An expanded prescribing role for pharmacists - an Australian perspective

Health information communication technology evaluation frameworks for pharmacist prescribing: A systematic scoping review

BACKGROUND

Information communication technology (ICT) is instrumental in pharmacists' current practice and emerging roles. One such role is prescribing, which requires the use of clinical guidelines and documentation of decision-making, commonly via ICT. Development and refinement of ICT should be guided by evaluation frameworks that describe or measure features of ICT and its implementation. In the context of pharmacist prescribing, these evaluation frameworks should be specific to health stakeholders and the pharmacy setting.

OBJECTIVES

To identify ICT evaluation frameworks from health-related literature and review frameworks relevant to the development, implementation, and evaluation of pharmacist prescribing.

METHODS

A database search of CINAHL, Cochrane Library, EMBASE, Medline (Ovid), ProQuest, Scopus, Web of Science and grey literature was conducted, using combinations of keywords relating to 'ICT', 'utilization', 'usability', and 'evaluation framework'. Abstracts and titles were screened according to inclusion criteria. Identified evaluation frameworks were critiqued for relevance to pharmacy practice.

RESULTS

Twenty-two articles were identified, describing the development or application of 20 evaluation frameworks. None of the frameworks was developed specifically for pharmacy practice. The Technology Acceptance Model (TAM), describing use behavior, behavior intention, perceived usefulness, and perceived ease of use, was the most widely utilized framework. The Information System Success (ISS) and Human-Organization and Technology Fit (HOT-fit) are notable evaluation frameworks that address user and organizational influences in health ICT utility, and factors of both can address the limitation of TAM.

CONCLUSIONS

The findings call for development of an agile evaluation framework for the system under review; however, this can prove difficult due to the heterogenicity and complexity of the healthcare system, particularly contemporary pharmacy practice. While the TAM appears useful to evaluate user attitudes and intentions towards ICT, its relevance to ICT in contemporary community pharmacy practice requires exploration.

Pharmacist prescribing: a review of perceptions and attitudes of patients, pharmacists and other interested professionals

Pharmacist prescribing is a growing reality in some developed counties, with varied health systems. Understanding the contribution that this activity can offer in the healthcare process, and investigating its acceptance is of utmost importance for the countries that implement and regulate this type of system. This literature review aimed to design a state-of-the-art academic investigation on the perception, opinions, and attitudes in the context of pharmacist prescribing practices in countries that have adopted this system. To achieve this, the present study conducted an investigation of the Medline, Scopus, Embase, SciELO, and Lilacs databases, resulting in the selection of 17 studies. From the analysis of the articles, three categories of discussion arose: "understanding of the practice and perceived benefits", "acceptance and adherence to the practice, and "hindrances to the practice". The results showed varied acceptance and perceptions among the different publics, depending, among other questions, on the level of knowledge and experience of the patients and health professionals, on the profile of the pharmacists, or on the prescribing modality. This study highlights some challenges involved in the practice of pharmacist prescribing, and its findings can be useful in suggesting a means through which to strengthen the practice.

Pharmacist prescribing: a review of perceptions and attitudes of patients, pharmacists and other interested professionals

Abstract Pharmacist prescribing is a growing reality in some developed counties, with varied health systems. Understanding the contribution that this activity can offer in the healthcare process, and investigating its acceptance is of utmost importance for the countries that implement and regulate this type of system. This literature review aimed to design a state-of-the-art academic investigation on the perception, opinions, and attitudes in the context of pharmacist prescribing practices in countries that have adopted this system. To achieve this, the present study conducted an investigation of the Medline, Scopus, Embase, SciELO, and Lilacs databases, resulting in the selection of 17 studies. From the analysis of the articles, three categories of discussion arose: “understanding of the practice and perceived benefits”, “acceptance and adherence to the practice, and “hindrances to the practice”. The results showed varied acceptance and perceptions among the different publics, depending, among other questions, on the level of knowledge and experience of the patients and health professionals, on the profile of the pharmacists, or on the prescribing modality. This study highlights some challenges involved in the practice of pharmacist prescribing, and its findings can be useful in suggesting a means through which to strengthen the practice.

Community pharmacist interventions in ear health: a scoping review

BACKGROUND

In Australia, around 3.6 million people suffer from hearing loss, more than 1.3 million with preventable hearing conditions. Ear diseases are prevalent in Indigenous populations, particularly children and are associated with poor educational outcomes and subsequent high rates of unemployment and incarceration. In Australia, rural and remote communities have rates of middle ear perforations five times the rate that the World Health Organisation regards to be a significant public health problem.Barriers to accessing ear health services have been identified including gaps in testing during the 'early years' and difficulty in accessing these services. Reducing the risk of hearing loss through improved ear health care can directly impact the ability to learn and develop. Collaboration between community, health providers and government is crucial to ensure necessary support for change. An opportunity presents for rural community pharmacists, who are both qualified and accessible to provide an ear health programme and thus improve health outcomes for both Indigenous and non-Indigenous Australians in their communities.

AIM

The aim of this study was to identify published evidence of pharmacists' involvement in ear health care interventions to inform the development of ear health services able to be delivered in rural community pharmacy in Australia.

DATA SOURCES

The search strategy was applied to the following electronic databases: MEDLINE, Scopus, CINAHL, Emcare, Cochrane, Google Scholar and Google.Study selection articles were included if they described an ear health intervention in a community pharmacy setting. The interventions reported in the articles were evaluated for their inclusion of effectiveness, whether the service was sustainable, and the inclusion of enablers and barriers to the provision of ear care. The articles were also thematically analysed using the Deadly Ears Deadly Kids Deadly Communities Framework. A total 8427 articles were identified and evaluated against inclusion and exclusion criteria, with eleven eligible articles suitable for inclusion in the review. The articles included were conducted in Australia (n = 4), England (n = 4), United States of America (n = 2) and Brazil (n = 1). The ear health interventions identified included hearing screening (n = 3), otoscopy pilot studies (n = 2), audiometry services (n = 1), specific education for undergraduate pharmacy students (n = 2) and a pharmacy-based clinic (n = 3). Effectiveness and sustainability were not formally reported in any of the included articles. Positive outcomes, funding availability, consumer access to community pharmacy, cost savings for consumers and improved connection to health providers were identified as enablers. Difficulty in attracting funding was the most commonly reported barrier.

CONCLUSIONS

Improving ear health of both Indigenous and non-Indigenous peoples through services provided in community pharmacy presents as an important opportunity for rural pharmacists. Pharmacists are accessible and thus well placed to improve ear healthcare and resultant quality of life for these vulnerable populations. This review has identified factors required to effectively develop ear health models of care in community pharmacy including a pharmacist training program, continuous funding to ensure sustainability and support from pharmacy stakeholders and the community.

State laws that authorize pharmacists to prescribe naloxone are associated with increased naloxone dispensing in retail pharmacies

BACKGROUND

The opioid crisis in the United States continues to worsen. Several states have passed laws granting pharmacists the authority to independently prescribe (not just dispense) naloxone. Since pharmacists are accessible healthcare providers, enhancing their ability to prescribe naloxone, an effective opioid overdose reversal agent, may help combat the ongoing opioid overdose epidemic.

METHOD

Using a nationally representative database on drug dispensing in 2010 to 2018 from Symphony Health, we conducted a cross-sectional study to assess whether state laws authorizing pharmacists to prescribe naloxone were associated with increased naloxone dispensing from retail pharmacies.

RESULTS

The number of naloxone prescriptions dispensed from retail pharmacies increased from 2010 to 2018 and doubled from 2017 to 2018. The presence of state laws authorizing pharmacists to prescribe naloxone is associated with an average increase of 331(95% CI = 43.56, 618.49) prescription dispensed per state per quarter. This represents an approximately 53% increase in naloxone dispensed compared to pharmacies in states where there were no such laws.

CONCLUSIONS

Our study suggests that state laws that allow pharmacists to prescribe and not just dispense naloxone at retail pharmacies can increase the availability and accessibility of naloxone. Adopting and implementing such laws may help reduce serious and life-threatening opioid overdoses.

Developing an Ear Health Intervention for Rural Community Pharmacy: Application of the PRECEDE-PROCEED Model

Unaddressed hearing loss affects an estimated 466 million people worldwide, costing over $750 billion globally, with rural communities being particularly disadvantaged, due to the greater inequity in access to healthcare services. This mixed-methods study aimed to use the PRECEDE-PROCEED model to develop and pilot a rural community pharmacy-based ear health service, LISTEN UP (Locally Integrated Screening and Testing Ear aNd aUral Program). The PRECEDE process involved an assessment of the predisposing, reinforcing and enabling constructs to support practice change through a scoping review, stakeholder surveys and interviews and consultation with governing bodies and regulatory authorities. The PROCEED segment structured the evaluation of the service pilot and informed planned implementation, process, impact and outcome evaluation. The pilot study conducted in February 2021 included 20 participants, with the most common ear complaints presented being pain, pressure or blockage. All these participants reported high levels of satisfaction with the service, would recommend the service to others and would attend the pharmacy first before seeing a GP for future ear complaints. The PRECEDE-PROCEED model provides a comprehensive model to guide the design of the LISTEN UP program, an innovative model, expanding services offered by rural community pharmacies, with preliminary results demonstrating high consumer satisfaction.

Role Theory: A Framework to Explore Health Professional Perceptions of Expanding Rural Community Pharmacists' Role

Pharmaceutical care is a concept which has moved the pharmacy profession from their primary focus on the product to optimising drug therapy for the individual patient. Expanded pharmacy practice beyond pharmaceutical care will further challenge the role perceptions that other health professionals have about pharmacists. Role theory as a philosophical perspective was used to explore rural and remote health professionals' beliefs on pharmacists expanding their clinical role by conducting twenty-three semi-structured interviews. Five role theory categories described the data, role ambiguity, role conflict, role overload, role identity and role insufficiency. The health professionals interviewed were found to be uncertain about the boundaries between the traditional roles of the pharmacist compared to that of the expanded roles. A perceived lack of accountability by pharmacists was seen as a major contributor to role conflict, which in turn was found to impact the ability of pharmacists and other health professionals to work collaboratively. Perspectives of other health professionals on pharmacists adopting expanded practice models has highlighted significant concerns with role conflict and role identity. Acknowledging and developing clear strategies to address these concerns is essential to ensure that expanded pharmacy practice can be effectively integrated to improve access to health services and thus health outcomes for rural Australians.

Addressing the rheumatology workforce shortage: A multifaceted approach

A significant challenge facing the field of rheumatology is the projected gap between the growing demand for rheumatologists and the available workforce. In order to improve access to care, augmenting the rheumatology workforce is required. Herein we discuss potential solutions to the anticipated workforce shortage, including 1) expanding the training of rheumatology physicians; 2) increasing nurse practitioner, physician assistant and pharmacist utilization in rheumatology practice; 3) growing the use of telemedicine; and 4) reducing burnout in order to retain practicing rheumatologists. Building on the existing literature in these areas, we propose a multifaceted approach to addressing the rheumatology workforce shortage.

Community pharmacist workflow: Space for Pharmacy-based Interventions and Consultation TimE study protocol

BACKGROUND

Pharmacists' roles are expanding to delivering a wider set of professional services including medication management optimisation, vaccinations and screening services. Robust research determining whether pharmacists have the capacity to offer such services in the Australian community pharmacy setting is lacking. This protocol details a mixed methods study that investigates the variation in pharmacists' daily tasks and the workspace they work in as a measure of their workload capacity for expanding pharmacy services.

METHODS

An observational time and motion study will be conducted in up to twenty community pharmacies in metropolitan and rural regions of Australia. A trained observer will follow a pharmacist and record the type, location and duration of tasks undertaken over the course of their working day. Data will be collected and analysed using the electronic Work Observation Method By Activity Timing (WOMBAT) tool. Pharmacists' work patterns will be described as time for each task, and by proportionating multitasking and interruptions. This information will be combined with workspace data collected using floor plans, photographs and a qualitative assessment of the working environment completed by the observer. Analysis will include heat-mapped floor plans visually highlighting pharmacist movements.

DISCUSSION

Pharmacists may provide solutions to the strained health workforce and system. There is limited quantitative evidence on whether pharmacists have the time or work setting to support such needs. The use of time and motion methodology is novel to Australian community pharmacy research, and the findings will provide a better understanding of pharmacists' capacity and work environment.

Perspectives of future pharmacists on the potential for development and implementation of pharmacist prescribing in Qatar

Background Pharmacists in many developed countries have been granted prescribing authorities under what is known as "non-medical prescribing" or "pharmacist prescribing". However, such prescribing privileges are not available in many developing countries. Objective The objective of this study was to determine the perspectives of future pharmacists (recent pharmacy graduates and pharmacy students) on pharmacist prescribing and its potential implementation in Qatar. Methods A convergent parallel mixed-methods design was used: (1) a cross-sectional survey using a pre-tested questionnaire and; (2) focus group discussions to allow for an in-depth understanding of the issue, with a focus on pharmacists prescribing competencies as well as barriers for its implementation. Main outcome measures Future pharmacists' perspectives and attitudes towards pharmacist prescribing in Qatar. Results The majority of the respondents (94.4%) indicated awareness of the prescribing competency related to selecting treatment options. Furthermore, the majority (92.4%) believed that pharmacists should undergo prescribing training and accreditation before been legally allowed to prescribe, a point that was reiterated in the focus group discussions. Participants generally expressed support for collaborative and supplementary prescribing models when developing prescribing frameworks for Qatar. Four categories emerged under the theme barriers to implementation of pharmacist prescribing: lack of prescribing competency, pharmacist mindset, lack of accessibility to patient records and counseling rooms, and diversity of education and training background. Conclusion The majority of recent pharmacy graduates and students were in favor of pharmacist prescribing been implemented in Qatar. However, a special training program was deemed necessary to qualify pharmacists to prescribe safely and effectively.

Effects of pharmacist prescribing on patient outcomes in the hospital setting: a systematic review

OBJECTIVE

The objective of the review was to synthesize the best available evidence on the safety and effectiveness of pharmacist prescribing on patient outcomes in patients who present to hospital.

INTRODUCTION

Pharmacist prescribing is legal in many countries. Different models of prescribing include dependent, collaborative and independent. Existing reviews of pharmacist prescribing focus on studies in the community setting, or both community and hospital settings. Other reviews focus on descriptions of current practice or perspectives of clinicians and patients on the practice of pharmacist prescribing. A systematic review on the effects of pharmacist prescribing on patient outcomes in the hospital has not been previously undertaken and is important as this practice can help ease the burden on the healthcare system.

INCLUSION CRITERIA

Studies with controlled experimental designs comparing pharmacist prescribing to medical prescribing in the hospital setting were included in the review. Primary outcomes of interest included clinical outcomes such as therapeutic failure or benefit, adverse effects, and morbidity or mortality. Secondary outcomes included error rates in prescriptions, medication omissions on the medication chart, time or proportion of International Normalized Ratios in therapeutic range, time to reach therapeutic range, and patient satisfaction.

METHODS

A comprehensive three-step search strategy was utilized. The search was conducted in January 2017 in eight major databases from database inception. Only studies in English were included. The recommended Joanna Briggs Institute approach to critical appraisal, study selection and data extraction was used. Narrative synthesis was performed due to heterogeneity of the studies included in the review.

RESULTS

The 15 included studies related to dependent and collaborative prescribing models. In four studies that measured clinical outcomes, there was no difference in blood pressure management between pharmacists and doctors while patients of pharmacist prescribers had better cholesterol levels (mean difference in low density lipoprotein of 0.4 mmol/L in one study and 1.1 mmol/L in another; mean difference in total cholesterol of 1.0 mmol/L) and blood sugar levels (mean difference of fasting blood sugar levels of 15 mg/dL, mean difference of glycosylated hemoglobin of 2.6%). In two studies, pharmacists were better at adhering to warfarin dosing nomograms than doctors (average of 100% versus 62% compliance). In six studies, when prescribing warfarin according to dosing nomograms, equivalent numbers or more patients were maintained in therapeutic range by pharmacist prescribers compared to doctors. The incidence of adverse effects related to anticoagulant prescribing was similar across arms but all six studies were underpowered to detect this outcome. Three studies found that pharmacist prescribers made less prescribing errors (20 to 25 times less errors) and omissions (three to 116 times less omissions) than doctors when prescribing patients' usual medications on admission to hospital or in the preoperative setting. Two studies reported that patients were as satisfied with the services provided by pharmacist prescribers as with doctors.

CONCLUSIONS

This review provides low to moderate evidence that pharmacists can prescribe to the same standards as doctors. Pharmacists are better at adhering to dosing guidelines when prescribing by protocol and make significantly less prescribing errors when charting patients' usual medications on admission to hospital.

Barriers to pharmacist prescribing: a scoping review comparing the UK, New Zealand, Canadian and Australian experiences

Objectives

Non-medical prescribers, including pharmacists, have been found to achieve comparable clinical outcomes with doctors for certain health conditions. Legislation supporting pharmacist prescribing (PP) has been implemented in the United Kingdom (UK), Canada and New Zealand (NZ); however, to date, Australian pharmacists have not been extended prescribing rights. The purpose of this review was to describe the barriers to PP found in the literature from the UK, Canada, NZ and Australia, and examine the implications of these for the development of PP in Australia.

Methods

We conducted a scoping review, which included peer-reviewed and grey literature, and consultation with stakeholders. Sources – Scopus, PubMed and CINAHL; Google Scholar, OpenGrey and organisational websites from January 2003 to March 2018 in the UK, Canada, NZ and Australia. Inclusion criteria – articles published in English, related to implementation of PP and articulated barriers to PP.

Key findings

Of 863 unique records, 120 were reviewed and 64 articles were eligible for inclusion. Three key themes emerged: (1) Socio-political context, (2) Resourcing issues and (3) Prescriber competence. The most common barriers were inadequate training regarding diagnostic knowledge and skills, inadequate support from authorities and stakeholders, and insufficient funding/reimbursement.

Conclusions

If implementation of PP is to occur, attention needs to be focused on addressing identified barriers to PP implementation, including fostering a favourable socio-political context and prescriber competence. As such, a concerted effort is required to develop clear policy pathways, including targeted training courses, raising stakeholder recognition of PP and identifying specific funding, infrastructure and resourcing needs to ensure the smooth integration of pharmacist prescribers within interprofessional clinical teams.

Family physicians' perceptions of pharmacists prescribing in Alberta

Canadian pharmacists now have prescribing authority and little is documented about the physicians' perception, experience and relational dynamics evolving around the pharmacists' prescribing practice. The objective of this study was to explore Albertan family physicians' perceptions and experiences of pharmacists' prescribing practice. We used purposeful and maximum variation sampling method and semi-structured face to face or telephone interviews to collect data. From October 2014 to February 2016, we interviewed 12 family physicians in Alberta, having experience with pharmacist prescribing. Interviews were audio recorded and transcribed verbatim for analysis using an interpretive description method, guided by "Relational Coordination" theory. NVivo software was used to manage the data. Three key beliefs (i.e., renewal versus initiate new prescription, community versus team pharmacists, and "I am responsible") about pharmacist prescribing were identified. Trust and communication were prominent themes which shaped participants' collaboration with pharmacist prescribers. Participants were classified as either "collaborative" or "consultative". Participants had greater collaboration with the team pharmacist prescribers compared to community pharmacists due to a higher level of trust and ease of communication. Renewal prescribing by any pharmacist was well accepted but participants showed hesitancy in accepting pharmacist-initiated prescriptions. Our findings provide insight into interprofessional collaboration and communication between physician and pharmacist prescribers.

Current and Potential Roles in Sports Pharmacy: A Systematic Review

(1) Background: The objective of this systematic review was to evaluate current and potential roles for pharmacists in sports medicine and to identify key themes in outcomes reported in studies. (2) Methods: EMBASE, MEDLINE, CINAHL, Scopus and the Cochrane Library were searched in January 2019. Peer-reviewed, original research articles were considered for inclusion. Articles published in a language other than English were excluded. Quality appraisal was performed independently by two authors. (3) Results: Findings of 11 eligible articles (10 observational and 1 experimental study design) were grouped into three themes: (i) doping prevention and control, (ii) injury management and first aid, and (iii) educational and curricular needs. Pharmacists were perceived as a good potential source of information about doping and are enthusiastic about counseling athletes, but lack knowledge and confidence in this area. While pharmacists were frequently consulted for advice on managing sprains and strains, their advice was not always guided by current evidence. Pharmacists and pharmacy students recalled limited opportunity for education in sports pharmacy. (4) Conclusion: Pharmacists showed a willingness and an aptitude to counsel athletes. However, lack of knowledge and confidence, and limited educational opportunities, were key barriers. More research is necessary to support pharmacists in this role.

A comparative study regarding antibiotic consumption and knowledge of antimicrobial resistance among pharmacy students in Australia and Sri Lanka

INTRODUCTION

Antimicrobial resistance (AMR) is a major global health challenge. Pharmacists play a key role in the health care setting to support the quality use of medicines. The education and training of pharmacy students have the potential to impact on patterns of antibiotic use in community and hospital settings. The aim of this study was to investigate and compare antibiotic use and knowledge of antibiotics and AMR among undergraduate pharmacy students in Australian and Sri Lankan universities.

METHODS

A cross-sectional survey was conducted in Australian and Sri Lankan universities that offer a pharmacy degree. A paper-based survey was utilised in Sri Lanka and an identical survey distributed online among pharmacy students in Australia. Descriptive and comparative data analyses were performed.

RESULTS

476 pharmacy students from 14 universities in Australia and 466 students from 6 universities in SL completed the survey. Participants commonly reported previous antibiotic use [Australia (88%) and Sri Lanka (86%)]. The majority of students [Australia (89%) and Sri Lanka (77%)] reported they obtained antibiotics with a prescription. Australian pharmacy students correctly reported regarding optimal antibiotic use for certain disease conditions when compared to Sri Lankan students (P<0.05). A greater antibiotic knowledge level regarding AMR was found among Australian students compared to Sri Lankan students (p<0.05).

CONCLUSION

This study provides an understanding about antibiotic consumption and knowledge on AMR among pharmacy students in a developed country, Australia and a developing country, Sri Lanka. These findings identify possible misconceptions about antibiotics and a lower level of knowledge of AMR amongst Sri Lankan undergraduate pharmacy students. Future research should focus on implementation of a strategic education plan for undergraduate pharmacy students in Sri Lankan universities. The curricula of pharmacy courses in Australian universities may inform such a plan.

General practice pharmacists in England: Integration, mediation and professional dynamics

BACKGROUND

A number of key publications in recent years have advocated a more integrated vision of UK primary care involving increased multi-professional communication and understanding. This has resulted in a marked change in the roles being undertaken by pharmacists. Community pharmacists have traditionally provided a medicine supply function and treated minor ailments in addition to delivering a suite of locally commissioned services; however these functions have not necessarily been part of a programme of care involving the other clinicians associated with the patient. An integrated model of care would see much closer working between pharmacy and general practice but also with pharmacists not only working with, but in the practice, in an enhanced patient-facing role, trained as independent prescribers. This has implications for the dynamics amongst professionals in this environment.

OBJECTIVES

This exploratory multiple case study attempts to explore these changing dynamics across ten GP surgeries throughout the South-East of England.

METHODS

Semi-structured, in-depth interviews were conducted with one nurse, one pharmacist and one physician from each clinic, and survey data was collected from 38 patients who had appointments with a pharmacist.

RESULTS

The data suggested that the pharmacists who had enhanced roles perceived some uncertainty about their professional role and identity, which resulted in instability and insecurity and that this uncertainty led to both professional and interprofessional tension with their primary care colleagues. The survey data revealed that n = 35 (92%) patients stated they were 'very satisfied' or 'satisfied' with their appointment. And n = 37 (97%) were 'very comfortable' or 'comfortable' discussing their medications with the pharmacist. In addition, 36 patients (95%) reported that they strongly agreed or agreed with the clinical recommendations made by the pharmacist.

CONCLUSIONS

These findings are discussed in relation to role expansion and professional/interprofessional relations before key practical suggestions are offered.

Expanding the clinical role of community pharmacy: A qualitative ethnographic study of medication reviews in Ontario, Canada

Medication reviews by community pharmacists are an increasingly common strategy to improve medication management for chronic conditions, and are part of wider efforts to make more effective use of community-based health professionals. To identify opportunities to optimize the medication review program in Ontario, Canada, we explored how providers and clients interpret and operationalize medication reviews within everyday community pharmacy practice. We conducted a qualitative ethnographic study at four pharmacies in Ontario, Canada, including non-participant observation of provider and client activities and interactions with specific attention to medication reviews, as well as brief ethnographic interviews with providers and clients, and in-depth, semi-structured interviews with providers. We report on 72h of field research, observation of 178 routine pharmacist-client interactions and 29 medication reviews, 62 brief ethnographic interviews with providers and clients, and 7 in-depth, semi-structured interviews with providers. We found that medication reviews were variably conducted across the dimensions of duration, provider type, location, and interaction style, and that local contexts and system-wide developments influence their meaning and practice. Medication reviews are exemplary of policy efforts to enhance the role of community pharmacies within health systems and the scope of practice of pharmacists as healthcare professionals. Our study highlights the importance of the local structure of community pharmacy practice and the clinical aspirations of pharmacists in the delivery of medication reviews.

Assessing pharmacists' readiness to prescribe oral antibiotics for limited infections using a case-vignette technique

Background Pharmacist's skills are underutilized whilst they are directly involved with antibiotic supply to the community. Addressing this issue could lead to better use of antibiotics and hence decreased resistance. Objective Explore how pharmacists can prescribe oral antibiotics to treat a limited range of infections whilst focusing on their confidence and appropriateness of prescribing. Setting Community pharmacies, Western Australia. Method Data were collected using a self-administered questionnaire also containing case vignettes. These were distributed to a random sample of metropolitan and rural community pharmacies in Western Australia. A Generalised Estimating Equation was used to compare respondents' level of confidence in treating various infections and to assess appropriateness of prescribing. Main outcome measure Appropriateness and confidence of antibiotic prescribing. Results A response rate of 34.2% (i.e. 425 responses to case vignettes) was achieved from 240 pharmacies. There were high levels of confidence to treat simple infections such as uncomplicated UTIs (n = 73; 89.0%), impetigo (n = 65; 79.3%), mild bacterial skin infections (n = 62; 75.6%) and moderate acne (n = 61; 72.4%). Over 80% of respondents were confident to prescribe amoxicillin (n = 73; 89%), trimethoprim (n = 72; 87.8%), amoxicillin and clavulanic acid (n = 70; 85.4%), flucloxacillin (n = 70; 85.4%) and cephalexin (n = 68; 82.9%). High levels of appropriate antibiotic prescribing were shown for uncomplicated UTI (97.2%), cellulitis (98.2%) and adolescent acne (100.0%). Conclusion This study identified key limited infections and antibiotics for which pharmacists were supportive and confident to prescribe. This role could lead to better use of antibiotics in the community and minimisation of resistance.

Management of hypertension in an Australian community pharmacy setting – patients’ beliefs and perspectives

Objective

To explore patients' perspectives and experiences following a trial of a pharmacist-led service in hypertension management.

Methods

A qualitative study comprising individual interviews was conducted. Patients of a community pharmacy, where a pharmacist-led hypertension management service had been trialled in selected metropolitan regions in Sydney (Australia), were recruited to the study. Emergent themes describing patients' experiences and perspectives on the service were elicited via thematic analysis (using manual inductive coding).

Key findings

Patients' (N = 18) experiences of the service were extremely positive, especially around pharmacists' monitoring of blood pressure and provision of advice about medication adherence. Patients' participation in the service was based on their trust in, and relationship with, their pharmacist. The perception of working in a ‘team' was conveyed through the pharmacist's caring style of communication and the relaxed atmosphere of the community pharmacy. Patients felt that the community pharmacy was an obvious place for such a service because of their regular contact with the pharmacist, but was limited because the pharmacists were not able to prescribe medication.

Conclusion

Patients were extremely positive about the role of, and their experience of, the pharmacy-based hypertension management service. Factors contributing to the patients' positive experiences provide important insights for community pharmacy practice. Good rapport with the pharmacist and a long-term relationship underpin patient engagement in such services. Restrictions on the pharmacists' scope of practice prevent their expertise, and the benefits of their accessibility as a primary point of contact, from being fully realised.

Pharmacists’ Perceptions Regarding Optimization of Antibiotic Prescribing in the Community

Background and Objective:

The overuse of antibiotics in the community is a primary cause of antibiotic resistance. Community pharmacists are the most accessible health professionals and so they are in an ideal position to implement interventions to ensure the appropriate use of antibiotics. This study aimed to explore the role of community pharmacists in the optimization of antibiotic prescribing and utilization.

Method:

Four focus groups were conducted with community pharmacists in Perth, Western Australia. Audio-recorded data were compared with field notes, transcribed, and thematically analyzed.

Results:

There were twenty-four participants in four focus group sessions. Four main themes were identified: patient perceptions and behaviors, prescribing behaviors, pharmacists’ roles and responsibilities, and health care system interventions in relation to antibiotic utilization. A number of interventions that could be implemented by community pharmacists were identified. In addition to interventions that are currently in place in Australia, forward dispensing, improved interprofessional collaboration, an expansion of current prescribing role, and vaccination capabilities were also suggested.

Conclusions:

This study indicated that current scope of pharmacists’ roles has room for more intervention strategies aimed at improving antibiotic prescribing and utilization in the community.

Implementation and evaluation of a pharmacist-led hypertension management service in primary care: outcomes and methodological challenges

Background:

Suboptimal utilisation of pharmacotherapy, non-adherence to prescribed treatment, and a lack of monitoring all contribute to poor blood (BP) pressure control in patients with hypertension.

Objective:

The objective of this study was to evaluate the implementation of a pharmacist-led hypertension management service in terms of processes, outcomes, and methodological challenges.

Method:

A prospective, controlled study was undertaken within the Australian primary care setting. Community pharmacists were recruited to one of three study groups: Group A (Control – usual care), Group B (Intervention), or Group C (Short Intervention). Pharmacists in Groups B and C delivered a service comprising screening and monitoring of BP, as well as addressing poor BP control through therapeutic adjustment and adherence strategies. Pharmacists in Group C delivered the shortened version of the service.

Results:

Significant changes to key outcome measures were observed in Group C: reduction in systolic and diastolic BPs at the 3-month visit (P<0.01 and P<0.01, respectively), improvement in medication adherence scores (P=0.01), and a slight improvement in quality of life (EQ-5D-3L Index) scores (P=0.91). There were no significant changes in Group B (the full intervention), and no differences in comparison to Group A (usual care). Pharmacists fed-back that patient recruitment was a key barrier to service implementation, highlighting the methodological implications of screening.

Conclusion:

A collaborative, pharmacist-led hypertension management service can help monitor BP, improve medication adherence, and optimise therapy in a step-wise approach. However, blood pressure screening can effect behaviour change in patients, presenting methodological challenges in the evaluation of services in this context.

Pharmacist prescribing: A scoping review about the views and experiences of patients and the public

BACKGROUND

Policy-makers and health professionals' views about pharmacist prescribing have been well studied, but less is known about the views of the public and patients.

OBJECTIVE

To describe from existing literature the views and experiences of patients as well as the views of the public about pharmacist prescribing.

METHODS

Sources: Medline, EMBASE, and International Pharmaceutical Abstracts from inception to November 2015; reference lists of included studies.

INCLUSION CRITERIA

English-language studies describing the views and experiences of patients and the views of the public about pharmacist prescribing. Two reviewers independently screened titles and abstracts and one reviewer charted data. The University of British Columbia Patient Experience Framework was used to categorize and synthesize findings about patients' experience. Views were described using a descriptive thematic synthesis approach.

RESULTS

Out of 2377 unique records, 35 articles were reviewed in full for eligibility. Three studies were excluded because participants were not patients or the public, eight studies were not about prescribing, and four studies were abstracts. Two articles were identified from the bibliographies of included studies. In total, twenty-two studies met inclusion criteria. Fourteen studies were quantitative (63.6%), six were qualitative (27.3%) and two were mixed design (9.1%) studies. Four studies (18.2%) were conducted in Canada (Saskatchewan, Newfoundland and Labrador, Nova Scotia), one (4.5%) in Australia, one (4.5%) in the United States (Washington) and the remaining in the United Kingdom (n = 16, 72.7%). The most commonly explored dimensions of patient experiences were access, interpersonal communication, and patient-reported impacts of care. Patients reported high satisfaction with appointment times, communication with the pharmacist prescriber and the services received. The public supported pharmacist prescribing in limited situations (chronic conditions, minor ailments, repeat medications). The public were concerned about privacy during consultations but patients were less so. Both patients and the public shared concerns regarding lack of adequate resources to ensure safe prescribing by pharmacists (e.g., lack of pharmacists' access to medical records, lack of additional staff support to fulfill prescribing responsibilities).

CONCLUSION

Patients' experiences with pharmacist prescribing were generally positive. There were shared concerns between patients and the public about pharmacist prescribing. Opportunities for further research include strategies for building public experience with pharmacist prescribing and methods for addressing concerns identified by patients and the public.

The case of pharmacist prescribing policy in Israel

Pharmacy prescribing policy in Israel has been negotiated and changed in recent years in order to improve patient treatment and access to medicines, and reduce national health insurance costs by allowing pharmacists to prescribe medications. Various stakeholders and institutions were involved in the formulation process, affecting the process while representing different motives. The complexity of pharmacy prescribing policy formulation is universal - any policy project needs, for strategic and tactical reasons, to acquire an inventory of institutions involved, identify the key players and explore potential support or opposition among them. This article uses the field (theory) of new institutional economics to explain the process of pharmaceutical institutional change and identifies the stakeholders who are involved in the reform.

In the framework of pharmaceutical policies, seven models of prescribing practices are outlined, and the Canadian and British prescribing models are presented. The paper then focuses on the Israeli case and the main issues that concern decision-makers in the Israeli health system, such as inequality in access to health services and the erosion of the notion of universal health services. These concerns and the involvement of different stakeholders, such as The Israeli Medical Association (IMA) and health funds, influenced and directed the final Pharmacist Prescribing Law. After several rejections and amendments the law was passed, enabling experienced pharmacists to prescribe only to patients with a previous prescription given by a physician in the hope it would improve services to patients and reduce physicians’ workloads. Here, the topic of the new prescribing policy is introduced, using tools from the new institutional school in political economy.

A scoping review of research on the prescribing practice of Canadian pharmacists

BACKGROUND

Pharmacists in Canada have been prescribing since 2007. This review aims to explore the volume, array and nature of research activity on Canadian pharmacist prescribing and to identify gaps in the existing literature.

METHODS

We conducted a scoping review to examine the literature on prescribing by pharmacists in Canada according to methodological trends, research areas and key findings. We searched for peer-reviewed research articles and abstracts in the Ovid MEDLINE, Ovid EMBASE and International Pharmaceutical Abstracts databases without any date limitations. A standardized form was used to extract information.

RESULTS

We identified 156 articles; of these, 26 articles and 12 abstracts met inclusion criteria. One-half of the research studies (20) used quantitative methods, including surveys, trials and experimental designs; 11 studies used qualitative methods and 7 used other methods. Research on pharmacist prescribing demonstrated an improvement in patient outcomes (13 studies), varied stakeholder perceptions (10 studies) and factors that influence this practice change (11 studies). Pharmacist prescribing was adopted when pharmacists practised patient-centred care. Stakeholders held contrasting perceptions of pharmacist prescribing.

DISCUSSION

Canadian research has demonstrated the benefit of pharmacist prescribing on patient outcomes, which is not present in the international literature. Future research may consider a meta-analysis addressing the impact on patient health. Gaps in research include comparisons between provinces, effects on physicians' services, overall patient safety and access to health care systems and economic implications for society.

CONCLUSION

A growing body of research on pharmacist prescribing has captured the early impact of prescribing on patient outcomes, perceptions of practice and practice change. Opportunities exist for pan-Canadian research that examines the system impact.

Continued Dispensing: what medications do patients believe should be available?

Background. Continued Dispensing (CD) is a new medication supply method for certain medications in Australia. It aims to prevent treatment interruption as a result of patients’ inability to obtain a new valid prescription. The only currently eligible patients for this service are statin and/or oral contraceptives users who have been using these medications for 6 months or more, have not utilized the CD method during the last 12 months, and cannot obtain an immediate appointment with the prescriber in order to get a new prescription. This study aimed to investigate patients’ attitudes towards potential extension and expansion of this medication supply method.

Methods. A randomly selected 301 users of these medications from all Australian States were recruited using Computer Assisted Telephone Interview (CATI).

Result. The response rate was 79%. The majority of the participants (73.3%) did not agree with current restriction on CD utilization frequency. They also supported, to varying degrees, inclusion of all the proposed medications (support ranged from 44.2–78.4%). In this regard, participants who suffered from a specific disease did not differ significantly from those without the disease except in case of patients with depression (p = 0.001).

Conclusions. Participants of this study strongly supported both CD extension and expansion. A future critical review of the current version of CD is highly recommended in order to enhance CD capability to achieve its goals.

Using scenarios to test the appropriateness of pharmacist prescribing in asthma management

OBJECTIVE

To explore the potential for community pharmacist prescribing in terms of usefulness, pharmacists' confidence, and appropriateness, in the context of asthma management.

METHODS

Twenty community pharmacists were recruited using convenience sampling from a group of trained practitioners who had already delivered asthma services. These pharmacists were asked to complete a scenario-based questionnaire (9 scenarios) modelled on information from real patients. Pharmacist interventions were independently reviewed and rated on their appropriateness according to the Respiratory Therapeutic Guidelines (TG) by three expert researchers.

RESULTS

In seven of nine scenarios (78%), the most common prescribing intervention made by pharmacists agreed with TG recommendations. Although the prescribing intervention was appropriate in the majority of cases, the execution of such interventions was not in line with guidelines (i.e. dosage or frequency) in the majority of scenarios. Due to this, only 47% (76/162) of the interventions overall were considered appropriate. However, pharmacists were deemed to be often following common clinical practice for asthma prescribing. Therefore 81% (132/162) of prescribing interventions were consistent with clinical practice, which is often not guideline driven, indicating a need for specific training in prescribing according to guidelines. Pharmacists reported that they were confident in making prescribing interventions and that this would be very useful in their management of the patients in the scenarios.

CONCLUSIONS

Community pharmacists may be able to prescribe asthma medications appropriately to help achieve good outcomes for their patients. However, further training in the guidelines for prescribing are required if pharmacists are to support asthma management in this way.

What prescribing means to pharmacists: a qualitative exploration of practising pharmacists in Alberta

Objective

In 2007 Alberta, Canada, became the first North American jurisdiction to adopt prescribing legislation for pharmacists. In light of these legislative changes and expanded scope of pharmacy practice, we evaluated what ‘prescribing’ means to pharmacists in Alberta and the application of prescribing in pharmacy practice.

Methods

We invited pharmacists to participate in semi-structured telephone interviews using closed and open-ended questions. Pharmacists working in community, hospital or other settings were selected using a mix of random and purposive sampling. Interviews were audiorecorded and transcribed, and data were entered into nVIVO 9 software. Transcriptions were analysed by two investigators using an interpretive description approach to identify themes.

Key findings

Thirty-eight pharmacists were interviewed, of whom 13 had additional (independent) prescribing authorization. Prescribing had a wide breadth of meaning to the pharmacists in our study, which included writing a new prescription and extending an existing prescription, as well as advising on non-prescription medications. Pharmacists described prescribing in terms of the physical act of writing the prescription and as part of the patient care process as well as the legislated definition of pharmacist prescribing. The sense of increased responsibility associated with prescribing was noted by many pharmacists.

Conclusion

Prescribing had diverse meanings to pharmacists in our study, and appeared to be context-specific. Understanding the meaning prescribing holds for individual pharmacists is important to explore whether pharmacist’s definition of this expanded scope has shaped pharmacists’ enactment of prescribing practice.

Integrating a pharmacist into the general practice environment: opinions of pharmacist's, general practitioner's, health care consumer's, and practice manager's

Background

Pharmacists are viewed as highly trained yet underutilised and there is growing support to extend the role of the pharmacist within the primary health care sector. The integration of a pharmacist into a general practice medical centre is not a new concept however is a novel approach in Australia and evidence supporting this role is currently limited. This study aimed to describe the opinions of local stakeholders in South-East Queensland on the integration of a pharmacist into the Australian general practice environment.

Methods

A sample of general practitioners, health care consumers, pharmacists and practice managers in South-East Queensland were invited to participate in focus groups or semi-structured interviews. Seeding questions common to all sessions were used to facilitate discussion. Sessions were audio recorded and transcribed verbatim. Leximancer software was used to qualitatively analyse responses.

Results

A total of 58 participants took part in five focus groups and eighteen semi-structured interviews. Concepts relating to six themes based on the seeding questions were identified. These included positively viewed roles such as medication reviews and prescribing, negatively viewed roles such as dispensing and diagnosing, barriers to pharmacist integration such as medical culture and remuneration, facilitators to pharmacist integration such as remuneration and training, benefits of integration such as access to the patient’s medical file, and potential funding models.

Conclusions

These findings and future research may aid the development of a new model of integrated primary health care services involving pharmacist practitioners.