Impacts on practice

  • Provision of a point-of-care C-reactive protein testing service in community pharmacies is a valuable addition to pharmacists’ clinical decision making in managing respiratory tract infections and can contribute to antimicrobial stewardship.

  • Point-of-care C-reactive protein testing is simple, reliable and fast, better engaging patients in shared decision-making about management of their respiratory tract infections

  • While ease of access to the service and the credibility of pharmacists can facilitate service provision and uptake, key barriers include time constraints and remuneration

Introduction

In keeping with international trends, community pharmacy in Australia has evolved to a rapidly changing landscape and paradigm shift in practice, from mainly dispensing and supply, to increased provision of professional services, including primary health care, advice and support, education for consumers on the use of medicines, health promotion and disease prevention [1]. Ease of accessibility to community pharmacies makes this practice setting an ideal ‘health hub destination’ for the public [2]. In many countries, including Australia, the United Kingdom (UK), Canada, New Zealand and the United States of America (USA), community pharmacies provide enhanced services including blood pressure monitoring, smoking cessation, weight reduction, vaccinations and medicines reviews [3,4,5]. Pharmacists regularly provide over-the-counter (OTC) treatment and management advice for minor ailments, including respiratory tract infections (RTIs), where recommendations are typically based on presenting signs and symptoms, rather than diagnostic tests [6, 7]. Currently, there are limitations to the management of RTIs in community pharmacy settings, as diagnosis based solely on signs and symptoms is unable to differentiate between viral and bacterial infections [8].

Although most RTIs are of viral origin, more than 60% of patients with RTIs are prescribed antimicrobials by general practitioners (GPs) in Australia [9,10,11]. Antimicrobial resistance (AMR) is recognised globally as an important health threat, causing increased morbidity and cost. Factors for the development of AMR are mainly overuse and inappropriate use of antimicrobials [12]. Despite initiatives to decrease antimicrobial use, substantial increases in global antibiotic consumption are reported [9, 11, 13]. Efforts to optimise the use of antimicrobials have focused on antimicrobial stewardship (AMS) programs in hospitals with limited initiatives in the primary care setting [14]. Targeted interventions in community settings could have a large impact on reducing antimicrobial consumption, especially for those with RTIs [2].

C-reactive protein (CRP) is the most suitable biomarker to guide the use of antibiotics in RTIs [15]. CRP is an acute marker of inflammation [16]. Levels of CRP can increase dramatically in response to inflammation, infection or injury [17]. The National Institute for Health and Care Excellence (NICE) recommends that point-of-care (POC) CRP testing should be considered when an individual presents with RTI symptoms [18]. POC CRP testing has been implemented successfully in primary care settings in the UK and several European countries, including Belgium, Spain, Poland and the Netherlands [19, 20], to differentiate bacterial from viral infections, potentially reducing unnecessary antibiotic prescribing [21,22,23,24].

A feasibility study of POC CRP testing was recently undertaken in Western Australian community pharmacies to support pharmacists’ management of RTIs [25]. Many participants presenting with symptoms of RTI had CRP levels less than 5 mg/L (60/131; 45.8%) and when provided with a CRP result, changed their perceptions about the need for antibiotics [25]. All participants were satisfied with the POC CRP testing service and most reported they would use it again. Although several other POC tests, including plasma lipids [26], blood glucose [27] and international normalised ratio [28], have been offered in some Australian community pharmacies, data on facilitators and barriers to implementing POC testing are limited. Both national [29] and international [30] pharmacy organisations recognise a role for community pharmacy in POC testing into the future, however, it is not known whether facilitators and barriers reported in other conditions would be similar [1, 4, 31,32,33,34]. It is therefore important to obtain the experiences of community pharmacists in the provision of POC testing, and factors that may influence widespread implementation of such services in the Australian community pharmacy setting. Additionally, the significant AMS potential of POC CRP testing, made a ‘novel’ POC testing service worthy of evaluation.

Aim

This study aimed to explore pharmacists’ experiences and perspectives, including barriers and facilitators to service provision and uptake by consumers, regarding the implementation and sustainability of POC CRP testing in RTI management in purposively selected community pharmacies in Western Australia (WA).

Ethics approval

Curtin University Human Research Ethics Committee approved the study (HRE2019-0139; 21/03/2019) and included on the Australian New Zealand Clinical Trials Registry (ACTRN12619000965101).

Method

This qualitative study forms part of a larger feasibility study which trialled a POC CRP testing service (‘the service’) in five purposively selected community pharmacies in metropolitan WA, selected from 126 pharmacies responding to an expression of interest, based on pharmacy location, size, available facilities and model of operation [25]. Purposive selection allowed for maximum variation in the sample to enable in-depth inquiry into pharmacists’ experiences and perspectives of the service from a range of pharmacies.. In keeping with qualitative methodology, this approach was followed to improve credibility and reliability, and to obtain information rich data [35]. The study was conducted over an eight-week period from June to August 2019 coinciding with the influenza season in Australia. Each pharmacy was required to recruit 25–30 adult patients, details of which are described elsewhere [25].

Design and setting

Qualitative data were obtained from in-depth one-to-one semi-structured telephone interviews using a census sample of 10 champion pharmacists based in the participating community pharmacies, to gain an in-depth understanding of pharmacists’ experiences and perspectives about the study and provision of ‘the service’. The development, analysis and reporting of this pilot study followed qualitative research criteria [36].

Interview tool and data collection

A semi-structured interview tool was developed, comprising of four parts: Part A–Pharmacist professional experience/roles; Part B–Pharmacy characteristics; Part C–Experiences with the POC CRP service; and Part D–Training and resources. The interview tool was face validated by four academics/pharmacists; two research team members were involved with a practice run. To avoid bias and assumptions, all interviews were conducted by the research assistant (RI), a female pharmacist involved in the implementation of ‘the service’ within the feasibility study and with extensive pharmacy experience. The experience of the interviewer allowed appropriate digression to enable collection of information-rich data. Following consent from participating pharmacists, audio-recorded interviews were conducted and transcribed verbatim by a professional transcription service. Transcripts were not returned to participants for participant checking. Transcripts were de-identified by replacing participants’ identities with specific codes. For example, ‘PO1-A’ denoted participant number 1 who practised in Pharmacy A. All interviews and analyses were conducted between September 2019 and February 2020. Participants were reimbursed AUD$50 for participation.

Data analysis

De-identified transcripts were imported into NVivo version 12 Pro for subsequent organisation and thematic analysis. Two experienced qualitative researchers (TFS and PC), both academic pharmacists involved in the implementation and evaluation of the pilot study, inductively analysed the data independently to identify themes. To gain an in-depth understanding of the topics discussed, the researchers read the transcripts repeatedly before ideas were coded as ‘nodes’. Nodes were then grouped to form a working coding framework. Subsequently codes were grouped into categories to form sub-themes and themes. The two researchers met to agree on themes. Conflicts were resolved by discussion until a consensus was reached. Triangulation was informed with findings from a previous study [25].

Results

All pharmacists agreed to be interviewed. Data saturation was reached after six interviews, however, all 10 pharmacists who were engaged with the feasibility study, were interviewed. Interviews with the other four pharmacists did not result in any additional themes, confirming data saturation (ie no new themes emerging). The duration of interviews ranged from 28.2 to 60.2 min (mean: 50.7 ± 10.2 min). Demographic characteristics of participants and their practice settings are summarised in Table 1. Most of the participants were female (8/10; 80%). The mean age was 36 years (range: 22–53 years), with half (5/10; 50%) aged between 31 and 35 years. Years of practice experience ranged from one to 32 years (mean: 13.1 ± 11.1 years; median: 9.0 years).

Table 1 Demographic characteristics of participants and their practice settings (n = 10)
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Five main themes emerged through thematic analysis:

  • Enhanced service provision

  • Decision-making and AMS

  • Facilitators to successful service delivery

  • Barriers and challenges

  • Public demand for ongoing provision

Enhanced service provision

Pharmacists perceived ‘the service’ as a well-structured opportunity to explore the provision of a new professional service, stating that it broadened the scope of pharmacy practice. The service was perceived as simple, reliable, fast and accurate, and that the test result and its interpretation provided valuable information to the consumer about their health, which would not be provided if they had gone straight to their GP:

It just adds to our ability to help them when they come in asking for something for an upper RTI. It gave us an opportunity to improve our services…. (PO1-A)

As pharmacists are freely accessible, they are often the first point of call. Many felt they played a huge role in primary healthcare as frontline workers by providing services that were attractive to the public and within their scope of practice. They reported that POC CRP testing assisted them to triage consumers more appropriately and either refer them to their GP for antibiotics if needed or prevent unnecessary antibiotic prescribing, as exemplified by the following comments:

We’re their first stop before they go see a doctor for anything…we can sort of say, "… your CRP is higher than it should be. You're going to need antibiotics or make an appointment with the doctor." (PO2-A)

[Patients]...bring up other things like ‘my blood pressure's been a bit all over the place’. Being able to be so freely accessible, I think we've really got a huge role in the health industry, because we are front line. (PO8-D)

Pharmacists reported that the process of POC CRP testing was professional and improved pharmacists’ professional image (Table 2). They also reported increased consumer engagement, with consumers returning to the pharmacy, seeking advice on other health related issues. Several reported they had attracted new clientele. Pharmacists considered that the clientele perceived them to be knowledgeable, supportive and able to provide tools to improve their health.

It gave us an opportunity to appear very professional the way it was done. With the gloves, and the alcohol wipe and everything, it was very professional how we did it…was … a good image for us… professional. (PO1-A).

Table 2 Facilitators and barriers to the provision of point-of-care C-reactive protein testing
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Further, some reported that the provision of ‘the service’ enabled an improvement in their professional relationship with their local GPs. In one case, the doctor referred the patient to the pharmacist for CRP testing.

Decision-making and antimicrobial stewardship

Pharmacists reported that ‘the service’ assisted their clinical decision-making and recommendations. They felt reassured they could confidently advise consumers they were likely experiencing a viral infection based on’ the service’ result, providing good consumer satisfaction. The consumer was then more likely to trust the pharmacist regarding the recommendation for an OTC product:

…we get something out of every CRP testing because that allows us to make a decision more confidently, and patients are now convinced about the type of preparations or the type of products that we recommend. (PO3-B)

Several pharmacists reported that consumers saw value in ‘the service’ because it provided both the pharmacist and consumer with a better insight to their condition, and allowed consumers to make a conscious decision about the appropriateness of antibiotics. Several pharmacists reported that consumers had booked a GP’s appointment but following the outcome of the CRP test, it provided evidence for them that antibiotics were unlikely to be beneficial so they cancelled their GP’s appointment:

I had a lady who was going on holidays, and…she said, “The doctor's given me antibiotics to take, but I don't like taking them. I really don't know whether I should or not because she [doctor] said not to take them unless I needed them.” So we were able to show her where she was at the time. (PO7-D)

Pharmacists were aware of the global AMR health threat, with some commenting that antibiotics were overprescribed. They perceived ‘the service’ had contributed towards AMS and reduced unnecessary antibiotic use:

We had a lady who being on antibiotics a couple of weeks before, thought she was better. She came in and she thought, "Oh, no. I've got it again." And we said, "No. Look. Let me have a look and make sure it's not a secondary viral infection after you've had the first one." Her CRP was normal and she thought maybe it's just the virus carrying on. So she got more cold and flu tablets and she came back, "Thank you guys so much. You just saved me a trip to the doctor again." Just helping the community because you're reducing antibiotic use. (PO2-A)

Pharmacists recognised that many people who visit their GP expected to be prescribed antibiotics, although often unnecessarily:

We're seeing people who tend to overuse antibiotics far more often than they might have when I first qualified...people don't want to walk out of a doctor's appointment that they've just paid or not paid for without a prescription in hand...They're going to go fill it. (PO6-C)

While AMS is important to prevent unnecessary prescriptions of antibiotics, respondents also described situations when CRP testing sped up referral to a GP when antibiotics may have been warranted. Pharmacists were able to confidently refer patients when POC CRP testing values were higher than expected. ‘The service’ assisted with decision-making about whether antibiotics were justified in patients reluctant to take them. For example, in two scenarios (Table 3–Quotes 1&2), where the consumer was reluctant to visit their GPs for antibiotics, the pharmacist persuaded the consumer to visit their GP due to the elevated CRP levels.

Table 3 Examples of quotes related to antimicrobial stewardship
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In one case (Table 3–Quote 3), a patient who visited their doctor because they had been unwell for a few weeks, was told they had a viral infection and antibiotics were not needed. Following the POC CRP testing at the pharmacy, the elevated CRP level prompted the pharmacist to refer the patient back to the doctor for antibiotics.

Facilitators, barriers and challenges to successful service delivery

A number of influential factors emerged from the interviews with some facilitating, and others posing challenges to, the success of service implementation and provision (Table 2). Factors facilitating service provision included the accessibility and credibility of pharmacists, having a supportive team, practice experience and marketing and promotion strategies to encourage service uptake.

Barriers to service provision and uptake included a lack of time and difficulty with rostering of pharmacists (as it was difficult to anticipate RTI presentations during service hours), both of which were linked to remuneration. Pharmacists reported they were often unable to contact a person by phone for follow-ups and a better option could be to send an SMS. Follow-up contact is not common practice in community pharmacy and would not normally be part of a service in every day practice. Some pharmacists reported challenging interactions with GPs and a lack of understanding by health professionals about ‘the service’. Some reported that it was difficult to contact GPs, as they had limited shifts or the receptionist’s unwillingness to allow the pharmacist to speak with the GP. Using the GP’s email address or another secure mechanism of messaging GPs, could make interactions less challenging.

Public demand for ongoing provision

Despite the challenges and barriers, all pharmacists were supportive for ongoing provision of ‘the service’ and believed there is a public demand for such a service. All pharmacists expressed an interest in continuing with service provision beyond the study period.

I think there is a public need for this service…because my patients really valued it, and they said to me, "Oh, this is great. It would be great if we could have this all the time. (PO7-D)

I've seen in practice myself whereby people are overusing or underusing antibiotics. I think there is a public need for this service definitely...and the public need to be aware and need to understand that … antibiotics is not always the answer... (PO9-E)

Discussion

To our knowledge, this is the first study investigating pharmacists’ perceptions of a POC CRP testing service for consumers with symptoms of RTIs presenting to community pharmacies in Australia. Pharmacists perceived ‘the service’ to be within their scope of practice, and it offered an opportunity to impart valuable information to consumers. They reported that CRP testing gave them confidence in their clinical decision-making and built consumer trust. It led to high consumer satisfaction by providing a better insight into their clinical condition and allowed them to make an informed decision about whether antibiotics were appropriate for them.

Given the global antimicrobial resistance crisis [37], pharmacists have an important role in minimising the inappropriate use of antimicrobials. Targeted interventions, such as POC CRP testing in community pharmacies, could have a large impact on reducing antimicrobial consumption, especially for RTIs. Pharmacists perceived ‘the service’ contributed to AMS. A major barrier to the implementation of AMS in community pharmacy is the lack of access to patient’s records and laboratory data. CRP POC testing along with access to the national MyHealthRecord (national online summary of health information of an individual) [38] will help to address this barrier [39]. Information may not be complete due to the autonomy of the individual to not have certain health information recorded.

Most patients with acute RTIs do not benefit from antibiotic therapy [40,41,42]. However, antibiotics are frequently prescribed for consumers presenting to their GP [43,44,45]. Although pharmacists recognised that AMS was important to prevent unnecessary antibiotic prescriptions, in cases where CRP values were higher than expected, pharmacists were able to confidently refer consumers to their GP in a timely manner. Further, results of CRP testing could justify antibiotic use in consumers reluctant to take prescribed antibiotics.

Internationally, many pharmacies provide on-site preventative care services [46]. In Australia, several studies have reported positive outcomes following evaluation of community pharmacist experiences providing disease state management services, including delivery of a specialist asthma service [47], atrial fibrillation screening [48], and POC testing as part of hyperlipidaemia [26] and anticoagulant monitoring [28]. In this study, pharmacists perceived ease of accessibility to pharmacies as an important aspect facilitating uptake of pharmacy services, which has been previously reported [31, 49]. It seemed that the success of ‘the service’ was related to the pharmacist’s engagement with the consumer. Had ‘the service’ been devolved to an assistant, it may have impacted on perceived professionalism. Hence, if ‘the service’ became widely available and was adequately remunerated, it would not be recommended to delegate CRP POC testing tasks to untrained or semi trained staff members.

Implementing a new service is not without challenges and requires careful planning and testing to ensure sustainability [50, 51]. Previous studies investigating the implementation of professional or enhanced services in Australian community pharmacy over many years have identified a range of common barriers and facilitators [2, 4, 33, 50, 51]. This study demonstrated some commonalities in barriers and facilitators for the provision of a CRP testing service.

Facilitators to service provision includes building rapport with physicians, pharmacy layout to ensure availability of a private or designated area for the service, adequate remuneration, consumer demand for the service, having adequate staff, good communication and teamwork, and having external support when needed [22, 33, 50]. While the methodology of the feasibility study addressed some of these factors including availability of a designated area and external support, participating pharmacists identified some of the other facilitators, including enhanced relationships with GPs and having a supportive team, which were also identified in a recent systematic review, investigating factors influencing national implementation of innovations within community pharmacy [33].

Although POC testing services provide opportunities to pharmacies to expand their services to improve the prevention and treatment of infectious diseases [46], deficits in pharmacist training and education [46], pharmacist time constraints, staff shortages, lack of return on investment/ inadequate remuneration and lack of access to medical records have been reported as barriers to service implementation (when the pilot study was conducted, the MyHealthRecord was not yet fully launched, but as My Health Record is fully integrated, there may be some access to medical records) [4]. In this study, perceived barriers included inadequate remuneration to justify employing multiple pharmacists at one time, as the walk-in nature of ‘the service’ made it difficult to predict when busy times were likely to occur. This has been reported in other studies [4, 22, 52]. Despite the availability of two pharmacists, competing demands, such as the provision of influenza vaccinations during the peak influenza season, were also reported to be a barrier and a contributor to erratic recruitment. Pharmacists had conflicting views as to who should pay for ‘the service’ if it was implemented; with some pharmacists suggesting a user-pay system, while others stated a service fee should be covered by Medicare, Australia’s publically funded universal health insurance scheme.

As this was a pilot study, pharmacists commented that there was excess documentation that needed to be completed for every consumer who was provided with ‘the service’. If ‘the service’ was implemented in routine practice, documentation would be reduced.

Studies investigating factors affecting the implementation of POC CRP in GP clinics identified similar themes to this study. Albeit the difference in primary care setting, certain factors that could impede the implementation of POC CRP were consistent and include staffing and cost while factors that could facilitate the implementation include confidence in clinical decision making and improvement in provider and patient engagement. [22].

The wider feasibility study of which this qualitative study formed a part, was designed as to pilot the POC CRP testing service in a small number of purposively selected community pharmacies, resulting in a small sample size, a potential limitation of the study, although a census sample was interviewed. Involvement of researchers with extensive experience in qualitative research added to the credibility and trustworthiness of the study. All participants initially underwent training to ensure they had the appropriate knowledge and skills for POC CRP testing (information on training has been reported elsewhere and is currently under review). This may have contributed to the relatively narrow spectrum of viewpoints. Nevertheless, several common themes emerged, which were supported by other studies investigating barriers and facilitators of service implementation. Reflection on the clinical and operational outcomes of the larger feasibility study [25], and participants’ responses to the post-pilot questionnaire, provided evidence of credibility and triangulation. Nonetheless, recruitment of participants from within the confines of the feasibility study (in the interest of credibility, the participants had lived experience of providing the service) means that the findings should be cautiously generalised to the whole community pharmacy population. As this study was done prior to COVID-19, this would likely be another barrier identified especially with people with RTI symptoms presenting to community pharmacies. Further research is required involving a large mixed methods study to evaluate the requirements for full implementation in community pharmacies.

Conclusion

Pharmacists perceived the POC CRP testing service to be valuable in clinical decision making in the management of RTIs and potentially reducing inappropriate antibiotic use. The test was simple, reliable, fast and accurate although time constraints and competing demands were perceived as barriers to service provision. Although there is a perceived public need for POC CRP testing in Australian community pharmacies, adequate remuneration, potentially through government funding, is essential for successful implementation and delivery. While this study focussed on a POC CRP testing service, the lessons learnt are relevant in implementation of pharmacy POC testing services more broadly.