East & South East England Specialist Pharmacy Services East of England, London, South Central & South East Coast Research methods: answering questions in practice Dr Catherine Duggan, Director for Clinical Pharmacy [Development & Evaluation] East & South East England Specialist Services NHS

East & South East England Specialist Pharmacy Services The presentation To identify and describe the use of different research methods, why different methods are used and the benefits of one against another.

East & South East England Specialist Pharmacy Services The presentation How to start to incorporate research into the day job? How to bridge the gap between research and practice? How to ensure a core number of oncology pharmacists contribute to the research agenda?

East & South East England Specialist Pharmacy Services Science Evidence Policy Practice

East & South East England Specialist Pharmacy Services The presentation Taking some problems in practice, start to describe how we might tackle them from various perspectives, using different methods…

East & South East England Specialist Pharmacy Services Problems in practice 1.How to reduce inconsistencies in prescribing between primary and secondary care? 2.How to provide patients with the drug related information they need? 3.How can we measure how effective pharmacists are in patient care?

East & South East England Specialist Pharmacy Services Where to start? There is no such thing as a good methodology or a bad methodology... The key is to understand the application of the appropriate methodology for the question in hand

East & South East England Specialist Pharmacy Services Qualitative vs. Quantitative approaches Qualitative: Phenomenological Hypothesis-generating (bottom- up/inductive) Common in early stages of a field of research Statistical analysis is never used Quantitative: Positivist/Experimental Hypothesis-testing (top- down/deductive) Common in later stages of a field of research Statistical analysis often used

East & South East England Specialist Pharmacy Services Commonly used qualitative and quantitative methods Qualitative: Interviews: –Face to face Focus groups Observation studies Quantitative: Survey: –Postal –Face to face –Telephone Randomised controlled trial: –Parallel groups –Cross over

East & South East England Specialist Pharmacy Services Problem 1 How can we reduce inconsistencies in prescribing between primary and secondary care?

East & South East England Specialist Pharmacy Services Where to start? Survey? Trial? Observations? Interviews?

East & South East England Specialist Pharmacy Services Where to start? A survey identified unintentional discrepancies between supplies of prescribed drugs highest in supplies obtained in the community following discharge This formed the focus of the intervention study- a trial

East & South East England Specialist Pharmacy Services Medical In-patients were recruited into CONTROL or TRIAL cohorts TRIAL cohort discharged with information on medicines for their community pharmacist Consensus panel judged the CLINICAL SIGNIFICANCE of the observed discrepancies

East & South East England Specialist Pharmacy Services Summary Findings

East & South East England Specialist Pharmacy Services Effectiveness of the Intervention

East & South East England Specialist Pharmacy Services Information should be provided to the community pharmacists for all medical patients discharged from hospital. In summary,

East & South East England Specialist Pharmacy Services Problem 2 How to provide patients with the drug related information they need?

East & South East England Specialist Pharmacy Services The background ~ 50% (?) of chronic patients do not comply with prescribed therapy Side effects and Toxicity Interactions and allergies Difficult to take Forgetfulness Patients’ beliefs and behaviours

East & South East England Specialist Pharmacy Services Compliance Paternalism Professionals know best Experts hold the key to information Adherence Move away from paternalism Empowering the patient Provide patients with some information Concordance Move towards empowerment Expert patients Standard information For everyone

East & South East England Specialist Pharmacy Services From Compliance to Concordance... Simply a move from paradigm to paradigm? A shift in perspective? Increased patient involvement?

East & South East England Specialist Pharmacy Services Research shows us information is good…

East & South East England Specialist Pharmacy Services Majority of patients want more information than they are given Patients want to obtain an ‘explanation of their problem’ rather than ‘tests and diagnoses’ Patients want the full picture, presented in a non- alarming way, a balanced, honest assessment of positive and negative aspects of treatment Providing information to patients leads to better understanding of their medication and increased adherence

East & South East England Specialist Pharmacy Services But, a lack of understanding or information overload may influence the way patients view their prescribed drug(s) and ultimately influences the way they take them…or don’t

East & South East England Specialist Pharmacy Services Many patients have poor understanding of terminology Many patients don’t understand prescription instructions Many patients criticise failures to communicate the things they really want or need to know Many perceive a communication ‘gap’ between themselves and healthcare professionals

East & South East England Specialist Pharmacy Services –How do we know which patients want information and which patients don’t? –How much information do they want and when? –Will the “information” affect their medicines taking behaviour? So…

East & South East England Specialist Pharmacy Services Where to start? Survey? Trial? Observations? Interviews?

East & South East England Specialist Pharmacy Services TRIAL cohort discharged with Information on drugs at discharge for their Community pharmacist 500 patients’ perceptions towards their illness & behaviours towards Rx DESIRE for information => worry DESIRE for information => age & socioeconomics

East & South East England Specialist Pharmacy Services Diagnosis and desire for information…?

East & South East England Specialist Pharmacy Services Info needs Anxiety Tolerance Duggan QSHSC, 2008

East & South East England Specialist Pharmacy Services In summary, The way we provide information to patients affects their perceptions of their drugs and their medicines taking

East & South East England Specialist Pharmacy Services Problem 3 How can we measure how effective pharmacists are in patient care?

East & South East England Specialist Pharmacy Services Where to start? Survey? Trial? Observations? Interviews?

East & South East England Specialist Pharmacy Services Evidence of benefit of pharmacists- UK Clinical pharmacy- accepted interventions from ward visits Clinical setting, pharmacist experience and available time predict rate System change: integration Length of stay reduced by 2 days Readmission rates decreased by 20% Fiscal benefits included an average return of £7.50 for every £1 invested System change: automation 34% increase in items dispensed within 2 hours 16% reduction in dispensing error 19% reduction in staff time for dispensing Intervention studies

East & South East England Specialist Pharmacy Services Evidence of benefit of pharmacists- US Inverse association between pharmacists per 100 beds and mortality rates Inverse association between pharmacists per 100 beds and length of stay Inverse association between pharmacists per 100 beds and rates of adverse drug reactions Association between clinical pharmacy services and lower mortality rates Association between higher numbers of clinical pharmacists and lower drug costs Surveys, census, outcome measures

East & South East England Specialist Pharmacy Services Mortality rate Index W W W W W W R-Square = 0.16 R-Square = 0.76 Borja-Lopetegi, Bates, Webb 2007 Saving lives Evidence of benefit

East & South East England Specialist Pharmacy Services

Why do we need to publish? Isn’t it someone else’s job?

East & South East England Specialist Pharmacy Services Pharmacy evidence gap Research articles on health professions education World Health Report 2006.

East & South East England Specialist Pharmacy Services To be a consultant (level) pharmacist, one has to demonstrate expertise across 6 clusters including Research and Evaluation Through publication of robust evidence, pharmacists can contribute to science, to pharmaceutical care and the wider research agenda.

East & South East England Specialist Pharmacy Services Summary Its imperative: –we understand research principles –we undertake research from an early stage in career development to incorporate research into the day job –practitioners are involved in research to bridge the gap between research and practice Make R&E part of CPD to ensure a core number of oncology pharmacists contribute to the research agenda

East & South East England Specialist Pharmacy Services Science Evidence Policy Practice

East & South East England Specialist Pharmacy Services East of England, London, South Central & South East Coast Research methods: answering questions in practice Dr Catherine Duggan, Director for Clinical Pharmacy [Development & Evaluation] East & South East England Specialist Services NHS