'New Medicine Service': supporting adherence in people starting a new medication for a long-term condition: 26-week follow-up of a pragmatic randomised controlled trial

Improving medication adherence in cardiovascular disease

Non-adherence to medication is a global health problem with far-reaching individual-level and population-level consequences but remains unappreciated and under-addressed in the clinical setting. With increasing comorbidity and polypharmacy as well as an ageing population, cardiovascular disease and medication non-adherence are likely to become increasingly prevalent. Multiple methods for detecting non-adherence exist but are imperfect, and, despite emerging technology, a gold standard remains elusive. Non-adherence to medication is dynamic and often has multiple causes, particularly in the context of cardiovascular disease, which tends to require lifelong medication to control symptoms and risk factors in order to prevent disease progression. In this Review, we identify the causes of medication non-adherence and summarize interventions that have been proven in randomized clinical trials to be effective in improving adherence. Practical solutions and areas for future research are also proposed.

An evaluation of written materials for supporting hypertensive patient education and counselling when performing a new medicine service in Poland

BACKGROUND

The New Medicine Service (NMS) was developed in England more than ten years ago, as a three-stage consultation led by community pharmacists to support patients taking new medication for a chronic disease. In Poland, the scheme was officially introduced in January 2023. However, its implementation into common practice has been presented with various obstacles, including the need to develop relationships with general practitioners, resolve the payment structure, and provide training with adequate supporting materials. Hence, written materials have been designed for use as an optional tool for counselling patients receiving an NMS in community pharmacies.

METHODS

The present study evaluates the ability of these materials to inform patients about the need to adhere to anti-hypertensive medication. A group of 401 randomly-selected adult visitors to pharmacies and/or healthcare centres were surveyed; one third had hypertension in their history.

RESULTS

The structure, grammar and readability of the text achieved the required threshold of 40% according to the Plain Language Index. The designed materials effectively informed the patients about anti-hypertensive medication, reflected in an increased score in a knowledge test, and were rated positively regarding information level, comprehensibility and presentation.

CONCLUSION

The proposed material may serve as an additional, "patient-friendly" educational tool for use as part of an NMS.

Economic evaluation of pharmacy services: a systematic review of the literature (2016-2020)

BACKGROUND

Economic evaluation is crucial for healthcare decision-makers to select effective interventions. An updated systematic review of the economic evaluation of pharmacy services is required in the current healthcare environment.

AIM

To conduct a systematic review of literature on economic evaluation of pharmacy services.

METHOD

Literature (2016-2020) was searched on PubMed, Web of Sciences, Scopus, ScienceDirect, and SpringerLink. An additional search was conducted in five health economic-related journals. The studies performed an economic analysis describing pharmacy services and settings. The reviewing checklist for economic evaluation was used for quality assessment. The incremental cost-effectiveness ratio and willingness-to-pay threshold were the main measures for cost-effective analysis (CEA) and cost-utility analysis (CUA), while cost-saving, cost-benefit-ratio (CBR), and net benefit were used for cost-minimization analysis (CMA) and cost-benefit analysis (CBA).

RESULTS

Forty-three articles were reviewed. The major practice settings were in the USA (n = 6), the UK (n = 6), Canada (n = 6), and the Netherlands (n = 6). Twelve studies had good quality according to the reviewing checklist. CUA was used most frequently (n = 15), followed by CBA (n = 12). Some inconsistent findings (n = 14) existed among the included studies. Most agreed (n = 29) that pharmacy services economically impact the healthcare system: hospital-based (n = 13), community pharmacy (n = 13), and primary care (n = 3). Pharmacy services were found to be cost-effectiveness or cost-saving among both developed (n = 32) and in developing countries (n = 11).

CONCLUSION

The increased use of economic evaluation of pharmacy services confirms the worth of pharmacy services in improving patients' health outcomes in all settings. Therefore, economic evaluation should be incorporated into developing innovative pharmacy services.

Piloting an opioid callback program in community pharmacies

BACKGROUND

Although opioid prescribing has recently trended downward, opioid-related overdoses and deaths have drastically increased. Community pharmacists are accessible health care providers who are well positioned to disseminate information on opioid safety and to educate and counsel on medication use, managing adverse events, and proper medication disposal. Patient callbacks facilitate appropriate medication usage. We developed an opioid callback program that provides a framework for pharmacists to follow up with patients with an opioid prescription.

OBJECTIVES

This study aimed to (1) describe the development of the opioid callback initiative and (2) report results from a pilot test in 2 community pharmacies.

METHODS

The opioid callback process and data collection forms were collaboratively developed with community pharmacists at each site. Data recorded on the opioid callback forms were descriptively analyzed and chi-square test of independence explored differences by pain durations related to opioid disposal, security, and safety. Participating pharmacy staff were interviewed to identify facilitators and barriers to implementation, as well as opportunities for improvement.

RESULTS

Forty-one opioid callbacks were attempted and 36 were completed (87.8%). Pharmacists were statistically significantly more likely to discuss naloxone with patients with chronic pain (89.5%) than those with acute pain (46.2%). Pharmacists reported that the program successfully raised awareness of opioid disposal opportunities and safe opioid practices, including storage and naloxone ownership. They expressed patients' willingness to answer questions and appreciation for the extra attention and care.

CONCLUSION

Community pharmacists are well positioned to address the opioid crisis as access points for medication questions, opioid safety education, opioid disposal, naloxone, and medications for people with an opioid use disorder. This study presents a proof of concept for a pharmacist-led opioid callback program. Expansion could help inform patients about how to use opioids safely, how to treat an opioid overdose, and where to dispose of unused medications.

A systematic review of economic evaluations of pharmacist services

BACKGROUND

Challenges to the provision of health care are occurring internationally and are expected to increase in the future, further increasing health spending. As pharmacist roles are evolving and expanding internationally to provide individualised pharmaceutical care it is important to assess the cost-effectiveness of these services.

OBJECTIVES

To systematically synthesise the international literature regarding published economic evaluations of pharmacy services to assess their cost-effectiveness and clinical outcomes.

METHODS

A systematic review of economic evaluations of pharmacy services was conducted in MEDLINE, EMBASE, PubMed, Scopus, Web of Science, CINAHL, IPA and online journals with search functions likely to publish economic evaluations of pharmacy services. Data were extracted regarding the interventions, the time horizon, the outcomes and the incremental cost-effectiveness ratio. Studies' quality of reporting was assessed using the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) statement.

RESULTS

Seventy-five studies were included in the systematic review, including 67 cost-effectiveness analyses, 6 cost-benefit analyses and 2 cost-consequence analyses. Of these, 57 were either dominant or cost-effective using a willingness-to-pay threshold of NZ$46 645 per QALY. A further 11 studies' cost-effectiveness were unable to be evaluated. Interventions considered to be most cost-effective included pharmacist medication reviews, pharmacist adherence strategies and pharmacist management of type 2 diabetes mellitus, hypertension and warfarin/INR monitoring. The quality of reporting of studies differed with no studies reporting all 28 items of the CHEERS statement.

CONCLUSIONS

There is strong economic evidence to support investment in extended pharmacist services, particularly those focussed on long-term chronic health conditions.

Exploring stakeholders' perspectives on the quality of services provided through community pharmacies

INTRODUCTION

It is important to understand the factors impacting the quality of services provided through community pharmacies. Exploring how key stakeholders perceive good quality in these services is a logical first step. This could also inform the development of quality measures, such as quality indicators (QIs).

AIM

To identify key stakeholders' perspectives on the quality of services provided through community pharmacies in Norway, specifically by exploring their experiences and perceptions about what constitutes good service quality.

METHODS

A convenient sampling approach was used to recruit participants for five semi-structured focus groups from Facebook, pharmacy chains, and patient organizations. The interviews with twenty-six participants were conducted via Microsoft Teams. Interviews were transcribed verbatim, and an inductive thematic analysis with a reflexive approach was used.

RESULTS

Four main themes emerged from the analysis; 1) sufficient and substantively suitable information to cover individual needs, 2) communication skills and relationships with the pharmacy professionals, 3) customer satisfaction with knowledgeable employees and conveniently located pharmacies, and 4) factors that affect the pharmacy working environment.

CONCLUSION

This study has identified areas that pharmacy professionals and customers regard as essential to define good quality of community pharmacy services. Effective communication skills, appropriate provision of information, customer satisfaction, and working environment are all essential factors when developing quality metrics for community pharmacies.

Assessing the digital literacy levels of the community pharmacy workforce using a survey tool

OBJECTIVES

To investigate the digital literacy of staff in London, UK, community pharmacies and to explore their perceptions about the use of eHealth tools.

METHODS

The study population was community pharmacy staff (N = 21,346) in Greater London. A survey tool was divided into six sections: Use of the internet; Use of social media; Use of mobile health applications (MHAs); Perception of and practical use of digital health tools; Scenario-based questions and demographics. Responses were analysed in SPSS. Following data collection, Health Education England's (HEE's) Digital Capabilities Framework (DCF) was published. The authors mapped the survey tool retrospectively to the framework.

KEY FINDINGS

Almost all respondents (98.0%, n = 551/562) used eHealth tools at work, mainly to access medicine information (89.8%, n = 495/551). Almost one-third (31.7%, N = 178/562) used social media regularly, while many (79.4%, N = 446/562) were aware of MHAs. Self-perceived digital literacy indicated that 63.3% (n = 356/562) deemed themselves to be above average. Under 35s rated their digital literacy more highly than over 35s (P < 0.001). HEE's DCF indicated that actual digital literacy was lower than that of self-perceived. Despite the high use of eHealth tools, respondents were reluctant to recommend these to the public for health advice.

CONCLUSIONS

Community pharmacy staff self-report their digital literacy to be high yet do not use these skills for public health purposes. Furthermore, these self-reported skills appear to be over-estimated. Despite high levels of use of digital tools at work, staff do not use them for public health, therefore, further training to build confidence to better utilise them is recommended.

What affected UK adults' adherence to medicines during the COVID-19 pandemic? Cross-sectional survey in a representative sample of people with long-term conditions

Aim

Medicines non-adherence is associated with poorer outcomes and higher costs. COVID-19 affected access to healthcare, with increased reliance on remote methods, including medicines supply. This study aimed to identify what affected people's adherence to medicines for long-term conditions (LTCs) during the pandemic.

Subject and methods

Cross-sectional online survey of UK adults prescribed medicines for LTCs assessing self-reported medicines adherence, reasons for non-adherence (using the capability, opportunity and motivation model of behaviour [COM-B]), medicines access and COVID-19-related behaviours.

Results

The 1746 respondents reported a mean (SD) of 2.5 (1.9) LTCs, for which they were taking 2.4 (1.9) prescribed medicines, 525 (30.1%) reported using digital tools to support ordering or taking medicines and 22.6% reported medicines non-adherence. No access to at least one medicine was reported by 182 (10.4%) respondents; 1048 (60.0%) reported taking at least one non-prescription medicine as a substitute; 409 (23.4%) requested emergency supply from pharmacy for at least one medicine. Problems accessing medicines, being younger, male, in the highest socioeconomic group and working were linked to poorer adherence. Access problems were mostly directly or indirectly related to the COVID-19 pandemic. Respondents were generally lacking in capabilities and opportunities, but disruptions to habits (automatic motivation) was the major reason for non-adherence.

Conclusion

Navigating changes in how medicines were accessed, and disruption of habits during the COVID-19 pandemic, was associated with suboptimal adherence. People were resourceful in overcoming barriers to access. Solutions to support medicines-taking need to take account of the multiple ways that medicines are prescribed and supplied remotely.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10389-022-01813-0.

Two-way Automated Text Messaging Support From Community Pharmacies for Medication Taking in Multiple Long-term Conditions: Human-Centered Design With Nominal Group Technique Development Study

BACKGROUND

Reviews of digital communication technologies suggest that they can be effective in supporting medication use; however, their use alongside nondigital components is unclear. We also explored the delivery of a digital communication intervention in a relatively novel setting of community pharmacies and how such an intervention might be delivered to patients with multiple long-term conditions. This meant that despite the large number of intervention examples available in the literature, design questions remained, which we wanted to explore with key stakeholders. Examples of how to involve stakeholders in the design of complex health care interventions are lacking; however, human-centered design (HCD) has been suggested as a potential approach.

OBJECTIVE

This study aimed to design a new community pharmacy text messaging intervention to support medication use for multiple long-term conditions, with patient and health care professional stakeholders in primary care.

METHODS

HCD was used to map the intervention "journey" and identify design questions to explore with patients and health care professionals. Six prototypes were developed to communicate the intervention concept, and a modified version of the Nominal Group Technique was used to gather feedback. Nominal group meetings generated qualitative data using questions about the aspects that participants liked for each prototype and any suggested changes. The discussion was analyzed using a framework approach to transform feedback into statements. These statements were then ranked using a web-based questionnaire to establish a consensus about what elements of the design were valued by stakeholders and what changes to the design were most important.

RESULTS

A total of 30 participants provided feedback on the intervention design concept over 5 nominal group meetings (21 health care professionals and 9 patients) with a 57% (17/30) response rate to the ranking questionnaire. Furthermore, 51 proposed changes in the intervention were generated from the framework analysis. Of these 51 changes, 27 (53%) were incorporated into the next design stage, focusing on changes that were ranked highest. These included suggestions for how text message content might be tailored, patient information materials, and the structure for pharmacist consultation. All aspects that the participants liked were retained in the future design and provided evidence that the proposed intervention concept had good acceptability.

CONCLUSIONS

HCD incorporating the Nominal Group Technique is an appropriate and successful approach for obtaining feedback from key stakeholders as part of an iterative design process. This was particularly helpful for our intervention, which combined digital and nondigital components for delivery in the novel setting of a community pharmacy. This approach enabled the collection and prioritization of useful multiperspective feedback to inform further development and testing of our intervention. This model has the potential to minimize research waste by gathering feedback early in the complex intervention design process.

Recommendations for community pharmacy to improve access to medication advice for people from ethnic minority communities: A qualitative person-centred codesign study

INTRODUCTION

Medicines-centred consultations are vital to support medicine effectiveness and optimize health outcomes for patients. However, inequalities negatively impact ethnic minority populations when accessing medicines advice. It is important to identify opportunities to improve access for these communities however, knowledge of how best to achieve this is lacking; this study will generate recommendations to improve access to medicines advice from community pharmacies for people from ethnic minority communities.

METHODS

A series of codesign workshops, with four groups of patient-stakeholders, were conducted between September-November 2021; they took place in-person or via video call (adhering to COVID-19 restrictions). Existing evidence-based perceptions affecting access to medicines advice were critiqued and recommendations were generated, by use of reflexive thematic analysis, to improve access for ethnic minority patients. The workshops were audio-recorded and transcribed verbatim. QSR NVivo (Version 12) facilitated data analysis.

RESULTS

Twelve participants were recruited using purposive sampling; including eight UK citizens, two asylum seekers and two participants in receipt of residency visas. In total, four different ethnic minority groups were represented. Each participant took part in a first and second workshop to share and cocreate recommendations to improve access to medicines advice in community pharmacies. Three recommendations were developed and centred on: (i) delivering and providing culturally competent medicines advice; (ii) building awareness of accessing medicines advice from community pharmacies; and (iii) enabling better discussions with patients from ethnic minority communities.

CONCLUSIONS

These recommendations have the potential to support community pharmacy services to overcome ethnic inequalities affecting medicines advice; service commissioners should consider these findings to best meet the needs of ethnic minority patients. Cultural competence training for community pharmacy staff could support the creation of pharmacies as inclusive healthcare settings. Collaborative working with ethnic minority communities could enable specific tailoring of medicines-centred services to best meet their needs.

PATIENT OR PUBLIC CONTRIBUTION

The National Institute for Health Research (NIHR) and Newcastle University Patient and Public Involvement and Engagement group had extensive input in the study design and conceptualization. Seven patient champions were appointed to the steering group to ensure that the research was conducted, and findings were reported, with cultural competence.

TRIAL REGISTRATION

Not applicable.

Drug-related problems and satisfaction among patients receiving pharmacist-led consultations at the initiation of cardiovascular drugs

BACKGROUND

Drug-related problems (DRPs) lead to substantial morbidity and mortality and increase healthcare costs. Several interventions have been developed to reduce DRPs and improve the outcome of drug therapy.

OBJECTIVE

To investigate DRPs identified through a pharmacist-led intervention and to assess patient satisfaction with the intervention.

METHODS

Patients received two pharmacist consultations 1-2 weeks and 3-5 weeks after collecting a new cardiovascular medicine. Information about patient characteristics, beliefs about medicines (BMQ), DRPs, and patient evaluations were collected using questionnaires.

RESULTS

Pharmacists identified DRPs among 52.4% and 43.1% of the 633 patients at consultation 1 and 2, respectively. Of the DRPs reported in consultation 1, 43.7% were solved at consultation 2. Among patients with side effects, patients who received advice on managing these in consultation 1 where more likely to have solved problems at consultation 2 (61.2% vs. 42.6%, p = 0.008). Female gender, high BMQ concern and the number of new medicines were associated with DRPs. Patients were highly satisfied with the intervention. Predictors of satisfaction were female gender, older age, higher BMQ necessity, face-to-face consultations, longer duration of consultation 1, and solved problems in consultation 2.

CONCLUSIONS

The results indicate that the pharmacist-led follow-up intervention can aid early identification and solving of DRPs in patients prescribed new cardiovascular drugs. Knowledge of factors associated with DRPs and patients' satisfaction may allow further improvement of the intervention.

Effectiveness of a medication adherence management intervention in a community pharmacy setting: a cluster randomised controlled trial

BACKGROUND

Non-adherence to medications continues to be a burden worldwide, with significant negative consequences. Community pharmacist interventions seem to be effective at improving medication adherence. However, more evidence is needed regarding their impact on disease-specific outcomes. The aim was to evaluate the impact of a community pharmacist-led adherence management intervention on adherence and clinical outcomes in patients with hypertension, asthma and chronic obstructive pulmonary disease (COPD).

METHODS

A 6-month cluster randomised controlled trial was conducted in Spanish community pharmacies. Patients suffering from hypertension, asthma and COPD were recruited. Patients in the intervention group received a medication adherence management intervention and the control group received usual care. The intervention was based on theoretical frameworks for changing patient behaviour. Medication adherence, disease-specific outcomes (Asthma Control Questionnaire (ACQ) scores, Clinical COPD Questionnaire (CCQ) scores and blood pressure levels) and disease control were evaluated. A multilevel regression model was used to analyse the data.

RESULTS

Ninety-eight pharmacies and 1186 patients were recruited, with 1038 patients completing the study. Patients receiving the intervention had an OR of 5.12 (95% CI 3.20 to 8.20, p<0.05) of being adherent after the 6 months. At the end of the study, patients in the intervention group had lower diastolic blood pressure levels (mean difference (MD) -2.88, 95% CI -5.33 to -0.43, p=0.02), lower CCQ scores (MD -0.50, 95% CI -0.82 to -0.18, p<0.05) and lower ACQ scores (MD -0.28, 95% CI -0.56 to 0.00, p<0.05) when compared with the control group.

CONCLUSIONS

A community pharmacist-led medication adherence intervention was effective at improving medication adherence and clinical outcomes in patients suffering from hypertension, asthma and COPD. Future research should explore the implementation of these interventions in routine practice.

TRIAL REGISTRATION NUMBER

ACTRN12618000410257.

A qualitative exploration of the barriers and facilitators affecting ethnic minority patient groups when accessing medicine review services: Perspectives of healthcare professionals

Introduction

Healthcare inequalities and ethnicity are closely related. Evidence has demonstrated that patients from ethnic minority groups are more likely to report a long‐term illness than their white counterparts; yet, in some cases, minority groups have reported poorer adherence to prescribed medicines and may be less likely to access medicine services. Knowledge of the barriers and facilitators that impact ethnic minority access to medicine services is required to ensure that services are fit for purpose to meet and support the needs of all.

Methods

Semistructured interviews with healthcare professionals were conducted between October and December 2020, using telephone and video call‐based software. Perspectives on barriers and facilitators were discussed. Interviews were audio‐recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the Newcastle University Faculty of Medical Sciences Ethics Committee.

Results

Eighteen healthcare professionals were interviewed across primary, secondary and tertiary care settings; their roles spanned medicine, pharmacy and dentistry. Three themes were developed from the data regarding the perceived barriers and facilitators affecting access to medicine services for ethnic minority patients. These centred around patient expectations of health services; appreciating cultural stigma and acceptance of certain health conditions; and individually addressing communication and language needs.

Conclusion

This study provides much‐needed evidence relating to the barriers and facilitators impacting minority ethnic communities when seeking medicine support. The results of this study have important implications for the delivery of person‐centred care. Involving patients and practitioners in coproduction approaches could enable the design and delivery of culturally sensitive and accessible medicine services.

Patient or Public Contribution

The Patient and Public Involvement and Engagement (PPIE) group at Newcastle University had extensive input in the design and concept of this study before the research was undertaken. Throughout the work, a patient champion (Harpreet Guraya) had input in the project by ensuring that the study was conducted, and the findings were reported, with cultural sensitivity.

Advancing Mental heaLth Provision In PHarmacY (AMPLIPHY): A feasibility study

BACKGROUND

Specifically-designed community pharmacy-based services represent opportunities to support people with their mental health. As few such services exist worldwide, the Advancing Mental HeaLth Provision In PharmacY (AMPLIPHY) was designed with stakeholders. The purpose was to support people with their mental health when initiated on new prescription or change in drug, dose or quantity of antidepressant, through a series of consultations (up to 3 months).

OBJECTIVE(S)

The aim was to evaluate the feasibility of the AMPLIPHY service. The objectives were to: i) pilot the service; ii) examine anonymous consultation data to understand patients' characteristics, priorities and consultation focus and iii) Evaluate pharmacists' experiences.

METHODS

This service evaluation involved a concurrent mixed methods design. Patient characteristics were extracted from consultation notes and descriptive statistics applied. Content analysis was used to summarise consultation foci and comparisons between patients' priorities with consultation content were made. Pharmacists were interviewed at the start (n = 10) and end (n = 4) of the pilot with themes identified using thematic analysis.

RESULTS

Seventy-six patients participated (63% of recruitment target). The median age was 39 (IQR 28-47) and 62% were female. Seventy percent of patients had one consultation, 26% had two and 4% had three. Prescription for new antidepressant was the most common reason for entry (74%) and sertraline was most prescribed (46%). Consultations commonly focussed on life experience (n = 51), medication (n = 47), health (n = 42), support (n = 36) and patients' expression of their feelings (n = 31). The pharmacists' experiences were summarised in three themes: i) Motivation, ii) Practicalities and iii) Experience and Outcomes.

CONCLUSIONS

Pharmacists were motivated to deliver this novel service and some patients were willing to join the service. Analysis of patient demographics, consultation notes and interviews provide insight into the strengths and challenges of the service and provides a blueprint for future service developments.

Cost-Utility Analysis of a Medication Adherence Management Service Alongside a Cluster Randomized Control Trial in Community Pharmacy

BACKGROUND

It is necessary to determine the cost utility of adherence interventions in chronic diseases due to humanistic and economic burden of non-adherence.

PURPOSE

To evaluate, alongside a cluster-randomized controlled trial, the cost-utility of a pharmacist-led medication adherence management service (MAMS) compared with usual care in community pharmacies.

MATERIALS AND METHODS

The trial was conducted over six months. Patients with treatments for hypertension, asthma or chronic obstructive pulmonary disease (COPD) were included. Patients in the intervention group (IG) received a MAMS based on a brief complex intervention, whilst patients in the control group (CG) received usual care. The cost-utility analysis adopted a health system perspective. Costs related to medications, healthcare resources and adherence intervention were included. The effectiveness was estimated as quality-adjusted life years (QALYs), using a multiple imputation missing data model. The incremental cost-utility ratio (ICUR) was calculated on the total sample of patients.

RESULTS

A total of 1186 patients were enrolled (IG: 633; CG: 553). The total intervention cost was estimated to be €27.33 ± 0.43 per patient for six months. There was no statistically significant difference in total cost of medications and healthcare resources per patient between IG and CG. The values of EQ-5D-5L at 6 months were significantly higher in the IG [IG: 0.881 ± 0.005 vs CG: 0.833 ± 0.006; p = 0.000]. In the base case, the service was more expensive and more effective than usual care, resulting in an ICUR of €1,494.82/QALY. In the complete case, the service resulted in an ICUR of €2,086.30/QALY, positioned between the north-east and south-east quadrants of the cost-utility plane. Using a threshold value of €20,000/QALY gained, there is a 99% probability that the intervention is cost-effective.

CONCLUSION

The medication adherence management service resulted in an improvement in the quality of life of the population with chronic disease, with similar costs compared to usual care. The service is cost-effective.

Interventions to improve adherence to pharmacological therapy for chronic obstructive pulmonary disease (COPD)

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic lung condition characterised by persistent respiratory symptoms and limited lung airflow, dyspnoea and recurrent exacerbations. Suboptimal therapy or non-adherence may result in limited effectiveness of pharmacological treatments and subsequently poor health outcomes.

OBJECTIVES

To determine the efficacy and safety of interventions intended to improve adherence to single or combined pharmacological treatments compared with usual care or interventions that are not intended to improve adherence in people with COPD.

SEARCH METHODS

We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register, CENTRAL, MEDLINE and Embase (search date 1 May 2020). We also searched web-based clinical trial registers.

SELECTION CRITERIA

RCTs included adults with COPD diagnosed by established criteria (e.g. Global Initiative for Obstructive Lung Disease). Interventions included change to pharmacological treatment regimens, adherence aids, education, behavioural or psychological interventions (e.g. cognitive behavioural therapy), communication or follow-up by a health professional (e.g. telephone, text message or face-to-face), multi-component interventions, and interventions to improve inhaler technique.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Working in pairs, four review authors independently selected trials for inclusion, extracted data and assessed risk of bias. We assessed confidence in the evidence for each primary outcome using GRADE. Primary outcomes were adherence, quality of life and hospital service utilisation. Adherence measures included the Adherence among Patients with Chronic Disease questionnaire (APCD). Quality of life measures included the St George's Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT) and Clinical COPD Questionnaire (CCQ).

MAIN RESULTS

We included 14 trials (2191 participants) in the analysis with follow-up ranging from six to 52 weeks. Age ranged from 54 to 75 years, and COPD severity ranged from mild to very severe. Trials were conducted in the USA, Spain, Germany, Japan, Jordan, Northern Ireland, Iran, South Korea, China and Belgium. Risk of bias was high due to lack of blinding. Evidence certainty was downgraded due to imprecision and small participant numbers. Single component interventions Six studies (55 to 212 participants) reported single component interventions including changes to pharmacological treatment (different roflumilast doses or different inhaler types), adherence aids (Bluetooth inhaler reminder device), educational (comprehensive verbal instruction), behavioural or psychological (motivational interview). Change in dose of roflumilast may result in little to no difference in adherence (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.22 to 1.99; studies = 1, participants = 55; low certainty). A Bluetooth inhaler reminder device did not improve adherence, but comprehensive verbal instruction from a health professional did improve mean adherence (prescription refills) (mean difference (MD) 1.00, 95% CI 0.46 to 1.54). Motivational interview improved mean adherence scores on the APCD scale (MD 22.22, 95% CI 8.42 to 36.02). Use of a single inhaler compared to two separate inhalers may have little to no impact on quality of life (SGRQ; MD 0.80, 95% CI -3.12 to 4.72; very low certainty). A Bluetooth inhaler monitoring device may provide a small improvement in quality of life on the CCQ (MD 0.40, 95% CI 0.07 to 0.73; very low certainty). Single inhaler use may have little to no impact on the number of people admitted to hospital compared to two separate inhalers (OR 1.47, 95% CI 0.75 to 2.90; very low certainty). Single component interventions may have little to no impact on the number of people expereincing adverse events (very low certainty evidence from studies of a change in pharmacotherapy or use of adherence aids). A change in pharmacotherapy may have little to no impact on exacerbations or deaths (very low certainty). Multi-component interventions Eight studies (30 to 734 participants) reported multi-component interventions including tailored care package that included adherence support as a key component or included inhaler technique as a component. A multi-component intervention may result in more people adhering to pharmacotherapy compared to control at 40.5 weeks (risk ratio (RR) 1.37, 95% CI 1.18 to 1.59; studies = 4, participants = 446; I² = 0%; low certainty). There may be little to no impact on quality of life (SGRQ, Chronic Respiratory Disease Questionnaire, CAT) (studies = 3; low to very low certainty). Multi-component interventions may help to reduce the number of people admitted to hospital for any cause (OR 0.37, 95% CI 0.22 to 0.63; studies = 2, participants = 877; low certainty), or COPD-related hospitalisations (OR 0.15, 95% CI 0.07 to 0.34; studies = 2, participants = 220; moderate certainty). There may be a small benefit on people experiencing severe exacerbations. There may be little to no effect on adverse events, serious adverse events or deaths, but events were infrequently reported and were rare (low to very certainty).

AUTHORS' CONCLUSIONS

Single component interventions (e.g. education or motivational interviewing provided by a health professional) can help to improve adherence to pharmacotherapy (low to very low certainty). There were slight improvements in quality of life with a Bluetooth inhaler device, but evidence is from one study and very low certainty. Change to pharmacotherapy (e.g. single inhaler instead of two, or different doses of roflumilast) has little impact on hospitalisations or exacerbations (very low certainty). There is no difference in people experiencing adverse events (all-cause or COPD-related), or deaths (very low certainty). Multi-component interventions may improve adherence with education, motivational or behavioural components delivered by health professionals (low certainty). There is little to no impact on quality of life (low to very low certainty). They may help reduce the number of people admitted to hospital overall (specifically pharmacist-led approaches) (low certainty), and fewer people may have COPD-related hospital admissions (moderately certainty). There may be a small reduction in people experiencing severe exacerbations, but evidence is from one study (low certainty). Limited evidence found no difference in people experiencing adverse events, serious adverse events or deaths (low to very low certainty). The evidence presented should be interpreted with caution. Larger studies with more intervention types, especially single interventions, are needed. It is unclear which specific COPD subgroups would benefit, therefore discussions between health professionals and patients may help to determine whether they will help to improve health outcomes.

Prevalence and Nature of Medication Errors and Medication-Related Harm Following Discharge from Hospital to Community Settings: A Systematic Review

Background

Little is known about the epidemiology of medication errors and medication-related harm following transition from secondary to primary care. This systematic review aims to identify and critically evaluate the available evidence on the prevalence and nature of medication errors and medication-related harm following hospital discharge.

Methods

Studies published between January 1990 and March 2019 were searched across ten electronic databases and the grey literature. No restrictions were applied with publication language or patient population studied. Studies were included if they contained data concerning the rate of medication errors, unintentional medication discrepancies, or adverse drug events. Two authors independently extracted study data.

Results

Fifty-four studies were included, most of which were rated as moderate (39/54) or high (7/54) quality. For adult patients, the median rate of medication errors and unintentional medication discrepancies following discharge was 53% [interquartile range 33–60.5] (n = 5 studies) and 50% [interquartile range 39–76] (n = 11), respectively. Five studies reported adverse drug reaction rates with a median of 27% [interquartile range 18–40.5] and seven studies reported adverse drug event rates with a median of 19% [interquartile range 16–24]. For paediatric patients, one study reported a medication error rate of 66.3% and another an adverse drug event rate of 9%. Almost a quarter of studies (13/54, 24%) utilised a follow-up period post-discharge of 1 month (range 2–180 days). Drug classes most commonly implicated with adverse drug events were antibiotics, antidiabetics, analgesics and cardiovascular drugs.

Conclusions

This is the first systematic review to explore the prevalence and nature of medication errors and adverse drug events following hospital discharge. Targets for future work have been identified.

Electronic supplementary material

The online version of this article (10.1007/s40264-020-00918-3) contains supplementary material, which is available to authorized users.

The impact of community pharmacists on older adults in Turkey

OBJECTIVE

This study aimed to evaluate the impact of theory-based, structured, standardized pharmaceutical care services led by community pharmacists (CPs) on patient-related outcomes in older Turkish adults.

PRACTICE DESCRIPTION

This prospective, quasi-experimental pilot study was conducted at the national level at community pharmacies in Turkey. After virtual training of CPs, pharmaceutical care services including medicine bag check-up, medication review, patient medicine card, patient education, and counseling services (including motivational interviewing) were delivered to promote medication adherence in older adults.

PRACTICE INNOVATION

Theory-based, structured, standardized pharmaceutical care services addressing medication adherence problems in older Turkish adults with noncommunicable diseases.

EVALUATION METHODS

Descriptive data (including demographic and clinical data, medication-related problems by using the DOCUMENT classification, potential inappropriate prescribing by using the Ghent Older People's Prescriptions Community Pharmacy Screening- (GheOP³S) tool, and pharmacy service satisfaction) were presented. Pre- and post-evaluation were compared by using the Wilcoxon test (for continuous variables) and McNemar's or McNemar-Bowker chi-square test (for categorical variables).

RESULTS

One hundred and thirty-eight medication-related problems were identified among 52 older adults. The medication adherence rate was significantly increased from 51.9% to 75%, and the mean of total quality of life (QoL) score rose significantly from 51.7 to 53.4 (P < 0.05). There was a statistically significant change in the median of necessity-concern differential (baseline: 7 [2.2-10.0] vs. final: 8.0 [5-11]; P < 0.05). At baseline, all patients had at least 1 potential inappropriate prescribing according to the GheOP³S tool, and the rate was 73.1% at the final assessment.

CONCLUSION

Community pharmacist-led pharmaceutical care services significantly improved patient-related outcomes (such as medication adherence, beliefs about medication, and QoL) in older adults with noncommunicable diseases. No statistically significant change was detected in their lifestyle behaviors (such as physical activity and diet program) or health awareness.

Adherence at 2 years with distribution of essential medicines at no charge: The CLEAN Meds randomized clinical trial

BACKGROUND

Adherence to medicines is low for a variety of reasons, including the cost borne by patients. Some jurisdictions publicly fund medicines for the general population, but many jurisdictions do not, and such policies are contentious. To our knowledge, no trials studying free access to a wide range of medicines have been conducted.

METHODS AND FINDINGS

We randomly assigned 786 primary care patients who reported not taking medicines due to cost between June 1, 2016 and April 28, 2017 to either free distribution of essential medicines (n = 395) or to usual medicine access (n = 391). The trial was conducted in Ontario, Canada, where hospital care and physician services are publicly funded for the general population but medicines are not. The trial population was mostly female (56%), younger than 65 years (83%), white (66%), and had a low income from wages as the primary source (56%). The primary outcome was medicine adherence after 2 years. Secondary outcomes included control of diabetes, blood pressure, and low-density lipoprotein (LDL) cholesterol in patients taking relevant treatments and healthcare costs over 2 years. Adherence to all appropriate prescribed medicines was 38.7% in the free distribution group and 28.6% in the usual access group after 2 years (absolute difference 10.1%; 95% confidence interval (CI) 3.3 to 16.9, p = 0.004). There were no statistically significant differences in control of diabetes (hemoglobin A1c 0.27; 95% CI -0.25 to 0.79, p = 0.302), systolic blood pressure (-3.9; 95% CI -9.9 to 2.2, p = 0.210), or LDL cholesterol (0.26; 95% CI -0.08 to 0.60, p = 0.130) based on available data. Total healthcare costs over 2 years were lower with free distribution (difference in median CAN$1,117; 95% CI CAN$445 to CAN$1,778, p = 0.006). In the free distribution group, 51 participants experienced a serious adverse event, while 68 participants in the usual access group experienced a serious adverse event (p = 0.091). Participants were not blinded, and some outcomes depended on participant reports.

CONCLUSIONS

In this study, we observed that free distribution of essential medicines to patients with cost-related nonadherence substantially increased adherence, did not affect surrogate health outcomes, and reduced total healthcare costs over 2 years.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02744963.

Adherence to triple-component antihypertensive regimens is higher with single-pill than equivalent two-pill regimens: A randomized controlled trial

Abstract

Using a single‐pill combination (SPC) for hypertension (HTN) treatment resulted in better adherence and persistence than a free‐equivalent combination in previous observational studies. The aim of this study is to confirm superior adherence with a triple‐component SPC compared with an equivalent two‐pill regimen in a randomized controlled trial (RCT) using a medication event monitoring system (MEMS). This is a multicenter, open‐label, RCT. Subjects were persons with HTN whose clinic blood pressure was not adequately controlled (systolic >140 mmHg or diastolic >90 mmHg) with a dual combination. Eligible patients were randomized to either the triple‐component SPC (olmesartan/amlodipine/hydrochlorothiazide 20/5/12.5 mg) group or the equivalent two‐pill (olmesartan/hydrochlorothiazide 20/12.5 mg + amlodipine 5 mg) group and maintained for 12 weeks. Primary outcomes were the difference in percentage of doses taken (PDT) and percentage of days with the prescribed dose taken correctly (PDTc) between the single‐ and two‐pill therapy groups, calculated from MEMS data. From 8 hospitals, 145 patients with HTN were randomized. The single‐pill group had significantly higher PDT and PDTc than the two‐pill group: median (25–75 percentile) PDT 95.1 (86.7–100.0) versus 92.1 (73.0–97.3); and PDTc 91.0 (79.4–96.5) versus 88.6 (69.2–96.3%), P = 0.04 for both by the Wilcoxon rank sum test. The single‐pill combination of the triple‐component antihypertensive regimen showed better adherence than the equivalent two‐pill therapy. Reducing pill burden by means of a single‐pill combination is an effective strategy for enhancing adherence to multiple‐agent antihypertensive therapy.

Implementation of a Pharmacogenomic Testing Service through Community Pharmacy in the Netherlands: Results from an Early Service Evaluation

Community pharmacy services have evolved to include medical and pharmaceutical interventions alongside dispensing. While established pharmacogenomic (PGx) testing is available throughout the Netherlands, this is primarily based in hospital environments and for specialist medicines. The aim of this work was to describe how best to implement PGx services within community pharmacy, considering potential barriers and enablers to service delivery and how to address them. The service was implemented across a selection of community pharmacies in the Netherlands. Data were captured on test outcomes and through a pharmacist survey. Following testing, 17.8% of the clinical samples were recommended to avoid certain medication (based on their current medicines use), and 14.0% to have their dose adjusted. Pre-emptive analysis of genotyped patients showed that the majority (99.2%) had actionable variants. Pharmacists felt confident in their operational knowledge to deliver the service, but less so in applying that knowledge. Delivering the service was believed to improve relationships with other healthcare professionals. These results add to the evidence in understanding how PGx can be delivered effectively within the community pharmacy environment. Training pharmacists in how to respond to patient queries and make clinical recommendations may enhance service provision further.

Process study within a pilot cluster randomised trial in community pharmacy: An exploration of pharmacist readiness for research

INTRODUCTION

Community pharmacies have an increasingly prominent public health function. This includes addressing alcohol, but guidance on delivery of alcohol interventions in this setting is lacking. We have developed an intervention that integrates attention to alcohol within existing community pharmacy medicine review services. This paper examines the experiences of community pharmacists (CPs) in conducting a pilot trial of the intervention, including the acceptability of the trial patient recruitment procedures and the training and support provided by the research team.

METHOD

The pilot trial was conducted in 10 community pharmacies in Yorkshire, England. One CP from each pharmacy was recruited via a multi-stage process to assess motivation, commitment and capacity to participate. Each CP attended a research training day and received on-going research support to conduct the trial. Semi-structured audio-recorded face-to-face interviews (lasting 40-105 min) were conducted with all the CPs at the end of the trial. Data were also available from three direct observations conducted during trial support visits. Data were analysed thematically.

RESULTS

The CPs were supportive of research in community pharmacy but had little direct experiences of research themselves. They valued the training and support provided, which had quickly identified areas where CPs were deviating from the study recruitment protocol. In some instances, the boundaries between research and practice became blurred with CPs making changes to their usual routines and interactions with patients to accommodate the research.

CONCLUSIONS

The trial procedures were acceptable to CPs, in part because of the training and support provided. There are also identifiable areas where CPs' readiness for research could be enhanced to facilitate participation in future trials in this setting.

A qualitative study exploring the lived experience of medication use in different disease states: Linking experiences of disease symptoms to medication adherence

WHAT IS KNOWN

Medication non-adherence leads to negative health outcomes. Medication adherence is predicted if patients understand the necessity of medication use to control disease symptoms and progression. It could be expected then, that patients with diseases with symptoms which are managed with medications, such as chronic obstructive pulmonary disorder or gout, or diseases with high-mortality rates, such as cancer, would have higher adherence rates than asymptomatic diseases, such as hypertension. However, poor medication adherence remains problematic in both symptomatic and asymptomatic diseases. Further work is needed to explore patient experiences of medication adherence to understand the link between adherence and symptom control.

OBJECTIVE

To explore patients' lived experiences of medication adherence.

METHODS

Participants were recruited from community pharmacies and general practices. Forty-one semi-structured interviews and three focus groups were used to collect data from patients with disease states that had different symptomatic and asymptomatic profiles. Inductive thematic analysis was used to identify key parts of the experience of using medications.

RESULTS

Participants reported similar experiences of medication adherence despite having different disease symptoms. Participants said that they used medications because it was an expected part of everyday life and that medications 'must be needed' because they had been supplied, rather than being used for a particular symptom. Participants reported short-term episodes of non-adherence were unlikely to lead to negative health outcomes but may result in negative social consequences.

DISCUSSION

The findings broaden our understanding of patient experiences of medication use by indicating patients with symptomatic and asymptomatic diseases share similar experiences of medication use. The necessity to use medications appeared to come from 'the system' of healthcare professionals, family and friends that supply and recommend medications.

WHAT IS NEW

There were key similarities in experiences of medication adherence in patients with different disease states. The negative consequences of short-term episodes of non-adherence were normalized by healthcare professionals.

CONCLUSION

Patients with symptomatic and asymptomatic diseases share similar experiences of medication adherence.

A Systematic Review of Randomized Controlled Trials of Telehealth and Digital Technology Use by Community Pharmacists to Improve Public Health

Community pharmacists (CPs) continue to have an important role in improving public health, however, advances in telehealth and digital technology mean that the methods by which they support their customers and patients are changing. The primary aim of this study was to identify which telehealth and digital technology tools are used by CPs for public health purposes and determine if these have a positive impact on public health outcomes. A systematic review was carried out using databases including PubMed and ScienceDirect, covering a time period from April 2005 until April 2020. The search criteria were the following: randomized controlled trials, published in English, investigating the delivery of public health services by community pharmacists using a telehealth or digital tool. Thirteen studies were included out of 719 initially identified. Nine studies detailed the use of telephone prompts or calls, one study detailed the use of a mobile health application, two studies detailed the use of a remote monitoring device, and one study detailed the use of photo-aging software. Public health topics that were addressed included vaccination uptake (n = 2), smoking cessation (n = 1), hypertension management (n = 2), and medication adherence and counseling (n = 8). More studies are needed to demonstrate whether or not the use of novel technology by CPs can improve public health.

A Qualitative Exploration to Understand Access to Pharmacy Medication Reviews: Views from Marginalized Patient Groups

Background: Vulnerable patients from marginalized groups (e.g., people with disabilities, people experiencing homelessness, black and minority ethnic communities) experience higher rates of ill-health, inequitable access to healthcare and low engagement with screening services. Addressing these disparities and ensuring healthcare provision is impartial and fair is a priority for the United Kingdom (UK) healthcare system. Aim: Using Levesque's access conceptual framework, this study explored the views of patients from marginalized groups, specifically on how access to pharmacy services could be improved and their experiences of receiving a medication review service. Method: Qualitative data were collected via semi-structured interviews on patient experiences of pharmacy services and how access to these could be improved (n = 10). Interviews of patients who had received a medication review from their pharmacist were also conducted (n = 10). Using an interpretivist approach, five 'demand-side' dimensions of Levesque's access conceptual framework were explored (ability to perceive a need for medication support, their ability to seek this support, ability to reach the pharmacy, ability to pay and engage). Results: The findings exposed the medicine, health and social care challenges of vulnerable people and how these are often not being adequately managed or met. Using the access formwork, we unpack and demonstrate the significant challenges patients face accessing pharmacy support. Discussion: Pharmacy organizations need to pay attention to how patients perceive the need for pharmacy support and their ability to seek, reach and engage with this. Further training may be needed for community pharmacy staff to ensure services are made accessible, inclusive and culturally sensitive. Effective engagement strategies are needed to enable the provision of a flexible and adaptable service that delivers patient-centred care. Policy makers should seek to find ways to reconfigure services to ensure people from diverse backgrounds can access such services.