Perspectives of people experiencing homelessness with recent non-fatal street drug overdose on the Pharmacist and Homeless Outreach Engagement and Non-medical Independent prescribing Rx (PHOENIx) intervention

INTRODUCTION

In Scotland, a third of all deaths of people experiencing homelessness (PExH) are street-drug-related, and less than half of their multiple physical- and mental health conditions are treated. New, holistic interventions are required to address these health inequalities. PHOENIx (Pharmacist Homeless Outreach Engagement and Non-medical Independent prescribing Rx) is delivered on outreach by National Health Service (NHS) pharmacist independent prescribers in partnership with third sector homelessness charity workers. We describe participant's perspectives of PHOENIx.

METHODS

This study aims to understand experiences of the PHOENIx intervention by participants recruited into the active arm of a pilot randomised controlled trial (RCT). Semi-structured in-person interviews explored participants' evaluation of the intervention. In this study, the four components (coherence, cognitive participation, collective action, reflexive monitoring) of the Normalisation Process Theory (NPT) framework underpinned data collection and analyses.

RESULTS

We identified four themes that were interpreted within the NPT framework that describe participant evaluation of the PHOENIx intervention: differentiating the intervention from usual care (coherence), embedding connection and consistency in practice (cognitive participation), implementation of practical and emotional operational work (collective action), and lack of power and a commitment to long-term support (reflexive monitoring). Participants successfully engaged with the intervention. Facilitators for participant motivation included the relationship-based work created by the PHOENIx team. This included operational work to fulfil both the practical and emotional needs of participants. Barriers included concern regarding power imbalances within the sector, a lack of long-term support and the impact of the intervention concluding.

CONCLUSIONS

Findings identify and describe participants' evaluations of the PHOENIx intervention. NPT is a theoretical framework facilitating understanding of experiences, highlighting both facilitators and barriers to sustained engagement and investment. Our findings inform future developments regarding a subsequent definitive RCT of PHOENIx, despite challenges brought about by challenging micro and macro-economic and political landscapes.

Provision of drug and alcohol services amidst COVID-19 pandemic: a qualitative evaluation on the experiences of service providers

BACKGROUND

The impact of COVID-19 pandemic on the provision of drug and alcohol (D&A) services and associated outcomes have been under-researched.

AIM

This study aimed to understand the experiences of service providers in relation to how drug and alcohol (D&A) services were affected during COVID-19 pandemic, including the adaptations made and lessons learnt for the future.

METHOD

Focus groups and semi-structured interviews were conducted with participants from various D&A service organisations across the UK. Data were audio recorded, followed by transcription and thematic analysis.

RESULTS

A total of 46 participants representing various service providers were recruited between October and January 2022. The thematic analysis identified ten themes. COVID-19 required significant changes to how the treatment was provided and prioritised. Expansion of telehealth and digital services were described, which reduced service wait times and increased opportunities for peer network. However, they described missed opportunities for disease screening, and some users risked facing digital exclusion. Participants who provided opiate substitution therapy service spoke of improving service provider/user trust following the shift from daily supervised treatment consumption to weekly dispensing. At the same time, they feared fatal overdoses and non-adherence to treatment.

CONCLUSION

This study demonstrates the multifaceted impact of the COVID-19 pandemic on UK-based D&A service provisions. The long-term impact of reduced supervision on Substance Use Disorder treatment and outcomes and any effect of virtual communications on service efficiency, patient-provider relationships and treatment retention and successes are unknown, suggesting the need for further study to assess their utility.

Treatment burden for people experiencing homelessness with a recent non-fatal overdose: a questionnaire study

BACKGROUND

People experiencing homelessness (PEH) who have problem drug use have complex medical and social needs, with barriers to accessing services and treatments. Their treatment burden (workload of self-management and impact on wellbeing) remains unexplored.

AIM

To investigate treatment burden in PEH with a recent non-fatal overdose using a validated questionnaire, the Patient Experience with Treatment and Self-management (PETS).

DESIGN AND SETTING

The PETS questionnaire was collected as part of a pilot randomised control trial (RCT) undertaken in Glasgow, Scotland; the main outcome is whether this pilot RCT should progress to a definitive RCT.

METHOD

An adapted 52-item, 12-domain PETS questionnaire was used to measure treatment burden. Greater treatment burden was indicated by higher PETS scores.

RESULTS

Of 128 participants, 123 completed PETS; mean age was 42.1 (standard deviation [SD] 8.4) years, 71.5% were male, and 99.2% were of White ethnicity. Most (91.2%) had >5 chronic conditions, with an average of 8.5 conditions. Mean PETS scores were highest in domains focusing on the impact of self-management on wellbeing: physical and mental exhaustion (mean 79.5, SD 3.3) and role and social activity limitations (mean 64.0, SD 3.5) Scores were higher than those observed in studies of patients who are not homeless.

CONCLUSION

In a socially marginalised patient group at high risk of drug overdose, the PETS showed a very high level of treatment burden and highlights the profound impact of self-management work on wellbeing and daily activities. Treatment burden is an important person-centred outcome to help compare the effectiveness of interventions in PEH and merits inclusion in future trials as an outcome measure.

Baseline characteristics of people experiencing homelessness with a recent drug overdose in the PHOENIx pilot randomised controlled trial

BACKGROUND

Drug-related deaths in Scotland are the highest in Europe. Half of all deaths in people experiencing homelessness are drug related, yet we know little about the unmet health needs of people experiencing homelessness with recent non-fatal overdose, limiting a tailored practice and policy response to a public health crisis.

METHODS

People experiencing homelessness with at least one non-fatal street drug overdose in the previous 6 months were recruited from 20 venues in Glasgow, Scotland, and randomised into PHOENIx plus usual care, or usual care. PHOENIx is a collaborative assertive outreach intervention by independent prescriber NHS Pharmacists and third sector homelessness workers, offering repeated integrated, holistic physical, mental and addictions health and social care support including prescribing. We describe comprehensive baseline characteristics of randomised participants.

RESULTS

One hundred and twenty-eight participants had a mean age of 42 years (SD 8.4); 71% male, homelessness for a median of 24 years (IQR 12-30). One hundred and eighteen (92%) lived in large, congregate city centre temporary accommodation. A quarter (25%) were not registered with a General Practitioner. Participants had overdosed a mean of 3.2 (SD 3.2) times in the preceding 6 months, using a median of 3 (IQR 2-4) non-prescription drugs concurrently: 112 (87.5%) street valium (benzodiazepine-type new psychoactive substances); 77 (60%) heroin; and 76 (59%) cocaine. Half (50%) were injecting, 50% into their groins. 90% were receiving care from Alcohol and Drug Recovery Services (ADRS), and in addition to using street drugs, 90% received opioid substitution therapy (OST), 10% diazepam for street valium use and one participant received heroin-assisted treatment. Participants had a mean of 2.2 (SD 1.3) mental health problems and 5.4 (SD 2.5) physical health problems; 50% received treatment for physical or mental health problems. Ninety-one per cent had at least one mental health problem; 66% had no specialist mental health support. Participants were frail (70%) or pre-frail (28%), with maximal levels of psychological distress, 44% received one or no daily meal, and 58% had previously attempted suicide.

CONCLUSIONS

People at high risk of drug-related death continue to overdose repeatedly despite receiving OST. High levels of frailty, multimorbidity, unsuitable accommodation and unmet mental and physical health care needs require a reorientation of services informed by evidence of effectiveness and cost-effectiveness. Trial registration UK Clinical Trials Registry identifier: ISRCTN 10585019.

Protocol for a pilot randomised controlled trial to evaluate integrated support from pharmacist independent prescriber and third sector worker for people experiencing homelessness: the PHOENIx community pharmacy study

BACKGROUND

People experiencing homelessness (PEH) have complex health and social care needs and most die in their early 40 s. PEH frequently use community pharmacies; however, evaluation of the delivery of structured, integrated, holistic health and social care intervention has not been previously undertaken in community pharmacies for PEH. PHOENIx (Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx) has been delivered and tested in Glasgow, Scotland, by NHS pharmacist independent prescribers and third sector homelessness support workers offering health and social care intervention in low threshold homeless drop-in venues, emergency accommodation and emergency departments, to PEH. Building on this work, this study aims to test recruitment, retention, intervention adherence and fidelity of community pharmacy-based PHOENIx intervention.

METHODS

Randomised, multi-centre, open, parallel-group external pilot trial. A total of 100 PEH aged 18 years and over will be recruited from community pharmacies in Glasgow and Birmingham. PHOENIx intervention includes structured assessment in the community pharmacy of health, housing, benefits and activities, in addition to usual care, through weekly visits lasting up to six months. A primary outcome is whether to proceed to a definitive trial based on pre-specified progression criteria. Secondary outcomes include drug/alcohol treatment uptake and treatment retention; overdose rates; mortality and time to death; prison/criminal justice encounters; healthcare utilisation; housing tenure; patient-reported measures and intervention acceptability. Analysis will include descriptive statistics of recruitment and retention rates. Process evaluation will be conducted using Normalisation Process Theory. Health, social care and personal resource use data will be identified, measured and valued.

DISCUSSION

If the findings of this pilot study suggest progression to a definitive trial, and if the definitive trial offers positive outcomes, it is intended that PHOENIx will be a publicly funded free-to-access service in community pharmacy for PEH. The study results will be shared with wider stakeholders and patients in addition to dissemination through medical journals and scientific conferences.

TRIAL REGISTRATION

International Clinical Trial Registration ISRCTN88146807. Approved protocol version 2.0 dated July 19, 2022.

Pharmacist and Homeless Outreach Engagement and Non-medical Independent prescribing Rx (PHOENIx): a study protocol for a pilot randomised controlled trial

INTRODUCTION

The number of people experiencing homelessness (PEH) is increasing worldwide. Systematic reviews show high levels of multimorbidity and mortality. Integrated health and social care outreach interventions may improve outcomes. No previous studies have targeted PEH with recent drug overdose despite high levels of drug-related deaths and few data describe their health/social care problems. Feasibility work suggests a collaborative health and social care intervention (Pharmacist and Homeless Outreach Engagement and Non-medical Independent prescribing Rx, PHOENIx) is potentially beneficial. We describe the methods of a pilot randomised controlled trial (RCT) with parallel process and economic evaluation of PEH with recent overdose.

METHODS AND ANALYSIS

Detailed health and social care information will be collected before randomisation to care-as-usual plus visits from a pharmacist and a homeless outreach worker (PHOENIx) for 6-9 months or to care-as-usual. The outcomes are the rates of presentations to emergency department for overdose or other causes and whether to progress to a definitive RCT: recruitment of ≥100 participants within 4 months, ≥60% of patients remaining in the study at 6 and 9 months, ≥60% of patients receiving the intervention, and ≥80% of patients with data collected. The secondary outcomes include health-related quality of life, hospitalisations, treatment uptake and patient-reported measures. Semistructured interviews will explore the future implementation of PHOENIx, the reasons for overdose and protective factors. We will assess the feasibility of conducting a cost-effectiveness analysis.

ETHICS AND DISSEMINATION

The study was approved by South East Scotland National Health Service Research Ethics Committee 01. Results will be made available to PEH, the study funders and other researchers.

TRIAL REGISTRATION NUMBER

ISRCTN10585019.

A systematic review of the nutritional status of adults experiencing homelessness

OBJECTIVES

To identify, appraise, and describe studies focussing on the nutritional characteristics of people experiencing homelessness (PEH).

STUDY DESIGN

Systematic (narrative) review.

METHODS

We identified full-text studies of any design and in the English language of adults (≥18 years) fulfilling the European Typology criteria for homelessness, based in community or hospital settings, and which report nutritional measures. Five electronic databases, 13 grey literature sources, reference lists, and forward citations were searched. Data on study characteristics and nutrition measures were collected and synthesised narratively. Risk of bias was assessed using relevant checklists for each study type.

RESULTS

A total of 1130 studies were identified and retrieved. After screening, six studies were included for review: three cross-sectional studies; two case-control studies; and one randomised control trial, involving a total of 1561 participants from various settings including shelters, drop-in centres, hospitals, and hostels. All included studies were from high-income countries. Studies reported a range of nutrition measures including anthropometry (e.g., body mass index (BMI)), serum micronutrients and biomarkers, and dietary intake. Between 33.3% and 68.3% of participants were overweight or obese; 3.5%-17% were underweight; and low blood levels of iron, folate, vitamins C, D, and B12, and haemoglobin were prevalent. PEH consumed high amounts of dietary fats and alcohol, and low amounts of fruits and vegetables compared with national guidelines and housed individuals. There was moderate to high risk of selection and measurement bias and confounding in included studies.

CONCLUSIONS

A majority of PEH are within unhealthy BMI ranges and are deficient in serum micronutrients and nutritional biomarkers. Studies using large data sets that examine multiple aspects of nutrition are needed to describe the nutritional characteristics of PEH.

REGISTRATION

This systematic review is based on a prespecified protocol registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42021218900).

Medicines prescribing for homeless persons: analysis of prescription data from specialist homelessness general practices

Background

Specialist homelessness practices remain the main primary care access point for many persons experiencing homelessness. Prescribing practices are poorly understood in this population.

Objective

This study aims to investigate prescribing of medicines to homeless persons who present to specialist homelessness primary care practices and compares the data with the general population.

Setting

Analyses of publicly available prescribing and demographics data pertaining to primary care in England.

Methods

Prescribing data from 15 specialist homelessness practices in England were extracted for the period 04/2019-03/2020 and compared with data from (a) general populations, (b) the most deprived populations, and (c) the least deprived populations in England.

Main outcome measure

Prescribing rates, measured as the number of items/1000 population in key disease areas.

Results

Data corresponding to 20,572 homeless persons was included. Marked disparity were observed in regards to prescribing rates of drugs for Central Nervous System disorders. For example, prescribing rates were 83-fold (mean (SD) 1296.7(1447.6) vs. 15.7(9.2) p = 0.033) items), and 12-fold (p = 0.018) higher amongst homeless populations for opioid dependence and psychosis disorders respectively compared to the general populations. Differences with populations in the least deprived populations were even higher. Prescribing medicines for other long-term conditions other than mental health and substance misuse was lower in the homeless than in the general population.

Conclusions

Most of the prescribing activities in the homeless population relate to mental health conditions and substance misuse. It is possible that other long-term conditions that overlap with homelessness are under-diagnosed and under-managed. Wide variations in data across practices needs investigation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11096-022-01399-3.

Understanding Stakeholder Views Regarding the Design of an Intervention Trial to Reduce Anticholinergic Burden: A Qualitative Study

Background: Anticholinergic burden (ACB), is defined as the cumulative effect of anticholinergic medication which are widely prescribed to older adults despite increasing ACB being associated with adverse effects such as: falls, dementia and increased mortality. This research explores the views of health care professionals (HCPs) and patients on a planned trial to reduce ACB by stopping or switching anticholinergic medications. The objectives were to explore the views of key stakeholders (patients, the public, and HCPs) regarding the potential acceptability, design and conduct of an ACB reduction trial. Materials and Methods: We conducted qualitative interviews and focus groups with 25 HCPs involved in prescribing medication with anticholinergic properties and with 22 members of the public and patients who were prescribed with the medication. Topic guides for the interviews and focus groups explored aspects of feasibility including: 1) views of a trial of de-prescribing/medication switching; 2) how to best communicate information about such a trial; 3) views on who would be best placed and preferred to undertake such medication changes, e.g., pharmacists or General Practitioners (GPs)? 4) perceived barriers and facilitators to trial participation and the smooth conduct of such a trial; 5) HCP views on the future implementability of this approach to reducing ACB and 6) patients' willingness to be contacted for participation in a future trial. Qualitative data analysis was underpinned by Normalization Process Theory. Results: The public, patients and HCPs were supportive of an ACB reduction trial. There was consensus among the different groups that key points to consider with such a trial included: 1) ensuring patient engagement throughout to enable concerns/potential pitfalls to be addressed from the beginning; 2) ensuring clear communication to minimise potential misconceptions about the reasons for ACB reduction; and 3) provision of access to a point of contact for patients throughout the life of a trial to address concerns; The HCPs in particular suggested two more key points: 4) minimise the workload implications of any trial; and 5) pharmacists may be best placed to carry out ACB reviews, though overall responsibility for patient medication should remain with GPs. Conclusion: Patients, the public and HCPs are supportive of trials to reduce ACB. Good communication and patient engagement during design and delivery of a trial are essential as well as safety netting and minimising workload.

Comparing the Impact of Primary Care Practice Design in Two Inner City UK Homelessness Services

Background: Specialist homeless primary health care services in the United Kingdom have arisen from the need for bespoke approaches to providing health care for people experiencing homelessness but descriptions of the design characteristics of homeless health services together with associated long-term condition (LTC) prevalence, health care utilization, and prescribing remain unexplored, thereby limiting our understanding of potential impact of service configuration on outcomes. Aim: Description of specialist homeless general practitioner services in Glasgow and Edinburgh, in terms of practice design (staff, skill mix, practice systems of registration, and follow-up); and exploration of the potential impact of differences on LTC prevalence, health care utilization, and prescribing. Method: Patient data were collected from computerized general practitioner records in Glasgow (2015, n = 133) and Edinburgh (2016, n = 150). Homeless health service configuration and anonymized patient data, including demographics, LTCs service utilization, and prescribing were summarized and compared. Results: Marked differences in infrastructure emerged between 2 practices, including the patient registration process, segmentation versus integration of services, recording systems, and the availability of staff expertise. Patient characteristics differed in terms of LTC diagnoses, health care utilization and prescribing. Higher rates of recorded mental health and addiction problems were found in Edinburgh, as well as higher rates of physical LTCs, for example, cardiovascular and respiratory conditions. There were significantly higher rates of consultations with nurses and other staff in Edinburgh, although more patients had consultations with pharmacists in Glasgow. Medication adherence was low in both cohorts, and attendance at referral appointments was particularly poor in Glasgow. Conclusion: Service design and professional skill mix influence recording of LTCs, service uptake, and identification and management of health conditions. Service configuration, professional skill mix, and resources may profoundly affect diagnoses, utilization of health care, and prescribing. Attention to homeless service design is important when providing care to this disadvantaged patient group.

Scope, quality and inclusivity of international clinical guidelines on mental health and substance abuse in relation to dual diagnosis, social and community outcomes: a systematic review

OBJECTIVE

It is estimated that up to 75% of patients with severe mental illness (SMI) also have substance use disorder (SUD). The aim of this systematic review was to explore the scope, quality and inclusivity of international clinical guidelines on mental health and/or substance abuse in relation to diagnosis and treatment of co-existing disorders and considerations for wider social and contextual factors in treatment recommendations.

METHOD

A protocol (PROSPERO CRD42020187094) driven systematic review was conducted. A systematic search was undertaken using six databases including MEDLINE, Cochrane Library, EMBASE, PsychInfo from 2010 till June 2020; and webpages of guideline bodies and professional societies. Guideline quality was assessed based on 'Appraisal of Guidelines for Research & Evaluation II' (AGREE II) tool. Data was extracted using a pre-piloted structured data extraction form and synthesized narratively. Reporting was based on PRISMA guideline.

RESULT

A total of 12,644 records were identified. Of these, 21 guidelines were included in this review. Three of the included guidelines were related to coexisting disorders, 11 related to SMI, and 7 guidelines were related to SUD. Seven (out of 18) single disorder guidelines did not adequately recommend the importance of diagnosis or treatment of concurrent disorders despite their high co-prevalence. The majority of the guidelines (n = 15) lacked recommendations for medicines optimisation in accordance with concurrent disorders (SMI or SUD) such as in the context of drug interactions. Social cause and consequence of dual diagnosis such as homelessness and safeguarding and associated referral pathways were sparsely mentioned.

CONCLUSION

Despite very high co-prevalence, clinical guidelines for SUD or SMI tend to have limited considerations for coexisting disorders in diagnosis, treatment and management. There is a need to improve the scope, quality and inclusivity of guidelines to offer person-centred and integrated care.

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

OBJECTIVES

Most patients receive systemic anticancer therapy (SACT) as day cases and toxicities, if they occur, are likely to appear first in primary care. Pharmaceutical care can be delivered by community pharmacists, but little is known about the epidemiology of SACT toxicities in the community and potential interventions to address these which raise the following questions: what are the typologies of SACT-associated toxicities experienced by community-based patients and what are the associated pharmaceutical care issues (PCIs)? The aim of this study was to identify toxicities and pharmaceutical care issues of patients prescribed SACT for lung cancer and understand the potential for community pharmacists to deliver aspects of cancer care including toxicity management.

METHODS

Retrospective analysis of clinical records of patients prescribed oral and parenteral SACT in 2013-14, to describe patient characteristics; SACT toxicity; PCIs and episodes of unscheduled care.

KEY FINDINGS

Twelve categories of toxicity and 13 categories of PCIs were identified from 50 patients. More PCIs were observed with oral SACT/oral-parenteral combinations than with parenteral regimens. The PCIs which could be managed by community pharmacists were mucositis; skin toxicity; gastrointestinal toxicity; reinforcing patient education and identification/prevention of drug interactions.

CONCLUSIONS

Community pharmacists are ideally placed to provide pharmaceutical care to patients with lung cancer prescribed SACT. Cancer specialists in secondary care can signpost patients to community pharmacists for early management of low-grade SACT toxicity.

Pharmacist led homeless outreach engagement and non-medical independent prescribing (Rx) (PHOENIx) intervention for people experiencing homelessness: a non- randomised feasibility study

BACKGROUND

Homelessness and associated mortality and multimorbidity rates are increasing. Systematic reviews have demonstrated a lack of complex interventions that decrease unscheduled emergency health services utilisation or increase scheduled care. Better evidence is needed to inform policy responses. We examined the feasibility of a complex intervention (PHOENIx: Pharmacist led Homeless Outreach Engagement Nonmedical Independent prescribing (Rx)) to inform a subsequent pilot randomised controlled trial (RCT).

METHODS

Non-randomised trial with Usual Care (UC) comparator group set in Greater Glasgow and Clyde Health Board, Scotland. Participants were adult inpatients experiencing homelessness in a city centre Glasgow hospital, referred to the PHOENIx team at the point of hospital discharge, from 19th March 2018 until 6th April 2019. The follow up period for each patient started on the day the patient was first seen (Intervention group) or first referred (UC), until 24th August 2019, the censor date for all patients. All patients were offered and agreed to receive serial consultations with the PHOENIx team (NHS Pharmacist prescriber working with Simon Community Scotland (third sector homeless charity worker)). Patients who could not be reached by the PHOENIx team were allocated to the UC group. The PHOENIx intervention included assessment of physical/mental health, addictions, housing, benefits and social activities followed by pharmacist prescribing with referral to other health service specialities as necessary. All participants received primary (including specialist homelessness health service based general practitioner care, mental health and addictions services) and secondary care. Main outcome measures were rates of: recruitment; retention; uptake of the intervention; and completeness of collected data, from recruitment to censor date.

RESULTS

Twenty four patients were offered and agreed to participate; 12 were reached and received the intervention as planned with a median 7.5 consultations (IQR3.0-14.2) per patient. The pharmacist prescribed a median of 2 new (IQR0.3-3.8) and 2 repeat (1.3-7.0) prescriptions per patient; 10(83%) received support for benefits, housing or advocacy. Twelve patients were not subsequently contactable after leaving hospital, despite agreeing to participate, and were assigned to UC. Two patients in the UC group died of drug/alcohol overdose during follow up; no patients in the Intervention group died. All 24 patients were retained in the intervention or UC group until death or censor date and all patient records were accessible at follow up: 11(92%) visited ED in both groups, with 11(92%) hospitalisations in intervention group, 9(75%) UC. Eight (67%) intervention group patients and 3(25%) UC patients attended scheduled out patient appointments.

CONCLUSIONS

Feasibility testing of the PHOENIx intervention suggests merit in a subsequent pilot RCT.

Assessing Risks of Polypharmacy Involving Medications With Anticholinergic Properties

PURPOSE

Anticholinergic burden (ACB), the cumulative effect of anticholinergic medications, is associated with adverse outcomes in older people but is less studied in middle-aged populations. Numerous scales exist to quantify ACB. The aims of this study were to quantify ACB in a large cohort using the 10 most common anticholinergic scales, to assess the association of each scale with adverse outcomes, and to assess overlap in populations identified by each scale.

METHODS

We performed a longitudinal analysis of the UK Biobank community cohort (502,538 participants, baseline age: 37-73 years, median years of follow-up: 6.2). The ACB was calculated at baseline using 10 scales. Baseline data were linked to national mortality register records and hospital episode statistics. The primary outcome was a composite of all-cause mortality and major adverse cardiovascular event (MACE). Secondary outcomes were all-cause mortality, MACE, hospital admission for fall/fracture, and hospital admission with dementia/delirium. Cox proportional hazards models (hazard ratio [HR], 95% CI) quantified associations between ACB scales and outcomes adjusted for age, sex, socioeconomic status, body mass index, smoking status, alcohol use, physical activity, and morbidity count.

RESULTS

Anticholinergic medication use varied from 8% to 17.6% depending on the scale used. For the primary outcome, ACB was significantly associated with all-cause mortality/MACE for each scale. The Anticholinergic Drug Scale was most strongly associated with mortality/MACE (HR = 1.12; 95% CI, 1.11-1.14 per 1-point increase in score). The ACB was significantly associated with all secondary outcomes. The Anticholinergic Effect on Cognition scale was most strongly associated with dementia/delirium (HR = 1.45; 95% CI, 1.3-1.61 per 1-point increase).

CONCLUSIONS

The ACB was associated with adverse outcomes in a middle- to older-aged population. Populations identified and effect size differed between scales. Scale choice influenced the population identified as potentially requiring reduction in ACB in clinical practice or intervention trials.

A descriptive study of a novel pharmacist led health outreach service for those experiencing homelessness

OBJECTIVES

To illustrate and review this new service and to describe the demographics of the patient group and the typology of interventions made by the pharmacist prescribers.

METHODS

Pharmacists provided pop-up, drop-in (no appointment needed) health clinics to various homeless support venues in Glasgow City Centre. Data from pharmacists' interventions (n = 52) and patient demographics were gathered from clinical records. Data were then extracted, transcribed and analysed.

KEY FINDINGS

The demographics of the homeless patient group consisted mainly of white middle-aged males (mean age 39.8 years), of Scottish ethnicity and living in homeless hostels. Medications were prescribed by pharmacists in 62% of all patients. New medications were initiated in 69% of these patients; repeat/re-issues of lapsed medications were issued in 66% of these patients; changes were made to existing medication in 16%. The most commonly prescribed items were as follows: wound dressings; antihypertensives; antidiabetics; analgesics; inhalers; antidepressants; and nutritional supplements. Pharmacists diagnosed a new clinical issue in 69% of patients, most commonly with infections (skin or respiratory) in 36% of patients. Sixty-two per cent of patients had their presenting symptoms managed by the pharmacist alone. Patient engagement was good with 85% subsequently attending either a follow-up with the pharmacist or onward referral (to specialist services, secondary care, general practitioner appointment etc).

CONCLUSIONS

Assertive outreach by pharmacist independent prescribers for people who are homeless is feasible and leads to increased access to medicines for acute and chronic health problems. Further work is needed to evaluate the impact of this new service on key clinical outcomes.

Patient-reported barriers to medication adherence in heart failure in Scotland

OBJECTIVES

Medication adherence is the end result of a complex set of interwoven factors. Non-adherence with medication in heart failure patients is associated with excess mortality and morbidity. Studies describing interventions to improve adherence in heart failure are limited by a lack of robust methods and inconsistent outcomes. The aim of this evaluation was to explore the barriers to medication adherence in Scottish heart failure patients in order to inform the development of complex interventions.

METHODS

Qualitative patient interviews. Participants were aged ≥18 years with current or previous signs or symptoms of clinical heart failure, reduced left ventricular ejection fraction ≤45% and confirmed adherence of <80% in tablet counts of heart failure therapy. Thematic analysis was employed.

KEY FINDINGS

Eleven patients were recruited. The median age was 79 years old, and participants were typically from socially deprived communities. Participants were prescribed a mean 9.9 different medications per day. Seven distinct themes emerged around barriers to medication adherence: co-morbidity; treatment burden; health literacy; trust in NHS; socioeconomic factors; autonomy and health expectations.

CONCLUSIONS

The factors affecting medication adherence in heart failure are multi-factorial and are unlikely to be improved by one single-faceted intervention. Future interventions need to treat patients holistically, build their trust as partners, simplify complex treatment regimens where possible and involve educational and social elements. The skill set and opportunities afforded to pharmacists may be well placed to deliver many of these aspects but this would need tested in the context of the development of complex interventions.

A non-randomised controlled pilot study of clinical pharmacist collaborative intervention for community dwelling patients with COPD

UK, home-based patients with COPD receive specialist care from respiratory physicians, nurses, and general practitioners (GPs), but increasing complexity of therapeutic options and a GP/Nurse workforce crisis suggests merit in testing the role of home visits by a clinical pharmacist. We conducted a non-randomised intervention study with a contemporaneous comparator group, in Glasgow (Scotland). A clinical pharmacist (working closely with a consultant respiratory physician) visited patients with COPD living at home, assessing respiratory and other co-morbid conditions, and medicines then, with patient approval, agreed treatment modifications with a consultant physician. Comparator group-patients were drawn from another hospital out-patient clinic. Main outcomes were exacerbations during 4-months of follow-up and respiratory hospitalisations (number and duration) after 1 year. In the intervention group, 86 patients received a median of three home visits; 87 received usual care (UC). At baseline, patients in the intervention group were similar to those in UC in terms of respiratory hospitalisations although slightly younger, more likely to receive specific maintenance antibiotics/Prednisolone and to have had exacerbations. Sixty-two (72.1%) of the intervention group received dose changes; 45 (52.3%) had medicines stopped/started and 21 (24.4%) received an expedited review at the specialist respiratory consultant clinic; 46 (53.5%) were referred to other healthcare services. Over one-third were referred for bone scans and 11% received additional investigations. At follow-up, 54 (63.5%) of intervention group participants had an exacerbation compared with 75 (86.2%) in the UC group (p = 0.001); fewer had respiratory hospitalisations (39 (45.3%) vs. 66 (76.7%); p < 0.001). Hospitalisations were shorter in the intervention group. Pharmacist-consultant care for community dwelling patients with COPD, changed clinical management and improved outcomes. A randomised controlled trial would establish causality.

Clinical pharmacists, working in collaboration with respiratory specialists, can help people who live at home with chronic obstructive pulmonary disease (COPD) better manage their medications and symptoms. In a non-randomised pilot study, Richard Lowrie from the NHS Greater Glasgow and Clyde,
UK, and colleagues found that patients with COPD who receive standard at-home care—which includes visits to GP surgeries and hospital-based respiratory out-patient clinics, and visits from respiratory specialist nurses—were more likely to experience exacerbations and need lengthy hospital stays than those who additionally received home visits from a clinical pharmacist. The pharmacist, in consultation with the patient’s respiratory physician, often proposed medication changes and suggested additional testing or referrals that presumably explain the improved health outcomes. The authors conclude that a large, randomised trial is warranted to further evaluate the merits of this collaborative intervention for community dwelling patients with COPD.

A systematic review of interventions by healthcare professionals to improve management of non-communicable diseases and communicable diseases requiring long-term care in adults who are homeless

OBJECTIVE

Identify, describe and appraise trials of interventions delivered by healthcare professionals to manage non-communicable diseases (NCDs) and communicable diseases that require long-term care or treatment (LT-CDs), excluding mental health and substance use disorders, in homeless adults.

DESIGN

Systematic review of randomised controlled trials (RCTs), non-RCTs and controlled before-after studies. Interventions characterised using Effective Practice and Organisation of Care (EPOC) taxonomy. Quality assessed using EPOC risk of bias criteria.

DATA SOURCES

Database searches (MEDLINE, Embase, PsycINFO, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Applied Social Sciences Index and Abstracts (ASSIA) and Cochrane Central Register of Controlled Trials), hand searching reference lists, citation searches, grey literature and contact with study authors.

SETTING

Community.

PARTICIPANTS

Adults (≥18 years) fulfilling European Typology of Homelessness criteria.

INTERVENTION

Delivered by healthcare professionals managing NCD and LT-CDs.

OUTCOMES

Primary outcome: unscheduled healthcare utilisation.

SECONDARY OUTCOMES

mortality, biological markers of disease control, adherence to treatment, engagement in care, patient satisfaction, knowledge, self-efficacy, quality of life and cost-effectiveness.

RESULTS

11 studies were included (8 RCTs, 2 quasi-experimental and 1 feasibility) involving 9-520 participants (67%-94% male, median age 37-49 years). Ten from USA and one from UK. Studies included various NCDs (n=3); or focused on latent tuberculosis (n=4); HIV (n=2); hepatitis C (n=1) or type 2 diabetes (n=1). All interventions were complex with multiple components. Four described theories underpinning intervention. Three assessed unscheduled healthcare utilisation: none showed consistent reduction in hospitalisation or emergency department attendance. Six assessed adherence to specific treatments, of which four showed improved adherence to latent tuberculosis therapy. Three concerned education case management, all of which improved disease-specific knowledge. No improvements in biological markers of disease (two studies) and none assessed mortality.

CONCLUSIONS

Evidence for management of NCD and LT-CDs in homeless adults is sparse. Educational case-management interventions may improve knowledge and medication adherence. Large trials of theory-based interventions are needed, assessing healthcare utilisation and outcomes as well as assessment of biological outcomes and cost-effectiveness.

Interventions by healthcare professionals to improve management of physical long-term conditions in adults who are homeless: a systematic review protocol

INTRODUCTION

People experiencing homelessness are at increased risk of, and have poorer outcomes from, a range of physical long-term conditions (LTCs). It is increasingly recognised that interventions targeting people who are homeless should be tailored to the specific needs of this population. This systematic review aims to identify, describe and appraise trials of interventions that aim to manage physical LTCs in homeless adults and are delivered by healthcare professionals.

METHODS AND ANALYSIS

Seven electronic databases (Medline, EMBASE, Cochrane Central Register of Controlled Trials, Assia, Scopus, PsycINFO and CINAHL) will be searched from 1960 (or inception) to October 2016 and supplemented by forward citation searching, handsearching of reference lists and searching grey literature. Two reviewers will independently review titles, abstract and full-texts using DistillerSR software. Inclusion criteria include (1) homeless adults with any physical LTC, (2) interventions delivered by a healthcare professional (any professional trained to provide any form of healthcare, but excluding social workers and professionals without health-related training), (3) comparison with usual care or an alternative intervention, (4) report outcomes such as healthcare usage, physical and psychological health or well-being or cost-effectiveness, (5) randomised controlled trials, non-randomised controlled trials, controlled before-after studies. Quality will be assessed using the Cochrane EPOC Risk of Bias Tool. A meta-analysis will be performed if sufficient data are identified; however, we anticipate a narrative synthesis will be performed.

ETHICS AND DISSEMINATION

This review will synthesise existing evidence for interventions delivered by healthcare professionals to manage physical LTCs in adults who are homeless. The findings will inform the development of future interventions and research aiming to improve the management of LTCs for people experiencing homelessness. Ethical approval will not be required for this systematic review as it does not contain individual patient data. We will disseminate the results of this systematic review via conference presentations, healthcare professional networks, social media and peer-reviewed publication.

TRIAL REGISTRATION NUMBER

PROSPERO registration number: CRD42016046183.

Incentivised chronic disease management and the inverse equity hypothesis: findings from a longitudinal analysis of Scottish primary care practice-level data

BACKGROUND

The inverse equity hypothesis asserts that new health policies initially widen inequality, then attenuate inequalities over time. Since 2004, the UK's pay-for-performance scheme for chronic disease management (CDM) in primary care general practices (the Quality and Outcomes Framework) has permitted practices to except (exclude) patients from attending annual CDM reviews, without financial penalty. Informed dissent (ID) is one component of exception rates, applied to patients who have not attended due to refusal or non-response to invitations. 'Population achievement' describes the proportion receiving care, in relation to those eligible to receive it, including excepted patients. Examination of exception reporting (including ID) and population achievement enables the equity impact of the UK pay-for-performance contract to be assessed. We conducted a longitudinal analysis of practice-level rates and of predictors of ID, overall exceptions and population achievement for CDM to examine whether the inverse equity hypothesis holds true.

METHODS

We carried out a retrospective, longitudinal study using routine primary care data, analysed by multilevel logistic regression. Data were extracted from 793 practices (83% of Scottish general practices) serving 4.4 million patients across Scotland from 2010/2011 to 2012/2013, for 29 CDM indicators covering 11 incentivised diseases. This provided 68,991 observations, representing a total of 15 million opportunities for exception reporting.

RESULTS

Across all observations, the median overall exception reporting rate was 7.0% (7.04% in 2010-2011; 7.02% in 2011-2012 and 6.92% in 2012-2013). The median non-attendance rate due to ID was 0.9% (0.76% in 2010-2011; 0.88% in 2011-2012 and 0.96% in 2012-2013). Median population achievement was 83.5% (83.51% in 2010-2011; 83.41% in 2011-2012 and 83.63% in 2012-2013). The odds of ID reporting in 2012/2013 were 16.0% greater than in 2010/2011 (p < 0.001). Practices in Scotland's most deprived communities were twice as likely to report non-attendance due to ID (odds ratio 2.10, 95% confidence interval 1.83-2.40, p < 0.001) compared with those in the least deprived; rural practices reported lower levels of non-attendance due to ID. These predictors were also independently associated with overall exceptions. Rates of population achievement did not change over time, with higher levels (higher remuneration) associated with increased rates of overall and ID exception and more affluent practices.

CONCLUSIONS

Non-attendance for CDM due to ID has risen over time, and higher rates are seen in patients from practices located in disadvantaged areas. This suggests that CDM incentivisation does not conform to the inverse equity hypothesis, because inequalities are widening over time with lower uptake of anticipatory care health checks and CDM reviews noted among those most in need. Incentivised CDM needs to include incentives for engaging with the 'hard to reach' if inequalities in healthcare delivery are to be tackled.

Research is 'a step into the unknown': an exploration of pharmacists' perceptions of factors impacting on research participation in the NHS

OBJECTIVE

This study explored National Health Service (NHS) pharmacists' perceptions and experiences of pharmacist-led research in the workplace.

DESIGN

Semistructured, face-to-face discussions continued until distinct clusters of opinion characteristics formed. Verbatim transcripts of audio-recordings were subjected to framework analysis.

SETTING

Interviews were carried out with 54 pharmacists with diverse backgrounds and roles from general practices and secondary care in the UK's largest health authority.

RESULTS

The purpose and potential of health services research (HSR) was understood and acknowledged to be worthwhile by participants, but a combination of individual and system-related themes tended to make participation difficult, except when this was part of formal postgraduate education leading to a qualification. Lack of prioritisation was routinely cited as the greatest barrier, with motivation, confidence and competence as additional impediments. System-related themes included lack of practical support and pharmacy professional issues. A minority of highly motivated individuals managed to embed research participation into routine activity.

CONCLUSIONS

Most pharmacists realised the desirability and necessity of research to underpin pharmacy service expansion, but a combination of individual and professional level changes is needed to increase activity. Our findings provide a starting point for better understanding the mindset of hospital-based and general practice-based pharmacists towards research, as well as their perceived barriers and supports.

Physical health indicators in major mental illness: data from the Quality and Outcome Framework in the UK

BACKGROUND

In the UK, the Quality and Outcome Framework (QOF) has specific targets for general practictioners to record body-mass index (BMI) and blood pressure (BP) in major mental illness, diabetes, and chronic kidney disease. Although incentives are given for aspects of major mental illness (schizophrenia, bipolar disorder, and related psychoses), barriers to care can occur. Our aim was to compare recording of specific targets for BP and BMI in individuals with major mental illness relative to diabetes and chronic kidney disease across the UK.

METHODS

Using 2012 and 2013 QOF data from 9731 general practices across all four countries in the UK, we calculated median payment, population achievement, and exception rates for BP indicators in major mental illness and chronic kidney disease and BMI indicators in major mental illness and diabetes. Differences in unweighted rates between practices in the same UK country were tested with a sign test. Differences in population achievement rate between practices in different countries were compared with those in England by use of a quantile regression analysis.

FINDINGS

UK payment and population achievement rates for BMI recording in major mental illness were significantly lower than were those in diabetes (payment 92·7% vs 95·5% and population achievement 84·0% vs 92·5%, p<0·0001) and exception rates were higher (8·1% vs 2·0%, p<0·0001). For BP recording, UK payment and population achievement rates were significantly lower for major mental illness than for chronic kidney disease (94·1% vs 97·8% and 87·0% vs 97·1%, p<0·0001), whereas exception rate was higher (6·5% vs 0·0%, p<0·0001). This difference was observed for all UK countries. Median population achievement rates for BMI and BP recording in major mental illness were significantly lower in Scotland than in England (for BMI -1·5%, 99% CI -2·7 to -0·3, and for BP -1·8%, -2·7 to -0·9; p<0·0001 for both). There were no cross-jurisdiction differences for chronic kidney disease and diabetes.

INTERPRETATION

We found lower payment rates, higher exception rates, and lower population achievement rates for BMI and BP recording in major mental illness than in diabetes and chronic kidney disease throughout the UK. We also found variation in these rates between countries. This finding is probably multifactorial, reflecting a combination of patient, clinician, and wider organisational factors; however, it might also suggest inequality in access to certain aspects of health care for people with major mental illness.

FUNDING

None.

A cluster randomised controlled trial of a pharmacist-led collaborative intervention to improve statin prescribing and attainment of cholesterol targets in primary care

Background

Small trials with short term follow up suggest pharmacists’ interventions targeted at healthcare professionals can improve prescribing. In comparison with clinical guidance, contemporary statin prescribing is sub-optimal and achievement of cholesterol targets falls short of accepted standards, for patients with atherosclerotic vascular disease who are at highest absolute risk and who stand to obtain greatest benefit. We hypothesised that a pharmacist-led complex intervention delivered to doctors and nurses in primary care, would improve statin prescribing and achievement of cholesterol targets for incident and prevalent patients with vascular disease, beyond one year.

Methods

We allocated general practices to a 12-month Statin Outreach Support (SOS) intervention or usual care. SOS was delivered by one of 11 pharmacists who had received additional training. SOS comprised academic detailing and practical support to identify patients with vascular disease who were not prescribed a statin at optimal dose or did not have cholesterol at target, followed by individualised recommendations for changes to management. The primary outcome was the proportion of patients achieving cholesterol targets. Secondary outcomes were: the proportion of patients prescribed simvastatin 40 mg with target cholesterol achieved; cholesterol levels; prescribing of simvastatin 40 mg; prescribing of any statin and the proportion of patients with cholesterol tested. Outcomes were assessed after an average of 1.7 years (range 1.4–2.2 years), and practice level simvastatin 40 mg prescribing was assessed after 10 years.

Findings

We randomised 31 practices (72 General Practitioners (GPs), 40 nurses). Prior to randomisation a subset of eligible patients were identified to characterise practices; 40% had cholesterol levels below the target threshold. Improvements in data collection procedures allowed identification of all eligible patients (n = 7586) at follow up. Patients in practices allocated to SOS were significantly more likely to have cholesterol at target (69.5% vs 63.5%; OR 1.11, CI 1.00–1.23; p = 0.043) as a result of improved simvastatin prescribing. Subgroup analysis showed the primary outcome was achieved by prevalent but not incident patients. Statistically significant improvements occurred in all secondary outcomes for prevalent patients and all but one secondary outcome (the proportion of patients with cholesterol tested) for incident patients. SOS practices prescribed more simvastatin 40 mg than usual care practices, up to 10 years later.

Interpretation

Through a combination of educational and organisational support, a general practice based pharmacist led collaborative intervention can improve statin prescribing and achievement of cholesterol targets in a high-risk primary care based population.

Trial Registration

International Standard Randomised Controlled Trials Register ISRCTN61233866

Experiences of a community pharmacy service to support adherence and self-management in chronic heart failure

BACKGROUND

Heart failure (HF) is common, disabling and deadly. Patients with HF often have poor self-care and medicines non-adherence, which contributes to poor outcomes. Community pharmacy based cognitive services have the potential to help, but we do not know how patients view community-pharmacist-led services for patients with HF.

OBJECTIVE

We aimed to explore and portray in detail, the perspectives of patients receiving, and pharmacists delivering an enhanced, pay for performance community pharmacy HF service.

SETTING

Community pharmacies and community-based patients in Greater Glasgow and Clyde, Scotland.

METHODS

Focus groups with pharmacists and semi-structured interviews with individual patients by telephone. Cross sectional thematic analysis of qualitative data used Normalization Process Theory to understand and describe patient's reports.

MAIN OUTCOME MEASURE

Experiences of receiving and delivering an enhanced HF service.

RESULTS

Pharmacists voiced their confidence in delivering the service and highlighted valued aspects including the structured consultation and repeated contacts with patients enabling the opportunity to improve self care and medicines adherence. Discussing co-morbidities other than HF was difficult and persuading patients to modify behaviour was challenging. Patients were comfortable discussing symptoms and medicines with pharmacists; they identified pharmacists as fulfilling roles that were needed but not currently addressed. Patients reported the service helped them to enact HF medicines and HF self care management strategies.

CONCLUSION

Both patients receiving and pharmacists delivering a cognitive HF service felt that it addressed a shortfall in current care. There may be a clearly defined role for pharmacists in supporting patients to address the burden of understanding and managing their condition and treatment, leading to better self management and medicines adherence. This study may inform the development of strategies or policies to improve the process of care for patients with HF and has implications for the development of other extended role services.

'Help for Hay Fever', a goal-focused intervention for people with intermittent allergic rhinitis, delivered in Scottish community pharmacies: study protocol for a pilot cluster randomized controlled trial

BACKGROUND

Despite the availability of evidence-based guidelines for managing allergic rhinitis in primary care, management of the condition in the United Kingdom (UK) remains sub-optimal. Its high prevalence and negative effects on quality of life, school performance, productivity and co-morbid respiratory conditions (in particular, asthma), and high health and societal costs, make this a priority for developing novel models of care. Recent Australian research demonstrated the potential of a community pharmacy-based 'goal-focused' intervention to help people with intermittent allergic rhinitis to self-manage their condition better, reduce symptom severity and improve quality of life. In this pilot study we will assess the transferability of the goal-focused intervention to a UK context, the suitability of the intervention materials, procedures and outcome measures and collect data to inform a future definitive UK randomized controlled trial (RCT).

METHODS/DESIGN

A pilot cluster RCT with associated preliminary economic analysis and embedded qualitative evaluation. The pilot trial will take place in two Scottish Health Board areas: Grampian and Greater Glasgow & Clyde. Twelve community pharmacies will be randomly assigned to intervention or usual care group. Each will recruit 12 customers seeking advice or treatment for intermittent allergic rhinitis. Pharmacy staff in intervention pharmacies will support recruited customers in developing strategies for setting and achieving goals that aim to avoid/minimize triggers for, and eliminate/minimize symptoms of allergic rhinitis. Customers recruited in non-intervention pharmacies will receive usual care. The co-primary outcome measures, selected to inform a sample size calculation for a future RCT, are: community pharmacy and customer recruitment and completion rates; and effect size of change in the validated mini-Rhinoconjunctivitis Quality of Life Questionnaire between baseline, one-week and six-weeks post-intervention. Secondary outcome measures relate to changes in symptom severity, productivity, medication adherence and self-efficacy. Quantitative data about accrual, retention and economic measures, and qualitative data about participants' experiences during the trial will be collected to inform the future RCT.

DISCUSSION

This work will lay the foundations for a definitive RCT of a community pharmacy-based 'goal-focused' self-management intervention for people with intermittent allergic rhinitis. Results of the pilot trial are expected to be available in April 2013.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN43606442.

Pharmacist-led medication review clinics in general practice: the views of Greater Glasgow GPs

Objectives

To ascertain general practitioners' views of a pharmacist-led medication review (PLMR) service. In particular, to quantify the percentage of GPs who perceived PLMR to be a useful service to their practices; to explore key service benefits, problems and areas for future improvement; and to quantify the percentage of GPs who believed service benefits outweighed problems.

Method

Semi-structured interviews with a purposive sample of six GPs informed the development of a self-completion postal questionnaire. The questionnaire was sent to all 258 GPs in the 82 practices where PLMR clinics were held. GP views on aspects of the PLMR process were elicited using a Likert scale. Closed questions sought views on overall service value. Free-text responses were sought on benefits, problems and areas for future improvement.

Key findings

The response rate was 84% for GPs (93% of practices were represented). Ninety-five per cent of respondents considered PLMR to be a useful service. Key perceived benefits (improved prescribing practice, raised standards of patient care and satisfaction, and increased GP knowledge and confidence) outweighed problems (space and time constraints, limited GP-pharmacist contact, occasional patient dissatisfaction). Only a minority of GPs felt that the written pharmacy referrals relating to specific patients were inappropriate. Views were divided as to whether PLMR increased or decreased practice workload. Suggestions for future improvements included increased GP-pharmacist communication and extended pharmacist roles.

Conclusion

The Glasgow model of PLMR deployed across a large Primary Care Trust by a team of pharmacists was viewed by those GPs who had received input as a useful service. The majority of GPs exposed to the service believed benefits outweighed problems.

A laboratory based intervention to improve appropriateness of lipid tests and audit cholesterol lowering in primary care

PROBLEM

A need exists to reduce inequalities in lipid testing, to provide relevant, individual, patient based interpretation for users, and to audit lipid lowering in primary care.

DESIGN

Model to compare laboratory activity between different general practices; construction of computer based strategies to define the lipid tests to be done and to interpret results for primary and secondary coronary prevention patients; introduction of the strategies into routine use; monitoring of any change after the intervention; and investigation of the potential of the strategies to produce audit data for primary care groups.

BACKGROUND AND SETTING

Hospital clinical laboratory serving 22 general practices covering 150 000 patients in Bishop Auckland area County Durham. Key measurements for improvement: Reduction in differences in testing for the different serum lipids in coronary prevention. Production of usable audit data for the primary care groups involved.

STRATEGIES FOR CHANGE

Four different categories of coronary prevention patient, with, for each category, the defined lipid tests to be done and advice to be given (based on the results), using the computer based strategies.

EFFECTS OF CHANGE

Standardised test activity and the qualitative profile of the tests performed changed significantly. The strategies were readily adopted (median use 78%) within six months of introduction.

LESSONS LEARNT

Computer based strategies can correct qualitative and quantitative differences in test requesting, provide interpretative guidance in accordance with national guidelines, and offer a cost effective model to monitor results of cholesterol lowering in general practice.