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Structural elements associated with the provision of phamaceutical care in community phamacy practice… Ramaswamy-Krishnarajan, John 2002

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STRUCTURAL ELEMENTS ASSOCIATED WITH THE PROVISION OF PHARMACEUTICAL CARE IN COMMUNITY PHARMACY PRACTICE IN CANADA by JOHN RAMASWAMY-KRISHNARAJAN Bachelor of Pharmacy, Bangalore University, 1991 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES Faculty of Pharmaceutical Sciences Division of Pharmacy Practice We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA February 2002 © John Ramaswamy-Krishnarajan, 2002 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia Vancouver, Canada DE-6 (2/88) 11 ABSTRACT The concept of pharmaceutical care is a philosophy of practice and has been presented to be an effective process for monitoring drug therapy to meet the needs of patients and the health care system. A number of pharmaceutical care models and practice guidelines have been proposed, developed and implemented in community pharmacy settings. A s the pharmacy profession becomes more patient-focused using pharmaceutical care standards, it is important that pharmacists be able to assess the quality of that care and recognize the barriers that impede the provision of that care. Farris and Kirk ing maintain that Donabedian's structure-process-outcome paradigm can be applied to pharmaceutical care as a framework of quality assessment. Structure represents a necessary measure of quality and its assessment is crucial when structure can be associated with process and/or outcomes. This current study addresses the structure and process components of pharmaceutical care and reviews the structural elements that support the provision of pharmaceutical care in community pharmacy practice in Canada. This study examines the structural changes that have been made in community pharmacies that have adopted a pharmaceutical care model/program. A data collection instrument was developed which included the Community Pharmacy Structural Elements Questionnaire (CPSEQ) and the Behavioral Pharmaceutical Care Scale (BPCS) . The C P S E Q was used to gather information regarding structural changes made in community pharmacies and the B P C S was used to gather information regarding pharmacists' efforts towards the provision of pharmaceutical care. The data collection instruments were administered to 261 community pharmacists across Canada who had been identified to have been affiliated with a pharmaceutical care model/program and were likely to have implemented pharmaceutical care practices. The instrument was also administered to a reference group of 197 community pharmacists who were not affiliated to any pharmaceutical care model/program. The information gathered was used to determine the most frequent structural elements observed in community pharmacies that had implemented a pharmaceutical care model/program and in progressive community pharmacies that were actively providing pharmaceutical care. The exploratory analysis revealed the presence of progressive community pharmacy practices in Canada that were actively making structural changes and providing pharmaceutical care. Among the structural changes that were consistently reported in these community Ill pharmacy practices were re-organization of pharmacists' duties, re-organization of pharmacy technicians' duties, formal training program for pharmacists, on-the-job training for pharmacy technicians, incorporation of a private or semi-private counselling room, and incorporation of audio-visual educational equipment. iv T A B L E O F C O N T E N T S Page ABSTRACT ii TABLE OF CONTENTS iv LIST OF TABLES vii LIST OF FIGURES x LIST OF APPENDICES xi LIST OF ABBREVIATIONS xii ACKNOWLEDGEMENTS xiv INTRODUCTION 01 The Advent of Pharmaceutical Care 01 Pharmaceutical Care and Drug Related Morbidity 03 Drug Related Morbidity and Mortality 04 Pharmaceutical Care: A Professional Practice for the Health Care System 08 Pharmaceutical Care: An Overview 09 The Provision of Pharmaceutical Care 11 Organizing for Pharmaceutical Care 13 Quality of Pharmaceutical Care 13 Assessing the Quality of Pharmaceutical Care 14 Structural Requirements for the Provision of Pharmaceutical Care 18 Current Status of Pharmaceutical Care Practice 27 Barriers to the Provision of Pharmaceutical Care 28 Measures to Overcome Barriers to Pharmaceutical Care 30 Objectives 32 Statement of the Research Question 32 Objectives of the Study 32 METHODS 33 Overview 33 Ethics Approval 34 Development of Data Collection Instrument 34 Community Pharmacy Structural Elements Questionnaire (CPSEQ) 35 Behavioral Pharmaceutical Care Scale (BPCS) 38 Psychometric Analysis of CPSEQ 39 V Administration of Survey 43 Sample Selection 43 Survey Administration 46 Data Entry 48 Analysis 49 Respondent Summary 49 Descriptive Analysis 50 Exploratory Analysis 51 RESULTS 55 Respondent Summary 55 Response Rate 55 Respondent Classification 55 Demographic Characteristics 60 Sex, Age group, Educational qualification, and Work experience 60 Descriptive Results - 1 62 Staffing Levels of the Pharmacy 62 Basic Operational Features of the Pharmacy 65 Trends Influencing Decision to Implement a Pharmaceutical Care Practice 66 Descriptive Results - 2 73 Study Group 73 Reference Group 81 Study Group - Pharmaceutical Care Model/Program Affiliation 88 Study Group - Chain and Independent Pharmacies 91 Exploratory Results 94 Comparison of Lowest Quartile Sub-group and Highest Quartile Sub-group of Study Group 94 Comparison of Lowest Quartile Sub-group and Highest Quartile Sub-group of Reference Group 102 Matched Study Group and Reference Group (Location - Urban and Rural, Number of Pharmacists on Staff, and Ownership -Chain and Independent) 109 Matched Study Group and Reference Group (Location - Urban and Rural, Number of Pharmacists on Staff, and Ownership -Chain and Independent, Province of Respondent) 120 DISCUSSION 131 Respondent Summary 131 Demographic Characteristics 132 Descriptive Results - 1 133 Staffing Levels of the Pharmacy 134 Basic Operational Features of the Pharmacy 135 Trends Influencing Decision to Implement a Pharmaceutical Care Practice 135 Descriptive Results - 2 137 Study Group 138 Reference Group 140 Study Group - Pharmaceutical Care Model/Program Affiliation 141 Study Group - Chain Pharmacies and Independent Pharmacies 143 Exploratory Results 145 Comparison of Lowest Quartile (LQ) Sub-group and Highest Quartile (HQ) Sub-group of Study Group 147 Comparison of Lowest Quartile (LQ) Sub-group and Highest Quartile (HQ) Sub-group of Reference Group 149 Matched Study Group and Reference Group 151 Limitations of the Study 156 Summary 158 CONCLUSIONS 161 Objective 1: Development of CPSEQ and Administration of Survey 162 Objective 2: To Examine Community Pharmacies Affiliated with a Pharmaceutical Care Model/Program 163 Objective 3: To Examine Innovative Community Pharmacy Practices 164 Implications for Pharmacy Practice 164 Implications for Future Research 166 REFERENCES 168 APPENDICES 178 LIST OF TABLES Table Page 1 Response Rate - Study group and Reference group 56 2 Ownership categories of study group and reference group 58 3 Pharmaceutical care models/programs in study group 58 4 Demographic characteristics of study group and reference group 61 5 Staffing levels of the pharmacy in the study group and the reference group 64 6 Basic operational features of the study group pharmacies and the reference group pharmacies 67 7 Workload rating of study group and reference group 68 8 Performance of the study group on the BPCS 75 9 Number of hours allocated for pharmaceutical care activities in the study group 77 10 Description of structural changes in the study group 78 11 Importance ratings of structural element categories 80 12 Performance of the reference group on the BPCS 82 13 Number of hours allocated for pharmaceutical care activities in the reference group 84 14 Description of structural changes in the reference group 85 15 Importance ratings of structural element categories 87 16 BPCS performances of the study group respondents categorized by their pharmaceutical care model/program affiliations 89 17 Frequency of structural changes in study group pharmacies categorized by pharmaceutical care model/program affiliation 90 18 Performance of chain and independent pharmacies on the BPCS 92 19 Description of structural changes in chain and independent pharmacies 93 Vlll 20 Distribution of pharmaceutical care models/programs 96 21 Performance on the BPCS 97 22 Hours per day specifically allocated for pharmaceutical care activities 97 23 Mann-Whitney Test for structural element categories of LQ sub-group and HQ sub-group 99 24 Pearson's chi-square test for structural changes in LQ sub-group and HQ sub-group 100 25 Performance of the LQ sub-group and HQ sub-group on the BPCS 104 26 Number of hours per day specifically allocated for pharmaceutical care activities 104 27 Mann-Whitney tests for structural element categories " 105 28 Pearson's chi-square test for structural changes in the LQ sub-group and HQ sub-group 107 29 Distribution of pharmaceutical care models/programs in matched study group 111 30 BPCS performance of the matched study group and reference group 112 31 Number of hours per day specifically allocated for pharmaceutical care activities in the matched study group and reference group 117 32 Mann-Whitney comparison of the structural element categories of matched study group and reference group 117 33 Chi-square test of structural elements of matched study group and reference group 118 34 Distribution of pharmaceutical care models/programs in matched study group 122 35 BPCS performance of the matched study group and reference group 123 36 Number of hours specifically allocated for pharmaceutical care activities in the matched study group and reference group 128 37 Mann-Whitney comparison of the structural element categories of matched study group and reference group 128 Chi-square test of structural elements of matched study group and reference group X LIST OF FIGURES Figure Page 1 Analytical Framework 54 2 Study group and reference group respondents reporting changes to their practice in order to provide pharmaceutical care 70 3 Study group and reference group pharmacies reporting use of a pharmaceutical care model 70 4 Study group pharmacies affiliated with pharmaceutical care models/programs that made changes or made no changes to provide pharmaceutical care 71 5 Trends influencing the study groups' and reference groups' decision to implement a pharmaceutical care practice 72 6 BPCS score distribution of the study group 76 7 Normal probability plot of the study groups' BPCS scores 76 8 BPCS score distribution of the reference group 83 9 Normal probability plot of the reference groups'BPCS scores 83 10 Histogram of BPCS score distribution of the matched study group 113 11 Histogram of BPCS score distribution of the matched reference group 113 12 Normal probability plot (Q-Q plot) of BPCS scores of the matched study group 114 13 Normal probability plot (Q-Q plot) of BPCS score of the matched reference group 114 14 Histogram of BPCS score distribution of the matched study group 124 15 Histogram of BPCS score distribution of the matched reference group 124 16 Normal probability plot (Q-Q plot) of BPCS. scores of the matched study group 125 17 Normal probability plot (Q-Q plot) of BPCS scores of the mateched reference group 125 X I LIST OF APPENDICES Appendix Page 1 Certificate of Approval 178 2 Table of Structural Elements 180 3 Community Pharmacy Structural Elements Questionnaire and Behavioral Pharmaceutical Care Scale 184 4 Content Validity Form 205 5 Pharmaceutical care models/programs in community pharmacy practice in Canada 217 Description of Pharmaceutical care models/programs 219 6 Survey Administrative Materials: Script for Initial Telephone Contact, Cover Letter for Survey Questionnaire, Thank-you/Reminder Card 224 7 Responses to open-ended option of CPSEQ Items 227 LIST OF ABBREVIATIONS APhA American Pharmaceutical Association ASHP American Society of Health-System Pharmacists BCASMEP British Columbia Asthma Self Management Education Pro BCCS Blau's Career Commitment Scale BPCS Behavioral Pharmaceutical Care Scale CPSEQ Community Pharmacy Structural Elements Questionnaire CVI Content Validity Index DPC Direct Patient Care DPCM Dalhousie Pharmaceutical Care Model DRJV1 Drug-related morbidity and mortality GPC Geriatric Pharmaceutical Care Model HOP Health Outcomes Pharmacies HQ Highest Quartile IHDEP In Home Drug Evaluation Program IPA International Pharmaceutical Abstracts K-S Kolmogorov-Smirnov LQ Lowest Quartile MSQ Minnesota Job Satisfaction Scale OCS Organizational Commitment Scale PREP Pharmaceutical care Research and Education Program Q-Q Quantile-Quantile SCRIP Study of Cardiovascular Risk Intervention by Pharmacists SD Standard Deviation SPEP Structured Practical Experience Program SPO Structure-Process-Outcome SPSS Statistical Package for the Social Sciences UMCAP University of Montreal Clinical Associate Program X I V A C K N O W L E D G E M E N T S I wish to sincerely thank my two supervisors, Dr. David Hill and Dr. Timothy-John Grainger-Rousseau, for their mentoring and thought-provoking discussions throughout my Master's research. I greatly appreciate their patience, guidance and ongoing encouragement. I also like to thank my research committee members, Dr. Peter Soja, Dr. David Fielding, Dr. Marc Levine and Dr. Bruce Carleton for their valuable suggestions and insight into my thesis work. I would like to gratefully acknowledge the assistance of Ms. Sylvia Goshal in designing the survey instrument. In addition, I would like to thank the assistance of Dr. Rosemin Kassam, Ms. Pam Pascinyk, Mr. Regis Vallaincourt, Mr. Eric Trepanier, Mr. Peter Cook and Ms. Rola Priatel in conducting the content validity assessment of the survey instrument. I sincerely appreciate the assistance and cooperation provided by Mr. Shawn McKelvey in helping to conduct the pilot test of the survey. I would also like to acknowledge the help of Ms. Anne Scott and Ms. Patricia Kealy for the French translation of the survey instrument and the English translation of the French survey responses, respectively. My sincerest thanks to all the respondents of the survey, without their cooperation and participation, this research project would not have been possible. I am also very grateful to Dr. Robert Prosser for his statistical advise which was very valuable in the analysis of the data. I would also like to thank Ms. Malar Benet for her assistance with the editing of this thesis. My gratitude also goes to Apotex Inc. for providing me with financial support during my studies. A research grant provided by Apotex Inc. made this research project possible. I would like to express my gratitude to my wife, Kathy, for her patient love, unfailing support, and constant encouragement throughout my graduate studies. A special thanks to my mother, Pushpam, my dad, Rajah, and my entire family for their support, love and understanding during my graduate studies. 1 C H A P T E R 1 I N T R O D U C T I O N The Advent of Pharmaceutical Care T h e c o n c e p t o f p h a r m a c e u t i c a l c a r e h a s e m e r g e d f r o m c o n t e m p o r a r y d e v e l o p m e n t o f p r a c t i c e i n t h e f i e l d o f p h a r m a c y o v e r t h e p a s t d e c a d e , t o p r o v i d e t h e p r a c t i t i o n e r w i t h a n o p p o r t u n i t y t o m e e t t h e n e e d s o f t h e p a t i e n t a n d t h e h e a l t h c a r e s y s t e m . T h e s e n e e d s h a v e r i s e n b e c a u s e o f t h e i n c r e a s i n g c o m p l e x i t y o f d r u g t h e r a p y , t h e i n c r e a s i n g n u m b e r o f d r u g p r o d u c t s a v a i l a b l e i n t h e m a r k e t , a n d i m p o r t a n t l y , t h e s i g n i f i c a n t l e v e l o f d r u g - r e l a t e d m o r b i d i t y a n d m o r t a l i t y a s s o c i a t e d w i t h h i g h h u m a n , e c o n o m i c a n d s o c i a l c o s t s . T h e h e a l t h c a r e n e e d s o f s o c i e t y are i n c r e a s i n g d u e to t h e p r e s e n c e o f a n i n c r e a s i n g p r o p o r t i o n o f e l d e r l y p o p u l a t i o n a n d c u l t u r a l l y d i v e r s e p o p u l a t i o n ( S i g a n g a a n d H u y n h 1 9 9 7 ; S p e n c e r 1 9 8 9 ) . T h e a v e r a g e n u m b e r o f c h r o n i c d i s e a s e s a m o n g p a t i e n t s i s a l s o i n c r e a s i n g ( P u b l i c H e a l t h S e r v i c e 1 9 9 0 ) . T h e r e f o r e , p a t i e n t s are s e e k i n g h e a l t h c a r e f r o m v a r i o u s h e a l t h c a r e p r a c t i t i o n e r s w h o u s e a v a r i e t y o f d r u g p r o d u c t s as p a r t o f p a t i e n t t r e a t m e n t . T e c h n o l o g i c a l a d v a n c e s h a v e i n c r e a s e d t h e a m o u n t o f m e d i c a t i o n i n f o r m a t i o n a v a i l a b l e t o t h e p u b l i c . T h e r e i s a n e e d t o assess t h e q u a l i t y o f i n f o r m a t i o n t h a t i s a v a i l a b l e . T h e s e a d v a n c e s are a l s o a s s i s t i n g t h e h e a l t h c a r e p r a c t i t i o n e r w i t h p a t i e n t d a t a s t o r a g e , t r a n s f e r , a c c e s s a n d a n a l y s i s . T e c h n o l o g i c a l a d v a n c e s are a l s o i n c r e a s i n g t h e n u m b e r o f d r u g p r o d u c t s , w i t h v a r y i n g d e g r e e s o f e f f e c t i v e n e s s a n d r i s k , t h a t are n o w a v a i l a b l e f o r p u b l i c u s e . H e a l t h c a r e t r e n d s s u c h as g r e a t e r p a t i e n t a u t o n o m y , i n f o r m e d c o n s e n t a n d e m p o w e r m e n t , h a v e g i v e n r i s e t o o p p o r t u n i t i e s f o r p h a r m a c i s t s to e x p a n d t h e i r r o l e a n d 2 become health educators for patients regarding drug therapy and pharmaceutical options (Brodie, et al. 1980). Increased costs and utilization rates of medications have prompted payors to control cost of drug expenditures by emphasizing requirements for low cost alternatives. All of the above factors have created health care situations where ambulatory and institutionalized patients are frequently treated by multiple prescribers with a variety of drugs, many with potentially harmful adverse effect profiles. Several pharmacy leaders have argued for the need to control the increasing mortality and morbidity rates associated with adverse consequences to drug therapy (Manasse 1989b; Strand, et al. 1998c). There is a need within pharmacy profession for professional satisfaction. The art of compounding drug preparations is rarely used in contemporary pharmacy practice. Furthermore, repackaging and distribution of drug products seems to be insufficient as a professional calling (Francke, et al. 1964). Another issue within the pharmacy practice profession that has gained greater attention is the financial reward - the adequate compensation for the value of the pharmacy services provided by the pharmacist in an era of increasing competition. The concept of pharmaceutical care is a philosophy of practice, which was envisioned to address the needs of the patient and the health care system. Pharmaceutical care has been widely accepted as a safe, effective and efficient process of monitoring drug therapy to achieve optimal outcomes. It provides pharmacists with an opportunity to expand their roles to include identifying, resolving, and preventing medication-related problems in patients. Pharmaceutical care calls for a collaboration of prescribers, health care professionals and patients to manage the drug use process in order to avoid drug-related illness (Hepler and Grainger-Rousseau 1995). Furthermore, assuming the responsibility to optimize the medication use process and deliver pharmaceutical care is a new and challenging role for pharmacists and also a source of personal satisfaction. 3 The emergence of pharmaceutical care and its impact has infused all sectors of the pharmacy profession. Pharmacy sites have modified physical layouts to accommodate the delivery of pharmaceutical care. New software programs have evolved to complement traditional pharmacy dispensing computer systems (Felkey 1997). A number of pharmaceutical care practice guidelines and models have been proposed (American Society of Health-System Pharmacy 1996; Ramaswamy-Krishnarajan and Grainger-Rousseau 2000). These pharmaceutical care models and guidelines include the pharmacy technician as an integral part of the pharmaceutical care team. New standards have been developed to certify pharmacist competency and to ensure the consistent delivery of pharmaceutical care (Barner and Bennet 1999; Farris, etal. 1999). Pharmaceutical Care And Drug Related Morbidity The need to control drug-related morbidity and mortality (DRM) has been a major driving force and provides the foundation for the emergence of pharmaceutical care. DRM occurs as a result of: (1) inappropriate prescribing, (2) inappropriate delivery of drugs, (3) inappropriate behavior by patients (non-compliance), (4) patient idiosyncrasy (mistake or accident), and (5) inappropriate monitoring of drug therapy (Hepler and Grainger-Rousseau 1995; Hepler and Strand 1990). The concept of pharmaceutical care is a response to the largely unmet need to address this problem and subsequently, to shoulder the societal responsibility of preventing DRM. The following section will provide an overview of DRM and the reasons why safe and efficient drug therapy is important. 4 Drug Related Morbidity and Mortality Drug-related morbidity and mortality is a serious problem in health care system today. Drugs are used to achieve definite outcomes that improve a patient's quality of life. These outcomes include: (1) cure of disease, (2) reduction or elimination of symptoms, (3) arresting or slowing of a disease process, and (4) preventing a disease or its symptoms (Hepler and Strand 1990; Strand, et al. 1992). However, when drugs are administered, the potential for adverse outcomes that may diminish a patient's quality of life is always present (Bates, et al. 1995; Classen, et al. 1997). Therefore, outcomes that are less than optimal may contribute to drug-related morbidities and mortalities (DRM). DRM includes both treatment failure (e.g., failure to cure or control a disease) and production of new medical problems (e.g., an adverse or toxic drug effect). There are many benefits that can be achieved by drug therapy, but it also can involve an element of risk. Pharmaceutical products are potentially dangerous substances - dangers inherent from the drug and also from its use. The problem arises from negligence, bad judgement and both human and system error. Manasse suggested that the term "drug misadventuring" captures the essence of negative drug experiences due to adverse reactions, side effects, drug-induced illness, drug interactions, contra-indications, drug intolerance, and human or system errors (i.e., mistakes made in the preparation, distribution, and administration of drugs) (Manasse 1989a). Furthermore, Manasse also suggested that the extensive use of pharmaceuticals as well as system errors were responsible for "drug misadventuring". 5 Costs of Drug Related Morbidity and Mortality DRM is costly and, for the most part, preventable if recognized by the patient, caretaker or clinician. If not recognized and resolved, drug-related morbidity can lead to drug-related mortality, the "ultimate therapeutic miscarriage" (the failure of a therapeutic agent to produce the intended therapeutic outcome) (Hepler and Strand 1990). The consequences of DRM can be costly, not only to the health care system, but also to human lives and society as a whole. Economic costs of drug related morbidity and mortality In 1995, Johnson and Bootman estimated that, in the United States, the economic cost associated with DRM in ambulatory care was U.S.$ 76 billion per year (Johnson and Bootman 1995). In 1993, Coambs et al. estimated that the economic cost to Canada's health care system due to prescription medication noncompliance and inappropriate use could be as high as $7- $9 billion per year (Coambs, et al. 1995). This study estimated only, the direct costs of non-compliance. Furthermore, the cost estimates were based on other literature that estimated DRM. The cost estimate was based on the estimated number of noncompliance-related hospital admissions, nursing home admissions, and ambulatory care treatment that were reported in the literature. Indirect costs were assumed to be equal to direct costs, while intangible costs were not estimated. In spite of these study limitations, this is the only estimate available for Canada but gives a measure of the total economic costs to the health care system due to medication non-compliance and inappropriate drug use. Humanistic costs of drug related morbidity and mortality A 1967 Canadian study surveyed all patients admitted to the public medical service of The Montreal General Hospital over a 12-month period. The study reported that, of the 731 6 patients surveyed, 132 (18 %) suffered 193 adverse reactions to drugs during the year of the study (Ogilvie and Ruedy 1967). In France, Trunet et al. (1980) studied all patients admitted to a multi-disciplinary intensive care unit to determine how many of the conditions were drug-related and, of these, what number were potentially avoidable. Of 325 patients admitted in the course of one year, 12.6% were hospitalized because of drug-related problems. Of these, 46.3% were admitted with drug-related problems that were potentially preventable. In 1986, Trunet et al., in a similar study, reported on 1651 hospitalizations and showed that 97 patients (5.88 %) were admitted due to drug-induced illness and 2.6 % were preventable (Trunet, et al. 1986). Furthermore, preventable drug-related deaths were also reported by Porter and Jick, and Dubois and Brook in two separate studies (Dubois and Brook 1988; Porter and Jick 1977). Porter and Jick reported that among 26,462 carefully monitored medical inpatients over a period of five years, 24 patients or 0.9 per 1,000 died as a result of a drug or group of drugs. Six of the deaths may have been preventable. Dubois and Brook reviewed 182 deaths from 12 hospitals with the help of a panel of clinical experts. They found that, based on a majority decision by the panel, 27% of the deaths were drug-related which might have been prevented. Societal costs of drug related morbidity and mortality The social cost of DRM accounts for temporary or permanent harm and loss of productivity of society's members. Furthermore, there are societal costs when there is a loss of faith or credibility in the professions. Society can also withdraw privilege or social standing from professions when trusted professions are no longer seen as acting in the best interests of society (Manasse 1989b). 7 Prevention of Drug Related Morbidity and Mortality Human costs associated with the quality of life, health, and general well-being are clearly of utmost importance to any health care system (Strand, et al. 1998c). Economic costs of DRM when combined with human costs and social costs as discussed above present a challenge that cannot be ignored. Prevention of DRM may actually decrease total costs while improving quality of care. Much of the problem is not inherent in the drug products, but in the way they are prescribed, dispensed, and used by patients (Hepler and Strand 1990). According to Hepler and Strand, DRM can be prevented if the following three elements can be defined. First, the drug-related problem must be recognizable; second, the causes of that outcome must be identifiable; and third, those causes must be controllable (Hepler and Strand 1990). This would, therefore, suggest that the prevention of DRM depends on the standard of health care provided. The more comprehensive the care provided, the better are the chances of preventing DRM. Manasse suggested that a new order is needed for the resolution of "drug misadventuring" (Mannase 1989b). Manasse also suggested that a new structural-functional approach is required in the entire gamut of therapeutic decision-making, drug distribution, drug-use monitoring, and systematic reporting of DRM in the population. All drug-related problems -actual or potential, should be identified, their causes determined, and solutions for their resolution offered. One such potential solution to the problem is improving the process of medication use by implementing a system of continuous evaluation and improvement of drug use. Such a system is described by Hepler and Grainger-Rousseau as a pharmaceutical care system that is a collaborative approach to therapy by the patient, physician and pharmacist to improve patient outcomes (Hepler and Grainger-Rousseau 1995). 8 Pharmaceutical Care: A Professional Practice for the Health Care System In order to address the needs of the health care system, such as the prevention of D R M , health professionals need to take responsibility for assuring positive outcomes of drug therapy in patients whom they serve. The pharmaceutical care process is designed not only to meet challenges presented to the health care system, but also to meet patient's drug-related needs by ensuring appropriate, effective, safe and convenient drug therapy. Hepler and Strand have emphasized that the provision of pharmaceutical care involves three distinct functions: (1) identifying potential and actual drug-related problems, (2) resolving actual drug-related problems, and (3) preventing potential drug-related problems (Hepler and Strand 1990). Pharmaceutical care practice has a comprehensive perspective and involves a commitment to the reduction and prevention of D R M . There are studies showing that improved pharmaceutical services such as drug-use control services and drug therapy monitoring can greatly reduce the total cost of care and the length of hospitalization (Borgsdorf, et al. 1994; Clapham, et al. 1988; Herfindal, et al. 1983; McKenney and Wasserman 1979). There is also evidence to support the positive effects of pharmaceutical care on medication cost, quality of patient care, economic and morbidity outcomes, and in the detection and resolution of drug-related problems (Boyko, et al. 1997; Currie, et al. 1997; Diment and Evans 1995; Hanlon, et al. 1996; Lobas, et al. 1992; Shalansky and Chen 1996a; Shalansky, et al. 1996b). These studies provided support that improvement of quality of care, improvement of patient's quality of life, reduction of medication costs, decrease in the length of stay of patient in the hospital, increase in the number of drug-related problems identified and resolved were among the benefits that can be achieved by the provision of pharmaceutical care. 9 Pharmaceutical Care: An Overview Pharmaceutical care was first defined by Mikeal et al. in 1975, as "the provision of any personal health service involving the decision whether to use, the use and the evaluation of the use of drugs, including the range of services from prevention, diagnosis and treatment, to rehabilitation provided by physicians, dentists, nurses, pharmacists and other health personnel" (Mikeal, et al. 1975). Their definition was based on the American Public Health Association's definition of 'medical care'. Brodie et al. (1980) conceptualized pharmaceutical care as a theory of practice to improve drug use control. Hepler and Strand (1990) proposed pharmaceutical care as a philosophy of practice and defined it as, "responsible provision of drug therapy for the purpose of achieving definite outcomes intended to improve a patient's quality of life". Pharmaceutical care is used to describe care that is associated with pharmaceutical agents, and is not limited simply to an association with the individual who provides it. Pharmaceutical care, by definition, is collaborative, and therefore this concept and philosophy is not reserved for any one profession or group of professionals (Trinca 1993). Although most of the underlying research and the theory behind the concept were initiated within the profession of pharmacy, it is not necessary that pharmaceutical care should be provided only by pharmacists. Health care professionals such as pharmacists, physicians and nurses are involved in the drug use process, and therefore it is possible that pharmaceutical care will be provided by a variety of health care professionals. However, pharmacy is the profession that is most concerned with drugs. Pharmacists are highly qualified with the necessary knowledge and training in pharmaceutics and pharmacology. Therefore, pharmacy as a profession is in a unique position and it is the societal role of the profession to be responsible for assuring safe and effective drug use. Since the widespread acceptance of this philosophy and standard of practice, a number of pharmaceutical care models and practice guidelines have been proposed, developed and implemented in a variety of settings (Kennie, et al. 1998; Ramaswamy-Krishnarajan and Grainger-Rousseau 2000). However, despite the general acceptance of the philosophy of pharmaceutical care, its provision in the pharmacy practice setting is not a universal reality. The Janus Commission Report pointed out a few salient reasons for the lacklustre implementation of pharmaceutical care by pharmacy practitioners (Bootman, et al. 1997). The Commission noted that the majority of colleges and schools of pharmacy did not have faculty interested in research programs or projects designed to evaluate, demonstrate, and market the pharmaceutical care practice model. This was further supported by a American College of Clinical Pharmacy White Paper, which recommended that there should be a more effective collaboration between pharmacy educators and the profession to improve experiential education, to develop new patient-centered practice models, and to increase student professionalism (American College of Clinical Pharmacy 2000). Furthermore, the Janus Commission also felt that the pharmaceutical care practice model placed exclusive focus on individual patients and questioned whether consideration should be given to broadening the definition of pharmaceutical care to include population-based and systems-based delivery and analysis of pharmaceutical care. On the other hand, many researchers feel that pharmaceutical care is a patient-centered practice. Strand comments, "Respect for personhood is central to pharmaceutical care practice" and also that "The relational nature of pharmaceutical care requires that we respect the patient's autonomy, preferences, and needs" (Strand 1997). Exploring the status of research on pharmaceutical care, there are studies demonstrating the value of specific pharmacists' services in reducing DRM (Gattis, et al. 1999). However, there is a growing concern that there is a lack of definitive research demonstrating positive 11 patient outcomes from the implementation of the pharmaceutical care practice model (Kennie, et al. 1998; Nahata 2000). It appears that most studies were deficient in research design, outcome measurement, or sample size. It also appears that some of the reasons for these deficiencies are the complexity of pharmaceutical care practice models and the difficulty in fulfilling the criteria required. Kennie et al. (1998) have recommended that standards for pharmaceutical care research should be developed and accepted by the profession. Among other recommendations, it was also noted that pharmaceutical care research should not only emphasize the evaluation of patient outcomes, but must first evaluate the structures that exist for the provision of pharmaceutical care. The Provision of Pharmaceutical Care Pharmaceutical care involves a process through which a practitioner co-operates with a patient and other health care professionals in designing, implementing, and monitoring a therapeutic plan that will produce specific therapeutic outcomes for the patient (Strand, et al. 1992). Pharmaceutical care practice makes a practitioner responsible for the drug-related needs of patients in such a way that drug therapy can be monitored in detail using a rational, systematic approach. In order to provide pharmaceutical care, the practitioner takes responsibility to ensure that all drug therapy is appropriately indicated and that all indications for drug therapy are being appropriately acted upon. The practitioner also accepts responsibility for ensuring that the patient's drug therapies are as safe and effective as possible. This can be achieved by identifying, resolving, and preventing drug therapy problems so that the patient can attain the goals of therapy. It is also the responsibility of the practitioner to make sure that the patient is able to comply with the medication and care plan instructions in order to ensure optimal patient outcomes. Hepler and Strand have stressed that in order to deliver pharmaceutical care, a practitioner should: (1) take time to determine the patient's specific wishes, preferences, and needs concerning his or her health and illness, and (2) make a commitment to continue care once it is initiated (Hepler and Strand 1990). Hepler and Angaran have described a course of action that the practitioner needs to initiate when providing pharmaceutical care (Hepler and Angaran 1996). Firstly, the practitioner needs to establish a caring relationship with the patient. Establishing a relationship will assure the patient of a common interest with the practitioner, which is the patient's welfare. Secondly, the practitioner needs to gather and document information about the patient. Information should include basic demographic, administrative, medical, pharmaceutical, and sociobehavioral aspects. Specific care activities that need to be provided, and the appropriateness of the activities, depend on the completeness and accuracy of patient information gathered. Thirdly, the practitioner must evaluate the therapeutic plan in the context of other treatment objectives. This is the process where the practitioner reconciles the clinical objectives; values, such as quality of life; and therapeutic possibilities. Once a therapeutic plan is established, the fourth step in the enactment of pharmaceutical care by the practitioner is the construction of a written monitoring plan. A written plan should be developed to obtain the information that is needed to monitor the patient's progress toward clinical and quality of life objectives. The fifth step, following the development of a monitoring plan, is for the practitioner to discuss the objectives and responsibilities with others. The practitioner should make his new duties and responsibilities explicit to his colleagues and other caregivers. The practitioner should also be prepared to demonstrate the corresponding responsibilities that others, including the patient, are expected to take on. The sixth step for the practitioner is the implementation of the monitoring plan. Pharmaceutical care involves not just therapeutic drug monitoring, but also monitoring clinical effect. The practitioner should evaluate the patient's progress toward definite outcomes such as treatment success or failure. Finally, the seventh step in enacting pharmaceutical care is to resolve any pharmaceutical problems that were detected in monitoring and to document all relevant information obtained, problems identified, actions taken, and recommendations made. Organiz ing for Pharmaceutical Care Quality of Pharmaceutical Care Drugs must be used within a system that assures that consideration is given to providing all of the pharmaceutical functions needed for pharmaceutical care. Therefore, the quality of pharmaceutical care provided is of utmost importance in order to justify the professional claims of pharmaceutical care services. Much emphasis has been placed on the importance of quality measurement and improvement in pharmacy practice and it is believed that a focus on quality will provide an opportunity to advance the cause of pharmaceutical care on behalf of the patients whom pharmacy serves (Ellis 1998). Pharmaceutical care is provided for the direct benefit of the patient and the provider is responsible directly to the patient for the quality of that care (Angaran 1992). There is a shift from the general trend of evaluating providers on the basis of price to evaluating providers on the basis of performance (Medical News And Perspectives 1997). This trend is affecting all health professions, including pharmacy. Therefore, the provision of high-quality pharmaceutical care and the ability to assess the quality of that care, are paramount as the profession becomes more patient-focused (Gitlow and Melby 1991). Farris and Kirking (1993a) maintain that 14 pharmaceutical care represents the highest quality care that pharmacy can deliver and should be the level of care that all pharmacists seek to provide to their patients. It is also the appropriate perspective for defining the quality of care in pharmacy. Assessing the Quality of Pharmaceutical care The most direct route to an assessment of the quality of care is an examination of the components of that care. Donabedian (1980) has proposed a framework for assessing the quality of care of a system. The framework consists of three components: structure, process and outcome. The basic premise of this framework is that structure influences process to potentiate the probability of producing quality medical care. A similar assumption for the link between process and outcome proposes that a better process leads to better outcomes. This framework for the assessment of quality of care is possible because specified structural characteristics increase the probability of providing specific kinds of care. Furthermore, specified properties of the process of care improve the probability of obtaining specific changes in the health and well-being of individuals and populations (Donabedian 1988a). Farris and Kirking (1993b) believe that Donabedian's structure, process and outcome paradigm can also be applied to pharmaceutical care as a framework for quality assessment. Furthermore, they have noted that structure represents a necessary measure of quality and its assessment is crucial when structure can be associated with process and/or outcomes. In order to understand the structure-process-outcome (SPO) framework in the context of pharmaceutical care, the important aspects of structure, process and outcome components in the pharmacy setting will be discussed in the following sections. 15 Structure Structure is defined as the attributes of the setting(s) in which care is provided. These attributes include the tools and resources the providers have at their disposal and the physical and organizational settings in which the providers work to provide care. The basic character of structure is that it is relatively stable, that it functions to produce care or is a feature of the "environment" of care, and that it influences the kind of care that is provided (Donabedian 1980). Structural attributes characterize the potential for the provision of quality pharmaceutical care. Examples of structural elements in pharmacy practice are a licensed pharmacist, professional legislation and a regulatory body, and physical facilities (Farris and Kirking 1993b). Another example of structural elements is the organization of pharmacy practice settings to receive, document, process, and utilize information in providing care. Also included as structural elements are adequate work space, resources, personnel, policies, procedures and available time to provide care. An appropriate structure in community pharmacy practices establishes the capacity to provide quality pharmaceutical care. Structure influences process and potentiates the provision of pharmaceutical care. Organizational setting is an essential structural element that is often associated with the provision of care. According to Meuller et al., modern organizations no longer rely so much on direct control of employees to bring about co-operation and productivity. Instead, they do this more indirectly. The control is not utilitarian or coercive but instead, is through normative and symbolic inducements that emanate from the way the organization is structured. The goal of management in introducing this control is to produce greater job satisfaction and higher organizational commitment (Mueller, et al. 1994). According to Lincoln and Kalleberg, organizations have structures that facilitate social integration, participation/autonomy in decision making, legitimacy of the authority structure, and promotion and mobility within the organization (Lincoln and Kalleberg 1985; Lincoln and Kalleberg 1990). These conditions, in turn, influence employee job satisfaction, career commitment and organizational commitment. Thus, greater job satisfaction, career commitment and organizational commitment among pharmacists will then, in this argument, lead to more successful provision of pharmaceutical care. A study conducted by Gaither and Mason found that levels of career commitment of pharmacists varied across personal (e.g., demographics, personal traits) and environmental (e.g., pay, social support) variables (Gaither and Mason 1994). Another study conducted by Kong (1995) reported that pharmacists who believed that pharmaceutical care would have a more positive effect on pharmacy had higher levels of career and organizational commitment. Support and perceptions about the impact of the pharmaceutical care movement are predictors of career and organizational commitment. Studies also show that there is a positive association between pharmacist's level of job satisfaction and involvement in clinical pharmacy activities or professional activities like patient counselling (Kawabata, et al. 1998; Olson and Lawson 1996; Ortiz, etal. 1992). Process Process refers to the ways in which health care is provided and received. Process is the set of activities that are carried out between practitioners and patients in providing care. In the pharmacy setting, the provision of pharmaceutical care is the desired process. Process criteria of quality assessment usually are categorized as being either technical or interpersonal (Donabedian 1988b). Technical aspects of care in pharmacy represent the procedures and tests pharmacists employ when ensuring that optimal drug therapy is provided. The interpersonal component of process addresses the characteristics of the interaction between patients and pharmacy employees, including the pharmacist (Farris and Kirking 1993b). Strand et al. (1992) have discussed the nine steps of pharmaceutical care: (1) establish the pharmacist-patient relationship, (2) collect, synthesize, and interpret the relevant information, (3) list and rank the patient's drug-related problems, (4) establish a desired pharmacotherapeutic outcome for each drug-related problem, (5) determine feasible pharmacotherapeutic alternatives, (6) choose the best pharmacotherapeutic solution and individualize the therapeutic regimen, (7) design a therapeutic drug-monitoring plan, (8) implement the individualized regiment and monitoring plan, and (9) follow-up to measure success in individual cases and in long-term implementation. These nine steps of pharmaceutical care discussed by Strand et al. (1992) incorporate both the technical and interpersonal components of care, and are considered essential in the provision of pharmaceutical care. Outcome Outcome describes the effect of care on the health status of patients and populations. Outcome is a broad-based aspect of care that incorporates not only the effects of treatment but also, any lifestyle changes achieved through treatment and the degree of patient satisfaction with treatment. In the pharmacy setting, the provision of pharmaceutical care is the desired process. The pharmacotherapeutic outcomes of pharmaceutical care are appropriate drug use and prevention of drug-related problems (Strand, et al. 1992). Hepler and Strand contend that the outcomes of pharmaceutical care are cure of disease, elimination or reduction of symptoms, slowing of the disease process, and preventing disease or symptomatology (Hepler and Strand 1990). Psychological, economic and social outcomes should also be considered in the assessment of the quality of pharmaceutical care. 18 Structural Requirements for the Provision of Pharmaceutical Care Structure and process have been the primary focus of most quality assurance programs because they are the most visible and easily documented aspects of health care. They establish the capability of an organization to provide care. A n unfavourable outcome can be corrected only i f the associated structure and process are well-documented and evaluated for possible changes and improvements. In 1975, Jackson et al. applied Donabedian's structure-process-outcome model in the evaluation of the quality of pharmaceutical services and examined the link between structure and process in the traditional community pharmacy practice. A random selection of 50 community pharmacists was. used in the study. A l l of the 50 pharmacists were observed in the pharmacy for a period of eight hours. They were scored on their performance on structure and process variables that were previously identified. Results indicated a significant correlation of 0.327 (p < 0.05) between structure and process in community pharmacy practice (Jackson, etal . 1975). There has been much emphasis placed on evaluating the structural component of pharmaceutical care. Farris and Kirk ing (1993b) maintain that "...structure has its place in quality assessment and should be assessed periodically to ensure that validated structure criteria are present because they indicate a capacity to provide quality pharmaceutical care". Kennie et al. (1998) recommend that pharmaceutical care research should not only emphasize the evaluation of patient outcomes, but must first evaluate the structures that exist for the provision of pharmaceutical care. This study wi l l focus on the structural criteria that are associated with the provision of pharmaceutical care. The various categories of structural elements that need to be assessed are discussed below in the following sections. Re-organization of work duties Re-organization of pharmacists' duties and pharmacy technicians' duties are pivotal in bringing about a role redefinition for the provision of pharmaceutical care. These duties include a decreased pharmacist involvement in technical functions such as data entry, filling prescriptions and an increased pharmacist involvement in provision of professional services such as disease specific clinics, drug therapy decision making, and cognitive services. Janke and Tobin (1997c) argue that as pharmaceutical care is implemented and practice changes, the pharmacist's role shifts from dispensing to patient care. Campagna and Newlin (1997) have pointed out that ancillary personnel need to be deployed to relieve the pharmacist of many technical functions and thereby improve the use of the pharmacist's time to engage in drug therapy decision making. One of the criteria for pharmacy practice change that was identified in a study conducted by Doucette and Koch was that dispensing has been changed to a technician-managed process, with the pharmacist interacting with patients (Doucette and Koch 2000). Re-organization of pharmacy technicians' duties include increased pharmacy technician involvement in technical functions such as receiving patients at the dispensary, data entry, filling prescriptions, answering the telephone, stocking, compounding, and running the till (Kassam, et al. 1998). The White Paper on pharmacy technicians by the American Pharmaceutical Association and the American Society of Health-System Pharmacists recommends that a key element in the profession's strategy for achieving pharmaceutical care is for the pharmacist to delegate routine functions to well-qualified, appropriately supervised pharmacy technicians (APhA-ASHP 1996). Janke et al. (1996a) also maintain that technicians are a valuable resource in assuming distributive functions so pharmacists can dedicate their time to patient care activities. A self-reported work-sampling study conducted by Schneider and Nickman (1998), showed that delegating technical duties to pharmacy technicians allowed the pharmacist to 20 maximize time spent on clinical, professional and patient care activities. Re-organization of pharmacy technicians' duties leads to higher responsibilities for pharmacy technicians and may result in improved job satisfaction and motivation. Re-designing physical layout The objective of re-designing physical layout is to create an environment that provides the necessary work space, resources, and time for pharmacists to provide pharmaceutical care. Some of the changes to physical layout that have been discussed in the literature are: 1. an unelevated pharmacist workstation to facilitate patient contact (Lin, et al. 1996). 2. an elevated work pharmacy technician workstation - lets pharmacists and technicians maintain eye contact while giving technicians a good view of the entire pharmacy and the rest of the store (Lin, et al. 1996). 3. a layout accommodating the needs of the disabled to improve counselling environment for disabled patients (Lin, et al. 1996). 4. a patient waiting area to decrease the pressure faced by the pharmacist in a busy store with a line of patients at the dispensary (Kyriakos 1988; Laskoski 1992). 5. a private patient counselling room to increase privacy for confidential conversation, enhance patient counselling environment and increase patients' willingness to provide information during sit-down counselling sessions (Campbell 1998; Farris and Kirking 1993b; Kassam, et al. 1998; Laskoski 1992; Slezak 1997). 6. a semi-private patient counselling area is less inhibiting to patients to communicate with pharmacist, and is discreet while providing adequate amount of privacy for patients preferring a comfortable, open conversation (Dhalla 1997; Doucette and Koch 2000; Fox 1995; Slezak 1996; Strand, et al. 1998b). 7. audio-visual educational equipment and educational materials to complement, supplement and reinforce patient counselling and to add value to patient care services (Doucette and Koch 2000; Janice and Kennie 1996c; Slezak 1997). 8. removal of the cash register from the dispensary and into a check out area to improve workflow within the dispensary and to reduce congestion in the store; movement of dispensary from the back to the front of the pharmacy to improve the professional image of the store (Cobden 1998; Laskoski 1992; Slezak 1997). 9. fixtures (signage, panels, lighting) to draw patients to certain areas, organize flow of traffic, and accent important areas of the store; carpeting throughout the store to decrease noise, reduce physical fatigue and improve comfort of patients and pharmacist; and warm colours for the walls to make the over-all appearance inviting for patients and provide pleasant work environment for the staff (Cobden 1998; Kyriakos 1987; Kyriakos 1988; Laskoski 1992; Lin, et al. 1996; Schneider and Nickman 1998). 10. drive-through windows for refill prescriptions to reduce customer congestion and increase patient convenience although there is a reduced opportunity for interaction between the patient and pharmacist (Holt 1992; Laskoski 1992). Pharmacist training The pharmacist must possess the knowledge, skills, values, and attitudes necessary to provide pharmaceutical care. There are two types of competencies that the pharmacist must demonstrate in order to perform necessary pharmacy practice functions - general competencies and professional competencies (Meyer and Trinca 1996). General competencies include thinking, communicating, having values and applying ethical principles, self-awareness, and 22 self-learning. Professional competencies include problem solving, decision-making, managing, learning, educating, collaborating, and preparing for the future. In addition, pharmacists may need training in therapeutics, identification of drug-related problems, development of a patient care plan, communication skills, interviewing techniques and problem-solving skills to meet the specific objectives of pharmaceutical care. Lack of communication skills; educational tools; ability to recognize situations in which specific knowledge is necessary; ability to select and apply scientific, technical, and clinical information in a timely and appropriate manner; and expertise to make drug therapy decisions have been identified as barriers for providing professional services (Campagna and Newlin 1997; Knapp 1979; Louie and Robertson 1993; Raisch 1993). Kennie et al. (1998) have recommended that a pharmacist's qualifications and/or- certification in providing pharmaceutical care should be addressed and described. A recommendation by the ACCP White Paper was that a credible, co-ordinated certification and credentialing process, whereby all qualified pharmacists can demonstrate patient care competence, should be developed (American College of Clinical Pharmacy 2000). Doucette and Koch (2000) have also identified pharmaceutical care training as a significant and necessary pharmacy practice change. Pharmaceutical care certification programs and training programs have been developed that train the pharmacist in areas such as: components of pharmaceutical care; practice re-engineering; to engage in initial patient care experience; self-directed and problem-based learning of therapeutic knowledge; drug therapy management of disease states and patient characteristics frequently associated with drug therapy problems; documentation of care and continuity of care; communication skills; and motivation of pharmacists to devote time and energy to meet patients' drug-related needs (Barner and Bennet 1999; Diment and Evans 1995; Farris, et al. 1999; Kassam, et al. 1999; Strand, et al. 1998d). 23 Pharmacy technician training Pharmacy technicians have a growing role, as pharmacists depend on them to facilitate expansion of the profession's scope of practice. The White Paper on Pharmacy Technicians, by the American Pharmaceutical Association and the American Society of Health-System Pharmacists, has recommended that the profession of pharmacy should begin to plan for the promulgation of uniform national standards for pharmacy technician training (APhA-ASHP 1996). Farris and Kirking (1993b) have also identified trained and/or certified pharmacy technicians as structural criteria of pharmaceutical care. Pharmacy technician certification programs and training programs have been developed that define the roles of the pharmacy technician and can direct the pharmacy technician to work more effectively with the pharmacists to improve patient care (Janke, et al. 1996a; Janke and MacDonald 1997a; Murer 1996). Pharmacy technician training may also positively influence pay, hiring, promotions and personal satisfaction for the pharmacy technician. Financial compensation Every prescription order dispensed presents an opportunity for the pharmacist to apply necessary skills and knowledge to provide a variety of pharmaceutical care services to benefit the patient. Therefore, there is a need to reimburse the pharmacist for the cognitive services provided by the pharmacist. However, traditionally, reimbursement has been directly linked to the provision of drug products rather than the cognitive services provided (Knapp 1979). In order to expand pharmaceutical care to the level of the typical community pharmacy, standard compensation systems must evolve that encourage and reward pharmacists for the time and effort required to provide this level of care (Rupp 1996). Determining and procuring financial compensation for the application of pharmacist's skills has been identified as one of the key 24 factors and barriers for the provision of pharmaceutical care services (Barnes, et al. 1996; Campagna and Newlin 1997; Raisch 1993). An exploratory study of community pharmacy practice changes identified payment received for non-dispensing pharmacy services as a criterion for pharmacy practice change (Doucette and Koch 2000). Another study exploring the link between pharmaceutical care services and the percentage of prescriptions covered by third-party plans reinforces that provision of innovative pharmacy services requires appropriate financial incentives (Miller and Ortmeier 1995). A study conducted to determine how barriers and incentives affect the performance of pharmacists in identification and resolution of potential drug-related problems affirmed reimbursement as one of the important factors affecting the volume of cognitive services performed and documented (Christensen and Hansen 1999a). The study reported that performance of cognitive services was strongly affected by payment and other situational factors, including practice setting and volume of prescriptions dispensed. The White Paper by the American College of Clinical Pharmacy (2000) makes a recommendation that the feasibility of pursuing agendas for reimbursement of pharmacists' clinical activities must be explored between pharmacy organizations and trade associations. A reimbursement system for pharmaceutical care has been discussed by Strand et al. that takes into account the separation of patient care from the drug product (Strand, et al. 1998a). There is also a government program established in Quebec to compensate pharmacists for preventing or resolving drug-related problems (Poirier and Gariepy 1996). Christensen et al. (1996b) describe the methods used in the Washington State Cognitive Activities and Reimbursement Effectiveness project, in which financial compensation was made to pharmacists for providing cognitive services. 25 Store policy and procedure The provision of pharmaceutical care involves many critical functions that need to be performed as a team by the pharmacist and pharmacy support staff. In order to provide pharmaceutical care to many patients on a repeated basis requires an efficient and effective organization. A key factor to consider prior to implementation of pharmaceutical care is the redefinition of dispensary processes and procedures. It is the responsibility of the practice managers to develop policies and standardize procedures that facilitate the patient care process in the pharmacy (Wichman, et al. 1993). Development of these policies and procedures may improve the efficiency in the pharmacy and thereby maximize time to provide pharmaceutical care. Some examples of policy and procedural changes are: store requirement for new patients to complete a thorough patient demographic information sheet which may save time in collecting such information; requirement for sit-down counselling for all new and refill prescriptions in order to ensure comprehensive care is provided; and requirement for documentation of patient care plan in order to permit monitoring, continuity of care and follow-up (Kassam, et al. 1998; O'Malley and Vaillancourt 1997; Slezak 1997). Janke and MacLeod-Richards, and Janke and Tobin have also enumerated a few procedural changes to improve efficiency in the dispensary (Janke and MacLeod-Richards 1997b; Janke and Tobin 1997c). Technological changes As pharmacists make their transition to pharmaceutical care, incorporation of technology will expand the ability of pharmacies to provide professional services, supplement their information systems and support their pharmaceutical care initiatives. The pharmacy profession stands to benefit greatly from the proliferation of technological innovation. Technology can be deployed to dispense most prescriptions, provide drug information to patients and facilitate 26 the exchange of patient-specific data among, and within, health care systems. The use of medication dispensing technologies may accelerate the transition of pharmacists from the traditional, product-focused dispensing role to that of patient-focused service provider (Barker, et al. 1998). Pharmacy software applications can be used as tools that help pharmacists in establishing a patient database, screening for and resolving drug-related problems, providing patient information and education, monitoring patient outcomes, facilitating case management and documentation, accessing online services and information, and processing claims for reimbursement of cognitive services. Felkey (1997) reviewed the diverse pharmacy software applications and suggests that the most important applications are those that help pharmacists rapidly access drug information. Technological advances have brought about new automated systems which include systems such as simple automatic pill counters and sophisticated systems that automate the entire dispensing process. A detailed description of automated medication dispensing systems that are currently available was provided by Glover (1997) who maintained that these medication dispensing systems could increase the time that pharmacists devote to patient-focused services. Benefits of the automated pharmacy systems are: they replace many labour-intensive tasks, thereby saving pharmacist and technician time; relieve on-the-job stress and free pharmacists from "count and pour" dispensing for more rewarding, patient-centered tasks (Barker, et al. 1998). Another significant technological advance is the introduction of hardware/software systems that answer pharmacy phones and allows patients to refill their prescriptions using the telephone keypad. Benefits of the phone answering systems are that the telephone calls coming into the pharmacy are reduced, which in turn reduces interruptions so that pharmacists can be 2 7 more task-focused and allows the pharmacist to spend more time for patient focused services (Smith 1998). Current Status of Pharmaceutical Care Practice As noted, the process of pharmaceutical care has been described to be a potential solution to the problem of drug-related morbidity and mortality. However, the existence of a defined pharmaceutical care process is not assurance that it will, in fact, be implemented by pharmacists. Despite widespread acceptance and understanding of the philosophy and importance of pharmaceutical care, the structural requirements for establishing a pharmaceutical care practice remain to be fully developed. The adoption and practice of pharmaceutical care among individual pharmacists is rather slow with widely varying levels of readiness for rendering pharmaceutical care (Berger and Grimley 1997). There is also an indication that pharmacists may be apprehensive about embracing a new shift in their practice (Desselle 1997). The results of a study conducted by Schommer and Cable (1996), on 163 practicing pharmacists, showed that pharmacists were engaged in passive pharmaceutical care activities such as information gathering and being a drug information source more frequently than active ones such as patient counselling and drug monitoring. Also, there are observations that a large number of pharmacists still perform mainly distributive functions and very little performance of pharmaceutical care functions (Odedina, et al. 1997; Ringold, et al. 1999). The existence of many barriers may be a possible reason for the inertia and hesitancy in provision of pharmaceutical care by pharmacists as part of routine pharmacy practice (Monk 1998). 28 Barriers to the Provision of Pharmaceutical Care The provision of pharmaceutical care faces barriers to a similar extent as do any other new concepts. Pharmacists may need to overcome actual as well as perceived barriers to be able to provide pharmaceutical care. Many potential barriers to pharmaceutical care have been identified and evaluated in the literature. Penna (1990) has identified several barriers to pharmaceutical care: attitudinal barriers such as pharmacists' preoccupation with dispensing drug products and providing services without due regard for the outcomes of therapy; organizational barriers such as the organizational framework; professional barriers such as co-operation with physicians, nurses and all those who treat illnesses and prescribe or administer drugs; financial barriers such as the compensation method and economic incentive to provide pharmaceutical care; logistical barriers such as lack of access to patient medical information, and access to other health-care professionals and patients; and cognitive barriers such as lack of competence. Campagna and Newlin (1997) have also identified similar factors influencing drug therapy decision making and have also included barriers in the practice setting such as physical layout and design, and pattern of work as key factors. Excessive workload and lack of time, lack of financial compensation and patients' attitudes such as being uninterested in counselling were identified, in a survey conducted by Barnes et al. (1996), as significant barriers to the provision of prospective and retrospective drug review and counselling services. Another study, conducted by Raisch (1993), categorized barriers into four types: situational barriers such as financial compensation, workload and physical layout of the pharmacy; cognitive barriers, such as inadequate training and lack of communication skills; legal barriers, such as allowances to increased use of pharmacy technicians; and attitudinal barriers, such as pharmacists' perceptions that patients do not want to be counselled and inter-professional conflicts with prescribers. 29 This study surveyed 73 pharmacists to evaluate their perceptions of barriers to performing cognitive services in community pharmacy. The survey consisted of a list of potential barriers to performing cognitive services. The pharmacists rated the barriers on a scale of 1 (least important) to 5 (most important). The study reported that a heavy workload and lack of reimbursement were principal factors limiting pharmacists' cognitive services. Based on experience and informal observations of the authors in their work with community practitioners, McDonough et al. (1998) described the following obstacles to the implementation of pharmaceutical care in the community setting: pharmacists' attitudes, such as lack of motivation and fear of change; lack of advanced practice skills in clinical problem solving, communication and documentation; resource-related constraints, such as time, finances, space and personnel; system-related constraints, such as lack of reimbursement and physician resistance; intra-professional obstacles, such as limitations imposed by boards of pharmacy; and academic/educational obstacles, such as curricular limitations of schools and colleges of pharmacy. The authors concluded that these obstacles do not block progress permanently, but are impediments that can be overcome by community pharmacists with effective planning, sustained commitment, and proper support. Similar barriers and obstacles to the provision of pharmaceutical care, such as lack of incentives, lack of time, pharmacist competence, lack of documentation, lack of appropriate physical structures, pharmacist and patient attitudes, poor relationship with physician, organizational structures, staffing levels, lack of an adequate patient database, unwillingness to take full advantage of technological advances, and developing a market for pharmaceutical care have been identified in the literature (Campbell 1998; Feinberg 1991; Hepler 1998; Louie and Robertson 1993; May 1993; Miller and Ortmeier 1995; Nau, et al. 1998; Shane 1992). Measures to Overcome Barriers to Pharmaceutical Care 30 These barriers and obstacles to the provision of individualized, optimal pharmaceutical care are well known to community pharmacists. In order for a successful provision of a pharmaceutical care practice, a complete reassessment and restructuring of the manner in which pharmacists practice may be needed. The depth and complexity of change required to overcome barriers and reposition a practice for pharmaceutical care may be intimidating. Pharmacy practice change involves two primary components: the arrangement of resources in the pharmacy and the activities performed by the pharmacists (Doucette and Koch 2000). The resources in the pharmacy may determine the level of pharmaceutical care a pharmacist is positioned to provide. There may be a need for the re-organization of pharmacy practice settings to receive, document, process.and utilize information in providing pharmaceutical care. Changes in the health care delivery system such as resources, personnel, policies and procedures may be required for the provision of pharmaceutical care. It may be essential that adequate work space, resources, and time are available for pharmacists to provide pharmaceutical care. Specific factors that motivate pharmacists in forming an intention to provide pharmaceutical care, and thereby enacting behavioral intention, may need to be addressed. Organizational structures that facilitate greater pharmacists' job satisfaction, career commitment, and organizational commitment may be essential structural elements associated with the provision of pharmaceutical care. The activities performed by pharmacists to provide pharmaceutical care are also changing as their practices evolve (Feder 1996). Some of the activities performed by pharmacists are making physical assessments and educating patients, administering patient outcome measures, and documenting pharmacist-patient encounters. Other activities may also include establishing working relationships with other practitioners and with faculty, marketing their services, 31 working to obtain reimbursement for new services, and participating in practice-based research. There have been efforts made to focus on the process activities of providing pharmaceutical care. A number of pharmaceutical care models and practice guidelines have been proposed, developed and implemented in a variety of settings. However, there has been minimal work done on evaluating the structural requirements and barriers associated with the provision of pharmaceutical care. Many pharmacy practices across the country have been working to change their practices in order to achieve the goal of overcoming the structural barriers to the provision of pharmaceutical care. Community pharmacy practices have been making changes to the arrangement of resources in the pharmacy as well as to the activities performed by the pharmacists. There is much to be learned from the experiences of these community pharmacy sites that have implemented a pharmaceutical care practice. This study will describe the structural changes that have been made in selected community pharmacies in Canada that have adopted a pharmaceutical care model/program and also in community pharmacies that are actively providing pharmaceutical care outside of any affiliation with a pharmaceutical care model/program. This study will address the structure and process components of pharmaceutical care to characterize the structural elements that support the provision of pharmaceutical care in community pharmacy practice in Canada. 32 Objectives Statement of the Research Question What are the structural elements that are associated with the provision of pharmaceutical care in community pharmacy practice in Canada? Objectives of the Study There were three main objectives to this study: 1. To develop a data collection instrument to gather information regarding structural changes and process activities in a community pharmacy practice. 2. To examine the structural changes associated with the provision of pharmaceutical care among community pharmacy practices that have adopted a pharmaceutical care model. 3. To examine the structural changes associated with the provision of pharmaceutical care practice among community pharmacy practices that may or may not be affiliated with a pharmaceutical care model/program and may be actively providing pharmaceutical care as measured by an instrument designed to evaluate this outcome. 33 CHAPER II METHODS Overview This study was designed to evaluate the structural elements associated with the provision of pharmaceutical care in community pharmacy practice in Canada. The study addressed the structure and process components that are associated with the provision of pharmaceutical care. A taxonomy of current structural elements in innovative community pharmacy practices will be a valuable resource for practitioners who are intending to implement a pharmaceutical care practice. A data collection instrument (Community Pharmacy Structural Elements Questionnaire) was developed based on the information obtained from a literature search of articles reporting structural changes in community pharmacy practices. The instrument also included a job satisfaction scale, a career commitment scale and an organizational commitment scale. Further, this instrument included the Behavioral Pharmaceutical Care Scale developed by Odedina and Segal (1996), which was used to gather information and to measure the process component of pharmaceutical care. The data collection instruments were administered to community pharmacists across Canada who had been identified to have been affiliated with a pharmaceutical care model/program and to have implemented pharmaceutical care practices. The instrument was also administered to a reference group of community pharmacists who were not affiliated with any of the identified pharmaceutical care model/program. The information gathered from the instrument was used to determine the preferred structural elements observed in 34 community pharmacies that had implemented a pharmaceutical care model/program and in community pharmacies that were making significant efforts to provide pharmaceutical care. Ethics Approval A formal approval for this M.Sc . research study was obtained from the Behavioral Ethics Review Board of the University of British Columbia. The certificate of approval is included in Appendix 1. Development of Data Collection Instrument The data collection instrument consisted of two sections. First, a Community Pharmacy Structural Elements Questionnaire was designed to gather information about the community pharmacy and pharmacy personnel, changes to pharmacy structure and activities, and demography of respondents. This section also included a job satisfaction scale, a career commitment scale and an organizational commitment scale. The next section of the data collection instrument consisted of the Behavioral Pharmaceutical Care Scale which included items designed to measure pharmacists efforts towards the provision of a pharmaceutical care practice representing the following dimensions, namely, direct patient care, referral and consultation, and pharmaceutical care instrumental activities. 35 Community Pharmacy Structural Elements Questionnaire (CPSEQ) The CPSEQ was developed from information obtained from a literature search. Journal articles reporting changes in community pharmacy practices were gathered through electronic searches of Medline and HealthSTAR, and through manual searches of the International Pharmaceutical Abstracts (IPA). The search was limited to articles in English published since 1980. Keywords used for the search were patient counselling, pharmacy, workload, community pharmacy services, and layout. Combined keyword searches were: patient counselling and pharmacy, workload and pharmacies, layout and pharmacies, patient focused care and community pharmacy, and pharmaceutical care and community pharmacy. Relevancy to the study was based on whether the article reported actual changes in pharmacist or technician duties, physical layout, pharmacist continuing education, technician retraining, reimbursement system, pharmacy policy, and technology in community pharmacy practice. There was a total of 282 citations obtained from the search, of which 20 articles were found to be relevant to the study (APhA-ASHP 1996; Barnes, et al. 1996; Dhalla 1997; Fox 1995; Greer 1997a; Greer 1997b; Greer 1997c; Janke, et al. 1996b; Janke and Kennie 1996c; Janke and Tobin 1997d; Kyriakos 1987; Kyriakos 1988; Laskoski 1992; Lin, et al. 1996; Murer 1996; Pevere 1992; Poirier and Gariepy 1996; Raisch 1993; Slezak 1996; Slezak 1997). The 20 articles reporting structural changes were reviewed and a table of structural elements associated with the implementation of pharmaceutical care in community pharmacy practice was created. The purpose of the table was to categorize indicators of structural elements and to link common themes of changes reported in community pharmacy practice. A description of the study site, study methodology, structural element observed, and results of the structural element were noted in the table. This table is included in Appendix 2. 3 6 The changes to structural elements in community pharmacy that were uncovered in the literature search were: reorganization of pharmacists' and pharmacy technicians' duties, changes in physical layout, pharmacist training, pharmacy technician retraining, financial compensation, modification of store policy and procedures and technological changes. Questions were then constructed for these indicators. The CPSEQ was divided into three sections: (I) Demographic Information, (II) Questions on structural elements, and (III) Comments. It consisted of 18 questions, of which ten were open-ended and eight were closed-ended. Ten of the questions were short answer type, five were multiple choice type, and three were check-box type. A pre-test of the CPSEQ was conducted in the summer of 1997. The purpose of the pre-test was to evaluate whether the CPSEQ effectively captured information about the structural elements implemented in a selection of community pharmacy sites and to determine how to improve the content and format of the instrument. Three community pharmacies using a pharmaceutical care practice model were contacted. The questionnaire was sent to each test site by facsimile. The participants were given a two week time period to complete the questionnaire. The responses were reviewed on receipt of the completed questionnaire and follow-up telephone interviews were scheduled with the participants. The interviews were performed to clarify the participants' responses and comments. The interview also gave an opportunity for participants to provide constructive criticism on the content and format of the questionnaire. Several points for improvement of the data collection instrument were identified from the pre-test study. Improvements to the CPSEQ were made based on the findings of the pre-test. The instrument was improved using contemporary social survey strategies such as giving special consideration to measuring structural concepts (construction of scales), wording questions (open-ended and close-ended) and formatting questionnaires such that the instrument could serve as an appropriate tool to capture data. Further review of the literature was also conducted to add a 37 few more items to the CPSEQ (Barker, et al. 1998; Felkey 1997; Gait and Narducci 1997; Glover 1997; Holt 1992; Kassam, et al. 1998; Smith 1998; Wilson and Whelan 1995). Likert rating scale questions were included to determine pharmacists' views on the importance of making various structural changes in order to provide pharmaceutical care. The short form of the Minnesota Job Satisfaction Scale (MSQ), Blau's career commitment scale (BCCS), and Allen and Meyer's organizational commitment scale (OCS) were included to measure pharmacists' job satisfaction, career commitment and organizational commitment, respectively (Allen and Meyer 1990; Blau 1985; Blau 1988; Weiss, et al. 1967). The Hoyt reliability co-efficient, reported by the authors for the short form of the Minnesota Job Satisfaction Scale, varied from 0.87 and 0.92. The reliabilities for the affective commitment domain, the continuance commitment domain and the normative commitment domain, as reported by the authors of the Organizational Commitment Scale, were 0.87, 0.75 and 0.79, respectively. Psychometric analysis of the CPSEQ was conducted to assess the reliability and content validity and a few modifications were made. The updated version of the CPSEQ is divided into four sections: (I) Pharmacy and Pharmacy Personnel, (II) Pharmacy Structure and Activities, (III) Organizational Structure and (IV) Demographic Information. The CPSEQ has 30 questions consisting of 132 items, which include 20 job satisfaction scale items, seven career commitment scale items and 18 organizational commitment scale items. Twenty-four of the questions are closed-ended while six are open-ended. The responses to 1 6 of the questions are multiple choice, check-box type, the responses to eight of the questions are short answer type, and the responses to seven of the questions are Likert scale type. There were open-ended "other, please specify" options to seven of the closed-ended questions. The final version of the CPSEQ is included in Appendix 3. All the items within each of the structural element categories mentioned in Question 17 of the CPSEQ were given an equivalent score of one. The scores were then added up to give 38 a total score for each category of structural elements. The total score represents a quantitative measure of the extent to which the structural element category has been put in place in a pharmacy site in order to support pharmaceutical care. The responses to the MSQ, the BCCS, and the OCS are scored separately as specified by the authors. The responses to the items of the Likert rating scale questions 18 and 19 of the CPSEQ for all the respondents were summed to give a total rating score for each item. The average of the total score was then taken as the overall rating of the item (structural element category) for the group of respondents. Behavioral Pharmaceutical Care Scale (BPCS) Odedina and Segal (1996) developed the BPCS as a reliable and validated tool for measuring pharmacists' efforts to provide pharmaceutical care. The BPCS is made up of 36 behavioral activities which represent the following dimensions of pharmaceutical care: (1) Direct Patient Care, (2) Referral/Consultation and (3) Pharmaceutical Care Instrumental activities. Reliability coefficients for the domains of the BPCS, such as documentation activities, patient-assessment activities, therapeutic objective and monitoring-plan activities, referral and consultation activities were reported to be 0.72, 0.90, 0.74, and 0.82 respectively. The content validity index value for the whole instrument was found to be 0.79. The possible score range on the BPCS is a minimum of 16 and a maximum of 180. The BPCS is a measure of pharmacists' efforts relative to the provision of pharmaceutical care. The BPCS was used in this study to capture data related to the pharmaceutical care process and to identify community pharmacy sites where substantive efforts are being made to provide pharmaceutical care. 39 Psychometric Analysis of CPSEQ The psychometric properties of the CPSEQ needed to be evaluated before the administration of the survey since it was a newly constructed instrument. The other scales in the data collection instrument, such as the BPCS, job satisfaction scale, career commitment scale and organizational commitment scale, had previously been administered and their psychometric properties were known. Therefore, the psychometric properties such as the reliability and content validity of only the CPSEQ needed to be determined. Reliability of CPSEQ Reliability refers to the reproducibility and dependability of the measurement of an instrument. Coefficient alpha was the measure of reliability that was used. Coefficient alpha provides a measure of how consistently subjects perform across items measuring the same construct. Coefficient alpha can be estimated by calculating the variances between items and among items of the instrument. This is possible because reliability is the proportion of error variance to the total variance yielded by the instrument subtracted from 1 , the index 1 indicating perfect reliability. The equation that was used to calculate the reliability coefficient: r« = 1 - V e / V, where, rtt - reliability coefficient, V e = error variance, and V t = total variance. The method of reliability assessment recommended by Kerlinger (1986) was used to determine the internal consistency for the CPSEQ. 40 Pilot test of data collection instrument In order to estimate the reliability of the data collection instruments, a pilot test was conducted. The pilot test was also conducted to detect and solve any difficulties that may have risen during survey administration. The pilot test was administered to pharmacists from 28 pharmacy sites that had implemented the Live Well Consultations pharmaceutical care program, which was developed by PharmaSave Limited. The pilot test was also administered to a reference group of pharmacists from another 28 Pharmasave pharmacy sites that had not implemented any pharmaceutical care program. There was a 50% response rate from both groups of pharmacy sites. Content Validity of CPSEQ Validity is the extent to which the instrument measures what it purports to measure (Benson and Clark 1982). Content validity is the representativeness of the content, that is, the substance, matter, and topic of a measuring instrument. Content validity is of primary importance in developing better measures. The process of content validity determination, by its nature, demands rigor in its assessment. The method of content validity assessment, as outlined by Lynn (1986), was followed to determine content validity of the CPSEQ. The specific content validity that was determined for the CPSEQ was: (1) the content validity for each item of the CPSEQ and (2) the content validity for the whole instrument. To assess the content validity of the CPSEQ, five experts were selected to judge the instrument. The experts were chosen on the basis of their extensive knowledge of the concept of pharmaceutical care and their direct involvement in its implementation. The expert panel consisted of two faculty members from the Faculty of Pharmaceutical Sciences at the University of British Columbia and three practicing pharmacists in community pharmacy. 41 The experts were provided with specific instructions and directions on how to evaluate the CPSEQ. The expert panel was given a list of objectives that guided the construction of the instrument and another list of items designed specifically to test the objectives. The experts were asked to (1) assess the relevancy of each of the items to the content addressed by the objectives, (2) judge if they believe the items on the instrument adequately represent the content in the domain of interest, i.e., structural elements associated with the provision of pharmaceutical care, and (3) assess the content relevance of each item to the concept of pharmaceutical care. The experts were asked to evaluate each item on a 4-point ordinal scale where 1 = not relevant, 2 = unable to assess relevance without revision, 3 = relevant but needs minor alteration, and 4 = very relevant. The experts were also instructed to identify specific structural elements that may have been omitted from the instrument. The content validity assessment form and the administration materials are included in Appendix 4. A content validity index (CVI) was computed for each item of the CPSEQ and for the whole instrument. The CVI for each item was the proportion of experts who rated the item as content valid - a rating of 3 or 4. The CVI for whole instrument was the proportion of all items judged to be content valid. Translation of Data Collection Instrument The data collection instrument had to be translated to French in order to facilitate the administration of the survey to the French speaking areas of Canada. The whole instrument including the title page, instructions page, cover letter and reminder/thank-you card was translated to French by a professional English to French translator. The translator was an approved translator of the British Columbia Translators Association. 42 Three experts were chosen to proof read the French version of the data collection instruments. The experts spoke French as their first language and were chosen on the basis of their extensive knowledge of the concept of pharmaceutical care and their direct involvement in its implementation. The expert panel consisted of one faculty member from the Faculty of Pharmaceutical Sciences at the University of British Columbia and two practicing pharmacists in community pharmacy. The experts were instructed to proof read the French version and to give their suggestions for corrections that may be needed for the French translation. The experts were also instructed to assess the content validity of the French version of the data collection instrument. The assessment of the content validity of the French version was conducted in the same manner as the content validity assessment of the English version. The experts provided a few suggestions for correction to the translation after proof reading the French version. These suggestions were handed to the original translator of the data collection instrument for approval. The translator approved the corrections and made the necessary corrections to the translation. The final French version of the data collection instrument is included in Appendix 3. Results of the Psychometric Analysis The reliability co-efficient alpha of the C P S E Q scale, which is Question 17 in the data collection instrument, was found to be 0.86. The reliability coefficient alpha of the success rating scale, which is Question 18 in the data collection instrument, was found to be 0.58 and that of the importance rating scale, which is Question 19 in the data collection instrument, was found to be 0.85. The generally acceptable alpha value that is recommended by Benson and Clark for reliability estimates is 0.80 or greater (Benson and Clark 1982). According to Robinson et al., an internal consistency estimate of 0.60 is an acceptable level of alpha (Robinson, et al. 1991). 43 The content validity index for each item in the C P S E Q ranged from 0.80 to 1.00. The C V I for five of the items was 0.80, while the rest had a C V I of 1.00. The C V I for the instrument as a whole was 0.95. For the five experts used in this study, the proportion of experts whose endorsement was required to establish content validity beyond the 0.05 level of significance was 0.83 (Lynn 1986). Administration of Survey Sample Selection The survey collected information from two groups of community pharmacy practices -the study group and a reference group. The study group consisted of progressive pharmacy practices that may have made structural changes to implement a pharmaceutical care practice. The prospective respondents of the study group were the key pharmacists who were identified as potential providers of pharmaceutical care at their community pharmacy site. These respondents were assumed to be providers of pharmaceutical care through a pharmaceutical care model or program involving practice guidelines. These respondents provided information regarding the structural changes that may have been implemented at their respective community pharmacy sites. The respondents also provided infoimation regarding the extent of pharmaceutical care that was being provided at their community pharmacy site. Similar information was also gathered from a reference group of community pharmacy practices, which were not involved in any of the pharmaceutical care models/programs that were identified. The respondents in the reference group were the pharmacists in the reference community pharmacy sites. 44 Study Group In order to select the study group, an update and review of pharmaceutical care models implemented in community pharmacy practice in Canada was conducted (Ramaswamy-Krishnarajan and Grainger-Rousseau 2000). This review helped in identifying innovative community pharmacies, which had incorporated pharmaceutical care models/programs into their practice. In order to obtain information on pharmaceutical care models/programs in Canada, personal contacts were made with: 1. researchers who had worked on the development and implementation of pharmaceutical care models from the University of British Columbia, University of Alberta, University of Saskatchewan, University of Manitoba, University of Toronto, University of Montreal, Laval University, Dalhousie University and Memorial University of Newfoundland; 2. officials from all the provincial regulatory authorities for pharmacy in Canada and provincial voluntary pharmacy associations, (i.e., many had supported initiatives for evaluating the impact and implementation of pharmaceutical care in practice in their respective provinces); and 3. co-ordinators of Pharmaceutical Care Steering Committees and Pharmaceutical Care Task Force in all the provinces. The above contacts were asked to identify community pharmacy sites that had incorporated pharmaceutical care models or programs to their practice. They were also asked to identify the key pharmacist who was involved with provision of pharmaceutical care and incorporation of the pharmaceutical care practice at the community pharmacy site. A total of six pharmaceutical care models in community pharmacy practice in Canada were identified through these external contacts. These pharmaceutical care models were implemented at a total of 192 community 45 pharmacy sites across Canada. In addition to these six models, the schools of pharmacy at the University of Toronto and University of Montreal each had programs in their curriculum that facilitated the preceptor training and practice of pharmaceutical care at both community and institutional settings required for undergraduate structured practice experiences. A total of 59 community pharmacy sites were involved with the pharmaceutical care program of the University of Toronto. A total of 50 community pharmacy sites were involved with pharmaceutical care program of the University of Montreal. A consolidated list of names, addresses and telephone numbers of innovative community pharmacies and the key pharmacist of each of the pharmacy site was made from the sources mentioned above. A detailed description of the pharmaceutical care models/programs is provided in Appendix 5. Reference Group The sample frame also included a reference group of community pharmacists in Canada who could provide information regarding their respective pharmacy sites. This reference group was selected from all other community pharmacists who were not in the study group. The reference group was selected from a list of community pharmacists from each province across Canada. The registrars of the regulatory bodies of each province were contacted and asked to provide a list of 40 names of community pharmacists, their work site addresses, and work telephone numbers. From this list of 40 names from each province, 20 were randomly selected for each province using a table of random numbers to get a total of 200 community pharmacists for the reference group. A n attempt was initially made to solicit a random sample of reference group pharmacies from each province. The methods of random selection that were used by the regulatory bodies of each province were ambiguous and unclear. Therefore the reference group was not considered a random sample. 46 S u r v e y A d m i n i s t r a t i o n T h e t o t a l n u m b e r o f p o t e n t i a l r e s p o n d e n t s i d e n t i f i e d f o r t h e s t u d y g r o u p w a s 3 0 1 . T h e t o t a l n u m b e r o f p o t e n t i a l r e s p o n d e n t s s e l e c t e d f o r t h e r e f e r e n c e g r o u p w a s 2 0 0 . T h e n a m e s o f p h a r m a c i s t s , n a m e s o f t h e i r r e s p e c t i v e c o m m u n i t y p h a r m a c y s i t e , t h e s i te a d d r e s s e s a n d t h e p h o n e n u m b e r s o f b o t h t h e s t u d y g r o u p a n d t h e r e f e r e n c e g r o u p w a s a d d e d o n t o a d a t a b a s e . T h e n a m e s , a d d r e s s e s a n d t h e p h o n e n u m b e r s o f b o t h t h e g r o u p s w e r e c a r e f u l l y c o m p a r e d t o m a k e s u r e that t h e r e w a s n o d u p l i c a t i o n o f s u r v e y p a r t i c i p a n t s . Telephone Contact T h e s t u d y g r o u p p a r t i c i p a n t s a n d t h e r e f e r e n c e g r o u p p a r t i c i p a n t s w e r e c o n t a c t e d b y t e l e p h o n e . T h e p a r t i c i p a n t s w e r e g i v e n a b r i e f e x p l a n a t i o n o f t h e s t u d y a n d w e r e i n v i t e d to p a r t i c i p a t e i n t h e s t u d y . T h e m a i l i n g a d d r e s s w a s a l s o c o n f i r m e d d u r i n g t h i s i n i t i a l t e l e p h o n e c o n t a c t . A s t a n d a r d s c r i p t f o r t h e t e l e p h o n e c o n v e r s a t i o n w a s u s e d f o r t h i s i n i t i a l t e l e p h o n e c o n t a c t w i t h t h e p a r t i c i p a n t s . T h e s c r i p t f o r t e l e p h o n e c o n v e r s a t i o n w i t h t h e p a r t i c i p a n t s i s i n c l u d e d i n A p p e n d i x 6. Mailing of the Survey M a i l i n g o f t h e s u r v e y c o m m e n c e d i m m e d i a t e l y a f ter t h e i n i t i a l t e l e p h o n e c o n t a c t . T h e s u r v e y p a c k a g e c o n s i s t e d o f t h e d a t a c o l l e c t i o n i n s t r u m e n t i n a b o o k l e t f o r m , t h e c o v e r le t ter a n d a s e l f - a d d r e s s e d p o s t a g e p a i d e n v e l o p e . T h e c o v e r le t ter i s i n c l u d e d i n A p p e n d i x 6. A m a s t e r l i s t o f a l l t h e n a m e s , a d d r e s s e s a n d p h o n e n u m b e r s o f the s t u d y g r o u p a n d t h e r e f e r e n c e g r o u p w a s m a i n t a i n e d . T h i s l i s t w a s u s e d t o r e g i s t e r t h e date t h e d a t a c o l l e c t i o n i n s t r u m e n t w a s 47 mailed, the date the response was received and also the serial number of the data collection instrument. The respondents were given a three-week deadline to respond. The deadline date was stamped on the front of the questionnaire booklet along with the instructions and there was a reminder of the deadline on the back of the questionnaire booklet. There were instructions on the questionnaire booklet to instruct the respondents to mail the completed survey using the enclosed postage paid self-addressed envelope. A total of 458 surveys were mailed out to potential respondents. 261 of the surveys were mailed to the study group and 197 of the surveys were mailed to the reference group. The mailing of the English surveys commenced on August 27, 1999 and continued on ti l l October 06, 1999. During this period, the first follow-up and the second follow-up procedures were also conducted. The mailing of the French surveys was conducted on October 20, 1999. The first follow-up and the second follow-up procedures for the French surveys were conducted until November 22, 1999. A s soon as the responses were returned by mail, they were logged on the master list, given a unique identifying number, and were filed. This procedure helped to identify the non-respondents from the respondents. First Follow-up A t the end of the second week of mailing the questionnaires, a reminder/thank-you card was send to both the respondents and non-respondents. The reminder/thank you card thanked the respondents for their participation and also urged the non-respondents to complete and mail the survey. The reminder/thank-you card is included in Appendix 6. 48 Second Follow-up During the fourth week of the initial mailing of the survey, the non-respondents were contacted by telephone. The non-respondents were asked if they received the survey in the mail and the reason for not responding to the survey. The non-respondents were also asked if there was any part of the questionnaire that needed further explanation. The non-respondents were reminded again of the importance of the study and that their participation would be valuable to the study. Furthermore, questionnaires were mailed again to non-respondents who either did not receive the first questionnaire package or had misplaced it. No financial incentives or material benefits were offered to any survey participants to reward or to encourage a higher response rate. Translation of French Responses The responses that were received from the French speaking areas of Canada were sent to a translator in order to be translated from French to English. The translator was a registered member of the British Columbia Translators Association. Few of the items of the data collection instrument required a short written response and comments from the respondents. These responses were translated from French to English. Data Entry The data collected through the questionnaire was translated into a form appropriate for analysis by computer and a database was created. Appropriate numeric codes were assigned for responses to closed-ended questions, open-ended questions and for non-responses. This coding system created an exhaustive and non-overlapping categorization of responses that unambiguously put each answer into one, and only one, place that could be shared by 49 researchers. The study group and the reference group could also be separately identified during analysis. Data entry of the responses was conducted meticulously so that each case could be identified using a unique identifying number. The database included all the responses from the study group and the reference group. Analysis The analysis of the data that was gathered through the survey was conducted using the Statistical Package for the Social Sciences (SPSS). The analysis of the data was conducted in three stages - respondent summary, descriptive analysis, and exploratory analysis. A diagram of the analytical framework is presented in Figure 1. Respondent Summary The respondent summary was conducted to obtain the response rate of the survey and to classify the respondents based on their ownership category, location of pharmacy, and the pharmaceutical care model/program affiliation of the pharmacy. The response rate was obtained for both the study group as well as the reference group. The classification of the respondents based on ownership and location was also conducted for both the study group and the reference group. The classification of respondents based on pharmaceutical care model/program affiliation was conducted only for the study group. Frequencies and percentages were used to describe the response rate and to compile the respondent classifications. 50 This stage of the analysis also included a description of the demographic characteristics of the respondents such as sex, age group, educational qualification and work experience. Frequencies and percentages were used to describe the sex, age group, and educational qualifications of respondents. Mean, standard deviation and range were used to describe work experience of respondents. The description of the demographic characteristics of the study group and the reference group were compiled separately. Descriptive Analysis Descriptive Analysis -1 Section one of the descriptive analysis was conducted to compile preliminary findings about the staffing levels and basic operational features of the pharmacy. Details of staffing levels, such as number of pharmacists on staff, the number of full-time and part-time pharmacy technicians on staff, and support personnel on staff, were compiled for both the study group and the reference group. Frequencies and percentages were used to describe the staffing levels. The descriptions of the basic operational features of the pharmacy were the number and type of shifts in the pharmacy, number of pharmacists and pharmacy technicians working per shift and the workload of the pharmacy. Frequencies, percentages and means were used to describe the basic operational features of the pharmacy for the study group as well as the reference group. This section of the descriptive analysis also included compilation of information regarding the pharmaceutical care model/program used in the pharmacy and the trends that influenced decision to implement a pharmaceutical care practice in the pharmacy. This information was also described using frequencies and percentages. 51 Descriptive Analysis - 2 The descriptive analysis (section two) was conducted to report the performance of the study group and reference group on the BPCS and to report the number of hours specifically allocated in the pharmacy for pharmaceutical care related activities. This section also presented an opportunity to conduct a descriptive analysis of the structural changes in the pharmacy and the importance ratings of the structural element categories. The performance of the two groups on the BPCS was described using mean, standard deviation, range, and percentile scores. A distribution histogram of the BPCS scores was plotted. The normality of distribution of the BPCS scores was assessed by constructing a Quantile-Quantile plot and also by performing a Kolmogorov-Smirnov Lilliefors test. The number of hours specifically allocated for pharmaceutical care related activities was described using frequencies and percentages. Description of the structural changes reported in the pharmacy, for the study group and reference group, was also done using frequencies and percentages. The importance ratings of the structural element categories were described by obtaining a mean for the sum of the ratings of all respondents. This descriptive analysis was also conducted for the study group across each of the pharmaceutical care model/program classifications and also across ownership categories (chain pharmacy and independent pharmacy). Exploratory Analysis The exploratory analysis was conducted at two levels. Firstly, there was an exploratory comparison conducted between sub-groups selected within the study group and reference group. 52 Secondly, the exploratory analysis was conducted to compare the structural changes and the performance on the BPCS between matched study group and the reference group pharmacies. The performance of the respondents on the BPCS was used to select two sub-groups for the study and reference groups. Respondents above the 75th percentile of the BPCS score distribution were selected as the highest quartile (HQ) sub-group which represented pharmacies assumed to be making significant progress towards providing pharmaceutical care. Respondents below the 25th percentile of the BPCS score distribution were selected as the lowest quartile (LQ) sub-group representing pharmacies, that in the assessment of the researchers were judged to be making little progress towards providing pharmaceutical care. The HQ and LQ sub-groups were compared for the number of hours allocated for pharmaceutical care activities, the frequency of changes of structural element categories as a whole, and the frequency of changes of individual structural elements. Mann-Whitney tests were conducted to compare the structural element categories. Pearson's chi-square test was used to compare and test for significant differences in the number of hours allocated for pharmaceutical care activities; and in the frequency of changes of individual structural elements. Since there was a number of statistical tests conducted, the level of significance for all tests was conservatively set at 0.01. A direct comparison of the study group and the reference group was not possible, because the reference was not a randomized selection. In order to create some opportunity for meaningful comparison, the study group and the reference group were matched by key variables. The two groups were first matched with three variables - location of pharmacy (urban or rural, as designated by postal code), number of pharmacists on staff, and ownership (chain or independent). This matching process yielded 73 matched pharmacies in each of the study group and reference group. These matched pharmacies were further matched with another variable -province of pharmacy. This matching yielded 36 matched pharmacies for both the groups. The matched study group and reference group pharmacies were then compared and tested for difference in the performance on the BPCS, number of hours allocated for pharmaceutical care activities, the frequency of changes of structural element categories as a whole, and the frequency of changes of individual structural elements. In order to compare the performances on the BPCS of the matched pharmacies in the study group and reference group, firstly, Levene's test for equality of variances was conducted and, thereafter, an independent samples t-test was conducted. Mann-Whitney tests were conducted to compare the difference in changes to structural element categories as a whole. Pearson's chi-square test was used to compare the difference in the frequency of changes of individual structural elements. The level of significance for all the statistical tests was set at 0.01. ;ure 1. Analytical Framework C P S E Q and BPCS Study group Reference group Descriptive Analysis - 1 1. Staffing levels 2. Basic operational features 3. Trends influencing decision to implement pharmaceutical care Descriptive Analysis - 2 1. Performance on the BPCS 2. No. of hours/day allocated for pharmaceutical care 3. Frequency of structural changes 4. Importance ratings of structural categories Study group 1. High quartile sub- group 2. Low quartile sub-group Reference group 1. High quartile sub-group 2. Low quartile sub-group * * Exploratory Analysis 1. Comparison of no. of hours/day allocated for pharmaceutical care (Pearsons chi-square test) 2. Comparison of structural changes (Pearson' chi-square test, Mann-Whitney test) Matching of Study group and Reference group 1. First level of matching (3 variable matching) 2. Second level of matching (4 variable matching) * Exploratory Analysis 1. Performance on the BPCS (T-test) 2. Comparison of no. of hours/day allocated for pharmaceutical care (Pearsons chi-square test) 3. Comparison of structural changes (Pearson' chi-square test, Mann-Whitney test) 55 CHAPTER III R E S U L T S Respondent Summary Respondent summary includes the response rate of the survey, and descriptive data of pharmaceutical care models/programs among respondents, ownership categories of respondents, and location of respondents. Response Rate A detailed description of the response rate of the study group and the reference group from each of the provinces are presented in Table 1. Questionnaires were mailed to 261 study group pharmacies and 197 reference group pharmacies. There were no community pharmacies in New Brunswick, Prince Edward Island and Newfoundland meeting the study group criteria. The response rate for the study group was 62% and the response rate for the reference group was 41%. Respondent Classification The study group and reference group respondents were classified based on their ownership status, i.e., whether they belonged to a chain pharmacy or an independent Table 1. Response Rate - Study group and Reference group Study group Reference group Province No. of Questionnaires Sent Received No. of Questionnaires Sent Received British Columbia •• 42 24 20 10 Alberta 47 31 20 7 Saskatchewan 29 24 19 8 Manitoba 12 9 20 5 Ontario 80 52 20 6 Quebec 50 21 19 5 New Brunswick NA NA 20 9 Prince Edward Island NA NA 20 7 Nova Scotia 1 1 20 13 Newfoundland NA NA 19 11 Total 261 162 197 81 Response Rate 62% 41% Note: There were no respondents in New Brunswick, Prince Edward Island, or Newfoundland meeting the study group criteria. 57 pharmacy, and also based on the pharmacy location, whether rural or urban. The study group was also classified based on the pharmaceutical care model/program that had been adopted at the pharmacy. Ownership categories There were five defined ownership categories. The categories were (1) drug store chain pharmacy, (2) grocery store chain pharmacy, (3) mass merchandiser chain pharmacy, (4) independent pharmacy (banner) and (5) independent pharmacy (other). This categorization was based on the classifications as defined by the Canadian Association of Chain Drug Stores. Drug store chain pharmacies include such pharmacies as Shoppers Drug Mart, London Drugs, Pharmaprix, and Jean Coutu Pharmacy. Grocery store chain pharmacies include such pharmacies as Safeway pharmacy, Save-on pharmacy, and Extra Foods pharmacy. Mass merchandiser chain pharmacies include such pharmacies as The Bay pharmacy, Zellers pharmacy, and Walmart pharmacy. Independent (Banner) pharmacies include such pharmacies as People's Drug Mart, Pharmasave, and Drug Store pharmacy. Frequency of pharmacy ownership categories among the two groups of respondents is presented in Table 2. Independent pharmacies were the highest percentage of respondents for the study group and the reference group with 64.8% and 51.9% respectively. Grocery store chain pharmacies were the lowest percentage of respondents in the reference group with 1.2%. There were no grocery store chain pharmacies among the study group respondents. The frequency of drug store chain pharmacies and independent (banner) pharmacies were similar for both the study group and the reference group. 58 Pharmaceutical care models/programs Frequency of the pharmaceutical care models/programs in the study group pharmacies is presented in Table 3. Among the eight pharmaceutical care models/programs that were adopted by the 162 study group pharmacies, the Health Outcome Pharmacies model was implemented at 87 pharmacies. Thirty-one study group pharmacies were involved in the Structured Practical Experience Program conducted by the University of Toronto while 21 study group pharmacies were involved in the University of Montreal Clinical Associate Program. Location of pharmacy The study group and the reference group were classified as urban pharmacies or rural pharmacies. This classification was based on the Statistics Canada Postal Code Conversion Guide (Statistics Canada 1999). According to this guide, to identify urban and rural is to use the second position of the postal code. If it is '0', it is rural; anything other than '0' is urban. In the study group, 71.6% of the pharmacies were urban and 28.4% of the pharmacies were rural. In the reference group, 77.7% of the pharmacies were urban and 22.2% of the pharmacies were rural. Table 2. Ownership categories of study group and reference group Ownership category Study group (N =162) n(%) Reference group (N = 81) n (%) Independent (Other) 105 (64.8) 42 (51.9) Independent (Banner) 29(17.9) 17(21.0) Drug store chain 26(16.0) 17(21.0) Mass merchandiser chain 2(1.2) 4 (4.9) Grocery store chain 0 1 (1.2) Table 3. Pharmaceutical care models/programs in study group Pharmaceutical care models n (%) Health Outcomes Pharmacies Model (HOP) 87 (53.7) University of Toronto Structured Practical Education Program (SPEP) 31 (19.1) University of Montreal Clinical Associate Program (UMCAP) 21 (13) BC Asthma Self Management Education Program (BCASMEP) 8 (4.9) Geriatric Pharmaceutical Care Model (GPC) 8 (4.9) Pharmaceutical Care Research and Education Program (PREP) 5(3.1) Dalhousie Pharmaceutical Care Model (DPC) 1 (0.6) In Home Drug Evaluation Program (IHDEP) 1 (0.6) Total (N) 162 60 Demographic Characteristics Sex, Age group, Educational qualification, and Work experience Demographic data for the 162 study group respondents and , 81 reference group respondents are presented in Table 4. The study group consisted of 39.5% female respondents and 60.5% male respondents and the reference group consisted of 43.2% female respondents and 56.8% male respondents. In the study group there were about 30% respondents in each of the 20 to 35 years, 36 to 45 years, and 46 to 55 years age group while there were only 10% respondents in the 56 to 65 years age group. A similar trend was also seen in the reference group with regards to the age group of the respondents. Ninety three percent of the study group and 90% of the reference group had the educational qualification of B.Sc. (Pharmacy). About 3.7% of the study group and 8.6% of the reference group also reported other educational qualification, such as Bachelor of Pharmacy, which is the professional degree designation awarded at some universities. In addition, 1.9% of the study group and 1.2% of the reference group reported the Master of Science as an educational qualification and also, another 1.9% of the study group reported the Doctor of Pharmacy (PharmD) as an educational qualification. The mean years of work experience as a pharmacist for the study group was 18.6 ± 9.8 and the mean years of work experience as a pharmacist for the reference group was 17.5 ± 9.9. Table 4. Demographic characteristics of study group and reference group Demographic characteristic Study group n (%) Reference group n (%) Sex - Male Female 98 (60.5) 64 (39.5) 46 (56.8) 35 (43.2) Age group (in years) - 20-35 - 36-45 - 46-55 - 56-65 48 (29.6) 49 (30.2) 48 (29.6) 17(10.5) 22 (27.2) 30 (37.0) 21 (25.9) 08 (9.9) Educational qualification B. Sc. (Pharmacy) - M. Sc. Pharm. D. - Other 152 (93.8) 03 (1.9) 01 (1.9) 06 (3.7) 73 (90.1) 01 (1.2) 00 (0.0) 07 (8.6) Work experience (in years) - Mean ± SD Range 18.6 ±9.8 1-41 17.5 ±9 .9 1-39.5 N 162 81 62 Descriptive Results -1 The section one of the descriptive results includes preliminary findings about the staffing levels and basic operational features of the study group and reference group pharmacies. It also includes information about the pharmaceutical care models/programs being used in the pharmacy and the trends that influenced their decision to implement a pharmaceutical care practice. Staffing Levels of the Pharmacy The staffing level data gathered about the pharmacies included the number of pharmacists on staff, the number of full-time and part-time pharmacy technicians on staff, and the number of support personnel on staff The descriptive data of the staffing levels of the pharmacy in the study group and in the reference group are presented in Table 5. The median number of pharmacists on staff for the study group and the reference group was three. The prevalence of one or two pharmacists on staff in the study group was 5.6% and 25.3% respectively while the prevalence of one or two pharmacists on staff in the reference group was 1 1 . 1 % and 28.4% respectively. However, the frequency of four to six pharmacists or seven to ten pharmacists on staff in the study group was 30.2% and 6.8% respectively while the frequency of four to six pharmacists in the reference group was 22.2% with no occurrences of seven or more pharmacists on staff. A complement of one full-time pharmacy technician was the most frequently reported technician staffing option for the study group as well as the reference group with 33.3% and 42% respectively. Forty-two percent of the study group and 49.4% of the reference group did not 63 have any part-time pharmacy technicians on staff. However, 28.4% of the former and 24.7% of the latter had one part-time technician on staff. Thirty-seven percent of the reference group pharmacies and 48.1% of the study group pharmacies had cashiers on staff, while 1.2% of the former and 3.7% of the latter had receptionists on staff. Furthermore, 14.8% of the study group pharmacies and 13.6% of the reference group pharmacies had secretarial personnel on staff. Finally, 31.5% of the study group pharmacies and 14.8% of the reference group pharmacies reported that they employed other support personnel on staff. The other support personnel reported by the two groups were specified as accountants, front store personnel, book-keepers, clerks, stock and inventory control personnel, compliance packaging personnel, over the counter coordinators, health care technician, pharmacy aids, nurses, patient aid nurse, naturopaths, and student interns. Table 5. Staffing levels of the pharmacy in the study group and the reference group Staffing levels of the pharmacy Study group Reference group n (%) n (%) No. of pharmacists on staff - 1 9 (5.6) 9(11.1) - 2 41 (25.3) 23 (28.4) - 3 52 (32.1) 29 (35.8) - 4-6 49 (30.2) 18 (22.2) - 7-10 11 (6.8) 0 (0.0) Median 3 3 No. of full-time pharmacy technicians - None 36 (22.2) 24 (29.6) - 1 54 (33.3) 34 (42.0) - 2 35 (21.6) 9(11.1) - 3 21 (13.0) 9(11.1) - 4 10(6.2) 1(1.2) - 5 6(3.7) -- >5 - 2 (2.5) missing - 2 (2.5) No. of part-time pharmacy technicians None 68 (42.0) 40 (49.4) - 1 46 (28.4) 20 (24.7) - 2 25 (15.4) 11 (13.6) - 3 9 (5.6) 5 (6.2) - 4 5(3.1) 2 (2.5) - 5 3(1.9) -- >5 5(3.1) -missing 1 (0.6) 3 (3.7) No. of support personnel Cashier 78 (48.1) 30 (37.0) - Receptionist 6 (3.7) 1(1.2) Secretarial personnel 24(14.8) 11 (13.6) - Other 51 (31.5) 12(14.8) N 162 81 65 Basic Operational Features of the Pharmacy The basic operational features of the pharmacy that were considered included number and type of shifts in pharmacy, number of pharmacists working per shift and number of pharmacy technicians working per shift. Descriptive data of the basic operational features of the study group pharmacies and the reference group pharmacies are presented in Table 6. Number and Type of Shifts, Number of Pharmacists and Pharmacy Technicians Working per Shift Most of the pharmacies in the study group had one or two shifts per day with a frequency of 45.7% and 49.4% respectively. Similarly, in the reference group, 35.8% had one shift per day and 61.7%o had two shifts per day. Day shift was the most frequently observed shift for the study group pharmacies and the reference group pharmacies with 100%) and 97.5% respectively. Additionally, 58.6% of the study group pharmacies and 67.9%> of the reference group pharmacies also had night shifts. Among the study group pharmacies, 63.6% utilized one pharmacist per shift while 70.4% of the reference group pharmacies utilized one pharmacist per shift. It is also evident from Table 6 that 25.9%o of the study group pharmacies and 24.7% of the study group pharmacies utilized two pharmacists per shift. Among the study group pharmacies, 43.8% utilized one pharmacy technician per shift, and among the reference group pharmacies, 51.9% utilized one pharmacy technician per shift. The frequency of utilization of two pharmacy technicians per shift was lower for both study group and reference group with 28.4%> and 19.8% respectively. Workload Respondents were asked to rate on a five-point Likert scale, one being strongly agree and five being strongly disagree to the statement - the current number of pharmacists and pharmacy technicians working per shift was sufficient to manage the workload. The results of the rating are presented in Table 7. The study group and the reference group respondents rated the workload statement for pharmacists similarly at 2.2 and 2.0 respectively. Both groups of respondents tended toward agreement that the number of pharmacists working for each shift was sufficient to manage the workload. The study group and the reference group respondents also rated the workload statement for pharmacy technicians similarly at 2.0 and 2.2 respectively, hence tending to agree that the number of pharmacy technicians working per shift is sufficient to manage the workload. Trends Influencing Decision to Implement a Pharmaceutical Care Practice The respondents reported whether they made changes to their practice in order to provide pharmaceutical care. They also reported if a pharmaceutical care model was being used at their pharmacy. Finally, they also specified the trends that influenced their decision to implement a pharmaceutical care practice at their pharmacy. Table 6. Basic operational features of the study group pharmacies and the reference group pharmacies. Basic operational feature of the Study group Reference group pharmacy n (%) n (%) Number of shifts/day in pharmacy - 1 74 (45.7) 29 (35.8) - 2 80 (49.4) 50(61.7) - 3 7 (4.3) 1(1.2) - 4 1 (0.6) -missing - 1(1.2) Type of shifts in pharmacy - Morning shift (6:00 am-2:00 pm) 10(6.2) 0 (0.0) - Day shift (9:00 am-6:00 pm) 162 (100) 79 (97.5) - Night shift (2:00 pm-10:00 pm) 95 (58.6) 55 (67.9) - Late night shift (10:00 pm-6:00am) 2(1.2) 1(1.2) Missing - 2 (2.5) No. of pharmacists working per shift - 1 103 (63.6) 57 (70.4) - 1.5 4 (2.5) 1(1.2) - 2 42 (25.9) 20 (24.7) - 3 7(4.3) 1(1.2) - 4 3(1.9) 1(1.2) missing 3(1.9) 1(1.2) No. of pharmacy technicians working/shift not applicable 22(13.6) 17(21.0) - 1 71 (43.8) 42 (51.9) - 1.5 1 (0.6) -- 2 46 (28.4) 16(19.8) - 3 15 (9.3) 2 (2.5) - 4 5(3.1) 1(1.2) - 5 2(1.2) 1(1.2) missing - 2 (2.5) N 162 81 68 Table 7. Workload rating of study group and reference group Workload scale Study group Reference group Pharmacists N = 162 N = 81 The current number of pharmacists working for each shift is sufficient to manage the workload in the pharmacy Mean rating 2.2 2.0 Pharmacy technicians N = 141* N = 65* The current number of pharmacy technicians working per shift is sufficient enough to manage the workload of the pharmacy Mean rating 2.0 2.2 Scale: 1 = Strongly agree to 5 = Strongly disagree * Pharmacies with no pharmacy technicians on staff were not included. Changes to practice in order to provide pharmaceutical care The respondents were asked to report whether they had made changes to their practice in order to provide pharmaceutical care. The responses of the study group and the reference group are illustrated in Figure 2, with 94.4% of the study group reporting in the affirmative while 70.4%o of the reference group also reported that they had made changes to their practice in order to provide pharmaceutical care. 69 Use of a pharmaceutical care practice model in pharmacy The respondents also reported whether a pharmaceutical care practice model was being used in their pharmacy (Question number 14 of CPSEQ). One hundred and nine (67.3%) of the study group respondents reported that a pharmaceutical care practice model was implemented at their pharmacy while only 23 (28.4%) of the reference group respondents reported the same. (Figure 3). Description of study group pharmacies affiliated with a pharmaceutical care models/programs that made changes to practice The number of study group pharmacies affiliated with a pharmaceutical care model/program reporting that they did or did not make changes to their practice in order to provide pharmaceutical care is presented in Figure 4. Trends influencing decision to implement a pharmaceutical care practice The respondents were asked to specify the trends that influenced their decision to implement a pharmaceutical care practice. The study group and reference group responses are illustrated in Figure 5. The most frequently reported trend that influenced the decisions of both the groups was greater patient involvement in their health care (greater patient autonomy). 70 Figure 2. Study group and reference group respondents reporting changes to their practice i n order to provide pharmaceutical care Figure 3. Study group and reference group pharmacies report ing use o f a pharmaceutical care mode l • Y e s • N o Study group R e f e r e n c e group Figure 4. Study group pharmacies affiliated with pharmaceutical care models/programs that made changes or made no changes to provide pharmaceutical care H O P 84 | 3 | D P C 11 U M C A P 17 | | -S P E P 31 I -G P C 7 l h IHDEP 1 1 P R E P IE] B C A S M E P l h 1 i 0 20 40 60 80 100 SI made changes •made no changes Study Group: N= 162 HOP: Health Outcomes Pharmacies Model (n = 87) DPC: Dalhousie Pharmaceutical Care Model (n = 1) U M C A P : University of Montreal Clinical Associate Program (n = 21) SPEP: Structured Practical Experience Program, University of Toronto (n = 31) GPC: Geriatric Pharmaceutical Care Model (n = 8) IHDEP: In-Home Drug Evaluation Program (n = 1) PREP: Pharmaceutical care Research and Education Program (n = 5) B C A S M E P : British Columbia Asthma Self Management and Education Program (n = 8) Figure 5. Trends influencing the study groups' and reference groups' decision to implement a: pharmaceutical care practice Trend 1 Trend 2 Trend 3 Trend 4 Trend 5 Trend 6 Trend 7 Trend 8 Other I 35% 44% 40% 40% I rrr/o 24% 32% 33% , 14% """ "I 28... 0% 20% 40% 5 6 % 60% I 82% • Reference group M Study group 80% 100% Trend 1: Increase in health care demands and costs Trend 2: Greater patient involvement in their health care; greater patient autonomy Trend 3: Aging of the baby boom generation Trend 4: Increase in demand for convenience Trend 5: Greater demand for accessibility Trend 6: Increase in the integration of computer technology into pharmacy practice Trend 7: Increased demand for home health care products Trend 8: Greater inter-pharmacy competition Other: Desire for professional enrichment, desire to enhance patient care and health outcomes, motivation for business and financial rewards, concern for future of profession, increased professional competition, involvement in a pharmaceutical care model. 73 Descriptive Results - 2 The performance of the respondents on the Behavioral Pharmaceutical Care Scale (BPCS), the number of hours specifically allocated, in the pharmacy for pharmaceutical care related activities, description of structural changes, and the importance ratings of the structural elements are presented in this section of the descriptive results. These descriptive results are presented for both the study group and the reference group. Furthermore, descriptive results are presented for the study group across each of the pharmaceutical care model/program classifications and also for the study group across ownership categories (chain pharmacy and independent pharmacy). Study Group Performance on the Behavioral Pharmaceutical Care Scale (BPCS) The BPCS measures the respondents' efforts toward the provision of pharmaceutical care. The BPCS has a minimum score of 16 and maximum possible score of 180. The performance of the study group on the BPCS is presented in Table 8. The mean score of the study group was 110.9 ± 28.6. The lowest score in the study group was 39 and the highest score was 171. The 25th percentile score was 93 and the 75th percentile score was 130.2. A histogram displaying the distribution of the BPCS scores of the study group is presented in Figure 6. To examine whether the BPCS scores exhibit a normal distribution, a Quantile-Quantile (Q-Q) plot was constructed. The Q-Q plot is a scatterplot of the scores' distribution against a normal distribution. The plot shows the scores on the x-axis, and the 74 corresponding predicted values from a standard normal distribution on the y-axis. If the scores follow a normal distribution, the points will cluster along a straight line. The Q-Q plot of the study group's BPCS scores is presented in Figure 7. The scores in the plot are linear, therefore the assumption of normality is reasonable. In addition to the Q-Q plot, the Kolmogorov-Smirnov Lilliefors (K-S Lilliefors) test, which is a formal test to assess the normality of the BPCS score distribution, was conducted. It tested the null hypothesis that the scores are from a normal distribution. Results of the K-S Lilliefors test for normality of the study groups' BPCS score distribution is shown in Table 8. Since the p value for the test was large (p > 0.200), the normality assumption is acceptable. Number of hours specifically allocated for pharmaceutical care activities The respondents were asked to report the number of hours per day that had been specifically allocated in their pharmacy for pharmaceutical care activities. The number of hours ranged from zero to above eight hours and above. A description of the number of hours allocated for pharmaceutical care activities in the study group pharmacies are presented in Table 9. Sixty six percent of the study group pharmacies had allocated zero to three hours per day, while 28.2 percent had allocated four to seven hours and 5.8 percent had allocated eight hours and above for pharmaceutical care activities. Table 8. Performance of the study group on the BPCS. Performance on the BPCS Study group (N = 162) BPCS Score Mean 110.9 Standard Deviation 28.61 Range Minimum 39 Maximum 171 Percentiles 25 93 50 110.5 75 130.2 Test of Normality of Distribution Kolmogorov-Smirnov Lilliefors Test Statistic 0.045 Degrees of freedom 162 p value > 0.200 76 Figure 6. BPCS score distribution of the study group 30 CD CT 20 10 M e a n = 1 10.9 S t d . D e v = 28 .61 R a n g e = 39 -- 1 71 N = 162 40 60 80 100 120 140 160 50 70 90 1 10 130 150 170 B P C S S c o r e s Figure 7. Normal probability plot of the study groups' BPCS scores Normal Q -Q Plot of B P C S •o CD "G CD Q . X LU 20 40 60 80 100 120 140 160 180 200 Observed Value 77 Table 9. Number of hours allocated for pharmaceutical care activities in the study group Number of hours specifically allocated for Study group, pharmaceutical care activities N - 162 Number of hours 0 - 3 6 6 . 0 % 4 - 7 2 8 . 2 % 8 and above 5 . 8 % Description of structural changes The respondents were asked to specify the structural changes that had been made in the pharmacy in order to provide pharmaceutical care. A categorized list of structural elements was included in the questionnaire. Additionally, the respondents were also asked to report any other changes that were not included in the list. A detailed description of the frequency of structural changes in the study group is presented in Table 10. Increased pharmacist involvement in the provision of professional services was the most frequent with 93 .8%) of the study group pharmacies having incorporated this structural change. Among the list of structural changes, 6 6 . 7 % of the pharmacies had incorporated a private patient counselling room and 63.6% had incorporated a semi-private patient counselling room. Pharmacists' training was reported in 83.3%o of the pharmacies. Table 10. Description of structural changes in the study group I D . Key Structural elements Study group n (%) A Re-organization of pharmacists' duties A.l Decreased pharmacist involvement in technical functions (e.g. data entry, filling prescriptions) 105 (64.8) A.2 Increased pharmacist involvement in the provision of professional services (e.g. patient counselling, disease specific clinics, blood glucose monitoring service, medication evaluation service) 152 (93.8) B Re-organization of pharmacy technicians' duties B.l Increased pharmacy technician involvement in technical functions (e.g. data entry, filling prescriptions, dealing with calls that do not require pharmacist's input, running cash register) 123 (75.9) C Changes in physical layout C l Incorporation of unelevated pharmacist workstation 72 (44.4) C.2 Incorporation of elevated pharmacy technician workstation 15 (9.3) C.3 Creation of layout accommodating the needs of the disabled 58 (35.8) C.4 Incorporation of a patient waiting area 108 (66.7) C.5 Incorporation of a private patient counselling room 108 (66.7) C.6 Incorporation of semi-private patient counselling area (e.g. alcove, booth) 103 (63.6) C.7 Incorporation of audio-visual educational equipment (TV, VCR, Videos, CD's, etc.) 87 (53.7) C.8 Incorporation of educational materials (books, brochures, displays, patient-package inserts, etc.) 143 (88.3) C.9 Movement of the dispensary from the back to the front of the pharmacy 16(9.9) CIO Incorporation of drive-through windows 2(1.2) C. l l Removal of the cash register out of the dispensary and into a check out area 47 (29.0) C.12 Incorporation of fixtures (signage, panels, lighting, etc.) 57 (35.2) C.13 Incorporation of carpeting throughout the store 41 (25.3) C.14 Incorporation of warm colours for the walls 62 (38.3) C.15 Others* 19(11.7) * Detailed description of 'others' in each category is presented in Appendix 7. Table 10. Continued. ID. Key Structural elements Study group n (%) D Pharmacist training D.l Formal training program 135 (83.3) D.2 Others* 60 (37.0) E Pharmacy technician retraining (re: provision of pharmaceutical care) E.l On the job training 99 (61.1) E.2 Formal technician certification program 36 (22.2) E.3 Others* 13 (8.0) F Financial compensation F.l Payment by patients 31 (19.1) F.2 Payment by second party payer (government programs) 41 (25.3) F.3 Payment by third party payer (private insurance companies) 27(16.7) F.4 Others* 33 (20.4) G Modification of your pharmacy's policy and procedure G.l Requirement for sit down counselling for all new and refill prescriptions 35 (21.6) G.2 Requirement for new patients to complete a thorough patient demographic information sheet 17(10.5) G.3 Others* 45 (27.8) H Technological changes H.l Change in the software used 93 (57.4) H.2 Change in the hardware used 75 (46.3) H.3 Incorporation of hardware/software systems that answer pharmacy phones 11 (6.8) H.4 Incorporation of automatic pill counters 33 (20.4) H.5 Others* 20(12.3) * Detailed description of'others' of each category is presented in Appendix 7. 80 Importance rating of structural element categories The respondents were asked to rate the importance of the structural element categories for the successful provision of pharmaceutical care. The rating scale was from one to five; one being not important at all and five being very important. The results of the importance rating of the study group are present in Table 11. The study group tended to rate all of the eight structural element categories as important. Re-organization of pharmacists' duties was rated the highest at 4.5, while technological changes was rated lowest at 3.5. Table 11 Importance ratings of structural element categories Structural element category Study group (N = 162) Re-organization of pharmacists' duties 4.5 Re-organization of pharmacy technicians' duties 4.2 Pharmacist training 4.2 Changes in physical layout 3.9 Financial compensation 3.9 Technological changes 3.5 Pharmacy technician retraining 3.4 Modification of your pharmacy's policy & procedure 3.4 Scale: 1 = not important at all to 5 = very important 81 Reference Group Performance on the Behavioral Pharmaceutical Care Scale The performance of the reference group on the BPCS is presented in Table 12. The mean score of the reference group was 95.3 ± 26.5. The lowest score in the study group was 16 and the highest score was 156. The 25th percentile score was 76 and the 75th percentile score was 114.5. A histogram displaying the distribution of the BPCS scores of the reference group is presented in Figure 8. To examine whether the BPCS scores exhibits a normal distribution, a Q-Q plot was constructed. (Figure 9). The scores in the plot are more or less linear, therefore the assumption of normality of the BPCS score distribution is reasonable. Kolmogorov-Smirnov Lilliefors (K-S Lilliefors) test for normality was conducted to assess the normality of the BPCS score distribution. Results of the K-S Lilliefors test for normality of the reference groups' BPCS score distribution is shown in Table 12. Since the observed significance level for the test was large at > 0.200, the normality assumption is not unreasonable. Table 12. Performance of the reference group on the BPCS Performance on the BPCS Reference group (N = 81) BPCS Score Mean 95.3 Standard Deviation 26.5 Range Minimum 16 Maximum 156 Percentiles 25 76 50 95 75 114.5 Test of Normality of Distribution Kolmogorov-Smirnov Lilliefors Test Statistic 0.048 Degrees of freedom 81 p value > 0.200 Figure 8. BPCS score distribution of the reference group 83 20 >* o c C T CD 10 1 1 Wm mm 'A Wit.  • • i f • HI H I • i •/AS-• •fHH Bill 11111 ' 4 " "'/,-/ * •'///// t§ §1 • i t | | | | | | Wmm. 111111 • 2 0 4 0 6 0 8 0 100 120 140 1 6 0 3 0 5 0 7 0 9 0 110 1 3 0 150 BPCS Scores M e a n = 9 5 . 3 S t d . D e v = 2 6 . 4 8 R a n g e = 16 - 1 5 6 N = 8 1 . 0 0 Figure 9. Normal probability plot of the reference groups' BPCS scores Normal Q-Q Plot of B P C S N o r m a l L i n e B P C S 2 0 4 0 6 0 8 0 1 0 0 1 2 0 1 4 0 1 6 0 Observed Value 84 Number of hours specifically allocated for pharmaceutical care activities The respondents were asked to report the number of hours per day that had been specifically allocated in their pharmacy for pharmaceutical care activities. The number of hours ranged from zero to eight hours and above. A description of the number of hours allocated for pharmaceutical care activities in the reference group pharmacies are presented in Table 13. Among the reference group pharmacies 78.4% had allocated zero to three hours per day, while 18.9%o had allocated four to seven hours and 2.7% had allocated eight hours and above for pharmaceutical care activities. Description of structural changes A detailed description of the frequency of structural changes in the reference group is presented in Table 14. Increased pharmacist involvement in the provision of professional services was the most frequent with 80.2% of the reference group pharmacies having incorporated this structural change. Among the list of structural changes, 28.4%> of the pharmacies had incorporated a private patient counselling room and 50.6% had incorporated a semi-private patient counselling room. Pharmacists' training was seen in 44.4% of the pharmacies. Table 13. Number of hours allocated for pharmaceutical care activities in the reference group. Number of hours specifically allocated for Reference group pharmaceutical care activities N = 81 Number of hours 0-3 78.4% 4-7 18.9% 8 and above 2.7% Table 14. Description of structural changes in the reference group I D . Key Structural elements Reference group n (%) A Re-organization of pharmacists' duties A.l Decreased pharmacist involvement in technical functions (e.g. data entry, filling prescriptions) 38 (46.9) A.2 Increased pharmacist involvement in the provision of professional services (e.g. patient counselling, disease specific clinics, blood glucose monitoring service, medication evaluation service) 65 (80.2) B Re-organization of pharmacy technicians' duties B.l Increased pharmacy technician involvement in technical functions (e.g. data entry, filling prescriptions, dealing with calls that do not require pharmacist's input, running cash register) 52 (64.2) C Changes in physical layout C l Incorporation of unelevated pharmacist workstation 33 (40.7) C.2 Incorporation of elevated pharmacy technician workstation 4 (4.9) C.3 Creation of layout accommodating the needs of the disabled 29 (35.8) C.4 Incorporation of a patient waiting area 46 (56.8) C.5 Incorporation of a private patient counselling room 23 (28.4) C.6 Incorporation of semi-private patient counselling area (e.g. alcove, booth) 41 (50.6) C.7 Incorporation of audio-visual educational equipment (TV, VCR, Videos, CD's, etc.) 30 (37.0) C.8 Incorporation of educational materials (books, brochures, displays, patient-package inserts, etc.) 62 (76.5) C.9 Movement of the dispensary from the back to the front of the pharmacy 3 (3.7) CIO Incorporation of drive-through windows 2 (2.5) C. l l Removal of the cash register out of the dispensary and into a check out area 6 (7.4) C.12 Incorporation of fixtures (signage, panels, lighting, etc.) 22 (27.2) C.13 Incorporation of carpeting throughout the store 7 (8.6) C.14 Incorporation of warm colours for the walls 14(17.3) C.15 Others 7 (8.6) Table 14. Continued. ID. Key Structural elements Reference group n (%) D Pharmacist training D.l Formal training program 36 (44.4) D.2 Others 30 (37.0) E Pharmacy technician retraining (re: provision of pharmaceutical care) E . l On the job training 32 (39.5) E.2 Formal technician certification program 13 (16.0) E.3 Others 9(11.1) F Financial compensation F.l Payment by patients 8 (9.9) F.2 Payment by second party payer (government programs) 15 (18.5) F.3 Payment by third party payer (private insurance companies) 16(19.8) F.4 Others 8 (9.9) G Modification of your pharmacy's policy and procedure G.l Requirement for sit down counselling for all new and refill prescriptions 8 (9.9) G.2 Requirement for new patients to complete a thorough patient demographic information sheet 14(17.3) G.3 Others 19(23.5) H Technological changes H.l Change in the software used 37(45.7) H.2 Change in the hardware used 22 (27.2) H.3 Incorporation of hardware/software systems that answer pharmacy phones 2 (2.5) H.4 Incorporation of automatic pill counters 10(12.3) H.5 Others 2 (2.5) 87 Importance rating of structural element categories The results of the importance rating of the reference group are present in Table 15. The reference group tended to rate all of the eight structural element categories as important. Re-organization of pharmacists' duties was rated the highest at 4.2, while technological changes was rated lowest at 3.4. Table 15. Importance ratings of structural element categories Structural element category Reference group (N = 162) Re-organization of pharmacists' duties 4.2 Re-organization of pharmacy technicians' duties 3.8 Pharmacist training 3.8 Changes in physical layout 3.6 Financial compensation 3.6 Technological changes 3.4 Pharmacy technician retraining 3.2 Modification of your pharmacy's policy & procedure 3.2 Scale: 1 = not important at all, to 5 = very important 88 Study Group - Pharmaceutical Care Model/Program Affiliation Dalhousie Pharmaceutical Care Model and the In-Home Drug Evaluation Program were not included in this part of the analysis because there was only one study group pharmacy affiliation for each of these two pharmaceutical care models/programs. Eighty-seven study group pharmacies were affiliated with the Health Outcome Pharmacies Model (HOP), 31 were affiliated with the Structured Practical Experience Program, University of Toronto (SPEP) and 21 were affiliated with the University of Montreal Clinical Associate Program (UMCAP). Performance on the Behavioral Pharmaceutical Care Scale The BPCS performances of the study group respondents categorized by their pharmaceutical care model/program affiliations are presented in Table 16. The HOP pharmacies had a mean score of 112.3 ± 28.5, the SPEP pharmacies had a mean score of 108.8 ± 22.5 and the UMCAP pharmacies had a mean score of 104.6 ± 34.8. Description of structural changes A detailed description of the frequency of structural changes in the study group pharmacies categorized by their pharmaceutical care model/program affiliation is presented in Table 17. 89 Table 16. BPCS performances of the study group respondents categorized by their pharmaceutical care model/program affiliations BPCS HOP SPEP UMCAP BCASMEP GPCM PREP Scores n = 87 n = 31 n = 21 n = 8 n = 8 n = 5 Mean 112.3 108.8 104.6 93.8 114.8 131.8 Std. Dev. 28.52 22.52 34.80 27.47 22.76 26.05 Range Minimum 39 70 39 62 81 93 Maximum 171 150 168 136 148 164 Table 17. Frequency of structural changes in study group pharmacies categorized by pharmaceutical care model/program affiliation Structural HOP SPEP UMCAP BCASMEP GPCM PREP elements n = 87 n = 31 n = 21 n = 8 n = 8 n = 5 ID. % % % % % % A.l 62.1 87.1 38.1 37.5 75 100 A.2 95.4 100 76.2 87.5 100 100 B.l 70.1 96.8 57.1 75 87.5 100 C l 43.7 48.4 23.8 62.5 50 80 C.2 9.2 6.5 9.5 12.5 0 20 C.3 37.9 38.7 4.8 50 37.5 80 C.4 71.3 71.0 42.9 62.5 50 100 C.5 65.5 67.7 52.4 62.5 100 100 C.6 71.3 58.1 52.4 37.5 37.5 80 C.7 64.4 54.8 9.5 12.5 75 60 C.8 95.4 96.8 57.1 62.5 87.5 100 C.9 10.3 9.7 9.5 12.5 0 20 CIO 0 3.2 0 0 12.5 0 C l l 35.6 19.4 0 37.5 50 40 C.12 40.2 35.5 4.8 50 12.5 80 C.13 31.0 16.1 14.3 0 50 40 C.14 39.1 35.5 38.1 12.5 37.5 , 80 C.15 10.3 9.7 4.8 12.5 25 40 D.l 86.2 93.5 61.9 87.5 62.5 100 D.2 33.3 35.5 47.6 25 62.5 20 E.l 62.1 80.6 33.3 50 37.5 80 E.2 18.4 38.7 14.3 25 25 20 E.3 4.6 19.4 9.5 12.5 0 0 F.l 19.5 19.4 14.3 37.5 12.5 20 F.2 21.8 9.7 52.4 50 37.5 20 F.3 18.4 12.9 14.3 25 12.5 20 F.4 23 3.2 9.5 25 87.5 0 G.l 16.1 22.6 47.6 12.5 12.5 40 G.2 13.8 6.5 9.5 0 0 20 G.3 25.3 38.7 4.8 37.5 37.5 40 H.l 63.2 71 28.6 50 37.5 40 H.2 52.9 41.9 52.4 25 12.5 20 H.3 6.9 6.5 9.5 0 12.5 0 H.4 17.2 29.0 0 62.5 25 40 H.5 16.1 9.7 9.5 0 12.5 0 Note: The key for identification of structural elements can be found in Table 10 and Table 14. 91 Study Group - Chain Pharmacies and Independent Pharmacies Drug store chain pharmacies, grocery store chain pharmacies, and mass merchandiser chain pharmacies were grouped together under Chain pharmacies. Independent (banner) pharmacies and independent (other) pharmacies were grouped together under Independent pharmacies. There were a total of 28 chain pharmacies and 134 independent pharmacies in the study group. Performance on the Behavioral Pharmaceutical Care Scale (BPCS) The BPCS performances of the study group chain pharmacies and independent pharmacies are presented in Table 18. The mean BPCS score of the chain pharmacies was 108.1 with a standard deviation of 26.2, and the scores ranged from 59 to a maximum of 149. The mean score of the independent pharmacies was 111.5 with a standard deviation of 29.1 with a minimum score of 39 and a maximum score of 171. Description of structural changes A detailed description of the frequency of structural changes in the chain pharmacies and independent pharmacies is presented in Table 19. Increased pharmacist involvement in the provision of professional services was the most frequent with 92.9% of the chain pharmacies and 94%o of the independent pharmacies having incorporated this structural change. Incorporation of a private patient counselling room was reported in 71.4%o of the chain pharmacies and 65.7% of the independent pharmacies. Incorporation of a semi-private patient counselling room was reported in 50%> of the chain pharmacies and 66.4% of the independent pharmacies. Seventy-92 five percent of the chain pharmacies and 85.1% of the independent pharmacies had implemented pharmacists' training program. Table 18. Performance of chain and independent pharmacies on the BPCS BPCS Score Independent pharmacy (n = 134) Chain pharmacy (n = 28) Mean 111.5 108.1 Std. Deviation 29.13 26.25 Range: Minimum 39 59 Maximum 171 149 Table 19. Description of structural changes in chain and independent pharmacies Structural Independent pharmacies Chain pharmacies elements n = 134 n = 28 ID. % % A.1 61.2 82.1 A.2 94.0 92.9 B.l 73.9 85.7 C l 40.3 64.3 C.2 9.0 10.7 C.3 34.3 42.9 C.4 66.4 67.9 C.5 65.7 71.4 C.6 66.4 50.0 C.7 56.0 42.9 C.8 90.3 78.6 C.9 11.9 0 CIO 0.7 3.6 C. l l 34.3 3.6 C.12 35.1 35.7 C.13 29.1 7.1 C.14 43.3 14.3 C.15 11.9 10.7 D.l 85.1 75.0 D.2 34.3 50.0 E.l 63.4 50.0 E.2 17.2 46.4 E.3 6.0 17.9 F.l 22.4 3.6 F.2 26.9 17.9 F.3 18.7 7.1 F.4 22.4 10.7 G.l 22.4 17.9 G.2 11.9 3.6 G.3 25.4 39.3 H.l 58.2 53.6 H.2 50.0 28.6 H.3 4.5 17.9 H.4 17.9 32.1 H.5 11.9 14.3 Note: The key for identification of structural elements can be found in Table 10 and Table 14. 94 Exploratory Results Two types of exploratory analyses of the study group and the reference group were conducted. First, the BPCS score distribution of the study group and the reference group was used to select two sub-groups for each of the groups. Respondents above the 75th percentile of the BPCS score distribution were selected as the highest quartile (HQ) sub-group. The HQ sub-group represents pharmacies at the higher end of provision of pharmaceutical care as measured by the BPCS. Respondents below the 25th percentile of the BPCS score distribution were selected as lowest quartile (LQ) sub-group. The LQ sub-group represents pharmacies at the lower end of provision of pharmaceutical care as measured by the BPCS. Second, the study group pharmacies were matched with the reference group pharmacies at two levels. The first level of matching included three variables, namely location - urban or rural, number of pharmacists on staff, and ownership - chain or independent. At the first level there was a matching of 73 study group pharmacies and 73 reference group pharmacies. The first level matched pharmacies were then used to perform a second level of matching with another variable - the province of the pharmacy. The second level of matching provided a match of 36 study group pharmacies and 36 reference group pharmacies. Exploratory analyses were conducted at both levels of matching. Comparison of Lowest Quartile (LQ) Sub-group and Highest Quartile (HQ) Sub-group of Study Group There were 45 study group pharmacies in the LQ sub-group and 44 study group pharmacies in the HQ sub-group. The LQ sub-group and the HQ sub-group of the study 95 group were compared for the distribution of pharmaceutical care models/programs, the number of hours allocated for pharmaceutical care activities, the frequency of changes of structural categories as a whole, and the frequency of changes of individual structural elements. Performance on the Behavioral Pharmaceutical Care Scale (BPCS) The performance of the LQ sub-group and HQ sub-group on the BPCS is presented in Table 20. The mean score of the LQ sub-group was 76.5 ±15.1 and the mean score of the HQ sub-group was 146.4 ± 11.8. The scores ranged from 39 to 93 in the LQ sub-group and the HQ sub-group scores ranged from 130 to 171. Distribution of pharmaceutical care models/programs in LQ and HQ sub-groups The distribution of pharmaceutical care models/programs among the LQ and HQ sub-groups is presented in Table 21. Health Outcomes Pharmacies (HOP) had the highest representation in both the LQ sub-group and the HQ sub-group with 21 pharmacies and 24 pharmacies respectively. Number of hours specifically allocated for pharmaceutical care activities A description of the number of hours per day allocated for pharmaceutical care activities in the LQ and HQ sub-group pharmacies is presented in Table 22. In the LQ sub-group, 78.3% of the pharmacies had allocated zero to three hours per day, while only 37.5%) of the HQ sub-group pharmacies had allocated similar hours for pharmaceutical care activities. In fact, in the HQ sub-group pharmacies, 50%) had allocated four to seven hours per day and 12.5% had allocated eight hours and above per day for pharmaceutical care activities, whereas only 19.6% and 2.2%o of the LQ sub-group pharmacies had allocated similar hours respectively. 96 A higher percentage of HQ sub-group pharmacies had allocated more hours for pharmaceutical care activities than the LQ sub-group. Furthermore, a lower percentage of HQ sub-group pharmacies had allocated zero to three hours for pharmaceutical care activities than the LQ sub-group pharmacies. Pearson's chi-square test was conducted to compare the frequency of allocation of hours for pharmaceutical care activities between the HQ sub-group and LQ sub-group. The results of this test are presented in Table 22. Since the observed p value is less than 0.01, the notion that a higher percentage of HQ sub-group pharmacies had allocated more hours for pharmaceutical care activities is not unreasonable. Table 20. Performance on the BPCS BPCS Score LQ sub-group HQ sub-group Mean 76.5 146.4 Standard Deviation 15.11 11.8 Range Minimum 39 130 Maximum 93 171 Table 21. Distribution of pharmaceutical care models/programs PC Models/Programs LQ sub-group n (%) HQ sub-group n (%) Health Outcomes Pharmacies Model 21 (46.6) 24 (54.5) Structured Practical Experience Program 9 (20.0) 6(13.6) University of Montreal Clinical Associate Program 8(17.7) 5(11.3) BC Asthma Self Management Education Program 3 (6.6) 2 (4.5) Geriatric Pharmaceutical care Model 2 (4.4) 3 (6.8) Pharmaceutical care Research and Education Program 1 (2.2) 3 (6.8) Dalhousie Pharmaceutical care Model 1 (2.2) 0 In Home Drug Evaluation 0 1 (2.2) N 45 44 Table 22. Hours per day specifically allocated for pharmaceutical care activities Number of hours reported to be allocated for pharmaceutical care activities LQ sub-group n = 45 HQ sub-group n = 44 Number of hours 0-3 4-7 8 and above 78.3 % 19.6% 2.2 % 37.5 % 50.0 % 12.5 % Pearson's chi-square test Statistic Degrees of freedom p value 15.1 2 < 0.01 Structural element categories ofLQ sub-group and HQ sub-group The structural elements in the eight structural categories were combined to obtain a score for each structural element category. The scores for LQ sub-group and HQ sub-group structural element categories were ranked. Mann-Whitney test was conducted to compare the ranks of the structural element categories of the two sub-groups. Table 23 summarizes the results of the Mann-Whitney test. The mean rank of the HQ sub-group for re-organization of pharmacists' duties, changes in physical layout, pharmacist training, financial compensation, and modification of pharmacy's policy and procedures was higher than the LQ sub-group (p < 0.01). Comparison of structural changes of LQ sub-group and HQ sub-group The LQ sub-group and HQ sub-groups were compared for the frequency of structural changes to each structural element. Pearson's chi-square test was conducted to test whether there was a difference in the percentage of pharmacies between the sub-groups making the structural changes (Table 24). The structural changes that were observed in a higher frequency in the HQ sub-group pharmacies were decreased pharmacist involvement in technical functions, incorporation of unelevated pharmacist workstation, and requirement for sit down counselling for all new and refill prescriptions. Table 23. Mann-Whitney Test for structural element categories of LQ sub-group and HQ sub-group Structural element categories LQ sub-group Mean Rank HQ sub-group Mean Rank p value Re-organization of pharmacists' duties 36.9 53.2 <0.01 Re-organization of pharmacy technicians' duties 42.1 47.9 0.14 Changes in physical layout 34.3 55.8 .< 0.01 Pharmacist training 39.5 50.5 0.01 Pharmacy technician retraining 40.2 49.8 0.04 Financial compensation 38.5 51.5 0.01 Modification of pharmacy's policy & procedures 36.8 53.3 < 0.01 Technological changes 40.1 49.9 0.06 Table 24. Pearson's chi-square test for structural changes in LQ sub-group and HQ sub-group Structural elements LQ sub-group N = 45 HQ sub-group N = 44 p value Re-organization of Pharmacists' duties 1. Decreased pharmacist involvement in technical functions 51.1% 90.9% < 0.01 2. Increased pharmacist involvement in provision of professional services 91.9% 95.5% 0.41 Re-organization of pharmacy technicians' duties 1. Increased pharmacy technician involvement in technical functions 71.1% 84.1% 0.14 Changes in physical layout 1. Incorporation of unelevated pharmacist workstation 35.6% 63.6% < 0.01 2. Incorporation of elevated pharmacy technician workstation 6.7% 15.9% 0.16 3. Creation of layout accommodating the needs of the disabled 22.2% 56.8% < 0.01 4. Incorporation of a patient waiting area 48.9% 75% 0.01 5. Incorporation of a private patient counselling room 64.4% 77.3% 0.18 6. Incorporation of semi-private patient counselling area 62.2% 65.9% 0.71 7. Incorporation of audio-visual educational equipment 37.8% 68.2% < 0.01 8. Incorporation of educational materials 73.3% 95.5% < 0.01 9. Movement of the dispensary from the back to the front of the pharmacy 8.9% 11.4% 0.69 10. Incorporation of drive-through windows 0% 2.3% 0.30 11. Removal of the cash register out of the dispensary and into a check out area 24.4% 34.1% 0.31 12. Incorporation of fixtures 24.4% 45.5% 0.03 13. Incorporation of carpeting throughout the store 15.6% 31.8% 0.07 14. Incorporation of warm colours for the walls 20% 56.8% < 0.01 15. Others 8.9% 22.7% 0.07 Table 24. Continued. Structural elements LQ sub-group N = 45 HQ sub-group N = 44 P value Pharmacist Training 1. Formal training program 77.8% 86.4% 0.29 2. Other training 28.9% 47.7% 0.06 Pharmacy Technician Retraining 1. On the job training 53.3% 65.9% 0.22 2. Formal technician training program 13.3% 34.1% 0.02 3. Other 11.1% 6.8% 0.47 Financial Compensation 1. Payment by patients 15.6% 25% 0.26 2. Payment by second party payers 22.2% 25% 0.75 3. Payment by third party payers 6.7% 27.3% < 0.01 4. Other 11.1% 27.3% 0.05 Modification of pharmacy's policy & procedure 1. Requirement for sit down counselling for all new & refill prescriptions 11.1% 35.4% < 0.01 2. Requirement for new patients to complete a thorough patient demographic info sheet 6.7% 13.6% 0.27 3. Other 20% 38.6% 0.05 Technological changes 1. Change in the software 57.8% 65.9% 0.43 2. Change in the hardware 37.8% 47.7% 0.34 3. Incorporation of hardware/software systems that answer pharmacy phones 2.2% 11.4% 0.08 4. Incorporation of automatic pill counters 20% 29.5% 0.29 5. Other 11.1% 11.4% 0.97 1 Comparison of Lowest Quartile (LQ) Sub-group and Highest Quartile (HQ) Sub-group of BPCS Score Distribution of Reference group There were 20 pharmacies in the LQ sub-group and 20 pharmacies in the HQ sub-group. The LQ sub-group and the HQ sub-group of the reference group were compared for the number of hours allocated for pharmaceutical care activities, the frequency of changes of structural categories as a whole and the frequency of changes of individual structural elements. Performance on the Behavioral Pharmaceutical Care Scale (BPCS) The performance of the LQ sub-group and HQ sub-group on the BPCS is presented in Table 25. The mean score of the LQ sub-group was 61.1 ± 16 and the mean score of the HQ sub-group was 128.9 ± 12.2. The scores ranged from 0 to 75 in the LQ sub-group and the HQ sub-group scores ranged from 115 to 156. Number of hours specifically allocated for pharmaceutical care activities A description of the number of hours per day allocated for pharmaceutical care activities in the LQ and HQ sub-group pharmacies are presented in Table 26. In the LQ sub-group, 87.5 percent of the pharmacies allocated zero to three hours per day, while only 55 percent of the HQ sub-group pharmacies had allocated similar hours for pharmaceutical care activities. In fact, in the HQ sub-group pharmacies, 35 percent had allocated four to seven hours per day and 10 percent had allocated eight hours and above per day for pharmaceutical care activities, whereas only 12.5 percent and zero percent of the LQ sub-group pharmacies had allocated similar hours respectively. A higher percentage of HQ sub-group pharmacies had allocated more hours for pharmaceutical care activities than the LQ sub-group. Furthermore, a lower percentage of HQ sub-group pharmacies had allocated zero to three hours for pharmaceutical care activities than the LQ sub-group pharmacies. Pearson's chi-square test was conducted to compare the frequency of allocation of hours for pharmaceutical care activities between the HQ sub-group and LQ sub-group. The results of this test are presented in Table 26 and indicate, however, that there was no difference in the frequency of allocation of hours per day for pharmaceutical care activities between the sub-groups (p = 0.093). Structural element categories of LQ sub-group and HQ sub-group The scores for LQ sub-group and HQ sub-group structural element categories were ranked. Mann-Whitney tests were conducted to compare the ranks of the structural element categories of the two sub-groups. Table 27 summarizes the results of the Mann-Whitney test. The mean ranks of the HQ sub-group for re-organization of pharmacists' duties, re-organization of pharmacy technicians' duties, pharmacist training and modification of pharmacy's policy and procedures were higher than the LQ sub-group (p < 0.01). Table 25. Performance of the LQ sub-group and HQ sub-group on the B P C S (Reference Group) BPCS Score LQ sub-group HQ sub-group Mean 61.1 128.9 Standard Deviation 16.06 12.26 Range Min imum 0 115 Maximum 75 156 Table 26. Number of hours per day specifically allocated for pharmaceutical care activities (Reference Group) No. of hours specifically allocated for pharmaceutical care activities LQ sub-group n = 20 HQ sub-group n = 20 Number of hours 0 - 3 4 - 7 8 and above 87.5 % 12.5 % 0.0 % 55.0 % 35.0 % 10.0% Pearson's chi-square test Chi-square statistic Degrees of freedom p value 4.75 2 0.093 Table 27. Mann-Whitney tests for structural element categories (Reference Group) Structural element category LQ sub-group Mean Rank N = 20 HQ sub-group Mean Rank N = 20 p value Re-organization of pharmacist' duties 14.7 26.2 < 0.01 Re-organization of pharmacy technicians' duties 16.5 24.5 < 0.01 Changes in physical layout 16.4 24.5 0.02 Pharmacist training 15.2 25.7 < 0.01 Pharmacy technician retraining 16.8 24.2 0.02 Financial compensation 19.2 21.8 0.39 Modification of pharmacy's policy & procedures 15.1 25.9 < 0.01 Technological changes 20.2 20.7 0.88 Comparison of structural changes The L Q sub-group and H Q sub-groups were compared for the frequency of structural changes to each structural element. Pearson's chi-square test was conducted to test whether there was a difference in the percentage of pharmacies between the sub-groups making the structural changes. Table 28 summarizes the results of the Pearson's chi-square tests. The structural changes that were observed in a higher frequency in the H Q sub-group pharmacies (i.e., p < 0.01) were decreased pharmacist involvement in technical functions, increased pharmacist involvement in provision of professional services, increased pharmacy technician involvement in technical functions, and formal training program for pharmacist. Table 28. P e a r s o n ' s c h i - s q u a r e test f o r s t r u c t u r a l c h a n g e s i n t h e L Q s u b - g r o u p a n d H Q s u b - g r o u p ( R e f e r e n c e G r o u p ) Structural elements LQ sub-group N = 20 HQ sub-group N = 20 p value Re-organization of Pharmacists' duties 1. D e c r e a s e d p h a r m a c i s t i n v o l v e m e n t i n t e c h n i c a l f u n c t i o n s 3 0 % 7 5 % < 0 . 0 1 2. I n c r e a s e d p h a r m a c i s t i n v o l v e m e n t i n p r o v i s i o n o f p r o f e s s i o n a l s e r v i c e s 5 0 % 9 5 % < 0 .01 Re-organization of pharmacy technicians' duties 1. I n c r e a s e d p h a r m a c y t e c h n i c i a n i n v o l v e m e n t i n t e c h n i c a l f u n c t i o n s 4 5 % 8 5 % < 0 . 0 1 Changes in physical layout 1. I n c o r p o r a t i o n o f u n e l e v a t e d p h a r m a c i s t w o r k s t a t i o n 2 5 % 4 5 % 0 . 1 8 2 . I n c o r p o r a t i o n o f e l e v a t e d p h a r m a c y t e c h n i c i a n w o r k s t a t i o n 0 % 1 0 % 0 . 1 4 3 . C r e a t i o n o f l a y o u t a c c o m m o d a t i n g t h e n e e d s o f t h e d i s a b l e d 1 5 % 4 5 % 0 . 0 3 4 . I n c o r p o r a t i o n o f a p a t i e n t w a i t i n g a r e a 4 0 % 6 5 % 0.11 5. I n c o r p o r a t i o n o f a p r i v a t e p a t i e n t c o u n s e l l i n g r o o m 2 0 % 3 0 % 0 . 4 6 6. I n c o r p o r a t i o n o f s e m i - p r i v a t e p a t i e n t c o u n s e l l i n g a r e a 3 0 % 4 0 % 0 . 5 0 7. I n c o r p o r a t i o n o f a u d i o - v i s u a l e d u c a t i o n a l e q u i p m e n t 3 0 % 5 5 % 0.11 8. I n c o r p o r a t i o n o f e d u c a t i o n a l m a t e r i a l s 6 0 % 8 5 % 0 . 0 7 9. M o v e m e n t o f t h e d i s p e n s a r y f r o m the b a c k t o t h e f r o n t o f t h e p h a r m a c y 5 % 5 % 1 .00 10. I n c o r p o r a t i o n o f d r i v e - t h r o u g h w i n d o w s 0 % 5 % 0.31 11. R e m o v a l o f t h e c a s h r e g i s t e r o u t o f t h e d i s p e n s a r y a n d i n t o a c h e c k o u t a r e a 0 % 2 0 % 0 . 0 3 12. I n c o r p o r a t i o n o f f i x t u r e s 1 5 % 3 5 % 0 . 1 4 13. I n c o r p o r a t i o n o f c a r p e t i n g t h r o u g h o u t the s t o r e 1 0 % 5 % 0 . 5 4 14. I n c o r p o r a t i o n o f w a r m c o l o u r s f o r t h e w a l l s 5 % 1 0 % 0 . 5 4 15. O t h e r s 5 % 1 0 % 0 . 5 4 Table 28. Continued. Structural elements LQ sub-group N = 20 HQ sub-group N = 20 p value Pharmacist Training 1. Formal training program 20% 70% <0.01 2. Other training 25% 30% 0.72 Pharmacy Technician Retraining 1. On the job training 20% 50% 0.04 2. Formal technician training program 15% 20% 0.67 3. Other 5% 20% 0.15 Financial Compensation 1. Payment by patients 10% 5% 0.54 2. Payment by second party payers 15% 15% 1.00 3. Payment by third party payers 15% 30% 0.25 4. Other 5% 10% 0.54 Modification of pharmacy's policy & procedure 1. Requirement for sit down counselling for all new & refill prescriptions 5% 25% 0.07 2. Requirement for new patients to complete a thorough patient demographic info sheet 10% 30% 0.11 3. Other 5% 35% 0.01 Technological changes 1. Change in the software 50% 55% 0.75 2. Change in the hardware 40% 35% 0.74 3. Incorporation of hardware/software systems that answer pharmacy phones 5% 0% 0.31 4. Incorporation of automatic pi l l counters 15% 20% 0.67 5. Other 0% 5% 0.31 109 Matched Study Group and Reference Group (Location - Urban or Rural, Number of Pharmacists on Staff, and Ownership - Chain or Independent) The study group and the reference group were matched with three variables, which were location - urban or rural, number of pharmacists on staff, and ownership - chain pharmacy or independent pharmacy. The matching process yielded 73 matched pharmacies in the study group and the reference group. A n exploratory analysis was conducted using these matched pharmacies from the study group and the reference group. First, the performances of the matched groups on the Behavioral Pharmaceutical Care Scale were examined. Then the matched study group and reference group were compared for the number of hours allocated for pharmaceutical care activities, the frequency of changes of structural categories as a whole, and the frequency of changes of individual structural elements. Distribution of pharmaceutical care models/programs in study group The distribution of pharmaceutical care models/programs in the matched study group is presented in Table 29. Health Outcomes Pharmacies (HOP) had the highest representation with 44 pharmacies and there were 15 pharmacies affiliated with SPEP. Performance on the Behavioral Pharmaceutical Care Scale (BPCS) The performances of the matched study group and reference group on the B P C S are presented in Table 30. The mean score of the matched study group was 110.1 ± 29.3. The lowest score was 39 and the highest score was 171. The mean score of the matched reference group was 96.0 ± 24.7. The lowest score was 53 and the highest score was 156. A histogram displaying the distribution of the BPCS scores of the matched study group and reference group are presented in Figure 10 and Figure 11 respectively. To examine whether the BPCS scores are normally distributed, Q-Q plots were constructed which are presented in Figure 12 and Figure 13. The scores in the plots are approximately linear, therefore, a claim of normality of the BPCS score distributions for the matched study group and the reference group is reasonable. In addition to the Q-Q plot, the K-S Lilliefors test for normality was conducted to assess the normality of the BPCS score distribution. The normality assumption of the BPCS score distributions of the matched study and reference groups cannot be rejected (p > 0.200) (Table 30). Levene's test for equality of variances was conducted to test whether the variances of the two groups were similar. The null hypothesis that the two group's variances are equal was tested by this test. The results of the tests are included in Table 30. The p value of Levene's test was larger than 0.01 at 0.356, thereby the null hypothesis that the variances are equal cannot be rejected. An independent samples t-test was conducted in order to test whether there was a difference in the mean scores of the two groups. The mean BPCS score of the matched study group was higher than that of the matched reference group (p < 0.01) (Table 30). Table 29. Distribution of pharmaceutical care models/programs in matched study group Pharmaceutical care models/programs Study group N (%) Health Outcomes Pharmacies Model 44 (30.1) Structured Practical Experience Program 15 (10.3) University of Montreal Clinical Associate Program 9 (6.2) BC Asthma Self Management Education Program 2(1.4) Geriatric Pharmaceutical care Model 2(1.4) Dalhousie Pharmaceutical care Model 1 (0.7) Pharmaceutical care Research and Education Program 0 In Home Drug Evaluation 0 N 73 Table 30. BPCS performance of the matched study group and reference group Performance on the BPCS Study group (N = 73) Reference group (N = 73) BPCS score Mean 110.1 96.0 Standard Deviation 29.36 24.77 Range Minimum 39 53 Maximum 171 156 Test of normality of distribution Kolmogorov-Smirnov Test Statistic 0.067 0.065 Degrees of freedom 73 73 p value > 0.200 > 0.200 Levene's test for equality of variances Equal variances assumed p value 0.356 Independent samples t-test T-statistic 3.153 Degrees of freedom 144 P value < 0.01 Mean Difference 14.2 113 Figure 10. Histogram of B P C S score distribution of the matched study group Matched study group 14 12 10 8 6 4 o c Zl * cr 40 60 80 100 120 140 160 50 70 90 110 130 150 170 Mean = 110.2 Std. Dev = 29.36 Range = 3 9 - 1 7 1 N = 73 BPCS Scores Figure 11. Histogram of B P C S score distribution of the matched reference group Matched reference group r 1 Mean = 96 Std. Dev = 24.77 Range = 5 3 - 1 5 6 N = 73 50 70 90 110 130 150 60 80 100 120 140 160 B P C S S c o r e s 14 Figure 12. Normal probability plot (Q-Q plot) of BPCS scores of the matched study group Matched study group ° Normal Line ° BPCS 20 40 60 80 O b s e r v e d V a l u e 100 120 140 160 180 Observed V a l u e Number of hours per day specifically allocated for pharmaceutical care activities A description of the number of hours allocated for pharmaceutical care activities in the matched study group and reference group is presented in Table 31. In the matched reference group, 79.4% of the pharmacies had allocated zero to three hours per day, while 66.2% of the matched study group pharmacies had allocated similar hours for pharmaceutical care activities. Further, in the matched study group pharmacies 31% had allocated four to seven hours and 2.8% had allocated eight hours and above for pharmaceutical care activities, whereas only 17.6% and 2.9% of the matched reference group pharmacies had allocated similar hours respectively. A higher percentage of matched study group pharmacies had allocated more hours for pharmaceutical care activities than the matched reference group. Pearson's chi-square test was conducted to compare the frequency of allocation of hours for pharmaceutical care activities between the two groups. The results of this test are presented in Table 31. Since the observed p value was 0.18, which exceeds 0.01, there is no significant difference in the allocation of pharmacy hours for pharmaceutical care activities between the two groups. Structural element categories of matched study group and reference group Mann-Whitney comparisons of the matched study group and reference group were conducted to test whether the scores of structural element categories in the two groups were different. Table 32 summarizes the results of the Mann-Whitney test. The mean ranks of the matched study group for re-organization of pharmacists' duties, pharmacist training, changes in physical layout, and technological changes were higher than the matched reference group (p < 0.01). 116 Comparison of structural elements The matched study group and reference groups were compared for the frequency of structural changes to each structural element. Pearson's chi-square test was conducted to examine whether there was a difference in the percentage of pharmacies between the two groups making the structural changes. Table 33 summarizes the results of the Pearson's chi-square tests. The structural changes that were observed in a higher frequency in the matched study group were decreased pharmacist involvement in technical functions, incorporation of a private patient counselling room, and a formal training program for pharmacist (p < 0.01). 117 Table 31. Number of hours per day specifically allocated for pharmaceutical care activities in the matched study group and reference group No. of hours specifically allocated Matched study group Matched reference for pharmaceutical care activities group Number of hours 0 - 3 66.2 % 79.4 % 4 - 7 31 .0% 17.6% 8 and above 2.8 % 2.9 % Pearson's chi-square test Chi-square statistic 3.363 Degrees of freedom 2 p value 0.18 Table 32. Mann-Whitney comparison of the structural element categories of matched study group and reference group Structural element category Study group Mean Rank N = 73 Reference group Mean Rank N = 73 p value Re-organization of pharmacist' duties 82.9 64 < 0.01 Re-organization of pharmacy technicians' duties 77 70 0.20 Changes in physical layout 81.7 61.2 0.01 Pharmacist training 84.3 62.6 < 0.01 Pharmacy technician retraining 81.1 65.8 0.01 Financial compensation 78.3 68.6 0.11 Modification of pharmacy's policy & procedures 77 70 0.26 Technological changes 85.7 61.2 < 0.01 Table 33. Chi-square test of structural elements of matched study group and reference group Structural Elements Study group N = 73 Reference group N = 73 p value Re-organization of Pharmacists' duties 1. Decreased pharmacist involvement in technical functions 69.9% 47.9% < 0.01 2. Increased pharmacist involvement in provision of professional services 93.2% 80.8% 0.02 Re-organization of pharmacy technicians' duties 1. Increased pharmacy technician involvement in technical functions 75.3% 65.8% 0.20 Changes in physical layout 1. Incorporation of unelevated pharmacist workstation 38.4% 43.8% 0.50 2. Incorporation of elevated pharmacy technician workstation 8.2% 5.5% 0.51 3. Creation of layout accommodating the needs of the disabled 27.4% 35.6% 0.28 4. Incorporation of a patient waiting area 57.5% 56.2% 0.86 5. Incorporation of a private patient counselling room 69.9% 31.5% < 0.01 6. Incorporation of semi-private patient counselling area 61.6% 50.7% 0.18 7. Incorporation of audio-visual educational equipment 45.2% 35.6% 0.23 8. Incorporation of educational materials 90.4% 76.7% 0.02 9. Movement of the dispensary from the back to the front of the pharmacy 6.8% 2.7% 0.24 10. Incorporation of drive-through windows 0% 1.4% 0.31 11. Removal of the cash register out of the dispensary and into a check out area 26% 8.2% < 0.01 12. Incorporation of fixtures 31.5% 26% 0.46 13. Incorporation of carpeting throughout the store 23.3% 9.6% 0.02 14. Incorporation of warm colours for the walls 28.8% 17.8% 0.11 15. Others 8.2% 9.6% 0.77 Table 33. Continued. Structural Elements Sample Reference group N = 73 group N = 73 p value Pharmacist Training 1. Formal training program 79.5% 43.8% < 0.01 2. Other training 39.7% 38.4% 0.86 Pharmacy Technician Retraining 1. On the job training 60.3% 39.7% 0.01 2. Formal technician training program 23.3% 16.4% 0.30 3. Other 6.8% 11% 0.38 Financial Compensation 1. Payment by patients 16.4% 11% 0.33 2. Payment by second party payers 16.4% 17.8% 0.82 3. Payment by third party payers 20.5% 17.8% 0.67 4. Other 17.8% 9.6% 0.14 Modification of pharmacy's policy & procedure 1. Requirement for sit down counselling for all 24.7% 11% 0.03 new & refill prescriptions 2. Requirement for new patients to complete a thorough patient demographic info sheet 12.3% 15.1% 0.63 3. Other 24.7% 21.9% 0.69 Technological changes 1. Change in the software 58.9% 45.2% 0.09 2. Change in the hardware 50.7% 28.8% < 0.01 3. Incorporation of hardware/software systems 6.8% 2.7% 0.24 that answer pharmacy phones 4. Incorporation of automatic pi l l counters 15.1% 9.6% 0.31 5. Other 16.4% 2.7% < 0.01 120 Matched Study Group and Reference Group (Location - Urban or Rural, Number of Pharmacists on Staff, Ownership - Chain or Independent, Province of Respondent) The previously matched study group and reference group pharmacies were further matched for the province where they were located. The matching process yielded 36 matched pharmacies in the study group and the reference group. Exploratory analyses were conducted using these matched pharmacies from the study group and the reference group. First, the performances of the matched groups on the Behavioral Pharmaceutical Care Scale were examined. Then the matched study group and reference group were compared for the number of hours allocated for pharmaceutical care activities, the frequency of changes of structural categories as a whole, and the frequency of changes of individual structural elements. Distribution of pharmaceutical care models/programs in study group The distribution of pharmaceutical care models/programs in the matched study group is presented in Table 34. Health Outcomes Pharmacies (HOP) had the highest representation with 23 pharmacies and there were 5 pharmacies affiliated with the University of Montreal Clinical Associate Program. Performance on the Behavioral Pharmaceutical Care Scale (BPCS) The performances of the matched study group and reference group on the BPCS are presented in Table 35. The mean score of the matched study group was 103 ± 32.1. The lowest score was 39 and the highest score was 168. The mean score of the matched reference group was 97.7 ± 25.9. The lowest score was 55 and the highest score was 155. The distributions of the BPCS scores of the matched study group and reference group are presented in Figure 14 and Figure 15 respectively. The histograms showed that the BPCS scores of the two groups appear to be normally distributed. To examine whether the scores followed a normal distribution, a Quantile-Quantile (Q-Q) plot was constructed. The Q-Q plot of the BPCS scores are presented in Figure 16 and Figure 17. The scores in the plot are linear, so the premise of normality of the distributions is valid. In addition to the Q-Q plot, the K-S Lilliefors test for normality, which is a formal test to assess the normality of the BPCS score distribution was conducted. The normality assumption of the BPCS score distributions of the matched study and reference groups cannot be rejected (p > 0.200) (Table 35). Levene's test for equality of variances was conducted to test whether the variances of the two groups were similar. The results of the tests are included in Table 35. The p-value of Levene's test was higher than 0.01 at 0.264, thereby the null hypothesis that the variances are equal cannot be rejected. In order to examine whether there was a difference in the mean BPCS scores of the two groups, an independent samples t-test was conducted. The difference in the mean BPCS scores of matched study and reference groups was not significant (p = 0.44) (Table 35). The mean BPCS score of the matched study group was 103 and that of the matched reference group was 97.7. Table 34. Distribution of pharmaceutical care models/programs in matched study group Pharmaceutical care models/programs Study group n (%) Health Outcomes Pharmacies Model 23 (31.9) University of Montreal Clinical Associate Program 5 (6.9) Structured Practical Experience Program 3 (4.2) Geriatric Pharmaceutical care Model 2 (2.8) BC Asthma Self Management Education Program 2 (2.8) Dalhousie Pharmaceutical care Model 1(1.4) Pharmaceutical care Research and Education Program 0 In Home Drug Evaluation 0 N 36 123 Table 35. B P C S performance of the matched study group and reference group Performance on the BPCS Study group (N = 36) Reference group (N = 36) BPCS Score Mean 103.0 97.7 Standard Deviation 32.1 25.9 Range Min imum 39 55 Maximum 168 155 Test of Normality of Distribution Kolmogorov-Smirnov Test Statistic 0.052 0.091 Degrees of freedom 36 36 p value > 0.200 > 0.200 Levene's Test for Equality of Variances Equal variances assumed p value 0.264 Independent samples t-test Degrees of freedom 70 p value 0.44 Mean Difference 5.3 124 Figure 14. Histogram of BPCS score distribution of the matched study group Matched study group Mean = 103 Std. Dev = 32.20 Range = 39 - 168 N = 36 40 60 80 " 100 " 120 " 140 " 160 " 50 70 90 110 130 150 170 B P C S Scores Figure 15. Histogram of BPCS score distribution of the matched reference group Matched reference group Mean = 98 Std. Dev = 25.92 Range = 55 -155 N = 36 30 50 70 90 110 130 150 170 40 60 80 100 120 140 160 BPCS Scores o CD CT 0) 125 Figure 16. Normal probability plot (Q-Q plot) of BPCS scores of the matched study group Matched study group 2 20 40 60 80 100 120 140 160 180 Observed Value Figure 17. Normal probability plot (Q-Q plot) of BPCS scores of the matched reference group Matched reference group 2 40 60 80 100 120 140 160 Observed Value Number of hours per day specifically allocated for pharmaceutical care activities A description of the number of hours per day allocated for pharmaceutical care activities in the matched study group and reference group is presented in Table 36. In the matched reference group, 76.5% of the pharmacies had allocated zero to three hours per day, while 66.7%> of the matched study group pharmacies had allocated similar hours for pharmaceutical care activities. Further, in the matched study group pharmacies 30.6%> had allocated four to seven hours, whereas only 20.6% matched reference group pharmacies had allocated similar hours for pharmaceutical care activities. A higher percentage of matched study group pharmacies had allocated more hours for pharmaceutical care activities than the matched reference group. Pearson's chi-square test was conducted to compare the frequency of allocation of hours for pharmaceutical care activities between the two groups. The results of this test are presented in Table 36. Since the observed p value was 0.63, which exceeds 0.01, there is no significant difference in the allocation of pharmacy hours for pharmaceutical care activities between the two groups. Structural element categories of matched study group and reference group Mann-Whitney comparison of the matched study group and reference group was conducted to test whether the scores of structural element categories in the two groups were different. Table 37 summarizes the results of the Mann-Whitney test. The mean rank of the matched study group for re-organization of pharmacists' duties was higher than the matched reference group (p < 0.01). 127 Comparison of structural elements The matched study group and reference groups were compared for the frequency of structural changes to each structural element. Pearson's chi-square test was conducted to examine whether the percentage of pharmacies between the two groups making the structural changes was different. Table 38 summarizes the results of the Pearson's chi-square tests. The structural element that was observed in a higher frequency in the matched study group was a formal training program for pharmacist, decreased pharmacist involvement in technical functions, and incorporation of a private patient counselling room (p < 0.01). 128 Table 36. Number of hours specifically allocated for pharmaceutical care activities in the matched study group and reference group No. of hours specifically allocated Matched study group Matched reference for pharmaceutical care activities group No. of hours 0-3 66.7 % 76.5 % 4-7 30.6 % 20.6 % 8 and above 2.8 % 2.9 % Pearson's chi-square test Chi-square statistic 0.912 Degrees of freedom 2 p value 0.63 Table 37. Mann-Whitney comparison of the structural element categories of matched study group and reference group Structural element category Study group Mean Rank N = 36 Reference group Mean Rank N = 36 p value Re-organization of pharmacists' duties 42.2 30.7 < 0.01 Re-organization of pharmacy technicians' duties 40 33 0.06 Changes in physical layout 38.7 34.2 0.36 Pharmacist training 41.5 31.4 0.02 Pharmacy technician retraining 40.5 32.4 0.07 Financial compensation 38.7 34.2 0.30 Modification of pharmacy's policy & procedures 37.8 35.1 0.52 Technological changes 40.5 32.4 0.08 Table 38. Chi-square test of structural elements of matched study group and reference group Structural Elements Study group N = 36 Reference group N = 36 p value Re-organization of Pharmacists duties 1. Decreased pharmacist involvement in technical functions 80.6% 52.8% 0.01 2. Increased pharmacist involvement in provision of professional services 94.4% 80.6% 0.07 Re-organization of pharmacy technicians' duties 1. Increased pharmacy technician involvement in technical functions 83.3% 63.9% 0.06 Changes in physical layout 1. Incorporation of unelevated pharmacist workstation 38.9% 33.3% 0.62 2. Incorporation of elevated pharmacy technician workstation 5.6% 5.6% 1.00 3. Creation of layout accommodating the needs of the disabled 25% 36.1% 0.30 4. Incorporation of a patient waiting area 55.6% 58.3% 0.81 5. Incorporation of a private patient counselling room 72.2% 44.4% 0.01 6. Incorporation of semi-private patient counselling area 61.1% 38.9% 0.05 7. Incorporation of audio-visual educational equipment 44.4% 27.8% 0.14 8. Incorporation of educational materials 86.1% 69.4% 0.08 9. Movement of the dispensary from the back to the front of the pharmacy 2.8% 5.6% 0.55 10. Incorporation of drive-through windows 0% 0% 11. Removal of the cash register out of the dispensary and into a check out area 16.7% 11.1% 0.49 12. Incorporation of fixtures 22.2% 25.0% 0.78 13. Incorporation of carpeting throughout the store 8.3% 11.1% 0.69 14. Incorporation of warm colours for the walls 16.7% 22.2% 0.55 15. Others 5.6% 13.9% 0.23 Table 38. Continued. Structural Elements Study group N = 36 Reference group N = 36 p value Pharmacist Training 1. Formal training program 66.7% 36.1% < 0.01 2. Other training 47.2% 41.7% 0.63 Pharmacy Technician Retraining 1. On the job training 61.1% 38.9% 0.05 2. Formal technician training program 19.4% 13.9% 0.52 3. Other 5.6% 5.6% 1.00 Financial Compensation 1. Payment by patients 19.4% 13.9% 0.52 2. Payment by second party payers 25% 22.2% 0.78 3. Payment by third party payers 22.2% 19.4% 0.77 4. Other 13.9% 11.1% 0.72 Modification of pharmacy's policy & procedure 1. Requirement for sit down counselling for all new & refill prescriptions 22.2% 13.9% 0.35 2. Requirement for new patients to complete a thorough patient demographic info sheet 8.3% 8.3% 1.00 3. Other 19.4% 16.7% 0.75 Technological changes 1. Change in the software 47.2% 38.9% 0.47 2. Change in the hardware 41.7% 36.9% 0.62 3. Incorporation of hardware/software systems that answer pharmacy phones 8.3% 2.8% 0.30 4. Incorporation of automatic pill counters 19.4% 8.3% 0.17 5. Other 11.1% 2.8% 0.16 131 CHAPTER IV DISCUSSION Respondent Summary ,The response rate to the survey was 62% for the study group and 41% for the reference group (Table 1). The follow-up procedures that were used to increase the response rate included a reminder post-card and a second telephone call to discuss any reasons for non-response. A second mailing of questionnaire was conducted to non-respondents who either did not receive the questionnaires the first time or had misplaced the questionnaires. There was no financial incentive offered to increase the response rate. This was a reasonably positive response rate considering the fact that there were no inducements soliciting responders and the fact that the questionnaire required about an hour to complete. A possible reason for the higher response rate in the study group could be that these respondents were known to be involved in a pharmaceutical care model/program and, therefore, were motivated and were able to identify with the purpose and objectives of the survey more than the reference group. The 162 respondent community pharmacies in the study group represent about 2.3% of the total number of community pharmacies in Canada (the total number of community pharmacies as of December 1999 was 6944) (IMS HEALTH 2000). The highest number of respondents in the study group was from Ontario, and represented 2% of total community pharmacies in that province (IMS HEALTH 2000). The highest number of respondents in the reference group was from Nova Scotia, and represented 8.5% of the total community pharmacies in that province (IMS HEALTH 2000). The representation of independent (other) pharmacies was higher than the national proportion for both the study group and the reference group with 64.8% and 51.9% respectively. Independent (other) pharmacies only make up 30% of total number of pharmacies in Canada (Taro Pharmaceuticals Inc. 2000). Mass merchandiser and grocery store pharmacies were under represented in the study group as well as in the reference group with 1.2% and 6.1% respectively. The national statistics for mass merchandiser and grocery store pharmacies is 13% of the total number of community pharmacies (Taro Pharmaceuticals Inc. 2000). In the study group, the HOP model was implemented in 53.7% of the pharmacies. As well, 19.1% of the study group were participants in the SPEP program from the University of Toronto, and 13% were participants of the University of Montreal Clinical Associate Program (UMCAP). The HOP model was a commercially available model and was implemented in pharmacies in British Columbia, Alberta, Saskatchewan, Manitoba and Ontario. The SPEP and UMCAP were academic pharmaceutical care programs and were localised only to Ontario and Quebec respectively. The BCASMEP and GPC were provincial programs and were implemented in pharmacies in British Columbia and Manitoba respectively. The PREP pharmacies and the DPC pharmacy were part of a research study conducted by the University of Alberta and the Dalhousie University, Nova Scotia respectively. The IHDEP was implemented at one pharmacy in Saskatchewan and was part of an exploratory study. A detailed description of the pharmaceutical care models/programs and their current status is provided in Appendix 5. Demographic Characteristics The demographic characteristics of the study group and the reference group were comparable for the male to female ratio, age groups of respondents, educational qualification 133 of respondents and the mean years of work experience of respondents. The percentage of male respondents was higher than female respondents in both the study group and the reference group (Table 4). The percentage of pharmacists within the defined age groups was comparable to the national statistics for similar age groups. About 59.8% of the study group respondents and 64.2%o of the reference group respondents were under the age of 45. Nationally, about 53.9% of pharmacists are under the age of 40 (Human Resources Development Canada 2001). The fact that more than one half of the study group and reference group respondents were below the age of 46 suggests that the respondents were relatively young. In the study group, 10.5% of the respondents, and in the reference group, 9.9%> of the respondents, were over the age of 55. This is comparable to the national statistic of 12.1% of pharmacists over the age of 55 (Human Resources Development Canada 2001). The mean years of work experience for the study group and the reference group was similar at 18.6 ± 9.8 and 17.5 ± 9.9 respectively, which is consistent with the occurrence of more than one half of the respondents under the age of 46. Descriptive Results -1 The descriptive findings about the study group and the reference group are presented in Tables 5 and 6. The descriptive results include the staffing levels of the pharmacy, basic operational features of the pharmacy, and trends influencing decision to implement a pharmaceutical care practice. 134 Staffing Levels of the Pharmacy The median number of pharmacists on staff in the study group and the reference group was three. The average number of pharmacists per pharmacy in Canada, is 2.6 pharmacists (Taro Pharmaceuticals Inc. 2000). The average number of part-time pharmacy technicians per pharmacy in Canada is two and the average number of full-time pharmacy technicians per pharmacy is 1.8 (Taro Pharmaceuticals Inc. 2000). The presence of more than three pharmacists on staff was higher in the study group compared to the reference group. This pattern of staffing level is consistent with the number of full-time and part-time pharmacy technicians - the study group having a more frequent incidence of more than three pharmacy technicians on staff compared to the reference group. A similar pattern of higher staffing levels in the study group can be seen in the level of support personnel on staff (Table 5). In addition to the employment of cashiers, receptionists, and secretarial personnel, the study group and the reference group also reported other support personnel. These other support personnel included accountants, front store personnel, book-keepers, clerks, health care technicians, stock and inventory control personnel, compliance packaging personnel, over-the-counter co-ordinators, nurses, student interns, naturopaths, patient aid nurses, and pharmacy aids. Pharmacies with a higher staffing level of support personnel have the advantage of freeing the dispensary pharmacists from administrative, clerical and other non-clinical duties that do not require the pharmacists' skills. This in turn may increase pharmacist time for involvement in pharmaceutical care activities. Basic Operational Features of the Pharmacy The operational features of the pharmacy that were examined in this study were the number and type of shifts in pharmacy, number of pharmacists working per shift, and number of pharmacy technicians working per shift. The results are presented in Table 6. About one half of the pharmacies in the study group and the reference group had at least two shifts per day. Day shift business operating hours (9am - 6pm) was scheduled in all of the pharmacies in the study group and reference group, while an afternoon shift (2pm - 10pm) was also scheduled in more than one half of the pharmacies in both groups. The study group pharmacies utilized more pharmacists per shift than the reference group. The incidence of two and more pharmacists working per shift was higher in the study group. A similar trend was apparent also in the utilization of pharmacy technicians per shift, with a higher incidence of two or more pharmacy technicians per shift in the study group. In a related question, the respondents in the study group and the reference group both tended to agree that the current number of pharmacists and pharmacy technicians working for each shift was sufficient to manage the workload in the pharmacy (Table 7). Utilizing more pharmacy technicians to carry out much of the dispensing processes would help to free pharmacist time to take a more active role in patient care (Campagna and Newlin 1997; Janke, et al. 1996a). Trends Influencing Decision to Implement a Pharmaceutical Care Practice In the study group, almost all of the respondents reported that they had made changes to their practice in order to provide pharmaceutical care (Figure 2). One hundred and fifty three (94.4 %) study group respondents out of the 162, reported in the affirmative. This presents some indication that, as expected, the study group pharmacies were actively attempting to provide pharmaceutical care and also that they were complying with the requirements and recommendations of the pharmaceutical care models/programs. At the same time, 70.4% of the reference group also reported that they had made changes to their practice in order to provide pharmaceutical care. This is also an indication that there may be many active community pharmacy sites attempting to create a pharmaceutical care style of practice among the reference group respondents. The respondents were asked to report whether a pharmaceutical care practice model was being used in their pharmacy. In the study group, interestingly, only about two-thirds of the respondents indicated that a pharmaceutical care practice model was in place in the pharmacy (Figure 3) despite the fact that the selection criterion was that they were, in fact, affiliated with a pharmaceutical care model or program. Furthermore, 28.4% of the reference group also reported the use of the pharmaceutical care practice model in their pharmacy. A possible reason for this confounding finding could be a misinterpretation of the wording of the question in the survey. Since the question was worded to inquire about their affiliation with a pharmaceutical care practice model, the pharmacies that were affiliated with pharmaceutical care programs such as the SPEP and UMCAP may not have readily identified themselves as being actively part of a pharmaceutical care practice model. Further, it appears that some pharmacies in the reference group may have incorporated self-designed and loosely defined pharmaceutical care practice models that were unknown to the researcher. The respondents were asked to report the trends that influenced their decision to implement a pharmaceutical care practice. Greater patient involvement in their health care (greater patient autonomy) was the trend that was most frequently indicated by both the study group and the reference group. The second most frequently reported trend was greater inter-pharmacy competition. A high percentage of respondents, especially in the study group, were more responsive to greater patient involvement in their health care. This is a possible indication of perceptiveness on the part of these respondents toward patient care and a desire to fulfil patients' needs, a basic tenet of the prevailing pharmaceutical care philosophy. On the other hand, about one half of the reference group and more than one half of the study group also indicated that greater inter-pharmacy competition was an influencing trend in their decision to implement pharmaceutical care. Since a majority of the study group and reference group consisted of independent pharmacies, implementation of a pharmaceutical care practice could also be a strategy to compete with larger chain operations. The respondents also indicated in the open-ended section of the question that a desire for professional enrichment, a desire to enhance patient care, and a concern for the future of the profession as motivating factors to implement a pharmaceutical care practice. Similar motivating factors were indicated by pharmacists involved in the Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP) conducted in Alberta and Saskatchewan (Simpson, et al. 2001). Descriptive Results - 2 This section of the descriptive results includes the performance of the respondents on the Behavioral Pharmaceutical Care Scale (BPCS), the number of hours specifically allocated in the pharmacy for pharmaceutical care related activities, and description of structural changes that was made in the pharmacy. The BPCS measures the respondents' effort towards the provision of pharmaceutical care. The measurement is conducted on three pharmaceutical care domains, namely, the direct patient care domain, referral and consultation domain and pharmaceutical care 138 instrumental activities domain. The minimum score on the BPCS was 16 and the maximum possible score was 180. This descriptive investigation was conducted in four parts. The first part included only the study group and the second part included only the reference group. The third part of descriptive investigation was conducted for the study group respondents grouped by their pharmaceutical care model/program affiliation. The fourth part of descriptive investigation was conducted for study group respondents grouped by their ownership categories - chain affiliated pharmacies and independent pharmacies. Study Group The study group's performance on the BPCS is presented in Table 8. The study group's performance on the BPCS was higher compared to an initial study using the BPCS on a sample of 617 community pharmacists in Florida, USA. The mean score on that study was 80.8 and had a standard deviation of 26.8 (Odedina and Segal 1996). The mean BPCS score of the study group was also higher when compared to another study involving 230 community pharmacists in Northern Ireland. The mean BPCS score in that study was 74.7 with a standard deviation of 19.3 (Bell, et al. 1998). The higher mean BPCS score of the study group compared to these two studies could be a reflection of the training program provided by the pharmaceutical care models/programs. The distribution of the BPCS scores of the study group followed a normal distribution (Figure 6). This was confirmed by the Quantile-Quantile (Q-Q) plot (Figure 7) and the Kolmogorov-Smirnov (K-S) test for normality (Table 8). A high BPCS mean score was not unexpected since the study group respondents were affiliated with a pharmaceutical care model/program and therefore, were expected to be high performers on the BPCS. The finding of some unusually low BPCS scores in the study group was unexpected which might indicate that, despite an affiliation with a well defined practice model, there were respondents who could not demonstrate much in the way of positive patient care efforts as measured through the BPCS. This also accords with the finding that only 34% of the study group respondents had specifically allocated above four hours per day for pharmaceutical care related activities in the pharmacy, while over 60% only allocated from zero to three hours per day for similar activities (Table 9). The structural changes that were made by the study group were examined using the Community Pharmacy Structural Elements Questionnaire (CPSEQ). Re-organization of pharmacists' duties and re-organization of pharmacy technicians' duties were the highest frequency of changes evident in the study group. A formal pharmacist training program, incorporation of a private patient counselling room and a semi-private patient counselling area were also evident in a higher frequency (Table 10). This was not unexpected since a formal pharmacist training program was a requirement in order to be affiliated with all the pharmaceutical care models/programs. Incorporation of a private patient counselling room was also either a recommendation or a requirement in most of the pharmaceutical care models/programs (Appendix 5). More than one half of the respondents had on-the-job training for pharmacy technicians to orient them towards provision of pharmaceutical care. Incorporation of technology was also evident among the study group respondents with about one half reporting changes in the software and hardware being used. One in five of the respondents also reported incorporation of automatic pill counters. Re-organization of pharmacists' duties received the highest rating of 4.5 on a possible importance scale of five (Table 11). Re-organization of pharmacy technicians' duties and pharmacist training received the next highest rating of 140 importance. The importance rating was congruent and consistent with the frequency of specific structural changes in the study group. Reference Group The reference group's performance on the BPCS is presented in Table 12. The mean score of the study group on the BPCS was 95 with a standard deviation of 27.1. The lowest score was 0 and the highest score was 156. The reference group had a lower mean score compared to the study group. The distribution of the BPCS scores of the reference group followed a normal distribution (Figure 8). This was confirmed by the Q-Q plot (Figure 9) and the K-S test for normality (Table 12). The reference group respondents were not affiliated to a pre-defined pharmaceutical care model/program and therefore, were not anticipated to be high performers on the BPCS. Interestingly, 18.9% of the reference group respondents specifically allocated above four hours per day for pharmaceutical care related activities in the pharmacy (Table 13). Even though the percentage of respondents that had allocated above four hours per day for pharmaceutical care related activities is low, the BPCS score distribution indicates a segment of community pharmacy practices in the reference group were involved in contemporary "pharmaceutical care style" activities. The CPSEQ results of structural changes for the reference group are presented in Table 14. Similar to the study group results, re-organization of pharmacists' duties and re-organization of pharmacy technicians' duties were the highest frequency of changes evident in the reference group. Incorporation of a semi-private patient counselling area and incorporation of patient educational materials were also evident in high frequency within the reference group. 141 However, the structural changes reported by the reference group in most categories were lower in frequency compared to that reported by the study group. This may be an indication of the extent of acceptance of the pharmaceutical care philosophy and the associated practice changes among mainstream community pharmacy practices and especially among independent practices, in Canada. Re-organization of pharmacists' duties received the highest rating of 4.2 on a possible importance scale of five (Table 15). Re-organization of pharmacy technicians' duties and pharmacist training received the next highest rating of importance. The importance rating is comparable with the frequency of specific structural changes among the reference group pharmacies. The importance rating of the structural element categories of the reference group was very similar to that of the study group. Study Group - Pharmaceutical Care Model/Program Affiliation Pharmacies affiliated to the Dalhousie pharmaceutical care model and the In-Home Drug Evaluation Program were not included in this part of the analysis because there was only one pharmacy involved for each of the two pharmaceutical care model/program. Comparisons of BPCS performance and structural changes between pharmacies affiliated to the other six pharmaceutical care models/programs are presented in Table 16 and Table 17. This descriptive comparison was performed in order to observe if there were any patterns of difference or similarity in the BPCS performance or structural changes between pharmacies affiliated to different pharmaceutical care models/programs. The mean BPCS scores of the HOP, SPEP, and UMCAP pharmacies were similar to the study group as a whole. The,mean BPCS scores of the BCASMEP pharmacies were slightly lower than the study group as a whole at 93.8 while the mean BPCS scores of the PREP pharmacies were higher at 131.8. The differences in the mean BPCS scores could be partially attributable to the small sample size of the pharmacies that were affiliated with these latter two pharmaceutical care models/programs. A similar pattern of structural changes was observed among the HOP, SPEP and UMCAP pharmacies. A high frequency of re-organization of pharmacists' duties, re-organization of pharmacy technicians' duties, incorporation of private and semi-private counselling area, incorporation of audio-visual educational equipment, incorporation of patient educational materials, formal training program for pharmacist, and on-the-job training for pharmacy technician was observed among the HOP, SPEP and UMCAP pharmacies. A similar pattern of structural changes was also observed in the study group as a whole. Re-organization of pharmacists' duties and re-organization of pharmacy technicians' duties were evident in higher frequency among the SPEP pharmacies compared to the HOP and UMCAP pharmacies. However, incorporation of private counselling room and incorporation of semi-private counselling area were observed in higher frequency among the HOP pharmacies. The HOP model was a commercially available model and incorporation of a private or semi-private counselling area were among the few requirements of the model itself. Therefore, this simply indicates the extent of adherence to the requirements of the HOP model by the HOP pharmacies. The SPEP is an academic program and possibly more importance was placed on re-organization of pharmacists' and pharmacy techncians' duties (i.e., student teaching focus) which was reflected from the higher frequency of these structural elements compared to the other pharmaceutical care models/programs. Furthermore, the pattern of structural changes reported by the HOP pharmacies and SPEP pharmacies may be an indication that the former may have placed more emphasis on the nature of their physical practice environment while the latter may have assigned more importance to the cognitive nature of the practice. A detailed description 143 of the required and recommended structural changes of the eight pharmaceutical care models/programs is presented in Appendix 5. Study Group - Chain Pharmacies and Independent Pharmacies A descriptive comparison of the chain pharmacies and the independent pharmacies of the study group was conducted in order to observe whether there were any differences in the performance on the BPCS or in structural changes among pharmacies of different ownership categories. Drug store chain pharmacies, grocery store chain pharmacies, mass merchandiser chain pharmacies were grouped together as chain pharmacies. Independent (other) and independent (banner) were grouped together as independent pharmacies. Comparisons of the BPCS performance and the structural changes of the chain and independent pharmacies are presented in Table 18 and Table 19. The mean BPCS scores of the chain pharmacies and the independent pharmacies were similar and comparable to the study group as a whole. The mean BPCS score of chain pharmacies was 108.1 and that of the independent pharmacies was 111.5. This is an indication that the efforts of pharmacists, as measured by the BPCS, toward the provision of pharmaceutical care in both the chain and independent pharmacies of the study group were comparable. The pattern of frequency of structural changes in the chain pharmacies and independent pharmacies was similar and also comparable to that of the study group as a whole. Re-organization of pharmacists' duties, re-organization of pharmacy technician's duties, incorporation of patient waiting area, incorporation of private counselling room, incorporation of semi-private counselling area, incorporation of audio-visual educational equipment, incorporation of patient educational materials, formal training program for pharmacist, and on-the-job training for pharmacy technician were the structural changes that were reported in higher frequency than the other structural changes. In the re-organization of pharmacists' duties, decreased pharmacist involvement in technical functions was reported in a notably higher frequency by the chain pharmacies than by the independent pharmacies. In accordance with the above structural change, increased pharmacy technician involvement in technical functions was also reported in a higher frequency by the chain pharmacies than the independent pharmacies. Chain pharmacies are generally larger operations with more financial resources, and therefore, many of these pharmacies may have more pharmacy technicians on staff. This advantage may allow the chain pharmacies to have a more refined allocation of workload. Incorporation of a private counselling room was reported in slightly higher frequency in the chain pharmacies while incorporation of a semi-private counselling area was reported in higher frequency among the independent pharmacies. The frequency of incorporation of automatic pill counters was also reported in higher frequency in the chain pharmacies. Chain pharmacies are generally corporately controlled tight business operations in terms of cost and profit margins, which could be the reason why the structural changes, that are generally assumed to provide definite patient care or economic outcomes were observed in a higher frequency. The frequency of modification of pharmacy's policy and procedures was higher in the independent pharmacies. A possible reason for this could be that the independent pharmacies might have more flexibility in making policy and procedural changes within the pharmacy than the chain pharmacies. The frequency of financial compensation changes was low for both the chain and independent pharmacies. However, the independent pharmacies reported a higher frequency of these changes than the chain pharmacies. Payment by government programs was difficult to interpret because each province has its own financial compensation system. A higher frequency of independent 145 pharmacies had developed a payment system for provision of professional services possibly through the patient, third party payers, and other available payers. Exploratory Results The results of the descriptive analyses shows that, for both the study group and reference group, there were many pharmacies making strong attempts (with high BPCS scores) at providing pharmaceutical care and also pharmacies seemingly demonstrating poor attempts (with low BPCS scores) at providing pharmaceutical care. The study group was expected to be largely composed of community pharmacies where substantial effort was being made to provide pharmaceutical care by virtue of the research project selection criteria. The study group was selected based on the criterion that the pharmacy was affiliated with a pharmaceutical care model or program. The distribution of the BPCS scores of the study group and the reference group indicates that both groups were composed of some community pharmacies that were making strong attempts (with high BPCS scores) to provide pharmaceutical care. There were 44 pharmacy sites and 20 pharmacy sites in the highest quartile of the BPCS score distribution of the study group and reference group respectively. The mean BPCS score of these pharmacy sites of the study group and the reference group was 146 and 128 respectively. The results of the descriptive analysis also show that there was a pattern in the frequency of structural changes made among the study group pharmacies and the reference group pharmacies. A similar pattern of structural changes was observed for both groups with the study group reporting a higher frequency of structural changes than the reference group. Therefore, exploratory analyses were conducted to compare the difference in structural changes between pharmacies that were at the high end of the BPCS score distribution from those at the low end in both the study and reference groups. The results of the exploratory analyses would be helpful in providing some signals to the pattern of structural changes that were reported in pharmacy practices that were making substantial efforts to provide pharmaceutical care. In order to conduct this analysis, the BPCS score distribution of the study group and the reference group was used to select two sub-groups from each of the groups. Respondents above the 75th percentile of the BPCS score distribution were selected as the high quartile (HQ) sub-group which was made up of community pharmacies that were deemed to be making much effort to provide pharmaceutical care. Respondents below the 25th percentile of the BPCS score distribution were selected as the low quartile (LQ) sub-group, which was made up of community pharmacies that were assumed to be making very little effort to provide pharmaceutical care. ' A similar approach conducted to explore factors influencing the implementation of pharmaceutical care in community practice, used the Direct Patient Care (DPC) domain of the BPCS to classify respondents into providers and non-providers of pharmaceutical care (Odedina, et al. 1995). Using the BPCS-DPC score distribution, in that study, respondents at the top 10% were categorized as providers, while respondents at the bottom 1 0 % were categorized as non-providers of pharmaceutical care. Factors that facilitated the respondents' provision of pharmaceutical care were then compared for both groups of respondents. Exploratory analyses were also conducted to compare a cohort of matched study group and reference group pharmacies. The reference group was not a randomized representation of community pharmacies, although it was selected from community pharmacies across all provinces in Canada. This was a limitation of the study design and therefore statistical inferences of the study group compared to the general population of all Canadian pharmacies was not possible. In order to partially overcome this limitation, the reference group 147 pharmacies were matched with the study group pharmacies using several key variables. Two levels of matching were conducted - the first level of matching included three variables, namely location, number of pharmacists on staff and ownership; while the second level of matching included the above three variables and province of respondent. The matched reference group pharmacies and study group pharmacies were then compared for the performance on the BPCS, the number of hours allocated for pharmaceutical care activities, the frequency of changes of structural element categories as a whole and the frequency of changes of individual structural elements. These comparisons were conducted at both levels of matching for the study group and reference group pharmacies. These comparisons would be useful in helping to reveal which combination of pharmacy characteristics might contribute to the difference in structural changes reported by the study group pharmacies. That is, these comparisons could offer more insight to whether affiliation with a pharmaceutical care model/program predicted the state of pharmaceutical care in the pharmacy and the nature of structural changes made by the pharmacy. Comparison of Lowest Quartile (LQ) Sub-group and Highest Quartile (HQ) Sub-group of Study Group Health Outcomes Pharmacies (HOP) had the highest representation in the LQ sub-group as well as in the HQ sub-group. This was not unexpected as the majority of the pharmacies in the study group were affiliated to HOP. SPEP and UMCAP had the next highest representation in the two sub-groups (Table 20). This was also comparable to their overall representations in the study group. The mean BPCS score of the LQ sub-group was 76.5 with a standard deviation of 15.1 while the mean BPCS score of the HQ sub-group was 146.4 with a standard deviation of 11.8 (Table 21). The HQ sub-group had reported allocation of higher number of hours per day for pharmaceutical care activities at the pharmacy than the LQ sub-group (Table 22). An allocation of higher number of hours per day for pharmaceutical care activities by the HQ sub-group was expected since the performance of the duties described in the BPCS will likely take time. This also validates the finding that the HQ sub-group pharmacies were actively providing pharmaceutical care. The Mann-Whitney test for comparison of the structural element categories shows that the HQ sub-group obtained higher scores than the LQ sub-group (p < 0.01) for re-organization of pharmacists' duties, changes in physical layout, modification of pharmacy's policy and procedures, pharmacist training and financial compensation (Table 23). Pearson's chi-square tests were conducted in order to determine which of the structural changes were reported in higher frequency among the HQ sub-group pharmacies. The results of the Pearson's chi-square tests for frequency of structural changes are presented in Table 24. In the re-organization of pharmacists' duties category, decreased pharmacist involvement in technical functions was reported in a higher frequency in the HQ sub-group than the LQ sub-group (p < 0.01). This is an important structural change associated with the provision of pharmaceutical care since it is required for the pharmacist to free up time to focus on patients' medication related problems. In the changes in physical layout category, the incorporation of unelevated pharmacist workstation, the creation of layout accommodating the needs of the disabled, the incorporation of a patient waiting area, the incorporation of audio-visual educational equipment, the incorporation of patient education materials, and the incorporation of warm colours for the walls were also reported in a higher frequency by the HQ sub-group than by the LQ sub-group (p < 0.01). Since the incorporation of a counselling area was a requirement in most of the pharmaceutical care models/programs, both the sub-groups were complying with this requirement. This is apparent from the high frequency of reporting of this structural change by both sub-groups. In the pharmacist training category, both sub-groups were complying with the requirement of the pharmaceutical care model/program in establishing a formal training program. In the financial compensation category, payment by third party payers was significantly higher in the HQ sub-group. In the modification of pharmacy's policy and procedures category, the requirement for sit down counselling for all new and refill prescriptions was reported in a higher frequency in the HQ sub-group than in the LQ sub-group. The HQ sub-group consists of progressive community pharmacy practices and can be assumed to be more proficient in the provision of pharmaceutical care than those in the LQ sub-group. The results of the exploratory analysis reveal that the HQ sub-group pharmacies had allocated definite hours per day for pharmaceutical care activities. These community pharmacy practices have also made some changes to ensure that certain structural elements are in place to aid in their endeavour to provide pharmaceutical care. The experiences of these community pharmacy practices will serve as a useful resource and management tool to assist pharmacists in their efforts towards achieving a pharmaceutical care practice. Comparison of Lowest Quartile (LQ) Sub-group and Highest Quartile (HQ) Sub-group of the Reference Group Exploratory analyses were also performed on the LQ and HQ sub-groups of the reference group pharmacies. The mean BPCS score of the HQ sub-group was 128.9, while the LQ sub-group had a mean BPCS score of 61.1 (Table 25). The mean BPCS score of HQ sub-group of the reference group pharmacies was 17.5 points lower than that of the HQ sub-group of the study group pharmacies, however, it was higher than that of the collective total study group pharmacies which had a mean BPCS score of 110. Therefore, this suggests that there were many community pharmacy practices among the reference group pharmacies that seemed to be adopting pharmaceutical care into their practice. The Mann-Whitney tests for comparison of the structural element categories revealed that the scores for re-organization of pharmacists' duties, re-organization of pharmacy technicians' duties, pharmacist training, and modification of pharmacy's policy and procedures were higher for the HQ sub-group than the LQ sub-group (p < 0.01) among the reference group pharmacies (Table 27). Pearson's chi-square tests were conducted in order to determine which of the structural changes were reported in a higher frequency by the HQ reference pharmacy sub-group. The results of the tests are presented in Table 28. In the re-organization of pharmacists' duties category, decreased pharmacist involvement in technical functions, and increased pharmacist involvement in provision of professional services were reported in a higher frequency (p < 0.01). In the re-organization of pharmacy technicians' duties category, increased pharmacy technician involvement in technical functions was reported in a higher frequency (p < 0.01). In the pharmacist training category, formal pharmacist training program was reported in a higher frequency (p < 0.01). The results of this section of the exploratory analysis revealed that there are progressive community pharmacy practices among the reference group pharmacies. The reference group pharmacies were not affiliated to a pharmaceutical care model/program. However, the HQ sub-group of the reference group displayed a high performance on the BPCS, and also made structural changes very similar to those reported by the HQ study sub-group pharmacies. These community pharmacy practices also reported a refined allocation of workload. The HQ sub-group pharmacies in the reference group also reported a higher frequency of structural changes than its LQ sub-group pharmacies in such areas as incorporation of a patient waiting area, incorporation of a semi-private patient counselling room, incorporation of audio-visual educational equipment, incorporation of patient educational materials, and a formal pharmacist training program. The BPCS performance of the HQ sub-group within the reference group, and the pattern of structural changes that was evident among these innovative community pharmacy practices, provides a perception of the extent of acceptance of the pharmaceutical care philosophy and standards among mainstream community pharmacy practices in Canada even in the absence of a formal pharmaceutical care model/program. Matched Study Group and Reference Group Comparison of First Level of Matched Study Group and Reference Group The first level of matching of the study group and the reference group using three variables, namely, location - urban or rural, number of pharmacists on staff, and ownership -chain or independent pharmacy resulted in a match of 73 pharmacies from the study and reference groups. The matching process did not yield any representation of pharmacies affiliated to the PREP and IHDEP (Table 29). Pharmacies affiliated to the HOP had the highest representation from the study group. The mean BPCS score of the matched study group was 110.1 (S.D. ± 29.3) and the mean BPCS score of the matched reference group was 96 (S.D. ± 24.7) (Table 30). The performance on the BPCS by the matched study group and the reference group was very similar when compared to that of the collective study and reference groups (study group mean score was 110.9 and the reference group mean score was 95). The distributions of the BPCS scores of the matched study group and reference group followed normal distribution (Figures 10 and 11). This was confirmed by the Q-Q plots of the BPCS scores of the matched study group and reference group (Figures 12 and 13) and the K-S tests for normality (Table 30). An independent samples t-test revealed that the mean BPCS score of the matched study group was significantly higher than that of the matched reference group (p < 0.01) (Table 30). The matched study group pharmacies were therefore, making more effort to provide pharmaceutical care than the matched reference group pharmacies as measured by the BPCS. However, even though the number of hours allocated for pharmaceutical care activities was higher in the matched study group, a Pearson's chi-square test showed that it was not significantly higher than the matched reference group (p = 0.18) (Table 31). Although the BPCS scores of the matched reference group pharmacies was lower than the matched study group pharmacies, the former seemed to be also taking some initiative in allocating hours to provide pharmaceutical care. The Mann-Whitney test for comparison of the structural element categories showed that the matched study group obtained significantly higher scores for re-organization of pharmacists' duties, changes in physical layout, pharmacist training, pharmacy technician retraining, and technological changes than the matched reference group (p < 0.01) (Table 32). The structural element category scores represent the extent of structural changes made in a particular category. A few of the elements in the changes in physical layout category and the pharmacist training category were recommended or required structural changes for the study group pharmacies. Pearson's chi-square tests were conducted in order to compare the frequency of the reported structural changes between the matched study group and the matched reference group. The results are presented in Table 33. In the re-organization of pharmacists' duties category, decreased pharmacist involvement in technical functions was reported in a higher frequency in the matched study group (p < 0.01). In the pharmacist training category, the existence of a formal pharmacist training program was also more frequently reported by the matched study group (p < 0.01). In the technological changes category, changes in hardware and other technological changes (details of other technological changes are presented in Appendix 7) were reported in a higher frequency by the matched study group than the matched reference group (p < 0.01). In the changes in physical layout category, the matched study group reported a higher frequency of incorporation of private patient counselling room and removal of the cash register out of the dispensary and into a check out area (p < 0.01). In the pharmacy technician retraining category, on-the-job training was reported in higher frequency in the matched study group (p < 0.01). Increased pharmacist involvement in provision of professional services, increased pharmacy technician involvement in technical functions, and incorporation of patient educational materials were also reported in high frequency in both the matched study group and reference group. The matched study group was deemed to consist of progressive community pharmacy practices that were making strong efforts in their practices to provide pharmaceutical care. The matched study group pharmacies can be considered as pharmacy practice leaders and the exploratory results highlighted the structural changes that were notably different from the matched reference group. The endeavours of the matched study group pharmacies to provide pharmaceutical care and the related structural changes that were observed in these pharmacies followed a similar pattern as the progressive community pharmacy practices identified in the preceding exploratory analyses. The results of this section of exploratory analysis also provided some evidence that affiliation to a pharmaceutical care model/program may assist pharmacy practices by providing direction about key structural changes. Comparison of Second Level of Matched Study Group and Reference Group The second level of matching of the study group and the reference group was conducted using four variables, namely, location - urban or rural, number of pharmacists on staff, ownership - chain or independent pharmacy and province of respondent. This matching was conducted to ensure that the comparisons between the study group and reference group were examined using Canadian pharmacy characteristics known to effect certain operational outcomes (Taro Pharmaceuticals Inc. 2000). It was also conducted to observe if the pattern of structural changes persisted at a higher level of matching. There were 36 pharmacies in the study group and in the reference group that matched on these four variables. The mean BPCS score of the matched study group was 103 (S.D. ± 32.1) and the mean BPCS score of the matched reference group was 97.7 (S.D. ± 25.9) (Table 35). The distributions of the BPCS scores of the matched study group and reference group followed a normal distribution (Figures 14 and 15). This was confirmed by the Q-Q plots of the BPCS scores of the matched study group and reference group (Figures 16 and 17) and the K-S test for normality (Table 35). An independent samples t-test of the mean BPCS scores of the matched study and reference groups revealed that there was no statistical difference between the mean BPCS scores of the two groups (p = 0.44) (Table 35). Furthermore, even though the number of hours allocated for pharmaceutical care activities was higher in the matched study group, a Pearson's chi-square test showed that it was not significantly higher than the matched reference group (p = 0.63) (Table 36). The reason for this could be that at this level of matching, the inclusion of the new matching variable, i.e., province of respondent, and the resulting smaller sample size may be explanatory factors for the BPCS performance of the respondents. The Mann-Whitney test for comparison of the structural element categories showed that the matched study group obtained a higher score for re-organization of pharmacists' duties (p < 0.01) (Table 37). The extent of structural changes among the matched study group pharmacies in the above category was significantly higher than the matched reference group. Pearson's chi-square tests were conducted in order to determine which of the structural changes were reported more frequently in the matched study group. The results are presented in Table 38. In the re-organization of pharmacists' duties category, decreased pharmacist involvement in technical functions was reported in a higher frequency by the matched study group than the matched reference group (p < 0.01). In the changes to physical layout category, the matched study group reported incorporation of a private patient counselling room in a higher frequency than the matched reference group (p < 0.01). Similarly, in the pharmacist training category, the existence of a formal pharmacist training program was reported in a higher frequency by the matched study group (p < 0.01). Furthermore, structural changes such as increased pharmacist involvement in provision of professional services, increased pharmacy technician involvement in technical functions, incorporation of a patient waiting area, incorporation of a semi-private patient counselling area, incorporation of patient educational materials, and on-the-job pharmacy technician training were also reported in higher frequency by both the matched study group and matched reference group. At the second level of matching, the matched study group did not exhibit a higher BPCS performance than the matched reference group. However, this section of the exploratory results highlights some of the structural changes that were observed in a significantly higher frequency in the matched study group pharmacies. The salient feature of the comparisons of the second level of matched study group and reference group is that the pattern of significant structural 156 changes was still consistent with that of the first level of matching. This may also be an indication that the study group pharmacies are compliant with some of the requirements and recommendations of the pharmaceutical care models/programs. Limitations of the Study There were several limitations in the study design. The following limitations were identified: 1. In the selection of a putative reference group, the provincial pharmacy regulatory bodies were requested to provide a randomized list of 40 community pharmacies from their respective provinces. However, in some cases, the procedures used by the provincial pharmacy regulatory bodies to generate a randomized list were unclear. Therefore, the reference group was deemed not to be a random selection of community pharmacies. Furthermore, the study group consisted of community pharmacies that were affiliated to one of the eight pharmaceutical care models/programs. Consequently, a direct comparison of the study group with the reference group was not possible. To overcome this limitation, a matching process was conducted to match the study group and the reference group on selected variables. 2. The Community Pharmacy Structural Elements Questionnaire (CPSEQ) and the Behavioral Pharmaceutical Care Scale (BPCS) which were used in this survey required self-assessment, so there was opportunity for respondents to give false answers in order to appear better at providing pharmaceutical care (i.e., social desirability bias). However, the pharmacists were assured of total anonymity and confidentiality of their responses, which may have helped to control for this behavior. There were possibilities for misinterpretation of certain questions in the CPSEQ due to question wording. The wording of Question 14, required the respondents to report if a 'pharmaceutical care practice model' was being used in the pharmacy. Respondents affiliated to a pharmaceutical care program may not have identified themselves as using an identifiable pharmaceutical care practice model. In Question 18 of CPSEQ, the wording does not indicate whether the term 'success in providing pharmaceutical care' refers to the success in implementation of structural changes or the success in the outcomes of implementation of structural changes. Subsequently, the responses to Question 18 were not included for analysis. The survey asked the respondents simply to indicate the changes that have been made in the pharmacy in order to provide a pharmaceutical care practice. No supplemental information was requested to determine the timing of any actual structural changes made in the pharmacy or whether or not the changes were part of a pharmaceutical care strategy. The survey did not include a question about the prescription volume of the community pharmacy. This question could have provided useful information about the workload of the pharmacy particularly with respect to interpretation of staffing levels. Financial incentive was not provided to increase the response rate of the survey. The survey required a commitment of approximately one-hour of the respondents' time for completion. A financial inducement may have increased the response rate. However, initial telephone contacts were made with the respondents to explain the significance of the study and the importance of their participation. A second mailing of questionnaire and a mailing of thank-you/reminder cards were carried out to achieve the 62% and 41% response rate for the study group and reference group respectively. 158 Summary The descriptive results indicated the presence of progressive community pharmacy practices in both the study and reference groups that were demonstrating considerable effort toward the provision of pharmaceutical care as measured by the BPCS. The descriptive results also revealed that there was a pattern of higher staffing levels of pharmacists, pharmacy technicians and support personnel in the study group and, consistently, utilization of more pharmacists and pharmacy technicians per work shift in the study group than the reference group. Greater patient involvement in their health and greater patient autonomy was the trend that influenced most of the study group and reference group respondents' decisions to implement a pharmaceutical care practice. Furthermore, respondents also reported that greater inter-pharmacy competition, desire for professional enrichment, desire to enhance patient care and concern for future of profession as motivational factors in their decision to implement a pharmaceutical care practice. The distribution of the BPCS scores of the study group and the reference group shows that, while there were practice leaders making strong efforts to provide pharmaceutical care, there were also pharmacies in both groups that reported less impressive results in their attempts to provide pharmaceutical care. A similar pattern of structural changes was observed for both groups. However, the study group did report a higher frequency of certain structural changes than the reference group. A comparison of the HQ sub-group and the LQ sub-group of the study group and the reference group revealed a consistent pattern of structural changes that were reported more frequently among the progressive community pharmacy practices (HQ sub-groups). A comparison of the matched study group and reference group showed that the mean BPCS score of the matched study group was higher than that of the matched reference group (when province of the respondent was excluded as a matching criterion). Comparison of the actual structural changes of the two matched groups revealed a consistent pattern of structural changes among the matched study group that were reported in a higher frequency. Some of the structural changes indicated in the questionnaire did not follow a similar pattern as observed for the other structural changes. These structural changes were reported in low frequency in all the levels of exploratory analysis. Examples of these structural changes are incorporation of elevated pharmacy technician workstation, incorporation of drive-through windows, incorporation of fixtures, incorporation of carpeting throughout the store, incorporation of warm colours for the walls, formal training program for pharmacy technician, and incorporation of hardware/software systems that answer pharmacy phones. These structural changes, although occasionally considered to be beneficial in the provision of pharmaceutical care, however, may not have been determined to be important enough by the community pharmacy practices surveyed in this research project to actually make these changes. Furthermore, these structural changes may not have been recommended or required by the pharmaceutical care models/programs. Some of the structural changes were present in a higher frequency among the progressive community pharmacy practices or pharmacy practice leaders and also conformed to a consistent pattern. These structural changes were re-organization of pharmacists' duties, re-organization of pharmacy technicians' duties, incorporation of unelevated pharmacist workstation, incorporation of a patient waiting area, incorporation of a private patient counselling room, incorporation of semi-private patient counselling area, incorporation of audio-visual educational equipment, incorporation of educational materials, formal training program for pharmacists, on-the-job training for pharmacy technician, and requirement for sit down counselling for all new and 160 refill prescriptions. The efforts of these community pharmacy practices in providing pharmaceutical care and the critical structural changes that were reported will be a useful resource tool to assist aspiring community pharmacists in their attempts to implement pharmaceutical care practices. 161 CHAPTER V CONCLUSIONS Pharmaceutical care is a relatively new pharmacy practice standard that remains to be fully implemented on a widespread basis in typical mainstream community pharmacies of Canada or the United States. There are many challenges and barriers that influence the implementation of a pharmaceutical care practice in the community setting. The barriers that impede practice change such as workflow and workload, physical layout and design, pharmacists' and pharmacy technicians' training, lack of financial incentives, lack of time for providing pharmaceutical care, lack of access to patient medical information, technological restraints, organizational barriers, attitudinal barriers, and professional barriers have been identified and discussed in the literature. Pharmacy practice change to provide pharmaceutical care can be observed in the arrangement of resources in the pharmacy and also in the activities performed by the pharmacist, or following the defining terms in this research project, the structure and process components of care. The structural resources in a pharmacy may include such elements as physical layout, personnel, equipment, and pharmacist's training. Some of the process activities include educating patients, administering patient outcome measures and documenting pharmacist-patient encounters. Many innovative community pharmacists across Canada are working to change their practices to provide pharmaceutical care. There are a number of community pharmacy practice sites that are affiliated to pharmaceutical care models/programs and are making a commitment toward the implementation of a pharmaceutical care practice. The objectives of this explorative study were: (1) to develop a data collection instrument to gather information regarding structural changes and process activities in a community pharmacy practice, (2) to examine the structural changes that were reported in community pharmacy practices affiliated with a pharmaceutical care model/program, and (3) to examine the structural changes reported in community pharmacy practices that were actively providing pharmaceutical care irrespective of their affiliation with a pharmaceutical care model/program. Objective 1: Development of CPSEQ and Administration of Survey The CPSEQ was developed to gather information about structural changes in community pharmacy. The BPCS was also included to the data collection instrument to gather information regarding process-related activities and to measure pharmacists' effort towards the provision of pharmaceutical care. The CPSEQ was pilot tested and psychometric analysis was conducted. The reliability of the CPSEQ scale was found to be 0.86 and the content validity index of the CPSEQ was 0.95. The CPSEQ including the BPCS was administered to a study group consisting of 261 community pharmacy practices that were affiliated to a pharmaceutical care. model/program. The questionnaires were also administered to a reference group consisting of a selection of 197 community pharmacy practices across Canada and were not part of any of the identified pharmaceutical care models/programs. The descriptive results of this study indicated: 1. The presence of progressive community pharmacy practices making efforts towards the provision of pharmaceutical care in both the study group as well as in the reference group. There were also pharmacy sites in both groups reporting very modest achievement towards a pharmaceutical care practice. 2. There was a pattern of higher staffing levels of pharmacists, pharmacy technicians and support personnel in the study group and consistently, utilization of more pharmacists and pharmacy technicians per work shift as well in the study group. 3. There was a consistent pattern of certain structural changes being reported for both the study and reference groups. However, the study group reported higher frequency of the structural changes than the reference group. 4. The limitations in the construction of the CPSEQ that were identified earlier suggests that several improvements to the survey instrument would be beneficial for future use of the questionnaire. Objective 2: To Examine Community Pharmacies Affiliated with a Pharmaceutical Care Model/Program An exploratory analysis was conducted to compare a matched study group and reference group. The exploratory results indicate that: 1. The matched study group pharmacies reported higher BPCS scores than the matched reference group pharmacies. 2. The matched study group reported a higher frequency of certain structural changes than the matched reference group. These included: re-organization of pharmacists' duties, incorporation of a private patient counselling room, formal pharmacist training program, on the job pharmacy technician retraining and changes in the computer hardware being used. 164 Objective 3: To Examine Community Pharmacy Practices Actively Providing Pharmaceutical Care The performance of the study group and the reference group on the BPCS was used to identify two sub-groups of community pharmacy sites - a high quartile sub-group representing progressive community pharmacies deemed to be making much effort to provide pharmaceutical care and a low quartile sub-group representing community pharmacies judged to be making little effort to provide pharmaceutical care. The results of this exploratory analysis show that: 1. There was a consistent pattern of structural changes that was higher among the HQ sub-group compared to the LQ sub-group. These structural changes included: re-organization of pharmacists' duties, re-organization of pharmacy technicians' duties, an unelevated pharmacist workstation, a patient waiting area, a private patient counselling room, a semi-private patient counselling area, audio-visual educational equipment, the use of educational materials, a formal training program for pharmacists, on-the-job training for pharmacy technicians, and the requirement for sit down counselling for all new and refill prescriptions. Implications for Pharmacy Practice The results of this study should have implications for the pharmacy profession. Clearly, pharmacists need to overcome many barriers in order to implement pharmaceutical care practices. This study characterizes some of the important structural changes that have been made by selected Canadian community pharmacies to facilitate better pharmaceutical care practices. The structural changes that were reported in a higher frequency among the community pharmacy sites participating in distinctive pharmaceutical care models/programs or in place in community pharmacies reporting high BPCS scores were the re-organization of pharmacists' duties and the re-organization of pharmacy technicians' duties. These workflow changes in the pharmacy may be pivotal in overcoming the 'lack of time' barrier that pharmacists frequently raise as an obstacle to more thorough patient care activities. Decreasing involvement in technical functions and delegating these functions to appropriately trained pharmacy technicians may improve the use of the pharmacist's time to be involved in professional patient care activities. Other important structural changes that were frequently reported were the changes to physical layout such as incorporation of a private patient counselling room, a semi-private counselling area, an unelevated pharmacist workstation, a patient waiting area, the use of audio-visual educational equipment, and other educational materials. These structural elements are seen to be beneficial in facilitating patient contact, increasing privacy for confidential conversation, enhancing patient counselling environment, and adding resources that complement and reinforce patient counselling. The benefits of these changes to the physical layout of the pharmacy in overcoming barriers such as workspace, resources and time to enhance the provision of pharmaceutical care has also been widely discussed in the literature. Furthermore, structural elements such as formal training program for pharmacists and on-the-job training for pharmacy technician were also reported more frequently. Pharmacists and pharmacy technicians may require additional training to overcome barriers such as weak communication skills; the selection of appropriate patient educational tools; the ability to recognize situations in which specific knowledge is necessary; the ability to select and apply scientific, technical, and clinical information in a timely and appropriate manner; and the expertise to make drug therapy decisions. Also reported more frequently was a change in pharmacy procedures to require sit-down counselling for all new and refill prescriptions. This procedural change may be beneficial in ensuring comprehensive care is being provided including monitoring, continuity of care and follow-up. It may also be beneficial in improving the efficiency in the pharmacy and thereby maximizing the time to provide comprehensive pharmaceutical care. The structural changes pre-identified in the C P S E Q , the structural changes that were reported by the respondents in the questionnaire (included in Appendix 7), and the structural changes that were reported in a higher frequency among community pharmacy sites participating in distinctive pharmaceutical care models/programs and among community pharmacies reporting high B P C S scores provide a preliminary, although not an exhaustive, listing of structural elements that may facilitate the provision of pharmaceutical care. The structural elements listing reported here might be beneficial in overcoming some of the obstacles faced by community pharmacists in implementing a pharmaceutical care practice. This preliminary listing of structural elements w i l l be a useful resource tool to assist aspiring community pharmacists in their attempts to implement a pharmaceutical care practice. Implications for Future Research This is an exploratory study and the findings reported should be interpreted as preliminary pending other more methodical studies. Researchers interested in structural elements associated with the provision of a pharmaceutical care practice are encouraged to consider these results as they move ahead in their own investigations. This study is intended to offer guidance for further research to provide stronger evidence on structural changes associated with the provision of pharmaceutical care in community pharmacy. Similar studies need to be conducted in order to compile a more complete listing of structural elements that are associated with the provision of pharmaceutical care in community pharmacy practice. Studies that investigate changes to reimbursement methods, the impact of practice changes to the financial success of the pharmacy business enterprise, and studies that investigate the technological and organizational variables associated with a pharmaceutical care practice also need to be conducted. Future research to link the structure and process components of pharmaceutical care should take into consideration the limitations that were identified in this study. Establishing an association between structure and process would be a significant step towards overcoming barriers that impede the implementation of a pharmaceutical care practice in community pharmacy. Once the pharmacy profession is aware of a definite association between structure and process and the benefits o f having an appropriate pharmacy structure, the number of community pharmacy sites adapting to a pharmaceutical care practice should increase. 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In: Knowlton CH, Penna RP, editors. Pharmaceutical Care. Chapman and Hall, p 257-96. Schneider JK, Nickman NA. 1998. Improved use of time after structural and staffing changes to an ambulatory care pharmacy. American Journal of Health-System Pharmacists 55:2505-8. Schommer JC, Cable GL. 1996. Current Status of Pharmaceutical Care Practice: Strategies for Education. American Journal of Pharmaceutical Education 60:36-42. Shalansky SJ, Chen R. 1996a. Improved detection of drug-related problems in intensive care unit patients. American Journal of Health-System Pharmacists 53:185-6. Shalansky SJ, Nakagawa R, Wee A. 1996b. Drug-related problems identified and resolved using pharmaceutical care versus traditional clinical monitoring. Canadian Journal of Hospital Pharmacy 49(6):282-8. Shane RR. 1992. Prerequisites for Pharmaceutical Care. American Journal of Hospital Pharmacy 49:2790-1. Siganga WW, Huynh TC. 1997. Barriers to the Use of Pharmacy Services: The Case of Ethnic Populations. Journal of the American Pharmaceutical Association NS 37(3):335-40. Simpson SH, Johnson JA, Biggs C, Biggs RS, Kuntz A, Semchuk W, Taylor JG, Farris KB, Tsuyuki RT. 2001 Jun 11. Practice-Based Research: Lessons from Community Pharmacist Participants. Pharmacotherapy 21 (6):731-9. Slezak M. 1996. Ritzman's Counter Strategy. American Druggist :20-3. Slezak M. 1997. New Look for a New Age. American Druggist:20-4. Smith TJ. 1998. Automated Refill Prescription Systems. The Efficient Pharmacy :3-4. Spencer G. 1989. Projections of the Population of the United States, by Age, Sex, and Race: 1988 to 2080. Current Population Reports, Population Estimates and Projections. Washington, DC: U.S. Department of Commerce, Bureau of the Census. Series P-25, No. 1018. Statistics Canada. 1999. Statistics Canada Postal Code Conversion File.: Minister of Industry. p31. Strand LM. 1997. Re-visioning the Profession. Journal of the American Pharmaceutical Association NS 37(4):474-8. Strand LM, Cipolle RJ, Morley PC. 1992. Pharmaceutical Care: An Introduction. Kalamazoo (MI): The Upjohn Company. 177 Strand L M , Cipolle R J , Morley P C . 1998a. A Reimbursement System for Pharmaceutical Care. In: Zollo S, Navrozov M , editors. Pharmaceutical Care Practice. The M c G r a w - H i l l Companies, Inc. p 267-96. Strand L M , Cipolle RJ , Morley P C . 1998b. Building a Practice Uti l iz ing the Practice Management System. In: Zollo S, Navrozov M , editors. Pharmaceutical Care Practice. The M c G r a w - H i l l Companies, Inc. p 237-65. Strand L M , Cipolle R J , Morley P C . 1998c. Drug-Related Morbidity and Mortality: The Challenge for Pharmaceutical Care. In: Zollo S, Navrozov M , editors. Pharmaceutical Care Practice. McGraw-Hi l l , p 37-72. Strand L M , Cipolle RJ , Morley P C . 1998d. Preparing the Pharmaceutical Care Practitioner. In: Zollo S, Navrozov M , editors. Pharmaceutical Care Practice. The M c G r a w - H i l l Companies, Inc. p 297-335. Taro Pharmaceuticals Inc. 2000. 2000 Community Pharmacy Trends Report. Trinca C E . 1993. Future Scenarios in Primary Care: How W i l l Pharmacists Join the Team? American Journal of Pharmaceutical Education 57:193-4. Trunet P, Borda IT, Rouget A V , Rapin M , Lhoste F. 1986. The role of drug-induced illness in admissions to an intensive care unit. Intensive Care Medicine 12:43-6. Trunet P, LeGal l J-R, Lhoste F, Regnier B , Saillard Y , Carlet J, Rapin M . 1980. The Role of Iatrogenic Disease in Admissions to Intensive Care. Journal of the American Pharmaceutical Association 244(23):2617-20. Weiss D J , Dawis R V , England G W , Lofquist L H . 1967. Manual for the Minnesota Satisfaction Questionnaire. Minnesota. University of Minnesota. Minnesota studies in vocational rehabilitation: xx i i . Wichman K , Hales B , O'Brodovich M , Paton T, Wielenga J. 1993. Management Considerations to Implementing Pharmaceutical Care. The Canadian Journal of Hospital Pharmacy 46(6):265-7. 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The information derived from this questionnaire will aid us in the formation of a classification of structural changes that are necessary for the successful provision of pharmaceutical care. We appreciate your time and effort in participating in this important study I. PHARMACY AND PHARMACY PERSONNEL 185 The questions in this section are for the purpose of gathering information about the pharmacy in which you work and the personnel working in the pharmacy. 1. For what type of pharmacy do you work? {please indicate with a checkmark) • an independent pharmacy : is defined as one to three pharmacies under the same legal ownership and includes true independents, voluntary chains, and franchises. • a chain pharmacy: is defined as four or more pharmacies under the same legal ownership. 2. How many stores does your independent pharmacy practice or chain pharmacy practice include? • 1 • 2 • 3 • 4-10 • 11-15 • 16-20 • >20 3. In total, how many pharmacists do you have on staff in your pharmacy? • 1 • • 2 • 3 • 4 -6 • 7 -10 186 4. How many shifts are there in your pharmacy? (Please be specific, e.g., 8:30 a.m. - 4:30 p.m.) 5. Please indicate the number of pharmacists working for each shift? 6. Which shift is the busiest in the pharmacy? (Please be specific, e.g., 8:30 a.m. - 4:30 p.m.) 7. Please indicate if you agree or disagree with the following statement: The current number of pharmacists working for each shift is sufficient to manage the workload in the pharmacy, {please circle) Strongly agree Strongly disagree 1 2 3 4 5 8. Which of the following support personnel are on staff in your pharmacy? • Pharmacy technician • Secretarial personnel • Receptionist • Cashier • other, please specify: • none If there are no pharmacy technicians on staff, go to Section II, Question 14 on page 4 187 9. In total, how many pharmacy technicians are on staff in your pharmacy? a. no. of full-time pharmacy technicians: b. no. of part-time pharmacy technicians: 10. Please specify the number of pharmacy technicians working for each shift. 11. Please indicate if you agree or disagree with the following statement: The current number of pharmacy technicians working per shift is sufficient enough to manage the workload of the pharmacy, {please circle) Strongly agree Strongly disagree 1 2 3 4 5 12. Are the pharmacy technicians certified through a formal technician certification program? • yes • no If yes, go on to Question 14 _^ 13. Have the pharmacy technicians gone through an alternate training program? • yes • no. If yes, please specify what type of training is involved (e.g. on the job training) II. PHARMACY STRUCTURE AND ACTIVITIES 188 This section includes questions about pharmacy structure and pharmaceutical care related activities. Please indicate all structural changes that have been made in your pharmacy. 14. Is a pharmaceutical care practice model being used in your pharmacy? {please indicate with a checkmark) Pharmaceutical care involves actively monitoring, evaluating and documenting individual patients' drug therapy in order to achieve definite outcomes. • yes • no If no, go to Question 16 15. Please specify, if this is a commercially available model or an academically available model. • commercially available: obtained from an independent company for a fee. • academically available: obtained from a non-profit organization (e.g. a University) for research or educational purposes. • other, please specify: 16. Have you made any changes to your practice in order to provide pharmaceutical care? • yes • no 17. Please indicate with a checkmark, all the changes that have been made in your pharmacy in order to provide pharmaceutical care? a. Reorganization of pharmacists' duties (workflow changes) • decreased pharmacist involvement in technical functions (e.g. data entry, filling prescriptions) • increased pharmacist involvement in the provision of professional services (e.g. patient counselling, disease specific clinics, blood glucose monitoring service, medication evaluation service) 189 b. Reorganization of pharmacy technicians' duties • increased pharmacy technician involvement in technical functions (e.g. data entry, filling prescriptions, dealing with calls that do not require pharmacist's input, running cash register) c. Changes in physical layout • incorporation of unelevated pharmacist workstation • incorporation of elevated pharmacy technician workstation • creation of layout accommodating the needs of the disabled • incorporation of a patient waiting area • incorporation of a private patient counselling room • incorporation of semi-private patient counselling area (e.g. alcove, booth) • incorporation of audio-visual educational equipment (TV, VCR, Videos, CDs, etc.) • incorporation of educational materials (books, brochures, displays, patient-package inserts, etc.) • movement of the dispensary from the back to the front of the pharmacy • incorporation of drive-through windows • removal of the cash register out of the dispensary and into a check out area • incorporation of fixtures (signage, panels, lighting, etc.) • incorporation of carpeting throughout the store • incorporation of warm colours for the walls • others, please specify d. Pharmacist Training Pharmacists may need additional training in therapeutics, identification of drug-related problems, development of patient care plan, communication skills and interviewing techniques, problem-solving skills, etc. in order to demonstrate competence to provide pharmaceutical care. • formal training program, please specify • others, please specify 190 e. Pharmacy technician retraining (re: provision of pharmaceutical care) • on the job retraining • formal technician certification program • others, please specify f. Financial Compensation Modification of previous reimbursement system for professional services such as drug interventions, medication management, disease specific clinics, and glucose monitoring services. • payment by patients • payment by second party payer (government programs) • payment by third party payers (private insurance companies) others, please specify g. Modification of your pharmacy's policy and procedure • requirement for sit down counselling for all new and refill prescriptions • requirement for new patients to complete a thorough patient demographic information sheet • others, please specify h. Technological changes • change in the software used • change in the hardware used • incorporation of hardware/software systems that answer pharmacy phones • incorporation of automatic pill counters • others, please specify 191 18. Please indicate if the following structural changes were successful/not successful in providing pharmaceutical care, {please circle) (1 = very successful, 5 = not successful at all and NA = not applicable) very not successful successful a. Re-organization of pharmacists'duties 1 2 3 4 5 N A b. Re-organization of pharmacy technicians' duties 1 2 3 4 5 N A c. Changes in physical layout 1 2 3 4 5 N A d. Pharmacist training 1 2 3 4 5 N A e. Pharmacy technician retraining 1 2 3 4 5 N A f. Financial compensation 1 2 3 4 5 N A g. Modification of pharmacy's policy and 1 2 3 4 5 N A procedure. h. Technological changes 1 2 3 4 5 N A 19. Please indicate how you would rate, in order of importance, the following structural changes for the successful provision of pharmaceutical care, {please circle) (1 = very important and 5 = not important at all) very not important important at all a. Re-organization of pharmacists' duties 1 2 3 4 5 b. Re-organization of pharmacy technicians' duties 1 2 3 4 5 c. Changes in physical layout 1 2 3 4 5 d. Pharmacist training 1 2 3 4 5 e. Pharmacy technician retraining 1 2 3 4 5 f. Financial compensation 1 2 3 4 5 g. Modification of pharmacy's policy and 1 2 3 4 5 procedure h. Technological changes 1 2 3 4 5 192 20. On an average, how many hours per day is specifically allocated in your pharmacy for pharmaceutical care? {please indicate with a checkmark) • <1 • 1 • 2 • 3 • 4 • 5 - 7 • 8 - 10 • >10 21. Please indicate if the following trends have influenced your decision to implement a pharmaceutical care practice model? {please checkmark applicable boxes) • Increase in health care demands and costs • Greater patient involvement in their health care; greater patient autonomy • Aging of the baby boom generation • Increase in demand for convenience • Greater demand for accessibility • Increase in the integration of computer technology into pharmacy practice • Increased demand for home health care products Greater inter-pharmacy competition others, please specify 22. Are there any current legal bylaws in pharmacy practice that you would like to see changed or any new bylaws which you would like to see implemented in order to facilitate the provision of patient focused care in community pharmacy practice? • yes • no If yes, please specify the changes . III. ORGANIZATIONAL STRUCTURE 193 The questions in this section are for the purpose of measuring the level of your job satisfaction, career commitment, and organizational commitment. 23. The Minnesota Satisfaction Questionnaire - Short Form Copyright 1977, Vocational Psychology Research University of Minnesota. Reproduced by permission. The purpose of the following questions is to give you a chance to tell how you feel about your job, what things you are satisfied with and what things you are not satisfied with. Very Sat. means I am very satisfied with this aspect of my job. Sat. means I am satisfied with this aspect of my job N means I can=t decide whether I am satisfied or not with this aspect of my job. Dissat. means I am dissatisfied with this aspect of my job. Very Dissat. means I am very dissatisfied with this aspect of my job. On my present job, this is how I feel about Very Dissat. Dissat. N Sat. a. Being able to keep busy all the time • • • • • b. The chance to work alone on the job • • • • • c. The chance to do different things from time to time • • • • • d. The chance to be a somebody in the community • • • • • e. The way my boss handles his/her workers • • • • • f. The competence of my supervisor in making decisions • • • • • g- Being able to do things that dont go against my consciences • • • • h. The way my job provides for steady employment • • • • • i. The chance to do things for other people • • • • • j- The chance to tell people what to do • • • • • Very Very Dissat. Dissat. N Sat. Sat. ./contd. 194 Very Dissat. Dissat. N Sat. Very Sat. k. The chance to do something that makes use of my abilities • • • • • 1. The way company policies are put into practice • • • • • m. My pay and the amount of work I do • • • • • n. The chances for advancement on this job • • • • • 0. The freedom to use my own judgement • • • • • P- The chance to try my own methods of doing the job • • • • • q- The working condition • • • • • r. The way my co-workers get along with each other • • • • • s. The praise I get for doing a good job • • • • • t. The feeling of accomplishment I get from the job • • • • • Very Dissat. Dissat N Sat. Very Sat. 24. Career Commitment Scale Copyright 1985 Blau, GJ. Reproduced by permission The following questions are designed to measure your attitude towards your profession. Please indicate if you agree or disagree with the following statements. (1 = strongly disagree and 5 = strongly agree), {please circle) Strongly Strongly Disagree Agree a. If I could get another job different from being a pharmacist and paying the same amount, I would probably take it. 1 2 3 4 5 b. I definitely want a career for myself in pharmacy. 1 2 3 4 5 ./contd. 195 Strongly Strongly Disagree Agree c. If I could do it all over again, I would not choose to work in the pharmacy profession. 1 2 3 4 5 d. If I had all the money I needed without working, I would probably still continue to work in the pharmacy profession. 1 2 3 4 5 e. I like this vocation too well to give it up. 1 2 3 4 5 f. This is the ideal vocation for a life work. 1 2 3 4 5 g. I am disappointed that I ever entered the pharmacy profession. 1 2 3 4 5 25. Organizational Commitment Scale Copyright 1990 Allen and Meyer. Reproduced by permission. The following statements are designed to measure your level of organizational commitment. Please indicate if you agree or disagree with the following statements. (1 = strongly disagree and 5 = strongly agree), {please circle) Strongly Strongly Disagree Agree a. I would be very happy to spend the rest of my career with this organization. 1 2 3 4 5 b. I really feel as if this organization's problems are 1 2 3 4 5 my own. c. I do not feel a strong sense of a belonging to my organization. 1 2 3 4 5 d. I do not feel emotionally attached to this organization. 1 2 3 4 5 ,/contd. 196 Strongly Strongly Disagree Agree e. I do not feel like part of the family at my organization. 1 2 3 4 5 f. This organization has a great deal of personal meaning for me. 1 2 3 4 5 g. Right now, staying with my organization is a matter of necessity as much as desire. 1 2 3 4 5 h. It would be very hard for me to leave my organization right now, even if I wanted to. 1 2 3 4 5 i. Too much of my life would be disrupted if I decided to leave this organization. 1 2 3 4 5 j. I feel that I have too few options to consider leaving this organization. 1 2 3 4 5 k. If I had not already put so much of myself into this organization, I might consider working elsewhere. 1 2 3 4 5 1. One of the few negative consequences of leaving this organization would be the scarcity of available alternatives. 1 2 3 4 5 m. I do not feel any obligation to remain with my current employer. 1 2 3 4 5 n. Even if it were to my advantage,T do not feel it would be right to leave my organization now. 1 2 3 4 5 o. I would feel guilty if I'left my organization now. 1 2 3 4 5 p. This organization deserves my loyalty. 1 2 3 4 5 q. I would not leave my organization right now because I have a sense of obligation to the people in it. 1 2 3 4 5 r. I owe a great deal to my organization. 1 2 3 4 5 197 IV. DEMOGRAPHIC INFORMATION The following questions are for the purpose of gathering individual background information. All information you provide will be kept strictly confidential at all times. 26. Sex: • Male • Female 27. Age: • 20-35 • 36-45 • 46-55 • 56-65 28. Educational qualifications: • B. Sc. (Pharm) • M. Sc. • Pharm. D • Ph. D. • Other, please specify: 29. Please indicate the number of years of your work experience as a pharmacist. 30. Are there any other structural changes that you think should be implemented in order to facilitate the provision of pharmaceutical care in community pharmacy practice? Please specify. Please go on to Part B of the questionnaire PART B Revised Behavioral Pharmaceutical Care Scale Copyright 1994 Odedina and Segal Think about the last five (5) patients/customers of yours who presented a new prescription used to treat a chronic condition such as asthma or diabetes. Please indicate how many of these five patients you provided the following activities to by circling the appropriate response. Ask the patient to describe his/her medical condition, including a description of medical problems and symptomatology. all 5 4 .3 2 1 none Document information about the patient's medical conditions on written records, computerized notes or by other formal mechanisms in a form that could be read and interpreted by another health care practitioner in my absence. all 5 4 3 2 1 none Document all medications currently being taken by the patient on written records, computerized notes or by other formal mechanisms in a form that could be read and interpreted by another health care practitioner in my absence. all 5 4 3 2 1 none Ask the patient what he/she wants to achieve from the drug therapy. all 5 4 3 2 1 none Document the desired therapeutic objectives for the patient. all 5 4 3 2 1 none 6. Check the patient's records for potential drug-related problems, all 5 4 3 2 1 none 199 7. Discuss the patient's drug therapy with him or her. all 5 4 3 2 1 none 8. Verify that the patient understands the information I present to him or her. all 5 4 3 2 1 none II. Next, we would like you to think about the last five (5) patients/customers of yours who presented a refill prescription used to treat a chronic condition such as asthma or diabetes. Please indicate how many of these five patients you provided the following activities to by circling the appropriate response. 9. Ask the patient questions to assess actual patterns of use of the medication. all 5 4 3 2 1 none 10. Ask the patient questions to find out if he/she might be experiencing drug-related problems. all 5 4 3 2 1 none 11. Ask the patient questions to find out about the perceived effectiveness of drugs he/she is taking. all 5 4 3 2 1 none 12. Ask the patient questions to ascertain whether the therapeutic objective(s) is (are) being reached. all 5 4 3 2 1 none 200 If a drug-related problem was detected for any of these 10 patients (see questions 6 and 10), please go on to question 13. If a drug-related problem was not uncovered for any of these 10 patients, please answer the following: A drug-related problem was not uncovered because: • I do not check for drug-related problems in my patients (skip to Question 19) • I routinely check for drug-related problems, but these 10 patients did not experience any (Go to question 13 and answer the questions on the basis of the last few patients who experienced drug-related problems) III. Now, think about the last five (5) patients/customers of yours whom you discovered were experiencing drug-related problems. Please indicate how many of these five patients you provided the following activities to by circling the appropriate response. 13. Document the drug-related problems, potential or actual, on written notes. all 5 4 3 2 1 none 14. Document the desired therapeutic objective(s) for each of the drug-related problem identified. all 5 4 3 2 1 none 15. Implement a strategy to resolve (or prevent) the drug-related problems. all 5 4 3 2 1 none 16. Establish follow-up plans to evaluate the patient's progress toward his/her drug therapy objectives. all 5 4 3 2 1 none 201 17. Carry out the follow-up plans established for the patient's progress toward his/her drug therapy objectives. all 5 4 3 2 1 none 18. Document any intervention made on the patient's file, prescription, report or medical order in a form that could be read and interpreted by another health care professional. all 5 4 3 2 1 none IV. In general, considering all the patients/customers with chronic conditions that you saw in the last six weeks, please indicate the extent to which you provided pharmaceutical care to these patients by placing X above the appropriate response. X For example: Always Never 19. How often did you try to provide pharmaceutical care to these patients? Always Never 20. How often did you make the psychological commitment and the effort required to improve their medical outcomes? Always Never V. Now, we would like to ask you some questions about your dealings with colleagues and other health care providers when providing pharmaceutical care to your patients. In general, considering all the patients you saw in the last two weeks, please indicate how often you actually carried out the following activities. Mark X above the appropriate response. For questions which deal with communication, we are referring to communication that the pharmacist initiates. 21. Discuss patients' problems with other pharmacists in my practice group. Very often Not at all 202 22. Make referrals to other pharmacists whenever it is in the best interest of the patient. Very often Not at all 23. Make referrals to a physician when necessary. Very often Not at all 24. Refer patients to specific physicians upon their request. Very often__ . Not at all 25. Communicate patients' progress on their drug therapy to their physicians or their providers Very often Not at all 26. Initiate discussion with physicians whenever I believe one of their patients is experiencing a drug-related problem or may experience a drug-related problem. Very often Not at all 27. Provide physicians (upon referral) with a written summary of the patient's medication history and related problems. Very often Not at all 28. Refer patients with social problems, such as inability to afford medications, to appropriate agencies for help. Very often Not at all 203 VI. Still considering all the patients you saw in the last two weeks, please indicate how often you actually carried out the following activities. Mark X above the appropriate response. 29. Use a quiet location for patient counselling. Very often Not at all 30. Double-check each prescription prepared by other personnel before giving the medication to the patient. Very often Not at all 31. Use appropriate information services e.g. personal reference library, on-line computer search, and subscription to drug information services, to assist me in my practice when necessary. Very often Not at all 32. Inquire of patients their satisfaction with my services in order to evaluate my work. Very often Not at all 33. Participate regularly in high quality continuing education programs to maintain and improve my competency. Very often Not at all 34. Use the clinical outcomes of my patients to evaluate my work. Very often Not at all 35. Provide written copies'of patient information to professional colleagues authorized to have such information. Very often Not at all 36. Provide general medical information to patients. Very often Not at all 204 THANK YOU VERY MUCH FOR COMPLETING THE QUESTIONNAIRE Please mail your questionnaire in the enclosed postage-paid envelope. Please return completed questionnaires by: The return address is: Mr. John Krishnarajan Faculty of Pharmaceutical Sciences University of British Columbia 2146 East Mall, Vancouver, BC, V6T 1Z3. 205 A P P E N D I X 4 Content Validity Form Content Validity of the Community Pharmacy Structural Elements Questionnaire Objective of the Study: To develop a taxonomy of structural elements that are required for the successful implementation of pharmaceutical care in community pharmacy practice in Canada. Objectives of the questionnaire: 1. To gather data regarding the structural changes made in innovative community pharmacy practices in order to implement pharmaceutical care. Structural changes include: Human resource issues, workflow, design and physical layout, organizational issues such as job satisfaction, career commitment, and organizational commitment, reimbursement, technological changes, and changes in policy. 2. To measure the extent of structural changes that have been made. This will be achieved by giving an equivalent score of one to every structural element mentioned in the questionnaire and also to structural elements that are not mentioned in the questionnaire but reported by the respondents in the open-ended sections of the questionnaire. Total score will represent the extent of structural changes made at the site. 3. To measure the extent to which community pharmacists rate the importance of structural elements in the provision of pharmaceutical care. Objectives of the Content Validity test: 1. To assess the content representativeness or content relevance of elements of the Community Pharmacy Structural Elements Questionnaire (CPSEQ) to the objectives of the study. 2. To assess that the items on the CPSEQ adequately represent the content in the domain of interest, which is, the structural elements that are required for the successful implementation of pharmaceutical care. Instructions: 1. Judge the content relevance of each item of the questionnaire and the respective response categories to the objectives mentioned above on a four-point scale. 1= not relevant; 2 = unable to assess relevance without item revision; 3 = relevant but needs minor alteration; 4 = very relevant and succinct. 2. Judge the overall content relevancy of the instrument to the objectives of the study. 3. Identify, i f any, area(s) of structural elements that might have been omitted from the instrument. 206 Please refer to the Community Pharmacy Structural Elements Questionnaire and proceed systematically through the items of the questionnaire and response categories and judge the content relevance of each item. 1 = not relevant 2 = unable to assess relevance without item revision 3 = relevant but needs minor alteration 4 = very relevant and succinct Please circle the appropriate response. If you choose 2 or 3 for any item, please state the item revision or alteration in the provided space. I. Pharmacy and Pharmacy Personnel The questions in this section are for the purpose of gathering information about the pharmacy and the personnel working in the pharmacy. Qn. 1. For what type of pharmacy do you work? Not relevant 1 .2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 2. How many stores does your independent pharmacy practice or chain pharmacy practice include? Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 3. In total, how many pharmacists do you have on staff in your pharmacy? Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) 207 Qn. 4. How many shifts are there in your pharmacy? (Please be specific, e.g., 8:30 a.m.- 4:30 p.m.) Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 5. Please indicate the number of pharmacists working for each shift? Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 6. Which shift is the busiest in the pharmacy? (Please be specific, e.g., 8:30 a.m. - 4:30 p.m.) Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 7. Please indicate i f you agree or disagree with the following statement: The current number of pharmacists working for each shift is sufficient to manage the workload in the pharmacy. Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) 208 Qn. 8. Which of the following support personnel are on staff in your pharmacy? Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 9. In total, how many pharmacy technicians are on staff in your pharmacy? Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 10. Please specify the number of pharmacy technicians working for each shift. Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 11. Please indicate if you agree or disagree with the following statement: The current number of pharmacy technicians working per shift is sufficient enough to manage the workload of the pharmacy. Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) 209 Qn. 12. Are the pharmacy technicians certified through a formal technician certification program? Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 13. Have the pharmacy technicians gone through an alternate training program? If yes, please specify what type of training is involved (e.g., on the job training). Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) II. Pharmacy Structure and Activities This sections includes questions about pharmacy structure and pharmaceutical care related activities. Qn. 14. Is a pharmaceutical care practice model being used in your pharmacy? Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 15. Please specify, if this is a commercially available model or an academically available model. Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) 210 Qn. 16. Have you made any changes to your practice in order to provide pharmaceutical care? Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 17. Please indicate with a checkmark, all the changes that have been made in your pharmacy in order to provide pharmaceutical care? a. Reorganization of pharmacists' duties (workflow changes) Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) b. Reorganization of pharmacy technicians' duties Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) c. Changes in physical layout Not relevant 1 2 3 4 Proposed Revision (if 2 or 3 was circled) Very relevant 211 d. Pharmacist Training Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) e. Pharmacy technician retraining (re: provision of pharmaceutical care) Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) f. Financial Compensation Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) g. Modification of your pharmacy's policy and procedure Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) 212 h. Technological changes Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 18. Please indicate if the following structural changes were successful/not successful in providing pharmaceutical care. Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 19. Please indicate how you would rate, in order of importance, the following structural changes for the successful provision of pharmaceutical care. Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 20. On an average, how many hours per day are specifically allocated in your pharmacy for pharmaceutical care? Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) 213 Qn. 21. Please indicate if the following trends have influenced your decision to implement a pharmaceutical care practice model? Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 22. Are there any current legal bylaws in pharmacy practice that you would like to see changed or any new bylaws which you would like to see implemented in order to facilitate the provision of a patient focused care in community pharmacy practice? If yes, please specify the changes. Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) III. Organizational Structure The questions in this section are for the purpose of measuring the level of job satisfaction, career commitment, and organizational commitment. Qn. 23. The Minnesota Job Satisfaction Questionnaire. Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) 214 Qn. 24. Career Commitment Scale. Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 25. Organizational Commitment Scale. Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) IV. Demographic Information Qn. 26. Sex Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 27. Age Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) 215 Qn. 28. Educational qualifications Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 29. Please indicate the number of years of your work experience as a pharmacist. Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Qn. 30. Are there any other structural changes that you think should be implemented in order to facilitate the provision of pharmaceutical care in community pharmacy practice? Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) Please judge the overall content relevancy of the Community Pharmacy Structural Elements Questionnaire to the objectives of the study. Not relevant 1 2 3 4 Very relevant Proposed Revision (if 2 or 3 was circled) If there are any areas that you feel have been omitted from the Community Pharmacy Structural Elements Questionnaire, please list below. 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C C £ es 2 > es j " es o O ft u z * es .a E -o^  es 3 k. cu &X) es u ° 2 cu 2 CJ S i E f c » S e CJ X a 5 .a cs 3 p S ft U O o 'cn 224 APPENDIX 6 Script for Initial Telephone Contact Hello, may I speak with . (If person is not in, ask when they are expected back) Hi, My name is John Krishnarajan. How are you? I am a graduate student in the Faculty of Pharmaceutical Sciences at the University of British Columbia,. My graduate supervisors are Dr. Timothy-John Grainger-Rousseau and Dr. David Hill. I am calling with regards to our research project that we are currently working on. This project deals with evaluating the structural changes that have been made in community pharmacy in order to implement pharmaceutical care. As part of this project, we are conducting a survey to gather information regarding pharmacy structures that are necessary for the implementation of pharmaceutical care. We would like to invite you to participate in this survey. By participating in this survey, you would be able to identify specific factors that may assist you in improving your business and practice. Your contribution to this project would be very valuable to us. Are you interested in participating in the survey? (If yes) Thank you very much for agreeing to participate in the survey. We will be mailing out this survey to you this week and you should receive it by next week. All information that you provide will be kept strictly confidential and used only for research purposes. (If no) This is for my graduate thesis, so you participation and support for the project would be greatly appreciated. If you have any questions with regards to this survey, you can ask me now. (If no questions) Thanks once again for your time. Have a good day. Goodbye. 225 Cover Letter for Survey Questionnaire Thank you very much for agreeing to participate in the project, 'Taxonomy of structural requirements to successfully implement pharmaceutical care in community pharmacy practice in Canada' conducted by Dr. Timothy-John Grainger-Rousseau, Dr. David S. Hill and Mr. John Krishnarajan. As members of the health care team, pharmacists must be accountable for their part in the provision of health care. It is the responsibility of the profession to define the structures that are necessary to take on this challenge. This project will provide a valuable resource to the profession in moving towards this goal. Your co-operation in this study will help to establish a resourceful classification of structural requirements to implement pharmaceutical care practice. The findings will also serve as a useful resource, and learning tool, in order for practising pharmacists to make concerted efforts towards achieving a pharmaceutical care practice to help improve patient outcomes. The information that you provide in the questionnaire will be confidential and will be used solely for research purposes. Your identity will be kept confidential at all times and any data reported from the study identify sites by a numerical code known only to the researchers. Data gathered through this questionnaire, including your identity will be coded and stored in our database accessible only by the researchers. Once again, I thank you for taking the time to participate in this study. If you have any questions, please do not hesitate to contact me at (604) 872-6618 or (604) 822-4715. Yours sincerely, John Krishnarajan, B. Pharm. M.Sc. Candidate. APPENDIX 7 Table A.4. Responses to open-ended options of CPSEQ Items Question No. Description of Responses 17.c. Other changes in physical layout i) Creation of defined prescription drop-off area and prescription pick-up area. ii) Creation of computer terminals a. Terminals in counselling room or area a. Internet access for medical and patient info b. Blood pressure monitor, weight scale, and body fat analyzer interfaced with the computer iii) Re-organizing dispensary layout to create a better flow of work to organize and speed-up dispensing a. U-shaped design of dispensary counter with work flowing from the left to the right. iv) Creation of separate workstation for each pharmacist including consultation desks v) Creation of expanded compounding lab vi) Creation of a seminar or lecture room vii) Technical functions conducted away from and physically behind the patient-pharmacist interaction area. viii) Creation of a lower ceiling and inclusion of softer lighting ix) Movement of dispensary to center of store x) Incorporation of cool and calming colours to the walls xi) Incorporation of lowered counters to increase interaction with patients xii) Incorporation of a patient information library xiii) Incorporation of special displays of information, eg., depression, arthritis. 17. d. Other pharmacist training i) Continuing education programs and seminars ii) Disease state management seminars iii) Company sponsored workshops a. Shoppers Drug Mart - Healthwatch training programs b. Pharmasave training programs c. Jean Coutu training academy iv) Natural Asthma and Respiration Training Certification v) Attendance and participation in pharmacy conferences vi) Seminars and workshops provided by provincial pharmacy regulatory bodies and provincial pharmacy associations vii) Pharmaceutical company sponsored training programs a. Apotex - PACE Time to Talk program b. Pfizer-PCPP Question No. Description of Responses 17. d. Other pharmacist training viii) Instore training: meeting of small groups of pharmacists ix) Informal meetings with other pharmaceutical care providers 17.e. Other pharmacy technician training i) Health outcome pharmacies' technician training program ii) Corporate sponsored training and seminars a. Shoppers Drug Mart Accredited pharmacy assistant program b. Jean Coutu Program for pharmacy technicians iii) Computer based training modules iv) One-day courses about task redirection and technical responsibilities v) Compounding courses 17.f. Other financial compensation systems i) Government funding a. Reimbursement for pharmaceutical opinions in Quebec ii) Funding from provincial pharmacy associations a. Ontario pharmaceutical association fee guide b. Manitoba pharmaceutical association c. British Columbia Pharmanet payment for well-defined set of interventions iii) Funding from pharmaceutical companies a. Apotex Time to Talk program b. Roche Diagnostics c. Altimed iv) Funding from drug manufacturers for disease specific clinics 17.g Other pharmacy store policies and procedures i) Call up (call back) procedure after 'X' days after filling prescriptions ii) One day a week and one pharmacist specifically allocated for counselling, medical reviews and follow up procedures iii) Checklist of services provided by pharmacist handed to patient iv) Home visits v) Private counselling for new prescriptions vi) Patient medical history gathered vii) Handouts of information sheets to patients for new prescriptions viii) Requirement to offer counselling for all new and refill prescriptions Question No. Description of Responses 17.h Other technological changes i) CPU networking - availability of profiles at all workstations ii) CD ROM texts iii) Computer tracking of Blood glucose monitoring and Blood pressure monitoring iv) Cordless headsets for technicians v) Improved software a. Features for documentation b. Cognitive services documentation and billing program (QSI DATA) c. Features for decision-making d. Features for interventions and call backs e. Features for herbal drug interactions vi) Internet access to research areas for drug information 

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