Does social environment affect arthritis patients' ability to remain on methotrexate treatment?

□ Drug toxicity is still a major limiting factor for methotrexate treatment continuation □ Treatment discontinuation within 12 months of start of methotrexate in this UK cohort was 20% (SE 2%) □ The monitoring of tolerance to methotrexate has implications for the dispensing of the drug in primary care □ Although social circumstances may have a role in arthritis patients' psychosocial health status, continuation rates of methotrexate in “affluent” and “deprived” patients were similar at the end of the first and second years of treatment □ The reasons for lower socio‐economic groups being discontinued on lower methotrexate doses warrant further study     

Pharmaceutical care across different social groups

More items were prescribed in the deprived area, but for less expensive medicines Similar numbers of patients received aspirins and statins, but fewer additional cardiovascular drugs were used in the deprived area More diabetics had systolic blood pressure above 160mmHg in the deprived area More antibiotics were prescribed in the deprived area The GPs did seem to prescribe in a different way in the two communities; this might be a reflection of being able to practice more concordant consultations in the more affluent area     

Educational strategies to promote evidence‐based community pharmacy practice: a cluster randomised controlled trial

□ Cluster randomised controlled trial of educational strategies in community pharmacy □ Comparison of educational outreach visits and continuing professional development as strategies for implementing guidelines for the sale of over‐the‐counter (OTC) medicines □ Outcome measures derived using simulated patients visits □ Neither educational strategy produced significant change in the sale of OTC medicines □ Further research required to identify effective and efficient educational strategies in community pharmacy.     

Use of over‐the‐counter medicines in children

Objective To assess the reasons for over‐the‐counter (OTC) medicine use in children and the sociodemographic factors influencing this choice of self‐care rather than GP consultation. Method Questionnaires were sent to the home address of a randomly generated list of children under 12 years of age from three GP practices in the East Midlands selected to represent bottom, middle and top tertiles of deprivation on the basis of the Jarman score. Analysis using chi‐square and Mann‐Whitney tests was used to identify associated factors (number of carers in the home, number of children, deprivation score, parent/carer's age, age and number of children in the house) of the responses. Setting Primary care setting in the East Midlands region of England. Key findings From 424 completed questionnaires returned (response rate 61%), 413 parents/carers had purchased OTC medicines. Fifty‐one different products had been purchased, with analgesic/antipyretic and cough/cold remedies the most frequently bought. The most commonly reported reasons for parent/carer initiated medication were to avoid troubling the GP with minor childhood ailments (79% of respondents) and to have medicines available in case of future need (74%). Cost was a barrier to buying OTC medicines for the more deprived. Advice‐seeking behaviour was associated with the symptom, the number of children, affluence and the age of the child. Conclusion Parent/carer initiated use of OTC medication is widespread, particularly for analgesic/antipyretic and cough/cold remedies. Differences in advice‐seeking behaviour are associated with the presenting symptom and a variety of sociodemographic factors.     

Working alongside nursing staff to review medication in nursing homes

□ Pharmacists performed medication reviews in nursing homes using the nursing staff as a source of information □ Lack of access to medical records did hamper the review but was not the main reason for non‐implementation □ The recommendations were more likely to be implemented if further clinical information was supplied to the general practitioner □ All of the pharmacists, all of the nursing staff responding and a majority of the GPs who responded wished to see the project continue □ Future training of community pharmacists should focus on “how to review”.     

Developing an R&D agenda for pharmacy workforce research

□ A consultation exercise was conducted to identify and prioritise the research agenda on the pharmacy workforce □ A two‐ound Delphi technique was employed for the main study □ People from all sectors of the profession were invited to contribute their views on what research should be carried out □ Ninety per cent of respondents agreed that the top priority for research was to “identify the levels, causes and implications of turnover among different cohorts of pharmacists” □ The need to take forward aspects of the proposed programme is now a matter of some urgency for the profession and the National Health Service     

Development and evaluation of a survey tool to explore patients' perceptions of their prescribed drugs and their need for drug information

Objective — To explore the effect of providing information about their prescribed drugs on patients' perceptions and use of the drugs. Method — A survey tool was administered to 501 general medical patients in their own homes during a trial to reduce discrepancies between supplies of hospital prescribed drugs and those received in the community following hospital discharge. The patient sample was randomly recruited into two cohorts: 264 in the intervention group (given information regarding drugs prescribed on discharge from hospital to take to their community pharmacy) and 237 in the comparison group. Responses to the survey were explored to assess any effects on patients of providing such information. Setting — Domiciliary visits to general medical patients in East London. Key findings — The survey tool was subjected to factor analysis and reliability testing. Principal components analysis (PCA) was used to extract five factors that described an intrinsic desire for information, perceived impact of the illness, perceived utility of medicines, anxiety about illness and worry about changes to medicines. Internal consistency was good, ranging from 0.8 to 0.91 (Cronbach's coefficient alpha). Interconstruct relationships between the scales, patient demographics and the two cohorts were explored. The findings indicated that the degree of patient empowerment is related to two constructs: “intrinsic desire for information” and “worry about changes to medicines.” Patients who expressed a low degree of worry about changes and a high desire for information about their drugs seemed less worried and more empowered when given additional information. Conversely, those who expressed worries about changes in their medicines and did not want information about their medicines (were happy knowing little) seemed more worried and less empowered when given additional information about those changes. Conclusion — Further exploration of relationships between patient perceptions and information provision is needed to influence appropriately the development of pharmaceutical care between hospital and community.     

Gender and age influences on prescription and consultation frequency for multiple sclerosis patients

□ The study aimed to examine whether gender and age affects the burden of disease in secondary care in terms of number of prescribed drugs and number of consultations with the general practitioner (GP) for multiple sclerosis and control patients □ Anonymised data for 1996 was obtained for all patients (patient years at risk = 220,538) from 24 GP practices in the GP Morbidity Database who had a Read code of MS at some point from 1993 to 1996 and a randomly selected age, gender and surgery matched control group □ A total of 216 cases was identified, giving a prevalence of 97.9 per 105 (based on patient years at risk in the database for 1996; n=220,538). Sixty‐seven per cent (145/216) of cases were female. The mean age was 46.7 (range 17 to 84 years) □ Gender differences for the MS patients, but not controls were found. For example, although females in both the control and MS population had significantly more consultations than the corresponding males, only the control females had more items prescribed than control males (p=0.033) □ This study warrants further work to elucidate whether specific therapeutic areas or MS‐treated symptoms are influenced by gender     

The Aston Medication Adherence Study: mapping the adherence patterns of an inner-city population

Background The Aston Medication Adherence Study was designed to examine non-adherence to prescribed medicines within an inner-city population using general practice (GP) prescribing data. Objective To examine non-adherence patterns to prescribed oral medications within three chronic disease states and to compare differences in adherence levels between various patient groups to assist the routine identification of low adherence amongst patients within the Heart of Birmingham teaching Primary Care Trust (HoBtPCT). Setting Patients within the area covered by HoBtPCT (England) prescribed medication for dyslipidaemia, type-2 diabetes and hypothyroidism, between 2000 and 2010 inclusively. HoBtPCT’s population was disproportionately young, with seventy per cent of residents from Black and Minority Ethnic groups. Method Systematic computational analysis of all medication issue data from 76 GP surgeries dichotomised patients into two groups (adherent and non-adherent) for each pharmacotherapeutic agent within the treatment groups. Dichotomised groupings were further analysed by recorded patient demographics to identify predictors of lower adherence levels. Results were compared to an analysis of a self-report measure of adherence [using the Modified Morisky Scale^© (MMAS-8)] and clinical value data (cholesterol values) from GP surgery records. Main outcome Adherence levels for different patient demographics, for patients within specific longterm treatment groups. Results Analysis within all three groups showed that for patients with the following characteristics, adherence levels were statistically lower than for others; patients: younger than 60 years of age; whose religion is coded as “Islam”; whose ethnicity is coded as one of the Asian groupings or as “Caribbean”, “Other Black” and “African”; whose primary language is coded as “Urdu” or “Bengali”; and whose postcodes indicate that they live within the most socioeconomically deprived areas of HoBtPCT. Statistically significant correlations between adherence status and results from the selfreport measure of adherence and of clinical value data analysis were found. Conclusion Using data from GP prescribing systems, a computerised tool to calculate individual adherence levels for oral pharmacotherapy for the treatment of diabetes, dyslipidaemia and hypothyroidism has been developed. The tool has been used to establish nonadherence levels within the three treatment groups and the demographic characteristics indicative of lower adherence levels, which in turn will enable the targeting of interventional support within HoBtPCT.     

Compliance,concordance and the revolving door of care: caring for elderly people with mental health problems

□ The project involved community pharmacists receiving specialised training, becoming integrated into the community mental health teams and providing pharmaceutical care when making joint domiciliary visits with the key workers. □ Community pharmacists, psychiatrists and key workers all wanted the project to develop into a service and had similar views about the general benefits of the study. However, they had contrasting expectations of the project, based on their own perspectives on compliance, concordance and models of care □ The key workers valued the provision of monitored dosage systems for patients with confusion or memory problems. But the pharmacists felt that they were being expected to organise compliance aids; they recognised that it was their role to assess complaince and that other measures could be taken before organising an MDS □ The psychiatrists stated that involuntary non‐compliance with medication, arising from confusion, memory and physical problems, was a major issue and the project had made improvements in this area; they wanted to keep patients in the community and particularly valued reductions in morbidity, relapses and the “revolving door of care”     

“In the eye of the beholder”: pharmacy students have more positive perceptions of medicines than students of other disciplines

Objective — Exploratory study to examine whether pharmacy students differ significantly from students on other courses in their beliefs about medicines. Method — Questionnaire study assessing beliefs about medicines in general and perceptions of personal sensitivity to the potential adverse effects of medication. Setting — Undergraduate students sampled from each academic year of five degree courses. Five hundred and seventy completed questionnaires were analysed. Key findings — The findings indicated significant differences between students on the basis of their chosen course. Pharmacy students were significantly more likely than engineering, accountancy, social policy, and humanities students to believe that medicines in general are beneficial, and were significantly less likely to perceive medicines as potentially harmful. Humanities students were more likely than most other groups to believe that medicines are over‐prescribed by doctors. The observed relationship between course and medication beliefs remained statistically significant when controlling for ethnic background, experience of taking prescribed medication, and year of study. A further analysis revealed no significant effect of year of course on medication beliefs, and no significant interaction between course and year of study. Conclusion — The findings suggest that students' attitudes were formed before they arrived at university, rather than being “shaped” by the course over a three‐year period. The implications of these findings for patient‐pharmacist communication are discussed.     

Poor correlation between predicted ideal and prescribed digoxin dose: a community‐based pharmacokinetic study in the elderly

□ This study assessed if population‐based pharmacokinetics predicted measured plasma digoxin concentrations in elderly community‐managed patients □ Twenty‐seven per cent of the sample showed plasma concentrations consistent with a therapeutic level over an entire 24‐hour dosing schedule; 36 per cent showed therapeutic levels for at least some of the dosing schedule; the remainder showed digoxin concentrations not consistent with achieving a therapeutic plasma concentration for any part of the dosing schedule □ The mean daily prescribed dose of digoxin was significantly lower than that predicted from population kinetics.     

Medically‐enhanced normality: an alternative perspective on the use of medicines for non‐medical purposes

Objective To consider public perspectives on the use of medicines for non‐medical purposes, a usage called medically‐enhanced normality (MEN). Method Examples from the literature were combined with empirical data derived from two Danish research projects: a Delphi internet study and a Telebus (telephone interview) study with a stratified random representative sample. Results The results of these studies indicate an acceptance of medicine usage where “enhancement” strategies are part of the rationale for medicine use. These strategies include an overall desire to enhance the quality of life, eg, to optimise economic, working and family conditions. The term “doping” does not cover or explain the use of medicines as enhancement among healthy non‐athletes. Conclusion We recommend wider use of the term medically‐enhanced normality as a conceptual framework for understanding and analysing perceptions of what is considered rational medicine use in contemporary society.