William R. Doucette

Physician and pharmacist collaboration to improve blood pressure control.

BACKGROUND Studies have demonstrated that blood pressure (BP) control can be improved when clinical pharmacists assist with patient management. The objective of this study was to evaluate if a physician and pharmacist collaborative model in community-based medical offices could improve BP control. METHODS This was a prospective, cluster randomized, controlled clinical trial with clinics randomized to a control group (n = 3) or to an intervention group (n = 3). The study enrolled 402 patients (mean age, 58.3 years) with uncontrolled hypertension. Clinical pharmacists made drug therapy recommendations to physicians based on national guidelines. Research nurses performed BP measurements and 24-hour BP monitoring. RESULTS The mean (SD) guideline adherence scores increased from 49.4 (19.3) at baseline to 53.4 (18.1) at 6 months (8.1% increase) in the control group and from 40.4 (22.6) at baseline to 62.8 (13.5) at 6 months (55.4% increase) in the intervention group (P = .09 for adjusted between-group comparison). The mean BP decreased 6.8/4.5 mm Hg in the control group and 20.7/9.7 mm Hg in the intervention group (P < .05 for between-group systolic BP comparison). The adjusted difference in systolic BP was -12.0 (95% confidence interval [CI], -24.0 to 0.0) mm Hg, while the adjusted difference in diastolic BP was -1.8 (95% CI, -11.9 to 8.3) mm Hg. The 24-hour BP levels showed similar effect sizes. Blood pressure was controlled in 29.9% of patients in the control group and in 63.9% of patients in the intervention group (adjusted odds ratio, 3.2; 95% CI, 2.0-5.1; P < .001). CONCLUSIONS A physician and pharmacist collaborative intervention achieved significantly better mean BP and overall BP control rates compared with a control group. Additional research should be conducted to evaluate efficient strategies to implement team-based chronic disease management. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00201019.

A Cluster Randomized Trial to Evaluate Physician/Pharmacist Collaboration to Improve Blood Pressure Control

This was a prospective, cluster randomized controlled trial in patients with uncontrolled hypertension aged 21 to 85 years (mean, 61 years). Pharmacists made recommendations to physicians for patients in the intervention clinics (n=101) but not patients in the control clinics (n=78). The mean adjusted difference in systolic blood pressure (BP) between the control and intervention groups was 8.7 mm Hg (95% confidence interval [CI], 4.4–12.9), while the difference in diastolic BP was 5.4 mm Hg (CI, 2.8–8.0) at 9 months. The 24‐hour BP levels showed similar effects, with a mean systolic BP level that was 8.8 mm Hg lower (CI, 5.0–12.6) and a mean diastolic BP level that was 4.6 mm Hg (CI, 2.4–6.8) lower in the intervention group. BP was controlled in 89.1% of patients in the intervention group and 52.9% in the control group (adjusted odds ratio, 8.9; CI, 3.8–20.7; P<.001). Physician/pharmacist collaboration achieved significantly better mean BP values and overall BP control rates, primarily by intensification of medication therapy and improving patient adherence.

Comprehensive Medication Therapy Management: Identifying and Resolving Drug-Related Issues in a Community Pharmacy

OBJECTIVE The aim of this study was to characterize comprehensive medication therapy management (MTM) involving a community pharmacy and local physicians by describing the drug-related issues encountered, identifying which medication types were associated with these issues, and listing the actions taken by physicians and pharmacists to address them. METHODS In the MTM program studied, community pharmacists and physicians worked together to manage the drug therapy of ambulatory Iowa Medicaid recipients dispensed > or =4 medications for chronic conditions by a community pharmacy. After initial assessment, pharmacists made written recommendations to the patients physician, and the physicians subsequently responded. Data were extracted from pharmacy records for patients who made > or =1 visit during the first 2 years of the program. Collected data included patient demographics, number of chronic conditions and medications at enrollment, type and number of drug-related issues, medication category, pharmacist recommendations, and physician acceptance of recommendations. RESULTS Data were gathered for 150 patients. The mean (SD) age was 54.4 (19.4) years and 74.0% were female. They were taking a mean (SD) of 9.3 (4.6) medications and had a mean (SD) of 6.1 (3.1) medical conditions at enrollment. A total of 886 drug-related issues were classified into 7 categories: inappropriate adherence (25.9%), needs additional therapy (22.0%), wrong drug (13.2%), unnecessary drug therapy (12.9%), adverse drug reaction (11.1%), dose too low (9.7%), and dose too high (5.3%). Overall, physicians accepted 313 (47.4%) of the 659 recommendations to alter drug therapy made by pharmacists, with the highest rates of agreement to stop or change a medication (50.3% and 50.0%, respectively) and the lowest rate of agreement to start a new medication (41.7%). CONCLUSION The MTM program showed that drug therapy for ambulatory patients taking multiple medications to treat chronic conditions can be improved through collaboration between physicians and community pharmacists.

Influential Characteristics of Physician/Pharmacist Collaborative Relationships

BACKGROUND A theoretical model of physician/pharmacist collaborative relationships, driven by 3 groups of relationship characteristics termed participant, context, and exchange, has been developed. There are no studies that have examined the types of characteristics which most influence development of collaborative relationships between physicians and pharmacists. OBJECTIVE To test the model and determine which drivers most influence physician/pharmacist collaboration. METHODS Data on the relationship drivers and collaborative practice were collected via a mailed survey of a random sample of 1000 primary care physicians in Iowa. Participant variables include demographics; context drivers refer to the practice environment and professional interactions between physicians and pharmacists. Exchange characteristics describe the nature of social exchange and were elicited using scores from 3 domains (relationship initiation, trustworthiness, role specification) of the Physician/Pharmacist Collaboration Instrument (PPCI). Five additional questions asked about the physicians collaborative practice with a pharmacist. Hierarchical linear regression analysis was performed with collaborative practice as the dependent variable and measures of participant, context, and exchange drivers as independent variables. RESULTS Three hundred forty usable surveys (34%) were returned. Almost 70% of the respondents were male and aged 45.8 ± 9.9 years (mean ± SD). The majority were family practice physicians (72.1%) in private practice (67.3%). Regression analyses produced an R2 = 0.804 (p < 0.001). Significant predictors in the model were internal medicine physicians, professional interaction with a pharmacist, and the 3 domains of exchange drivers from the PPCI (p < 0.05). CONCLUSIONS Although participant and context factors influenced physician/pharmacist collaborative relationships, exchange characteristics were the most influential relationship drivers. Role specification, trustworthiness, and relationship initiation were positively associated with physician/pharmacist collaborative practice. Recognition of these drivers may help pharmacists who are developing collaborative working relationships with physicians. But, studies are needed to delineate other factors that may influence physician/pharmacist relationships.

Assessment of Patients' Perceptions and Beliefs Regarding Herbal Therapies

We evaluated the demographics and beliefs regarding safety and efficacy of herbal therapy among individuals in Iowa and assessed the willingness to discuss the use of these products with health care providers. We distributed 1300 surveys to two random samples: patients attending eight clinics, and residents of the state (mailing). Data were categorized according to herb use and compared between users and nonusers. The response rate was 61% (794 people), with 41.6% of respondents reporting herb use. They were predominately white women and were likely to have had education beyond high school (p<0.05). Their use of prescription drugs was high (p<0.05). Although users rated safety and efficacy of herbs higher than nonusers (p<0.05), both groups believed that health care providers should be aware of use and would provide this information.

The role of primary care physicians in cancer care.

ABSTRACTBACKGROUNDThe demand for oncology services in the United States (US) is increasing, whereas a shortage of oncologists looms. There is the need for a better understanding of the involvement of primary care physicians (PCPs) in cancer care.OBJECTIVETo characterize the role of PCPs in cancer care, compare it with that of oncologists, and identify factors explaining greater PCP involvement in cancer care.DESIGNNational survey of physicians caring for cancer patients conducted by the Cancer Care Outcomes Research and Surveillance Consortium.PARTICIPANTS1694 PCPs; 1621 oncologists.MEASUREMENTSQuestionnaires mailed during 2005 and 2006 examined the participation of physicians in 12 aspects of care for cancer patients.MAIN RESULTSOver 90% of PCPs fulfilled general medical care roles for patients with cancer such as managing comorbid conditions, chronic pain, or depression; establishing do-not-resuscitate status; and referring patients to hospice. Oncologists were less involved in these roles. Determining the treatment preferences of individual patients and deciding on the use of surgery were the only cancer care roles in which ≥50% of PCPs participated. Twenty-two percent of PCPs reported no direct involvement in cancer care roles while 19% reported heavy involvement. PCPs who were aged ≥50 years, were internists or geriatricians, taught medical students, saw more cancer patients, or experienced referral barriers fulfilled more roles. Rural practice location was not associated with greater PCP involvement in cancer care.CONCLUSIONSPCPs across the US have an active role in cancer patient management. Determining the optimal interface between PCPs and oncologists in delivering and coordinating cancer care is an important area for future research.

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.

Collaborative Working Relationships Between Pharmacists and Physicians: An Exploratory Study

OBJECTIVES To determine the degree of collaboration in a limited number of pharmacist-physician professional relationships and identify variables important in establishing collaboration between pharmacists and physicians. DESIGN A multicase design, using a personal interview and a mailed survey. SETTING Iowa. PARTICIPANTS Pharmacists in 10 community pharmacies and physicians with whom they collaborated. INTERVENTION Two researchers independently judged the stage of collaboration for each case and the level of effect each influence variable had on the development of pharmacist-physician collaboration. MAIN OUTCOME MEASURES Using the Collaborative Working Relationship Model, nine indicators of collaboration were assessed. In addition, influence variables were studied, which included individual, context, and exchange characteristics believed to affect the development of collaborative working relationships between pharmacists and physicians. RESULTS A Perrealt-Leigh reliability index of 0.89 was calculated as an estimate of interrater reliability of the judgments of nine indicators of collaboration. Four pharmacies were rated as having achieved early-stage collaboration, while six pharmacies were at late-stage collaboration. A high level of joint care activities, care communication, and increased accessibility to the physician and to patient information characterized late-stage collaboration. Six variables, labeled as discriminating, helped distinguish between early-stage collaboration and late-stage collaboration: the development of bidirectional communication, caring for mutual patients, the ability to identify a win-win opportunity, adding value to the medical practice, physician convenience, and movement toward balanced dependence between the pharmacist and physician. CONCLUSION The development of collaboration between pharmacists and physicians is influenced by characteristics of exchanges occurring between them. Continued study of collaborative working relationships between physicians and pharmacists can assist health care practitioners in developing a team-based approach to patient care, improving the ability of pharmacists and physicians to work together to coordinate patient care.

Influences on member commitment to group purchasing organizations

Abstract Group purchasing organization (GPOs) have become an important part of some sectors of our economy, such as health care. To be successful at obtaining favorable purchase terms, a GPO must be able to foster and maintain the commitment of its members. Four positive influences on member commitment are hypothesized: (1) satisfaction with the GPO; (2) the perceived commitment of other GPO members; (3) the degree of information exchange between member and GPO; and (4) trust in the GPO. The suitability of alternatives to membership in the GPO was predicted to negatively influence member commitment. These hypotheses were tested with data from a mail survey returned by 249 (49.8%) retail pharmacies. A multiple regression analysis identified significant positive associations between member commitment and commitment of other members, information exchange, and trust. Also, the suitability of alternatives showed a significant negative relationship with commitment. Implications of the findings for managers and researcher are discussed.