Group consultations are an important care option that is starting to gain traction in the USA and Australia. This review summarises the likely benefi ts accruing from a systems approach to implementing group consultations widely in the NHS and other socialised healthcare systems. Existing evidence is mapped to fi ve distinct systems approaches: (1) development; (2) different age groups; (3) patient-centred pathway of care; (4) NHS system changes; and (5) education. Implications are discussed for patients and staff, who both benefi t from group consultations once embedded; ranging from improved access and effi ciency to more enjoyable multidisciplinary team working, improved resource management, and maintained/better outcomes. Moreover, even patients who don't attend group consultations can benefi t from system effects of long-term implementation. Changing behaviour and health systems is challenging, but change requires systematic experimentation and documentation of evidence. We conclude that group consultations have unique potential for delivering system-wide benefi ts across the NHS.

ObjectivesThe key objectives of this study were to quantify extent of prescribing, reasons for deprescribing, common therapeutic groups of medicines deprescribed and adverse events.MethodsA retrospective analysis was carried out on a quality improvement project where 422 care home residents in 20 care homes received a medicines optimisation review with a pharmacist and other members of the healthcare team (general medical practitioner, care home nurse). Data on number, type and cost of medicines were collected. Statistical analysis was performed to test for differences between pharmacist-only review and the pharmacist plus general practitioner (GP), and to identify any correlation between the original number of medicines and the number of medicines stopped.ResultsOf the 422 patients reviewed, 298 (70.6%) had at least one medicine stopped with 704 medicines being stopped. This represented 19.5% of the medicines originally prescribed (3602 medicines). There was no statistically significant difference between pharmacist only and pharmacist plus GP in terms of stopping medicines. The main groups of medicines stopped were laxatives, skin products and bone protection. There was weak correlation between the original number of medicines prescribed and the number stopped.ConclusionsThis study has shown that medicines optimisation reviews can lead to a reduction in polypharmacy for care home residents through a deprescribing process. Patients' medicine regimens were simplified and optimised while making financial significant savings for the National Health Service.

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Objective To show the safety and efficacy of subcutaneous (SC) methotrexate (MTX) compared to oral MTX, alternative disease‐modifying antirheumatic drugs (DMARDs) monotherapy, biologic monotherapy, and combinations (conventional and biologic combination groups) in routine clinical practice. Methods Clinical and laboratory data were retrospectively analyzed for rheumatology clinic attendances at a large Northeast England hospital trust between January 2014 and January 2018. Rates of adverse events and stop events (transaminitis [serum alanine aminotransferase level of >80 units/liter] or neutropenia [neutrophil count of <2.0 × 109/liter]) were calculated, with adjustment for duration of DMARD exposure. Results In the present study, 8,394 patients received DMARDs, with 2,093 patients receiving oral MTX and 949 patients receiving SC MTX. The median dose was 15 mg (interquartile range [IQR] 10–20 mg) for oral MTX, and 20 mg (IQR 15–25 mg) for SC MTX (P < 0.0001). Continuation rates were higher for SC MTX therapy when adjusted for follow‐up duration, with a rate ratio (RR) of 1.54 (95% confidence interval [95% CI] 1.40–1.70) (P < 0.0001). For the time period assessed, 2,382 patients experienced 4,358 adverse events, with 1,711 incidents of transaminitis and 2,647 incidents of neutropenia recorded. Significantly fewer adverse events were observed in patients who received SC MTX monotherapy versus those who received biologic and combination DMARD therapies (P < 0.01). Compared to oral MTX, SC MTX was associated with a nonsignificant trend toward lower rates of neutropenia, but only a slightly higher rate of transaminitis (RR 1.26 [95% CI 1.07–1.48]) (P = 0.006), despite significantly higher doses of MTX. Conclusion Subcutaneous MTX is safe in routine clinical practice. This is the largest study yet reported on SC MTX and provides observational data that SC MTX is continued longer and better tolerated in patients compared to other therapy groups, especially oral MTX.

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Background:Methotrexate (MTX) is established as both first line therapy and combination therapy anchor drug for Rheumatoid Arthritis (RA) and other peripheral inflammatory arthritis such as Psoriatic Arthritis (PsA). There is evidence subcutaneous (sc) MTX is more effective than oral MTX, with fewer treatment failures1–3, but it is not known if this holds true in routine practice and in combination.Objectives:To show the safety & efficacy of sc MTX therapy in routine practice, compared to oral MTX, alternate monotherapy and combination therapies.Methods:The Therapy Audit Monitoring System (TAMS, www.therapyaudit.com/tamonitor) was installed Jan 2014. Since then all new patients starting disease modifying therapy and existing patients are entered. The database was queried for diagnosis, dose and response, together with adverse events (defined as ALT>80U/l or neutrophils<2.0x109/l). Statistical comparisons used the two proportion Z test, T-test or exact rate ratio test, as appropriate: significance threshold p<0.05.ResultsPatient groupsOral MTX onlysc MTX onlyBiologics onlyConventionalCombinationBiologicCombination Total patients ever exposed – n20939495701596552Patients affected by abnormal LFTsn (%)198(10%)100(10%)47(8%)154(10%)72(13%)Patients affected by low neutrophilsn (%)140(7%)64(7%)66(12%)219(14%)115(21%)Current patients9204253459213848394 patients had received one or more therapies with 4109 current patients identified. Including combinations, 2650 started oral MTX (1463 current) and 1343 sc MTX (911 current). Mean (range) oral MTX dose was 17 (2.5–30) mg and sc MTX was 21 (5–40) mg (p<0.0001). 4356 adverse events were observed over follow-up in 2382 patients, with 1710 (39%) due to ALT>80U/I and 2646 (61%) to neutrophils<2.0x109/I. Abnormal ALT events by drug: oral MTX 486, sc MTX 222 (p=0.92 sc vs. oral). Similarly, low neutrophil count (<2.0x109/l): oral MTX 491, sc MTX 151 (p<0.00001 sc vs. oral). Rate ratios (RR) for low neutrophils for oral MTX-only vs. sc MTX-only showed highly significant differences (RR=1.40, 95% CI: 1.17–1.70; p=0.0002). 14% (1197/8294) of all patients had post-treatment DAS28 scores. Of these 59% (67/113) patients on sc MTX only, and 72% (273/377) on conventional combination achieved DAS<5.1 compared to 69% (69/98) biologic-only and 78% (102/131) biologic-combination. Sensitivity analyses examined response & toxicity by group (data not included).Conclusions:sc MTX is safe and effective in routine practice at doses up to 40 mg. It has lower toxicity than oral MTX in monotherapy and combination, despite a higher mean dose with highly significant reduction in neutropenia rate and the same rate of liver problems compared to oral. This is the largest study of sc MTX yet reported and supports use of higher doses in selected patients and aggregation or replication of data like this may support license extension for sc MTX beyond 30 mg. If patients are usually switched to sc MTX when oral MTX is ineffective or not tolerated, many do not progress to biologic therapy: delivering good care ...

Group consultations are becoming more and more common as the patient benefits are increasingly recognised. This article clarifies what a group consultation entails and the best ways of implementing them in practice

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