Community pharmacy-based point-of-care testing: A case study of pharmacist-physician collaborative working relationships

The role of community pharmacists in point-of-care testing and treatment for influenza and Group A Streptococcus -a narrative review using Ecological Systems Theory

BACKGROUND

Point-of-care testing (POCT) is a valuable diagnostic approach for identifying pathogens such as Group A Streptococcus (GAS) and influenza. Early detection through POCT allows for timely initiation of appropriate treatments improving public health outcomes and minimizing antibiotic misuse. Community pharmacists are well positioned to offer POCT and treatment, but they face significant system level barriers to widespread implementation and reach.

METHODS

This narrative review employs Ecological Systems Theory to examine the role of community pharmacists in the implementation of POCT and subsequent treatment for respiratory infections and synthesize findings from a range of studies at different levels of the system. Medline was used to identify articles with MESH headings of rapid diagnostic tests and community pharmacists. Articles were reviewed and used to inform the synthesis. Additional articles were identified using free-text search to fill gaps in the domains.

RESULTS

The review indicates that community pharmacists are well-positioned to provide POCT for respiratory infections, addressing barriers such as appointment availability, scheduling difficulties, and distance to primary care facilities. The accessibility of neighborhood pharmacies can significantly reduce health disparities by offering timely testing and treatment options. Studies demonstrate that early intervention facilitated by POCT in pharmacies leads to better health outcomes and more efficient use of antibiotics and antivirals.

CONCLUSIONS

Community pharmacists play a crucial role in expanding access to POCT and treatment for respiratory infections, particularly in underserved areas. Their involvement can lead to improved public health outcomes by ensuring early and appropriate treatment. Future research should focus on overcoming barriers to POCT implementation in pharmacies and further quantifying the impact on health disparities and treatment efficacy. The integration of POCT services in community pharmacies represents a significant advancement in public health strategy, enhancing the overall healthcare delivery system.

Coaching strategies for the Flip the Pharmacy practice transformation initiative in Pennsylvania independent community pharmacies

BACKGROUND

Flip the Pharmacy (FtP) is a nationwide initiative to scale practice transformation in community pharmacies. Participating pharmacies are coached through monthly practice transformation initiatives and document their patient-care activities through Pharmacist electronic Care (eCare) Plans.

OBJECTIVES

The objective of this study was to identify peer coaching strategies to facilitate practice transformation in Pennsylvania community pharmacies.

METHODS

This was a qualitative study using semistructured interviews with practice transformation coaches and pharmacy champions participating in Pennsylvania's FtP program. The interview guide was informed by the Consolidated Framework for Implementation Research and elicited information using the intervention characteristics, inner setting, characteristics of individuals, and process domains. Interviews were conducted in person or via telephone over a 3-month period. An inductive qualitative thematic analysis was performed to identify coaching strategies.

RESULTS

A total of 18 key informants were interviewed: 6 pharmacy champions and 12 practice transformation coaches. The following 5 coaching strategies emerged: (1) learn to use the pharmacy's specific Pharmacist eCare Plan software, (2) build a trusting relationship with the pharmacy, (3) engage all pharmacy team members in practice transformation, (4) adapt communication strategies to the pharmacy's preference, and (5) tailor goals to the pharmacy's stage of practice transformation.

CONCLUSION

This study elicited 5 peer coaching strategies to support community pharmacy practice transformation initiatives. These findings can be used to further practice transformation efforts in community pharmacies through FtP and other initiatives aimed at expansion of community pharmacy patient care services.

Independent Community Pharmacists' Experience in Offering Pharmacogenetic Testing

Objective

This study assessed pharmacist experiences with delivering pharmacogenetic (PGx) testing in independent community pharmacies.

Methods

We conducted a cluster randomized trial of independent community pharmacies in North Carolina randomized to provide either PGx testing as a standalone service or integrated into medication therapy management (MTM) services. Surveys and pharmacist data about the delivery of PGx testing were collected. Semi-structured interviews were also conducted.

Results

A total of 36 pharmacists participated in the study from 22 pharmacies. Sixteen pharmacists completed the pre-study and post-study surveys, and four pharmacists completed the semi-structured interviews. Thirty-one percent (11/36) of pharmacists had had some education in personalized medicine or PGx prior to the study. The only outcome that differed by study arm was the use of educational resources, with significantly higher utilization in the PGx testing only arm (p=0.007). Overall, compared to the pre-study assessment, pharmacists' knowledge about PGx significantly improved post-study (p=0.018). In the post-study survey, almost all pharmacists indicated that they felt qualified/able to provide PGx testing at their pharmacy. While 75% of pharmacists indicated that they may continue to provide PGx testing at their pharmacy after the study, the major concerns were lack of reimbursement for PGx counseling and consultation given the necessary time required.

Conclusion

Our findings demonstrated a positive experience with delivering PGx testing in the community pharmacy setting with little difference in pharmacists' experiences in providing PGx testing with or without MTM. Pharmacists were confident in their ability to provide PGx testing and were interested in continuing to offer testing, though sustained delivery may be challenged by lack of prescribing provider engagement and reimbursement.

Informing collaborative relationships between community pharmacists and health care professionals in primary care practices

BACKGROUND

Collaborative relationships between community pharmacists and health care professionals in primary care practices can assist with the provision of medication and disease management services in community pharmacy settings.

OBJECTIVES

The objective was to describe the attitudes of providers working in primary care practices with on-site pharmacist collaborators to understand how to facilitate similar collaborations with pharmacists in community pharmacy settings.

METHODS

This qualitative study was conducted among physicians, nurse practitioners, and nurses of 3 primary care practice sites in the Commonwealth of Pennsylvania. A demographic survey and a semistructured interview were conducted to elicit feedback on participant perceptions about building relationships with community pharmacists. Interviews were audio-recorded and transcribed. A qualitative analysis was performed to identify emerging themes using an inductive approach. Demographic data were summarized using descriptive statistics. This study was approved by the University's Institutional Review Board.

RESULTS

Nineteen interviews were conducted. Fifty-eight percent of participants were physicians and 68% were female with a mean age of approximately 46 years. Five themes were identified: (1) Pharmacists were highly valued and were effective team members to promote coordination of medication-related care; (2) Direct access to pharmacists facilitates efficient communication and effective patient care; (3) Trust is the foundation of an effective collaboration between pharmacists and providers; (4) Pharmacists demonstrating responsibility for patients enables collaboration with providers who view themselves as stewards of patient care; and (5) Providers believe that community pharmacists' dispensing requirements may limit their ability to participate in patient care.

CONCLUSIONS

The following strategies to establish relationships with primary care practices are suggested: pharmacists should initiate face-to-face relationships with providers in practices; communication and patient interventions should be conveyed directly to providers and be conducted by the same person; and pharmacists need to demonstrate their commitment to patient care by following up promptly on patient interventions.

Expanding pharmacists' roles: Pharmacists' perspectives on barriers and facilitators to collaborative practice

OBJECTIVE

The pharmacy profession is shifting from transactional dispensing of medication to a more comprehensive, patient-centered model of care. Collaborative practice agreements (CPAs) extend the role of a pharmacist to initiate, monitor, modify, and discontinue drug therapies and provide other clinical services. Although collaborative practice has been shown to improve health system efficiency and patient outcomes, little is known about how pharmacists perceive CPAs. To explore pharmacists' perspectives of CPAs, including barriers and facilitators to CPA implementation.

METHODS

Semistructured key informant interviews were used to elicit information from licensed pharmacists practicing in a variety of settings in Arizona. Thematic analysis was used to identify key qualitative themes.

RESULTS

Seventeen interviews of pharmacists with (n = 11, 64.7%) and without (n = 6, 35.3%) CPAs were conducted in April-May 2019. The pharmacists saw their role in CPAs as supportive, filling a care gap for overburdened providers. A heightened sense of job satisfaction was reported owing to increased pharmacist autonomy, application of advanced knowledge and clinical skills, and ability to have a positive impact on patients' health. Challenges to the implementation of CPAs included liability and billing issues, logistic concerns, some experiences with provider hesitancy, and lack of information and resources to establish and maintain a CPA. The barriers could be overcome with conscious team-building efforts to establish trust and prove the worth of pharmacists in health care teams; strategic engagement of stakeholders in the development of CPAs, including billing and legal departments; and mentorship in the CPA creation process.

CONCLUSIONS

The pharmacists in this study enjoyed practicing collaboratively and had overall positive perceptions of CPAs. As health worker shortages become more dire and pharmacy practice evolves to expand the role of pharmacists in providing direct patient care, CPAs will be an important tool for restructuring care tasks within health systems.

Pharmacy-Based Infectious Disease Management Programs Incorporating CLIA-Waived Point-of-Care Tests

There are roughly 48,000 deaths caused by influenza annually and an estimated 200,000 people who have undiagnosed human immunodeficiency virus (HIV). These are examples of acute and chronic illnesses that can be identified by employing a CLIA-waived test. Pharmacies across the country have been incorporating CLIA-waived point-of-care tests (POCT) into disease screening and management programs offered in the pharmacy. The rationale behind these programs is discussed. Additionally, a summary of clinical data for some of these programs in the infectious disease arena is provided. Finally, we discuss the future potential for CLIA-waived POCT-based programs in community pharmacies.

Pharmacy Education Needs to Address Diagnostic Safety

The American Association of Colleges of Pharmacy, the Accreditation Council for Pharmacy Education, and the Center for the Advancement of Pharmacy Education frame patient safety from the perspective of medication management, which is also the current focus of pharmacy education and training. With the growing appreciation that diagnostic errors represent an urgent and actionable patient safety concern, the National Academy of Medicine has recommended diagnostic safety training for all health care professions. The Society to Improve Diagnosis in Medicine has worked with an interprofessional consensus group to identify a set of 12 key competencies necessary to achieve diagnostic quality and safety that focuses on individual, team-based, and system-related competencies. Much of this already exists in pharmacy education, but pharmacy training programs need to give graduates more guidance on how they contribute to the diagnostic process and the prevention and detection of diagnostic errors. We describe the current state of progress in this regard, and what steps are needed by training programs to provide content and assessment so that graduates achieve the requisite competencies. Governing and advisory bodies need to expand the expectations around patient safety to include diagnostic safety.

Creating a Pharmacotherapy Collaborative Practice Network to Manage Medications for Children and Youth: A Population Health Perspective

Children with special health care needs (CSHCN) use relatively high quantities of healthcare resources and have overall higher morbidity than the general pediatric population. Embedding clinical pharmacists into the Patient-Centered Medical Home (PCMH) to provide comprehensive medication management (CMM) through collaborative practice agreements (CPAs) for children, especially for CSHCN, can improve outcomes, enhance the experience of care for families, and reduce the cost of care. Potential network infrastructures for collaborative practice focused on CSHCN populations, common language and terminology for CMM, and clinical pharmacist workforce estimates are provided. Applying the results from the CMM in Primary Care grant, this paper outlines the following: (1) setting up collaborative practices for CMM between clinical pharmacists and pediatricians (primary care pediatricians and sub-specialties, such as pediatric clinical pharmacology); (2) proposing various models, organizational structures, design requirements, and shared electronic health record (EHR) needs; and (3) outlining consistent documentation of CMM by clinical pharmacists in CSHCN populations.

Point-of-care testing (POCT) and evidence-based laboratory medicine (EBLM) - does it leverage any advantage in clinical decision making?

Point-of-care testing (POCT) is the analysis of patient specimens outside the clinical laboratory, near or at the site of patient care, usually performed by clinical staff without laboratory training, although it also encompasses patient self-monitoring. It is able to provide a rapid result near the patient and which can be acted upon immediately. The key driver is the concept that clinical decision making may be delayed when samples are sent to the clinical laboratory. Balanced against this are considerations of increased costs for purchase and maintenance of equipment, staff training, connectivity to the laboratory information system (LIS), quality control (QC) and external quality assurance (EQA) procedures, all required for accreditation under ISO 22870. The justification for POCT depends upon being able to demonstrate that a more timely result (shorter turnaround times (TATs)) is able to leverage a clinically important advantage in decision making compared with the central laboratory (CL). In the four decades since POCT was adapted for the self-monitoring of blood glucose levels by subjects with diabetes, numerous new POCT methodologies have become available, enabling the clinician to receive results and initiate treatment more rapidly. However, these instruments are often operated by staff not trained in laboratory medicine and hence are prone to errors in the analytical phase (as opposed to laboratory testing where the analytical phase has the least errors). In some environments, particularly remote rural settings, the CL may be at a considerable distance and timely availability of cardiac troponins and other analytes can triage referrals to the main centers, thus avoiding expensive unnecessary patient transportation costs. However, in the Emergency Department, availability of more rapid results with POCT does not always translate into shorter stays due to other barriers to implementation of care. In this review, we apply the principles of evidence-based laboratory medicine (EBLM) looking for high quality systematic reviews and meta-analyses, ideally underpinned by randomized controlled trials (RCTs), looking for evidence of whether POCT confers any advantage in clinical decision making in different scenarios.

Physician-reported factors that encourage collaboration with community pharmacists

OBJECTIVE

To determine factors that encourage physicians to establish collaborative practice agreements with community pharmacists.

METHODS

A 20-item cross-sectional survey was mailed to a random sample of 1000 family medicine physicians practicing in North Carolina. Two weeks after the initial mailing, a reminder was sent to physicians. Physicians were entered into a drawing to receive a gift card as an incentive for survey completion. The questionnaire collected demographic information, factors important to physicians for collaboration with a community pharmacist, and physician perceptions of pharmacist qualifications. Descriptive statistics were used to analyze patterns in the Likert scale survey responses.

RESULTS

Of the 1000 mailed surveys, 67 were returned as undeliverable, resulting in a final sample size of 933 surveys. One hundred forty-six family medicine physicians responded to the survey, yielding a 15.6% response rate. Respondents were 58% male, 73% had been practicing longer than 10 years, and 60% had an academic affiliation. Our results indicate that an established relationship with a community pharmacist is the most important factor when considering a collaborative practice agreement. At least 90% of physicians reported that the most important pharmacist contributions were drug therapy adverse effect management, drug interaction management, medication access assistance, prescription counseling, and medication adherence. A majority of physicians reported that community pharmacists improve quality outcomes and metrics (74% and 72%, respectively).

CONCLUSION

Physicians in North Carolina recognize the value of the services a pharmacist can provide to their patients. Developing relationships between community pharmacists and physicians and describing the value of additional credentialing in the provision of patient care will be integral in establishing collaborative practice agreements in the community setting.