Practice-based Pharmacists Research Articles

Patients\u2019 experiences of pharmacists in general practice: an exploratory qualitative study

BackgroundSince 2015, pharmacists have been integrating into English general practices and more recently into primary care networks. General practice-based pharmacists provide a range of patient-facing services, such as medication reviews, management of long-term conditions and minor ailments, prescribing duties and answering queries over the telephone. Literature reports patients’ satisfaction with general practice-based pharmacists’ services, however, previous research captured only limited experiences. The aim of the current study was to pursue an extensive exploration of patients’ experiences of pharmacists in general practice.MethodsGeneral practice-based pharmacists, working in practices in West London, Surrey and Berkshire, handed invitation packs to patients seen during consultations. Patients that wanted to take part in the study were invited to undertake a qualitative, in-depth, face-to-face, semi-structured interview within the practice with which each patient was registered. Interviews lasted from 15 min to more than 1 h and were audio-recorded. Recruitment continued until data saturation. Audio-recordings were transcribed verbatim and transcripts analysed thematically.ResultsTwenty participants were interviewed. Four themes were discerned: awareness (“I had been coming to this practice for 24 years and I didn’t know that there was a pharmacist”); accessibility (“People ring for a GP [general practitioner] appointment … it’s Monday and they [receptionist] tells you ‘We can slot you in on Friday’ … with a pharmacist on board, they can [instantly] look at you”); interactions (“I’ve always had a really good interaction with them [pharmacists] and they listen and they take on board what I’m trying to say”); and feedback (“It’s easier [to collect feedback instantly] because I could have forgotten half of what they [pharmacists] have told me in an hour or so’s time”).ConclusionsFindings indicate that pharmacists’ integration into general practices could improve accessibility to, and the quality of, care received. The findings will assist policy development to provide general practice-based pharmacists’ services as per patients’ needs.

The cardiology training needs of general practice-based pharmacists.

As the role of the general practice clinical pharmacist (GPCP) evolves, there has been a shift towards patient-facing roles across multiple conditions. This study aimed to measure the self-reported cardiology training needs of GPCPs. An online survey was developed. Participants were shown a list of statements on cardiac conditions and medication across seven sub-domains. Participants self-reported their knowledge against each statement using a Likert Scale. Participants were considered to require training in that topic where they had 'disagreed', 'strongly disagreed' or expressed a 'neutral' rating in ≥3/7 areas. Participants were shown a list of single statements around cardiology test result knowledge and clinical assessment skills. Respondents who 'disagreed', 'strongly disagreed' or declared a 'neutral' position with the statement were judged to need training in that topic. Seventy-three out of 135 (54%) GPCPs responded. Acute coronary syndrome had the highest training requirement (38/73, 52%) within conditions. Fifty-nine out of 73 (81%) required training on sacubitril/valsartan and 57/73 (78%) with ivabradine. Fifty-four out of 73 (74%) and 44/73 (60%) required training on how to interpret natriuretic peptides and troponin, respectively. Fifty-nine out of 73 (81%), 48/73 (66%) and 55/73 (75%) required training on interpreting ECG, echocardiogram and coronary angiography, respectively. Reduced length of experience in general practice (<2 years) was commonly associated with increased training needs. There are areas of unmet cardiology training needs within GPCPs that require further support. As the GPCP role evolves, discussion is needed with national pharmacy stakeholders to decide how to incorporate this learning into routine training programmes.

A systematic review of general practice-based pharmacists' services to optimize medicines management in older people with multimorbidity and polypharmacy.

Few studies have evaluated roles of general practice-based pharmacists (PBPs), particularly in optimizing medicines management for older people with both multimorbidity and polypharmacy. To explore the types and effectiveness of services provided by PBPs, either alone or in collaboration with other primary health care professionals, that sought to optimize medicines management for older people with multimorbidity and polypharmacy. Eight electronic databases and three trial registries were searched for studies published in English until April 2020. Inclusion criteria were randomized controlled trials, non-randomized controlled trials and controlled before-and-after studies of services delivered by PBPs in primary care/general practice, for patients aged ≥65 years with both multimorbidity and polypharmacy that focused on a number of outcomes. The Cochrane risk of bias tool for randomized trials (RoB 1) and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) assessment tool were used for quality assessment. A narrative synthesis was conducted due to study heterogeneity. Seven studies met inclusion criteria. All included studies employed PBP-led medication review accompanied by recommendations agreed and implemented by general practitioners. Other patient-level and practice-level interventions were described in one study. The limited available evidence suggested that PBPs, in collaboration with other practice team members, had mixed effects on outcomes focused on optimizing medicines management for older people. Most included studies were of poor quality and data to estimate the risk of bias were often missing. Future high-quality studies are needed to test the effects of PBP interventions on a well-defined range of medicines management-related outcomes.

General practitioner practice-based pharmacist input to medicines optimisation in the UK: pragmatic, multicenter, randomised, controlled trial

BackgroundChanging demographics across the UK has led to general practitioners (GPs) managing increasing numbers of older patients with multi-morbidity and resultant polypharmacy. Through government led initiatives within the National Health Service, an increasing number of GP practices employ pharmacist support. The purpose of this study is to evaluate the impact of a medicines optimisation intervention, delivered by GP practice-based pharmacists, to patients at risk of medication-related problems (MRPs), on patient outcomes and healthcare costs.MethodsA multi-centre, randomised (normal care or pharmacist supplemented care) study in four regions of the UK, involving patients (n = 356) from eight GP practices, with a 6-month follow-up period. Participants were adult patients who were at risk of MRPs.ResultsMedian number of MRPs per intervention patient were reduced at the third assessment, i.e. 3 to 0.5 (p < 0.001) in patients who received the full intervention schedule. Medication Appropriateness Index (MAI) scores were reduced (medications more appropriate) for the intervention group, but not for control group patients (8 [4–13] to 5 [0–11] vs 8 [3–13] to 7 [3–12], respectively; p = 0.001). Using the intention-to-treat (ITT) approach, the number of telephone consultations in intervention group patients was reduced and different from the control group (1 [0–3] to 1 [0–2] vs 1 [0–2] to 1 [0–3], p = 0.020). No significant differences between groups were, however, found in unplanned hospital admissions, length of hospital stay, number of A&E attendances or outpatient visits. The mean overall healthcare cost per intervention patient fell from £1041.7 ± 1446.7 to £859.1 ± 1235.2 (p = 0.032). Cost utility analysis showed an incremental cost per patient of − £229.0 (95% CI − 594.6, 128.2) and a mean QALY gained of 0.024 (95% CI − 0.021 to 0.065), i.e. indicative of a health status gain at a reduced cost (2016/2017).ConclusionThe pharmacist service was effective in reducing MRPs, inappropriateness of medications and telephone consultations in general practice in a cost-effective manner.Trial registration: ClinicalTrials.Gov, NCT03241498. Registered 7 August 2017—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03241498

Multiplicity and complexity: a qualitative exploration of influences on prescribing in UK general practice

ObjectivesDespite widespread availability of evidence-based guidelines to inform rational use of medicines, considerable unwarranted variation exists in prescribing. A greater understanding of key determinants of contemporary prescribing in UK general...

Campaign letter for RPS elections 2021: Farzana Haq on boosting pharmacists with advanced skills

I am passionate that our profession has rewarding career pathways for pharmacists in increasingly clinical roles, and that practice-based pharmacists with advanced clinical skills are able to practice in a patient-facing role. The pharmacotherapy service (PTS), as described in the 2018 General Medical Services (GMS) contract in Scotland, was unexpected for many of us. Once […]

Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study.

Growing prevalence of atrial fibrillation (AF) in the ageing population and its associated life-changing health and resource implications have led to a need to improve its early detection. Primary care is an ideal place to screen for AF; however, this is limited by shortages in general practitioner (GP) resources. Recent increases in the number of clinical pharmacists within primary care makes them ideally placed to conduct AF screening. This study aimed to determine the feasibility of GP practice-based clinical pharmacists to screen the over-65s for AF, using digital technology and pulse palpation during the influenza vaccination season. Screening was conducted over two influenza vaccination seasons, 2017-2018 and 2018-2019, in four GP practices in Kent, United Kingdom. Pharmacists were trained by a cardiologist to pulse palpate, record, and interpret a single-lead ECG (SLECG). Eligible persons aged ≥65 years (y) attending an influenza vaccination clinic were offered a free heart rhythm check. Six hundred four participants were screened (median age 73 y, 42.7% male). Total prevalence of AF was 4.3%. All participants with AF qualified for anticoagulation and were more likely to be male (57.7%); be older; have an increased body mass index (BMI); and have a CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes, previous Stroke, Vascular disease, Age 65-74 years, Sex category) score ≥ 3. The sensitivity and specificity of clinical pharmacists diagnosing AF using pulse palpation was 76.9% (95% confidence interval [CI] 56.4-91.0) and 92.2% (95% CI 89.7-94.3), respectively. This rose to 88.5% (95% CI 69.9-97.6) and 97.2% (95% CI 95.5-98.4) with an SLECG. At follow-up, four participants (0.7%) were diagnosed with new AF and three (0.5%) were initiated on anticoagulation. Screening with SLECG also helped identify new non-AF cardiovascular diagnoses, such as left ventricular hypertrophy, in 28 participants (4.6%). The screening strategy was cost-effective in 71.8% and 64.3% of the estimates for SLECG or pulse palpation, respectively. Feedback from participants (422/604) was generally positive. Key limitations of the study were that the intervention did not reach individuals who did not attend the practice for an influenza vaccination and there was a limited representation of UK ethnic minority groups in the study cohort. This study demonstrates that AF screening performed by GP practice-based pharmacists was feasible, economically viable, and positively endorsed by participants. Furthermore, diagnosis of AF by the clinical pharmacist using an SLECG was more sensitive and more specific than the use of pulse palpation alone. Future research should explore the key barriers preventing the adoption of national screening programmes.

Pharmacy services and role development in UK general practice: a cross-sectional survey.

The 'Clinical Pharmacists in General Practice' (CPGP) pilot provided a template for general practice pharmacy professionals' (GPPPs) roles encouraging NHS England to fund >2000 practice-based pharmacists. However, many GPPPs work outside the CPGP initiative and little is known about the services they provide. To explore services provided by all UK GPPPs (pharmacists/pharmacy technicians), including the types of services, perceived benefits and barriers to role development. A 26-item electronic questionnaire was developed using SurveyMonkey and piloted during cognitive interviews. A cross-sectional survey was conducted via social media, primary care organisations and emails to CPGP pilot sites between November 2018 and March 2019. Three reminders were sent 1 week apart. Ninety-one complete responses were received (81 pharmacists; 10 technicians). Over 80% of pharmacists provided clinical services, such as medication reviews or management of long-term conditions. More pharmacists within CPGP pilot managed repeat prescribing requests (P=0.035). Technicians took responsibility for primarily non-clinical roles, including commissioning or safety alerts/drug recalls. A third of GPPPs wished to develop care home services. Perceived benefits of GPPPs' services included improved utilisation/development of professional skills, identifying medicines-related issues and reduction in medication waste. Respondents were satisfied with professional relationships but reported workload issues, limited patient awareness of their roles and restricted opportunities to contribute to service development, which was associated with unsatisfactory support/mentorship (P<0.001). General practice pharmacy professionals deliver clinical and non-clinical services which may benefit patients, general practice and the healthcare system. General practices and national organisations should provide GPPPs with tailored support and exploit the combined strengths of pharmacists and pharmacy technicians to tackle increased workload.

Pharmacists detecting atrial fibrillation in general practice: a qualitative focus group study.

BackgroundAtrial fibrillation (AF) affects up to 10% of people aged ≥65 years, yet a third of all cases remain undetected. Practice-based pharmacists are in an ideal position to facilitate opportunistic AF screening, while increasing general practice capacity at a time of workforce crisis.AimTo explore the perspectives of three stakeholder groups involved in the ‘Pharmacists Detecting Atrial Fibrillation’ (PDAF) study to elucidate the facilitators and barriers to pharmacist-led AF screening in general practice.Design & settingA qualitative study took place, comprising homogeneous focus groups with stakeholders in Kent, UK.MethodThe stakeholder groups — patients, general practice staff (GPS), and clinical pharmacists (CPs) — were recruited using convenience sampling. Audio-recordings were transcribed verbatim and analysed using a deductive Theoretical Domains Framework (TDF) approach.ResultsTwenty-five patients, four pharmacists, and nine practice staff participated in six focus groups. Three main themes were identified: knowledge and awareness; prioritisation of resources; and environmental considerations. The public’s lack of awareness of AF-related risks and pharmacist-led screening services was highlighted. Practice-based pharmacists were perceived as an underutilised educational resource which, together with novel electrocardiogram devices, enabled convenient access to screening while reducing GPs’ workload. Participants agreed that AF screening should be incorporated into personalised health checks and at-risk groups should be prioritised, such as care home residents. Patients favoured the general practice environment over the community pharmacy where concerns of privacy, staffing, and commercialisation were raised.ConclusionThe findings of this study support the introduction of pharmacist-led AF screening programmes in general practice surgeries. Commissioners should consider the added value of utilising CPs and focus on the delivery of AF screening within an integrated service.

Community pharmacy teams\u2019 experiences of general practice-based pharmacists: an exploratory qualitative study

BackgroundIn England, since 2015, there has been a formal drive to integrate pharmacists into general practice as a new healthcare service. Research efforts have offered insights into how general practice-based professionals and patients view the service, however, they took no account of community pharmacy teams’ opinions. There have been anecdotal statements about opposition from community pharmacies to the service, due to fears of losing business. The aim of the current study was to identify the experiences and perceptions of community pharmacy teams regarding pharmacists’ presence in general practice.MethodsThe National Health Service Choices website was used to identify community pharmacies within a radius of two miles from eight West London general practices. The search resulted in 104 community pharmacies which were all contacted via telephone. Pharmacy staff who verbally expressed their interest to participate were then provided with the study’s documents. Qualitative, face-to-face, semi-structured interviews were conducted inside the pharmacy from which each participant was recruited. Interviews lasted 30 to 45 min and were audio-recorded. Audio-recordings were transcribed verbatim and transcripts analysed thematically.ResultsForty-eight community pharmacy staff participated. Four themes were discerned: awareness (“I knew that [pharmacists] have already been implemented [in general practice] but I haven’t really followed it … where does the pharmacist role come?”); interactions (“I’m just so pleased that there’s a pharmacist professional in the general practice … because we speak the same language!”); patient care (“if I was a patient knowing that there is a general practitioner and a pharmacist [in general practice], I would … think ‘nothing can go wrong at the moment’”); and funding challenges (“if general practices take on the extra responsibility of stop smoking or flu vaccination campaigns … financially, this would affect this pharmacy”).ConclusionsThe current study revealed the perceived impact of general practice-based pharmacists on community pharmacies would be improved communication between pharmacies and practices. Findings will inform policy so that any future framing of pharmacists’ presence in general practice considers the needs of community pharmacies.

Impact of the pharmacist-led intervention on the control of medical cardiovascular risk factors for the primary prevention of cardiovascular disease in general practice: A systematic review and meta-analysis of randomised controlled trials.

To conduct a systematic review and meta-analysis of the effectiveness of general practice-based pharmacist interventions in reducing the medical risk factors for the primary prevention of cardiovascular events. A systemic search was undertaken in 8 databases: PubMed, MEDLINE, EMBAS, PsycINFO, Cochrane Library, CINAHL Plus, SCOPUS and Science Citation Index, with no start date up to 27 March 2019. Randomised controlled trials assessing the effectiveness of pharmacist-led interventions delivered in the general practice in reducing the medical risk factors of cardiovascular events were included in the review. The risk of bias in the studies was assessed using the Cochrane risk of bias tool. A total of 1604 studies were identified, with 21 randomised controlled trials (8933 patients) meeting the inclusion criteria. Fourteen studies were conducted in patients with diabetes, 7 in hypertension, 2 involving dyslipidaemia, and 2 with hypertension and diabetes together. The most frequently used interventions were medication review and medication management. The quality of the included studies was variable. Patients receiving pharmacist-led interventions were associated with a statistically significant reduction in their systolic blood pressure (-9.33 mmHg [95% Confidence Interval (CI) -13.36 to -5.30]), haemoglobin A1C (-0.76% [95% CI -1.15 to -0.37]) and low-density lipoprotein-cholesterol (-15.19 mg/dL [95% CI -24.05 to -6.33]). Moreover, practice-based pharmacists' interventions were also reported to have a positive impact on patient adherence to medications. The findings of this review suggest that pharmacist-led interventions in general practice can significantly reduce the medical risk factors of cardiovascular disease events. These findings support the involvement of pharmacists as healthcare providers in managing patients with hypertension, diabetes and dyslipidaemia.

Capturing pharmacists\u2019 impact in general practice: an e-Delphi study to attempt to reach consensus amongst experts about what activities to record

BackgroundIn the UK, there is ongoing integration of pharmacists into general practice as a new healthcare service in primary care. Evaluation of the service involves national measures that require pharmacists to record their work, on the general practice clinical computer systems, using electronic activity codes. No national agreement, however, has been established on what activities to record. The purpose of this study was to attempt to reach consensus on what activities general practice-based pharmacists should record.MethodsThe e-Delphi method was chosen as it is an excellent technique for achieving consensus. The study began with an initial stage in which screening of a general practice clinical computer system and discussion groups with pharmacists from two ‘pharmacists in general practice’ sites identified 81 codes potentially relevant to general practice-based pharmacists’ work. Twenty-nine experts (pharmacists and pharmacy technicians from the two sites along with experts recruited through national committees) were then invited by e-mail to participate as a panel in three e-Delphi questionnaire rounds. In each round, panellists were asked to grade or rank codes and justify their choices. In every round, panellists were provided with anonymised feedback from the previous round which included their individual choices along with their co-panellists’ views. Final consensus (in Round 3) was defined as at least 80% agreement. Commentaries on the codes from all e-Delphi rounds were pooled together and analysed thematically.ResultsTwenty-one individual panellists took part in the study (there were 12 responses in Round 1, 18 in Round 2 and 16 in Round 3). Commentaries on the codes included three themes: challenges and facilitators; level of detail; and activities related to funding. Consensus was achieved for ten codes, eight of which related to activities (general and disease specific medication reviews, monitoring of high-risk drugs and medicines reconciliation) and two to patient outcomes (presence of side effects and satisfactory understanding of medication).ConclusionsA formal consensus method revealed general practice-based pharmacists’ preferences for activity coding. Findings will inform policy so that any future shaping of activity coding for general practice-based pharmacists takes account of pharmacists’ actual needs and preferences.

Practice-based pharmacist scheme doubles return on investment

Practice-based pharmacist scheme doubles return on investment

Supporting prescribing in Irish primary care: protocol for a non-randomised pilot study of a general practice pharmacist (GPP) intervention to optimise prescribing in primary care

BackgroundPrescribing for patients taking multiple medicines (i.e. polypharmacy) is challenging for general practitioners (GPs). Limited evidence suggests that the integration of pharmacists into the general practice team could improve the management of these patients. The aim of this study is to develop and test an intervention involving pharmacists, working within GP practices, to optimise prescribing in Ireland, which has a mixed public and private primary healthcare system.MethodsThis non-randomised pilot study will use a mixed-methods approach. Four general practices will be purposively sampled and recruited. A pharmacist will join the practice team for 6 months. They will participate in the management of repeat prescribing and undertake medication reviews (which will address high-risk prescribing and potentially inappropriate prescribing, deprescribing and cost-effective and generic prescribing) with adult patients. Pharmacists will also provide prescribing advice regarding the use of preferred drugs, undertake clinical audits, join practice team meetings and facilitate practice-based education. Throughout the 6-month intervention period, anonymised practice-level medication (e.g. medication changes) and cost data will be collected. A nested Patient Reported Outcome Measure (PROM) study will be undertaken during months 4 and 5 of the 6-month intervention period to explore the impact of the intervention in older adults (aged ≥ 65 years). For this, a sub-set of 50 patients aged ≥ 65 years with significant polypharmacy (≥ 10 repeat medicines) will be recruited from each practice and invited to a medication review with the pharmacist. PROMs and healthcare utilisation data will be collected using patient questionnaires, and a 6-week follow-up review conducted. Acceptability of the intervention will be explored using pre- and post-intervention semi-structured interviews with key stakeholders. Quantitative and qualitative data analysis will be undertaken and an economic evaluation conducted.DiscussionThis non-randomised pilot study will provide evidence regarding the feasibility and potential effectiveness of general practice-based pharmacists in Ireland and provide data on whether a randomised controlled trial of this intervention is indicated. It will also provide a deeper understanding as to how a pharmacist working as part of the general practice team will affect organisational processes and professional relationships in a mixed public and private primary healthcare system.

RPS and CPPE launch Faculty handbook for practice-based pharmacists

RPS and CPPE launch Faculty handbook for practice-based pharmacists

Research is ‘a step into the unknown’: an exploration of pharmacists’ perceptions of factors impacting on research participation in the NHS

ObjectiveThis study explored National Health Service (NHS) pharmacists’ perceptions and experiences of pharmacist-led research in the workplace.DesignSemistructured, face-to-face discussions continued until distinct clusters of opinion characteristics formed. Verbatim transcripts of...

A randomised, controlled study to quantify the benefits of community pharmacist interventions on the prescribing of cardiovascular drugs in general practice

Abstract Focal points

Content validity of indicators of the appropriateness of long-term prescribing started during a hospital admission

Abstract Focal points

Symposium on roles of and cooperation between academic- and practice-based pharmacy clinicians

The findings of an academic symposium as they relate to the history and role of the academic pharmacy clinician, the strengths and limitations of the academic pharmacy clinician model, and the framework for future synergistic work relations among clinical pharmacy practitioners are summarized. On April 23, 2008, a symposium was convened to bring key thought leaders together to discuss the relationship of the academic-based pharmacy clinician and the practice-based pharmacy clinician. Participants included clinical faculty and administrators from two colleges of pharmacy, practice-based clinical pharmacists and pharmacy managers from seven health care institutions, and representatives from the American Association of Colleges of Pharmacy, the American College of Clinical Pharmacy, and the American Society of Health-System Pharmacists. Symposium participants discussed the roles and expectations of clinical pharmacists based on primary affiliation within the contemporary practice model for academic- and practice-based pharmacy clinicians and identified sources of conflict for academic- and practice-based pharmacy clinicians. Symposium participants agreed that in order to succeed, the academic-based and the practice-based pharmacy clinicians must function in a true partnership as each individual has strengths, resources, and benefits to bring to the relationship. Furthermore, knowledge, consideration, and an understanding of the potentially different goals and objectives of each institution are critical. A symposium attended by clinical faculty members and administrators from two colleges of pharmacy, practice-based clinical pharmacists and pharmacy managers from seven health care institutions, and representatives from three national pharmacy organizations was conducted to discuss the roles of and cooperation between academic- and practice-based pharmacy clinicians.

The use of medication for chronic pain in primary care, and the potential for intervention by a practice-based pharmacist

The majority of people with chronic pain use analgesics regularly. Ensuring their safe and appropriate use is important. This study aimed to describe patterns of analgesic prescribing in one general practice, devise a method of identifying chronic pain patients from prescribing records, and assess prescribing recommendations made after a pharmacist-led review of analgesic prescribing and identify the proportion of these acted on by GPs. Prescribing records in a practice of 6720 patients were searched and 678 patients were identified as receiving prescriptions for analgesics. 230 were invited to participate and sent a questionnaire, including questions about chronic pain severity, general health and medications used. This was repeated after six months. The pharmacist completed a detailed medication review using information from medical records, questionnaires and personal interviews. Prescribing recommendations were made to GPs. 192 recommendations about safe or appropriate prescribing were made for 86% of participants after records review, 56% being directly related to analgesic use. After 6 months all recommendations had been implemented in 77% of the patients. Few additional recommendations were made after interview. There was little or no relationship with changes in chronic pain severity or general or psychological health. We have demonstrated a method of identifying patients with chronic pain in primary care, and the feasibility and acceptability of a pharmacist-led intervention. This is of potential value in primary care, as relevant prescribing recommendations were made for most patients although further research is required to assess these.