Heather E. Barry

An exploration of nursing home managers' knowledge of and attitudes towards the management of pain in residents with dementia

The aims of this study were to explore the knowledge, attitudes and beliefs that nursing home managers hold with regard to the assessment and management of pain in residents with dementia and to determine how these may be affected by the demographic characteristics of the respondents.

Characteristics of service users and provider organisations associated with experience of out of hours general practitioner care in England: population based cross sectional postal questionnaire survey

Objective To investigate the experience of users of out of hours general practitioner services in England, UK. Design Population based cross sectional postal questionnaire survey. Setting General Practice Patient Survey 2012-13. Main outcome measures Potential associations between sociodemographic factors (including ethnicity and ability to take time away from work during working hours to attend a healthcare consultation) and provider organisation type (not for profit, NHS, or commercial) and service users’ experience of out of hours care (timeliness, confidence and trust in the out of hours clinician, and overall experience of the service), rated on a scale of 0-100. Which sociodemographic/provider characteristics were associated with service users’ experience, the extent to which any observed differences could be because of clustering of service users of a particular sociodemographic group within poorer scoring providers, and the extent to which observed differences in experience varied across types of provider. Results The overall response rate was 35%; 971 232/2 750 000 patients returned surveys. Data from 902 170 individual service users were mapped through their registered practice to one of 86 providers of out of hours GP care with known organisation type. Commercial providers of out of hours GP care were associated with poorer reports of overall experience of care, with a mean difference of −3.13 (95% confidence interval −4.96 to −1.30) compared with not for profit providers. Asian service users reported lower scores for all three experience outcomes than white service users (mean difference for overall experience of care −3.62, −4.36 to −2.89), as did service users who were unable to take time away from work compared with service users who did not work (mean difference for overall experience of care −4.73, −5.29 to −4.17). Conclusions Commercial providers of out of hours GP care were associated with poorer experience of care. Targeted interventions aimed at improving experience for patients from ethnic minorities and patients who are unable to take time away from work might be warranted.

Potentially Inappropriate Prescribing Among People with Dementia in Primary Care: A Retrospective Cross-Sectional Study Using the Enhanced Prescribing Database

BACKGROUND Little is known about prescribing appropriateness for community-dwelling people with dementia (PWD). OBJECTIVE To estimate potentially inappropriate prescribing (PIP) prevalence among PWD in primary care in Northern Ireland, and to investigate associations between PIP, polypharmacy, age, and gender. METHODS A retrospective cross-sectional study was conducted, using data from the Enhanced Prescribing Database. Patients were eligible if a medicine indicated for dementia management was dispensed to them during 1 January 2013-31 December 2013. Polypharmacy was indicated by use of ≥4 repeat medications from different drug groups. A subset of the Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria, comprising 36 indicators, was applied to the dataset. Overall prevalence of PIP and the prevalence per each STOPP criterion was calculated as a proportion of all eligible persons in the dataset. Logistic regression was used to investigate associations between PIP, polypharmacy, age, and gender. RESULTS The study population comprised 6826 patients. Polypharmacy was observed in 81.5% (n = 5564) of patients. PIP prevalence during the study period was 64.4% (95% CI 63.2- 65.5; n = 4393). The most common instance of PIP was the use of anticholinergic/antimuscarinic medications (25.2%; 95% CI 24.2-26.2; n = 1718). In multivariable analyses, both polypharmacy and gender (being female) were associated with PIP, with odds ratios of 7.6 (95% CI 6.6-8.7) and 1.3 (95% CI 1.2-1.4), respectively. No association was observed between PIP and age, after adjustments for gender and polypharmacy. CONCLUSION This study identified a high prevalence of PIP in community-dwelling PWD. Future interventions may need to focus on certain therapeutic categories and polypharmacy.

The use of patient experience survey data by out-of-hours primary care services: a qualitative interview study

Background English National Quality Requirements mandate out-of-hours primary care services to routinely audit patient experience, but do not state how it should be done. Objectives We explored how providers collect patient feedback data and use it to inform service provision. We also explored staff views on the utility of out-of-hours questions from the English General Practice Patient Survey (GPPS). Methods A qualitative study was conducted with 31 staff (comprising service managers, general practitioners and administrators) from 11 out-of-hours primary care providers in England, UK. Staff responsible for patient experience audits within their service were sampled and data collected via face-to-face semistructured interviews. Results Although most providers regularly audited their patients’ experiences by using patient surveys, many participants expressed a strong preference for additional qualitative feedback. Staff provided examples of small changes to service delivery resulting from patient feedback, but service-wide changes were not instigated. Perceptions that patients lacked sufficient understanding of the urgent care system in which out-of-hours primary care services operate were common and a barrier to using feedback to enable change. Participants recognised the value of using patient experience feedback to benchmark services, but perceived weaknesses in the out-of-hours items from the GPPS led them to question the validity of using these data for benchmarking in its current form. Conclusions The lack of clarity around how out-of-hours providers should audit patient experience hinders the utility of the National Quality Requirements. Although surveys were common, patient feedback data had only a limited role in service change. Data derived from the GPPS may be used to benchmark service providers, but refinement of the out-of-hours items is needed.

Establishing the validity of English GP Patient Survey items evaluating out-of-hours care

Background A 2014 national audit used the English General Practice Patient Survey (GPPS) to compare service users’ experience of out-of-hours general practitioner (GP) services, yet there is no published evidence on the validity of these GPPS items. Objectives Establish the construct and concurrent validity of GPPS items evaluating service users’ experience of GP out-of-hours care. Methods Cross-sectional postal survey of service users (n=1396) of six English out-of-hours providers. Participants reported on four GPPS items evaluating out-of-hours care (three items modified following cognitive interviews with service users), and 14 evaluative items from the Out-of-hours Patient Questionnaire (OPQ). Construct validity was assessed through correlations between any reliable (Cochrans α>0.7) scales, as suggested by a principal component analysis of the modified GPPS items, with the ‘entry access’ (four items) and ‘consultation satisfaction’ (10 items) OPQ subscales. Concurrent validity was determined by investigating whether each modified GPPS item was associated with thematically related items from the OPQ using linear regressions. Results The modified GPPS item-set formed a single scale (α=0.77), which summarised the two-component structure of the OPQ moderately well; explaining 39.7% of variation in the ‘entry access’ scores (r=0.63) and 44.0% of variation in the ‘consultation satisfaction’ scores (r=0.66), demonstrating acceptable construct validity. Concurrent validity was verified as each modified GPPS item was highly associated with a distinct set of related items from the OPQ. Conclusions Minor modifications are required for the English GPPS items evaluating out-of-hours care to improve comprehension by service users. A modified question set was demonstrated to comprise a valid measure of service users’ overall satisfaction with out-of-hours care received. This demonstrates the potential for the use of as few as four items in benchmarking providers and assisting services in identifying, implementing and assessing quality improvement initiatives.

Economical, Clinical, and Humanistic Outcomes and Pharmaceutical Care

This chapter outlines the Economical, Clinical, and Humanistic Outcomes (ECHO) model as a framework for the multidimensional classification of outcomes. Moving on from the traditional disease-oriented model, the ECHO model ensures that economic and humanistic measures are evaluated, as well as clinical variables. Consideration of all three outcome types is important when evaluating pharmaceutical care interventions through well-designed, rigorous trials.

A qualitative study of healthcare professionals’ perceptions of barriers and facilitators to successful medicines management for people with dementia in primary care.

not available: SESSION 1: GS MIXTE RESPIRATION Bitter taste receptors in the lung: a new pharmacological target? S Grassin-Delyle UPRES EA220, Hôpital Foch, Universit e Versailles Saint Quentin en Yvelines, Saint Quentin en Yvelines Bitter taste receptors (TAS2Rs) are known for long for their role in taste as sensors of the presence of toxic compounds in foods, but their unexpected expression in airways epithelium and smooth muscle cells or in peripheral blood leucocytes has been recently documented. This family of GPCRs includes about 25 members in humans and each subtype has a variable selectivity towards bitter compounds, some of them being restrictedly selective to a unique molecule and others responding to a wider range. More than a hundred molecules such as chloroquine, caffeine, strychnine, colchicine or erythromycin have thus been described as TAS2R agonists while TAS2R19, 41, 42, 45 and 60 are considered as orphans since no agonist has been identified. In the airways, the initial observation by Desphandes et al. (2010) described the relaxation of pre-contracted mouse trachea following exposure to chloroquine, denatonium, quinine or saccharine, which was suggested to be even more pronounced that the relaxation obtained with the reference relaxing agents b2 adrenoreceptor agonists. Interestingly, an original intracellular signaling pathway in the response of airway smooth muscle cells to bitter-taste receptor agonists was proposed, involving the G-protein bc subunit and leading to a localized increase in intracellular calcium, which in turn causes membrane hyperpolarisation through an activation of large conductance potassium channels (BK Ca). In addition to these results in cell cultures or airways preparations, inhaled bitter tastants were shown effective in decreasing airway resistance in ovalbumin-sensitized mice, but very little is known in humans to date. However, transcriptome analysis revealed upregulation of TAS2R signaling in peripheral blood leucocytes from patients with severe asthma, as well as a correlation between clinical markers of asthma severity and TAS2R expression. Overall, these works suggest that bitter taste receptors may constitute a new pharmacological target for obstructive lung diseases such as asthma and COPD. We will address the role of bitter taste receptors in respiratory pharmacology, with a special focus on results obtained in human tissues.

Pharmacists’ perceptions of the barriers and facilitators to successful medicines management for people with dementia in primary care

Abstract of paper presented at the Health Services Research and Pharmacy Practice Conference, University of Nottingham, UK, 10–11 April 2017In recent years, self-care has been in the forefront of UK health policy [1], with community pharmacies being promoted as a first point of contact for patients [2], when seeking advice for the treatment of a variety of conditions and minor ailments. As more medicines have become available without prescription this has led to community pharmacists dealing with a wider range of presenting problems and spending more time on making clinical decisions. Aims / objectives The area of how community pharmacists make a clinical diagnosis is under-researched. The aim of this exploratory study was to gain an initial insight on how community pharmacists make clinical decisions in order to reach a diagnosis. Method A qualitative methodology was employed where semi-structured, face-to-face interviews were conducted with community pharmacists that had been practicing for at least six months at the time of the interviews and did not hold, or were working towards, a prescribing qualification. Pharmacists were identified through snow balling sampling and consent sheets sent to their pharmacies’ registered address. Pharmacists who returned completed consent forms were recruited to the study. All interviews were audio recorded and transcribed ad verbatim. Interviews were analysed, with a team-based approach, using a clinical reasoning based framework analysis to identify themes and subthemes. Ethical approval was granted by the ethics committee at the University of Wolverhampton. Results Eight interviews were conducted across England, with five male and three female pharmacists, who had been practicing for periods ranging from one to forty years. The major theme that emerged from the analysis was the poor diagnostic knowledge and ability of the pharmacists and a non-evidence based approach to decision-making. Pharmacists constantly used and overly relied on mnemonic methods both for diagnostic purposes and product selection. Their motives within consultations appeared to be establishing an appropriate product to recommend, rather than the need to establish a diagnosis, and the inability to differentiate between the two processes. However, they did have a sense of the limitations of the methods they used and an awareness for the need to ‘delve deeper’ during consultations but could not articulate how or why this was the case. Themes and sub-themes are explained using confirmatory quotes from the data. Discussion or Conclusion The findings of this study suggest that even though community pharmacists are tasked with advising symptom-presenting patients, their poor clinical reasoning skills are preventing them from reaching appropriate diagnoses. In order for community pharmacists to better perform this role, greater emphasis should be given in teaching and practicing clinical reasoning skills during their studies and through continuous professional development. The study is limited by its small sample size. 1. Department of Health. The NHS Plan. A Plan for Investment, A Plan for Reform [Internet]. London: National Health Service; 2000 [cited 6 October 2012]. Available from: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_4002960 2. Royal Pharmaceutical Society. Improving Urgent and Emergency care through better use of pharmacists [Internet]; 2014 [cited 5 October 2016]. Available from: http://www.rpharms.com/policy-pdfs/urgent-and-emergency-care.pdf

The development of a core outcome set for medicines management interventions in people with dementia

Focal Points: Aim was to assess the impact of an educational intervention delivered by community pharmacists to improve self-management for people with mild to moderate psoriasis. Educational advice from pharmacists improved significantly patient knowledge, disease severity and quality of life. Community pharmacists could provide an important contribution to the care of patients with psoriasis Introduction: Psoriasis is a chronic inflammatory skin condition affecting up to 3% of the population in the UK. Most patients have mild to moderate disease which can be managed in primary care with topical therapies. Studies suggest that patients want, but rarely get, advice on the use of prescribed treatments. Community pharmacists have developed a more clinically focused supportive role with patients, though their role in helping those with long-term dermatological conditions is less clear. The aim of this research was to assess the impact of an educational intervention delivered by community pharmacists to improve self-management for people with mild to moderate psoriasis. Methods: Seven study pharmacies were selected based on their location (urban, rural etc.) to provide a range of different settings and pharmacists recruited via a comprehensive research network. Each was given a training guide on the management of psoriasis, with emphasis on patient education. Pharmacists identified patients prescribed topical psoriasis treatments, invited them to participate in the study (opportunistically or via a letter of invite) and obtained informed consent. During a face-to-face consultation in the pharmacy, the pharmacists provided education on psoriasis and its management and arranged a follow-up consultation 6 weeks later. During the consultations, pharmacists assessed patients’ knowledge and understanding of psoriasis and its management using the person-centred dermatology self-care index (PEDESI). This ten item tool evaluates the educational and support needs of those with long-term skin conditions. Pharmacists assigned an “ability score” for each item reflecting understanding. Scores were summed to give an overall score ranging from zero (worse state) to 30 (best state). In addition, disease severity and quality of life were self-assessed by patients using the self-assessed psoriasis and severity index (SAPASI) and dermatology quality of life index (DLQI) respectively. The primary outcome measure was the change in PEDESI score at at 6 weeks and secondary outcomes were changes in SAPASI and DLQI values. The study was approved by an NHS ethics committee. Results: Pharmacists recruited a total of 47 patients ̧ though 5 were lost to follow-up. The number of patients recruited per pharmacy ranged from 1 to 10. There was a significant increase in mean PEDESI scores (25.15 versus 17.78 P < 0.001) at 6 weeks compared to baseline. The increased mean PEDESI scores was mirrored by a rise in ability scores across all questions. Both SAPASI (11.60 versus 7.74, P < 0.001) and DLQI (7.21 versus 4.14, P < 0.001) scores improved significantly and 17 patients experienced a clinically meaningful change in quality of life, defined as a four-point improvement on the scale. Discussion: Pharmacist-led educational advice to patients with psoriasis improved disease and treatment knowledge, reducing disease severity and the impact on quality of life. Though limited by the sample size and a single follow-up, this is the first study to explore the potential role of pharmacists in helping to facilitate effective self-management in patients with long-term skin conditions. The results suggest a potential role for community pharmacists in the care of patients with psoriasis. Further studies are needed to explore the costeffectiveness of the intervention on patient-related disease outcomes compared to other services.

How appropriate is prescribing for people with dementia in primary care? A cross-sectional analysis

pharmacy, preferred opening hours and a validated tool to measure expectations of service quality. Using the edited electoral role to identify the sample, a pilot of 100 households was undertaken, followed by the main distribution to all households in the immediate area and a random sample from a neighbouring location (total 400). Reminders were sent to nonresponders one and two months after the first mailing. Data was stored and analysed in SPSS (descriptive frequencies).