Serving an Inner City vvith Community Pharmacy A community pharmacist provides personalized services) delivering medications to senior citizens and responding to the changing health care needs of an inner city. by Maureen Flanagan
hen economics forced community pharmacist Amos W. Drummond to close the doors of Personalized Pharmacy Services in Washington, D.C., in August 1993, he had no intention of giving up the personalized medication delivery and consulting service that had formed the basis of his practice. Now, as co-owner of his new pharmacy, Fairfax Village Pharmacy in the Southeast section of Washington, D.C., Drummond continues to deliver medications to inner-city residents, particularly senior citizens, and to consult with them about their medication problems. At the same time, he has broadened his practice to offer additional services that fill gaps in the health care system for getting prescription medications to those who need them most. Drummond started Personalized Pharmacy Services after graduating from Howard University School of Pharmacy in Washington, D.C., in 1989. He and his partner, Jacques Jackson, wanted to bring back the 1960s' practice of making home consultation visits. With two drivers and a technician, Personalized Pharmacy Services made between 45 and 160 deliveries a day to their patients, mostly senior citizens living in the surrounding D.C., Maryland, and Virginia communities. Drummond and Jackson each made about 15 deliveries every month, visiting 40-60% of the pharmacy's patients in the course of a year. "When you're making home visits, you can fmd out ftrsthand about a patient's illnesses," Drummond says. Personal visits are an invaluable source of information on a patient's medication needs, he says. Because of economic hard times and restrictive third party networks, Drummond and his partner were forced to close their pharmacy (where Drummond lived on the second floor).
Amos W. Drummond counsels Washington, D.C, residents Mr. and Mrs. Herman Robinson on orc purchases. W'hen patients purchase orcs, Drummond often intervenes to prevent drug-drug interactions and other problems.
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Amos Drummond's Philosophy of Care
But before they did , the opportunity arose to buy a 3,200-sq ft pharmacy on the • Home visits and an comer lot of a neighborhood emphasis on the needs of shopping center across the elderly are important town. This larger facility proparts of pharmacy vided more space for frontservices. end business and greater opportunity for walk-in busi• The community pharmacist is a critical intermeness. In August 1992, they diary between patients bought Fairfax Village Pharand practitioners. macy and launched a new venture, while maintaining • The bottom line is not their commitment to a home money, but improving a patient's quality of life. delivery and consultation service. • Pharmacists must fight At Fairfax Village Pharmafor equal access to third cy, they dispense a maxiparty reimbursement. mum of 200 prescriptions • Participating in health daily, compared with 80 at fairs and seminars and the old pharnlacy, and sell conducting blood pressure an array of over-the-counter monitoring and brown-bag (aT C) medications and seminars help maintain a household items , most of high community profile. which serve the needs of senior citizens. They employ 11 people, full- or part-time-three pharmacists, four clerks and cashiers, and two full-time drivers. Even though Drummond has cut back the number of home visits to three or four a month and charges $1 for deliveries (previously, delivery was free) , he is still committed to providing personal services for seniors. Early on a cold January morning, he stopped by a patient's home before his pharmacy doors opened at 8:00 am. The patient had been prescribed ulcer medication, then returned a week later to purchase Maalox because of early-morning stomach problems. Drummond suspected a problem because the patient should not have had to supplement his prescription with OTC dnlgs. The visit proved useful. Drummond found that a medication interaction was reducing the life of the prescription drug and alerted the physician to the problem. Because of situations like this, Drummond is alert to peculiar or unusual OTC purchases made at his pharmacy. It helps to be "nosy, " he says, and it pays off because the quality of a patient's life can be dramatically changed by interventions of this kind. He notes other benefits, too. For the senior citizens he sees at home, the visits mean more than just the delivery of medication. "Sometimes, we're the only ones they've talked to all day," he says.
Critical Intermediary Drummond views the community pharmacist as a critical intermediary between patients and practitioners-a vital link AMERICAN PHARMACY
in the health care chain. In his own practice, he works with phYSicians, visiting nurses, and other health care professionals, adding his observations and expertise about the status of a patient's health and medication history. And like the delivery service he runs, he is often the one to drive the extra mile to keep the links together. For example , a dentist might notice that a patient has missed a checkup. He calls the nurse taking care of the patient and finds out that the patient is having a problem with diarrhea and cannot leave the house. This information is shared with the patient's physician and then with Drummond, who can deliver the necessary medication. In this way, Drummond gets referrals from other health care providers-and does the same for them. He is also willing to serve as a referral service to other pharmacies when his own pharmacy is not equipped to handle a patient's needs, or is not in a patient's network of providers. Even if his patients go elsewhere, if they feel that his pharmacy is taking care of them, they will come back, he says. Dnlmmond is also flexible with his patients about payment, taking a loss at times when there is little chance of reimbursement. He will accommodate the needs of those who have no medical insurance coverage, are lmemployed, or are between jobs. For Drummond, the bottom line is not money, but improving a patient's quality of life.
Fighting to Stay in Business Operating a personalized practice has not been easy in this age of belt tightening and new pressures on community pharmacies. "We're fighting to stay in business," Drummond says. Many of his mentors, pharmacists who had a successful business five years ago, are now out of business. Five years ago, about 300 independent pharmacies were in business in the Washington, D.C. , area, and now approximately 100 are still open. By Dnlmmond's estimate, 92 closed in 1992 alone. "It looks grim," he says, not only for independents, but for specialty pharmacy services, such as those providing oxygen home supply or home health care products. By comparison, there are some 1,500 chain pharmacies in the D.C. area. One of Dnlmmond's biggest problems-and one reason he had to close his first business-is that he has been locked out of many third party payment plans. He estimates that independents can usually register with about 20% of health benefit plans: out of every 100 prescriptions, Fairfax Village Pharmacy cannot fill 18, and he must send those patients elsewhere, usually to a chain pharmacy. In a situation like this, independents cannot compete with the chains, he says. "Equal access to health care plans is paramount for us" to stay in business, he says. As vice president of the Washington - District of Columbia Pharmaceutical Association, Dnlmmond is looking at equal access legislation that has been proposed in Maryland and Virginia, with the hope of having similar legislation adopted in the District. Equal access is the July 1994
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only way that independent notes, which chain pharmapharmacies like his can stay cies often ignore. Drumin business and provide permond keeps a high commusonalized and communitynity profile by participating based services. Meanwhile, in health fairs and seminars Fairfax Village Pharmacy has and conducting blood presjoined a 116-member buying sure monitoring and browngroup to help it remain combag seminars. He has begun petitive. "Without that , it working with patients in would be almost impossible nursing homes and group to survive, " he says. homes, and he sees the posOn some days, Drummond sibility of more services for says he wishes he could close these growing and often down his pharmacy and ignored inner-city groups. He become a self-employed lobis developing strategies that byist , fighting for equal focus on caring for patients access to phannacy services, infected with the human better health care for seniors, immunodeficiency vinlS and and more inner-city services. those with acquired immunLou Capel receives help from Drummond in managing He wrote a lengthy letter odeficiency syndrome-parseveral chronic medications. addreSSing these issues to ticularly newborns-and is Hillary Rodhaln Clinton, the defining a role for pharmadriving force behind President Clinton's health care reform cists as members of the health care team. Another important issue, he says, is making health care plan. For reform to be effective, he believes that these issues more accessible to inner-city residents. Public transportation must be examined in a coordinated manner. to and from health care facilities-which is an agenda item in President Clinton's health care bill-must be part of the overall plan of a reformed health care system, he says. Choosing Community Pharmacy Dnlmmond and his partner have tapped into smaller segDnlmmond has been a long-time observer of how pharmaments of their community and are ready to serve the diversicies work. Growing up in Nashville, Tenn., he helped stock ty of cultures found in inner cities. Although less than 1% of the shelves of his neighborhood pharmacy, earning about his patients are Hispanic, Dnlffiffiond works with translators $3.25 an hour. From this close-up view of working in a community pharmacy, he decided to make it his profession. from South American embassies to improve communication with this patient population, and he is willing to do the same While attending Howard, he worked at several large local for other ethnic groups who speak another language. chains and hospitals. But in the end, Dnlmmond turned to independent pharmacy because "you can interact with residents at a more in-depth level than you can in the chain environment. " Cutting Edge "Community pharmacies can be on the cutting edge," Community ties are what Drummond stresses most-both Dnlmmond maintains. To a large extent, health care reform their good and bad aspects. In an age of street crime, illegal and societal pressures will defme the new community phardrugs, and economic stress, Drummond says that his pharmamacy, so the future of pharmacy is still unclear. But however cy is a highly visible target. His pharmacy has been burglarthe health care system is reformed, big changes lie ahead for ized, and the front window of his store has been smashed pharmacies and other health care providers. Pharmacists, several times. With replacement costs at $300 a window, Drummond says, must be a part of those changes. though, he has decided to put the money into other areas "We're in the same galaxy as other health care professionand has replaced the windows with plywood boards. Since als but sometimes on the edge of the galaxy, like Pluto," he then, the storefront has been untouched: "no chewing gum, says. He has hope, however, that independent pharmacies no graffiti," he says. will be recognized for their value in serving those in inner cities, who fall outside the mainstream. "Community pharmacies have to be innovative to survive," he says. Drummond High Community Profile adds that he is ready for the challenge. As community service providers, pharmacists face positive challenges, too, Drummond says. "There are a host of servMaureen Flanagan is assistant editor, American Phannacy. ices that inner-city community pharmacies can provide, " he Vol. NS34, No.7
Pharmacists' Vievvs of Patient Counseling Pharmacists believe that patient familiarity with a medication and the seriousness of possible outcomes from its use are important considerations in counseling. by Jon C. Schommer, PhD, and Joseph B. Wiederholt, PhD
Abstract The goal of this study was to assess whether pharmacists rate eight elements of counseling of equal importance in different dispensing situations. A sample of 708 pharmacists was asked to complete a pretested questionnaire about patient counseling; 697 provided usable responses, for a response rate of 98% . Using multivariate analysis of variance and analysis of variance, we found significant differences (p < 0.01) in pharmacists' ratings of the importance of counseling patients in different situations. Pharmacists used patient familiarity with the medication and the perceived seriousness of potential consequences to the patient to determine the importance of each element of counseling.
The Omnibus Budget Reconciliation Act of 1990 COBRA '90) mandated that pharmacists counsel all Medicaid patients receiving prescription medications, beginning January 1, 1993. These mandatory patient counseling requirements have focused attention 011 the need to define what constitutes appropriate patient counseling by pharmacists. 1,2 Pedersen and Schulz examined the meaning of the term "counseling" for pharmacists and identified two conceptual views. 3 In one view, counseling is providing information that is factual, objective, and drug-Oriented; in the other, counseling is .providing subjective, patient-oriented advice that is the pharmacist's reasoned opinion. Under the first view of counseling, the pharmacist's responsibility extends to, but not beyond, providing facts about elements specific to the drug, without consideration of the individual patient. Providing written information on the drugs dispensed would be an appropriate way to accomplish the factual type of counseling. The factual view posits that, for every drug dispensing situation, the pharmacist should convey the same counseling elements, i.e., product name, directions for use, side effects and interactions, to the patient. In the second view of counseling, the pharmacist's responsibility extends beyond the provision of factual information to include advice and assessment based primarily on patientspecific variables, e.g., recommending appropriate drug-taking July 1994
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behavior that fits the patient's lifestyle, or assessing which information most needs to be reinforced for a particular patient. In this type of counseling, pharmacists actively decide what infonnation should be conveyed to a particular patient. Thus, the elements of the counseling provided depend on the dispensing situation and the patient. For example, some researchers have reported that the elements of counseling that a phannacist conveys to a patient depend on whether the dispensed medication is a new ("original") prescription order or a refill ("renewal,,).4 Other factors are the classification of the drug (i.e. , prescription or over-the-counter [OTC] medication)5-8 and the perceived seriousness of the dispensing situation. 9-12 This study was designed to detennine phannacists' conceptual view of counseling by'assessing whether phannacists rated several elements of counseling of equal importance in different dispensing situations or rated some elements of greater or lesser importance depending on the type of situation. We assumed that if pharmacists rate the elements of counseling of equal importance for different dispensing situations, phannacists more likely view counseling as providing objective, factual drug infonnation. However, if phannacists rate the importance of certain elements of counseling differently, depending on the dispensing situation, they likely view counseling as providing advice, based on their judgment, and specific to a given situation.
Six Dispensing/Counseling Situations Situation 1 = Original prescription and patient unfamiliar with it. Situation 2 = Renewed prescription and patient familiar with it. Situation 3 = Nonsteroidal anti-inflammatory agent available by prescription only. Situation 4 = Nonstero~dal anti-inflammatory agent available over the counter. Situation 5 = New prescription/pharmacist busy/serious situation. Situation 6 = Renewed prescription/pharmacist not busy/situation not serious.
each of these elements of patient counseling on an II-point scale from 0 , "of no importance, " through 10, "of great importance," for the given situation. Three pairs of situations were developed to help assess variability in what phannacists considered appropriate to tell patients under different situations (see Figure 1). These situations were developed based on reported research, 4 personal experiences of the authors, comments from an expert panel of phannacists, and questionnaire pretest results.
Methods Situation 1: Original Prescription and Patient Unfamiliar with It
Developing the Survey Questionnaire The six situations that follow were designed to collect data from phannacists about their views of patient counseling and practice characteristics. Each questionnaire included one of these six dispensing situations. Pharmacists were asked to rate the importance of conveying to patients each of the eight elements of patient counseling in the situation described in that questionnaire. The elements selected for comparison were based on the definition of "appropriate consultation" proposed by the National Association of Boards of Phannacy13 and included: • The name of the medication and its purpose. • Directions for use and storage. • Side effects. • Interactions with other medications. • Contraindications. • Administration-price, generic availability, renewals. • Continuity of therapy-how this medication works with others; what this medication replaces. • Monitoring-how to assess the medication's effectiveness; action to take if a problem occurs. Also, a ninth item was called "other." Pharmacists rated Vol. NS34, No.7 July 1994
A parent presents an amoxicillin suspension prescription for her one-year-old child. The dosage and directions are appropriate for a one-year-old child. As the parent hands you the prescription, she says this is her child's first ear infection and [she] has no experience in using a prescription for a child's ear infection. The physician has authorized two refills as needed for subsequent ear infections. You have collected all pertinent patient profile information. The child has no known allergies.
Situation 2: Renewed Prescription and Patient Familiar with It A parent presents an amoxicillin suspension bottle to be refilled for her one-year-old child. She tells you that the pediatrician told her that her child may get ear infections periodically and [she should] use the amoxicillin exactly as [she did] the first time. The dosage and directions are appropriate for a one-year-old child. The physician has authorized two refills as needed for subsequent ear infections. You have collected all pertinent patient profile information. The child has no known allergies.
flashes on the screen In Situations 1 and 2, we Pharmacists may need more telling you that for the last compared the importance three months, the patient rating given when a pharmahas been taking warfarin education and training on how cist dispensed a new preprescribed by Dr. Thromscription order to a patient bosis, a specialist. to monitor patient profiles and not familiar with the product, with that given when a how to counsel patients. Situation 6: Renewed pharmacist dispensed a Prescription/Pharmarenewal prescription for the cist Not Busy/Not a same medication to a patient Serious Situation who had used it before. Because researchers have It's Sunday morning at 11 am. Business is slow found that more counseling and you've been catching up on some paper work. Your next occurs for original prescriptions than for renewals,4,14,15 we door neighbor, a close friend, stops in to pick up a refill he hypothesized that pharmacists' ratings of the importance of called in the day before. The prescription is for his blood preseach element of counseling would be higher for original presure medication, [which] he has been taking for the last five scription orders than for renewals. years with good results. After he takes his blood pressure on
Situation 3: New Prescription for Nonsteroidal AntiInflammatory Agent Available by Prescription Only A 70-year-old female patient presents a new prescription for Feldene. The prescription has refills for one year. The dosage and directions are appropriate. Her proftle shows she has no known allergies and has taken the prescription hydrochlorothiazide for blood pressure for the last 10 years.
Situation 4: Nonsteroidal Anti-Inflammatory Agent Available OTe A 70-year-old female patient asks to purchase Advil over the counter. Her proftle shows she has no known allergies and has taken the prescription hydrochlorothiazide for blood pressure for the last 10 years.
We developed Situations 3 and 4 to compare the effect of a drug's classification (prescription or OTC) on pharmacists' ratings of the importance of each element of counseling. The prescription and OTC products were from the same therapeutic class of medication-non-steroidal anti-inflammatory drugs (NSAIDs)-and the situations were similar in other respects. The NSAID category was chosen because it contains both prescription and OTC drug products. From these situations, we could learn whether a drug's classification would affect pharmacists' ratings of the importance of information to be conveyed to a patient. Situation 5: New Prescription/Pharmacist Busy/Serious Situation You are extremely busy. Ten people are waiting for their prescriptions, the telephone is ringing off the hook, your technician is at lunch, and a pharmaceutical sales representative just walked in. You are presented with a new prescription for aspirin in high dosage from Dr. Arthritis, a general practitioner. As you enter the prescription into the computer, a warning
the machine located in your pharmacy, he states, "137/85, right on the money again, " and then asks for his refill.
In Situations 5 and 6, we compared how the seriousness of problems seen in a dispensing situation affected pharmacists' ratings of the importance of conveying specific information to a patient when the pharmacist is under different levels of time pressure, which presumably would affect the ease of cOlIDseling. In Situation 5, a busy pharmacist faces a serious situation, and in Situation 6, a pharmacist who is not busy faces a nonserious situation. Comparisons between these situations can help determine whether the type of dispensing situation or time pressures have a greater effect on how pharmacists rate the importance of the counseling elements.
Sample and Data Collection The questionnaire was administered to pharmacists during an introductory session of a Wisconsin Pharmacy Examining Board project, called the Wisconsin Pharmacy Self-Inspection. 16 For that project, the investigators divided Wisconsin into four areas (Southern, Western, North Central, and Eastern). The 156 pharmacists attending the seminars at Southern Wisconsin sites were used to pretest the questionnaire. In Western, North Central, and Eastern Wisconsin, a census sample of managing pharmacists from 895 pharmacies had been invited to attend the Wisconsin Self-Inspection introductory sessions between August and December 1991. The questionnaire, revised into its fmal form, was administered to 708 pharmacists attending one of these sessions. Each questionnaire described one of the six possible situations. The questionnaires were ordered sequentially, with Situation 1 through Situation 6, and distributed systematically to pharmacists after a random start. Ordering of questionnaires in this sequence helped prevent the occurrence of order bias.
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Data Analysis Data were analyzed using descriptive statistics for: • Practice setting (independent or small chain, chain larger than 10 units, hospital or long-term-care facility, clinic, or other). • Position (manager, assistant manager, chief pharmacist, staff pharmacist, intern, or other). • Age. • Years in practice. • Average daily prescription volunle (0-75, 76-150, 151-225,226-300, or more than 300). • Use of technicians. • COlmselor role orientation (eight-item measure of pharmacists' attitudes toward counseling). • Proportion of refills. • Proportion of elderly patients. These statistics were selected based on previous research4 and used to ascertain that respondents who received Situation 1 and Situation 2 were similar across these variables. The same cOl11parisons were made for respondents who received Situation 3 compared with 4, and 5 compared with 6. Comparisons were nlade using the chi-square statistic or two-tailed t test. Multivariate analysis of variance (MANOYA) was conducted to consider mean importance scores for all six situations, using the eight elements of cOlmseling as the dependent variables; the type of situation was the independent variable. This analysis was conducted to make comparisons across all six situations and all eight elements of counseling simultaneously. Mean importance scores for each element of counseling were compared among the six situations , using a one-way analysis of variance (ANaYA).
This uniqueness can affect their rating of the importance of counseling. Data collected for this study were pharmacists ' selfreports. How pharmacists' conceptual views of patient COlmseling affect actual counseling behaviors was not assessed. We suggest future research to investigate pharmacists' counseling behaviors at pharmacy practice sites.
Results Response Rate and Description of the Sample Of the 708 pharmacists asked to participate in this study, 51 % practiced in an independent or small chain pharmacy, 19% in chain pharmacies (> 10 lmitS) , 17% in hospitals, 10% in clinics, and 3% in other settings. Of the total, 63% reported they were in a managerial position. The respondents' average age was 44 years (range = 21 to 75), and average total years of practice was 19 (range = 0 to 48). Respondents who received the questionnaire with Situation 1 were not significantly different from those who received Situation 2 in practice setting, position, average daily prescription volume, use of technicians (chi-square, alpha = 0.05), age, years of practice, counselor role orientation, proportion of refills, and proportion of elderly patients (t test, alpha = 0 .05). No significant differences were found for those who received Situation 3 compared with 4, and 5 compared with 6. Thus, each group of pharmacists for compared situations was similar across each of the variables, and differences in groups' responses probably are not due to differences among these variables.
Limitations The results are applicable to pharmacy practices similar to those in Wisconsin. Although 79% of Wisconsin pharmacies were represented in the sample, the majority of respondents Importance of Counseling Elements Table 1 contains mean importance scores across all six situpracticed in a managerial capacity. Results should not be considered representative of all Wisconsin pharmacists, but they ations for all eight elements of counseling. The Hotellings and are representative of pharmacists in managerial roles who Wilks statistics were significant (p < 0.01), which suggests may have responsibility for pharmacy consultation policies mean importance scores among the six situations were differwithin their practice settings. ent, even when interrelations among the dependent variSome of the distributions of responses for each of the ables (i.e. , elements of counPharmacists used their judgment elements of counseling were seling) were controlled. skewed, with the majority of Mean importance scores and expertise to determine what responses near the high end for all eight elements of of importance on the rating counseling within each situainformation should be conveyed scale. Also only a small numtion were averaged and comto the patient. ber of dispensing situations pared. Situation 5 had the were investigated, when in highest average (7.5), folfact phaf111acists face a lowed by Situation 3 (7.3) , Situation 1 (7.2), Situation 4 unique situation each tinle they dispense a prescription. (6.9), Situation 2 (6.4), and Vol. NS34, No.7
Situation 6 (5.7). Situations 5, 3, 1, and 4-those with the highest averages-involved dispensing medications new to the patient and, it could be argued, in decreasing order of potential problems for the patient. Situation 4 involved dispensing the first renewal of a prescription, and Situation 6 involved dispensing a renewal for a prescription medication the patient had been taking for five years. ANOVA statistics for all but two of the elements of counseling were significant. Only "continuity of therapy" and "monitoring" were not significantly different (p < 0.001 across the six different situations). Table 1 also contains the rankings of the importance of the different counseling elements for each situation. Overall, the elements "directions for use and storage," "side effects, " and "monitoring" were ranked of greatest importance. Within each situation, however, variation in importance rank is evident. For example, the most important element of counseling reported for Situation 1 (original prescription for amoxicillin suspension) was "directions for use and storage," followed by "name of medication and purpose. " For Situation 2 (renewal prescription for amoxicillin suspension), "directions for use and storage" ranked most important, and "monitoring" ranked second. For Situation 3 (prescription for Feldene), "directions for
use and storage" was the most important element of counseling. This is consistent with the importance given this element for the original amoxicillin prescription. For Situation 4 (purchase of OTC Advil) , the element of counseling ranked most important was provision of side-effect information. For Situation 5 (new prescription!busy/serious situation), the elements of counseling ranked most important were interaction and contraindication information. This is in contrast to Situation 6 (renewal/not busy/situation not serious), for which monitoring and continuity of therapy information were ranked the most important elements of counseling.
Discussion Comparison of all six situations showed that the overall importance of providing all eight elements of counseling followed a pattern. Counseling had greater importance in situations involving a medication that was dispensed to a patient unfamiliar with the medication. Situations in which the pharmacist likely perceived potentially serious consequences to the patient also were of greater importance.
Importance of Eight Elements of Patient Counseling Mean Importanc e Scores Elements of Counseling
Situation 1 (N = 121)
Situation 2 (N = 120)
Situation 3 (N = 116)
Situation 4 (N = 117)
Situation 5 (N = 110)
Name of medication and purpose
8.4 (2) :1=
8 .5 (2 )
7 .4 (4)
Directions for use and storage
7 .9 (1)
6 .6 (4)
5 .9 (6)
6 .5 (6)
6 .8 (3)
7 .7 (3)
9 .3 (2)
4 .2 (8)
5 .2 (8)
3 .1 (8)
Continuity of therapy
6 .6 (5)
5 .9 (6)
App roxi m ate F
< 0 .001
= 0 .38
= 693; 15 questionnaires unusable because o f m iss i ng data .
t ANOVA one-way results of an eleme nt of counseling across S ituati ons 1- 6.
:j: ( )
sign ifies rank w ithin each situati on :
Situation 1 = Original presc r iption an d patient unfamiliar w ith it. Situation 2 = Renewed prescription and patient familiar with it. Situation 3 = Nonsteroidal anti-inflammatory age nt available by p rescription only. Situation 4 = Nonsteroidal a nti-inflammatory agent ava il able over the counter.
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Based on the average for all eight elements, counseling was most important in Situation 5, in which a serious drugdrug interaction was detected by the pharmacist processing an original prescription order. In such a serious situation, in which the patient probably is unfamiliar with the medication regimen, most pharmacists would counsel the patient no matter how busy they were. The next three highest importance scores across all eight elements were for Feldene, amoxicillin suspension, and Advil, respectively, which were dispensed to patients presllffiably unfamiliar with them. Pharmacists rated provision of elements of counseling more important for these medications than for prescription renewals, probably because the patient was believed to be unfamiliar with these medications. Also, the ordering of Feldene, amoxicillin suspension, and Advil probably reflects pharmacists' perceived seriousness of potential consequences for the patient. The two remaining situations (Situation 2, renewal/patient familiar; and Situation 6, renewal/not busy/not serious situation) received the lowest importance scores among the eight elements of counseling. In both situations, the patient received a renewal prescription. Elements of counseling for Situation 2, in which the patient received the flrst renewal of amoxicillin suspension, were rated more important overall
Situation 6 (N = 109)
Total (N = 693)*
Situation 5 = New prescription/pharmacist busy/serious situation. Situation 6 = Renewed prf?scription/pharmacist not busy/situation not serious. Note: Rating scale: 0 = "of no importance" through 10 = "of great importance. II
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than for Situation 6, in which the patient received a renewal of hydrochlorothiazide that had been used for the past flve years. Therefore, the more familiar a patient is with a medication, the less importance pharmacists place on elements of counseling for that patient. The patterns of patients' familiarity and perceived seriousness of potential consequences are apparent throughout all six situations. Pharmacists appear to use this information to help determine what and how much counseling their patients need. The specillc elements of patient counseling that pharmacists ranked most important varied, depending on the situation. In the most serious situation (5), the counseling elements "interactions" and "contraindications" were most important. In fact, these elements of counseling were rated extremely important (mean importance scores> 9.0). The information was specific to the potentially serious consequences for the patient, suggesting that pharmacists were using their judgment and expertise to determine what information should be conveyed to the patient. For the other new prescription orders (Situations 1 and 3), pharmacists judged the most important elements of C01IDSeling to be "directions for use and storage" and "name of medication and purpose." This counseling helps a patient understand how to use medication properly and what it is for. In the pharmacists' opinion, those counseling elements are most critical for the patient to know. For the original dispensing of aTe Advil (Situation 4), pharmacists apparently focused on "side effects," perhaps because labeling on aTe medications provides extensive information on directions for use. For the flrst renewal of an amoxicillin prescription order (Situation 2), pharmacists thought it was important to reiterate "directions for use and storage," although the next most important element of counseling was "monitoring." For a renewal of hydrochlorothiazide, which the patient had taken for flve years (Situation 6), pharmacists indicated that the most important element of counseling was "monitoring." Even with time available for counseling, pharmacists rated all elements of counseling relatively low for Situation 6. Some pharmacists may even decide that none of these elements of counseling are important enough to counsel the patient in this situation. Since many prescription dispensing situations are similar to Situation 6, patients who reportedly have not received any counseling may have flt this category. We showed that pharmacists considered monitoring information relatively important in a situation in which the patient was familiar with the medication; however, other researchers have reported that patients in Wisconsin receive monitoring information infrequently.4 This research suggests that although pharmacists believe that monitoring information should be known by patients who have been taking medication for some time, pharmacists may not be providing this information. Pharmacists may need more education and training on how to monitor patient profiles and how to counsel patients AMERICAN PHARMACY
about monitoring informaaddition, how do pharmaOveral~ "directions for use and tion (e.g., how to assess medcists' views compare with ications' effectiveness; patients' and payers' views? storage, ~~ "side effects, ~~ and actions to take if problems We believe that more sysoccur). For example, the tematic research should be "monitorlng~~ were considered patient in Situation 6 would conducted to answer these questions. not receive counseling in the most important elements most pharmacies because of counseling. many pharmacists probably are not comfortable with providing monitoring services. Conclusions The patient in Situation 6 may be monitored for potassium, cholesterol, and gluPharmacists rated the cose blood levels, as well as importance of each of eight for adequate kidney function . A pharmacist who inquires elements of counseling differently, depending on the situaabout whether these are being checked and monitored tion they encountered. Patients' familiarity with medication would be offering a valuable service. and pharmacists' perceived seriousness of potential consePharmacists in Wisconsin appeared to reject the view that quences to patients influenced phamlacists' opinions of the appropriate counseling is merely the provision of informaoverall importance of counseling and the elements of countion that is factual , objective, and drug-oriented, such as seling that were most important to provide. information contained in patient package inserts, because Therefore, we conclude that pharmacists do not view that may not meet patients' information needs. If a patient is patient counseling simply as the provision of information known to misunderstand and worry about side effects, the that is factual, objective, and dependent only on which drug pharmacist may need to explain that certain side effects are is dispensed. Rather, they view patient counseling as a servrare. Some pharmacists prefer to monitor patients for certain ice they provide, using their expertise and judgment, and side effects covertly, rather than cause the patient to worry. specific to individual patients and their medication needs. Patients have diverse medication profiles, familiarity and According to Pedersen and Schulz, for pharmacists to comexpertise with their medications, mental abilities, and motiply with this view of counseling, they must actively decide vation for receiving counseling. Pharmacists probably use what information should be conveyed to particular patients many different strategies and methods for counseling differto meet their needs. 3 ent patients. A defmition of appropriate patient counseling The results of this study have implications for implementashould take into consideration the variability that pharmation of and compliance with federal and state counseling regcists face in different dispensing situations. ulations. Because dispensing situations are unique, levels of Strategies for improving patient counseling by pharmacists counseling by pharmacists will vary. These variations pose should be targeted at educating pharmacists about the imporenforcement and reimbursement challenges for state Medicaid tance of counseling all patients. If one accepts the defmition of agencies and other third party plans that adopt the OBRA '90 counseling as one of advice, pharmacists may need more educounseling requirements. Pharmacists' professional judgcation and training in how to determine what elements are ments about what constitutes an appropriate level of patient important to convey to patients who receive prescription counseling should be considered, as policy makers monitor renewals and OTC medications. pharmacist compliance with counseling regulations and standThe results of this study raise some questions for further ards, and reimburse pharmacists for counseling services. research. For example, what decision criteria do pharmacists Jon c. Schommer, PhD, AFPE-NABP, is R. W Hammel Fellow use to determine whether or not to counsel patients? Is drugand assistant professor, pharmacy administration, College of specific, written information alone adequate for counseling Pharma(y, The Ohio State University, Columbus, Ohio. Joseph B. patients about their medications? Can written information be Wiederholt, PhD, is associate professor, pharmacy administration, tailored to meet individual patient needs, taking into considUniversity of Wisconsin -Madison, School of Pharmacy, Sonderegeration their total medication regimen, disease states, abiliger Research Center. ties, motivations, and familiarity with their medications? Do pharmacists have a correct conceptual view of patient counThis project was funded partially through a grant from the seling? Should pharmacists be educated to provide informaNational Association of Boards of Pharmacy Foundation and The tion to patients receiving renewed prescriptions? What are Sonderegger Research Center: InterdiSCiplinary Research in Social the specific barriers to and facilitators of the provision of and Administrative Pharmacy. patient counseling in different practice environments? In AMERICAN PHARMACY
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An earlier version of this paper was presented at the 1992 Annual Meeting of the American Pharmaceutical Association, San Diego, Calif., March 14, 1992.
References 1. Bloom MZ. FDA's Kessler: a prescription for change. Am Pharm . 1991;NS31:874-7. 2. Brushwood DB. The pharmacist's duty to warn: toward a knowledgebased model of professional responsibility. Drake Law Review. 1991;40:1-60. 3. Pedersen C, Schulz RM. Patient counseling: a conceptual analysis. Pharmacy Law Annual 1990. Vienna, Va: American Society for Pharmacy Law;1990:61-6. 4. Wiederholt JB, Clarridge BR, Svarstad BL. Verbal consultation regarding prescription drugs: findings from a statewide study. Med Care. 1992;30: 159-73. 5. Robinson OJ, Stewart RB. The elderly: understanding their nonprescription needs. Am Pharm. 1981;21 :664-8. 6. Michocki RJ. What to tell patients about OTC drugs. Geriatrics. 1982;37(6):113-126. 7. Fincham JE. Over-the-counter drug use and misuse by the ambulatory elderly: a review of the literature. J Geriatr Drug Ther. 1986;1 (2):3- 21. 8. Lumpkin JR, Strutton HD, Lim C, et al. The effect of self-reliance and information needs on over-the-counter medication use among the elderly. J Pharm Market Management. 1989;4( 1):25-43. 9. Kirking OM. Pharmacist perceptions of their role in outpatient drug therapy counseling. Columbus, Ohio: The Ohio State University, 1980. Dissertation. 10. Pitting EG, Hammel RW. Pharmacists' compliance with an 'appropriate consultation' requirement. Wisc Pharm. October 1983:255,258- 63. 11. Schommer JC, Wiederholt JB. A pilot study of barriers to pharmacist- patient communication reported by pharmacists. Poster paper presented at the 139th Annual Meeting of the American Pharmaceutical Association; March 14,1992; San Diego, Calif. 12. Schondelmeyer SW, Trinca CEo Consumer demand for a pharmacist conducted prescription counseling service. Am Pharm . 1983; NS23:321-4. 13. National Association of Boards of Pharmacy. Model Regulations of Appropriate Consultation, 1990. 14. Ascione FJ, Kirking OM, Duzey OM, et al. A survey of patient education activities of community pharmacists. Patient Education and Counseling. 1985;7:359-66. 15. Gannon K. Do you pass? Drug Topics. June 4,1990:32- 4,36,40. 16. Schommer JC, Wiederholt JB, McGregor TO. The Wisconsin Pharmacy Self-Inspection Project: an application of the theory of continuous improvement. Presented at the Annual Meeting of the American Society for Pharmacy Law; March 14,1992; San Diego, Calif.
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