Research in Social and Administrative Pharmacy

Collaborative prescribing: A qualitative exploration of a role for pharmacists in mental health

2011-08-10

Abstract: Background: Collaborative prescribing has been proposed as an extension of practice for advanced pharmacist practitioners. A lack of research investigating how pharmacists might be most effective as prescribers in mental health was identified.Objective: To explore health professionals’ and consumers’ attitudes and beliefs that relate to the role of specialist mental health pharmacists working as collaborative prescribers within their advanced scope of practice in secondary care.Methods: Semistructured interviews were conducted with key informants in the New Zealand mental health sector. Participants were selected via a purposive sampling method, including health professionals (n=9) and consumers (n=3). NVivo software was used to analyze data, using a thematic analysis approach to develop a series of key themes from the interviews. Common themes were extracted, which were used to gather results and draw conclusions.Results: The key findings include a widespread acknowledgment of the role of specialist pharmacists as collaborative prescribers in mental health and as integral members of the multidisciplinary team; however, consumers were unaware of pharmacists’ role in secondary care. The role was seen to extend current practice particularly in medication management after assessment and diagnosis by a medical practitioner. Concerns regarding demonstrating competence, practitioner role/boundary confusion, insufficient training and workforce development, hesitancy by pharmacists to extend role, consumer awareness, and public perception of the traditional pharmacist role were identified. Solutions discussed included education by the profession; relationship building, training, and robust competency assessments; and a structured framework for implementing a collaborative prescribing model.Conclusions: This study suggests there was recognition and acceptance of the role that specialist pharmacist practitioners could play in contributing to the care of mental health consumers as collaborative prescribers; their medication expertise being regarded highly. Further research is necessary to investigate how current resource constraints will allow for collaborative prescribing to be implemented within the context of mental health practice.

The association of race, comorbid anxiety, and antidepressant adherence among Medicaid enrollees with major depressive disorder

Chung-Hsuen Wu, Steven R. Erickson, John D. Piette, Rajesh Balkrishnan — 2011-09-28

Abstract: Background: Depressed patients often have comorbid anxiety. African-Americans with depression are less likely to adhere to antidepressant treatment. Knowledge of the association between race, comorbid anxiety, and adherence among Medicaid enrollees with depression is limited.Objective: The objective of this study was to evaluate the association of race, comorbid anxiety, and antidepressant adherence, and persistence among Medicaid enrollees with major depressive disorder (MDD).Methods: The MarketScan® Multi-State Medicaid Database (Thomson Reuters, Ann Arbor, MI) was used in this retrospective cross-sectional study. Medicaid enrollees aged between 18 and 64 years, with MDD but without bipolar disorders, and with a newly initiated antidepressant between January 1, 2004 and December 31, 2006 were identified. An index date was assigned corresponding to the newly initiated antidepressant. Patients having claims for any antidepressant refills during the 12 months before the index date were excluded. Eligible patients were then followed-up for 12 months after the index date. Adherence was measured by a modified medication possession ratio. Adherence was evaluated using multivariate logistic regression. Persistence was assessed based on treatment discontinuation and examined by Kaplan-Meier survival curves and Cox-propositional hazard regression models.Results: A total of 3083 Medicaid patients with MDD were included. Approximately, 25% of patients had comorbid anxiety. The odds of adhering to antidepressants were 40% lower among African-Americans than Caucasians, adjusting for covariates (AOR [adjust odds ratio]=0.60; 95% confidence interval [CI]=0.51-0.72, P<.001). MDD patients with comorbid anxiety were more likely to adhere to antidepressants than patients with MDD alone (AOR=1.55, 95% CI=1.27-1.90, P<.001). African-Americans had a higher hazard of not persistently taking antidepressants (hazard ratio=1.47, 95% CI=1.30-1.65, P<.001). The interaction between race and comorbid anxiety was not associated with adherence or persistence.Conclusions: Among Medicaid enrollees with MDD, race and comorbid anxiety disorders are significantly associated with antidepressant adherence and persistence. Physicians need to recognize comorbid anxiety and race as 2 important determinants of antidepressant use behaviors when they encounter Medicaid patients with MDD.

A qualitative assessment of a community pharmacy cognitive pharmaceutical services program, using a work system approach

Michelle A. Chui, David A. Mott, Leigh Maxwell — 2011-08-08

Abstract: Background: Although lack of time, trained personnel, and reimbursement have been identified as barriers to pharmacists providing cognitive pharmaceutical services (CPS) in community pharmacies, the underlying contributing factors of these barriers have not been explored. One approach to better understand barriers and facilitators to providing CPS is to use a work system approach to examine different components of a work system and how the components may impact care processes.Objectives: The goals of this study were to identify and describe pharmacy work system characteristics that pharmacists identified and changed to provide CPS in a demonstration program.Methods: A qualitative approach was used for data collection. A purposive sample of 8 pharmacists at 6 community pharmacies participating in a demonstration program was selected to be interviewed. Each semistructured interview was audio recorded and transcribed, and the text was analyzed in a descriptive and interpretive manner by 3 analysts. Themes were identified in the text and aligned with 1 of 5 components of the Systems Engineering Initiative for Patient Safety (SEIPS) work system model (organization, tasks, tools/technology, people, and environment).Results: A total of 21 themes were identified from the interviews, and 7 themes were identified across all 6 interviews. The organization component of the SEIPS model contained the most (n=10) themes. Numerous factors within a pharmacy work system appear important to enable pharmacists to provide CPS. Leadership and foresight by the organization to implement processes (communication, coordination, planning, etc.) to facilitate providing CPS was a key finding across the interviews. Expanding technician responsibilities was reported to be essential for successfully implementing CPS.Conclusions: To be successful in providing CPS, pharmacists must be cognizant of the different components of the pharmacy work system and how these components influence providing CPS.

Self-reported responses to medication therapy management services for older adults: Analysis of a 5-year program

Daniel M. Cook, Paula V. Moulton, Teresa M. Sacks, Wei Yang — 2011-09-28

Abstract: Background: Medication therapy management (MTM) services provide essential reviews of drug regimens and are increasingly recognized as beneficial to patient safety, improved health outcomes, and cost savings.Objective: To assess patient behavioral outcomes from an MTM service, including actions following receipt of a pharmacist report.Methods: A retrospective analysis of an MTM program at the Sanford Center for Aging (NV, USA) was conducted. Outcome measures included whether the patient discussed the review with the physician, whether any changes in the client’s drug regimen occurred, and whether the client feels more knowledgeable about his or her medications. Predictor variables included basic demographics, prescription insurance status, number of prescriptions taken, self-reported health status, and use of medications considered to be high risk. The analysis plan involved the use of multivariate logistic regression models.Results: The odds of discussing the medication review with physicians, making changes recommended in the report, and both discussing and making a change were 65%, 60%, and 67%, respectively, lower among those below poverty level than among those above poverty level; 95% confidence intervals (CIs): 0.15, 0.80; 0.18, 0.85; and 0.15, 0.73, respectively. The odds of those using high-risk drugs of making changes in drug regimens, and of discussing with physicians and making changes together, were 2 times higher than the odds of those not using these drugs, 95% CIs: 1.02, 4.31 and 1.20, 4.87, respectively. The likelihood of those reporting good or excellent health of doing the combination of discussing the MTM report with physicians and to make a drug regimen change was 2 times greater than for those reporting poor to fair health, 95% CI: 1.08, 3.65. Gender, ethnicity, age group, rural status, prescription drug insurance, and high polypharmacy were not significant factors for acting on the medication review in the adjusted model.Conclusion: MTM services are associated with enhanced patient self-advocacy, but like other interventions, they are constrained by social disparities. Greater attention to the resources of target populations to respond to pharmacy services is merited.

Rurality and other factors associated with adherence to immunosuppressant medications in community-dwelling solid-organ transplant recipients

2011-08-19

Abstract: Background: Data on immunosuppressant adherence of community-dwelling adult solid-organ transplant recipients (SOTRs) from rural populations in the United States are limited. Therefore, understanding the association of rurality and other factors of immunosuppressant adherence will help providers design and deliver patient-centered adherence enhancing interventions.Objectives: The objective was to examine factors associated with a previously validated 4-item Immunosuppressant Therapy Adherence Scale (ITAS) score in community-dwelling adult SOTRs who received a transplant from an academic center in the Midwestern United States.Methods: For this observational study, cross-sectional survey data (patient demographic, medical condition, immunosuppressant therapy, and self-reported ITAS) received from adult SOTRs aged 19 years or older with other data from an academic transplant center’s database were merged. Using multivariate logistic regression, significant SOTR characteristics associated with being adherent (ITAS score=12) versus nonadherent (ITAS score <12) were examined.Results: The survey response rate was 30% (n=556/1827). Those SOTRs responding (n=556) had a kidney (48%), liver (47%), or other (4.5%) transplant. They were more likely to be 50- to 64-year olds (52%), men (55%), white (90%), metroresident (59%), with an annual income less than $55,000. The SOTRs were living with a transplant for 6.3 years (median), reported excellent-to-good health status (77%), and received different immunosuppressant regimens. More than half of the SOTRs (58%) were adherent. In multivariate analyses, compared with patients aged 65 years or older, younger patients, nonmetro rural- versus metroresident, and those having more (≥6) versus less (<6) comorbidities were significantly less likely to report adherence. SOTRs receiving tacrolimus-based combination immunosuppressant versus tacrolimus alone were more likely to report adherence.Conclusions: When designing and delivering patient care-centered interventions including those that use technology to increase immunosuppressant adherence, providers need to consider rural residence besides other well-established patient factors (younger age, immunosuppressant drug, and comorbidities) of nonadherence.

Characterizing specialized compounding in community pharmacies

Jennifer Anne Giam, Andrew J. McLachlan, Ines Krass — 2011-08-08

Abstract: Background: Compounding is a traditional role of pharmacists that declined with the availability of manufactured medicines. Compounding is now increasingly offered by community pharmacies as a specialized service, and there are calls for regulatory and practice standard changes. However, the characteristics of specialized compounding are not well understood.Objectives: The objective of this study was to conduct an in-depth exploration of the motivations, experiences, and practices of pharmacists who deliver “specialized compounding services” in Australian pharmacies.Methods: In-depth interviews of 18 pharmacists responsible for compounding in pharmacies offering specialized compounding were conducted using a semistructured interview guide based on an organizational framework. Participants were selected using purposive sampling. Characteristics of specialized compounding practice compared with routine compounding and routine dispensing were explored. Interviews were audiotaped and transcribed verbatim, then analyzed using the method of “constant comparison” to identify emergent themes.Results: Pharmacists providing specialized compounding reported that compared with their prior routine practice, they used a greater variety of ingredients and dosage forms for more clinical conditions, used different equipment and processes, and had upgraded facilities for handling compounded products. Patient and physician interactions were more involved and in the case of physicians, more collaborative compared with routine dispensing. Participants reported feeling more empowered in their roles, with improved professional satisfaction.Conclusions: Pharmacists in specialized compounding pharmacies report greater collaboration and interaction with prescribers and patients compared with their routine compounding and dispensing. This contributed to perceptions of empowerment and increased professional satisfaction. Specialized compounding may also be an avenue for reprofessionalization. The organization of compounding as a specialized service should be considered in proposed changes to compounding regulations and practice standards.

Challenges to counseling customers at the pharmacy counter—Why do they exist?

Susanne Kaae, Janine Morgall Traulsen, Lotte Stig Nørgaard — 2011-09-28

Summary: Challenges to engage pharmacy customers in medicine dialogues at the counter have been identified comprising a new and extended clinical role for pharmacists in the health care system. This article seeks to expand understanding of factors involved in successful interaction at the pharmacy counter between customers and pharmacy staff to develop their relationship further. Practical challenges to customer encounters experienced by community pharmacists are discussed using theory from the field of mainly inter-relational communication and particular studies on pharmacy communication. Preconceived expectation of customers, the type of question asked by pharmacy staff, and differences in perception of illness and medicines between staff and customers are discussed. Both staff and customer influence the outcome of attempts by pharmacy staff to engage customers in dialogue about their medicine use through a complex mechanism of interaction. It is recommended that practitioners and researchers begin to distinguish, both theoretically and practically, between the content of a conversation and the underlying relationship when exploring and further developing the therapeutic relationship between pharmacy personnel and customers.

Separation of prescribing and dispensing in Malaysia: A summary of arguments

Asrul Akmal Shafie, Mohamed Azmi Hassali, Saira Azhar, Ooi Guat See — 2011-08-08

Summary: The role of pharmacists has transformed significantly because of changes in pharmacists' training and population health demands. Within this context, community pharmacists are recognized as important health personnel for the provision of extended health services. Similarly, in Malaysia, the need to transform community pharmacy practice has been discussed by all interested parties; however, the transition has been slow due in part to the nonexistence of a dispensing separation policy between pharmacists and medical doctors in private community practices. For decades, medical doctors in private community practices have had the right to prescribe and dispense, thus diluting the role of community pharmacists because of overlapping roles. This article explores dispensing separation in Malaysia and, by taking into account the needs of health professionals and health care consumers, suggests a mechanism for how dispensing separation practice can be implemented.

The quality of online antidepressant drug information: An evaluation of English and Finnish language Web sites

Marjo Prusti, Susanna Lehtineva, Marika Pohjanoksa-Mäntylä, J. Simon Bell — 2011-06-29

Abstract: Background: The Internet is a frequently used source of drug information, including among people with mental disorders. Online drug information may be narrow in scope, incomplete, and contain errors of omission.Objective: To evaluate the quality of online antidepressant drug information in English and Finnish.Methods: Forty Web sites were identified using the search terms antidepressants and masennuslääkkeet in English and Finnish, respectively. Included Web sites (14 English, 8 Finnish) were evaluated for aesthetics, interactivity, content coverage, and content correctness using published criteria. All Web sites were assessed using the Date, Author, References, Type, Sponsor (DARTS) and DISCERN quality assessment tools.Results: English and Finnish Web sites had similar aesthetics, content coverage, and content correctness scores. English Web sites were more interactive than Finnish Web sites (P<.05). Overall, adverse drug reactions were covered on 21 of 22 Web sites; however, drug-alcohol interactions were addressed on only 9 of 22 Web sites, and dose was addressed on only 6 of 22 Web sites. Few (2/22 Web sites) provided incorrect information. The DISCERN score was significantly correlated with content coverage (r=0.670, P<.01), content correctness (r=0.663, P<.01), and the DARTS score (r=0.459, P<.05).Conclusions: No Web site provided information about all aspects of antidepressant treatment. Nevertheless, few Web sites provided incorrect information. Both English and Finnish Web sites were similar in terms of aesthetics, content coverage, and content correctness.

2012-05-01