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BPC 2008: Pharmacy practice research reviewed

Sixty-six pharmacy practice research papers were presented at 2008’sBritish Pharmaceutical Conference. Clare Bellingham reviews a selectionof the most interesting papers

by Clare Bellingham

Sixty-six pharmacy practice research papers were presented at 2008’s British Pharmaceutical Conference. Clare Bellingham reviews a selection of the most interesting papers


Times have changed. Over the past couple of years, the new community pharmacy contracts have dominated the practice research presented at the British Pharmaceutical Conference. Not so this year (2008). Instead, public health and long-term conditions move to the fore.

Perhaps this reflects the fact that the pharmacy contracts have been in place for a few years now, so researchers’ attention is focused elsewhere.

Reading through all the papers presented at BPC left me with the definite impression that opinions are what count this year. Pharmacists’ opinions, pharmacy technicians’ opinions, public opinion: they have all been surveyed. Many of these surveys will be of great interest to pharmacists.

But the practice research would have been richer if it had contained more quantitative research too.

Our journey through this year’s papers starts with long-term conditions, then moves on to public health. Next is community pharmacy and risk management, before ending up with support and education for pharmacists.

Long-term conditions

Assisted suicide is not an obvious place to start a section on long-term conditions. But, as pharmacists take on more responsibilities in the management of long-term conditions, it is something about which pharmacists need to be aware. Mooney (Aintree University Hospitals NHS Foundation Trust) et al surveyed 52 pharmacists and found that all wanted more debate and official guidance on physician-assisted suicide.

The research revealed that 57 per cent of participants thought a physician should inform a pharmacist of the intended purpose of drugs prescribed for assisted suicide. Almost all agreed that pharmacists should have a “conscience clause”, allowing them to opt out of providing such drugs. Overall, 87 per cent of female participants and 57 per cent of male participants thought assisted suicide was justifiable.

On a more positive note, Al-khdour (Queen’s University Belfast) et al found that a pharmacy-led management programme for chronic obstructive pulmonary disease (COPD) improved adherence to treatment and reduced hospital admissions. The programme involved patient education and medication review. Patients were given information booklets and an action plan for acute exacerbations.

The study randomly assigned 173 patients with moderate to severe COPD to the intervention group or a control group. Patients in the intervention group were admitted to hospital less than the control group (19 per cent versus 43 per cent), attended the hospital’s emergency department less (25 per cent versus 53 per cent) and had higher adherence scores (82 per cent versus 60 per cent).

Schneider found that pharmacists are failing to stick to Pharmaceutical Society of Australia guidelines on salbutamol (Imarin/Dr

Should salbutamol ever become available over the counter (OTC) in the UK then lessons could be learnt from Australia. The Pharmaceutical Society of Australia has produced standards for OTC sales of salbutamol.

But Schneider (University of Western Australia) et al found that community pharmacists and assistants are failing to stick to them. They sent simulated patients into 160 pharmacies: not one pharmacist or assistant covered all of the recommended points.

Some form of assessment was provided by 84 per cent of pharmacies. The most common question was about prior use of salbutamol (58 per cent of visits), followed by patient identity (56 per cent), other medication (28 per cent), regular medical review (28 per cent) and frequency of reliever use (26 per cent). Only four pharmacists or assistants asked patients if they knew how to use the inhaler.

In New Zealand, Gauld (Pharma Projects, Auckland) et al examined how pharmacists were getting on with having oseltamivir available OTC — a new development in New Zealand in 2007. During the 2007 influenza season, 14 out of 26 pharmacists had supplied oseltamivir. The number of packs sold ranged from zero to 40.

Purchases were mainly driven by consumer request or doctor referral, with only nine of the participating pharmacists actively recommending oseltamivir.

Back to prescription medicines, and differences in the rates of people discontinuing antihypertensive drugs due to adverse events were found by Baqir (Northumbria Healthcare NHS Foundation Trust). In a study of 453 people who started antihypertensive therapy, the most commonly discontinued therapeutic class was calcium channel blockers (29 per cent of patients starting a calcium channel blocker), followed by thiazide diuretics (19 per cent of patients).

In addition, Baqir detected differences between the drugs in each class. Lisinopril was better tolerated than perindopril, and lercanidipine was better tolerated than amlodipine.

In a second paper, Baqir audited the use of antiplatelets and statins in patients aged over 40 years with diabetes. Of 447 patients (after excluding those who had previously had adverse events with an antiplatelet or statin), 68 were not being prescribed an antiplatelet and 50 were not being prescribed a statin. This equated to one in four patients not receiving appropriate prophylaxis for cardiovascular disease.

Sweeney et al (Liverpool John Moores University) assessed GPs’ prescribing of antibiotics and their adherence to a local formulary. They found antibiotic use had declined over the past three years. Compliance with guidelines was associated with individual GPs, rather than practices, and prescribing of co-amoxiclav, clarithromycin, quinolones and clindamycin was frequently outside the formulary guidance.

Psychoactive prescribing in nursing homes in Northern Ireland was tackled by Patterson (Queen’s University Belfast) et al. They compared the Fleetwood NI model of structured pharmaceutical care to usual care in 22 nursing homes. The Fleetwood model involves pharmacists regularly visiting the home to make recommendations for improving drug therapy and produce pharmaceutical care plans.

At baseline, both groups had around 50 per cent of patients taking inappropriate psychoactive medicines. But after 12 months, this dropped to 20 per cent of patients in the Fleetwood NI group with no change in the usual care group.

In a second paper by Patterson et al, an economic comparison of the Fleetwood NI model and usual care found no significant difference in overall health care costs per resident. A third paper estimated the cost of pharmacist input to provide the Fleetwood NI model, which was found to be £80.25 (range £32.85 to £93.58).

Potential inappropriate prescribing and prescribing omissions were tackled by Ryan (University College Cork) et al. They evaluated a tool called STOPP/START (Screening Tool of Older People’s potentially inappropriate Prescriptions and Screening Tool to Alert doctors to Right Treatments).

In a study involving 575 patients, potentially inappropriate prescribing was identified in 24 per cent of patients and prescribing omissions in 21 per cent. Benzodiazepines were the most commonly identified inappropriate medicines, and aspirin the most frequently omitted medicine.

Bourke (The Village Green Surgery, Wallsend) and Baqir revealed gaps in monitoring for patients who receive disease-modifying antirheumatic drugs (DMARDs). They conducted an audit on 57 patients prescribed DMARDs. Of the 13 who were managed entirely in primary care, eight had no recent or incomplete tests.

The rest were monitored in secondary care but the practice was not given any information about the monitoring. The patients managed in primary care now have to tell receptionists the date of their most recent blood test when they order their DMARD prescription.

Patients’ attitudes towards medicines will clearly affect their adherence to treatment. Not surprisingly, Parham (University of London) et al found that patients who had an accepting attitude towards treatment were most adherent. More interesting were the differences between patients with different long-term conditions.

An accepting attitude towards treatment was found in 71 per cent of patients with renal disease but only 48 per cent with inflammatory bowel disease and 43 per cent with bipolar disorder.

Attitudes also counted for Kumarasamy (Robert Gordon University) et al, who surveyed 41 patients with chronic fatigue syndrome and found that 34 per cent thought complementary and alternative medicines were more effective than traditional medicines in alleviating their fatigue.

Brien et al (Liverpool John Moores University) investigated the use of combination inhalers. Among 871 patients, Seretide was prescribed more frequently than Symbicort (roughly two-thirds of patients). Forty per cent of these inhalers were found to be prescribed outside their product licence, mostly in COPD (rather than asthma) patients.

The researchers state that if comparability is assumed, switching these patients from Seretide to Symbicort would save £5,100 per annum.

Public health

Few members of the public are aware that community pharmacies offer a public health service, according to a survey carried out in one primary care trust in England. But worse still, Krska et al (Liverpool John Moores University) also found that promotion of the public health service might not be sufficient to encourage its use. They surveyed 45 pharmacists and 102 members of the public.

Just over half of the public said they were unlikely to use pharmacy’s public health service. The public identified the most important factors in obtaining public health advice as staff knowledge (97 per cent), staff friendliness (85 per cent) and confidentiality (85 per cent).

Hamarneh et al (Queen’s University Belfast) also collected public opinion on pharmacists’ role in public health. In general, the 1,000 members of the public interviewed thought it was the role of a nurse, rather than a community pharmacist, to provide information about heart disease, to perform diagnostic tests and to give lifestyle advice.

Further bad news on the public perception of pharmacists’ role in public health came from a survey of 343 people by Morecroft and Krska (Liverpool John Moores University). Not only did the public think pharmacy did not have a major role in providing public health activities, but they thought medicines activities — considered the important aspect of pharmacy’s role — were not important in public health.

They did however believe pharmacy had a role in smoking cessation, providing clean needles for drug misusers and diabetes screening.

But it is not all bad news on the public health front. Matthews (Caerphilly Local Health Board) and Smith report that community pharmacies are a suitable outlet for expanding sexual health services to young people. They piloted a free condom and sexual health advice scheme in pharmacies, and received positive feedback from young people.

Notman (Robert Gordon University) et al, in a survey of 577 community pharmacists, found that pharmacists would be willing to become more involved in services for opioid misusers if they received increased remuneration (82 per cent), were confident that the patient was stable (79 per cent) and had greater integration with other health professionals (78 per cent).

Community pharmacy

If the public health research has left you feeling miserable, here is some positive news on medicines use reviews (MURs) to cheer you up.

Mohammad (Medway School of Pharmacy) et al compared the number of clinical drug therapy problems in 120 people who had had an MUR with 120 control patients in Kent. The control patients were matched to the MUR patients by being drawn from the same general practice and matched for age, sex and number of repeat medicines.

After six months, the number of clinical drug therapy problems was reduced by 64 per cent in the MUR group, compared with 3 per cent in the control group.

Rosenbloom (King’s College London) and Graham also researched MURs. They surveyed just over 100 pharmacies in Hertfordshire in 2006 and again in 2008. The number of pharmacies with an approved consultation area increased from 76 per cent in 2006 to 89 per cent in 2008. By early 2008, 87 per cent of pharmacies were able to offer MURs.

Barriers to offering MURs were time management and paperwork. The local pharmaceutical committee appointed an MUR facilitator in 2007 who helped 51 per cent of pharmacists identifying patient recruitment problems and 50 per cent of those identifying paperwork problems to overcome these issues.

Do pharmacists think they can compete for NHS funding to develop services? That’s what Bush et al (Aston University) aimed to find out when they surveyed 1,023 pharmacists. Pharmacists working in small chains and independent pharmacies were the most negative, with 37 and 33 per cent, respectively, believing pharmacists could not compete for funding.

This compared with 23 per cent of supermarket pharmacists and 18 per cent of pharmacists working for multiples. They also identified a difference between countries with 27 per cent of pharmacists in England and Wales, and 16 per cent of pharmacists in Scotland saying pharmacists could not compete for funding.

Halsall et al (University of Manchester) also looked at developing pharmacy services. They interviewed 47 patients, pharmacists, pharmacy staff and service commissioners to find out how high quality services can be developed. Three domains that characterised quality of care emerged: accessibility, effectiveness and positive perceptions of those involved at the point of care.

Bush et al (Aston University) are back again with another questionnaire, this time investigating how different pharmacists view themselves. While 86 per cent of locums and 78 per cent of employee pharmacists considered themselves more health professional than business-oriented, only 48 per cent of pharmacy owners felt the same way.

A bleak future for independent community pharmacies was identified by Gidman (University of Central Lancashire). She interviewed pharmacists in north-west England and found respondents were pessimistic about the future for independent contractors. Particular concerns were the effect of the new pharmacy contract on profitability and business viability, and decreasing business values.

Pharmacist prescribing has been a hugely popular topic in recent years at BPC but this year’s review contains just one paper. Lloyd and Hughes (Queen’s University Belfast) sought the opinions of 40 pharmacist supplementary prescribers and 31 of their mentors. Most participants said supplementary prescribing produced patient benefits and increased mentors’ understanding of pharmacists’ skills.

However, almost all expressed concerns over independent prescribing, with both professions identifying diagnosis and lack of clarity over professional roles as particular concerns.

Reducing risk

Community pharmacists make patient safety their key priority when recommending OTC medicines, and do not take an evidence-based approach to treatment. This is the finding of research conducted by Hanna and Hughes (Queen’s University Belfast).

They interviewed 26 community pharmacists and found that safety was the only reason a sale was ever refused, not a lack of efficacy. Pharmacists approached efficacy on the basis of their experience and feedback from patients, rather than on evidence.

When chloramphenicol eye-drops were reclassified as a pharmacy medicine in 2005, concerns were voiced that this might cause increased antibiotic resistance. Hinchcliffe and Walker (National Public Health Service for Wales) knock this theory on the head. They examined prescribing and sales data for chloramphenicol after the switch, and found a reduction in prescribed chloramphenicol that was more than compensated for by new OTC sales.

They then examined data on antimicrobial resistance from eye swabs sent to public health laboratories. The proportion of resistant samples increased in 2006 but returned to preclassification levels in 2007.

Prescribing competence might improve if the most commonly reported cause of error is targeted: errors due to knowledge-based mistakes. This is the conclusion of a systematic review conducted by Tully (University of Manchester) et al. The most common error-producing conditions were lack of training and the prescriber’s experience, with poor communication also mentioned.

Turning to hospital pharmacy, Williams (University of Manchester) and Ashcroft found that the vast majority of 256 pharmacists and pharmacy staff at nine hospitals thought their department was striving to improve patient safety. However, it was not all good news. Up to 40 per cent (range 5–40 per cent) said they were never or rarely given feedback about patient safety problems and 19 per cent (range 12–41 per cent) were worried that any errors they reported would be kept on their personnel file, indicating that the blame culture is still alive.

The causes of labelling mistakes in prevented dispensing incidents in two pharmacy dispensaries (one automated, one manual), were explored by Anto (King’s College London) et al. The prevented incident rates were 353/100,000 for the manual dispensary and 255/100,000 in the automated dispensary.

Label mistakes accounted for 48 per cent of the incidents at the manual dispensary and 59 per cent at the automated dispensary. Staff interviewed suggested that using fast search codes when selecting drugs and instructions in labelling could reduce mistakes because it limited the information on the computer screen and improved accuracy.

Liu (King’s College London) et al assessed hospital-manufactured product labels to work out best practice for a new range of products. Features introduced on the new range were use of unique features for each strength, use of colour, an emphasis on critical information and improved readability.

Schneider (University of Bath) et al assessed whether the intravenous (IV) route of giving antibiotics was being used appropriately at one acute NHS trust. Altogether, 156 courses of IV antibiotics were scrutinised for switching to an oral preparation. Of these, 69 per cent were switched and 31 per cent (48 cases) were not.

The researchers assessed how appropriate the IV route was in these 48 cases. They found that in 13 cases, the IV route was inappropriate and that it was questionable in a further two.

Many patients admitted to hospital have a cannula inserted but never used (Adam Hart-Davis/Science Photo Library)

It is perhaps related that Kumarasamy (Robert Gordon University) et al report that many patients are having a cannula inserted on admission to hospital irrespective of need.

They studied the records of 345 patients and found 91 per cent of patients had a cannula inserted. Of these, 27 per cent were not used, putting patients at needless risk of cannula-related complications.

Communication between anticoagulation clinics, GPs and community pharmacists is the main barrier to implementing the National Patient Safety Agency guidelines on oral anticoagulation, according to Otesile and Rosenbloom (King’s College London).

They conducted an audit of 22 general practices and found many were unable to provide information about patients’ target international normalised ratio (INR) values, intended duration of treatment or recent INR history.

Furthermore, most patients failed to present their yellow book to GPs when requesting prescriptions. On the positive side, warfarin was always prescribed in milligrams.

It is real-life experience that counts when it comes to learning about patient safety, according to Bradley (University of Manchester) et al. Most pharmacy students and graduates said that real-life examples from teacher-practitioners and clinical exposure through work experience was what helped them develop an understanding of patient safety issues.

Which leads us on to our final topic: education and support.

Education and support

Pharmacists are struggling to move from a continuing education mindset to a continuing professional development (CPD) mindset, according to Haughey (Queen’s University Belfast) et al. Their survey of pharmacists found that many did not fully understand the terminology associated with CPD and were frustrated when feedback on their portfolios highlighted the need to apply and evaluate their learning.

In 2006, the Centre for Pharmacy Postgraduate Education launched “learning@lunch”, a vocational learning programme for hospital pharmacists and technicians. Seston (University of Manchester) et al surveyed 1,720 pharmacists and technicians on the programme. Overall, respondents were satisfied with the content and found it relevant to their practice.

However, some were concerned about difficulties in balancing the learning needs of pharmacists and technicians in one format. And it is hardly surprising that some objected to being asked to take part in such activities during their lunch break.

From CPD to revalidation, and Potter et al (University of Manchester) gathered the opinions of 18 community pharmacists on revalidation. Overall, the pharmacists supported the concept of revalidation as a process to maintain professional standards and highlight areas of concern. But they were worried about what the process would involve and who would oversee it.

Pharmacy preregistration trainees want more feedback on their performance, report Willis et al (University of Manchester). They surveyed 701 trainees, of whom 37 per cent said they were overloaded at work and only 52 per cent said they had received feedback on their performance.

McIntosh et al (Robert Gordon University) turned their attention to the opinions of pharmacists in Scotland about the branches of the Royal Pharmaceutical Society. Of 392 pharmacists who returned questionnaires, 78 per cent had not attended a branch meeting in the previous year, although 75 per cent had attended an NHS Education for Scotland (NES) event.

However, positive views about branches were expressed, with 70 per cent of respondents agreeing that branches promote professional standards.

Career choices of male community pharmacists were explored by Gidman (University of Central Lancashire). Of 29 pharmacists interviewed, those with the highest levels of job satisfaction had cross-sector working arrangements and were working less than full-time in a community pharmacy.

Gidman comments that most respondents reported higher levels of job satisfaction than was found in a similar study of female community pharmacists.

Eden et al (University of Manchester) interviewed 12 newly qualified pharmacists who had chosen to leave the pharmacy profession. They found a general feeling of being underused and undervalued. Having been initially keen to embrace clinical services, their working experiences had left them feeling disillusioned. Three of the 12 decided to study medicine.

Perhaps another reason for leaving the profession is revealed by this final paper. Gidman (University of Central Lancashire) et al surveyed the lifestyle expectations of 123 first-year pharmacy students. One-third had unrealistic expectations of the lifestyle a pharmacy career could deliver, with 38 per cent stating they would be driving a Porsche within five years of graduating and 31 per cent that they would be earning the same, or more, than a lawyer. At least pharmacists start their careers with cheerful optimism.

Conference showcases leaders in the development of pharmacy practice

In a session entitled “Best of the best”, four pharmacists were showcased as leaders for the development of pharmacy practice. The quartet consisted of:

  • Stephen Gough, community pharmacy adviser for Central Lancashire Primary Care Trust
  • Stephen Foster, proprietor of Pierremont Pharmacy in Broadstairs, Kent
  • Clare Kerr, head of clinical services for Lloydspharmacy
  • Karen O’Brien, associate director of primary care commissioning for NHS Manchester

Mr Gough spoke about his involvement with a local initiative to develop collaborative working between several primary healthcare disciplines, and an integrated obesity programme for the PCT (see PJ, 13 September 2008, p306).

Stephen Foster: convenience, quality and clinical services are key to success (Craig Strong)

Mr Foster, whose pharmacy has won several national awards for its delivery of clinical services, said that, although his business has many income streams, it still needs to maintain a high prescription volume to remain viable.

He believes his business achieves this through three competitive advantages — convenience, high quality customer service and a wide range of clinical services.

The convenience aspect was illustrated by the fact that his pharmacy was open for 100 hours a week. To ensure high quality customer service, he had chosen, when opening his pharmacy, to employ staff because they were excellent at dealing with customers and not necessarily because they already had a pharmacy background.

The clinical services offered by his pharmacy include a vast range of advanced and enhanced services. Among them were a leg ulcer clinic run by district nurses, warfarin monitoring, physiotherapy, vascular risk screening, weight management clinics, sexual health screening and a range of holistic therapies.

He advised other community pharmacists to make themselves known to commissioners at their PCTs and to respect the contribution they can make as members of the primary healthcare team.

He added that pharmacists did not have to be working for large organisations to have the ability to influence commissioners.

Karen O’Brien: communication with PCTs is vital for developing services (Craig Strong)

Mrs O’Brien, who has been a driving force behind the development of many innovative sexual health services in Greater Manchester, agreed that getting pharmacists to communicate with PCTs was key to developing pharmacy services.

The money for service development is in practice-based commissioning, she said, so pharmacists need to be constantly “putting their case” to local service commissioners. She believes that pharmacy should have a “place at the table” when services are commissioned.

“I don’t just want it to be just GPs,” she said. “When people start talking about health, I want them to be talking about pharmacy.”

Mrs Kerr spoke about her involvement with implementing advanced and enhanced services at Lloyds pharmacies across the UK. These include a cholesterol and heart check service, which recently won a Pharmaceutical Care Award (PJ, 12 July 2008, p36), and other services such as medicines use reviews and diabetes screening.

Citation: The Pharmaceutical Journal URI: 10036468

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