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Hospital pharmacy service provision in Australia--1998.

The results of a 1998 national survey of pharmaceutical services in hospitals throughout Australia are reported. A self-administered questionnaire was sent to all directors of hospital pharmacy services and senior hospital pharmacy managers to determine the extent of clinical and nonclinical pharmacy services provided by hospitals in Australia. Respondents chose the services their departments provide from a list of 26 commonly provided services. The response rate was 58.5%. Respondents were fairly evenly divided between teaching and nonteaching hospitals, but most of the respondents were from public (versus nongovernment) hospitals. The five most commonly provided services were imprest (a wordstock of frequently used medications that are regularly restocked by the pharmacy department), informal drug education for hospital staff, review of medication charts, control of drug purchasing, and inpatient dispensing. Review of medication charts and provision of drug education for the hospital staff were the most widely provided clinical pharmacy services. The most common services available from hospital pharmacies throughout Australia were imprest, informal drug education for hospital staff, review of medication charts, control of drug purchasing for the hospital, and inpatient dispensing.

Australia↗

Implementing a performance evaluation system in a correctional managed care pharmacy.

The development and implementation of a departmental performance evaluation system for a correctional managed care pharmacy are described. Health care services for approximately 150,000 offenders within the Texas Department of Criminal Justice are provided through an arrangement with two university systems, the University of Texas Medical Branch (UTMB) and Texas Tech University Health Sciences Center. UTMB provides all distributive pharmacy services through a central pharmacy located in Huntsville, Texas. The pharmacy department distributes 9,000-15,000 medication orders daily to over 140 facilities. Each department within UTMB Correctional Managed Care is evaluated against predetermined quality indicators. This evaluation system is collectively called the operational performance evaluation system (OPES) and is used, in part, to determine pay-for-performance eligibility. Before fiscal year 2001, pharmacy distributive services were provided under a third university system. Joining the UTMB system required the pharmacy department to not only participate in OPES but to develop quality indicators and measurement systems to evaluate departmental performance. Indicators were chosen to reflect a commitment to quality while assuring appropriate productivity in the provision of pharmaceutical care. Seven pharmaceutical care quality indicators were chosen and weighted by perceived importance. A system for data collection, measurement, and reporting was also developed. Implementation of a departmental performance evaluation system provides a means to measure service quality, identify areas of weakness, track performance over time, and lower costs. By setting concrete goals, this system raises awareness and promotes interdependence among department personnel.

Community Pharmacy Services↗

Detection of medication nonadherence through review of pharmacy claims data.

The utility of pharmacy claims data in detecting improper medication use, medication changes, and formulary adherence was assessed. Pharmacists provided six months of pharmacy claims data to primary care physicians for patients on the day of their scheduled clinic appointments. Similar data, not supplied to physicians, were generated for a matched population of patients on the day of their scheduled clinic appointments. A blinded pharmacist abstracter reviewed dictated office notes for both control and treatment groups. Medication adherence and medication changes were assessed by the abstracter as well as the difference in total medication costs for each of the groups before and after the pharmacy claims data were supplied. Surveys were distributed to physicians to determine whether pharmaceutical care was improved by the pharmacy claims data. In the treatment group, physicians detected medication nonadherence in 30.5% of their patients, while the abstracter noted nonadherence in 58.1% of patients. Physicians failed to detect any nonadherence in the control group, but the abstractor detected nonadherence in 57.1% of these patients. Changes in medication regimens occurred more often in the treatment group (p < 0.001). The mean percentage of patients switched to formulary agents significantly differed between the treatment and control groups (27.7% versus 0.0%, respectively) (p < 0.001). There were no differences in median drug costs for either group before or after the pharmacy claims data were provided. Provision of pharmacy claims data to physicians helped them detect medication nonadherence, evaluate therapeutic duplication or omissions, increase formulary use, and reduce the time required to obtain an accurate medication history.

Chi-Square Distribution↗

Pharmacy-and diagnosis-based risk adjustment for children with Medicaid.

BACKGROUND: Risk adjustment is useful for adjusting health care payments based on patients' health status. OBJECTIVE: This work seeks to examine how well pharmacy- and diagnosis-based risk adjusters predict child health expenditures in Medicaid populations. RESEARCH DESIGN: We used 1994-1995 Medicaid claims files for all children ages 0-18 years who were not covered by managed care in 3 states: Georgia, New Jersey, and Wisconsin. We examined separately 6 risk adjustment methods, 2 pharmacy-based and 4 diagnosis-based. We compared predictive accuracy of the methods for the whole sample and stratified by state and Medicaid enrollment category. FINDINGS: Models with risk adjustment (either diagnosis- or pharmacy-based) had better predictive accuracy than demographic models. The pharmacy and diagnosis-based models had similar predictive accuracy. Risk adjuster performance differed by Medicaid enrollment category and state. Risk-adjusted models generally underpredict expenditures in populations with worse health status (eg, those in the Supplemental Security Income program [SSI]). The pharmacy-based models performed well for children in SSI relative to children in foster care. CONCLUSIONS: Both pharmacy- and diagnosis-based risk adjustment improved the prediction of health expenditures compared models without risk adjustment. No single risk adjuster performed best in all situations, suggesting that optimal choices of risk adjusters may differ by purpose and context.

Adolescent↗

Interprofessional clinical education of medical and pharmacy students.

Pharmacists have become increasingly involved in influencing prescribing. Pharmaceutical education has changed accordingly, with increased teaching in therapeutics, partly on hospitals wards, giving students an insight into diseases and helping communication with clinicians. To extend this idea we have designed joint therapeutics teaching sessions with pharmacy and medical students. The scheme involves final year pharmacy students who have completed a course in clinical pharmacy and medical students who have completed their second MB. Interdisciplinary pairs of students are assigned a patient with common medical and therapeutic problems, such as arthritis, diabetes and cardiac failure; patients on multiple drug treatments are preferred. They jointly obtain a history: the medical student performs basic clerking, while the pharmacy student obtains the medication history. The medical student subsequently presents a brief medical history, with a summary of the patient's current problems. For each problem, the pharmacy student presents the current therapy, its rationale and how it is to be monitored. Experience with 73 students over 3 years has shown that almost all found sessions with students from another discipline useful. Few felt that members of the pairs contributed unequally. The main problem appeared to be insufficient time (although 2 1/2 h were allowed). Most students favoured more such sessions. Little difference in ability appeared between the two disciplines; there was considerable co-operation and little nascent 'professional rivalry'. The medical students were more comfortable interviewing patients, and the pharmacy students more confident analysing drug therapy. It is concluded that such interdisciplinary sessions are a successful method of clinical teaching and should be encouraged.

Drug Therapy↗

Rural pharmacy not delivering on its health promotion potential.

OBJECTIVE: To investigate the level and perceived quality of health promotion advice received from rural pharmacists. DESIGN: Self-administered written survey on access to and quality of pharmacy services in rural Western Australia completed by rural residents. SETTING: Rural pharmacy. PARTICIPANTS: Four hundred and eighty-three respondents who regularly used a pharmacy. OUTCOME MEASURES: Items in the survey included frequency of receiving prevention advice and satisfaction ratings on health and pharmacy services. RESULTS: Eighty-eight per cent of respondents had never discussed exercise or diet with their pharmacist and 65% had never discussed preventing health problems. Receiving good prevention advice predicted satisfaction with health services in general but not satisfaction with pharmacy services. CONCLUSION: Pharmacies are being underutilised with respect to their capacity to deliver heath prevention advice and ways to capitalise on this potential need to be investigated.

Adult↗

Prevalence of gram-negative bacilli in nares and on hands of pharmacy personnel: lack of effect of occupational exposure to antibiotics.

Exposure to antibiotics alters host flora and facilitates colonization by gram-negative bacilli (GNB). This may be important among pharmacy personnel, who have frequent contact with antibiotics and who have sometimes been suspected of inadvertently introducing GNB into parenteral solutions during admixture. We evaluated the risk of colonization by GNB, especially by tribe Klebsielleae (TK) which can proliferate in intravenous fluids, by culturing the hands and nares of 98 pharmacy personnel and 56 control subjects. Four culture surveys of pharmacy personnel yielded mean isolation rates of 79 and 52% for GNB and TK, respectively, from hands and 12 and 6.7% for GNB and TK, respectively, from nares; these rates did not differ significantly from those for control subjects (P greater than 0.1). The frequency with which pharmacy personnel performed antibiotic admixture did not significantly affect the rate of isolation of GNB or TK (P greater than 0.2). No multiresistant strains were isolated, and susceptibility patterns were similar for GNB species from pharmacy personnel and controls. These data indicate that occupational exposure of pharmacy personnel to antibiotics is not of sufficient magnitude to increase rates of nasal colonization or hand contamination with GNB.

Anti-Bacterial Agents↗

Factors predicting the guideline compliant supply (or non-supply) of non-prescription medicines in the community pharmacy setting.

BACKGROUND: The reclassification of prescription only medicines to pharmacy and general sales list medicines (also known as non-prescription medicines) provides the public with greater access to medicines that they can purchase for self-care. There is evidence that non-prescription medicines may be associated with inappropriate supply. This study investigated factors predicting evidence-based (guideline compliant) supply or non-supply of non-prescription medicines. METHOD: Secondary analysis of results from a randomised controlled trial of educational interventions to promote the evidence based supply of non-prescription medicines. Ten actors made simulated patient (customer) visits to 60 community pharmacies using seven scenarios reflecting different types of presentations. The dependent variable was appropriate (guideline compliant) supply of antifungal medication for treatment of vaginal candidiasis. RESULTS: No significant association was shown between guideline compliant behaviour and pharmacy type or location, or with the actor making the visit. The likelihood of guideline compliant outcome was significantly greater with symptom presentations than with condition or product presentations (p < 0.001). The likelihood of a guideline compliant outcome increased (a) as more information was exchanged (p < 0.001), (b) with the use of WWHAM (a mnemonic frequently used by medicine counter assistants during consultations for non-prescription medicines) (p < 0.001); (c) when specific WWHAM questions were used (including "description of symptoms" (p < 0.001) and "whether other medication was currently being used" (p < 0.001); and (d) in consultations involving solely pharmacists compared with those involving only medicine counter assistants (p = 0.017). After adjustment for presentation type, a significant association persisted between appropriate outcome and consultations with WWHAM scores of 2 and > or = 3, respectively. CONCLUSIONS: The nature and extent of information exchange between pharmacy staff and customers has a strong influence on the guideline compliant supply of non-prescription medicines. Future interventions to promote the safe and effective use of non-prescription medicines should address the apparent deficit in communication between pharmacy staff in general, and medicine counter assistants in particular, which may reflect both pharmacy staff skills and customer expectations.

Adult↗

Sexually transmitted and reproductive tract infections in symptomatic clients of pharmacies in Lima, Peru.

OBJECTIVE: To determine prevalences and predictors of sexually transmitted and reproductive tract infections among men and women seeking care at pharmacies. METHODS: Men and women with urethral discharge or dysuria and vaginal discharge were enrolled at 12 central and 52 smaller pharmacies in Lima, Peru. All participants answered a questionnaire. Men provided urine for polymerase chain reaction (PCR) testing for Neisseria gonorrhoeae and Chlamydia trachomatis, and for leucocyte esterase testing. Women provided self-obtained vaginal swabs for PCR testing for N gonorrhoeae and C trachomatis, Trichomonas vaginalis culture and bacterial vaginosis and Candida. RESULTS: Among 106 symptomatic men, N gonorrhoeae and C trachomatis were detected in 34% and were associated with urethral discharge compared with dysuria only (odds ratio (OR) 4.3, p = 0.003), positive urine leucocyte esterase testing (OR 7.4, p = 0.009), less education (OR 5.5, p = 0.03), and with symptoms for <5 days (OR 2.5, p = 0.03). Among 121 symptomatic women, 39% had bacterial vaginosis or T vaginalis, and 7.7% had candidiasis. N gonorrhoeae and C trachomatis were detected in 12.4% of the women. Overall, 48.8% had one or more of these infections. No factors were associated with vaginal infection, and only symptoms of vaginal discharge for <5 days were associated with N gonorrhoeae and C trachomatis (OR 4.0, p = 0.02). The main reason reported for seeking advice at pharmacies by both men and women was trust in pharmacy workers. CONCLUSIONS: Among men and women presenting to pharmacies with urethral and vaginal symptoms, rates of urethral and vaginal infections were comparable to those found in other clinical settings. Pharmacies can contribute to the care and prevention of sexually transmitted infection in developing countries.

Adolescent↗

Hospital pharmacy in Portugal and its future trends.

The authors begin by presenting a brief historical summary of hospital pharmacists' activities in Portugal, especially since the 1950s. They state their views on the present situation of hospital pharmacy in various aspects, namely: general legislation; activities and premises of pharmacy services; pharmaceutical career and staff recruitment; the National Hospital Formulary of Medicines and Pharmacy and Therapeutic Committees; acquisition, production and distribution of medicines; and clinical pharmacy activities. Future trends of hospital pharmacy in Portugal are summarized, stressing the following points: evolution of production and information, unit dose distribution, and steady increase of other clinical pharmacy activities.

Formularies, Hospital as Topic↗

Barriers to compliance with OBRA'90 regulations in community pharmacies.

OBJECTIVE: To identify which barriers have been most significant to community pharmacists in their ability to comply with the Omnibus Budget Reconciliation Act of 1990 (OBRA'90) regulations during its first year of implementation. METHODS: Mailing of a two-page survey in April 1994. SETTING: Four hundred randomly selected community pharmacies in the Commonwealth of Massachusetts. PARTICIPANTS: Of 400 pharmacies surveyed, 156 surveys were completed and returned for analysis. RESULTS: Barriers that were considered most significant to pharmacies surveyed in their ability to implement OBRA'90 regulations were excessive workload, lack of financial compensation, and patients' attitudes. Of least significance were inadequate knowledge about drugs, inadequate references, and store layout. Almost half the responding pharmacists indicated that OBRA'90 regulations had not affected or changed their practice, one-quarter of the pharmacists believed their practice was less rewarding after OBRA'90, and about one-fifth believed it was more rewarding. CONCLUSIONS: Community pharmacists in Massachusetts are making an attempt to comply with OBRA'90, but there are specific barriers that are affecting their ability to do so. The OBRA'90 regulations appear to have had little impact on the practice of most community pharmacies. Community pharmacy management needs to examine (1) expanded roles of supportive personnel to give pharmacists more time to spend counseling patients, (2) reimbursement mechanisms for cognitive service, and (3) approaches to educating patients about these changes in the pharmacy profession.

Costs and Cost Analysis↗

Conscientious objection to assisted death: can pharmacy address this in a systematic fashion?

OBJECTIVE: To describe a legal structure for the accommodation of pharmacists' rights of conscience in the dispensing of drugs for pharmaceutically assisted death. BACKGROUND: Pharmacists have indicated that there is disagreement in the profession regarding the appropriateness of a practice known as "pharmaceutically assisted death," in which lethal medications are prescribed for terminally ill patients who want to end their lives. Pharmacists who object to pharmaceutically assisted death may be asserting a conscientious objection that threatens to create a conflict with their employers. In addition, pharmacists who support pharmaceutically assisted death, but whose employers forbid the dispensing of medications for this purpose, may face a similar conflict. Current laws and principles of professional ethics fail to adequately address the resolution of either of these conflicts. DISCUSSION: We propose a system within which the pharmacy profession could accommodate the right to conscientious objection without sacrificing the quality of patient care. At the heart of our proposal is the understanding that employers must respect an employee's right to beliefs that differ from those of the employer and, correspondingly, the understanding that employees must respect the employer's duty to provide products and services to those who seek them from the employer. CONCLUSIONS: Pharmacy associations can adopt policies for conscientious objection and have those policies become law through action of the state legislature or the state board of pharmacy. This approach could lead to the development of a clear policy and procedure for resolving the issue of conscientious objection within the pharmacy community, making it far less likely that institutions outside pharmacy would be required to develop a solution for pharmacy.

Ethics, Pharmacy↗

[Area distribution of out-issued prescriptions from Saiseikai Kurihashi Hospital and behavior patterns of outpatients for selection of pharmacy].

The area distribution of out-issued prescriptions for outpatients in Saiseikai Kurihashi Hospital was surveyed over 6 months from the first day of out-issue. Behavior patterns of outpatients in the selection of pharmacy were also investigated. Our survey included the out-issued prescriptions in eight surrounding newly established pharmacies together with the first out-issue. Computer simulation indicated that 70% of the outpatients selected the surrounding pharmacies when they received their out-issued prescriptions the first time. However, the percentage of surrounding pharmacies selected by the patients decreased to 60% the second time, and then again increased to 80% the third time. The results suggest that most outpatients use surrounding pharmacies, although they try to use the pharmacies near their homes for a time.

Choice Behavior↗

Structural features of pharmacy function--the analysis using structural equation modeling.

In order to examine the structural features of community pharmacy function and to clarify areas meriting priority in efforts to expand pharmacy functions in the home care field, a questionnaire survey was conducted. Using the distribution of responses regarding the actual conditions entailed in the 16 categories of pharmacy services, factor analysis was carried out. Structural equation modeling was performed and the fitness of the path model constructed to study the interrelatedness of the individual factors extracted by factor analysis was considered. Four factors comprised pharmacy services "dispensing", "supply of goods", "offering home care", and "cooperation in community health and medical programs". The interrelatedness of four pharmacy functions by the result of structural equation modeling indicated the following insights. 1) By strengthening "cooperation in community health and medical programs", it is possible to directly improve the functions of "dispensing", and "offering home care". An improvement in "collecting and utilizing patient information", "providing appropriate instruction", "providing introductions to medical institutions and physicians", and "supplying over-the-counter drugs" can be expected as a result of direct benefits accrued by "cooperation in community health and medical programs". 2) By strengthening "offering home care", it is possible to directly improve "supply of goods". An improvement in "stocking long-term care goods and sanitary goods" can be expected as a result of direct benefits accrued by "offering home care". In conclusion, this study indicated that the areas meriting priority in the expansion and upgrading of pharmacy functions is stronger "cooperation in community health and medical programs".

Community Pharmacy Services↗

Management of sexually transmitted diseases in urban pharmacies in The Gambia.

This study aimed to describe the quality and costs of sexually transmitted disease (STD) case management in urban pharmacies in The Gambia, and explore pharmacy workers' (PWs) willingness to improve the STD care they provide. PWs from 24 registered pharmacies were interviewed in order to collect information on their knowledge and practices regarding management of STDs. The same pharmacies were visited by a male 'simulated client' (SC) to ascertain how urethral discharge syndrome (UDS) cases were managed in practice. Fifteen (63%) pharmacies were equipped for treatment of UDS, pelvic inflammatory disease (PID) and genital ulcer syndrome (GUS), according to national guidelines. Appropriate syndromic management for UDS was mentioned by 11% of PWs but actually given to 4.4% of the SC visits. None of the PID or GUS cases would be treated correctly. Forty-two per cent of PWs advised on partner notification, 38% on safe sex and 29% on treatment compliance in the SC visits. The reported costs for treatment of UDS, PID and GUS ranged from $2.5-$15.0. The cost of treatment actually purchased by the SC averaged $3.5 (range $1.5-$9.6) for UDS. Excluding the pharmacy sector from interventions will limit the impact of STD control measures. Regular training in syndromic management and rational drug use, with a concise manual for reference are recommended. Strategies to lower the cost of drugs should be explored.

Adult↗

Injection drug users report good access to pharmacy sale of syringes.

OBJECTIVE: To examine injection drug users (IDUs) opinions and behavior regarding purchase of sterile syringes from pharmacies. DESIGN: Focus groups. SETTING: Urban and rural sites in Colorado, Connecticut, Kentucky, and Missouri. PATIENTS OR OTHER PARTICIPANTS: Eight focus groups, with 4 to 15 IDU participants per group. INTERVENTIONS: Transcripts of focus group discussions were evaluated for common themes by the authors and through the use of the software program NUD*IST. MAIN OUTCOME MEASURES: Knowledge of human immunodeficiency virus (HIV), pharmacy use, barriers to access from pharmacies, high-risk and risk-reducing behavior, and rural/urban difference. RESULTS: Almost all participants knew the importance of using sterile syringes for disease prevention and reported buying syringes from pharmacies more than from any other source. Two IDUs believed pharmacists knew the syringes were being used for injecting drugs and perceived pharmacists' sales of syringes to be an attempt to contribute to HIV prevention. Most IDUs reported that sterile syringes were relativity easy to buy from pharmacies, but most also reported barriers to access, such as having to buy in packs of 50 or 100, being made to sign a book, having to make up a story about being diabetic, or having the feeling that the pharmacists were demeaning them. While the majority of IDUs reported properly cleaning or not sharing syringes and safely disposing of them, others reported inadequate cleaning of syringes and instances of sharing syringes or of improper disposal. There were few differences in IDUs' reported ability to buy syringes among states or between urban and rural sites, although the data suggest that IDUs could buy syringes more easily in the urban settings. CONCLUSION: For the most part, participants understood the need for sterile syringes in order to protect themselves from HIV, hepatitis B virus, and hepatitis C virus and saw pharmacies as the best source of sterile syringes. Although these data are not generalizable, they suggest that pharmacists can and do serve as HIV-prevention service providers in their communities.

Attitude of Health Personnel↗

Knowledge and attitudes about smoking cessation among pharmacy technicians.

OBJECTIVE: To evaluate the knowledge and attitudes of pharmacy technicians before and after attending a continuing education program about smoking cessation. DESIGN: A pre/post survey of a single group. SETTING: Two statewide meetings of the Iowa Pharmacy Association. PARTICIPANTS: Pharmacy technicians. INTERVENTION: One 2-hour continuing education (CE) course about smoking cessation for pharmacy technicians. MAIN OUTCOME MEASURES: Changes in scores before and after the CE sessions among three domains (knowledge, efficacy, and outcome) of a validated survey instrument. RESULTS: Fifty-one technicians completed both the presession and postsession questionnaire. For the three survey domains, technicians' knowledge (P = .034), efficacy (P < .001), and outcome (P < .001) showed significant improvement between the presession and postsession surveys (Wilcoxon signed rank test). CONCLUSION: Pharmacy technicians who attended a CE program on smoking cessation improved their knowledge, attitudes, and self-confidence in helping smokers quit. Additional research should be conducted to test the role of pharmacy technicians in smoking cessation promotion.

Adult↗

Prevalence of compounding in independent community pharmacy practice.

OBJECTIVES: To determine the extent of prescription compounding in independent community pharmacies and identify factors that influence the decision of independent pharmacists whether to provide compounding services. DESIGN: Cross-sectional survey. SETTING: Illinois, Missouri, Kansas, and Iowa. PARTICIPANTS: 370 pharmacists in charge. INTERVENTION: Anonymous questionnaire mailed in January 2005. MAIN OUTCOME MEASURES: Percentage of pharmacies that provide compounding; percentage of dispensed prescriptions that require compounding; factors contributing to decisions whether to provide compounding service. RESULTS: Overall, 94% of respondent pharmacies provided compounding services at the time of this survey. Prescriptions that required compounding represented less than 1% of total prescriptions for the majority (58.3%) of respondents. The main reasons for the decision to provide compounding service were wanting to provide full pharmaceutical care to patients (73.8% of compounders) and responding to requests by prescribers (48.7%). Pharmacies that did not provide compounding service cited the main reason as not receiving prescriptions that required compounding (63.6% of noncompounders). CONCLUSION: Compounding remains a component of pharmacy practice in the independent community setting. Prescriptions that required compounding represented 2.3% of all prescriptions dispensed by compounding pharmacies.

Community Pharmacy Services↗