Implementation of medication reviews in community pharmacy: reaching consensus on stakeholders' recommendations for mechanisms of change using the nominal group technique.

BACKGROUND: Since 2022, patients with five or more medicines are eligible for a medication review (MR) in a community pharmacy remunerated by the German health system. However, implementation has been slow, with few pharmacies providing MRs. Stakeholders' input is necessary to detail how implementation strategies can be executed effectively on a national level. Prior research identified "external facilitation" and "altering incentives" as crucial strategies to achieve implementation outcomes. AIM: To gather stakeholders' recommendations for, and obtain consensus on, mechanisms of change that allow implementation strategies to work in practice. METHOD: The consensus method used was the nominal group technique (NGT) with NGT-discussions held separately with pharmacy owners and pharmacy chambers employees. Votes were summed and the relative importance (rI) calculated, defined as (score achieved for a mechanism)/(maximum possible score) × 100. Content analysis provided context for the highest ranked mechanisms and allowed linking to implementation outcomes. RESULTS: Four NGT-discussions were held in 2023 (n = 2 owners; n = 2 chamber employees) with a total of 17 participants. The overall highest ranked mechanisms were fit-for-purpose software (rI = 154.7) detailed process support (rI = 104.9) and an expert support line (rI = 77.7). These together with financial viability (rI = 40.0) were prioritised by both participant groups. Three mechanisms were favoured for both implementation strategies, namely software, process support and materials (rI = 34.3). CONCLUSION: This study identified stakeholders' priorities for mechanisms of change to implement MRs in community pharmacies. Focusing efforts on the prioritised mechanisms is likely to significantly advance a national implementation plan for countries which are at an early implementation stage.

Implementation of the national antimicrobial stewardship competencies for UK undergraduate healthcare professional education within undergraduate pharmacy programmes: a survey of UK schools of pharmacy.

Background: Pharmacists play a key role in antimicrobial stewardship (AMS). Consensus-based national AMS competencies for undergraduate healthcare professionals in the UK reflect the increasing emphasis on competency-based healthcare professional education. However, the extent to which these are included within undergraduate pharmacy education programmes in the UK is unknown. Objectives: To explore which of the AMS competencies are delivered, including when and at which level, within UK undergraduate MPharm programmes. Methods: A cross-sectional online questionnaire captured the level of study of the MPharm programme in which each competency was taught, the method of delivery and assessment of AMS education, and examples of student feedback. Results: Ten institutions completed the survey (33% response rate). No institution reported covering all 54 AMS competencies and 5 of these were taught at half or fewer of the institutions. Key gaps were identified around taking samples, communication, outpatient parenteral antimicrobial therapy and surgical prophylaxis. The minimum time dedicated to AMS teaching differed between institutions (range 9-119 h), teaching was generally through didactic methods, and assessment was generally through knowledge recall and objective structured clinical examinations. Feedback from students suggests they find AMS and antimicrobial resistance (AMR) to be complex yet important topics. Conclusions: UK schools of pharmacy should utilize the competency framework to identify gaps in their AMS, AMR and infection teaching. To prepare newly qualified pharmacists to be effective at delivering AMS and prescribing antimicrobials, schools of pharmacy should utilize more simulated environments and clinical placements for education and assessment of AMS.

Just a 'romantic idea'? A theory-based interview study on medication review implementation with pharmacy owners.

BACKGROUND: Recent legal changes in Germany entitle patients on multiple medications to receive a medication review (MR). However, the provision of MRs is not mandatory and pharmacy owners decide whether to implement this service in their pharmacies. AIM: To determine pharmacy owners' attitudes towards MRs, explore their experiences with MR implementation and examine their perceptions of barriers and facilitators towards implementation of MRs in community pharmacies. METHOD: Pharmacy owners were invited to participate in semi-structured interviews. Purposive sampling was used with selection criteria being MR-implementation stage, and geographical location of the pharmacy. The topic guide was based on a systematic review and the Framework for Implementation of Services in Pharmacy (FISpH). Interviews were recorded, transcribed verbatim and coded directly against the FISpH. RESULTS: Twenty-one pharmacy owners were interviewed. Despite participants' consistent positive attitude towards MRs, most believed that providing MRs on an economically viable basis would be challenging. Several practical suggestions emerged which would enable community pharmacies a smoother implementation of MRs. Suggestions included employing 'change facilitators', who visit and support implementing pharmacies; national awareness campaigns targeting patients and health professionals; reducing bureaucracy; continuing professional development; involving technicians in some MR-tasks; and offering an additional incentive to lower the initial implementation threshold. CONCLUSION: This research identified numerous factors that are likely to increase owners' and managers' support to the idea of MRs. This may be of interest to any country planning implementation of MRs.

Experiences of key stakeholders with the implementation of medication reviews in community pharmacies: A systematic review using the Consolidated Framework for Implementation Research (CFIR).

BACKGROUND: Though medication reviews have shown positive patient outcomes, they are still not widely implemented in community pharmacies. Published reviews on their implementation often include several other pharmacy services, making them non-specific. Using the Consolidated Framework for Implementation Research (CFIR) to focus solely on the experiences of different stakeholders with the implementation of medication reviews will help to better understand relevant facilitators and barriers. OBJECTIVES: To critically appraise, synthesise and present the available evidence on experiences of key stakeholders with the implementation of medication reviews and to identify barriers and facilitators to its implementation in community pharmacies. METHODS: A systematic literature search was conducted in four databases for studies published in English, Spanish or German. Key search terms included: implementation, pharmac*, medication review, facilitator, barrier. Study selection, quality assessment and data extraction were performed by two independent reviewers. Findings were mapped directly against the constructs of the CFIR. RESULTS: Out of 924 retrieved records 24 articles from 9 countries met the inclusion criteria. Key facilitators identified included pharmacists' openness to practice change and a high degree of patient satisfaction post medication review. Attracting patients to the service was stated as challenging due to an unawareness of the scope and potential benefit of a medication review. The dominant barrier was inadequate remuneration, as it impacted all additional resourcing and ultimately the viability of the service. Further barriers included difficult professional relationships with doctors and little mandate from health authorities. Most reports were from the employed pharmacists' perspective and concerned the inner setting, other perspectives were under-reported. CONCLUSIONS: Results of this systematic review illustrate different stakeholders' experiences and add to the understanding of challenges in the implementation process. Nevertheless, findings also highlight how scarce reporting of external stakeholders' views is and that filling this gap can unveil hidden barriers and facilitators. REGISTRATION: PROSPERO register (CRD 42019122836).

Exploring pharmacists' perceptions of the feasibility and value of pharmacist prescribing of antimicrobials in secondary care in Scotland.

OBJECTIVES: The introduction of non-medical prescribing in the UK has provided opportunities and challenges for pharmacists to help ensure prudent use of antimicrobials. The objective of this research was to explore pharmacists' perceptions of the feasibility and value of pharmacist prescribing of antimicrobials in secondary care in Scotland. METHODS: Pharmacists' perceptions were explored using focus groups in five Scottish regions representing (a) urban and rural areas and (b) district general hospitals and large teaching centres. Senior hospital pharmacists, both prescribers and non-prescribers, working in specialities where antimicrobials are crucial to patient management, were invited to participate. A topic guide was developed to lead the discussions, which were audio-recorded and transcribed. The framework approach to data analysis was used. KEY FINDINGS: Six focus groups took place and some emerging themes and issues are presented. Pharmacists believed that the feasibility of antimicrobial prescribing is dependent upon the patient's clinical condition and the area of clinical care. They identified potential roles and opportunities for pharmacist prescribing of antimicrobials. Perceived benefits included giving patients quicker access to medicines, reducing risk of resistance and better application of evidence-based medicine. CONCLUSIONS: Pharmacists feel they have a good knowledge base to prescribe and manage antimicrobial treatment, identifying possible opportunities for intervention. Roles within a multidisciplinary antimicrobial team need to be clearly defined.

Antimicrobial optimisation in secondary care: the pharmacist as part of a multidisciplinary antimicrobial programme--a literature review.

The aims of this literature review were: (i) to determine what roles have been supported by evidence for the pharmacist in optimising antimicrobial treatment as part of an antimicrobial multidisciplinary team (AMDT) in secondary care; and (ii) to describe the outcomes of interventions of an AMDT in secondary care with pharmacy involvement. Both descriptive and primary research reports were identified and included. The hospital pharmacist emerged as a key member of the AMDT. The dispensary pharmacist was mainly involved in the screening processes and was crucial in implementing restriction policies. The general ward-based clinical pharmacist was involved in guideline development, formulary management, intravenous-to-oral conversions and evaluations of programme outcomes through monitoring of drug usage, and also facilitated identification of patients with specific needs who could be referred to the specialist pharmacist. A role emerged for the specialist pharmacist who was an integral part of the AMDT and was involved in activities including reviewing of more complex patients, attending ward rounds and streamlining of initial empirical antimicrobial treatment. Outcomes of interventions reported in primary research have been classified into: drug outcomes, where most trials measured and reported an increase in adherence to guidelines; microbiological outcomes, only considered in a few trials; clinical outcomes, with different parameters measured and a maintenance or improvement reported; and financial outcomes. The latter were reported in all trials with numerous cost savings, although not all were statistically significant. Moreover, the cost of the intervention was not always considered.