s The line between counselling and adherence support | I2P: Information to Pharmacists - Archive
Publication Date 29/04/2010         Volume. 2 No. 4   
Information to Pharmacists

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Regular updates from the global world of pharmacy.
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Feature Contribution

Introducing Jeanette Sell - The Colac Community Leader who took on a Pharmacy Monopoly

Peter Sayers

In the April edition of i2P, a story involving the ministerial removal of pharmacy location rules was published.
It involved a disparate group of Colac residents coming together to fight the location rules and to establish a third independent pharmacy.
The story was important for a number of important reasons:
(i) The Colac residents did not want a "chain-type" pharmacy.
(ii) They wanted true competition between local pharmacies to avoid a perceived monopoly.
(iii) They wanted good old-fashioned pharmacy personalised service in an appropriate time frame.

As pharmacists we often bemoan the spectre of "Colesworth" providing pharmacy services and the potential for them to strip personalised service out of the independent pharmacy environment.
Yet the existing Colac pharmacies (having the same owner) did exactly that.
The question I pose is if this is the direction of pharmacy (as formulated by the PGA supply side pharmacy and warehouse-type pharmacies) the Colac community have clearly demonstrated that those models are not the preferred version.
i2P asked Jeanette Sell to tell her story in her own words.

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My two bob’s worth on COAG’s Health Funding ‘Reform’ (sic)

Pat Gallagher

Health Reform? Is that what we have been given by COAG: I don’t think so at all. It is wrong from the get go. In that 60% will come from here; 30% will be taken away from there; 40% will be paid by them and we will layer some more highly experienced and very necessary bureaucrats on the top to make sure no one ever knows what is actually going on.
Same old, same old, just tarted up differently so the punters think something is happening.
Health Reform it aren’t. Pretending to reform hospital funding it is.
Not a word about technology, e-health, savings, over-staffing of suits in place of white coats and blue blouses, blame shifting, waste, incompetence and all the other ills that riddle the hospital operational (non-clinical related) networks.

And there are enough ills for a zillion hypochondriacs to wallow in. Just this past week I had occasion to sample it first hand with a relative that needed emergency attention. The ambulance picked her up at 6:55 pm, after just a ten minute wait. We arrived at the hospital about the same time as the ambulance at 7:15 pm.
So far so good.

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A once in every five years opportunity that must be taken.

Neil Retallick

On July 1 2006, the Federal Government reduced the pharmacy wholesaling margin from 10% to 7%. This action was an outcome of the Government’s negotiations with the Pharmacy Guild as these two parties hammered out the 5 year deal that was the Fourth Community Pharmacy Agreement (4CPA).
To put this change into today’s context, Sigma’s wholesaling business turned over around $2.4 billion in the last twelve months.
If 70% of this turnover is generated by dispensary medicines, and if 65% of these are PBS items, then the 4CPA pulled about $33 million in revenues off Sigma’s top line in today’s dollars.

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The Light and Dark side of some Pharmacies

Loretta Marron OAM BSc

Living in outback Queensland, especially during the long periods of drought, the elderly grazier has struggled from day-to-day to keep his cattle property going.
He had only been 12 years old when his father died, but with the Second World War still raging, and with no men available, the local police officer had issued him with a drivers licence and told him to go home to help his mother run the property.
That had been the end of his schooling and to this day, he can still barely read and write.

Comments: 1

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Pharmacist Support Service now Extended to Tasmania

Staff Writer

Tasmanian pharmacists now have access to the Pharmacists’ Support Service (PSS), developed by the Victorian PSA.
It can be contacted by phone on the toll free number: 1300 244 910.

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Expensive drugs cost Australia billions

Staff Writer

Consumers and the Australian Government are paying up to 10 times more for generic cholesterol-lowering drugs compared to the United Kingdom, according to research carried out by health economists at the University of Sydney.

A recent study published by the Medical Journal of Australia (MJA) found Australia could have saved approximately $900 million on statin treatments (drugs used to lower cholesterol) over the past four years and could save up to an additional $3.2 billion over the next 10 years.

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Doors open on Australia's first zero-emission home

Staff Writer

Pharmacy designers in Australia have yet to come up with a zero emission pharmacy building, but they will have a model t draw from in the form of an AusZEH private home, designed and built by CSIRO.
Designed to fit the Australian climate – and the lifestyle of a typical middle-income family – Australia's first Zero Emission House (AusZEH) has been officially opened  in Melbourne.
Working with industry partners Delfin-Lend Lease and the Henley Property Group, and supported by the AusZEH consortium, CSIRO designed and built the demonstration house 30 kilometres north of Melbourne’s CBD, in the community of Laurimar in Doreen, Victoria.
The eight-star energy-efficiency rated AusZEH showcases off-the-shelf building and renewable energy-generation technologies, and new future-ready energy management systems.
Nearly 13 per cent of Australia’s greenhouse gas emissions are due to home energy use.

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Pain Management and Analgesic Sales

Neil Johnston

With the changes occurring restricting the sale of analgesic products within pharmacies, there has not been a great deal of discussion as to how best to handle these changes.
It has been said that the new processes impact severely on the pharmacist’s workflow.

The analgesic market is a very large one within pharmacy and the ability to lose a major income stream is very real.
The following is a press release from the PSA and we have asked Mark Coleman to comment on the various issues:

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The line between counselling and adherence support

Dr Linda Bryant (PGDipPharm, MPharm, DPharm(Auck), FACPP, FNZCP, FPSNZ, MCAPA)

articles by this author...

Linda is a New Zealand Clinical Advisory Pharmacist working as part of a team with GP's and nurses, in a medication advisory role. New Zealand clinical pharmacists get some encouragement to work independently in a variety of settings not necessarily tied to a community pharmacy. Through her company, Comprehensive Pharmaceutical Solutions, she contracts to Primary Health Organisations, lecturing postgraduate students in Clinical Pharmacy and undertaking evaluations of services. Linda's PhD thesis involved investigation into the barriers of implementing Comprehensive Pharmaceutical Care (clinical medication reviews) in primary care.

I was asked a question by a nurse yesterday that set me thinking. She asked where she could find information on what is expected by way of counselling at the time of dispensing for a prescription. On which website could she find this information – the Pharmaceutical Society or the Ministry of Health?
This set the cat amongst the pigeons somewhat. She liked the attention her mother got as part of the Medicine Use Review service, but wondered whether things may not have got this far if some information and direction had been given at the time of dispensing.
Unfortunately, being asked the question in front of others started a litany of accusations about the extent of counselling that people experienced from their community pharmacist, and even a comment about where counselling did occur because for someone’s family member, the information on fluoxetine was overheard by others in the shop.

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While it is accepted that there is variability in the extent of counseling at the time of dispensing, I did wonder about the question of the border between counseling at the time of dispensing (brief interventions), versus the receipt of a considerably larger payment for providing counseling when the person becomes ‘high risk’. There is also the question of whether a 45 to 60 minute session, with extensive information imparted, is as effective as brief interventions whenever the patient is seen, along with reinforcement. The brief intervention studies in the literature indicate that 4 x 5 minutes sessions are just as effective, if not more so, than one x 20 minutes.

Counseling is a generic term that is usually poorly defined in studies of pharmacist – patient communication. Yet there is often the claim that pharmacists ‘counsel’ patients, and this is an important role with significant effects on health outcomes. There appears, however, to be little clarity regarding what is meant by counseling. Is it the simple instructions given out when medicines are dispensed, saying how to take the medicines? Is it information given about the medicine, including expected adverse effects and benefits? Or is it a more in-depth two-way discussion involving asking and listening and taking into account the patient’s perspective. Questions arise regarding the type and extent of ‘counseling’ required for more complex patients, including those who have been identified as non-compliant.

The type of counseling provided by community pharmacists has been noted to be of the ‘instruction and information giving’ or technical type, rather than being motivational.1 In this study 62% of patients said they would not consider paying a fee for pharmacists’ counseling, so although 75% of people felt that the pharmacists’ counseling helped them in taking their medicine, they did not value it highly in terms of willingness-to-pay.

Looking at counseling from a different perspective, patients were asked to give a brief description of their experience with newly prescribed medicines on their second presentation.2 Of 700 patients who were asked, 154 (22%) had concerns regarding side effects or perceived ineffectiveness of the medicine. While community pharmacists may provide counseling or information when the prescription is first presented, this study suggests that checking with the patient when they present with the second prescription, might identify drug-related problems that could be acted on at this time.

It has been found that time was a barrier to providing primary health care advice.3 In the study population of 394 pharmacies in the USA, the average time spent explaining drug benefits to patients was 33 seconds for pharmacies processing less than 80 scripts/day, 29 seconds for pharmacies dispensing 80 to 110 scripts, and 20 seconds for those processing an average of 167 scripts per day. A similar UK study of advice given by pharmacists found that the average time taken to give advice with a prescription was 27 seconds per prescription and only 3 of 18 pharmacists averaged more than one minute.
Conversely advice about over-the-counter medicines was an average of 111 seconds per item.4

Similarly, lack of time (63%), lack of privacy (51%) and lack of reimbursement (13%) ranked highly as
barriers for pharmacists providing patient counseling at the time of dispensing.5 Smith et al.6 found that time-stressed pharmacists were significantly less likely to perform 12 of 22 counseling behaviours. However, perceived skill and interest in compliance counseling, and job satisfaction also correlated significantly with the extent of counseling.

A word of caution was raised by Salter et al.7 who performed discourse analysis of community pharmacist consultations during a domiciliary visit to undertake a medication review in people older than 80 years. This study indicated a potential reduced quality of life due to undermining of the person’s confidence in their self-management. Community pharmacists are usually focused on the brief instruction and information-giving counseling style associated with dispensing, rather than motivational style that may be more appropriate in a clinical consultation. Pharmacists found many opportunities to offer advice, information, and instruction. These advice-giving modes were rarely initiated by the patients and were given despite a no problem response and deliberate displays of competence and knowledge by patients. Advice was often resisted or rejected. Pharmacists may need to take care to adopt the style of counseling appropriate for the patient and the service, rather than risk undermining the patient’s confidence in their medicines and their ability to manage them.

So, what are the contractual requirements for counseling at the time of dispensing in New Zealand? From the Base pharmacy contract:

Provision of essential advice and counseling includes: (i) directions for the safe and effective use of the Pharmaceutical; (ii) the expected outcomes of therapy; (iii) what to do if side-effects occur; (iv) storage requirements of the Pharmaceutical; (v) disposal of unused Pharmaceuticals.

When reviewing the adherence support service (Medicine Use Review), how much of this service should have been done at the time of dispensing? To be of any value to the profession, services have to be affordable and sustainable. Would it not perhaps be better to be clear on verbal advice given at the time of the initial dispensing of a medicine, plus specific follow-up at the second dispensing (or sooner), along with an annual check of any issues occurring. Information may be best provided in the form of brief interventions rather than extended sessions. We need to be clear what is part is the professional dispensing services, and what is specific to adherence support.

If adequate counseling isn’t done at the time of dispensing, then remote / robotic dispensing services would be acceptable.

 

1. Report S. Patients confirm that medication counseling helps. Am J Hosp Pharm. 1994;51(13):1606, 1608.

2. Hugtenburg JG, Blom AT, Gopie CT, Beckeringh JJ. Communicating with patients the second time they present their prescription at the pharmacy. Discovering patients' drug-related problems. Pharm World Sci. 2004;26(6):328-32.

3. Muirhead G. Where does the time go? Drug Topics 1996:128-140.

4. Savage I. Time for prescription and OTC advice in independent community practice. Pharm Journ 1997;258:873-77.

5. Schommer JC, Wiederholt JB. Pharmacists' perceptions of patients' needs for counseling. American Journal of Hospital Pharmacy. 1994;51(4):478-85.

6. Smith SL, Golin CE, Reif S. Influence of time stress and other variables on counseling by pharmacists about antiretroviral medications. Am J Health-Sys Pharm. 2004;61:1120-9.

7. Salter C, Holland R, Harvey I, Henwood K. "I haven't even phoned my doctor yet." The advice giving role of the pharmacist during consultations for medication review with patients aged 80 or more: qualitative discourse analysis. Bmj 2007;334(7603):1101.

 

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