Background: over 50% of older people in hospital are prescribed a pre-admission medicine that is potentially inappropriate; however, deprescribing by geriatricians and pharmacists is limited. This study aimed to characterise geriatricians’ and pharmacists’ barriers and enablers to deprescribing in hospital. It also intended to develop a framework of intervention components to facilitate implementation of hospital deprescribing. Methods: fifty-four geriatricians and pharmacists representing four UK hospitals attended eight focus groups. We designed a topic guide to invite discussions about barriers and enablers to deprescribing. After thematic analysis, themes were mapped to the theoretical domains framework (TDF), enabling prioritisation of domains for behaviour change. We then identified evidence-based intervention components for changing behaviour within prioritised TDF domains. Results: geriatricians and pharmacists described several deprescribing enablers in the hospital setting including alignment with their role and generalist knowledge, and routine patient monitoring. Five prioritised TDF domains represent the key barriers and enabler: patient and caregiver attachment to medication (social influence); perceptions that deprescribing is riskier than continuing to prescribe (beliefs about consequences); pharmacists’ working patterns limiting capacity to support deprescribing (environmental context and resources); deprescribing being a low hospital priority (goals) and incentives to deprescribe (reinforcement). Prioritised TDF domains aligned with 44 evidence-based intervention components to address the barriers and enabler to hospital deprescribing. Conclusion: the behavioural determinants and their associated intervention components provide a hospital deprescribing implementation framework (hDIF). Intervention components should be selected from the hDIF to provide a theory and evidence-based intervention tailored to hospital contexts.

Prescribing medicines for older adults in care homes is known to be sub-optimal. Whilst trials testing interventions to optimise prescribing in this setting have been published, heterogeneity in outcome reporting has hindered comparison of interventions, thus limiting evidence synthesis. The aim of this study was to develop a core outcome set (COS), a list of outcomes which should be measured and reported, as a minimum, for all effectiveness trials involving optimising prescribing in care homes. The COS was developed as part of the Care Homes Independent Pharmacist Prescribing Study (CHIPPS). A long-list of outcomes was identified through a review of published literature and stakeholder input. Outcomes were reviewed and refined prior to entering a two-round online Delphi exercise and then distributed via a web link to the CHIPPS Management Team, a multidisciplinary team including pharmacists, doctors and Patient Public Involvement representatives (amongst others), who comprised the Delphi panel. The Delphi panellists (n = 19) rated the importance of outcomes on a 9-point Likert scale from 1 (not important) to 9 (critically important). Consensus for an outcome being included in the COS was defined as ≥70% participants scoring 7–9 and <15% scoring 1–3. Exclusion was defined as ≥70% scoring 1–3 and <15% 7–9. Individual and group scores were fed back to participants alongside the second questionnaire round, which included outcomes for which no consensus had been achieved. A long-list of 63 potential outcomes was identified. Refinement of this long-list of outcomes resulted in 29 outcomes, which were included in the Delphi questionnaire (round 1). Following both rounds of the Delphi exercise, 13 outcomes (organised into seven overarching domains: medication appropriateness, adverse drug events, prescribing errors, falls, quality of life, all-cause mortality and admissions to hospital (and associated costs)) met the criteria for inclusion in the final COS. We have developed a COS for effectiveness trials aimed at optimising prescribing in older adults in care homes using robust methodology. Widespread adoption of this COS will facilitate evidence synthesis between trials. Future work should focus on evaluating appropriate tools for these key outcomes to further reduce heterogeneity in outcome measurement in this context.

Deprescribing is a partnership between practitioners, patients and caregivers. External characteristics including age, comorbidities and polypharmacy are poor predictors of attitude towards deprescribing. This hospital-based study aimed to describe the desire of patients and caregivers to be involved in medicine decision-making, and identify attitudinal predictors of desire to try stopping a medicine. Patients and caregivers recruited from seven Older People’s Medicine wards across two UK hospitals completed the revised Patients’Attitudes Towards Deprescribing (rPATD) questionnaire. Patients prescribed polypharmacy and caregivers involved in medication decision-making of such patients were eligible. A target of 150 patients and caregivers provided a 95% confidence interval of ±11.0% or smaller around rPATD item agreement. Descriptive statistics characterised participants and rPATD responses. Responses to items regarding desire to be involved in medication decision-making and desire to try stopping a medicine were used to address the aims. Binary logistic regression provided the adjusted odds ratios (OR) for predictors of desire to try stopping a medicine. Patient participants (N = 75) were a median (IQ) 87.0 (83.0, 90.0) years old and the median (IQ) number of pre-admission medication was 8.0 (6.0, 10.0). Caregiver participants (N = 76) were a median (IQ) 70.0 (57.0, 83.0) years old and the majority were a spouse (63.2%). For patients and caregivers respectively, the following were reported: 58.7 and 65.8% wanted to be involved in medication decision-making; 29.3 and 43.5% reported a desire to try stopping a medicine. Attitudinal predictors of low desire to try stopping a medicine for patients and caregivers are a perception that there are no unnecessary prescribed medicines [OR = 0.179 (patients) and 0.044 (caregivers)] and no desire for dose reduction [OR = 0.199 (patients) and 0.024 (caregivers)]. A perception of not being prescribed too many medicines also predicted low patient desire to try stopping a medicine [OR = 0.195]. A substantial proportion of patients and caregivers did not want to be involved medication decision-making, however this should not result in practitioners dismissing deprescribing opportunities. The three diagnostic indicators for establishing desire to try stopping a medicine are perceived necessity of the medicine, appropriateness of the number prescribed medications and a desire for dose reduction.

Chronic obstructive pulmonary disease (COPD) is a progressive chronic condition that can be effectively managed by smoking-cessation, optimising prescribed therapy and providing treatment to prevent chest infections from causing hospitalisation. The government agenda in the UK is for community pharmacists to become involved in chronic disease management, and COPD is one area where they are ideally located to provide a comprehensive service. This study aims to evaluate the effect of a community pharmacy-based COPD service on patient outcomes. Patients in one UK location were recruited over a 10-week period to receive a community pharmacy-based COPD support service consisting of signposting to or provision of smoking-cessation service, therapy optimisation and recommendation to obtain a rescue pack containing steroid and antibiotic to prevent hospitalisation as a result of chest infection. Data were collected over a 6-month period for all recruited patients. Appropriate clinical outcomes, patient reported medication adherence, quality of life and National Health Service (NHS) resource utilisation were measured. Three hundred six patients accessed the service. Data to enable comparison before and after intervention was available for 137 patients. Significant improvements in patient reported adherence, utilisation of rescue packs, quality of life and a reduction in routine general practitioner (GP) visits were identified. The intervention cost was estimated to be off-set by reductions in the use of other NHS services (GP and accident and emergency visits and hospital admissions). Results suggest that the service improved patient medicine taking behaviours and that it was cost-effective.

Aims: Pharmacogenetics (PGx) in the UK is currently implemented in secondary care for a small group of high‐risk medicines. However, most prescribing takes place in primary care, with a large group of medicines influenced by commonly occurring genetic variations. The goal of this study is to quantitatively estimate the volumes of medicines impacted by implementation of a population‐level, pre‐emptive pharmacogenetic screening programme for nine genes related to medicines frequently dispensed in primary care in 2019.Methods: A large community pharmacy database was analysed to estimate the national incidence of first prescriptions for 56 PGx drugs used in the UK for the period 1 January–31 December 2019. These estimated prescription volumes were combined with phenotype frequency data to estimate the occurrence of actionable drug–gene interactions (DGI) in daily practice in community pharmacies.Results: In between 19.1 and 21.1% (n = 5 233 353–5 780 595) of all new prescriptions for 56 drugs (n = 27 411 288 new prescriptions/year), an actionable drug–gene interaction (DGI) was present according to the guidelines of the Dutch Pharmacogenetics Working Group and/or the Clinical Pharmacogenetics Implementation Consortium. In these cases, the DGI would result in either increased monitoring, guarding against a maximum ceiling dose or an optional or immediate drug/dose change. An immediate dose adjustment or change in drug regimen accounted for 8.6–9.1% (n = 2 354 058–2 500 283) of these prescriptions.Conclusions: Actionable drug–gene interactions frequently occur in UK primary care, with a large opportunity to optimise prescribing.

Background The UK government currently recommends that all patients receive medicines reconciliation (MR) from a member of the pharmacy team within 24 hours of admission and subsequent discharge. The cost-effectiveness of this intervention is unknown. A pilot study to inform the design of a future randomised controlled trial to determine effectiveness and cost-effectiveness of a pharmacist-delivered service was undertaken. Method Patients were recruited 7 days a week from 5 adult medical wards in 1 hospital over a 9 month period and randomised using an automated system to intervention (MR within 24 hours of admission and at discharge) or usual care which may include MR (control). Recruitment and retention rates were determined. Length of stay (LOS), quality of life (EQ-5D-3L), unintentional discrepancies (UDs) and emergency readmission (ER) within 3 months were tested as outcome measures. The feasibility of identifying and measuring intervention-associated resources was determined. Result 200 patients were randomised to either intervention or control. Groups were comparable at baseline. 95 (99%) patients in the intervention received MR within 24 hours, while 62 (60.8%) control patients received MR at some point during admission. The intervention resolved 250 of the 255 UDs identified at admission. Only 2 UDs were identified in the intervention group at discharge compared with 268 in the control. The median LOS was 94 hours in the intervention arm and 118 hours in the control, with ER rates of 17.9% and 26.7%, respectively. Assuming 5% loss to follow-up 1120 patients (560 in each arm) are required to detect a 6% reduction in 3-month ER rates. Conclusions The results suggest that changes in outcome measures resulting from MR within 24 hours were in the appropriate direction and readmission within 3 months is the most appropriate primary outcome measure. A future study to determine cost-effectiveness of the intervention is feasible and warranted. Trial registration number ISRCTN23949491.