The Effectiveness and Cost-Effectiveness of Community Diagnostic Centres: A Rapid Review

Objectives: To examine the effectiveness of community diagnostic centres as a potential solution to increasing capacity and reducing pressure on secondary care in the UK. Methods: A comprehensive search for relevant primary studies was conducted in a range of electronic sources in August 2022. Screening and critical appraisal were undertaken by two independent reviewers. There were no geographical restrictions or limits to year of publication. A narrative synthesis approach was used to analyse data and present findings. Results: Twenty primary studies evaluating twelve individual diagnostic centres were included. Most studies were specific to cancer diagnosis and evaluated diagnostic centres located within hospitals. The evidence of effectiveness appeared mixed. There is evidence to suggest diagnostic centres can reduce various waiting times and reduce pressure on secondary care. However, cost-effectiveness may depend on whether the diagnostic centre is running at full capacity. Most included studies used weak methodologies that may be inadequate to infer effectiveness. Conclusion: Further well-designed, quality research is needed to better understand the effectiveness and cost-effectiveness of community diagnostic centres.

Factors affecting the patient journey and patient care when receiving an unlicensed medicine: A systematic review

BACKGROUND

Unlicensed medicines are used across the UK to treat an individual's clinical needs when there are no appropriate licensed alternatives. Patients, carers and parents have reported facing challenges with unlicensed medicines at the points of transfer of care between settings, a key time when medication errors may occur. There is little known about the patient journey as a whole, or the factors affecting patient care when receiving an unlicensed medicine.

OBJECTIVE

A systematic review of UK literature to better understand factors that affect the entire patient journey from the decision to initiate treatment with an unlicensed medicine to the point at which treatment is supplied through a community pharmacy or ends.

METHODS

Scopus, OVID EMCARE, EMBASE, OVID Medline ALL, CINAHL, Web of Science and Joanna Briggs Institute were searched from 1968 (introduction of the Medicines Act) until November 2020, using the PRISMA guidelines. Narrative synthesis of UK studies was employed to analyse descriptive and qualitative data on any reported findings that would impact the patient journey or care related to the use of unlicensed medicines, and any described barriers or enablers.

RESULTS

Forty-five studies met criteria for final inclusion, with high levels of heterogeneity in terms of designs and methods. Specific challenges that were seen to impact the continuity of care across care settings, patient safety and provision of patient-centred care included diversity of clinical needs and impact of patient population age; healthcare professional awareness and acceptability of the use of unlicensed medicines; the hierarchical structure of the NHS; inconsistent doses and formulations with varying bioequivalence; patient/parent/carer/public awareness of unlicensed medicines use and perceived acceptability.

CONCLUSIONS

This review identified a clear need for consistent information to be provided to healthcare professional and patients alike to support the safe and effective use of unlicensed medicines across care settings.

Unlicensed "Special" Medicines: Understanding the Community Pharmacist Perspective

Objective

Community pharmacy staff are responsible for obtaining and supplying unlicensed “special” medicines to patients in primary care. Less well-defined parameters for safe and effective use of unlicensed compared to licensed medicines, along with issues around maintaining consistency between care settings or among manufacturers, have been associated with increased risks. This study aimed to explore the views and experiences of community pharmacy staff on accessing and supplying unlicensed “special” medicines to patients in Wales and the perceived impact of challenges faced on patient care.

Methods

A qualitative, phenomenological approach was employed, involving semi-structured interviews with pharmacists and pharmacy technicians working at one small chain of community pharmacies in Wales. The interview schedule focused on the personal experiences and perceptions of the participants on the processes involved in accessing and supplying unlicensed “special” medicines from a community pharmacy. Interviews were audio-recorded and transcribed verbatim.

Results

A total of six participants completed the interview. Three main themes were constructed from inductive thematic analysis of the transcribed interviews: requirement for additional patient responsibilities; influences on the confidence felt by pharmacy staff when accessing and supplying unlicensed “special” medicines; and continuity of supply.

Conclusion

This study gives a preliminary insight into the views and experiences of community pharmacy staff in Wales when accessing and supplying unlicensed “special” medicines. Further research is required to see if these views and experiences are representative of community pharmacy staff across the country.

Session 3: Boosting primary and recurrent rectal cancer: how far can we push the radiotherapy envelope?

Neoadjuvant pelvic radiotherapy is widely used for patients with advanced rectal cancer. The trade-off between dose and response is well-established, yet little consensus remains on the precise methods of delivery and doses given in different scenarios. Professor Vuong reviews the evidence base and trial evidence on the escalation of radiotherapy dose and the methods of achieving this.

Session 3: Intra-operative radiotherapy - creating new surgical boundaries

In patients with advanced and recurrent colorectal cancer, surgical resection with clear margins is the greatest challenge and is limited by known anatomical constraints. Preoperative or intra-operative assessment of the limits of surgical dissection may help to explore the possibility of improving resectability through either targeted external beam radiotherapy or intra-operative radiotherapy. Professor Chang reviews the evidence base and potential advantages and disadvantages of this approach, whilst the expert panel agree a consensus on the evidence for assessment and therapy of such patients.

Session 2: Synchronous metastatic disease-liver first or primary first? The oncologist decides

There have been no randomized trial data to guide teams with regard to the order of surgery in patients with synchronous metastatic disease. On the one hand patients with borderline resectable liver metastases may lose the opportunity to undergo curative liver resection if the primary is resected first. For other patients, a symptomatic primary cancer may not be amenable to a delay. In the absence of clear evidence-based outcomes, Professor Van Cutsem shares the recent expert consensus opinions on the current recommendations and an overview of the limited evidence base available.

Session 3: Beyond the boundaries of Total Mesorectal Excision - where surgeons fear to tread

Approximately 10-15% of patients present with an advanced rectal cancer that extends beyond the conventional total mesorectal excision (TME) planes. In such cases extending the surgery to ensure resection with clear margins (R0 resection) is essential in order to achieve long-term cure. Professor Holm describes the techniques of beyond-TME exenterative surgery, the methods of patient selection and outcomes.

Session 1: The evolution and development of the multidisciplinary team approach: USA, European and UK experiences - what can we do better?

The process of determining the best treatments that should be offered to patients with newly diagnosed colon and rectal cancer remains highly variable around the world. The aim of this expert review was to agree the key elements of good quality preoperative treatment decision making.

Session 2: Extramural vascular invasion and extranodal deposits: should they be treated the same?

Professor Nagtegaal has already highlighted that lymph nodes are probably not responsible for the development of liver metastases. If they are not, then is there another mechanism? Professor Haboubi addresses the question of extranodal deposits - their frequency and their importance in the development of metastatic disease. The experts review the evidence and discuss whether this information will alter treatment decisions and staging systems in the future.

Session 1: Colon cancer - 10 years behind the rectum

The improvements in surgical technique brought about by the widespread adoption of total mesorectal excision plane dissection in rectal cancer has substantially improved survival and recurrence rates from this disease. For the first time in 50 years, the outcomes in rectal cancer have overtaken those of colon cancer. Professor Madoff's overview lecture and the experts' round table discussion address whether applying the surgical principles already achieved in rectal cancer can meet with similar success in colon cancer, how this can be achieved and the challenges we face.

Intra-operative antibiotic bead maker--point of technique

Chronic osteomyelitis is a disease of soft tissue and bone and it is common in the developing countries. The management of this debilitating disease requires the delivery of the appropriate chemotherapeutic agent at the site of the infection after adequate debridement. The search for a suitable carrier for these chemotherapeutic agents is the advent of the 'septopal' or gentamycin-polymethylmethacrylate (gentamycin-PMMA) beads. Septopal beads are expensive and are not affordable by patients in the developing countries. Moreover, most of the micro-organisms (mixed flora) responsible for chronic osteomyelitis in our hospitals are sensitive to ceftriaxone and only in a few cases were gentamycin-sensitive micro-organisms isolated. Therefore, it was imperative that patient-specific and antibiotic-specific PMMA beads would be the way forward and this is the reasoning behind the production of the intra-operative antibiotic bead maker (IABM) and the point of technique is hereby presented.