Search

Background: There is limited evidence on the safety of Hormone Replacement Therapy (HRT) in women with cancer. Therefore, we systematically examined HRT use and cancer-specific mortality in women with 17 site-specific cancers. Methods: Women newly diagnosed with 17 site-specific cancers from 1998 to 2019, were identified from general practitioner (GP) records, hospital diagnoses or cancer registries in Scotland, Wales and England. Breast cancer patients were excluded because HRT is contraindicated in breast cancer patients. The primary outcome was time to cancer-specific mortality. Time-dependent Cox regression models were used to calculate adjusted hazard ratios (HR) and 95% confidence intervals (95% CIs) for cancer-specific mortality by systemic HRT use. Results: The combined cancer cohorts contained 182,589 women across 17 cancer sites. Overall 7% of patients used systemic HRT after their cancer diagnosis. There was no evidence that HRT users, compared with non-users, had higher cancer-specific mortality at any cancer site. In particular, no increase was observed in common cancers including lung (adjusted HR = 0.98 95% CI 0.90, 1.07), colorectal (adjusted HR = 0.79 95% CI 0.70, 0.90), and melanoma (adjusted HR = 0.77 95% CI 0.58, 1.02). Conclusions: We observed no evidence of increased cancer-specific mortality in women with a range of cancers (excluding breast) receiving HRT. [ABSTRACT FROM AUTHOR]

Background: Quality of life (QoL) is an important outcome to capture in clinical trials evaluating deprescribing interventions. Objective: We aimed to conduct a scoping review to examine how QoL has been measured in deprescribing trials among older people and identify potentially relevant QoL scales, to better inform QoL measurement in future deprescribing trials. Methods: We searched MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Trials, Google Scholar, Epistemonikos, ClinicalTrials.gov, and reference lists of eligible studies (from inception to October 2023). We included randomized and non-randomized comparative studies with a control group that evaluated deprescribing and polypharmacy reduction interventions in people ≥ 65 years of age and measured QoL as an outcome. We also included studies describing the development and validation of QoL scales related to deprescribing, polypharmacy, or medication burden in adults ≥ 18 years of age. Two independent reviewers screened titles and abstracts, then full texts. Two independent reviewers extracted data from 25% of eligible studies in order to verify agreement, then a single reviewer extracted data from the remaining studies, which a second reviewer cross-checked. We critically appraised scales based on the COSMIN checklist. Results: We retrieved 7290 articles, of which 52 were eligible for inclusion, including 44 deprescribing trials and eight scale development studies. From these studies, we found 21 scales that have been used in the context of deprescribing/polypharmacy (12 generic scales used in clinical trials and nine medication-specific scales). Variations of the generic EQ-5D were the most used scales. The measurement properties of scales for capturing changes in QoL from deprescribing were uncertain. Medication-specific QoL scales have not been employed in deprescribing clinical trials and thus, their performance in this context is also not clear. Conclusions: Several existing QoL scales have been applied to the context of deprescribing/polypharmacy clinical trials, and new scales specific to the problem have been proposed. If deprescribing does impact QoL, our findings suggest it is uncertain whether existing QoL scales can practically and reliably capture such a change or whether any scale is best. However, this review compares various aspects of the scales that researchers and clinicians can consider in decisions about measuring QoL in deprescribing trials, and in planning future research. Protocol Registration: Open Science Framework: osf.io/aez6w. [ABSTRACT FROM AUTHOR]

The article summarizes the Proceedings of the International Ambulatory Drug Safety Symposium held in Munich, Germany in June 2023. The symposium aimed to address challenges in maximizing ambulatory drug safety and brought together scientists from 12 countries. The symposium focused on knowledge generation and implementation, including innovations in research, risk prediction, surveillance, decision support, collaboration, and intervention design. The symposium discussed the challenges of improving medication safety in ambulatory care and emphasized the need for tailored interventions and alignment between knowledge generation and implementation efforts. Experts in pharmacoepidemiology, health services research, and clinical medicine participated in the symposium. [Extracted from the article]

Background: Older adults (≥ 65 years) with cancer receiving palliative care often have other health conditions requiring multiple medications. Aim: To describe and assess the appropriateness of prescribing for older adults with cancer in the last seven days of life in an inpatient palliative care setting. Method: Retrospective observational study of medical records for 180 patients (60.6% male; median age: 74 years; range 65–94 years) over a two-year period. Medication appropriateness was assessed using: STOPPFrail, OncPal deprescribing guideline and criteria for identifying Potentially Inappropriate Prescribing in older adults with Cancer receiving Palliative Care (PIP-CPC). Results: 94.5% of patients had at least one other health condition (median 3, IQR 2–5). The median number of medications increased from five (IQR 3–7) seven days before death, to 11 medications on the day of death (IQR 9–15). The prevalence of PIP varied depending on the tool used: STOPPFrail (version 1: 17.2%, version 2: 19.4%), OncPal (12.8%), PIP-CPC (30%). However, the retrospective nature of the study limited the applicability of the tools. Increasing number of medications had a statistically significant effect on risk of PIP across all tools (STOPPFrail (version 1: 1.29 (1.13–1.37), version 2: 1.30 (1.16–1.48)); OncPal 1.13 (1.01–1.27); PIP-CPC 0.70 (0.61–0.82)). Conclusion: This study found that the number of medications prescribed to older adults with cancer increased as time to death approached, and the prevalence of PIP varied with the application of different tools. The study also highlights the difficulties of examining PIP in this patient cohort. [ABSTRACT FROM AUTHOR]

Background: Antibiotic-induced gut dysbiosis has been associated with colorectal cancer (CRC) in older adults. This study will investigate whether an association exists between antibiotic usage and early-onset colorectal cancer (CRC), and also evaluate this in later-onset CRC for comparison.Methods: A case-control study was conducted using primary care data from 1999-2011. Analysis were conducted separately in early-onset CRC cases (diagnosed < 50 years) and later-onset cases (diagnosed ≥ 50 years). Conditional logistic regression was used to calculate odds ratios and 95% confidence intervals (CI) for the associations between antibiotic exposure and CRC by tumour location, adjusting for comorbidities.Results: Seven thousands nine hundred and three CRC cases (445 aged <50 years) and 30,418 controls were identified. Antibiotic consumption was associated with colon cancer in both age-groups, particularly in the early-onset CRC cohort (<50 years: adjusted Odds Ratio (ORadj) 1.49 (95% CI 1.07, 2.07), p = 0·018; ≥50 years (ORadj (95% CI) 1.09 (1.01, 1.18), p = 0·029). Antibiotics were not associated with rectal cancer (<50 years: ORadj (95% CI) 1.17 (0.75, 1.84), p = 0.493; ≥50 years: ORadj (95% CI) 1.07 (0.96, 1.19), p = 0.238).Conclusion: Our findings suggest antibiotics may have a role in colon tumour formation across all age-groups. [ABSTRACT FROM AUTHOR]

Key summary points: Aim: This review aimed to identify, describe and discuss different interventions targeting medication use optimization in nursing homes and to identify research gaps. Finding: Prescription of the whole medication regimen or of specific medication classes was the most studied aspect. Medication review and multidisciplinary approaches appeared to be effective strategies in reducing appropriate use, but further large-scale randomized trials are needed. Messages: Efforts to optimize medication use among nursing home residents are still needed and should focus on less evaluated intervention components, specific medication classes and medication use aspects not related to prescribing. Purpose: Polypharmacy, medication errors and adverse drug events are frequent among nursing home residents. Errors can occur at any step of the medication use process. We aimed to review interventions aiming at optimization of any step of medication use in nursing homes. Methods: We narratively reviewed quantitative as well as qualitative studies, observational and experimental studies that described interventions, their effects as well as barriers and enablers to implementation. We prioritized recent studies with relevant findings for the European setting. Results: Many interventions led to improvements in medication use. However, because of outcome heterogeneity, comparison between interventions was difficult. Prescribing was the most studied aspect of medication use. At the micro-level, medication review, multidisciplinary work, and more recently, patient-centered care components dominated. At the macro-level, guidelines and legislation, mainly for specific medication classes (e.g., antipsychotics) were employed. Utilization of technology also helped improve medication administration. Several barriers and enablers were reported, at individual, organizational, and system levels. Conclusion: Overall, existing interventions are effective in optimizing medication use. However there is a need for further European well-designed and large-scale evaluations of under-researched intervention components (e.g., health information technology, patient-centered approaches), specific medication classes (e.g., antithrombotic agents), and interventions targeting medication use aspects other than prescribing (e.g., monitoring). Further development and uptake of core outcome sets is required. Finally, qualitative studies on barriers and enablers for intervention implementation would enable theory-driven intervention design. [ABSTRACT FROM AUTHOR]

In Aotearoa New Zealand (NZ), ethnic inequities in health outcomes exist. Non-Māori experience better access to healthcare than Māori, including access to the quality use of medicines. Quality medicines use requires that medicines provide maximal therapeutic benefit with minimal harm. As older adults are more at risk of harm from medicines, and, because inequities are compounded with age, Māori older adults may be at more risk of medicines-related harm than younger and non-Māori populations. This narrative review examined ethnic variation in the quality use of medicines, including medicines utilisation and associated clinical outcomes, between Māori and non-Māori older adult populations in NZ. The review was structured around prevalence of medicine utilisation by medicine class and in particular disease states; high-risk medicines; polypharmacy; prevalence of potentially inappropriate prescribing (PIP); and association between PIP and clinical outcomes. 22 studies were included in the review. There is ethnic variation in the access to medicines in NZ, with Māori older adults often having reduced access to particular medicine types, or in particular disease states, compared with non-Māori older adults. Māori older adults are less likely than non-Māori to be prescribed medicines inappropriately, as defined by standardised tools; however, PIP is more strongly associated with adverse outcomes for Māori than non-Māori. This review identifies that inequities in quality medicines use exist and provides a starting point to develop pro-equity solutions. The aetiology of inequities in the quality use of medicines is multifactorial and our approaches to addressing the inequitable ethnic variation also need to be. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The prescribing of medications with anticholinergic and/or sedative properties is considered potentially inappropriate in older people (due to their side-effect profile), and the Drug Burden Index (DBI) is an evidence-based tool which measures exposure to these medications. Life and Living in Advanced Age: a Cohort Study in New Zealand (LiLACS NZ) is an ongoing longitudinal study investigating the determinants of healthy ageing. Using data from LiLACS NZ, this study aimed to determine whether a higher DBI was associated with poorer outcomes (hospitalisation, falls, mortality and cognitive function and functional status) over 36 months follow-up. Methods: LiLACS NZ consists of two cohorts: Māori (the indigenous population of New Zealand) aged ≥ 80 years and non-Māori aged 85 years at the time of enrolment. Data relating to regularly prescribed medications at baseline, 12 months and 24 months were used in this study. Medications with anticholinergic and/or sedative properties (i.e. medications with a DBI > 0) were identified using the Monthly Index of Medical Specialities (MIMS) medication formulary, New Zealand. DBI was calculated for everyone enrolled at each time point. The association between DBI at baseline and outcomes was evaluated throughout a series of 12-month follow-ups using negative binomial (hospitalisations and falls), Cox (mortality) and linear (cognitive function and functional status) regression analyses (significance p < 0.05). Regression models were adjusted for age, gender, general practitioner (GP) visits, socioeconomic deprivation, number of medicines prescribed and one of the following: prior hospitalisation, history of falls, baseline cognitive function [Modified Mini-Mental State Examination (3MS)] or baseline functional status [Nottingham Extended Activities of Daily Living (NEADL)]. Results: Full demographic data were obtained for 671, 510 and 403 individuals at baseline, 12 months and 24 months, respectively. Overall, 31%, 30% and 34% of individuals were prescribed a medication with a DBI > 0 at baseline, 12 months and 24 months, respectively. At baseline and 12 months, non-Māori had a greater mean DBI (0.28 ± 0.5 and 0.27 ± 0.5, respectively) compared to Māori (0.16 ± 0.3 and 0.18 ± 0.5, respectively). At baseline, the most commonly prescribed medicines with a DBI > 0 were zopiclone, doxazosin, amitriptyline and codeine. In Māori, a higher DBI was significantly associated with a greater risk of mortality: at 36 months follow-up, adjusted hazard ratio [95% confidence interval (CI)] 1.89 (1.11–3.20), p = 0.02. In non-Māori, a higher DBI was significantly associated with a greater risk of mortality [at 12 months follow-up, adjusted hazard ratio (95% CIs) 2.26 (1.09–4.70), p = 0.03] and impaired cognitive function [at 24 months follow-up, adjusted mean difference in 3MS score (95% CIs) 0.89 (− 3.89 to − 0.41), p = 0.02). Conclusions: Using data from LiLACS NZ, a higher DBI was significantly associated with a greater risk of mortality (in Māori and non-Māori) and impaired cognitive function (in non-Māori). This highlights the importance of employing strategies to manage the prescribing of medications with a DBI > 0 in older adults. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Behaviour change interventions offer clinical pharmacists many opportunities to optimise the use of medicines. 'MINDSPACE' is a framework used by a Government-affiliated organisation in the United Kingdom to communicate an approach to changing behaviour through policy. The Theoretical Domains Framework (TDF) organises constructs of psychological theories that are most relevant to behaviour change into 14 domains. Both frameworks offer a way of identifying what drives a change in behaviour, providing a target for an intervention. This article aims to compare and contrast MINDSPACE and the TDF, and serves to inform pharmacy practitioners about the potential strengths and weaknesses of using either framework in a clinical pharmacy context. It appears that neither framework can deliver evidence-based interventions that can be developed and implemented with the pace demanded by policy and practice-based settings. A collaborative approach would ensure timely development of acceptable behaviour change interventions that are grounded in evidence. [ABSTRACT FROM AUTHOR]

Background: Inappropriate antimicrobial prescribing has been reported in care homes. This may result in serious drug-related adverse events, Clostridium difficile colonization, and the development of antimicrobial resistance among care home residents. Interventions to improve antibiotic prescribing in nursing homes have been reported through clinical trials, but whether antifungal and antiviral prescribing and residential homes have been considered, or how outcomes were measured and reported in such interventions, remains unclear. Objectives: Our aims were to evaluate the effect of interventions to improve antimicrobial stewardship in care homes and to report the outcomes used in these trials. Methods: We searched 11 electronic databases and five trial registries for studies published until 30 November 2018. Inclusion criteria for the review were randomized controlled trials, targeting care home residents and healthcare professionals, providing interventions to improve antimicrobial prescribing compared with usual care or other interventions. The Cochrane tools for assessing risk of bias were used for quality assessment. A narrative approach was taken because of heterogeneity across the studies. Results: Five studies met the inclusion criteria. The studies varied in terms of types of infection, key targets, delivery of interventions, and reported outcomes. In total, 27 outcomes were reported across the studies, with seven not prespecified in the methods. The interventions had little impact on adherence to guidelines and prevalence of antimicrobial prescribing; they appeared to decrease total antimicrobial consumption but were unlikely to have affected overall hospital admissions and mortality. The overall quality of evidence was low because the risk of bias was high across the studies. Conclusion: The interventions had limited effect on improving antimicrobial prescribing but did not appear to cause harm to care home residents. The low quality of evidence and heterogeneity in outcome measurement suggest the need for future well-designed studies and the development of a core outcome set to best evaluate the effectiveness of antimicrobial stewardship in care homes. [ABSTRACT FROM AUTHOR]

Background Polypharmacy is associated with an increased risk of adverse drug events, inappropriate prescribing and medication errors. People with bronchiectasis have frequent pulmonary exacerbations that require antibiotic therapy. Objective This study aimed to measure polypharmacy and medication regimen complexity in bronchiectasis patients and to explore associations between these factors and oral and intravenous (IV) antibiotic use for suspected pulmonary exacerbations. Setting Patients were sampled from the Regional Bronchiectasis Clinic at the Belfast Health and Social Care Trust, Northern Ireland. Method Data on medicines were collected from patients' records and used to measure polypharmacy using three thresholds (≥ 4, ≥ 10, and ≥ 15 medicines'). Medication regimen complexity was calculated using the medication regimen complexity index (MRCI). Data analysis investigated differences in outcomes across polypharmacy thresholds and correlations with MRCI. Main outcome measure Primary outcomes were prescriptions for oral antibiotics and IV antibiotics, in the past 6 months and 2 years, respectively. Results Over three-quarters of the sample (N = 95) were prescribed ≥ 4 medicines (n = 74; 77.9%), 31 patients were prescribed ≥ 10 medicines (33.0%), and 12 patients (12.8%) were prescribed ≥ 15 medicines. The median MRCI was 26. Patients prescribed ≥ 10 medicines were over three times more likely to have had an IV antibiotic in the past 2 years (adjusted odd ratio 3.44, 95% confidence intervals 1.15-10.31). Conclusion There were significant differences in all outcomes across the '≥ 10 medicines' threshold. MRCI was positively correlated with oral and IV antibiotic usage. These findings also suggest a possible link between polypharmacy and medicines regimen complexity, and poorer outcomes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The use of multiple medicines (polypharmacy) is increasingly common in middle-aged and older populations. Ensuring the correct balance between the prescribing of 'many' drugs and 'too many' drugs is a significant challenge. Clinicians are tasked with ensuring that patients receive the most appropriate combinations of medications based on the best available evidence, and that medication use is optimised according to patients' clinical needs (appropriate polypharmacy). Historically, polypharmacy has been viewed negatively because of the associated medication safety risks, such as drug interactions and adverse drug events. More recently, polypharmacy has been identified as a risk factor for under-prescribing, such that patients do not receive necessary medications and this can also pose risks to patients' safety and well-being. The negative connotations that have long been associated with the term polypharmacy could potentially be acting as a driving factor for under-prescribing, whereby clinicians are reluctant to prescribe necessary medicines for patients who are already receiving 'many' medicines. It is now recognised that the prescribing of 'many' medicines can be entirely appropriate in patients with several chronic conditions and that the risks of adverse drug events that have been associated with polypharmacy may be greatly reduced when patients' clinical context is taken into consideration. In this article, we outline the current perspectives on polypharmacy and make the case for adopting the term 'appropriate polypharmacy' in differentiating between the prescribing of 'many' drugs and 'too many' drugs. We also outline the inherent challenges in doing so and provide recommendations for future clinical practice and research. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The importance of optimising medicines management for people with dementia has been emphasised through research and policy. However, evidence is currently lacking regarding how to achieve this in this patient population. Objective: The aim was to assess the effectiveness of medicines management interventions for people with dementia living in their own home or a care home, with or without nursing care. Methods: A systematic literature search was conducted in February 2016 across six electronic databases and three trial registries. Inclusion criteria were randomised controlled trials of medicines management (prescribing, dispensing, adherence, and/or review) interventions for people with dementia living in their own homes or care homes, with or without nursing. An assessment of quality was conducted for all studies, using the Cochrane tool for assessing the risk of bias. All outcomes were considered using a narrative approach. Results: Overall, 1365 articles were identified, with three studies eligible for inclusion ( n = 475 participants). The studies were heterogeneous both in terms of intervention components, setting, and outcomes used. Aspects of medicines management targeted included medication review, adherence, and administration. Improvements in psychotropic prescribing were observed; however, the interventions had limited effects on other outcomes such as wellbeing, falls and dementia severity. Conclusion: This review highlights the limited number of studies examining medicines management interventions for people with dementia. Of the work that has been conducted to date, emphasis has been placed on psychotropic drug use. Future research must target community-dwelling dementia patients and take a holistic approach to medicines management. [ABSTRACT FROM AUTHOR]

Background Potentially inappropriate prescribing (PIP) [encompassing potentially inappropriate medicines (PIMs) and potential prescribing omissions (PPOs)], is prevalent amongst older adults in primary and secondary care. However, PIP prevalence in intermediate care (IC) is unknown. Objective To determine the prevalence of PIMs/PPOs and associated patient factors. Setting Three IC facilities in Northern Ireland. Method The Screening Tool of Older People's Prescriptions and the Screening Tool to Alert doctors to Right Treatment were used to identify PIP over 8 weeks. Wilcoxon signed-rank tests were performed to compare the prevalence of PIMs/PPOs at admission and discharge. Spearman's correlation coefficients were calculated to determine factors associated with PIMs/PPOs (p < 0.05 considered significant). Main outcome measure Prevalence of PIMs/PPOs. Results 74 patients [mean age 83.5(±7.4) years] were included. Discharge medication data were available for 30 (40.5%) patients. 53 (71.6%) and 22 (73.3%) patients had ≥1 PIM at admission and discharge, respectively. 45 (60.8%) and 15 (50.0%) patients had ≥1 PPO at admission and discharge, respectively. No significant difference was found in PIM/PPO prevalence at admission compared to discharge (Z = -0.36, p = 0.72; Z = -1.63, p = 0.10). Increasing comorbidity and medication regimen complexity were associated with PIMs at admission (r = 0.265, p = 0.023; r = 0.338 p = 0.003). The number of medicines was correlated with PIMs at admission (r = 0.391, p = 0.001) and discharge (r = 0.515, p = 0.004). Conclusion Whilst IC represents an ideal setting in which to review prescribing, this study found PIP to be highly prevalent in older adults in IC, with no detectably significant change in prevalence between admission to and discharge from this setting. [ABSTRACT FROM AUTHOR]

Background: Previous interventions have shown limited success in improving medication adherence in older adults, and this may be due to the lack of a theoretical underpinning. Objective: This review sought to determine the effectiveness of theory-based interventions aimed at improving medication adherence in older adults prescribed polypharmacy and to explore the extent to which psychological theory informed their development. Data Sources: Eight electronic databases were searched from inception to March 2015, and extensive hand-searching was conducted. Eligibility Criteria: Interventions delivered to older adults (populations with a mean/median age of ≥65 years) prescribed polypharmacy (four or more regular oral/non-oral medicines) were eligible. Studies had to report an underpinning theory and measure at least one adherence and one clinical/humanistic outcome. Review Methods: Data were extracted independently by two reviewers and included details of intervention content, delivery, providers, participants, outcomes and theories used. The theory coding scheme (TCS) was used to assess the extent of theory use. Results: Five studies cited theory as the basis for intervention development (social cognitive theory, health belief model, transtheoretical model, self-regulation model). The extent of theory use and intervention effectiveness in terms of adherence and clinical/humanistic outcomes varied across studies. No study made optimal use of theory as recommended in the TCS. Conclusions: The heterogeneity observed and inclusion of pilot designs mean conclusions regarding effectiveness of theory-based interventions targeting older adults prescribed polypharmacy could not be drawn. Further primary research involving theory as a central component of intervention development is required. The review findings will help inform the design of future theory-based adherence interventions. [ABSTRACT FROM AUTHOR]

Background Despite the importance placed on the concept of the multidisciplinary team in relation to intermediate care (IC), little is known about community pharmacists' (CPs) involvement. Objective To determine CPs' awareness of and involvement with IC services, perceptions of the transfer of patients' medication information between healthcare settings and views of the development of a CP-IC service. Setting Community pharmacies in Northern Ireland. Methods A postal questionnaire, informed by previous qualitative work was developed and piloted. Main outcome measure CPs' awareness of and involvement with IC. Results The response rate was 35.3 % (190/539). Under half (47.4 %) of CPs 'agreed/strongly agreed' that they understood the term 'intermediate care'. Three quarters of respondents were either not involved or unsure if they were involved with providing services to IC. A small minority (1.2 %) of CPs reported that they received communication regarding medication changes made in hospital or IC settings 'all of the time'. Only 9.5 and 0.5 % of respondents 'strongly agreed' that communication from hospital and IC, respectively, was sufficiently detailed. In total, 155 (81.6 %) CPs indicated that they would like to have greater involvement with IC services. 'Current workload' was ranked as the most important barrier to service development. Conclusion It was revealed that CPs had little awareness of, or involvement with, IC. Communication of information relating to patients' medicines between settings was perceived as insufficient, especially between IC and community pharmacy settings. CPs demonstrated willingness to be involved with IC and services aimed at bridging the communication gap between healthcare settings. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Increased exposure to anticholinergic medication is problematic, particularly in those aged 80 years and older. Objective: The aim of this systematic review was to identify tools used to quantify anticholinergic medication burden and determine the most appropriate tool for use in longitudinal research, conducted in those aged 80 years and older. Methods: A systematic literature search was conducted across six electronic databases to identify existing tools. Data extraction was conducted independently by two researchers; studies describing the development of each tool were also retrieved and relevant data extracted. An assessment of quality was completed for all studies. Tools were assessed in terms of their measurement of the association between anticholinergic medication burden and a defined set of clinical outcomes, their development and their suitability for use in longitudinal research; the latter was evaluated on the basis of criteria defined as the key attributes of an ideal anticholinergic risk tool. Results: In total, 807 papers were retrieved, 13 studies were eligible for inclusion and eight tools were identified. Included studies were classed as 'very good' or 'good' following the quality assessment analysis; one study was unclassified. Anticholinergic medication burden as measured in studies was associated with impaired cognitive and physical function, as well as an increased frequency of falls. The Drug Burden Index (DBI) exhibited most of the key attributes of an ideal anticholinergic risk tool. Conclusion: This review identified the DBI as the most appropriate tool for use in longitudinal research focused on older people and their exposure to anticholinergic medication burden. [ABSTRACT FROM AUTHOR]

Digoxin has been shown to have an estrogenic effect and is associated with increased risk of gynecomastia and estrogen-sensitive cancers such as breast and uterus cancer. These findings, particularly recent observations of increased breast cancer risk, raise questions about the safety of digoxin use in breast cancer patients. Therefore, we investigated whether digoxin use after breast cancer diagnosis increased the risk of breast cancer-specific mortality in breast cancer patients. A cohort of 17,842 breast cancer patients newly diagnosed from 1998 to 2009 was identified from English cancer registries (from the National Cancer Data Repository). This cohort was linked to the UK Clinical Practice Research Datalink (to provide digoxin and other prescription records) and to the Office of National Statistics mortality data (to identify breast cancer-specific deaths). Using time-dependent Cox regression models, unadjusted and adjusted hazard ratios (HR) and 95 % confidence intervals (CIs) were calculated for the association between post-diagnostic exposure to digoxin and breast cancer-specific and all-cause mortality. In 17,842 breast cancer patients, there were 2219 breast cancer-specific deaths. Digoxin users appeared to have increased breast cancer-specific mortality compared with non-users (HR 1.73; 95 % CI 1.39-2.15) but this association was entirely attenuated after adjustment for potential confounders (adjusted HR 0.91; 95 % CI 0.72-1.14). In this large population-based breast cancer cohort study, there was little evidence of an increase in breast cancer-specific mortality with digoxin use after diagnosis. These results provide some reassurance that digoxin use is safe in breast cancer patients. [ABSTRACT FROM AUTHOR]

Background: No studies have been conducted in the UK context to date that categorise medications in terms of appropriateness for patients with advanced dementia, or that examine medication use in these vulnerable patients. Objectives: The objectives of this study were to categorise the appropriateness of a comprehensive list of medications and medication classes for use in patients with advanced dementia; examine the feasibility of conducting a longitudinal prospective cohort study to collect clinical and medication use data; and determine the appropriateness of prescribing for nursing home residents with advanced dementia in Northern Ireland (NI), using the categories developed. Methods: A three-round Delphi consensus panel survey of expert clinicians was used to categorise the appropriateness of medications for patients with advanced dementia [defined as having Functional Assessment Staging (FAST) scores ranging from 6E to 7F]. This was followed by a longitudinal prospective cohort feasibility study that was conducted in three nursing homes in NI. Clinical and medication use for participating residents with advanced dementia (FAST scores ranging from 6E to 7F) were collected and a short test of dementia severity administered. These data were collected at baseline and every 3 months for up to 9 months or until death. For those residents who died during the study period, data were also collected within 14 days of death. The appropriateness ratings from the consensus panel survey were retrospectively applied to residents' medication data at each data collection timepoint to determine the appropriateness of medications prescribed for these residents. Results: Consensus was achieved for 87 (90 %) of the 97 medications and medication classes included in the survey. Fifteen residents were recruited to participate in the longitudinal prospective cohort feasibility study, four of whom died during the data collection period. Mean numbers of medications prescribed per resident were 16.2 at baseline, 19.6 at 3 months, 17.4 at 6 months and 16.1 at 9 months. Fourteen residents at baseline were taking at least one medication considered by the consensus panel to be never appropriate, and approximately 25 % of medications prescribed were considered to be never appropriate. Post-death data collection indicated a decrease in the proportion of never appropriate medications and an increase in the proportion of always appropriate medications for those residents who died. Conclusions: This study is the first to develop and apply medication appropriateness indicators for patients with advanced dementia in the UK setting. The Delphi consensus panel survey of expert clinicians was a suitable method of developing such indicators. It is feasible to collect information on quality of life, functional performance, physical comfort, neuropsychiatric symptoms and cognitive function for this subpopulation of nursing home residents with advanced dementia. [ABSTRACT FROM AUTHOR]

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 Longitu Dinal 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. [ABSTRACT FROM AUTHOR]

Healthcare systems worldwide are facing an unprecedented demographic change as globally, the number of older people will triple to 2 billion by the year 2050. The resulting pressures on acute services have been instrumental in the development of intermediate care (IC) as a new healthcare model, which has its origins in the National Health Service in the UK. IC is an umbrella term for patient services that do not require the resources of a general hospital but are beyond the scope of a traditional primary care team. IC aims to promote timely discharge from hospital, prevent unnecessary hospital admissions and reduce the need for long-term residential care by optimizing functional independence. Various healthcare providers around the world have adopted similar models of care to manage changing healthcare needs. Polypharmacy, along with age-related changes, places older people at an increased risk of adverse drug events, including inappropriate prescribing, which has been shown to be prevalent in this population in other healthcare settings. Medicines management (the practice of maximizing health through optimal use of medicines) of older people has been discussed in the literature in a variety of settings; however, its place within IC is largely unknown. Despite IC being a multidisciplinary healthcare model, there is a lack of evidence to suggest that enhanced pharmaceutical involvement is core to the service provided within IC. This review article highlights the gap in the literature surrounding medicines management within IC and identifies potential solutions aimed at improving patient outcomes in this setting. [ABSTRACT FROM AUTHOR]

Purpose: Aspirin use is associated with reduced risk of, and death from, prostate cancer. Our aim was to determine whether low-dose aspirin use after a prostate cancer diagnosis was associated with reduced prostate cancer-specific mortality. Methods: A cohort of newly diagnosed prostate cancer patients (1998-2006) was identified in the UK Clinical Practice Research Datalink (confirmed by cancer registry linkage). A nested case-control analysis was conducted using conditional logistic regression to compare aspirin usage in cases (prostate cancer deaths) with up to three controls (matched by age and year of diagnosis). Results: Post-diagnostic low-dose aspirin use was identified in 52 % of 1,184 prostate cancer-specific deaths and 39 % of 3,531 matched controls (unadjusted OR 1.51, 95 % CI 1.19, 1.90; p < 0.001). After adjustment for confounders including treatment and comorbidities, this association was attenuated (adjusted OR 1.02 95 % CI 0.78, 1.34; p = 0.86). Adjustment for estrogen therapy accounted for the majority of this attenuation. There was also no evidence of dose-response association after adjustments. Compared with no use, patients with 1-11 prescriptions and 12 or more prescriptions had adjusted ORs of 1.07 (95 % CI 0.78, 1.47; p = 0.66) and 0.97 (95 % CI 0.69, 1.37; p = 0.88), respectively. There was no evidence of a protective association between low-dose aspirin use in the year prior to diagnosis and prostate cancer-specific mortality (adjusted OR 1.04 95 % CI 0.89, 1.22; p = 0.60). Conclusion: We found no evidence of an association between low-dose aspirin use before or after diagnosis and risk of prostate cancer-specific mortality, after potential confounders were accounted for, in UK prostate cancer patients. [ABSTRACT FROM AUTHOR]

Objective To determine UK non-medical prescribers' (NMPs) (supplementary or independent) current participation and self-reported competence in pharmacovigilance, and their perceptions of training and future needs. Setting Non-medical prescribers in health care in the United Kingdom. Awareness of and participation in the Yellow Card Scheme (YCS); attitudes towards ADR reporting; strategies to encourage reporting; pharmacovigilance training; and demographics. The sample comprised nurse (n = 912) and pharmacist (n = 2,439) NMPs in the UK. Main outcome measures Self-reported competence in pharmacovigilance, knowledge of and participation in the YCS, attitudes towards ADR reporting; strategies to encourage ADR reporting; pharmacovigilance training during NMP training. Results Six hundred and thirteen responses were received giving an overall response rate of 20.4 %. Response rates for nurse and pharmacist prescribers were 32.2 % (n = 293) and 13.1 % (n = 320) respectively. Three hundred and fifty-nine respondents (58.6 %) had submitted a Yellow Card. Although the majority of respondents (70.4 %) felt competent in pharmacovigilance, a third (34.2 %) said they needed further training. Respondents reported a positive attitude towards ADR reporting, yet only a minority (22.9 %) correctly answered factual questions about the YCS. Approximately a third of respondents (35.6 %) 'couldn't remember' if pharmacovigilance was covered in their prescribing training. Publicity and education were commonly suggested measures to enhance contribution to the YCS. Conclusion While NMPs report participation and competence in ADR reporting, there are several key issues to consider including the need for further training and support to optimise their role in pharmacovigilance. [ABSTRACT FROM AUTHOR]

The article discusses research investigating the prevalence of potentially inappropriate prescribing (PIP) in Irish long-term care (LTC) residents in the Cork region of Ireland. Topics include the use of validated, evidence-based, explicit criteria for defining instances of PIP, such as the Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP), an overview of the study's objectives, and a discussion of the results.

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. [ABSTRACT FROM AUTHOR]

Objective: To investigate the association between angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) and disease progression and survival in cancer patients. Methods: Using terms for cancer and ACEIs/ARBs, MEDLINE, EMBASE and Web of Science were systematically searched for observational/interventional studies that used clinically relevant outcomes for cancer progression and survival. Results: Ten studies met the inclusion criteria. Two studies showed a significant improvement in overall survival (OS) with ACEI/ARB use among patients with advanced pancreatic (HR 0.52, 95% CI 0.29-0.88) and non-small cell lung cancer (HR 0.56, 95% CI 0.33-0.95). An improvement in progression-free survival (PFS) was also reported for pancreatic cancer patients (HR 0.58, 95% CI 0.34-0.95) and patients with renal cell carcinoma (HR 0.54, p = 0.02). ACEI/ARB use was protective against breast cancer recurrence (HR 0.60, 95% CI 0.37-0.96), colorectal cancer distant metastasis (OR 0.22, 95% CI 0.08-0.65) and prostate specific antigen (PSA) failure in prostate cancer patients ( p = 0.034). One study observed a worse OS (HR 2.01, 95% CI 1.00-4.05) and PFS in ACEI users with multiple myeloma ( p = 0.085) while another reported an increased risk of breast cancer recurrence (HR = 1.56, 95% CI 1.02-2.39). Conclusion: There is some evidence to suggest that ACEI or ARB use may be associated with improved outcomes in cancer patients. Larger, more robust studies are required to explore this relationship further. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: In 2005, the European Commission recommended that all member states should establish or strengthen surveillance systems for monitoring the use of antimicrobial agents. There is no evidence in the literature of any surveillance studies having been specifically conducted in nursing homes (NHs) in Northern Ireland (NI). Objective: The aim of this study was to determine the prevalence of anti- microbial prescribing and its relationship with certain factors (e.g. indwelling urinary catheterization, urinary incontinence, disorientation, etc.) in NH residents in NI. Methods: This project was carried out in NI as part of a wider European study under the protocols of the European Surveillance of Antimicrobial Consumption group. Two point-prevalence surveys (PPSs) were conducted in 30 NHs in April and November 2009. Data were obtained from nursing notes, medication administration records and staff in relation to antimicrobial prescribing, facility and resident characteristics and were analysed descriptively. Results: The point prevalence of antimicrobial prescribing was 13.2% in April 2009 and 10.7% in November 2009, with a 10-fold difference existing between the NHs with the highest and lowest antimicrobial prescribing prevalence during both PPSs. The same NH had the highest rate of antimicrobial prescribing during both April (30.6%) and November (26.0%). The group of antimicrobials most commonly prescribed was the penicillins (April 28.6%, November 27.5%) whilst the most prevalent individual antimicrobial pre- scribed was trimethoprim (April 21.3%, November 24.3%). The majority of antimicrobials were prescribed for the purpose of preventing urinary tract infections (UTIs) in both April (37.8%) and in November (46.7%), with 5% of all participating residents being prescribed an antimicrobial for this reason. Some (20%) antimicrobials were prescribed at inappropriate doses, particularly those which were used for the purpose of preventing UTIs. Indwelling urinary catheterization and wounds were significant risk factors for anti- microbial use in April [odds ratio {OR} (95% CI) 2.0 (1.1, 3.5) and 1.8 (1.1, 3.0), respectively] but not in November 2009 [OR (95% CI) 1.6 (0.8, 3.2) and 1.2 (0.7, 2.2), respectively]. Other resident factors, e.g. disorientation, immobility and incontinence, were not associated with antimicrobial use. Furthermore, none of the NH characteristics investigated (e.g. number of beds, hospitalization episodes, number of general practitioners, etc.) were found to be associated with antimicrobial use in either April or November 2009. Conclusions: This study has identified a high overall rate of antimicrobial use in NHs in NI, with variability evident both within and between homes. More research is needed to understand which factors influence antimicrobial use and to determine the appropriateness of antimicrobial prescribing in this population in general and more specifically in the management of recurrent UTIs. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Use of non-steroidal anti-inflammatory drugs (NSAIDs) has been associated with a reduced risk of several cancers. This is thought to be through the inhibitory action on the cyclooxygenase (COX) enzyme, COX-2. Evidence for NSAIDs preventing head and neck cancer (HNC) is conflicting. We conducted a systematic literature review to investigate the association between NSAID/aspirin use and risk of head and neck cancer (HNC). Methodology: MEDLINE, EMBASE, PubMed, Cochrane Library, and Web of Science were systematically searched using terms for NSAIDs/aspirin, HNC, and observational/intervention study designs to identify studies published by December 2009. Results: Of 9,268 articles identified, two population-based prescribing database studies and three case-control studies met the selection criteria. The studies investigated different HNC sites. Only one study found a significant protective association of aspirin use with HNC risk (OR 0.75, 95% CI 0.58-0.96), and one showed a significantly increased risk of oral/oropharyngeal cancer with non-low-dose aspirin NSAID use (OR 3.5, 95% CI 1.8-6.7). Many of the studies identified lacked information on important confounding factors. Conclusion: No definitive conclusion on the effect of NSAIDs/aspirin on HNC risk was possible. Aspirin may protect against HNC, although further robust large-scale studies are required to clarify any possible association. [ABSTRACT FROM AUTHOR]

Objective: To investigate the relationship between statin use and pancreatic cancer risk. Methods: A nested case-control study was conducted within the UK GPRD. Cases had a diagnosis of primary malignant neoplasia of the exocrine pancreas. Controls were matched with cases on general practice site, sex and year of birth. Exposure of interest was exposure to statins since entry into the GPRD until 1 year before the case diagnosis date. Conditional logistic regression analyses were used to generate ORs and 95% CI associated with statin use compared to non-use. Results: A total of 1,141 pancreatic cancer cases and 7,954 controls were identified. Any use of a statin since entry into the GPRD (excluding the year prior to diagnosis) was not associated with the risk of pancreatic cancer OR 0.93 (95% CI, 0.76-1.14). Neither dose nor duration of statin use affected pancreatic cancer risk. When dose and duration of statin use combined were assessed, no evidence of reduced risk was seen for long-term users of high-dose statins OR 0.71 (0.42-1.20). Statin type (simvastatin vs atorvastatin) was not associated with pancreatic cancer risk. Conclusion: Statin use at doses for managing hypercholesterolaemia, in a UK population, was not associated with the risk of exocrine pancreatic cancer. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Recent years have seen a growing recognition that dementia is a terminal illness and that patients with advanced dementia nearing the end of life do not currently receive adequate palliative care. However, research into palliative care for these patients has thus far been limited. Furthermore, there has been little discussion in the literature regarding medication use in patients with advanced dementia who are nearing the end of life, and discontinuation of medication has not been well studied despite its potential to reduce the burden on the patient and to improve quality of life. There is limited, and sometimes contradictory, evidence available in the literature to guide evidence-based discontinuation of drugs such as acetylcholinesterase inhibitors, antipsychotic agents, HMG-CoA reductase inhibitors (statins), anti-bacterials, antihypertensives, antihyperglycaemic drugs and anticoagulants. Furthermore, end-of-life care of patients with advanced dementia may be complicated by difficulties in accurately estimating life expectancy, ethical considerations regarding withholding or withdrawing treatment, and the wishes of the patient and/or their family. Significant research must be undertaken in the area of medication discontinuation in patients with advanced dementia nearing the end of life to determine how physicians currently decide whether medications should be discontinued, and also to develop the evidence base and provide guidance on systematic medication discontinuation. [ABSTRACT FROM AUTHOR]

Background: Little is known about how community pharmacists make decisions about which over-the-counter (OTC) medication to supply to a patient and the role of clinical evidence in making those decisions.Objective: To explore factors that influence product selection by the pharmacist and the role of evidence-based practice in this decision.Methods: In this qualitative study, community pharmacists registered in Northern Ireland and recruited via advertising and various qualitative sampling techniques, participated in face-to-face, semi-structured interviews (June 2007-September 2007) to discuss issues around OTC medication, including the use of evidence, how they judged a product to be effective, and their views on evidence-based medicine and its application to OTC medication. All interviews were digitally recorded, fully transcribed and analysed using the principles of constant comparison.Results: Twenty-six pharmacists participated in interviews. Safety was the over-arching consideration for pharmacists when making decisions. The subordinate themes were product, patient and professional factors. In terms of the product subordinate theme, use or consideration of evidence was secondary in the selection of OTC medicines. Pharmacists considered the potential for harm in the first instance and if the product was deemed safe, although lacking any evidence for effectiveness, the product was supplied. In relation to patient factors, it emerged that pharmacists were influenced by patient demand for a particular OTC product and wanted to meet patient expectations, provided that the requested product was judged to be safe. Similarly, professional factors such as ethical considerations (primarily in relation to safety) and respecting patient choice also influenced decision making. However, pharmacists recognized the conflict between professional requirements to practise according to evidence-based principles and patient demands.Conclusion: This study suggests that pharmacists considered safety above all other factors when recommending OTC products to patients, and evidence of effectiveness was seldom considered when selling OTC medicines. If evidence-based practice is to influence this type of decision, pharmacists need to use the evidence that is available and be prepared to discuss evidence with patients. [ABSTRACT FROM AUTHOR]

Background: Adherence to medication is generally considered to be poor in many patient groups, but little is known about adherence to medication in the nursing home setting. It is also unclear if residents in nursing homes are involved in decision making about medication. Objective: This study sought to explore adherence to medication and resident involvement in prescribing and decision making in regard to medicines in the nursing home setting. Methods: This was a qualitative study. Participants took part in either semistructured interviews (general practitioners [GPs] and residents) or focus groups (nurses) to discuss issues around prescribing and adherence to medication in nursing homes for older people in Northern Ireland. All interviews and focus groups were digitally recorded, fully transcribed and analysed using the principles of constant comparison. Results: Eight GPs and 17 residents participated in semi-structured interviews and nine nurses participated in two focus groups (n = 4; n = 5). The main theme that emerged was control, which was manifested in many ways. Both groups of healthcare professionals needed to maintain control of prescribing or administration of medication in order to ensure safety, quality and continuity of care. All residents accepted control without question, reported that they were adherent to medication and had little involvement in prescribing decisions or administration of their own medicines. Although the healthcare professionals thought that more involvement in decisions around medication would contribute to resident autonomy and empowerment, it was also recognized that this could adversely affect control within the nursing home. Conclusion: Although adherence with medication was generally perceived not to be a problem in the nursing homes setting in this study, other findings raise major challenges for resident involvement in an important aspect of their own care. Although there may be some residents, because of cognitive decline, who are unable to become involved in aspects of decisions about prescribing and self-administration, healthcare professionals providing care to these patients should strive to involve them as far as possible in their own care. [ABSTRACT FROM AUTHOR]

Compliance with medication has been frequently cited as a problem for patients living in community settings. However, there has been little commentary on compliance issues for residents in nursing homes. This is probably due to the assumption that residents will receive their medication on a regular basis and administration will be supervised and, therefore, compliance is not perceived to be a problem. However, regular compliance may not always be appropriate if the medication has not been reviewed for appropriateness and this 'enforced' compliance may give rise to side effects or adverse effects. Residents may also be exposed to 'erratic' compliance because of inconvenient administration times for staff or difficult and time-consuming administration instructions. This may have clinical implications for residents who require medication at regular intervals, e.g. those who have Parkinson's disease. Enforced or erratic compliance is at odds with shared decision making, which is being promoted as a way of empowering patients. It could be argued that because of a high degree of cognitive impairment, it is not appropriate for nursing home residents to become involved in decision making about medications. However, the nursing home population is heterogeneous in nature and the assumption should not be made that all residents are incapable of becoming more involved in some aspects of their own care. A greater focus on resident-centred care may promote more empowerment and autonomy, both generally and with respect to compliance with medication in particular, in nursing home residents. [ABSTRACT FROM AUTHOR]

Prescribing in care homes for older people has been the focus of much research and debate because of inappropriate drug choice and poor monitoring practices. In the US, this has led to the implementation of punitive and adversarial regulation that has sought to improve the quality of prescribing in this healthcare setting. This approach is unique to the US and has not been replicated elsewhere. The literature has revealed that there are limitations as to how much can be achieved with regulation that is externally imposed (an ‘external factor’). Other influences, which may be categorised as ‘internal factors’ operating within the care home (e.g. patient, physician and care-home characteristics), also affect prescribing. However, these internal and external factors do not appear to affect prescribing uniformly, and poor prescribing practices in care homes continue to be observed. One intangible factor that has received little attention in this area of healthcare is that of organisational culture. This factor has been linked to quality and performance within other health organisations. Consideration of organisational culture within care-home settings may help to understand what drives prescribing decisions in this particularly vulnerable patient group and thus provide new directions for future strategies to promote quality care. [ABSTRACT FROM AUTHOR]

Background: Since 1998, a prospective payment system (PPS) for Medicare services provided by nursing homes in the US has been in operation. Concerns have been expressed that the PPS may affect the quality of care delivered to residents. This study evaluates the impact of the PPS on pharmacological secondary ischaemic stroke prevention in nursing homes. Study design: The nationally mandated Minimum Data Set and Online Survey Certification and Automated Record data system from 1997 and 2000 for four states were used. We conducted a quasi-experimental study comparing the pharmacological treatment rates for secondary stroke prevention in the pre-PPS period (1997) with those in the post-PPS period (2000) in residents who experienced an ischaemic stroke within 6 months (n1997 = 5008; n2000 = 5243) of living in nursing facilities (n1997 = 1226; n2000 = 1092) in Kansas, Maine, Mississippi or Ohio. The sample was stratified according to recommendations for use of warfarin. Logistic regression models adjusting for clustering effects of residents residing in homes using generalised estimating equations provided estimates of the PPS effect on use of antiplatelets and the use of warfarin. Results: The unadjusted proportion of use of pharmacological agents for the secondary prevention of stroke was similar for warfarin in both time periods and increased for antiplatelets in 2000. Relative to the pre-PPS era, the likelihood of use of antiplatelets increased in the post-PPS era (adjusted odds ratio 1.26; 95% CI 1.15, 1.38); there was no effect on the use of warfarin. Conclusion: Although the lack of a PPS effect on pharmacological management of secondary ischaemic stroke is encouraging, there is still room for improvement in overall stroke management. [ABSTRACT FROM AUTHOR]

The quality of nursing home care has been subject to intense investigation and scrutiny, particularly in the US. In particular, there has long been concern about the extensive use of psychotropic agents, notably antipsychotics, hypnotics and anxiolytics, in this setting. These drugs have been described as ‘chemical restraints’, in that they were used to sedate and subdue patients, partly to compensate for poor staffing levels and to minimise staff contact with patients. However, following a damning Institute of Medicine report to the US Congress, use of such drugs became regulated under a unique administrative initiative: the Nursing Home Reform Act, embedded within the Omnibus Budget Reconciliation Act 1987 (OBRA 87). Research has indicated that psychotropic drug use in nursing homes has declined markedly following the implementation of this regulation. In addition, explicit criteria for potentially inappropriate medication use were incorporated within the guidelines for nursing home inspectors from 1 July 1999. Because regulations have targeted poor prescribing, rather than promoting the use of effective drugs in older residents, it has been difficult to determine whether outcomes have improved for nursing home residents as a result. However, US government agencies have responded to continuing concerns about nursing home care through the implementation of quality indicators which are used to guide and plan inspections of such facilities and to compare nursing homes within the same state. Although there are a limited number of quality indicators relating to prescribing, this represents a move away from adversarial regulation, which focuses on poor practice, and attempts to improve quality of care. An important role for educational initiatives and interventions has been advocated by some commentators and these have proved to be successful in the nursing home environment. Other countries have not implemented such restrictive prescribing regulation in nursing homes. Exemplars of innovative prescribing models, involving pharmacists and encouraging resident-centred care, may offer a more palatable approach to improving drug use in this vulnerable population. [ABSTRACT FROM AUTHOR]

Adherence to medication is one of the most intriguing and complex behaviours demonstrated by patients. Non-adherence to a therapeutic regimen may result in negative outcomes for patients and may be compounded in populations with multiple morbidities which require multiple drug therapy. Such a population is exemplified by the elderly. However, non-adherence may not be more prevalent in older patients and there is no consensus in the literature that age is a predictor of poor adherence. Indeed, older patients may deliberately choose not to adhere to medication (intentional non-adherence) to avoid adverse effects. Furthermore, many of the studies on adherence lack commonality in terms of how adherence is measured, the definition of an `older' patient and the range of disease states which have been examined. Adherence may also be affected by access to medications which may be restricted by the use of formularies or insurance programmes. However, non-adherence may represent a greater risk in older people resulting in-poor disease control which may be compounded with multiple morbidity and polypharmacy. [ABSTRACT FROM AUTHOR]