Audit of community pharmacists' prescribing interventions: Quality assessment of a newly reimbursed service.

OBJECTIVES: To evaluate community pharmacists' reimbursed prescribing interventions (called pharmaceutical opinions/POs in Canada) by determining the types of drug-related problems (DRPs) identified; the type, quality, and clinical impact of recommendations made; and variation in recommendation quality across regions, pharmacy ownership type, and pharmacy size. DESIGN: Retrospective audit of randomly sampled service documentation records. SETTING: Community pharmacies in Ontario, Canada, 3 years after implementation of a government program that reimburses pharmacies for providing DRP-based POs to physicians. PARTICIPANTS: Thirty-six community pharmacies in 4 regions of Ontario. MAIN OUTCOME MEASURES: For each PO, 2 experienced clinical pharmacists independently, and then by consensus, determined the primary drug implicated and its therapeutic category, the type of DRP, and the type of prescriber recommendation. Each PO recommendation was assessed for clinical impact, evidence base, and overall quality. Chi-square analyses assessed the relationship between PO quality and pharmacy characteristics. RESULTS: Of 563 POs, 261 (46%) met reimbursement criteria for stating a DRP and prescriber recommendation. Among these eligible POs, systemic antiinfective (22%), alimentary tract and metabolism (19%), nervous system (15%), and cardiovascular (15%) drugs were most commonly identified in the DRP. Adverse drug reactions (which included drug interactions) were the most common type of DRP (42.5%), followed by "dose too high" (16%) and "needs additional therapy" (14%). Top recommendations were to change the drug (41%) and to decrease the dose (20%). The quality of the pharmacist's recommendation was judged to be good to excellent in 70% of the 261 eligible POs; quality was associated with region and ownership type. CONCLUSION: PO quality was suboptimal: the primary issue was failure to state a prescriber recommendation. Collaborative efforts are needed from community pharmacy stakeholders (schools of pharmacy, regulatory colleges, and continuing education providers) to help pharmacists enhance the quality of their POs, beginning with their clinical documentation skills.

Multiple mini-interview predictive validity for performance on a pharmacy licensing examination.

CONTEXT: Predictive validity studies on the use of the multiple mini-interview (MMI) have been primarily in medicine. OBJECTIVES: This study sought to determine the predictive validity of the MMI for performance within a pharmacy programme and on the Pharmacy Examining Board of Canada (PEBC) Qualifying Examination for licensure, and to compare the predictive validity of the MMI with that of pre-pharmacy grade point average (GPA) and Pharmacy College Admission Test (PCAT) score. METHODS: Admissions data for 223 graduates of the pharmacy programme at the University of Toronto were matched to programme and licensure outcome measures. Multiple linear regression assessed the predictive ability of the MMI, pre-pharmacy GPA, PCAT and covariates for performance in final-year experiential rotations, cumulative GPA (cGPA) and PEBC-MCQ (multiple-choice question examination) and PEBC-OSCE (objective structured clinical examination) overall and subcomponent scores. RESULTS: The PCAT, pre-pharmacy GPA and age significantly predicted the PEBC-MCQ overall score. The MMI was the only significant predictor of overall score on the PEBC-OSCE (ß = 0.17, p = 0.02); it also predicted communication and performance subscores. Scores on the PCAT and female gender predicted the communication subscore. Pre-pharmacy GPA, age and female gender significantly predicted cGPA. The MMI was the only significant predictor of institutional/ambulatory rotation score (ß = 0.26, p = 0.00). CONCLUSIONS: The MMI, designed to measure non-academic attributes including communication, motivation and problem-solving skills, was the only admissions tool with significant predictive validity for performance on the PEBC-OSCE national pharmacy certification examination and in an institutional/ambulatory rotation. These findings, from a single cohort of undergraduates, provide the first report of the predictive validity of the MMI for performance on pharmacy licensure examinations and thereby strengthen the evidence for its use in health professions selection. Prior university academic performance significantly predicted cGPA and performance on the PEBC-MCQ. Performance on the PCAT also predicted PEBC-MCQ results.

Exploring deprescribing opportunities for community pharmacists using the Behaviour Change Wheel.

BACKGROUND: Deprescribing, the planned and supervised process of stopping or reducing doses of medications, can reduce the use of harmful or unnecessary medications. However, deprescribing is challenging for patients and prescribers to implement. Community pharmacists have the potential to contribute to deprescribing, but whether they are well positioned to do so effectively remains unclear. OBJECTIVES: To explore community pharmacists' involvement with deprescribing, and identify strategies for enhancing this involvement. METHODS: We conducted qualitative telephone interviews with 17 community pharmacists in Ontario, Canada. The Behaviour Change Wheel's COM-B model was used to inform the development of the interview guide. Four investigators coded three transcripts independently to develop the codebook. One investigator coded the remainder and generated themes relating to the first study objective using inductive thematic analysis. Two phases of analysis were then used to satisfy the second study objective: the first without the explicit use of theory, and the second using the Behaviour Change Wheel as a theoretical framework. RESULTS: Pharmacists' involvement in deprescribing was affected by: 1) their understanding of which medications should be stopped and by whom, 2) their access to patient information, and 3) competing clinical and business/technical demands of their daily activities. Findings support recommendations for optimizing community pharmacists' involvement in deprescribing by focusing on specific steps within deprescribing, expanding pharmacists' understanding of how to integrate deprescribing into their practices, and defining their deprescribing role with multi-stakeholder engagement. CONCLUSIONS: This study is the first to connect community pharmacists' real-world deprescribing challenges with theory-informed recommendations for enhancing their contributions to deprescribing. This study also explored the role of theory in pragmatically-oriented qualitative work by analyzing data without the explicit use of theory as the first step to analysis. Findings inform recommendations for enhancing community pharmacists' contributions to deprescribing.

Implementation of a reimbursed medication review program: Corporate and pharmacy level strategies.

BACKGROUND: In 2006, the Ontario drug plan greatly reduced community pharmacy reimbursement for generic drugs. In exchange, a fee-for-service medication review program was introduced to help patients better understand their medication therapy and ensure that medications were taken as prescribed. A qualitative study of community pharmacy implementation strategies was undertaken to inform a mixed methods evaluation of the program. PURPOSE: To describe strategies used by community pharmacies to implement a government-funded medication review service. METHODS: Key informant interviews were conducted with pharmacy corporate executives and managers, as well as independent pharmacy owners. All pharmacy corporations in the province were approached; owners were purposively sampled from the registry of the pharmacist licensing body to obtain diversity in pharmacy attributes; and pharmacy managers were identified through a mix of snowball and registry sampling. Thematic qualitative coding and analysis were applied to interview transcripts. RESULTS: 42 key informants, including 14 executives, 15 managers/franchisees, and 11 owners, participated. The most common implementation strategy was software adaptation to flag eligible patients and to document the service. Human resource management (task shifting to technicians and increasing the technician complement), staff training, and patient identification and recruitment processes were widely mentioned. Motivational strategies including service targets and financial incentives were less frequent but controversial. Strategies typically unfolded over time, and became multifaceted. Apart from the use of targets in chain pharmacies only, strategies were similar across pharmacy ownership types. DISCUSSION: Ontario community pharmacies appeared to have done little preplanning of implementation strategies. Strategies focused on service efficiency and quantity, rather than quality. Unlike other jurisdictions, many managers supported the use of targets as motivators, and very few reported feeling pressured. This detailed account of a range of implementation strategies may be of practical value to community pharmacy decision makers.

Willingness to pay for inhaled insulin: a contingent valuation approach.

PURPOSE: To determine the willingness to pay (WTP) of patients with diabetes mellitus for inhaled insulin. METHODS: A contingent valuation survey was administered to 96 diabetic outpatients at St. Michael's Hospital, Toronto, Canada. Standardised information about inhaled insulin and subcutaneous rapid-acting insulin was provided via video. Participants' WTP for their preferred product was elicited in Canadian dollars (Can dollars) using a 'payment-scale' method. RESULTS: The mean age of participants was 51.8 years (SD 13.4). Seventy-seven patients had type 2 and 19 had type 1 diabetes. Significantly more participants preferred inhaled insulin over subcutaneous insulin (85 vs 11; p < 0.01). Mean monthly WTP for inhaled insulin (153.70 Can dollars, SD 99.90) was significantly more than the typical 50 Can dollars per month for subcutaneous insulin (p < 0.01). Significantly more participants with type 2 diabetes using oral drugs than those with type 1 diabetes and using insulin preferred inhaled insulin (98.5% vs 69%, p < 0.001). Diabetic patients who did not use insulin were willing to pay significantly more than were insulin users (p < 0.001). Multiple regression analysis showed that income was significantly associated with WTP for inhaled insulin. CONCLUSION: Diabetic patients, particularly those who are not using insulin, indicated that they would prefer inhaled insulin over insulin injection and would be willing to pay a substantial amount per month to use it. An economic evaluation of inhaled insulin would provide important information to healthcare policy decision makers and private payers about its economic value.

Relationship between daily dose frequency and adherence to antihypertensive pharmacotherapy: evidence from a meta-analysis.

BACKGROUND: Rates of patient adherence (compliance) to pharmacotherapy range from <5% to >90%. Negative determinants include multiple daily dosing (MDD), chronic duration, and asymptomatic disease. Reports suggest that once-daily (QD) dosing may improve adherence, but their findings are inconclusive. OBJECTIVE: The purpose of this study was to compare the rates of adherence with QD, twice-daily (BID), and MDD antihypertensive drug regimens. METHODS: MEDLINE, Embase, and International Pharmaceutical Abstracts databases were searched to identify comparative trials of patient adherence to antihypertensive medication in solid, oral formulations. Data were combined using a random-effects meta-analytic model. RESULTS: Eight studies involving a total of 11,485 observations were included (1,830 for QD dosing, 4405 for BID dosing, 4147 for dosing >2 times daily [>BID], and 9655 for MDD), in which the primary objective was to assess adherence. The average adherence rate for QD dosing (91.4%, SD = 2.2%) was significantly higher (Z = 4.46, P < 0.001) than for MDD (83.2%, SD = 3.5%). This rate was also significantly higher (Z = 2.22, P = 0.026) than for BID dosing (92.7% [SD = 2.3%] vs 87.1% [SD = 2.9%]). The difference in adherence rates between BID dosing (90.8%, SD = 4.7%) and >BID dosing (86.3%, SD = 6.7%) was not significant (Z = 1.82, P = 0.069). CONCLUSIONS: The results of this meta-analysis demonstrate that with antihypertensive medications, QD dosing regimens are associated with higher rates of adherence than either BID or MDD regimens.

Development and pilot testing of a multiple mini-interview for admission to a pharmacy degree program.

OBJECTIVES: To develop and pilot test a multiple mini-interview (MMI) to select students for admission to a pharmacy degree program. METHODS: A nominal group process was used to identify 8 important nonacademic attributes of pharmacists, with relative importance determined by means of a paired-comparison survey of pharmacy stakeholders (ie, university-affiliated individuals with a vested interest in the quality of student admitted to the pharmacy program, such as faculty members, students, admissions staff members, and practitioners). A 10-station MMI based on the weighted-attribute blueprint was pilot tested with 30 incoming pharmacy students. MMI score reliability (intraclass correlation coefficient [ICC]) and correlation with other admissions tool scores were determined. RESULTS: Station scores provided by student interviewers were slightly higher than those of faculty member or practitioner interviewers. While most interviewers judged a 6-minute interview as "just right" and an 8-minute interview "a bit long," candidates had the opposite opinion. Station scenarios had face validity for candidates and interviewers. The ICC for the MMI was 0.77 and correlations with prepharmacy average (PPA) and Pharmacy College Admission Test (PCAT) composite were negligible. CONCLUSIONS: MMI feasibility was confirmed, based on the finding that interview scores were reliable and that this admissions tool measures different attributes than do the PCAT and PPA.

When does pharmaceutical care impact health outcomes? A comparison of community pharmacy-based studies of pharmaceutical care for patients with asthma.

BACKGROUND: Pharmaceutical care (PC) as a philosophy of care and practice model is now >14 years old. It is important to determine whether PC influences health outcomes. Such outcomes are best studied in specific disease states where variables are minimized and specific outcomes have been established. We analyzed 4 multi-site controlled studies that evaluated PC in community pharmacies for patients with asthma. Study results varied widely. OBJECTIVE: To understand factors contributing to positive outcomes from PC for asthma. METHODS: The 4 studies were compared on the basis of 10 aspects of their research design, as well as 10 elements of PC. Dr. McLean conducted the initial analysis, and his assessments were confirmed by Dr. MacKeigan. RESULTS: Important differences were found in the type of pharmacy where PC was delivered (chain vs independent), how pharmacies were selected (required vs volunteered), patient selection (on asthma medication vs uncontrolled disease), pharmacist training (4-h workshop vs certification over several weeks), the nature of PC protocol (computer reminders vs detailed care protocol), rigor of the protocol (intervention vs requirement to reach self-management), and the level of pharmacist adherence to the PC protocol (<50% vs 90%). Differences were also found in study design. CONCLUSIONS: More favorable PC outcomes were associated with use of all elements of PC, independent pharmacies, pharmacist certification, a detailed PC protocol, targeting patients with uncontrolled asthma, and a practice system facilitating PC.

Instruments for measuring patient satisfaction with pharmacy services in the spanish language.

AIM OF THE REVIEW: The purpose of this paper is to identify and evaluate instruments used to assess patient satisfaction with pharmacy services available in the Spanish language, and specifically those designed to assess pharmaceutical care provided in community pharmacies. METHOD: A literature search was conducted in seven databases, using keywords: "patient satisfaction" and "Spanish" with and without the term "pharmacy". Publications that described the development or translation and/or adaptation of a questionnaire to assess patient satisfaction with pharmacy services in the Spanish language were retained. Publications were excluded if they were abstracts from conferences, reviews, letters or notes. The criteria used also excluded manuscripts where patient satisfaction was not assessed with a questionnaire. Instruments were evaluated according to evidence of the psychometric properties considered relevant: content validity, reliability and construct validity. RESULTS: While 83 publications describing instruments to measure patient satisfaction with health care services in the Spanish language were identified, only two pertained to satisfaction with pharmacy services. Both assessed patient satisfaction with pharmaceutical care. One questionnaire, developed in Spanish only, includes four dimensions that comprehensively assessed pharmaceutical care practice; however, its reliability was only partially evaluated. The other questionnaire was developed in both Spanish and English. It was considered narrower in scope, assessing satisfaction with the pharmacist only. However, evidence was provided that the two versions of the questionnaire were reliable, valid and linguistically equivalent. CONCLUSION: A comprehensive, reliable, and valid instrument for assessing patient satisfaction with pharmaceutical care in community pharmacies in the Spanish language is not yet available. The two published questionnaires that we have identified are a beginning, further research and development is needed.

Double discounting of QALYs.

Quality-adjusted life-years (QALYs) calculated from time tradeoff (TTO) based preferences have a time preference component. To impose a conventional discount rate on these implicitly discounted QALYs introduces some degree of double discounting. The purpose of this study was to determine the magnitude of the double discounting effect and the effectiveness of a suggested method for avoiding double discounting in a TTO-based QALY model. Our analysis used holistic and composite preference scores obtained with the TTO technique in a prior study of four hypothetical treatment paths in type 2 diabetes. Discounted composite preference scores were significantly discrepant from holistic preference scores. Adjusting TTO-based quality weights prior to external discounting reduced the discrepancy only slightly. Since time preference effects may vary with health state context, the double discounting effect needs further investigation.

Patient satisfaction with pharmaceutical care: update of a validated instrument.

OBJECTIVE: To develop a questionnaire for measuring patient satisfaction with pharmaceutical care and to establish its factorial composition. DESIGN: Single intervention, noncomparative, 20-item self-administered questionnaire. SETTING: Iowa. PARTICIPANTS: Seven hundred seventy-five prescription patrons of eight community pharmacies whose pharmacists had received training in pharmaceutical care but who had not yet implemented it. INTERVENTIONS: An instrument originally developed to measure patient satisfaction with traditional community pharmacy services was modified to focus on the elements of pharmaceutical care. This revised questionnaire was mailed to participants. MAIN OUTCOME MEASURES: Participant responses to items in the questionnaire. RESULTS: The survey response rate was 55%. Factor analysis and item analysis identified two dimensions of pharmaceutical care. We labeled the dimensions Friendly Explanation (including items related to friendliness of care, the setting of care, and medication counseling) and Managing Therapy (items dealing with the concept of pharmaceutical care-managing drug therapy and solving therapy problems). Respondents scored items on the Managing Therapy scale lower than they did items on the Friendly Explanation scale. The scales were highly correlated. Two other hypothesized dimensions of care-Consideration/Caring Relationships and Setting-were subsumed in the final scale of Friendly Explanation. CONCLUSION: The instrument provides information on patients' satisfaction with two dimensions of pharmacy services. The instrument may be useful to practicing pharmacists, but it should be used cautiously until it is tested among patrons of pharmacies known to provide different levels of care.

Clinical pharmacy services in the home: Canadian case studies.

OBJECTIVES: To describe clinical home care services provided by Canadian pharmacists and to identify facilitators of and barriers to the provision of these services. DESIGN: Home care practices in Canada were identified using key informant and snowball sampling methods. Case descriptions of each pharmacy were composed using data obtained via a faxed questionnaire and a follow-up telephone interview. SETTING: Community and institutional pharmacies across Canada. PARTICIPANTS: Sixteen pharmacists with practices that met three criteria: at least one home visit conducted per week, visits conducted specifically for clinical purposes beyond routine prescription counseling, and documentation of home care services. INTERVENTION: Faxed questionnaire and follow-up telephone interview. MAIN OUTCOME MEASURES: Pharmacist characteristics, pharmacy characteristics, types of clinical home care services, home care-related products and dispensing services, referral system, reimbursement, barriers and facilitators, and evaluative strategies. RESULTS: Twelve practices were in community pharmacies, nine of them independents. Home care services were provided primarily to address noncompliance and at the request of other health professionals. Elderly patients were the predominant service recipients. Services provided in most practices included compliance support, medication regimen review, monitoring of new medications, and patient education and training. Less than one-third of practices compiled evaluative data on these services. Most practices did not bill for services rendered. Lack of reimbursement was cited as the most important practice barrier, and having other sources of funding, such as high prescription revenues, was viewed as the major facilitator. CONCLUSION: Clinical home care practice is rare in Canadian pharmacy; reimbursement is a major barrier. Practices described in these case studies were initiated to address a perceived important patient need. To enable further dissemination of clinical home care practice, pharmacists need to establish formal linkages with other home care providers, evaluate their services, and use the data obtained to develop marketing and reimbursement strategies.