Prescribing and deprescribing guidance for benzodiazepine and benzodiazepine receptor agonist use in adults with depression, anxiety, and insomnia: an international scoping review

Background

Clinical practice guidelines and guidance documents routinely offer prescribing clinicians' recommendations and instruction on the use of psychotropic drugs for mental illness. We sought to characterise parameters relevant to prescribing and deprescribing of benzodiazepine (BZD) and benzodiazepine receptor agonist (BZRA), in clinical practice guidelines and guidance documents internationally, for adult patients with unipolar depression, anxiety disorders and insomnia to understand similarities and discrepancies between evidence-based expert opinion.

Methods

A Scoping Review was conducted to characterize documents that offered evidence-based and/or consensus pharmacologic guidance on the management of unipolar depression, anxiety disorders, obsessive-compulsive disorders, post-traumatic stress disorders and insomnia. A systematic search was conducted of PubMed, SCOPUS, PsycINFO and CINAHL from inception to October 13, 2023 and supplemented by a gray literature search. Documents were screened in Covidence for eligibility. Subsequent data-charting on eligible documents collected information on aspects of both prescribing and deprescribing.

Findings

113 documents offering guidance on BZD/BZRA use were data-charted. Overall, documents gathered were from Asia (n = 11), Europe (n = 34), North America (n = 37), Oceania (n = 7), and South America (n = 4) with the remainder being "International" (n = 20) and not representative to any particular region or country. By condition the documents reviewed covered unipolar depressive disorders (n = 28), anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder (n = 42) and Insomnia (n = 25). Few documents (n = 18) were sufficiently specific and complete to consider as de-prescribing focused documents.

Interpretation

Documents were in concordance in terms of BZD and BZRA not being used routinely as first-line pharmacologic agents. When used, it is advisable to restrict their duration to "short-term" use with the most commonly recommended duration being less than four weeks. Documents were less consistent in terms of prescriptive recommendations for specific drug, dosing and administration pattern (i.e regular or 'as needed') selection for each condition. Deprescribing documents were unanimously in favor of gradual dose reduction and patient shared decision-making. However, approaches towards dose-tapering differed substantially. Finally, there were inconsistencies and/or insufficiency of detail, among deprescribing documents, in terms of switching to a long-acting BZD, use of adjunctive pharmacotherapies and micro-tapering.

Funding

The authors received no funding for this work.

Development and validation of a theory-based questionnaire examining barriers and facilitators to discontinuing long-term benzodiazepine receptor agonist use

BACKGROUND

Long-term use of benzodiazepine receptor agonists (BZRAs) is a persistent healthcare challenge and poses patient safety risks. Interventions underpinned by behaviour change theory are needed to support discontinuation of long-term BZRA use. The aim of this study was to develop and validate a questionnaire based on the Theoretical Domains Framework (TDF) to examine mediators of behaviour change relating to the discontinuation of long-term BZRA use.

METHODS

An initial 52 item questionnaire was developed using the 14 domains of TDF version 2 and iteratively refined over two rounds. The questionnaire was disseminated online via online support groups that focused on BZRAs to community-based adults with either current or previous experience of taking BZRAs on a long-term basis (≥3 months). Confirmatory factor analysis was undertaken to assess the questionnaire's reliability, discriminant validity and goodness of fit. The Standardized Root Mean Square Residual (SRMR), Root Mean Square Error of Approximation (RMSEA) and Comparative Fit Index (CFI) were calculated.

RESULTS

Following an iterative process of adjustment, the results obtained from confirmatory factor analysis resulted in the final questionnaire consisting of 29 items across nine theoretical domains. The internal consistency reliability values across these domains ranged from 0.62 to 0.85. For the final model, the SRMR was 0.23, the RMSEA was 0.11 and the CFI was 0.6.

CONCLUSIONS

The questionnaire offers a potential tool that could be used to identify domains that need to be targeted as part of a behaviour change intervention at an individual patient level. Further research is needed to assess the questionnaire's acceptability and usability, and to develop a scoring system so that domains can be prioritised and subsequently targeted as part of an intervention.

Interventions to improve the appropriate use of polypharmacy for older people

BACKGROUND

Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, so that many medicines may be used to achieve better clinical outcomes for patients. This is the third update of this Cochrane Review.

OBJECTIVES

To assess the effects of interventions, alone or in combination, in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 13 January 2021, together with handsearching of reference lists to identify additional studies. We ran updated searches in February 2023 and have added potentially eligible studies to 'Characteristics of studies awaiting classification'.

SELECTION CRITERIA

For this update, we included randomised trials only. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy (four or more medicines) in people aged 65 years and older, which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people).

DATA COLLECTION AND ANALYSIS

Four review authors independently reviewed abstracts of eligible studies, and two authors extracted data and assessed the risk of bias of the included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We identified 38 studies, which includes an additional 10 in this update. The included studies consisted of 24 randomised trials and 14 cluster-randomised trials. Thirty-six studies examined complex, multi-faceted interventions of pharmaceutical care (i.e. the responsible provision of medicines to improve patients' outcomes), in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists, nurses and geriatricians, and most were conducted in high-income countries. Assessments using the Cochrane risk of bias tool found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low. It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool) (mean difference (MD) -5.66, 95% confidence interval (CI) -9.26 to -2.06; I2 = 97%; 8 studies, 947 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs) (standardised mean difference (SMD) -0.19, 95% CI -0.34 to -0.05; I2 = 67%; 9 studies, 2404 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIM (risk ratio (RR) 0.81, 95% CI 0.68 to 0.98; I2 = 84%; 13 studies, 4534 participants; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.48, 95% CI -1.05 to 0.09; I2 = 92%; 3 studies, 691 participants; low-certainty evidence), however it must be noted that this effect estimate is based on only three studies, which had serious limitations in terms of risk of bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPO (RR 0.50, 95% CI 0.27 to 0.91; I2 = 95%; 7 studies, 2765 participants; very low-certainty evidence). Pharmaceutical care may make little or no difference to hospital admissions (data not pooled; 14 studies, 4797 participants; low-certainty evidence). Pharmaceutical care may make little or no difference to quality of life (data not pooled; 16 studies, 7458 participants; low-certainty evidence). Medication-related problems were reported in 10 studies (6740 participants) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies. This also applied to studies examining adherence to medication (nine studies, 3848 participants).

AUTHORS' CONCLUSIONS

It is unclear whether interventions to improve appropriate polypharmacy resulted in clinically significant improvement. Since the last update of this review in 2018, there appears to have been an increase in the number of studies seeking to address potential prescribing omissions and more interventions being delivered by multidisciplinary teams.

An assessment of the reporting of tapering methods in antidepressant discontinuation trials using the TIDieR checklist

BACKGROUND

The importance of tapering is increasingly recognised when discontinuing antidepressant medication. However, no previous studies have examined the reporting of antidepressant tapering methods in published studies.

AIM

The aim of this study was to assess the completeness of reporting of antidepressant tapering methods in a published systematic review using the Template for Intervention Description and Replication (TIDieR) checklist.

METHOD

A secondary analysis was conducted of studies included in a Cochrane systematic review that examined the effectiveness of approaches for discontinuing long-term antidepressant use. The completeness of reporting of antidepressant tapering methods in included studies was independently assessed by two researchers using the 12 items from the TIDieR checklist.

RESULTS

Twenty-two studies were included in the analysis. None of the study reports described all checklists items. No study clearly reported what materials had been provided (item 3) or whether tailoring had occurred (item 9). With the exception of providing a name for the intervention or study procedures (item 1), only a minority of studies clearly reported on any of the remaining checklist items.

CONCLUSION

The findings highlight a lack of detailed reporting of antidepressant tapering methods in published trials to date. This needs to be addressed as poor reporting could hinder replication and adaptation of existing interventions, as well as the potential for successful translation of effective tapering interventions into clinical practice.

Evidence for using point-of-care diagnostics in the management of respiratory tract infections in primary care: a scoping review protocol

Background:  Antimicrobial resistance (AmR) is widely considered a global health threat and is associated with significant morbidity, mortality and costs. Inappropriate antimicrobial use is the most important modifiable risk factor for AmR. Most human antimicrobial medicines use occurs in primary care [prescribed by general practitioners (GPs), dispensed by community pharmacists (CPs)]. However, up to 50% of use is deemed inappropriate. Point-of-care diagnostic tests are used as a basis for antimicrobial stewardship interventions to improve the diagnostic certainty of respiratory tract infections (RTIs), and therefore ensure prudent antimicrobial use. However, there is a lack of guidance on their use, and they are therefore not routinely used in clinical practice. Objective: A scoping review will be conducted to synthesise the available evidence to inform the development of best practice guidance for using point-of-care diagnostics in the management of RTIs in primary care. Methods: A scoping review will be conducted following guidance from the Joanna Briggs Institute (JBI) and reported using the PRISMA-ScR guidelines. Databases including Web of Science, MEDLINE, CINAHL, EMBASE, the International HTA database and the Cochrane Central Register of Controlled Trials, as well as grey literature, will be searched. Screening will be undertaken independently by two reviewers to identify studies and literature reporting the use of point-of-care diagnostics in the management of RTIs in primary care by GPs and/ or CPs. Findings will be described using narrative synthesis. Conclusion:  The findings of this scoping review will be used to produce draft guidance on the use of point-of-care diagnostic tests in primary care, which will undergo further development using a Delphi consensus methodology involving experts in the field of RTIs, antimicrobial stewardship, point-of-care diagnostics and primary care.

Primary care-based models of care for osteoarthritis; a scoping review

OBJECTIVE

To identify and describe the extent, nature, characteristics, and impact of primary care-based models of care (MoCs) for osteoarthritis (OA) that have been developed and/or evaluated.

DESIGN

Six electronic databases were searched from 2010 to May 2022. Relevant data were extracted and collated for narrative synthesis.

RESULTS

Sixty-three studies pertaining to 37 discrete MoCs from 13 countries were included, of which 23 (62%) could be classified as OA management programmes (OAMPs) comprising a self-management intervention to be delivered as a discrete package. Four models (11%) focussed on enhancing the initial consultation between a patient presenting with OA at the first point of contact into a local health system and the clinician. Emphasis was placed on educational training for general practitioners (GPs) and allied healthcare professionals delivering this initial consultation. The remaining 10 MoCs (27%) detailed integrated care pathways of onward referral to specialist secondary orthopaedic and rheumatology care within local healthcare systems. The majority (35/37; 95%) were developed in high-income countries and 32/37 (87%) targeted hip/and or knee OA. Frequently identified model components included GP-led care, referral to primary care services and multidisciplinary care. The models were predominantly 'one-size fits all' and lacked individualised care approaches. A minority of MoCs, 5/37 (14%) were developed using underlying frameworks, three (8%) of which incorporated behaviour change theories, while 13/37 (35%) incorporated provider training. Thirty-four of the 37 models (92%) were evaluated. Outcome domains most frequently reported included clinical outcomes, followed by system- and provider-level outcomes. While there was evidence of improved quality of OA care associated with the models, effects on clinical outcomes were mixed.

CONCLUSION

There are emerging efforts internationally to develop evidence-based models focused on non-surgical primary care OA management. Notwithstanding variations in healthcare systems and resources, future research should focus on model development alignment with implementation science frameworks and theories, key stakeholder involvement including patient and public representation, provision of training and education for providers, treatment individualisation, integration and coordination of services across the care continuum and incorporation of behaviour change strategies to foster long-term adherence and self-management.

Pharmaceutical policies: effects of policies regulating drug marketing

BACKGROUND

The costs of developing new treatments and bringing them to the market are substantial. The pharmaceutical industry uses drug promotion to gain a competitive market share, and drive sale volumes and industry profitability. This involves disseminating information about new treatments to relevant targets. However, conflicts of interest can arise when profits are prioritised over patient care and its benefits. Drug promotion regulations are complex interventions that aim to prevent potential harm associated with these activities.

OBJECTIVES

To assess the effects of policies that regulate drug promotion on drug utilisation, coverage or access, healthcare utilisation, patient outcomes, adverse events and costs.

SEARCH METHODS

We searched Epistemonikos for related reviews and their included studies. To find primary studies we searched MEDLINE, CENTRAL, Embase, EconLit, Global Index Medicus, Virtual Health Library, INRUD Bibliography, two trial registries and two sources of grey literature. All databases and sources were searched in January 2023.

SELECTION CRITERIA

We planned to include studies that assessed policies regulating drug promotion to consumers, healthcare professionals or regulators and third-party payers, or any combination of these groups.In this review we defined policies as laws, rules, guidelines, codes of practice, and financial or administrative orders made by governments, non-government organisations or private insurers. One of the following outcomes had to be reported: drug utilisation, coverage or access, healthcare utilisation, patient health outcomes, any adverse effects (unintended consequences), and costs. The study had to be a randomised or non-randomised trial, an interrupted time series analysis (ITS), a repeated measures (RM) study or a controlled before-after (CBA) study.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed eligibility for inclusion of studies. When consensus was not reached, any disagreements were discussed with a third review author.  We planned to use the criteria suggested by Cochrane Effective Practice and Organisation of Care (EPOC) to assess the risk of bias of included studies. For randomised trials, non-randomised trials, and CBA studies, we planned to estimate relative effects, with 95% confidence intervals (CI). For dichotomous outcomes, we planned to report the risk ratio (RR) when possible and adjusted for baseline differences in the outcome measures. For ITS and RM, we planned to compute changes along two dimensions: change in level and change in slope. We planned to undertake a structured synthesis following EPOC guidance.  MAIN RESULTS: The search yielded 4593 citations, and 13 studies were selected for full-text review. No study met the inclusion criteria.

AUTHORS' CONCLUSIONS

We sought to assess the effects of policies that regulate drug promotion on drug use, coverage or access, use of health services, patient outcomes, adverse events, and costs, however we did not find studies that met the review's inclusion criteria. As pharmaceutical policies that regulate drug promotion have untested effects, their impact, as well as their positive and negative influences, is currently only a matter of opinion, debate, informal or descriptive reporting. There is an urgent need to assess the effects of pharmaceutical policies that regulate drug promotion using well-conducted studies with high methodological rigour.

Priorities for future research on reducing and stopping psychiatric medicines using a James Lind Alliance priority setting partnership: The PROTECT study protocol

Background: There is a growing number of service users looking to discontinue use of psychiatric medicines. Tapering is the recommended approach for reducing and/or discontinuing the use of psychiatric medicines. This involves gradually reducing the dose over time to minimise the potential for withdrawal symptoms. However, many uncertainties exist regarding the process of reducing and stopping psychiatric medicines. This study will use a James Lind Alliance Priority Setting Partnership to determine the Top 10 unanswered questions and uncertainties about reducing and stopping psychiatric medicines. Methods : The Priority Setting Partnership will be conducted using the James Lind Alliance methodology. It will involve seven stages: (i) creating an international Steering Group of representatives from key stakeholder groups that will include people with lived experience of taking and/or stopping psychiatric medicines, family members, carers/supporters and healthcare professionals, and identifying potential partners to support key activities (e.g. dissemination); (ii) gathering uncertainties about reducing and stopping psychiatric medicines from key stakeholders using an online survey; (iii) data processing and summarising the survey responses; (iv) checking the summary questions against existing evidence and verifying uncertainties; (v) shortlisting the questions using a second online survey; (vi) determining the Top 10 research questions through an online prioritisation workshop; (vii) disseminating results. Conclusions : This study will use a Priority Setting Partnership to generate a Top 10 list of research questions and uncertainties about reducing and stopping psychiatric medicines. This list will help to guide future research and deliver responsive and strategic allocation of research resources, with a view to ultimately improving the future health and well-being of individuals who are taking psychiatric medicines.

Cross-sectional questionnaire study of the experiences of community pharmacists in Northern Ireland during the early phases of the COVID-19 pandemic: preparation, experience and response

OBJECTIVES

To examine the views and experiences of community pharmacists in Northern Ireland (NI) regarding changes in community pharmacy practice/processes in preparation for, and response to, the COVID-19 pandemic.

DESIGN

Cross-sectional telephone-administered questionnaire.

SETTING AND PARTICIPANTS

Geographically stratified representative sample of 130 community pharmacists in NI between March and May 2021.

OUTCOME MEASURES

Community pharmacists' responses to questions focusing on their preparation, experience and response to the COVID-19 pandemic. Descriptive analysis was conducted including frequencies and percentages. Free-text comments were summarised using thematic analysis.

RESULTS

One hundred and thirty pharmacists completed the questionnaire. Pharmacists responded comprehensively to implementing infection control measures, for example, management of social distancing in the shop (96.2%), making adjustments to premises, for example, barriers/screens (95.4%), while maintaining medicines supply (100.0%) and advice to patients (93.1%). Newly commissioned services were provided, for example, emergency supply service (93.1%), influenza vaccination for healthcare workers (77.7%) and volunteer deliveries to vulnerable people (54.6%). Pharmacists were least prepared for the increased workload and patients' challenging behaviour, but the majority (96.9%) reported that they felt better prepared during the second wave. Pharmacists agreed/strongly agreed that they would be able to re-establish normal services (87.7%), were willing to administer COVID-19 vaccines (80.7%) and provide COVID-19 testing (60.8%) in the future.

CONCLUSIONS

Community pharmacists remained accessible and maintained supply of essential medicines and advice to patients throughout the pandemic. Provision of modified and additional services such as vaccination reinforced the clinical and public health role of pharmacy.

Mobile phone applications to support psychotropic tapering: a scoping review protocol

Background: In the context of a recovery-oriented approach to mental healthcare, the role of psychotropic medication over extended or indefinite periods is increasingly being called into question. To minimise the risks of withdrawal symptoms and relapse, it is crucial that service users who want to discontinue psychotropic medication are supported throughout the tapering process. However, in the absence of effective interventions and supports, service users are increasingly relying on online resources for guidance and support. To date, the evidence base for mobile phone applications (‘apps’) and app-based interventions supporting discontinuation of psychotropic use has not been examined. This scoping review aims to examine the content, underpinning evidence base and impact of available mobile phone apps and app-based interventions to support psychotropic tapering. Methods: A scoping review will be conducted using the Joanna Briggs Institute guidance and results will be reported using the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA-ScR) guideline. Several electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, ACM and IEEE Xplore) will be searched from 2008 onwards. Searches of the major app stores will also be conducted, specifically Apple's App Store (iOS) and Google Play Store (Android). Following screening, key information will be extracted from the included studies and apps. Identified apps will be coded using the Behaviour Change Technique (BCT) Taxonomy. The findings will be described using narrative synthesis. Conclusions: This scoping review will provide a broad overview of available apps to support psychotropic tapering, including a summary of their content using the BCT Taxonomy. The review findings will guide future research relating to the development, implementation and evaluation of app-based interventions to support the tapering of psychotropic medication.

A scoping review of the methods and processes used by regulatory bodies to determine pharmacists' readiness for practice

BACKGROUND

There is an expectation from government, regulatory bodies, patients, the public, and other healthcare professions that pharmacists are competent professionals who can practice independently. Regulation of the profession requires pharmacy graduates to register with a recognised regulatory body before being considered 'ready to practise' independently.

OBJECTIVE

To examine the methods and processes used by national regulatory bodies to determine pharmacists' readiness to practise.

METHODS

A scoping review was conducted using three electronic databases (Embase, Scopus, CINAHL) and websites of national regulatory bodies. Articles were eligible for inclusion if they described the methods and processes used by regulatory bodies to determine pharmacists' readiness to practise. Data were extracted relating to readiness to practise, the registration exam and the role of newly qualified pharmacists, post-registration. Extracted data were collated using narrative descriptive summaries and accompanying tables.

RESULTS

Identified data sources referred to registration of pharmacists across 11 different countries. No sources provided a definition for the term 'ready to practise'. Ten countries were identified as holding a registration examination with varying formats and curricula. Written and oral exams, competency based written assessments, Objective Structured Clinical Examinations and a combination of these were identified with written exam being the most popular (n = 8). In all but one country, the regulator was responsible for delivery of the exam. In most cases (n = 7), the exam was mapped to a pre-defined set of competencies with only a few (n = 4) explaining how these competencies were developed. Only two sources made reference to the role of the newly qualified pharmacist post-registration.

CONCLUSION

The review has established a paucity of research and publicly available information on the methods and processes used by national regulators to determine pharmacists' readiness to practise. There is no pharmacy definition of being 'ready to practise'. Assessment methods vary widely and, currently, no gold standard is apparent.

Supporting safe and gradual reduction of long‐term benzodiazepine receptor agonist use: Development of the SAFEGUARDING‐BZRAs toolkit using a codesign approach

Introduction

Long‐term benzodiazepine receptor agonist (BZRA) use persists in healthcare settings worldwide and poses risks of patient harm.

Objective

This study aimed to develop an intervention to support discontinuation of long‐term BZRA use among willing individuals.

Methods

The intervention development process aligned with the UK Medical Research Council's complex intervention framework. This involved a previous systematic review of brief interventions targeting long‐term BZRA use in primary care and qualitative interviews based on the Theoretical Domains Framework that explored barriers and facilitators to discontinuing long‐term BZRA use. A codesign approach was used involving an active partnership between experts by experience, researchers and clinicians. Intervention content was specified in terms of behaviour change techniques (BCTs).

Results

The SAFEGUARDING‐BZRAs (Supporting sAFE and GradUAl ReDuctIon of loNG‐term BenZodiazepine Receptor Agonist uSe) toolkit comprises 24 BCTs and includes recommendations targeted at primary care‐based clinicians for operationalizing each BCT to support individuals with BZRA discontinuation.

Conclusion

The SAFEGUARDING‐BZRAs toolkit has been developed using a systematic and theory‐based approach that addresses identified limitations of previous research. Further research is needed to assess its usability and acceptability by service users and clinicians, as well as its potential to effectively support safe and gradual reduction of long‐term BZRA use.

Patient or Public Contribution

The qualitative interview phase included patients as participants. The codesign process included ‘experts by experience’ with either current or previous experience of long‐term BZRA use as collaborators.

Key stakeholders' views, experiences and expectations of patient and public involvement in healthcare professions' education: a qualitative study

BACKGROUND

Patients and the public have an integral role in educating healthcare professionals. Authentic partnerships between higher education institutions and patients and the public are essential. This study examined key stakeholders' views, experiences and expectations of patient and public involvement (PPI) including the nature of the involvement and requirements for partnership.

METHODS

Purposive and snowball sampling was used to recruit key stakeholders, including patients and members of the public involved in health professions education, and academics interested in PPI. Focus groups were held with patient and public participants, providing the opportunity to gain multiple perspectives in an interactive group setting. Academics with an interest in PPI were interviewed using a semi-structured approach. Topic guides were derived from the literature and piloted prior to data collection. Focus groups and interviews were conducted until data saturation was achieved. All data was audio-recorded, transcribed, anonymised and thematically analysed.

RESULTS

Four focus groups were conducted involving 23 patient and public participants (median number of participants per focus group of 6). Nine interviews were conducted with academics (face-to-face [n = 8] or by telephone [n = 1]). Five themes were developed: previous experiences of PPI, training requirements, challenges/barriers to PPI, facilitators of PPI and future ideas for PPI. All participants held positive views of the value of PPI. Participants had mixed views in terms of training, which depended on the level of involvement, but similar views on the challenges and facilitators for PPI in education. There was agreement that PPI requires institutional vision and investment to build strong relationships and a culture of PPI best practice.

CONCLUSIONS

There is a need for more strategic and formal involvement of patients and the public to ensure that that PPI becomes sustainably embedded in health professions education.

Supporting sAFE and GradUAl ReDuctIon of loNG-term BenzodiaZepine Receptor Agonist uSe: development of the SAFEGUARDING-BZRAs toolkit using a co-design approach

Introduction

Long-term benzodiazepine receptor agonist (BZRA) use (>3 months) persists worldwide and poses risks of harm. Effective interventions are needed to address this issue.

Aim

To develop an intervention to support discontinuation of long-term benzodiazepine receptor agonist (BZRA) use.

Methods

The intervention development process built on previous qualitative work that used the Theoretical Domains Framework (TDF) to explore perceived barriers and facilitators to discontinuing long-term BZRA use (1). A co-design approach was used whereby lay individuals and professionals worked as equals during the research process based on principles of authentic participation and collaboration (2). The co-design team included five ‘experts by lived experience’ with experience of long-term BZRA use who previously provided input on other related work as patient and public involvement representatives or responded to an expression of interest call on social media. Two online co-design team meetings were held. During the first meeting, a summary of previous findings was presented together with a long-list of behaviour change techniques (BCTs) generated using established mapping matrices in which BCTs were reliably allocated to the TDF. Each team member independently documented their decision as to whether each BCT should be included in a short-list for potential inclusion in the final intervention using online polling software. The a priori decision rule was that 70% of team members had to agree regarding the inclusion/exclusion of a BCT. All other BCTs were then discussed at a follow-up meeting. A finalised list of BCTs for inclusion in the intervention was agreed at the second meeting using a consensus-based approach involving the same decision rule. Potential ways in which BCTs could be operationalised were then discussed.

Results

Thirty BCTs were discussed and six BCTs were excluded. For example, team members recommended avoiding ‘Social comparison’ as individual circumstances and experiences of discontinuation and associated withdrawal symptoms are unique and not directly comparable. Given the number of included BCTs, the co-design team recommended presenting them as a toolkit. The SAFEGUARDING-BZRAs (Supporting sAFE and GradUAl ReDuctIon of loNG-term BenzodiaZepine Receptor Agonist uSe) toolkit comprises 24 BCTs: ‘Goal setting (behaviour)’, ‘Review behaviour goal(s)’, ‘Review outcome goal(s)’, ‘Feedback on behaviour’, ‘Self-monitoring of behaviour’, ‘Social support (practical)’, ‘Social support (emotional)’, ‘Information about health consequences’, ‘Monitoring of emotional consequences’, ‘Information about emotional consequences’, ‘Prompts/cues’, ‘Habit reversal’, ‘Graded tasks’, ‘Pros and cons’, ‘Comparative imagining of future outcomes’, ‘Social reward’, ‘Self-reward’, ‘Reduce negative emotions’, ‘Distraction’, ‘Adding objects to the environment’, ‘Body changes’, ‘Verbal persuasion about capability’, ‘Focus on past success’ and ‘Credible source’. The toolkit includes recommendations targeted at primary care-based clinicians for operationalising each BCT to support BZRA discontinuation.

Conclusion

The SAFEGUARDING-BZRAs toolkit has been developed using a systematic, theory-based approach that addresses identified limitations of previous research (e.g. lack of detailed intervention description). In terms of limitations, it is possible that a different group of individuals may have developed a different type of intervention. To overcome this, a priori decision rules were used for decision making. Further research is needed to assess the toolkit’s usability and acceptability by service users and clinicians.

References

(1) Lynch et al. Health Expect. [in press] DOI: 10.1111/hex.13392.

(2) O’Donnell et al. BMC Health Serv Res. 2019;19(1):797

Mobile phone applications to support psychotropic tapering: a scoping review protocol

Background: In the context of a recovery-oriented approach to mental healthcare, the role of psychotropic medication over extended or indefinite periods is increasingly being called into question. To minimise the risks of withdrawal symptoms and relapse, it is crucial that service users who want to discontinue psychotropic medication are supported throughout the tapering process. However, in the absence of effective interventions and supports, service users are increasingly relying on online resources for guidance and support. To date, the evidence base for mobile phone applications (‘apps’) and app-based interventions supporting discontinuation of psychotropic use has not been examined. This scoping review aims to examine the content, underpinning evidence base and impact of available mobile phone apps and app-based interventions to support psychotropic tapering. Methods: A scoping review will be conducted using the Joanna Briggs Institute guidance and results will be reported using the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA-ScR) guideline. Several electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, ACM and IEEE Xplore) will be searched from 2008 onwards. Searches of the major app stores will also be conducted, specifically Apple's App Store (iOS) and Google Play Store (Android). Following screening, key information will be extracted from the included studies and apps. Identified apps will be coded using the Behaviour Change Technique (BCT) Taxonomy. The findings will be described using narrative synthesis. Conclusions: This scoping review will provide a broad overview of available apps to support psychotropic tapering, including a summary of their content using the BCT Taxonomy. The review findings will guide future research relating to the development, implementation and evaluation of app-based interventions to support the tapering of psychotropic medication.

Primary care-based models of care for osteoarthritis: a scoping review protocol

Background: The burden of osteoarthritis (OA) to individuals and health systems is substantial and is expected to increase due to population ageing and rising prevalence of obesity and multimorbidity. Primary care-based models of care (MoCs) are being increasingly developed in response to this growing burden. However, these MoCs have yet to be formally reviewed. A MoC can be defined as an ‘evidence-informed strategy, framework or pathway that outlines the optimal manner in which condition-specific care should be delivered to consumers within a local health system’.

Objective: To identify and describe the available research regarding the extent, nature and characteristics of MoCs for OA that have been developed or evaluated in primary care.

Methods: A scoping review will be conducted in accordance with the Arksey and O’Malley scoping review framework and the PRISMA-ScR guidelines. Systematic literature searches of MEDLINE, EMBASE, CINAHL, PsychINFO, Web of Science and LILACs will be conducted from 2010 to present, aligning with publication dates of recent clinical guidelines. A structured iterative search of grey literature will be conducted. Full-text original quantitative or mixed method studies which describe the development or evaluation of MoCs for OA in primary care will be considered. Data will be charted and synthesised and a narrative synthesis will be conducted.

Conclusions: This scoping review will provide a broad overview regarding the extent, nature and characteristics of the available literature on primary care based MoCs for OA. Findings will be used to identify gaps in the current evidence to identify areas for future research.

Pharmacists' involvement in COVID-19 vaccination across Europe: a situational analysis of current practice and policy

One year since the emergence of the COVID-19 pandemic, rapid response measures have been implemented internationally to mitigate the spread of the virus. Following rapid and successful pre-clinical and human trials, several vaccines have been authorised for use across Europe through the European Medicines Agency and national regulatory authorities. Clinical trials have shown promising results including important reductions in disease severity, hospitalisation and mortality. In order to maximise the public health benefit of available vaccines, there is a pressing need to vaccinate a large proportion of the population. Internationally, this has prompted coordination of existing services at enormous scale, and development and implementation of novel vaccination strategies to ensure maximum inoculation over the shortest possible timeframe. Pharmacists are being promoted as healthcare professionals that enhance roll-out of COVID-19 vaccination programmes. This paper aims to summarise current policy and practice in relation to pharmacists’ involvement in COVID-19 vaccination in 13 countries across Europe.

Development of a European competency framework for health and other professionals to support behaviour change in persons self-managing chronic disease

BACKGROUND

Healthcare and other professionals are expected to support behaviour change in people living with chronic disease. However, effective behaviour change interventions are largely absent in routine encounters. The Train4Health project, a European strategic partnership for higher education, sought to address this problem. The primary aim of this study, which is part of an early work package, was to develop an interprofessional competency framework for health and other professions to support behaviour change for the self-management of chronic disease at a European level. A secondary aim was to derive a set of behaviour change techniques (BCTs) from an established taxonomy to link with framework competencies.

METHODS

The study comprised two interlinked parts. Part 1 involved a two-round e-Delphi study with an interprofessional panel of 48 experts across 12 European countries to develop the behaviour change competency framework. Preparatory work included drafting a list of competency statements based on seven existing frameworks. Part 2 involved an expert panel of six behavioural psychologists deriving a set of BCTs to link with framework competencies. Their feedback was based on preparatory work, which focused on seven high priority chronic diseases for self-management, identified through European projects on self-management and identifying five relevant target behaviours from key clinical guidelines. A literature search yielded 29 effective BCTs for the target behaviours in the selected chronic diseases.

RESULTS

Twenty-seven competency statements, were presented in Round 1 to the Delphi panel. Consensus was achieved for all statements. Based on comments, two statements were removed, one was added, and 14 were modified. All 15 statements subjected to Round 2 were consensus-approved, yielding a total of 12 foundational competencies for behaviour change in self-management of chronic disease and 14 behaviour change competencies. Four behaviour change competencies related to BCTs. Behavioural psychologists' feedback led to a core set of 21 BCTs deemed applicable to the five target behaviours across the seven chronic diseases.

CONCLUSIONS

A behaviour change competency framework comprising 26 statements for European health and other professionals to support self-management of chronic disease was developed, linked with a core set of 21 BCTs from an established taxonomy.

Primary care-based models of care for osteoarthritis: a scoping review protocol

Background: The burden of osteoarthritis (OA) to individuals and health systems is substantial and is expected to increase due to population ageing and rising prevalence of obesity and multimorbidity. Primary care-based models of care (MoCs) are being increasingly developed in response to this growing burden. However, these MoCs have yet to be formally reviewed. A MoC can be defined as an 'evidence-informed strategy, framework or pathway that outlines the optimal manner in which condition-specific care should be delivered to consumers within a local health system'. Objective: To identify and describe the available research regarding the extent, nature and characteristics of MoCs for OA that have been developed or evaluated in primary care. Methods: A scoping review will be conducted in accordance with the Arksey and O'Malley scoping review framework and the PRISMA-ScR guidelines. Systematic literature searches of MEDLINE, EMBASE, CINAHL, PsychINFO, Web of Science and LILACs will be conducted from 2010 to present, aligning with publication dates of recent clinical guidelines. A structured iterative search of grey literature will be conducted. Full-text original quantitative or mixed method studies which describe the development or evaluation of MoCs for OA in primary care will be considered. Data will be charted and synthesised and a narrative synthesis will be conducted. Conclusions: This scoping review will provide a broad overview regarding the extent, nature and characteristics of the available literature on primary care based MoCs for OA. Findings will be used to identify gaps in the current evidence to identify areas for future research.

Interventions to optimise medication prescribing and adherence in older people with cancer: A systematic scoping review

Introduction

Older adults with cancer often require multiple medications (polypharmacy) comprising cancer-specific treatments, supportive care medications (e.g. analgesics) and medications for pre-existing conditions. The reported prevalence of polypharmacy in older adults with cancer ranges from 13–92% (1). Increasing numbers of medications pose risks of potentially inappropriate prescribing and medication non-adherence.

Aim

The aim of this scoping review was to provide an overview of evaluations of interventions to optimise medication prescribing and/or adherence in older adults with cancer, with a particular focus on the interventions, study populations and outcome measures that have been assessed in previous evaluations.

Methods

Four databases (PubMed, EMBASE, CINAHL, PsycINFO) were searched from inception to 29th November 2019 using relevant search terms (e.g. cancer, older adults, prescribing, adherence). Eligible studies evaluated interventions seeking to improve medication prescribing and/or adherence in older adults (≥65 years) with an active cancer diagnosis using a comparative evaluation (e.g. inclusion of a control group). All outcomes for studies that met inclusion criteria were included in the review. Two reviewers independently screened relevant abstracts for inclusion and performed data extraction. As a scoping review aims to provide a broad overview of existing literature, formal assessments of methodological quality of included studies were not undertaken. Extracted data were collated using tables and accompanying narrative descriptive summaries. The review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines (2).

Results

The electronic searches yielded 21,136 citations (Figure 1). Nine studies met inclusion criteria. Included studies consisted of five randomised controlled trials (RCTs), including one cluster RCT, and four before-and-after study designs. Studies were primarily conducted in oncology clinics, ranging from single study sites to 109 oncology clinics. Sample sizes ranged from 33 to 4844 patients. All studies had a sample population with a mean/median age of ≥65 years, however, only two studies focused specifically on older populations. Interventions most commonly involved patient education (n=6), and were delivered by pharmacists or nurses. Five studies referred to the intervention development process and no studies reported any theoretical underpinning. Three studies reported on prescribing-related outcomes and seven studies reported on adherence-related outcomes, using different terminology and a range of assessments. Prescribing-related outcomes comprised assessments of medication appropriateness (using Beers criteria), drug-related problems and drug interactions. Adherence-related outcomes included assessments of self-reported medication adherence and calculation of patients’ medication possession ratio.

Conclusion

The main strength of this scoping review is that it provides a broad overview of the existing literature on interventions aimed at optimising medication prescribing and adherence in older adults with cancer. The review highlights a lack of robust studies specifically targeting this patient population and limited scope to pool outcome data across included studies. Limitations of the review were that searches were restricted to English language publications and no grey literature was searched. Future research should focus specifically on older patients with cancer, and exercise rigour during intervention development, evaluation and reporting in order to generate findings that could inform future practice.

References

1. Maggiore RJ, Gross CP, Hurria A. Polypharmacy in older adults with cancer. The oncologist. 2010;15(5):507–22.

2. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467–73.

Barriers and facilitators to discontinuing long-term use of benzodiazepine receptor agonists: a qualitative study using the Theoretical Domains Framework

Introduction

Long-term use (>3 months) of benzodiazepine receptor agonists (BZRAs) persists in healthcare settings worldwide despite guidelines recommending short-term use (≤4 weeks). Potential harms of long-term BZRA use include dependence and withdrawal symptoms. A systematic review highlighted that brief interventions targeting long-term BZRA use lacked theoretical underpinning and were often poorly described (1). It is advocated that interventions should be systematically developed and reported, use an appropriate theory-base and involve key stakeholders in their development. Semi-structured interviews based on the Theoretical Domains Framework (TDF) can be used to identify patient-level barriers and facilitators that should be targeted by interventions (2).

Aim

The aim of this study was to explore the views and experiences of individuals who had previously used BZRAs on a long-term basis through semi-structured interviews and to identify key theoretical domains that acted as barriers and facilitators to discontinuing long-term BZRA use.

Methods

A multi-strand convenience sampling method was used to recruit participants through community pharmacies, general practices and social media (e.g. Twitter, Instagram). Individuals who had successfully discontinued long-term BZRA use were eligible to participate if they were ≥18 years of age, community dwelling and resident in the Republic of Ireland. Individuals with a: cognitive impairment, history of epilepsy, serious mental illness (e.g. prescribed anti-psychotics) or receiving opioid substitution treatment were excluded. Semi-structured interviews were conducted using a TDF-based topic guide (2). Questions covering each TDF domain were used to explore participants’ perceptions of barriers and facilitators to discontinuing long-term BZRA use. Data were recorded and transcribed verbatim. Transcripts were independently checked for accuracy. Data were analysed using the framework method. Interviews continued until data saturation was achieved. Ethical approval was granted by the RCSI Research Ethics Committee.

Results

Thirteen patients were interviewed (seven female; median age: 43 years; median duration of use: six years). Key barriers to discontinuing BZRA use were identified under the ‘Emotions’ and ‘Reinforcement’ domains. These included participants’ first-hand experience of withdrawal symptoms and resultant fear towards discontinuation of the medication. ‘Intentions’ and ‘Social influences’ were identified as key theoretical domains that facilitated participants in discontinuing BZRA use. For example, participants described having strong intentions to discontinue BZRA use and discussed the positive influence of healthcare professionals such as community pharmacists in supporting them.

Conclusion

The study findings indicate that individuals who have successfully discontinued long-term BZRA use often have strong intentions to do so, as well as the support of healthcare professionals. However, challenges to discontinuing BZRA use include withdrawal symptoms and negative emotions towards the discontinuation process. The main strength of this study is that it used the TDF to examine barriers and facilitators to discontinuing long-term BZRA use. A notable limitation was that none of the participants were aged ≥65 years which limits the transferability of the findings. Future work will look to examine the views and experiences of current long-term BZRA users, integrate the findings with this study and map key domains to behaviour change techniques to inform the development of an intervention to reduce long-term BZRA use.

References

1. Lynch T, Ryan C, Hughes CM, Presseau J, van Allen ZM, Bradley CP, et al. Brief interventions targeting long-term benzodiazepine and Z-drug use in primary care: a systematic review and meta-analysis. Addiction. 2020;115(9):1618–39.

2. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation Science. 2012;7(1):37.

Provision of clinical pharmacy services during the COVID-19 pandemic: Experiences of pharmacists from 16 European countries

Background

The pharmacy profession has an important role in the frontline healthcare response to COVID-19 across all settings.

Objective

This study sought to explore the views and experiences of clinical pharmacists in relation to the provision of clinical pharmacy services during COVID-19.

Methods

Semi-structured qualitative interviews were conducted with pharmacists working in clinical roles in healthcare settings across Europe. Participants were recruited through professional organisations of clinical and hospitals pharmacists combined with a snowballing technique. The Pharmacy Emergency Preparedness and Response Framework and Disaster Preparedness Framework for pharmacy services were used to generate data which were analysed using the thematic framework method.

Results

Twenty-two participants from 16 European countries described a range of measures to protect patients, public and healthcare staff against virus transmission including developing and disseminating educational materials. Most described their involvement in aspects of evidence provision such as facilitating clinical trials, gathering and appraising evidence and disseminating clinical information. Many hospital-based pharmacists were reassigned to new roles such as intensive care. Routine clinical services were extensively interrupted and remote forms of communication were used. Most were motivated by a strong sense of professionalism to continue delivering services. A number of facilitators and barriers to prevention, preparedness and response actions were identified which related to uptake of new roles, recognition of pharmacists roles in the healthcare team, information gathering, communication with patients and healthcare professionals, and provision of routine clinical services.

Conclusions

Participants in this multinational qualitative study described a range of service adaptations and adoption of novel roles to prevent and mitigate the public health impact of the pandemic. The study findings may help to inform governments, public health agencies and healthcare systems in harnessing ongoing service provision and adapt to any future interruptions.

A survey of the European Society of Clinical Pharmacy members' research involvement, and associated enablers and barriers

Background Building research capacity of European Society of Clinical Pharmacy (ESCP) members aligns to the organisation's aim of advancing research. Objective To determine members' aspirations and needs in research training and practice, and to explore ways in which ESCP could provide support. Setting ESCP's international membership. Method Cross-sectional survey of members in 2018, followed by focus groups with samples of respondents attending an ESCP symposium. Survey items were: research activities; interests, experience and confidence; and Likert statements on research conduct. Principal component analysis (PCA) clustering of Likert statements from a previous study was used, with scores for each component calculated. Focus groups discussed barriers to research and how ESCP could provide support. Data analysis involved collating and comparing all themes. Main outcome measures Research interest, experience and confidence; attitudinal items; barriers to research; ESCP support. Results The response rate was 16.7% (83/499), with 89.2% (n = 74) involved in research and 79.5% (n = 66) publishing research in the preceding 2 years. While overwhelmingly positive, responses were more positive for research interest than experience or confidence. PCA component scores (support/opportunities, motivation/outcomes, and roles/characteristics) were positive. Thirteen members participated in focus groups, identifying barriers of: insufficient collaboration; lack of knowledge, skills, training; unsupportive environment; insufficient time; and limited resources. ESCP could support through mentorship, collaboration, education and funding. Conclusion Study participants were highly active, interested, experienced, confident and positive regarding research. There is an opportunity for ESCP to harness these activities and provide support in the form of mentoring, education and training, and facilitating collaboration.

An audit of prescribing practices for benzodiazepines and Z-drugs

Concerns persist over the use of benzodiazepines and Z-drugs in Ireland. A prospective prescription audit was conducted in 81 community pharmacies across Ireland over a four week period. The study sought to assess the level of prescription compliance with key components of benzodiazepine and Z-drug prescribing guidelines. 28% of audit booklets issued were returned, yielding data on 4,418 prescriptions. The findings suggest that little progress has been made in improving the prescribing of benzodiazepines and Z-drugs in Ireland in the decade since publication of the Benzodiazepine Committee's report. Fewer than one fifth of prescriptions (18.8%) were fully compliant with the assessment criteria and the majority (53.7%) had multiple discrepancies. This study highlights the importance of monitoring and auditing benzodiazepine and Z-drug prescribing practices. Interventions involving patients, prescribers and pharmacists are required to improve the prescribing and use of these medications in Ireland.