Counselling quality in community pharmacies: implementation of the pseudo customer methodology in Germany

Objectives: To investigate a new method for evaluating counselling performance of staff in community pharmacies and to assess the quality of patient counselling. Method: Trained pseudo customers, instructed to play their role according to two different self-medication scenarios, visited voluntarily participating community pharmacies in Berlin. After documenting the counselling process, immediately after each visit, outside the pharmacy on an assessment form, the pseudo customer re-entered the pharmacy and gave detailed performance feedback to the counsellor and the pharmacist in charge in order to provide support for improving counselling skills and practice behaviour, when appropriate. This was followed with a written summary of the general performance of all participating pharmacies and additional individual feedback and suggestions for improvement. Educational needs were identified for subsequent performance-based educational strategies such as group-workshops, team-training and on-site team-coaching. Results: Forty-nine community pharmacies in Berlin volunteered to participate in this pilot study. Ninety-eight per cent of the participating pharmacies offered advice. However, in 36% of the cases, advice was only given on request. The different types of scenarios – presentation of a symptom or request for a specific product – made a great difference to the spontaneity of questions and advice. At least one question to check on accuracy of self-diagnosis was asked in 95% of the cases of symptom presentation but in only 47% of the cases of specific product request. Information on appropriate self-medication was provided on at least one item in 74% of pseudo customer visits, but most of the time the information was not sufficient. Communication skills (nonverbal elements, comprehensibility etc.) were very good or good in 54% of the visits. Potential for improvement was mainly in relation to the use of open-ended questions to gain more information and on counselling about appropriate self-medication. Direct feedback was given in 96% of the pharmacies (one person refused to accept feedback and one feedback had to be postponed because of time shortage). All of the participants regarded counselling as an important subject in pharmacy practice. Conclusion: The pseudo customer method was successfully used in this study of German community pharmacies. It was shown that pseudo customer visits and performance feedback following the counselling process, were feasible in daily practice and well accepted by the participants. A training program, focussing on areas in most need of improvement, has been developed. The promising results have led to the Federal Chamber of Pharmacists in Germany adopting this method as part of a continuous quality improvement program in community pharmacies.     

Self-Care in the Twenty First Century: A Vital Role for the Pharmacist

In order for the global healthcare system to remain sustainable, healthcare spending needs to be reduced, and self-treating certain conditions under the guidance of a pharmacist provides a means of accomplishing this goal. This article was developed to describe global healthcare trends affecting self-care with a specific focus on the role of the pharmacist in facilitating over-the-counter (OTC) medication management. Potential healthcare-related economic benefits associated with the self-care model are outlined. The importance of the collaboration between healthcare providers (HCPs), including specialists, primary care providers, and pharmacists, is also discussed. The evolving role of the pharmacist is examined and recommendations are provided for ways to successfully engage with other HCPs and consumers to optimize the pharmacist’s unique qualifications and accessibility in the community. Using the management of frequent heartburn with an OTC proton-pump inhibitor as a model, the critical role of the pharmacist in patient self-treatment of certain symptoms will be discussed based on the World Gastroenterology Organization’s recently published guidelines for the community-based management of common gastrointestinal symptoms. As the global healthcare system continues to evolve, self-care is expected to have an increasing role in treating certain minor ailments, and pharmacists are at the forefront of these changes. Pharmacists can guide individuals in making healthy lifestyle choices, recommend appropriate OTC medications, and educate consumers about when they should consult a physician. Funding: Pfizer Inc.     

Asthma management by New Zealand pharmacists: a pharmaceutical care demonstration project

BACKGROUND: Pharmaceutical care services became recognized in New Zealand in the mid-1990s, albeit with limited evidence of the acceptability and effectiveness of the model. An asthma-specific pharmaceutical care service was trialled in southern New Zealand, based on a 'problem-action-outcome' method, with pharmacists adopting a patient-centred, outcome-focused approach with multidisciplinary consultation. OBJECTIVE: To report on the implementation and outcomes of a specialist asthma service offered by community pharmacists. DESIGN: Pharmacists in five pharmacies, servicing predominantly rural, established clientele, received training in the asthma service and research documentation. Ten patients per pharmacy were recruited in each year (years 1 and 2) of the study. The patients were entered into the study in cohorts of five per pharmacy twice yearly, with year 2 mirroring year 1. The phase-in design minimized the impact on the pharmacists. The patients acted as their own controls. All patients received individualized care and had approximately monthly consultations with the pharmacist, with clinical and quality of life (QoL) monitoring. RESULTS: A total of 100 patients were recruited. On average, 4.3 medication-related problems were identified per patient; two-thirds of them were compliance-related. The most common interventions were revision of patients' asthma action plans, referral and medication counselling. Clinical outcomes included reduced bronchodilator use and improved symptom control in around two-thirds of patients. Asthma-specific QoL changes were more positive and correlated well with clinical indicators. CONCLUSION: Further research is warranted to integrate this service into daily practice. Clinical outcomes were generally positive and supported by QoL indicators. Characteristics of New Zealand practice and this sample of pharmacies may limit the generalizability of these findings.     

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.     

The paperless labeling initiative: a proof-of-concept study

BACKGROUND: Traditional paper professional package inserts (PPIs) are used on a daily basis by a variety of healthcare providers to locate and disseminate drug information. Unfortunately, paper PPIs are sometimes not accessible to the healthcare provider, appear unreadable due to varied font sizes, and are often considered not to be user-friendly. In December 2000, the Food and Drug Administration proposed regulations that would revise the format of PPIs. OBJECTIVE: To determine whether electronic delivery of PPI information is achievable in community pharmacy practice settings. METHODS: Electronic PPIs are an alternative means of delivering this information. This 12-week proof-of-concept study evaluated the Health Information Designs/Thomson Healthcare and Etreby Computer Company for electronic delivery of PPIs in 6 chain and 4 independent community pharmacies, with 5 pharmacies evaluating each system. Participating pharmacists were asked 9 questions designed to determine the feasibility of implementing electronic PPI delivery, as well as pharmacist satisfaction with each system. RESULTS: Pharmacists deemed both systems to be accessible and user-friendly. Pharmacists from both groups felt that the electronic PPIs were challenging to read and that printing took too long. CONCLUSIONS: Future studies in a more diverse selection of dispensing sites, including pharmacies (community and hospital based), clinics, and physician practices, need to be performed to maximize the use of electronic PPIs.     

Pharmacist intervention program for control of hypertension

BACKGROUND: Pharmaceutical care programs have been shown to improve outcomes in hypertension. However, most programs required direct access to patient medical chart and patient consultation sessions by appointment. OBJECTIVE: To follow the current practice of community pharmacy, exploring the effect of an intervention program on blood pressure (BP) and factors affecting BP. METHODS: Treated hypertensive patients were enrolled in a 9-month controlled study involving 9 community pharmacies. The PRECEDE-PROCEED model was used as conceptual framework to identify factors affecting BP, to incorporate those factors in an intervention program, and to evaluate the impact of the program. A computerized decision-aid tool was used by pharmacists from 4 pharmacies to provide pharmaceutical care to subjects (n = 41); pharmacists from the 5 other pharmacies performed usual care (n = 59). As there was a statistically significant interaction due to family income in describing the impact of pharmacists' intervention on BP, population was stratified by family income in the analyses. RESULTS: Compared with the control group, the pharmacy program resulted in significant systolic BP reduction (-7.8 vs. 0.5 mm Hg; p = 0.01) and an increase in the proportion of controlled patients only for those with high incomes. In the high-income group, the program also had a positive impact on physical activity, self-reported adherence, health concerns, and information transmitted. The low-income group did not appear to benefit from the program. CONCLUSIONS: Pharmacist intervention can modify factors affecting adherence, improve adherence, and reduce BP levels in patients treated with antihypertensive agents. Impact of pharmacist intervention on BP differed according to patient income status.     

Advice-giving on self-medication: perspectives of community pharmacists and consumers in Singapore

BACKGROUND: In Singapore, community pharmacists provide an advice-giving service to consumers who seek self-medication for minor ailments management. This service has not been studied formally from the perspectives of pharmacists and consumers. OBJECTIVES: The study aimed to identify (i) the approach taken by pharmacists in providing advice for self-medication and (ii) consumers' behaviour in self-treatment and their perception of the advice-giving role of the community pharmacist. METHOD: The pharmacists and consumers were surveyed independently using two structured questionnaires. RESULTS AND DISCUSSION: All community pharmacists who participated in the survey were confident in providing advice on self-medication. However, none of them recorded the consultations and only 17.5% of them had documented their general physician referrals. Most consumers (66.3%) would self-medicate and only consult a professional when the desired outcome was not achieved. Less than 10% of consumers would approach the pharmacists as the first option for advice. More than half of the pharmacists felt that the advice they rendered deserved a fee whereas only 28.4% of the consumers were willing to pay. Both parties thought the fee should not be more than S5 dollars (US3 dollars). CONCLUSION: Generally, there is congruence in the perspectives on self-medication between the advice-giving pharmacist and the consumer. The consumers still lack awareness that pharmacists can help them to self-medicate more safely and effectively. Therefore, more effort in public education is warranted. The current state of poor documentation of the advisory function of community pharmacists should be improved.     

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.     

Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP): a randomized trial design of the effect of a community pharmacist intervention program on serum cholesterol risk.

OBJECTIVE: To determine the efficacy of a program of intervention by pharmacists on lipid risk management in patients at high risk for cardiovascular events. METHODS: Randomized, multicenter (44 sites in Alberta and Saskatchewan) study of community pharmacist intervention versus usual care in 1000 patients. Patients are those at high risk of vascular events (existing atherosclerotic vascular disease, or diabetes with > or = 1 other risk factor). After obtaining consent, the pharmacist calls the Project Office to randomize. Patients allocated to intervention receive a brochure and education about cardiovascular risk factors. Pharmacists also complete a physician contact form, which lists the patient's risk factors, medications, and any recommendations. A point-of-care cholesterol test is performed, the result is discussed with the patient, and it is entered on the contact form. If appropriate, the patient is asked to see his or her primary care physician for further assessment and/or treatment, and the form is faxed to the physician. Patients are followed up at two, four, eight, 12, and 16 weeks. During follow-up visits, pharmacists provide educational reinforcement and check for primary end point occurrence. Patients allocated to usual care receive the brochure only, with minimal follow-up. The primary end point is a composite of measurement of a complete lipid panel by the physician, or addition or modification of lipid-lowering drug therapy. Substudies will evaluate economics (third-party payer and pharmacy manager perspective), patient satisfaction, and quality of life. CONCLUSIONS: SCRIP (Study of Cardiovascular Risk Intervention by Pharmacists) is a unique ongoing trial that is evaluating a community pharmacist intervention designed to optimize cholesterol risk management in patients at high risk for cardiovascular events.     

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.