Abstract：
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.
OBJECTIVE: To undertake an evaluation of patient and carer access to medicines at end-of-life within the context of models of service delivery.
METHODS: 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.
METHODS: (i) General Practitioner services (ii) Palliative care clinical nurse specialist prescribers (iii) a 24/7 palliative care telephone support line service.
METHODS: 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.
RESULTS: 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.
OBJECTIVE: To undertake an evaluation of patient and carer access to medicines at end-of-life within the context of models of service delivery.
METHODS: 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.
METHODS: (i) General Practitioner services (ii) Palliative care clinical nurse specialist prescribers (iii) a 24/7 palliative care telephone support line service.
METHODS: 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.
RESULTS: 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.
摘要：
背景：在生命的最后12个月中，患者在家中获得良好的药物是有效控制症状的关键，预防痛苦和避免计划外和紧急护理。
目的：在服务提供模型的背景下，对患者和护理人员在生命末期获得药物的情况进行评估。
方法：评估，服务交付模型的混合方法案例研究，包括成本分析。分析的单位是服务交付模型，具有嵌入式子单元的分析。
方法：（i）全科医生服务（ii）姑息治疗临床护士专家处方（iii）24/7姑息治疗电话支持线服务。
方法：提供临终护理的医疗保健专业人员；住在家里的患者，在生命的最后12个月里，和他们的照顾者。
方法：在每种情况下：患者/护理人员在8周内完成了关于药物访问经历的结构化日志。日志被用作顺序备忘录，在研究进入时对患者/护理人员进行半结构化访谈，在四个和八个星期。医疗保健专业人员参加了半结构化访谈，重点是他们在促进获得药物方面的经验，包括障碍,和促进因素。从患者记录中提取有关处方药的数据。还从一系列文件中收集了每个案例的详细背景数据。病人,使用框架分析对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。我们估算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。
结果：获取药物是一个复杂和系统相互依赖的过程，需要患者进行大量的协调工作。护理人员和医疗保健专业人员。案例研究强调了不同服务交付模式在获取药物的速度和难易程度方面的差异。关键问题是处方人员的多样化，关系连续性和团队整合的重要性，使用电子处方系统，共享记录和改善社区药房库存。服务之间的每位患者处方成本差异不大，但在中期内考虑合格人群时差异很大。
结论：通过增加护士和药剂师处方人员的数量，可以改善药物获取的经验，并改善对电子处方系统和患者记录的专业间共享访问，在优先考虑关系连续性的护理交付系统中。社区药房的姑息治疗药物库存也需要变得更加可靠。
目的：在服务提供模型的背景下，对患者和护理人员在生命末期获得药物的情况进行评估。
方法：评估，服务交付模型的混合方法案例研究，包括成本分析。分析的单位是服务交付模型，具有嵌入式子单元的分析。
方法：（i）全科医生服务（ii）姑息治疗临床护士专家处方（iii）24/7姑息治疗电话支持线服务。
方法：提供临终护理的医疗保健专业人员；住在家里的患者，在生命的最后12个月里，和他们的照顾者。
方法：在每种情况下：患者/护理人员在8周内完成了关于药物访问经历的结构化日志。日志被用作顺序备忘录，在研究进入时对患者/护理人员进行半结构化访谈，在四个和八个星期。医疗保健专业人员参加了半结构化访谈，重点是他们在促进获得药物方面的经验，包括障碍,和促进因素。从患者记录中提取有关处方药的数据。还从一系列文件中收集了每个案例的详细背景数据。病人,使用框架分析对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。我们估算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。
结果：获取药物是一个复杂和系统相互依赖的过程，需要患者进行大量的协调工作。护理人员和医疗保健专业人员。案例研究强调了不同服务交付模式在获取药物的速度和难易程度方面的差异。关键问题是处方人员的多样化，关系连续性和团队整合的重要性，使用电子处方系统，共享记录和改善社区药房库存。服务之间的每位患者处方成本差异不大，但在中期内考虑合格人群时差异很大。
结论：通过增加护士和药剂师处方人员的数量，可以改善药物获取的经验，并改善对电子处方系统和患者记录的专业间共享访问，在优先考虑关系连续性的护理交付系统中。社区药房的姑息治疗药物库存也需要变得更加可靠。
