Caroline A. Gaither

Evaluation of Community Pharmacy Service Mix: Evidence from the 2004 National Pharmacist Workforce Study

OBJECTIVES To describe the mix of pharmacy services being offered in different types of community pharmacy practices and to identify factors associated with a community pharmacy offering pharmacy services. DESIGN Cross-sectional study. SETTING Community pharmacies (independent, chain, mass merchandiser, and supermarket pharmacies). PARTICIPANTS Pharmacists practicing full-time or part-time who worked in community pharmacies and responded to the 2004 National Pharmacist Workforce Survey. INTERVENTION Mailed survey from the 2004 National Pharmacist Workforce Survey, which included core content questions for all sampled pharmacists and supplemental surveys that included workplace questions for a selected subsample of pharmacists. MAIN OUTCOME MEASURES Type and frequency of pharmacy services being offered in a community pharmacy, including dispensing and product-related services (e.g., specialty compounding), and pharmacist care services (e.g., immunizations, smoking cessation, health screening, medication therapy management, wellness screening, nutritional support, and disease management services). RESULTS Four pharmacist care services were reported as being offered at more than 10% of community pharmacy practices: immunizations, smoking cessation, health screening, and diabetes management. The number of pharmacist care services offered at a community pharmacy was positively associated with having at least three pharmacists on duty, innovativeness of the pharmacy, status as an independent pharmacy, and status as a supermarket pharmacy. More than one half of the community pharmacy practices did not offer any of the eight pharmacist care services included in a pharmacy service index. CONCLUSION Pharmacy services were reported at relatively few community pharmacies, and were associated with pharmacy innovativeness, pharmacist staffing levels, and pharmacy setting. Some community pharmacies are offering pharmacy services as part of their business strategy, while others are dedicated to dispensing services. Continued study of pharmacy service availability in community pharmacies is needed to improve our understanding of our capacity to deliver such services, including medication therapy management services.

A modified model of pharmacists' job stress: the role of organizational, extra-role, and individual factors on work-related outcomes.

BACKGROUND Understanding the effects of job stress continues to be a concern for health-care providers as workload and personnel needs increase. OBJECTIVE The overall objective of this study was to test a direct effects model of job stress that examines the characteristics of the organizational environment (interpersonal interactions, environmental aspects, the level of compensation and advancement, role stress, and availability of alternative jobs); extra-role factors (work-home conflict); job stress; individual factors (career commitment); and the work-related psychological outcomes of job satisfaction, organizational commitment, and job turnover intention. METHODS A cross-sectional mail survey was sent to a nationwide random sample of 4895 licensed pharmacists in the United States. Previously validated summated Likert-type scales measured each of the study variables. Data analyses included descriptive statistics, and exploratory and confirmatory factor analyses. Structural equation modeling was used to estimate the final model. RESULTS A response rate of 46% was achieved. Psychometric analyses indicated acceptable reliability and validity. The study model fit the data well (CFI[comparative fit index] = 0.90, RMSEA[root mean square error of approximation] = 0.05). Organizational factors in the form of role overload (standardized beta = 0.45) and conflict (0.31) and ease of finding a job with better interpersonal characteristics (0.26) had the largest effects on job stress. Interpersonal characteristics were also one of the strongest predictors of job satisfaction (-0.61) and organizational commitment (-0.70). Work-home conflict directly affected job turnover intention (0.11) and career commitment (-0.16). Other significant, but sometimes, opposite direct effects were found. Job satisfaction and organizational commitment directly affected job turnover intention. CONCLUSIONS Given the increased demand for pharmacy services, health-care organizations will benefit from increasing positive and reducing negative work outcomes. Increased focus on enhancing interpersonal interactions, developing commitment to the profession, and greater consideration of nonwork factors could help pharmacists better manage their work environments. Future research should continue to refine these models to further enhance our understanding of the effects of job stress in the health professional workplace.

Career Commitment: A Mediator of the Effects of Job Stress on Pharmacists' Work-Related Attitudes

OBJECTIVE The hypothesis for this study was that career commitment mediates the effects of job stress on several work-related attitudes of pharmacists. The effects of job stress, career commitment, met expectations, job satisfaction, and organizational commitment on job turnover intention were also investigated. DESIGN Cross-sectional mail survey. SETTING Nationwide sample of licensed pharmacy practitioners in the United States. PARTICIPANTS 1,088 respondents (full- or part-time chain, independent, or hospital pharmacists) to a previous study. MAIN OUTCOME MEASURES Rating scales measured each of the study variables. Demographic information was also collected. Data analyses included descriptive statistics, confirmatory factor analysis, and structural equation modeling with latent variables. INTERVENTIONS None. RESULTS Responses were received from 653 pharmacists out of 921 contacted (71%). The effects of job stress on job turnover intention were mediated through career commitment, met expectations, organizational commitment, and job satisfaction. Career commitment positively affected met expectations (beta = 0.35), and met expectations positively affected organizational commitment (beta = 0.66) and job satisfaction (beta = 0.78). An increase in the mean level of job satisfaction and organizational commitment decreased the likelihood of job turnover intention. Independent pharmacy owners tended to have the most positive attitudes toward work. CONCLUSION Strategies should be developed to increase the career commitment of pharmacists. Increased commitment can reduce the negative effects of job stress and improve work-related attitudes.

Understanding the scientific issues embedded in the generic drug approval process.

OBJECTIVE To review the major scientific issues embedded in the generic drug approval process. DATA SOURCES Articles indexed initially under terms such as generic medications, generic drugs, bioequivalence, and bioinequivalence. These terms were used to search indexing services such as MEDLINE, International Pharmaceutical Abstracts, CINAHL (a database of nursing and allied health literature), and Science Citation Index. Additional data sources included the Code of Federal Regulations and regulatory guidances from the Food and Drug Administration (FDA) Center for Drug Evaluation and Research. STUDY SELECTION Performed by the authors. DATA EXTRACTION Not applicable. DATA SYNTHESIS Despite the fact that regulations regarding bioequivalence have been in place for more than 20 years, controversies over bioequivalence continue to arise. Consensus on many of these issues is driving the development of new FDA guidances regarding bioequivalence. Still, despite the issuance of new guidance and consensus building among scientists, many clinicians and consumers remain uninformed regarding the scientific basis for establishing bioequivalence and the generic drug approval process in general. Although some have suggested that the generic drug approval process is flawed, overall, it appears that the process works. CONCLUSION Understanding the generic drug approval process and the issues surrounding bioequivalence is of paramount importance to both clinicians and scientists.

Pharmacist Participation in the Workforce: 1990, 2000, and 2004

OBJECTIVE To examine work variables for licensed pharmacists for 1990, 2000, and 2004. DESIGN Three cross-sectional, descriptive studies. SETTING United States. PARTICIPANTS Licensed pharmacists: 1,623 in 1990; 2,092 in 2000; and 1,564 in 2004. These numbers of usable responses to the three respective surveys represented 54.0%, 42.7%, and 33.8% of those receiving surveys. INTERVENTION Mailed survey from the 2004 National Pharmacist Workforce Survey; data from the national studies of the pharmacist workforce conducted in 1990 and 2000. MAIN OUTCOME MEASURES Characteristics of pharmacists; work setting, work position and age distribution of actively practicing pharmacists. Work status of licensed pharmacists; proportion actively practicing pharmacy. Proportion of pharmacists working part-time overall and by age group, weekly hours worked by actively practicing pharmacists, and full-time equivalents (FTEs) by age group. Proportion of pharmacists with secondary pharmacy employment; work setting, hours worked, and weeks worked in secondary pharmacy employment. RESULTS In each year studied, more than 86% of licensed pharmacists were actively practicing pharmacy. In 2004, the largest proportion of actively practicing women pharmacists was between the ages of 31 and 45, and the largest proportion of actively practicing men pharmacists was between the ages of 46 and 60. Across the survey years, the proportion of all actively practicing pharmacists working part-time increased, and the proportion of women working part-time was at least double that of men except in 2004. In 2004, the FTE contribution for women was 0.81 and 0.91 for men. CONCLUSION The decrease in FTE contributions by all pharmacists and the aging of the male pharmacist population raise concerns about the adequacy of current and future pharmacist supply. As the demand for pharmacists continues to evolve, pharmacy must continue to monitor the pharmacist workforce to show how pharmacists react to changes to better inform projections of the pharmacist workforce.

Decision making and effort in the self-regulation of hypertension: testing two competing theories.

We compare the ability of two social psychological models to explain self-regulation decisions to control hypertension by 208 patients at a hospital clinic: the theory of planned behaviour (TPB) and the model of goal-directed behaviour (MGB). The sample was drawn from patients at a large research hospital in North America. The findings show that the MGB not only explains significantly more variance in decision making than the TPB, but it provides an account for how reasons for acting become integrated and transformed into intentions to act, which the TPB does not address. The MGB does this in part by introducing the variable, desire, as an essential mediator between reasons for acting and intentions. The MGB also incorporates the effects of anticipated emotions on decision making, which are forms of forward-looking counterfactual thinking with respect to goals. In addition, the present study reconceptualized instrumental behaviour to encompass how hard one tries to act in the senses of (1) devoting time to planning with respect to reducing/maintaining blood pressure, (2) expending mental/physical energy to reduce/maintain blood pressure, (3) maintaining will power to reduce/maintain blood pressure, and (4) sustaining self-discipline (e.g. in overcoming obstacles) to reduce/maintain blood pressure. Key differences, as well as commonalities, in decision making are pointed-out between men and women and between people whose goal is to reduce versus maintain blood pressure.

Organizational factors influencing pharmacy practice change.

BACKGROUND Some pharmacists have changed the focus of their practice from solely dispensing. Emerging services they have added include medication therapy management and other pharmacy services. OBJECTIVE To assess the effect of entrepreneurial orientation, resource adequacy, and pharmacy staffing on pharmacy practice change. METHODS A total of 1847 licensed U.S. pharmacists received 2 mail surveys as part of a larger national pharmacist survey. The core survey collected information about practice setting, prescription volume, and staffing. The supplemental survey assessed how the pharmacy had changed over the past 2 years to enable the delivery of pharmacy services. The amount of change was assessed by 12 items, which were summed to provide an aggregate change index. Five variables from organizational change literature were assessed as influences on practice change: proactiveness, risk taking, autonomy, work ethic, and adequacy of resources. In addition, the associations of pharmacist and technician staffing with practice change were assessed. A multiple linear regression analysis was performed with the aggregate change index as the dependent variable and the 7 potential influences on change as the independent variables. RESULTS Four hundred usable surveys were analyzed. At least some level of practice change was reported in 60% of pharmacies surveyed. The linear regression analysis of the model was significant (P<.001) with an R-square value of 0.276. Significant influences on change were 2 dimensions of entrepreneurial orientation-proactiveness and autonomy-as well as adequacy of resources and pharmacy technician staffing. CONCLUSIONS Many pharmacies reported that some aspects of their practice have changed, such as collecting patient information and documenting care. Few reported changes in asking patients to pay for pharmacy services. These findings support previous results, which show that the capacity for organizational change can be augmented by increasing proactiveness, autonomy among employees, and the availability of adequate and appropriate resources.

Gender Differences in the Self-Regulation of Hypertension

The theory of planned behavior was adapted and revised to explain efforts made by patients to regulate their hypertension. A test of this theory of self-regulation revealed significant differences between men (N = 105) and women (N = 102) in their decision making and goal pursuit activities. For men, attitude toward success had both direct and indirect (through desire and intentions) effects on efforts to regulate hypertension. Attitudes had no influence on effort for women. Perceived behavioral control had both direct and indirect (through desire and intentions) effects on effort for men but no effects for women. Intentions influenced effort for men but not women. In contrast, perceived subjective norms had direct effects on effort for women but not for men. Effort was found also to be a function of past efforts at trying to regulate hypertension for both men and women. The study results confirm the existence of differences in the manner in which men and women perceive health maintenance. Additionally, the theory of self-regulation was found to serve as a useful framework in understanding the role of goal-setting and goal-striving in the management of chronic conditions.

Integrating medication therapy management in the primary care medical home: A review of randomized controlled trials.

PURPOSE Randomized controlled trials (RCTs) that evaluated the effect of medication therapy management (MTM) on patient outcomes in the primary care medical home were reviewed to determine how these services may be integrated into the primary care medical home. METHODS A literature search was conducted to identify RCTS published between 1989 and 2009 that evaluated the impact of MTM services on patient outcomes. To qualify as MTM services, the interventions had to include both a review of medication therapy and patient interactions, including educating patients about drug therapy, identifying potential barriers to medication adherence, and helping patients manage their diseases. The internal validity of the studies was evaluated using previously published criteria. The description, specification, and appropriateness of study objectives, study population, intervention, randomization, blinding, outcome measures, statistical analysis, and conclusions were evaluated. RESULTS A total of 1795 publications were identified, but only 8 met the inclusion criteria. These studies targeted patients with specific medical conditions or patients with multiple medications without specifying a medical condition. The interventions varied in intensity (i.e., frequency and length of patient contact), ranging from a single patient contact in a community pharmacy setting to multiple visits with an ambulatory care pharmacist practicing in a collaborative care model. Two of the 8 studies obtained expected results. These studies targeted patients with unrealized therapeutic goals, and the interventions involved collaboration between pharmacists and physicians and extensive patient follow-up. CONCLUSION Of 1795 publications identified, 8 were RCTs meeting selection criteria for evaluation of the effect of MTM services on patient outcomes. Two service elements that benefit patient care were identified: (1) selecting patients with specific therapeutic problems and (2) implementing MTM services that involve timely communication with primary care providers to discuss therapeutic problems, along with routine patient follow-up to support medication adherence to changes in therapy.

The Medication Assessment Program: Comprehensive medication assessments for persons taking multiple medications for chronic diseases

OBJECTIVE To describe the development, implementation, and evaluation of a pharmacist patient care program for persons taking multiple medications for chronic diseases. DESIGN Pilot study. SETTING Services were provided in Michigan within community pharmacies and through home and work-site visits, between October 2004 and September 2006. PARTICIPANTS 30 pharmacists and 67 patients 18 years of age or older who took four or more medications on a routine basis (three or more times per week). INTERVENTIONS The comprehensive medication assessments identified medication- and health-related problems. Pharmacists provided patient education supported by written educational materials and written recommendations for improving drug therapy and overall patient health. MAIN OUTCOME MEASURES Patient knowledge regarding medications, diagnoses, and healthy lifestyle practices; types of recommendations made; recommendation acceptance rates; pharmacist assessment of program effects. RESULTS The program was developed and implemented through a collaborative approach that included pharmacists, colleges of pharmacy, and employers. Pharmacists were supported by various administrative and clinical services offered by the colleges. Three employers adopted the program as a service for their employees, retirees, and dependents. A total of 67 patients received comprehensive medication assessments. Patients tended to be women, tended to be older, and took an average of 12.6 medications. Pharmacists provided 662 recommendations related to drug therapy, healthy lifestyle practices, and the need for medical evaluation. Recommendation acceptance rates, changes in patient knowledge, and pharmacist evaluation of program effects indicated that the program had a positive effect on patient health. CONCLUSION A collaborative approach to developing and implementing comprehensive medication assessments was found to be beneficial in improving patient understanding of medications, diagnoses, and healthy lifestyle choices. Written pharmacist recommendations resulted in actions that improved self-monitoring skills and drug therapy appropriateness. College of pharmacy administrative and clinical service support was instrumental in network participation and the provision of care.