Evaluating the potential outcomes of pharmacist-led activities in the Australian general practice setting: a prospective observational study.

BACKGROUND: Pharmacists have been co-located in general practice teams to support the quality use of medicines and optimise patient health outcomes. Evidence of the impact of pharmacist-led activities in Australian general practices is sparse. AIM: This study aimed to evaluate the potential outcomes of pharmacist-led activities in Australian general practices. METHOD: A prospective observational study was conducted in eight general practices in the Australian Capital Territory, where each general practice employed a pharmacist on a part-time basis for 18 months. A recommended, but flexible, list of activities was provided for pharmacists. Descriptive information on general practice pharmacist-led activities, collected with an online diary, was analysed. The potential clinical, economic, and organisational impact of pharmacist-led clinical activities was evaluated using the CLinical Economic Organisational (CLEO) tool, with a modified economic dimension. RESULTS: Nine pharmacists reported 4290 activities over 3918.5 work hours in general practice. Medication management services were the primary clinical activity of pharmacists. In medication reviews, 75% of the pharmacists' recommendations were fully accepted by general practitioners. Conducting clinical audits, updating patients' medical records, and providing information to patients and staff were other major activities of pharmacists. Of 2419 clinical activities, around 50% had the potential for a moderate or major positive clinical impact on patients. Sixty-three per cent of activities had the potential to decrease healthcare costs. Almost all the pharmacist-led clinical activities had a positive organisational impact. CONCLUSION: Most pharmacist-led clinical activities in general practice had the potential for a positive impact on patients and reduction in healthcare costs, supporting the expansion of this model in Australia.

Factors contributing to pharmacists leaving employment in general practice in Australia: an exploratory study.

OBJECTIVE: To identify perceived factors contributing to pharmacists leaving employment in general practice. METHODS: Qualitative semi-structured interviews were conducted with pharmacists who had left employment in general practice within 12 months of commencing (5 pharmacists out of 14 recruited into these roles) in Canberra, Australia. Thematic analysis was undertaken. KEY FINDINGS: The main specific reasons cited for leaving were lack of utilisation and part-time hours, while the over-arching themes identified were: challenges of the new role, poor role definition, professional relationships and job satisfaction. CONCLUSIONS: In this cohort of newly appointed general practice pharmacists, employment turnover was relatively high. The interview findings indicated a need for strategies, including having clear role descriptions that are understood by all members of the practice team, so that pharmacists with appropriate skillsets can be supported and retained in the general practice setting.

Interprofessional collaboration within general practice teams following the inclusion of non-dispensing pharmacists.

BACKGROUND: Pharmacists have been included in general practice teams to provide non-dispensing services in the Australian Capital Territory (ACT) since 2016. Interprofessional collaboration and team effectiveness are key considerations in providing high-quality patient care. These concepts have not been well studied following the inclusion of a pharmacist in general practice teams. METHODS: A mixed methods study was conducted to explore collaboration between pharmacists and health professionals in eight general practices in the ACT, where pharmacists were included in their teams. A validated survey instrument was adapted and utilised to assess the changes in interprofessional collaboration over time following the addition of a pharmacist. Another validated survey was utilised to explore team effectiveness at the end of the study. Semi-structured interviews, with a thematic analysis, were conducted with a purposeful sample of general practice staff members to understand the factors influencing the development of interprofessional collaboration. RESULTS: In total, 56 and 41 participants completed the baseline and follow-up survey, including 26 who completed both surveys to assess the change in collaboration over time. Interprofessional collaboration scores were high initially and did not change over time. Team effectiveness was also high at the end of the study. Twenty-one individuals participated in interviews, which generated four main interrelated themes related to interprofessional collaboration: professional working relationships, trust, commitment to collaboration, and barriers to collaboration. Trust was integral to professional working relationships and commitment to collaboration. The barriers to collaboration included not having a role description for pharmacists, inadequate interest to initiate working relationships, lack of dedicated time for interaction, lack of utilisation, and poor awareness of pharmacist-led activities in general practice. CONCLUSION: Interprofessional collaboration was initially high and not influenced by the addition of a pharmacist, perhaps reflecting the inherent nature of the general practices willing to include a pharmacist within their team. Introducing a clear job description for pharmacists, and dedicating time to interact with pharmacists, could be beneficial in improving trust and professional working relationships and enhancing collaboration between the pharmacists and other general practice team members.

Patients' Opinions towards the Services of Pharmacists Based in General Practice.

Pharmacists have been included in general practice teams to provide non-dispensing services for patients. In Australia, pharmacists' role in general practice has been slowly expanding. However, there is a paucity of research to explore patients' opinions toward pharmacist-led services in general practice. This study aimed to assess patient awareness, perceived needs, and satisfaction with these services. A cross-sectional survey was conducted with a purposeful sample of patients who visited six general practices in the Australian Capital Territory that included pharmacists in their team. The survey was informed by the literature and pre-tested. The survey was distributed to two samples: patients who had seen a pharmacist and those who had not seen a pharmacist. Of 100 responses received, 86 responses were included in the analysis: patients who had seen a pharmacist (n = 46) and patients who had not seen a pharmacist (n = 40). Almost all the patients who utilised pharmacist-led services were highly satisfied with those services. Among patients who had not seen a pharmacist, 50% were aware of the existence of general practice pharmacists. Patients who had visited the pharmacist rated higher scores for perceived needs. Patient satisfaction towards the pharmacist-led services in general practices was very high, and patients supported the expansion of these services. However, awareness of the availability of general practice pharmacist services could be improved.

Interprofessional Collaboration and Team Effectiveness of Pharmacists in General Practice: A Cross-National Survey.

As team-based care continues to evolve, pharmacists have been included in general practice teams in many countries, to varying extents, to improve medication use and patient safety. However, evidence on interprofessional collaboration and team effectiveness of pharmacists in general practice is sparse. This study aimed to compare the extent of interprofessional collaboration and team effectiveness of general practice pharmacists in Australia with international sites (Canada and the UK), and identify the factors associated with interprofessional collaboration and team effectiveness. General practice pharmacists from Australia, Canada, and the UK were identified through professional organisations and networks, and invited to participate in an online survey, adapted from existing validated tools. The survey explored interprofessional collaboration through four sub-domains (professional interactions, relationship initiation, trust and role clarity, and commitment to collaboration) and team effectiveness of general practice pharmacists. Of the 101 respondents (26 from Australia, 44 from Canada and 31 from the UK), 79% were female and 78% were aged below 50 years. Interprofessional collaboration and team effectiveness appeared to be high and similar between countries. Total scores for collaboration of pharmacists were 86.1 ± 7.4 in Australia, 88.5 ± 7.5 in the UK, and 89.1 ± 7.3 in Canada (mean ± SD, where higher scores represent more advanced collaboration), while the team effectiveness scores of the pharmacists were 88.6 ± 14.6 in Canada, 91.8 ± 14.6 in Australia and 97.5 ± 14.0 in the UK. Pharmacists who had worked in general practice for a longer time showed advanced interprofessional collaboration while those who worked exclusively in general practice had higher scores for team effectiveness. Overall, general practice pharmacists in the three countries were highly collaborative with general practitioners. Long-term employment and longer work hours could enhance interprofessional collaboration and team effectiveness in general practice pharmacists by improving trust and working relationships over time.

General practice pharmacists in Australia: A systematic review.

BACKGROUND: The inclusion of pharmacists into general practices in Australia has expanded in recent years. This systematic review aimed to synthesise the literature of qualitative and quantitative studies, and identify the knowledge gaps, related to pharmacists working in general practice in Australia. METHODS: This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, EBSCOhost, EMBASE, and the Cochrane Library were searched from the inception of databases to January 2021. The search was focused on studies investigating general practice pharmacists in Australia. The quality of each study was appraised using the Mixed Method Appraisal Tool criteria. The narrative synthesis approach was utilised to describe data due to the heterogeneity among study designs and measures. RESULTS: Twenty-five studies were included in this review. General practice pharmacists engaged in various non-dispensing patient care services, with medication management reviews being the primary activity reported. General practice pharmacists' characteristics and an environment with a willingness of collaboration were the notable influencing factors for successfully including pharmacists in general practices. Factors that posed a challenge to the adoption of general practice pharmacists were lack of funding and other resources, poorly defined roles, and absence of mentoring/training. CONCLUSION: This review has summarised the characteristics, activities, benefits, barriers, and facilitators of including pharmacists in general practices in Australia. General practice pharmacists are well accepted by stakeholders, and they can engage in a range of patient-centred activities to benefit patients. There is a need for more robust research to explore the patient and economic outcomes related to clinical activities that a pharmacist can perform in general practice, as a foundation to developing an appropriate and sustainable funding model. The findings of this review will be beneficial for pharmacists, researchers, policymakers, and readers who wish to implement the role of general practice pharmacists in the future.

Prevalence, risk factors and predicted risk of cardiac events in chronic kidney disease of uncertain aetiology in Sri Lanka: A tubular interstitial nephropathy.

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with 'traditional' chronic kidney disease (CKD). However, chronic kidney disease of uncertain aetiology (CKDu), a tubular interstitial nephropathy is typically minimally proteinuric without high rates of associated hypertension or vascular disease and it is unknown if the rates of CVD are similar. This study aimed to identify the prevalence and the risk of CVD in patients with CKDu. This cross-sectional study included patients with confirmed CKDu who were attending two renal clinics in CKDu endemic-area. A detailed medical history, blood pressure, electrocardiogram (resting and six minutes vigorous walking), echocardiograms, appropriate laboratory parameters and medical record reviews were used to collect data at baseline. The WHO/Pan American Health Organization, cardiovascular risk calculator was employed to determine the future risk of CVD. The clinics had recorded 132 number of patients with CKDu, of these 119 consented to participation in the study. The mean age was 52 (± 9.5) years and mean eGFR was 51.1 (± 27.61); a majority (81.5% (n = 97)) were males. Thirty-four patients (28.6%) had evidence of ischaemic heart disease (IHD). Troponin-I (p = 0.02), Age >50 years (p = 0.01) and hyperuricemia (p = 0.01) were significantly associated with IHD in CKDu. Left ventricular hypertrophy was reported in 20.2% (n = 24). According to the risk calculator, 97% of the enrolled patients were at low risk (<10%) for experiencing a cardiovascular event within the next 10 years. Patients with CKDu have low prevalence and risk for CVD, implying that a majority are likely to survive to reach end-stage kidney disease. Our findings highlight the need for developing strategies to minimize the progression of CKDu to end-stage renal disease.

Evaluation of General Practice Pharmacists: Study Protocol to Assess Interprofessional Collaboration and Team Effectiveness.

The inclusion of pharmacists into general practices has expanded in Australia. However, there is a paucity of research examining interprofessional collaboration and team effectiveness after including a pharmacist into the general practice team in primary or community care. This is a protocol for a cross-national comparative mixed-methods study to (i) investigate interprofessional collaboration and team effectiveness within the general practice team after employing pharmacists in general practices in the Australian Capital Territory (ACT) and (ii) to compare interprofessional collaboration and team effectiveness of pharmacists in general practice across Australia with international sites. The first objective will be addressed through a multiphase sequential explanatory mixed-method design, using surveys and semi-structured interviews. The study will recruit general practice pharmacists, general practitioners, and other health professionals from eight general practices in the ACT. Quantitative and qualitative results will be merged during interpretation to provide complementary perspectives of interprofessional collaboration. Secondly, a quantitative descriptive design will compare findings on interprofessional collaboration (professional interactions, relationship initiation, exchange characteristics, and commitment to collaboration) and team effectiveness of general practice pharmacists in Australia with international sites from Canada and the United Kingdom. The results of the study will be used to provide recommendations on how to best implement the role of general practice pharmacists across Australia.

An Analysis of Rate of Progression and Associated Risk Factors of Chronic Kidney Disease of Uncertain Etiology in Sri Lanka.

Chronic kidney disease of uncertain etiology (CKD-u) is an important public health issue in Sri Lanka and around the world, but published evidence of the progression of this disease is scanty. Our aim is to analyze the progression patterns and the associated risk factors of definite and probable CKD-u cases. This observational study was based on records of CKD-u cohort from 2005-14 at Girandurukotte, an endemic area for CKD-u in Uva Province, Sri Lanka. Data (rate of progression, survival, and risk factors) were analyzed using R statistical software. CKD-u cases (379) were included in analyses based on the adequacy of variables. Mean age was 53 years, male-to-female ratio of 2.5:1, and smoking were significant risk factors (P <0.10) for CKD-u progression. Males had 2.3 times hazard for CKD-u survival than females, and males who smoked had 2.57 times risk of CKD-u progression than nonsmoking males. Faster eGFR decline rate of >5 mL/min/1.73 m2/year have been identified in 25% of the sample (n = 100); this group is significantly younger than the slower progression group (mean age 46 years) and was at an early stage at the time of presentation (mean eGFR 76.02). CKD-u progression was not equal in all patients but faster in young people who presented at earlier stages. Continuous exposure to environmental risk factors may influence the rate of progression. Females have higher CKD-u survival rates than males. Tobacco smoking was associated with a lower survival of CKD-u but could be a proxy indicative of other exposures.

Correction: Evaluation of biochemical profile of Chronic Kidney Disease of uncertain etiology in Sri Lanka.

[This corrects the article DOI: 10.1371/journal.pone.0232522.].

Evaluation of biochemical profile of Chronic Kidney Disease of uncertain etiology in Sri Lanka.

Chronic Kidney Disease of uncertain etiology (CKDu) is an endemic, disease that mostly affects young agricultural workers in the rural dry zone of Sri Lanka. This study was designed to identify specific biochemical manifestations of CKDu cases. All (119) non-dialysis definite CKDu patients in Girandurukotte and Wilgamuwa were selected. Blood and urine samples were collected and measured biochemical parameters. All analyses were performed in IBM SPSS statistics version 23 (IBM Corp, USA). The median blood pressure was normal though nearly half of the patients (45.4%) who were in the advanced stages (Stage 3b, 4 and 5) of CKDu. Patients without a history of hypertension before the diagnosis of CKDu (100%) and minimal proteinuria (26%) are similar to the previous findings. Patients without a history of diabetes before the CKDu diagnosis had high percentages of diabetes (15.7%) and pre-diabetes (59.8%) and hence indicated the possibility of uremia induced impaired glucose intolerance in the rural areas of the country. There were 62.2% patients who had low vitamin D and only a minority had evidence of bone mineral diseases. Out of liver disease markers serum glutamic pyruvic transaminases (SGPT), serum glutamic oxaloacetic transaminases (SGOT), gamma-glutamyl transferase (GGT), and Lactic acid degydrogenase (LDH) had an inverse correlation with the advancement of the disease indicating subclinical liver disease. Osmolality in serum and urine showed a discrepancy despite > 50% of CKDu patients had increased their serum osmolality. The current study supports most of the previously described manifestations of CKDu. Moreover, some specific patterns have been identified which need to be validated in a larger group.

Snap shot view on anaemia in chronic kidney disease of uncertain aetiology.

AIM: Anaemia is a well-known complication of chronic kidney disease but there are no published studies on the pattern of anaemia in chronic kidney disease of uncertain aetiology (CKDu). This study aims to find out the prevalence, causes and associations of anaemia in CKDu to identify any unique features which are different from already described anaemia in chronic kidney disease. METHOD: All (119) biopsy-confirmed CKDu patients in two endemic clinics (Girandurukotte and Wilgamuwa) were selected as cases. Blood samples (10 mL) were collected from the peripheral veins into Potassium-Ethylenediaminetetraacetic acid (K-EDTA) tubes, plain tubes and Na-citrated tubes. Serum was separated immediately by centrifugation at 3000 rpm for 10 min. Spot urine samples were collected into empty, sterile, polypropylene urine containers. All analyses were performed in IBM spss statistics version 23 (IBM Corp, Armonk, New York). RESULTS: The overall prevalence of anaemia in 119 non-dialysis CKDu patients was 72.3% with the highest prevalence seen in females compared to males (P < 0.001). The prevalence of anaemia in CKDu patients with progression to renal failure was 66.7% - stage 1, 60% - stage 2, 50% - stage 3a, 95% - stage 3b, 79.2% - stage 4 and 100% - stage 5 (P = 0.005). Of CKDu patients, 44.3% had anaemia of chronic disease with iron deficiency. CKDu patients with anaemia had a high inflammatory score were seen in both early and late stages of CKDu. There were a similar proportion of patients with both early and late CKDu having unexplained anaemia. CONCLUSION: The current study showed a significant association of anaemia with disease severity among CKDu patients. Iron deficiency is a crucial aetiology factor of anaemia in CKDu and inflammation likely to effects adversely on anaemia of CKDu.