Protocol for the Paediatric Otorrhoea Study (POSt): a multi-methods study to understand the burden of paediatric otorrhoea in the UK

INTRODUCTION

Paediatric otorrhoea (PO) refers to the leakage of fluid through a perforation in the ear drum, resulting from an infection of the middle ear of a child or young person (CYP). PO frequently results in hearing loss which may lead to developmental delay, restricted communication and reduced educational attainment.Epidemiological information for PO is largely derived from low-income countries. The aim of this study will be to establish the incidence of PO within the UK and to understand the impact of PO on CYP and their families' everyday lives. It will build the foundations for a randomised controlled trial investigating the best antibiotic treatment for PO.

METHODS AND ANALYSIS

The study will consist of two work packages. (1) Data from the Clinical Practice Research Datalink (CPRD), January 2005 to July 2021, will be used to determine the incidence of patient presentations with PO to primary care in the UK. It will also explore the current antimicrobial prescribing practice for PO in primary care. (2) Thirty semi-structured interviews will be conducted from 13 July to 31 October 2023 with CYP and their parents/carers to help identify the impact of PO on everyday life, the patient journey and how service users define treatment success. Three medical professional focus groups will be used to understand the current management practice, how treatment success is measured and acceptability to randomise patients. Thematic analysis will be used.

ETHICS AND DISSEMINATION

The Health Research Authority, The Health and Social Care Research Ethics Committee (23/NI/0082) and the CPRD's research data governance panel (22_002508) reviewed this study. Results will be disseminated at medical conferences, in peer-reviewed journals and via social media. The study will cocreate a webpage on healthtalk.org, with the Dipex Charity, about PO to ensure members of the public can learn more about the condition.

TRIAL REGISTRATION NUMBER

ISRCTN46071200.

Knowledge support for optimising antibiotic prescribing for common infections in general practices: evaluation of the effectiveness of periodic feedback, decision support during consultations and peer comparisons in a cluster randomised trial (BRIT2) - study protocol

INTRODUCTION

This project applies a Learning Healthcare System (LHS) approach to antibiotic prescribing for common infections in primary care. The approach involves iterations of data analysis, feedback to clinicians and implementation of quality improvement activities by the clinicians. The main research question is, can a knowledge support system (KSS) intervention within an LHS implementation improve antibiotic prescribing without increasing the risk of complications?

METHODS AND ANALYSIS

A pragmatic cluster randomised controlled trial will be conducted, with randomisation of at least 112 general practices in North-West England. General practices participating in the trial will be randomised to the following interventions: periodic practice-level and individual prescriber feedback using dashboards; or the same dashboards plus a KSS. Data from large databases of healthcare records are used to characterise heterogeneity in antibiotic uses, and to calculate risk scores for clinical outcomes and for the effectiveness of different treatment strategies. The results provide the baseline content for the dashboards and KSS. The KSS comprises a display within the electronic health record used during the consultation; the prescriber (general practitioner or allied health professional) will answer standard questions about the patient's presentation and will then be presented with information (eg, patient's risk of complications from the infection) to guide decision making. The KSS can generate information sheets for patients, conveyed by the clinicians during consultations. The primary outcome is the practice-level rate of antibiotic prescribing (per 1000 patients) with secondary safety outcomes. The data from practices participating in the trial and the dashboard infrastructure will be held within regional shared care record systems of the National Health Service in the UK.

ETHICS AND DISSEMINATION

Approved by National Health Service Ethics Committee IRAS 290050. The research results will be published in peer-reviewed journals and also disseminated to participating clinical staff and policy and guideline developers.

TRIAL REGISTRATION NUMBER

ISRCTN16230629.

Observational study assessing the frequency and impact of medication reviews in UK primary care for people aged ≥65 years

BACKGROUND

Medication reviews are considered an opportunity for reducing polypharmacy. However, there is little evidence about their impact in a real-world setting.

AIM

To quantify numbers of older adults having a medication review in 2019, identify systematic differences in access to medication reviews, and assess the impact of medication reviews on the numbers of medicines prescribed.

METHOD

We defined a population of people aged ≥65 years with at least one active prescription on 01/01/2019 using anonymised electronic health records from the Clinical Practice Research Datalink. We used Cox regression to compare characteristics of people who did and did not have a medication review recorded in their health records in 2019. We compared the maximum number of concurrent prescriptions ('polypharmacy count') in the 3 months before and after a recorded medication review.

RESULTS

Of 591 552 people (median age = 74 years, 54.5% female), 305 503 (51.6%) had a medication review in 2019. Living in a care home (hazard ratio [HR] 1.51, 95% confidence interval [CI] =1.40 to 1.62), a prior medication review in 2018 (HR 1.83, 95% CI = 1.69 to 1.98), and increasing baseline polypharmacy count (5-9 medicines versus 1 medicine HR 1.41, 95% CI = 1.37 to 1.46) were most strongly associated with having a review. Overall, there was a small mean increase in polypharmacy count after a review (+0.13 medicines, 0.12-0.14). For people prescribed ≥10 medicines before the review, polypharmacy count decreased on average (mean -0.14 medicines, -0.15 to -0.12).

CONCLUSION

Although a majority (>50%) of people had a recorded medication review in 2019, these reviews had a small overall impact on polypharmacy in this study population.

Use of locum doctors in NHS trusts in England: analysis of routinely collected workforce data 2019-2021

OBJECTIVES

Temporary doctors, known as locum doctors, play an important role in the delivery of care in the National Health Service (NHS); however, little is known about the extent of locum use in NHS trusts. This study aimed to quantify and describe locum use for all NHS trusts in England in 2019-2021.

SETTING

Descriptive analyses of data on locum shifts from all NHS trusts in England in 2019-2021. Weekly data were available for the number of shifts filled by agency and bank staff and the number of shifts requested by each trust. Negative binomial models were used to investigate the association between the proportion of medical staffing provided by locums and NHS trust characteristics.

RESULTS

In 2019, on average 4.4% of total medical staffing was provided by locums, but this varied substantially across trusts (25th-75th centile=2.2%-6.2%). Over time, on average two-thirds of locum shifts were filled by locum agencies and a third by trusts' staff banks. On average, 11.3% of shifts requested were left unfilled. In 2019-2021, the mean number of weekly shifts per trust increased by 19% (175.2-208.6) and the mean number of weekly unfilled shifts per trust increased by 54% (32.7 to 50.4). Trusts rated by the Care Quality Commission (CQC) as inadequate or requiring improvement (incidence rate ratio=1.495; 95% CI 1.191 to 1.877), and smaller trusts had a higher use of locums. Large variability was observed across regions for use of locums, proportion of shifts filled by locum agencies and unfilled shifts.

CONCLUSIONS

There were large variations in the demand for and use of locum doctors in NHS trusts. Trusts with poor CQC ratings and smaller trusts appear to use locum doctors more intensively compared with other trust types. Unfilled shifts were at a 3-year high at the end of 2021 suggesting increased demand which may result from growing workforce shortages in NHS trusts.

The association of strong opioids and antibiotics prescribing with general practitioner burnout

Background: Prescribing of strong-opioids and antibiotics has important implications for patient safety. General Practitioner (GP) wellness can affect the overprescribing of both medications in primary care. Aim: To examine the associations between strong opioid and antibiotic prescribing with practice-weighted GP-burnout and wellness scores. Design and Setting: A cross-sectional study using prescription data on strong-opioids/antibiotics from the Oxford-RCGP-RSC linking to a GP-wellbeing survey overlaying the same 4-month period December2019-April2020. Methods: Adult prescriptions were measured as tablets per-patient. Burnout in GPs was measured using the shortened versions of the emotional exhaustion and depersonalisation dimensions. Association was examined by fitting a multilevel generalised-linear-model with negative-binomial distribution. Results: Data for 40,227 patients (13,483 strong opioids and 26,744 antibiotics) were linked to 57 practices and 320 GPs. Greater strong opioid prescribing was associated with increased emotional exhaustion (IRR 1.19, 95%CI 1.10-1.24), depersonalisation (1.10, 1.01-1.16), job dissatisfaction (1.25, 1.19-1.32), diagnostic-uncertainty (1.12, 1.08-1.19) and turnover intention (1.32, 1.27-1.37) in GPs. Greater antibiotic prescribing was associated with increased emotional exhaustion (1.19, 1.05-1.37), depersonalisation (1.24, 1.08-1.49), job dissatisfaction (1.11, 1.04-1.19), sickness-presenteeism (1.18, 1.11-1.25) and turnover intention (1.38, 1.31-1.45) in GPs. Increased strong-opioid and antibiotic prescribing was also found in GPs working longer hours (3.95, 3.39-4.61; 5.02, 4.07-6.19, respectively) and in practices in the north of England (1.96, 1.61-2.33; 1.56, 1.12-3.70, respectively). Conclusion: We found higher rates of prescribing of strong opioids/antibiotics in practices with GPs with more burnout symptoms, job dissatisfaction and turnover intentions, working longer hours and in practices in the north of England serving more deprived populations.

Identifying and managing psoriasis-associated comorbidities: the IMPACT research programme

Background

Psoriasis is a common, lifelong inflammatory skin disease, the severity of which can range from limited disease involving a small body surface area to extensive skin involvement. It is associated with high levels of physical and psychosocial disability and a range of comorbidities, including cardiovascular disease, and it is currently incurable.

Objectives

To (1) confirm which patients with psoriasis are at highest risk of developing additional long-term conditions and identify service use and costs to patient, (2) apply knowledge about risk of comorbid disease to the development of targeted screening services to reduce risk of further disease, (3) learn how patients with psoriasis cope with their condition and about their views of service provision, (4) identify the barriers to provision of best care for patients with psoriasis and (5) develop patient self-management resources and staff training packages to improve the lives of people with psoriasis.

Design

Mixed methods including two systematic reviews, one population cohort study, one primary care screening study, one discrete choice study, four qualitative studies and three mixed-methodology studies.

Setting

Primary care, secondary care and online surveys.

Participants

People with psoriasis and health-care professionals who manage patients with psoriasis.

Results

Prevalence rates for psoriasis vary by geographical location. Incidence in the UK was estimated to be between 1.30% and 2.60%. Knowledge about the cost-effectiveness of therapies is limited because high-quality clinical comparisons of interventions have not been done or involve short-term follow-up. After adjusting for known cardiovascular risk factors, psoriasis (including severe forms) was not found to be an independent risk factor for major cardiovascular events; however, co-occurrence of inflammatory arthritis was a risk factor. Traditional risk factors were high in patients with psoriasis. Large numbers of patients with suboptimal management of known risk factors were found by screening patients in primary care. Risk information was seldom discussed with patients as part of screening consultations, meaning that a traditional screening approach may not be effective in reducing comorbidities associated with psoriasis. Gaps in training of health-care practitioners to manage psoriasis effectively were identified, including knowledge about risk factors for comorbidities and methods of facilitating behavioural change. Theory-based, high-design-quality patient materials broadened patient understanding of psoriasis and self-management. A 1-day training course based on motivational interviewing principles was effective in increasing practitioner knowledge and changing consultation styles. The primary economic analysis indicated a high level of uncertainty. Sensitivity analysis indicated some situations when the interventions may be cost-effective. The interventions need to be assessed for long-term (cost-)effectiveness.

Limitations

The duration of patient follow-up in the study of cardiovascular disease was relatively short; as a result, future studies with longer follow-up are recommended.

Conclusions

Recognition of the nature of the psoriasis and its impact, knowledge of best practice and guideline use are all limited in those most likely to provide care for the majority of patients. Patients and practitioners are likely to benefit from the provision of appropriate support and/or training that broadens understanding of psoriasis as a complex condition and incorporates support for appropriate health behaviour change. Both interventions were feasible and acceptable to patients and practitioners. Cost-effectiveness remains to be explored.

Future work

Patient support materials have been created for patients and NHS providers. A 1-day training programme with training materials for dermatologists, specialist nurses and primary care practitioners has been designed. Spin-off research projects include a national study of responses to psoriasis therapy and a global study of the prevalence and incidence of psoriasis. A new clinical service is being developed locally based on the key findings of the Identification and Management of Psoriasis Associated ComorbidiTy (IMPACT) programme.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 3. See the NIHR Journals Library website for further project information.

Primary care clinical management following self-harm during the first wave of COVID-19 in the UK: population-based cohort study

OBJECTIVES

A substantial reduction in self-harm recorded in primary care occurred during the first wave of COVID-19 but effects on primary care management of self-harm are unknown. Our objectives were to examine the impact of COVID-19 on clinical management within 3 months of an episode of self-harm.

DESIGN

Retrospective cohort study.

SETTING

UK primary care.

PARTICIPANTS

4238 patients with an index episode of self-harm recorded in UK primary care during the COVID-19 first-wave period (10 March 2020-10 June 2020) compared with 48 739 patients in a prepandemic comparison period (10 March-10 June, 2010-2019).

OUTCOME MEASURES

Using data from the UK Clinical Practice Research Datalink, we compared cohorts of patients with an index self-harm episode recorded during the prepandemic period versus the COVID-19 first-wave period. Patients were followed up for 3 months to capture subsequent general practitioner (GP)/practice nurse consultation, referral to mental health services and psychotropic medication prescribing. We examined differences by gender, age group and Index of Multiple Deprivation quintile.

RESULTS

Likelihood of having at least one GP/practice nurse consultation was broadly similar (83.2% vs 80.3% in the COVID-19 cohort). The proportion of patients referred to mental health services in the COVID-19 cohort (4.2%) was around two-thirds of that in the prepandemic cohort (6.1%). Similar proportions were prescribed psychotropic medication within 3 months in the prepandemic (54.0%) and COVID-19 first-wave (54.9%) cohorts.

CONCLUSIONS

Despite the challenges experienced by primary healthcare teams during the initial COVID-19 wave, prescribing and consultation patterns following self-harm were broadly similar to prepandemic levels. We found no evidence of widening of digital exclusion in terms of access to remote consultations. However, the reduced likelihood of referral to mental health services warrants attention. Accessible outpatient and community services for people who have self-harmed are required as the COVID-19 crisis recedes and the population faces new challenges to mental health.

Visual impairment and medication safety: a protocol for a scoping review

BACKGROUND

The number of individuals with a visual impairment in the UK was estimated a few years ago to be around 1.8 million. People can be visually impaired from birth, childhood, early adulthood or later in life. Those with visual impairment are subject to health inequities and increased risk for patient safety incidents in comparison to the general population. They are also known to be at an increased risk of experiencing medication errors compared to those without visual impairment. In view of this, this review aims to understand the issues of medication safety for VI people.

METHODS/DESIGN

Four electronic bibliographic databases will be searched: MEDLINE, Embase, PsycInfo and CINAHL. Our search strategy will include search combinations of two key blocks of terms. Studies will not be excluded based on design. Included studies will be empirical studies. They will include studies that relate to both medication safety and visual impairment. Two reviewers (SG and LR) will screen all the titles and abstracts. SG, LR, RM, SCS and PL will perform study selection and data extraction using standard forms. Disagreements will be resolved through discussion or third party adjudication. Data to be collected will include study characteristics (year, objective, research method, setting, country), participant characteristics (number, age, gender, diagnoses), medication safety incident type and characteristics.

DISCUSSION

The review will summarise the literature relating to medication safety and visual impairment.

Anticholinergic drugs and risk of dementia: Time for action?

Evidence suggests that the prescription of bladder anticholinergics is increasing. Recent studies have accentuated concerns about whether certain prescribed medications could increase risk of dementia, including anticholinergic drugs, and specifically anticholinergics used for bladder symptoms. Nevertheless, it can be difficult to draw together the evidence to review the case for possible causation. Recognising this issue in 1965, Bradford-Hill set out nine criteria to help assess whether evidence of a causal relationship could be inferred between a presumed cause and an observed effect. In this commentary, we explore the extent to which associations between anticholinergics and dementia satisfy the Bradford-Hill criteria and examine the potential implications. First, we look at studies that have examined the relationship between anticholinergic drugs with urological properties (bladder drugs) and the onset of dementia, and then present those studies which specifically focus on the cognitive effects of bladder drugs that affect muscarinic receptors in the brain versus the bladder on older people along with suggestions for future research. We also discuss the risks and benefits of these drugs for treating overactive bladder. If it can be shown that certain medications carry a specific risk of dementia, it is possible that initiatives to change prescribing could become a key tool in reducing the risk of dementia and may be easier to implement than some lifestyle changes.

Exploring the experiences of changes to support access to primary health care services and the impact on the quality and safety of care for homeless people during the COVID-19 pandemic: a study protocol for a qualitative mixed methods approach

Background

Despite high level of health care need amongst people experiencing homelessness, poor access is a major concern. This is sometimes due to organisational and bureaucratic barriers, but also because they often feel stigmatised and treated badly when they do seek health care. The COVID-19 pandemic and the required social distancing measures have caused unprecedented disruption and change for the organisation of primary care, particularly for people experiencing homelessness. Against this backdrop there are many questions to address regarding whether the recent changes required to deliver services to people experiencing homelessness in the context of COVID-19 will help to address or compound problems in accessing care and inequalities in health outcomes.

Methods

An action led and participatory research methodology will be employed to address the study objectives. Interviews with people experiencing homelessness were will be conducted by a researcher with lived experience of homelessness. Researchers with lived experience are able to engage with vulnerable communities in an empathetic, non-judgemental way as their shared experience promotes a sense of trust and integrity, which in turn encourages participation in research and may help people speak more openly about their experience. The experiences of health professionals and stakeholders delivering and facilitating care for people experiencing homelessness during the pandemic will also be explored.

Discussion

It is important to explore whether recent changes to the delivery of primary care in response to the COVID-19 pandemic compromise the safety of people experiencing homelessness and exacerbate health inequalities. This could have implications for how primary healthcare is delivered to those experiencing homelessness not only for the duration of the pandemic but in the future.

Impact of a national primary care pay-for-performance scheme on ambulatory care sensitive hospital admissions: a small-area analysis in England

OBJECTIVE

We aimed to spatially describe hospital admissions for ambulatory care sensitive conditions (ACSC) in England at small-area geographical level and assess whether recorded practice performance under one of the world's largest primary care pay-for-performance schemes led to reductions in these potentially avoidable hospitalisations for chronic conditions incentivised in the scheme.

SETTING

We obtained numbers of ACSC hospital admissions from the Hospital Episode Statistics database and information on recorded practice performance from the Quality and Outcomes Framework (QOF) administrative dataset for 2015/2016. We fitted three sets of negative binomial models to examine ecological associations between incentivised ACSC admissions, general practice performance, deprivation, urbanity and other sociodemographic characteristics.

RESULTS

Hospital admissions for QOF incentivised ACSCs varied within and between regions, with clusters of high numbers of hospital admissions for incentivised ACSCs identified across England. Our models indicated a very small effect of the QOF on reducing admissions for incentivised ACSCs (0.993, 95% CI 0.990 to 0.995), however, other factors, such as deprivation (1.021, 95% CI 1.020 to 1.021) and urbanicity (0.875, 95% CI 0.862 to 0.887), were far more important in explaining variations in admissions for ACSCs. People in deprived areas had a higher risk of being admitted in hospital for an incentivised ACSC condition.

CONCLUSION

Spatial analysis based on routinely collected data can be used to identify areas with high rates of potentially avoidable hospital admissions, providing valuable information for targeting resources and evaluating public health interventions. Our findings suggest that the QOF had a very small effect on reducing avoidable hospitalisation for incentivised conditions. Material deprivation and urbanicity were the strongest predictors of the variation in ACSC rates for all QOF incentivised conditions across England.

Comparison of Self-reported Measures of Hearing With an Objective Audiometric Measure in Adults in the English Longitudinal Study of Ageing

IMPORTANCE

An effective and sustainable hearing loss (HL) screening strategy for the early detection of and intervention for HL in older adults is needed.

OBJECTIVES

To examine the concordance of self-reported measures of hearing difficulty with objective hearing data and the factors associated with the potential discordances among these measures across different population subgroups of a representative sample of people 50 years and older in England.

DESIGN, SETTING, AND PARTICIPANTS

This study was a cross-sectional analysis of wave 7 of the English Longitudinal Study of Ageing (ELSA), a large, population-based, prospective cohort study that provides a unique resource for exploring issues associated with aging in England in the 21st century. The full analytic cohort was composed of 9666 individuals participating in the ELSA wave 7, which collected information from June 1, 2014, to May 31, 2015. This study further analyzed a sample of 8529 adults 50 to 89 years of age who had an assessment of their hearing by self-reported measures, and consented to assessment by a qualified nurse via a hearing screening device, and did not have an ear infection or a cochlear implant. Bivariate analyses were performed from July 1 to December 30, 2018, and multivariate analysis from January 1 to June 30, 2019. Multiple logistic regression models examined factors associated with misclassification of hearing difficulties across several categories among those with objectively identified HL.

EXPOSURES

The study examined whether age, marital status, retirement status, indicators of socioeconomic position, and lifestyle factors (such as body mass index, physical activity, and tobacco and alcohol consumption) were associated with the concordance between self-reported hearing problems and manual audiometry among older adults.

MAIN OUTCOMES AND MEASURES

Self-reported hearing measures, including hearing in background noise, compared with objective audiometric assessments.

RESULTS

A total of 9666 study participants (5368 female [55.5%]; mean [SD] age, 67.4 [14.4] years) provided responses regarding their hearing difficulties, hearing in noise, quality of care in hearing, and hearing aid recommendation in ELSA wave 7. Within the cohort, 684 individuals (30.2%) with objectively measured HL greater than 35 dB HL at 3.0 kHz went undetected by the self-report measure, whereas the new constructed categories for moderate and moderately severe or severe HL resulted in 9.3% increased sensitivity. Factors associated with misreporting hearing difficulties (while they had objectively measured HL >35 dB HL at 3.0 kHz, in the better-hearing ear) were as follows: female sex (odds ratio [OR], 1.97; 95% CI, 1.18-3.28), no educational qualifications (OR, 1.37; 95% CI, 1.26-2.55), routine or manual occupation (OR, 1.43; 95% CI, 1.28-2.61), tobacco consumption (OR, 1.14; 95% CI, 1.08-1.90), alcohol intake above the low-risk-level guidelines (OR, 1.13; 95% CI, 1.11-2.34), and lack of moderate physical activity (OR, 1.25; 95% CI, 1.03-1.42). Age was largely associated with misreporting of moderately severe to severe HL; the odds were 5.75 (95% CI, 1.17-8.13) higher for those 65 to 74 years of age and 7.08 (95% CI, 1.41-9.30) higher for those 75 to 89 years of age to not report their hearing difficulties compared with those 50 to 64 years of age. In addition, socioeconomic indicators, such as educational level (OR, 1.95; 95% CI, 1.63-6.01) and occupation (OR, 2.07; 95% CI, 1.78-5.40), along with lifestyle factors, such as smoking (OR, 1.46; 95% CI, 1.25-2.48) and alcohol intake above the low-risk-level guidelines (OR, 1.86; 95% CI, 1.67-5.12), were factors associated with misreporting moderately severe or severe HL.

CONCLUSIONS AND RELEVANCE

The use of a screening measure for audiometric testing and a self-report measure is essential for accurately identifying older people with HL. The results of this study should be considered by HL researchers who analyze self-reported hearing data as a surrogate measurement of audiometric hearing to identify bias in their observed analytic research results.

Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study

Background

Health care-related harm is an internationally recognized threat to public health. The United Kingdom’s national health services demonstrate that upwards of 90% of health care encounters can be delivered in ambulatory settings. Other countries are transitioning to more family practice-based health care systems, and efforts to understand avoidable harm in these settings is needed.

Methods

We developed 100 scenarios reflecting a range of diseases and informed by the World Health Organization definition of ‘significant harm’. Scenarios included different types of patient safety incidents occurring by commission and omission, demonstrated variation in timeliness of intervention, and conditions where evidence-based guidelines are available or absent. We conducted a two-round RAND / UCLA Appropriateness Method consensus study with a panel of family practitioners in England to define “avoidable harm” within family practice. Panelists rated their perceptions of avoidability for each scenario. We ran a k-means cluster analysis of avoidability ratings.

Results

Panelists reached consensus for 95 out of 100 scenarios. The panel agreed avoidable harm occurs when a patient safety incident could have been probably, or totally, avoided by the timely intervention of a health care professional in family practice (e.g. investigations, treatment) and / or an administrative process (e.g. referrals, alerts in electronic health records, procedures for following up results) in accordance with accepted evidence-based practice and clinical governance. Fifty-four scenarios were deemed avoidable, whilst 31 scenarios were rated unavoidable and reflected outcomes deemed inevitable regardless of family practice intervention. Scenarios with low avoidability ratings (1 s or 2 s) were not represented by the categories that were used to generate scenarios, whereas scenarios with high avoidability ratings (7 s 8 s or 9 s) were represented by these a priori categories.

Discussion

The findings from this RAND/UCLA Appropriateness Method study define the characteristics and conditions that can be used to standardize measurement of outcomes for primary care patient safety.

Conclusion

We have developed a definition of avoidable harm that has potential for researchers and practitioners to apply across primary care settings, and bolster international efforts to design interventions to target avoidable patient safety incidents that cause the most significant harm to patients.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0990-z) contains supplementary material, which is available to authorized users.

Socioeconomic and lifestyle factors associated with hearing loss in older adults: a cross-sectional study of the English Longitudinal Study of Ageing (ELSA)

OBJECTIVES

Aims were (1) to examine whether socioeconomic position (SEP) is associated with hearing loss (HL) among older adults in England and (2) whether major modifiable lifestyle factors (high body mass index, physical inactivity, tobacco consumption and alcohol intake above the low-risk-level guidelines) are associated with HL after controlling for non-modifiable demographic factors and SEP.

SETTING

We used data from the wave 7 of the English Longitudinal Study of Ageing, which is a longitudinal household survey dataset of a representative sample of people aged 50 and older.

PARTICIPANTS

The final analytical sample was 8529 participants aged 50-89 that gave consent to have their hearing acuity objectively measured by a screening audiometry device and did not have any ear infection.

PRIMARY AND SECONDARY OUTCOME MEASURES

HL defined as >35 dBHL at 3.0 kHz (better-hearing ear). Those with HL were further subdivided into two categories depending on the number of tones heard at 3.0 kHz.

RESULTS

HL was identified in 32.1% of men and 22.3% of women aged 50-89. Those in a lower SEP were up to two times more likely to have HL; the adjusted odds of HL were higher for those with no qualifications versus those with a degree/higher education (men: OR 1.87, 95%CI 1.47 to 2.38, women: OR 1.53, 95%CI 1.21 to 1.95), those in routine/manual occupations versus those in managerial/professional occupations (men: OR 1.92, 95%CI 1.43 to 2.63, women: OR 1.25, 95%CI 1.03 to 1.54), and those in the lowest versus the highest income and wealth quintiles (men: OR 1.62, 95%CI 1.08 to 2.44, women: OR 1.36, 95%CI 0.85 to 2.16, and men: OR1.72, 95%CI 1.26 to 2.35, women: OR 1.88, 95%CI 1.37 to 2.58, respectively). All regression models showed that socioeconomic and the modifiable lifestyle factors were strongly associated with HL after controlling for age and gender.

CONCLUSIONS

Socioeconomic and lifestyle factors are associated with HL among older adults as strongly as core demographic risk factors, such as age and gender. Socioeconomic inequalities and modifiable lifestyle behaviours need to be targeted by the health policy strategies, as an important step in designing interventions for individuals that face hearing health inequalities.

Understanding the implementation and adoption of an information technology intervention to support medicine optimisation in primary care: qualitative study using strong structuration theory

OBJECTIVES

Using strong structuration theory, we aimed to understand the adoption and implementation of an electronic clinical audit and feedback tool to support medicine optimisation for patients in primary care.

DESIGN

This is a qualitative study informed by strong structuration theory. The analysis was thematic, using a template approach. An a priori set of thematic codes, based on strong structuration theory, was developed from the literature and applied to the transcripts. The coding template was then modified through successive readings of the data.

SETTING

Clinical commissioning group in the south of England.

PARTICIPANTS

Four focus groups and five semi-structured interviews were conducted with 18 participants purposively sampled from a range of stakeholder groups (general practitioners, pharmacists, patients and commissioners).

RESULTS

Using the system could lead to improved medication safety, but use was determined by broad institutional contexts; by the perceptions, dispositions and skills of users; and by the structures embedded within the technology. These included perceptions of the system as new and requiring technical competence and skill; the adoption of the system for information gathering; and interactions and relationships that involved individual, shared or collective use. The dynamics between these external, internal and technological structures affected the adoption and implementation of the system.

CONCLUSIONS

Successful implementation of information technology interventions for medicine optimisation will depend on a combination of the infrastructure within primary care, social structures embedded in the technology and the conventions, norms and dispositions of those utilising it. Future interventions, using electronic audit and feedback tools to improve medication safety, should consider the complexity of the social and organisational contexts and how internal and external structures can affect the use of the technology in order to support effective implementation.

Preventing Acute Kidney Injury: a qualitative study exploring 'sick day rules' implementation in primary care

Background

In response to growing demand for urgent care services there is a need to implement more effective strategies in primary care to support patients with complex care needs. Improving primary care management of kidney health through the implementation of ‘sick day rules’ (i.e. temporary cessation of medicines) to prevent Acute Kidney Injury (AKI) has the potential to address a major patient safety issue and reduce unplanned hospital admissions. The aim of this study is to examine processes that may enable or constrain the implementation of ‘sick day rules’ for AKI prevention into routine care delivery in primary care.

Methods

Forty semi-structured interviews were conducted with patients with stage 3 chronic kidney disease and purposefully sampled, general practitioners, practice nurses and community pharmacists who either had, or had not, implemented a ‘sick day rule’. Normalisation Process Theory was used as a framework for data collection and analysis.

Results

Participants tended to express initial enthusiasm for sick day rules to prevent AKI, which fitted with the delivery of comprehensive care. However, interest tended to diminish with consideration of factors influencing their implementation. These included engagement within and across services; consistency of clinical message; and resources available for implementation. Participants identified that supporting patients with multiple conditions, particularly with chronic heart failure, made tailoring initiatives complex.

Conclusions

Implementation of AKI initiatives into routine practice requires appropriate resourcing as well as training support for both patients and clinicians tailored at a local level to support system redesign.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0480-5) contains supplementary material, which is available to authorized users.

Development of indicators to assess the quality of medicines reconciliation at hospital admission: an e-Delphi study

OBJECTIVE

The aim of this Delphi study was to examine consensus on the appropriateness of the medicines reconciliation (MR) indicators.

METHODS

Practising hospital pharmacists in UK hospitals conducting MR in hospital wards were invited to participate in the study. Appropriateness was defined using four criteria: clarity, importance, relevance and usefulness. The modified Delphi technique was selected as a structured method to develop consensus. RAND definition for consensus was used. In the second round, feedback on the first round was provided. The study did not require Research Ethics approval.

KEY FINDINGS

Sixty-five hospital pharmacists completed the first round Delphi, and 59 of them completed the second round. Their experience ranged from three to 33 years with an average of 16.6 years. Fifty-five indicators were sent to the panel after the pilot study. Each of the two rounds took approximately 8 weeks to be completed. Forty-one indicators reached consensus to be appropriate. Fourteen indicators did not reach consensus.

CONCLUSIONS

The Delphi technique was very effective for enhancing the panel participation as noticed in their responses both in the first and second rounds. Forty-one indicators achieved consensus as being appropriate to evaluate the MR process. These indicators could be used to assess the process and hence improve the quality of the patient care on hospital admission. The indicators need to be used in practice.

Examining the attitudes of hospital pharmacists to reporting medication safety incidents using the theory of planned behaviour

OBJECTIVE

To assess the effect of factors within hospital pharmacists' practice on the likelihood of their reporting a medication safety incident.

DESIGN

Theory of planned behaviour (TPB) survey.

SETTING

Twenty-one general and teaching hospitals in the North West of England.

PARTICIPANTS

Two hundred and seventy hospital pharmacists (response rate = 45%).

INTERVENTION

Hospital pharmacists were invited to complete a TPB survey, based on a prescribing error scenario that had resulted in serious patient harm. Multiple regression was used to determine the relative influence of different TPB variables, and participant demographics, on the pharmacists' self-reported intention to report the medication safety incident.

MAIN OUTCOME MEASURES

The TPB variables predicting intention to report: attitude towards behaviour, subjective norm, perceived behavioural control and descriptive norm.

RESULTS

Overall, the hospital pharmacists held strong intentions to report the error, with senior pharmacists being more likely to report. Perceived behavioural control (ease or difficulty of reporting), Descriptive Norms (belief that other pharmacists would report) and Attitudes towards Behaviour (expected benefits of reporting) showed good correlation with, and were statistically significant predictors of, intention to report the error [R = 0.568, R(2) = 0.323, adjusted R(2) = 0.293, P < 0.001].

CONCLUSIONS

This study suggests that efforts to improve medication safety incident reporting by hospital pharmacists should focus on their behavioural and control beliefs about the reporting process. This should include instilling greater confidence about the benefits of reporting and not harming professional relationships with doctors, greater clarity about what/not to report and a simpler reporting system.

The potential for using a Universal Medication Schedule (UMS) to improve adherence in patients taking multiple medications in the UK: a qualitative evaluation

Background

Poor adherence to prescribed medication has major consequences. Managing multiple long-term conditions often involves polypharmacy, potentially increasing complexity and the possibility of poor adherence. As a result of the globally recognised problems in supporting adherence to medication, some researchers have proposed the use of reminder charts. The main aim of the research was to explore the need for and perceptions around the ‘Universal Medication Schedule’ (UMS). Looking at ways in which pharmacists and General Practitioners (GPs) could use the UMS in NHS settings.

Methods

Semi-structured interviews were carried out with 10 GPs, 10 community pharmacists and 15 patients. Patients were aged 65 years and over, had multiple long-term conditions and were prescribed at least 5 medications. Interviews were recorded and transcribed and thematic analysis was conducted, using a framework approach to manage the data.

Results

Attitudes towards the UMS were mixed with stakeholders seeing benefits and limitations to the chart. Practitioners proposed a number of existing services where they thought the UMS could easily be integrated but there was evidence of role conflict with GPs feeling it may be best placed with pharmacists and vice versa. The potential for the UMS to be used as a tool to aid communication between the different services involved in a patient’s care was a key theme.

Conclusions

The UMS chart provides consolidated medicines information that might help to improve patients’ knowledge and health literacy, which may or may not improve adherence but could help patients in making informed decisions about their treatment. One of the key benefits of using the UMS in practice is that it could be introduced across services. In this way it may aid in medicines reconciliation between healthcare settings to ensure continuity of message, improve patient experience and create more joined up working between services. Further research is needed to test implementation in different services and to assess outcomes on patient understanding and adherence.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0749-8) contains supplementary material, which is available to authorized users.

Exploring safety systems for dispensing in community pharmacies: focusing on how staff relate to organizational components

Background

Identifying risk is an important facet of a safety practice in an organization. To identify risk, all components within a system of operation should be considered. In clinical safety practice, a team of people, technologies, procedures and protocols, management structure and environment have been identified as key components in a system of operation.

Objectives

To explore risks in relation to prescription dispensing in community pharmacies by taking into account relationships between key components that relate to the dispensing process.

Methods

Fifteen community pharmacies in England with varied characteristics were identified, and data were collected using non-participant observations, shadowing and interviews. Approximately 360 hours of observations and 38 interviews were conducted by the team. Observation field notes from each pharmacy were written into case studies. Overall, 52,500 words from 15 case studies and interview transcripts were analyzed using thematic and line-by-line analyses. Validation techniques included multiple data collectors co-authoring each case study for consensus, review of case studies by members of the wider team including academic and practicing community pharmacists, and patient safety experts and two presentations (internally and externally) to review and discuss findings.

Results

Risks identified were related to relationships between people and other key components in dispensing. This included how different levels of staff communicated internally and externally, followed procedures, interacted with technical systems, worked with management, and engaged with the environment. In a dispensing journey, the following categories were identified which show how risks are inextricably linked through relationships between human components and other key components: 1) dispensing with divided attention; 2) dispensing under pressure; 3) dispensing in a restricted space or environment; and, 4) managing external influences.

Conclusions

To identify and evaluate risks effectively, an approach that includes understanding relationships between key components in dispensing is required. Since teams of people in community pharmacies are a key dispensing component, and therefore part of the operational process, it is important to note how they relate to other components in the environment within which they operate. Pharmacies can take the opportunity to reflect on the organization of their systems and review in particular how they can improve on the four key categories identified.

Workplace stress in community pharmacies in England: associations with individual, organizational and job characteristics

OBJECTIVES

To describe the levels of workplace stress that community pharmacists perceive and to examine associations with individual, organizational and job characteristics.

METHODS

A cross-sectional mailed survey of 2000 randomly selected community pharmacists practising in England incorporating a validated organizational stress screening tool (ASSET).

RESULTS

Response rate was 48%. Community pharmacists reported significantly higher levels of stress than other health care workers for seven out of eight work-related stressors. Regression analyses demonstrated significant associations between a number of individual, organizational and job characteristics and stress. Long working days, being a pharmacy manager and working for large multiples were associated with higher reported levels of stress across a number of work-related stressors including work overload, control and the job itself. However, self-reported measures of workload (such as dispensing volume) were not associated with higher stress levels.

CONCLUSIONS

The growth in corporate ownership of community pharmacies, which is associated with more stressful working environments, together with current economic pressures could have consequences not only for the future well-being of pharmacists but also for patient safety.

Culture in community pharmacy organisations: what can we glean from the literature?

PURPOSE

The aim of this paper is to report on the findings of a systematic literature review-seeking to elicit existing evidence of the nature of organisational culture in community pharmacy organisations.

DESIGN/METHODOLOGY/APPROACH

This review takes a novel approach to systematically identifying and synthesising the peer-reviewed research literature pertaining to organisational culture in this setting, its antecedents and outcomes.

FINDINGS

The review provides an overview of the scope of and research methods used in the identified literature, together with a narrative synthesis of its findings, framed within five dimensions of organisational culture: the professional-business role dichotomy; workload, management style, social support and autonomy; professional culture; attitudes to change and innovation; and entrepreneurial orientation.

RESEARCH LIMITATIONS/IMPLICATIONS

There is a need for more detailed and holistic exploration of organisational culture in community pharmacy, using a greater diversity of research methods and a greater focus on patient-related outcomes.

ORIGINALITY/VALUE

This paper demonstrates that, whilst little research has explicitly investigated organisational culture in this context, there exists a range of evidence describing aspects of that culture, some of the environmental and organisational factors helping to shape it, and its impact on the pharmacy workforce, services delivered and business outcomes. It highlights the importance of the business-professional role dichotomy in community pharmacy; the influence of individual pharmacists' characteristics and organisational setting; and the impact on pharmacists' wellbeing and job satisfaction and the services delivered. It provides less evidence of the impact of organisational culture on the quality and safety of service provision.

Qualitative insights into job satisfaction and dissatisfaction with management among community and hospital pharmacists

BACKGROUND

Job satisfaction research in pharmacy has predominantly been investigated using quantitative measures that have generally overlooked satisfaction with management.

OBJECTIVE

This article explores pharmacists' experiences and perceptions of management and examines the implications for job satisfaction.

METHODS

Semi-structured interviews were conducted with a convenience sample of 11 community and 15 hospital pharmacists in the North West of England (n=26). The interview schedule was composed of broad questions relating to job satisfaction and dissatisfaction, allowing for the exploration of original themes. Interviews were transcribed verbatim and entered into NVivo8. Template analysis was used to develop a hierarchical list of codes representing themes and the relationships between themes.

RESULTS

Dissatisfaction with management emerged as a dominant aspect of pharmacists' job dissatisfaction. Of the 26 pharmacists interviewed, 24 commented on their dissatisfaction with management, whereas only 8 participants commented on positive experiences. Both hospital and community pharmacists expressed dissatisfaction with their line management, and how the organizations they worked for were managed.

CONCLUSIONS

Findings suggest that satisfaction with management is an important and significant contributor to job satisfaction overall. It would appear that pharmacists' job satisfaction is compromised by poor line management, lack of recognition, and support from management, which may lead to an increase in turnover and a reduction in job satisfaction.

Professional status in a changing world: The case of medicines use reviews in English community pharmacy

The health professions are engaged in an ongoing and dynamic process involving reflection and adaptation, with factors such as socio-economic and cultural developments and technological innovations compelling professions to respond to changed circumstances. This paper concerns English community pharmacy, where recent reforms provide financial incentives to deliver interventions, which have the potential for pharmacists to promote their knowledge and skills, as part of a professionalising strategy. The paper, drawing on interviews with 49 pharmacists, describes how responses to reforms are not necessarily in accordance with either national policy goals or enhancement of professional status. Debates about professional status and role extension have often focused on health professions' subordination to medicine. This paper highlights the importance and interplay of other factors which help explain the inability to capitalise fully on the potential contribution to professional status, which reforms to extend professional roles afford.

Learning about patient safety: organizational context and culture in the education of health care professionals

OBJECTIVES

This study investigated the formal and informal ways pre-registration students from medicine, nursing, physiotherapy and pharmacy learn about keeping patients safe. This paper gives an overview of the study and explores findings in relation to organizational context and culture.

METHODS

The study employed a phased design using multiple qualitative methods. The overall approach drew on 'illuminative evaluation'. Ethical approval was obtained. Phase 1 employed a convenience sample of 13 pre-registration courses across the UK. Curriculum documents were gathered, and course directors interviewed. Phase 2 used eight case studies, two for each professional group, to develop an in-depth investigation of learning across university and practice by students and newly-qualified practitioners in relation to patient safety, and to examine the organizational culture that students and newly-qualified staff are exposed to. Analysis was iterative and ongoing throughout the study, using frameworks agreed by all researchers.

RESULTS

Patient safety was felt to have become a higher priority for the health care system in recent years. Incident reporting was a key feature of the patient safety agenda within the organizations examined. Staff were often unclear or too busy to report. On the whole, students were not engaged and may not be aware of incident reporting schemes. They may not have access to existing systems in their organization. Most did not access employers' induction programmes. Some training sessions occasionally included students but this did not appear to be routine.

CONCLUSIONS

Action is needed to develop an efficient interface between employers and education providers to develop up-to-date curricula for patient safety.

Assessing quality in community pharmacy

Objective

This review aimed to identify English-language instruments used to assess quality in community pharmacy and to evaluate their reported validity, reliability, feasibility and acceptability. Method A systematic review was conducted to identify literature relating to the use of instruments to assess quality in community pharmacy. The electronic databases searched included Embase, International Pharmaceutical Abstracts, Medline, e-PIC and Pharmline, covering the period of time between January 1990 and March 2007. Reference lists of identified studies and websites of pharmacy bodies were also searched.

Key findings

Ten instruments were identified from Canada, Malta, the UK and the US. These were used for quality-assurance and/or quality-improvement purposes and focused on: clinical governance systems; organisational culture/maturity; safety (climate and systems); effectiveness of pharmacy services; and stakeholders' feedback on services. The assessments were at different stages of development, and the majority had not been tested for construct validity, reliability and feasibility.

Conclusions

Assessments with high validity and reliability give a good indication of the quality of care provided and can indicate areas for improvement. Further research is needed to establish a composite view of quality in community pharmacy; and many of the instruments identified required validation.

Equity in the distribution of community pharmacies in England: impact of regulatory reform

OBJECTIVES

To examine whether relaxation of control of entry regulations for community pharmacy contracts in England, introduced in 2005, affected the distribution of community pharmacies relative to population need indicators.

METHODS

Community pharmacy locations and population need indicators were used to calculate three summary measures of distributional equity across Primary Care Trust (PCT) areas (n = 152): the Gini coefficient, Atkinson Index and community pharmacies per PCT population. The indicators were adjusted for need using data from NHS GP contract Quality and Outcomes Framework disease registers, deprivation, all-cause mortality and elderly population rates.

RESULTS

Numbers of community pharmacies increased by 397 (4%) between 2005 and 2007 with three supermarket chains accounting for 152 (38%) of new pharmacies. Over one-quarter of PCTs experienced increases of 5% or more in community pharmacies per capita between 2005 and 2007. Gini and Atkinson indicators showed small increases in distributional equity across all population needs indicators.

CONCLUSION

Deregulation was associated with more community pharmacies per capita and a small increase in geographic equity of community pharmacy distribution at PCT level. Future research should continue to monitor how pharmacy distribution changes over time and assess the extent to which the new regulatory framework has allowed clustering of pharmacies which could result in increased inequity below PCT level.

A systematic review of the effectiveness of strategies for reducing fracture risk in children with juvenile idiopathic arthritis with additional data on long-term risk of fracture and cost of disease management

OBJECTIVES

To review outcome measures and treatment costs in children with juvenile idiopathic arthritis (JIA) and low bone mineral density (BMD) and/or fragility fractures. To review evidence for effectiveness and safety of bisphosphonates and calcium and/or vitamin D in these children. To assess long-term bone health in adults with JIA.

DATA SOURCES

Major databases were searched up to July 2005 for effectiveness studies and up to January 2005 for costs.

REVIEW METHODS

A structured search strategy was conducted. For the evaluation of long-term bone health, outcome data were derived from two cohorts of adult patients with JIA. As there were few published cost data, an ongoing UK longitudinal study (CAPS) provided background data on the cost of managing JIA.

RESULTS

Sixteen studies (78 children with JIA) were included. At baseline, the children had BMD below the expected values for age- and sex-matched children; treatment with bisphosphonates increased BMD with mean percentage increases in spine BMD varying from 4.5 to 19.1%. None of the studies with control groups compared results between the intervention and control groups, they only compared each group with its own baseline. Overall, studies were heterogeneous in design, of variable quality and with no consistency in methods of assessing and reporting outcomes. Hence, data could not be combined or an effect size calculated. A further 43 papers were included in the safety review; side-effects were generally transient. Two studies assessed treatment with calcium and/or vitamin D; BMD was increased from 0.75 to 0.830 g/cm2 after 6 months and BMD Z-score from -2.8 to -2.3 after 6 months and -2.4 after 1 year. There are relatively few long-term studies on the occurrence of low BMD and fragility fractures in children with JIA, with most studies only following children for 1 or 2 years. However, the long- and short-term data indicate that children with JIA have a lower BMD and more fractures than children without JIA. There are very few data on long-term bone health from adults who have JIA, but studies indicate that low BMD persists into adulthood, although adults in remission from JIA may attain the same BMD as healthy adults. From the available data, any predictors of low BMD and fractures in children and adults with JIA remain uncertain. No studies were found that discussed the costs of treating children with JIA and low BMD and/or fragility fractures. In CAPS, 297 of 457 children with JIA attended a 12-month follow-up visit. The mean annual total cost per child in the first year after diagnosis was 1649 pounds (standard deviation 1093 pounds, range 401-6967 pounds). The highest cost component was appointments with paediatric rheumatologists. The study is continuing to accrue and follow up patients and further analyses will be undertaken as the study progresses.

CONCLUSIONS

BMD, adjusted for size, should be assessed as the primary outcome in studies of bone health in children with JIA. Quantitative computed tomography could be used where equipment is available as it offers the advantage of measuring volumetric density. Bisphosphonates are a promising treatment for osteoporosis in children with JIA, but the quality of the current evidence is poor. The accurate assessment of outcome is crucial. There are still uncertainties about the use of bisphosphonates in children, including whether the positive effects of treatment continue over time, the length of treatment and the maximal bone mass gain that can be achieved. Adults with JIA may have persistent low BMD compared with an otherwise healthy population together with an increased risk of fracture. There are no studies evaluating the costs of treating children with JIA and low BMD and/or fragility fractures. There are few data evaluating the costs of treating JIA in general. In the first 12 months after diagnosis, children with all JIA disease subtypes consume large, but highly variable, quantities of health service resources, the largest component being the consultant rheumatology appointments. Data from a larger cohort, over a longer period, are required to substantiate these results further. Further research is needed to assess more clearly the role and permit licensing of bisphosphonates for treatment of children, and in particular, longer-term studies.

The effectiveness and cost-effectiveness of pimecrolimus and tacrolimus for atopic eczema: a systematic review and economic evaluation

OBJECTIVES

To consider the effectiveness and cost-effectiveness of pimecrolimus for mild to moderate atopic eczema and tacrolimus for moderate to severe atopic eczema compared with current standard treatment in adults and children.

DATA SOURCES

Electronic databases. Experts and the manufacturers of these agents were also approached for information.

REVIEW METHODS

The systematic review was carried out using standard methodological guidelines and a stringent quality assessment strategy. A state transition (Markov) model was developed to estimate cost--utility of tacrolimus and pimecrolimus separately, compared with current standard practice with topical corticosteroids, (a) as first-line treatment and (b) as second-line treatment. Pimecrolimus was also compared to emollients only.

RESULTS

The pimecrolimus trial reports were of varying quality; however when compared with a placebo (emollient), pimecrolimus was found to be more effective and to provide quality of life improvements. There is very little evidence available about pimecrolimus compared with topical corticosteroids. Compared with a placebo (emollient), both 0.03% and 0.1% tacrolimus were found to be more effective. Compared with a mild corticosteroid, 0.03% tacrolimus is more effective in children as measured by a 90% or better improvement in the Physician's Global Evaluation (PGE). Compared with potent topical corticosteroids, no significant difference in effectiveness is seen with 0.1% tacrolimus as measured by a 75% or greater improvement in the PGE. Minor application site adverse effects are common with tacrolimus. However, this did not lead to increased rates of withdrawal from treatment in trial populations. The PenTag economic model demonstrates a large degree of uncertainty, which was explored in both deterministic and stochastic analyses. This is the case for the cost-effectiveness of pimecrolimus and tacrolimus in first- or second-line use compared with topical steroids. In all cases immunosuppressant regimes were estimated to be more costly than alternatives and differences in benefits to be small and subject to considerable uncertainty.

CONCLUSIONS

There is limited evidence from a small number of randomised controlled trials (RCTs) that pimecrolimus is more effective than placebo treatment in controlling mild to moderate atopic eczema. Although greater than for pimecrolimus, the evidence base for tacrolimus in moderate to severe atopic eczema is also limited. At both 0.1% and 0.03% potencies, tacrolimus appears to be more effective than the placebo treatment and mild topical corticosteroids. However, these are not the most clinically relevant comparators. Compared with potent topical corticosteroids, no significant difference was shown. Short-term adverse effects with both immunosuppressants are relatively common, but appear to be mild. Experience of long-term use of the agents is lacking so the risk of rare but serious adverse effects remains unknown. No conclusions can be confidently drawn about the cost-effectiveness of pimecrolimus or tacrolimus compared with active topical corticosteroid comparators. Areas for further research should focus on the effectiveness and safety of the treatments through good-quality RCTs and further economic analysis.

What has happened to antimicrobial usage in primary care in the United Kingdom since the SMAC report? - description of trends in antimicrobial usage using the General Practice Research Database

BACKGROUND

The aim of the study was to assess antibiotic prescribing within the United Kingdom for three of the Standing Medical Advisory Committee recommendations 'four things which could be done'.

METHODS

We conducted a retrospective survey of morbidity and antibiotic prescribing data between 1993 and 2001 using the national General Practice Research Database. Antibiotic prescribing was linked to diagnoses of cough/cold and sore throat; length of antibiotic course for uncomplicated cystitis.

RESULTS

The rate of antibiotic prescribing for cough/cold declined between 1993 (43.7 per 1000 patient years at risk) and 1999 (23.5 per 1000 patient years at risk) and has since increased slightly (to 30.5 per 1000 patient years at risk in 2001). Antibiotic prescribing for sore throat declined between 1995 (80.6 per 1000 patient years at risk) and 1999 and has since remained static (42.1 per 1000 patient years at risk in 2001). Trimethoprim was the most commonly used antibiotic for episodes of uncomplicated cystitis and the prescription of 3 day (or less) courses has increased from 16.4 per cent in 1998 to 41.5 per cent in 2001.

CONCLUSIONS

For the SMAC recommendation to limit prescribing for uncomplicated cystitis to 3 days in otherwise fit women there has been demonstrable impact since the publication of the SMAC report. For two recommendations (no prescribing of antibiotics for simple coughs and colds; no prescribing of antibiotics for viral sore throats) the impact has been less clear against the background of a general reduction in antimicrobial prescribing.

Why are eligible patients not prescribed aspirin in primary care? A qualitative study indicating measures for improvement

BACKGROUND

Despite evidence-based guidelines, aspirin prescribing for the secondary prevention of stroke is sub-optimal. Little is known about why general practitioners do not prescribe aspirin to indicated patients. We sought to identify and describe factors that lead general practitioners (GPs) not to prescribe aspirin to eligible stroke patients. This was the first stage of a study exploring the need for and means of improving levels of appropriate aspirin prescribing.

METHOD

Qualitative interviews with 15 GPs in the West Midlands.

RESULTS

Initially, many GPs did not regard their prescribing as difficult or sub-optimal. However on reflection, they gave several reasons that lead to them not prescribing aspirin for eligible patients or being uncertain. These include: difficulties in applying generic guidelines to individuals presenting in consultations, patient resistance to taking aspirin, the prioritisation of other issues in a time constrained consultation and problems in reviewing the medication of existing stroke patients.

CONCLUSION

In order to improve levels of appropriate aspirin prescribing, the nature and presentation risk information available to GPs and patients must be improved. GPs need support in assessing the risks and benefits of prescribing for patients with combinations of complicating risk factors, while means of facilitating improved GP-patient dialogue are required to help address patient uncertainty. A decision analysis based support system is one option. Decision analysis could synthesise current evidence and identify risk data for a range of patient profiles commonly presenting in primary care. These data could then be incorporated into a user-friendly computerised decision support system to help facilitate improved GP-patient communication. Measures of optimum prescribing based upon aggregated prescribing data must be interpreted with caution. It is not possible to assess whether low levels of prescribing reflect appropriate or inappropriate use of aspirin in specific patients where concordance between the GP and the patient is practised.

Head lice diagnosed in general practice in the West Midlands between 1993 and 2000: a survey using the General Practice Research Database

The potential of the General Practice Research Database (GPRD) for communicable disease surveillance was explored using head lice as an example. All diagnoses of head lice and prescriptions for parasiticidal agents from 1993 to 2000 in the West Midlands were analysed. Diagnoses reached a peak of 28.2 per 1,000 patient years at risk and total prescriptions reached a peak of 27.1 per 1,000 patient years at risk in 1997. Malathion and permethrin were prescribed most often. The proportion of further parasiticidal prescriptions issued within 30 days of the initial prescription increased to a peak of 11.5% of prescriptions in 1997. The ratio of the same:different further prescriptions changed during the study period, reaching a high of 5:1 in 2000. These trends are mirrored by the Royal College of General Practitioners (RCGP) Weekly Returns Service and Prescribing Analysis and Cost (PACT) data. Use of GPRD provides additional insights into patient data, particularly on prescribing, that would not be available from other sources.