Heterogeneity after harmonisation: A retrospective cohort study of bleeding and stroke risk after the introduction of direct oral anticoagulants in four Western European countries

PURPOSE

Database heterogeneity can impact effect estimates. Harmonisation provided by common protocols and common data models (CDMs) can increase the validity of pharmacoepidemiologic research. In a case study measuring the changes in the safety and effectiveness of stroke prevention therapy after the introduction of direct oral anticoagulants (DOACs), we performed an international comparison.

METHODS

Using data from Stockholm, Denmark, Scotland and Norway, harmonised with a common protocol and CDM, two calendar-based cohorts were created: 2012 and 2017. Patients with a diagnosis code of atrial fibrillation 5 years preceding the 1-year cohort window were included. DOAC, vitamin K antagonist and aspirin treatment were assessed in the 6 months prior to the start of each year while strokes and bleeds were assessed during the year. A Poisson regression generated incidence rate ratios (IRRs) to compare outcomes from 2017 to 2012 adjusted for changes in individual-level baseline characteristics.

RESULTS

In 280 359 patients in the 2012 cohort and 356 779 in the 2017 cohort, treatment with OACs increased on average from 45% to 65%, while treatment with aspirin decreased from 30% to 10%. In all countries except Scotland, there were decreases in the risk of stroke and no changes in bleeding risk, after adjustment for changes in baseline characteristics. In Scotland, major bleeding (IRR 1.09, 95% confidence interval [CI] [1.00; 1.18]) and intracranial haemorrhage (IRR 1.31, 95% CI [1.13; 1.52]) increased from 2012 to 2017.

CONCLUSIONS

Stroke prevention therapy improved from 2012 to 2017 with a corresponding reduction in stroke risk without increasing the risk of bleeding in all countries, except Scotland. The heterogeneity that remains after methodological harmonisation can be informative of the underlying population and database.

Barriers and facilitators to pharmacy professionals’ specialist public health roles: a mixed methods UK-wide pharmaceutical public health evidence review

Introduction

Pharmaceutical Public Health (PPH) is defined as “the application of pharmaceutical knowledge, skills and resources to the science and art of preventing disease, prolonging life, promoting, protecting and improving health for all through organised efforts of society”.1 In the UK (and globally) pharmacy professionals (PPs) contribute to the delivery of local and national public/population health (PH) interventions.2,3 However, little is known to what extent PPs have specialist/advanced roles within PH practice.

Aim

The mixed methods review, commissioned by the UK Chief Pharmaceutical Officers in 2020, aimed to explore PPs’ specialist PH contributions including barriers and opportunities.

Methods

Databases available through PubMed were searched to retrieve articles published in English (2011- 2021) on seven topics including: emergency preparedness resilience and response (EPRR); integrating pharmacy to better support public health protection and improvement goals; public health skills and mitigating health inequalities. Two independent electronic surveys were developed, piloted and deployed for pharmacy and public health specialists via email cascade and social media. The surveys explored the extent to which PPs are involved in PH roles including the barriers and opportunities. Descriptive statistics summarised the data, and open-ended responses were themed. The NHS Health Research Authority tool identified this project did not require ethical approval as the surveys were service evaluation.

Results

Rapid Evidence reviews: Following assessment of 2,542 articles, 448 evidence statements were extracted from 135 relevant articles. They were predominantly from USA (39%) and UK (29%), with fewer high-quality reviews (17) or guidance (12), than moderate/low-quality reviews (42), single studies (33), or quantitative research (33). Common themes of PPs’ contributions included: surveillance and intelligence gathering; advocacy for their communities; signposting; delivery of health improvement and protection services; supporting people with long-term-conditions; and EPRR. Barriers identified included: limited public and professional awareness of pharmacy’s contribution to public health and under-resourced PH training. Pharmacy and PH professionals Surveys: There were UK-wide responses from 128 PPs and 37 PH specialists. Opportunities identified by PPs included: PH areas they directly contribute to (45%); qualifications, knowledge and skills (27%); strategic position in the community (19%), recent changing health landscape (4%). Barriers included lack of defined career pathway (20%); poor professional recognition (18%); limited resources (16%); lack of training and support (15%) and organisational and structural barriers (10%). PH specialists identified at least 12 areas from the Faculty of PH’s functions and standards, they believed additional benefits would be realised by PPs working directly within PH teams. Although only 40% PH specialists had PPs working within their teams, 83% stated that it would be beneficial or very beneficial to have PPs specialising in PH.

Discussion/Conclusion

Dedicated PPH training and system-wide leadership are required to fully realise population-level benefits. Low responses to the surveys present a study limitation, however, there was consensus from the themes emerging from both surveys and rapid evidence reviews findings. Pharmacy professionals make specialist contributions to PH despite barriers. Further investigation is required to identify how best to deploy advanced PPH resources. Future qualitative studies should be considered.

References

1. Walker, R. Pharmaceutical public health: the end of pharmaceutical care? The Pharmaceutical Journal 2000;264:340–1.

2. PHE (2017). Pharmacy: A Way Forward for Public Health https://www.gov.uk/government/publications/community-pharmacy-public-health-interventions (accessed 31 July 2021)

3. Thomson K, Hillier-Brown F, Walton N, Bilaj M, Bambra C, Todd A. The effects of community pharmacy-delivered public health interventions on population health and health inequalities: A review of reviews. Prev Med. 2019 Jul;124:98-109.

Pharmacists in primary care in Scotland: a mixed-methods exploration of pharmacists’ perceptions of a national educational resource package

Introduction

There is growing pressure on primary care, which has resulted in an increased number of clinical pharmacists working within the setting. To help support this growing workforce in their role and with their development, several countries have created educational resources. Within Scotland, an educational resource package was created for pharmacists working in General Practice, containing a Competency and Capability Framework, an online platform and educational and clinical supervision. The implementation of these resources in Scotland has not been evaluated thus far, therefore it is unclear to what extent they may support and facilitate pharmacists in their professional role.

Aim

The aim of this project was to assess pharmacists’ perceptions of the educational resource package available to General Practice pharmacists in Scotland.

Methods

A mixed-methods study comprising an online questionnaire and semi-structured telephone interviews was undertaken between July and October 2019. The questionnaire sought to provide a more representative overview, with the interviews designed to gain an in-depth understanding, to support the development of recommendations to improve the educational resource package.

A previously validated, online questionnaire (1) was used to explore pharmacists’ view on the adoption, acceptability, appropriateness, and feasibility of the educational resources based on Proctor’s model of implementation outcomes (2); similarly, the semi-structured telephone interviews explored pharmacists’ experiences with the resources, in addition to inquiring about its adoption, acceptability, appropriateness, and feasibility.

The questionnaire included a Likert scale and free-text questions; quantitative responses were summarised, whereas the qualitative answers underwent a content analysis directed by Proctor’s implementation outcomes. The interview results were structured using the framework approach, with the data undergoing a thematic or summative content analysis.

Results

Overall, 52 pharmacists completed the questionnaire and 12 participated in the interviews. The results indicated widespread adoption and acceptance of the educational resource package. The level of acceptance was influenced by the perceived purpose of completing the resources, such as if they believed it provided development opportunities. Its appropriateness depended on the pharmacist’s individual situation since previous experiences and current job role differed. Additionally, several barriers complicated the feasibility of the resources, such as insufficient support and guidance.

Conclusion

The adoption and acceptance of the educational resource package for General Practice pharmacists in Scotland indicated its suitability for supporting their role; however, further facilitation would enhance their engagement with the resources, and potentially improve their perception of its appropriateness and feasibility. Despite the limited sample size, the study provided an in-depth understanding of general practice pharmacists perceptions of the educational recourse package, based on an established model.

References

(1) Proctor E, Silmere H, Raghavan R, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38(2):65-76.

(2) Weiner BJ, Lewis CC, Stanick C, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017; 12(1): 108.

Pharmacists in primary care in Scotland: an exploration of competencies required for the provision of pharmacy services within general practice

Introduction

Efforts are increasingly being made to implement pharmacists working in General Practice to support General Practitioners and alleviate pressure, mainly by providing pharmacotherapy services such as medication reviews and authorising prescribing requests (1). While there is wide interest in the contributions pharmacists can make within primary care, there is limited research exploring the competencies pharmacists need to safely and effectively provide care in this area.

Aim

The aim of this project was to identify competencies required for pharmacists providing pharmacotherapy services in General Practice.

Methods

Modified eDelphi study (2), comprising a series of online questionnaires conducted between July 2019 and January 2020. Participants were pharmacists working in General Practice in Scotland.

The first questionnaire consisted of open-ended questions aimed at generating a list of competencies; competency categories and individual competency items relating to pharmacotherapy service tasks were identified based on the free text responses using content analysis. Subsequently, the second questionnaire aimed to establish consensus regarding the importance of the collected competencies, using a rating scale from 1 (“not important”) to 10 (“very important”); participants’ scores were aggregated using modes and medians, and the level of agreement among participants with regards to the importance of competencies was evaluated by calculating the percentage of scores between 8 and 10. Due to the novelty of this work and the resultant uncertainty surrounding participants’ responses, no cut-off point for agreement was pre-specified.

Results

Overall, 10 pharmacists completed the first questionnaire, and 11 completed the second. Building on the findings from the first questionnaire, a framework of competencies necessary to provide pharmacotherapy services in General Practice was developed, comprising eight competency categories, with a total of 31 individual competency items: General Skills (e.g. ability to record patient information); IT Skills (e.g. ability to use GP computer system to update documentation); Legal & Professional Frameworks (e.g. understanding of clinical guidelines); Procedural Skills (e.g. ability to arrange follow-up); Multidisciplinary Team Communication Skills (e.g. ability to communicate with others within the GP practice); Consultation Skills (e.g. ability to take a complete history); Clinical Knowledge (e.g. knowledge related to conditions being treated); and Clinical Skills (e.g. ability to interpret clinical information). All eight competency categories were considered important across the pharmacotherapy service, with high agreement (between 71 and 85%) among participants.

Conclusion

Using a bottom-up, exploratory approach, this study confirmed that practicing within the General Practice setting requires a wide set of competencies, including – but not limited to – advanced clinical and consultation skills. Nevertheless, findings should be interpreted cautiously due to the limited sample size; although results have tentatively been validated using a paper-based version of the second online questionnaire during an in-person event with General Practice pharmacists, results might not be reflective of all pharmacists working in this setting.

References

(1) Scottish Government. (2017). The 2018 General Medical Services Contract in Scotland. Retrieved from https://www.glasgowlmc.co.uk/download/contract%20and%20contractural%20Issues/The-2018-General-Medical-Services-Contract-in-Scotland.pdf

(2) Hsu, C. C., & Sandford, B. A. (2007). The Delphi technique: Making sense of consensus. Practical Assessment, Research & Evaluation, 12, Article10. https://doi.org/10.7275/pdz9-th90

A national, multicentre web-based point prevalence survey of antimicrobial use and quality indices among hospitalised paediatric patients across South Africa

OBJECTIVES

Data on antimicrobial consumption among the paediatric population in public hospitals in South Africa is limited. These needs to be addressed to improve future use and reduce antimicrobial resistance rates. Consequently, the objective is to quantify antimicrobial usage;and identify and classify which antimicrobials are used in the peadiatric population in public sector hospitals in South Africa according to World Health Organiosation (WHO) AWaRe list of antimicrobials METHODS: Conduct a point prevalence survey among 18 public sector hospitals from nine provinces using a newly developed web-based application. The data will be analysed according to the WHO AwaRe list to guide future quality improvement programmes.

RESULTS

1261 paediatric patient files were reviewed with 49.7% (627/1261) receiving at least one antimicrobial, with 1013 antimicrobials prescribed overall. The top five antimicrobials included ampicillin (16.4%), gentamycin (10.0%), amoxicillin and enzyme inhibitor (9.6%), ceftriaxone (7.4%), and amikacin (6.3%). Antimicrobials from the Access classification were the most used (55.9%) with 3.1% being from the Reserve classification. The most common infectious conditions were pneumonia (21.3%; 148/1013) and clinical sepsis (16.0%; 111/1013). Parenteral administration (75.6%) and prolonged surgical prophylaxis (66.7%; 10/15) were common and concerns. 28% of the paediatric patients had cultures requested for them before antimicrobial treatment (284/1013) however only 38.7% (110/284) of culture results were available in the files.

CONCLUSION

Overall, antimicrobial prescribing is common among paediatric patients in South Africa. Interventions should be targeted at improving antimicrobial prescribing, including surgical prophylaxis, and encouraging greater use of oral antibiotics.

A point prevalence survey of antimicrobial utilisation patterns and quality indices amongst hospitals in South Africa; findings and implications

Objectives: Antimicrobial use is growing, driven mainly by rising demands in developing countries. Knowing how antimicrobials are prescribed is important. Consequently, we undertook a point prevalence survey (PPS) quantifying antimicrobial consumption among 18 public sector hospitals across South Africa.Method: A purpose-built web-based application was used to collect PPS data.Results: Out of 4407 adult patients surveyed, 33.6% were treated with an antimicrobial. The most frequently prescribed groups were a combination of penicillins including β-lactamase inhibitors. Amoxicillin combined with an enzyme inhibitor accounted for 21.4% total DDDs. In the medical and surgical wards, Access antimicrobials (54.1%) were mostly used, while in the ICU, Watch antimicrobials (51.5%) were mostly used. Compliance with the South African Standard Treatment Guidelines and Essential Medicines List was 90.2%; however, concerns with extended use of antimicrobials for surgical prophylaxis (73.2% of patients).Conclusion: The web-based PPS tool was easy to use and successful in capturing PPS data since the results were comparable to other PPS studies across Africa. High use of amoxicillin combined with an enzyme inhibitor, possibly because it was among the broad-spectrum antimicrobials in the Access group. The findings will assist with future targets to improve antimicrobial prescribing among public sector hospitals in South Africa.

Development of a web-based application to improve data collection of antimicrobial utilization in the public health care system in South Africa

Objective

Determining antimicrobial utilization patterns in hospitals can be a challenge given personnel and resource constraints with paper-based systems. A web-based application (APP) was developed in South Africa to address this, building on a recent point prevalence survey (PPS) using a paper-based system. Consequently, there was a need to test and evaluate the ease of use of a newly developed app and potential time saving versus paper-based methods for PPS. The findings can be used to further refine the APP.

Methods

The developed app was tested in a large academic public hospital in a PPS in South Africa. During data collection, the app was evaluated for functionality on 35 variables and subsequently refined. After data collection, the app was evaluated in terms of its time-saving potential and ease of use.

Results

181 patient’s files were surveyed across 13 wards in the hospital, with the antimicrobial usage findings similar to the previous paper-based study in the same hospital. The median age for males was 45.5 years and 42 years for females. Overall 80 out of 181 (44%) patients received antibiotics. Whilst 38% (12 out of 31) of patients in the adult surgical ward received antimicrobials, the prevalence was the highest (78%) in the pediatric medical wards. All the data collectors were confident in using the app after training and found the tool is not complex at all to use. In addition, the time taken to plan for the study and to collect data was considerably reduced. Reduced time spent in data collection and analysis is important for timely instigation of quality improvement programs in resource limited settings.

Conclusions

All data collectors would recommend the app for future PPSs. Several concerns with data entry were identified, which have now been addressed. The app development has been successful and is now being deployed across South Africa as part of a national PPS as well as wider.

Cost burden of Clostridioides difficile infection to the health service: A retrospective cohort study in Scotland

BACKGROUND

Clostridioides difficile infection (CDI) is associated with high healthcare demands and related costs.

AIM

To evaluate the healthcare and economic burden of CDI in hospitalized patients with community- (HOCA-CDI) or hospital-associated CDI (HOHA-CDI) in the National Health Service in Scotland.

METHODS

A retrospective cohort study was conducted, examining data between August 2010 and July 2013 from four patient-level Scottish datasets, linked to death data. Data examined included prior antimicrobial prescriptions in the community, hospitalizations, length of stay and mortality. Each CDI case was matched to three hospital-based controls on the basis of age, gender, hospital and date of admission. Descriptive economic evaluations were based on bed-day costs for different types of wards.

FINDINGS

Overall, 3304 CDI cases were included in the study. CDI was associated with additional median lengths of stay of 7.2 days for HOCA-CDI and 12.0 days for HOHA-CDI compared with their respective, matched controls. The 30-day mortality rate was 6.8% for HOCA-CDI and 12.4% for HOHA-CDI. Overall, recurrence within 90 days of the first CDI episode occurred in 373/2740 (13.6%) survivors. The median additional expenditure for each initial CDI case compared with matched controls was £1713. In the 6 months after the index hospitalization, the cost associated with a CDI case was £5126 higher than for controls.

CONCLUSION

Using routinely collected national data, we demonstrated the substantial burden of CDI on healthcare services, including lengthy hospital stays and readmissions, which increased the costs of managing patients with CDI compared with matched controls.

Residual effect of community antimicrobial exposure on risk of hospital onset healthcare-associated Clostridioides difficile infection: a case-control study using national linked data

BACKGROUND

Associations between antimicrobial exposure in the community and community-associated Clostridioides difficile infection (CA-CDI) are well documented but associations with healthcare-associated CDI (HA-CDI) are less clear. This study estimates the association between antimicrobial prescribing in the community and HA-CDI.

METHODS

A matched case-control study was conducted by linking three national patient level datasets covering CDI cases, community prescriptions and hospitalizations. All validated cases of HA-CDI (August 2010 to July 2013) were extracted and up to three hospital-based controls were matched to each case on the basis of gender, age, hospital and date of admission. Conditional logistic regression was applied to estimate the association between antimicrobial prescribing in the community and HA-CDI. A sensitivity analysis was conducted to consider the impact of unmeasured hospital antimicrobial prescribing.

RESULTS

Nine-hundred and thirty unique cases of HA-CDI with onset in hospital and no hospital discharge in the 12 weeks prior to index admission were linked with 1810 matched controls. Individuals with prior prescription of any antimicrobial in the community had an odds ratio (OR) = 1.41 (95% confidence interval (CI) 1.13-1.75) for HA-CDI compared with those without. Individuals exposed to high-risk antimicrobials (cephalosporins, clindamycin, co-amoxiclav or fluoroquinolones) had an OR = 1.86 (95% CI: 1.33-2.59). After accounting for the likely impact of unmeasured hospital prescribing, the community exposure, particulary to high-risk antimicrobials, was still associated with elevated HA-CDI risk.

CONCLUSIONS

Community antimicrobial exposure is an independent risk factor for HA-CDI and should be considered as part of the risk assessment of patients developing diarrhoea in hospital.

Statin use in Brazil: findings and implications

INTRODUCTION AND OBJECTIVES

Statins have become an integral part of treatment to reduce cardiac events in patients with cardiovascular disease. However, their use within the public healthcare system in Brazil is unknown. Consequently, we sought to determine and characterize statin use in primary healthcare delivered by the public health system (SUS) in Brazil and evaluate associated patient factors to improve future use.

METHODS

Cross-sectional study with a national representative sample from five Brazilian regions, derived from the National Survey on Access, Use and Promotion of Rational Use of Medicines using a multi-stage complex sampling plan. Patients over 18 years old were interviewed from July 2014 to May 2015. The prevalences of statin use and self-reported statin adherence were determined amongst medicine users. The associations between statin use and sociodemographic/health condition variables were assessed using logistic regression.

RESULTS

A total of 8803 patients were interviewed, of whom 6511 were medicine users. The prevalence of statin use was 9.4% with simvastatin (90.3%), atorvastatin (4.7%) and rosuvastatin (1.9%) being the most used statins. Poor adherence was described by 6.5% of patients. Statin use was significantly associated with age ≥65 years old, higher educational level, residence in the South, metabolic and heart diseases, alcohol consumption and polypharmacy.

CONCLUSIONS

This is the first population based study in Brazil to assess statin use in SUS primary healthcare patients. Addressing inequalities in access and use of medicines including statins is an important step in achieving the full benefit of statins in Brazil, with the findings guiding future research and policies.

Influence of multiple initiatives in Sweden to enhance ARB prescribing efficiency following generic losartan; findings and implications for other countries

BACKGROUND

Encouraging the prescribing of ACEIs first line vs. angiotensin receptor blockers (ARBs) has been a health authority focus with generic ACEIs as ACEIs and ARBs have similar effectiveness and there is limited coughing with ACEIs. This includes Sweden with its multiple initiatives keeping expenditure on renin-angiotensin inhibitor drugs similar between 2001 and 2007 despite appreciably increased volumes. Generic losartan became available and was reimbursed in March 2010 providing further opportunities for the authorities in Sweden to save costs with all ARBs seen as similar in managing hypertension and CHF at appropriate doses.

AIMS

The main aim of this study was to assess changes in the utilisation of losartan vs. other single ARBs after generic losartan alongside accompanying demand-side measures. Additional aims were to (i) assess changes in the price of generic losartan and single ARB expenditure over time; (ii) suggest additional programmes, if needed; and (iii) analyse utilisation of ARB FDCs and compare with ACEI FDCs.

METHODS

Retrospective observational study using an interrupted time series design.

RESULTS

Multiple demand-side measures introduced among the 21 Counties in Sweden significantly enhanced the utilisation of generic losartan, growing from 26% to 27% of total ARBs (DDD basis) before generic losartan to 40% by August 2011. Losartan was principally generics (97% by August 2011). Expenditure/DDD for generic losartan was 10% of the pre-patent loss price in August 2011. This reduced total single ARB expenditure by 26% by the study end despite a 16% increase in utilisation. Greater utilisation of ARB FDCs than seen with ACEI FDCs. This may be due to similarities in prices between single and FDC ARBs.

DISCUSSION

Multiple demand-side measures appreciably enhanced ARB prescribing efficiency, mirroring other studies. No significant increase in losartan utilisation following generics was seen in European countries where no specific measures were instigated. Losartan price reduction was in line with expectations.

CONCLUSION

Multiple and intensive demand-side measures are needed to change physician prescribing habits. Authorities cannot rely on physicians transferring their activities from one class to another without interventions.

Are specific initiatives required to enhance prescribing of generic atypical antipsychotics in Scotland?: International implications

BACKGROUND

National and regional authorities in Scotland have introduced multiple measures to appreciably enhance prescribing efficiency for the proton pump inhibitors (PPIs), statins and renin-angiotensin inhibitor drugs. Generic oral risperidone recently became available in Scotland; however, schizophrenia is a complex disease with advice from respected authorities suggesting that treatment should be individualised.

AIMS

To assess (i) changes in atypical antipsychotic drug (AAP) utilisation and expenditure following the availability of oral generic risperidone in Scotland; (ii) to determine (a) current INN prescribing rates for risperidone following generic availability and (b) decrease in expenditure/DDD for generic risperidone; (iii) to suggest additional measures that could possibly be introduced in Scotland to further enhance prescribing of generic AAPs; and (iv) to provide guidance to NHS Scotland as well as other European authorities on the implications.

METHODS

Retrospective observational study and an interrupted time series design.

RESULTS

No appreciable change in the utilisation patterns of risperidone pre- and postgeneric availability. Appreciable INN prescribing averaged 93-98% of total oral risperidone. Generic risperidone was 84% below prepatent loss prices by study end, reducing annual expenditure for oral risperidone in 2010 by GB£3.19mn compared with prepatent loss situation. However, overall expenditure on AAPs increased by 42% from 2005 to 2010.

DISCUSSION

As expected, there was no change in utilisation patterns for risperidone, although potential to influence prescribing patterns. Continued high INN prescribing suggests no problems with generic risperidone in practice. Costs will start to decrease as more AAPs lose their patents (olanzapine and quetiapine). There is the possibility to accelerate this reduction through educational activities.

CONCLUSION

There is potential to realise some savings with generic AAPs. However, this is limited by the complexity of the disease area. Any measures introduced must aim at increasing the prescribing of generic AAPs first line in suitable patients.

Equity and efficiency: striving for a solution for the introduction of new medicines

The aim of this study was to describe the evolution of mechanisms to manage the introduction of new medicines and their impact on the health-care system in Scotland. The study was a review of published and unpublished national audits and surveys on the introduction of new medicines in Scotland. Before the Scottish Medicines Consortium (SMC) was established, Area Drug and Therapeutics Committees (ADTCs) played a key role in advising National Health Service (NHS) Boards in Scotland on the use of new medicines. There was evidence of variation in the medicines evaluated and, in some cases, the evidence used leading to different decisions for the same medicine. After the SMC was established, ADTC decisions had become more consistent and comprehensive. The role of ADTCs evolved from evaluation of medicines to assessment of local implications and implementation of SMC advice. There was increased recognition of the importance of monitoring medicine use. This review demonstrated a clear evolution in the evaluation and implementation of new medicines by ADTCs across NHS Scotland. After the SMC was established, more medicines were considered by ADTCs and there was greater consistency in those considered for local implementation. ADTCs have moved from evaluation of new medicines to other aspects of medicine management, including assessment of local implications and implementation of SMC advice.

Integrating the community pharmacist into the diabetes team: evaluation of a new care model for patients with Type 2 diabetes mellitus

Focal points

Factors influencing community pharmacist participation in clinical audit: a qualitative study of barriers and drivers of change

Focal points