KEY POINTS By 2046, 1 in 5 Albertans will be 65 years of age or older, and those aged 80 years and older are expected to double within the same time frame.[1][1] Health and social care systems worldwide face considerable challenges to meet the societal and economic demands as more people live longer

KEY POINTSBy 2046, 1 in 5 Albertans will be 65 years of age or older, and those aged 80 years and older are expected to double within the same time frame.[1][1] Health and social care systems worldwide face considerable challenges to meet the societal and economic demands as more people live longer

Residents in care homes are often very frail, have complex medicine regimens and are at high risk of adverse drug events. It has been recommended that one healthcare professional should assume responsibility for their medicines management. We propose that this could be a pharmacist independent prescriber (PIP). This feasibility study aimed to test and refine the service specification and proposed study processes to inform the design and outcome measures of a definitive randomised controlled trial to examine the clinical and cost effectiveness of PIPs working in care homes compared to usual care. Specific objectives included testing processes for participant identification, recruitment and consent and assessing retention rates; determining suitability of outcome measures and data collection processes from care homes and GP practices to inform selection of a primary outcome measure; assessing service and research acceptability; and testing and refining the service specification.Mixed methods (routine data, questionnaires and focus groups/interviews) were used in this non-randomised open feasibility study of a 3-month PIP intervention in care homes for older people. Data were collected at baseline and 3 months. One PIP, trained in service delivery, one GP practice and up to three care homes were recruited at each of four UK locations. For ten eligible residents (≥ 65 years, on at least one regular medication) in each home, the PIP undertook management of medicines, repeat prescription authorisation, referral to other healthcare professionals and staff training. Outcomes (falls, medications, resident's quality of life and activities of daily living, mental state and adverse events) were described at baseline and follow-up and assessed for inclusion in the main study. Participants' views post-intervention were captured in audio-recorded focus groups and semi-structured interviews. Transcripts were thematically analysed.Across the four locations, 44 GP practices and 16 PIPs expressed interest in taking part; all care homes invited agreed to take part. Two thirds of residents approached consented to participate (53/86). Forty residents were recruited (mean age 84 years; 61% (24) were female), and 38 participants remained at 3 months (two died). All GP practices, PIPs and care homes were retained. The number of falls per participating resident was selected as the primary outcome, following assessment of the different outcome measures against predetermined criteria. The chosen secondary outcomes/outcome measures include total falls, drug burden index (DBI), hospitalisations, mortality, activities of daily living (Barthel (proxy)) and quality of life (ED-5Q-5 L (face-to-face and proxy)) and selected items from the STOPP/START guidance that could be assessed without need for clinical judgement. No adverse drug events were reported. The PIP service was generally well received by the majority of stakeholders (care home staff, GPS, residents, relatives and other health care professionals). PIPs reported feeling more confident implementing change following the training but reported challenges accommodating the new service within their existing workload.Implementing a PIP service in care homes is feasible and acceptable to care home residents, staff and clinicians. Findings have informed refinements to the service specification, PIP training, recruitment to the future RCT and the choice of outcomes and outcome measures. The full RCT with internal pilot started in February 2016 and results are expected to be available in mid late 2020.

To evaluate a multi-sectoral training programme for pre-

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

Prescribing medicines for older adults in care homes is known to be sub-optimal. Whilst trials testing interventions to optimise prescribing in this setting have been published, heterogeneity in outcome reporting has hindered comparison of interventions, thus limiting evidence synthesis. The aim of this study was to develop a core outcome set (COS), a list of outcomes which should be measured and reported, as a minimum, for all effectiveness trials involving optimising prescribing in care homes. The COS was developed as part of the Care Homes Independent Pharmacist Prescribing Study (CHIPPS).

In this so-called ‘post-truth era’, the importance of robust evidence has assumed more significance than ever. Healthcare needs to be informed by rigorous research that can underpin practice and healthcare delivery and ultimately improve outcomes for patients. But in the development and implementation of studies that will generate the necessary evidence, what outcomes should be measured? A cursory overview of studies performed in any given area reveals a huge number of outcomes being measured, making evidence synthesis and assessing the overall effectiveness of interventions very difficult. For example, Beuscart et al. undertook a systematic review of trials in medication review in older people, reporting that 327 different outcomes were identified in 47 published studies. There was marked heterogeneity in the outcomes used, with adverse events and patient-related outcomes poorly evaluated. In another field of research, more than 25 000 outcomes had appeared only once or twice in oncology trials. Therefore, in an effort to overcome the issues of range and heterogeneity within outcome selection, the Core Outcome Measures in Effectiveness Trials (COMET) Initiative was established (http://comet-initiative.org/). COMET advocates for the development and application of agreed standardised sets of outcomes known as ‘core outcome sets’ (COSs). A COS represents the minimum that should be measured and reported in all trials of a specific condition or field of research. The COMET website maintains a database of all ongoing and published COS studies to minimise duplication and share examples of good practice. Recently added COS projects include ‘Development of an International Core Outcome Set for Best Care for the Dying Person’, and ‘Development of a provide core domain set for polymyalgia rheumatica’ (http://comet-initiative.org/). Guidance has been provided to help researchers develop a COS in any given area. The essential steps are as follows: (1) establishing the scope of the COS, (2) identifying the existing knowledge, (3) stakeholder involvement and (4) a consensus exercise. Scope refers to the specific area of health or health care to which the COS will apply. It should also consider the health condition, populations and types of interventions covered by the COS. For example, in the case of medicines use in older people, the scope may include all older people or only those who reside in care homes. Furthermore, the focus may include all medications, or only those used in the management of dementia. Identifying existing knowledge requires some form of literature search to establish what outcomes have been measured and reported in previous studies in the area. COS developers will often consult systematic reviews in the area of the COS or may undertake a systematic review to allow them to compile a list of outcomes for potential inclusion in a COS. The third step in COS development is the involvement of key stakeholders. This may include patients and the public, healthcare professionals, regulators, industry representatives and researchers. This list of stakeholders is not exhaustive, and their involvement should be informed by the scope of the COS in question. Stakeholder views, elicited through interviews or focus groups on what should be included in a COS, are essential to ensure that the outcomes selected are meaningful, not just from a clinical and scientific standpoint, but also from a patient’s perspective. Identifying and accessing key patient and public stakeholders can be particularly challenging, but liaising with support groups, patient advocacy groups and/or charities may be a helpful strategy. The fourth and final step in COS development is an exercise, whereby stakeholder views are sought using a consensus method to condense the outcomes suggested in the preceding stages into the final COS. There is no single preferred consensus method, although the Delphi technique has been widely used. This technique is a long-established method that facilitates informed decision-making by obtaining consensus from a range of opinions in areas of research where there is limited information. The Delphi technique can be applied through face-to-face stakeholder panel meetings led by a facilitator or via the completion of questionnaires distributed by post or online, or using a combination of a questionnaire

Rationale, aims and objectives: Intermediate care (IC) describes a range of services targeted at older people, aimed at preventing unnecessary hospitalisation, promoting faster recovery and maximising independence. The introduction of IC has created a new interface between primary and secondary care. Older people are known to be at an increased risk of medication-related problems when transferring between healthcare settings and pharmacists are often not included as part of IC multidisciplinary teams. This study aimed to explore community pharmacists’ (CPs) awareness of IC services and to investigate their views of and attitudes towards the medicines management aspects of such services, including the transfer of medication information. Method: Semi-structured interviews were conducted, recorded, transcribed verbatim and analysed using a constant comparative approach with CPs practising in the vicinity of IC facilities in Northern Ireland, UK. Results: Interviews were conducted with 16 CPs. Three themes were identified and named ‘left out of the loop’, ‘chasing things up’ and ‘closing the loop’. CPs felt that they were often ‘left out of the loop’ with regards to both their involvement with local IC services and communication across the healthcare interfaces. As a result, CPs resorted to ‘chasing things up’ as they had to proactively try to obtain information relating to patients’ medications. CPs viewed themselves as ideally placed to facilitate medicines management across the healthcare interfaces (i.e., ‘closing the loop’), but several barriers to potential services were identified. Conclusion: CPs have limited involvement with IC services. There is a need for improvement of effective communication of patients’ medication information between secondary care, IC and community pharmacy. Increasing CP involvement may contribute to improving continuity of care across such healthcare interfaces, thereby increasing the person-centeredness of service provision.

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

BACKGROUND:Intermediate care (IC) describes a range of services targeted at older people, aimed at preventing unnecessary hospitalisation, promoting faster recovery from illness and maximising independence. Older people are at increased risk of medication-related adverse events, but little is known about the provision of medicines management services in IC facilities. This study aimed to describe the current provision of medicines management services in IC facilities in Northern Ireland (NI) and to explore healthcare workers' (HCWs) and patients' views of, and attitudes towards these services and the IC concept.METHODS:Semi-structured interviews were conducted, recorded, transcribed verbatim and analysed using a constant comparative approach with HCWs and patients from IC facilities in NI.RESULTS:Interviews were conducted with 25 HCWs and 18 patients from 12 IC facilities in NI. Three themes were identified: 'concept and reality', 'setting and supply' and 'responsibility and review'. A mismatch between the concept of IC and the reality was evident. The IC facility setting dictated prescribing responsibilities and the supply of medicines, presenting challenges for HCWs. A lack of a standardised approach to responsibility for the provision of medicines management services including clinical review was identified. Whilst pharmacists were not considered part of the multidisciplinary team, most HCWs recognised a need for their input. Medicines management was not a concern for the majority of IC patients.CONCLUSIONS:Medicines management services are not integral to IC and medicine-related challenges are frequently encountered. Integration of pharmacists into the multidisciplinary team could potentially improve medicines management in IC.

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