Clinical pharmacy services are reimbursed in Germany: challenges of real world implementation remain

Attitudes and expectations toward medication review among community pharmacy customers in Germany: a cross-sectional study

Background

Since knowledge about customers' attitudes towards medication reviews in community pharmacies is limited, the objective of this study was to gain insight into customers' perceived facilitators and barriers to participate in this service, with the aim of identifying areas to facilitate the implementation process.

Methods

In spring 2024, we conducted a prospective, questionnaire-based survey for a total of 58 days. All customers (≥18 years) in 3 pharmacies in Germany, regardless of whether they were eligible for medication reviews or not, were approached during their pharmacy visit in person and invited to complete the tablet-based questionnaire on-site. The pilot-tested, multilingual questionnaire covered socio-demographic-data and customers' attitudes towards medication reviews. Potential benefits of medication reviews were rated regarding their perceived importance on a 3-point-Likert-scale (0 = not important, 1 = important, 2 = very important). A mean score was calculated for each benefit. Data were analyzed descriptively and binary logistic regression analyses were applied to explore associations of selected predictors with awareness of medication reviews or expected benefits.

Results

A total of 1561 pharmacy customers participated, with 59.2% (interquartile range (IQR): 17.9%) of patients being approached daily. Awareness of medication reviews was low (18.0%, n = 281/1561), whereby female participants (odds ratio (OR): 1.211 (0.914-1.603)) and those who request pharmacies' consultation services (OR: 1.020 (1.012-1.029) were more likely to know it. Key expectations towards benefits included better knowledge of medicines (mean score: 1.4 ± 0.7), fewer side-effects (1.4 ± 0.7) and fewer problems with their medication (e.g. interactions; 1.3 ± 0.7). No difference was found for prior awareness of medication reviews in terms of benefit expectations.

Conclusion

Gaining knowledge and improving medication safety through a medication review is most valuable to customers. By clearly explaining the purpose and expected benefits of medication reviews, the outreach and impact could be increased.Trial registration: German Clinical Trials Register identifier: DRKS00032446.

Streamlining the quality assessment in medication reviews: a biased random sampling approach using BRANT-MERQS criteria

BACKGROUND

Medication review type 3 (MR3) is a comprehensive and collaborative clinical service designed to optimize patient treatment. The BRussels ANTwerp Medication Review Quality score (BRANT-MERQS) assesses MR3 quality, incorporating 45 general and 4 project-specific criteria. Using all BRANT-MERQS criteria is laborious and time-intensive, necessitating the development of a more efficient, streamlined version that preserves reliability.

AIM

The aim of this study was to create a reliable and more efficient scoring system to evaluate the quality of MR3.

METHOD

A random but weighted subset of the BRANT-MERQS quality criteria was employed in repeated tests. This technique helped determine the required subsample size for accurate quality scores. The weighting was based on previously assessed importance of each criterion.

RESULTS

Repeated sampling showed that a 10-criteria random subsample yielded dependable quality scores. The biased sampling approach (5-3-1 ratio, 5 for highly important criteria, 3 for moderately important criteria and 1 for less important criteria) offered improvements compared to an unbiased one.

CONCLUSION

A more efficient MR3 quality evaluation was developed using the BRANT-MERQS scoring table. A 10 criteria biased subsample, representing one-third of the full assessment, ensures both time efficiency and consistency in quality assessment.

Pharmacy Customers' Attitudes Towards Expanded Pharmacy Services in Croatia

Pharmacists have been recognized as the most accessible healthcare professionals, and research has been carried out on expanded pharmacy services they could provide. Additional pharmacy services are a cost-effective way to prevent medication errors, reduce the number of drug-related problems, and prevent chronic disease progression. Therefore, this study aims to evaluate pharmacy service users' views of expanded pharmacy services in Croatia. This study included 745 participants. Patients who have a healthcare professional in their family more frequently knew of the existence of e-health records and the option to share it with their pharmacists (134, 56.3% vs. 229, 45.2%, p = 0.005), while persons that have chronic illness more frequently visit the same pharmacy (176, 77.9% vs. 178, 34.3%, p < 0.001). Participants are confident that pharmacists can provide screening services and education on inhaler usage; however, only around 60% agreed that pharmacists can independently lead therapy adjustment, medication substitution, or monitor therapy based on test results. Our findings should be supported with projects evaluating the cost-effectiveness of such services as they would be accepted by a greater number of pharmacy service users if covered by the national health insurer.

Impact of a Clinical Decision Support System on the Efficiency and Effectiveness of Performing Medication Reviews in Community Pharmacies: A Randomized Controlled Trial

BACKGROUND

Clinical decision support systems (CDSSs) already support community pharmacists in conducting medication reviews (MRs) by identifying important information on interactions and suggesting clinical solutions. However, their impact in terms of quality and time savings is widely unexplored. The aim of our study was to investigate whether MRs are performed faster and better with or without using a CDSS.

METHODS

In a randomized controlled study with a cross-over design, 71 pharmacists performed a total of four MRs, two with and two without the use of a CDSS. The primary endpoint was defined as the time required for the MRs. The secondary endpoints were the number of predefined relevant drug-related problems (DRPs) detected and pharmacist satisfaction.

RESULTS

Without the use of a CDSS, pharmacists needed between 25.7% and 30.7% more time to perform a MR than with a CDSS. In addition, significantly more relevant DRPs were detected in the MRs with CDSS than without CDSS (70% vs. 50%; p = 0.0037). Furthermore, participants stated that they felt more confident using a CDSS for MRs than without.

CONCLUSIONS

Our results demonstrate that MRs can be performed both faster and better when using a CDSS than without. Consequently, community pharmacists benefit from the use of CDSSs for MRs, as do patients in terms of their drug therapy safety.

Implementation, barriers, solving strategies and future perspectives of reimbursed community pharmacy services - a nationwide survey for community pharmacies in Germany

BACKGROUND

Since June 2022, the legal framework has been created for German community pharmacies to offer their patients five reimbursed community pharmacy services that go beyond the current operating regulations. However, little is known about barriers that hinder their implementation. We therefore aimed to investigate the implementation of reimbursed community pharmacy services (i), barriers to the implementation (ii), solving strategies to overcome the barriers (iii), and future perspectives (iv). The objective of this study is to find out how the implementation of community pharmacy services can be facilitated for community pharmacies so that more services can be offered.

METHODS

In July 2023, we created an online survey and sent it to pharmacists in community pharmacies, including those who offered reimbursed community pharmacy services and those who did not.

RESULTS

Overall, 218 pharmacists from 218 different community pharmacies participated. (i) Of those, 176 (81%) already offered at least one reimbursed community pharmacy service. (ii) For hypertension service, 33% of the offering pharmacists reported barriers in "Communicating with patients," and 41% reported "Too little patient demand." For polymedication service, 53% of the offering pharmacists indicated "Barriers in communication with physicians," and 44% mentioned "Fear of competing with physicians." (iii) The most frequently reported solving strategies of pharmacists in offering pharmacies were taking advanced training (median of all five services 42%) and developing standardized procedures (median of all five services 34%). In contrast, pharmacists in non-offering pharmacies had not developed any solving strategies (median of all five services 40%). (iv) 64% of the pharmacists in non-offering pharmacies could imagine being able to offer reimbursed community pharmacy services in the future.

CONCLUSIONS

Many German pharmacies already offer reimbursed community pharmacy services. However, there are still barriers to widespread implementation. Therefore, customized support regarding the needs of the pharmacies should be provided since most pharmacists who do not yet offer these services today can imagine offering them in the future.

Telepharmacy versus Face-to-Face Approach in Providing Inhaler Technique Training Service: A Non-Inferiority Assessment Among German Pharmacy Students

Background

The use of telepharmacy in delivering pharmaceutical care services has grown in the past few years; however, there are perceptions of its inappropriateness for providing medical device training among pharmacy students and practicing pharmacists.

Objective

The primary objective of this study was to determine if the telepharmacy approach for providing inhaler technique training service was non-inferior to the face-to-face approach regarding pharmacy students' performance in simulated patient encounters. Secondary objectives were to determine students' self-assessment of their ability to demonstrate and practice inhaler technique between the two modes of communication and their perceptions of telepharmacy.

Methods

A randomized crossover non-inferiority trial was conducted among undergraduate pharmacy students. Outcomes were measured by comparing Objective Structured Clinical Examination (OSCE) scores of participants' performance between two modes of communication while providing inhaler technique training service. Moreover, the participants also completed self-assessment and perception questionnaires.

Results

The telepharmacy approach was non-inferior to the face-to-face approach for demonstrating and practicing the correct inhaler technique based on OSCE scores and a predefined non-inferiority margin of -10%. The results also revealed no significant differences in student self-confidence between the two modes of communication. Moreover, participants had a largely positive perception of telepharmacy and its use in providing inhaler technique training service.

Conclusion

Considering our findings, telepharmacy is a viable alternative to traditional face-to-face consultations for providing inhaler technique training service. However, to address perceived difficulties and differences between virtual and face-to-face consultations, the pharmacy curriculum should include more telepharmacy-related didactic content with experiential learning and simulations.

Exploring the need and potential of ambulatory pharmacy practice for empowering patient and care delivery in India

In recent years, rapidly changing disease profile patterns, shortage & uneven utilization of healthcare professionals contributed massive burden on the Indian healthcare system, which resulted in varying, fragmented, inconsistent healthcare delivery to the patients and poor patient management. Patients often face and experience many challenges like lack of accessibility, poor patient-healthcare provider relationships, and inadequate quality of care, resulting in unnecessary economic burden in managing their health conditions. Thus Indian healthcare reform is essential in enhancing its capacity to fulfill patients' health needs that can be addressed by focusing on key sustainable strategies and initiatives meant for enhancing coordination of care, expanding services accessibility, redeveloping healthcare infrastructure, implementing workforce innovation and strong governance with the incorporation of core principles such as patient-centeredness, integrated care and collaborative care approaches. The clinical and ambulatory pharmacy practice are fragment of the healthcare delivery which delivers pharmaceutical care and fulfils the needs of patients across healthcare settings. This paper focuses on the present & future perspectives of ambulatory pharmacy practice in India and the factors to be considered for implementing it in patient care.

From the Randomized AMBORA Trial to Clinical Practice: Comparison of Medication Errors in Oral Antitumor Therapy

The randomized AMBORA trial showed that medication errors are frequent in patients treated with oral antitumor therapeutics and that they can be substantially reduced by an intensified clinical pharmacological/pharmaceutical care program. While randomized controlled trials are essential to generate clinical evidence, their generalizability in real-world is not always given. The AMBORA care program was implemented in clinical routine within the AMBORA Competence and Consultation Center (AMBORA Center) at the Comprehensive Cancer Center Erlangen-EMN, allowing a thorough comparison of medication error frequencies and characteristics. Our primary analysis compared data at therapy initiation of new oral antitumor therapeutics from the AMBORA trial intervention group (n = 98) and the AMBORA Center (n = 142). Medication errors involving the oral antitumor therapeutics were twofold higher in real-world compared to the randomized controlled trial (mean 0.83 ± 0.80 per patient vs. 0.41 ± 0.53, P < 0.001). We observed more complex oral antitumor therapeutic regimens, a higher median number of medications, and a higher ECOG status in clinical routine vs. the randomized trial. A high percentage of medication errors was completely solved in both groups (85.7% vs. 88.3%, ns). Medication error characteristics within the complete medication (oral antitumor therapeutics and concomitant medication) were similar in both groups (e.g., patient-related causes, drug-drug/drug-food interactions). Taken together, medication errors were even more frequent in clinical routine than in the randomized controlled trial and a high rate was solved in clinical routine by a clinical pharmacological/pharmaceutical care program.

Implementation of medication reviews in community pharmacy: reaching consensus on stakeholders' recommendations for mechanisms of change using the nominal group technique

BACKGROUND

Since 2022, patients with five or more medicines are eligible for a medication review (MR) in a community pharmacy remunerated by the German health system. However, implementation has been slow, with few pharmacies providing MRs. Stakeholders' input is necessary to detail how implementation strategies can be executed effectively on a national level. Prior research identified "external facilitation" and "altering incentives" as crucial strategies to achieve implementation outcomes.

AIM

To gather stakeholders' recommendations for, and obtain consensus on, mechanisms of change that allow implementation strategies to work in practice.

METHOD

The consensus method used was the nominal group technique (NGT) with NGT-discussions held separately with pharmacy owners and pharmacy chambers employees. Votes were summed and the relative importance (rI) calculated, defined as (score achieved for a mechanism)/(maximum possible score) × 100. Content analysis provided context for the highest ranked mechanisms and allowed linking to implementation outcomes.

RESULTS

Four NGT-discussions were held in 2023 (n = 2 owners; n = 2 chamber employees) with a total of 17 participants. The overall highest ranked mechanisms were fit-for-purpose software (rI = 154.7) detailed process support (rI = 104.9) and an expert support line (rI = 77.7). These together with financial viability (rI = 40.0) were prioritised by both participant groups. Three mechanisms were favoured for both implementation strategies, namely software, process support and materials (rI = 34.3).

CONCLUSION

This study identified stakeholders' priorities for mechanisms of change to implement MRs in community pharmacies. Focusing efforts on the prioritised mechanisms is likely to significantly advance a national implementation plan for countries which are at an early implementation stage.

Insights into participation in ward rounds in hospitals: A survey of clinical pharmacists' perceptions

Introduction

Clinical pharmacists' participation in ward rounds (WRs) has been a great chance to contribute to team-based care in the hospital setting and significantly improve patient outcomes and quality of life. Hence, the objective of this investigation was to explore the perceptions of clinical pharmacists in Yemen regarding their participation in WRs and the factors influencing their involvement.

Methods

An online survey of Yemeni clinical pharmacists was conducted and lasted for two months. Descriptive statistics were used to analyse the survey responses.

Results

a total of 120 participants were involved. About 3 out of 10 pharmacists had not previously participated in WRs, with only 30% having always or most of the time participated in word rounds alongside physicians. The results showed a positive perception of WR participation, with a median and IQR of 5(4-5). However, a lack of awareness of WR roles and the time-consuming nature of participation were the reasons for non-involvement.

Conclusion

The study highlights the positive perceptions of Yemeni clinical pharmacists towards ward rounds, but emphasises the need to address awareness and time constraints. Emphasising patient-centered care and longer internship durations can improve clinical pharmacist involvement. Future research should focus on optimising clinical pharmacist participation for better patient outcomes and care quality.

Global landscape of community pharmacy services remuneration: a narrative synthesis of the literature

Community pharmacists form a vital part of the health system all around the globe. Pharmacy remuneration models are aimed to ensure that pharmacies are sustained, and pharmacists could provide cost-effective services to the patients. This review summarizes the pharmacy services remuneration systems from different parts of the globe. Some countries have well-established reimbursement systems that recognize and compensate community pharmacies for their services, others are in the process of expanding the scope of reimbursable services. It further concludes by highlighting the ongoing efforts to incorporate pharmacist-provided services into reimbursement schemes and the need for standardized and consistent approaches to pharmacy remuneration globally.

Clinical pharmacy services in mental health in Europe: a commentary paper of the European Society of Clinical Pharmacy Special Interest Group on Mental Health

A large proportion of the world's disease burden is attributable to mental illnesses. Although effective interventions are available, many patients still have limited access to evidence-based treatments. Aside from access, treatment gaps, including inappropriate medication selection and monitoring, are also routinely recognised. Mental health clinical pharmacists can help address these gaps and enable patients to receive optimised pharmaceutical care, particularly appropriate medication selection and monitoring. The European Society of Clinical Pharmacy (ESCP) Special Interest Group on Mental Health was established to improve standardised service provision in mental health settings across Europe. The Special Interest Group identified significant barriers (predominantly associated with reimbursement and position within the multidisciplinary team) to effective pharmaceutical care amongst those with mental illnesses. This commentary presents recommendations to address these gaps through improved mental health clinical pharmacy service provision.

Barriers and facilitators for the implementation of the CombiConsultation by general practitioners, pharmacists and practice nurses: a qualitative interview study

BACKGROUND

The CombiConsultation is a consultation with the pharmacist for patients with a chronic condition, aligned with the periodic consultation with the practice nurse or general practitioner. Implementation requires adjustments in the working methods of these healthcare providers and therefore behavioural changes.

AIM

The aim of this study was to identify the barriers and facilitators that determine the behavioural changes by pharmacists, general practitioners and practice nurses required for the implementation of the CombiConsultation.

METHOD

Ten community pharmacists, 5 practice nurses and 5 general practitioners were sampled from practices enrolled in the CombiConsultation study. Their views regarding the implementation of this clinical pharmacy service were explored using interviews based on the 14 domains of the Theoretical Domains Framework (TDF), which are linked to the Capability-Opportunity-Motivation-Behaviour-model. Barriers and facilitators in the domains were assessed by content analysis.

RESULTS

Twelve barriers and 23 facilitators were found within 13 TDF domains with high agreement between the healthcare providers. Important facilitators for implementation were the pharmacists' expertise in pharmacotherapy (capability), access to medical data and physical proximity between professional practices (opportunity). Barriers were pharmacists' insufficient consultation- and clinical-reasoning skills (capability), insufficient staff (opportunity) and reimbursement and lack of coordination among all involved healthcare providers (motivation).

CONCLUSION

All healthcare providers are motivated to implement the CombiConsultation. An existing collaborative practice, with a clear and accepted professional role of the pharmacist is essential. Training of pharmacists in consultation and clinical-reasoning skills can be beneficial, as well as arrangements on the consultation logistics, and reimbursement.

Impact of a Digital Tool on Pharmacy Students' Ability to Perform Medication Reviews: A Randomized Controlled Trial

Digital Medication Review Tools (DMRTs) are increasingly important in pharmacy practice. To ensure that young pharmacists are sufficiently competent to perform medication reviews after graduation, the introduction of DMRTs teaching in academic education is necessary. The aim of our study was to demonstrate the effect of DMRTs use on pharmacy students' performance when conducting a medication review (MR) in a randomized controlled pre-post design. Forty-one pharmacy students were asked to complete a MR within 60 min, followed by a 10-min consultation with (intervention group) and without a DMRT (control group). The MR performance was subdivided into four categories: communication skills, subjective and objective patient data, assessment, and plan. Performance was assessed using objective structured clinical examinations (OSCEs) and analytical checklists. With the use of DMRTs, the overall performance was improved by 17.0% compared to the control group (p < 0.01). Improvement through DMRTs was seen in the subcategories "Assessment" and "Plan". Furthermore, pharmacy students liked using DMRTs and felt more confident overall. Our study results demonstrate that DMRTs improve the performance of MRs, hence DMRTs should become an integral part of pharmacy curriculum. Consequently, digitally enabled pharmacists using DMRTs will be better prepared for their professional careers in pharmacy practice.

Patient experiences and opinions on medication review: a qualitative study

BACKGROUND

Medication reviews are a structured critical evaluation of a patient's pharmacotherapy, carried out by a healthcare professional, but are not yet a routine pharmaceutical service in Belgium. A pilot project to initiate an advanced medication review (= type 3 medication review) in community pharmacies was set up by the Royal Pharmacists' Association of Antwerp.

AIM

To investigate the experiences and opinions of patients who participated in this pilot project.

METHOD

Qualitative study through semi-structured interviews with participating patients.

RESULTS

Seventeen patients from six different pharmacies were interviewed. The medication review process with the pharmacist was perceived as positive and instructive by fifteen interviewees. The extra attention that the patient received was highly appreciated. However, the interviews revealed that patients did not fully understand the purpose and structure of this new service or were aware of the subsequent contact and feedback with the general practitioner. Medication reviews in the home setting put patients more at ease, were highly appreciated, and enabled also to address practical problems such as drug dosing or storage requirements.

CONCLUSION

This qualitative study analysed patients' experiences during a pilot project on the implementation of type 3 medication review. Although most patients were enthusiastic about this new service, a lack of patients' understanding of the whole process was also observed. Therefore, better communication to patients by pharmacists and general practitioners about the goals and components of this type of medication review is needed, with the added benefit of increased efficiency.

Self-care and self-medication as central components of healthcare in Germany - on the way to evidence-based pharmacy

In Germany, self-care is, above all interpreted as the prevention and treatment of minor injuries and illnesses by the patients themselves - that is, without a physician's prescription or medical advice. Maintaining one's health in the sense of a preventive approach through non-medicinal measures also plays an important role. Self-medication in this context is the treatment with approved over-the-counter-(OTC)-medications. In addition, other OTC-products such as dietary supplements as well as complementary and alternative medicines including homeopathic medications are frequently requested options by pharmacy customers. OTC-medications are central components of the German healthcare system, with expert advice from pharmacists in community pharmacies (CP) enabling safe and effective treatment. Additionally, screening for appropriate self-medication by pharmacists ensures that serious illnesses receive timely medical attention. In addition to prescribed medication, self-medication is an important part of the CP business in Germany. In contrast to prescription products, the price of OTC-products is not regulated. As a consequence, the price of OTC-products (including also pharmacy-only drugs) is influenced by competition among CPs and mail-order pharmacies, respectively. The sales of OTC-products for self-medication outside pharmacies, e.g. in drugstores and supermarkets, is restricted to a limited number of specific products. Evidence-based counseling in CPs, while generally advocated still remains a challenge. The evidence for the usage of OTC-products from clinical studies is not yet optimally integrated into everyday pharmacy practice. Information tools such as EVInews offering regular newsletters and a database have been developed to reduce the evidence-to-practice gap and to improve the overall counseling quality. Furthermore, the switching of drugs from prescription-only to pharmacy-only status also challenge CPs to provide adequate and updated guidance.