Uptake and effectiveness of a community pharmacy intervention programme to improve asthma management

What is known and Objective: Pharmacists frequently see patients with asthma in the community who have suboptimal management. This study aimed to compare the uptake and effectiveness of pharmacist‐initiated mailed and face‐to‐face interventions for patients whose asthma may not be well managed. Methods: Seventy‐one community pharmacies in South Australia, Tasmania and Victoria (Australia) installed a software application that data‐mined dispensing records, generating a list of patients who had received six or more asthma reliever inhalers in the preceding 12 months. The pharmacists were randomized, by pharmacy, to perform either a mailed or face‐to‐face intervention, whereby these patients received educational material and a referral to their general practitioner (GP) for an asthma management review. Matching patients from each pharmacy were also randomly assigned to a control group for ‘usual care’. Results and Discussion: A total of 1483 patients were identified and grouped as follows: 510 (34·4%) mailed intervention, 480 (32·4%) face‐to‐face intervention and 493 (33·2%) controls. Significantly fewer face‐to‐face interventions were offered than mailed interventions (66·6% vs. 89·4%, respectively; χ² = 64·2, P < 0·0001). There were significant improvements in the preventer‐to‐reliever ratio after the intervention period (P < 0·0001) in each group. In a per‐protocol analysis, the magnitude of improvement in the face‐to‐face intervention group was greater than in the mailed intervention group. The reverse was true in an intention‐to‐treat analysis. The improvement in the P : R ratios was mainly due to significant decreases in reliever usage. What is new and Conclusion: Community pharmacy dispensing records can effectively identify patients with suboptimal asthma management, who can then be referred to their GP for review. Time constraints in busy pharmacies may limit the uptake and effectiveness of face‐to‐face interventions in the ‘real world’ setting, making mailed interventions an attractive option.     

The sustainability of a community pharmacy intervention to improve the quality use of asthma medication

What is known and Objective: A previously published asthma intervention used a software application to data mine pharmacy dispensing records and generate a list of patients with potentially suboptimal management of their asthma; in particular, a high rate of provision of reliever medication. These patients were sent educational material from their community pharmacists and advised to seek a review of their asthma management from their general practitioner. The intervention resulted in a 3‐fold improvement in the ratio of dispensed preventer medication (inhaled corticosteroids) to reliever medication (short‐acting beta‐2 agonists). This follow‐up study aimed to determine the long‐term effects of the intervention programme on the preventer‐to‐reliever (P:R) ratio. Methods: The same data mining software was modified so that it could re‐identify patients who were originally targeted for the intervention. Community pharmacists who participated in the previous intervention installed the modified version of the software. The dispensing data were then de‐identified, encrypted and transferred via the Internet to a secure server. The follow‐up dispensing data for all patients were compared with their pre‐ and post‐intervention data collected originally. Results and Discussion: Of the 1551 patients who were included in the original study, 718 (46·3%) were eligible to be included in the follow‐up study. The improved P:R ratio was sustained for at least 12 months following the intervention (P < 0·01). The sustained increase in the P:R ratio was attributed to significant decreases in the average daily usage of reliever medication (P < 0·0001). What is new and Conclusion: The follow‐up study demonstrated a sustained improvement in the ratio of dispensed preventer medication to reliever medication for asthma. The intervention has the potential to show long‐lasting and widespread improvements in asthma management, improved health outcomes for patients, and ultimately, a reduced burden on the health system.     

The challenge of integrating community pharmacists into the primary health care team: a case study of local pharmaceutical services (LPS) pilots and interprofessional collaboration

The aim of this paper is to investigate interprofessional collaboration between general practitioners (GPs) and pharmacists involved in the delivery of enhanced pharmacy services under the local pharmaceutical services (LPS) contract in England. Previous research suggests that a number of interprofessional barriers exist between community pharmacists and GPs which hinders the integration of community pharmacists into the primary health care team (PHCT). One of the aims of the LPS contract, introduced in England in 2002 as an alternative to national contractual arrangements, was to enable pharmacists to work more closely with other health care professionals. A two-stage survey was distributed to all pharmacists involved in the first wave of LPS and in-depth interviews undertaken with pharmacists and GPs at six of the LPS sites. Overall the level to which the LPS pharmacists felt integrated into the PHCT did not substantially increase with the introduction of LPS, although co-location was reported to have facilitated integration. New relationships were formed with GPs and existing ones strengthened. A good existing working relationship with GPs was found to be an important factor in the successful operation of the pilots as many were dependent on GPs for patient referrals. The findings suggest that establishing interprofessional collaboration between GPs and pharmacists is a piecemeal process, with a reliance on goodwill and trust-based relationships.     

Pharmacist‐led intervention study to improve inhalation technique in asthma and COPD patients

Rational and aims Inhaled therapy is the mainstay of treatment in patients with asthma and chronic obstructive pulmonary disease (COPD). For effectiveness of pharmacotherapy, correct use of medication is required. The aims of this study were to survey the quality of inhalation technique in patients and to determine the effect of a single intervention in community pharmacies by means of standardized procedures. Methods A total of 757 patients with asthma or COPD were randomly selected by 55 community pharmacies. At baseline, patients were interviewed and their inhalation technique was assessed with a 21‐items checklist. Any error was recorded and, if necessary, patients were instructed in the proper use of their device. After 4–6 weeks, demonstration of inhalation technique was repeated in the community pharmacies and a pre–post comparison was performed. Results A total of 597 patients (78.9%) made at least one mistake in performing the inhalation technique at baseline. This number dropped to 214 (28.3%) from the first to the second appointment. All patients did benefit from the pharmacists' intervention regardless of their former training experiences. Conclusions Inhalation technique of asthma and COPD patients is poor. In daily practice, community pharmacy‐based pharmacists are well suited to significantly supplement doctor‐based education in inhalation technique.     

Considerations of prescribers and pharmacists for the use of non‐selective β‐blockers in asthma and COPD patients: An explorative study

Rationale, aims, and objectives

Despite recommendations in prevailing guidelines to avoid the use of non‐selective (NS) β‐blockers in patients with asthma or COPD, on average, 10 patients per community pharmacy receive NS β‐blockers monthly. The aim of our study was to identify the reasons of prescribers and pharmacists to treat asthma and COPD patients with NS β‐blockers.

Methods

Fifty‐three community pharmacists in the Netherlands selected patients with actual concurrent use of inhalation medication and NS β‐blockers. For at least 5 patients, each pharmacist screened all medication surveillance signals and actions taken at first dispensing. Each pharmacist selected 3 different initial prescribers for a short interview to explore their awareness of the co‐morbidity and reasons to apply NS β‐blockers.

Results

Pharmacists identified 827 asthma/COPD patients with actual use of NS β‐blockers. From these, 153 NS β‐blocker prescribers were selected and interviewed (64 general practitioners, 45 ophthalmologists, 24 cardiologists, and 20 other prescribers). One hundred seven prescribers were aware of the drug‐disease interaction of the asthma or COPD co‐morbidity when initiating the NS β‐blocker, and 46 were not. From these, 40 prescribers did not consider the contraindication to be relevant. For 299 patients, medication surveillance signals and actions at first dispensing were retrieved. Patients used predominantly ocular timolol (39.8%), and the oral preparations propranolol (30.8%) and carvedilol (15.1%). In 154 cases, the pharmacy system generated a warning alert.

Conclusions

A substantial number of prescribers was unaware of the co‐morbidity or did not regard NS β‐blockers contraindicated, despite prevailing clinical guidelines. Improvement programs should target prescribers' awareness and knowledge of NS β‐blockers in patients with asthma or COPD.     

Comparative evaluation of patient information leaflets by pharmacists,doctors and the general public

This study was undertaken to compare and contrast the views of pharmacists, general practitioners (GPs) and the general public on the value or otherwise of pharmacy-generated patient information leaflets. All three groups perceived these leaflets to be useful and an aid to improving compliance. Concerning the information included in leaflets, GPs rated the inclusion of a section on side-effects as being the least important, whilst pharmacists and the general public rated information on the storage of medicines as being least important. Pharmacists' estimates on what percentage of patients actually read leaflets were significantly lower than estimates by the general public. General practitioners and pharmacists generally concurred on the types of patients for whom leaflets are considered unsuitable, although a significantly higher percentage of pharmacists than GPs identified unsuitable patients. There were reservations by the pharmacists concerning the cost-effectiveness of leaflet facilities and on the value of leaflets compared with verbal counselling. The general public expressed the view that a leaflet facility would affect their choice of pharmacy and that they would be prepared to wait an additional short time to receive such a leaflet. Almost all GPs thought that it was in the patient's best interest to receive an information leaflet.     

Consumer satisfaction among patients and their general practitioners about involving nurse specialists in primary care for patients with urinary incontinence

Scand J Caring Sci; 2013; 27; 253–259 Consumer satisfaction among patients and their general practitioners about involving nurse specialists in primary care for patients with urinary incontinence Background: Urinary incontinence (UI) is a very common problem, but existing guidelines on UI are not followed. To bring care in line with guidelines, we planned an intervention to involve nurse specialists on UI in primary care and assessed this in a randomised controlled trial. Alongside this intervention, we assessed consumer satisfaction among patients and general practitioners (GPs). Methods: Patients’ satisfaction with the care provided by either nurse specialists (intervention group) or GPs (control group), respectively, was measured with a self‐completed questionnaire. GPs’ views on the involvement of nurse specialists were measured in a structured telephone interview. Results: The patient satisfaction score on the care offered by nurse specialists was 8.4 (scale 1–10), vs. 6.7 for care‐as‐usual by GPs. Over 85% of patients would recommend nurse specialist care to their best friends and 77% of the GPs considered the role of the nurse specialist to be beneficial, giving it a mean score of 7.2. Conclusions: Although the sample was relatively small and the stability of the results only provisionally established, substituting UI care from GP to nurse specialist appears to be welcomed by both patients and GPs. Small changes like giving additional UI‐specific information and devoting more attention to UI (which had been given little attention before) would provide a simple instrument to stimulate patients to change their behaviour in the right direction.     

Evaluation of the effectiveness of UK community pharmacists' interventions in community palliative care

INTRODUCTION: In 1997, the Royal Pharmaceutical Society of Great Britain Working Party reported that UK community pharmacists had a crucial role in effective medicines management and effective symptom control for those receiving palliative care in the community. However, prior to the integration of community pharmacists into the community palliative team, it is necessary to evaluate the effectiveness of their pharmaceutical interventions. AIM: To assess the effectiveness of community pharmacists' clinical interventions in supporting palliative care patients in primary care using an independent multidisciplinary panel review. METHODS: Patients with a life expectancy of less than 12 months were each registered with a single pharmacy and their consent was obtained for the community pharmacists to access their general practitioner (GP) case records. The community pharmacists received training in palliative pharmaceutical care and documenting interventions. The trained community pharmacists provided palliative pharmaceutical care to the recruited patients. At the end of a 10-month period, the clinical interventions were reviewed by an independent multidisciplinary expert panel consisting of a palliative care consultant, a Macmillan nurse (community palliative care nurse) and a hospital pharmacist with special interest in palliative care. RESULTS: Fourteen community palliative care teams (including community pharmacists, GPs and community nurses) took part in the study and 25 patients were recruited over the 10-month recording period. All but one patient had a diagnosis of cancer; the other patient had chronic obstructive pulmonary disease. By the end of the project, 14 patients had died. Community pharmacists recorded a total of 130 clinical interventions. Thirty interventions were excluded as insufficient information had been documented to allow review by the panel. Eighty-one per cent of the interventions were judged by the expert panel likely to be beneficial. However, 3% were judged likely to be detrimental to the patients' well-being. CONCLUSIONS: Most of the clinical interventions made by the community pharmacists for palliative pharmaceutical care were judged by the expert panel as being likely to be beneficial. The result supports the view that when community pharmacists are appropriately trained and included as integrated members of the team, they can intervene effectively to improve pharmaceutical care for palliative care patients.     

Improving the outcomes of anticoagulation in rural Australia: an evaluation of pharmacist-assisted monitoring of warfarin therapy

OBJECTIVE: The aim of this project was to assess whether rural pharmacist involvement in the management of patients receiving warfarin has the potential to lead to safer and more effective anticoagulation, and is valued and welcomed by patients and their general practitioners (GPs). METHODS: A convenience sample of rural pharmacists was trained in the use of the CoaguChek S International Normalized Ratio (INR) monitor and then conducted pharmacy-based testing for approximately 3 months. Two types of testing were performed in the pharmacy: (i) comparison testing was defined as pharmacy-based tests taken within 4 h of conventional laboratory testing or (ii) additional testing, which was a pharmacy-based test with no direct comparison laboratory test taken. Pharmacists, GPs and patients completed anonymous satisfaction surveys after the completion of the pharmacy-based testing. RESULTS: Pharmacists from 16 rural pharmacies were trained to use the CoaguChek S monitor. During the trial period, 518 INR tests were performed in the pharmacies on 137 different patients. A total of 120 tests were evaluated against results from laboratory testing. The pharmacy-based INR values were significantly correlated with the laboratory INR values (mean of 2.32+/-0.77 and 2.32+/-0.59 respectively; r=0.88, P<0.0001). A total of 398 additional pharmacy-based tests were conducted in the pharmacy and 8.5% of the additional tests resulted in a subsequent dosage change. The monitoring was well received by pharmacists, GPs and patients. CONCLUSIONS: The results of the trial were very positive. The CoaguChek S monitor in pharmacy-based testing performed accurately compared with conventional laboratory testing. Further research needs to be conducted on the impact of community pharmacy-conducted INR monitoring on patient care and outcomes.     

General practitioner–pharmacist interactions in professional pharmacy services

Australian community pharmacies offer a range of professional pharmacy services (PPS) which include Home Medicines Review (HMR) and the Diabetes Medication Assistance Service (DMAS). The extent of interaction and collaboration between general practitioners (GPs) and pharmacists in the context of these services is unknown. Therefore, the aim of this study was to investigate (1) the nature and extent of interactions between GPs and community pharmacists and; (2) the factors that influence these interactions in the context of PPS. Individual semi-structured face-to-face and telephone interviews were conducted with a purposive sample of 15 GPs and 15 pharmacists in rural and metropolitan areas of New South Wales, Australia. The results indicated that involvement in PPS resulted in a perceived increase in the level of interactions between the pharmacist and GP. Factors found which may influence collaborative behaviour in PPS include interactional, practitioner and environmental determinants. These factors are in line with what has previously been reported however, facilitators of collaboration in the primary care, PPS context included additional environmental factors such as the presence of rules and protocols, interprofessional continuing education and the availability of adequate remuneration. Attention to these environmental factors as well as the more established interactional and practitioner determinants will improve collaboration in PPS.     

General practitioner-pharmacist interactions in professional pharmacy services

Australian community pharmacies offer a range of professional pharmacy services (PPS) which include Home Medicines Review (HMR) and the Diabetes Medication Assistance Service (DMAS). The extent of interaction and collaboration between general practitioners (GPs) and pharmacists in the context of these services is unknown. Therefore, the aim of this study was to investigate (1) the nature and extent of interactions between GPs and community pharmacists and; (2) the factors that influence these interactions in the context of PPS. Individual semi-structured face-to-face and telephone interviews were conducted with a purposive sample of 15 GPs and 15 pharmacists in rural and metropolitan areas of New South Wales, Australia. The results indicated that involvement in PPS resulted in a perceived increase in the level of interactions between the pharmacist and GP. Factors found which may influence collaborative behaviour in PPS include interactional, practitioner and environmental determinants. These factors are in line with what has previously been reported however, facilitators of collaboration in the primary care, PPS context included additional environmental factors such as the presence of rules and protocols, interprofessional continuing education and the availability of adequate remuneration. Attention to these environmental factors as well as the more established interactional and practitioner determinants will improve collaboration in PPS.     

Attitudes of Australian pharmacists towards practice-based research

Background and objective: The aim was to conduct a national cross‐sectional survey of randomly selected Australian pharmacists to determine their attitudes towards and involvement in pharmacy practice research. This included the canvassing of perceived barriers and potential solutions to promote research activity in pharmacy practice. Methods: A questionnaire was developed around those used in UK and Australasian studies of general practitioners’ attitudes towards research. Questions assessed attitudes to research, involvement in research, barriers and facilitators to involvement, self‐assessed understanding of research terminology, and access to and use of electronic bibliographic databases. One thousand pharmacists were randomly and proportionately selected from the State and Territory Pharmacy Board registers to receive the anonymous questionnaire by mail. Non‐respondents were sent a follow‐up reminder and second copy of the questionnaire after 3 weeks. Results: A response rate of 37% was achieved. Approximately, one‐third of responding pharmacists were presently, or had been, involved in research activities, and generally reported positive experiences. Lack of time and never being approached or not being aware of the opportunities were major barriers to pharmacist participation in research. Approximately, one‐third of the pharmacists were not interested in participating in research. There was low usage of publicly available electronic bibliographic databases and of scientific journals. Although there was overwhelming recognition of the value of research to the profession, few pharmacists possessed a good understanding of key terms related to research and evidence‐based practice (e.g. P‐value or number needed to treat). Conclusion: There was overwhelming recognition of the value of research to the pharmacy profession. Important factors encouraging individual pharmacists to participate in research were a desire to improve the profession, the opportunity to learn more about disease management and to provide enhanced services to patients, and personal interest.     

Community health practitioner’s practice guideline for a changing health care: Korean contribution

Aims and objectives. The specific aims of the study were (1) to identify community residents’ health problems and community health practitioners’ activities, (2) to explore community health practitioners’ perception of the practice guidelines and (3) to provide recommendations for the development of a new practice guideline in the future. Background. Community health practitioners in Korea are recognised as a critical component of the public health workforce in rural areas. Community health practitioners are registered nurses with six months special training, who have the chief responsibility of delivering primary health care to remote or isolated communities. Although there has been numerous changes in focus of community health practitioners practice over the two decades, community health practitioners guidelines have never been updated since being first developed in 1981. Design. This investigation employed a cross‐sectional survey and focus group interview. Methods. The samples included two different groups: 1003 community health practitioners participated in a survey and a group of 12 community health practitioners participated in a focus group interview. A measure of perception of the guideline was developed from Mansfield’s work. Goolsby’s criteria were revised and used to guide the focus group interview. Results. The participants recognised that the role of community health practitioners is in a process of transition and expect to use well developed guidelines that will allow an appropriate response to the needs of the community. Community health practitioners are generally supportive of practice guidelines although they report various contextual, social and resource barriers to the use of practice guidelines. Finally, the researchers have provided recommendations for the development of new community health practitioners practice guidelines. Conclusion. A newly developed community health practitioners guideline should assist in articulating new roles and responsibilities in the practice of community health practitioners and establish a foundation for knowledge, skills and training necessary for them to work independently. Relevance to clinical practice. New services made available for under‐recognised health problems may be a direct outcome of newly developed guidelines.