Asthma is one of the most common chronic conditions affecting the Australian population. Amongst primary healthcare professionals, pharmacists are the most accessible and this places pharmacists in an excellent position to play a role in the management of asthma. Globally, trials of many community pharmacy-based asthma care models have provided evidence that pharmacist delivered interventions can improve clinical, humanistic and economic outcomes for asthma patients. In Australia, a decade of coordinated research efforts, in various aspects of asthma care, has culminated in the implementation trial of the Pharmacy Asthma Management Service (PAMS), a comprehensive disease management model.
There has been research investigating asthma medication adherence through data mining, ways in which usual asthma care can be improved. Our research has focused on self-management education, inhaler technique interventions, spirometry trials, interprofessional models of care, and regional trials addressing the particular needs of rural communities. We have determined that inhaler technique education is a necessity and should be repeated if correct technique is to be maintained. We have identified this effectiveness of health promotion and health education, conducted within and outside the confines of the pharmacy, in public for a and settings such as schools, and established that this outreach role is particularly well received and increases the opportunity for people with asthma to engage in their asthma management.
Our research has identified that asthma patients have needs which pharmacists delivering specialized models of care, can address. There is a lot of evidence for the effectiveness of asthma care by pharmacists, the future must involve integration of this role into primary care.
Asthma; community pharmacy; pharmacists’disease state management; self-management; health promotion; inhaler technique
The use of medicines is an essential component of many public health programs (PHPs). Medicines are important not only for their capacity to treat and prevent diseases. The public confidence in healthcare system is inevitably linked to their confidence in the availability of safe and effective medicines and the measures for ensuring their rational use. However, pharmacy services component receives little or no attention in most public health programs in developing countries. This article describes the strategies, lessons learnt, and some accomplishments of Howard University Pharmacists and Continuing Education (HU-PACE) Centre towards improving hospital pharmacy practice through PHP in Nigeria.
In a cross-sectional survey, 60 hospital pharmacies were randomly selected from 184 GHAIN-supported health facilities. The assessment was conducted at baseline and repeated after at least 12 months post-intervention using a study-specific instrument. Interventions included engagement of stakeholders; provision of standards for infrastructural upgrade; development of curricula and modules for training of pharmacy personnel; provision of job aids and tools amongst others. A follow-up hands-on skill enhancement based on identified gaps was conducted. Chi-square was used for inferential statistics. All reported p-values were 2-tailed at 95% confidence interval.
The mean duration of service provision at post-intervention assessment was 24.39 (95% CI, 21.70–27.08) months. About 16.7% of pharmacies reported been trained in HIV care at pre-intervention compared to 83.3% at post-intervention. The proportion of pharmacies with audio-visual privacy for patient counseling increased significantly from 30.9% at pre-intervention to 81.4% at post-intervention. Filled prescriptions were cross-checked by pharmacist (61.9%) and pharmacy technician (23.8%) before dispensing at pre-intervention compared to pharmacist (93.1%) and pharmacy technician (6.9%) at post intervention. 40.0% of pharmacies reported tracking consumption of drugs at pre-intervention compared to 98.3% at post-intervention; while 81.7% of pharmacies reported performing periodic stock reconciliation at pre-intervention compared to 100.0% at post-intervention. 36.5% of pharmacies were observed providing individual counseling on medication use to patients at pre-intervention compared to 73.2% at post-intervention; and 11.7% of pharmacies had evidence of monitoring and reporting of suspected adverse drug reaction at pre-intervention compared to 73.3% at post-intervention. The institution of access to patients’ clinical information by pharmacists in all pharmacies at post-intervention was a paradigm shift.
Through public health program, HU-PACE created an enabling environment and improved capacity of pharmacy personnel for quality HIV/AIDS and TB services. This has contributed in diverse ways to better monitoring of patients on pharmacotherapy by pharmacists through access of pharmacists to patients’ clinical information.
Pharmaceutical care; HIV/AIDS; Public health programs; Patients; Nigeria
To describe the education, research, practice, and policy related to pharmacist interventions to improve medication adherence in community settings in the United States.
Authors used MEDLINE and International Pharmaceutical Abstracts (since 1990) to identify community and ambulatory pharmacy intervention studies which aimed to improve medication adherence. The authors also searched the primary literature using Ovid to identify studies related to the pharmacy teaching of medication adherence. The bibliographies of relevant studies were reviewed in order to identify additional literature. We searched the tables of content of three US pharmacy education journals and reviewed the American Association of Colleges of Pharmacy website for materials on teaching adherence principles. Policies related to medication adherence were identified based on what was commonly known to the authors from professional experience, attendance at professional meetings, and pharmacy journals.
Research and Practice: 29 studies were identified: 18 randomized controlled trials; 3 prospective cohort studies; 2 retrospective cohort studies; 5 case-controlled studies; and one other study. There was considerable variability in types of interventions and use of adherence measures. Many of the interventions were completed by pharmacists with advanced clinical backgrounds and not typical of pharmacists in community settings. The positive intervention effects had either decreased or not been sustained after interventions were removed. Although not formally assessed, in general, the average community pharmacy did not routinely assess and/or intervene on medication adherence.
National pharmacy education groups support the need for pharmacists to learn and use adherence-related skills. Educational efforts involving adherence have focused on students’ awareness of adherence barriers and communication skills needed to engage patients in behavioral change.
Several changes in pharmacy practice and national legislation have provided pharmacists opportunities to intervene and monitor medication adherence. Some of these changes have involved the use of technologies and provision of specialized services to improve adherence.
Researchers and practitioners need to evaluate feasible and sustainable models for pharmacists in community settings to consistently and efficiently help patients better use their medications and improve their health outcomes.
Medication Adherence; Pharmacists; Education; Pharmacy; United States
This study will provide guiding information about the population perception, views and satisfaction with pharmacist’s performance as health care provider in the community pharmacy setting in Riyadh, Saudi Arabia.
The study was conducted in Riyadh, Saudi Arabia, from July through December 2010. A total of 125 community pharmacies in Riyadh city were randomly selected according to their geographical distribution (north, south, east, and west). They represent about 10–15% of all community pharmacies in the city. The questionnaire composed of 8 items about patients’ views and satisfaction with the pharmacists’ role in the current community pharmacy practice. The questionnaire was coded, checked for accuracy and analyzed using the Statistical Package for Social Sciences (SPSS) version 17.0 for Windows (SPSS Inc., Chicago, Illinois).
The response rate was almost 85% where 2000 patients were approached and 1699 of them responded to our questionnaire. The majority of respondents is young adults and adults (82.8%), male (67.5%) and married (66.9%). Seventy one percent of respondents assured that community pharmacist is available in the working while only 37.3% of respondents perceived the pharmacist as a mere vendor. About 38% assured sou moto counseling by the pharmacist, 35% reported pharmacist plays an active role in their compliances to treatments, 43% acknowledged the role of pharmacist in solving medication related problems, 34% considered the pharmacist as a health awareness provider and 44.6% felt that pharmacist is indispensable and an effective part of the health care system.
The image and professional performance of community pharmacist are improving in Saudi Arabia. The Saudi patients show better satisfaction, perception and appreciation of the pharmacists’ role in the health care team. However, extra efforts should be paid to improve the clinical skills of the community pharmacists. Community pharmacists need to be able to reach out to patient, assess their hesitations and promptly offer solution which was appreciated by the patients as the survey indicates. They should play a pro-active role in becoming an effective and indispensable part of health care. Furthermore, they should be able to advice, guide, direct and persuade the patient to comply correct usage of drugs. Finally, community pharmacists should equip themselves with appropriate knowledge and competencies in order to tender efficient and outstanding pharmaceutical health care.
Community; Pharmacist; Satisfaction; Care; Drug; Perception
Pharmacists in Australia are accessible health care professionals, and their provision of clinical pharmacy interventions in a range of areas has been proven to improve patient outcomes. Individual clinical pharmacy interventions in the area of asthma management have been very successful. An understanding of the nature of these interventions will inform future pharmacy services. What we do not know is when pharmacists provide a complex asthma service, what elements of that service (interventions) they choose to deliver.
To explore the scope and frequency of asthma-related clinical interventions provided by pharmacists to patients in an evidence-based complex asthma service.
Pharmacists from 4 states/territories of Australia were trained in asthma management. People with asthma had 3 or 4 visits to the pharmacy. Guided by a structured patient file, the pharmacist assessed the patient’s asthma and management and provided interventions where and when considered appropriate, based on their clinical decision making skills. The interventions were recorded in a checklist in the patient file. They were then analysed descriptively and thematically.
Pharmacists provided 22,909 clinical pharmacy interventions over the service to 570 patients (398 of whom completed the service). The most frequently delivered interventions were in the themes ’Education on asthma’, ’Addressing trigger factors’, ’Medications - safe and effective use’ and ’Explore patient perspectives’. The patients had a high and ongoing need for interventions. Pharmacists selected interventions based on their assessment of perceived need then revisited and reinforced these interventions.
Pharmacists identified a number of areas in which patients required interventions to assist with their asthma management. Many of these were perceived to require continuing reinforcement over the duration of the service. Pharmacists were able to use their clinical judgement to assess patients and provide clinical pharmacy interventions across a range of asthma management needs.
Asthma; Pharmaceutical Services; Pharmacists; Evidence-Based Practice; Australia
Medication regimens for asthma are particularly vulnerable to adherence problems because of the requirement for long-term use and periods of symptom remission experienced by patients. Pharmacists are suited to impact medication adherence given their training, skills, and frequent contact with patients. The Empowering pharmacists in asthma management through interactive SMS (EmPhAsIS) trial involves an intervention leveraging mobile health (mHealth) technology to support community pharmacy practice with the hypothesis of improved medication adherence in asthma.
This study is a pragmatic pharmacy-based, cluster, randomized controlled trial with 12 months of intervention delivery and follow-up. Pharmacies (the clusters) will be randomized at a 1:1 ratio to provide intervention or usual care. The EmPhAsIS intervention consists of patient asthma education, short message service (SMS)-based monthly assessment of adherence, and follow-up of non-adherent individuals by community pharmacists. There are no inclusion or exclusion criteria for pharmacies. Patients are eligible if they: are 14 years of age or older, fill a prescription for inhaled corticosteroid (either monotherapy or in a combination inhaler with long-acting beta-agonists), have been diagnosed with asthma, possess a mobile phone with SMS capabilities, and have no communication difficulties such as inability to communicate in English, or significant impairment in vision, hearing, or speech. The primary outcome is adherence to inhaled corticosteroids ascertained by the medication possession ratio, the ratio of the days of medication supplied to days in a given time interval. This study will also evaluate secondary outcomes including: asthma control, asthma-related quality of life, asthma-related hospital admissions, and use of reliever medications during the follow-up period. A nested economic evaluation using a probabilistic decision-analytic model will be used to perform a cost-effectiveness analysis from the societal perspective of the intervention compared with usual care over a 10-year time horizon.
Considering the prevalence of asthma, the extent of the non-adherence problem in this disease, and the availability of effective treatments, there is a tremendous potential to reduce the burden of asthma through improving adherence. This is the first study of an intervention based on mobile communication technology involving community pharmacists in asthma management.
ClinicalTrials.gov identifier: NCT02170883; date of registration: 19 June 2014.
Asthma; Medication adherence; Inhaled corticosteroids; Cluster randomized controlled trial; Community pharmacy; Pharmacy practice research
In the Netherlands, 5.6 % of acute hospital admissions are medication-related. Almost half of these admissions are potentially preventable. Reviewing medication in patients at risk in primary care might prevent these hospital admissions. At present, implementation of medication reviews in primary care is suboptimal: pharmacists lack access to patient information, pharmacists are short of clinical knowledge and skills, and working processes of pharmacists (focus on dispensing) and general practitioners (focus on clinical practice) match poorly. Integration of the pharmacist in the primary health care team might improve pharmaceutical care outcomes.
The aim of this study is to evaluate the effect of integration of a non-dispensing pharmacist in general practice on the safety of pharmacotherapy in the Netherlands.
The POINT study is a non-randomised controlled intervention study with pre-post comparison in an integrated primary care setting. We compare three different models of pharmaceutical care provision in primary care: 1) a non-dispensing pharmacist as an integral member of a primary care team, 2) a pharmacist in a community pharmacy with a predefined training in performing medication reviews and 3) a pharmacist in a community pharmacy (care as usual). In all models, GPs remain accountable for individual medication prescription. In the first model, ten non-dispensing clinical pharmacists are posted in ten primary care practices (including 5 – 10 000 patients each) for a period of 15 months. These non-dispensing pharmacists perform patient consultations, including medication reviews, and share responsibility for the pharmaceutical care provided in the practice. The two other groups consist of ten primary care practices with collaborating pharmacists. The main outcome measurement is the number of medication-related hospital admissions during follow-up. Secondary outcome measurements are potential medication errors, drug burden index and costs. Parallel to this study, a qualitative study is conducted to evaluate the feasibility of introducing a NDP in general practice.
As the POINT study is a large-scale intervention study, it should provide evidence as to whether integration of a non-dispensing clinical pharmacist in primary care will result in safer pharmacotherapy. The qualitative study also generates knowledge on the optimal implementation of this model in primary care. Results are expected in 2016.
Trial registration number
NTR4389, The Netherlands National Trial Register, 07-01-2014.
Pharmacotherapy; Polypharmacy; Non-dispensing clinical pharmacist; General practice; Primary care; Hospitalisation
The Italian Ministry of Health decided to introduce community professional services in 2010. This trial provides an opportunity to evaluate the outcomes of a new professional pharmacy service: Italian Medicines Use Review (I-MUR) aimed at reducing the severity of asthma and its associated costs.
This is a cluster randomised controlled trial of the I-MUR service. Data will be collected over time before, during and after pharmacists’ intervention. Fifteen Italian regions will be involved and it is aimed to recruit 360 community pharmacists and 1800 patients. Each pharmacist will receive training in medicines use review, recruit five patients, administer the Asthma Control Test and provide the I-MUR service. Pharmacists will be allocated to different groups, one group will be trained in and provide the I-MUR service immediately after completion of the baseline ACT score, the other group will receive training in the I-MUR and provide this service three months later. Group allocation will be random, after stratification by region of Italy. The I-MUR service will involve gathering data following each patient consultation including demographic details, patients regular medications, including those used for asthma, their attitude towards their medications and self-reported adherence to treatments. In addition, pharmacists will identify and record pharmaceutical care issues and any advice given to patients during the I-MUR, or recommendations given to doctors. Pharmacists will upload trial data onto a web platform for analysis. The primary outcome measure is the severity of asthma before, during and after the I-MUR assessed using the Asthma Control Test score. Secondary measures: number of all active ingredients used by patients during and after the I-MUR, number of pharmaceutical care issues identified during the I-MUR, patients’ self-reported adherence to asthma medication during and after the I-MUR, healthcare costs based on the severity of asthma, before, during and after the I-MUR service provision.
This study has been developed because of the need for a new way of working for pharmacists and pharmacies; it is the first trial of any community pharmacy-based pharmaceutical care intervention in Italy. The results will inform future policy and practice in Italian community pharmacy.
Trial registration number
Asthma; Medicines use review; Cluster randomised controlled trial (RCT); Community pharmacy
To describe medication adherence education, practice, research and policy efforts carried out by pharmacists in Spain in the last decade.
A literature review using Medline and Embase was conducted covering the last ten years. Additional pharmaceutical bibliographic sources in Spain were consulted to retrieve articles of interest from the last decade. Articles were included if a pharmacist was involved and if medication adherence was measured or there was any direct or indirect pharmacist intervention in monitoring and/or improving adherence. Articles focusing on the development of tools for adherence assessment were collected. Pre- and post-graduate pharmacy training programs were also reviewed through the Spanish Ministry of Education and Science website. Information regarding policy issues was gathered from the Spanish and Autonomous Communities of Education and Health Ministries websites.
Pharmacists receive no specific training focused on adherence. There is no specific government policies for pharmacists in Spain related to medication adherence regardless of their practice setting. A total of 24 research studies met our inclusion criteria. Of these, 10 involved pharmacist intervention in monitoring and/or improving adherence and 14 assessed only adherence. Ten studies involved hospital pharmacists working in collaboration with another healthcare professional.
At present in Spain, the investigative role of the pharmacist is not well developed in the area of medication adherence. Adherence improvement services provided to patients by pharmacists are not implemented in a systematic way. However, recent efforts to implement new initiatives in this area may provide the basis for offering new cognitive services aimed at improving patient adherence in the near future.
Medication Adherence; Pharmacists; Spain
To investigate older patient, physician and pharmacist perspectives about the pharmacists’ role in pharmacist-patient interactions.
Eight focus group discussions.
Senior centers, community pharmacies, primary care physician offices.
Forty-two patients aged 63 and older, 17 primary care physicians, and 13 community pharmacists.
Qualitative analysis of focus group discussions.
Participants in all focus groups indicated that pharmacists are a good resource for basic information about medications. Physicians appreciated pharmacists’ ability to identify drug interactions, yet did not comment on other specific aspects related to patient education and care. Physicians noted that pharmacists often were hindered by time constraints that impede patient counseling. Both patient and pharmacist participants indicated that patients often asked pharmacists to expand upon, reinforce, and explain physician-patient conversations about medications, as well as to evaluate medication appropriateness and physician treatment plans. These groups also noted that patients confided in pharmacists about medication-related problems before contacting physicians. Pharmacists identified several barriers to patient counseling, including lack of knowledge about medication indications and physician treatment plans.
Community-based pharmacists may often be presented with opportunities to address questions that can affect patient medication use. Older patients, physicians and pharmacists all value greater pharmacist participation in patient care. Suboptimal information flow between physicians and pharmacists may hinder pharmacist interactions with patients and detract from patient medication management. Interventions to integrate pharmacists into the patient healthcare team could improve patient medication management.
pharmacist-patient interactions; provider-patient communication; prescription medication; qualitative research methods
Community pharmacists are well placed to deliver adherence support services as well as other pharmaceutical services to patients. They are often the last point of contact with patients collecting medicines in the healthcare chain, and they tend to be visited by patients on a regular basis to collect prescription medicines. They have the opportunity to reinforce information already received from other health practitioners, provide further information and monitor adherence to therapy.
The past decade has seen an increase in focus on the importance of adherence to therapy, not only in the higher education sector, but also in government policy and community pharmacy practice. Adherence monitoring and promotion has not only become the foundation of courses taught in pharmacy schools, but has become an essential component of disease management and pharmaceutical services delivered by community pharmacists.
This article aims to describe the education, research, practice and policy in the area of adherence to therapy in Australia with a focus on community pharmacists.
A search of MEDLINE and International Pharmaceutical Abstracts as well as hand searches of the bibliographies of retrieved articles was conducted for the period 2000-2008. All pharmacy schools in Australia were also contacted to obtain information on the patient adherence to therapy content of their courses.
Ten studies met the inclusion criteria. Only one study had a specific adherence focus, with the remainder including adherence support and monitoring as part of the overall interventions delivered by the community pharmacists. In the majority of cases the interventions resulted in an improvement in patients’ adherence to therapy. The research was supported by government and pharmacy professional organisation initiatives in the area of cognitive pharmaceutical services. All universities which responded delivered specific patient adherence courses.
Australian pharmacy schools are educating cohorts of students who will have the skills to monitor and support patient medication adherence in the context of contemporary pharmacy practice. This is supported by research evidence, government policy and fits well into the move to expand community pharmacy services to include chronic disease state management and primary health care.
Medication Adherence; Pharmacists; Australia
To assess the public’s attitudes towards the community pharmacist’s role in Qatar, to investigate the public’s use of community pharmacy, and to determine the public’s views of and satisfaction with community pharmacy services currently provided in Qatar.
Materials and methods
Three community pharmacies in Qatar were randomly selected as study sites. Patients 16 years of age and over who were able to communicate in English or Arabic were randomly approached and anonymously interviewed using a multipart pretested survey.
Over 5 weeks, 58 patients were interviewed (60% response rate). A total of 45% of respondents perceived community pharmacists as having a good balance between health and business matters. The physician was considered the first person to contact to answer drug- related questions by 50% of respondents. Most patients agreed that the community pharmacist should provide them with the medication directions of use (93%) and advise them about the treatment of minor ailments (79%); however, more than 70% didn’t expect the community pharmacist to monitor their health progress or to perform any health screening. Half of the participants (52%) reported visiting the pharmacy at least monthly. The top factor that affected a patient’s choice of any pharmacy was pharmacy location (90%). When asked about their views about community pharmacy services in Qatar, only 37% agreed that the pharmacist gave them sufficient time to discuss their problem and was knowledgeable enough to answer their questions.
This pilot study suggested that the public has a poor understanding of the community pharmacist’s role in monitoring drug therapy, performing health screening, and providing drug information. Several issues of concern were raised including insufficient pharmacist– patient contact time and unsatisfactory pharmacist knowledge. To advance pharmacy practice in Qatar, efforts may be warranted to address identified issues and to promote the community pharmacist’s role in drug therapy monitoring, drug information provision, and health screening.
pharmacist; public; attitudes; Qatar
The study objective is to investigate the impact of mandatory clinical clerkship courses on 5th-year pharmacy students’ attitudes and perceived barriers toward providing pharmaceutical care (PC).
A cross-sectional survey was conducted among 5th-year pharmacy students undertaking mandatory clinical clerkship in the University of Gondar, Ethiopia. A pharmaceutical care attitudes survey (PCAS) questionnaire was used to assess the attitude (14 items), commonly identified drug-related problem/s (1 item) during clerkships, and perceived barriers (12 items) toward the provision of PC. Statistical analysis was conducted on the retrieved data.
Out of the total of 69 clerkship students, 65 participated and completed the survey (94.2% response rate). Overall, 74.45% of participants opinioned a positive attitude toward PC provision. Almost all respondents agreed that the primary responsibility of pharmacists in the healthcare setting was to prevent and solve medication-related problems (98.5%), practice of PC was valuable (89.3%), and the PC movement will improve patient health (95.4%), respectively. Unnecessary drug therapy (43%), drug–drug interactions (33%), and non-adherence to medications (33%) were the most common drug-related problems identified in wards. Highly perceived barriers for PC provision included lack of a workplace for counseling in the pharmacy (75.4%), a poor image of pharmacist’s role in wards (67.7%), and inadequate technology in the pharmacy (64.6%). Lack of access to a patient’s medical record in the pharmacy had significant association (P<0.05) with PC practice, performance of PC during clerkship, provision of PC as clinical pharmacists, and Ethiopian pharmacists benefiting by PC.
Ethiopian clinical pharmacy students have a good attitude toward PC. Efforts should be targeted toward reducing these drug therapy issues, and aiding the integration of PC provision with pharmacy practice.
students; Ethiopia; clinical pharmacy program; clerkship; pharmaceutical care
The purpose of this report is to characterize the patient population served by the Grace Lamsam Pharmacy Program and to describe program outcomes.
A chart review was conducted for all patients (n=100) participating in the Grace Lamsam Pharmacy Program from January 1, 2007 to February 6, 2008. The primary outcome data collected were the medication related problems (unnecessary drug therapy, needs additional drug therapy, ineffective drug therapy, dosage too low, dosage too high, adverse drug reaction, noncompliance, and needs different drug product) identified by pharmacists, the number and type of pharmacist interventions made, estimated cost savings from perspective of the patient and clinical data (hemoglobin A1C, blood pressure measurements, and LDL-C) for patients with diabetes, hypertension, and hyperlipidemia, respectively. Basic demographic data was collected, including: patient gender, age, education level, race/ethnicity, marital status, and income. Patients’ smoking status, type and number of medical conditions, medications being used at baseline, and number of pharmacist visits per patient during the study review period were also recorded.
The majority of patients cared for were male, middle-aged, and African-American. The majority (90%) of patients had an income below 150% of the 2007 Federal poverty level. Patients were most commonly treated for diabetes, hypertension, and hyperlipidemia. During the period of review, 188 medication related problems were identified and documented with noncompliance being the most common medication related problem identified. Pharmacists completed 477 Pharmaceutical Manufacturer Assistance Program applications for 68 patients. These interventions represented a cost savings from the patients’ perspective of approximately 243 USD per month during the review period. Blood pressure, A1C, and LDL-C readings improved in patients enrolled in the clinical pharmacy program at the free clinic and the community health center.
A clinical pharmacy services model provides a role for the pharmacist in an interdisciplinary team (beyond the traditional dispensing role) to identify medication related problems in the drug therapy of patients who utilize safety-net provider health care services.
Poverty; Homeless Persons; Medication Therapy Management; Pharmacists; United States
Given the increasing prevalence of diabetes and the lack of patients reaching recommended therapeutic goals, novel models of team-based care are emerging. These teams typically include a combination of physicians, nurses, case managers, pharmacists, and community-based peer health promoters (HPs). Recent evidence supports the role of pharmacists in diabetes management to improve glycemic control, as they offer expertise in medication management with the ability to collaboratively intensify therapy. However, few studies of pharmacy-based models of care have focused on low income, minority populations that are most in need of intervention. Alternatively, HP interventions have focused largely upon low income minority groups, addressing their unique psychosocial and environmental challenges in diabetes self-care. This study will evaluate the impact of HPs as a complement to pharmacist management in a randomized controlled trial.
The primary aim of this randomized trial is to evaluate the effectiveness of clinical pharmacists and HPs on diabetes behaviors (including healthy eating, physical activity, and medication adherence), hemoglobin A1c, blood pressure, and LDL-cholesterol levels. A total of 300 minority patients with uncontrolled diabetes from the University of Illinois Medical Center ambulatory network in Chicago will be randomized to either pharmacist management alone, or pharmacist management plus HP support. After one year, the pharmacist-only group will be intensified by the addition of HP support and maintenance will be assessed by phasing out HP support from the pharmacist plus HP group (crossover design). Outcomes will be evaluated at baseline, 6, 12, and 24 months. In addition, program and healthcare utilization data will be incorporated into cost and cost-effectiveness evaluations of pharmacist management with and without HP support.
The study will evaluate an innovative, integrated approach to chronic disease management in minorities with poorly controlled diabetes. The approach is comprised of clinic-based pharmacists and community-based health promoters collaborating together. They will target patient-level factors (e.g., lack of adherence to lifestyle modification and medications) and provider-level factors (e.g., clinical inertia) that contribute to poor clinical outcomes in diabetes. Importantly, the study design and analytic approach will help determine the differential and combined impact of adherence to lifestyle changes, medication, and intensification on clinical outcomes.
ClinicalTrials.gov identifier: NCT01498159
(3–10): Diabetes mellitus/drug therapy; Patient compliance; Patient education; Pharmacists; Community health workers
To apply sociological theories to understand public trust in extended services provided by community pharmacists relative to those provided by general practitioners (GPs).
Qualitative study involving focus groups with members of the public.
The West of Scotland.
26 purposively sampled members of the public were involved in one of five focus groups. The groups were composed to represent known groups of users and non-users of community pharmacy, namely mothers with young children, seniors and men.
Trust was seen as being crucial in healthcare settings. Focus group discussions revealed that participants were inclined to draw unfavourable comparisons between pharmacists and GPs. Importantly, participants' trust in GPs was greater than that in pharmacists. Participants considered pharmacists to be primarily involved in medicine supply, and awareness of the pharmacist's extended role was low. Participants were often reluctant to trust pharmacists to deliver unfamiliar services, particularly those perceived to be ‘high risk’. Numerous system-based factors were identified, which reinforce patient trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments. Our data indicate that the nature and context of public interactions with GPs fostered familiarity with a specific GP or practice, which allowed interpersonal trust to develop. By contrast, participants' exposure to community pharmacists was limited. Additionally, a good understanding of the GPs' level of training and role promoted confidence.
Current UK initiatives, which aim to implement a range of pharmacist-led services, are undermined by lack of public trust. It seems improbable that the public will trust pharmacists to deliver unfamiliar services, which are perceived to be ‘high risk’, unless health systems change in a way that promotes trust in pharmacists. This may be achieved by increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services.
Why do the public access GPs for services, which are also available in community pharmacies?
What sort of services do the public trust community pharmacists to deliver?
What factors underpin greater public trust in GP services relative to community pharmacy services?
Public trust in GPs was greater than that in pharmacists; many were reluctant to trust pharmacists to deliver unfamiliar ‘high-risk’ services.
Numerous system-based factors reinforce public trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments.
This study suggests that increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services could build public trust.
Strengths and limitations of this study
This is the first study to apply sociological perspectives of trust to understand public perspectives of community pharmacy.
The qualitative approach has allowed us to gather in-depth information in an under-researched area.
The study methodology limits generalisation, although theme saturation was achieved and the context of the study is explicitly defined.
To provide pharmacists’ perspectives on medication adherence barriers for patients with human immunodeficiency virus (HIV) and to describe pharmacists’ strategies for promoting adherence to antiretroviral medications.
Multisite, qualitative, descriptive study.
Four midwestern U.S. states, from August through October 2009.
19 pharmacists at 10 pharmacies providing services to patients with HIV.
Pharmacists were interviewed using a semistructured interview guide.
Main outcome measures
Barriers to medication adherence, pharmacist interventions, challenges to promoting adherence.
Pharmacists reported a range of adherence barriers that were patient specific (e.g., cognitive factors, lack of social support), therapy related (e.g., adverse effects, intolerable medications), and structural level (e.g., strained provider relationships). They used a combination of individually tailored, patient-specific interventions that identified and resolved adherence barriers and actively anticipated and addressed potential adherence barriers. Pharmacist interventions included medication-specific education to enhance patient self-efficacy, follow-up calls to monitor adherence, practical and social support to motivate adherence, and patient referrals to other health care providers. However, the pharmacists faced internal (e.g., lack of time, lack of trained personnel) and external (e.g., insurance policies that disallowed patient enrollment in automatic prescription refill program) challenges.
Pharmacists in community settings went beyond prescription drug counseling mandated by law to provide additional pharmacy services that were tailored to the needs of patients with HIV. Given that many individuals with HIV are living longer, more research is needed on the effectiveness and cost effectiveness of pharmacists’ interventions in clinical practice, in order to inform insurance reimbursement policies.
Clinical interventions; pharmacists; patient-centered care; barriers; medication adherence; health promotion; human immunodeficiency virus
To understand how community pharmacists use electronic prescribing (e-prescribing) technology; and to describe the workflow challenges pharmacy personnel encounter as a result of using e-prescribing technology.
Cross-sectional qualitative study.
Seven community pharmacies in Wisconsin from December 2010 to March 2011
16 pharmacists and 14 pharmacy technicians (in three chain and four independent pharmacies).
Think-aloud protocol and pharmacy group interviews.
Main outcome measures
Pharmacy staff description of their use of e-prescribing technology and challenges encountered in their daily workflow related to this technology.
Two contributing factors were perceived to influence e-prescribing workflow: issues stemming from prescribing or transmitting software, and issues from within the pharmacy. Pharmacies experienced both delays in receiving, and inaccurate e-prescriptions from physician offices. Receiving an overwhelming number of e-prescriptions with inaccurate or unclear information resulted in significant time delays for patients as pharmacists contacted physicians to clarify wrong information. In addition, pharmacy personnel reported that lack of formal training and the disconnect between the way pharmacists verify accuracy and conduct drug utilization review and the presentation of e-prescription information on the computer screen significantly influenced the speed of processing an e-prescription.
E-prescriptions processing can hinder pharmacy workflow. As the number of e-prescriptions transmitted to pharmacies increases due to legislative mandates; it is essential that the technology that supports e-prescriptions (both on the prescriber and pharmacy operating systems) be redesigned to facilitate pharmacy workflow processes and to prevent unintended consequences, such as increased medication errors, user frustration, and stress.
E-prescribing; electronic prescribing; community pharmacy; workflow
To describe the practice, education and research concerning medication adherence in Danish community pharmacy.
The authors supplemented their expertise in the area of medication adherence through their contacts with other educators and researchers as well as by conducting searches in the Danish Pharmacy Practice Evidence Database, which provides annually updated literature reviews on intervention research in Danish pharmacy practice.
Practice: Medication adherence is the focus of and/or is supported by a large number of services and initiatives used in pharmacy practice such as governmental funding, IT-supported medicine administration systems, dose-dispensing systems, theme years in pharmacies on adherence and concordance, standards for counselling at the counter, pharmacist counselling, medication reviews and inhaler technique assessment. Education: In Denmark, pharmacy and pharmaconomist students are extensively trained in the theory and practice of adherence to therapy.
Pharmacy staff can choose from a variety of continuing education and post-graduate programmes which address patient adherence.
Nine ongoing and recently completed studies are described. Early research in Denmark comprised primarily smaller, qualitative studies centred on user perspectives, whereas later research has shifted the focus towards larger, quantitative, controlled studies and action-oriented studies focusing on patient groups with chronic diseases (such as diabetes, asthma, coronary vascular diseases).
Our analysis has documented that Danish pharmaceutical education and research has focused strongly on adherence to treatment for more than three decades. Adherence initiatives in Danish community pharmacies have developed substantially in the past 5-10 years, and, as pharmacies have prioritised their role in health care and patient safety, this development can be expected to continue in future years.
Medication Adherence; Pharmacists; Denmark
In recent years, the focus of pharmacists as traditional drug dispensers has shifted to more active and participative role in risk assessment, risk management, and other medication related consultation activities. Pharmacy profession is evolving steadily in the United Arab Emirates (UAE). Pharmacists in UAE are so much occupied in their administrative and managerial duties that dispensing is mostly attended to by pharmacy technicians. Pharmacist-led patient counseling is limited to the dosage and frequency of medications and rarely adverse reactions and drug interactions with other medications. Therefore we decided to perform quantitative questionnaires study to explore the role of pharmacist in patient counseling in UAE, the evaluation of pharmacist's opinion on patient counseling and the potential determinants of personal consultation. Results show the frequency and nature of inquiries received by pharmacist. Five to twenty inquires per month are received from patient, most of them related to drug prescription and dose recommendation. Thirty nine percent of pharmacists received inquiries from doctors, most of them related to the dose and mode of action. Ninty two percent of the pharmacists agreed that patient counseling is their professional responsibility. About 82% of pharmacists agreed that counseling will increase their sales and enhance the reputation of their pharmacies. Seventy percent of pharmacists mentioned that they need to undergo training for effective counseling while 46% of pharmacists felt that more staff in the pharmacies would have a positive influence on patient compliance to medication therapies and patient safety. The potential determinants of personal consultation show that 52% of participants trusted pharmacist and 55% considered the pharmacist as a friend. Forty eight percent of participants visited the pharmacy for medical recommendation while 30% for drug compounding, 72% agreed that pharmacist conducts full instruction while 31% agreed about full investigation. In conclusion, reorganization of the pharmacist's activities may improve pharmaceutical consultations. Pharmacists must be exposed to recent trends in drug therapy, dosage forms, dosage, adverse effects and interaction. This will go a long way in providing rational use of drugs to the patients and improve their quality of life.
Attitudes and behaviors; community pharmacists; patient counseling; patient information leaflets; personal consultation
Patient self-management is a key approach to manage non-communicable diseases. A pharmacist-led approach in patient self-management means collaborative care between pharmacists and patients. However, the development of both patient self-management and role of pharmacists is limited in Hong Kong. The objectives of this study are to understand the perspectives of physicians, pharmacists, traditional Chinese medicine (TCM) practitioners, and dispensers on self-management of patients with chronic conditions, in addition to exploring the possibilities of developing pharmacist-led patient self-management in Hong Kong.
Participants were invited through the University as well as professional networks. Fifty-one participants comprised of physicians, pharmacists, TCM practitioners and dispensers participated in homogenous focus group discussions. Perspectives in patient self-management and pharmacist-led patient self-management were discussed. The discussions were audio recorded, transcribed and analysed accordingly.
The majority of the participants were in support of patients with stable chronic diseases engaging in self-management. Medication compliance, monitoring of disease parameters and complications, lifestyle modification and identifying situations to seek help from health professionals were generally agreed to be covered in patient self-management. All pharmacists believed that they had extended roles in addition to drug management but the other three professionals believed that pharmacists were drug experts only and could only play an assisting role. Physicians, TCM practitioners, and dispensers were concerned that pharmacist-led patient self-management could be hindered, due to unfamiliarity with the pharmacy profession, the perception of insufficient training in disease management, and lack of trust of patients.
An effective chronic disease management model should involve patients in stable condition to participate in self-management in order to prevent health deterioration and to save healthcare costs. The role of pharmacists should not be limited to drugs and should be extended in the primary healthcare system. Pharmacist-led patient self-management could be developed gradually with the support of government by enhancing pharmacists' responsibilities in health services and developing public-private partnership with community pharmacists. Developing facilitating measures to enhance the implementation of the pharmacist-led approach should also be considered, such as allowing pharmacists to access electronic health records, as well as deregulation of more prescription-only medicines to pharmacy-only medicines.
patient self-management; pharmacist-led patient self-management; chronic disease; health policy; Hong Kong
Community pharmacies are widely distributed and developments in this sector will greatly improve pharmaceutical health care delivery.
To provide consumer’s perceptions towards the contribution of community pharmacists in the dispensing process.
The study was performed from mid-October to mid-November 2013 in Dawadmi, KSA. Data were carried out using a structured face-to-face questionnaire with randomly selected 100 consumers at different community pharmacies. The questionnaire composed of nine closed questions about consumer’s perceptions towards the pharmacist’s role, counselling quality and dispensing errors in community pharmacies.
Consumers perceive that pharmacists are not committed to dispense medications with prescription (72%), it is embarrassing to ask questions to the pharmacist in the current pharmacy premises (48%), pharmacists do not give enough counselling about their medications (48%) and they previously encountered a dispensing error (26%).
The professional performance of community pharmacists in dispensing is below expectation. Majority of consumers perceive that community pharmacists are violating pharmacy law and giving them insufficient medicine information while dispensing. Authorities should stimulate both pharmacist’s and consumer’s awareness by educational campaign, improve standards for the profession and penalise violators. It is a necessity for community pharmacies to develop consultation areas to assure privacy, improve counselling quality, and reduce dispensing errors.
Dispensing; Counselling; Community pharmacy
Pharmacists may improve medication-related outcomes during transitions of care. The aim of the Iowa Continuity of Care Study was to determine if a pharmacist case manager (PCM) providing a faxed discharge medication care plan from a tertiary care institution to primary care could improve medication appropriateness and reduce adverse events, rehospitalization and emergency department visits.
Design. Randomized, controlled trial of 945 participants assigned to enhanced, minimal and usual care groups conducted 2007 to 2012. Subjects. Participants with cardiovascular-related conditions and/or asthma or chronic obstructive pulmonary disease were recruited from the University of Iowa Hospital and Clinics following admission to general medicine, family medicine, cardiology or orthopedics. Intervention. The minimal group received admission history, medication reconciliation, patient education, discharge medication list and medication recommendations to inpatient team. The enhanced group also received a faxed medication care plan to their community physician and pharmacy and telephone call 3–5 days post-discharge. Participants were followed for 90 days post-discharge. Main Outcomes and Measures. Medication appropriateness index (MAI), adverse events, adverse drug events and post-discharge healthcare utilization were compared by study group using linear and logistic regression, as models accommodating random effects due to pharmacists indicated little clustering.
Study groups were similar at baseline and the intervention fidelity was high. There were no statistically significant differences by study group in medication appropriateness, adverse events or adverse drug events at discharge, 30-day and 90-day post-discharge. The average MAI per medication as 0.53 at discharge and increased to 0.75 at 90 days, and this was true across all study groups. Post-discharge, about 16% of all participants experienced an adverse event, and this did not differ by study group (p > 0.05). Almost one-third of all participants had any type of healthcare utilization within 30 days post-discharge, where 15% of all participants had a 30-day readmission. Healthcare utilization post-discharge was not statistically significant different at 30 or 90 days by study group.
The pharmacist case manager did not affect medication use outcomes post-discharge perhaps because quality of care measures were high in all study groups.
Clinicaltrials.gov registration: NCT00513903, August 7, 2007.
Clinical pharmacist; Care transitions; Continuity of care; Medication reconciliation; Medication care plan
An essential component of quality care for limited English proficient (LEP) patients is language access. Linguistically accessible medication instructions are particularly important, given the serious consequences of error and patient responsibility for managing often complex medication regimens on their own. Approximately 21 million people in the U.S. were LEP at the time of the 2000 census, representing a 50% increase since 1990. Little information is available on their access to comprehensible medication instructions. In an effort to address this knowledge gap, we conducted a telephone survey of 200 randomly selected NYC pharmacies. The primary focus of the survey was translation need, capacity, and practice. The majority of pharmacists reported that they had LEP patients daily (88.0%) and had the capacity to translate prescription labels (79.5%). Among pharmacies serving LEP patients on a daily basis, just 38.6% translated labels daily; 22.7% never translated. In multivariate analysis, pharmacy type (OR=4.08, 95%CI=1.55–10.74, independent versus chain pharmacies) and proportion of Spanish-speaking LEP persons in the pharmacy’s census tract (OR=1.09, 95%CI=1.05–1.13 for each 1% increase in Spanish LEP population) were associated with increased label translation. Although 88.5% of the pharmacies had bilingual staff, less than half were pharmacists or pharmacy interns and thus qualified to provide medication counseling. More than 80% of the pharmacies surveyed lacked systematic methods for identifying linguistic needs and for informing patients of translation capabilities. Consistent with efforts to improve language access in other health care settings, the critical gap in language appropriate pharmacy services must be addressed to meet the needs of the nation’s large and ever-growing immigrant communities. Pharmacists may require supplemental training on the need and resources for meeting the verbal and written language requirements of their LEP patients. Dispensing software with accurate translation capability and telephonic interpretation services should be utilized in pharmacies serving LEP patients. Pharmacists should post signs and make other efforts to inform patients about the language resources available to them.
LEP patients; Medical instructions; Pharmacists; Label translation; Immigrants; Language access
Hispanics with limited English proficiency face communication challenges that affect medication use and outcomes. Pharmacists are poised to help patients use medications safely and effectively, however scant research has explored factors that may impact pharmacists’ communication with Spanish-speaking patients (SSPs).
Guided by Social Cognitive Theory (SCT), the purpose of this study was to examine the relationships between pharmacy environmental factors, pharmacists’ cognition and pharmacists’ communication with SSPs.
A cross-sectional survey used a vignette to quantify the amount of information pharmacists would provide to a SSP. Pharmacy environmental factors (language-assistance resources, Spanish-speaking staff, and number of Spanish-speaking patients) and pharmacists’ cognition (self-efficacy beliefs and cultural sensitivity) that may influence communication also were assessed. The relationships between environmental factors, cognition and pharmacists’ communication with SSPs, including indirect relationships, were examined using composite indicator structural equation (CISE) modeling.
Of the 183 respondents, the majority were white (91%) and male (63%) with a mean age of 47 years (SD=12.77). The CISE modeling revealed that the number of SSPs served by the pharmacy and the pharmacist's self-efficacy in communicating with SSPs were significantly directly associated with pharmacist's provision of information to SSPs. Two environmental factors (presence of interpreter services and Spanish-speaking staff) operated indirectly through self-efficacy to significantly impact the provision of information.
Study findings identify both environmental factors and cognition that could contribute to pharmacists’ communication behavior with SSPs. Thus, future interventions to improve pharmacists’ communication with SSPs may include training pharmacists to integrate interpretative services and Spanish-speaking staff into service delivery, as well as strengthening pharmacists’ self-efficacy beliefs.
Pharmacists; Communication; Spanish-speaking patients