Building the evidence for the impact of pharmacists in general practice: a mixed methods study

Oral presentation by final year PhD researcher, Georgios Dimitrios Karampatakis, at the PhD Pharmacy Conference, April 2019, Henley Business School, University of Reading.

Georgios Dimitrios Karampatakis
Professor Kath Ryan1, Dr Nilesh Patel1 and Dr Graham Stretch2
1Reading School of Pharmacy, University of Reading, Reading, RG6 6UB. UK
2Ealing GP Federation, 179C Bilton Road, Perivale, Greenford, Middlesex, UB6 7HQ. UK

Background: Since 2015, there has been an initiative to integrate pharmacists into UK general practices as a new healthcare service for patients. The goal is to have one general practice-based pharmacist per 30,000 patients by 2020/21. Despite the existence of some generic national measures (key performance indicators – KPIs), little is known about the service’s impact on patients and the healthcare system.

Objective: To identify strengths and limitations of the service (i.e. what works well and what does not, areas for improvement etc.) from the perspective of those involved.

Methods: The project uses a mixed methods design. Focus groups were conducted with general practice-based pharmacists to identify problems with measuring their impact. An e-Delphi study was then undertaken to identify the activities that general practice-based pharmacists thought should be recorded. In-depth interviews with community pharmacists and patients were carried out to elicit their experiences of the service (patient interviews are yet to be completed). All qualitative data was analysed thematically and quantitative data from the e-Delphi study was reported as descriptive statistics. Analysis and reporting are still ongoing.

Results: The national KPIs were deemed not to be fit for purpose in identifying pharmacists’ impact. Broad consensus was reached on a number of activities (disease specific and general medication reviews, medicines reconciliations and high-risk drug monitoring) viewed as the most important tasks to record for identifying general practice based pharmacists’ impact. Community pharmacists reported enhanced communication between themselves and their surrounding general practices as a result of pharmacists’ presence in general practice. Preliminary findings from patient interviews suggest that patients appreciate the opportunity for thorough discussions with pharmacists and, additionally, emphasize the importance of advertising the pharmacist’s role in this setting.

Conclusions: Results will inform general practices and national policy on how to shape the service to best meet the needs and expectations of healthcare providers and patients.

The experiences of people living with peripheral neuropathic pain in Kuwait: A process map of the patient journey

Oral presentation by final year PhD researcher, Maryam Alkandari, at the PhD Pharmacy Conference, April 2019, Henley Business School, University of Reading.

Maryam Alkandari
Professor Kath Ryan and Dr Amelia Hollywood
Reading School of Pharmacy, University of Reading, UK

Background: Peripheral neuropathy is a neurological disease characterized by pain, numbness, tingling, swelling, or muscle weakness due to nerve damage. It can be caused by multiple factors such as trauma, infections and metabolic problems such as diabetes. In Kuwait 54% of the diabetic population, have peripheral neuropathy. Understanding the patient journey by mapping their management plan is essential to identify areas for
improvement.

Method: In this exploratory, qualitative study conducted in Kuwait, 25 subjects with peripheral neuropathy took part in a one-on-one semi-structured interviews lasting 45-60 minutes. Interviews were transcribed, translated and coded using NVivo 12. Four individual patient journeys were mapped out in detail, then compared and condensed into a single process map. The remaining 21 interviews were then reviewed to ensure the final map represented all patient journeys. The map was then compared to existing international standards.

Results: Participants reported similar care pathways for their peripheral neuropathy and faced various difficulties; psychological (not receiving satisfactory care), medical issues (shortage of specialists) and administrative problems (long waiting referral periods). The process map identified that the current Kuwait system has similar pharmacological treatment guidelines to the UK. Major improvable gaps in care were apparent, however, including inadequate follow-up, waiting time, loss of medical documents, non-compliance with treatment protocols, variability in access to newer medicines, lack of patient awareness of the disease and its treatment, and poor communication between healthcare providers.

Discussion: Mapping the current patient journey identified areas for improvement. When compared to UK standards, the map indicated the need for an integrated approach within the Kuwait medical team, the use of technology for electronic medical recording and report transmission, along with education for patients.

Conclusion: Analysis of this pioneer patient journey map provided a strong strategic direction for the Kuwaiti healthcare system to address the patient experience in peripheral neuropathy.

Nurse involvement in the prescribing of antipsychotics in dementia in care homes

Poster presentation by PhD candidate, Amna Raza, at the the PhD Pharmacy Conference, April 2019, Henley Business School, University of Reading.

Amna Raza
1Professor Parastou Donyai, 1,2 Tim Langran and 2Sundus Jawad
1Department of Pharmacy, University of Reading, Reading, RG6 6UB; 2Berkshire CCG
Study Background: The behavioural and psychological symptoms of dementia (BPSD) describe a set of distressing symptoms (e.g. anxiety, aggression, calling out, wandering) that can affect the overall quality of life and the quality of care provided to those living with dementia. Antipsychotics are sometimes prescribed for the management of BPSD but they are associated with an increased risk of adverse effects including stroke and death. The high use of antipsychotics has been reported in care home settings, where one third of patients have dementia or memory problems. Studies have found that on-site staff request to prescribe antipsychotics is one of the major factors responsible for problematic
prescribing. There is in fact a dearth of evidence in the literature focussed on interventions that aim to change nursing staff beliefs and behaviour toward antipsychotic prescribing. Moreover, the theoretical underpinning of much of the work focussing on behaviour change in this area is unclear as studies have not made explicit the theoretical framework of their interventions. This provided the rationale for adapting an intervention based on Behaviour Change Techniques (BCT) to change nurses’ attitude toward prescribing in the current project.

Aim: To evaluate the effectiveness of behavioural change intervention on staff attitudes toward the use of antipsychotics in people with dementia in care homes (n=6) and on the actual prescribing of antipsychotics for these residents.

Methodology: This is a mixed method study, planned to be completed in 5 steps. Step 1: Antipsychotic in Dementia Attitude Questionnaire (ADAQ) constructed from an existing nurses’ behaviour questionnaire was revised using Theory of Planned Behaviour (TPB) construct procedure as described in Ajzen (2006). The resultant questionnaire (ADAQ-v1) will be subjected to content validity check and followed by pilot testing of questionnaire. The finalised version of questionnaire going to be named as ADAQ-vf will be used to determine nurses’ attitude toward prescribing of antipsychotics. Step 2:The researcher will review patient medication record by physical visit to each care home to monitor prescribing of antipsychotics in residents. Step 3: A work shop will be conducted to increase the understanding of staff about managing BPSD through posters and quick reference cards. Step 4: After 6 and 12 months of the study, the perception of nursing staff using ADAQ-vf and prescribing of antipsychotics for residents will be monitored . Step 5: Usability of the training material will be assessed by interviewing staff at each care homes at the end of the project.

A Pluralistic Qualitative Study of Medicine Adherence in Patients after Myocardial Infarction

Poster presentation by PhD candidate, Hannah Piekarz, at the the PhD Pharmacy Conference, April 2019, Henley Business School, University of Reading.

Hannah Piekarz

Professor Parastou Donyai and Mrs Catherine Langran

Reading School of Pharmacy, University of Reading, Reading, RG6 6UB. UK

 

Following an acute myocardial infarction (AMI), patients are prescribed a regime of cardioprotective medicines to prevent recurrent cardiovascular events and mortality. This is strongly recommended in international guidelines as clinical evidence shows improved long-term outcomes for patients who receive optimal therapy. Medication adherence in this patient group is poor, and current interventions such as physical memory aids or psychological motivational patient interviews have made improvements, but a single practical intervention with a significant effect to improve adherence has yet to be developed and implemented.

Medicine adherence comes from a complex set of behaviours, and this study aims to better understand the beliefs and experiences of medicine-taking in this group of patients. This will be completed through semi-structured interviews starting with people recruited from support groups, then snowballing will be used to draw in further appropriate participants. Data will be analysed using three methods in order to obtain multiple perspectives and a richer, more in-depth set of results. Grounded theory analysis will be used to model the processes involved in adherence to medication following AMI, interpretative phenomenological analysis will be used in order to better understand the experience from a patient’s perspective, and discourse analysis to illustrate the power relationships that exist through the process.

The results of this study could be used to better understand the problem of non-adherence in this group and then inform the design of an appropriate intervention to improve medicine adherence following AMI.

Pharmacist non-medical prescribing in primary care. A systematic review of views, opinions and attitudes

Poster presentation by PhD student, Timothy Mills, at the PhD Pharmacy Conference, April 2019, Henley Business School, University of Reading.

Timothy Mills
Dr Nilesh Patel and Professor Kath Ryan
Reading School of Pharmacy, University of Reading, Reading, RG6 6UB UK

Introduction: Non-medical prescribers (NMPs) are healthcare professionals, such as pharmacists and nurses, who have obtained an advanced qualification in prescribing. Uptake of non-medical prescribing by pharmacists has been slow. Pharmacist prescribing is intended to provide quicker and more efficient patient access to medicines, a reduction in doctor workload and enhanced professional satisfaction. This systematic review asks: “What are the barriers and facilitators to non-medical prescribing by primary care pharmacists?”

Aim: The purpose of this review is to look at the views, opinions and attitudes of pharmacists or graduates towards or about non-medical prescribing in primary care.

Methods: Medline, ScienceDirect, Embase and the University of Reading Summon Service were searched to identify qualitative and mixed methods papers that addressed the Aim. Papers published between January 2003 and September 2017 were included. Studies were quality assessed using the CASP checklist. The articles were coded and analysed using thematic synthesis.

Results: Eighty-five full text articles were reviewed from which 14 met the inclusion criteria. All articles were of moderate or high quality. Thematic synthesis identified two themes: (1) practice environment and (2) pharmacist’s role. Non-medical pharmacist prescribers reported increased job satisfaction and sense of professionalism, however, they often felt under prepared for the reality of unsupervised practice. Some pharmacists report prescribing has legitimised previous practice. Mentoring during training and post qualification improved pharmacists’ confidence to prescribe. They experienced both support and resistance from members of the primary care team, including other pharmacists and doctors. The practicalities of doing the job are hindered by the lack of access to patient records and resources.

Conclusion: The review identified perceived and real barriers to non-medical prescribing that could be overcome with appropriate training, mentoring and a supportive environment. Consideration of these will assist and advance pharmacist prescribing in primary care, with the associated positive outcomes for both patient care and the pharmacy profession