Pharmacist's identity development within multidisciplinary primary health care teams in Ontario; qualitative results from the IMPACT project.

BACKGROUND: Multidisciplinary team development generates changes in roles, responsibilities, and identities of individual health care providers. The Integrating Family Medicine and Pharmacy to Advance Primary Care Therapeutics (IMPACT) project introduced pharmacists into family practice teams across Ontario, Canada, to provide medication assessments, drug information, and academic detailing and to develop office system enhancements to improve drug therapy. OBJECTIVE: To analyze pharmacists' narrative accounts during early integration to study identity development within emerging team-based care. METHOD: Qualitative design using 63 pharmacist narrative reports of pharmacists' experiences over a 9-month integration period. Four independent researchers with varied professional backgrounds used immersion and crystallization to identify codes and iterative grounded theory to determine and debate process and content themes relevant to identity development. RESULTS: The pharmacists' narratives spoke of the daily experiences of integrating into a family practice setting: feeling valued and contributing concretely to patient care; feeling underutilized; feeling like a nuisance, or feeling as though working too slowly. Pharmacist mentors helped deal with uncertainty and complexity of care. Pharmacists perceived that complementary clinical contributions enhanced their status with physicians and motivated pharmacists to take on new responsibilities. Changes in perspective, clinic-relevant skill development, and a new sense of professionalism signaled an emerging pharmacist family practice identity. CONCLUSION: Pharmacists found that the integration into team-based primary health care provided both challenges and fresh opportunities. Pharmacists' professional identities evolved in relation to valued role models, emerging practice-level opportunities, and their patient-related contributions.

Integrating pharmacists into family practice teams: physicians' perspectives on collaborative care.

OBJECTIVE: To explore family physicians' perspectives on collaborative practice 12 months after pharmacists were integrated into their family practices. DESIGN: Qualitative design using focus groups followed by semistructured interviews. SETTING: Seven physician-led group family practices in urban, suburban, and semirural Ontario communities. PARTICIPANTS: Twelve purposively selected family physicians participating in the IMPACT (Integrating family Medicine and Pharmacy to Advance primary Care Therapeutics) project. METHODS: We conducted 4 exploratory focus groups to gather information on collaborative practice issues in order to construct our interview guide. We later interviewed 12 physicians 1 year into the integration process. Focus groups and interviews were audiotaped and transcribed verbatim. Four researchers used immersion and crystallization techniques to identify codes for the data and thematic editing to distil participants' perspectives on physician-pharmacist collaborative practice. FINDINGS The focus groups revealed concerns relating to operational efficiencies, medicolegal implications, effects on patient-physician relationships, and work satisfaction. The follow-up semistructured interviews revealed ongoing operational challenges, but several issues had resolved and clinical and practice-level benefits surfaced. Clinical benefits included having colleagues to provide reliable drug information, gaining fresh perspectives, and having increased security in prescribing. Practice-level benefits included group education, liaison with community pharmacies, and an enhanced sense of team. Persistent operational challenges included finding time to learn about pharmacists' role and skills and insufficient space in practices to accommodate both professionals. CONCLUSION: Physicians' perspectives on collaborative practice 12 months after pharmacists were integrated into their family practices were positive overall. Some ongoing operational challenges remained. Several of the early concerns about collaborative practice had been resolved as physicians discovered the benefits of working with pharmacists, such as increased security in prescribing.

Narrative reports to monitor and evaluate the integration of pharmacists into family practice settings.

PURPOSE: Narratives can capture unfolding events and negotiation of roles and thus can help to evaluate interventions in interdisciplinary health care teams. We describe a practical qualitative method, the narrative report, and its role in evaluating implementation research. METHODS: We used narrative reports as a means to evaluate an intervention to integrate pharmacists into group family practices. The pharmacists submitted 63 written narrative reports during a 1-year period. Our interdisciplinary research team analyzed these reports to monitor the progress of the implementation, to identify pharmacists' needs, and to capture elements of the integration process. RESULTS: The monthly narrative reports allowed the research team to document early learning and calibrate the program in terms of clinical support, adapting roles, and realigning expectations. The reports helped the research team stay in tune with practice-related implementation challenges, and the preliminary summary of narrative findings provided a forum for sharing innovations among the integrating pharmacists. CONCLUSION: The narrative report can be a successful qualitative tool to track and evaluate the early stages of an intervention in the context of evolving primary health care teams.

Do patients' expectations influence their use of medications? Qualitative study.

OBJECTIVE: To investigate whether patients' expectations influence how they take their medications by looking at the expectations patients have of their medications and the factors that affect these expectations. DESIGN: Qualitative study using in-depth interviews and a grounded-theory approach. SETTING: A large city in Ontario. PARTICIPANTS: A total of 18 community-dwelling adult patients taking medication for at least 6 months. METHOD: Both purposive and convenience sampling techniques were used. The initial strategy comprised stratified, maximum variation, and typical case sampling. The research team developed a semistructured interview guide after a preliminary review of the literature. Individual, face-to-face, in-depth interviews were conducted and audiotaped. At the end of the interviews, basic demographic information was collected. Interviewers were debriefed following each interview and their comments on relevant contextual information, general impressions of the interview, and possible changes to the interview guide were audiotaped. Audiotapes of each interview, including the debriefing, were transcribed verbatim, cleaned, and given a unique identifying number. At least 2 team members participated in analyzing the data using an operational code book that was modified to accommodate emerging themes as analysis continued. MAIN FINDINGS: Patients' expectations were more realistic than idealistic. Many participants acted on their expectations by changing their medication regimens on their own or by seeking additional information on their medications. Expectations were affected by patients' beliefs, past experiences with medications, relationships with their health care providers, other people's beliefs, and the cost of medication. Patients actively engaged in strategies to confirm or modify their expectations of their medications. CONCLUSION: A range of factors (most notably past experiences with medications and relationships with health care providers) influenced patients' expectations of their medications. More comprehensive discussion between patients and their health care providers about these factors could affect whether medications are used optimally.

Developing a tool to measure contributions to medication-related processes in family practice.

Successful team care requires a shared understanding of roles and expertise. This paper describes the development and preliminary exploration of the psychometric properties of a tool designed to measure contributions to family practice medication-related processes. Our team identified medication-related processes commonly occurring in family practice. We assessed clinical appropriateness using a sensibility questionnaire and pilot-tested with 11 pharmacists, nurses and physicians. We performed a simulated exercise to group the processes and assessed the internal consistency of the groupings using Cronbach's alpha coefficient. We examined test-retest reliability using intra-class coefficient (ICC). Following three revisions, the final Medication Use Processes Matrix (MUPM) included 22 medication-related processes and scale descriptors reflecting contribution to each process. Mean sensibility ratings were high for each component. We developed five theoretical groupings (diagnosis & prescribing, monitoring, administrative/documentation, education, medication review) and found their overall internal consistency was good (alpha > 0.80). The test-retest reliability was strong (ICC > 0.80). Preliminary validation showed significant differences in how health professionals view interprofessional contributions toward medication-related processes. Interprofessional care requires a negotiated understanding of processes and contributions. The MUPM provides an explicit description of medication-related processes in primary care, measures perceived contributions and emerges as a new tool to measure collaborative care in family practices.

Prescribing of potentially inappropriate medications to elderly people.

OBJECTIVE: To estimate the prevalence and predictors of medications deemed potentially inappropriate for the elderly among family physicians' patients aged 65 and older (seniors) taking multiple prescribed medications. METHODS: Forty-eight randomly selected family practices in 16 towns and cities in Southern Ontario, Canada and 889 of their senior patients were recruited into a randomized trial. We conducted a cross-sectional analysis of prescription insurance data from the provincial universal prescription insurance database over 12 months, from the 777 seniors who completed the trial and agreed to have their data released. The prevalence and patient and physician predictors of use of a potentially inappropriate medication (PIM), as defined by published widely accepted criteria, were examined. RESULTS: The median number of prescriptions filled was 24. Nearly one-fifth (16.3%) of the seniors received at least one prescription for a PIM, with short-acting benzodiazepine prescriptions for longer than 30 days (6.4%) and oxybutynin (3.7%) being the types prescribed most frequently. In univariate and multiple variable analyses, women were found to be statistically significantly more likely to be prescribed a PIM (adjusted OR = 1.6; 95% confidence interval = 1.0-2.4). Age, education, self-rated health, number of health conditions, and number of prescriptions were not associated with PIM use. Physician gender, family medicine certification status, and time since graduation were not significantly associated with PIM prescribing. CONCLUSIONS: Prescribing of PIMs, especially of short-acting benzodiazepines was common in seniors taking multiple medications. Interventions to reduce use of PIM, especially long-term benzodiazepines, are important in primary care.

Collaboration between community pharmacists and family physicians: lessons learned from the Seniors Medication Assessment Research Trial.

OBJECTIVES: To learn about the experiences of specially trained expanded role pharmacists (ERPs) and family physicians in a program in which they worked together to optimize drug therapy for elderly patients (aged 65 and older) and to identify shortcomings of the program, obstacles to its implementation, and strategies to overcome these obstacles. DESIGN: Qualitative opinion analysis. PARTICIPANTS: Six family physicians and six community-based ERPs who had participated in a randomized controlled trial (Seniors Medication Assessment Research Trial [SMART]). INTERVENTION: In-depth interviews. MAIN OUTCOME MEASURES: Themes that emerged from the interviews regarding the strengths and weaknesses of and ways to improve the program. RESULTS: ERPs and physicians differed in their perceptions of appropriate roles for ERPs. ERPs saw the program as an opportunity to take on new professional roles. Physicians appreciated the information they received from ERPs about their patients' adherence and use of nonprescription medications, but they did not want ERPs to directly counsel their patients. Some physicians questioned the value of the program for some patients, since the inclusion criteria for patients were broad and not all patients meeting the criteria needed intense interventions by ERPs. Both ERPs and physicians identified the need to refine the referral process and to work out professional role relationships and ongoing collaboration more fully. If the program were to be implemented as a routine service, physicians were concerned about the demands on their staff and office space and the need for an external compensation mechanism. CONCLUSION: Issues to be addressed for future programs include clarification of the roles of pharmacist and physician when the professionals work together, targeting of appropriate patients for the program, identification of a more efficient way to deliver recommendations, and development of an appropriate compensation mechanism.

Coding accuracy of administrative drug claims in the Ontario Drug Benefit database.

BACKGROUND: Every year in Ontario, the records of over 42 million prescriptions dispensed to persons eligible for Ontario Drug Benefit (ODB) benefits are transmitted to a central database. The ODB database is the second largest database of medications in Canada, containing records on almost half of all medications dispensed in Ontario. There is no information about the reliability of the coding on the ODB drug claims database and, therefore, the objective of this study was to estimate the reliability of coding of the Drug Identification Number, and the date, quantity and duration of the dispensation on claims sent to the ODB. METHODS: To meet this objective, approximately 100 randomly selected prescriptions dispensed from each of 50 pharmacies in southern Ontario between July 1, 1998 and December 31, 1999 were audited. For each claim, the written information on the prescription was compared with the electronic information submitted to the ODB database. Logistic regression was used to test the association between coding errors and the location, owner affiliation, and productivity of each pharmacy (defined as the annual volume of dispensations divided by the annual number of hours worked by all pharmacists and pharmacy assistants). RESULTS: Of the 183 pharmacies owners invited to participate, consent to abstract information was obtained in 50, yielding a participation rate of 27%. Of the 5155 dispensed prescriptions, 37 errors were found, yielding an overall error rate of 0.7% (95% CI 0.5% to 0.9%). None of the characteristics of pharmacies that were examined (location, owner affiliation, productivity) was associated with coding errors. CONCLUSIONS: Pharmacists almost always dispense the medication that is prescribed and this information is reliably transmitted to the ODB drug claims database. This means that any conclusions drawn by researchers using these data are not likely to be compromised by low coding reliability.

A randomized controlled trial of a pharmacist consultation program for family physicians and their elderly patients.

BACKGROUND: Pharmacists can improve patient outcomes in institutional and pharmacy settings, but little is known about their effectiveness as consultants to primary care physicians. We examined whether an intervention by a specially trained pharmacist could reduce the number of daily medication units taken by elderly patients, as well as costs and health care use. METHODS: We conducted a randomized controlled trial in family practices in 24 sites in Ontario. We randomly allocated 48 randomly selected family physicians (69.6% participation rate) to the intervention or the control arm, along with 889 (69.5% participation rate) of their randomly selected community-dwelling, elderly patients who were taking 5 or more medications daily. In the intervention group, pharmacists conducted face-to-face medication reviews with the patients and then gave written recommendations to the physicians to resolve any drug-related problems. Process outcomes included the number of drug-related problems identified among the senior citizens in the intervention arm and the proportion of recommendations implemented by the physicians. RESULTS: After 5 months, seniors in the intervention and control groups were taking a mean of 12.4 and 12.2 medication units per day respectively (p = 0.50). There were no statistically significant differences in health care use or costs between groups. A mean of 2.5 drug-related problems per senior was identified in the intervention arm. Physicians implemented or attempted to implement 72.3% (790/1093) of the recommendations. INTERPRETATION: The intervention did not have a significant effect on patient outcomes. However, physicians were receptive to the recommendations to resolve drug-related problems, suggesting that collaboration between physicians and pharmacists is feasible.

Recruiting family physicians and patients for a clinical trial: lessons learned.

BACKGROUND: The randomized controlled trial (RCT) is the most definitive tool for evaluating an intervention. However, methodological deficiencies may limit the internal or external validity of the RCT. OBJECTIVE: Our aim was to describe the tactics used and the resources required randomly to select and recruit family physicians (FPs) and their patients aged 65 and older (seniors) for a community-based cluster RCT in primary care. METHODS: We randomly selected 48 FPs in 24 urban and rural sites in Southern Ontario, and 889 of their community-dwelling seniors (approximately 20 per FP) taking five or more medications daily. To accomplish this, the principal investigator (an FP) contacted the eligible FPs. The participating FPs' office staff then generated and contacted the roster of eligible seniors, with support provided by the research staff. RESULTS: Of the 163 randomly selected FPs telephoned, 94 were ineligible and 48 (69.6%) of the remaining 69 participated. The rosters were generated with the assistance of the research staff (taking 1.5-8.0 hours) in each of the 48 practices, using electronic appointment records (n = 26), electronic billing records (n = 17), electronic medical records (n = 2) or written charts or file cards (n = 3). Of the 2078 seniors approached, 799 were ineligible and 889 (69.5%) of the remaining 1279 participated. Seniors' refusal rates among practices ranged from 4.8 to 62.3%. CONCLUSIONS: Recruitment of a representative sample and generalizability of results are possible in RCTs in primary care. Involvement of an FP in physician recruitment and clinical research nurses who provided assistance to office staff were keys to success.