Migraineurs' perceptions of and interactions with pharmacists: a qualitative study

Exploring community pharmacists' clinical decision-making using think aloud and protocol analysis

BACKGROUND

Clinical decision-making (CDM) is the dynamic process used to gather, interpret and evaluate data to select an evidence-based choice of action. As the role of the pharmacist becomes more patient-focused, effective CDM skills are increasingly vital to achieve patient outcomes centred on quality, safety and efficacy.

OBJECTIVE

To examine how community pharmacists reason through a clinical problem and what factors assist or hinder decision-making.

METHOD

Fifteen New Zealand registered community pharmacists in central Auckland were presented with a bacterial conjunctivitis case. Think Aloud and protocol analysis were employed to examine pharmacists' cognitive processes when working through the case. Factors that affect CDM were explored through semi-structured interviews and analyzed using thematic analysis.

RESULTS

Pharmacists used pattern recognition and analytical reasoning to diagnose and recommend treatment. Three main factors affecting CDM were: 1. community pharmacy environment, where pharmacy size and layout prevented patient privacy; 2. clinical knowledge, which was outdated and limited by poor access to up-to-date resources; and 3. patient factors, where CDM was affected by time, patient's attitudes, and language barriers. When uncertain, pharmacists typically referred patients to their GP to ensure patient safety and believed offering treatment was not within their scope of practice.

CONCLUSION

Pharmacists used dual processing when encountering a familiar case. Further research is required to explore how pharmacists apply CDM when exposed to less familiar, more complex cases presenting greater ambiguity. Barriers in community pharmacy deter effective CDM skills and could inhibit community pharmacists from fulfilling their expanding role within the modern healthcare system.

What influences the information exchange during self-medication consultations in community pharmacies? A non-participant observation study

BACKGROUND

Although pharmaceutical staff consider guideline-compliant information exchange during self-medication consultations as crucial, they have not fully integrated it into practice. It is unclear what prevents pharmaceutical staff from implementing their positive intentions into their actual everyday practice. To improve the information exchange during the current consultation practice, a deeper understanding of its implementation is needed.

OBJECTIVES

The aim was to evaluate the factors influencing information exchange during self-medication consultations in German community pharmacies.

METHODS

We performed a non-participant observation of real-life consultations with post-consultation interviews of pharmaceutical staff in 10 pharmacies. The information exchanged during self-medication consultations was evaluated via 7 guideline-recommended information parameters in 2 stages of information exchange: (a) 'information gathering' and (b) 'provision of information'. Directly after each observed consultation, pharmaceutical staff's opinion about the consultation, the customer's interest and their own performance was questioned. Factors associated with the observed extent of information exchange were analysed by Poisson regression analysis.

RESULTS

In the 379 self-medication consultations with 46 pharmaceutical staff members, 454 different customer enquiries were addressed, and 483 medications were dispensed. In median, 2 predefined information parameters (First-/Third quartile: 1/4) were fulfilled during an enquiry and 2 parameters (First-/Third quartile: 1/3) were fulfilled for a dispensed medication. Pharmaceutical staff were satisfied with 85% of their consultations and perceived 76% of them as easy to handle. In both information stages, information exchange increased when 'customers were perceived to be interested in counselling' (p < 0.001) and decreased when customers had a 'specific medication request' (p < 0.001).

CONCLUSIONS

Information exchange in pharmacies needs to be better integrated into daily practice. Strategies to encourage information exchange should also include pharmaceutical staffs' perception of their own counselling technique. Ongoing patient-centred trainings should facilitate strategies to engage uninterested customers or costumers with specific medication requests in consultations.

Public's perspectives on guideline-recommended self-medication consultations in German community pharmacies

The aim of this study was to assess the public's opinions and expectations of self-medication consultations in German community pharmacies with special emphasis on the acceptance of guideline-recommended consultation. In a cross-sectional study in the city centre of Leipzig, Germany, we conducted a questionnaire-based survey administered via an interview with passers-by from June to September 2018. The structured questionnaire contained questions assessing (I) previous experience with self-medication consultations, (II) possible reasons for declining self-medication consultations, (III) the attitude towards information gathering and (IV) expectations of self-medication consultations. (I) 92% of the 963 respondents stated they were generally satisfied with self-medication consultations in community pharmacies. Around one-fifth of all respondents claimed that they would like to be asked more health-related questions (22%) and receive more information on non-prescription drugs (20%). (II) Privacy issues (39%) and reluctance to talk about some medical conditions (43%) were the most frequent reasons for declining self-medication consultation. (III) Respondents understood the need for answering guideline-recommended questions (85-96%) and did not mind being asked these questions (70-96%). (IV) Most of the respondents expected to be counselled even if they did not ask for it directly (69%). Pharmacies were further expected to recommend the best drug, even if it was not what the customer initially intended to buy (87%). However, more than half of the respondents would consider counselling as unimportant if they knew exactly which medication they wanted to buy (56%) or if they had used the non-prescription drug before (70%). The majority also expected to receive guideline-recommended drug information (each item at least 52%). Thus, our study shows that respondents were mostly in line with the required standards of self-medication counselling guidelines. Customers expect high-quality counselling on self-medication. These findings support pharmaceutical staff's understanding of customers' barriers and expectations during self-medication consultations.

Managing Minor Ailments; The Public's Preferences for Attributes of Community Pharmacies. A Discrete Choice Experiment

BACKGROUND

Demand for health services continues to rise. Greater use of community pharmacy services instead of medical services for minor ailments could help relieve pressure on healthcare providers in high-cost settings. Community pharmacies are recognised sources of treatment and advice for people wishing to manage these ailments. However, increasing the public's use of pharmacy services may depend on attributes of pharmacies and their staff. This study aimed to determine the general public's relative preferences for community pharmacy attributes using a discrete choice experiment (DCE).

METHOD

A UK-wide DCE survey of the general public was conducted using face-to-face computer-assisted personal interviews. Attributes and levels for the DCE were informed by a literature review and a cohort study of community pharmacy customers. The context for the experiment was a minor ailment scenario describing flu-like symptoms. The DCE choice sets described two hypothetical community pharmacy services; respondents were asked to choose which (if either) of the two pharmacies they would prefer to help them manage symptoms. Data from 1,049 interviews were analysed using an error components logit model. Willingness to pay (WTP), a monetary measure of benefit, was estimated for the different attribute levels.

RESULTS

When seeking help or treatment for flu-like symptoms, respondents most valued a pharmacy service that would improve their understanding and management of symptoms (WTP = £6.28), provided by staff who are trained (WTP (pharmacist) = £2.63: WTP(trained assistant) = £3.22), friendly and approachable (WTP = £3.38). Waiting time, pharmacy location and availability of parking also contributed to respondents' preferences. WTP for a service comprising the best possible combination of attributes and levels was calculated as £55.43.

CONCLUSION

Attributes of a community pharmacy and its staff may influence people's decisions about which pharmacy they would visit to access treatment and advice for minor ailments. In line with the public's preferences, offering community pharmacy services that help people to better understand and manage symptoms, are provided promptly by trained staff who are friendly and approachable, and in a local setting with easy access to parking, has the potential to increase uptake amongst those seeking help to manage minor ailments. In this way it may be possible to shift demand away from high-cost health services and make more efficient use of scarce public resources.

A systematic review in select countries of the role of the pharmacist in consultations and sales of non-prescription medicines in community pharmacy

BACKGROUND

Much has been studied in regard to non-prescription medicines (NPMs), but the impact of greater emphasis toward patient self-selection of such agents is still not well understood, and evidence in the literature might be equivocal.

OBJECTIVE

The aim was to examine whether or not pharmacist interventions are important in the sale of NPMs and to summarize the evidence of pharmacists' contribution in maintaining patient safety and improving the quality of consultations involving NPMs.

METHODS

Seven online databases were searched to identify the literature on studies conducted within the UK and in countries comparable to the UK reporting on consultations and selling of NPMs published between 1980 and 2013. All study designs except for quantitative surveys were eligible for inclusion into the review. The data extraction and quality assessment were performed according to the National Institute for Health and Care Excellence guidelines. The data extracted from the studies were analyzed and presented qualitatively.

RESULTS

Eighty-three studies from an original 12,879 citations were included in this review. Just under half of the studies were published between 2000 and 2009 (n = 38; 46%). Thirty-three (44%) of the studies were conducted in the UK. The review showed that in terms of the contribution of community pharmacy staff in consultations for NPMs, non-pharmacist staff dealt with a large proportion of the consultations and pharmacists were usually involved in the consultation through referral from non-pharmacist staff member. Counseling was not consistently offered to everyone. Where counseling was provided it was not always of sufficient quality. Consultations were performed much better when symptoms were presented compared to when people made a direct product request. Pharmacists were reported to conduct better consultations than non-pharmacist staff. There was evidence to suggest that where counseling was appropriately provided this afforded the person a safe environment to utilize their NPMs.

CONCLUSIONS

Seeking methods to develop better engagement with customers accessing pharmacy services for NPMs is necessary to enhance the interaction between these two parties. Efforts to enhance the community pharmacy environment to bring about a more positive experience for people using pharmacy is needed at present and will be important if the model for the selection of NPMs is modified in the UK. More studies are needed to allow a better understanding of the impact self-selection may have on patient safety in the community pharmacy context.

Access to Triptans for Acute Episodic Migraine: A Qualitative Study

OBJECTIVE

Our study aims to examine factors related to access of triptans among multiple stakeholder groups.

BACKGROUND

Triptans are a cornerstone of pain management for the acute treatment of migraine, but actual utilization of triptans is lower than ideal. Initial and continued access to triptans may be an important clinical issue in the acute treatment of migraines, but factors affecting access at the patient, provider, and health-care system levels have not been comprehensively explored.

METHODS

A qualitative study was conducted in Ontario, Canada, between August 2013 and January 2014. Three participant groups were recruited to the qualitative study: (1) migraineurs who have experience accessing triptans; (2) physicians, including primary care physicians (PCPs) and neurologists, who have prescribed triptans; and (3) pharmacists who have dispensed triptans. Qualitative data were collected through one-on-one, semi-structured telephone interviews. The framework approach was used for data collection and analysis.

RESULTS

Data collected from 19 migraineurs, 6 physicians, and 8 pharmacists were included in the analysis. Study participants discussed various factors that facilitate or hinder access to triptans, which were synthesized into four themes that emerged at the patient, provider, and health-care systems levels: (1) awareness; (2) apathy; (3) advocacy; and (4) affordability. Across all participant groups, awareness of available treatments and coverage policies for those treatments were potential factors relating to timely drug provision. Participants describe apathy in terms of patients' health-seeking behaviors and physicians' lack of concern toward migraine, which were seen as factors that could delay diagnosis and provision of appropriate treatment. Patients engaging in self-advocacy enhanced their ability to seek timely and appropriate provision of triptans at the patient level. At the health-care provider level, pharmacists were identified by patients as advocates for receiving more effective treatments for their migraines; pharmacists also self-identified with the advocate role. The affordability of triptans was a key concern impacting access at the systems level, but coverage limitations (eg, quantity limits) were also described to influence the appropriateness of prescribed migraine treatment.

CONCLUSION

This study fills a gap in knowledge about access to triptans and how this may be impacted by patient, provider, and health-care systems barriers. Overall, our study sheds light on the experiences of prescribing, dispensing, and accessing triptans for migraine treatment, and unveils important information that can impact how patients access these drugs.

Validation of a survey tool assessing effectiveness of an educational intervention on the caring behaviors and referral activities of community pharmacists for migraineurs

BACKGROUND

Community pharmacists are in an ideal position to ameliorate migraineur under-consulting, under-diagnosis, and under-treatment. Contemporary education/training on developing therapeutic alliances with patients and in advanced pharmacotherapy may further motivate pharmacists to impact the care of migraineurs.

OBJECTIVES

The objectives of this study were to assess pharmacists' perceptions of a migraine training program and their self-assessment of subsequent impact on patient care and to develop and assess a tool evaluating the impact of the training program from the patients' perspectives: (1) for patients diagnosed with migraines - identify perceptions of care by pharmacists who have undergone specialty training in migraine vs. pharmacists who have not; and (2) for patients with recurrent headaches and not diagnosed with migraines - identify perceptions of pharmacist effectiveness and thoroughness, after specialty training, to identify a potential migraine diagnosis and referral for advanced care vs. pharmacists that have not undergone specialty training.

METHODS

This study employed a mixed method survey design using community pharmacies from the Tulsa, Oklahoma and Pittsburgh, Pennsylvania greater metropolitan areas. Pharmacists from intervention pharmacies received specialty training on migraine and were surveyed on their current practices and about the education program. Approximately 1 month after the training, control and intervention pharmacists were surveyed on current practices. Additionally, patients from both pharmacies were surveyed to assess Migraine Disability Assessment (MIDAS) and pharmacists' delivery of care derived from the Pharmacists' Care of Migraineurs Scale (PCMS). Surveys were handed out for a period of 3-months.

RESULTS

There were 16 pharmacists and 61 patients recruited. There was no difference in patient perceptions of pharmacists' care or in patient self-perceptions between migraineurs and recurrent headache sufferers. Ninety-two percent of pharmacists agreed that the program could be transferred to an internet-based educational program. The 14-item patient survey, however, demonstrated good internal consistency reliability, with each question having a Cronbach's alpha 0.80 or higher.

CONCLUSIONS

There are few studies evaluating the role and potential impact community pharmacists can have on patients suffering from migraines or recurrent headaches. While no difference was found between the groups, the internal reliability of the survey questions and the need to address needs of migraineurs warrants tool dissemination and a larger-scale study.