Biomedical subjects
Publications and source records attributed to I C K Wong.
A total of 709 unlicensed and off-label medicines were prescribed for 338 patients discharged from a paediatric hospital between 1 November 2003 and 31 January 2004. Thirty three per cent of patients had difficulty obtaining these medications in primary care which caused treatment disruption. The main problems were: (1) community pharmacies being unable to supply; and (2) GPs' refusal to prescribe.
OBJECTIVE: To develop a practitioner led definition of a prescribing error for use in prevalence/incidence studies in paediatric practice. DESIGN: A two stage Delphi technique was used to obtain the views of a panel of expert health professionals working in the hospital paediatric setting. The extent of their agreement on a definition of a prescribing error, and on 40 scenarios that might be classified as prescribing errors in paediatric practice, was obtained. RESULTS: Response rates were 84% (n = 42) in the first Delphi round and 95% (n = 40) in the second. Consensus was to accept the general definition of a prescribing error. In addition, there was consensus that 27 of the 40 scenarios should be included as prescribing errors, 10 should be excluded, and three may be considered prescribing errors depending on the individual clinical situation. Failure to communicate essential information, transcription errors and the use of drugs, formulations, or doses inappropriate for the individual patient were considered prescribing errors. Deviations from policies or guidelines, use of unlicensed and off-label drugs, and omission of non-essential information were not considered prescribing errors. CONCLUSION: A general definition of a prescribing error has been developed that is applicable to the paediatric setting, together with more detailed guidance regarding the types of events that should be included. These findings are suitable for use in future research into the incidence and nature of prescribing errors in paediatrics.
Specific targeting of patients with a previous asthma hospitalisation could be more focused if predictors could be identified. This study was an observational retrospective analysis using ridge and linear multivariate regression analysis. Patient asthma management data were extracted from the hospital and general practice notes of those that had been admitted with an acute exacerbation of their asthma over a 5-year period. From the prescribing data, the annual doses of preventer (P) and reliever (R) medication were converted to defined daily doses then divided to give a P:R ratio. Preliminary statistical analysis was used to identify any association between either the P:R ratio or for the number of general practitioner (GP) practice appointments (PA) and their asthma management data. Multivariate regression analysis was applied to the P:R ratio and to PA to determine a model between each of these and asthma management data/events. GPs gave consent to access the data of 115 (out of 440) asthmatics, age >5 years, admitted to a district general hospital for asthma exacerbations between 1994 and 1998. The multivariate analysis revealed that PA was associated with oral prednisolone rescue courses (PRCs) and age whilst the P:R ratio was associated to PRCs and more reliever usage but not preventers. Patients with low preventer usage with respect to their reliever medication should be targeted for medication review as these were the patients prescribed more prednisolone courses and their increased PAs reflect this. This could decrease visits to the doctor and acute exacerbations.
BACKGROUND: It is estimated that 200 million prescriptions for children and adolescents were issued in the UK during 2002. Therefore, it is important for the National Service Framework for Children (NSFC) to include advice on managing medicines effectively for children. This literature review was performed at the request of the NSFC Medicines External Working Group in order to provide underpinning evidence in the development of advice on managing medicines. METHODS: Detabases, websites and conference abstracts were searched systematically to identify information on managing medicines in children in 2003. This article reported the results on medication review, concordance, enhanced medicines access through community pharmacy services and the use of medicines in schools. RESULTS AND CONCLUSIONS: Although there is little evidence specific to paediatrics, the objectives and rationale of medication review could be expected to apply to chronic diseases in children. Issues such as polypharmacy, wastage, repeat prescriptions and medication problems could be similar. The benefits seen in adults may also occur in children, and medication review may possibly have a role in the management of medicines in children. There is an obvious role for pharmacists in ensuring the safety of over-the-counter medications and provision of information and education to parents, carers and adolescents. Evaluation and provision of necessary education and training to community pharmacists is needed, even in the most basic paediatric issues such as sugar-free medications. The evidence suggests that treatment compliance and adherence are generally lower in children than in adults, particularly in adolescents as they approach independence. Those with learning disabilities and infants are likely to be at risk of non-compliance, although little work has been done in these populations. Children and adolescents need appropriate parental and professional support in taking control of their medication and treatment. The management of medicines in school would appear to be far from ideal. Further research into school-based medicines education and outreach clinics would also be beneficial.
OBJECTIVE: To examine the policy, administration, and supervision of medicine administration in primary schools within the Greater London area (GLA). DESIGN: A prospective survey using postal questionnaires sent to 172 randomly selected primary schools within the GLA. PARTICIPANTS: Head teachers of primary schools. RESULTS: Some 65% of head teachers replied. Less than 50% of responding head teachers had actually read the national guidelines Supporting Pupils with Medical Needs and only 30% of respondents were aware of other members of staff who had read the document. A total of 95% of respondents followed a policy/procedure in caring for the medical needs of pupils. Over 80% of respondents had staff handling the pupils' medical needs, staff handling access to stored medicines, and prior arrangements for staff training. However, it is worrying that a quarter of the schools did not keep a written record of medicines given to children in schools. The majority of staff with responsibility for medicine administration in schools are support staff. The most encouraging findings were that for the majority of schools with children using the EpiPen and rectal diazepam, there were trained staff to administer these medicines. CONCLUSIONS: The majority of schools had a policy in place to deal with medicine administration, although further work should be conducted to analyse the content of such policies. It is very important that training is directed at staff responsible for medicine administration and not just at teachers. Most schools were willing to administer rectal diazepam and EpiPen treatment in an emergency.
Psychotropic medication use by children in the USA has increased. We used the IMS MIDAS Prescribing Insights to examine prescribing trends in nine countries between the years 2000 and 2002. Trends in seven countries rose significantly from year 2000 to 2002; the UK had the highest increase (68%).
AIMS: To characterise prescribing patterns of antidepressants (ATDs) to children and adolescents aged < or =18 years in the UK. METHODS: Subjects issued at least one ATD prescription between 1 January 1992 and 31 December 2001 were identified from the UK General Practice Research Database. Prescribing patterns, annual prevalence, morbidity patterns, and time to discontinuation of ATD use were identified. RESULTS: A total of 24,976 subjects received 93,091 prescriptions; 51,868 (55.7%), 38,429 (41.3%), and 2708 (2.9%) prescriptions were for tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and other ATDs respectively. ATD prevalence increased 1.7-fold from 1992 to 2001. TCA prevalence decreased by 30% from 3.6 to 2.5 per 1,000; SSRI prevalence increased 10 times from 0.5 to 4.6 per 1,000. In new ATD users aged < or =10 years, the most common diagnosis associated with TCA use was nocturnal enuresis (75.1%); in those aged > or =15 years, it was depression (45.8%). Depression was also associated with SSRI use (69.0%). For new users with depression, the median treatment durations for TCAs and SSRIs were 30 and 58 days respectively. TCA users were more likely to terminate treatment than SSRI users (TCAs v fluoxetine: 1.40, 95% CI 1.32 to 1.47; non-fluoxetine SSRIs v fluoxetine: 1.01, 95% CI 0.96 to 1.07). CONCLUSIONS: SSRIs have gained popularity for the treatment of depression compared with TCAs. TCAs are still used despite their lack of efficacy in prepubertal depression and their moderate effect in adolescents. However, >50% of subjects discontinue treatment after two months, with TCA users stopping earlier than SSRI users.
BACKGROUND: Asthma hospital admissions and readmissions are unacceptably high, thus, a method to identify those at greatest risk could be helpful. METHODS: An observational retrospective study using a Cox regression to determine the relationship between the time interval between admissions and possible covariates of a readmission. The covariates were age, sex, ethnicity, smoking habit, history of allergy or eczema/hay fever, age of onset, Townsend index (TI), Jarman score (JS), and drugs on discharge. Those with p < 0.2, together with interacting covariates, from the preliminary analysis were eligible for the multivariate Cox regression analysis. RESULTS: Of the 523 patients admitted between 1994 and 1998 because of their asthma, complete data were available for 440. Of these, 112 were readmitted. Eligible covariates for the multivariate Cox regression analysis were sex, allergy status, history of eczema/hay fever, the JS and TI together with interactions between JS and TI, JS and allergy, and allergy with eczema/hay fever. There were 278 subjects (71 with a readmission) with complete data for these eligible covariates. The multivariate analysis revealed that female sex (odds ratio [OR] = 2.65, 95% confidence interval [CI] 1.42, 4.92), high JS (OR = 2.03, 95% CI 1.13-3.65), and history of allergy (OR = 1.88, 95% CI 1.06-3.32) formed the final model as significant predictors of readmission. CONCLUSION: Females with a history of allergy that were registered at a practice with a high workload (JS) had a higher risk of readmission. The analysis method used highlights how those at risk of readmission can be identified so that they can be targeted post discharge.
INTRODUCTION: In 1997, the Royal Pharmaceutical Society of Great Britain Working Party reported that UK community pharmacists had a crucial role in effective medicines management and effective symptom control for those receiving palliative care in the community. However, prior to the integration of community pharmacists into the community palliative team, it is necessary to evaluate the effectiveness of their pharmaceutical interventions. AIM: To assess the effectiveness of community pharmacists' clinical interventions in supporting palliative care patients in primary care using an independent multidisciplinary panel review. METHODS: Patients with a life expectancy of less than 12 months were each registered with a single pharmacy and their consent was obtained for the community pharmacists to access their general practitioner (GP) case records. The community pharmacists received training in palliative pharmaceutical care and documenting interventions. The trained community pharmacists provided palliative pharmaceutical care to the recruited patients. At the end of a 10-month period, the clinical interventions were reviewed by an independent multidisciplinary expert panel consisting of a palliative care consultant, a Macmillan nurse (community palliative care nurse) and a hospital pharmacist with special interest in palliative care. RESULTS: Fourteen community palliative care teams (including community pharmacists, GPs and community nurses) took part in the study and 25 patients were recruited over the 10-month recording period. All but one patient had a diagnosis of cancer; the other patient had chronic obstructive pulmonary disease. By the end of the project, 14 patients had died. Community pharmacists recorded a total of 130 clinical interventions. Thirty interventions were excluded as insufficient information had been documented to allow review by the panel. Eighty-one per cent of the interventions were judged by the expert panel likely to be beneficial. However, 3% were judged likely to be detrimental to the patients' well-being. CONCLUSIONS: Most of the clinical interventions made by the community pharmacists for palliative pharmaceutical care were judged by the expert panel as being likely to be beneficial. The result supports the view that when community pharmacists are appropriately trained and included as integrated members of the team, they can intervene effectively to improve pharmaceutical care for palliative care patients.