Evaluation of a practice enhancement program to implement pharmaceutical care

American Journal of Pharmaceutical Education, Fall 1999 by Farris, Karen B, Kassam, Rosemin, Cox, Cheryl E, Volume, Carlyn I, Et al

The aim of this project was to assess the effectiveness of a practice enhancement program in training community pharmacists to provide pharmaceutical care. A mid- and post-test with no control group design was used. Nine pharmacists in five pharmacies completed the program comprised of 40 hours of face-toface sessions, 10-weeks of structure/process changes and case work-ups for five paper cases and six practicum patients. Structure and process changes adopted and work-ups for two standard patients and a description of care provided to practicum patients were used to evaluate the program, All pharmacies implemented some of the structure and process changes. For the standard patient, the average was 59 /-8 percent for the mid-test and 78 /- 10 percent for the post-test (P

INTRODUCTION

Pharmaceutical care has been offered as pharmacists' societal responsibility to prevent drug-related morbidity and mortality(1,2). Yet, the adoption of pharmaceutical care among community pharmacists is not pervasive(3). This low adoption is likely due to complex interactions among a number of variables including drug product focus, lack of monetary incentives, patient attitudes and physician attitudes(4-7). Pharmacists attitudes and skills, however, may also be barriers to changing pharmacy practice(8,9).

Various program have sought to facilitate the adoption of pharmaceutical care. Programs having the most extensive evaluation focused on pharmacist competencies and on pharmacy system changes. Kimberlin, et aL, sought to increase knowledge and skills in analyzing medication profiles, identifying additional information needed to solve problems, identifying drug-related problems, developing a plan to resolve problems and role-playing for interventions(10,1 1). The training program for the treatment pharmacists involved a home study program and a day-long workshop. In their experimental study of 102 pharmacists and 762 patients, treatment patients reported more interactions with pharmacists, however the interactions did not lead to improvements in knowledge of medications, medication-taking behavior or detection of drug-related problems or the measures employed were not responsive. The authors suggest that environment or system changes should accompany initiatives to improve individual pharmacists' competencies.

Currie, et al., also evaluated the effect of a training program for community pharmacists on the detection and intervention of drug-related problems(12). The program focused on improving problem-solving and communicating skills not on therapeutic knowledge. Thirty hours were spent in direct contact with educators and 10 hours were spent on independent study. The pharmacy also made structural and procedural changes, as a semi-private patient care area was added. Using a randomized, prospective design in one pharmacy, treatment patients were 8.6 (95 percent confidence interval = 4.8-15.5) times more likely to have a drug-related problem identified and 8.1 (95 percent confidence interval = 4.7-14.2) times more likely to have an intervention performed than patients in the control group. While the authors argue that selection bias of the study participants was unlikely to have accounted for the large differences detected, low enrollment rates (28 percent) were noted in the treatment group. In addition, statistical comparison of the treatment and control groups in terms of demographic information was not presented. Thus, the comparability of the study groups was unclear in terms of age, sex and number of medications, particularly since the latter may be associated with number of drug-related problems.

Finally, Mehra and Wuller provided a series of six twohour workshops and a two-hour final practicum as a means to improve clinical skills among community pharmacists(13). The goal of this program was to prepare eleven pharmacists for being preceptors. After the program, five of nine pharmacists reported they needed more training to precept students, but all participants reported they would be ready in the near future, Most pharmacists in the program reported improvements in clinical skills, especially regarding monitoring devices. The authors suggest that clinical knowledge is critical and the most important tool in providing pharmaceutical care.

In summary, knowledge is an important key to change practice. Pharmacists' skills and their environment, however, may be more related to practice change and the maintenance of practice change. In-depth programs have not been evaluated to change practice.

OBJECTIVES

The overall aim of this project was to assess the effectiveness of a practice enhancement program (PEP) in training community pharmacists to provide pharmaceutical care. The specific goals were to develop generalists who: (i) implemented pharmacy systems to support pharmaceutical care; (ii) provided comprehensive pharmaceutical care to elderly, ambulatory patients; (iii) provided pharmaceutical care consistently and reproducibly, (iv) provided continuous care; (A,,,) collaborated with patients and healthcare providers in the provision of pharmaceutical care; and (vi) learned via self-directed strategies. The program was based on a Social Learning Theory framework with a focus on structure and process changes in the pharmacies as well as pharmacists' competencies'. Importantly, we sought to raise the level of drug-related problem identification and intervention above levels reported in community pharmacy observation studies(14-16). Ethical approval was obtained from the University of Alberta Faculty of Medicine Ethics Review Committee.