Open ownership of pharmacies reduces the quality of pharmaceutical care for the consumer.

Thesis (MBA)-University of Natal, Durban, 2003.South Africa is currently grappling with amendments to a number of laws relating to the supply of drugs. One of these amendments removes the requirement that only a pharmacist may own an interest in a retail pharmacy. While this may be opposed by retail pharmacists, the question is really: Will this measure benefit consumers by improving the access to drugs by bringing to this sector a measure of competition and hence reduced prices or will this measure reduce the quality of pharmaceutical care for consumers due to a lack of a relationship based on trust? The emergence of brands such as HealthPharm (Pick 'n Pay), Purchase Milton & Associates- PM&A (New Clicks), and the Checkers (Shoprite Group of Companies) are becoming increasingly popular among consumers (Andy Gray, 1997). This study investigates the impact of these changes on the consumer receiving affordable quality pharmaceutical care. It aims to establish a relationship between consumers and their pharmacist that is based on trust. Quantitative analysis of consumers and pharmacists revealed that there is a relationship based on trust between these parties. Statistical analysis of these samples also reveal a consumer trend suggesting that consumers and pharmacists require a relationship based on trust to achieve the goals of pharmaceutical care. Open ownership of pharmacies will not provide the consumer with an opportunity to develop this relationship with their pharmacist and thus reduce the quality of pharmaceutical care received

An evaluation of the feasibility to use digital solutions to support the provision of healthcare in the NHS

In England, there is an increase in prevalence of patients with long-term conditions (LTC) with approximately 26 million people having at least one LTC, utilising 70% of the total health and social budget. The Five Year Forward View and the NHS Long Term plan have identified that digital healthcare is a cost-effective technology that has the potential to integrate systems, improve efficiencies and have better clinical and social outcomes for patients. Whilst the successful implementation of digital healthcare in the NHS has been challenging, the severe acute respiratory syndrome coronavirus-2 (COVID-19) has been a major driver to support the rapid implementation of digital technology to safely maintain services and public health. This thesis aimed to evaluate the feasibility of using digital solutions to support the provision of healthcare in the borough of Croydon. Overall, a mixed-method approach consisting of quantitative and qualitative techniques was used to investigate the usability and acceptability of three technology enabled care solutions: a telehealth monitoring system in care home with residents with dementia, a follow up telephonic solution post-discharge and a digital stethoscope to screen for congenital murmurs. The study that assessed the potential role of telehealth system for monitoring residents with dementia living in a care home took place over three six-month phases [control phase (CP), active monitoring phase (AMP) and active monitoring with text alerts (AMTAP)]. The solution involved carers recording vital signs and completing health assessment questions. In AMTAP, the early warning triage system generated text alerts when abnormal responses or vital signs were detected. Twenty-seven residents participated during the CP and AMP whilst only fourteen residents participated during AMTAP. The quantitative section of this study calculated the frequency effect of the telehealth solution on the general practitioner visits (GPV), antibiotic prescribing (AP), emergency department (ED) visits and hospital inpatient (IP) events whilst the qualitative section of this study explored multidisciplinary healthcare professionals (HCPs) awareness and experiences of the telehealth system and reported on their perceptions pre and post implementation. The digital healthcare solution resulted in more frequent monitoring of residents’ vital signs (weekly vs monthly) resulting in an increase in frequency of GP (p=0.009) and AP (p<0.001) and a decrease in ED, IP and duration of an admission. Multidisciplinary HCPs were interviewed pre-AMP (n=33) and post-AMP (n=28). HCPs working with the digital solution reported increase knowledge and awareness after using the digital solution whereas HCPs who did not have direct contact reported a lack of understanding and awareness. Barriers to implementation included: lack of resources, training, inadequate staffing, equipment failure and poor system implementation. Indirect beneficial outcomes included: improved medication changes for residents and improved professional satisfaction and therefore HCPs wanted to use digital healthcare in the future. The second study evaluated a post discharge telephonic intervention by two nurses in the role of discharge advocates (DA) to ensure that the patients received the required post discharge care. The intervention was part of a funded project aiming to design a readmission prediction risk score system (OPTIMAL) to identify patients in need of a post discharge intervention to prevent a readmission within 30 days of discharge. The DA recruited eligible patients into the intervention (n=740) and control arms (n=730). It was determined that a sample size of 265 patients’ evaluations per a group (total 530, [intervention (n=265) and control (n=265)]) would be needed to determine patients’ satisfaction levels at 95% confidence interval. The sample extracted for evaluation had a statistically significant (p=0.001) higher mean OPTIMAL 30-day readmission risk score than the study arms. The OPTIMAL risk score of admission was reflective of the actual rate of re-admission with an average predictive score of 16.28% and actual 30-day readmission rate of 15.12% (n=223) for the whole sample. In the sample tested, the OPTIMAL predictive percentage readmission scores were 20.27% and 20.91% in the evaluation and control arms compared to (n=61, 23%) actual 30 days readmission rate across both arms. There was no significant difference in 30-day readmission rate between the study control and intervention arms. However, the percentage actual readmission rate was statistically significantly lower for the intervention evaluation group (9.4%) as compared to the control evaluation group (13.5%) (p<0.001). The DA call was perceived positively by patients as they felt that the DA understood their health status (81.1%) and was quite helpful (82.2%). Based on the findings, perhaps the intervention should not have been offered to all patients but to those that will most benefit from it, so targeted intervention based on the OPTIMAL readmission risk score, as the intervention did statistically significantly lower readmission rate for those patients. Lastly, an investigation was conducted to evaluate both the feasibility of an electronic stethoscope for the detection of congenital heart murmurs and its usability and associated software amongst clinicians with different levels of experience. Paediatric patients (n=72) with suspected murmurs attending a Paediatric Cardiologist led outpatient clinic and forty age-matched participants with no discernible murmurs consented to 30-second heart sound Consultant Paediatrician verified recordings using a 3M™ Littmann® Electronic Stethoscope Model 3200 to create a heart sound database. MATLAB (The MathWorks Inc., USA) was used to create sound waveforms and the 3M™ Littmann Steth Assist Heart and Lung Sound Visualization Software® was used to record and playback heart sounds. For the recordings without murmurs (n=6), the waveform between heart sounds appeared regular and smooth whereas in the recordings with murmurs (n=6) the waveforms between heart sounds had varying frequency with some higher frequency components. This was apparent with grade 3 and above murmurs, but this was less apparent in grade one and two murmurs, hence not proving a useful tool for screening. Clinicians (n=38) retrospective assessment of heart sounds played through a Bluetooth speaker resulted in system sensitivity of 77% and a specificity of 69%. The ability to distinguish between a normal and abnormal heart sound when listening to the audio samples was related to the experience of the clinician, with consultants scoring the highest. Unfortunately, clinicians (61%) reported that they would not be comfortable to confirm a diagnosis remotely using the system. All clinicians were able to acquire heart sounds using the electronic stethoscope. However, only Consultants (n=11), Senior House Officers (SHOs) and Registrars (n=4) ranked the electronic stethoscope with an acceptable System Usability Scale (SUS) score (≥70). Clinicians identified advantages for the system, with potential use as an educational tool and for the retrospective review of heart sounds. The three studies above evaluated the feasibility of using digital solutions to support the provision of healthcare. The evaluation has proven that digital solutions have the potential to support HCPs in healthcare provision, but the technology, organisation and patients need to be considered so that the proper ‘digital fit’ can be achieved to ensure that digital solutions are adopted by HCPs and that patients can experience the full benefits from them for both their healthcare and social outcomes

A cross-sectional survey investigating women's information sources, behaviour, expectations, knowledge and level of satisfaction on advice received about diet and supplements before and during pregnancy

Background The reported long-term effects of poor maternal nutrition and uptake of recommended supplements before and during pregnancy was the impetus behind this study. Our objectives were to investigate and understand women’s expectations, knowledge, behaviour and information sources used regarding the use of nutrition and vitamin supplements before and during pregnancy. Methods A cross-sectional survey using a self-administered questionnaire was undertaken. A purposive sampling technique was used. Women attending the antenatal clinic at Croydon University Hospital during 2015 were invited to take part in the study. The data was analysed using descriptive statistics, paired sample T-tests and Chi-squared tests, with the level of significance set at 5% (p < 0.05). Results A total of 133 pregnant women completed the survey. Analysis of the results showed that women are currently using electronic resources (33%, n = 42) rather than healthcare professionals (19%, n = 25) as an information source before pregnancy. Women who sourced information through the internet were significantly more likely to take folic acid (p = 0.006) and vitamin D (p = 0.004) before pregnancy. Women preferred to receive information from the antenatal clinic (62%, n = 83), internet (46%, n = 61) and from mobile applications (27%, n = 36). Although women believed they had sufficient knowledge (60%, n = 80) and had received adequate advice (53%, n = 70) concerning the correct supplements to take, this was not demonstrated in their behaviour, with only a small number of women (37%, n = 49) taking a folic acid supplement before pregnancy. Women mistakenly perceived the timing of supplement advice as correct, with only a small number of women (18%, n = 23) considering the advice on supplements as too late. Conclusions Despite the small sample size, this study demonstrated that women did not receive timely and/or accurate advice to enable them to take the recommended supplements at the optimal time. Women had the misconception that they understood the correct use of pregnancy supplements. This misunderstanding may be prevented by providing women intending to become pregnant with a structured, approved electronic source of information that improves their supplements uptake

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Albiglutide and cardiovascular outcomes in patients with type 2 diabetes and cardiovascular disease (Harmony Outcomes): a double-blind, randomised placebo-controlled trial

Background: Glucagon-like peptide 1 receptor agonists differ in chemical structure, duration of action, and in their effects on clinical outcomes. The cardiovascular effects of once-weekly albiglutide in type 2 diabetes are unknown. We aimed to determine the safety and efficacy of albiglutide in preventing cardiovascular death, myocardial infarction, or stroke. Methods: We did a double-blind, randomised, placebo-controlled trial in 610 sites across 28 countries. We randomly assigned patients aged 40 years and older with type 2 diabetes and cardiovascular disease (at a 1:1 ratio) to groups that either received a subcutaneous injection of albiglutide (30–50 mg, based on glycaemic response and tolerability) or of a matched volume of placebo once a week, in addition to their standard care. Investigators used an interactive voice or web response system to obtain treatment assignment, and patients and all study investigators were masked to their treatment allocation. We hypothesised that albiglutide would be non-inferior to placebo for the primary outcome of the first occurrence of cardiovascular death, myocardial infarction, or stroke, which was assessed in the intention-to-treat population. If non-inferiority was confirmed by an upper limit of the 95% CI for a hazard ratio of less than 1·30, closed testing for superiority was prespecified. This study is registered with ClinicalTrials.gov, number NCT02465515. Findings: Patients were screened between July 1, 2015, and Nov 24, 2016. 10 793 patients were screened and 9463 participants were enrolled and randomly assigned to groups: 4731 patients were assigned to receive albiglutide and 4732 patients to receive placebo. On Nov 8, 2017, it was determined that 611 primary endpoints and a median follow-up of at least 1·5 years had accrued, and participants returned for a final visit and discontinuation from study treatment; the last patient visit was on March 12, 2018. These 9463 patients, the intention-to-treat population, were evaluated for a median duration of 1·6 years and were assessed for the primary outcome. The primary composite outcome occurred in 338 (7%) of 4731 patients at an incidence rate of 4·6 events per 100 person-years in the albiglutide group and in 428 (9%) of 4732 patients at an incidence rate of 5·9 events per 100 person-years in the placebo group (hazard ratio 0·78, 95% CI 0·68–0·90), which indicated that albiglutide was superior to placebo (p&lt;0·0001 for non-inferiority; p=0·0006 for superiority). The incidence of acute pancreatitis (ten patients in the albiglutide group and seven patients in the placebo group), pancreatic cancer (six patients in the albiglutide group and five patients in the placebo group), medullary thyroid carcinoma (zero patients in both groups), and other serious adverse events did not differ between the two groups. There were three (&lt;1%) deaths in the placebo group that were assessed by investigators, who were masked to study drug assignment, to be treatment-related and two (&lt;1%) deaths in the albiglutide group. Interpretation: In patients with type 2 diabetes and cardiovascular disease, albiglutide was superior to placebo with respect to major adverse cardiovascular events. Evidence-based glucagon-like peptide 1 receptor agonists should therefore be considered as part of a comprehensive strategy to reduce the risk of cardiovascular events in patients with type 2 diabetes. Funding: GlaxoSmithKline

Healthcare use, costs and quality of life in patients with end-stage kidney disease receiving conservative management: results from a multi-centre observational study (PACKS)

Background: Previous research has explored the cost of providing renal replacement therapies in patients with end-stage kidney disease and their quality of life. This is the first study to examine the healthcare costs of patients receiving conservative care without dialysis for end-stage kidney disease. This alternative to dialysis is an option for patients who prefer a supportive and palliative care approach. Aim: Descriptive cost and quality of life analyses alongside a UK-based multi-centre observational study in patients receiving conservative management for end-stage kidney disease. Design: Health service use was recorded up to 12 months after making the decision to receive conservative management. Mean costs were calculated for each 3-month time period. The annual cost was calculated in two ways: by using only patients with complete cost data and by using all available data weighted by the number of patients at each time point. Setting: In total, 42 patients who opted for conservative management over dialysis were recruited. Results: Mean costs were £1622 (0�3 months), £1008 (3�6 months), £554 (6�9 months) and £2626 (9�12 months). Mean annual cost based on complete data (n = 8) was £5511, and the weighted mean annual cost was £5620. Conclusion: The importance of this study is twofold. First, it provides substantive new information for health and social care planning of conservative management by demonstrating where demand exists for services, in both the United Kingdom and other countries with a comparable health service structure. Second, methodologically, it indicates that it is feasible to collect service use data directly from this patient population.</p

Advances in adoptive T-cell therapy for metastatic melanoma

Adoptive T cell therapy (ACT) is a fast developing, niche area of immunotherapy (IO), which is revolutionising the therapeutic landscape of solid tumour oncology, especially metastatic melanoma (MM). Identifying tumour antigens (TAs) as potential targets, the ACT response is mediated by either Tumour Infiltrating Lymphocytes (TILs) or genetically modified T cells with specific receptors – T cell receptors (TCRs) or chimeric antigen receptors (CARs) or more prospectively, natural killer (NK) cells. Clinical trials involving ACT in MM from 2006 to present have shown promising results. Yet it is not without its drawbacks which include significant auto-immune toxicity and need for pre-conditioning lymphodepletion. Although immune-modulation is underway using various combination therapies in the hope of enhancing efficacy and reducing toxicity. Our review article explores the role of ACT in MM, including the various modalities – their safety, efficacy, risks and their development in the trial and the real world setting

Advances in Adoptive T-cell Therapy for Metastatic Melanoma

Adoptive T cell therapy (ACT) is a fast developing, niche area of immunotherapy (IO), which is revolutionising the therapeutic landscape of solid tumour oncology, especially metastatic melanoma (MM). Identifying tumour antigens (TAs) as potential targets, the ACT response is mediated by either Tumour Infiltrating Lymphocytes (TILs) or genetically modified T cells with specific receptors – T cell receptors (TCRs) or Chimeric antigen receptors (CARs) or more prospectively, natural killer (NK) cells. Clinical trials involving ACT in MM from 2006 to present have shown promising results. Yet it is not without its drawbacks which include significant auto-immune toxicity and need for pre-conditioning lymphodepletion. Although immune-modulation is underway using various combination therapies in the hope of enhancing efficacy and reducing toxicity. Our review article explores the role of ACT in MM, including the various modalities – their safety, efficacy, risks and their development in the trial and the real world setting