Evaluation of a community pharmacy-based influenza and group A streptococcal pharyngitis disease management program using polymerase chain reaction point-of-care testing

Factors influencing Implementation of point-of-care testing for acute respiratory infectious diseases in community pharmacies: A scoping review using the Consolidated Framework for Implementation research

BACKGROUND

Emerging evidence suggests pharmacy-based point-of-care (POC) testing for acute respiratory infectious diseases is beneficial, but not widely implemented. A theory-informed review to understand the factors influencing service Implementation is lacking.

OBJECTIVE

To examine the extent, range, and nature of research available on enablers and barriers to POC testing Implementation for infectious respiratory diseases in community pharmacies and identify their underpinning theoretical constructs using the Consolidated Framework for Implementation Research (CFIR).

METHODS

Scoping review guided by the JBI Manual for Evidence Synthesis. A comprehensive search from inception to June 28th, 2022 was conducted using Medline, Embase, CINAHL, Cochrane Library, and ProQuest dissertations without date or language restriction. Eligible articles investigated barriers and/or facilitators to strep throat, influenza, C-reactive protein, and COVID-19 POC testing in community pharmacies. Two reviewers independently performed title & abstract screening, full-text screening, and data extraction. Content analysis was conducted according to a pre-established Framework and concepts were mapped to the CFIR.

RESULTS

Forty-three studies were included. Most originated from the USA (n = 24; 56%) and investigated strep throat. The majority were testing/initial Implementation projects (n = 23; 54%) conducted in urban centers (n = 17; 40%). Thirty-six (84%) studies used quantitative methodology, while 6 (14%) were qualitative. Only four studies (9%) used theory to guide their inquiry. The 124 identified Implementation factors mapped onto 21 CFIR constructs, covering all 5 domains. The domain "Outer setting" (n = 35/43; 81%) was most prevalent as were the constructs "Patient needs and resources," (n = 21/43; 49%) "External policy & incentives," (n = 17/43; 40%) and "Relative advantage" (n = 17/43; 40%).

CONCLUSION

A large volume of research explores factors influencing the Implementation of pharmacy-based respiratory infectious disease POC testing services, but few studies use qualitative or theory-informed methods. Knowledge of the wide range of facilitators and barriers identified can help pharmacy managers and researchers design strategies to support successful service Implementation.

Point-of-care testing in private pharmacy and drug retail settings: a narrative review

BACKGROUND

Point-of-care testing (POCT) using rapid diagnostic tests for infectious disease can potentially guide appropriate use of antimicrobials, reduce antimicrobial resistance, and economise use of healthcare resources. POCT implementation in private retail settings such as pharmacies and drug shops could lessen the burden on public healthcare. We performed a narrative review on studies of POCTs in low- and middle-income countries (LMICs), and explored uptake, impact on treatment, and feasibility of implementation.

METHODS

We searched MEDLINE/PubMed for interventional studies on the implementation of POCT for infectious diseases performed by personnel in private retail settings. Data were extracted and analysed by two independent reviewers.

RESULTS

Of the 848 studies retrieved, 23 were included in the review. Studies were on malaria (19/23), malaria and pneumonia (3/23) or respiratory tract infection (1/23). Nine randomised controlled studies, four controlled, non-randomised studies, five uncontrolled interventions, one interventional pre-post study, one cross-over interventional study and three retrospective analyses of RCTs were included. Study quality was poor. Overall, studies showed that POCT can be implemented successfully, leading to improvements in appropriate treatment as measured by outcomes like adherence to treatment guidelines. Despite some concerns by health workers, customers and shop providers were welcoming of POCT implementation in private retail settings. Main themes that arose from the review included the need for well-structured training with post-training certification covering guidelines for test-negative patients, integrated waste management, community sensitization and demand generation activities, financial remuneration and pricing schemes for providers, and formal linkage to healthcare and support.

CONCLUSION

Our review found evidence that POCT can be implemented successfully in private retail settings in LMICs, but comprehensive protocols are needed. High-quality randomised studies are needed to understand POCTs for infectious diseases other than malaria.

Molecular point-of-care testing in the community pharmacy setting: current status and future prospects

INTRODUCTION

Clinical Laboratory Improvement Amendments (CLIA)-waived point-of-care tests (POCTs) have been available since the late 1980s, but their use in community pharmacy has expanded over the last several years. Barriers exist for community-pharmacy-based CLIA-waived POC testing, including pharmacy workflow, pharmacist scope of practice, and reimbursement. As pharmacies work to reduce these barriers, the number of pharmacies participating in POCT programs has dramatically increased. There are several lateral flow and nucleic acid amplification CLIA-waived POC tests available for use in community pharmacy settings. The majority of data regarding pharmacy-based POC testing programs currently highlights the role of lateral flow testing for influenza and acute pharyngitis.

AREAS COVERED

A comprehensive review of the current state of CLIA-waived rapid point-of-care infectious pathogen testing in community pharmacies is presented.

EXPERT OPINION

Knowing which CLIA-waived rapid POCTs are available and understanding their key characteristics will be helpful in identifying the best tests to incorporate into individual pharmacies. Choices will also depend on specific pharmacy workflow patterns, local populations and insurances, and state regulations regarding pharmacist scope of practice. As nucleic acid amplification tests evolve, the business case and the framework for implementation for using molecular tests in community pharmacy will become clearer.

Evaluation of a pharmacist-led drive-up anticoagulation clinic during the coronavirus 2019 pandemic

Background

The University of Kentucky HealthCare Anticoagulation Clinic at the Gill Heart and Vascular Institute in Lexington, Kentucky, designed and implemented a drive-up clinic for warfarin management with the goal to minimize person-to-person exposure during the coronavirus disease 2019 (COVID-19) pandemic.

Objective

The purpose of this study was to evaluate the effect on warfarin management in a pharmacist-led anticoagulation service when transitioned from an in-person clinic to a drive-up clinic during the COVID-19 pandemic.

Methods

This is a retrospective observational cohort study of 68 patients seen in the University of Kentucky HealthCare Anticoagulation Clinic on warfarin therapy for any indication. Patients were included if they had scheduled visits at least 3 times in the period 6 months before, during, and after the initiation of the drive-up clinic. The primary outcome is the difference in time in therapeutic range (TTR) before and during the drive-up clinic.

Results

The difference between the mean TTR in period 1 (69.1% ± 23.2%) and period 2 (69.6% ± 19.2%) was not statistically significant (P = 0.882). The mean TTR in period 3 (70.5% ± 20.8%) did not differ in statistical significance from either period 1 (P = 0.688) or period 2 (P = 0.746). Safety outcomes including reported bleeding events and emergency department visits or hospital admissions for bleeding or thrombotic events were consistently low across each period.

Conclusion

The results of this study illustrate that a drive-up clinic for warfarin management may be a reasonable alternative approach to providing care for outpatient anticoagulant management and may support nontraditional clinic models for long-term management of anticoagulation and other chronic disease states.

Pharmacists as important prescribers of coronavirus disease 2019 (COVID-19) antivirals

Although pharmacists are key members of the healthcare team, they are currently ineligible to independently prescribe the oral coronavirus disease 2019 (COVID-19) antivirals. We report the roles pharmacists have undertaken during the COVID-19 pandemic and provide evidence for the support of independent oral COVID-19 antiviral prescribing.

A systematic literature review and meta-analysis of community pharmacist-led interventions to optimise the use of antibiotics

Aims

The aim of this systematic review is to assess the effects of community pharmacist‐led interventions to optimise the use of antibiotics and identify which interventions are most effective.

Methods

This review was conducted according to the PRISMA guidelines (PROSPERO: CRD42020188552). PubMed, EMBASE and the Cochrane Central Register of Controlled Trials were searched for (randomised) controlled trials. Included interventions were required to target antibiotic use, be set in the community pharmacy context, and be pharmacist‐led. Primary outcomes were quality of antibiotic supply and adverse effects while secondary outcomes included patient‐reported outcomes. Risk of bias was assessed using the ‘Cochrane suggested risk of bias criteria’ and narrative synthesis of primary outcomes conducted.

Results

Seventeen studies were included covering in total 3822 patients (mean age 45.6 years, 61.9% female). Most studies used educational interventions. Three studies reported on primary outcomes, 12 on secondary outcomes and two on both. Three studies reported improvements in quality of dispensing, interventions led to more intensive symptom assessment (up to 30% more advice given) and a reduction of over‐the‐counter supply up to 53%. Three studies led to higher consumer satisfaction, effects on adherence from nine studies were mixed (risk difference 0.04 [−0.02, 0.10]). All studies had unclear or high risks of bias across at least one domain, with large heterogeneity between studies.

Conclusions

Our review suggests some positive results from pharmacist‐led interventions, but the interventions do not seem sufficiently effective as currently implemented. This review should be interpreted as exploratory research, as more high‐quality research is needed.

Are We Making the Most of Community Pharmacies? Implementation of Antimicrobial Stewardship Measures in Community Pharmacies: A Narrative Review

Community pharmacists recognize the need to implement antimicrobial stewardship activities in community pharmacies. They are in a unique position to provide triage for common primary care indications and to lower the burden of patients at general practitioners’ offices. However, research shows that, in some areas, dispensing of antimicrobials without valid prescription is still highly prevalent. Regardless of training, every community pharmacist can give his contribution to antimicrobial stewardship. One of the basic elements should be antimicrobial dispensing according to regulations, either prescription only, or according to guidelines where pharmacists have prescribing authority. Patient consultation supported with educational materials, such as leaflets, may reduce patients’ expectations to receive antibiotics for self-limiting infections and reduce pressure on general practitioners to prescribe antibiotics on patients’ demand. Treatment optimization may be achieved in collaboration with the prescribing general practitioners or by providing feedback. At last, pharmacists provided with additional training may be encouraged to provide consultation services to long-term care facilities, to introduce point-of-care testing for infectious diseases in their pharmacies or prescribe antimicrobials for uncomplicated infections. These services are welcomed by patients and communities. Expanding pharmacy services and pharmacists’ prescribing autonomy have shown a positive impact by reducing antibiotics consumption, thus ensuring better compliance with treatment guidelines.

Pharmacists’ role in infectious pandemics: illustration with COVID-19

In 2020 pharmacists around the globe were faced with overwhelming challenges due to the global coronavirus pandemic. This chapter describes salient issues impacting pharmacists’ response to the COVID-19 infectious disease pandemic. The chapter emphasizes the response in the United States and within regions to inform the readers of principles related to the scope of practice and practice in the community, point-of-care testing, critical care and health systems, and long-term care. Pharmacy educators responded to graduate essential healthcare workers on time. The chapter ends following the lead of World Health Organization Director-General advising “first, prepare and be ready; second, detect, protect, and treat; third, reduce transmission; and fourth, innovate and learn.”

Point-of-care testing in pharmacies-An evaluation of the service from the lens of resource-based theory of competitive advantage

BACKGROUND

Point-of-care tests (POCTs) are innovative services that are increasingly offered in community pharmacies. Assessments of these services should consider their financial sustainability in addition to their effectiveness if they are to be successful over time in a competitive environment.

OBJECTIVES

The aim of this research was to review and evaluate the POCT practice innovations literature through the lens of the resource-based theory (RBT) of competitive advantage.

DATA SOURCES

Articles describing POCT services were identified systematically through PubMed, exclusively.

STUDY SELECTION

All POCT articles in the review met the following inclusion criteria: (1) articles were published after 1999; (2) interventions were pharmacist-led innovations within a community pharmacy; (3) articles described research studies with results; and (4) articles were published in English, Spanish, or Portuguese.

DATA EXTRACTION

The RBT was operationalized using a strengths, weaknesses, opportunities, threats matrix and a business model canvas, which were employed to extract and analyze data. Articles were assessed according to the degree to which they articulated elements that the RBT needed to assess their financial sustainability in targeted markets.

RESULTS

A total of 36 articles describing POCTs and associated services were included in this review. Most of the studies reported aspects pertaining to the contextual environment of the innovation, value proposition, key activities, partners, and channels of distribution. However, the competitive dimension of the environment, as well as the cost structure and revenue streams, were often neglected in the studies.

CONCLUSIONS

The RBT is a widely tested framework that can be used for planning and reporting POCT practice innovations. On the basis of this framework, pharmacists seem to do a good job in describing how to provide POCT but fall short in explaining how these services are sustainable over time.

Primary healthcare policy and vision for community pharmacy and pharmacists in the United States

The United States (US) has a complex healthcare system with a mix of public, private, nonprofit, and for-profit insurers, healthcare institutions and organizations, and providers. Unlike other developed countries, there is not a single payer healthcare system or a national pharmaceutical benefits scheme/plan. Despite spending over USD 10,000 per capita in healthcare, the US is among the worst performers compared to other developed countries in outcomes including life expectancy at birth, infant mortality, safety during childbirth, and unmanaged chronic conditions (e.g., asthma, diabetes). Primary care is delivered by physicians and advanced practice providers (i.e., nurse practitioners and physician assistants) in a variety of settings including large health systems, federally qualified health centers or free clinics that provide care to the underserved, or specific facilities for veterans or American Indian and Alaska native peoples. Since 2010, primary care delivery has shifted toward providing patient-centered, coordinated, comprehensive care focused on providing proactive, rather than reactive, population health management, and on the quality, versus volume, of care. Community pharmacy comprises a mix of independently owned, chain, supermarket and mass merchant pharmacies. Community pharmacies provide services such as immunizations, medication therapy management, medication packaging, medication synchronization, point-of-care testing and, in specific states where legislation has been passed, hormonal contraception, opioid reversal agents, and smoking cessation services. There has been criticism regarding the lack of standard terminology for services such as medication synchronization and medication therapy management, their components and how they should be provided, which hampers comparability across studies. One of the main challenges for pharmacists in the US is the lack of provider status at the federal level. This means that pharmacists are not allowed to use existing fee-for-service health insurance billing codes to receive reimbursement for non-dispensing services. In addition, despite there being regulatory infrastructure in multiple states, the extent of service implementation is either low or unknown. Research found that pharmacists face numerous barriers when providing some of these services. State fragmentation and the lack of a single pharmacy organization and vision for the profession are additional challenges.