Evaluating categorisation and clinical relevance of drug-related problems in medication reviews.

OBJECTIVES: We aimed to evaluate the categorisation and clinical relevance of DRPs identified by community pharmacists, and further, to assess the quality of interventions with the patients and the physicians as documented by the pharmacists. SETTING: 23 Norwegian community pharmacies. METHOD: Patients with type 2 diabetes were recruited by 24 community pharmacists who performed structured medication reviews based on the patients' drug profiles and patient interviews. The DRPs identified were subsequently categorised. An evaluation group (EG) retrospectively evaluated the reviews. Clinical/practical relevance of each DRP and quality of community pharmacists' intervention with patients and physician were scored. Average agreement between the EG and the community pharmacists was calculated. Internal agreement in the EG was calculated using a modified version of Fleiss' Kappa coefficient. RESULTS: A total of 73 patients were included (mean age 62 years, 52% female, on average prescribed 8.7 drugs). The pharmacists identified 88 DRPs in 43 of the patients. The most common DRPs were adverse drug reactions (22%) and wrong drug or dose used by patient (14%). Anti-diabetic drugs and lipid modifying drugs were associated with the most DRPs. The EG agreed with detection and categorisation of DRPs in more than 80% of the cases. The clinical/practical relevance of the detected DRPs was scored by the EG to be high or medium in 87% of the cases. The quality of the follow-up with patients and physicians was scored to be good or satisfactory in 93 and 98% of the cases, respectively. CONCLUSIONS: Pre-defined categories of DRPs supported by structured forms were reliable and valid tools for identifying DRPs. The evaluation demonstrated that community pharmacists were able to identify DRPs of high to medium clinical/practical relevance, and to perform follow-ups of the DRPs with the patients and the physicians with a good or satisfactory quality.

Community pharmacists' prescription intervention practices--exploring variations in practice in Norwegian pharmacies.

BACKGROUND: Evidence suggests that prescription intervention frequencies have been found to vary as much as 10-fold among Norwegian pharmacies and among pharmacists within the same pharmacy. OBJECTIVE: To explore community pharmacists' perceptions of how their prescription intervention practices were influenced by their working environment, their technological resources, the physical and social structures of the pharmacies, their relations with colleagues, and to the individual pharmacist's professional skills. METHODS: Two focus groups consisting of 14 community pharmacists in total, from urban and rural areas in Norway, discussed their working procedures and professional judgments related to prescription interventions. Organizational theories were used as theoretical and analytical frameworks in the study. A framework based on Leavitt's organizational model was to structure our interview guide. The study units were the statements of the individual pharmacists. Recurrent themes were identified and condensed. RESULTS: Two processes describing variations in the dispensing workflow including prescription interventions were derived--an active dispensing process extracting information about the patient's medication from several sources and a fast dispensing process focusing mainly on the information available on the prescription. Both workflow processes were used in the same pharmacies and by the same pharmacist but on different occasions. A pharmacy layout allowing interactions between pharmacist and patients and a convenient organization of technology, layout, pharmacist-patient and pharmacist-coworker transactions at the workplace was essential for detecting and solving prescription problems. Pharmacists limited their contact with general practitioners when they considered the problem a formality and/or when they knew the answers themselves. The combined use of dispensing software and the Internet was a driving force toward more independent and cognitively advanced prescription interventions. CONCLUSION: Implementation of a general organizational model made it easier to analyze and interpret the pharmacists' intervention practices. Working environment, technology, management and professional skills may all contribute to variations in pharmacists' prescription intervention practices in and between community pharmacies.

[Communication about prescription interventions between pharmacists and general practitioners]. / Samhandling mellom allmennleger og apotek ved korreksjon av resepter.

BACKGROUND: Pharmacists intervene on about 2 % of prescriptions dispensed in Norwegian community pharmacies. The aim of this study was to explore how general practitioners (GPs) and community pharmacists communicate and document prescription interventions, and to discuss what both professions consider to be best practice. MATERIAL AND METHODS: Five GPs, five community pharmacists and two medical secretaries were recruited, from two regions in Norway, to form two focus groups. The groups were invited to discuss 12 real examples of prescription interventions (from a former study of pharmacy practice) from six intervention categories. Statements from the focus groups were analyzed and recurrent themes identified. RESULTS: The GPs and pharmacists described varying management of the pharmacists' prescription interventions. Both expected the other profession to file these interventions and would only file a selection themselves. Correction of prescription interventions was not a well-established functionality of the GPs' electronic medical record systems. Lack of guidelines caused individual variations in both GP and pharmacist handling of such interventions. In general, the pharmacists prioritized to contact GPs for the clinically relevant interventions. GPs wanted more feedback than that provided by the pharmacists. INTERPRETATION: Joint guidelines for use in pharmacies and GP surgeries, are needed on communication, documentation, and priorities of prescription interventions. IT-software should be developed to facilitate real-time communication between the parties.

Price control as a strategy for pharmaceutical cost containment - what has been achieved in Norway in the period 1994-2004?

OBJECTIVES: To describe and evaluate the different price control strategies implemented in Norway after its accession to the European Economic Area (1994-2004). METHODS: Interviews with ten key persons who had broad insight into the field in question were held. All the available literature was reviewed. RESULTS: Direct price control involving international reference pricing of prescription drugs, and the subsequent price revisions, that occurred from the year 2000 onwards, resulted in predictable and substantial price reductions. With respect to the indirect methods which targeted the off-patent market, the price reductions resulting from reference-based pricing (1993-2000) were only marginal and the achieved savings derived mainly from increased patients' charges. The introduction of generic substitution in 2001 led to increased market shares for non-branded products, but discounts from the manufacturers were not reflected in retail prices. An index price system (2003-2004) was therefore created; but as it entailed negative economical incentives for the pharmacy chains, the price changes did not meet the expectations. CONCLUSION: The direct pricing strategy, i.e. the international reference pricing, was considered to be the most successful method. In contrast, due to the unpredictability of the market situation, the resulting effects of the indirect methods, i.e. reference-based pricing, generic substitution, and index pricing, were more limited.

Self-efficacy in counseling in Norwegian chain pharmacies: a cross-sectional study.

BACKGROUND: After pharmacy reform in Norway in 2001, pharmacy chains have systematically trained their personnel in advising self-medication of some symptoms and diseases to increase their competence. It may be important to reveal factors at work that increase self-efficacy in counseling as part of enhancing good pharmacy practice. OBJECTIVES: The aims of this study were to investigate (1) self-efficacy in counseling among pharmacy personnel in respect to a range of medical complaints, and (2) the relationship between self-efficacy in counseling and pharmacy staff's education, age, years of work in pharmacy and psychosocial factors. METHODS: A web-based questionnaire about self-efficacy in counseling, psychosocial factors, and demographic variables was completed by 693 individuals from 299 randomly selected community chain pharmacies in Norway. Multiple regression analysis was used to assess the relationship between self-efficacy and gender, age, years of work in pharmacy, and psychosocial factors. RESULTS: On a scale from 0 (very difficult) to 10 (no problem), the mean score for self-efficacy on all 21 symptoms or needs was 7.2 (SD=1.3). Allergy, flu, and headache received the highest self-efficacy scores and leg ulcer treatment, self-test kits, and tiredness received the lowest scores. Significant associations between self-efficacy in counseling and years of work in pharmacy (P=.017), role clarity (P<.001), positive challenges at work (P=.002), and role conflict (P<.001) were observed. CONCLUSIONS: Self-efficacy in counseling among pharmacy personnel seems to be high for providing advice for symptoms where over-the-counter medicines are available. Role clarity, positive challenge, and years of work in pharmacy are associated positively with self-efficacy in counseling, whereas role conflict is associated negatively. Future research may examine implications for self-efficacy in actual behavior and patient outcomes.

Characteristics and quality of adverse drug reaction reports by pharmacists in Norway.

PURPOSE: To evaluate the characteristics and quality of adverse drug reaction (ADR) reports submitted by pharmacists, and thereby assess the possible contribution of pharmacists to the spontaneous reporting system for ADRs in Norway. METHODS: An open, prospective study was conducted where dispensing pharmacists from 39 pharmacies were encouraged to report ADRs over a 3-month period. The submitted ADR reports were compared to reports by physicians from the same time period. All reports were evaluated for selected characteristics, that is distribution of Anatomical Therapeutic Chemical (ATC) classification codes of suspected drugs, distribution of ADRs according to system-organ classes and the quality of the reports. RESULTS: A total of 118 reports covering 274 ADRs received from the pharmacists were compared to 109 ADR reports with 304 ADRs submitted by physicians. Pharmacists more often reported ADRs related to cardiovascular drugs, alimentary tract and metabolism drugs and respiratory drugs, whereas physicians more frequently reported ADRs related to musculoskeletal drugs and antineoplastic and immunomodulating agents. ADRs reported by pharmacists more frequently described gastrointestinal reactions while physicians reported more ADRs in relation to the cardiovascular and blood system. Whereas 68% of the physicians' reports were classified as serious, only 5% of the pharmacists' reports were serious. More than 50% of the reports submitted by pharmacists concerned ADRs following a generic substitution, in contrast to only 2% of the physicians' reports. The pharmacists' reports were found to be of a lower documentation grade. However, there was no substantial difference in a subjective assessment of the quality of information in the reports submitted by the two categories of health professionals. CONCLUSIONS: Pharmacists submit valuable ADR reports which provide information complimentary to physicians' reports. This emphasises that pharmacist ADR reporting might constitute an important addition to the spontaneous reporting system.

[Prescription changes in pharmacies]. / Endring av resepter i apotekene.

BACKGROUND: Prescriptions must sometimes be changed or clarified before dispensing in order to provide a safe and professional service. The aims of this study were to gain insight into the types of prescription interventions performed by pharmacists, to explore the reason behind the interventions and to describe to which extent and how interventions are documented and communicated to the prescribers. MATERIAL AND METHODS: Prescription interventions (N = 1,084) performed at a community pharmacy in Norway from January 2002 to September 2004 were categorised. Two focus groups were used to validate the categories. The pharmacists in these groups were invited to discuss working procedures and professional judgements related to prescription interventions. RESULTS: The prescription interventions were grouped into seven categories. The two largest categories were "drugs not available" (37%) and "clarification of drug choice and dosage" (22%). Many interventions are not communicated to the prescribers. In principal, the pharmacists felt that interventions should be communicated to the prescriber even if this is often not the case. CONCLUSION: Pharmacists intervene on a range of prescription issues that are not communicated to the prescribers. Feedback requires time and resources for all involved. By ensuring that computer systems used by general practitioners comply with reimbursement legislation and technical requirements for prescriptions, the demand for many prescription interventions will be reduced. There is a need for a joint professional discussion on differentiation and standardisation of feedback on prescription interventions.

[Prescription errors--dimension and measures]. / Forskrivningsfeil--omfang og oppklaring.

BACKGROUND: A prescription should contain sufficient information to dispense the right medicine with correct instructions for use. The information given on the prescription also forms the basis for reimbursement of drug expenses. Knowledge of prescription errors may improve the procedures of the prescribing physician and the pharmacy. MATERIAL AND METHOD: Prescriptions without information on the indication of the drug therapy were registered in ten Norwegian pharmacies during two days in the autumn of 2004. Other errors and omissions on prescriptions were registered in nine of the pharmacies during a five week period. RESULTS AND INTERPRETATION: A total of 1884 (39%) of the 4667 prescriptions included in the first part of the study contained no information on the indication. A total of 1696 other errors and omissions were registered on 1359 (2%) of the 69,315 prescriptions included in the second part of the study. The most common errors and omissions were incomplete instructions for use (26%), missing information about the patient (17%), and errors and omissions related to reimbursement of drug expenses. 294 (17%) of the errors were judged to have potential clinical significance if they had not been corrected. The most common intervention was to interview the patient or to contact the prescribing physician. The most common changes were to change or clarify drug and dose.