The Pharmaceutical Journal
Vol 269 No 7216 p409-414
21 September 2002

This article
Reprint
Photocopy

British Pharmaceutical Conference 2002 summary

Pharmacy practice research

BPC 2002 presentations previewed

With the demise of centrally funded places for branch representatives at the BPC this year there may be fewer practising pharmacists at the research presentations. One aim of this review is therefore to raise awareness of the research being conducted, to encourage pharmacists to identify those abstracts of relevance to their work and to search for them on the website.

The descriptions are brief, and readers are encouraged to refer to the original abstract. The page number of each abstract within the IJPP supplement is given in parentheses.

Community practice

"Pharmacy in the future: implementing the NHS plan" will require many changes in community practice and several papers presented research in that area. A pilot study for a repeat prescribing scheme was investigated in Wiltshire by J. Loader, C. McCarthy, K. Callow and R. Gudgeon (pR11). Many positive outcomes were demonstrated. Increased control over the process led to a reduction in wastage of medicines and associated cost savings. Two areas of the scheme were found to be in need of modification, getting the quantities of as "required medication" correct and managing changes to medication.

A checking technician programme in community pharmacy was evaluated by W. Jones and P. M. Rutter (pR90). They found that exercise is feasible, patient safety is not compromised and the dispensing process became safer. Further research to investigate how the pharmacists working pattern will change is proposed.

A potential role of community pharmacy in the provision of anticoagulant services has been identified by A. Khan and P. M. Rutter (pR50). A survey sent to every primary care trust (PCT), with a response rate of 26 per cent, found that only 2 per cent of them currently involved community pharmacists in anticoagulant services, although 60 per cent said they were about to involve them.

An insight into the provision of diagnostic and screening services provided by community pharmacies found that pregnancy testing still remains the most widely offered service. A. Dhoot and P. M. Rutter (pR51) report that a small number of pharmacies have now begun to offer new diagnostic services such as Helicobacter pylori tests and osteoporosis testing as advances in technology have made these services possible.

The potential contribution of community pharmacists in osteoporosis risk assessment and its management was researched in 25 pharmacies by the Pharmacy Alliance. M. Gray, Z. Rajaei-Dehkordi, M. Ewan and R. Wysocki (pR34) found that patients' knowledge of bone health was increased during the study, as was their daily calcium intake. Patients at high risk of osteoporosis were identified and appropriately managed in the pharmacy or referred to the GP.

A study by S. Cooper, S. Phul and J. A. Cantrill (pR57) has found that advice is given on about one fifth of occasions when NHS prescriptions are presented in pharmacies. Patients using prescription collection services are less likely to receive advice compared with customers presenting their own prescription.

Gaps in the provision of information to individuals beginning courses of antidepressant medication were identified by S. Garfield, F. J. Smith and S. A. Francis (pR59). Adverse drug reactions were the most commonly reported unmet information need. The research suggests that pharmacists should develop services to respond to these information needs.

A gap in appreciating the current role carried out by community pharmacists in nursing homes was identified by Y. Akiya, C. Anderson and A. Avery (pR32), who used in-depth interviews with nurses and pharmacists. They suggest that collaborative work with nurses would enable identification of drug-related problems.

C. Hughes and S. McCann (pR36) used focus groups to investigate barriers to interprofessional working between community pharmacist and GPs in Northern Ireland. The main barriers were the shopkeeper image, access, awareness and hierarchy. They conclude that these barriers must be addressed to improve this key partnership in primary care.

The potential for shifting the demand for consultations for minor ailments from GPs to community pharmacies was investigated through the Direct Supply of Medicines Scheme in two areas in Scotland. E. I. Schafheutle, P. R. Noyce, C. Sheehy and L. Jones (pR63) found that three-quarters of consultations under the scheme involved patients with age-related exemptions; over half being children under 16. Of the non-prescription medicines supplied, over 44 per cent cost £1 or less; the mean net ingredient cost was about £2.

J. Mohammed, J. F. Marriott, C. A. Langley and K. A. Wilson (pR44) used a stratified sample of Birmingham pharmacies to investigate perceptions of the loss of resale price maintenance (RPM). Theme analysis indicated that its removal may have led to changes in community pharmacy, with an increased range of services provided, a decreased sales potential and an increase in the purchase of medicines by patients. The average price data indicates that RPM removal has resulted in little variation in pricing between independent and multiple pharmacies, though supermarket outlets show evidence of targeted discounting.

As part of a systematic review to explore change and innovation in community pharmacy, J. Inch, C. M. Bond, A. M. Grant and A. W. Laing (pR98) have investigated the extent of the impact of information technology in community pharmacy. They predicted further change through a review of experience from the backing and legal sectors. The main theme would be a changed interaction with the customer.

A model for identifying and treating the misuse and abuse of over-the-counter drugs is being tested in eight pharmacies in Belfast. M. Wazaify, J. C. McElnay and C. M. Hughes (pR92) report on the ongoing research that requires pharmacists to identify suspected clients through record-keeping of sales of products liable to misuse. Pharmacists are now recruiting patients into the harm-minimisation phase of the study.

Hospital practice

Several papers presented research into new working practices in hospital pharmacy services. J. Scanlan, A. Stewart, L. Fitzgerald and S. Freeborn (pR76) have measured the impact of pharmacy ward-based teams. Using technicians freed about a third of pharmacists' time to pursue clinical issues. Completion of prescriptions on the ward streamlined the dispensary workload and removed delays in discharge.

Two papers by R. J. Hobson and G. J. Sewell report data from a survey of pharmacist discharge prescription transcription services. Thirty-six per cent of the hospital pharmacy respondents were offering these services. The most common reason given for implementing a transcribing service was to reduce delays in the discharge process (pR62). However they did not have a large impact on the overall number of discharge prescriptions written in hospital (pR12).

One-stop dispensing, an initiative to streamline the supply of medication to patients, was audited in Kent and Canterbury Hospital over a two-week period by S. Jones (pR74). More medication is held on the wards, making storage more of a problem. The cost of failure of the one-stop system is estimated at over £1,000 a week in wasted medication alone.

S. Ansar and J. Silverthorne (pR31) have investigated patients' own drugs (POD) and self-administration of medicines (SAM) schemes in a sample of trusts. POD schemes were in place in 77 per cent and SAM schemes in 48 per cent of responding pharmacies. The authors conclude that extra guidance on implementing such schemes is needed, with minimum standards set for monitoring their effect on patient care.

A structured approach to medication history taking and medication review for older people was the aim of a paper by S. C. Tulip, P. Cheung, D. Campbell and P. Walters (pR58). They found that using a structured approach avoided ill-considered changes to therapy and ensured more accurate therapeutic decisions.

In a study to investigate pharmacist interventions on preregistration house officers' prescribing decisions, M. P. Higgins, J. C. Scanlan and D. Milligan (pR88) found that each cohort of house officers made approximately 45 prescribing decisions that required a pharmacist intervention in each one-week sampling period.

Primary care

The number of pharmacists working in GP practices is increasing and three papers presented aspects of their work. S. Evans, J. Taylor and R. Walker (pR79) describe the impact of implementing a pharmacist-led temazepam withdrawal programme. The practice reduced its prescribing from being ranked second of 35 practices in the locality to 15th by the end of the 12-month programme.

A pharmacist-led hypertension drug use review in a Gloucestershire practice, described by S. Braybrook, J. Thomas, P. S. Wilkin, W. Haynes and D. Conaty (pR20), has resulted in improved control of hypertension and optimised prescribing costs.

The question of knowing whether second medication reviews identify important clinical problems was investigated by D. R. Petty, P. Knapp, D. K. Raynor, A. Z. Zermansky and N. Freemantle (pR70). After eight months patients on four or more medicines received more interventions than those on fewer than four but the proportion was reduced. The authors conclude that subsequent review, as suggested in the National Service Framework for Older People, is warranted.

Workforce issues

Employers struggling to maintain adequate levels of pharmacist staff will be pleased to note that researchers are addressing the problem. In a review of the labour market from 1991 to 2001, K. Hassell, P. Shann and R. Fisher (pR27) report that workforce shortages were common in the two main employment markets. Numbers in community pharmacy have increased by 8 per cent compared with an overall growth on the register of 20 per cent; women represent over half of the workforce and 18 per cent of the pharmaceutical register is aged over 60. Of the entire register 11 per cent have an overseas registered address, with 76 per cent of these having trained in the UK.

R. Mullen, K. Hassell and P. R. Noyce (pR91) used a postal survey of primary care pharmacists to provide an insight into workforce mobility. Hospital pharmacists are more likely to leave that sector completely to pursue a career in primary care whereas community pharmacists are more likely to take on roles in primary care in addition to their community pharmacy base. Thus the impact would be greater in the hospital sector.

A survey to identify whether community pharmacists are prepared to work extended opening hours was conducted by S. Saini, C. A. Langley, J. F. Marriott and K. A. Wilson (pR45) among a 5 percent cross-sectional sample of the Royal Pharmaceutical Society's membership. Around one fifth of community pharmacy respondents believed that patients should have access to at least one community pharmacy 24 hours a day, but only 3.4 per cent were prepared to work at any time over a 24 hour period.

P. M. Rutter (pR49) compared four contrasting community pharmacies to determine whether activities associated with pharmaceutical care were affected by prescription volume and/or staffing levels. He found that the physical act of dispensing still accounts for most of a pharmacist's time. Activities associated with pharmaceutical care, such as counselling, communication with other health care workers and counter-prescribing were infrequently performed.

Interprofessional issues

One aim of "Pharmacy in the future: implementing the NHS plan" is to get pharmacists working more flexibly alongside other health professionals. J. N. R. Wilson, M. I. Berr and L. Cope (pR85) investigated the relationship between community pharmacists and GPs in the Sefton area. Pharmacists considered relationships to be poor whereas GPs considered them to be good; both groups agreed that relationships need to be improved. Time restriction was seen as a significant barrier to co-operation. Both groups were in favour of pharmacist development of repeat dispensing schemes, electronic prescribing and shared learning.

C. Bateson, C. Duggan and I. Bates (pR15) used an evidence-based approach to developing and evaluating a standardised method of documenting drug-related information across the health care interface. The study, which is ongoing, has found that providing GPs and community pharmacists with written drug-related information tends towards delaying readmission to hospital.

S. Simpson Prentis, K. Atkin, D. K. Raynor and S. J. Closs (pR14) used semi-structured interviews with GPs, practice nurses and pharmacists to explore their understanding of the term "medicines management". Each respondent viewed medicines management in relation to specific tasks and activities, their own specialist training and in the context of current health priorities. Successful interprofessional work requires reconciling these interpretations.

S. C. Tulip, P. Cheung, D. Campbell and P. Walters (pR93) used focus groups and interviews to seek the views of health care professionals on a proposed pharmaceutical care model for an NHS trust. They found support among all grades of doctors, nurses and pharmacy staff. The main barrier to implementation was perceived to be a lack of resources. Cultural barriers were also identified.

J. Krska and S. Ross (pR86) compared the ability of different health care professionals to review medication in patients aged 75 and over. When GPs receive training and use a similar review process to that used by pharmacists, they are more able to identify pharmaceutical care issues than they could from case note reviews alone. Nurses similarly trained are able to identify some issues. Given limited availability of pharmacist time, the authors suggest that training of GPs and nurses in reviewing medicines should be considered.

Risk management

Medication error has a high profile at the moment and, as might be expected, several papers looked at aspects of dispensing errors. An insight into how errors are perceived by patients is presented by P. J. Bates (pR94). He used a semi-structured interview technique to determine the attitudes of 10 patients who visited a community pharmacy at least once a month. The patients were tolerant of a one-off mistake, provided no harm had resulted, and said they would return to the same pharmacy on the basis of a good service. All the patients checked their own medicines, but doubted that others did the same. They felt that pharmacists should not confuse similar drug names and packaging, because they should know their job well enough. They all thought that mistakes should be recorded for legal reasons.

An unofficial scheme for reporting dispensing errors in NHS hospitals has been in place since 1991. During that time chief pharmacists from 89 hospitals have submitted 7,158 dispensing error reports. Analysing these reports, D. E. Roberts, M. G. Spencer, R. Burfiield and S. Bowden (pR6) record that the most common errors were supply of the wrong drug (23 per cent), the wrong strength (23 per cent), the wrong directions (10 per cent) and the wrong quantity (10 per cent). Factors contributing to the errors were look-alike/sound-alike drug names (33 per cent), high workload/low staffing (23 per cent), inexperienced staff (20 per cent) and transcription (14 per cent). To reduce dispensing errors in NHS hospitals the authors suggest three actions. First, the pharmaceutical industry needs to work closely with health care professionals and regulatory bodies to eradicate risks associated with look-alike/sound-alike drugs and to provide better visual cues on drug strength and identity. Secondly, chief pharmacists must match workload with adequate numbers of experienced staff and use automated dispensing systems where possible. Finally, staff should be made aware of the 10 drugs most likely to be involved in dispensing errors and that transcription is a risk area.

P. Quinlan, D. M. Ashcroft and A. Blenkinsopp (pR68) carried out a baseline survey of dispensing errors over a four-week period in 38 community pharmacies in the West Midlands, using the Royal Pharmaceutical Society's audit documentation. They found a mean error rate of 0.26 per cent, but with a considerable variation in error rates between pharmacies. Half thought that they had underreported errors that had occurred. Of the errors reported, most were classified as a near miss and relatively few reached the patient.

P. Quinlan, D. M. Ashcroft and A. Blenkinsopp (pR67), who looked at prescribing interventions made by the same 38 pharmacies, found the mean intervention rate was 0.69 per cent. Interventions made in 0.08 per cent of prescriptions were classified by the contributing pharmacists as potentially serious to the patient.

Y. F. Chen, K. E. Neil, A. J. Avery and M. E. Dewey (pR29) used data collected from nine community pharmacies in Nottingham during one month to identify potential prescribing problems. Problem reporting rates varied and were highest in the two pharmacies with the lowest dispensing volume. A mean incidence rate of 0.6 per cent was identified. A sample of prescriptions was screened for drug interactions. The authors found that not all potentially hazardous drug combinations were detected by some of the computer systems in community pharmacies and that pharmacists do not always act on triggered alerts. Communication between community pharmacies and GPs was infrequent.

A key factor of clinical governance in addition to risk management is quality improvement. E. M. McGovern, A. Campbell, H. Lindsay, D. A. M. Thomsom and S. M. Bryson (pR8) used a self-audit dispensing module which encouraged audit and reaudit. More than a third of pharmacists in Greater Glasgow participated in locality-based support groups to facilitate change. Intervention was associated with improvement in record keeping, availability of written protocols and aspects of extemporaneous dispensing. The model will be extrapolated to other topics in both community and hospital pharmacy.

Education, training and professional development

Recognising that preregistration trainees have limited clinical skills at the beginning of the postgraduate year, hospital trusts in the South Thames area have been using objective structured clinical examinations (OSCEs) to assess patient-focused competencies. D. McRobbie, G. Fleming, M. Ortner, I. Bates and J. G. Davies (pR7) found that although the training programme significantly improved the competence of the trainees, deficiencies remain in some core skills at the end of the year. These findings have significant implications for employers in relation to their expectations of newly qualified pharmacists. The authors suggest that new graduates should not be working in isolation but should be considered as training grades.

The value of OSCEs during undergraduate training was assessed in a survey of preregistration trainees by P. M. Rutter and D. Brown (pR48). Most respondents felt that the experience of OSCEs had proved beneficial in preparing them for practice. No significant differences of opinion were found between hospital preregistration trainees and their community counterparts.

At a time when the requirement for evidence of continuing professional development (CPD) is being piloted by the Royal Pharmaceutical Society, the findings of the survey conducted by J. M. Attewell, A. Blenkinsopp and P. Black (pR9) are particularly pertinent. Among a purposive sample of 21 community pharmacists practising in Nottingham, few understood and practised the principles of CPD. There was little reported evaluation of learning and many pharmacists were unsure how they could do this. Very few pharmacists had a personal development plan, but over half thought they would be of value. A recurring theme was that pharmacists queried the relevance of CPD once their career had progressed as far as they desired and saw themselves in "maintenance" mode.

A CPD portfolio development toolkit was shown to be a valuable resource to help pharmacists adapt to mandatory portfolio based CPD. G. Thompson (pR75) found that participants attending an introductory CPD evening were engaged in most of the activities that can contribute to CPD and that the toolkit facilitates the production of a reflective commentary of these activities. A key element of facilitation was the availability of examples of documentation of CPD activities based on current issues.

F. Kelly, A. T. Sare, K. A. Williams and S. I. Benrimoj (pR72) used a combination of workshops and onsite training to present a pilot programme to deliver innovative consumer assessment techniques as part of the adoption of flexible protocols for the supply of non-prescription medicines. Greater emphasis was placed on training non-pharmacist staff in recognition of their significant role in this area. Evaluation, by comparison of a test and a control group, has shown increased information provision in the test sites, greater assessment of concurrent medication and improved referral to the pharmacist.

Research to clarify the form and scope of ethics teaching for pharmacy students has been carried out by J. Wingfield, P. Bissell, C. Anderson and S. Sadler (pR97). Respondents in a focus group identified specific ethical dilemmas arising from the supply of emergency hormonal contraception, the sale of homoeopathic products, misuse of medicines, euthanasia, assisted suicide, drug trials and the commercial environment of pharmacy.

Prescribing

Adherence to National Institute for Clinical Excellence guidelines for the prescribing of proton pump inhibitors (PPI) following endoscopic diagnosis was investigated by C. E. Curtis, N. Ford, J. F. Marrriott, K. A. Wilson and C. A. Langley (pR41). In over a third of cases where a diagnosis was sought, none could be determined endoscopically. However, in agreement with guidelines, the lowest possible dose of PPI was followed with maintenance doses prescribed in one quarter of cases overall.

K. Shemilt, R. Airley and C. Clareburt (pR78) investigated the nature and extent to non-adherence to the NICE guidelines for COX-2 selective inhibitors. In a study collecting data in one health centre in Liverpool they found that 77 per cent of patients were not prescribed COX-2 inhibitors according to the guidelines. The study highlights the need for education relating to effective and appropriate prescribing.

Influences on prescribing were researched by K. Åström, C. Duggan and I. Bates (pR10), who surveyed all GPs in two east London primary care trusts. The strongest influencing factors were recommendation by a specialist or peer, guidelines and previous experience with the drug. The weakest factors were visits from drug representatives, advertisements and internet information. GPs agreed and complied with local formularies but they did not use them very much. The influence of pharmaceutical advisers on GPs seemed uncertain.

Indicators of prescribing aim to draw attention to issues that may need investigation. However, H. E. Kendall and S. M. Naisbitt (pR54) have queried whether an improvement in the benzodiazepine prescribing indicator reflects more appropriate prescribing of hypnotics. Lower prescribing of temazepam and nitrazepam was replaced by increased prescribing of the newer hypnotics, with an overall increase in total hypnotic prescribing.

Indicators for the appropriateness of long-term prescribing started during a hospital admission were assessed for content validity by a random sample of clinical hospital and practice pharmacists. N. Javed and M. P. Tully (pR55) have found that the three most important indicators were "indication in discharge summary", "questionable high risk therapeutic combination" and "hazardous drug-drug combination". The three least important indicators were "less suitable for prescribing according the BNF", "indication upheld in the BNF" and "drug in hospital formulary".

The influence of organisational characteristics on the pharmacological management of depression in US nursing homes was examined by C. M. Hughes and K. L. Lapane (pR35). Although overall depression was under-treated, there was a trend towards increased antidepressant use in homes that were part of a chain, were based in a hospital or had an Alzheimer's unit.

Variation in prescribing with socio-economic markers were identified by J. A. Harding and J. C. McElnay (pR16) in two West Midland areas. More items were prescribed in the deprived area, but for less expensive medicines. Similar numbers received aspirin and statins, but fewer additional cardiovascular drugs were used in the deprived area. The authors suggest that this could be a reflection of more concordance in consultation in the affluent area and that changed patient demands of the health care system require further investigation.

A. Offia and R. Walker (pR37) have investigated the validity of the Welsh general practice morbidity database which has been used as the basis for a number of prescribing based studies. They found a marked variation between practices in the completeness of prescribing data in the database and that all previous prescribing studies that have used the database should be interpreted with caution.

N. B. Collins, R. J. Beard, C. A. Candlish and A. J. Worsley (pR24) have developed an assessment tool to inform prescribing of osteoporosis preventative treatment. They conclude that at present there are no systems to verify whether continuation of medication on discharge occurs. Further work to sample prescribing in primary care is planned.

R. Daniszewsi, C. A. Langley, J. F. Marriott, K. A. Wilson, P. Clewes and M. Wilkinson (pR42) have investigated wastage from excess prescribing in the medicines returned to GPs and community pharmacies. Changed or stopped therapy was the reason for return in 56 per cent of cases, with 66 per cent having been prescribed in a quantity of one month or more.

EHC supply

Not surprisingly, the provision of emergency hormonal contraception (EHC) is the subject of several presentations at the conference. P. Bissell and C. Anderson (pR83) developed a semi-covert audit using two trained women researchers who requested EHC from 10 pharmacies that had previously agreed to participate. Although the sample was small, they conclude that in the main the service is being provided appropriately.

E. M. Seston, I. Smith, J. A. Cantrill and K. O'Brien (pR22) tracked the impact of the deregulation of EHC on a patient group direction (PGD) scheme in the north-west of England. Consultation rates under PGD were not affected and continued to rise. Although the PGD is within a health action zone (HAZ), 16 per cent of users of the PGD scheme were from outside the area, which places a financial pressure on the HAZ, which is in effect subsidising other areas.

The attitudes of pharmacists involved in supplying EHC through a PGD were explored by a survey sent to 98 pharmacies in Manchester, Salford and Trafford by E. M. Seston, I. Smith and L. K. Watkins (pR23). Most respondents thought a private room or area was necessary. One cause of dissatisfaction among the pharmacists offering the scheme was lack of personal remuneration.

In a study using a vignette describing a woman requesting EHC, H. Hope, L. Dye, P. Knapp, J. Sowter and D. K. Raynor (pR71) have found the attitudes of GPs, pharmacists and practice nurses towards the supply of EHC are affected by patient characteristics. The three factors that affected attitude were job type, prior use of EHC and marital status. There was a negative attitude towards repeat use of EHC, particularly by a single woman.

An assessment of the knowledge of EHC among women was presented by M. Day, P. Knapp, L. Dye, J. Sowter and D. K. Raynor (pR56), who found that knowledge was good in terms of how to obtain and take, but less good in terms of side effects. The frequency of some side effects was greatly over-estimated and some symptoms wrongly attributed to EHC.

In in-depth interviews, 12 students who had bought EHC from pharmacies in the East Midlands cited access, convenience and confidentiality as key benefits for pharmacy sale. P. Bissell, R. Harness and C. Anderson (pR30) found that four of the 12 students made a decision to engage in unprotected intercourse because they were aware that EHC was available from a pharmacy.

Adverse drug reactions

C. J. Morris, J. A. Cantrill, A. J. Avery and R. L. Howard (pR60) have investigated preventable drug-related morbidity (PRDM) using a Delphi technique to develop a consensus on the 34 indicators for PDRM valid in the UK. They conclude that, although it is easily possible to identify preventable drug-related hospital admissions, identifying the process of care to prevent their occurrence is more challenging.

A comparison of discharge ICD-10 (International Classification of Disease) codes and yellow cards submitted to the Committee on Safety of Medicines from a large teaching hospital found that screening the former produced three times as many reports over the same time period. S. N. Dent, A. R. Cox, J. F. Marriott, C. A. Langley and K. A. Wilson (pR40) found that little overlap existed between cases detected by the two methods, and that both under-reported serious ADRs. This work supports the case for pharmacists to be more involved in reporting ADRs.

Several papers from the Drug Safety Research Unit at Southampton look at the safety profile of rofecoxib. D. Layton, J. Riley, L. Wilton and S. A. W. Shakir (pR13), using a prescription-event monitoring (PEM) study, found that gastrointestinal symptoms, commonly associated with treatment with other non-steroidal anti-inflammatory drugs (NSAIDs), were the most frequently reported adverse event. Difficulty in excluding pre-existing cardiac disease precluded identification of a causal relationship for thromboembolic events. Doctors should continue to prescribe NSAIDs, including COX-2 specific inhibitors, with some caution.

Extending the work from the PEM, E. L. Heeley, D. Layton and S. A. W. Shakir (pR39) used signal generation to investigate the incidence of colitis during rofecoxib treatment. Incidence rate ratios (IRR) were calculated for the event by comparing the incidence in rofecoxib-treated patients with that for the whole database of 77 other drugs and subsequently with four other NSAIDs. From the signal raised it suggests that the incidence of colitis is higher in rofecoxib than in the other groups. However, this may be because rofecoxib is being preferentially prescribed to patients with pre-existing colitis, because the more traditional NSAIDS are known to exacerbate colitis.

A specific comparison of rofecoxib with meloxicam using data from the PEM has found a significant reduction in the incidence of symptomatic ulcers but no difference in the incidence of complicated ulcers in users of rofecoxib. D. Layton, E. Heeley, K. Hughes and S. A. W. Shakir (pR5) found a non-linear relationship between age and risk of GI events which warrants further investigation.

Prescribing data from 11 GP practices in Wales collected from 1993 to 1998 was interrogated by A. Offia and R. Walker (pR38) to identify medicine-associated constipation in primary care. The study allowed the risk of drug-induced constipation to be quantified for antipsychotics, antidepressants, analgesics, drugs for genito-urinary disorders and preparations used in anaemia. Although other studies have reported that NSAID users discontinue treatment because of constipation, this association was not found in the Welsh study.

Users' experiences

In the new NHS, which places an increasing importance on the views of users, it is rewarding to see that pharmacy practice researchers are keeping us abreast of this development. Pharmacists' access to medical records had the support of the majority of patients surveyed by K. A. Wilson, J. Jesson and R. Patel (pR64). Only a small minority had concerns about pharmacist confidentiality.

Inhaler-users' views of the image conveyed by model "patients" in patient information leaflets and a touchscreen programme were explored by I. Savage (pR82). A third of users said the choice of model mattered to them. One advantage of multimedia techniques such as a touchscreen was that information could be personalised to suit the user.

T. S. Sesselberg, N. J. Gray and J. D. Klein (pR61) report on research in the United States into adolescents' knowledge and opinions of over-the-counter and complementary medicines. They concluded that pharmacists need to be aware of the messages that teenagers receive through the media that appeal to their sense of well-being and concerns about their appearance.

T. S. Sesselberg, N. J. Gray and J. D. Klein (pR52) have also found that American adolescents have a poor understanding of the nature of medicines. They conclude that health professionals cannot assume that their concept of allopathic and complementary medicines will match those of the patients they are trying to engage.

Research by N. J. Gray, J. D. Klein, J. A. Cantrill and P. R. Noyce (pR53) into UK adolescents' perceptions of the internet as a health source has found that less than one-third looked for health information online. Those who did were as likely to look for information about a family member's illness as their own health.

Assessment of the quality of life in patients receiving treatment for gastro-oesophageal reflux disease was the aim of the work presented by A. S. Inglott, L. M. Azzopardi and M. Z. Adami (pR81). They found that patients receiving omeprazole 20mg once daily reported the greatest improvement in quality of life and suggested that pharmacists should use quality of life measurement to monitor effectiveness of drug therapy.

C. Morecroft, J. Cantrill, M. P. Tully and M. Crossley (pR65) have assessed differences in perceptions between patients and GPs regarding treatment of hypertension. They found incongruity with GPs expressing benefits at a population-based level, whereas patients require information at a more personal level. The findings have implications for concordance research.

Concordance and compliance

To ensure a knowledgeable and empowered patient population capable of accepting the principles of concordance, D. Engova, C. Duggan, P. MacCallum and I. Bates conclude that patients' understanding of their warfarin treatment needs to be improved (pR69). In a random sample of patients attending an outpatient anticoagulant clinic, they found that high adherence to warfarin is not always supported by understanding of treatment. Positive general beliefs about medicines and trust in physicians have stronger influences than specific perceptions of warfarin.

C. Hughes, E. F. R. Miller, J. Peat and J. C. McElney present some ongoing research to look at the effects of patient personality traits on relationships with health care professionals and on adherence to medication regimens (pR95). Those who score low in the personality factor "conscientiousness" and those low in self efficacy are more likely to take more medication than that prescribed by their doctor.

Compliance failure with oral chemotherapy was investigated in haematology outpatients by L. Stokes, A. Smith, C. A. Langley, J. F. Marriott and K. A. Wilson (pR47). Over half the patients experienced difficulty, apparently related not to the time of dosing but to the size of dose units and difficulty with the foil packed agents.

C. Lennon, C. M. Hughes and J. C. McElnay report that depression is associated with non-adherence in patients with heart disease (pR18). They suggest that such patients would be likely to benefit from some form of treatment for depression. This in turn may improve adherence rates.

Research by E. K. Taylor, D. Patty, R. Goldstein and D. K. Raynor has found that many elderly patients suffering chronic pain are not prescribed therapeutic does of analgesics and that less that 50 per cent take the full prescribed dose (pR26). They suggest that pharmacists have a potential role to play in addressing both these issues.

Diabetes care

Adherence to diabetes self-care activities can reduce the risk of developing complications. S. M. Aburuz, J. C. McElnay, J. S. Millership, W. J. Andrews and S. Smyth (pR96), studying patients with type 2 diabetes, found that despite them receiving high quality health care, including the services of a diabetes consultant, a dietician and specialist nurse education, a high percentage had poor diet behaviour and poor exercise behaviour. The results suggest that disease management interventions by community pharmacists should focus on younger patients, those who have concerns about their medications and those receiving multiple diabetic medications.

An investigation by L. Tadros, E. Barnes and M. Ledger-Scott (pR87) showed that a pharmacist-led education programme for type 2 diabetes patients can have a significant impact on glycaemic control and improve patients' understanding and their quality of life. Patients showed increased self-esteem and motivation towards diabetes management.

Complementary therapies

In a study of Australian patients with type 2 diabetes, R. M. Clifford, W. A. Davis, K. Batty and T. M. E. Davis (pR19) found that 23.6 per cent also used complementary medicines. About half the medicines used can have clinically significant effects, supporting the view that an important part of clinical assessment was to obtain details of non-prescription medicines.

Information sources for the use of herbal medicines were investigated by C. Gulian, J. Barnes and S. A. Francis (pR33), who approached customers in three health food stores, three independent pharmacies and three national chain pharmacies. Forty-five per cent of herbal medicine users had sought information before last purchasing a product, mostly consulting non-pharmacy, non-professional sources. The authors suggest that future work should consider pharmacists' training needs with regard to herbal medicines and ways to encourage the public to seek information and advice from a pharmacist.

Paediatric care

The specialist area of paediatrics is the subject of four research papers. R. A. Elliott, K. Payne, L. M. Davies, J. K. Moore and E. W. Moore (pR66) reported on children's outcomes and parents' preferences for the induction and maintenance of anaesthesia for day-case surgery. Parents tended to prefer the induction method they had experienced previously, suggesting the influence of familiarity. The study suggested that parent's preferences may be influenced by factors other than transient clinical outcomes such as nausea and vomiting.

L. M. Azzopardi, A. S. Inglott and M. Z. Adami (pR80) have evaluated the management of gastro-oesophageal reflux in infants. They found variation in current practice and concluded that more emphasis needs to be made on the significance of lifestyle changes. Pharmacists could have a role in devising guidelines.

B. U. Kluettgens, G. J. Sewell and A. J. Nunn (pR77) investigated paediatric nutrition practice by a postal questionnaire in five European countries. The differences are mainly related to the involvement of different professionals. Standardising parenteral nutrition and producing the solutions in batches makes more extensive quality assurance possible and commercial manufacture practicable and therefore increase the safety of this treatment.

Variation in the electrolyte concentrations in neonatal parenteral nutrition was investigated by J. Wright, J. F. Marriott, C. A. Langley, K. A. Wilson and J. Smith (pR46). Measured concentrations were generally higher than expected for sodium and lower than expected for potassium. For magnesium, similar numbers of concentrations were found to be higher or lower than expected. The variations, detected by end product testing, make accurate predictions of potential clinical outcomes difficult.

Miscellany

Inevitably, when attempting to group research papers some will fall outside the main categories. One such paper, by H. Woodruff, A. Thompkins, D. Mottram and P. Williamson (pR28) has looked at public perceptions on doping in sport. They found that the public has clear views on drug use in sport but has limited knowledge of the drugs. The authors felt that pharmacists should equip themselves with sufficient awareness and knowledge to provide accurate information for those members of the public seeking advice.

H. F. Boardman, E. Thomas, D. S. Millson and P. R. Croft (pR73) conducted a postal survey of a random sample of patients in Staffordshire to ascertain medicines use and health care consultation for headache in adults. Older headache sufferers reported headache as frequently as younger sufferers, but of shorter duration and less painful. Medicine use was lower in older sufferers, but when they used it they reported it more effective than younger sufferers. Similar number of sufferers consulted a health care professional, but fewer older people consulted a pharmacist.

P. Shearin, K. Hepburn, S. Hands, J. McAteer and L. Braddick (pR84) report on a pilot scheme to offer a smoking cessation programme in a young offenders institution, which resulted in four of 11 participants stopping. The authors describe the scheme as a successful example of multidisciplinary working across non-profit and commercial environments.

In a study of patients' experiences of over-the counter treatments for irritable bowel syndrome, H. Anderson, E. Bartley, A. M. Davison, S. L. Haines and P. J. Rogers (pR21) show that patients perceive significant relief when taking either OTC mebeverine or peppermint oil products. The authors cite the study as evidence that it is feasible to conduct multi-centre community pharmacy based studies on OTC medicine use.

A. K. Schweizer, C. O'Neill, C. M. Hughes and D. Macauley (pR89) used a qualitative research approach to identify current pathways used to diagnose and treat urinary tract infections in nursing home residents. All interviews agreed on the nurse being the key player and the majority of prescriptions were written without patient examination by the GP. A balance must be sought between a management approach that works in practice and the need for judicious use of antibiotics.

Following dissemination of standards or the set-up and maintenance of syringe drivers in palliative care, C. M. Hirsch, J. F. Marriott, C. A. Langley, K. A. Wilson and C. Faull (pR43) have identified variable or deficient areas of practice in a hospice setting. Issues of nurse training, variability in prescribing practices, provision of written information for patients, labelling and documentation of the diluent used were all identified as areas in which compliance with standards could be improved.

A study to ascertain current practice of regional anaesthetic techniques conducted by S. Alagell, R. Elliott and P. Noyce (pR25) found that it had changed from the trials included in a recent meta-analysis. Further research on the impact of modern anaesthetic drugs and techniques on outcome is therefore needed.

J. Thornton, R. Elliott and M. P. Tully (pR17) have evaluated the clinical outcome after high technology home treatment for cystic fibrosis. There was a significantly greater improvement in lung function from the start to the end of treatment for hospital courses compared with home courses and the mean decline in lung function over a year was significantly less in patients who received treatment in hospital. Both short and long-term outcomes appear to be superior for patients treated in hospital compared with those treated at home.