Exploring the concept of patient centred communication for the pharmacy practice

Background Patient centred communication can improve pharmaceutical care, but is not well described for pharmacists. Aim of the review To provide a comprehensive and accessible overview of the concept of patient centred communication for the pharmacy practice. Method A scoping review and thematic analysis was undertaken to synthesize the extracted data and present it in a model. Results Literature search and selection resulted in eighteen articles. Thematic analysis of the extracted data led to five categories regarding patient centred communication. Two categories refer to phases of a pharmaceutical consultation: (1) shared problem defining and (2) shared decision making; three refer to underlying concepts and assumptions about patient centredness regarding (3) the patient, (4) the pharmacist and (5) the therapeutic relation. The categories were modelled in the so called Utrecht’s Model for Patient centred communication in the Pharmacy. Conclusion Although there might be barriers to implement patient centred communication in the pharmacy, the concept of patient centred communication as described in the literature is relevant for the pharmacy practice.

The Effect of Pharmacotherapy Audit Meetings on Early New Drug Prescribing by General Practitioners

Background:

New drugs are cornerstones of clinical practice. However, when included in practice in an erratic fashion, there is valid concern about uncertain risk–benefit for patients and increased healthcare expenditures. In several countries, general practitioners (GPs) and pharmacists work closely together to ensure proper use of new drugs in clinical practice.

Objective:

To estimate the effect of pharmacotherapy audit meetings (PTAMs) between GPs and community pharmacists on prescribing of newly marketed drugs by GPs.

Methods:

We conducted an observational study of new drug prescribing in a cohort of 103 GPs, working in 59 practices, from 1999 until 2003. The main outcome measures were the decisions to start therapy with a new drug or with an existing older drug from the same therapeutic category within the first 6 months after market introduction. Multilevel modeling was used for analyses.

Results:

Overall, in 6.1% of the decisions to start drug therapy, GPs chose the drug that was most recently introduced into the market. The GPs attending lowquality PTAMs made 1861 decisions to start therapy; in 112 (6.0%) of those decisions, a new drug was preferred over an older alternative. GPs participating in high-quality PTAMs preferred a new drug in only 3.4% of the 3138 decisions made. Compared with GPs participating in PTAMs on the highest quality level (level 4), GPS attending level 1 or level 2 PTAMs were more than twice as likely to start therapy with new drugs than with older drugs (OR 2.24; 95% CI 1.04 to 4.81 vs OR 2.31; 95% CI 1.30 to 4.09, respectively).

Conclusions:

PTAMs may be an effective way to control early prescribing of new drugs in general practice. For PTAMs to be effective, it is vital that GPs and pharmacists set common goals on how to optimize pharmacotherapy. This concordance should be reflected in PTAMs that result in concrete decisions with auditing of GP prescribing behavior. Pharmacists should play an active role in organizing PTAMs to increase their influence on drug prescribing.

Which Pharmacists Contribute to High-Level Pharmacotherapy Audit Meetings with General Practitioners?

Background:

In the Netherlands, community pharmacists and general practitioners (GPs) collaborate in pharmacotherapy audit meetings (PTAMs) to optimize pharmacotherapy.

Objective:

To identify associations between the quality level of PTAMs and characteristics of pharmacists.

Methods:

We used a cross-sectional questionnaire design in a Dutch general practice and community pharmacy setting to estimate the contribution of pharmacists to the quality level of PTAMs. The questionnaire was sent to 123 community pharmacies working closely with 104 GP practices. The outcome variable was the quality level of PTAMs. The questionnaire provided information on 4 topics that were used as independent variables: characteristics of the PTAMs, provision of pharmacotherapy activities, characteristics of the pharmacists, and characteristics of the pharmacies.

Results:

In total, 109 (88.6%) pharmacists completed the questionnaire, with 103 participating in 62 different PTAMs. Seventeen pharmacists participated in level 1 PTAMs (lowest level), 57 in level 2, 21 in level 3, and 8 in PTAMs at the highest level. The multinomial logistic regression identified only one significant association: pharmacists who participated in the highest quality level reported that they undertake initiatives in PTAMs (OR 2.98; 95% CI 1.07 to 8.26) more frequently compared with pharmacists participating on the lowest level.

Conclusions:

In light of existing evidence, the role of pharmacists in PTAMs seems to be important. Pharmacists should create a distinct profile of their expertise, allowing them to professionalize PTAMs by undertaking more initiatives. PTAMs offer pharmacists a great opportunity to become integral members of the prescribing process.

Communication during counseling sessions about inhaled corticosteroids at the community pharmacy

BACKGROUND

Pharmaceutical care is one of the major tasks of pharmacists, which aims to improve patient outcomes. Counseling patients with asthma or chronic obstructive pulmonary disease about their use of inhaled corticosteroids (ICS) might enhance medication adherence and symptom control. Therefore, effective pharmacist-patient communication is very important. In this regard, both affective communication, for handling emotions, and instrumental communication, for exchanging biomedical and lifestyle information, are relevant. Until now, only few studies have explored pharmacist-patient communication, and further insight is needed in this regard. The aim of this study is to investigate how pharmacists and pharmacy technicians communicate about ICS with patients with asthma and/or chronic obstructive pulmonary disease, what topics are discussed by them, and whether pharmacists and pharmacy technicians differ in their communication during counseling sessions.

METHODS

Patients aged ≥18 years who had used ICS for at least 1 year and filled at least two ICS prescriptions in the preceding year were recruited through 12 pharmacies. Participants had one counseling session with a pharmacist or a pharmacy technician, which was video-recorded. The process and content of the provider-patient communication were analyzed using the Roter interaction analysis system, adapted to the pharmaceutical setting.

RESULTS

A total of 169 sessions were recorded and analyzed. The communication appeared largely instrumental. Lifestyle, psychosocial issues, and ICS adherence were not discussed in detail. The pharmacists had longer conversations and more affective talk than the pharmacy technicians.

CONCLUSION

Pharmacists and pharmacy technicians may need to pay more attention to ICS adherence, lifestyle, and psychosocial topics. They differed in their communication; the pharmacists exhibited more affective behavior and discussed medical and therapeutic issues more extensively compared to the pharmacy technicians. Educational courses for pharmacists and pharmacy technicians could focus more on the discussion of adherence, lifestyle, and psychosocial topics with patients.

Cue-Responding Behaviors During Pharmacy Counseling Sessions With Patients With Asthma About Inhaled Corticosteroids: Potential Relations With Medication Beliefs and Self-Reported Adherence

The aim of this study was to examine cue-responding behavior at the pharmacy while counseling about inhaled corticosteroids (ICS) in relation to medication adherence and medication beliefs. Patients with asthma aged ≥18 years using ICS were recruited from 12 pharmacies. Counseling sessions were video-recorded. Patients' emotional and informational cues and pharmacists' and pharmacy technicians' cue-responding behaviors were coded using an expanded version of the Medical Interview Aural Rating Scale. The Beliefs about Medicines Questionnaire assessed patients' ICS concern and necessity beliefs. Self-reported ICS adherence was measured by four questions. During the 86 sessions, patients expressed on average 2.3, mostly informational, cues (70.8%). In 26.7% of the sessions, no cues were expressed. Pharmacists' and technicians' responses to emotional cues (59.3%) were mostly inadequate, and to informational cues mostly appropriate (63.6%). Providing inappropriate information (20.3%) was related to higher concerns post session (p < .05), and cue exploration to higher self-reported adherence at 3 months (p < .05). Apparently, providers' responses to patients' cues might have therapeutic value. In addition, patients might need to be encouraged to ask questions and express their concerns.

Beliefs about inhaled corticosteroids: Comparison of community pharmacists, pharmacy technicians and patients with asthma

OBJECTIVES

To compare pharmacists' and pharmacy technicians' perceptions of patients' beliefs regarding inhaled corticosteroids (ICS) with those of patients and to compare the ICS beliefs of pharmacists and technicians with those of patients with asthma.

METHODS

1269 community pharmacies were approached to fill out an online questionnaire; 1952 patients were sent a questionnaire by post. Beliefs (i.e., necessity and concerns) regarding ICS were measured using (an adapted version of) the Beliefs about Medicines Questionnaire (BMQ-specific). Pharmacists and technicians were instructed to fill out the BMQ for themselves, and to fill it out in the way they thought most of their patients would complete it.

RESULTS

136 pharmacists, 90 pharmacy technicians and 161 patients with asthma completed the questionnaire. Pharmacists and technicians thought patients had more concerns about ICS than patients themselves reported (p < 0.0001). They also thought that patients had stronger beliefs in their personal need for ICS than patients reported (p < 0.01). Pharmacists reported lower levels of concerns than patients (p < 0.05) and both providers attributed a higher level of necessity to ICS than patients did (p < 0.0001).

CONCLUSION

Pharmacists and technicians overestimate the personal need for treatment as well as the concerns patients with asthma have regarding ICS. They also have, to some extent, stronger positive beliefs about ICS than patients. If pharmacists and technicians expect that patients share their positive views about ICS, they might be less likely to elicit and address patients' doubts and concerns about ICS, which might be relevant for effective ICS treatment and subsequent patient outcomes.

Decreasing the load? Is a Multidisciplinary Multistep Medication Review in older people an effective intervention to reduce a patient's Drug Burden Index? Protocol of a randomised controlled trial

INTRODUCTION

Older people often use medications with anticholinergic or sedative side effects which increase the risk of falling and worsen cognitive impairment. The Drug Burden Index (DBI) is a measure of the burden of anticholinergic and sedative medications. Medication reviews are typically done by a pharmacist in collaboration with a general practitioner to optimise the medication use and reduce these adverse drug events. We will evaluate whether a Multidisciplinary Multistep Medication Review (3MR) is an effective intervention to reduce a patient's DBI.

METHODS

A randomised controlled trial including 160 patients from 15 community pharmacies will be conducted. Per pharmacy, 1 pharmacist will perform a structured 3MR in close collaboration with the general practitioner, including the objective to reduce the DBI.

ANALYSIS

Primary outcome--the difference in proportion of patients having a decrease in DBI ≥ 0.5 in the intervention and control groups at follow-up. Secondary outcomes--anticholinergic and sedative side effects, falls, cognitive function, activities of daily living, quality of life, hospital admission, and mortality.

ETHICS AND DISSEMINATION

The burden of patients will be kept at a minimum. The 3MR can be considered as usual care by the pharmacist and general practitioner. Medical specialists will be consulted, if necessary. The intervention is specifically aimed at older community-dwelling patients in an attempt to optimise prescribing, in particular, to reduce medication with anticholinergic and sedative properties. Study results will be published in peer-reviewed journals and will be distributed through information channels targeting professionals.

TRIAL REGISTRATION NUMBER

NCT02317666; Pre-results.

Communication with patients who are dispensed a first prescription of chronic medication in the community pharmacy

OBJECTIVE

To analyze information and communication in the community pharmacy when patients collect a first dispensing for chronic medication.

METHODS

In 3 pharmacies in the South-West of the Netherlands, counter-based communication with patients receiving a first dispensing for chronic medication was observed and audiotaped. Each contact was analyzed by two observers using an observation checklist. An 11-item questionnaire was given to the patients.

RESULTS

72 Patients were included. Only pharmacy technicians provided information. Average contact lasted approximately 2min. A computer checklist to support information giving was closely followed. Interactions were structured with introduction and closure. Mostly, information was given without exploring needs of the patient. Questioning showed open-ended questions (26%); check-questions and questions asking feedback (57%). A mean general score given was 5.8 (range 1-9). Of 46 responders who filled in a questionnaire, the majority felt that information was useful, clear and understandable.

CONCLUSION

Our results show a concise and efficient way of information giving, closely related to a computer checklist. Technicians dominate the interaction. They ask few questions. Patients are satisfied about provided information and the contact.

PRACTICE IMPLICATIONS

We suggest a more patient-centered way of communication to increase patients' participation and to meet patients' needs for information.

Patients' perceptions and illness severity at start of antidepressant treatment in general practice

OBJECTIVES

Patients' perceptions are important to consider when trying to understand why patients often do not follow prescriptions for antidepressant treatment. This study aimed to investigate the influence of patients' perceptions and illness severity at the start on antidepressant-medication-taking behaviour.

METHODS

Eighteen community pharmacies in the Netherlands participated in this 6-month follow-up study. One hundred and ten patients presenting a first antidepressant prescription, prescribed by a general practitioner (GP), were included. A questionnaire was completed at inclusion, after 6 and 26 weeks.

KEY FINDINGS

Of all 110 patients, eight (7.3%) did not initiate drug taking, 32 (29.1%) discontinued use, six (5.5%) switched to different antidepressant medication, and 64 (58.2%) continued on the same antidepressant during follow-up. Compared to continuers, non-initiators had lower belief scores for impact of illness (P = 0.044), perceived norm GP (P < 0.001), intention to take medication (P < 0.001), and attitude towards medication (P = 0.004). Furthermore, non-initiators were less severely depressed (P = 0.024). Discontinuers and continuers did not differ in illness severity at inclusion. However, discontinuers more often reported a non-specific reason for use, such as fatigue and sleeping problems (P = 0.014). Compared to continuers, switchers had higher illness severity scores at inclusion (depression, P = 0.041; anxiety, P = 0.050). During follow-up depression and anxiety severity improved for all treatment groups and reached the same level of severity at 6 months.

CONCLUSIONS

Patients' illness and treatment perceptions and illness severity influence their decisions about antidepressant drug taking. Patients' care could be improved by eliciting patients' beliefs about illness and treatment and assessing illness severity before prescribing.

The decision to continue or discontinue treatment: experiences and beliefs of users of selective serotonin-reuptake inhibitors in the initial months--a qualitative study

BACKGROUND

Little is known about patients' views on taking selective serotonin-reuptake inhibitors (SSRIs) and their decision-making processes regarding either continuation or discontinuation within a few months of initiating therapy.

OBJECTIVE

To explore the experiences and beliefs of SSRI users in relation to initiation and execution of treatment, with the intention to identify patterns leading to discontinuation or continuation of treatment.

METHODS

Semistructured qualitative interview study. Eighteen patients, older than 18 years, were interviewed 3 months after starting SSRI treatment prescribed by a general practitioner (GP), 9 of whom had discontinued (discontinuers) and 9 of whom continued treatment (continuers).

RESULTS

Two main patterns lead to either discontinuation or continuation of use. Continuers were satisfied with the GP's role during initiation and execution of SSRI treatment and fully trusted their decision. Continuers' attitudes toward treatment were predominantly positive; they seemed to have little doubt about the necessity of using an SSRI and hardly considered discontinuing for fear of relapse. Discontinuers, on the other hand, seemed to be less involved in decision making and often appeared to have little confidence in their GPs. Most discontinuers felt that they lacked knowledge, and their attitude toward taking SSRIs was rather negative. Discontinuers often were unconvinced about the necessity of using an SSRI and appeared to have a strong desire to discontinue treatment.

CONCLUSION

Lack of shared decision making between patient and GP, limited counseling during treatment, lack of knowledge, and patients' negative attitudes toward SSRI use and the disease itself, hampered the acceptance of the SSRI and brought on the decisional conflict to discontinue treatment. Health care professionals could be more supportive during the initial months of SSRI treatment by eliciting patients' considerations for continuing or discontinuing treatment.

Patients' perceptions of information received at the start of selective serotonin-reuptake inhibitor treatment: implications for community pharmacy

BACKGROUND

Pharmacists are increasingly acknowledging their responsibility to inform and counsel patients. However, it is unclear how these tasks are implemented and whether patients' needs are being fulfilled.

OBJECTIVE

To examine patients' perceptions of information received at the start of selective serotonin-reuptake inhibitor (SSRI) treatment, aiming to identify (1) information needs and (2) the potential role of the community pharmacist as information provider.

METHODS

A qualitative descriptive study comprising semi-structured telephone interviews was carried out with patients who had recently started a new course of SSRI treatment. Patients were recruited through 6 Dutch community pharmacies. The interviews were guided by the following topics: type of information obtained, unmet information needs, preferred information provider, and the role of the pharmacist.

RESULTS

Forty-one patients took part in an interview. Information needs varied widely among patients; overall, patients felt that they would benefit from information tailored to their needs. Many patients required more concrete and practical information on adverse effects and delayed onset of action than was provided. In addition, an explanation of the term dependency in the context of SSRI use and a discussion of the necessity for use and believed harms of long-term treatment were important to patients. Regardless of patients' needs, the role of the pharmacist was generally perceived as limited, and patients identified several pharmacy-related barriers to improved communication, including the timing of information (mainly restricted to first-time dispensing), lack of time and privacy, lack of empathy and a protocol-driven way of providing information, and inexperience of pharmacy technicians.

CONCLUSIONS

Patients starting treatment with antidepressants may benefit from information tailored to their personal needs. Along with the prescribing physician, community pharmacists could have an important role in informing and counseling patients.

Characteristics and Reasons Associated with Nonacceptance of Selective Serotonin-Reuptake Inhibitor Treatment

Background:

Studies have shown that up to 38% of patients who start treatment with antidepressants fill only a single prescription at the pharmacy, apparently not accepting treatment.

Objective:

To determine characteristics and reasons associated with nonacceptance of selective serotonin-reuptake inhibitor (SSRf) treatment,

Methods:

A retrospective study was conducted in 37 community pharmacies in the Netherlands; patients who presented a prescription from a general practitioner (GP) for a newly started SSRI treatment were selected, Nonaccepters were defined as patients who filled only one SSRI prescription; patients who received at least 3 fills of an SSRI prescription were defined as accepters. Patient characteristics were obtained from automated dispensing records and from questionnaires. Areas of evaluation included sociodemographics, disease, and treatment. Nonaccepters were asked their reasons for not filling second prescriptions.

Results:

Of the patients who started SSRI treatment, 22.0% were nonaccepters, filling only a single prescription. Fifty-seven nonaccepters and 128 accepters were included in our analysis. Nonacceptance was more common among patients with a low level of education (OR 2.6; 95% CI 1.1 to 5.9) and in patients who reported nonspecific symptoms like fatigue, stress, and restlessness as the reason for SSRI use (OR 2.7; 95% CI 1.4 to 5.5). Of the nonaccepters, 29.8% (n = 17) did not start SSRI use, and 70.2% (n = 40) discontinued SSRI use within 2 weeks. Fear of adverse effects and the actual occurrence of adverse effects were main reasons for not accepting SSRI treatment. Of the nonaccepters, 55.0% discontinued treatment without informing their GPs.

Conclusions:

Acceptance of SSRI treatment is a decisive moment in a patient's adherence to treatment initiated by his or her GP and deserves more attention; GPs and pharmacists should address treatment issues, especially in groups at risk for nonacceptance.

Initial benzodiazepine use and improved health-related quality of life

OBJECTIVE

The health-related quality of life (HRQOL) of initial benzodiazepine users was measured over time. Furthermore, benzodiazepine usage characteristics as determinants of change in mental and physical health status of the benzodiazepine users were examined.

METHODS

In the only pharmacy of a Dutch community of 13,500 and during four months from November 1994, all patients with a benzodiazepine prescription and no history of benzodiazepine use over a period of 12 months before inclusion, were invited to participate. A total of 106 initial benzodiazepine users were matched for age and gender. In a six-month follow-up study, HRQOL was measured with the RAND-36. Consequently, in a nested case control design, determinants of change in mental and physical functioning over the six-month period were analysed using the Mental Component Summary and the Physical Component Summary.

RESULTS

At baseline, initial benzodiazepine users showed a lower HRQOL as compared to reference subjects. After six-month follow-up, benzodiazepine users presented an absolute increase in HRQOL, while the reference subjects maintained a stable HRQOL. Diazepam and the male gender were associated with an increase in physical functioning over time. Younger age, a lower daily dose (DDD < 0.75) and a period of use between 16 and 60 days were associated with better mental functioning over time.

CONCLUSION

This study is one of the first to associate improvement in HRQOL over time of starting benzodiazepine users with specific usage characteristics, such as limited duration of use and a low dosage.

The impact of attitudes and beliefs on length of benzodiazepine use: a study among inexperienced and experienced benzodiazepine users

Prolonged benzodiazepine use is a widespread phenomenon in medical practice. In the present article, we argue that psychological models may contribute to our understanding of benzodiazepine use. This study examined variables derived from the theory of planned behaviour and the health belief model in relation to the length of benzodiazepine use. Data were collected from a sample of all benzodiazepine users with a request for this medicine in the only pharmacy in a Dutch community (N=467). Determinants of the length of benzodiazepine use were analysed separately for inexperienced and experienced users using structural equation modelling (SEM) analyses. For both groups, results showed that the intention to use benzodiazepines was a predictor of length of use. Attitudes towards benzodiazepine use had an indirect influence on length of use, through intentions. Furthermore, a positive attitude toward using benzodiazepines was related to the perceived norm of the prescriber. Experienced users were more inclined to consume benzodiazepines when they had less control over drug taking. In this group, the belief that benzodiazepine use leads to dependence was associated with less control over drug taking and a high intention to use the drug. In addition, older experienced users reported a higher intention to use the drug. For inexperienced users, the perceived attitude of the prescriber towards use of the medicine was a strong determinant. Finally, results of SEM-analyses showed that the model accounted for far more variance in behaviour for experienced users (67%), than for inexperienced users (18%).

Initial 3-month usage characteristics predict long-term use of benzodiazepines: an 8-year follow-up

OBJECTIVE

The aim of the study was to identify initial usage predictors for prolonged benzodiazepine use.

METHODS

An 8-year pharmacy data-based study (1983-1992) was carried out on a retrospective cohort of 425 initial benzodiazepine users. The setting was the only pharmacy in a community of 13,500 people.

RESULTS

Among the 425 initial users, 36% had a single initial exposure year, 50% had two to seven exposure years, and 14% had benzodiazepine use during all 8 years of follow-up. Prolonged use over more years was associated with an initial high number of prescriptions, elderly patients and initial use of hypnotics. Two patterns of irregular prolonged use were investigated: increase in use was associated with a shorter length of the first usage period and switching to another benodiazepine during the first 90 days; relapses of use were associated with a shorter length of first usage period and initial use of an anxiolytic. Gender and initial dosage were not associated with prolonged use at all.

CONCLUSION

During the first 90 days after initiation of benzodiazepine use, a number of determinants of prolonged benzodiazepine use were visible. The prescribers of these drugs and the pharmacists should advise rational use not only at the start but also at the moment of the first repeat prescription in order to prevent needless prolonged use and dependence.

Comparing patterns of long-term benzodiazepine use between a Dutch and a Swedish community

BACKGROUND

There is much concern about the widespread long-term use of benzodiazepines. Utilisation data can give a foundation for interventions for appropriate use.

OBJECTIVE

To compare long-term usage patterns of benzodiazepines in a Dutch and a Swedish community in different periods.

METHODS

Eight-year follow-up patterns of use were investigated with respect to the characteristics of those who continued use over the whole follow-up period. In the Dutch community of 13,500, the data of a cohort of 1358 benzodiazepine users were analysed during the years 1984-1991; in the Swedish community of 20,000 people, a cohort of 2038 benzodiazepine users was followed from 1976.

RESULTS

At the end of the follow-up period, 32.9% of the Dutch cohort and 33% of the Swedish cohort had continued use of benzodiazepines. The two overall survival curves showed similar patterns. Stratification for age, gender, previous versus initial use and heavy versus non-heavy use showed comparable proportions of patients continuing benzodiazepine use over time.

CONCLUSION

The parallels in the results of two cohorts in different countries and different periods are striking and give support to the idea to stimulate interventions to reduce long-term benzodiazepine use.