Feasibility of pharmaceutical care intervention

From 18 pharmacists (recruiters and non-recruiters) who received the questionnaire 14 replied (78%). Two recruiters and two non-recruiters did not reply. Moreover, the minutes of a focus group with three caregivers were analysed. Comments during the completion of the satisfaction questionnaire in the cross-sectional study were recorded for 22 caregivers [66]. Emerging topics were grouped into four major themes, such as image of community pharmacy, interaction with physicians, interaction with patients and caregivers, and community pharmacy setting.

The cross-sectional study was conducted in several cities (e.g. Leipzig = L and Augsburg = A) [66]. Caregivers were coded accordingly. Pharmacists’ statements from the narrative reports were coded with a “P”.

Interaction with patients and caregivers

The presence of mutual trust between pharmacist and patient/caregiver was helpful for the initiation of pharmaceutical care. If this was not present patient and caregiver often denied study participation.

“The patient doesn’t want to participate because he fears data abuse and disclosure of personal problems as well as he doesn’t know what pharmaceutical care is.“ [P5]

A central barrier was that patients had no prior experience and knowledge of the changing role of community pharmacy towards pharmaceutical care.

Within pharmaceutical care pharmacists appreciated the change from a customer focused to a therapeutic relationship. One pharmacist [P12] valued as a success “the personal opening up of two patients and their caregivers”. The therapeutic relationship also extended beyond the study:

“All patients I cared for ask for me if they are uncertain or if they need independent information.” [P18]

Additionally, it was very important for caregivers to have somebody to talk to “release psychological stress” [P1].

Pharmacists succeeded in informing patients about medication intake and drug interactions. Barriers were seen in the higher priority of physicians in counselling.

Arguments for pharmaceutical care were lacking if the patient felt well-informed by the respective physician. Here, the accountability of the pharmacist remained unclear.

Moreover, patients feared pharmaceutical care could use up too much time (frequent visits to pharmacy, completing forms).

Interaction with physicians

Contacts between pharmacists and physicians were nearly exclusively by telephone. At inclusion the study pharmacists had to get in touch with the respective physician to confirm patients’ ability to consent. This step turned out to be a major barrier during the course of the study.

“The biggest problem was the cooperation with the physicians, especially the signature at inclusion.” [P18]

Physicians’ often displayed scepticism about pharmaceutical care (i.e. increased pharmacists’ involvement in pharmacotherapy). Many GPs and specialists were not willing to discuss or implement therapy changes with the pharmacist. Even GPs and specialists did not always communicate and cooperate to optimise pharmacotherapy.

One patient [patient 42] with renal failure and hypertension was not prescribed an ACE inhibitor. The pharmacist [P5] contacted the nephrologist who supported the use of an ACE inhibitor in this patient. But he did not want to interfere with the pharmacotherapy prescribed by the GP. Only if GP had asked for an evaluation of pharmacotherapy, he would have given a recommendation to start an ACE inhibitor.

“Even after having talked to the nephrologist, I reach nothing concerning the prescription of an ACE-inhibitor – communication between the two doctors is not realisable.” [P5]

But there are also examples where pharmacists and physicians cooperated successfully.

“The patient [patient 49] has been treated on Aricept 5 mg for quite a while. His wife is unsatisfied, since he more and more degrades and participates less in daily activities.

Having talked to me, the psychiatrist increased the dose to 10 mg … According to his wife he blossoms out. He is much more alert.” [P5]

In the future pharmaceutical care should seek more involvement of physicians or at least they should be more informed about additional pharmacists’ activities. One pharmacist also recommended multidisciplinary quality circles with pharmacists and physicians [P12].

Community pharmacy setting (institution and personal)

Lack of time was the most prevalent barrier to pharmaceutical care in the community pharmacy setting.

“Documentation and literature research always took place at home in my free time since in everyday working life there’s no time to do that.” [P18]

In particular, one pharmacist [P12] annotated that she had no time in her daily routine to prepare herself for the phone calls to physicians.

Furthermore, pharmacists referred to the lack of reimbursement for pharmaceutical care. Without payment pharmaceutical care presents a loss-making business.

Moreover, study pharmacists suffered from lack of support from colleagues and pharmacy owners. Additionally they criticised the set-up of the community pharmacy as being inappropriate for pharmaceutical care (e.g. lack of discretion).

Image of community pharmacy (institution and personal)

Generally the role of community pharmacy for Alzheimer patients/caregivers varied considerably. Provision of drug information does not seem to be of major importance for many patients/caregivers:

“I am very positive about my pharmacist. They deliver items; there I get all my health magazines.” [caregiver 2 in focus group]

GPs and neurologists are primarily seen as source of information concerning drugs with the pharmacist lacking behind. Also a shop-keeper image is prevalent.

“I primarily regard the pharmacy as a shop. Perhaps for further queries, but apart from this the doctor is responsible. I don’t see the pharmacist as the person who is responsible for profound information to the patient. That is the doctor. The pharmacist should not turn into a pseudo-doctor in diagnostics, indication and prescription of medicines.” [L-03]

By contrast, other patients long for more involvement of their pharmacist.

“Counselling in my pharmacy is a good thing, especially since my doctor does not always do everything. In general, there should be more counselling in the pharmacy.”

[L-04]

Moreover, barriers to counselling expressed by caregivers were the pharmacy being too crowded and changing persons in charge, which impedes the establishment of a therapeutic relationship.

“It’s really difficult in a big community pharmacy when there are a lot of personnel. You don’t always get the same contact person. …” [A-02]

The setting of the individual community pharmacy had an impact on pharmacists’

interaction with patients/caregivers and physicians. Additionally, it also influenced the general image of community pharmacy (Fig. 29). The image of community pharmacy and its interactions with physicians impacted one another.

Image of community pharmacy

Interaction with patients and caregivers Interaction with physicians

Setting of individual community pharmacy Image of community pharmacy

Interaction with patients and caregivers Interaction with physicians

Setting of individual community pharmacy

Fig. 29 Mapping of the main themes influencing feasibility of pharmaceutical care