This is the first exploration of service providers' attitudes and beliefs of quality and quality improvement in the community pharmacy setting in the UK.
A series of interviews and focus groups was ...conducted with stakeholders from the pharmacy profession in the UK. Interviews were semi-structured and conducted face-to-face or by telephone. Focus groups were conducted with naturally-occurring groups i.e. at pharmacy conferences. Interviews and focus groups were audio-recorded, transcribed and analysed systematically using an interpretive approach.
Forty-two individuals participated across four focus groups and four interviews. A maximum variation sample was achieved in terms of pharmacist and pharmacy characteristics. Participants were generally positive about the need for quality and quality improvement and provided multifaceted and interlinked interpretations of quality and acknowledged its dynamic nature "quality moves forward". The challenge of standardising practice whilst providing person-centred care emerged: "you don't want to lose the personal touch, but you can't have people having a variable experience and one day it's fantastic and the next day it isn't". A variety of quality measurement methods were identified including direct observation (by internal and external agents) and feedback (mystery shoppers, colleagues, regulatory inspectors, service users), suggesting that standardisation was also needed in terms of future quality measurement. There was a tendency to report negative events as triggers for improvement. Future initiatives could adopt more positive approaches including positive deviants "There's nothing more powerful than people who've come up with something really good sharing it with their other colleagues".
The results are being used to develop and evaluate future quality improvement initiatives in this sector. These are likely to be targeted at organisational, team and individual levels.
Klebsiella pneumoniae is a major cause of opportunistic healthcare-associated infections, which are increasingly complicated by the presence of extended-spectrum beta-lactamases (ESBLs) and ...carbapenem resistance. We conducted a year-long prospective surveillance study of K. pneumoniae clinical isolates in hospital patients. Whole-genome sequence (WGS) data reveals a diverse pathogen population, including other species within the K. pneumoniae species complex (18%). Several infections were caused by K. variicola/K. pneumoniae hybrids, one of which shows evidence of nosocomial transmission. A wide range of antimicrobial resistance (AMR) phenotypes are observed, and diverse genetic mechanisms identified (mainly plasmid-borne genes). ESBLs are correlated with presence of other acquired AMR genes (median n = 10). Bacterial genomic features associated with nosocomial onset are ESBLs (OR 2.34, p = 0.015) and rhamnose-positive capsules (OR 3.12, p < 0.001). Virulence plasmid-encoded features (aerobactin, hypermucoidy) are observed at low-prevalence (<3%), mostly in community-onset cases. WGS-confirmed nosocomial transmission is implicated in just 10% of cases, but strongly associated with ESBLs (OR 21, p < 1 × 10
). We estimate 28% risk of onward nosocomial transmission for ESBL-positive strains vs 1.7% for ESBL-negative strains. These data indicate that K. pneumoniae infections in hospitalised patients are due largely to opportunistic infections with diverse strains, with an additional burden from nosocomially-transmitted AMR strains and community-acquired hypervirulent strains.
Oral hypoglycemic agents (OHAs) are highly effective in managing Type 2 diabetes if taken appropriately. This study assessed adherence to OHAs among patients with Type 2 diabetes and explored factors ...associated with adherence behaviour.
Mixed methods were used comprising a cross-sectional study using the Arabic version of the Morisky Medication Adherence Scale followed by semi-structured interviews using the Theoretical Domain Framework to explore key determinants of adherence.
The cross-sectional study included 395 patients of whom 40% achieved a high level of OHA adherence. Lower adherence was associated with younger age (Odds Ratio (OR) 1.084; 95% CI 1.056 to 1.112), higher numbers of non-OHAs (OR 0.848; 95% CI 0.728 to 0.986) and higher HbA1c levels (OR 0.808; 95% CI 0.691 to 0.943). Semi structured interviews based on the Theoretical Domain Framework were completed with 20 patients and identified a wide range of factors potentially associated with OHA adherence, particularly behavioural related factors (e.g. scheduling medication intake, ability to develop a habitual behaviour), social influences (e.g. acting as a role model, the effect of family support), and gaps in knowledge about diabetes and its management with OHAs.
This unique mixed-methods study has highlighted possible reasons for the low levels of OHA adherence in this patient population. Whilst the theoretically-derived determinants of behaviour illustrate the complexities associated with OHA adherence, they also provide a robust underpinning for future intervention(s) development to improve adherence and maximise patient health outcomes.
Aims
This study was designed to evaluate whether survival rates in patients with heart failure (HF) are better than those in patients with diagnoses of the four most common cancers in men and women, ...respectively, in a contemporary primary care cohort in the community in Scotland.
Methods and results
Data were obtained from the Primary Care Clinical Informatics Unit from a database of 1.75 million people registered with 393 general practices in Scotland. Sex‐specific survival modelling was undertaken using Cox proportional hazards models, adjusted for potential confounders. A total of 56 658 subjects were eligible for inclusion in the study. These represented a total of 147 938 person‐years of follow‐up (median follow‐up: 2.04 years). In men, HF (reference group; 5‐year survival: 55.8%) had worse mortality outcomes than prostate cancer hazard ratio (HR) 0.61, 95% confidence interval (CI) 0.57–0.65; 5‐year survival: 68.3%, and bladder cancer (HR 0.88, 95% CI 0.81–0.96; 5‐year survival: 57.3%), but better outcomes than lung cancer (HR 3.86, 95% CI 3.65–4.07; 5‐year survival: 8.4%) and colorectal cancer (HR 1.23, 95% CI 1.16–1.31; 5‐year survival: 48.9%). In women, HF (reference group; 5‐year survival: 49.5%) had worse mortality outcomes than breast cancer (HR 0.55, 95% CI 0.51–0.59; 5‐year survival 77.7%), but better outcomes than colorectal cancer (HR 1.21, 95% CI 1.13–1.29; 5‐year survival 51.5%), lung cancer (HR 3.82, 95% CI 3.60–4.05; 5‐year survival 10.4%), and ovarian cancer (HR 1.98, 95% CI 1.80–2.17; 5‐year survival 38.2%).
Conclusions
Despite advances in management, HF remains as ‘malignant’ as some of the common cancers in both men and women.
Background Anticoagulation for stroke prevention in atrial fibrillation (AF) has, historically, been under-used in older people. The aim of this study was to investigate prescribing of oral ...anticoagulants (OACs) for people aged greater than or equai to 75 years in the UK before and after direct oral anticoagulants (DOACs) became available. Methods A cohort of patients aged greater than or equai to 75 years with a diagnosis of AF was derived from the Clinical Practice Research Datalink (CPRD) between January 1, 2003, and December 27, 2017. Patients were grouped as no OAC, incident OAC (OAC newly prescribed) or prevalent OAC (entered study on OAC). Incidence and point prevalence of OAC prescribing were calculated yearly. The risk of being prescribed an OAC if a co-morbidity was present was calculated; the risk difference (RD) was reported. Kaplan-Meier curves were used to explore persistence with anticoagulation. A Cox regression was used to model persistence with warfarin and DOACs over time. Results The cohort comprised 165,596 patients (66,859 no OAC; 47,916 incident OAC; 50,821 prevalent OAC). Incidence of OAC prescribing increased from 111 per 1000 person-years in 2003 to 587 per 1000 person-years in 2017. Older patients (greater than or equai to 90 years) were 40% less likely to receive an OAC (RD -0.40, 95% CI -0.41 to -0.39) than younger individuals (75-84 years). The likelihood of being prescribed an OAC was lower with a history of dementia (RD -0.34, 95% CI -0.35 to -0.33), falls (RD -0.17, 95% CI -0.18 to -0.16), major bleeds (RD -0.17, 95% CI -0.19 to -0.15) and fractures (RD -0.13, 95% CI -0.14 to -0.12). Persistence with warfarin was higher than DOACs in the first year (0-1 year: HR 1.25, 95% CI 1.17-1.33), but this trend reversed by the third year of therapy (HR 0.75, 95% CI 0.63-0.89). Conclusions OAC prescribing for older people with AF has increased; however, substantial disparities persist with age and co-morbidities. Whilst OACs should not be withheld solely due to the risk of falls, these results do not reflect this national guidance. Furthermore, the under-prescribing of OACs for patients with dementia or advancing age may be due to decisions around risk-benefit management. Trial registration EUPAS29923. First registered on: 27/06/2019. Keywords: Older people, Anticoagulant, Atrial fibrillation, Warfarin, Dabigatran, Rivaroxaban, Apixaban, Edoxaban
ObjectivesTo explore the views of professional stakeholders on the future of community pharmacy services in England. Specific objectives related to expectations of how community pharmacy services ...will be provided by 2030 and factors that will influence this.DesignQualitative, using semistructured interviews in person or via telephone/Skype. The topic guide was informed by a recent policy review that used the Walt and Gilson policy framework. Transcripts were analysed using inductive thematic analysis.SettingEngland.ParticipantsExternal stakeholders were representatives of non-pharmacy organisations, including policy-makers, commissioners and representatives of healthcare professions. Internal stakeholders were community pharmacists or pharmacy organisation representatives. Interviewees were identified using stakeholder mappingResultsIn total, 25 interviews were completed (7 external stakeholders and 18 internal stakeholders, of which 10 were community pharmacists). Community pharmacy was recognised as having a key role in expanding health system capacity (‘…pharmacy is the obvious person to take on those roles…’), particularly for long-term condition management (eg, adherence, reducing polypharmacy, monitoring), urgent care (eg, minor illnesses) and public health (including mental health). For these contributions to be developed and optimised, greater integration and collaboration with general practices will be needed (‘…there is no room for isolationism in pharmacy anymore…’), as well as use of technology in a patient-centred way and full access to health records. These changes will require workforce development together with appropriate commissioning and contractual arrangements. Community pharmacy is currently undervalued (‘…the complete misunderstanding by senior Government officials is very scary’) and recent investment in general practice pharmacists rather than community pharmacy was seen as a missed opportunity.ConclusionsCommunity pharmacy as a sector could and should be developed to increase health service capacity to address its current challenges. Numerous modifications are required from a range of stakeholders to create the environment in which these changes can occur.
Objective: Because confessions are sometimes unreliable, it is important to understand how jurors evaluate confession evidence. We conducted a content analysis testing an attribution theory model for ...mock jurors' discussion of coerced confession evidence in determining verdicts. Hypotheses: We tested exploratory hypotheses regarding mock jurors' discussion of attributions and elements of the confession. We expected that jurors' prodefense statements, external attributions (attributing the confession to coercion), and uncontrollable attributions (attributing the confession to defendant naivety) would predict more prodefense than proprosecution case judgments. We also expected that being male, politically conservative, and in support of the death penalty would predict proprosecution statements and internal attributions, which in turn would predict guilty verdicts. Method: Mock jurors (N = 253, Mage = 47 years; 65% women; 88% White, 10% Black, 1% Hispanic, 1% listed "other") read a murder trial synopsis, watched an actual coerced false confession, completed case judgments, and deliberated in juries of up to 12 members. We videotaped, transcribed, and reliably coded deliberations. Results: Most mock jurors (53%) rendered a guilty verdict. Participants made more prodefense than proprosecution statements, more external than internal attributions, and more internal than uncontrollable attributions. Participants infrequently mentioned various elements of the interrogation (police coercion, contamination, promises of leniency, interrogation length) and psychological consequences for the defendant. Proprosecution statements and internal attributions predicted proprosecution case judgments. Women made more prodefense and external attribution statements than men, which in turn predicted diminished guilt. Political conservatives and death penalty proponents made more proprosecution statements and internal attributions than their counterparts, respectively, which in turn predicted greater guilt. Conclusions: Some jurors identified coercive elements of a false confession and rendered external attributions for a defendant's false confession (attributing the confession to the coercive interrogation) during deliberation. However, many jurors made internal attributions, attributing a defendant's false confession to his guilt-attributions that predicted juror and jury inclinations to convict an innocent defendant.
Public Significance Statement
This research highlights internal attributions as a potential underlying psychological determinant of wrongful convictions in cases involving coerced confessions. Researchers and legal practitioners can leverage these findings to improve jurors' evaluation of confession evidence to facilitate justice, particularly for defendants whose actual innocence renders them vulnerable to false confession and wrongful conviction.
ObjectivesDespite widespread availability of evidence-based guidelines to inform rational use of medicines, considerable unwarranted variation exists in prescribing. A greater understanding of key ...determinants of contemporary prescribing in UK general practice could inform strategies to promote evidence-based prescribing. This study explored (1) current influences on prescribing in general practice and (2) the possibility that general practice-based pharmacists (PBPs) may contribute to greater engagement with evidence-based prescribing.DesignSemistructured, telephone interviews and a focus group were conducted, audio-recorded and transcribed verbatim. Thematic analysis was undertaken.ParticipantsGeneral practice prescribers: general practitioners (GPs), PBPs, nurses.Key informants: individuals within the National Health Service (NHS) with responsibility for influencing, monitoring and measuring general practice prescribing.SettingGeneral practices and NHS organisations in England.ResultsInterviews with 17 prescribers (GPs (n=6), PBPs (n=6), nurses (n=5)) and 6 key informants, and one focus group with five key informants were undertaken between November 2018 and April 2019. Determinants operating at individual, practice and societal levels impacted prescribing and guideline use. Prescribers’ professional backgrounds, for example, nursing, pharmacy, patient populations and patient pressure were perceived as substantial influences, as well as media portrayal and public perceptions of medicines.Prescribers identified practice-level determinants of prescribing, including practice culture and shared beliefs. Key informants tended to emphasise higher-level influences, including NHS policies, availability of support and advice from secondary care and generic challenges associated with medicines use, for example, multimorbidity.Participants expressed mixed views about the potential of PBPs to promote evidence-based prescribing in general practice.ConclusionPrescribing in UK general practice is influenced by multiple intersecting factors. Strategies to promote evidence-based prescribing should target modifiable influences at practice and individual levels. Customising strategies for medical and non-medical prescribers may maximise their effectiveness.
Background:
Stigma toward mentally ill individuals acts as a barrier to accessing care and receiving treatment.
Aim:
To review current evidence pertaining to stigma toward mental illness in the ...Middle East in order to inform effective and sustainable interventions in this region.
Methods:
We conducted a systematic literature search using the PubMed database and evaluated all identified studies according to specific inclusion criteria.
Results:
Stigma toward individuals with mental illness does exist in the Middle East. Stigmatizing attitudes are particularly high toward culturally proscribed mental illnesses like alcohol abuse and lower for other disorders such as depression and psychosis.
Conclusions:
We propose the following initiatives to reduce stigma toward mental illness in the Middle East: (a) educate families to enable them to support their affected relatives, (b) increase cooperation between psychiatrists and faith healers and (c) educate young people in schools to increase their awareness and understanding of mental illnesses and to combat negative stereotypes.
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