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East & South East England Specialist Pharmacy Services
East of England, London, South Central & South East Coast
Research methods:
answering questions in practice
Dr Catherine Duggan,
Director for Clinical Pharmacy
[Development & Evaluation]
East & South East England Specialist Services NHS
East & South East England Specialist Pharmacy Services
The presentation
• To identify and describe the use of different research
methods, why different methods are used and the
benefits of one against another.
East & South East England Specialist Pharmacy Services
The presentation
• How to start to incorporate research into the day job?
• How to bridge the gap between research and practice?
• How to ensure a core number of oncology pharmacists
contribute to the research agenda?
East & South East England Specialist Pharmacy Services
Science
Evidence
Practice
Policy
East & South East England Specialist Pharmacy Services
The presentation
• Taking some problems in practice, start to describe how
we might tackle them from various perspectives, using
different methods…
East & South East England Specialist Pharmacy Services
Problems in practice
1.
2.
3.
How to reduce inconsistencies
in prescribing between
primary and secondary care?
How to provide patients with
the drug related information
they need?
How can we measure how
effective pharmacists are in
patient care?
East & South East England Specialist Pharmacy Services
Where to start?
There is no such thing as a good methodology or a bad
methodology...
The key is to understand the application of the appropriate
methodology for the question in hand
East & South East England Specialist Pharmacy Services
Qualitative vs. Quantitative approaches
•
•
Qualitative:
Phenomenological
•
•
Quantitative:
Positivist/Experimental
•
Hypothesis-generating (bottomup/inductive)
•
Hypothesis-testing (topdown/deductive)
•
Common in early stages of a field of
research
•
Common in later stages of a field of
research
•
Statistical analysis is never used
•
Statistical analysis often used
East & South East England Specialist Pharmacy Services
Commonly used qualitative and quantitative methods
• Qualitative:
• Quantitative:
• Interviews:
– Face to face
• Survey:
– Postal
– Face to face
– Telephone
• Focus groups
• Observation studies
• Randomised controlled trial:
– Parallel groups
– Cross over
East & South East England Specialist Pharmacy Services
Problem 1
How can we reduce
inconsistencies in prescribing
between primary and
secondary care?
East & South East England Specialist Pharmacy Services
Where to start?
Survey?
Trial?
Observations?
Interviews?
East & South East England Specialist Pharmacy Services
Where to start?
A survey identified unintentional discrepancies between
supplies of prescribed drugs highest in supplies obtained
in the community following discharge
This formed the focus of the intervention study- a trial
East & South East England Specialist Pharmacy Services
Medical
In-patients were
recruited into
CONTROL or
TRIAL cohorts
TRIAL cohort
discharged with
information
on medicines
for their
community
pharmacist
Consensus panel
judged the
CLINICAL
SIGNIFICANCE of
the observed
discrepancies
East & South East England Specialist Pharmacy Services
Summary Findings
CONTROL GROUP
TRIAL GROUP
Patients
237
264
Drugs
1328
1408
Discrepancies
795
(59.9%)
622
(44.2%)
Unintentional Discrepancies
700
(52.7%)
454
(32.2%)
Potentially significant
Unintentional Discrepancies
139
(10.5%)
92
(6.5%)
Clinically significant Unintentional
Discrepancies
27
(2.0%)
17
(1.2%)
East & South East England Specialist Pharmacy Services
Effectiveness of the Intervention
NNT
RRR
Prevention of a potentially clinically significant
discrepancy
7
54%
Prevention of a clinically significant discrepancy
15
47%
Prevention of a clinically significant discrepancy,
accounting for study “drop-outs”
19
37%
East & South East England Specialist Pharmacy Services
In summary,
Information should be
provided to the
community
pharmacists for all
medical patients
discharged from
hospital.
East & South East England Specialist Pharmacy Services
Problem 2
How to provide patients
with the drug related
information they need?
East & South East England Specialist Pharmacy Services
The background
~ 50% (?) of chronic patients do not comply
with prescribed therapy
•
•
•
•
•
Side effects and Toxicity
Interactions and allergies
Difficult to take
Forgetfulness
Patients’ beliefs and behaviours
East & South East England Specialist Pharmacy Services
Compliance
Paternalism
Professionals
know best
Experts hold the
key to information
Adherence
Move away from
paternalism
Empowering the patient
Provide patients with
some information
Concordance
Move towards
empowerment
Expert patients
Standard information
For everyone
East & South East England Specialist Pharmacy Services
From Compliance to Concordance...
• Simply a move from paradigm to
paradigm?
• A shift in perspective?
• Increased patient involvement?
East & South East England Specialist Pharmacy Services
Research shows us
information is good…
East & South East England Specialist Pharmacy Services
• Majority of patients want more information than
they are given
• Patients want to obtain an ‘explanation of their
problem’ rather than ‘tests and diagnoses’
• Patients want the full picture, presented in a nonalarming way, a balanced, honest assessment of
positive and negative aspects of treatment
Providing information to patients leads to better
understanding of their medication and increased
adherence
East & South East England Specialist Pharmacy Services
But, a lack of understanding or
information overload may
influence the way patients view
their prescribed drug(s) and
ultimately influences the way they
take them…or don’t
East & South East England Specialist Pharmacy Services
• Many patients have poor understanding of
terminology
• Many patients don’t understand
prescription instructions
• Many patients criticise failures to
communicate the things they really want
or need to know
• Many perceive a communication ‘gap’
between themselves and healthcare
professionals
East & South East England Specialist Pharmacy Services
So…
– How do we know which patients want
information and which patients don’t?
– How much information do they want and
when?
– Will the “information” affect their medicines
taking behaviour?
East & South East England Specialist Pharmacy Services
Where to start?
Survey?
Trial?
Observations?
Interviews?
East & South East England Specialist Pharmacy Services
DESIRE for
information
=> worry
TRIAL cohort
discharged with
Information on drugs
at discharge for their
Community pharmacist
500 patients’
perceptions towards
their illness &
behaviours
towards Rx
DESIRE for
information
=> age &
socioeconomics
East & South East England Specialist Pharmacy Services
Diagnosis and desire for information…?
Standardised
z-scores for EID scale
1.0
.8
.6
.4
.2
.0
-.2
-.4
-.6
-.8
-1.0
N=
118
Diabetes
210
83
214
Oncology (CNS)
Endocrine
573
254
Cardiovascular
Respiratory
Gastrointestinal
East & South East England Specialist Pharmacy Services
.8
.6
.4
.2
0.0
-.2
Mean
-.4
Zscore:EID
Info needs
-.6
Zscore: AI
Anxiety
-.8
Zscore: TI
cardiovascular
respiratory
gastrointestinal
Tolerance
Endocrine
Brain tumour
Diabetic
primary diagnosis
Duggan QSHSC, 2008
East & South East England Specialist Pharmacy Services
In summary,
The way we provide
information to patients
affects their perceptions of
their drugs and their
medicines taking
East & South East England Specialist Pharmacy Services
Problem 3
How can we measure how
effective pharmacists are in
patient care?
East & South East England Specialist Pharmacy Services
Where to start?
Survey?
Trial?
Observations?
Interviews?
East & South East England Specialist Pharmacy Services
Evidence of benefit of pharmacists- UK
Clinical pharmacy- accepted interventions from ward visits
Clinical setting, pharmacist experience and available time predict rate
System change: integration
Length of stay reduced by 2 days
Readmission rates decreased by 20%
Fiscal benefits included an average return of £7.50 for every £1
invested
System change: automation
34% increase in items dispensed within 2 hours
16% reduction in dispensing error
19% reduction in staff time for dispensing
Intervention studies
East & South East England Specialist Pharmacy Services
Evidence of benefit of pharmacists- US
Inverse association between pharmacists per 100 beds and mortality rates
Inverse association between pharmacists per 100 beds and length of stay
Inverse association between pharmacists per 100 beds and rates of
adverse drug reactions
Association between clinical pharmacy services and lower mortality rates
Association between higher numbers of clinical pharmacists and lower
drug costs
Surveys, census, outcome measures
East & South East England Specialist Pharmacy Services
Key performance indicators F1(medical)
Low Activity
High Activity
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Evidence of
benefit
200
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Saving lives
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150
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R-Square = 0.16
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Borja-Lopetegi, Bates, Webb 2007
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100
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50
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W
R-Square = 0.76
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W
W
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0
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70
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80
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90
Mortality rate Index
ê
100
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110
ê
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120
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East & South East England Specialist Pharmacy Services
East & South East England Specialist Pharmacy Services
Why do we need to publish?
Isn’t it someone else’s job?
East & South East England Specialist Pharmacy Services
Pharmacy evidence gap
Research articles
on health
professions
education
World Health Report 2006.
East & South East England Specialist Pharmacy Services
To be a consultant (level)
pharmacist, one has to
demonstrate expertise
across 6 clusters including
Research and Evaluation
Through publication of
robust evidence,
pharmacists can contribute
to science, to
pharmaceutical care and
the wider research agenda.
East & South East England Specialist Pharmacy Services
Summary
• Its imperative:
– we understand research principles
– we undertake research from an early stage in career development
to incorporate research into the day job
– practitioners are involved in research to bridge the gap between
research and practice
• Make R&E part of CPD to ensure a core number of
oncology pharmacists contribute to the research agenda
East & South East England Specialist Pharmacy Services
Science
Evidence
Practice
Policy
East & South East England Specialist Pharmacy Services
East of England, London, South Central & South East Coast
Research methods:
answering questions in practice
Dr Catherine Duggan,
Director for Clinical Pharmacy
[Development & Evaluation]
East & South East England Specialist Services NHS