Identifying frailty in primary care: a qualitative description of family physicians' gestalt impressions of their older adult patients.

BACKGROUND: Many tools exist to guide family physicians' impressions about frailty status of older adults, but no single tool, instrument, or set of criteria has emerged as most useful. The role of physicians' subjective impressions in frailty decisions has not been studied. This study explores how family physicians conceptualize frailty, and the factors that they consider when making subjective decisions about patients' frailty statuses. METHODS: Descriptive qualitative study of family physicians who practice in a large urban academic family medicine center as they participated in one-on-one "think-aloud" interviews about the frailty status of their patients aged 80 years and over. Of 23 eligible family physicians, 18 shared their impressions about the frailty status of their older adult patients and the factors influencing their decisions. Interviews were audio-recorded, transcribed, and thematically analyzed. RESULTS: Four themes were identified, the first of which described how physicians conceptualized frailty as a spectrum and dynamic in nature, but also struggled to conceptualize it without a formal definition in place. The remaining three themes described factors considered before determining patients' frailty statuses: physical characteristics (age, weight, medical conditions), functional characteristics (physical, cognitive, social) and living conditions (level of independence, availability of supports, physical environment). CONCLUSIONS: Family physicians viewed frailty as multifactorial, dynamic, and inclusive of functional and environmental factors. This conceptualization can be useful to make comprehensive and flexible evaluations of frailty status in conjunction with more objective frailty tools.

Exploring pharmacy service users' support for and willingness to use community pharmacist prescribing services.

BACKGROUND: In 2012, community pharmacists in Ontario, Canada gained regulatory authority to independently prescribe, including renew and adapt prescriptions. Studies have explored views of pharmacists, physicians and policymakers about pharmacist prescribing but less is known about the views of community pharmacy services users. OBJECTIVE: To describe Ontario community pharmacy service users' support for and stated willingness to use pharmacist prescribing services. METHODS: A qualitative descriptive study was conducted with 19 adults who had filled or refilled prescription(s) at a community pharmacy within the past three months. Participants were recruited through purposive and snowball sampling. Data were collected through one-on-one, semi-structured interviews between May and September 2016. Interview transcripts were coded and thematic analysis conducted. The first two transcripts were independently coded and analyzed by 2 researchers and after consensus was achieved, the lead researcher coded and analyzed the remainder of the data. RESULTS: Most community pharmacy service users lacked experience with pharmacist prescribing services but perceived some potential benefits, including personal convenience. The majority of participants supported pharmacist prescribing. Support for and stated willingness to use pharmacist prescribing services varied by the type of service and was contingent upon the clinical purpose of the prescription, pharmacists' access to patient clinical information (e.g. health records), and the extent of pharmacist-physician collaboration during the prescribing process. CONCLUSION: Community pharmacy service users in Ontario expressed varying support for and stated willingness to use pharmacist prescribing services. This seemed to be due to their perceptions of the pharmacists' role (compared to physicians) and concerns about risks. Understanding these contributing factors will help implement strategies that address concerns and facilitate use of community pharmacists' prescribing services.

Pharmacist prescribing: A scoping review about the views and experiences of patients and the public.

BACKGROUND: Policy-makers and health professionals' views about pharmacist prescribing have been well studied, but less is known about the views of the public and patients. OBJECTIVE: To describe from existing literature the views and experiences of patients as well as the views of the public about pharmacist prescribing. METHODS: Sources: Medline, EMBASE, and International Pharmaceutical Abstracts from inception to November 2015; reference lists of included studies. INCLUSION CRITERIA: English-language studies describing the views and experiences of patients and the views of the public about pharmacist prescribing. Two reviewers independently screened titles and abstracts and one reviewer charted data. The University of British Columbia Patient Experience Framework was used to categorize and synthesize findings about patients' experience. Views were described using a descriptive thematic synthesis approach. RESULTS: Out of 2377 unique records, 35 articles were reviewed in full for eligibility. Three studies were excluded because participants were not patients or the public, eight studies were not about prescribing, and four studies were abstracts. Two articles were identified from the bibliographies of included studies. In total, twenty-two studies met inclusion criteria. Fourteen studies were quantitative (63.6%), six were qualitative (27.3%) and two were mixed design (9.1%) studies. Four studies (18.2%) were conducted in Canada (Saskatchewan, Newfoundland and Labrador, Nova Scotia), one (4.5%) in Australia, one (4.5%) in the United States (Washington) and the remaining in the United Kingdom (n = 16, 72.7%). The most commonly explored dimensions of patient experiences were access, interpersonal communication, and patient-reported impacts of care. Patients reported high satisfaction with appointment times, communication with the pharmacist prescriber and the services received. The public supported pharmacist prescribing in limited situations (chronic conditions, minor ailments, repeat medications). The public were concerned about privacy during consultations but patients were less so. Both patients and the public shared concerns regarding lack of adequate resources to ensure safe prescribing by pharmacists (e.g., lack of pharmacists' access to medical records, lack of additional staff support to fulfill prescribing responsibilities). CONCLUSION: Patients' experiences with pharmacist prescribing were generally positive. There were shared concerns between patients and the public about pharmacist prescribing. Opportunities for further research include strategies for building public experience with pharmacist prescribing and methods for addressing concerns identified by patients and the public.

Long-term opioid use after discharge from inpatient musculoskeletal rehabilitation.

OBJECTIVE: To determine: (i) the prevalence of opioid-naïve patients discharged on opioids from a musculoskeletal rehabilitation inpatient unit; (ii) the prevalence of opioid use 6 months after discharge; and (iii) the efficacy of the Opioid Risk Tool in identifying long-term opioid use. DESIGN: Prospective study. PARTICIPANTS: Sixty-four opioid-naïve patients who were exposed to opioids during admission and who were discharged on an opioid. METHODS: Potentially eligible patients' charts were reviewed. Participants were interviewed during admission to obtain the opioid risk score and contacted 6 months after discharge via a semi-structured telephone interview. RESULTS: Twenty-eight percent of opioid-naïve patients, who were discharged on opioids were still using opioids 6 months after discharge from rehabilitation. There was a trend for higher Opioid Risk Tool scores in those still using opioids than in individuals who were not using opioids at 6 months (p = 0.053). CONCLUSION: Patients who are prescribed opioids during a hospital admission should be screened for risk of opioid misuse. This data suggests that the Opioid Risk Tool could identify a patient's potential for becoming a long-term user of opioids.