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Research Paper International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2015, 23, pp. 95–101
Evaluating pharmacist prescribing for minor ailments Kerry Mansella, Nicole Bootsmana, Arlene Kuntzb and Jeff Taylora a
College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon and bDrug Plan & Extended Benefits Branch, Ministry of Health, Regina,
SK, Canada
Keywords community pharmacy; consumer attitudes; health-seeking behaviour; lay perspectives; patient attitudes; prescribing Correspondence Dr Kerry Mansell, College of Pharmacy and Nutrition, University of Saskatchewan, 110 Science Place, Saskatoon, SK S7N 5C9, Canada. E-mail: [email protected] Received October 1, 2013 Accepted May 20, 2014 doi: 10.1111/ijpp.12128
Abstract Objectives Saskatchewan is the second Canadian province to allow pharmacists to prescribe medications for minor ailments and the only province that remunerates for this activity. The aim of this project was to determine whether patients prescribed such treatment by a pharmacist symptomatically improve within a set time frame. Methods Pharmacists were asked to hand a study-invitation card to anyone for whom they prescribed a medication for a minor ailment during the 1-year study period. Consenting participants contacted the study researchers directly and were subsequently instructed to complete an online questionnaire at the appropriate follow-up time. Key findings Ninety pharmacies in Saskatchewan participated, accruing 125 participants. Cold sores were the most common minor ailment (34.4%), followed by insect bites (20%) and seasonal allergies (19.2%). Trust in pharmacists and convenience were the most common reasons for choosing a pharmacist over a physician, and 27.2% would have chosen a physician or emergency department if the minor ailment service were not available. The condition significantly/completely improved in 80.8%; only 4% experienced bothersome side effects. Satisfaction with the pharmacist and service was strong; only 5.6% felt a physician would have been more thorough. Conclusions Participants were very satisfied with their symptomatic improvement and with the service in general, albeit for a small number of conditions. Participants reported getting better, and side effects were not a concern. These results are encouraging for pharmacists; however, a comparison of physician care with pharmacist care and unsupported self-care is required to truly know the benefit of pharmacist prescribing.
Introduction Pharmacist prescribing has been positioned by various authorities as a way to reduce health-care costs and improve access. Pharmacists across Canada,[1,2] and indeed the world,[3] are at various stages of adding this to their scope of practice. In the UK, pharmacists have been able to prescribe since 2003 and have had independent prescribing rights since 2006.[4] Swiss pharmacists are triaging patients for cystitis, conjunctivitis and pharyngitis and can video-consult with a physician during a case.[5] Pharmacists in more than 40 American states have been granted some form of prescribing authority.[6,7] These examples indicate both the range of models available and the varying interpretation of the term pharmacist prescribing. © 2014 Royal Pharmaceutical Society
In 2007, Alberta became the first province in Canada to allow pharmacists to prescribe medications.[8] All of the remaining provinces have adopted or are currently pursuing various degrees of prescriptive authority for pharmacists.[9] Nova Scotia added minor ailments as an expanded aspect of practice in January 2011. As of March 2011, new legislation has also broadened Saskatchewan pharmacists’ scope of practice, enabling them to prescribe certain medications for minor ailments (self-limiting and self-diagnosed ailments) from a list of agents previously only prescribable by a physician. Beginning February 2012, Saskatchewan became the first province to pay for minor ailment prescribing ($18 for each approved case). International Journal of Pharmacy Practice 2015, 23, pp. 95–101
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Part of the impetus for adding this service was a need for less expensive yet still effective care. Many reports from various countries describe the impact that minor ailments have on already busy clinics and emergency departments.[10–13] A study performed in the UK found 19% of visits to an emergency room could have been managed by primary care physicians, while 8% could have been off-loaded to pharmacies.[14] Thirteen percent of all physician visits in Ontario (circa 1989) were for colds and flu, representing 12.5% of government payments to physicians.[15] There is, of course, concern for whether pharmacistdirected care will be of an appropriate standard.[16] Much of the evaluative work to date has focused on patient satisfaction, pharmacist consultation skills[4,17–19] and pharmacist acceptance of the service.[20–22] Patients have expressed satisfaction with the process and a trust in pharmacists and would recommend the service to others.[18] Symptom improvement subsequent to pharmacist intervention has received less attention. One report from Sweden evaluated outcomes for patients getting advice on over-thecounter (OTC) medicines for minor ailments in community pharmacies (allergy, musculoskeletal, dyspepsia symptoms).[23] Assessors found that pharmacist advice was appropriate in 86.8% of the encounters. Among the 182 people who complied completely with the advice given, 135 (74.2%) experienced great improvement in symptoms, but 18 (7.2%) did not experience any relief. If the pharmacy practitioner had not been available at the time, 56.8% would have turned to medical care as their first option. Evaluation in Canada (to date) appears limited to prescribing of emergency contraception,[24,25] adapting aspects of prescriptions,[26] and public perceptions of the service.[27] A formal analysis is necessary for minor ailment prescribing in order to justify (and perhaps expand) the program; pharmacists will have to provide evidence they can indeed prescribe in an effective and safe manner. The aim of this project was to determine whether patients prescribed such treatment by a pharmacist symptomatically improve within a set time frame.
Pharmacist prescribing for minor ailments
each condition. This included logging all minor ailment prescriptions initiated by the pharmacist onto a provincial-wide database. No sample size determination was made for this project. Instead, we attempted to capture all those who had a medication prescribed to them for a minor ailment by a pharmacist in a community pharmacy setting. We estimated this to be approximately 200 cases before commencing. Advertisements and e-mail asking for recruitment sites were sent to all 351 pharmacies in the province. Pharmacists wishing to join were sent shelf-talkers (advertisements added to shelving to alert pharmacy clientele to the new service) for each of the seven conditions, a set of twenty 4″ × 6″ patient recruitment cards and FAQs about the study (including phrasing one might use for potential candidates on whether they may want to participate). After being prescribed an eligible agent, patients were asked (by the prescribing pharmacist) to consider participation in evaluating the service. The 4″ × 6″ card was given if interest was shown. The card identified them as people receiving a medicine for a minor ailment and sought their participation in the project. It stated that the researchers were not affiliated with their pharmacy and mentioned a $10 gift card for those completing the online survey. To reduce the risk of coercion, patients were asked to contact the research team (only if interested) once they left the pharmacy. No data collection took place in pharmacies, nor did pharmacists supply researchers with any names of potential candidates. Those patients desiring to participate in the study contacted the study researchers via e-mail or phone, and the researchers provided potential participants with a website link (via e-mail) to complete the questionnaire online by a set date. The timing for data collection and sending the questionnaire link depended on the condition: either 7 days (for such things as cold sores or insect bites) or 30 days (for acne and seasonal allergies) after having the prescription filled. Patient consent was implied upon filling out the questionnaire.
Data collection: online survey
Methods Patients were recruited over a 1-year period (September 2012 to August 2013) within the province of Saskatchewan, Canada. Adults were eligible for inclusion if they were prescribed an agent by a pharmacist for an applicable condition (allergic rhinitis, diaper dermatitis, cold sores, canker sores, insect bites, mild acne, thrush); no other criteria were required. If the medicine was for a child, a parent could participate. Pharmacists received official training for this practice endeavor and were to follow prescribing guidelines jointly developed by an interdisciplinary working group for © 2014 Royal Pharmaceutical Society
No data collection tool meeting all our needs (clinical outcomes) existed. Therefore, one was created for the study. Guiding documents included a study pertaining to urinary tract symptoms in the UK,[28] pharmacist recommendations for dyspepsia,[29] patient feedback on pharmacist prescribing in Scotland[18] and the UK,[4,30] and outcomes subsequent to general OTC medicine recommendations.[23] Information from other studies guided our requirements for clinical improvement scales,[31–33] side effects, convenience relative to treatment satisfaction,[34–36] what patients would do if a pharmacist was not available for help[23,37] and plans subsequent to visiting a pharmacy.[30,38] International Journal of Pharmacy Practice 2015, 23, pp. 95–101
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Once the basic components of the online survey had been identified, it was reviewed by eight pharmacy practice colleagues, 50 fourth-year pharmacy students and five pharmacists at a continuing education event on minor ailment prescribing. Pretesting of the document and the online system for understandability and user-friendliness was undertaken on a convenience sample of 10 consumers who had received advice in the past for a variety of minor ailments. Responder feedback was averaged based on scores of 1 (strongly disagree), 2 (disagree), 3 (agree) and 4 (strongly agree). Ethical approval was granted by the Research Ethics Board of the University of Saskatchewan.
Results Ninety pharmacies (25.6% of Saskatchewan pharmacies) agreed to participate. These were spread throughout the province, in both the two largest centers and smaller cities and towns. The number of patients over the 1-year study period who were prescribed a medicine and completed the online survey was 125. Demographic details for these responders appear in Table 1. Most were in the pharmacy to get help for themselves, were female and were generally healthy. Cold sores were the most frequently presented symptom, followed by seasonal allergies (Table 2). Approximately 45% were seeing a health-care professional for the first time for
Table 1
Patient demographics (n = 125)
Who was the patient? Self A child Another adult Gender Female Male Age (year) 1 or less 2–5 6–9 10–19 20–29 30–39 40–49 50–59 60–69 70 or older General health status (self-perceived) Excellent Very good Good Fair Poor All data given as n (%). © 2014 Royal Pharmaceutical Society
102 (81.6) 18 (14.4) 5 (4.0) 83 (66.4) 42 (33.6) 7 (5.6) 3 (2.4) 0 (0) 11 (8.8) 17 (13.6) 27 (21.6) 12 (9.6) 26 (20.8) 13 (10.4) 9 (7.2) 29 (23.2) 66 (52.8) 27 (21.6) 1 (0.8) 2 (1.6)
their condition. Most had suffered with symptoms for about a day before asking for help, but chronic sufferers were also evident. Of those choosing a pharmacist over a doctor for this episode, 192 reasons were offered in explanation (Table 3). Trust in pharmacists and convenience were the main reasons. Thirty-four would have gone to a doctor or an emergency room had this service not been in place. Subsequent to pharmacist recommendations (Table 4), symptoms either resolved completely or were greatly improved. Potential problems during medicine-taking were assessed across four items – side effects, expense, difficulty to use and speed of therapy. Side effects did not seem to be problematic during therapy. Two people had concerns about their medicine and had stopped taking it at follow-up, and only 4% (5/125) reported that they were bothered by side effects. Satisfaction with the pharmacist and service provided was strong (Table 4), with most also happy with the level of privacy afforded them. The notion that a doctor would have been more thorough was largely rejected, although seven agreed/strongly agreed with this statement.
Discussion Although only representing a fraction of all minor ailment encounters in the province, the results indicate patients were satisfied with the outcome, both in clinical terms and in terms of pharmacist attributes. Patients chose this route of care due to convenience but also trusted that pharmacists are equipped to handle minor ailments. Rarely did anyone seek a
Table 2
Aspects of the condition
Condition (n = 125) Acne Cold sores Diaper rash Canker sores Seasonal allergies Oral thrush Insect bites Patient had seen an HCP for condition before (n = 124) Yes No How long symptoms had been present at time of pharmacy visit (n = 125) 1 day 2–3 days 4–5 days 6–7 days Several weeks About 6 months About 1 year Several years
9 (7.2) 43 (34.4) 5 (4.0) 8 (6.4) 23 (18.4) 12 (9.6) 25 (20.0) 68 (54.8) 56 (45.2)
38 (30.4) 22 (17.6) 18 (14.4) 15 (12.0) 12 (9.6) 4 (3.2) 3 (2.4) 13 (10.4)
All data given as n (%). International Journal of Pharmacy Practice 2015, 23, pp. 95–101
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Table 3
Pharmacist prescribing for minor ailments
Pathway to the encounter
How did assistance occur? (n = 123) You asked for the help Help was offered to you IF assistance was requested, why pharmacist care rather than a physician? Number of reasons provided by responders (n = 88) 1 reason 2 reasons 3 reasons 4 reasons 5 reasons 6 reasons Reasons provided by responders (n = 192) Doctor’s office was closed Could not get appointment soon enough Did not want to wait at MD clinic No family doctor Condition not serious enough for MD Trust pharmacists for minor ailments Easier to go to a pharmacist Other IF you had not asked for help, what would you have done instead? (n = 88) Nothing Use something you already had at home Purchase an over-the-counter medicine without help Go to a doctor Go to the ER Other After seeing the pharmacist, did you later see a doctor? (n = 125) Yes No
Table 4 88 (71.5) 35 (28.5)
43 (48.9) 12 (13.6) 14 (15.9) 13 (14.8) 5 (5.7) 1 (1.1) 6 (3.1) 19 (9.9) 28 (14.6) 2 (1.0) 39 (20.3) 50 (26.0) 33 (17.2) 15 (7.8)
5 (5.7) 7 (8.0) 38 (43.2) 31 (35.2) 3 (3.4) 4 (4.5)
4 (3.2) 121 (96.8)
All data given as n (%).
doctor after consulting the pharmacist first, and most felt the process was just as thorough as if provided by a physician. That people asked for the help, as opposed to it being offered once they were at the pharmacy, suggests some degree of demand for the service. As with any study, there are limitations to the data we collected. Primarily, we failed to collect feedback for the vast majority of events occurring during the study period. Only 25.6% of community pharmacies in Saskatchewan participated in this study. Although we are not sure exactly how many minor ailment prescriptions were given out by these pharmacies during the study period, 5542 minor ailment prescriptions were billed for reimbursement by Saskatchewan pharmacies up until June 2013.[39] Hence, a significant number of minor ailment prescriptions were not captured, and the true response rate is not known. Further, it is also not possible to consider those we did capture to be a representative sample of the larger whole. The data collection form could also be a source of study limitations. Potential patient behavior and outcomes were © 2014 Royal Pharmaceutical Society
Outcomes (n = 125)
Clinical improvement, n (%) The condition got worse The condition did not change The condition improved Somewhat Moderately Significantly Complete resolution Problems with the recommended therapy (score), mean (SD)a Side effects were a problem The medicine was expensive The medicine was difficult to use The medicine did not work fast enough At follow-up (7 days or 30 days), what is your plan now? The condition is completely cleared so you stopped taking the medicine The medicine is working fine so far so you plan to keep taking it You have some concerns about the medicine but still plan to keep taking it You have some concerns about the medicine so you stopped taking it The condition is not improving so you will seek out a pharmacist The condition is not improving so you will seek out a doctor Other Evaluation of the encounter (score), mean (SD)a The pharmacist explained how to use the medicine Some things about the encounter could have been better The pharmacist asked appropriate questions The pharmacist spent enough time to determine the best treatment You found the advice to be confusing The area in the pharmacy had adequate privacy The pharmacist made sure this medicine was safe for you A doctor would have been more thorough You would seek advice from this pharmacist for another minor condition You would seek advice from other pharmacists for another minor condition
0 (0) 1 (0.8) 124 (99.2) 6 (4.8) 17 (13.7) 36 (29.0) 65 (52.4)
1.3 (0.6) 1.7 (0.9) 1.3 (0.7) 1.6 (0.8) 78 (62.4) 35 (28.0) 2 (1.6) 2 (1.6) 2 (1.6) 0 (0) 6 (4.8) 3.8 (0.4) 1.4 (0.7) 3.8 (0.7) 3.7 (0.5) 1.4 (0.9) 3.3 (0.7) 3.7 (0.5) 1.6 (0.7) 3.8 (0.5) 3.4 (0.8)
Scores are presented as means based on a system where 1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree.
a
condensed to a limited number of responder options, which were far from exhaustive. This likely led to an oversimplification of actual behaviour. Also, only seven minor ailments were evaluated, so it is not possible to extrapolate these findings to other minor ailments not studied. Finally, patient selection bias may have occurred if pharmacists were more encouraging of patients to participate in the study if the minor ailment assessment sessions went well or if they had a positive relationship with the patient. Further, as the ailments International Journal of Pharmacy Practice 2015, 23, pp. 95–101
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were, by definition, minor ailments, it is possible these patients would have gotten better without intervention, depending on the nature of the minor ailment. Minor ailments are a very common part of daily life and can impact significantly on the health-care system.[40,41] Pillay et al. found that 10 conditions accounted for 75% of all UK physician consults involving minor ailments.[11] They accounted for approximately 10 to 20% of GP workload,[11,42–44] with some doctors becoming a bit frustrated by this state of affairs.[45] The public may be frustrated too. Retail clinics have sprung up in the USA as a cheaper and more convenient alternative to physician care for minor ailments.[46,47] The evidence specific to pharmacists prescribing medicines for minor ailments is relatively new. To reiterate our findings, patients claimed to get better subsequent to following pharmacist recommendations. For this, pharmacists followed practice guidelines developed for the seven conditions assessed. In a report from another country with this service, Bojke et al. provided UK patients with the option of visiting a community pharmacy instead of a medical practice for minor ailments (thrush, head lice, constipation, indigestion, hay fever, diarrhoea, fever, earache, headache and common cold symptoms).[48] Just over 1100 patients requested this path. The intervention allowed pharmacists to prescribe medicines limited at the time to general practitioners. No attempt was made at assessing clinical outcomes, however; instead, focus was on GP consultation rates and economic aspects. Again in the UK, a project was undertaken to determine whether community pharmacies (rather than physicians) as the first stop for treatment of head louse infestation would represent an acceptable and effective means of management.[49] Pharmacists were allowed to dispense agents usually available only by prescription. The authors stressed that the study was a look at the organisation of care delivery, rather than clinical outcomes. In general, the scheme was well received by most people, although some were embarrassed to speak to pharmacists about head lice (given privacy concerns in community pharmacies). Privacy did not materialise as an issue during our study of Saskatchewan citizens, but the embarrassment factor might be considered low for the conditions under consideration. In addition to direct assessment of clinical improvement, we also asked participants whether their next step might involve seeing a doctor (in other words, reconsultation for the same situation). Four participants had plans to see a doctor after getting pharmacist advice (two already had that appointment arranged). An extensive examination of reconsultation rates was not part of our study, but they have received attention elsewhere. In a program to steer UK patients to pharmacists for minor ailments, 576 people chose pharmacies out of 1522 intending to seek medical care.[50] Finally, a review of pharmacist interventions by Paudyal et al.
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determined that reconsultation rates ranged from 2.4 to 23.4% in various studies to date.[51] Most participants were healthy, providing some evidence that patients brought simple, uncomplicated situations to the pharmacy. A critical aspect to the feasibility of pharmacist prescribing is what patients would do had a pharmacist option not been available. Our study participants would mainly have purchased an OTC medicine (without help), followed by going to a doctor. Elsewhere, in one report where 396 people used such a service in the UK, 230 (58.1%) said they would have made an appointment with their doctor had the service not been in place.[37] Also in the UK, Davidson et al. found that had a pharmacy minor ailments scheme not been in place, almost 80% would have visited an MD, with 15% resorting to buying an OTC product.[52] In Sweden, 56.8% of customers would have turned to medical care had the pharmacy practitioner not been available.[23] Different health-care system dynamics make it difficult to fairly compare results across countries, but a general sense of costsavings might be a fair conclusion.
Conclusions This report is encouraging news for pharmacists, patients and the health-care system in general, albeit for a limited number of minor ailments. Patients were satisfied with symptom improvement and with the service in general. This seemed to be applicable to minor ailments of short duration and to ones more chronic in nature. However, given that many of the situations were self-limiting in nature, to truly know the benefit of pharmacist involvement would require a comparison of physician care to pharmacist care to self-care.
Declarations Conflict of interest The Author(s) declare(s) that they have no conflicts of interest to disclose.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Authors’ contributions All Authors state that they had complete access to the study data that support the publication. KM and JT were responsible for the conception and design of the study, analyzing the data, and writing the manuscript. NB was responsible for coordination of the study, and helping draft the manuscript. AK was responsible for helping with study design and drafting the manuscript.
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27. Perepelkin J. Public opinion of pharmacists and pharmacist prescribing. Can Pharm J 2011; 22: 86–93. 28. Kirby M et al. The professional competence of pharmacists in recommending Flomax Relief MR (tamsulosin) to men with lower urinary tract symptoms. Pharm J 2011; Jan: e1–e5. 29. Westerlund T et al. Evaluation of a model for counseling patients with dyspepsia in Swedish community pharmacies. Am J Health Syst Pharm 2003; 60: 1336–1341. 30. Stewart DC et al. Pharmacist prescribing in primary care: the views of patients across Great Britain who had experienced the service. Int J Pharm Pract 2011; 19: 328–332. 31. Ritvo E et al. Psychosocial judgements and perceptions of adolescents with acne vulgaris: a blinded, controlled comparison of adult and peer evaluations. Bio Psych Soc Med 2011; 5: 11. 32. Schulz M et al. Safety and usage pattern of an over-the-counter ambroxol cough syrup: a community pharmacybased cohort study. Int J Clin Pharmacol Ther 2006; 44: 409–421. 33. Juniper EF et al. Development and testing of a new measure of health status for clinical trials in rhinoconjunctivitis. Clin Exp Allergy 1991; 21: 77–83. 34. Atkinson MJ et al. Validation of a general measure of treatment satisfaction, the Treatment Satisfaction Questionnaire for Medication (TSQM), using a national panel study of chronic disease. Health Qual Life Outcomes 2004; 2: 12. 35. Regas J et al. Minimally important difference of the Treatment Satisfaction with Medicines Questionnaire (SATMED-Q). BMC Med Res Methodol 2011; 11: 142. 36. Feldman SR, Chen DM. How patients experience and manage dryness and irritation from acne treatment. J Drugs Dermatol 2011; 10: 605–608. 37. Baqir W et al. Cost analysis of a community pharmacy ‘minor ailment scheme’ across three primary care trusts in the North East of England. J Public Health (Oxf) 2011; 33: 551– 555.
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International Journal of Pharmacy Practice 2015, 23, pp. 95–101
Research Paper International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2015, 23, pp. 95–101
Evaluating pharmacist prescribing for minor ailments Kerry Mansella, Nicole Bootsmana, Arlene Kuntzb and Jeff Taylora a
College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon and bDrug Plan & Extended Benefits Branch, Ministry of Health, Regina,
SK, Canada
Keywords community pharmacy; consumer attitudes; health-seeking behaviour; lay perspectives; patient attitudes; prescribing Correspondence Dr Kerry Mansell, College of Pharmacy and Nutrition, University of Saskatchewan, 110 Science Place, Saskatoon, SK S7N 5C9, Canada. E-mail: [email protected] Received October 1, 2013 Accepted May 20, 2014 doi: 10.1111/ijpp.12128
Abstract Objectives Saskatchewan is the second Canadian province to allow pharmacists to prescribe medications for minor ailments and the only province that remunerates for this activity. The aim of this project was to determine whether patients prescribed such treatment by a pharmacist symptomatically improve within a set time frame. Methods Pharmacists were asked to hand a study-invitation card to anyone for whom they prescribed a medication for a minor ailment during the 1-year study period. Consenting participants contacted the study researchers directly and were subsequently instructed to complete an online questionnaire at the appropriate follow-up time. Key findings Ninety pharmacies in Saskatchewan participated, accruing 125 participants. Cold sores were the most common minor ailment (34.4%), followed by insect bites (20%) and seasonal allergies (19.2%). Trust in pharmacists and convenience were the most common reasons for choosing a pharmacist over a physician, and 27.2% would have chosen a physician or emergency department if the minor ailment service were not available. The condition significantly/completely improved in 80.8%; only 4% experienced bothersome side effects. Satisfaction with the pharmacist and service was strong; only 5.6% felt a physician would have been more thorough. Conclusions Participants were very satisfied with their symptomatic improvement and with the service in general, albeit for a small number of conditions. Participants reported getting better, and side effects were not a concern. These results are encouraging for pharmacists; however, a comparison of physician care with pharmacist care and unsupported self-care is required to truly know the benefit of pharmacist prescribing.
Introduction Pharmacist prescribing has been positioned by various authorities as a way to reduce health-care costs and improve access. Pharmacists across Canada,[1,2] and indeed the world,[3] are at various stages of adding this to their scope of practice. In the UK, pharmacists have been able to prescribe since 2003 and have had independent prescribing rights since 2006.[4] Swiss pharmacists are triaging patients for cystitis, conjunctivitis and pharyngitis and can video-consult with a physician during a case.[5] Pharmacists in more than 40 American states have been granted some form of prescribing authority.[6,7] These examples indicate both the range of models available and the varying interpretation of the term pharmacist prescribing. © 2014 Royal Pharmaceutical Society
In 2007, Alberta became the first province in Canada to allow pharmacists to prescribe medications.[8] All of the remaining provinces have adopted or are currently pursuing various degrees of prescriptive authority for pharmacists.[9] Nova Scotia added minor ailments as an expanded aspect of practice in January 2011. As of March 2011, new legislation has also broadened Saskatchewan pharmacists’ scope of practice, enabling them to prescribe certain medications for minor ailments (self-limiting and self-diagnosed ailments) from a list of agents previously only prescribable by a physician. Beginning February 2012, Saskatchewan became the first province to pay for minor ailment prescribing ($18 for each approved case). International Journal of Pharmacy Practice 2015, 23, pp. 95–101
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Part of the impetus for adding this service was a need for less expensive yet still effective care. Many reports from various countries describe the impact that minor ailments have on already busy clinics and emergency departments.[10–13] A study performed in the UK found 19% of visits to an emergency room could have been managed by primary care physicians, while 8% could have been off-loaded to pharmacies.[14] Thirteen percent of all physician visits in Ontario (circa 1989) were for colds and flu, representing 12.5% of government payments to physicians.[15] There is, of course, concern for whether pharmacistdirected care will be of an appropriate standard.[16] Much of the evaluative work to date has focused on patient satisfaction, pharmacist consultation skills[4,17–19] and pharmacist acceptance of the service.[20–22] Patients have expressed satisfaction with the process and a trust in pharmacists and would recommend the service to others.[18] Symptom improvement subsequent to pharmacist intervention has received less attention. One report from Sweden evaluated outcomes for patients getting advice on over-thecounter (OTC) medicines for minor ailments in community pharmacies (allergy, musculoskeletal, dyspepsia symptoms).[23] Assessors found that pharmacist advice was appropriate in 86.8% of the encounters. Among the 182 people who complied completely with the advice given, 135 (74.2%) experienced great improvement in symptoms, but 18 (7.2%) did not experience any relief. If the pharmacy practitioner had not been available at the time, 56.8% would have turned to medical care as their first option. Evaluation in Canada (to date) appears limited to prescribing of emergency contraception,[24,25] adapting aspects of prescriptions,[26] and public perceptions of the service.[27] A formal analysis is necessary for minor ailment prescribing in order to justify (and perhaps expand) the program; pharmacists will have to provide evidence they can indeed prescribe in an effective and safe manner. The aim of this project was to determine whether patients prescribed such treatment by a pharmacist symptomatically improve within a set time frame.
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each condition. This included logging all minor ailment prescriptions initiated by the pharmacist onto a provincial-wide database. No sample size determination was made for this project. Instead, we attempted to capture all those who had a medication prescribed to them for a minor ailment by a pharmacist in a community pharmacy setting. We estimated this to be approximately 200 cases before commencing. Advertisements and e-mail asking for recruitment sites were sent to all 351 pharmacies in the province. Pharmacists wishing to join were sent shelf-talkers (advertisements added to shelving to alert pharmacy clientele to the new service) for each of the seven conditions, a set of twenty 4″ × 6″ patient recruitment cards and FAQs about the study (including phrasing one might use for potential candidates on whether they may want to participate). After being prescribed an eligible agent, patients were asked (by the prescribing pharmacist) to consider participation in evaluating the service. The 4″ × 6″ card was given if interest was shown. The card identified them as people receiving a medicine for a minor ailment and sought their participation in the project. It stated that the researchers were not affiliated with their pharmacy and mentioned a $10 gift card for those completing the online survey. To reduce the risk of coercion, patients were asked to contact the research team (only if interested) once they left the pharmacy. No data collection took place in pharmacies, nor did pharmacists supply researchers with any names of potential candidates. Those patients desiring to participate in the study contacted the study researchers via e-mail or phone, and the researchers provided potential participants with a website link (via e-mail) to complete the questionnaire online by a set date. The timing for data collection and sending the questionnaire link depended on the condition: either 7 days (for such things as cold sores or insect bites) or 30 days (for acne and seasonal allergies) after having the prescription filled. Patient consent was implied upon filling out the questionnaire.
Data collection: online survey
Methods Patients were recruited over a 1-year period (September 2012 to August 2013) within the province of Saskatchewan, Canada. Adults were eligible for inclusion if they were prescribed an agent by a pharmacist for an applicable condition (allergic rhinitis, diaper dermatitis, cold sores, canker sores, insect bites, mild acne, thrush); no other criteria were required. If the medicine was for a child, a parent could participate. Pharmacists received official training for this practice endeavor and were to follow prescribing guidelines jointly developed by an interdisciplinary working group for © 2014 Royal Pharmaceutical Society
No data collection tool meeting all our needs (clinical outcomes) existed. Therefore, one was created for the study. Guiding documents included a study pertaining to urinary tract symptoms in the UK,[28] pharmacist recommendations for dyspepsia,[29] patient feedback on pharmacist prescribing in Scotland[18] and the UK,[4,30] and outcomes subsequent to general OTC medicine recommendations.[23] Information from other studies guided our requirements for clinical improvement scales,[31–33] side effects, convenience relative to treatment satisfaction,[34–36] what patients would do if a pharmacist was not available for help[23,37] and plans subsequent to visiting a pharmacy.[30,38] International Journal of Pharmacy Practice 2015, 23, pp. 95–101
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Once the basic components of the online survey had been identified, it was reviewed by eight pharmacy practice colleagues, 50 fourth-year pharmacy students and five pharmacists at a continuing education event on minor ailment prescribing. Pretesting of the document and the online system for understandability and user-friendliness was undertaken on a convenience sample of 10 consumers who had received advice in the past for a variety of minor ailments. Responder feedback was averaged based on scores of 1 (strongly disagree), 2 (disagree), 3 (agree) and 4 (strongly agree). Ethical approval was granted by the Research Ethics Board of the University of Saskatchewan.
Results Ninety pharmacies (25.6% of Saskatchewan pharmacies) agreed to participate. These were spread throughout the province, in both the two largest centers and smaller cities and towns. The number of patients over the 1-year study period who were prescribed a medicine and completed the online survey was 125. Demographic details for these responders appear in Table 1. Most were in the pharmacy to get help for themselves, were female and were generally healthy. Cold sores were the most frequently presented symptom, followed by seasonal allergies (Table 2). Approximately 45% were seeing a health-care professional for the first time for
Table 1
Patient demographics (n = 125)
Who was the patient? Self A child Another adult Gender Female Male Age (year) 1 or less 2–5 6–9 10–19 20–29 30–39 40–49 50–59 60–69 70 or older General health status (self-perceived) Excellent Very good Good Fair Poor All data given as n (%). © 2014 Royal Pharmaceutical Society
102 (81.6) 18 (14.4) 5 (4.0) 83 (66.4) 42 (33.6) 7 (5.6) 3 (2.4) 0 (0) 11 (8.8) 17 (13.6) 27 (21.6) 12 (9.6) 26 (20.8) 13 (10.4) 9 (7.2) 29 (23.2) 66 (52.8) 27 (21.6) 1 (0.8) 2 (1.6)
their condition. Most had suffered with symptoms for about a day before asking for help, but chronic sufferers were also evident. Of those choosing a pharmacist over a doctor for this episode, 192 reasons were offered in explanation (Table 3). Trust in pharmacists and convenience were the main reasons. Thirty-four would have gone to a doctor or an emergency room had this service not been in place. Subsequent to pharmacist recommendations (Table 4), symptoms either resolved completely or were greatly improved. Potential problems during medicine-taking were assessed across four items – side effects, expense, difficulty to use and speed of therapy. Side effects did not seem to be problematic during therapy. Two people had concerns about their medicine and had stopped taking it at follow-up, and only 4% (5/125) reported that they were bothered by side effects. Satisfaction with the pharmacist and service provided was strong (Table 4), with most also happy with the level of privacy afforded them. The notion that a doctor would have been more thorough was largely rejected, although seven agreed/strongly agreed with this statement.
Discussion Although only representing a fraction of all minor ailment encounters in the province, the results indicate patients were satisfied with the outcome, both in clinical terms and in terms of pharmacist attributes. Patients chose this route of care due to convenience but also trusted that pharmacists are equipped to handle minor ailments. Rarely did anyone seek a
Table 2
Aspects of the condition
Condition (n = 125) Acne Cold sores Diaper rash Canker sores Seasonal allergies Oral thrush Insect bites Patient had seen an HCP for condition before (n = 124) Yes No How long symptoms had been present at time of pharmacy visit (n = 125) 1 day 2–3 days 4–5 days 6–7 days Several weeks About 6 months About 1 year Several years
9 (7.2) 43 (34.4) 5 (4.0) 8 (6.4) 23 (18.4) 12 (9.6) 25 (20.0) 68 (54.8) 56 (45.2)
38 (30.4) 22 (17.6) 18 (14.4) 15 (12.0) 12 (9.6) 4 (3.2) 3 (2.4) 13 (10.4)
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Table 3
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Pathway to the encounter
How did assistance occur? (n = 123) You asked for the help Help was offered to you IF assistance was requested, why pharmacist care rather than a physician? Number of reasons provided by responders (n = 88) 1 reason 2 reasons 3 reasons 4 reasons 5 reasons 6 reasons Reasons provided by responders (n = 192) Doctor’s office was closed Could not get appointment soon enough Did not want to wait at MD clinic No family doctor Condition not serious enough for MD Trust pharmacists for minor ailments Easier to go to a pharmacist Other IF you had not asked for help, what would you have done instead? (n = 88) Nothing Use something you already had at home Purchase an over-the-counter medicine without help Go to a doctor Go to the ER Other After seeing the pharmacist, did you later see a doctor? (n = 125) Yes No
Table 4 88 (71.5) 35 (28.5)
43 (48.9) 12 (13.6) 14 (15.9) 13 (14.8) 5 (5.7) 1 (1.1) 6 (3.1) 19 (9.9) 28 (14.6) 2 (1.0) 39 (20.3) 50 (26.0) 33 (17.2) 15 (7.8)
5 (5.7) 7 (8.0) 38 (43.2) 31 (35.2) 3 (3.4) 4 (4.5)
4 (3.2) 121 (96.8)
All data given as n (%).
doctor after consulting the pharmacist first, and most felt the process was just as thorough as if provided by a physician. That people asked for the help, as opposed to it being offered once they were at the pharmacy, suggests some degree of demand for the service. As with any study, there are limitations to the data we collected. Primarily, we failed to collect feedback for the vast majority of events occurring during the study period. Only 25.6% of community pharmacies in Saskatchewan participated in this study. Although we are not sure exactly how many minor ailment prescriptions were given out by these pharmacies during the study period, 5542 minor ailment prescriptions were billed for reimbursement by Saskatchewan pharmacies up until June 2013.[39] Hence, a significant number of minor ailment prescriptions were not captured, and the true response rate is not known. Further, it is also not possible to consider those we did capture to be a representative sample of the larger whole. The data collection form could also be a source of study limitations. Potential patient behavior and outcomes were © 2014 Royal Pharmaceutical Society
Outcomes (n = 125)
Clinical improvement, n (%) The condition got worse The condition did not change The condition improved Somewhat Moderately Significantly Complete resolution Problems with the recommended therapy (score), mean (SD)a Side effects were a problem The medicine was expensive The medicine was difficult to use The medicine did not work fast enough At follow-up (7 days or 30 days), what is your plan now? The condition is completely cleared so you stopped taking the medicine The medicine is working fine so far so you plan to keep taking it You have some concerns about the medicine but still plan to keep taking it You have some concerns about the medicine so you stopped taking it The condition is not improving so you will seek out a pharmacist The condition is not improving so you will seek out a doctor Other Evaluation of the encounter (score), mean (SD)a The pharmacist explained how to use the medicine Some things about the encounter could have been better The pharmacist asked appropriate questions The pharmacist spent enough time to determine the best treatment You found the advice to be confusing The area in the pharmacy had adequate privacy The pharmacist made sure this medicine was safe for you A doctor would have been more thorough You would seek advice from this pharmacist for another minor condition You would seek advice from other pharmacists for another minor condition
0 (0) 1 (0.8) 124 (99.2) 6 (4.8) 17 (13.7) 36 (29.0) 65 (52.4)
1.3 (0.6) 1.7 (0.9) 1.3 (0.7) 1.6 (0.8) 78 (62.4) 35 (28.0) 2 (1.6) 2 (1.6) 2 (1.6) 0 (0) 6 (4.8) 3.8 (0.4) 1.4 (0.7) 3.8 (0.7) 3.7 (0.5) 1.4 (0.9) 3.3 (0.7) 3.7 (0.5) 1.6 (0.7) 3.8 (0.5) 3.4 (0.8)
Scores are presented as means based on a system where 1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree.
a
condensed to a limited number of responder options, which were far from exhaustive. This likely led to an oversimplification of actual behaviour. Also, only seven minor ailments were evaluated, so it is not possible to extrapolate these findings to other minor ailments not studied. Finally, patient selection bias may have occurred if pharmacists were more encouraging of patients to participate in the study if the minor ailment assessment sessions went well or if they had a positive relationship with the patient. Further, as the ailments International Journal of Pharmacy Practice 2015, 23, pp. 95–101
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were, by definition, minor ailments, it is possible these patients would have gotten better without intervention, depending on the nature of the minor ailment. Minor ailments are a very common part of daily life and can impact significantly on the health-care system.[40,41] Pillay et al. found that 10 conditions accounted for 75% of all UK physician consults involving minor ailments.[11] They accounted for approximately 10 to 20% of GP workload,[11,42–44] with some doctors becoming a bit frustrated by this state of affairs.[45] The public may be frustrated too. Retail clinics have sprung up in the USA as a cheaper and more convenient alternative to physician care for minor ailments.[46,47] The evidence specific to pharmacists prescribing medicines for minor ailments is relatively new. To reiterate our findings, patients claimed to get better subsequent to following pharmacist recommendations. For this, pharmacists followed practice guidelines developed for the seven conditions assessed. In a report from another country with this service, Bojke et al. provided UK patients with the option of visiting a community pharmacy instead of a medical practice for minor ailments (thrush, head lice, constipation, indigestion, hay fever, diarrhoea, fever, earache, headache and common cold symptoms).[48] Just over 1100 patients requested this path. The intervention allowed pharmacists to prescribe medicines limited at the time to general practitioners. No attempt was made at assessing clinical outcomes, however; instead, focus was on GP consultation rates and economic aspects. Again in the UK, a project was undertaken to determine whether community pharmacies (rather than physicians) as the first stop for treatment of head louse infestation would represent an acceptable and effective means of management.[49] Pharmacists were allowed to dispense agents usually available only by prescription. The authors stressed that the study was a look at the organisation of care delivery, rather than clinical outcomes. In general, the scheme was well received by most people, although some were embarrassed to speak to pharmacists about head lice (given privacy concerns in community pharmacies). Privacy did not materialise as an issue during our study of Saskatchewan citizens, but the embarrassment factor might be considered low for the conditions under consideration. In addition to direct assessment of clinical improvement, we also asked participants whether their next step might involve seeing a doctor (in other words, reconsultation for the same situation). Four participants had plans to see a doctor after getting pharmacist advice (two already had that appointment arranged). An extensive examination of reconsultation rates was not part of our study, but they have received attention elsewhere. In a program to steer UK patients to pharmacists for minor ailments, 576 people chose pharmacies out of 1522 intending to seek medical care.[50] Finally, a review of pharmacist interventions by Paudyal et al.
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determined that reconsultation rates ranged from 2.4 to 23.4% in various studies to date.[51] Most participants were healthy, providing some evidence that patients brought simple, uncomplicated situations to the pharmacy. A critical aspect to the feasibility of pharmacist prescribing is what patients would do had a pharmacist option not been available. Our study participants would mainly have purchased an OTC medicine (without help), followed by going to a doctor. Elsewhere, in one report where 396 people used such a service in the UK, 230 (58.1%) said they would have made an appointment with their doctor had the service not been in place.[37] Also in the UK, Davidson et al. found that had a pharmacy minor ailments scheme not been in place, almost 80% would have visited an MD, with 15% resorting to buying an OTC product.[52] In Sweden, 56.8% of customers would have turned to medical care had the pharmacy practitioner not been available.[23] Different health-care system dynamics make it difficult to fairly compare results across countries, but a general sense of costsavings might be a fair conclusion.
Conclusions This report is encouraging news for pharmacists, patients and the health-care system in general, albeit for a limited number of minor ailments. Patients were satisfied with symptom improvement and with the service in general. This seemed to be applicable to minor ailments of short duration and to ones more chronic in nature. However, given that many of the situations were self-limiting in nature, to truly know the benefit of pharmacist involvement would require a comparison of physician care to pharmacist care to self-care.
Declarations Conflict of interest The Author(s) declare(s) that they have no conflicts of interest to disclose.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Authors’ contributions All Authors state that they had complete access to the study data that support the publication. KM and JT were responsible for the conception and design of the study, analyzing the data, and writing the manuscript. NB was responsible for coordination of the study, and helping draft the manuscript. AK was responsible for helping with study design and drafting the manuscript.
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