Background: Outcomes-based education in the health professions has emerged as a priority for curriculum planners striving to align with societal needs. However, many struggle with effective methods...

The CanMEDS initiative: implementing an outcomes-based framework of physician competencies

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Treating TB in people with HIV

A lively debate in the final plenary at last year’s Royal College of General Practitioners (RCGP) Annual Primary Care Conference considered the provocation: ‘My Doctor Makes Me Sick — what can we do about it?’. The event was run by the Heseltine Institute for Public Policy & Practice at Liverpool University, in conjunction with Mersey Faculty and the RCGP. It followed on from a public debate ‘My doctor makes me sick’ held in Liverpool at the opening of the conference. The audience were invited to propose solutions to current concerns about overmedicalisation, treatment burden, and over- and under-diagnosis. Two of the final eight proposals related to reducing prescribing. GPs called for incentives not to use medicines and for deprescribing; both seen as necessary to support the individually-tailored care that GPs and patients1 seek. But GPs have described needing help in tailoring prescribing to individual needs, particularly when individual needs may appear to be at odds with the ‘ideal’ described by guidelines for best practice.2 So how can we help professionals and patients tackle a problem of perceived overprescribing and problematic polypharmacy?

Solutions to problematic polypharmacy: learning from the expertise of patients.

Shared decision-making is increasingly advocated as an ideal model of treatment decision-making in the medical encounter. To date, the concept has been rather poorly and loosely defined. This paper attempts to provide greater conceptual clarity about shared treatment decision-making, identify some key characteristics of this model, and discuss measurement issues. The particular decision-making context that we focus on is potentially life threatening illnesses, where there are important decisions to be made at key points in the disease process, and several treatment options exist with different possible outcomes and substantial uncertainty. We suggest as key characteristics of shared decision-making (1) that at least two participants-physician and patient be involved; (2) that both parties share information; (3) that both parties take steps to build a consensus about the preferred treatment; and (4) that an agreement is reached on the treatment to implement. Some challenges to measuring shared decision-making are discussed as well as potential benefits of a shared decision-making model for both physicians and patients.

Shared Decision-making in the Medical Encounter: What Does It Mean? (Or, It Takes at Least Two to Tango)

OBJECTIVE: To systematically review empirical evidence on the prevalence and nature of medication administration errors (MAEs) in health care settings. DATA SOURCES: Ten electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, Scopus, Applied Social Sciences Index and Abstracts, PsycINFO, Cochrane Reviews and Trials, British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, and Health Management Information Consortium) were searched (1985-May 2012). STUDY SELECTION AND DATA EXTRACTION: English-language publications reporting MAE data using the direct observation method were included, providing an error rate could be determined. Reference lists of all included articles were screened for additional studies. DATA SYNTHESIS: In all, 91 unique studies were included. The median error rate (interquartile range) was 19.6% (8.6-28.3%) of total opportunities for error including wrong-time errors and 8.0% (5.1-10.9%) without timing errors, when each dose could be considered only correct or incorrect. The median rate of error when more than 1 error could be counted per dose was 25.6% (20.8-41.7%) and 20.7% (9.7-30.3%), excluding wrong-time errors. A higher median MAE rate was observed for the intravenous route (53.3% excluding timing errors (IQR 26.6-57.9%)) compared to when all administration routes were studied (20.1%; 9.0-24.6%), where each dose could accumulate more than one error. Studies consistently reported wrong time, omission, and wrong dosage among the 3 most common MAE subtypes. Common medication groups associated with MAEs were those affecting nutrition and blood, gastrointestinal system, cardiovascular system, central nervous system, and antiinfectives. Medication administration error rates varied greatly as a product of differing medication error definitions, data collection methods, and settings of included studies. Although MAEs remained a common occurrence in health care settings throughout the time covered by this review, potential targets for intervention to minimize MAEs were identified. CONCLUSIONS: Future research should attend to the wide methodological inconsistencies between studies to gain a greater measure of comparability to help guide any forthcoming interventions.

Prevalence and Nature of Medication Administration Errors in Health Care Settings: A Systematic Review of Direct Observational Evidence

Medicines use reviews (MURs), introduced into the new community pharmacy contract as an advanced service in April 2005, are intended to be structured, concordance-centred reviews with patients receiving medicines for long-term conditions to establish a picture of their use of the medicines — both prescribed and nonprescribed. Evaluation of the MUR service has identified the training and development needs of pharmacists, the attitudes of pharmacists towards the MUR service, and barriers and facilitators to MURs. Identified barriers to performing MURs include a lack of marketing of potential benefits to patients and GPs, and the perception that the public may be concerned that MURs may encroach on the responsibilities of GPs. Other GP-related barriers include variability in the level of awareness of MURs among GPs, the format in which the MUR information is provided to GPs, GPs’ perception of commercial versus professional drivers for the pharmacist, and GPs’ uncertainty of the value of MURs to patient care. As a supplement to a wider study into MUR outcomes regarding prescribed medication and pharmacists’ views and attitudes towards MURs, we opportunistically surveyed a small sample of GPs located within Cornwall and Isles of Scilly Primary Care Trust to explore their perceptions of MURs. The PCT has a population of about 500,000 and has 70 GP practices (323 partners) and 88 community pharmacies. At the time of this survey, 57 pharmacies were undertaking MURs and 5,398 MURs had been conducted between April 2006 and March 2007.

General practitioners' perceptions of medicines use reviews by pharmacists

Medicines use reviews (MURs), introduced as part of the advanced service of the new pharmacy contract in England, are structured, concordance-centred reviews with patients receiving medicines for longterm conditions to establish a picture of their use of medicines, both prescribed and nonprescribed. Although this service creates an opportunity to explore patients’ experiences with a view to improving their knowledge and use of medicines, little is known about the impact and value of MURs. Pharmacists’ involvement in the medication review process has been tested in a number of randomised controlled trials. In general these have shown that clinical medication review by pharmacists with specific training and with full access to all relevant information shows some positive findings such as identification and resolution of medication-related problems and a reduction in prescribing costs. However, other studies, in which pharmacists had access to limited clinical data, have demonstrated that such clinical medication reviews do not seem to translate into measurable benefits to patients or health services, leading to questions over the value of pharmacist-led medication reviews and in particular the MUR service. Despite being an advanced service of the pharmacy contract, there is little evidence to support their effectiveness and their value for money. Indeed research has identified specific challenges associated with MURs. These include GPs’ poor reception of the MUR service and paperwork, the commercial pressure to undertake MURs as perceived by some pharmacists, and the lack of confidence that pharmacists may experience in conducting MURs. In addition, previous work has suggested that patients’ experiences of a more specific type of medication review were not always as positive as they could have been. We report the findings of a small scale study that aimed to quantify the effect of MURs on GPs’ prescribing and, using a nested qualitative study, explore pharmacists’ perceptions of the impact of MURs on patients, thus allowing us to match a provider perspective of MURs against routinely collected prescribing data. In doing so we aim to establish how pharmacists’ beliefs and expectations relate to GP prescribing practices for a target group of patients with or at risk of coronary heart disease (CHD). CHD is a national priority. The average pharmacy is expected to have 122 people with angina and 24 people each year needing treatment following a heart attack. Patients with CHD are potentially at risk of suboptimal adherence to their medicines and may be viewed as a group of patients for whom there are opportunities to discuss and improve concordance issues.These risk factors arise for a number of reasons. Patients may be started on multiple medicines all at once after suffering a myocardial infarction. They may be taking multiple medicines, and/or medicines that require strict dosage instructions (which may affect compliance — eg, nitrates and statins), or patients may have limited understanding of why they are taking their medicines. To better understand the impact of MURs on patients with CHD we aimed to quantify the effect on GP prescribing for patients who have undergone such a review. Although we know that GPs have concerns over the MUR service, we know little of pharmacists’ perceptions of this service. Therefore we also explored community pharmacists’ perceptions of MURs and its impact on patients. It was expected that for patients with CHD any recommendations arising from the MUR process and communicated to the GP would mainly be concerned with improving the ease with which patients are able to take their medicines.We also expected there would be some clinical issues relayed to the GP relating to identification of drug therapy problems.

What do pharmacists think of MURs and do they change prescribed medication

shown elsewhere that old age, poor survival, DHA of residence, and place of death were all positively associated with DCO registration.3 All the studies Gulliford cites have used the Thames cancer registry as the sampling frame for studies of case notes and all exclude DCO cases from their sample. Our second concern relates to the use of cancer registry data for health services research. National Health Service (NHS) purchasers are now funding registries directly; we consider it essential that the reliability and the validity of registry data be confirmed before these are used as a basis for needs assessment, service outcomes, and provision. Registry data cannot be used when they are inaccurate or incomplete. In a previous paper we have shown that part of the problem lies with the incompleteness of clinical notes,9 and in that paper we chose to focus on quality control within the registry. Gulliford asks how we assessed the reliability of our own data abstraction. Before beginning work, the two doctors who carried out the abstraction liaised with registry staff to confirm the criteria used when coding date of diagnosis, stage, and treatment. Data were abstracted on each set of case notes by the two doctors separately and checked for interobserver bias. Further checks took place at clinical audit meetings with surgeons and pathologists when cases with absent or discordant information was audited. All of this is described in a previous work cited in our paper.9 We regret the ambiguity in the abstract which could be taken to mean that the registry had data on treatment for DCO cases. However, the background and methods sections make clear that the registry definition of DCO cases was the one followed in this study. References to disagreements involving DCO cases in the abstract would be better described as disagreements involving DCO cases for which we subsequently retrieved clinical data. DCO cases are important because their exclusion from the sample can bias measurements of treatment and survival. In other papers we have attempted to measure the impact of DCO cases on national survival and the effect of losing them.3 10 In conclusion may we identify what we take to be the strengths of our paper? Our objective was to identify factors in the registration process affecting reliability. We showed error in three areas in which the registry has explicit written policies: the retrospective follow up ofDCO cases, six-month active follow up of cases, and the coding criteria for date of diagnosis. The registry has responded positively to this audit and to our recommendations for improving the internal quality of registry data. ALLYSON M POLLOCK NEIL VICKERS Department of Public Health Sciences, St George's Hospital Medical School, Cranmer Terrace, London SW17 ORE

https://qualitysafety.bmj.com/content/qhc/5/2/121.1.full.pdf

Medication errors during hospital drug rounds.

Objectives To explore existing mechanism to ensure quality assurance of medicine use reviews (MURs), and to identify those parameters of an MUR that community pharmacists consider as indicators of quality. Setting Community pharmacists undertaking MURs in Cornwall, United Kingdom. Method A questionnaire was developed to investigate pharmacists’ attitudes towards MURs and towards quality assurance of MURs. Questionnaires were distributed during December 2008 to a sample of pharmacists in Cornwall accredited to provide the service. Main outcome measures Community pharmacists’ attitudes towards quality assurance of MURs. Results Fifty completed questionnaires were returned, a third of which were from locum pharmacists. The most frequently reported determinant for undertaking an MUR was the pharmacist’s judgement. Company policy to deliver MURs was acknowledged as a potential indicator of a sub-optimal MUR. Pharmacists shared a common sense of what constitutes a “poor” MUR but not what defines a quality one. Conclusion For peer review to operate as an effective mechanism to assure quality of MURs, pharmacists need to develop an effective forum to share their practice experiences.

Community pharmacists’ perceptions of medicines use reviews and quality assurance by peer review

Background Antipsychotic medications are used among 19%-58% of adults with intellectual disabilities to manage challenging behaviour against the NICE guideline recommendations. Studies show that it is possible to completely withdraw antipsychotics in about one third of adults with intellectual disabilities and a dose reduction of 50% or more in another third. Method In Cornwall, over three years the present authors developed a structured pathway to withdraw antipsychotics among adults with intellectual disabilities which involved people with intellectual disabilities and their carers, GPs, community learning disability team members and pharmacists. Results The present authors managed to withdraw antipsychotics totally among 46.5% (33/71) and reduced over 50% of dosage in another 11.3% (8/71) of adults with intellectual disabilities. At three months follow-up no one required hospital admission or change in placement. Conclusion It is possible to withdraw/reduce antipsychotics in a high proportion of adults with intellectual disabilities if a concerted effort is made involving all stakeholders from the outset.

Michael Wilcock

Papers

General practitioners' perceptions of medicines use reviews by pharmacists

What do pharmacists think of MURs and do they change prescribed medication

Medication errors during hospital drug rounds.

Community pharmacists’ perceptions of medicines use reviews and quality assurance by peer review

A structured programme to withdraw antipsychotics among adults with intellectual disabilities: The Cornwall experience