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Pharmacists' preferences for providing patient-centred services Grindrod, Kelly Anne 2009

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 PHARMACISTS’ PREFERENCES FOR PROVIDING PATIENT-CENTRED SERVICES by  Kelly Anne Grindrod  B.Sc.(Pharmacy), University of Alberta, 2003 Pharm.D., University of British Columbia, 2007  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE in The Faculty of Graduate Studies (Pharmaceutical Sciences)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  August 2009  Kelly Anne Grindrod, 2009   ii ABSTRACT Introduction: In Canada, most pharmacists are not paid to provide patient-centred services and in other jurisdictions, most programs for these types of services have suffered from low uptake and limited sustainability. Objective: To determine pharmacists’ preferences for providing patient-centred services. Methods: Senior students and pharmacists in British Columbia and Alberta were recruited to complete a questionnaire that included a discrete choice experiment. Using 18 different choice-sets, respondents were asked if they preferred to provide one of two hypothetical patient-centred services or to provide typical pharmacy services. Each service differed by the following attributes: type of service; personal income; setting; job satisfaction; professional service fee; and required continuing education. Multinomial logit and latent class regression modeling was used to determine respondents’ relative preference weights for each attribute. Results: Of 539 respondents who completed the questionnaire, 49% were dispensary pharmacists or managers, 12% were dispensary owners or regional managers, 21% were clinical pharmacists and 16% were students. Respondents were very averse to seeing a decrease in their income or job satisfaction and preferred to have access to a weeklong course or a paid preceptorship. Respondents also preferred to provide medication or disease management services, but were not as interested in providing screening services. Finally, respondents had a slight preference for providing services in a clinic rather than a dispensary. Preferences differed according to several factors including respondents’ employment and time in practice.     iii Conclusion: Compared to offering only typical pharmacy services, many pharmacists seem to prefer to provide patient-centred services. However, before adopting these services, most pharmacists will need assurance that their income and job satisfaction will be maintained or increase, and that they will have access to suitable continuing education programs. Pharmacists who are attracted to clinical roles will be more interested in the type of service to be delivered. Decision-makers and pharmacy leaders who are looking to develop and implement a program for patient-centred pharmacy services should carefully consider these preferences to improve the likelihood that the program will be successful and sustainable.        iv TABLE OF CONTENTS Abstract.......................................................................................................................................ii
 Table
of
Contents.................................................................................................................... iv
 List
of
Tables ...........................................................................................................................vii
 List
of
Figures........................................................................................................................... ix
 Abbreviations ........................................................................................................................... x
 Acknowledgements................................................................................................................xi
 Co­Authorship
Statement ...................................................................................................xii
 1.
 Patient­Centred
Services
&
The
Pharmacist:
A
Challenged
Relationship ....1
 1.1.
 Modern
Pharmacy
Services................................................................................................1
 1.2.
 Patient­Centred
Pharmacy
Services
in
Canada ...........................................................3
 1.3.
 Care
Gaps
&
Canadian
Pharmacists’
Scope
of
Practice .............................................4
 1.4.
 Thesis
Objectives,
Hypotheses
&
Organization...........................................................5
 1.5.
 Conclusion................................................................................................................................6
 1.6.
 References ...............................................................................................................................7
 2.
 Remuneration
for
Patient­Centred
Pharmacy
Services:
A
Literature
 Review .............................................................................................................................. 11
 2.1.
 Introduction ......................................................................................................................... 11
 2.2.
 Patient­Centred
Pharmacy
Services............................................................................. 12
2.2.1.
 Medication
Therapy
Management........................................................................................12
2.2.2.
 Chronic
Disease
Management ................................................................................................13
2.2.3.
 Disease
Screening ........................................................................................................................16
 2.3.
 Systematic
Review
of
Remuneration
Programs
for
Patient­Centred
Pharmacy
 Services.................................................................................................................................. 17
 2.4.
 Results.................................................................................................................................... 18
2.4.1.
 Payers................................................................................................................................................19
2.4.2.
 Types
of
Service............................................................................................................................20
2.4.3.
 Remuneration................................................................................................................................20
2.4.4.
 Evaluation
of
Outcomes ............................................................................................................21
 2.5.
 Discussion ............................................................................................................................. 24
2.5.1.
 Methodological
Concerns
&
Limitations............................................................................25
2.5.2.
 Considerations
in
Moving
Forward......................................................................................26
 2.6.
 Conclusion............................................................................................................................. 28
 2.7.
 References ............................................................................................................................ 40
 3.
 Pharmacists’
Preferences
for
Providing
Patient­Centred
Pharmacy
 Services:
Focus
Groups................................................................................................ 49
 3.1.
 Introduction ......................................................................................................................... 49
 3.2.
 Qualitative
Methodology.................................................................................................. 50
 3.3.
 Methods ................................................................................................................................. 52
3.3.1.
 Participants.....................................................................................................................................52
3.3.2.
 Focus
Group
Interviews
with
Key
Stakeholders ............................................................53
3.3.3.
 Focus
Group
Analysis .................................................................................................................53
 3.4.
 Results.................................................................................................................................... 54
     v 3.4.1.
 Current
Practice
Environment ...............................................................................................54
3.4.2.
 The
Need
for
Education.............................................................................................................59
3.4.3.
 Remuneration
Models................................................................................................................60
3.4.4.
 Planning
for
Implementation..................................................................................................61
 3.5.
 Discussion ............................................................................................................................. 63
3.5.1.
 Methodological
Concerns
&
Limitations............................................................................66
3.5.2.
 Recommendations
for
Implementation .............................................................................68
 3.6.
 Conclusion............................................................................................................................. 69
 3.7.
 References ............................................................................................................................ 72
 4.
 Pharmacists’
Roles
and
Patient­Centred
Pharmacy
Services
in
British
 Columbia
and
Alberta.................................................................................................. 76
 4.1.
 Introduction ......................................................................................................................... 76
 4.2.
 Methods ................................................................................................................................. 77
4.2.1.
 Participants.....................................................................................................................................77
4.2.2.
 Questionnaire
Design .................................................................................................................78
4.2.3.
 Statistical
Analysis.......................................................................................................................79
 4.3.
 Results.................................................................................................................................... 79
4.3.1.
 Sample
Characteristics ..............................................................................................................79
4.3.2.
 Job
Satisfaction..............................................................................................................................81
4.3.3.
 Patient‐Centred
Pharmacy
Services ....................................................................................81
4.3.4.
 Remuneration
for
Patient‐Centred
Pharmacy
Services ..............................................82
 4.4.
 Discussion ............................................................................................................................. 83
4.4.1.
 Methodological
Concerns
&
Limitations............................................................................85
 4.5.
 Conclusion............................................................................................................................. 86
 4.6.
 References ............................................................................................................................ 95
 5.
 Pharmacists’
Preferences
for
Providing
Non­Dispensing
Services:
A
 Discrete
Choice
Experiment ...................................................................................... 98
 5.1.
 Introduction ......................................................................................................................... 98
 5.2.
 Methods ...............................................................................................................................100
5.2.1.
 Participants.................................................................................................................................. 100
5.2.2.
 Selection
of
Attributes
&
Levels.......................................................................................... 100
5.2.3.
 Questionnaire
Development ................................................................................................ 101
5.2.4.
 Statistical
Analysis.................................................................................................................... 103
5.2.5.
 Sample
Size
Determination................................................................................................... 107
 5.3.
 Results..................................................................................................................................107
5.3.1.
 Sample
Characteristics ........................................................................................................... 108
5.3.2.
 Multinomial
Logit
Model........................................................................................................ 108
5.3.3.
 Latent
Class
Model.................................................................................................................... 111
 5.4.
 Discussion ...........................................................................................................................113
5.4.1.
 Methodological
Concerns
&
Limitations......................................................................... 114
 5.5.
 Conclusion...........................................................................................................................116
 5.1.
 References ..........................................................................................................................140
 6.
 Marketing
Non­Dispensing
Services
to
Pharmacists:
Conclusions............145
 6.1.
 Introduction .......................................................................................................................145
 6.2.
 Summary
of
Key
Research
Findings...........................................................................147
 6.3.
 Discussion
&
Conclusions ..............................................................................................151
 6.4.
 References ..........................................................................................................................156
     vi Appendix
1:
Ethics
Certificates ......................................................................................159
 Appendix
2:
Focus
Group
Questions ............................................................................163
 Appendix
3:
Discrete
Choice
Experiments.................................................................164
 A.3.1.
 Introduction ...................................................................................................................164
 A.3.2.
 Theoretical
Background.............................................................................................165
 A.3.3.
 Experimental
Design ...................................................................................................167
A.3.3.1.
 Identification
of
Attributes
and
Attribute
Levels .................................................... 167
A.3.3.2.
 Questionnaire
Development ............................................................................................ 169
A.3.3.3.
 Statistical
Analysis................................................................................................................ 171
 A.3.4.
 Methodological
Concerns
&
Challenges ................................................................173
A.3.4.1.
 Non‐demanders
in
Discrete
Choice
Experiments ................................................... 173
A.3.4.2.
 Decision
Making
Strategies............................................................................................... 174
A.3.4.3.
 Rationality
vs.
Irrationality............................................................................................... 175
 A.3.5.
 Discrete
Choice
Experiments
of
Pharmacy
Services.........................................175
 A.3.6.
 Conclusion.......................................................................................................................177
 A.3.7.
 References.......................................................................................................................179
 Appendix
4:
Questionnaire
(self­administered
online) ........................................182
       vii LIST OF TABLES Table 2.1: Summary of characteristics of ongoing programs for the remuneration of patient-centred pharmacy services............................................................................ 31
  Table 2.2: Summary of evaluations of ongoing programs for patient-centred pharmacy services...................................................................................................................... 34
  Table 3.1: Focus group participants’ province of practice and current employment ....... 70
  Table 3.2:  Themes identified from pharmacist focus groups on disease-specific patient- centred pharmacy services ........................................................................................ 71
  Table 4.1: Demographics and job descriptions of pharmacist respondents (N=452) ....... 88
  Table 4.2: Demographics and job descriptions of student respondents (N=87) ............... 90
  Table 4.3: Pharmacists' satisfaction with job, providing pharmacy services, pharmacy organization and relationships with others (N=452)................................................. 91
  Table 4.4: The provision of pharmacy services by pharmacists and students (N=529)* . 93
  Table 4.5: Pharmacist and student opinions on remuneration for patient-centred services (N=529)*................................................................................................................... 94
  Table 5.1: Attributes and levels to assess pharmacists’ preferences for the delivery of patient-centred services........................................................................................... 125
  Table 5.2:  Effect coding of variables for the multinomial logit model of pharmacists’ preferences for patient-centred services.................................................................. 127
  Table 5.3: Pharmacist characteristics overall and according to the consistency of answers for fixed-repeated questions 5 and 13..................................................................... 128
  Table 5.4:  Multinomial logit model of respondents’ mean preference weights for providing patient-centred services .......................................................................... 130
  Table 5.5:  Multinomial logit model of respondents’ mean preference weights according to employment status for all respondents................................................................ 131
  Table 5.6: Multinomial logit model of respondents’ mean preference weights according to time in practice for all respondents..................................................................... 133
  Table 5.7: Overview of latent class model estimation results ........................................ 135
      viii Table 5.8:  Latent class model of pharmacists’ mean preference weights for providing patient-centred services........................................................................................... 136
  Table 5.9:  Latent class model of pharmacy students’ mean preference weights for providing patient-centred services .......................................................................... 139
  Table 6.1: Pharmacists and pharmacy students’ preferences for providing patient-centred services in a discrete choice experiment................................................................. 155
     ix LIST OF FIGURES Figure 2.1: Trial flow summary for systematic review of patient-centred pharmacy remuneration programs ............................................................................................. 30
  Figure 5.1:  Sample discrete choice experiment choice-set for pharmacists’ preferences for patient-centred pharmacy services .................................................................... 117
  Figure 5.2:  Respondents’ mean preference weights and 95% confidence intervals for providing patient-centred services for all respondents (multinomial logit model). 118
  Figure 5.3:  Respondents’ mean preference weights and 95% confidence intervals according to employment for all respondents (multinomial logit model) .............. 119
  Figure 5.4:  Relative importance of attributes of patient-centred pharmacy services according to employment for all respondents (multinomial logit model) .............. 120
  Figure 5.5:  Respondents’ mean preference weights and 95% confidence intervals according to time in practice for all respondents (multinomial logit model) ......... 121
  Figure 5.6:  Relative importance of attributes of patient-centred pharmacy services according to time in practice for all respondents (multinomial logit model) ......... 122
  Figure 5.7: Relative importance of attributes of patient-centred pharmacy services to pharmacists (latent class model) ............................................................................. 123
  Figure 5.8: Relative importance of attributes of patient-centred pharmacy services to pharmacy students (latent class model) .................................................................. 124
  Figure A.1:  Example discrete choice experiment choice-set for new pharmacy hypertension services .............................................................................................. 178
      x ABBREVIATIONS BC British Columbia CDM Chronic Disease Management COPD Chronic Obstructive Pulmonary Disease DCE Discrete Choice Experiment DRP Drug-Related Problem FEV1 Forced Expiratory Volume in 1 second IIA Independent of Irrelevant Alternatives iid Independently and identically distributed LCM Latent Class Model LTC Long-Term Care MNL Multinomial Logit Model MTM Medication Therapy Management MXL Mixed Logit Model NLM Nested Logit Model PharmD Doctor of Pharmacy Degree QALY Quality Adjusted Life Years RBRVS Resource-Based Relative Value Scale SD Standard Deviation SE Standard Error UBC University of British Columbia       xi ACKNOWLEDGEMENTS  I am grateful to the faculty, staff and my fellow students at the University of British Columbia who have supported me in my studies of patient-centred pharmacy services. In particular, I am most appreciative of Drs. Carlo Marra and Larry Lynd who continually guide me in the development of my career and in my research interests. I also thank Dr. Ross Tsuyuki for his ongoing support of my education and career over the past several years. It is with mentors such as these that I am learning to ask the hard questions and to make those questions heard. Thank you.  Thanks are also owed to my family who has supported (even encouraged) my ongoing pursuit of knowledge in spite of the costs – both time and money. Thank you for your patience and your pride.     xii CO-AUTHORSHIP STATEMENT  The work presented in this thesis was conducted and disseminated by the Master’s candidate. The Master’s candidate contributed to the identification and design of the research described herein, participated in the research, completed all data analyses and prepared the manuscripts. The co-authors of the manuscripts that comprise this thesis made contributions only as is commensurate with a thesis committee, as experts in a specific area as it pertains to the work or under the direct guidance of the candidate. The co-authors reviewed each manuscript prior to submission for publication and offered critical evaluations; however, the candidate was responsible for the writing and the final content of these manuscripts.   1 1. PATIENT-CENTRED SERVICES & THE PHARMACIST: A CHALLENGED RELATIONSHIP  Viewing the drug as a product, rather than an object toward which their services are to be directed, forces pharmacists to violate some of the basic rules of being professional. The pharmacist becomes the agent through which the drug may be obtained rather than an individual who makes some contribution of service. -Smith & Knapp, 19811  1.1. Modern Pharmacy Services Pharmacy, as a healthcare profession, is at a crossroads. While the mass production of pharmaceuticals has reduced the pharmacist from apothecary to medication dispenser, patient-centred care has long been considered a means to regain autonomy.2 Yet, even as the profession has advocated a focus on the patient and not the product, pharmacists’ basic technical abilities have become central to their professional identity. Many pharmacists have wanted to change the way they practice, but the services that foster patient-centred care have conflicted with current pharmacy business models. Now, after decades of stalled change, pharmacists are being faced with a decision – either accept the status quo or change direction and move to a new standard of care. Pharmaceutical care was first described by Hepler and Strand twenty years ago and has since become the central ideology of modern pharmacy practice.2 As “the responsible provision of medication therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life”, pharmaceutical care requires that pharmacists ensure     2 the safe and effective use of medication therapy. Since its inception, it has been heralded as a patient-centred approach for pharmacists and has become the cornerstone of many pharmacy undergraduate curricula. That said, few pharmacists have actually put theory to practice. Using labels such as “community pharmacist”, “hospital pharmacist” and even “clinical pharmacist” to distinguish between commitments to care, the profession has fragmented as it has moved ahead with disparate visions for practice. Consequently, many pharmacists have continued to accept and even embrace a status quo, preferring to remain in a technical role rather than that of a healthcare professional. The focus on consumer convenience means that pharmacists are often restricted by shift-work, poor working conditions, and time constraints. In today’s practice, it is widely expected that pharmacists are always available to deliver products and product-specific information in a reliable, accurate and timely manner. However, the cost of this convenience is that the pharmacist rarely has the time or information to assess a patient’s medication therapy for safety and effectiveness. In comparison to the fast-service expectation of employers, undergraduate pharmacy students are encouraged to become medication experts with a vast knowledge of the products they dispense. Students are taught that the public views them as a valuable and trusted source of information and that, when they graduate and become pharmacists, they will be responsible for the safety and well-being of their patients. However, each year, despite their training and knowledge, many ‘medication experts’ start their practices by joining the majority of the profession in accepting the status quo. The result is that, despite shifts in professional ideology, pharmacists have made very little progress in terms of improving the quality of care they deliver to patients in the community.     3  1.2.  Patient-Centred Pharmacy Services in Canada Given that many practicing pharmacists are complacent with the status quo, and many future pharmacists are similarly complacent, a certain reluctance to change is evident.3 Considering that pharmacists are encouraged to care for their patients but taught to deliver medications, this complacency may, in part, be due to confusion around the meaning of ‘patient-centred services’. Also described as ‘clinical services’ or ‘cognitive services’, patient-centred services focus on the needs of the individual patient. In pharmacy, these services often use a disease-specific approach (e.g., chronic disease management (CDM), medication therapy management (MTM)) to pharmaceutical care. In contrast, product-centred services focus on the delivery of the product and include services such as dispensing, compound preparation, compliance packaging and formulary-based therapeutic substitutions. In Canada, most pharmacists are paid to deliver medications and are expected to offer patient-centred care as a value-added service. As a result, patient- and product- centred services are not mutually exclusive and the distinction between the two is often blurred. In fact, almost all ‘patient-centred’ pharmacy services introduced in recent decades have been dispensing-related, including interventions for inappropriate prescriptions, trial prescription plans and the development of medication profiles.4-7 While many provinces and some third party payers are now looking to pay for services that are unrelated to dispensing such as smoking cessation,8 most are paid out-of-pocket by patients or provided free of charge by the pharmacist. The result is that pharmacists     4 have learned to concentrate on the product in order to service their businesses, pharmaceutical suppliers and themselves all before serving the central client – the patient.  1.3. Care Gaps & Canadian Pharmacists’ Scope of Practice While there is a clear need for the safe and efficient delivery of medications, there is also a need for the safe and effective use of medications. Despite the existence of well- designed clinical trials and well-established guidelines, the prevention and management of many chronic diseases is suboptimal. For example, while antihypertensives and statins are widely recognized to be well tolerated and to reduce serious cardiovascular events,9-12 many people at risk are inadequately managed.13-17 In a similar example, despite guideline recommendations that people with rheumatoid arthritis receive disease modifying anti-rheumatic medications shortly after diagnosis,18 only a small portion have access to these medications.19 These care gaps may be attributable to a lack of awareness by clinicians or patients, fear of adverse effects or limited affordability. Regardless, available medications for many common conditions provide less benefit than they could to individual patients and to society in general because they are not prescribed, not taken or not used appropriately. For many chronic diseases, medication therapy is the treatment standard for both prevention and management. Pharmacists, who currently play only a very small role in disease management, have been recognized as the most accessible health professional.20 They are ideally positioned to provide care in the community setting and in response to this, many Canadian provinces have started expanding pharmacists’ scope of practice purportedly to address gaps in care. In fact, as of February 2009, seven provinces had     5 already granted some form of prescribing privilege to pharmacists.21 In British Columbia, Alberta, Saskatchewan, Manitoba, New Brunswick and Nova Scotia, pharmacists now provide services to extend prescriptions and in some cases, to adapt existing prescriptions for appropriateness.22,23 In addition, in both Alberta and Quebec, pharmacists working in highly specialized areas can also prescribe medications specific to their area of practice.24 With these initiatives, pharmacists are now at a point where they can realistically consider a move to start providing patient-centred services.  1.4.  Thesis Objectives, Hypotheses & Organization Given the need for improved patient care by pharmacists, the clear care gaps in disease management and the limited remuneration of patient-centred pharmacy services in the community, the overall objective of this thesis was to determine pharmacists’ preferences for providing patient-centred services. The specific objectives of this thesis were:  1. To quantify, using a discrete choice experiment, pharmacists’ preferences for different aspects of patient-centred services, including humanistic, environmental and financial characteristics; and  2. To evaluate what factors are associated with pharmacists’ preferences for providing patient-centred services, including pharmacist demographics and their prior experience with providing these services.     6  1.5. Conclusion Legislative changes across Canada are enabling pharmacists to have a greater role in the healthcare system. In the area of disease management, multiple gaps in care have been identified between clinical trial data, guideline recommendations and real-world clinical practice. It is here that pharmacists are likely to have the greatest impact on patient care. That said, even well designed programs that consider both the needs of the patient and the healthcare system are unlikely to succeed if pharmacists are not willing to provide the new services. This is significant because, to our knowledge, pharmacists’ preferences for providing patient-centred services have never been systematically evaluated. To elucidate these preferences and to ensure that future programs are widely adopted by pharmacists, we sought to describe pharmacists’ preferences for patient- centred services in a way that can be used in both the development and the implementation of patient-centred pharmacy services in Canada.     7 1.6.  References  1 Smith MC, Knapp DA. Pharmacy drugs and medical care. 3rd ed. Baltimore, MD: Williams and Wilkins; 1981. 2 Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharmacy 1990;47:533-43. 3 de Oliveira D, Shoemaker S. Achieving patient centredness in pharmacy practice: openness and the pharmacist's natural attitude. J Am Pharm Assoc 2006;46:56-64. 4 Jones EJ, Mackinnon NJ, Tsuyuki RT. Pharmaceutical care in community pharmacies: practice and research in Canada. Ann Pharmacother 2005;39:1527-33. 5 The "Follow-up" MedsCheck. Toronto, ON: Ontario Ministry of Health and Long-Term Care, 2007. (Accessed August 4, 2009, at http://www.health.gov.on.ca/english/providers/pub/drugs/meds_check/medscheck_mn.ht ml.) 6 MedsCheck program provides better care for patients. Toronto, ON: Ontario Ministry of Health and Long-Term Care, 2007. (Accessed August 4, 2009, at http://www.health.gov.on.ca/english/providers/pub/drugs/meds_check/medscheck_mn.ht ml.) 7 Introducing the MedsCheck program. Toronto, ON: Ontario Ministry of Health and Long-Term Care, 2007. (Accessed August 4, 2009, at http://www.health.gov.on.ca/english/providers/pub/drugs/meds_check/medscheck_mn.ht ml.)      8  8 Health service providers: Pharmacy. Windsor, ON: Greenshield Canada, 2008. (Accessed July 3, 2008, at http://www.greenshield.ca/English/HealthServiceProviders/Pharmacy/SmokingCessation. htm.) 9 Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002;360:7-22. 10 Pyŏrälä K, Pedersen TR, Kjekshus J, Faergeman O, Olsson AG, Thorgeirsson G. Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease. A subgroup analysis of the Scandinavian Simvastatin Survival Study (4S). Diabetes Care 1997; 20:614-20. 11 Sever PS, Dahlöf B, Poulter NR, et al. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial--Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial. Lancet 2003;361:1149-58. 12 Turnbull F, Neal B, Ninomiya T, et al; for the Blood Pressure Lowering Treatment Trialists' Collaboration. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ 2008;336:1121-3. 13 Abookire SA, Karson AS, Fiskio J, Bates DW. Use and monitoring of "statin" lipid- lowering drugs compared with guidelines. Arch Intern Med 2001;161:53-8.      9  14 Cournot M, Cambou JP, Quentzel S, Danchin N. Key factors associated with the under-prescription of statins in elderly coronary heart disease patients: Results from the ELIAGE and ELICOEUR surveys. Int J Cardiol 2006;111:12-8. 15 Andrade SE, Gurwitz JH, Filed TS, et al. Hypertension management: the care gap between clinical guidelines and clinical practice. Am J Managed Care 2004;10:481-6. 16 Ong K, Cheung B, Man Y, Lau C, Lam K. Prevalence, awareness, treatment and control of hypertension among United States adults 1999-2004. Hypertension 2007;49:69-75. 17 Leenen FH, Dumais J, McInnis NH, et al. Results of the Ontario survey on the prevalence and control of hypertension. CMAJ 2008;178:1441-9. 18 American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 Update. Arthritis Rheum 2002;46:328-46. 19 Lacaille D, Anis AH, Guh DP, JM. E. Gaps in care for rheumatoid arthritis: a population study. Arthritis Rheum 2005;53:241-8. 20 Building on Values: The Future of Health Care in Canada. Ottawa, ON: Commission of the Future of Health Care in Canada (The Romanow Commission), 2002. (Accessed June 12, 2009, at http://publications.gc.ca/pub?id=237274&sl=0.) 21 Sketris IS. Extending prescribing privileges in Canada. Canadian Pharmacists Journal 2009;142:17-9. 22 Casey Q. Pharmacists get bigger role. Telegraph Journal 2008: May 21. (Accessed June 14, 2008, at http://telegraphjournal.canadaeast.com/search/article/302118.)      10  23 Manitoba Society of Pharmacists. Bill 41 passed with pharmacists retaining voting rights. MSP Member Update 2006;4. (Accessed April 21, 2008, at http://www.msp.mb.ca/newsletter/newsletter_4-31.htm.) 24 Additional prescribing authorization now available in Alberta. In: The transition times: helping you navigate change. Edmonton, AB: Alberta College of Pharmacists, 2008. (Accessed April 21, 2008, at http://pharmacists.ab.ca/Downloads/documentloader.ashx?id=4799.)   11 2. REMUNERATION FOR PATIENT-CENTRED PHARMACY SERVICES: A LITERATURE REVIEWi  2.1. Introduction For many years, the profession of pharmacy has been undergoing a major ideological shift. As the healthcare system becomes increasingly strained, pharmacists are in an ideal position to move away from a traditional dispensing role towards one that focuses on patient care. To ensure that this shift in professional responsibilities is a success, pharmacists will need to change their current business model and move towards alternate means of compensation. At present, most community pharmacists in Canada are not paid to provide services other than dispensing.1 Within the current payment model, pharmacists are expected to provide basic medication-specific patient information and provide guidance to patients and physicians. The extent of these services is dependent on the pharmacist’s interpretation of each prescription and their knowledge of a patient’s other medications and diseases. Currently, most patient-centred pharmacy services are developed in the context of health services research. Wide-scale implementation is hindered by a notable absence of remuneration. This lack of support has been a common barrier to change and has limited the availability of many evidence-based pharmacy services. This literature review examines the evidence and existing remuneration models for patient-centred pharmacy services. The goal of this review is to assist Canadian pharmacists in creating a platform  i A version of the chapter has been published. Chan P, Grindrod KA, Bougher D, Pasutto FM, Wilgosh C, Eberhart G, Tsuyuki R. A systematic review of remuneration systems for clinical pharmacy care services. Canadian Pharmacists Journal 2008;141:102-12.   12 from which they can develop their own remuneration programs in collaboration with both public payers and private payers.  2.2. Patient-Centred Pharmacy Services  Patient-centred services are those that focus on the needs of the individual patient rather than on the delivery of a product. In the pharmacy, these services typically centre on the disease or on the medication regimen and included medication therapy management (MTM), chronic disease management (CDM) and screening for the presence of chronic diseases.  2.2.1. Medication Therapy Management Based largely on the ideology of pharmaceutical care, MTM services are those that focus on the safe and effective use of medications.2 Historically, pharmacists have been attracted to the medication focus of MTM prompting the Academy of Managed Care Pharmacy to release a 2008 report titled ‘Sound medication therapy management programs’ to provide a clear definition of MTM programs.3 The document, endorsed by numerous pharmacy organizations including the American Association of Colleges of Pharmacy, the American College of Clinical Pharmacy and the American Pharmacists Association, states that the goal of MTM is the ‘safe, effective, appropriate and economical use of medications’. Further, they state that MTM services should include the following attributes: be patient-centred, be interdisciplinary, encourage effective communication between care givers, have a population and individual patient   13 perspective, provide flexibility, be evidence-based and encourage the mutual promotion of MTM services by healthcare providers and by health plans.3 Despite support for and interest in MTM, evidence for benefits of these services has differed. In a 2007 systematic review, pharmacist-led medication reviews in the elderly did not improve patient outcomes such as mortality or hospital admissions.4 This review included studies that were published before 2006 and has since been validated by several recent well-designed randomized, controlled trials of pharmacist MTM services, including the HeartMed study5 in patients with heart failure, the POLYMED study6 in elderly patients with four or more medications and at least one additional risk factor and the MEDMAN study7 in patients with coronary heart disease. It appears that, despite interest of decision-makers and pharmacists alike, MTM services alone are not likely to provide sweeping improvements in medication therapy. Future studies are needed to identify why these services have had such underwhelming results, and in the meantime, programs centred on MTM will need to carefully consider their objectives and evaluate whether those objectives are being met.  2.2.2. Chronic Disease Management  Pharmacy CDM services typically involve disease-specific patient education together with targeted MTM. While CDM services are generally not offered in pharmacies, they are the most well studied and are the most likely of all patient-centred services to improve patient and health system outcomes. A systematic review of pharmacists professional services found 20 studies published between 1990 and 2002 that looked at pharmaceutical care, several of which were specific to asthma, chronic   14 obstructive pulmonary disease (COPD) and hypertension.8 Of the studies that examined a CDM approach, there were some improvements in surrogate endpoints (e.g., blood pressure in patients with hypertension) and reductions in health resource use. Similarly, in a 2007 Cochrane review of outpatient pharmacy services that included 25 studies and 16 000 patients, pharmacist services were again shown to improve surrogate endpoints.9 In addition, while these studies demonstrated that outpatient pharmacy services increase the number of follow-up and kept appointments, there was also some evidence of reduced hospital visits. However, though 18 of the 25 included studies were randomized, controlled trials, many studies were excluded due to poor methodological design and there was some suggestion of a publication bias. In addition, most disease-specific studies focused on interventions for diabetes, hypertension, hyperlipidemia, and COPD, leaving questions about the pharmacist’s role in other chronic conditions relatively unanswered. Despite the increasing number of studies evaluating pharmacy CDM services, the impact of clinical pharmacists continues to be measured by surrogate markers of health. For example, several studies have considered the different ways for pharmacists to participate in diabetes management. A 2005 study in Australia showed that a clinical pharmacist, using a pharmaceutical care-based approach with face-to-face and telephone appointments, could improve blood pressure and blood glucose in people with Type 2 diabetes over one year.10 In the same year, another study in the U.S. showed that clinical pharmacists in the primary care setting, together with diabetes care coordinators, could use an evidence-based treatment algorithm to improve the same surrogate endpoints.11 More recently, a six-month intervention by a pharmacist-nurse team in a Canadian community pharmacy setting reduced overall blood pressure in people with diabetes who   15 had blood pressure readings above 130/80 mmHg.12 Given the difficulties in carrying out large-scale health services research, it is unlikely that many future studies will be powered to assess more relevant clinical endpoints such as cardiovascular events or mortality. Instead, this information will need to come from program evaluations, which in the case of diabetes, is not widely available. When looking to implement CDM services in the community pharmacy setting, several issues arise. First, despite the focus on respiratory conditions, diabetes, and cardiovascular risk reduction, other conditions should also be considered. Osteoarthritis, for example, is generally managed symptomatically with non-prescription medications and pharmacists have already demonstrated that they can reduce the use of potentially dangerous non-steroidal anti-inflammatory agents in this population while still improving pain management.13 Second, studies of CDM services often rely on pharmacists with extensive clinical training in settings outside the community pharmacy. Considering that most patients who need improved care are managed in the primary care and community setting, and that pharmacists are highly accessible to almost all members of the public, a community pharmacy-based intervention should reach more individuals. Certainly, this has already been demonstrated in the cholesterol management of people at high risk for cardiovascular events.14 Given the promising results described above and the many limitations of the studies to date, research is still needed to evaluate if pharmacy CDM services improve clinical outcomes, to determine the most appropriate conditions to target with these services, and to demonstrate that these services can be delivered safely and effectively in the community setting.    16 2.2.3. Disease Screening Disease screening is the least studied of all conventional patient-centred pharmacy services. That said, many chronic conditions are under-diagnosed and as a result, under- managed. Given the wide accessibility of pharmacists, screening services could potentially identify many individuals in need of care. In support of this, a Canadian pilot study recently showed that pharmacists, using a simple questionnaire, could reliably identify individuals living in the community with previously undiagnosed osteoarthritis.15 In another Canadian study, pharmacists, using heel ultrasound technology to assess bone mineral density, doubled the identification of osteoporosis in the community, though this identification did not improve management.16 In Australia, pharmacists, using a risk assessment questionnaire and a finger-prick test for capillary blood glucose, increased the diagnosis of diabetes and pre-diabetes.17 Similarly, pharmacists in the U.S., using a screening questionnaire and measuring plasma glucose, total cholesterol, high-density lipoprotein cholesterol and blood pressure improved the identification of diabetes, hypertension and hyperlipidemia and improved the management of patients already diagnosed.18 In all of these studies, pharmacists, using simple screening tools such as questionnaires and minimally invasive tests, were able to reliably identify patients in need of improved care. Considering the logistical challenges to implementing more involved patient-centred services such as CDM and MTM in today’s product-centred pharmacy, more attention needs to be paid to the role that screening services can have in expanding pharmacists’ scope of practice.    17 2.3. Systematic Review of Remuneration Programs for Patient-Centred Pharmacy Services For the review, patient-centred services were defined as those that enhanced a patient’s medication therapy or overall health and did not include medication preparation, distribution, or any tasks that could be delegated to a typical Canadian pharmacy technician with basic training. In consultation with a medical librarian, we searched the following databases from the date of inception to June 2006: MEDLINE, EMBASE, International Pharmaceutical Abstracts, EconLit, Scopus, Web of Science, Google Scholar and PubMed. Examples of search terms include the following: pharmacist, community pharmacy service, pharmaceutical economics, pharmaceutical services, reimbursement, and cognitive service. We searched the World Wide Web for grey literature, hand searched pertinent journals and reference lists and contacted experts in the area of pharmacy practice research to identify papers that were missed in the electronic search. Authors were contacted to obtain missing or unclear information. We included English language articles describing or evaluating current remuneration programs for patient-centred pharmacy services in any setting. Articles must have described a program where remuneration was paid by a third party other than the patient (e.g., government) and be separate from dispensing fees. We excluded programs that required the patient to pay for services directly to ensure a focus on programs intended for wide-scale implementation. We also excluded small programs that included private agreements between a small number of pharmacists and their patients or payers.   18 One reviewer was responsible for reviewing titles to generate a list of abstracts for review. Two reviewers independently assessed abstracts and full text articles for inclusion. Disagreements were resolved by discussion and when they remained unresolved, a third independent reviewer was consulted. Two independent reviewers extracted data. To make studies comparable, all costs were converted to Canadian dollars (CAD) using the exchange rate for the year of the most recently published remuneration figures and then inflating the figures to a 2006 price base using the healthcare component of the Canadian Consumer Price Index. Due to the nature of the review subject and significant heterogeneity between programs, data were compiled qualitatively and effect measures were not calculated. A panel consisting of representatives from The Centre for Community Pharmacy Research and Interdisciplinary Strategies (c/COMPRIS), Faculty of Pharmacy and Pharmaceutical Sciences at the University of Alberta, the Alberta College of Pharmacists, and Alberta Health and Wellness (Government of Alberta) were gathered to review and make conclusions on the findings from the literature review, and to provide recommendations for developing an action plan to promote remunerated patient-centred services in Canadian pharmacy practice based on lessons learned from other programs.  2.4. Results We identified 28 established programs that provided pharmacies and pharmacists with remuneration for patient-centred services independent of the dispensing of a product (see Figure 2.1). Of the remuneration programs identified, 12 were developed for community pharmacies, seven for hospital pharmacies (both inpatient and outpatient),   19 one for primary care, two for care provided in patients’ homes, and two for long-term care. The four remaining programs were for various sites not specific to community or hospital pharmacy. Seventeen programs were established and funded by government agencies, nine programs by private third party payers, one program was established and funded by both a government and a third party payer, and one was established by an unknown source. Only 15 programs were providing ongoing services at the time of the review and are described in Table 2.1.19-48  2.4.1. Payers  Payers of community-based patient-centred pharmacy services included both government and private third party payers, though the majority of regional or national programs involved government payers. In programs where private third party payers provided remuneration, reasons cited for involvement included the development of legislation mandating them to do so (e.g., the Diabetes Outpatient Education system in U.S.), negotiations between local pharmacist groups and third party payers (e.g., the Asheville Project), and partnerships between private pharmacy consultancy groups and third party payers. 32,33,36,49,50 All hospital-based programs for the remuneration of patient-centred services were initiated in the early 1980’s and have since been discontinued,51-56 with the exception of those in Japan. In regards to Japanese hospital-based services, the current status of remuneration has changed from the model described in the papers retrieved for this review and no further information could be obtained.57-59   20 2.4.2. Types of Service The main types of services remunerated included MTM, CDM, and non- dispensing services related to medication distribution (medication-related services). MTM services typically included a medication review by a pharmacist to resolve any medication-related issues.28,30,39,41,50,57 Early CDM services focused on the post-discharge care of hospitalized patients with multiple disease states51,53,54 but after 1980, CDM services typically involved diabetes-related education, training and monitoring in the community setting.32,35,39 Medication-related services without a MTM component included counseling for prescription and over-the-counter medications and the management of medication-related issues in consultation with prescribing physicians.19,22, 48,60, With the exception of services that were initiated during the distribution of a medication, most programs encouraged or required physician involvement at some point.30,35,41,48,49,57 Most programs also required pharmacists to take additional training or complete a competency assessment and some included a quality assurance component.35,48,49,50  2.4.3. Remuneration The most common remuneration model was the resource-based relative value scale (RBRVS) which typically involved setting a fixed rate to be paid per intervention, depending on the time spent or effort required (similar to a fee-for-service model). The capitation model, which sets a rate on a per-patient scale, was less common. In all programs, the remunerated amount correlated with the time and effort required of the pharmacist, which translated into greater rates for MTM and CDM services compared to   21 medication-related services. The rate of payment for MTM ranged from $27- $170/review, depending on factors such as the number of medication-related problems resolved, the number of interventions performed and the time spent per patient. Payments for CDM ranged from $33-$135/visit, with higher remuneration rates paid for group sessions. Payments for medication-related services ranged from $4-$17/intervention, depending on the time spent on the intervention and whether or not a physician was contacted.  2.4.4. Evaluation of Outcomes At the time of this review, only 14 programs had been evaluated for an effect on clinical, humanistic or economic outcomes, seven of which were still in operation. Significant heterogeneity made comparison between evaluations difficult and most evaluations focused on health provider satisfaction and program uptake, with clinical and economic outcomes rarely evaluated (see Table 2.2).19-22,27,29,30,32,33,48,50,61,63  Humanistic Outcomes The proportion of pharmacies that enrolled to provide patient-centred services was 80% or above in programs such as Australia’s Home Medicines Review, Iowa’s Pharmaceutical Case Management and the Asheville Project. However, the proportion of enrolled pharmacies actually providing service differed. The percentage of eligible patients receiving an intervention was high for developing programs such as Iowa’s short-lived Outcomes Based Reimbursement Program and the Asheville Project (74% and 100%, respectively).32,33,50 In established, ongoing programs, intervention rates were   22 generally lower, with rates at approximately 20% for both the nation-wide Australian Home Medicines Review and the U.K.’s Medicine Use Review/Prescription Interventions.41-43,48 Despite having one of the highest proportions of enrolled pharmacies that were actually providing interventions, only 33% of eligible patients in Iowa’s Pharmaceutical Case Management program met with the pharmacist, half of which received the intervention.29 The proportion of claims that were successfully billed was generally high with 100% of claims being paid in Nova Scotia’s Inhaled Respiratory Medication Program and the U.K.’s Medicines Use Review and Prescription Intervention program, and 83% being paid in Washington’s now discontinued Cognitive Activities and Reimbursement Effectiveness project.22,48,60,64 As to adequacy of the remuneration, 60% of pharmacists in the Australian Home Medicines Review program felt that the rate was insufficient for a review that took an average time of 3.5 hours.40 For this program, the cost of accreditation ranged from $2 800 to $7 900, with incentives of between $710 and $1 421 given to re-accrediting and newly accredited pharmacists. To cover the cost of accreditation, it was estimated that 11 reviews needed to be completed. As a result, 20% of accredited pharmacists said they were unlikely to maintain or were unsure of maintaining accreditation.40  Clinical Outcomes Generally, programs for patient-centred services were determined to be beneficial to patients and no program was associated with worsened patient outcomes. In the Asheville Project, diabetes management by pharmacists improved hemoglobin A1c,   23 blood pressure, influenza vaccination rates and the proportion of patients receiving eye and foot examinations.32,33 In the Australian Home Medicines Review program, a survey of 57 patients found that some outcomes improved after patients received a review including the number of medication-related health problems and reports of anxiety and depression.63  Economic Outcomes Medical cost savings were suggested in several of the programs but were generally limited to estimates. In Washington’s Cognitive Activities and Reimbursement Effectiveness Project, the annual cost savings to Medicaid was estimated to be between $22 and $119 per patient, though this did not account for all interventions that could have led to cost-savings.64 The Iowa Pharmaceutical Care Delivery Demonstration Project was determined to be budget neutral when both medical and pharmaceutical claims were considered.50 Comparatively, the Australian Home Medicines Review program demonstrated cost-savings along with gains in quality adjusted life years and future cost savings, suggesting that budget gains may be evident after the demonstration project progresses into a permanent program.63 In Scotland’s Minor Ailment Service, pharmacist-led assessments allowed 40% of general practitioner visits for minor ailments to be transferred to pharmacists and nurses.45 In the Asheville project, the number of sick days decreased every year between 1997 and 2001.33    24 2.5. Discussion In this review, we identified 28 distinct programs of remuneration for patient-centred pharmacy services, 15 of which were still active at the time of the review. Services included MTM, CDM and medication-related services. Government payers supported over half of programs. Remuneration rates were highly variable and only 14 programs evaluated clinical, economic or humanistic outcomes. Generally, the most common humanistic outcome was poor pharmacist uptake due concerns over lack of physician awareness or acceptance, time constraints, and inadequate reimbursement. The few programs that evaluated both clinical and economic outcomes suggested that the beneficial clinical effects were accompanied by neutral or beneficial effects on health system use, as seen with the Iowa Pharmaceutical Case Management program,61 the Ashville Project,30,31 and the Australian Home Medicines Review.40,44  Despite the publication of numerous articles addressing remuneration of pharmacy services, very few papers have discussed specific programs and even fewer have evaluated and compared existing programs. In a 1999 systematic review of the pharmacy remuneration literature, McDonald et al. reviewed studies that evaluated different types of pharmacy remuneration models and their effect on pharmacist practice patterns, medication use patterns and client outcomes.65 The review included only eight studies, one of which was of high methodological quality, and the authors concluded that despite the large volume of literature on pharmacy remuneration, there was a lack of controlled studies on the effects of remuneration. These results, similar to the observations in our systematic review, demonstrate that despite the various programs in place around the world, very few have been rigorously evaluated.   25  2.5.1. Methodological Concerns & Limitations This review was limited by the significant heterogeneity of identified programs and corresponding evaluations. As a result, it provides a qualitative summary of the current literature surrounding remuneration programs for patient-centred pharmacy services. Most models differed substantially in their scope, remuneration rates, patient groups and payers. Despite a very broad search, there was a general paucity of information on both current and discontinued programs and an even greater lack of evaluative studies with respect to economic and patient outcomes. As a result, this review was limited to programs described in the literature and those in multiple pharmacies and does not discuss small programs implemented in only one or two pharmacies. In the programs identified, pharmacist participation was usually high during enrollment and accreditation stages, but actual intervention rates were often lower than expected. It was evident that most pharmacists were eager to change pharmacy practice, but the extent to which they were willing to provide patient-centred services was variable. Numerous factors likely affected uptake of these programs, but one of the most important determinants of success may have been pharmacists’ personal belief in the potential benefits of patient-centred care. If a pharmacist was not determined to provide ‘above- and-beyond’ services to begin with, then patient-centred services would not be delivered optimally, regardless of how nurturing the environment was. The influence of the current pharmacy business model likely also played a significant role as pharmacists and corporate pharmacy stakeholders may have continued to find dispensing more efficient and lucrative under the current remuneration programs than in the patient-centred   26 programs that required implementation, increased time and effort and a questionable financial rate of return.  2.5.2. Considerations in Moving Forward  In 2005, a report on MTM was prepared for the American Pharmacists Association to provide a model for payers to use when developing remuneration programs for pharmacists.66 The report provided numerous recommendations for both pharmacists and third party payers based on a literature review, opinion leaders and stakeholder interviews and the implementation of the Medicare MTM service. Some of the recommendations to pharmacists included standardizing and packaging service offerings of various intensities, standardizing billing and service delivery, cultivating widespread patient support, increasing physician awareness and conducting a systematic evidence-based review of the literature surrounding MTM. Recommendations for the third party payers included determining a target number of individuals, working with pharmacists to develop MTM services, developing mechanisms to evaluate overall health costs and developing payment systems that covered the cost of pharmacy labour. Given the findings and limitations described above, it may be appropriate to first implement a program in a select group of pharmacists already practicing at an advanced level, such as those managing their own specialty clinics (e.g., outpatient anticoagulation management). Implementing a pilot program with all levels of pharmacists participating may result in a high initial uptake but a low actual output, a trend seen in many of the existing programs.29 Demonstrated success in terms of clinical, economic and humanistic outcomes within a selected group of pharmacists would allow others to benefit from this   27 experience and could provide motivation to engage in an alternative remuneration program. In developing a viable business model that will be readily accepted and maintained, implementation costs also need to be considered in order to ensure adequate pharmacist training, reasonable documentation of interventions, and participation in the certification and accreditation processes. Successful implementation is of the utmost importance to provide value to funders for the large number of healthcare dollars being invested. Another consideration is the type of model that will meet the needs of payers, pharmacists and patients. The role of a single model (professional services only) versus a mixed model (high level professional services, lower level professional services, and dispensing services) should be thoroughly explored to ensure that all involved parties participate to ensure sustainability. Finally we need to consider and focus on the number of patients who require “high level” service, such as those with multiple co-morbidities and risk factors, and determine if matching patients with pharmacists who have the right skill sets through a referral program would improve patient uptake of the program. Through our review of over 7 000 published titles, it was apparent patient-centred pharmacy services can provide a benefit to patients, payers and the healthcare system. The main issue is in conveying these benefits to stakeholders to promote demand for such services. Payers, whether governments, employers or insurers, need to realize the benefits of patient-centred pharmacy services in order to commit support. Pharmacists should look to provide services with proven benefit to attract employers and governments to subsidize them as part of an employee benefit. Exemplified in the Asheville Project, employers in Ashville realized the associated cost savings of patient-centred CDM and provided   28 comprehensive financial support to pharmacists and patients, leading to eventual cost- savings and sustained long-term benefits to patients.32,33 During our panel group discussion, it was pointed out that lost productivity due to sickness-related absenteeism is one of the biggest problems in organizations. As a consequence, many employers may be willing to pay for patient-centred services if they realized cost savings. Employee participation would potentially increase because the employer is willing to support pharmacy care as a benefit, reinforcing the credibility of pharmacy services. As more patients become involved in wellness programs, physicians may be more willing to collaborate with pharmacists regarding patient treatment goals, leading to better outcomes. Physicians may also be more willing to refer patients to receive care once pharmacists demonstrate their strengths in managing chronic care. Patients also need to recognize the benefit of patient-centred care and make demands for this level of service. They need to better understand what pharmacists can do for them in addition to providing medications. Marketing the services is one mechanism to achieve this. The success of a product or service is largely determined by supportive marketing and the subsequent demand generated. Conveying the substantial benefit of pharmacist care to patients, payers, and physicians is the most persuasive marketing strategy to help them embrace reimbursement for its provision.  2.6. Conclusion Remuneration for patient-centred pharmacy services is still a relatively new concept, without a long-standing history and with few examples to guide development and implementation. Even with the current programs in place, different geographic locations   29 and settings need different programs to meet their healthcare priorities. Further, the best available evidence appears to support services such as CDM and screening with some concerns remaining about the ability of MTM services to improve patient outcomes. Only with ongoing monitoring and evaluation can we ensure that new programs are delivering optimal care and meeting the needs of patients, providers and healthcare systems.   30  Figure 2.1: Trial flow summary for systematic review of patient-centred pharmacy remuneration programs   7039 Titles 2226 Abstracts 4813 Titles Excluded 286 Full Text Articles 1940 Abstracts Excluded 17 Full Text Articles from Hand Search 49 Full Text Articles Included 254 Full Text Articles Excluded   31 Table 2.1: Summary of characteristics of ongoing programs for the remuneration of patient-centred pharmacy services  Program (Year) Location Setting Payer Target Patient Services Canada Pharmaceutical Opinion and Refusal to Dispense19-21 (1978-present)  Quebec  Community Government  All plan recipients  DRP, refusal to dispense  Inhaled Respiratory Medication Program22 (2000-present)  Nova Scotia Community Government  Asthma Initial counseling on inhaler use, follow-up education United States Mississippi Pharmacy Disease Management Program23-26 (1998-present)  Mississippi Community Government  Chronic diseases Compliance assessment, medication review Pharmaceutical Case Management Program27-30 (2000-present)  Iowa Community Government  > 4 medications, ambulatory, 1 of 12 targeted disease states MTM The Asheville Project31-33 (1997-present)  North Carolina Community, Hospital Employer insurance plan Diabetes, asthma Education, CDM   32 Program (Year) Location Setting Payer Target Patient Services Diabetes Self- Management Training34-36 (1998-present)  Various states Outpatient facilities, Community Government  Diabetes Education Diabetes Outpatient Education34-36 (1998-present) Various US states Outpatient facilities, Community  Government  Diabetes Education Pediatric Asthma/Diabetes Management Program37-39 (2005-present)   Ohio Outpatient facilities, Community Government  Diabetes, asthma Education, CDM Australia Home Medicines Review40-44 (2001-present)  Australia Patient home Government  High risk (complex medication regimen, chronic diseases) MTM Residential Medication Management Review40-44 (2005-present)  Australia LTC  Government  High-risk (complex medication regimen, chronic diseases) MTM   33  Program (Year) Location Setting Payer Target Patient Services United Kingdom Minor Ailment Service45 (2006-present) Scotland Community Government  Exempt from prescription charges, not residing in care facility  Diagnosing minor ailments and prescribing Public Health Service45 (2006-present) Scotland Community Government  Low income, exempt from prescription charges, not residing in care facility  Education, public health involvement Medicines Use Review and Prescription Interventions48 (2005-present)  Wales Community  Government  High risk, targeted by local health authorities MTM Europe Quality circles (1997) and Pharmaceutical Consultation in Nursing Homes46 (2002 - present?)  Switzerland LTC  N/A N/A N/A Family Pharmacy Contract47 (2003-present?)  Germany Community Private health insurance Asthma, COPD MTM CDM, chronic disease management, COPD, chronic obstructive pulmonary disease, DRP, drug related problems, LTC, long-term care, MTM, medication therapy management, N/A, not applicable   34 Table 2.2: Summary of evaluations of ongoing programs for patient-centred pharmacy services  Program Design Humanistic Outcomes Clinical Outcomes Economic Outcomes Iowa Pharmaceutical Case Management Program27,29,30,61  Prospective cohort (1 year) Patient uptake: of 3 037 eligible patients, 763 (27%) received service.  Pharmacist uptake: of 117 enrolled pharmacies, 40-60% provided minimal services. Barriers included poor patient access, pharmacy staffing or start-up issues, and lack of physician acceptance.  12.5% increase in Medication Appropriateness Index (P<0.0001) and use of high- risk medications. No difference in health system use.  No differences in medical claims. The Asheville Project (Diabetes)62  Longitudinal cohort (5 year)  Patient uptake: 187 eligible  Over 5 years, number of patients with optimal hemoglobin A1c increased with every follow-up visit.  Diabetes-specific costs increased 85% and all- diagnosis costs decreased 16%. Sick days decreased for one employer group with estimated increase in annual productivity of $25 981.    35 Program Design Humanistic Outcomes Clinical Outcomes Economic Outcomes The Asheville Project (Asthma)62  Longitudinal cohort (5 year)  Patient uptake: 207 eligible  All measures of asthma control improved and were sustained for up to 5 years. Proportion of patients with asthma action plan increased from 63 to 99%. Emergency department visits decreased from 10% to 1%, and hospitalizations from 4% to 2%.  Spending on asthma medications increased, asthma- related claims decreased and total asthma-related costs were significantly lower than historical projections.  Direct savings averaged $812/patient/year, and indirect savings were estimated at $1 378/patient/year. Indirect costs due to missed and nonproductive workdays decreased from 10.8 days/year to 2.6 days/year.    36 Program Design Humanistic Outcomes Clinical Outcomes Economic Outcomes Australian Home Medicines Review63  Interviews, focus groups, case-studies, survey and economic cost-benefit analysis  Patient Uptake: between 2000- 2005, 70,000 reviews completed.  Pharmacist Uptake: 13% of Australian pharmacists accredited. Motivations included professional development and satisfaction gained from a more active role in care. Barriers included the initial cost of accreditation, rural location, insufficient remuneration, lack of patient awareness, low physician buy- in, time constraints (est. 3 hours/review).  In a survey of 57 respondents, 88% saw their physician for a follow-up but 58% did not discuss the review. Cost effective, and gains in QALY. Increasing cost- effectiveness expected in the future.   37 Program Design Humanistic Outcomes Clinical Outcomes Economic Outcomes Nova Scotia Inhaled Respiratory Medication Program22  Survey  Pharmacist uptake: 39% of surveys returned. In previous 3 months, 34% of interventions were for switching delivery devices, 58% for optimizing spacer device use, and 37% for follow-up after replacing spacer device. Barriers included time constraints, conflicting objectives of owner/manager vs. staff, patient identification, inadequate fees, lack of awareness of program.  N/A 42% of interventions billed to payer   38 Program Design Humanistic Outcomes Clinical Outcomes Economic Outcomes Quebec Pharmaceutical Opinion and Refusal to Dispense19-21  Survey Pharmacist Uptake: 56% of surveys returned: 40% of staff pharmacists and 44% of pharmacy owners billed for pharmaceutical opinions in previous 3 months.  Factors associated with billing: filling 100-250 prescriptions daily, the belief that the intervention is good pharmacy practice, the perception that billing is rapid, younger age/fewer years in practice, prior attendance at continuing education sessions on refusal/opinion, availability of technical staff, and use of decision-support computer programs.  Employees were more likely to bill for refusal to fill than for pharmaceutical opinion.  N/A N/A   39 Program Design Humanistic Outcomes Clinical Outcomes Economic Outcomes Wales Medicines Use Review & Prescription Interventions48  Database Pharmacist Uptake: From April 2005 to March 2006, there were 14 623 reviews performed and a total of $7 159 454 was paid to pharmacies. N/A N/A German Family Pharmacy Contract47  Database Uptake: By 2005, 83% (17 790) of pharmacists, 60% (34 000) physicians, and 20% (1 400 000) of insurance plan members joined the trilateral contract. N/A N/A U.K. Minor Ailment Service45  Database Pharmacist Uptake: Up to 40% of physician visits were transferred to pharmacists/nurses for minor ailments.  N/A N/A DRP, drug-related problem, FEV1, forced expiratory volume in one second, HRQL, health related quality of life, N/A, not applicable, QALY, quality adjusted life years   40 2.7. References  1 Jones EJ, MacKinnon NJ, Tsuyuki RT. Pharmaceutical care in community pharmacies: practice and research in Canada. Ann Pharmacother 2005;39:1527-33 2 Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharmacy 1990;47:533-43. 3 Sound medication therapy management programs. Version 2.0. Alexandria, VA: Academy of Managed Care Pharmacy, 2008. (Accessed July 2, 2009, at http://www.amcp.org/amcp.ark?p=AA8CD7EC.) 4 Holland R, Desborough J, Goodyear L, Hall S, Wright D, Loke YK. Does pharmacist- led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis. Br J Clin Pharmacol 2008;65:303-16. 5 Holland R, Brooksby I, Leneghan E et al. Effectiveness of visits from community pharmacists for patients with heart failure: HeartMed randomized controlled trial. BMJ 2007;334:1098. 6 Leneghan E, Holland R, Brooks A. Home-based medication review in a high risk elderly population in primary care – the POLYMED randomized controlled trial. Age Ageing 2007;36:292-7. 7 The Community Pharmacy Medicine Management Projects Evaluation Team. The MEDMAN study: a randomized controlled trial of community pharmacy-led medicines management for patients with coronary heart disease. Fam Pract 2007;24:189-200. 8 Roughead L, Semple S, Vitry A. The value of pharmacist professional services    41  in the community setting. The Pharmacy Guild of Australia Website, 2009. (Accessed July 2, 2009, at http://beta.guild.org.au/research/funded_projects.asp.) 9 Beney J, Bero LA, Bond C. Expanding the roles of outpatient pharmacists: effects on health services utilization, costs, and patient outcomes. Cochrane Database of Systematic Reviews 2000; Issue 2. Art. No.: CD000336. DOI: 10.1002/14651858.CD000336. 10 Clifford RM, Davis WA, Batty KT, Davis TM; Freemantle Diabetes Study. Effect of a pharmaceutical care program on vascular risk factors in type 2 diabetes: the Fremantle Diabetes Study. Diabetes Care 2005;28:771-6. 11 Rothman RL, Malone R, Bryant B et al. A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes. Am J Med 2005;118:276-84. 12 McLean DL, McAlister FA, Johnson JA et al. A randomized trial of the effect of community pharmacist and nurse care on improved blood pressure management in patients with diabetes mellitus: study of cardiovascular risk intervention by pharmacists- hypertension (SCRIP-HTN). Arch Intern Med 2008;168:2355-61. 13 Hay EM, Foster NE, Thomas E et al. Effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in people aged over 55 presenting to primary care: pragmatic randomised trial. BMJ 2006;333:995. 14 Tsuyuki RT, Johnson JA, Koon KT et al. A randomized trial of the effect of community pharmacist intervention on cholesterol risk management: The study of cardiovascular risk intervention by pharmacists (SCRIP). Arch Intern Med 2002; 162:1149-55.    42  15 Marra CA, Cibere J, Tsuyuki RT et al. Improving osteoarthritis detection in the community: pharmacist identification of new, diagnostically confirmed osteoarthritis. Arthritis Rheum 2007;57:1238-44. 16 Yuksel N, Majumdar SR, Biggs C, Tsuyuki RT. Community pharmacist-initiated screening program for osteoporosis: randomized controlled trial. Osteoporosis Int 2009: (Epub accessed July 2, 2009, at http://www.springerlink.com/content/l211567425l41374/.) 17 Krass I, Mitchell B, Clarke P et al. Pharmacy diabetes care program: analysis of two screening methods for undiagnosed type 2 diabetes in Australian community pharmacy. Diabetes Res Clin Pract 2007;75:339. 18 Snella KA, Canales AE, Irons BK et al. Pharmacy- and community-based screenings for diabetes and cardiovascular conditions in high-risk individuals. J Am Pharm Assoc 2006;46:370-7. 19 Kroger E, Moisan J, Gregoire J. Billing for cognitive services: Understanding Quebec pharmacists' behavior. Ann Pharmacother 2000;34:309-16. 20 Poirier S. Reimbursement for cognitive services: Quebec's experience. American Pharmacy 1992;NS32:432-60. 21 Poirier S, Gariepy Y. Compensation in Canada for resolving drug-related problems. J Am Pharm Assoc 1996;NS36:117-22. 22 Murphy AL, MacKinnon NJ, Flanagan PS, Bowles SK, Sketris IS. Pharmacists' participation in an inhaled respiratory medication program: Reimbursement of professional fees. Ann Pharmacother 2005;39:655-61.    43  23 Chang ZG, Kennedy DT, Holdford D, Small RE. Payment for pharmaceutical services. Virginia Pharmacist 2000;84:11-6. 24 Anonymous. Medicaid to pay Mississippi pharmacists for disease management. Am J Health Syst Pharm 1998;55:1238-9. 25 Disease management services. In: Pharmacy Manual. Jackson, MS: Mississippi Division of Medicaid, 2006. (Accessed October 2, 2007, at http://www.dom.state.ms.us/pharmacy.pdf.) 26 Young D. Promising results revealed in Mississippi disease management program. Am J Health Syst Pharm 2003;60:1720-4. 27 Young D. Pharmaceutical case management helps Iowa Medicaid patients. Am J Health Syst Pharm 2003;60:414-6. 28 Thompson CA. Minnesota pharmacists use CPT codes. Am J Health Syst Pharm 2006;63:1208-10. 29 Chrischilles EA, Carter BL, Lund BC, et al. Evaluation of the Iowa Medicaid pharmaceutical case management program. J Am Pharm Assoc 2004; 44:337-49. 30 Carter BL, Chrischilles EA, Scholz D, Hayase N, Bell N. Extent of services provided by pharmacists in the Iowa Medicaid pharmaceutical case management program. J Am Pharm Assoc 2003;43:24-33. 31 Bunting BA, Cranor CW. The Asheville Project: Long-Term Clinical, Humanistic, and Economic Outcomes of a Community-Based Medication Therapy Management Program for Asthma. J Am Pharm Assoc 2006;46:133-47.    44  32 Cranor CW, Christensen DB. The Ashville project: Short-term outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc 2003;43:149-59. 33 Cranor CW, Bunting BA, Christensen DB. The Ashville project: Long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc 2003;43:173-84. 34 Moore K. Getting paid: Billing Medicare for diabetes self-management training. Family Practice Management 2002;9:18. 35 State-Based Diabetes Prevention & Control Programs. Centers for Disease Control and Prevention Website. 2007. (Accessed August 11, 2007, at http://www.cdc.gov/DIABETES/states/.) 36 Covered medical and other health services. In: Medicare Benefit Policy Manual. Baltimore, MD: Centers for Medicare and Medicaid Services, 2006:193-9. (Accessed September 12, 2007, at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.) 37 Vogenberg FR, Hull S. Coding for medication therapy management services. J AHIMA 2006;77:74-9. 38 Reynolds B. Ohio health agency ties MTM services to new CPT codes. American Pharmacists Association Website. 2005. (Accessed August 8, 2007, at http://www.pharmacist.com/AM/PrinterTemplate.cfm?Section=Search1&template=/CM/ HTMLDisplay.cfm&ContentID=8638.) 39 Anonymous. BCMH announces two new MTMS opportunities. Ohio State Board of Pharmacy News 2006:Feb. (Accessed November 13, 2006, at http://pharmacy.ohio.gov/sbn2006-02-all.htm.)    45  40 About Home Medicines Review. The Pharmacy Guild of Australia Website. 2007.(Accessed August 20, 2007, at http://beta.guild.org.au/mmr/content.asp?id=53.) 41 The facts on accreditation and remuneration for medication reviews. Barton, Australia: Australian Association of Consultant Pharmacy, 2006. (Accessed August 20, 2007, at https://www.aacp.com.au/.) 42 Medication Management Reviews. Australian Government Department of Health and Ageing Website. 2007. (Accessed November 13, 2007, at http://www.health.gov.au/internet/wcms/publishing.nsf/Content/Medication+Managemen t+Reviews.) 43 Home Medicines Review. Australian Government Medicare Australia Website. 2007 (Accessed November 13, 2007, at http://www.medicareaustralia.gov.au/providers/incentives_allowances/pharmacy_agreem ent/hmr.htm.) 44 Benrimoj S, Roberts AS. Providing patient care in community pharmacies in Australia. Ann Pharmacother 2005;39:1911-7. 45 Community Pharmacy. National Health Service Scotland Website. 2007. (Accessed April 23, 2007, at http://www.communitypharmacy.scot.nhs.uk/documentation.html.) 46 Guignard E, Bugnon O. Pharmaceutical care in community pharmacies: Practice and research in Switzerland. Ann Pharmacother 2006;40:512-7. 47 Eickhoff C, Schulz M. Pharmaceutical care in community pharmacies: Practice and research in Germany. Ann Pharmacother 2006;40:729-35.    46  48 The new contract for community pharmacy: A funding reference guide. Bucks, England: Pharmaceutical Services Negotiating Committee, 2005. (Accessed June 14, 2006, at http://www.psnc.org.uk/index.php.) 49 Farris KB, Kumbera P, Halterman T, Fang G. Outcomes-based pharmacist reimbursement: Reimbursing pharmacists for cognitive services. J Manag Care Pharm 2002;8:383-93. 50 Anonymous. Impact of pharmaceutical care delivered in the community pharmacy setting: Results of a two year demonstration projects. Iowa Pharmacist 2000;55:18-24. 51 Fudge RP, Latiolais CJ. Blue cross pays for clinical pharmacist services in training hemophiliacs for home care self-therapy. Pharmacy Times 1976;42:36-41. 52 Maddox RR, Vanderveen TW, Jones M, et al. Collaborative clinical pharmacokinetic services. Am J Hosp Pharm 1981;38:524-9. 53 Pathak DS, Nold EG. Cost-effectiveness of clinical pharmaceutical services: A follow- up report. Am J Hosp Pharm 1979;36:1527-9. 54 Patterson LE, Huether RJ. Reimbursement for clinical pharmaceutical services. Am J Hosp Pharm 1978;35:1373-5. 55 Robinson JD. Pharmacokinetics service for ambulatory patients. Am J Hosp Pharm 1981;38:1713-6. 56 Schad R, Schneider PJ, Nold EG. Reimbursable pharmacy teaching program for adrenalectomy patients. Am J Hosp Pharm 1979;36:1212-4. 57 Akaho E, Armstrong EP, Fujii M. Pharmaceutical care innovations in Japan. J Am Pharm Assoc 1996;NS36:123-7.    47  58 Akaho E, MacLaughlin EJ, Takeuchi Y. Comparison of prescription reimbursement methodologies in Japan and the United States. J Am Pharm Assoc 2003;43:519-26. 59 Armstrong EP, Akaho E, Fujii M. Japanese pharmacy: Innovation mixed with tradition. Ann Pharmacother 1995;29:181-5. 60 Christensen DB, Holmes G, Fassett WE, et al. Influence of a financial incentive on cognitive services: CARE project design/implementation. J Am Pharm Assoc 1999;39:629-39. 61 Chrischilles EA, Carter B, Voelker M et al; The PCM Evaluation Team. Medicaid Pharmaceutical Case Management Program: report of the program evaluation. Iowa City, Iowa: 2002. (Accessed October 3, 2007, at http://www.iarx.org/Documents/PCM%20Final%20Report.pdf.) 62 Bunting BA, Cranor CW. The Asheville Project: Long-Term Clinical, Humanistic, and Economic Outcomes of a Community-Based Medication Therapy Management Program for Asthma. J Am Pharm Assoc 2006;46:133-47. 63 Urbis Keys Young. Evaluation of the home medicines review program (Pharmacy Component): final report. Prepared for the Pharmacy Guild of Australia. 2005. (Accessed October 3, 2007, at http://www.guild.org.au/uploadedfiles/Medication_Management_Reviews/Overview/Urb is%20Keys%20Young%20evaluation.pdf.) 64 Smith DH, Fassett WE, Christensen DB. Washington state CARE project: Downstream cost changes associated with the provision of cognitive services by pharmacists. J Am Pharm Assoc 1999;39:650-7.    48  65 McDonald S, Lopatka H, Bachynsky J, Kirwin D. Systematic review of pharmacy reimbursement literature. Institute of Health Economics 1999;Working Paper 99-4:1-63. (Accessed September 1, 2007, at http://www.ihe.ca/documents/1999-04paper.pdf.) 66 DaVanzo J, Dobson A, Koenig L, Book R. Medication therapy management services: A critical review. J Am Pharm Assoc 2005;45:580-7.   49 3. PHARMACISTS’ PREFERENCES FOR PROVIDING PATIENT-CENTRED PHARMACY SERVICES: FOCUS GROUPSi  3.1. Introduction In his influential 2002 report on the future of healthcare in Canada, Roy Romanow envisioned a program where pharmacists, as part of a healthcare team, would optimize medication therapy and act as a medication information resource - in essence, becoming the ‘medication expert’ that pharmacists often advocate themselves to be.1 Since this report, ongoing legislative changes have enabled pharmacists to start providing new services that are unrelated to dispensing. Unfortunately, there is no readily available remuneration program that has proven sustainable. In other parts of the world, pharmacies and government agencies attempting to increase pharmacists’ scope of practice have, after initial success, met with disappointing results.2-4 In many cases, pharmacists have been unable or unwilling to incorporate these new activities into their already busy practices and change has proven temporary. What can we learn from these experiences in Canada? The autonomy of a profession is tied to its ability to control its own remuneration, influence policy decisions and make independent judgments.5 For pharmacists to gain control of their profession, they must move from a practice that relies on the prescriptive decisions of physicians and technical aspects of dispensing, to one that emphasizes their contribution to the healthcare system.  i A version of this chapter has been accepted for publication. 1) Grindrod KA, Rosenthal M, Lynd LD, Marra CA, Bougher D, Wilgosh C, Tsuyuki R. Pharmacist perspectives on providing chronic disease management services in the community (Part 1): Current Practice Environment. Canadian Pharmacists Journal 2009;142: Sept/Oct. 2) Rosenthal M, Grindrod KA, Lynd LD, Marra CA, Bougher D, Wilgosh C, Tsuyuki R. Pharmacist perspectives on providing chronic disease management services in the community (Part 2): Development & Implementation. Canadian Pharmacists Association 2009;142: Nov/Dec.   50 To better understand pharmacists’ views on practice change in Canada, we approached pharmacists directly, using a qualitative approach, to ask for their opinions on providing disease-specific patient-centred services and on receiving payment for these services. The purpose of this study was to provide Canadian pharmacists with a voice and to discuss what pharmacists perceived to be the potential enablers and challenges to providing these services in their current practice environment.  3.2. Qualitative Methodology Generally, qualitative research explores findings that may be overlooked with more empirical methodologies to help answer the question of “why?”6 Therefore, taking the objective of the study into consideration, a phenomenological approach, an epistemological tradition used by qualitative analysis, was taken to enable researchers to gather lived experiences from community pharmacists in Alberta and British Columbia (BC). The practice of qualitative analysis is based on two assumptions.7 The first is epistemological and states that “a phenomenon should be viewed in context”, meaning that a researcher should gather knowledge/experiences from stakeholders in their own words. The second is ontological and suggests “there is not a single [all encompassing] reality apart from our perceptions” meaning that to have an understanding of pharmacy practice, it is important to gather the words and ideas of practicing pharmacists. As a result, in this study it was important to speak directly with pharmacists to understand their current practices in relation to patient-centred services and remuneration.   51 Focus groups have a long history of use in social scientific and market research as a strategy for obtaining the thoughts and feelings of a group of people efficiently.8-12 However, given the potential for diversity, there is debate over the most appropriate methods of analysis. A growing body of research suggests that focus group data represents a group of participants at the moment of the focus group, rather than individual participants as might be the case with interview data. This means that analysis of focus group data as if it were interview data is not appropriate because it assumes that the participants’ perspectives are their own, not a product of the interaction with the group.13- 16 Consequently, focus group data analysis is the study of group interaction with careful attention paid to moments of consensus, potential censoring, and dissonance.15 There are other issues surrounding the generalizability of focus group results. As a recognized drawback of qualitative analysis, a number of alternative methods have been proposed to address this issue. One approach is a theoretical generalization where “the data gained from a particular study provide a degree of generality or universality to allow their projection to other contexts or situations which are comparable to that of the original study.”15 This connection is based on the premise that if a second similar group of participants is placed in a similar context, they would likely reach comparable conclusions. Another alternative is to replace the term “generalizability” with the notion of transferability to consider the degree to which data can be shifted to other contexts or settings.7 By moving in this direction, the researcher is no longer responsible for making these connections, but others who wish to use the data must, after considering their methods, procedures and audience, determine if the results fit their situation.11    52 3.3. Methods We conducted a series of focus groups with pharmacists to integrate their perspectives into the discussion on the advancement of community pharmacy practice and leadership in patient care. Consequently, eight focus groups were conducted to capture pharmacists’ thoughts on the enablers and challenges to patient-centred pharmacy services. All research protocols were approved through local research ethics review boards at both the University of Alberta and the University of BC (see Appendix 1).  3.3.1. Participants We recruited key stakeholders from all facets of pharmacy practice: staff pharmacists, dispensary managers and owners, hospital pharmacists, primary care pharmacists, and regional managers from large chain retailers in both Alberta and BC. To recruit participants, a notice explaining the project was placed in provincial newsletters produced by the Alberta Pharmacists’ Association and the BC Pharmacy Association. This approach was intended to allow all pharmacists interested in discussing patient- centred pharmacy services with an opportunity to participate. To further facilitate this desire and allow rural participation, both face-to-face and telephone focus groups were held. Researchers also contacted pharmacists affiliated with the Centre for Community Research and Interdisciplinary Strategies (c/COMPRIS) in Alberta, and the Community Pharmacy Research Network (CPRN) in BC to seek their participation.    53 3.3.2. Focus Group Interviews with Key Stakeholders Focus group questions were designed to cultivate several areas of inquiry including, but not limited to, what factors might enable the implementation of patient- centred services using chronic disease management as an example (CDM), what factors would challenge implementation, what further education pharmacists felt they would require, and the advantages and disadvantages of particular reimbursement models (see Appendix 2). Due to the potential for thoughts and opinions to diverge greatly amongst the stakeholder groups (i.e., staff pharmacists, pharmacy managers and owners, pharmacy regional managers), these groups were separated to ensure that focus groups were composed of individuals with similar backgrounds and experience.11 The sample size was set a priori at 48 participants to allow for approximately eight participants in three focus groups in both Alberta and BC. This value considered a range of focus group sizes (between 4-12 participants) that is suggested in much of the literature.8-10 All focus group sessions were conducted by an experienced interviewer, recorded, and fully transcribed. The focus groups were continued until novel information was no longer being obtained and saturation was achieved. All participants received a $50 honorarium.  3.3.3. Focus Group Analysis Using a phenomenological approach, the qualitative analysis was performed by two researchers. This approach required an iterative, or back and forth process whereby we examined transcripts individually for recurring topics using focus groups questions as signposts. We then combined and reassessed these analyses to further refine themes,   54 ensure consistency and identify exemplifying quotations. Transcripts were then examined to identify participant quotes and ideas that may have contradicted the major themes. This process, called reflexivity,17 demanded that researchers confront their own biases and predispositions, ultimately creating a richer analysis of the material. After this process was completed another layer of analytic investigation was added as the remaining members of the research team more closely examined the major themes identified and their connection to the research question. This form of triangulation allowed for a variety of perspectives on the focus group material, strengthening and enriching the final analysis.  3.4.  Results Of the 36 participants, 14 identified as staff pharmacists (including community, hospital, long-term care and primary care), 14 as dispensary managers/owners and eight as regional managers from large-chain community pharmacies (see Table 3.1). Over the eight focus groups, pharmacist discussions on the challenges and enablers to patient- centred pharmacy services centred on four major themes: the current practice environment, the need for education, remuneration and the plan for implementation (summarized in Table 3.2).  3.4.1. Current Practice Environment The current practice environment enabled, but largely challenged the provision of patient-centred services by pharmacists. Specifically, when discussing their practices, participant comments focused on three major components: the perception of the   55 pharmacist as healthcare professional; access to information; and the current model for pharmacist involvement in care.  Pharmacist as Healthcare Professional All groups discussed the current and potential role of the pharmacist as it related to physicians, patients, and employers, identifying distinct challenges in the relationships with these parties. Physicians were the only healthcare professional that pharmacists discussed despite several pharmacists coming from clinical settings where direct contact with a variety of other professionals is common. While those practicing in primary care or in hospitals often described this relationship as an enabler to practice change, several community pharmacists described a limited relationship with physicians: I can go in, and discuss with the physician right next door to our store…where I feel our niche is [in terms of the diabetes services we can provide to their patients] and for some reason, the next time that they see a newly diagnosed patient with diabetes, it slips their mind. (Pharmacy Owner) In these discussions, the pharmacists’ particular focus on relationships with physicians likely spoke to the power attributed to the physician as the healthcare team leader. Physicians, in the eyes of pharmacists, may have acted as gatekeepers to patients’ access of pharmacy services. Participants also described their beliefs about how patients perceived the role of pharmacists, though these discussions were generally limited to regional managers and owners and focused on patient desire for services:   56 I think there is need [for patient-centred services]… Demand…has to be clarified because I think a lot of patients don’t necessarily understand that they have a need for more comprehensive medicine management, or better management of their disease. (Pharmacy Owner) Many of the regional managers felt that without the appropriate “demand” from patients, new pharmacy services would not be sustainable. However, as one regional manager pointed out, this relationship is dynamic and evolving: We customize [the medication review], we spend way more time than I think [the patients] ever expected, and from all the feedback we’ve received, it’s been a fantastic experience for them, just having somebody review [their medications]. (Regional Manager) In regards to the perception that patients drive “demand” for new services, the participating regional managers may have been underestimating the role of those in their employ and their ability to advertise new services to the public. Unlike regional managers and owners’ concern about patient perceptions, staff pharmacists often described altruistic motivations in their attempts to do more for their patients and were concerned that management did not support this expanding role: I don’t get paid for it, but I want to do it because I care about that [patient], and I [want to] make a difference in that life… [But my] pharmacy doesn’t recognize it. In fact, they might even look upon it in an unfavorable manner because in the end, it’s taking away from their time. (Staff Pharmacist) However, pharmacy owners and regional managers regularly expressed support of patient-centred services even describing successful programs in their own pharmacies.   57 This represents an interesting contradiction between the understanding of staff pharmacists and management in relation to the expanding roles of pharmacists. Both parties expressed an independent interest in providing patient-centred services to patients but did not seem to communicate this interest effectively with one another. Consequently, management, in the eyes of staff pharmacists acted as a barrier to providing patient- centred services.  Access to Information Many community-based participants felt they had limited access to the information required to provide patient-centred services, a topic left largely unaddressed by hospital or primary care pharmacists who seemed to have ready access to such resources. These concerns centred on access to general disease-specific information and to patient-specific clinical information. Several community-based participants cited difficulty accessing the current guidelines for chronic diseases. There is no central body that provides guidelines to community pharmacists, for the management of disease…[So] we’re relying on product-based educators, to bring us guidelines…and that is, as you can tell by the tone of my voice, it’s something that I’m quite upset about. (Pharmacy Owner) In addition, some participants felt that available guidelines failed to acknowledge the potential contribution of pharmacists. This inability to access information represented a major stumbling block to community pharmacists as they felt that without this information they would be unable to provide effective care to their patients.    58 No Established Model for Patient-centred Services All focus group discussions identified a perceived lack of time outside of current dispensing responsibilities. Specifically, there was concern that typical pharmacy practice is not flexible enough to simply incorporate patient-centred services: The way that it’s put, by corporate [to] the community though, is that you have to fit it into your already hugely busy day. And…that really intimidates a lot of pharmacists when you get to work, and from the second you walk into the dispensary, you’re running as fast as you can, [talking] as fast as you can, [and filling] prescriptions [as fast as you can]… (Staff Pharmacist) In support of this observation, pharmacy owners and regional managers wished to review a business model for patient-centred services prior to committing their support for proposed changes: At the end of the day, the challenge [is] that you have to show profit or else you can’t pay your bills and move forward…Right now the model is still being formulated…[and the proposed] reimbursement for professional services isn’t enough to justify spending labour towards this activity because it doesn’t pay… (Regional Manager) Moreover, the current dispensing model, the pharmacy layout, and the lack of documentation systems were identified by participants in all levels of community practice as impediments to the provision of patient-centred services. As one regional manager pointed out, “pharmacies are really set up for the traditional medication dispensing model.”    59 3.4.2. The Need for Education Many of the participants seemed hesitant when discussing their level of knowledge and their ability to provide patient-centred services with statements like: “We would probably need extensive education, or extensive catching up with the recent studies, the recent guidelines, and then a way to keep [up] with any new things so…we’re always on the cutting edge …” (Staff Pharmacist). Some staff pharmacists and managers also felt that training in topics such as literature evaluation and patient education were required for practice change to be successful. When discussing disease-specific training, the existence of a standardized program for patient-centred services was of key importance to many of the participants: If we’re kind of going forward as a profession, there needs to be some regularized training set up, so that people can be going forward with the same skill sets. Then you need to do the hands-on stuff, too, where you do a locum or residency in the hospital or some specialized setting where you can learn and actually deal with [the disease-state] before going out. (Manager) Participants were not only interested in gaining knowledge about various disease states, but were interested in being provided with the opportunity to apply this knowledge in a monitored environment. They speculated that a mentoring period would increase pharmacists’ confidence before they had to independently provide patient interventions in the community. Participants also felt that standardized training would address concern over accountability for patient outcomes: You know, you can’t charge $150 and the outcome is so minimal, it’s not going to make a difference to anything. But if you’re [going to] be saving re-admissions to   60 the hospital, I think that’s huge, and then I think you should be compensated accordingly. (Staff Pharmacist) However, many participants did not support the idea of receiving a bonus payment for patients that achieved these clinical targets.  3.4.3. Remuneration Models As one of the greatest impediments to practice change, participants identified the need for remuneration that is separate from dispensing to legitimize new practice initiatives. This would serve to ensure that their contribution to patient care was recognized by patients, physicians, and employers, because as one staff pharmacist put it, “on a corporate level, it does come down to dollars and cents.” No clear conclusion from the focus groups could be drawn regarding the type of remuneration best suited to community practice but when asked, most staff pharmacists preferred a fee-for-service model to ensure they were paid for all aspects of care. Comparatively, some managers and owners also pointed to a capitation as having the potential to encourage the efficient and effective care of patients. With respect to specific dollar values, regional managers, store managers and owners were the only groups to provide explicit recommendations for remuneration. To this group, it was important that remuneration take the form of a direct billing process and provide an adequate fee; “If you’re not paying them at least $150 dollars an hour, it’s not going to be worth [pharmacists] time, they’re [going to] start cutting corners…” (Owner). The amount provided by management exceeded that of staff pharmacist   61 participants who suggested, when specifically asked to provide a value, they should be paid enough to cover their current salaries (approximately $40-50/hour).  3.4.4. Planning for Implementation When discussing the implementation of a program for patient-centred pharmacy services, participants discussed the need for a clear plan that considers the typical pharmacy’s organizational structure and the need for advocacy and support. To implement services in a typical community pharmacy, participants thought the store layout, computer systems and documentation software would all need to be updated. Participants identified a need for private consultation spaces because, as one regional manager explained, “pharmacies are really set up for the traditional medication dispensing model. They’re not really well set up for those sit down conversations with patients, over longer periods of time.” The ideal private space was considered to be physically distant from the dispensary to assist the pharmacist in establishing their new role as separate from dispensing. This separation was important because, as mentioned previously, a lack of patient awareness was cited as a barrier to practice advancement. Some participants went so far as to suggest setting up private practices similar to those of physicians so that they could gain their “independence from corporate structures” (Staff Pharmacist). Considering that the new services would involve the recreation of pharmacists’ public image, a physical distance between the different pharmacy services would serve to ensure that patients viewed pharmacists as healthcare professionals capable of providing a valued healthcare service. Having access to documentation systems was also of key importance because “we have to make sure whatever we say is   62 documented, otherwise we never saw the patient, or didn’t do anything…” (Staff Pharmacist). Comments like this one stemmed from pharmacists’ contention that in some instances they were already providing additional services to patients but without documentation, their contributions were not recognized.  Obtaining support for the advancement of pharmacy practice was another concern for participants: “I think the most important thing…in the beginning is having a pharmacist that’s [going to] do patient-centred services, a patient that’s interested, and a doctor [to support the program]” (Staff Pharmacist). Regional managers in particular were concerned with the perceived lack of patient support. One regional manager commented that “I don’t think the public can even fathom that there is another service that the pharmacist can provide” and went on to describe his struggle to grow his business. In his experience, patients and physicians have needed constant reminders about the services his pharmacy provides and the value they add to patient care.  While also mentioning patient support as being of importance, staff pharmacist participants were particularly concerned with the impact that service provision would have on their coworkers. Unlike regional managers, they emphasized the importance of staff “buy-in” to any program. More specifically, they were apprehensive about who would be performing their current duties if they were providing patient-centred services to patients, recognizing that, “…someone else is going to have to pick that [extra work] up…” (Staff Pharmacist). Consequently, each of the different players in pharmacy practice had different opinions about where support was needed to implement patient- centred services.   63 All participants expressed interest in implementing patient-centred services into their practices, however, the focus groups also brought to light some gaps in communication between staff pharmacists and management. One staff pharmacist stated: The way that [patient-centred service is] put, by corporate, to the community pharmacy is that you have to fit it into your already hugely busy day. And…that really intimidates a lot of pharmacists when presently you get to work, and from the second you walk into the dispensary, you’re running as fast as you can, [talking] as fast as you can, [and filling] prescriptions [as fast as you can]… (Staff Pharmacist) This concern over employers’ expectations served to complicate matters. Although participants felt that support from patients and physicians was of great importance, to many this support was unobtainable or unrealistic without realistic support from employers.  3.5. Discussion Using focus groups, we asked pharmacists for their thoughts and opinions on disease- specific patient-centred pharmacy services such as CDM. Participants included staff pharmacists from the community, hospital, and primary care settings, dispensary managers and owners, and regional pharmacy managers. When asked to describe the enablers and challenges to providing these services, participants focused on the current practice environment, the need for education, remuneration and implementation. When discussing their thoughts and opinions on how best to develop and implement a new services, participants focused on issues such as the current physical layout of community   64 pharmacies and the need for private counseling spaces, the lack of documentation and information systems, and the need for support from patients, physicians, pharmacists and coworkers. Participants also sought a sustainable remuneration model to fund pharmacists and their businesses and for improved educational opportunities. Overall, pharmacists’ perceptions differed between stakeholder groups, especially when discussing their relationships with others. While this has been reported elsewhere,18,19 the degree to which participants were concerned about their relationships with physicians and employers varied. For example, staff pharmacists practicing in the community setting felt that physician and employer expectations hampered their ability to provide patient-centred services. Unbeknownst to most staff pharmacists, regional managers generally favoured a move towards providing patient-centred services, provided there was sufficient support in place for business needs and appropriate “demand” from patients. In addition, pharmacists practicing outside the community setting felt that relationships with their own managers and physician colleagues encouraged the delivery of patient-centred services. There have been a small number of qualitative studies conducted with pharmacists in an effort to better understand their perspective on the advancement of pharmacy practice.3,18,20 Generally these studies have used semi-structured interviews to collect data. Only one of these studies was conducted with pharmacists in a similar situation to those in Alberta and BC18 as the remaining studies were conducted in Australia where patient-centred services were already available to some extent. Though the context makes the results qualitatively different, the pharmacist thoughts and opinions were similar to   65 those of our focus groups, including concerns about remuneration, time and physical space concerns. Although participants’ own beliefs about physician perceptions of the role of pharmacists were also consistent with the literature,21-23 the same cannot be said about pharmacists beliefs about patient perceptions. Many participants focused on ‘public’ or ‘patient’ demand for patient-centred services, rather than the need for these services. By doing so, participants may have been demonstrating the pharmacists’ natural tendency to provide product-centric services (i.e., counseling, product education and medication adherence) as they continued to identify with their traditional roles rather than their roles as healthcare professionals.24 Furthermore, participants may have also been showing a lack of confidence in their own role as healthcare professionals. While there may be a gradual shift in the profession towards achieving meaningful relationships with patients that improve the safety and effectiveness of medication therapy, a failure to account for the complexities of this relationship may result in frustration for pharmacists and confusion for patients.25  Overall, focus group participants identified a sense of responsibility for patient care and a need for disease-specific education programs and sustainable remuneration systems. Despite this, many pharmacists in Alberta and BC have yet to translate this desire into sustainable practice change. This is best evidenced by the complaint by many pharmacists that they had poor access to disease-specific information whereas those currently providing patient-centred services were familiar with the guidelines for common chronic diseases (e.g., asthma, diabetes), including open-access clinical practice guidelines in BC (www.health.gov.bc.ca/gpac/index.html). To successfully incorporate   66 patient-centred services into pharmacy practice, pharmacists will need to be motivated to provide these services and will also need to be supported through modifications to the systems they operate under and the physical layout of the pharmacy. In addition, a cornerstone of this model will need to be the realistic remuneration of the services they provide, something that is often inadequate.  3.5.1. Methodological Concerns & Limitations In considering the results of this study, it is important to understand some of the limitations. Similar to other researchers in BC, due to ethical and privacy restrictions around recruitment,26 we were only able to employ a convenience sampling strategy leading to a probable selection bias.  Rather than recruiting a representative sample of all pharmacists in Alberta and BC, we likely identified pharmacists with a particular interest in providing patient-centred services. In terms of generalizability, many of the challenges discussed herein are likely to be even greater for other pharmacists. While this was not ideal, there are circumstances where this can be appropriate.27 As with our study question, a convenience sampling strategy can be useful when a topic has not been well studied in the past and where specific questions and areas of inquiry are not well established. Further, in cases where the resources available to the researcher limit the amount of data that can be collected, this sampling technique can be used. Due to the physical distance between participants in the telephone focus groups, these participants may have had difficulty finding a “common communicative ground” using methods like non-verbal communication.13 That said, this medium did offer a level of anonymity that may have allowed participants to speak more freely than they otherwise   67 might have. Also, in both BC and Alberta, we had tremendous difficulty recruiting participants. When contacted directly, staff pharmacists often stated that they did not have time to participate or that they were not interested in participating in this type of research. This has been experienced by other pharmacy practice researchers and possible explanations have included the following barriers to participation: a mindset that is not amenable to research, a lack of communication between researchers and pharmacists, constraints of pharmacists’ current practice (time, staff, and money), pharmacists’ concern over their skills/knowledge, and a lack of incentive.28,29 In an effort to increase participation and allow this focus group to take place, several hospital pharmacists with a background in community practice were allowed to contribute. However this meant that for several questions, this group was forced to speculate on the perspectives of community pharmacists. Consequently, the inclusion of their comments has been carefully scrutinized to ensure that we do not unduly weight their status as hospital pharmacists. Despite these methodological concerns there was a great deal of consistency in the topics raised in each of the groups. For example, almost all groups discussed the time constraints under which they worked. Furthermore, any differences that arose in thoughts or perceptions were clearly attributable to the particular stakeholders that were targeted for participation. For instance, many of the regional managers talked about patient care initiatives that their companies already had in place as positive examples of their commitment to provide patient-centred services. However, when staff pharmacists were discussing these same programs they often lamented them as increasing an already heavy workload.   68  3.5.2. Recommendations for Implementation The advancement of pharmacy practice, the creation of a sustainable program for new services and the integration of a new remuneration model are complex topics in need of a multifaceted approach to implementation. This is exemplified in the advocacy and support theme as staff pharmacists focused their attention on gaining employer and colleague support, while regional manager participants directed their attention toward securing patient interest. This and other examples from the discussions do not necessarily suggest that each group did not recognize the concerns raised by the other, but that their primary focuses were different. Keeping this diversity in mind, we have summarized participants’ overriding recommendations. To implement patient-centred pharmacy services, healthcare decision-makers and pharmacy leaders should do the following:  1. Develop a comprehensive practice and business model for the delivery of patient- centred pharmacy services; 2. Ensure that remuneration is financially attractive enough to encourage uptake and adequate to cover all costs including staffing and the creation of “protected” time for pharmacists to dedicate solely to patient-centred services; 3. Establish and communicate managerial support to pharmacists by addressing issues such as lack of physical space in the pharmacy; 4. Allow pharmacists access to information systems including patient records and service-specific documentation systems;   69 5. Develop and disseminate pharmacy-specific clinical guidelines for patient- centred services; 6. Increase training opportunities for pharmacists in the retrieval and evaluation of clinical information; 7. Market pharmacists’ patient-centred services to key stakeholders, including patients, physicians, employers and pharmacists; and, 8. Create a culture of responsible patient-centred care.   3.6. Conclusion For one pharmacist, a perceived barrier to providing patient-centred services may be an enabler for another. As a result, one of the biggest barriers to practice change may be pharmacists' concerns and their perceptions of those around them, including patients, physicians and employers. Although all stakeholders will need to address this, it is pivotal that individual pharmacists understand their role in patient-centred care and strive to overcome the challenges to providing these services. Stated another way, it may well be that the greatest barrier to practice change towards patient-centred services is pharmacists themselves.   70  Table 3.1: Focus group participants’ province of practice and current employment  Stakeholder Group No. of Focus Groups Alberta BC Total Staff Pharmacists* 3 8 6 14 Dispensary Managers/Owners 3 6 8 14 Regional Managers 2 4 4 8 Total 8 18 18 36 *Includes staff in community dispensaries, hospital and primary care   71 Table 3.2:  Themes identified from pharmacist focus groups on disease-specific patient-centred pharmacy services  Theme Description Current practice environment Encompasses the challenges and enablers to providing patient-centred services including outside perceptions of the pharmacist as healthcare professional, access to information and the need for a model of practice.  Need for Education Outlines the kinds of additional training pharmacists identified as being needed if patient-centred services are to be provided.  Remuneration Discusses the advantages and disadvantages of several potential payment models posed to focus group participants.  Implementation Discusses the need for an implementation plan that considers the organization of current pharmacy services and includes advocacy and support from both within and outside the profession.    72 3.7. References  1 Romanow R. Building on values: the future of health care in Canada. Saskatoon, SK: Commission on the Future of Health Care in Canada, 2002:356 pages. 2 Chan P, Grindrod KA, Bougher D, et al. A systematic review of remuneration systems for clinical pharmacy care services. Canadian Pharmacists Journal 2008;141:102-12. 3 Roberts A, Benrimoj S, Chen T, Wlliams K, Hopp T, Aslani P. Understanding practice change in community pharmacy: a qualitative study in Australia. Res Social Adm Pharm 2005;1:546-64. 4 Kroger E, Moisan J, Gregoire J-P. Understanding Quebec pharmacists' behavior. Ann Pharmacother 2000;34:309-16. 5 Elston M. The politics of professional power: medicine in a changing health service In: Gabe J, Calnan M, eds. The sociology of the health service. London and New York: Routledge, 1991. 6 Glicken MD. Social Research: a simple guide. Boston, MA: Allyn and Bacon, 2003. 7 Trochim WMK. The research methods knowledge base. 2nd ed. Cincinnati, OH: Atomic Dog Publishers, 2001. 8 Beyea SC, Nicoll LH. Learn more using focus groups. AORN J 2000;71:897-900. 9 Brannen J, Pattman R. Work-family matters in the workplace: the use of focus groups in a study of a UK social services department. Qualitative Research 2005;5:523-42. 10 Cote-Arsenault D, Morrison-Beedy D. Practical advice for planning and conducting focus groups. Nurs Res 1999;48:280-3.    73  11 Kreuger RA, Casey MA. Focus groups: a practical guide for applied research. 3rd ed. Thousand Oaks, CA: Sage Publications, 2000. 12 Puchta C, Potter J. Focus group practice. London, UK: Sage Publications, 2004. 13 Hyden L-C, Bulow PH Who’s talking: drawing conclusions from focus groups – some methodological considerations. Int J Soc Res Meth 2003;6:305-21. 14 Hollander JA. The social contexts of focus groups. J Contemp Ethnogr 2004;33:602- 37. 15 Sim J. Collecting and analyzing qualitative data: issues raised by focus groups. J Adv Nurs 1998;28:345-52. 16 Lehoux P, Poland B, Daudelin G. Focus group research and "the patient's view". Soc Sci Med 2006;63:2091-104. 17 Scwandt T. Dictionary of qualitative inquiry. 2nd ed. Thousand Oaks, CA: Sage Publications, 2001. 18 Bell HM MJ, Hughes CM, Woods A. A qualitative investigation of the attitudes and opinions of community pharmacists to pharmaceutical care. J Soc Admin Pharm 1998;15:284-95. 19 Mottram DR, Jogia P, West P. The community pharmacists' attitudes toward the extended role. J Soc Adm Pharm 1995;12:12-7. 20 Bandana S, Krass I, Armour C. Specialization in asthma: current practice and future roles – a qualitative study of practicing community pharmacists. J Soc Adm Pharm 2001;18:169-77.    74  21 Hughes C, McCann S. Perceived interprofessional barriers between community pharmacists and general practitioners: a qualitative assessment. Br J Gen Pract 2003;53:600-6. 22 Edmunds J, Calnan M. The reprofessionalisation of community pharmacy? An exploration of attitudes to extended roles for community pharmacists amongst pharmacists and general practitioners in the United Kingdom. Soc Sci Med 2001;53:943- 55. 23 Adamcik B, Ransford H, Oppenheimer P, Brown J, Eagan P, Weissman F. New clinical roles for pharmacists: a study of role expansion. Soc Sci Med 1986;23:1184-1200. 24 de Oliveira DR, Shoemaker SJ. Achieving patient centredness in pharmacy practice: openness and the pharmacist's natural attitude. J Am Pharm Assoc 2006;46:56-64. 25 Austin Z, Gregory P, Martin J. Characterizing the professional relationship of community pharmacists. Res Soc Adm Pharm 2006;2:533-46. 26 Harris MA, Levy AR, Teschke K. Personal privacy and public health: Impacts of privacy legislation on health research in Canada. Can J Public Health 2008;99:293-6. 27 Riffe D, Lacy S, Fico FG. Analyzing media messages: using quantitative content analysis in research. Mahwah, NJ: Lawrence Erlbaum Associates, 2005. 28 Armour C, Brillant M, Krass I. Pharmacists’ views on involvement in pharmacy practice research: strategies for facilitating participation. Pharmacy Practice 2007;5:59- 66.    75  29 Weinberger M, Murray MD, Marrero DG, et al. Issues in conducting randomized controlled trials of health services research interventions in nonacademic practice settings: the case of retail pharmacies. Health Serv Res 2002;37:1067-77   76 4. PHARMACISTS’ ROLES AND PATIENT-CENTRED PHARMACY SERVICES IN BRITISH COLUMBIA AND ALBERTAi  4.1. Introduction Our healthcare system is in need of additional primary healthcare professionals and pharmacists are in need of a new practice model. One solution is to focus on the long- term management of patients in ambulatory settings by non-physician healthcare providers.1 If pharmacists are going to fill this role, as suggested in a number of commissioned reports on the status of healthcare in Canada,2,3 we must better understand community pharmacists’ current roles and their desire to provide and obtain remuneration for patient-centred pharmacy services. The health services research literature describes a variety of patient-centred pharmacy services for disease screening, 4,5 medication therapy management (MTM)6 and chronic disease management (CDM).7-10 In a systematic review of remuneration programs, we found 28 programs that implemented these services, most of which were fee-for-service models paid by government and many of which suffered from poor uptake by pharmacists, patients and physicians.11 In a series of focus groups we also found that pharmacists who had limited experience with patient-centred services struggled to implement these services in their own practices. Challenges cited included workload constraints, poor relationships with non-pharmacist stakeholders, limited access to patient information and the medical literature and a need for improved interpretation skills of available information. In contrast, pharmacists who routinely offered these services (i.e.,  i A version of this chapter will be submitted for publication. Grindrod KA, Marra CA, Tsuyuki RT, Lynd LD. Pharmacist’s roles and patient-centred pharmacy services in British Columbia and Alberta.   77 those employed in the primary care or hospital setting) were enabled by the same factors.12 To build on these findings and to gather more information on the feasibility of implementing patient-centred services in the community pharmacy setting in Canada, we surveyed pharmacists to explore their current roles and experiences with providing services such as screening, MTM and CDM. Conducted in tandem with a discrete choice experiment (DCE), which is described in Chapter 5, the primary objective of this study was to determine pharmacists’ preferences for providing patient-centred services.  4.2.  Methods 4.2.1. Participants Pharmacists were eligible to participate if they were licensed to practice pharmacy in Alberta or BC or were enrolled in the final year of a pharmacy undergraduate program in either province. Due to the low response rate that plagues many pharmacy practice- based research surveys,13-15 we attempted to reach pharmacists using multiple strategies. A convenience sample was recruited through several pharmacy-related organizations, including professional associations, medication wholesalers, chain-store companies and hospital pharmacy departments. Interested pharmacists were directed to our website to complete the questionnaire and participants were given the opportunity to enter a prize draw in BC or receive a $20 honorarium in Alberta.    78 4.2.2. Questionnaire Design The online questionnaire explored four main areas as they related to patient- centred pharmacy services, including demographics, job satisfaction, experience with providing services, and opinions on remuneration. Pharmacists completed all four sections of the questionnaire whereas pharmacy students completed an abbreviated version that considered their most recent job (during the summer or school year) and did not include the job satisfaction component. Demographic questions gathered information on personal characteristics, training and employment. Most job satisfaction questions used a 5-point Likert scale to rate satisfaction in areas such as pharmacists’ relationships with others in their practices, providing typical and patient-centred pharmacy services, and their current pharmacy environment. Based on our experiences in the focus groups, we anticipated that many pharmacists would have limited experience with patient-centred services and remuneration, so questions on these two areas were designed to both define available options and gather information. Typical pharmacy services were described to respondents as those where 75% of the time is spent filling prescriptions (including medication counseling and blister packing), 20% of the time is spent providing over-the-counter medication consultations and 5% of time is spent in activities such as administration and patient-centred care.16 In comparison, patient-centred services were described as services that are unrelated to dispensing and include screening, MTM and CDM. In the questionnaire, we used the following examples of patient-centred services: screening for the presence of a chronic disease (e.g., blood pressure measurements to screen for hypertension, heel ultrasound screening for osteoporosis, screening questionnaire for osteoarthritis); providing MTM by   79 doing a comprehensive medication review to look for medication-related problems (e.g., medication interactions, appropriateness of therapy); and managing the ongoing care of a patient with a chronic disease (e.g., diabetes) which may include screening, MTM, patient education, disease monitoring and communication with the healthcare team. Finally, the professional service fee was defined as the fee charged for providing the pharmacy service. We also clarified that the professional service fee does not usually go directly to the pharmacist providing the service, but to the pharmacy or business and is similar to a dispensing fee or physician fee-for-service.  4.2.3. Statistical Analysis Descriptive statistics were used to evaluate the characteristics of the study sample (e.g., age, practice setting). All continuous variables were reported as means and standard deviations (SD), while categorical variables were presented as the proportion of the sample within each group. For questions related to patient-centred pharmacy services, the results were compared between students, dispensary staff (pharmacists and dispensary managers), regional managers/owners and clinical pharmacists with the statistical significance set at 5%. Categorical variables were compared using chi-squared tests and continuous variables were compared using one-way analysis of variance.  4.3. Results 4.3.1. Sample Characteristics Of 634 participants who responded and started the online questionnaire, 539 (85%) completed the entire questionnaire including the DCE. The demographic   80 characteristics of pharmacist and student respondents are summarized in Tables 4.1 and 4.2, respectively. Overall, there was representation from both rural (population below 1 000 individuals) and urban communities. There was also representation from all health regions in BC and Alberta, with more participants residing in health regions that included large metropolitan centres (population over 1 000 000 individuals). Slightly more than a third of pharmacist respondents graduated in the past ten years and just over two-thirds graduated in the past twenty years. In terms of their current job, 452 (88%) pharmacists had a gross annual income of over $50,000 (CAD). In addition, just over three-quarters worked at least five days per week and 59% were employed as staff or management in a community-based dispensary. Only 12% had completed clinical training in the form of a post-graduate PharmD or a clinical residency and 14% had completed disease-specific clinical training through an accredited certificate program (e.g., Certified Diabetes Educator). Although 14% were pharmacy owners or regional managers and 25% were employed in a clinical setting, 55% thought that they would prefer one of these roles. Of the 87 fourth-year student respondents, 86% had most of their pharmacy experience in community pharmacy dispensaries and many worked at least one day per week in this setting over the school year (54%) or during the most recent summer months (68%). Following graduation, almost three-quarters (74%) planned to work in a community pharmacy dispensary, most commonly in a large chain and 25% planned to work in hospital, with or without a hospital residency. No student respondents planned to pursue a community pharmacy residency, to work in a primary care clinic, to work for the pharmaceutical industry or to leave the profession altogether.    81  4.3.2. Job Satisfaction Pharmacists were asked to reflect on their current job satisfaction (see Table 4.3). Although 79% claimed to be satisfied with their current job, 16% were considering a change in their job and 12% were considering a change in their career. In addition, 45% of dispensary staff and 38% of regional managers and owners thought that they would be satisfied if they were only able to provide typical pharmacy services, but only 10% of clinical pharmacists thought they would be satisfied in this situation (p<0.001). In contrast, almost three-quarters (74%) of pharmacists felt that providing patient-centred services would increase their job satisfaction and this was not significantly different between groups. In terms of time, only 52% of pharmacists were satisfied with the number of scheduled work breaks they received during the day and 40% felt they had sufficient time to care for their patients. While over three-quarters of pharmacist respondents felt they had adequate access to health information on the Internet and 61% had sufficient access to patient information, only half felt they had adequate documentation systems in their workplace. Finally, most respondents were satisfied with their relationships with others, including physicians, patients, employers and coworkers.  4.3.3.  Patient-Centred Pharmacy Services To examine the current delivery of patient-centred services by pharmacists, we asked pharmacists to consider their main job over the past year and students to consider their current or most recent job (see Table 4.4). Overall, 64% of students and 72% of staff   82 pharmacists spent most of their time dispensing. In contrast, 46% of pharmacists employed in a clinical setting spent most of their time providing clinical services. While over three-quarters of respondents (76%) offered non-dispensing services in their practice, 47% of all pharmacists and 59% of students spent less than 10% of their time providing services ‘not directly related to dispensing’. In addition, 44% of all respondents were interested in administering vaccinations to patients. Though few pharmacists and students appeared to be offering screening, MTM or CDM services regardless of their practice setting, we asked all respondents to consider the logistics of providing such services. When asked how they would like to provide these patient-centred services, most said they preferred scheduled appointments to the traditional walk-in interactions of most community pharmacy dispensaries (78% for screening, 95% for MTM, 92% for CDM). They also felt that screening services, such as osteoporosis heel scanning or cholesterol monitoring would take an average of 20 (SD 12) minutes per patient, MTM would take an average of 37 (SD 21) minutes per patient and CDM would take 37 (SD 38) minutes per patient (no significant differences between groups).  4.3.4. Remuneration for Patient-Centred Pharmacy Services All respondents were asked for their thoughts on the remuneration of patient- centred services (see Table 4.5). To clarify that a professional service fee is generally paid to a business rather than directly into the pocket of the provider, we asked participants to consider what a professional service fee should cover. Most felt that fees should be adequate to cover pharmacist and support staff salaries as well as professional   83 expenses such as malpractice insurance. Fewer respondents thought business expenses such as overhead, advertising, profits and inventory should be included. Most respondents thought pharmacist salaries should increase for providing patient-centred services. After considering the components of a fee, two-thirds felt that an adequate fee would equate to $100-150 per hour of service provided. The most popular types of payment models were the basic fee-for-service model where payment is given each time a service is provided to a patient (e.g., $50 per medication review), and the resource-based relative value scale (RBRVS) model where the fee-for-service is based on the resources required to provide the service17 (e.g., if Service A requires twice as much time and a higher level of expertise than Service B, Service A is paid at a rate of $100 and Service B is paid at a rate of $50). The capitation model was less popular (a set fee covers all services for a patient over a certain period of time, e.g., $400/patient/year) as were the outcomes-based models that proposed to pay pharmacists an additional fee for reaching chronic disease targets (e.g., an additional $10 is provided when a patient achieves a target cholesterol level). When asked which parties should pay the fee, 91% thought the government should pay, 95% thought third party insurance plans should pay and only 55% thought that patients should also be asked to pay.  4.4. Discussion In our survey of pharmacists’ thoughts on providing patient-centred services, many pharmacists claimed to be satisfied with their current roles. Despite this, most respondents spent at least three-quarters of their time dispensing, an activity that brought   84 satisfaction to just over a third of respondents. At the same time, while most pharmacists thought that offering patient-centred services such as screening, MTM and CDM would improve their level of job satisfaction, few actually offered these services on a regular basis. From a monetary perspective, most respondents felt they needed to be paid more to provide patient-centred services, and thought that professional service fees should be adequate to cover their salaries and those of their supporting staff. As would be expected, a higher number of regional managers and owners thought professional service fees should be adequate to cover the additional costs of integrating this service into to their business including overhead and advertising costs. These results suggest that the majority of pharmacists in BC and Alberta are spending most of their time in a non-professional capacity on activities that do not bring them job satisfaction. Unlike professional services, which require individual judgment and expertise, typical pharmacy services are simple, repetitive and as a result, non- professional.18 Because most community pharmacy jobs are centred around these non- professional services, the professional values of the community pharmacist and the organizational values of the community pharmacy are often in conflict, forcing pharmacists to either adapt to the expectations of community employers or work outside the community setting.18 This was particularly apparent in the 65 pharmacist respondents who did not agree that they would be satisfied with providing typical pharmacy services, but who spent at least three-quarters of their time dispensing and the 49 pharmacist who also did not agree that these services would bring them satisfaction but who choose to work jobs where the same amount of time was spent on non-dispensing activities.   85 One of the challenges facing the professionalization of pharmacy and the implementation of patient-centred services is the question of what constitutes a ‘patient- centred’ vs. ‘product-centred’ service. In a recent survey of Alberta pharmacists’ experiences with diabetes management, over 90% of respondents reported that they regularly provided medication counseling and approximately 80% assessed adherence and provided education on over-the-counter medications.19 In contrast to these services, which are routinely offered during medication dispensing, patient-centred services such as CDM (e.g., blood pressure monitoring and management) and MTM (e.g., assessment of medication-related nephrotoxicity) were offered by far fewer respondents. Similarly, in the U.S., pharmacists were surveyed after the 2006 implementation of the Medicaid- funded MTM program.20 When asked about how the legislation changed their practices, pharmacists practicing in physicians’ offices reported that they provided more CDM services while community pharmacists tended to provide screening services and immunizations. These findings, which are consistent with our results that very few pharmacists offered screening, MTM or CDM regardless of where they practiced, suggest that pharmacists are very slow to adopt services that have no association with typical pharmacy services.  4.4.1. Methodological Concerns & Limitations There are some limitations to consider when looking at the results of this study. Due to ethical and privacy restrictions around participant recruitment in BC, we were unable to contact potential participants directly to obtain a purposive sample of pharmacists. Instead, we relied on several third parties to distribute our recruitment material in order to   86 gather a convenience sample of pharmacists and students. While pharmacist respondent demographics were similar to the general demographics of pharmacists across Canada,21 there was a slight over-representation of pharmacists working outside the community pharmacy setting (hospital, primary care and long-term care). For this reason, the results described herein may be biased towards pharmacists who are more motivated to provide patient-centred services. However, this is likely not the case given that so few respondents were actually providing services. Regardless, if respondents are in fact more motivated, then they will probably be early adopters of patient-centred services and their input is valuable in determining pharmacists’ thoughts on the remuneration of these services. Another challenge in designing a survey of this nature is that, in our experience, few pharmacists understand the meaning of ‘patient-centred service’ and even fewer understand how professional service fees are used to run a business. To address this, we spent considerable time during survey design and during the pilot phase to add questions that had pharmacists reflect on the meaning of product-centred vs. patient-centred services, consider the purpose of professional service fees and distinguish between personal income and fee. Compared to the findings in our focus groups, it appeared that most pharmacists had a better appreciation of these issues in the survey.12  4.5.  Conclusion As the profession of pharmacy moves ahead with introducing patient-centred services such as screening, MTM and CDM, pharmacists’ understanding of these services must be addressed. For many pharmacists and students alike, there is a disconnect between how   87 they see their current role and the role that they think will bring them satisfaction. Furthermore, it is concerning that twenty years after the introduction of patient-centred concepts such as pharmaceutical care, both pharmacists and students have little experience providing these services, especially patient-centred services such as MTM. Consequently, any efforts to improve the delivery of patient-centred pharmacy services will need to include significant education and advocacy directed at practicing community pharmacists.   88 Table 4.1: Demographics and job descriptions of pharmacist respondents (N=452)   N (%) Pharmacist Characteristics Province British Columbia 180 (40) Alberta 272 (60) Years practiced <10 years  173 (38) 10-19 years 142 (31) >20 years 137 (30) Annual Salary (Gross) <$50,000  26 (6) $50,000-$100,000  271 (60) >$100,000 127 (28) N/A 28 (6) Two-income household 274 (61) Education Undergraduate/Entry Level PharmD 344 (76) Graduate Level PharmD 11 (2) Residency  43 (10) Graduate Degree  18 (4) Other  36 (8) CDM Certifications Certified Diabetes Educator 14 (3) Certified Asthma Educator 14 (3) Certified Geriatric Pharmacist 3 (1) Other 30 (7) Job Descriptions Current Position Dispensary Staff 265 (59) Regional Managers/Owners 65 (14) Clinical* 112 (25) Other  10 (2) Ideal Position Dispensary Staff 170 (38) Regional Managers/Owners 115 (25) Clinical* 135 (30) Other  32 (7)   89   N (%) Job Descriptions cont… Current Job Setting Private Store  66 (15) Medium Chain 59 (13) Large Chain  170 (38) Regional Management in Chain 15 (3) Clinical* 112 (25) Other  30 (7) Size of community where practice located <100,000 191 (42) 100,000-999,999 128 (28) >1,000,000 133 (30) Work as a pharmacist >5d per week 345 (76) N/A, not applicable/not available, PharmD, Doctor of Pharmacy Degree *Clinical: hospital, primary care or long term care     90 Table 4.2: Demographics and job descriptions of student respondents (N=87)   N (%) Student Characteristics Province British Columbia 85 (98) Alberta 2 (2) Planned Household Income After Graduation One-income 30 (34) Two-income 17 (20) Live with family, no contribution 9 (10) Live with family, contribute 30 (34) Job Descriptions Planned Future Employment Dispensary 64 (74) Clinical* 3 (3) Residency 19 (22) Other 1 (1) Majority of Pharmacy Experience Dispensary 75 (86) Clinical* 10 (11) Other 2 (2) Days Worked in a Dispensary/wk (School Year) <1 day 40 (46) 1-2 days 42 48) >3 days 5 (6) Days Worked in Dispensary/wk (Summer) <1 day 27 (31) 1-2 days 10 (11) >3 days 50 (57) *Clinical: hospital, primary care or long-term care     91 Table 4.3: Pharmacists' satisfaction with job, providing pharmacy services, pharmacy organization and relationships with others (N=452)   N (%) N (%) N (%) Current Job Disagree Neutral Agree Currently satisfied with job 47 (10) 46 (10) 359 (79) Find job rewarding 33 (7) 58 (13) 361 (80) Do not enjoy being a pharmacist 369 (82) 56 (12) 27 (6) Considering leaving job 300 (66) 81 (18) 71 (16) Considering a career change 331 (73) 68 (15) 53 (12) Providing disease management services will increase job satisfaction 37 (8) 81 (18) 334 (74) Providing Pharmacy Services Dissatisfied Neutral Satisfied Only able to provide typical pharmacy services 190 (42) 104 (23) 158 (35) Able to provide screening services 11 (2) 87 (19) 354 (78) Able to provide MTM services 5 (1) 44 (10) 403 (89) Able to provide CDM services 15 (3) 61 (14) 376 (83) Pharmacy Organization Dissatisfied Neutral Satisfied Work Schedule 73 (16) 54 (12) 325 (72) Scheduled Breaks 129 (29) 86 (19) 237 (52) Enough time to provide appropriate care to patients 144 (32) 127 (28) 181 (40) Access to patient information 105 (23) 71 (16) 276 (61) Internet access 63 (14) 39 (9) 350 (77) Documentation Systems 97 (21) 121 (27) 234 (52)   92   N (%) N (%) N (%) Relationships with Others Dissatisfied Neutral Satisfied Pharmacist Colleagues 16 (4) 46 (10) 390 (86) Employers 45 (10) 79 (17) 328 (73) Technicians 21 (5) 69 (15) 362 (80) Patients 13 (3) 50 (11) 389 (86) Physicians 48 (11) 95 (21) 309 (68) CDM, chronic disease management, MTM, medication therapy management    93 Table 4.4: The provision of pharmacy services by pharmacists and students (N=529)*   Students** N=87 Dispensary Staff N=265 Regional Managers/ Owners N=65 Clinical Staff N=112   N (%) N (%) N (%) N (%) Prescriptions/Week‡ <100 14 (16) 98 (34) 33 (51) 11 (10) 100-299 58 (67) 152 (57) 27 (42) 25 (22) >300 15 (17) 15 (6) 1 (2) 27 (24) N/A 0 (0) 8 (3) 4 (6) 49 (44) Time Spent Dispensing†‡ <10% 5 (6) 1 (0.3) 1 (2) 44 (39) 25% 6 (7) 14 (5) 6 (12) 24 (21) 50% 20 (23) 60 (23) 11 (22) 33 (29) 75% 56 (64) 190 (72) 32 (64) 11 (10) Time Spent Clinical†‡ <10% 50 (57) 165 (62) 24 (48) 10 (9) 25% 22 (25) 76 (29) 19 (38) 9 (8) 50% 11 (13) 19 (7) 6 (12) 41 (37) >75% 2 (2) 5 (2) 1 (2) 52 (46) Patient Services Offered†‡ Screening 2 (2) 6 (2) 0 (0) 0 (0) MTM 4 (5) 51 (19) 5 (10) 1 (1) CDM 11 (13) 30 (11) 3 (6) 2 (2) Drug Information 17 (20) 45 (17) 9 (18) 7 (6) TDM 9 (10) 9 (3) 2 (4) 62 (55) Other 16 (18) 43 (16) 19 (38) 40 (36) None 28 (32) 81 (31) 12 (24) 0 (0) CDM, chronic disease management, MTM, medication therapy management, TDM, therapeutic drug monitoring *Does not include pharmacists currently working in ‘other’ positions (N=10), **Students were asked to comment on their current or most recent job, †Regional managers (N=15) were not asked these questions, ‡ p<0.05    94 Table 4.5: Pharmacist and student opinions on remuneration for patient-centred services (N=529)*   Students** N=87 Dispensary Staff N=265 Regional Managers/ Owners N=65 Clinical Staff N=112  N (%) N (%) N (%) N (%) Professional Services Fees Should Consider: Pharmacist Salaries 80 (92) 241 (91) 61 (94) 99 (88) Other Salaries† 54 (62) 206 (78) 56 (86) 77 (69) Business Overhead† 43 (49) 166 (63) 57 (88) 63 (56) Profits† 39 (45) 150 (57) 48 (74) 35 (31) Store Inventory† 36 (41) 115 (43) 26 (40) 28 (25) Advertising 51 (59) 172 (65) 48 (74) 62 (55) Insurance† 61 (70) 219 (83) 57 (88) 87 (78) Other† 3 (3) 21 (8) 3 (5) 18 (16) Salary Should Increase if Providing Patient-Centred Services† 82 (94) 233 (88) 54 (83) 87 (78) Professional Fee/Service Hour† $50  43 (49) 72 (27) 12 (18) 45 (40) $100  38 (44) 162 (61) 32 (49) 59 (53) $150  6 (7) 31 (12) 21 (32) 8 (7) Mean Ranking of Possible Payment Models (SD) Capitation 3.5 (1.3) 3.6 (1.3) 3.9 (1.3) 3.5 (1.4) Fee-for-service 2.3 (1.2) 2.1 (1.2) 2.3 (1.3) 2.5 (1.3) Outcomes-based capitation 3.7 (1.2) 3.8 (1.1) 3.5 (1.2) 3.5 (1.3) Outcomes-based fee-for-service 3.1 (1.3) 3.0 (1.2) 2.6 (1.2) 3.1 (1.3) RBRVS 2.4 (1.5) 2.5 (1.4) 2.6 (1.4) 2.4 (1.4) RBRVS, resource-based relative value scale, SD, standard deviation, *Does not include pharmacists currently working in ‘other’ positions (N=10), **Students were asked to comment on their current or most recent job, †p<0.05   95 4.6. References  1 Montague T. Patients first: closing the health care gap in Canada. Mississauga (ON): John Wiley and Sons, Canada, 2004. 2 Building on Values: The Future of Health Care in Canada. Ottawa, ON: Commission of the Future of Health Care in Canada (The Romanow Commission), 2002. (Accessed June 12, 2009, at http://publications.gc.ca/pub?id=237274&sl=0.) 3 The Pharmaceutical Task Force. The report of pharmaceutical policy recommendations for the Ministry of Health. Vancouver (BC): Ministry of Health, 2008. 4 Yuksel N, Majumdar SR, Biggs C, Tsuyuki RT. Community pharmacist-initiated screening program for osteoporosis: randomized controlled trial. Osteoporosis Int 2009: (Epub accessed July 2, 2009, at http://www.springerlink.com/content/l211567425l41374/.) 5 Marra CA, Cibere J, Tsuyuki RT et al. Improving osteoarthritis detection in the community: pharmacist identification of new, diagnostically confirmed osteoarthritis. Arthritis Rheum 2007;57:1238-44. 6 Holland R, Desborough J, Goodyear L, Hall S, Wright D, Loke YK. Does pharmacist- led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis. Br J Clin Pharmacol 2008;65:303-16. 7 Roughead L, Semple S, Vitry A. The value of pharmacist professional services in the community setting. The Pharmacy Guild of Australia Website, 2009. (Accessed July 2, 2009, at http://beta.guild.org.au/research/funded_projects.asp.)    96  8 Beney J, Bero LA, Bond C. Expanding the roles of outpatient pharmacists: effects on health services utilization, costs, and patient outcomes. Cochrane Database of Systematic Reviews 2000; Issue 2. Art. No.: CD000336. DOI: 10.1002/14651858.CD000336. 9 Tsuyuki RT, Johnson JA, Koon KT et al. A randomized trial of the effect of community pharmacist intervention on cholesterol risk management: The study of cardiovascular risk intervention by pharmacists (SCRIP). Arch Intern Med 2002;162:1149-55. 10 Hay EM, Foster NE, Thomas E et al. Effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in people aged over 55 presenting to primary care: pragmatic randomised trial. BMJ 2006;333:995. 11 Chan P, Grindrod KA, Bougher D, et al. A systematic review of remuneration systems for clinical pharmacy care services. Canadian Pharmacists Journal 2008;141:102-12. 12 Grindrod KA, Rosenthal M, Lynd LD, et al. Pharmacist perspectives on providing chronic disease management services in the community (Part 1): Current Practice Environment; (Accepted to the Canadian Pharmacist Journal 2009 for the Sept/Oct issue). 13 Hanson AL, Bruskiewitz RH, DeMuth JE. Pharmacists' perceptions of facilitators and barriers to lifelong learning. American Journal of Pharmacy Education 2007;71:1-9. 14 Maio V, Belazi D, Goldfarb NI, Phillips AL, Crawford AG. Use and effectiveness of pharmacy continuing-education materials. Am J Health Syst Pharm 2003;60:1644-9. 15 Scott V, Amonkar M, Madhavan S. Pharmacists’ preferences for continuing education and certificate programs. Ann Pharmacother 2001;35:289-99. 16 ATKearny. Activity based costing study. Full report: study findings and analysis. (2007). Prepared for the BC Pharmacy Association, BC Ministry of Health, and the    97  Canadian Association of Chain Drug Stores. (Accessed June 22, 2009, at http://www.bcpharmacy.ca/press_room/ABCstudy.htm.) 17 Hsiao WC, Braun P, Dunn D, Becker ER. Resource-based relative values. An overview. JAMA 1988;260:2347-53. 18 Latif DA. Ethical cognition and selection-socialization in retail pharmacy. J Bus Ethics 2000;25:343-57. 19 Simpson SH, Haggarty S, Johnson JA, Schindel TJ, Tsuyuki RT, Lewanczuk R. Survey of pharmacist activities and attitudes in diabetes management. Canadian Pharmacists Journal 2009;142:128-34. 20 Beatty SJ, Rodis JL, Bellebaum KL, Mehta BH. Community and ambulatory pharmacy: evaluation of patient care services and billing patterns before implementation of Medicare Part D. J Am Pharm Assoc 2006;46:707-14. 21 Workforce trends for pharmacists for selected provinces and territories in Canada. Ottawa, ON: Canadian Institute for Health Information, 2007. (Accessed June 1, 2009, at http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=download_form_e&cw_sku=WTPS PTIC2007PDF&cw_ctt=1&cw_dform=N.)   98 5. PHARMACISTS’ PREFERENCES FOR PROVIDING NON-DISPENSING SERVICES: A DISCRETE CHOICE EXPERIMENTi  5.1.  Introduction In Canada, we are currently seeing a move towards an expanded scope of practice for pharmacists. While most new initiatives have focused on the expansion of typical pharmacy services (i.e., prescription refills and adaptations), some provinces have gone further and implemented programs for patient-centred pharmacy services such as medication therapy management (MTM) and granted prescribing privileges to highly specialized pharmacists.1 Encouraging these advances, pharmacy practice researchers have also demonstrated that pharmacists, when providing other patient-centred services such as disease screening and chronic disease management (CDM), can improve patient and health system outcomes, especially in conditions such as diabetes,2-4 osteoarthritis,5,6 and cardiovascular disease.7 However, even though pharmacists appear to be open to providing patient-centred services, they do not always choose to do so when given the opportunity.8 In fact, few programs attempting to implement these services in the real-world setting have proven sustainable and this limited success is due, in large part, to poor uptake by pharmacists as many are still concerned about the constraints of their current working environments and the perceptions of those outside the profession.8-11 While this may help to explain why pharmacists make some of the choices they do, very little information is available to guide future program development and implementation. As the profession of pharmacy  i A version of this chapter will be submitted for publication. Grindrod KA, Marra CA, Colley L, Tsuyuki RT, Lynd LD. Pharmacists’ preferences for providing non-dispensing services: a discrete choice   99 moves to adopt a broader role in the healthcare system, we need to better understand pharmacists’ preferences for different patient-centred services such as disease screening, MTM and CDM to ensure that future programs are more successful. Discrete choice experiments (DCEs) are increasingly being used to better understand preferences for health services and they also have the potential to guide decision-making. While many healthcare-related DCEs have focused on consumer preferences,12 many questions remain about providers’ own preferences for these services. Given that healthcare providers are the gatekeepers to any such service, a failure to consider their preferences may mean that new services are rarely offered to the public. This is likely the case with patient-centred pharmacy services given the lack of success already demonstrated by those attempting to implement these services in pharmacies.8 For this reason, we completed a DCE to identify pharmacists’ stated preferences for providing patient-centred services. The primary objective of this study was to quantify pharmacists’ preferences for different aspects of patient-centred services, including the humanistic, environmental and financial characteristics of these services. The secondary objective of this study was to evaluate what factors are associated with pharmacists’ preferences for providing patient-centred services, including pharmacist demographics and their prior experience with providing these services.    experiment.   100 5.2. Methods 5.2.1. Participants To assess pharmacists’ preferences, pharmacists from Alberta and British Columbia (BC) were recruited through several pharmacy-related organizations, including professional associations, medication wholesalers, chain-store companies and hospital pharmacy departments. In addition, pharmacy students in BC were recruited through a pharmacy practice course in the Faculty of Pharmaceutical Sciences (pharmacy students in Alberta were not directly recruited). Eligible participants included pharmacists who were licensed to practice pharmacy in Alberta or BC or students who were enrolled in their final year of a pharmacy undergraduate program in either province. Interested pharmacists and pharmacy students were directed to a secure website to complete the questionnaire and were given the opportunity to enter a prize draw in BC or receive a $20 honorarium in Alberta.  5.2.2. Selection of Attributes & Levels See appendix 3 for a description of DCE methodology. To determine the attributes for the DCE, we reviewed the literature on patient-centred pharmacy services and remuneration programs for these services,8 and undertook a series of focus groups with pharmacy stakeholders.9 In the review, we found that most services have included some aspect of MTM or CDM, with a limited focus on disease screening. We also found that fee-for-service payment models were commonly used to remunerate patient-centred pharmacy services and that these services were offered in both dispensaries and clinical settings. The findings from the focus groups suggested that pharmacists were most   101 concerned with four aspects of patient-centred services: the challenges and enablers to offering services, the need for additional education, remuneration options and the plan for implementation. In particular, staff pharmacists were concerned with having adequate employer support and pharmacy managers and owners were concerned that remuneration be sufficient to cover business costs. With this information, we described patient-centred services using 6 different attributes (see Table 5.1). While the type of service, the setting, the professional service fee and the need for education were all attributes that specifically described the service itself, we also included attributes for other factors that could influence the decision to adopt a service. For the job satisfaction attribute, we described several of the challenges that concerned the focus group participants, including time constraints and relationships with others. We also included an income attribute to emphasize that the professional service fee is separate from the pharmacists’ personal income.  5.2.3. Questionnaire Development To determine pharmacists’ preferences for the different attributes of patient- centred services, we developed an online survey that included 18 DCE choice-sets asking respondents to choose between two hypothetical service alternatives (see Figure 5.1 for an sample choice-set and Appendix 4 for the full survey). In every choice-set, respondents could also choose a ‘typical pharmacy service’ alternative if they preferred the status quo. “Typical pharmacy services” were described to the respondent as the pharmacist spending 75% of the time filling prescriptions (including medication counseling and blister packing), 20% doing OTC consultations, and 5% on other activities such as administration and patient-centred care.13 In addition to the DCE   102 choice-sets, we also included questions on pharmacist demographics, job descriptions, experiences with patient-centred services and opinions on remuneration.  Overall, there were 810 possible choice-set combinations (each alternative was described by six attributes, one with two levels, four with three levels and one with five levels). To reduce the number of choice-sets that each respondent had to complete, Sawtooth® CBC/SSI Web version 6.4.2 (Sawtooth Software, Inc. Sequim, WA, USA) software was used to create a fractional-factorial design that used 320 choice-sets divided into 20 different versions (16 choice-sets per version). During the design process, the final versions were checked to optimize orthogonality, level balance, and to minimize overlap. Questionnaire versions were hand-checked to limit the number of dominant scenarios that did not require respondents to make any trade-offs. To assess the consistency of an individual’s responses, we also added two identical choice-sets at the positions of choice-set 5 and 13. Prior to recruitment, the DCE questionnaire was pilot tested by 20 pharmacists to ensure the following objectives were met: 1) the questionnaire was comprehensive and clear; 2) the attribute levels were consistent with the range of pharmacists’ preferences; and 3) the frequency of non-demanders (i.e., the choice of the ‘typical pharmacy service’ alternative) was reasonable. The final survey was designed to take respondents between 15-30 minutes to complete.    103 5.2.4. Statistical Analysis Study Characteristics Using SAS® statistical software version 9.1 for Linux (SAS Institute Inc., Cary, NC, USA), descriptive statistics were used to evaluate the characteristics of the study sample. All continuous variables were summarized as means and standard deviations, while categorical variables were presented as the proportion of the sample in each group. To assess for demographic differences between those who answered the fixed-repeated questions consistently and those who answered inconsistently, categorical variables were compared using Chi-square tests and continuous variables were compared using one-way analysis of variance, with significance set at 5%.  Multinomial Logit Model To estimate pharmacists’ relative preferences for each attribute, the DCE data were analyzed using multinomial logit models (MNL) in SAS®.14,15 We included all attribute levels described in Table 5.1 and added a level to the attribute ‘service type’ for the ‘typical pharmacy services’ option. In the general model, the preferences of the entire sample were considered. Considering that respondents’ preferences likely differed according to their experience with patient-centred services, we also segmented the MNL by employment (student, staff pharmacist, regional manager/owner, clinical pharmacist) and time in practice (<10 years, 10-20 years, >20 years). We then compared coefficients using the Wald test to look for statistically significant differences across the subgroups. For the MNL, we evaluated the professional service fee on a continuous scale and used effect coding for the categorical attributes. To do this, we created M-1 variables for   104 each M-category predictor (see Table 5.2). Each attribute level was coded as 1 when it was in the category of interest and 0 when it was not. For each attribute, the contrast category was coded as -1. Considering that a pharmacist or pharmacy student’s utility (U) for a specific patient-centred service is described by a non-explainable random component (ε) and an explainable component, we estimated pharmacists’ preferences using the following model:  € Uitj = βeducation1x1itj + βeducation2x2itj + βeducation3x3itj + βeducation4x4 itj + βincome1x5itj + β income2x6itj + βsatisfaction1x7itj + βsatisfaction2x8itj + βservice1x9itj + βservice2x10itj + βservice3x11itj + βwork x12itj + β fee x13itj + εitj  Eq. (5.1)  where an individual (i=1,...,n) chose an alternative (j=1,…,3) in each choice-set (t=1,…,16) with the following attributes of service: the amount of education required to provide that service (x1ij,..., x4ij); whether their income (x5ij, x6ij) or job satisfaction (x7ij, x8ij) would be affected; the type of service to be provided (x9ij,…, x11ij); where the service would be offered (x12ij); and the professional service fee (x13ij). The probability that an alternative in a given choice-set will be chosen is equal to the probability that an individual’s utility gained from that alternative is greater than the utility from another alternative. Thus, the probability that an individual i chooses alternative k in choice-set t is estimated using the following:  € Pitk = exp( ′ β Xitk ) exp( ′ β Xitj )j=1 J ∑     Eq. (5.2)    105 where Xitj is a vector of observed variables and β' is the vector of parameters to estimated and does not vary between individuals.  Latent Class Model To account for preference heterogeneity between respondents, we also developed a latent class model (LCM) using Latent GOLD® version 4.5 (Statistical Innovations, Inc., Belmont, MA, USA).16 Unlike the MNL, the LCM allows preferences to differ between respondents by assuming that individuals’ decisions depend on observed characteristics, such as service attributes and sociodemographics, and on unobserved factors, such as attitudes and perceptions about a specific service.17-19 Because these unobserved (latent) factors fluctuate leading to heterogeneity in preferences, we assumed that respondents could be sorted into a set of classes though we could not know which class they would belong to (even if the respondents themselves could have predicted this). To determine pharmacists and pharmacy students’ preferences, we estimated the probability that an individual i would choose alternative k in choice-set t given their membership in a specific class (q=1,…,Q):  € Pitk q = exp( ′ β qXitk ) exp( ′ β qXitj )j=1 J ∑      Eq. (5.3)  where Xitj is a vector of observed variables and β'q is the vector of parameters to be estimated which were allowed to vary between respondents.18 Note that, in this model,   106 we assumed that individuals were observed over multiple choice-sets but that the observed choices were independent, given the class assignment.17 We also determined the probability that an individual would belong to a specific class using their observed characteristics (Zi):  € Hiq = exp( ′ θ qZi) exp( ′ θ qZi)q=1 Q ∑      Eq. (5.4)  where θ’ was the latent class parameter vector to be estimated. Thus, when considering latent factors, the probability that a patient-centred pharmacy service will be chosen can be estimated using the following:  € Pitk q = Hiq Pitk q t=1 T ∏       q=1 Q ∑     Eq. (5.5)  To estimate the preferences of both pharmacists and pharmacy students’ while accounting for heterogeneity, we effect coded the attributes (as described above) and estimated models with up to six classes, both with and without demographic covariates. Pharmacists and students were separated into two groups to allow for population-specific demographic variables to be included in the final model (e.g., students were not asked questions about job satisfaction). For both groups, we used a backwards selection method to determine the most appropriate demographics to include. To determine the number of classes for the LCM we compared three model statistics to determine the model that fit   107 the data the best: the Bayesian Information Criteria (BIC), the Akaike Information Criteria (AIC) and the log-likelihood function.  5.2.5. Sample Size Determination Recognizing that there is likely to be a difference in preferences between students, pharmacists, and pharmacy managers/owners, we targeted a sample of at least 100 community pharmacy managers/owners, 100 pharmacists and 50 pharmacy students. The primary analysis for this study was the evaluation of pharmacists and pharmacy students’ preferences using MNL. Considering that MNL prohibits the use of generally applied sample size calculations based on hypothesis testing,20,21 we based the necessary sample size on the number of attributes included in the study and the expected number of stratification variables. The final regression model included 13 attribute levels plus up to six additional stratification variables, so a minimum of 190 participants was needed to allow for 10 observations for each independent variable.  5.3. Results Of 634 respondents who started the online questionnaire, 539 (85%) completed all 18 DCE choice-sets, including the two fixed-repeated questions (the responses to the fixed- repeated questions were not included in the analysis). For the 452 pharmacist respondents, the average time to complete the survey was 51 minutes, compared to 25 minutes for the 87 student respondents. Several pharmacists appeared to take a break from the survey at some point with one respondent taking over 30 hours to complete the survey. In total, 539 respondents completed 8 624 choice-sets. In addition, 349 (77%)   108 pharmacist respondents and 59 (68%) student respondents answered the fixed-repeated questions consistently, completing a total of 6 528 choice-sets.  5.3.1. Sample Characteristics Respondent characteristics are summarized in Table 5.3. Slightly more than a third of pharmacist respondents graduated in the past year and just over two-thirds graduated in the past twenty years. Most pharmacists (88%) had a gross annual income of over $50,000 (CAD) and 58% were employed in a community-based dispensary as either a staff pharmacist or dispensary manager. Only 12% had pursued formal clinical training in the form of a post-graduate PharmD or a clinical residency and an additional 14% had pursued disease-specific clinical training and accreditation. In regards to student respondents, 68% had worked at least 1 day a week in a dispensary over the past summer and almost three-quarters planned to work in a dispensary role on graduation, with the majority seeking employment in a large pharmacy chain.  5.3.2. Multinomial Logit Model  To assess respondents’ preferences for patient-centred pharmacy services, a general MNL was used to estimate overall preferences and to assess whether inconsistencies in responses affected the final estimates. In addition, the general MNL was segmented according to the respondent’s current employment status and time in practice.    109  General Multinomial Logit Model The regression coefficients, which represent the preference weights from the general MNL for all respondents and for consistent respondents, can be seen in Table 5.4 and Figure 5.2. The preference weights were generally similar regardless of whether a respondent answered the fixed-repeated questions consistently, the exception being that consistent respondents had a slightly lower preference weight for receiving education through workshops and for providing screening services compared to the entire sample of respondents. For the general model with all respondents, based on the spread of the utilities personal income and job satisfaction were the most important attributes for providing patient-centred services. While respondents were averse to providing the typical pharmacy services that are common in traditional community pharmacy practice, they did prefer to provide MTM and CDM services and did not have a significant preference for providing screening services. In addition, prior to providing a patient-centred pharmacy service, respondents preferred to receive education through a 1-week CDM course or through a 1-month paid preceptorship and were averse to being offered a 2-hour seminar or to not being offered any educational opportunities. In terms of where the service would be provided, respondents had a slight positive preference for providing this service in a clinic such as a physician’s office compared to a traditional dispensary. Overall, respondents had a positive preference for the professional service fee, with a fee of $100/hour having a similar preference weight to having personal income or job satisfaction stay neutral.    110 Segmented Multinomial Logit Model  Statistically significant differences were seen in all attributes across employment categories (see Table 5.5 and Figure 5.3). In terms of education needed before providing patient-centred services, only regional managers and owners had a positive preference for a 2-hour orientation session and the opposite was true for a 1-month paid preceptorship. Regional managers and owners, students, and clinical pharmacists were all more averse to providing typical pharmacy services compared to staff pharmacists. In addition, clinical pharmacists had the greatest preference for providing services in the clinical setting and for providing CDM services. When considering the relative importance of each attribute, staff pharmacists and regional managers/owners were the most concerned about changes to their personal income and staff pharmacists, regional managers/owners and students were all similarly averse to changes in their job satisfaction (Figure 5.4). In contrast, pharmacists working in a clinical position were most concerned with the type of service they would be providing.  In general, preference weights did not differ significantly according to the amount of time respondents had been practicing (see Table 5.6 and Figure 5.5). The only exception was job satisfaction where students were the most averse to being dissatisfied and pharmacists who had practiced for over 20 years were the least concerned with being satisfied. In addition, as seen in Figure 5.6, the relative importance of each attribute was similar across groups.    111 5.3.3. Latent Class Model The inclusion of covariates significantly improved the model compared to not including any covariates. As seen in Table 5.7, the AIC, BIC and log-likelihood measures level off at around the 3-4 class models for pharmacist respondents and the 2-3 class models for student respondents. After considering the interpretability of the classes using the relative importance of the attributes and the demographic covariates, we selected a 3- class model for the pharmacists and a 2-class model for the students. Compared to an MNL for only pharmacists or students, the log-likelihoods improved with the LCM suggesting that there was heterogeneity in respondents’ preferences for providing patient- centred services.  Pharmacists For the LCM of pharmacists’ preferences, we included respondents’ current employment status, ideal employment, time in practice, satisfaction with their job, expected satisfaction from providing patient-centred services and whether they thought they should be paid more to provide patient-centred services (see Table 5.8). In the final model, 38% of respondents were in class 1, 36% were in class 2 and 26% were in class 3. Those in class 1 highly valued their job satisfaction and personal income and selected the ‘typical pharmacy services’ option in 45% of their choices. In general, they tended to be staff pharmacists who were currently satisfied with their job and were the least likely to agree that providing disease management services would increase their job satisfaction. Respondents in class 2 placed the greatest value on the type of service that would be delivered and chose the ‘typical pharmacy services’ option very rarely (4%). When   112 asked, members of this group often preferred to be in a clinical position or at least one with some clinical responsibility and did not believe they should be paid more to provide patient-centred services. Finally, respondents in class 3 placed the highest value on income and chose the ‘typical pharmacy services option’ 20% of the time. While members of this group were likely to be working in a clinical position, they were also more likely to have been in practice for over 20 years and preferred to be a regional manager or pharmacy owner. This final group was also the least likely to agree that they were satisfied with their current job and thought providing patient-centred services would increase this satisfaction. In addition, they were more likely to want to be paid more to provide these services.  Students To estimate students’ preference weights, we used a similar approach and included students’ most recent summer employment (see Table 5.9). In the 2-class LCM, student respondents were evenly distributed between the classes (50% in each class). The first class valued service type above all other attributes (Figure 5.7). Over the previous summer, this group was likely to work less than one day per week in a community pharmacy, instead choosing employment in hospital pharmacies or research studentships or not working at all. In contrast, the other class of student respondents valued personal income and job satisfaction above the other attributes and were less likely to have worked outside a community pharmacy.     113 5.4. Discussion Overall, respondents had the greatest preferences for seeing their own personal income or job satisfaction increase and similarly, were most averse to seeing decreases in these attributes. Pharmacists employed as either staff pharmacists in a dispensary or as dispensary managers were most concerned with attributes that affected their personal quality of life (i.e., personal income, job satisfaction). Though the same could be said for regional managers and owners, this group was also concerned with the professional service fee. As expected, clinical pharmacists were most concerned with the type of service offered and were less interested in receiving continuing medical education than their counterparts. Pharmacists did prefer to be paid a higher professional service fee, but this preference was moderate compared to attributes that directly affected respondents, such as personal income or job satisfaction. Finally, students, likely to be the most idealistic of the sample, were most concerned with job satisfaction. When considering the influence of the unobserved latent factors on these preferences, pharmacists were divided into three main groups. Interestingly, respondents who were likely to value job satisfaction were already working in positions that met these needs. In contrast, pharmacists who were most interested in providing patient-centred services were more likely to either be working as clinical pharmacists or to want to be working in a clinical setting. The third group, in which respondents were focused on their own personal income, had practiced longer and was interested in moving from largely clinical roles to ownership or management roles. Students were evenly divided into one group that valued income and had typically worked in a community pharmacy over the previous   114 summer and one group that valued service and chose instead to work in clinical or research type positions.  5.4.1. Methodological Concerns & Limitations  To estimate pharmacists and pharmacy students’ preferences for providing patient-centred services, we used both a MNL and a LCM. While we segmented the MNL by employment and time in practice, this only accounted for some respondent heterogeneity. Furthermore, the MNL assumes that there is independence of irrelevant alternatives (IIA). By including the ‘typical pharmacy service’ option we likely violated this assumption as respondents may have employed a two-step decision making process to first decided to provide a service and then to choose the service to provide. To account for any heterogeneity in unobserved factors and for correlation between these factors, and to relax the IIA between classes we used a LCM.22 The LCM provided a better fit for the data than did the MNL, suggesting that there was heterogeneity between respondents’ preferences for providing patient-centred pharmacy services.  Despite our unique approach to assessing pharmacists’ preferences for providing patient-centred services, there are several limitations in this study that should be noted. The first is in regards to the use of the DCE methodology to determine pharmacists and pharmacy students’ preferences. DCEs gather information on stated preferences meaning that the choices made by individuals are not under real market constraints. When compared to hypothetical situations, these constraints may lead individuals to choose different services in the real-world setting. Considering that there is a notable absence of programs to pay pharmacists to provide patient-centred services in Canada, few   115 respondents were currently providing these services. However, despite their limited experience and the fact that all choices were hypothetical, respondents appeared to choose service options that were consistent with their demographics (e.g., clinical pharmacists chose clinical services over typical pharmacy services).  A second consideration was that the fixed-repeated questions that were added to assess respondent reliability were not answered consistently by 24% of respondents. While it would generally be assumed that these respondents did not fully understand the tasks or were inconsistent in their decision process, Lancsar and Louviere argue that this may be due issues with the DCE or test design, or that respondents were learning about their preferences as they progressed through the questionnaire.23 In our experience, most pharmacists have given little thought to the remuneration of patient-centred services. Considering the complexity of the attributes of this DCE, it is possible that respondents learned about their preferences and trade-offs over the course of the exercise. That said, the preference weights for the entire sample and the sample of ‘consistent’ respondents were similar. It is fairly well established that pharmacists have low participation rates in pharmacy practice research.24-28 The risk of volunteer bias, also known as non-respondent bias, is an important consideration when assessing preferences for patient-centred services. 29-31 Pharmacist participation in research is likely impacted by complacency, time constraints, staffing and management support. Due to the subject matter of this survey and barriers to pharmacist participation, we suspect that highly motivated pharmacists were more likely to respond than less motivated or disempowered pharmacists. That said, respondent characteristics were similar to the general demographics of pharmacists practicing in   116 Canada,32 though we had a slight over-representation of pharmacists working outside the dispensary (hospital, primary care and long-term care). However, given that these individuals are likely already providing patient-centred services to their patients, their input is valuable in determining preferences for the remuneration of these services.  5.5. Conclusion During the development and implementation of new patient-centred services such as CDM or MTM, decision-makers should develop tailored messaging to encourage the uptake of new programs. For example, clinical pharmacists should be targeted and included in these programs, as they are more likely to be interested in providing patient- centred services. On the other hand, many pharmacists employed in community pharmacies are somewhat uninterested in the type of service to be delivered and instead will need reassurance that there will be minimal changes to their own personal income and that they will have access to continuing education programs such as week-long CDM courses and paid preceptorships. In the future, the findings of this DCE should be used to improve the uptake of patient-centred services.   117 Figure 5.1:  Sample discrete choice experiment choice-set for pharmacists’ preferences for patient-centred pharmacy services  If these were your only options, which practice model would you choose? [Assume that you have sufficient technical support, liability insurance, and documentation systems to provide these services.]    Option 1 Option 2 Option 3 Service Type: Medication review & management Screening for the presence of a chronic disease  NONE: I prefer to provide typical pharmacy services  Place of work: Dispensary Clinic Professional service fee:  $150/service hour $100/service hour Your income: Increase 15% Decrease15% Education required before you can provide the service:  Workshop (2d) CDM course (1wk) Job satisfaction in all other aspects of your work:  Satisfied Dissatisfied  I would choose:         118 Figure 5.2:  Respondents’ mean preference weights and 95% confidence intervals for providing patient-centred services for all respondents (multinomial logit model)   CDM, chronic disease management, MTM, medication therapy management   119 Figure 5.3:  Respondents’ mean preference weights and 95% confidence intervals according to employment for all respondents (multinomial logit model)   CDM, chronic disease management, MTM, medication therapy management   120  Figure 5.4:  Relative importance* of attributes of patient-centred pharmacy services according to employment for all respondents (multinomial logit model)   *Relative importance: Maximum effects of each attribute rescaled to sum to one across attributes   121 Figure 5.5:  Respondents’ mean preference weights and 95% confidence intervals according to time in practice for all respondents (multinomial logit model)   CDM, chronic disease management, MTM, medication therapy management   122 Figure 5.6:  Relative importance* of attributes of patient-centred pharmacy services according to time in practice for all respondents (multinomial logit model)   *Relative importance: Maximum effects of each attribute rescaled to sum to one across attributes   123 Figure 5.7: Relative importance* of attributes of patient-centred pharmacy services to pharmacists (latent class model)   *Relative importance: Maximum effects of each attribute rescaled to sum to one across attributes   124 Figure 5.8: Relative importance* of attributes of patient-centred pharmacy services to pharmacy students (latent class model)   *Relative importance: Maximum effects of each attribute rescaled to sum to one across attributes   125 Table 5.1: Attributes and levels to assess pharmacists’ preferences for the delivery of patient-centred services  Attributes Definition Levels Description Screening Assessing a patient for the presence of chronic diseases  MTM Comprehensive medication reviews  Service Patient-centred service alternatives CDM Prevention, detection, and management of chronic diseases  Dispensary Semi-private or private counseling space in the dispensary  Setting Location of service delivery Clinic  Primary care, stand-alone clinic or ambulatory care clinic Decrease 15%  Stay same  Income Pharmacists’ personal income Increase 15%  Total income of a pharmacist. For most pharmacists, this is the salary paid by their employer. $50/hour  $100/hour  Fee Hourly billing rate for providing service $150/hour  A fee-for-service that does not go directly to the pharmacist. The fee is paid to the business and is similar to a dispensing fee or physician fee-for-service. (e.g., for a fee of $100/hour, a 1/2 hour service is billed at $50, or 1/2 the hourly rate).   126  Attributes Definition Levels Description None No additional education required  Orientation session (2 hours) Seminar on new service and billing  Workshop (2 days) Seminars, case-studies on new service and billing  CDM course (1 week) Seminars, case-studies, and hands-on sessions on communication and documentation skills  Education Education required before providing service Paid Preceptorship (1month) Seminars, case studies, hands-on sessions, and practical experience in a clinical environment under guidance of experienced practitioner. The pharmacist is paid a salary while completing the preceptorship.  Dissatisfied  Neutral  Job Satisfaction Satisfaction with other aspects of job Satisfied  Includes work schedule, scheduled breaks, relationships with others (e.g., employers, coworkers, physicians, and patients), and workload. CDM, chronic disease management, MTM, medication therapy management   127 Table 5.2:  Effect coding of variables for the multinomial logit model of pharmacists’ preferences for patient-centred services  Attribute x1ij x2ij x3ij x4ij X5ij x 6ij x 7ij x 8ij x 9ij x 10ij x 11ij x 12ij Education None 1 0 0 0 Orientation (2h) 0 1 0 0 Workshop (2d) 0 0 1 0 CDM Course (1wk) 0 0 0 1 Preceptorship (1mo) -1 -1 -1 -1 Income Decrease 15%     1 0 Stay same     0 1 Increase 15%     -1 -1 Job Satisfaction Dissatisfied       1 0 Neutral       0 1 Satisfied       -1 -1 Service Typical Pharmacy Service         1 0 0 Screening         0 1 0 MTM         0 0 1 CDM         -1 -1 -1 Setting Dispensary            1 Clinic            -1 CDM, chronic disease management, MTM, medication therapy management   128 Table 5.3: Pharmacist characteristics overall and according to the consistency of answers for fixed-repeated questions 5 and 13   All Pharmacists N=452 Consistent N=349 Inconsistent N=103  N (%) N (%) N (%) p-value Province    0.36 BC 180 (40) 135 (39) 45 (44) Alberta 272 (60) 214 (61) 58 (56) Years practiced    0.43 <10 years 173 (38) 128 (37) 45 (44) 10-19 years 142 (31) 113 (32) 29 (28) >20 years 137 (30) 108 (31) 29 (28) Annual Salary (Gross)    0.12 <$50,000  26 (6) 19 (5) 7 (7) $50,000-$100,000  271 (60) 202 (58) 69 (67) >$100,000 127 (28) 106 (30) 21 (20) N/A 28 (6) 22 (6) 6 (6) Mean no. children (SD) 1.3 (1.2) 1.3(1.2) 1.2 (1.1) 0.49 Education     0.32 Undergraduate/Entry Level PharmD 369 (82) 280 (80) 89 (86) Graduate Level PharmD 11 (2) 10 (3) 1 (1) Residency  48 (11) 41 (12) 7 (7) Graduate Degree 23 (5) 17 (5) 6 (6) Current Employment     0.52 Dispensary Staff 265 (59) 202 (58) 63 (61) Regional Managers/Owners 65 (14) 49 (14) 16 (16) Clinical* 112 (25) 91 (26) 21 (20) Other  10 (2) 7 (2) 3 (3)   129  All Pharmacists N=452 Consistent N=349 Inconsistent N=103  N (%) N (%) N (%) p-value Size of community where practice located    0.62 Rural (<100,000) 191 (44) 149 (43) 42 (41) Urban (100,000-999,999) 128 (29) 95 (27) 33 (32) Large Metropolitan (>1,000,000) 133 (30) 105 (30) 28 (27) PharmD, Doctor of Pharmacy Degree, SD, standard deviation *Clinical: hospital, primary care, long-term care   130 Table 5.4:  Multinomial logit model of respondents’ mean preference weights for providing patient-centred services  All Respondents Consistent Respondents Attribute Mean (SE) Mean (SE) Education None -0.27  (0.04) -0.27* (0.04) Orientation (2h) -0.07* (0.03) -0.05  (0.04) Workshop (2d) 0.04   (0.03) 0.01   (0.04) CDM Course (1wk) 0.17*  (0.03) 0.19*  (0.04) Preceptorship (1mo) 0.12*  (0.03) 0.12*  (0.04) Fee $100/hour 0.23*  (0.04) 0.19*  (0.05) Income Decrease 15% -1.09* (0.03) -1.07* (0.03) Stay same 0.25*  (0.02) 0.24*  (0.03) Increase 15% 0.83*  (0.02) 0.83*  (0.03) Job Satisfaction Dissatisfied -0.95* (0.03) -0.93* (0.03) Neutral 0.27*  (0.02) 0.27*  (0.03) Satisfied 0.68*  (0.02) 0.66*  (0.03) Service Typical Pharmacy Service -0.34* (0.05) -0.34* (0.06) Screening 0.02   (0.03) 0.01  (0.03) MTM 0.18*  (0.03) 0.18*  (0.03) CDM 0.14*  (0.03) 0.15*  (0.03) Setting Dispensary -0.05* (0.01) -0.07* (0.02) Clinic 0.05*  (0.01) 0.07* (0.02) No. of individuals 539 408 No. of observations 8624 6528 Log-likelihood -7319.00 -5586.00 CDM, chronic disease management, MTM, medication therapy management, SE, standard error *p-value <0.05 (mean preference weight is significantly different from zero)   131 Table 5.5:  Multinomial logit model of respondents’ mean preference weights according to employment status for all respondents  Attribute Students Staff Pharmacists Managers/ Owners Clinical Pharmacists p-Value  Mean (SE) Mean (SE) Mean (SE) Mean (SE) Education None -0.17 (0.09) -0.34* (0.05) -0.28* (0.10) -0.20* (0.07) 0.10 Orientation (2h) -0.11 (0.09) -0.13* (0.05) 0.14 (0.10) -0.07 (0.07) 0.04 Workshop (2d) 0.003 (0.09) 0.11* (0.05) 0.002 (0.10) -0.05 (0.07) 0.08 CDM Course (1wk) 0.19* (0.09) 0.16* (0.05) 0.18 (0.09) 0.20* (0.07) 0.67 Preceptorship (1mo) 0.08 (0.09) 0.20* (0.05) -0.04 (0.10) 0.12 (0.07) 0.05 Fee $100/hour 0.17 (0.10) 0.25* (0.06) 0.60* (0.11) 0.08 (0.08) 0.37 Income Decrease 15% -1.09* (0.07) -1.34* (0.05) -0.94* (0.08) -0.91* (0.05) <0.001 Stay same 0.18* (0.06) 0.30* (0.03) 0.29* (0.06) 0.25* (0.05) 0.59 Increase 15% 0.90* (0.06) 1.04* (0.04) 0.65* (0.06) 0.66* (0.05) <0.001 Job Satisfaction Dissatisfied -1.16* -1.13* (0.04) -0.74* (0.07) -0.74* (0.05) <0.001 Neutral 0.35* (0.06) 0.28* (0.03) 0.30* (0.06) 0.20* (0.05) 0.65 Satisfied 0.81* (0.06) 0.86* (0.04) 0.44* (0.06) 0.54* (0.05) <0.001 Service Typical Pharmacy Service -0.53* (0.13) -0.13 (0.08) -0.02 (0.15) -1.06* (0.12) <0.001 Screening 0.12 (0.07) 0.002 (0.04) -0.05 (0.08) 0.11 (0.06) 0.64 MTM 0.20* (0.07) 0.14* (0.04) 0.03 (0.08) 0.43* (0.06) 0.19 CDM 0.21* (0.07) -0.01 (0.04) 0.04 (0.08) 0.53* (0.06) <0.001   132 Attribute Students Staff Pharmacists Managers/ Owners Clinical Pharmacists p-Value  Mean (SE) Mean (SE) Mean (SE) Mean (SE)  Setting Dispensary -0.01 (0.04) 0.10* (0.02) 0.03 (0.04) -0.37* (0.03) <0.001 Clinic 0.01 (0.04) -0.10* (0.02) -0.03 (0.04) 0.37* (0.03) <0.001 No. of Individuals 87 265 65 112 No. of Observations 1392 4240 1040 1792 Log-likelihood -1127.00 -3471.00 -957.47 -1316.00 CDM, chronic disease management, MTM, medication therapy management, SE, standard error *p-value <0.05 (mean preference weight is significantly different from zero)   133   Table 5.6: Multinomial logit model of respondents’ mean preference weights according to time in practice for all respondents  Attribute Students < 10 years 10-20 years >20 years p-Value  Mean (SE) Mean (SE) Mean (SE) Mean (SE) Education None -0.17* (0.09) -0.27* (0.06) -0.18* (0.07) -0.42* (0.07) 0.22 Orientation (2h) -0.11 (0.09) -0.05 (0.06) -0.06 (0.07) -0.08 (0.07) 0.65 Workshop (2d) 0.003 (0.09) 0.02 (0.06) 0.03 (0.07) 0.10 (0.07) 0.57 CDM Course (1wk) 0.19* (0.09) 0.13* (0.06) 0.18* (0.07) 0.22* (0.07) 0.83 Preceptorship (1mo) 0.08 (0.09) 0.17* (0.06) 0.03 (0.07) 0.18* (0.07) 0.68 Fee $100/hour 0.17* (0.10) 0.28* (0.07) 0.22* (0.08) 0.20* (0.08) 0.10 Income Decrease 15% -1.09* (0.07) -1.14* (0.05) -1.09* (0.05) -1.04* (0.05) 0.94 Stay same 0.18* (0.06) 0.29* (0.04) 0.24* (0.04) 0.27* (0.04) 0.17 Increase 15% 0.90* (0.06) 0.85* (0.04) 0.85* (0.05) 0.77* (0.05) 0.24 Job Satisfaction Dissatisfied -1.16* (0.07) -1.06* (0.05) -0.87* (0.05) -0.80* (0.05) <0.001 Neutral 0.35* (0.06) 0.29* (0.04) 0.23* (0.04) 0.24* (0.04) 0.13 Satisfied 0.81* (0.06) 0.77* (0.04) 0.64* (0.05) 0.56* (0.05) 0.02 Service Typical Pharmacy Service -0.53* (0.13) -0.30* (0.09) -0.32* (0.10) -0.27* (0.10) 0.10 Screening 0.12 (0.07) 0.02 (0.05) 0.004 (0.06) -0.02 (0.06) 0.12 MTM 0.20* (0.07) 0.15* (0.05) 0.16* (0.06) 0.22* (0.06) 0.74 CDM 0.21* (0.07) 0.14* (0.05) 0.15* (0.06) 0.07 (0.06) 0.27 Setting Dispensary -0.01 (0.04) -0.05* (0.03) -0.06* (0.03) -0.08* (0.03) 0.17 Clinic 0.01 (0.04) 0.05* (0.03) 0.06* (0.03) 0.08* (0.03) 0.17   134 Attribute Students < 10 years 10-20 years >20 years p-Value  Mean (SE) Mean (SE) Mean (SE) Mean (SE) No. of Individuals 87 173 142 137 No. of Observations 1392 2768 2272 2192 Log-likelihood -1127.00 -2304.00 -1966.00 -1894.00 CDM, chronic disease management, MTM, medication therapy management, SE, standard error *p-value <0.05 (mean preference weight is significantly different from zero)   135 Table 5.7: Overview of latent class model estimation results  No. of Classes LL BIC AIC No. of Parameters Pharmacists Without Covariates 1 (MNL) -6181.2215 12441.9208 12388.4429 13 2 -5266.1494 10697.3682 10586.2988 27 3 -5055.9097 10362.4805 10193.8195 41 4 -4880.9995 10098.2515 9871.999 55 5 -4781.9038 9985.6516 9701.8075 69 6 -4688.1686 9883.7729 9542.3373 83 With Covariates 2 -5132.22 10501.99 10342.43 39 3 -4893.94 10183.81 9917.87 65 4 -4696.23 9946.76 9574.45 91 5 -4569.18 9851.04 9372.36 117 6 -4457.00 9785.06 9200.01 143 Students Without Covariates 1 (MNL) -1126.9239 2311.9047 2279.8479 13 2 -961.2881 2043.1557 1976.5762 27 3 -909.1841 2001.4704 1900.3682 41 4 -877.6061 2000.8372 1865.2122 55 5 -846.8703 2001.8882 1831.7405 69 6 -821.2179 2013.1062 1808.4358 83 With Covariates 2 -958.48 2050.94 1976.96 30 3 -904.73 2019.35 1903.45 47 4 -868.60 2023.01 1865.19 64 5 -844.82 2051.38 1851.64 81 6 -805.83 2049.33 1807.67 98 AIC, Akaike Information Criteria, BIC, Bayesian Information Criteria, LL, log-likelihood function, MNL, multinomial logit model   136 Table 5.8:  Latent class model of pharmacists’ mean preference weights for providing patient-centred services  Attribute Class 1 Class 2 Class 3  Mean (SE) Mean (SE) Mean (SE) Education None -0.30* (0.08) -0.30* (0.06) -0.48* (0.11) Orientation (2h) -0.01 (0.08) -0.05 (0.06) -0.09 (0.11) Workshop (2d) 0.15† (0.08) -0.04 (0.06) 0.22* (0.10) CDM Course (1wk) 0.13† (0.08) 0.21* (0.06) 0.17 (0.10) Preceptorship (1mo) 0.03 (0.08) 0.18* (0.06) 0.19† (0.11) Fee $100/hour 0.40* (0.10) 0.19* (0.07) 0.36* (0.13) Income Decrease 15% -2.08* (0.12) -0.46* (0.04) -2.16* (0.13) Stay same 0.66* (0.07) 0.17* (0.04) 0.43* (0.07) Increase 15% 1.42* (0.07) 0.29* (0.04) 1.73* (0.10) Job Satisfaction Dissatisfied -1.82* (0.09) -0.90* (0.05) -0.61* (0.08) Neutral 0.58* (0.06) 0.25* (0.04) 0.10 (0.07) Satisfied 1.24* (0.06) 0.65* (0.04) 0.51* (0.08) Service Typical Pharmacy Service 0.46* (0.12) -1.58* (0.14) -0.99* (0.18) Screening -0.14 (0.07) 0.31* (0.06) 0.28* (0.09) MTM -0.05 (0.07) 0.58* (0.06) 0.49* (0.09) CDM -0.26 (0.07) 0.69* (0.06) 0.22* (0.09) Setting Dispensary 0.19 (0.04) -0.28* (0.03) 0.15* (0.05) Clinic -0.19 (0.04) 0.28* (0.03) -0.15* (0.05)   137  Attribute Class 1 Class 2 Class 3 Covariates Intercept 0.03 (0.20) 0.59* (0.20) -0.62* (0.25) Current Job Staff Pharmacist 0.37* (0.14) -0.47* (0.14) 0.10 (0.16) Regional Managers/Owner 0.27 * (0.18) 0.29 (0.18) -0.56* (0.22) Clinical -0.63* (0.19) 0.17 (0.17) 0.46* (0.21) Ideal Job Staff Pharmacist 0.18 (0.15) -0.26 (0.17) 0.08 (0.20) Regional Manager/Owner -0.12 (0.17) -0.63* (0.19) 0.75* (0.20) Clinical -0.03 (0.18) 0.34* (0.17) -0.32 (0.20) Other -0.04 (0.29) 0.55* (0.24) -0.52 (0.32) Time in Practice <10 years 0.12 (0.11) 0.22 (0.12) -0.33* (0.13) 10-20 years 0.11 (0.11) -0.09 (0.12) -0.02 (0.12) >20 years -0.23* (0.12) -0.13 (0.12) 0.35* (0.13) Currently satisfied with job Disagree -0.18 (0.19) -0.14 (0.20) 0.32 (0.19) Neutral -0.20 (0.19) -0.02 (0.19) 0.22 (0.19) Agree 0.38* (0.14) 0.16 (0.14) -0.54* (0.14) Providing disease management services will increase job satisfaction Disagree 0.32 (0.19) -0.15 (0.22) -0.17 (0.27) Neutral 0.08 (0.16) 0.21 (0.17) -0.30 (0.22) Agree -0.40* (0.13) -0.06 (0.14) 0.47* (0.17) Salary should increase if providing patient-centred services Yes 0.002 (0.12) -0.36* (0.12) 0.36* (0.17) No 0.002 (0.12) 0.36* (0.12) -0.36* (0.17)   138 Attribute Class 1 Class 2 Class 3 Probability of belonging to each class 0.38 (0.02) 0.36 (0.02) 0.26 (0.02) No. of Individuals 442 No. of Observations 7072 Log Likelihood Function -4893.94 CDM, chronic disease management, MTM, medication therapy management, SE, standard error *p-value <0.05 (mean preference weight is significantly different from zero)     139 Table 5.9:  Latent class model of pharmacy students’ mean preference weights for providing patient-centred services  Attribute Class 1 Class 2  Mean (SE) Mean (SE) Education None -0.21 (0.12) -0.15 (0.15) Orientation (2h) -0.10 (0.12) -0.05 (0.14) Workshop (2d) -0.04 (0.12) 0.07 (0.14) CDM Course (1wk) 0.22 (0.12) 0.11 (0.14) Paid Preceptorship (1mo) 0.14 (0.12) 0.01 (0.15) Fee $100/hour 0.07 (0.14) 0.26 (0.17) Income Decrease 15% -0.78* (0.09) -1.85* (0.15) Stay same 0.12 (0.08) 0.44* (0.10) Increase 15% 0.66* (0.08) 1.41* (0.11) Job Satisfaction Dissatisfied -0.97* (0.09) -1.54* (0.13) Neutral 0.18* (0.08) 0.57* (0.10) Satisfied 0.79* (0.09) 0.97* (0.11) Service Typical Pharmacy Service -2.73* (0.39) -0.03 (0.21) Screening 0.77* (0.15) 0.05 (0.12) MTM 0.97* (0.15) 0.004 (0.12) CDM 1.00* (0.15) -0.02 (0.12) Setting Dispensary -0.12* (0.05) 0.20* (0.07) Clinic 0.12* (0.05) -0.20 (0.07) Covariates Intercept -0.04 (0.12) 0.04 (0.12) Employment in a community pharmacy over previous summer months <1 day/wk 0.38* (0.19) -0.38* (0.19) 1-2 days/wk -0.16 (0.26) 0.16 (0.26) 3-4 days/wk 0.07 (0.19) -0.07 (0.19) >5 days/wk -0.30 (0.21) 0.30 (0.21) Probability of belonging to each class 0.50 (0.05) 0.50 (0.05) No. of Individuals 87 No. of Observations 1392 Log Likelihood Function -958.48 CDM, chronic disease management, MTM, medication therapy management, SE, standard error *p-value <0.05 (mean preference weight is significantly different from zero)   140 5.1. References  1 Sketris IS. Extending prescribing privileges in Canada. Canadian Pharmacists Journal 2009;142:17-9. 2 Clifford RM, Davis WA, Batty KT, Davis TM; Freemantle Diabetes Study. Effect of a pharmaceutical care program on vascular risk factors in type 2 diabetes: the Fremantle Diabetes Study. Diabetes Care 2005;28:771-6. 3 Rothman RL, Malone R, Bryant B et al. A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes. Am J Med 2005;118:276-84. 4 McLean DL, McAlister FA, Johnson JA et al. A randomized trial of the effect of community pharmacist and nurse care on improved blood pressure management in patients with diabetes mellitus: study of cardiovascular risk intervention by pharmacists- hypertension (SCRIP-HTN). Arch Intern Med 2008;168:2355-61. 5 Hay EM, Foster NE, Thomas E et al. Effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in people aged over 55 presenting to primary care: pragmatic randomised trial. BMJ 2006;333:995. 6 Marra CA, Cibere J, Tsuyuki RT et al. Improving osteoarthritis detection in the community: pharmacist identification of new, diagnostically confirmed osteoarthritis. Arthritis Rheum 2007;57:1238-44. 7 Tsuyuki RT, Johnson JA, Koon KT et al. A randomized trial of the effect of community pharmacist intervention on cholesterol risk management: The study of cardiovascular risk intervention by pharmacists (SCRIP). Arch Intern Med 2002; 162:1149-55.    141  8 Chan P, Grindrod KA, Bougher D, et al. A systematic review of remuneration systems for clinical pharmacy care services. Canadian Pharmacists Journal 2008;141:102-12. 9 Grindrod KA, Rosenthal M, Lynd LD, et al. Pharmacist perspectives on providing chronic disease management services in the community (Part 1): Current Practice Environment; (Accepted to the Canadian Pharmacist Journal 2009 for the Sept/Oct issue). 10 Bell HM MJ, Hughes CM, Woods A. A qualitative investigation of the attitudes and opinions of community pharmacists to pharmaceutical care. J Soc Admin Pharm 1998;15:284-95. 11 Mottram DR, Jogia P, West P. The community pharmacists' attitudes toward the extended role. J Soc Adm Pharm 1995;12:12-7. 12 Ryan M, Gerard K. Using discrete choice experiments to value health care programmes: current practice and future research reflections. Appl Health Econ Health Policy 2003;2:55-64. 13 ATKearny. Activity based costing study. Full report: study findings and analysis. (2007). Prepared for the BC Pharmacy Association, BC Ministry of Health, and the Canadian Association of Chain Drug Stores. (Accessed June 22, 2009, at http://www.bcpharmacy.ca/press_room/ABCstudy.htm.) 14 Getting started modeling: the basic MNL model. In: Hensher DA, Rose, JM, Greene WH. Applied choice analysis: A Primer. New York, NY: Cambridge University Press, 2005:88-99.    142  15 Train KE. Discrete choice methods with simulation. 2nd ed. New York, NY: Cambridge University Press, 2009. (Accessed June 25, 2009, at http://elsa.berkeley.edu/books/choice2.html.) 16 Boxall PC, Adamowicz WT. Understanding heterogeneous preferences in random utility models: a latent class approach. Environmental and Resource Economics 2002; 23:421-46. 17 Greene WH, Hensher DA. A latent class model for discrete choices analysis: contrasts with mixed logit. Transportation Research Part B 2003; 37:681-98. 18 Hole AR. Modelling heterogeneity in patients’ preferences for the attribute of a general practitioner appointment. J Health Econ 2008;27:1078-94. 19 McFadden, D. The choice theory approach to market research. Marketing Science 1986;5:275-97. 20 Maddala GS. Limited-dependent and qualitative variables in econometrics. Cambridge, England: Cambridge University Press, 1983. 21 Ratcliffe J, Buxton M, McGarry T, Sheldon R, Chancellor J. Patients' preferences for characteristics associated with treatments for osteoarthritis. Rheumatology 2004;43:337- 45. 22 Ben-Akiva M, Walker J, Bernardino AT, Gopinath DA, Morikawa T, Polydoropoulou A. Integration of choice and latent variable models. Austin, USA: Proceedings of 8th International Conference on Travel Behavior, 1999.    143  23 Lancsar E, Louviere J. Deleting ‘irrational’ responses from discrete choice experiments: a case of investigating or imposing preferences? Health Econ 2006;15:797- 811. 24 Weinberger M, Murray MD, Marrero DG, et al. Issues in conducting randomized controlled trials of health services research interventions in nonacademic practice settings: the case of retail pharmacies. Health Serv Res 2002;37:1067-77. 25 Armour C, Brillant M, Krass I. Pharmacists’ views on involvement in pharmacy practice research: strategies for facilitating participation. Pharmacy Practice 2007;5:59- 66. 26 Scott V, Amonkar M, Madhavan S. Pharmacists’ preferences for continuing education and certificate programs. Ann Pharmacother 2001;35:289-99. 27 Maio V, Belazi D, Goldfarb NI, Phillips AL, Crawford AG. Use and effectiveness of pharmacy continuing-education materials. Am J Health Syst Pharm 2003;60:1644-9. 28 Hanson AL, Bruskiewitz RH, DeMuth JE. Pharmacists' perceptions of facilitators and barriers to lifelong learning. Am J Pharm Ed 2007;71:1-9. 29 Sackett DL. Bias in analytic research. J Chronic Dis 1979;32:51-63. 30 Choi BC, Noseworthy AL. Classification, direction, and prevention of bias in epidemiologic research. J Occup Med 1992;34:265-71. 31 Greenland S. Basic methods for sensitivity analysis of biases. Int J Epidemiology 1996;25:1107-16. 32 Workforce trends for pharmacists for selected provinces and territories in Canada. Ottawa, ON: Canadian Institute for Health Information, 2007. (Accessed June 1, 2009, at    144  http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=download_form_e&cw_sku=WTPS PTIC2007PDF&cw_ctt=1&cw_dform=N.)     145 6. MARKETING NON-DISPENSING SERVICES TO PHARMACISTS: CONCLUSIONSi  6.1.  Introduction Pharmacists, when acting in a professional capacity, can improve health outcomes.1,2 Now, with the challenges facing increasingly overburdened health systems, pharmacists are being urged to act in this professional capacity. But even with advances in pharmacy health services research and remuneration programs encouraging pharmacists to adopt new pharmacy services, one central issue remains –pharmacists are not always interested in providing patient-centred care. While this may sound simplistic, time and time again, programs that have been developed to expand pharmacists’ scope of practice have been largely unsuccessful at changing practice. If anything, pharmacy services have become more focused on the technical aspects of typical pharmacy services such as medication dispensing and compounding.  The crux of the matter, though, is that not all pharmacists are alike. In fact, a small proportion of the profession continues to seek out employment and offer services aimed at improving health outcomes. Even in the more traditional setting of the community pharmacy dispensary, the literature abounds with examples of pharmacists who have looked beyond the product to offer patient-centred professional services. For instance, Willink and Isetts (2005) studied four successful and innovative community practices in the U.S. to determine what characteristics differentiated these practices from their more traditional counterparts.3 They found that these sites had a philosophy of  i A version of this chapter will be submitted for publication. Grindrod KA, Marra CA, Tsuyuki RT, Lynd LD. Marketing non-dispensing services to pharmacists.   146 practice that determined the services to be provided and a sense of responsibility for patient therapy and care decisions. These sites also had processes in place that allowed pharmacists to develop relationships with their patients and management systems that considered the physical environment, documentation, recruitment and remuneration. Furthermore, pharmacists in these practices had the opportunity to apply and constantly update their clinical knowledge.  Along a similar vein, many other studies have trialed community-based patient- centred service programs.4 Arguably, the most successful program has been the ongoing Ashville Project in the U.S. where, over the past decade, pharmacists have improved the delivery of diabetes and asthma care for city employees.5-7 Part of what makes this program so unique is that it relies on the established and ongoing remuneration of these innovative services, involves a complete and intensive disease-specific education program, and has notable buy-in from patients, employers and pharmacists. Additionally each of the respective resources and supports were in place simultaneously, including training and remuneration, maximizing the chances for success. With small-scale initiatives involving only a handful of pharmacists, it is reasonable to assume that most of the involved care providers will be supportive and satisfied considering that they likely had input during program development. Large programs, on the other hand, are designed for use by a diverse group of providers and are much less likely to meet all providers’ needs. For those looking to implement patient-centred services on a wider scale (e.g., provincial), these examples are encouraging but also underscore the fact that new programs need to be well thought-out, sustainable and have input from the care providers.   147 Historically, most public programs for patient-centred pharmacy services have been targeted at a large group of pharmacists working in the community setting.8 Unfortunately, even though many of these programs have proven unpopular, little has been done to change the approach. With the growing interest in expanding pharmacists scope of practice across Canada,9-11 we sought to characterize pharmacists’ preferences for providing patient-centred services. This chapter describes our findings and summarizes what it is that pharmacists want in order to provide these services. It is our hope that the results of this study will inform both program development and implementation – providing pharmacists with a voice and providing decision makers and pharmacy leaders with guidance on how to improve the likelihood that their proposed services are delivered to the public.  6.2.  Summary of Key Research Findings To explore pharmacists’ preferences for providing patient-centred pharmacy services, we completed a systematic review,8 a series of pharmacist focus groups,12,13 a questionnaire of pharmacists’ experiences and opinions, and a choice-based study of pharmacists’ stated preferences called a discrete choice experiment (DCE). In all four phases of this study, one thing was certain – many pharmacists are reluctant to adopt new pharmacy services. In the systematic review, we found that most programs suffered from poor pharmacist uptake with many pharmacists complaining about time constraints and inadequate remuneration. With similar complaints in the focus groups, staff pharmacists felt unsupported and were wary of expanding their scope of practice whereas regional managers and owners were concerned that pharmacists were uninterested and that   148 remuneration was insufficient. In the questionnaire, many pharmacists thought that providing patient-centred services would increase their job satisfaction, but few were actually offering any services that were unrelated to dispensing.  Recognizing that no program will satisfy every pharmacist, we used the DCE to examine pharmacists’ preferences for providing patient-centred services. A DCE is a choice-based exercise in which an individual is asked to choose between two or more products or services. Using the examples of disease screening, medication therapy management (MTM) and chronic disease management (CDM), we gave pharmacists a variety of scenarios and asked them to choose the service they most preferred to provide. To make this choice, respondents were asked to consider the type of service to be delivered (screening, MTM, CDM, typical pharmacy services), where the service would be delivered (dispensary, clinic), the professional service fee (between $50-150/hour of service), their satisfaction with all other aspects of their job, potential changes to their own personal income, and potential education required to provide the service. More than 500 respondents made over 8 000 choices and included community, hospital, primary care pharmacists, and long-term care pharmacists, regional managers of large chains, dispensary owners and pharmacy students in the fourth year of an undergraduate pharmacy education.  Overall, pharmacists were most concerned with maintaining or increasing their own personal income and job satisfaction. In addition, while they most preferred to provide MTM services, likely because these services maintain a focus on medications, they were also interested in providing CDM services which can include an MTM component and were averse to only providing typical pharmacy services. In terms of   149 education, pharmacists wanted continuing education opportunities and were most interested in more intensive options such as weeklong CDM courses or paid preceptorships. Finally, pharmacists also preferred to be paid a higher professional services fee and to be in a clinic rather than a dispensary. In addition to the general findings described above, it was clear that pharmacists’ preferences differed according to a number of factors. In terms of their current employment, pharmacists working in the community preferred to have their income stay the same or increase and were very averse to seeing it decrease. While the same could be said for regional managers and owners, this group was also very interested in receiving higher professional service fees. For pharmacists practicing in a clinical setting (hospital, primary care, long-term care), their choices were most influenced by the type of service that was being provided – while they were most interested in providing MTM or CDM, this group was particularly averse to providing typical pharmacy services. Finally, pharmacy students, likely to be the most idealistic group, were most concerned that they would be satisfied with aspects of their job that were unrelated to the type of service being provided (e.g., scheduled breaks, relationships with others). Though it is easy to quickly classify pharmacists according to their current roles, many pharmacists interested in providing patient–centred services are not working in jobs that support these interests. As a result, their current employment does not necessarily represent their preferences. Recognizing that pharmacists have different attitudes and beliefs that are not easily captured, we wanted to look more closely at the decisions that respondents made in order to describe how they differed in their preferences. As seen in Table 6.1, preferences appear to be split according to three different classes of   150 pharmacists and two different classes of pharmacy students. The largest pharmacist class, with 38% of all pharmacist respondents, was most likely to include staff pharmacists who were satisfied with their job and did not think that offering patient-centred services would increase their job satisfaction. Not surprisingly, when choosing one service over another, this group was most concerned with either maintaining or increasing their job satisfaction. The second class, comprised of 36% of all pharmacist respondents, practiced in a variety of settings and was more likely to be interested in having a clinical practice. Likely as a direct result of this, these respondents were most concerned with the type of service they would be offering, preferring to offer CDM, MTM and disease screening services (in decreasing preference). As expected, this group was also very averse to providing typical pharmacy services. Finally, respondents in the third class (26% of all pharmacist respondents) were more likely to be clinical pharmacists who had been in practice for over 20 years. Interestingly, this group was not satisfied with their current employment, preferring instead to be in management or ownership role. While they believed that patient-centred services would increase their job satisfaction, they also wanted to be paid more to provide these services. Consistent with this, when choosing between one service and another, this group was most concerned with having their personal income stay the same or increase. Given that students generally have limited pharmacy experience and few opportunities to work outside the community setting, the classes of student respondents were more difficult to describe. That said, it appears that fourth year pharmacy students were evenly divided into two classes. One class was comprised of students concerned with realizing a higher personal income and job satisfaction. Unconcerned with the type   151 of service they would be offering, this group was more likely to have spent the most recent summer months working in a community pharmacy dispensary. In contrast, respondents in the second class of pharmacy students were very averse to providing typical pharmacy services, instead preferring to provide CDM, MTM and disease screening services. Consistent with these preferences, this group was more likely to seek out summer employment in a hospital or research setting or not at all.  6.3. Discussion & Conclusions This thesis describes many findings that can guide the development and implementation of patient-centred pharmacy services. Aside from discussing possible reasons that these services have not been widely adopted in the past (time constraints, inadequate remuneration, limited buy-in from patients and physicians), we have described several key considerations for healthcare decision-makers and pharmacy leaders. The first of these considerations is that few pharmacists have had experience with providing patient-centred services. In addition, when looking to implement these services in their practices, pharmacists are generally most concerned about their own personal income and job satisfaction and are most interested in providing services that have a medication focus such as MTM and in some cases, CDM. Finally, and perhaps most importantly, pharmacists’ preferences for different aspects of patient-centred care differ according to a number of factors. While some of these factors are obvious, like their current employment situation, they are not always measurable, like their personal attitudes or beliefs. Even so, it is these preferences that will largely dictate whether a   152 pharmacist will choose to offer a new service or will choose to continue with the status quo. Interestingly, this final consideration is highly intuitive but has remained largely absent in program development. It is unclear why so many programs have aimed for wide-scale implementation without first examining the preferences of pharmacists. Based on our findings, the poor uptake of these programs could be largely explained by these preferences. Some pharmacists are keen to offer services that will improve the outcomes of their patients, regardless of whether they will see any personal benefit. For many others, the risk that they will see a reduction in their personal income or job satisfaction outweighs their altruistic motivations. As a result, these groups need to be considered separately. For example, for a new MTM program, pharmacists who are motivated to offer patient-centred services could be invited into a small-scale pilot program. Following a successful pilot, program developers could expand the program to pharmacists who are motivated to offer the service, recognizing that this group will need to be assured that their income will stay the same, or better yet, will increase. Finally, when the program is already well established and deemed a success, it could be opened up to the remaining pharmacists, recognizing that many of these pharmacists are happy with the status quo and are not apt to offer the new service.  Considering that historical efforts to improve the delivery of patient-centred services have typically failed, one of the strengths of this research is that it looks beyond the type of services pharmacists can offer and seeks to find a way to improve the uptake of these services. By changing the approach to implementing patient-centred services and also changing the expectation that all pharmacists will be receptive, it is possible that new   153 programs will be increasingly sustainable and effective. Using an approach widely employed in the development and marketing of new products and services, we have created a guide for those looking to implement patient-centred pharmacy services by concentrating on pharmacists’ preferences. This approach is unique and our findings can be far-reaching and relevant to many other jurisdictions that are looking to expand pharmacists’ scope of practice. In addition, because this approach considered the preferences of a diverse group of pharmacist stakeholders – trainees, community pharmacists, clinical pharmacists, managers and owners - we have also been able to demonstrate that the preferences of one group are not the same as the preferences of another. With this consideration in mind, the developers of any new program will need to make a considerable effort to hear the voices of all concerned groups – not just the loudest ones.  One of the limitations of this research is that many respondents had little to no experience with providing patient-centred services. As a result, we were only able to capture their stated preferences using hypothetical scenarios. To address this and validate our findings, programs that use our suggestions should be evaluated for uptake. In addition, the effectiveness of these programs should also be evaluated to ensure that they are having a positive impact on patient outcomes and health resource use, and are cost- effective overall. Finally, pharmacists themselves should be asked to provide feedback on whether these services improved the quality of their work life and met their needs. Ultimately, all pharmacists will have to make a choice. With healthcare systems worldwide challenged in their ability to provide care, the status quo is unsustainable. As pharmacists reevaluate their roles in healthcare, they must look to the patient, not the   154 product, in their services. If pharmacists accept that they need to adopt a new model of care, they could make a significant difference in the health of their patients and in their lives as healthcare professionals. Using this information, it is our hope that future efforts to deliver patient-centred pharmacy care consider the voices of pharmacists and that these efforts are successful and widespread.   155 Table 6.1: Pharmacists and pharmacy students’ preferences for providing patient-centred services in a discrete choice experiment  Class Size Most Important Attribute Respondent Characteristics Pharmacists 1 38% Job satisfaction Staff pharmacists  Currently satisfied with job  Do not believe patient-centred services will increase job satisfaction  2 36% Service type Unlikely to be staff pharmacists, prefer to be clinical pharmacists or similar  Do not believe income should increase for providing patient-centred services  3 26% Income Clinical pharmacists but prefer to be pharmacy regional managers or owners  Have practiced for over 20 years  Not likely to be satisfied with job  Believe patient-centred services will increase job satisfaction  Believe income should increase for providing patient-centred services  Students 1 50% Income, Job Satisfaction  Worked previous summer in community pharmacy dispensary 2 50% Service Type Unlikely to have worked summer in a community pharmacy dispensary   156 6.4. References  1 Beney J, Bero LA, Bond C. Expanding the roles of outpatient pharmacists: effects on health services utilization, costs, and patient outcomes. Cochrane Database of Systematic Reviews 2000; Issue 2. Art. No.: CD000336. DOI: 10.1002/14651858.CD000336. 2 Roughead L, Semple S, Vitry A. The value of pharmacist professional services in the community setting. The Pharmacy Guild of Australia Website, 2009. (Accessed July 2, 2009, at http://beta.guild.org.au/research/funded_projects.asp.) 3 Willink D, Isetts B. Becoming ‘indispensable’: developing innovative community pharmacy practices. J Am Pharm Assoc 2005;45:376-89. 4 Beney J, Bero LA, Bond C. Expanding the roles of outpatient pharmacists: effects on health services utilization, costs, and patient outcomes. Cochrane Database of Systematic Reviews 2000; Issue 2. Art. No.: CD000336. DOI: 10.1002/14651858.CD000336. 5 Cranor CW, Bunting BA, Christensen DB. The Ashville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc 2003;43:173-84. 6 Bunting BA, Cranor CW. The Asheville Project: Long-Term Clinical, Humanistic, and Economic Outcomes of a Community-Based Medication Therapy Management Program for Asthma J Am Pharm Assoc 2006;46:133-47. 7 Cranor CW, Christensen DB. The Ashville Project: short-term outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc 2003;43:149-59. 8 Chan P, Grindrod KA, Bougher D, et al. A systematic review of remuneration systems for clinical pharmacy care services. Canadian Pharmacists Journal 2008;141:102-12.    157  9 Romanow R. Building on values: the future of health care in Canada. Saskatoon: Commission on the Future of Health Care in Canada, 2002:356 pages. 10 The Pharmaceutical Task Force. The report of pharmaceutical policy recommendations for the Ministry of Health. Vancouver (BC): Ministry of Health, 2008; 1-34. 11 Task Force on a Blueprint for Pharmacy. Blueprint for pharmacy: the vision for pharmacy. Ottawa (ON): Canadian Pharmacists Association; 2008. (Accessed August 1, 2009, at http://www.pharmacists.ca/content/about_cpha/whats_happening/cpha_in_action/pdf/Blu eprintVision.pdf.) 12 Grindrod KA, Rosenthal M, Lynd LD, et al. Pharmacist perspectives on providing chronic disease management services in the community (Part 1): Current Practice Environment; (Accepted to the Canadian Pharmacist Journal for the Sept/Oct 2009 issue). 13 Rosenthal M, Grindrod K, Lynd LD, et al. Pharmacist perspectives on providing chronic disease management services in the community (Part 2): Development & Implementation; (Accepted to the Canadian Pharmacist Journal for the Nov/Dec 2009 issue).   158          APPENDICES   159 APPENDIX 1: ETHICS CERTIFICATES  University of British Columbia Ethics Certificate: Focus Groups    160 University of Alberta Ethics Certificate: Focus Groups    161 University of British Columbia Ethics Certificate: Discrete Choice Experiment    162 University of Alberta Ethics Certificate: Discrete Choice Experiment     163 APPENDIX 2: FOCUS GROUP QUESTIONS 1. Please introduce yourself and tell everyone an aspect of why you enjoy your career.  2. What do you understand the term “chronic disease management” to mean?  3. Presently are there any chronic diseases for which you feel that your intervention would have the most benefit for patients?  4. At the present time are there any chronic diseases that you would feel comfortable managing? a. What about these diseases makes them manageable at the present time?  5. Are there any chronic diseases you might be interested in managing for which you do not currently have formal training? a. What kinds of additional training would you need to implement a chronic disease management model?  6. Could you foresee any differences in the strategies required to successfully manage chronic diseases between urban and rural settings? a. What are these potential differences?  7. If chronic disease management were to become part of your practice what changes do you think might be required in your day to day routine?  8. What enablers presently exist for the implementation of a chronic disease management model? a. How might these enablers be further capitalized upon?  9. What are the present barriers to the implementation of a management model for chronic disease? a. Where are these barriers erected? b. How might they be overcome? c. 10. What kinds of supports would need to be in place for a chronic disease management model to be successfully implemented in your community pharmacy?  11. What kind monetary compensation would you expect when providing chronic disease management services? a. How would you like this compensation to be provided? (ex. Fee for service, flat rate/patient/month or a combination of the two) b. 12. Is there anything that you would like to add or elaborate upon further?   164 APPENDIX 3: DISCRETE CHOICE EXPERIMENTS  A.3.1. Introduction When rolling out new pharmacy services in the community setting, pharmacists’ preferences will likely dictate if a service will be offered to the public and if it will suffer from poor uptake. Until recently, these preferences have been examined using qualitative methods (focus groups, surveys, interviews). Unfortunately, one of the major drawbacks is that these methods likely miss complexities such as trade-off behaviours or the relative strength of preference. Given that this is a challenge to many health services researchers regardless of whether they consider patient or provider preferences for service, it is becoming increasingly common to further examine preferences using methods borrowed from disciplines such as economics, psychology and marketing. Preferences can be measured in a variety of ways and the methods chosen depend on the certainty of the question and whether individuals will be asked to scale their preference or make a choice.1 When time permits, choice-based methods are generally preferred because they provide information on trade-offs. In terms of pharmacy services, preferences could be demonstrated by observing the choices of pharmacists who have access to various service alternatives. Certainly, in countries such as Australia, the U.K., and the U.S., where patient-centred services were implemented alongside traditional dispensing services,2 the poor uptake of new services suggests that most pharmacists preferred dispensing. However, while these decisions were made under real market constraints and are generalizable,3 it is difficult to determine why pharmacists chose dispensing services over the new services.   165 An alternative to the revealed preference data described is to ask pharmacists to choose between hypothetical services. The advantage of these stated preference methods is that we are not limited to currently available services so we can examine preferences for new services before they are implemented. We can also collect information on sociodemographic factors that may influence preferences (e.g., time in practice) to better understand why some individuals prefer one service to another. Unfortunately, one of the drawbacks is that hypothetical choices are not limited by real market constraints and what may sound reasonable on paper may not be as attractive in real-life. For these reasons, when looking to determine pharmacists’ preferences for patient-centred services, pharmacists’ choices in the real-world setting and their hypothetical choices can be used together to create a clearer picture of what is really wanted. By answering this question, future services can be tailored to pharmacy providers to ensure that these services are both adopted and sustained over the long-term.  A.3.2. Theoretical Background Using knowledge of the decision-making process and multivariate modeling, the fundamental theory of discrete choice experiments (DCE) was derived from the interdisciplinary fields of psychology, economics and statistics.4 Originally developed for market research,5 DCEs can be used to collect information on stated preference by asking individuals to consider products or services and to choose the one most preferred. To do this, it is assumed that a product or service can be described by attributes (or characteristics) and that every attribute is further described by two or more levels. This method also assumes that respondents have unique preferences for each attribute level.   166 This preference, known as a utility, is represented by the choice made and is the relative value someone places on an attribute level (a higher utility means that someone has a higher preference for that attribute level). By comparing the utilities for alternative products or service, we can determine the decision most important to participants. Using random utility theory, the utility (U) of an individual (i=1,…,n) for a specific alternative (j=1,…,J) is described by an explainable component (Vij) and a non- explainable random component (εij):  € Uij =Vij + εij       Eq. (A.1)  The explainable component includes the attributes (Xij) of the service, as viewed by the individual, and the characteristics of individual (Zi). Within this component, β and θ are the coefficients to be estimated:  € Vij = Xijβ + Ziθ       Eq. (A.2)  The non-explainable random component may be due to the presence of unobservable attributes, preference variation, errors in measurement or individual variability.4 As mentioned earlier, the DCE method assumes individuals will choose the alternative with the highest utility. Since the non-explainable random component is not observed in the choice, an individual’s choice is probabilistic rather than deterministic.6 Assuming a joint probability distribution for the non-explainable random component, the probability (P) an individual’s utility is maximized by choosing a specific alternative (Yi) is as follows:   167  € P(Yi1) = P(Ui1 >Uij ) = P(Vi1 + εi1 >Vij + εij ) = P(Vi1 −Vij > εi1 −εij )      Eq. (A.3)  The joint probability distribution for the non-explainable random component is chosen based on what is known about the unobserved factors and dictates how DCE preferences are modeled.  A.3.3. Experimental Design Several resources describe the experimental design and analysis of DCEs, both general7 and specific to healthcare4,8,9. Simply put, a DCE is designed by first identifying the products or services of interest (real or hypothetical) and breaking them down into attributes and attribute levels. Once the attributes and attribute levels have been identified, they can be used to describe a series of alternative products or services that are combined into choice-sets. The choice-sets are given to a sample of the target population and the data gathered is used to elicit preferences.  A.3.3.1. Identification of Attributes and Attribute Levels  Several methods can be used to identify potential attributes and attribute levels. In the case of health services research, potential service models and a list of possible attributes can be identified by reviewing the literature or with qualitative methods such as focus groups, interviews and surveys of stakeholders.10 Following this, the list is reduced to the most relevant attributes, ensuring they are not ambiguous or correlated with one   168 another.7 Then, for each attribute, a list of attribute levels is identified to reflect the range of plausible and relevant alternatives. While it can be difficult to determine the ideal number of attribute levels (too few will misrepresent the utility relationships and too many will be burdensome for respondents), levels are chosen to optimize information gathered on the utilities associated with each attribute level. In addition, levels must be both feasible and reasonable to ensure that choices are as realistic as possible. To provide an example of attributes and attribute levels, managers at a pharmacy chain may want to know pharmacists’ preferences for providing hypertension services. While they could simply ask pharmacists in a basic survey, it would be difficult to identify why one service was more popular than another. Instead, to better understand pharmacists’ preferences for one of these services, they could do some background work and identify that pharmacists consider three main attributes when choosing to provide a service: 1) the “type of service” possible levels: screening, medication therapy management (MTM), chronic disease management (CDM)); 2) the “time spent with patient” (possible levels: 15 minutes, 30 minutes, or 60 minutes); and, 3) the “location of service” (possible levels: dispensary or family physician’s office). Had they also identified ‘relationship with patient’ as an attribute, ambiguity would have made it difficult to determine what pharmacists felt a ‘good’ relationship was. Similarly, for some pharmacists, the time spent with the patient may have correlated with the relationship with the patient. For both reasons, ‘relationship’ would have been a poor choice for an attribute. Once the attributes have been identified, the need for a ‘none’ alternative should be considered. For many services, there will be individuals who are either content with the   169 status quo or who do not like the alternatives presented. By forcing them to choose one of the alternatives, their preferences or utility associated with some attributes could be overestimated.11 To ensure DCE results are realistic, a ‘none’ alternative can provide these non-demanders with an appropriate alternative. In the case of the pharmacy hypertension service, many pharmacists may not choose to provide the service if they are content with dispensing or if they do not feel qualified. For this reason, it would be prudent to offer a ‘none’ alternative that represents the status quo.  A.3.3.2. Questionnaire Development Once the attributes and attribute levels are identified, the choice-sets can be designed. Choice-sets must be created to ensure that only one service alternative is chosen (alternatives are mutually exclusive) and that the list of service alternatives is exhaustive but finite.6 The number of choice-sets depends on the number of service alternatives to be presented, and the number of possible attributes and attribute levels.1 For the hypertension service example, there are two service alternatives per choice-set, each described by three attributes (type of service, time spent with patient, location of service delivery). One attribute has two levels and two have three levels. In total, there would be 18 (21 x 32) possible choice-sets. In this case, a respondent could easily complete all choice-sets making a full-factorial design (one in which all possible combinations are used) possible. The advantage of using the full-factorial design is that, during study analysis, it is possible to test all the main effects (effects of each attribute) and interaction effects (effects between attributes).   170 Using this information, the pharmacy managers could create a choice-set and ask pharmacists to choose the alternative they most prefer (see Figure 4.1). For this choice- set, if a pharmacist prefers to limit patient contact time and remain in his or her current work environment, they may choose the screening service because it has a higher overall utility than the MTM service. To better understand these underlying utilities, the managers could ask pharmacists to continue to choose between a series of similar alternatives to gather information on how each attribute is driving the pharmacists decisions. For more complex questions with multiple attributes and attribute levels, the number of choice-sets can be large and a full-factorial design can be burdensome for respondents. In these situations, there are two ways to reduce the number of choice-sets provided to respondents: a blocked design and a fractional-factorial design. For the blocked design, choice-sets are randomly divided into blocks to create a series of different surveys (i.e., if there are 256 possible choice-sets, 16 questionnaires are developed with 16 choice-sets each). For a fractional-factorial design, only a sample of the possible choice-sets is used in the final questionnaire. To further maximize the number of choice-sets used for fractional-factorial designs, the sample of choice-sets can also be blocked to create multiple versions. When creating a fractional-factorial design, several considerations are made. First, the questionnaire design must provide adequate degrees of freedom to estimate the final model (including all main effects and relevant interaction effects). Second, the design should be orthogonal, meaning that all attribute levels should appear with one another with equal frequency. Third, all attribute levels should appear with equal frequency and   171 with minimal overlap in choice-sets. Fourth, there should be no dominant alternatives in the choice-sets to ensure that all alternatives have an equal probability of being chosen. Finally, the number of choice-sets to include in a questionnaire should be considered. Some sources suggest that up to 32 choice-sets per respondent is appropriate4 but individual variability increases with number of choice-sets, so this number is better kept to a minimum. Following questionnaire development, the DCE should be pilot tested on the target group to ensure that it is easy to understand and that it represents the realistic range of alternatives. This can be done by asking open-ended questions at the end of each pilot either in the questionnaire or through interviews.  A.3.3.3. Statistical Analysis To determine respondent preferences, all main effects are modeled:  € Vij = β0 + β1ij (X1ij ) + β2ij (X2ij )+,...,βkij (Xkij )    Eq. (A.4)  Choice-data can be coded using dummy coding or effect coding for categorical variables. For dummy coding, the number of dummy variables to be created per attribute is the number of attribute levels minus 1, and the base level is assigned a value of 0. Although dummy coding allows for the testing of the non-linear effects of all attributes, it confounds the established ‘base’ level of an attribute with the overall mean. For the hypertension attribute ‘time spent with patient’, the utility for the base level of 15 minutes would be the same as the overall mean:   172  € Vtime = β0 + βtime1(0) + βtime2(0) = β0 + 0 + 0 = β0      Eq. (A.5)  For this reason, it has become standard to use effect coding which does not confound the base attribute level with the overall mean of the attribute utility function. Effect coding is similar to dummy coding, except that the base attribute level is assigned a value of -1. Using effect coding, the utility for the base attribute level would now be:  € Vtime = β0 + βtime1(−1) + β time2(−1) = β0 −βtime1 −β time2     Eq. (A.6)   To choose the most appropriate model we need information on whether alternatives in the choice-set are independent and whether respondents’ preferences are heterogeneous (though it is difficult to initially determine if there is preference heterogeneity in either the explainable or non-explainable utility components, focus groups or a literature reviews can shed some light on this a priori). The most basic model is the multinomial logit model (MNL), which assumes that the unobserved factors that makeup the non-explainable random components of the utility are independently and identically distributed (iid). The MNL also assumes that all options within a choice-set are independent of irrelevant alternatives (IIA) meaning that there is proportional substitutability across alternvations.6 By comparison, the nested logit model (NLM) relaxes the IIA assumption between nests and if no correlation exists and the IIA   173 assumption holds, the NLM collapses into a MNL.15,11 The mixed logit model (MXL) relaxes the IIA assumption by allowing correlation across subjects and allows for preference heterogeneity by incorporating individual deviations from the mean. The MXL also allows the random component to follow any distribution and can approximate any DCE model.12 The latent class model relaxes the IIA assumption and accounts for heterogeneity by allowing preferences to vary between classes of individuals.13  A.3.4.  Methodological Concerns & Challenges DCEs can provide valuable information on the preferences of a group but there are several methodological challenges that must be considered.  A.3.4.1. Non-demanders in Discrete Choice Experiments As discussed earlier, some individuals may not wish to choose one of the available alternatives. Rather than forcing an individual to choose an option that they would not normally choose, a ‘none’ alternative can be added. Though few DCEs have included this option, by accounting for non-demanders, preference measures can be more representative of real-world conditions.14 That said, by choosing the ‘none’ alternative, we assume that an individual actually prefers that option when they may actually be opting-out of making a decision, especially if the decision is challenging.15 To minimize this, it has been suggested that the attributes of all alternatives should be described for the ‘none’ alternative to ensure they are weighed carefully.11 Another consideration is the IIA assumption. When creating a choice-set, it is assumed that all available alternatives can be substituted for one another. However, when   174 a ‘none’ alternative is present, an individual may employ a multi-step decision making process whereby they first decide if the service alternatives are attractive, and if not, decide if they prefer the ‘none’ alternative. Because the ‘none’ alternative does not directly compete with the service alternatives but rather with the decision choose a service at all, the IIA assumption does not hold. To address this, an analytic model that considers the cross-elasticity of substitution across alternatives should be used (NLM and MXL have been suggested11).  A.3.4.2. Decision Making Strategies According to the choice at hand, individuals use different decision-making strategies, which can affect both the choice made, and whether an individual will be a non- demander. Because DCEs minimize the presence of dominant options, decisions can be difficult, leading decision-makers to try to create dominant choices. One example is the use of the lexicographic decision strategy to order attributes according to importance. Using this strategy, a decision-maker decides if one choice is clearly dominant by looking at the service attribute that is most important to them. The service with the dominant attribute level will be chosen and if there is no dominant choice, the second attribute will be considered, then the third and so on.15 Approaches such as this can minimize the number of non-demanders because decisions are less difficult. However, by limiting the consideration given to the other attributes, less information is gathered from choice data. To minimize this, individuals completing choice tasks should be encouraged to consider all attributes and choice-sets should be designed in a way that maximizes this.    175 A.3.4.3. Rationality vs. Irrationality  One area of controversy is whether to disregard ‘irrational’ choices. Typically, DCEs include some measure of participant rationality or internal consistency. Methods to measure rationality include adding choice-sets that assess transitivity, test-retest or logic.16 In tests of transitivity, an individual who prefers A to B and B to C should prefer A to C (C should be the least desirable option). In test-retest questions, an individual who prefers A to B in one question should prefer A to B when the question is repeated. In logic tests, an individual should prefer a clearly dominant option. Convention has been to exclude individuals who fail these tests, as they are deemed to be ‘irrational’. However, Lancsar and Louviere17 argue these cases of irrationality may be due to a shortcoming of the test or DCE design, or alternatively, to the respondent learning about their preferences as they progress through the choice-sets. If this is the case, excluding ‘irrational’ individuals could bias the results. Either way, the final preference estimates for all respondents and rational respondents should be compared. If there is a significant difference between the groups, more investigations should be done to assess this.  A.3.5. Discrete Choice Experiments of Pharmacy Services In regards to pharmacy services, one DCE was recently completed that examined community pharmacists’ preferences for existing and potential roles under the Scottish Community Pharmacy contract.18 In this DCE, Scott et al. used a literature review, focus groups and interviews to identify seven attributes that defined pharmacists roles in primary care: pharmacy team; change in annual income; location for the service; type of service; change in number of prescriptions dispensed per month; integration with primary   176 and secondary care; and type of minor illness and health promotion advice provided. They employed a fractional-factorial design with two alternatives per choice-set, they had 914 respondents from across Scotland. Using dummy coding to construct a probit model, the authors of this DCE found that pharmacists preferred to have a pharmacy assistant to only having a cashier and preferred to have more income to less. While pharmacists did not have a strong preference to provide either repeat dispensing or CDM, they did prefer to perform medication reviews in the dispensary compared doing them in a physician’s office or not at all. Similarly, they also preferred to provide minor illness services to providing both minor illness and health promotion advice or to neither service. The authors concluded that the pharmacist respondents placed ‘a higher value on organizational aspects of work’ rather than on the new pharmacy services. The DCE described above provides some insight into pharmacists’ preferences for new pharmacy services, especially considering that the pharmacists preferred to provide services consistent with their product-centred roles (medication reviews, repeat dispensing, minor illness advice) to more patient-centred roles (CDM, health promotion advice). That said, this study did have some limitations. First, the authors did not account for non-demanders and had a slight over-representation from middle aged pharmacists. Also, in the analysis, they did not account for preference heterogeneity in their probit model and did not segment the results across different types of respondents, making it difficult to determine whether the results are representative of all pharmacists. That said, this study does provide insight into pharmacists’ preferences for changes in the way they practice.   177  A.3.6. Conclusion  Given the past challenges faced by those developing programs for patient-centred pharmacy services, more needs to be known about pharmacists’ preferences for these services. To guide the development and implementation of these programs, pharmacists’ revealed preferences should be considered and their stated preferences should be elucidated. For the latter, choice-based measures of preference are ideal. Using DCE methodology, pharmacies preferences for evidence-based services such as CDM, MTM and screening should be explored.   178 Figure A.1:  Example discrete choice experiment choice-set for new pharmacy hypertension services   Option 1 Option 2 Option 3 Type of Service Screening MTM Time spent with patient 15 minutes 60 minutes Location Dispensary Clinic I do not want to offer either of these services Choose one option MTM, Medication Therapy Management   179  A.3.7. References  1 Drummond MF, Sculpher MJ, Torrance GW, O’Brien BJ, Stoddart GL. Methods for the economic evaluation of health care programmes. 3rd ed. New York, NY: Oxford University Press, 2005:141-61. 2 Chan P, Grindrod KA, Bougher D, et al. A systematic review of remuneration systems for clinical pharmacy care services. Canadian Pharmacists Journal 2008;141:102-12. 3 Paradigms of choice data. In: Hensher DA, Rose, JM, Greene WH. Applied choice analysis: A Primer. New York, NY: Cambridge University Press, 2005:88-99. 4 Lancsar E, Louviere J. Conducting discrete choice experiments to inform healthcare decision making: a user’s guide. Pharmacoeconomics 2008;26:661-77. 5 Louviere J, Woodworth G. Design and analysis of simulate consumer choice or allocation experiments: an approach based on aggregated data. J Mark Res 1983;890:11- 7. 6 Train KE. Discrete choice methods with simulation. 2nd ed. New York, NY: Cambridge University Press, 2009. (Accessed June 25, 2009, at http://elsa.berkeley.edu/books/choice2.html.) 7 Processes in setting up stated choice experiments. In: Hensher DA, Rose JM, Greene WH. Applied choice analysis: A Primer. New York, NY: Cambridge University Press, 2005:100-60. 8 Ryan M, Bate A, Eastmond CJ, Ludbrook A. Use of discrete choice experiments to elicit preferences. Qual Health Care 2001;10:i55-i60.    180  9 Ryan M, Scott D, Reeves C, et. al. Eliciting public preferences for health care: a systematic review of the techniques. Health Technol Assess 2001;5(5):1-186. 10 Coast J, Horrocks S. Developing attributes and levels for discrete choice experiments using qualitative methods. Journal of Health Services Research & Policy 2007;12:25-30. 11 Ryan M, Skatun D. Modelling non-demanders in choice experiments. Health Econ 2004;13:397-402. 12 McFadden D, Train KE. Mixed MNL models for discrete response.  Journal of Applied Econometrics 2000;15:447-70. 13 Colombo S, Hanley N, Louviere J. Modeling preference heterogeneity in stated choice data: an analysis for public good generated by agriculture. Agricultural Economics 2009;40:307-22. 14 Ryan M, Gerard K. Using discrete choice experiments to value health care programmes: current practice and future research reflections. Appl Health Econ Health Policy 2003;2:55-64. 15 Dhar R. Context and task effects on choice deferral. Marketing Lectures 1997;8:119- 30. 16 Johnson FR, Ozdemir S, Mansfield C, et al. Crohn’s disease patients’ risk-benefit preferences: serious adverse event risks versus treatment efficacy. Gastroenterology 2007;133:769-79. 17 Lancsar E, Louviere J. Deleting ‘irrational’ responses from discrete choice experiments: a case of investigating or imposing preferences? Health Econ 2006;15:797- 811.    181  18 Scott A, Bond C, Inch J, Grant A. Preferences of community pharmacists for extended roles in primary care: a survey and discrete choice experiment. Pharmacoeconomics 2007; 25:783-92.   182 APPENDIX 4: QUESTIONNAIRE (SELF-ADMINISTERED ONLINE)   The following pages contain the entire online questionnaire that pharmacists and pharmacy students completed. Included are 18 discrete choice experiment (DCE) choice- sets. As described in Chapter 6, with the number of attributes and attribute levels included in the final DCE we could have used 810 possible choice-sets. To reduce this number, we employed a fractional factorial design that used only 320 choice-sets divided into 20 different versions (16 choice-sets per version). In addition, we included two fixed-repeated questions at the position of question 5 and 13 to assess respondent consistency. As such, the survey included in this appendix includes only one version of the DCE.     Pharmacists & Chronic Disease Management   What matters to you?  We want to know pharmacists preferences and opinions on getting paid for their expanding roles. If you are a pharmacist or a 4th year pharmacy student in BC or Alberta, we want to hear what you think. The survey takes between 15-30 minutes. Participants that complete the survey can enter a draw for a Dell Laptop or one of four $250 Future Shop Gift Cards. The information used for the draw cannot be connected with survey responses and will only be used to distribute the prizes. All survey responses are anonymous. Click "next" to enter the survey.    Next Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Start  Pharmacists & Chronic Disease Management Study Consent to Participate   Study of Understanding Pharmacists’  Perspectives on Remuneration and Transition towards Chronic Disease Management – Discrete Choice Experiment(SUPPORT–CDM DCE)  This agreement is available at http://www.core.ubc.ca/support/consent.html  SPONSOR Canadian Foundation for Pharmacy FOR QUESTIONS ABOUT PARTICIPATING IN THE SURVEY Your continued participation should be as informed as your initial consent so you should feel free to ask for clarification or new information throughout your participation. If you have any questions or desire further information with respect to this study, you may contact the Principal Investigator, Dr. Larry Lynd, at 604-806- 9447. You are being invited to take part in this research study because you are either a licensed pharmacist or a 4th year pharmacy student in the province of either British Columbia or Alberta. YOUR PARTICIPATION IS VOLUNTARY Principle Investigator: Larry Lynd, PhD Assistant Professor Faculty of Pharmaceutical Sciences University of British Columbia 604.806.9447 Co-Investigator: Carlo Marra, PhD Associate Professor Faculty of Pharmaceutical Sciences University of British Columbia 604.806.9810 Co-Investigator: Ross Tsuyuki, PharmD, Msc Professor Faculty of Medicine University of Alberta Con sen t Your participation is entirely voluntary. You have the right to refuse to participate in this study. If you decide to participate, your decision is not binding and you may choose to withdraw from the study at any time without any negative consequences to your professional standing or to your current or future employment. WHO IS CONDUCTING THE STUDY? This study is being conducted by the Collaboration for Outcomes Research and Evaluation (CORE), located at the University of British Columbia (UBC) and Providence Health Care. In addition, researchers from the Centre for Community Pharmacy Research and Interdisciplinary Strategies (c/COMPRIS) at the University of Alberta are also involved. This study is supported by a grant from the Canadian Foundation for Pharmacy and trainee funds from the Michael Smith Foundation for Health Research and the Canadian Institutes for Health Research. BACKGROUND Many Canadian provinces are expanding allied health professionals’  (i.e., nurses, pharmacists) roles. Pharmacy practice-based research has demonstrated that new services by community pharmacists, such as chronic disease management and medication therapy management, can improve patient care. Worldwide, many new practice and payment models have been developed to support these services. Most models have been directly funded by government agencies, have focused on CDM (e.g. diabetes education) and have employed fee-for-service payment systems. Unfortunately, poor pharmacist participation has meant that many models have proven unsustainable. Despite this, very little research has been done to ask pharmacists about their opinions and preferences for providing services that are unrelated to dispensing. WHAT IS THE PURPOSE OF THE STUDY? The purpose of this study is to investigate Canadian pharmacists’  preferences for providing CDM to patients in the community setting. In addition, we would like to determine the value that pharmacists place on different aspects of payment models, using a survey technique known as a discrete choice experiment (DCE). WHO CAN PARTICIPATE IN THE STUDY? You are eligible to participate if you meet the following criteria: ·         Licensed to practice pharmacy in the provinces of Alberta or BC, or; ·         Enrolled in the 4th  year of the Bachelor of Science in Pharmacy program at either the University of British Columbia or the University of Alberta. WHO SHOULD NOT PARTICIPATE IN THE STUDY? If you do not hold a license to practice pharmacy or are currently enrolled in a pharmacy program, you are not eligible to participate. WHAT DOES THE STUDY INVOLVE? This study will take place in both Alberta and British Columbia. In total, 200 participants will be enrolled in the study. To participate, you will be required to complete an online survey about payment models that support CDM by pharmacists. There will be two sections to complete. It should take you approximately 15-30 minutes to complete the survey. You may have received this letter through your local pharmacy college, association or employer. In this study, the role of these organizations is limited to forwarding the Letter of Information to pharmacists practicing in Alberta and British Columbia. Your participation and your individual survey responses will not be shared with any third party.   Your participation and your individual survey responses will not be shared with any third party. Overview of the Study This study seeks to understand pharmacist preferences for payment models that support CDM by pharmacists. These services may include patient education, medication reviews or CDM. Using a special type of survey, known as a DCE, pharmacists will be asked to trade-off different characteristics of potential models. The DCE is a method commonly used in market research. By analyzing survey results, we can identify the characteristics of payments models that are most important to pharmacists. For example, a survey may ask a pharmacist to make a choice between being paid $30 for a 15 minute medication review or $120 for 60 minutes of diabetes management. By varying these different characteristics (e.g., fee paid) according to their levels (e.g., $30, $120), we can determine both the characteristics and levels that pharmacists preferred. If You Decide to Join This Study: Specific Procedures Survey Once you have logged on to the website (www.core.ubc.ca/support) and accessed the survey, you will be asked to review and agree to the informed consent agreement. You may also access the consent agreement on the website. You will then be directed to the first section of the survey which will ask a series of questions about you, including your year of graduation, gender, age and your current job description. The purpose of these questions is to determine how certain characteristics influence your preferences for providing CDM. The second section of the survey will include 18 questions to determine your preferences for different aspects of CDM. In each question, you will be given two scenarios and asked to choose your preferred scenario. It will take you approximately 15-30 minutes to participate in the research study. You may complete the questionnaire at home or at work by accessing the website. Prize Draw for Survey Tell us what you think and you could WIN a Dell laptop or one of four $250 gift cards to Future Shop. On the last page of the survey, you will be redirected to a separate webpage. On this webpage, you will be asked to provide your name and mailing address. Your contact information will be kept in a password protected file and will only be used for prize mailings. Your contact information will not be connected with your questionnaire responses and will be destroyed once all the prizes have been distributed. You are not required to provide your contact information and may choose to remain anonymous. Permission to contact you for future studies On completion of the survey, you will be redirected to the website where you will be asked if you would like to be contacted for future studies. This information will not be shared with any third party and will only be used to send out information on upcoming studies. Your confidentiality will be respected. Information that discloses your identity will not be released without your consent unless required by law or regulation.  No records that identify you by name or initials will be allowed to leave the investigators office. RIGHTS AND COMPENSATION By signing this form, you do not give up any of your legal rights and you do not release the participating institutions from their legal and professional duties. There will be no costs to you for participation in this study. You will not be charged for any research procedures. CONFIDENTIALITY Your confidentiality will be respected. Information that discloses your identity will not be released without your consent unless required by law or regulation.  However, research records identifying you may be inspected in the presence of the investigator or his or her designate, by representatives of (name the sponsoring company, if relevant), Health Canada, (the U.S. Food and Drug Administration, if relevant), and the UBC-PHC Research Ethics Board for the purposes of monitoring the research.  No records that identify you by name or initials will be allowed to leave the investigator’s office. By agreeing to provide consent, you are authorizing this access. If results of the trial are published, you will not be identified in any way. RIGHTS AS A RESEARCH SUBJECT If you have any concerns about your rights as a research subject and/or your experiences while participating in this study, contact the ‘Research Subject Information Line in the University of British Columbia Office of Research Services’  at 604-822-8598”  or the Chair of the UBC-PHC Research Ethics Board at 604-682-2344 ext 63496. CONSENT TO PARTICIPATE IN SUPPORT-CDM DCE I have read and understood the subject information provided on the website. I understand that my participation in this study is entirely voluntary and that I may decline to participate in the study or that I may withdraw from it at any time. I understand that I am not waiving any of my legal rights by agreeing to participate in this study. I understand that there is no guarantee that this study will provide any benefits to me. I have had sufficient time to consider the information provided. I have had the opportunity to have my questions answered. I understand that all of the information collected will be kept private and that the results will be used for scientific objectives. I have read this agreement and I freely consent to participate in this research study under the direction of the Principal Investigator, Dr. Larry Lynd.   nmlkj I Agree  nmlkj I Disagree    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia  Pharmacists & Chronic Disease Management STUDY ELIGIBILITY To be included in this study, you must be either a licensed pharmacist or a 4th year pharmacy student.  Which of the fol lowing best describes your current status:   nmlkj Currently l icensed by the Col lege of Pharmacists of Brit ish Columbia  nmlkj Currently l icensed by the Alberta Col lege of Pharmacists  nmlkj 4th Year Pharmacy Student at the University of Brit ish Columbia  nmlkj 4th Year Pharmacy Student at the University of Alberta  nmlkj None of  the above    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Pharmac i s tS ta tus  Pharmacists & Chronic Disease Management Before you get started, here are some helpful hints. 1. Once you've answered al l  the questions on the screen, c l ick 'next'  to advance. 2. To see more information about a specif ic term (e.g., typical pharmacy services), hold your mouse pointer over the term. If you cannot see the definit ion, click here to have a l ist of def init ions appear in a separate browser. It should look like this:    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia In t ro     Pharmacists & Chronic Disease Management SECTION I: ABOUT YOU You may decline to answer some questions in this section, but please remember it is very important that we get the most accurate and complete information we can. All the information you provide is completely confidential and anonymous. 1. How long have you been a pharmacist?   nmlkj Less than 5 years  nmlkj 5-9 years  nmlkj 10-19 years  nmlkj 20-29 years  nmlkj More than 30 years 2. Do you l ive in a two-income household?   nmlkj Yes  nmlkj No 3. How many chi ldren do you have?  4. How many children are sti l l  l iving at home? [If you do not have any children, please skip to the next question.]     Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Grad Mar i ta lS ta tus Ch i l d ren Ch i l d ren2   Pharmacists & Chronic Disease Management 5. What pharmacy-related educat ion have you received? [Select all that apply]    gfedc Undergraduate Pharmacy Degree (e.g. BScPharm, BSP)   gfedc PharmD (entry-level)   gfedc PharmD (post-BScPharm)   gfedc Community Residency   gfedc Hospital Residency   gfedc Accredited Disease Management Program (e.g. Cert i f ied Diabetes Educator)   gfedc Graduate Degree (e.g. MSc, PhD, MBA):    gfedc Other: 6. What accredited disease management cert i f icat ion(s) have you completed? [Select all that apply]    gfedc Cert i f ied Diabetes Educator   gfedc Certif ied Asthma Educator   gfedc Certif ied Geriatric Pharmacist   gfedc Other:   gfedc None of  the above    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Educat ion Educat ion_1 Educat ion_2 Educat ion_3 Educat ion_4 Educat ion_5 Educat ion_6 Educat ion_7 Educat ion_7_other Educat ion_8 Educat ion_8_other Educat ion2 Educat ion2_1 Educat ion2_2 Educat ion2_3 Educat ion2_4 Educat ion2_4_other Educat ion2_5   Pharmacists & Chronic Disease Management 7. How many days per week have you worked as a pharmacist  over the past 12 months?   nmlkj Less than 1 day per  week  nmlkj 1-2 days per  week  nmlkj 3-4 days per  week  nmlkj 5 or more days per week 8. Please est imate your gross annual income (before taxes) from your work as a pharmacist over the past 12 months?   nmlkj Less than $25,000  nmlkj $25,000 to $49,999  nmlkj $50,000 to $74,999  nmlkj $75,000 to $99,999  nmlkj $100,000 to $124,999  nmlkj Greater than $125,000  nmlkj I  prefer not to answer this quest ion    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia DaysWo rked I n c o m e    Pharmacists & Chronic Disease Management SECTION II: WORK ENVIRONMENT Please consider only the past 12 months when answering these questions. If you practice in more than one setting, describe the one where you spend most of your time. 1. What best descr ibes your current posit ion? [Note: if you have more than one position, you can provide additional information in the next question.]   nmlkj Community pharmacist (staff)  nmlkj Community pharmacy store manager  nmlkj Community pharmacy owner  nmlkj Regional manager (includes regional manager, director, CEO etc.)  nmlkj Outpatient hospital pharmacist  nmlkj Inpatient hospital pharmacist  nmlkj Long-term care pharmacist  nmlkj Primary care pharmacist  nmlkj Other:  2. I f  you have more than one posit ion, please select the opt ions that best descr ibe your other posit ions. [If you do not have another position, please skip to the next question] [Select all that apply.]    gfedc Community pharmacist (staff)   gfedc Community pharmacy store manager   gfedc Community pharmacy owner   gfedc Regional manager (includes regional manager, director, CEO etc.)   gfedc Outpatient hospital pharmacist   gfedc Inpatient hospital pharmacist   gfedc Long-term care pharmacist   gfedc Primary care pharmacist   gfedc Other:  3. What is your ideal pharmacy posit ion?   nmlkj Community pharmacist (staff)  nmlkj Community pharmacy store manager  nmlkj Community pharmacy owner  nmlkj Regional manager (includes regional manager, director, CEO etc.)  nmlkj Outpatient hospital pharmacist  nmlkj Inpatient hospital pharmacist JobDesc r ip t i on JobDescr ip t ion_9_other JobDesc r ip t i onOther JobDesc r ip t i onOther_1 JobDesc r ip t i onOther_2 JobDesc r ip t i onOther_3 JobDesc r ip t i onOther_4 JobDesc r ip t i onOther_5 JobDesc r ip t i onOther_6 JobDesc r ip t i onOther_7 JobDesc r ip t i onOther_8 JobDesc r ip t i onOther_9 JobDescr ip t ionOther_9_other Idea lDesc r i p t i on  nmlkj Long-term care pharmacist  nmlkj Primary care pharmacist  nmlkj Other:     Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Idea lDesc r ip t i on_9_other  Pharmacists & Chronic Disease Management You indicated that you are a community pharmacist, manager or owner. What type of pharmacy do you work in?   nmlkj Independent community pharmacy  nmlkj Banner store or small chain-store pharmacy  nmlkj Large chain-store pharmacy  nmlkj Other:     Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia WorkEnv i ro1 WorkEnv i ro1_4_other   Pharmacists & Chronic Disease Management 4. What types of  patient-services does your pract ice provide? [Select all that apply]    gfedc Screening for the presence of chronic diseases   gfedc Medication review & management   gfedc Managing al l  aspects of chronic diseases (e.g., diabetes)   gfedc Prescription tailoring (e.g., bio-identical hormone replacement therapy)   gfedc Drug information unrelated to dispensing (e.g., telephone service)   gfedc Therapeutic drug monitoring (e.g., pharmacokinetic monitoring of anti-epileptic medications)   gfedc Renal dosing of medication therapy   gfedc Other:    gfedc No patient services other than f i l l ing prescript ions, counsel ing and OTC consultat ions 5. In your pharmacy, how many prescript ions are dispensed dai ly? [This does not include prescription batching, methadone, daily refills, or nursing home prescriptions.]   nmlkj Less than 50  nmlkj 50 to 99  nmlkj 100 to 199  nmlkj 200 to 299  nmlkj 300 to 399  nmlkj Greater than 400  nmlkj Not appl icable  nmlkj I  prefer not to answer this quest ion    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia WorkEnv i ro2 WorkEnv i ro2_1 WorkEnv i ro2_2 WorkEnv i ro2_3 WorkEnv i ro2_4 WorkEnv i ro2_5 WorkEnv i ro2_6 WorkEnv i ro2_7 WorkEnv i ro2_8 WorkEnv i ro2_8_other WorkEnv i ro2_9 WorkEnv i ro5   Pharmacists & Chronic Disease Management 6. When you are working as a pharmacist,  est imate the percentage of t ime you spend providing directly related to dispensing (e.g., medication counseling, drug distribution, bl ister packing, OTC product selection, compounding)?   nmlkj Less than 10% (e.g., 45 minutes of an 8-hour shift)  nmlkj 25% (e.g., 2 hours of an 8-hour shift)  nmlkj 50% (e.g., 4 hours of an 8-hour shift)  nmlkj More than 75% (e.g., 6 hours of an 8-hour shift) 7. When you are working as a pharmacist,  est imate the percentage of your t ime that you spend providing services not directly related to dispensing (e.g., disease screening, medication management, diabetes education, drug information unrelated to dispensing)?   nmlkj Less than 10% (e.g., 45 minutes of an 8-hour shift)  nmlkj 25% (e.g., 2 hours of an 8-hour shift)  nmlkj 50% (e.g., 4 hours of an 8-hour shift)  nmlkj More than 75% (e.g., 6 hours of an 8-hour shift)    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia WorkEnv i ro3 WorkEnv i ro4  Pharmacists & Chronic Disease Management 8. Where is your practice geographical ly located?   nmlkj Rural area (populat ion less than 1000)  nmlkj Small urban area (population 1000 to 99,999)  nmlkj Medium urban area (population 100,000 to 499,999)  nmlkj Large urban area (populat ion 500,000 to 999,999)  nmlkj Large metropol itan area (populat ion greater than 1,000,000)    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia WorkRu ra l  Pharmacists & Chronic Disease Management 9. In the introduction, you indicated that you are a pharmacist in BC. In what health authority is your practice geographical ly located?   nmlkj Vancouver Coastal  nmlkj Fraser  nmlkj Vancouver Island  nmlkj Interior  nmlkj Northern  nmlkj Provincial Health Service  nmlkj Other:    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia WorkBCHA WorkBCHA_7_other  Pharmacists & Chronic Disease Management 9. In the introduction, you indicated that you are a pharmacist in Alberta. In what health region is your practice geographical ly located?   nmlkj Chinook Health  nmlkj Pal l iser Health Region  nmlkj Calgary Health Region  nmlkj David Thompson Health Region  nmlkj East Central  Health  nmlkj Capital  Health  nmlkj Aspen Regional Health  nmlkj Peace Country Health  nmlkj Northern Lights Health Region  nmlkj Other:    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia WorkABHA WorkABHA_10_other     Pharmacists & Chronic Disease Management SECTION I: ABOUT YOU You may decline to answer some questions in this section, but please remember it is very important that we get the most accurate and complete information we can. All the information you provide is completely confidential and anonymous. 1. Where have you had most of your pharmacy experience?   nmlkj Community pharmacy  nmlkj Outpatient hospital pharmacy  nmlkj Inpatient hospital pharmacy  nmlkj Primary care clinic  nmlkj Other: 2. When you graduate, which opt ion wi l l  best descr ibed your household income?   nmlkj One-income household  nmlkj Two-income household  nmlkj Live with family (won't contr ibute to household expenses)  nmlkj Live with family (contribute to household expenses)  nmlkj Other: 3. How many chi ldren do you have?  4. How many children are sti l l  l iving at home? [If you do not have any children, please skip to the next question.]     Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia StudJobDesc r ip t i on StudJobDescr ip t ion_5_other StudMar i ta lS ta tus StudMar i ta lSta tus_5_other S tudCh i l d ren StudCh i l d ren2   Pharmacists & Chronic Disease Management SECTION I: ABOUT YOU 5. What educat ion have you received? [Select all that apply]    gfedc Undergraduate degree   gfedc Graduate degree (e.g. MSc, PhD)   gfedc Other:    gfedc None of  the above 6. Where do you plan to work after you graduate?   nmlkj Community pharmacy  nmlkj Hospital pharmacy  nmlkj Hospital pharmacy residency  nmlkj Community pharmacy residency  nmlkj Primary care clinic  nmlkj Pharmaceutical industry  nmlkj Other:  nmlkj None of  the above - I  p lan to leave the profession    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia StudEducat ion StudEducat ion_1 StudEducat ion_2 StudEducat ion_3 StudEducat ion_3_other StudEducat ion_4 StudFutDescr ip t ion StudFutDescr ip t ion_7_other   Pharmacists & Chronic Disease Management SECTION I: ABOUT YOU 7. P lease est imate the average number of days per week that you worked in a community pharmacy during the last school year?   nmlkj Less than 1 day per  week  nmlkj 1-2 days per  week  nmlkj 3-4 days per  week  nmlkj 5 or more days per week 8. P lease est imate the average number of days per week that you worked in a community pharmacy during the most recent summer months?   nmlkj Less than 1 day per  week  nmlkj 1-2 days per  week  nmlkj 3-4 days per  week  nmlkj 5 or more days per week    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia StudDaysWorked S tudDaysWorkedSummer  Pharmacists & Chronic Disease Management SECTION I: ABOUT YOU Why did you work in a community pharmacy less than 1 day per week during the most recent summer months?   nmlkj Worked in hospital pharmacy  nmlkj Worked for pharmaceutical industry  nmlkj Worked for pharmacy organization (e.g., CPhA)  nmlkj Worked in research studentship  nmlkj Unable to f ind employment  nmlkj Not interested in working in summer months  nmlkj Other:    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia StudDaysSummerWhy StudDaysSummerWhy_7_other    Pharmacists & Chronic Disease Management SECTION II: STUDENT WORK ENVIRONMENT Please consider your most recent job in a community pharmacy. If you worked in more than one pharmacy, describe the one where you spent most of your time. 1. What type of community pharmacy have you worked in most recently?   nmlkj Independent community pharmacy  nmlkj Banner store or small chain-store pharmacy  nmlkj Large chain-store pharmacy  nmlkj Other:  2. What patient services did the pharmacy provide? [Select all that apply]    gfedc Screening for the presence of chronic diseases   gfedc Medication review & management   gfedc Managing al l  aspects of chronic diseases (e.g., diabetes)   gfedc Prescription tailoring (e.g., bio-identical hormone replacement therapy)   gfedc Drug information unrelated to dispensing (e.g., telephone service)   gfedc Therapeutic drug monitoring (e.g., pharmacokinetic monitoring of anti-epileptic medications)   gfedc Renal dosing of medication therapy   gfedc Other:    gfedc No patient services other than f i l l ing prescript ions, counsel ing and OTC consultat ions 3. In the pharmacy, est imate how many prescript ions were dispensed dai ly.   nmlkj Less than 50  nmlkj 50 to 99  nmlkj 100 to 199  nmlkj 200 to 299  nmlkj 300 to 399  nmlkj Greater than 400  nmlkj Not appl icable  nmlkj I  prefer not to answer this quest ion StudWorkEnv i ro1 StudWorkEnv i ro1_4_other StudWorkEnv i ro2 StudWorkEnv i ro2_1 StudWorkEnv i ro2_2 StudWorkEnv i ro2_3 StudWorkEnv i ro2_4 StudWorkEnv i ro2_5 StudWorkEnv i ro2_6 StudWorkEnv i ro2_7 StudWorkEnv i ro2_8 StudWorkEnv i ro2_8_other StudWorkEnv i ro2_9 StudWorkEnv i ro5    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia   Pharmacists & Chronic Disease Management 4. Est imate the percentage of your t ime that you spent providing services directly related to dispensing (e.g. medication counseling, drug distribution, bl ister packing, OTC product selection)?   nmlkj Less than 10% (e.g., 45 minutes of an 8-hour shift)  nmlkj 25% (e.g., 2 hours of an 8-hour shift)  nmlkj 50% (e.g., 4 hours of an 8-hour shift)  nmlkj More than 75% (e.g., 6 hours of an 8-hour shift)  nmlkj Not appl icable 5. Est imate the percentage of your t ime that you spent providing services not related to dispensing (e.g. medication review, diabetes education, drug information)?   nmlkj Less than 10% (e.g., 45 minutes of an 8-hour shift)  nmlkj 25% (e.g., 2 hours of an 8-hour shift)  nmlkj 50% (e.g., 4 hours of an 8-hour shift)  nmlkj More than 75% (e.g., 6 hours of an 8-hour shift)  nmlkj Not appl icable    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia StudWorkEnv i ro3 StudWorkEnv i ro4  Pharmacists & Chronic Disease Management SECTION III: SATISFACTION WITH WORK This section asks some very specific questions about your job satisfaction. All the information provided is anonymous and not linked to your identity. 1. Please rate your agreement with the following statements:  St rong ly  d i sag ree  D i sag ree  Neutra l  Ag ree  S t rong ly  agree I am currently sat isf ied with my job  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj I find my job rewarding  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj I  do not enjoy being a pharmacist  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj I am considering leaving my current job  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj I enjoy al l aspects of my job  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj I am considering a career change  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj Providing d isease management services wil l increase my job satisfact ion  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Sa t i s f i edWork Sat i s f i edWork_r1 Sat i s f i edWork_r1 Sat i s f i edWork_r1 Sat i s f i edWork_r1 Sat i s f i edWork_r1 Sat i s f i edWork_r2 Sat i s f i edWork_r2 Sat i s f i edWork_r2 Sat i s f i edWork_r2 Sat i s f i edWork_r2 Sat i s f i edWork_r3 Sat i s f i edWork_r3 Sat i s f i edWork_r3 Sat i s f i edWork_r3 Sat i s f i edWork_r3 Sat i s f i edWork_r4 Sat i s f i edWork_r4 Sat i s f i edWork_r4 Sat i s f i edWork_r4 Sat i s f i edWork_r4 Sat i s f i edWork_r5 Sat i s f i edWork_r5 Sat i s f i edWork_r5 Sat i s f i edWork_r5 Sat i s f i edWork_r5 Sat i s f i edWork_r6 Sat i s f i edWork_r6 Sat i s f i edWork_r6 Sat i s f i edWork_r6 Sat i s f i edWork_r6 Sat i s f i edWork_r7 Sat i s f i edWork_r7 Sat i s f i edWork_r7 Sat i s f i edWork_r7 Sat i s f i edWork_r7  Pharmacists & Chronic Disease Management SECTION III: SATISFACTION WITH WORK 2. In the past 12 months, have you left  your job or started a new job?   nmlkj Yes  nmlkj No    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Sat i s f i edQu i t  Pharmacists & Chronic Disease Management SECTION III: SATISFACTION WITH WORK 2b. Why did you leave your job or start  a new job?      Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Sat i s f i ed2   Pharmacists & Chronic Disease Management SECTION III: SATISFACTION WITH WORK 3. If you were only able to provide typical pharmacy services in your job, how satisfied with your job would you be?  Very  d i s sa t i s f i ed  D i s sa t i s f i ed Ne i the r  sa t i s f i ed  nor d i s sa t i s f i ed  Sa t i s f i ed  Very  sa t i s f i ed Typical Pharmacy Services  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj 4. If you were able to provide the following services, how satisfied with your job would you be?  Very  d i s sa t i s f i ed  D i s sa t i s f i ed Ne i the r  sa t i s f i ed  nor d i s sa t i s f i ed  Sa t i s f i ed  Very  sa t i s f i ed Screening for the presence of a chronic d isease  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj Medication review & management  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj Managing all aspects of  a chronic d isease  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Sa t i s f i edS ta tusQuo Sat i s f i edSta tusQuo_r1 Sat i s f i edSta tusQuo_r1 Sat i s f i edSta tusQuo_r1 Sat i s f i edSta tusQuo_r1 Sat i s f i edSta tusQuo_r1 Sa t i s f i edCDM Sat i s f i edCDM_r1 Sat i s f i edCDM_r1 Sat i s f i edCDM_r1 Sat i s f i edCDM_r1 Sat i s f i edCDM_r1 Sat i s f i edCDM_r2 Sat i s f i edCDM_r2 Sat i s f i edCDM_r2 Sat i s f i edCDM_r2 Sat i s f i edCDM_r2 Sat i s f i edCDM_r3 Sat i s f i edCDM_r3 Sat i s f i edCDM_r3 Sat i s f i edCDM_r3 Sat i s f i edCDM_r3  Pharmacists & Chronic Disease Management SECTION III: SATISFACTION WITH WORK 5. While the type of service you provide affects your job satisfaction, there are many other aspects of your job that also influence your satisfaction. How satisfied are you with other aspects of your work?  Very  d i s sa t i s f i ed  D i s sa t i s f i ed Ne i the r  sa t i s f i ed  nor d i s sa t i s f i ed  Sa t i s f i ed  Very  sa t i s f i ed Work schedule  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj Scheduled breaks  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj Enough t ime to provide appropr iate care to pat ients  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj Access to pat ient information  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj Internet access  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj Documentation systems  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj Relationship with pharmacist col leagues  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj Relationship with employer  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj Relationship with technicians  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj Relationship with pat ients  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj Relationship with physicians  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Sat i s f i edOthe r Sat i s f i edOther_r1 Sat i s f i edOther_r1 Sat i s f i edOther_r1 Sat i s f i edOther_r1 Sat i s f i edOther_r1 Sat i s f i edOther_r2 Sat i s f i edOther_r2 Sat i s f i edOther_r2 Sat i s f i edOther_r2 Sat i s f i edOther_r2 Sat i s f i edOther_r3 Sat i s f i edOther_r3 Sat i s f i edOther_r3 Sat i s f i edOther_r3 Sat i s f i edOther_r3 Sat i s f i edOther_r4 Sat i s f i edOther_r4 Sat i s f i edOther_r4 Sat i s f i edOther_r4 Sat i s f i edOther_r4 Sat i s f i edOther_r5 Sat i s f i edOther_r5 Sat i s f i edOther_r5 Sat i s f i edOther_r5 Sat i s f i edOther_r5 Sat i s f i edOther_r6 Sat i s f i edOther_r6 Sat i s f i edOther_r6 Sat i s f i edOther_r6 Sat i s f i edOther_r6 Sat i s f i edOther_r7 Sat i s f i edOther_r7 Sat i s f i edOther_r7 Sat i s f i edOther_r7 Sat i s f i edOther_r7 Sat i s f i edOther_r8 Sat i s f i edOther_r8 Sat i s f i edOther_r8 Sat i s f i edOther_r8 Sat i s f i edOther_r8 Sat i s f i edOther_r9 Sat i s f i edOther_r9 Sat i s f i edOther_r9 Sat i s f i edOther_r9 Sat i s f i edOther_r9 Sat i s f i edOther_r10 Sat i s f i edOther_r10 Sat i s f i edOther_r10 Sat i s f i edOther_r10 Sat i s f i edOther_r10 Sat i s f i edOther_r11 Sat i s f i edOther_r11 Sat i s f i edOther_r11 Sat i s f i edOther_r11 Sat i s f i edOther_r11  Pharmacists & Chronic Disease Management Section IV: Chronic Disease Management In this section, we will assess your preferences for providing new pharmacy services. The questions are choice-based and use specific terminology. To acquaint you with these terms, we will begin by asking some general questions.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia CMDIn t ro    Pharmacists & Chronic Disease Management Section IV: Chronic Disease Management 1. How long do you expect it would take, per patient, per visit, to adequately provide the following services. [Do not include the time required for background research or documentation.]  minutes to screen for the presence of a chronic disease (e.g. measure blood pressure to screen for hypertension, heel ultrasound screening for osteoporosis, screening quest ionnaire for osteoarthrit is)  minutes to perform a comprehensive medication review to look for drug-related problems (e.g. drug interactions, appropriateness of therapy)  minutes to manage the ongoing care of a patient with a chronic disease. This may include medication management, patient education, disease monitoring and communication with the healthcare team.     Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia In te rven t i onT imeSc reen In t e r ven t i onT imeMedMan In te rven t i onT imeDSM  Pharmacists & Chronic Disease Management Section IV: Chronic Disease Management Services 2. How do you prefer to provide the following services?  W a l k - in  Schedu l ed  Appo in tmen t Screening for the presence of a chronic d isease  nmlkj  nmlkj Medication review & management  nmlkj  nmlkj Managing all aspects of  a chronic disease  nmlkj  nmlkj    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Appo in tmen t Appo in tment_r1 Appo in tment_r1 Appo in tment_r2 Appo in tment_r2 Appo in tment_r3 Appo in tment_r3  Pharmacists & Chronic Disease Management Section IV: Chronic Disease Management Services New service models require us to consider how each stakeholder is compensated. You will need to be familiar with the following definitions to answer the remainder of the survey.  Your income: The total amount of money that you make as a pharmacist. For most pharmacists, this is the salary paid by their employer.   Professional service fee: The fee charged by the pharmacist for providing a pharmacy service. This fee does not  go to the pharmacist. This fee is paid to the pharmacy and is s imi lar to a dispensing fee or a physician fee-for-service.   **Note: your income and the professional service fee are independent. One can increase even as the other decreases or stays the same. For example, your income can increase even when the standard dispensing fee stays the same or decreases.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Paymen t In t r o  Pharmacists & Chronic Disease Management Section IV: Chronic Disease Management Services 3. Should your income increase i f  your role expands to include patient services not related to dispensing (e.g., screening, medication reviews and disease management)?  nmlkj Yes  nmlkj No    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Sa lary    Pharmacists & Chronic Disease Management The following three questions related to professional services fees. 4. Who should pay the professional service fee for new pharmacy services that are not related to dispensing (e.g., screening, medication reviews and disease management)?  St rong ly  d i sag ree  D i sag ree  Neutra l  Ag ree  S t rong ly  agree Pat ients  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj Provincial government  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj Insurance companies (e.g., Blue Cross)  nmlkj  nmlkj  nmlkj  nmlkj  nmlkj 5. A professional service fee is  often paid to a business and used to cover business costs.  Which of the fol lowing need to be considered when rol l ing out new professional service fees for new pharmacy services that are not re lated to dispensing? [Select all that apply.]    gfedc Pharmacist salaries   gfedc Support staff salaries (e.g., technicians, pharmacy assistants, cashiers)   gfedc Business overhead costs (e.g., rent, bi l ls, administrative expenses)   gfedc Profits   gfedc Store inventory (e.g., general, pharmaceuticals, assistive devices)   gfedc Advertising of services   gfedc Insurance (e.g., store, pharmacist l iabil ity)   gfedc Other:  6. Based on your response to the previous quest ion,  what should the professional service fee be for new pharmacy services that are not related to dispensing? [Includes visits of less than 1 hour duration. For example, one 30 minute visit would equal one half of the hourly rate.]   nmlkj $50 for every hour of service  nmlkj $100 for every hour of service  nmlkj $150 for every hour of service    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Paymen t Payment_ r1 Payment_ r1 Payment_ r1 Payment_ r1 Payment_ r1 Payment_ r2 Payment_ r2 Payment_ r2 Payment_ r2 Payment_ r2 Payment_ r3 Payment_ r3 Payment_ r3 Payment_ r3 Payment_ r3 Pro fSe rvFee1 Pro fServFee1_1 Pro fServFee1_2 Pro fServFee1_3 Pro fServFee1_4 Pro fServFee1_5 Pro fServFee1_6 Pro fServFee1_7 Pro fServFee1_8 Pro fServFee1_8_other P ro fSe rvFee2  Pharmacists & Chronic Disease Management Section IV: Chronic Disease Management Services 7. Below is a l ist  of factors to be considered when deciding on a chronic disease management model. [Please rank the following in order of importance. For the most important factor, enter the number '1', for the least important, enter the number '6'.]    Type of service: Pharmacy services that are not related to dispensing. (e.g., screening, medication review, or managing all aspects of a chronic disease)   Your place of work: The type of environment where you practice pharmacy. (e.g., dispensary, clinical setting)   Your income: The total amount of money you make as a pharmacist. (e.g., salary paid by your employer)   Professional service fee: The fee charged by the pharmacist for providing a pharmacy service. The fee does not go to the pharmacist. The fee is paid to the pharmacy and is s imilar to a dispensing fee or a physic ian fee-for-service.   Education: Education required before you can provide new services. (e.g., orientation session, workshop, disease management course, or paid preceptorship)   Job satisfaction in all other aspects of your work: Your sat isfact ion with aspects of your work not direct ly related to the types of services you provide. (e.g., work schedule, scheduled breaks, relationships, and workload)    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Att r ibutes Att r ibutes_1 Att r ibutes_2 Att r ibutes_3 Att r ibutes_4 Att r ibutes_5 Att r ibutes_6  Pharmacists & Chronic Disease Management Section IV: Chronic Disease Management Services This is the most important section of the survey. You will now be shown a series of side-by- side practice models. Imagine that you can work in either practice model. Choose the model that you prefer.  The models may appear repetit ive but each one is unique. When making your choice, assume that you have sufficient technical support, liability insurance and documentation systems to provide these services. No model is perfect. Each t ime you make a choice, you wil l  have to make trade-offs.     Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia DCE2  Pharmacists & Chronic Disease Management Section IV: Chronic Disease Management Services You may also choose neither model.  When choosing neither, you are indicating that you prefer the typical pharmacy practice. In a typical pharmacy, 75% of a pharmacists time is spent f i l l ing prescriptions (including medication counsel ing and blister packing), 20% is spent doing OTC consultat ions, and 5% is  spent on other act ivit ies such as administrat ion and patient-centred care.     Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia DCE3  Pharmacists & Chronic Disease Management Section IV: Chronic Disease Management Services Important Definitions  To see more information about a specif ic term, hold your mouse pointer over the term. For a full l ist of definitions, click here or cl ick the l ink at the bottom of the choice sets.     Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia DCE4   Pharmacists & Chronic Disease Management Choice set 1 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Medication review & management Screening for the presence of a chronic disease NONE: I would choose to provide typical pharmacy services. Your place of work: Dispensing pharmacy Clinical setting Your income: Increases by 15% Decreases by 15% Professional service fee: $150/service hour $100/service hour Education required before you can provide the service: Workshop (2 days) Disease-State Management Course (1 week) Job satisfaction in all other aspects of your work: Satisfied Dissatisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC1 F reeCBC1_ t ime(h i dden) CBCRAN1   Pharmacists & Chronic Disease Management Choice set 2 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Managing all aspects of a chronic disease Screening for the presence of a chronic disease NONE: I would choose to provide typical pharmacy services. Your place of work: Dispensing pharmacy Clinical setting Your income: Stays the same Decreases by 15% Professional service fee: $50/service hour $150/service hour Education required before you can provide the service: None Orientation Session (2 hours) Job satisfaction in all other aspects of your work: Neither satisfied nor dissatisfied Satisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC2 F reeCBC2_ t ime(h i dden) CBCRAN2   Pharmacists & Chronic Disease Management Choice set 3 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Managing all aspects of a chronic disease Medication review & management NONE: I would choose to provide typical pharmacy services. Your place of work: Clinical setting  Dispensing pharmacy Your income: Increases by 15% Stays the same Professional service fee: $50/service hour $100/service hour Education required before you can provide the service: Paid Preceptorship (1 month) Orientation Session (2 hours) Job satisfaction in all other aspects of your work: Dissatisfied Neither satisfied nor dissatisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC3 F reeCBC3_ t ime(h i dden) CBCRAN3   Pharmacists & Chronic Disease Management Choice set 4 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Screening for the presence of a chronic disease Medication review & management NONE: I would choose to provide typical pharmacy services. Your place of work: Dispensing pharmacy Clinical setting Your income: Stays the same Decreases by 15% Professional service fee: $150/service hour $50/service hour Education required before you can provide the service: Paid Preceptorship (1 month) Workshop (2 days) Job satisfaction in all other aspects of your work: Dissatisfied Neither satisfied nor dissatisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC4 F reeCBC4_ t ime(h i dden) CBCRAN4   Pharmacists & Chronic Disease Management Choice set 5 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Managing all aspects of a chronic disease Medication review & management NONE: I would choose to provide typical pharmacy services. Your place of work: Dispensing pharmacy Clinical setting Your income: Decreases by 15% Increases by 15% Professional service fee: $50/service hour $150/service hour Education required before you can provide the service: Paid Preceptorship (1 month) Workshop (2 days) Job satisfaction in all other aspects of your work: Satisfied Dissatisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC5 F reeCBC5_ t ime(h i dden) CBCF IX1   Pharmacists & Chronic Disease Management Choice set 6 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Medication review & management Managing all aspects of a chronic disease NONE: I would choose to provide typical pharmacy services. Your place of work: Clinical setting  Dispensing pharmacy Your income: Stays the same Increases by 15% Professional service fee: $150/service hour $100/service hour Education required before you can provide the service: None Disease-State Management Course (1 week) Job satisfaction in all other aspects of your work: Dissatisfied Satisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC6 F reeCBC6_ t ime(h i dden) CBCRAN5   Pharmacists & Chronic Disease Management Choice set 7 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Managing all aspects of a chronic disease Screening for the presence of a chronic disease NONE: I would choose to provide typical pharmacy services. Your place of work: Dispensing pharmacy Clinical setting Your income: Decreases by 15% Increases by 15% Professional service fee: $50/service hour $100/service hour Education required before you can provide the service: Paid Preceptorship (1 month) None Job satisfaction in all other aspects of your work: Satisfied Neither satisfied nor dissatisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC7 F reeCBC7_ t ime(h i dden) CBCRAN6   Pharmacists & Chronic Disease Management Choice set 8 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Screening for the presence of a chronic disease Managing all aspects of a chronic disease NONE: I would choose to provide typical pharmacy services. Your place of work: Dispensing pharmacy Clinical setting Your income: Increases by 15% Stays the same Professional service fee: $50/service hour $100/service hour Education required before you can provide the service: Orientation Session (2 hours) Workshop (2 days) Job satisfaction in all other aspects of your work: Dissatisfied Satisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC8 F reeCBC8_ t ime(h i dden) CBCRAN7   Pharmacists & Chronic Disease Management Choice set 9 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Medication review & management Screening for the presence of a chronic disease NONE: I would choose to provide typical pharmacy services. Your place of work: Dispensing pharmacy Clinical setting Your income: Decreases by 15% Stays the same Professional service fee: $150/service hour $50/service hour Education required before you can provide the service: Disease-State Management Course (1 week) Workshop (2 days) Job satisfaction in all other aspects of your work: Neither satisfied nor dissatisfied Satisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC9 F reeCBC9_ t ime(h i dden) CBCRAN8   Pharmacists & Chronic Disease Management Choice set 10 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Medication review & management Managing all aspects of a chronic disease NONE: I would choose to provide typical pharmacy services. Your place of work: Dispensing pharmacy Clinical setting Your income: Decreases by 15% Increases by 15% Professional service fee: $100/service hour $150/service hour Education required before you can provide the service: None Orientation Session (2 hours) Job satisfaction in all other aspects of your work: Neither satisfied nor dissatisfied Dissatisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC10 F reeCBC10_ t ime(h i dden) CBCRAN9   Pharmacists & Chronic Disease Management Choice set 11 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Screening for the presence of a chronic disease Medication review & management NONE: I would choose to provide typical pharmacy services. Your place of work: Dispensing pharmacy Clinical setting Your income: Increases by 15% Stays the same Professional service fee: $100/service hour $50/service hour Education required before you can provide the service: Paid Preceptorship (1 month) Disease-State Management Course (1 week) Job satisfaction in all other aspects of your work: Neither satisfied nor dissatisfied Satisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC11 F reeCBC11_ t ime(h i dden) CBCRAN10   Pharmacists & Chronic Disease Management Choice set 12 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Managing all aspects of a chronic disease Medication review & management NONE: I would choose to provide typical pharmacy services. Your place of work: Dispensing pharmacy Clinical setting Your income: Decreases by 15% Increases by 15% Professional service fee: $150/service hour $100/service hour Education required before you can provide the service: Workshop (2 days) Paid Preceptorship (1 month) Job satisfaction in all other aspects of your work: Dissatisfied Satisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC12 F reeCBC12_ t ime(h i dden) CBCRAN11   Pharmacists & Chronic Disease Management Choice set 13 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Managing all aspects of a chronic disease Medication review & management NONE: I would choose to provide typical pharmacy services. Your place of work: Dispensing pharmacy Clinical setting Your income: Decreases by 15% Increases by 15% Professional service fee: $50/service hour $150/service hour Education required before you can provide the service: Paid Preceptorship (1 month) Workshop (2 days) Job satisfaction in all other aspects of your work: Satisfied Dissatisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC13 F reeCBC13_ t ime(h i dden) CBCF IX2   Pharmacists & Chronic Disease Management Choice set 14 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Managing all aspects of a chronic disease Screening for the presence of a chronic disease NONE: I would choose to provide typical pharmacy services. Your place of work: Clinical setting  Dispensing pharmacy Your income: Decreases by 15% Stays the same Professional service fee: $150/service hour $50/service hour Education required before you can provide the service: Disease-State Management Course (1 week) None Job satisfaction in all other aspects of your work: Neither satisfied nor dissatisfied Dissatisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC14 F reeCBC14_ t ime(h i dden) CBCRAN12   Pharmacists & Chronic Disease Management Choice set 15 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Managing all aspects of a chronic disease Screening for the presence of a chronic disease NONE: I would choose to provide typical pharmacy services. Your place of work: Clinical setting  Dispensing pharmacy Your income: Decreases by 15% Stays the same Professional service fee: $100/service hour $150/service hour Education required before you can provide the service: Orientation Session (2 hours) None Job satisfaction in all other aspects of your work: Dissatisfied Satisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC15 F reeCBC15_ t ime(h i dden) CBCRAN13   Pharmacists & Chronic Disease Management Choice set 16 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Screening for the presence of a chronic disease Medication review & management NONE: I would choose to provide typical pharmacy services. Your place of work: Clinical setting  Dispensing pharmacy Your income: Decreases by 15% Increases by 15% Professional service fee: $150/service hour $50/service hour Education required before you can provide the service: Paid Preceptorship (1 month) Disease-State Management Course (1 week) Job satisfaction in all other aspects of your work: Satisfied Neither satisfied nor dissatisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC16 F reeCBC16_ t ime(h i dden) CBCRAN14   Pharmacists & Chronic Disease Management Choice set 17 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Medication review & management Managing all aspects of a chronic disease NONE: I would choose to provide typical pharmacy services. Your place of work: Clinical setting  Dispensing pharmacy Your income: Increases by 15% Stays the same Professional service fee: $50/service hour $100/service hour Education required before you can provide the service: Orientation Session (2 hours) Workshop (2 days) Job satisfaction in all other aspects of your work: Neither satisfied nor dissatisfied Dissatisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC17 F reeCBC17_ t ime(h i dden) CBCRAN15   Pharmacists & Chronic Disease Management Choice set 18 of 18  If these were your only options, which practice model would you choose? [Assume you have sufficient technical support, liability insurance and documentation systems to provide these services.] Choose by clicking one of the buttons below: Service Type:  Medication review & management Managing all aspects of a chronic disease NONE: I would choose to provide typical pharmacy services. Your place of work: Clinical setting  Dispensing pharmacy Your income: Increases by 15% Decreases by 15% Professional service fee: $150/service hour $50/service hour Education required before you can provide the service: None Orientation Session (2 hours) Job satisfaction in all other aspects of your work: Dissatisfied Satisfied  nmlkj nmlkj nmlkj Click here to see the definitions in a separate window.    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia F reeCBC18 F reeCBC18_ t ime(h i dden) CBCRAN16    Pharmacists & Chronic Disease Management  Section IV: Chronic Disease Management Services  You are finished the choice-based questions. We will now ask a few final questions.  8. Which of the fol lowing professional service fee models do you consider most viable? [Please rank the following. For the most viable model, enter the number '1', for the least viable model, enter the number '5'.]    Capitation: per-person fee that covers al l  services provided over a certain period of t ime (e.g., $400/patient for medication management for 1 year)   Fee-for-service: payment each t ime a service is provided to a patient  (e.g., $50 for a medication review)    Outcomes-based capitation: in addit ion to a capitat ion fee, a separate fee is paid when a pat ient reaches a chronic d isease target (e.g., $400/patient year plus $10 for achieving target cholesterol levels in a patient with cardiovascular disease)   Outcomes-based fee-for-service: in addit ion to a fee-for-service, a separate fee is  paid when a pat ient reaches a chronic d isease target (e.g., $50 per medication review plus $10 for achieving target cholesterol levels in a patient with cardiovascular disease)   Resource-based Relative Value Scale: fee-for-service payment that is based on the relat ive cost of the resources required to provide the service (e.g., if Service A requires twice as many resources (e.g., time and level of difficulty) as Service B, then Service A is paid at a rate of $100 and Service B is paid at a rate of $50) The following question(s) relate to pharmacist incentive fees. 9. I f  your wage or salary remained the same, would you need to be paid an addit ional incent ive fee to encourage you to to provide pharmacy services that are unrelated to dispensing (e.g., screening, F reeCBC19 F reeCBC19_ t ime(h i dden) Pha rmMode l Pha rmMode l _1 Pha rmMode l _2 Pha rmMode l _3 Pha rmMode l _4 Pha rmMode l _5 Incen t i veFee1 mediat ion review and disease management)?  nmlkj Yes  nmlkj No    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia   Pharmacists & Chronic Disease Management 10. Who should pay you this incentive fee?  nmlkj The patient receiving the service  nmlkj Your employer (e.g., pharmacy)  nmlkj Third party payer (e.g., provincial government, insurance company)  nmlkj Other:  nmlkj None of  the above - I do not think that pharmacists should be provided an incentive fee 11. What do you think is a fair incentive fee for every hour of service that you provide (e.g., screening, medicat ion reviews, managing al l  aspects of the disease)?  $    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia In cen t i veFee2 Incent i veFee2_4_other Incen t i veFee3  Pharmacists & Chronic Disease Management 12. Are you wil l ing to administer vaccinations to patients?   nmlkj Yes  nmlkj Maybe - I need more information  nmlkj No - I do not think this is a pharmacist 's job  nmlkj No - I  am bothered by needles  nmlkj No - I am bothered by blood  nmlkj No - I do not have t ime  nmlkj No:    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Vacc ine Vacc ine_7_other  Pharmacists & Chronic Disease Management 13. If  yes, are you wil l ing to administer vaccinations to the fol lowing types of patients? [Select all that apply] [If you are not interested in administering vaccines, click next].    gfedc Infants ( less than 1 year)   gfedc Children (1-12 years)   gfedc Teens (12-18 years)   gfedc Adults (over 18 years old)   gfedc None of  the above    Next  0%   100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Vacc ine2 Vacc ine2_1 Vacc ine2_2 Vacc ine2_3 Vacc ine2_4 Vacc ine2_5  Pharmacists & Chronic Disease Management Thanks for participating in SUPPORT-CDM. You wi l l  now be redirected to our website. There you wi l l  be given the opt ion to enter a draw to WIN a Del l  Laptop or one of four $250 Future Shop gift cards. If  you are not redirected, please click here. P o w e r e d  b y  S a w t o o t h  S o f t w a r e ,  I n c .  0%  100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia T h a n k s  Pharmacists & Chronic Disease Management Sorry, you are not eligible. You have indicated that you do not provide consent to participate or are not licensed to practice pharmacy and you are not a 4th year pharmacy student in Alberta or BC. If this is the case, you are not eligible to participate in this study. If this is incorrect then use the back button on your browser and refresh the page. Thank you for your interest. P o w e r e d  b y  S a w t o o t h  S o f t w a r e ,  I n c .  0%  100% Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia Exc luded

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