Point-of-care testing for infectious diseases: Opportunities,barriers, and considerations in community pharmacy

ObjectivesTo identify opportunities to perform point-of-care (POC) testing and/or screening for infectious diseases in community pharmacies, provide an overview of such tests and how they are used in current practice, discuss how the Clinical Laboratory Improvement Amendments of 1988 (CLIA) affect pharmacists performing POC testing, and identify and discuss barriers and provide recommendations for those wanting to establish POC testing for infectious diseases services in community pharmacies.Data sourcesPubMed and Google Scholar were searched from November 2012 through May 2013 and encompassed the years 2000 and beyond for the narrative review section of this article using the search terms rapid diagnostic tests, POC testing and infectious diseases, pharmacy services, CLIA waiver, and collaborative drug therapy management. All state boards of pharmacy in the United States were contacted and their regulatory and legislative websites accessed in 2012 and January 2013 to review relevant pharmacy practice laws.Data synthesisPOC testing for infectious diseases represents a significant opportunity to expand services in community pharmacies. Pharmacist education and training are addressing knowledge deficits in good laboratory practices and test performance and interpretation. Federal regulations do not define the qualifications for those who perform CLIA-waived tests, yet few pharmacists perform such services. Fewer than 20% of states address POC testing in their statutes and regulations governing pharmacy.ConclusionPOC testing for infectious diseases could benefit patients and society and represents an opportunity to expand pharmacy services in community pharmacies. Existing barriers to the implementation of such services in community pharmacies, including deficits in pharmacist training and education along with state regulatory and legislative variance and vagueness in statutes governing pharmacy, are not insurmountable.     

Pharmacist-reported practice change as a result of a statewide community pharmacy accreditation program

ObjectivesTo assess pharmacist-reported practice change as a result of participation in a community pharmacy accreditation program.SettingCommunity pharmacy practice in Wisconsin.Practice innovationThe Wisconsin Pharmacy Quality Collaborative (WPQC) is a network of pharmacies and pharmacists who provide standardized pharmacy services. WPQC is based on a unique set of quality-based best practices designed to improve patient safety in the medication use process. WPQC is supported by the statewide pharmacy organization, the Pharmacy Society of Wisconsin (PSW), which provides resources focused on implementation and engagement to support the success of WPQC-accredited pharmacies.Program evaluationPSW used a 24-question online survey to evaluate the degree of pharmacist-reported practice change as a result of the WPQC quality-based best practices.ResultsPharmacist-reported frequency and consistency of all quality-based best practices and services increased after WPQC accreditation (P < 0.05), with the exception of robotic dispensing systems, holding regular staff meetings for team communication, and providing incentives for recording quality-related events. In addition, quality-based best practices and WPQC services had a positive impact on pharmacist perceptions of their quality of patient care, patient safety, patient satisfaction, and patient relationships in WPQC-accredited pharmacies. The majority of pharmacies valued WPQC accreditation and shared positive comments about their experiences.ConclusionA community pharmacy accreditation program using standardized quality-based best practices can create and reinforce behavior change in the community pharmacy setting to positively affect patient care and medication safety. Research is needed to determine if there are actual behavior changes as a result of WPQC accreditation compared with pharmacies that have elected not to participate.     

Helping Unlock Better Care (HUB|C) using quality improvement science in community pharmacies – An implementation method

IntroductionCommunity pharmacists’ optimal scope of practice extends far beyond traditional dispensing or compounding, and health promotion or chronic disease management services based in the pharmacy can generate significant social and economic value. But, with many competing demands and performance expectations from patients, payers, and policymakers, many pharmacies face challenges when introducing, maintaining, optimizing, or integrating their service offerings. Quality Improvement (QI) science may provide a practical change management framework for pharmacy professionals to lead their teams in embracing optimal scope and in making pharmacy-based services more feasible and attractive for all parties.Project aimsTo build community pharmacies’ capacity for continuous QI (CQI) and to understand how the implementation of CQI is best achieved in this setting.MethodsCommunity pharmacies will undertake a process of change within one or more existing pharmacy services. Participatory action research principles will empower these sites to identify their own opportunities for improvement, generate change ideas, and trial and study those ideas in practice, using a QI system built on the Model for Improvement and Plan-Do-Study-Act (PDSA) cycles. An external Quality Facilitator will consult and train an internal Change Champion and other pharmacy staff to use QI tools and strategy. Mixed methods will be used to explore changes in pharmacy service quality, and to understand the experience of the pharmacy professionals taking part in the QI process.Intended outcomesTo assess the capacity and willingness of community pharmacies to undertake self-directed QI initiatives, with the support of an external Quality Facilitator and an established QI approach. Understandings surrounding the transferability of this process, including further scale-up, and the production of additional change management tools are additional potential outcomes of this work.     

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.     

Implementation study of an intermediate medication review in Belgian community pharmacies

BackgroundThe Association of Pharmacists in Belgium (APB) and local pharmacy associations launched a pilot project in collaboration with research teams from three Belgian universities to study the impact and implementation-related issues of a medication review (MR) service type 2a in Belgian community pharmacies.ObjectiveThe aim of this paper is to describe the implementation process of the MR service and to present the implementation evaluation of the pilot study (testing stage).MethodsThe pilot project was a prospective observational study using mixed methods. The implementation evaluation was based on the RE-AIM model and the framework for the implementation of services in pharmacy (FISpH). Collected implementation outcomes were classified into four dimensions: reach, adoption, implementation and intent of maintenance.ResultsDuring the testing stage, 80 pharmacies participated in the study, but 25 dropped out (31%), mainly because of a reported lack of time (adoption). The 55 remaining pharmacies included 457 patients. Recruiting patients into the service was challenging for pharmacists as 48.5% of patients refused the pharmacists' proposal (reach). Internal organizational factors were major barriers for pharmacists, followed by the lack of adoption by the pharmacy team. Large pharmacies in which pharmacy owner led the project were observed to be more proactive in implementing the MR service by integrating organizational strategies to assist the implementation process (implementation). Interviewed pharmacists perceived this new service as a professionally satisfying activity. Among participating pharmacists, 92.5% found this service feasible in practice, but believed it required adapted resources to reorganize the internal pharmacy workload, additional support, such as broad-based media campaigns to increase physicians' and patients’ awareness and attitudes towards the service, and modified software (maintenance).ConclusionsThe medication review service was implemented in 68% of participating pilot Belgian community pharmacies but would require adapted resources and supports for larger scale implementation.     

Factors associated with the intensity of government remunerated and unremunerated service provision in community pharmacies

BackgroundMany community pharmacies provide medication and disease state management services with and without specific remuneration. Availability of these services is often reported, however little is known about factors influencing the intensity of their provision.ObjectiveTo investigate factors associated with the intensity of provision of selected government remunerated and unremunerated community pharmacy services in Western Australia (WA).MethodsA questionnaire was mailed to a random sample of 421/628 (67%) community pharmacies in WA. The first dependent variable was intensity of government remunerated MedsCheck and Diabetes MedsCheck service frequencies per month. The second was the intensity of the sum of government unremunerated asthma screening, blood glucose testing, cholesterol testing and smoking cessation disease state management service frequencies per week. Principal Component Analysis defined attitudinal components influencing service provision. Linear regression with bootstrap confidence intervals determined variables associated with intensity of provision of the selected services. The variables were: pharmacist; pharmacy setting characteristics; and, attitudinal factors.ResultsThe questionnaire yielded a response rate of 49.2%. Attitudinal components that facilitated service provision were: general practitioners (GPs) willingness to collaborate; pharmacists are capable and ready; and pharmacists require further training. Staff capability and low return on investment were barriers to increased service provision. The intensity of government remunerated services was independently associated with pharmacies having pharmacy interns, fewer dispensary technicians, and being capable and ready to provide the services. Higher intensity of the provision of the unremunerated disease state management services was independently associated with the intensity of provision of MedsCheck and Diabetes MedsCheck services.ConclusionsImproved pharmacy workflow, achieved by the availability of pharmacy interns, and pharmacists being capable and ready, were important factors in the intensity of MedsCheck and Diabetes MedsCheck services. Intensity of the provision of government remunerated services facilitated a higher prevalence of disease state management services provision.     

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.     

山东省社会药房慢性病管理现状调查研究

目的 调研山东省内社会药房开展慢性病管理的现状,为提高管理水平提供参考。方法 选择山东省5个地市155个社会药房为研究对象,问卷调查慢性病管理的人员配备、服务项目和阻滞因素等;分地市选取1 155例慢性病患者为研究对象,调研患者对药房慢性病管理的认知、需求、参与和认可情况。结果 社会药房主要围绕高血压(90.5%)、糖尿病(87.5%)和慢阻肺(75.2%)等慢性病开展服务,管理项目主要有用药指导(90.3%)、健康教育(89%)和生化指标检测(85.8%),阻滞性因素是缺少专业管理人员(61.3%)、患者依从性差(52.9%)和对药房缺少信任(48.4%)。患者对慢性病的认知度(65.2%)低,参与药房管理的积极性低(56.5%);期望药房建立慢性病管理专区(57.7%),检测生化指标(56.2%),提供用药指导(50.8%);73.6%的患者信任药房的管理,满意度为86.7%。结论 慢性病管理在一定程度上满足了患者的疾病康复需求和健康管理需求,但仍面临多重挑战,社会药房需要利用好各类利好政策,从发展方向、发展路径和发展模式上大胆创新、不断探索。     

医药分开背景下社会药房药事服务费探索

目的：分析社会药房药事服务费收费机制,为深化医药卫生体制改革提供参考和建议。方法：通过定性分析和研究推理,探索社会药房药事服务收费管理机制并提出改革建议。结果：设立社会药房药事服务费,对全面取消以药养医、落实医药分开、提升药品流通企业转型升级具有重要的价值和意义。结论：应尽快创设社会药房药事服务费管理机制,建立合理的执业药师专业服务的补偿机制和激励机制。     

Designing a theory and evidence informed pharmacogenomic testing service in community pharmacy in England

IntroductionPharmacogenomics (PGx) uses DNA to predict an individual's response to a medicine. Internationally, the delivery of PGx is frequently via community pharmacies, who can take a saliva sample, send it off for analysis and contribute to the final clinical decision making. No similar service has been set up in England.AimTo identify the barriers, enablers and Behaviour Change Techniques (BCTs) to inform a service specification for delivery of a community pharmacy based PGx service in England.MethodThis qualitative co-design research study was designed in three stages using action-orientated theory-based frameworks and tools. The first stage mapped perceptions, barriers to, and enablers for, implementing a community pharmacy based PGx service, derived from a previous qualitative study onto the Theoretical Domains Framework (TDF). The second stage utilised the Theory and Techniques Tool (TTT) to link the identified TDF domain with corresponding BCTs. The final stage used a Delphi survey followed by a Nominal Group Technique session to facilitate community pharmacists selecting their preferred BCTs to include in a service specification.ResultsThe existing qualitative data were mapped onto six TDF domains: Knowledge, Skills, Social/professional role and identity, Optimism, Beliefs about Consequences, and Environmental context and resources. Forty-six BCTs were identified using the TTT and the consensus methods resulted in nine selected BCTs: Review outcome goal(s), Feedback on behaviour, Instruction on how to perform behaviour, Demonstration of the behaviour, Credible source and Adding objects to the environment.ConclusionUsing a range of action-orientated theoretical frameworks and tools, pragmatic BCTs have been identified as part of a co-design process, which can now be used as the basis to develop a service specification for the implementation of a PGx testing service in a community pharmacy setting in England.     

Strategies for implementing the Appointment-Based Model at a rural independent chain of community pharmacies

BackgroundThe Appointment-Based Model (ABM) is a care model that helps community pharmacists streamline their medication dispensing workflow while simultaneously integrating patient care into the medication preparation process through medication synchronization. Implementation of the ABM has varied across community pharmacies. Further studies that identify tailored implementation approaches are needed to support broad adoption of the ABM in practice.Objectives(1) To determine facilitators and barriers to ongoing adoption and implementation of the ABM at a small chain of rural independent pharmacies where adoption has stalled and (2) to identify implementation strategies to support further adoption of the ABM at these pharmaciesMethodsThis project was an exploratory, mid-implementation study. Semistructured interviews were conducted with pharmacy staff who participated in the ongoing implementation and use of the ABM at the pharmacies. Interviews elicited stakeholder-centered perspectives on (1) experiences with the ABM to date, (2) processes and roles for the ABM, and (3) opinions on how implementation of the ABM could be improved at the pharmacies. Rapid qualitative assessment methodology was used for analysis to identify facilitators and barriers and to select implementation strategies.ResultsThirty-one pharmacy personnel were interviewed: pharmacists (n = 10), pharmacy technicians (n = 7), and fill clerks (n = 14). The research team identified 6 facilitators and 4 barriers to the implementation of the ABM at the pharmacies. Five implementation strategies were selected based on the facilitators and barriers: (1) capture and share local knowledge across pharmacy sites, (2) conduct educational outreach visits, (3) conduct ongoing training, (4) prepare patients to be active participants in the ABM, and (5) organize clinician implementation team meetings.ConclusionsDevelopment of a stakeholder-driven implementation approach may support further implementation and adoption of the ABM in practice.     

Establishing a community pharmacy-based fall prevention service – An implementation study

BackgroundCommunity pharmacists are in the position to contribute to fall prevention, but this is not yet common practice.ObjectiveThe aim of this study was to evaluate the implementation of a community pharmacy-based fall prevention service.MethodsA fall prevention service, consisting of a fall risk screening and assessment including a medication review, was implemented in pharmacies during three months. A preparative online training was provided to the pharmacy team to enhance adoption of the service. Included patients were aged ≥70 years, using ≥5 drugs of which ≥1 fall risk-increasing drug. The implementation process was quantitively assessed by registering medication adaptations, recommendations, and referrals. Changes in patient scores on the Short Fall Efficacy Scale-International (FES-I) and a fall prevention knowledge test were documented at one month follow-up. Implementation was qualitatively evaluated by conducting semi-structured interviews with pharmacists before and after the project, based on the consolidated framework of implementation research.ResultsThe service was implemented in nine pharmacies and 91 consultations were performed. Medication was adapted of 32 patients. Patients' short FES-I scores were significantly higher at follow-up (p = 0.047) and patients’ knowledge test scores did not differ (p = 0.86). Pharmacists experienced the following barriers: lack of time, absence of staff, and limited multidisciplinary collaboration. Facilitators were training, motivated staff, patient engagement, and project scheduling.ConclusionThe service resulted in a substantial number of medication adaptations and lifestyle recommendations, but many barriers were identified that hamper the sustained implementation of the service.