Medicine authentication technology as a counterfeit medicine-detection tool: a Delphi method study to establish expert opinion on manual medicine authentication technology in secondary care

The impact of global falsified medicines regulation on healthcare stakeholders in the legitimate pharmaceutical supply chain: a systematic review

Background

Falsified medicines and their international regulation impacts all healthcare sectors and their actors. These regulations aim to strengthen and protect the global pharmaceutical supply chain against falsified medicines. However, an evaluation of the impacts of these regulations on key stakeholders within the legitimate supply chain have not been explored.

Objective

This research aimed to evaluate both the positive and negative impacts of falsified medicines regulation on key stakeholders within the global pharmacy sector including including manufacturers, wholesalers, hospital pharmacies, community pharmacy and patients.

Design

This research consists of a systematic review and thematic analysis concerning falsified medicines regulation and the subsequent impacts of existing global regulations on healthcare. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and checklist were utilized for reporting in this systematic review.

Data sources and methods

A search of three databases, Embase, ProQuest and PubMed, was undertaken to determine studies applicable to the research question. The Mixed Methods Appraisal Tool (MMAT) was used to assess methodological quality and risk of bias for all included studies.

Results

From the initial 657 studies, a final set of 13 relevant studies were identified. The most frequently reported falsified medicines regulation was the Falsified Medicines Directive (FMD) [n = 11]. The impact of falsified medicines regulation in the literature related to four areas: (1) Financial, (2) Social, (3) Organizational, and (4) Pharmacy Practice. These common themes across the included studies frequently relate to challenges and/or concerns associated with falsified medicines regulation implementation as well as both the logistics and practicality of incorporating falsified medicines regulations into daily operations.

Conclusion

Implementation and enforcement of falsified medicines regulation does not yet appear to categorically fulfill the primary aim of the regulations, to strengthen the drug supply chain. However, in recent years, such regulations have challenged the legitimate pharmaceutical supply change actors as they attempt to successfully implement these regulations. Studies mainly detail the negative impacts of regulation during the implementation phase but with the overall benefit pertaining to the prioritization and enhancement of patient care and safety within the healthcare sector.

Core Descriptor Sets for Rectal Prolapse Outcomes Research Using a Modified Delphi Consensus

BACKGROUND

There is wide variation in prolapse care.

OBJECTIVE

To determine core descriptor sets for rectal prolapse to enhance outcomes research.

DESIGN

Descriptors for patients undergoing rectal prolapse surgery were generated through a systematic review and expert opinion. Stakeholders were recruited internationally via listserv and social media. Experts were encouraged to consider the minimum descriptors that could be considered during clinical care, and descriptors were grouped into core descriptor sets. Consensus was defined as greater than 70% agreement.

SETTING

A 3-round Delphi process using a 9-point Likert scale based on expert results was distributed via survey. The final interactive meeting used a polling platform.

PARTICIPANTS

The Pelvic Floor Disorders Consortium interdisciplinary group convened to advance the clinical care of pelvic floor disorders.

MAIN OUTCOME MEASURES

To achieve expert consensus for core descriptor sets for rectal prolapse using a modified Delphi method.

RESULTS

A total of 206 providers participated, with survey response rates of 82% and 88%, respectively. Responders were from North America (56%), Europe (29%), and Latin America, Asia, Australia, New Zealand, and Africa (15%). Ninety-one percent of participants identified as colorectal surgeons and 80% reported >5 years of experience (35% reported >15 years). Fifty-seven attendees participated in the final meeting and voted on core descriptor sets. Ninety-three percent of participants agreed that descriptors such as age, BMI, frailty, nutrition, and the American Society of Anesthesiology score correlated to physiologic status. One hundred percent of participants agreed to include baseline bowel function. One hundred percent of participants reported willingness to complete a synoptic operative report. Follow-up intervals 1, 3, and 5 years after surgery (76%) with a collection of recurrence and functional outcomes at those time periods reached an agreement.

LIMITATIONS

Individual bias, self-identification of experts, and paucity of knowledge related to rectal prolapse.

CONCLUSIONS

This represents the first steps toward international consensus to unify language and data collection processes for rectal prolapse. See Video Abstract .

CONJUNTOS DE DESCRIPTORES BSICOS PARA LA INVESTIGACIN DE RESULTADOS DE PROLAPSO RECTAL MEDIANTE UN CONSENSO DELPHI MODIFICADO

ANTECEDENTES:Existe una amplia variación en la atención del prolapso.OBJETIVO:Determinar conjuntos de descriptores básicos para el prolapso rectal para mejorar los resultados de la investigación.DISEÑO:Los descriptores para pacientes sometidos a cirugía de prolapso rectal se generaron a través de una revisión sistemática y la opinión de expertos. Las partes interesadas fueron reclutadas internacionalmente a través de listas de servicio y redes sociales. Se animó a los expertos a considerar los descriptores mínimos que podrían considerarse durante la atención clínica, y los descriptores se agruparon en conjuntos de descriptores básicos. El consenso se definió como > 70% de acuerdo.AJUSTE:Se distribuyó mediante encuesta un proceso Delphi de tres rondas que utiliza una escala Likert de 9 puntos basada en resultados de expertos. La reunión interactiva final utilizó una plataforma de votación.PARTICIPANTES:El grupo interdisciplinario del Consorcio de Trastornos del Suelo Pélvico se reunió para avanzar en la atención clínica de los trastornos del suelo pélvico.MEDIDAS PRINCIPALES DE RESULTADOS:Lograr el consenso de expertos para los conjuntos de descriptores básicos para el prolapso rectal utilizando un método Delphi modificado.RESULTADOS:Participaron 206 proveedores con tasas de respuesta a la encuesta del 82% y 88% respectivamente. Los encuestados procedían de América del Norte (56%), Europa (29%) y América Latina, Asia, Australia, Nueva Zelanda y África (15%). El noventa y uno por ciento se identificó como cirujanos colorrectales y el 80% reportó más de 5 años de experiencia (35% > 15 años). Cincuenta y siete asistentes participaron en la reunión final y votaron sobre conjuntos de descriptores básicos. El noventa y tres por ciento estuvo de acuerdo en que descriptores como edad, índice de masa corporal, fragilidad, nutrición y puntuación de la Sociedad Estadounidense de Anestesiología se correlacionaban con el estado fisiológico. El cien por ciento estuvo de acuerdo en incluir la función intestinal inicial. El 100% refirió disposición para realizar un informe operativo sinóptico. Los intervalos de seguimiento 1,3,5 años después de la cirugía (76%) con un conjunto de recurrencias y los resultados funcionales en esos períodos de tiempo coincidieron.LIMITACIONES:Sesgo individual, autoidentificación de los expertos y escasez de conocimientos relacionados con el prolapso rectal.CONCLUSIONES:Esto representa los primeros pasos hacia un consenso internacional para unificar el lenguaje y los procesos de recolección de datos para el prolapso rectal. (Traducción-Yesenia Rojas-Khalil ).

Gaining consensus on emotional wellbeing themes and preferences for digital intervention type and content to support the mental health of young people with long-term health conditions: A Delphi study

BACKGROUND

Young people (YP) with long-term conditions (LTCs) are at greater risk of psychological distress than those without LTCs. Despite this, there is a scarcity of quality digital interventions designed to help improve mental wellbeing in this population. The aim of this study was to determine what YP, parents and health professionals preferred for future interventions.

METHODS

Twenty-six YP with asthma, diabetes and/or epilepsy (the three most common LTCs in YP), 23 parents of YP with LTCs and 10 health professionals mainly in paediatric specialisms (total n = 59) took part in an online Delphi study to gain consensus (set at 75% agreement) on four questions across three rounds. Participants ordered psychological themes that may be experienced by YP with LTCs by importance and ranked digital intervention types and delivery modes by importance or usefulness. The most common results were reported if no consensus was reached by round 3.

RESULTS

Participants preferred a mobile phone app (73% agreement) and a mixture of one-on-one and group support for an intervention (75% agreement). The two highest ranked psychological themes were anxiety (44%) and wanting to appear 'normal' (38%), and the top intervention type was 'general counselling' (54% agreement).

CONCLUSION

There was a clear desire for an app to help with the psychological aspects of living with LTCs and for a combination of one-to-one and group intervention elements. Anxiety and wanting to appear 'normal' might be two closely linked psychological challenges that could be addressed by a single intervention.

IMPLICATIONS

The results will be important to consider for a future intervention, although further consultation will be needed for app development.

PATIENT OR PUBLIC CONTRIBUTION

Two YP with a LTC provided feedback on the study protocol including the aims and procedures of the project. Another six YP with LTCs were consulted on an early draft of the study questionnaire (the four questions), which was subsequently revised. Once the project began, a patient and public involvement group consisting of two YP with LTCs and one parent of a YP with an LTC gave feedback on the research process, lay report of the results and dissemination plan.

Consensus statement on the interhospital transfer of patients with acute aortic syndrome: TRAVERSING Delphi study

BACKGROUND

Standardisation of referral pathways and the transfer of patients with acute aortic syndromes (AAS) to regional centres are recommended by NHS England in the Acute Aortic Dissection Toolkit. The aim of the Transfer of Thoracic Aortic Vascular Emergencies to Regional Specialist INstitutes Group study was to establish an interdisciplinary consensus on the interhospital transfer of patients with AAS to specialist high-volume aortic centres.

METHODS

Consensus on the key aspects of interhospital transfer of patients with AAS was established using the Delphi method, in line with Conducting and Reporting of Delphi Studies guidelines. A national patient charity for aortic dissection was involved in the design of the Delphi study. Vascular and cardiothoracic surgeons, emergency physicians, interventional radiologists, cardiologists, intensivists and anaesthetists in the United Kingdom were invited to participate via their respective professional societies.

RESULTS

Three consecutive rounds of an electronic Delphi survey were completed by 212, 101 and 58 respondents, respectively. Using predefined consensus criteria, 60 out of 117 (51%) statements from the survey were included in the consensus statement. The study concluded that patients can be taken directly to a specialist aortic centre if they have typical symptoms of AAS on the background of known aortic disease or previous aortic intervention. Accepted patients should be transferred in a category 2 ambulance (response time <18 min), ideally accompanied by transfer-trained personnel or Adult Critical Care Transfer Services. A clear plan should be agreed in case of a cardiac arrest occurring during the transfer. Patients should reach the aortic centre within 4 hours of the initial referral from their local hospital.

CONCLUSIONS

This consensus statement is the first set of national interdisciplinary recommendations on the interhospital transfer of patients with AAS. Its implementation is likely to contribute to safer and more standardised emergency referral pathways to regional high-volume specialist aortic units.

Career Needs Assessment for Early Career Academic Surgeons Using a Modified Accelerated Delphi Process

INTRODUCTION

Over the past 2 decades, physicians' wellbeing has become a topic of interest. It is currently unclear what the current needs are of early career academic surgeons (ECAS).

METHODS

Consensus statements on academic needs were developed during a Delphi process, including all presenters from the previous European Surgical Association (ESA) meetings (2018-2022). The Delphi involved (1) a literature review, (2) Delphi form generation, and (3) an accelerated Delphi process. The Delphi form was generated by a steering group that discussed findings identified within the literature. The modified accelerated e-consensus approach included 3 rounds over a 4-week period. Consensus was defined as >80% agreement in any round.

RESULTS

Forty respondents completed all 3 rounds of the Delphi. Median age was 37 years (interquartile range 5), and 53% were female. Majority were consultant/attending (52.5%), followed by PhD (22.5%), fellowship (15%), and residency (10%). ECAS was defined as a surgeon in 'development' years of clinical and academic practice relative to their career goals (87.9% agreement). Access to split academic and clinical contracts is desirable (87.5%). Consensus on the factors contributing to ECAS underperformance included: burnout (94.6%), lack of funding (80%), lack of mentorship (80%), and excessive clinical commitments (80%). Desirable factors to support ECAS development included: access to e-learning (90.9%), face-to-face networking opportunities (95%), support for research team development (100%), and specific formal mentorship (93.9%).

CONCLUSION

The evolving role and responsibilities of ECAS require increasing strategic support, mentorship, and guidance on structured career planning. This will facilitate workforce sustainability in academic surgery in the future.

Development of a Clinical Data Model Addressing the Nursing Focus "Anxiety": A Consensus Development Study

Anxiety disorders are among the most prevalent mental disorders worldwide. However, anxiety is not exclusive to anxiety disorders. In fact, the nursing discipline approaches anxiety as a human response to health conditions/life processes. Health information systems should primarily contribute to improving the quality of care, patient safety, and the effectiveness of care delivery. Nevertheless, nursing information systems still fail to incorporate evidence-based clinical data models addressing the nursing focus "anxiety." Thus, this study aimed to obtain consensus on the data to be included in a clinical data model addressing the nursing focus "anxiety," its organization, and its interrelationships by using a brainstorming session and a modified e-Delphi technique with a panel of nurse experts from across Portugal. Eight experts participated in the brainstorming session. A total of 59 and 54 participants completed the survey in e-Delphi rounds 1 and 2, respectively. Consensus was achieved to all data presented to the participants, and these data were later included in the clinical data model. This evidence-based clinical data model, grounded on a nursing theory and with standardized nursing language, will substantially contribute to nursing documentation and, consequently, to nursing care targeted at patients with anxiety.

Adapting community child and family health service models for rural and other diverse settings: A modified Delphi study to identify key elements

Inequity in health outcomes is pervasive, with poorer health outcomes identified in rural, regional and remote communities. An international call to action emphasises the need for service models adapted for less well-resourced settings. The aim of this study was to identify key elements of a framework for the adaptation of specialist community-based child and family health (CFH) service models for rural and other under-resourced settings. A modified Delphi study was undertaken with a 12-person expert panel in CFH including Australian and international professionals and parents from rural and remote communities. The study was informed by the WHO Framework for Strengthening Health Service Systems building blocks, the outcomes of an integrative review of literature and a Participatory Action Research study. Experts assessed 107 potential elements for service model development and rated them for importance when adapting service models for different contexts. Round 1 of the Delphi generated considerable consensus with 80 of the 107 potential elements identified as necessary for the service model adaptation framework. A further 17 elements for CFH service models were added in round 2. While multiple varied elements are important for adapting CFH service models for diverse settings, some elements had common themes. Experts highlighted the importance of community engagement and participation; utilising both data and local knowledge to develop a robust understanding of the community context; and the need for a flexible approach to funding and modes of service delivery to address barriers to implementation and access.

Protocol for the development of a reporting guideline for causal and counterfactual prediction models in biomedicine

INTRODUCTION

While there are guidelines for reporting on observational studies (eg, Strengthening the Reporting of Observational Studies in Epidemiology, Reporting of Studies Conducted Using Observational Routinely Collected Health Data Statement), estimation of causal effects from both observational data and randomised experiments (eg, A Guideline for Reporting Mediation Analyses of Randomised Trials and Observational Studies, Consolidated Standards of Reporting Trials, PATH) and on prediction modelling (eg, Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis), none is purposely made for deriving and validating models from observational data to predict counterfactuals for individuals on one or more possible interventions, on the basis of given (or inferred) causal structures. This paper describes methods and processes that will be used to develop a Reporting Guideline for Causal and Counterfactual Prediction Models (PRECOG).

METHODS AND ANALYSIS

PRECOG will be developed following published guidance from the Enhancing the Quality and Transparency of Health Research (EQUATOR) network and will comprise five stages. Stage 1 will be meetings of a working group every other week with rotating external advisors (active until stage 5). Stage 2 will comprise a systematic review of literature on counterfactual prediction modelling for biomedical sciences (registered in Prospective Register of Systematic Reviews). In stage 3, a computer-based, real-time Delphi survey will be performed to consolidate the PRECOG checklist, involving experts in causal inference, epidemiology, statistics, machine learning, informatics and protocols/standards. Stage 4 will involve the write-up of the PRECOG guideline based on the results from the prior stages. Stage 5 will seek the peer-reviewed publication of the guideline, the scoping/systematic review and dissemination.

ETHICS AND DISSEMINATION

The study will follow the principles of the Declaration of Helsinki. The study has been registered in EQUATOR and approved by the University of Florida's Institutional Review Board (#202200495). Informed consent will be obtained from the working groups and the Delphi survey participants. The dissemination of PRECOG and its products will be done through journal publications, conferences, websites and social media.

Pharmacists' views on the impact of the falsified medicines directive on community pharmacies: A cross-sectional survey

Background

The Falsified Medicines Directive (FMD) was implemented to minimise the circulation of falsified medicines in the legal pharmaceutical supply chain. Whilst pharmacists are involved in the final step of the FMD requirements with the decommissioning of medicines at the point of supply to patients, limited research has been conducted to investigate the impact of fulfilling these requirements on the relevant stakeholders.

Objective

To examine community pharmacists' views on how the FMD has affected their practice.

Methods

An online survey was disseminated via email in June 2020 to pharmacists in Ireland (n = 4727), who were invited to participate if practising full time or part time in community pharmacies. Quantitative data were captured through multiple option and Likert-scale questions, and analysed using descriptive and inferential statistics. Qualitative data were captured by use of a free-text box, with the open comments analysed thematically.

Results

In total, 618 valid responses were received (13.1% response rate). Most perceived that FMD requirements increased waiting times for patients (82%) and reduced time interacting with patients (65%). Only 28% agreed/strongly agreed that the introduction of the FMD legislation improves patient safety. In the open comments, the need for medicine authentication was acknowledged, but it was believed that this should be the wholesalers' responsibility, not pharmacists' responsibility. The additional step of medicines decommissioning was viewed as a time-consuming distraction to clinical checks that increased the risk for error. Pharmacists complained that they were not remunerated for the lost staff productivity or the additional software and equipment costs. Many pharmacists felt that the increased workload was disproportionate to the small risk of patients receiving falsified medicines.

Conclusions

Key stakeholder engagement is required to optimise the implementation and integration of the FMD procedures into community pharmacy practice with minimal impact on dispensing and without compromising patient care.

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The Falsified Medicines Directive procedures have disrupted pharmacists' workflow.

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They distract from clinical checks and reduce time interacting with patients.

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Many believed that patient safety has been negatively impacted.

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Pharmacists experienced frustration with software and hardware problems.

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Potential benefits are not being capitalised on to offset the increased workload.

Key performance and training parameters in primary total hip arthroplasty - an expert consensus using the Delphi technique

AIMS

Primary total hip arthroplasty (THA) is a commonly performed and successful operation which orthopaedic trainees must demonstrate competence in prior to completion of surgical training. An assessment of agreement between surgical trainers regarding the critical steps of a primary THA has never been undertaken. The aim of this study was to define and rank the key steps of a primary THA regards ease of teaching and their importance in achieving the best patient outcome.

MATERIALS AND METHODS

The Delphi technique with 3 iterative rounds was used to establish expert group consensus. The benchmark for consensus was set at an 80% agreement in any category for each step of a THR. The intra-class correlation coefficient (ICC) was used to report on the inter- and intra-rater reliabilities between and within participants responses respectively in rounds 2 and 3.

RESULTS

50 consultant orthopaedic hip surgeons completed round 2, and 28 completed round 3. Overall, 27 steps (54 parameters) were identified, with 16 parameters achieving consensus agreement for their impact on patient outcome, and 17 for ease of teaching. The inter-rater ICC for patient outcome parameters was 0.89 and 0.92 in rounds 2 and 3 respectively while for teaching parameters it was 0.82 and 0.73. 50% of surgeons agreed that acetabular reaming, assessing and accurately restoring leg length, and acetabular cup anteversion were the 3 most difficult steps to teach trainees, while 90% agreed these 3 steps were substantially important to patient outcome. Another 5 steps achieved consensus for their substantial impact on patient outcome but failed to achieve consensus for ease of teaching.

CONCLUSIONS

The results of this expert consensus have produced a rank-order list of the key steps in primary THA, which may be used for orthopaedic curriculum development and guiding focused improvements for surgical training in primary THR including simulation.

Medicine quality in high-income countries: The obstacles to comparative prevalence studies

The entry of falsified and substandard medicines into the legitimate pharmaceutical supply chain has negative impacts on healthcare systems, patient safety, and patient access to medicine. The COVID-19 pandemic has highlighted the importance of access to safe medicine through legitimate pharmaceutical supply chains and the willingness of criminals to target medical products such as PPE (personal protective equipment) and COVID-19 treatments. In this article, we analyse data from the United Kingdom (UK) national medicine alert and recall database to identify and understand recent cases of substandard and falsified medicine in the UK’s healthcare systems. Using the UK as a case study, we describe that national drug alert and recall data are useful in their current form to record and understand cases of substandard and falsified medicines in the supply chain. However, if regulatory agencies published further data, these drug recall databases may be useful to support longitudinal and international comparative medicine quality studies. We suggest that regulatory agencies publish the number of affected medicine packs in each recalled batch, as part of the recall process. This will help policy makers, practitioners, and researchers to better understand, monitor and compare the quality of medicines within legitimate supply chains.

Falsified Drugs in the Opinion of Patients Diagnosed with Cardiovascular Diseases-Nationwide and Cross-Sectional Study on the Example of EU-Member Country

Background: In light of a falsified medications pandemic, understanding the patient perspective on falsified medicines is warranted. Our study aimed to investigate the perspectives regarding falsified medicines among patients with cardiovascular diseases. Methods: Computer-assisted telephone interviews were conducted based on a questionnaire: (i) Respondents suffering from cardiovascular diseases and (ii) respondents not being chronically ill. Only participants below 50 years of age were included. Results: We enrolled 1200 respondents total, 800 in the study group and 400 in the control group (in cooperation with a professional public opinion research center). The vast majority of participants agreed that community pharmacies are the only place that ensures the secure purchasing of non-falsified drugs (67.01% study group and 65.25% control group; p < 0.01). The majority of respondents were convinced that purchasing medications on the Internet is associated with a higher risk of receiving falsified drugs. Patients diagnosed with cardiovascular diseases and those with “non-satisfactory financial situation” had significantly decreased likelihoods of obtaining a high score in general knowledge on falsified medications (OR = 0.64 and OR = 0.58, respectively). Conclusions: Awareness of the risks associated with falsified drugs among patients with cardiovascular diseases remains high but still insufficient.

We Agree, Don't We? The Delphi Method for Health Environments Research

OBJECTIVE

This overview is intended to provide the process framework for built environment researchers to use the Delphi method. The article outlines the methodological criteria originally established for the Delphi method, as well as commonly accepted modifications, to advance guidance for evidence-based built environment considerations.

BACKGROUND

Increasingly used in healthcare research, the Delphi method is a process for gaining consensus through controlled feedback from a panel-a group made up of experts or individuals knowledgeable on the subject. The method is often used where there is limited or conflicting evidence, where participants may be geographically dispersed, and where anonymity is desired to control for dominant individuals. The Delphi method consists of panel selection, development of content surveys, and iterative stages of anonymous responses to gain consensus. Panelists receive feedback after each round in the form of a statistical representation of the overall group's response. The goal of multiple iterations in the Delphi method is to reduce the range of responses and gain expert consensus, which is often seen as more credible than conjecture or individual opinion.

CONCLUSION

With a geographic diversity of healthcare design expertise, and with so many aspects of healthcare design lacking a robust body of supporting empirical research, the Delphi method is well-suited to developing evidence-based design recommendations and considerations for healthcare built environments.

A systematic review of substandard, falsified, unlicensed and unregistered medicine sampling studies: a focus on context, prevalence, and quality

Substandard and falsified (SF) medicines are a global issue contributing to antimicrobial resistance and causing economic and humanitarian harm. To direct law enforcement efficiently, halt the spread of SF medicines and antimicrobial resistance, academics, NGOs and government organisations use medicine quality sampling studies to estimate the prevalence of the problem. A systematic review of medicine quality studies was conducted to estimate how the methodological quality of these studies and SF prevalence has changed between 2013 and 2018. We also aimed to critique medicine sampling study methodologies, and the systematic review process which generates prevalence estimates. Based on 33 studies, the overall estimated median (Q1-Q3) prevalence of SF medicines appears to have remained high at 25% (7.7%-34%) compared with 28.5% in 2013. Furthermore, the methodological quality of prevalence studies has improved over the last 25 years. Definitive conclusions regarding the prevalence of SF medicines cannot be drawn due to the variability in sample sizes, consistency of design methods, and a lack of information concerning contextual factors affecting medicine quality studies. We contend that studies which present cumulative average prevalence figures are useful in a broad sense but could be improved to create more reliable estimates. We propose that medicine quality studies record the context of the study environment to allow systematic reviewers to compare like with like. Although, the academic rigour of medicine quality studies is improving, medicine sampling study limitations still exist. These limitations inhibit the accurate estimation of SF medicine prevalence which is needed to support detailed policy changes.

Expert consensus on the conservative management of patients with chronic venous disease in CEAP clinical classes C0s-C3 in Italy

OBJECTIVES

To define a consensual approach for the conservative treatment of patients C0s-C3.

METHOD

The project was structured into two phases. The first one involved a group of Italian specialists in angiology and/or vascular surgery with the aim to compare their therapeutic choices in the management of patients in CEAP C0s-C3. The second phase used a Delphi consensus in order to elaborate practical statements on the conservative management of these patients.

RESULTS

The first phase involved a group of 166 Italian specialists while the second phase involved a Steering Committee of 6 specialists and a panel of 20 specialists. At the end of the third round, a consensus >80% was reached on seven assertions.

CONCLUSION

Seven statements have been drafted by a group of Italian specialists to provide physicians with practical guidance for the conservative treatment of C0s-C3 patients. Outstanding issues on the management of these patients were identified, confirming the urgent need of further research.

Medicine authentication technology: a quantitative study of incorrect quarantine, average response times and offline issues in a hospital setting

OBJECTIVES

To introduce serialised medicines into an operational hospital dispensary and assess the technical effectiveness of digital medicine authentication (MA) technology under European Union Falsified Medicines Directive (EU FMD) conditions.

DESIGN

Thirty medicine lines were serialised using 2D data matrix labels and introduced into an operational UK National Health Service (NHS) hospital dispensary. Staff were asked to check medicines for two-dimensional (2D) data matrices and scan those products, in addition to their usual medicine preparation and checking processes. Four per cent of the study medicines were labelled with a 2D barcode which generated a pop-up, identifying the medicine as either authenticated elsewhere (falsified), authenticated here, expired or recalled.

SETTING

An NHS teaching hospital based in the UK, the same site as the Naughton et al 2016 study.

PARTICIPANTS

General Pharmaceutical Council registered, accredited accuracy checking technicians and pharmacists.

PRIMARY OUTCOME MEASURES

Average response times, offline issues, instances of incorrect quarantine and workarounds. The EU FMD maximum response time is 300 milliseconds (ms).

RESULTS

During the checking stage of medicine preparation, the average response time for MA in this study was 131 ms. However, 4.67% of attempted authentications experienced offline issues, an increase of 4.23% from the previous study. An increase in offline instances existed alongside an increase in incorrect quarantine.

CONCLUSIONS

Digital drug screening has the capability of operating with average response times which are below the maximum EU FMD limit of 300 ms. However, there was an increased incidence of offline errors and cases of incorrect quarantine. The practical and legal implications of supplying a substandard or falsified medicine during offline periods without prior authentication or withholding supply until online status resumes are not yet fully understood.

Future Information Technology Tools for Fighting Substandard and Falsified Medicines in Low- and Middle-Income Countries

Substandard and falsified (SF) medicines have emerged as a global public health issue within the last two decades especially in low- and middle-income countries (LMICs). Serious consequences of this problem include a loss of trust and increased financial costs due to less disease control and more frequent complications during therapy. Of note, antimicrobial resistance is an additional long-term implication of poor-quality antimicrobials. This review covers information technology tools including medicines authentication tools (MAT) as mobile apps and messaging service, 2D barcoding approaches with drug safety alert systems, web based drug safety alerts, radiofrequency identification tags, databases to support visual inspection, digital aids to enhance the performance of quality evaluation kits, reference libraries for identification of falsified and substandard medicines, and quality evaluation kits based on machine learning for field testing. While being easy to access and simple to use, these initiatives are gaining acceptance in LMICs. Implementing 2D barcoding based on end-to-end verification and "Track and Trace" systems has emerged as a step toward global security in the supply chain. A breakthrough in web-based drug safety alert systems and data bases was the establishment of the Global Surveillance and Monitoring System by the World Health Organization in 2013. Future applications include concepts including "lab on a chip" and "paper analytical devices" and are claimed to be convenient and simple to use as well as affordable. The principles discussed herein are making profound impact in the fight against substandard and falsified medicines, offering cheap and accessible solutions.

The EU Falsified Medicines Directive: Key Implications for Dispensers

The EU Falsified Medicines Directive (FMD) mandates the serialisation of prescription-only medicines using a two-dimensional (2D) barcode by pharmaceutical companies and the systematic verification of this 2D barcode in pharmacies. This European directive has ramifications for many stakeholders, including market authorization holders, wholesalers, parallel importers, and dispensers.

Focusing primarily on the impact on UK dispensers, the following questions are addressed in this article: Where should the affected medicines be scanned? and who will pay for the incoming changes to practice? The role of the EU FMD in terms of drug recalls, the preparation required for EU FMD compliance, and the potential for added healthcare value are also discussed.

Dispensers must prepare for the February 2019 EU FMD deadline date by choosing a point within their dispensing processes to scan medicines. Dispensers must also budget appropriately for the incoming costs associated with new hardware and processes.

Hospital Audit as a Useful Tool in the Process of Introducing Falsified Medicines Directive (FMD) into Hospital Pharmacy Settings-A Pilot Study

Background: Recently, the European Union has introduced the Falsified Medicines Directive (FMD). Additionally, in early 2016, a Delegated Act (DA) related to the FMD was published. The main objective of this study was to evaluate the usefulness of external audits in the context of implementing new regulations provided by the FMD in the secondary care environment. Methods: The external, in-person workflow audits were performed by an authentication company in three Polish hospital pharmacies. Each audit consisted of a combination of supervision (non-participant observation), secondary data analysis, and expert interviews with the use of an independently designed authorial Diagnostic Questionnaire. The questionnaire included information about hospital drug distribution procedures, data concerning drug usage, IT systems, medication order systems, the processes of medication dispensing, and the preparation and administration of hazardous drugs. Data analysis included a thorough examination of hospital documentation in regard to drug management. All data were subjected to qualitative analysis, with the aim of generating meaningful information through inductive inference. Results: Only one dispensing location in the Polish hospitals studied has the potential to be a primary authentication area. In the audited hospitals, an Automated Drug Dispensing System and unit dose were not identified during the study. Hospital wards contained an enclosed place within the department dedicated to drug storage under the direct supervision of senior nursing staff. An electronic order system was not available. In the largest center, unused medications are re-dispensed to different hospital departments, or may be sold to various institutions. Additionally, in one hospital pharmacy, pharmacists prepared parenteral nutrition and chemotherapeutic drugs for patients admitted to the hospital. Conclusions: External audits might prove beneficial in the course of introducing new regulations into everyday settings. However, such action should be provided before the final implementation of authentication services. To sum up, FMD can impact several hospital departments.