The pharmaceutical care of patients with hypertension: an examination of service models in primary care in the US

Background: In the UK, the delivery of health care in cardiovascular disease is guided by 'national service frameworks', which are a source of standards of practice and evidence that help to define and aid the implementation of service models capable of responding to public health goals. The revised British Hypertension Society guidelines reflect a lower target blood pressure consistent with those recommended in the US and by the WHO. The lowering of the target for the control of blood pressure has increased the estimated proportion of treated patients with inadequate control in the UK from 37% to 72%. Objective: To identify the requirements for the provision of a pharmacy service that supports hypertension monitoring, and to gain insights into how such a service might be delivered as part of a wider provision of pharmaceutical care in the UK. Method: Two pharmacists followed a structured programme of observation involving three centres in the United States (Minnesota, Colorado and Iowa). Twelve clinical settings were observed, and the pharmacists who provided the services were also the subjects of documented interviews. The settings offered different models of pharmaceutical care from which issues relevant to the international development of such services were identified. Findings: Differences noted between the service models observed included; physical environment of the community pharmacy, the use and type of documentation, methods of blood pressure measurement, extent of monitoring and followup, interprofessional communication and service orientation in terms of the provision of comprehensive pharmaceutical care to patients or specific disease management. Conclusion: If clearly defined operational models of pharmaceutical care practice in the primary care setting are to form part of a national public health strategy in the UK, they must also be capable of responding to local opportunities and patients' needs. Future development of models and services must be patientcentred and more widely informed by the range of practice experience gained elsewhere.     

Community pharmacy based provision of pharmaceutical care to older patients

Aim: To measure the outcomes of a harmonised, structured pharmaceutical care programme provided to elderly patients by community pharmacists.Method: A randomised, controlled, longitudinal, clinical trial with repeated measures was performed over an 18month period, involving community pharmacies (5 intervention and 5 control) in Northern Ireland. Elderly, ambulatory patients ( 65 years), taking 4 or more prescribed medications were eligible for participation. Patients attending an intervention pharmacy received education on medical conditions, implementation of compliance strategies, rationalising of drug regimens and appropriate monitoring; patients attending control sites received normal services. A battery of clinical, humanistic and economic outcomes were assessed.Results: A significantly higher proportion of intervention patients were compliant at the end of the 18month study and experienced fewer problems with medication compared to control patients (P < 0.05). There was little impact on quality of life and health care utilisation.Conclusions: Pharmaceutical care provision to communitydwelling patients resulted in an improvement in medication compliance and evidence of costsavings. Future pharmaceutical care studies may benefit from a more focussed selective approach to data collection and outcomes measurement.     

The importance that community pharmacists in Malta place on the introduction of pharmaceutical care

The results from a study to assess the importance Maltese pharmacists placed on various aspects of pharmaceutical care and their willingness to provide such care are reported. A modified version of the Behavioural Pharmaceutical Care Scale (BPCS) questionnaire (consisting of three dimensions and 14 domains( was mailed to the 198 privately owned community pharmacies in Malta. A total of 99 questionnaires were returned following two reminder telephone calls. Pharmacists were asked to score the importance of each pharmaceutical care activity contained in the modified BPCS on a 6 point Likert scale ranging from 0 to 5. The overall score for the questionnaire, which illustrated the importance pharmacists attributed to various aspects of pharmaceutical care, ranged from 90 to 170 with a mean score of 134.8. There was little difference recorded between the scores for the three dimensions. The Referral and Consultation domain recorded a slightly higher score than the other two domains. Younger pharmacists obtained significantly higher scores (p>0.05; KruskalWallis test) in the Verification of Patient Understanding domain. Approximately 72% of respondents indicated that they were willing to provide pharmaceutical care, but remarked that a number of issues e.g. reimbursement, qualified support staff, GPpharmacist cooperation, had to be addressed. A series of strategic steps are needed to help pharmacists resolve these issues before pharmaceutical care programmes could be offered by Maltese community pharmacists.     

Quantification of communication processes, is it possible?

The PAS^® system (ProblemAnalysisSolutionsystem) is developed to quantify oral communication processes during counselling in pharmacy practice. The pharmacist translates the patients' drugrelated questions into a Pcode, the analysis of the question into an Acode and finally the given solution upon the question into a Scode. The PAS^® system has been developed for two goals. First, for the registation of drugrelated questions from patients which gives the pharmacist insight in the most common issues addressed by patients. Second, it might help the pharmacist to structure the communication with the patient during the consultation. Fortyone pharmacists participated in the evaluation of the PAS^® system. The validation of the PAS^® system consisted of two phases: the external validation and the internal validation. Kappa values were calculated as a measure of agreement in the coding by the pharmacists. The kappavalue of the external validation for the P , A and Scodes for the total set of questions indicate a moderate to poor agreement. This means that pharmacists categorize drugrelated questions from patients in a different way. Therefore we conclude that the PAS system is less reliable for research purpose. The kappavalue of the internal validation for the Pcode varies from 0.42 to 0.91. For the Acode it varies from 0.07 to 0.35 and for the Scode from zero to 0.68. Internal reproducibility is good for Pcode but not for the Acode and Scode This implies that the pharmacist can use the Pcodes for registration of patients' questions in his own pharmacy. Moreover, the usage of the PAS^® system during counselling in pharmacy practice can structure the consultation.     

Pharmaceutical care until the end: the role of pharmacists in euthanasia in the Netherlands

Euthanasia and physicianassisted suicide continue to remain a controversial point of discussion in today's society. Patients will seek to increase their role in the decisions concerning their own health and death care. Pharmacists are also confronted with euthanasia: they not only have to provide the necessary drugs, but are also affected in every area of their life. Euthanasia can be seen as a contradiction to the mission of pharmacy practice. If, however, the activities of pharmacists include pharmaceutical care, the contradiction may not necessarily be present. Pharmaceutical care begins with the recognition that responsibilities of patient care cannot be relegated solely to other health professionals. Pharmaceutical care recognizes some of the most important needs of the terminally ill. If based on a patientcentered approach, euthanasia might be a logical last step in the efforts to alleviate the patient's sufferings.     

Evaluation of the impact of pharmacist''s advice giving on the outcomes of self‐medication in patients suffering from dyspepsia

The aim of this study was to investigate the outcomes of selfmedication in patients suffering from dyspepsia by comparing changes in the Health related Quality of Life before and after selfmedication of dyspeptic disorders. Another study objective was the quantitative and qualitative analysis of the pharmacist's advicegiving to patients with dyspepsia. Therefore the impact of the counselling by the pharmacist on the patient's health outcomes was surveyed and compared between study and control pharmacies. Moreover, the study analysed the influence of a special training on the services provided by the pharmacies with regard to selfmedication.A beneficial effect of selfmedication on the HRQoL of patients with dyspepsia on a weekly basis has been detected in the study. There is evidence that advicegiving and counselling by the pharmacists in selfmedication have a measurable impact on selfmedication outcomes. Moreover, the study reveals that patients value the information provided by the pharmacist. Pharmacists gathered the relevant and comprehensive information from the patients having dyspeptic symptoms and provided advice concerning OTCdrugs. Moreover, pharmacists frequently discussed the relevance of factors aggravating dyspeptic disorders such as lifestyle, drinking, smoking, and manner of nutrition with the patient. Training programs and treatment guidelines for the pharmacist seem to obtain a positive effect on his performance. The findings of the study substantiate the value of a pharmacistcontrolled selfmedication. The study results suggest that the quality of primary health care in selfmedication would improve if pharmacists' involvement were even more intense.     

Distribution of pharmaceuticals ? a Norwegian logistic perspective

There is a general concern about rising costs of pharmaceutical expences. One political measure is a more efficient distribution system, which can take the form of new channels for retailing. In Norway mailorder pharmacy (MOP) has been brought to the agenda due to the recently proposed law regulating pharmacies (Apoteklov), market developments abroad, demand for selfmedication, the increase in OTCproducts and advances in information technology. Mailorder pharmacy involves direct delivery of medications through postal mail to patients or those responsible for dispensing medication. With reference to the USA, mailorder pharmacy has filled a niche in the market and several other countries are following. We are convinced that it is possible to maintain a high level of service quality in the sense of safety, councelling and compliance, and that there is a potential to develop a model for this distribution form in Norway. We believe that the actors in the Norwegian pharmaceutical market are better served in taking a more active role in this area and where possible initiating pilot projects in mailorder distribution. The pharmacists will continue to play an important role as a retail outlet and should, with their influence over patients, their knowledge and experience, contribute towards developing MOP to be a safe and complementary sales outlet. Developing such a solution demands the right balance between performance and quality on the one hand and efficiency on the other; two criteria, which we believe, do not contradict each other.     

Pharmaceutical care in Denmark: perceived importance of medicine‐related problems and participation in postgraduate training

Objective: To investigate the readiness of Danish community pharmacists to provide pharmaceutical care. Special focus was on information provided to patients on medicinerelated problems and participation in postgraduate training.Method: National crosssectional survey distributed to all Danish community pharmacies (N = 288). Response rate 75.7%; nonresponders were interviewed by telephone to establish their reasons for not participating.Main outcome measures: Prioritisation of information to patients regarding medicinerelated problems. Postgraduate courses selected by pharmacists during the past three years. Results: In accordance with the profile of Danish community pharmacists, respondents were primarily female and half were below 45 years of age. The main reason given for not responding was lack of time. The prioritisation of information to patients regarding medicinerelated problems resulted in three clusters of answers. The overall topics of the clusters were: information related to the technicalpractical use of medicines; information related to pharmacotherapeutic aspects of medicine use; and information related to the function of the medicine. The clusters accounted for 61.9% of the total variance. The most frequently attended postgraduate courses were on quality assurance and specific diseases. Conclusion: The patient information prioritised by Danish community pharmacists is primarily of a technicalpractical nature. The postgraduate training pursued is primarily technical without much focus on the philosophy of pharmaceutical care. These factors contribute to the lack of proper readiness of pharmacists to practice pharmaceutical care.     

A longitudinal study of United Kingdom pharmacists'' misdemeanours – trials, tribulations and trends

Background: Standards of UK pharmacy practice are maintained by the Royal Pharmaceutical Society of Great Britain, which has the power to take a range of sanctions, including removal of the right to practice, against those found guilty of malpractice. This function is currently under review.Objective: To conduct a longitudinal study in order to define trends and identify areas where remedial or preventative support could be focused.Method: Case analysis of reports of individuals' misdemeanours published in the British Pharmaceutical Journal over a 12year period (September 1988 October 2000). Professional and personal misdemeanours were considered.Main outcome measure: Nature of misdemeanour, conviction or disciplinary proceedings against individual, practising pharmacists in the study period. Reasons offered for committing the misdemeanour and penalties applied.Results: 344 cases, involving a wide range of personal (162) and professional (590) misdemeanours were found. On an annual basis, the maximum incidence of pharmacists found guilty of any misdemeanour was extremely low (<0.1 of 1% on the pharmaceutical register). The most common professional misdemeanour was failure to keep adequate written records. The most common personal misdemeanour was fraud. The most common reason cited for committing any misdemeanour was financial gain. Numbers in individual offence categories were persistent but low and there were few obvious trends with time. The odds of involvement ratio for male versus female pharmacists was 7.36 (CI: 5.2310.35) and for ethnic minority versus Caucasian pharmacists was 3.8 (CI: 3.064.72). The most stringent penalties (either imprisonment or removal of the right to practice and frequently both) were applied to cases involving personal use or trafficking of drugs subject to abuse.Conclusions: The current selfregulation of pharmacy practice in the UK involves a wide range of misdemeanours of varying severity; but the incidence of reports of pharmacists found guilty of malpractice was extremely low. The nature of misdemeanours appeared to change little over the period of the study; this study therefore indicates the spectrum of misdemeanours likely to be encountered by a regulating board in the immediate to mediumterm future. If regulatory changes such as competencebased practice rights are introduced, the spectrum may change.     

Pilot study in humans on the pharmacokinetics and safety of propofol 6% SAZN

In a pilot study on the first application of Propofol 6% SAZN in humans, the pharmacokinetics and safety of the new product seem to be similar to those of Propofol 1% SAZN and Diprivan®10 after bolus injection. The results will have to be confirmed in a larger clinical study in order to develop Propofol 6% SAZN as an alternative for Diprivan®10.