Int J Clin Pharm (2014) 36:1014–1022 DOI 10.1007/s11096-014-9989-7
RESEARCH ARTICLE
Exploring the implementation of a medication adherence programme by community pharmacists: a qualitative study Julien Marquis • Marie P. Schneider • Brenda Spencer • Olivier Bugnon • Sophie Du Pasquier
Received: 6 December 2013 / Accepted: 22 July 2014 / Published online: 20 August 2014 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2014
Abstract Background Medication adherence has been identified as an important factor for clinical success. Twenty-four Swiss community pharmacists participated in the implementation of an adherence support programme for patients with hypertension, diabetes mellitus and/or dyslipidemia. The programme combined tailored consultations with patients about medication taking (expected at an average of one intervention per month) and the delivery of each drug in an electronic monitoring system (MEMS6TM). Objective To explore pharmacists’ perceptions and experiences with implementation of the medication adherence programme and to clarify why only seven patients were enrolled in total. Setting Community pharmacies in Frenchspeaking Switzerland. Method Individual in-depth interviews were audio-recorded, with 20 of the pharmacists who participated in the adherence programme. These were transcribed verbatim, coded and thematically analysed. Process quality was ensured by using an audit trail detailing the development of codes and themes; furthermore, J. Marquis M. P. Schneider O. Bugnon Community Pharmacy, School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland J. Marquis M. P. Schneider O. Bugnon S. Du Pasquier Community Pharmacy, Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland B. Spencer Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland S. Du Pasquier (&) Community Pharmacy, Pharmacie de la Policlinique Me´dicale Universitaire, Rue du Bugnon 44, 1011 Lausanne, Switzerland e-mail: [email protected]
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each step in the coding and analysis was verified by a second, experienced qualitative researcher. Main outcome measure Community pharmacists’ experiences and perceptions of the determining factors influencing the implementation of the adherence programme. Results Four major barriers were identified: (1) poor communication with patients resulting in insufficient promotion of the programme; (2) insufficient collaboration with physicians; (3) difficulty in integrating the programme into pharmacy organisation; and (4) insufficient pharmacist motivation. This was related to the remuneration perceived as insufficient and to the absence of clear strategic thinking about the pharmacist position in the health care system. One major facilitator of the programme’s implementation was pre-existing collaboration with physicians. Conclusion A wide range of barriers was identified. The implementation of medication adherence programmes in Swiss community pharmacies would benefit from an extended training aimed at developing communication and change management skills. Individualised onsite support addressing relevant barriers would also be necessary throughout the implementation process. Keywords Cognitive pharmaceutical services Community pharmacy Interdisciplinary collaboration Implementation Medication adherence Pharmacists Qualitative research Switzerland
Impact of findings on practice •
Pharmacists’ commitment in implementing a novel service should be evaluated throughout the process, and tailored assistance should be delivered according to the barriers identified.
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• •
•
Health professionals should be encouraged to take active roles in promoting medication adherence. Pharmacists’ pre- and post-graduate education should address the challenges of delivering cognitive pharmaceutical services and their integration into daily practice. Pharmacists’ communication skills should be reinforced to promote medication adherence programmes and improve collaboration with doctors.
Introduction Medication adherence has been recognised as a key factor in reaching successful clinical outcomes for chronic conditions [1–3]. Its promotion is part of the quality standards for pharmaceutical services established jointly by the International Pharmaceutical Federation and the World Health Organisation [4], and community pharmacists have engaged in delivering medication adherence programmes in various countries [5]. In Switzerland, the pharmacy based within the Department of Ambulatory Care and Community Medicine (PMU) has developed a successful medication adherence counselling programme dedicated to chronically ill patients, most of whom are HIV positive [6]. This institutional university pharmacy operates as a community pharmacy; however, as a result of being located within an ambulatory care centre, it capitalises on strong interprofessional collaborations. Continuity of care is ensured when delivering the adherence programme, as physicians refer patients and act on pharmacists’ reports. The intervention, which is delivered by a trained pharmacist, combines motivational interviewing with electronic drug monitoring (EDM via MEMSTM). A 6 month pilot study revealed that adherence dropped off more slowly (p \ 0.0001) in the intervention group (EDM combined with pharmacists’ intervention) than in the control group (EDM only) [7]. To extend this programme, a study called NARC (NonAdherence Risk Control) was conducted between 2008 and 2010. Twenty-four community pharmacies enrolled in a programme targeting medication adherence issues by patients with common pathologies (diabetes, hypertension and dyslipidemia) and using a minimum of three drugs. The programme combined the delivery of each drug in MEMSTM (with a display continuously informing the patient how many times the container has been opened throughout the day) and consultations with patients about taking their medication (expected at an average of one intervention per month). The consultations aimed at addressing adherence barriers through personalised solutions, including a reminder service (through SMS messaging) if necessary. A report addressing patient adherence
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issues and possible actions was sent to the patients’ physicians. Pharmacists were responsible for enrolling patients in the study either by identifying potential participants on the basis of insufficient medication refills and recruiting them and/or by delegating this task to local physicians. Obtaining physician collaboration was, however, a requisite step (before or after enrolling patients), as pharmacists were only reimbursed by the national healthcare insurance scheme (equivalent to about €17.55 per week) if the service had been prescribed [8, 9]. Enrolled pharmacists participated in a 3-h training on medication adherence, communication with patients, promotion of the programme to the physicians and the use of the study’s equipment. On-going support was delivered by the principal investigator, who visited or contacted the pharmacies once a month. After 2 years, the study was stopped and the planned analysis of clinical outcomes was abandoned because only seven subjects in total had been included.
Aim of the study The aim of the qualitative study was to explore pharmacists’ perceptions and experiences with NARC implementation and clarify the very limited inclusion rate.
Ethical approval The NARC study was approved by the Ethics Committee of Canton de Vaud (Switzerland) and included a pharmacist satisfaction survey about the programme’s implementation. At the time of the study, no other specific ethical approval was required to conduct qualitative interviews with health professionals.
Method Design A qualitative study was conducted with 20 of the 24 pharmacists who had consented to participate in the NARC programme (Table 1). Four pharmacists were excluded because they were involved in a subsequent project, which might have influenced their opinions due to an intensive training related to adherence management. Interviews An interview guide was prepared to ensure that the five following themes (no order was imposed) were discussed:
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Table 1 Characteristics of pharmacists and their pharmacies (n = 20)
Pharmacists responsible for the programme Male
12 (60 %)
Average age (median; IQR)
40.95 (43; 32; 48.25)
Average years of experience (median; IQR) Average percentage of full-time post worked (median; IQR)
15.13 (15; 7.75; 22.25) 91.25 (100; 80; 100)
Position of pharmacist responsible for the programme Owner
8 (40 %)
Manager
6 (30 %)
Deputy
6 (30 %)
Human resources: equivalent average full-time employees a
Corporate banner brings economically independent pharmacies together. On the contrary, pharmacies belonging to a chain are managed by a private company
b
Pharmacy sizes are based on operating annual income (in millions of €) described by the systematic study of pharmacy costs (RoKa 2007): small B1.42 mio; medium, 1.42–2.03 mio; moderately large 2.03–2.85 mio; large [2.85 mio. [16]
c
[10,000 inhabitants
Pharmacists (median; IQR)
2.17 (2; 1.58; 2.33)
Dispensary technicians (median; IQR)
4.53 (4.5; 2.73; 5.8)
Total (median; IQR)
6.70 (6.33; 4.78; 8.05)
Pharmacy typesa Independent
8 (40 %)
Corporate banner
9 (45 %)
Chain
3 (15 %)
Annual operating income/turnoverb 2.03–2.85 mio € [2.85 mio €
9 (45 %) 8 (40 %)
Not reported
3 (15 %)
Location Urbanc
11 (55 %)
Rural
9 (45 %)
Table 2 Three categories of pharmacists, separated by their degree of success in patient enrolment Degree of success in implementing the programme
Number of pharmacists
Participant code
Level 0:
Pharmacists did not tell their patients that the service existed
6
L0
Level 1:
Pharmacists failed to enrol any patients despite having promoted the service
8
L1
Level 2:
Pharmacists managed to enrol one or two patients and monitored them in their pharmacies for periods ranging from 1 month to more than 1 year
6
L2
(1) routine organisation; (2) employees’ knowledge and skills; (3) patients’ needs and expectations; (4) collaboration with physicians; and (5) equipment and procedures used during the NARC study. This guide was developed on the basis of pharmacists’ comments collected during implementation and the literature about practice changes in community pharmacies [10–12]. It derived partly from organisational theory to ensure that the five interdependent variables proposed in this framework (task, technology, participants, structure and environment) were addressed during the interviews [12]. Semi-structured in-depth interviews were conducted with an empathetic and non-judgmental attitude. The interview process was tested on two pharmacists who had participated in a similar medication adherence programme;
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this brought minor corrections to the guide. All interviews were recorded with the pharmacists’ consent. After interviews, participants also completed a structured questionnaire to obtain their demographic data and organisational data about their pharmacy and their staff (Table 1). Interviews took place in August and September 2009. Analyses Interviews were transcribed verbatim, transferred into a manual coding computer programme (Weft-QDA) and analysed thematically [13, 14]. Using an iterative process, a coding scheme was developed inductively on the collected data. Each interview was coded according to the final coding scheme [15] and structured hierarchically into themes and
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sub-themes. The coded data were classified into three categories in a matrix according to level of achievement of the pharmacy in the implementation of the programme (Table 2). This allowed an inter-pharmacy comparison and an inter-category comparison [13]. The analysis initially focussed on general trends and then on deviant cases [14]. A second experienced researcher assisted in setting up the coding system. Five interviews were coded in parallel to check on matching opinions for the structure of the coding tree and on the clarity of the codes.
Results All 20 pharmacists recruited agreed to participate in the interviews (60 min on average). Table 1 presents the characteristics of the pharmacies and their staff. All pharmacies had an operating annual income of over €2.03 million, which is close to the Swiss average (€2.15 million). However, the number of employees was below the Swiss average (6.7 vs. 7.3 equivalent full-time posts) [16]. The factors influencing implementation of the medication adherence programme were grouped into four themes. Two themes were related to the relationships established with external stakeholders: promotion of the programme to patients and collaboration with physicians. Two other themes concerned factors internal to the pharmacy: problems linked to the integration of the programme into routine organisation and pharmacists’ motivation to implement the programme. Findings are illustrated by the quotations below. The alphanumeric code identifies to what degree the medication adherence programme was implemented in the pharmacy concerned (see Table 2). Poor communication with patients resulting in insufficient promotion of the programme Successful promotion of the medication adherence programme to patients rested on four factors: the ability to identify patients that experienced adherence issues; the strategy used to present the programme; the ability to communicate about medication adherence; and the patient’s interest in taking part. One-third of pharmacists did not promote the medication adherence programme to any patients at all; one-third proposed it to fewer than ten patients; and one-third proposed it to more than ten patients.
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dispensing of drugs is systematically logged in computer systems, there were no efficient computer functions to aid in analysing medication adherence. Computer systems are not optimal. They don’t let you rapidly identify adherence problems. […] That’s a problem for NARC; in fact, it is a problem for all adherence-monitoring follow-up. (L2-12) Programme presentation strategy Although the adherence programme was usually proposed to patients at the pharmacy counter, one pharmacist stood out by making an appointment with patients to talk about their treatments in a private space. This facilitated the promotion of the programme as tailored to a patient’s needs. Although the pharmacist only proposed these consultations to two patients, they were both enrolled in the study. No further patients were approached because the pharmacist started the study rather late and his enrolment strategy was very time-consuming. Unwillingness and difficulties in speaking about adherence Nearly half of the pharmacists indicated that they feared bothering their patients. Some pharmacists appeared to wait for a signal from the patient that he or she was open to speaking about adherence. They were afraid of being too intrusive, infringing on the patient’s ‘private life,’ or complicating things for them. They assumed that patients would feel ‘obliged’ to participate or ‘monitored.’ Consequently, the programme was only proposed to a limited number of patients or proposed in a tentative manner. Three pharmacists remarked that more extensive training could have assisted them in promoting the programme. Lack of patient interest Many pharmacists described the difficulties of interacting with patients because these usually considered managing their treatment adequately; thus pharmacists perceived that assistance was unwelcomed. Anyway, at least with the people I came across, it didn’t encourage them to talk about their treatment or touch on something in particular. It was really, ‘No, no, there’s nothing to worry about, everything is fine.’ So there, that quickly cuts short the discussion. (L2-03) A pharmacist that managed to enrol only one patient after fifty contacts underlined the significant effort he made: ‘‘I think that the NARC project is the most difficult project that I’ve done because you had to really, really discuss it with people a lot and persuade them.’’ (L2-02).
Identification and selection of patients Identifying medication adherence problems when checking prescriptions was perceived as a difficult task. Indeed, identifying such problems requires an in-depth analysis of the patient’s medication history, and even though the
Insufficient collaboration with physicians Half of the pharmacists did not inform any local physicians about the existence of the project because they feared a
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negative reaction. The reasons put forward were linked to deficient or bad collaboration or to a perception that physicians would consider the programme to be interference by pharmacists in their domain of activity. Other pharmacists met with physicians personally or chose to contact them by mail. Meeting physicians Only one-quarter of pharmacists actually met local physicians to present the programme. This resulted in two pharmacists enrolling one patient each on the basis of a physician prescription. Previously set-up collaborations with these physicians appeared to have favoured a new form of partnership. Another pharmacist faced a physician’s refusal to participate because he did not want his patients being ‘monitored.’ At the beginning, the physician was enthusiastic. So I brought along the brochures, I discussed it with him; I showed him the drug monitor and everything that goes with it. But after a certain time, […] as I could see that I didn’t have any clients arriving with prescriptions for the drug monitor, I telephoned [the physician] and he said, ‘Oh, no, we don’t like monitoring our clients’. (L2-02). Information letter Three pharmacists applied an indirect communication strategy with physicians by sending an information letter. Two of them made no personal followup. Their motivation was to ensure that physicians obtained complete information about the programme and not only partial information via a patient. The letters were not linked to a proactive offer of collaboration. Because our big fear was that we would speak about it to the patient and then the patient… would go and speak about it differently or would present the project to the physician in such a way that the physician would take offence. (L0-23) Difficulty in integrating the programme into pharmacy organisation Four types of barriers to implementing the medication adherence programme in community pharmacies were identified: lack of practical experience, differing reorganisation, insufficient human resources and insufficient delegation. Lack of experience Nearly half of the pharmacists would have liked to have practiced the different stages of the NARC programme during their training to feel more at ease in real situations. Their lack of experience, when added to the initial difficulty in enrolling patients, seems to have rapidly led to a loss of confidence in their abilities to
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effectively put the programme into operation. On the other hand, six pharmacists were quickly able to try out the whole process (from enrolment into the programme and discussions with the patient to managing the EDM dispenser) and encountered no difficulties. I think that there are some pharmacists who said to themselves after a while, ‘Oh, I don’t know whether I’d still be able use… go back to the programme’, and so I think they hesitated to even propose the programme. I was pleased that I had somebody fairly quickly, so that I could familiarise myself with everything and, after that, I knew there was nothing to worry about. (L2-03) Differing reorganisation Pharmacists appeared to have adopted a wait-and-see attitude, not planning workload reallocation or reorganisation in the pharmacy as long as a patient had been enrolled. Some of them thought that anticipating such organisational changes was unnecessary because only a limited number of patients would be involved. I didn’t want to change the organisation of the pharmacy just to do that. So, we did a bit as a sideline, and that made us realise how difficult it was. And at least it will have taught me one thing: to think about organising things differently for future services. (L1-13) Insufficient human resources The team composition and size were considered as barriers to the introduction of new practices. Indeed, promotion and implementation of the programme required the presence of at least two pharmacists so that one of them could concentrate fully on the adherence programme. Even for pharmacies with several pharmacists, the programme required a reallocation of workloads. The only thing is resources. You’ve got to say, […] Okay, well, my job is actually to address these extra activities, […]. Sometimes, you should tell yourself that there’s a need for another 50 % post, I don’t know… just for this kind of project. (L1-09) Insufficient delegation One pharmacist, who enrolled two patients, was particularly insistent about how the technical help received from his dispensary technician had been vital on an organisational level: ‘‘for managing and reading the electronic pill monitor readouts, printing adherence reports and all sorts of administrative tasks.’’ (L2-12) In the other pharmacies, dispensary technicians had rarely been involved and had only briefly been informed that the programme even existed. This absence of delegation of responsibilities to technicians was not only attributable to
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pharmacists’ attitudes (i.e., they did not wish to involve staff before having tried out the programme themselves) but was also sometimes due to resistance by staff themselves. Furthermore, six pharmacists responsible for the programme in their pharmacies were deputy pharmacists (not head pharmacists), which are not the most favourable hierarchical positions from which to advance the programme. Finally, some head pharmacists aimed to delegate programme implementation but considered that their deputy pharmacists or other pharmacy staff lacked the necessary skills. … what I really heard frequently from the dispensary technicians; they had the impression that it was very far from their practical concerns. […] It wasn’t a good experience from the beginning, there were a lot of refusals by the team to take part and I was very clearly annoyed about that. (L1-01) Insufficient pharmacist motivation Pharmacists were hesitant about implementing the adherence programme and lacked motivation for other reasons: other activities that restricted their involvement with the NARC project; or ambiguity regarding the financial remuneration and the reorientation of the pharmacist as a service provider. Other priorities For most pharmacies, the programme was merely of secondary importance. Implementation of the NARC programme was in direct competition with various activities, such as: commitments to local politics (L0-08, L0-11); renovation of the pharmacy (L1-14, L0-20); quality certification (L0-10); pharmaceutical assistance to nursing homes (L0-20, L0-08); or taking over a new pharmacy (L1-01, L1-14). The NARC project became one of those things that we’d quite like to do, but that we don’t give ourselves the time to do. So, all the regular things got done first. (L1-01) Remuneration and the role of the pharmacist The pharmacists’ statements suggest an ambiguous attitude with regard to remuneration for the NARC programme. Remuneration did not represent an incentive for the pharmacists because the programme seemed to be treated as a timelimited project. With this short term perspective, pharmacists appeared uncomfortable asking for remuneration, fearing a negative reaction from patients and physicians. Even if the intentions are laudable, we’re in a commercial system where we have to sell—in inverted commas—a service, so that we can bill it. You have to be able to propose a service to the patients, to
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argue the case so that they accept it and then bill them afterwards. Well, that is what an insurance broker does, but… I do find it hard to play that game. (L0-05) Once they took a long-term view of the medication adherence programme, remuneration seemed to be essential, but one-third of pharmacists judged the remuneration to be inadequate with respect to the time and human resources required to provide the programme. I have difficulty believing that the future of our company is in providing such services, even if it is some people’s opinion, because there’s still quite a gap between what it brings in and what it costs in terms of human resources. (L0-11) In comparison, filling weekly pill organisers—a service reimbursed at the same rate as the NARC programme and widely carried out by community pharmacies—was perceived as less complex and more profitable. The investments in terms of communication and the work reorganisation required to implement the NARC programme were deemed to be dissuasive.
Discussion This study investigated pharmacists’ experiences and opinions related to the implementation of a medication adherence programme (NARC) in community pharmacies. This study had several limitations. First, data were collected by the principal NARC investigator. Pharmacists might have toned down their criticism about different aspects of the study (i.e., relevancy, training, support and documentation). However, each pharmacist was clearly informed about the limited number of patients enrolled throughout the study and the rationale of collecting data on the various barriers. Second, due to the two-year delay between the initiation of the programme’s implementation and the qualitative study, certain operational details might have been omitted. Third, this study only integrates pharmacists’ points of view and not those of the other stakeholders—the patients and physicians. Pharmacists faced many barriers to implementing the programme. Adopting a truly proactive role in the promotion of medication adherence was one major challenge [17]. Despite the fact that the MEMS was intended to guide and support medication adherence, it was difficult for pharmacists to promote its use as such. They anticipated negative reactions from patients when proposing that their medication-taking be monitored. A programme to support medication adherence might well be more favourably
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received if it were proposed to the patient within the context of a medication use review (polymedication check)—a service recently introduced in Switzerland [9, 17] whose primary aim is drug-related problem solving. Alternatively, it could be better accepted in the context of managed care if the patient perceives that physicians and pharmacists share a similar attitude of guidance rather than monitoring. A second challenge was the complexity of the service and the number of skills pharmacists had to master to deliver it. Not only pharmaceutical skills but also a high aptitude for communication and a leadership attitude were necessary. Pharmacists should not only be trained to deliver the programme but also to identify and recruit patients. In that sense, a more intense training programme would have been helpful. In other studies, identification of and communication with potential subjects have also been described as challenges [18–21]. Specific training combined (or not) with assistance by the research team for the recruitment of patients is a strategy that has been described to assist pharmacists in this step [18, 22]. A certification as service provider has also been described as a guarantee of the pharmacist’s competencies [18]. Another challenge for pharmacists was creating a form of partnership with physicians that went against the two professions’ usual working habits: the pharmacist had to suggest to the physician that he/she prescribe a cognitive pharmaceutical service (CPS) [23]. Pre-existing collaboration with physicians has been recognised as a facilitator, including in Switzerland [11, 24]; alternatively, particular attention should be paid to this issue. [18, 20, 25–27]. In Switzerland, at the time of the NARC study, the programme was very innovative in terms of interdisciplinary collaboration. Physicians-pharmacists quality circles based on extended interprofessional collaboration were rarely routinely implemented [28]. The few pharmacists engaged in such a programme were more successful in convincing physicians to adhere to the project. Although it has been suggested that pharmacists should be proactive and not rely solely on physicians to enrol patients in adherence support programmes [29], extensive support in assisting pharmacists when promoting the service to the physicians (i.e., courier, meeting) would have been useful [18]. Additionally, both professions should share similar views and objectives with regard to medication adherence support. Thus, as the study revealed that physicians might consider adherence monitoring as intrusive, it would be necessary to clarify their awareness of the problems surrounding adherence and its management. One final challenge was to create ‘buy-in’ by the pharmacists themselves. Despite their enrolment in the study, most of them did not take a very active part in the programme and quickly lost motivation after a few
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unsuccessful attempts at enrolling patients. In accordance with the five steps of the innovation-decision process developed by Rogers (knowledge, persuasion, decision, implementation and confirmation) [30] and recent definitions used to describe the dissemination and implementation steps [31], the study revealed that pharmacists’ consent to participate and their attendance at the teaching session did not translate to a robust commitment to apply it. The training and assistance offered throughout the NARC study were primarily technical in nature and did not act as catalysts of the programme implementation. The remuneration was not considered as a motivator either. The financial constraints of reorganisation (mostly in terms of human resources) were anticipated to be superior to the income, which was perceived as uncertain. Pharmacists who signed up for the NARC programme had not fully integrated the necessary changes to deliver CPS; they stayed focussed on the routine activities of dispensing medication for which their organisation was optimised. Thus, the majority of pharmacists did not demonstrate sufficient leadership or foresight—skills that are essential to motivating personnel and pushing through the organisational changes necessary to carry out such a programme [32–35]. To reduce the reorganisation involvement, selecting pharmacies that have hired a second pharmacist with availability to deliver the service or assume a routine workload would have been appropriate [18, 20]. Several studies have reported on the difficulties to gain pharmacists’ commitment to deliver an adherence programme or another CPS [22, 36, 37]; competition with other services can be a reason for this [29]. Filling weekly pill organisers represented an easier alternative service that was remunerated and thus deterred pharmacists from engaging in a more complex CPS. The programme was very innovative in Switzerland. It requested new attitudes and behaviours not only in the management of the pharmacy but also with regard to collaboration with physicians and contact with patients. Although the adherence programme had been successfully implemented within the specific context of the PMU pharmacy, the obstacles related to the gap between routine and CPS provision was too difficult to overcome in traditional community pharmacies. To promote CPS, especially those concerning medication adherence, pharmacists would need to develop their interpersonal skills. A specific, certified, post-graduate training programme aimed at enhancing pharmacists’ leadership skills and their capacity to implement such services are requested [38]. Undergraduate training should also introduce future pharmacists to such issues. Furthermore, a formative evaluation including the use of qualitative methods should be planned throughout the implementation
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of such services with the aim of efficiently addressing any type of barrier [39–41]. Finally, endorsement and support by professional associations would be highly beneficial [11, 18, 35].
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are necessary. Competent authorities and professional bodies should endorse this new vision. Acknowledgments We wish to thank all the pharmacists who granted interviews and/or participated in the NARC study. We also wish to thank Alison Roberts for her contribution to the design of the interview guide.
Conclusion Implementing an adherence programme implies an important change in pharmacists’ vision of their position within the health system. It requires interprofessional collaboration and the development of a shared view of the role that pharmacists and physicians hold with regard to patient adherence and treatment management. This represents a long-term development for which the reorganisation of workloads, adjustments in human resources and the acquisition of novel skills
Funding This study was funded by the Department of Ambulatory Care and Community Medicine, University of Lausanne, Switzerland. Conflicts of interest The authors have no conflicts of interest to declare.
Appendix See Table 3.
Table 3 Interview guide Area
Description
Checklist
1. Pharmacy organisation
A pharmacy is a complex work environment, mixing business and healthcare activities. In this area, the aim is to explore whether
Pharmacy layout
1. development strategies and
Staff turnover Time allowed to the project
2. organisational components have been implemented around the NARC study. 2. Staff knowledge and skills
The characteristics of each staff member influence the development of any new practice. In this area the aim is to explore how these characteristics have influenced implementation of the NARC study.
Development priorities
Skills/attitudes/difficulties in getting started and in communicating with patients Strategy for engaging the entire pharmacy team Staff resources Knowledge–Education Skills Motivation Involvement
3. Opinions and experiences of patients’ expectations and needs
Patients have needs and expectations related to their health status and the health system. In this area, the aim is to explore interviewee’s opinions and experiences with NARC linked with the needs and the expectations of the patients.
Attitude towards the presentation of the NARC study (verbal or not) Patient’s reasons for: Acceptance Refusal
4. Collaboration and experiences with physicians
Integrated care is a component of the NARC study. Physicians can also include patients. Every adherence report is sent to the physician. Therefore, the exploration of collaboration with physicians is an important issue.
Existing relationship Presentation of the NARC study Attitude and willingness to collaborate Physicians including patients Collaboration with pharmacists around the NARC study
5. Experiences with tools and processes of the NARC study
NARC materials, processes and tutorials have been created for the implementation of the study. In this area, the aim is to explore reluctance or difficulties in using NARC materials and processes and opinions about the 3 h training.
Internet portal 3-h training Handbook MEMS Remuneration system and business plan Inclusion criteria Helpline
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Int J Clin Pharm (2014) 36:1014–1022 21. Kaae S, Norgaard LS. How to engage experienced medicine users at the counter for a pharmacy-based asthma inhaler service. Int J Pharm Pract. 2012;20(2):99–106. 22. Niquille A, Lattmann C, Bugnon O. Medication reviews led by community pharmacists in Switzerland: a qualitative survey to evaluate barriers and facilitators. Pharm Pract. 2010;8(1):35–42. 23. Hughes CM, McCann S. Perceived interprofessional barriers between community pharmacists and general practitioners: a qualitative assessment. Br J Gen Pract. 2003;53(493):600–6. 24. Roberts AS, Benrimoj SI, Chen TF, Williams KA, Aslani P. Practice change in community pharmacy: quantification of facilitators. Ann Pharmacother. 2008;42(6):861–8. 25. Barnes JM, Riedlinger JE, McCloskey WW, Montagne M. Barriers to compliance with OBRA’90 regulations in community pharmacies. Ann Pharmacother. 1996;30(10):1101–5. 26. Kroger E, Moisan J, Gregoire JP. Billing for cognitive services: understanding Quebec pharmacists’ behavior. Ann Pharmacother. 2000;34(3):309–16. 27. Lowrie R, Johansson L, Forsyth P, Bryce SL, McKellar S, Fitzgerald N. Experiences of a community pharmacy service to support adherence and self-management in chronic heart failure. Int J Clin Pharm. 2014;36(1):154–62. 28. Niquille A, Ruggli M, Buchmann M, Jordan D, Bugnon O. The nineyear sustained cost-containment impact of swiss pilot physicians– pharmacists quality circles. Ann Pharmacother. 2010;44(4):650–7. 29. Carter BL, van Mil JW. Comparative effectiveness research: evaluating pharmacist interventions and strategies to improve medication adherence. Am J Hypertens. 2010;23(9):949–55. 30. Rogers EM. Diffusion of innovations. 5th ed. New York: Free Press; 2003. ISBN 0-7432-2209-1. 31. Rabin BA, Brownson RC, Haire-Joshu D, Kreuter MW, Weaver NL. A glossary for dissemination and implementation research in health. J Public Health Manag Pract. 2008;14(2):117–23. 32. Roberts AS, Benrimoj SI, Chen TF, Williams KA, Hopp TR, Aslani P. Understanding practice change in community pharmacy: a qualitative study in Australia. Res Soc Adm Pharm. 2005;1(4):546–64. 33. Feletto E, Wilson LK, Roberts AS, Benrimoj SI. Flexibility in community pharmacy: a qualitative study of business models and cognitive services. Pharm World Sci. 2010;32(2):130–8. 34. Kaae S, Sondergaard B, Haugbolle LS, Traulsen JM. The relationship between leadership style and provision of the first Danish publicly reimbursed cognitive pharmaceutical service—a qualitative multicase study. Res Soc Adm Pharm. 2011;7(2):113–21. 35. Hopp TR, Sorensen EW, Herborg H, Roberts AS. Implementation of cognitive pharmaceutical services (CPS) in professionally active pharmacies. Int J Pharm Pract. 2005;13(1):21–31. 36. van de Steeg-van Gompel C, Wensing M, De Smet PAGM. Implementation of adherence support for patients with hypertension despite antihypertensive therapy in general practice: a cluster randomized trial. Am J Hypertens. 2010;23(9):1038–45. 37. Dualde E, Faus MJ, Santonja FJ, Fernandez-Llimos F. Effectiveness of a videoconference training course on implementing pharmacy services. Pharm World Sci. 2009;31(6):638–42. 38. Holdford DA. Leadership theories and their lessons for pharmacists. Am J Health Syst Pharm. 2003;60(17):1780–6. 39. Peters DH, Adam T, Alonge O, Agyepong IA, Tran N. Implementation research: what it is and how to do it. BMJ. 2013;347:f6753. 40. Stetler CB, Legro MW, Wallace CM, Bowman C, Guihan M, Hagedorn H, et al. The role of formative evaluation in implementation research and the QUERY experience. J Gen Intern Med. 2006;21(Suppl 2):S1–8. 41. Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50(3):217–26.
RESEARCH ARTICLE
Exploring the implementation of a medication adherence programme by community pharmacists: a qualitative study Julien Marquis • Marie P. Schneider • Brenda Spencer • Olivier Bugnon • Sophie Du Pasquier
Received: 6 December 2013 / Accepted: 22 July 2014 / Published online: 20 August 2014 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2014
Abstract Background Medication adherence has been identified as an important factor for clinical success. Twenty-four Swiss community pharmacists participated in the implementation of an adherence support programme for patients with hypertension, diabetes mellitus and/or dyslipidemia. The programme combined tailored consultations with patients about medication taking (expected at an average of one intervention per month) and the delivery of each drug in an electronic monitoring system (MEMS6TM). Objective To explore pharmacists’ perceptions and experiences with implementation of the medication adherence programme and to clarify why only seven patients were enrolled in total. Setting Community pharmacies in Frenchspeaking Switzerland. Method Individual in-depth interviews were audio-recorded, with 20 of the pharmacists who participated in the adherence programme. These were transcribed verbatim, coded and thematically analysed. Process quality was ensured by using an audit trail detailing the development of codes and themes; furthermore, J. Marquis M. P. Schneider O. Bugnon Community Pharmacy, School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland J. Marquis M. P. Schneider O. Bugnon S. Du Pasquier Community Pharmacy, Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland B. Spencer Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland S. Du Pasquier (&) Community Pharmacy, Pharmacie de la Policlinique Me´dicale Universitaire, Rue du Bugnon 44, 1011 Lausanne, Switzerland e-mail: [email protected]
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each step in the coding and analysis was verified by a second, experienced qualitative researcher. Main outcome measure Community pharmacists’ experiences and perceptions of the determining factors influencing the implementation of the adherence programme. Results Four major barriers were identified: (1) poor communication with patients resulting in insufficient promotion of the programme; (2) insufficient collaboration with physicians; (3) difficulty in integrating the programme into pharmacy organisation; and (4) insufficient pharmacist motivation. This was related to the remuneration perceived as insufficient and to the absence of clear strategic thinking about the pharmacist position in the health care system. One major facilitator of the programme’s implementation was pre-existing collaboration with physicians. Conclusion A wide range of barriers was identified. The implementation of medication adherence programmes in Swiss community pharmacies would benefit from an extended training aimed at developing communication and change management skills. Individualised onsite support addressing relevant barriers would also be necessary throughout the implementation process. Keywords Cognitive pharmaceutical services Community pharmacy Interdisciplinary collaboration Implementation Medication adherence Pharmacists Qualitative research Switzerland
Impact of findings on practice •
Pharmacists’ commitment in implementing a novel service should be evaluated throughout the process, and tailored assistance should be delivered according to the barriers identified.
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• •
•
Health professionals should be encouraged to take active roles in promoting medication adherence. Pharmacists’ pre- and post-graduate education should address the challenges of delivering cognitive pharmaceutical services and their integration into daily practice. Pharmacists’ communication skills should be reinforced to promote medication adherence programmes and improve collaboration with doctors.
Introduction Medication adherence has been recognised as a key factor in reaching successful clinical outcomes for chronic conditions [1–3]. Its promotion is part of the quality standards for pharmaceutical services established jointly by the International Pharmaceutical Federation and the World Health Organisation [4], and community pharmacists have engaged in delivering medication adherence programmes in various countries [5]. In Switzerland, the pharmacy based within the Department of Ambulatory Care and Community Medicine (PMU) has developed a successful medication adherence counselling programme dedicated to chronically ill patients, most of whom are HIV positive [6]. This institutional university pharmacy operates as a community pharmacy; however, as a result of being located within an ambulatory care centre, it capitalises on strong interprofessional collaborations. Continuity of care is ensured when delivering the adherence programme, as physicians refer patients and act on pharmacists’ reports. The intervention, which is delivered by a trained pharmacist, combines motivational interviewing with electronic drug monitoring (EDM via MEMSTM). A 6 month pilot study revealed that adherence dropped off more slowly (p \ 0.0001) in the intervention group (EDM combined with pharmacists’ intervention) than in the control group (EDM only) [7]. To extend this programme, a study called NARC (NonAdherence Risk Control) was conducted between 2008 and 2010. Twenty-four community pharmacies enrolled in a programme targeting medication adherence issues by patients with common pathologies (diabetes, hypertension and dyslipidemia) and using a minimum of three drugs. The programme combined the delivery of each drug in MEMSTM (with a display continuously informing the patient how many times the container has been opened throughout the day) and consultations with patients about taking their medication (expected at an average of one intervention per month). The consultations aimed at addressing adherence barriers through personalised solutions, including a reminder service (through SMS messaging) if necessary. A report addressing patient adherence
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issues and possible actions was sent to the patients’ physicians. Pharmacists were responsible for enrolling patients in the study either by identifying potential participants on the basis of insufficient medication refills and recruiting them and/or by delegating this task to local physicians. Obtaining physician collaboration was, however, a requisite step (before or after enrolling patients), as pharmacists were only reimbursed by the national healthcare insurance scheme (equivalent to about €17.55 per week) if the service had been prescribed [8, 9]. Enrolled pharmacists participated in a 3-h training on medication adherence, communication with patients, promotion of the programme to the physicians and the use of the study’s equipment. On-going support was delivered by the principal investigator, who visited or contacted the pharmacies once a month. After 2 years, the study was stopped and the planned analysis of clinical outcomes was abandoned because only seven subjects in total had been included.
Aim of the study The aim of the qualitative study was to explore pharmacists’ perceptions and experiences with NARC implementation and clarify the very limited inclusion rate.
Ethical approval The NARC study was approved by the Ethics Committee of Canton de Vaud (Switzerland) and included a pharmacist satisfaction survey about the programme’s implementation. At the time of the study, no other specific ethical approval was required to conduct qualitative interviews with health professionals.
Method Design A qualitative study was conducted with 20 of the 24 pharmacists who had consented to participate in the NARC programme (Table 1). Four pharmacists were excluded because they were involved in a subsequent project, which might have influenced their opinions due to an intensive training related to adherence management. Interviews An interview guide was prepared to ensure that the five following themes (no order was imposed) were discussed:
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Table 1 Characteristics of pharmacists and their pharmacies (n = 20)
Pharmacists responsible for the programme Male
12 (60 %)
Average age (median; IQR)
40.95 (43; 32; 48.25)
Average years of experience (median; IQR) Average percentage of full-time post worked (median; IQR)
15.13 (15; 7.75; 22.25) 91.25 (100; 80; 100)
Position of pharmacist responsible for the programme Owner
8 (40 %)
Manager
6 (30 %)
Deputy
6 (30 %)
Human resources: equivalent average full-time employees a
Corporate banner brings economically independent pharmacies together. On the contrary, pharmacies belonging to a chain are managed by a private company
b
Pharmacy sizes are based on operating annual income (in millions of €) described by the systematic study of pharmacy costs (RoKa 2007): small B1.42 mio; medium, 1.42–2.03 mio; moderately large 2.03–2.85 mio; large [2.85 mio. [16]
c
[10,000 inhabitants
Pharmacists (median; IQR)
2.17 (2; 1.58; 2.33)
Dispensary technicians (median; IQR)
4.53 (4.5; 2.73; 5.8)
Total (median; IQR)
6.70 (6.33; 4.78; 8.05)
Pharmacy typesa Independent
8 (40 %)
Corporate banner
9 (45 %)
Chain
3 (15 %)
Annual operating income/turnoverb 2.03–2.85 mio € [2.85 mio €
9 (45 %) 8 (40 %)
Not reported
3 (15 %)
Location Urbanc
11 (55 %)
Rural
9 (45 %)
Table 2 Three categories of pharmacists, separated by their degree of success in patient enrolment Degree of success in implementing the programme
Number of pharmacists
Participant code
Level 0:
Pharmacists did not tell their patients that the service existed
6
L0
Level 1:
Pharmacists failed to enrol any patients despite having promoted the service
8
L1
Level 2:
Pharmacists managed to enrol one or two patients and monitored them in their pharmacies for periods ranging from 1 month to more than 1 year
6
L2
(1) routine organisation; (2) employees’ knowledge and skills; (3) patients’ needs and expectations; (4) collaboration with physicians; and (5) equipment and procedures used during the NARC study. This guide was developed on the basis of pharmacists’ comments collected during implementation and the literature about practice changes in community pharmacies [10–12]. It derived partly from organisational theory to ensure that the five interdependent variables proposed in this framework (task, technology, participants, structure and environment) were addressed during the interviews [12]. Semi-structured in-depth interviews were conducted with an empathetic and non-judgmental attitude. The interview process was tested on two pharmacists who had participated in a similar medication adherence programme;
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this brought minor corrections to the guide. All interviews were recorded with the pharmacists’ consent. After interviews, participants also completed a structured questionnaire to obtain their demographic data and organisational data about their pharmacy and their staff (Table 1). Interviews took place in August and September 2009. Analyses Interviews were transcribed verbatim, transferred into a manual coding computer programme (Weft-QDA) and analysed thematically [13, 14]. Using an iterative process, a coding scheme was developed inductively on the collected data. Each interview was coded according to the final coding scheme [15] and structured hierarchically into themes and
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sub-themes. The coded data were classified into three categories in a matrix according to level of achievement of the pharmacy in the implementation of the programme (Table 2). This allowed an inter-pharmacy comparison and an inter-category comparison [13]. The analysis initially focussed on general trends and then on deviant cases [14]. A second experienced researcher assisted in setting up the coding system. Five interviews were coded in parallel to check on matching opinions for the structure of the coding tree and on the clarity of the codes.
Results All 20 pharmacists recruited agreed to participate in the interviews (60 min on average). Table 1 presents the characteristics of the pharmacies and their staff. All pharmacies had an operating annual income of over €2.03 million, which is close to the Swiss average (€2.15 million). However, the number of employees was below the Swiss average (6.7 vs. 7.3 equivalent full-time posts) [16]. The factors influencing implementation of the medication adherence programme were grouped into four themes. Two themes were related to the relationships established with external stakeholders: promotion of the programme to patients and collaboration with physicians. Two other themes concerned factors internal to the pharmacy: problems linked to the integration of the programme into routine organisation and pharmacists’ motivation to implement the programme. Findings are illustrated by the quotations below. The alphanumeric code identifies to what degree the medication adherence programme was implemented in the pharmacy concerned (see Table 2). Poor communication with patients resulting in insufficient promotion of the programme Successful promotion of the medication adherence programme to patients rested on four factors: the ability to identify patients that experienced adherence issues; the strategy used to present the programme; the ability to communicate about medication adherence; and the patient’s interest in taking part. One-third of pharmacists did not promote the medication adherence programme to any patients at all; one-third proposed it to fewer than ten patients; and one-third proposed it to more than ten patients.
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dispensing of drugs is systematically logged in computer systems, there were no efficient computer functions to aid in analysing medication adherence. Computer systems are not optimal. They don’t let you rapidly identify adherence problems. […] That’s a problem for NARC; in fact, it is a problem for all adherence-monitoring follow-up. (L2-12) Programme presentation strategy Although the adherence programme was usually proposed to patients at the pharmacy counter, one pharmacist stood out by making an appointment with patients to talk about their treatments in a private space. This facilitated the promotion of the programme as tailored to a patient’s needs. Although the pharmacist only proposed these consultations to two patients, they were both enrolled in the study. No further patients were approached because the pharmacist started the study rather late and his enrolment strategy was very time-consuming. Unwillingness and difficulties in speaking about adherence Nearly half of the pharmacists indicated that they feared bothering their patients. Some pharmacists appeared to wait for a signal from the patient that he or she was open to speaking about adherence. They were afraid of being too intrusive, infringing on the patient’s ‘private life,’ or complicating things for them. They assumed that patients would feel ‘obliged’ to participate or ‘monitored.’ Consequently, the programme was only proposed to a limited number of patients or proposed in a tentative manner. Three pharmacists remarked that more extensive training could have assisted them in promoting the programme. Lack of patient interest Many pharmacists described the difficulties of interacting with patients because these usually considered managing their treatment adequately; thus pharmacists perceived that assistance was unwelcomed. Anyway, at least with the people I came across, it didn’t encourage them to talk about their treatment or touch on something in particular. It was really, ‘No, no, there’s nothing to worry about, everything is fine.’ So there, that quickly cuts short the discussion. (L2-03) A pharmacist that managed to enrol only one patient after fifty contacts underlined the significant effort he made: ‘‘I think that the NARC project is the most difficult project that I’ve done because you had to really, really discuss it with people a lot and persuade them.’’ (L2-02).
Identification and selection of patients Identifying medication adherence problems when checking prescriptions was perceived as a difficult task. Indeed, identifying such problems requires an in-depth analysis of the patient’s medication history, and even though the
Insufficient collaboration with physicians Half of the pharmacists did not inform any local physicians about the existence of the project because they feared a
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negative reaction. The reasons put forward were linked to deficient or bad collaboration or to a perception that physicians would consider the programme to be interference by pharmacists in their domain of activity. Other pharmacists met with physicians personally or chose to contact them by mail. Meeting physicians Only one-quarter of pharmacists actually met local physicians to present the programme. This resulted in two pharmacists enrolling one patient each on the basis of a physician prescription. Previously set-up collaborations with these physicians appeared to have favoured a new form of partnership. Another pharmacist faced a physician’s refusal to participate because he did not want his patients being ‘monitored.’ At the beginning, the physician was enthusiastic. So I brought along the brochures, I discussed it with him; I showed him the drug monitor and everything that goes with it. But after a certain time, […] as I could see that I didn’t have any clients arriving with prescriptions for the drug monitor, I telephoned [the physician] and he said, ‘Oh, no, we don’t like monitoring our clients’. (L2-02). Information letter Three pharmacists applied an indirect communication strategy with physicians by sending an information letter. Two of them made no personal followup. Their motivation was to ensure that physicians obtained complete information about the programme and not only partial information via a patient. The letters were not linked to a proactive offer of collaboration. Because our big fear was that we would speak about it to the patient and then the patient… would go and speak about it differently or would present the project to the physician in such a way that the physician would take offence. (L0-23) Difficulty in integrating the programme into pharmacy organisation Four types of barriers to implementing the medication adherence programme in community pharmacies were identified: lack of practical experience, differing reorganisation, insufficient human resources and insufficient delegation. Lack of experience Nearly half of the pharmacists would have liked to have practiced the different stages of the NARC programme during their training to feel more at ease in real situations. Their lack of experience, when added to the initial difficulty in enrolling patients, seems to have rapidly led to a loss of confidence in their abilities to
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effectively put the programme into operation. On the other hand, six pharmacists were quickly able to try out the whole process (from enrolment into the programme and discussions with the patient to managing the EDM dispenser) and encountered no difficulties. I think that there are some pharmacists who said to themselves after a while, ‘Oh, I don’t know whether I’d still be able use… go back to the programme’, and so I think they hesitated to even propose the programme. I was pleased that I had somebody fairly quickly, so that I could familiarise myself with everything and, after that, I knew there was nothing to worry about. (L2-03) Differing reorganisation Pharmacists appeared to have adopted a wait-and-see attitude, not planning workload reallocation or reorganisation in the pharmacy as long as a patient had been enrolled. Some of them thought that anticipating such organisational changes was unnecessary because only a limited number of patients would be involved. I didn’t want to change the organisation of the pharmacy just to do that. So, we did a bit as a sideline, and that made us realise how difficult it was. And at least it will have taught me one thing: to think about organising things differently for future services. (L1-13) Insufficient human resources The team composition and size were considered as barriers to the introduction of new practices. Indeed, promotion and implementation of the programme required the presence of at least two pharmacists so that one of them could concentrate fully on the adherence programme. Even for pharmacies with several pharmacists, the programme required a reallocation of workloads. The only thing is resources. You’ve got to say, […] Okay, well, my job is actually to address these extra activities, […]. Sometimes, you should tell yourself that there’s a need for another 50 % post, I don’t know… just for this kind of project. (L1-09) Insufficient delegation One pharmacist, who enrolled two patients, was particularly insistent about how the technical help received from his dispensary technician had been vital on an organisational level: ‘‘for managing and reading the electronic pill monitor readouts, printing adherence reports and all sorts of administrative tasks.’’ (L2-12) In the other pharmacies, dispensary technicians had rarely been involved and had only briefly been informed that the programme even existed. This absence of delegation of responsibilities to technicians was not only attributable to
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pharmacists’ attitudes (i.e., they did not wish to involve staff before having tried out the programme themselves) but was also sometimes due to resistance by staff themselves. Furthermore, six pharmacists responsible for the programme in their pharmacies were deputy pharmacists (not head pharmacists), which are not the most favourable hierarchical positions from which to advance the programme. Finally, some head pharmacists aimed to delegate programme implementation but considered that their deputy pharmacists or other pharmacy staff lacked the necessary skills. … what I really heard frequently from the dispensary technicians; they had the impression that it was very far from their practical concerns. […] It wasn’t a good experience from the beginning, there were a lot of refusals by the team to take part and I was very clearly annoyed about that. (L1-01) Insufficient pharmacist motivation Pharmacists were hesitant about implementing the adherence programme and lacked motivation for other reasons: other activities that restricted their involvement with the NARC project; or ambiguity regarding the financial remuneration and the reorientation of the pharmacist as a service provider. Other priorities For most pharmacies, the programme was merely of secondary importance. Implementation of the NARC programme was in direct competition with various activities, such as: commitments to local politics (L0-08, L0-11); renovation of the pharmacy (L1-14, L0-20); quality certification (L0-10); pharmaceutical assistance to nursing homes (L0-20, L0-08); or taking over a new pharmacy (L1-01, L1-14). The NARC project became one of those things that we’d quite like to do, but that we don’t give ourselves the time to do. So, all the regular things got done first. (L1-01) Remuneration and the role of the pharmacist The pharmacists’ statements suggest an ambiguous attitude with regard to remuneration for the NARC programme. Remuneration did not represent an incentive for the pharmacists because the programme seemed to be treated as a timelimited project. With this short term perspective, pharmacists appeared uncomfortable asking for remuneration, fearing a negative reaction from patients and physicians. Even if the intentions are laudable, we’re in a commercial system where we have to sell—in inverted commas—a service, so that we can bill it. You have to be able to propose a service to the patients, to
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argue the case so that they accept it and then bill them afterwards. Well, that is what an insurance broker does, but… I do find it hard to play that game. (L0-05) Once they took a long-term view of the medication adherence programme, remuneration seemed to be essential, but one-third of pharmacists judged the remuneration to be inadequate with respect to the time and human resources required to provide the programme. I have difficulty believing that the future of our company is in providing such services, even if it is some people’s opinion, because there’s still quite a gap between what it brings in and what it costs in terms of human resources. (L0-11) In comparison, filling weekly pill organisers—a service reimbursed at the same rate as the NARC programme and widely carried out by community pharmacies—was perceived as less complex and more profitable. The investments in terms of communication and the work reorganisation required to implement the NARC programme were deemed to be dissuasive.
Discussion This study investigated pharmacists’ experiences and opinions related to the implementation of a medication adherence programme (NARC) in community pharmacies. This study had several limitations. First, data were collected by the principal NARC investigator. Pharmacists might have toned down their criticism about different aspects of the study (i.e., relevancy, training, support and documentation). However, each pharmacist was clearly informed about the limited number of patients enrolled throughout the study and the rationale of collecting data on the various barriers. Second, due to the two-year delay between the initiation of the programme’s implementation and the qualitative study, certain operational details might have been omitted. Third, this study only integrates pharmacists’ points of view and not those of the other stakeholders—the patients and physicians. Pharmacists faced many barriers to implementing the programme. Adopting a truly proactive role in the promotion of medication adherence was one major challenge [17]. Despite the fact that the MEMS was intended to guide and support medication adherence, it was difficult for pharmacists to promote its use as such. They anticipated negative reactions from patients when proposing that their medication-taking be monitored. A programme to support medication adherence might well be more favourably
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received if it were proposed to the patient within the context of a medication use review (polymedication check)—a service recently introduced in Switzerland [9, 17] whose primary aim is drug-related problem solving. Alternatively, it could be better accepted in the context of managed care if the patient perceives that physicians and pharmacists share a similar attitude of guidance rather than monitoring. A second challenge was the complexity of the service and the number of skills pharmacists had to master to deliver it. Not only pharmaceutical skills but also a high aptitude for communication and a leadership attitude were necessary. Pharmacists should not only be trained to deliver the programme but also to identify and recruit patients. In that sense, a more intense training programme would have been helpful. In other studies, identification of and communication with potential subjects have also been described as challenges [18–21]. Specific training combined (or not) with assistance by the research team for the recruitment of patients is a strategy that has been described to assist pharmacists in this step [18, 22]. A certification as service provider has also been described as a guarantee of the pharmacist’s competencies [18]. Another challenge for pharmacists was creating a form of partnership with physicians that went against the two professions’ usual working habits: the pharmacist had to suggest to the physician that he/she prescribe a cognitive pharmaceutical service (CPS) [23]. Pre-existing collaboration with physicians has been recognised as a facilitator, including in Switzerland [11, 24]; alternatively, particular attention should be paid to this issue. [18, 20, 25–27]. In Switzerland, at the time of the NARC study, the programme was very innovative in terms of interdisciplinary collaboration. Physicians-pharmacists quality circles based on extended interprofessional collaboration were rarely routinely implemented [28]. The few pharmacists engaged in such a programme were more successful in convincing physicians to adhere to the project. Although it has been suggested that pharmacists should be proactive and not rely solely on physicians to enrol patients in adherence support programmes [29], extensive support in assisting pharmacists when promoting the service to the physicians (i.e., courier, meeting) would have been useful [18]. Additionally, both professions should share similar views and objectives with regard to medication adherence support. Thus, as the study revealed that physicians might consider adherence monitoring as intrusive, it would be necessary to clarify their awareness of the problems surrounding adherence and its management. One final challenge was to create ‘buy-in’ by the pharmacists themselves. Despite their enrolment in the study, most of them did not take a very active part in the programme and quickly lost motivation after a few
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unsuccessful attempts at enrolling patients. In accordance with the five steps of the innovation-decision process developed by Rogers (knowledge, persuasion, decision, implementation and confirmation) [30] and recent definitions used to describe the dissemination and implementation steps [31], the study revealed that pharmacists’ consent to participate and their attendance at the teaching session did not translate to a robust commitment to apply it. The training and assistance offered throughout the NARC study were primarily technical in nature and did not act as catalysts of the programme implementation. The remuneration was not considered as a motivator either. The financial constraints of reorganisation (mostly in terms of human resources) were anticipated to be superior to the income, which was perceived as uncertain. Pharmacists who signed up for the NARC programme had not fully integrated the necessary changes to deliver CPS; they stayed focussed on the routine activities of dispensing medication for which their organisation was optimised. Thus, the majority of pharmacists did not demonstrate sufficient leadership or foresight—skills that are essential to motivating personnel and pushing through the organisational changes necessary to carry out such a programme [32–35]. To reduce the reorganisation involvement, selecting pharmacies that have hired a second pharmacist with availability to deliver the service or assume a routine workload would have been appropriate [18, 20]. Several studies have reported on the difficulties to gain pharmacists’ commitment to deliver an adherence programme or another CPS [22, 36, 37]; competition with other services can be a reason for this [29]. Filling weekly pill organisers represented an easier alternative service that was remunerated and thus deterred pharmacists from engaging in a more complex CPS. The programme was very innovative in Switzerland. It requested new attitudes and behaviours not only in the management of the pharmacy but also with regard to collaboration with physicians and contact with patients. Although the adherence programme had been successfully implemented within the specific context of the PMU pharmacy, the obstacles related to the gap between routine and CPS provision was too difficult to overcome in traditional community pharmacies. To promote CPS, especially those concerning medication adherence, pharmacists would need to develop their interpersonal skills. A specific, certified, post-graduate training programme aimed at enhancing pharmacists’ leadership skills and their capacity to implement such services are requested [38]. Undergraduate training should also introduce future pharmacists to such issues. Furthermore, a formative evaluation including the use of qualitative methods should be planned throughout the implementation
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of such services with the aim of efficiently addressing any type of barrier [39–41]. Finally, endorsement and support by professional associations would be highly beneficial [11, 18, 35].
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are necessary. Competent authorities and professional bodies should endorse this new vision. Acknowledgments We wish to thank all the pharmacists who granted interviews and/or participated in the NARC study. We also wish to thank Alison Roberts for her contribution to the design of the interview guide.
Conclusion Implementing an adherence programme implies an important change in pharmacists’ vision of their position within the health system. It requires interprofessional collaboration and the development of a shared view of the role that pharmacists and physicians hold with regard to patient adherence and treatment management. This represents a long-term development for which the reorganisation of workloads, adjustments in human resources and the acquisition of novel skills
Funding This study was funded by the Department of Ambulatory Care and Community Medicine, University of Lausanne, Switzerland. Conflicts of interest The authors have no conflicts of interest to declare.
Appendix See Table 3.
Table 3 Interview guide Area
Description
Checklist
1. Pharmacy organisation
A pharmacy is a complex work environment, mixing business and healthcare activities. In this area, the aim is to explore whether
Pharmacy layout
1. development strategies and
Staff turnover Time allowed to the project
2. organisational components have been implemented around the NARC study. 2. Staff knowledge and skills
The characteristics of each staff member influence the development of any new practice. In this area the aim is to explore how these characteristics have influenced implementation of the NARC study.
Development priorities
Skills/attitudes/difficulties in getting started and in communicating with patients Strategy for engaging the entire pharmacy team Staff resources Knowledge–Education Skills Motivation Involvement
3. Opinions and experiences of patients’ expectations and needs
Patients have needs and expectations related to their health status and the health system. In this area, the aim is to explore interviewee’s opinions and experiences with NARC linked with the needs and the expectations of the patients.
Attitude towards the presentation of the NARC study (verbal or not) Patient’s reasons for: Acceptance Refusal
4. Collaboration and experiences with physicians
Integrated care is a component of the NARC study. Physicians can also include patients. Every adherence report is sent to the physician. Therefore, the exploration of collaboration with physicians is an important issue.
Existing relationship Presentation of the NARC study Attitude and willingness to collaborate Physicians including patients Collaboration with pharmacists around the NARC study
5. Experiences with tools and processes of the NARC study
NARC materials, processes and tutorials have been created for the implementation of the study. In this area, the aim is to explore reluctance or difficulties in using NARC materials and processes and opinions about the 3 h training.
Internet portal 3-h training Handbook MEMS Remuneration system and business plan Inclusion criteria Helpline
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