Routine opioid outcome monitoring in community pharmacy: Pilot implementation study protocol

BackgroundIncreases in opioid use and related harms such as mortality are occurring in many high income countries. Community pharmacists are often in contact with patients at risk of opioid-related harm and represent an ideal point for intervention. Best practice in monitoring opioid-related outcomes involves assessing analgesia, pain functioning, mood, risks and harms associated with opioid use. Community pharmacists are well-placed to undertake these tasks.ObjectivesOur pilot study will test the implementation of a computer-facilitated screening and brief intervention (SBI). The SBI will support pharmacist identification of opioid-related problems and provide capacity for brief intervention including verbal reinforcement of tailored information sheets, supply of naloxone and referral back to the opioid prescriber. The SBI utilises software that embeds study procedures into dispensing workflow and assesses opioid outcomes with domains aligned with a widely accepted clinical framework.MethodsWe will recruit and train 75 pharmacists from 25 pharmacies to deliver the Routine Opioid Outcome Monitoring (ROOM) SBI. Pharmacists will complete the SBI with up to 500 patients in total (20 per pharmacy). Data will be collected on pharmacists’ knowledge and confidence through pre- and post-intervention online surveys. Data on feasibility, acceptability and implementation outcomes, including naloxone supply, will also be collected.Project impactOur study will examine changes in pharmacists’ knowledge and confidence to deliver the SBI. Through the implementation pilot, we will establish the feasibility and acceptability of a pharmacist SBI that aims to improve monitoring and clinical management of patients who are prescribed opioids.     

Expanding pharmacists’ roles: Pharmacists’ perspectives on barriers and facilitators to collaborative practice

ObjectiveThe pharmacy profession is shifting from transactional dispensing of medication to a more comprehensive, patient-centered model of care. Collaborative practice agreements (CPAs) extend the role of a pharmacist to initiate, monitor, modify, and discontinue drug therapies and provide other clinical services. Although collaborative practice has been shown to improve health system efficiency and patient outcomes, little is known about how pharmacists perceive CPAs. To explore pharmacists’ perspectives of CPAs, including barriers and facilitators to CPA implementation.MethodsSemistructured key informant interviews were used to elicit information from licensed pharmacists practicing in a variety of settings in Arizona. Thematic analysis was used to identify key qualitative themes.ResultsSeventeen interviews of pharmacists with (n = 11, 64.7%) and without (n = 6, 35.3%) CPAs were conducted in April-May 2019. The pharmacists saw their role in CPAs as supportive, filling a care gap for overburdened providers. A heightened sense of job satisfaction was reported owing to increased pharmacist autonomy, application of advanced knowledge and clinical skills, and ability to have a positive impact on patients’ health. Challenges to the implementation of CPAs included liability and billing issues, logistic concerns, some experiences with provider hesitancy, and lack of information and resources to establish and maintain a CPA. The barriers could be overcome with conscious team-building efforts to establish trust and prove the worth of pharmacists in health care teams; strategic engagement of stakeholders in the development of CPAs, including billing and legal departments; and mentorship in the CPA creation process.ConclusionsThe pharmacists in this study enjoyed practicing collaboratively and had overall positive perceptions of CPAs. As health worker shortages become more dire and pharmacy practice evolves to expand the role of pharmacists in providing direct patient care, CPAs will be an important tool for restructuring care tasks within health systems.     

Pharmacists’ perspectives on HIV testing in community pharmacies

ObjectiveTo assess the feasibility, readiness, and acceptability of offering rapid human immunodeficiency virus (HIV) testing in community pharmacies.DesignQualitative study.SettingCommunity pharmacies in Indiana from May to September 2012.Participants17 licensed community pharmacists.InterventionSemistructured interviews among a convenience sample of community pharmacists.Main outcome measuresCommunity pharmacists’ self-reported attitudes toward rapid HIV testing in community pharmacies, perceptions of peer acceptability, and opinions about readiness for implementation of the practice in community pharmacies.ResultsParticipants accepted the idea of pharmacy-based HIV testing, describing it as accessible, convenient, and nonstigmatizing. Acceptability was closely linked to positive patient relationships and pharmacist comfort with consultation. Identified challenges to pharmacy-based HIV testing included staffing issues, uneasiness with delivering positive test results, lack of information needed to link patients to care, insufficient consulting space, and need for additional training. Participants indicated that peer beliefs about the acceptability of pharmacist-based HIV testing would vary but that more recently trained pharmacists likely would be more accepting of the practice.ConclusionMost participants felt that offering HIV testing was a reasonable addition to the evolving role of the community pharmacist, pending resolution of personal and institutional barriers.     

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.     

Views and experiences of community pharmacists and superintendent pharmacists regarding the New Medicine Service in England prior to implementation

BackgroundThe New Medicine Service (NMS) was introduced to community pharmacies in England in October 2011. The NMS aims to improve adherence to new medicines in patients with selected long term conditions. The service consists of two follow-up consultations within 1 month in addition to usual care.ObjectivesThis study explored community pharmacist and superintendent pharmacist views and experiences of the NMS in the 5 weeks prior to its implementation to identify potential facilitators and barriers to its success. The study also investigated participant experiences of the introduction and provision of existing pharmacy services in order to contrast with the implementation of the NMS.MethodsThis study consisted of four focus groups with a total of 15 community pharmacists representing locums and employees of small, medium and large chain pharmacies. In addition, 5 semi-structured interviews were conducted with superintendent pharmacists representing independent, small chain, supermarket and large multiple pharmacies. Data were audio-recorded, transcribed verbatim and thematically analyzed.ResultsBoth pharmacists and superintendent pharmacists were positive about the NMS and identified potential benefits for patients and the pharmacy profession. Awareness of the service was high, however, some confusion between the NMS and changes to Medicine Use Reviews was evident in all focus groups due to their similarity and coincidental implementation. This confusion was not observed in the interviews with superintendent pharmacists. Participants identified pharmacists' positive attitude, the similarity to current practice and the self-accreditation procedure as potential facilitators to service implementation. Potential barriers identified included a perceived lack of interest and awareness by GPs of the service, and the payment structure. Participants were concerned about the speed of implementation, and the absence of some materials needed prior to the start of the service.ConclusionsParticipants were enthusiastic about the potential of the NMS to benefit patients and the pharmacy profession. Participants were able to identify several potential barriers and facilitators to the provision of the service. It remains to be seen whether the factors identified affected the early implementation of the service.     

1例冠状动脉旁路移植术后合并感染患者抗感染治疗的药学监护

目的：浅谈临床药师对冠状动脉旁路移植术（coronary artery bypass graft,CABG）后合并感染患者使用抗菌药物的监护体会。方法：临床药师参与1例CABG术后患者治疗,根据患者的相关检验指标、感染情况,结合患者生命体征变化制定和调整抗感染药物方案,关注药物疗效与不良反应。结果：通过临床药师的医学服务,如该患者在术后抗感染方面提供安全、优质的个体化药学服务。结论：通过以上临床实践,临床药师对心外科患者术后抗感染药物的合理应用起到了积极的促进作用。     

1例肝硬化合并胸腔积液患者的抗感染治疗及药学监护

目的临床药师通过参与临床药物治疗,对患者进行药学监护,探讨临床药师在临床治疗中的价值。方法结合1例肝硬化合并胸腔积液患者,参与治疗方案的制订,对患者进行用药教育,跟踪疗效及不良反应。结果临床药师参与临床用药,实施药学监护,可以提高药物治疗效果,减少药物不良反应的发生。结论临床药师的参与,可使临床用药更加规范合理,具有一定的参考价值。     

县级医院临床药师工作技能的培养及规范化考核

目的 探讨县级医院临床药师的工作技能培养和规范化考核指标。方法 通过我院临床药师参与临床药物治疗实践,分析总结县级医院临床药师知识结构的重要性和细化量化临床药师工作指标的必要性。结果 临床药师的知识转型是参与查房与会诊、用药监护和用药指导的必备条件,实施规范化考核是深入开展临床药学工作并持续提升药学服务质量的保障。结论 县级医院临床药师需参与临床多学科的药学服务,在实践中丰富临床知识,在落实考核指标中持续提升工作质量。     

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.     

1例舒尼替尼致药物性肝损伤的临床药学监护

目的 探讨舒尼替尼致急性药物性肝损伤的药物治疗及药学监护的方法,提高临床药师药学监护能力。方法 临床药师对1例患者服用舒尼替尼后出现急性肝损伤的病例进行分析和讨论,对肝损伤进行分型及严重程度判断,协助医师制订治疗措施。结果 医师采纳临床药师的意见和建议,患者肝损伤逐渐好转。结论 临床药师通过与医师协作,对患者实施个体化药学治疗,保证了患者用药安全、有效,提高了药学监护水平。     

Funding pharmacists in general practice: A feasibility study to inform the design of future economic evaluations

BackgroundFunding is a significant barrier to employing general practice pharmacists.Objective(s)To explore the feasibility of determining the cost-benefit of pharmacists in Australian general practice.MethodsTwo part-time pharmacists were employed by general practices in Canberra, Australia. Diaries of the pharmacists were analysed to determine time worked and participation in income-generating activities, including Government-funded programs: Asthma Cycle of Care, Home Medicine Reviews, and Health Care Assessments. Scenarios using different practice and business models were entered into value-cost models to determine the income generated by the pharmacists relative to their salary.ResultsOver 19 weeks, pharmacists A and B supported 47 and 23 Asthma Cycle of Care activities, generating income to the general practice of AU$4,700 and AU$2,300, respectively. The pharmacists spent 36.4 and 24.1 hours on activities usually conducted by general practitioners (GPs), allowing additional time for GP-patient consultations. Value-cost models determined AU$0.61 - AU$1.20 income generation by pharmacists per AU$1 salary.ConclusionsIt was feasible to determine the value-cost ratios of employing pharmacists in general practice using these methods. Future work should focus on developing a robust business model that includes health care system savings resulting from practice pharmacist interventions, determined from randomised controlled trials.     

Evaluation approaches,tools and aspects of implementation used in pharmacist interventions in residential aged care facilities: A scoping review

BackgroundThe medication expertise of pharmacists is widely acknowledged and there is ongoing interest in their potential role to reduce medication-related harm amongst residents living in residential aged care facilities (RACFs). An increased understanding of how these interventions are evaluated could support adoption of these interventions in the real world.ObjectiveTo systematically explore the application of evaluation approaches, evaluation tools and aspects of implementation (implementation factors i.e. barriers and facilitators, and assessing implementation fidelity) used in pharmacist intervention in RACF peer-reviewed literature.MethodsA search strategy was applied to MEDLINE, CINAHL, Cochrane Library and Web of Science databases for publications between 1 January 2000 and 27 August 2020 based on defined inclusion and exclusion criteria. Articles that reported on evaluated pharmacist interventions impacting residents in RACFs or which outlined study participant perspectives in relation to these interventions were included.Results2003 published articles were identified, out of which 56 articles met the inclusion criteria. Fifty-three articles reported on outcome evaluations. Four articles used evaluation guidance with 1 article explicitly guided by an evaluation framework. Relationships, trust and respect between pharmacists and RACF health care team members were one of the most reported factors influencing intervention success. None of the 56 articles used a theory or model, assessed implementation fidelity or employed a logic model.ConclusionsTo date there appears to be sparse utilisation of available evaluation approaches, evaluation tools and implementation aspects in pharmacist intervention in RACF peer-reviewed literature. By embracing these evaluation approaches, evaluation tools and aspects of implementation, pharmacy practice researchers have an opportunity to contribute to evaluation research in RACFs and beyond.     

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.     

The Tennessee medication therapy management program: A hybrid type 2 effectiveness-implementation trial study protocol

BackgroundPharmacist-led medication therapy management (MTM) programs are considered evidence-based and have clearly defined core components. Despite this, MTM programs are often implemented without fidelity due to notable implementation barriers, such as physician-pharmacist relationships and pharmacist access to patient medical records. To improve MTM implementation, the Tennessee Medicaid program developed a MTM intervention that incorporates implementation strategies to address some of the known barriers to implementation (e.g., formalizing pharmacist-physician relationships through collaborative practice agreements, ensuring pharmacists’ access to medical records).ObjectivesThe purpose of this hybrid type 2 effectiveness-implementation study is to (1) assess the effectiveness of the MTM pilot program in Tennessee (e.g., medication adherence, healthcare utilization, quality and cost of care) and (2) assess the implementation of the MTM pilot program (e.g., feasibility, appropriateness, acceptability, penetration).MethodsThe Tennessee MTM pilot program is being assessed as a hybrid type 2 effectiveness-implementation study with a quasi-experimental design. A mixed methods approach (QUAN + QUAL) for the purpose of complementarity (e.g., answering related research questions). Data will include surveys, interviews, MTM platform encounter information, and medical and pharmacy claims. Initial analyses will include data between January 2018 and December 2019.ConclusionThe study will further add to the evidence base of MTM interventions by testing an intervention that addresses known barriers to implementation and simultaneously collecting data on effectiveness and implementation to speed up MTM translation. The Tennessee MTM program is expected to serve as a guide to other states seeking to expand pharmacist-delivered clinical services to their Medicaid members, particularly those intending to incorporate MTM into programs seeking to improve primary care delivery. Further, by improving the implementation of MTM, the pilot program is expected to improve the reliability of MTM program benefits including healthcare quality and cost and patient outcomes.     

Pharmacist-led transitions-of-care services in primary care settings: Opportunities,experiences, and challenges

ObjectiveTo initiate a call to action for ambulatory care pharmacists to play a more active role in transitional care management within primary care settings by discussing relevant opportunities, experiences, and challenges.SummaryWith the shift to value-based health care, greater emphasis is being placed on improving patient care quality at the lowest cost. This represents an opportunity for pharmacist integration into primary care teams to address medication management challenges in the postdischarge period. Primary care pharmacists are uniquely positioned to close gaps in care not typically addressed by hospital-based programs. These pharmacists can provide complex transition interventions tailored toward individual patients, including comprehensive medication review, patient counseling, and direct collaboration with providers. For broad acceptance of these services, current challenges include identifying and prioritizing high-risk patients, establishing the cost-effectiveness of these strategies, and ultimately applying dissemination and implementation methodologies to increase the potential impact of these interventions.ConclusionOpportunities are expanding for primary care pharmacists to play a more substantial role in transitional care management in sustainable ways. For widespread implementation of these strategies, additional research is necessary to determine their clinical effectiveness as well as cost-effectiveness and to understand better the barriers and facilitators to adopting these interventions.     

General practice pharmacists in England: Integration,mediation and professional dynamics

BackgroundA number of key publications in recent years have advocated a more integrated vision of UK primary care involving increased multi-professional communication and understanding. This has resulted in a marked change in the roles being undertaken by pharmacists. Community pharmacists have traditionally provided a medicine supply function and treated minor ailments in addition to delivering a suite of locally commissioned services; however these functions have not necessarily been part of a programme of care involving the other clinicians associated with the patient. An integrated model of care would see much closer working between pharmacy and general practice but also with pharmacists not only working with, but in the practice, in an enhanced patient-facing role, trained as independent prescribers. This has implications for the dynamics amongst professionals in this environment.ObjectivesThis exploratory multiple case study attempts to explore these changing dynamics across ten GP surgeries throughout the South-East of England.MethodsSemi-structured, in-depth interviews were conducted with one nurse, one pharmacist and one physician from each clinic, and survey data was collected from 38 patients who had appointments with a pharmacist.ResultsThe data suggested that the pharmacists who had enhanced roles perceived some uncertainty about their professional role and identity, which resulted in instability and insecurity and that this uncertainty led to both professional and interprofessional tension with their primary care colleagues. The survey data revealed that n = 35 (92%) patients stated they were ‘very satisfied’ or ‘satisfied’ with their appointment. And n = 37 (97%) were ‘very comfortable’ or ‘comfortable’ discussing their medications with the pharmacist. In addition, 36 patients (95%) reported that they strongly agreed or agreed with the clinical recommendations made by the pharmacist.ConclusionsThese findings are discussed in relation to role expansion and professional/interprofessional relations before key practical suggestions are offered.