The influence of intervention complexity on barriers and facilitators in the implementation of professional pharmacy services - A systematic review

Implementation of an adult life-course vaccine review service, VaxCheck, in community pharmacy: A qualitative analysis

BACKGROUND

Community pharmacists are well placed to identify and vaccinate unimmunized or under-immunized individuals who can put themselves and communities at risk of preventable disease. We designed and tested VaxCheck, a novel life-course vaccine review service that can be used to raise awareness and guide personal vaccination action plans, in community pharmacies in Ontario, Canada.

OBJECTIVE

To understand the experiences of community pharmacists and staff directly involved with providing the VaxCheck service as part of initial testing.

METHODS

Semi-structured interviews were performed with pharmacy staff from 9 pharmacies who participated in the study. Interviews were conducted at baseline and following each of 3 Plan-Do-Study-Act quality improvement cycles. Activities undertaken to perform VaxCheck were assessed. An inductive thematic analysis was performed to identify dominant themes and subthemes. Activities and descriptive codes were then correlated to the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Twenty-six interviews were conducted. Pharmacy staff described VaxCheck activities as spanning 3 stages: (1) Promotion/offering of VaxCheck, (2) Completing the VaxCheck, and (3) Enacting recommendations and follow-up. VaxCheck activities were compatible with workflow related to delivery of other vaccines and medication reviews. Thematic analysis found 3 considerations guided VaxCheck adoption: (1) Aligning VaxCheck with workflow through flexible integration, (2) Enabling patient-oriented vaccination services, and (3) Contributing to community healthcare provision. Data aligned with all CFIR domains with strengths noted in constructs from the "Innovation characteristics" and "Individuals" domains. Barriers to implementation were identified in "Inner setting," "Outer setting," and "Process" domains, such as pharmacy workflow capacity, patient knowledge about vaccination, availability of vaccine records, and interactions with other healthcare providers.

CONCLUSION

Community pharmacists found VaxCheck to be a valuable, accessible service that was well-received by patients and supported adult vaccination reviews and individualized recommendations. VaxCheck was compatible with pharmacy workflow but needed additional resources for sustainability and promotion with stakeholders.

Linking Inner Context and Innovation Factors: Examining a pharmacy-based intervention through the eyes of pharmacy staff

INTRODUCTION

Community pharmacies, as unique and accessible healthcare venues, are ideal locations to implement interventions aiming to improve patient care. However, these interventions may increase workload or disrupt workflow for community pharmacists, technicians, and other staff members, threatening long-term sustainment. There are growing calls from the field of implementation science to design for intervention sustainment and maintenance by maximizing innovation fit. Senior Safe™, an intervention to facilitate safer over-the-counter (OTC) product selection by older adults, serves as a case study to examine the congruence between Innovation Factors and community pharmacy Inner Context constructs and their implications for workload and sustainment.

METHODS

Using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, this qualitative study identified factors surrounding Senior Safe implementation. Semi-structured interviews were conducted with staff from pharmacies where Senior Safe was implemented. Two coders independently analyzed interview transcripts using deductive analysis based on EPIS constructs. Thematic analysis was used to generate three themes that encapsulated innovation fit.

RESULTS

Nineteen pharmacy staff members participated, with the majority reporting no significant change in their workload or workflow due to Senior Safe. Interview feedback supported a pre-existing culture of the healthcare system to engage patients, of leadership commitment to patient safety initiatives, and of an amplified role of pharmacy technicians.

DISCUSSION AND CONCLUSION

Pharmacy staff interviews revealed congruence between Innovation Factors and Inner Context that likely yielded intervention workload neutrality. This study highlighted the importance for researchers to consider maintenance and sustainability when designing and implementing an intervention and the critical influence of culture and leadership support during this process.

Exploring the heterogeneity in community pharmacist-led medication review studies - A systematic review

BACKGROUND

Findings on the effectiveness of medication reviews led by community pharmacists (CPs) are often inconclusive. It has been hypothesized that studies are not sufficiently standardized, and thus, it is difficult to draw conclusions.

OBJECTIVE(S)

To examine differences in the way CP-led medication review studies are set up. This was accomplished by investigating (1) patient selection criteria, (2) components of the medication review interventions, (3) types of outcomes, and (4) measurement instruments used.

METHODS

A systematic literature search of randomized controlled trials of CP-led medication reviews was carried out in PubMed and Cochrane Library. Information on patient selection, intervention components, and outcome measurements was extracted, and frequencies were analyzed. Where possible, outcomes were mapped to the Core Outcome Set (COS) for medication review studies. Finally, a network analysis was conducted to explore the influence of individual factors on outcome effects.

RESULTS

In total, 30 articles (26 studies) were included. Most articles had a drug class-specific or disease-specific patient selection criterion (n = 19). Half of the articles included patients aged ≥60 years (n = 15), and in 40% (n = 12/30) patients taking 4 drugs or more. In 24 of 30 articles, a medication review was comprised with additional interventions, such as distribution of educational material and training or follow-up visits. About 40 different outcomes were extracted. Within specific outcomes, the measurement instruments varied, and COS was rarely represented.

CONCLUSION

The revealed differences in patient selection, intervention delivery, and outcome assessment highlight the need for more standardization in research on CP-led medication reviews. While intervention delivery should be more precisely described to capture potential differences between interventions, outcome assessment should be standardized in terms of outcome selection by application of the COS, and with regard to the selected core outcome measurement instruments to enable comparison of the results.

Revisiting the opioid and naloxone education (ONE) program: Program evaluation using the RE-AIM model four years later

OBJECTIVE

The Opioid and Naloxone Education (ONE) Program focuses on community pharmacy-based patient screening and interventions to improve population health with regard to opioid use. The purpose of this paper is to reevaluate the ONE Program performance using the RE-AIM model, in comparison to the review performed in 2019.

METHODS

The program performance of the ONE Program was evaluated from January 1, 2021 to December 31, 2022 was evaluated using the five domains of the RE-AIM model. Reach was defined as the proportion of patients receiving opioid prescriptions who completed the screening. Efficacy was defined as the proportion of individuals identified as at risk who received a pharmacist intervention. Adoption was defined as the proportion of community pharmacies who enrolled in the ONE Program. Implementation was defined as the proportion of pharmacies that enrolled that provided at least five patient screenings. Maintenance was defined as the proportion of pharmacies that completed at least one screening three months. These results were compared against evaluation of the program from October 12, 2018 to June 1, 2019.

RESULTS

Approximately 7.28 % of patients receiving opioid prescriptions were screened for risk of opioid misuse and accidental overdose (Reach). Of the patients screened, 97.4 % of patients at risk for opioid misuse or accidental overdose received a pharmacist-led intervention (Efficacy). Additionally, 49.6 % of the pharmacist that enrolled in the ONE Program completed at least five screenings (79 %) and of those, 86.4 % maintained the program three months later.

CONCLUSIONS

In years four and five of implementation, the ONE Program demonstrated improvement in four of the five domains of the RE-AIM model compared to years one and two. However, Reach declined over time. This reevaluation has demonstrated the importance of longitudinal program assessment, and the possibility of improved program performance over time.

Could pharmacy technicians play a role in supporting the appropriate and safe use of traditional and complementary medicines?

Across the world traditional and complementary medicine (T&CM) product use is prevalent with some countries reporting greater than 50% of the population using these products. T&CM products are primarily self-selected through retail outlets including pharmacies. Pharmacists across the world generally agree they should play a role in ensuring the appropriate and safe use of T&CM products but report being time and resource poor to do so. In this commentary, it is proposed that pharmacy technicians as members of the pharmacy workforce, who with adequate education, and supportive technologies could support pharmacists in providing guidance to consumers and patients about the appropriate and safe use of T&CM products. Pharmacy technicians play a crucial role in the pharmacy workforce, serving as integral members of healthcare teams fulfilling a wide array of tasks essential for the efficient functioning of pharmacies and ensuring the safe dispensation of medications. They have been described by pharmacists as the "the face of the pharmacy" in the community setting and relied on not only for mitigating and triaging problems, but also be primarily responsible for developing rapport, eliciting trust and even loyalty from pharmacy patrons. As such, there is a momentous opportunity for pharmacy technicians to play a role in providing T&CM advice and triaging the need for pharmacists' intervention where harm, or risk of is identified.

Factors influencing Implementation of point-of-care testing for acute respiratory infectious diseases in community pharmacies: A scoping review using the Consolidated Framework for Implementation research

BACKGROUND

Emerging evidence suggests pharmacy-based point-of-care (POC) testing for acute respiratory infectious diseases is beneficial, but not widely implemented. A theory-informed review to understand the factors influencing service Implementation is lacking.

OBJECTIVE

To examine the extent, range, and nature of research available on enablers and barriers to POC testing Implementation for infectious respiratory diseases in community pharmacies and identify their underpinning theoretical constructs using the Consolidated Framework for Implementation Research (CFIR).

METHODS

Scoping review guided by the JBI Manual for Evidence Synthesis. A comprehensive search from inception to June 28th, 2022 was conducted using Medline, Embase, CINAHL, Cochrane Library, and ProQuest dissertations without date or language restriction. Eligible articles investigated barriers and/or facilitators to strep throat, influenza, C-reactive protein, and COVID-19 POC testing in community pharmacies. Two reviewers independently performed title & abstract screening, full-text screening, and data extraction. Content analysis was conducted according to a pre-established Framework and concepts were mapped to the CFIR.

RESULTS

Forty-three studies were included. Most originated from the USA (n = 24; 56%) and investigated strep throat. The majority were testing/initial Implementation projects (n = 23; 54%) conducted in urban centers (n = 17; 40%). Thirty-six (84%) studies used quantitative methodology, while 6 (14%) were qualitative. Only four studies (9%) used theory to guide their inquiry. The 124 identified Implementation factors mapped onto 21 CFIR constructs, covering all 5 domains. The domain "Outer setting" (n = 35/43; 81%) was most prevalent as were the constructs "Patient needs and resources," (n = 21/43; 49%) "External policy & incentives," (n = 17/43; 40%) and "Relative advantage" (n = 17/43; 40%).

CONCLUSION

A large volume of research explores factors influencing the Implementation of pharmacy-based respiratory infectious disease POC testing services, but few studies use qualitative or theory-informed methods. Knowledge of the wide range of facilitators and barriers identified can help pharmacy managers and researchers design strategies to support successful service Implementation.

Designing and psychometric evaluation of pharmacists' attitude toward ethical challenges questionnaire in pharmacy practice: A mixed‑method study

PURPOSE

Knowledge advancement exposes the pharmacists to new ethical and professional challenges in providing pharmaceutical care. The pharmacist's attitude towards the ethical challenges of pharmacy practice could be of great help in assessing pharmacist's ethical sensitivity. This study aimed to design a valid and reliable questionnaire for measuring pharmacists' attitudes.

METHODS

The present study is the second phase of a sequential exploratory mixed‑method study for designing and psychometric evaluation of the questionnaire. In the first phase the questionnaire was developed using semi-structured interviews followed by content analysis. The psychometric evaluation of the questionnaire was performed examining the validity (face, content, and construct), and reliability (internal consistency and Intraclass Correlation Coefficient and Standard Error of Measurement) in a sample of pharmacists practicing in community pharmacies in Tehran and Tabriz, Iran (n = 504). The construct validity of the questionnaire was determined using exploratory and confirmatory factor analysis.

RESULTS

The Scale‑Content Validity Index/Average (S‑CVI/AVE) was calculated at 0.84. The results of exploratory factor analysis supported 22 items in four factors including regulations and rules, professional communications, providing and supplying medicine, and consultation and providing pharmaceutical care that are explained by a total of 49.50% of the variance. Also, confirmatory factor analysis confirmed goodness of fit indices and model fit. Cronbach's alpha Coefficient was 0.919 and ICC was 0.914.

CONCLUSIONS

The psychometric evaluation of the present questionnaire shows a native, valid and reliable instrument to assess pharmacists' attitudes toward ethical challenges which could be a mirror of pharmacists ethical sensitivity.

Barriers and facilitators to implementing priority setting and resource allocation tools in hospital decisions: A systematic review

Health care budgets in high-income countries are having issues coping with unsustainable growth in demand, particularly in the hospital setting. Despite this, implementing tools systematising priority setting and resource allocation decisions has been challenging. This study answers two questions: (1) what are the barriers and facilitators to implementing priority setting tools in the hospital setting of high-income countries? and (2) what is their fidelity? A systematic review using the Cochrane methods was conducted including studies of hospital-related priority setting tools reporting barriers or facilitators for implementation, published after the year 2000. Barriers and facilitators were classified using the Consolidated Framework for Implementation Research (CFIR). Fidelity was assessed using priority setting tool's standards. Out of thirty studies, ten reported program budgeting and marginal analysis (PBMA), twelve multi-criteria decision analysis (MCDA), six health technology assessment (HTA) related frameworks, and two, an ad hoc tool. Barriers and facilitators were outlined across all CFIR domains. Implementation factors not frequently observed, such as 'evidence of previous successful tool application', 'knowledge and beliefs about the intervention' or 'external policy and incentives' were reported. Conversely, some constructs did not yield any barrier or facilitator including 'intervention source' or 'peer pressure'. PBMA studies satisfied the fidelity criteria between 86% and 100%, for MCDA it varied between 36% and 100%, and for HTA it was between 27% and 80%. However, fidelity was not related to implementation. This study is the first to use an implementation science approach. Results represent the starting point for organisations wishing to use priority setting tools in the hospital setting by providing an overview of barriers and facilitators. These factors can be used to assess readiness for implementation or to serve as the foundation for process evaluations. Through our findings, we aim to improve the uptake of priority setting tools and support their sustainable use.

Implementation factor mapping of a pilot study of point-of-care C-reactive protein testing for respiratory tract infections in community pharmacy

Background

Explicit consideration of implementation factors in community pharmacy service development may facilitate widespread implementation and sustainability.

Objectives

This study involved mapping the methodology for the pilot study of point-of-care C-reactive protein (CRP) testing to support pharmacists' management of respiratory tract infections in Western Australian pharmacies against an implementation factor framework, focussing on the resources and training program provided to participating pharmacy staff.

Methods

Phase 1 involved post hoc mapping of the pilot study methodology against the framework previously described by Garcia-Cardenas et al.; phase 2 was an a priori evaluation of the resources and training program, involving pre-training, post-training, and post-pilot questionnaires administered to pharmacists and pharmacy assistants/interns. A mixed model analysis compared pharmacists' responses at the three time points.

Results

Employment of comprehensive strategies to optimise service feasibility and sustainability was demonstrated across the five domains of ‘professional service’, ‘pharmacy staff’, ‘pharmacy’, ‘local environment’ and ‘system’; further consideration of ‘consumer’ or ‘patient’ factors is needed to address issues such as patient refusal. Study pharmacists (n = 10) and pharmacy assistants/interns (n = 5) reported high levels of satisfaction with the training (100% ‘good’/‘excellent’). Pharmacists reported significantly improved attitudes towards, confidence in, and knowledge about CRP testing and service provision from pre- to post-training (p < 0.05). Positive perceptions were maintained at the post-pilot time point.

Conclusions

Post hoc mapping of implementation factors highlighted potential strengths and deficiencies of the current service model. Systematic, prospective mapping, coupled with strategies to explicitly emphasise the patient perspective, may have value in optimising service implementation or modifying future service delivery models.

Medication reviews in community pharmacy: a scoping review of policy, practice and research in Canada

Objectives

This scoping review aims to systematically map the empirical evidence on publicly funded medication reviews provided by community pharmacists in Canada and identify gaps that could inform future research directions.

Methods

We used a scoping review framework and PRISMA guidelines for Scoping Reviews to conduct the study. Three electronic databases were searched for papers published between January 2000 until August 2020. Data was charted on study characteristics, and a thematic synthesis was performed.

Key findings

Of 41 original studies included, most were conducted in Ontario (n = 21). Majority of the studies employed quantitative designs (70%). Five major themes identified were program uptake, patient health outcomes, stakeholder beliefs and attitudes, processes and collaboration and pharmacy workplace culture, which varied considerably. At the individual, organizational and policy levels, many factors were interrelated and influenced the implementation of reimbursed medication reviews by community pharmacists. Gaps in eligibility policy highlighted some patients who may have complex needs are excluded. Variation in clinical outcomes may relate to different types of medication review and pharmacist practice across Canada. Few researchers evaluated eligibility criteria, the impact of policy changes, strategies to engage patients and healthcare professionals, patient–pharmacist communication or compared practice models of medication reviews. About 12% of the research applied a theoretical framework.

Summary

Publicly funded medication reviews in Canadian community pharmacies reduce medication-related problems and potentially improve patient health outcomes. Future research and policies could consider addressing barriers and exploring models for sustainable delivery of high-quality medication reviews internationally.