Clinical management protocols for community pharmacist-led management of urinary tract infections: a review of the grey literature and quality appraisal.

BACKGROUND: Pharmacist-led management of urinary tract infections has been introduced as a service in the United Kingdom, Canada, United States of America, New Zealand, and Australia. The management of acute uncomplicated urinary tract infections by community pharmacists has gained increasing attention as a potential avenue to alleviate the burden on primary healthcare services. AIM: The objectives of the review were to: (1) identify protocols for community pharmacist management of acute uncomplicated urinary tract infections in women aged 16-65 years; (2) outline their key components; and (3) appraise the quality of protocols. METHOD: A grey literature search was undertaken for protocols intended for use by community pharmacists for the management of acute uncomplicated urinary tract infections in women aged 16-65 years, met the definition of a clinical management protocol and written in English. Their quality was appraised using the Appraisal Guidelines for Research and Evaluation version II instrument. RESULTS: Forty of the 274 records screened were included. Content analysis identified ten key components: common signs/symptoms, differential diagnosis, red flags/referral, choice of empirical antibiotic therapy, nonprescription medications, nonpharmacological/self-care advice, patient eligibility criteria, patient follow-up, dipstick testing recommendations, and recommendations on antimicrobial resistance. The lowest scoring domains in the quality assessment were 'Editorial Independence' and 'Rigour of Development'. Only four protocols were deemed high-quality. CONCLUSION: The review demonstrates that clinical management protocols for pharmacist-led management of urinary tract infections consist of similar recommendations, despite variation in international practice. However, the findings highlight a deficiency in the quality of most clinical management protocols governing pharmacist-led urinary tract infection management.

Aboriginal and Torres Strait Islander peoples.

BackgroundIn Australia, medications can be prescribed by medical practitioners, dentists, nurses, and dispensed by pharmacists. Until recently, pharmacists have been limited to prescribing Schedule 2 and 3 medications, and optometrists, podiatrists, and nurse practitioners can prescribe medications under their scope of practice in some areas of Australia. Recently, the New South Wales (NSW) Government initiated a trial where approved pharmacists in NSW and Australian Capital Territory have an expanded scope of practice to prescribe further medications for urinary tract infections, dermatology conditions (mild to moderate atopic dermatitis, herpes zoster (shingles), impetigo, and mild plaque psoriasis), and resupply of contraceptives. This protocol is for a sub-study of the larger research trial and will explore the perspectives of Aboriginal and Torres Strait Islander peoples and communities including clinicians, healthcare services, and community members about the expanded scope of pharmacists' practice.Methods and analysisYarning circles (group) and individual yarns (semi-structured interviews) will be conducted with leaders, clinicians working with Aboriginal and Torres Strait Islander peoples (general practitioners, nurses, Aboriginal health workers, community pharmacists), Aboriginal Elders, and community members to understand perspectives of the risks, benefits, opportunities, and issues associated with pharmacists prescribing for these specific conditions. Ethics approval was obtained through the Aboriginal Health and Medical Research Council of NSW.ConclusionThe findings of this sub-study will clarify Aboriginal and Torres Strait Islander peoples' unique perspectives, including perception of risks and opportunities.

Mapping the concept of health care integration: A lexicographic analysis of scientific literature.

BACKGROUND: Systems fragmentation is a major challenge for an efficient organization, integration being a potential solution also proposed in health care field, including pharmacy as a player. However, the use of different terms and definitions in the literature hinders the comparison of different integration initiatives. OBJECTIVE: To identify and map the terms used in scientific literature regarding integration in health care and to characterize each emerging topic. METHODS: A lexicographic analysis of the integration of healthcare systems literature indexed in PubMed was conducted. Ten different systematic searches, four using only Medical Subject Headings (MeSH) and six using text words, were conducted in March 2023. Journal scattering was analyzed following Bradford's distribution using the Leimkuhler model. An overall text corpus was created with titles and abstracts of all the records retrieved. The corpus was lemmatized, and the most used bigrams were tokenized as single strings. To perform a topic modeling, the lemmatized corpus text was analyzed using IRaMuTeQ, producing descending hierarchic classification and a correspondence analysis. The 50 words with higher chi-square statistics in each class were considered as representative of the class. RESULTS: A total of 42,479 articles published from 1943 to 2023 in 4469 different journals were retrieved. The MeSH "Delivery of Health Care, Integrated", created in the 1996 MeSH update, was the most productive retrieving 33.7 % of the total articles but also retrieving 22.6 % of articles not retrieved in any other search. The text word "Integration" appeared in 15,357 (36.2 %) records. The lexicographic analysis resulted in 7 classes, named as: Evidence and implementation, Quantitative research, Professional education, Qualitative research, Governance and leadership, Clinical research, and Financial resources. Association between the classes and the searches or the text-words used ranged from moderate to weak demonstrating the lack of a standard pattern of use of terms in literature regarding healthcare integration. CONCLUSIONS: The term "integration" and the MeSH "Delivery of Health Care, Integrated" are the most used to represent the concept of integration in healthcare and should be the preferred terms in the literature.

The landscape of self-care in Australia: A pharmacy perspective.

The evolving landscape of self-care in Australia underscores the imperative of recognizing and integrating the crucial role of pharmacists in promoting greater levels of self-care. Although the social and economic justifications for self-care are acknowledged internationally and in the literature, there is very little policy recognition in relation to self-care specifically in Australian health policy. Additionally, the distinct contributions of pharmacies to self-care, i.e., their experiences and accessibility in primary health care, are not consistently highlighted. Community pharmacies in Australia are currently navigating a transformative shift, expanding their scope of practice to deliver highly individualized care, with a special emphasis on the implementation of professional services crucial for the sector's enduring viability. Although pharmacists already play a substantial role in supporting self-care, there exists a compelling demand for a systematic and structured approach. Despite the limited availability of theoretical frameworks or models for pharmacists in self-care support within the existing literature, tangible practical evidence attests to the success of interventions. In an era where patients increasingly assume responsibility for self-managing conditions, the pharmacist's role in facilitating self-care and judicious self-medication is pivotal, promising not only tangible benefits for individuals but also contributing significantly to the long-term sustainability of the healthcare system in Australia. This necessitates a strategic and comprehensive framework that positions pharmacists as essential catalysts in the broader landscape of healthcare, ensuring their contributions are optimally leveraged to enhance patient outcomes and system efficiency.

The clinical and economic evidence of the management of urinary tract infections by community pharmacists in women aged 16 to 65 years: a systematic review.

BACKGROUND: Many countries are experiencing an increased demand for health care and a shortage of health professionals in rural areas, impacting an individual's ability to receive timely treatment. The management of uncomplicated urinary tract infections by community pharmacists is usual practice in some regions of the United Kingdom and Canada, and Queensland, Australia. AIM: To systematically gather, assess, and synthesize the available peer-reviewed published literature on the management of uncomplicated UTIs by community pharmacists in women aged 16-65 years, provide an understanding of the clinical and economic evidence, while also identifying the essential components of interventions employed. METHOD: A systematic review was conducted to identify primary studies detailing interventions for the management of uncomplicated UTIs by community pharmacists. PubMed, PsycINFO, Scopus, Cochrane, CINAHL, EMBASE, and Web of Science were searched to February 2023. Non-primary and qualitative studies were excluded. Study details were recorded in a tailored data extraction form. The quality of studies was assessed using the Joanna Briggs Institute tools. RESULTS: Ten publications were included following review of 2129 records. High self-reported cure rates between 84 and 89% and referral rates of about 7% were reported. A single study found pharmacist management was cost effective compared to general practitioner management. No randomized controlled trials were found and papers were of variable quality. CONCLUSION: Preliminary evidence suggests pharmacist-led management of uncomplicated UTIs is safe and effective, however no firm conclusion can be provided since the methodologies reported in included studies have significant limitations.

Identification of high-risk patients for referral through machine learning assisting the decision making to manage minor ailments in community pharmacies.

Background: Data analysis techniques such as machine learning have been used for assisting in triage and the diagnosis of health problems. Nevertheless, it has not been used yet to assist community pharmacists with services such as the Minor Ailment Services These services have been implemented to reduce the burden of primary care consultations in general medical practitioners (GPs) and to allow a better utilization of community pharmacists' skills. However, there is a need to refer high-risk patients to GPs. Aim: To develop a predictive model for high-risk patients that need referral assisting community pharmacists' triage through a minor ailment service. Method: An ongoing pragmatic type 3 effectiveness-implementation hybrid study was undertaken at a national level in Spanish community pharmacies since October 2020. Pharmacists recruited patients presenting with minor ailments and followed them 10 days after the consultation. The main outcome measured was appropriate medical referral (in accordance with previously co-designed protocols). Nine machine learning models were tested (three statistical, three black box and three tree models) to assist pharmacists in the detection of high-risk individuals in need of referral. Results: Over 14'000 patients were included in the study. Most patients were female (68.1%). With no previous treatment for the specific minor ailment (68.0%) presented. A percentage of patients had referral criteria (13.8%) however, not all of these patients were referred by the pharmacist to the GP (8.5%). The pharmacists were using their clinical expertise not to refer these patients. The primary prediction model was the radial support vector machine (RSVM) with an accuracy of 0.934 (CI95 = [0.926,0.942]), Cohen's kappa of 0.630, recall equal to 0.975 and an area under the curve of 0.897. Twenty variables (out of 61 evaluated) were included in the model. radial support vector machine could predict 95.2% of the true negatives and 74.8% of the true positives. When evaluating the performance for the 25 patient's profiles most frequent in the study, the model was considered appropriate for 56% of them. Conclusion: A RSVM model was obtained to assist in the differentiation of patients that can be managed in community pharmacy from those who are at risk and should be evaluated by GPs. This tool potentially increases patients' safety by increasing pharmacists' ability to differentiate minor ailments from other medical conditions.

Spanish translation of the ABC taxonomy for medication adherence.

BACKGROUND: The Ascertaining Barriers to Compliance (ABC) taxonomy was developed aiming at systematizing definitions and operationalizations of medication adherence. Its translation is crucial to improve the generalizability, application and comparison of study findings. OBJECTIVE: To provide a consensus translation of the ABC taxonomy from English to Spanish. METHODS: A two-phased approach was used, according to the Preferred Methods for the Translation of the ABC Taxonomy for Medication Adherence. Two literature reviews were conducted: to identify Spanish synonyms and definitions of the ABC taxonomy, and to identify a panel of Spanish-speaking experts in medication adherence. A Delphi survey was designed based on the synonyms and definitions found. The experts previously identified were invited to participate in the Delphi. A consensus of ≥85% was established for the first round. A moderate consensus (50-75%), a consensus (75-95%) or a strong consensus (>95%) were considered to be necessary in the second round. RESULTS: Forty potential synonyms of the ABC taxonomy terms were identified from a total of 270 papers. The response rate during the first Delphi round was 32% (63/197) and in the second round 86% (54/63). A strong consensus was reached for the term "inicio del tratamiento" (96%) and consensus for the term "implementación" (83%). A moderate consensus was obtained for "adherencia a la medicación" (70%), "interrupción del tratamiento" (52%), "manejo de la adherencia" (54%) and "disciplinas relacionadas con la adherencia" (74%). No consensus was reached for the term persistence. Five out of the seven definitions reached a consensus in the first round, and two definitions a moderate consensus after the second round. CONCLUSION: The adoption of the Spanish taxonomy will increase transparency, comparability and transferability of results in the field of medication adherence. This may facilitate benchmarking of adherence strategies between Spanish-speaking researchers and practitioners, and other language speakers.

BC Clinical impact of medication reviews with follow-up in cardiovascular older patients in primary care: A cluster-randomized controlled trial.

AIMS: Cardiovascular diseases (CVD) are the primary cause of death in Chile. Pharmacist-led medication review with follow-up (MRF) has improved CVD risk factors control in Europe and North America. However, their healthcare systems differ from Chile's, precluding generalizability. This trial aimed to determine the effect of MRF on CVD risk factor control among older patients with polypharmacy attending public primary care centres in Chile. METHODS: A cluster-randomized controlled trial was conducted in 24 centres. Patients older than 65 years with moderate-to-high CVD risk, five or more medications, hypertension, type 2 diabetes or dyslipidaemia, received MRF in addition to usual care or usual care alone for 12 months. Primary outcome measures were clinical goal achievement for hypertension, type 2 diabetes and dyslipidaemia, as well as medication adherence, medication number and CVD risk score. Adjusted generalized estimating equations were used, with odds ratios (ORs) for binary measures and mean differences for continuous measures. RESULTS: In total, 324 patients from 12 centres (174 MRF group, 150 usual care group, six centres each) received four pharmacist visits. Significant improvements were found for goal achievement in hypertension (OR 4.37, 95% confidence interval [CI] 2.54 to 7.51, P = .001), LDL cholesterol (OR 3.67, 95% CI 2.13 to 6.33, P = .001), type 2 diabetes (OR 6.97, 95% CI 3.69 to 13.2, P = .001), medication adherence (OR 6.60, 95% CI 1.36 to 31.9, P = .022), medications number (-0.86, 95% CI -1.14 to -0.58, P < .001) and CVD risk score (-2.27, 95% CI -2.84 to -1.69, P < .001). CONCLUSION: Pharmacist-led medication review with follow-up improved cardiovascular disease risk factor control and medication adherence. This study supports pharmacists' inclusion in primary care teams.

Community pharmacy and primary health care - Types of integration and their applicability: A narrative review.

BACKGROUND: There is an urgent need for health care systems to be more efficient and efficacious. An approach to integrate public and private provider organizations such as community pharmacies and public primary health care (PHC) merits consideration. The objective of this review was to identify the types of integration in health care settings and discuss their applicability to the potential integration of community pharmacy and PHC. METHODS: A narrative review using Medline, Scopus and SciELO databases was performed in which terms related to health were combined with terms related to integration. Levels and Types of integration: 14 types of integration were identified (two in breadth, seven as enablers and five in system levels). A model was created which classifies and assigns the types of integration to the different levels of the health system and to the breadth, intensity, and enablers of the integration process. Due to the nature of community pharmacy and PHC system, a horizontal integration at the micro level, supported by meso and macro levels policy, is suggested. The different elements of intensity and enablers can significantly influence the process. CONCLUSION: The application of principles, concepts and types of integration suggest that it might be feasible and practical to integrate community pharmacies and PHC. However, the conflictive historical context would need to be overcome with appropriate policy and incentives.

Strengthening patients' triage in community pharmacies: A cluster randomised controlled trial to evaluate the clinical impact of a minor ailment service.

BACKGROUND: Self-perceived minor ailments might conceal other health conditions if patients are not appropriately assisted by health care professionals. The aim of the study was to evaluate the patient-related outcomes of a community pharmacy Minor Ailment Service (MAS) compared to usual pharmacist care (UC). METHODS: A cluster randomised controlled trial was conducted over six months in community pharmacy in the province of Valencia (Spain). Patients seeking care or requesting a product for a minor ailments considered in the study (dermatological problems, gastrointestinal disturbance, pain and upper respiratory tract related symptoms) were included. The intervention consisted of a standardised pharmacist-patient consultation guided by a web-based program using co-developed management protocols and patients' educational material. Patients were followed up by phone ten days later. Primary clinical outcomes were appropriate medical referral and modification of direct product request. Secondary outcomes were symptom resolution and reconsultation rates. RESULTS: A total of 808 patients (323 MAS and 485 UC) were recruited in 27 pharmacies of 21 municipalities. Patients visiting MAS pharmacies had higher odds for being referred to a physician (OR = 2.343, CI95% = [1.146-4.792]) and higher reconsultation rates (OR = 1.833, CI95% = [1.151-2.919]) compared to UC. No significant differences between groups were observed for modification of direct product request and symptom resolution. CONCLUSIONS: The use of management protocols through the MAS strengthened the identification of referral criteria such as red flags in patients suffering minor ailments. These patients with symptoms of minor ailments possibly due to more severe illness were to be referred and evaluated by physicians. Results reinforce that MAS increases safety for those patients consulting in community pharmacy for minor ailments. TRIAL REGISTRATION: Trial registration number: ISRCTN17235323. Retrospectively registered 07/05/2021, https://www.isrctn.com/ISRCTN17235323.

Development and validation of a tool to measure collaborative practice between community pharmacists and physicians from the perspective of community pharmacists: the professional collaborative practice tool.

BACKGROUND: Collaborative practice between community pharmacists and physicians is becoming increasingly common. Although tools and models to explore collaborative practice between both health care professionals have been developed, very few have been validated for their use in clinical practice. The objective of this study was to develop and validate a tool for measuring collaborative practice between community pharmacists and physicians from the perspective of community pharmacists. METHODS: The DeVellis method was used to develop and validate the Professional Collaborative Practice Tool. A pool of 40 items with Likert frequency scales was generated based on previous literature and expert opinion. This study was undertaken in Spain. A sample of community pharmacists providing medication reviews with follow-up and a random sample of pharmacists providing usual care were invited to participate. Exploratory and confirmatory factor analysis was used to assess the tool's reliability and content validity. RESULTS: Three hundred thirty-six pharmacists were invited with an overall response rate of 84.8%. The initial 40 items selected were reduced to 14 items. Exploratory Factor Analysis provided a 3-factor solution explaining 62% of the variance. Confirmatory Factor Analysis confirmed the three factors "Activation for collaborative professional practice," the "Integration in collaborative professional practice," and the "Professional acceptance in collaborative professional practice." The tool demonstrated an adequate fit (X2/df = 1.657, GFI = 0.889 and RMSEA = 0.069) and good internal consistency (Cronbach's alpha = 0.924). CONCLUSIONS: The Professional Collaborative Practice Tool has shown good internal reliability and criterion validity. The tool could be used to measure the perceived level of collaborative practice between community pharmacists and physicians and monitor changes over time. Its applicability and transferability to other settings should be evaluated.

Integration of community pharmacy in primary health care: The challenge.

Community pharmacies and pharmacists predominantly operate in a retail environment independently of other health care providers, and they are not often viewed as an integral member of the healthcare team. Thus, they remain overlooked or excluded during integration processes of health care systems. At the same time, there are calls by the profession at national and international levels for community pharmacy to be integrated within primary care systems. The COVID-19 pandemic appears to have further stimulated this desire. When pressing for integration, various terms, such as integration, integrated care, or interprofessional collaboration, are used in an interchangeable manner leading to lack of clarity, ambiguity and confusion for health care policy makers, planners, and other healthcare professionals. The literature was reviewed to identify critical components for community pharmacy to consider for integration. From the five selected articles describing integration of community pharmacies, four different constructs were identified: consensus, connectivity, communication and trust. The integration of community pharmacy into the health system may translate into better access for patients to primary care services, contribute to cost effectiveness, and promulgate the sustainability of the system. However significant political, economic, social, and practice change would be required by all stakeholders. Further research is needed to underpin a consensus for a definition, the type of integration, and the model optimally suited to integrate community pharmacy into primary care. These models, specific and adaptable to each national health care system and political environment, would need to be consensus-based by principal stakeholders to overcome a variety of barriers, including government resistance. Mere calls or demands by the pharmaceutical profession, although laudable, will not be sufficient to overcome the historical, cultural, and economic challenges.

Using network analysis to explore factors moderating the implementation of a medication review service in community pharmacy.

BACKGROUND: Implementation factors are hypothesised to moderate the implementation of innovations. Although individual barriers and facilitators have been identified for the implementation of different evidence-based services in pharmacy, relationships between implementation factors are usually not considered. OBJECTIVES: To examine how a network of implementation factors and the position of each factor within this network structure influences the implementation of a medication review service in community pharmacy. METHODS: A mixed methods approach was used. Medication review with follow-up service was the innovation to be implemented over 12 months in community pharmacies. A network analysis to model relationships between implementation factors was undertaken. Two networks were created. RESULTS: Implementation factors hindering the service implementation with the highest centrality measures were time, motivation, recruitment, individual identification with the organization and personal characteristics of the pharmacists. Three hundred and sixty-nine different interrelationships between implementation factors were identified. Important causal relationships between implementation factors included: workflow-time; characteristics of the pharmacy-time; personal characteristics of the pharmacists-motivation. Implementation factors facilitating the implementation of the service with highest centrality scores were motivation, individual identification with the organization, beliefs, adaptability, recruitment, external support and leadership. Four hundred and fifty-six different interrelationships were identified. The important causal relationships included: motivation-external support; structure-characteristics of the pharmacy; demographics-location of the pharmacy. CONCLUSION: Network analysis has proven to be a useful technique to explore networks of factors moderating the implementation of a pharmacy service. Relationships were complex with most implementation factors being interrelated. Motivation and individual identification with the organisation seemed critical factors in both hindering and facilitating the service implementation. The results can inform the design of implementation programs and tailored strategies to promote faster implementation of innovations in pharmacy.

Effectiveness of a medication adherence management intervention in a community pharmacy setting: a cluster randomised controlled trial.

BACKGROUND: Non-adherence to medications continues to be a burden worldwide, with significant negative consequences. Community pharmacist interventions seem to be effective at improving medication adherence. However, more evidence is needed regarding their impact on disease-specific outcomes. The aim was to evaluate the impact of a community pharmacist-led adherence management intervention on adherence and clinical outcomes in patients with hypertension, asthma and chronic obstructive pulmonary disease (COPD). METHODS: A 6-month cluster randomised controlled trial was conducted in Spanish community pharmacies. Patients suffering from hypertension, asthma and COPD were recruited. Patients in the intervention group received a medication adherence management intervention and the control group received usual care. The intervention was based on theoretical frameworks for changing patient behaviour. Medication adherence, disease-specific outcomes (Asthma Control Questionnaire (ACQ) scores, Clinical COPD Questionnaire (CCQ) scores and blood pressure levels) and disease control were evaluated. A multilevel regression model was used to analyse the data. RESULTS: Ninety-eight pharmacies and 1186 patients were recruited, with 1038 patients completing the study. Patients receiving the intervention had an OR of 5.12 (95% CI 3.20 to 8.20, p<0.05) of being adherent after the 6 months. At the end of the study, patients in the intervention group had lower diastolic blood pressure levels (mean difference (MD) -2.88, 95% CI -5.33 to -0.43, p=0.02), lower CCQ scores (MD -0.50, 95% CI -0.82 to -0.18, p<0.05) and lower ACQ scores (MD -0.28, 95% CI -0.56 to 0.00, p<0.05) when compared with the control group. CONCLUSIONS: A community pharmacist-led medication adherence intervention was effective at improving medication adherence and clinical outcomes in patients suffering from hypertension, asthma and COPD. Future research should explore the implementation of these interventions in routine practice. TRIAL REGISTRATION NUMBER: ACTRN12618000410257.

Exploración de las opiniones de agentes implicados sobre la integración entre la farmacia comunitaria y los equipos de atención primaria / Stakeholder views of the integration of community pharmacy and primary health care teams

Introducción: Dado el aislamiento existente entre los farmacéuticos comunitarios y los miembros de los equipos de atención primaria en nuestro país, se diseñó este estudio para explorar las opiniones de profesionales de la salud de Osakidetza y de farmacia comunitaria, sobre la posibilidad de inte-gración de ambos colectivos. Método: Se diseñó un estudio cualitativo utilizan-do el Grupo Focal como método de obtención de información con análisis temático del contenido. La reunión tuvo lugar en el Centro de Salud de Gros (OSI Donostialdea). Participaron diferentes profesionales tanto de Osakidetza (n=6) como de la farmacia comunitaria (n=2). Todo el proceso de la reunión grupal y su informe, se realizó siguiendo los Standards for Reporting Qualitative Research (SRQR). Resultados: La Farmacia tiene como elementos fuertes su frecuentación, cercanía y facilidad de ac-ceso viéndose como un recurso no suficientemente aprovechado. A pesar de la dificultad conceptual de integrar un colectivo privado con otro público, se entendía la necesidad de acercamiento inter-profesional a través de una integración funcional, proceso que por su complejidad será lento y largo. Se debe comenzar con los programas locales ya existentes, proyectos pequeños, con objetivos concretos e indicadores medibles y mejorando la comunicación interprofesional y el conocimiento mutuo. Se analizaron las barreras a superar y los agentes implicados que deberían participar en cualquier proyecto futuro de integración siguiendo un modelo de diseño compartido.Conclusiones: Parece importante integrar funcio-nalmente la Farmacia comunitaria en Osakidetza – SVS.(AU)

Introduction: Due to the lack of integration of com-munity pharmacy and primary health care teams a study was designed to explore the views of stake-holders in the Basque health care system (Osakide-tza) on the integration of community pharmacy and primary healthcare teams.Method: A qualitative study, using focus group technique was used. The group met in the Gros health care center (IHO Donostialdea). There were 6 participants from the Basque primary health care system and 2 from community pharmacy. The whole focus group process followed the “Standards for Reporting Qualitative Research (SRQR”) and data generated was thematic content analysis.Results: The group identified the inherent strengths of community pharmacy as accessibility, geograph-ical distribution and frequency of visits by patients. Pharmacy was seen as a resource that was not optimally used. Despite the philosophical dilemma posed by the integration of a private (community pharmacy) and public (salaried health care profes-sionals) sector, there was seen a need for interpro-fessional collaboration, via functional integration due to the complexities and length of time required. The starting point was identified as existing rela-tively small local programs with specific objectives and measurable outcomes that increase commu-nication and build mutual confidence. The content analysis indicated a number of barriers and iden-tified potential stakeholders that should codesign any future potential integration program.Conclusions: There was general support for the integration of community pharmacy in the primary care system however this was tempered with sig-nificant barriers which would suggest a lengthy and complex process.(AU)

Cost-Utility Analysis of a Medication Adherence Management Service Alongside a Cluster Randomized Control Trial in Community Pharmacy.

BACKGROUND: It is necessary to determine the cost utility of adherence interventions in chronic diseases due to humanistic and economic burden of non-adherence. PURPOSE: To evaluate, alongside a cluster-randomized controlled trial, the cost-utility of a pharmacist-led medication adherence management service (MAMS) compared with usual care in community pharmacies. MATERIALS AND METHODS: The trial was conducted over six months. Patients with treatments for hypertension, asthma or chronic obstructive pulmonary disease (COPD) were included. Patients in the intervention group (IG) received a MAMS based on a brief complex intervention, whilst patients in the control group (CG) received usual care. The cost-utility analysis adopted a health system perspective. Costs related to medications, healthcare resources and adherence intervention were included. The effectiveness was estimated as quality-adjusted life years (QALYs), using a multiple imputation missing data model. The incremental cost-utility ratio (ICUR) was calculated on the total sample of patients. RESULTS: A total of 1186 patients were enrolled (IG: 633; CG: 553). The total intervention cost was estimated to be €27.33 ± 0.43 per patient for six months. There was no statistically significant difference in total cost of medications and healthcare resources per patient between IG and CG. The values of EQ-5D-5L at 6 months were significantly higher in the IG [IG: 0.881 ± 0.005 vs CG: 0.833 ± 0.006; p = 0.000]. In the base case, the service was more expensive and more effective than usual care, resulting in an ICUR of €1,494.82/QALY. In the complete case, the service resulted in an ICUR of €2,086.30/QALY, positioned between the north-east and south-east quadrants of the cost-utility plane. Using a threshold value of €20,000/QALY gained, there is a 99% probability that the intervention is cost-effective. CONCLUSION: The medication adherence management service resulted in an improvement in the quality of life of the population with chronic disease, with similar costs compared to usual care. The service is cost-effective.

A cost utility analysis alongside a cluster-randomised trial evaluating a minor ailment service compared to usual care in community pharmacy.

BACKGROUND: Minor ailments are "self-limiting conditions which may be diagnosed and managed without a medical intervention". A cluster randomised controlled trial (cRCT) was designed to evaluate the clinical, humanistic and economic outcomes of a Minor Ailment Service (MAS) in community pharmacy (CP) compared with usual care (UC). METHODS: The cRCT was conducted for 6 months from December 2017. The pharmacist-patient intervention consisted of a standardised face-to-face consultation on a web-based program using co-developed protocols, pharmacists' training, practice change facilitators and patients' educational material. Patients requesting a non-prescription medication (direct product request) or presenting minor ailments received MAS or UC and were followed-up by telephone 10-days after the consultation. The primary economic outcomes were incremental cost-utility ratio (ICUR) of the service and health related quality of life (HRQoL). Total costs included health system, CPs and patient direct costs: health professionals' consultation time, medication costs, pharmacists' training costs, investment of the pharmacy and consultation costs within the 10 days following the initial consultation. The HRQoL was obtained using the EuroQoL 5D-5L at the time of the consultation and at 10-days follow up. A sensitivity analysis was carried out using bootstrapping. There were two sub-group analyses undertaken, for symptom presentation and direct product requests, to evaluate possible differences. RESULTS: A total of 808 patients (323 MAS and 485 UC) were recruited in 27 CPs with 42 pharmacists (20 MAS and 22 UC). 64.7% (n = 523) of patients responded to follow-up after their consultation in CP. MAS patients gained an additional 0.0003 QALYs (p = 0.053). When considering only MAS patients presenting with symptoms, the ICUR was 24,733€/QALY with a 47.4% probability of cost-effectiveness (willingness to pay of 25,000€/QALY). Although when considering patients presenting for a direct product request, MAS was the dominant strategy with a 93.69% probability of cost-effectiveness. CONCLUSIONS: Expanding community pharmacists' scope through MAS may benefit health systems. To be fully cost effective, MAS should not only include consultations arising from symptom presentation but also include an oversight of self-selected products by patients. MAS increase patient safety through the appropriate use of non-prescription medication and through the direct referral of patients to GP. TRIAL REGISTRATION: ISRCTN, ISRCTN17235323 . Registered 07/05/2021 - Retrospectively registered.

Cost-utility analysis of medication review with follow-up for cardiovascular outcomes: A microsimulation model.

BACKGROUND: Cardiovascular diseases are the leading cause of death. Pharmacist-led medication review with follow-up might be cost-effective preventing cardiovascular diseases. OBJECTIVE: To undertake a cost-utility analysis of the addition of pharmacist-led medication review with follow-up to usual care compared to usual care alone for cardiovascular outpatients. MATERIALS AND METHODS: A state-transition microsimulation model was built to project outcomes over a lifetime time horizon. Inputs from a cluster randomized controlled trial conducted in primary health care centers in Chile with full-time pharmacists were used. Probabilities were estimated using patient-level data. Utilities and costs associated with each health state were obtained from the literature, whereas the intervention costs were retrieved from the trial. The public third-party payer perspective was used. Uncertainty was evaluated through one-way and probabilistic sensitivity analyses. RESULTS: For the base case analysis, an incremental cost-effectiveness ratio of $963 per quality-adjusted life-year was observed which was considered cost-effective. The results were robust to sensitivity analyses and were driven by decreased cardiovascular events resulting in lower mortality. CONCLUSIONS: Medication review with follow-up was deemed a cost-effective addition to usual care with low uncertainty.

Data-driven approach for tailoring facilitation strategies to overcome implementation barriers in community pharmacy.

BACKGROUND: Implementation research has delved into barriers to implementing change and interventions for the implementation of innovation in practice. There remains a gap, however, that fails to connect implementation barriers to the most effective implementation strategies and provide a more tailored approach during implementation. This study aimed to explore barriers for the implementation of professional services in community pharmacies and to predict the effectiveness of facilitation strategies to overcome implementation barriers using machine learning techniques. METHODS: Six change facilitators facilitated a 2-year change programme aimed at implementing professional services across community pharmacies in Australia. A mixed methods approach was used where barriers were identified by change facilitators during the implementation study. Change facilitators trialled and recorded tailored facilitation strategies delivered to overcome identified barriers. Barriers were coded according to implementation factors derived from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Tailored facilitation strategies were coded into 16 facilitation categories. To predict the effectiveness of these strategies, data mining with random forest was used to provide the highest level of accuracy. A predictive resolution percentage was established for each implementation strategy in relation to the barriers that were resolved by that particular strategy. RESULTS: During the 2-year programme, 1131 barriers and facilitation strategies were recorded by change facilitators. The most frequently identified barriers were a 'lack of ability to plan for change', 'lack of internal supporters for the change', 'lack of knowledge and experience', 'lack of monitoring and feedback', 'lack of individual alignment with the change', 'undefined change objectives', 'lack of objective feedback' and 'lack of time'. The random forest algorithm used was able to provide 96.9% prediction accuracy. The strategy category with the highest predicted resolution rate across the most number of implementation barriers was 'to empower stakeholders to develop objectives and solve problems'. CONCLUSIONS: Results from this study have provided a better understanding of implementation barriers in community pharmacy and how data-driven approaches can be used to predict the effectiveness of facilitation strategies to overcome implementation barriers. Tailored facilitation strategies such as these can increase the rate of real-time implementation of innovations in healthcare, leading to an industry that can confidently and efficiently adapt to continuous change.