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Prescribing cascades can lead to unnecessary medication use, healthcare costs, and patient harm. Pharmacists oversee prescriptions from multiple prescribers and are well positioned to identify such cascades, making pharmacists key stakeholders to address them. To evaluate community pharmacists' awareness, identification, and management of prescribing cascades and to assess behavioural determinants that may be targeted in future strategies to minimise inappropriate prescribing cascades. An online survey was developed using the Theoretical Domains Framework (TDF) and emailed to all registered community pharmacists in Ireland (n = 3775) in November 2021. Quantitative data were analysed using descriptive and inferential statistics. Free-text sections were given to capture reasons for non-resolution of identified prescribing cascades and suggestions to aid prescribing cascade identification and management; this text underwent content analysis. Of the 220 respondents, 51% were aware of the term ' prescribing cascade' before the survey, whilst 69% had identified a potentially inappropriate prescribing cascade in practice. Over one third were either slightly confident (26.4%) or not confident at all (10%) in their ability to identify potentially inappropriate prescribing cascades in patients' prescriptions before the survey, whilst 55.2% were concerned that patients were receiving prescribing cascades they had not identified. Most respondents wanted further information/training to help prescribing cascade identification (88.3%) and management (86.1%). Four predominant TDF domains identified were common to both i) influencing non-resolution of identified prescribing cascades and ii) in the suggestions to help identify and manage prescribing cascades: ' Environmental Context and Resources' , 'Social/Professional Role and Identity', 'Social Influences' and ' Memory, Attention and Decision Processes'. There is a clear need to provide additional resources to help community pharmacists identify and manage prescribing cascades. These findings will support the development of theory-informed behaviour change strategies to aid the minimisation of inappropriate prescribing cascades and decrease the risk of medication-related harm for patients. • First study to explore community pharmacists' views on prescribing cascades. • Pharmacists concerned they did not identify prescribing cascades in their patients. • Pharmacists want more resources to help identify and manage prescribing cascades. • To prevent prescribing cascades, most agreed that software alerts would be useful. • This study identified key behavioural targets for minimising prescribing cascades. [ABSTRACT FROM AUTHOR]

Background: People who take medications often experience challenges including making decisions about risks versus benefits and integrating medication management with all aspects of life (e.g., social and work responsibilities). Existing medication self-management frameworks are primarily adherence-focused and lack integrating holistic perspectives.Objective: To explore the priorities of people with chronic medication experience (i.e., take at least 1 medication daily for at least 3 months) and what they can contribute to the understanding of medication self-management.Methods: Concept mapping is a participatory, mixed-methods approach with 3 stages: brainstorming, sorting/rating, and mapping. Group brainstorming discussions were held with participants who generated statements about what mattered to them regarding medications in their everyday lives. In sorting/rating, individual participants grouped statements into thematic piles and rated their importance and feasibility. During mapping, a subset of participants discussed and agreed on a visual map and named the statement clusters. Following mapping, the researchers analyzed rating results, stratified by participant characteristics (gender, age, duration of medication use, number of medications, and chronic conditions).Results: Sixty-three participants generated 1044 statements during 8 brainstorming sessions, which the researchers synthesized into 94 statements. Fifty-four participants individually sorted and rated the statements. Most statements were rated highly on both importance and feasibility, regardless of participant characteristics. Eight participants attended the mapping session. The final map had 9 thematic clusters, which were named by participants as: 1) researching and becoming educated about medications; 2) social support; 3) effectiveness of medication; 4) self-ownership of medication; 5) ease of use; 6) convenience and accessibility; 7) information provided by healthcare provider; 8) personal interactions with healthcare provider; and 9) patient involvement and trust.Conclusions: Results enhance existing medication management frameworks by providing a more comprehensive perspective. Understanding medication self-management requires more research that incorporates and prioritizes the perspectives of individuals who manage their medications. [ABSTRACT FROM AUTHOR]

Background: Medication changes during transitions of care is a recognized challenge that has been linked to adverse events. The delivery of medication instructions during transition from hospital to home is a priority area for improvement.Objective: The goals of this work were to 1) understand the current experiences of patients and families; and 2) co-design tools to improve medication information transfer during transitions of care together with patients, families, and providers.Methods: A participatory action approach, using mixed methods within a design thinking framework was used. Participants were chosen from patient groups at higher risk of adverse events, guided by extreme user design, which posits that needs of extreme users can also fit the majority. Providers, patients and family (users) were interviewed to understand current experiences with medication information transfer during transitions of care and to solicit input on potential elements to inform tool design. Users were engaged in iterative creation of prototypes.Results: A total of 116 patients, family caregivers, and providers were engaged throughout this project. Findings highlighted challenges currently experienced, strengthening the case for tools that engage the patient and family in medication information transfer. Important information included why medications were prescribed, how to take them, side effects, and an explanation of the role of community pharmacists. Displaying information in a grid format was preferred. Two tools were prototyped: (1) A Medication Whiteboard for engaging patients and families in creating their medication routine, and (2) A Patient Oriented Medication List for providing medication instructions and as a reference once patients are home.Conclusions: Through the use of mixed methods within a design thinking framework, the team was able to understand the challenges and design prototypes of tools that both engage patients and families in developing their medication routine and improve medication information transfer during transitions of care. [ABSTRACT FROM AUTHOR]

Introduction: Community pharmacists' optimal scope of practice extends far beyond traditional dispensing or compounding, and health promotion or chronic disease management services based in the pharmacy can generate significant social and economic value. But, with many competing demands and performance expectations from patients, payers, and policymakers, many pharmacies face challenges when introducing, maintaining, optimizing, or integrating their service offerings. Quality Improvement (QI) science may provide a practical change management framework for pharmacy professionals to lead their teams in embracing optimal scope and in making pharmacy-based services more feasible and attractive for all parties.Project Aims: To build community pharmacies' capacity for continuous QI (CQI) and to understand how the implementation of CQI is best achieved in this setting.Methods: Community pharmacies will undertake a process of change within one or more existing pharmacy services. Participatory action research principles will empower these sites to identify their own opportunities for improvement, generate change ideas, and trial and study those ideas in practice, using a QI system built on the Model for Improvement and Plan-Do-Study-Act (PDSA) cycles. An external Quality Facilitator will consult and train an internal Change Champion and other pharmacy staff to use QI tools and strategy. Mixed methods will be used to explore changes in pharmacy service quality, and to understand the experience of the pharmacy professionals taking part in the QI process.Intended Outcomes: To assess the capacity and willingness of community pharmacies to undertake self-directed QI initiatives, with the support of an external Quality Facilitator and an established QI approach. Understandings surrounding the transferability of this process, including further scale-up, and the production of additional change management tools are additional potential outcomes of this work. [ABSTRACT FROM AUTHOR]

Background: Deprescribing, the planned and supervised process of stopping or reducing doses of medications, can reduce the use of harmful or unnecessary medications. However, deprescribing is challenging for patients and prescribers to implement. Community pharmacists have the potential to contribute to deprescribing, but whether they are well positioned to do so effectively remains unclear.Objectives: To explore community pharmacists' involvement with deprescribing, and identify strategies for enhancing this involvement.Methods: We conducted qualitative telephone interviews with 17 community pharmacists in Ontario, Canada. The Behaviour Change Wheel's COM-B model was used to inform the development of the interview guide. Four investigators coded three transcripts independently to develop the codebook. One investigator coded the remainder and generated themes relating to the first study objective using inductive thematic analysis. Two phases of analysis were then used to satisfy the second study objective: the first without the explicit use of theory, and the second using the Behaviour Change Wheel as a theoretical framework.Results: Pharmacists' involvement in deprescribing was affected by: 1) their understanding of which medications should be stopped and by whom, 2) their access to patient information, and 3) competing clinical and business/technical demands of their daily activities. Findings support recommendations for optimizing community pharmacists' involvement in deprescribing by focusing on specific steps within deprescribing, expanding pharmacists' understanding of how to integrate deprescribing into their practices, and defining their deprescribing role with multi-stakeholder engagement.Conclusions: This study is the first to connect community pharmacists' real-world deprescribing challenges with theory-informed recommendations for enhancing their contributions to deprescribing. This study also explored the role of theory in pragmatically-oriented qualitative work by analyzing data without the explicit use of theory as the first step to analysis. Findings inform recommendations for enhancing community pharmacists' contributions to deprescribing. [ABSTRACT FROM AUTHOR]

One area of focus of the Bruyère Evidence-Based Deprescribing Guidelines Symposium held in March 2018 was encouraging the routine inclusion of deprescribing recommendations in clinical guidelines. Clinical guidelines often do not accommodate frailty or patients with multiple comorbid conditions. This can give rise to complex medication regimens and risk of medication harm. Despite monitoring and stopping treatment being a key part of rational prescribing, deprescribing is often overlooked in general and in the context of guidelines. There are several challenges to increasing deprescribing recommendations in clinical guidelines. These include limited evidence on the effects of deprescribing, lack of awareness among guideline developers, potential conflicts of interest, and lack of incentives for deprescribing research. To date, medicines regulators, payers, governments, and journals have not encouraged the inclusion of deprescribing recommendations in guidelines. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system could address some of these challenges through its focus on values and preferences, distinct rating of quality of evidence and strength of recommendations, downgrading quality due to indirect evidence, and an explicit approach to conflicts of interest. Further work to adapt GRADE methods to deprescribing could be of benefit. Establishing deprescribing recommendations as a routine part of clinical guidelines is an important opportunity to improve evidence-based clinical practice, and ultimately, patient care. [ABSTRACT FROM AUTHOR]

A World Café workshop was held at the Bruyère Evidence-Based Deprescribing Guidelines Symposium in March 2018 with 30 participants (researchers, clinicians, policy makers, stakeholders). This workshop explored priorities for future work in the field of deprescribing and deprescribing guidelines through group discussion. The discussions were guided by the following questions: (1) What are deprescribing research priorities (to inform guideline development), (2) What outcome measures are important for developing deprescribing guidelines, and (3) How do we evaluate the implementation and effectiveness of deprescribing guidelines? Discussion from all 3 questions identified 6 main priority areas: (1) conducting high-quality and long-term clinical trials that measure patient-important outcomes, (2) focusing on patient involvement and perspectives, (3) investigating the pharmacoeconomics of deprescribing interventions, (4) understanding deprescribing interventions in different populations, (5) generating evidence on clinical management during deprescribing (e.g. managing adverse drug withdrawal effects, subsequent re-prescribing), and (6) implementing interventions in clinical practice. These topics represent what a group of experienced researchers, clinicians, and stakeholders in the field collectively felt was important to consider for design and implementation of future deprescribing studies. The aim is for these findings to stimulate future discussions and be considered by granting agencies, policy makers, deprescribing research networks, and individual researchers planning future deprescribing studies. [ABSTRACT FROM AUTHOR]

Deprescribing is a clinically important and feasible innovation that ensures medication efficacy, reduces harms, and mitigates polypharmacy. It involves reducing doses or stopping medications that are not useful, no longer needed, or which may be causing harm. It may also involve changing to a safer agent or using non-pharmacological approaches for care instead. Clinical guidelines combined with behaviour changes (of health care providers (HCPs), the public, and health care decision-makers) are needed to integrate deprescribing into routine practice. Using rigorous international standards, the Bruyère Research Institute Deprescribing Guidelines research team validated a ground-breaking deprescribing guideline methodology and developed or co-developed 5 evidence-based deprescribing guidelines. In March 2018, the team hosted an international symposium convening HCPs, researchers, public agencies, policymakers, and patient advocates in Ottawa, Ontario, Canada. This 3-day symposium aimed to facilitate knowledge exchange amongst guideline developers, users, and the public; initiate partnerships and collaborations for new deprescribing guideline recommendations and effectiveness research; and to continue work on HCP deprescribing education activities. An interprofessional planning committee developed an overall agenda, and small groups worked on session objectives and formats for different components: methods for rigorous deprescribing guideline development, implementation experiences, research/evaluation experiences and educational needs. Through a series of keynote speakers, panel discussions, and small working groups, the symposium provided a forum for participants to meet one another, learn about their different experiences with deprescribing guidelines, and develop collaborations for future initiatives. One hundred thirty participants, from 10 countries and representing over 100 institutions and organizations took part. Symposium proceedings are presented in this issue of RSAP for sharing with the wider community engaged in the care of patients with problematic polypharmacy. [ABSTRACT FROM AUTHOR]

Background: In 2012, community pharmacists in Ontario, Canada gained regulatory authority to independently prescribe, including renew and adapt prescriptions. Studies have explored views of pharmacists, physicians and policymakers about pharmacist prescribing but less is known about the views of community pharmacy services users.Objective: To describe Ontario community pharmacy service users' support for and stated willingness to use pharmacist prescribing services.Methods: A qualitative descriptive study was conducted with 19 adults who had filled or refilled prescription(s) at a community pharmacy within the past three months. Participants were recruited through purposive and snowball sampling. Data were collected through one-on-one, semi-structured interviews between May and September 2016. Interview transcripts were coded and thematic analysis conducted. The first two transcripts were independently coded and analyzed by 2 researchers and after consensus was achieved, the lead researcher coded and analyzed the remainder of the data.Results: Most community pharmacy service users lacked experience with pharmacist prescribing services but perceived some potential benefits, including personal convenience. The majority of participants supported pharmacist prescribing. Support for and stated willingness to use pharmacist prescribing services varied by the type of service and was contingent upon the clinical purpose of the prescription, pharmacists' access to patient clinical information (e.g. health records), and the extent of pharmacist-physician collaboration during the prescribing process.Conclusion: Community pharmacy service users in Ontario expressed varying support for and stated willingness to use pharmacist prescribing services. This seemed to be due to their perceptions of the pharmacists' role (compared to physicians) and concerns about risks. Understanding these contributing factors will help implement strategies that address concerns and facilitate use of community pharmacists' prescribing services. [ABSTRACT FROM AUTHOR]

Interest in 'resurrecting' the lifeless by supporting breathing has been described since ancient times. For centuries, methods of resuscitating animals, then humans and specifically the 'lifeless' neonate were debated and discussed. Over time, with experimentation and worldwide collaboration, endotracheal tubes and laryngoscopes specific to the newborn were created and their use refined. This historical work has meant that today, the neonatal community focuses on refining the science and the art of intubation for the benefit of the newborn; who, where, when and how to intubate, with what devices and medications, bringing about significant change in the area of neonatal intubation. Recent work has focused on alternatives to neonatal intubation as the risks of endotracheal intubation and mechanical ventilation have become clearer. Appreciating the history of neonatal intubation and its (somewhat cyclical) changes over time can show us how far we've come and how far we can still go in the resuscitation and respiratory support of newborns. [ABSTRACT FROM AUTHOR]

Objectives: To examine how recent Doctor of Pharmacy graduates feel about providing full-scope pharmacist services (such as prescribing and immunization) and whether characteristics such as recent graduates' institutional and personal demographics, practice setting (e.g., busyness of practice, time spent directly with patients), or additional education after graduation affect their perceptions of feeling able and sure to perform services.Design: Cross-sectional survey.Setting and Participants: Recent graduates from 2 pharmacy schools in Ontario, Canada, who were licensed Ontario pharmacists and provided direct patient care in a community pharmacy setting.Outcome Measures: Dichotomous variables measured how able (less or more able) and sure (less or more sure) recent pharmacy graduates felt in performing 14 full-scope pharmacist services.Results: Of the 231 survey respondents (23.2% response rate), 120 met the inclusion criteria. Overall, graduates felt prepared to perform these services in practice, although for many services, graduates felt more sure than able. Busier practice settings and services that were provided less frequently had a negative impact on new graduate's perceptions of being able and sure. Respondents who were younger or were pursuing further postgraduate training also felt less able and sure.Conclusion: It is important for employers of new graduates and academics who train pharmacy students to recognize and encourage new graduates' feelings of being sure and able to provide full-scope pharmacist services. However, new graduates were not immune to the impacts of busy practice settings on provision of these services and should be supported in their development and interest in further training. [ABSTRACT FROM AUTHOR]

Background: Recognizing the potential effect of sex and gender on health outcomes, there is a shift toward conducting sex and gender-based analysis (SGBA) within health research. However, little is known about the extent to which SGBA has been incorporated into pharmacy practice research.Objectives: To understand the extent to which SGBA is included in pharmacy practice research.Method: Scoping review of English-language studies identified through MEDLINE, Embase, International Pharmacy Abstracts (IPA), and CINAHL (inception to Jan 2014). Two raters independently screened citations to identify titles and abstracts that included key words related to sex or gender and studies that could be categorized as pharmacy practice research. One author extracted data from included studies related to study design, population, intervention/exposure and outcomes, with results reviewed by another. All authors reviewed eligible articles to categorize them based on a previously-developed typology, and to assess four criteria: 1) the inclusion of sex or gender in research objectives, 2) the depth of sex/gender analysis incorporated into study designs and reporting, 3) the inclusion of sex or gender considerations in interpretation of study results, 4) the intentional and accurate use of sex/gender language.Results: Of 458 unique search results, only six articles met the inclusion criteria. Two of these six publications included sex/gender considerations in a model consistent with sex/gender based analysis as described by Hammarström. Three of the six studies inaccurately applied sex and gender terminology, whereas the two studies that featured sex or gender in their primary research question did use these terms appropriately.Conclusion: Despite increasing attention on the need for considering sex and gender, there was a paucity of pharmacy practice research publications that conducted SGBA. This presents an opportunity to explore sex, gender and intersectionality when pursuing studies that explore the impact of pharmacists interventions on patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Policy-makers and health professionals' views about pharmacist prescribing have been well studied, but less is known about the views of the public and patients.Objective: To describe from existing literature the views and experiences of patients as well as the views of the public about pharmacist prescribing.Methods: Sources: Medline, EMBASE, and International Pharmaceutical Abstracts from inception to November 2015; reference lists of included studies.Inclusion Criteria: English-language studies describing the views and experiences of patients and the views of the public about pharmacist prescribing. Two reviewers independently screened titles and abstracts and one reviewer charted data. The University of British Columbia Patient Experience Framework was used to categorize and synthesize findings about patients' experience. Views were described using a descriptive thematic synthesis approach.Results: Out of 2377 unique records, 35 articles were reviewed in full for eligibility. Three studies were excluded because participants were not patients or the public, eight studies were not about prescribing, and four studies were abstracts. Two articles were identified from the bibliographies of included studies. In total, twenty-two studies met inclusion criteria. Fourteen studies were quantitative (63.6%), six were qualitative (27.3%) and two were mixed design (9.1%) studies. Four studies (18.2%) were conducted in Canada (Saskatchewan, Newfoundland and Labrador, Nova Scotia), one (4.5%) in Australia, one (4.5%) in the United States (Washington) and the remaining in the United Kingdom (n = 16, 72.7%). The most commonly explored dimensions of patient experiences were access, interpersonal communication, and patient-reported impacts of care. Patients reported high satisfaction with appointment times, communication with the pharmacist prescriber and the services received. The public supported pharmacist prescribing in limited situations (chronic conditions, minor ailments, repeat medications). The public were concerned about privacy during consultations but patients were less so. Both patients and the public shared concerns regarding lack of adequate resources to ensure safe prescribing by pharmacists (e.g., lack of pharmacists' access to medical records, lack of additional staff support to fulfill prescribing responsibilities).Conclusion: Patients' experiences with pharmacist prescribing were generally positive. There were shared concerns between patients and the public about pharmacist prescribing. Opportunities for further research include strategies for building public experience with pharmacist prescribing and methods for addressing concerns identified by patients and the public. [ABSTRACT FROM AUTHOR]

We wished to describe how HR is first determined in preterm infants; and when HR is determined clinically, to compare it with the HR subsequently measured using PO. For the 24 infants whose HR was assessed clinically as <100 bpm, the subsequent PO HR was <100 bpm on 20 (83%) occasions. Table 1 Distribution of heart rate (HR) by clinical assessment compared with the subsequent pulse oximetry HR, n = 70. [Extracted from the article]

Objectives: To describe the Pharmacy Communication Partnership (PROMPT) program's approach to improving medication management for patients during transitions from hospital to the community.Setting: Two general internal medicine units within a multisite academic hospital in Canada.Practice Innovation: Designed by an interprofessional working group, PROMPT uses evidence-informed approaches to facilitate communication between pharmacists in different settings: faxing of the discharge prescription and medical discharge summary to a patient's community pharmacy, followed by a telephone call to the community pharmacist.Evaluation: A multimethod cross-sectional study used telephone surveys and retrospective chart reviews to describe: 1) the characteristics of patients that hospital pharmacists thought would benefit from PROMPT and the community pharmacies that served them; 2) the number and nature of communication attempts made by community and hospital pharmacists; and 3) community pharmacists' views about PROMPT's potential impact on continuity of care and potential program enhancements.Results: A convenience sample of 100 patients (median age 77 years, interquartile range 66 to 83) who received care from 86 pharmacies were used to evaluate the program. The majority of community pharmacists participating in the surveys considered the intervention to be helpful. Of the 53.7% (n = 44/82) community pharmacists who received discharge summaries, 93.2% (n = 41/44) found the summaries to be useful. Themes arising from community pharmacists' comments were categorized into 3 topics: 1) the benefits of PROMPT; 2) topics of discussion and clarification during telephone calls with hospital pharmacists; and 3) future program improvements.Conclusion: Community pharmacists described PROMPT as a time-efficient and helpful bridge linking community pharmacy to hospital inpatient care. Opportunities for future research include determining the characteristics of patients who may benefit most from PROMPT, determining the optimal components of discharge information needed by community pharmacists to enhance medication management, and evaluating whether follow-up telephone calls from the hospital to community pharmacists are necessary for all patients. [ABSTRACT FROM AUTHOR]

Objective: To determine the proportion of infants who had the tasks recommended in the neonatal resuscitation guidelines performed within 30 and 60 seconds of birth, and the time taken to perform each task. Study design: From video recordings in delivery rooms, we determined the time from birth and arrival on a resuscitation table to warm, assess heart rate (HR), attach an oximeter, and provide respiratory support for each infant. We determined the proportion of infants who had these tasks completed by 30 and 60 seconds, and the median time taken to perform each task. Results: We reviewed and analyzed data from 189 infants (median gestational age, 29 weeks [IQR, 27-34 weeks]; median birth weight, 1220 g [IQR, 930-2197 g]). Twelve infants (6%) were not on the resuscitation table within 30 seconds of birth. Less than 10% of infants were placed in polyethylene bags or had their HR determined by 30 seconds. By 60 seconds, 48% were in polyethylene bags, 33% had their HR determined, 38% received respiratory support, and 60% had an oximeter attached. The median time taken to perform all tasks was greater than that recommended in the guidelines. Conclusion: Most newborns were not managed within the time frame recommended in resuscitation guidelines. The recommended 30- and 60-second intervals may be too short. [Copyright &y& Elsevier]

Objectives To assess the effect of a proton pump inhibitor (PPI) deprescribing guideline on PPI usage and PPI drug costs in one long-term care home in Ontario, Canada. Design Interrupted time-series analysis to compare monthly PPI usage and average monthly PPI cost per resident 9 months before guideline implementation to 12 months after. Setting One long-term care home in Ottawa, Ontario, Canada. Participants Long-term care residents prescribed a PPI over a 21-month period (n = 335). Intervention PPI deprescribing guideline and decision support tool used during quarterly medication reviews. Measurements (1) Total number of PPI prescriptions (PPI usage) and (2) average PPI drug cost per resident. We also measured the proportion of residents whose PPI was deprescribed in the preguideline period and postguideline period. Results The deprescribing guideline was associated with a decrease in PPI usage but the association was not statistically significant (−8.7 prescriptions, 95% confidence interval [CI] −22.0 to 4.6). The PPI guideline led to a significant decrease in average monthly PPI drug cost per resident over time (0.16 CAD reduction per month; 95% CI −0.29 to −0.03). In the 9 months before intervention, 57 (27.8%) of 205 eligible residents had their PPI deprescribed, and in the 12 months after intervention 134 (50.0%) of 268 eligible residents had their PPI deprescribed (difference in proportions of 22.2%; 95% CI 13.4–30.4). Discussion/conclusion The deprescribing guideline was associated with a decline PPI usage; however, this negative association was not statistically significant. PPI usage declined in the initial 6 months after guideline implementation but began to climb back to baseline after this, which may explain the lack of a significant reduction in PPI usage. This suggests that it was difficult to maintain PPI deprescribing efforts long-term. Although implementation of a PPI deprescribing guideline may lead to an initial reduction in PPI usage, and a significant reduction in the average cost of PPI prescriptions over time, it is imperative to explore ways to sustain deprescribing guideline use. [ABSTRACT FROM AUTHOR]