One lithium level >1.0 mmol/L causes an acute decline in eGFR: findings from a retrospective analysis of a monitoring database

Objectives Lithium is a mainstay of bipolar disorder treatment, however, there are still differences in opinion on the effects of lithium use on renal function. The aim of this analysis was to determine if there is an association between short-term exposure to various elevated lithium levels and estimated-glomerular filtration rate (eGFR) at ≤3 months, 6 months (±3 months) and 1 year (±3 months) follow-up. Setting Norfolk-wide (UK) lithium register and database. Participants 699 patients from the Norfolk database. Primary outcome measures eGFR change from baseline at ≤3 months, 6 months (±3 months) and 1 year (±3 months) after exposure to a lithium level within these ranges: 0.81–1.0 mmol/L (group 2), 1.01–1.2 mmol/L (group 3) and 1.21–2.0 mmol/L (group 4). The reference group was patients whose lithium levels never exceeded 0.8 mmol/L. Results Compared to the reference group, groups 3 and 4 showed a significant decrease in eGFR in the first 3 months after exposure (p=0.047 and p=0.040). At 6 months (±3 months) postexposure group 4 still showed a decline in eGFR, however, this result was not significant (p=0.298). Conclusions These results show for the first time that a single incident of a lithium level >1.0 mmol/L is associated with a significant decrease in eGFR in the following 3 months when compared to patients whose lithium levels never exceeded 0.8 mmol/L. It is still not known whether the kidneys can recover this lost function and the impact that more than a single exposure to a level within these ranges can have on renal function. These results suggest that lithium level monitoring should be undertaken at least every 3 months, in line with current UK guidelines and not be reduced further until the impact of more than one exposure to these lithium levels has been fully established

The potential for deprescribing in care home residents with Type 2 diabetes

Background: Type 2 diabetes is a common diagnosis in care home residents that is associated with potentially inappropriate prescribing and thus risk of additional suffering. Previous studies found that diabetes medicines can be safely withdrawn in care home residents, encouraging further investigation of the potential for deprescribing amongst these patients. Objectives: Describe comorbidities and medicine use in care home residents with Type 2 diabetes; identify number of potentially inappropriate medicines prescribed for these residents using a medicines optimisation tool; assess clinical applicability of the tool. Setting Thirty care homes for older people, East Anglia, UK. Method: Data on diagnoses and medicines were extracted from medical records of 826 residents. Potentially inappropriate medicines were identified using the tool ‘Optimising Safe and Appropriate Medicines Use’. Twenty percent of results were validated by a care home physician. Main outcome measure: Number of potentially inappropriate medicines. Results: The 106 residents with Type 2 diabetes had more comorbidities and prescriptions than those without. Over 90 % of residents with Type 2 diabetes had at least one potentially inappropriate medication. The most common was absence of valid indication. The physician unreservedly endorsed 39 % of the suggested deprescribing, and would consider discontinuing all but one of the remaining medicines following access to additional information. Conclusion: UK care home residents with Type 2 diabetes had an increased burden of comorbidities and prescriptions. The majority of these patients were prescribed potentially inappropriate medicines. Validation by a care home physician supported the clinical applicability of the medicines optimisation tool

The national consultation skills for pharmacy practice program in England

Background: Pharmacy professionals are playing an increasing role in caring for patients, yet evidence has shown their consultation skills are lacking. Objective: This article aims to discuss the need to enhance pharmacy professionals' (pharmacists and pharmacy technicians) consultation skills in England and describe the development of a national consultation skills training program to meet these needs. Methods: The Centre for Pharmacy Postgraduate Education led on a project to create a consultation skills training program for all pharmacy professionals across England. The program embedded a set of consultation skills practice standards developed by a large task and finish group consisting of pharmacy professionals of varying roles from the National Health Service, private pharmacy organizations and academia. Key findings: A Consultation Skills for Pharmacy Practice (CSfPP) training program, consisting of a distance learning workbook and website, was produced and disseminated to all registered pharmacy professionals in England, in March 2014. Conclusions: The first consultation skills training program of its kind was created that aimed to address the growing need to improve the consultations skills of pharmacy professionals in England. Future work will examine the reception of the CSfPP among pharmacy professionals and the impact it has on their practice

Exploring what patients think when answering the Interpersonal Skills Questionnaire (ISQ): A ‘think aloud’ study

Background: The Interpersonal Skills Questionnaire (ISQ) was developed to collect patient feedback on consultation skills of practitioners. However, it has not yet been evaluated with pharmacists. Objective: To explore the thinking process of patients as they completed the ISQ following a consultation with a pharmacist. Methods: A qualitative think aloud (TA) methodology was used to explore patients' thinking while completing the ISQ following a consultation with a pharmacist. The study was conducted in secondary care with outpatients ≥18 years old. Interviews were carried out in rounds and were informally analysed (i.e., by writing notes while listening to recordings) to identify any associated major problem(s). Discussions were held between researchers to determine whether changes were needed based on patients' comments. Results: Eight patients in total (50% females) participated in this study (mean age: 48 years). Three rounds of TA were conducted. Most items of the ISQ were interpreted similarly by all participants with no major problems necessitating refining the ISQ. Conclusions: Modification of the ISQ was unnecessary as interviews demonstrated no major problems with its use. The ISQ is thus a potentially suitable tool to collect patient feedback on pharmacists' consultations

COVID-19 pandemic challenges and lessons learned by pharmacy educators around the globe

The coronavirus identified in 2019 (COVID-19) has affected peoples’ lives worldwide. This pandemic forced both pharmacy faculty members and students to adapt to a new teaching and learning environment not only in the United States but around the globe. Pharmacy educators faced challenges and opportunities to convert classroom learning and experiences, as well as student assessments, to a remote or online format. The unique approaches taken to overcome difficulties in various countries showed pharmacy faculty members’ resilience in the face of adversity and their determination to continue providing education to students. The pandemic also shed light on areas needing improvement for pharmacy educators to work on in the future

Learning from community pharmacists' initial experiences of a workplace-based training program

Introduction:  To prepare community pharmacists for the provision of clinical and patient-focused services, a novel postgraduate course for community pharmacists in the United Kingdom was developed. The program incorporated personal development planning against a personal development framework, workplace mentoring, employment of work-based assessment tools, activities that encouraged increased inter-professional working, reflection, and opportunities for peer support. Objectives were to identify course components that support development, describe the effect on practice, and explore the perceived advantages and disadvantages of this model of postgraduate education. Methods:  Interviews were conducted with a purposive sample of 15 community pharmacists after they had completed approximately one year of the three-year course. A topic guide covering approaches to learning, rationale for course selection, course experiences to date, and impact on practice was used. Interview recordings were thematically analyzed. Results:  Two themes were identified. ‘Support for learning’ describes the components of the course that provided support for learning, including opportunities to learn with and from others, workplace mentoring, and facilitated access to general practitioners. ‘Outcomes of learning’ encompasses how the course was a way of effecting change within existing roles and the increase in confidence and motivation to change practice. Conclusions:  The model has merit in supporting community pharmacists to develop the confidence and competence required for extended clinical and patient-focused roles. While this model of learning seems to provide educational value, further research is required to determine whether the additional resources required to provide workplace mentoring, use work-based assessment tools, and encourage inter-professional working are justified

Clinical and cost effectiveness of a multi-professional medication reviews in care homes (CAREMED)

Objectives With 70% of care home residents experiencing a medication error every day in the UK, better multi‐professional working between medical practitioners, pharmacists and care homes was recommended. The aim of this study was to determine the effectiveness (falls reduction) and cost‐effectiveness, of a multi‐professional medication review (MPMR) service in care homes for older people. Method A total of care homes in the East of England were cluster randomised to ‘usual care’ or two multi‐professional (General practitioner, clinical pharmacist and care homes staff) medication reviews during the 12‐month trial period. Target recruitment was 900 residents with 10% assumed loss to follow‐up. Co‐primary outcome measures were number of falls and potentially inappropriate prescribing assessed by the Screening Tool of Older Persons Prescriptions. Key findings A total of 826 care home residents were recruited with 324 lost to follow‐up for at least one primary outcome measure. The mean number of falls per resident per annum was 3.3 for intervention and 3.0 for control (P = 0.947). Each resident was found to be prescribed 0.69 (intervention) and 0.85 (control) potentially inappropriate medicines after 12 months (P = 0.046). No significant difference identified in emergency hospital admissions or deaths. Estimated unadjusted incremental mean cost per resident was £374.26 higher in the intervention group. Conclusions In line with other medication review based interventions in care homes, two MPMRs improved medication appropriateness but failed to demonstrate improvements in clinical outcomes. From a health system perspective costs where estimated to increase overall and therefore a different model of medicines management is required

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Pharmacist provided medicines reconciliation within 24 hours of admission and on discharge: A randomised controlled pilot study

Background: The UK government currently recommends that all patients receive medicines reconciliation (MR) from a member of the pharmacy team within 24 hours of admission and subsequent discharge. The cost-effectiveness of this intervention is unknown. A pilot study to inform the design of a future randomised controlled trial to determine effectiveness and cost-effectiveness of a pharmacist delivered service was undertaken. Method: Patients were recruited seven days a week from five adult medical wards in one hospital over a 9 month period and randomised using an automated system to intervention (MR within 24 hours of admission and at discharge) or usual care which may include MR (control). Recruitment and retention rates were determined. Length of stay(LOS), quality of life (EQ-5D-3L), unintentional discrepancies(UDs) and emergency re-admission(ER) within 3 months were tested as outcome measures. The feasibility of identifying and measuring intervention associated resources was determined. Result: 200 patients were randomised to either intervention or control. Groups were comparable at baseline.95(99%) of patients in the intervention received MR within 24 hours, whilst 62(60.8%) of control patients received MRat some point during admission. The intervention resolved 250 of the 255 UDs identifed at admission. Only 2 UDs were identifed in the intervention group at discharge compared with 268 in the control. The median LOS was 94 hours in the intervention arm and 118 hours in the control, with ER rates of 17.9% and 26.7%,respectively. Assuming 5% loss to follow up 1120 patients (560 in each arm) are required to detect a 6% reduction in 3 month ER rates. Conclusions: The results suggest that changes in outcome measures resulting from MR within 24 hours were in the appropriate direction and readmission within 3 months is the most appropriate primary outcome measure. A future study to determine cost-effectiveness of the intervention is feasible and warranted