Pharmacists' perceptions of mental health care, psychiatrists, and mentally ill patients

The attitudes of hospital pharmacists in Texas toward mental health care, psychiatrists, and mentally ill patients were evaluated. The pretested survey instrument contained 33 statements, which the respondents graded on a five-step Likert scale. These questionnaires were mailed to a random sample of 300 pharmacists. In general, the 170 respondents perceived psychiatrists and mentally ill patients in a positive manner. The psychiatrist was viewed as a true professional with legitimate expertise, and mentally ill patients were considered to be basically similar to normal individuals, generally rational, nondangerous, and without blame for their disease. The pharmacists showed more negative attitudes toward hospitals for mentally ill patients. They supported statements that depicted mental hospitals as understaffed, too drug oriented, and at times insensitive to individual needs. The surveyed hospital pharmacists generally demonstrated healthy, unprejudiced views toward psychiatrists and mentally ill patients; however, their attitudes toward mental hospitals were skewed in the negative direction.     

Clinical significance of clinical interventions in community pharmacy: a randomised trial of the effect of education and a professional allowance

Objectives To assess the clinical significance of clinical interventions undertaken by community pharmacists, and to explore the effect of providing education and/or remuneration on the clinical significance of interventions. Design Randomised trial involving four groups of community pharmacists; expert panel to assess the clinical significance of the interventions. Methods The “proactive” clinical interventions undertaken by community pharmacists during the trial were reviewed by an expert panel for assessment of avoided adverse health consequences and clinical significance. The panel used a validated assessment instrument developed from the existing research literature and a pilot study by the authors. Data analysis Agreement between experts was determined using the kappa statistic. In addition, the results of the expert panel were analysed for cases where the majority of experts provided the same assessment of clinical significance (ie, consensus). Results Overall, there was no statistically significant difference in the clinical significance of clinical interventions undertaken by the four study groups. However, there were significant differences (95% CI) in the types of proactive interventions undertaken, with the two groups that received an educational intervention being more likely to engage in more complex intervention areas, such as drug/drug interactions and adverse/side effects. Analysis of consensus revealed that 52% of proactive clinical interventions were deemed to be “clinically significant” and 2% were deemed to be either “clinically very significant” or “potentially life‐saving”. When extrapolated to national Australian prescribing figures, a mean of 3,752 potentially life‐saving interventions by community pharmacists could be expected per year (95% CI 454 to 13,554). Conclusion The results of this study provide the first estimates of the potential clinical benefits associated with clinical interventions in Australian community pharmacies. The study contributes evidence on the value of pharmaceutical services to the health care system. As such, it is expected that the study findings will provide a platform for discussion and decision‐making.     

Perceived factors influencing the development of primary care‐based pharmaceutical care in Scotland

Objective — To obtain the views of key pharmacists in Scotland (potential policy‐makers and innovative practising pharmacists) on a systematic approach to pharmaceutical care and on the factors important in its development. Method — Semi‐structured interviews, based on factors identified from the literature as resources required for, or barriers to, pharmaceutical care development. Key findings — All 16 interviewees agreed with the systematic approach and identified community pharmacies as the key locus for the delivery of pharmaceutical care in primary care. Many expressed similar views in relation to remuneration, the need for training, physical resources, relationships with general practitioners to facilitate access to clinical information from medical records, repeat dispensing systems and improvements to existing computer systems to support the necessary documentation. Divergent opinions were expressed on the need for registration of patients with community pharmacies, on the use of dispensing technicians and on what specific literature and information from medical records would be required to support pharmaceutical care. While all agreed that there was insufficient evidence available of the benefits of pharmaceutical care, many felt that its development should nonetheless be progressed. Conclusion — Many of the views expressed are similar to those identified among community pharmacists in similar studies. Planning of future services needs to involve community pharmacists if indeed they are key to pharmaceutical care provision.     

Drug‐related problems in elderly general practice patients receiving pharmaceutical care

Objective To describe the types of drug‐related problems identified by pharmacists providing pharmaceutical care to elderly patients in the primary care or general medicine setting, and the impact of their recommendations on drug‐related outcomes. Methods Searches of the MEDLINE, EMBASE, CINAHL, HealthSTAR, and International Pharmaceutical Abstracts electronic databases from 1990 to 2002 were conducted and a manual search of references from retrieved articles and references on file was performed. Large (n> 100) randomised, controlled studies comparing the provision of pharmaceutical care to usual care in seniors in primary care or general medicine settings were included. Two reviewers evaluated articles based on inclusion criteria and extracted data from the intervention arm of each study, resolving discrepancies by consensus. Nine original articles were included for analysis. Key findings The mean number of drug‐related problems (DRPs) identified per patient was 3.2 and the mean number of recommendations made per patient was 3.3. The most common DRP identified was not taking/receiving a prescribed drug appropriately (35.2%, range 4.7–49.3%). The most common recommendations made involved patient education (37.2%, range 4.6–48.2%). Implementation rates were generally high for all types of recommendations, with the highest being for provision of patient education (81.6%). The small number of studies available examining measures of drug utilisation and costs, health services utilisation, and patient outcomes produced inconsistent results, making it difficult to draw conclusions. Conclusions Substantial numbers and a wide range of DRPs were identified by pharmacists who provided pharmaceutical care to seniors in the primary care and general medicine setting. Pharmacists' drug‐therapy recommendations were well accepted; however, further study is needed to determine the impact of these recommendations on health‐related outcomes.     

Impact of medication regimen reviews performed by community pharmacists for ambulatory patients through liaison with general medical practitioners

Objective — To evaluate the cost and clinical benefits of the provision of medication regimen reviews (MRRs) by community pharmacists for patients identified and referred by a general practitioner using a collaborative approach. Method — There were two cohorts of patients — 105 in stage 1 and 170 in stage 2 — from 34 GPs. The reviews were performed by 45 community pharmacists who had completed a training programme in MRR. The protocol was as follows: (1) a proforma MRR request form, including relevant clinical information and the patient's current regimen, was completed by the GP, (2) the review was conducted by the pharmacist and documented in a proforma report, (3) pharmacists and GPs met to discuss the review findings and recommendations for each patient, and (4) three months later, GPs were surveyed to verify any accepted recommendations and changes to medication regimen. A clinical panel estimated the clinical significance of the regimen changes for a subset of 141 cases. Key findings — The patients had an average of five diagnoses, with cardiovascular disease (34 per cent) and musculoskeletal disease (15 per cent) the most common conditions. A total of 2,220 medications were prescribed, representing a mean of eight per patient. In all, 869 changes to therapy were observed at the three‐month follow up: 47 per cent drug ceased; 17 per cent dose reduced; 11 per cent dose increased; and 12 per cent drug changed. Examining the impact of MRR on the mean number of medications per patient, the null hypothesis of no difference pre‐ and post‐MRR was rejected. There was a mean reduction of one medication per patient (P<0.001). As a consequence of this reduction, the average annual cost of medications was reduced by $A240 per patient. This translated to a projected annual cost saving for medication alone of $A90 per patient after offsetting the $A150 cost (professional remuneration) of the MRR. Considering health outcomes, overall, the reviewers rated at least 40 per cent of the MRR changes as leading to a positive effect on the patient's health. Conclusion — This study provides a good indication that MRR through GP‐pharmacist collaboration in the community can lead to positive clinical benefits and reduction in health care costs.     

Public perceptions of community pharmacists in Benin City,Nigeria

Objective — To determine public perceptions of community pharmacists and pharmacies in Benin City, Nigeria. Method — A self‐completion questionnaire was distributed to a stratified random sample of 1,500 households. Data were collected using a 22‐item, Likert‐type scale which was shown to have 0.77 reliability. The neutral point was assumed to be 66 on the scale of 22 to 110. Scores above 66 were interpreted as positive perception. Results — The response rate was 68.3 per cent (1,025/1500). Almost two‐thirds (64 per cent) of respondents perceived the community pharmacist as a health care provider, and 70 per cent agreed that community pharmacists are needed, especially in the area of medicinal product selection (76 per cent). However, 52 per cent believed pharmacists are profit motivated and only 43 per cent said they would be willing to pay for pharmacist consultation. Respondents reported difficulty in differentiating between pharmacists and pharmacy attendants, with only 58 per cent reporting that they could tell the difference. The pharmacists scored 76.37 ± 27.63, with 60 per cent of respondents scoring them above 66. Conclusion — This study found that community pharmacists received a moderately positive rating from the public. There is a need for community pharmacists to carve out a more distinct professional identity for themselves.     

Drug-related problems in Parkinson��s disease: the role of community pharmacists in primary care

Objective Although Parkinson??s disease is a common disorder in the elderly, there have been very few studies of the role of the pharmaceutical care services in detecting and reducing problems associated with drug treatment in community settings. The aim of this study was therefore to investigate the type and frequency of drug-related problems identified in patients with Parkinson??s disease by community pharmacists over an 8-month period and to assess the pharmaceutical service interventions, the type and frequency of intervention outcomes and the clinical benefits for the patients. Setting Community pharmacies in Germany. Method Thirty-two community pharmacists recruited 113 outpatients with idiopathic Parkinson??s disease who were receiving anti-Parkinsonian medication. Main outcome measure Drug-related problems. Results A total of 331 drug-related problems were identified by the pharmacists. Patients not receiving a medication, despite the presence of an indication or symptom, accounted for the highest proportion of drug-related problems (26.3%). The pharmacists proposed a total of 474 interventions, the most common of which was giving the patient treatment advice (19.6%). Intervention outcomes were recorded for 215 of the 331 drug-related problems, for which there were 553 individual outcome results. Adjustments of the drug regimen accounted for the highest percentage of individual results (43.6%). Conclusion Structured pharmaceutical care processes by community pharmacists have the potential to make a valuable contribution to health care and enhance the health outcomes of patients with Parkinson??s disease.     

Developing and evaluating a model for pharmaceutical care in Australian community pharmacies

Objective — To develop and evaluate a medication management service. The service was based on the principles of pharmaceutical care and targeted patients at risk of medication misadventure, primarily elderly patients, in five community pharmacies. Methods — In phase one, pharmacists defined the service in consultation with consumers, medical practitioners and professional pharmacy organisations. Agreed characteristics of the service were: patient selection criteria, a structured patient care process, systematic documentation, a quality assurance process and a complementary relationship with services of other health professionals. Implementation and evaluation of the service occurred in the second phase. The service was provided over an 11-month period to 205 patients. Key findings — Of the patients who received the service, 179 (87 per cent) had one or more medication or health-related problems. Pharmacists identified a total of 526 problems. Follow-up was available for 432 problems and 75 per cent of these problems were well managed by the end of the study. Of the 115 consumers surveyed, 74 responded. Eighty-five per cent of respondents believed the service had made a “significant” or “great” contribution to their health and 64 per cent thought that their knowledge of their medication had improved. Health economic evaluation indicated that net cost benefits were delivered to the health system. The net annual cost savings per patient ranged from $A40 to $A311. Conclusion — Pharmacists were able to apply the principles of pharmaceutical care to meet the needs of at-risk consumers in the community. Further development of this service delivery model is under way and would appear to offer substantial advantages to consumers and the health system.     

Doctors' and pharmacists' attitudes to the use of sugar‐free and sugar‐containing medicines in the elderly

Background — Much progress has been made towards the prescribing and dispensing of sugar‐free alternatives for medicines used long‐term in children. However, older people may also take sugar‐containing medicines and those with natural teeth are at risk of dental caries. Objective — To assess the knowledge and attitudes of health professionals with regard to the use of sugar‐free medicines with prolonged oral clearance in elderly people. Method — Postal questionnaire survey of three groups of health professionals (general practitioners, community pharmacists, consultant geriatricians). Statistical analysis using factor analysis, Mann Whitney U test and Kruskal Wallis test. Setting — Five districts of north‐east England. Key findings — The overall response rate was 66 per cent (349 responses). Support for the use of sugar‐free medicines was greater among GPs than pharmacists (P=0.014). There was general agreement that, wherever possible, pharmacists should dispense sugar‐free medicines for elderly people, although more GPs (P<0.0001) and consultant geriatricians (P=0.024) agreed than pharmacists. More pharmacists than GPs believed sugar‐free medicines to be more expensive although there was general uncertainty about whether this deters doctors and pharmacists from using them. There was a good understanding of the role of sugars in medicines in the aetiology of dental disease, although respondents felt that elderly people were unaware of this link. Only 51 per cent of respondents agreed that government should subsidise sugar‐free medicines production. Ninety‐four per cent felt that the pharmaceutical industry should produce more sugar‐free products. Conclusion — Although there is support for the sugar‐free option, there is a need to raise the awareness of health professionals to barriers which currently discourage utilisation, and to encourage a more multi‐professional approach in the education of health professionals, health care providers, manufacturers and regulators with regard to sugar control in medicines use and related regulatory issues.     

Extended adherence support by community pharmacists for patients with hypertension: a randomised controlled trial

Objective — To determine the effects of a patient‐centred intervention by community pharmacists on adherence to treatment for hypertension. Study design — Randomised controlled trial. Method — Randomisation was at pharmacy level. Pharmacists in the intervention group used a structured, brief questioning protocol to identify patients' medication‐related problems and their information needs relating to hypertension and its treatment. Advice, information and referral to the general practitioner (GP) were provided by the pharmacist, based on patients' responses. Pharmacists in the control group provided usual care. The intervention was delivered three times at approximately two‐month intervals. Blood pressure measurements were collected retrospectively from GP medical records. Patients completed feedback questionnaires at baseline and post‐study. The questionnaire comprised a self‐reported adherence measure and explored satisfaction with pharmaceutical services. Setting — Twenty community pharmacy sites (11 intervention and nine controls) in one health authority area in England. Outcome measures — Control of blood pressure; patient satisfaction with pharmaceutical services; self‐reported adherence. Results — In total, 180 patients (101 intervention and 79 control) from 43 general medical practices completed the trial. Patients whose blood pressure was uncontrolled prior to the study were more likely to become controlled in the intervention group (P<0.05). Most of the effect on self‐reported adherence was seen after the first intervention. Patient satisfaction was high prior to the study and was increased in the intervention group after the study. The increase was statistically significant for five items relating to communication between pharmacist and patient. Conclusion — A simple intervention delivered by community pharmacists produces positive effects on blood pressure control, self‐reported adherence and on patient satisfaction with pharmaceutical services.     

The development and evaluation of an extended adherence support programme by community pharmacists for elderly patients at home

Objective —To devise, implement and evaluate a medication adherence support service by community pharmacists for elderly patients living at home and at risk of non‐adherence. Method — Six community pharmacists identified patients who were 65 years of age and older, prescribed four or more regular medicines and living alone. A random sample of patients was visited at home and assessed for adherence‐related problems using a structured interview. The pharmacist then drew up an action plan in conjunction with the patient and general practitioner (GP), and returned for a second home visit, where the revised regime was delivered and explained. A self‐reported adherence questionnaire was also administered. After two months an independent researcher visited the patients at home to assess progress. Setting — Six community pharmacies in the city of Leeds, UK, and patients' homes. Key findings — A total of 143 patients were recruited and 441 medicine‐related problems were identified. Of these, 241 (55 per cent) required the provision of information and advice, 106 (24 per cent) required consultation with the GP and 86 (20 per cent) required changes in the presentation of the medicines. The median number of regular prescribed medicines fell from six to five (P<0.001). Overall, there was a reduction in the number of patients with one or more problems from 94 per cent to 58 per cent (P<0.001). The proportion of patients who reported non‐adherence fell from 38 per cent to 14 per cent (P<0.001). Conclusion — This study shows that community pharmacists can target patients at risk of medication non‐adherence and, using a structured approach, identify problems and implement solutions. The pharmacy patient medication record is an underutilised tool for identifying patients with adherence problems. The software needs enhancing to enable pharmacists to maximise their use of these records in adherence support. An adherence support programme needs to take more account of intentional non‐adherence and should be closely linked with the rest of the primary health care team.     

Professional perspectives on a feasibility study of GP‐pharmacist collaboration in the management of angina

Objective — To report the views and experiences of a convenience sample of community pharmacists and general practitioners (GPs) who participated in a five‐month feasibility study exploring the ways in which community pharmacists could contribute to the management of patients with stable angina when working in partnership with GPs. Method — Five pharmacists delivered a specified model of care, which represented one component of a district‐wide strategy aimed at improving the management of ischaemic heart disease (IHD), to 208 patients in eight general practices. The care involved six evidence‐based interventions: smoking cessation, dietary advice, exercise, aspirin, beta‐blockers and statins. This paper illuminates professional perspectives concerning involvement in the study. The findings of semi‐structured interviews exploring views and experiences of the pharmacists during the first and the final month of the study and those of the GPs at completion of the study are reported. Setting — St Helens and Knowsley, UK, an area with a high IHD standardised mortality rate (SMR). Key findings — The pharmacists reported high levels of satisfaction and success in relation to the study interventions and more professionally satisfying relationships with patients and GPs. Successes with therapeutic interventions were described, both within and external to the study protocol. The GPs expressed a high level of satisfaction with the conduct and outcome of the pharmacist delivered care and heightened awareness of the need to review their approach to preventive care for IHD patients. Conclusion — The findings confirm that pharmacists and GPs can work in partnership to deliver a specified model of care to patients with stable IHD and also inform the debate on a role for community pharmacists as dependent prescribers.     

Analysis of the information and support needs generated by a community pharmacy‐based methadone treatment programme

Background — Methadone treatment has been provided in Ireland since 1998 under the methadone protocol scheme. Two liaison pharmacists were employed by the Eastern Health Board to interface between pharmacists dispensing methadone in primary and tertiary care. Objective — To analyse and review the inquiries received and addressed by one liaison pharmacist in the first year of operation of a community pharmacy‐based methadone treatment scheme. Method — Inquiries received were recorded by the pharmacist using a standard data collection form. Using content analysis, key themes were identified and each inquiry was classified. Data were analysed using standard computer software. Key findings — Two primary categories of liaison inquiry were addressed: “patient‐related” inquiries, requiring the organisation of community pharmacy‐based methadone dispensing services for patients, and “pharmacy‐related” inquiries, which were requests from community pharmacists for information or support. Two thirds of the inquiries were “patient‐related.” The primary users of the liaison service were prescribers employed by the addiction services and community pharmacists. Conclusion — The liaison pharmacy service handled diverse inquiries, with an emphasis on the facilitation of the provision of pharmaceutical care for patients requiring community pharmacy‐based methadone dispensing services. The liaison service had a significant secondary role in the provision of support and information for community pharmacists. The study findings are of relevance to those involved in developing and introducing primary care‐based services for drug misusers.     

Compliance,concordance and the revolving door of care: caring for elderly people with mental health problems

□ The project involved community pharmacists receiving specialised training, becoming integrated into the community mental health teams and providing pharmaceutical care when making joint domiciliary visits with the key workers. □ Community pharmacists, psychiatrists and key workers all wanted the project to develop into a service and had similar views about the general benefits of the study. However, they had contrasting expectations of the project, based on their own perspectives on compliance, concordance and models of care □ The key workers valued the provision of monitored dosage systems for patients with confusion or memory problems. But the pharmacists felt that they were being expected to organise compliance aids; they recognised that it was their role to assess complaince and that other measures could be taken before organising an MDS □ The psychiatrists stated that involuntary non‐compliance with medication, arising from confusion, memory and physical problems, was a major issue and the project had made improvements in this area; they wanted to keep patients in the community and particularly valued reductions in morbidity, relapses and the “revolving door of care”     

Exploring community pharmacists' perceptions of their professional relationships with physicians,in Canada and the Netherlands

Objective — To explore community pharmacists' levels of interaction with, and perceptions of, physicians in primary care in Canada and the Netherlands Method — Interviews with community pharmacists Setting — Thirty-six community pharmacies in Vancouver, Canada, and 36 in the Nijmegen and Arnhem areas of the Netherlands Key findings — Dutch pharmacists were more likely to have “face-to-face contacts with the physician in the pharmacy setting” (P=0.008) and structured professional meetings with physicians (P<0.001). Canadian pharmacists were more likely to agree that “interaction with physicians is mainly limited to phone/fax” (P<0.001) and “the concept of pharmaceutical care is difficult to implement” (P=0.006). Qualitative analysis revealed that in both countries pharmacists had concerns about the attitudes of physicians and issues concerning territoriality. There were also many constructive comments and these enabled consideration of actions to enhance patient care Conclusion — The findings of the study suggest four areas which could contribute to improved patient care: (1) Increasing levels of professional interaction; (2) developing a mutual understanding of roles; (3) participating in joint initiatives to benefit patients through the extended role of pharmacists; (4) conducting structured meetings between professionals with an emphasis on the care of individual patients     

Shared care in the UK: failings of the past and lessons for the future

Aims —To explore and evaluate the implementation of shared care in the UK, to identify failings and to make recommendations for successful implementation of shared care in the future. Methods —The study utilised a triangulation approach, employing three different methods to explore the production and format of shared care protocols (SCPs) and the perceived use and future trends of shared care. A postal survey of hospital pharmacists and pharmaceutical and medical advisers in health authorities and interviews with health care professionals provided insight into perceptions of shared care and recommendations for the future. A content analysis of a sample of SCPs in current use assessed the utility of SCPs in practice. Results — A total of 321 SCPs were identified that described 99 different drugs and treatments. The protocols varied considerably with no apparent standard either within or between regions, but there was a correlation between the patient‐related information available, information across the health care interface (r=0.355, P=0.05) and pharmaceutical information (r=0.401, P=0.05). There were expressions of uncertainty about the benefit of such protocols to patients. Health authority staff in particular expressed predominantly negative attitudes in the questionnaire whereas the pharmacists were more positive. The transfer of prescribing and associated costs from hospital to community (described as “cost shifting”) was repeatedly identified as a barrier, together with competing professional interests and reluctance to change with the times. General practitioners (GPs) were most commonly excluded from the production of SCPs, which may enforce negative feelings around implementation of SCPs across the health care interface. Improved information technology and better use of evidence‐based guidelines and protocols were seen as ways forward in developing shared care. Conclusions — Since 1991, a large number of SCPs have been produced in the UK but the benefits to patients are not clear. There is a general perception of cynicism about their use; “cost‐shifting” is perceived as their main purpose. There appears to have been no formal evaluation of their use or mechanisms for their implementation, and distribution has been erratic. This study highlights that, with greater involvement of health care professionals, better communication systems and the removal of identified barriers, shared care is a concept essential in the evolving NHS.     

Community pharmacists' identification of natural health product/drug interactions in older persons

Objective To document the prevalence and significance of potential natural health products (NHPs)/prescribed drug interactions in a sample of older adults; to determine whether community pharmacists detected these drug interactions; and to characterise users and non‐users of NHPs. Setting The project involved 15 community pharmacists providing pharmaceutical care to 213 non‐institutionalised older adults. Method The study was a subanalysis of a prospective, non‐randomised, before‐and‐after trial of the provision of pharmaceutical care. Pharmacists documented each time medication‐specific information or advice was provided to subjects. The numbers and types of NHPs that clients reported taking and the number of potentially significant NHP/prescribed drug interactions were determined. Whether pharmacists identified such drug interactions and made the necessary interventions were also documented. Results Forty‐two NHPs were reported 96 times by 49 (23%) clients, most commonly glucosamine (n = 10), garlic (n = 10), prune juice (n = 9), and Ginkgo biloba (n = 6). There was a total of 446 possible NHP/prescribed drug combinations in the 49 clients, of which 53 (12%) were considered to be of potential clinical significance. Of these 53 combinations, three pharmacists identified four (8%) potential interactions in three different patients. Although gender, mean age and number of reported medical conditions did not differ between users and non‐users of NHPs, users reported taking fewer prescribed drugs compared with non‐users (5.0 ± 3.2 vs 6.0 ± 2.9, respectively, P = 0.043) and more non‐prescribed drugs (4.2 ± 2.5 vs 2.1 ± 2.0, respectively, P < 0.0001). Conclusion The reported prevalence of NHP and the potential for NHP/prescribed drug interactions in our sample of older adults were high. Pharmacists providing pharmaceutical care did not commonly identify potentially significant NHP/prescribed drug interactions.