Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling.

BACKGROUND: To reduce expenditure on, and wastage of, drugs, some commissioners have encouraged general practitioners to issue shorter prescriptions, typically 28 days in length; however, the evidence base for this recommendation is uncertain. OBJECTIVE: To evaluate the evidence of the clinical effectiveness and cost-effectiveness of shorter versus longer prescriptions for people with stable chronic conditions treated in primary care. DESIGN/DATA SOURCES: The design of the study comprised three elements. First, a systematic review comparing 28-day prescriptions with longer prescriptions in patients with chronic conditions treated in primary care, evaluating any relevant clinical outcomes, adherence to treatment, costs and cost-effectiveness. Databases searched included MEDLINE (PubMed), EMBASE, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Cochrane Central Register of Controlled Trials. Searches were from database inception to October 2015 (updated search to June 2016 in PubMed). Second, a cost analysis of medication wastage associated with < 60-day and ≥ 60-day prescriptions for five patient cohorts over an 11-year period from the Clinical Practice Research Datalink. Third, a decision model adapting three existing models to predict costs and effects of differing adherence levels associated with 28-day versus 3-month prescriptions in three clinical scenarios. REVIEW METHODS: In the systematic review, from 15,257 unique citations, 54 full-text papers were reviewed and 16 studies were included, five of which were abstracts and one of which was an extended conference abstract. None was a randomised controlled trial: 11 were retrospective cohort studies, three were cross-sectional surveys and two were cost studies. No information on health outcomes was available. RESULTS: An exploratory meta-analysis based on six retrospective cohort studies suggested that lower adherence was associated with 28-day prescriptions (standardised mean difference -0.45, 95% confidence interval -0.65 to -0.26). The cost analysis showed that a statistically significant increase in medication waste was associated with longer prescription lengths. However, when accounting for dispensing fees and prescriber time, longer prescriptions were found to be cost saving compared with shorter prescriptions. Prescriber time was the largest component of the calculated cost savings to the NHS. The decision modelling suggested that, in all three clinical scenarios, longer prescription lengths were associated with lower costs and higher quality-adjusted life-years. LIMITATIONS: The available evidence was found to be at a moderate to serious risk of bias. All of the studies were conducted in the USA, which was a cause for concern in terms of generalisability to the UK. No evidence of the direct impact of prescription length on health outcomes was found. The cost study could investigate prescriptions issued only; it could not assess patient adherence to those prescriptions. Additionally, the cost study was based on products issued only and did not account for underlying patient diagnoses. A lack of good-quality evidence affected our decision modelling strategy. CONCLUSIONS: Although the quality of the evidence was poor, this study found that longer prescriptions may be less costly overall, and may be associated with better adherence than 28-day prescriptions in patients with chronic conditions being treated in primary care. FUTURE WORK: There is a need to more reliably evaluate the impact of differing prescription lengths on adherence, on patient health outcomes and on total costs to the NHS. The priority should be to identify patients with particular conditions or characteristics who should receive shorter or longer prescriptions. To determine the need for any further research, an expected value of perfect information analysis should be performed. STUDY REGISTRATION: This study is registered as PROSPERO CRD42015027042. FUNDING: The National Institute for Health Research Health Technology Assessment programme

Evaluation of international recruitment of health professionals in England

Objectives: To explore whether a period of intensive international recruitment by the English National Health Service (NHS) achieved its objectives of boosting workforce numbers and to set this against the wider costs, longer-term challenges and questions arising. Methods: A postal survey of all pre-2006 NHS providers, Strategic Health Authorities and Deans of Postgraduate Medical Education obtained information on 284 (45%) organizations (142 completed questionnaires). Eight subsequent case studies (74 interviews) covered medical consultant, general practitioner, nurse, midwife and allied health professional recruitment. Results: Most respondents had undertaken or facilitated international recruitment between 2001 and 2006 and believed that it had enabled them to address immediate staff shortages. Views on longer-term implications, such as recruit retention, were more equivocal. Most organizations had made only a limited value-for-money assessment, balancing direct expenditure on overseas recruitment against savings on temporary staff. Other short and long-term transaction and opportunity costs arose from pressures on existing staff, time spent on induction/pastoral support, and human resource management and workforce planning challenges. Though recognized, these extensive ‘hidden costs’ for NHS organizations were harder to assess as were the implications for source countries and migrant staff. Conclusions: The main achievement of the intensive international recruitment period from a UK viewpoint was that such a major undertaking was seen through without major disruption to NHS services. The wider costs and challenges meant, however, that large-scale international recruitment was not sustainable as a solution to workforce shortages. Should such approache

Survey of undergraduate pain curricula for healthcare professionals in the United Kingdom

The prevalence and burden of pain has long been reported as problematic. Comprehensive pain education in undergraduate programmes is essential for developing knowledgeable, skilled and effective healthcare professionals. This cross-sectional survey describes the nature, content and learning strategies for pain curricula in undergraduate healthcare programmes in major universities in the United Kingdom (UK). Document analysis also highlighted gaps in pain-related standards from professional regulators and a higher education quality assurance body. The sample consisted of 19 higher education institutions delivering 108 programmes across dentistry, medicine, midwifery, nursing, occupational therapy, pharmacy, physiotherapy and veterinary science. Seventy-four (68.5%) questionnaires were returned averaging 12.0 h of pain content with physiotherapy and veterinary science students receiving the highest input. Pain education accounted for less than 1% of programme hours for some disciplines. Traditional teaching methods dominated (e.g. lectures 87.8%) and only two programmes had fully implemented the International Association for the Study of Pain's (IASP) curricula. Minimal pain-related standards were found from professional regulators and the quality assurance documents. Pain education is variable across and within disciplines and interprofessional learning is minimal. Published curricula for pain education have been available for over 20 years but are rarely employed and pain is not a core part of regulatory and quality assurance standards for health professions. The hours of pain education is woefully inadequate given the prevalence and burden of pain. Recommendations include the introduction of pain-related educational standards across all professions, greater integration of pain content in undergraduate programmes and interprofessional approaches to the topic

A preliminary insight into the role and importance of management skills in the prevention of occupational derailment: An exploratory analysis of UK and Spanish pharmacists

YesThe aim of this study was to examine the prevalence and importance of management skills in the pharmacy profession and pharmacists’ ability to respond to current and future challenges in healthcare provision. As service professionals, pharmacists are engaged based on their expertise and skills, and are noted for their contribution to the knowledge-based economy and control over the application of their knowledge (Abbott, 1991). The same premise would apply to other professionals e.g. healthcare (nurses, doctors and psychologists); legal (lawyers, solicitors and barristers); consultancy; accountancy; banking and architecture (von Nordenflycht, 2010). An exploratory analysis of UK and Spanish pharmacists’ roles and their adoption of management skills was thus undertaken. Both healthcare systems are very similar and likewise the clinical training and role of pharmacists, professional standards and regulations are similar but there are subtle differences. Data were collected using semi-structured online surveys; two thirds of the data were collected from a UK audience and the final third from Spanish pharmacists. The data collection was planned and iterative in the first two stages (stage one influencing stage two) (UK) and the final stage (Spain) offered an opportunistic comparator study. The results demonstrated that there was overwhelming support for management skills to be part of undergraduate studies. The outputs of this study identify the most important management skills pharmacists need to perform effectively. Consideration was also given to the impact of inability to perform in their role, and hence the possibility of occupational derailment (leaving their role or being demoted). These findings offer important learning to support workforce development in all professional services