Knowledge, attitudes and beliefs about chronic noncancer pain in primary care: a Canadian survey of physicians and pharmacists.

BACKGROUND: Primary care providers' knowledge, attitudes and beliefs (KAB) regarding chronic noncancer pain (CNCP) are a barrier to optimal management. OBJECTIVES: To evaluate and identify the determinants of the KAB of primary care physicians and pharmacists, and to document clinician preferences regarding the content and format of a continuing education program (CEP). METHOD: Physicians and pharmacists of 486 CNCP patients participated. Physicians completed the original version of the KnowPain-50 questionnaire. Pharmacists completed a modified version. A multivariate linear regression model was developed to identify the determinants of their KAB. RESULTS: A total of 137 of 387 (35.4%) physicians and 110 of 278 (39.5%) pharmacists completed the survey. Compared with the physicians, the pharmacists surveyed included more women (64% versus 38%) and had less clinical experience (15 years versus 26 years). The mean KnowPain-50 score was 69.3% (95% CI 68.0% to 70.5%) for physicians and 63.8% (95% CI 62.5% to 65.1%) for pharmacists. Low scores were observed on all aspects of pain management: initial assessment (physicians, 68.3%; pharmacists, 65.4%); definition of treatment goals and expectations (76.1%; 61.6%); development of a treatment plan (66.4%; 59.0%); and reassessment and management of longitudinal care (64.3%; 53.1%). Ten hours of reported CEP sessions increased the KAB score by 0.3 points. All clinicians considered a CEP for CNCP to be essential. Physicians preferred an interactive format, while pharmacists had no clear preferences. CONCLUSION: A CEP to improve primary care providers' knowledge and competency in managing CNCP, and to reduce false beliefs and inappropriate attitudes regarding CNCP is relevant and perceived as necessary by clinicians.

Impact of a debate on pharmacy students' views of online pharmacy practice.

OBJECTIVES: To evaluate the impact of a debate on pharmacy students' perceptions, using online pharmacy practice as the debate topic. METHODS: This is a quasi-experimental interrupted time-series study. A 60 min debate was organized as a lunchtime meeting. A four-category Likert scale questionnaire (fully agree, partially agree, partially disagree, fully disagree) measured the debate participants' level of agreement with 25 statements (main issues associated with online pharmacy) in the pre-phase (before the debate), post-phase 1 (after the debate) and post-phase 2 (6 months after the debate). One hundred and seventy-seven students were recruited (response rate of 100% in the pre-phase and post-phase 1, 31% in post-phase 2). Four questions measured the perceptions of the students on this pedagogical technique. KEY FINDINGS: The overall proportion of respondents in favour of online pharmacy practice showed little variation among the three phases. However, on average (mean ± SD) 43 ± 8% of the respondents changed their opinion, 21 ± 7% reversed their opinion, 22 ± 4% nuanced their opinion and 1 ± 1% radically changed their opinion. Respectively 98% (post-phase 1) and 96% (post-phase 2) of the respondents were of the opinion that debate was a very useful teaching formula in their pharmacist training and 79 and 66% thought debate significantly changed their opinion of the issue. CONCLUSIONS: Few data have been collected on the use of debates as part of healthcare professional training. The impact of a debate on how pharmacy students feel about online pharmacy practice is described.

Physician-pharmacist collaborative care in dyslipidemia management: the perception of clinicians and patients.

BACKGROUND: Collaborative practices allow physicians and pharmacists to comanage pharmacotherapy to maximize the benefits of medication regimens. The Trial to Evaluate an Ambulatory primary care Management program for patients with dyslipidemia (TEAM) study compared the efficacy of a physician-pharmacist collaborative primary care (PPCC) intervention, where pharmacists requested laboratory tests and adjusted medication dosage, to the usual care (UC) for patients under treatment with lipid-lowering medication. OBJECTIVE: In a qualitative study nested within the TEAM study, the perceptions of physicians, pharmacists, and patients regarding the PPCC model, interprofessional collaboration, and the clinicians' willingness to implement the model in their practice were explored. METHODS: In the area of Montreal (Quebec, Canada), TEAM study participants assigned to the PPCC group were invited to participate. Individual semistructured interviews with physicians (n=7) and 2 six-member focus groups with pharmacists (n=12) and patients (n=12) were analyzed using a phenomenological approach. RESULTS: The vast majority of participants reported PPCC was more structured and systematic than the UC they had received previously, wherein physicians prescribe and adjust pharmacotherapy and pharmacists provide the counseling and dispense medications. Many patients felt they received better follow-up and reported being reassured and well informed, making them more inclined to care for themselves better. These feelings were attributed largely to the pharmacists' accessibility and ability to communicate with them easily. Given the physician shortage, physicians perceived interprofessional collaboration as almost inevitable. They considered PPCC to be safe and effective. However, obstacles were also identified. Physicians were concerned that it might alter their special relationship with patients and threaten their overall medical follow-up. Pharmacists felt enthusiastic about their new role, but found PPCC time consuming and thought it might not be applicable to all the patients. CONCLUSIONS: PPCC model was highly appreciated by patients, and clinicians saw it as beneficial to patients. However, several obstacles still have to be overcome before the model can be implemented in the current health care context.

A cluster randomized controlled Trial to Evaluate an Ambulatory primary care Management program for patients with dyslipidemia: the TEAM study.

BACKGROUND: Few studies have reported the efficacy of collaborative care involving family physicians and community pharmacists for patients with dyslipidemia. METHODS: We randomly assigned clusters consisting of at least two physicians and at least four pharmacists to provide collaborative care or usual care. Under the collaborative care model, pharmacists counselled patients about their medications, requested laboratory tests, monitored the effectiveness and safety of medications and patients' adherence to therapy, and adjusted medication dosages. After 12 months of follow-up, we assessed changes in low-density lipoprotein (LDL) cholesterol (the primary outcome), the proportion of patients reaching their target lipid levels and changes in other risk factors. RESULTS: Fifteen clusters representing a total of 77 physicians and 108 pharmacists were initially recruited, and a total of 51 physicians and 49 pharmacists were included in the final analyses. The collaborative care teams followed a total of 108 patients, and the usual care teams followed a total of 117 patients. At baseline, mean LDL cholesterol level was higher in the collaborative care group (3.5 v. 3.2 mmol/L, p = 0.05). During the study, patients in the collaborative care group were less likely to receive high-potency statins (11% v. 40%), had more visits with health care professionals and more laboratory tests, were more likely to have their lipid-lowering treatment changed and were more likely to report lifestyle changes. At 12 months, the crude incremental mean reduction in LDL cholesterol in the collaborative care group was -0.2 mmol/L (95% confidence interval [CI] -0.3 to -0.1), and the adjusted reduction was -0.05 (95% CI -0.3 to 0.2). The crude relative risk of achieving lipid targets for patients in the collaborative care group was 1.10 (95% CI 0.95 to 1.26), and the adjusted relative risk was 1.16 (95% CI 1.01 to 1.34). INTERPRETATION: Collaborative care involving physicians and pharmacists had no significant clinical impact on lipid control in patients with dyslipidemia. International Standard Randomized Controlled Trial register no. ISRCTN66345533.

Physician-pharmacist collaborative care for dyslipidemia patients: knowledge and skills of community pharmacists.

INTRODUCTION: In a physician-pharmacist collaborative-care (PPCC) intervention, community pharmacists were responsible for initiating lipid-lowering pharmacotherapy and adjusting the medication dosage. They attended a 1-day interactive workshop supported by a treatment protocol and clinical and communication tools. Afterwards, changes in pharmacists' knowledge, their skills, and their satisfaction with the workshop were evaluated. METHODS: In a descriptive study nested in a clinical trial, pharmacists assigned to the PPCC intervention (n = 58) completed a knowledge questionnaire before and after the workshop. Their theoretical skills were evaluated with the use of a vignette approach (n = 58) after the workshop and their practical skills were assessed by direct observation with study patients (n = 28). RESULTS: The mean (SD) overall knowledge score was 45.8% (12.1%) before the workshop; it increased significantly to 89.3% (8.3%) afterwards (mean difference: 43.5%; 95% CI: 40.3%-46.7%). All the pharmacists had an overall theoretical-skill score of at least 80%, the minimum required to apply the PPCC in the trial. From 92.9% to 100% of the pharmacists' interventions with study patients complied with the treatment protocol. DISCUSSION: In primary care, a short continuing-education program based on a specific treatment protocol and clinical tools is necessary and probably sufficient to prepare pharmacists to provide advanced pharmaceutical care.

Compounding dermatologic preparations in developing countries.

Access to medications and their proper use are essential in developing countries. An interdisciplinary team of dermatologists and pharmacists created a master list of preparations useful for treating the most common dermatologic disorders in tropical and equatorial areas. The first pilot project was done at Cardinal Leger Hospital in Leogane, Haiti. Training was given to local staff at that hospital in 2005. Four years later, the clinic continues to prepare and offer, at a reasonable price, drugs that the population needs.

Evaluation of a training and communication-network nephrology program for community pharmacists.

OBJECTIVES: To assess the feasibility and impact of implementing ProFiL program to optimize community-pharmacist management of drug-related problems among chronic kidney disease patients followed in a predialysis clinic. The program comprises a training workshop, communication-network program and consultation service. SETTING: Forty-two community pharmacies, 101 pharmacists, and 90 chronic kidney disease patients attending a predialysis clinic in Laval (Canada). Patients were followed-up for 6 months. METHOD: In a six-month, pilot, open, cluster-randomized controlled trial, community pharmacies were assigned to ProFiL or the usual care. Chronic kidney disease patients of these pharmacies attending a predialysis clinic were recruited. ProFiL pharmacists attended a workshop, received patient information (diagnoses, medications, and laboratory-test results) and had access to a consultation service. Their knowledge and satisfaction were measured before and after the workshop. The mean numbers of pharmacists' written recommendations to physicians (pharmaceutical opinions) and refusals to dispense a medication were computed. RESULTS: Of the ProFiL pharmacists, 84% attended the workshop; their knowledge increased from 52% to 88% (95% CI: 29-40%). Most ProFiL pharmacists rated workshop (95%), communication program (82%) and consultation service (59%) as "excellent" or "very good"; 82% said the program improved the quality of their follow-up. The consultation service received 21 requests. ProFiL and usual care pharmacists issued a mean of 0.50 and 0.02 opinion/patient, respectively, (95% CI of the adjusted difference: 0.28-1.01 opinion/patient). CONCLUSION: The results of this pilot study suggest that ProFiL can be implemented and may help community pharmacists intervene more frequently to manage drug-related problems. However, a larger-scale study with longer follow-up is necessary to evaluate the impact of the program on management of drug-related problems and its clinical relevance.

Use of over-the-counter medications and natural products in patients with moderate and severe chronic renal insufficiency.

BACKGROUND: Use of over-the-counter medications and natural products may be associated with drug-related problems among patients with chronic renal insufficiency. The aim of this study is to describe the use of nonprescription medications in patients attending a predialysis clinic and identify drug-related problems associated with the use of these products. METHODS: In a 6-month cluster randomized controlled trial, patients with moderate (n = 46) and severe (n = 41) chronic renal insufficiency were interviewed over the telephone at baseline by a community pharmacist to document their use of over-the-counter medications and natural products. The safety of each product was assessed, and drug-related problems were identified independently by 2 pharmacists. RESULTS: Overall, 83% (95% confidence interval [CI], 72 to 94) of patients with moderate chronic renal insufficiency and 68% (95% CI, 54 to 83) with severe chronic renal insufficiency reported using at least 1 over-the-counter medication. Contraindicated over-the-counter medications were reported by 9% of patients. Natural products were used by 22% (95% CI, 10 to 34) and 29% (95% CI, 15 to 43) of patients with moderate and severe chronic renal insufficiency, respectively. Similarly, 3% of patients reported using at least 1 contraindicated natural product. Patients had consulted a health professional for 49% of over-the-counter medications and 19% of natural products. Overall, 65 drug-related problems were identified. CONCLUSION: The use of over-the-counter medications and natural products is highly prevalent in patients with chronic renal insufficiency and often is associated with a drug-related problem. These results emphasize the importance for community pharmacists to closely monitor the use of these products in patients with chronic renal insufficiency.

Telephone follow-up of patients receiving antibiotic prescriptions from community pharmacies.

PURPOSE: The impact of a community pharmacist telephone follow-up intervention (PTFI) on clinical outcomes, pharmaceutical care, and costs for patients undergoing antibiotic treatment was studied. METHODS: Patients receiving usual pharmacist intervention (UPI) were compared with PTFI patients in a multicenter, randomized, controlled trial. RESULTS: Compared with the UPI group (n = 129), the PTFI group (n = 126) had more drug-related problems (DRPs) (PTFI = 53%, UPI = 8%; p < 0.001). Oral recommendations (PTFI = 52%, UPI = 6%; p < 0.001), as well as recognized (PTFI = 10%, UPI = 2%; p = 0.015) and study-specific (PTFI = 5%, UPI = 1%; p = 0.064) pharmaceutical advices, were issued for more patients. The mean difference in the change in the number of infectious symptoms between the two groups (-0.24 symptom, 95% confidence interval [CI] = -1.22 to 0.74) and the change in the infection severity score (mean difference = -0.05 unit, 95% CI = -0.35 to 0.25) were small and not statistically significant. Adherence to treatment and patient satisfaction did not differ across the two intervention groups. The incremental direct costs of the PTFI varied from $2.65 to $5.11 (Canadian dollars) per patient, depending on whether cognitive services were reimbursed. CONCLUSION: A telephone follow-up by community pharmacists during antibiotic therapy was simple and quick and created opportunities to intervene with patients, but it did not create a greater change in the number of infectious symptoms or the infection severity score than did usual care.

Persistence with treatment in newly treated middle-aged patients with essential hypertension.

BACKGROUND: Antihypertensive agents have been found to decrease morbidity and/or mortality associated with cardiovascular disease (CVD). Surveys have shown that hypertension has been diagnosed in many patients but remains uncontrolled. One factor may be the lack of persistence to treatment. OBJECTIVE: To evaluate persistence with antihypertensives and its determinants among newly treated patients. METHODS: A cohort of 21,011 patients with essential hypertension was reconstructed from prescription records in the Régie de l'assurance maladie du Québec administrative database. We included subjects between 50 and 64 years of age newly treated for hypertension with diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, calcium-channel blockers, or angiotensin II receptor blockers prescribed individually or in combination. Cohort entry was from January 1, 1998, to December 31, 2000. Subjects were considered newly treated if they had not taken any antihypertensive agents in the year prior to the index date, which was defined as the date of the first prescription. Patients were followed until June 30, 2001; death; end of coverage; or occurrence of CVD. Main outcome measure was the persistence rate. The cumulative persistence rate was determined by Kaplan-Meier analysis. The rate ratio of discontinuing antihypertensive therapy was estimated using the Cox regression model. RESULTS: The mean age of patients was 58 years. Persistence with antihypertensive therapy fell to 75% in the first 6 months after treatment and continued to decline over the next 3 years to 55%. During a one-year period of follow-up, with diuretics used as the reference class and controlling for several variables, patients prescribed other antihypertensive classes or combined therapy (HR 0.71; 95% CI 0.67 to 0.75) were found to have a better rate of persistence. Having diabetes (HR 0.86; 95% CI 0.79 to 0.94) and dyslipidemia (HR 0.71; 95% CI 0.66 to 0.76) increased the rate of persistence. Similar values were observed during the 3-year period of follow-up. CONCLUSIONS: Barriers to persistence occur early in the course of therapy, and adherence continues to decline over a period of 3 years. Patients were least persistent to diuretic therapy.