Primary Care Research in Northern Ireland: where’s the

evidence?

Carmel M. Hughes

School of Pharmacy

Queen’s University Belfast

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.”

The view from the Cochrane Library

“Higher quality evidence is needed to determine the effectivenessof self-care treatment for acute cough”

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

Two main strands in primary care research

• Community– Community pharmacy– Community pharmacy and general

practice

• Long-term care– Nursing homes for older people

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

Evidence for what we do

• Responding to symptoms with over-the-counter medications

• Management of minor ailments– Cluster RCT

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

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

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?

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

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

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

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

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

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

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

Brave new world of clinical research in the UK- hindrance or help?

• Regulation– Governance– Ethics

• Clinical Trials Units– Logistical, methodological and

analytical support

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

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

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