GP-pharmacist Collaboration Research Articles

Does Collaboration between General Practitioners and Pharmacists Improve Risk Factors for Cardiovascular Disease and Diabetes? A Systematic Review and Meta-Analysis.

To assess whether inter-professional, bidirectional collaboration between general practitioners (GPs) and pharmacists has an impact on improving cardiovascular risk outcomes among patients in the primary care setting. It also aimed to understand the different types of collaborative care models used. Systematic review and Hartung-Knapp-Sidik-Jonkman random effects meta-analyses of randomised control trials (RCTs) in inter-professional bidirectional collaboration between GP and pharmacists assessing a change of patient cardiovascular risk in the primary care setting. MEDLINE, EMBASE, Cochrane, CINAHL and International Pharmaceutical Abstracts, scanned reference lists of relevant studies, hand searched key journals and key papers until August 2021. Twenty-eight RCTs were identified. Collaboration was associated with significant reductions in systolic and diastolic blood pressure (23 studies, 5,620 participants) of -6.42 mmHg (95% confidence interval (95%CI) -7.99 to -4.84) and -2.33 mmHg (95%CI -3.76 to -0.91), respectively. Changes in other cardiovascular risk factors included total cholesterol (6 studies, 1,917 participants) -0.26 mmol/L (95%CI -0.49 to -0.03); low-density lipoprotein (8 studies, 1,817 participants) -0.16 mmol/L (95%CI -0.63 to 0.32); high-density lipoprotein (7 studies, 1,525 participants) 0.02 mmol/L (95%CI -0.02 to 0.07). Reduction in haemoglobin A1c (HbA1C) (10 studies, 2,025 participants), body mass index (8 studies, 1,708 participants) and smoking cessation (1 study, 132 participants) was observed with GP-pharmacist collaboration. Meta-analysis was not conducted for these changes. Various models of collaborative care included verbal communication (via phone calls or face to face), and written communication (emails, letters). We found that co-location was associated with positive changes in cardiovascular risk factors. Although it is clear that collaborative care is ideal compared to usual care, greater details in the description of the collaborative model of care in studies is required for a core comprehensive evaluation of the different models of collaboration.

Antimicrobial stewardship by Australian community pharmacists: Uptake, collaboration, challenges, and needs

ObjectiveTo assess community pharmacists’ (CPs’) awareness and uptake of evidence-based antimicrobial stewardship (AMS) strategies, attitudes toward collaboration with general practitioners (GPs), and needs to improve AMS practices. MethodsA nationwide survey of randomly sampled community pharmacies across Australia was conducted in April-October 2019. ResultsThe response rate of CPs was 30.7% (613 of 2000) and 592 participating CPs (96.5%) described the key barriers to and facilitators of improving AMS. CPs (447 of 613, 72.9%) were familiar with AMS but felt that they would require training (468 of 612, 76.5%) and access to AMS practice guidelines (566 of 605, 93.6%). Respondents perceived that AMS programs could reduce the inappropriate use of antimicrobials (409 of 612, 66.8%) and the costs of treating infection (508 of 612, 83.0%). CPs often counseled patients (591 of 609, 97.0%) and reviewed drug interactions or allergies (569 of 607, 93.8%) before dispensing antimicrobials. Respondents less often used the national Therapeutic Guidelines: Antibiotic (274 of 602, 45.5%) or assessed guideline-compliance of prescribed antimicrobials (231 of 609, 37.9%). CPs were less likely to communicate with GPs (254 of 609, 41.8%) when an antimicrobial prescription was believed to be suboptimal and perceived that GPs are not receptive to their intervention regarding the antimicrobial choice (500 of 606, 82.6%) and dosage (416 of 606, 68.6%). Point-of-care tests (114 of 596, 19.1%) and patient information leaflets (149 of 608, 24.5%) were used uncommonly. Most respondents supported policies that could foster GP-pharmacist collaboration (560 of 606, 92.4%), limit accessibility of selected antimicrobials (420 of 604, 74.4%), and reduce repeat-dispensing of antimicrobial prescriptions (448 of 604, 74.2%). CPs faced interpersonal, interactional, structural, and resource-level barriers to collaborate with GPs for practicing AMS. ConclusionsCPs are aware of the importance of sensible use of antimicrobials but have had limited training and resources to conduct AMS activities. Improving GPs’ receptiveness and system structures for increased GP-CP collaboration seem to be a priority to accelerate CP-led AMS implementation. Further study is required to understand the views of stakeholders about the feasibility of implementing evidence-based GP-CP collaborative AMS approaches.

A Nationwide Survey of Australian General Practitioners on Antimicrobial Stewardship: Awareness, Uptake, Collaboration with Pharmacists and Improvement Strategies.

Implementing antimicrobial stewardship (AMS) programs is central to optimise antimicrobial use in primary care. This study aims to assess general practitioners’ (GPs’) awareness of AMS, uptake of AMS strategies, attitudes towards GP–pharmacist collaboration in AMS and future AMS improvement strategies. A paper-based survey of nationally representative GPs across Australia was conducted in 2019. Of 386 respondent GPs, 68.9% were familiar with AMS. Respondents most frequently used the Therapeutic Guidelines (TG) (83.2%, 321/385) and delayed antimicrobial prescribing (72.2%, 278/385) strategies, whereas few utilised point-of-care tests (18.4%, 71/382), patient information leaflets (20.2%, 78/384), peer prescribing reports (15.5%, 60/384) and audit and feedback (9.8%, 38/384). GPs were receptive to pharmacists’ recommendations on the choice (50.5%, 192/381) and dose (63%, 241/382) of antimicrobials, and more than 60% (235/381) supported a policy fostering increased GP–pharmacist collaboration. Most GPs agreed to have AMS training (72%, 278/386), integration of electronic TG (eTG) with prescribing software (88.3%, 341/386) and policies limiting the prescribing of selected antimicrobials (74.4%, 287/386) in the future. Conclusively, GPs are aware of the importance of judicious antimicrobial prescribing but inadequately uptake evidence-based AMS strategies. The majority of GPs support GP–pharmacist collaborative AMS approaches to optimise antimicrobial use. Developing a feasible GP–pharmacist collaborative AMS implementation model and facilitating stewardship resources and training could foster AMS activities in primary care.

A mixed methods analysis of community pharmacists' perspectives on delivering COPD screening service to guide future implementation.

Studies have shown that COPD screening by community pharmacists is effective, but it is unknown if it can be successfully implemented in Australian pharmacies. We aimed to investigate the pharmacist-perceived barriers and facilitators to the implementation of a community pharmacy-based COPD screening service guided by implementation science methodology. Trained pharmacists participated in a 6 month longitudinal study designed and based on implementation science frameworks. Pharmacists completed feedback questionnaires pre-and post-study and participated in semi-structured telephone interviews about their experience of implementing the service, the training provided, their views on patient recruitment, their interactions with health professionals and patients, and their future recommendations for such a service. Interviews were recorded and transcribed verbatim, analysed thematically, and questionnaire and interview data were triangulated. Of 20 pharmacists providing questionnaire data, 15 pharmacists (male 53%; age 39.8 ± 8.6yrs, rural 47%) participated in an interview. Questionnaire data revealed that pharmacists engaged positively with the service and reported that it was very useful for patients and for the profession. In-depth qualitative analysis revealed 6 main implementation themes: 1. Patient recruitment (pharmacists lacked patient recruitment skills), 2. Adaptation and entrepreneurship (protocol adaptation increased patient engagement), 3. Training and resource needs (face-to-face training was preferred for skill-based learning), 4. Lack of GP involvement (sub-optimal GP-pharmacist collaboration), 5. Factors related to the operation or full implementation phase (high professional satisfaction, need for remuneration) and 6. Suggestions for refining the screening service (raise public awareness about the service, provide service remuneration, use electronic methods to improve GP referral uptake). A number of effective adaptations to the service were reported by pharmacists, such as advertising, recruitment practices, patient inclusion criteria and inter-professional communication with GPs which would be beneficial to implementation. This mixed methods study identified a number of key facilitators to service implementation and challenges such as difficulty with patient recruitment, low public awareness of pharmacy-based clinical services, remuneration, and sub-optimal GP-pharmacist collaboration. Working with stakeholders to identify and resolve challenges and to optimise the fit of the service for individual settings may lead to increasingly successful implementation of pharmacy-based service models.

General practitioners' perceptions of the current status and pharmacists' contribution to primary care in Iceland.

Background For the past several years pharmacists' responsibilities have expanded globally from traditional tasks of dispensing medications to collaborating with other health care professionals in patient care. Similar developments have not occurred in outpatient settings in Iceland. Objective The aim of this study was to explore Icelandic general practitioners' views on the current status of primary care, their perceptions of pharmacists as a health care profession, and their attitudes towards future GP-pharmacist collaboration in primary care in Iceland. Setting Twelve primary care clinics in Iceland. Methods Semi-structured in-depth interviews were conducted with general practitioners from different primary care clinics in Iceland. A purposive and snowball sampling technique was used to select participants. All interviews were recorded and transcribed verbatim. The transcripts were categorized by themes and then analyzed using conventional content analysis. Main outcome measure General practitioners' attitudes towards pharmacists. Results Twenty general practitioners from twelve different primary care clinics in Iceland were interviewed. There are several unmet needs regarding medicines and patient monitoring in the Icelandic health care system. General practitioners suggested ways in which these gaps may be addressed and pharmacist-led clinical service was one of the suggestions. Currently, their communication with pharmacists in the primary sector solely surrounds practical non-clinical issues. Due to increasing polypharmacy and multimorbidity, they suggested that pharmacists should be more involved in patient care. Conclusions General practitioners believe that pharmacist-led clinical service can increase the quality of patient therapy. To improve communication between these health care providers, pharmacists must also re-professionalize (strengthening the profession´s status through new responsibilities and tasks), not having a conflict of interest and showing that they have expertise in patient care.

Medicines use reviews: a potential resource or lost opportunity for general practice?

BackgroundPatient non-adherence to medicines represents a significant waste of health resource and lost opportunity for health gain. Medicine management services are a key health policy strategy to encourage patients to take medicines as they are prescribed. One such service is the English Medicines Use Review (MUR) which is an NHS-funded community pharmacy service involving a patient-pharmacist consultation aiming to improve patients’ knowledge of medicines and their use. To date the evidence for MURs to improve patient health outcomes is equivocal and GPs are reported to be sceptical about the value of the service. This paper presents the patient’s perspective of the MUR service and focuses on the importance of GP-pharmacist collaboration for patient care. Suggestions on how MURs may have value to GPs through the delivery of increased patient benefit are discussed.MethodA qualitative study involving ten weeks of ethnographic observations in two English community pharmacies. Observations were made of all pharmacy activities including patient-pharmacist MUR consultations. Subsequent interviews with these patients were conducted to explore their experience of the service. Interviews with the pharmacy staff were conducted after the period of observations. A thematic approach was used to analyse the data.ResultsFifty-four patients agreed to have their MUR observed of which thirty-four were interviewed. Seventeen pharmacy staff were also interviewed. Patients reported positive views about MURs. However, there was little evidence suggesting that pharmacists and GPs were working collaboratively or communicating outcomes resulting from MURs. MURs were conducted in isolation from other aspects of patient care. Patients considered GPs to have authority over medicines making a few wary that MURs had the potential to cause tensions between these professionals and possibly adversely affect their own relationship with their doctor.ConclusionsThis study reveals the potential for effective GP-pharmacist collaboration to improve the capacity of the MUR service to support patient medicine taking. Closer collaboration between GPs and pharmacists could potentially improve patients’ use of medicines and associated health care outcomes. The current lack of such collaboration constitutes a missed opportunity for pharmacists and GPs to work together with patients to improve effective prescribing and optimise patient use of medicines.

Development and validation of a measure and a model of general practitioner attitudes toward collaboration with pharmacists

Collaboration between general practitioners (GPs) and community pharmacists has been shown to be effective in improving patient outcomes. However, little is known about GP attitudes toward collaborating with their pharmacist counterparts and variables that influence this interprofessional collaboration. To develop and validate, in the context of primary care in Australia 1) an instrument to measure GP attitudes toward collaborating with pharmacists and 2) a model that illustrates how GP attitudes (and other variables) influence GP-pharmacist collaborative behavior. The "Attitudes Toward Collaboration Instrument for GPs" (ATCI-GP) was developed to measure GP attitudes toward GP-pharmacist collaboration based on existing literature and qualitative interviews with GPs and community pharmacists. The ATCI-GP and a previously validated behavioral measure "Frequency of Interprofessional Collaboration Instrument for GPs" (FICI-GP) were included in a survey and administered to a sample of 1145 GPs in 12 divisions of general practice across Australia. Principal component analysis (PCA) was used to assess the structure of the ATCI-GP. Structural equation modeling was used to determine how attitudes (measured by the ATCI-GP) and other variables, influence collaborative behavior (measured by the FICI-GP). Three hundred and seventy-six surveys were completed and returned for a response rate of 33%. PCA of the ATCI-GP suggested a two factor ("interactional and practitioner determinants" and "role for pharmacist in medication management") solution accounting for 66.2% of the variance. The model for GP-pharmacist collaboration demonstrated adequate fit (χ(2)/df = 2.27, CFI = .99, RMSEA = .060, 90% CI [.052-.069]). Factors found to predict collaboration included: 1) Interactional and practitioner determinants 2) environmental determinants and 3) GP perception of the pharmacists' role in medication management. The study provides evidence for the validity of the ATCI-GP for measuring GP-pharmacist collaboration from the GPs perspective and supports a model for collaboration in which collaborative behavior is influenced by a number of variables.

Factors Predicting GP-Pharmacist Interprofessional Collaboration in Primary Care from the Pharmacist's Perspective: A Structural Equation Modelling Approach

s / Research in Social and Admin sharing between providers and healthcare settings was the key. Conclusions: The findings of this study suggest that changes may be necessary at several levels (i.e. consumer, provider and environmental) before an effective interprofessional approach to SDM in mental health can be implemented. General Practitioners’ Views on Pharmacists Potential Contributions to Medication-Related Services in New Zealand E. Hatah, R. Braund, S. Duffull, J. Tordoff, School of Pharmacy, University of Otago, Dunedin New Zealand, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Malaysia Objectives: The objective of this study was to evaluate general practitioners’ (GPs) perceptions of pharmacists’ contributions to medication-related services using a strengths, weaknesses, opportunities and threats (SWOT) analysis. The specific services discussed were medication review and prescribing. Methods: In 2011, qualitative, face-to-face semi-structured interviews with 18 GPs from two localities in New Zealand were undertaken. The cohorts of GPs included those with differing years of practice and whose patients had or had not undergone a pharmacist-lead adherence support medication review (Medication Use Review, MUR). GPs were asked their opinions of pharmacist’s provision of MUR, clinical medication review and prescribing. Data were analysed thematically using NVivo 8 and grouped by SWOT category. TheUniversity of Otago Ethics Committee gave approval for the study. Results: The SWOT analysis revealed that GPs’ thought their own skills and training in diagnosis and treatment and knowledge of clinical conditions were their major strengths. GPs’ weaknesses were limited time for medication reviews, heavy workloads and limitations in knowledge of pharmacology. GPs thought pharmacists had strengths in the latter and might have more time for in depth review of medications if funded by the health system to do so. However, GPs perceived the new medication-related services by pharmacists could confuse the patients and might increase GP workloads. GPs thought pharmacists might have a limited role in medication review or prescribing but would prefer that such activities took place in a GP’s surgery. Conclusions: GPs perceived their own skills were wellsuited to reviewing medication and prescribing for patients but acknowledged some weaknesses such as lack of time for in-depth review and a limited knowledge of pharmacology. They thought that pharmacists had strengths in these areas and that there was a possibility of working collaboratively together with pharmacists in these services in the future if collocation of activities occurred. Factors Predicting GP-Pharmacist Interprofessional Collaboration in Primary Care from the Pharmacist's Perspective: A Structural Equation Modelling Approach C. Van, D. Costa, B. Mitchell, P. Abbott, I. Krass, Faculty of Pharmacy, University of Sydney, Australia, School of Psychology, University of Sydney, Australia, School of Medicine, University of Western Sydney,

General Practitioners’ Views on Pharmacists Potential Contributions to Medication-Related Services in New Zealand

s / Research in Social and Admin sharing between providers and healthcare settings was the key. Conclusions: The findings of this study suggest that changes may be necessary at several levels (i.e. consumer, provider and environmental) before an effective interprofessional approach to SDM in mental health can be implemented. General Practitioners’ Views on Pharmacists Potential Contributions to Medication-Related Services in New Zealand E. Hatah, R. Braund, S. Duffull, J. Tordoff, School of Pharmacy, University of Otago, Dunedin New Zealand, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Malaysia Objectives: The objective of this study was to evaluate general practitioners’ (GPs) perceptions of pharmacists’ contributions to medication-related services using a strengths, weaknesses, opportunities and threats (SWOT) analysis. The specific services discussed were medication review and prescribing. Methods: In 2011, qualitative, face-to-face semi-structured interviews with 18 GPs from two localities in New Zealand were undertaken. The cohorts of GPs included those with differing years of practice and whose patients had or had not undergone a pharmacist-lead adherence support medication review (Medication Use Review, MUR). GPs were asked their opinions of pharmacist’s provision of MUR, clinical medication review and prescribing. Data were analysed thematically using NVivo 8 and grouped by SWOT category. TheUniversity of Otago Ethics Committee gave approval for the study. Results: The SWOT analysis revealed that GPs’ thought their own skills and training in diagnosis and treatment and knowledge of clinical conditions were their major strengths. GPs’ weaknesses were limited time for medication reviews, heavy workloads and limitations in knowledge of pharmacology. GPs thought pharmacists had strengths in the latter and might have more time for in depth review of medications if funded by the health system to do so. However, GPs perceived the new medication-related services by pharmacists could confuse the patients and might increase GP workloads. GPs thought pharmacists might have a limited role in medication review or prescribing but would prefer that such activities took place in a GP’s surgery. Conclusions: GPs perceived their own skills were wellsuited to reviewing medication and prescribing for patients but acknowledged some weaknesses such as lack of time for in-depth review and a limited knowledge of pharmacology. They thought that pharmacists had strengths in these areas and that there was a possibility of working collaboratively together with pharmacists in these services in the future if collocation of activities occurred. Factors Predicting GP-Pharmacist Interprofessional Collaboration in Primary Care from the Pharmacist's Perspective: A Structural Equation Modelling Approach C. Van, D. Costa, B. Mitchell, P. Abbott, I. Krass, Faculty of Pharmacy, University of Sydney, Australia, School of Psychology, University of Sydney, Australia, School of Medicine, University of Western Sydney,

Impact of medication regimen reviews performed by community pharmacists for ambulatory patients through liaison with general medical practitioners

Abstract Objective To evaluate the cost and clinical benefits of the provision of medication regimen reviews (MRRs) by community pharmacists for patients identified and referred by a general practitioner using a collaborative approach. Method There were two cohorts of patients — 105 in stage 1 and 170 in stage 2 — from 34 GPs. The reviews were performed by 45 community pharmacists who had completed a training programme in MRR. The protocol was as follows: (1) a proforma MRR request form, including relevant clinical information and the patient's current regimen, was completed by the GP, (2) the review was conducted by the pharmacist and documented in a proforma report, (3) pharmacists and GPs met to discuss the review findings and recommendations for each patient, and (4) three months later, GPs were surveyed to verify any accepted recommendations and changes to medication regimen. A clinical panel estimated the clinical significance of the regimen changes for a subset of 141 cases. Key findings The patients had an average of five diagnoses, with cardiovascular disease (34 per cent) and musculoskeletal disease (15 per cent) the most common conditions. A total of 2,220 medications were prescribed, representing a mean of eight per patient. In all, 869 changes to therapy were observed at the three-month follow up: 47 per cent drug ceased; 17 per cent dose reduced; 11 per cent dose increased; and 12 per cent drug changed. Examining the impact of MRR on the mean number of medications per patient, the null hypothesis of no difference pre- and post-MRR was rejected. There was a mean reduction of one medication per patient (P<0.001). As a consequence of this reduction, the average annual cost of medications was reduced by $A240 per patient. This translated to a projected annual cost saving for medication alone of $A90 per patient after offsetting the $A150 cost (professional remuneration) of the MRR. Considering health outcomes, overall, the reviewers rated at least 40 per cent of the MRR changes as leading to a positive effect on the patient's health. Conclusion This study provides a good indication that MRR through GP-pharmacist collaboration in the community can lead to positive clinical benefits and reduction in health care costs.

Professional perspectives on a feasibility study of GP-pharmacist collaboration in the management of angina

Abstract Objective To report the views and experiences of a convenience sample of community pharmacists and general practitioners (GPs) who participated in a five-month feasibility study exploring the ways in which community pharmacists could contribute to the management of patients with stable angina when working in partnership with GPs. Method Five pharmacists delivered a specified model of care, which represented one component of a district-wide strategy aimed at improving the management of ischaemic heart disease (IHD), to 208 patients in eight general practices. The care involved six evidence-based interventions: smoking cessation, dietary advice, exercise, aspirin, beta-blockers and statins. This paper illuminates professional perspectives concerning involvement in the study. The findings of semi-structured interviews exploring views and experiences of the pharmacists during the first and the final month of the study and those of the GPs at completion of the study are reported. Setting St Helens and Knowsley, UK, an area with a high IHD standardised mortality rate (SMR). Key findings The pharmacists reported high levels of satisfaction and success in relation to the study interventions and more professionally satisfying relationships with patients and GPs. Successes with therapeutic interventions were described, both within and external to the study protocol. The GPs expressed a high level of satisfaction with the conduct and outcome of the pharmacist delivered care and heightened awareness of the need to review their approach to preventive care for IHD patients. Conclusion The findings confirm that pharmacists and GPs can work in partnership to deliver a specified model of care to patients with stable IHD and also inform the debate on a role for community pharmacists as dependent prescribers.