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Medication reviews led by community pharmacists in Switzerland: a qualitative survey to evaluate barriers and facilitators

Objective 1) To evaluate the participation rate and identify the practical barriers to implementing a community pharmacist-led medication review service in francophone Switzerland and, 2) To assess the effectiveness of external support. Methods A qualitative survey was undertaken to identify barriers to patient inclusion and medication review delivery in daily practice among all contactable independent pharmacists working in francophone Switzerland (n=78) who were members of a virtual chain (pharmacieplus), regardless of their participation in a simultaneous cross-sectional study. This study analyzed the dissemination of a medication review service including a prescription and drug utilization review with access to clinical data, a patient interview and a pharmaceutical report to the physicians. In addition, we observed an exploratory and external coaching for pharmacists that we launched seven months after the beginning of the cross-sectional study. Results Poor motivation on the part of pharmacists and difficulties communicating with physicians and patients were the primary obstacles identified. Lack of time and lack of self-confidence in administering the medication review process were the most commonly perceived practical barriers to the implementation of the new service. The main facilitators to overcome these issues may be well-planned workflow organization techniques, strengthened by an adequate remuneration scheme and a comprehensive and practice-based training course that includes skill-building in pharmacotherapy and communication. External support may partially compensate for a weak organizational framework. Conclusions To facilitate the implementation of a medication review service, a strong local networking with physicians, an effective workflow management and a practice- and communications-focused training for pharmacists and their teams seem key elements required. External support can be useful to help some pharmacists improve their service management skills. Adequate remuneration seems necessary to encourage initial investments to provide such a service. Future research in this area may help improve the process and design of training programs, as well as the monitoring of implementation for each new pharmaceutical service.


ABSTRACT *
Objective: 1) To evaluate the participation rate and identify the practical barriers to implementing a community pharmacist-led medication review service in francophone Switzerland and, 2) To assess the effectiveness of external support. Methods: A qualitative survey was undertaken to identify barriers to patient inclusion and medication review delivery in daily practice among all contactable independent pharmacists working in francophone Switzerland (n=78) who were members of a virtual chain (pharmacieplus), regardless of their participation in a simultaneous cross-sectional study. This study analyzed the dissemination of a medication review service including a prescription and drug utilization review with access to clinical data, a patient interview and a pharmaceutical report to the physicians. In addition, we observed an exploratory and external coaching for pharmacists that we launched seven months after the beginning of the cross-sectional study. Results: Poor motivation on the part of pharmacists and difficulties communicating with physicians and patients were the primary obstacles identified. Lack of time and lack of self-confidence in administering the medication review process were the most commonly perceived practical barriers to the implementation of the new service. The main facilitators to overcome these issues may be wellplanned workflow organization techniques, strengthened by an adequate remuneration scheme and a comprehensive and practice-based training course that includes skill-building in pharmacotherapy and communication. External support may partially compensate for a weak organizational framework. Conclusions: To facilitate the implementation of a medication review service, a strong local networking with physicians, an effective workflow management and a practice-and communications-focused training for pharmacists and their teams seem key elements required. External support can be useful to help some pharmacists improve their service

Medication reviews led by community pharmacists in Switzerland: a qualitative survey to evaluate barriers and facilitators
Anne NIQUILLE, Chantal LATTMANN, Olivier BUGNON.

INTRODUCTION
For more than fifteen years, pharmacists have been aware that their role should go beyond simply selling medications, and that they should provide services to support the modern healthcare system. 1 However, the implementation of new community pharmacy services has faced several barriers.

2-4
A recent study carried out in the United States assessed pharmacists' actual and perceived barriers to the implementation of medication therapy management services. The results suggested a difference between pharmacists who currently deliver services and those who are interested in doing so. 5 The former were principally concerned with receiving adequate remuneration, independent of whether or not they were already receiving compensation. The second group expressed concerns about staff shortages and poor access to medical information. It is also interesting to note that pharmacists providing services found most barriers less constraining compared with those who did not provide services. In addition, an Australian survey identified facilitators of practice change in community pharmacies, and separately, the socalled Seven-Factor Solution has been proposed, which includes: a good relationship with local physicians, remuneration for each pharmaceutical service delivered or in an implementation phase, an area specifically designated for services within pharmacies, patients' expectations regarding such services, sufficiently well-trained staff, communication within the team, and finally external support/assistance with clinical aspects and/or implementation. [6][7] A cross-sectional study regarding the impact of a community pharmacist-led medication review service was launched in French-speaking part of Switzerland in 2007. 8 One major aim of that study was to evaluate the potential contribution of this kind of pharmaceutical intervention into disease management programs. The medication review process chosen within this study is complex and known as clinical medication review. 9 It is based on an analysis of a patient' drugs regimen conducted by a community pharmacist, in order to optimize efficiency and safety. 10 For this purpose, the pharmacist ought to evaluate the patient medication records and clinical data, and carry out a face-toface interview. After a systematic analysis of drug related problems, pharmacists sent recommendations to physicians who remain free to apply them or not. Everything is archived to monitor the patient and monitoring the delivery. The crosssectional study ran for seven months with a poor inclusion rate, even though several facilitators were provided, including remuneration, specific training, practical handbook, pharmacotherapeutic support, and basic collaborative care experiences with the physicians-pharmacists quality circles. 11,12 This provided a good opportunity to assess the actual and perceived barriers to implement this kind of community pharmacy-led medication review service in Switzerland.
The survey evaluated the participation rate of pharmacists and physicians, the process of patients inclusion, the effectiveness of an external support and identified the practical barriers to implementing an advanced community pharmacist-led medication review service

Setting
A cross-sectional study was conducted in Frenchspeaking part of Switzerland in collaboration with 90 independent community pharmacists, all members of a virtual chain (pharmacieplus). Those pharmacists are similar to the other Swiss community pharmacies' owners. The aim of this study was to evaluate the potential contribution of this kind of pharmaceutical intervention into disease management programs, All of the pharmacists for whom an e-mail address easily obtain (n=78), whether participating to the cross-sectional study or not, were invited to take part in our retrospective and qualitative survey that aimed to identify barriers and facilitators.

Specific information and training for medication review service delivery
The virtual chain financed training courses and engaged themselves to remunerate participating members with 200 Swiss Francs (130 Euros / 190 US Dollar) per medication review. Each pharmacist was invited to join one of the three day-long training courses (scheduled between February and June 2007), which presented practical aspects of how to conduct an advanced medication review service and explained our study in the context of daily pharmacy practice.

Specific practice handbook
An electronic, specific practice handbook (created using Microsoft Excel 2000) was issued to all participants and provided comprehensive information (a step-by-step description of the enrolment of patients and medication review service) and materials (flowchart, models of letters addressed to patients and physicians, data collection forms). The whole study process is summarized in Table 1.

Questionnaires
We identified three groups of pharmacists: informed pharmacists who did not participate (n=60), trained pharmacists who volunteered to participate but who actually did not complete the study (n=4) and pharmacists who completed the entire study (n=14). The opinions of each of the three groups of pharmacists were evaluated using a specific questionnaire (respectively questionnaires 1, 2 and 3). Questionnaire 1 contained an introduction letter that reminded participants of the purpose of the study and fifteen items. They concern the awareness and the quality of information about the study, an evaluation of nine barriers that had been identified a priori by the investigators, with a possibility to add more, and the interest in external support. Finally, five closed-form questions were included to characterize the pharmacy (pharmacist work hours, number of customers and estimation of the proportion of regular customers, estimation of the proportion of prescription drug sales).
Questionnaire 2 contained nineteen items exploring experiences, and particular problems encountered in using the electronic quality handbook. The organizational framework inside of the pharmacy, such as the allocation of pharmacist resources, the tasks delegated to assistants or technicians, and lack of time as a major barrier to carrying out the study were also evaluated as well as a priori opinions about collaborating with physicians and patients before starting the study, the willingness to participate immediately after the training session, and the interest in external support. We also asked about remuneration and any additional barriers that they perceived. The same five questions as used in Questionnaire 1 were included to characterize the pharmacy.
Questionnaire 3, composed of eighteen items, explored problems encountered during the study, perspectives on the medication review service, planning within the pharmacy, task assignment processes, the time required to participate and whether that represented a practical difficulty, the training course and the remuneration total. Collaboration with both physicians and patients was also explored. The characterization of the pharmacy was assessed using the same five questions as included in Questionnaires 1 and 2. Three additional questions were incorporated in this questionnaire when it was issued to a pharmacist who had elected to receive external support.

External support
Because of a poor inclusion rate, the investigators recommended external support to help certain pharmacists to implement the advanced medication review service. The support was intended primarily to assist pharmacists with organizing and planning the service. We also attempted to relieve the pharmacist of all technical and administrative tasks, in order to let the pharmacist focus on the direct contact with physicians and patients.
A mentoring pharmacist visited each pharmacy at least three times to perform logistic steps 1.1, 1.6, 2.1 and 2.2 (see Table 1). If requested by participating pharmacists, the mentoring pharmacist was also able to provide pharmacotherapeutic support to entirely or partly complete step 3.

Participation and inclusion rate
Head pharmacists for whom an e-mail address was available were invited to complete Questionnaire 1 (n=60), four pharmacists received Questionnaire 2 and fourteen Questionnaire 3. Nine of these individuals conducted the study without help and five with external support. Pharmacists only contacted 145 (62%) of the 224 physicians who had at least one eligible patient. Ultimately, 61 of these contacted physicians agreed to participate, equivalent to a refusal rate of 58% (Figure 1). The refusal rate of contacted patients is 59% (n=134). Nevertheless, this represents only 18% of the total number of eligible patients (n=738). This difference arises from the loss of 250 patients due mostly to the lack of contacts between pharmacists and physicians, 178 additional patients due to physicians who did not participate and 84 excluding patients for medical reasons by their physicians.

Barriers to implementing the medication review service
The response rate and the general characteristics of the responders are detailed for each group of pharmacists in Table 2.   Physician-pharmacist quality circles: A Swiss project based on local networking between physicians and pharmacists to improve prescription practices (10;11) In the group of non-participants, only 12 of the 60 pharmacists (20%) responded after we had sent them Questionnaire 1. Three pharmacists of the twelve insisted that they had been unaware of the study prior to receiving the survey. Of the others, two considered that the information was insufficient.
Five pharmacists had heard about our program via the e-mail newsletter of the virtual chain. Three pharmacists (25%) thought they would have participated if they had been better informed. Of the barriers listed in Table 3 reported that the data extraction process and use of the quality handbook seemed complicated. With regards to time management, two pharmacists operated the study during work hours, but only as a second priority when they had nothing else to do. Two pharmacists tried to conduct the study outside of their normal work hours. None of these individuals delegated study-relevant tasks to an assistant or technician. Although three of these pharmacists considered the remuneration insufficient, it represented a real barrier for only one. All estimated that they could have reasonably spent one to two hours per week to deliver medication reviews for the proposed remuneration. Concerning their a priori opinions about contacting physicians, two thought that it would be problematic because physicians would find the pharmaceutical service too time consuming for them and would be too concerned about losing their patients' trust. One thought this would not be a problem and the last did not answer. Concerning the contact of patients, only one pharmacist thought that this might be a sensitive issue. From this group, one pharmacist eventually agreed to participate in the study with an external support.
The last group included eleven of the fourteen pharmacists who had implemented the medication review service. The biggest problem was collaborating with physicians. The pharmacists reported that physicians basically have no time for this kind of service and see pharmacists only as drug retailers, they were difficult to contact and convince, and physicians also had to be repeatedly reminded to complete their tasks (i.e. validating their patients' eligibility, completing the clinical data form, assessing pharmaceutical recommendations). These pharmacists thought that an advanced medication review service might be useful for chronically-diseased patients, increasing the trust of physicians and patients, optimizing treatment regimens and helping to highlight the value of the pharmacist within the healthcare system.

External support
An external support has been proposed to fourteen pharmacists, including three who completed the training course but lacked confidence, two who had been identified by the investigators, and nine who completed Questionnaires 1 and 2. Nine of these individuals initially agreed to participate with the support but ultimately only five fully completed our study. Three pharmacists explained that they lacked confidence in contacting and collaborating with physicians, one failed to set appointments for patient interviews in time, and in another case the pharmacy had no eligible patients who met the inclusion criteria. The five pharmacists who needed external support did not want to complete medication reviews by themselves and as a result 38 medication reviews were completed with assistance from the mentoring pharmacist. In the latter case, the average time taken to complete each medication review was 2.1 hours, not including the time spent by the mentoring pharmacist. This same metric was 6.4 hours for community pharmacists who did not receive external support.

DISCUSSION
In the Swiss primary care setting, there is no organizational incentive for health professionals to work together. However, there is increasing awareness of the need to improve the safety, effectiveness and efficiency of the healthcare system. For the past 15 years, Swiss community pharmacists have been moving towards a more patient-and cognitive services-oriented approach. Medication review services may play a role in helping chronic patients to get the most out of their medications.
The results of our qualitative assessment show that the main barrier encountered in the implementation of medication review services in community pharmacies focuses on health professionals themselves. Only 14 pharmacists participated (16%), despite the support of the virtual chain's management. The majority of pharmacists seemed unable to invest time and resources in developing new services.
Physician participation clearly depended on pharmacists' self-confidence to contact them, so their pre-existing relationship was generally found to be very important. So, one-third of the eligible patients did not enroll because their pharmacists did not contact a significant proportion of the physicians in their neighborhood. Mutual trust should be strengthened to avoid the non-participation of physicians in the future. 13 A good approach to reinforce collaborative care at the local level is to conduct a physicianspharmacists quality circle to improve the safety and efficiency of the prescriptions. 11,12 Ten of the thirteen pharmacists who completed the crosssectional study moderated at least one quality circle with physicians at the same time.
In addition, few patients are aware of pharmaceutical services in general, and they do not know much about medication reviews led by a pharmacist in collaboration with their physicians. Even so, 41% agreed to go to an interview with their pharmacists, and they consented to an exchange of clinical data between their physicians and pharmacists. It seems that patients understand the need for coordinated monitoring of their chronic treatments and are not a significant barrier to the implementation of an advanced medication review service. In terms of participation issues, the need to increase pharmacist communication skills is an emerging priority, especially in the context of other health care providers and patients. In addition, information about specialized pharmaceutical services for the public, physicians and public health authorities must be improved.
A lack of time was clearly a problem for the majority of pharmacists who completed the study, but even more so for those who did not participate (Table 4). Medication review services in daily practice need excellent workflow organization. To make time in their already busy schedules, pharmacists need to learn to better delegate tasks within their teams. To be efficient, delegation requires good team communication within the pharmacy and special training for staff.

Major facilitators
Major barriers management as well as specific skills for medication reviews (e.g., patient selection, data analysis to identify eligible patients, conducting patient interviews, report writing). Computer skills are also critical (data management, literature reviews, outcomes monitoring). This constituted a major barrier to using some of the practical remote support provided by the investigators.
The time and resource burdens are not problematic if the remuneration is adequate. Pharmacists did not generally find that the remuneration provided was sufficient, but the majority did not consider this a major problem for the pilot phase. However, time spent by pharmacists receiving external support is significantly lower (Table 4), which tends to prove the profitability of the service will improve with the acquisition of experience in this field. The benefit of the medication review, particularly from the point of view of safety, effectiveness and cost containment, remain to be demonstrated in order to secure funding from health insurance companies and the government.
As Figure 2 shows, we would recommend a focus on training, remuneration, on-site organization and communication to resolve many of the issues that we encountered. Our results show that external support compensates for poor training or for poor on-site organization, making the remuneration and communication issues less important for the pilot phase. As found in a previous similar survey, pharmacists who actually participated in the study requested better remuneration but not the pharmacists who did not participate. 5 In the future, a more systematic assessment of barriers to providing pharmaceutical services among a larger population of pharmacists may provide more insight into the problems we identified.
We note the relevance of the practice change framework used by Roberts and al. to build the Seven-Factor Solution. 7

CONCLUSIONS
Pharmacists who have participated to a crosssectional study regarding the implementation of a community pharmacist-led advanced medication review service encountered several barriers, as well as solicited pharmacists who choose to not participate at all. Our qualitative survey suggests that this implementation is facilitated by a strong local networking with physicians, an effective workflow management and a practice-and communications-focused training for pharmacists and their teams. External support can help certain pharmacists improve their service-management skills. Adequate remuneration is necessary to allow initial investments but it is not the only trigger to provide this kind of new service. Future research in this area may help improve the process and design of training programs, as well as the monitoring of implementation for each new pharmaceutical service.