Evaluating team-based learning in a foundation training pathway for trainee pharmacists

BACKGROUND

A new programme incorporating online study days delivered using team-based learning (TBL) for hospital-based trainee pharmacists (TPs) in the North of England was created. To our knowledge, TBL has not previously been used in educational programmes for TPs designed to supplement their workplace learning. The project aimed to investigate the experiences of TPs learning using online TBL by exploring their perceptions on their engagement, learning, and satisfaction with TBL.

METHOD

Data were collected using online anonymous surveys at the end of four online TBL study days. A bespoke survey consisted of 5-point or 4-point Likert scale and two free text questions. TBL Student Assessment Instrument (SAI), a validated survey, was used to assess TPs' acceptance of TBL. Survey data was summarized descriptively, and free text comments analysed using thematic analysis.

RESULTS

TPs developed accountability to their team, remained engaged with TBL delivery online and stated a preference for and satisfaction with this method. TPs valued opportunities to apply their knowledge in challenging scenarios and learn from discussions with their peers, the larger group, and facilitators. TBL was also perceived to be an engaging approach to learning and helped to maintain their interest with the teaching material. However, TPs struggled to engage with pre-work outside of the class due to competing work priorities.

DISCUSSION

This study shows that online TBL was well accepted by TPs and can be successfully used to deliver education to large cohorts of learners. The model developed shows potential for scalability to larger numbers of learners.

Barriers and enablers to healthcare system uptake of direct oral anticoagulants for stroke prevention in atrial fibrillation: a qualitative interview study with healthcare professionals and policy makers in England

OBJECTIVE

To better understand the factors influencing the uptake of direct oral anticoagulants (DOACs) across different health economies in National Health Service England from the perspective of health professionals and other health economy stakeholders.

DESIGN

Qualitative interview study using a critical realism perspective and informed by the Diffusion of Innovations in Service Organisations model.

SETTING

Three health economies in the North of England, United Kingdom.

PARTICIPANTS

Healthcare professionals involved in the management of patients requiring oral anticoagulants, stakeholders involved in the implementation of DOACs and representatives of pharmaceutical industry companies and patient support groups.

INTERVENTION

Semistructured interviews (face-to-face or telephone) were conducted with 46 participants. Interviews were analysed using the Framework method.

RESULTS

Identified factors having an impact on the uptake of DOACs were grouped into four themes: perceived value of the innovation, clinician practice environment, local health economy readiness for change, and the external health service context. Together, these factors influenced what therapy options were offered and prescribed to patients with atrial fibrillation. The interviews also highlighted strategies used to improve or restrict the uptake of DOACs and tensions between providing patient-centred care and managing financial implications for commissioners.

CONCLUSIONS

The findings contribute to the wider literature by providing a new and in-depth understanding on the uptake of DOACs. The findings may be applicable to other new medicines used in chronic health conditions.

Impact of Pharmacist-Led Interventions to Improve Clinical Outcomes for Adults With Type 2 Diabetes at Risk of Developing Cardiovascular Disease: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis of randomised controlled trials is to evaluate the impact of pharmacist-led interventions on cardiovascular disease (CVD) risk factors among patients with type 2 diabetes.

METHOD

A literature review was conducted according to PRISMA guidelines using 4 electronic databases: Embase, MEDLINE, CINHAL and the Cochrane Central Register of Controlled Trials. We searched for pharmacist interventions among adults with type 2 diabetes and cardiovascular disease in randomised controlled trials from inception to May 2021 in primary care, diabetes clinics and hospitals. The clinical outcomes measured glycosylated haemoglobin (HbA1c), blood pressure (BP) and lipid profile. The non-clinical outcomes included medication adherence, smoking, health-related quality of life and the cost of the intervention. For the meta-analysis, clinical outcomes were pooled with the random effect model in RevMan 5.3. The Cochrane risk-of-bias tool was used to assess the quality of the included studies.

RESULTS

We retrieved 223 studies,141 of which were included in the review. Ten published articles met the inclusion criteria and were included in the meta-analysis. The pharmacists delivered the interventions alone or collaboratively with other healthcare professionals in hospitals or similar settings. The overall result showed a significant reduction in HbA1c (n = 10; standard deviation in mean value [SDM]: -.53%, 95% CI: -.84, -.23) and systolic BP (n = 10; [SDM]: -.35 mmHg, 95% CI: -.51, -.20) in pharmacist intervention groups. For the non-clinical outcomes, the review revealed variable results from pharmacist intervention compared with those standard care.

CONCLUSION

Pharmacy interventions provide evidence for pharmacists' decisive role in diabetes care management and reducing cardiovascular risk factors among adults with type 2 diabetes.

Barriers and facilitators to the uptake of new medicines into clinical practice: a systematic review

BACKGROUND

Implementation and uptake of novel and cost-effective medicines can improve patient health outcomes and healthcare efficiency. However, the uptake of new medicines into practice faces a wide range of obstacles. Earlier reviews provided insights into determinants for new medicine uptake (such as medicine, prescriber, patient, organization, and external environment factors). However, the methodological approaches used had limitations (e.g., single author, narrative review, narrow search, no quality assessment of reviewed evidence). This systematic review aims to identify barriers and facilitators affecting the uptake of new medicines into clinical practice and identify areas for future research.

METHOD

A systematic search of literature was undertaken within seven databases: Medline, EMBASE, Web of Science, CINAHL, Cochrane Library, SCOPUS, and PsychINFO. Included in the review were qualitative, quantitative, and mixed-methods studies focused on adult participants (18 years and older) requiring or taking new medicine(s) for any condition, in the context of healthcare organizations and which identified factors affecting the uptake of new medicines. The methodological quality was assessed using QATSDD tool. A narrative synthesis of reported factors was conducted using framework analysis and a conceptual framework was utilised to group them.

RESULTS

A total of 66 studies were included. Most studies (n = 62) were quantitative and used secondary data (n = 46) from various databases, e.g., insurance databases. The identified factors had a varied impact on the uptake of the different studied new medicines. Differently from earlier reviews, patient factors (patient education, engagement with treatment, therapy preferences), cost of new medicine, reimbursement and formulary conditions, and guidelines were suggested to influence the uptake. Also, the review highlighted that health economics, wider organizational factors, and underlying behaviours of adopters were not or under explored.

CONCLUSION

This systematic review has identified a broad range of factors affecting the uptake of new medicines within healthcare organizations, which were grouped into patient, prescriber, medicine, organizational, and external environment factors. This systematic review also identifies additional factors affecting new medicine use not reported in earlier reviews, which included patient influence and education level, cost of new medicines, formulary and reimbursement restrictions, and guidelines.

REGISTRATION

PROSPERO database (CRD42018108536).

MO201ANALYSIS OF USAGE OF SODIUM ZIRCONIUM CYCLOSILICATE (SZC) AT HULL UNIVERSITY TEACHING HOSPITALS

Background and Aims

Renin Angiotensin Aldosterone System (RASS) inhibitor therapy is key to the management of several chronic long term conditions; however, RAAS inhibitors can cause hyperkalaemia and thus limiting its use. Sodium zirconium cyclosilicate, was approved in the UK as part of the management of hyperkalaemia in adults. Although the efficacy and safety of SZC has been demonstrated in clinical trials, there isn’t an abundance of data of its use in clinical practice. This study investigated the efficacy and safety of SCZ in the short-term management of hyperkalaemia in patients admitted acutely to hospital.

Method

This retrospective study analysed prescriptions and medical notes of patients who received SCZ treatment between June and December 2020 at Hull University Teaching Hospitals. Eligible patients (>16years and received SCZ) were identified from pharmacy dispensing data. Data collected included patient demographics, prescribed medication that could affect serum potassium levels prior to starting SZC, indication, dose of SCZ, potassium level at start and 72hrs after treatment and if the patient was on renal replacement therapy (RRT). In addition, speciality of the prescriber and reported adverse effects were noted. Data analysis was descriptive.

Results

During the study period, SZC was prescribed to 59 patients on 73 different occasions. Fifty-two (71%) were male, mean age was 58 years (range 17 – 88 years). Twenty-two patients (37%) were on RASS inhibitors, six patients on a potassium sparing diuretic, and 21 on a beta-blocker before treatment with SZC.

Thirteen patients (22%) were on a combination of at least two of these medicines. Nineteen patients (32%) were on haemodialysis and four patients (7%) were on peritoneal dialysis (PD) prior to treatment with SZC.

The documented reason for SZC use included hyperkalaemia secondary to dialysis access failure, acute kidney injury, pharmacotherapy induced hyperkalaemia and pre-emptive prescribing to allow time to create a new RRT access.

Thirty-three (56%) patients had their serum potassium level checked at start and 72hrs after treatment with SZC. The remaining patients had their biochemical profiles checked more than 72 hours after starting SZC with inconsistent time frames and thus, were excluded from the further analysis.

In haemodialysis patients, the median serum potassium level at start of treatment with SZC was 5.7mmol/L (range 4.6mmol/L – 6.3mmol/L) while in PD patients the median potassium level 6.4mmol/L (range 4.4mmol/L – 6.4mmol/L). The mean decrease in serum potassium was 0.73mmol/L (range 0.1mmolo/L – 3mmol/L) and 1.7mmol/L (range 0.1 -1.6mmol/L) in HD and PD patients respectively.

For patients not on RRT prior to treatment with SZC, and median serum potassium level at start of treatment was 6.0mmol/L (range 5.5mmol/L – 6.7mmol/L). In these patients, a mean decrease in serum potassium of 1.1mmol/L (range 0.2mmol/L – 2.4mmol/L) was observed.

Twenty-three patients (70%) received 10g and ten patients received the 5g dose of SZC.

Patients who had the 10g doses had a mean reduction in serum potassium of 1.0mmol/L (range 0.1mmol/L - 3.0mmol/L) and patients who received 5g doses had a mean reduction of 0.97mmol/L (range 0.2mmol/L – 1.9mmol/L) over the 72-hour period.

There were no reported side effects.

It was found that SZC was initiated by a range of specialities (see Figure 1). The nephrology team accounted for the majority (45%) of prescriptions.

Notably, the cardiology team initiated only one prescription.

Conclusion

Our data from clinical practice indicates that SZC is effective and well-tolerated treatment in the management of hyperkalaemia. Our results also suggest that the reduction in potassium level was not vastly different for patients started on the 5g dose vs the 10g dose but this requires further research with larger study sample sizes.

Limitations of the study included small sample size and retrospective nature of the study.

Patient Perspectives on Factors Affecting Direct Oral Anticoagulant Use for Stroke Prevention in Atrial Fibrillation

INTRODUCTION

Oral anticoagulant therapy choices for patients with atrial fibrillation (AF) expanded in the last decade with the introduction of direct oral anticoagulants (DOAC). However, the implementation of DOACs was slow and varied across different health economies in England. There is limited evidence on the patient role in the uptake of new medicines, including DOACs, apart from considering their demographic and clinical characteristics. Hence, this study aimed to address the gap by exploring the view of patients with AF on factors affecting DOAC use.

METHODS

A qualitative study using semi-structured interviews was conducted in three health economies in the North of England. Adult patients (>18 years) diagnosed with non-valvular AF, prescribed an oral anticoagulant (vitamin K antagonist or DOAC), and able to give written consent were recruited. Data were collected between August 2018 and April 2019. Audio recorded interviews were transcribed verbatim and analyzed using the framework method.

RESULTS

Four themes with eleven subthemes discussed identified factors affecting the use of DOACs. They were linked to limited healthcare financial and workforce resources, patient involvement in decision-making, patient knowledge about DOACs, safety concerns about oral anticoagulants, and oral anticoagulant therapy impact on patients' daily lives. Lack of a) opportunities to voice patient preferences and b) information on available therapy options resulted in some patients experiencing difficulties with the prescribed therapy. This was reported to cause negative impact on their daily lives, adherence, and overall satisfaction with the therapy.

CONCLUSION

Greater patient involvement in decision-making could prevent and resolve difficulties encountered by some patients and potentially improve outcomes plus increase the uptake of DOACs.

Patients’ perspectives on factors affecting their involvement in decision-making on oral anticoagulant therapy for stroke prevention in non-valvular atrial fibrillation

Introduction

Acknowledging patients’ preferences and addressing their concerns is thought to improve patients’ satisfaction with consultations, resulting in improved adherence and health benefits [1]. Adherence to oral anticoagulant (OA) therapy in non-valvular atrial fibrillation (NVAF) is crucial to prevent AF-related strokes. Previous research on anticoagulation in NVAF indicated that decision-making was dominated by prescribers, but patients offered several therapy options reported being involved [2]. Identifying the patient’s perspective on factors affecting their involvement could help to deliver more patient-centred care in the management of AF.

Aim

To explore patients’ perspectives and experiences concerning factors affecting their involvement in decision-making about OA therapy for stroke prevention in NVAF.

Methods

Semi-structured face-to-face interviews were conducted with patients in three health economies in the North of England between August 2018 and April 2019. An interview topic guide based on narrative review findings [2] was developed and refined by a Patient and Public Involvement (PPI) group to ensure clarity. Theoretical sampling was used to recruit adults (>18 years) diagnosed with NVAF, prescribed OA (vitamin K antagonist or direct oral anticoagulant (DOAC)), and able to give written consent. Up to 30 potential participants were approached by a member of their direct care team (nurse or pharmacist) in secondary and primary care anticoagulation or arrhythmia clinics. PPI members recruited patients from a local patient support group. Data collection continued until data saturation was achieved. Audio recorded interviews were transcribed verbatim and analysed using the Framework method.

Results

A total of 21 patient with median (IQR) age of 73 years (65–78 years) were interviewed. Eleven patients took DOACs. The median (IQR) time of taking OA was 3 years (4 weeks-7 years), warfarin 7 years (3–9 years) and DOAC 1 year (4 weeks-4 years). Interviews lasted between 15 and 48 minutes (average 27 minutes). Three themes were identified during analysis (Figure 1). Patients described therapy decisions being made by just the clinician, jointly with the clinician, and in few cases by the patient alone. The lack of involvement resulted from patients perceiving that there was only a choice between accepting and refusing the therapy, and clinician’s role was to make decisions. Limited consultation times, lack of continuous relationship with a clinician and knowledge about OAs options discouraged patients from being involved and some patients reported difficulties with the prescribed therapy. Patients that were involved considered safety of therapy options and impact on daily life.

Conclusions

Limited consultation time, patient’s perception of clinician’s role, quality of patient-clinician relationship, and patients’ awareness of therapy options were main factors influencing the level of patient involvement in the decision-making. Support from both organisation and clinicians (e.g., longer consultations, availability of different therapy options) is needed to facilitate greater patient involvement, which could prevent difficulties encountered by some patients. The main strength of this study was recruitment of participants from three health economies differing in anticoagulation service provision models, which enabled greater insight into potential barriers. However, the sample was lacking ethnic diversity and could have potential of recall bias.

References

1. Shay LA and Lafata JE. (2015). Where is the evidence? A systematic review of shared decision making and patient outcomes. Medical Decision Making. 35 (1): 114–131.

2. Medlinskiene K, Petty D, Richardson S and Stirling K. (2018) Are patients with non-valvular atrial fibrillation involved in decision-making about oral anticoagulants? A literature review. International Journal of Pharmacy Practice. 26 (Suppl. 1): 42–43.

Uptake of Oral Anticoagulants for Stroke Prevention in Patients with Atrial Fibrillation in a Single Clinical Commissioning Group in England Without Restrictions to Their Use

BACKGROUND AND OBJECTIVE

In England, the uptake of direct oral anticoagulants (DOACs) for stroke prevention in atrial fibrillation has been slow and varied across different Clinical Commissioning Groups (CCGs). This study aimed to profile the prescribing of oral anticoagulants for stroke prevention in patients with atrial fibrillation over 3 years in a CCG without restrictions to DOACs use to understand more about organisational and/or individual barriers to the early uptake of DOACs.

METHODS

Data were collected from nine general practices between 1 April 2012 and 31 March 2015 of patients who were initiated on the oral anticoagulant therapy. Data were analysed descriptively and with independent Student's t test and Chi square test to explore if there was an association between type of oral anticoagulant initiated and sex, age, type of prescriber and prior aspirin use.

RESULTS

The early uptake of DOACs significantly increased over the study period (p < 0.0001; medium size effect φc = 0.372). There was no statistically significant difference between sex or age and type of oral anticoagulant initiated. Primary-care prescribers were responsible for initiating the majority of oral anticoagulants (71%; N = 257) and driving the use of DOACs (72%, N = 71). Patients switched from aspirin to an oral anticoagulant were more likely to be initiated on warfarin than a DOAC.

CONCLUSIONS

The early use of DOACs, in a CCG without restrictions to their use, was embraced by primary-care prescribers in this particular CCG.

Patient and public involvement in designing and conducting doctoral research: the whys and the hows

PLAIN ENGLISH SUMMARY

Evidence shows that public and patient involvement in research has a positive effect on its quality and end-results. Thus, public and patient involvement in all stages of research is becoming commonplace. There are limited detailed examples however, that describe how to make this possible, especially for those doing PhD research. Doctoral researchers are often new to research practice or have limited experience and are often bound by strict time and financial constraints. It is also not usually a requirement of the award to involve public and patients in their research. Hence, they may not feel confident or motivated to involve or engage with public and patients during their research. We, four doctoral researchers, share examples from our own research studies that have included different approaches to public and patient involvement. Two studies formed public and patient advisory groups who helped design the research questions, data collection tools and recruitment methods. One enlisted the help of an online public and patient panel from a local hospital. A different study worked with patients from an established group to help define key medical words. We did face some challenges, such as the need to develop good group work skills and to apply for grants to cover reimbursement, but we all found it beneficial to involve patients in our studies. We noticed a positive effect on each study's progression and an improvement in our own self-esteem. In addition, having public and patient involvement helped reduce the isolation we felt as doctoral researchers. Thus, we strongly encourage more doctoral researchers to involve public and patients in their studies.

ABSTRACT

Public and patient involvement (PPI) has been shown to have a positive impact on health and social care research. However, adequate examples describing how to operationalise effective PPI, especially in doctoral studies, are lacking. Hence, doctoral researchers new to research, or those with limited experience, can be discouraged from facilitating PPI in their research. This paper aims to describe and discuss in detail the approaches used by four doctoral researchers to incorporate PPI at different stages of their research studies from study design to disseminating findings.We aim to inform other doctoral researchers about the challenges and limitations relating to PPI that we faced. Through these, we share pragmatic recommendations for facilitating PPI during doctoral studies.The description of four case studies demonstrated that PPI could be incorporated at various stages during doctoral research. This has had a beneficial impact on our research study progression, researcher self-esteem and lastly, helped alleviate researcher isolation during doctoral studies.