Elsevier

Health Policy

Volume 122, Issue 3, March 2018, Pages 256-262
Health Policy

Expanding the clinical role of community pharmacy: A qualitative ethnographic study of medication reviews in Ontario, Canada

https://doi.org/10.1016/j.healthpol.2017.10.007Get rights and content

Highlights

  • We explored how providers and clients interpret and operationalize medication reviews.

  • Medication reviews varied in duration, provider type, location and interaction style.

  • Local contexts and system-wide developments influence meaning and practice of reviews.

  • Medication reviews are exemplary of policy efforts to expand community pharmacists’ roles.

Abstract

Medication reviews by community pharmacists are an increasingly common strategy to improve medication management for chronic conditions, and are part of wider efforts to make more effective use of community-based health professionals. To identify opportunities to optimize the medication review program in Ontario, Canada, we explored how providers and clients interpret and operationalize medication reviews within everyday community pharmacy practice. We conducted a qualitative ethnographic study at four pharmacies in Ontario, Canada, including non-participant observation of provider and client activities and interactions with specific attention to medication reviews, as well as brief ethnographic interviews with providers and clients, and in-depth, semi-structured interviews with providers. We report on 72 h of field research, observation of 178 routine pharmacist-client interactions and 29 medication reviews, 62 brief ethnographic interviews with providers and clients, and 7 in-depth, semi-structured interviews with providers. We found that medication reviews were variably conducted across the dimensions of duration, provider type, location, and interaction style, and that local contexts and system-wide developments influence their meaning and practice. Medication reviews are exemplary of policy efforts to enhance the role of community pharmacies within health systems and the scope of practice of pharmacists as healthcare professionals. Our study highlights the importance of the local structure of community pharmacy practice and the clinical aspirations of pharmacists in the delivery of medication reviews.

Introduction

As the number of individuals living with multiple chronic diseases grows, health systems increasingly seek to mobilize community-based health professionals such as pharmacists, community workers or paramedics to sustain individuals’ health, well-being and independence. Community-based medication management is an area of particular policy interest given the challenges clients with chronic conditions face in safely and effectively managing multiple medications [1], [2]. Many jurisdictions, including Canada, the United States, the United Kingdom, Australia and New Zealand, have implemented community-based medication reviews [3], [4], [5], [6], [7], [8], [9], [10], which are intended to support clients in understanding and appropriately using their medications, and may also involve efforts to ensure the suitability of the client’s medication regime [3], [5], [7], [9], [10]. As well, many jurisdictions have begun to expand the scope of practice of community pharmacists [11], [12], for example to permit pharmacy prescribing, alongside the delivery of these new services [3−10].

Since 2007, Ontario has implemented successive policies to initiate and expand a medication review program alongside an expanded pharmacist scope of practice. The medication review program now includes annual in-pharmacy consultations for individuals taking three or more prescription medications for a chronic condition or for those with diabetes, and episodic in-pharmacy reviews for these individuals when they experience new health issues (e.g., hospital discharge, medication change) [3]. The program also supports home visits by pharmacists for individuals who are residents of long-term care homes or home-bound. According to formal policy, these reviews must be conducted as a one-on-one consultation between the client and pharmacist in an acoustically private area [3]. Pharmacists are required to review all medications (including over-the-counter medications and natural products) to ensure they are being taken properly as well as identify and attempt to resolve any problems the client may be having in managing their medications (consulting with the client’s general or family physician, if necessary) [3]. In addition, pharmacists are expected to provide an accurate up-to-date medication list alongside any recommendations for the client to take home. Clients are encouraged to share a copy of their medication list with their general or family physician [3].

Alongside funding and guidance for an expanded medication review program, pharmacists’ scope of practice has been expanded in Ontario. Pharmacists may intervene into a physician’s prescription if they identify a potential drug-related problem at the time of conducting a review or dispensing a medication, by submitting a pharmaceutical opinion to the prescribing physician, for the latter’s review and decision [13]. Similar medication review programs alongside similar expanded scopes of practice have been implemented in other Canadian provinces, such as Alberta, British Columbia, and New Brunswick [14], [15], [16].

A growing literature explores the implementation of these policy initiatives in Canada and internationally [17], [18], [19], [20], [21], [22], [23], [24], [25], including the professional and organizational conditions that support their uptake, and the expectations of both providers and clients regarding this expanded clinical role.

Identified barriers to conducting medication reviews include lack of time, space, pharmacist education, client awareness of and interest in the program, as well as the difficulties in ensuring sufficient pharmacist overlap and coverage to conduct reviews [17], [18], [19], [20], [26], [27]. As well, the attitudes and expectations of pharmacists, clients, and general or family physicians have an important influence [19], [21], [24], [25], [28], [29], [30], [31], [32], [33], [34], [35].

Several studies have identified support for expanded community-based pharmacy services among pharmacists [19], [28], [29], [30], [31], and the clients who receive such services [21], [24], [32], [33]. However, general or family physicians are typically less supportive of an expanded scope for pharmacists [34], [35]. While an expanded technical role (i.e., medication dispensing) for pharmacists is often well received by physicians, an expanded clinical role (i.e., prescribing for minor ailments, prescription renewals and medication reviews) raises concerns about a lack of mandate, legitimacy, and adequacy [34].

Given policy interest in optimizing Ontario’s medication review program, and the complexity of known challenges facing program implementation, this paper aims to analyze and contextualize how providers and clients interpret and operationalize medication reviews within everyday community pharmacy practice.

Section snippets

Materials and methods

We conducted a qualitative ethnographic study at four pharmacies in Ontario, Canada’s largest province (population 13.7 million), from June 2014 to August 2015 [36]. With ethics approval from the University of Toronto Health Sciences Research Ethics Board, we recruited 4 pharmacies, sampling for variation across two dimensions: pharmacies owned by major commercial chains vs. independents, and pharmacies in large urban settings vs. smaller residential communities. We engaged in non-participant

Results

In total, we conducted 72 h of field research, observed 178 routine pharmacist-client interactions and 29 medication reviews, and conducted 62 brief ethnographic interviews with pharmacy providers and clients. In addition, 7 in-depth semi-structured interviews, 1–1.5 h in length, were conducted with pharmacy providers. Pharmacy site characteristics are shown in Table 1.

We identified 3 main themes: (i) the “anatomy” of a medication review, in terms of its duration, the type of provider involved,

Discussion

We conducted a qualitative ethnographic study at four pharmacies in Ontario, Canada from June 2014 to August 2015. We conducted non-participant observation of the activities and behaviour of pharmacy providers and clients, brief ethnographic interviews with pharmacy providers and clients at each pharmacy site, and in-depth, semi-structured interviews with pharmacy providers. This methodological strategy enabled us to gain detailed insight into how medication reviews are understood and conducted

Conclusions

Medication reviews are exemplary of policy efforts to enhance the role of community pharmacies within health systems and the scope of practice of pharmacists as healthcare professionals. Medication reviews are complex interventions [43], [44] that rely not simply on adequate information systems, physical space in which to conduct reviews, or sufficient financial capacity to ensure staff time and availability for coverage. Such factors may be important, and research and policy development may be

Funding

This project was funded by Blueprint for Pharmacy (Fund # 495679). The funder had no involvement in the study design; collection, analysis and interpretation of data; writing of the report; and in the decision to submit the article for publication.

Conflict of interest statement

The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Research ethics

This study received ethical approval from the University of Toronto Health Sciences Research Ethics Board.

Acknowledgement

We would like to thank the pharmacy staff and clients who agreed to participate and thus made this study possible.

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