Zachariah Nazar

A systematic review of the role of community pharmacies in improving the transition from secondary to primary care

AIM We set out to determine the potential contribution of community pharmacists to improve the transfer of care of patients from secondary to primary care settings. METHOD We systematically reviewed the literature on interventions that involved community pharmacy post-discharge. We considered all relevant studies, including both randomized and non-randomized controlled trials, irrespective of patient population. Our primary outcome was any impact on patient and medication outcomes, while the secondary outcome was to identify intervention characteristics that influenced all reported outcomes. RESULTS We retrieved 14 studies that met our inclusion criteria. There were four studies reporting outcomes relating to the identification and rectification of medication errors that were significantly improved with community pharmacy involvement. Other patient outcomes such as medication adherence and clinical control were not unanimously positively or negatively influenced via the inclusion of community pharmacy in a transfer of care post-discharge intervention. Some inconsistencies in implementation and process evaluation of interventions were found across the reviewed studies. This limited the accuracy with which true impact could be considered. CONCLUSIONS There is evidence that interventions including a community pharmacist can improve drug related problems after discharge. However, impact on other outcomes is not consistent. Further studies are required which include process evaluations to describe fully the context of the intervention so as to determine better any influencing factors. Also applying more stringent controls and closer adherence to protocols in both intervention and control groups would allow clearer correlations to be made between the intervention and the outcomes.

Summative service and stakeholder evaluation of an NHS-funded community Pharmacy Emergency Repeat Medication Supply Service (PERMSS).

Objectives Service and stakeholder evaluation of an NHS-funded service providing out-ofhours (OOH) emergency repeat medications to patients self-presenting at community pharmacies. Setting Community pharmacies across the North East of England accredited to provide this service. Participants Patients self-presenting to community pharmacies during OOH periods with emergency repeat medication supply requests. Intervention Community pharmacists assessed each request for clinical appropriateness and when suitable provide an emergency repeat medication supply, with additional pharmaceutical advice and services if required. Primary outcomes Number of emergency repeat medication supplies, time of request, reason for access, medication(s), pharmaceutical advice and services provided. Secondary outcomes were community pharmacist and patient satisfaction. Results A total of 2485 patients were managed across 227 community pharmacies (15 December 2014 to 7 April 2015). Most patients presented on Saturdays, with increased activity over national holidays. Older age was associated with increased service use. Of the 3226 medications provided, 439 were classified as high risk. Patients found this service easy to access and were willing to access the community pharmacy in the future for medication-related issues. In the absence of this service, 50% of patients would have missed their medication(s) until they saw their doctor and a further 46% would have accessed an alternative service. The cost of National Health Service (NHS) service(s) for patients who would have accessed an alternative OOH service was estimated as 37 times that of the community pharmacy service provided. Community pharmacists were happy to provide this service despite increased consultation times and workload. Conclusions Community pharmacists were able to manage patients’ OOH requests for emergency repeat medication and patients were happy with the service provided. Since the service cost was favourable when compared with alternative OOH services, it would be a viable option to reduce the workload on the wider NHS.

Use of a service evaluation and lean thinking transformation to redesign an NHS 111 refer to community Pharmacy for Emergency Repeat Medication Supply Service (PERMSS)

Objectives To demonstrate the contribution of community pharmacy from NHS 111 referrals out of hours (OOH) for emergency supply repeat medication requests via presentation of service activity, community pharmacist feedback and lean thinking transformation. Design Descriptive service evaluation using routine service activity data over the pilot period; survey of community pharmacists, and service redesign through lean thinking transformation. Setting North East of England NHS 111 provider and accredited community pharmacies across the North East of England. Participants Patients calling the North East of England NHS 111 provider during OOH with emergency repeat medication supply requests. Interventions NHS 111 referral to community pharmacies for assessment and if appropriate, supply of emergency repeat medication. Main outcome measures Number of emergency repeat medication supply referrals, completion rates, reasons for rejections, time of request, reason for access, medication(s), pharmaceutical advice and services provided. Secondary outcomes were community pharmacist feedback and lean thinking transformation of the patient pathway. Results NHS 111 referred 1468 patients to 114 community pharmacies (15/12/2014–7/4/2015). Most patients presented on Saturdays, with increased activity over national holidays. Community pharmacists completed 951 (64.8%) referrals providing 2297 medications; 412 were high risk. The most common reason for rejecting referrals was no medication in stock. Community pharmacists were positive about the provision of this service. The lean thinking transformation reduced the number of non-added value steps, waits and bottlenecks in the patient pathway. Conclusions NHS 111 can redirect callers OOH from urgent and emergency care services to community pharmacy for management of emergency repeat medication supply. Existing IT and community pharmacy regulations allowed patients to receive a medication supply and pharmaceutical advice. Community pharmacists supported integration into the NHS OOH services. Adopting lean thinking provided a structured framework to evaluate and redesign the service with the aim to improve effectiveness and efficiency.

Consensus methodology to determine minor ailments appropriate to be directed for management within community pharmacy

Background: National Health Service (NHS) 111, a medical helpline for urgent care used within the England and Scotland, receives significant numbers of patient calls yearly for a range of clinical conditions. Some are considered high acuity and mainly directed to urgent and emergency care. Low acuity conditions are also directed to these costly, overburdened services. Community pharmacy is a recognised setting for effective low acuity condition management and could offer an alternative. Objective: To design and evaluate a new NHS111 pathway re‐directing patients with low acuity conditions to community pharmacy. Methods: Two consensus development stakeholder workshops were undertaken. A “low acuity” condition was defined as one that can be clinically assessed by a community pharmacist and requires a treatment and/or advice available within a community pharmacy. Retrospective NHS111 patient data (February–August 2016) from the North East of England and access to the NHS Pathways clinical decision support software were available to stakeholders. The NHS111 data demonstrated the volume of patient calls for these conditions that could have been redirected to community pharmacy. Results: Stakeholders reached consensus that 64 low acuity conditions could be safely redirected to community pharmacy via NHS111. This represented approximately 35,000 patients (11.5% of total) being shifted away from the higher cost settings in the North East region alone during February–August 2016. The stakeholder group discussions provided rationale behind their classifications of conditions to ensure patient safety, the care experience and added value. Conclusions: The resulting definitive list of low acuity conditions that could be directed to community pharmacy via NHS111 could result in a shift of workload from urgent and emergency care settings. Future work needs to evaluate the cost, clinical outcomes, patient satisfaction of a community pharmacy referral service that has the potential to improve integration of community pharmacy in the wider NHS.

A consensus approach to investigate undergraduate pharmacy students' experience of interprofessional education

Objective. To assess the development of knowledge, attitudes, and behaviors for collaborative practice among first-year pharmacy students following completion of interprofessional education. Methods. A mixed-methods strategy was employed to detect student self-reported change in knowledge, attitudes, and behaviors. Validated survey tools were used to assess student perception and attitudes. The Nominal Group Technique (NGT) was used to capture student reflections and provide peer discussion on the individual IPE sessions. Results. The validated survey tools did not detect any change in students’ attitudes and perceptions. The NGT succeeded in providing a milieu for participating students to reflect on their IPE experiences. The peer review process allowed students to compare their initial perceptions and reactions and renew their reflections on the learning experience. Conclusion. The NGT process has provided the opportunity to assess the student experience through the reflective process that was enriched via peer discussion. Students have demonstrated more positive attitudes and behaviors toward interprofessional working through IPE.

0086 qualitative analysis of stakeholders’ perspectives on the impact of the Healthy Living Pharmacy (HLP) project in Portsmouth

Research poster from Royal Pharmaceutical Society (RPS) Annual Conference 2013, 8-9 September 2013, Birmingham, UKFocal points 1. Polypharmacy is common amongst patients with limited life expectancy; 2. Prescribing of inappropriate medicines for patients with limited life expectancy can lead to multiple drug interactions of varying severity; 3. Patients with limited life expectancy should have their medicines reviewed in line with the original therapeutic goals. Background For patients with limited life expectancy – typically surviving for less than one year from diagnosis – polypharmacy is common as medication is prescribed to manage both life limiting illness and to treat or prevent other long-term conditions. Consequently, there is an increased risk of developing drug-related toxicity resulting from drug-drug or drugdisease interactions. The aim of this work was to assess the prevalence of inappropriate medication and identify any potential theoretical drug-drug interactions in patients attending a specialist palliative care unit. Methods This was a prospective study that examined medication and medical histories for patients attending a specialist palliative care day care centre from November 2012 until March 2013. Medication was assessed for appropriateness using a conceptual framework, which considers remaining life expectancy of the patient, time until benefit of the treatment, goals of care and treatment targets. 1 Consensus was reached via Delphi methodology using a range of clinical pharmacists and consultants in palliative medicine; to reach consensus agreement was required from all panel members. Drug interactions were identified and assessed according to significance using the drug interaction recognition software, Proscript. Drug interactions identified as significant were further sub-classified as moderate or severe based upon the potential to cause harm or hospitalisation, if they were reversible or irreversible and, if any treatment would be required to manage the outcome. Results A total of 132 patients were assessed during the study period, 108 (82%) had cancer, 8 (6%) congestive heart failure, 11 (8%) severe chronic obstructive pulmonary disease and 5 (4%) Parkinson’s disease. In total, the number of medications taken was 1532 (mean per patient, 12; range 1 to 21). Of the 1532 medicines assessed, 238 (16%) were considered to be inappropriate given the patients limited life expectancy. Out of the 132 patients assessed, 92 (70%) were taking at least one inappropriate medication. The most common therapeutic group considered inappropriate were the statins, which were prescribed in 35 patients (27%). The drug interaction recognition software identified a total of 267 potential drug interactions: 155 were considered non-significant, while 112 were classified as significant. Among those identified as significant, 92 were considered moderate while 20 were considered severe. In our study, discontinuing inappropriate medicine would prevent 57 non-significant, 23 moderate and 8 severe potential drug interactions. The most frequent major potential drug interaction that could be prevented by discontinuing inappropriate medication was between simvastatin (> 20 mg daily) and amlodipine, a well-defined drug interaction, which increases the risk of myopathy; this was identified in 4 patients. Discussion Our results show that the majority of people accessing the day care centre in a specialist palliative care unit are being prescribed many inappropriate medications in view of their life limiting illness. These inappropriate medications contribute to potential drug interactions and thereby increase the risk of patients developing drug-related toxicty. Our findings are consistent with the literature and build upon our previous work that showed patients with advanced lung cancer take many inappropriate medications, some of which can potentially interact with chemotherapy and contribute to negative outcomes for patients. 2 In conclusion, these findings demonstrate there is potential for pharmacists to become involved in medication review for patients with limited life expectancy in order to faciliate discontinuation of inappropriate medication in the context of the origninal therapeutic goals. References 1. Holmes HM, Hayley DC, Alexander GC et al. Reconsidering medication appropriateness for patients late in life. Archives of Internal Medicine. 2006, 166, 605-9. 2. Todd A, Williamson S, Husband A, et al. Patients with advanced lung cancer: is there scope to discontinue inappropriate medication? International Journal of Clinical Pharmacy. 2013, 35, 181-4The End of Life Care Strategy published by the Department of Health in 2008, describes the role healthcare and non-healthcare professionals, including pharmacists, can play in the delivery of care to people at the end of life. The minimum level of skills and knowledge described for the effective provision of healthcare within various sectors highlights the need for the highest level of communication skills and collaborative working within healthcare teams1. Pharmacy education has responded to develop curricula that incorporate experience-based learning that involves ‘participation in practice’ evolving along a spectrum from passive observation to performance. This study reports students’ qualitative evaluation of a placement in practice with respect to outcomes achieved from the experience.• This study aimed to explore the views of the senior learning and development managers (SLDMs) at large multiple community pharmacies (LMCPs) on pharmacist professional development. • Participants recognised that community pharmacists cannot fulfil their roles without further development. • Employer support for postgraduate qualifications as a means to address these development needs has been limited and opportunities have tended to be restricted to community pharmacists performing successfully in their role.