Tommy Westerlund

Provision of pharmaceutical care by community pharmacists: a comparison across Europe

Objective To investigate the provision of pharmaceutical care by community pharmacists across Europe and to examine the various factors that could affect its implementation. Methods A questionnaire-based survey of community pharmacies was conducted within 13 European countries. The questionnaire consisted of two sections. The first section focussed on demographic data and services provided in the pharmacy. The second section was a slightly adapted version of the Behavioral Pharmaceutical Care Scale (BPCS) which consists of three main dimensions (direct patient care activities, referral and consultation activities and instrumental activities). Results Response rates ranged from 10–71% between countries. The mean total score achieved by community pharmacists, expressed as a percentage of the total score achievable, ranged from 31.6 (Denmark) to 52.2% (Ireland). Even though different aspects of pharmaceutical care were implemented to different extents across Europe, it was noted that the lowest scores were consistently achieved in the direct patient care dimension (particularly those related to documentation, patient assessment and implementation of therapeutic objectives and monitoring plans) followed by performance evaluation and evaluation of patient satisfaction. Pharmacists who dispensed higher daily numbers of prescriptions in Ireland, Germany and Switzerland had significantly higher total BPCS scores. In addition, pharmacists in England and Ireland who were supported in their place of work by other pharmacists scored significantly higher on referral and consultation and had a higher overall provision of pharmaceutical care. Conclusion The present findings suggest that the provision of pharmaceutical care in community pharmacy is still limited within Europe. Pharmacists were routinely engaged in general activities such as patient record screening but were infrequently involved in patient centred professional activities such as the implementation of therapeutic objectives and monitoring plans, or in self-evaluation of performance.

Drug related problems after discharge from an Australian teaching hospital.

Objective To reconcile patients’ medicines and to classify drug related problems identified during medication review conducted after discharge from hospital. Setting Patients were discharged from the cardiology unit of Westmead Hospital after recruitment into the Westmead Medicines Project which ran from 2004 to 2007. Method This retrospective study involved an analysis of drugs, diseases and drug related problems in medication review reports available for 76 out of 85 patients who received a Home Medicines Review (HMR). Data sources for medication reconciliation and analyses also included hospital discharge summaries (n = 70) and GP referrals for HMR (n = 44). Comprehensive clinical profiles were constructed for the 76 subjects whose drug related problems were identified, coded, and then classified from their HMR reports. Main outcome measures Number, type, distribution and international classification of drugs, diseases and drug-related problems. Results Patients were prescribed drugs for a broad range of cardiovascular, circulatory, endocrine, respiratory and digestive system diseases. Mean number of drugs per patient in discharge summaries: 8.7 ± SD 3.3 (range 3–19); in GP referrals: 8.9 ± SD 4.3 (range 2–23); and in HMR reports: 10.8 ± SD 4.0 (range 3–24). Mean number of diseases per patient in discharge summaries: 4.1 ± SD 2.9 (range 1–11); and in HMR reports: 4.7 ± SD 2.6 (range 1–12). A total of 398 drug related problems were identified for 71 (93.3%) patients with mean 5.6 ± SD 4.3 problems (range 1–21). The most frequently recorded problems were the patients’ uncertainty about drug aim: n = 128 (32.0%); potential interactions n = 89 (22.4%); and adverse reactions n = 60 (15.1%). Conclusion This study showed that patients recently discharged from a tertiary care hospital had a significant number of drug related problems. Classification of drugs and diseases revealed a broad range of non-cardiovascular medicines and conditions in the patients from an acute care cardiology unit. We found that home medicines review provided continuity of care and an opportunity for medication reconciliation which revealed marked differences in number of drugs, between hospital discharge and medicines review. The patients’ uncertainly about their drugs and their diverse range of co-morbidities indicated the need for timely counselling by pharmacists in the community.

Medicine-taking behaviour and drug-related problems in adolescents of a Swedish high school

Objectives To examine (1) which over-the-counter (OTC) and prescription drugs adolescents most frequently use and for which ailments or diseases, and (2) which DRPs adolescents have experienced, as well as if and by whom these problems were resolved. Setting A high school in Helsingborg, Sweden. Methods A self-completion questionnaire was designed and used in students with a median age of 17 in late 2005 and early 2006. To enable students to identify DRPs they may have experienced, the questionnaire contained a list of DRPs in lay language. The questionnaires were distributed by the teachers to be completed by the students in the classroom. Main outcome measures: Self-reported prevalence of OTC and prescription drug use and experienced drug-related problems. Results A total of 245 students (99%) took part, 138 females and 107 males. OTCs had been used occasionally by 37.7% of the girls and 62.6% of the boys, while 10.9% and 6.5% respectively were daily users. Analgesics were the most frequently used OTCs. DRPs had been experienced by 31.1% of the female and 19.6% of the male students, the most common of which was therapy failure (too little or no effect), accounting for 46.5% of the girls’ and 38.1% of the boys’ OTC DRPs. Eighty-five percent of the problems with OTCs had been resolved, half of them by the teenagers themselves. Prescription drugs had been used occasionally by 31.9% of the female and 29.0% of the male students, while 28.3% and 26.2% respectively reported using such drugs on a daily basis. Antibiotics were the most frequently taken prescription drugs. DRPs related to prescribed drugs were reported by 32.6% of the girls and 10.3% of the boys. The most common DRPs were side effects, accounting for 34.8% of the girls’ problems, and therapy failure, experienced by 28.6% of the boys. All the boys’ DRPs were reported to be resolved, but only 75% of those of the girls. Physicians were stated to have resolved the problems in 41.4% of the cases. Conclusions There is a need to develop the interface between pharmacy practitioners and adolescents, as the study has demonstrated frequent use of OTCs and prescription drugs as well as a high prevalence of DRPs in adolescents. The reasons for therapy failure, which was the most common problem, should be further explored and measures taken by pharmacists and physicians to minimise it.

Swedish general practitioners’ attitudes towards treatment guidelines – a qualitative study

BackgroundDrug therapy in primary care is a challenge for general practitioners (GPs) and the prescribing decision is influenced by several factors. GPs obtain drug information in different ways, from evidence-based sources, their own or others’ experiences, or interactions with opinion makers, patients or colleagues. The need for objective drug information sources instead of drug industry-provided information has led to the establishment of local drug and therapeutic committees. They annually produce and implement local treatment guidelines in order to promote rational drug use. This study describes Swedish GPs’ attitudes towards locally developed evidence-based treatment guidelines.MethodsThree focus group interviews were performed with a total of 17 GPs working at both public and private primary health care centres in Skåne in southern Sweden. Transcripts were analysed by conventional content analysis. Codes, categories and themes were derived from data during the analysis.ResultsWe found two main themes: GP-related influencing factors and External influencing factors. The first theme emerged when we put together four main categories: Expectations and perceptions about existing local guidelines, Knowledge about evidence-based prescribing, Trust in development of guidelines, and Beliefs about adherence to guidelines. The second theme included the categories Patient-related aspects, Drug industry-related aspects, and Health economic aspects. The time-saving aspect, trust in evidence-based market-neutral guidelines and patient safety were described as key motivating factors for adherence. Patient safety was reported to be more important than adherence to guidelines or maintaining a good patient-doctor relationship. Cost containment was perceived both as a motivating factor and a barrier for adherence to guidelines. GPs expressed concerns about difficulties with adherence to guidelines when managing patients with drugs from other prescribers. GPs experienced a lack of time to self-inform and difficulties managing direct-to-consumer drug industry information.ConclusionsPatient safety, trust in development of evidence-based recommendations, the patient-doctor encounter and cost containment were found to be key factors in GPs’ prescribing. Future studies should explore the need for transparency in forming and implementing guidelines, which might potentially increase adherence to evidence-based treatment guidelines in primary care.

Medical care and drug-related problems: Do doctors and pharmacists speak the same language?

Optimal communication between physicians and pharmacists is important for patient care. However, pharmacists and doctors do not always seem to understand each other. They have been professionalized differently, and do not always speak the same language. Especially in the areas of prescribing, medication review, and medicine use, there can be differences in views. This contribution clarifies some essential concepts that doctors and pharmacists use. Thus we hope that our commentary contributes to a better understanding of each others role and the importance of interprofessional cooperation for the benefit of the patient.

Theory-based interventions to reduce prescription of antibiotics-a randomized controlled trial in Sweden

BACKGROUND Upper respiratory tract infections (URTIs) are the most common reason for consulting a GP and for receiving an antibiotic prescription, although evidence shows poor benefit but rather increasing antibiotic resistance. Interventions addressing physicians have to take into consideration the complexity of prescribing behaviour. OBJECTIVE To study whether interventions based on behavioural theories can reduce the prescribing of antibiotics against URTIs in primary care. Setting and subjects. GPs at 19 public primary health care centres in southern Sweden. METHODS We performed a randomized controlled study using two behavioural theory-based interventions, the persuasive communication intervention (PCI) and the graded task intervention (GTI), which emerged from social cognitive theory and operant learning theory. GPs were randomized to a control group or one of two intervention groups (PCI and GTI). MAIN OUTCOME MEASURES Changes in the rate of prescription of antibiotics against URTIs in primary care patients of all ages and in patients aged 0-6 years. RESULTS No significant differences were seen in the prescription rates before and after the interventions when patients of all ages were analysed together. However, for patients aged 0-6 years, there was a significant lower prescription rate in the PCI group (P = 0.037), but not the GTI group, after intervention. CONCLUSION Theory-based interventions have limited impact on reducing the prescription of antibiotics against URTIs in primary care. Future studies are needed to draw firm conclusions about their effects.

GPs’ views on patient drug use and the pharmacist’s role in DRP management

Objective The aim of this study was to examine general practitioners’ (GPs’) views on (1) patients’ drug-related problems (DRPs) and noncompliance and (2) the role of pharmacy practitioners in DRP management. Method A brief questionnaire was designed and distributed to 224 GPs in Sweden. Results Totally 152 GPs responded (68%). Most felt that pharmacy practitioners could improve patients’ drug use by identifying DRPs. A majority of the GPs also found presentations and analyses of their local pharmacies’ DRP documentation valuable. According to the GPs’ experiences, adverse drug effects and therapy failure were the most salient problems in patients’ drug use. Half of the doctors believed that 50–75% of their patients were compliant with their prescribed drug treatments. A majority of the GPs found a 75–95% degree of compliance acceptable. Conclusion The surveyed GPs demonstrated very positive attitudes towards the role of pharmacy practitioners in improving patients’ drug use and managing DRPs. The GPs realised that many patients were not compliant with their prescribed drug treatments and accepted an imperfect compliance.

Consumer views on safety of over-the-counter drugs, preferred retailers and information sources in Sweden: after re-regulation of the pharmacy market

Background: The availability of over-the-counter drugs (OTCs) has increased in Sweden since a re-regulation of the pharmacy market in 2009, through which non-pharmacy retailers became permitted to provide certain OTCs. Objective: To examine the adult general public’s views on safety, purchasing and information channels, storage and disposal of OTCs in Sweden, three years after the re-regulation of the pharmacy market. Methods: A questionnaire study in 2012-13 in a stratified, random sample of all inhabitants in Sweden ≥ 18 years old. Results: Totally 8,302 people (42%) answered the questionnaire. Seven percent found OTCs completely harmless regardless of how they are being used, 18% felt they should be used only on health professionals’ recommendation. Differences in how OTCs are perceived were however found with regards to respondents’ country of birth, family type, educational level and income. The pharmacy was still the preferred OTC drug retailer by 83% of the respondents and preferred information source by 80% Reasons for preferred retailers were primarily due to out of habit (45%), counseling provided (35%), the product range (34%) and the confidence in staff (27%). Analgesics are the most common OTCs to have at home (90%). The bathroom cabinet is the primary site for storage (42%) and 16% throw their OTC leftovers in the trash. Conclusions: The study population does not consider OTCs as harmless regardless of how they are used, but on the other hand feels they should not be taken on health professionals’ recommendation only. The pharmacy is still the preferred retailer and information source, and there is room for further improvement in the storage and disposal of OTCs. A return of OTC drug leftovers to the pharmacy should be further encouraged. Due to several limitations, great caution should however be observed when generalizing the results to the adult population of Sweden.