PINCER trial: a cluster randomised trial comparing the effectiveness and cost-effectiveness of a pharmacist-led IT-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices

Background: Medication errors in general practice are an important source of potentially preventable morbidity and mortality. Building on previous descriptive, qualitative and pilot work, we sought to investigate the effectiveness, cost-effectiveness and likely generalisability of a complex pharm acist-led IT-based intervention aiming to improve prescribing safety in general practice. Objectives: We sought to: • Test the hypothesis that a pharmacist-led IT-based complex intervention using educational outreach and practical support is more effective than simple feedback in reducing the proportion of patients at risk from errors in prescribing and medicines management in general practice. • Conduct an economic evaluation of the cost per error avoided, from the perspective of the National Health Service (NHS). • Analyse data recorded by pharmacists, summarising the proportions of patients judged to be at clinical risk, the actions recommended by pharmacists, and actions completed in the practices. • Explore the views and experiences of healthcare professionals and NHS managers concerning the intervention; investigate potential explanations for the observed effects, and inform decisions on the future roll-out of the pharmacist-led intervention • Examine secular trends in the outcome measures of interest allowing for informal comparison between trial practices and practices that did not participate in the trial contributing to the QRESEARCH database. Methods Two-arm cluster randomised controlled trial of 72 English general practices with embedded economic analysis and longitudinal descriptive and qualitative analysis. Informal comparison of the trial findings with a national descriptive study investigating secular trends undertaken using data from practices contributing to the QRESEARCH database. The main outcomes of interest were prescribing errors and medication monitoring errors at six- and 12-months following the intervention. Results: Participants in the pharmacist intervention arm practices were significantly less likely to have been prescribed a non-selective NSAID without a proton pump inhibitor (PPI) if they had a history of peptic ulcer (OR 0.58, 95%CI 0.38, 0.89), to have been prescribed a beta-blocker if they had asthma (OR 0.73, 95% CI 0.58, 0.91) or (in those aged 75 years and older) to have been prescribed an ACE inhibitor or diuretic without a measurement of urea and electrolytes in the last 15 months (OR 0.51, 95% CI 0.34, 0.78). The economic analysis suggests that the PINCER pharmacist intervention has 95% probability of being cost effective if the decision-maker’s ceiling willingness to pay reaches £75 (6 months) or £85 (12 months) per error avoided. The intervention addressed an issue that was important to professionals and their teams and was delivered in a way that was acceptable to practices with minimum disruption of normal work processes. Comparison of the trial findings with changes seen in QRESEARCH practices indicated that any reductions achieved in the simple feedback arm were likely, in the main, to have been related to secular trends rather than the intervention. Conclusions Compared with simple feedback, the pharmacist-led intervention resulted in reductions in proportions of patients at risk of prescribing and monitoring errors for the primary outcome measures and the composite secondary outcome measures at six-months and (with the exception of the NSAID/peptic ulcer outcome measure) 12-months post-intervention. The intervention is acceptable to pharmacists and practices, and is likely to be seen as costeffective by decision makers.

Black stem rust "...two blighted ears of wheat, which few persons would have thought it worthwhile to carry with them round the world..."

A brief survey of the history of this most severe pathogen of wheat and our developing understanding of it.

Whose land was it anyway? The Crichel Down Rules and the sale of public land

The guiding principle of compulsory purchase of interests in land in England and Wales is that of fairness, best stated in the words of Lord Justice Scott in Horn v Sunderland Corporation when he said that the owner has “the right to be put, so far as money can do it, in the same position as if his land had not been taken from him”. In many instances, land acquired by compulsion subsequently becomes surplus to the requirements of the acquiring authority. This may be because the intended development scheme was scrapped, or substantially modified, or that after the passage of time the use of the land for which the purchase took place is no longer required. More controversially it may be that for ‘operational reasons’ the acquiring authority knowingly purchased more land than was required for the scheme. Under these circumstances, the Crichel Down Rules (‘the Rules’) require government departments and other statutory bodies to offer back to the former owners or their successors, any land previously so acquired by, or under the threat of, compulsory purchase.

'They Shall Speak the Arabic Language and Take Pride in it': reconsidering the fate of Coptic after the Arab Conquest

The complaints on the adoption of Arabic by the Copts that are voiced by the Apocalypse of Pseudo-Samuel have often been quoted as the expiring words of the dying Coptic language. This article seeks to show that they are not to be taken so literally, and that they should rather be inserted in the context of a rift within the medieval Coptic church over the question of language choice, and beyond this, over that of accommodation with the Muslims. The use of Arabic by the episcopal church of Miṣr and by some prominent figures around it, which was linked to their proximity to the Fatimid court, was resented and denounced by more traditional circles, centred on the Patriarchate and on some important monasteries such as the one at Qalamūn where the Apocalypse was written. The suggestion is also made that the text is contemporary with the beginning of Coptic literary production in Arabic and with the introduction of Egyptian Christians at the caliphal court, namely in the last quarter of the tenth century, at the time of Severus ibn al-Muqqafa‘.