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.     

Pharmaceutical care and its relationship to prescribing behaviour of general practitioners

Objective To study the correlation between pharmaceutical care and prescribing routines of general practitioners (GPs).Methods Cross-sectional study; 201 pharmacies, 408 general practices, The Netherlands, 2000/2001. The variation in prescribing behaviour was characterised using 20 validated prescribing indicators based on general practice guidelines. The general construct ‘adherence to guidelines’ served as the dependent variable and was formed by summing the scores of the prescribing indicators. Four possible determinants of the variation were determined on the basis of survey questions: the construct ‘the pharmacist’s attitude towards pharmaceutical care’, and three partial constructs derived from the pharmacist’s care-providing function: the care for the individual patient, the cooperation with general practitioners and the registration of the care provided. A multiple linear regression analysis was then performed.Main outcome measure The weighted score for the prescribing indicators.Results The weighted average score for the prescribing indicators was 65% (SD 3.7). The response rate to the survey was 71%. The pharmacist’s attitude to pharmaceutical care, as well as the degree to which the pharmacist provided care for the individual patient, the degree to which he cooperated with the general practitioner and the degree to which he registered the care provided were not correlated with the ‘adherence to guidelines’ by the general practitioner with whom the pharmacist frequently cooperated.Conclusion Variations between general practitioners in the quality of prescribing, as measured by their adherence to guidelines, were not correlated with pharmaceutical care by the pharmacist with whom they cooperated on a day-to-day basis.     

Use of simulated patients to assess the clinical and communication skills of community pharmacists

Objective To investigate the quality and appropriateness of Emergency Hormonal Contraception (EHC) supply from community pharmacies. Setting Community pharmacies in the southwest of England during 2007. Method Two simulated patient (‘mystery shopper’) scenarios to each participating pharmacy, one where the supply of EHC would be appropriate (scenario 1) and one where there was a drug interaction between EHC and St John’s Wort, and the supply inappropriate (scenario 2). Pharmacy consultations were rated using criteria developed from two focus groups: one with pharmacist academics and one with female university students. Feedback to pharmacists to inform their continuing professional development was provided. Main outcome measure Scores on rating scales encompassing the clinical and communication skills of the participating community pharmacists completed immediately after each mystery shopper visit. Results 40 pharmacist visits were completed: 21 for scenario 1 and 19 for scenario 2. Eighteen pharmacists were visited twice. Five pharmacists visited for scenario 2 supplied EHC against professional guidance, although other reference sources conflicted with this advice. Pharmacies which were part of the local PGD scheme scored higher overall in scenario 1 (P = 0.005) than those not part of the scheme. Overall the communication skills of pharmacists were rated highly although some pharmacists used jargon when explaining the interaction for scenario 2. Conclusion Formatively assessing communication skills in an integrative manner alongside clinical skills has been identified as an important part of the medical consultation skills training and can be incorporated into the routine assessment and feedback of pharmacy over-the-counter medicines advice.     

Exploring the domains of appropriateness of drug therapy, using the Nominal Group Technique

Objective: To explore the domains encompassed within the assessment of the appropriateness of prescribing for an individual patient.Method: The Nominal Group Technique was used to address the question "How can we assess inappropriate drug therapy of individual patients that is responsive to pharmaceutical care?" The group participants were a self-selected group of nine pharmacists and one pharmacologist attending an international working conference on the Outcomes of Pharmaceutical Care. Item generation was followed by discussion for clarification and operationalisation. Voting achieved a consensus, defined as 70%, agreement on the importance of items for inclusion in an instrument to assess appropriateness.Results: Sixty-seven items were initially generated. During discussion, similar items were combined and items were grouped into domains. Items that considered the patient's perspective were commonly suggested, but many were discarded after discussing their operationalisation. Consensus was obtained that eighteen items, in seven domains, should be included in the instrument. The domains were indication and drug choice (5 items), effectiveness (2), risks and safety (2), dosage (3), interactions (1), practical use (4), and monitoring (1).Conclusion: It is hoped that, with adequate testing, these indicators of appropriateness of prescribing can be used by pharmacists to begin to routinely assess the impact of pharmaceutical care on the quality of prescribing for patients under their care.     

Satisfaction predictors and attitudes towards electronic prescribing systems in three UK hospitals

Objective Measuring satisfaction of technology users, along with satisfaction determinants, is important to enhance system utilisation and identify potential problems. The aim of this study was to investigate pharmacists’ and doctors’ attitudes towards e-prescribing systems, and assess the predictors of their satisfaction. Method A cross-sectional survey was conducted, with 67 pharmacists and 335 doctors in three English hospitals completing a pre-piloted, postal questionnaire. Results The majority of pharmacists and doctors agreed that their e-prescribing system improved the efficiency of prescribing, and reduced dosage regimen errors. However, the majority did not believe that the system created more time for near-patient clinical activities, or sped up patient discharge. More pharmacists than doctors believed that the system improved the quality of patient care. Doctors were more likely to perceive that the e-prescribing system reduced formulation and omission errors. Doctors and pharmacists from the same hospital had similar opinions about the strengths and weaknesses of the e-prescribing system. Nine variables (out of 29 potential independent variables), seven of which were related to e-prescribing system efficiency, were significant predictors of user satisfaction. Conclusion Overall, respondents were satisfied with the systems; however, pharmacists were generally more satisfied than doctors. The number of satisfaction predictors related to the feelings about e-prescribing system efficiency was larger than those predictors related to the quality of patient care. Implications for practice These findings contribute to better understanding of how pharmacists and doctors perceive e-prescribing systems, and also have implications for system development, training, and how an e-prescribing system can be most effectively ‘marketed’ to different user groups.     

Providing feedback to hospital doctors about prescribing errors; a pilot study

Objective To assess the feasibility and acceptability of obtaining data on prescribing error rates in routine practice, and presenting feedback on such errors to medical staff. Setting One clinical directorate of a London teaching trust. Methods Ward pharmacists recorded all prescribing errors identified in newly written medication orders on one day each fortnight between February and May 2005. We examined prescribing errors reported on the trust’s medication incident database for the same period. Main outcome measures Prescribing errors identified and recorded by ward pharmacists, prescribing errors reported as incident reports; prescribing error rates per clinical specialty; lead consultants’ views on receiving feedback on errors for their specialty. Results During eight data collection days, 4,995 new medication orders were examined. Of these, 462 (9.2%; 95% confidence interval 8.5 –10.1%) contained at least one prescribing error. There were 474 errors in total. Pharmacists indicated that they would have reported 19 (4%) of the prescribing errors as medication incidents. Eight prescribing errors were reported for the entire four-month study period on non-data collection days. Feedback was presented to lead clinicians of 10 clinical specialties. This included graphical summaries showing how the specialty compared with others, and a list of errors identified. This information was well-received by clinicians. Conclusion Prescribing errors identified by ward pharmacists can be systematically fed back at the level of the clinical specialty; this is acceptable to the consultants involved. Incident report data is subject to gross under-reporting. Routinely providing feedback for each consultant team or for individual prescribers will require more focussed data collection.     

Views of pharmacists and mentors on experiential learning for pharmacist supplementary prescribing trainees

Objective To explore the views and experiences of pharmacists and their mentoring designated medical practitioners (DMPs) about the ‘period of learning in practice’ (PLP) as part of supplementary prescribing (SP) training. Method Two focus groups (n = 5 and 7) of SP pharmacists were organised in Scotland. The experiences and views of DMPs (n = 13) were explored using one-to-one telephone interviews. The focus groups and interviews were transcribed verbatim and analysed using the framework approach. Main outcome measures Views and experiences of pharmacists and DMPs about the PLP. Results Planning the PLP in consultation with the DMP was found to be crucial for an optimal learning experience. Pharmacists who did not have a close working relationship with the medical team had difficulties in identifying a DMP and organising their PLP. Participants stressed the importance of focusing on and achieving the core competencies for prescribers during the PLP. Input from doctors involved in the training of others, review of consultation videos, and formal independent assessment including clinical assessment at the end of the PLP might improve the quality of the PLP. Forums for discussing experiences during the PLP and gathering information might be valuable. Conclusion Our findings have implications for prescribing training for pharmacists in the future. The PLP should focus on core competencies with input from doctors involved in the training of others and have a formal assessment of consultation skills. Support for pharmacists in organising the PLP and forums for discussing experiences during the PLP would be valuable.     

The effect on medication errors of pharmacists charting medication in an emergency department

Objective To determine the frequency and clinical significance of medication errors when (a) pharmacists elicit medication histories in the Emergency Department after medications have been prescribed by doctors and (b) pharmacists obtain and chart medication histories prior to doctors’ approval. Setting The Queen Elizabeth Hospital, a 350 bed South Australian teaching hospital, serving the local adult community. Method Emergency Department patients at risk of medication misadventure were recruited in two phases with a ‘usual practice’ arm (6 weeks) and a ‘pharmacist medication charting’ arm (5 weeks) reflecting an alternative intervention. In the ‘usual care’ arm, medication histories were compiled by a pharmacy researcher after a doctor had completed the medication chart. The researcher-elicited medication histories were compared with the doctors’ medication charts and unintentional discrepancies were recorded. In the ‘pharmacist medication charting’ arm, the same process was followed except the researcher compiled the patients’ medication histories at triage, prior to patients seeing a doctor. The medication history was then transcribed onto a medication chart for authorisation by a doctor. In addition, whether resolution of unintentional discrepancies for patients in the ‘usual care’ arm had occurred by discharge was determined by examining patients’ medical records. Main outcome measure Frequency of unintentional discrepancies and medication errors. Results The study included 45 and 29 patients in the ‘usual care’ and intervention arms, respectively. In the ‘usual care’ arm, 75.6% of patients had one or more unintentional discrepancies compared with 3.3% in the ‘pharmacist medication charting’ arm. This resulted in an average of 2.35 missed doses per patient in the ‘usual care’ arm and 0.24 in the intervention arm. In addition, an average of 1.04 incorrect doses per patient were administered in the ‘usual care’ arm and none in the ‘pharmacist medication charting’ arm. The differences observed between the arms were statistically significant (P < 0.05) and deemed clinically significant by a multidisciplinary panel. Conclusion This study provides evidence for pharmacists eliciting medication histories to prepare medication charts at the earliest possible opportunity following a patient’s presentation to the Emergency Department     

Five-year follow-up of drug utilization for secondary prevention in coronary artery disease

Objective Despite the availability of various prevention guidelines on coronary artery disease, secondary prevention practice utilizing aspirin, beta-blockers, angiotensin converting enzyme inhibitors and statins still can be sub-optimal. In this study, we aimed to assess the guideline adherence of secondary prevention prescribing and the continuity of adherence for a 5-year period in a small cohort of patients angiographically diagnosed to have coronary artery disease. Method In this prospective study, 73 patients who were angiographically diagnosed to have CAD were followed up for 5 years. The baseline demographic and clinical data were collected just before angiography. The baseline drug data were collected at the day of discharge. The fifth year data were taken from the patients via face-to-face consultations or phone interviews. Results The ‘initial prescribing rate’ at discharge was found to be 82% for aspirin, 49% for statins, 44% for ACE inhibitors and 55% for beta-blockers. ‘Continuity of prescribing’ for 5 years was 45% for aspirin, 26% for statins, 17% for ACE inhibitors and 20% for beta-blockers. Conclusions Besides the sub-optimal prescribing of secondary prevention drugs, absence of continuity of prescribing seems to be a challenging issue in pharmaceutical care of coronary artery disease patients.     

Using discrete choice experiments to evaluate alternative electronic prescribing systems

Objective — To assess the relative importance to pharmacists and general practitioners (GPs) of different characteristics of electronic prescribing systems. Methods — A discrete choice experiment (DCE) was used to obtain preferences for the following attributes of an electronic prescribing scheme: “typical response time”, “frequency of slow responses”, “frequency of unscheduled downtime”, “length of unscheduled downtime”, “frequency of scheduled downtime”, and “frequency of lost/corrupted data”. Preferences of GPs and pharmacists were compared using the Likelihood ratio test and the Wald statistic. The rate at which respondents were willing to trade between attributes and benefit scores for different systems were estimated. Rationality of responses and theoretical validity of responses to the DCE were also assessed. Subjects and setting — 199 pharmacists and 197 GPs in Scotland. Key findings — The usable response rate for the DCE was 42.4 per cent. Preferences of pharmacists and GPs were significantly different. Given the units of measurement, the most important attribute for pharmacists was “length of unscheduled downtime” whereas for GPs it was “typical response time”. Evidence was found of rationality of responses and theoretical validity. Conclusions — All technical attributes of an electronic prescribing system assessed in this study were considered by the respondents to be important. Discrete choice experiments provide useful information on the relative importance and trade‐offs between attributes as well as benefit scores for different systems. The preferences of pharmacists and GPs are significantly different. Future research should investigate the nature of the benefit function, the assumption of trading across attributes and the external validity of the technique.     

The effect of pharmacist education on asthma treatment plans for simulated patients

Objective To determine if an educational program designed for community pharmacists to help patients self manage their asthma could improve pharmacists abilities to facilitate asthma treatment plans. Setting Hamilton and Toronto, Ontario, Canada. Method A randomized controlled trial involving volunteer community pharmacists who received either an asthma education program (AEP; intervention group) or a delayed AEP (control group). The AEP consisted of a one-day workshop and two follow-up telephone calls. Teaching methods progressed from a didactic approach to self-directed learning and role playing with simulated patients (SPs). The primary outcome was measured by SPs who conducted unannounced pharmacy visits. Main Outcomes Measures The number of appropriate (defined a priori) action plans facilitated by the pharmacist was the primary outcome. Facilitated was defined as the pharmacist recommending a specific plan, taking responsibility for telephoning the physician, or ensuring the patient would take responsibility for contacting the physician. Results Thirty-three pharmacists were randomized to the intervention group and 31 pharmacists were randomized to the control group. Pharmacists in the intervention group facilitated an appropriate plan in 44.8% of situations (117 out of a possible 261) compared with 29.3% (79 out of a possible 270) in the control group, (mean difference 15.5% (95% CI: 7.4–23.8%; P = 0.0004)). Intervention group pharmacists were better able to facilitate plans for the ‘under use of inhaled corticosteroids,’ ‘exposure to pet dander as an asthma trigger,’ and ‘overuse of short-acting beta-agonist’ problems. Intervention group pharmacists exhibited better overall communication skills (including empathy, coherence, verbal skills, and nonverbal skills). Conclusion This AEP produced improvements in pharmacists’ abilities to facilitate plans for SPs in a community pharmacy setting.     

Exploring patients’ perspectives of pharmacist supplementary prescribing in Scotland

Aim The aim of this study was to explore patients’ perspectives and experiences of pharmacist supplementary prescribing (SP) in Scotland. Method A survey in primary and secondary care in Scotland. Pharmacist supplementary prescribers (n = 10) were purposively selected across Scotland. All pharmacists distributed questionnaires to 20 consecutive patients as they attended appointments during October to December 2006. Reminders were mailed to all 20 patients by each pharmacist 2 weeks after initial distribution. Main outcome measures The questionnaire contained items on: attitudes towards pharmacist SP derived from earlier qualitative research; consultation satisfaction derived from a validated scale developed initially for general practitioners, with the term ‘doctor’ being replaced by ‘pharmacist prescriber’; and demographics. Closed and Likert scales were used as response options. Results One pharmacist withdrew. The patient response rate was 57.2% (103/180). The median age was 67 years (interquartile range 56.5–73 years), with 53.4% being female. Most (76, 73.8%) consulted with the pharmacist in a general practice setting. Patients reported positive consultation experiences with 89.3% agreeing/strongly agreeing that they were satisfied with the consultation, 78.7% thought the pharmacist told them everything about their treatment and 72.9% felt the pharmacist was interested in them as a person. Most patients were positive in their attitudes, agreeing that they would recommend a pharmacist prescriber to others and that they had trust in the pharmacist. However, 65% would prefer to consult a doctor. Conclusion Most patient respondents were satisfied with, and had a positive attitude towards, pharmacist prescribing consultations. However, most patients would still elect to see a doctor given the choice.     

Scottish pharmacists’ views and attitudes towards continuing professional development

Objectives To summarise Scottish pharmacists’ views and attitudes towards Continuing Professional Development (CPD). Setting Random sample of RPSGB registered Scottish pharmacists. Method A postal questionnaire of pharmacists’ CPD activity, views and attitudes was developed, piloted and sent to 2420 pharmacists. Questions were collated to produce total scores and to rate pharmacists’ motivation and attitudes to CPD separately. The number of CPD hours reported by sector and gender were compared (‘t’ test) and differences identified between hospital, community and primary care in relation to mean motivational attitudinal scores (Mann-Whitney test). Results Five hundred and forty three pharmacists completed the questionnaire (22.4% response rate). In this study 9.8% of the pharmacists reported spending no time on CPD. Comparisons of hours showed primary care pharmacists and hospital pharmacists reported similar times spent on CPD and significantly more time than community pharmacists (68 h and 66 h vs 45 h; P < 0.05). No statistically significant differences between genders were revealed. Internal reliability on motivation and attitude scores ranged from 0.74–0.83 (Cronbach’s alpha). Although scores were similar across sectors of practice in terms of motivation and attitudinal questions, statistical differences were consistent; showing higher scores for separate motivation and attitude among pharmacists in primary care than in hospital or community practice sectors (Mann Whitney test; P < 0.001). Community pharmacists had a statistically significantly lower attitude score than pharmacists in hospital or primary care sectors (Mann Whitney test; P < 0.001). Conclusion There is a section of pharmacists still not participating in CPD. Primary care pharmacists reported most motivation and scored highest in attitude score. Community pharmacists appear to be the sector requiring most support to increase not only their motivation to CPD but also their confidence and ability in participation.     

Development of the Joint Commission's indicators for monitoring the medication use system

The Joint Commission on Accreditation of Healthcare Organizations, as part of the Agenda for Change, has directed extensive efforts toward the development and testing of patient care indicators. The medication use indicators are designed to target processes and outcomes of the drug use system as defined by five major components: 1) selection and prescribing, 2) preparation and dispensing, 3) administration, 4) monitoring and 5) systems management/control. The indicators focus on several aspects of the drug use process including: serum drug level monitoring, medication errors, adverse drug reactions, patient teaching, pharmacist interventions and the appropriateness of prescribing. The testing of indicators is currently underway at test-site hospitals and includes 2 major phases: Alpha and Beta. Alpha-testing is designed to assess the face validity and collectability of the indicators, while Beta-testing will evaluate data collection and analysis as well as the reliability of the indicators. These indicators are intended to serve as measures of aspects of patient care that can be used to guide and monitor the quality and appropriateness of health care delivery and to facilitate continuous improvement in care.     

Methods of utilizing baseline values for indirect response models

This study derives and assesses modified equations for Indirect Response Models (IDR) for normalizing data for baseline values (R ₀) and evaluates different methods of utilizing baseline information. Pharmacodynamic response equations for the four basic IDR models were adjusted to reflect a ratio to, a change from (e.g., subtraction), or percent change relative to baseline. The original and modified IDR equations were fitted individually to simulated data sets and compared for recovery of true parameter values. Handling of baseline values was investigated using: estimation (E), fixing at the starting value (F1), and fixing at an average of starting and returning values of response profiles (F2). The performance of each method was evaluated using simulated data with variability under various scenarios of different doses, numbers of data points, type of IDR model, and degree of residual errors. The median error and inter-quartile range relative to true values were used as indicators of bias and precision for each method. Applying IDR models to normalized data required modifications in writing differential equations and initial conditions. Use of an observed/baseline ratio led to parameter estimates of k _in = k _out and inability to detect differences in k _in values for groups with different R ₀, whereas the modified equations recovered the true values. An increase in variability increased the %Bias and %Imprecision for each R ₀ fitting method and was more pronounced for ‘F1’. The overall performance of ‘F2’ was as good as that of ‘E’ and better than ‘F1’. The %Bias in estimation of parameters SC₅₀ (IC₅₀) and k _out followed the same trend, whereas use of ‘F1’ or ‘F2’ resulted in the least bias for S _max (I _max). The IDR equations need modifications to directly assess baseline-normalized data. In general, Method ‘E’ resulted in lesser bias and better precision compared to ‘F1’. With rich datasets including sufficient information on the return to baseline, Method ‘F2’ is reasonable. Method ‘E’ offers no significant advantage over ‘F1’ with datasets lacking information on the return to baseline phase. Handling baseline responses properly is an essential aspect of applying pharmacodynamic models.     

Content validity of indicators of the appropriateness of long‐term prescribing started during a hospital admission

Fifty‐seven hospital pharmacists and 31 GP practice‐based pharmacists responded to a questionnaire (response rate 43 per cent) to assess 14 indicators The three most important indicators overall were “indication in discharge summary”, “questionable high‐risk therapeutic combination” and “hazardous drug‐drug combination” The three least important indicators were “less suitable for prescribing according to BNF”, “indication upheld in BNF” and “drug in hospital formulary” Assessment of content validity requires a panel of experts rather than a representative sample     

Validating the Children’s Medicines Use Questionnaire (CMUQ) in Australia

Objective: To pilot test the validity and reliability of the English version of the Children’s Medicines Questionnaire (CMUQ) and to explore the attitudes of Australian caregivers towards the use of medicines in children. Setting: Survey of Australian parents and primary care givers of children 0–15 years. Methods: The questionnaire was translated from Finnish to English then back-translated to ensure semantic equivalence. A total of 153 parents/main caregiver of a child aged 0–15 years were recruited via convenience sampling. Construct validity of the attitudinal section of the CMUQ was performed using exploratory factor analysis. Reliability was assessed using the Cronbach’s alpha coefficient as a marker of internal consistency. Three focus groups were conducted to explore participants’ attitudes towards medicating children and to triangulate quantitative data. Main outcome measure: Construct validity and internal reliability of the CMUQ. Results: Factor analysis generated a parsimonious four factor solution explaining 50% of variance in the data. The four subscales representing the four factor solution each returned a Cronbach’s Alpha coefficient >0.6, indicating good internal consistency. Participants in focus groups were satisfied with the structure and content of the questionnaire. There were 5 emergent themes through focus group discussions with parents and primary care givers of children, regarding the perception of medicines use in children. These included, ‘concerns about the negative effects of medicines’, ‘medicines are useful, necessary and safe in treating illnesses in children’, ‘the body’s natural processes are sufficient in fighting illness’, ‘over the counter medicines are effective and useful in treating illness’, ‘perception of alternative medicines use in children’. Conclusions: The CMUQ is a valid and reliable tool to measure parents’ medicine use for their children in an Australian sample. Although small modifications should be made, this instrument will be valuable in informing the development of medicines information for this cohort in the future.