1. Primary Care Research in Northern Ireland: where’s the evidence? Carmel M. Hughes School of Pharmacy Queen’s University Belfast

3. The view from the Lancet “There is now widespread acknowledgement of the absence of a sound evidence base underpinning many of the decisions made in primary care.”

4. The view from the Cochrane Library “Higher quality evidence is needed to determine the effectiveness of self-care treatment for acute cough”

5. 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

6. Two main strands in primary care research Community –Community pharmacy –Community pharmacy and general practice Long-term care –Nursing homes for older people

7. 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

8. Evidence for what we do Responding to symptoms with over-the-counter medications Management of minor ailments –Cluster RCT

9. 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

10. 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

11. 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?

12. 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

13. 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

14. 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

15. 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

16. Fleetwood approach 1.Screening for high-risk patients 2.Medication review 3.Resident assessment by the consultant pharmacist – pharmaceutical care needs 4.Pharmacist intervention and direct communication with the prescriber 5.Formalised pharmaceutical care planning

17. Main outcome from Fleetwood After one year, the odds of a resident receiving an inappropriate psychoactive drug in an intervention home = 0.26 (95% CI: 0.14, 0.49) compared to a resident in the control group of homes

18. 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

19. Brave new world of clinical research in the UK- hindrance or help? Regulation –Governance –Ethics Clinical Trials Units –Logistical, methodological and analytical support

20. 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

21. 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

22. 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 Burwell Dean of the Harvard Medical School