Respondents' demographics coincided with other published data for US pharmacists in terms of percentage who compounded,10
and degree earned; thus, the respondents have no apparent distinguishing characteristics.
Most of the independent pharmacists compounded, although some (9.5%) limited the complexity of compounding to mixing commercial products.10,13
Because the survey instrument lacked a compounding definition, some respondents may have interpreted such mixing as compounding, a potential limitation of this work. No information was collected to distinguish between preparations made from the component ingredients or those made by mixing 2 or more commercially available products, although some respondents volunteered clarifying information. However, the inclusion of mixing commercial products as compounding was not necessarily inappropriate. Mixing commercial products can require application of the pharmacist's education to avoid dispensing a preparation of unacceptable quality.
Respondents identified the 3 most common cases presenting in their pharmacy that stimulated compounded solutions to optimize patient therapies. Combinations of ingredients and dosage forms not commercially available were the reasons that compounding was most frequently carried out, regardless of independent variable considered, in a majority of the respondent's pharmacies. Compounding dilutions or higher strength preparations are regular tasks in almost 44% of the respondent's pharmacies. As considered previously, even “simple” mixing requires understanding of chemical and physical compatibility of active and inactive ingredients. Concepts from physics and chemistry are applied to plan and execute basic compounding. Although the science foundation knowledge to compound is in courses prerequisite to the pharmacy professional program, transfer of knowledge from one field to another has to be guided, suggesting that compounding education is a necessity.16,17
The independent pharmacists selected reasons to compound that were consistent with tenets of pharmaceutical care. Independent pharmacists with PharmD degrees were more likely to compound because therapeutic outcomes were not met with commercial products. Although ranked as sixth based on percent of responses overall, 24.3% of the clinical respondents identified this reason for compounding (18 selected as first choice), compared with 11.2% of pharmacists educated before 1975 (1 selected as first choice). This difference was not significant, possibly because of the lower number of respondents that selected the option: still the numerical differences were striking. Those with PharmD degrees (either as only or second degree) prepared relatively more of most dosage form types than did their colleagues with BS degrees. Almost 80% (79.1%) of the respondents wanted to compound to provide care to the patient. More than 50% (52.3%) specified compounding in concert with a prescriber, including 53.7% of the independent pharmacists who began practice since 1975 and 49.5% of those who began practice in 1975 or before (p
< 0.01). Independent pharmacists who began practice prior to 1975 (40.0%) were more likely to say compounding was just a part of the job (p
< 0.01). This statement may be evidence of the intended change in viewpoint, from product-focused to patient focused, first introduced as clinical care
in the 1960s and punctuated later by the definition of pharmaceutical care
by Hepler and Strand.6
A higher number of independent pharmacists who began practice more recently than 1975 selected patient care as an important reason to compound (81.3%; 110 of these selected patient care as the primary reason to compound), suggesting that those entering practice since 1975 completed their education with the understanding and expectation of patient-focused care. This finding is consistent with Schommer and Cable's suggestion that those who began practice after 1975 experienced a patient-focused education (ie, clinical) compared with those educated prior to that time, who received a more product-focused education (ie, pre-clinical).8
A relatively higher prescription volume does not diminish the emphasis that the respondent pharmacists placed on providing compounding services to meet patient needs, as more pharmacists with a prescription volume of 980 prescriptions or more per week (median prescription volume for all respondents, n = 369) selected patient care as an important reason to compound (84.1%, compared with 72.8% of pharmacists dispensing less than 980 prescriptions per week, p < 0.05), indicating that the choice to compound is based on a patient's therapy needs to a greater extent than on the total prescription volume of a pharmacy. Approximately 27% of those who compound more than 0.5% (median percentage of compounds to total prescription volume for all respondents, n = 369) of the total prescription volume selected therapeutic outcomes as an important reason to compound, compared with only 11.5% of respondents compounding less than 0.5% of their total prescription volume (p < 0.05). These findings highlight younger pharmacists (entered practice since 1975) included compounding services as an ongoing component of contemporary practice and recognized the patient as a reason to do it regardless of pharmacy prescription volume. Hence, compounding is not limited to independent pharmacists trained primarily in BS programs prior to 1975.
Identification of the dosage forms most frequently compounded by the respondents establishes an initial definition of knowledge and skill sets appropriate for generalist pharmacy practice. The top 3 dosage forms (based on percentage of independent pharmacists that make each) are the same regardless of variable used for analysis, and are dermatological preparations for local effects (including ointments, creams, and gels), oral solutions, and suspensions for oral use. Sterile compounding was done in fewer than 10% of the respondent pharmacies, but the decision to limit the practice types surveyed is a factor here. Expansion of this work into additional practice types is necessary to fully define relevant curricular objectives for generalist practitioner preparation.
Regardless of degree earned, inclination toward or opportunity to compound, the vast majority (94.9%) of the responding pharmacists completed a required course in pharmacy school that had a laboratory component (Table ). Lack of education or training for compounding was cited as an issue for only a small subset of the respondent pharmacists (4.6%): hence, most received at least an exposure to compounding in pharmacy school. No information was collected systematically as to the quantity or quality of the experience, although voluntary comments from 4 respondents revealed their experiences in pharmacy school were inadequate for contemporary or complex compounding (eg, “very limited,” “make it relevant info, not how things were made 50 years ago,” etc).
Most pharmacists educated prior to 1975 reported being self-taught and learning from books, suggesting that pharmacy school education was insufficient in itself to provide the full complement of knowledge and skill. It is unlikely that any pharmacist began his or her practice with all of the compounding knowledge needed. Even with a strong pharmacy school foundation, new drugs and drug products are regularly released without dosage forms or excipient combinations appropriate or palatable to each potential patient. Outside of pharmacy school, a variety of sources are available for pharmacists to develop their knowledge base and gain experience (Table ). More recent graduates have relied on compounding support services (Other [sources], Table ) offered by commercial organizations. This switch to outside agencies for training may be in response to the decline in compounding education in schools of pharmacy or may reflect the growth of niche compounding businesses, where the pharmacist must extend his/her knowledge base beyond the basics from pharmacy school to meet more patients' needs.18
More inquiry is required to identify if other factors also contribute.
Most of the respondents (84.7% of those who offer compounding services and 79.2% of those who do not) believe compounding should be taught in PharmD curricula as a required course with a laboratory (Table ). Clearly, independent pharmacists would like to see compounding outcomes in the curriculum to prepare student pharmacists with basic compounding skill and knowledge for pharmaceutical care practice.
Recommendations Based on the data and perceptions gathered, pharmacists should be able to meet patient care needs by compounding. Several dosage forms were compounded at least once per week in more than half of the practices surveyed. At a minimum, each graduate should be capable of designing, preparing, and evaluating compounded dermatological preparations for local effects (ointments, creams and gels), oral solutions, and oral suspensions that meet all aspects of pharmaceutical care practice. A generalist pharmacist can reasonably expect to be called upon to make these and should be qualified to do so. Graduates should also be able to combine and/or dilute commercial products and modify dosage forms to meet patient therapy needs, and be able to affirm that all preparations dispensed will be safe and effective within a specified timeframe.
Additional dosage forms may be common regionally and it would be incumbent on each PharmD program to appropriately consider this in curricular development. A well-developed program should address, at a minimum, specific content and skill guidelines identified by the United States Pharmacopeia, Center for the Advancement of Pharmacy Education, and National Association of Boards of Pharmacy to graduate generalist pharmacists capable of basic compounding. Curricular objectives should specify that students demonstrate competency in a problem-solving process to design, prepare, and evaluate compounded dosage forms, and confidently describe how the resultant preparation is appropriate for the patient and drug. PharmD education should demonstrate the role compounding has in optimizing patient outcomes, emphasizing the relevance of compounding to pharmaceutical care practice.
When asked to comment on how compounding education should be carried out in pharmacy school, 24 respondents (7.5%) selected both required course and elective course (each with laboratory component). These responses suggest that an optimal approach to teaching compounding would prepare students for generalist practice and allow options for students planning for compounding practice. In addition to the required basic knowledge and skills, elective options can provide deeper and broader compounding exposure. Alternately, a longitudinal compounding experience might be considered, with didactic instruction and laboratory experiences early followed by practice collaborative experiential training.
As a service to graduates and the profession, pharmacy schools might consider offering continuing education (CE) programs for pharmacists who specialize in compounding. CE programs for contemporary practice would be an extension of a well-structured curriculum, bring practitioners and educators together, and provide a great opportunity for curricular dialog to strengthen professional pharmacy education and practice.