Terry Porteous

Are pharmacy-based minor ailment schemes a substitute for other service providers?: A systematic review

BACKGROUND Pharmacy-based minor ailment schemes (PMASs) have been introduced throughout the UK to reduce the burden of minor ailments on high-cost settings, including general practice and emergency departments. AIM This study aimed to explore the effect of PMASs on patient health- and cost-related outcomes; and their impact on general practices. DESIGN AND SETTING Community pharmacy-based systematic review. METHOD Standard systematic review methods were used, including searches of electronic databases, and grey literature from 2001 to 2011, imposing no restrictions on language or study design. Reporting was conducted in the form recommended in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and checklist. RESULTS Thirty-one evaluations were included from 3308 titles identified. Reconsultation rates in general practice, following an index consultation with a PMAS, ranged from 2.4% to 23.4%. The proportion of patients reporting complete resolution of symptoms after an index PMAS consultation ranged from 68% to 94%. No study included a full economic evaluation. The mean cost per PMAS consultation ranged from £1.44 to £15.90. The total number of consultations and prescribing for minor ailments at general practices often declined following the introduction of PMAS. CONCLUSION Low reconsultation and high symptom-resolution rates suggest that minor ailments are being dealt with appropriately by PMASs. PMAS consultations are less expensive than consultations with GPs. The extent to which these schemes shift demand for management of minor ailments away from high-cost settings has not been fully determined. This evidence suggests that PMASs provide a suitable alternative to general practice consultations. Evidence from economic evaluations is needed to inform the future delivery of PMASs.

A cohort study of influences, health outcomes and costs of patients’ health-seeking behaviour for minor ailments from primary and emergency care settings

Objectives To compare health-related and cost-related outcomes of consultations for symptoms suggestive of minor ailments in emergency departments (EDs), general practices and community pharmacies. Design Observational study; prospective cohort design. Setting EDs (n=2), general practices (n=6) and community pharmacies (n=10) in a mix of rural/urban and deprived/affluent areas across North East Scotland and East Anglia. Participants Adults (≥18 years) presenting between 09:00 and 18:00 (Monday–Friday) in general practices and 09:00–18:00 (Monday–Saturday) in pharmacies and EDs with ≥1 of the following: musculoskeletal pain; eye discomfort; gastrointestinal disturbance; or upper respiratory tract-related symptoms. Interventions Participants completed three questionnaires: baseline (prior to index consultation); satisfaction with index consultation and follow-up (2 weeks after index consultation). Main outcome measures Symptom resolution, quality of life, costs, satisfaction and influences on care-seeking behaviour. Results 377 patients participated, recruited from EDs (81), general practices (162) and community pharmacies (134). The 2-week response rate was 70% (264/377). Symptom resolution was similar across all three settings: ED (37.3%), general practice (35.7%) and pharmacy (44.3%). Mean overall costs per consultation were significantly lower for pharmacy (£29.30 (95% CI £21.60 to £37.00)) compared with general practice (£82.34 (95% CI £63.10 to £101.58)) and ED (£147.09 (95% CI £125.32 to £168.85)). Satisfaction varied across settings and by measure used. Compared with pharmacy and general practice use, ED use was significantly (p<0.001) associated with first episode and short duration of symptom(s), as well as higher levels of perceived seriousness and urgency for seeking care. Convenience of location was the most common reason for choice of consultation setting. Conclusions These results suggest similar health-related outcomes and substantially lower costs with pharmacy consultations for minor ailments. Effective strategies are now needed to shift demand for minor ailment management away from EDs and general practices to the community pharmacy setting.

Screening for major diseases in community pharmacies: a systematic review

The aim of this systematic review was to assess the published evidence about the feasibility and acceptability of community pharmacy‐based screening for major diseases.

A randomised controlled trial of the effects of note-based medication review by community pharmacists on prescribing of cardiovascular drugs in general practice

Objective Recent trends in primary care have seen closer working relationships between community pharmacists and general practitioners (GPs) in an attempt to improve the effectiveness and efficiency of prescribing. Community pharmacists are appropriate for a role in the management of prescribed medicines because of their detailed training in pharmacology, therapeutics and pharmaceutics. The aim of this project was to quantify the benefit of a general practice‐based, community pharmacist‐led, note‐based medication review of patients with hypertension or angina.

Physical Disease and Resilient Outcomes: A Systematic Review of Resilience Definitions and Study Methods

Background Findings from physical disease resilience research may be used to develop approaches to reduce the burden of disease. However, there is no consensus on the definition and measurement of resilience in the context of physical disease. Objective The aim was to summarize the range of definitions of physical disease resilience and the approaches taken to study it in studies examining physical disease and its relationship to resilient outcomes. Methods Electronic databases were searched from inception to March 2013 for studies in which physical disease was assessed for its association with resilient outcomes. Article screening, data extraction, and quality assessment were carried out independently by 2 reviewers, with disagreements being resolved by a third reviewer. The results were combined using a narrative technique. Results Of 2280 articles, 12 met the inclusion criteria. Of these studies, 1 was of high quality, 9 were of moderate quality, and 2 were low quality. The common findings were that resilience involves maintaining healthy levels of functioning following adversity and that it is a dynamic process not a personality trait. Studies either assessed resilience based on observed outcomes or via resilience measurement scales. They either considered physical disease as an adversity leading to resilience or as a variable modifying the relationship between adversity and resilience. Conclusion This work begins building consensus as to the approach to take when defining and measuring physical disease resilience. Resilience should be considered as a dynamic process that varies across the life-course and across different domains, therefore the choice of a resilience measure should reflect this.

Estimating the burden of minor ailment consultations in general practices and emergency departments through retrospective review of routine data in North East Scotland

Background. Minor ailment attendances in general practices and emergency departments (EDs) place significant burden on health care resources. Objectives. To estimate the prevalence and type of minor ailment consultations for adults in general practice and ED that could be managed in a community pharmacy. Methods. Retrospective review of routine data from general practices (n = 2) and one ED in North East Scotland. Two independent consensus panels assessed each consultation summary to determine whether it represented a minor ailment. Outcomes included prevalence of consultations for minor ailments in general practice and ED and frequency of different minor ailment type that could be managed in community pharmacies. Results. In total, of the 494 general practice and 550 ED consultations assessed, 13.2% [95% confidence interval (CI): 18.6–25.9%] and 5.3% (95% CI: 4.0–8.0%), respectively, were categorized as minor ailments suitable for management in community pharmacies. Consensus among panel members was moderate for general practice consultations, but fair to poor for ED consultations. Agreement between uni- and multi-disciplinary panels was good. Applied to national data, these estimates would equate to ~18 million general practice and 6500000 ED consultations that could be redirected to community pharmacy, equating to ~£1.1 billion in resources. Conclusion. Minor ailment consultations still present a major burden on higher cost settings. Effective strategies are needed to raise awareness among patients and health professionals regarding conditions that can be managed effectively in pharmacies and to change patient health-seeking behaviour for such conditions.

Preferences for Managing Symptoms of Differing Severity: A Discrete Choice Experiment

BACKGROUND To design cost-effective health services it is important to understand why people adopt particular symptom management strategies. AIM To establish the relative importance of factors that influence decision making when managing symptoms of differing severity, to establish how people trade between these factors, and to estimate the monetary value placed on different management types. DESIGN Discrete choice experiment. SETTING UK online research panel. METHOD Successive members of an online panel were invited to participate until 480 discrete choice experiment questionnaires were completed. Relative preferences for managing three symptom scenarios of varying severity were measured. Symptom management was described by three characteristics (management type, availability, and cost). Preferences for ways of managing symptoms were measured by using conditional logit analysis. RESULTS A total of 98.5% of the completed questionnaires were valid (473 of 480 respondents). People preferred to manage minor symptoms by self-care or by visiting a pharmacy and were willing to pay £21.58 and £19.06, respectively, to do so. For managing moderately severe symptoms, people preferred to consult a general practitioner and were willing to pay £34.86 for this option. People preferred to manage potentially very severe symptoms by consulting a general practitioner and were willing to pay £73.08 to do so. Respondents were willing to trade between management types; options less preferred became more attractive when waiting time and cost were reduced. CONCLUSION People value self-care, supported self-care, and general practitioner consultation differently depending on the type of symptoms. Manipulating costs to users and waiting times for different services could allow policymakers to influence the services people choose when managing symptoms.

Managing Minor Ailments; The Public’s Preferences for Attributes of Community Pharmacies. A Discrete Choice Experiment

Background Demand for health services continues to rise. Greater use of community pharmacy services instead of medical services for minor ailments could help relieve pressure on healthcare providers in high-cost settings. Community pharmacies are recognised sources of treatment and advice for people wishing to manage these ailments. However, increasing the public’s use of pharmacy services may depend on attributes of pharmacies and their staff. This study aimed to determine the general public’s relative preferences for community pharmacy attributes using a discrete choice experiment (DCE). Method A UK-wide DCE survey of the general public was conducted using face-to-face computer-assisted personal interviews. Attributes and levels for the DCE were informed by a literature review and a cohort study of community pharmacy customers. The context for the experiment was a minor ailment scenario describing flu-like symptoms. The DCE choice sets described two hypothetical community pharmacy services; respondents were asked to choose which (if either) of the two pharmacies they would prefer to help them manage symptoms. Data from 1,049 interviews were analysed using an error components logit model. Willingness to pay (WTP), a monetary measure of benefit, was estimated for the different attribute levels. Results When seeking help or treatment for flu-like symptoms, respondents most valued a pharmacy service that would improve their understanding and management of symptoms (WTP = £6.28), provided by staff who are trained (WTP (pharmacist) = £2.63: WTP(trained assistant) = £3.22), friendly and approachable (WTP = £3.38). Waiting time, pharmacy location and availability of parking also contributed to respondents’ preferences. WTP for a service comprising the best possible combination of attributes and levels was calculated as £55.43. Conclusion Attributes of a community pharmacy and its staff may influence people’s decisions about which pharmacy they would visit to access treatment and advice for minor ailments. In line with the public’s preferences, offering community pharmacy services that help people to better understand and manage symptoms, are provided promptly by trained staff who are friendly and approachable, and in a local setting with easy access to parking, has the potential to increase uptake amongst those seeking help to manage minor ailments. In this way it may be possible to shift demand away from high-cost health services and make more efficient use of scarce public resources.

Management of drug misuse: an 8-year follow-up survey of Scottish GPs

This study repeated a Scotland-wide survey of one-in-four GPs from 2000, to compare findings with 2008. A 60% response was achieved (of 1065). Almost 44% of GPs were treating drug misusers (62% in 2000). Enhanced services were provided by less than half of practices. Seven per cent of responders were only comfortable prescribing below the recommended minimum dose of 60 mg methadone, (33% in 2000). Over 70% offered blood-borne virus screening and 71% were aware of patients using psychostimulants. Recent changes, particularly the new GP contract may have decreased GP involvement in treating drug misusers.

Using discrete choice experiments to evaluate alternative electronic prescribing systems

Objective — To assess the relative importance to pharmacists and general practitioners (GPs) of different characteristics of electronic prescribing systems.