Importance of Applied Research to Daily Clinical Practice - Postgraduate Seminar

1. Importance of Applied Research to Daily Clinical Practice - Postgraduate Seminar Hotel ILF, Budějovická 15, Prague 4, 140 00 15th October 2013 A/Prof Tim Chen Vice President, SAPS, FIP Timothy.chen@sydney.edu.au

2. The University of Sydney Founded 1850

6. Overview • Background • Types of applied research – considerations and case examples • Study designs & levels of evidence • Qualitative Vs quantitative • Retrospective Vs prospective • Multi-disciplinary Vs unidisciplinary • Using evidence based protocols • Concluding comments

7. Background - Considerations

8. Introduction Learning Objectives Using examples from the literature, • Explain how and why applied research is essential for informing daily clinical practice • Explain how and why daily clinical practice is essential for informing applied research • Explain the link between clinical practice, applied research and the published literature

9. Background - Considerations Primary literature Secondary literature Tertiary literature Gray literature Others Community Hospital Aged care facilities Clinics Multidisciplinary / Unidisciplinary Others Descriptive Hypothesis testing Qualitative / Quantitative Prospective / retrospective Simple / complex Others

10. Background - Considerations Primary literature Secondary literature Tertiary literature Gray literature Others Patient Consumer Community Hospital Aged care facilities Clinics Multidisciplinary / Unidisciplinary Others Descriptive Hypothesis testing Qualitative / Quantitative Prospective / retrospective Simple / complex Others

11. NHMRC - Levels of Evidence

12. Evidence from Literature Systematic Reviews

13. CONCLUSION Robust conclusions could not be drawn from the evidence due to variability in design, interventions, outcomes and results. The interventions implemented in the studies in this review led to the identification and resolution of medication-related problems, however evidence of an effect on resident-related outcomes was not found. There is a need for high-quality cluster-randomised controlled trials testing clinical decision support systems and multidisciplinary interventions that measure well-defined, important resident-related outcomes.

14. Meta-AnalysisUse of Psychotropic Medicines in RACF

15. Meta-AnalysisUse of Psychotropic Medicines in RACF

17. Applied ResearchExamples of Educational Interventions …designed to change practice

18. Mental Health Stigma – Implications for Pharmacy Feel more comfortable & confident communicating about physical conditions rather than mental health conditions

19. Stigma – Implications for Pharmacy • Feel more comfortable & confident communicating about physical conditions rather than mental health conditions • … preferentially counsel patient about the CV medicines and not their psychotropic medicines • What can we do about this?

20. What is mental health stigma? • Social cognitive model of stigma: • Knowledge Ignorance • Attitudes Prejudice • Behaviour Discrimination Thornicroft, G. Shunned 2006.

21. Stigma – Pharmacy Interventions

22. ` Usual tutorial Usual tutorial PLUS MHCE

23. ` Usual tutorial Usual tutorial PLUS MHCE • Improved social distance – measure of stigma • Improved provision of pharmaceutical services • Now included in our UG training at The University of Sydney

24. Mental Health Stigma – Pharmacy Interventions

25. Comparing face-to-face and online Nguyen, Chen, O’Reilly . Soc Psychiatry Psychiatr Epidemiol 2012

26. Applied ResearchExamples of Qualitative Studies …interviews & focus groups

27. Medication Adherence – The Challenges • Multiple health care professions

28. Medication Adherence – The Challenges ‘‘Patients need information that is pitched at their level of recovery and level of understanding…I feel that it’s the responsibility of all clinicians that when you’re giving a medication, you give adequate information that suits the needs of the patient.’’ (Respondent 31; Mental health nurse)

29. Medication Adherence – The Challenges ‘‘I think if there is a lack of continuity of care particularly if there is a chronic mental illness and a person gets a lot of different, mixed messages about therapeutics, yes I think it’s a problem…. they just follow the message that they prefer.’’ (Respondent 29; General practitioner)

30. Medication Adherence – The Challenges ‘‘The other most important thing is addressing any side-effects…. you encourage them [patients] actively to talk about any side-effects they have and accordingly either adjust the dose of the medicine or change them to another medication so they’re more comfortable and their quality of life doesn’t deteriorate because of the medication.’’ (Respondent 24; Psychiatrist)

31. Factors influencing inappropriate Prescribing of Medications in RACF: a qualitative study Mouna Sawan • “I think we are facing challenge with the nursing staff to manage the patients. It is really difficult to manage a behaviorally disturbed patient. It's not that easy. I get frustrated sometimes like they want to use antipsychotic agents for patients who are screaming. That's not going to do anything and they probably make them more sleepy and more Parkinsonian …” (GP)

32. Factors influencing inappropriate Prescribing of Medications in RACF: a qualitative study Mouna Sawan, PhD candidate • “I think we are facing challenge with the nursing staff to manage the patients. It is really difficult to manage a behaviorally disturbed patient. It's not that easy. I get frustrated sometimes like they want to use antipsychotic agents for patients who are screaming. That's not going to do anything and they probably make them more sleepy and more Parkinsonian …” • “The GP's comment was when they tried to stop (medication), the family questions them saying, "Are you giving up on my mum? Do you think she's dying?" (RN)

33. Factors influencing inappropriate Prescribing of Medications in RACF: a qualitative study Mouna Sawan, PhD candidate • “I think we are facing challenge with the nursing staff to manage the patients. It is really difficult to manage a behaviorally disturbed patient. It's not that easy. I get frustrated sometimes like they want to use antipsychotic agents for patients who are screaming. That's not going to do anything and they probably make them more sleepy and more Parkinsonian …” • “The GP's comment was when they tried to stop (medication), the family questions them saying, "Are you giving up on my mum? Do you think she's dying?“ • “They’re the necessary evil sometimes (antipsychotics), we do have to use it, It’s when you use it for behavior sometimes it’s not appropriate … sometimes  you use it unnecessarily a bit longer than usual …it needs to be reviewed at times and we forget to review it and we leave it on for too long” (GP)

34. Tools for Qualitative Research • Tools to manage data • N Vivo • Leximancer

35. Applied ResearchExamples of medication review studies

36. Comparative Study GP review PLUS Pharmacist review Pharmacist review Chen, Bennett, Smith et al., 2000; http://www.guild.org.au/public/dmmrfiles/report_stgeorge.pdf

37. Stages Of Intervention Chen, Crampton, Krass, Benrimoj. JSAP, 1999; 16:134-144.

38. Impact on Use of Medications Chen, Bennett, Smith et al., 2000; http://www.guild.org.au/public/dmmrfiles/report_stgeorge.pdf

39. Interactive Case Study Meeting

40. Post-discharge HMRs & Case Conference

41. Case Conference Meeting Pharmacist and Medical Practitioner Chen, Bennett, Smith et al., 2000 http://www.guild.org.au/public/dmmrfiles/report_stgeorge.pdf

42. Impact of HMR on MAI – a measure of prescribing appropriateness Castelino et al., Annals of Pharmacother, 2010.

43. Consumer View about Medication ReviewCarter et al. RSAP 8 (2012) 487-498

45. Example of Current Honours Students Projects in Applied Research

46. Depression Screening – in pharmacy

47. MRC Guidance on evaluation of complex interventions http://www.sphsu.mrc.ac.uk/Complex_interventions_guidance.pdf

48. Aside – Other Key References from MRC Guidelines

49. Depression screening in community pharmacy Male in 40s to 50s Asked for a vitamin that could help with stress, sleep, depression. He used to take one previously and wanted some for a 'friend’. He became emotional after counselling and suggested that the product request could be for himself (as well as his friend). Referred to GP A feasibility study N=12 pharmacies Wong, Chen, O’Reilly, Chen (2013)

50. Depression screening in community pharmacy Female in 20s to 30s Came in asking for a medication for cold symptoms. She said that she had trouble sleeping and had been very stressed. Further questioning revealed that the patient had history of post-natal depression. Referred to GP A feasibility study N=12 pharmacies Wong, Chen, O’Reilly, Chen (2013)