Future methods in pharmacy practice research.

This article describes the current and future practice of pharmacy scenario underpinning and guiding this research and then suggests future directions and strategies for such research. First, it sets the scene by discussing the key drivers which could influence the change in pharmacy practice research. These are demographics, technology and professional standards. Second, deriving from this, it seeks to predict and forecast the future shifts in use of methodologies. Third, new research areas and availability of data impacting on future methods are discussed. These include the impact of aging information technology users on healthcare, understanding and responding to cultural and social disparities, implementing multidisciplinary initiatives to improve health care, medicines optimization and predictive risk analysis, and pharmacy as business and health care institution. Finally, implications of the trends for pharmacy practice research methods are discussed.

Do patients initiate therapy? Primary non-adherence to statins and antidepressants in Iceland.

BACKGROUND: Primary non-adherence occurs when a drug has been prescribed but the patient fails to have it dispensed at the pharmacy. AIMS: To assess primary non-adherence to statins and antidepressants in Iceland, the association of demographic factors with primary non-adherence, and the time from when a prescription is issued until it is dispensed. METHODS: Data on patients receiving a new prescription for a statin or an antidepressant from the Primary Health Care database were linked with dispensing histories from The Icelandic Prescription Database. The proportion of patients who did not have their prescription dispensed within a year from issuing (primary non-adherent) was assessed, as well as the time from issue until dispensing. Associations between demographic factors and primary non-adherence were estimated using logistic regression. RESULTS: The overall primary non-adherence was 6.3% and 8.0% for statins and antidepressants, respectively. The majority of patients had their prescription dispensed within 7 days (85% for statins, 87% for antidepressants). Being disabled and receiving a prescription for an expensive drug was associated with higher rates of primary non-adherence. CONCLUSION: The rate of primary non-adherence to statins and antidepressants in Iceland is low. Vulnerable groups such as the disabled should be given special attention when new drugs are prescribed.

The association between lifting an administrative restriction on antidepressant dispensing and treatment patterns in Iceland.

PURPOSE: On March 1st 2009, restrictions on the dispensing of selective serotonin reuptake inhibitors (SSRI) in Iceland were lifted. Incident rates and changes in early discontinuation and switching before and after the change were investigated. METHODS: New users of antidepressants between March 1st 2006 and March 1st 2010 were selected from the Icelandic Prescriptions Database. The study population was split into one intervention cohort (2009) and three comparison cohorts (2006, 2007, and 2008). Incidence rate ratios (IRR) and odds ratios (OR) were used to compare incidence rates and early discontinuation. RESULTS: The overall incidence rates of antidepressant use decreased from 33.10 to 28.71 per 1000 persons per year (IRR 0.87; 95% confidence interval (CI), 0.78-0.97) from the 2006 to the 2009 cohort. The incidence rate for SSRIs did not change over the period. Early discontinuation for SSRIs increased from 30.2% in 2006 to 34.1% in 2009 (OR 1.19; 95% CI 1.06-1.33). CONCLUSIONS: The change in reimbursement does not seem to have affected incidence rates but it may be related to increased early discontinuation, which can lead to increased drug wastage. It might be more clinically rational to initiate patients on smaller supply, allowing for more frequent check-up visits.

A question of emphasis: efficiency or equality in the provision of pharmaceuticals.

The reported results are part of the overall evaluation of the new drug distribution legislation that went into effect in March 1996, liberalising ownership of community pharmacies in Iceland. We addressed the following question: What impact did the legislation have on users' access to and costs of pharmaceuticals? Seven focus group discussions were conducted with pharmacy customers in different locations in May, August and October 1997. Widespread ignorance about the legislation was observed. Pharmacy customers preferred to discuss the role of physicians in 'irrational drug use' to discussing community pharmacies. A definite split was observed between urban and rural pharmacy customers; whereas definite changes were reported in the urban setting (lower prices and increased access), the rural population's perception is that it is being left out. Although the study design is not generalisable, it is clear that the equilibrium between equality and efficiency in pharmaceutical distribution in Iceland has shifted. The introduction of the free market system has increased inequality between rural and urban residents in exchange for increased efficiency.

Cost containment of pharmaceutical use in Iceland: the impact of liberalization and user charges.

OBJECTIVES: Iceland was the first Nordic country to liberalise its drug distribution system, in March 1996. Subsequent regulation in January 1997 increased patients' share of drug costs. The objectives of this study were to test the assumptions that liberalizing community pharmacy ownership would lower reimbursement costs for the state's Social Security Institute and that increasing patient charges would reduce use and, therefore, lower the cost to the Institute. METHODS: Based on the assumptions, we built and tested two models using interrupted time series designs that contrast the monthly reimbursement costs before and after the legislation and regulation took effect. A control variable (the number of office visits to general practitioners) was tested to assess other events in the health care arena. Monthly data on these variables were provided by the Icelandic State Social Security Institute for January 1993 to August 1998 for reimbursement costs and to December 1998 for office visits to general practitioners. RESULTS: Reimbursement costs have risen steadily throughout the period under study. The interrupted time series analysis did not show a substantial effect from the legislative change in March 1996 or from the regulatory intervention in January 1997. CONCLUSIONS: The main argument used for liberalizing community pharmacy ownership in Iceland was built on false assumptions regarding the effect on drug reimbursement costs to the state. It will be necessary to find more promising interventions to halt the rapidly increasing cost of drugs.

Over-the-counter codeine use in Iceland: the impact of increased access.

BACKGROUND: The objective of this study was to test the assumption that liberalizing community pharmacy ownership in Iceland would lead to increased irrational use of over-the-counter pain relievers containing codeine. METHODS: Based on this assumption we built and tested a model using an interrupted time series design that contrasts the monthly sales data for over-the-counter pain relievers containing codeine before and after the legislation took effect. RESULTS: The total use of over-the-counter pain relievers containing codeine as well as those containing paracetamol and codeine has risen steadily throughout the period under study. The interrupted time series did not show a substantial effect from the legislative change on the use of all over-the-counter codeine pain relievers, paracetemol with codeine, and aspirin with codeine combinations. CONCLUSION: The assumption that increased access leads to irrational use of over-the-counter medicines is not substantiated in the case of over-the-counter pain relievers containing codeine.

Technicians or patient advocates?--still a valid question (results of focus group discussions with pharmacists).

New legislation went into effect in Iceland in March 1996 making it the first Nordic country to liberate their drug distribution system. The term liberalization implies the abolishment of the professional monopoly in that ownership was not tied to the pharmacy profession anymore. Focus group discussions with community pharmacists in the capital area Reykjavík and rural areas were employed to answer the research question: How has the pharmacists' societal role evolved after the legislation and what are the implications for pharmacy practice? The results showed firstly that the public image and the self-image of the pharmacist has changed in the short time since the legislative change. The pharmacists generally said that their patient contact is deteriorating due to the discount wars, the rural pharmacists being more optimistic, and believing in a future competition based on quality. Secondly, the results showed that the pharmacists have difficulties reconciling their technical paradigm with a legislative and professional will specifying customer and patient focus. This study describes the challenges of a new legislation with a market focus for community pharmacists whose education emphasized technical skills. This account of the changes in the drug distribution system in Iceland highlights some of the implications for pharmacists internationally.

No struggle, no strength: how pharmacists lost their monopoly.

Research accounts of the struggle of professions to attain and maintain a monopoly, strategies of exclusion and usurpation, make for interesting and often exciting reading. The purpose of this article is to present a less frequently reported phenomenon--the study of a profession that had a monopoly, and then lost it. The authors attempt to answer the question: under what circumstances will a profession support the state in breaking their own monopoly? The study looked at the pharmacy profession in Iceland in the light of the recent change in drug legislation. Interviews with key actors in the pharmacy profession were conducted to gain an understanding of how they interpreted and experienced this change. Three factors contributed to the break in the professional monopoly: (1) political desire to take advantage of new competition and deregulation policy, (2) desire to cut the health budget and (3) internal divisions within the profession. The results of the study revealed at least four internal divisions within the pharmacy profession: (1) urban/rural, (2) employer/employee, (3) lower/higher education and (4) young/old. The article illustrates how a profession weakened by internal strife became prey to the government's cost cutting activities. This study is an example of how internal conflicts not only weakened the profession, but created a climate conducive to losing its monopoly. Our findings raise fundamental questions about the future of professions in society today.

Factors influencing the detection rate of drug-related problems in community pharmacy.

This study analyzes relationships between the number of drug-related problems detected in community pharmacy practice and the educational level and other characteristics of pharmacy personnel and their work sites. Random samples of pharmacists, prescriptionists and pharmacy technicians were drawn nationwide in Sweden. One hundred and forty-four (63%) of those meeting the inclusion criteria agreed to take part. The participants documented medication-related problems, interventions and patient variables on a data collection form. The drug-related problems were weighted by the number of patients served by each professional. The regression analysis showed the educational level of the professional to have a statistically significant effect on the detection rate, with pharmacists finding on average 2.5 more drug-related problems per 100 patients than prescriptionists and about 3.6 more than technicians. Previous participation in a study or activity on drug-related problems and the size of the pharmacy also had statistically significant effects on the problem detection rate. The use of open-ended questions to create a dialogue with the patient seemed to be a successful means to discover problems. The results of this study indicate the importance of education and training of pharmacy personnel in detection of drug-related problems. This findings speaks in favor of increasing the pharmacist to other personnel ratio, provided the higher costs will be offset by societal benefits.