Mapping the implementation of pharmacogenomic testing in community pharmacies 2003-2021 using the Theoretical Domains Framework: A scoping review.

BACKGROUND: Pharmacogenetic (PGx) testing is an evidence-based approach to finding effective medication therapies. While community pharmacists are ideally situated to provide PGx testing, the extent of its implementation is limited within community pharmacies. OBJECTIVE: This study aimed to explore trends in the international peer-reviewed primary literature on community pharmacists' implementation of PGx and map the main findings on the Theoretical Domains Framework (TDF). METHODS: A literature search and 2-step screening were conducted per PRISMA Extension for Scoping Reviews. Inclusion criteria were English language, community pharmacy setting, full papers, and empirical research. Data were collated in a data extraction form. The main findings were deductively mapped on the TDF with a content analysis approach. RESULTS: Of 1176 identified documents screened, 39 were included in this scoping review. Four groups of research were identified: pre-implementation surveys (interviews, and focus groups [56%, n = 22]); PGx implementation (single cohort to assess feasibility [38%, n = 15]); PGx implementation (controlled study to assess feasibility [n = 1, 2.5%]); and efficacy of PGx (2.5%, n = 1). Most studies throughout the 4 groups sought pharmacists' perceptions (46%, n = 18) and used the quantitative paradigm (77%, n = 30). TDF mapping documented positive beliefs about the benefits of PGx testing as a part of the pharmacists' role. Barriers to PGx use included pharmacists' awareness of knowledge gaps, low confidence in interpreting and communicating PGx results, concerns about cost, privacy, and integration into pharmacy workflow. CONCLUSION: Research addressing PGx implementation within the community pharmacy evolved from assessing individuals' perceptions of PGx to determining the feasibility of PGx testing in pharmacies and evaluating the impact of PGx testing on patient outcomes in depression. Mapping the main findings on the TDF facilitates the development of multidimensional interventions, potentially targeting patients, pharmacists, and health policy.

Family physicians' perceptions of pharmacists prescribing in Alberta.

Canadian pharmacists now have prescribing authority and little is documented about the physicians' perception, experience and relational dynamics evolving around the pharmacists' prescribing practice. The objective of this study was to explore Albertan family physicians' perceptions and experiences of pharmacists' prescribing practice. We used purposeful and maximum variation sampling method and semi-structured face to face or telephone interviews to collect data. From October 2014 to February 2016, we interviewed 12 family physicians in Alberta, having experience with pharmacist prescribing. Interviews were audio recorded and transcribed verbatim for analysis using an interpretive description method, guided by "Relational Coordination" theory. NVivo software was used to manage the data. Three key beliefs (i.e., renewal versus initiate new prescription, community versus team pharmacists, and "I am responsible") about pharmacist prescribing were identified. Trust and communication were prominent themes which shaped participants' collaboration with pharmacist prescribers. Participants were classified as either "collaborative" or "consultative". Participants had greater collaboration with the team pharmacist prescribers compared to community pharmacists due to a higher level of trust and ease of communication. Renewal prescribing by any pharmacist was well accepted but participants showed hesitancy in accepting pharmacist-initiated prescriptions. Our findings provide insight into interprofessional collaboration and communication between physician and pharmacist prescribers.

Exploring the role of teams and technology in patients' medication decision making.

OBJECTIVES: We know little about how electronic health records (EHRs) should be designed to help patients, pharmacists, and physicians participate in interprofessional shared decision making. We used a qualitative approach to understand better how patients make decisions with their health care team, how this information influences decision making about their medications, and finally, how this process can be improved through the use of EHRs. DESIGN: Participants from 4 regions across Canada took part in a semistructured interview and completed a brief demographic survey. The interview transcripts were thematically analyzed by means of the multidisciplinary framework method. SETTINGS AND PARTICIPANTS: Thirty participants, 18 years of age and older with at least one chronic illness, were recruited from across Canada. We interviewed participants in their homes, at the school of pharmacy, or another location of their choosing. RESULTS: We identified 4 main themes: (1) complexity of patient decision making: who, where, what, when, why; (2) relationships with physicians and pharmacists: who do I trust for what?; (3) accessing health information for decision making: how much and from where?; and (4) patients' methods of managing information for health decision making. Across the themes, participants appreciated expert advice from professionals and wanted to be informed about all options, despite concerns about limited knowledge. EHRs were perceived as a potential solution to many of the barriers identified. CONCLUSION: Patients make decisions with their health care providers as well as with family and friends. The pharmacist and physicians play different roles in helping patients in making decisions. We found that making EHRs accessible not only to health care providers but also to patients can provide a cohesive and clear context for making medication-related decisions. EHRs may facilitate clear communication, foster interprofessional understanding, and improve patient access to their health information. Future research should examine how to develop EHRs that are adaptive to user needs and desires.

Assessing the knowledge to practice gap: The asthma practices of community pharmacists.

BACKGROUND: Community pharmacists are well positioned to identify patients with poorly controlled asthma and trained to optimize asthma therapy. Yet, over 90% of patients with asthma live with uncontrolled disease. We sought to understand the current state of asthma management in practice in Alberta and explore the potential use of the Chat, Check and Chart (CCC) model to enhance pharmacists' care for patients with asthma. METHODS: An 18-question survey was used to examine pharmacists' monitoring of asthma control and prior use of the CCC tools. Descriptive statistics were used to characterize the response rate, sample demographics, asthma management and CCC use. Survey validity and reliability were established. RESULTS: One hundred randomly selected pharmacists completed the online survey with a 40% (100/250) response rate. A third of responding pharmacists reported talking to most patients about asthma symptoms and medication, with a greater focus on talking with patients on new prescriptions over those with ongoing therapies. Fewer than 1 in 10 pharmacists routinely talked to most patients about asthma action plans (AAPs). The majority of pharmacists (76%) were familiar with the CCC model, and 83% of those reported that the CCC model influenced their practice anywhere from somewhat (45%) to a great deal (38%). Both scales had good reliability, and factor analysis provided support for scale validity. CONCLUSIONS: There was considerable variability in pharmacists' activities in monitoring asthma. Pharmacists rarely used AAPs. The CCC model had a high level of self-reported familiarity, use and influence among pharmacists.

Evaluating the potential for pharmacists to prescribe oral anticoagulants for atrial fibrillation.

BACKGROUND: Oral anticoagulant therapy (OAC) to prevent atrial fibrillation (AF)-related strokes remains poorly used. Alternate strategies, such as community pharmacist prescribing of OAC, should be explored. METHODS: Approximately 400 pharmacists, half with additional prescribing authority (APA), randomly selected from the Alberta College of Pharmacists, were invited to participate in an online survey over a 6-week period. The survey consisted of demographics, case scenarios assessing appropriateness of OAC (based on the 2014 Canadian Cardiovascular Society AF guidelines) and perceived barriers to prescribing. Regression analysis was performed to determine predictors of knowledge. RESULTS: A total of 35% (139/397) of pharmacists responded to the survey, and 57% of these had APA. Depending on the case scenario, 55% to 92% of pharmacists correctly identified patients eligible for stroke prevention therapy, but only about a half selected the appropriate antithrombotic agent; there was no difference in the knowledge according to APA status. In multivariable analysis, predictors significantly associated with guideline-concordant prescribing were having the pharmacist interact as part of an interprofessional team (p = 0.04) and direct OAC (DOAC) self-efficacy (confidence in ability to extend, adapt, initiate or alter prescriptions; p = 0.02). Barriers to prescribing OAC for APA pharmacists included a lack of AF and DOAC knowledge and preference for consulting the physician first, but these same pharmacists also identified difficulty in contacting the physician as a major barrier. INTERPRETATION AND CONCLUSION: Community pharmacists can identify patients who would benefit from stroke prevention therapy in AF. However, physician collaboration and further training on AF and guidelines for prescribing OAC are needed.

Any questions? Yes, do pharmacists monitor medications at refill?

OBJECTIVES: To describe pharmacists' self-reported refill monitoring activities and test for demographic and work setting differences that contribute to variation. METHODS: This study used a cross-sectional survey design. A 4-contact survey was mailed to 599 community pharmacists randomly selected from a list provided by the state board of pharmacy. Surveys were mailed in June and July 2013. Descriptive statistics and analysis of variance were used to characterize these data. RESULTS: Of the 599 surveys mailed, 269 complete responses were received for a 44.9% response rate. Pharmacists reported reviewing the patient's medication profile for 40% of refills. Of the 29% of refills handed off, pharmacists asked 70% of patients if they had any questions and 23% a specific question about drug therapy. Pharmacists at mass merchandisers and those in smaller towns were least likely to examine the profile, whereas pharmacists working at independent stores, owners, and pharmacists with a BS Pharm degree were most likely to hand off refills to patients. Demographic and work-setting characteristics factors were not associated with the rate of asking specific questions about the patient's drug therapy, although pharmacists with a BS Pharm, at an independent store, or working in the smallest towns were least likely to ask "Any questions?" when handing off the prescription. CONCLUSION: Pharmacists reported reviewing patient profiles, handing off prescriptions, and asking medication-specific questions to fewer than one-half of patients picking up refills. Pharmacists were more likely to inquire if patients had any questions than to ask specific questions, and other researchers have reported that the former phrasing may inadvertently serve to reduce patient engagement.

Standardized patients' preferences for pharmacist interactive communication style: A mixed method approach.

BACKGROUND: Interactive communication approaches may help to shift pharmacy practice toward more patient-centered care. One example of such an approach is the 3 prime questions (3PQs). Patients' preferences for pharmacists' interactive communication styles were not identified in the literature. OBJECTIVE: The purpose of this paper was to explore standardized patient (SP) preferences, satisfaction, and perceptions of pharmacists' communication style and changes in pharmacist to standardized patient talk-time ratio. DESIGN: Mixed methods, before and after evaluation. SETTING: SPs were hired from the University of Alberta's Standardized Patient Program, Canada. PARTICIPANTS: Twelve SPs and 10 pharmacists. INTERVENTION: SPs were video recorded interacting with the same pharmacists before and after pharmacist training on the 3PQs. SPs participated in an open-ended interview using stimulated recall on videos of their pharmacist encounters. MAIN OUTCOME MEASURES: Explore SP preferences, satisfaction, and perceptions of pharmacists' communication style, in addition to changes in pharmacist to standardized patient talk-time ratio before and after the intervention RESULTS: Generally SPs were satisfied with pharmacists' interactive communication style post training. Qualitative themes varied with SPs' preference for an interactive approach (58%, i.e., Conversation with Equals, Double Check, and Manageable Information) or traditional approach (33%, i.e., Expected Information, Shouldn't the Pharmacist Know, and Feels Uncomfortable) and improvements in item scores varied by type of prescription. Pharmacists' use of the 3PQs increased patient talk time for scenarios with new chronic and acute medication, though pharmacists still dominated the conversation. CONCLUSION: Just over half of SPs preferred an interactive communication style, although a third of SPs preferred a communication style that focused on information provision. Patients had more time to talk in some interactive encounters. Pharmacists may need to be aware of patient expectations when using the 3PQs.

Pharmacists on primary care teams: Effect on antihypertensive medication management in patients with type 2 diabetes.

OBJECTIVE: To identify which activities produced a significant improvement in blood pressure control in patients with type 2 diabetes when pharmacists were added to primary care teams. METHODS: This prespecified, secondary analysis evaluated medication management data from a randomized controlled trial. The primary outcome was a change in treatment, defined as addition, dosage increase, or switching of an antihypertensive medication during the 1-year study period. The secondary outcome was a change in antihypertensive medication adherence using the medication possession ratio (MPR). RESULTS: The 200 evaluable trial patients had a mean age of 59 (SD, 11) years, 44% were men, and mean blood pressure was 130 (SD, 16)/74 (SD, 10) mm Hg at baseline. Treatment changes occurred in 45 (42%) of 107 patients in the intervention group and 24 (26%) of 93 patients in the control group (RR, 1.63; 95% CI, 1.08-2.46). Addition of a new medication was the most common type of change, occurring in 34 (32%) patients in the intervention group and 17 (18%) patients in the control group (P = 0.029). Adherence to antihypertensive medication was high at baseline (MPR, 93%). Although medication adherence improved in the intervention group (MPR, 97%) and declined in the control group (MPR, 91%), the difference between groups was not significant (P = 0.21). CONCLUSION: The observed improvement in blood pressure control when pharmacists were added to primary care teams was likely achieved through antihypertensive treatment changes and not through improvements in antihypertensive medication adherence.

A scoping review of research on the prescribing practice of Canadian pharmacists.

BACKGROUND: Pharmacists in Canada have been prescribing since 2007. This review aims to explore the volume, array and nature of research activity on Canadian pharmacist prescribing and to identify gaps in the existing literature. METHODS: We conducted a scoping review to examine the literature on prescribing by pharmacists in Canada according to methodological trends, research areas and key findings. We searched for peer-reviewed research articles and abstracts in the Ovid MEDLINE, Ovid EMBASE and International Pharmaceutical Abstracts databases without any date limitations. A standardized form was used to extract information. RESULTS: We identified 156 articles; of these, 26 articles and 12 abstracts met inclusion criteria. One-half of the research studies (20) used quantitative methods, including surveys, trials and experimental designs; 11 studies used qualitative methods and 7 used other methods. Research on pharmacist prescribing demonstrated an improvement in patient outcomes (13 studies), varied stakeholder perceptions (10 studies) and factors that influence this practice change (11 studies). Pharmacist prescribing was adopted when pharmacists practised patient-centred care. Stakeholders held contrasting perceptions of pharmacist prescribing. DISCUSSION: Canadian research has demonstrated the benefit of pharmacist prescribing on patient outcomes, which is not present in the international literature. Future research may consider a meta-analysis addressing the impact on patient health. Gaps in research include comparisons between provinces, effects on physicians' services, overall patient safety and access to health care systems and economic implications for society. CONCLUSION: A growing body of research on pharmacist prescribing has captured the early impact of prescribing on patient outcomes, perceptions of practice and practice change. Opportunities exist for pan-Canadian research that examines the system impact.

Managing common ambulatory conditions: Exploring clinical decision making performance between pharmacists and family physicians.

Background: Prescribing is part of the expanded scope of practice for pharmacists in Alberta, Canada. Given these responsibilities, clinical decision making (the outcome from the diagnostic and therapeutic decision making process) is an essential skill for pharmacists. The current study compared diagnostic and therapeutic decision-making between Additional Prescribing Authority (APA) pharmacists and family physicians using a set of common ambulatory clinical cases that both practitioners could encounter in the community as part of their daily practice. Objectives: To explore clinical decision making performance and behaviors between APA pharmacists and family physicians during the assessment and prescribing of common ambulatory conditions. Methods: Eight written ambulatory clinical cases were developed by a panel of experts in both family medicine and pharmacy that were commonly encountered in both professions' daily practice. Participating APA pharmacists and family physicians reviewed the cases and responded with likely diagnoses, recommended treatments, and reported confidence in therapeutic choices. The responses of 18 APA pharmacists and 9 family physicians in community practices were analyzed. Results: There were no significant differences in diagnostic accuracy, therapeutic accuracy, confidence in diagnostic choices, and confidence in therapeutic choices between APA pharmacists and family physicians to these common ambulatory presentations. Conclusions: This study provides preliminary insights regarding the capabilities of pharmacists in the assessment of common ambulatory community conditions and suggests that APA pharmacists are making similar diagnostic and therapeutic decisions to family physicians. Future research could focus on examining the performance of pharmacists trained in different pharmacy education models, as well as their ability to provide clinical assessment in other specialties, or in more uncommon clinical scenarios.

Patient assessment and documentation integrated in community practice: chat, check, and chart.

OBJECTIVE: To explore how pharmacists integrated the Chat, Check and Chart (CCC) tools in community practice and to identify barriers and facilitators to use. DESIGN: Concurrent nested mixed-method study. Open-ended, semi-structured qualitative interviews on tools use and a quantitative survey were completed via telephone. SETTING: Community-based pharmacy practice. PARTICIPANTS: 39 community pharmacists consented to interviews 2 months after the CCC training workshop; 22 completed an interview. INTERVENTION: Workshop training on CCC tools and workplace implementation strategies. MAIN OUTCOME MEASURES: Barriers, facilitators and implementation strategies for CCC tools. RESULTS: More pharmacists were implementing or had made patient assessment part of their practice (54%) than documentation of patient care (36%). Integration was facilitated by patient success, collaborative worksite, personal beliefs, and provincial regulations. Lack of routines, patient expectations, reimbursement, and time were familiar barriers. Strategies to overcome these barriers included practicing new habits, using technology, starting small, using physical reminders, and recognizing benefits. CONCLUSION: Patient care tools for assessment and documentation had both positive and negative effects on patients, pharmacists, and community pharmacies because of demands on time, lack of resources, and limited personal, external, and patient expectations of pharmacists' care. Findings resulted in Alberta College of Pharmacists academic detailing of the CCC tools during onsite pharmacy assessments to help pharmacists meet or exceed provincial practice standards.

Evaluation of Medication Incidents in a Long-term Care Facility Using Electronic Medication Administration Records and Barcode Technology.

Objective To describe the frequency, type, and severity of reported medication incidents that occurred at a long-term care facility (LTCF) despite electronic medication administration record and barcode-assisted medication administration (eMAR-BCMA) use. The study also contains analysis for the contribution of staff workarounds to reported medication administration errors (MAEs) using an established typology for BCMA workarounds, characterize if the eMAR-BCMA technology contributed to MAEs, and explore characteristics influencing incident severity. Design Retrospective incident report review. Setting A 239-bed LTCF in Alberta, Canada, that implemented eMAR-BCMA in 2013. Participants 270 paper-based, medication incident reports submitted voluntarily between June 2015 and October 2017. Interventions None. Results Most of the 264 resident-specific medication incidents occurred during the administration (71.9%, 190/264) or dispensing (28.4%, 75/264) phases, and 2.3% (6/264) resulted in temporary harm. Medication omission (43.7%, 83/190) and incorrect time (22.6%, 43/190) were the most common type of MAE. Workarounds occurred in 41.1% (78/190) of MAEs, most commonly documenting administration before the medication was administered (44.9%, 35/78). Of the non-workaround MAEs, 52.7% (59/112) were notassociated with the eMAR-BCMA technology, while 26.8% (30/112) involved system design shortcomings, most notably lack of a requirement to scan each medication pouch during administration. MAEs involving workarounds were less likely to reach the resident (74.4 vs 88.8%; relative risk = 0.84, 95% CI 0.72-0.97). Conclusion Administration and dispensing errors were the most reported medication incidents. eMAR-BCMA workarounds, and design shortcomings were involved in a large proportion of reported MAEs. Attention to optimal eMAR-BCMA use and design are required to facilitate medication safety in LTCFs.

What are the respiratory health research priorities in Alberta, Canada? A stakeholder consultation.

OBJECTIVE: The Respiratory Health Strategic Clinical Network (RHSCN) was launched to facilitate respiratory and sleep health through implementation of innovative, patient-centred, evidence-informed coordinated services in Alberta. In collaboration with project partners, the RHSCN aimed to determine the respiratory research priorities for Alberta. DESIGN: The four phases of this research prioritisation project were (1) identifying research questions from stakeholders, (2) determining which research questions had been answered in existing literature, (3) prioritising unanswered questions and (4) finalising the priorities through an inperson workshop. SETTING: The study occurred in Alberta, Canada over a 2-year period beginning in March 2017. PARTICIPANTS: A total of 448 patients, clinicians and other stakeholders consented to participate in the survey. RESULTS: A total of 595 possible questions were submitted, with 343 unique questions identified. Of the questions, 94 were out of scope, 155 answered by existing literature and 10 were combined with others, while 83 were determined to be unanswered in the literature. Stakeholders were surveyed again to prioritise the remaining 83 questions and they were reviewed by the project's Steering Committee (clinicians and patients). At the inperson workshop, the Steering Committee identified 17 research topics as priority areas for respiratory and sleep research in Alberta. CONCLUSION: A stakeholder-led research prioritisation process identified optimal clinical management/follow-up, equitable access to services, and management of social, psychological and mental health issues related to respiratory/sleep health as priority research areas.

Influence of pharmacy practice on community pharmacists' integration of medication and lab value information from electronic health records.

OBJECTIVES: To describe how an electronic health record (EHR) was integrated into community pharmacists' patterns of patient care and to explore factors that are related to the use of medication and laboratory value information from the EHR. DESIGN: Descriptive, exploratory, nonexperimental study. SETTING: Edmonton, Canada, between November 2008 and March 2009. PARTICIPANTS: 16 pharmacists, 3 pharmacy technicians, and 2 pharmacy interns from primary care networks, long-term care settings, community independent and chain pharmacies, and grocery store pharmacies. INTERVENTION: Qualitative interviews. MAIN OUTCOME MEASURE: Pharmacists' self-reported use of EHR. RESULTS: Pharmacists in a patient-centered care practice (involving medication therapy management activities) were more likely to adopt the EHR for medication history and laboratory values, whereas pharmacists whose practice was focused on medication dispensing primarily used the EHR for patient demographic and dispensing records. Six general factors influenced the use of EHR: patients, pharmacists, pharmacy, other health professionals (i.e., physicians), EHR, and environment. Access to the medical record versus EHR and timeliness were barriers specific to pharmacists in a patient-centered practice. Factors that affected EHR use for pharmacists with primarily a dispensing practice were role understanding, dispensing versus lab records, valid reasons for using EHR, and fear of legal and disciplinary issues. CONCLUSION: Many community pharmacists embraced the EHR as a part of practice change, particularly those in patient-centered care practices. Practice type (patient-centered care or dispensing) greatly influenced pharmacists' use of EHR, specifically laboratory values. Because these qualitative findings are exploratory in nature, they may not be generalized beyond the participating pharmacies.

Including the Reason for Use on Prescriptions Sent to Pharmacists: Scoping Review.

BACKGROUND: In North America, although pharmacists are obligated to ensure prescribed medications are appropriate, information about a patient's reason for use is not a required component of a legal prescription. The benefits of prescribers including the reason for use on prescriptions is evident in the current literature. However, it is not standard practice to share this information with pharmacists. OBJECTIVE: Our aim was to characterize the research on how including the reason for use on a prescription impacts pharmacists. METHODS: We performed an interdisciplinary scoping review, searching literature in the fields of health care, informatics, and engineering. The following databases were searched between December 2018 and January 2019: PubMed, Institute of Electrical and Electronics Engineers (IEEE), Association for Computing Machinery (ACM), International Pharmaceutical Abstracts (IPA), and EMBASE. RESULTS: A total of 3912 potentially relevant articles were identified, with 9 papers meeting the inclusion criteria. The studies used different terminology (eg, indication, reason for use) and a wide variety of study methodologies, including prospective and retrospective observational studies, randomized controlled trials, and qualitative interviews and focus groups. The results suggest that including the reason for use on a prescription can help the pharmacist catch more errors, reduce the need to contact prescribers, support patient counseling, impact communication, and improve patient safety. Reasons that may prevent prescribers from adding the reason for use information are concerns about workflow and patient privacy. CONCLUSIONS: More research is needed to understand how the reason for use information should be provided to pharmacists. In the limited literature to date, there is a consensus that the addition of this information to prescriptions benefits patient safety and enables pharmacists to be more effective. Future research should use an implementation science or theory-based approach to improve prescriber buy-in and, consequently, adoption.

Ensuring quality qualitative research reporting in community pharmacy: a systematic literature review.

OBJECTIVES: To evaluate the reporting quality for a sample of community pharmacy qualitative research articles based on the Standards for Reporting Qualitative Research (SRQR) guidelines, data interpretation and use of theory. METHODS: A systematic literature search was conducted using Ovid MEDLINE to identify qualitative research related to community pharmacy. Data were extracted and evaluated based on the SRQR standards, data interpretation level and use of theory. Adherence to standards was analysed using descriptive statistics. KEY FINDINGS: Eighty-one studies were retrieved through the database search (n = 81). Then, 31 studies met the inclusion criteria after screening abstracts and full texts. Twelve out of 21 SRQR were present in more than 80% of the studies. However, essential standards, such as research approach, reflexivity and trustworthiness techniques, were absent or partially present in 30 (97%) studies, 30 (97%) studies and 21 (68%) studies, respectively. Data interpretation level was descriptive in 27 (87%) studies and interpretive or partially interpretive in 4 (13%) studies. Theory was absent in 19 (60%) and implied, partially integrated or retrospectively applied in 12 (40%) of the studies. CONCLUSION: Trustworthiness and quality of qualitative inferences within community pharmacy research could be enhanced with increasing awareness about reporting; the approach and paradigm, reflexivity, trustworthiness techniques, data interpretation level and theoretical use.