Universal health coverage for mental health: the contribution of clinical pharmacists

International Journal of Clinical Pharmacy -     

Exploring the role of renal pharmacists in outpatient dialysis centres: a qualitative study

Background Pharmacists?? involvement in outpatient dialysis centres in Australia is currently limited, despite the positive contribution of pharmacists to renal patients?? medication management and health outcomes outlined in the literature. An expanded role for pharmacists in this setting may be required as a consequence of the increasing burden of renal disease in the population. Objective To explore renal-specialised hospital pharmacists?? intentions to implement pharmacy services in outpatient dialysis centres. Setting Australian renal-specialised hospital pharmacists. Method Semi-structured interviews were conducted with a purposeful sample of renal pharmacists recruited through the Society of Hospital Pharmacists of Australia Renal Special Interest Group. The interview guide was developed based on the theory of planned behaviour. To identify behavioural intention, the three components of the theory??attitudes, subjective norm, and perceived behavioural control??were explored. The interviews were recorded, transcribed verbatim, and thematically content analysed following a qualitative approach. Main Outcome Measures Pharmacists?? views on their potential involvement and perceived ease or difficulty in implementing pharmacy services in outpatient dialysis centres. Results Thirteen renal pharmacists were interviewed until data saturation achievement. The following services for this setting were suggested: medication reconciliation, medication review, patient education, promotion of compliance, involvement in protocol development with subsequent anaemia/phosphate management. Pharmacists demonstrated positive attitudes towards the implementation of the services. Outcomes expected included benefits to patients, the renal team, and the pharmacy profession, as well as economic savings due to dose optimisation and improvement of patients?? adherence. Subjective norm was favourable meaning that nephrologists, nurses and patients were expected to be receptive towards future pharmacy services. Barriers pointed out for the implementation comprised: funding, hospital administrators?? approval, time and staff shortage, academic training, relationship with physicians, and attitudes of pharmacists, renal team, and patients. Facilitators mentioned by respondents included: having an interview room with access to information sources, consent from the team, access to patients?? profiles, and a full-time pharmacist with a clearly defined role. Conclusion Pharmacists showed positive attitudes, favourable subjective norm and strong perceived behavioural control, which originated a clear behavioural intention to develop pharmacy services in outpatient dialysis centres. The potential barriers and enablers outlined should be taken into account, as well as the holistic approach for the successful implementation of cognitive pharmacy services.     

A national study of the mental health literacy of community pharmacists

BackgroundCommunity pharmacists are in a prime position to communicate with and assist those with mental health needs. However, mental health literacy, which includes beliefs and knowledge of mental health conditions, can impact the provision of pharmacy services. The mental health literacy of community pharmacists in New Zealand is currently unknown.ObjectivesTo assess the mental health literacy of community pharmacists in New Zealand.MethodsWe employed a national cross-sectional online survey, evaluating attitudes towards mental illness, ability to recognise depression using a vignette and followed by questions related to the helpfulness of various interventions, and willingness to provide pharmacy services for people with mental illness in comparison to cardiovascular diseases. Additionally, opportunities for mental health training were explored. Participants were community pharmacists working in New Zealand contacted via mailing lists of professional bodies.ResultsWe received responses from 346 participants. The majority of participants showed positive attitudes towards mental illness and correctly identified depression in the vignette (87%). Participants rated counsellors (84%) and physical activity (92%) as the most helpful professionals and intervention respectively while only 43% considered antidepressants as helpful for depression. When compared to other people in the community, long-term functioning of the individual described in the vignette was rated poorly, especially in terms of increased likelihood to attempt suicide (85%) and reduced likelihood to be a productive worker (64%). Approximately 30% of participants reported reduced confidence/comfort while approximately half of participants reported greater interest in providing mental health-related care compared to cardiovascular disease. The participants also highlighted several areas for future mental health training they wished to undertake.ConclusionsWe have identified positive attitudes towards mental illness in our study. Participants correctly identified and supported evidence-based interventions for mild to moderate depression. However, we highlighted the need for ongoing mental health training to address knowledge gaps and enhance the confidence in providing mental health-related care.     

Patterns of clozapine prescribing in a mental health service in New Zealand

Objective To describe clozapine prescribing in a mental health service in Auckland, New Zealand and compare it with national and international treatment guidelines. Setting A large public mental health service for adults in Auckland, New Zealand. Method A retrospective cross-sectional study of all adult outpatients and stable inpatients being treated with clozapine on 31st March 2007 in one mental health service in Auckland, New Zealand. Data on patient characteristics, diagnosis, duration of illness, number of hospitalisations, legal status relating to their treatment, living situation, marital status and occupational activity were recorded from case notes. Data collected on clozapine included date of initiation, dose and duration of treatment. Prior antipsychotic use and information on all other psychotropic drugs prescribed was also collected. Data were entered into a custom-designed Microsoft Access database and analysed using SPSSv15.0. Main outcome measures Clozapine prescribing patterns and concordance with best practice recommendations for clozapine use. Results 402 adult mental health outpatients and stable inpatients were eligible for inclusion. The mean daily dose of clozapine was 383 (SD 166) mg. For those first presenting after universal government funding, the mean time between presentation and initiation of clozapine, was 2.8 (SD 1.9) years, compared to 5.7 (SD 3.3) years prior to funding. Of those presenting after universal government funding, approximately two-thirds (69.0%) had ≤2 trials with other antipsychotics prior to commencing clozapine; of whom the majority (62.0%) received only second-generation antipsychotics (SGA). Both the number of antipsychotic agents trialled and the time to clozapine initiation has fallen since government subsidy was introduced in 1999. Based on a analysis of annualised hospitalization rates, it appears that shortening the delay to receiving clozapine leads to fewer hospitalisations in this treatment-resistant population, although this did not achieve statistical significance in our study. Conclusions Contemporary management of patients with treatment resistant schizophrenia in New Zealand is broadly in line with national and international best practice guidelines. There is some evidence, based on hospitalisation rates, to support the assertion that shorter delays in accessing clozapine leads to better outcomes. This needs further evaluation using measures of clinical outcome including objective measures of functioning.     

Repeat prescribing processes in primary care: a qualitative study

Objective To investigate the characteristics, local agreements and changes regarding repeat prescribing processes in primary health care in Finland. Setting Twenty‐eight municipal health centres nationwide. Method Twenty‐eight physicians and 28 medical receptionists were given semi‐structured telephone interviews about repeat prescribing practices. The repeat prescribing process of each health centre was displayed as a flow chart and the processes were classified according to the quality of the practical flow and the medication review. Key findings There are various ways of carrying out repeat prescribing in different health centres. In some centres, a review of the medications is recognised as part of the repeat prescribing process, but in others there is no systematic review of the patients' medication. Repeat prescribing is often performed in a busy atmosphere. Repeat prescribing systems have evolved over time without proper management, and few local guidelines exist. Conclusions There is a need to reorganise the repeat prescribing systems in primary health care. A regular review of long‐term medications, in particular, needs to become a part of the repeat prescribing process. There is a need for both local and national guidelines.     

A qualitative exploration of the enablers and barriers to the provision of outpatient clinics by hospital pharmacists

Background

With increasing demands on the National Health Service (NHS), Scottish Government-led pharmacy strategy has prioritised the development and expansion of outpatient services. Pharmacist-led outpatient clinics have been shown to reduce hospital admissions and improve patient outcomes. However, expanding these contemporary models of care has proved challenging, and there are few qualitative data about the factors affecting the provision of these.

Aim

This study aimed to explore the enablers and barriers to hospital pharmacists providing outpatient clinics within the largest health authority in Scotland, NHS Greater Glasgow & Clyde (NHSGGC).

Method

Between August and October 2020, one-to-one semi-structured interviews were conducted virtually using the videoconferencing platform Microsoft Teams^®, with NHSGGC hospital pharmacists who did or did not provide clinics. Audio- and video-recordings of the interviews were transcribed verbatim and underwent thematic analysis.

Results

16 hospital pharmacists were interviewed; 50% were clinic providers and 50% were not. Analysis generated seven themes: clinical or service need, individual factors, clinic structure and processes, additional clinical skills and training, competing priorities, macro-level pharmacy working, and external stakeholder relationships. Many of these were interdependent and had the potential to be an enabler or a barrier to clinic provision, depending on the context or individual.

Conclusion

The enablers and barriers to hospital pharmacists providing outpatient clinics are multifaceted, incorporating individual, systematic and professional factors. The implementation of new national professional curricula may help address many of these factors, however prospective research needs to accompany this vision.

     

Community pharmacists in Virginia dispensing naloxone under a standing order: A qualitative study

BackgroundIn 2016, the Virginia Health Commissioner signed a standing order into law allowing licensed pharmacists to dispense opioid receptor antagonists (ORAs) for overdose reversal.ObjectivesUsing the theory of planned behavior as an initial guide to study development, the aim of this qualitative study was to explore community pharmacists’ attitudes, subjective norm, perceived behavioral control, and behavioral intention toward dispensing ORAs under a standing order in Virginia.MethodsSemi-structured interviews were conducted with community pharmacists across the Commonwealth between June 2018 and October 2019. Interviews were recorded, transcribed verbatim, and thematically analyzed.ResultsTwenty-one community pharmacists were interviewed. Pharmacists were confused about the specifics and the processes involved with dispensing naloxone under the standing order. Furthermore, many recognized the underuse of the standing order. Positive attitudes focused on the life-saving action of ORAs. Negative attitudes included encouraging risky behaviors by patients, negatively affecting the patient-pharmacist relationship, offending or contributing to stigmatizing patrons, and having liability issues to the pharmacy. Subjective norms regarding dispensing of ORAs under the standing order were perceived to be favorable among peer pharmacists and primary care and emergency department physicians but may be seen as profit-seeking by patients. Barriers to service provision included lack of guidance from corporate offices (in chain pharmacies), inadequate training, patient out-of-pocket costs, reimbursement issues, inadequate staffing and time, and stigma. Facilitators comprised the existence of practice site-specific protocols, the REVIVE! training, technician support, increased community awareness, physician collaboration, pharmacist training, and employer guidance. Whereas some pharmacists intended to become more familiarized with the standing order, others did not intend to actively identify patients who were at risk of an opioid overdose.ConclusionPharmacists expressed mixed behavioral intention toward dispensing ORAs under the standing order. Future research should focus on quantifying the uptake of the standing order at the state level.     

Independent prescribing by pharmacists: a study of the awareness, views and attitudes of Scottish community pharmacists

Aims To investigate community pharmacists’ awareness, views and attitudes relating to independent prescribing by community pharmacists and their perceptions of competence and training needs for the management of some common conditions.Setting Community pharmacies in Scotland.Method A pre-piloted postal questionnaire was mailed to 500 randomly selected community pharmacies in Scotland for completion by the ‘main pharmacist’.Main outcome measures Scottish community pharmacists’ awareness, views and attitudes towards independent prescribing by community pharmacists; perceived competence and training needs in relation to diagnosis and treatment of conditions in four therapeutic areas; perceptions about patient accessibility to medicines and safety of independent prescribing by community pharmacists; and attitudes towards becoming an independent prescriber. The items regarding perceptions and attitudes were subjected to Principal Components Analysis (PCA) to identify the domains. Univariate analysis was performed on individual items in the questionnaire against total scores on the identified domains; significant variables in univariate analysis were further analysed in linear regression models.Results A response rate of 43.4% (217/500) was achieved. Despite expressing confidence in their abilities to become independent prescribers and feeling competent in diagnosing and treating those conditions listed in the questionnaire, clinical training prior to implementation of independent prescribing was regarded important by 211 (97.7%) respondents, while 191 (88.4%) regarded clinical training in drugs used for treating the conditions to be important. Gaining improved patient consultation skills and ability to communicate prescribing actions to GP practices were regarded to be important by 125 (57.9%) and 172 (80.0%), respectively. In PCA, three domains—confidence in independent prescribing, satisfaction with the␣current methods of supply, and requirements for the process of independent prescribing were identified. Practising more hours per week as a pharmacist (p = 0.01), supplementary prescribing training (p = 0.02), and involvement in Scottish Executive pharmaceutical care model schemes (p = 0.02), were found to be associated with greater ‘confidence in independent prescribing’.Conclusion High awareness of independent prescribing and perceived competence in diagnosing and selecting appropriate drugs for treating many common conditions were identified. Prescribing training with emphasis on evidence-based medicine, generic issues of prescribing and diagnostic and consultation skills is warranted before independent prescribing is undertaken by community pharmacists.     

Migraineurs' perceptions of and interactions with pharmacists: a qualitative study

Aims and objectives Migraine is an underdiagnosed and undertreated condition. Diagnosed and undiagnosed migraineurs come into frequent contact with pharmacists, who are in a unique position to intervene and potentially improve the therapeutic outcomes of migraineurs; however, little is known about migraineurs' attitudes towards pharmacists' roles and the experiences they have shared with pharmacists. The purpose of this study was to evaluate migraineurs' perceptions of the roles that pharmacists may play in helping them manage their disease. Setting Duquesne University, Pittsburgh, Pennsylvania, USA. Method The study employed the use of two focus groups of migraineurs from a university population, approached from a phenomenologic perspective. Focus‐group sessions were conducted using a flexible interview guide. Focus‐group content was digitally recorded, then transcribed, verified for accuracy and content analysed according to established criteria, employing the use of a formal coding procedure. Inductive analysis was performed to establish patterns, themes and categories in the data. Key findings Six principal themes emerged. Among the most important findings were that (1) migraineurs were concerned about managing their headaches and the impact migraine has on their lives and their families' lives, (2) migraineurs did not discuss their headaches or migraine therapy with pharmacists and (3) migraineurs believe that many communication barriers exist in their pharmacistpatient relationship. Conclusion Community pharmacists have an opportunity to impact the level of care provided to migraine sufferers. As such, community pharmacists should strive to remove communication barriers and be more proactive during interactions with these patients. Further study may examine how pharmacists can elicit more social support for migraineurs and to help migraineurs cope with their condition.     

Expanded prescribing: a comparison of the views of Australian hospital and community pharmacists

Background Community pharmacies and hospitals are the two main professional areas for pharmacists. There is currently a lack of comparison of pharmacists working in these two distinct settings in relation to an expanded prescribing role. Objective To compare the attitudes of hospital and community pharmacists regarding an expanded prescribing role. Setting Australian pharmacists. Methods A self-administered postal survey was used to collect the data. Data analysis was performed using SPSS^® v19. Kendall’s tau-c test was used to compare the mean values between categorical variables (i.e. hospital or community pharmacists) and continuous variables measuring attitudes on a Likert scale (i.e. reasons in favour and barriers of pharmacist prescribing, preferred therapeutic areas of prescribing and prescribing models). A Chi square test was used to analyse categorical variables (i.e. demographics). Main outcome measure The opinion of hospital and community pharmacists regarding an expanded prescribing role. Results A response rate of 40.4 % was achieved (1,049/2,592). Where significant differences were located, community pharmacists were more supportive of all proffered potential reasons in favour of pharmacist prescribing (p < 0.05) whereas hospital pharmacists were more in agreement with all suggested barriers to such a role (p < 0.05). In a supplementary (collaborative) prescribing model, hospital pharmacists were more confident than community pharmacists in prescribing for heart failure (p < 0.001) and anticoagulant therapies (p = 0.004). In an independent prescribing model hospital pharmacists were more supportive of prescribing anticoagulant therapies (p = 0.002). Significant differences were found between the two groups in relation to their support for independent prescribing (p = 0.020) and extension of the emergency supply 3 days rule to 30 days (p = 0.011). Conclusion This study suggests that there are differences between hospital and community pharmacists in what they regard as potential reasons in favour of an expanded pharmacist prescribing role, perceived barriers to such a role and whether to prescribe independently of doctors. Hospital pharmacists’ attitudinal differences in terms of support for certain therapeutic areas of prescribing reflects probably their existing active role in clinical decision making processes in patients who are often seriously ill.     

In their own words: Community pharmacists and their health education role

During the past decade, there has been much discussion about the role of the community pharmacist in health education. This paper is based upon interviews with a small sample of practising community pharmacists. It reports on their perceptions of the nature of their health education role, the practicalities of implementing this role and the obstacles that need to be overcome. The pharmacists were clear about their health education role as it related to advice on prescribed medicines. However, they were uncertain about other aspects of the health education role. These uncertainties are related to their education in a biomedical and functionalist paradigm together with ethical concerns about interference in the lifestyles of patients. Both these aspects influence the manner in which pharmacists communicate. The paper discusses the need for further advances towards patient orientated pharmacy, which is the essential direction for a health education role.     

The role of the clinical pharmacist in mental health hospital-in-the-home: A scoping review

BackgroundThe concept of integrating a clinical pharmacist (CP) within a Hospital-in-the-Home (HiTH) program is relatively new. Little is known about the role of a pharmacist in HiTH programs focused on mental health (MH).ObjectivesTo describe the role of a CP within an MH-HiTH program, focusing on the specific tasks performed by a pharmacist in this position, their benefits and limitations.MethodsMEDLINE, CINAHL, EMBASE, Cochrane Database of Systematic Reviews, PsycINFO, Web of Science and the grey literature were searched without any date limits for references in English that included 2 or more of the following key terms (or their synonyms): “HiTH”, “clinical pharmacist” and “mental health”. Two reviewers independently screened and analysed the data.ResultsOf 60,482 screened references, 6 included all 3 key terms: 2 were HiTH guideline documents, 2 were conference abstracts and 2 were journal articles. These papers discussed MH-HiTH programs or similar home-care services where a CP was incorporated in the treating team to address medication management and adherence during a home visit. There is evidence that MH-HiTH CPs identify and resolve medication-related problems (MRPs), as well as improve medication adherence, patient care, hospital admission rates and emergency department presentations. An additional 54 references including 2 key terms provided corroborating evidence of an MH-HiTH CP role focused on improving patient care via 4 key groups of tasks: clinical pharmacy, mental healthcare, home medicines review and facilitation of care transition through medication reconciliation and follow-up.ConclusionsAlthough there is currently a paucity of literature describing the incorporation of a CP in an MH-HiTH program, preliminary evidence shows it can improve medication management. This has potential to improve patient outcomes as has been seen in similar home-based settings, but limitations such as time constraints are notable barriers. More robust studies are needed to evaluate these outcomes.