Pharmacy Technicians' Contribution to Counselling at Community Pharmacies in Denmark.

(1) Background: pharmacy technicians are the largest group of staff at Danish community pharmacies and play a vital role in counselling customers on prescription medication, over-the-counter (OTC) medication and non-medical products. This is the first study carried out to specifically analyse how they contribute to counselling and identification of drug-related problems (DRPs) at Danish community pharmacies. (2) Methods: seventy-six pharmacy technicians from 38 community pharmacies registered data on all of their customer visits for five days, over a four-week period, between January and March 2019. Data were analysed in SPSS version 24. (3) Results: 58.9% of all registered customers (n = 10,417) received counselling. They identified DRPs for 15.8% of all registered customers (n = 2800). Counselling by pharmacy technicians solved, or partially solved, problems for 70.4% of customers with DRPs. Pharmacy technicians estimated that 25.2% of customers receiving counselling (n = 2621) were saved a visit to the general practitioner (GP). (4) Conclusions: as community pharmacists get more involved in complex services, it would be necessary to expand the roles of pharmacy technicians. Pharmacy technicians contribute to medication safety via counselling, and identifying and handling DRPs for all customers. This study documents the role of pharmacy technicians in customer counselling at Danish community pharmacies. It provides evidence to researchers and policy makers to support discussions on the future role of pharmacy technicians at community pharmacies.

Safe and effective use of medicines for patients with type 2 diabetes - A randomized controlled trial of two interventions delivered by local pharmacies.

BACKGROUND: Poor management of chronic medical treatments may result in severe health consequences for patients as well as costs for society. Non-adherence is common among patients with type 2 diabetes. Interventions by community pharmacists may assist in improving adherence and consequently health outcomes for patients with type 2 diabetes. OBJECTIVES: The study aimed to investigate whether a comprehensive and a brief individually targeted intervention for patients with type 2 diabetes could improve implementation of drug therapy in Danish community pharmacies. The interventions intended to give patients more competence and support to improve adherence and self-management in order to reach treatment goals for diabetes and blood pressure as well as goals for patient perceived outcomes. METHODS: This study was an RCT, comparing two interventions; basic intervention (BI) and extended intervention (EI). The intervention model sought to identify drug-related problems as well as issues experienced by patients in relation to medicines use, and consequently find individually tailored solutions to address the identified problems. RESULTS: The trial included five pharmacies; five pharmacists and five pharmaconomists, and 205 patients; BI (39 patients), EI (41 patients), Control (125 patients). Patient reported systolic blood pressure improved in both groups and significantly in the EI group compared to the control group (P = 0.020). Increase in disease-related knowledge was higher in the EI group compared to the control group (P = 0.006), but not in the BI group (P = 0.139). Except for quality of life, the EI group reported significantly higher improvement in all aspects of beneficial effects from participating in the trial when compared to the control group. No significant differences were detected for changes in hospital admissions or in doctor visits. The two intervention groups reported significantly higher satisfaction with all aspects of patient satisfaction with pharmacy staff in the project than control patients. CONCLUSIONS: The study showed improvement in patient health, well-being, knowledge, and satisfaction as a result of the trial, particularly for the EI group. Thus a program comprising patient narratives, problem and resource identification, and multi-dimensional individually tailored patient medication management solutions seems to be an appropriate intervention to ensure outcome improvement of non-adherent patients.

The relationship between leadership style and provision of the first Danish publicly reimbursed cognitive pharmaceutical service--a qualitative multicase study.

BACKGROUND: Evidence suggests that leadership style is important to the sustainability of cognitive pharmaceutical services, yet only scarce literature on the relationship exists. OBJECTIVES: Support of the sustainability of the first publicly reimbursed cognitive service in Denmark, the Inhaler Technique Assessment Service (ITAS), was ascertained through a qualitative study to explore how leadership style shapes the implementation process of the service. Sustainability in this project was defined as the state where those asthma patients whose symptom status is negatively clinically affected (as defined by Global Initiative for Asthma guidelines) by inappropriate inhalation technique are identified and offered the service by pharmacy staff. METHODS: The study was an exploratory qualitative multicase study that used triangulation of both data sources and methods. A theoretical framework of Bolman and Deal inspired the analysis of how leadership style influenced the local process of implementation of the ITAS. Four pharmacies were selected for the analysis because they differed in terms of leadership actions in their implementation process and achievement of ITAS sustainability. The analysis was inductive and linked factors that influence ITAS provision as perceived by employees with the interpreted leadership style of the owner. RESULTS: Three main themes emerged: (1) the alignment of the owner and staff values, (2) whether owners perceived ITAS development as being under their own control, and (3) whether owners explicated the responsibilities of employees in the implementation process. The themes were interrelated. CONCLUSIONS: Pharmacy owner's leadership style was significant to sustainability of the ITAS. A strong wish by the owner to have ITAS implemented was important, followed by aligning the owner's values and visions with those of the employees. The widespread perception by owners that experienced users are not interested in the ITAS needs to be addressed to achieve sustainability.

Development of new concepts of non-adherence measurements among users of antihypertensives medicines.

OBJECTIVE: To identify various types of non-adherence among users of antihypertensive medications by establishing components of adherence measures and use these components for measuring the prevalence of non-adherence. SETTING: Twelve community pharmacies from the Danish county of Funen. METHOD: Users of antihypertensive medication were included in the study. 2,914 medication users received questionnaires by mail. Participating patients were asked to fill in two questionnaire regarding demographics, self-reported blood pressure, and various adherence measures. Two factor analyses were conducted based on responses to questions. MAIN OUTCOME MEASURES: Medication-taking behaviour and self-efficacy (beliefs about ability and capacity to accomplish a task), respectively. Other measures of non-adherence collected by questionnaire were also addressed in the data for comparison of prevalence with the developed concepts. RESULTS: 1,426 (49%) participants answered the questionnaires. The analyses resulted in two sets of components: three adherence behaviour measures and two self-efficacy measures which showed similarities in concepts. The adherence behaviour measures included two concepts of intentional nonadherence (associated with aspects of self-regulation and effect concerns, respectively) and one measure of non-intentional non-adherence. Prevalence of the developed measures of behaviour related non-adherence ranged from 10.3 to 34.9% depending on which type of non-adherence measure was used. Established measures of non-adherence resulted in prevalence between 2.2 and 39.6%. CONCLUSIONS: The study showed that concepts of non-adherence measurements could be determined including self-efficacy aspects, unintentional non-adherence and intentional non-adherence related to self-regulation and effect concerns respectively. The prevalence of the adherence behaviour components were found to be between 10.3 and 34.9%, which is in the range of expected values. Associations between the new concepts of non-adherence measurement and characteristics of nonadherers remain to be established and would be a subject for further studies.

Pharmacy student driven detection of adverse drug reactions in the community pharmacy setting.

PURPOSE: Post-marketing safety studies of adverse drug reactions (ADRs) form an important part of pharmacovigilance. Countries having a formal pharmacovigilance system to a large extent rely on voluntary ADR reporting from health professionals through spontaneous report systems. The contribution of pharmacists in ADR reporting, although varies significantly among countries. Pharmacists in community pharmacies are in a unique position for detection of experienced ADRs by the drug users. The study reports from a study on community pharmacy internship students' proactive role in ADR detection through direct encountering and questioning with drug users. METHOD: Pharmacy students undertaking internship in a community pharmacy were approached. Thirteen students from nine community pharmacies participated in the project as data collectors. Prior to the study students attended an educational seminar focusing on ADR detection and reporting in general. Ibuprofen was chosen as the drug of study. Pharmacy students approached recurrent drug users purchasing the drug. Participating users were asked about experienced ADRs linked to ibuprofen use. Reported ADRs were collected and analysed. RESULTS: Hundred and twenty eight ibuprofen users participated in the study out of who thirty three reported forty five ADRs possibly linked to ibuprofen use. The reported ADRs followed earlier reported patterns of distribution with gastric pain showing up as the most commonly reported symptom followed by heartburn, nausea, diarrhoea and constipation. CONCLUSIONS: Through adequate training community pharmacy internship students get competencies and are capable of detecting and reporting ADRs through direct questions to drug users.

"Patients don't lie"; a view on adherence in asthma.

OBJECTIVE: The primary objective of this article is to examine the extent of self-reported non-adherence among patients participating in a controlled trial of an asthma compliance optimization intervention. The secondary objective is to introduce a two-question questionnaire that is, in wording and design, a neutral tool for disclosure of non-adherence behaviour. METHOD: Data in this study was obtained as part of a controlled trial on an SMS monitoring and compliance intervention developed for Danish asthma patients. The trial was conducted from November 2007 to May 2008. A total of 244 patients participated in the study. Two new designed nonadherence questions were asked in immediate succession. This practice, along with the wording of the questions and use of the Web as medium, constitute a new approach to self-reported adherence assessment. RESULTS: A total of 43.9% of the participants in the trial reported non-adherence to the medical dosage regime for which they had, only one question earlier, documented their awareness. CONCLUSION: This illustrates that at least 43.9% of the participants in the trial dared to report nonadherence to asthma medication.

Provision of pharmaceutical care by community pharmacists: a comparison across Europe.

OBJECTIVE: To investigate the provision of pharmaceutical care by community pharmacists across Europe and to examine the various factors that could affect its implementation. METHODS: A questionnaire-based survey of community pharmacies was conducted within 13 European countries. The questionnaire consisted of two sections. The first section focussed on demographic data and services provided in the pharmacy. The second section was a slightly adapted version of the Behavioral Pharmaceutical Care Scale (BPCS) which consists of three main dimensions (direct patient care activities, referral and consultation activities and instrumental activities). RESULTS: Response rates ranged from 10-71% between countries. The mean total score achieved by community pharmacists, expressed as a percentage of the total score achievable, ranged from 31.6 (Denmark) to 52.2% (Ireland). Even though different aspects of pharmaceutical care were implemented to different extents across Europe, it was noted that the lowest scores were consistently achieved in the direct patient care dimension (particularly those related to documentation, patient assessment and implementation of therapeutic objectives and monitoring plans) followed by performance evaluation and evaluation of patient satisfaction. Pharmacists who dispensed higher daily numbers of prescriptions in Ireland, Germany and Switzerland had significantly higher total BPCS scores. In addition, pharmacists in England and Ireland who were supported in their place of work by other pharmacists scored significantly higher on referral and consultation and had a higher overall provision of pharmaceutical care. CONCLUSION: The present findings suggest that the provision of pharmaceutical care in community pharmacy is still limited within Europe. Pharmacists were routinely engaged in general activities such as patient record screening but were infrequently involved in patient centred professional activities such as the implementation of therapeutic objectives and monitoring plans, or in self-evaluation of performance.

Sustaining delivery of the first publicly reimbursed cognitive service in Denmark: a cross-case analysis.

OBJECTIVES: The aim was to identify local organisational factors that affect sustained delivery of the first Danish publicly reimbursed cognitive service, the Inhaler Technique Assessment Service (ITAS). The ITAS is a 10-min interactive counselling session during which pharmacy staff assess the inhalation technique of individual asthma patients at the pharmacy counter, and correct any errors. Knowledge of how the organisation of a local pharmacy influences ITAS provision will be used to develop quality indicators as part of a targeted quality-assurance system to support the sustainability of the service in all Danish community pharmacies. METHODS: Qualitative methods included field observations, semi-structured interviews, group interviews and the collecting of documentary material. Data-source and method triangulation were applied. Seven pharmacies were included in the study. A cross-case analysis compared pharmacies with sustained and reduced numbers of services based on three selected themes: administration of the ITAS, leadership interventions and professional values of pharmacy owner and staff. KEY FINDINGS: Pharmacies with sustained delivery had introduced systematic evaluations of the local delivery of the ITAS and made ongoing efforts to improve staff competencies. They dealt with individual barriers such as lack of knowledge of rarely distributed inhalation devices and communication techniques. Pharmacy staff in general rarely assessed patients' clinical needs before offering the service and rarely provided follow-up. Thus, pharmacy staff failed to utilise the full clinical potential of the ITAS. CONCLUSIONS: In order to achieve and support further ITAS sustainability, the knowledge, skills and professional values of pharmacy staff must be developed. Human resource leadership techniques would be useful in achieving this aim, as would focusing on the service by providing systematic evaluations.

Development of a qualitative exploratory case study research method to explore sustained delivery of cognitive services.

OBJECTIVE: To develop, apply and evaluate a new research method to establish relationships between structural and process elements of the provision of cognitive services. In-depth knowledge about how local organisational structural elements of community pharmacies shape the implementation process of cognitive services is needed to develop targeted quality assurance systems to ensure that the services are continuously provided to the patients who need them. The first publicly reimbursed cognitive service in Denmark, the Inhaler Technique Assessment Service (ITAS) is used as the case. SETTING: The research method was developed at the Faculty of Pharmaceutical Sciences at the University of Copenhagen and later applied to seven community pharmacies geographically spread around Denmark. METHODS: A pilot study as well as a subsequent literature review was conducted to determine which structure-process elements to focus on in the research method as well as to select appropriate theories and methods. RESULTS: The developed research method was a qualitative exploratory multi-case study, that was based on method triangulation of field observations, semi-structured interviews, group interviews as well as collection of documentary material. The three main themes of the research method were: the administration of tasks, leadership style and professional values. We integrated the organisational theories of Mintzberg, Bolman and Deal as well as Sørensen to support and clarify the data collection process and analyses. A cross-case analysis and an exploratory contextual analysis relating the leadership style of the pharmacy owner to the ITAS provision were applied to the collected data. CONCLUSION: The developed qualitative exploratory multi-case study research method was satisfactory with regard to achieving nuanced and in-depth results of some relationships between structural and process elements of provision of cognitive services. The research method can be considered an important supplement to the existing literature on the sustainability of cognitive services.

The relevance of political prestudies for implementation studies of cognitive services in community pharmacies.

BACKGROUND: Studies of cognitive services implementation in the pharmacy sector traditionally focus on individual and/or organizational factors to explain why some pharmacies are successful and others are not. The social and political context of the origins of these services is rarely part of the analysis. Researchers and practitioners in the field of pharmacy practice research are increasingly being encouraged to take into account the specific political and societal climate which often plays a defining role in the success or failure of cognitive services implementation in community pharmacies. OBJECTIVE: The aim of this article is to argue for the inclusion of political pre-studies as part of the study design for implementation studies on reimbursed services in community pharmacy. METHODS: A political pre-study of the Inhaler Technique Assessment Service (ITAS) introduced in Denmark in 2004 serves as an example of this approach and is described in detail. Documentary analysis was used in order to gain knowledge of the political background of the ITAS. RESULTS: Political pre-studies provide a more precise understanding of the background of the cognitive services and the way they are being performed, thereby supporting more valid results for subsequent implementation studies. CONCLUSION: Political pre-studies were shown to be a useful prerequisite when designing implementation studies of cognitive services in community pharmacies and can provide valuable insight into the ultimate success or failure of these services.

Agreement between self-reported data on medicine use and prescription records vary according to method of analysis and therapeutic group.

OBJECTIVE: This study compared national self-reported data on medicine use and national prescription records at the individual level. STUDY DESIGN AND SETTING: Data from the nationally representative Danish health survey conducted in 2000 (n=16,688) were linked at the individual level to national prescription records covering 1999-2000. Kappa statistics and 95% confidence intervals were calculated. RESULTS: Applying the legend time method to medicine groups used mainly on a chronic basis revealed good to very good agreement between the two data sources, whereas medicines used as needed showed fair to moderate agreement. When a fixed-time window was applied for analysis, agreement was unchanged for medicines used mainly on a chronic basis, whereas agreement increased somewhat compared to the legend time method when analyzing medicines used as needed. CONCLUSION: Agreement between national self-reported data and national prescription records differed according to method of analysis and therapeutic group. A fixed-time window is an appropriate method of analysis for most therapeutic groups.

Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care.

OBJECTIVE: To estimate the incidence and describe characteristics of preventable adverse drug events (pADEs) in ambulatory care. DATA SOURCES: Studies were searched in PubMed (1966-March 2007), International Pharmaceutical Abstracts (1970-December 2006), the Cochrane database of systematic reviews (1993-March 2007), EMBASE (1980-February 2007), and Web of Science (1945-March 2007). Key words included medication error, adverse drug reaction, iatrogenic disease, outpatient, ambulatory care, primary health care, general practice, patient admission, hospitalization, observational study, retrospective studies, health services research, and follow-up studies. Additional articles were found in the reference sections of retrieved articles. STUDY SELECTION AND DATA EXTRACTION: Peer-reviewed articles assessing pADEs in ambulatory care, with detailed descriptions/frequency distributions of (1) ADE/pADE incidence, (2) clinical outcomes, (3) associated drug groups, and/or (4) underlying medication errors were included. Study country, year and design, sample size, follow-up time, ADE/pADE identification method, proportion of ADEs/pADEs and ADEs/pADEs requiring hospital admission, and frequency distribution of adverse outcome, associated drug groups, or medication errors were extracted. DATA SYNTHESIS: Twenty-nine studies met inclusion criteria: 14 were ambulatory-based and 15 were hospital-based. Seven studies enrolled only elderly patients. The median ADE incidence was 14.9 (range 4.0-91.3) per 1000 person-months, and the pADE incidence was 5.6 per 1000 person-months (1.1-10.1). The median ADE preventability rate was 21% (11-38%). The median incidence of ADEs requiring hospital admission was 0.45 (0.10-13.1) per 1000 person-months, and the median incidence of pADEs requiring hospital admission was 4.5 per 1000 person-months. Cardiovascular drugs, analgesics, and hypoglycemic agents together accounted for 86.5% of pADEs, and 77.2% of pADEs resulted in symptoms of the central nervous system, electrolyte/renal system, and gastrointestinal tract. Medication errors resulting in pADEs occurred in the prescribing and monitoring stages. The most frequent drug therapy problem and error of commission reported in ambulatory-based studies on pADEs was the use of inappropriate drugs (42.7%; 40.4-45%). For pADEs requiring hospital admission, the most frequent drug therapy problem and error of omission reported was inadequate monitoring (45.4%; range 22.2-69.8%). Failure to prescribe prophylaxis to patients taking nonsteroidal antiinflammatory drugs or antiplatelet drugs frequently caused gastrointestinal toxicity, whereas lack of monitoring of diuretic, hypoglycemic, and anticoagulant use caused over- or under-diuresis, hyper- or hypoglycemia, and bleeding. CONCLUSIONS: ADEs in ambulatory care are common, with many being preventable and many resulting in hospitalization. Quality improvement programs should target errors in prescribing and monitoring, especially for patients using cardiovascular, analgesic, and hypoglycemic agents.

[Can Danish health care registries provide data for specific drug-related hospital admissions in type 2 diabetes?]. / Kan danske registre anvendes ved utilsigtede haendelser ved type 2-diabetes?

INTRODUCTION: Preventable drug-related hospital admissions (pDRAs) occur frequently but with unknown incidence in type 2 diabetes. The objective of this study was to assess the extent to which Danish health care registries can provide data for specific pDRA indicators in diabetes. MATERIALS AND METHODS: Operationalization of indicators was based on a random 10% sample of the Danish population from 2001-2003 with data from The National Patient Registry, The National Health Insurance Service Registry and The Register of Medicinal Product Statistics. Persons with at least one prescription for an oral antidiabetic agent were identified as type 2 diabetes patients. The frequency and the DRG-value of pDRAs were identified for 2002-2003. RESULTS: The 22 defined indicators were operationalized. Indicator validity was reduced due to lack of laboratory data and data on actual medicine use. The patient material consisted of 9,791 persons and 15,645 person years. 1,198 persons were identified with 9,621 pDRAs. Renal problems preceded by no ACE-inhibitor or angiotensin-2-receptor antagonist therapy were frequent (63.85 (CI 59.89-67.81) per 1,000 person-years), as were secondary AMIs preceded by no ASA, beta-blocker or statin therapy (4.92 (CI 3.82-6.02), 9.52 (CI 7.99-11.05) and 12.66(CI 10.89-14.42) per 1,000 person years). The resulting costs of the identified pDRAs were estimated at DKK 55.7 mill. CONCLUSION: Danish health care registries can provide data for explicit pDRA-indicators in diabetes. However, the validity is reduced as laboratory data and data on actual medicine use are not being registered.