Research in Social and Administrative Pharmacy - Articles in Press

The role of the community pharmacist in fulfilling information needs of patients starting oral antidiabetics - Corrected Proof

Egbert J.F. Lamberts, Marcel L. Bouvy, Rolf P. van Hulten — 2010-01-18

Abstract: Background: Community pharmacy is in the middle of a paradigm shift from provider of medication to provider of care around medication. Much of this care involves giving information to patients so as to maximize pharmacotherapy outcomes; however, this is not necessarily recognized by patients. The initiation of chronic medication for diseases, such as type 2 diabetes mellitus (T2DM), arouses much uncertainty in patients, and it is not certain how information provision roles by pharmacists are viewed.Objectives: To obtain insight in the information needs of patients who have recently started treatment with oral antidiabetics and to investigate the opportunities for pharmacy regarding the provision of information for patients with T2DM.Methods: A qualitative study with both semistructured telephone interviews and patient focus group discussions was conducted. Individual patients' comments were categorized and used in a strengths, weaknesses, opportunities, and threats (SWOT) analysis exploring the role of the community pharmacist in the field of providing information at the moment of initiation of T2DM oral medication.Results: From interviews with 42 patients and 2 focus groups, discussions emerged that the general practitioner (GP) does not fulfill all information needs. For the pharmacist, there is an opportunity, as patients feel a need for information and like to discuss drug-related issues. SWOT analysis revealed main strengths of the pharmacy as “expertise” and “service and kindness.” Together with more cooperation with GPs and nurse practitioners, these strengths give the pharmacist the opportunity to further develop pharmaceutical care activities.Conclusion: Pharmacists are challenged to increase their visibility as health care provider while keeping logistic service on a high level and improving cooperation with other health care providers.

Examining the development of pharmacist-physician collaboration over 3 months - Corrected Proof

Yifei Liu, William R. Doucette, Karen B. Farris — 2010-01-18

Abstract: Background: Pharmacist-physician collaboration may result in improved patient care. The model of collaborative working relationship (CWR) synthesizes such collaboration into 5 progressive stages, which are impacted by individual, context, and exchange characteristics; however, no study has demonstrated how to distinguish the 5 collaborative stages.Objective: Using CWR, the study objective was to identify factors associated with pharmacist-physician collaboration at baseline and at 3 months.Methods: This study consisted of 2 self-administered surveys mailed to a random sample of 750 Iowa pharmacists. The first survey assessed collaborative care at baseline and individual, context, and exchange characteristics. The second survey assessed collaborative care 3 months later. The measures for CWR constructs were modified from previously validated instruments. Individual characteristics; context characteristics, including practice setting, professional interaction, current collaboration status (yes/no); and exchange characteristics, including relationship initiation, trustworthiness, and role specification were obtained. Descriptive statistics, reliability analysis, and bivariate correlations were performed. Two regressions were conducted, wherein collaborative care at baseline and at 3 months were regressed over relationship initiation, trustworthiness, role specification, professional interaction, current collaboration, practice setting, and physician specialty, wherein the data for independent variables collected at baseline were used in both regression procedures.Results: Response rates were 33% (n=239) and 79% (n=188) for the first and second surveys, respectively. In the regression analyses, 85% and 35% of the variance in collaborative care at baseline and at 3 months, respectively, were explained. Trustworthiness and role specification were 2 predictors of collaborative care at baseline, and trustworthiness and professional interaction were 2 predictors of collaborative care at 3 months.Conclusions: Different factors were associated with collaborative care at different study times, which support a dynamic model of CWR.

Variation in patients' and pharmacists' attribution of symptoms and the relationship to patients' concern beliefs in medications - Corrected Proof

Olayinka O. Shiyanbola, Karen B. Farris — 2010-01-18

Abstract: Background: The process by which symptoms are identified and characterized is related to adverse drug event reporting. Patient and pharmacist symptom attribution may differ and be related to certain patient characteristics.Objectives: (1) To compare attribution of symptoms to a cause for patients and pharmacists; (2) to quantify the association between patients' concern beliefs and patient-pharmacist agreement on patients' symptom attribution to medications; and (3) to identify any associations between patients' propensity to agree with pharmacists' assessments of symptom attribution with various clinical and/or sociodemographic characteristics.Methods: An Internet survey of Medicare beneficiaries was administered by Harris Interactive®. The survey elicited information on health symptoms that subjects experienced and to whom they reported these symptoms. If subjects did not experience symptoms and did not report them, the reasons for not reporting were elicited. A clinical expert panel reported ratings about respondents' (1) likelihood of the symptom experienced being attributed to a medication and (2) probability of the symptom being attributed to the reason the patient stated. Frequencies of unreported symptoms for each reason/category were examined. Chi-square and Fisher's exact test analyses examined the variations between patients' and pharmacists' ratings of symptom attribution to medications and associations between attribution and patient sociodemographic and clinical characteristics, such as the number of medications used. Independent sample t tests examined how attributions were related to concern beliefs.Results: Most patients thought their symptom(s) were the result of their disease, something other than medications or age. There was no statistically significant difference between patients' and pharmacists' symptom attribution (χ2=1.376, P=.24). Individuals whose symptom attributions differed from pharmacists were likely to have stronger concern beliefs in medication (t=−3.03, P<.01).Conclusions: Patients' concern about their medications may be related to their symptom attributions. Older adults may not consider these concerns when asked about their symptom attributions.

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

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.

Characteristics of container labeling in a sample of commonly prescribed children's oral medications - Corrected Proof

Lorraine S. Wallace, Amy J. Keenum, Jennifer E. DeVoe — 2009-12-08

Abstract: Background: Time constraints often limit the amount of instruction pharmacists can provide to patients regarding accurate prescription medication use.Objectives: To assess the content, text point size, and reading difficulty of medication container labels and auxiliary warning labels (stickers) of 2 commonly prescribed children's medications (prednisolone and amoxicillin) dispensed by 20 US pharmacies. Secondly, to examine variability of pharmacy interpretations of electronically generated physician instructions (signatures [sigs]).Methods: All medication container labels were evaluated on the following: presence and rank order of 7 Food and Drug Administration (FDA)-required label items, presence of additional label content (eg, fill date), and whether each label content item was emphasized in some way (eg, highlighting). Presence, placement, content, and color of auxiliary warning labels (stickers) were also assessed. Text point size of pharmacy name, instructions, medication name, and instructional/warning stickers was measured to the nearest centimeter. Reading grade level (RGL) of medication label instructions and auxiliary warning labels was estimated using the Lexile Analyzer (available via the Internet [http://www.lexile.com]). Amount and timing of medication administration of pharmacy interpretations of sigs were examined.Results: All containers included the 7 FDA-required label items. Text point sizes varied widely (pharmacy name [mean ± standard deviation [SD] = 12.0 ± 3.9] versus auxiliary warning labels [mean ± SD = 6.8 ± 1.1]). Four (10%) containers did not include any additional type of warnings related to the medication, beyond the dosage amount and administration frequency. Mean Lexile score of warning stickers was 488.3 ± 316.3 (approximately third to fourth RGL), whereas that of pharmacy-generated instructions was 648.3 ± 215.9 (approximately fifth to sixth RGL). Prednisolone sig instructions were presented in 14 distinct ways by the pharmacies, whereas amoxicillin sig instructions were interpreted in 16 different ways.Conclusions: Although all prescriptions reviewed met the minimum FDA-required labeling standards, pharmacy characteristics were more likely to be prominently emphasized on the labels than were medication instructions and patient information. Systematic initiatives to standardize and call attention to key medication instructions and warnings should be considered.

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? - Corrected Proof

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.

Problem prescriptions in Sweden necessitating contact with the prescriber before dispensing - Corrected Proof

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.

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

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.

Consumers' views of pharmacogenetics—A qualitative study - Corrected Proof

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.

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

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.

Electronically transmitted prescriptions not picked up at pharmacies in Sweden - Corrected Proof

Fredrik Ax, Anders Ekedahl — 2009-10-12

Abstract: Background: Electronically transmitted prescriptions (ETPs) became common after 1995 in Sweden; however, it is accompanied by a substantial increase in the number of prescriptions not picked up at pharmacies.Objective: To investigate the “no pick-up” rates of ETPs at pharmacies across type of drug and patient age and gender and the reasons patients' report for no pick-up.Methods: A cross-sectional study examining no pick-up of ETPs transmitted during 3 months in 2002, and a mail survey of patients to determine the reasons for failure to pick-up in the county of Sörmland, Sweden, with a population of 261,000, and 21 pharmacies. Chi-square tests were used for calculations of frequency differences among groups.Results: The overall no pick-up rate of ETPs was 2.5%; men had consistently higher rates than women. The highest rates were seen for adolescents and young adults. Rates were higher than average for antibiotics. About 60% of the answers indicated that prescriptions not picked up were duplicate prescriptions or not needed. “Unintentional nonadherence” was reported by one-fifth of patients.Conclusions: No pick-up rate in general was low (2.5%), but there were differences across patient age and gender, the rates being higher among adolescents and young adults. Duplicate prescriptions may explain a significant share of the abandoned prescriptions.

Development of a new scale to measure self-reported medication nonadherence - Corrected Proof

Elizabeth J. Unni, Karen B. Farris — 2009-10-12

Abstract: Background: A major drawback in the medication adherence literature today is the absence of a gold standard for measuring medication adherence. Objective measures of nonadherence such as prescription claims and pill count, while quantifying nonadherence, do not provide the reasons for nonadherence, hence making it difficult to develop intervention strategies. Self-reported measures are helpful to determine reasons for nonadherence; however, widely used self-reported measures such as the Morisky scale are restricted to only few potential reasons.Objectives: The objective of this study was to develop a new scale to measure self-reported nonadherence and to compare it with the existing Morisky scale.Methods: A cross-sectional study of adult U.S. population on cholesterol-lowering and asthma maintenance medications was used. Data on nonadherence were collected using (1) the newly developed Medication Adherence Reasons Scale (MARS), (2) Morisky scale, and (3) an objective self-reported measure.Results: A total of 840 responses were collected. Factor analysis of MARS resulted in 5 subscales in cholesterol-lowering medications and 3 subscales in asthma maintenance medications. The level of agreement between both scales in identifying adherents and nonadherents as measured by kappa coefficient was 0.381 in cholesterol-lowering medications and 0.545 in asthma medications. MARS was able to identify various other significant reasons for nonadherence than that identified by the Morisky scale.Conclusion: A new subjective measure of medication nonadherence based on the frequently reported reasons of nonadherence was developed, and it showed adequate reliability when compared with the Morisky scale to warrant future study.

Prescribing trends for management of congestive heart failure from 2002 to 2004 - Corrected Proof

Tonya Crawford, Larry W. Segars, Rafia S. Rasu — 2009-09-22

Abstract: Background: The incidence and prevalence of the patients diagnosed with congestive heart failure (CHF) continues to grow in the United States. The use of prescription drugs is a vital part of the management of CHF, and pharmacological regimens may vary among patients.Objectives: To examine the CHF prescription trends in the United States and to determine present prescribing patterns.Methods: National Ambulatory Medical Care Survey and both divisions (outpatient and emergency department) of the National Hospital Ambulatory Medical Care Survey from 2002 to 2004 were used to acquire the appropriate data. All analyses used weighted data to represent national estimates. The unit of analysis was individual patient visits. Analysis of the data was accomplished using SPSS 14.0.2 and Stata/SE 9.2 statistical programs.Results: During the 3 study years, 24,213,096 weighted visits were associated with a diagnosis of CHF. More than half (56.2%) of the study population were female; over 75% of the subjects were older than 65 years. Over one-quarter (27.3%; 6,618,208 visits) of CHF-related visits were not associated with being prescribed a CHF-related medication. Loop diuretics were the most commonly used medication (35%). Cardiovascular specialists (odds ratio [OR]=5.28; 95% confidence interval [CI]: 1.82-15.3; P=.002), general/family practice physicians (OR=4.5, 95% CI: 1.69-12.0; P=.003), and internal medicine physicians (OR=3.85, 95% CI: 1.39-10.7; P=.010) were more likely to prescribe CHF-related medication compared with other medical specialties. CHF patients who reside in the Northeast were more likely to receive CHF-related medications than other regions (Midwest OR=0.24; South OR=0.20; West OR=0.23; P<.05) of United States.Conclusions: There were regional and medical specialty-related variations for prescribing CHF-related medications. The results from this study suggest a need for increased awareness of the benefit of CHF-related medications in the management of CHF. The increased implementation of the CHF management guidelines would improve overall patient care.

Patterns and predictors of antipsychotic medication use among the U.S. population: Findings from the Medical Expenditure Panel Survey - Corrected Proof

Chi-Chuan Wang, Joel F. Farley — 2009-09-22

Abstract: Background: Given the importance of pharmacological treatment in mental disorders, it is important to have a thorough understanding of predictors and variations in antipsychotic use.Objective: To provide a description of patient characteristics associated with antipsychotic use and to examine predictors of atypical antipsychotic use among antipsychotic users.Methods: Data were obtained from the 2004 and 2005 Medical Expenditure Panel Survey. Dependent variables were annual, self-reported, atypical and typical antipsychotic use. Independent variables included predisposing, enabling, and need characteristics according to Andersen's Behavioral Model. In addition to descriptive statistics, logistic regression analyses were performed to examine the determinants of antipsychotic use.Results: Patients aged 65 and older were 0.63 times as likely to use antipsychotics as patients aged 26-45. Poor and near-poor patients were 1.55 and 1.37 times as likely to use antipsychotics as middle- to high-income patients, respectively. The odds of antipsychotic use were 2.95 and 1.99 times for patients with public and prescription insurance coverage, respectively. Patients with a usual source of health care were 1.51 times as likely to use antipsychotics as those without. Compared with typical antipsychotic use, patients aged 25 and younger were 3.88 times as likely to use atypical antipsychotics as patients aged between 26 and 45. Urban residents were 1.87 times as likely as rural residents to use atypical antipsychotics. The odds of antipsychotic and atypical antipsychotic use for the poor mental health population were 8.73 and 3.87 times as patients with good to excellent mental health status.Conclusions: Predisposing and need factors play important roles in determining the use of antipsychotics. However, among antipsychotic users, the use of atypical versus typical antipsychotics appears to have been influenced primarily by need. These findings should be useful to clinicians and policy makers in directing antipsychotic treatments to patients in need.

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

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.

A latent class analysis of job satisfaction and turnover among practicing pharmacists - Corrected Proof

Patrick C. Hardigan, Nisaratana Sangasubana — 2009-08-17

Abstract: Background: Research on job satisfaction and turnover using latent class analysis (LCA) has been conducted in other disciplines. LCA has seldom been applied to social pharmacy research and may be especially useful for examining job situation constructs in pharmacy organizations.Objective: The objective of the study was to determine the probability of turnover among practicing pharmacists using LCA.Methods: Using a cross-sectional descriptive design, 2400 randomly selected pharmacists with active licenses in Florida were surveyed. A model was created using LCA, then fit indices were used to determine whether underlying “job satisfaction clusters” were present. Once identified, these clusters along with the covariate practice site were modeled on a distal outcome turnover.Results: A 5-class model appeared to best fit the data: a “pseudo-satisfied” class that contained 8% of the sample, a “career-goal” class that contained 11% of the sample, a “satisfied class” that contained 44% of the sample, a “job-expectation” class that contained 3% of the sample, and an “unsatisfied class” that contained 17% of the sample. In terms of predicting the distal outcome “turnover,” the calculated odds ratios indicate that compared with class 3 or the satisfied group, class 2 was 14 times more likely, class 4 was 17 times more likely, and class 5 was 26 times more likely to state that they do not intend to be employed with their current employer 1 year from now.Conclusion: The LCA method was found to be effective for finding relevant subgroups with a heterogeneous at-risk population for turnover. Results from the analysis indicate that job satisfaction may be parsed into smaller, more interpretable and useful subgroups. This result holds great promise for practitioners and researchers, alike.

Factors related to pharmacists' care of migraineurs - Corrected Proof

Shane P. Desselle, Monica K. 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.

A multi-theoretical approach to linking medication adherence levels and the comparison of outcomes - Corrected Proof

Nathaniel M. Rickles — 2009-08-03

Abstract: Background: There has been relatively little theoretical research exploring the cognitive complexity of how patients decide the level to which they adhere to prescribed regimens.Objectives: To integrate various psychosocial theories into a conceptual framework to review how patients relate their medication use behavior to therapeutic outcomes and how such relationships affect subsequent medication use.Methods: Key psychosocial theories were reviewed involving health beliefs and medication adherence, individual control, and how individuals might compare outcomes with expectations and alternatives. These concepts were integrated into one larger multilevel explanatory model, the Dynamic Exchange Model for Medication Adherence Levels and Comparison of Outcomes (DEMMALCO), explaining how patients might attribute outcomes related to their medication use and choose future actions based on expectations and alternatives available. Key assumptions of the model were also identified.Results: DEMMALCO indicates that patients make initial attributions of their control over their illness, which affects their subsequent adherence to their regimens. The model suggests that patients actively compare their treatment outcomes with their expectations about outcomes and the outcomes that are related to their best alternative. They are thought to reassess how their control in treatment was related to those outcomes and subsequently modify their adherence behavior based on the presence or absence of resources.Conclusions: Strengths and limitations of the model are noted. DEMMALCO may help inform researchers and clinicians on new ways to conceptualize, monitor, and change medication adherence behavior.

Roles and responsibilities of pharmacists with respect to natural health products: Key informant interviews - Corrected Proof

Shade Olatunde, Heather Boon, Kristine Hirschkorn, Sandy Welsh, Jana Bajcar — 2009-07-30

Abstract: Background: Although many pharmacies sell natural health products (NHPs), there is no clear definition as to the roles and responsibilities (if any) of pharmacists with respect to these products.Objective: The purpose of this study was to explore pharmacy and stakeholder leaders' perceptions of pharmacists' professional NHP roles and responsibilities.Methods: Semi-structured key informant interviews were conducted with pharmacy leaders (n=17) and stakeholder (n=18) leaders representing consumers, complementary and alternative medicine practitioners, conventional health care practitioners, and industry across Canada.Results: All participants believed a main NHP responsibility for pharmacists was in safety monitoring, although a one challenge identified in the interviews was pharmacists' general lack of NHP knowledge; however, stakeholder leaders did not expect pharmacists to be experts, but should have a basic level of knowledge about NHPs.Conclusion: Participants described pharmacists' professional roles and responsibilities for NHPs as similar to those for over-the-counter drugs; more awareness of existing NHP-related pharmacy policies is needed, and pharmacy owners/managers should provide additional training to ensure front-line pharmacists have appropriate knowledge of NHPs sold in the pharmacy.

Health care consequences of black-box warnings for antidepressants in the United States and Canada - Corrected Proof

Saurabh Nagar, Sandhya Mehta, Vinod Bhatara, Rajender Aparasu — 2009-07-30

A black-box warning is a health advisory that the U.S. Food and Drug Administration (FDA) requires a pharmaceutical company to place in the labeling of specific agents or classes of medications. These boxed warnings inform prescribers about a significant risk of serious or life-threatening adverse effects. A black-box warning is the strongest warning issued by the FDA and is so named because of the black border that usually surrounds the text of the warning. In recent years, FDA has required black-box warnings for several psychotropic classes, including antipsychotics for geriatric use and antidepressants for pediatric use.

Community pharmacists' prescription intervention practices—Exploring variations in practice in Norwegian pharmacies - Corrected Proof

Ingunn Mandt, Anne Marie Horn, Anders Ekedahl, Anne Gerd Granas — 2009-07-30

Abstract: Background: Evidence suggests that prescription intervention frequencies have been found to vary as much as 10-fold among Norwegian pharmacies and among pharmacists within the same pharmacy.Objective: To explore community pharmacists' perceptions of how their prescription intervention practices were influenced by their working environment, their technological resources, the physical and social structures of the pharmacies, their relations with colleagues, and to the individual pharmacist's professional skills.Methods: Two focus groups consisting of 14 community pharmacists in total, from urban and rural areas in Norway, discussed their working procedures and professional judgments related to prescription interventions. Organizational theories were used as theoretical and analytical frameworks in the study. A framework based on Leavitt's organizational model was to structure our interview guide. The study units were the statements of the individual pharmacists. Recurrent themes were identified and condensed.Results: Two processes describing variations in the dispensing workflow including prescription interventions were derived—an active dispensing process extracting information about the patient's medication from several sources and a fast dispensing process focusing mainly on the information available on the prescription. Both workflow processes were used in the same pharmacies and by the same pharmacist but on different occasions. A pharmacy layout allowing interactions between pharmacist and patients and a convenient organization of technology, layout, pharmacist-patient and pharmacist-coworker transactions at the workplace was essential for detecting and solving prescription problems. Pharmacists limited their contact with general practitioners when they considered the problem a formality and/or when they knew the answers themselves. The combined use of dispensing software and the Internet was a driving force toward more independent and cognitively advanced prescription interventions.Conclusion: Implementation of a general organizational model made it easier to analyze and interpret the pharmacists' intervention practices. Working environment, technology, management and professional skills may all contribute to variations in pharmacists' prescription intervention practices in and between community pharmacies.

Pharmacists' experience of conflict in community practice - Corrected Proof

Zubin Austin, Paul A.M. Gregory, J. Craig Martin — 2009-07-30

Abstract: Background: Interpersonal conflict may be characterized as intellectual disagreement with emotional entanglement. Although interpersonal conflict has been studied and described in different health care settings, there is little research that focuses on community pharmacists and the ways in which they experience conflict in professional practice.Objective: To describe and characterize the experience of interpersonal conflict within community pharmacy practice.Methods: A self-reporting narrative log was developed in which actively recruited pharmacists reported and reflected on their day-to-day experiences of interpersonal conflict in professional practice. Focus groups of pharmacists were convened after data analysis to provide context and confirmation of identified themes. Based on this analysis, an explanatory model for interpersonal conflict in community pharmacy practice was generated.Participants were actively recruited from community pharmacy settings in the Toronto (Canada) area. A total of 41 community pharmacists participated.Findings: Interpersonal conflict in pharmacy practice is ubiquitous and results from diverse triggers. A conflict stance model was developed, based on the worldview and the communication style of the individual pharmacist. Specific conflict stances identified were imposing, thwarting, settling, and avoiding. Further testing and refinement of this model are required.Conclusion: The impact of conflict in pharmacy practice is significant. Pharmacists' experience of conflict led to development of the 4-stance model described in this research: further work to confirm this model and to extend it to other pharmacy practice or health care settings is required. In addition, further work to discern methods for enhancing conflict resolution and management skills of pharmacists using this model should be undertaken.

Letter to the editor - Corrected Proof

Claude Dussart, Gilles Grelaud — 2009-07-30

A shift in practice philosophy at a French military teaching hospital pharmacy: Practice and research implications To improve the accuracy of dispensing, the French military teaching hospital “Desgenettes” in Lyon, France has implemented a prescription system with individualized daily dispensing, in use since 1992. This system of medication distribution is a pharmacy-coordinated method of dispensing and controlling medications in organized health-care settings. Medications are contained in single unit packages dispensed in a ready-to-administer form. Not more than a 24-hour supply of doses is delivered to or available at the patient care area at any time. This system has been computerized since 1996. Today, 280 of the 296 beds of the establishment are served by the system. Pharmacists monitor all medication therapy for patients.

Letter to the editor - Corrected Proof

Salah Aburuz — 2009-07-30

The Case for Evidence-Based Pharmaceutical Care: Pharmaceutical care was defined by Hepler and Strand in the early 1990s as the responsible provision of drug-related care for the purpose of achieving definite outcomes that improve patients' quality of life. Since that time, pharmaceutical care has evolved and is currently being applied in many countries around the world. Medication therapy management represents some addition to the paradigm but is based mainly on the concept and principles of pharmaceutical care.

Forward and backward transitions in pharmacy-based immunization services - Corrected Proof

Salisa C. Westrick — 2009-04-29

Abstract: Background: Community pharmacies can engage in immunization services by contracting with an external workforce (outsourced mechanism) or staff pharmacists (in-house mechanism) to deliver the services. Because an outsourced mechanism generally requires lower organizational commitment, pharmacies often start with an outsourced mechanism. Later, these pharmacies can have 1 of the following transitions: sit on a fence by continuing with an outsourced mechanism, move backward by abandoning any immunization services, or move forward by implementing an in-house mechanism.Objectives: Using Rogers' Diffusion of Innovations model and Behavioral Theory of the Firm as guidance, this study identified the associations between perceived characteristics of immunization services and backward/forward transitions.Methods: A cross-sectional mail survey was conducted to collect data from key informants of Washington State community pharmacies during May-July 2004 (response rate=46.9%). A total of 106 pharmacies were included in the analysis. Based on pharmacy's immunization service transitions, these pharmacies were identified as Fence sitters, Backward movers, or Forward movers. Relationships between these transitions, pharmacy characteristics, and perceived characteristics of immunization services were analyzed using bivariate and multinomial logistic regression techniques.Results: Backward and Forward movers had less positive assessments of outsourced services when compared with Fence sitters. Backward and Forward movers differed in their perceptions of in-house services; Backward movers generally perceived no differences between these 2 services, whereas Forward movers generally perceived in-house services to be superior to outsourced services. Furthermore, the odds of being a Forward mover increased as perceived technical and social benefits of outsourced services decreased, perceived compatibility of in-house services increased, and perceived complexity of in-house services decreased.Conclusions: Perceived characteristics of outsourced and in-house innovations were associated with backward and forward transitions. Findings can be used to guide the development of strategies for facilitating organizational change and preventing the abandonment of immunization services.