Attitudes of Finnish community pharmacists toward concordance

BACKGROUND: Concordance is a new model of interaction between healthcare professionals and patients. The work of pharmacists and patients in the consultation is a negotiation between equals, and the aim is therapeutic alliance between them. OBJECTIVE: To assess Finnish community pharmacists' attitudes toward concordance and its perceived impact on pharmacist-patient consultations during a 4-year Finnish project (TIPPA Project 2000-2003) aimed at promoting patient counseling. METHODS: A survey of a random sample of 734 community pharmacists in Finland was conducted in 2002. The questionnaire included an attitudinal scale and 2 open-ended questions on the impact of the TIPPA Project on patient counseling. Attitudes toward concordance were measured using a modified version of the LATCon scale. The construct validity and internal consistency of the scale were evaluated using factor analysis and Cronbach's alpha. Mean summative factor scores (MSS) and 95% confidence intervals were calculated for each factor. The responses to the open-ended questions were content analyzed. RESULTS: A response rate of 51% (n = 376) was obtained. Almost 80% of the respondents strongly agreed that the highest priority in patient counseling was to establish a therapeutic alliance between the pharmacist and patient. Factor analysis of the attitudinal scale yielded 3 primary factors explaining 37.6% of the variance, interpreted as respecting patients' beliefs (alpha = 0.60; MSS = 1.90; 95% CI 2.25 to 2.40), establishing a therapeutic alliance (alpha = 0.65; MSS = 1.36; 95% CI 1.31 to 1.40), and sensitivity to patients' reactions (alpha = 0.66; MSS = 2.33; 95% CI 1.83 to 1.96). Results of the open-ended questions indicated that the TIPPA Project had a positive impact on pharmacists' attitudes toward concordance. CONCLUSIONS: Respondents to our survey were supportive of concordance. The TIPPA Project elicited a positive impact on pharmacists' attitudes toward counseling. Pharmacist education through programs such as TIPPA can aid in the implementation of a concordance-based counseling practice.     

Evidence-based practice by pharmacists: utilization and barriers

BACKGROUND: Evidence-based medicine (EBM) is the use of the current best evidence from research to make practice and policy decisions. Little is known regarding the attitudes of pharmacists toward EBM. OBJECTIVE: To determine the attitudes of pharmacists toward EBM, the extent that pharmacists use evidence to make decisions, and identify barriers to the use of evidence. METHODS: A self-administered questionnaire was mailed to 2000 randomly selected Illinois licensed pharmacists. The questionnaire assessed the pharmacists' attitudes toward EBM, the extent to which recommendations are based on primary and tertiary literature, and perceived barriers to the use of EBM. RESULTS: Completed responses were received from 323 pharmacists (17.2% response rate). Overall, respondents had positive attitudes toward EBM (58% positive, 32% somewhat positive). Respondents thought research findings were useful (42%) or very useful (42%) to daily practice. Nearly one-half (49.8%) of respondents had conducted a primary literature search within the past year. Hospital pharmacists and pharmacists in other practice settings were more likely than community pharmacists to conduct a literature search in the past year (75%, 61%, and 30%, respectively; p < 0.001). Although 86% of respondents reported having Internet access at home, only 42% of all respondents identified that they had PubMed access at home. Common barriers to the use of EBM include lack of time (45%), physician attitudes toward pharmacist recommendations (19%), and access to resources (11%). CONCLUSIONS: Pharmacist respondents have positive attitudes toward EBM and the application of research findings to practice.     

初诊2型糖尿病患者疾病态度对短期胰岛素泵强化治疗后血糖控制的影响

目的：探讨初诊2型糖尿病患者对疾病的态度对短期胰岛素泵强化治疗后血糖控制的影响。方法：118例持续皮下胰岛素输注（CSII）治疗后获得临床缓解的初诊2型糖尿病患者完成1年随访,分别于基线期、出院后3个月、6个月、1年使用密西根糖尿病管理评定量表（DCP）评价患者对糖尿病的态度（包括积极态度、消极态度、自我护理能力、自我管理重要性认识、自我管理坚持性认识）,并检测患者糖化血红蛋白水平（HbA1c）水平,采用Spearman相关分析探讨患者对疾病态度与HbA1c水平的相关性。结果：65例缓解期≥1年患者为缓解组,53例缓解期〈1年患者为治疗失效组;缓解组患者初中文化的比例明显低于治疗失效组,大学或以上文化的比例明显高于治疗失效组（P〈0.05）。经过2周CSII治疗后两组患者血糖指标均明显改善,缓解组患者CSII治疗后的空腹血糖（FPG）和餐后2 h血糖（2 hPG）低于治疗失效组,伴随胰岛素第一时相分泌（AIR）值高于治疗失效组（P〈0.05）。随访期内缓解组患者积极态度、自我护理能力、自我管理重要性认识和坚持性认识得分较基线升高,并高于同时期的治疗失效组（P〈0.05）,消极态度得分逐渐降低,并低于同时期的治疗失效组（P〈0.05）,而治疗失效组患者积极态度、自我护理能力、自我管理重要性认识和坚持性认识得分较基线下降,消极态度得分则始终维持较高的水平;Spearmen相关分析显示,除0个月外,各随访期HbA1c水平与积极态度、自我护理能力、自我管理重要性认识和坚持性认识得分呈显著负相关,与消极态度得分呈正相关。结论：糖尿病患者对疾病的态度对初诊糖尿病患者CSII后血糖控制具有重要影响,因此应重视对初诊2型糖尿病患者进行心理教育,使患者形成良好的管理疾病的态度,进而更好的控制病情,维持理想的生存质量。     

Pharmaceutical care and community pharmacists' understanding of bisphosphonate dosing information

OBJECTIVES: To evaluate pharmacists' knowledge of approved dosing information for cyclic etidronate, alendronate and risedronate in the treatment of postmenopausal osteoporosis; and to assess its relationship to demographic and pharmaceutical care factors. DESIGN: Fax-back questionnaire to evaluate pharmacists' knowledge of approved bisphosphonate dosing information and their involvement in pharmaceutical/patient care activities through independent indices. SETTING: Community pharmacies in both urban and rural settings in British Columbia. Participants: Pharmacies surveyed with 22% response rate (163 pharmacists), 47% male and 54% owners/managers. Most were independent (31%) or volunteer chain (28%) pharmacies. MEASUREMENTS AND MAIN RESULTS: Mean bisphosphonate dosing knowledge score was 76 +/- 11% (mean +/- SD). Mean scores (+/-SD) for questions pertaining to alendronate (92 +/- 13%) were higher than risedronate (81 +/- 26%) and etidronate (48 +/- 19). Pharmacists were least familiar with approved dosing instructions regarding the lack of need to remain upright after etidronate dosing, spacing out of etidronate from food/antacids/calcium/vitamins, and whether risedronate may be taken at bedtime. Factors found to affect pharmacists' bisphosphonate knowledge scores included employment in higher volume pharmacies and greater number of years in practice. Pharmacists in the upper tertile of pharmaceutical care index scores had similar bisphosphonate knowledge scores to those delivering less pharmaceutical care. Pharmacist gender, being owner/manager, and continuing education hours were not significantly associated with higher knowledge or pharmaceutical care scores. CONCLUSIONS: There is a wide range of knowledge of bisphosphonate dosing and delivery of pharmaceutical care amongst community pharmacists surveyed. Given the importance of proper bisphosphonate dosing to optimize drug absorption and to minimize toxicity, pharmacist education should be a priority.     

The short-term impact of a continuing medical education program on providers' attitudes toward treating diabetes

OBJECTIVE: The objective of this study was to evaluate the short-term impact of a 7-h type 2 diabetes continuing medical education (CME) program. Outcomes included a measure of health care providers' diabetes knowledge and the Diabetes Attitude Scale (DAS), a validated measure of attitudes toward diabetes. RESEARCH DESIGN AND METHODS: A CME program on type 2 diabetes was presented by an expert panel in Chicago during November 1998. A before-after trial with pre- and postintervention measurements of diabetes knowledge and attitudes toward diabetes was administered as part of the program. A convenience sample of the 129 health care providers in attendance resulted in 91 (71%) completed pre- and postintervention surveys. RESULTS: Within-subjects analysis revealed increases in knowledge and more favorable attitudes toward diabetes after the program. Between-subjects analysis revealed that attitude changes differed for physicians as compared with allied health care providers. CONCLUSIONS: A CME program was associated with an increase in knowledge of diabetes and more favorable attitudes toward diabetes as measured by the DAS. The DAS changes were subtly different for the physician group as compared with the allied health care provider group. These results suggest that the DAS can be a useful instrument for measuring the short-term impact of educational interventions.     

Controversial beliefs about diabetes and its care.

OBJECTIVE--The purpose of this study was to identify specific beliefs that differentiate health-care professionals whose attitudes toward diabetes agreed most strongly with a group of national diabetes experts from those whose attitudes disagreed most strongly. RESEARCH DESIGN AND METHODS--The sample for this study included 271 physicians, 834 nurses, and 546 dietitians who completed a Diabetes Attitudes Survey. The sample included specialists in diabetes care and nonspecialists. Controversial beliefs about diabetes and its care were determined by comparing the beliefs of the 10% of the sample whose attitudes were most concordant (with the national panel) with the beliefs of the 10% of the sample whose attitudes were the most discordant. Ten beliefs met the criteria for being defined as controversial. RESULTS--The most controversial beliefs concerned whether the patient or the physician should be the primary decision maker in diabetes care, the meaning of patient noncompliance, and the seriousness of non-insulin-dependent diabetes mellitus. The 10% of the sample with the most discordant attitudes contained a disproportionately large number of physicians, nonspecialists in diabetes, and health-care professionals who had been in practice longer than the other members of the sample. CONCLUSIONS--This study identifies some important differences in beliefs between younger health-care professionals who specialize in diabetes and older nonspecialists. Such beliefs should be addressed in continuing education programs with the aim being to foster the widespread adoption of a contemporary approach to diabetes care.     

Attitudes of internal medicine physicians toward type 2 diabetes

BACKGROUND: This study was designed to identify differences among internists in their attitudes about diabetes and how those attitudes influence practice behavior. METHODS: A cross-sectional study of 55 internists in an academic medical center was done using the Diabetes Attitude Scale (DAS-3), a valid and reliable measure of attitudes toward diabetes. RESULTS: Most respondents were white (89%), male (65%), and < or = 40 years old (85%). On the need for special training, internists were significantly different from the standardized norm for the DAS-3. Similar differences were observed on the seriousness of type 2 diabetes, the value attached to "tight control," and patient autonomy. Differences by age, sex, and level of training were not significant. CONCLUSION: Regardless of age, sex, or level of training, internal medicine physicians have negative attitudes toward type 2 diabetes that require future educational interventions.     

Towards an optimal model for community-based diabetes care: design and baseline data from the Mayo Health System Diabetes Translation Project

The objective of the Mayo Health System Diabetes Translation Project is to assess the impact of three different models of care on the overall quality of diabetes care in the community. The unit of study is the primary care practice with a different model of care implemented at each of three sites. The design incorporates a comparison of a diabetes guideline implementation team initiative (Practice model A), a guideline initiative combined with clinical use of a Diabetes Electronic Management System (DEMS) by primary care providers (Practice model B) and a guideline initiative combined with DEMS utilization combined with electronic review of DEMS patient encounters by an endocrinologist (Practice model C). Administrative data sets were used to define the patient population at each practice. Patients were designated as new, attending or non-attending based on their pattern of visits over the preceding 12 months. A random sample of 200 charts from attending patients at each site was audited at baseline for diabetes-related process and outcome measures. This audit will be repeated yearly during the 2 years of the project. Baseline data revealed significant differences across sites in adherence to certain key indicators of the quality of diabetes care including: frequency of documentation of eye examinations (19, 39 and 37% for sites A, B and C, respectively), haemoglobin A1c monitoring (64, 89 and 77%) and microalbumin monitoring (3, 15 and 6%). The interventions being assessed in this study include traditional (diabetes education; guideline implementation) and modern (DEMS; telemedicine specialist review) methods for improving the quality of diabetes care. In spite of variation in baseline quality indicators, the setting and design should lead to broad applicability of the results and help determine an optimal model of diabetes care in the community.     

The influence of treatment modality and ethnicity on attitudes in type 2 diabetes

OBJECTIVE: The study examines diabetes attitude differences by treatment modality (insulin vs. no insulin), race/ethnicity, and the interaction of these two variables for people with type 2 diabetes. RESEARCH DESIGN AND METHODS: Data were collected with the Diabetes Care Profile (DCP), an instrument that assesses psychosocial factors related to diabetes. Participants (n = 672) were recruited in the metropolitan Detroit, Michigan, area from 1993 to 1996. A total of 68% of these participants were African-Americans with type 2 diabetes, and 32% were Caucasians with type 2 diabetes. Analyses of covariance were performed to examine the effects of race/ethnicity, treatment, and their interaction for each DCP scale. RESULTS: The four patient categories (two ethnicities by two treatment modalities) differed by age, years with diabetes, education, and sex distribution. Treatment modality had a significant effect on 6 of the 16 DCP scales (Control, Social and Personal Factors, Positive Attitude, Negative Attitude, Self-Care Ability, and Exercise Barriers). Ethnicity was a significant effect for three scales (Control, Support, and Support Attitudes). The interaction of race/ethnicity and treatment modality was a significant effect for two related attitude scales (Positive Attitude and Negative Attitude). CONCLUSIONS: The results suggest that attitudes toward diabetes are similar for African-American and Caucasian patients with type 2 diabetes. The results also suggest that treatment modality has a greater effect on attitudes than either race/ethnicity or the interaction effect. However, Caucasian patients using insulin differed from the other patient groups by having the least positive and the most negative attitudes regarding diabetes.     

Interprofessional health care teams: attitudes and environmental factors associated with participation by community pharmacists

The purpose of this study was to determine whether community pharmacists are prepared to assume a more active role as members of the primary health care team. A secondary objective was to develop multi-items scales for future studies involving pharmacists, as well as other health professions. This paper reports on rates of participation by community pharmacists as members of interprofessional health care teams, the extent to which this participation was related to pharmacists' attitudes about their preparedness for this role, their relationship with physicians, and their assessment of potential barriers to interprofessional teamwork within their practice setting. A mail questionnaire was sent to community pharmacists across Canada between February and April, 2004. The overall response rate was 35.2% (470/1337) with the highest response rate in the Prairie Provinces (40.6%) and the lowest in Quebec (24.4%). Pharmacists on teams were more likely to agree their training and skills were sufficient to participate, and to report good relations with physicians. Pharmacists on teams were more likely to agree there was more opportunity to meet and get to know other health disciplines, and to see teamwork as part of their role. They were also more likely to agree physicians wanted their input, and less likely to see other disciplines as being too protective of their professional "turf". Pharmacists on teams did not differ from those not on teams in rating lack of time, bad past experiences with teamwork, financial reimbursement or proximity to other health care workers as barriers to being a member of a community-based primary care team.     

Attitudes of pharmacists toward mental illness and providing pharmaceutical care to the mentally ill

BACKGROUND: Few studies have examined the attitudes of pharmacists toward mental illness. OBJECTIVE: To study the attitudes of Alabama pharmacists toward both mental illness and the providing of pharmaceutical care to mentally ill patients. METHODS: The survey used in this project was composed of 3 sections. Section 1 collected demographic information, section 2 asked 11 Likert-type questions concerning attitudes toward mental illness, and section 3 asked about attitudes toward providing pharmaceutical care to mentally ill patients. The surveys were distributed to pharmacists attending 3 school-sponsored continuing education programs. RESULTS: One hundred eighty-seven pharmacists participated in the survey. The vast majority (>90%) of participants disagreed or strongly disagreed with statements that mentally ill patients are easily recognizable, unintelligent, and do not care how they look. Approximately 30-50% of participants expressed being "more" or "much more" confident, comfortable, interested, and likely to perform pharmaceutical care activities for mentally ill patients relative to medically ill patients, while only approximately 5-20% of participants expressed being "less" or "much less" so. Several demographic factors, including gender, age, and years in practice, were associated with attitudes toward providing pharmaceutical care to mentally ill patients. CONCLUSIONS: Pharmacists expressed generally positive attitudes toward both mental illness and the providing of pharmaceutical care to mentally ill patients.     

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

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

Physician documentation of diabetes care: use of a diabetes flow sheet and patient education clinic

We assessed two interventions designed to improve the care of patients with diabetes mellitus by documenting the complications of their disease. These were a flow sheet, included with outpatient medical records, and a weekly patient education clinic, in which a nurse educator provided individualized instruction to patients with diabetes. Physician compliance with recommendations of the National Diabetes Advisory Board for diabetes care was measured before (n = 45) and after (n = 158) these interventions. The numbers of referrals to ophthalmologists increased from 22% to 46%, urinalyses increased from 58% to 77%, and lower extremity examinations increased from 36% to 61%. Nutrition education documentation increased from 51% to 69%, and diabetes education documentation increased from 31% to 61%. These results suggest that a significant improvement in physicians' documentation of care of patients with diabetes can be achieved by using a flow sheet and a diabetes patient education clinic.     

Structured personal diabetes care in primary health care affects only women's HbA1c

OBJECTIVE: Diabetic men and women differ in lifestyle and attitudes toward diabetes and may benefit differently from interventions to improve glycemic control. We explored the relation between HbA1c (A1C), sex, treatment allocation, and their interactions with behavioral and attitudinal characteristics in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: Six years after their diabetes diagnosis, a population-based sample of 874 primary care patients cluster-randomized to receive structured personal care or routine care reported lifestyle, medication, social support, diabetes-related consultations, and attitudes toward diabetes. Multivariate analyses were applied, split by sex. RESULTS: A marked intervention effect on A1C was confined to the structured personal care women. The median A1C was 8.4% in structured personal care women and 9.2% in routine care women (P < 0.0001) and 8.5% in structured personal care men and 8.9% in routine care men (P = 0.052). Routine care women had a 1.10 times higher A1C than structured personal care women, (P < 0.0001, adjusted analysis). Structured personal care women had relatively more consultations than routine care women, but neither number of consultations nor other covariates helped to explain the sex difference in A1C. Irrespective of treatment allocation, women had more adaptive attitudes toward diabetes but lacked support compared with men. CONCLUSIONS: In this study, the observed effect of structured personal care on A1C was present only among women, possibly because they were more inclined to comply with regular follow-up and had a tendency to have a more adaptive attitude toward diabetes.     

Pharmaceutical care in community pharmacies: practice and research in Canada

OBJECTIVE: To discuss the provision of pharmaceutical care in community pharmacies in Canada including the following topics: organization and delivery of health services, health service policy, methods of payment, types of pharmacy services provided, types of cognitive pharmacy services, research in community pharmacy, and future plans for community pharmacy services. DATA SYNTHESIS: The implementation of pharmaceutical care in Canadian community pharmacies continues to become more widespread. However, barriers to the provision of pharmaceutical care still exist, including the current shortage of pharmacists and lack of reimbursement systems for cognitive services. Evidence of the value of pharmaceutical care in Canadian community pharmacies has been supported by several pharmacy practice research projects. The pharmacist's role in patient care is expected to continue to expand. CONCLUSIONS: Although Canadian pharmacists' capabilities are not yet universally recognized and applied to their full potential, there is reason to be optimistic about the future of pharmaceutical care in the community setting in Canada.