The effects of pharmacist prescribing on patient outcomes in the hospital setting: a systematic review

Objectives To synthesize the best available evidence on the safety and effectiveness of pharmacist prescribing on patient outcomes in patients who present to hospital. Background Pharmacist prescribing is legal in many countries. Different models of prescribing include dependent, collaborative and independent. Existing reviews of pharmacist prescribing focus on studies in the community setting, or both community and hospital settings. Other reviews focus on descriptions of current practice or perspectives of clinicians and patients on the practice of pharmacist prescribing. A systematic review on the effects of pharmacist prescribing on patient outcomes in the hospital has not been previously undertaken and is important as this practice can help ease the burden on the healthcare system. Inclusion criteria Studies with controlled experimental designs comparing pharmacist prescribing to medical prescribing in the hospital setting were included in the review. Primary outcomes of interest included clinical outcomes such as therapeutic failure or benefit, adverse effects and morbidity or mortality. Secondary outcomes included error rates in prescriptions, medication omissions on the medication chart, time or proportion of International Normalized Ratios in therapeutic range, time to reach therapeutic range and patient satisfaction. Methods A comprehensive three-step search strategy was utilized. The search was conducted in January 2017 in eight major databases from database inception. Only studies in English were included. The recommended Joanna Briggs Institute approach to critical appraisal, study selection and data extraction was used. Narrative synthesis was performed due to heterogeneity of the studies included in the review. Results The fifteen included studies related to dependent and collaborative prescribing models. In four studies that measured clinical outcomes, there was no difference in blood pressure management between pharmacists and doctors while patients of pharmacist prescribers had better cholesterol levels (mean difference in low density lipoprotein of 0.4 mmol/L in one study and 1.1 mmol/L in another; mean difference in total cholesterol of 1.0 mmol/L) and blood sugar levels (mean difference of fasting blood sugar levels of 15 mg/dL, mean difference of glycosylated hemoglobin of 2.6 %). In two studies, pharmacists were better at adhering to warfarin dosing nomograms than doctors (average of 100% versus 62% compliance). In six studies, when prescribing warfarin according to dosing nomograms, equivalent numbers or more patients were maintained in therapeutic range by pharmacist prescribers compared to doctors. The incidence of adverse effects related to anticoagulant prescribing was similar across arms but all six studies were underpowered to detect this outcome. Three studies found that pharmacist prescribers made less prescribing errors (20 to 25 times less errors) and omissions (three to 116 times less omissions) than doctors when prescribing patients’ usual medications on admission to hospital or in the pre-operative setting. Two studies reported that patients were as satisfied with the services provided by pharmacist prescribers as with doctors. Conclusions This review provides low to moderate evidence that pharmacists can prescribe to the same standards as doctors. Compared to doctors, pharmacists are better at adhering to dosing guidelines when prescribing by protocol and make significantly less prescribing errors when charting patients’ usual medications on admission to hospital.Thesis (M.Clin.Sc.) -- University of Adelaide, Joanna Briggs Institute, 201

Radiographer-led discharge for emergency care patients, requiring projection radiography of minor musculoskeletal injuries: a scoping review.

This is the final version. Available on open access from BMC via the DOI in this recordAvailability of data and materials: All data used and analysed during this study are included in this published article.BACKGROUND: Pressure on emergency departments (EDs) from increased attendance for minor injuries has been recognised in the United Kingdom. Radiographer-led discharge (RLD) has potential for improving efficiency, through radiographers trained to discharge patients or refer them for treatment at the point of image assessment. This review aims to scope all RLD literature and identify research assessing the merits of RLD and requirements to enable implementation. METHODS: We conducted a scoping review of studies relating to RLD of emergency care patients requiring projection radiography of minor musculoskeletal (MSK) injuries. MEDLINE, Embase and CINAHL, relevant radiography journals and grey literature were searched. Articles were reviewed and the full texts of selected studies were screened against eligibility criteria. The data were extracted, collated and a narrative synthesis completed. RESULTS: Seven studies with varying study designs were included in the review. The small number of studies was possibly due to a generally low research uptake in radiography. The main outcome for four studies was reduced length of stay in ED, with recall and re-attendance to ED a primary outcome in one study and secondary outcome for two other studies. The potential for increased efficiency in the minor MSK pathway patient pathway and capacity for ED staff was recognised. Radiographers identified a concern regarding the risk of litigation and incentive of increased salary when considering RLD. The studies were broadly radiographer focussed, despite RLD spanning ED and Radiology. CONCLUSION: There were a low number of RLD active radiographers, likely to be motivated individuals. However, RLD has potential for generalisability with protocol variations evident, all producing similar positive outcomes. Understanding radiography and ED culture could clarify facilitators for RLD to be utilised more sustainably into the future. Cost effectiveness studies, action research within ED, and cluster randomised controlled trial with process evaluation are needed to fully understand the potential for RLD. The cost effectiveness of RLD may provide financial support for training radiographers and increasing their salary, with potential future benefit of reduction in workload within ED. RLD implementation would require an inter-professional approach achieved by understanding ED staff and patient perspectives and ensuring these views are central to RLD implementation

Towards UK poSt Arthroplasty Follow-up rEcommendations (UK SAFE): protocol for an evaluation of the requirements for arthroplasty follow-up, and the production of consensus-based recommendations

Introduction: Hip and knee arthroplasties have revolutionised the management of degenerative joint diseases and, due to an ageing population, are becoming increasingly common. Follow-up of joint prostheses is to identify problems in symptomatic or asymptomatic patients due to infection, osteolysis, bone loss or potential peri-prosthetic fracture, enabling timely intervention to prevent catastrophic failure at a later date. Early revision is usually more straight-forward surgically and less traumatic for the patient. However, routine long-term follow-up is costly and requires considerable clinical time. Therefore, some centres in the UK have curtailed this aspect of primary hip and knee arthroplasty services, doing so without an evidence-base that such disinvestment is clinically- or cost-effective. Methods: Given the timeline from joint replacement to revision, conducting a randomised controlled trial (RCT) to determine potential consequences of disinvestment in hip and knee arthroplasty follow-up is not feasible. Furthermore the low revision rates of modern prostheses, less than 10% at 10 years, would necessitate thousands of patients to adequately power such a study. The huge variation in follow-up practice across the UK also limits the generalisability of an RCT. This study will therefore use a mixed-methods approach to examine the requirements for arthroplasty follow-up and produce evidence- and consensus-based recommendations as to how, when and on whom follow-up should be conducted. Four interconnected work packages will be completed: 1) a systematic literature review; 2a) analysis of routinely-collected NHS data from five national datasets to understand when and which patients present for revision surgery; 2b) prospective data regarding how patients currently present for revision surgery; 3) economic modelling to simulate long-term costs and quality-adjusted life years associated with different follow-up care models; 4) a Delphi-consensus process, involving all stakeholders, to develop a policy document which includes a stratification algorithm to determine appropriate follow-up care for an individual patient

Conceptual models in health economic evaluation: a new role

Healthcare budgets are limited, and decisions must be made about which healthcare technologies should be funded from these limited budgets. Decision makers rely on clinical and cost-effectiveness evidence on which to base their decisions, the gold standard vehicle for this evidence is a clinical trial. Guidance exists for conducting economic evaluations alongside clinical trials using standard treatment arm-based comparisons to assess cost-effectiveness, however because of differences in the purposes of the clinical effectiveness and cost-effectiveness analyses this conventional treatment arm-based economic evaluation is often uncertain. Furthermore, economic evaluations focus on the final cost-effectiveness summary measure without consideration of what is driving this measure. There is scope for providing a more detailed understanding of the conventional cost-effectiveness results. Conceptual models are simplified versions of real-life systems in a visual format, illustrating how key components of the system are linked and interact within it. In the field of economic evaluation conceptual models are recommended for and used as a guide to establish the structure of decision analytic models, in other fields they are also used as a communication tool, to aid understanding of the system and to give direction to research. The aim of this thesis was to expand the role of conceptual models in economic evaluation. This thesis proposed a new role for conceptual models to provide additional understanding to decision makers, extending the conventional economic evaluation analysis beyond a treatment arm-based analysis. This role was demonstrated using two case studies as illustrative examples, aiming to show how the role could be applied. This thesis demonstrates the value of an additional conceptual model driven analysis to supplement the conventional treatment arm-based analysis, adding further insight into the trial mechanism and what is driving the economic evaluation results. The contribution of this thesis to the field of economic evaluation is twofold; a new role for conceptual models in economic evaluation and a methodological framework for developing conceptual models in this new role

By incorporating the education of medical students and medical trainees in outpatient clinics, is the patient experience enhanced and their quality of care improved?

Background:There is limited consensus on whether medical trainees in secondary care outpatient departments affect patient care that is delivered, despite the increasing momentum to provide more clinical education in this setting.Objectives:The aim of this thesis was to explore the experiences of patients attending local teaching hospitals, before conducting a review of the literature, to ascertain whether medical training impacts on the quality of care delivered in secondary care outpatient clinics.Methods:Twenty-nine patients attending teaching clinics in a local hospital trust were interviewed. Thematic analysis was applied to reports on their experiences and their opinions on the relationship between trainees and quality of care, which provided a base for the search strategy of the scoping review and also a means to triangulate the evidence in the discussion.A broad range of English-language studies from 1994-2014 were then searched using a variety of electronic databases alongside the hand-searching of key medical education journals. Two researchers made the final decisions on paper inclusion according to predetermined inclusion and exclusion criteria.Results:Patients who were interviewed were happy to participate in teaching clinics, but none believed that their clinical outcome was altered by having a trainee present.In the scoping review, fifty-four papers met the inclusion criteria. Patient satisfaction was variable. Issues of concern included consent, quality of the research undertaken, discrepancies regarding whether teaching clinics afforded a higher quality of care and global patient satisfaction scores failing to provide the whole picture on patient experience.ConclusionPatients appear less satisfied with their experience of teaching clinics in secondary care compared to other health care settings. Future research should include robust studies on how the patient experience can be improved and clinical outcomes measured to enable safe and effective care for patients and a valuable learning experience for trainees

Diabetes-Related Complication in Canada; Prevalence of Complication, Their Association with Determinants and Future Potential Cost-Effectiveness of Pharmacy-Based Intervention

In the 21st century, diabetes mellitus (DM) emerged as one of the most prevalent non-communicable diseases, and poses a major problem for every health system in the world. Its global prevalence has more than doubled in the last three decades. As diabetes has become more prevalent, the health programming designed to target diabetes patients has remained inadequate and only heightened the burden. This heightened burden has manifested itself in the increased risk of complications common among patients with diabetes. These complications vary widely, and are typically categorized as either micro-vascular or macro-vascular depending upon the size of blood vessels that are compromised. Due to the havoc that can ensue by either type of complication, the increased risk of diabetes-related complications has been recognized as a serious threat to population health. To gain insight into the threat posed and how it will likely present in the Canadian population, patient’s data from the diabetes component of Survey on Living with Chronic Diseases in Canada (SLCDC-DM-2011) was analyzed. This analysis revealed that among Canadian diabetes patients, 80.26 percent reported having at least one type of diabetes-related complication. The most frequently reported complications were high blood pressure (54.65%), cataracts (29.52%), poor circulation (21.68%), and heart disease (19.4%). This analysis also revealed the predictive role of socio-economic factors associated with diabetes-related complications in Canada. Being married, having a higher income, and having a higher level of education were protective against most complications. In contrast, low levels of physical activity and high levels of HbA1C were important risk factors for many diabetes–related complications. Identifying common diabetes-related complications, protective factors and risk factors is useful for combating the threat posed by diabetes-related complications. To combat this threat in practice, healthcare professionals will play a significant role in the control and management of diabetes and its complications. Diabetes is a chronic disease that needs long-term treatment, and thus multi-disciplinary teams will be required. Increasingly, pharmacists are being determined as having a prominent position on these teams due to their accessibility to the Canadian population, and their expanding scope of practice. This profession has contributed positively to the long-term prognosis of patients with diabetes, in part, by aiding in the control and management of the disease. This aid oftentimes comes in the form of pharmacy-based interventions. Pharmacy-based interventions include a variety of services aimed at enabling patients with diabetes to have better control of their condition. I conducted a systematic review and meta-analysis to evaluate the effects of pharmacy-based interventions on clinical and non-clinical outcomes associated with diabetes-related complications. Four main databases were searched. Based upon my meta-analysis, the standardized absolute mean difference in reduction of HbA1C (%) from baseline to the time of the last follow-up significantly favoured patients in the pharmacy-based intervention group compared to those receiving care as usual (0.96%; 95% CI 0.71: 1.22, P<0.001). In addition, the standardized absolute mean difference in reduction of BMI unit (kg/m2) was 0.61 (95% CI 0.20: 1.03, P<0.001) in favour of the pharmacy-based intervention group. Both of these results demonstrate the positive effect pharmacy-based interventions can have on clinical outcomes. However, there is a dearth of evidence about the effects of pharmacy-based interventions on non-clinical outcomes, including health care utilization and quality of life. Therefore, it was not possible to evaluate non-clinical outcomes associated with diabetes-related complications in the same way. Each year healthcare expenses incurred from diabetes and its complications total more than US$827 billion. This health care cost is significant, and is only expected to grow alongside diabetes’ increasing prevalence. In light of this, a debate over the comparative effectiveness of the different strategies used to manage diabetes and its complications has been sparked. The development of analytic models that can be used as tools in determining budget prioritization and cost-effectiveness of interventions is beginning to be prioritized. To conduct an economic evaluation of these interventions, simulation models are necessary. These models estimate health outcomes, such as life years saved or Quality Adjusted Life Years (QALYs) gained, and account for the costs and health consequences associated with diabetes, its complications and risk factors. I developed a hybrid (agent-based/system dynamic) individual-level micro simulation model using 2,931 patient records from the SLCDC-2011. This model extrapolated the effects of pharmacy-based interventions on health outcomes, costs and health-related quality of life (HRQOL) over time through time-varying risk factors of diabetes-related complications. The treatment effects of pharmacy-based interventions were modeled as reductions in HbA1c levels, BMI, systolic blood pressure and LDL, all of which can affect the risk of progressing long-term complications. The annual costs of diabetes-related complications, as well as, costs associated with pharmacy-based intervention from a societal prospective, were also considered. Using this data, the micro-simulation model was able to estimate the expected number of major health events (heart failure, stroke, amputation, and blindness), QALYs over a patient’s lifetime, the patient’s economic burden on the health care system, and the extent to which pharmacy-based intervention can modify these outcomes. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the uncertainty around the results. Based on the results from my micro-simulation model, a pharmacy–based intervention could avert a total of 155 deaths associated with complications, 19 heart failures, 159 strokes, 24 amputations and 29 blindness events in a population of 2,931 patients over the next 50 years. In addition, the intervention could add 1,246 additional life-years (0.42 per patients) and 953 additional quality-adjusted life-years (0.32 per patients). The intervention would also be cost-effective in comparison to usual care, as indicated by the incremental discounted cost per QALY gained ($3928). Overall, these results suggest that an integrated pharmacy-based intervention could be a cost-effective strategy to control and manage diabetes-related complications in Canada. This is promising and has important public health implications that should not be ignored

Is comprehensive medication review cost-effective for patients admitted to hospital?

Problematic polypharmacy is a major public health problem, linked to high morbidity, mortality and use of National Health Service (NHS) resources. Medicines optimisation supports management of polypharmacy, chronic conditions and comorbidities by ensuring appropriate use of medicines. A key component is comprehensive medication review (CMR) – evaluating patients’ medication to optimise use and reduce medication-related problems and waste. CMR is recommended for problematic polypharmacy but its cost-effectiveness in UK hospitals is unknown and uptake is low. This thesis investigates CMR cost-effectiveness in UK NHS hospitals. CMR is complex, with multiple interacting components, and economic evaluation should accommodate the context and complexity. Two de novo cost-effectiveness models were developed, which demonstrated that CMR compared to usual care is a cost-effective use of resources for the general population of elderly acutely hospitalised patients over a short timeframe and for elderly patients with heart failure over a long timeframe. Analysis of data from 3,043 patients in five London hospitals revealed the difference between the number of medicines on discharge and the number of medicines on admission was less with CMR than with usual care. CMR was associated with an increase in the number of medicines deprescribed, held and started. The saving from deprescribing medicines was -£2.78 per month per patient larger in the CMR group than in the usual care group. The results of the empirical study complement the findings from both cost-effectiveness models. Further review and analysis showed that targeting CMR at patients with significant morbidity and mortality, potentially inappropriate prescribing and high treatment costs may increase its health and economic impact. This was exemplified by the cost-effectiveness of CMR for patients with heart failure; the study could be replicated for other diseases. This thesis indicates that well-delivered CMR should be routine hospital care for older patients with co-morbidity and/or specific target conditions.Open Acces

Applying Process-Oriented Data Science to Dentistry

Background: Healthcare services now often follow evidence-based principles, so technologies such as process and data mining will help inform their drive towards optimal service delivery. Process mining (PM) can help the monitoring and reporting of this service delivery, measure compliance with guidelines, and assess effectiveness. In this research, PM extracts information about clinical activity recorded in dental electronic health records (EHRs) converts this into process-models providing stakeholders with unique insights to the dental treatment process. This thesis addresses a gap in prior research by demonstrating how process analytics can enhance our understanding of these processes and the effects of changes in strategy and policy over time. It also emphasises the importance of a rigorous and documented methodological approach often missing from the published literature. Aim: Apply the emerging technology of PM to an oral health dataset, illustrating the value of the data in the dental repository, and demonstrating how it can be presented in a useful and actionable manner to address public health questions. A subsidiary aim is to present the methodology used in this research in a way that provides useful guidance to future applications of dental PM. Objectives: Review dental and healthcare PM literature establishing state-of-the-art. Evaluate existing PM methods and their applicability to this research’s dataset. Extend existing PM methods achieving the aims of this research. Apply PM methods to the research dataset addressing public health questions. Document and present this research’s methodology. Apply data-mining, PM, and data-visualisation to provide insights into the variable pathways leading to different outcomes. Identify the data needed for PM of a dental EHR. Identify challenges to PM of dental EHR data. Methods: Extend existing PM methods to facilitate PM research in public health by detailing how data extracts from a dental EHR can be effectively managed, prepared, and used for PM. Use existing dental EHR and PM standards to generate a data reference model for effective PM. Develop a data-quality management framework. Results: Comparing the outputs of PM to established care-pathways showed that the dataset facilitated generation of high-level pathways but was less suitable for detailed guidelines. Used PM to identify the care pathway preceding a dental extraction under general anaesthetic and provided unique insights into this and the effects of policy decisions around school dental screenings. Conclusions: Research showed that PM and data-mining techniques can be applied to dental EHR data leading to fresh insights about dental treatment processes. This emerging technology along with established data mining techniques, should provide valuable insights to policy makers such as principal and chief dental officers to inform care pathways and policy decisions

The role of interprofessional education within the medical undergraduate palliative care curriculum : a systematic review

INTRODUCTION:In the near future, population changes will impact on palliative care provision. We have to evolve to meet patients’ changing needs. Part of this evolution is to develop the role of the multidisciplinary team to provide patient-centred care. This highlights a learning need within medical education which can be achieved through the development of collaboration skills. Interprofessional education (IPE) has been utilised as a pedagogic tool by health professions in order to enhancing such skills. OBJECTIVES:To identify and synthesis evidence on the use of IPE as a method of delivering palliative care teaching to undergraduate medical students.METHOD:Primary studies were identified by searching bibliographic databases; MEDLINE, EMBASE, AMED, CINAHL, ERIC, BEI, BNI, PsychINFO, CENTRAL and the index of thesis and dissertations (UK) from January 1993 to February 2015. This was augmented by searching references from the preliminary search and key conference proceedings. Studies were included if the educational initiative was attended by two or more professions, including undergraduate medical students. A narrative synthesis of identified studies was performed with Kirkpatrick’s hierarchy of evaluation as a framework to assess learning outcomes. Data-driven thematic analysis was performed and a thematic schema created to illustrate the factors underpinning IPE. RESULTS:Eleven studies were identified. Significant variability in study quality was observed. Overall IPE was generally well received by students and facilitators. A positive response to educational initiatives was influenced by the perceived relevance and benefit of content to later clinical practice. Recruitment and educational setting were found to influence student satisfaction and motivation. Barriers to the implementation of IPE included; cultural differences and participant background. The consideration of learning outcomes in accordance with kirkpatrick’s hierarchy highlighted a paucity of data relating to societal and patient impact, with a lack of longterm follow-up.CONCLUSION:There is potential value in the use of IPE within the medical undergraduate palliative care curriculum, however there is need for more robust research with longterm follow-up