Pharmacists' interventions on clinical asthma outcomes: a systematic review

The objective of this systematic review was to evaluate the impact of pharmacists' interventions on clinical asthma outcomes on adult patients and to identify the outcome indicators used.PubMed, Scopus, Web of Science and Scielo were searched. Studies addressing pharmacists' interventions on adult asthma patients reporting clinical asthma outcomes were incorporated.11 clinical outcomes were identified in 21 studies. 10 studies measured the impact of the intervention on asthma control. Randomised controlled trials (RCT) and non-RCTs found positive results in percentages of controlled patients and Asthma Control Questionnaire (ACQ) scores. Discordant results were found for Asthma Control Test results. Asthma severity was assessed in four studies. One RCT found a significant decrease in the percentage of severe patients; two non-RCTs found significant improvements in severity scores. 11 studies reported pulmonary function indicators, showing inconsistent results. Eight studies measured asthma symptoms; three RCTs and four non-RCTs showed significant improvements.RCTs and non-RCTs generated similar results for most outcomes. Based on the evidence generated by RCTs, pharmacists' have a positive impact on the percentage of controlled patients, ACQ scores, severity and symptoms. Future research should report using the core outcome set of indicators established for asthma (PROSPERO CRD42014007019).

Implementation of medication review with follow-up in a Spanish community pharmacy and its achieved outcomes

BACKGROUND

Despite many research studies demonstrating the benefit in clinical, economic, and humanistic outcomes of professional pharmacy services, there is a paucity of evidence when these services become incorporated into the usual practice of a community pharmacy.

OBJECTIVE

The objective of the present study was to evaluate the clinical, economic, and humanistic impact of a pharmacist-conducted medication review with follow-up following 18 months implementation.

SETTING

Community pharmacies in Spain.

METHOD

The study used an effectiveness-implementation hybrid design. During the follow-up, patients attended the pharmacy on a monthly basis and received the medication review with follow-up service.

MAIN OUTCOME MEASURE

Economic, clinical, and humanistic measures were used to assess the impact of the service.

RESULTS

132 patients received the service. During the 18 months of follow-up, 408 negative outcomes related to medicines (which are uncontrolled health problems) were identified, of which 393 were resolved. The average number of medicines used by patients significantly decreased from 6.1 (SD: 2.9) to 3.3 (SD: 2.2). A significant decrease was also observed in hospitalizations [OR = 0.31 (IC 95% = 0.10-0.99)] and in emergency department visits [OR = 0.16 (IC 95% = 0.05-0.55); p = 0.001]. A general trend to increase all quality of life domains was observed over time. The higher increase was observed in the construct health transition [mean increase: 30.7 (SD: 25.4)], followed by bodily pain [mean increase: 22.3 (SD: 25.4)], and general health [mean increase: 20.7 (SD: 23.7)]. Medication knowledge significantly increased in terms of aggregated domains of dose, frequency, drug indication [from 8.9 (SD: 17.5) to 87.9 (SD: 25.0)], and dose and frequency [from 9.3 (SD: 17.9) to 92.5 (22.1)]. Although a slight improvement was observed in terms of drug indication, this increase was not statistically significant. 68 out of 132 patients (51.5%) were non-adherent to their treatment. This number decreased to 1 (0.8%) after the follow-up [OR = 0.007 (IC 95%: 0.001-0.053) p < 0.001].

CONCLUSION

A community pharmacy based medication review with follow-up service delivered by a trained pharmacist, has positive effects across clinical, economic, and humanistic outcomes. These results are consistent with previous studies. Incorporating community pharmacists into the multidisciplinary team is a reliable solution to improve health care.

Cost-utility analysis of a medication review with follow-up service for older adults with polypharmacy in community pharmacies in Spain: the conSIGUE program

BACKGROUND

The concept of pharmaceutical care is operationalized through pharmaceutical professional services, which are patient-oriented to optimize their pharmacotherapy and to improve clinical outcomes.

OBJECTIVE

The objective of this study was to estimate the incremental cost-effectiveness ratio (ICER) of a medication review with follow-up (MRF) service for older adults with polypharmacy in Spanish community pharmacies against the alternative of having their medication dispensed normally.

METHODS

The study was designed as a cluster randomized controlled trial, and was carried out over a time horizon of 6 months. The target population was older adults with polypharmacy, defined as individuals taking five or more medicines per day. The study was conducted in 178 community pharmacies in Spain. Cost-utility analysis adopted a health service perspective. Costs were in euros at 2014 prices and the effectiveness of the intervention was estimated as quality-adjusted life-years (QALYs). In order to analyze the uncertainty of ICER results, we performed a non-parametric bootstrapping with 5000 replications.

RESULTS

A total of 1403 older adults, aged between 65 and 94 years, were enrolled in the study: 688 in the intervention group (IG) and 715 in the control group (CG). By the end of the follow-up, both groups had reduced the mean number of prescribed medications they took, although this reduction was greater in the IG (0.28 ± 1.25 drugs; p < 0.001) than in the CG (0.07 ± 0.95 drugs; p = 0.063). Older adults in the IG saw their quality of life improved by 0.0528 ± 0.20 (p < 0.001). In contrast, the CG experienced a slight reduction in their quality of life: 0.0022 ± 0.24 (p = 0.815). The mean total cost was <euro>977.57 ± 1455.88 for the IG and <euro>1173.44 ± 3671.65 for the CG. In order to estimate the ICER, we used the costs adjusted for baseline medications and QALYs adjusted for baseline utility score, resulting in a mean incremental total cost of -<euro>250.51 ± 148.61 (95 % CI -541.79 to 40.76) and a mean incremental QALY of 0.0156 ± 0.004 (95 % CI 0.008-0.023). Regarding the results from the cost-utility analysis, the MRF service emerged as the dominant strategy.

CONCLUSION

The MRF service is an effective intervention for optimizing prescribed medication and improving quality of life in older adults with polypharmacy in community pharmacies. The results from the cost-utility analysis suggest that the MRF service is cost effective.

A systematic review of implementation frameworks of innovations in healthcare and resulting generic implementation framework

BACKGROUND

Implementation science and knowledge translation have developed across multiple disciplines with the common aim of bringing innovations to practice. Numerous implementation frameworks, models, and theories have been developed to target a diverse array of innovations. As such, it is plausible that not all frameworks include the full range of concepts now thought to be involved in implementation. Users face the decision of selecting a single or combining multiple implementation frameworks. To aid this decision, the aim of this review was to assess the comprehensiveness of existing frameworks.

METHODS

A systematic search was undertaken in PubMed to identify implementation frameworks of innovations in healthcare published from 2004 to May 2013. Additionally, titles and abstracts from Implementation Science journal and references from identified papers were reviewed. The orientation, type, and presence of stages and domains, along with the degree of inclusion and depth of analysis of factors, strategies, and evaluations of implementation of included frameworks were analysed.

RESULTS

Frameworks were assessed individually and grouped according to their targeted innovation. Frameworks for particular innovations had similar settings, end-users, and 'type' (descriptive, prescriptive, explanatory, or predictive). On the whole, frameworks were descriptive and explanatory more often than prescriptive and predictive. A small number of the reviewed frameworks covered an implementation concept(s) in detail, however, overall, there was limited degree and depth of analysis of implementation concepts. The core implementation concepts across the frameworks were collated to form a Generic Implementation Framework, which includes the process of implementation (often portrayed as a series of stages and/or steps), the innovation to be implemented, the context in which the implementation is to occur (divided into a range of domains), and influencing factors, strategies, and evaluations.

CONCLUSIONS

The selection of implementation framework(s) should be based not solely on the healthcare innovation to be implemented, but include other aspects of the framework's orientation, e.g., the setting and end-user, as well as the degree of inclusion and depth of analysis of the implementation concepts. The resulting generic structure provides researchers, policy-makers, health administrators, and practitioners a base that can be used as guidance for their implementation efforts.

Newest Vital Sign as a proxy for medication adherence in older adults

OBJECTIVE

To assess the utility of the Newest Vital Sign (NVS) as a proxy for medication adherence in community-dwelling older adults.

DESIGN

Descriptive cross-sectional study.

SETTING

12 adult day care centers in the Lisbon metropolitan area, Portugal, between March and May 2009.

PARTICIPANTS

100 white community-dwelling older adults.

INTERVENTION

Participants were administered the NVS, Single Item Literacy Screener (SILS), and self-reported Measure of Adherence to Therapy (MAT).

MAIN OUTCOME MEASURES

Health literacy and medication adherence.

RESULTS

The mean (±SD) age of the respondents was 73.3 ± 7.8 years and 71% were women. The NVS score was 0.81 ± 0.10 (of 6 possible points), and 95% of the respondents scored in the three lowest possible scores, indicating a notable floor effect. Age was found to be inversely correlated with NVS score (P = 0.003). The MAT score was 36.2 ± 4.7 (range 17-42). No statistically significant association between the NVS and level of education (P = 0.059 [Kruskal-Wallis]), gender (P = 0.700 [Mann-Whitney]), SILS (P = 0.167), or MAT (P = 0.379) was identified.

CONCLUSION

The utility of the NVS as a proxy for medication adherence in community-dwelling older adults is limited because of a floor effect that hinders its predictive power for medication adherence.

Renal nurses' views of the potential role of pharmacists in outpatient dialysis centres: a qualitative study

OBJECTIVES

The aim of this study was to explore the differences in the views of Australian and Portuguese renal nurses on the provision of clinical pharmacy services in outpatient dialysis centres.

METHODS

Semi-structured interviews were conducted with Australian and Portuguese renal nurses. The interviews were recorded and thematically content-analysed.

KEY FINDINGS

Three main themes were identified: nurses' opinions towards pharmacists' current role; nurses' opinions towards pharmacists' future role; and future clinical pharmacy services to be provided. While Australian nurses appeared to be aware of pharmacists' competencies and viewed a role for pharmacists within the team, Portuguese nurses showed low expectations of pharmacists and regarded them as external to the team.

CONCLUSIONS

Previous or lack of exposure to pharmacists' clinical skills and the existence of health policies that promote interprofessional collaboration appear to influence nurses' views.

Clinical relevance of information in the Summaries of Product Characteristics for dose adjustment in renal impairment

PURPOSE

Information about dosing adjustments in patients with chronic kidney disease is important to avoid toxicity for several medicines. The aim of our study was to assess the clinical relevance of the instructions for dose adjustment in patients with renal impairment provided in the Summaries of Product Characteristics (SmPCs) approved by the European Medicines Agency (EMA).

METHODS

SmPCs available on the EMA website on April 2011 were retrieved, and information on the elimination route and instructions for use in renal impairment was analysed independently by two of the authors. SmPCs were classified as containing 'explicit' or 'poor' information based on whether they presented (or not) instructions for use of the medicine in renal impairment. Information was considered 'relevant' if SmPCs provided clear instructions for dose adjustment.

RESULTS

Of the 356 SmPCs analysed, 13.8 and 37.4 % were classified as providing poor information and explicit but not relevant information, respectively. Only 48.8 % SmPCs provided both explicit and relevant information on medicine use in renal impairment. No difference was found in the average time since last update among SmPCs classified as containing explicit or poor information, as well as those classified as containing relevant or not relevant information. Also, no association was found between the clinical relevance of the information and whether or not the medication was an orphan drug, and 80 % SmPCs did not provide information on the use of the medicine in patients undergoing haemodialysis.

CONCLUSIONS

Based on our analysis, current versions of SmPCs are characterised by several information deficits and by containing recommendations that are not relevant to clinical practice in terms of dose adjustment in renal impairment. These shortcomings might limit their usefulness for healthcare professionals and integration into clinical decision-making support systems.

Evidence of the clinical effectiveness of cognitive pharmaceutical services for aged patients

BACKGROUND

cognitive pharmaceutical services (CPSs) encompass a variety of pharmacists' interventions to optimise pharmacotherapy. The clinical effectiveness of CPSs for aged patients remains controversial.

OBJECTIVE

to analyse and describe the evidence of the clinical effectiveness of CPSs in aged patients by means of performing a systematic review of systematic reviews.

METHODS

using the recommended methodology by Cochrane, a search was undertaken for systematic reviews of the clinical effectiveness of CPSs in MEDLINE, EMBASE, DOAJ, SCIELO and COCHRANE LIBRARY. Reviews were assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) instrument. Quality of the evidence in the reviews was ranked using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

RESULTS

a total of 14 systematic reviews and one meta-analysis were analysed. The overall quality of the reviews was moderate. High and moderate strength of evidence was found for the positive effect of certain CPSs on reducing the number and improving the appropriateness of medicines. There was conflicting evidence of the effect on adherence. There was limited evidence of high and moderate strength on clinical outcomes. No positive evidence was found on mortality, hospitalisations, functional capacity and cognitive function. No systematic reviews reported the effect on the level of control of health problems.

CONCLUSIONS

certain types of CPSs reduce the number of medicines and improve the appropriateness of prescriptions. Longer follow-up periods and/or the use of surrogate clinical variables measuring the short-term impact are required to demonstrate the effect on clinical outcomes.

Designing a model to minimize inequities in hemodialysis facilities distribution

Portugal has an uneven, city-centered bias in the distribution of hemodialysis centers found to contribute to health care inequities. A model has been developed with the aim of minimizing access inequity through the identification of the best possible localization of new hemodialysis facilities. The model was designed under the assumption that individuals from different geographic areas, ceteris paribus, present the same likelihood of requiring hemodialysis in the future. Distances to reach the closest hemodialysis facility were calculated for every municipality lacking one. Regions were scored by aggregating weights of the "individual burden", defined as the burden for an individual living in a region lacking a hemodialysis center to reach one as often as needed, and the "population burden", defined as the burden for the total population living in such a region. The model revealed that the average travelling distance for inhabitants in municipalities without a hemodialysis center is 32 km and that 145,551 inhabitants (1.5%) live more than 60 min away from a hemodialysis center, while 1,393,770 (13.8%) live 30-60 min away. Multivariate analysis showed that the current localization of hemodialysis facilities is associated with major urban areas. The model developed recommends 12 locations for establishing hemodialysis centers that would result in drastically reduced travel for 34 other municipalities, leaving only six (34,800 people) with over 60 min of travel. The application of this model should facilitate the planning of future hemodialysis services as it takes into consideration the potential impact of travel time for individuals in need of dialysis, as well as the logistic arrangements required to transport all patients with end-stage renal disease. The model is applicable in any country and health care planners can opt to weigh these two elements differently in the model according to their priorities.

Pharmacists' interventions in the management of patients with chronic kidney disease: a systematic review

BACKGROUND

Patients with chronic kidney disease have multiple comorbidities and require complicated therapeutic regimens. The role of pharmacists caring for these patients has been documented, but no review of the impact of these interventions has occurred to date. The aim of this work is to assess the impact of pharmacists' interventions in patients with chronic kidney disease.

METHODS

Medline, International Pharmaceutical Abstracts, Pharmacy Abstracts and the Cochrane Library were searched for quantitative studies addressing the contribution of pharmacists' interventions in patients with chronic kidney disease. Quality of controlled studies was assessed using the Downs and Black scale.

RESULTS

The search identified 37 studies (38 articles), involving 4743 participants, eligible for inclusion in the review. An uncontrolled design corresponded with 80% of the studies. Twenty-one articles (55.3%) reported outcome measures and process indicators, 4 (10.5%) reported only outcome measures and 13 (34.2%) reported only process indicators. Pharmacists identified 2683 drug-related problems in 1209 patients. The results from eight controlled studies (average quality score 0.57, SD = 0.10) demonstrated that pharmacists' interventions reduced all-cause hospitalisations [mean (SD) 1.8 (2.4) versus 3.1 (3.0), P = 0.02] and cumulative time hospitalised [mean (SD) 9.7 (14.7) versus 15.5 (16.3) days, P = 0.06], reduced the incidence of end-stage renal disease or death in patients with diabetic nephropathy (14.8 versus 28.2 per 100 patient-years, adjusted relative risk 60%, P < 0.001), improved management of anemia (mean 69.8 versus 43.9%, P = 0.0001 and 64.8 versus 40.4%, P = 0.043 patients on goal hemoglobin and transferrin saturation, respectively), blood pressure [systolic mean (SD) 145.3 (16.8) versus 175.8 (33.9) mmHg, P = 0.029; diastolic mean (SD) 77.0 (10.2) versus 91.8 (12.0) mmHg, P = 0.020], calcium and phosphate parameters [serum phosphate levels mean (SD) 1.81 (0.54) versus 2.07 (0.25) mmol/L, P = 0.03; calcium-phosphate product mean (SD) 4.43 (1.20) versus 4.80 (0.51) mmol(2)/L(2), P = 0.04] and lipid management [total cholesterol mean (SD) 4.4 (1.1) versus 5.0 (1.4) mmol/L, P = 0.06; low density lipoprotein cholesterol mean (SD) 2.3 (0.9) versus 2.8 (1.0) mmol/L, P = 0.013]. Results from uncontrolled studies revealed positive impact of pharmacists' interventions on reduced number of transplant rejections [mean (SD) 0.22 (0.42) versus 0.50 (0.51) episodes, P = 0.008] and adverse events (49 in 16.0% patients versus 73 in 21.3% patients, P < 0.05).

CONCLUSIONS

The evidence of pharmacists' interventions in patients with chronic kidney disease is sparse, of variable quality and with heterogeneous outcomes. On the basis of best available evidence, pharmacists' interventions may have a positive impact on outcomes of patients with chronic kidney disease.

Non-prescription medicine supply: protocols and practice

Focal points

Factors used by pharmacists in the recommendation of the active ingredient(s) and brand of non-prescription analgesics for a simple, tension and migraine headache

The objective of this study was to determine the factors (dimensions) that are considered by community pharmacists in their recommendation of the active ingredients and brands in non-prescription analgesics for an adult with a simple, tension or migraine headache. The research was conducted in four stages: a qualitative stage, a pre-pilot study, a pilot survey and the main quantitative study. The main study was conducted across 1,500 randomly selected Australian community pharmacies (68.3 per cent usable response rate). Principal components analysis with varimax rotation was employed on a list of statements concerning pharmacists' recommendation of the active ingredient(s) and the brand. For each type of headache, a four factor solution was interpreted for reasons for recommendation of the active ingredient(s) and reasons for recommendation of the brand. All the factors extracted were meaningful and easily interpreted. The highest percentage of the total variance was explained by the clinical influences factor for simple (20.4 per cent) and tension headache (18.8 per cent) and the two clinical influences factors for migraine headache (20.3 per cent and 10.1 per cent, respectively), indicating that the clinical influences construct accounted for the highest potential influence on pharmacists' recommendation of the active ingredient(s). The highest percentage of the total variance was explained by the economic influences factor for simple (29.9 per cent), tension (28.8 per cent) and migraine headache (30.8 per cent), indicating that the economic influences construct accounted for the highest potential influence on pharmacists' brand recommendation. This research could be useful for educators, professional associations and pharmaceutical companies in pharmacy-oriented marketing strategies.

Shaping practice behaviour: novel training methodology

Context

Some studies that have used “pseudo-patron” methods have provided the basis for criticism of pharmacists' performance and have stigmatised these methods in pharmacy research.

Objective

To test and refine the use of pseudo-patron methodology, with feedback to practitioners, as a means of implementing behaviour change.

Method

In the studies reported in this paper practice behaviour was shaped by conducting a workshop and then providing ongoing training in the form of feedback and coaching immediately after a pseudo-patron visit. The involvement of pseudo-patrons was negotiated with pharmacists and their staff and embedded within their professional development.

Results

An initial study showed that, compared with controls, pseudo-patron trained pharmacists were significantly more likely to identify off-label (not in accordance with label specifications) analgesic use (P&lt;0.01) and were more likely to discuss the use of alternatives (P&lt;0.02). The methodology was refined and in a subsequent study pharmacists were even more likely to identify misuse (P&lt;0.001), assess readiness to change (P&lt;0.001) and deliver an appropriate intervention (P&lt;0.001).

Conclusions

The results of the studies presented in this paper demonstrate that the inclusion of pseudo-patron visits in pharmacist training is feasible and that a combination of workshops and performance feedback, including positive and corrective elements, can produce substantial protocol adherence in the natural setting. The use of pseudo-patron methods as part of a training programme is effective in shaping behaviour of pharmacists and pharmacy assistants.

Patient drug information and consumer choice of pharmacy

Objective

The purpose of this study was to investigate whether there is an association between the level of drug information provided in community pharmacies and business performance as measured by consumer satisfaction and consumer loyalty.

Method

After an initial qualitative phase and a pilot survey, a questionnaire was administered to 253 consumers in 10 high and low information provision pharmacies.

Setting

The study took place in community pharmacies in the Sydney metropolitan and Newcastle areas of New South Wales, Australia.

Key findings

There was no significant difference in the summed consumer scores of behavioural intention or consumer satisfaction between the two pharmacy types. However, this study showed that up to 41 per cent of consumers (n=182) currently patronising low provider pharmacies indicated a preference for a high information provider pharmacy given equivalent convenience and no preformed loyalties to a particular pharmacist. This represents a potential net shift of 24 per cent of consumers from low information provider pharmacies to high provider pharmacies.

Conclusion

This study provides initial evidence to show that the level of provision of drug information has the potential to increase consumer patronage and loyalty to a community pharmacy. The full implications of this should become more apparent as the number and convenience of high provider pharmacies increases and more low provider consumers are exposed to this type of pharmacy.

Dimensions of pharmacists' preferences for cough and cold products

In Australia, purchases of cough and cold products have been found to involve pharmacists' recommendation more frequently than other minor health problems, but little information exists to explain pharmacists' preferences for cough and cold products. This report undertakes the preliminary step of identifying the underlying dimensions of preferences of this product group, using principal factor analysis of a range of potential influences on preference. Qualitative methods and review of the literature were used to develop a list of 42 influences on pharmacists' preferences for these products. A mail survey of 1,200 community pharmacists followed (response 66 per cent). Factor analysis reduced the 42 influences to seven factors, namely, advertising (variance explained, 13.65 per cent), non-scientific [product] (6.96 per cent), non-scientific [social] (4.70 per cent), financial (3.31 per cent), experience/economics (2.86 per cent), clinical (2.15 per cent) and restriction/ingredients (1.61 per cent) influences. These factors indicate the dimensions of preference and may be further analysed using multiple regression to determine their relative influence in explaining preference for specific products, enabling assessment of the appropriateness of product selection and the development of marketing strategies.

Review of computerised patient medication records to determine potential clinical interventions in community pharmacy

The potential intervention rate for cardiovascular drugs dispensed in community pharmacy was investigated by a retrospective study of 300 patient medication records (PMRs) collected from 10 community pharmacies in Sydney, Australia. A medication review protocol and operational definitions were developed for 17 types of clinical intervention and three levels of clinical significance. Spearman's correlation coefficient (rs) was used to examine the relationship between total number of potential interventions and predictor variables. From 5,271 medications dispensed, 1,509 (28.6 per cent) potential interventions were identified. The most frequent types of potential intervention were precautions (27.6 per cent), overutilisation (17 per cent) and dose discrepancy (16.3 per cent). Of the interventions classified as being of major clinical significance, 61.3 per cent were precautions, 19.7 per cent drug interactions and 19 per cent contraindications. The cardiovascular drug classes with the highest potential intervention rate were inotropics (93.2 per cent) and anticoagulants (89.5 per cent). There was a statistically significant correlation between the number of potential interventions per patient and the total number of medications dispensed per patient (rs=0.68, P&lt;0.001), the total number of cardiovascular drugs dispensed per patient (rs=0.67, P&lt;0.001) and the number of different prescribing doctors per patient (rs=0.29, P&lt;0.001). This study demonstrates the potential for community pharmacists to review computerised PMRs and intervene in patients' drug therapy, thereby reducing iatrogenic problems and improving health outcomes for patients.

Clinical significance of clinical interventions in community pharmacy: a randomised trial of the effect of education and a professional allowance

Objectives

To assess the clinical significance of clinical interventions undertaken by community pharmacists, and to explore the effect of providing education and/or remuneration on the clinical significance of interventions.

Design

Randomised trial involving four groups of community pharmacists; expert panel to assess the clinical significance of the interventions.

Methods

The “proactive” clinical interventions undertaken by community pharmacists during the trial were reviewed by an expert panel for assessment of avoided adverse health consequences and clinical significance. The panel used a validated assessment instrument developed from the existing research literature and a pilot study by the authors.

Data analysis

Agreement between experts was determined using the kappa statistic. In addition, the results of the expert panel were analysed for cases where the majority of experts provided the same assessment of clinical significance (ie, consensus).

Results

Overall, there was no statistically significant difference in the clinical significance of clinical interventions undertaken by the four study groups. However, there were significant differences (95% CI) in the types of proactive interventions undertaken, with the two groups that received an educational intervention being more likely to engage in more complex intervention areas, such as drug/drug interactions and adverse/side effects. Analysis of consensus revealed that 52% of proactive clinical interventions were deemed to be “clinically significant” and 2% were deemed to be either “clinically very significant” or “potentially life-saving”. When extrapolated to national Australian prescribing figures, a mean of 3,752 potentially life-saving interventions by community pharmacists could be expected per year (95% CI 454 to 13,554).

Conclusion

The results of this study provide the first estimates of the potential clinical benefits associated with clinical interventions in Australian community pharmacies. The study contributes evidence on the value of pharmaceutical services to the health care system. As such, it is expected that the study findings will provide a platform for discussion and decision-making.

Implementing cognitive services in community pharmacy: a review of models and frameworks for change

Objective

To investigate models and frameworks for the implementation of cognitive pharmaceutical services (CPS) in community pharmacy.

Method

Relevant literature published in English was identified through searches of online databases (no date limits), texts, conference proceedings, and bibliographies of identified literature. Literature that involved a discussion of models or frameworks for community pharmacy practice change in relation to the implementation of CPS was selected for review. Many of the identified studies were conceptual in nature, and although they were selected in the same way as the empirical research papers, were not able to be critically reviewed in an equivalent manner. A narrative, rather than systematic review, was considered more appropriate.

Key findings

Many of the identified models focused on specific services, seeming to overlook the complexity of the implementation process. Many relied on behavioural theories, with an assumption that changing pharmacists' knowledge, skills or attitude will automatically result in successful change, often ignoring organisational aspects of change. Models that included business aspects remain largely untested, and where testing occurred sample sizes were generally small and populations conveniently or purposively sampled, limiting the generalisability of the findings.

Conclusion

The factors affecting change are more than just those confined to the individual pharmacist who is providing a service, and the implementation process is more complex, involving a range of organisational factors. Research is needed to identify the key elements of a framework for how new CPS should be implemented and delivered.

Clinical intervention rates in community pharmacy: a randomised trial of the effect of education and a professional allowance

Objectives

To quantify the rate of clinical interventions by community pharmacists, and to determine the effect of providing targeted education and/or fee-for-service professional remuneration on the rate of clinical interventions.

Methods

A randomised trial involving four groups of 10 community pharmacies: group A served as a control and received neither education nor remuneration; group B received education and professional remuneration; group C received “advanced” education and professional remuneration; and group D received professional remuneration with no education. Pharmacists in all groups documented interventions for three one-week periods. Types of intervention were pre-specified by the researchers and logged as such by the pharmacists. Interventions were categorised as “reactive” or “proactive” by a panel comprising a community pharmacist and a hospital pharmacist. Logistic regression analysis was used to compare differences in intervention rates between the groups at baseline, between groups over time (six weeks), and within groups over time.

Results

87,130 prescription items were dispensed in the study period, and there were 762 clinical interventions, an intervention rate of 0.87%. Of the total, 375 (0.43%) were proactive and 387 (0.44%) were reactive. Groups B and C showed increases in clinical intervention rates immediately after the educational intervention, but these rates then decreased between week 1 and 2. Over the study period, group D had statistically significant reductions in intervention rates from baseline (total, reactive and proactive), and group A showed statistically significant reductions in reactive intervention rates.

Conclusions

The results from this study show that providing remuneration alone or maintaining the status quo (ie, neither remuneration nor education) did not lead to an increase in clinical interventions in community pharmacies. Increases in rates within the groups receiving education and remuneration were short lived. Developing and implementing educational programmes in addition to fee-for-service remuneration packages may have a positive impact on clinical intervention rates. Longitudinal work is required to investigate the sustainable effects of longer-term education strategies on clinical interventions in community pharmacy.

Does advice from pharmacy staff vary according to the nonprescription medicine requested?

BACKGROUND

Community pharmacy has long been advocated as an appropriate gateway of supply for nonprescription medicines and health-related advice. Consumers sometimes self-treat the symptoms of minor illness, yet there is conflicting evidence over their ability to do so properly. Emerging trends also suggest a variable approach to nonprescription medicine supply by pharmacy staff. Understanding of this is limited and more structured exploration is needed.

OBJECTIVE

To explore variation in pharmacy staff response to requests for nonprescription medicines from different legislative schedules through analysis of data collected using pseudo-patient methods.

METHODS

Consumers posed as pharmacy patrons (ie, pseudo-patients, simulated patients) and requested 1 of 3 specific nonprescription medicines by name. Two of these, ibuprofen and a branded cold and flu medication, could be sold by any pharmacy staff member (these were considered Pharmacy Medicine). The third, a combination analgesic containing paracetamol (acetaminophen), codeine, and doxylamine, required pharmacist involvement in the sale (considered Pharmacist Only Medicine). Pseudo-patient visits measured the service provided in each pharmacy by observing whether staff performed particular behaviors such as providing advice regarding the drugs.

RESULTS

Staff response was generally superior when pseudo-patients requested the combination analgesic that required pharmacist intervention. Medicine advice was provided verbally to 84.9% of pseudo-patients requesting this analgesic compared with 51.1% of those requesting the cold and flu medication. Similar trends were observed for other behaviors.

CONCLUSIONS

Emerging patterns imply that pharmacy staff response may vary according to the medicine requested. It may be that pharmacists and their staff prioritize drugs or behaviors that they consider critically relevant as part of a risk management approach. This has possible implications for future scheduling policy. Further research using a range of scenarios would more fully explore the breadth of such behavior. This would aid identification of medicines that trigger professional intervention and inform development of targeted training programs.

Audio taping simulated patient encounters in community pharmacy to enhance the reliability of assessments

OBJECTIVES

To assess whether audio taping simulated patient interactions can improve the reliability of manually documented data and result in more accurate assessments.

METHODS

Over a 3-month period, 1340 simulated patient visits were made to community pharmacies. Following the encounters, data gathered by the simulated patient were relayed to a coordinator who completed a rating form. Data recorded on the forms were later compared to an audiotape of the interaction. Corrections were tallied and reasons for making them were coded.

RESULTS

Approximately 10% of cases required corrections, resulting in a 10%-20% modification in the pharmacy's total score. The difference between postcorrection and precorrection scores was significant.

CONCLUSIONS

Audio taping simulated patient visits enhances data integrity. Most corrections were required because of the simulated patients' poor recall abilities.

Practice change in community pharmacy: quantification of facilitators

BACKGROUND

There has been an increasing international trend toward the delivery of cognitive pharmaceutical services (CPS) in community pharmacy. CPS have been developed and disseminated individually, without a framework underpinning their implementation and with limited knowledge of factors that might assist practice change. The implementation process is complex, involving a range of internal and external factors.

OBJECTIVE

To quantify facilitators of practice change in Australian community pharmacies.

METHODS

We employed a literature review and qualitative study to facilitate the design of a 43-item "facilitators of practice change" scale as part of a quantitative survey instrument, using a framework of organizational theory. The questionnaire was pilot-tested (n = 100), then mailed to a random sample of 2000 community pharmacies, with a copy each for the pharmacy owner, employed pharmacist, and pharmacy assistant. The construct validity and reliability of the scale were established using exploratory factor analysis and Cronbach's alpha, respectively.

RESULTS

A total of 735 (37%) pharmacies responded, with 1303 individual questionnaires. Factor analysis of the scale yielded 7 factors, explaining 48.8% of the total variance. The factors were: relationship with physicians (item loading range 0.59-0.85; Cronbach's alpha 0.90), remuneration (0.52-0.74; 0.82), pharmacy layout (0.52-0.79; 0.81), patient expectation (0.52-0.85; 0.82), manpower/staff (0.49-0.66; 0.80), communication and teamwork (0.37-0.65; 0.77), and external support/assistance (0.47-0.69; 0.74).

CONCLUSIONS

All of the factors demonstrated good reliability and construct validity and explained approximately half of the variance. Implementing CPS requires support not only with the clinical aspects of service delivery, but also for the process of implementation itself, and remuneration models must reflect this. The identified facilitators should be used in a multilevel strategy to integrate professional services into the community pharmacy business, engaging pharmacists and their staff, policy makers, educators, and researchers. Further research is required to determine additional factors impacting the capacity of community pharmacies to implement change.

[Barriers for the implementation of cognitive services in Spanish community pharmacies]

OBJECTIVE

To identify and assess barriers for dissemination, implementation, and sustainability of different cognitive services in Spanish community pharmacies.

DESIGN

Qualitative study through semi-structured interviews followed by a descriptive analysis.

METHOD

Two groups of experts related to Spanish community pharmacy were chosen. One with 15 community pharmacists with a relevant professional activity, while the other group (n=18) was related to pharmacy strategists.

RESULTS

The lack of university clinical oriented learning, lack of pharmacists' attitude towards change and some uncertainty over their professional future were identified as barriers at the pharmacists' level. In relation to pharmacy as an organization the lack of clear messages by their leaders and the small volume of Spanish pharmacies were identified as barriers. In the category of pharmacy profession, the current reimbursement system, the lack of university clinical education, and the lack of leadership by current representative organizations were the barriers found. The lack of real involvement by health authorities, the lack of knowledge about the objectives of pharmacy cognitive services, and the lack of demand of these services by patients where also identified as barriers.

CONCLUSIONS

Finally, 12 barriers were identified and grouped into 6 categories. These barriers fit in with the barriers identified in other countries.

A system for monitoring quality standards in the provision of non-prescription medicines from Australian community pharmacies

There is a growing trend, globally, for consumers to self-medicate with non-prescription medications for common ailments. Pharmacists and pharmacy assistants are thought to be in a unique position to support consumers' purchases of these medicines through the application of knowledge and skills, in an environment in which safety and quality remains paramount. Standards of practice have been developed by the profession to address the provision of these medicines, using a consumer-focused and risk management approach. The application of these standards has been monitored since 2002, by the Quality Care Pharmacy Support Centre (QCPSC), created as a joint venture between the University and the Pharmacy Guild of Australia. The establishment of the QCPSC has allowed the development of a system to monitor and improve the application of standards for the provision of non-prescription medicines to consumers in community pharmacies in Australia. This system is unique in two aspects. The first is the use of pseudo-patient methodology, also called "mystery shoppers", "pseudo-customers" and "simulated patients", for the purpose of both assessment and quality improvement. The second unique aspect is the capturing of data based on assessments of behaviour in practice environments. To date, the centre has conducted 14,738 standards maintenance assessment (SMA) visits, involving over 4,200 pharmacies across all states and territories in Australia. The data generated by such a system create a feedback mechanism for policy decision-making in the area of Quality Use of Medicines (QUM) for non-prescription medicines, which is of critical importance to the health and safety of consumers.

Monitoring quality standards in the provision of non-prescription medicines from Australian Community Pharmacies: results of a national programme

INTRODUCTION

Standards of practice have been developed by the pharmacy profession to address the provision of non-prescription medicines, using a consumer-focused and risk management approach. The application of these standards in Australian community pharmacies has been monitored since 2002 by the Quality Care Pharmacy Support Centre (QCPSC).

METHODS

Between September 2002 and September 2005, 7785 standards maintenance assessment visits were conducted in 4282 pharmacies, using pseudo-patient methodology. 1909 were symptom-based requests (SBRs) and 5876 were direct product-based requests (DPRs), of which 2864 were for pharmacist-only medicines (POMs) and 3012 were for pharmacy medicines (PMs). 2756 pharmacies received two visits, and 747 received three visits. A pharmacy's performance was scored out of 10 at each visit (scores 0-3: "unsatisfactory"; 4-6: "satisfactory"; and 7-10: "excellent").

RESULTS

There was wide variation in performance at baseline, with 1453 (34%) of pharmacies scoring

CONCLUSION

Repeated pseudo-patient visits lead to notable improvement in behaviour in the handling of non-prescription medicines in community pharmacies. A range of factors need to be considered when measuring these behaviours, such as scenario or medicine type, as they have considerable influence on performance. Future research should focus on issues of quality control, to better understand what makes some pharmacies perform satisfactorily and others unsatisfactorily, and what is required to shift performance from "satisfactory" to "excellent".

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MESH Headings

• Benchmarking
• Education, Pharmacy, Continuing
• Evidence-Based Medicine
• Government Agencies
• Guideline Adherence
• Humans
• New South Wales
• Nonprescription Drugs/classification
• Nonprescription Drugs/standards
• Patient Simulation
• Pharmacies/classification
• Pharmacies/standards
• Process Assessment, Health Care
• Professional Competence
• Program Development
• Quality Indicators, Health Care

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Providing Patient Care in Community Pharmacies in Australia

OBJECTIVE

To describe Australia's community pharmacy network in the context of the health system and outline the provision of services.

DATA SYNTHESIS

The 5000 community pharmacies form a key component of the healthcare system for Australians, for whom health expenditures represent 9% of the Gross Domestic Product. A typical community pharmacy dispenses 880 prescriptions per week. Pharmacists are key partners in the Government's National Medicines Policy and contribute to its objectives through the provision of cognitive pharmaceutical services (CPS). The Third Community Pharmacy Agreement included funding for CPS including medication review and the provision of written drug information. Funding is also provided for a quality assurance platform with which the majority of pharmacies are accredited. Fifteen million dollars (Australian) have been allocated to research in community pharmacy, which has focused on achieving quality use of medicines (QUM), as well as developing new CPS and facilitating change. Elements of the Agreements have taken into account QUM principles and are now significant drivers of practice change. Although accounting for 10% of remuneration for community pharmacy, the provision of CPS represents a significant shift in focus to view pharmacy as a service provider. Delivery of CPS through the community pharmacy network provides sustainability for primary health care due to improvement in quality presumably associated with a reduction in healthcare costs.

CONCLUSIONS

Australian pharmacy practice is moving strongly in the direction of CPS provision; however, change does not occur easily. The development of a change management strategy is underway to improve the uptake of professional and business opportunities in community pharmacy.

Understanding practice change in community pharmacy: a qualitative research instrument based on organisational theory

INTRODUCTION

The past decade has seen a notable shift in the practice of pharmacy, with a strong focus on the provision of cognitive pharmaceutical services (CPS) by community pharmacists. The benefits of these services have been well documented, yet their uptake appears to be slow. Various strategies have been developed to overcome barriers to the implementation of CPS, with varying degrees of success, and little is known about the sustainability of the practice changes they produce. Furthermore, the strategies developed are often specific to individual programs or services, and their applicability to other CPS has not been explored. There seems to be a need for a flexible change management model for the implementation and dissemination of a range of CPS, but before it can be developed, a better understanding of the change process is required.

OBJECTIVES

This paper describes the development of a qualitative research instrument that may be utilised to investigate practice change in community pharmacy. Specific objectives included gaining knowledge about the circumstances surrounding attempts to implement CPS, and understanding relationships that are important to the change process.

METHODS

Organisational theory provided the conceptual framework for development of the qualitative research instrument, within which two theories were used to give insight into the change process: Borum's theory of organisational change, which categorizes change strategies as rational, natural, political or open; and Social Network Theory, which helps identify and explain the relationships between key people involved in the change process.

RESULTS

A semi-structured affecting practice change found in the literature that warranted further investigation with the theoretical perspectives of organisational change and social networks. To address the research objectives, the instrument covered four broad themes: roles, experiences, strategies and networks.

CONCLUSION

The qualitative research instrument developed in this study provides a starting point for future research to lead to a description and understanding of practice change in community pharmacy, and subsequent development of models for the sustainable implementation of CPS.

Community pharmacy in Australia

This article describes the evolution of community pharmacy in the Australian health system, and assesses its current and potential future contribution to health care. A central theme is the unique extent and accessibility of community pharmacy to the public, with a vast and dispersed infrastructure that is funded by private enterprise. The viability of community pharmacy as a retail trade depends on a diversification of its service roles and retention of its product-supply roles. Initiatives by the pharmacy profession, the pharmacy industry and the Australian Government are likely to give community pharmacy an increasingly prominent place in health promotion and primary, secondary and tertiary prevention, especially in relation to the management of chronic diseases.

Economic impact of increased clinical intervention rates in community pharmacy. A randomised trial of the effect of education and a professional allowance

OBJECTIVE

To determine the economic impact of an interventional programme aimed to increase the rate of clinical interventions undertaken in community pharmacy. STUDY DESIGN AND PERSPECTIVE: A randomised controlled trial of 4 parallel groups of pharmacies, conducted from a government perspective. Economic evaluations were based on savings/costs attributable to healthcare costs avoided, healthcare costs incurred by the pharmacists' actions, change in medication costs, pharmacy time and telephone calls made by the pharmacist. The study was conducted during November and December 1996 and costings were based on 1997 figures.

INTERVENTIONS

A professional fee-for-service [10 Australian dollars ($A; $A1 = 6.50 US dollars) per intervention] and education (an intensive 1-week course or advanced education) were implemented in an attempt to increase clinical interventions by the pharmacists. Group A pharmacies (n = 10) served as a control group and received neither education nor remuneration; group B received education and professional remuneration (n = 9); group C had received prior continued education and now received advanced education and professional remuneration (n = 11); and group D received professional remuneration with no education.

MAIN OUTCOME MEASURES AND RESULTS

The proactive clinical interventions in group C saved a mean of $A85.35 per 1000 prescriptions [95% confidence interval (CI)-$A157.11 to $A24.95). This was 4 times greater than savings generated by pharmacies in group B (mean savings of $A25.65 per 1000 prescriptions) and 6 times greater than control pharmacies. A sensitivity analysis which extrapolated results to Australian prescription figures showed that the control group was capable of generating savings in the order of $A2.4 million per year while pharmacists in group C would save the healthcare system $A15 million per year.

CONCLUSIONS

These results provide the first economic estimates for the provision of clinical interventions in Australian community pharmacies. It is believed that they illustrate the value of pharmaceutical services to the healthcare system and to the Australian community in terms of both quality of care and savings.

Topical antimicrobial prophylaxis in minor wounds

OBJECTIVE

To evaluate the ability of a novel topical antimicrobial gel containing cetrimide, bacitracin, and polymyxin B sulfate to prevent infections of minor wounds.

DESIGN

A clinical trial compared the test preparation with placebo and a povidone iodine antiseptic cream.

SETTING

Five primary schools in Sydney, Australia, participated in the study over a 6-week spring/summer school term.

SUBJECTS

Children aged 5-12 years with parental consent were eligible for study participation. Accidental injuries occurring at school were treated in a standardized manner by nurses at each site.

OUTCOME MEASURES

Wounds were evaluated by the medical practitioner after 3 days of topical treatment. The clinical outcome was classified as resolution or suspected infection. If a clinical infection was suspected, the injury was swabbed for microbiologic evaluation. Growth of a dominant microorganism was classified as a microbiologic infection.

RESULTS

Of the 177 injuries treated, there were nine clinical infections. A comparison of these showed a significant difference among treatment groups (p < 0.05). This difference was associated with the test preparation and placebo; the test preparation reduced the incidence of clinical infection from 12.5% to 1.6% (p < 0.05; 95% CI, 0.011 to 0.207). A comparison of microbiologic infections showed no significant differences among treatment groups (p > 0.05).

CONCLUSIONS

The novel gel preparation containing cetrimide, bacitracin, and polymyxin B sulfate showed therapeutic action and reduced the incidence of clinical infections in minor accidental wounds. It may be a suitable product for first aid prophylaxis.

In vitro interactions of neomycin sulfate, bacitracin, and polymyxin B sulfate

BACKGROUND

Neomycin sulfate, bacitracin, and polymyxin B sulfate have been combined in topical preparations to provide a complementary antimicrobial spectrum for the prevention of minor wound infections. The advisability of the inclusion of neomycin sulfate has been questioned since it may cause contact sensitization.

METHODS

To assess the value of neomycin, microdilution checkerboard titrations were used to determine the in vitro interactions between two-antibiotic and three-antibiotic combinations against reference strains of bacteria commonly associated with wound infections. Using Fractional Inhibitory Concentration (FIC) indices (< 0.5 indicates synergism with two-drug combinations), the combination of neomycin/bacitracin was synergistic for both S. aureus and Ps. aeruginosa; neomycin/polymyxin B was synergistic for E. faecalis, and the bacitracin/polymyxin B combination was synergistic against Ps. aeruginosa. A three-drug combination of neomycin/bacitracin/polymyxin B had FIC values of < 1 for all organisms, indicating synergy and substantiating the clinical role of neomycin sulfate in current topical formulations.

RESULTS

Neomycin has the lowest safety profile of the drugs in this combination. A replacement agent should ideally have similar or superior synergistic capabilities with the remaining drugs and contribute to the therapeutic efficacy of the preparation. Additionally, because of the strongly synergistic tendencies displayed by the three-drug combination, it may be possible to reduce the antibiotic concentrations present in current formulations.

CONCLUSION

By developing this concept, there is potential for the formulation of topical preparations to be based on a sound theoretical and clinical rationale.

Cardiovascular effects of a chlorpheniramine/paracetamol combination in hypertensive patients who were sensitive to the pressor effect of pseudoephedrine

Twelve hypertensive patients who were classified as pseudoephedrine-sensitive in a preliminary trial were selected for further investigation with single doses of pseudoephedrine 60 mg, a combination of chlorpheniramine 4 mg with paracetamol 650 mg and placebo. A double-blind, randomised, crossover study design was followed. Treatment with pseudoephedrine produced significant effects on all the four variables measured (systolic, diastolic and mean arterial blood pressure, and heart rate). Effects of the chlorpheniramine/paracetamol combination were found to be not significantly different from placebo. It was concluded that the combination may be useful as a medication for 'colds' in hypertensive patients, since it does not induce cardiovascular effects such as those observed with pseudoephedrine.

A controlled clinical trial on the cardiovascular effects of single doses of pseudoephedrine in hypertensive patients

Twenty hypertensive patients received single oral doses of pseudoephedrine 60 mg or placebo in a double-blind, randomised, crossover trial. Systolic, diastolic, mean arterial blood pressure, and heart rate were measured at 5 min intervals for 30 min prior to and 210 min after the administration of pseudoephedrine or placebo. Statistically significant differences between the two treatments were observed with changes in systolic blood pressure (P less than 0.03) and heart rate (P less than 0.01) but not in diastolic (P greater than 0.03) and mean arterial blood pressure (P greater than 0.1). Minor differences in the number of reported side effects between the two treatments were not statistically significant.

Pharmacokinetics of non-prescription sympathomimetic agents

The pharmacokinetics of non-prescription sympathomimetic agents are discussed with respect to absorption from the gastrointestinal tract, volumes of distribution, metabolism and renal excretion. Where specific data are not available, postulations are made with inference from the chemical structures of these agents, or from studies with other drugs. No studies on hypertensive patients have been found, but attempts are made to correlate any possible changes in the pharmacokinetics of these sympathomimetic agents to hypertensive patients as a high proportion of the elderly population is hypertensive. Sympathomimetic agents with lesser polar hydroxyl groups, for example, are thought to be more lipophilic and are more readily absorbed from the gastrointestinal tract, have higher volumes of distribution, and are more extensively metabolized. Major metabolic pathways include oxidation, deamination, demethylation, and conjugation. Most of these agents are excreted primarily through the kidneys and due to their basic nature, the rate of excretion is dependent on urinary pHs. Any alteration in kidney functions such as in the aged is, therefore, expected to have some clinical significance on the pharmacokinetics of these agents.