Responding to cough presentations: an interview study with Cambodian pharmacies participating in a National Tuberculosis Referral Program.

RATIONALE, AIMS AND OBJECTIVES: Asia-Pacific carries a high burden of respiratory-related mortality. Timely referral and detection of tuberculosis cases optimizes patient and public health outcomes. Registered private pharmacies in Cambodia participate in a National Tuberculosis Referral Program to refer clients with cough suggestive of tuberculosis to public sector clinics for diagnosis and care. The objective of this study was to investigate clinical intentions of pharmacy staff when presented with a hypothetical case of a client with prolonged cough suggestive of tuberculosis. METHOD: A random sample of 180 pharmacies was selected. Trained interviewers administered a hypothetical case scenario to trained pharmacy staff. Participants provided 'yes'/'no' responses to five clinical actions presented in the scenario. Actions were not mutually exclusive. Data were tabulated and compared using chi-square tests or Fisher's exact tests. RESULTS: Overall, 156 (92%) participants would have referred the symptomatic client in the case scenario. Participants who would have referred the client were less likely to sell a cough medicine (42% vs. 100%, P < 0.001) and less likely to sell an antibiotic (19% vs. 79%, P < 0.001) than those who would not have referred the client. CONCLUSION: Involving pharmacies in a Referral Program may have introduced concepts of appropriate clinical care when responding to clients presenting with cough suggestive of tuberculosis. However, results showed enhancing clinical competence among all referral programme participants particularly among non-referring pharmacies and those making concurrent sales of cough-related products would optimize pharmacy-initiated referral. Further research into actual clinical practices at Referral Program pharmacies would be justified.

Stakeholder perceptions of a pharmacy-initiated tuberculosis referral program in Cambodia, 2005-2012.

Intensifying detection of tuberculosis (TB) symptomatic patients is a priority for Cambodia's National Tuberculosis Program, in a country where two-thirds of the population has latent TB infection. In 2005, the National Tuberculosis Program initiated a public-private mix (PPM) collaborative program with external and local stakeholders to identify and refer persons with TB symptoms from private sector pharmacies to public sector clinics for diagnosis and treatment. This qualitative study conducted in-depth interviews with organizational stakeholders to assess their perceptions of PPM program collaboration and its sustainability in the long term. Results showed that stakeholders perceived that collaboration and efficient management had contributed to positive program performance. However, stakeholders expressed anxiety over program sustainability should external resources be reduced. Recent developments in pharmacy undergraduate education and recognition of pharmacy providers' contribution to public health interventions may challenge PPM stakeholders to shift the paradigm from dependence on external agencies to confidence in local expertise and infrastructure.

Referral of tuberculosis symptomatic clients from private pharmacies to public sector clinics for diagnosis and treatment in Cambodia.

RATIONALE, AIMS AND OBJECTIVES: Cambodia is one of the 22 countries with a high burden of tuberculosis (TB). People often first seek treatment for cough and other TB symptoms through private pharmacies. The National Tuberculosis Programme trained willing private sector pharmacies to refer TB symptomatic clients to their closest public sector clinic for diagnosis and treatment. The study objective was to investigate factors associated with referral of TB symptomatic clients from pharmacies to public sector clinics in Phnom Penh, Cambodia. METHOD: Face-to-face structured interviews were conducted with staff from a stratified random sample of 180 private pharmacies in Phnom Penh in 2012. Trained interviewers were Khmer speakers. Logistic regression was used to compute odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with self-reported referral during the previous 3 months. RESULTS: Fifty (29.6%) pharmacies reported that they had referred 125 clients (range 1-10) to public sector clinics during the previous 3 months. In total, 164 (96.5%) pharmacies reported that they always referred all TB symptomatic clients to DOTS (directly observed treatment, short course) clinics. More than 6-year participation in the programme (OR 5.23, 95% CI 1.93-14.18) and willingness to always continue referring (OR 12.24, 95% CI 11.61-93.10) were associated with referral of one or more clients in the previous 3 months. Referral to the client's closest clinic was negatively associated with referral (OR 0.45, 95% CI 0.23-0.99). CONCLUSION: Pharmacies' ongoing commitment to the Referral Programme was strongly associated with referral. Increased advocacy among the high number of non-referring pharmacies may improve programme performance. Factors negatively associated with referral may need investigation.

Community pharmacists' preferences for continuing education delivery in Australia.

INTRODUCTION: New technologies such as the Internet offer an increasing number of options for the delivery of continuing education (CE) to community pharmacists. Many of these options are being utilized to overcome access- and cost-related problems. This paper identifies learning preferences of Australian community pharmacists for CE and identifies issues with the integration of these into contemporary models of CE delivery. METHODS: Four focus group teleconferences were conducted with practicing community pharmacists (n = 15) using a semistructured format and asking generally about their CE and continuing professional development (CPD) experiences. RESULTS: Pharmacists reported preferences for CE that were very closely aligned to the principles of adult learning. There was a strong preference for interactive and multidisciplinary CE. Engaging in CPD was seen as valuable in promoting reflective learning. DISCUSSION: These results suggest that pharmacists have a strong preference for CE that is based on adult learning principles. Professional organizations should take note of this and ensure that new CE formats do not compromise the ability of pharmacists to engage in interactive, multidisciplinary, and problem-based CE. Equally, the role of attendance-based CE in maintaining peer networks should not be overlooked.

A critical evaluation of the therapeutic range of indinavir.

OBJECTIVE: To provide a summary of the patient population, study characteristics, and important findings of the key studies in the literature evaluating concentration-effect relationships and the therapeutic range for indinavir. DATA SOURCES: Literature search strategy involved using MEDLINE (1966-July 2001) and AIDSLINE (MEDSCAPE) databases (up to July 2001). Reference lists from primary literature and review articles were also examined, and conference abstracts were obtained. STUDY SELECTION: English-language articles were considered suitable for review if the clinical trials in HIV patients reported on concentration-effect relationships and/or pharmacokinetic breakpoints or threshold concentrations. A search of the literature identified 20 peer-reviewed references from 18 separate studies including journal articles and conference abstracts. DATA EXTRACTION: The targeted pharmacokinetic parameters and breakpoint values, the rationale for their selection or method of identification, and other study details and limitations were summarized. DISCUSSION: This article highlights the heterogeneity of studies evaluating the therapeutic range of indinavir and provides a summary of important findings of the key studies in the literature evaluating concentration-effect relationships and therapeutic range. Tables are provided to enable clinicians to make use of currently available information on the therapeutic range of indinavir. CONCLUSIONS: There is insufficient evidence to recommend a general therapeutic range for indinavir. Future investigations should incorporate both pharmacokinetics and pharmacodynamics in order to define a broadly applicable therapeutic range.