患者和护理人员临终时获得药物的途径:ActMed混合方法研究

S. Latter, N. Campling, J. Birtwistle, A. Richardson, M. Bennett, D. Meads, A. Blenkinsopp, L. Breen, Zoe Edwards, C. Sloan, E. Miller, S. Ewings, M. Santer, Lesley Roberts
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引用次数: 0

摘要

患者在生命的最后12个月在家获得药物对于有效控制症状、预防痛苦和意外入院至关重要。有限的证据表明,服务提供的不同组成部分存在问题,据我们所知,创新对临终服务提供的影响仍未得到评估。在服务提供模式的背景下,对患者和护理人员在生命结束时获得药物的情况进行评估。该研究采用了多阶段混合方法设计,包括(1)系统的文献综述;(2) 对提供临终关怀的保健专业人员进行在线问卷调查;(3) 服务提供模式的混合评价方法案例研究,包括成本和成本效益分析;(4) 采访社区药剂师、药品批发商和经销商;以及(5)建立共识专家研讨会。英格兰的社区和初级保健临终服务。提供临终关怀的医疗保健专业人员、生命最后12个月住在家中的患者及其护理人员。一项系统审查发现,缺乏关于服务提供模式和患者临终时获得药物的经验的证据。共有1327名保健专业人员完成了一项在线调查。研究结果表明,全科医生仍然是患者获得处方的主要途径,但护士和初级保健药剂师也在积极参与。然而,只有42%的临床护理专家和27%的社区护士接受过处方医生培训。大多数(58%)开处方的护士和药剂师无法使用电子处方系统。卫生保健专业人员对获得共享患者记录以方便获得药物的满意度很低,39%的卫生保健专业人士要么根本不满意,要么只是稍微满意。受访者认为,如果获得更多药物,疼痛控制将有显著改善。案例研究(n = 4) 强调了不同服务提供模式在获取药品的速度和便利性方面的差异。卫生保健专业人员的协调促进了获取过程。协调工作往往是繁重的,例如,因为很难获得全科医生服务,或者因为社区药房药品的库存不可靠。考虑到中期内符合条件的人群,服务之间的处方成本差异很大。供应链通常确保了姑息药物的库存,但这是由社区药剂师在多个复杂系统和批发商界面中进行繁重工作所支撑的。患者记录缺乏足够的细节来构建时间表。社区药房服务专员、批发商和分销商很难招聘。获取药品需要大量的协调工作。获取延迟与过度依赖全科医生处方的服务提供模式、社区药房药品库存不可靠以及临床护士专家无法获得电子处方有关。关键问题是关系和团队整合,使处方医生队伍多样化,获得共享记录和改善社区药房库存。进一步的研究应考虑护理和药房服务的政策和实践行动,以发挥其帮助患者获得药物的潜力,同时注意改善专业服务接口之间的协调和共享电子记录。本研究注册号为CRD42017083563,试验注册号为ISRCTN12762104。该项目由国家卫生与护理研究所(NIHR)卫生与社会护理提供研究计划资助,并将在《卫生与社会保健提供研究》上全文发表;第10卷,第20期。有关更多项目信息,请访问NIHR期刊图书馆网站。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Patient and carer access to medicines at end of life: the ActMed mixed-methods study
Patient access to medicines at home during the last 12 months of life is critical for effective symptom control, prevention of distress and unplanned admission to hospital. The limited evidence suggested problems with different components of service delivery and, to the best of our knowledge, the impact of innovations in end-of-life service delivery has remained unevaluated. To provide an evaluation of patient and carer access to medicines at end of life within the context of models of service delivery. The study used a multiphase mixed-methods design, comprising (1) a systematic literature review; (2) an online questionnaire survey of health-care professionals delivering end-of-life care; (3) evaluative mixed-method case studies of service delivery models, including cost and cost-effectiveness analysis; (4) interviews with community pharmacists and pharmaceutical wholesalers and distributors; and (5) an expert consensus-building workshop. Community and primary care end-of-life services in England. Health-care professionals delivering end-of-life care and patients living at home in the last 12 months of life and their carers. A systematic review identified a lack of evidence on service delivery models and patient experiences of accessing medicines at end of life. A total of 1327 health-care professionals completed an online survey. The findings showed that general practitioners remain a predominant route for patients to access prescriptions, but nurses and primary care-based pharmacists are also actively contributing. However, only 42% of clinical nurse specialists and 27% of community nurses were trained as prescribers. The majority (58%) of prescribing nurses and pharmacists did not have access to an electronic prescribing system. Health-care professionals’ satisfaction with access to shared patient records to facilitate medicines access was low, with 39% of health-care professionals either not at all or only slightly satisfied. Respondents perceived that there would be a significant improvement in pain control if access to medicines was greater. Case studies (n = 4) highlighted differences in speed and ease of access to medicines between service delivery models. Health-care professionals’ co-ordination facilitated the access process. The work of co-ordination was frequently burdensome, for example because general practitioner services were hard to access or because the stock of community pharmacy medicines was unreliable. Prescription cost differentials between services were substantial when accounting for the eligible population over the medium term. The supply chain generally ensured stocks of palliative medicines, but this was underpinned by onerous work by community pharmacists navigating multiple complex systems and wholesaler interfaces. Patient records lacked sufficient detail for timelines to be constructed. Commissioners of community pharmacy services and wholesalers and distributors were difficult to recruit. Accessing medicines required considerable co-ordination work. Delays in access were linked to service delivery models that were over-reliant on general practitioners prescribing, unreliable stocks of community pharmacy medicines and clinical nurse specialists’ lack of access to electronic prescribing. Key issues were relationships and team integration, diversifying the prescriber workforce, access to shared records and improved community pharmacy stock. Further research should consider policy and practice action for nursing and pharmacy services to fulfil their potential to help patients access medicines, together with attention to improving co-ordination and shared electronic records across professional service interfaces. This study is registered as CRD42017083563 and the trial is registered as ISRCTN12762104. This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 20. See the NIHR Journals Library website for further project information.
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