Interprofessional communication between community pharmacists and general practitioners: a qualitative study

Developing practical recommendations for drug-disease interactions in patients with hypertension

Background

Hypertension, a significant risk factor for cardiovascular diseases, demands proactive management as cardiovascular diseases remain the leading cause of death worldwide. Reducing systolic and diastolic blood pressure levels below recommended reference values of <140/90 mmHg can lead to a significant reduction of the risk of CVD and all-cause mortality. However, treatment of hypertension can be difficult and the presence of comorbidities could further complicate this treatment. Drugs used to manage these comorbidities may inadvertently have an impact on blood pressure, resulting in a phenomenon known as drug-disease interaction. This study aims to assess the safety of medication that can affect blood pressure in patients with hypertension and provide practical recommendations for healthcare professionals.

Methods

For the development of recommendations for the drug-disease interaction (DDSI) hypertension, a six-step plan that combined literature selection and multidisciplinary expert opinion was used. The process involved (1) defining the scope of the DDSI and selecting relevant drugs, (2) collecting evidence, (3) data-extraction, (4) reaching of expert consensus, (5) publication and implementation of the recommendations in healthcare systems and (6) updating the information.

Results

An increase of 10 mmHg in systolic blood pressure and 5 mmHg in diastolic blood pressure was defined as clinically relevant. Corticosteroids, danazol, and yohimbine caused a clinically relevant DDSI with hypertension. Several other drugs with warnings for hypertension in the official product information were assessed to have no clinically relevant DDSI due to minor influence or lack of data on blood pressure. Drugs with evidence for a relevant change in blood pressure which are prescribed under close monitoring of blood pressure according to clinical guidelines, were deemed to be not clinically relevant for signalling.

Conclusion

This study provides specific recommendations that can be implemented directly in clinical practice, for example, in clinical decision support systems, potentially resulting in safer drug use in patients with hypertension and better healthcare by reducing alert fatigue. Future research should focus on evaluating the effectiveness of implementation strategies and their impact on reducing unsafe use of medication in patients with hypertension.

Does power distance in healthcare teams linked to patient satisfaction? A multilevel study of interprofessional care teams in a referral hospital in Indonesia

BACKGROUND

Interprofessional care teams collaborate to provide care to patients in hospitals to ensure their full recovery. To provide quality patient care, healthcare workers must have a comprehensive understanding of each other's roles and collaborate effectively. Good interpersonal skills are also essential for maintaining cooperative and collaborative relationships, listening, and respecting other team member's values and positions. Therefore, this study aimed to investigate the effect of power distance in interprofessional care on patients' satisfaction.

METHOD

A quantitative study was conducted in a hospital by using a questionnaire instrument to collect information from patients and members of the interprofessional care team. The respondents included 10 geriatric, 19 palliative, 36 cancer, 8 burn, and 18 medical intermediate care (MIC) teams. Subsequently, a hierarchical regression analysis was conducted to examine whether interprofessional care could significantly predict the relationship between team power distance and patient satisfaction.

RESULTS

The measurement of the effect of power distance in interprofessional care among doctors, nurses, pharmacists, and nutritionists on patient satisfaction revealed nonsignificant results. However, the final analysis indicated negative coefficients with regard to power distance for nutritionists (-0.033098), nurses (-0.064912), and pharmacists (-0.006056). These findings indicated that the power distance associated with these professions was linked with decreased patient satisfaction.

CONCLUSIONS

The results suggested that power distance within an interprofessional care team can reduce patient satisfaction.

Perceptions of conflicting information about long-term medications: a qualitative in-depth interview study of patients with chronic diseases in the Swiss ambulatory care system

OBJECTIVE

Patients with multiple long-term conditions visit various healthcare professionals and are exposed to medication information from various sources causing an increased risk of patients perceiving contradictory medication information. The aims of this study are to: (1) characterise conflicting medication information perceived by patients with long-term conditions, (2) better understand the related impact on patients' medication self-management and healthcare system navigation and (3) explore ways in which such events could be prevented.

DESIGN

This study was conducted through qualitative semistructured interviews. Data were analysed using thematic analysis.

SETTING

Community pharmacies and medical centres in Geneva, Switzerland.

PARTICIPANTS

This study included outpatients from April 2019 to February 2020. Patients were included after participating in a quantitative survey of perceived conflicting information about medications for long-term diseases.

METHODS

Semistructured audiotaped interviews of 20 to 60 min following a pre-established interview guide to explore participants' perceptions of conflicting information. Interviews were transcribed verbatim, and a thematic analysis was conducted with inductive and deductive coding using MAXQDA (2018, Release 18.2.3).

RESULTS

Twenty-two patients were interviewed, until data saturation, mentioning indication or need for a medication as the main topic of conflicting information between two healthcare professionals. Perceived conflicting information often resulted from insufficient information provided and poor communication leading to confusion, doubts and medication non-adherence. Patients expected more information and more interprofessional communication on their medications. As a result of conflicting information, most participants learnt or were learning to take an active role and become partners of the healthcare providers.

CONCLUSION

The need to strengthen and improve communication and interprofessional collaborative practice among healthcare professionals and with the patient is emerging to increase the quality and consistency of information about medications, and consequently, to ensure better use and experience of medications.

Positioning of community pharmacists in interactions with general practitioners and patients regarding prescribing and using antibiotics

Interprofessional collaboration between general practitioners (GPs) and community pharmacists (CPs) is important for ensuring antibiotics are used correctly and combating antibiotic resistance. The study's main objective was to investigate how CPs, GPs and patients, respectively, position CPs in their interactions with patients on antibiotic-related matters in Norwegian pharmacies. Seven focus-group interviews were performed. Data were analyzed using systematic text condensation. Positioning theory was used to identify positions assigned to CPs by themselves, by GPs and by patients. CPs position themselves as helpful, accessible drug specialists responsible for advising on antibiotic use, but also consider themselves dependent on GP-supplied information to do so. GPs position CPs as helpful, responsible businesspeople who, however, lack clinical experience and are overzealous gatekeepers. Patients position CPs as helpful people who supply information in "everyday language" and as the GP's extended arm. Patients utter they are best served when GPs and CPs collaborate. This discrepancy is a barrier to optimal service to patients in general, and to proper antibiotic use in particular.

Relationship between assertiveness in community pharmacists and pharmacist-initiated prescription changes

BACKGROUND

Despite the usefulness of assertiveness by healthcare professionals in improving patient safety, few studies have evaluated the assertiveness of community pharmacists. Community pharmacists' assertiveness might be associated with pharmacist-initiated prescribing changes to improve medication safety.

OBJECTIVES

Our objective was to examine which types of assertiveness-related self-expression are associated with community pharmacist-initiated prescribing changes while adjusting for possible confounding factors.

METHODS

We conducted a cross-sectional survey in Japan between May and October 2022 in 10 prefectures. Community pharmacists belonging to a large pharmacy chain were recruited. The outcome variable was the frequency of community pharmacist-initiated prescription changes over 1 month. Community pharmacists' assertiveness was assessed using the Interprofessional Assertiveness Scale (IAS) and 3 sub-domains (nonassertive, assertive, and aggressive self-expression). Participants were classified into 1 of 2 categories based on medians. Demographic and clinical characteristics were compared by group with univariate analysis. A generalized linear model (GLM) was used to investigate the association between pharmacist-initiated prescription changes as an ordinal variable and pharmacists' assertiveness.

RESULTS

Of 3346 community pharmacists invited, 963 were included in the analysis. Participants with high assertive self-expression scores had a significantly higher frequency of pharmacist-initiated prescription changes. There was no association between nonassertive or aggressive self-expression and pharmacist-initiated prescription changes. After adjustments, high assertive self-expression remained associated with a high frequency of community pharmacist-initiated prescription changes (odds ratio, 1.34; 95% confidence interval, 1.02-1.74; p = 0.032).

CONCLUSIONS

Higher assertive self-expression among community pharmacists is associated with higher frequency of pharmacist-initiated prescription changes.

Factors influencing clinical pharmacists' integration into the clinical multidisciplinary care team

Objectives: To investigate the factors influencing clinical pharmacists' integration into the clinical multidisciplinary care team, using interprofessional collaboration between clinical pharmacists and physicians as the focus. Methods: Through stratified random sampling, a cross-sectional questionnaire survey was conducted among clinical pharmacists and physicians in secondary and tertiary hospitals in China from July to August 2022. The questionnaire, comprising the Physician-Pharmacist Collaborative Index (PPCI) scale to reflect the collaboration level and a combined scale to measure influencing factors, was made available in two versions for clinical pharmacists and physicians. Multiple linear regression was adopted to analyze the association between the collaboration level and influencing factors, as well as the heterogeneity of the significant factors in hospitals of different grades. Results: Valid self-reported data from 474 clinical pharmacists and 496 paired physicians were included, who were serving in 281 hospitals from 31 provinces. In terms of participant-related factors, standardized training and academic degree, respectively, exerted significant positive effects on the perceived collaboration level by clinical pharmacists and physicians. In terms of context characteristics, manager support and system construction were the main factors for improving collaboration. In terms of exchange characteristics, clinical pharmacists having good communication skills, physicians trusting others' professional competence and values, and both parties having consistent expectations had significant positive effects on collaboration. Conclusion: The study provides a baseline data set on the current level and associated factors of clinical pharmacists' collaboration with other professionals in China and other countries with a related health system, providing references for individuals, universities, hospitals, and national policymakers to facilitate the development of clinical pharmacy and multidisciplinary models and further improve the patient-centered integrated disease treatment system.

Hello Operator? A Pharmacy Practice Simulation to Increase Student Confidence in Telephone Communication Skills

Background: Communicating interprofessionally using the telephone is an essential skill within pharmacy practice. Student pharmacists' ability to perform this task effectively and efficiently may be hindered by generational changes, social anxiety, and very few opportunities to practice these skills. Objective: The purpose of this study was to develop and implement a simulation allowing students to practice interprofessional communication and assess the simulation's impact on students' confidence in providing pharmacy-related interventions to another health care professional via telephone. Methods: Faculty developed a simulation focused on interprofessional telephone communication. Baseline student information was collected to quantify pharmacy work experience in terms of practice setting, duration of employment, and skills. Presimulation and postsimulation surveys evaluated self-assessed telephone-related skills, attitudes, and confidence. Quantitative data were analyzed with descriptive statistics. Qualitative data were evaluated through a thematic analysis of students' reflective responses to 2 open-ended questions. Results: Of the 53 pharmacy students that participated in the simulation, 44 (83%) and 43 (81%) completed the anonymous presimulation and postsimulation surveys. Students significantly improved as reflected in the following response: "I have confidence in my ability to provide pharmacy-related interventions to another health care professional in a logical and concise manner via telephone call." Significant improvement also occurred in the ability to work independently, communicate an order change to another health care professional, justify recommendations, answer a drug information question, and discuss recommendations in a logical and concise manner. Conclusion: The simulation discussed in this article provided students an opportunity to practice interprofessional telephone communication in a low-risk environment and resulted in significant growth in confidence and skills.

Overcoming Barriers in Nurse-Pharmacist Collaborations on Wards - Qualitative Expert Interviews with Nurses and Pharmacists

Purpose

Interprofessional collaboration in healthcare is an essential element in promoting patient safety. However, little research is available on the collaboration between nurses and pharmacists. To optimize processes, mutual understanding is needed, which can be gained by examining the perspectives of those collaborating professional groups. We aimed to identify barriers to the interprofessional collaboration of nurses and pharmacists as well as preconditions and solution strategies to devise approaches for optimizing teamwork in inpatient settings.

Methods

We recruited pairs of collaborating nurses and pharmacists from different hospitals in German-speaking countries and conducted qualitative expert interviews by phone with each of them individually. Transcribed interviews were assessed using qualitative content analysis.

Results

We conducted 12 interviews each with the collaborating nurses and pharmacists. The most frequently mentioned barriers to optimal collaboration were "skepticism due to perception as controller" (reported mainly by pharmacists), "organizational implementation", and "limited (possibilities of) presence" (reported by both professional groups). A solution strategy proposed to overcome such barriers was "explaining added value". This added value was found in "clinical-pharmaceutical activities as complement by additional perspective" and "reducing workload in tasks distant from the patient".

Conclusion

Nurses, pharmacists and hospital management should recognize the added value of intensifying their collaboration regarding patient-related services. A combination of logistical and clinical-pharmaceutical activities should be established at the level of drug application since interviewees endorsed collaboration. A stepwise process must be anticipated to address existing barriers, including some redefinition of professional roles.

Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety

INTRODUCTION

Over 4 billion prescriptions are dispensed each year to patients in the United States, with the number of prescriptions continuing to increase. There is a growing recognition of pharmacists' potential in improving medication safety in community settings, in collaboration with primary care providers (PCPs). However, the nature of collaboration has not been well defined, and barriers and strategies are not articulated.

AREA COVERED

For this narrative review, published studies were retrieved from PubMed between January 2000 and December 2020. Search terms included "patient safety," "medication safety," "collaboration," "primary care physician," and "community pharmacy." Resulting articles were categorized as follows: defining collaboration, types of collaboration, and barriers and solutions to collaboration.

EXPERT OPINION

It is important to understand the factors within a community pharmacy setting that limit or facilitate community pharmacists' participation in medication safety activities. Strategies such as medication review are a common form of collaboration. Barriers to collaboration include misconceptions regarding roles and differences in access to clinical information and community pharmacy practice variability. Future recommendations include increasing training and utilization of pharmacists/PCP teams, increasing community pharmacists' practice in emerging roles, and expanding the community pharmacist role in transitions of care from the hospital to the community.

Impact of interventions by a community pharmacist on care burden for people with dementia: development and randomized feasibility trial of an intervention protocol

Background

Traditionally, the role of pharmacists has been to manage and monitor pharmacotherapy for patients with dementia. However, additional intervention by community pharmacists to collect and share patient information with other professionals may help reduce the care burden among caregivers. The aims of this study were to examine (1) the feasibility of a designed community pharmacist working procedure in dementia care and (2) the expected impact of pharmacist intervention on care burden.

Methods

This was a randomized, open-label, parallel-group feasibility study, involving eight Nara City pharmaceutical association member pharmacies that provided consent to participate. These pharmacies were assigned to an intervention group or a control group at a 1:1 ratio. The subjects were patients with dementia and their primary caregivers that visited the participating pharmacies and provided consent to participate. Pharmacists in the intervention group actively collected information from the patients’ family physicians and care managers and intervened to address medication-related problems, while those in the control group only performed their normal duties. The primary endpoint was a change in the caregiver’s score on the Japanese version of Zarit Caregiver Burden interview (J-ZBI) from the baseline to after 5 months of follow-up. The changes in mean J-ZBI scores from the beginning to the end of the study period of the two groups were compared.

Results

Obtaining consent from caregivers was certainly difficult, but possible. Pharmacists managed to fill out the survey form while practising pharmaceutical care. Totally, nine patients and nine caregivers in the intervention group and nine patients and eight caregivers in the control group completed the study. The changes in J-ZBI scores could be calculated for seven cases in the intervention group and five cases in the control group. The J-ZBI scores were found to decrease by 1.0 in the intervention group and increase by 3.0 in the control group.

Conclusions

The protocol presented was considered feasible, but, the intervention process needs to be simplified in order to conduct a large study. Also, improvements are needed in the various survey forms and in the explanatory documents for caregivers. Although the sample size was small, the effect sizes suggested that community pharmacist interventions for patient with dementia may reduce the care burden for caregivers.

Trial registration

UMIN000039949 (registration date: 1 April 2020, retrospectively registered)

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01071-7.

Perspectives of primary care providers on multidisciplinary collaboration to prevent medication-related falls

Background

The causes of falls are often multifactorial. The prevention of falls benefits from a multidisciplinary approach. As people who fall are generally older and users of polypharmacy who frequently visit pharmacies, pharmacists may contribute to fall prevention.

Objective(s)

This study aims to explore the perceptions of primary care providers on multidisciplinary collaboration in fall prevention especially with pharmacists.

Methods

Two focus groups were held with each of the following health disciplines: physiotherapists, home care nurses, and practice nurses. A topic list was developed based on the capability opportunity motivation – behaviour (COM-B) model and the theoretical domains framework (TDF). Focus groups were audiotaped and transcribed verbatim. Data were collected in the Netherlands between March and June 2021.

Results

Six online focus groups were held with 17 physiotherapists, 14 home care nurses, and 15 practice nurses. Participants reported to collaborate multidisciplinary to prevent falls, but they had very limited collaboration with community pharmacists regarding fall prevention. Participants had limited knowledge on drugs that increase the risk of falls. This contributed to their low awareness of the potential role of pharmacists in fall prevention. Other reasons for poor collaboration in fall prevention were lack of agreements with pharmacists, limited coordination and communication. Participants were open to more collaboration with pharmacists and believed this could potentially improve patient outcomes.

Conclusions

Multidisciplinary agreements among health care providers, including community pharmacists, about referral criteria, roles and responsibilities, communication and coordination, could stimulate further collaboration in fall prevention.

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Fall prevention needs to receive more attention from primary care providers.

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Primary care providers have low awareness of the potential role of pharmacists in fall prevention.

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Primary care providers are positive about collaborating with community pharmacists to prevent falls.

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Primary care providers need enhanced communication and coordination, clarification of roles, and agreements.

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Primary care providers expect community pharmacists to focus on deprescribing of fall risk-increasing drugs (FRIDs).

Long-term clinical and cost-effectiveness of collaborative care in people with uncontrolled type 2 diabetes mellitus and polypharmacy: A multicenter randomized controlled trial

AIMS

This study examined the effectiveness of a collaborative care model on clinical and humanistic outcomes, medical cost, productivity loss, and its cost-effectiveness in managing uncontrolled Type 2 Diabetes Mellitus (T2DM).

METHODS

A randomized controlled study was conducted in two outpatient health institutions in Singapore. Patients aged above 21 years with HbA1c > 7% and polypharmacy were included. Eligible patients were randomized into the intervention (collaborative care) and control (usual care) arms.

RESULTS

A total of 255 patients were included in the analysis. Compared to the control arm, the intervention arm achieved significantly greater glycated hemoglobin (HbA1c) reduction (mean difference: 0.25, 95%CI: [0.001, 0.50], p = 0.049) and quality-adjusted life year (QALY) (+0.011, 95%CI: [0.003, 0.019], p = 0.011) at 12 months. The costs per additional HbA1c and QALY improvements over one year were $40.52 and $920.91 respectively. Activity impairment was lower in the intervention group both at 6 months (12.7% vs 19.0%; p = 0.022) and at 12 months (6.7% vs 14.0%; p = 0.008).

CONCLUSIONS

The collaborative care model achieved earlier HbA1c reduction and reduced patients' activity impairment without decreasing work productivity or increasing medical costs. This intervention is cost-effective for improving glycemic control and quality of life in patients with T2DM.

Lithium surveillance by community pharmacists and physicians in ambulatory patients: a retrospective cohort study

BACKGROUND

Shared care agreements between clinical pharmacists and physicians can improve suboptimal lithium monitoring in in- and outpatient settings. However, it is unknown whether incorporating community pharmacists in such agreements can also improve lithium monitoring in an outpatient setting.

AIM

To assess the necessity for a shared care agreement for lithium monitoring in our region by investigating: intervention rates by community pharmacists and whether those are sufficient; lithium monitoring by physicians in ambulatory patients; the extent of laboratory parameter exchange to community pharmacists.

METHOD

Patient files of lithium users were surveyed in a retrospective cohort study among 21 community pharmacies in the Northern Netherlands. Outcome was the intervention rate by community pharmacists and whether those were deemed sufficient by an expert panel. Additionally, we investigated both the percentages of patients monitored according to current guidelines and of laboratory parameters exchanged to community pharmacists.

RESULTS

129 patients were included. Interventions were performed in 64.4% (n = 29), 20.8% (n = 5), and 25.0% (n = 1) of initiations, discontinuations, and dosage alterations of drugs interacting with lithium, respectively. The expert panel deemed 40.0% (n = 14) of these interventions as "insufficient". Physicians monitored 40.3% (n = 52) of the patients according to current guidelines for lithium serum levels and kidney functions combined. Approximately half of the requested laboratory parameters were available to the community pharmacist.

CONCLUSION

Intervention rates by community pharmacists and lithium monitoring by physicians can be improved. Therefore, a shared care agreement between community pharmacists, clinical pharmacists, and physicians is needed to improve lithium monitoring in ambulatory patients.

Implementation of a pharmacy e-interconsultation integrated in patient medical record

OBJECTIVE

To describe the phases of development and the success of implementation of the pharmacist non-face-to-face consultation in primary and hospital setting.

METHOD

A descriptive and retrospective study was conducted to implement pharmacist non-face-to-face consultation with the clinician, integrated in the patient medical record. A working group was created to define content of the consultation, time of answer and the pharmacist appointment schedule integrated in the patient record. The number and type of consultations and pharmacist documentations were measure during the study period.

RESULTS

530 non-face-to-face consultations were collected from April 2018 to September 2019, principally from hospital setting, but also from primary care. The main motive of consultation was high cost drugs application. The pharmacist documentations in medical record increased after non-face-to-face consultation implementation from 98 in the prior period to 375 afterwards. As a conclusion, pharmacist non-face-to-face consultation has been successfully implemented in our health area, enhancing pharmacist presence in patient medical record and improving the communication between the pharmacists and the physicians.

Identification of factors for a successful implementation of medication reviews in community pharmacies: Using Positive Deviance in pharmaceutical care

Background Pharmacists in community pharmacies worldwide successfully conduct an increasing number of medication reviews (MR). Since June 2012 MR are incorporated in the German ordinance on the operation of pharmacies as pharmaceutical service. In November 2014, a German guideline for MR was established. Different teaching programmes for MR were implemented since. Despite these favorable conditions, only few pharmacies conduct MR regularly. Objective: Identification of factors necessary for a successful implementation of MR in community pharmacies. Setting: Community pharmacies located in the area of the Pharmacists’  Chamber Westphalia-Lippe (Part of Northrhine-Westphalia, Germany). Method: Following a Positive-Deviance approach, telephone interviews were conducted in community pharmacies with pharmacy-owners, MR-trained employed pharmacists, and technicians. Data evaluation was performed using qualitative content analysis. Main outcome results: Successful strategies for implementing MR in community pharmacies. Results: Forty-four interviews were conducted and analysed. Thirty-three success factors were identified. Data analysis revealed two groups of success-factors important for implementation of MR; organisational (n = 25) and individual factors (n = 8). Relevant organisational success-factor were involvement of the entire team with active involvement of technicians, documentation of results in the pharmacy software and training in patient-identification and communication. Restructuring of workflows increased time-periods for MR. Important individual success-factors were: motivation and identification with the service, routine in execution to enhance self-esteem, and specialisation in pharmacotherapy of particular diseases. Pharmacy-owners play a pivotal role as motivators. Professional healthcare attitude, exhibited in daily routine, leads to increased acceptance by patients and practitioners and thus increases implementation-rates considerably. Conclusion: We were able to define strategies for successful implementation of MR in community pharmacies.

Management of drug-disease interactions: a best practice from the Netherlands

Background Drug-disease interactions are situations where pharmacotherapy may have a negative effect on patients' comorbidities. In these cases, it can be necessary to avoid that drug, adjust its dose or monitor therapy. In the Netherlands, pharmacists have developed a best practice how to systematically evaluate drug-disease interactions based on pharmacological considerations and implement recommendations for specific drug-disease interactions. Aim To describe the development of recommendations for drug-disease interactions and the implementation in prescribing and dispensing practice in the Netherlands. Setting Pharmacies and physicians' practices in primary care and hospitals in the Netherlands. Development A multi-disciplinary expert panel assessed if diseases had clinically relevant drug-disease interactions and evaluated drug-disease interactions by literature review and expert opinion, and subsequently developed practice recommendations. Implementation The recommendations were implemented in all clinical decision support systems in primary care and hospitals throughout the Netherlands. Evaluation Recommendations were developed for 57 diseases and conditions. Cardiovascular diseases have the most drug-disease interactions (n = 12, e.g. long QT-syndrome, heart failure), followed by conditions related to the reproductive system (n = 7, e.g. pregnancy). The number of drugs with recommendations differed between 6 for endometriosis and tympanostomy tubes, and up to 1171 in the case of porphyria or even all drugs for pregnancy. Conclusion Practice recommendations for drug-disease interactions were developed, and implemented in prescribing and dispensing practice. These recommendations support both pharmacists and physicians by signalling clinically relevant drug-disease interactions at point of care, thereby improving medication safety. This practice may be adopted and contribute to safer medication use in other countries as well.

Primary healthcare policy and vision for community pharmacy and pharmacists in Germany

Germany is the highest populated country in Europe with a population of 82.3 million in 2019. As in many other developed countries, it has an aging population. Approximately 10% of the gross domestic product is spent on healthcare. The healthcare system is characterized by its accessibility. Patients are generally free to choose their primary care physicians, both family doctors and specialists, pharmacy, dentist, or emergency service. Up to a certain income, health insurance is mandatory with the statutory health insurance (SHI) system, covering 88% of the population. Major challenges are the lack of cooperation and integration between the different sectors and healthcare providers. This is expected to change with the introduction of a telematic infrastructure that is currently being implemented. It will not only connect all providers in primary and secondary care in a secure network but will also enable access to patients' electronic record/medical data and at the same time switch from paper to electronic prescriptions. Approximately 52,000 of the 67,000 pharmacists are working in approximately 19,000 community pharmacies. These pharmacies are owner-operated by a pharmacist. Pharmacists may own up to three subsidiaries nearby to their main pharmacy. Community pharmacy practice mainly consists of dispensing drugs, counselling patients on drug therapy and safety, and giving advice on lifestyle and healthy living. Many cognitive pharmaceutical services have been developed and evaluated in the past 20 years. Discussions within the profession and with stakeholders on the national level on the roles and responsibilities of pharmacists have resulted in nationally agreed guidelines, curricula, and services. However, cognitive services remunerated by the SHI funds on the national level remain to be negotiated and sustainably implemented. A law passed in November 2020 by parliament will regulate the remuneration of pharmaceutical services by the SHI funds with an annual budget of EUR 150 million. The type of services and their remuneration remain to be negotiated in 2021. The profession has to continue on all levels to advocate for a change in pharmacy practice by introducing pharmacy services into routine care.

The medication discrepancy detection service: A cost-effective multidisciplinary clinical approach

OBJECTIVE

To estimate the effectiveness of a Medication Discrepancy Detection Service (MDDS), a collaborative service between the community pharmacy and Primary Care.

DESIGN

Non-controlled before-and-after study.

SETTING

Bidasoa Integrated Healthcare Organisation, Gipuzkoa, Spain.

PARTICIPANTS

The service was provided by a multidisciplinary group of community pharmacists (CPs), general practitioners (GPs), and primary care pharmacists, to patients with discrepancies between their active medical charts and medicines that they were actually taking.

OUTCOMES

The primary outcomes were the number of medicines, the type of discrepancy, and GPs' decisions. Secondary outcomes were time spent by CPs, emergency department (ED) visits, hospital admissions, and costs.

RESULTS

The MDDS was provided to 143 patients, and GPs resolved discrepancies for 126 patients. CPs identified 259 discrepancies, among which the main one was patients not taking medicines listed on their active medical charts (66.7%, n=152). The main GPs' decision was to withdraw the treatment (54.8%, n=125), which meant that the number of medicines per patient was reduced by 0.92 (9.12±3.82 vs. 8.20±3.81; p<.0001). The number of ED visits and hospital admissions per patient were reduced by 0.10 (0.61±.13 vs 0.52±0.91; p=.405 and 0.17 (0.33±0.66 vs. 0.16±0.42; p=.007), respectively. The cost per patient was reduced by €444.9 (€1003.3±2165.3 vs. €558.4±1273.0; p=.018).

CONCLUSION

The MDDS resulted in a reduction in the number of medicines per patients and number of hospital admissions, and the service was associated with affordable, cost-effective ratios.

Complementing or conflicting? How pharmacists and physicians position the community pharmacist

Background:

Interprofessional collaboration between pharmacists and physicians in primary care has been linked to improved patient outcomes. How professionals position themselves and each other can shed light upon their relationship, and positioning theory can be used as a tool to better understand intergroup relations.

Objectives:

1) To identify how community pharmacists position themselves, and how they are positioned by general practitioners. 2) To assess how well these positions correspond, how the positions align with a proactive position for the pharmacists, and discuss how the positions could potentially impact collaboration.

Methods:

In this qualitative study, data were collected through six focus group interviews held between June and October 2019, three with pharmacists and three with physicians. The focus group interviews were conducted using a semi-structured interview guide. Data were audio recorded, transcribed verbatim, and analyzed using the Systematic text condensation method. Positioning theory was used as a theoretical framework to identify the positions assigned to community pharmacists by the pharmacists themselves and by the physicians.

Results:

Twelve pharmacists and ten physicians participated. The pharmacists positioned themselves as the “last line of defense”, “bridge-builders”, “outsiders” – with responsibility, but with a lack of information and authority – and “practical problem solvers”. The physicians positioned pharmacists as “a useful checkpoint”, “non-clinicians” and “unknown”.

Conclusions:

The study revealed both commonalities and disagreements in how community pharmacists position themselves and are positioned by general practitioners. Few of the positions assigned to pharmacists by the physicians support an active role for the pharmacists, while the pharmacists´ positioning of themselves is more diverse. The physicians´ positioning of pharmacists as an unknown group represents a major challenge for collaboration. Increasing the two professions´ knowledge of each other may help produce new positions that are more coordinated, and thus more supportive towards collaboration.

Effective communication and collaboration with health professionals: A qualitative study of primary care pharmacists in Western Australia

BACKGROUND

The expanded provision of professional services by community pharmacists in the primary care setting encompasses the necessity to communicate and collaborate with other health professionals. Little is currently known about contemporary processes employed for their achievement.

OBJECTIVE

To explore contemporary processes employed for effective communication and collaboration between primary care pharmacists and health professionals.

METHODS

In-depth semi-structured interviews were conducted with pharmacists practising in primary care settings requiring varying expertise, practice experience and speciality backgrounds. Interviews were audio-recorded, transcribed verbatim and coded using NVivo version 11. Data were analysed following an inductive approach to facilitate thematic analysis.

RESULTS

Twenty-six pharmacists were interviewed, which achieved data saturation. Five overarching themes emerged as participants described their experiences and perspectives regarding processes employed for communication and collaboration: i) tailored means of communication, ii) referral processes, iii) facilitators for effective interactions, iv) barriers to effective interactions, and v) implementation of a national digital health record. Participants acknowledged that the changing landscape of the Australian health system affected communication and collaboration with other health professionals. The changes resulted in participants' acceptance of a multidisciplinary approach to healthcare, which was contingent upon effective communication, interactions and relationships with other health professionals. Varying levels of formality and characteristics of referrals were identified, however the nature of the communication was tailored to the individual scenario or circumstance that was considered appropriate.

CONCLUSIONS

Pharmacists exercised judgment on a case-by-case basis when tailoring the means of communication. The establishment of a consistent and structured two-way referral process between health professionals within the primary care setting is important, which includes use of the national digital health record. Increased awareness and appreciation of each health professional's roles and expertise would further enhance inter-professional collaboration.

Impact of training and structured medication review on medication appropriateness and patient-related outcomes in nursing homes: results from the interventional study InTherAKT

BACKGROUND

Uncoordinated interprofessional communication in nursing homes increases the risk of polypharmacy and inappropriate medication use. This may lead to augmented frequency of adverse drug events, hospitalizations and mortality. The aims of this study were (1) to improve interprofessional communication and medication safety using a combined intervention and thus, (2) to improve medication appropriateness and health-related outcomes of the included residents.

METHODS

The single-arm interventional study (2014-2017) was conducted in Muenster, Germany and involved healthcare professionals and residents of nursing homes. The intervention consisted of systematic education of participating healthcare professionals and of a structured interprofessional medication review which was performed via an online communication platform. The primary endpoint was assessed using the Medication Appropriateness Index MAI. Secondary endpoints were: cognitive performance, delirium, agitation, mobility, number of drugs, number of severe drug-drug interactions and appropriateness of analgesics. Outcomes were measured before, during and after the intervention. Data were analyzed using descriptive and inference-statistical methods.

RESULTS

Fourteen general practitioners, 11 pharmacists, 9 nursing homes and 120 residents (n = 83 at all testing times) participated. Overall MAI sum-score decreased significantly over time (mean reduction: -7.1, CI95% -11.4 - - 2.8; median = - 3.0; dCohen = 0.39), especially in cases with baseline sum-score ≥ 24 points (mean reduction: -17.4, CI95% -27.6 - - 7.2; median = - 15.0; dCohen = 0.86). MAI sum-score of analgesics also decreased (dCohen = 0.45). Mean number of severe drug-drug interactions rose slightly over time (dCohen = 0.17). The proportion of residents showing agitated behavior diminished from 83.9 to 67.8%. Remaining secondary outcomes were without substantial change.

CONCLUSION

Medication appropriateness increased particularly in residents with high baseline MAI sum-scores. Cognitive decline of participating residents was seemingly decelerated when compared with epidemiologic studies. A controlled trial is required to confirm these effects. Interprofessional interaction was structured and performance of medication reviews was facilitated as the online communication platform provided unlimited and consistent access to all relevant and updated information.

TRIAL REGISTRATION

DRKS Data Management, ID: DRKS00007900 , date of registration: 2015-09-02 (retrospectively registered i.e. 6 weeks after commencement of the first data collection).

Factors influencing interprofessional collaboration between community pharmacists and general practitioners-A systematic review

Effective interprofessional collaboration is critical for sustaining high quality care in the context of the increasing burden on primary healthcare services. Despite this, there is limited understanding of the factors contributing to effective collaboration between general practitioners and community pharmacists. The aim of this systematic review was to identify the factors that impact on interprofessional collaboration between general practitioners (GPs) and community pharmacists (CPs). Keywords and synonyms were combined and applied to four databases (EMBASE, CINAHL, SCOPUS, and MEDLINE) to identify articles published between January 2000 to April 2017. Relevant journals and reference lists were also hand-searched. A total of 37 articles met the eligibility criteria. Factors that posed a challenge to effective interprofessional collaboration were the perceived imbalance in hierarchy and power between the professions and a lack of understanding of each other's skills and knowledge. Experience of collaboration with the other party led to greater understanding of each other's capabilities and potential role in co-delivering patient care. The physical environment was also identified as important, with co-location and other resources to facilitate clear and regular communication identified as important facilitators of interprofessional collaboration. The review findings highlight a range of approaches that may positively influence interprofessional collaboration between GPs and CPS such as co-location, co-education to understand the professional capabilities of each group, and utilising compatible technologies to facilitate communication between the two professions.

Family physicians' perceptions of pharmacists prescribing in Alberta

Canadian pharmacists now have prescribing authority and little is documented about the physicians' perception, experience and relational dynamics evolving around the pharmacists' prescribing practice. The objective of this study was to explore Albertan family physicians' perceptions and experiences of pharmacists' prescribing practice. We used purposeful and maximum variation sampling method and semi-structured face to face or telephone interviews to collect data. From October 2014 to February 2016, we interviewed 12 family physicians in Alberta, having experience with pharmacist prescribing. Interviews were audio recorded and transcribed verbatim for analysis using an interpretive description method, guided by "Relational Coordination" theory. NVivo software was used to manage the data. Three key beliefs (i.e., renewal versus initiate new prescription, community versus team pharmacists, and "I am responsible") about pharmacist prescribing were identified. Trust and communication were prominent themes which shaped participants' collaboration with pharmacist prescribers. Participants were classified as either "collaborative" or "consultative". Participants had greater collaboration with the team pharmacist prescribers compared to community pharmacists due to a higher level of trust and ease of communication. Renewal prescribing by any pharmacist was well accepted but participants showed hesitancy in accepting pharmacist-initiated prescriptions. Our findings provide insight into interprofessional collaboration and communication between physician and pharmacist prescribers.

Optimizing pharmaceutical care for pediatric patients with dermatitis: perspectives of parents and pharmacy staff

Background Atopic dermatitis affects 10–20% of the children worldwide. Unfortunately not all patients who receive treatment have optimal treatment outcomes. Objective To assess the view of parents and pharmacy staff in order to optimize pharmaceutical care for young atopic dermatitis patients. Setting Community pharmacies in the Netherlands. Method We first held an expert panel meeting to determine experts’ views on treatment of atopic dermatitis and their suggestions for areas of improvement. This input was used to develop the interview guide. We conducted telephone interviews with parents of children (aged 0–12 years) with atopic dermatitis and face-to-face interviews with pharmacy staff members. All interviews were audiotaped and transcribed verbatim. Transcripts were coded using qualitative data analysis software. Codes were used to identify themes. Main outcome measure Perspectives of parents of young atopic dermatitis patients and pharmacy staff about treatment. Results We interviewed 29 parents and 18 pharmacy staff members. Many parents mentioned fear of steroid adverse effects, with intentional nonadherence as a consequence, and difficulties with the application of topical treatment. Pharmacy employees also mentioned to encounter these issues. Some employees themselves expressed concerns towards use of steroids. Most parents were satisfied with the information they received; however, they need more practical lifestyle advices, e.g. about bathing or clothing. Both pharmacists and pharmacy technicians mentioned that technicians often lack knowledge to support patients optimally in correct medication use. Conclusion Parents’ perceptions about topical corticosteroids might negatively influence treatment outcomes. Pharmacy staff has an important role to inform parents of children with eczema on the appropriate use of topical corticosteroids and emollients. Counseling should not be influenced by their own prejudices about topical corticosteroids. Close collaboration between primary care providers should ensure that parents receive uniform messages.

Patient selection and general practitioners' perception of collaboration in medication review

BACKGROUND

Implementation of collaborative Medication Review (MR) into routine care faces several barriers.

OBJECTIVE

The study aim was to gain information on patient selection for a MR by general practitioners (GPs). GP selection was compared to objective selection criteria on identifying patients, who would benefit from a MR the most. A secondary objective of this study was to get insight into GPs perception on interprofessional collaboration with pharmacists.

METHODS

GPs were interviewed for a qualitative study on expected outcomes of MR in former study patients. They were asked to select patients, for whom they expected a major benefit from the MR. Results were compared to objective selection criteria, obtained from the WestGem study. Further interviews were done on aspects of patient selection and perception of interprofessional collaboration, results were presented descriptively.

RESULTS

The study covered 6 GPs with 78 former study patients. GPs would have chosen 45 out of the 78 patients (57.7%) for a MR. According to changes in the Medication Appropriateness Index, 24 of these patients had a greater benefit from the MR. Patient selection by the number of prescribed drugs had reached a higher specificity at a cut-off of 9 drugs, compared to selection by the GP (67% vs. 61.5%). GPs mentioned medication safety, certain diseases, polymedication, multimorbidity as selection criteria. Increasing quality of therapy and better insight into the patient's drug regimen was appreciated by the GPs as perceived personal advantage of the MR. GPs preferred to have a MR initiated by themselves, but appraised concise interprofessional collaboration with pharmacists.

CONCLUSIONS

Patient selection for MR should take objective parameters into account and combine them with subjective impressions. GPs preferred the initiation of a MR by themselves but expressed a positive attitude towards collaboration with a pharmacist afterwards. Recommendations should be relevant and concise.

Direct observation of telephone communication between community pharmacies and prescribers in New Zealand

Background Phone calls between pharmacists and prescribers play an important role in resolving potential errors and other issues. Despite their importance in patient care, and sometimes causing frustration for pharmacists, there is little research on these calls. Objective To quantify how long calls between pharmacists and prescribers are, how often phone calls occur, why calls are made, and who is called. Method An observational study was conducted with 130.5 h observed in 11 community pharmacies over 8 weeks in Dunedin, New Zealand, recording information about all incoming and outgoing calls. Data captured included information on length, date, time, reason for call, pharmacy staff involved, health professionals involved, and the place being called. We also surveyed pharmacists' perceptions of this communication. Results Data on 95 phone calls was captured. The mean length was 110 s (95% CI 88-133), at an average of 0.7 calls per hour. The most frequent reasons for calling were clarifications and dose inquiries. Conclusion Calling prescribers is perceived as a frustrating; however the frequency of calls we observed was low, but some were long. The amount of time spent for pharmacist interventions may be reduced using alternative communication methods but these need further study.

The Introduction of a Full Medication Review Process in a Local Hospital: Successes and Barriers of a Pilot Project in the Geriatric Ward

For the majority of Belgian hospitals, a pharmacist-led full medication review process is not standard care and, therefore, challenging to introduce. With this study, we aimed to evaluate the successes and barriers of the implementation of a pharmacist-led full medication review process in the geriatric ward at a local Belgian hospital. To this end, we carried out an interventional study, performing a full medication review on older patients (≥70 years) with polypharmacy (≥5 drugs) who had an unplanned admission to the geriatric ward. The process consisted of 3 steps: (1) medication reconciliation upon admission; (2) medication review using an explicit reviewing tool (STOPP/START criteria or GheOP³S tool), followed by a discussion between the pharmacist and the geriatrician; and (3) medication reconciliation upon discharge. Ethical approval was obtained from the Ethical Commission of the Ghent University Hospital. Outcomes included objective data on the interventions (e.g., number of drug discrepancies; number of potentially inappropriate prescriptions (PIP)); as well as subjective experiences (e.g., satisfaction with service; opinion on inter-professional communication). There was a special focus on communication aspects within the introduction of this process. In total, 52 patients were included in the study, taking a median of 10 drugs (IQR 8-12). Upon admission, 122 drug discrepancies were detected. During medication review, 254 PIPs were detected and discussed, leading to an improvement in the appropriateness of medication use. The satisfaction of community pharmacists concerning additional communication and the satisfaction of the patients after counselling at discharge were positive. However, several barriers were encountered, such as the time-consuming process to gather necessary information from different sources, the non-continuity of the service due to the lack of trained personnel or the lack of safe, electronic platforms to share information. The communicative and non-communicative successes and hurdles encountered during this project need to be addressed in order to improve the full medication review process and to strengthen the role of the clinical pharmacist.