Pharmacists' perceptions of advancing public health priorities through medication therapy management

Testing the feasibility of the QuitAid smoking cessation intervention in a randomized factorial design in an independent, rural community pharmacy

BACKGROUND

Adult smoking rates in the USA are highest in economically depressed rural Appalachia. Pharmacist-delivered tobacco cessation support that incorporates medication therapy management (such as the QuitAid intervention) is a promising approach to address this need.

METHODS

Twenty-four adult smokers recruited between September and November 2021 through an independent pharmacy in rural Appalachia were randomized in a non-blinded 2 × 2 × 2 factorial design to (1) pharmacist delivered QuitAid intervention (yes vs. no); (2) combination nicotine replacement therapy (NRT) gum + NRT patch (vs. NRT patch); and/or (3) 8 weeks of NRT (vs. standard 4 weeks). Participants received 4 weeks of NRT patch in addition to the components to which they were assigned. Participants completed baseline and 3-month follow-up assessments. Primary outcomes were feasibility of recruitment and randomization, retention, treatment adherence, and fidelity.

RESULTS

Participants were recruited in 7 weeks primarily through a referral process, commonly referred to as ask-advise-connect (61%). Participants were on average 52.4 years old, 29.2% were male and the majority were white (91.6%) and Non-Hispanic (91.7%). There was a high level of adherence to the interventions, with 85% of QuitAid sessions completed, 83.3% of the patch used, and 54.5% of gum used. Participants reported a high level of satisfaction with the program, and there was a high level of retention (92%).

CONCLUSIONS

This demonstration pilot randomized controlled study indicates that an ask-advise-connect model for connecting rural smokers to smoking cessation support and providing QuitAid for smoking cessation is feasible and acceptable among rural Appalachian smokers and independent pharmacists. Further investigation into the efficacy of a pharmacist-delivered approach for smoking cessation is needed.

TRIAL REGISTRATION

The trial was retrospectively registered at ClinicalTrials.gov. Trial #: NCT05649241.

Reaching adults who smoke cigarettes in rural Appalachia: Rationale, design & analysis plan for a mixed-methods study disseminating pharmacy-delivered cessation treatment

INTRODUCTION

Unlike other U.S. geographical regions, cigarette smoking prevalence remains stagnant in rural Appalachia. One avenue for reaching rural residents with evidence-based smoking cessation treatments could be utilizing community pharmacists. This paper describes the design, rationale, and analysis plan for a mixed-method study that will determine combinations of cessation treatment components that can be integrated within community pharmacies in rural Appalachia. The aim is to quantify the individual and synergistic effects of five highly disseminable and sustainable cessation components in a factorial experiment.

METHODS

This sequential, mixed-method research design, based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, will use a randomized controlled trial with a 25 fully crossed factorial design (32 treatment combinations) to test, alone and in combination, the most effective evidence-based cessation components: (1) QuitAid (yes vs. no) (2) tobacco quit line (yes vs. no) (3) SmokefreeTXT (yes vs. no) (4) combination NRT lozenge + NRT patch (vs. NRT patch alone), and (5) eight weeks of NRT (vs. standard four weeks).

RESULTS

Logistic regression will model abstinence at six-months, including indicators for the five treatment factors and all two-way interactions between the treatment factors. Demographic and smoking history variables will be considered to assess potential effect modification. Poisson regression will model quit attempts and percent of adherence to treatment components as secondary outcomes.

CONCLUSION

This study will provide foundational evidence on how community pharmacies in medically underserved, rural regions can be leveraged to increase utilization of existing evidence-based tobacco cessation resources for treating tobacco dependence.

CLINICAL TRIALS

NCT05660525.

Attitudes, perceptions, and barriers of community pharmacists in Rwanda towards health promotion: a cross sectional study

Background

The practice of Pharmacists has changed worldwide over the past years. Today, health promotion is better known as an important part of modern pharmacy practice. Involving Community Pharmacists in health promotion is thus considered a valuable option in addressing public health issues. However, the literature on this practice remains unsubstantiated in African countries. In Rwanda, Community Pharmacists are believed to be solely involved in dispensing and very little has been studied about their role in health promotion. Thus, this study aimed to evaluate attitudes, perceptions, and barriers of Community Pharmacists in Rwanda towards their involvement in health promotion.

Methods

A cross-sectional study was conducted among 236 licensed Community Pharmacists in Rwanda from 23rd January to 23rd June, 2021. A list of all respondents was obtained from Rwanda Food and Drugs Authority. All participants were randomly enrolled. Each community pharmacy was represented by one Pharmacist. We collected data from community pharmacy settings using a self-administered questionnaire made of close and open-ended questions. Statistical analyses were performed using Statistical Packages for Social Sciences (SPSS) version 25.

Results

Of the 236 respondents, (n = 149, 63.1%) were male and (n = 87,37%) were female. The average age was 38.1 years (SD = 4.3). More than half confirmed that professional curriculum is adequate for offering health promotion services (n = 152, 64.4%).Majority responded that health promotion is part of their responsibility, and they are willing to provide health promotion services (n = 233,98.7%).The statement that “Pharmacists should not be involved in public health activities “was opposed by many (n=174,73.7%).The most sought-after service provided was education to drug misuse (n=211, 89.4%).Three major barriers to provision of health promotion were: lack of coordination with other healthcare professionals(n=106,69%),structure of healthcare system (n=157,67%),and lack of equipment (n=144,61%).Most Pharmacists disagreed with the statement that “patients are not interested in getting health promotion services”(n = 134,57%).

Conclusion

Though Community Pharmacists faced several challenges that hindered their participation in health promotion, they had positive attitudes towards promoting public health messages. There are several barriers like lack of structure to provide health promotion services that need to be addressed to boost more active participation of Pharmacists in health promotion.

Incorporating medication therapy management into community pharmacy workflows

Medication Therapy Management (MTM) is a group of pharmacist-provided services that optimize individual patients' drug therapy outcomes. Since community pharmacies' primary business platform is the dispensing of medications, and providing MTM services is a secondary source of revenue, pharmacies with limited resources are operationally challenged when trying to efficiently deliver both types of services. To address this problem, we follow a queueing network approach to develop an operational model of a community pharmacy workflow. Through our model, we derive structural results to determine conditions for a pharmacy to achieve economies of scope when providing both prescription and MTM services. We also develop a process simulation to compare different scenarios according to our economies of scope model, varying in provided services, personnel, service demand, and other operational variables. Outcomes examined include profitability, service rate, and sensitivity of some operation variables to profitability. Based on our results, we provide practical insights to help community pharmacy administrators and healthcare policy makers in their decision process.

Evaluating the feasibility of pharmacist-facilitated tobacco cessation interventions in independent community pharmacies in rural Appalachia

BACKGROUND

Smoking rates in the United States are the highest in underserved rural regions. Thus, more points of contact are needed to link smokers to evidence-based cessation programs.

OBJECTIVES

The purpose of this study was to conduct an evaluation to determine the feasibility, acceptability, and interest among rural pharmacists in implementing a pharmacist-facilitated smoking cessation program in independent community pharmacies in rural Appalachian communities in Virginia, North Carolina, Tennessee, and West Virginia.

METHODS

This study utilized a complementary sequential mixed-methods approach to explore independent community pharmacists and technicians' experiences and beliefs about implementing a tobacco cessation program in their pharmacy.

RESULTS

There were 49 pharmacists or technicians who completed the survey and 7 pharmacists who participated in the interviews. Four main findings emerged from the data: 1) pharmacies can help fill the gap in tobacco cessation services in rural communities, 2) under current practice, tobacco cessation resources when offered by independent community pharmacies are not always formalized, 3) there are known barriers, such as reimbursing for services, that need to be addressed to provide tobacco cessation in an independent pharmacy setting, and 4) the Ask-Advise-Connect model is a feasible tobacco cessation approach in a pharmacy.

CONCLUSION

Although pharmacists may be ideally situated to build capacity for smoking cessation in rural areas, smoking cessation interventions need to use existing approaches that compensate pharmacists for their time spent counseling patients. Furthermore, simple documentation and billing systems are needed to maximize utilization of tobacco cessation products and services provided in the pharmacy.

Community pharmacists' perceptions on providing fall prevention services: a mixed-methods study

Background Pharmacists may contribute to fall prevention particularly by identifying and deprescribing fall risk-increasing drugs (FRIDs) in patients with high fall risk. Objective To assess community pharmacists’ perceptions on providing fall prevention services, and to identify their barriers and facilitators in offering these fall prevention services including deprescribing of FRIDs. Setting A mixed-methods study was conducted with Dutch pharmacists. Method Quantitative (ranking statements on a Likert scale, survey) and qualitative data (semi-structured interviews) were collected. Out of 466 pharmacists who were invited to participate, 313 Dutch pharmacists ranked statements, about providing fall prevention, that were presented during a lecture, and 205 completed a survey. To explore pharmacists’ perceptions in-depth, 16 were interviewed. Quantitative data were analysed using descriptive statistics. All interviews were audiotaped and transcribed verbatim. The capability opportunity motivation-behaviour model was applied to interpret and analyse the findings of qualitative data. Main outcome measure Community pharmacists’ views on providing fall prevention. Results Pharmacists stated that they were motivated to provide fall prevention. They believed they were capable of providing fall prevention by FRID deprescribing. They perceived limited opportunities to contribute. Major barriers included insufficient multidisciplinary collaboration, patient unwillingness to deprescribe FRIDs, and lack of time. Facilitators included goal-setting behaviour, financial compensation, and skilled communication. Conclusion Despite the complex decision-making process in medication-related fall prevention, community pharmacists are motivated and feel capable of providing fall prevention. Opportunities for pharmacists to provide fall prevention services should be enhanced, for example by implementing multidisciplinary agreements.

Community pharmacists' and residents' decision making and unmet information needs when completing comprehensive medication reviews

OBJECTIVE

To (1) characterize community pharmacists' and community pharmacy residents' decision making and unmet information needs when conducting comprehensive medication reviews (CMRs) as part of medication therapy management and (2) explore any differences between community pharmacists and community pharmacy residents in CMR decision making and unmet information needs.

DESIGN

Thirty-to 60-minute semistructured interviews framed using a clinical decision-making model (CDMM) were conducted with community pharmacists and residents.

SETTING AND PARTICIPANTS

Participants were recruited from practice-based research networks and researchers' professional networks. Eligible participants had completed or supported the completion of at least 2 CMRs in the last 30 days.

OUTCOME MEASURES

Two researchers independently coded transcripts using a combination of inductive and deductive methods to identify themes pertaining to community pharmacists' and residents' decision making and unmet information needs in the provision of CMRs. Discrepancies among researchers' initial coding decisions were resolved through discussion.

RESULTS

Sixteen participants (8 pharmacists and 8 residents) were interviewed. Themes were mapped to 5 CDMM steps. Participants primarily used subjective information during "case familiarization"; objective information was secondary. Information used for "generating initial hypotheses" varied by medication therapy problem (MTP) type. During "case assessment," if information was not readily available, participants sought information from patients. Thus, patients' levels of self-management and health literacy influenced participants' ability to identify and resolve MTPs, as described under "identifying final hypotheses." Finally, participants described "decision-making barriers," including communication with prescribers to resolve MTPs. Although pharmacist and resident participants varied in the types of MTPs identified, both groups cited the use and need of similar information.

CONCLUSION

Community pharmacists and residents often rely primarily on patient-provided information for decision making during CMRs because of unmet information needs, specifically, objective information. Moreover, confidence in MTP identification and resolution is reduced by communication challenges with prescribers and limitations in patients' ability to convey accurate and necessary information.

Impacting Student Self-Efficacy and Beliefs of Medication Therapy Management Through a Two-Week Elective

Objective. To develop and introduce an intensive, two-week Foundations of Medication Therapy Management (MTM) elective course into the Doctor of Pharmacy curriculum, and to determine whether the course impacted students' self-confidence in their abilities to perform MTM services and future plans and beliefs about implementing MTM in practice. Methods. The MTM course was an interactive learning environment where students performed actual comprehensive medication reviews within a real-world documentation platform. A 20-item, Likert-scale survey was administered before and after the course to measure students' confidence in learned skills, future plans for using MTM, and beliefs about MTM. Results. Students reported a significant improvement in 10 MTM-specific skill domains. There were significant changes in students' self-confidence in their ability to provide MTM services and in their beliefs about MTM-related services. Students reported overall improvement in self-perceived MTM specific skills. There was no significant change in students' willingness or plans to engage in MTM-related practice in the future. Conclusion. The findings showed that following participation in an MTM elective course, student pharmacists' perceived ability to deliver MTM care increased and their opinions about MTM services improved. Providing a brief MTM elective course that used first-person case studies may empower student pharmacists to confidently perform MTM services in subsequent courses and in their future practice.

Solidarity or dissonance? A systematic review of pharmacist and GP views on community pharmacy services in the UK

There has been a strong policy emphasis over the past decade on optimising patient-centred care and reducing general practitioners' (GPs') workload by extending community pharmacy services and collaboration between pharmacists and GPs. Our aim was to review current evidence of pharmacists' and GPs' views of extended community pharmacy services and pharmacists' roles in the United Kingdom (UK). A systematic review was undertaken looking at UK studies investigating pharmacists' and/or GPs' views of community pharmacy services or roles from 2005 to 2017. A range of databases were searched including EMBASE, PubMed, Scopus, Web of Science, International Pharmaceutical Abstracts (IPA), PsycINFO, Science Direct and The Cumulative Index to Nursing and Allied Health Literature (CINAHL). In addition, reference lists of included studies were screened and grey literature was searched. Following the application of inclusion/exclusion criteria, the quality of papers was critically analysed, findings were extracted into a grid and subjected to narrative synthesis following thematic analysis. The search strategy yielded a total of 4,066 unique papers from which 60 were included. Forty-seven papers covered pharmacists' views, nine combined both pharmacists' and GPs' views and four covered GPs' views. Study designs included interviews (n = 31, 52%), questionnaire surveys (n = 17, 28%) and focus groups (n = 7, 12%). Three main themes emerged from the data: "attitudes towards services/roles", "community pharmacy organisations" and "external influences". Pharmacists and GPs perceived a number of barriers to successful implementation and integration of pharmacy services. Moreover, collaboration between pharmacists and GPs remains poor despite the introduction of extended services. Overall, extending community pharmacy services require quality-driven incentives and joint working between community pharmacists and GPs to achieve better integration within the patient's primary care pathway.

Point-Of-Care Testing Curriculum and Accreditation for Public Health-Enabling Preparedness, Response, and Higher Standards of Care at Points of Need

Objectives: To develop awareness of benefits of point-of-care testing (POCT) education in schools of public health, to identify learning objectives for teaching POCT, to enable public health professionals and emergency responders to perform evidence-based diagnosis and triage effectively and efficiently at points of need, and to better improve future standards of care for public health practice, including in limited-resource settings and crisis situations.

Methods: We surveyed all U.S. schools of public health, colleges of public health, and public health schools accredited by the Council on Education in Public Health (CEPH). We included accredited public health programs, so that all states offering public health education were represented. We analyzed survey data, public health books, and board certification guidelines. We used PubMed to identify public health curriculum papers, and assessed 2019 CEPH accreditation requirements. We merged POCT knowledge bases to design a new curriculum for teaching public health students and practitioners the principles and practice of POCT.

Results: Public health curricula, certification requirements, and textbooks generally do not include POCT instruction. Only one book, Global Point of Care: Strategies for Disasters, Emergencies, and Public Health Resilience, and one online course on public health preparedness address POCT and public health intervention issues. The topic, POC HIV/HCV ED testing, appeared in one course and POC diagnostics in local clinics, in another. Papers on public health curriculum have not incorporated POCT. No curriculum addresses POCT in isolation units during quarantine, despite evidence that recent Ebola virus disease cases in the U.S. and elsewhere proved unequivocally the need for POCT. The modular learning objectives identified in this paper were customized for public health students. Public health graduates can use boot camps, online credentialing, and self-study to acquire POCT skills.

Conclusions: Enhancing accreditation requirements, academic training, board certification, and field experience will generate public health healthcare professionals who will rely upon evidence-based medical decision making at points of care, including during crises when time is of the essence. A POCT-enabled public health workforce can help prevent and stop outbreaks. Public health-based medical professionals urgently need the skills necessary to perform POCT and prepare America and other nations for threats portending significant adverse medical, economic, social, and cultural impact.

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.

Barriers and facilitators to dispensing of intranasal naloxone by pharmacists

BACKGROUND

Although misuse of prescription opioids has reached epidemic proportions, pharmacy-based preventive services to combat this epidemic are limited. The aims of this study were to identify barriers and facilitators to the dispensing of intranasal naloxone (INN) by pharmacists in New Mexico.

METHODS

For this mixed-methods study, a qualitative component (focus group) informed the development of a quantitative component (electronic survey) distributed to all pharmacists registered with the New Mexico Board of Pharmacy and practicing in the state. A 46-item survey included questions about pharmacists' concerns regarding dispensing INN, barriers and facilitators to dispensing INN, efforts needed to increase availability and utilization of pharmacist-dispensed INN, and characteristics of respondents and their pharmacies.

RESULTS

Pharmacists from all geographical regions and all types of pharmacy settings were represented in the sample (final N = 390, participation rate 23.5%, including a subset of 182 community pharmacists). The main barriers identified were (1) out-of-pocket costs for patients; (2) time constraints for pharmacists; and (3) inadequate reimbursement for pharmacists. The main facilitators were (1) increased awareness among opioid-using patients and family members about the need for INN; (2) additional education to the general public; and (3) additional training for pharmacists on how to initiate discussions about INN with high-risk patients. Some community pharmacists were concerned that INN dispensing would promote opioid abuse (16.5%) and attract undesirable clientele (14.3%). In a multivariable logistic regression analysis of a community pharmacy subset, a higher number of concerns about INN (odds ratio [OR] = 0.87; 95% confidence interval [CI]: 0.82-0.93) and a pharmacy setting in a chain grocery or a "big box" store (OR = 0.38; 95% CI: 0.16-0.92) were associated with decreased odds of dispensing INN.

CONCLUSIONS

Effective intervention strategies for increasing dispensing of intranasal naloxone by pharmacists should focus on pharmacists' concerns, include education to multiple audiences, and address provider-level, system-level, and society-level barriers.

Pharmacist contributions to the ten essential services of public health in three National Association of Boards of Pharmacy regions

BACKGROUND

Pharmacists have contributed to improved population health through the delivery of public health services, but their contributions often go unrecognized within the larger health care system.

OBJECTIVES

To determine pharmacist perceptions of their contributions to the 10 essential services of public health and to compare those contributions among pharmacists in Iowa, North Dakota, and Manitoba.

METHODS

Licensed pharmacists in Iowa, North Dakota, and Manitoba were sent an online survey of their perceived level of achievement of the 10 essential services of public health.

RESULTS

A total of 649 pharmacists completed the survey. The 3 essential services that scored the highest overall were enforce laws and regulations that protect health and ensure safety, inform and educate people about health issues, and participate in ongoing training beyond continuing education requirements. Contributions of pharmacists to the 10 essential services of public health were previously evaluated by frequency of citation in the published literature. There was relative agreement between what was reported in the literature and what was determined by survey. One exception was "enforce laws and regulations that protect health and ensure safety," which was rarely reported in the literature but was reported in the survey to be the most frequently delivered service.

CONCLUSION

Pharmacist contributions to improved population health should be reported with the use of the 10 essential services of public health. This will increase recognition of pharmacist contributions and better align the disciplines of pharmacy and public health. In particular, pharmacists should consider ways to increase their level of involvement in the community and in partnership with other health care professionals.

Assessment of pharmacists' delivery of public health services in rural and urban areas in Iowa and North Dakota

Background:

The profession of pharmacy is expanding its involvement in public health, but few studies have examined pharmacists’ delivery of public health services.

Objective:

To assess Iowa and North Dakota pharmacists’ practices, frequency of public health service delivery, level of involvement in achieving the essential services of public health, and barriers to expansion of public health services in rural and urban areas.

Methods:

This study implemented an on-line survey sent to all pharmacists currently practicing pharmacy in Iowa and North Dakota.

Results:

Overall, 602 valid responses were analyzed, 297 in rural areas and 305 in urban areas. Three practice settings (chain stores [169, 28.2%], independent community pharmacies [162, 27.0%], and hospital pharmacies [156, 26.0%]) comprised 81.2% of the sample. Both chain and independent community pharmacists were more commonly located in rural areas than in urban areas (P<0.05). For some public health services, pharmacists in rural areas reported higher frequency of delivery than did pharmacists in urban areas (P < .05) that included: medication therapy management, immunizations, tobacco counseling, and medication take-back programs. For some essential services, pharmacists (particularly independents) in rural areas reported more frequent delivery than did pharmacists in urban areas (P < .05), these included: evaluate the services the pharmacy provides, partner with the community to identify and help solve health problems, and conduct needs assessments to identify health risks in my community.

Conclusion:

Rural pharmacists more frequently deliver public health services than urban in both Iowa and North Dakota. These findings should be interpreted to be primarily due to differences in the role of the rural pharmacist and the quest for certain opportunities that rural pharmacists are seeking.