Post discharge medicines use review (dMUR) service for older patients: Cost-savings from community pharmacist interventions

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Community pharmacist perceptions of delivering post-hospital discharge Medicines Use Reviews for elderly patients

Background The UK’s Department of Health has recommended that formal communication channels between hospital and community pharmacy should be established so that post discharge Medicines Use Reviews (dMUR) become an integral part of the medicines pathway. Objective To investigate the perspective of community pharmacists on the usefulness of dMUR referrals from hospital, the suitability of patients referred and overall views on the service. Method Self-completed survey distributed to 21 community pharmacists who had received referrals from the hospital during a 9-month randomized controlled feasibility study. Results Nineteen pharmacists (90.4%) returned the survey. Seven (36.8%) felt that it was hard to engage patients with dMURs. Failure or inability of patients to attend the pharmacy were the most common barriers. Reasons for medication changes (n=5) and indications for new medicines (n=4) were the most common examples of extra information that would be useful on referral. Community pharmacists held positive opinions on the dMUR service and could see the benefit to patients. Pharmacists wanted more referrals but reported performing few dMURs outside this study. Conclusion This study highlights the need to improve communication between hospital and community pharmacies and to overcome barriers to performing dMURs outside the pharmacy premises in this patient group. Impact of Findings on Practice • Referral of elderly patients from hospital to community pharmacy for a Medicines Use Review is well received by community pharmacists and is feasible • Reasons for medication changes and indications for new medicines started in hospital would be welcomed with the referral • Difficulty in patients leaving home to attend the pharmacy was the most common barrier to completion of the reviews • Contractual restrictions placed on UK community pharmacists limit their ability to provide the service to housebound patient

Transitional care of older patients utilising community pharmacists via the dMUR service

Background: Post-discharge Medicines Use Reviews (dMURs) were introduced into the English community pharmacy contract in 2011, with the aim of improving understanding and use of medication by patients who have experienced changes to their medicines in hospital. Early evidence showed uptake of dMURs to be poor. Furthermore, despite being a nationally commissioned service, there is little evidence of the benefit of dMURs to patients. In light of the documented medication problems that occur in older people on transfer of care, a randomised controlled feasibility study was devised to investigate the feasibility and potential outcomes of a transitional care service for older patients which utilises community pharmacists via the dMUR service Methods: Hospital pharmacists identified in-patients aged over 65 years who could potentially benefit from a dMUR. Participants were randomised to be referred for a dMUR with their usual community pharmacist or to receive standard discharge care. Results and Contribution: This study is the first to report on patient outcomes following dMUR referrals. Through interventions made by community pharmacists, referrals may provide a 4-fold return on investment to the NHS in terms of improved quality of care. There were trends towards a shorter length of stay on readmission and reduction in A&E visits in the months following dMUR, and they may also prevent medication related readmissions and deterioration in medication adherence and physical health over time. However this work revealed significant challenges in providing dMUR referral services to older patients. Being housebound due to poor mobility or health is a major barrier, due to difficulties experienced by community pharmacists with providing domiciliary dMURs. Carer management of medication is another. It is proposed that the provision of domiciliary dMURs should be facilitated by simplifying and clarifying the process for community pharmacists. Proxy dMURs with carers should be allowed in certain cases. Another key proposal is that the dMUR service should be re-designed to involve at least two parts. Remuneration should reflect the complexity and time needed for dMURs compared to ‘standard’ MURs. Lack of time of hospital pharmacists is a barrier to recruiting appropriate patients for dMUR referral and making good quality referrals. Electronic referral from hospital to community pharmacy may assist and should be implemented more widely. It is also suggested that hospital pharmacies should be remunerated for making referrals

Hospital referral of older patients to community pharmacy: outcome measures in a feasibility study

Background Post-discharge medication use reviews in English community pharmacy aim to improve medicine support to recently discharged patients. However, there is little evidence of their impact on patient outcomes. Objective Identify potential outcome measures to investigate the impact of a hospital to community pharmacy referral service for older patients that utilises post-discharge medication reviews. Method Pharmacists at a district general hospital identified in-patients aged over 65 years who could benefit from a medication use review. Participants were randomised to receive referral for review, or standard discharge care. Participants were followed up at 4 weeks and 6 months via the hospital’s patient administration system and by postal questionnaire, regarding readmissions, medication adherence, health related quality of life and enablement. Results Fifty-nine participants were recruited. There were no statistically significant differences in outcomes between intervention and control groups. However there were trends towards shorter length of stay on readmission and improved self-reported physical health for intervention group participants. There were no preventable medication related readmissions involving participants who had received a post-discharge medication use review as part of the study. Conclusion This feasibility study could be scaled up to a full pilot study, followed by an adequately powered randomised controlled trial, in order to further investigate the effects of medication use review referral post-discharge

Care home residents’ quality of life and its association with CQC ratings and workforce issues: the MiCareHQ mixed-methods study

Abstract Background Care home staff have a critical bearing on quality. The staff employed, the training they receive and how well they identify and manage residents’ needs are likely to influence outcomes. The Care Act 2014 (Great Britain. The Care Act 2014. London: The Stationery Office; 2014) requires services to improve ‘well-being’, but many residents cannot self-report and are at risk of exclusion from giving their views. The Adult Social Care Outcomes Toolkit enables social care-related quality of life to be measured using a mixed-methods approach. There is currently no equivalent way of measuring aspects of residents’ health-related quality of life. We developed new tools for measuring pain, anxiety and depression using a mixed-methods approach. We also explored the relationship between care home quality, residents’ outcomes, and the skill mix and employment conditions of the workforce who support them. Objectives The objectives were to develop and test measures of pain, anxiety and depression for residents unable to self-report; to assess the extent to which regulator quality ratings reflect residents’ care-related quality of life; and to assess the relationship between aspects of the staffing of care homes and the quality of care homes. Design This was a mixed-methods study. Setting The setting was care homes for older adults in England. Participants Care home residents participated. Results Three measures of pain, anxiety and low mood were developed and tested, using a mixed-methods approach, with 182 care home residents in 20 care homes (nursing and residential). Psychometric testing found that the measures had good construct validity. The mixed-methods approach was both feasible and necessary with this population, as the majority of residents could not self-report. Using a combined data set (n = 475 residents in 54 homes) from this study and the Measuring Outcomes in Care Homes study (Towers AM, Palmer S, Smith N, Collins G, Allan S. A cross-sectional study exploring the relationship between regulator quality ratings and care home residents’ quality of life in England. Health Qual Life Outcomes 2019;17:22) we found a significant positive association between residents’ social care-related quality of life and regulator (i.e. Care Quality Commission) quality ratings. Multivariate regression revealed that homes rated ‘good/outstanding’ are associated with a 12% improvement in mean current social care-related quality of life among residents who have higher levels of dependency. Secondary data analysis of a large, national sample of care homes over time assessed the impact of staffing and employment conditions on Care Quality Commission quality ratings. Higher wages and a higher prevalence of training in both dementia and dignity-/person-centred care were positively associated with care quality, whereas high staff turnover and job vacancy rates had a significant negative association. A 10% increase in the average care worker wage increased the likelihood of a ‘good/outstanding’ rating by 7%. Limitations No care homes rated as inadequate were recruited to the study. Conclusions The most dependent residents gain the most from homes rated ‘good/outstanding’. However, measuring the needs and outcomes of these residents is challenging, as many cannot self-report. A mixed-methods approach can reduce methodological exclusion and an over-reliance on proxies. Improving working conditions and reducing staff turnover may be associated with better outcomes for residents. Future work Further work is required to explore the relationship between pain, anxiety and low mood and other indicators of care homes quality and to examine the relationship between wages, training and social care outcomes. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 19. See the NIHR Journals Library website for further project informatio

Cardio-respiratory fitness, habitual physical activity and serum brain derived neurotrophic factor (BDNF) in men and women

Short episodes of high intensity exercise transiently increase serum levels of BDNF in humans, but serum levels of BDNF at rest appear to be lower in more physically active humans with greater levels of energy expenditure. The relationship between serum BDNF concentration, cardio-respiratory fitness (Åstrand–Rhyming test estimated VO2 max) and volume of long-term, regular exercise and sporting activity (Baecke Habitual Physical Activity Index) was investigated in 44 men and women between the age range of 18–57 years. In this group an inverse relationship between resting serum BDNF concentration and measures of both estimated VO2 max (r = ?0.352; P &lt; 0.05) and long-term sporting activity (r = ?0.428, P &lt; 0.01) was found. These results indicate that increased levels of cardio-respiratory fitness and habitual exercise are associated with lower resting levels of serum BDNF in healthy humans. This is the first study to demonstrate an inverse relationship between a physiological estimate of cardio-respiratory fitness and serum BDNF.<br/

<i>Lp</i> mice display a spectrum of outflow tract abnormalities.

<p><b>A,B</b>) <i>In situ</i> hybridisation on E10.5 <i>Lp/+</i> and <i>Lp/Lp</i> embryos reveals normal expression of <i>Tbx20</i> in the mutant embryo, but illustrates the abnormal heart loop (the outline of the outflow tract and ventricular chambers is indicated by the dotted lines). <b>C,D</b>) H&E sections of E14.5 <i>Lp/+</i> and <i>Lp/Lp</i> embryos show the double outlet right ventricle in the mutant embryo (the arrows indicate the communication between and the aorta and the ventricle). <b>E–H</b>) β-gal staining (blue) of wholemount stained <i>Lp/+</i> and <i>Lp/Lp</i> E10.5 embryos shows that NCC migration (labelled by <i>Wnt1-Cre</i> based lineage tracing) appears normal in the mutants. Transverse sections (G,H) show that although the OFT is reduced in length, there is normal migration of NCC into the outflow vessel (arrow). The bars in G,H indicate the characteristic shortened outflow tract seen in the mutant. <b>I–L</b>) β-gal staining of wholemount stained <i>Lp/+</i> and <i>Lp/Lp</i> E9.5 embryos shows that the SHF, labelled by <i>Isl1-Cre</i> based lineage tracing, appears normal in the mutants, however the cells appear disorganised (arrows). <b>M,N</b>) Isl1 antibody labels SHF cells in the distal outflow tract (brown staining – arrows). These cells appear disorganised in the <i>Lp/Lp</i> embryo at E9.5 (N′ arrow, compare to M′). Ao – aorta, LV - left ventricle, OFT - outflow tract, RV - right ventricle.</p