primary care research in northern ireland: where’s the evidence? carmel m. hughes school of...
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Primary Care Research in Northern Ireland: where’s the
evidence?
Carmel M. Hughes
School of Pharmacy
Queen’s University Belfast
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The view from the Lancet
“There is now widespread acknowledgement of the absence ofa sound evidence base underpinning many of the decisionsmade in primary care.”
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The view from the Cochrane Library
“Higher quality evidence is needed to determine the effectivenessof self-care treatment for acute cough”
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Outline of presentation
• Context
• Evidence for what we do
• Evidence for what we should do
• Challenges in the brave new world of primary care/clinical research
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Two main strands in primary care research
• Community– Community pharmacy– Community pharmacy and general
practice
• Long-term care– Nursing homes for older people
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Methodological approaches
• Randomised controlled trials– Cluster trials
• Qualitative approaches– Exploratory work– To inform development of interventions– To explore more deeply the impact (or
lack thereof) of interventions
• Everything in between– Cross-sectional, case-control
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Evidence for what we do
• Responding to symptoms with over-the-counter medications
• Management of minor ailments– Cluster RCT
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What influences pharmacists when making decisions about OTC
medication?
• Qualitative study involving community pharmacists– Guided by an interview schedule– What products they recommended, factors
influencing recommendations, views on an evidence-based approach to OTC meds
• Interviews transcribed, validated and analysed
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First, do no harm
• Safety was the over-arching consideration when counter prescribing with OTC products
• Refusal to sell a product was never based on effectiveness (perceived) of a product
• Seldom considered evidence– Pharmacists felt uncomfortable discussing
lack of evidence with patients
– Recognised the role of the placebo effect
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Lesser of two evils• Utilise the placebo effect for the
greater good?
• Avoid unnecessary contacts with GP practices?
• Reinforce the concept of community pharmacies as the first point of contact, particularly for minor ailments?
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Re-engineering primary care services
• Cluster RCT– GP practices (n=20) and associated
community pharmacies (n=37)– Intervention GP practices (n=10) referred
patients with upper respiratory tract infections symptoms to pharmacies (n=17) where they were assessed and up to two OTC products were supplied for treatment
– Control GP practices-usual practice– Primary outcome-change in antibiotic
prescribing
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Main findings
• Over 2300 patients recruited• Significant reduction in prescribing of
amoxicillin at 6 months post-intervention in the intervention practices compared to control sites– OR 0.4 (0.23-0.70)– Costs reduced in intervention sites– High levels of support for this kind of
service from patients, GPs, GP support staff and pharmacists
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Evidence for what we should do
• Nursing homes on the periphery of the primary care sector in the UK– Care provided by GPs; medicines
supplied by community pharmacy– Some specialist provision from
geriatric and psychiatric services– General concern over quality of
care provided in this environment
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Lessons from America
• Pharmacists working with doctors to improve the quality of prescribing
• Demonstration project in North Carolina
• Study recently completed in N. Ireland– Cluster RCT in 22 nursing
homes– Pharmacist-led intervention– Main outcome: No. residents
taking one or more inappropriate psychoactive drugs
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Fleetwood approach
1. Screening for high-risk patients2. Medication review3. Resident assessment by the
consultant pharmacist – pharmaceutical care needs
4. Pharmacist intervention and direct communication with the prescriber
5. Formalised pharmaceutical care planning
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Main outcome from FleetwoodAfter one year, the odds of a resident receiving an inappropriate After one year, the odds of a resident receiving an inappropriate psychoactive drug in an intervention home = 0.26 psychoactive drug in an intervention home = 0.26 (95% CI: 0.14, 0.49) compared to a resident in the control (95% CI: 0.14, 0.49) compared to a resident in the control group of homesgroup of homes
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The challenges• Research regulation• Research funding and capacity• Recruitment
– Practitioners and patients• Retention
– Practitioners and patients• Relationships
– Between practitioners and between patients
• Getting evidence into practice
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Brave new world of clinical research in the UK- hindrance or help?
• Regulation– Governance– Ethics
• Clinical Trials Units– Logistical, methodological and
analytical support
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The UK Clinical Research Network was established to
support clinical research and to facilitate the conduct of
trials and other well-designed studies across the UK
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Getting evidence into practice
• Need to influence policy– Research should inform policy
• Need to influence practice– Are practitioners users of research?
If today’s practitioners are to retain their professionalism, clinicians’ information and research appraisal skills need to be improved urgently. Glasziou et al BMJ 2008; 337: 704-705
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Prepare for uncertainty
My students are dismayed when I say to them “Half of what you will be taught will, in 10 years times, have been shown to be wrong. And the trouble is, none of your teachers knows which half”
Dr Sidney BurwellDean of the Harvard Medical School