Forward and backward transitions in pharmacy-based immunization services

Determinants to immunization information system implementation in independent community pharmacies in rural Alabama

BACKGROUND

Immunization information systems (IISs) facilitate consolidated vaccination data within each state. Many have limited pharmacy participation, especially Alabama. As pharmacists increasingly engage in delivery of vaccines recommended across the life span, it is critical to understand the barriers to IIS implementation, particularly in rural community pharmacies where access to primary care may be limited.

OBJECTIVE

The purpose of this study was to identify barriers and facilitators to IIS implementation in rural, independent community pharmacies in Alabama.

METHODS

Qualitative interviews with rural, independent community pharmacy personnel and IIS experts in both states with high IIS participation and Alabama (state with low IIS participation) were conducted. States with high participation were identified as those with ≥75% of adults recorded in their respective state IIS. Less than 25% of Alabama adults were recorded in the state IIS at the time of this study. Deductive coding using CFIR constructs was conducted with a second coder to ensure inter-rater reliability. CFIR Rating Rules were applied to the coded data to allow for identification of constructs that have the greatest impact on implementation.

RESULTS

A total of twenty-five participants (16 pharmacy personnel; 9 IIS experts) were interviewed. During interviews, 32 of 39 CFIR constructs were mentioned and 11 constructs with a strong influence (+2 or -2) were identified. These included, "adaptability", "complexity", "compatibility", "available resources", "access to knowledge and information", "needs and resources of those served by the organization", "peer pressure", "external policy and initiatives", "knowledge and beliefs about the innovation", "engaging key stakeholders", and "engaging innovation participants".

CONCLUSIONS

This qualitative study explored perceived barriers and facilitators to IIS implementation in the rural, independent community pharmacy setting from the perspectives of pharmacy personnel and IIS experts. Factors identified can be used to inform the development of resources and implementation strategies to improve IIS uptake and participation.

Community pharmacists workforce readiness to deliver vaccination services: A cross-sectional study from Jordan

This study assesses Jordanian community pharmacists’ readiness and willingness to deliver vaccination services in their practice sites. Between February and April 2021, a self‐administered online questionnaire was distributed via social media, WhatsApp messages, and personal communication. The questionnaire targeted practicing community pharmacies. Descriptive and inferential data analysis was carried out. A total of 403 community pharmacists participated in the study. Almost 146 (36%) community pharmacists reported vaccinating patients in their practice sites. However, readiness assessment revealed that only 54 (13.4%) pharmacists received the required training and qualifications. Moreover, 33 (8.2%) study participants worked in adequately equipped and designed community pharmacies. Overall, surveyed participants held positive attitudes toward their involvement in vaccination services: 260 (64.5%) pharmacists were willing to vaccinate patients, and 227 (65.0%) out of unready, unqualified, participants were willing to get needed training and qualifications. According to study participants, regulatory and professional bodies (Ministry of Health, Jordan Pharmacists Association) are influential in supporting pharmacist‐vaccinators. Among the investigated factors, organizational structure and employment status were significantly associated with pharmacists’ readiness to deliver vaccination. This study revealed that further work is needed to increase pharmacists’ and pharmacies’ readiness to deliver vaccination services and that regulators should follow a more active approach in highlighting the importance of training and the impact of training in patients’ safety and satisfaction.

Perceptions of HPV vaccination and pharmacist-physician collaboration models to improve HPV vaccination rates

Background

Human Papillomavirus (HPV) is the most common sexually transmitted disease in the United States (US), with 12 cancer causing strains. Vaccination rates in the southern US fall below the national average. Pharmacists provide an opportunity to improve vaccination rates.

Objectives

The objectives of this study were to 1) identify barriers and facilitators to providing the HPV vaccine and Vaccines for Children (VFC) program participation in pharmacies and clinics, and 2) assess pharmacy staff, clinic staff, and parent perceptions of 3 collaboration models to improve HPV vaccination.

Methods

A developmental formative evaluation was conducted with pharmacy staff, primary care clinic staff, and parents of adolescent children. Interview guides were informed by the Consolidated Framework for Implementation Research (CFIR). Barriers and facilitators to HPV vaccination and VFC participation were explored. Additionally, acceptability of 3 collaboration models were explored: 1) a shared-responsibility model in which a physician provides the first dose of HPV vaccine with the second provided in the pharmacy, 2) a pharmacy-based model in which a clinic refers patients to the pharmacy to receive both doses, and 3) an insourced model in which pharmacists schedule days to provide the vaccine in the collaborating clinic.

Results

Twenty-nine interviews were conducted between August 2019 and June 2020. Both pharmacy and clinic staff had positive views toward the HPV vaccine and vaccinations in general. Pharmacists and physicians reported parental awareness and education as a barrier to HPV vaccination. Counseling about HPV vaccine was reported as being more time-consuming because of the stigma associated with the vaccine. Parents were willing to have their children vaccinated for HPV in the pharmacy but desired their child's physician be involved in the immunization process. The shared-responsibility model was the most favored of the 3 collaboration models.

Conclusion

Perceptions of the HPV vaccine and vaccination in pharmacies were positive. Collaboration between clinics and pharmacies to improve HPV vaccination rates is viewed positively by pharmacy staff, clinic staff, and parents. This study will guide implementation of pharmacist-physician collaborative models to improve vaccination through pharmacy participation in the VFC program and HPV vaccination.

Medicare Annual Wellness Visits: A Scoping Review of Current Practice Models and Opportunities for Pharmacists

Objective:

To explore the existing practice models and practice opportunities surrounding pharmacist-delivered Medicare Annual Wellness Visits (AWVs), with the goal of improving patient access through advanced pharmacy-based health services.

Data Sources:

English-language articles published in peer-reviewed journals from January 2011 to March 2018 were reviewed by searching PubMed and Google Scholar databases using permutations of terms such as “pharmacist/pharmacy,” “Medicare,” “Annual Wellness Visit,” “develop/development,” and “implement/implementation.”

Study Selection and Data Extraction:

Original articles reporting resources (inputs), processes, and programmatic outcomes (uptake and delivery, interventions made, financial models, satisfaction) of pharmacist-delivered AWV services were retained.

Data Synthesis:

Eight articles describing 6 unique studies representing current pharmacist-delivered AWV practices were included in the final review. All identified articles used observational study designs and were published in peer-reviewed journals from 2014 to 2017. Five studies utilized staff (in-house) pharmacists working in internal or family medicine clinics via collaborative practice agreements; one study described a model for outsourcing AWV services through a community pharmacy. Pharmacists completed 37 to 300 AWVs and performed both medication- and non-medication-related interventions, with a mean of 3.5 to 5.4 interventions/patient. Quarterly revenue ranged from $3750 to $22 340 (USD), with 40 pharmacist-hours required for initial program development.

Implications for Patient Care and Clinical Practice:

This scoping review will serve as a guide for pharmacists wishing to implement AWV services in their own practices.

Conclusions:

There is opportunity for ambulatory/community pharmacists to expand their practices to include AWV services in states that allow collaborative practice agreements. Interprofessional collaboration between physicians and pharmacists can optimize and aid adoption of pharmacist-delivered AWV services.

Pharmacists as immunizers, their pharmacies and immunization services: A survey of Ontario community pharmacists

Background

To improve patient access to the influenza vaccine in Ontario, pharmacists have been authorized to administer the vaccine since 2012. A survey was conducted to describe pharmacist immunizers, their pharmacies and immunization services.

Methods

Ontario community pharmacists completed an anonymous online survey regarding influenza immunization. Descriptive, comparative and multivariate statistics were used to analyze data on pharmacists' personal demographics, current workplace characteristics, immunization certification status and past and anticipated experience vaccinating.

Results

Of the 4307 community pharmacists contacted, 18.4% (n = 780) completed the survey. Most (81.3%, n = 603) were certified to administer vaccines, with those practising in urban pharmacies twice as likely to be certified compared to pharmacists practising in rural pharmacies (odds ratio = 2.04; 95% confidence interval, 1.04 to 4.01, p = 0.04). In the past influenza season, 70% of pharmacists had administered over 50 vaccines and 37% worked at pharmacies that had administered more than 300 vaccines. Respondent-provided profiles of immunization services described partnerships with public health, a variety of approaches for in-pharmacy and external advertising and patient vaccine access mainly through walk-in.

Discussion

Ontario community pharmacists demonstrate strong engagement with this expanded scope and there is further capacity for immunization service provision through engaging rural pharmacies, addition of other vaccines and leveraging the positive relationship with public health. Patients and the public benefit from easy access to the service and the additional in-store and external promotion of influenza vaccination that is provided by pharmacists and pharmacies.

Conclusion

These provincial benchmarking data provide direction for maintaining and expanding community pharmacist-provided influenza immunization.

Application of the Consolidated Framework for Implementation Research to community pharmacy: A framework for implementation research on pharmacy services

BACKGROUND

Community pharmacies are an increasingly important health care setting with opportunities for improving quality and safety, yet little is understood about determinants of implementation in this setting.

OBJECTIVE

This paper presents an implementation framework for pharmacy based on the Consolidated Framework for Implementation Research (CFIR).

METHODS

This study employed a critical review of 45 articles on professional services provided in community pharmacies, including medication therapy management (MTM), immunizations, and rapid HIV testing.

RESULTS

The relevant domains and associated constructs for pharmacy services were as follows. Intervention Characteristics ultimately depend on the specific service; of particular note for pharmacy are relative advantage and complexity. The former because implementation of services can pose a cost-benefit challenge where dispensing is the primary role and the latter because of the greater challenge implementing multi-faceted services like MTM compared to a discrete service like immunizations. "In terms of Outer Setting, pharmacies are affected by patient needs and acceptance, and external policies and incentives such as reimbursement and regulations. For Inner Setting, structural characteristics like pharmacy type, size and staff were important as was pharmacists' perception of their role and available resources to provide the service. Key Characteristics of Individuals include training, preparedness, and self-efficacy of the pharmacist for providing a new service. Few studies revealed relevant Process constructs, but if they did it was primarily related to engaging (e.g., champions).

CONCLUSIONS

As pharmacists' roles in health care are continuing to expand, a framework to inform implementation research in community pharmacy (and other) settings is crucially needed.

The Hidden Role of Community Pharmacy Technicians in Ensuring Patient Safety with the Use of E-Prescribing

OBJECTIVES

It has been reported that supportive personnel, such as pharmacy technicians, are key participants in the use of health information technology. The purpose of this study was to describe how pharmacy technicians use e-prescribing and to explore the characteristics of technicians that support pharmacists in ensuring patient safety.

METHODS

This was a qualitative study that used observations, interviews, and focus groups to understand the role of pharmacy technicians in e-prescribing. Fourteen pharmacy technicians and 13 pharmacists from five community pharmacies participated. Observations lasted about nine hours in each pharmacy. Follow-up interviews and two separate focus groups were later conducted. Observation field notes and audio recordings were transcribed and thematically analyzed.

RESULTS

Pharmacy technicians were primarily responsible for all steps leading up to pharmacist review of the e-prescription and dispensing of medications to the patient. Technician characteristics, including experience, certification status, and knowledge of appropriate medication use, were reported as important factors in supporting a pharmacist's role in ensuring patient safety with the use of e-prescribing.

CONCLUSION

Study findings indicate that pharmacy technicians have an important role in supporting pharmacists to prevent medication errors. Certain characteristics of pharmacy technicians were identified with the potential to improve the e-prescription medication dispensing process and decrease patient harm through the identification and resolution of errors.

Community pharmacies as sites of adult vaccination: A systematic review

Vaccine-preventable deaths among adults remain a major public health concern, despite continued efforts to increase vaccination rates in this population. Alternative approaches to immunization delivery may help address under-vaccination among adults. This systematic review assesses the feasibility, acceptability, and effectiveness of community pharmacies as sites for adult vaccination. We searched 5 electronic databases (PubMed, EMBASE, Scopus, Cochrane, LILACS) for studies published prior to June 2016 and identified 47 relevant articles. We found that pharmacy-based immunization services (PBIS) have been facilitated by state regulatory changes and training programs that allow pharmacists to directly provide vaccinations. These services are widely accepted by both patients and pharmacy staff, and are capable of improving access and increasing vaccination rates. However, political and organizational barriers limit the feasibility and effectiveness of vaccine delivery in pharmacies. These studies provide evidence to inform policy and organizational efforts that promote the efficacy and sustainability of PBIS.

The role of community pharmacy-based vaccination in the USA: current practice and future directions

Community pharmacy-based provision of immunizations in the USA has become commonplace in the last few decades, with success in increasing rates of immunizations. Community pharmacy-based vaccination services are provided by pharmacists educated in the practice of immunization delivery and provide a convenient and accessible option for receiving immunizations. The pharmacist’s role in immunization practice has been described as serving in the roles of educator, facilitator, and immunizer. With a majority of pharmacist-provided vaccinations occurring in the community pharmacy setting, there are many examples of community pharmacists serving in these immunization roles with successful outcomes. Different community pharmacies employ a number of different models and workflow practices that usually consist of a year-round in-house service staffed by their own immunizing pharmacist. Challenges that currently exist in this setting are variability in scopes of immunization practice for pharmacists across states, inconsistent reimbursement mechanisms, and barriers in technology. Many of these challenges can be alleviated by continual education; working with legislators, state boards of pharmacy, stakeholders, and payers to standardize laws; and reimbursement design. Other challenges that may need to be addressed are improvements in communication and continuity of care between community pharmacists and the patient centered medical home.

Factors influencing pharmacists' adoption of prescribing: qualitative application of the diffusion of innovations theory

Background

In 2007, Alberta became the first Canadian jurisdiction to grant pharmacists a wide range of prescribing privileges. Our objective was to understand what factors influence pharmacists’ adoption of prescribing using a model for the Diffusion of Innovations in healthcare services.

Methods

Pharmacists participated in semi-structured telephone interviews to discuss their prescribing practices and explore the facilitators and barriers to implementation. Pharmacists working in community, hospital, PCN, or other settings were selected using a mix of random and purposive sampling. Two investigators independently analyzed each transcript using an Interpretive Description approach to identify themes. Analyses were informed by a model explaining the Diffusion of Innovations in health service organizations.

Results

Thirty-eight participants were interviewed. Prescribing behaviours varied from non-adoption through to product, disease, and patient focused use of prescribing. Pharmacists’ adoption of prescribing was dependent on the innovation itself, adopter, system readiness, and communication and influence. Adopting pharmacists viewed prescribing as a legitimization of previous practice and advantageous to instrumental daily tasks. The complexity of knowledge required for prescribing increased respectively in product, disease and patient focused prescribing scenarios. Individual adopters had higher levels of self-efficacy toward prescribing skills. At a system level, pharmacists who were in practice settings that were patient focused were more likely to adopt advanced prescribing practices, over those in product-focused settings. All pharmacists stated that physician relationships impacted their prescribing behaviours and individual pharmacists’ decisions to apply for independent prescribing privileges.

Conclusions

Diffusion of Innovations theory was helpful in understanding the multifaceted nature of pharmacists’ adoption of prescribing. The characteristics of the prescribing model itself which legitimized prior practices, the model of practice in a pharmacy setting, and relationships with physicians were prominent influences on pharmacists’ prescribing behaviours.

The social network paradigm and applications in pharmacy

BACKGROUND

There have been calls for research to include contextual and macrolevel factors within explanatory models of human health. A network approach focuses on the influence of relationships to predict behavior.

OBJECTIVES

The first objective was to describe the social network paradigm based in sociology that uses network principles and methods to visualize, quantify, and predict outcomes using the structure and function of relationships. The second objective was to discuss applications of this approach in the context of health to guide future research in pharmacy.

METHODS

This was a descriptive overview of conceptual models, methods, measures, and analyses that are used in the social network paradigm.

RESULTS

The social network paradigm contains conceptual models that rely on relational and structural assumptions to make predictions related to human behavior. Although there is not 1 dominate theory of social networks, several models hold across applications and are commonly used by scholars. The methodology emphasized considerations of network boundaries, sampling strategies, and the type of data collected. Specific variables used in social network analysis were defined and dichotomized into constructs of centrality and cohesion. Network analysis was described in terms of available computational programs, data management, and statistical testing. Related research in health care was applied and ideas for pharmacy were proposed using a social network-based theoretical model.

CONCLUSIONS

There is growing momentum for health behaviorists to gain familiarity for studying the effect of social networks on behavior. Applications in pharmacy using social network models, methods, and analysis can be used as a stand-alone perspective or in conjunction with other theoretical perspectives in an effort to explain human health or organizational behavior in health care settings.

Three-year financial analysis of pharmacy services at an independent community pharmacy

OBJECTIVE

To assess the financial performance of pharmacy services including vaccinations, cholesterol screenings, medication therapy management (MTM), adherence management services, employee health fairs, and compounding services provided by an independent community pharmacy.

METHODS

Three years (2008-10) of pharmacy records were examined to determine the total revenue and costs of each service. Costs included products, materials, labor, marketing, overhead, equipment, reference materials, and fax/phone usage. Costs were allocated to each service using accepted principles (e.g., time for labor). Depending on the service, the total revenue was calculated by multiplying the frequency of the service by the revenue per patient or by adding the total revenue received. A sensitivity analysis was conducted for the adherence management services to account for average dispensing net profit.

RESULTS

7 of 11 pharmacy services showed a net profit each year. Those services include influenza and herpes zoster immunization services, MTM, two adherence management services, employee health fairs, and prescription compounding services. The services that realized a net loss included the pneumococcal immunization service, cholesterol screenings, and two adherence management services. The sensitivity analysis showed that all adherence services had a net gain when average dispensing net profit was included.

CONCLUSION

Most of the pharmacist services had an annual positive net gain. It seems likely that these services can be sustained. Further cost management, such as reducing labor costs, could improve the viability of services with net losses. However, even with greater efficiency, external factors such as competition and reimbursement challenge the sustainability of these services.

Technology-based methods of dietary assessment: recent developments and considerations for clinical practice

PURPOSE OF REVIEW

The objective of this review is to provide an overview of recent findings in technology-based methods for the collection and analysis of dietary information, and explore the potential implications of these technologies for dietary assessment in a clinical setting.

RECENT FINDINGS

Numerous technology-based methods for dietary assessment have emerged in recent years. These methodologies have the potential to enhance the dietary assessment process, and overall appear to yield valid results in a wide variety of populations. However, as is the case with the existing technologies they are designed to replace, none is error free and each has its own unique limitations. Therefore, the decision to incorporate one of these methodologies into clinical practice should only be made after a thorough evaluation of the methodology and with specific outcome goals in mind.

SUMMARY

Evidence supporting the emerging role of technology-based methods for dietary assessment is growing. As technological advances move rapidly forward it is important to consider a theoretical foundation to help guide the translation of these innovations into routine use in clinical practice.