Development and validation of a measure and a model of general practitioner attitudes toward collaboration with pharmacists

BackgroundCollaboration between general practitioners (GPs) and community pharmacists has been shown to be effective in improving patient outcomes. However, little is known about GP attitudes toward collaborating with their pharmacist counterparts and variables that influence this interprofessional collaboration.ObjectivesTo develop and validate, in the context of primary care in Australia 1) an instrument to measure GP attitudes toward collaborating with pharmacists and 2) a model that illustrates how GP attitudes (and other variables) influence GP-pharmacist collaborative behavior.MethodsThe “Attitudes Toward Collaboration Instrument for GPs” (ATCI-GP) was developed to measure GP attitudes toward GP-pharmacist collaboration based on existing literature and qualitative interviews with GPs and community pharmacists. The ATCI-GP and a previously validated behavioral measure “Frequency of Interprofessional Collaboration Instrument for GPs” (FICI-GP) were included in a survey and administered to a sample of 1145 GPs in 12 divisions of general practice across Australia. Principal component analysis (PCA) was used to assess the structure of the ATCI-GP. Structural equation modeling was used to determine how attitudes (measured by the ATCI-GP) and other variables, influence collaborative behavior (measured by the FICI-GP).ResultsThree hundred and seventy-six surveys were completed and returned for a response rate of 33%. PCA of the ATCI-GP suggested a two factor (“interactional and practitioner determinants” and “role for pharmacist in medication management”) solution accounting for 66.2% of the variance. The model for GP-pharmacist collaboration demonstrated adequate fit (χ²/df = 2.27, CFI = .99, RMSEA = .060, 90% CI [.052–.069]). Factors found to predict collaboration included: 1) Interactional and practitioner determinants 2) environmental determinants and 3) GP perception of the pharmacists' role in medication management.ConclusionsThe study provides evidence for the validity of the ATCI-GP for measuring GP-pharmacist collaboration from the GPs perspective and supports a model for collaboration in which collaborative behavior is influenced by a number of variables.     

A mixed methods analysis of community pharmacists' perspectives on delivering COPD screening service to guide future implementation

BackgroundStudies have shown that COPD screening by community pharmacists is effective, but it is unknown if it can be successfully implemented in Australian pharmacies.ObjectiveWe aimed to investigate the pharmacist-perceived barriers and facilitators to the implementation of a community pharmacy-based COPD screening service guided by implementation science methodology.MethodsTrained pharmacists participated in a 6 month longitudinal study designed and based on implementation science frameworks. Pharmacists completed feedback questionnaires pre-and post-study and participated in semi-structured telephone interviews about their experience of implementing the service, the training provided, their views on patient recruitment, their interactions with health professionals and patients, and their future recommendations for such a service. Interviews were recorded and transcribed verbatim, analysed thematically, and questionnaire and interview data were triangulated.ResultsOf 20 pharmacists providing questionnaire data, 15 pharmacists (male 53%; age 39.8 ± 8.6yrs, rural 47%) participated in an interview. Questionnaire data revealed that pharmacists engaged positively with the service and reported that it was very useful for patients and for the profession. In-depth qualitative analysis revealed 6 main implementation themes: 1. Patient recruitment (pharmacists lacked patient recruitment skills), 2. Adaptation and entrepreneurship (protocol adaptation increased patient engagement), 3. Training and resource needs (face-to-face training was preferred for skill-based learning), 4. Lack of GP involvement (sub-optimal GP-pharmacist collaboration), 5. Factors related to the operation or full implementation phase (high professional satisfaction, need for remuneration) and 6. Suggestions for refining the screening service (raise public awareness about the service, provide service remuneration, use electronic methods to improve GP referral uptake). A number of effective adaptations to the service were reported by pharmacists, such as advertising, recruitment practices, patient inclusion criteria and inter-professional communication with GPs which would be beneficial to implementation.ConclusionThis mixed methods study identified a number of key facilitators to service implementation and challenges such as difficulty with patient recruitment, low public awareness of pharmacy-based clinical services, remuneration, and sub-optimal GP-pharmacist collaboration. Working with stakeholders to identify and resolve challenges and to optimise the fit of the service for individual settings may lead to increasingly successful implementation of pharmacy-based service models.     

Implementing screening interventions in community pharmacy to promote interprofessional coordination of primary care – A mixed methods evaluation

BackgroundScreening is a critical component of efforts to reduce the population burden of cardiovascular disease (CVD), by facilitating early use of cost-effective prevention and treatment strategies. While international evidence suggests that screening in community pharmacies improves screening access and identifies at-risk individuals, concerns from medical organisations about the absence of interdisciplinary coordination and related lack of continuity of care with general practice have significantly contributed to reluctance from some stakeholders to endorse, and engage with, pharmacy-based screening initiatives. The Cardiovascular Absolute Risk Screening (CARS) study was designed to address these challenges and promote an interprofessional approach to screening for cardiovascular disease risk by pharmacists. This study describes the impact of the CARS implementation model on interdisciplinary coordination and continuity of care.MethodsIn addition to clinical training, pharmacists at eleven participating pharmacies were provided with implementation training, resources and support to promote interprofessional coordination. Completion of training and pharmacy implementation plans, both of which highlighted GP engagement strategies, were pre-requisites for screening commencement. Using mixed methods approaches, data were analyzed from screening records (n = 388), researcher interviews with patients at 6–10 weeks post-screening (n = 248, 64%), and pharmacist interviews (n = 10).ResultsScreening records suggested that 94% of screened individuals were advised to seek formal GP assessment, and 98% consented to sharing of results. Among interviewed participants, 81% recalled direct pharmacist action to facilitate GP engagement. Among interviewees who had seen their GP already (n = 70), 79% reported that their GP was aware of the results (another 16% were uncertain). Pharmacists reported positive GP feedback stemming from efforts at early engagement, but an absence of ongoing collaboration.ConclusionsUse of implementation planning by pharmacists, alongside clinical training, can effectively promote an interdisciplinary coordination focus by pharmacists.     

Development and initial validation of the Pharmacist Frequency of Interprofessional Collaboration Instrument (FICI-P) in primary care

BackgroundExisting validated measures of pharmacist-physician collaboration focus on measuring attitudes toward collaboration and do not measure frequency of collaborative interactions.ObjectiveTo develop and validate an instrument to measure the frequency of collaboration between pharmacists and general practitioners (GPs) from the pharmacist’s perspective.MethodsAn 11-item Pharmacist Frequency of Interprofessional Collaboration Instrument (FICI-P) was developed and administered to 586 pharmacists in 8 divisions of general practice in New South Wales, Australia. The initial items were informed by a review of the literature in addition to interviews of pharmacists and GPs. Items were subjected to principal component and Rasch analyses to determine each item’s and the overall measure’s psychometric properties and for any needed refinements.ResultsTwo hundred and twenty four (38%) of pharmacist surveys were completed and returned. Principal component analysis suggested removal of 1 item for a final 1-factor solution. The refined 10-item FICI-P demonstrated internal consistency reliability at Cronbach’s alpha = 0.90. After collapsing the original 5-point response scale to a 4-point response scale, the refined FICI-P demonstrated fit to the Rasch model. Criterion validity of the FICI-P was supported by the correlation of FICI-P scores with scores on a previously validated Physician-Pharmacist Collaboration Instrument. Validity was also supported by predicted differences in FICI-P scores between subgroups of respondents stratified on age, colocation with GPs, and interactions during the intern-training period.ConclusionThe refined 10-item FICI-P was shown to have good internal consistency, criterion validity, and fit to the Rasch model. The creation of such a tool may allow for the measure of impact in the evaluation of interventions designed to improve interprofessional collaboration between GPs and pharmacists.     

Opportunity or threat? General practitioner perceptions of pharmacist prescribing

Objective In recent years prescribing rights have been extended beyond doctors and dentists in the UK, first to nurses and subsequently to pharmacists. The aim of the study was to explore general practitioner (GP) perceptions of the advantages and disadvantages of pharmacist supplementary prescribing and the future introduction of independent prescribing. Method A qualitative study was conducted with GPs from three practices, in each of which a pharmacist prescriber was regularly working. Key findings The prescribing pharmacists, all of whom were already working in the practice when they qualified as prescribers, had negotiated new areas of work. Not all GPs in the practices referred patients to the prescribing pharmacists. Those GPs who did refer patients generally described benefits from the service, with some ambivalence. There was evidence that the GPs had, to some extent, redefined their professional boundaries, and delegated some routine work which involved no diagnosis and only limited decision making. In this way the GPs exercised control over the interprofessional boundaries. Conclusion The study findings indicate selective acceptance of pharmacist prescribing by GPs.     

Integration and differentiation: A conceptual model of general practitioner and community pharmacist collaboration

BackgroundThe drive for integrative systems and collaboration across organizations and professions involved in the provision of health and social care has led to the development of a number of scales and models that conceptualize collaborative behavior. Few models have captured the dynamics of the collaboration between community pharmacy and general medicine, 2 professional groups that are increasingly being encouraged to adopt more collaborative practices to improve patient care.ObjectivesThis article presents a new model of collaboration derived from interviews with general practitioners (GPs) and community pharmacists in England involved in service provision that required some form of collaboration.MethodsQualitative interviews were conducted with purposive samples of 13 GPs and 18 community pharmacists involved in the provision of local pharmaceutical services pilots and 14 GPs and 13 community pharmacists involved in the provision of repeat dispensing.ResultsThe model highlights key components of collaboration, including the importance of trust, communication, professional respect, and “knowing” each other. It is argued here that previous models fail to recognize the asymmetry and differentiation between GPs and community pharmacists, including differences in perception toward and importance assigned to trust and communication. GPs were found to adopt demarcation strategies toward community pharmacies and pharmacists, with independent pharmacies being favored over multiple chains and regular pharmacists favored over locum/sessional pharmacists. This differentiation was repeatedly highlighted by GPs and found to affect their ability or willingness to collaborate.ConclusionThe model provides a foundation for the future development of strategy and research focused on the improvement or study of collaborative relationships between community pharmacy and general practice.     

Collaboration in chronic care: unpacking the relationship of pharmacists and general medical practitioners in primary care

Objectives The objective of this research was to gain deeper understanding of the expectations, experiences and perceptions of Australian general medication practitioners (GPs) and pharmacists around collaboration in chronic illness (asthma) management in the primary care setting. Methods A qualitative research methodology utilising a semi‐structured interview guide, based on theory and an empirical approach, was used to fulfill the objectives of this study. Face‐to‐face interviews with pharmacists (n = 18) and GPs (n = 7) were recorded, transcribed and coded for concepts and themes. Relationships between concepts and themes were examined and used to describe the nature of collaborative relationships in the primary care setting. Key findings A relationship between GPs and pharmacists currently exists although there is minimal collaboration and there are several areas of practice and patient care in which the two professional groups are mismatched. At the same time, this research uncovered key aspects of the GP–pharmacist relationship, which could be used to develop more collaborative relationships in the future. The findings from this study were evaluated in light of the Collaborative Working Relationships model and published literature. Conclusions A model for the development of GP–pharmacist relationship has been postulated which articulates the dynamic nature of professional relationship in primary care and highlights a pathway to more collaborative practice. Future research should focus on further developing this model.     

Impact of residential medication management reviews on anticholinergic burden in aged care residents

Objectives:

The primary objective of this study was to investigate the impact of Residential Medication Management Reviews (RMMRs) on anticholinergic burden quantified by seven anticholinergic risk scales.

Design:

Retrospective analysis.

Setting:

Accredited pharmacists conducted RMMRs in aged-care facilities (ACFs) in Sydney, Australia.

Participants:

RMMRs pertained to 814 residents aged 65 years or older.

Measurements:

Anticholinergic burden was quantified using seven scales at baseline, after pharmacists’ recommendations and after the actual GP uptake of pharmacists’ recommendations. Change in the anticholinergic burden was measured using the Wilcoxon sign rank test.

Results:

At baseline, depending on the scale used to estimate the anticholinergic burden, between 36% and 67% of patients were prescribed at least one regular anticholinergic medication (ACM). Anticholinergic burden scores were significantly (p?<?0.001) lower after pharmacists’ recommendations as determined by each of the seven scales. The reduction in anticholinergic burden was also significant (p?<?0.001) after GPs’ acceptance of the pharmacists’ recommendations according to all scales with the exception of one scale which reached borderline significance (p?=?0.052).

Conclusion:

Despite the limitations of the retrospective design and differences in the estimation of anticholinergic burden, this is the first study to demonstrate that RMMRs are effective in reducing ACM prescribing in ACF residents, using a range of measures of anticholinergic burden. Future studies should focus on whether a decrease in anticholinergic burden will translate into improvement in clinical outcomes.     

“My pharmacist”: Creating and maintaining relationship between physicians and pharmacists in primary care settings

BackgroundPharmacists and physicians are being increasingly encouraged to adopt a collaborative approach to patient care, and delivery of health services. Strong collaboration between pharmacists and physicians is known to improve patient safety, however pharmacists have expressed difficulty in developing interprofessional working relationships. There is not a significant body of knowledge around how relationships influence how and when pharmacists and physicians communicate about patient care.ObjectivesThis paper examines how pharmacists and primary care physicians communicate with each other, specifically when they have or do not have an established relationship.MethodsThematic analysis of data from semi-structured interviews with nine primary care physicians and 25 pharmacists, we examined how pharmacists and physicians talk about their roles and responsibilities in primary care and how they build relationships with each other.ResultsWe found that both groups of professionals communicated with each other in relation to the perceived scope of their practice and roles. Three emerging themes emerged in the data focusing on (1) the different ways physicians communicate with pharmacists; (2) insights into barriers discussed by pharmacists; and (3) how relationships shape collaboration and interactions. Pharmacists were also responsible for initiating the relationship as they relied on it more than the physicians. The presence or absence of a personal connection dramatically impacts how comfortable healthcare professionals are with collaboration around care.ConclusionThe findings support and extend the existing literature on pharmacist-physician collaboration, as it relates to trust, relationship, and role. The importance of strong communication is noted, as is the necessity of improving ways to build relationships to ensure strong interprofessional collaboration.     

Improving communication of medication changes using a pharmacist-prepared discharge medication management summary

Background Discontinuity of care between hospital and primary care is often due to poor information transfer. Medication information in medical discharge summaries (DS) is often incomplete or incorrect. The effectiveness and feasibility of hospital pharmacists communicating medication information, including changes made in the hospital, is not clearly defined. Objective To explore the impact of a pharmacist-prepared Discharge Medication Management Summary (DMMS) on the accuracy of information about medication changes provided to patients’ general practitioners (GPs). Setting Two medical wards at a major metropolitan hospital in Australia. Method An intervention was developed in which ward pharmacists communicated medication change information to GPs using the DMMS. Retrospective audits were conducted at baseline and after implementation of the DMMS to compare the accuracy of information provided by doctors and pharmacists. GPs’ satisfaction with the DMMS was assessed through a faxed survey. Main outcome measure Accuracy of medication change information communicated to GPs; GP satisfaction and feasibility of a pharmacist-prepared DMMS. Results At baseline, 263/573 (45.9%) medication changes were documented by doctors in the DS. In the post-intervention audit, more medication changes were documented in the pharmacist-prepared DMMS compared to the doctor-prepared DS (72.8% vs. 31.5%; p < 0.001). Most GPs (73.3%) were satisfied with the information provided and wanted to receive the DMMS in the future. Completing the DMMS took pharmacists an average of 11.7 minutes. Conclusion The accuracy of medication information transferred upon discharge can be improved by expanding the role of hospital pharmacists to include documenting medication changes.     

Process of translation and cross-cultural adaptation of two Australian instruments to evaluate the physician-pharmacist collaboration in Germany

BackgroundBuilding interprofessional working relationships between physicians and pharmacists is essential to ensure high-quality patient care. To assess which factors influence the performance and success of their collaboration, validated instruments should be used, such as the Australian “Attitudes Toward Collaboration Instrument (ATCI)” and the “Frequency of Interprofessional Collaboration Instrument (FICI)”. Both instruments were already translated in a previous German study, but not pretested for comprehensibility or cultural appropriateness to ensure that the target group is able to adequately answer the translated items.ObjectivesTo translate and particularly cross-culturally adapt two Australian instruments measuring physicians' and pharmacists’ attitudes towards interprofessional collaboration and the frequency of their interactions for use in Germany.MethodsThe ATCI and FICI were translated following internationally recognised guidelines. Two-step cognitive interviewing was performed with physicians and pharmacists working in ambulatory care in Germany. The “Standards for Reporting Qualitative Research” were used to report this study.ResultsOverall, 2 forward and 2 back translations, and 38 cognitive interviews, i.e. cognitive probing (N = 10) and behaviour observation (N = 28), with 18 physicians and 20 pharmacists were performed. Experts discussed all potential changes. The ATCI and FICI were translated introducing 15 minor (e.g. paraphrasing, item order) and 6 major (e.g. 2 more items in FICI, additional response options) adaptations. The ATCI-P/GP-German and FICI-P/GP-German were found to be easy to answer and clearly-phrased.ConclusionThis study shows the importance of using recognised methods to translate and adapt questionnaires, consisting of at least four steps: forward translation, back translation, cognitive interviewing and finalisation (each reviewed by an expert panel making their decisions by consensus). A profoundly pretested German-speaking instrument is now available to evaluate and describe interprofessional collaboration between physicians and pharmacists. However, collecting further sociodemographic and contextual information seems necessary for enhanced interpretation of future results.     

General practitioners' perceptions of pharmacists' new services in New Zealand

Background In recent years, the pharmacy profession has moved towards more patient-oriented services. Some examples are medication review, screening and monitoring for disease, and prescribing. The new services are intended to be in close collaboration with general practitioners (GPs) yet little is known of how GPs in New Zealand perceive these new services. Objective To examine GPs?? perceptions of pharmacists?? new services. Setting Study was undertaken at GPs?? practices in two localities in New Zealand. Methods Qualitative, face to face, semi-structured interviews were undertaken of 18?GPs. The cohort included GPs with less/more than 20?years of practice, and GPs who had experience of working in localities where some patients had undergone a medication review (Medicines Use Review, MUR) by community pharmacists. GPs were asked to share their perceptions about pharmacists providing some new services. Data were thematically analysed with constant comparison using NVivo 8 software. Using a business strategic planning approach, themes were further analysed and interpreted as the services?? potential Strengths, Weaknesses, Opportunities and Threats (SWOTs). Main outcomes measure GPs?? perceptions of pharmacists?? new services. Results GPs were more supportive of pharmacists?? playing active roles in medication review and less supportive of pharmacists practising screening-monitoring and prescribing. Discussions Pharmacists?? knowledge and skills in medication use and the perceived benefits of the services to patients were considered the potential strengths of the services. Weaknesses centred around potential patient confusion and harm, conflict and irritation to GPs?? practice, and the potential to fragment patient-care. Opportunities were the possibilities of improving communication, and having a close collaboration and integration with GPs?? practice. Apparent threats were the GPs?? perceptions of a related, and not renumerated, increase in their workloads, and the perception of limited benefit to patients. Conclusion Pharmacists should exploit their own strengths and the potential opportunities for these services, and reduce any weaknesses and threats. A possible strategic plan should include increased effective communication, piloting services, and the integration of some services into medical practices.     

The physician perspective on pharmacist-physician collaboration and trust

BackgroundHealth care has shifted to focus less on individual practitioners and more on providing interprofessional and collaborative patient care. A strong working relationship among pharmacists and physicians is imperative for patient care and safety.ObjectivesThe objective of this research was to examine physician perspectives of the relationship between physicians and pharmacists, specifically evaluating the qualities and actions necessary for pharmacists to establish trust to provide the best quality of patient care.MethodsSemistructured qualitative key informant interviews were conducted with 11 physicians. Questions were designed to gather information about the physicians’ experiences with pharmacists and perceived barriers and opportunities for building trust and collaboration. The Unified Theory of Trust and Collaboration was used as a theoretical framework.ResultsThe ability to cooperate was the most important aspect identified by all 11 physicians in creating effective collaboration along with respect, knowledge, communication, and trust. Common barriers identified with the pharmacist-physician relationship were the lack of identity, rapport, knowledge, positive attitude, and communication.ConclusionBuilding trust and narrowing the gaps of communication are crucial in achieving effective collaborative practice among health professionals. Pharmacists and physicians must have the capability to cooperate with one another, understand the common moral responsibility they share, recognize the implications of their personal behavior on their professional relationships, and focus on their scope of practice without crossing boundaries. Through positive behaviors of civility, communication, adaption, and mutual respect in their individual roles, pharmacists and physicians can enhance their relationship and practice collaboratively.     

Stakeholder perspectives on pharmacist involvement in a memory clinic to review patients’ medication management and assist with deprescribing

BackgroundMemory clinics usually involve a team of health professionals who assess and review people with memory impairment. Memory clinic patients are typically older, have multiple comorbidities and potentially inappropriate polypharmacy. Pharmacists are not typically part of memory clinic teams.ObjectiveTo explore stakeholder perspectives on pharmacist involvement in a memory clinic to conduct medication reviews and assist with deprescribing potentially inappropriate/unnecessary medications.MethodsQuantitative and qualitative evaluation of stakeholder perspectives within a deprescribing feasibility study. Patient/carer questionnaires were administered at 6-month follow-up. Fax-back surveys were sent to general practitioners (GPs) shortly after the pharmacist review. A focus group was conducted with memory clinic staff and semi-structured interviews with pharmacists at conclusion of the study. Focus group/interviews were transcribed and thematically analysed.ResultsMost patients/carers found the pharmacist medication review helpful (84%, 31/37) and believed it was important to have pharmacists in the memory clinic (92%, 36/39). Twenty-one (48%) GPs responded to the survey; most found the pharmacist reports useful for identifying inappropriate medication and providing deprescribing recommendations (86% and 81%, respectively), and 90% thought a pharmacist review should be part of the memory clinic service. Feedback from memory clinic staff and pharmacists was largely positive. Questions were raised by some staff about whether deprescribing fell within the clinic's scope of practice. Challenges associated with memory clinic-GP communication were highlighted.ConclusionPatients, GPs and memory clinic staff were receptive to increased pharmacist involvement in the memory clinic. Stakeholder feedback will inform the development and delivery of pharmacist medication reviews and deprescribing in memory clinics.     

A retrospective analysis of patient care activities in a community pharmacy mental illness and addictions program

BackgroundThe Bloom Program, a community pharmacy-based mental health and addictions care program, was developed and implemented to optimize pharmacists' care of eligible patients. Characterizing pharmacists' activities in the Bloom Program can facilitate program quality improvement and contribute more broadly to the knowledge base regarding pharmacists’ roles and contributions to patient care.ObjectivesTo characterize the patient care activities of the pharmacists in the Bloom Program.MethodsA retrospective analysis of patient charts for participants enrolled in the program for three months or longer was conducted. Using all available documentation, pharmacists’ activities were coded into eight non-mutually exclusive categories: navigation/resource support, urgent triage, medication management, collaboration/communication, education, social support, self-care, and other.Results2055 activities from 1144 patient care encounters were identified for 126 participants (48 ± 16 years of age, 61% female, 5 regular medications). Medication management was coded most often per encounter (73%). Each of social support, collaboration/communication, and education were coded in 20–25% of encounters. Frequency of navigation/resources, self-care, and urgent triage were 16.6%, 13.5%, and 2.8%, respectively. Non-medication management activities represented 59.4% of all pharmacist patient care services.ConclusionsMedication management activities were coded in over 70% of patient encounters for pharmacists delivering a community pharmacy-based mental illness and addictions program. However, this accounted for 40.6% of activities with an average of 1.8 activities per encounter. Other activities were identified frequently (e.g., education, collaboration, social support, navigation and resource support) and help to characterize the nature of pharmacist-patient encounters and facilitates a better understanding of the role of the pharmacist in mental illness and addictions patient care.