Patients' perceived benefit from and satisfaction with asthma-related pharmacy services

Cancer genetic counseling for childhood cancer predisposition is associated with improved levels of knowledge and high satisfaction in parents

Previous surveys of adults with cancer have revealed increased levels of genetic knowledge, varying levels of worry, and high satisfaction with cancer genetic counseling. We sought to determine the impact of cancer genetic counseling on parental levels of genetic knowledge, worry about cancer, and satisfaction in the context of suspected cancer predisposition in a child. We hypothesized that parents would be satisfied with cancer genetic counseling and that cancer genetic counseling would improve baseline parental genetic knowledge and decrease levels of worry. Parents were recruited from a pediatric cancer predisposition clinic in the United States. A survey was administered to two cohorts: One cohort had received cancer genetic counseling in the past and only completed one survey (post-only, n = 26), and another cohort completed the survey before and after cancer genetic counseling (pre/post, n = 23). The survey included questions on demographics, knowledge of genetics, worry levels, and satisfaction with the cancer genetic counseling service. The post-genetic counseling survey also contained a free-text section for parents to indicate what they took away from the sessions. Parental levels of genetics knowledge increased by an average of 1.9 points (p = .01), with 65.2% of parents demonstrating an increase in genetics knowledge score. Average worry levels did not change significantly (p = .37), with 52.2% of parents indicating decreased worry, and 34.8% indicating increased worry. Overall, 91.8% of parents reported high levels of satisfaction. Our results show that cancer genetic counseling in a pediatric cancer predisposition clinic improves parental levels of genetics knowledge. Satisfaction rates suggest that parents find this service beneficial. These results demonstrate the positive impacts of cancer genetic counseling on parents of children in which a hereditary cancer syndrome is known or suspected.

Community pharmacy interventions for health promotion: effects on professional practice and health outcomes

BACKGROUND

Community pharmacies are an easily accessible and cost-effective platform for delivering health care worldwide, and the range of services provided has undergone rapid expansion in recent years. Thus, in addition to dispensing medication, pharmacy workers within community pharmacies now give advice on a range of health-promoting behaviours that aim to improve health and to optimise the management of long-term conditions. However, it remains uncertain whether these health-promotion interventions can change the professional practice of pharmacy workers, improve health behaviours and outcomes for pharmacy users and have the potential to address health inequalities.

OBJECTIVES

To assess the effectiveness and safety of health-promotion interventions to change community pharmacy workers' professional practice and improve outcomes for users of community pharmacies.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, six other databases and two trials registers to 6 February 2018. We also conducted reference checking, citation searches and contacted study authors to identify any additional studies.

SELECTION CRITERIA

We included randomised trials of health-promotion interventions in community pharmacies targeted at, or delivered by, pharmacy workers that aimed to improve the health-related behaviour of people attending the pharmacy compared to no treatment, or usual treatment received in the community pharmacy. We excluded interventions where there was no interaction between pharmacy workers and pharmacy users, and those that focused on medication use only.

DATA COLLECTION AND ANALYSIS

We used standard procedures recommended by Cochrane and the Effective Practice and Organisation of Care review group for both data collection and analysis. We compared intervention to no intervention or to usual treatment using standardised mean differences (SMD) and 95% confidence intervals (95% CI) (higher scores represent better outcomes for pharmacy user health-related behaviour and quality of life, and lower scores represent better outcomes for clinical outcomes, costs and adverse events). Interpretation of effect sizes (SMD) was in line with Cochrane recommendations.

MAIN RESULTS

We included 57 randomised trials with 16,220 participants, described in 83 reports. Forty-nine studies were conducted in high-income countries, and eight in middle-income countries. We found no studies that had been conducted in low-income countries. Most interventions were educational, or incorporated skills training. Interventions were directed at pharmacy workers (n = 8), pharmacy users (n = 13), or both (n = 36). The clinical areas most frequently studied were diabetes, hypertension, asthma, and modification of cardiovascular risk. Duration of follow-up of interventions was often unclear. Only five studies gave details about the theoretical basis for the intervention, and studies did not provide sufficient data to comment on health inequalities. The most common sources of bias were lack of protection against contamination - mainly in individually randomised studies - and inadequate blinding of participants. The certainty of the evidence for all outcomes was moderate. We downgraded the certainty because of the heterogeneity across studies and evidence of potential publication bias. Professional practice outcomes We conducted a narrative analysis for pharmacy worker behaviour due to high heterogeneity in the results. Health-promotion interventions probably improve pharmacy workers' behaviour (2944 participants; 9 studies; moderate-certainty evidence) when compared to no intervention. These studies typically assessed behaviour using a simulated patient (mystery shopper) methodology. Pharmacy user outcomes Health-promotion interventions probably lead to a slight improvement in health-related behaviours of pharmacy users when compared to usual treatment (SMD 0.43, 95% CI 0.14 to 0.72; I² = 89%; 10 trials; 2138 participants; moderate-certainty evidence). These interventions probably also lead to a slight improvement in intermediate clinical outcomes, such as levels of cholesterol or glycated haemoglobin, for pharmacy users (SMD -0.43, 95% CI -0.65 to -0.21; I² = 90%; 20 trials; 3971 participants; moderate-certainty evidence). We identified no studies that evaluated the impact of health-promotion interventions on event-based clinical outcomes, such as stroke or myocardial infarction, or the psychological well-being of pharmacy users. Health-promotion interventions probably lead to a slight improvement in quality of life for pharmacy users (SMD 0.29, 95% CI 0.08 to 0.50; I²= 82%; 10 trials, 2687 participants; moderate-certainty evidence). Adverse events No studies reported adverse events for either pharmacy workers or pharmacy users. Costs We found that health-promotion interventions are likely to be cost-effective, based on moderate-certainty evidence from five of seven studies that reported an economic evaluation.

AUTHORS' CONCLUSIONS

Health-promotion interventions in the community pharmacy context probably improve pharmacy workers' behaviour and probably have a slight beneficial effect on health-related behaviour, intermediate clinical outcomes, and quality of life for pharmacy users. Such interventions are likely to be cost-effective and the effects are seen across a range of clinical conditions and health-related behaviours. Nevertheless the magnitude of the effects varies between conditions, and more effective interventions might be developed if greater consideration were given to the theoretical basis of the intervention and mechanisms for effecting behaviour change.

Patient Satisfaction With a Comprehensive Medication Review Provided by a Community Pharmacist

Background: The comprehensive medication review (CMR) is one of the most commonly delivered medication therapy management services, and it is a required service to be provided to Medicare Part D beneficiaries. Despite the large body of evidence available on medication therapy management benefits, and the growing value placed on it by payers, there has been little research assessing patient satisfaction with these services. Objectives: The primary objective of this study was to determine patient satisfaction with a face-to-face or telephonic CMR provided by a chain community pharmacist. The study secondarily assessed patients' perceived value of the service while also collecting demographic information. Methods: A Likert-type satisfaction survey was distributed to patients on completion of a face-to-face or telephonic CMR in either Outcomes or Mirixa by members of a clinical team (7 clinical pharmacists and 4 residents) within a chain community pharmacy. Participants were asked to return the survey in a self-addressed stamped envelope within 1 week of the CMR. Results: The response rate for the survey was 33% (31 of 95 surveys returned). The study found that approximately 70% (21 of 31) strongly agreed with being overall satisfied with the CMR. Conclusion: This research study provided insight to patients' perceptions of a CMR provided by a community pharmacist. Patient views of the CMR were positive, with patients finding CMR delivery in a community pharmacy valuable. Further investigation of specific interventions and approaches during a medication review could help identify ways to increase patient satisfaction.

What works for whom in pharmacist-led smoking cessation support: realist review

BACKGROUND

New models of primary care are needed to address funding and staffing pressures. We addressed the research question "what works for whom in what circumstances in relation to the role of community pharmacies in providing lifestyle interventions to support smoking cessation?"

METHODS

This is a realist review conducted according to RAMESES standards. We began with a sample of 103 papers included in a quantitative review of community pharmacy intervention trials identified through systematic searching of seven databases. We supplemented this with additional papers: studies that had been excluded from the quantitative review but which provided rigorous and relevant additional data for realist theorising; citation chaining (pursuing reference lists and Google Scholar forward tracking of key papers); the 'search similar citations' function on PubMed. After mapping what research questions had been addressed by these studies and how, we undertook a realist analysis to identify and refine candidate theories about context-mechanism-outcome configurations.

RESULTS

Our final sample consisted of 66 papers describing 74 studies (12 systematic reviews, 6 narrative reviews, 18 RCTs, 1 process detail of a RCT, 1 cost-effectiveness study, 12 evaluations of training, 10 surveys, 8 qualitative studies, 2 case studies, 2 business models, 1 development of complex intervention). Most studies had been undertaken in the field of pharmacy practice (pharmacists studying what pharmacists do) and demonstrated the success of pharmacist training in improving confidence, knowledge and (in many but not all studies) patient outcomes. Whilst a few empirical studies had applied psychological theories to account for behaviour change in pharmacists or people attempting to quit, we found no studies that had either developed or tested specific theoretical models to explore how pharmacists' behaviour may be affected by organisational context. Because of the nature of the empirical data, only a provisional realist analysis was possible, consisting of five mechanisms (pharmacist identity, pharmacist capability, pharmacist motivation and clinician confidence and public trust). We offer hypotheses about how these mechanisms might play out differently in different contexts to account for the success, failure or partial success of pharmacy-based smoking cessation efforts.

CONCLUSION

Smoking cessation support from community pharmacists and their staff has been extensively studied, but few policy-relevant conclusions are possible. We recommend that further research should avoid duplicating existing literature on individual behaviour change; seek to study the organisational and system context and how this may shape, enable and constrain pharmacists' extended role; and develop and test theory.

Developing a patient satisfaction questionnaire for services provided in Iranian community pharmacies

Objective:

To develop a valid and reliable instrument in the Persian language for evaluating patient satisfaction with services provided in community pharmacies.

Methods:

We selected a valid and reliable instrument from the literature and translated it to the Persian language. Some new items were added to the first draft based on the special characteristics of the Iranian health system. Then, the feasibility of utilizing the new instrument was assessed. In the third step, we conducted a formal content validity study to calculate content validity indices. Having completed the content validity study, the factorial structure of new instruments was determined by implementing a factorial analysis. Finally, the reliability of the instrument was assessed by assessment of Cronbach's alpha coefficient and test-retest reliability.

Findings:

The developed instrument demonstrated suitable validity and reliability. The final instrument showed desirable content validity, with inter-rater agreement of 94% and 97% for relevance and clarity, respectively. Scale content validity indices for relevance and clarity were calculated as 96% and 92%, respectively, and comprehensiveness was calculated as 100%. Factor analysis resulted in seven factors with a cumulative variance of 62.14%. In internal consistency reliability, Cronbach's alpha for the whole instrument was 0.912. About test-retest reliability, six items showed almost perfect agreement, 18 items showed substantial agreement, and three items showed moderate agreement. Therefore, test-retest reliability assessment too demonstrated appropriate results.

Conclusion:

The instrument demonstrated excellent validity and reliability for application in Iran. This instrument is useful for evaluating patient satisfaction with services provided in community pharmacies in the Persian-speaking communities.

Effectiveness of implementation strategies for clinical guidelines to community pharmacy: a systematic review

Background

The clinical role of community pharmacists is expanding, as is the use of clinical guidelines in this setting. However, it is unclear which strategies are successful in implementing clinical guidelines and what outcomes can be achieved. The aim of this systematic review is to synthesise the literature on the implementation of clinical guidelines to community pharmacy. The objectives are to describe the implementation strategies used, describe the resulting outcomes and to assess the effectiveness of the strategies.

Methods

A systematic search was performed in six electronic databases (Medline, EMBASE, CINAHL, Web of Science, Informit, Cochrane Library) for relevant articles. Studies were included if they reported on clinical guidelines implementation strategies in the community pharmacy setting. Two researchers completed the full-search strategy, data abstraction and quality assessments, independently. A third researcher acted as a moderator. Quality assessments were completed with three validated tools. A narrative synthesis was performed to analyse results.

Results

A total of 1937 articles were retrieved and the titles and abstracts were screened. Full-text screening was completed for 36 articles resulting in 19 articles (reporting on 22 studies) included for review. Implementation strategies were categorised according to a modified version of the EPOC taxonomy. Educational interventions were the most commonly utilised strategy (n = 20), and computerised decision support systems demonstrated the greatest effect (n = 4). Most studies were multifaceted and used more than one implementation strategy (n = 18). Overall outcomes were moderately positive (n = 17) but focused on process (n = 22) rather than patient (n = 3) or economic outcomes (n = 3). Most studies (n = 20) were rated as being of low methodological quality and having low or very low quality of evidence for outcomes.

Conclusions

Studies in this review did not generally have a well thought-out rationale for the choice of implementation strategy. Most utilised educational strategies, but the greatest effect on outcomes was demonstrated using computerised clinical decision support systems. Poor methodology, in the majority of the research, provided insufficient evidence to be conclusive about the best implementation strategies or the benefit of clinical guidelines in this setting. However, the generally positive outcomes across studies and strategies indicate that implementing clinical guidelines to community pharmacy might be beneficial. Improved methodological rigour in future research is required to strengthen the evidence for this hypothesis.

Protocol registration

PROSPERO 2012:CRD42012003019.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0337-7) contains supplementary material, which is available to authorized users.

Patient reactions to community pharmacies' roles: evidence from the Portuguese market

BACKGROUND

There is little knowledge about how patients perceive and react to the extended role of community pharmacies.

AIM

To develop a model describing the expanded role of Portuguese community pharmacies as comprising three roles - medicines supplier, advice provider and community health promoter - and two important patient reactions: satisfaction and loyalty.

DESIGN

In 2010, 1200 face-to-face interviews were conducted with patients of community pharmacies in Portugal. A model comprising the three pharmacy roles and the two patient reactions was developed and tested using structural equation modelling.

RESULTS

The results showed that the model was appropriate and that the roles of medicines supplier, advice provider and community health promoter were positively related to patients' satisfaction and loyalty.

CONCLUSIONS

These results show that patients are aware of the different roles played by community pharmacies in Portugal. The data support the idea that the movement of Portuguese pharmacists' extended role, framed within a global context where society sends expectations regarding the role of organizations in the community in which they operate, is producing positive results for both patients and pharmacists.

Intervention research to enhance community pharmacists' cognitive services: a systematic review

BACKGROUND

Positive impact of community pharmacists' cognitive pharmaceutical services (CPS) is well documented. However, community pharmacists have been slow to expand CPS roles. This systematic review explores how community pharmacy intervention research can help inform efforts to expand cognitive pharmaceutical service delivery.

OBJECTIVES

To: 1) identify community pharmacy CPS intervention studies that report data on pharmacist behaviors, either as a final study outcome itself or as a fidelity measure in patient outcome studies, and 2) describe the state of this research to help frame future research agendas.

METHODS

Empirical articles examining improvement or expansion of community pharmacist cognitive services published through December 2010 were searched using various search engines, bibliography searches and authors' libraries. Studies were included if they: 1) reported findings on pharmacist behaviors during cognitive service delivery, 2) employed a minimum of pre-post design or two study arms for pharmacists/pharmacies, and 3) were in community-based pharmacies.

RESULTS

A total of 50 studies evaluated impact of community pharmacy based CPS delivery; however, only 21 included a pharmacist behavior outcome measure as a final outcome or as a fidelity measure. The majority (14 out of 21) of studies used a randomized controlled trial design. Nearly half (10 of 21) addressed asthma or tobacco cessation. Limited details were provided about interventions to prepare pharmacists for CPS delivery. The most frequent measures of pharmacist behavior were patient surveys and observation of pharmacists' behavior by secret shoppers; electronic data sets were rarely used.

CONCLUSIONS

There is a need for well-designed intervention research that evaluates how interventions impact on pharmacist cognitive service behavior. Positive findings from this review reinforce that planned interventions have the potential to improve and expand pharmacist cognitive service delivery; however, more detail is needed in study publications for this potential to be fully realized.

The effect of community pharmacy-based interventions on patient health outcomes: a systematic review

Many studies have demonstrated the beneficial effects that pharmacist-provided patient care services can have on patient health outcomes. However, the effectiveness of patient care services delivered by pharmacists in community pharmacy settings, where organizational barriers may affect service implementation or limit effectiveness, remains unclear. The authors systematically reviewed the literature on the effectiveness of pharmacist-delivered patient care services in community pharmacy settings in the United States. Of the 749 articles retrieved, 21 were eligible for inclusion in the review. Information concerning 134 outcomes was extracted from the included articles. Of these, 50 (37.3%) demonstrated statistically significant, beneficial intervention effects. The percentage of studies reporting favorable findings ranged from 50% for blood pressure to 0% for lipids, safety outcomes, and quality of life. Our findings suggest that evidence supporting the effectiveness of pharmacist-provided direct patient care services delivered in the community pharmacy setting is more limited than in other settings.

Factors affecting pharmacists' pediatric asthma counseling

OBJECTIVE

To explore various factors that may influence community pharmacists' pediatric asthma counseling.

DESIGN

Cross-sectional.

SETTING

Maryland from September 2002 through March 2003.

PARTICIPANTS

Random sample of 400 community pharmacists.

INTERVENTION

Mail survey.

MAIN OUTCOME MEASURES

Pharmacists' attitude, subjective norm, perceived behavioral control, intention to provide pediatric asthma counseling, and reported counseling using the theory of planned behavior as a framework; demographic and pharmacy characteristics.

RESULTS

98 of 389 (25%) eligible pharmacists responded. Most acknowledged the importance of providing asthma counseling to children (54%) or caregivers (68%). However, only a small number reported demonstrating to children or caregivers or asking them to demonstrate how to use antiasthmatic medications. Multivariate logistic regressions revealed that intention to counsel was a significant predictor of providing counseling for children or caregivers (odds ratio [OR], 3.95 and 3.09, respectively). Intention to counsel children was significantly associated with subjective norm (OR, 1.88) and perceived ease of counseling (OR, 1.48); intention to counsel caregivers was significantly associated with perceived ease (OR, 1.45). Pharmacists also reported the following barriers that made counseling difficult: lack of time, lack of parent's interest, and lack of placebo devices useful for demonstration of inhalation technique.

CONCLUSION

Despite a positive attitude toward providing asthma counseling, the majority of pharmacists reported not fully engaging in counseling. A number of barriers to counseling were reported that, if targeted, could improve the management of pediatric asthma through pharmacist-initiated counseling.

Patient evaluation of a community pharmacy medications management service

BACKGROUND

A patient-centered approach is increasingly recognized as an important component in the evaluation of healthcare services.

OBJECTIVE

To assess patient satisfaction with, attitudes toward, and expectations of or experience with community pharmacy in general, and to evaluate the effect of the community pharmacy-led medications management service on these factors.

METHODS

Postal questionnaire surveys were completed at baseline and after 12 months (follow-up) as part of a randomized controlled trial of the service. The setting was 9 primary care organizations in England. Patients with coronary heart disease were recruited from general practice registers and randomly allocated to the intervention (pharmacy-led medications management service) or control group.

RESULTS

Survey response rates at baseline and follow-up were 88.4% (1232/1394) and 80.1% (1085/1355), respectively. The respondents indicated that they wanted pharmacists to provide dispensing, medications review, advice on medications and health, private consultation areas, and short visit times. At follow-up, intervention patients were more likely than control patients (p < 0.01) to rate the service provided by their pharmacist with a higher level of satisfaction, and most intervention patients stated a preference for seeing their physician to discuss their medications, although this was less marked than in control patients (76% vs 85%; p < 0.01). Intervention patients were also more willing than control patients to ask the pharmacist questions that they would be unable to ask a physician (20% vs 11%, respectively; p < 0.01), to ask the pharmacist questions about their medications (32% vs 18%, respectively; p < 0.01), and to recommend this practice to others (51% vs 40%, respectively; p < 0.01).

CONCLUSIONS

Pharmacist intervention was associated with significant and positive changes in patient satisfaction. While patients probably continue to prefer a physician-led service, they value aspects of a pharmacy service. Patients generally preferred discussing medications with the family physician, but experiencing the community pharmacy-led service resulted in an attitudinal shift toward the pharmacist. These findings suggest a benefit in developing the community pharmacist's role as a reviewer of, and adviser on, patients' medications.

Using the Health Belief Model to test factors affecting patient retention in diabetes-related pharmaceutical care services

BACKGROUND

Diabetes is one of the deadliest and most costly diseases. Attrition rates among patients in diabetes management programs may preclude optimal success. Theoretical models, such as the Health Belief Model, may be useful for identifying factors responsible for patients' continued enrollment in such programs.

OBJECTIVES

(1) To design and test a reliable and valid survey instrument for assessing patients' perceptions of diabetes-related pharmaceutical care services. (2) To determine factors affecting patient retention in pharmaceutical care services.

METHODS

This cross-sectional exploratory study used convenience sampling to survey type 1 and 2 diabetes patients receiving pharmaceutical care at 25 Eckerd Pharmacy sites in Florida. Survey items were designed using constructs from the Health Belief Model. Reliability (Cronbach's alpha) and validity (exploratory factor analysis) were assessed. Independent t tests, Pearson's correlation coefficients, and multiple regression analysis were conducted.

RESULTS

Seventy usable surveys were returned (47%). In the absence of pharmaceutical care, patients felt susceptible to at least one of 8 diabetes-related conditions (hypoglycemia, hyperglycemia, diabetic foot infections, eye problems, cardiovascular risks, blood pressure problems, cholesterol problems, and kidney diseases). For these conditions, about 48% to 95% of patients perceived that their threat had reduced because of pharmaceutical care. Accordingly, more than half perceived the services as beneficial, with counseling for blood sugar monitoring rated as the most beneficial. All respondents rated the services as helpful, and 64 intended to continue regular utilization. Overall helpfulness of the service and patient retention were positively correlated (r=0.33, P<.00). Perceived susceptibility predicted perceived threat reduction (R(2)=0.22, P<.01). Perceived threat reduction, blood sugar monitoring, and overall helpfulness of the service predicted patient retention in the service (R(2)=0.41, P<.00). Factor analysis extracted 4 factors: perceived threat reduction, perceived susceptibility, perceived benefits, and blood sugar monitoring. Cronbach's alphas for the scales ranged from 0.63 to 0.91.

CONCLUSION

Two key constructs of the Health Belief Model influence use of diabetes-related pharmaceutical care services: perceived susceptibility and threat reduction. In an effort to increase patient retention, pharmacists need to assess patient perceptions and structure their services to address patient perceptions and concerns.

Questionnaire to assess patient satisfaction with pharmaceutical care in Spanish language

OBJECTIVE

To develop and validate a questionnaire, in Spanish, for assessing patient satisfaction with pharmaceutical care received in community pharmacies.

DESIGN

Selection and translation of questionnaire's items; definition of response scale and demographic questions. Evaluation of face and content validity, feasibility, factor structure, reliability and construct validity.

SETTING

Forty-one community pharmacies of the province of Santa Fe. Argentina.

PARTICIPANTS

Questionnaire administered to patients receiving pharmaceutical care or traditional pharmacy services.

MAIN OUTCOME MEASURE

Pilot test to assess feasibility. Factor analysis used principal components and varimax rotation. Reliability established using internal consistency with Cronbach's alpha. Construct validity determined with extreme group method.

RESULTS

A self-administered questionnaire with 27 items, 5-point Likert response scale and demographic questions was designed considering multidimensional structure of patient satisfaction. Questionnaire evaluates cumulative experience of patients with comprehensive pharmaceutical care practice in community pharmacies. Two hundred and seventy-four complete questionnaires were obtained. Factor analysis resulted in three factors: Managing therapy, Interpersonal relationship and General satisfaction, with a cumulative variance of 62.51%. Cronbach's alpha for the whole questionnaire was 0.96, and 0.95, 0.88 and 0.76 for the three factors, respectively. Mann-Whitney test for construct validity did not showed significant differences between pharmacies that provide pharmaceutical care and those that do not, however, 23 items showed significant differences between the two groups of pharmacies.

CONCLUSION

The questionnaire developed can be a reliable and valid instrument to assess patient satisfaction with pharmaceutical care in community pharmacies in Spanish. Further research is needed to deepen the validation process.

The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma

OBJECTIVE

To assess clinical, humanistic, and economic outcomes of a community-based medication therapy management (MTM) program for 207 adult patients with asthma over 5 years.

DESIGN

Quasi-experimental, longitudinal pre-post study.

SETTING

12 pharmacy locations in Asheville, N.C. PATIENTS/OTHER PARTICIPANTS: Patients with asthma covered by two self-insured health plans; professional educator at Mission Hospitals; 18 certificate-trained community and hospital pharmacists.

INTERVENTIONS

Education by a certified asthma educator; regular long-term follow-up by pharmacists (reimbursed for MTM by health plans) using scheduled consultations, monitoring, and recommendations to physicians.

MAIN OUTCOME MEASURES

Changes in forced expiratory volume in 1 second (FEV1), asthma severity, symptom frequency, the degree to which asthma affected people's lives, presence of an asthma action plan, asthma-related emergency department/hospital events, and changes in asthma-related costs over time.

RESULTS

All objective and subjective measures of asthma control improved and were sustained for as long as 5 years. FEV1 and severity classification improved significantly. The proportion of patients with asthma action plans increased from 63% to 99%. Patients with emergency department visits decreased from 9.9% to 1.3%, and hospitalizations from 4.0% to 1.9%. Spending on asthma medications increased; however, asthma-related medical claims decreased and total asthma-related costs were significantly lower than the projections based on the study population's historical trends. Direct cost savings averaged 725 dollars/patient/year, and indirect cost savings were estimated to be 1230 dollars/patient/year. Indirect costs due to missed/nonproductive workdays decreased from 10.8 days/year to 2.6 days/year. Patients were six times less likely to have an emergency department/hospitalization event after program interventions.

CONCLUSION

Patients with asthma who received education and long-term medication therapy management services achieved and maintained significant improvements and had significantly decreased overall asthma-related costs despite increased medication costs that resulted from increased use.

Complex Pharmaceutical Care Intervention in Pulmonary Care

OBJECTIVE

The IPMP study (Interventions on the principle of Pulmonary Medication Profiles) investigates and describes the results of complex pharmaceutical care interventions provided to selected pulmonary patients to improve their drug use. This paper describes the patients' opinions about the care provided and the results of the intervention.

METHOD

Questionnaires investigating patients' opinions about provided pharmaceutical care were sent to 185 patients participating in the IPMP study after the intervention by their pharmacists had been finished. One year after the start of the intervention, patients were invited to a final consultation by their pharmacists to evaluate their drug use and their symptoms (n = 138). At this point in time pharmacists investigated the knowledge of the patients about the medication and their inhaler technique again.

MAIN OUTCOME MEASURE

The influence of the intervention on patients' symptoms. Change in drug-related problems, knowledge and skills concerning pulmonary medication after intervention. Satisfaction of the patients with the provided pharmaceutical care.

RESULTS

In total 141 out of 185 patients completed the questionnaire. Patients were satisfied with the intervention by their pharmacists and considered it important. The majority (67%) reported that they had learned more about their medication or the inhaler technique, resulting in significantly improved coping behaviour with their pulmonary medication compared with patients who valued the intervention as a nice conversation with their pharmacist only. Patients with improved ability to cope reported statistically significantly fewer symptoms compared with patients reporting no change in behaviour (chi-square test, P < 0.05). In the final consultation of 138 patients, pharmacists observed increased knowledge and skills and decreased drug-related problems. The patients concerned were pleased with the change in treatment and were more satisfied with their current medication as compared with their earlier reports.

CONCLUSION

Patients can be influenced effectively by the tailored intervention of pharmacists resulting in improved ability to cope with pulmonary medication and in fewer reported adverse effects and symptoms. Patients attributed these results to the intervention of the pharmacists.

Instruments for Measuring Patient Satisfaction with Pharmacy Services in the Spanish Language

AIM OF THE REVIEW

The purpose of this paper is to identify and evaluate instruments used to assess patient satisfaction with pharmacy services available in the Spanish language, and specifically those designed to assess pharmaceutical care provided in community pharmacies.

METHOD

A literature search was conducted in seven databases, using keywords: "patient satisfaction" and "Spanish" with and without the term "pharmacy". Publications that described the development or translation and/or adaptation of a questionnaire to assess patient satisfaction with pharmacy services in the Spanish language were retained. Publications were excluded if they were abstracts from conferences, reviews, letters or notes. The criteria used also excluded manuscripts where patient satisfaction was not assessed with a questionnaire. Instruments were evaluated according to evidence of the psychometric properties considered relevant: content validity, reliability and construct validity.

RESULTS

While 83 publications describing instruments to measure patient satisfaction with health care services in the Spanish language were identified, only two pertained to satisfaction with pharmacy services. Both assessed patient satisfaction with pharmaceutical care. One questionnaire, developed in Spanish only, includes four dimensions that comprehensively assessed pharmaceutical care practice; however, its reliability was only partially evaluated. The other questionnaire was developed in both Spanish and English. It was considered narrower in scope, assessing satisfaction with the pharmacist only. However, evidence was provided that the two versions of the questionnaire were reliable, valid and linguistically equivalent.

CONCLUSION

A comprehensive, reliable, and valid instrument for assessing patient satisfaction with pharmaceutical care in community pharmacies in the Spanish language is not yet available. The two published questionnaires that we have identified are a beginning, further research and development is needed.

A systematic review of the research on communication between patients and health care professionals about medicines: the consequences for concordance

OBJECTIVES

We draw on a systematic review of research on two-way communication between patients and health practitioners about medicines in order to determine the extent to which concordance is, or is not, being put into practice.

DATA SOURCES

Six electronic databases were searched using the following categories of search terms: health care professionals, patients/consumers, medicine-taking/prescribing and communication. Articles were also identified from handsearches of journals, article reference lists and the Concordance website.

REVIEW METHODS

Studies published between 1991 and 2000 were included. Studies were not excluded on the basis of design, methods or language employed. Abstracts of identified articles were assessed by at least two reviewers and the full articles were assessed by one reviewer and checked by at least one other reviewer. Data on the design, analysis and relevant findings were extracted.

RESULTS

A total of 11 801 abstracts were reviewed and 470 full articles were retrieved. Of the 134 articles subsequently included, 116 were descriptive studies. All but 10 of the papers were written in English. There were mixed findings about the extent to which patients feel that their beliefs, experience and preferences about medicines can be shared. Doctors tend to dominate discussions in consultations, although patient participation is associated with positive outcomes. Health care professionals' behaviour can impede as well as enhance patient involvement.

CONCLUSIONS

There is little research that examines fundamental issues for concordance such as whether an exchange of views takes place. It is possible that interventions are needed to facilitate the development of concordance in practice.

The impact of a pharmacist intervention on 6-month outcomes in depressed primary care patients

The object of the study was to evaluate outcomes of a randomized clinical trial (RCT) of a pharmacist intervention for depressed patients in primary care (PC). We report antidepressant (AD) use and depression severity outcomes at 6-months. The RCT was conducted between 1998 and 2000 in 9 eastern Massachusetts PC practices. We studied 533 patients with major depression and/or dysthymia as determined by a screening test done at the time of a routine PC office visit. The majority of participants had recurrent depressive episodes (63.5% with >/=4 lifetime episodes), and 49.5% were taking AD medications at enrollment. Consultation in person and by telephone was performed by a clinical pharmacist who assisted the primary care practitioner (PCP) and patient in medication choice, dose, and regimen, in accordance with AHCPR depression guidelines. Six-month AD use rates for intervention patients exceeded controls (57.5% vs. 46.2%, P =.03). Furthermore, the intervention was effective in improving AD use rates for patients not on ADs at enrollment (32.3% vs. 10.9%, P =.001). The pharmacist intervention proved equally effective in subgroups traditionally considered difficult to treat: those with chronic depression and dysthymia. Patients taking ADs had better modified Beck Depression Inventory (mBDI) outcomes than patients not taking ADs, (-6.3 points change, vs. -2.8, P =.01) but the outcome differences between intervention and control patients were not statistically significant (17.7 BDI points vs. 19.4 BDI points, P =.16). Pharmacists significantly improved rates of AD use in PC patients, especially for those not on ADs at enrollment, but outcome differences were too small to be statistically significant. Difficult-to-treat subgroups may benefit from pharmacists' care.

Do community pharmacists influence prescribing?

OBJECTIVES

To evaluate whether community pharmacists have the ability to influence prescribing decisions and to determine the extent to which they do so.

DATA SOURCES

International Pharmaceutical Abstracts was searched for articles published between January 1970 and September 2002 and MEDLINE was searched for articles published between January 1966 and September 2002 that contain the terms pharmaceutical care or pharmacist and intervention.

STUDY SELECTION

Selected studies documented pharmacist interventions that resulted in a change in prescribing that required influencing the prescriber, included a complete description of methods and results, and were conducted in community pharmacies in the United States.

DATA EXTRACTION

Selected studies were examined to determine whether, in what ways, and to what extent community pharmacists influenced prescribing.

DATA SYNTHESIS

Community pharmacists in traditional practices regularly, but infrequently, recommend to prescribers that they initiate, discontinue, or change drug therapy. Prescribers usually accept and implement pharmacists' suggestions. Pharmacists are more likely to intervene to correct drug therapy problems when they have been trained to provide pharmaceutical care and have modified their practices to accommodate a more patient-centered style of practice. In the larger reviewed studies, pharmacists intervened to change therapy for the majority of their patients.

CONCLUSION

Community pharmacists routinely intervene to influence prescribing. They do so, for the most part, to correct clinical problems or to provide their patients with more affordable therapy. In the majority of interventions, physicians accept and implement pharmacists' suggestions.

Unmet needs in the medication use process: perceptions of physicians, pharmacists, and patients

OBJECTIVES

To explore the perception of unmet needs in the medication use process from the perspectives of three of the principal participants in the process--physicians, pharmacists, and patients--and to identify the individual(s) or strategy(ies) perceived to be the best or most likely candidate(s) to resolve the problems identified.

PARTICIPANTS

Physicians (primary care, cardiology, oncology, and obstetrics/gynecology specialties), pharmacists (community and health-system settings), and patients from four medium-sized U.S. cities. The survey instrument was modified for each group.

MAIN OUTCOME MEASURES

The medication use process was divided into nine steps, based on a previous study. A two-part question was framed for each step. In part A, respondents were asked to indicate their level of agreement (on a 5-point scale) about whether the step was being conducted appropriately. In part B, those who disagreed with a statement in part A were asked their opinions on the best possible candidate or strategy for improving that step.

RESULTS

Both physicians and pharmacists identified four areas of unmet needs: timing of physician visit, patient counseling, patient use of medications, and patient monitoring. Each group held itself primarily responsible for the resolution of most of these problems. Patients did not identify any unmet needs from the survey. In responses to open-ended questions, however, they cited medication cost, appropriateness, access, and convenience as problems.

CONCLUSION

Providers and patients reported substantially different perspectives on medication use problems and on improving the process. Addressing the unmet needs identified in this study will require better understanding, communication, and collaboration among physicians, pharmacists, and patients.

Provision of drug information to patients by pharmacists: the impact of the Omnibus Budget Reconciliation Act of 1990 a decade later

Drug-related illness in the United States factors substantially in health care costs, although often these illnesses and their attendant costs are preventable. One strategy for minimizing adverse drug reactions is to provide drug information to consumers in the form of prescription counseling at pharmacies. The Omnibus Budget Reconciliation Act of 1990 (OBRA 1990) contained provisions for mandating such counseling to Medicaid patients. OBRA 1990 was implemented in 1993, but most states acted quickly to extend counseling services to all patients receiving prescription drugs. We looked at the extent and quality of prescription counseling available in community pharmacies 1 decade after OBRA 1990 was written. We evaluated the counseling services afforded at large chain pharmacies, independent community pharmacies, and on-line pharmacies for a hydrochlorothiazide prescription. We found that most (69%) pharmacies offered to provide prescription counseling service, and that average counseling index scores, a measure of the quality or extent of information provided as determined by a Rasch analysis, were generally satisfactory. Our observations based on a single prescription for hydrochlorothiazide, along with other studies, suggest that there is a positive upward trend in the number of pharmacies providing prescription drug information, and that the extent of information provided suggests that the objectives of OBRA 1990 and related legislation to reduce ADRs are being fundamentally satisfied.

Improving pediatric asthma outcomes in the community setting: does pharmaceutical care make a difference?

OBJECTIVE

To assess the effect of a structured program of pharmaceutical care on changes in disease control, functional status, and health services utilization for pediatric and adolescent patients with moderate-to-severe asthma.

DESIGN

Randomized, controlled trial.

SETTING

Community and clinic pharmacies (14 intervention and 18 usual care pharmacies) in western Washington State.

PATIENTS

Three hundred thirty children, aged 6 to 17 years, with asthma.

INTERVENTION

Structured training for the intervention group pharmacists to provide individualized asthma management services during patient-pharmacist encounters for up to 1 year following the patient's enrollment into the study.

MAIN OUTCOME MEASURES

The primary outcome measure was change in pulmonary function as measured by peak expiratory flow rate and spirometry. Secondary outcome measures included changes in functional status and use of asthma-related health care services.

RESULTS

The intervention had no significant effect on the health or health services use outcomes of study subjects. When compared with the usual care group, there was no evidence that patients from the intervention group experienced improvements in pulmonary function, functional status, quality of life, asthma management, or satisfaction with care. In addition, there were no differences between groups in use of anti-inflammatory medications, total or asthma-related medical care utilization, or total or asthma-related school days lost.

CONCLUSION

This pharmaceutical care intervention had no significant effect on the health or health services use outcomes of pediatric patients with asthma. The intervention may not have been powerful enough to significantly affect pharmacists' behaviors and asthma patients' outcomes in community pharmacy settings, and there is evidence that the pharmacists' compliance with the study protocol was low due, in part, to patient- and practice-related obstacles.

Health professionals' and consumers' views on the role of the pharmacy personnel and the pharmacy service in Hanoi, Vietnam--a qualitative study

OBJECTIVES

To explore the views of health professionals and consumers concerning (i) the role of the pharmacy personnel and (ii) the pharmacy service in Hanoi, Vietnam.

METHOD

A qualitative approach influenced by both content analysis and phenomenography was used. The different groups of participants were selected by purposive sampling, whereas the representatives from each group were selected based on availability. Data were collected by means of face-to-face interviews. Pre-tested, semi-structured interview guides were used. The interviews were tape-recorded and transcribed. The analysis followed commonly applied procedures in qualitative research. The views of the respondents were categorized and described concerning the main issues.

RESULTS

A total of 21 interviews were conducted with six pharmacists, five medical doctors, five pharmacy students and five pharmacy customers. An interpreter was used in 16 cases. The role of the pharmacy personnel was viewed in three different ways, as: counsellor, doctor's assistant or businessman. It was also believed that sometimes the pharmacy personnel might play a double role--both as doctor and pharmacist. They were considered to have a passive or active role in the provision of information to the customers. Some of the subjects put emphasis on the quality of the information given, and some others considered the information given at the pharmacies as merely a reiteration of the doctor's instruction. Concerning the pharmaceutical field in general, three different categories could be discerned, which describe the interviewee's perspective on the main actors influencing pharmacy practice: a mutual, a central and an individual perspective.

CONCLUSION

This study describes different ways of viewing the role of the pharmacy personnel and the pharmacy service in Hanoi. The estimation of the impact of the different views on the pharmacy profession in Hanoi requires another kind of study.

Patient satisfaction with pharmaceutical care: update of a validated instrument

OBJECTIVE

To develop a questionnaire for measuring patient satisfaction with pharmaceutical care and to establish its factorial composition.

DESIGN

Single intervention, noncomparative, 20-item self-administered questionnaire.

SETTING

Iowa.

PARTICIPANTS

Seven hundred seventy-five prescription patrons of eight community pharmacies whose pharmacists had received training in pharmaceutical care but who had not yet implemented it.

INTERVENTIONS

An instrument originally developed to measure patient satisfaction with traditional community pharmacy services was modified to focus on the elements of pharmaceutical care. This revised questionnaire was mailed to participants.

MAIN OUTCOME MEASURES

Participant responses to items in the questionnaire.

RESULTS

The survey response rate was 55%. Factor analysis and item analysis identified two dimensions of pharmaceutical care. We labeled the dimensions Friendly Explanation (including items related to friendliness of care, the setting of care, and medication counseling) and Managing Therapy (items dealing with the concept of pharmaceutical care-managing drug therapy and solving therapy problems). Respondents scored items on the Managing Therapy scale lower than they did items on the Friendly Explanation scale. The scales were highly correlated. Two other hypothesized dimensions of care-Consideration/Caring Relationships and Setting-were subsumed in the final scale of Friendly Explanation.

CONCLUSION

The instrument provides information on patients' satisfaction with two dimensions of pharmacy services. The instrument may be useful to practicing pharmacists, but it should be used cautiously until it is tested among patrons of pharmacies known to provide different levels of care.

Ambulatory care pharmacy services: has the agenda changed?

OBJECTIVE

To provide an extensive review of ambulatory care clinical pharmacy services and evaluate the services and research data in the field.

DATA SOURCES

MEDLINE was searched from January 1992 through July 1999. Search terms included pharmacy, clinical pharmacy, and pharmaceutical care, cross-referenced with ambulatory care, primary care, family medicine, and managed care.

STUDY SELECTION

Relevant peer-reviewed studies and reports since our previous article in 1992 were selected and described. Literature prior to 1992 was briefly reviewed.

DATA SYNTHESIS

The relevant literature was reviewed and some examples from the authors' institutions are provided. Much research has continued to be published documenting the value of clinical pharmacy services in ambulatory care, including in community pharmacy, anticoagulation services, family medicine, primary care clinics, Veterans Affairs Medical Centers, and managed care. However, these innovative services are underrepresented in the community at large. The vast majority of the public does not have access to these types of services.

CONCLUSIONS

There will be continued and dramatic expansion of ambulatory care pharmacy services in the new decade beginning in the year 2000. It will be critical that standards of practice be very high. We believe there is a critical need for visible demonstration projects and large multicenter research projects that demonstrate the value of these services.