Implementation study of an intermediate medication review in Belgian community pharmacies

Integrating design thinking and implementation science principles in delivering a medication review service in the community pharmacy setting-An implementation testing study

BACKGROUND

Medication review (MR) services are evidenced-based practices in which a systematic assessment of a patient's medication is conducted, primarily aiming to optimize drug therapy and minimize adverse drug events through pharmacist interventions. Although studies show that MR services are effective, the implementation of MR services in Malaysia has been challenging due to several barriers. An MR services blueprint was developed to be adapted to the Malaysian community pharmacy setting as part of tailoring strategies.

OBJECTIVE

Through utilizing the design thinking triple diamond model and implementation science principles, a powerful guide for healthcare researchers and stakeholders to assist with effective service implementation, this study aimed to evaluate the implementation testing and observe the effectiveness of the developed MR service blueprint.

METHOD

The study utilizes an effectiveness-implementation Type 3 hybrid implementation science framework conducted from May 2021 to April 2022. Employing a qualitative ethnographic approach, researchers observed pharmacy study sites during the implementation of MR services. Both qualitative and quantitative data were collected across exploration, preparation, testing, and operational phases. Implementation outcomes evaluated include phases, reach, fidelity, acceptability, as well as implementation barriers and strategies. MR intervention outcomes included service characteristics and the number and type of drug-related problems and interventions offered.

RESULTS

17 community pharmacists were invited to pilot the MR service blueprint for six months in their setting. Of this, 78.5% (n = 11) of the pharmacies reached the testing phase, and 36% (n = 4) reached the implementation phase. Fifty-four patients were in the study, giving an implementation reach of 70%. The majority of surveyed patients expressed satisfaction with the service. The total DRP identified was 133, and 64 interventions were provided by the pharmacists. Facilitation strategies such as "Engage stakeholders by creating ownership of the change" and "Equip stakeholders with training" are needed to overcome the barriers.

CONCLUSION

This study marked the beginning of successful MR service implementation at Malaysian community pharmacies. Future studies with multi-level partnered strategies are required to reach full implementation and sustainability.

Interpretative phenomenological analysis of the collaboration among healthcare professionals in the nursing home setting

Background

The theory of planned behavior (TPB) postulates that behavioral performance is guided by the intention to perform that behavior, influenced by attitudes, subjective norms, and perceived behavioral control. This framework can be applied to studying interprofessional collaboration among healthcare professionals to enhance patient safety and public health within nursing homes.

Objectives

This study aimed to explore the roles of physicians, pharmacists, and nurses in the interprofessional collaboration process while identifying facilitators and barriers to effective collaboration among healthcare professionals.

Methods

A qualitative interpretative phenomenological analysis (IPA) was carried out. Individual semi-structured interviews were conducted with 19 healthcare professionals. Qualitative data were then integrated and analyzed through the lens of the TPB.

Findings

The IPA revealed the ten following themes, considered as both facilitators and barriers to interprofessional collaboration among healthcare professionals in the nursing home setting: communication, roles and responsibilities, willingness and recognition of collaboration's importance, mutual knowledge, trust, confidence, support from decision-makers, protocols, and technology were considered as facilitators while distance was considered as a barrier.

Conclusion

Enhancing pharmacist-physician collaboration and refining pharmacist-nurse collaboration were essential goals. Intention for collaboration was influenced by attitudes (such as communication and mutual understanding), subjective norms (including support from decision-makers), and perceived behavioral control (such as confidence and adherence to protocols and technology). Addressing these factors could improve collaboration, enhancing residents' quality of life and professionals' sense of achievement.

General practitioners-community pharmacists pharmacotherapy discussion groups: Analysis of their implementation through a series of case studies

Background

The evolution of primary care practice has led to the implementation of pharmacotherapy discussion groups between general practitioners and community pharmacists (PPPDGs) in some countries. The aim of these groups is to improve drug prescribing practices and strengthen interprofessional relationships.

Objective

To gain more insight into factors involved in successful implementation of PPPDGs.

Methods

PPPDG implementation in three countries (Belgium, the Netherlands, Switzerland), was analyzed in a series of case studies. A grid describing different evaluation criteria was completed by stakeholders in their respective country. The data collection was followed by a literature review.

Results

Various models were used to implement PPPDGs within each country and different dynamics were encountered. PPPDGs lead to positive effects on the quality and cost-effectiveness of drug prescribing and on the collaboration between general practitioners (GPs) and community pharmacists (CPs). Factors involved in implementation were also identified, such as expectations of GPs and CPs, configuration of the implemented model, and the role of CPs in the healthcare organization.

Conclusions

This study provides insight into the factors involved in successful implementation of PPPDGs in Belgium, the Netherlands and Switzerland. The findings can be used by healthcare professionals to improve the safety, cost-effectiveness of drug prescriptions and systems in primary care. This study offers a starting point for further research in the field.

Key elements in the quality assessment of a type 3 medication review

Background: Medication reviews are a structured evaluation of a patient's pharmacotherapy with the aim of optimizing medicines use and improving health outcomes. This entails detecting drug related problems and recommending interventions. A high level of quality is essential for the successful implementation of this service in community pharmacies but currently there is no instrument or tool to assess that overall quality. Aim: This study investigated the development of quality criteria of type 3 medication reviews (MR3s). Methods: After surveying the literature, an electronic questionnaire was developed to gather information about quality criteria for MR3. This survey, in Dutch, was distributed electronically. Four groups were queried: 1) pharmacists, mainly working in the Netherlands, involved in practice research and contacted through the PRISMA (Practice Research In Collaboration With Pharmacists) foundation, 2) Belgian pharmacy academics and pharmacists active in professional associations (APA), 3) Belgian pharmacists trained in medication review (MR) by the Royal Pharmacists Association of Antwerp (KAVA) and 4) Belgian pharmacy students. The survey included 57 criteria, divided into eight domains, which were ranked according to their importance by the participants. The results were analyzed statistically using the nonparametric Kruskal-Wallis test. Results: The survey was completed by 95 participants, including 42 PRISMA pharmacists, 19 APA pharmacists, 18 KAVA pharmacists and 16 pharmacy students. Opinions from participants from the different groups overlapped significantly. The use of simple and understandable language in the conversation with the patient was considered essential by the majority. Discussing the usefulness and purpose of a MR3 with the patient was also rated highly by all groups. Differences of opinion were present in aspects about laboratory values, the use of specific tools, and reporting to and consultation with the treating physician. The participants themselves formulated a limited number of additional assessment criteria. Conclusion: There was widespread agreement on the hierarchy of the quality assessment criteria for MR3s. Minor differences were related to the experience of the participants. With these results and a small number of suggested extra criteria, a quality assessment instrument for MR3 can be created.

Community pharmacists' perceptions on multidisciplinary heart failure care: an exploratory qualitative study

BACKGROUND

Heart failure (HF) is an important health problem and guidelines recommend multidisciplinary management. The pharmacist is an important member of the multidisciplinary heart failure team, both in the hospital and community setting. This study aims to explore the perceptions of community pharmacists on their role in HF care.

METHODS

We conducted a qualitative study based on face-to-face semi-structured interviews with 13 Belgian community pharmacists between September 2020 and December 2020. We used the Qualitative Analysis Guide of Leuven (QUAGOL) method as guidance for data analysis until data saturation was reached. We structured interview content into a thematic matrix.

RESULTS

We identified two major themes: heart failure management and multidisciplinary management. Pharmacists feel responsible for the pharmacological and non-pharmacological management of heart failure, citing easy access and pharmacological expertise as important assets. Diagnostic uncertainty, lack of knowledge and time, disease complexity and difficulties in communication with patients and informal care providers are barriers to optimal management. General practitioners are the most important partners in multidisciplinary community heart failure management, although pharmacists perceive a lack of appreciation and cooperation and deplore communication difficulties. They feel intrinsically motivated to provide extended pharmaceutical care in HF but cite the lack of financial viability and information sharing structures as important barriers.

CONCLUSION

The importance of pharmacist involvement in multidisciplinary heart failure teams is undisputed by Belgian pharmacists, who cite easy access and pharmacological expertise as important assets. They point out several barriers impeding evidence-based pharmacist care for outpatients with heart failure: diagnostic uncertainty and disease complexity, lack of multidisciplinary information technology and insufficient resources. We recommend that future policy should focus on improved medical data exchanges between primary and secondary care electronic health records as well as the reinforcement of interprofessional relationships between locally affiliated pharmacists and general practitioners.

Just a 'romantic idea'? A theory-based interview study on medication review implementation with pharmacy owners

BACKGROUND

Recent legal changes in Germany entitle patients on multiple medications to receive a medication review (MR). However, the provision of MRs is not mandatory and pharmacy owners decide whether to implement this service in their pharmacies.

AIM

To determine pharmacy owners' attitudes towards MRs, explore their experiences with MR implementation and examine their perceptions of barriers and facilitators towards implementation of MRs in community pharmacies.

METHOD

Pharmacy owners were invited to participate in semi-structured interviews. Purposive sampling was used with selection criteria being MR-implementation stage, and geographical location of the pharmacy. The topic guide was based on a systematic review and the Framework for Implementation of Services in Pharmacy (FISpH). Interviews were recorded, transcribed verbatim and coded directly against the FISpH.

RESULTS

Twenty-one pharmacy owners were interviewed. Despite participants' consistent positive attitude towards MRs, most believed that providing MRs on an economically viable basis would be challenging. Several practical suggestions emerged which would enable community pharmacies a smoother implementation of MRs. Suggestions included employing 'change facilitators', who visit and support implementing pharmacies; national awareness campaigns targeting patients and health professionals; reducing bureaucracy; continuing professional development; involving technicians in some MR-tasks; and offering an additional incentive to lower the initial implementation threshold.

CONCLUSION

This research identified numerous factors that are likely to increase owners' and managers' support to the idea of MRs. This may be of interest to any country planning implementation of MRs.

Perspectives of pharmacists on medication reviews- Exploring implementation research in service establishment in community settings

BACKGROUND

Pharmacists' roles have been evolving to include more patient-centered care services such as medication reviews that help patients receive the most benefits from their medication. In Malaysia, medication review is yet to be widely implemented in the community pharmacy setting for several reasons, including the non-dispensing separation healthcare system. To establish and implement a feasible medication review service model in Malaysia, it is important to gather community pharmacists' perspectives on such services.

AIM

To explore community pharmacists' perceptions of barriers, facilitators, and strategies for the implementation of a medication review service in Malaysia.

METHODS

A focus group discussion followed by semi-structured interviews were conducted among purposively sampled community pharmacists with an interest in medication review service. A framework analysis approach using the consolidated framework for implementation research (CFIR) was utilized to generate and analyze the data. After data mapping, the CFIR-ERIC (expert recommendations for implementing change) matching tool was used to generate the strategies according to the barriers identified.

RESULTS

Twenty community pharmacists participated in this study. Several barriers and facilitators to service implementation were identified based on the respondent's input. The CFIR-ERIC strategies matching tool analysis reported potential plans that can mitigate the barriers such as: identify and prepare champions, conduct local consensus discussions, conduct educational meetings, alter incentive/allowance structures, and develop a formal implementation blueprint.

CONCLUSION

Multifaceted strategies are required to ensure the successful implementation of medication review services in Malaysia. The findings of this study will assist in the development of a sustainable medication review service blueprint for the Malaysian community pharmacy setting.

Barriers to Medication Review Process Implementation—Cross-Sectional Study among Community Pharmacists in Jordan

The medication review process (MRP) is an extended, vital role of community pharmacists in improving health outcomes of medication use, yet it is neither systematically nor comprehensively provided bycommunity pharmacies in Jordan. This study aimed to identify the potential barriers hinderingMRP implementation bycommunity pharmacists in Jordan. A total of 550 community pharmacists electronically received a previously constructed and validated Arabic questionnaire explicitly developed to assess the current medication review practices and factors hindering the MRP, of whom 417 answered the questionnaire, giving a response rate of 75.8%. Among the investigated six categories’ seventeen barriers tothe implementation of the MRP, the highest rating was found for remuneration barriers (55.8%), followed by barriers related to regulations and patients, which scored 52.3% and 48.8%, respectively. Resource-related barriers were recognizedby 44.6% of participants, while qualifications and barriers related to physicians scored 42.9% and 41.8%, respectively. Although community pharmacists in Jordan are eager to extend their roles from traditional to more patient-centered ones, they encounter various barriers hinderingsuch development. Regulation adjustments accompanied by cost-effective remuneration and proper training are strong facilitators for community pharmacists to initiate the medication review service; make available the needed resources; and invest efforts, time, and money to operate it.

Does a pharmacist-led medication use review improve medication adherence in polymedicated aged patients? Methodological choices matter!

RATIONALE, AIMS AND OBJECTIVES

The rise in chronic diseases urges for an identification of interventions that improve adherence. However, no golden standard exists for evaluating adherence in polymedicated patients. The objectives were to investigate the impact of a pharmacist-led medication use review (MUR) service on adherence implementation rates for chronic medication, and to evaluate the appropriateness of two adherence calculation approaches in this regard.

METHOD

Before-after study (SIMENON study) including ambulatory, aged, polymedicated patients. Refill data were used to calculate the proportion of days covered (PDC) per medication before and after the MUR. Adherence was assessed for chronic, solid, oral medication using a prescription-based and interval-based approach, and the performance of both approaches was compared.

RESULTS

Adherence was evaluated for 1483 medications from 316 patients. The median baseline PDC per medication was 0.95 (prescription-based method) and 0.91 (interval-based approach). Pearson correlation between both approaches was 0.616 (P < .0001). The prescription-based approach found less medication below the adherence threshold of 0.80 (319 medications; 21.5% vs 481 medications; 32.4%). Using the prescription-based approach, the proportion of non-adherent patients at baseline was 61.7% (195/316 patients), of which 54.9% (107/195 patients) was only non-adherent for one medication. Median PDC scores increased significantly from 0.95 to 0.99 and 0.91 to 0.99 with the prescription-based and interval-based approach respectively (both P < .0001). Only considering the 319 medications with baseline PDC scores <0.8 using the prescription-based approach, the median PDC scores significantly increased from 0.67 to 0.84 (P < .0001), with a median score improvement of 18.3%.

CONCLUSIONS

Although baseline adherence was high in this population of polymedicated aged patients, both calculation methods showed the MUR significantly improved adherence. The prescription-based approach was considered the most appropriate method. Based on these findings and literature evidence, it is recommended to implement the MUR service in Belgium and target non-adherent patients for maximal effect.

Implementation of pharmaceutical services in Brazilian primary health care: a cross-sectional study

BACKGROUND

In the Brazilian public health system, primary health care (PHC) is provided by the municipalities and is considered the entry level of the Unified Health System (SUS). Governmental pharmaceutical services (PharmSes) are part of the SUS, including PHC, and are the most significant way in which patients access medicine and services. Considering the diversity of the country, the municipalities have the autonomy to decide how PharmSes are implemented. Even though policies and procedures should be implemented as expected by policy makers and experts, municipality characteristics may interfere with implementation fidelity. Therefore, this study evaluated the degree to which the PharmSes in PHC were delivered as intended in Brazilian municipalities.

METHODS

We analysed data from a secondary database originating from a cross-sectional nationwide study carried out by the Ministry of Health and the World Bank from 2013 to 2015. Data on 465 municipalities and the Federal District were collected from 4939 governmental PharmSes. A rating system comprising 43 indicators was developed and applied to the dataset to obtain the implementation degree (ID) of each PharmSe. Additionally, the IDs of the two PharmSes dimensions and the nine components were measured.

RESULTS

Overall, the ID of the PharmSes in Brazilian PHC was evaluated as critical. The ID was critical in 81% of the municipalities (n = 369), incipient in 14% (n = 65) and unsatisfactory in 4.8% (n = 22). Regarding the PharmSes dimensions, the 'medicine management' (MM) ID was considered critical (Mean = 46%), while the 'care management' (CM) ID was incipient (Mean = 22%). In terms of the PharmSes components, the highest ID was achieved by 'forecasting' (58%). In contrast, 'continuing education and counselling' showed the lowest figure (ID = 11%) in the whole sample, followed by 'information and communication' and 'teamwork'.

CONCLUSIONS

The degree to which PharmSes were implemented was critical (ID< 50%). This analysis demonstrated that PharmSes were implemented with low fidelity, which may be related to the low availability of medicine in PHC. Although the care management component requires more attention, considering their incipient ID, all components must be reviewed. Municipalities must increase their investment in PharmSes implementation in order to maximize the benefits of these services and guarantee the essential right of access to medicine.

Experiences of key stakeholders with the implementation of medication reviews in community pharmacies: A systematic review using the Consolidated Framework for Implementation Research (CFIR)

BACKGROUND

Though medication reviews have shown positive patient outcomes, they are still not widely implemented in community pharmacies. Published reviews on their implementation often include several other pharmacy services, making them non-specific. Using the Consolidated Framework for Implementation Research (CFIR) to focus solely on the experiences of different stakeholders with the implementation of medication reviews will help to better understand relevant facilitators and barriers.

OBJECTIVES

To critically appraise, synthesise and present the available evidence on experiences of key stakeholders with the implementation of medication reviews and to identify barriers and facilitators to its implementation in community pharmacies.

METHODS

A systematic literature search was conducted in four databases for studies published in English, Spanish or German. Key search terms included: implementation, pharmac*, medication review, facilitator, barrier. Study selection, quality assessment and data extraction were performed by two independent reviewers. Findings were mapped directly against the constructs of the CFIR.

RESULTS

Out of 924 retrieved records 24 articles from 9 countries met the inclusion criteria. Key facilitators identified included pharmacists' openness to practice change and a high degree of patient satisfaction post medication review. Attracting patients to the service was stated as challenging due to an unawareness of the scope and potential benefit of a medication review. The dominant barrier was inadequate remuneration, as it impacted all additional resourcing and ultimately the viability of the service. Further barriers included difficult professional relationships with doctors and little mandate from health authorities. Most reports were from the employed pharmacists' perspective and concerned the inner setting, other perspectives were under-reported.

CONCLUSIONS

Results of this systematic review illustrate different stakeholders' experiences and add to the understanding of challenges in the implementation process. Nevertheless, findings also highlight how scarce reporting of external stakeholders' views is and that filling this gap can unveil hidden barriers and facilitators.

REGISTRATION

PROSPERO register (CRD 42019122836).

Implementation evaluation of an interprofessional programme (Siscare) for supporting patients with type 2 diabetes in a Swiss primary care setting

BACKGROUND

In 2016, the Swiss government decided to back the implementation of an interprofessional patient support programme to redefine and extent the pharmacist's role in primary care. The programme, called Siscare, includes regular motivational interviews by pharmacists; medication adherence, patient-reported, and clinical outcomes monitoring; and pharmacist-physician interactions.

OBJECTIVE

To assess, from a pharmacy team's perspective, the implementation of Siscare for patients with type 2 diabetes taking at least one oral antidiabetic treatment, followed for 15 months, in a primary care setting of the French-speaking part of Switzerland.

METHODS

This prospective, multicentre, observational, cohort study used a hybrid implementation-effectiveness design and the Framework for the Implementation of Services in Pharmacy (FISpH). Quantitative and qualitative methods assessed outcomes at three levels (process, outcomes and impact) at each stage of the implementation process (exploration, preparation, operation, sustainability).

RESULTS

An advisory board with 10 representatives of key national stakeholders committed to supporting the study and 41 pharmacies were trained for Siscare. Of these, 33 (80%) had at least one of five implementation strategies in place 12 weeks after the start of patient inclusion and 27 (66%) have included ≥1 patient; mean inclusion per pharmacy: 8 (SD 6) patients [range: 1-29] with a total of 212 patients. Nine pharmacies (22%) met the target of 10 patients. An ordered three-step process of the implementation was observed in pharmacies: internal organisation, preparation of interprofessional practice, and relationship building with patients. Influencing factors were pharmacists' skills in motivational interviewing, support from pharmacy owners, pre-existing local interprofessional networks, and profitability of the programme.

CONCLUSIONS

This implementation evaluation supports the feasibility and acceptability from the pharmacy team's perspective of Siscare. The programme's implementation on a wider scale is still difficult due to the inertia inherent in any fundamental change in practices and the economic-political uncertainties influencing the actors in primary care.

Qualitative study of medication review in Flanders, Belgium among community pharmacists and general practitioners

Objective Examining the implementation barriers and facilitators of this service as provided by Belgian community pharmacists in collaboration with general practitioners. Setting Community pharmacies in Flanders. Method Qualitative study through interviews of pharmacists and general practitioners. Main outcome measure Opinions and experiences of pharmacists and general practitioners about type 3 medication review. Results Sixteen community pharmacists and thirteen general practitioners were interviewed and generally gave a positive assessment of the project. The general practitioners saw the pharmaceutical and pharmacotherapeutic recommendations of the pharmacists as an added value for the patients. The pharmacists indicated that performing an medication review was time-consuming, but that it improved their professional relationship with general practitioners and patients. They reported obstacles in obtaining information: cumbersome access to individual patient data (laboratory values) and difficulties in finding and choosing adequate medical information sources. Moreover, pharmacists indicated that there is a need for adequate reimbursement and additional training to make the implementation sustainable. Conclusion Both pharmacists and general practitioners were enthusiastic about medication reviews. The implementation improved the interprofessional collaboration. However, important barriers remain, such as the considerable investment of time and the difficulty in gathering all the necessary information. The sustainable implementation of type 3 medication review in Belgium requires adequate reimbursement and additional training.

Medical staff perspective on factors influencing their prescribing decisions: a cross-sectional study in Mekong Delta, Vietnam

Objectives

Understanding medical staff’s prescription behaviors helps improve the quality of prescriptions and the rationality of medication use. Although factors affecting the prescribing decisions were discussed in various studies worldwide, limited knowledge of these issues has been reported in Vietnam. This paper aims to examine factors that influence prescribing behavior concerning medical staff’s demographics and characteristic differences.

Methods

Quantitative descriptive cross-sectional study, using adapted questionnaire consisting of 27 factors divided into 9 factor categories, was conducted with medical staff in Mekong Delta during June–July, 2019. Rasch analysis was performed to assess the questionnaire psychometric properties. Descriptive analysis, parametric tests and non-parametric tests were utilized to address the study objectives.

Key findings

A total of 201 participants completed the questionnaire. A majority of participants (&gt;90%) agreed that their own decision to prescribe a drug was influenced by several factors such as drug safety and efficacy (92.5%), patient history (92.0%), patient income (92.0%) and patient disease status (91.0%). There were significant age differences in influences on prescribing decision. Medical staff aged under 30 appreciated the role of pharmacists higher than whose aged 31–40 (P-value = 0.010) and over 40 (P-value = 0.013). Additionally, they were more concerned with ‘patient characteristics’ including patient request, expectations, and disease status when making prescribing decisions compared with whose aged over 40 (P-value = 0.005).

Conclusions

The study revealed various factors influencing medical staff prescription decision-making processes. These findings could be useful for pharmaceutical companies in Vietnam in developing marketing strategies, and for policy-makers in timely improvement of prescription quality.