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Health professional students' and faculties' perceptions of pharmacists as measured by a cartoon technique.

Perceptions of pharmacists' roles held by health professional students and faculty were evaluated by a projective cartoon technique. Cartoons of a pharmacist, a pharmacist and a physician, and a pharmacist and a nurse, all at a patient's bedside, were used as the survey instruments. From the dialogue provided by respondents in the cartoon conversational balloons, perceptions of the type of interaction, relationship between the figures, and pharmacists' role activities were determined. The survey was given to the entire student body and the faculty in three professional colleges (pharmacy, nursing, and medicine) of The University of Texas. The overall response rate was 34.2%. In response to the pharmacist-patient cartoon, pharmacists were depicted as independently consulting patients about their medications and monitoring their therapy. Some nursing and medical respondents stated that they had never seen a pharmacist at a patient's bedside. Responding to the pharmacist-physician cartoon, pharmacists' interactions with physicians were depicted as involving specific patient therapy and seemed to suggest a peer relationship. Pharmacy and medical respondents perceived clinical roles for the pharmacist. In response to the pharmacist-nurse cartoon, traditional roles were illustrated for the pharmacists, and subordinate-authoritative relationships were seen in the interactions between pharmacists and nurses. The cartoon technique appeared to be useful in determining role perceptions.

Attitude of Health Personnel↗

Pharmacist liability.

The various legal theories under which pharmacists may be found liable are reviewed. The pivotal element in determining pharmacist malpractice is the study that was owed to the patient. A pharmacist's principal duties to the patient are to dispense the correct drug and to label it correctly; failure to fulfill either of these responsibilities had led to successful claims of malpractice. There have been only a few cases in which the court ruled that the pharmacist had a duty to warn the patient about a potential adverse drug effect or interaction. However, as the role of the pharmacist expands, more courts may begin to find pharmacists liable for failing to warn the patient under specific circumstances. Pharmacists have a heightened duty to warn the patient about potential problems associated with nonprescription drugs that they recommend. A pharmacist may escape liability if there was a lack of proximate cause. Similarly, the defenses of contributory or comparative negligence and voluntary assumption of risk are based on some conduct by the plaintiff that negates or modifies the pharmacist's negligence. Statutes of limitation can also exclude liability. Courts have not found pharmacists liable under strict liability theories. A breach of warranty claim has rarely been successful. Pharmacists could be found liable for negligent selection of therapeutic alternatives but probably not for injuries allegedly caused by correctly selected equivalent agents. Although no cases have been reported, pharmacists could be subjected to negligence-based liability for nondistributive pharmaceutical services. As pharmacists assume more responsibilities, pharmacist malpractice law will expand.

Duty to Warn↗

Low pharmacist counseling rates in the Kansas City, Missouri, metropolitan area.

OBJECTIVE: To quantify the percentage of patients counseled by community-based pharmacists. METHODS: Phase I consisted of a 15-minute observational period of pharmacist counseling in 50 randomly selected pharmacies in the Kansas City, MO, area. In phase II, a survey was mailed to the same pharmacies to obtain policies, self-reported rates of counseling, baseline workload, and personnel information, as well as perceived communication barriers. RESULTS: Forty-six of 50 pharmacies were observed in phase I after excluding 10 ineligible pharmacies and adding 6 replacement pharmacies. Pharmacists provided counseling in only 14 of the 46 pharmacies (30%). Nineteen percent (20/106) of all patients received pharmacist-initiated counseling. Pharmacists in independent pharmacies were observed counseling a significantly higher percentage of patients than were pharmacists in chain pharmacies (44% vs. 11%; p = 0.014). Technicians were observed counseling 5 patients in chain pharmacies. Detailed verbal counseling, defined as four or more of a group of major counseling components, was provided to only 8 of the 20 patients who were counseled by a pharmacist (40%; 8% of all patients). In phase II, 31 of 51 surveys (61%) were returned. During the requested survey time period, pharmacies estimated that approximately five prescriptions were filled every 15 minutes, 51.5% of which were new. Pharmacists in chain pharmacies reported dispensing greater numbers of prescriptions than did pharmacists in independent pharmacies. These data and the reported counseling rates indicated that 50% of all patient prescriptions should be counseled. This is a higher rate than actually observed. All pharmacies reported that pharmacists completed the counseling; however, 10% of the respondents reported that technicians also counseled patients. Contrary to the findings in phase I, slightly more than 50% of the pharmacists reported using detailed verbal counseling. CONCLUSIONS: The overall observed rate of counseling in community pharmacies is low. In the Kansas City area, independent pharmacists counsel a greater than average percentage of their patients. Even if the national counseling rate is double what was observed, millions of patients are leaving pharmacies without the benefit of pharmacotherapeutic guidance. If pharmacists are slow to meet these challenges, other service providers will relieve pharmacists of that responsibility.

Counseling↗

Community pharmacist-child medication communication: magnitude, influences, and content.

OBJECTIVE: To describe community pharmacist-child medication communication with respect to its magnitude, influences, and content. DESIGN: Cross-sectional descriptive study. SETTING: Indiana. PARTICIPANTS: 460 community pharmacists. INTERVENTION: Mailed questionnaire was used for data collection. Sections included: (1) pharmacists' practice of medication communication with children and with adults; (2) factors influencing the pharmacist's decision to communicate with children about medications; (3) elements of pharmacist-parent and pharmacist-child communication; and (4) demographics. MAIN OUTCOME MEASURE: Daily percentage of children to whom pharmacists talked directly about medications. RESULTS: Response rate was 44.7% with no indications of nonresponse bias. Most respondents were staff pharmacists in chain pharmacies. On average, pharmacists reported engaging in communications about medications with 20.7% of children and 57.0% of adults on a daily basis (t = 23.5, P < or = .0001). Experience as a preceptor and prescription volume significantly influenced the frequency of pharmacists' communication with either adults or children. Pharmacists provided more medication information to parents than to their children, and more medication information to older children than to younger children. Children of all ages were likely to be comforted and given information about the medicine's taste. CONCLUSION: Preliminary insights into the interaction between pharmacists and child patients are provided by this study. Considering the relatively low frequency of pharmacist-child communication, interventions aimed at influencing the child's and caregiver's motivation to seek information about the child's care, and improving pharmacist's knowledge about children's cognitive development at various ages may enhance the involvement of children in self-treatment.

Adult↗

Involvement of immunization-certified pharmacists with immunization activities.

BACKGROUND: Immunization certification courses allow pharmacists to directly administer vaccines to their patients. However, the demographics and level of immunization involvement of immunization-certified pharmacists compared with those noncertified are unknown. OBJECTIVE: To document the demographics, professional activities, and job satisfaction of immunization-certified pharmacists compared with pharmacists not certified for immunization. METHODS: In a cross-sectional pilot study, immunization-certified pharmacists were compared with noncertified pharmacists via a postal-mailed questionnaire. The questionnaire consisted of demographic and practice site characteristics, involvement in immunization services, and a job satisfaction survey. RESULTS: Response rates were 48% (n = 101) and 36% (n = 158) for immunization-certified and noncertified pharmacists, respectively. Significantly more certified pharmacists were involved in immunizations (99% vs 24%; p < 0.001). Desire to improve the health care of the public and personal satisfaction were important factors that encouraged pharmacists to become certified to administer vaccines. Seventy-four percent of immunization-certified pharmacists directly administered the vaccines, primarily influenza (96%), pneumococcal (77%), hepatitis (55%), and diphtheria, pertussis, tetanus (19%). Adequate training, time, support from management and staff, and liability coverage were important factors that allowed pharmacists to incorporate immunizations into their practice. No significant differences in job satisfaction were observed between immunization-certified and noncertified pharmacists. CONCLUSIONS: Immunization-certified pharmacists are using their skills to administer vaccines to patients within their communities. Efforts to increase the number of these pharmacists throughout the US should be undertaken.

Certification↗

Destination, future intentions and views on practice of British-based pharmacists 5 and 10 years after qualifying.

OBJECTIVES: The first ever Pharmacy Workforce Census of pharmacists in Great Britain (GB) was conducted in 2002, and repeated in 2003. Both census surveys aimed to gather empirical data on the employment profile of pharmacists to aid the workforce planning process. The aim of this paper is to compare the work profile and employment destination of two graduate cohorts of pharmacists to explore what changes take place in employment practices and how quickly they occur. SETTING: GB-based pharmacists. METHODS: A two-page postal questionnaire was sent to 38,000 GB-registered pharmacists in August 2003, to provide various data on employment patterns, intentions to work abroad, and desire to practise pharmacy. The pharmacists were contacted using addresses stored on the Pharmaceutical Register, a statutory record of all pharmacists and pharmacy premises held by the Royal Pharmaceutical Society of Great Britain (RPSGB). A sub-set of this large data set--pharmacists who qualified in 1992 and those who qualified in 1997--was selected for comparison. MAIN OUTCOME MEASURE: Sector of employment and strength of desire to practice. RESULTS: A response rate of 75% was achieved for the overall census, while the response rate from the two graduation cohorts was 62% and 58%. Larger proportions of women compared with men, even after only 5 years of working as a pharmacist, are either not working or work part-time. Among the women, these patterns increase significantly for those with a greater number of years on the Pharmaceutical Register. There is evidence that pharmacists move out of the two main sectors of practice (hospital and community) with increasing years on the Register, and some gender differences in job mobility are observed. The School of Pharmacy from which pharmacists graduate appears to have some effect on practice patterns although more research is needed to explore this further. Desire to practise pharmacy is weaker among those practitioners who work in the community sector of practice, and younger pharmacists are more likely to intend working abroad. CONCLUSIONS: Part-time work patterns are implemented fairly quickly after qualifying, particularly among the women pharmacists. Given that female students account for over 60% of all intake onto pharmacy courses current supply problems will continue if work patterns continue along this trajectory. The ability of the profession to meet current, never mind extended roles, is thus called into question.

Adult↗

Pharmacists' liability into the year 2000.

OBJECTIVE: To educate the pharmacy community regarding areas of potential liability arising from the pharmacist's role in the changing health care delivery system. DATA SOURCES: Published cases (LEXIS and Westlaw), literature (NEXIS and Westlaw), and abstracts available through July 1998. CASE SELECTION AND DATA ABSTRACTION: Selected on the basis of the authors' objectives and the usefulness of the information for practicing pharmacists. DATA SYNTHESIS: As the pharmacist's role in the health care delivery system continues to change, so too does the pharmacist's exposure to liability. Although historically a pharmacist had no common law "duty to warn," new laws requiring a pharmacist to counsel patients, along with increased scrutiny by the media, have increased the pharmacist's potential for liability. An evaluation of recent case law indicates that state courts are increasingly willing to extend a pharmacist's duty to warn where the pharmacist has special knowledge of the patient or the patient's condition, contraindicated drug usage, where a prescription substantially exceeds the maximum safe dosage, or where a pharmacist fills or refills a prescription without physician authorization. A recent issue that may add to the list of potential liability concerns is the substitution of generically equivalent narrow therapeutic index drug products. CONCLUSION: The pharmacist's role in the ever changing health care delivery system, along with the public's increased scrutiny of pharmacists' dispensing practices, may inevitably extend a pharmacist's duty to warn a patient of potential problems related to prescription drug products. This trend is expected to continue into the new millennium.

Forecasting↗

Pharmaceutical care research and education project: pharmacists' interventions.

OBJECTIVES: To describe the processes of care used by community pharmacists participating in the Pharmaceutical Care Research and Education Project (PREP) in terms of drug-related problems (DRPs), pharmacists' recommendations, and status of DRPs at follow-up, and to determine characteristics associated with DRPs. DESIGN: Descriptive analysis of the treatment group from a larger randomized, controlled cluster design. SETTING: Five independent community pharmacies in Alberta. PARTICIPANTS: One hundred fifty-nine patients who were covered under Alberta Health and Wellness's senior drug benefit plan (i.e., 65 years or older), were taking three or more medications concurrently according to pharmacy records, were able to complete telephone interviews as determined by pharmacists, maintained residence in Alberta for 12 of the 15 study months, agreed to receive their prescription medications only from the study pharmacy during the study period, and provided informed consent. MAIN OUTCOME MEASURES: Frequency of DRPs, recommendations, status of DRPs, and analysis of clinical results as determined during pharmacists' follow-up care. RESULTS: In telephone surveys, patients reported taking 4.7 prescription medications per day, but pharmacists documented 8.7 prescription medications per day in their records. Pharmacists documented 559 DRPs, a mean (+/- SD) of 3.9+/-3.2 problems per patient. Approximately 39% of problems were actual DRPs, while 60% were potential DRPs. Medical conditions associated most frequently with a DRP involved the respiratory, cardiovascular, and musculoskeletal systems. The most common DRP categories were "patient requires drug therapy" or "patient requires influenza or pneumococcal vaccination." Pharmacists wrote 551 initial clinical notes using the subjective, objective, assessment, plan (SOAP) format, and they recorded 346 follow-up interventions, also using SOAP notes. Counseling, preventive consultations, and clinical monitoring represented 40% of their recommendations. In 80% of situations, the pharmacist made the recommendation directly to the patient. On follow-up, 40% of the 559 DRPs identified were resolved, controlled, or improved. Patients accepted 76% of pharmacists' recommendations, and physicians accepted 72% of pharmacists' suggested resolutions of DRPs. Pharmacists were more likely to follow up about actual DRPs, as compared with potential ones; overall, they followed up on 62% of identified DRPs. CONCLUSION: Pharmacists identified more DRPs for study patients than previous community-based, observational studies have reported. Undertreatment appears to be a prevalent DRP. Community pharmacists' recommendations to prevent and resolve DRPs were made primarily to patients and were well accepted. More follow-up was needed for all DRPs. When follow-up occurred, the DRP results generally showed improvement.

Aged↗

Pharmacist job turnover, length of service, and reasons for leaving, 1983-1997.

Pharmacist job turnover from 1983 to 1997 was studied. Data were collected from a randomized 1997 mail survey of 1600 licensed pharmacists in four states (Ohio, Massachusetts, Oregon, and Alabama). The survey instrument included questions on pharmacist demographics, work schedules, salary, and work history. A total of 541 pharmacists responded, yielding an adjusted response rate of 34.5%. Information was provided on a total of 1697 jobs with start dates from 1931 to 1997. Pharmacist job turnover was fairly steady across the 1983-1997 period, averaging 11% annually. The average median tenure of pharmacists who left jobs was 32 months. The percentage of pharmacists leaving jobs and ranking stress as the reason for leaving increased, and the percentage of leavers ranking salary as the reason decreased. Women had a significantly higher annual turnover rate (15%) than men (9.7%), and they stayed in jobs for significantly less time (25.2 months) than men (56.5 months). There were no differences in turnover rates across practice settings. A larger percentage of pharmacists leaving jobs in large chain and institutional settings ranked stress as a reason for leaving than pharmacists leaving independent or small chain pharmacies. A larger percentage of pharmacists leaving independent or small chain pharmacies ranked salary as a reason than pharmacists in the other two settings. Pharmacist job turnover averaged 11% per year between 1983 and 1997. Pharmacists who left jobs typically stayed less than three years. The percentage citing stress as a reason for leaving increased, and the percentage citing salary decreased.

Female↗

The needs and sources of drug information among pharmacists in Hong Kong.

The objective of this study was to determine the drug information needs of pharmacists in Hong Kong, the sources of drug information available and the constraints limiting their ability to fulfil drug information needs at practice sites. A questionnaire survey was carried out in January 1995 of community (230 retail pharmacies, 10 outpatient clinics) and 44 hospital pharmacists working in Hong Kong. The information sought included: place of practice, availability of reference texts, journals or periodicals at practice sites, types of clinical pharmacy services provided, frequency and types of drug information questions received, sources of drug information used, needs for a drug information service, and constraints limiting their ability to fulfil drug information needs at practice sites. Ninety-four pharmacists (hospital 68.2%, community 26.6%) responded. Hospital pharmacists generally had more reference texts and journals/periodicals at practice sites than community pharmacists. The majority of pharmacists in this survey were involved in a variety of clinical pharmacy services, including the delivery of drug information to other health-care professionals and the general public. Community pharmacists were most often asked questions about over-the-counter drugs, drug dosage and drug identification. Hospital pharmacists were most often asked questions about drug identification and availability of drugs. The most important drug information sources for both the community and hospital pharmacists were their own knowledge and work-place reference texts. Few pharmacists frequently used the service provided by the national Drug and Poisons Information Bureau (DPIB). The scarcity of drug information sources was perceived as an important constraint by both community and hospital pharmacists when fulfilling drug information needs at practice sites. Lack of time was considered an equally important constraint by the hospital pharmacists. A national drug information service was generally felt to be necessary. In conclusion, inadequacy in drug information sources was perceived to be a very important constraint limiting the pharmacists surveyed in fulfilling drug information needs at their individual practice sites. However, many were unaware that the drug information requested was already available. Regular attempts to publicize this territory-wide DPIB are obviously needed.

Community Pharmacy Services↗

The expanding role of the transplant pharmacist in the multidisciplinary practice of transplantation.

INTRODUCTION: The burgeoning clinical discipline and growth of organ transplantation has resulted in an expansion in the number of healthcare specialists to support clinical care and research. The past 10 yrs have seen a dramatic increase in the number of immunosuppressive agents and other medications used in transplantation, resulting in more complex medication regimens and greater potential for interactions, adverse effects and increased costs. PURPOSE: To determine how transplant pharmacists are being integrated into transplant clinical practice. Transplant centres were identified through UNOS Transplant Administrators Committee list serve. A survey was then distributed via e-mail to 159 individuals representing 118 solid organ transplant centres. RESULTS: Forty-one (35%) of the 118 centres responded, with 36 evaluable surveys. Of the 36 centres, 28 (78%) had transplant pharmacist support and eight did not have a pharmacist dedicated to transplant (two of the eight were recruiting). A majority of the respondents had multi-organ transplant responsibilities. Eighty-six per cent of pharmacists were involved in kidney transplant, 71% in liver, 50% in pancreas, 25% in heart, and 7% in lung. Pharmacist salaries were most often funded by a department of pharmacy (74%), followed by college of pharmacy (12%), transplant centre (8%) and department of surgery (6%). Almost all of the pharmacist's clinical practice time focused on post-transplant care (99%). The average percentage of the pharmacist's time was: 43% inpatient, 15% outpatient, 14% research, 6% other transplant related, and 22% non-transplant related. Of the 28 pharmacists, 25 had a PharmD degree, two a BS and one had a PhD in Pharmacy. The average number of organs transplanted among the responding centres was 99 kidneys, 45 livers, 28 pancreas, 14 heart, and 26 lungs. The number of transplants did not differ between the programmes with pharmacist clinical support vs. those without designated pharmacist support. CONCLUSION: The survey indicates that many solid organ transplant centres have incorporated transplant pharmacists into the multidisciplinary transplant clinical team. Transplant pharmacists are funded most often by the hospital pharmacy. Most transplant pharmacists spend the majority of their time in clinical practice, but also play a key role in research.

Humans↗

Pharmacy-perceived barriers to cancer pain control: results of the North Carolina Cancer Pain Initiative Pharmacist Survey.

OBJECTIVE: To assess pharmacists' knowledge, attitudes, and beliefs regarding the use of narcotics in cancer pain management, identify pharmacist counseling activities for cancer pain patients, assess pharmacy-related barriers to cancer pain management, and evaluate the availability of narcotic analgesics. METHODS: Mailing of a six-page survey. SETTING: Five hundred randomly selected pharmacists registered in North Carolina. PARTICIPANTS: Of 500 pharmacists surveyed, 141 surveys were completed and returned for a response rate of 28.2 percent. RESULTS: Pharmacists surveyed were knowledgeable regarding the problem of undertreatment of cancer pain. More than 80 percent of respondents replied that most cancer patients experience pain at some time during their illness. Eighty-five percent of respondents agreed that the nurse must believe the patient's report of pain and that the patient is the best judge of the intensity of the pain. Conservative physician prescribing patterns and conservative administration patterns of nurses were identified as perceived barriers to adequate pain management by 51 and 44 percent of respondents, respectively. Less than 30 percent of respondents frequently counseled cancer pain patients and were unable to identify patients who have cancer pain as a major medical illness. Hospital pharmacists recommended adjunctive therapy more often than did community pharmacists (p = 0.013). Interventions in pain management regimens were more often conducted by hospital pharmacists than by community pharmacists (p = 0.049). Differences in availability of narcotics was noted among practice sites for some more potent narcotics. Of the pharmacists surveyed, only 43 percent had attended a continuing education program on cancer pain management. Ninety-six percent of respondents were interested in attending a continuing education program in the future. CONCLUSIONS: Pharmacists in North Carolina are aware that the undertreatment of cancer pain is a serious medical problem. Unfortunately, pharmacists appear to be unable to identify patients with cancer pain as a major medical problem; therefore, counseling activity is limited. Addiction is still perceived as a barrier by some pharmacists. Through organizations such as the North Carolina Pain Initiative, these problems can be addressed.

Community Pharmacy Services↗

The role of pharmacists in HIV/STD prevention: evaluation of an STD syndromic management intervention in Nepal.

OBJECTIVE: To evaluate the effects of a pilot sexually transmitted disease (STD) syndromic case management training for pharmacists in Nepal on STD drug dispensing behavior, HIV/STD prevention communication, and condom promotion and sales. METHODS: Pre- and post-intervention interviews with samples of 160 pharmacists were conducted utilizing the simulated client method to collect data on pharmacists' response to men reporting urethral discharge. In order to assess the long-term effects, a sub-sample of 38 pharmacists trained 7-9 months before the follow-up survey was analysed separately. RESULTS: There were no significant differences in the percentages of pharmacists who suggested taking medications, dispensed medications, or referred clients to a physician. The proportion of pharmacists who recommended an injection declined from 27% to 14%. Prior to the intervention, only one pharmacist (0.8%) dispensed the correct drugs and regimen for the syndromic treatment of urethritis. This increased to 45% immediately following the training. In a sub-sample of pharmacists who were interviewed 7-9 months after the training, the correct drugs and regimen were dispensed by 26%. The proportion of pharmacists who recommended to clients to have their sex partners treated increased from 5% to 21%. Although the proportion of pharmacists who suggested condom use increased from 14% to 24%, the proportion of pharmacists actually selling a condom or giving advice on HIV testing remained low and unchanged pre- and post-intervention. Over one-third of pharmacists mentioned HIV or AIDS in their interactions with clients, compared to 9% prior to the intervention. CONCLUSIONS: The findings suggest that STD services provided by pharmacists can be significantly improved through a short-term training intervention, although the improvements are modest and probably time-limited. Interventions must be more intensive and combined with regular follow-ups if they are to meet their desired goals of improving STD treatment in a pharmacy setting.

Anti-Infective Agents↗

Pharmacist's attitudes towards dispensing errors: their causes and prevention.

OBJECTIVE: To assess the attitudes of pharmacists towards the issue of dispensing errors. METHOD: A postal survey was undertaken among all Tasmanian-registered pharmacists residing in Australia. The anonymous questionnaire sought opinions on whether the risk of dispensing errors and the actual numbers of errors are increasing, the major factors contributing to the occurrence of dispensing errors, factors that can best minimize the risk of dispensing errors, the number of prescription items that one pharmacist can safely dispense in a day and whether Australia should have a regulatory maximum dispensing load, and an estimation of the number of recent errors at the pharmacist's workplace. RESULTS: Completed questionnaires were received from 209 pharmacists (50% response rate). Most pharmacists (82%) believed that the risk of dispensing errors is increasing. The principal contributing factors nominated were: high prescription volumes, pharmacist fatigue, pharmacist overwork, interruptions to dispensing, and similar or confusing drug names. The main factors identified as being important in reducing the risk of dispensing errors were: having mechanisms for checking dispensing procedures, having a systematic dispensing workflow, checking the original prescription (duplicate) when dispensing repeats, improving the packaging and labelling of drug products, having drug names that are distinctive, counselling patients at the time of supply, keeping one's knowledge of drugs up-to-date, avoiding interruptions, reducing workloads on pharmacists, improving doctors' handwriting, and privacy when counselling patients. Most pharmacists (72%) stated that they were aware of dispensing errors that had left the pharmacy undetected, in their place of practice during the past 6 months. The median number of such dispensing errors that they were aware of was three. A median of 150 was nominated as the maximum number of prescription items that can be safely dispensed per 9-h day (i.e. 17 items per hour) by or in the presence of one pharmacist. Most pharmacists (58%) stated that there should be a regulatory guideline for the safe dispensing load in Australia. CONCLUSION: Dispensing errors are occurring in numbers well above reports to regulatory authorities or professional indemnity insurance companies, and seem to be accepted as part of practice. High prescription volumes, pharmacist fatigue and overwork appear to be important factors. The profession needs to be proactive and standards must be set appropriately high (i.e. zero error tolerance).

Adult↗

New York State primary care physicians' attitudes to community pharmacists' clinical services.

BACKGROUND: Recent changes in education law and regulations governing the practice of pharmacy in New York State have extended the clinical responsibilities of pharmacists. There is limited information in the United States about physicians' opinions of these potential activities by pharmacists. OBJECTIVE: To determine the attitudes of New York State primary care physicians, who practice in a community setting, of community pharmacists as providers of these services, as well as further extended services. METHODS: Questionnaires were mailed to a randomly selected sample of 1400 board-certified internists and family practitioners chosen from New York State counties with populations of less than 251,000. Questions were structured to determine perceptions toward specific extended roles, pharmacists' dispensing of particular drugs without a prescription, the current role of pharmacists, and the relationship between the professions. RESULTS: There were 630 (47.4%) responses, of which 594 (44.7%) were analyzed. Most physicians (93%) agreed that pharmacists should report adverse drug reactions and advise them on cost-effective prescribing (75.6%). Few (23%) believed that pharmacists should initiate a community pharmacy and therapeutics committee. Most responders (64%) agreed that pharmacists could provide, without a prescription, a 3-day course of a vaginal cream containing 2% butoconazole for vaginal candidiasis in nonpregnant women and a rectal suppository containing steroids for hemorrhoid sufferers (61%). However, few (5%) agreed with dispensing antibiotics for sore throats or a 4- to 6-week supply of ranitidine for nightly "point" abdominal tenderness that is relieved by food (5%). Most physicians agreed that pharmacists should provide their patients with information concerning the drug's dose and administration (92%), possible adverse drug reactions (89%), and possible food and drug interactions (97%). Few believed that pharmacists should provide screening services for their patients. CONCLUSIONS: This survey suggests that most physicians support the current patient-counseling activities of community pharmacists. However, there was little support for limited prescribing by pharmacists, even within specific protocols. Increased information to patients was deemed desirable, but few physicians believed that pharmacists should provide health screening services.

Adult↗

The quality of the professional practice of community pharmacists: what can still be improved in Europe?

This article describes a research project concerning the professional practice of community pharmacists in Western Europe. In 1990 interviews were held with key figures and practising pharmacists in the Netherlands, Belgium, Great Britain, Sweden and Portugal. In 1991 a questionnaire was sent which was answered by 929 pharmacists. Concerning the quality of the professional practice it appeared that pharmacists have integrated certain structure aspects such as the use of a computer or a separate patient consultation room to varying degrees. Also concerning process aspects with regard to quality, for example the degree to which attention is given to counter work and prescription controls, there are large differences between pharmacists from the different countries. These differences between pharmacists appeared to depend upon differences in legal rules (such as the compulsory presence of a pharmacist in Belgium, Sweden and Portugal or the compulsory prescription control by a pharmacist before delivery in Great Britain), financial and economic circumstances, internal organizational characteristics of the pharmacy and the individual personal task conceptions of the pharmacist. New developments, for example in areas of patient information and computer use, seem to be followed most in the Netherlands and Sweden. General statements about differences in quality are not easily made because the community pharmacy in other countries also has certain positive aspects, such as being easily accessible (Portugal), personal involvement of the pharmacist (Belgium) and personal control by the pharmacist (Great Britain). Looking at the diversity within Europe the conclusion can be reached that the European pharmacist' does not yet exist.

Education, Pharmacy↗

Physicians' perceptions of communication with and responsibilities of pharmacists.

OBJECTIVE: To understand physicians' perceptions of (1) their communication with pharmacists, (2) pharmacists' professional duties, and (3) the degree of responsibility with which pharmacists perform these tasks. DESIGN: Structured interviews with convenience sample of physicians in phase 1; written survey mailed to convenience sample of physicians in phase 2. PARTICIPANTS: Six physicians in Wyoming in phase 1, and 313 primary care physicians who were members of the Wyoming Medical Society in phase 2. MAIN OUTCOME MEASURES: Physicians' attitudes and experiences related to their interactions with pharmacists and their perceptions about pharmacists' responsibilities. RESULTS: Usable surveys were returned by 176 physicians (response rate = 59.1%). Age ranged from 27 to 86 years (mean +/- SD = 43.5 +/- 10.4 years), 79.5% were men, and 50.6% were in family practice. Almost 25% had personal contact with pharmacists regarding patients' medications four or more times daily, but 20.6% rarely had this type of contact. Pharmacists contacted physicians' offices regarding prescription refills frequently, with 28.7% reporting 10 or more contacts daily. For 79.2% of respondents, an office nurse had the most contact with pharmacists. Respondents were most comfortable with pharmacists' responsibilities of catching prescription errors (88.0%), providing patient education (65.1%), suggesting nonprescription medications (63.4%), and suggesting prescription medications to physicians (52.0%). Respondent's age was negatively correlated with three functions related to pharmacotherapeutic regimens: designing regimens, monitoring effects of failed regimens, and monitoring outcomes. The most common negative experiences with pharmacists involved pharmacists' scaring the patient, dispensing unauthorized refills, and making inappropriate comments in the presence of patients. CONCLUSION: Future research with a larger, more representative sample of physicians will help explain this dynamic relationship. These preliminary results should be useful in training future physicians and pharmacists.

Communication↗

Pharmacists' attitudes about pharmacy sale of needles/syringes and needle exchange programs in a city without needle/syringe prescription laws.

We assessed pharmacists' practices for needle and syringe (NS) sales and their attitudes toward a needle exchange program through a telephone survey of 75 randomly selected pharmacies in Baltimore, Maryland, where possession of drug paraphernalia is illegal but where NS can be purchased without a prescription. Pharmacists' (n=46) procedures for NS sales included asking for picture identification (54%), requiring a prescription (34%), or requiring a diabetic identification (DID, 34%) for NS purchase; multiple responses were allowed. The median number of prescription and nonprescription NS sold per month was 950. Most (86.6%) pharmacists reported selling NS without prescriptions at their discretion. Pharmacists sold a median of 16 nonprescription NS per month. Pharmacists who required prescriptions or DID (56.5%) sold nonprescription NS significantly less often than those who did not require prescriptions or DID (p=.007). Most pharmacists (87%) were aware of the needle exchange program, 78.3% supported the program, and 67.4% supported selling nonprescription NS in pharmacies. Although there was no difference in anticipated effects of needle exchange or in support for needle exchange between pharmacists who did or did not require prescriptions, DID, or both, pharmacists who did require these items were significantly less likely to support pharmacy sales of nonprescription NS than pharmacists with less restrictive sales policies (p=.04). Although most pharmacists surveyed supported access to sterile NS by injection drug users through a needle exchange program, there was a diversity of approaches to nonprescription NS sales among pharmacists in a city that does not require prescriptions for access to sterile NS. Most supported nonpharmacy needle exchange programs, and more than one half limited injection drug users' access to NS through restrictive sales practices. To reduce injection drug users' exposure to HIV, pharmacists should be educated about HIV prevention and injection drug use and be included in development of HIV prevention programs, including legal pharmacy NS sales.

Attitude of Health Personnel↗