Asthma Friendly Pharmacies: A Model to Improve Communication and Collaboration among Pharmacists,Patients, and Healthcare Providers

Pharmacists, with expertise in optimizing drug therapy outcomes, are valuable components of the healthcare team and are becoming increasingly involved in public health efforts. Pharmacists and pharmacy technicians in diverse community pharmacy settings can implement a variety of asthma interventions when they are brief, supported by appropriate tools, and integrated into the workflow. The Asthma Friendly Pharmacy (AFP) model addresses the challenges of providing patient-focused care in a community pharmacy setting by offering education to pharmacists and pharmacy technicians on asthma-related pharmaceutical care services, such as identifying or resolving medication-related problems; educating patients about asthma and medication-related concepts; improving communication and strengthening relationships between pharmacists, patients, and other healthcare providers; and establishing higher expectations for the pharmacist’s role in patient care and public health efforts. This article describes the feasibility of the model in an urban community pharmacy setting and documents the interventions and communication activities promoted through the AFP model.     

Clinical Pharmacy Services in the Home

Articles on clinical pharmacy services in the home began appearing 3 decades ago but numbers have greatly increased in the last decade. This overview of the English language literature identified 66 reports describing 57 home-based clinical pharmacy programs. Most programs were provided in the context of a time-limited research project. Medication reviews (defined as comprehensive assessment of the appropriateness of the medication regimen) and medication management (defined as assessment and support of medication compliance) were the most common services provided. Primary care, post-hospital discharge, and home healthcare were the typical service contexts, and elderly patients at high risk of medication problems were the primary target population. The early literature predominantly focused on medication management and patient counseling services based in the US; however, since 1991, reports of medication review programs in the UK and Australia have dominated.Barriers to home-based clinical services have been identified at the healthcare system, pharmacy, pharmacist, physician, and patient levels. The most common barriers are lack of (or inadequate) remuneration and the related barriers of community pharmacy or pharmacist time constraints, and the cost and time to attain and maintain pharmacist qualifications. Other important barriers are difficulty in accessing the physician to discuss drug therapy recommendations, and inadequate patient referrals. Additional barriers pertaining to the delivery of the clinical service include inadequate clinical training of community pharmacists, service provision by a pharmacist unknown to the patient, and limited access to patient information for the pharmacist. Patient barriers are lack of awareness, reluctance to accept an intervention from the pharmacist, inaccessibility, and forgetting appointments or refusing the service after initial agreement.The most commonly cited facilitators pertain to the pharmacist-physician relationship; foremost among these is having an established working relationship between the pharmacist and family physician. Others are face-to-face meetings between pharmacist and prescribing physician, and facilitator positions in Divisions of General Practice. A few facilitators of the referral system, pharmacist motivation, and service delivery have also been identified.Evaluative data were provided for 48 programs; 21 programs were evaluated within a randomized controlled trial. Thirteen of these trials found at least one statistically significant difference between groups; however, although important outcomes such as hospitalization and quality of life were often examined, the only parameter that was affected on a consistent basis was medication compliance (four of six trials).The literature on clinical pharmacy services in the home is growing and maturing. While medication review is the most common type of service reported, several other types of clinical services have been explored in this setting. Although evaluation of impact has become more rigorous over time, the overall evidence is limited and many questions remain about optimal practice models and target patient populations. Given the time intensity of home-based services, it is important that more research be conducted to provide firm evidence of value.     

A randomized trial to measure the optimal role of the pharmacist in promoting evidence-based antibiotic use in acute care hospitals.

BACKGROUND: There is a considerable gap between randomized clinical trials and implementing the results into practice. This is particularly relevant in the use of broad-spectrum antibiotics in hospitals. Hospital pharmacists can be effective vehicles for bridging this gap and promoting evidence-based medicine. To determine the most effective way of using the pharmacist in this role, a prospective cefotaxime intervention study was conducted with randomization incorporated into the design as well as patient-related therapeutic outcomes. METHODS: A total of 323 patients who were prescribed cefotaxime were randomized into an intervention or nonintervention group where only the former was challenged by pharmacists for inappropriate cefotaxime usage relative to hospital guidelines. The primary outcome was the appropriateness of cefotaxime prescribing between groups. Logistic regression analysis was then used to identify factors that were associated with successful clinical response. RESULTS: Overall, 94% of orders in the intervention group met cefotaxime dosage criteria compared with 86% in the control group (p = .018). However, there was no impact with respect to promoting cefotaxime use for an appropriate indication (81% vs. 80%; p = .67). There was a trend for improved clinical outcomes in patients who received cefotaxime within hospital guidelines (OR = 1.73; p = .31). CONCLUSIONS: The pharmacist as a vehicle for promoting the appropriate use of broad-spectrum antibiotics in the acute care hospital setting can improve the dosing of such agents. However, several barriers to optimizing the impact of the pharmacist were implied by the data. Removing these barriers could increase the pharmacists' utility as an agent for improved patient care.     

A pharmacist model of perceived responsibility for drug therapy outcomes

Pharmacists in community and ambulatory care settings are in a unique position to reduce drug-related morbidity and to optimize patient outcomes by identifying, resolving, and preventing drug therapy problems. This particular approach to pharmacy practice expands traditional pharmacist responsibilities of dispensing pharmaceuticals and providing drug information to optimizing patients' drug therapy outcomes. However, pharmacists in general, and community pharmacists in particular, have yet to incorporate this expanded professional role into daily practice. The objective of this study was to examine the validity of a pharmacist model of perceived responsibility for drug therapy outcomes based on the triangle model of responsibility. A survey instrument was tested among community and ambulatory care pharmacists in Florida, USA. The survey instrument contained the following pharmacist-related constructs from the model: clarity of standards, personal control, professional duty, and perceived responsibility for drug therapy outcomes. The model was examined by testing hypothesized relationships between the model constructs and pharmacists' reports of providing pharmaceutical care. The survey response rate was 40.9% (525/1283). All of the study measures exhibited Cronbach alpha values greater than .70. A measurement model was tested using confirmatory factor analysis. The chi2/df ratio (3.02), CFI (.95), and residual (.051) indicated a good fit of the item data to the constructs. According to path analysis, clarity of standards, personal control, and professional duty were significantly related to perceived responsibility for drug therapy outcomes, which in turn, was significantly related to pharmaceutical care provision. Perceived responsibility for drug therapy outcomes acted as a mediator of the effects of clarity of standards, personal control, and professional duty on pharmaceutical care provision. These findings have implications for pharmacy practice and research.     

Clinical and other specialty services offered by pharmacists in the community: the international arena and Israel

The community pharmacy setting is a venue that is readily accessible to the public. In addition, it is staffed by a pharmacist, who is a healthcare provider, trained and capable of delivering comprehensive pharmaceutical care. As such, community pharmacists have a colossal opportunity to serve as key contributors to patients’ health by ensuring appropriate use of medications, preventing medication misadventures, identifying drug-therapy needs, as well as by being involved in disease management, screening, and prevention programs. This unique position gives the pharmacist the privilege and duty to serve patients in roles other than solely that of the stereotypical drug dispenser.Worldwide, as well as in Israel, pharmacists already offer a variety of pharmaceutical services and tend to patients’ and the healthcare system’s needs. This article provides examples of professional, clinical or other specialty services offered by community pharmacists around the world and in Israel and describes these interventions as well as the evidence for their efficacy. Examples of such activities which were recently introduced to the Israeli pharmacy landscape due to legislative changes which expanded the pharmacist’s scope of practice include emergency supply of medications, pharmacists prescribing, and influenza vaccination. Despite the progress already made, further expansion of these opportunities is warranted but challenging. Independent prescribing, as practiced in the United Kingdom or collaborative drug therapy management programs, as practiced in the United States, expansion of vaccination programs, or wide-spread recognition and reimbursement for medication therapy management (MTM) programs are unrealized opportunities. Obstacles such as time constraints, lack of financial incentives, inadequate facilities and technology, and lack of professional buy-in, and suggested means for overcoming these challenges are also discussed.     

Relational continuity of care in community pharmacy: A systematic review

Relational continuity of care (COC) is becoming an important concept related to improving healthcare quality, reducing medical costs and increasing patient satisfaction with primary care. While community pharmacy (CP) has a considerable role in primary care, there are few reports dedicated to the role of relational COC in CP. This study reviewed the existing evidence of relational COC in CP and its effect on patients. PubMed, Embase, CINAHL, Cochrane Library CENTRAL and Google Scholar were used to search for relevant studies from the date of database inception through to January 2021, which were appraised according to eligibility criteria. There were no limitations on the primary outcome or language. Case reports and studies without control groups were excluded. The Newcastle–Ottawa quality assessment scale was used to assess the quality of the studies. Database searches identified 13 records. Relational COC measures in the included studies were grouped in three kinds; pharmacy-visiting pattern, Continuity of Care Index and loyalty. The assessed outcomes were medication adherence behaviour (e.g., the proportion of days covered, medication possession ratio), adverse drug reactions, potentially inappropriate drug prescribing and clinical outcomes. The odds of patients adhering to their medication regimen were about 1.1~2.5 times higher among those who consistently visited a single pharmacy compared to patients visiting multiple pharmacies. Additionally, the care provision with a high level of relational continuity could lower inappropriate drug use by 21~32 per cent and the use of other costly services by 12~29 per cent. This study suggests that a high degree of relational COC in CP could improve safe use of medications among patients. Future research is needed to employ more rigorous methods to reduce heterogeneity and to measure effects on clinical outcomes.     

An outreach intervention to implement evidence based practice in residential care: a randomized controlled trial [ISRCTN67855475]

Background

The aim of this project was to assess whether outreach visits would improve the implementation of evidence based clinical practice in the area of falls reduction and stroke prevention in a residential care setting.

Methods

Twenty facilities took part in a randomized controlled trial with a seven month follow-up period. Two outreach visits were delivered by a pharmacist. At the first a summary of the relevant evidence was provided and at the second detailed audit information was provided about fall rates, psychotropic drug prescribing and stroke risk reduction practices (BP monitoring, aspirin and warfarin use) for the facility relevant to the physician. The effect of the interventions was determined via pre- and post-intervention case note audit. Outcomes included change in percentage patients at risk of falling who fell in a three month period prior to follow-up and changes in use of psychotropic medications. Chi-square tests, independent samples t-test, and logistic regression were used in the analysis.

Results

Data were available from case notes at baseline (n = 897) and seven months follow-up (n = 902), 452 residential care staff were surveyed and 121 physicians were involved with 61 receiving outreach visits. Pre-and post-intervention data were available for 715 participants. There were no differences between the intervention and control groups for the three month fall rate. We were unable to detect statistically significant differences between groups for the psychotropic drug use of the patients before or after the intervention. The exception was significantly greater use of "as required" antipsychotics in the intervention group compared with the control group after the pharmacy intervention (RR = 4.95; 95%CI 1.69–14.50). There was no statistically significant difference between groups for the numbers of patients "at risk of stroke" on aspirin at follow-up.

Conclusions

While the strategy was well received by the physicians involved, there was no change in prescribing patterns. Patient care in residential settings is complex and involves contributions from the patient's physician, family and residential care staff. The project highlights challenges of delivering evidence based care in a setting in which there is a pauCity of well controlled trial evidence but where significant health outcomes can be attained.     

The impact of supervision on stock management and adherence to treatment guidelines: a randomized controlled trial

Ensuring the availability of essential drugs and using them appropriately are crucial if limited resources for health care are to be used optimally. While training of health workers throughout Zimbabwe in drug management (including stock management and rational drug use) resulted in significant improvements in a variety of drug use indicators, these achievements could not be sustained, and a new strategy was introduced based on the supervision of primary health care providers. This was launched in 1995 with a training course in supervisory skills for district pharmacy staff. In order to evaluate the impact of the supervision and the effectiveness of the training programme, adherence to standard treatment guidelines (STG) and stock management protocols was evaluated in a randomized controlled trial. The study compared three different groups of health facilities: those that received supervision for either use of STG (n = 23) or stock management (n = 21) - each facility acting as control for the other area of supervision - and a comparison group of facilities which received no supervision (n = 18). On-the-spot supervision by a specially trained pharmacy staff, based around identified deficiencies, took place at the start of the study and 3 months later. The evaluation compared performance on a variety of drug management indicators at baseline and 6-8 months after the second supervisory visit. The results of the study showed that, following supervision, overall stock management improved significantly when compared with the control and comparison groups. Similar improvements were demonstrated for adherence to STG, although the effect was confounded by other interventions. The study also showed that supervision has a positive effect on improving performance in areas other than those supervised, and demonstrated that pharmacy technicians with limited clinical skills can be trained to influence primary health care workers to positively improve prescribing practices. Allocating resources to supervision is likely to result in improved performance of health workers with regard to the rational use of essential drugs, resulting in improved efficiency and effectiveness.     

Role of a Psychiatric Pharmacist in a Los Angeles “Skid-Row” safety-net clinic

Limited access to a psychiatrist prompted a collaborative practice agreement between a psychiatric pharmacist, a psychiatric pharmacy resident, and primary care physicians at the Center for Community Health, a safety-net clinic providing comprehensive care to the homeless in Skid Row, Los Angeles, CA, USA. From July 2009 to February 2010, 36 (75%) of the 48 patients referred to the psychiatric pharmacy resident met the criteria for the chart review. Twenty-six (54%) were seen for regular follow-up care over 7 months. Most referrals were for depression, bipolar disorder, and posttraumatic stress disorder. The types of drug therapy problems, pharmacist interventions, and clinical mental health outcomes are discussed.     

基于门诊自动化药房模式提高医院药师专业技能的实践探索

目的探讨门诊自动化药房模式下提高药师专业技能的措施。方法结合我院门诊自动化药房模式下调剂工作的改变,采取与传统调剂模式对比的方法进行探讨。结果自动化药房改变了传统的发药模式,减轻了药师的劳动强度,提高了工作效率,为门诊药房工作和管理带来了积极的影响,但自动化药房系统也会出现以前未出现的一些新问题。通过加强药师处方审核的学习以及药物知识的学习,建立药师职业技能的量化考核细则,药师工作积极性提高,工作效率得到提升。结论自动化药房模式下,可通过加强药师职业技能培训和建立与之相匹配的奖惩制度,来提高药师专业技能。     

某院门诊药房工作的现状及完善

目的 探讨提高某院门诊药房药学服务水平和药师工作效率方法.方法 对门诊药房主要存在的问题、影响药学服务水平和药师工作效率的相关因素进行分析.结果 门诊药房应从工作流程各环节全面入手,引导患者正确排队;提高审核处方的效率和质量;明确药品用法和缩短调配时间;学习沟通技巧与艺术及减少药患纠纷;提升药师专业素质:落实奖惩规定从而减少退药.结论 合理利用现代科技,寻求医院其他部门配合,更好地为患者提供优质高效服务.