Search

Background: Despite developing a polypharmacy core outcome set (COS) in primary care, it is not clear how these outcomes should be measured., Aim: To select outcome measurement instruments (OMIs) for a COS targeting appropriate polypharmacy in older patients in primary care., Method: Following the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guideline, OMIs were identified from a Cochrane review focusing on appropriate polypharmacy. The quality of OMIs was assessed using a published checklist. Subsequently, two rounds of Delphi questionnaires were conducted via the SoGoSurvey ® platform, engaging stakeholders (researchers, clinicians and journal editors specialising in geriatric primary care) to achieve consensus on OMIs using a scale encompassing "agree", "disagree", or "unsure". Consensus was achieved if 70% or more participants chose "agree" and 15% or fewer chose "disagree.", Results: The quality of 20 OMIs identified from the Cochrane review was evaluated. Seven OMIs were selected based on meeting the COSMIN guideline's minimum requirements. Out of 188 potential participants, 57 (30.3%) consented to participate. Rounds 1 and 2 of Delphi exercises were completed by 50 respondents, achieving agreement on three OMIs: 'number of serious adverse drug reactions (ADRs)' (98%), 'number of deaths' (76%), and 'number of patients who fell' (70%) for measuring 'serious ADRs,' 'mortality,' and 'falls,' respectively. No agreement was reached for 'medication appropriateness,' 'medication side-effects,' 'quality of life,' and 'medication regimen complexity.', Conclusion: OMIs were selected for a limited number of outcomes in the polypharmacy COS. Future research should identify suitable OMIs for the remaining four outcomes., Competing Interests: Conflicts of interest The authors declare no competing interests., (© 2024. The Author(s).)

Background: Anticholinergic medications and associated anticholinergic burden can impair cognitive function and increase mortality rates in patients with dementia., Aim: To explore community pharmacists' knowledge of anticholinergic burden and perceptions of their role in anticholinergic burden management amongst patients with dementia., Method: A self-administered, postal questionnaire was distributed to all registered community pharmacies in Northern Ireland (n = 526) on two occasions (October and November 2022). The questionnaire comprised four sections: (1) demographics associated with pharmacists and pharmacies, (2) contact between community pharmacists and patients with dementia/their carers, and types of medication-related queries received by pharmacists, (3) understanding and knowledge about anticholinergic burden, and (4) community pharmacist role in management of anticholinergic burden in patients with dementia. Data were analysed descriptively using Stata v17., Results: A response rate of 15.2% (80/526) was achieved. Most contact was with patients with dementia/carers in their own homes. Community pharmacists lacked knowledge about anticholinergic burden in dementia, did not use any anticholinergic burden scales in their practice (n = 77, 96.3%), and rarely discussed anticholinergic burden with patients, carers (n = 60, 75.0%), or other healthcare professionals (n = 42, 52.5%). However, they were positive about their role in future interventions and saw value in managing anticholinergic burden in patients with dementia as part of a multidisciplinary primary healthcare team (n = 67; 83.3%)., Conclusion: Despite the low response rate, the study findings have highlighted community pharmacists' willingness to contribute to the management of anticholinergic burden in patients with dementia. Further research is required to understand how this can be achieved., Competing Interests: Conflicts of interest: The authors have no conflicts of interest to declare., (© 2024. The Author(s).)

COVID-19 has changed life beyond recognition for millions of individuals, as countries implement social distancing measures to prevent disease transmission. For certain patient groups, such as community-dwelling older people with dementia (PwD), these restrictions may have far-reaching consequences. Medicines management may be adversely affected and deserves careful thought. PwD face unique challenges with medicines management compared to other older people, often relying upon support from family/carers and primary healthcare professionals. This article considers potential issues that PwD may face with each component of medicines management (prescribing, dispensing, administration, adherence, review), and based on previous research, highlights strategies to support PwD and their carers during this time. Primary healthcare professionals must be attentive to medicines-related needs of community-dwelling PwD, particularly those living alone, both during the pandemic and as restrictions are lifted. Carers of PwD continue to have a critical role to play in medicines management, and also require support.

Background People with visual impairment often report poorer health and encounter many challenges when using medicines. Pharmacists can play a significant role in optimising medicines use for these patients. However, little is known about pharmacists' current practices when providing services to this population nor the impact of such services, if any, on medicines optimisation-related outcomes. Aim of the review This systematic review aims to identify the types, and assess the effectiveness of, interventions provided by pharmacists on medicines optimisation-related outcomes. Method Systematic searches of the following electronic databases were carried out from date of inception to March 2018: Cochrane Library; MEDLINE; EMBASE; International Pharmaceutical Abstracts; Scopus; and Cumulative Index to Nursing and Allied Health Literature. Several trial registries and grey literature resources were also searched. Any randomised controlled trials, non-randomised controlled trials, controlled before-and-after studies, or interrupted time series analyses reporting on interventions provided by pharmacists to adult visually impaired patients and/or their caregivers in order to improve medicines optimisation-related outcomes of medicine safety, adherence, patient satisfaction, shared decision making, or quality of life were included. Results A total of 1877 titles/abstracts were screened, and 27 full text articles were assessed for eligibility. On examination of full texts, no studies met the inclusion criteria for this review. Conclusion This review highlights the need for future research that would be vital for promoting the safe and effective use of medicines and the delivery of pharmaceutical care services to people with visual impairment.

Background The Medicines use review (MUR) service, provided by community pharmacists, seeks to optimise patients' use of medicines. There is limited evidence on the clinical effectiveness of this service. Structuring MURs to include an assessment of prescribing appropriateness, facilitated by a validated prescribing screening tool, has the capacity to enhance this service. Objective To explore community pharmacists' views on the facilitators and barriers towards the utilisation of a screening tool as a guide to conducting structured MURs. Setting Community Pharmacy, Northern Ireland. Method Using the 14 domain Theoretical Domains Framework (TDF), semi-structured interviews were conducted with community pharmacists. Interviews were digitally recorded, transcribed verbatim and analysed using the Framework method. Main Outcome Measure Pharmacists' views towards utilisation of a screening tool as a guide to conducting structured MURs. Results Based on the analysis of 15 interviews, 11 TDF domains ('Knowledge', 'Skills', 'Social and professional role and identity', 'Beliefs about capabilities', 'Beliefs about consequences', 'Reinforcement', 'Goals', 'Memory, attention and decision process', 'Environmental context and resources', 'Social influences', 'Behavioural regulation') were deemed relevant. Facilitators included: knowledge of patients, clinical knowledge, perceived professional role, patients' clinical outcomes, influence of peers. Barriers included: prioritisation of other clinical activities, inability to access patients' clinical information, perceived alienation from the primary healthcare team and staffing issues. Conclusions Using the TDF, key facilitators and barriers were identified in the use of a screening tool as a guide to conducting MURs. These findings may assist in further development of MURs as a means to optimise patients' medicines use.

Microneedles (MNs) are a novel transdermal drug delivery platform, rapidly progressing from a substantive evidence base, towards commercialisation. As part of this transition, it is important to consider the future use of MNs by older people in order to ensure optimal therapeutic outcomes for this unique and increasing population group. This paper, therefore, considers the use of MNs by those aged over 65 years, investigating insertion parameters in ageing skin, alongside the feasibility and acceptability of the technology. Hydrogel-forming MN arrays were applied to seven subjects aged over 65 years, with breach of the stratum corneum confirmed using optical coherence tomography. Insertion depths recorded in each case were similar to a comparative group, aged 20-30 years. Skin recovery was, however, demonstrated to occur at a slower rate in the older subjects, as measured using transepidermal water loss. Qualitative methods, including focus groups and semi-structured interviews, were employed to collect the views and opinions of older people and community pharmacists respectively. The overall consensus was positive, with a number of benefits to MN-mediated drug delivery identified, such as reduced dosing frequency, improved adherence and an alternative delivery route where oral or injectable medication was precluded. Concerns centred on practical issues associated with age-related functional decline, including, for example, reduced dexterity and skin changes. The presentation of this work collectively provides the first convincing report of the importance of further translational research in this area to support future MN use in older people, ensuring an age-appropriate delivery platform.

The development of health interventions is receiving increasing attention within the scientific literature. In the past, interventions were often based on the ISLAGIATT principle: that is, 'It seemed like a good idea at the time'. However, such interventions were frequently ineffective because they were either delivered in part or not at all, demonstrating a lack of fidelity, or because little attention had been paid to their development, content, and mode of delivery. This commentary seeks to highlight the latest methodological advances in the field of intervention development, drawing on health psychology literature, together with guidance from key organisations and research consortia which are setting standards for development and reporting. Those working within pharmacy practice research can learn from the more systematic approach being advocated, and apply these methods to help generate evidence to support new services and professional roles.

Purpose: The purpose of this study is to establish the prevalence of potentially inappropriate prescribing (PIP) in middle-aged adults (45-64 years) in two populations with differing socio-economic profiles, and to investigate factors associated with PIP, using the PROMPT (PRescribing Optimally in Middle-aged People's Treatments) criteria., Methods: A retrospective cross-sectional study was conducted using 2012 data from the Enhanced Prescribing Database (EPD), covering the full population in Northern Ireland and the Health Services Executive Primary Care Reimbursement Service (HSE-PCRS) database, covering the most socio-economically deprived third of the population in this age group in the Republic of Ireland. The prevalence for each PROMPT criterion and overall prevalence of PIP were calculated. Logistic regression was used to investigate the association between PIP and gender, age group and polypharmacy., Results: This study included 441,925 patients from the EPD and 309,748 patients from the HSE-PCRS database. Polypharmacy was common in both datasets (46.7 % in the HSE-PCRS and 20.3 % in the EPD). The prevalence of PIP was 42.9 % (95%CI 42.7, 43.1) in the HSE-PCRS and 21.1 % (95%CI 21.0, 21.2) in the EPD. Age group, female gender and polypharmacy were significantly associated with PIP in both populations (p < 0.05) and polypharmacy had the strongest association., Conclusions: PIP is common amongst middle-aged people with the risk of PIP increasing with polypharmacy. Differences in the prevalence of polypharmacy and PIP between the two populations may relate to heterogeneity in healthcare services and different socio-economic profiles, with higher rates of multimorbidity and associated polypharmacy in more deprived groups.

Purpose: We sought to estimate the prevalence of potentially inappropriate prescriptions (PIP) and potential prescribing omissions (PPOs) using a subset of the STOPP/START criteria in a population based sample of Irish adults aged ≥ 65 years using data from The Irish LongituDinal Study on Ageing (TILDA)., Methods: A subset of 26 PIP indicators and 10 PPO indicators from the STOPP/START criteria were applied to the TILDA dataset. PIP/PPO prevalence according to individual STOPP/START criteria and the overall prevalence of PIP/PPO were estimated. The relationship between PIP and PPOs and polypharmacy, age, gender and multimorbidity was examined using logistic regression., Results: The overall prevalence of PIP in the study population (n=3,454) was 14.6 %. The most common examples of PIP identified were NSAID with moderate-severe hypertension (200 participants; 5.8 %) and aspirin with no history of coronary, cerebral, or peripheral vascular symptoms or occlusive event (112 participants; 3.2 %). The overall prevalence of PPOs was 30 % (n=1,035). The most frequent PPO was antihypertensive therapy where systolic blood pressure consistently >160 mmHg (n=341, 9.9 %), There was a significant association between PIP and PPO and polypharmacy when adjusting for age, sex and multimorbidity (adjusted OR 2.62, 95 % CI 2.05-3.33 for PIP and adjusted OR 1.46, 95 % CI 1.23-1.75 for prescribing omissions)., Conclusion: Our findings indicate prescribing omissions are twice as prevalent as PIP in the elderly using a subset of the STOPP/START criteria as an explicit process measure of potentially inappropriate prescribing and prescribing omissions. Polypharmacy was independently associated with both PPO and PIP. Application of such screening tools to prescribing decisions may reduce unnecessary medication, related adverse events, healthcare utilisation and cost.

Purpose: We sought to estimate the prevalence of potentially inappropriate prescribing (PIP) in the Northern Ireland (NI) population aged ≥70 years, to investigate factors associated with PIP and to calculate total gross cost of PIP., Methods: A retrospective cross-sectional population study was carried out in those aged ≥70 years in 2009/2010 who were in primary care in NI. Data were extracted from the Enhanced Prescribing Database, which provides details of prescribed and dispensed medications for each individual registered with a general practitioner. Twenty-eight PIP indicators from the Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP) criteria were applied to these data. PIP prevalence according to individual STOPP criteria and the overall prevalence of PIP were estimated. The relationship between PIP and polypharmacy, age and gender was examined using logistic regression. Gross cost of PIP was ascertained., Results: The overall prevalence of PIP in the study population (n = 166,108) was 34 %. The most common examples of PIP identified were proton pump inhibitors at maximum therapeutic dose for >8 weeks (17,931 patients, 11 %), non-steroidal anti-inflammatory drugs >3 months (14,545 patients, 9 %) and long-term long-acting benzodiazepines (10,147 patients, 6 %). PIP was strongly associated with polypharmacy, with those receiving seven different medications being fivefold more likely to be exposed to PIP than those on zero to three medications (odds ratio 5.04, 95 % confidence interval 4.84-5.25) The gross cost of PIP was estimated to be 6,098,419, Conclusions: Consistent with other research, the prevalence of PIP was high among the study cohort, increased with polypharmacy and was associated with significant cost.

Background: With increasing deregulation of prescription-only medicines and drive for self-care, pharmacists have greater scope to manage more conditions. This brings added responsibility to be competent healthcare professionals who deliver high quality evidence-based patient care., Objective: This study sought to establish pharmacists' attitudes towards an evidence based approach for over-the-counter medication., Setting: Pharmacists working in community pharmacies across Northern Ireland., Method: Following ethical approval, a pre-piloted, self-completed questionnaire was distributed to all community pharmacies in Northern Ireland (n = 529) in September 2008. The development of the questionnaire was largely informed by the findings of a previous qualitative study. It consisted of six sections (mainly closed questions) covering factors that influence decisions regarding over-the-counter medication, recently deregulated prescription-only medicines, medications that lack evidence of effectiveness, knowledge of evidence-based practice, evidence-based practice with over-the-counter medication and demographic information. On receipt of questionnaires, responses to the closed questions were imported into SPSS(®) (version 17.0) for analysis which largely took the form of descriptive statistics. Chi-square and the Mann-Whitney U test were used for association between responses and demographic information with an a priori level of less than 0.05 (P < 0.05) set as significant., Main Outcome Measure: Pharmacists' attitudes and opinions in relation to decision making about over-the-counter medication and evidence of effectiveness were measured., Results: A 39.5% (209/529) response rate was achieved. Most pharmacists [191/208 (91.8%)] 'strongly agreed' or 'agreed' that safety was the over-riding concern when dealing with over-the-counter medication. While 88.3% (181/205) 'strongly agreed' or 'agreed' that they were familiar with the concept of evidence-based practice, only 38.0% (78/205) 'strongly agreed' or 'agreed' they knew how to critically appraise research papers. Furthermore, less than a quarter [49/205 (23.9%)] appeared to be familiar with the work of the Cochrane Collaboration. Most [188/207 (90.8%)] 'strongly agreed' or 'agreed' that regardless of evidence of effectiveness, cough medicines were an important management option., Conclusion: Safety was the primary concern when making decisions about over-the counter medicines. Pharmacists lacked knowledge of evidence-based practice and considered medicines which lacked evidence of effectiveness to have an important role in self-care. These factors present barriers to the widespread implementation of evidence-based practice.

Objective: Health care in the United Kingdom (UK) has undergone a significant change in terms of the range of professionals who are permitted to prescribe medications. This study aimed to capture information on pharmacist prescribing in Northern Ireland (NI)., Setting: Primary and secondary care in NI., Method: A structured self-administered questionnaire was developed and sent to all pharmacists who were identified as qualified prescribers in NI (n = 105), although only 100 respondents provided details of their prescribing status i.e. currently prescribing, previous prescribers and those who had never prescribed. Three versions of the questionnaire were developed to accommodate each category of prescriber. The questionnaire, which sought information on clinical areas/practice settings of prescribers, their working arrangements and barriers to prescribing was distributed by mail on two occasions to maximise response rates. Descriptive analyses were used as appropriate, together with Chi-squared tests or Fisher exact tests to evaluate associations between responses and demographic information, with significance set a priori at P < 0.05. Qualitative data (from the free text response section) were analysed for recurring themes using content analysis., Results: A response rate of 76.0% (n = 76) was achieved. There were more female respondents (73.7%) than males (26.3%). Nearly 50% of respondents were currently prescribing (n = 36; 47.4%), 46.1% (n = 35) had never prescribed and 6.6% (n = 5) had prescribed in the past. There were perceived benefits in terms of patient care and perception of the pharmacist within the health care team. A number of barriers to pharmacist prescribing were reported. Independent prescribing was viewed as the way forward, although pharmacists expressed reluctance to prescribe without a diagnosis or beyond the team setting., Conclusion: Pharmacy prescribing has yet to fully embedded in routine practice. This study has shown that the number of qualified prescribers in NI is relatively small and not all have taken up prescribing responsibilities. Well recognised barriers were reported as reasons as to why qualified prescribers were unable to use their prescribing skills. Further research should provide an in-depth understanding of pharmacy prescribing in NI and examine patients' experiences of this form of practice.

Objective: Using a self-reported work sampling methodology this study investigated how community pharmacists utilised their time, and quantified how much time pharmacists devoted to specific activities., Setting: Community pharmacies (n = 30) in the Greater Belfast area., Method: A classification system was developed to define all activities (professional, semi-professional, and non-professional tasks) which could potentially be performed by a community pharmacist in the course of a normal working day (from 9.00 to 6.00 pm). A random bleeper device was used which was programmed to bleep randomly approximately 13 times per day (over 12 days) at which time the pharmacist recorded their precise activity (using the classification system) at that time on a proforma. All completed data sheets for each pharmacy were entered into an Excel spreadsheet, where the number of observations for each activity was expressed as a proportion of the total number of observations per day. Statistical analysis was carried out in SPSS, comparing these data to similar data which had been collected in 1998., Results: Pharmacists in this study were found to spend approximately 49% of their time engaged in professional activities, 31% in semi-professional activities and 20% involved in non-professional activities which was similar to that reported in 1998. Most time was spent on assembly and labelling of products, whilst staff training occupied the least amount of pharmacists' time. Pharmacists with a prescription volume of less than 1,499 per month spent significantly more time counselling patients on OTC medicines and responding to symptoms than those dispensing 1,500 items/month or more (P = 0.027). Pharmacists who employed a pre-registration student apportioned less time to the assembly and labelling of products compared to those without a student (P = 0.08). Pharmacists with three or more staff spent less time on coding and endorsing of prescriptions compared to those with less staff (P = 0.086)., Conclusion: Pharmacists in this study are spending more time checking prescriptions (essential component of pharmaceutical care) and are still managing to spend only 20% of their time on non-professional activities. However, there had been relatively little change in the way in which pharmacists in this sample spent their time compared to a previous study.

Objective: To investigate the provision of pharmaceutical care by community pharmacists across Europe and to examine the various factors that could affect its implementation., Methods: A questionnaire-based survey of community pharmacies was conducted within 13 European countries. The questionnaire consisted of two sections. The first section focussed on demographic data and services provided in the pharmacy. The second section was a slightly adapted version of the Behavioral Pharmaceutical Care Scale (BPCS) which consists of three main dimensions (direct patient care activities, referral and consultation activities and instrumental activities)., Results: Response rates ranged from 10-71% between countries. The mean total score achieved by community pharmacists, expressed as a percentage of the total score achievable, ranged from 31.6 (Denmark) to 52.2% (Ireland). Even though different aspects of pharmaceutical care were implemented to different extents across Europe, it was noted that the lowest scores were consistently achieved in the direct patient care dimension (particularly those related to documentation, patient assessment and implementation of therapeutic objectives and monitoring plans) followed by performance evaluation and evaluation of patient satisfaction. Pharmacists who dispensed higher daily numbers of prescriptions in Ireland, Germany and Switzerland had significantly higher total BPCS scores. In addition, pharmacists in England and Ireland who were supported in their place of work by other pharmacists scored significantly higher on referral and consultation and had a higher overall provision of pharmaceutical care., Conclusion: The present findings suggest that the provision of pharmaceutical care in community pharmacy is still limited within Europe. Pharmacists were routinely engaged in general activities such as patient record screening but were infrequently involved in patient centred professional activities such as the implementation of therapeutic objectives and monitoring plans, or in self-evaluation of performance.

Objective and Setting: The pharmacy profession in Northern Ireland (NI) is currently experiencing major changes in practice development. The aim of this study was to determine the levels of job satisfaction and stress in pharmacists in NI in the context of these changes., Method: A questionnaire was adapted from one previously used in the United States (US). Following minor amendments and piloting, the survey was distributed by mail on two occasions (January/February 2007) to all registered community and hospital pharmacists in NI (n = 1,965). Data were entered into SPSS (version 15) and analysed using descriptive statistics, t-test and regression analysis. The significance level was set at P < 0.05., Results: The overall response rate was 39% (n = 766). Of the potentially highest stress score of 165, overall mean scores were significantly higher for community than hospital pharmacists (P < 0.05). Both groups found interruptions, excessive workload, and inadequate staffing to be the most stressful aspects of their employment. Just over 30% (n = 178) of community pharmacists and half of all hospital pharmacists cited feeling often or frequently stressed because of imminent changes in contractual or organisational arrangements. Regression analysis indicated that sector of work (community or hospital) appeared to account for differences in self-reported stress., Conclusion: Any developments in professional practice need to be considered in the context of the well-being of the health professionals who implement, and are affected by, the changes. Unless stress in pharmacy is recognised and reduced, pharmacists and patients may be at risk.

Objective: To assess the suitability of an American model of pharmaceutical care for nursing home residents (The Fleetwood model) for application in nursing homes in the United Kingdom., Method: Pharmacists (those from a hospital setting or involved in prescribing support), general practitioners, nursing home managers and advocates for older people were invited to participate in semi-structured interviews or focus groups. The American Fleetwood model was explained to all participants who were asked for their views and opinions on how such a model could be adapted for use in the UK setting. All interviews and focus groups were tape-recorded, transcribed verbatim and analysed using the framework method., Main Outcome Measure: An adapted model of pharmaceutical care for use in UK nursing homes., Results: There was general concern about prescribing in nursing homes, particularly in relation to psychoactive drugs. All participants were supportive of the proposed model of care and endorsed the greater involvement of pharmacists. However, participants also recognised that unlike pharmacists in the US nursing home setting for which the Fleetwood model had been developed, pharmacists implementing this approach in the UK would face major challenges in relation to access to records (medical and medication), prescribers and residents., Conclusion: The findings highlighted the key elements of access which will need to be considered if this model of pharmaceutical care is to be applied to nursing home residents in the UK. IMPACT OF FINDINGS ON PRACTICE: The model has been revised to take account of the challenges relating to access and will be tested in a randomised controlled trial.

Objective: We aimed to explore, using qualitative methods, the perspectives of patients with hypertension on issues relating to concordance in prescribing., Method: This study took place in NHS general practices in Northern Ireland. A purposeful sample of patients who had been prescribed anti-hypertensive medication for at least one year were invited to participate in focus groups or semi-structured interviews; data were analysed using constant comparison., Main Outcome Measures: The perspectives of patients with hypertension on issues relating to concordance in prescribing., Results: Twenty-five individuals participated in five focus groups; two participated in semi-structured interviews. Participants felt they could make valuable contributions to consultations regarding their management. They were prepared to negotiate with GPs regarding their medication, but most deferred to their doctor's advice, perceiving doctors' attitudes and time constraints as barriers to their greater involvement in concordant decision-making. They had concerns about taking anti-hypertensive drugs, were aware of lifestyle influences on hypertension and reported using personal strategies to facilitate adherence and reduce the need to take medication., Conclusions: Participants indicated a willingness to be involved in concordance in prescribing anti- hypertensive medication but needed health professionals to address their concerns and confusion about the nature of hypertension. These findings suggest that there is a need for doctors and other healthcare professionals with responsibility for prescribing to develop skills specifically to explore the beliefs and views underlying an individual's medication use. Such skills may need to be developed through specific training programmes at both undergraduate and postgraduate level.

Objective: To elucidate the steps in the management of urinary tract infections (UTIs) in elderly nursing home residents, in order to derive data which would assist in an economic evaluation of such infections., Method: Maximum variation sampling was used to recruit General Practitioners (GPs) and nurses (who worked in nursing homes), into the study. Using semi-structured interviews, a topic guide was used to explore diagnosis, treatment and the role of GPs and nurses in the management of UTIs in nursing home residents. Thematic analysis was employed to identify the main themes., Main Outcome Measures: A comprehensive description of the management of UTIs in nursing home residents that will be used in a future economic evaluation of the costs of this prevalent infection in this setting., Results: Ten GPs and nurses respectively took part in the interviews. Three overarching themes emerged from the interviews: information, processes and decision-making. Health care professionals described the key symptoms for diagnosis (information), testing procedures to confirm the presence of an infection (processes); many variations in management pathways were described. The nurse was central to decision-making in treatment i.e. prescribing of an antibiotic. Most GPs reported that they accepted the nursing staff's assessment of the resident and seldom visited a patient in a nursing home for a UTI., Conclusions: The management approach to UTIs varied greatly and was a more complex process than anticipated. Identification of the component steps will be used to perform an economic evaluation of UTIs in nursing homes.

Objective: This study sought to explore the views of community pharmacists as to their present and potential role in providing care to the residents of nursing and residential home in Northern Ireland., Method: A structured questionnaire was developed and mailed to all community pharmacists in Northern Ireland (n = 508) on 2 occasions., Results: A response rate of 50% was achieved. Over 40% of responding pharmacists (42.1%) were currently providing medication-related services to care homes for the elderly and 57.9% were not. Of those who were providing services, 50 to 80% were already providing advice to care homes regarding record-keeping, compliance devices, storage and administration of medicines and the use of more appropriate formulations. More than 75% of pharmacists who were not providing services to care homes for the elderly supported all services detailed in a checklist provided on the questionnaire. For pharmacists who were providing services to care homes, 89% agreed that they required access to an up-to-date medical history of care home residents. Over 60% of pharmacists who worked with care homes had experienced difficulties when ordering prescriptions from general practice surgeries. Just over 75% of all respondents stated that they wanted to be more involved in providing pharmaceutical services to care homes to the elderly., Conclusion: Community pharmacists expressed enthusiasm for provision of services to care home residents. On-going developments in community pharmacy practice in the UK may facilitate the development of this role and may guide policy development for long-term care in other countries.

Objective: The aim of this study was to develop and pilot a harm-minimisation model for the identification and treatment of over-the-counter (OTC) drug abuse/misuse by community pharmacists., Method: Extensive consultation was conducted during the development of the model. This included an exploratory conference involving an interdisciplinary group of delegates and detailed individual consultation with a range of healthcare practitioners. Consultation with a psychologist specialising in communication skills allowed development of the communication aspects of the model. A comprehensive manual detailing the model was prepared., Results: The model is designed to be used by community pharmacists in conjunction with other healthcare professionals. It focuses on the abuse/misuse of opioids, laxatives and antihistamines and can be broadly divided into three phases, namely: patient identification and recruitment, treatment/referrals and data collection/outcome measurement. Client identification is via record-keeping which is implemented alongside an information campaign promoting safe use of OTC medicines. Once identified, the pharmacist aims to recruit clients using the developed communication strategies. Treatment depends on whether the problem is misuse or abuse and on the product. Several treatment paths are available including treatment according to an agreed protocol and referring to the GP or community addiction team (CAT). Two pharmacists were recruited and trained to pilot the model. Of the clients, 18 were identified as abusing/misusing OTC products over a one-month period. The subject of inappropriate OTC use was raised with 14 of these clients. Some success was noted in that clients agreed to stop using the product and/or to try safer alternatives. As expected, some sales had to be refused, as the client was unwilling to accept the pharmacist's intervention., Conclusion: This study represents the first reported structured attempt by community pharmacists in the UK to address the abuse/misuse of OTC medication. Work is now ongoing to modify this model in light of the pilot study findings.

Aim: To measure the outcomes of a harmonized, structured pharmaceutical care programme provided to elderly patients by community pharmacists., Method: A randomised, controlled, longitudinal, clinical trial with repeated measures was performed over an 18-month period, involving community pharmacies (5 intervention and 5 control) in Northern Ireland. Elderly, ambulatory patients (> or = 65 years), taking 4 or more prescribed medications were eligible for participation. Patients attending an intervention pharmacy received education on medical conditions, implementation of compliance strategies, rationalizing of drug regimens and appropriate monitoring; patients attending control sites received normal services. A battery of clinical, humanistic and economic outcomes were assessed., Results: A significantly higher proportion of intervention patients were compliant at the end of the 18-month study and experienced fewer problems with medication compared to control patients (P < 0.05). There was little impact on quality of life and health care utilisation., Conclusions: Pharmaceutical care provision to community-dwelling patients resulted in an improvement in medication compliance and evidence of cost-savings. Future pharmaceutical care studies may benefit from a more focussed selective approach to data collection and outcomes measurement.

Aim of the Study: To gain more detailed information on the current pharmaceutical service provision in nursing and residential homes in Northern Ireland and to assess the views of care staff on future pharmacy services., Method: A structured questionnaire was developed and mailed to all nursing and residential homes (n = 586) in Northern Ireland on two occasions., Results: A response rate of 68% (n = 396) was obtained. The most frequent services currently provided by community pharmacists were the supply of medication and the collection of unwanted, discontinued or out-of-date medicines. The majority of respondents also reported receiving advice on safe-keeping, correct administration of medicines, advice on more appropriate formulations and advice on patient medication records from the community pharmacist. Over a third of all the respondents received advice on compliance devices. A similar proportion stated that their care staff were trained by the pharmacist on broad medication management issues. Over 90% of all homes strongly supported staff training by pharmacists on the recognition of medication-related problems as a future service. Over 70% of all respondents thought additional guidelines and advice for missed dosages and the use of home remedies would be beneficial. A review of patient medication records to assess drug-drug interactions and possible adverse drug reactions by pharmacists was supported by over 65% of all respondents., Conclusions: This work has demonstrated that those responsible for care in nursing and residential facilities strongly support further involvement by the pharmacist in these care facilities; pharmacy policy makers must ensure that such services are developed to meet the needs of these vulnerable elderly residents.

Aim: The aim of the present research was to establish the current extent of pharmacists' contact with illicit drug users in Northern Ireland, their willingness to provide services for this group and to compare the findings with data from a 1995 national survey of community pharmacies in England and Wales., Method: The questionnaire developed by the National Addiction Centre for research in England/Wales was used to collect data. It was mailed on two occasions (March and April 1999) together with a covering letter and a prepaid return envelope to all community pharmacies in Northern Ireland (n = 507). A final reminder letter was included in the local wholesalers' medical delivery for the attention of the pharmacist in May 1999., Main Outcome Measure: The extent to which Northern Ireland pharmacists had contact with and provided services to illicit drug users compared to pharmacists in England/Wales., Results: A response rate of 67.5% was achieved. Respondents in Northern Ireland were providing fewer services to drug users than those in England/Wales. Respondents reported dispensing methadone for the treatment of addiction/misuse to only 9 patients, while only 17 pharmacists had been asked to sell injecting equipment in the previous week and no pharmacist was participating in a needle exchange scheme. However, most respondents indicated their willingness to provide such services. Barriers towards the provision of services were, however, highlighted e.g. the need for training and the establishment of support systems., Conclusion: Pharmacists in Northern Ireland are in a position to contribute to the policy agenda in Northern Ireland for drug misuse, prevention, treatment and harm minimisation--roles which the survey indicates they are willing to embrace. However, training programmes, support systems and adequate remuneration packages must be established before they will be in a position to participate fully.

Aim: To investigate the abuse of non-prescription (over-the-counter; OTC) products in Northern Ireland., Method: A structured questionnaire covering various aspects of OTC drug abuse was mailed to all 509 community pharmacies in Northern Ireland., Results: 253 responses were received (response rate 49.7%) after two mailings. Pharmacists named 112 OTC products they perceived were being abused in Northern Ireland. These were classified into 8 groups, with opioids, antihistamines and laxatives the most frequently reported. The frequency of abuse of all product groups was perceived to be either increasing or static. The number of clients suspected of abuse over a three-month period ranged from 0 to 700 (median = 10, mode = 6) with 55% being regular customers. Pharmacists employed several methods to limit patient access to products of abuse. The most common technique was to keep the product out of sight. Others included additional client questioning, providing advice and limiting the quantity of product sold. The majority of respondents agreed their role could be extended to include other methods of dealing with abusers, including participation in harm-reduction programmes to wean abusers off products. Geographical region and location of pharmacy were not significant factors in the abuse of OTC products., Conclusions: Pharmacists in Northern Ireland perceive abuse and misuse of OTC products to be occurring in practice. Current methods employed for dealing with it are inadequate. Research into methods of effectively dealing with OTC abuse/misuse is required and has commenced on the basis of these findings.

Lack of time to implement pharmaceutical care has been cited as a barrier to the routine provision of this extended patient-care service. Using self-reported work sampling methodology, this study investigated how community pharmacists utilise their time. Pharmacists working in community pharmacies in the Greater Belfast area were found to spend approximately 49% of their time engaged in professional activities, 29% in semi-professional activities and 22% involved in non-professional activities. The activity to which pharmacists devoted the majority of their time was product assembly and labelling, this being a task which can be performed by trained technical staff. Only 9.5% of community pharmacists' time was devoted to counselling patients on their prescription medicines. Wide variation in the amount of time apportioned to each activity was observed between the participating community pharmacists (n = 30). Staffing levels within the community pharmacy were found to significantly influence pharmacists' involvement in a number of activities, with pharmacists who worked in pharmacies employing multiple pharmacists devoting more time to the assembly and labelling of products and less time to administrative tasks, non-professional encounters and to miscellaneous professional activities. Pharmacists working in pharmacies with a high prescription turnover were found to devote significantly less time to counselling patients regarding OTC products and in responding to patient symptoms.

The results from a study to assess the importance Maltese pharmacists placed on various aspects of pharmaceutical care and their willingness to provide such care are reported. A modified version of the Behavioural Pharmaceutical Care Scale (BPCS) questionnaire (consisting of three dimensions and 14 domains) was mailed to the 198 privately owned community pharmacies in Malta. A total of 99 questionnaires were returned following two reminder telephone calls. Pharmacists were asked to score the importance of each pharmaceutical care activity contained in the modified BPCS on a 6 point Likert scale ranging from 0 to 5. The overall score for the questionnaire, which illustrated the importance pharmacists attributed to various aspects of pharmaceutical care, ranged from 90 to 170 with a mean score of 134.8. There was little difference recorded between the scores for the three dimensions. The Referral and Consultation domain recorded a slightly higher score than the other two domains. Younger pharmacists obtained significantly higher scores (p < 0.05; Kruskal-Wallis test) in the Verification of Patient Understanding domain. Approximately 72% of respondents indicated that they were willing to provide pharmaceutical care, but remarked that a number of issues e.g. reimbursement, qualified support staff, GP-pharmacist co-operation, had to be addressed. A series of strategic steps are needed to help pharmacists resolve these issues before pharmaceutical care programmes could be offered by Maltese community pharmacists.

Objective: The buccal absorption of captopril does not exhibit the classical pH/partition hypothesis, suggesting that mechanisms other than passive diffusion are involved in its absorption; animal studies have suggested that a peptide carrier-mediated transport system may be responsible for its absorption. The present study evaluated the effects of pH on octanol partitioning, and on the buccal absorption of enalapril and lisinopril, using in vitro techniques and buccal partitioning in human volunteer subjects., Methods: The partitioning of enalapril and lisinopril into n-octanol was examined over the pH range of 3 9 at room temperature., Results: Enalapril exhibited maximal partitioning into the organic phase at pH 4 5; minimal partitioning was recorded at pH values 8 and 9. The partitioning of lisinopril into n-octanol was found to be maximal at pH 9 and minimal at pH 3. Using the buccal absorption technique, the partitioning of enalapril and lisinopril (0.5 mg), was examined in six healthy male volunteers from buffered solutions (pH 3, 4, 5, 6, 7, 8 and 9). In the case of enalapril, lowest buccal partitioning occurred at pH 3, 8 and 9, while maximal partitioning occurred at pH 5; absorption of lisinopril was not extensive at any pH, but was greatest at pH 6. These results, in addition to the n-octanol partition coefficients, indicated that enalapril obeyed the normal lipid partition hypothesis with respect to buccal absorption. The buccal absorption of lisinopril also obeyed the lipid partition hypothesis over the pH range 3-7. These findings are in direct contrast to those for captopril. The buccal partitioning experiments were repeated at the maximal pH for absorption for each angiotensin converting enzyme (ACE) inhibitor, but with the addition of cephradine (0.05 mmol x l(-1))., Conclusion: The data indicated that the presence of this peptide transport inhibitor had no effect on the buccal absorption of enalapril (0.06 mmol x l(-1)) and lisinopril (0.057 mmol x l(-1)), which suggests that both drugs do not share a common buccal absorption pathway with cephradine.

Objective: The pharmacokinetics and pharmacodynamics of buffered sublingual captopril were assessed in patients with congestive heart failure (CHF)., Methods: The study was carried out in a randomised single-blind cross-over fashion (n = 6, 4 males and 2 females) and involved two study days, at least 7 days apart. Baseline measurements were carried out for plasma renin activity (PRA), blood pressure (B.P.) and heart rate (H.R.). Captopril (12.5 mg) was administered sublingually with dibasic potassium phosphate which maintained salivary pH at 7, or perorally with 100 ml of water. Further B.P., H.R. measurements and venous blood samples were taken over a 3 hour period post-drug administration. Blood samples were analysed for captopril and PRA levels., Results: tmax after buffered sublingual administration of captopril, which ranged from 40-60 min (median = 40 min), was significantly shorter than after peroral administration (range 60-120 min, median = 90 min). Cmax was slightly greater after buffered sublingual than after peroral administration with mean values of 108.2 vs. 94.0 ng.ml-1. AUC values were similar after both routes of administration. Systolic and diastolic B.P. vs. time profiles for each administration method were significantly different i.e. sublingual administration produced an earlier reduction in B.P., however, HR did not differ significantly between the two routes., Conclusion: The data indicate that this novel administration method of captopril leads to an increased rate, but an unchanged extent of captopril absorption, suggesting a modest therapeutic advantage with the use of buffered sublingual captopril if a rapid reduction in blood pressure is required.

The effect of pH on the buccal and sublingual absorption of captopril was evaluated using in vitro techniques and human studies. Partitioning of captopril into n-octanol was lowest over the pH range 5 to 8 and highest at pH values 3, 4 and 9. Using the buccal absorption technique, the partitioning of captopril (2 mg) was examined in six healthy male volunteers from buffered solutions (pH 3, 4, 5, 6, 7, 8, and 9). Lowest buccal partitioning occurred at pH 3 while maximal buccal partitioning occurred at pH 7. These data clearly indicated that the buccal absorption of captopril pharmacokinetic and pharmacodynamic parameters were determined after administration of buffered sublingual captopril (pH 7, optimal hP for absorption as determined from the buccal partitioning data) and unbuffered sublingual captopril. The study was performed in eight healthy volunteers in a randomised single-blind cross-over fashion. The tmax for captopril was found to be approximately 11 minutes earlier after buffered versus unbuffered sublingual administration and AUC0-30 min increased by approximately 30% in the case of buffered captopril. Cpmas, AUC0-180 min and relative bioavailability did not differ between the buffered and unbuffered administration. Pharmacodynamic parameters (BP, heart rate and plasma renin activity) did not differ significantly between buffered and unbuffered sublingual administration. The increased rate of captopril absorption after buffered sublingual administration was small and is likely to offer little therapeutic advantage over conventional sublingual formulation.