Cooperation between community pharmacists and general practitioners in eastern Germany: attitudes and needs
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- Wüstmann, A., Haase-Strey, C., Kubiak, T. et al. Int J Clin Pharm (2013) 35: 584. doi:10.1007/s11096-013-9772-1
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Background Regions of decreasing medical supply with long distances to pharmacy or practice require a good collaboration between practitioners and pharmacists. Objective To determine and compare the attitudes of community pharmacists and practitioners towards each other regarding collaboration. Setting Mecklenburg-Western Pomerania in Germany. Method 749 general practitioners and practitioners specialized in diabetes care as well as 344 community pharmacists received a 38-item survey regarding their interrelations and attitudes towards each other. Main outcome measure Descriptive statistics of the practitioners’ attitudes towards pharmacists in comparison to the pharmacists’ attitudes towards practitioners in terms of perception of their role, reliability, functions, frequency and helpfulness of contact, cooperation in promoting medication adherence and quality of communication. Results Response rates were 19.4 % (n = 145) for practitioners and 24.4 % (n = 84) for pharmacists. 144 (76.6 %) of practitioners and 79 (71.5 %) of pharmacists strongly trusted the other health care providers’ statements and expertise (p = 0.0076). Practitioner–pharmacist interactions on average were of low frequency. They were, however, perceived to be helpful. The majority of pharmacists (62.7 %) regard their responsibility to ensure adherence with long-term medication to be equal to that of general practitioners. In contrast, the vast majority of practitioners (90.1 %) estimated their proportion of responsibility for adherence to long-term medication to be 75 % or more. At the same time, practitioners perceived the pharmacists’ current influence on patient adherence to long-term medication as generally positive (65.0 %). This is in line with the pharmacists’ self-perception (94.7 %). Conclusion The general trust of both health care providers towards each other is a good pre-condition for further collaborations. However, increased frequency in practitioner–pharmacist-interactions is necessary. Additionally, the role perceptions of pharmacists and practitioners should be harmonised as there are still misunderstandings in the responsibilities of both parties.
Impact of findings on practice statements
To ensure sufficient patient care and avoid drug related problems, the frequency of interactions between pharmacists and general practitioners in regions of decreasing medical supply should increase.
Pharmacists and general practitioners may need to explore ways to harmonise role perceptions to overcome misunderstandings on responsibilities and functions.
Pharmacists should be granted more competences in the promotion of patients’ adherence to long-term medications since they have the possibility to attend to the patients in their daily pharmaceutical practice and can significantly contribute to improving adherence.
Quality and safety of health care provision have increasingly been challenged during the last years. Ageing societies, increasing complexity of the medication market, decline of medical supply particularly in rural areas and reduction of health system resources have put tremendous burden on health care professionals. Home-medication reviews conducted in a rural area of North-eastern Germany with reduced medical supply revealed a substantial number of drug-related problems such as lack of or incorrect medication lists, expired medications, drug–drug interactions including such involving over-the-counter (OTC) medication, adverse drug events, deficiency in adherence and potentially inappropriate medication [1–3]. In order to provide strategies to solve these problems, many countries worldwide have started to intensify collaboration between general practitioners and community pharmacists. A systematic review of studies investigating patient benefits of these collaboration programs found evidence for beneficial effects of interventions on the basis of collaboration between community pharmacists and general practitioners . Furthermore, a meta-analysis conducted from US randomized controlled trials revealed that among humanistic outcomes particularly medication adherence was significantly improved by incorporating pharmacists as members of health care teams in direct patient care .
A prerequisite for an effective collaboration between community pharmacists and general practitioners is an equal perception of the interprofessional collaboration on both sides. However, this issue has not been investigated thoroughly so far. A couple of studies have been undertaken to investigate perception of and attitudes towards pharmacist–practitioner collaborations [6–14]. The only validated instrument to measure collaboration has been developed by Zillich et al. [15–17] which analysis interprofessional domains of trustworthiness, role specification, and relationship initiation. A questionnaire on frequency and helpfulness of pharmacist–practitioner interprofessional interactions as well as attitudes towards pharmacists’ traditional roles and extended functions was developed by Owens et al. . As medication adherence has been identified as an outcome measure that was significantly improved by inclusion of pharmacists into health care teams, Laubscher et al.  designed a questionnaire to assess physicians’ opinion on pharmacists’ role to support medication adherence. Of note, most of these surveys only addressed the practitioners’ point of view and none of these investigations were designed to compare perceptions of and attitudes towards pharmacist–practitioner collaborations from both, pharmacists’ and practitioners’ points of view in the same regional and temporal setting. As collaborative health care models are increasingly encouraged within the German health care system just recently, yet the opinions and views of health care professionals particularly community pharmacists and general practitioners in Germany have not been investigated systematically so far, we have initiated a survey that addressed these important issues.
Aim of the study
The purpose of this survey was to determine attitudes of general practitioners and community pharmacists towards collaboration with each other. The survey addressed professional relationship, current frequency and perceived helpfulness of pharmacist–practitioner-interactions and attitudes towards pharmacists’ functions to promote adherence from both practitioners’ and pharmacists’ point of view. This survey was part of a study (ClinicalTrials.gov Identifier NCT01587599) to establish a collaborative model of medication management for multimorbid patients with impaired mobility in a region with declining medical supply and is directed to researchers and decision makers who are involved in development and evaluation of pharmacist–physician collaborative model systems in health care.
This cross-sectional survey was conducted in August 2010 among a sample of community pharmacists and a sample of practitioners consisting of general practitioners and practitioners with qualifications as diabetes specialists in Mecklenburg-Western Pomerania, Germany. All participants received a 6-page questionnaire which had to be filled in and returned to the study centre. The participation was voluntary and the involved persons were not paid for completing the questionnaire nor offered any other form of compensation.
Sample selection and recruitment
Participants were recruited using web-based registries of practitioners and pharmacists. 344 community pharmacists and 749 practitioners of Mecklenburg-Western Pomerania were included in the present survey. Physicians working in inpatient settings and medical care specialists apart from such specialized in diabetes were excluded. The respondents could answer by mail, email or fax. For financial reasons we could not send out reminders. Deadline for returning the questionnaire was 3 months after the initial contact.
Topics, item ranges, scale types, coefficient α and references of part 1–5 of the survey
(Transformed) ranges per item and scale types
Internal consistency (α)
1–7 (maximum item count = 42)
1–7 (maximum item count = 35)
1–7 (maximum item count = 21)
‘Frequency and helpfulness of interactions’
−2 to +2
‘Expanded and traditional functions of pharmacists’
−2 to +2
Do pharmacists have a role in promoting adherence to chronic medication
Pharmacist-/practitioner-conducted activities to promote medication adherence
1–5 → 5-point-Likert-Scales transformed to −2 to +2
Reasons for not wishing to be contacted by GPs about non-adherent patients
Free text (open responses)
Extent of the responsibility of pharmacists/practitioners to promote adherence
75:25, 50:50, 25:75, 0:100 (extent in percent of responsibilities of pharmacists and practitioners, respectively)
Quality of collaboration with four types of health care providers
1 to 5 + 0
0.82 (for the scale “teamwork climate” of the SAQ-A)
→ 5-point-Likert-Scale +0
Part one contained fourteen items adopted from Zillich et al. [15–17], which were summed up within three major topics, ‘trustworthiness’, ‘role specification’ and ‘relationship initiation’. Questions were mainly directed towards assessing attitudes of the respective counterpart. As an exception, the relationship initiation domains focused solely on the attempt of pharmacists as initiators.
Part two referred to a survey addressing frequency of interactions between practitioners and pharmacists and helpfulness when having been actually conducted . Potential purposes of interactions asked were to assess the non-compliance of a patient, acquire or provide information on cost-related aspects of a drug therapy, discuss adverse drug effects, drug interactions and OTC-drugs as well as herbal remedies and dietary supplements and receive or provide necessary recommendations before starting the treatment.
Four items with the topic ‘attitudes toward traditional and extended functions of pharmacists’ composed part three of our questionnaires. Addressed functions were counseling of patients about adequate usage, risks and benefits of new prescriptions, reporting of allergies, drug interactions and dosage discrepancies to the practitioner, discussions about OTC-drugs with patients, and pharmacists’ involvement in decisions when optimising drug therapy .
Part four consulted eleven out of nineteen items of the Canadian questionnaire which determined whether GPs and pharmacists interacted to ensure patients’ medication adherence . Practitioners and pharmacists were asked to comment on pharmacists’ role in promoting medication adherence, the extent to which the two health care providers should be responsible for promoting adherence, and the impact of community pharmacists on adherence of their patients.
Lastly, part five inquired daily experience of responders concerning quality of collaboration with practitioners, pharmacists, nurses or care services. This part was based on an excerpt of the ‘SAQ-A’ (safety attitudes questionnaire-ambulatory version) .
To ensure equivalent content of the translated items back-translation was carried out by an English native speaker with long experience in pharmacy education in German academia. He was blinded to the study details and the original wording. Back-translation was assessed for discrepancies in conceptual content to the original instruments and discussed until reaching satisfaction. We did not undertake a pre-testing of our final questionnaires as the items closely referred to questionnaires that had already been used successfully.
Descriptive analyses calculated means and standard deviations for the respective item, statistical analyses included t test, two-tailed Mann–Whitney U test (CI = 95 %) and Chi Square test. A p value of <0.05 was considered statistically significant. Data were analysed using Microsoft Excel 2007 and Graph Pad Prism 3.0.
A total of 145 (response rate 19.4 %) of the questionnaires were returned by the medical practitioners and 84 (24.4 %) by the pharmacists.
Trustworthiness, relationship initiation and role specification (Part 1)
Frequency and helpfulness of interactions (Part 2)
Most interactions were perceived as helpful (Fig. 2b) except that practitioners questioned the helpfulness of discussing OTC-medications to some extent (mean −0.23 [−0.41 to −0.05]) as well as being advised for drug therapy (−0.04 [−0.25 to 0.17]). Both items were perceived to be helpful to a significantly higher extent by pharmacists (0.27 [0.05–0.49] and 0.83 [0.59–1.07], respectively, p < 0.01). Both health professions agreed on the helpfulness of interactions regarding drug abuse and non-adherence, cost-related issues and adverse side effects similarly (range 0.24–0.94). Again, the overall item mean of practitioners (0.25) was lower than that of pharmacists (0.70).
Traditional and extended functions and value of community pharmacists (Part 3)
Highest agreements of practitioners (n = 140) on traditional functions of pharmacists were found for contacting practitioners in case of allergies, drug–drug interactions or concerns on dosage [item mean 1.39(SD ± 0.91)] followed by counseling patients on new prescriptions (0.64 ± 1.20). Both of these items have been agreed on even to a significantly higher degree by pharmacists (1.75 ± 0.58, p < 0.05 and 1.75 ± 0.65, p < 0.0001, respectively, n = 80). On the extended role of pharmacists to discuss therapeutic alternatives with patients practitioners rather disagreed (−0.69 ± 1.14) while pharmacists felt rather neutral (0.0 ± 1.39, p < 0.05). Concerning the statement that pharmacists are a ‘value source of information’, some agreement was obtained from practitioners (0.45 ± 1.13) while pharmacists agreed rather strongly to this topic (1.55 ± 0.78, p < 0.05).
Pharmacists’ role and extent of pharmacists’ and practitioners’ responsibility in ensuring patients’ adherence (Part 4)
8 of 120 practitioners (6.7 %) and 15 of 75 pharmacists (20.0 %) judged pharmacists’ current influence on patients’ adherence to chronic medication strongly positive, 70 (58.3 %) of practitioners and 56 (74.7 %) of pharmacists characterised the influence to be somewhat positive, 39 (32.5 %) and 4 (5.3 %) to be minimal or not existing, respectively. 3 (2.5 %) of practitioners even stated that pharmacists have somewhat negative influence on this issue. Concerning contact rate to patients, particularly with regard to medication adherence, 16 (11.5 %) of practitioners (n = 139) said that they communicate daily with pharmacists, 38 (27.3 %) once a week, 36 (25.9 %) once a month, 25 (18.0 %) once a year and 24 (17.3 %) never.
Practitioners’ and pharmacists’ assessments of the helpfulness for pharmacist- or practitioner-conducted activities to promote the medication adherence on a scale ranging from −2 (strongly disagree) to +2 (strongly agree)
Scale mean ± SD practitioners
Scale mean ± SD pharmacists
Pharmacists’ activity (N = number of respondents to this issue)
Identifying patients not refilling chronic medications regularly.
N = 137
N = 76
0.5 ± 1.3
1.1 ± 1.0
Identifying patients who are not receiving guideline recommended medications
N = 142
N = 77
0.1 ± 1.2
0.4 ± 1.1
Emphasizing medication benefits rather than potential side effects.
N = 143
N = 80
0.9 ± 1.1
1.2 ± 0.9
Providing a diagnosis or clinical indication on prescriptions.
N = 134
N = 79
−0.8 ± 1.2
0.5 ± 1.2
Documentation of potential barriers to adherence on prescriptions.
N = 133
N = 74
−0.4 ± 1.2
0.1 ± 1.1
Documentation of the clinical indication on the prescription label to promote patient adherence
N = 135
N = 76
0.8 ± 1.2
1.6 ± 1.5
Quality of co-operation with four different health care providers (Part 5)
Multimorbid patients with restrictions in mobility are in urgent need of well co-operating health care providers particularly in rural areas. This is, to our knowledge, the first study which investigated the mutual assessment of collaboration of pharmacists and practitioners from both points of view within a rural German setting. The main findings of this study are, firstly, the existence of a basic prerequisite for practitioner–pharmacist-collaborations, namely an analogue, two-way and high-scored assessment within the domains trustworthiness, role specification and relationship initiation as meaningful predictors of collaboration. While, secondly, cooperation is currently rather insufficient, our study respondents would appreciate interactions to happen more frequently. A further significant finding is practitioners’ and pharmacists’ approval that pharmacists are a value source of information and play a role in ensuring patients’ adherence.
For a professional and resilient cooperation trust has to be developed and conflicts on antiquated and contrarian roles have to be eliminated. Specifically, when collaboration is not yet pronounced, readiness to its initiation is of enormous importance. Our study results show that these pre-conditions for a collaborative relationship are mainly assured: Findings on trustworthiness reveal that pharmacists and practitioners view this domain in a similar positive manner, which suggests a two-way high level of trust of the other’s word and expertise. A markedly higher rating of practitioners regarding role specification indicates that these feel more strongly that both health care providers should be mutually dependent on each other than pharmacists do. However, a congruent opinion on balanced dependences among pharmacists and practitioners does not exist so far, instead, roles and responsibilities for each other lack agreement. Findings on pharmacist-initiated relationship allow the conclusion, that pharmacists see themselves as relationship initiators, a function, that is appreciated by the practitioners as well. Hence, framework requirements for an effective “collaborative working relationship” (CWR)  are already existing but not yet fully developed.
Having ensured that these necessary pre-conditions are available, we focused on the status of hands-on experience with an effective CWR. Exploring frequency and helpfulness of various interactions between practitioners and pharmacists, we noticed that those were mainly occurring infrequently but appreciated by both parties—with the exception of asking or being asked for input to an appropriate drug therapy and discussing OTC drugs, both assessed rather critically. The first topic in our opinion is a task which practitioners want to carry out by themselves and in which pharmacists don’t want to interfere. The second one seems to be neglected at all. OTC-drugs do probably not have the same position as prescription drugs, especially concerning benefits, interactions and contraindications. We suggest paying more attention to this topic as various patients are unaware that OTC-drugs may cause serious adverse effects when used inappropriately . Self-medication with these agents has become widespread due to an increase of medications available as OTC. For instance, chronic OTC-analgesics are used predominantly by the elderly, which demands to closely monitor self-medication habits of this age cohort [20, 21].
An important function of pharmacists is promotion of patients’ medication adherence. Positive effects of pharmacist-led interventions to approach this aspect have been shown in earlier studies . Our studies’ majority of practitioners and pharmacists ascribe pharmacists to have a positive influence on enhancement of medication adherence. Nevertheless, role perception of practitioners and pharmacists towards this task is divergent: while pharmacists call for a balanced ratio of responsibility, practitioners feel themselves more dedicated to promote patients’ medication adherence. The reason may be that practitioners are not familiar with the skills of pharmacists or undervalue these possibly due to missing experience with a CWR.
The degree of pharmacist–physician collaborations varies extensively throughout the world. The International Pharmaceutical Federation (FIP) has defined five levels of collaboration from minimal contact between the health care providers to collaborative pharmacy practice, where the pharmacist is authorized to initiate or modify medicine therapy. Particularly in Australia, Canada, the United Kingdom and the United States (US), degree of collaboration has been taken to higher levels where the pharmacists are requested to supply medicine without the requirement of a prescription, to advise patients on referral from the prescriber, or even possess authority for dependent or independent prescribing . In Germany, collaboration between community pharmacists and general physicians is still realized on the lowest level, where the two professionals basically act mostly independently and with clearly defined but separate responsibilities. These differences in health systems may very likely account for the differences that we found concerning physicians’ views on pharmacists’ roles concerning input to drug therapy and frequency of interactions as compared to perceptions of US and Canadian physicians of their pharmacists.
A limitation of the study is its low response rate which may introduce some bias to the results. Obviously those participants responded who were highly motivated which could be due to a particularly positive or negative view on practitioner–pharmacist collaboration or both. If this was the case we would have expected a shift to the extremes on our Likert scales assessing perception of collaboration by pharmacists and practitioners. Distribution analyses revealed that those values were distributed normally which is indicative for us that despite the low response rate the absolute number of responses was high enough to still be representative.
This is the first survey that investigated perceptions on pharmacist–practitioner collaboration from both pharmacists’ and practitioners’ points of view in the same regional and temporal setting. The results of the survey revealed overall comparable degrees of agreement to fundamental factors of the interprofessional relationship, perception of frequency and helpfulness of interprofessional interactions, and appraisal of traditional pharmacists’ functions. Although these findings demonstrate the existence of a foundation for a functional collaborative relationship in the investigated pilot region in North-eastern Germany, more research is needed particularly on barriers that might prevent the installation of effective pharmacist–practitioner collaborations in primary health care that are urgently warranted in health systems worldwide.
We acknowledge all participants of our survey. Anna-Franziska Wüstmann and Carsten Haase-Strey contributed equally to the publication.
Part of this survey was funded by the Förderinitiative Pharmazeutische Betreuung e.V., Berlin, Germany.
Conflicts of interest