Continuation of opioid replacement program delivery in the aftermath of cyclones in Queensland,Australia: A qualitative exploration of the perspectives of pharmacists and opioid replacement therapy staff

BackgroundCyclones can significantly impact on communities and their healthcare services. Community members with chronic diseases, including opioid dependence, who rely on these healthcare services are placed at an increased risk of treatment disruption during a disaster event. Disruptions to the continuity of the opioid replacement therapy (ORT) service can potentially lead to relapse, withdrawal, and risky behaviours in clients with potential repercussions for the community.ObjectiveTo explore the effects of Queensland (QLD) cyclones on opioid treatment programs within Queensland community and hospital pharmacies from three perspectives.MethodQualitative research methods were used. Participants comprised five community pharmacists, four Queensland opioid treatment program (QOTP) employees, and five public hospital pharmacists. Participants were identified as they had worked in Townsville, Rockhampton, Mackay, or Yeppoon in a community impacted by a cyclone and involved with ORT supply. Interviews were recorded and data were analysed by two methods - manual coding and the text analytics software Leximancer®.ResultsThe two themes that emerged from the manual coding process were ‘disaster preparedness’ and ‘continuity of service’. The key themes from the Leximancer® analysis aligned with the two manual coding themes with no new themes identified. Primary dosing site closures in disaster-affected areas led to increased pressures on hospitals and other community pharmacy dosing sites to supply ORT doses to clients. However, a lack of dosing information available to pharmacists and strict legislative requirements made continuity of ORT supply during these cyclones difficult.ConclusionContinuation of ORT services during and in the aftermath of a cyclone event is complex. This research highlighted a need for a coordination of efforts and shared dosing information between QOTP employees, community pharmacists, and hospital pharmacists. To improve continuity of ORT services, it is essential that these stakeholders engage with each other in preparing for and responding to future events.     

Development of the adult complexity tool for pharmaceutical care (ACTPC) in hospital: A modified Delphi study

BackgroundHospital pharmacists play an essential role in patient care; however, a lack of resources means pharmacists are unable to review all patients daily. Consequently, there is a demand for reliable screening tools to allocate care to patients with urgent and/or complex pharmaceutical needs. Several tools have been developed, but no broad consensus exists on the design of a screening tool to be used in the adult hospital setting.ObjectiveTo obtain expert consensus on the design of a pharmaceutical care complexity screening tool for use on admission to hospital.MethodsTwo Delphi studies were conducted: the first sought to gain consensus from experts including pharmacists, academics and physicians on the components of a pharmaceutical complexity tool, the second to achieve consensus from UK chief pharmacists and clinical service pharmacy managers on the clinical appropriateness and practicality of the tool. Tool components and Delphi statements were identified and refined from our previous systematic review, UK survey and interview study of prioritisation tools. A valid definition for consensus was used.ResultsOver 300 components were extracted from the interview data and systematic review and then refined for inclusion in the first Delphi study. Thirty-three experts completed Delphi One and consensus was reached on 92 components. Components were grouped into demographic, clinical and medication components and condensed to 33 items, which were included in the first draft of the Adult Complexity Tool for Pharmaceutical Care (ACTPC). The tool stratified patients into highly, moderately or least complex. Forty expert panellists completed Delphi Two and consensus was reached on review frequency and experience of pharmacy practitioner at each level. These decisions were incorporated into the final version of the ACTPC.ConclusionsThe ACTPC is the first systematically designed and internationally agreed tool for use on medical admission to hospital. It has potential to enable the delivery of targeted patient-centred pharmaceutical care.     

Validation of an assessment,medical problem-oriented plan,and care plan tools for demonstrating the clinical pharmacist's activities

BackgroundIdentifying, preventing, and resolving medical problems are some of the most central functions of clinical pharmacy (CP) and pharmaceutical care (PC) practitioners. Usually, the practitioners and researchers find a challenging to link the problem and the appropriate intervention to be included in the care plan. A comprehensive, well-structured, validated, simple use and standardized tool, which fulfill these requirements in daily clinical practice, are currently rare.PurposeTo design and validate a comprehensive medical problem-oriented plan (MPOP) classification system in addition to assessment and care plan tools for use in practicing, researching, and teaching CP and PC.Materials and methodsThe methodology was composed of five steps: literature searching and classification of the problems; developing the assessment of treatments and care plan templates; implementing the tutorial; validation; completion and evaluation of the final version.ResultsThe classification system (MPOP tool) is an open hierarchical structure, where higher levels are broadly defined, consisting of 5 main categories, and lower levels become more specific. In the MPOP tool's final version, a total of 24 major subcategories were distributed to the major five categories as 4 (Indication), 5 (Effectiveness), 7 (Safety), 3 (Patient), and 5 (Miscellaneous). Different minor subcategories (subcategory 2, n = 62) and 95 plans (interventions) were determined. Each of the subcategories and plans includes a notes section that represents a specific detail. There was strong agreement on using the MPOP tool between the two authors (κ = 1.000, p < 0.0005) and between three random clinical pharmacists out of 17 (κ = 0.947, 95% CI, 0.840 to 1.055, p < 0.0005). The validity and reliability statistics demonstrate that the Alsayed_v1 tools are extremely appropriate. The majority of users expressed high satisfaction with all the assessment, MPOP, and care plan tools.ConclusionThe Alsayed_v1 tools introduced in this paper were applied to actual patient cases and were validated. These tools include: assessment of treatments, MPOP, and care plan. Including the interventions in the classification system is important especially in PC research where the type of recommendations should be documented to assess the value and impact of the service and saves the time of practitioners in typing the appropriate interventions. By applying the steps within these Alsayed tools, the clinical pharmacists can actively provide the best practice to achieve the optimal patient outcome.     

Cost benefit analysis of clinical pharmacist interventions in medical intensive care unit in Palestine medical complex: Prospective interventional study

BackgroundClinical pharmacy services in the critical health care settings have expanded dramatically.Study problem.Clinical pharmacy services have limited implementation in Palestine. Many intensive care units (ICUs) patients do not get the intended beneficial effects of their treatment due to treatment related problems and their consequent cost burden.AimTo evaluate the impact of the clinical pharmacist interventions on costs of care and safety of patient by assessing treatment related problems among medical ICUs patients in Palestine.MethodologyA prospective interventional study was conducted at medical ICU of the major public hospital in Ramallah city over a 4-month period (between September and December 2020). Patients were randomly assigned to either an intervention or a control group (With / without clinical pharmacist involvement). Treatment related problems were identified in both study groups by the clinical pharmacist, but interventions were only provided to the intervention group. The total economic benefit included both cost savings from intervention and cost avoidance from preventable adverse drug events (ADEs) resulted from CP interventions. The primary outcomes with the clinical pharmacist interventions were net benefit and benefit to cost ratio, which were calculated using previously published methodologies and adjusted to the Palestinian settings. The analysis of CP interventions acceptance by physicians was performed.ResultsDuring the 4-month study period, the 117 patients admitted to the ICU were included into the analysis; 66 patients in the intervention group and 51 in the control group. The interventions made by a clinical pharmacist resulted in direct cost saving of NIS8,990.05 ($2799.63) and cost avoidance of NIS22,087.5 ($ 6878.37). Translated into a net savings of NIS188.35 ($58.65) per intervention and NIS470 ($146.36) per patient. Comparison of benefits (NIS31,077.55) ($9678.00) and costs (NIS19,043.928) ($5930.55) indicate a net economic benefit to the institution of (NIS 12,033.623) ($3747.44) and a benefit cost ratio of 1.63.ConclusionIntegrating a clinical pharmacist in the ICU team was investment that resulted in benefits in term of cost saving and cost avoidance.     

Pharmacists experience of and perspectives about recruiting patients into a community pharmacy asthma service trial

BackgroundResearch trials testing the impact of community pharmacy services require adequate and appropriate recruitment of patients by participating pharmacists, however, this step presents an ongoing challenge.ObjectiveTo identify factors affecting recruitment of patients in community pharmacies participating in a multi-center trial of a pharmacy asthma service in Australia (Pharmacy Trial Program – Asthma and Rhinitis Control (PTP-ARC).MethodsThe PTP-ARC protocol required identification and recruitment of seven eligible asthma patients per pharmacy. Pharmacists responsible for sites that failed to recruit or retain any patients into the PTP-ARC trial participated in a semi-structured telephone interview about their experiences with these elements of the trial. The interviews were recorded, transcribed and coded using QSR International's NVivo 11 software. The analysis was conducted with reference to the COM-B framework (Capability, Opportunity, Motivation).ResultsPharmacists from 47 of 50 eligible pharmacies were interviewed. Seventeen factors were isolated and mapped to the COM-B framework. Psychological capability (recruitment hesitancy, research literacy and health literacy), physical capability (technological barriers, staffing issues and pharmacy busyness), physical opportunity (patient busyness, trial timing, study protocol, support and location), social opportunity (health literacy and supportive milieu), reflective motivation (incentive for participation, simplification) and automatic motivation (patient attitudes and pharmacist-felt experience) were factors affecting pharmacists' participation. Challenges identified included: issues with the software, unfamiliarity with research procedures generally (and specifically with the PTP-ARC protocols), the patients' lack of interest and pharmacists’ lack of time.ConclusionsTo the best of our knowledge, this is the first study to focus on issues affecting patient recruitment into a pharmacy health services (asthma) trial in real time. To propel evidence-based trials towards practice implementation, user-friendly software, pharmacists’ training on research and patient-engagement and adequate remuneration to address pharmacist time issues need to be key foci for health services design and implementation research.     

Pharmacist-led medication reconciliation at patient discharge: A scoping review

BackgroundOne of the strategies to promote patient safety in care transitions is medication reconciliation (MR), which is conducted by the pharmacist at the patient's discharge from hospital. However, there are divergences about this process and about the pharmacist's role in conducting such intervention.ObjectiveTo systematically review the literature that reports the MR process led by pharmacists at patient discharge and map the different methods, strategies and tools used in the process.MethodsRelevant studies were searched in the following databases: EMBASE, MEDLINE (PubMed), The Cochrane Library, and LILACS. No language restriction or publication date was applied. The studies considered eligible were those involving and describing pharmacist-led MR processes at acute patient discharge from hospital, with an experimental, quasi-experimental, or observational design. The characteristics of the studies and the MR processes were identified and then a qualitative synthesis was performed.ResultsFifty studies were included. The majority of them were observational ones (82%), and the main outcome was medication discrepancies (42%). The studies were mostly conducted in university hospitals (70%) and in internal medicine wards (54%). Pharmacists were responsible mainly for gathering medication histories (72%), and identifying (96%) and solving (98%) pharmacotherapeutic problems. The main sources of information on pre-admission medications were patient/caregiver interviews (66%) and records from other care providers (40%). Only 30% of the studies described a patient discharge plan, and 14% shared information of the patient's pharmacotherapy with community pharmacists.ConclusionThe concept of MR and the pharmacist-led activities in the process varied in the literature, as well as the pharmacotherapy assessment focus and the communication strategies towards patients and other care providers, showing that standardization of the process and concepts is necessary.     

Identifying the important outcomes to measure for pharmacy-led,clinical services within primary care: A nominal group technique approach

BackgroundThe introduction of clinical pharmacy services is part of a multi-disciplinary approach to reduce pressure on primary care. Ascertaining the impact of clinical pharmacists in general practice is vital to ensure intended benefits are achieved. However, this is complicated by poor quality evidence, multiple interventions, and a lack of agreement regarding outcome measures.ObjectivesTo develop an outcomes framework for clinical pharmacy services delivered in Scottish general practice using a consensus methodology.MethodsA modified nominal group technique (NGT) was conducted using Microsoft Teams and Qualtrics. This involved a pre-NGT questionnaire, silent generation of ideas, round robin, discussions, ranking, and a final consensus exercise. A selective sampling strategy recruited experienced pharmacists from Scottish health regions. NGT ranking results were used to signify relative importance of the outcome areas. NGT discussions underwent inductive thematic analysis to explore key areas considered.ResultOverall, 13 (median: 24 years of experience) pharmacists participated, representing 11 of 14 Scottish regions. In total, 21 outcome areas, derived from the literature and a pre-NGT questionnaire, were considered during the NGT ranking exercise. Consensus identified five important outcome areas: Patient Experience, Medication Related Adverse Events, Cost-Effectiveness, Medication Optimisation, and Health Related Quality of Life. Thematic analysis highlighted the importance of the outcome framework's target audience, factors influencing the interpretation of outcomes, and the feasibility of the associated outcome measures.ConclusionsThe five key outcome areas will facilitate evidence-based decisions regarding service delivery. Future work should develop a measurement plan, involving routinely collected sources of outcomes data. The feasibility of collecting outcomes in the real-world context should be considered, identifying measures which are easy to collect within existing data infrastructures. This paper describes a replicable method to gain consensus for a national approach to data collection from a strong theoretical basis using an online methodology.     

Barriers to the use of patient safety information sources by community pharmacies

BackgroundWhen patient safety information is communicated across a regulatory jurisdiction or country, the potential to enhance the safety of community pharmacy practice is significant. While there currently exists a number of sources for patient safety information (e.g., websites, safety bulletins, online tools), knowledge of the barriers that may inhibit the use of such information sources within community pharmacies is limited.ObjectiveThis research explores community pharmacy manager use of Canadian patient safety information sources and the barriers that may limit the use of such sources.MethodsA qualitative research study design using semi-structured interviews was conducted with 15 community pharmacy managers in the Halifax Regional Municipality of Nova Scotia, Canada. The study explored how pharmacists access and engage a variety of information sources, including corporate intranets, websites, and tools provided by third party data base repositories. Interview data were analyzed using thematic analysis.ResultsFive general barriers were identified: lack of time to access information sources and its contents; too many sources of available information; too much information not relevant to community pharmacy practice; complexity navigating online information sources; and lack of community pharmacy involvement in source design.ConclusionWhile pharmacies do use safety information sources to enhance practice safety, their ability to incorporate this information is inhibited by their general lack of time available to access and read safety information, lack of knowledge about where to get this information, and lack of tailored information for the community pharmacy context. Future initiatives should address increasing information awareness of available sources, consolidating and reducing information overload of such sources, and packaging information to better fit with pharmacists’ needs.     

Factors influencing the implementation of pharmaceutical care in outpatient settings: A systematic review applying the Consolidated Framework for Implementation Research

BackgroundPharmaceutical care in outpatient settings is a type of health service that has been shown to contribute to decreasing drug-related morbidity and mortality rates. However, every process of implementing a new service brings about changes and transformations in the work routine, thus posing challenges.ObjectivesThis systematic review aims to identify barriers to and facilitators for the implementation of pharmaceutical care in outpatient settings by applying the CFIR method, a framework based on the theory of health services, used to analyze and synthesize research data, which can direct strategies for the service to work as planned.MethodsA systematic review was conducted exploring the barriers to and facilitators for the implementation of pharmaceutical care in outpatient settings. The MEDLINE, EMBASE, CINAHL, COCHRANE, and LILACS databases were consulted.ResultsEight studies were included: five qualitative ones, two mixed-method ones, and a quantitative one. The most frequent CFIR constructs identified were Patient Needs and Resources (n = 30, 10.75%), Knowledge and Beliefs about the Intervention (n = 31, 11.11%), Networks and Communications (n = 34, 12.19%), and Available Resources (n = 56, 20.07%). The most cited barriers were: insufficient human resources, patients' unawareness of the existence of the pharmaceutical care service, and pharmacists’ resistance to changes. Facilitators included: the opportune presentation of the service to the healthcare team; the use of electronic devices for specific guidance; and the assessment of patient satisfaction.ConclusionsThis systematic review allowed detecting key guidelines to improve the implementation process, including (1) defining an implementation method and exploring it extensively during the pre-implementation phase, (2) ensuring human and financial resources, (3) determining how the new service will interact with other existing services. More research is needed to understand how these factors can affect the implementation of clinical services.     

Experiences of key stakeholders with the implementation of medication reviews in community pharmacies: A systematic review using the Consolidated Framework for Implementation Research (CFIR)

BackgroundThough medication reviews have shown positive patient outcomes, they are still not widely implemented in community pharmacies. Published reviews on their implementation often include several other pharmacy services, making them non-specific. Using the Consolidated Framework for Implementation Research (CFIR) to focus solely on the experiences of different stakeholders with the implementation of medication reviews will help to better understand relevant facilitators and barriers.ObjectivesTo critically appraise, synthesise and present the available evidence on experiences of key stakeholders with the implementation of medication reviews and to identify barriers and facilitators to its implementation in community pharmacies.MethodsA systematic literature search was conducted in four databases for studies published in English, Spanish or German. Key search terms included: implementation, pharmac*, medication review, facilitator, barrier. Study selection, quality assessment and data extraction were performed by two independent reviewers. Findings were mapped directly against the constructs of the CFIR.ResultsOut of 924 retrieved records 24 articles from 9 countries met the inclusion criteria. Key facilitators identified included pharmacists' openness to practice change and a high degree of patient satisfaction post medication review. Attracting patients to the service was stated as challenging due to an unawareness of the scope and potential benefit of a medication review. The dominant barrier was inadequate remuneration, as it impacted all additional resourcing and ultimately the viability of the service. Further barriers included difficult professional relationships with doctors and little mandate from health authorities. Most reports were from the employed pharmacists’ perspective and concerned the inner setting, other perspectives were under-reported.ConclusionsResults of this systematic review illustrate different stakeholders' experiences and add to the understanding of challenges in the implementation process. Nevertheless, findings also highlight how scarce reporting of external stakeholders’ views is and that filling this gap can unveil hidden barriers and facilitators.RegistrationPROSPERO register (CRD 42019122836)     

Estimating the potential economic impact of the Wasfaty program on costs of antidiabetic treatment: An initiative for the digital transformation of health

IntroductionThe Saudi health care transformation is taking place through the implementation of many initiatives and programs to serve Saudi Vision 2030, which aims to improve health care services by focusing on digitalization and privatization. This study aimed to evaluate the economic impact of implementing the new digital health transformation initiative (Wasfaty service) on the health care budget using diabetes mellitus as an example.MethodsThis study presents a cost analysis evaluation following the implementation of the Wasfaty program during the period between 2017 and 2021. The study compared the pre-Wasfaty period and the Wasfaty period in terms of direct medical costs. Data sources were the Ministry of Health for pre-Wasfaty data and the National Unified Procurement Company, which runs the Wasfaty program, for Wasfaty data. The study focuses on diabetic medications for outpatients. This health economic evaluation used the cost per visit, and sensitivity analyses were conducted utilizing the cost per patient according to the prevalence of diabetes mellitus.ResultsAfter implementing the transformation using the Wasfaty service, the estimated annual mean cost savings per visit were USD 109.18 (SAR 409.43), and the cost savings per patient with a prevalence of 11% were USD 13.89 (SAR 52.1). The saving costs were USD 11,750,600 (SAR 44,064,750) for human resources and USD 97,473,469 (SAR 365,525,508) for pharmacies’ operation costs without including warehouse expenditures. The savings from the clinical decision support system preventing undesirable medication costs were estimated at USD 9,842,720 (SAR 36,910,201), and savings from the prevention of undesirable adverse events were estimated at USD 137,332,615 (SAR 514,997,308) for a 6% prediction. The total healthcare expenditure savings were USD 258,762,981 to 274,972,971 (SAR 970,361,178 ± 1,031,148,640).ConclusionsImplementing the new digitization and privatization initiatives (i.e., the Wasfaty program) as a result of the transformation in the health care sector had led to a significant reduction in health care expenditures and cost savings with respect to clinical and pharmacy services using diabetes mellitus as an example.     

Pharmacists’ experience of a diabetes risk-assessment service and analytical quality control in community pharmacies – A focus-group study

BackgroundHealthcare services such as diabetes risk-assessment are increasingly common in community pharmacies. Knowledge of community pharmacists’ experiences of such services could ease the implementation of a larger-scale service.ObjectivesTo explore Norwegian pharmacists’ experience of a diabetes risk-assessment service, including analytical quality control, in a community-pharmacy setting.MethodsThree focus-group interviews were conducted in Norway between August and September 2017. Systematic text condensation was used, an analytic approach well suited for thematic content analysis across interview data. Fourteen pharmacists took part, recruited from a project offering a diabetes risk-assessment service, including measurements of Glycated hemoglobin A1c (HbA1c), in Norwegian community pharmacies.ResultsThe pharmacists emphasized the importance of using their knowledge and skills to promote good health. They considered offering this service as being compatible with their role as pharmacists. As communication is an essential part of their work, the pharmacists evaluated their communication skills as being good. Nevertheless, how to communicate the offering of this service was seen as a challenge, for instance recruiting participants and communicating in an understandable and professional way. Inclusion of the whole pharmacy staff as a team was experienced as an important success factor for implementation of a risk-assessment service. Analytical quality control was perceived as being a natural part of their job and a manageable task.ConclusionsOffering a diabetes risk-assessment service is in line with the way a selected group of Norwegian community pharmacists perceived their professional role. However, they were uncomfortable recruiting participants, and expressed the wish for more support from the pharmacy chain. Our results add performance of analytical quality control as part of the ongoing development involving expansion of pharmacists' professional role. Future implementation studies may also benefit from giving both the pharmacy staff and customers sufficient time to familiarize themselves with the new service before measuring effects.