Ontario family physician readiness to collaborate with community pharmacists on drug therapy management

Article Outline

• Abstract
• Introduction
• Methods
  • Sampling
  • Sample size
  • Survey instrument
  • Instrument validity and reliability
  • Survey procedures
  • Data management
  • Data analysis
• Results
  • Interactions with community pharmacists
  • Perceived advantages and disadvantages of collaboration
  • Readiness to collaborate
  • Comparison of urban and rural physicians on readiness to collaborate
  • Predictors of readiness to collaborate
  • Open-ended question responses
• Discussion
  • Limitations
• Conclusions
• Appendix. Excerpts from study questionnaire
  • Physician Readiness to Collaborate with Community Pharmacists on Drug Therapy Management
• References
• Copyright

Abstract 

Background

Empirical evidence suggests that pharmacist-physician collaboration can improve patients' clinical outcomes; however, such collaboration occurs relatively infrequently in the community setting. There has been little research on physicians' perspectives of such collaboration.

Objective

To ascertain Ontario family physician readiness to collaborate with community pharmacists on drug therapy management.

Methods

The survey instrument was based on the transtheoretical model of behavior change. It enquired about 3 physician behaviors that represented low-, mid-, and high-level collaboration with pharmacists. The survey was distributed by fax or mail to a random sample of 848 Ontario family physicians and general practitioners, stratified by practice location (urban/rural).

Results

The response rate was 36%. Most respondents reported conversing with community pharmacists about a patient's drug therapy management 5 or fewer times per week. Eighty-four percent reported that they regularly took community pharmacists' phone calls, whereas 78% reported that they sometimes sought pharmacists' recommendations regarding their patients' drug therapy. Twenty-eight percent reported that they sometimes referred their patients to community pharmacists for medication reviews, with 44% unaware of such a service. There were no differences in physician readiness to engage in any of the 3 collaborative behaviors in urban versus rural settings. More accurate patient medication lists were perceived as the main advantage (pro) of collaborating with community pharmacists and pharmacists' lack of patient information as the main disadvantage (con). Collectively, perceived pros of collaboration were positive predictors of physician readiness to collaborate on all 3 behaviors, whereas perceived cons were negative predictors for the low- and mid-level behaviors. Female physicians were more likely than males to seek pharmacists' recommendations, whereas more experienced physicians were more likely to refer patients to pharmacists for medication reviews.

Conclusions

Overall, Ontario physicians were more engaged in the low- and mid-level collaboration with community pharmacists with respect to drug therapy management. The strongest predictor of physician readiness to collaborate was perceived advantages of collaboration.

Keywords: Pharmacist, Physician, Collaboration, Community, Drug therapy management, Family medicine, Transtheoretical model of behavior change

Back to Article Outline

Introduction 

Medication-related errors have been shown to be a significant problem affecting patient care in the ambulatory setting.¹, ², ³, ⁴ In recent years, increasing attention has been focused on strategies to enhance the safety and effectiveness of drug prescribing and use. Collaboration between community pharmacists and family physicians is one of these strategies. There is considerable evidence that pharmacist involvement on hospital teams favorably impacts patient care, reducing mortality rates and adverse drug events.⁵ In the community setting, pharmacist-physician collaboration on drug therapy management has been associated with improved clinical outcomes in several chronic disease states.⁶, ⁷, ⁸ Health care authorities and organizations in Canada and the United States have expressed support for collaborative patient care⁹, ¹⁰ and/or increased pharmacist-physician collaboration.¹¹, ¹², ¹³

Since the 1990s, the pharmacy profession has increasingly embraced a patient-centered philosophy of practice termed pharmaceutical care, a key component of which involves close collaboration with physicians on drug therapy management.¹³ Individual pharmacists have expressed strong interest in collaborating with physicians; however, such collaboration occurs infrequently in the community setting.¹⁴ Pharmacists have identified a number of barriers to the implementation of pharmaceutical care, including their own attitudes, lack of time, space, training, reimbursement, and management support. Another consistently mentioned barrier is lack of cooperation from physicians.¹⁵, ¹⁶, ¹⁷, ¹⁸, ¹⁹, ²⁰, ²¹ However, there have been few attempts to research the physician's point of view on collaboration with pharmacists, especially in Canada.²¹, ²², ²³

The primary objectives of this study were to determine Ontario family physician readiness to collaborate with community pharmacists on drug therapy management and the potential predictors (sociodemographic and attitudinal) of their readiness to collaborate. Based on the work of McDonough and Doucette,²⁴ we postulated that, because physicians and pharmacists often share a greater number of patients in rural settings and are more likely to interact socially in their local community, rural physicians are more likely to collaborate with pharmacists in the management of patients' drug therapies. Therefore, a secondary objective was to examine whether physician readiness to collaborate varies across urban and rural settings.

The conceptual framework for this study of pharmacist-physician collaboration was the transtheoretical model of behavior change.²⁵ This model describes behavior change as a series of stages: precontemplation, when individuals are not considering changing their behavior; contemplation, when they are thinking about it; preparation, when they are taking concrete steps toward it; and action, when they have changed their behavior. The model also proposes that individuals continuously weigh the advantages (pros) of changing their behavior against the disadvantages (cons), and that the relative perceived importance of the pros increases and that of the cons decreases as individuals progress through the stages of change. Another predictor of change included in the model is self-efficacy, or the individual's situation-specific confidence. Finally, the model proposes a number of processes (mental or physical) used to progress through the stages (eg, substituting desirable behaviors for undesirable ones). Although the model has been widely used to study patient behavior,²⁶, ²⁷ it has only been used in 4 studies of physician readiness to change pertaining to cancer-screening and smoking cessation-counseling practices.²⁸, ²⁹, ³⁰, ³¹

Back to Article Outline

Methods 

A stratified random sample of 848 community-based family physicians and general practitioners in Ontario was surveyed. Specialists, hospital-based or retired physicians, and those practicing outside of Ontario, were not eligible. The sampling frame used for the survey was the 2006 electronic version of the Canadian Medical Directory.³²

Sampling 

A total of 10,600 eligible physicians were identified from the Canadian Medical Directory. They were stratified into urban or rural groups. Our intention was to use Statistics Canada's census classification³³ to define urban (Census Metropolitan Areas and Census Agglomerations) and rural (all other areas) according to 6-digit postal codes. However, the electronic version of the Canadian Medical Directory only allowed stratification based on the first 3 digits (Forward Sortation Area[FSA] codes) of physicians' practice address postal codes. For FSA codes that contained either all urban or all rural postal codes, this was not a problem. However, for FSAs that included both urban and rural postal codes, we had to develop decision rules to assign an urban or rural designation. Four hundred and twenty-four physicians were sampled from each stratum.

Each returned survey's unique identification code was used to identify the respondent's name from our master list. Using the respondents' names, we retrieved their 6-digit practice postal codes from the College of Physicians and Surgeons of Ontario Web site and confirmed the original assignment to urban or rural areas based on the 3-digit FSA code. If necessary, respondents were reassigned to urban or rural groups.

Sample size 

The survey sample size was based on the objective of detecting a 20% difference in the proportion of family physicians reporting collaborative behaviors in the urban and rural regions. It was adjusted upward to account for an estimated 90% useable records in the database, a 30% response rate, and 90% useable returned questionnaires. Based on these parameters, it was estimated that the survey would have to be sent to 424 family physicians in each stratum, for a total sample size of 848 family physicians.

Survey instrument 

The 3-page questionnaire included 5 content areas: current level and topics of communication with pharmacists, perceived advantages (pros) pros and disadvantages (cons) cons of collaboration, readiness to engage in collaborative drug therapy management behaviors, demographic information, and an open-ended question inviting additional comments regarding collaboration with pharmacists. The 5 pro and 4 con items, derived from 2 qualitative studies about pharmacist-physician collaboration in Ontario,³⁴, ³⁵ had 5-point rating scales, where 1=not at all important and 5=extremely important. Collaboration was operationalized as 3 distinct behaviors on a continuum: taking pharmacists' phone calls (low), seeking pharmacists' recommendations regarding patients' drug therapy (mid), and referring patients to pharmacists for medication reviews (high) (Appendix). Each behavior had response options that reflected each of the stages of change.²⁵ Although the transtheoretical model specifies a time frame for each stage of change, a predefined time component did not seem applicable for the behaviors in this study. Another change made was to qualify action stage statements with respect to the frequency of the behavior so as to avoid extremely skewed response distributions that would preclude the use of our statistical analysis method (multinomial logistic regression). For the mid- and high-level behaviors, this was “sometimes,” but for the low-level behavior, it was “regularly.”

The questionnaire was pilot tested with a convenience sample of 7 community-based family physicians in Toronto. As a result, an additional precontemplative response option (about lack of awareness) was created for referring patients to pharmacists for medication reviews.

Instrument validity and reliability 

Before pilot testing, the questionnaire was reviewed for content validity by the research team, including 1 family physician and 2 pharmacists. Factor validity of the summated pro and con scales was established through principal components analysis of scores for the 9 pro and con items, and scale reliability was assessed by Cronbach's alpha coefficient. The construct validity of the collaborative behaviors was evaluated by testing the hypothesis that the proportion of physicians collaborating with pharmacists would be greater for the low- versus mid- and mid- versus high-level collaborative behaviors.

Survey procedures 

The survey was administered in the fall of 2006. The fax method was selected as the primary mode of distribution because of its relative cost-effectiveness compared with the mail method and because it has been shown to be physicians' preferred method of communication.³⁶ The mail method was used when a fax number was not available in the Canadian Medical Directory or on the College of Physicians and Surgeons of Ontario Web site or when a fax number was not in service at the point of first communication (30% of the sample). An introductory letter was followed by the questionnaire and cover letter 1 week later. Nonrespondents received 2 reminders, 1 and 3 weeks after the questionnaire was first sent. The second reminder was accompanied by a replacement questionnaire. All participants were instructed to return the survey by fax, regardless of the method by which they had received it. No incentives were provided to survey respondents.

Data management 

Frequency distributions for the stages of change items were inspected to ensure an adequate number of physicians in each stage for the purposes of multinomial logistic regression analysis. Few (<5) physicians reported being in the preparation stage for the low- and mid-level collaborative behaviors. Because the preparation stage is more similar to the action stage than the contemplation stage (ie, action and preparation are behaviors, whereas contemplation is a cognition), we collapsed the preparation stage into the action stage to achieve adequate cell sizes for the low- and mid-level collaborative behaviors. Summated rating scales were constructed for the pros and cons of collaboration. To reduce the number of unusable cases because of missing responses to individual pro or con items, the average of pro and con scores was used in the regression analysis.

Data analysis 

The difference in the proportion of physicians in the action stage across the 3 collaborative behaviors was tested by applying McNemar's test to pairwise comparisons. Chi-square analysis was used to test the association between urban/rural location and proportion of physicians in the action stage for each collaborative behavior. Multinomial logistic regression models were constructed for each collaborative behavior with gender, number of years in practice, location of practice (urban/rural), academic affiliation, practice type, and perceptions of pros and cons of collaborating with pharmacists as predictors of stage of change. Analysis of each regression model tested the overall significance of each predictor variable and provided parameter estimates with odds ratios by stage of change. All statistical analyses were conducted with the Statistical Program for Social Sciences (SPSS Inc., Chicago, IL, USA), version 11.0. Responses to the open-ended question were content analyzed independently by 2 researchers.³⁷ Main themes were compared, and differences were reconciled. The study was reviewed and approved by the University of Toronto Research Ethics Board.

Back to Article Outline

Results 

The overall survey response rate was 36%; it was higher for surveys distributed by fax (38%) than by mail (30%). Of the 848 physicians surveyed, 36 declared themselves ineligible to participate (eg, not in family medicine), whereas 6 mailed surveys were undeliverable. Of the 297 returned questionnaires, 12 were deemed ineligible according to the demographic information provided, whereas another 5 were eliminated because of significant (greater than 35%) missing data. Thus, 280 useable surveys were obtained. The useable response rate was 35%.

Survey respondents were similar to the 2007/2008 Ontario population of family physicians/general practitioners with regard to gender, type of practice (group/solo), practice location (urban/rural), and mean number of years in practice (Table 1).³⁸ A significantly greater proportion of survey respondents had hospital appointment, academic affiliation, and College of Family Physicians of Canada (CCFP) certification.

Table 1. Respondent characteristics compared with those of the Ontario population of family physicians/general practitioners

Variable	Survey respondents (n=280)	Ontario population of family physicians/general practitionersa (n=10,855)	Statistical significance of the differencec
	%	%	P value
Gender			.28
Male	65.5	63.8
Female	34.5	36.2
CCFP certification	66.7	60.8	.02
Type of practiceb			.49
Solo	29.3	30.3
Group	64.6	67.2
Only family physicians/general practitioners	45.7	46.3
Same site	33.9
Multiple sites	11.8
With other health professionals	18.9	20.9
Other	3.9	2.4
Practice location			.12
Urban	83.2	85.7
Rural	16.8	14.3
Hospital appointment/privileges	81.4	26.9	<.01
Academic affiliation	29.1	17.6	<.01
Mean number of years in practice (SD)	20.8 (11.2)	20.7	.88

SD, standard deviation.

Interactions with community pharmacists 

Direct communication (telephone or face-to-face) with pharmacists about a patient's drug therapy management was reported to occur 5 or fewer times per week by most (70%) of the respondents. When all modes and types of communication were considered, the main topic was related to dispensing (eg, prescription clarification or drug plan issues) rather than drug therapy management (eg, drug interactions, drug information questions, medication compliance, and others). Only 4.3% of respondents reported that they relied on the pharmacist as their main source of medication information; most (54.6%) relied on the Compendium of Pharmaceuticals and Specialties (CPS).³⁹

Perceived advantages and disadvantages of collaboration 

Principal components analysis of pro and con item scores resulted in a 2-factor solution, with all the pros loading heavily on 1 factor and all of the cons loading heavily on the second factor. Cronbach's alpha coefficient was 0.82 for the 5-item pro scale and 0.74 for the 4-item con scale. Respondents perceived more accurate patient medication lists as the most important advantage (pro) of collaborating with a pharmacist (Table 2). Pharmacists' lack of patient information, including lab results and diagnoses, was seen as the most important disadvantage (con). When the importance of the pros and cons was examined by stage of change, the pros of collaboration were consistently rated more important than the cons, except in the precontemplation stage, which is consistent with the predictions of the transtheoretical model.

Table 2. Family physicians' perceptions of the advantages (pros) and disadvantages (cons) of collaborating with community pharmacists on drug therapy management

Advantages (Pros)/Disadvantages (Cons)	Mean importancea (SD)	Median importance	Interquartile range
Advantages (pros)
More accurate patient medication lists	4.1 (0.9)	4.0	1.0
Availability of a health professional to monitor the safety and effectiveness of patients' drug therapies	3.5 (1.2)	4.0	1.0
Availability of an impartial drug information source	3.3 (1.2)	3.0	1.75
Ability to delegate time-consuming tasks (eg, medication reviews)	3.2 (3.0)	3.0	2.0
Availability of a health professional familiar with clinical guidelines for instituting drug therapy	3.0 (1.2)	3.0	2.0
Disadvantages (cons)
Pharmacists lack full information about the patient (eg, diagnosis, lab test results)	3.4 (3.5)	3.5	2.0
Interaction with the pharmacist takes time away from other patient care activities	2.7 (1.2)	3.0	2.0
Encroachment of the pharmacist on the physician's field of expertise	2.1 (2.0)	2.0	2.0
Increased liability	2.0 (2.0)	2.0	2.0

SD, standard deviation.

Readiness to collaborate 

The proportion of physicians in the action stage was significantly greater for the low-level collaborative behavior (taking pharmacists' phone calls) than the mid-level collaborative behavior (seeking pharmacists' recommendations) (P<.05) and also for the mid- versus the high-level collaborative behavior (referring patients to pharmacists for medication reviews) (P<.05) (Table 3). Therefore, the construct validity of the 3 collaborative behaviors was supported. The proportion of physicians in the action stage was not statistically different between subgroups defined by method of survey administration (mail vs fax) for any of the 3 collaborative behaviors (P>.05).

Table 3. Family physician readiness to engage in collaborative behaviors with community pharmacists

Readiness stage	Collaborative behavior
	Number (%) taking pharmacists' phone calls	Number (%) seeking pharmacists' recommendations	Number (%) referring patients to pharmacists for medication reviews
Precontemplation	28 (10.0)	34 (12.1)
Don't see a need			39 (13.9)
Not aware service exists			123 (43.9)
Contemplation	14 (5.0)	25 (8.9)	18 (6.4)
Preparation	2 (0.7)	3 (1.1)	14 (4.6)
Action	234 (83.6)	217 (77.5)	78 (27.9)
No response/multiple responses	2 (0.7)	1 (0.4)	9 (3.2)
Total	280	280	280

Comparison of urban and rural physicians on readiness to collaborate 

There were no statistically significant differences between urban and rural physicians in their readiness to regularly take pharmacists' phone calls (χ² =0.06, df=1, P=1.00), seek pharmacists' recommendations (χ²=0.48, df=1, P=.56) or refer patients to pharmacists for medication reviews (χ²<0.03, df=1, P=1.00).

Predictors of readiness to collaborate 

The only significant predictors of physician readiness to take pharmacists' phone calls were pros and cons of collaborating with community pharmacists (Table 4). The more important the pros, the less likely the physician was to be in the precontemplation than the action stage, and more likely to be in the contemplation versus the action stage. In other words, physicians who perceived the pros of collaborating as more important were more likely to be found in the contemplation or action stage. The more important the cons, the more likely the physician was to be in the precontemplation and contemplation stages than the action stage.

Table 4. Significant predictors (P<.05) of family physician readiness to collaborate with community pharmacists overall and by stage of change

Collaborative behavior	Predictor variable	Overall significance (P value)	Readiness stagea	Predictor variable	Odds ratio	95% Confidence zinterval
Taking pharmacists' phone calls	Pros	<.01	Precontemplation (n=28)	Pros	0.51	0.30-0.86
	Cons	<.01		Cons	2.66	1.60-4.45
			Contemplation (n=14)	Pros	2.66	1.21-5.80
				Cons	2.84	1.47-5.50
Seeking pharmacists' recommendations	Pros	<.01	Precontemplation (n=34)	Pros	0.40	0.24-0.67
	Cons	<.01		Cons	1.91	1.21-3.03
	Gender	.04		Genderb	0.34	0.12-0.97
			Contemplation (n=25)	Cons	1.92	1.17-3.17
Referring patients to pharmacists for medication reviews	Pros	<.01	Precontemplation (not aware service exists) (n=123)	Pros	0.50	0.33-0.76
	Years in practice	<.01
			Precontemplation (don't see a need) (n=42)	Pros	0.15	0-0.28
			Preparation (n=14)	Years in practice	1.08	1.01-1.15

Readiness to seek pharmacists' recommendations was similarly predicted by the perceived importance of pros and cons. Another predictor was physician gender, with females more likely to be in the action stage than the precontemplation stage.

Significant predictors of physician readiness to refer patients to pharmacists for medication reviews—the high-level collaborative behavior—were perceived importance of the pros of collaboration and number of years in practice. Respondents with more years in practice were more likely to be in the preparation stage than the action stage.

Open-ended question responses 

One hundred and three respondents (36.7%) provided at least 1 comment. Many of them reported collaborating and having a good working relationship with local pharmacists. Others described positive experiences with particular pharmacists, commenting on their personal attributes (eg, helpful, knowledgeable, approachable).

The primary concern expressed in these comments was that pharmacists lack patient information, including diagnosis and laboratory test results (an item on the list of cons), potentially rendering their suggestions less useful and/or unsafe. Other less commonly mentioned barriers to collaboration included physician remuneration and time. Overall, the favorable comments outnumbered the unfavorable ones.

Back to Article Outline

Discussion 

High proportions of family physicians reported regularly taking community pharmacists' phone calls and sometimes seeking community pharmacists' recommendations, whereas few family physicians reported sometimes referring their patients to pharmacists for medication reviews. Adverbs in the aforementioned action statements have been italicized to highlight the fact that the stated frequency of the behavior was not standardized across the 3 collaborative behaviors. Thus, although it appears that endorsement of the low- and mid-level collaborative behaviors was similar, had both behaviors been described as occurring regularly, the mid-level behavior would likely have been endorsed by a smaller proportion of respondents.

The few physicians (28%) collaborating on the high-level collaborative behavior is at least partially explained by the fact that a significant percentage of physicians (44%) were not even aware that community pharmacists could conduct medication reviews. Four months after survey completion, Ontario's MedsCheck program was implemented,⁴⁰ whereby the provincial drug plan remunerates pharmacies for conducting medication reviews. Physician awareness would have increased greatly since that time.

Apart from the high proportion of physicians regularly taking pharmacists' phone calls about drug therapy management issues, several of this study's findings indicated that there is little collaboration on drug therapy management activities between family physicians and community pharmacists: most physicians had 5 or fewer conversations a week with community pharmacists about a patient's drug therapy management; when all types and topics of communications with pharmacists were taken into consideration, dispensing-related issues predominated; and few physicians relied on community pharmacists as their main source of medication information. The lack of direct communication, in particular, may be a lost opportunity to build collaborative relationships, given that it has been postulated to be a facilitator of such relationships.²⁴ As such, it might be recommended that pharmacists attempt to increase the frequency of their direct professional interactions with physicians who are patient focused and facilitate physicians' problem solving with respect to drug therapy management.

Access to patient information (clinical and medication) emerged as an important issue in this study: respondents perceived more accurate patient medication lists as the main advantage of collaborating with community pharmacists and pharmacists' lack of patient clinical information as the main disadvantage. Pharmacists and health policy makers in Canada and the United States have already recognized the importance of this issue.¹⁵, ¹⁶, ¹⁸, ¹⁹, ⁴¹ The Task Force on the Blueprint for Pharmacy (in Canada) has identified advancement and implementation of information and communication technology as 1 of 5 key directions for the future of pharmacy and has developed an action plan to address it.¹³ In Ontario, the e-Health agency is working to create a comprehensive electronic health record for all Ontarians by 2015, through which pharmacists will have access to patient clinical information, whereas physicians will have access to comprehensive patient medication records.⁴¹

The only consistently significant predictor of physician readiness to collaborate (ie, across all 3 collaborative behaviors) was the perceived pro of collaboration, whereas the perceived cons of collaboration were predictive of physician readiness to take pharmacists' phone calls and seek pharmacists' recommendations. The relationships were in the direction predicted by the transtheoretical model²⁵: the higher the pros, the more likely the physician was to be in the action stage than the precontemplation stage, and the higher the cons, the more likely the physician was to be in the precontemplation or contemplation stage than the action stage. The finding that physicians who rated the pros higher were more likely to be in the contemplation than the action stage with regard to taking pharmacists phone calls is consistent with the transtheoretical model, given that contemplation is a stage in which individuals typically weigh the importance of the pros and cons roughly equally, and are thus, often ambivalent about changing their behavior.²⁶ Therefore, a key strategy for increasing community-based physicians' collaboration with pharmacists appears to lie in highlighting the potential advantages of collaboration and/or diminishing perceptions of the disadvantages and costs associated with collaboration.

Female gender was a significant predictor of physician readiness to seek pharmacists' recommendations, with females more likely than males to be in the action stage than the precontemplation stage. This may relate to gender differences in leadership style, as previous research has illustrated that females typically lead in a more democratic or participatory style, whereas males are more likely to lead in a more autocratic or directive style.⁴²

Number of years in practice was a significant predictor of physician readiness to refer patients to pharmacists for medication reviews, with more experienced physicians more likely to be in the preparation stage than the action stage. In comparison, other studies have found that younger physicians are more receptive of expanded pharmacy roles than older physicians.⁴³, ⁴⁴ Findings from this study may have been a statistical aberration, given the low numbers in the preparation stage.

Limitations 

The survey response rate was relatively low (36%). Thus, the generalizability of its findings to the population of Ontario family physicians is not known, although the similarity between these 2006 survey respondents and the 2007/2008 Ontario population of family physicians on most demographic characteristics provides some reassurance. The only significant disparities were that a greater proportion of survey respondents had CCFP certification, hospital privileges, and academic affiliations, potentially making them more likely to collaborate with pharmacists, given their likely exposure to pharmacist expertise in the hospital and/or potentially greater knowledge of the research literature regarding the benefits of interprofessional care.

Another limitation of this study was the very low number of physicians in the preparation stage for any of the 3 collaborative behaviors. This could have been because of the failure to properly operationalize preparation, either by not adequately capturing preparation activities or by not using a time component to define this stage (as recommended by the transtheoretical model), or it could have been because the collaborative behaviors in question do not involve preparation. A study of physician readiness to change cancer-screening practices encountered similar difficulties in operationalizing the preparation stage in the survey instrument.²⁸

Finally, the survey involved only Ontario physicians. The development of collaborative relationships between community pharmacists and family physicians in other jurisdictions may differ, depending on the health care workforce, policies, and systems.

Back to Article Outline

Conclusions 

This study of Ontario family physicians' readiness to collaborate with community pharmacists on drug therapy management was the first to investigate interprofessional collaboration using the transtheoretical model. It showed that family physicians were more likely to collaborate with community pharmacists on low- to mid-level collaborative behaviors; that these physicians directly communicated with pharmacists very infrequently on drug therapy issues; and that physicians' perceptions of the advantages of collaboration were consistently significant predictors of their collaborative activities. There was some evidence that female and experienced physicians had a greater propensity to collaborate with pharmacists. Future studies should retest these potential predictors and practice location (urban/rural) to corroborate these findings. In addition, future studies should find alternate ways of operationalizing the transtheoretical model, particularly the preparation stage.

Back to Article Outline

Appendix. Excerpts from study questionnaire 

Physician Readiness to Collaborate with Community Pharmacists on Drug Therapy Management 

For each of the behaviours identified in items #4-6 below check the box that most closely represents your current thoughts or actions.

For items #7-15, please indicate how much each of the following influences your intention to collaborate with community pharmacists.

Do you have any other comments in regards to collaboration with community pharmacists on patient's drug therapy management:

Back to Article Outline

References 

1. Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000;
   • View In Article
2. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348:1556–1564
   • View In Article
   • CrossRef
3. Goulding MR. Inappropriate medication prescribing for elderly ambulatory care patients. Arch Intern Med. 2004;164:305–312
   • View In Article
   • MEDLINE
   • CrossRef
4. Zhan C, Correa-de-Araujo R, Bierman AS, et al. Suboptimal prescribing in elderly outpatients: potentially harmful drug-drug and drug-disease combinations. J Am Geriatr Soc. 2005;53:262–267
   • View In Article
   • MEDLINE
   • CrossRef
5. Kaboli PJ, Hoth AB, McClimon BJ, et al. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med. 2006;166:955–964
   • View In Article
   • MEDLINE
6. Machado M, Bajcar J, Guzzo GC, et al. Sensitivity of patient outcomes to pharmacist interventions. Part I: systematic review and meta-analysis in diabetes management. Ann Pharmacother. 2007;41:1569–1582
   • View In Article
   • CrossRef
7. Machado M, Bajcar J, Guzzo GC, et al. Sensitivity of patient outcomes to pharmacist interventions. Part II: systematic review and meta-analysis in hypertension management. Ann Pharmacother. 2007;41:1770–1781
   • View In Article
   • CrossRef
8. Roughead EE, Semple SJ, Vitry AI. Pharmaceutical care services: a systematic review of published studies, 1990 to 2003, examining effectiveness in improving patient outcomes. Int J Pharm Pract. 2005;13:53–70
   • View In Article
   • CrossRef
9. Canadian Medical Association Working Group. Putting Patients First: Patient Centered Collaborative Care. Ottawa, Canada: Canadian Medical Association; July 2007;
   • View In Article
10. Interprofessional Care Steering Committee. Interprofessional care: a blueprint for action in Ontario. August 2007;Available at http://www.healthforceontario.ca/upload/en/whatishfo/ipc%20blueprint%20final.pdfAccessed 20.01.09
    • View In Article
11. Romanow RJ. Building on Values: the Future of Health Care in Canada. Final Report. Ottawa, Canada: National Library of Canada; 2002;
    • View In Article
12. American College of Physicians—American Society of Internal Medicine. Pharmacist scope of practice: position paper. Ann Intern Med. 2002;136:79–85
    • View In Article
    • MEDLINE
13. Task Force on a Blueprint for Pharmacy. Blueprint for pharmacy: the vision for pharmacy. Available at http://www.pharmacists.ca/content/about_cpha/whats_happening/cpha_in_action/pdf/BlueprintVision.pdf2008;Accessed 10.11.08
    • View In Article
14. McKesson Canada . Trends and insights: community pharmacy in Canada. Available at http://www.mckesson.ca/documents/Trends_2007.pdf2008;Accessed 20.03.08
    • View In Article
15. Odedina FT, Segal R, Hepler CD. Providing pharmaceutical care in community practice: differences between providers and non-providers of pharmaceutical care. J Soc Admin Pharm. 1995;12(4):170–180
    • View In Article
16. Amsler MR, Murray MD, Tierney WM, et al. Pharmaceutical care in chain pharmacies: beliefs and attitudes of pharmacists and patients. J Am Pharm Assoc. 2001;41(6):850–855
    • View In Article
17. Reebye RN, Avery AJ, Van Der Bosch WJHM, et al. Exploring community pharmacists' perceptions of their professional relationships with physicians, in Canada and the Netherlands. Int J Pharm Pract. 1999;7:149–158
    • View In Article
    • CrossRef
18. Dobson RT, Henry CJ, Taylor JG, et al. Interprofessional health care teams: attitudes and environmental factors associated with participation by community pharmacists. J Interprof Care. 2006;20(2):119–132
    • View In Article
    • MEDLINE
    • CrossRef
19. McDonough RP, Rovers JP, Currie JD, et al. Obstacles to the implementation of pharmaceutical care in the community setting. J Am Pharm Assoc. 1998;38:87–95
    • View In Article
20. Volume CI, Farris KB, Huyghebaert T. Barriers to pharmaceutical care: perceptions of Alberta community pharmacists. Can Pharm J. 1999;132(2):36–42
    • View In Article
21. Howard M, Trim K, Woodward C, et al. Collaboration between community pharmacists and family physicians: lessons learned from the seniors medication assessment research trial. J Am Pharm Assoc. 2003;43(5):566–572
    • View In Article
22. Pottie K, Farrell B, Haydt S. Integrating pharmacists into family practice teams: physicians' perspectives on collaborative care. Can Fam Physician. 2008;54:1714–1715e1-5
    • View In Article
23. Simpson SH, Johnson JA, Farris KB, et al. Physician perceptions of enhanced community pharmacist care in cholesterol management. Can Pharm J. 2005;138(4):33–39
    • View In Article
24. McDonough RP, Doucette WR. Developing collaborative working relationships between pharmacists and physicians. J Am Pharm Assoc. 2001;41(5):682–692
    • View In Article
25. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol. 1983;51:390–395
    • View In Article
    • CrossRef
26. Prochaska JO, Velicer WF. The transtheoretical model of health behaviour change. Am J Health Promot. 1997;12(1):38–48
    • View In Article
    • MEDLINE
27. Prochaska JO, Norcross JC, DiClemente CC. Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward. New York, NY: Avon Books; 1995;
    • View In Article
28. Main DS, Cohen SJ, DiClemente CC. Measuring physician readiness to change cancer screening: preliminary results. Am J Prev Med. 1995;11(1):54–58
    • View In Article
    • MEDLINE
29. Honda K, Gorin SS. A model of stage of change to recommend colonoscopy among urban primary care physicians. Health Psychol. 2006;25(1):65–73
    • View In Article
    • MEDLINE
    • CrossRef
30. Park ER, DePue JD, Goldstein MG, et al. Assessing the transtheoretical model of change constructs for physicians counseling smokers. Ann Behav Med. 2003;25(2):120–126
    • View In Article
    • MEDLINE
    • CrossRef
31. Park ER, Eaton CA, Goldstein MG, et al. The development of a decisional balance measure of physician smoking cessation interventions. Prev Med. 2001;33:261–267
    • View In Article
    • MEDLINE
    • CrossRef
32. Scott's Directories. Canadian medical directory. Available at http://www.mdselect.com2006;Accessed 5.10.06
    • View In Article
33. Statistics Canada. 2001 Census geography: illustrated glossary. Available at http://geodepot.statcan.ca/Diss/Reference/COGG/Index_e.cfm2001;Accessed 5.10.06
    • View In Article
34. Taylor A. Community Pharmacists' Perceptions of Their Collaborative Working Relationships With Physicians for Drug Therapy Management: An Exploratory Study. Toronto, Canada: University of Toronto; 2007;[masters thesis]
    • View In Article
35. MacKeigan LD, Marshman JA, Ellison PA, et al. A Collaborative Process for Integrating a Pharmacist into a Primary Care Group. Final project report. University of Toronto. January 2008.
    • View In Article
36. Lensing SY, Gillaspy SR, Simpson P, et al. Encouraging physicians to respond to surveys through the use of fax technology. Eval Health Prof. 2000;23(3):349–350
    • View In Article
    • MEDLINE
37. Miles MB, Huberman MA. Qualitative Data Analysis: An Expanded Sourcebook. Thousand Oaks, CA: Sage Publications; 1994;
    • View In Article
38. 2007 National Physician Survey. Available at http://www.nationalphysiciansurvey.ca/nps/2007_Survey/2007nps-e.aspAccessed 8.02.08
    • View In Article
39. Canadian Pharmacists Association. Compendium of Pharmaceuticals and Specialties. Ottawa, Canada: Canadian Pharmacists Association; 2008;
    • View In Article
40. Ontario Ministry of Health and Long Term Care. MedsCheck program. Available at http://www.health.gov.on.ca/english/providers/pub/drugs/meds_check/pdf/guide_medscheck.pdf2007;Accessed 20.04.08
    • View In Article
41. e-Health Ontario . Ontario's e-Health Strategy 2009-2012. Available at http://www.ehealthontario.on.ca/pdfs/About/eHealthStrategy.pdf2009;Accessed 1.06.09
    • View In Article
42. Eagly AH, Johnson BT. Gender and leadership style: a meta-analysis. Psychol Bull. 1990;108:233–256
    • View In Article
    • CrossRef
43. Bradshaw SJ, Doucette WR. Community pharmacists as patient advocates: physician attitudes. J Am Pharm Assoc. 1998;38:598–602
    • View In Article
44. Ranelli PL, Biss J. Physicians' perceptions of communication with and responsibilities of pharmacists. J Am Pharm Assoc. 2000;40:625–630
    • View In Article