Medicines optimisation: A pharmacist’s contribution to delivery and education Barry JUBRAJ This thesis is submitted in partial fulfilment of the requirements of Kingston University for the degree of Doctor of Philosophy by Publication July 2019 Electronic version minus publications This work was funded by Pharmacy Research UK (Grant reference PRUK-2018-TB-L1-1-BJ) The views expressed are those of the author and not necessarily that of Pharmacy Research UK. Word count (excluding abstract, acknowledgements, contents list, references and appendices) = 29,980 PhD by Publication – Barry Jubraj Medicines optimisation: A pharmacist’s contribution to delivery and education Abstract This thesis describes the author’s publication history from 2001 to 2019, and relates this to their key career milestones from registration as a pharmacist in 1991. From a career output of over 80 items published in a variety of media, eleven key publications form the basis of four publication themes, which the author has related to the concept of medicines optimisation. An exemplar case is used to illustrate these publication themes, arranged into four chapters: a) improving the patient experience and supporting medication adherence b) providing safe care: medication review, polypharmacy and deprescribing c) making medicines optimisation part of routine practice through clinical education, and d) supporting safe practice through professional and personal development of healthcare staff. Following Chapter 1 (introduction), the second chapter discusses the author’s contribution to the medication adherence agenda which closely relates to their outputs encouraging the development of pharmacists’ consultation skills, particularly with patients who have a learning disability. The third chapter discusses the author’s published outputs in the areas of medication review, polypharmacy and deprescribing, the success of which they outline as contingent on the improved communication skills and person-centred approach described in Chapter 2. Chapters four and five discuss the author’s wide-ranging contribution as a clinical educator with a focus on developing others, which the author contends is an essential underpinning of the mission to deliver the benefits of medicines optimisation. The exemplar case from the introduction is briefly revisited to illustrate that the author’s publications directly relate to the challenges of the patient’s medication regime which in turn relate to three of the four Royal Pharmaceutical Society principles of medicines optimisation. The conclusion of this thesis includes a summary of the methodologies used in the key publications, and summarises the author’s belief that their career activity, leading to their publications, broadly align to the concept of medicines optimisation. Moreover, a recommendation can be made that education of all stakeholders should be explicitly mentioned in any future refinements of its definition. Page 2 PhD by Publication – Barry Jubraj Table of Contents Abstract ............................................................................................................................................... 2 Table of Contents ................................................................................................................................ 3 Acknowledgements ............................................................................................................................. 7 Dedication ........................................................................................................................................... 9 Chapter 1: Introduction .................................................................................................................... 10 1.1 Prologue .................................................................................................................................. 10 1.2 Medicines Optimisation: why is it important? ........................................................................ 11 1.3 Definitions of ‘medicines optimisation’ .................................................................................. 11 1.4 ‘Medicines Optimisation’: a concept now central to health policy, particularly in England .. 12 1.5 An evidence-base for medicines optimisation ........................................................................ 13 1.6 The broader context of medicines optimisation..................................................................... 13 1.7 Medicines Optimisation: Scotland, Wales and Northern Ireland ........................................... 15 1.8 Medicines Optimisation in overseas countries ....................................................................... 16 1.9 Medicines Optimisation: a typical medication regime encountered by the author............... 17 Figure 2: Medication list before review ................................................................................ 18 Figure 3: Medication list following review by the author, geriatrician and patient ............. 18 1.10 Aims of this thesis ................................................................................................................ 20 1.11 Method, literature used and rationale for key publications used in this thesis ................... 21 1.12 Summary .............................................................................................................................. 21 Figure 4: Key publication themes .......................................................................................... 22 Figure 5: Career and personal timeline with key publications ............................................. 23 Chapter 2: Medicines Optimisation: Improving the patient experience and supporting medication adherence ......................................................................................................................................... 24 2.1 Introduction ............................................................................................................................ 24 2.2 Key publication 1: Haemodialysis patients’ beliefs about treatment: implications for adherence to medication and fluid-diet restrictions .................................................................... 25 2.2.1 Background ...................................................................................................................... 25 2.2.2 The author’s MSc adherence research ............................................................................ 26 2.2.3 The subsequent publication and impact of the research ................................................ 27 2.3 Key publication 2: Why we should understand the patient experience? Clinical empathy and Medicines Optimisation ................................................................................................................ 29 2.3.1 Background ...................................................................................................................... 29 2.3.2 Article development......................................................................................................... 30 Page 3 2.3.3 Impact and associated outputs ........................................................................................ 31 2.4 Key publication 3: Pharmacy consultations with patients with learning disabilities .............. 32 2.4.1 Background ...................................................................................................................... 32 2.4.2 Article development......................................................................................................... 34 2.4.3 Impacts and associated outputs, including MMP publications ....................................... 34 2.5 Summary ................................................................................................................................. 37 Table 1: Feedback examples on the author’s contribution to the learning disability agenda with respect to medicines ..................................................................................................... 39 Chapter 3: Medicines Optimisation: Providing safe care: Medication review, polypharmacy and deprescribing .................................................................................................................................... 40 3.1. Background ............................................................................................................................ 40 3.2. Introduction to author involvement ...................................................................................... 42 3.3 Key publication 4: Intermediate Care [An optimal setting for review of inappropriate medication in elderly patients] ..................................................................................................... 43 3.3.1 Background ...................................................................................................................... 43 3.3.2 The elderly care rehabilitation STOPIT study ................................................................... 43 3.3.3 Subsequent publications and impact of the research ..................................................... 44 3.3.4 Review of Medication in Acute Care – the ReMAC project ............................................. 46 3.4 Key publication 5: A pilot survey of junior doctors’ attitudes and awareness around medication review: time to change our educational approach? .................................................