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Introduction: There is a paucity of research on and a limited understanding of patient and public involvement (PPI) in the context of research in homelessness and, in particular, direct involvement of people with lived and living experience of homelessness (PEH) as expert advisors. We aim to report on outcomes and reflections from lived experience advisory panel (LEAP) meetings and PPI activities, held throughout the study lifecycle of a pilot randomised‐controlled trial (RCT) focused on evaluating integrated health and practical support for PEH. Methods: Community Pharmacy Homeless Outreach Engagement Non‐medical Independent prescribing Rx (PHOENIx Community Pharmacy RCT) is an integrated health and social care intervention for people experiencing homelessness who present to community pharmacy. Intervention includes weekly support from a pharmacist prescriber and a third sector support worker for up to 6 months. PPI activities undertaken throughout the study were documented, including outcomes of LEAP meetings. Outcome reporting followed Guidance for Reporting Involvement of Patients and the Public 2 Short Form (GRIPP2‐SF). Results: In total, 17 members were recruited into the LEAP; six meetings (three in two study sites) were held. PPI input was also received through representation from homelessness third sector organisation staff as study co‐applicants and core membership in the trial steering committee. Together, the PPI activities helped shape the study proposal, design of study materials, data analysis and dissemination materials. LEAP panel members offered valuable input via their experience and expertise into the delivery and refinement of interventions. Although longitudinal input was received from some LEAP members, ensuring repeat attendance in the pre‐planned meetings was challenging. Conclusion: People who face social exclusion and marginalisation can provide highly valuable input as equal partners in co‐design and delivery of interventions seeking to improve their health and well‐being. Fluid membership and flexible methods of seeking and incorporating advice can offer pragmatic approaches to minimising barriers to continued involvement in research. Patient or Public Contribution: This study reports findings and learning relevant to involvement of people with lived and living experience of homelessness as advisors in a research study. It is important for researchers to offer fluid memberships and use diverse methods to receive input from lived experience members, as traditional PPI methodology may be insufficient to ensure inclusivity. Staff and volunteers from third sector organisations were important PPI partners who bring their experience based on frontline service provision, often as the first port of call for people experiencing severe and multiple disadvantage. Trial Registration: ISRCTN88146807. [ABSTRACT FROM AUTHOR]

Context: People experiencing homelessness (PEH) who also experience problem drug use, have complex medical and social needs, with barriers to accessing services and treatments. Their treatment burden (the workload of self-management and impact on well-being) has not been described. Objective: The aim of this sub study is to use a validated questionnaire, the Patient Experience with Treatment and Self- management (PETS), to investigate perceived treatment burden in PEH. Study Design: Baseline data from the Pharmacist Homeless Outreach Engagement Non medical Independent prescribing Rx (PHOENIx) Trial. Setting/Population: Study undertaken in Scotland. Participants were homeless adults age 18 years or older, who had at least one non-fatal drug related overdose in the preceding 6 months. Results: 123/128 (96%) of participants completed PETS at baseline interview; mean age 42.1 (SD 8.6); 71.5 % male, and 99.2% white ethnicity. 91.2% had more than 5 chronic health conditions with mean of 8.5/participant. Scores range from 0-100, with higher score indicating higher burden of treatment. Mean PETS scores were highest in the domains indicating the impact of self- management on well-being: physical/mental exhaustion (Mean=79.54, SD=3.26); and role-social activity limitations (Mean=64, SD=3.48). Impact summary score; aggregated mean scores of domains indicating the impact of the self management of well being, was higher (71.8 SD 10.99) than the work load summary score; aggregated mean score of domains indicating the work a patient has to do to maintain health (45.77 SD 12.46). Conclusions : In a socially vulnerable chronologically young group of patients with high risk of overdose, PETS can be used to measure treatment burden. This study identified a profound impact of self-management on well-being and daily activities in a population at high risk with few resources. Scores were markedly higher than those observed in studies of non-homeless patient samples, despite this population being a younger cohort. Measuring PETs for this patient group should help with future resource allocation, service planning and patient care, Presenters Caitlin Jones, BSc, MBChB, Frances Mair, MD, FRCGP, Andrea Williamson, David Eton, PhD, Richard Lowrie, PhD, Andrew McPherson, PhD, [...]

Context: Almost 400 million people globally have chronic obstructive pulmonary disease (COPD). People with COPD often have multimorbidity and experience frequent exacerbations leading to hospitalisation. A feasibility study has shown pharmacist home-visits can provide holistic care, improve medication adherence and reduce exacerbations and hospital admission. A pilot randomised controlled trial (RCT) is now investigating the implementation and potential effects of such pharmacist home-visits. Objective: To examine patient and health care professional (HCP) perceptions of the intervention, acceptability of trial procedures and identify likely barriers and facilitators to future implementation. Study Design & Analysis: Qualitative interviews as part of a process evaluation embedded in pilot RCT. Thematic Analysis is being undertaken; we are conceptualising the work of self-management, including the issue of treatment burden and implementation issues through a Normalisation Process Theory (NPT) lens while also utilising the Cumulative Complexity Model to consider factors influencing patient capacity to self-manage. Setting & Population: 15 patients and 8 HCPs over two sites in Scotland. Intervention/Instrument: Tailored intervention in the home for patients with moderate-to-severe COPD and comorbidity by pharmacists and physicians. Results: The pharmacist intervention was well received by patients and HCPs, it identified and addressed much unmet need. While the intervention was beneficial to most patients it may particularly benefit those of lower socioeconomic status who have experienced more challenges in prior health care and self-management and seemed to more greatly value additional input provided by the pharmacist. Trial procedures were broadly acceptable to participants and HCPs. Facilitators included: relationships between HCPs involved in implementation; positive views of the pharmacist; and patients experiencing improvements as a result of the intervention. Barriers and challenges included: stretched resources; Information Technology problems; and issues implementing the intervention across different sites. Conclusions: The tailored at home pharmacist intervention was perceived positively by patients and HCPs and trial procedures were acceptable, suggesting that a full-scale trial is feasible. Future research may consider targeting of such interventions towards more socioeconomically deprived individuals., Presenters Karen Wood, MA, Richard Lowrie, PhD, Georgia Smith, Frances Mair, MD, FRCGP, Elaine Rankine, Donald Noble, MD, MBChB, Lynda Attwood, BSc, MSc, Gillian Cameron, BSc, MSc, GPhC [...]

PURPOSE Anticholinergic burden (ACB), the cumulative effect of anticholinergic medications, is associated with adverse outcomes in older people but is less studied in middle-aged populations. Numerous scales exist to quantify ACB. The aims of this study were to quantify ACB in a large cohort using the 10 most common anticholinergic scales, to assess the association of each scale with adverse outcomes, and to assess overlap in populations identified by each scale. METHODS We performed a longitudinal analysis of the UK Biobank community cohort (502,538 participants, baseline age: 37-73 years, median years of follow-up: 6.2). The ACB was calculated at baseline using 10 scales. Baseline data were linked to national mortality register records and hospital episode statistics. The primary outcome was a composite of all-cause mortality and major adverse cardiovascular event (MACE). Secondary outcomes were all-cause mortality, MACE, hospital admission for fall/fracture, and hospital admission with dementia/ delirium. Cox proportional hazards models (hazard ratio [HR], 95% CI) quantified associations between ACB scales and outcomes adjusted for age, sex, socioeconomic status, body mass index, smoking status, alcohol use, physical activity, and morbidity count. RESULTS Anticholinergic medication use varied from 8% to 17.6% depending on the scale used. For the primary outcome, ACB was significantly associated with all-cause mortality/MACE for each scale. The Anticholinergic Drug Scale was most strongly associated with mortality/MACE (HR = 1.12; 95% CI, 1.11-1.14 per 1-point increase in score). The ACB was significantly associated with all secondary outcomes. The Anticholinergic Effect on Cognition scale was most strongly associated with dementia/delirium (HR = 1.45; 95% CI, 1.3-1.61 per 1 -point increase). CONCLUSIONS The ACB was associated with adverse outcomes in a middle- to older-aged population. Populations identified and effect size differed between scales. Scale choice influenced the population identified as potentially requiring reduction in ACB in clinical practice or intervention trials. Key words: anticholinergic burden; polypharmacy; multimorbidity; mortality; cardiovascular events, INTRODUCTION Many frequently prescribed medications for a range of medical conditions have anticholinergic properties. (1) The use of multiple anticholinergic medications leads to a cumulative effect, referred to as the [...]

Introduction: In Scotland, a third of all deaths of people experiencing homelessness (PExH) are street-drug-related, and less than half of their multiple physical- and mental health conditions are treated. New, holistic interventions are required to address these health inequalities. PHOENIx (Pharmacist Homeless Outreach Engagement and Non-medical Independent prescribing Rx) is delivered on outreach by National Health Service (NHS) pharmacist independent prescribers in partnership with third sector homelessness charity workers. We describe participant's perspectives of PHOENIx. Methods: This study aims to understand experiences of the PHOENIx intervention by participants recruited into the active arm of a pilot randomised controlled trial (RCT). Semi-structured in-person interviews explored participants' evaluation of the intervention. In this study, the four components (coherence, cognitive participation, collective action, reflexive monitoring) of the Normalisation Process Theory (NPT) framework underpinned data collection and analyses. Results: We identified four themes that were interpreted within the NPT framework that describe participant evaluation of the PHOENIx intervention: differentiating the intervention from usual care (coherence), embedding connection and consistency in practice (cognitive participation), implementation of practical and emotional operational work (collective action), and lack of power and a commitment to long-term support (reflexive monitoring). Participants successfully engaged with the intervention. Facilitators for participant motivation included the relationship-based work created by the PHOENIx team. This included operational work to fulfil both the practical and emotional needs of participants. Barriers included concern regarding power imbalances within the sector, a lack of long-term support and the impact of the intervention concluding. Conclusions: Findings identify and describe participants' evaluations of the PHOENIx intervention. NPT is a theoretical framework facilitating understanding of experiences, highlighting both facilitators and barriers to sustained engagement and investment. Our findings inform future developments regarding a subsequent definitive RCT of PHOENIx, despite challenges brought about by challenging micro and macro-economic and political landscapes. [ABSTRACT FROM AUTHOR]

The past ten years has seen a marked increase in the numbers of people experiencing homelessness globally and an associated public health epidemic of drug-related deaths. Drawing from qualitative interviews as part of a wider pilot randomised controlled trial (RCT) conducted in Glasgow, Scotland with National Health Service pharmacists and third sector homeless outreach caseworkers, insights from those with living experience of both homelessness and a recent non-fatal drug overdose will be presented. Twenty people experiencing homelessness with at least one drug overdose in the past six months were interviewed in person, in a homelessness drop in centre or in emergency accommodation between November 2021 and January 2022. Findings from our study indicate that participants' drug use and overdose risk were exacerbated during the Covid-19 pandemic due to the pervasive availability of illicit drugs for those placed in emergency accommodation, alongside reduced support and access to health and social care services. Additionally, multi-agency stressors such as a lack of autonomy and dehumanising experiences were reported, leading to a significant sense of powerlessness. Furthermore, the necessity of advocacy-based services as critical aspects of support was identified, with importance placed upon dedicated, homelessness staff and access to safe environments. [ABSTRACT FROM AUTHOR]

Context: Limitations to crop yield due to subsurface (5–15 cm depth) compaction layers (>2 MPa) and subsurface acidity (pHCa <4.8) have frequently been reported on the non-sodic soils of south-eastern Australia, but amendment studies have been limited in number and inconsistent in the extent and longevity of any response. Aim: We tested the hypothesis that amendment of subsurface acidity and compaction would lead to increased grain yield. Method: We investigated crop response to the alleviation of these combined subsurface soil constraints by using deep ripping and dry limestone injection to 30 cm depth over 3 years in a canola–cereal sequence. Key results: Deep tillage and injection of limestone into the soil both failed to produce significant grain yield responses in any year, despite the reduction of soil strength and increase in pH in subsurface layers. Early vegetative growth sometimes responded to the treatments, but the loss of stored soil water during drier than average seasons appeared to limit grain response. However, we also observed that a proportion of plant roots penetrated these relatively thin constraint layers in unamended soils. Conclusions: Amelioration of subsurface acidity and compaction does not necessarily increase grain yield. Implications: The effects of subsurface acidity and compaction should be tested on other species and during varying rainfall deciles. Given the potentially large resource requirements for deep amendment of soils, we propose that the selection of tolerant species and cultivars might be more effective in the short term. Recorded apparent declines in canola grain yield have been associated with abnormal canola roots. We investigated the amelioration of low subsurface soil pH and hardpans by deep lime placement and deep ripping. Despite increased soil pH and lower soil strength in the subsurface soil, there were no significant grain yield responses in either canola or cereals during drier than normal years. [ABSTRACT FROM AUTHOR]

Abstract. Nitrification and urease inhibitors have been used to reduce nitrous oxide ([N.sub.2]O) emissions and increase nitrogen use efficiency in many agricultural systems. However, their agronomic benefits, such as the [...]

Background: People experiencing homelessness (PEH) who have problem drug use have complex medical and social needs, with barriers to accessing services and treatments. Their treatment burden (workload of self-management and impact on wellbeing) remains unexplored. Aim: To investigate treatment burden in PEH with a recent non-fatal overdose using a validated questionnaire, the Patient Experience with Treatment and Self-management (PETS). Design and setting: The PETS questionnaire was collected as part of a pilot randomised control trial (RCT) undertaken in Glasgow, Scotland; the main outcome is whether this pilot RCT should progress to a definitive RCT. Method: An adapted 52-item, 12-domain PETS questionnaire was used to measure treatment burden. Greater treatment burden was indicated by higher PETS scores. Results: Of 128 participants, 123 completed PETS; mean age was 42.1 (standard deviation [SD] 8.4) years, 71.5% were male, and 99.2% were of White ethnicity. Most (91.2%) had >5 chronic conditions, with an average of 8.5 conditions. Mean PETS scores were highest in domains focusing on the impact of self-management on wellbeing: physical and mental exhaustion (mean 79.5, SD 3.3) and role and social activity limitations (mean 64.0, SD 3.5) Scores were higher than those observed in studies of patients who are not homeless. Conclusion: In a socially marginalised patient group at high risk of drug overdose, the PETS showed a very high level of treatment burden and highlights the profound impact of self-management work on wellbeing and daily activities. Treatment burden is an important person-centred outcome to help compare the effectiveness of interventions in PEH and merits inclusion in future trials as an outcome measure. [ABSTRACT FROM AUTHOR]

Dryland cereal production systems of south-eastern Australia require viable options for reducing nitrous oxide ([N.sub.2]O) emissions without compromising productivity and profitability. A 4-year rotational experiment with wheat (Triticum aestivum L.)--canola (Brassica napus L.)--grain legumes wheat in sequence was established at Wagga Wagga, NSW, Australia, in a semiarid Mediterranean-type environment where long-term average annual rainfall is 541 mm and the incidence of summer rainfall is episodic and unreliable. The objectives of the experiment were to investigate whether (i) tillage increases [N.sub.2]O emissions and (ii) nitrogen (N) application can improve productivity without increasing [N.sub.2]O emissions. The base experimental design for each crop phase was a split-plot design with tillage treatment (tilled versus no-till) as the whole plot, and N fertiliser rate (0, 25, 50 and 100 kg N/ha) as the subplot, replicated three times. This paper reports high resolution [N.sub.2]O emission data under a canola crop. The daily [N.sub.2]O emission rate averaged 0.55 g [N.sub.2]O-N/ha. day, ranging between -0.81 and 6.71 g [N.sub.2]O-N/ha.day. The annual cumulative [N.sub.2]O-N emitted was 175.6 and 224.3 g [N.sub.2]O-N/ha under 0 and 100 kg N/ha treatments respectively. There was no evidence to support the first hypothesis that tillage increases [N.sub.2]O emissions, a result which may give farmers more confidence to use tillage strategically to manage weeds and diseases where necessary. However, increasing N fertiliser rate tended to increase [N.sub.2]O emissions, but did not increase crop production at this site. Additional keywords: conservation tillage, greenhouse gases, nitrogen fertiliser, trace gas emission., Introduction In Australia, the agriculture sector is the dominant source of anthropogenic nitrous oxide ([N.sub.2]O), accounting for 78.6% of the net national [N.sub.2]O emissions (Commonwealth of Australia 2014). Globally, 70% [...]

Background: Anticholinergic burden (ACB), is defined as the cumulative effect of anticholinergic medication which are widely prescribed to older adults despite increasing ACB being associated with adverse effects such as: falls, dementia and increased mortality. This research explores the views of health care professionals (HCPs) and patients on a planned trial to reduce ACB by stopping or switching anticholinergic medications. The objectives were to explore the views of key stakeholders (patients, the public, and HCPs) regarding the potential acceptability, design and conduct of an ACB reduction trial. Materials and Methods: We conducted qualitative interviews and focus groups with 25 HCPs involved in prescribing medication with anticholinergic properties and with 22 members of the public and patients who were prescribed with the medication. Topic guides for the interviews and focus groups explored aspects of feasibility including: 1) views of a trial of de-prescribing/medication switching; 2) how to best communicate information about such a trial; 3) views on who would be best placed and preferred to undertake such medication changes, e.g., pharmacists or General Practitioners (GPs)? 4) perceived barriers and facilitators to trial participation and the smooth conduct of such a trial; 5) HCP views on the future implementability of this approach to reducing ACB and 6) patients' willingness to be contacted for participation in a future trial. Qualitative data analysis was underpinned by Normalization Process Theory. Results: The public, patients and HCPs were supportive of an ACB reduction trial. There was consensus among the different groups that key points to consider with such a trial included: 1) ensuring patient engagement throughout to enable concerns/potential pitfalls to be addressed from the beginning; 2) ensuring clear communication to minimise potential misconceptions about the reasons for ACB reduction; and 3) provision of access to a point of contact for patients throughout the life of a trial to address concerns; The HCPs in particular suggested two more key points: 4) minimise the workload implications of any trial; and 5) pharmacists may be best placed to carry out ACB reviews, though overall responsibility for patient medication should remain with GPs. Conclusion: Patients, the public and HCPs are supportive of trials to reduce ACB. Good communication and patient engagement during design and delivery of a trial are essential as well as safety netting and minimising workload. [ABSTRACT FROM AUTHOR]

Background: Epidemiological studies focused on primary healthcare needs of persons experiencing homelessness (PEH) are often based on data from specialist homeless healthcare services. Aim: To explore the presentation of PEH, coding of homelessness, and associated health conditions in mainstream primary care general practices in England. Design & setting: EMIS electronic database search of medical records was conducted across 48 general practices in a clinical commissioning group (CCG), representing one of the most socioeconomically deprived regions in England, which also lacks a specialist primary healthcare service for PEH. Method: Key terms and codes were used to identify PEH, their respective diagnoses across 22 health conditions, and prescribed medications over the past 4 years. Results: From a population of approximately 321 000, 43 (0.013%) people were coded as PEH, compared with a homelessness prevalence of 0.5% in the English general population. Mental health conditions were the most prevalent diagnoses among the PEH registrants (56.6%); the recorded prevalence of other common long-term conditions in PEH was lower than the levels observed in PEH registered with specialist homelessness health services. Conclusion: In a population with approximately four times higher rate of statutory homelessness, PEH representation in mainstream general practices was under-represented by several folds. As homelessness overlaps with mental health, substance misuse, and long-term health conditions, consistent coding of homelessness in medical records is imperative in order to offer tailored support and prevention actions when patients present for services. [ABSTRACT FROM AUTHOR]

Objectives: Most patients receive systemic anticancer therapy (SACT) as day cases and toxicities, if they occur, are likely to appear first in primary care. Pharmaceutical care can be delivered by community pharmacists, but little is known about the epidemiology of SACT toxicities in the community and potential interventions to address these which raise the following questions: what are the typologies of SACT-associated toxicities experienced by community-based patients and what are the associated pharmaceutical care issues (PCIs)? The aim of this study was to identify toxicities and pharmaceutical care issues of patients prescribed SACT for lung cancer and understand the potential for community pharmacists to deliver aspects of cancer care including toxicity management. Methods: Retrospective analysis of clinical records of patients prescribed oral and parenteral SACT in 2013-14, to describe patient characteristics; SACT toxicity; PCIs and episodes of unscheduled care. Key findings: Twelve categories of toxicity and 13 categories of PCIs were identified from 50 patients. More PCIs were observed with oral SACT/oral-parenteral combinations than with parenteral regimens. The PCIs which could be managed by community pharmacists were mucositis; skin toxicity; gastrointestinal toxicity; reinforcing patient education and identification/prevention of drug interactions. Conclusions: Community pharmacists are ideally placed to provide pharmaceutical care to patients with lung cancer prescribed SACT. Cancer specialists in secondary care can signpost patients to community pharmacists for early management of low-grade SACT toxicity. [ABSTRACT FROM AUTHOR]

Objectives: Medication adherence is the end result of a complex set of interwoven factors. Non‐adherence with medication in heart failure patients is associated with excess mortality and morbidity. Studies describing interventions to improve adherence in heart failure are limited by a lack of robust methods and inconsistent outcomes. The aim of this evaluation was to explore the barriers to medication adherence in Scottish heart failure patients in order to inform the development of complex interventions. Methods: Qualitative patient interviews. Participants were aged ≥18 years with current or previous signs or symptoms of clinical heart failure, reduced left ventricular ejection fraction ≤45% and confirmed adherence of <80% in tablet counts of heart failure therapy. Thematic analysis was employed. Key findings: Eleven patients were recruited. The median age was 79 years old, and participants were typically from socially deprived communities. Participants were prescribed a mean 9.9 different medications per day. Seven distinct themes emerged around barriers to medication adherence: co‐morbidity; treatment burden; health literacy; trust in NHS; socioeconomic factors; autonomy and health expectations. Conclusions: The factors affecting medication adherence in heart failure are multi‐factorial and are unlikely to be improved by one single‐faceted intervention. Future interventions need to treat patients holistically, build their trust as partners, simplify complex treatment regimens where possible and involve educational and social elements. The skill set and opportunities afforded to pharmacists may be well placed to deliver many of these aspects but this would need tested in the context of the development of complex interventions. [ABSTRACT FROM AUTHOR]

Objectives: To illustrate and review this new service and to describe the demographics of the patient group and the typology of interventions made by the pharmacist prescribers. Methods: Pharmacists provided pop‐up, drop‐in (no appointment needed) health clinics to various homeless support venues in Glasgow City Centre. Data from pharmacists' interventions (n = 52) and patient demographics were gathered from clinical records. Data were then extracted, transcribed and analysed. Key findings: The demographics of the homeless patient group consisted mainly of white middle‐aged males (mean age 39.8 years), of Scottish ethnicity and living in homeless hostels. Medications were prescribed by pharmacists in 62% of all patients. New medications were initiated in 69% of these patients; repeat/re‐issues of lapsed medications were issued in 66% of these patients; changes were made to existing medication in 16%. The most commonly prescribed items were as follows: wound dressings; antihypertensives; antidiabetics; analgesics; inhalers; antidepressants; and nutritional supplements. Pharmacists diagnosed a new clinical issue in 69% of patients, most commonly with infections (skin or respiratory) in 36% of patients. Sixty‐two per cent of patients had their presenting symptoms managed by the pharmacist alone. Patient engagement was good with 85% subsequently attending either a follow‐up with the pharmacist or onward referral (to specialist services, secondary care, general practitioner appointment etc). Conclusions: Assertive outreach by pharmacist independent prescribers for people who are homeless is feasible and leads to increased access to medicines for acute and chronic health problems. Further work is needed to evaluate the impact of this new service on key clinical outcomes. [ABSTRACT FROM AUTHOR]

Opioid substitution therapy (OST) is currently the gold standard treatment for patients with illicit opioid addiction (most commonly to heroin). Its use is evidence-based, with proven reductions in negative outcomes and increased positive outcomes for patients taking OST compared with those who do not. However, mortality rates and adverse outcomes, including hospitalisation and imprisonment, are still higher in illicit drug users and patients on OST compared with the general population. Polydrug use, male gender, increased age and injection of drugs are associated with higher mortality. Time points associated with the greatest risk of mortality include the first 2 weeks of commencing or discontinuing OST; during hospitalisation; within the first 28 days of discharge from hospital; and within the first 2 weeks of discharge from prison. Risk factors for hospitalisation include hepatitis C-positive status, HIV-positive status and co-morbid mental health disorders. The greatest risk factor for imprisonment and criminal recidivism is polydrug use. Continuity and consistency of OST are associated with lower risk of mortality, hospitalisation and re-incarceration. This article summarises the risk factors of these adverse outcomes in order to raise awareness among pharmacists and other healthcare professionals working with OST patients to optimise patient safety and reduce adverse outcomes. [ABSTRACT FROM AUTHOR]

Objective Identify, describe and appraise trials of interventions delivered by healthcare professionals to manage non-communicable diseases (NCDs) and communicable diseases that require long-term care or treatment (LT-CDs), excluding mental health and substance use disorders, in homeless adults. Design Systematic review of randomised controlled trials (RCTs), non-RCTs and controlled before-after studies. Interventions characterised using Effective Practice and Organisation of Care (EPOC) taxonomy. Quality assessed using EPOC risk of bias criteria. Data sources Database searches (MEDLINE, Embase, PsycINFO, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Applied Social Sciences Index and Abstracts (ASSIA) and Cochrane Central Register of Controlled Trials), hand searching reference lists, citation searches, grey literature and contact with study authors. Setting Community. Participants Adults (=18 years) fulfilling European Typology of Homelessness criteria. Intervention Delivered by healthcare professionals managing NCD and LT-CDs. Outcomes Primary outcome: unscheduled healthcare utilisation. Secondary outcomes: mortality, biological markers of disease control, adherence to treatment, engagement in care, patient satisfaction, knowledge, selfefficacy, quality of life and cost-effectiveness. Results 11 studies were included (8 RCTs, 2 quasiexperimental and 1 feasibility) involving 9-520 participants (67%-94% male, median age 37-49 years). Ten from USA and one from UK. Studies included various NCDs (n=3); or focused on latent tuberculosis (n=4); HIV (n=2); hepatitis C (n=1) or type 2 diabetes (n=1). All interventions were complex with multiple components. Four described theories underpinning intervention. Three assessed unscheduled healthcare utilisation: none showed consistent reduction in hospitalisation or emergency department attendance. Six assessed adherence to specific treatments, of which four showed improved adherence to latent tuberculosis therapy. Three concerned education case management, all of which improved disease-specific knowledge. No improvements in biological markers of disease (two studies) and none assessed mortality. Conclusions Evidence for management of NCD and LT-CDs in homeless adults is sparse. Educational casemanagement interventions may improve knowledge and medication adherence. Large trials of theory-based interventions are needed, assessing healthcare utilisation and outcomes as well as assessment of biological outcomes and cost-effectiveness. [ABSTRACT FROM AUTHOR]

Introduction People experiencing homelessness are at increased risk of, and have poorer outcomes from, a range of physical long-term conditions (LTCs). It is increasingly recognised that interventions targeting people who are homeless should be tailored to the specific needs of this population. This systematic review aims to identify, describe and appraise trials of interventions that aim to manage physical LTCs in homeless adults and are delivered by healthcare professionals. Methods and analysis Seven electronic databases (Medline, EMBASE, Cochrane Central Register of Controlled Trials, Assia, Scopus, PsycINFO and CINAHL) will be searched from 1960 (or inception) to October 2016 and supplemented by forward citation searching, handsearching of reference lists and searching grey literature. Two reviewers will independently review titles, abstract and full-texts using DistillerSR software. Inclusion criteria include (1) homeless adults with any physical LTC, (2) interventions delivered by a healthcare professional (any professional trained to provide any form of healthcare, but excluding social workers and professionals without health-related training), (3) comparison with usual care or an alternative intervention, (4) report outcomes such as healthcare usage, physical and psychological health or well-being or cost-effectiveness, (5) randomised controlled trials, non-randomised controlled trials, controlled before-after studies. Quality will be assessed using the Cochrane EPOC Risk of Bias Tool. A meta-analysis will be performed if sufficient data are identified; however, we anticipate a narrative synthesis will be performed. Ethics and dissemination This review will synthesise existing evidence for interventions delivered by healthcare professionals to manage physical LTCs in adults who are homeless. The findings will inform the development of future interventions and research aiming to improve the management of LTCs for people experiencing homelessness. Ethical approval will not be required for this systematic review as it does not contain individual patient data. We will disseminate the results of this systematic review via conference presentations, healthcare professional networks, social media and peer-reviewed publication. Trial registration number PROSPERO registration number: CRD42016046183. [ABSTRACT FROM AUTHOR]

Background: The inverse equity hypothesis asserts that new health policies initially widen inequality, then attenuate inequalities over time. Since 2004, the UK's pay-for-performance scheme for chronic disease management (CDM) in primary care general practices (the Quality and Outcomes Framework) has permitted practices to except (exclude) patients from attending annual CDM reviews, without financial penalty. Informed dissent (ID) is one component of exception rates, applied to patients who have not attended due to refusal or non-response to invitations. 'Population achievement' describes the proportion receiving care, in relation to those eligible to receive it, including excepted patients. Examination of exception reporting (including ID) and population achievement enables the equity impact of the UK pay-for-performance contract to be assessed. We conducted a longitudinal analysis of practice-level rates and of predictors of ID, overall exceptions and population achievement for CDM to examine whether the inverse equity hypothesis holds true.Methods: We carried out a retrospective, longitudinal study using routine primary care data, analysed by multilevel logistic regression. Data were extracted from 793 practices (83% of Scottish general practices) serving 4.4 million patients across Scotland from 2010/2011 to 2012/2013, for 29 CDM indicators covering 11 incentivised diseases. This provided 68,991 observations, representing a total of 15 million opportunities for exception reporting.Results: Across all observations, the median overall exception reporting rate was 7.0% (7.04% in 2010-2011; 7.02% in 2011-2012 and 6.92% in 2012-2013). The median non-attendance rate due to ID was 0.9% (0.76% in 2010-2011; 0.88% in 2011-2012 and 0.96% in 2012-2013). Median population achievement was 83.5% (83.51% in 2010-2011; 83.41% in 2011-2012 and 83.63% in 2012-2013). The odds of ID reporting in 2012/2013 were 16.0% greater than in 2010/2011 (p < 0.001). Practices in Scotland's most deprived communities were twice as likely to report non-attendance due to ID (odds ratio 2.10, 95% confidence interval 1.83-2.40, p < 0.001) compared with those in the least deprived; rural practices reported lower levels of non-attendance due to ID. These predictors were also independently associated with overall exceptions. Rates of population achievement did not change over time, with higher levels (higher remuneration) associated with increased rates of overall and ID exception and more affluent practices.Conclusions: Non-attendance for CDM due to ID has risen over time, and higher rates are seen in patients from practices located in disadvantaged areas. This suggests that CDM incentivisation does not conform to the inverse equity hypothesis, because inequalities are widening over time with lower uptake of anticipatory care health checks and CDM reviews noted among those most in need. Incentivised CDM needs to include incentives for engaging with the 'hard to reach' if inequalities in healthcare delivery are to be tackled. [ABSTRACT FROM AUTHOR]

Background: Small trials with short term follow up suggest pharmacists’ interventions targeted at healthcare professionals can improve prescribing. In comparison with clinical guidance, contemporary statin prescribing is sub-optimal and achievement of cholesterol targets falls short of accepted standards, for patients with atherosclerotic vascular disease who are at highest absolute risk and who stand to obtain greatest benefit. We hypothesised that a pharmacist-led complex intervention delivered to doctors and nurses in primary care, would improve statin prescribing and achievement of cholesterol targets for incident and prevalent patients with vascular disease, beyond one year. Methods: We allocated general practices to a 12-month Statin Outreach Support (SOS) intervention or usual care. SOS was delivered by one of 11 pharmacists who had received additional training. SOS comprised academic detailing and practical support to identify patients with vascular disease who were not prescribed a statin at optimal dose or did not have cholesterol at target, followed by individualised recommendations for changes to management. The primary outcome was the proportion of patients achieving cholesterol targets. Secondary outcomes were: the proportion of patients prescribed simvastatin 40 mg with target cholesterol achieved; cholesterol levels; prescribing of simvastatin 40 mg; prescribing of any statin and the proportion of patients with cholesterol tested. Outcomes were assessed after an average of 1.7 years (range 1.4–2.2 years), and practice level simvastatin 40 mg prescribing was assessed after 10 years. Findings: We randomised 31 practices (72 General Practitioners (GPs), 40 nurses). Prior to randomisation a subset of eligible patients were identified to characterise practices; 40% had cholesterol levels below the target threshold. Improvements in data collection procedures allowed identification of all eligible patients (n = 7586) at follow up. Patients in practices allocated to SOS were significantly more likely to have cholesterol at target (69.5% vs 63.5%; OR 1.11, CI 1.00–1.23; p = 0.043) as a result of improved simvastatin prescribing. Subgroup analysis showed the primary outcome was achieved by prevalent but not incident patients. Statistically significant improvements occurred in all secondary outcomes for prevalent patients and all but one secondary outcome (the proportion of patients with cholesterol tested) for incident patients. SOS practices prescribed more simvastatin 40 mg than usual care practices, up to 10 years later. Interpretation: Through a combination of educational and organisational support, a general practice based pharmacist led collaborative intervention can improve statin prescribing and achievement of cholesterol targets in a high-risk primary care based population. Trial Registration: International Standard Randomised Controlled Trials Register [ABSTRACT FROM AUTHOR]

Background The Quality and Outcomes Framework (QOF) has specific targets for body mass index (BMI) and blood pressure recording in major mental illness (MMI), diabetes, and chronic kidney disease (CKD). Although aspects of MMI (schizophrenia, bipolar disorder, and related psychoses) are incentivised, barriers to care may occur. Aim To compare payment, population achievement, and exception rates for blood pressure and BMI recording in MMI relative to diabetes and CKD across the UK. Design and setting Analysis of 2012/2013 QOF data from 9731 UK general practices 2 years after the introduction of the mental health, BMI, and blood pressure QOF indicators. Method Payment, exception, and population achievement rates for the MMI and CKD blood pressure indicators and the MMI and diabetes BMI indicators were calculated and compared. Results UK payment and population achievement rates for BMI recording for MMI were significantly lower than for diabetes (payment: 92.7% versus 95.5% and population achievement: 84.0% versus 92.5%, P<0.001) and exception rates were higher (8.1% versus 2.0%, P<0.001). For blood pressure recording, UK payment and population achievement rates were significantly lower for MMI than for CKD (94.1% versus 97.8% and 87.0% versus 97.1%, P<0.001), while exception rate was higher (6.5% versus 0.0%, P<0.001). This was observed for all countries. Compared with England, Northern Ireland had higher population achievement rates for both mental health indicators, whereas Scotland and Wales had lower rates. There were no cross-jurisdiction differences for CKD and diabetes. Conclusion Differences in payment, exception, and population achievement rates for blood pressure and BMI recording for MMI relative to CKD and diabetes were observed across the UK. These findings suggest potential inequalities in the monitoring of physical health in MMI within the UK primary care system. [ABSTRACT FROM AUTHOR]

Heart failure (HF) is a malignant condition with many presentations. The type of HF directs appropriate therapeutic management. Primary care is increasingly seen as a solution to improving the variation in outcomes seen in national HF audits. This article describes and summarises existing UK primary care HF services and emerging issues of importance, focusing on the identification of suitable patients. The authors suggest approaches to address these issues, and describe why ensuring the accuracy and completeness of disease registers is an essential first step. The authors propose that the systematic review of all HF patients in primary care, augmented with a few simple annual checks, could have a major long-term positive impact on outcomes. As the NHS struggles to cope with the increasing prevalence and burden of HF, the evidence base suggests that nurses and pharmacists may have a key role to play in delivering this process. [ABSTRACT FROM AUTHOR]

The article discusses research on the treatment and management of allergic rhinitis in primary care in Great Britain as of 2013. Topics include the effects of allergic rhinitis on respiratory conditions and patients' quality of life; the development of models of care for goal-oriented health intervention; disease prevalence of hay fever in Great Britain; and clinical trials on the reduction of symptoms through self-management intervention programs.

Persons experiencing homelessness have a high prevalence of severe mental health problems, alcohol dependence, substance misuse and infectious hepatitis C, and face up to twelve times higher mortality rates compared to the general population. They also face barriers to accessing healthcare. However, clinical pharmacy services are currently not available to homeless populations in England. The aim of this study was to conduct public involvement sessions with persons experiencing homelessness with a view to inform the design of patient-centred clinical pharmacy healthcare services. Qualitative methodology was used, using a focus group with homeless persons from emergency shelters and one to one engagement with those sleeping rough, using a topic guide. A total of nine homeless persons took part—seven males and two females. The participants of the sessions said that patient-centred clinical pharmacy services delivered for homeless persons would address many of their unmet needs around access to medicines, their understanding of prescribed medicines and holistic management of their health. The service would be able to make a positive impact on their health outcomes by screening for health conditions, facilitating better integration across services, referral and liaison with other services, and minimising misuse of prescribed medicines. The findings of this study will be used to inform the development, implementation and evaluation of a patient-centred clinical pharmacy service tailored to meet the specific needs of the homeless population. [ABSTRACT FROM AUTHOR]

Background: The Quality and Outcomes Framework (QOF) has specific targets for body mass index (BMI) and blood pressure recording in major mental illness (MMI), diabetes, and chronic kidney disease (CKD). Although aspects of MMI (schizophrenia, bipolar disorder, and related psychoses) are incentivised, barriers to care may occur.Aim: To compare payment, population achievement, and exception rates for blood pressure and BMI recording in MMI relative to diabetes and CKD across the UK.Design and Setting: Analysis of 2012/2013 QOF data from 9731 UK general practices 2 years after the introduction of the mental health, BMI, and blood pressure QOF indicators.Method: Payment, exception, and population achievement rates for the MMI and CKD blood pressure indicators and the MMI and diabetes BMI indicators were calculated and compared.Results: UK payment and population achievement rates for BMI recording for MMI were significantly lower than for diabetes (payment: 92.7% versus 95.5% and population achievement: 84.0% versus 92.5%, P<0.001) and exception rates were higher (8.1% versus 2.0%, P<0.001). For blood pressure recording, UK payment and population achievement rates were significantly lower for MMI than for CKD (94.1% versus 97.8% and 87.0% versus 97.1%, P<0.001), while exception rate was higher (6.5% versus 0.0%, P<0.001). This was observed for all countries. Compared with England, Northern Ireland had higher population achievement rates for both mental health indicators, whereas Scotland and Wales had lower rates. There were no cross-jurisdiction differences for CKD and diabetes.Conclusion: Differences in payment, exception, and population achievement rates for blood pressure and BMI recording for MMI relative to CKD and diabetes were observed across the UK. These findings suggest potential inequalities in the monitoring of physical health in MMI within the UK primary care system. [ABSTRACT FROM AUTHOR]