Impact of findings on practice

  • Poor communication between healthcare providers and with patients is a challenge and a contributing factor to poor patient knowledge.

  • Australian hospital pharmacists find that poor patient knowledge about medicines and disease states contribute to non-adherence.

  • Implemented services, such as the Home Medicines Review (HMR), are considered useful in improving adherence short term.

Introduction

In Australia, as in most industrialised countries, chronic illness represents a major burden. The National Health Priority Action Council reported that chronic illness was associated with 80% of the total burden of disease in terms of disability-adjusted life years in Australia in 2006 [1]. Australia also has an ageing population and the burden of chronic illness is likely to increase in the future as disabilities increase with age. Structural changes in the current health care system are needed to meet this increasing demand.

Health services have been under-researched in Australia despite the recognition of this shortfall in reviews of research conducted over the past 20 years [2]. Development of health services policy, and implementation of policy, needs to be informed by the experiences of patients, carers and healthcare providers. This study focuses on pharmacists and their involvement in services relating to management of medications by patients and carers. The focus on pharmacists is supported by several studies which have shown high acceptance of pharmaceutical care services by patients and their carers, recognising pharmacists as providers of valuable support in medication management [3–6]. Pharmacists are often regarded as the most accessible primary healthcare provider and have a unique opportunity to provide medication and healthcare advice [7]. Their position is also ideal to act as a “bridge” between patients and other healthcare providers and ensure continuity of care [5].

There are several government funded programs available in Australia to improve quality use of medicines and optimise patient outcomes. One such program is Dose Administration Aids (DAAs) where pharmacists divide patients’ medicines according to the dose schedule as prescribed by the patients’ doctor in a suitable device [8]. Another program is the home medicines review (HMR) that is provided jointly by general practitioners (GPs) and pharmacists. A HMR involves the patient’s GP referring the patient to a pharmacist, who conducts an interview with the patient preferably in the patient’s home, writes a report to the GP with clinical assessments and recommendations. The GP and patient then agree on a management plan [9, 10]. Despite mounting evidence of improved quality use of medicine following a HMR, the up-take remains low [11].

This study was conducted in collaboration with colleagues in the Serious and Continuing Illness Policy and Practice Study (SCIPPS), funded by the National Health and Medical Research Council. SCIPPS was designed to optimise chronic illness management in Australia through exploring the views of patients with chronic disease, their carers and healthcare providers, on incentives and barriers to optimal care. The results from interviews with patients and their carers have previously been reported [12], as have the views of healthcare providers on chronic illness management [13]. This article reports on the findings from group interviews and individual interviews with hospital pharmacists involved in the care of people with chronic illness.

Aim of the study

This study aimed to explore hospital pharmacists’ perceptions of incentives and barriers to managing patients with chronic illness and their suggestions for possible solutions, to explore their opinions of programs already implemented, and to facilitate integration of pharmacists’ views in future interventions and policy changes.

Method

In order to explore the perceptions of this group of healthcare providers, a rigorous approach to qualitative methods was utilised. The recruitment of respondents, data collection and analysis of data for this study are described below in detail.

Hospital pharmacists were recruited for this qualitative study. Acknowledging the potential differences in views between community and hospital pharmacists, community pharmacists’ perceptions were explored in a separate study [14]. Hospital pharmacies were identified through the Directory of Hospital Pharmacy and Pharmaceutical Organisations. In May 2008, invitation letters addressed to the director of each pharmacy were sent to six hospital pharmacies in western Sydney. The week following mail-out the invited pharmacies were contacted by the researcher (EL) to confirm interest in participating in a group interview. Group interviews were chosen over individual interviews as the preferred method as it has the advantages of being inexpensive, stimulating to respondents who can elaborate on responses offered by other respondents resulting in richer data [15]. However, to accommodate pharmacists’ practice schedule, both group interviews and individual interviews were conducted.

There was no pre-determined sample size and data collection stopped when no new themes were emerging from interviews, suggesting saturation of themes had been achieved. Interviews, of approximately 60 min duration, were held in meeting rooms in hospitals. Respondents were interviewed once and all interviews were moderated by a trained facilitator (EL) and another researcher (JB) took field notes.

The same interview guide developed and used by SCIPPS (Box 1) was used in this study. However, it was adapted to incorporate specific pharmacy-related questions (Q4). The interview guide was pilot tested during a group interview with hospital pharmacists. The same interview guide was used in all interviews.

Box 1. Topics covered in the interview

  1. 1.

    Perceived problems faced by healthcare providers, patients and carers in providing care/managing a chronic illness.

  2. 2.

    Challenges in managing more than one chronic illness.

  3. 3.

    Financial burden experienced by patients managing chronic illness/es.

  4. 4.

    Experience or expectations of HMR and other Commonwealth funded pharmacy programs.

  5. 5.

    Possible solutions to identified challenges.

This study was approved by the Australian National University Human Research Ethics Committee, the ACT Health Human Research Ethics Committee and Sydney West Area Health Service Human Research Ethics Committee. All respondents were provided an information sheet outlining the objective of the study, what participation involved, how confidentiality would be protected, that participation was voluntary and they could withdraw from the study at any time without that affecting existing or future relationships with the researchers. Any questions regarding this study were answered by EL before the respondents signed a consent form.

All interviews were digitally audio-recorded and transcribed verbatim. Informed by the principles of grounded theory, each interview was followed by a preliminary analysis to identify themes that needed clarification in subsequent interviews [16, 17]. To increase validity and reliability both researcher (EL and JB) were involved in the analytical process. Emerging themes were independently identified from transcripts, and compared and discussed to further develop the coding frame. The coding frame was cross-checked with respondents and other hospital pharmacists to provide an opportunity to further refine the coding frame and ensure that the findings were presented in a comprehensive and meaningful way.

Results

A total of 12 pharmacists were interviewed before data saturation had been achieved. Respondents ranged in age (22–62 years of age) and practice experience (6 months to over 35 years).

The key themes identified in the pharmacist interviews are discussed below. These themes were strongly evident in the data. Opposing views that were expressed are also discussed.

Challenges for pharmacists managing patients with chronic illnesses

One of the challenges pharmacists identified in providing care for patients with chronic illnesses was a strong perception of lack of communication; between healthcare providers and with patients. Where communication between healthcare providers occurred, it was perceived to be slow and ineffective.

Another challenge, related to lack of communication was the lack of continuity of care, both when patients were being admitted to and discharged from hospital. Hospital pharmacists did not have easy access to patients’ medication histories hence did not know what medications had been tried previously or how long the patients’ had been on the current medications and what the management plan had been prior to hospitalisation. This lack of information contributed to some pharmacists experiencing difficulties in encouraging doctors to maximise the dose of the medications the patients’ were currently taking instead of changing medications. Hospital pharmacists acknowledged their part in the poor information sharing with community pharmacists and expressed concerns that community pharmacists must be frustrated not knowing what, and the reasons for medication changes in hospital. Only when pharmacists were concerned about patients’ ability to manage the changes after discharge did they attempt to contact the patients’ community pharmacist, if they filled their prescription at one pharmacy only. The fact that some patients do not have a regular GP whereas other patients have multiple GPs and specialists was recognised by pharmacists as a potential problem.

“…I would suspect that the role of the GP, is starting to fade or become unknown like when you, you’ve got so many specialists looking after their individual speciality, how do they communicate with the GP? Who looks after the patient as a whole?” [sic] Pharmacist 4

Lack of multidisciplinary team approaches and holistic views were raised as another concern. This was thought to be aggravated by time issues such as short hospital admissions where only the most acute condition was addressed.

“I think that’s also a problem in hospital as well because they’re under thoracic team with COPD … whatever, and they’ve got this diabetes fumbling along, probably poorly managed but, and you know sometimes they might get an endocrine you know, consult or whatever but the team, like if you want to suggest things about, you know the oral, diabetes meds or whatever the team are often like ‘Oh their GP can fix it” like that’s – we’re doing the chest thing, we’ll fix that and then we just get them out, we need the bed for someone else.” [sic] Pharmacist 6

Perceived challenges for patients managing chronic illnesses

Pharmacists identified several difficulties they perceived patients to encounter in managing their chronic illness. One of the major difficulties was access to health care.

“Some patients ask for scripts but they can’t go to the GP, and they can’t go to the pharmacy [and they] can’t get [their] scripts [filled]. Just simple say ‘oh just go to pharmacy’ [doesn’t help, because] they can’t [go to the pharmacy] ‘cause they don’t have help.” [sic] Pharmacist 10

Even when health care and services were available to patients with chronic illnesses, hospital pharmacists sometimes experienced difficulties advising how patients could access these services. This was a stronger theme in interviews with pharmacists working at hospitals with a large referral area.

“there are specialist services that you can access for say, diabetes or patients with COPD but sometimes it can be difficult to find out how to access those services or knowing exactly the right person to contact.” Pharmacist 2

Another challenge pharmacists thought patients struggle with was the cost of medicines, which was perceived to be a contributing factor for non-adherence to medication regimens. Also poor patient knowledge about medicines, and disease states, were thought to result in poor decisions when patients had to prioritise which medicines to take and which advice to follow.

“It’s just going to be what they might need and that’s going to take because they don’t have enough money, and it can be quite expensive if it’s not, if they are on the borderline of that threshold, twenty-five dollars for one med is expensive, and then they’ve got the disease states to go with that as well, for your diabetics they’ve got renal and all that type of issues happening as well” [sic] Pharmacist 12

Poor patient knowledge was perceived to be a result of lack of information or information provided to the patient at an inappropriate time, i.e., to an acutely unwell and distressed patient in hospital. Different solutions to this problem were discussed with some pharmacists preferring to provide more written information to patients. This solution was not shared among pharmacists working in areas with many patients from diverse cultural and linguistic backgrounds where poor health literacy is common. Community-based education programs, delivered at no or low cost to the patients, were the preferred method in these areas.

Experiences of implemented services

Already implemented Commonwealth funded pharmacy programs such as HMRs were considered useful in assessing medication adherence, patient knowledge and to identify lifestyle factors previously unknown to healthcare providers. However, respondents also saw room for quality improvement of HMRs with better referrals from GPs and better training and accreditation of pharmacists conducting HMRs. To improve the quality of HMRs, some pharmacists suggested a change in guidelines to prevent one person (not necessarily accredited do conduct HMRs) to do the patient interview and another person (an HMR accredited pharmacist) writing the report.

“Sometimes you may see a patient in hospital who has had a home medicine review. And those patients seem to be a little bit more aware of what the pharmacist can do for them and they might say to you ‘oh yes I actually had a home medicine review by the pharmacist and they say oh I shouldn’t store my medicines you know, next to the kitchen sink or things like that you know, are actually quite important so you know, I think it’s quite beneficial in the long term for the patient.” [sic] Pharmacist 2

Opinions regarding DAAs varied with some pharmacists saying it was very beneficial for patients and it eased medication history taking whereas other pharmacists identified several challenges and suggested DAAs only to be used in selective sample of patients. They believed DAAs was not the solution to poor adherence, that DAAs are not that simple to use and that patients became too reliant on the DAA that they were longer able to identify what medications they were taking and for what conditions.

“I know it sounds stupid and you think that they’re [DAAs] really simple but a lot of people don’t know how to use them so, I had a lady coming in and she was just so distressed with her husband because she had been going up to the toilet all night, every night, she’d fallen over blah blah blah and her husband had been dutifully giving her all the tablets every day morning and night. But when he switched it over he had been giving the morning ones at night, and the night ones in the morning, she was getting 80 mg of Furosamide just before she went to bed and it’s just not, and I know they seem simple but they’re not and a lot of people you give it to them and they don’t know what to do with it.” [sic] Pharmacist 1

Suggestions and possible solutions

To improve the management of patients with chronic illness, interviewed pharmacists welcomed a teamwork approach with well defined roles for different team members. Pharmacists perceived their role to be the “medication expert” and to counsel and educate patients, carers and other healthcare providers regarding medications. This role definition was not thought to be shared by other healthcare providers.

“…other health professionals knowing the role of the pharmacists other than just supplying medicines and so that if they know the patient’s not going to be able to cope or having issues of compliance of understanding medicines then they should be calling me to do some counselling and start to refer patients to us” [sic] Pharmacist 4

Hospital pharmacists working in hospitals without liaison pharmacists suggested implementing such a role would help patients with chronic illness. Their view was to have a pharmacist attached to an outpatient clinic where newly discharged patients could seek advice. Pharmacists working at hospitals where this role had been implemented stressed the importance of better communication to have any real positive impact on patient outcomes. One suggestion to improve communication between different healthcare providers and with patients was to use information technique and create a national database where medical information could be stored.

Discussion

The aim of this qualitative research was to explore hospital pharmacists’ opinions and ideas to reflect, not represent, the population of interest. Although a small number of respondents, there was strong concordance of issues raised and saturation of themes was achieved.

Similar views were expressed by most pharmacists, with few disagreements. There are several possible reasons for this. As explained previously, the preferred form of interviewing was group interviews. However, this form of interviewing is not without problems as the group may be dominated by one person or a group culture may interfere with individual views. The moderator kept people from dominating the group and encouraged all respondents to participate in the discussion. Nonetheless, a senior person participated in one group interview and the person’s presence might have kept other respondents from expressing opposing opinions, resulting in similar views being expressed. To eliminate power imbalances in future group interviews, senior people such as heads of departments were not interviewed together with their staff. Another reasonable explanation for the high agreement was our homogenous sample of only hospital pharmacists working in Sydney West Area Health Service (SWAHS) but the data analysis of interviews conducted with other healthcare providers including doctors, nurses and allied health professionals in SWAHS and ACT revealed similar themes. That is, financial challenges, poor health literacy, seeking help inappropriately, and co-morbidities were linked with compliance; and a dysfunctional health care culture, inadequate access and lack of continuity were linked to fragmentation [13]. This suggest that the findings of this study are generalisable to other settings as well and that there is a need for joint interventions rather than specific interventions targeting pharmacists only. This is further supported by the results of a qualitative study with community pharmacists in which similar themes and themes regarding business related aspects were highlighted [14].

One of the major barriers in managing patients with chronic illness from pharmacists’ perspective was the perceived gap in communication. This may be potentially harmful if medicines are unintentionally omitted during drug history taking; necessary dose changes may not be implemented by patients if not appropriately documented or communicated [18, 19]. Acknowledging the potential privacy issues, pharmacists could see the benefit of a national electronic information system with complete drug history of every patient. One recommendation in the recent National Health and Hospitals Reform Commission report was that every Australian should have a personal electronic health record by 2012 [20]. The National E-Health Transition Agency (NEHTA) has been assigned the task to develop and deliver the best possible e-health system by the Australian governments. An evaluation of the Healthelink, an integrated electronic health record (IEHR) pilot in New South Wales, revealed overwhelming support for IEHR from patients and healthcare providers. However, not many people have actually accessed their IEHR, let alone shared it with somebody else making the use of IEHR questionable [21]. Similarly, in the UK, Greenhalgh et al., have explored patients’ attitudes to a centrally stored medical record [22]. Despite extensive information programs regarding the development of centrally stored medical records, the awareness and knowledge about these medical records were low. On the other hand, shared electronic health records projects have been successfully implemented in Brisbane and Northern Territory [23]. The trial showed that a patient’s shared records was accessed an average of 15 times over a 12-month period which resulted in a 26% reduction in inpatients costs for intervention patients. The system is now being evaluated for its potential to reduce errors that occur during handovers between different settings due to poor information sharing.

Other suggestions to improve the management and continuity of care for people with chronic illnesses by pharmacists included taking a multidisciplinary team approach with pharmacist outreach into the community from acute care services. Several Australian studies have investigated different liaison pharmacist strategies. Vuong et al., identified stakeholders’ views on a liaison pharmacist role and subsequently provided and evaluated such service [24, 25]. By visiting the patient at home within 5 days from hospital discharge they were able to minimise the risk of medication misadventure, improve patients self-perceived medication understanding and adherence [25]. Other studies have shown positive effects but a wider roll-out of the services has been limited by time constraints, poor remuneration, and lack of patient interest [26].

A further challenge in chronic illness management was the perceived poor patient knowledge regarding their disease state/s and medicines, and the high cost of medicines, resulting in low adherence to lifestyle advice and medicines. To improve adherence, pharmacists suggested more information and educational sessions, but a recent Cochrane review showed that not even the most effective interventions could sustain large improvements in adherence and treatment outcomes [27]. More research into cost-effective and successful interventions to improve adherence for chronic illness is needed.

Conclusion

In conclusion, these interviews have provided valuable information on the incentives and barriers pharmacists perceive in managing patients with chronic illness. Many of the challenges expressed during these interviews indicate the need for a coordinated multidisciplinary approach to policy development and practice.