Background

Good patient access to medicines at home during the last 12 months of life is critical for effective symptom control, prevention of distress and avoidance of unscheduled and urgent care.

Objectives

To undertake an evaluation of patient and carer access to medicines at end-of-life within the context of models of service delivery.

Design

Evaluative, mixed method case studies of service delivery models, including cost analysis. The unit of analysis was the service delivery model, with embedded sub-units of analysis.

Setting

(i) General Practitioner services (ii) Palliative care clinical nurse specialist prescribers (iii) a 24/7 palliative care telephone support line service.

Participants

Healthcare professionals delivering end-of-life care; patients living at home, in the last 12 months of life, and their carers.

Methods

Within each case: Patients/carers completed a structured log on medicines access experiences over an 8-week period. Logs were used as an aide memoire to sequential, semi-structured interviews with patients/carers at study entry, and at four and eight weeks.

Healthcare professionals took part in semi-structured interviews focused on their experiences of facilitating access to medicines, including barriers, and facilitating factors.

Data on prescribed medicines were extracted from patient records.

Detailed contextual data on each case were also collected from a range of documents.

Patient, carer and healthcare professional interview data were analysed using Framework Analysis to identify main themes. We estimated prescription costs and budget impact analysis of the different service models. Data were triangulated within each case. Cross-case comparison and logic models were employed to enable systematic comparisons across service delivery types.

Findings

Accessing medicines is a process characterised by complexity and systems inter-dependency requiring considerable co-ordination work by patients, carers and healthcare professionals. Case studies highlighted differences in speed and ease of access to medicines across service delivery models. Key issues were diversifying the prescriber workforce, the importance of continuity of relationships and team integration, access to electronic prescribing systems, shared records and improved community pharmacy stock. Per patient prescription cost differentials between services were modest but were substantial when accounting for the eligible population over the medium term.

Conclusions

Experiences of medicines access would be improved through increasing numbers of nurse and pharmacist prescribers, and improving shared inter-professional access to electronic prescribing systems and patient records, within care delivery systems that prioritise continuity of relationships. Community pharmacy stock of palliative care medicines also needs to become more reliable.

中文翻译：

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在社区获得姑息治疗药物：使用英格兰服务模式案例研究评估实践和成本

背景

在生命的最后 12 个月内，患者在家中良好地获得药物对于有效控制症状、预防痛苦和避免计划外和紧急护理至关重要。

目标

在服务提供模式的背景下，对患者和护理人员在临终时获得药物的情况进行评估。

设计

服务交付模型的评估性、混合方法案例研究，包括成本分析。分析单元是服务交付模型，具有嵌入的分析子单元。

环境

(i) 全科医生服务 (ii) 姑息治疗临床护士专家处方 (iii) 24/7 姑息治疗电话支持热线服务。

参与者

提供临终关怀的医疗保健专业人员；在生命的最后 12 个月内住在家里的患者及其照顾者。

方法

在每个案例中：患者/护理人员在 8 周内完成了一份结构化的药物获取体验日志。日志被用作辅助回忆录，用于在研究开始时以及在 4 周和 8 周时对患者/护理人员进行连续的半结构化访谈。

医疗保健专业人员参加了半结构化访谈，重点关注他们促进药物获取的经验，包括障碍和促进因素。

从患者记录中提取处方药数据。

还从一系列文件中收集了每个案例的详细背景数据。

使用框架分析对患者、护理人员和医疗保健专业人员的访谈数据进行分析，以确定主要主题。我们估计了不同服务模式的处方成本和预算影响分析。在每种情况下对数据进行三角测量。采用跨案例比较和逻辑模型来实现跨服务交付类型的系统比较。

发现

获取药物是一个复杂且系统相互依赖的过程，需要患者、护理人员和医疗保健专业人员进行大量协调工作。案例研究强调了不同服务提供模式在获得药物的速度和难易程度方面的差异。关键问题是使处方人员队伍多样化、关系连续性和团队整合的重要性、电子处方系统的访问、共享记录和改进的社区药房库存。服务之间的每位患者处方成本差异不大，但考虑到中期符合条件的人群时，差异很大。

结论

在优先考虑关系连续性的护理提供系统中，通过增加护士和药剂师开处方者的数量，并改善跨专业人士对电子处方系统和患者记录的共享访问，将改善药品获取的经验。姑息治疗药物的社区药房库存也需要变得更加可靠。