Mapping the concept of health care integration: A lexicographic analysis of scientific literature

BACKGROUND

Systems fragmentation is a major challenge for an efficient organization, integration being a potential solution also proposed in health care field, including pharmacy as a player. However, the use of different terms and definitions in the literature hinders the comparison of different integration initiatives.

OBJECTIVE

To identify and map the terms used in scientific literature regarding integration in health care and to characterize each emerging topic.

METHODS

A lexicographic analysis of the integration of healthcare systems literature indexed in PubMed was conducted. Ten different systematic searches, four using only Medical Subject Headings (MeSH) and six using text words, were conducted in March 2023. Journal scattering was analyzed following Bradford's distribution using the Leimkuhler model. An overall text corpus was created with titles and abstracts of all the records retrieved. The corpus was lemmatized, and the most used bigrams were tokenized as single strings. To perform a topic modeling, the lemmatized corpus text was analyzed using IRaMuTeQ, producing descending hierarchic classification and a correspondence analysis. The 50 words with higher chi-square statistics in each class were considered as representative of the class.

RESULTS

A total of 42,479 articles published from 1943 to 2023 in 4469 different journals were retrieved. The MeSH "Delivery of Health Care, Integrated", created in the 1996 MeSH update, was the most productive retrieving 33.7 % of the total articles but also retrieving 22.6 % of articles not retrieved in any other search. The text word "Integration" appeared in 15,357 (36.2 %) records. The lexicographic analysis resulted in 7 classes, named as: Evidence and implementation, Quantitative research, Professional education, Qualitative research, Governance and leadership, Clinical research, and Financial resources. Association between the classes and the searches or the text-words used ranged from moderate to weak demonstrating the lack of a standard pattern of use of terms in literature regarding healthcare integration.

CONCLUSIONS

The term "integration" and the MeSH "Delivery of Health Care, Integrated" are the most used to represent the concept of integration in healthcare and should be the preferred terms in the literature.

Spanish translation of the ABC taxonomy for medication adherence

BACKGROUND

The Ascertaining Barriers to Compliance (ABC) taxonomy was developed aiming at systematizing definitions and operationalizations of medication adherence. Its translation is crucial to improve the generalizability, application and comparison of study findings.

OBJECTIVE

To provide a consensus translation of the ABC taxonomy from English to Spanish.

METHODS

A two-phased approach was used, according to the Preferred Methods for the Translation of the ABC Taxonomy for Medication Adherence. Two literature reviews were conducted: to identify Spanish synonyms and definitions of the ABC taxonomy, and to identify a panel of Spanish-speaking experts in medication adherence. A Delphi survey was designed based on the synonyms and definitions found. The experts previously identified were invited to participate in the Delphi. A consensus of ≥85% was established for the first round. A moderate consensus (50-75%), a consensus (75-95%) or a strong consensus (>95%) were considered to be necessary in the second round.

RESULTS

Forty potential synonyms of the ABC taxonomy terms were identified from a total of 270 papers. The response rate during the first Delphi round was 32% (63/197) and in the second round 86% (54/63). A strong consensus was reached for the term "inicio del tratamiento" (96%) and consensus for the term "implementación" (83%). A moderate consensus was obtained for "adherencia a la medicación" (70%), "interrupción del tratamiento" (52%), "manejo de la adherencia" (54%) and "disciplinas relacionadas con la adherencia" (74%). No consensus was reached for the term persistence. Five out of the seven definitions reached a consensus in the first round, and two definitions a moderate consensus after the second round.

CONCLUSION

The adoption of the Spanish taxonomy will increase transparency, comparability and transferability of results in the field of medication adherence. This may facilitate benchmarking of adherence strategies between Spanish-speaking researchers and practitioners, and other language speakers.

Community pharmacy and primary health care - Types of integration and their applicability: A narrative review

BACKGROUND

There is an urgent need for health care systems to be more efficient and efficacious. An approach to integrate public and private provider organizations such as community pharmacies and public primary health care (PHC) merits consideration. The objective of this review was to identify the types of integration in health care settings and discuss their applicability to the potential integration of community pharmacy and PHC.

METHODS

A narrative review using Medline, Scopus and SciELO databases was performed in which terms related to health were combined with terms related to integration. Levels and Types of integration: 14 types of integration were identified (two in breadth, seven as enablers and five in system levels). A model was created which classifies and assigns the types of integration to the different levels of the health system and to the breadth, intensity, and enablers of the integration process. Due to the nature of community pharmacy and PHC system, a horizontal integration at the micro level, supported by meso and macro levels policy, is suggested. The different elements of intensity and enablers can significantly influence the process.

CONCLUSION

The application of principles, concepts and types of integration suggest that it might be feasible and practical to integrate community pharmacies and PHC. However, the conflictive historical context would need to be overcome with appropriate policy and incentives.

Systematic review of pragmatic randomised control trials assessing the effectiveness of professional pharmacy services in community pharmacies

BACKGROUND

Implementation of Professional Pharmacy Services (PPSs) requires a demonstration of the service's impact (efficacy) and its effectiveness. Several systematic reviews and randomised controlled trials (RCT) have shown the efficacy of PPSs in patient's outcomes in community pharmacy. There is, however, a need to determine the level of evidence on the effectiveness of PPSs in daily practice by means of pragmatic trials. To identify and analyse pragmatic RCTs that measure the effectiveness of PPSs in clinical, economic and humanistic outcomes in the community pharmacy setting.

METHODS

A systematic search was undertaken in MEDLINE, EMBASE, the Cochrane Library and SCIELO. The search was performed on January 31, 2020. Papers were assessed against the following inclusion criteria (1) The intervention could be defined as a PPS; (2) Undertaken in a community pharmacy setting; (3) Was an original paper; (4) Reported quantitative measures of at least one health outcome indicator (ECHO model); (5) The design was considered as a pragmatic RCT, that is, it fulfilled 3 predefined attributes. External validity was analyzed with PRECIS- 2 tool.

RESULTS

The search strategy retrieved 1,587 papers. A total of 12 pragmatic RCTs assessing 5 different types of PPSs were included. Nine out of the 12 papers showed positive statistically significant differences in one or more of the primary outcomes (clinical, economic or humanistic) that could be associated with the following PPS: Smoking cessation, Dispensing/Adherence service, Independent prescribing and MTM. No paper reported on cost-effectiveness outcomes.

CONCLUSIONS

There is limited available evidence on the effectiveness of community-based PPS. Pragmatic RCTs to evaluate clinical, humanistic and economic outcomes of PPS are needed.

Impact of a Multicomponent Digital Therapeutic Mobile App on Medication Adherence in Patients with Chronic Conditions: Retrospective Analysis

BACKGROUND

Strategies to improve medication adherence are widespread in the literature; however, their impact is limited in real practice. Few patients persistently engage long-term to improve health outcomes, even when they are aware of the consequences of poor adherence. Despite the potential of mobile phone apps as a tool to manage medication adherence, there is still limited evidence of the impact of these innovative interventions. Real-world evidence can assist in minimizing this evidence gap.

OBJECTIVE

The objective of this study was to analyze the impact over time of a previously implemented digital therapeutic mobile app on medication adherence rates in adults with any chronic condition.

METHODS

A retrospective observational study was performed to assess the adherence rates of patients with any chronic condition using Perx Health, a digital therapeutic that uses multiple components within a mobile health app to improve medication adherence. These components include gamification, dosage reminders, incentives, educational components, and social community components. Adherence was measured through mobile direct observation of therapy (MDOT) over 3-month and 6-month time periods. Implementation adherence, defined as the percentage of doses in which the correct dose of a medication was taken, was assessed across the study periods, in addition to timing adherence or percentage of doses taken at the appropriate time (±1 hour). The Friedman test was used to compare differences in adherence rates over time.

RESULTS

We analyzed 243 and 130 patients who used the app for 3 months and 6 months, respectively. The average age of the 243 patients was 43.8 years (SD 15.5), and 156 (64.2%) were female. The most common medications prescribed were varenicline, rosuvastatin, and cholecalciferol. The median implementation adherence was 96.6% (IQR 82.1%-100%) over 3 months and 96.8% (IQR 87.1%-100%) over 6 months. Nonsignificant differences in adherence rates over time were observed in the 6-month analysis (Fr(2)=4.314, P=.505) and 3-month analysis (Fr(2)=0.635, P=.728). Similarly, the timing adherence analysis revealed stable trends with no significant changes over time.

CONCLUSIONS

Retrospective analysis of users of a medication adherence management mobile app revealed a positive trend in maintaining optimal medication adherence over time. Mobile technology utilizing gamification, dosage reminders, incentives, education, and social community interventions appears to be a promising strategy to manage medication adherence in real practice.

Stakeholder analysis in health innovation planning processes: A systematic scoping review

Integrating health innovations into the health system is a complex endeavour that requires a well-designed planning process engaging key stakeholders. Stakeholder analyses lay the foundations to inform appropriate planning processes and undertake strategic actions. A systematic scoping review was performed to explore how stakeholder analyses are applied in health innovation planning processes and a guideline to report stakeholder analyses was developed. The literature search was conducted in PubMed, Scopus and DOAJ; grey literature was sought using Google. Articles reporting stakeholder analyses during the planning process of health policies, systems, products and technologies, and services and delivery methods were included. Fifty-one records were incorporated in the qualitative synthesis. Stakeholder analyses were conducted worldwide, used in all types of health innovations, applied in all phases of the planning process and conducted both prospectively and retrospectively. The steps followed to perform stakeholder analysis, the methods used, the stakeholder attributes analysed and how authors reported the analyses were heterogeneous. Forty-one studies reported the identification of stakeholders, 50 differentiated/categorised them and 25 analysed stakeholder relationships. Only some authors proposed future actions based on the results obtained in their stakeholder analysis. A list of Reporting Items for Stakeholder Analysis (i.e., the RISA tool) is proposed to contribute to the reporting guidelines to enhancing the quality and transparency of health research.

Evaluation of a Collaborative Protocolized Approach by Community Pharmacists and General Medical Practitioners for an Australian Minor Ailments Scheme: Protocol for a Cluster Randomized Controlled Trial

Background

Internationally, governments have been investing in supporting pharmacists to take on an expanded role to support self-care for health system efficiency. There is consistent evidence that minor ailment schemes (MASs) promote efficiencies within the health care system. The cost savings and health outcomes demonstrated in the United Kingdom and Canada open up new opportunities for pharmacists to effect sustainable changes through MAS delivery in Australia.

Objective

This trial aims to evaluate the clinical, economic, and humanistic impact of an Australian Minor Ailments Service (AMAS) compared with usual pharmacy care in a cluster randomized controlled trial (cRCT) in Western Sydney, Australia.

Methods

The cRCT design has an intervention group and a control group, comparing individuals receiving a structured intervention (AMAS) with those receiving usual care for specific health ailments. Participants will be community pharmacies, general practices, and patients located in Western Sydney Primary Health Network (WSPHN) region. A total of 30 community pharmacies will be randomly assigned to either intervention or control group. Each will recruit 24 patients, aged 18 years or older, presenting to the pharmacy in person with a symptom-based or product-based request for one of the following ailments: reflux, cough, common cold, headache (tension or migraine), primary dysmenorrhea, or low back pain. Intervention pharmacists will deliver protocolized care to patients using clinical treatment pathways with agreed referral points and collaborative systems boosting clinician-pharmacist communication. Patients recruited in control pharmacies will receive usual care. The coprimary outcomes are rates of appropriate recommendation of nonprescription medicines and rates of appropriate medical referral. Secondary outcomes include self-reported symptom resolution, health services resource utilization, and EuroQoL Visual Analogue Scale. Differences in primary outcomes between groups will be analyzed at the individual patient level accounting for correlation within clusters with generalized estimating equations. The economic impact of the model will be evaluated by cost-utility and cost-effectiveness analysis compared with usual care.

Results

The study began in July 2018. Thirty community pharmacies were recruited. Pharmacists from the 15 intervention pharmacies were trained. A total of 27 general practices consented. Pharmacy patient recruitment began in August 2018 and was completed on March 31, 2019.

Conclusions

This study may demonstrate the efficacy of a protocolized intervention to manage minor ailments in the community and will assess the clinical, economic, and humanistic impact of this intervention in Australian pharmacy practice. Pharmacists supporting patient self-care and appropriate self-medication may contribute to greater efficiency of health care resources and integration of self-care in the health system. The proposed model and developed educational content may form the basis of a national MAS service in Australia, using a robust framework for management and referral for common ailments.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618000286246; http://www.anzctr.org.au/ACTRN12618000286246.aspx

International Registered Report Identifier (IRRID)

DERR1-10.2196/13973

Collaborative health service planning: A stakeholder analysis with social network analysis to develop a community pharmacy service

BACKGROUND

Stakeholder participation optimizes health planning, fostering the acceptability and integration of new health services. Collaborative approaches may help overcome existing challenges in the development, implementation and evaluation of community pharmacy services (CPSs). Stakeholder analyses lay the foundation for building collaboration in the integrated delivery of health care.

OBJECTIVES

This stakeholder analysis was performed to organize a collaborative initiative to develop a CPS aimed at preventing cardiovascular diseases in Andalucía (Spain). It aimed to identify stakeholders, differentiate/categorize them, and analyze stakeholder relationships.

METHOD

Stakeholders were identified using the snowballing technique. To differentiate/categorize stakeholders and analyze the relationships (i.e., collaboration) an online web-based questionnaire was sent to 186 stakeholders. Stakeholders were asked for: (1) their influence, interest and attitude toward the initiative; (2) stakes/interests; (3) capacity to contribute to the initiative; (4) desire for involvement; (5) concerns; (6) whom they considered a key stakeholder; and (7) the level of collaboration they had with other stakeholders. Data analysis combined descriptive qualitative content analysis, descriptive quantitative analysis and social network analysis.

RESULTS

Of the 186 stakeholders approached, 96 (51.6%) participated. The identification process yielded 217 stakeholders (individuals, organizations or collectives), classified into 10 groups. Fifty-seven stakeholders were considered critical to the intended initiative. Most participant stakeholders supported the initiative and were willing to collaborate in the development of the CPS. Public health and science were the main driving interests. A collaboration network existed between the 96 stakeholders.

CONCLUSION

This study revealed the magnitude of the social system surrounding the development of a CPS aimed at preventing cardiovascular disease. A large array of stakeholders was identified and analyzed, and a group of critical stakeholders selected. Stakeholder characteristics such as attitude toward the initiative, potential contribution, desire for involvement, and the existing collaboration network, provided complementary information that was helpful for planning the process and stakeholder engagement.

Healthcare professional-patient relationships: Systematic review of theoretical models from a community pharmacy perspective

OBJECTIVE

To identify health care professional-patient relationship theoretical models and individual factors that may have an influence on this relationship and be relevant to community pharmacy practice.

METHODS

Using the recommended methodology by Prisma Statement, a search was undertaken in PubMed for health care professional-patient relationship theoretical models that included individual factors.

RESULTS

Eight theoretical models met the inclusion criteria. These models were classified based on their aim, their focus on the interaction process, external factors influencing the process, and their practical applications. The most common influential modifiable factors were knowledge, needs, values, expectations, beliefs and perceptions.

CONCLUSION

'The Theory of Goal Attainment' (TGA) appears to be the most useful model for community pharmacy practice. The perceptions and expectations of both patients and pharmacists could be the two most interesting modifiable factors to apply in pharmacy practice. These modifiable influential factors could be altered by specific training such as behavioral aspects.

PRACTICE IMPLICATIONS

No theoretical model has been specifically developed for analyzing the community pharmacist-patient relationship. TGA may be appropriate for community pharmacy practice, since it takes into consideration both, attaining patients health outcomes, as well as improving patient-pharmacist relationship.

Non-prescription medicines and Australian community pharmacy interventions: rates and clinical significance

OBJECTIVE

To quantify pharmacy intervention rates for non-prescription medications (pharmacist-only and pharmacy medicines), to document the clinical significance of these interventions and to determine the adverse health consequences and subsequent health care avoided as a result of the interventions.

METHODS

Non-prescription medicines interventions undertaken by community pharmacy staff were recorded in two field studies: a study of all Australian pharmacies to determine incidence rates for low-incidence, highly significant interventions, and a study of a sample of pharmacies to collect data on all non-prescription interventions. Recorded interventions were assessed by a clinical panel for clinical significance, potential adverse health consequence avoided, probability and likely duration of the adverse health consequence.

KEY FINDINGS

The rate of professional intervention that occurs in Australia for pharmacist-only and pharmacy medicines is 5.66 per 1000 unit sales (95% confidence interval 4.79-6.64). Rates of intervention varied by clinical significance. When considering health care avoided, the main impact of the interventions was avoidance of urgent general practitioner (GP) visits, followed by avoidance of regular GP visits and accident and emergency treatment. The most common adverse health consequences avoided were exacerbations of an existing condition (e.g. hypertension, asthma) and adverse drug effects.

CONCLUSIONS

This study demonstrates the way in which community pharmacy encourages appropriate non-prescription medicine use and prevents harm through intervening at the point of supply. It was estimated that Australian pharmacies perform 485912 interventions per annum when dealing with non-prescription medicines, with 101324 per annum being interventions that avert emergency medical attention or serious harm, or which are potentially life saving.

Non-prescription medicine supply: protocols and practice

Focal points

Patient drug information and consumer choice of pharmacy

Objective

The purpose of this study was to investigate whether there is an association between the level of drug information provided in community pharmacies and business performance as measured by consumer satisfaction and consumer loyalty.

Method

After an initial qualitative phase and a pilot survey, a questionnaire was administered to 253 consumers in 10 high and low information provision pharmacies.

Setting

The study took place in community pharmacies in the Sydney metropolitan and Newcastle areas of New South Wales, Australia.

Key findings

There was no significant difference in the summed consumer scores of behavioural intention or consumer satisfaction between the two pharmacy types. However, this study showed that up to 41 per cent of consumers (n=182) currently patronising low provider pharmacies indicated a preference for a high information provider pharmacy given equivalent convenience and no preformed loyalties to a particular pharmacist. This represents a potential net shift of 24 per cent of consumers from low information provider pharmacies to high provider pharmacies.

Conclusion

This study provides initial evidence to show that the level of provision of drug information has the potential to increase consumer patronage and loyalty to a community pharmacy. The full implications of this should become more apparent as the number and convenience of high provider pharmacies increases and more low provider consumers are exposed to this type of pharmacy.

Review of computerised patient medication records to determine potential clinical interventions in community pharmacy

The potential intervention rate for cardiovascular drugs dispensed in community pharmacy was investigated by a retrospective study of 300 patient medication records (PMRs) collected from 10 community pharmacies in Sydney, Australia. A medication review protocol and operational definitions were developed for 17 types of clinical intervention and three levels of clinical significance. Spearman's correlation coefficient (rs) was used to examine the relationship between total number of potential interventions and predictor variables. From 5,271 medications dispensed, 1,509 (28.6 per cent) potential interventions were identified. The most frequent types of potential intervention were precautions (27.6 per cent), overutilisation (17 per cent) and dose discrepancy (16.3 per cent). Of the interventions classified as being of major clinical significance, 61.3 per cent were precautions, 19.7 per cent drug interactions and 19 per cent contraindications. The cardiovascular drug classes with the highest potential intervention rate were inotropics (93.2 per cent) and anticoagulants (89.5 per cent). There was a statistically significant correlation between the number of potential interventions per patient and the total number of medications dispensed per patient (rs=0.68, P<0.001), the total number of cardiovascular drugs dispensed per patient (rs=0.67, P<0.001) and the number of different prescribing doctors per patient (rs=0.29, P<0.001). This study demonstrates the potential for community pharmacists to review computerised PMRs and intervene in patients' drug therapy, thereby reducing iatrogenic problems and improving health outcomes for patients.

Negative clinical outcomes associated with drug-related problems in heart failure (HF) outpatients: impact of a pharmacist in a multidisciplinary HF clinic

BACKGROUND

Drug-related negative outcomes (DNOs) are health problems that patients experience due to drug use or nonuse. Heart failure (HF) patients are at high risk of experiencing DNOs owing to polypharmacy, comorbidities, and age.

METHODS AND RESULTS

Ninety-seven consecutive HF patients were enrolled and followed for 6 months. A pharmacist, integrated within a multidisciplinary HF team, reviewed the medication of each patient to detect, resolve, and/or prevent possible DNOs, risks of developing a DNO (rDNOs) and the drug-related problems (DRPs) that are associated with them. We detected 147 DNOs/rDNOs with a mean of 1.5 ± 1.4 per patient. Among DNOs, 45% were due to a lack of a pharmacologic treatment (need for a drug) and 24% were treatments with an insufficient drug dose (quantitative ineffectiveness). Among rDNOs, 33% were due to use of an unsafe drug (nonquantitative lack of safety) and 30% to quantitative ineffectiveness. Ninety-four percent of DNOs/rDNOs were preventable, and, importantly, 5.5% were classified as clinically serious. During follow-up, pharmacist interventions solved or prevented the health problem in 83% of cases. The most frequently identified DRPs were "insufficiently treated health problem" (31%), "inadequate dose, regimen, or duration of a drug" (22%), "probability of adverse effects" (16%), and "nonadherence" (14%). A significant relationship between the number of DNOs/rDNOs and the number of drugs was found (P < .013).

CONCLUSIONS

Chronic HF outpatients have a high incidence of preventable DNOs. The inclusion of a pharmacist in multidisciplinary HF teams should be considered, because it is clinically beneficial for patients and it increases HF specialists' awareness of DNOs, especially those beyond HF.

Building capacity to implement cognitive pharmaceutical services: Quantifying the needs of community pharmacies

BACKGROUND

Community pharmacy is an industry undergoing a transformation, evolving from a traditional product supply orientation to a business capable of incorporating services. The theoretical framework of organizational flexibility is used to understand how pharmacies' capacity can be built to provide services and identify key areas needing improvement.

OBJECTIVE

To determine the needs of pharmacies that were important and the elements requiring improvement when implementing and delivering services.

METHODS

A mail survey of 2006 Australian community pharmacies was used to identify needs for service implementation. A 25-item scale was used to measure the level of importance (importance measure) of the items and the level of improvement (improvement measure) when implementing services. An exploratory factor analysis was conducted to assess the construct validity and reliability.

RESULTS

Responses were received from a total of 395 community pharmacies, with 355 usable responses (17.7%). Factor analysis yielded 3 factors on the importance measure, explaining 42.6% of the variance: (1) planning and performance (item loading range 0.749-0.455; Cronbach's alpha 0.806), (2) people and processes (0.829-0.392; 0.713), and (3) service awareness and infrastructure (0.723-0.310; 0.705). For the improvement measure, 46.9% of the variance was explained by 3 factors: (1) planning, performance, and service awareness (0.827-0.447; 0.858), (2) infrastructure (0.900-0.637; 0.822), and (3) people and processes (0.903-0.311; 0.707).

CONCLUSIONS

The analyses showed that there are gaps in the capacity of community pharmacy that could be addressed through business and management programs. The theoretical framework of organizational flexibility was useful in highlighting the key areas for stimulating change. To effectively implement services and sustain service delivery, more sophisticated planning and performance monitoring systems are required, supported by changes to infrastructure and staff mix. The critical area for policy makers is the speed at which programs can be restructured to include these issues to encourage the widespread implementation of services.

Implementing cognitive services in community pharmacy: a review of models and frameworks for change

Objective

To investigate models and frameworks for the implementation of cognitive pharmaceutical services (CPS) in community pharmacy.

Method

Relevant literature published in English was identified through searches of online databases (no date limits), texts, conference proceedings, and bibliographies of identified literature. Literature that involved a discussion of models or frameworks for community pharmacy practice change in relation to the implementation of CPS was selected for review. Many of the identified studies were conceptual in nature, and although they were selected in the same way as the empirical research papers, were not able to be critically reviewed in an equivalent manner. A narrative, rather than systematic review, was considered more appropriate.

Key findings

Many of the identified models focused on specific services, seeming to overlook the complexity of the implementation process. Many relied on behavioural theories, with an assumption that changing pharmacists' knowledge, skills or attitude will automatically result in successful change, often ignoring organisational aspects of change. Models that included business aspects remain largely untested, and where testing occurred sample sizes were generally small and populations conveniently or purposively sampled, limiting the generalisability of the findings.

Conclusion

The factors affecting change are more than just those confined to the individual pharmacist who is providing a service, and the implementation process is more complex, involving a range of organisational factors. Research is needed to identify the key elements of a framework for how new CPS should be implemented and delivered.

Monitoring quality standards in the provision of non-prescription medicines from Australian Community Pharmacies: results of a national programme

INTRODUCTION

Standards of practice have been developed by the pharmacy profession to address the provision of non-prescription medicines, using a consumer-focused and risk management approach. The application of these standards in Australian community pharmacies has been monitored since 2002 by the Quality Care Pharmacy Support Centre (QCPSC).

METHODS

Between September 2002 and September 2005, 7785 standards maintenance assessment visits were conducted in 4282 pharmacies, using pseudo-patient methodology. 1909 were symptom-based requests (SBRs) and 5876 were direct product-based requests (DPRs), of which 2864 were for pharmacist-only medicines (POMs) and 3012 were for pharmacy medicines (PMs). 2756 pharmacies received two visits, and 747 received three visits. A pharmacy's performance was scored out of 10 at each visit (scores 0-3: "unsatisfactory"; 4-6: "satisfactory"; and 7-10: "excellent").

RESULTS

There was wide variation in performance at baseline, with 1453 (34%) of pharmacies scoring

CONCLUSION

Repeated pseudo-patient visits lead to notable improvement in behaviour in the handling of non-prescription medicines in community pharmacies. A range of factors need to be considered when measuring these behaviours, such as scenario or medicine type, as they have considerable influence on performance. Future research should focus on issues of quality control, to better understand what makes some pharmacies perform satisfactorily and others unsatisfactorily, and what is required to shift performance from "satisfactory" to "excellent".

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MESH Headings

• Benchmarking
• Education, Pharmacy, Continuing
• Evidence-Based Medicine
• Government Agencies
• Guideline Adherence
• Humans
• New South Wales
• Nonprescription Drugs/classification
• Nonprescription Drugs/standards
• Patient Simulation
• Pharmacies/classification
• Pharmacies/standards
• Process Assessment, Health Care
• Professional Competence
• Program Development
• Quality Indicators, Health Care

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Grants Collapse

Affiliation(s)

S I Benrimoj Quality Care Pharmacy Support Centre, University of Sydney, New South Wales 2006, Australia.
Joel B Werner
Catherine Raffaele
Alison S Roberts
Filipa A Costa

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Economic impact of increased clinical intervention rates in community pharmacy. A randomised trial of the effect of education and a professional allowance

OBJECTIVE

To determine the economic impact of an interventional programme aimed to increase the rate of clinical interventions undertaken in community pharmacy. STUDY DESIGN AND PERSPECTIVE: A randomised controlled trial of 4 parallel groups of pharmacies, conducted from a government perspective. Economic evaluations were based on savings/costs attributable to healthcare costs avoided, healthcare costs incurred by the pharmacists' actions, change in medication costs, pharmacy time and telephone calls made by the pharmacist. The study was conducted during November and December 1996 and costings were based on 1997 figures.

INTERVENTIONS

A professional fee-for-service [10 Australian dollars ($A; $A1 = 6.50 US dollars) per intervention] and education (an intensive 1-week course or advanced education) were implemented in an attempt to increase clinical interventions by the pharmacists. Group A pharmacies (n = 10) served as a control group and received neither education nor remuneration; group B received education and professional remuneration (n = 9); group C had received prior continued education and now received advanced education and professional remuneration (n = 11); and group D received professional remuneration with no education.

MAIN OUTCOME MEASURES AND RESULTS

The proactive clinical interventions in group C saved a mean of $A85.35 per 1000 prescriptions [95% confidence interval (CI)-$A157.11 to $A24.95). This was 4 times greater than savings generated by pharmacies in group B (mean savings of $A25.65 per 1000 prescriptions) and 6 times greater than control pharmacies. A sensitivity analysis which extrapolated results to Australian prescription figures showed that the control group was capable of generating savings in the order of $A2.4 million per year while pharmacists in group C would save the healthcare system $A15 million per year.

CONCLUSIONS

These results provide the first economic estimates for the provision of clinical interventions in Australian community pharmacies. It is believed that they illustrate the value of pharmaceutical services to the healthcare system and to the Australian community in terms of both quality of care and savings.

Topical antimicrobial prophylaxis in minor wounds

OBJECTIVE

To evaluate the ability of a novel topical antimicrobial gel containing cetrimide, bacitracin, and polymyxin B sulfate to prevent infections of minor wounds.

DESIGN

A clinical trial compared the test preparation with placebo and a povidone iodine antiseptic cream.

SETTING

Five primary schools in Sydney, Australia, participated in the study over a 6-week spring/summer school term.

SUBJECTS

Children aged 5-12 years with parental consent were eligible for study participation. Accidental injuries occurring at school were treated in a standardized manner by nurses at each site.

OUTCOME MEASURES

Wounds were evaluated by the medical practitioner after 3 days of topical treatment. The clinical outcome was classified as resolution or suspected infection. If a clinical infection was suspected, the injury was swabbed for microbiologic evaluation. Growth of a dominant microorganism was classified as a microbiologic infection.

RESULTS

Of the 177 injuries treated, there were nine clinical infections. A comparison of these showed a significant difference among treatment groups (p < 0.05). This difference was associated with the test preparation and placebo; the test preparation reduced the incidence of clinical infection from 12.5% to 1.6% (p < 0.05; 95% CI, 0.011 to 0.207). A comparison of microbiologic infections showed no significant differences among treatment groups (p > 0.05).

CONCLUSIONS

The novel gel preparation containing cetrimide, bacitracin, and polymyxin B sulfate showed therapeutic action and reduced the incidence of clinical infections in minor accidental wounds. It may be a suitable product for first aid prophylaxis.

In vitro interactions of neomycin sulfate, bacitracin, and polymyxin B sulfate

BACKGROUND

Neomycin sulfate, bacitracin, and polymyxin B sulfate have been combined in topical preparations to provide a complementary antimicrobial spectrum for the prevention of minor wound infections. The advisability of the inclusion of neomycin sulfate has been questioned since it may cause contact sensitization.

METHODS

To assess the value of neomycin, microdilution checkerboard titrations were used to determine the in vitro interactions between two-antibiotic and three-antibiotic combinations against reference strains of bacteria commonly associated with wound infections. Using Fractional Inhibitory Concentration (FIC) indices (< 0.5 indicates synergism with two-drug combinations), the combination of neomycin/bacitracin was synergistic for both S. aureus and Ps. aeruginosa; neomycin/polymyxin B was synergistic for E. faecalis, and the bacitracin/polymyxin B combination was synergistic against Ps. aeruginosa. A three-drug combination of neomycin/bacitracin/polymyxin B had FIC values of < 1 for all organisms, indicating synergy and substantiating the clinical role of neomycin sulfate in current topical formulations.

RESULTS

Neomycin has the lowest safety profile of the drugs in this combination. A replacement agent should ideally have similar or superior synergistic capabilities with the remaining drugs and contribute to the therapeutic efficacy of the preparation. Additionally, because of the strongly synergistic tendencies displayed by the three-drug combination, it may be possible to reduce the antibiotic concentrations present in current formulations.

CONCLUSION

By developing this concept, there is potential for the formulation of topical preparations to be based on a sound theoretical and clinical rationale.

Cardiovascular effects of a chlorpheniramine/paracetamol combination in hypertensive patients who were sensitive to the pressor effect of pseudoephedrine

Twelve hypertensive patients who were classified as pseudoephedrine-sensitive in a preliminary trial were selected for further investigation with single doses of pseudoephedrine 60 mg, a combination of chlorpheniramine 4 mg with paracetamol 650 mg and placebo. A double-blind, randomised, crossover study design was followed. Treatment with pseudoephedrine produced significant effects on all the four variables measured (systolic, diastolic and mean arterial blood pressure, and heart rate). Effects of the chlorpheniramine/paracetamol combination were found to be not significantly different from placebo. It was concluded that the combination may be useful as a medication for 'colds' in hypertensive patients, since it does not induce cardiovascular effects such as those observed with pseudoephedrine.

A controlled clinical trial on the cardiovascular effects of single doses of pseudoephedrine in hypertensive patients

Twenty hypertensive patients received single oral doses of pseudoephedrine 60 mg or placebo in a double-blind, randomised, crossover trial. Systolic, diastolic, mean arterial blood pressure, and heart rate were measured at 5 min intervals for 30 min prior to and 210 min after the administration of pseudoephedrine or placebo. Statistically significant differences between the two treatments were observed with changes in systolic blood pressure (P less than 0.03) and heart rate (P less than 0.01) but not in diastolic (P greater than 0.03) and mean arterial blood pressure (P greater than 0.1). Minor differences in the number of reported side effects between the two treatments were not statistically significant.

Pharmacokinetics of non-prescription sympathomimetic agents

The pharmacokinetics of non-prescription sympathomimetic agents are discussed with respect to absorption from the gastrointestinal tract, volumes of distribution, metabolism and renal excretion. Where specific data are not available, postulations are made with inference from the chemical structures of these agents, or from studies with other drugs. No studies on hypertensive patients have been found, but attempts are made to correlate any possible changes in the pharmacokinetics of these sympathomimetic agents to hypertensive patients as a high proportion of the elderly population is hypertensive. Sympathomimetic agents with lesser polar hydroxyl groups, for example, are thought to be more lipophilic and are more readily absorbed from the gastrointestinal tract, have higher volumes of distribution, and are more extensively metabolized. Major metabolic pathways include oxidation, deamination, demethylation, and conjugation. Most of these agents are excreted primarily through the kidneys and due to their basic nature, the rate of excretion is dependent on urinary pHs. Any alteration in kidney functions such as in the aged is, therefore, expected to have some clinical significance on the pharmacokinetics of these agents.

Non-prescription sympathomimetic agents and hypertension

In recent years, considerable attention has been focused on the pressor effects of nonprescription sympathomimetic agents. The impact and usage of these agents especially ephedrine, pseudoephedrine, phenylpropanolamine and phenylephrine, in hypertensive patients has been the topic of constant debates. The present review is an attempt to report and evaluate all the clinical trials and cases of pressor reactions associated with these 4 agents. The study protocols used in these clinical trials are examined and comments made on any diversion from the standard design. Many factors are found to cause the discrepancies in the data available. It is concluded that ephedrine and phenylpropanolamine are best avoided by hypertensive patients due to higher probability of causing pressor reactions. Data on pseudoephedrine and phenylephrine appear to indicate non-significant effects on blood pressure of normotensive subjects when used at the recommended oral dose as nasal decongestants. Phenylephrine is also commonly employed in nasal and eye drops and the limited data available appear to support its usage in hypertensive patients. However, it is noted that most of the clinical trials involve normotensive subjects and the majority of the results could not be verified due to inadequacies in the study design. This paucity and inconclusive information on hypertensive patients warrants further investigations with emphasis on the study protocols used.

Consumer satisfaction with over-the-counter products in pharmacy and non-pharmacy students

Much of the work in the area of consumer satisfaction/dissatisfaction has revolved around dissatisfaction and complaining behavior (Anderson, Gunter, Altimus and Pittman, 1973). This is indeed an interesting phenomenon when one notes that a relatively small percentage (generally less than one-third) of consumers formally complain when dissatisfied (Trawick and Swan, 1979). Many of the numerous products and services on today's market prove to be unsatisfactory to consumers (Moore, Shuptrine and Thomas, 1979). Interest in this particular field of complaint behavior has resulted in a number of studies focusing on differences between complainers and noncomplainers, effects of purchase expectations being confirmed or denied, and descriptions of consumer problem areas (Bearden, Teel and Crockett, 1980).