Pharmaceutical Care Network Europe definition of quality indicators for pharmaceutical care: a systematic literature review and international consensus development.

BACKGROUND: Over the past 40 years, the tasks of pharmacists have shifted from logistic services to pharmaceutical care (PhC). Despite the increasing importance of measuring quality of care, there is no general definition of Quality Indicators (QIs) to measure PhC. Recognising this, a working group in a European association of PhC researchers, the Pharmaceutical Care Network Europe (PCNE), was established in 2020. AIM: This research aimed to review existing definitions of QIs and develop a definition of QIs for PhC. METHOD: A two-step procedure was applied. Firstly, a systematic literature review was conducted to identify existing QI definitions that were summarised. Secondly, an expert panel, comprised of 17 international experts from 14 countries, participated in two surveys and a discussion using a modified Delphi technique to develop the definition of QIs for PhC. RESULTS: A total of 182 QI definitions were identified from 174 articles. Of these, 63 QI definitions (35%) cited one of five references as the source. Sixteen aspects that construct QI definitions were derived from the identified definitions. As a result of the Delphi study, the panel reached an agreement on a one-sentence definition of QIs for PhC: "quality indicators for pharmaceutical care are validated measurement tools to monitor structures, processes or outcomes in the context of care provided by pharmacists". CONCLUSION: Building upon existing definition of QIs, an international expert panel developed the PCNE definition of QIs for PhC. This definition is intended for universal use amongst researchers and healthcare providers in PhC.

Knowledge and counseling preferences of the public and pharmacy staff on emergency contraception: Results of a cross-sectional study in Belgium.

OBJECTIVE: To assess the knowledge and counseling preferences of the public ('individuals') and pharmacy staff ('professionals') in Belgium on emergency contraceptive pills (ECPs). STUDY DESIGN: Cross-sectional study using 2 different anonymous, online surveys (one addressing the public and one professionals). RESULTS: Overall, 1518 individuals and 1118 professionals participated, obtaining a mean knowledge score of 6.3(±1.8)/10 and 5.0(±1.6)/10, respectively. For the public, a lower level of knowledge was found among men, nonhealthcare workers, and low educated individuals with no prior ECP use/purchase. For professionals, a lower level of knowledge was observed among pharmacy-technicians, French-speaking persons, and professionals with ≥5 years of experience and poorly involved in continuous education. CONCLUSIONS: Limited knowledge on ECPs was observed among the public and pharmacy staff in Belgium, underscoring educational and counseling opportunities on ECPs.

Development and Pilot Testing of a Dispensing Protocol on Emergency Contraceptive Pills for Community Pharmacists in Belgium.

Community pharmacists in Belgium frequently dispense emergency contraceptive pills (ECPs). However, variable and insufficient counseling practices exist across pharmacies, highlighting the need for standardization and quality improvement strategies. The aim of this project was to develop and test an ECP dispensing protocol for pharmacists. An 'experience-based' co-design approach involving academic and practicing pharmacists was applied, followed by a 4-month test period and interviews to assess users' experiences. In total, eight geographically dispersed pharmacies participated. Pharmacists (n = 15) reached a consensus on most items to be included in the protocol, which was subsequently tested in seven pharmacies, with overall 97 registered ECP conversations. Pharmacists considered the protocol complete but felt that not all items should be mentioned/questioned during all conversations. They suggested only subtle modifications to be made prior to delivering a final protocol ready for nationwide distribution. Despite attributing positive effects to having a protocol, no single pharmacist 'actively' used it at-the-counter but used it instead as a 'checklist' after the encounter. Pharmacists found that the paper-based format of the protocol hindered protocol-based dispensing. Future research is needed to provide evidence on the actual benefits of protocol application, as well as to identify factors influencing the implementation of ECP dispensing using a software-integrated protocol.

Diabetes and Cardiovascular Diseases Risk Assessment in Community Pharmacies: An Implementation Study.

The implementation of a new service is often challenging when translating research findings into routine clinical practices. This paper presents the results of the implementation study of a pilot project for a diabetes and cardiovascular diseases risk-assessment service in Belgian community pharmacies. To evaluate the implementation of the service, a mixed method was used that follows the RE-AIM framework. During the testing stage, 37 pharmacies participated, including five that dropped out due to a lack of time or COVID-19-related temporary obligations. Overall, 502 patients participated, of which 376 (74.9%) were eligible for according-to-protocol analysis. Of these, 80 patients (21.3%) were identified as being at high risk for the targeted diseases, and 100 (26.6%) were referred to general practice for further investigation. We presented the limited effectiveness and the key elements influencing optimal implementation. Additional strategies, such as interprofessional workshops, a data-sharing platform, and communication campaigns, should be considered to spread awareness of the new role of pharmacists. Such strategies could also promote collaboration with general practitioners to ensure the follow-up of patients at high risk. Overall, this service was considered easy to perform and feasible in practice but would require financial and external support to ensure its effectiveness, sustainability, and larger-scale implementation.

How to Choose the Right Inhaler Using a Patient-Centric Approach?

There are many different inhaler devices and medications on the market for the treatment of asthma and chronic obstructive pulmonary disease, with over 230 drug-delivery system combinations available. However, despite the abundance of effective treatment options, the achieved disease control in clinical practice often remains unsatisfactory. In this context, a key determining factor is the match or mismatch of an inhalation device with the characteristics or needs of an individual patient. Indeed, to date, no ideal device exists that fits all patients, and a personalized approach needs to be considered. Several useful choice-guiding algorithms have been developed in the recent years to improve inhaler-patient matching, but a comprehensive tool that translates the multifactorial complexity of inhalation therapy into a user-friendly algorithm is still lacking. To address this, a multidisciplinary expert panel has developed an evidence-based practical treatment tool that allows a straightforward way of choosing the right inhaler for each patient.

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

RATIONALE, AIMS AND OBJECTIVES: The rise in chronic diseases urges for an identification of interventions that improve adherence. However, no golden standard exists for evaluating adherence in polymedicated patients. The objectives were to investigate the impact of a pharmacist-led medication use review (MUR) service on adherence implementation rates for chronic medication, and to evaluate the appropriateness of two adherence calculation approaches in this regard. METHOD: Before-after study (SIMENON study) including ambulatory, aged, polymedicated patients. Refill data were used to calculate the proportion of days covered (PDC) per medication before and after the MUR. Adherence was assessed for chronic, solid, oral medication using a prescription-based and interval-based approach, and the performance of both approaches was compared. RESULTS: Adherence was evaluated for 1483 medications from 316 patients. The median baseline PDC per medication was 0.95 (prescription-based method) and 0.91 (interval-based approach). Pearson correlation between both approaches was 0.616 (P < .0001). The prescription-based approach found less medication below the adherence threshold of 0.80 (319 medications; 21.5% vs 481 medications; 32.4%). Using the prescription-based approach, the proportion of non-adherent patients at baseline was 61.7% (195/316 patients), of which 54.9% (107/195 patients) was only non-adherent for one medication. Median PDC scores increased significantly from 0.95 to 0.99 and 0.91 to 0.99 with the prescription-based and interval-based approach respectively (both P < .0001). Only considering the 319 medications with baseline PDC scores <0.8 using the prescription-based approach, the median PDC scores significantly increased from 0.67 to 0.84 (P < .0001), with a median score improvement of 18.3%. CONCLUSIONS: Although baseline adherence was high in this population of polymedicated aged patients, both calculation methods showed the MUR significantly improved adherence. The prescription-based approach was considered the most appropriate method. Based on these findings and literature evidence, it is recommended to implement the MUR service in Belgium and target non-adherent patients for maximal effect.

Provision of pharmaceutical care by community pharmacists: a comparison across Europe.

OBJECTIVE: To investigate the provision of pharmaceutical care by community pharmacists across Europe and to examine the various factors that could affect its implementation. METHODS: A questionnaire-based survey of community pharmacies was conducted within 13 European countries. The questionnaire consisted of two sections. The first section focussed on demographic data and services provided in the pharmacy. The second section was a slightly adapted version of the Behavioral Pharmaceutical Care Scale (BPCS) which consists of three main dimensions (direct patient care activities, referral and consultation activities and instrumental activities). RESULTS: Response rates ranged from 10-71% between countries. The mean total score achieved by community pharmacists, expressed as a percentage of the total score achievable, ranged from 31.6 (Denmark) to 52.2% (Ireland). Even though different aspects of pharmaceutical care were implemented to different extents across Europe, it was noted that the lowest scores were consistently achieved in the direct patient care dimension (particularly those related to documentation, patient assessment and implementation of therapeutic objectives and monitoring plans) followed by performance evaluation and evaluation of patient satisfaction. Pharmacists who dispensed higher daily numbers of prescriptions in Ireland, Germany and Switzerland had significantly higher total BPCS scores. In addition, pharmacists in England and Ireland who were supported in their place of work by other pharmacists scored significantly higher on referral and consultation and had a higher overall provision of pharmaceutical care. CONCLUSION: The present findings suggest that the provision of pharmaceutical care in community pharmacy is still limited within Europe. Pharmacists were routinely engaged in general activities such as patient record screening but were infrequently involved in patient centred professional activities such as the implementation of therapeutic objectives and monitoring plans, or in self-evaluation of performance.

Studying the impact of a medication use evaluation by the community pharmacist (Simenon): Patient-reported outcome measures.

BACKGROUND: In the SIMENON study, medication use reviews were conducted for older polymedicated home-dwelling patients across 56 Belgian community pharmacies. OBJECTIVE: To evaluate the impact of the service on patient-reported outcome measures and patient-reported experience measures, and to evaluate the suitability of the chosen instruments. METHODS: A before-after design was used to measure the impact of the medication use review in a subset of patients, participating in the SIMENON study. Patients completed self-report questionnaires before and 3 and 12 weeks after the intervention by letter, phone or e-mail. Six outcomes were evaluated: medication-related quality of life, adherence, self-management, patient satisfaction, fall incidents and use of emergency healthcare services. RESULTS: Questionnaires at baseline and endpoint were available for 83 patients (median age 77 years; median of 7 drugs) of 24 pharmacies. The Living with Medicines Questionnaire showed low medication burden at baseline (84.8/205) which increased to 85.7 three weeks later (n = 57; p = 0.219). Scores significantly reduced to 81.9 at twelve weeks (p = 0.031). The Probabilistic Medication Adherence Scale (n = 67) showed high median adherence scores at baseline (14/18) which remained unaltered (p = 0.974). The patient activation measure found low self-management in one third of the sample at baseline and endpoint (35.5% and 37.1% respectively; p = 0.243). The Patient Satisfaction with Pharmacist Services Questionnaire (n = 66) demonstrated high patient satisfaction. The number of patients with a hospitalization in the last three months decreased non-significantly from 14.8% to 11.1% in the post-measurement after 12 weeks (p = 0.227). No effect was observed on emergency room visits and falls. CONCLUSIONS: The medication use review reduced medication burden but did not impact the patient's adherence and self-management. However, adherence scores were high, medication burden was low at baseline and the sample size was limited. The Living with Medicines instrument is a promising instrument for future research to assess medication-related quality of life in older polymedicated patients.

Studying the impact of a medication use evaluation by the community pharmacist (Simenon): Drug-related problems and associated variables.

BACKGROUND: A medication use review (MUR) aims to optimize medication use, patient knowledge and can improve health outcomes. This pharmaceutical care service is not yet available in Belgium. OBJECTIVES: To describe drug-related problems (DRPs) detected during a MUR, subsequent interventions proposed by pharmacists and evolution of DRPs until follow-up and to identify patient-related variables associated with the number of reported DRPs. METHODS: Belgian community pharmacists provided a MUR to older polymedicated ambulatory patients and registered DRPs, interventions and resolution at follow-up using the PharmDISC classification. The relationship between 14 patient-related variables and the number of reported DRPs was investigated with univariate analysis. A prediction model was developed with significant variables using negative binomial regression analysis. RESULTS: Across 56 pharmacies, 453 patients received a MUR and 1196 DRPs were registered (median 3DRPs/patient, range 0-10). Only for 11.7% of patients no problems were identified. The top-3 causes were interaction (15.2%), inappropriate timing or frequency (13.5%) and adverse effect (11.9%). The top-3 recommended interventions by pharmacists were transmission of information (25.1%), in-depth patient counselling (15.0%) and therapy stop (8.2%). After six weeks, 42.6% of DRPs were resolved; data was missing for 33.3%. A higher number of chronic drugs, female gender and living alone were associated with more DRPs. The prediction model found that per additional chronic drug, the number of problems increases by 4.3% (95% CI: 2.0-6.6%). Male gender decreases DRPs by 22.1% (95% CI: 10.4-32.0%). Living alone provided no additional predictive value in the prediction model. Confounding process- and pharmacist-related variables also influenced the number of reported DRPs. CONCLUSION: A MUR appears an effective strategy to detect and resolve DRPs. The number of chronic medications and female gender predict a higher number of DRPs. These findings are a starting point for evidence-based eligibility criteria for a MUR service in Belgium.

Implementation study of an intermediate medication review in Belgian community pharmacies.

BACKGROUND: The Association of Pharmacists in Belgium (APB) and local pharmacy associations launched a pilot project in collaboration with research teams from three Belgian universities to study the impact and implementation-related issues of a medication review (MR) service type 2a in Belgian community pharmacies. OBJECTIVE: The aim of this paper is to describe the implementation process of the MR service and to present the implementation evaluation of the pilot study (testing stage). METHODS: The pilot project was a prospective observational study using mixed methods. The implementation evaluation was based on the RE-AIM model and the framework for the implementation of services in pharmacy (FISpH). Collected implementation outcomes were classified into four dimensions: reach, adoption, implementation and intent of maintenance. RESULTS: During the testing stage, 80 pharmacies participated in the study, but 25 dropped out (31%), mainly because of a reported lack of time (adoption). The 55 remaining pharmacies included 457 patients. Recruiting patients into the service was challenging for pharmacists as 48.5% of patients refused the pharmacists' proposal (reach). Internal organizational factors were major barriers for pharmacists, followed by the lack of adoption by the pharmacy team. Large pharmacies in which pharmacy owner led the project were observed to be more proactive in implementing the MR service by integrating organizational strategies to assist the implementation process (implementation). Interviewed pharmacists perceived this new service as a professionally satisfying activity. Among participating pharmacists, 92.5% found this service feasible in practice, but believed it required adapted resources to reorganize the internal pharmacy workload, additional support, such as broad-based media campaigns to increase physicians' and patients' awareness and attitudes towards the service, and modified software (maintenance). CONCLUSIONS: The medication review service was implemented in 68% of participating pilot Belgian community pharmacies but would require adapted resources and supports for larger scale implementation.