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Introduction: Access to medicines is a critical aspect of healthcare, and health technology assessment (HTA) agencies play a pivotal role in evaluating innovative medicines. Objectives: The objective of this study was to critically review Health Technology Assessment (HTA) recommendations for innovative medicines across the United Kingdom (England, Scotland, Wales and Northern Ireland) following their licensure by the European Medicines Agency (EMA) in 2017. By analysing HTA recommendations, we aimed to understand differences between licensing and reimbursement recommendations and explore variations in access to innovative treatments within the UK. Methods: The study focused on HTA decisions made between 2017 and 2020 in the UK for innovative medicines that were licensed by the European Medicines Agency (EMA) in 2017. Published documents were used for the analysis. The decisions were categorized as 'recommend without restrictions', 'recommend with restrictions', 'not recommended' or 'not assessed'. Results: In 2017, the EMA approved licenses for 56 new innovative medicines. Between 2017 and January 2020, the National Institute for Health and Care Excellence (NICE) in England completed the appraisal of 28 of these medicines. Out of the 28, 11 were 'recommended without restrictions', 15 were 'recommended with restrictions' and 2 were 'not recommended'. The majority of NICE recommendations (21 out of 26, or 81%) were made through managed access agreements. The Scottish Medicines Consortium (SMC) assessed 31 out of the 56 medicines licensed in 2017. Among these 31, 8 were 'recommended without any restriction', 22 were 'recommended with restrictions' and 1 was 'not recommended'. In Wales, the All Wales Medicines Strategy Group (AWMSG) follows NICE guidance and does not review a medicine if NICE is planning to assess it within the next 12 months. In Northern Ireland, HTA guidance from either NICE or SMC is followed, and a decision is adopted shortly after one of them makes its decision. In Northern Ireland, 39 recommendations were adopted from either NICE or SMC, including 10 without restrictions, 21 with restrictions and 8 not recommended decisions. Conclusions: This study sheds light on the complex landscape of medicine licensing and reimbursement in the UK. While licensing approval ensures safety and efficacy, it does not guarantee access to medicines without reimbursement recommendations. Health technology assessment (HTA) bodies play a crucial role in evaluating clinical effectiveness and cost-effectiveness. Our findings reveal variations in HTA adoption across UK countries, emphasizing the importance of timely recommendations. Notably, 'recommendations with restrictions' prevail, often linked to managed access agreements. As we navigate this complex system, optimizing patient care remains paramount. [ABSTRACT FROM AUTHOR]

In this month's article, George Winter discusses the potential for repurposed drugs to change the therapeutic landscape [ABSTRACT FROM AUTHOR]

Background: Children from disadvantaged backgrounds are at greater risk of attention‐deficit hyperactivity disorder (ADHD)‐related symptoms, being diagnosed with ADHD, and being prescribed ADHD medications. We aimed to examine how inequalities manifest across the 'patient journey', from perceptions of impacts of ADHD symptoms on daily life, to the propensity to seek and receive a diagnosis and treatment. Methods: We investigated four 'stages': (1) symptoms, (2) caregiver perception of impact, (3) diagnosis and (4) medication, in two data sets: UK Millennium Cohort Study (MCS, analytic n ~ 9,000), with relevant (parent‐reported) information on all four stages (until 14 years); and a population‐wide 'administrative cohort', which includes symptoms (child health checks) and prescriptions (dispensing records), born in Scotland, 2010–2012 (analytic n ~ 100,000), until ~6 years. We described inequalities according to maternal occupational status, with percentages and relative indices of inequality (RII). Results: The prevalence of ADHD symptoms and medication receipt was considerably higher in the least compared to the most advantaged children in the administrative cohort (RIIs of 5.9 [5.5–6.4] and 8.1 [4.2–15.6]) and the MCS (3.08 [2.68–3.55], 3.75 [2.21–6.36]). MCS analyses highlighted complexities between these two stages, however, those from least advantaged backgrounds, with ADHD symptoms, were the least likely to perceive impacts on daily life (15.7% vs. average 19.5%) and to progress from diagnosis to medication (44.1% vs. average 72.5%). Conclusions: Despite large inequalities in ADHD symptoms and medication, parents from the least advantaged backgrounds were less likely to report impacts of ADHD symptoms on daily life, and their children were less likely to have received medication postdiagnosis, highlighting how patient journeys differed according to socioeconomic circumstances. [ABSTRACT FROM AUTHOR]

As part of our series on medicines optimisation in people with additional needs, this article considers the health challenges that Deaf and hard of hearing patients face, and discusses how to improve healthcare access and tailor consultations to optimise health outcomes. [ABSTRACT FROM AUTHOR]

Background: The STOMP agenda (Stopping Over‐Medication of People with learning disabilities, autism, or both) drew focus to individuals with a diagnosis of a learning disability being prescribed psychotropic medication to manage 'behaviours that challenge'. The following study is an audit of two community learning disability services in the London boroughs of Westminster and Kensington and Chelsea for compliance with national guidance on the use of medication in this population, the impact of the COVID‐19 pandemic, and equality, diversity and anti‐racism. Method: Routinely collected data were audited relating to clients identified in each service, totalling 54 participants. Data were audited against five standards: minimum effective dose, medication reviews, alternative multidisciplinary input, the impact of the COVID‐19 pandemic and equality, diversity and anti–racism. Comparisons were made to the overall caseload (N = 365) where appropriate. Results: Evidence demonstrated a greater risk of receiving psychotropic medication to manage behaviours that challenge for service users from racialised backgrounds, further evidencing institutional and/or individualised racism within practice for this population. Prescriptions also increased in dosage during the COVID‐19 pandemic exacerbated by insufficient provision of alternative input and regular multi‐disciplinary review as required by national guidance. Conclusions: Community learning disability teams require dedicated, co‐produced STOMP pathways to review those at risk of over‐medication. Additional research is required to explore individual and systemic factors contributing to ethnic disparities in medication prescription for behaviours that challenge among people with learning disabilities. Further recommendations are considered around developing data collection, service user involvement, and future directions. Accessible summary: Abuse at care home (Winterbourne View) led the NHS to start a campaign known as STOMP to make sure people with learning disabilities and/or autism got the right medication.We looked at the medications people with learning disabilities in our area were given. We looked at how often these medications were checked by a doctor. We looked at what other support people were given.We also looked at how people with learning disabilities were affected by COVID‐19. We also looked at differences between people from different racial backgrounds.We found that some people were given more medications to manage their behaviour. We found that the medications were not checked as often as they should be. This happened most for Black, Brown, and Asian people.We spoke to a local service user project about our findings. They said they think racism is one of the reasons for more medications. They also said it is bad that people are on too much medication and that people should get more support. [ABSTRACT FROM AUTHOR]

New regulatory changes were introduced in January further restricting the prescription of valproate medicines in patients under 55 years of age due to the significant reproductive risks. This article discusses these changes as well as the other issues to consider to ensure valproate prescribing is as safe as possible, including monitoring for adverse effects and avoiding interactions. [ABSTRACT FROM AUTHOR]

Introduction: There is media concern over students using prescription stimulants as "cognitive enhancers" to try and improve their academic performance. However, there is limited evidence about the prevalence of this behaviour in the United Kingdom, or whether it has increased in recent years. Methods: We review survey studies on students' use of cognitive enhancers. Results: Overall reported use is low, with some inconclusive evidence that it is increasing. Use of modafinil appears to be higher than that of methylphenidate or dexamphetamine. Conclusion: There is a clear need for large‐scale research in this area, using representative sampling and survey methods that protect student anonymity. [ABSTRACT FROM AUTHOR]

Aim: Medicines non-adherence is associated with poorer outcomes and higher costs. COVID-19 affected access to healthcare, with increased reliance on remote methods, including medicines supply. This study aimed to identify what affected people's adherence to medicines for long-term conditions (LTCs) during the pandemic. Subject and methods: Cross-sectional online survey of UK adults prescribed medicines for LTCs assessing self-reported medicines adherence, reasons for non-adherence (using the capability, opportunity and motivation model of behaviour [COM-B]), medicines access and COVID-19-related behaviours. Results: The 1746 respondents reported a mean (SD) of 2.5 (1.9) LTCs, for which they were taking 2.4 (1.9) prescribed medicines, 525 (30.1%) reported using digital tools to support ordering or taking medicines and 22.6% reported medicines non-adherence. No access to at least one medicine was reported by 182 (10.4%) respondents; 1048 (60.0%) reported taking at least one non-prescription medicine as a substitute; 409 (23.4%) requested emergency supply from pharmacy for at least one medicine. Problems accessing medicines, being younger, male, in the highest socioeconomic group and working were linked to poorer adherence. Access problems were mostly directly or indirectly related to the COVID-19 pandemic. Respondents were generally lacking in capabilities and opportunities, but disruptions to habits (automatic motivation) was the major reason for non-adherence. Conclusion: Navigating changes in how medicines were accessed, and disruption of habits during the COVID-19 pandemic, was associated with suboptimal adherence. People were resourceful in overcoming barriers to access. Solutions to support medicines-taking need to take account of the multiple ways that medicines are prescribed and supplied remotely. [ABSTRACT FROM AUTHOR]

Background: People with long-term chronic conditions often struggle to access and navigate complex health and social services. Social prescription (SP) interventions, a patient-centred approach, help individuals identify their holistic needs and increase access to non-clinical resources, thus leading to improved health and well-being. This review explores existing SP interventions for people with long-term chronic conditions and identifies the opportunities and challenges of implementing them in primary healthcare settings. Methods: This rapid review followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines and searched relevant articles in three databases (PubMed/MEDLINE, EMBASE, and Web of Science) by using subject headings and keywords combined with Boolean operators. The search encompassed articles published between January 2010 and June 2023. Two authors independently conducted study screening and data abstraction using predefined criteria. A descriptive synthesis process using content analysis was performed to summarise the literature. Results: Fifteen studies were included, with all but one conducted in the United Kingdom, and revealed that social prescribers help guide patients with long-term chronic conditions to various local initiatives related to health and social needs. Effective implementation of SP interventions relies on building strong relationships between social prescribers and patients, characterised by trust, empathy, and effective communication. A holistic approach to addressing the unmet needs of people with long-term chronic conditions, digital technology utilisation, competent social prescribers, collaborative healthcare partnerships, clinical leadership, and access to local resources are all vital components of successful SP intervention. However, the implementation of SP interventions faces numerous challenges, including accessibility and utilisation barriers, communication gaps, staffing issues, an unsupportive work environment, inadequate training, lack of awareness, time management struggles, coordination and collaboration difficulties, and resource constraints. Conclusion: The present review emphasises the importance of addressing the holistic needs of people with long-term chronic conditions through collaboration and coordination, training of social prescribers, community connections, availability of local resources, and primary care leadership to ensure successful interventions, ultimately leading to improved patient health and well-being outcomes. This study calls for the need to develop or utilise appropriate tools that can capture people's holistic needs, as well as an implementation framework to guide future contextual SP interventions. [ABSTRACT FROM AUTHOR]

Strength training recommendations have been embedded within the UK's Chief Medical Officers' physical activity guidelines since 2011. There is limited evidence that these recommendations are used by exercise instructors in the community to underpin strength training prescription in the older adult population. This study aimed to explore exercise instructors' awareness and utilisation of the guidelines when prescribing strength training to older adults. Fifteen exercise instructors working with older adults in the UK participated in one online interview. A general inductive approach was conducted and thematic analysis allowed for major themes to be identified from the raw data. We found that most exercise instructors (n = 9), but not all (n = 6), were aware of the guidelines. Only one instructor (n = 1) had reportedly implemented the guidelines into their practice; other instructors reported that the guidelines were irrelevant. Instead, each of the instructors had their preferred sources of information that they relied on to underpin their exercise prescription, and each had their own interpretation of 'evidence-based strength training.' This individualised interpretation resulted in exceptionally varied prescription in the community and does not necessarily align with the progressive, evidence-based prescription known to build muscular strength. We suggest that (i) more detail on how to build muscular strength be embedded within the guidelines, (ii) a handbook on how to implement the guidelines be made available, (iii) theoretical and practical teaching materials and courses be updated, and/or (iv) a re-(education) of exercise instructors already in the field may be necessary to bring about a consistent, evidence-based strength prescription necessary for the best possible health and longevity outcomes for our ageing population. [ABSTRACT FROM AUTHOR]

Background: GP trainees may not have experienced a systematic and comprehensive education in safe prescribing. Therefore, a self-assessment prescribing review was developed. Aim: To determine whether the assessment was feasible, had face validity, and did not disadvantage particular groups of participants. Design & setting: An online survey that evaluates the opinions of GPs in training of a prescribing assessment in the UK. All full-time UK trainees who started their final year of GP training in August 2019 undertook the prescribing assessment along with their trainers, after which they completed an online anonymous feedback questionnaire. Method: The questionnaire completed by trainees sought their opinions of the assessment, and collected ethnicity and disability data. The trainer questionnaire was similar but did not include any demographic information. Results: The questionnaire was completed by 1741 trainees and 1576 trainers. There was no evidence that ethnic group and disability were related to aspects of the review. Most of the trainees (76.4%, n = 1330) and trainers (82.0%, n = 1293) agreed or strongly agreed that the prescribing review was helpful for assessing and learning about the trainee's prescribing. However, most participants (63.2%, n = 1092) took >4 hours to review their prescriptions. A majority of trainees (90.2%, n = 1571) reported that completing the assessment had resulted in a change in their prescribing practice. Conclusion: The majority of trainers and trainees reported that the prescribing assessment was helpful. The study was not able to assess whether there had been an actual change in practice that resulted in an error reduction. [ABSTRACT FROM AUTHOR]

Background: Gout is the most common inflammatory arthritis and is almost exclusively managed in primary care, however the course and severity of the condition is variable and poorly characterised. This research aims improve understanding about the frequency of, and factors associated with, gout flares in the UK and characterise the factors associated with the initiation of ULT. Methods: Using the Clinical Practice Research Database, patients with a coded incident gout diagnosis without a prior prescription for urate-lowering therapy (ULT) were identified. Gout flares post diagnosis and ULT initiation were identified through prescribing and coded data. Patient characteristics, co-morbidities and co-prescribing were co-variants. Factors associated with gout flares and ULT initiation were analysed using cox-proportional hazard model and logistic regression. Results: Fifty-one thousand seven hundred eighty-four patients were identified: 18,605 (35.9%, 95%CI 35.5–36.3%) had experienced ≥ 1 recurrent flare, 17.4% (95%CI 17.1–17.8%) within 12 months of diagnosis. Male sex, black ethnicity, higher BMI, heart failure, CKD, CVD and diuretic use were associated with flares, with the highest HR seen with high serum urate levels (≥ 540 µmol/L HR 4.63, 95%CI 4.03–5.31). ULT initiation was associated with similar variables, although higher alcohol intake and older age were associated with lower odds of ULT initiation but were not associated with flares. ULT was initiated in 27.7% (95%CI 27.3–28.0%): 5.7% (95%CI 5.5–5.9%) within 12 months of diagnosis. ULT initiation rates were higher in patients with recurrent flares. Conclusion: Approximately one in six people with incident gout had a second flare within 12 months. Factors associated with flare recurrence and ULT initiation were similar, but ULT initiation occurred later after diagnosis than previously thought. [ABSTRACT FROM AUTHOR]

Background Poor asthma control is associated with high short-acting β2-agonist (SABA) use. Aim Assess asthma-related healthcare resource utilisation (HCRU) and medication costs associated with high versus low SABA prescriptions in the United Kingdom (UK). Design and setting Analysis of SABINA I (SABA use IN Asthma), a retrospective longitudinal study using UK electronic health records (Clinical Practice Research Datalink GOLD 2008−2019 and Hospital Episode Statistics database). Method Eligible patients were ≥12 years old with SABA prescriptions in the past year. SABA prescriptions (canisters/year) were defined as high (≥3) or low (1−2). Association of SABA prescriptions with HCRU was assessed by negative binominal model adjusted for covariates. The UK unit costs from the National Health Service were applied to estimate total healthcare costs (2020). Medication costs were based on annual average number of canisters/year per patient. Results Overall, 186,061 patients with SABA prescriptions were included, of whom 51% were prescribed high SABA. Total annual average costs (HCRU and medication) were 52% higher in the high- versus low-SABA group (£2,256,091/1,000 versus £1,480,640/1,000 patients/year). Medication costs accounted for the majority of asthma-related costs. Across both groups, most HCRU costs were for non– exacerbation-related primary care/hospital outpatient visits. The annual average HCRU cost difference for high- versus low-SABA was greatest for hospitalisations (+230%; £15,521/1,000 versus £4,697/1,000 patients/year) and exacerbation-related primary care visits (+162%; £18,770/1,000 versus £7,160/1,000 patients/year). Asthma-related HCRU extrapolated to the broader UK asthma population was £108.5 million/year higher with high- versus low-SABA. Conclusion High- versus low-SABA prescriptions are associated with higher asthma-related HCRU costs. [ABSTRACT FROM AUTHOR]

Purpose: Osteoarthritis (OA) is a chronic painful condition that often affects large joints such as the knee. Treatment guidelines recommend paracetamol, nonsteroidal anti‐inflammatory drugs (NSAIDs), and opioids. Antidepressants and anti‐epileptic drugs (AEDs) are commonly prescribed for chronic noncancer pain conditions including OA, as an off‐label use. This study describes analgesic utilization in patients with knee OA at population level using standard pharmaco‐epidemiological methods. Method: This was a cross‐sectional study between 2000 and 2014 using data from the U.K. Clinical Practice Research Datalink (CPRD). The use of antidepressants, AEDs, opioids, NSAIDs, and paracetamol was studied in adults with knee OA using the following measures: annual number of prescriptions, defined daily doses (DDD), oral morphine equivalent dose (OMEQ), and days' supply. Results: In total, there were 8,944,381 prescriptions prescribed for 117,637 patients with knee OA during the 15‐year period. There was a steady increase in the prescribing of all drug classes, except for NSAIDs, over the study period. Opioids were the most prevalent class prescribed in every study year. Tramadol was the most commonly prescribed opioid, with the number of DDD increasing from 0.11 to 0.71 DDDs per 1000 registrants in 2000 and 2014, respectively. The largest increase in prescribing was for AEDs, where the number of prescriptions increased from 2 to 11 per 1000 CPRD registrants. Conclusion: There was an overall increase in the prescribing of analgesics apart from NSAIDs. Opioids were the most frequently prescribed class; however, the greatest increase in prescribing between 2000 and 2014 was observed in AEDs. [ABSTRACT FROM AUTHOR]

Background: Overprescription of short-acting beta-agonist (SABA) inhalers and blood eosinophil count have strong associations with exacerbation risk in asthma. However, in the authors' recent publication only a minority of patients overprescribed SABA (=6 inhalers in 12 months) were eosinophilic (=0.3 x 109 cells/l). Aim: To compare the characteristics of eosinophilic and non-eosinophilic patients with asthma overprescribed SABA inhalers, and identify latent classes using clinical variables available in primary care. Design & setting: Cross-sectional analysis of patients with asthma in North East London, England, using primary care electronic health record data. Method: Unadjusted and adjusted multi-variate regression models and latent class analysis. Results: Eosinophilia was significantly less likely in female patients (P = 0.004), those with multiple mental health comorbidities (P<0.001), and those with SABA on repeat prescription (P<0.001). Latent class analysis identified the following three classes of patients overprescribed SABA: class 1, which represents classical uncontrolled asthma (oral steroids required for exacerbations, step 2-3 asthma medications, high probability of being eosinophilic); class 2, which represents mild asthma (low exacerbation frequency, low asthma medication step, low probability of being eosinophilic); and class 3, which represents difficult asthma (high exacerbation frequency despite high-strength preventer inhalers, low probability of being eosinophilic). The mild asthma class was the largest. Conclusion: Many patients being overprescribed SABA were non-eosinophilic with a low exacerbation frequency, suggesting disproportionately high SABA prescription compared with other asthma control markers. Potential reasons for high SABA prescription in these patients included repeat prescription (being dispensed but not taken) and use of SABA for non-asthma breathlessness (for example, breathing pattern disorders with anxiety). Further research is needed into management of SABA overuse in patients without other markers of uncontrolled asthma. [ABSTRACT FROM AUTHOR]

Prescribing safely for refugees and asylum seekers presents a unique set of challenges. This article discusses some of the issues that need to be addressed, including removing barriers to medicine access and ensuring continuity of care, and outlines the work of the Refugee and Asylum Seeker Service at the Alliance for Better Care. [ABSTRACT FROM AUTHOR]

Background: Inhaler shortages were reported in the UK following declaration of the COVID-19 pandemic, prompting advice against stockpiling. Aim: To understand experiences and behaviours of patients with asthma requesting prescriptions from primary care during asthma medication shortages. Design & setting: UK asthma online community, between March and December 2020. Method: Thematic analysis of posts identified using search terms 'shortage', 'out of stock', 'prescribe', and 'prescription'. Results: Sixty-seven participants were identified (48 adults, two children, 17 unstated age). Factors leading to increased requests included the following: stockpiling; early ordering; realising inhalers were out of date; and doctors prescribing multiple medication items. Patients' anxieties that could lead to stockpiling included the following: fear of asthma attacks leading to admission and acquiring COVID-19 in hospital; lack of dose counters on some inhalers; and believing a lower amount of drug is delivered in the last actuations. Strategies adopted in relation to shortages or changes in treatment owing to out-of-stock medications included the following: starting stockpiling; ordering prescriptions early; contacting medical professionals for advice or alternative prescriptions; getting 'emergency prescriptions'; ordering online or privately; seeking medications in different pharmacies; contacting drug manufacturers; and keeping track of number of doses left in canisters. No evidence was found of anxiety-triggered asthma symptoms that required medications due to fear of COVID-19. Participants seemed to disregard advice against stockpiling. Conclusion: Better preparation is a key lesson from the COVID-19 pandemic. Clinicians, the pharmaceutical industry, and policymakers should use insights from this work to plan how to better manage medication shortages in future emergency situations. [ABSTRACT FROM AUTHOR]

Aims: To investigate the risk of cardiovascular disease (CVD) events and all‐cause mortality in patients with statin‐related adverse drug reaction (ADR) consultation in primary care and examine whether different treatments following the ADR affect subsequent outcomes. Methods: This was a retrospective cohort study of statin users between 2004 and 2019 using IQVIA Medical Research Data (formally known as the THIN database). Patients with statin‐related ADR consultation were matched by propensity score (1:1) to statin users without ADR consultation based on demographics, comorbidities and concomitant medication. Cox proportional hazard regression was used to compare the risk of subsequent CVD event and all‐cause mortality, stratified by history of CVD. In the secondary analysis among patients with statin‐related ADR, treatment changes within a 1‐year period following the ADR were examined and the outcomes were compared between different treatment groups. Results: Among 1 564 687 statin users, 19 035 (1.22%) had a statin‐related ADR consultation in primary care. The mean (standard deviation) follow‐up time was 6.32 (3.74) years and 5.31 (3.83) years for CVD primary and secondary prevention cohorts, respectively. Statin‐related ADR consultation was associated with subsequent CVD events in both cohorts (adjusted hazard ratio [HR] of 1.39 [95% CI 1.23, 1.57] and 1.34 [95% CI 1.25,1.42], respectively). In the secondary analysis among patients with statin‐related ADR consultation, we found that (i) continued statin prescription or combination of any statin with additional lipid‐lowering treatment (LLT) and (ii) other LLT only were associated with lower risks of CVD event (adjusted HR 0.71 [95% CI 0.64, 0.78] and 0.75 [95% CI 0.62, 0.92], respectively) and all‐cause mortality (adjusted HR 0.46 [95% CI 0.42, 0.50] and 0.52 [95% CI, 0.43, 0.64], respectively), compared to discontinuation of all LLT. Conclusion: Statin‐related ADR was associated with an increased risk of subsequent CVD event, indicating that these patients should be monitored more closely. Continued lipid‐lowering medication is of importance to protect against CVD events and mortality. [ABSTRACT FROM AUTHOR]

Objective: Around half of women do not take adjuvant endocrine therapy (AET) as prescribed. Research suggests that adherence rates vary across ethnic groups. This study compared AET adherences rates in White British women and women from minority ethnic groups in the United Kingdom. Methods: This is an observational study with 2001 breast cancer survivors recruited from outpatient clinics. Eligible women were diagnosed with primary breast cancer and prescribed AET within the last 3 years. Adherence was measured using the Medication Adherence Rating Scale. Eligible women were asked to complete a questionnaire pack that collected sociodemographic data such as age, relationship status and ethnicity. Independent samples t tests and χ2 tests were used to compare White British women and women from minority ethnic groups on self‐reported adherence to AET. Results: Of White British women, 27.8% were classed as non‐adherent, compared to 44.4% of women from minority ethnic groups. A logistic regression controlling for relevant demographics indicated that women from minority ethnic groups had a significantly higher risk of non‐adherence than women who were White British (odds ratio = 1.50, p = 0.03) Conclusion: Rates of non‐adherence to AET are higher in women from minority ethnic groups, which may contribute towards racial disparities in breast cancer outcomes. Research with larger and more diverse samples is needed to explore this further and to investigate the psychosocial factors driving differences in adherence. [ABSTRACT FROM AUTHOR]

Background Studies report an increased risk of self-harm or suicide in people prescribed mirtazapine compared with other antidepressants. Objectives To compare the risk of serious sel-fharm in people prescribed mirtazapine versus other antidepressants as second-line treatments. Design and setting Cohort study using anonymised English primary care electronic health records, hospital admission data and mortality data with study window 1 January 2005 to 30 November 2018. Participants 24 516 people diagnosed with depression, aged 18-99 years, initially prescribed a selective serotonin reuptake inhibitor (SSRI) and then prescribed mirtazapine, a different SSRI, amitriptyline or venlafaxine. Main outcome measures Hospitalisation or death due to deliberate self-harm. Age--sex standardised rates were calculated and survival analyses were performed using inverse probability of treatment weighting to account for baseline covariates. Results Standardised rates of serious self-harm ranged from 3.8/1000 person-years (amitriptyline) to 14.1/1000 person-years (mirtazapine). After weighting, the risk of serious self-harm did not differ significantly between the mirtazapine group and the SSRI or venlafaxine groups (HRs (95% CI) 1.18 (0.84 to 1.65) and 0.85 (0.51 to 1.41) respectively). The risk was significantly higher in the mirtazapine than the amitriptyline group (3.04 (1.36 to 6.79)) but was attenuated after adjusting for dose. Conclusions There was no evidence for a difference in risk between mirtazapine and SSRIs or venlafaxine after accounting for baseline characteristics. The higher risk in the mirtazapine versus the amitriptyline group might reflect residual confounding if amitriptyline is avoided in people considered at risk of self-harm. Clinical implications Addressing baseline risk factors and careful monitoring might improve outcomes for people at risk of serious self-harm. [ABSTRACT FROM AUTHOR]

Liver transplantation (LT) is a major surgical undertaking but, in a carefully selected population, it provides excellent outcomes in terms of prolongation of life and improvements in quality of life. This article outlines the processes of referral, assessment, operative course and post-transplant complications of LT, in the UK context. Specific consideration is also given to immunosuppressive medications and considerations around their prescription. The role of the advanced clinical practitioner (ACP) in primary or secondary care may focus on identifying potential candidates for transplantation and ensuring timely discussion and referral. Thus, a familiarity with eligibility criteria, and where to access this information, is important for all ACPs. Additionally, the increasing numbers of transplants performed in the UK mean that there is a large population of post-transplant patients in the wider community. These patients may present to healthcare services with a variety of issues relating to their LT, where early recognition and treatment has the potential to have major impacts on patient, or graft, function and longevity. Due to this, early discussions with specialist transplant centres is advised. [ABSTRACT FROM AUTHOR]

Evidence on therapeutic interventions and factors driving treatment intensification (TI) in people with incident depression in UK are scarce. To explore antidepressant prescribing patterns and factors influencing TI. and setting: Retrospective cohort study of adults with incident depression diagnosed between 2006 and 2017 using UK primary care database. Patterns of antidepressant prescriptions, and factors influencing TI were evaluated by sex. In 931,302 people with depression (90% initiating antidepressants), mean age was 39 years, 41% were male, 14% had cardiometabolic multimorbidity (CMM), and 54% were diagnosed at < 40 years. Being the most prescribed first-line antidepressant (62%), SSRI prescribing rate increased from 66 per 1000 person-years to 170 per 1000 person-years; 24% (2% dose escalation, 4% adding, 18% switching) of first-line antidepressant initiators intensified with 13 months median time to TI. Compared to 60–70 years, younger adults had significantly higher TI risk (range of hazards ratio, HR: 1.08–1.42). CMM and anxiety were associated with 15–24% and 39–49% significantly higher TI risks respectively. First-line antidepressant and deprivation status influenced TI differently by gender. Men and women with depression in UK have different antidepressant prescription patterns in real-world. Age at diagnosis, deprivation status and cardiometabolic multimorbidity are the major sociodemographic and non-psychiatric risk factors for therapeutic changes. [ABSTRACT FROM AUTHOR]

This article is a practical guide to using the British National Formulary (BNF) and BNF for Children (BNFC) App more effectively, to support safe prescribing. It provides a brief overview of app layout and navigation. Features that support safe prescribing are then explored, focusing on drug monographs and the Interactions Checker tool; examples are used for illustration. Location of information that is particularly relevant to prescribers is highlighted. The BNF app provides prescribers with fast, convenient access to validated, current information. However, it may need to be supplemented by other sources, and knowledge is only one element of the competencies needed to be a safe, effective prescriber. [ABSTRACT FROM AUTHOR]

This paper, based on the author's winning presentation at the BDNG Annual Conference in 2021, considers the flammability and fire risk posed by emollients. To test different risk factors, the author partnered with a local fire brigade, following a conversation with her firefighter husband, to understand the risks posed by emollient-soaked cloths and to carry out practical experiments to see how these risk factors translated to real-world scenarios. [ABSTRACT FROM AUTHOR]

Background: Potentially inappropriate prescribing (PIP) of asthma bronchodilator inhalers is associated with increased morbidity and mortality. Aim: To evaluate the effectiveness of feedback on the PIP of bronchodilator inhalers. Design and setting: Pragmatic cluster randomised trial involving 235 of 244 (96.3%) GP practices in one Scottish health board. Method: Practices were randomly allocated (1:1 ratio) to individualised feedback (including visualised medication histories for each patient and action-oriented messages) on PIP of bronchodilator inhalers from prescription data; feedback reports were sent in July 2015, February 2016, and August 2016. Controls were sent feedback on an unrelated subject. The primary outcome was the change in the mean number of patients per practice with PIP of bronchodilator inhalers from the baseline period (August 2014–July 2015) until the post-feedback period (February 2016–January 2017), identified through a composite of five individual measures using prescription data. Results: In the analysis of the primary outcome, the mean number of patients with PIP of bronchodilator inhalers fell in the 118 practices that were sent feedback from 21.8 per practice to 17.7 per practice. Numbers fell marginally in the 115 control practices, from 20.5 per practice to 20.2 per practice, with a statistically significant difference between the two groups. There were 3.7 fewer patients per practice with PIP of bronchodilator inhalers in the intervention practices versus the control practices (95% confidence interval = −5.3 to −2.0). Conclusion: Individualised feedback of PIP of asthma bronchodilators that included background information, visualised medication histories for each patient, and action-oriented messages was effective at reducing the number of patients exposed to excess or unsafe prescribing of bronchodilator inhalers. [ABSTRACT FROM AUTHOR]

Background: Little is known about trends in prescribing of anxiolytics (antidepressants, benzodiazepines, beta-blockers, anticonvulsants, and antipsychotics) for treatment of anxiety. Several changes may have affected prescribing in recent years, including changes in clinical guidance.Aim: To examine trends in prescribing for anxiety in UK primary care between 2003 and 2018.Design and Setting: A population-based cohort study using Clinical Practice Research Datalink (CPRD) data.Method: Analysis of data from adults (n = 2 569 153) registered at CPRD practices between 2003 and 2018. Prevalence and incidence rates were calculated for prescriptions of any anxiolytic and also for each drug class. Treatment duration was also examined.Results: Between 2003 and 2018, prevalence of any anxiolytic prescription increased from 24.9/1000 person-years-at-risk (PYAR) to 43.6/1000 PYAR, driven by increases in those starting treatment, rather than more long-term use. Between 2003 and 2006, incidence of any anxiolytic prescription decreased from 12.8/1000 PYAR to 10.0/1000 PYAR; after which incidence rose to 13.1/1000 PYAR in 2018. Similar trends were seen for antidepressant prescriptions. Incident beta-blocker prescribing increased over the 16 years, whereas incident benzodiazepine prescriptions decreased. Long-term prescribing of benzodiazepines declined, yet 44% of prescriptions in 2017 were longer than the recommended 4 weeks. Incident prescriptions in each drug class have risen substantially in young adults in recent years.Conclusion: Recent increases in incident prescribing, especially in young adults, may reflect better detection of anxiety, increasing acceptability of medication, or an earlier unmet need. However, some prescribing is not based on robust evidence of effectiveness, may contradict guidelines, and there is limited evidence on the overall impact associated with taking antidepressants long term. As such, there may be unintended harm. [ABSTRACT FROM AUTHOR]

Aim: To gain a greater understanding of the methods used by podiatric surgeons to access medicines in the UK. Within that, it is also relevant to establish the range and quantity of medicines utilised to support patient care. With the advent of independent prescribing for podiatrists, the authors were keen to identify whether prescribing was being adopted by a sub-speciality of the podiatry profession and whether alternate means of accessing medicines, such as Patient Group Directions or exemptions remain relevant in clinical practice. Methods: The PASCOM 10 system was accessed to generate reports for the 2019 calendar year relating to podiatric surgery. The following reports were requested; procedures, fixations, anaesthesia, demographics, medications, post-treatment sequelae, patient satisfaction (PSQ-10), Manchester Oxford foot/ankle questionnaire (MOXFQ), providers and referrals. Results: In 2019 there were 11189 admissions for podiatric surgery in England recorded on the PASCOM 10 database. A total of 103 surgery centres contributed data resulting in 18497 procedures. Care was primarily offered in NHS settings accounting for 91% of activity, 94% of these procedures were performed under a local anaesthetic block. 18576 medicines were supplied, administered or prescribed from a list of 70 individual items. 29% of all medicines were prescribed by a podiatrist. Controlled drugs accounted for 28.7% of all recorded medicines. Conclusions: Through analysis of PASCOM 10 data, the range of medicines accessed by podiatric surgeons and their teams to support patient care perioperatively and the routes of accessing these medicines have been identified. Encouragingly, independent prescribing appears to be a frequent choice for accessing certain medicines. There is thorough evidence of a need for greater prescribing rights. Of note, it appears the management of postoperative pain could be improved with wider access to controlled drugs, namely opioid analgesics. PASCOM-10 has the capacity to provide revealing data on prescribing in podiatric clinical practice that is unique in the UK, though more work is required to ensure the validity of the dataset. [ABSTRACT FROM AUTHOR]

Objectives: Explore the design, delivery and assessment of UK non-medical prescriber (NMP) programmes, and how they prepare prescribers for practice. This was to fill the current gap in knowledge around the specific educational approaches used to train NMPs. Methods: A qualitative research design was utilised and 16 programme directors from UK NMP programmes were interviewed through the online Zoom app. Results: These were organised into five major themes: taught content (pertaining to prescribing knowledge, safety, communication and continuing professional development); assessment methods of the programme; aims, objectives and goals of the programme; critical appraisals of programme leads on educational approaches and; improving the programme for future cohorts. Conclusions: Consideration should be given to adapting the teaching and assessment approaches highlighted by programme leads, particularly towards more interactive, simulated and blended learning approaches. [ABSTRACT FROM AUTHOR]

Background Most patients with mental illness are managed in primary care, yet there is a lack of data exploring potential prescribing safety issues in this setting for this population. Objectives Examine the prevalence of, between-practice variation in, and patient and practice-level risk factors for, 18 mental health-related potentially hazardous prescribing indicators and four inadequate medication monitoring indicators in UK primary care. Method Cross-sectional analyses of routinely collected electronic health records from 361 practices contributing to Clinical Practice Research Datalink GOLD database. The proportion of patients 'at risk' (based on an existing diagnosis, medication, age and/or sex) triggering each indicator and composite indicator was calculated. To examine between-practice variation, intraclass correlation coefficient (ICC) and median OR (MOR) were estimated using two-level logistic regression models. The relationship between patient and practice characteristics and risk of triggering composites including 16 of the 18 prescribing indicators and four monitoring indicators were assessed using multilevel logistic regression. Results 9.4% of patients 'at risk' (151 469 of 1 611 129) triggered at least one potentially hazardous prescribing indicator; between practices this ranged from 3.2% to 24.1% (ICC 0.03, MOR 1.22). For inadequate monitoring, 90.2% of patients 'at risk' (38 671 of 42 879) triggered at least one indicator; between practices this ranged from 33.3% to 100% (ICC 0.26, MOR 2.86). Patients aged 35-44, females and those receiving more than 10 repeat prescriptions were at greatest risk of triggering a prescribing indicator. Patients aged less than 25, females and those with one or no repeat prescription were at greatest risk of triggering a monitoring indicator. Conclusion Potentially hazardous prescribing and inadequate medication monitoring commonly affect patients with mental illness in primary care, with marked between-practice variation for some indicators. These findings support health providers to identify improvement targets and inform development of improvement efforts to reduce medication-related harm. [ABSTRACT FROM AUTHOR]

Background: Research on sickness absence has typically focussed on single diagnoses, despite increasing recognition that long-term health conditions are highly multimorbid and clusters comprising coexisting mental and physical conditions are associated with poorer clinical and functional outcomes. The digitisation of sickness certification in the UK offers an opportunity to address sickness absence in a large primary care population. Methods: Lambeth Datanet is a primary care database which collects individual-level data on general practitioner consultations, prescriptions, Quality and Outcomes Framework diagnostic data, sickness certification (fit note receipt) and demographic information (including age, gender, self-identified ethnicity, and truncated postcode). We analysed 326 415 people's records covering a 40-month period from January 2014 to April 2017. Results: We found significant variation in multimorbidity by demographic variables, most notably by self-defined ethnicity. Multimorbid health conditions were associated with increased fit note receipt. Comorbid depression had the largest impact on first fit note receipt, more than any other comorbid diagnoses. Highest rates of first fit note receipt after adjustment for demographics were for comorbid epilepsy and rheumatoid arthritis (HR 4.69; 95% CI 1.73–12.68), followed by epilepsy and depression (HR 4.19; 95% CI 3.60–4.87), chronic pain and depression (HR 4.14; 95% CI 3.69–4.65), cardiac condition and depression (HR 4.08; 95% CI 3.36–4.95). Conclusions: Our results show striking variation in multimorbid conditions by gender, deprivation and ethnicity, and highlight the importance of multimorbidity, in particular comorbid depression, as a leading cause of disability among working-age adults. [ABSTRACT FROM AUTHOR]

BACKGROUND Several antihypertensive drugs are available for the primary prevention of cardiovascular disease (CVD). However, existing evidence on prescription patterns was primarily generated among patients at high CVD risk with short-term follow-up, and failed to capture impacts of time and patient characteristics. Our objective was therefore to describe longitudinal prescription patterns for antihypertensive drugs for the primary prevention of CVD among patients with arterial hypertension in the United Kingdom. METHODS This population-based cohort study used data from the Clinical Practice Research Datalink, included 660,545 patients with hypertension who initiated an antihypertensive drug between 1998 and 2018. Antihypertensive treatments were measured by drug class and described overall and in subgroups, focusing on first-line therapy (first antihypertensive drug(s) recorded after a diagnosis of hypertension) and second-line therapy (antihypertensive drug(s) prescribed as part of a treatment change following first-line therapy). RESULTS Angiotensin-converting enzyme (ACE) inhibitors (29.0%), thiazide diuretics (22.1%), and calcium-channel blockers (CCBs) (21.0%) were the most prescribed first-line therapies. ACE inhibitors have been increasingly prescribed as first-line therapy since 2001. Men were more likely to be prescribed ACE inhibitors than women (43.5% vs. 32.1%; difference: 11.4%; 95% confidence interval [CI], 11.0%–11.8%), and Black patients were more likely to be prescribed CCBs than White patients (63.6% vs. 37.0%; difference: 26.6%; 95% CI, 24.8%–28.4%). CONCLUSIONS Antihypertensive prescription patterns for the primary prevention of CVD among patients with hypertension are consistent with treatment guidelines that were in place during the study period, providing reassurance regarding the use of evidence-based prescribing. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to investigate the association between oral anticoagulant type (direct oral anticoagulants (DOACs) vs vitamin K antagonists (VKAs)) and incident dementia or mild cognitive impairment (MCI) among patients with newly diagnosed atrial fibrillation (AF).Methods: Using linked electronic health record (EHR) data from the Clinical Practice Research Datalink in the UK, we conducted a historical cohort study among first-time oral anticoagulant users with incident non-valvular AF diagnosed from 2012 to 2018. We compared the incidence of (1) clinically coded dementia and (2) MCI between patients prescribed VKAs and DOACs using Cox proportional hazards regression models, with age as the underlying timescale, accounting for calendar time and time on treatment, sociodemographic and lifestyle factors, clinical comorbidities and medications.Results: Of 39 200 first-time oral anticoagulant users (44.6% female, median age 76 years, IQR 68-83), 20 687 (53%) were prescribed a VKA and 18 513 (47%) a DOAC at baseline. Overall, 1258 patients (3.2%) had GP-recorded incident dementia, incidence rate 16.5 per 1000 person-years. DOAC treatment for AF was associated with a 16% reduction in dementia diagnosis compared with VKA treatment in the whole cohort (adjusted HR 0.84, 95% CI: 0.73 to 0.98) and with a 26% reduction in incident MCI (adjusted HR 0.74, 95% CI: 0.65 to 0.84). Findings were similar across various sensitivity analyses.Conclusions: Incident EHR-recorded dementia and MCI were less common among patients prescribed DOACs for new AF compared with those prescribed VKAs. [ABSTRACT FROM AUTHOR]

Purpose: Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) may be treated with surgical mesh devices; evidence of their long-term complications is lacking. Patients and Methods: Rates of diagnoses of depression, anxiety or self-harm (composite measure) and sexual dysfunction, and rates of prescriptions for antibiotics and opioids were estimated in women with and without mesh surgery, with a diagnostic SUI/POP code, registered in the Clinical Practice Research Datalink (CPRD) gold database. Results: There were 220,544 women eligible for inclusion; 74% (n = 162,687) had SUI, 37% (n = 82,123) had POP, and 11% (n = 24,266) had both. Women undergoing mesh surgery for SUI or POP had about 1.1 times higher rates of antibiotic use. Women with no previous history of the outcome, who underwent mesh surgery had 2.43 (95% CI 2.19– 2.70) and 1.47 (95% CI 1.19– 1.81) times higher rates of depression, anxiety, or self-harm, 1.88 (95% CI 1.50– 2.36) and 1.64 (95% CI 1.02– 2.63) times higher rates of sexual dysfunction and 1.40 (95% CI 1.26– 1.56) and 1.23 (95% CI 1.01– 1.49) times higher opioid use for SUI and POP, respectively. Women with a history of depression, anxiety and self-harm had 0.3 times lower rates of these outcomes with SUI or POP mesh surgery (HR for SUI 0.70 (95% CI 0.67-0.73), HR for POP 0.72 (95% CI 0.65-0.79)). Women with a history of opioid use who had POP mesh surgery had about 0.09 times lower rates (HR 0.91 (95% CI 0.86– 0.96)) of prescriptions. Negative control outcome analyses showed no evidence of an association between asthma consultations and mesh surgery in women with POP, but the rate was 0.09 times lower (HR 0.91 (95% CI 0.87– 0.94)) in women with SUI mesh surgery, suggesting that study results are subject to some residual confounding. Conclusion: Mesh surgery was associated with poor mental and sexual health outcomes, alongside increased opioid and antibiotic use, in women with no history of these outcomes and improved mental health, and lower opioid use, in women with a previous history of these outcomes. Although our results suggest an influence of residual confounding, careful consideration of the benefits and risk of mesh surgery for women with SUI or POP on an individual basis is required. [ABSTRACT FROM AUTHOR]

Aim: To investigate factors associated with delays in receiving glucose‐lowering therapy in patients newly diagnosed with type 2 diabetes mellitus (T2DM), and explore the preferential order and time of intensifications. Materials and Methods: Retrospective cohort study including 120 409 adults with T2DM initiating first‐ to fourth‐line glucose‐lowering therapy in primary care between 2000 and 2018, using the UK Clinical Practice Research Datalink linked to Hospital Episode Statistics, Office of National Statistics death registration, and 2007 Index of Multiple Deprivation data. Associations were investigated using time‐to‐event analysis. Results: The longest delays to prescription of first‐line therapy were observed in older patients, of black or other ethnicities, and with multimorbidity. People from the most deprived areas received earlier first‐line treatment than those from the least deprived areas. The majority were treated with metformin (82.4%) as the first‐line prescription, sulphonylurea (50.4%) as second‐line, dipeptidyl peptidase‐4 inhibitor (27.7%) as third‐line, and insulin (28.0%) as fourth‐line. In the past 5 years, there was an increase in prescriptions of dipeptidyl peptidase‐4‐inhibitor and sodium‐glucose transport protein‐2 inhibitor. The median time was 0.5 years for first‐line prescription, 4.1 for second‐line, 4.6 for third‐line and 4.7 for fourth‐line. After T2DM diagnosis, 25% of patients developed cardiovascular disease and non‐cardiovascular disease complications within a median time of 12‐14 years, and received intensification 5‐6 years later. Conclusions: Within the complex challenges of managing blood glucose levels and risk of additional comorbidities, future health care research and guidelines should focus on overcoming therapeutic inertia particularly at an earlier stage for older patients, from ethnic minorities and with multimorbidities. [ABSTRACT FROM AUTHOR]

It is unknown how sequential drug patterns convey information on a patient's health status and treatment guidelines rarely account for this. Drug-agnostic longitudinal analyses of prescription trajectories in a population-wide setting are needed. In this cohort study, we used 24 years of data (1.1 billion prescriptions) from the Danish prescription registry to model the risk of sequentially redeeming a drug after another. Drug pairs were used to build multistep longitudinal prescription trajectories. These were subsequently used to stratify patients and calculate survival hazard ratios between the stratified groups. The similarity between prescription histories was used to determine individuals' best treatment option. Over the course of 122 million person-years of observation, we identified 9 million common prescription trajectories and demonstrated their predictive power using hypertension as a case. Among patients treated with agents acting on the renin-angiotensin system we identified four groups: patients prescribed angiotensin converting enzyme (ACE) inhibitor without change, angiotensin receptor blockers (ARBs) without change, ACE with posterior change to ARB, and ARB posteriorly changed to ACE. In an adjusted time-to-event analysis, individuals treated with ACE compared to those treated with ARB had lower survival probability (hazard ratio, 0.73 [95% CI, 0.64–0.82]; P < 1 × 10−16). Replication in UK Biobank data showed the same trends. Prescription trajectories can provide novel insights into how individuals' drug use change over time, identify suboptimal or futile prescriptions and suggest initial treatments different from first line therapies. Observations of this kind may also be important when updating treatment guidelines. [ABSTRACT FROM AUTHOR]

Our study aimed to describe levothyroxine prescription patterns and trends over time among pregnant women with subclinical hypothyroidism (SCH) in the United Kingdom. We used data from the Clinical Practice Research Datalink linked to its Pregnancy Register and the Hospital Episode Statistics database from 1998 to 2017. The study population included women with a diagnosis of SCH or an abnormal thyroid-simulated hormone (TSH) level one year prior to or during pregnancy. We compared characteristics between women who received a prescription for levothyroxine during pregnancy and those who did not. We further described the timing, dose, duration, and temporal trends of levothyroxine prescriptions. Our cohort included 6,757 pregnancies from 6,287 women with SCH, of whom 10% received levothyroxine during pregnancy. Among women who received levothyroxine, most received their first prescription during the first trimester (median gestational age: 7 weeks; interquartile range [IQR]: 0, 16) with a median daily dosage of 50 mcg (IQR: 50, 73). Levothyroxine prescription varied over time, decreasing from 23% of pregnant women in 1998 to 7.5% in 2003, remaining stable until 2014, and increasing to 12.5% in 2016. Smoking, diabetes, polycystic ovary syndrome, infertility, timing of SCH diagnosis, age, TSH level at diagnosis, and general practice regions were associated with prescription. Few women with SCH received levothyroxine during pregnancy, and treatment varied by patient characteristics and geographical regions. These results highlight the need to increase awareness among healthcare providers and will guide future studies that explore barriers to initiating levothyroxine treatment for women with SCH during pregnancy. [ABSTRACT FROM AUTHOR]

Background: Delayed (or "backup") antibiotic prescription, where the patient is given a prescription but advised to delay initiating antibiotics, has been shown to be effective in reducing antibiotic use in primary care. However, this strategy is not widely used in the United Kingdom. This study aimed to identify factors influencing preferences among the UK public for delayed prescription, and understand their relative importance, to help increase appropriate use of this prescribing option.Methods and Findings: We conducted an online choice experiment in 2 UK general population samples: adults and parents of children under 18 years. Respondents were presented with 12 scenarios in which they, or their child, might need antibiotics for a respiratory tract infection (RTI) and asked to choose either an immediate or a delayed prescription. Scenarios were described by 7 attributes. Data were collected between November 2018 and February 2019. Respondent preferences were modelled using mixed-effects logistic regression. The survey was completed by 802 adults and 801 parents (75% of those who opened the survey). The samples reflected the UK population in age, sex, ethnicity, and country of residence. The most important determinant of respondent choice was symptom severity, especially for cough-related symptoms. In the adult sample, the probability of choosing delayed prescription was 0.53 (95% confidence interval (CI) 0.50 to 0.56, p < 0.001) for a chesty cough and runny nose compared to 0.30 (0.28 to 0.33, p < 0.001) for a chesty cough with fever, 0.47 (0.44 to 0.50, p < 0.001) for sore throat with swollen glands, and 0.37 (0.34 to 0.39, p < 0.001) for sore throat, swollen glands, and fever. Respondents were less likely to choose delayed prescription with increasing duration of illness (odds ratio (OR) 0.94 (0.92 to 0.96, p < 0.001)). Probabilities of choosing delayed prescription were similar for parents considering treatment for a child (44% of choices versus 42% for adults, p = 0.04). However, parents differed from the adult sample in showing a more marked reduction in choice of the delayed prescription with increasing duration of illness (OR 0.83 (0.80 to 0.87) versus 0.94 (0.92 to 0.96) for adults, p for heterogeneity p < 0.001) and a smaller effect of disruption of usual activities (OR 0.96 (0.95 to 0.97) versus 0.93 (0.92 to 0.94) for adults, p for heterogeneity p < 0.001). Females were more likely to choose a delayed prescription than males for minor symptoms, particularly minor cough (probability 0.62 (0.58 to 0.66, p < 0.001) for females and 0.45 (0.41 to 0.48, p < 0.001) for males). Older people, those with a good understanding of antibiotics, and those who had not used antibiotics recently showed similar patterns of preferences. Study limitations include its hypothetical nature, which may not reflect real-life behaviour; the absence of a "no prescription" option; and the possibility that study respondents may not represent the views of population groups who are typically underrepresented in online surveys.Conclusions: This study found that delayed prescription appears to be an acceptable approach to reducing antibiotic consumption. Certain groups appear to be more amenable to delayed prescription, suggesting particular opportunities for increased use of this strategy. Prescribing choices for sore throat may need additional explanation to ensure patient acceptance, and parents in particular may benefit from reassurance about the usual duration of these illnesses. [ABSTRACT FROM AUTHOR]

Aim: To investigate the association between proton pump inhibitors (PPIs) and both all‐cause and cause‐specific mortality. Methods: We conducted a cohort study using the UK Clinical Practice Research Datalink GOLD database. We compared 733 885 new users of PPIs to 124 410 new users of H2 receptor antagonists (H2Ras). In a secondary analysis we compared 689 602 PPI new users to 1 361 245 nonusers of acid suppression therapy matched on age, sex and calendar year. Hazard ratios for all‐cause and cause‐specific mortality were estimated using propensity score (PS) weighted Cox models. Results: PPI prescription was associated with increased risk of all‐cause mortality, with hazard ratios decreasing considerably by increasing adjustment (unadjusted hazard ratio [HR] 1.65, 95% confidence interval [CI] 1.62‐1.69; PS‐weighted HR 1.38, 95% CI 1.33‐1.44; high‐dimensional PS‐weighted HR 1.31, 95% CI 1.26‐1.37). Short‐term associations were observed with mortality from causes where a causal short‐term association is unexpected (eg, lung cancer mortality: PS‐weighted HR at 6 months 1.77, 95% CI 1.39‐2.25). Adjusted hazard ratios were substantially higher when compared to nonusers (PS‐weighted HR all‐cause mortality 1.96, 95% CI 1.94‐1.99) rather than H2RA users. Conclusions: PPI prescription was strongly associated with all‐cause and cause‐specific mortality. However, the change in hazard ratios (a) by increasing adjustment and (b) between comparator groups indicates that residual confounding is likely to explain the association between poor health outcomes and PPI use, and fully accounting for this using observational data may not be possible. [ABSTRACT FROM AUTHOR]

We explored potential differences in time trends of gabapentinoid prescription and of opioid coprescription between 1993 and 2017 in the 4 UK nations using the Clinical Practice Research Datalink, a UK primary care database. There were distinct trends in annual rates of new gabapentin and pregabalin prescriptions in Northern Ireland. The rate of new gabapentin prescriptions rapidly increased after 2010 and exceeded that of the other nations by 2017 (rate of 836 [95% confidence interval: 787–887] per 100 000 person‐years). Additionally, the rate of new pregabalin prescriptions was higher during the entire study period, reaching a peak of 1139 (95% confidence interval: 1088‐1193) per 100 000 person‐years in 2010, 5‐fold higher than the other nations. Findings in Northern Ireland may be partly attributable to the high burden of anxiety disorders, an indication for pregabalin. Further exploration of reasons for discrepancies in gabapentinoid prescribing between UK nations is warranted. [ABSTRACT FROM AUTHOR]

Background: Many men receive 5-alpha reductase inhibitors (5ARIs) for ongoing treatment of benign prostatic hyperplasia (BPH). The increased risk of cardiovascular complications with 5ARIs has been documented in BPH studies and the occurrence of cerebral venous thrombosis, presumably due to increased estrogen level following 5ARI use, was described in multiple case reports. The objective of this study was to determine if 5ARIs with or without alpha blockers (AB) were associated with an increased risk of venous thromboembolism (VTE) in males with BPH. Methods: We conducted a nested case–control study among a population of men ages 40– 79 who received at least one 5ARI or AB prescription for treatment of BPH between 1995 and 2015 in the UK-based Clinical Practice Research Datalink GOLD. Cases of incident VTE (pulmonary embolism [PE] or deep venous thrombosis [DVT]) and matched controls were identified from this population. We used descriptive analyses and conditional logistic regression to evaluate the risk of VTE in users of 5ARIs compared to users of ABs. Results: For 5ARI only users, the adjusted odds ratios (aORs), (95% CI) for VTE were 1.51 (0.98– 2.32) in current 5ARI users and 1.23 (0.70– 2.17) in recent/distant past, compared to AB only users. However, the aOR (95% CI) in men who had 50 or more current 5ARI prescriptions compared to users of ABs only was higher: 2.29 (1.14– 4.63). For 5ARI with AB use, the aORs, (95% CI) for VTE were 1.16 (0.64– 2.10) in current 5ARI+AB users and 1.93 (0.71– 5.25) in recent/distant past, compared to AB only users. The aOR (95% CI) in men who had 50 or more current 5ARI+AB prescriptions compared to users of ABs only was 1.65 (0.64– 4.26). Conclusion: Current use of 5ARI, particularly long-term use, is associated with an increased risk of incident idiopathic VTE compared to patients treated with AB use only. [ABSTRACT FROM AUTHOR]

Aims: Pharmacogenetics (PGx) in the UK is currently implemented in secondary care for a small group of high‐risk medicines. However, most prescribing takes place in primary care, with a large group of medicines influenced by commonly occurring genetic variations. The goal of this study is to quantitatively estimate the volumes of medicines impacted by implementation of a population‐level, pre‐emptive pharmacogenetic screening programme for nine genes related to medicines frequently dispensed in primary care in 2019. Methods: A large community pharmacy database was analysed to estimate the national incidence of first prescriptions for 56 PGx drugs used in the UK for the period 1 January–31 December 2019. These estimated prescription volumes were combined with phenotype frequency data to estimate the occurrence of actionable drug–gene interactions (DGI) in daily practice in community pharmacies. Results: In between 19.1 and 21.1% (n = 5 233 353–5 780 595) of all new prescriptions for 56 drugs (n = 27 411 288 new prescriptions/year), an actionable drug–gene interaction (DGI) was present according to the guidelines of the Dutch Pharmacogenetics Working Group and/or the Clinical Pharmacogenetics Implementation Consortium. In these cases, the DGI would result in either increased monitoring, guarding against a maximum ceiling dose or an optional or immediate drug/dose change. An immediate dose adjustment or change in drug regimen accounted for 8.6–9.1% (n = 2 354 058–2 500 283) of these prescriptions. Conclusions: Actionable drug–gene interactions frequently occur in UK primary care, with a large opportunity to optimise prescribing. [ABSTRACT FROM AUTHOR]

Medical education has historically relied on high stakes knowledge tests sat in examination centres with invigilators monitoring academic malpractice. The COVID-19 pandemic has made such examination formats impossible, and medical educators have explored the use of online assessments as a potential replacement. This shift has in turn led to fears that the change in format or academic malpractice might lead to considerably higher attainment scores on online assessment with no underlying improvement in student competence. Here, we present an analysis of 8092 sittings of the Prescribing Safety Assessment (PSA), an assessment designed to test the prescribing skills of final year medical students in the UK. In-person assessments for the PSA were cancelled partway through the academic year 2020, with 6048 sittings delivered in an offline, traditionally invigilated format, and then 2044 sittings delivered in an online, webcam invigilated format. A comparison (able to detect very small effects) showed no attainment gap between online (M = 0.762, SD = 0.34) and offline (M = 0.761, SD = 0.34) performance. The finding suggests that the transition to online assessment does not affect student performance. The findings should increase confidence in the use of online testing in high-stakes assessment. [ABSTRACT FROM AUTHOR]

Background: Quality improvement (QI) initiatives are increasingly used to improve the quality of care and reduce prescribing errors. The Royal College of General Practitioners (RCGP) and Clinical Practice Research Datalink (CPRD) QI initiative uses routinely collected electronic primary care data to provide bespoke practice-level reports on prescribing safety. The aim of this study was to explore how the QI reports were used, barriers and facilitators to use, long-term culture change and perceived impact on patient care and practices systems as a result of receiving the reports.Methods: A qualitative study using purposive sampling of practices contributing to the CPRD, semi-structured interviews and inductive thematic analysis. We interviewed general practitioners, pharmacists, practice managers and research nurses.Results: We conducted 18 interviews, and organised themes summarising the use of QI reports in practice: receiving the report, facilitators and barriers to acting upon the reports, acting upon the report, and how the reports contribute to a quality culture. Effective dissemination of reports, and a positive attitude to audit and the perceived relevance of the clinical topic facilitated use. Lack of time and failure to see or act upon the reports meant they were not used. Factors influencing use of the reports included the structure of the report, ease of identifying cases, and perceptions about coding accuracy. GPs and pharmacists used the reports to conduct case reviews and directly contact patients to discuss unsafe prescribing and patient medication preferences. Finally, the reports contributed to the development of a quality culture within practices through promoting audit activity and acting as a reminder of good prescribing behaviours, promoting future patient safety initiatives, contributing to continuing professional development and improving local networks.Conclusions: This study found the reports facilitated individual case review leading to an enhanced sense of quality culture in practices where they were utilised. Our findings demonstrate that the reports were generally considered useful and have been used to support patient safety and clinical practice in specific cases. [ABSTRACT FROM AUTHOR]

Background: Guideline‐recommended antiemetic prophylaxis improves nausea and vomiting control in most patients undergoing chemotherapy. Multinational Association of Supportive Care in Cancer/European Society for Medical Oncology (MASCC/ESMO) antiemetic guidelines recommend prophylaxis with a neurokinin‐1 receptor antagonist (NK1RA), a 5‐hydroxytryptamine‐3 receptor antagonist (5‐HT3RA), and dexamethasone for patients receiving highly emetogenic chemotherapy (HEC), including anthracycline‐cyclophosphamide (AC)‐ and carboplatin (considered moderately emetogenic chemotherapy)‐based chemotherapy. Here, we analyze the use of NK1RA–5‐HT3RA–dexamethasone for antiemetic prophylaxis associated with HEC and carboplatin. Methods: The data source was the Global Oncology Monitor (Ipsos Healthcare). Geographically representative physicians from France, Germany, Italy, Spain, and the U.K. were screened for treatment involvement and number of patients treated per month. Patients' data from January to December 2018 were collected from medical charts and extrapolated on the basis of the total number of physicians who prescribe chemotherapy. The emetic risk of chemotherapy was classified per MASCC/ESMO guidelines. Results: Data from 45,324 chemotherapy‐treated patients were collected, representing a total extrapolated prevalence of 1,394,848 chemotherapy treatments included in the analysis. NK1RAs were used in 45%, 42%, and 19% of patients receiving cisplatin‐, AC‐, and carboplatin‐based chemotherapy, respectively; 18%, 24%, and 7% received the guideline‐recommended NK1RA–5‐HT3RA–dexamethasone combination; no antiemetics were prescribed for 12% of the treatments. Often, physicians' perception of the emetic risk of chemotherapy did not follow MASCC/ESMO guideline classification. Conclusion: Low adherence to antiemetic guidelines was revealed in clinical practice in five European countries, with 15% of all HEC‐/carboplatin‐based treatments receiving guideline‐recommended NK1RA–5‐HT3RA–dexamethasone prophylaxis and 12% of them receiving no antiemetics. New strategies for improving guideline adherence are urgently needed. Implications for Practice: Despite recent advances in antiemetic therapy, a substantial proportion of patients experience nausea and vomiting associated with chemotherapy in daily clinical practice. Antiemetic guidelines aim at prevention of chemotherapy‐induced nausea and vomiting (CINV), and guideline‐consistent antiemetic therapy can effectively prevent vomiting and, to a lesser extent, nausea in most patients with cancer. This study reports low adherence to antiemetic guidelines in the highly emetogenic chemotherapy setting in daily clinical practice across five European countries. Opportunity exists to increase adherence to antiemetic guideline recommendations. Implementation of strategies to facilitate guideline adherence can potentially improve CINV control. Adherence to antiemetic guidelines is associated with improved control of chemotherapy‐induced nausea and vomiting. This article analyzes the use of guideline‐recommended NK1RA‐based regimens for antiemetic prophylaxis of highly emetogenic chemotherapy and carboplatin regimens in real‐world clinical practice across Europe. [ABSTRACT FROM AUTHOR]

A literature review was conducted to ascertain the historical and current use of the terms 'compliance,' 'adherence' and 'concordance' in relation to prescribing. Although there is agreement that compliance is not appropriate in the context of patient behaviour, it is still used. The implications for clinician-patient relationship and engagement are considered. The competencies that guide prescribing practitioners in the United Kingdom embrace concepts of adherence and concordance but do not mention 'compliance'. Caution is given against changing vocabulary only. [ABSTRACT FROM AUTHOR]