services
There are a multitude of factors that can influence the implementation or continuing delivery of a pharmacy service. As early as 1979, a short article was published detailing the three key barriers that needed to be overcome to increase the pharmacist’s ability to provide pharmacy services: pharmacist knowledge/competency; interaction with other health professionals; and, reimbursement.93 An overview of pharmaceutical care published in 2004 identified several areas that must be satisfied for effective implementation of a pharmacy service: specific practice standards; adequate documentation mechanisms; appropriate inter-professional relationships between pharmacists and physicians; and, overcoming the barriers identified by the pharmacist themselves.94 An overview of the implementation issues arising within the field of health promotion within Canada published in 2006 found that the main barriers to
implementation were the lack of interest of the participants, lack of funds/resources and lack of skilled staff.95 A Danish study in 1999 surveyed pharmacists regarding the barriers to implementing pharmaceutical care in their practice, with pharmacists citing staff shortages, lack of computer support and lack of engagement with patients as the main barriers to pharmaceutical care implementation.96 A literature review conducted in Australia identified two main components with four areas that influence the
implementation of cognitive services in community pharmacy, where both individual and organisational level factors need to be considered in order to successfully implement cognitive services (Table 1-15).97
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al Training in clinical and other skills
Identification of motivators
Identification of learning resources Motivational strategies Org an is at io n al
Internal pharmacy environment
Pharmacy design/layout Planning and goal setting
Documentation of service provision
Utilisation of support staff and task delegation Quality assurance and improvement
Evaluation of performance and outcomes Description/definition of service
Use of technology
Policies and procedures manual Appointment cards
Software reminders
External pharmacy environment
Relationships with patients, prescribers and payers Target population identification
Support from a researcher or other pharmacists Feedback from pseudo-patrons
Business and financial
Reimbursement for service provision Merchandising plan
Business plan Marketing strategies
Resource assessment - financial and human Management of resources
Packaging services together
Table 1-15: Components of the process for the implementation of cognitive services97 A further review identified specific individual and organisational facilitators that
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Pharmacist competence Professional satisfaction
Education and training for pharmacy
assistants Pharmacists' knowledge of cognitive services
Education and training for pharmacists Pharmacists' attitudes towards cognitive services
Communication skills Pharmacists' confidence in ability to provide
cognitive services
Motivation Autonomy
Leadership skills Attitude of pharmacy staff
Organisational facilitators Physical environment (such as adequate
space/privacy and workflow) Interaction with other pharmacists
Culture of the pharmacy Support of management
Remuneration/incentives Access to reference literature
Sufficient and qualified staff/manpower Pharmacist-patient relationship
Use of pharmacy technicians Marketing
Delegation of tasks Support from professional organisations
and/or government Innovative practice orientation Low prescription volume
Patient demand/expectations Rural location
Relationship with doctors Legislation requiring or supporting provision of services
Equipment and technology (such as
computers) Attitude/perception of doctors
Access to patient information/records Attitude/perception of patients
Documentation system Examples from leading practitioners
Profile within the local community External advisors or mentors Attention for special patient groups Evidence of benefits of services Use of protocols
Table 1-16: Facilitators that can improve the implementation of cognitive services98 Numerous studies have been published and reported on the difficulties on implementing and maintaining delivery of services within the pharmacy environment, with many reporting on the initiatives required to overcome these difficulties. The following section reviews the barriers and facilitators to implementation and maintaining service delivery within these studies on a variety of different pharmacy services.
1.4.1.1
Raisch 1993
99An early study examining perceived barriers to providing cognitive services was
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and evaluating prescription orders before dispensing them (presumably detecting prescription errors), which were not a mandatory part of a pharmacist’s duties at the time. Barriers were divided into four types:
Situational barriers (such as working conditions and economic factors)
Cognitive barriers (such as lack of knowledge or ability to perform the service) Legal barriers (such as the influence of regulations for pharmacy practice) Attitudinal barriers (such as the pharmacist’s beliefs about themselves, other
health professionals and patients)
Pharmacists were given a list of barriers and required to rate them on a 5-point Likert scale, where 1 = least important and 5 = most important. A score of 0 indicated that the pharmacist did not feel the barrier was applicable. A total of 64 pharmacists returned the questionnaires, with excessive workload identified as the most common barrier (score = 2.9 ± 1.7), indicating that the pharmacists perceived that they did not have enough time to perform cognitive services. Other important barriers were lack of privacy (score = 1.9 ± 1.2), patients being uninterested in counselling (score = 1.9 ± 1.3) and poor store layout (such as a physical barrier between the pharmacist and the patient; score = 1.8 ± 1.6). An arbitrary ‘rate’ of providing cognitive services was also calculated by the number of patient counselling events or number of prescriber interactions divided by the number of prescriptions dispensed. Two barriers were found to be directly linked with the rates of provision of cognitive services, workload (p = 0.02) and peer pressure (p = 0.02), with pharmacists who perceived they had an excessive workload or perceived peer pressure (presumably the pressure to dispense rather than provide cognitive services) having a lower rate of providing cognitive services.
The authors noted that pharmacists were currently only reimbursed for dispensing medications, rather than for cognitive services, which therefore affected the amount of time that a pharmacist could spend on cognitive services. It was therefore an interesting finding that pharmacists did not feel lack of financial payment was an important barrier to providing cognitive services (score = 1.0 ± 1.0). A limitation of the study was that
pharmacists were not asked to identify or measure any internal barriers, such as lack of education, which may have also influenced the provision of cognitive services.
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1.4.1.2
Latif 1998
100In 1998, a survey was administered to pharmacists in the USA to examine the effects of workload pressure and beliefs of their employers or patients on their clinical decision making behaviour. Statements with 7-point Likert scale answers were used to determine the perceived beliefs of employers and patients, whereas the workload was measured by taking the number of prescriptions dispensed and accounting for the number of support staff at the time.
One hundred and thirty-one pharmacists completed the survey. The study found that workload pressures did not influence the provision of pharmaceutical care (p = 0.686), but that the perceived beliefs of the employers and patients accounted for 7.6% of the
variance (p = 0.003). This was in contrast to other studies that found that workload did affect the provision of services and could be explained by several possibilities. The authors noted that the measure of workload was not sensitive enough to capture the true
relationship. However, it also appears that the reporting procedure was not very robust, with pharmacists self-reporting any clinical decision making they made on the last five patients with chronic conditions, which did not capture the longer timeframe over which additional clinical decisions were most likely made.
1.4.1.3
Christensen and Hansen 1999
101A 1999 study aimed to determine the characteristics of pharmacies and pharmacists that were associated with the provision of cognitive services. Surveys were administered to the pharmacy owner/manager (to complete on behalf of the pharmacy) and each employee pharmacist enrolled in a larger trial that was examining reimbursement of cognitive services in community pharmacies in Washington, USA. The authors provided two sets of results: a model which predicted whether a pharmacy/pharmacist would perform any cognitive services, as well as a model to predict the rate of cognitive services provided. The performance rate of cognitive services was defined as the number of services
performed per 1000 prescriptions dispensed, which was similar to intervention studies in section 1.3.
The participants were split into two groups based on remuneration; Group One received reimbursement for the documentation of cognitive services, whereas Group Two did not. The authors received 76 pharmacy questionnaires and 162 pharmacist questionnaires from Group One, and 62 pharmacy and 126 pharmacist questionnaires from Group Two.
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Overall, the authors noted that the documentation of cognitive services was strongly linked to reimbursement.
Pharmacy characteristics
A logistic regression analysis was used to determine a model to predict whether a pharmacy would perform any cognitive services (performer vs non-performer). The variables that were significant and consequently included in the pharmacy model were perceptions of the pharmacist-in-charge about the usefulness of documenting cognitive services and the number of full-time pharmacists in the pharmacy. Together, these two factors had an overall prediction rate of 66.7%, with more ‘performers’ being correctly identified (88.1%) compared to ‘non-performers’ (31.4%). This shows the effect that attitude can have on the implementation of pharmacy programs, as the likelihood of the pharmacy performing cognitive services increased with a motivated pharmacist-in-charge. The number of full-time pharmacists was significantly correlated with several other factors, such as pharmacy size and prescription volume, indicating that workload was also a significant factor in the ability to provide cognitive services.
A multiple regression analysis was also performed to determine the factors that influence the rate of cognitive services performed by the pharmacy. The model explained
approximately 24% of the variance between the pharmacies, with three significant factors contributing to the model: reimbursement; monthly prescription volume; and, percentage of prescriptions dispensed to Medicaid recipients (government assistance for low income families). Pharmacies that were reimbursed, that dispensed less prescriptions per month, but a higher percentage of Medicaid prescriptions, had a higher rate of documenting cognitive services.
Pharmacist characteristics
A logistic regression analysis was also used to determine a model to predict whether a pharmacist would perform any cognitive services (performer vs non-performer). The variables that were included in the pharmacist model were pharmacist position,
perceptions of how burdensome the task of documentation was, and percentage of sales from prescriptions. The model had an overall prediction rate of 61%, with more
‘performers’ being correctly identified (79%) compared to ‘non-performers’ (33%). Pharmacist owner-managers who did not find the documentation of cognitive services to be burdensome were more inclined to document cognitive services. Interestingly, there
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were no significant associations with reimbursement, training, first year of practice, or attitudes and beliefs in the pharmacist model.
A multiple regression analysis was also performed on the pharmacist data to determine the factors that influence the rate of cognitive services performed, therefore all
pharmacists that recorded no cognitive services during the trial were excluded prior to the analysis. The model explained approximately 32% of the variance between the
pharmacists, with five significant factors contributing to the model: monthly prescription volume; reimbursement; percentage of prescriptions dispensed to Medicaid recipients; medical centre location; and, rural location. The only differences between the pharmacy and pharmacist model was the addition of the medical centre and rural location factors. The authors showed that the medical centre pharmacies had a higher percentage of sales relating to prescriptions, which may explain its influence, and surmised that rural
pharmacies may have a higher documentation rate of cognitive services due to an increased rapport with patients.
One limitation of this study is the way that prescription volume and pharmacist workloads were measured. Pharmacists were asked to record a “typical” prescription volume, rather than record the actual number of prescriptions dispensed, which may have affected the accuracy of the workload calculations.
1.4.1.4
Dunlop and Shaw 2002
16A survey administered to 348 New Zealand pharmacists aimed to determine their understanding of pharmaceutical care and barriers that prevent implementation of professional services to improve pharmaceutical care.16 The factors that were identified as barriers to the provision of pharmaceutical care included lack of time (87.0%), lack of reimbursement (81.9%) and lack of patient demand (64.1%). The pharmacists also felt that adequate knowledge and an adequate documentation process was necessary to
implement pharmaceutical care.
1.4.1.5
Westerlund et al. 2003
102Westerlund et al. published the results of a survey administered to pharmacists
participating in a study that electronically documented DRPs relating to OTC products. The questions aimed to determine the ease of use of the system and identify some of the factors that the pharmacists believed impacted on their use of the system.
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Of the 447 pharmacists that had participated in the OTC study, 376 (84%) responded to the survey. Interestingly, 139 (37%) of the respondents had not recorded any
interventions during the 10-week documentation period, allowing the researchers to attempt to quantify the differences between the ‘performers’ and ‘non-performers’. Most of the respondent pharmacists seemed highly motivated to document DRPs and the resulting interventions, with the authors noting that even the non-performers felt the documentation system was important to pharmacy practice. A significant relationship was found between the perceived interest in the project and the DRP documentation rate (p = 0.004). Almost 40% of participants did not perceive any time constraints to documenting the DRPs, with no significant difference detected between the perceived time constraints and the documentation rate, which is in contrast to results found by other studies. In general, the authors concluded that there was a need to change the attitudes among pharmacists and convert practice orientation towards professional service in order to improve patient care.
1.4.1.6
Svarstad et al. 2004
103A study published in 2004 used mystery shoppers to determine factors that influenced patient counselling in community pharmacies. The shoppers presented three new prescriptions to the 306 pharmacies in eight States of the USA and recorded the level of interaction with the pharmacist, as well as estimated pharmacist and pharmacy
demographics.
The shoppers found that an increased level of pharmacist interaction occurred with younger pharmacists (less than 35 years) who were working in less busy pharmacies. Pharmacists working in States with an increased intensity of regulations mandating counselling also had an increased level of pharmacist interaction, suggesting that legal requirements can have a significant impact on pharmacy practice. No interaction was found between the pharmacy type (chain vs independent) and the level of patient counselling, with the authors concluding that the busyness of the pharmacy was a better predictor of patient interaction compared to pharmacy type.
1.4.1.7
Becker et al. 2005
104and 2007
105Two studies by Becker et al. identified specific factors that contribute to the likelihood that a pharmacist will dispense a drug that interacts with another drug the patient is taking concurrently. Firstly, a literature review was undertaken that identified seven
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papers that discussed contributing factors. From the papers, three different groups of factors were identified:
Relationship between the pharmacist and prescriber, where patients with a single primary-care physician and a single dispensing pharmacy were less likely to receive interacting medications
Quality of the medication surveillance software, where the number of dispensed interacting medications can be decreased by the software, but too many or too few alerts can also contribute to an increased number of dispensed interacting medications
Pharmacy organisation and the knowledge of the pharmacist, both of which affect how the pharmacist manages the alerts provided within the software
Taking this knowledge, the authors then designed a study to examine the factors
influencing the dispensing of 10 common drug-drug interactions (such as macrolides and digoxin, or beta-blockers and beta2 agonists). The only drug-drug interaction where
commonalities were found was between macrolides and digoxin, where pharmacies that dispensed this combination regularly were medical centre pharmacies and pharmacies using one specific software system. This may indicate the effect that software alerts can have on the dispensing of drug-drug interactions, with the authors noting that this
software system was not as advanced in their alert systems as some of the other programs on the market. However, the authors also noted that the pharmacist’s attitude in using any of the software systems may have contributed to the effectiveness of the alerts, therefore the software systems themselves cannot be held fully accountable.
1.4.1.8
Irujo et al. 2007
106A Spanish study in 2005 examined the factors that influenced the under-reporting of ADRs within community pharmacies by comparing pharmacists that had reported an ADR within the last year compared to pharmacists that had not. Using a case-control method, 18 pharmacists who had reported an ADR were compared to 60 control pharmacists. The authors found that the factors positively associated with ADR reporting were older pharmacists with more years of experience, increased participation in educational activities related to the detection and resolution of DRPs, and a higher score on a knowledge survey delivered as part of the study.
1.4.1.9
Roberts et al. 2008
107A large amount of research has also been completed within Australia which aimed to identify the factors that influence practice change overall within the pharmacy
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environment, including factors that influence the introduction of new cognitive services. A 43-item quantitative survey using statements answered with a 5-point Likert scale was designed using organisational theory framework and mailed to 2000 community pharmacies within Australia.
Out of 2000 pharmacies, 735 responded with a yield of 1303 individual questionnaires (each pharmacy could provide a completed survey from the pharmacy owner, a
pharmacist employee and a pharmacy assistant). Factor analysis revealed 7 factors that explained 48.8% of the total variance: relationships with physician; remuneration; pharmacy layout; patient expectation; manpower and staff; communication and
teamwork; and, external support and assistance. The authors suggested requirements for successful practice change for each factor (Table 1-17).
Factor Requirements for successful practice change Relationship with physicians Build rapport with local physicians
Remuneration Provide incentive payments or a fee-for-service Pharmacy layout Provide a private or designated area for service
delivery
Patient expectation React to the patient's needs
Manpower/staff Decrease workforce shortages and provide additional staff for implementation
Communication and teamwork
Involve the whole pharmacy team in the implementation process, not just the pharmacy owner
External support and assistance
Provide support for planning and implementing change, as well as clinical support for the service Table 1-17: The seven key areas in implementing practice change identified by
Roberts et al.107
1.4.1.10
Uema et al. 2008
108A 2005 study into the perceived barriers to pharmaceutical care in Argentina examined the responses from 90 pharmacist questionnaires. The options were not pre-defined as seen in a similar study99, therefore the pharmacists were required to formulate five barriers to the implementation of pharmaceutical care in their own words and also rank their importance.
Some pharmacists reported less than 5 barriers in their questionnaire, resulting in 90 responses that detailed 323 situations that were considered barriers. Researchers analysed the questionnaires and manually grouped similar responses together, with the
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results showing that the three most important barriers were lack of time, lack of specific training and lack of communication skills with patients (Table 1-18). Interestingly, lack of reimbursement was only stated as a barrier in 3 (3.3%) questionnaires, which is in contrast