Guidelines for pharmacists integrating into primary care teams

Leverage points for establishing clinical decision-maker as a vital component of pharmacists' professional identity

This commentary explores how a change in the professional identity of pharmacists from medicines supplier to clinical decision-maker might take place. Three leverage points are identified that support this change. The first leverage point involves workplace culture. Pharmacists require workplaces that support them to assume direct responsibility for drug therapy decisions that may not have traditionally been part of pharmacy practice. The second leverage point involves terminology. Pharmacists need to be able to name and describe the process they use when making decisions about drug therapy. The third leverage point encompasses pharmacy education. Future pharmacists require a foundation that enables them to mobilize their knowledge and skills about drug therapy to act as clinical decision-makers with patients that require complex care. By acting on multiple leverage points, advocates for change in the pharmacy profession can assist pharmacists to establish themselves as decision-makers about drug therapy, shift their professional identity, and reformulate their view of the profession.

Acceptance rate of clinical pharmacists' recommendations-an ongoing journey for integration

Introduction: Multidisciplinary expert team collaboration in the clinical setting, which includes clinical pharmacist involvement can facilitate significant improvements in outcomes and optimize patient management by preventing drug-related problems (DRP). This type of collaboration is particularly valuable in patients with multi-morbidity and polypharmacy such as diabetic foot patients. Evidence regarding the successful integration of a new clinical pharmacist, without previous experience into a unit is still scarce. Therefore, this study aimed to describe and evaluate the actual successful integration process of the clinical pharmacist into a diabetic foot unit by measuring the change in recommendation acceptance rate over time. Methods: A prospective, exploratory treatment effectiveness study based on the recommendation acceptance rate of a new clinical pharmacist introduced into the diabetic foot unit was conducted over a 9- month period. The clinical pharmacist identified medical and drug-related problems (DRP) or any discrepancies in the prescribing and administration of medications. Each identified DRP was documented and formulated as a recommendation by the clinical pharmacist. The main outcome measure was the acceptance rate of recommendations over time. Results: A total of 86 patients, of which 67% were men, averagely aged 66.5 (SD 11.8) years were evaluated. Calculated BMI was 30.2 (SD 6.2). The average number of medical diagnoses was 8.9 (SD3.2), and 11.1 (SD 3.7) prescribed drugs for each patient. Cardiovascular disease was presented by 95% (n = 82) of the patients and 33% of them (n = 28) had uncontrolled hyperglycemia. Averagely, 3.3 (SD 1.9) DRPs were identified pre patient. The efficacy-related DRP recommendation acceptance rate increased over the study period from 37.8% in the first 4 months to 79.4% after a period of 4.75 months. Safety-related DRP recommendation acceptance rate increased from 56% to 67.6%. Conclusion: Improved clinical outcomes and optimized pharmacologic patient management may be achieved by the successful integration of a clinical pharmacist into the team. This study provides evidence of the increasing recommendation acceptance rate of integrated, pharmacist-driven comprehensive medication management in an unexperienced unit. To overcome challenges, team members should collaborate to fully integrate the clinical pharmacist into the team-based structure and utilize proper strategies to minimize and transcend barriers.

Evaluation of pharmaceutical care services in the Middle East Countries: a review of studies of 2013-2020

INTRODUCTION

Pharmaceutical care services (PCs) have evolved significantly over the last few decades, with a greater focus on patient's safety and proven effectiveness in a wide range of contexts. Many of the evidence supporting this technique comes from the United States, the evaluation and adoption of (PCs) which differ greatly across the globe.

OBJECTIVE

The goal of this study was to identify and assess the efficacy of pharmaceutical care services in various pharmaceutical aspects throughout seventeen Middle Eastern nations.

METHOD

The Arkesy and O'Malley technique was used to conduct a scoping review. It was conducted using PubMed/Medline, Scopus, Cochrane Library, Springer Link, Clinical Trials, and Web of Science etc. The Van Tulder Scale was utilized in randomized trials research, whereas the dawn and black checklists were used in non-randomized trials research. A descriptive and numerical analysis of selected research was done. The scope of eligible PCs, pharmaceutical implementers, study outcomes, and quality were all identified by a thematic review of research.

RESULTS

There were about 431,753 citations found in this study, and 129 publications were found to be eligible for inclusion after analysing more than 271 full-text papers. The study design was varied, with 43 (33.3%) RCTs and 86 (66.7%) n-RCTs. Thirty-three (25.6%) of the studies were published in 2020. Jordan, Saudi Arabia, and Turkey were home to the majority of the studies (25.6%, 16.3%, and 11.6%) respectively. Thirty-seven studies (19.7%) were concerned with resolving drug related problems (DRPs), whereas 27 (14.4%) were concerned with increasing quality of life (QOL) and 23 (12.2%) with improving drug adherence. Additionally, the research revealed that the average ratings of the activities provided to patients improved every year.

CONCLUSION

Studies in the Middle East continue to provide evidence supporting the positive impact of pharmaceutical care services on both hard and soft outcomes measured in most studies. Yet there was rare focus on the value of the implemented services. Thus, rigorous evaluation of the economic impact of implemented pharmaceutical care services in the Middle East and assessment of their sustainability is must.

GPs' and pharmacists' views of integrating pharmacists into general practices: a qualitative study

BACKGROUND

Practice-based pharmacists (PBPs) have been introduced into general practice across the UK to relieve some of the pressures within primary care. However, there is little existing UK literature that has explored healthcare professionals' (HCPs') views about PBP integration and how this role has evolved.

AIM

To explore the views and experiences of GPs, PBPs, and community pharmacists (CPs) about PBPs' integration into general practice and their impact on primary healthcare delivery.

DESIGN AND SETTING

A qualitative interview study in primary care in Northern Ireland.

METHOD

Purposive and snowball sampling were used to recruit triads (a GP, a PBP, and a CP) from across five administrative healthcare areas in Northern Ireland. Sampling of practices to recruit GPs and PBPs commenced in August 2020. These HCPs identified the CPs who had most contact with the general practices in which the recruited GPs and PBPs were working. Semi-structured interviews were recorded, transcribed verbatim, and analysed using thematic analysis.

RESULTS

Eleven triads were recruited from across the five administrative areas. Four main themes in relation to PBPs' integration into general practices were revealed: evolution of the role; PBP attributes; collaboration and communication; and impact on care. Areas for development were identified such as patient awareness of the PBP role. Many saw PBPs as a 'central hub-middleman' between general practice and community pharmacies.

CONCLUSION

Participants reported that PBPs had integrated well and perceived a positive impact on primary healthcare delivery. Further work is needed to increase patient awareness of the PBP role.

Building Interprofessional Collaborative Practices Through a Support Program for Patients With Type 2 Diabetes in Primary Care

INTRODUCTION

The building of interprofessional collaborative practices throughout the implementation process of a patient support program (Siscare) in primary care for patients with type 2 diabetes was assessed. Siscare included regular patient-pharmacist motivational-based interviews; medication adherence, patient-reported, and clinical outcomes monitoring; and physician-pharmacist interactions.

METHOD

This investigation was a prospective, multicenter, observational, mixed-methods cohort study. Interprofessionality was operationalized through four progressive levels of interrelationship practices between the health care professionals. The target number of patients per pharmacy was 10 among 20 pharmacies.

RESULTS

The project started with the recognition of Siscare by stakeholders, the creation of an interprofessional steering committee, and the adoption of Siscare by 41 pharmacies among 47 pharmacies in April 2016. Nineteen pharmacies presented Siscare at 43 meetings attended by 115 physicians. Twenty-seven pharmacies included 212 patients; however, no physician prescribed Siscare. Collaboration primarily occurred through the unidirectional transmission of information from the pharmacist to the physician (level 1: 70% of pharmacists transmitted interview reports to physicians), bidirectional exchange of information sometimes occurred (level 2: 42% received physician responses), and concerted measures of treatment objectives took place occasionally (level 3). Twenty-nine of 33 physicians surveyed were in favor of this collaboration.

DISCUSSION

Despite multiple implementation strategies, physician resistance and lack of motivation to participate exists, but Siscare was well received by pharmacists, patients, and physicians. Barriers to collaborative practice (financial and IT) need to be further explored. Interprofessional collaboration is a clear need to improve type 2 diabetes adherence and outcomes.

Patients' Satisfaction With Pharmaceutical Care Services Provided During COVID Pandemic: Experience From Greece

Introduction Private pharmacies can contribute to the health care system through primary care. Purpose The purpose of this study is to determine patients' expectations of pharmaceutical care services during covid pandemic in order to measure the level of patient satisfaction provided by the Greek healthcare system. Also, it is important to identify the associated factors that might affect patient satisfaction. Material and Method The sample of the study consisted of 168 customers of pharmacies in Athens. A patient satisfaction survey was conducted at health facilities operating in Athens. Data regarding socio-demographic characteristics and parameters that measure patients' expectations and satisfaction were collected through a closed-ended questionnaire that had been tested for validity and reliability. The patient's point of view was evaluated based on their expectation and perception of the pharmaceutical care services they had received. Data were entered into SPSS version 22 (IBM Corp, Armonk, NY ), and descriptive statistics, cross-tabs, and binary logistic regressions were utilized. P < 0.05 was used to declare association. Results About 89.3% of the participants were insured in the Greek health system. The main reason for visiting the pharmacy was the purchase of medicines and products (95.2%), vaccinations (19.6%), and consulting services for first aid (17.3%). The pharmacist was rated for his courtesy, willingness, friendliness, and reliability. Only 48.2% of participants knew that the pharmacy provided primary care services during the pandemic. The most common services provided were blood pressure measurement and intramuscular injections. Around 64.2% of them were fully satisfied. Pharmacists in primary care teams are uniquely positioned to facilitate practice expansion and make medicine a trusted resource for physicians, as well as improve health outcomes for patients. Conclusions The pharmacy has a leading role in health care due to easy access, and fast and immediate service. Patient-clients in Greek society trust their pharmacist as a health professional. Further research is suggested to ensure that through the delivery of health services by pharmacies, the cost of primary care could be lower.

Effectiveness of a pharmacist-led educational intervention on health outcomes in hypertension management at community pharmacies in Nigeria: A two-arm parallel single-blind randomized controlled trial

AIMS

This study determined the impact of a pharmacist-led educational intervention on the health outcomes of hypertensive patients in community pharmacies.

METHODS

A 2-arm parallel single-blind randomized trial design was adopted among hypertensive patients in 4 pharmacies in Abuja and Lokoja, Nigeria. A pharmacist-led educational intervention was provided to the patients in the intervention group. The study outcomes, namely changes in adherence to medication, quality of life and cost of medication were measured using MARS-10, SF-12 and official price list, respectively. Independent and paired-sample t-tests were conducted on the data.

RESULTS

A total of 128 patients participated in the study. All of them completed the study and were included in the analysis: 70 in the control arm and 58 in the intervention arm. There was a significant improvement in components of Behaviour (2.57 vs. 2.98), Attitude (2.59 vs. 3.14) and Negative attitude (1.62 vs. 1.92). There was a better improvement in adherence in the intervention arm: 8.05 ± 1.32 vs. 6.55 ± 2.24; t = -4.65, P = .0001. There were no changes in the respondents' health status after intervention in both groups (P < .05). There was a weak inverse association between the physical health component and mental health component: R = -0.2, P = .04 and a positive association with overall adherence (R = 0.26, P = .004) in the intervention group, in whom the monthly cost of treatment decreased from N2233.1 to N2068.4.

CONCLUSION

Community pharmacy educational intervention improves health outcomes, particularly with adherence among patients with hypertension. Health-related quality of life of the patients improved, but the physical health component was better than that of the mental health component.

Pharmacists practising in family medicine groups: An evaluation 2 years after experiencing a virtual community of practice

Background:

In 2018, a virtual community of practice (CoP) for pharmacists working in family medicine groups (FMGs) in Quebec province was developed. The aim of this CoP—called Réseau Québécois des Pharmaciens GMF (RQP GMF)—was to foster best practices by supporting FMG pharmacists. This study assesses the processes and outcomes of this CoP 2 years after its creation.

Methods:

We performed a cross-sectional web-based study from March to May 2020. All FMG pharmacists who were registered as members of the RQP GMF (n = 326) were sent an invitation via a newsletter. The link to the questionnaire was also publicized in the CoP Facebook group. The questionnaire comprised a 38-item validated instrument assessing 8 dimensions of the CoP. A descriptive analysis was performed.

Results:

A total of 112 FMG pharmacists (34.4%) completed the questionnaire. Respondents agreed that the RQP GMF was a joint enterprise (mean score, 4.18/5), that members shared their knowledge (mean score, 3.94/5) and engaged mutually (mean score, 3.50/5) and that the RQP GMF provided support (mean score, 3.92/5) and capacity building (mean score, 4.01/5). In general, they were satisfied with the implementation process (mean score, 3.68/5) and with activities proposed (mean score, 3.79/5). A lower proportion of respondents agreed that their participation in the RQP GMF generated external impacts, which led to a smaller mean score (3.37/5) for this dimension.

Conclusion:

The RQP GMF, one of the first communities of practice for pharmacists practising in family medicine groups, attained most of the objectives initially intended by the CoP. These results will facilitate the adaptation of processes and activities to better fulfil members’ needs. Can Pharm J (Ott) 2021;154:xx-xx.

Management of Drug-Drug Interactions among Critically Ill Patients with Chronic Kidney Disease: Impact of Clinical Pharmacist's Interventions

BACKGROUND AND OBJECTIVES

Drug-drug interactions (DDIs) can create a burden on prescribers to preserve patient safety. This study aimed to identify common DDIs in critically ill patients with chronic kidney disease (CKD) and to evaluate clinical pharmacist's interventions in managing DDIs among these patients.

METHODS

A prospective observational study was conducted from October 2018 to March 2019. The clinical pharmacist performed a medication chart review; DDIs were identified by using Lexicomp® drug interaction. Based on the occurrence of DDIs, patients were divided into group A: patients with DDI (n = 76) and group B: patients without DDI (n = 15). Clinical pharmacist's interventions were classified according to Pharmaceutical Care Network Europe. The National Coordinating Council for Medication Error Reporting and Prevention was used to categorize the severity outcomes of DDIs and the degree of patient harm.

RESULTS

A total of 273 DDIs were identified. The majority of DDIs (63.7%) required close monitoring of the therapeutic outcome to ensure maintaining patient safety. DDIs that needed to be managed by considering therapy modification and avoiding drug combination were accounted for 17.2 and 12.8% of the most common detected interactions, respectively. Seventy-eight percent of DDIs induced no harm to patient. Clinical pharmacist provided different types of recommendations to manage detected interactions, which ranged from therapy outcome monitoring to stop DDIs. A great proportion of pharmacist's interventions (92%) were accepted by prescribers. Compared to patients with stage 3 and 4 CKD, patients with stage 5 had a significantly higher number of DDIs (stage 3 vs 5: p = 0.0019, stage 4 vs 5: p = 0.0456). The number of comorbidities (p = 0.0003) and (p <0.0001) medications were found to be significantly greater in group A.

CONCLUSION

Clinical pharmacist performed important interventions in timely identifying, managing DDIs, and prevention of associated patient harms.

HOW TO CITE THIS ARTICLE

Aghili M, Kasturirangan MN. Management of Drug-Drug Interactions among Critically Ill Patients with Chronic Kidney Disease: Impact of Clinical Pharmacist's Interventions. Indian J Crit Care Med 2021;25(11):1226-1231.

'I thought it would be a very clearly defined role and actually it wasn't': a qualitative study of transition training for pharmacists moving into general practice settings in Wales

OBJECTIVE

Pharmacists are increasingly contributing to the skill mix of general practice surgeries to help alleviate pressures faced by UK doctors working in primary care. However, they need support in overcoming barriers to their integration. The purpose of this work was to evaluate a programme designed to support pharmacists' transition to working in general practice settings. We explored the learning needs of pharmacists', the barriers and enablers to their integration and provide recommendations based on our results.

INTERVENTION

A qualitative evaluation of a 1-year transition programme in Wales starting in September 2018 to support pharmacists' transition to working in general practice settings.

DESIGN AND SETTING

We employed an interpretative phenomenological approach involving 10 pharmacists across Wales enrolled on the transition to general practice training programme, and their tutors. Data were collected across two sequential phases: in phase 1 telephone interviews were held with pharmacists midway through their training; in phase 2, focus groups were conducted with both pharmacists and tutors towards the end of the programme.

RESULTS

Pharmacists enter general practice settings with a variety of prior experience. The programme provided a framework that pharmacists found helpful to map their experience to but the programme needed to be flexible to individual learning needs. The tutor role was typically regarded as the most valuable component, but interaction with the wider general practice team was critical to ease the transition. Pharmacists encountered a lack of clarity about their role which impeded their integration into the workplace team.

CONCLUSIONS

A formal programme with a designated tutor can support pharmacists' transition into general practice settings. The programme's competency framework facilitated reciprocal understanding of the pharmacist's role in the team, helped to manage expectations and enhanced collaborative practice. Recommendations to facilitate pharmacist integration into general practice settings are provided.

Implementation of pharmacist-led services in primary care: A mixed-methods exploration of pharmacists' perceptions of a national educational resource package

Background:

To help alleviate the global pressure on primary care, there has been an increase in the number of clinical pharmacists within primary care. Educational resources are necessary to support this workforce and their development within this role. An educational resource package was developed in Scotland to support the General Practice Clinical Pharmacists (GPCPs), containing a hard copy Competency and Capability Framework (CCF), an online platform (TURAS) and both clinical and educational supervisors in 2016.

Objective:

To examine the implementation of a competency-based educational resource package through the exploration of pharmacists’ perceptions of its adoption, acceptability, appropriateness, and feasibility.

Methods:

Participants were GPCPs who had been part of a national training event between 2016 and 2018. The participants were given the opportunity to complete an online questionnaire or a semi-structured telephone interview. Both data collection tools were based on Proctor’s model of implementation outcomes: adoption, acceptability, appropriateness and feasibility. Areas covered included GPCPs’ perceptions and level of adoption of the educational resource package developed to support them in their role.

Results:

Of a potential 164 participants, 52 (31.7%) completed the questionnaire and 12 (7.3%) completed the interview. GPCPs indicated widespread adoption and were accepting of the resources; however, it was suggested that its value was undermined, as it was not associated with a qualification. The appropriateness and feasibility of the resources depended on GPCPs’ individual situation (including current role, previous job experience, time available, support received from peers and supervisors, and perceptions of resources available).

Conclusions:

The suitability of the CCF was evidenced by participants’ adoption and acceptance of the resource, indicating the necessity of a competence-based framework to support the GPCPs’ role. However, its suitability was hindered in terms of varied perceptions of appropriateness and feasibility. Despite the limited sample size, the results indicate that the value of these resources should be promoted across primary care; nevertheless further facilitation is required to allow GPCPs to fully engage with the resources.

'Fitting in the pharmacist' - a qualitative analysis of the perceived relationship between community pharmacists and older adults with complex care needs

OBJECTIVES

To explore the current perceived relationship between older adults with varying levels of frailty and healthcare needs and community pharmacists.

METHODS

This qualitative study conducted a thematic analysis of focus groups with older adults and older adult caregivers and community pharmacist participants. Participants were recruited following a maximum variation sampling technique. Verbatim transcripts were inductively coded using NVivo to develop key findings.

KEY FINDINGS

Four major themes emerged: (i) Pharmacy Landscape, (ii) Prescription and Non-Prescription Drug Safety, (iii) Patient-Pharmacist Relationship and (iv) Recommendations for Pharmacy Practice. Themes demonstrate three key findings: (1) older adults approach drug information with a key focus on safety and cost of both prescription and non-prescription drugs, (2) there is a demonstrated opportunity, recognized by older adults and practitioners, for community pharmacists to expand their role in the care of older adults, (3) community pharmacists are able, interested and/or have already incorporated frailty assessments into their practice to better support their care of the older adult population with varying levels of frailty.

CONCLUSIONS

The results demonstrate a reason for the community pharmacist role to shift. The unique knowledge and skills of community pharmacists, coupled with their accessibility and strong patient-clinician relationship, have the potential to better support older adults with varying levels of frailty.

Clinical pharmacists in Dutch general practice: an integrated care model to provide optimal pharmaceutical care

Background Medication-related harm is a major problem in healthcare. New models of integrated care are required to guarantee safe and efficient use of medication. Aim To prevent medication-related harm by integrating a clinical pharmacist in the general practice team. This best practice paper provides an overview of 1. the development of this function and the integration process and 2. its impact, measured with quantitative and qualitative analyses. Setting Ten general practices in the Netherlands. Development and implementation of the (pragmatic) experiment We designed a 15-month workplace-based post-graduate learning program to train pharmacists to become clinical pharmacists integrated in general practice teams. In close collaboration with general practitioners, clinical pharmacists conduct clinical medication reviews (CMRs), hold patient consultations for medication-related problems, carry out quality improvement projects and educate the practice staff. As part of the Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in a primary care Team (POINT) intervention study, ten pharmacists worked full-time in general practices for 15 months and concurrently participated in the training program. Evaluation of this integrated care model included both quantitative and qualitative analyses of the training program, professional identity formation and effectiveness on medication safety. Evaluation The integrated care model improved medication safety: less medication-related hospitalisations occurred compared to usual care (rate ratio 0.68 (95% CI: 0.57–0.82)). Essential hereto were the workplace-based training program and full integration in the GP practices: this supported the development of a new professional identity as clinical pharmacist. This new caregiver proved to align well with the general practitioner. Conclusion A clinical pharmacist in general practice proves a feasible integrated care model to improve the quality of drug therapy.

Community pharmacists on the frontline in the chronic disease management: The need for primary healthcare policy reforms in low and middle income countries

In low- and middle-income countries (LMICs), over 12 million people die yearly from chronic diseases and this number is expected to increase if concerted actions are not taken. The purpose of this paper is to highlight the roles and impact of community pharmacists in chronic disease management support and the need for policymakers in LMICs to reposition community pharmacists appropriately for this extended role. Recent findings have shown that community pharmacists are the most accessible healthcare providers to the members of the community. Published evidence have demonstrated that community pharmacists' interventions in chronic diseases significantly improve economic, clinical, and humanistic outcomes. However, they are not officially recognized as primary healthcare providers in LMICs. Therefore, there is need for policy reforms that will encourage strategic use of the clinical skills of community pharmacists as part of the primary healthcare team in LMICs.

A scoping review of research on Canadian team-based primary care pharmacists

OBJECTIVES

An ageing population with an increasing prevalence of chronic disease and complex medication regimens has placed a strain on healthcare systems in Canada. A limited number of team-based primary care pharmacists are integrated into primary care clinics across the country, working alongside other members of the health care team to identify and resolve drug therapy problems and improve outcomes. While many studies have been completed in the area, the extent of research on integrated team-based primary care pharmacists in Canada is unknown. The objectives of this work were to describe the literature that exists surrounding pharmacists in a primary health care team setting in Canada. A scoping review of research focusing on pharmacists in team-based primary health care settings in Canada was performed. Thematic analysis was then performed to categorize the identified studies.

KEY FINDINGS

The search identified 874 articles, of which 93 met inclusion criteria relevant to the objective. From these 93 studies, 4 themes and 23 subthemes were identified, with some studies having more than one theme or subtheme. Themes identified were the following: primary care pharmacist scope of practice (n = 79 studies), collaboration/communication within the primary care setting (n = 26), chronic disease management (n = 24) and 'other' (n = 15).

SUMMARY

This research quantified and categorized 93 studies on pharmacists in interprofessional primary care teams in Canada. As this is an expanding role for pharmacists in Canada, understanding the current state of the literature is an important consideration when developing future team-based primary care roles.

A Descriptive Study Examining Trends in Pharmacist-Authored Original Research Publications in the Journal of the American Medical Association Network from 2000 to 2019

Pharmacists are expected to participate in the conduction of research to advance the profession and health care broadly. Additional opportunities for pharmacist research engagement have emerged with the increased integration of clinically trained pharmacists into interprofessional care teams. Research conducted over the past four decades has demonstrated an increasing trend of pharmacist-authored publications in medical journals. The purpose of this study was to build upon this work and investigate trends in pharmacist-authored original research publications within the JAMA Network over the past 20 years. A descriptive study design was used to retrospectively evaluate trends in the numbers of pharmacist-authored publications and authorship within those publications in nine JAMA Network journals. Data were aggregated into ten-year time periods (2000–2009 and 2010–2019) and compared using chi-square and Fisher’s exact tests. Overall, pharmacist-authored publications significantly increased over the ten-year period (2.0% to 3.0%, p < 0.001), including in five specific journals: JAMA, JAMA Dermatology, JAMA Neurology, JAMA Ophthalmology, and JAMA Surgery. There was no change in first—and senior-authored publications. While the overall pharmacist publication trend was positive, room for significant growth remains. A deeper understanding of the barriers and facilitators to pharmacist engagement in research is needed, along with strategies to enhance pharmacist research training.

The Evolving Role and Impact of Integrating Pharmacists into Primary Care Teams: Experience from Ontario, Canada

The movement to integrate pharmacists into primary care team-based settings is growing in countries such as Canada, the United States, the United Kingdom, and Australia. In the province of Ontario in Canada, almost 200 pharmacists have positions within interdisciplinary primary care team settings, including Family Health Teams and Community Health Centers. This article provides a narrative review of the evolving roles of pharmacists working in primary care teams, with a focus on evidence from Ontario, as well as drawing from other jurisdictions around the world. Pharmacists within primary care teams are uniquely positioned to facilitate the expansion of the pharmacist’s scope of practice, through a collaborative care model that leverages, integrates, and transforms the medication expertise of pharmacists into a reliable asset and resource for physicians, as well as improves the health outcomes for patients and optimizes healthcare utilization.

A profession in danger: Stakeholders' perspectives on supporting the pharmacy profession in Lebanon

Background

Lebanon boosts one of the highest pharmacists to population ratios globally (20.3/10,000). Yet, workforce analysis elicited serious concerns with the distribution, practice environments and regulation of Lebanese pharmacists. Recent workforce data shows that the profession has been majorly destabilized with hundreds of pharmacists closing their pharmacies or losing their employment. Proper planning for the future of the pharmacy profession in Lebanon necessitates a deeper understanding of the current challenges and the necessary policy and practice recommendations. The aim of this study is to examine stakeholders’ perspectives on the current pharmacist workforce challenges and the necessary measures to support the profession.

Methods

The research team carried out a series of semi-structured interviews with twenty-one key stakeholders within the pharmacy profession in Lebanon. We categorized stakeholders according to their experience as policy makers, practitioners, academicians, and media experts. The interview guide included questions about workforce trends, labor market challenges and recommendations for improvement. Interviews were transcribed and analyzed thematically.

Results

Four major themes emerged from this study: the oversupply of pharmacists in Lebanon, the demand supply imbalance, poor regulation of the pharmacy practice, and the difficult practice environment. There was a consensus among interviewees that the oversupply of pharmacists is due to the poor workforce planning and weak regulatory framework, combined with the easy integration of foreign-trained pharmacists into the labor market. The lack of coordination between the educational and practice sectors is further widening the demand-supply gap. Interviewees further revealed that the regulatory policies on pharmacy practice were outdated and/or weakly enforced which increases the risk of unethical practices and erodes the image of pharmacists in the society. With respect to the practice environment, there is an ongoing struggle by Lebanese pharmacists to maintain profitability and exercise their full scope of practice.

Conclusion

The poor pharmacy workforce planning and regulation is significantly weakening the pharmacy profession in Lebanon. A concerted effort between the various stakeholders is necessary to enhance workforce planning, regulate supply, optimize the integration of pharmacists into work sectors of need, and improve the financial and professional wellbeing of pharmacists in Lebanon.

Community pharmacists' evolving role in Canadian primary health care: a vision of harmonization in a patchwork system

Canada's universal public health care system provides physician, diagnostic, and hospital services at no cost to all Canadians, accounting for approximately 70% of the 264 billion CAD spent in health expenditure yearly. Pharmacy-related services, including prescription drugs, however, are not universally publicly insured. Although this system underpins the Canadian identity, primary health care reform has long been desired by Canadians wanting better access to high quality, effective, patient-centred, and safe primary care services. A nationally coordinated approach to remodel the primary health care system was incited at the turn of the 21st century yet, twenty years later, evidence of widespread meaningful improvement remains underwhelming. As a provincial/territorial responsibility, the organization and provision of primary care remains discordant across the country. Canadian pharmacists are, now more than ever, poised and primed to provide care integrated with the rest of the primary health care system. However, the self-regulation of the profession of pharmacy is also a provincial/territorial mandate, making progress toward integration of pharmacists into the primary care system incongruent across jurisdictions. Among 11,000 pharmacies, Canada's 28,000 community pharmacists possess varying authority to prescribe, administer, and monitor drug therapies as an extension to their traditional dispensing role. Expanded professional services offered at most community pharmacies include medication reviews, minor/common ailment management, pharmacist prescribing for existing prescriptions, smoking cessation counselling, and administration of injectable drugs and vaccinations. Barriers to widely offering these services include uncertainties around remuneration, perceived skepticism from other providers about pharmacists' skills, and slow digital modernization including limited access by pharmacists to patient health records held by other professionals. Each province/territory enables pharmacists to offer these services under specific legislation, practice standards, and remuneration models unique to their jurisdiction. There is also a small, but growing, number of pharmacists across the country working within interdisciplinary primary care teams. To achieve meaningful, consistent, and seamless integration into the interdisciplinary model of Canadian primary health care reform, pharmacy advocacy groups across the country must coordinate and collaborate on a harmonized vision for innovation in primary care integration, and move toward implementing that vision with ongoing collaboration on primary health care initiatives, strategic plans, and policies. Canadians deserve to receive timely, equitable, and safe interdisciplinary care within a coordinated primary health care system, including from their pharmacy team.

Family physician perceptions of barriers and enablers to integrating a co-located clinical pharmacist in a medical clinic: A qualitative study

OBJECTIVE

Pharmacists from The University of British Columbia Pharmacists Clinic provide comprehensive medication management services once to twice a month through the co-location model at multiple general practice clinics beginning from 2014 and consistently since 2016. For some of the clinics, this was the first experience with a co-located allied health professional. The objective of this study was to examine the perspectives of physicians who had a relatively long-standing relationship with a co-located pharmacist to identify barriers and facilitators to integrating a clinical pharmacist.

METHODS

A qualitative research methodology was used to gain the perspectives of physicians. Data were collected through convenience sampling and one-on-one semistructured interviews. In-person or telephone interviews were conducted from August 12, 2019, to September 10, 2019, and audio was recorded with the participants' consent. The recorded interviews were transcribed, and a thematic analysis with an inductive approach was used to analyze the data.

RESULTS

Eight physicians from 4 general practice clinics were interviewed. Analysis of the interviews identified 6 themes that contained barriers or enablers to the integration of a co-located pharmacist: (1) electronic medical record (EMR) use, (2) identifying patients and the referral process, (3) workload and logistics, (4) patients' willingness, (5) impact of in-person communication, and (6) shifting physicians' perspectives. The enablers included the use of an EMR to proactively identify patient referrals, a dedicated pharmacist workspace, a physician champion, and intentional scheduling of in-person physician-pharmacist case conferences. The barriers included identifying patients for referral, the lack of EMR interoperability, pharmacist availability, physician colleagues who were less committed to team-based care, and financial implications despite externally funded pharmacists.

CONCLUSION

The physician participants perceived several barriers and enablers to the integration of a pharmacist into their practice. The themes identified can be used to inform physicians and pharmacists on the integration process for team-based primary care.

Development of Key Performance Indicators for Capturing Impact of Pharmaceutical Care in Palestinian Integrative Healthcare Facilities: A Delphi Consensus Study

Background

The current study was performed to develop a consensus-based core inventory of key performance indicators (KPIs) to be used in capturing the impact of pharmaceutical care in healthcare facilities that employ integrative medicine paradigm in Palestine.

Methods

A panel of healthcare professionals and risk/quality assurance managers was composed employing a judgmental sampling technique. The study tool was a questionnaire. Views and opinions of the panelists on the roles of pharmacists in caring for patients admitted to or visiting healthcare facilities that employ integrative medicine were collected using 11 statements. An initial inventory of activities and services that potentially can be used as KPIs was compiled from the literature and interviews with key contact experts in the domain. Three iterative Delphi rounds were conducted among the panelists (n = 50) to achieve formal consensus on the KPIs that should be used. The consensus-based KPIs were ordered by the scores of the panelists.

Results

A total of 8 consensus-based KPIs were developed. The KPIs related to the number of problems related to medications and complementary and alternative medicine (CAM) that were resolved by pharmacists and CAM practitioners (p < 0.0001), number of patients for whom reconciliations were documented (p < 0.0001), number of patients receiving direct, comprehensive, and/or collaborative care (p < 0.0001), and number of patients for whom pharmacists and CAM practitioners were involved in implementing a therapeutic plan (p < 0.05) were rated significantly higher than the KPI (#8) related to the participation in multi-healthcare provider discussions/deliberations.

Conclusions

Consensus-based KPIs that can be used in capturing the impact of evidence-based CAM and pharmaceutical care of patients in healthcare facilities that employ integrative medicine paradigm were developed. Future studies are still needed to investigate if implementing these KPIs might promote evidence-based CAM and pharmaceutical care in healthcare facilities that employ the integrative medicine paradigm.

Appropriateness of Medications in Older Adults Living With Frailty: Impact of a Pharmacist-Led Structured Medication Review Process in Primary Care

Background: Older persons with frailty take multiple medications and are vulnerable to inappropriate prescribing. Objective: This study assesses the impact of a team-based, pharmacist-led structured medication review process in primary care on the appropriateness of medications taken by older adults living with frailty. Methods: This was a quasi-experimental pretest-posttest design in 6 primary care practices within an academic clinic in Edmonton, Alberta, Canada. We enrolled community dwelling older adults 65 years and older with frailty who have polypharmacy and/or 2 or more chronic conditions (ie, high-risk group for drug-related issues). The intervention was a structured pharmacist-led medication review using evidence-based explicit criteria (ie, Beers and STOPP/START criteria) and implicit criteria (ie, pharmacist expertise) for potentially inappropriate prescribing, done in the context of a primary care team-based seniors’ program. We measured the changes in the number of medications pre- and postmedication review, number of medications satisfying explicit criteria of START and STOPP/Beers and determined the association with frailty level. Data were analyzed using descriptive and inferential statistics (a priori significance level of P < .05). Results: A total of 54 participants (61.1% females, mean age 81.7 years [SD = 6.74]) enrolled April 2017 to May 2018 and 52 participants completed the medication review process (2 lost to hospitalization). Drug-related problems noted on medication review were untreated conditions (61.1%), inappropriate medications (57.4%), and unnecessary therapy (40.7%). No significant changes in total number of medications taken by patients before and after, but the intervention significantly decreased number of inappropriate medications (1.15 meds pre to 0.9 meds post; P = .006). Conclusion: A pharmacist-led medication review is a strategy that can be implemented in primary care to address inappropriate medications.

Quality Indicators of Pharmaceutical Care in Palestinian Integrative Healthcare Facilities: Findings of a Qualitative Study among Stakeholders

Background

Recently, there has been shifts from providing large volumes to providing higher quality of healthcare services. This qualitative exploratory study was conducted to explore the views of different stakeholders on activities and services that could serve as quality indicators of pharmaceutical care in Palestinian integrative healthcare facilities.

Methods

A judgmental sampling technique was used to invite and recruit stakeholders for this study. Semistructured in-depth interviews were conducted with the stakeholders. Data collected during the interviews were qualitatively analyzed using the interpretive description methodology. Themes, subthemes, and patterns were recognized using the Qualitative Analysis Guide of Leuven. The data were coded using RQDA software.

Results

Interviews (n = 22) were conducted with 9 complementary and alternative medicine practitioners, 8 pharmacists, 2 physicians, 2 nurses, and 1 risk/quality assurance manager. The interview median duration was 41 with an IQR of 22 min. Following the thematic analysis adopted to achieve the objectives of this study, six major themes emerged from the data collected from the interviews. The themes emerged from the data were (1) provision of collaborative, direct, and comprehensive patient care services; (2) common services and activities at the time of admission, during stay, at transition between wards/services/hospitals, and at discharge to home or community care; (3) screening for, identifying, and resolving problems; (4) collaboration with other healthcare providers; (5) professional development; and (6) performance and efficiency.

Conclusions

Quality indicators are invaluable for informing decisions relevant to justifying allocation of scarce resources, securing funds, and demonstrating value in activities and services within integrative healthcare facilities. Further studies are still needed to develop a set of measurable indicators to measure the impact of pharmaceutical care in integrative healthcare facilities.

Medication Therapy Management: Current Challenges

Medication therapy management (MTM) services have evolved as a means for pharmacists and other providers to assist patients and caregivers in improving therapeutic outcomes and reducing health care expenditures. More than a decade has passed since the Medicare Modernization Act of 2003 provided pharmacists with the opportunity to deliver MTM services to Medicare beneficiaries. MTM continues to offer pharmacists the opportunity to use their knowledge; yet, pharmacists have reported challenges with service delivery. Identifying the challenges that affect MTM services in pharmacy practice is necessary in order to seek improvement to MTM delivery. This narrative review explores the current challenges pharmacists face with MTM delivery, summarizes potential solutions for addressing challenges, and seeks to incite further debate, service reconfiguration, and ultimately service improvement of pharmacist-provided MTM services.

Clinical pharmacist facilitators in primary care: a descriptive study of their roles and services provided in general practices of southern New Zealand

INTRODUCTION Internationally, the inclusion of pharmacists into general practice as clinical pharmacy facilitators has improved patient outcomes. However, clinical pharmacists are relatively new to southern New Zealand general practices and their range of services has not been studied. AIMS To describe the implementation of clinical pharmacist services in general practices in the Southern region; to examine the tasks conducted by clinical pharmacy facilitators; and to determine the characteristics of patients who access this service. METHODS The establishment and development of the clinical pharmacy facilitator role was determined by documentation held within the local Primary Health Organisation. The activities performed by clinical pharmacy facilitators were collected from patient medical records for the period 31 March 2015 to 31 March 2018. To describe the characteristics of patients receiving these services, a retrospective case note review of patients seen by the facilitators was conducted. RESULTS The clinical pharmacy facilitator role was initiated with three pharmacists in three geographical locations across the region. Within 18 months, the number of facilitators was increased to eight. As a result of collaboration with the general practice team, 42% of referrals came from general practitioners directly. Overall, 2621 medicine-related problems were identified in 2195 patients. Dosage adjustment was the most common recommendation made by pharmacy facilitators. They consulted mostly older patients and patients taking five or more medicines. DISCUSSION With effective collaboration, clinical pharmacy facilitators can play a key role in optimisation of medicines therapy.

Quality Indicators of Pharmaceutical Care for Integrative Healthcare: A Scoping Review of Indicators Developed Using the Delphi Technique

Background

Recently, measuring and benchmarking provision of healthcare services has drawn a considerable attention. This scoping review was conducted to identify, describe, and summarize studies in which the Delphi technique was used to develop quality indicators of pharmaceutical care. The study also aimed to identify activities and services that could be used to capture the impact of pharmacist in integrative medicine.

Methods

Databases were searched from inception to February 2020 using key terms that were combined using Boolean operators. Studies were included if they were relevant to development of quality indicators of pharmaceutical care with regard to medications or complementary and alternative medicine (CAM) modalities. Full text of the selected studies was imported into EndNote. Studies were screened and data were extracted into a standard extraction form.

Results

Data were extracted from 31 studies. Of those, 24 (77.4%) were related to provision of pharmaceutical services relevant to medications and 7 (22.6%) were related to provision of care using CAM modalities. Most of the studies (67.7%) were published in 2010 and beyond. Almost half of the studies (48.4%) originated from the United States, United Kingdom, and Canada. A total of 42 different activities and services that could be used as quality indicators were identified from the studies included in this review. Activities and services were related to history taking, performing reconciliations, identifying and resolving therapy problems, providing collaborative care, designing care plans, optimal performance, and continuing education.

Conclusions

Although there is an increasing interest in improving healthcare delivery, quality indicators of pharmaceutical services and those relevant to CAM provision in healthcare facilities adopting the integrated healthcare paradigm are still limited. Future studies are needed to develop validated quality indicators that could be successfully used in measuring and benchmarking quality of services in integrated healthcare facilities.

Development of key performance indicators to capture in measuring the impact of pharmacists in caring for patients with epilepsy in primary healthcare: A Delphi consensual study

OBJECTIVE

This study was conducted to develop and achieve formal consensus on a core set of key performance indicators (KPIs) that can be captured in measuring the impact of pharmacists in caring for patients with epilepsy (PWE) visiting epilepsy clinics as outpatients in primary healthcare practice.

METHODS

In this study, a comprehensive literature search and review was conducted to extract candidate KPIs. Interviews with key contacts (6 pharmacists, 2 neurologists, 3 nurses, and 3 PWE) were also conducted to supplement the inventory set of KPI candidates. A three-round Delphi technique was followed among a panel of 40 members to achieve formal consensus on a core list of KPIs. Consensual KPIs were ranked by the ratings of the panelists.

RESULTS

The final consensual core set contained 8 KPIs in the thematic activity areas of pharmaceutical care, medication reconciliation and best possible medication history, patient education/counseling, interprofessional patient care, competence, and performance efficiency/patient satisfaction. The KPIs related to therapy problems identified and resolved by pharmacist and provision of proactive comprehensive direct patient care by a pharmacist received significantly higher (p-value: 0.0001) scores compared to the KPI related to complaints about pharmacists received.

CONCLUSION

Eight consensual KPIs to capture in measuring the impact of pharmacists in caring for PWE visiting epilepsy clinics as outpatients in primary healthcare practice were developed using the Delphi technique. If successfully adopted, implemented, captured, and analyzed, these consensual KPIs might help advance pharmaceutical care of PWE in primary healthcare practice.

The Creation of a Practice-Based Network of Pharmacists Working in Family Medicine Groups (FMG)

A needs assessment study of pharmacists working in family medicine groups (FMG) demonstrated the necessity to build a practice-based network. This network would foster a faster integration into FMG and a more efficient collaborative practice. It would also take advantage of an existing practice-based research network (PBRN)—the STAT (Soutien Technologique pour l’Application et le Transfert des pratiques novatrices en pharmacie) network. A working group of nine FMG pharmacists from the different regions of the province of Quebec, Canada, and a committee of partners, including the key pharmacy organizations, were created. Between January 2018 and May 2019, nine meetings took place to discuss the needs assessment results and deploy an action plan. The practice-based network first year activities allowed identifying pharmacists working in FMGs across the province. A directory of these pharmacists was published on the STAT network. The vision, mission, mandate, name («Réseau Québécois des Pharmaciens GMF») and logo were developed. The first few activities include: Bi-monthly newsletters; a mentorship program; short evidence-based therapeutic letters (pharmacotherapeutic capsules) and a start-up kit to facilitate integration of these pharmacists. The Quebec FMG pharmacist practice-based network has been launched. It is planned to evaluate the members’ satisfaction in late Spring 2020 with regards to activities and resources provided.

Pharmacy Students' Perspectives on Interprofessional Learning in a Simulated Patient Care Ward Environment

Objective. To assess pharmacy students' opinions of an interprofessional learning (IPL) course in their final year of the Bachelor of Pharmacy program at The University of Auckland. Methods. Pharmacy students participated in the second day of a two-day simulation-based course, WardSim, alongside medical and nursing students in an acute care, hospital ward setting. After finishing the course, all students were asked to complete a questionnaire. The responses of pharmacy, nursing, and medical students on the scaled questions were compared. An in-depth thematic analysis of the pharmacy students' responses to the open-ended questions was completed using an iterative process. Results. Significant differences were found among the students' responses regarding the prioritization of care, systematic assessment of patients, and communication strategies. Pharmacy students had less favourable responses regarding the IPL experience than medical and nursing students. However, overall responses were positive. Some of the themes that emerged among the pharmacy students' responses included: learning communication tools, being assertive in communicating with other health care professionals, and understanding their own and others' roles in the health care team. Furthermore, some pharmacy students reported feeling underprepared for and underutilized during patient care scenarios. Conclusion. An IPL experience in an acute patient care setting demonstrated clear and beneficial learning outcomes for pharmacy students, especially in regards to communicating and understanding their roles and those of others on their team. Tailoring the pre-work or scenarios for the IPL experience to be more pharmacy orientated and having pharmacy students participate on both days may improve the preparedness for IPL.

How do pharmacists in English general practices identify their impact? An exploratory qualitative study of measurement problems

BACKGROUND

In England, there is an ongoing national pilot to expand pharmacists' presence in general practice. Evaluation of the pilot includes numerical and survey-based Key Performance Indicators (KPIs) and requires pharmacists to electronically record their activities, possibly by using activity codes. At the time of the study (2016), no national evaluation of pharmacists' impact in this environment had been formally announced. The aim of this qualitative study was to identify problems that English pharmacists face when measuring and recording their impact in general practice.

METHODS

All pharmacists, general practitioners (GPs) and practice managers working across two West London pilot sites were invited, via e-mail, to participate in a focus group study. Appropriately trained facilitators conducted two audio-recorded, semi-structured focus groups, each lasting approximately 1 h, to explore experiences and perceptions associated with the KPIs. Audio-recordings were transcribed verbatim and the data analysed thematically.

RESULTS

In total, 13 pharmacists, one GP and one practice manager took part in the study. Four major themes were discerned: inappropriateness of the numerical national KPIs ("whether or not we actually have positive impact on KPIs is beyond our control"); depth and breadth of pharmacists' activity ("we see a huge plethora of different patients and go through this holistic approach - everything is looked at"); awareness of practice-based pharmacists' roles ("I think the really important [thing] is that everyone knows what pharmacists in general practice are doing"); and central evaluation versus local initiatives ("the KPIs will be measured by National Health Service England regardless of what we think" versus "what I think is more pertinent, are there some local things we're going to measure?").

CONCLUSIONS

Measures that will effectively capture pharmacists' impact in general practice should be developed, along with a set of codes reflecting the whole spectrum of pharmacists' activities. Our study also points out the significance of a transparent, robust national evaluation, including exploring the needs/expectations of practice staff and patients regarding pharmacists' presence in general practice.

Pharmacist-participated medication review in different practice settings: Service or intervention? An overview of systematic reviews

Introduction

Medication review (MR) is a pharmacy practice conducted in different settings that has a positive impact on patient health outcomes. In this context, systematic reviews on MR have restricted the assessment of this practice using criteria such as methodological quality, practice settings, and patient outcomes. Therefore, expanding research on this subject is necessary to facilitate the understanding of the effectiveness of MR and the comparison of its results.

Aim

To examine the panorama of systematic reviews on pharmacist-participated MR in different practice settings.

Methods

A literature search was undertaken in Biblioteca Virtual em Saúde (BVS), Embase, PubMed, Scopus, The Cochrane Library, and Web of Science databases through January 2018 using keywords for "medication review", "systematic review", and "pharmacist". Two independents investigators screened titles, abstracts, full texts; assessed methodological quality; and, extracted data from the included reviews.

Results

Seventeen systematic reviews were included, of which sixteen presented low to moderate methodological quality. Most of reviews were conducted in Europe (n = 7), included controlled primary studies (n = 16), elderly patients (n = 9), and long-term care facilities (n = 8). Seven reviews addressed MR as an intervention and thirteen reviews cited collaboration between physicians and pharmacists in the practice of MR. In addition, thirteen terminologies for MR were used and the main objective was to identify and solve drug-related problems and/or optimize the drug use (n = 11).

Conclusion

There is considerable heterogeneity in practice settings, population, definitions, terminologies, and approach of MR as well as poor description of patient care process in the systematic reviews. These facts may limit the comparison, summarization and understanding of the results of MR. Furthermore, the methodological quality of most systematic reviews was below ideal. Thus, international agreement on the MR process is necessary to assess, compare and optimize the quality of care provided.

Survey of pharmacist prescribing practices in Alberta

PURPOSE

Results of a survey to characterize pharmacist prescribing in the Canadian province of Alberta are reported.

METHODS

A cross-sectional survey of a random sample of pharmacists registered with the Alberta College of Pharmacists was conducted. The survey was developed in four stages, with evidence of reliability and construct validity compiled. Analysis of variance and chi-square testing were used to compare prescribing behaviors.

RESULTS

Three hundred fifty of 692 invited pharmacists (51%) completed the survey, with 76.9% and 11.1% indicating that they practiced in community and hospital settings, respectively, and 12.0% practicing in a consultant role (i.e., on a primary care team or in a long-term care setting). Overall, 93.4% of the pharmacists had prescribed. The most common practices were renewing prescriptions for continuity of therapy (92.3%), altering doses (74.3%), and substituting a medication due to a shortage (80.6%). Twenty-three pharmacists (6.6%) indicated that they did not prescribe because they were on an interprofessional team, had a consulting role, or preferred to fax physicians to request orders. Pharmacists with additional prescribing authorization (6.3% of the total survey population) were more likely to prescribe to adjust ongoing medications (63.6%) than to initiate a new medication (18.2%).

CONCLUSION

A survey showed that Alberta pharmacists prescribed in a manner that mirrored their practice environment. Compared with other groups, hospital and consultant pharmacists were more likely to adapt prescriptions, and community pharmacists were more likely to renew medications. Pharmacists in rural areas were prescribing most frequently.

Experiences of Pharmacy Trainees from an Interprofessional Immersion Training

Interprofessional education is essential in that it helps healthcare disciplines better utilize each other and provide team-based collaboration that improves patient care. Many pharmacy training programs struggle to implement interprofessional education. This purpose of the study was to examine the effect of a 30-h interprofessional training that included pharmacy students to determine if the training helped these students build valuable knowledge and skills while working alongside other health care professions. The interprofessional training included graduate-level trainees from pharmacy, behavioral health, nursing, and family medicine programs where the trainees worked within teams to build interprofessional education competencies based on the Interprofessional Education Collaborative core competencies. Sixteen pharmacy trainees participated in the training and completed pre- and post-test measures. Data were collected over a two-year period with participants completing the Team Skills Scale and the Interprofessional Attitudes Scale. Paired sample t-tests indicated that, after this training, pharmacy trainees showed significant increases in feeling better able to work in healthcare teams and valuing interprofessional practice.

Piloting the Integration of Non-Dispensing Pharmacists in the Australian General Practice Setting: A Process Evaluation

Introduction

This process evaluation examined the circumstances affecting implementation, intervention design and situational context of the twelve week pilot phase of a project integrating five pharmacists into twelve general practice sites in Western Sydney.

Description of Care Practice

This study used a mixed method study design using qualitative data obtained from semi-structured interviews and quantitative data collected by project pharmacists to analyse the process of the integrating pharmacists is general practice. Framework analysis of the interview transcripts was used to align the results with the key process evaluation themes of implementation, mechanism of impact and context. Preliminary quantitative data was used to provide implementation feedback and to support the qualitative findings.

Results

The interventional design included three phases, patient recruitment and selection, the pharmacist consultation and the communication and recording of recommendations. A number of barriers and facilitators affecting implementation were identified. Insight into the situational context of the intervention was gained from examining the differences between individual pharmacists and between practice sites.

Conclusion

Conducting a process evaluation in the pilot phase of an integrated care project can allow adjustments to be made to the project procedures to improve the effectiveness and reproducibility of the intervention going forward.

Integrating Physiotherapists into Primary Health Care Organizations: The Physiotherapists' Perspective

Purpose: This study's purpose was to gain insight into physiotherapists' perspectives on the perceived barriers and facilitators of integrating physiotherapists into primary health care (PHC) teams. Method: A qualitative descriptive approach consisting of semi-structured face-to-face or telephone interviews was used. Interviews were audio recorded, transcribed verbatim, and checked by the interviewers to ensure trustworthiness. Data were analyzed using Braun and Clarke's six steps to thematic analysis. Results: Eight participants were interviewed, representing physiotherapists from diverse demographics and geographical regions in Ontario. Common themes discussed were the orientation process, their experiences of integrating the physiotherapist's role into the organization, programme development compared with one-to-one care, the characteristics of the physiotherapist and the interdisciplinary team, and the resources available in the organization. Our key findings of influential factors for integration were (1) the diversity and novelty of new physiotherapists' role, (2) team members' understanding of the physiotherapists' role, and (3) physiotherapists' actions and values regarding PHC. Conclusions: The integration process is affected by factors ranging from individual to system levels. The integration of physiotherapists into PHC would be enhanced by a greater understanding of the role of physiotherapy in PHC by physiotherapists, other health care professionals, and system planners.

Impact of Pharmacists in a Community-Based Home Care Service: A Pilot Program

Background

Historically, pharmacists have not been included on home care teams, despite the fact that home care patients frequently experience medication errors. Literature describing Canadian models of pharmacy practice in home care settings is limited. The optimal service delivery model and distribution of clinical activities for home care pharmacists remain unclear.

Objectives

The primary objective was to describe the impact of a pharmacist based at a community home care office and providing home visits, group education, and telephone consultations. The secondary objective was to determine the utility of acute care clinical pharmacy key performance indicators (cpKPIs) in guiding home care pharmacy services, in the absence of validated cpKPIs for ambulatory care.

Methods

The Winnipeg Regional Health Authority hired a pharmacist to develop and implement the pilot program from May 2015 to July 2016. A referral form, consisting of consultation criteria used in primary care practices, was developed. The pharmacist also reviewed all patient intakes and all patients waiting in acute care facilities for initiation of home care services, with the goal of addressing issues before admission to the Home Care Program. A password-protected database was built for data collection and analysis, and the data are presented in aggregate.

Results

A total of 197 referrals, involving 184 patients, were received during the pilot program; of these, 62 were excluded from analysis. The majority of referrals (95 [70.4%]) were for targeted medication reviews, and 271 drug therapy problems were identified. Acceptance rates for the pharmacist's recommendations were 90.2% (74 of 82 recommendations) among home care staff and 47.0% (55 of 117 recommendations) among prescribers and patients. On average, 1.5 cpKPIs were identified for each referral.

Conclusions

The pilot program demonstrated a need for enhanced access to clinical pharmacy services for home care patients, although the best model of service provision remains unclear. More research is warranted to determine the optimal pharmacy service for home care patients and the most appropriate cpKPIs to measure its effects.

Activities performed by pharmacists integrated in family health teams: Results from a web-based survey

Objectives

Family health teams (FHTs), an interprofessional primary care practice model, were established in Ontario in 2005. As of October 2014, 191 FHT organizations were in operation, and 111 (58%) included one or several pharmacists. The objective of this study was to document the focus of pharmacist activities in FHTs.

Approach

We invited all 155 known FHT pharmacists to a web-based survey. The survey was constructed using information obtained from previously done semi-structured telephone interviews with pharmacists working in FHTs. The survey consisted of a list of activities, grouped into 5 main categories, and participants were asked to estimate time spent on each category. Free-text response questions allowed participants to identify activities not listed. Survey results were analyzed using descriptive statistics and content analysis for open-ended responses.

Results

Seventy (45%) pharmacists completed the survey. The mean respondent age was 43 years, and the average length of time working in an FHT was 4 years. All pharmacists reported being engaged in some form of direct patient care, including managing single therapeutic issues (96%), conducting general medication reviews (70%) and medication reconciliation after hospitalization (63%). Most reported providing education and drug information (83%). Pharmacists felt their work would increase patient medication adherence (94%) and physician adherence to recommended guidelines (86%), as well as reduce inappropriate prescribing (93%), polypharmacy (90%), emergency room and hospital utilization (70%-81%).

Conclusion

Pharmacists in FHTs are strongly focused on direct patient care activities, managing specific medication issues and unstructured drug information to physicians. The majority of pharmacists reported that their activities had a substantial impact on patient medication use and health. The findings from this survey can assist pharmacists new to FHT practice, health policy planning and health research to assess associations between pharmacist activities and measures of health and health care system performance.

Improving Ambulatory Care Resident Training: Preparing for Opportunities to Treat Mental Illness in the Primary Care Setting

PURPOSE

The development of an outpatient psychiatry clinical practice learning experience for PGY2 ambulatory care pharmacy residents in preparation for the treatment of psychiatric disorders in the primary care setting is described.

SUMMARY

With the increased prevalence of psychiatric disorders, significant mortality, and limited access to care, integration of mental health treatment into the primary care setting is necessary to improve patient outcomes. Given the majority of mental health treatment occurs in the primary care setting, pharmacists in patient-centered medical homes (PCMHs) are in a unique position with direct access to patients to effectively manage these illnesses. However, the increased need for pharmacist education and training in psychiatry has prompted a large, Midwestern academic health system to develop an outpatient psychiatry learning experience for PGY2 (Postgraduate Year 2) ambulatory care pharmacy residents in 2015. The goal of this learning experience is to introduce the PGY2 ambulatory care residents to the role and impact of psychiatric clinical pharmacists and to orient the residents to the basics of psychiatric pharmacotherapy to be applied to their future practice in the primary care setting.

CONCLUSION

The development of an outpatient psychiatry learning experience for PGY2 ambulatory care pharmacy residents will allow for more integrated and comprehensive care for patients with psychiatric conditions, many of whom are treated and managed in the PCMH setting.

Development of a Pharmacist REferral Program in a primary cARE clinic (PREPARE): A prospective cross-sectional study

BACKGROUND

Increasing demand for ambulatory health care services has led to the development of primary care multidisciplinary teams that include pharmacists. The objective of this study was to characterize referrals to a pharmacist in a primary care clinic (PCC) based in Chilliwack, British Columbia.

METHODS

This prospective cross-sectional study included all patients referred to the PCC pharmacist over 12 months (May 2015 to April 2016). Data regarding the source/reason for referral, patient demographics, medical problems/medications and number/category of identified drug therapy concerns (DTCs) were collected.

RESULTS

A total of 137 referrals were received. Mean age was 60 years and 59% were female. Twenty patients (15%) did not attend their appointment. Fifty-eight percent were new clinic patients identified using a Medication Risk Assessment Questionnaire (MRAQ), 30% were from PCC clinicians and 12% were from community family physicians. The most common reason for referral was for a medication review (82%). Median number of medical problems and medications per patient were 7 (interquartile range [IQR] 5) and 11 (IQR 7.5), respectively. A total of 460 DTCs were identified (median 4 per patient, IQR 3.5), of which 34% were medication without an indication and 28% an untreated indication.

DISCUSSION AND CONCLUSION

The most common source of referrals to a PCC pharmacist was for medication reviews of new patients using an MRAQ. Most referred patients had multiple medical problems and polypharmacy, and few were referred for disease-specific management. The number of DTCs per patient was variable and, despite polypharmacy being commonplace, almost one-third of patients had an untreated indication.

Exploring Electronic Medical Record and Self-Administered Medication Risk Screening Tools in a Primary Care Clinic

BACKGROUND

Electronic medical record (EMR) screening for indicators of medication risk could improve efficiency in identifying primary care clinic patients in need of clinical pharmacist care compared with patient self-reporting.

OBJECTIVES

To (a) compare the performance of an EMR medication risk assessment questionnaire (MRAQ) with a self-administered (SA) MRAQ and (b) explore each tool's ability to predict indicators of health behavior, health status, and health care utilization.

METHODS

A prospective cohort study was conducted with 143 adults who attended an academic family medicine center and were taking ≥ 2 medications. All participants completed the 10-item SA-MRAQ, Morisky Medication Adherence Scale, Chew's health literacy screener, Stanford Health Distress Scale, and SF-36 overall rating of health. A blinded investigator completed the EMR-MRAQ and a chart review to ascertain 6 months of health care utilization. Outcome measures included the following: (a) scores from the 5- and 10-item SA-MRAQs and 5-item EMR-MRAQ; (b) sensitivity and specificity to determine the accuracy of the 5-item EMR versus the 5-item SA risk scores; (c) correlations between risk assessments and health behavior/status scales; and (d) area under the receiver operator curve to determine how well a high-risk score predicted health care utilization.

RESULTS

The 5-item SA-MRAQ, the 5-item EMR-MRAQ, and the 10-item SA-MRAQ categorized 52.9% (55/104), 69.2% (99/143), and 17.6% (18/102) of participants as high risk, respectively. For the 104 participants who completed both 5-item MRAQ tools, the EMR-MRAQ had a sensitivity of 81.8% and specificity of 49.0% in detecting a high-risk SA-MRAQ score. Both 5-item risk assessments showed weak correlations with health distress and overall health, while the 10-item SA-MRAQ additionally showed weak correlations with medication adherence. The EMR-MRAQ was most effective in predicting all-cause emergency room visits/hospitalization (c-statistic = 0.69; 95% CI=0.57-0.81) and high clinic utilization (≥ 4 visits per 6 months; c-statistic = 0.77; 95% CI = 0.69-0.85). The EMR-MRAQ had high sensitivities but low specificities for these health care utilization outcomes, respectively (82.6% and 33.3%; 88.9% and 42.7%).

CONCLUSIONS

This pilot study suggests that EMR-MRAQ screening has high sensitivity but low specificity in comparison with self-reporting and was able to discriminate between those who would and would not experience health care utilization outcomes. These results justify further development and validation of an automated EMR-based tool to predict patient-important consequences of medication-related problems.

DISCLOSURES

This work was funded by the Canadian Society of Hospital Pharmacists Research and Education Foundation, which had no role in the analysis or interpretation of data or the decision to submit the manuscript for publication. The authors have no conflict of interests, potential or otherwise, to report. Makowsky had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design were contributed by Makowsky and Cor. Makowsky and Wong collected the data, and data interpretation was performed by Makowsky, Cor, and Wong. The manuscript was written by Makowsky and was critically reviewed for intellectual content by Makowsky, Cor, and Wong.

Pharmacy education in Jordan: updates

Objective

To describe the increasing number of pharmacy schools in Jordan.

Method

A review for numbers of schools and their curricula was conducted.

Key findings

To date, there are 18 pharmacy schools in Jordan. PharmD program is offered by two public schools. PhD program is offered by one school; while MSc program is offered by seven schools. Public pharmacy schools have two similar programs in terms of curricula, ‘regular’ and ‘parallel’. The ratio of pharmacists to 1000 population was 2.1 in 2012. Substantial increase in pharmacists’ integration is needed in public and private primary care settings.

Conclusions

Number of pharmacy schools and pharmacy graduates in Jordan seems to be ‘high’. If the schools are to remain on a track of growth, let the emphasis shift to PharmD expansion.

Hospital pharmacists seen through the eyes of physicians: qualitative semi-structured interviews

Background Pharmacist-physician collaboration can lead to many positive outcomes. However, collaboration between healthcare providers is complex and rarely performed optimally. Objectives To study physician-pharmacist collaboration in hospital settings, from the physician's point of view. Setting Eight regional non-teaching hospital facilities, within a local area of northwest Switzerland, supplied by an independent central pharmacy. Method Physicians were sampled using a maximal variation purposive method. Qualitative semi-structured interviews were conducted and their content was recorded. Mind maps were made with the collected data. An inductive approach was used for the analysis. Main outcome measure Physicians' main perceptions of hospital pharmacists. Results Twelve physicians and one medical student were interviewed (average interview length 37 min). Key opinions (n ≥ 7) include the following: physicians lack knowledge about hospital pharmacists' roles, competences and activities. Physicians report a lack of presence and involvement of hospital pharmacists. Although physicians value hospital pharmacists' complementary competences, they also point out a knowledge gap between them and that hospital pharmacists lack clinical competences. Some pharmaceutical activities (e.g. drug formulary management or participation in ward rounds) lead to significant drawbacks for physicians. Other pharmaceutical activities (e.g. teaching and supervision) are valued and sought for by physicians. Physicians report they take drug treatment decisions as they bear the legal responsibility. Conclusion The presence, visibility and implication of hospital pharmacists need to be improved, and physicians should be more aware of what they can offer them. Physicians' expectations and needs should be taken further into consideration and new models of interaction should be developed.