary care. FINDINGS: A total of 2821 abstracts and 175 full-text documents were assessed for eligibility, with 28 included. Analysis of documents alongside stakeholder consultation outlined 33 CMO configurations categorised under four themes: 1) HCPs roles, responsibilities and relationships; 2) HCPs training and education; 3) the format and process of the medication review 4) involvement and education of patients and informal carers. A number of key mechanisms were identified including clearly defined roles and good communication between MDT members, integration of pharmacists in the team, simulation-based training or team building training, targeting high-risk patients, using deprescribing tools and drawing on expertise of other HCPs (e.g., nurses and frailty practitioners), involving patents and carers in the process, starting with 'quick wins', offering deprescribing as 'drug holidays', and ensuring appropriate and tailored follow-up plans that allow continuity of care and management. CONCLUSION: We identified key mechanisms that could inform the design of future interventions and services that successfully embed deprescribing in primary care.

Automated search methods for identifying wrong patient order entry-a scoping review.

Objective: To investigate: (1) what automated search methods are used to identify wrong-patient order entry (WPOE), (2) what data are being captured and how they are being used, (3) the causes of WPOE, and (4) how providers identify their own errors. Materials and Methods: A systematic scoping review of the empirical literature was performed using the databases CINAHL, Embase, and MEDLINE, covering the period from database inception until 2021. Search terms were related to the use of automated searches for WPOE when using an electronic prescribing system. Data were extracted and thematic analysis was performed to identify patterns or themes within the data. Results: Fifteen papers were included in the review. Several automated search methods were identified, with the retract-and-reorder (RAR) method and the Void Alert Tool (VAT) the most prevalent. Included studies used automated search methods to identify background error rates in isolation, or in the context of an intervention. Risk factors for WPOE were identified, with technological factors and interruptions deemed the biggest risks. Minimal data on how providers identify their own errors were identified. Discussion: RAR is the most widely used method to identify WPOE, with a good positive predictive value (PPV) of 76.2%. However, it will not currently identify other error types. The VAT is nonspecific for WPOE, with a mean PPV of 78%-93.1%, but the voiding reason accuracy varies considerably. Conclusion: Automated search methods are powerful tools to identify WPOE that would otherwise go unnoticed. Further research is required around self-identification of errors.

Risk reduction intervention for raised blood pressure (REVERSE): protocol for a mixed-methods feasibility study.

INTRODUCTION: Around 40% of adults have pre-hypertension (blood pressure between 120-139/80-89), meaning they are at increased risk of developing hypertension and other cardiovascular disease-related conditions. There are limited studies on the management of pre-hypertension; however, guidance recommends that it should be focused on lifestyle modification rather than on medication. Self-monitoring of blood pressure could allow people to monitor and manage their risk status and may allow individuals to modify lifestyle factors. The purpose of this study is to determine the feasibility and acceptability, to both healthcare professionals and people with pre-hypertension, of blood pressure self-monitoring. METHODS AND ANALYSIS: A prospective, non-randomised feasibility study, with a mixed-methods approach will be employed. Eligible participants (n=114) will be recruited from general practices, pharmacies and community providers across Lancashire and South Cumbria. Participants will self-monitor their blood pressure at home for 6 months and will complete questionnaires at three timepoints (baseline, 6 and 12 months). Healthcare professionals and participants involved in the study will be invited to take part in follow-up interviews and a focus group. The primary outcomes include the willingness to engage with the concept of pre-hypertension, the acceptability of self-monitoring, and the study processes. Secondary outcomes will inform the design of a potential future trial. A cost-analysis and cost-benefit analysis will be conducted. ETHICS AND DISSEMINATION: Ethics approval has been obtained from London-Fulham NHS Research Ethics Committee, the University of Central Lancashire Health Ethics Review Panel and the HRA. The results of the study will be disseminated via peer-reviewed publications, feedback to service users and healthcare professionals, and to professional bodies in primary care and pharmacy. TRIAL REGISTRATION NUMBER: ISRCTN13649483.

Assessing the hidden burden and costs of COVID-19 pandemic in South Asia: Implications for health and well-being of women, children and adolescents.

The COVID-19 pandemic has disproportionately affected vulnerable populations. With its intensity expected to be cyclical over the foreseeable future, and much of the impact estimates still modeled, it is imperative that we accurately assess the impact to date, to help with the process of targeted rebuilding of services. We collected data from administrative health information systems in six South Asian countries (Afghanistan, Bangladesh, Nepal, India, Pakistan and Sri Lanka), to determine essential health services coverage disruptions between January-December 2020, and January-June 2021, compared to the same calendar months in 2019, and estimated the impact of this disruption on maternal and child mortality using the Lives Saved Tool. We also modelled impact of prolonged school closures on continued enrollment, as well as potential sequelae for the cohort of girls who have likely dropped out. Coverage of key maternal and child health interventions, including antenatal care and immunizations, decreased by up to 60%, with the largest disruptions observed between April and June 2020. This was followed by a period of recovery from July 2020 to March 2021, but a reversal of most of these gains in April/May 2021, likely due to the delta variant-fueled surge in South Asia at the same time. We estimated that disruption of essential health services between January 2020 and June 2021 potentially resulted in an additional 19,000 maternal and 317,000 child deaths, an increase of 19% and 13% respectively, compared to 2019. Extended school closures likely resulted in 9 million adolescents dropping out permanently, with 40% likely being from poorest households, resulting in decreased lifetime earnings. A projected increase in early marriages for girls who dropped out could result in an additional 500,000 adolescent pregnancies, 153,000 low birthweight births, and 27,000 additional children becoming stunted by age two years. To date, the increase in maternal and child mortality due to health services disruption has likely exceeded the overall number of COVID-19 deaths in South Asia. The indirect effects of the pandemic were disproportionately borne by the most vulnerable populations, and effects are likely to be long-lasting, permanent and in some cases inter-generational, unless policies aimed at alleviating these impacts are instituted at scale and targeted to reach the poorest of the poor. There are also implications for future pandemic preparedness.

Preventing erosion of oral polio vaccine acceptance: A role for vaccinator visits and social norms.

BACKGROUND: With continued challenges to the timeline for polio transmission interruption in Pakistan, including COVID-19, there is a risk of oral polio vaccine campaign fatigue among caregivers of young children. Renewed efforts to minimize oral polio vaccine acceptance erosion may be needed. This study examines the possible role of social norms in protecting against acceptance erosion and the role of vaccinators in promoting these social norms. METHODS: Data were analyzed from a poll conducted by local interview teams between February 23 and April 5, 2016, among 4,070 parents and other caregivers of children under age 5 living in areas at high-risk for polio transmission in Pakistan. The sample was drawn via a stratified multistage cluster design utilizing random route methods at the household level. We calculated the prevalence of subjective and descriptive social norms around vaccine acceptance; vaccine acceptance and commitment to vaccinate in future; and experiences and views of polio vaccinators across the population. We examined the relationship between these social norms and vaccination behaviors as well as the relationship between experiences with and views of vaccinators and social norms using uncontrolled comparisons (t-tests of proportion) and logistic repressions to control for demographics. RESULTS: Both descriptive and subjective positive social norms were associated with vaccine acceptance and future commitment. Positive experiences with and views of vaccinators (trust, perceived technical knowledge, compassion, and overall pleasantness of the interaction) were associated with both descriptive and subjective positive social norms. CONCLUSIONS: These data support the idea that positive social norms could be protective against erosion of oral polio vaccine acceptance and that positive experiences with, and views of, vaccinators could help promote these positive social norms. Creative community engagement efforts may be able to leverage positive experiences with vaccinators to help foster social norms and protect against the risk of acceptance erosion.

Persistently normal blood tests in patients taking methotrexate for RA or azathioprine for IBD: a retrospective cohort study.

BACKGROUND: Disease-modifying anti-rheumatic drugs (DMARDs), including methotrexate and azathioprine, are commonly used to treat rheumatoid arthritis (RA) and inflammatory bowel disease (IBD). Blood-test safety monitoring is mainly undertaken in primary care. Normal blood results are common. AIM: To determine the frequency and associations of persistently normal blood tests in patients with RA prescribed methotrexate, and patients with IBD prescribed azathioprine. DESIGN AND SETTING: Two-year retrospective study of a cohort taken from an electronic pseudonymised primary care/laboratory database covering >1.4 million patients across Hampshire, UK. METHOD: Patients with RA and IBD, and associated methotrexate and azathioprine prescriptions, respectively, were identified. Tests and test thresholds recommended by the National Institute for Health and Care Excellence were applied. Persistent normality was defined as no abnormalities of any tests nor alanine aminotransferase (ALT), white blood count (WBC), neutrophils, and estimated glomerular filtration rate (eGFR) individually. Logistic regression was used to identify associations with test normality. RESULTS: Of 702 265 adults, 7102 had RA and 8597 had IBD. In total, 3001 (42.3%) patients with RA were prescribed methotrexate and 1162 (13.5%) patients with IBD were prescribed azathioprine; persistently normal tests occurred in 1585 (52.8%) and 657 (56.5%) of the populations, respectively. In patients with RA on methotrexate, 585 (19.5%) had eGFR, 219 (7.3%) ALT, 217 (7.2%) WBC, and 202 (6.7%) neutrophil abnormalities. In patients with IBD on azathioprine, 138 (11.9%) had WBC, 88 (7.6%) eGFR, 72 (6.2%) ALT, and 65 (5.6%) neutrophil abnormalities. Those least likely to have persistent test normality were older and/or had comorbidities. CONCLUSION: Persistent test normality is common when monitoring these DMARDs, with few hepatic or haematological abnormalities. More stratified monitoring approaches should be explored.

Characterising risk of non-steroidal anti-inflammatory drug-related acute kidney injury: a retrospective cohort study.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for pain and inflammation. NSAID complications include acute kidney injury (AKI), causing burden to patients and health services through increased morbidity, mortality, and hospital admissions. AIM: To measure the extent of NSAID prescribing in an adult population, the degree to which patients with potential higher risk of AKI were exposed to NSAIDs, and to quantify their risk of AKI. DESIGN & SETTING: Retrospective 2-year closed-cohort study. METHOD: A retrospective cohort of adults was identified from a pseudonymised electronic primary care database in Hampshire, UK. The cohort had clinical information, prescribing data, and complete GP- and hospital-ordered biochemistry data. NSAID exposure (minimum one prescription in a 2-month period) was categorised as never, intermittent, and continuous, and first AKI using the national AKI e-alert algorithm. Descriptive statistics and logistic regression were used to explore NSAID prescribing patterns and AKI risk. RESULTS: The baseline population was 702 265. NSAID prescription fell from 19 364 (2.8%) to 16 251 (2.4%) over 2 years. NSAID prescribing was positively associated with older age, female sex, greater socioeconomic deprivation, and certain comorbidities (diabetes, hypertension, osteoarthritis, and rheumatoid arthritis) and negatively with cardiovascular disease (CVD) and heart failure. Among those prescribed NSAIDs, AKI was associated with older age, greater deprivation, chronic kidney disease (CKD), CVD, heart failure, diabetes, and hypertension. CONCLUSION: Despite generally good prescribing practice, NSAID prescribing was identified in some people at higher risk of AKI (for example, patients with CKD and older) for whom medication review and NSAID deprescribing should be considered.

Price versus clinical guidelines in primary care statin prescribing: a retrospective cohort study and cost simulation model.

OBJECTIVE: To investigate the relative impact of generic entry and National Institute for Health and Care Excellence clinical guidelines on prescribing using statins as an exemplar. DESIGN: Retrospective analysis of statin prescribing in primary care and cost simulation model. SETTING: Royal College of General Practitioners Research and Surveillance Centre (RCGP R&SC) database and Prescription Cost Analysis (PCA) database. PARTICIPANTS: New patients prescribed statins for the first time between July 2003 and September 2018. MAIN OUTCOME MEASURES: Shares of new patients prescribed one of the five statins available in the British National Formulary, and cost of prescribing statins to new and existing patients in primary care in England. RESULTS: General trends of statin' prescriptions were largely driven by a decrease in acquisition costs triggered by patent expiration, preceding NICE guidelines which themselves did not seem to affect prescription trends. Significant heterogeneity is observed in the prescription of the most cost-effective statin acrossGPs. A cost simulation shows that, between 2004 and 2018, the NHS could have saved £2.8bn (around 40% of the £6.3bn spent on statins during this time) if all GP practices had prescribed only the most cost-effective treatment. CONCLUSIONS: There is potential for large savings for the NHS if new and, whenever possible, ongoing patients are promptly switched to the first medicine that becomes available as generic within a therapeutic class as long as it has similar efficacy to still-patented medicines.

Reduction of oral liquid controlled drugs discrepancy in day-to-day practice.

OBJECTIVES: The storage, use and disposal of controlled drugs (CDs) in hospitals and other healthcare centres are governed by a combination of government legislation and local policy. In the UK, a running balance must be kept for Schedule 2 CDs and when discrepancies arise, they must be investigated and reconciled. Policies on acceptable discrepancies are varied and based on anecdotal evidence. This study was designed to simulate dosing and stock check procedures for oxycodone oral solution, as a sample CD solution, and evaluate where the volume losses that cause discrepancies could arise from. METHODS: Hypromellose solutions were formulated to simulate oxycodone commercial solutions. These were used to simulate dosing and stock check practices. Quantification of volume loss during simulated routine dosing and stock check of viscous oral CD formulations were performed in triplicate. KEY FINDINGS: Dosing with enteral syringes via a fitted rubber bung never resulted in volume loss. Volume loss was always observed during stock checks with no statistical difference between methods used. CONCLUSIONS: The findings of this study support the following recommendations. Hospital pharmacy departments should provide oxycodone and other CD liquid formulation bottles pre-fitted with a bung and make sure personnel use enteral syringes that are compatible with the chosen adaptor and of the most appropriate size for the intended dose. Stock checks should be limited to the minimum required by law or local policy.

An embedded implementation research initiative to tackle service delivery bottlenecks in the expanded programme on immunisation in Pakistan: Overview and reflections.

BACKGROUND: Embedded implementation research (IR) can play a critical role in health systems strengthening by tackling systems and implementation bottlenecks of a program. To achieve this aim, with the financial support of GAVI, the Vaccine Alliance, in 2016, the Government of Pakistan, UNICEF and the Alliance for Health Policy and Systems Research (AHPSR) launched an Embedded IR for Immunisation Initiative (the Initiative) to explore health systems and implementation bottlenecks, and potential strategies to tackle such bottlenecks in the Expanded Programme on Immunisation (EPI) in Pakistan. In total, 10 research teams were involved in the Initiative, which was the first of its kind in the country. In this paper, we provided a brief overview of the Initiative's approach as well as the key learnings including challenges and successes of the research teams which could inform future embedded IR Initiatives. METHODS: Data were collected from members of the IR teams through an online survey. In addition, in-depth interviews were conducted via phone and in-person from IR team members to explore further the challenges they faced while conducting IR in Pakistan and recommendations for future IR initiatives. The qualitative information obtained from these sources was collated and categorized into themes reflecting some of the challenges, successes, and lessons learned, as well as teams' recommendations for future initiatives. RESULTS: The embedded IR Initiative in Pakistan followed several steps starting with a desk review to compile information on key implementation challenges of EPI and ended with a dissemination workshop where all the research teams shared their IR results with policymakers and implementers. Key factors that facilitated the successful and timely completion of the studies included appreciation by and leadership of implementers in generation and use of local knowledge, identification of research priorities jointly by EPI managers and researchers and provision of continuous and high-quality support from in-country research partners. Participants in the Initiative indicated that challenges included a lack of clarity on the role and responsibilities of each partner involved and need for further support to facilitate use and dissemination of research findings. CONCLUSIONS: The Initiative established that an immunisation programme in a lower middle-income country can use small and time-bound embedded IR, based on partnerships between programme managers and local researchers, to generate information and evidence that can inform decision-making. Future embedded IR initiatives should strive to ensure effective coordination and active participation of all key stakeholders, a clear research utilisation plan from the outset, and efforts to strengthen research teams' capacity to foster utilisation of research findings.

Implementing an emergency department pharmacy service and its effect on medication safety.

OBJECTIVES: This service innovation project examined the effect an Emergency Department (ED) pharmacy service had on medication-related safety markers. METHODS: A pre-test/post-test design captured medication-related safety markers on admission data at ward level after patients had been seen in the ED. The markers were, medication omitted, incorrect medicines prescribed and the number of incorrect doses or frequency of doses. KEY FINDINGS: All three safety markers saw reductions. Mean (SD) medications omitted were reduced from 2.19 (±3.01) to 0.48 (±1.3), incorrect medication from 0.35 (±1.11) to 0.08 (±0.36) and the number of incorrect doses or frequency of doses from 0.38 (±0.69) to 0.13 (±0.38) per patient. All differences were statistically significant (P = 0.00). CONCLUSIONS: The service reduced medication error and the findings allowed a permanent pharmacy service to be introduced.

The Wessex Dementia Friendly Pharmacy Framework.

OBJECTIVES: To develop and launch a dementia friendly framework for community pharmacies in the Wessex region of England. METHODS: A framework consisting of essential (mandatory) and additional (non-mandatory) criteria were devised by local stakeholders and external scrutiny from the Alzheimer's Society. The framework was designed to allow pharmacy teams to achieve essential criteria without the need for approval by others (e.g. authorisation from internal company management structures). In total, 38 essential criteria across seven domains were devised. All essential criteria had to be met for pharmacies to be awarded dementia friendly status. Engagement events were organised to launch the framework detailing what it was and how pharmacies could meet each criterion. Pharmacies self-certified compliance with the framework criteria via an online platform, and validation activity was subsequently undertaken to see if pharmacies had appropriately self-certified against all essential criteria. KEY FINDINGS: Three hundred and fifty-five pharmacies (n = 504, 70%) engaged with the initiative, of which 330 uploaded self-certifications met all essential criteria of the framework. Validation visits showed self-certification to be appropriate in all but one visit (n = 11/12). Staff comments revealed that engaging with the framework had allowed them to be more aware of how better to support people with dementia. CONCLUSIONS: A dementia friendly framework was devised and implemented with a subsequent high level of uptake by community pharmacy.

Carrying out embedded implementation research in humanitarian settings: A qualitative study in Cox's Bazar, Bangladesh.

BACKGROUND: Embedded implementation research (IR) promotes evidence-informed policy and practices by involving decision-makers and program implementers in research activities that focus on understanding and solving existing implementation challenges. Although embedded IR has been conducted in multiple settings by different organizations, there are limited experiences of embedded IR in humanitarian settings. This study highlights some of the key challenges of conducting embedded IR in a humanitarian setting based on our experience with the Rohingya refugee population in Cox's Bazar, Bangladesh. METHODS AND FINDINGS: We collected qualitative data in between January and July 2019. First, we visited Rohingya refugee camps and interviewed representatives from different humanitarian organizations. Second, we conducted interviews with researchers from BRAC University who were engaged with data collection and analysis in a broader embedded IR study on maternal, newborn, child, and adolescent health (MNCAH) program implementation challenges. Data were analyzed using a thematic analysis approach. Two researchers developed and agreed on codes and relevant themes based on the objectives of this study. The findings of this study highlight several challenges encountered while conducting embedded IR in the Rohingya emergency setting in Cox's Bazar, which may have implications for other humanitarian settings. The overall context of the camps was complex, with more than 100 organizations devoted to providing health services for approximately 1 million refugees. Despite the presence of the Bangladesh government, United Nations agencies and other international organizations played key roles in making programmatic and policy decisions for the Rohingya. Because health service delivery modalities and policies and related implementation challenges for MNCAH programs for the refugees changed rapidly, the embedded IR approach used was flexible and able to adapt to changes identified, with research questions and methods modified accordingly. Access to the camps, reaching Rohingya respondents, overcoming language barriers in order to get quality information, and the limited availability of local research collaborators were additional challenges. Working with researchers or research institutes that are familiar with the context and have experience in conducting implementation and health systems research can help with collection of quality data, identifying key stakeholders and bringing them on board to ensure the execution of the project, and ensuring utilization of the research findings. Study limitations include possible constraints in generalizing our conclusions to other humanitarian settings. Implementation research conducted in additional humanitarian settings can contribute to the evidence on this topic. CONCLUSIONS: Findings indicate that embedded IR can be done effectively in humanitarian settings if the challenges are anticipated, and appropriate strategies and in-country partners put in place to address or mitigate them, before commencing the funding or starting of the project. Understanding the context and analyzing the role of relevant stakeholders prior to conducting the research, considering a simple descriptive method appropriate to answering real-time IR questions, and working with local researchers or research institutes with specific skill sets and prior experience conducting research in humanization contexts may reduce costs and time spent, and ensure collection of quality data relevant for policy and practice.

Differential diagnosis in pharmacy practice: Time to adopt clinical reasoning and decision making.

The delivery of healthcare in most developed countries is under increasing pressure. Ageing populations with increasingly complex needs, coupled with financial constraints and imbalances in workforce, mean that healthcare policies look to contain cost and utilise resource as effectively as possible. Self-care is now widely advocated as a mechanism to manage acute presentations with pharmacy identified as a key resource to support such policy. Pharmacy teams are ideally positioned to facilitate the management of patients who present with acute illness. However, current evidence suggests that patient assessment and establishing a differential diagnosis could be better. It appears that how pharmacists are taught at Schools of Pharmacy adopts a protocol driven approach, which assumes presentation of low acuity conditions, and we argue that this method must be replaced with a curriculum that adopts clinical reasoning. This paper sets out the process of clinical reasoning and how the profession could embrace this as a better model in establishing a diagnosis.

Hospital referral of older patients to community pharmacy: outcome measures in a feasibility study.

Background Post-discharge medication use reviews in English community pharmacy aim to improve medicine support to recently discharged patients. However, there is little evidence of their impact on patient outcomes. Objective Identify potential outcome measures to investigate the impact of a hospital to community pharmacy referral service for older patients that utilises post-discharge medication reviews. Method Pharmacists at a district general hospital identified in-patients aged over 65 years who could benefit from a medication use review. Participants were randomised to receive referral for review, or standard discharge care. Participants were followed up at 4 weeks and 6 months via the hospital's patient administration system and by postal questionnaire, regarding readmissions, medication adherence, health related quality of life and enablement. Results Fifty-nine participants were recruited. There were no statistically significant differences in outcomes between intervention and control groups. However there were trends towards shorter length of stay on readmission and improved self-reported physical health for intervention group participants. There were no preventable medication related readmissions involving participants who had received a post-discharge medication use review as part of the study. Conclusion This feasibility study could be scaled up to a full pilot study, followed by an adequately powered randomised controlled trial, in order to further investigate the effects of medication use review referral post-discharge.

Impact of pharmacy medicine information service advice on clinician and patient outcomes: an overview.

BACKGROUND: Pharmacy-led medicine information (MI) services are available in many countries to support clinicians and patients make decisions on use of medicines. OBJECTIVES: To establish what impact, if any, pharmacy-led MI services have on clinician and patient outcomes. METHODS: All published works indexed in Embase or PubMed, meeting this review's inclusion and exclusion criteria, that wholly or partially attempted to measure the effects of MI advice were retrieved and assessed. RESULTS: Twenty studies were reviewed. Five broad themes were identified describing study findings, three were specific to clinicians: their views on the effect MI answers had; actions they took; and influence on their decision making. A fourth theme centred on patient utilisation of advice, and the fifth on 'process measures' attempting to determine MI worth. DISCUSSION: Studies report on positive patient outcomes as a direct result of MI advice. Clinicians and patients acted upon the advice provided. Clinicians also reported using MI advice as a 'safety net', to check, reassure or confirm what to do. MI advice also demonstrated economic worth, although these studies are old. CONCLUSION: MI Service advice appears to affect clinician and patient outcomes. However, study design limitations require findings be viewed cautiously.

Equitable coverage? The roles of the private and public sectors in providing maternal, newborn and child health interventions in South Asia.

INTRODUCTION: The private sector accounts for an important share of health services available in South Asia. It is not known to what extent socioeconomic and urban-rural inequalities in maternal, newborn and child health (MNCH) interventions are being affected by the presence of private providers. METHODS: Nationally representative surveys carried out from 2009 to 2015 were analysed for seven of the eight countries in South Asia, as data for Sri Lanka were not available. The outcomes studied included antenatal care (four or more visits), institutional delivery, early initiation of breast feeding, postnatal care for babies, and careseeking for diarrhoea and pneumonia. Results were stratified according to quintiles of household wealth and urban-rural residence. RESULTS: At regional level, the public sector played a larger role than the private sector in providing antenatal (24.8% vs 15.6% coverage), delivery (51.9% vs 26.8%) and postnatal care (15.7% vs 8.2%), as well as in the early initiation of breast feeding (26.1% vs 11.1%). The reverse was observed in careseeking for diarrhoea (15.0% and 46.2%) and pneumonia (18.2% and 50.5%). In 28 out of 37 possible analyses of coverage by country, socioeconomic inequalities were significantly wider in the private than in the public sector, and in only four cases the reverse pattern was observed. In 20 of the 37 analyses, the public sector was also more likely to be used by the wealthiest women and children. CONCLUSION: The private sector plays a substantial role in delivering MNCH interventions in South Asia but is more inequitable than the public sector.