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Factors affecting practice-area choices by pharmacy students in the Midwest.

The results of a survey to determine the first-choice practice intentions of midwestern pharmacy students and to describe and quantify the factors affecting their decisions are reported. Questionnaires were sent to 12 pharmacy schools in American Association of Colleges of Pharmacy District IV and distributed during November 1988 to January 1989. The questionnaires were given to entry-level pharmacy students who were in their final year of study. The students were asked to indicate their preferred practice setting upon graduation and to rate the importance of 21 factors that a pharmacist might consider when selecting a first position. A total of 715 usable responses were received (response rate, 6.75%). OF the respondents, 83.2% were enrolled in B.S. degree programs and 16.8% in entry-level Pharm.D. degree programs. The distribution of first choices of a practice area was as follows: chain community pharmacy, 33.1%; hospital pharmacy, 27.6%; independent community pharmacy, 12.4%; industry, 8.4%; "other," 5.5%; ambulatory-care clinic, 5.2%; graduate school, 3.8%; department store, discount store, or grocery store, 1.7%; home health care, 1.5%; and nursing home, 0.8%. The three factors ranked as most important in affecting the choice of a practice area were personal fulfillment, salary, and the opportunity to use one's abilities and education. The ranking of the factors varied depending on the practice area chosen. Midwestern pharmacy students were most interested in chain community and hospital pharmacy practice settings. Retail-oriented students placed salary concerns first, whereas clinically oriented students emphasized personal fulfillment. These findings have implications for recruitment strategies.

Career Choice↗

[The hospital pharmacies in Copenhagen and their professional importance].

The first hospital pharmacies in Denmark in modern meaning were established of the Copenhagen Municipality: the General Hospital Dispensary (Almindelig Hospitals Dispensationsanstalt) in 1815, the Municipal Hospital Pharmacy (Kommunehospitalets Apotek) in 1863, the Sound Hospital Pharmacy (Oresundshospitalets Apotek) in 1904 and the Bispebjerg Hospital Pharmacy in 1913. Not only did the hospital pharmacies take care of the medicine supply to the municipal hospitals in Copenhagen, but the pharmacies, particularly the Municipal Hospital Pharmacy and the Bispebjerg Hospital Pharmacy, also carried out development and research work in the field of drug. Among other things, the Municipal Hospital composed a series of hospital pharmacopoeias in the period 1871-1922, from 1908 with the co-operation of the chief pharmacist at the Municipal Hospital, first Jens Otto Anton Volqvartz and later Niels Ludvig Møller, and in 1922 also in collaboration with the chief pharmacist at the Bispebjerg Hospital, Severin Søren Marcussen. In addition, Severin Soren Marcussen, also developed an iron mixture, "Idozan", for the treatment of anaemia and a sulphurous ointment, "Kathiolan", for the treatment of scabies, both of which were marketed by A/S Ferrosan, in 1920 and 1921 respectively. In 1936, the subsequent chief pharmacist at the Bispebjerg Hospital, Birger Norman Jensen, invented together with Hans Christian Hagedorn, MD, at Nordisk Insulinlaboratorium the first insulin composition with prolongated effect, protamininsulin, which was put on the market under the name of "Insulin Leo Retard". The Bispebjerg Hospital Pharmacy also participated in the development of medical utensils. In 1948, the pharmaceutical wholesaler Bang & Tegner A/S collaborated with the chief pharmacist Kaj Pedersen-Bjergaard, DSc, and consultant Karl Henrik Køster, MD, in developing the first sterile disposable set to intravenous and subcutaneous infusion, named "Batex Eengangssaet".

Denmark↗

Establishing a pharmacy department for a large pediatric hospital: managerial problems, opportunities, and lessons.

The process of planning and establishing a pharmacy department in a pediatric hospital is described, and lessons learned from the experience are summarized. Since its founding in 1954, Texas Children's Hospital (TCH) had shared pharmacy services with St. Luke's Episcopal Hospital. The decision to terminate the shared-services agreement in the mid-1980s made it necessary for TCH to establish an independent pharmacy department. A director of pharmacy was hired in March 1988, and November 30 of that year was set as the target for implementation of the TCH pharmacy. It was decided that six services--a decentralized unit dose distribution system, an i.v. admixture service, delivery services, ambulatory-care services, a formulatory system, and a drug information service--would be offered initially. Decisions concerning department organizational structure and staffing, space allocations, and a computer system were made. A multidisciplinary advisory committee was appointed; one of its responsibilities was to oversee inservice staff training. The pharmacy areas were to be opened on a staggered basis, beginning with the hematology-oncology clinic pharmacy. A number of problems arose immediately following the opening of the central pharmacy, including inaccurate computer profiles, lower-than-estimated productivity resulting from staff members' unfamiliarity with the new system, higher-than-estimated patient census, and orders for nonformulary drugs. Delays in drug delivery times were unacceptably high. A crisis-management plan was implemented to cover both short- and long-term problems, and within a few months operations had stabilized. The opening of the intensive-care and sixth-floor satellite pharmacies enhanced decentralized operations and had an important role in improving response times.(ABSTRACT TRUNCATED AT 250 WORDS)

Decision Making, Organizational↗

Patient acuity indicators as predictors of pharmacy workload.

The feasibility of using two workload indicators from a nursing patient-classification system as a means of predicting pharmacy workload was studied. Frequency data for 13 pharmacy distribution and clinical activities were recorded daily for 28 consecutive days and compared with daily data for acuity of patient illness and number of standard hours of nursing care required on nine nursing units. The strength of the associations between (1) pharmacy workload and patient acuity and (2) pharmacy workload and standard hours of nursing care was determined by linear regression analysis. Both same-day and one-day-lagged analyses were performed; the one-day-lagged analyses looked at pharmacy workload on a given day in relation to nursing workload on the previous day. A total of 252 observations were available for analysis. Pharmacy workload and same-day standard hours of nursing care were correlated most strongly, although all of the analyses yielded large coefficients of correlation. Analysis of data from individual nursing stations yielded smaller coefficients of correlation, especially for the one-day-lagged analyses. At least 73% of the variance in pharmacy workload could be attributed to variance in nursing workload. The index of patient acuity of illness and the number of standard hours of nursing care are good predictors of pharmacy workload of the same and the following days; the potential exists to use these nursing workload indicators in determining pharmacy staffing requirements.

Minnesota↗

Interhospital variations in hospital pharmacy markups.

The relationship between pharmacy pricing policies and overall hospital objectives was analyzed for 64 South Carolina hospitals in 1980. Using published hospital data, a linear regression model was developed to test the relationship between a pricing variable (the charge-to-cost ratio for each pharmacy) and five independent variables: demand (defined as hospital occupancy rate), industry structure (defined as affiliation or nonaffiliation with a multihospital system), level of hospital use by Medicare and Medicaid patients (defined as the proportion of hospital admissions for which reimbursement was based on costs), the contribution of nonoperating revenue, or subsidization (defined as the proportion of hospital nonoperating revenue to total expenses), and the contribution of operating revenues of departments other than pharmacy (defined as the proportion of non-pharmacy charges to total charges). In these predominantly nonprofit hospitals, the mean (+/- standard deviation) pharmacy markup was 1.99 +/- 0.49, with considerable inter-hospital variation. The level of hospital use by Medicare and Medicaid patients had the greatest influence on variation in markup, indicating that hospitals were responding to cost-based payer reimbursement practices by raising charges in areas with a high cost base, such as pharmacy. Nonoperating revenue and operating revenue of departments other than pharmacy also were significantly related to the charge-to-cost ratio. The relationship between the charge-to-cost ratio and either occupancy rate or affiliation with a multihospital system was not significant. The hospitals studied set pharmacy revenues to contribute to overall target income, but pharmacy prices were not set to achieve maximum profits by responding to changes in demand.

Costs and Cost Analysis↗

National survey of hospital pharmacy facilities: adequacy of facilities and changes planned.

The adequacy of existing space allocations for hospital pharmacy facilities and planned changes are described. A 12-page questionnaire was sent in July 1982 to the chief pharmacists in a random sample of 1846 hospitals in the United States stratified by 10 hospital types. The respondents in each hospital type and size were categorized by their perceived adequacy of existing space for pharmacy facilities and their plans for adding pharmacy functions and staff. Changes in pharmacy facilities that would improve pharmaceutical services were identified, as were planned changes in facilities. The amount of proposed space approved and not approved for pharmacies in hospitals of each type were determined. The response rate was 45.6%, and the respondents were representative of the population. Forty-nine percent of the respondents reported having adequate space. Only 35% of the respondents indicated that no changes could be made in facilities to improve pharmaceutical services. Forty-one percent of respondents planned one or more changes of some kind in pharmacy facilities; this ranged from 14% for long-term, nonprofit hospitals to 50% for long-term, for-profit hospitals. Sixty-six (8%) of the 843 hospitals had additional floor space approved and funded for the pharmacy; 71% had proposed space that was not approved. Sixty-three percent of all respondents planned new pharmaceutical functions; 56% and 42% planned an increase and no change, respectively, in the number of pharmacy staff members. Adding more space may be one way to improve hospital pharmacy facilities, but more attention also should be directed toward better use of existing space, equipment, and fixtures.

Data Collection↗

Diffusion of innovation: computer technology in hospital pharmacy.

The diffusion of computer technology in hospital pharmacy departments was studied by surveying pharmacy directors in a randomly selected sample of 501 hospitals in the United States with at least 100 beds. Pharmacy directors were asked to indicate for which of 17 tasks a computer or memory typewriter was used in the pharmacy department. The time of first adopting computers in the department was compared with the predicted S adoption curve; adoption time was also correlated with characteristics of the hospital, pharmacy, and pharmacy director. Of the 417 respondents, 308 reported use of a memory typewriter or computer in the pharmacy. Fifty-one directors reported only memory-typewriter use, and 94 reported both computer and memory-typewriter use. Maintenance of patient census lists and patient billing were the most frequent uses of computers. The primary uses of memory typewriters were preparation of letters and labels. There was no significant difference in the actual and predicted S curves for time of adoption of computers. The number of months since first adopting computers was positively correlated with hospital bed size and the pharmacy director's number of years as a pharmacist, years in current position and with current employer, and number of subordinates; it was also positively correlated with number of pharmaceutical services and number of computer uses in the department. Computer technology is becoming more universally accepted in hospital pharmacy, and research on the diffusion of innovations suggests that acceptance will continue to increase.

Computers↗

Survey of clinical pharmacy services in United Kingdom National Health Service hospitals.

The extent to which clinical pharmacy services are provided in National Health Service (NHS) hospitals in the United Kingdom was studied by means of a questionnaire. Questionnaires inquiring whether and to what extent certain clinical pharmacy services were provided were mailed to all NHS hospital pharmacies in 1992. The questionnaires also requested information about the hospital and the number and qualifications of pharmacists employed. The results were compared with those of a survey of pharmaceutical services in the United States. Of 508 questionnaires mailed, 416 usable responses were returned. Services commonly provided were inpatient drug therapy monitoring (96%), clinical trials support (92%), formulary management (89%), participation in drug and therapeutic committees (97%), and an on-site drug information center (60%). Services infrequently provided were therapeutic drug monitoring (21%), medication history-taking (16%), and a 24-hour on-site pharmacist (10%). Several services were associated with pharmacies that employed many pharmacists, pharmacists with advanced education, or specialist clinical pharmacists and pharmacies located in medical school teaching hospitals. U.K. hospital pharmacies provided fewer patient-oriented services and more drug information, therapy monitoring, and pharmacist education services than U.S. hospital pharmacies. Provision of clinical pharmacy services in the United Kingdom was associated with employment of many pharmacists, pharmacy clinical specialists, and pharmacists with advanced education.

Clinical Trials as Topic↗

The practice of pharmacy in England.

The practice of pharmacy in England is described. Community pharmacies have a contract with the Department of Health and Social Security to fill National Health Service prescriptions. A large proportion of the general public obtain their prescriptions free. Funding for the health service comes from taxes and automatic contributions from employers and employees. Aspects of hospital pharmacy practice and salaries are discussed, e.g., a junior pharmacist may expect to earn between $9000 and $12,000. There is very little unit-dose dispensing, and many hospitals are unable to provide 24-hour services. Hospital pharmacies function with fewer pharmacists than their U.S. counterparts, utilizing larger numbers of technicians. Clinical pharmacy practice centers around drug monitoring (ward pharmacy). Pharmacokinetic services are provided in a few places. Master of science degrees in clinical pharmacy are available. However, the future of clinical pharmacy practice in England depends on staffing levels and competition between and acceptance from other health disciplines.

Community Pharmacy Services↗

Japanese pharmacy: innovation mixed with tradition.

OBJECTIVE: To report the current status of pharmacy practice in Japan. DATA SOURCES: Published conference reports, journal articles, human resource consultation with medical and pharmacy practitioners, and site visitation by the authors. DATA EXTRACTION AND SYNTHESIS: Data on areas related to Japanese history, practice of pharmacy, and professional innovations were obtained through interviews and the literature. Information is provided to give an appreciation of current pharmacy practice in Japan. CONCLUSIONS: Japanese pharmacy practice is a strong combination of tradition and professional innovation. The potential for professional growth is immense; Japanese pharmacy has successfully established payment for nondistributive pharmacy services. Payment for cognitive services creates many positive incentives for the future practice of pharmacy in Japan.

Computers↗

Advice-giving in community pharmacies in the UK.

OBJECTIVES: To review (1) the published evidence on the information provided with prescribed and purchased medicines by pharmacists and pharmacy assistants, (2) clients' expectations of advice about medicines from community pharmacies and their experience and use of it, and (3) appropriateness and rigour of study methods used. METHODS: Papers, published between 1980 and 1995 inclusively, were identified based on searches of on-line databases, a published literature index, key pharmacy practice journals and cited references in the bibliographies of published papers. Those papers selected reported research findings on any aspect of medicines-related communications and the provision of advice about medicines to members of the public who visited pharmacies in the UK. The comparatively small volume of work and lack of design consistency meant that a subjective assessment, rather than a criteria-based objective review, was deemed appropriate. RESULTS: Forty-two suitable studies were identified and are reviewed. No common definition of 'advice' has emerged. Most studies reported were quantitative, concentrating on the frequency of advice-giving in community pharmacies and only one study considered the impact of advice on outcome. The quality of advice given was judged highly variable, although pharmacists' referrals, where made, were considered appropriate. Given that pharmacy assistants appear to make most of the medicine sales, remarkably few studies addressed their contribution to advice-giving. The review can provide little insight into what determines when advice is provided, but it does illuminate the disparity between the advice that clients say they want and what they actually seek. CONCLUSIONS: Where there appears to be a consensus that advice-giving in community pharmacies is wanted, this review reveals a lack of shared understanding between consumer bodies and the pharmacy profession about who needs advice and when and how it should be given. The need for unsolicited advice-giving associated with the sale of medicines is particularly contentious. With the current programme of deregulation of medicines, this is an increasingly important issue to resolve. The authors suggest a need for a consensus-building forum to generate guidelines that meet shared expectations between clients, community pharmacists, government and the pharmaceutical industry.

Community Pharmacy Services↗

Looking ahead--the report of the Study Commission on Pharmacy.

The findings and recommendations of the Study Commission on Pharmacy are presented. The Commission defined pharmacy as a knowledge system which produces a service. Practitioners in specific areas of pharmacy are considered to possess both common and differentiated knowledge and skills. While pharmacy as a system is viewed as effective and efficient with reference to drug products, it is far from satisfactory with reference to drug knowledge and information. Current forces of change in the health care system and forces of change internal to pharmacy are discussed in relation to their impact on pharmacists for the future. The Commission recommended that pharmacy should move to meet the health care system's unmet needs which involve drugs and drug information. Specific recommendations are summarized regarding educational objectives, the curriculum, the faculty and credentialling. These recommendations call for heavier emphasis in pharmacy education on the behavioral and social sciences, the establishment of a small body of "clinical scientists," and the creation of a National Board of Pharmacy Examiners.

Costs and Cost Analysis↗

Pharmacy practice in the Veterans Administration.

The current status of pharmaceutical services in the Veterans Administration (VA) is described. The mission of the VA Department of Medicine and Surgery is to ensure that quality medical care is provided on a timely basis to all eligible veterans. The VA operates 172 medical centers and 225 ambulatory-care clinics, which makes the VA Pharmacy Service the largest multiinstitutional pharmacy system in the United States. VA pharmacy staffs in VA hospitals range in size from four or five people to more than 100 employees. The VA Pharmacy Service programs are divided into inpatient programs and ambulatory-care programs. Clinical pharmaceutical services and education and research activities are integrated into these programs. A Regional Pharmacy Advisory Council composed of chiefs of pharmacy service from seven geographical regions coordinates the exchange of information between the Central Office and the regions. Current issues of priority for the VA Pharmacy Service include human resource management, material resource management, information resource management, public relations, program enhancement, and new technology. The VA health-care system is comprehensive and complex, and the Pharmacy Service programs reflect the VA mission to provide quality services and support programs that will generate new information or knowledge to improve the care of veterans.

Ambulatory Care Facilities↗

Research--the cornerstone of pharmacy practice. Harvey A.K. Whitney lecture.

Hospital pharmacy's need for a new commitment to research and the attendant sharing of responsibilities between pharmacy educators and pharmacy practitioners are described. Guided by the same philosophy of professional service that motivated early hospital pharmacists, individual pharmacists should work within their differentiated roles to advance the profession as a whole. For this advancement, research to acquire new knowledge and develop and evaluate new services is required. Research enhances the prestige and societal support of a profession. Pharmacists with differentiated skills and practice areas must support each other to advance the profession, particularly because of limited financial resources in both education and practice settings. Universities, including schools of pharmacy, have a responsibility for research as well as for the transmission of knowledge, and pharmacy faculty members should conduct research that supports the advancement of practice. To support research by faculty members, pharmacy practitioners can assume greater teaching responsibility. Schools of pharmacy and practicing pharmacists can work together to support research that will benefit the whole profession and society. Pharmacy practice faculty members who maintain a practice base and are involved in research have a critical role in this cooperative effort.

Awards and Prizes↗

Men and women as pharmacy managers.

The managerial position held by men and women pharmacists in three primary practice settings were examined and compared. A nationwide survey, using a pretested 12-page questionnaire, was sent to 2100 pharmacists in hospitals, independently owned pharmacies, and chain-store pharmacies. The variables examined by discriminant analysis were sex, age, years with employer, the number of times a pharmacist left practice, and educational level. A total of 767 completed questionnaires were used in the analysis for a 39.6% response rate, and 57.6% of the sample was women. Women were found to be significantly under represented in managerial positions in all three practice settings; however, there were a greater percentage of women in managerial positions in hospital pharmacies than in independently owned or chain-store pharmacies (p less than or equal to 0.001). When age was controlled in the analysis, there were more women at the staff level than men in all the age categories above 25. The discriminant analysis showed that advanced education was a significant factor in a pharmacist's position in hospital pharmacies but not in community pharmacies. The sex of the pharmacist showed the highest discriminating power in classifying the position of community pharmacists. Women pharmacists were under represented in managerial positions in all three practice environments. However, hospital pharmacy had a greater percentage of women in managerial positions than community pharmacy.

Adult↗

Do Mexico City pharmacy workers screen women for health risks when they sell oral contraceptive pills over-the-counter?

CONTEXT: In Mexico, oral contraceptives (OCs) are available to women over-the-counter in pharmacies. While past research has suggested that nonmedical providers, such as pharmacy workers, are capable of screening women for contraindications to OCs, little is known about their practices. METHODS: After selecting a 10% random sample of all pharmacies in Mexico City (n = 108), we surveyed the first available pharmacy worker to learn more about pharmacy workers' screening practices when selling OCs over-the-counter to women. RESULTS: While nearly all of the pharmacy workers surveyed had sold OCs without a prescription, only 31% reported asking women any questions before selling pills. Among those who asked questions, the most commonly asked questions were about other medications a woman was taking, about blood pressure and about alcohol intake. Pharmacy workers did not ask these questions consistently to all clients. CONCLUSION: Training pharmacy workers might be one strategy to improve screening of women for pill contraindications. However, pharmacy workers may lack the time and motivation to carry out such screening. An alternative strategy might be to better inform women to self-screen for pill contraindications.

Adolescent↗

Pharmacy approach to a case of acute diarrhoea with dehydration in Antalya, Turkey.

A study examining the approach of pharmacies to diarrhoeal disease in childhood was carried out in Antalya, Turkey. A fictitious case history of a 10 month infant with an acute diarrhoea of three days duration, which was clinically identical with viral diarrhoea and accompanied by moderate dehydration was hypothesised. Following this, final semester students of the medical faculty posed as relatives of the infant and sought the advice of pharmacy attendants. The approach, to this hypothesised case, of all 214 pharmacies in the Antalya municipality district was examined. Most of the pharmacy attendants (57.7%) did not ask any questions to determine a differential diagnosis or establish the degree of dehydration. Only 21.6% of the pharmacy attendants recommended consulting a doctor or health centre, 6.5% recommended Oral Rehydration Solution (ORS) without giving an explanation about the amount needed or for how long it should be administered, 44.4% only dispensed a drug, 23.8% dispensed a drug with ORS and 3.7% recommended infant formula. Antidiarrhoeals were dispensed by 67.2% of the pharmacies and 14% gave antibiotics. Also 5.6% of the pharmacy attendants advised a reduction in the infant's fluid intake, 17.3% said that they could not give an opinion regarding breast feeding 19.2% advised stopping breast feeding and 7.0% did not know. All the pharmacies except the ones with the appropriate recommendation 'consult a doctor or a health centre' responded with advice given without hesitation although they did not intend to inspect or examine the infant. The approaches for acute diarrhoea of the pharmacies were determined as inappropriate and harmful.

Acute Disease↗

Financial risk management of pharmacy benefits.

Financial risk management of pharmacy benefits in integrated health systems is explained. A managed care organization should assume financial risk for pharmacy benefits only if it can manage the risk. Horizontally integrated organizations often do not have much control over the management of drug utilization and costs. Vertically integrated organizations have the greatest ability to manage pharmacy financial risk; virtual integration may also be compatible. Contracts can be established in which the provider is incentivized or placed at partial or full risk. The main concerns that health plans have with respect to pharmacy capitation are formulary management and the question of who should receive rebates from manufacturers. The components needed to managed pharmacy financial risk depend on the type of contract negotiated. Health-system pharmacists are uniquely positioned to take advantage of opportunities opening up through pharmacy risk contracting. Functions most organizations must provide when assuming pharmacy financial risk can be divided into internal and external categories. Internally performed functions include formulary management, clinical pharmacy services and utilization management, and utilization reports for physicians. Functions that can be outsourced include claims processing and administration, provider- and customer support services, and rebates. Organizations that integrate the pharmacy benefit across the health care continuum will be more effective in controlling costs and improving outcomes than organizations that handle this benefit as separate from others. Patient care should not focus on payment mechanisms and unit costs but on developing superior processes and systems that improve health care.

California↗