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REVISiTing GPs in training prescribing to improve medication safety

16 Nov

Pharmacist_small

by Ndeshi Salema

In 2012, the PRACtICe study, funded by the General Medical Council, set out to determine the prevalence and nature of prescribing and monitoring errors in general practices in England. The PRACtICe study found that prescribing errors occur in around one in twenty, or about 5% of the prescriptions. This is important because:

The PRACtICe study also highlighted that, as a group, GPs in training may benefit from further support in prescribing. Further exploratory work took place to identify possible ways to support GPs in training with their prescribing, which resulted in the development of an educational intervention, called REVISiT.

The REVISiT intervention involves:

  • a retrospective review of GPs in training prescribing, which is completed by a pharmacist, followed by
  • individualised feedback on the results of this review in the form of a report, which is discussed in a face-to-face meeting setting.

A small feasibility study of the REVISiT intervention (a retrospective review of approximately 100 prescriptions prescribed by 10 GPs in training) found that 9% of the prescriptions by GPs in training contained an error. The percentage of errors made by GPs in training was much higher than the percentage that was found in the PRACTiCE study, which may be due to the relative inexperience of GPs in training. It also indicated some benefits of the REVISiT intervention in improving the knowledge, skills and attitudes of GPs in training towards prescribing.

Interviews with a variety of stakeholders (healthcare professionals, policymakers, and members of the public) have shown that there is support for REVISiT as an educational intervention that can help improve prescribing, not only for GPs in training but for all types of prescribers. This will enhance the safety of healthcare received by patients.

With funding from the NIHR Greater Manchester PSTRC, the REVISiT intervention is being further developed and tested, in preparation for a trial in the future.

European Conference on Mental Health: discussing care transitions

16 Nov

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by Natasha Tyler

NIHR Greater Manchester PSTRC Research Associate, Natasha Tyler recently presented her work entitled ‘Care Transitions: Patient Distress and Knowledge Sharing’ at the European Conference on Mental Health in Split, Croatia. The conference focused on discussions and collaboration between professionals, researchers and service users in the field of mental health. Natasha was presenting a paper that she is writing alongside Professor Justin Waring and Dr Nicola Wright regarding the distress experienced by those on acute inpatient mental wards during care transitions (when patients are moved from one place to another, or from one healthcare provider to another).

Care transitions are a vulnerable and high-risk stage of most care processes. The recent Healthwatch report found that patients often leave hospital too early or without appropriate levels of ongoing support. The quality and safety of care transitions depends on the involvement and coordination of multiple professionals working within and across multiple care settings. Research consistently shows that patients are often unprepared for the self-management role that occurs in the succeeding care setting, they receive inconsistent advice concerning illness management, and are frequently unable to contact the relevant healthcare professional with access to their care plan.

For people with acute mental health problems, the transition into and out of the hospital can be especially complicated, whereby issues of psychological distress or anxiety require particular consideration. The paper presented used data from focus groups that included 52 participants of different professions (doctors, ward nurses, community healthcare professionals) and service users. It found that service users felt particularly distressed regarding unplanned or unsupported discharge. Professionals also experienced stress as they felt unable to pay appropriate attention to preparing service users for care transitions, because they are overstretched and felt it outside their comfort zone. This was characterised by one poignant quote that was tweeted by interested academics attending the presentation ‘we have had a couple of incidents when we’ve had to discharge people to the pavement’.

Whilst at the conference, Natasha networked with a number of academics, she was particularly interested in research conducted in Finland using Assertive Community Treatment, an intensive and highly integrated approach for community mental health service delivery. The presentation was entitled ‘No more revolving door’; which is of particular relevance to mental health care transitions, whereby the metaphor ‘revolving door’ is used to describe an endless cycle of admission and discharge from inpatient acute services. The Finnish research reported a slight improvement in patient outcomes as a result of the service. This was relevant as Natasha is currently conducting a review of discharge interventions in acute metal health services in order to identify the most important outcomes to measure. When she asked the presenter how he chose the outcomes, he explained these were just the outcomes he felt most relevant. This supports the rationale for the necessity to develop a standardised set of core outcomes, which would reduce inconsistency in outcome reporting; which is the next phase of Natasha’s research.

Self-harm in older people

16 Nov

Old person sad_small

by Carly Rolfe

Self-harm in older people predominantly takes the form of self-poisoning, usually by medication overdose. A recent study by the NIHR Greater Manchester PSTRC found that older people who self-harm are 145 times more likely to die by suicide than older people who don’t self-harm.

From patient medical records, 2854 older people aged over 65 years who had harmed themselves and had at least one year of follow up were identified.  Only 12% were subsequently referred to mental health services following a self-harm episode. 59% were prescribed antidepressants, with 12% being a tricyclic antidepressant, a form of the medication which is known to be potentially dangerous in overdose.

Dr Cathy Morgan, from The University of Manchester, lead-author on the study paper recently published in Lancet Psychiatry, says:

“We emphasise the need for early intervention, careful alternative prescribing, and increased support when older adults consult after an episode of self-harm and with other health conditions.”

With there being limited studies in this area of research, interest in the work has been high, with 148 media outlets covering the findings in the paper’s first day of publication, including BBC Breakfast as well as national radio stations and press.

If a computer gives you a diagnosis, should it also give you an explanation?

15 Nov
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Jurors from previous Citizens’ Juries

by Malcolm Oswald

Artificial intelligence (AI) plays an increasing role in our daily lives. Computers are being trained how to do many things, including making medical diagnoses. For example, AI can diagnose skin cancer from skin images as reliably as dermatologists, and this clever software is only going to get better. But how do we know whether a diagnosis we get is accurate? If we are given it by a human doctor, we can ask for an explanation. However, the most advanced AI systems are very complex and do not just act according to pre-defined rules, but continue to “learn”, and it may not be possible to explain to a patient how the computer reached its diagnosis.

If you were given a diagnosis by a computer, and were given the choice, would you always prefer to be given an explanation of how the computer reached its diagnosis even if that meant the computer’s diagnosis was likely to be a little less accurate?

That is one question being put to two “citizens’ juries” being commissioned by the NIHR Greater Manchester Patient Safety Translational Research Centre (Greater Manchester PSTRC) in early 2019. Citizens Juries c.i.c. will recruit 18 people from around Manchester – chosen to represent a cross-section of the public – to come together for five days to hear expert evidence and tackle difficult questions concerning how AI should be used within healthcare. The process will then be repeated with 18 different people from around Coventry to see whether they reach the same conclusions.

The Greater Manchester PSTRC is collaborating on this project with the Information Commissioner’s Office which has the challenging task of regulating the use of AI. The results of the juries will feed directly into national guidance that the Information Commissioner’s Office has to produce on citizens’ rights to an explanation when decisions that affect people are made using AI.

For more information about citizens’ juries, see the Citizens Juries c.i.c. website, or if you have a specific enquiry about this project, email Dr Malcolm Oswald or the principal investigator, Prof Niels Peek.