Research in Social and Administrative Pharmacy

Building capacity to implement cognitive pharmaceutical services: Quantifying the needs of community pharmacies

Eleonora Feletto, Laura Kate Wilson, Alison Sarah Roberts, Shalom Isaac Benrimoj — 2009-10-16

Abstract: Background: Community pharmacy is an industry undergoing a transformation, evolving from a traditional product supply orientation to a business capable of incorporating services. The theoretical framework of organizational flexibility is used to understand how pharmacies' capacity can be built to provide services and identify key areas needing improvement.Objective: To determine the needs of pharmacies that were important and the elements requiring improvement when implementing and delivering services.Methods: A mail survey of 2006 Australian community pharmacies was used to identify needs for service implementation. A 25-item scale was used to measure the level of importance (importance measure) of the items and the level of improvement (improvement measure) when implementing services. An exploratory factor analysis was conducted to assess the construct validity and reliability.Results: Responses were received from a total of 395 community pharmacies, with 355 usable responses (17.7%). Factor analysis yielded 3 factors on the importance measure, explaining 42.6% of the variance: (1) planning and performance (item loading range 0.749-0.455; Cronbach's α 0.806), (2) people and processes (0.829-0.392; 0.713), and (3) service awareness and infrastructure (0.723-0.310; 0.705). For the improvement measure, 46.9% of the variance was explained by 3 factors: (1) planning, performance, and service awareness (0.827-0.447; 0.858), (2) infrastructure (0.900-0.637; 0.822), and (3) people and processes (0.903-0.311; 0.707).Conclusions: The analyses showed that there are gaps in the capacity of community pharmacy that could be addressed through business and management programs. The theoretical framework of organizational flexibility was useful in highlighting the key areas for stimulating change. To effectively implement services and sustain service delivery, more sophisticated planning and performance monitoring systems are required, supported by changes to infrastructure and staff mix. The critical area for policy makers is the speed at which programs can be restructured to include these issues to encourage the widespread implementation of services.

Problem prescriptions in Sweden necessitating contact with the prescriber before dispensing

Anders Ekedahl — 2009-11-02

Abstract: Background: Pharmacists have an important role in detecting, preventing, and solving prescription problems, which if left unresolved, may pose a risk of harming the patient.Objectives: The aim was to examine prescription problems detected at pharmacies in Sweden, where pharmacists consider it necessary to contact the prescribers for clarification, completion or correction of the prescriptions before dispensing, and to compare the intervention rates at public pharmacies at hospitals (PPHs) with those at city center pharmacies (CCPs).Methods: All attempts to contact the prescriber about a prescription problem were recorded by trained observers (pharmacy students). Analyses were made of overall distribution of problem prescriptions, including data from all 14 participating pharmacies, and a comparison between CCPs and PPHs with data from the 5 areas, each consisting of 1 CCP and 1 PPH (10 pharmacies). Chi-square-analyses were used to compare proportions, Spearman's rank-correlation coefficient was used to test correlation between recorded rates and dispensed volume, and Wilcoxon two-sample test was used to test differences between the CCPs and PPHs. P<.05 is regarded as statistically significant.Results: The pharmacists contacted the prescribers for 1% of all new prescriptions before dispensing. Errors that may compromise patient safety and medication outcome constituted almost 60% of the problems. However, there was an inverse correlation between the intervention rates and the pharmacy's dispensing volume. Significantly lower rates of problem prescriptions were recorded for women than for men. The highest rates were seen for prescriptions to patients younger than 15 years, and the rates decreased with increasing patient age. Pharmacists at PPHs contacted the prescribers about prescription problems twice as often as those at large CCPs. Pharmacists spent an average of 5minutes on the telephone to solve the problem (median time), but 25% of the prescriptions took 10minutes or more.Conclusions: Computerized physician order entry (CPOE) and electronically transmitted prescriptions (ETP) can not only reduce the total rate of prescription problems, but also introduce new clinically important errors that may compromise patient safety and medication outcome. The prescription problem rates in the present study differed across prescriber groups and patient age and gender, and the inverse correlation to pharmacy size indicates that all problems are not revealed and corrected and may thus reach the patient. CPOE and ETP have been used extensively in Sweden for the past decade, but the present study indicates that there is still a potential and need for improvement for the vision of “no prescribing errors/problems will reach the patient” to come true.

Receiving a pharmaceutical care service compared to receiving standard pharmacy service in Sweden–How do patients differ with regard to perceptions of medicine use and the pharmacy encounter?

2009-11-09

Abstract: Background: Qualitative research has shown that gaining control of medicine treatment and increased feelings of safety and empowerment are central concepts in patients' perceptions of a pharmaceutical care (PC) service provided in Sweden. However, little is known about any unique differences among patients receiving PC versus standard pharmacy services (SSs) and the impact of these services on patient-perceived outcomes.Objective: To describe and compare patients who had previously received a PC service and patients who had received a SS with regard to their perceptions of medicine use and the pharmacy encounter.Methods: Cross-sectional survey design comparing matched groups of patients who were previously elected to receive a PC service or who had received SS. Patients who were 60 years or older and used 5 or more prescription medicines concomitantly were included in the survey. Questionnaires included questions about perceptions of safety in drug therapy, general health, drug-related problems (DRPs), medication beliefs, adherence, and experiences of pharmacy encounters.Results: Patients receiving the PC service used more prescription medicines, reported poorer self-reported health, and less perceived safety in their medicine therapy than did patients in SS. PC patients reported that they felt safer with medications, felt a genuine interest from the pharmacist, received important information, and felt more prepared to see the doctor after having spoken to the pharmacist than did patients in SS. DRPs reported to a greater extent by patients receiving the PC service included difficulties opening containers, worries about side effects, experiences of side effects, worries about drug-drug interactions, and inadequate treatment effects. Adherence and medication beliefs showed no statistical difference between groups.Conclusion: Patients receiving a PC service are a worried, vulnerable, and information-seeking group. When compared with patients receiving SS, the PC patients are more insecure about their medicine therapy, although talking to a pharmacist increased their self-reported feelings of safety and provided better preparation for visits to the doctor.

Use of complementary and alternative medicine for treatment among African-Americans: a multivariate analysis

Jamie C. Barner, Thomas M. Bohman, Carolyn M. Brown, Kristin M. Richards — 2009-10-19

Abstract: Background: The use of complementary and alternative medicine (CAM) is substantial among African-Americans; however, research on characteristics of African-Americans who use CAM to treat specific conditions is scarce.Objective: To determine what predisposing, enabling, need, and disease-state factors are related to CAM use for treatment among a nationally representative sample of African-Americans.Methods: A cross-sectional study design was employed using the 2002 National Health Interview Survey (NHIS). A nationwide representative sample of adult (≥18 years) African-Americans who used CAM in the past 12 months (n=16,113,651 weighted; n=2,952 unweighted) was included. The Andersen Health Care Utilization Model served as the framework with CAM use for treatment as the main outcome measure. Independent variables included the following: predisposing (eg, age, gender, and education); enabling (eg, income, employment, and access to care); need (eg, health status, physician visits, and prescription medication use); and disease state (ie, most prevalent conditions among African-Americans) factors. Multivariate logistic regression was used to address the study objective.Results: Approximately 1 in 5 (20.2%) who used CAM in the past 12 months used CAM to treat a specific condition. Ten of the 15 CAM modalities were used primarily for treatment by African-Americans. CAM for treatment was significantly (P<.05) associated with the following factors: graduate education, smaller family size, higher income, region (northeast, midwest, west more likely than south), depression/anxiety, more physician visits, less likely to engage in preventive care, more frequent exercise behavior, more activities of daily living (ADL) limitations, and neck pain.Conclusions: Twenty percent of African-Americans who used CAM in the past year were treating a specific condition. Alternative medical systems, manipulative and body-based therapies, and folk medicine, prayer, biofeedback, and energy/Reiki were used most often. Health care professionals should routinely ask patients about the use of CAM, but when encountering African-Americans, there may be a number of factors that may serve as cues for further inquiry.

Future economic outlook of Nebraska rural community pharmacies based on break-even analysis of community operational costs and county population

Shellie L. Keast, Elgene Jacobs, Donald Harrison, Kevin Farmer, David Thompson — 2009-09-18

Abstract: Background: There is growing concern over increasingly limited access to local health care, including pharmacies, for rural citizens of the United States. Although geographically distant from most competitors, rural pharmacies may still struggle to generate an acceptable profit to remain economically viable. Therefore, a method for calculating the economic viability for a community pharmacy to recruit a potential new owner to assume the entrepreneurial risk is an important issue to consider when evaluating rural pharmacy access.Objectives: The primary objective of this study was to use a modified break-even analysis to predict the future financial potential of the current pharmacy business to attract a new owner. The secondary objective was to forecast a risk level for a Nebraska county to sustain the number of pharmacies in the country beyond current ownership.Methods: This research used data provided by pharmacies that responded to a Nebraska Medicaid cost of dispensing (COD) survey in addition to data from the US Census Bureau, US Office of Management and Budget, and the Nebraska State Board of Pharmacy. Break-even analysis was used to determine the point where the prescription volume of the pharmacy not only covered the variable and fixed costs but also maintained a reasonable profit to attract new ownership. Counties were classified into 3 risk levels based on the projected available prescription volume and the number of pharmacies in each county. Sensitivity analysis was performed on the risk levels to determine the impact of variance in projected available prescription volume on the projected future outlook for the pharmacies in each county.Results: Regression analysis of responses to the COD survey indicated that the annual break-even prescription volume ranged from 44,790 to 49,246 prescriptions per pharmacy per annum. The number of rural Nebraska pharmacies was projected to decline from 126 to 78. The number of counties in Nebraska without a single pharmacy was projected to increase from 19 to 26, and the number of counties with just one pharmacy was projected to increase from 17 to 31. Thus, the number of counties with 1 or no pharmacy was projected to increase to 57 out of the total 93 Nebraska counties.Conclusions: The forecasted closure of pharmacies in rural areas will cause significant portions of the state to be without a pharmacy. Low county populations will be unable to sustain a local prescription volume large enough to remove them from the high risk of pharmacy closure.

Consumers' views of pharmacogenetics—A qualitative study

Catherine A. Haddy, Helena M. Ward, Manya T. Angley, Ross A. McKinnon — 2009-10-16

Abstract: Background: Adverse drug reactions are recognized as a significant public health issue. Pharmacogenetics (PGx) provides a potential means of preventing some adverse drug reactions by predicting the optimal medication dose for an individual; however, PGx is rarely used in clinical practice. Thus far, there have been few studies investigating consumers' perceptions of the barriers to the implementation of PGx in clinical practice.Objectives: This study explored the views of the general public regarding their current use of medications, and their experiences of side effects and opinions on PGx.Methods: Members of the general public who suffered a chronic medical condition and/or had an immediate family member with a chronic medical condition were recruited to form 5 separate focus groups (n=35). Three separate age ranges were used in the focus groups. A questioning route was developed and used in focus groups to determine participants' experiences with medication use and opinions on PGx (referred to as “Personalized Medicine”). Focus group discussions were transcribed by 2 separate investigators, and qualitative analysis, based on the framework approach, was applied to the data. Data were independently coded to identify key themes then compared both within and between focus groups.Results: A common theme was a desire to have a holistic approach to disease diagnosis and medication selection. A wide range of views were expressed by the focus group participants. Concerns were raised regarding the current level of side effects experienced with medications. Storage and privacy of genetic information, and the costs involved, were also seen as potential barriers to implementation of PGx.Conclusions: PGx testing was seen as a potential positive contribution, but only if other factors were considered during the prescribing process. As participants desired a high level of information and effective communication from their health-care professionals, PGx education of clinicians and pharmacists will be essential to satisfy consumers' requirements.

Factors related to pharmacists' care of migraineurs

Shane P. Desselle, Monica L. Skomo — 2009-08-06

Abstract: Background: Migraine is a common, disabling, and underdiagnosed condition. Pharmacists are in an excellent position to help improve migraineur outcomes. The Pharmacists Care of Migraineurs Scale (PCMS) may be useful for documenting migraineur care and in the design and targeting of interventions aimed at improving care.Objectives: (1) To identify personal and situational work variables associated with pharmacists' provision of care to migraineurs that is measured using the PCMS; and (2) to determine which of these same variables are associated with each domain of care composing the PCMS.Methods: The PCMS is a 41-item measure eliciting pharmacists' frequencies of engagement in certain care behaviors comprising 7 unique domains. A survey questionnaire was mailed to a nationwide random sample of 6000 community pharmacists containing the PCMS and other items measuring personal and situational work variables. Factor scores of responses from a principal axis factoring procedure composing the PCMS were saved as dependent variables. Respondents' composite PCMS scores and each of the 7 factor scores were regressed over the personal and situational work variables in 8 unique stepwise regression procedures to identify those variables significant in explaining pharmacists' care of migraineurs.Results: The 3 independent study variables most closely related to provision of care to migraineurs were self-assessed knowledge of migraine, perceived difficulty (lack of), and caring ability. Models for individual PCMS domains were similar; however, some models included extroversion and pharmacy organizational culture variables, such as patient orientation and quality focus.Conclusions: Self-assessed knowledge of migraine, perceived lack of difficulty, and caring ability are important determinants in the level of care provided to migraineurs by pharmacists. Future study should further delineate the role of the pharmacy's work environment and pharmacists' training needs in elevating levels of care. Comprehensive continuing education programs on migraine management would appear advisable.

Full costs of dispensing and administering fluorouracil chemotherapy for outpatients: A microcosting study

2010-09-01

Abstract: Background: Although full costs (including direct and indirect costs) that incurred during the process of chemotherapy administration should be measured, many studies estimate only direct labor and medication costs associated with various chemotherapy delivery systems.Objectives: To estimate the total costs for dispensing and administration of fluorouracil when administered with leucovorin, by intravenous infusion or bolus, using a microcosting approach from the perspective of a provider or health system.Methods: A time-and-motion study was used to measure the time spent by (1) pharmacy staff in the handling, admixture, and dispensing of fluorouracil and (2) patients in the clinic. The study was performed at The Cancer Institute of New Jersey for an 8-month period. Costs of dispensing and administering fluorouracil were calculated per patient visit on the basis of resources used in the processing of fluorouracil and time spent by pharmacy staff and patient. All costs were standardized to 2005 dollars.Results: A total of 275 observations were made, and 74 (26.9%) of these were associated with fluorouracil-based chemotherapy. Pharmacy staff spent an average of 11 minutes for bolus fluorouracil with leucovorin infusion (fluorouracil/LCV-IV) and 8 minutes for bolus fluorouracil with bolus leucovorin (fluorouracil/LCV-B). Patients who received fluorouracil/LCV-IV spent an average of 203 minutes in the clinic, whereas patients who received fluorouracil/LCV-B spent 110 minutes. The average cost of administering fluorouracil/LCV-IV was $933, which comprised drug costs ($279), dispensing costs ($189), and administration costs ($465). The average cost of fluorouracil/LCV-B was $474, which comprised drug costs ($65), dispensing costs ($141), and administration costs ($268).Conclusions: This is the first study to formally demonstrate the high cost of administering the injectable form of fluorouracil chemotherapy with leucovorin, despite relatively low drug acquisition cost. Therefore, reimbursement rates for fluorouracil should be calculated in such a way that covers all costs, including overhead costs for the department.

Identifying early prescribers of Cycloxygenase-2 Inhibitors (COX-2s) in Nova Scotia, Canada: Considerations for targeted academic detailing

Kent E.M. Groves, Tony Schellinck, Ingrid Sketris, Neil J. MacKinnon — 2009-12-08

Abstract: Background: Expenditures on prescribed drugs in Canada are now well past those for all services provided by outpatient physicians ($26.9 billion vs. $21.5 billion in 2007). Government has the opportunity to dedicate resources to continuing medical education of physicians, and effective profiling would assist in the allocation of these educational resources.Objective: The purpose of this study was to evaluate physician prescribing patterns and establish criteria by which various prescribing profiles may be segmented and identified, so as to better target detailing and continuing medical education resources.Methods: A sample of 925 physicians practicing in Nova Scotia (NS) was characterized by age, sex, rural/urban nature of their practice and specialty. They were subsequently evaluated relative to all prescriptions filled by their patients who were beneficiaries of the NS Department of Health's senior's Pharmacare drug insurance program. The adoption of COX-2 inhibitors (eg, Vioxx® and Celebrex®) and their substitution for NS-NSAIDs (non-specific non-steroidal anti-inflammatory drugs, eg, Motrin®) from 1999 to 2003 were examined.Results: This analysis established the profiles of 2 key groups of physicians. The first consisted of those most likely to comprise the early, high volume COX-2-prescribing universe (profiles based on the absolute number of prescriptions written over a given period). These individuals were likely to be older, more experienced, male general practitioners operating in a rural practice. The second group consisted of those most likely to comprise the early, high-relative, COX-2-prescribing universe (prescribing of COX-2s relative to non-selective, non-steroidal anti-inflammatory drugs (NS-NSAIDs)). These individuals were likely to be younger, less experienced female general practitioners, operating in an urban practice.Conclusion: This research moves us closer to identifying unique physician segments that account for either the largest volume of prescriptions for new drugs, or the largest relative volume of prescriptions. Use of these physician groups can help continuing medical education providers target specific prescribers with information to assist them in examining and improving their prescribing.