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Background: Pharmacogenetic (PGx) testing is an evidence-based approach to finding effective medication therapies. While community pharmacists are ideally situated to provide PGx testing, the extent of its implementation is limited within community pharmacies., Objective: This study aimed to explore trends in the international peer-reviewed primary literature on community pharmacists' implementation of PGx and map the main findings on the Theoretical Domains Framework (TDF)., Methods: A literature search and 2-step screening were conducted per PRISMA Extension for Scoping Reviews. Inclusion criteria were English language, community pharmacy setting, full papers, and empirical research. Data were collated in a data extraction form. The main findings were deductively mapped on the TDF with a content analysis approach., Results: Of 1176 identified documents screened, 39 were included in this scoping review. Four groups of research were identified: pre-implementation surveys (interviews, and focus groups [56%, n = 22]); PGx implementation (single cohort to assess feasibility [38%, n = 15]); PGx implementation (controlled study to assess feasibility [n = 1, 2.5%]); and efficacy of PGx (2.5%, n = 1). Most studies throughout the 4 groups sought pharmacists' perceptions (46%, n = 18) and used the quantitative paradigm (77%, n = 30). TDF mapping documented positive beliefs about the benefits of PGx testing as a part of the pharmacists' role. Barriers to PGx use included pharmacists' awareness of knowledge gaps, low confidence in interpreting and communicating PGx results, concerns about cost, privacy, and integration into pharmacy workflow., Conclusion: Research addressing PGx implementation within the community pharmacy evolved from assessing individuals' perceptions of PGx to determining the feasibility of PGx testing in pharmacies and evaluating the impact of PGx testing on patient outcomes in depression. Mapping the main findings on the TDF facilitates the development of multidimensional interventions, potentially targeting patients, pharmacists, and health policy., (Copyright © 2022 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Objective To describe the frequency, type, and severity of reported medication incidents that occurred at a long-term care facility (LTCF) despite electronic medication administration record and barcode-assisted medication administration (eMAR-BCMA) use. The study also contains analysis for the contribution of staff workarounds to reported medication administration errors (MAEs) using an established typology for BCMA workarounds, characterize if the eMAR-BCMA technology contributed to MAEs, and explore characteristics influencing incident severity. Design Retrospective incident report review. Setting A 239-bed LTCF in Alberta, Canada, that implemented eMAR-BCMA in 2013. Participants 270 paper-based, medication incident reports submitted voluntarily between June 2015 and October 2017. Interventions None. Results Most of the 264 resident-specific medication incidents occurred during the administration (71.9%, 190/264) or dispensing (28.4%, 75/264) phases, and 2.3% (6/264) resulted in temporary harm. Medication omission (43.7%, 83/190) and incorrect time (22.6%, 43/190) were the most common type of MAE. Workarounds occurred in 41.1% (78/190) of MAEs, most commonly documenting administration before the medication was administered (44.9%, 35/78). Of the non-workaround MAEs, 52.7% (59/112) were notassociated with the eMAR-BCMA technology, while 26.8% (30/112) involved system design shortcomings, most notably lack of a requirement to scan each medication pouch during administration. MAEs involving workarounds were less likely to reach the resident (74.4 vs 88.8%; relative risk = 0.84, 95% CI 0.72-0.97). Conclusion Administration and dispensing errors were the most reported medication incidents. eMAR-BCMA workarounds, and design shortcomings were involved in a large proportion of reported MAEs. Attention to optimal eMAR-BCMA use and design are required to facilitate medication safety in LTCFs.

Research exploring the integration of pharmacogenomics (PGx) testing by pharmacists into their primary care practices (including community pharmacies) has focused on the "external" factors that impact practice implementation. In this study, additional "internal" factors, related to the capabilities, opportunities, and motivations of pharmacists that influence their ability to implement PGx testing, were analyzed. Semi-structured interview data from the Pharmacists as Personalized Medicine Experts (PRIME) study, which examined the barriers and facilitators to implementing PGx testing by pharmacists into primary care practice, were analyzed. Through thematic analysis, using the theoretical domains framework (TDF) domains as deductive codes, the authors identified the most relevant TDF domains and applied the behavioural change wheel (BCW) to generate intervention types to aid in the implementation of PGx testing. Pharmacists described how their professional identities, practice environments, self-confidence, and beliefs in the benefits of PGx impacted their ability to provide a PGx-testing service. Potential interventions to improve the implementation of the PGx service included preparing pharmacists for managing an increased patient load, helping pharmacists navigate the software and technology requirements associated with the PGx service, and streamlining workflows and documentation requirements. As interest in the wide-scale implementation of PGx testing through community pharmacies grows, additional strategies need to address the "internal" factors that influence the ability of pharmacists to integrate testing into their practices.

Objectives: To evaluate the reporting quality for a sample of community pharmacy qualitative research articles based on the Standards for Reporting Qualitative Research (SRQR) guidelines, data interpretation and use of theory., Methods: A systematic literature search was conducted using Ovid MEDLINE to identify qualitative research related to community pharmacy. Data were extracted and evaluated based on the SRQR standards, data interpretation level and use of theory. Adherence to standards was analysed using descriptive statistics., Key Findings: Eighty-one studies were retrieved through the database search (n = 81). Then, 31 studies met the inclusion criteria after screening abstracts and full texts. Twelve out of 21 SRQR were present in more than 80% of the studies. However, essential standards, such as research approach, reflexivity and trustworthiness techniques, were absent or partially present in 30 (97%) studies, 30 (97%) studies and 21 (68%) studies, respectively. Data interpretation level was descriptive in 27 (87%) studies and interpretive or partially interpretive in 4 (13%) studies. Theory was absent in 19 (60%) and implied, partially integrated or retrospectively applied in 12 (40%) of the studies., Conclusion: Trustworthiness and quality of qualitative inferences within community pharmacy research could be enhanced with increasing awareness about reporting; the approach and paradigm, reflexivity, trustworthiness techniques, data interpretation level and theoretical use., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Royal Pharmaceutical Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Competing Interests: Conflicts of Interest:The authors declare no conflict of interest.

Objectives: To characterize the educational interventions regarding prescription and nonprescription medication use for school-aged children, we systematically reviewed evidence of programs available for this age group., Methods: Searches in PubMed, CINAHL, EMBASE, ERIC, and International Pharmaceutical Abstracts were conducted. Search terms focused on: population education, school-age children, and medications. Studies were excluded if they were specific to a particular disease state or class of medication, drugs of misuse and illicit drugs. Data extraction included study design, location, educational intervention and duration, research methods, and main findings., Results: We found 14 studies representing 8 separate projects. Six projects were identified in the gray literature. Projects ranged from individual sessions to national programs. Quantitative studies showed improvement in knowledge, medication literacy, and confidence. The adoption of medication education strategies was dependent on the educator's comfort level and beliefs regarding medication safety., Conclusions: Credible medication education resources are available and have been shown to improve students' knowledge. There remains a need for multifaceted implementation and evaluation strategies. Strategies and resources are available to implement interventions in communities to address medication education in school-age children. Frameworks should be used to facilitate the implementation of effective health promotion strategies around safe-medication use for school-aged children., (© 2020, American School Health Association.)

Inhaled medications are critical in the pharmaceutical management of respiratory conditions, however, the majority of patients demonstrate at least one critical error when using an inhaler. Since community pharmacists can be instrumental in addressing this care gap, we aimed to determine the rate and type of critical inhaler errors in community pharmacy settings, elucidate the factors contributing to inhaler technique errors, and identify instances when community pharmacists check proper inhaler use. Fourth year pharmacy students on community practice placement (n = 53) identified 200 patients where at least one error was observed in 78% of participants when demonstrating inhaler technique. Prevalent errors of the users were associated with metered dose inhaler (MDI) (55.6%), Ellipta ® (88.3%), and Discus ® (86.7%) devices. Overall, the mean number of errors was 1.09. Possession of more than one inhaler, use of rescue inhaler, and poor control of asthma were found to be significant predictors of having at least one critical error. In all participating pharmacies, inhaler technique is mainly checked on patient request (93.0%) and for all new inhalers (79.0%)., Competing Interests: The authors declare no conflicts of interest.

Canadian pharmacists now have prescribing authority and little is documented about the physicians' perception, experience and relational dynamics evolving around the pharmacists' prescribing practice. The objective of this study was to explore Albertan family physicians' perceptions and experiences of pharmacists' prescribing practice. We used purposeful and maximum variation sampling method and semi-structured face to face or telephone interviews to collect data. From October 2014 to February 2016, we interviewed 12 family physicians in Alberta, having experience with pharmacist prescribing. Interviews were audio recorded and transcribed verbatim for analysis using an interpretive description method, guided by "Relational Coordination" theory. NVivo software was used to manage the data. Three key beliefs (i.e., renewal versus initiate new prescription, community versus team pharmacists, and "I am responsible") about pharmacist prescribing were identified. Trust and communication were prominent themes which shaped participants' collaboration with pharmacist prescribers. Participants were classified as either "collaborative" or "consultative". Participants had greater collaboration with the team pharmacist prescribers compared to community pharmacists due to a higher level of trust and ease of communication. Renewal prescribing by any pharmacist was well accepted but participants showed hesitancy in accepting pharmacist-initiated prescriptions. Our findings provide insight into interprofessional collaboration and communication between physician and pharmacist prescribers.

Background There are two fundamental approaches to clinical reasoning, intuitive and analytical. These approaches have yet to be well explored to describe how pharmacists make decisions to determine medication appropriateness. Objective (1) to identify the cognitive actions (i.e., operators) that pharmacists employ when they move from one cue (i.e., concept) to another, and (2) to describe the overall clinical reasoning approach taken by pharmacists when checking for medication appropriateness. Setting Pharmacists from a chain pharmacy in Canada were invited to participate in this study. Method Data was collected in private rooms using video recordings to capture simulated patient-pharmacist interactions of a new prescription medication. A simulated case scenario was used to gather two types of verbal reports, concurrent think-aloud and structured retrospective think-aloud from pharmacists. All verbal reports were video-recorded, transcribed verbatim, and analyzed using protocol analysis. Main outcome measure Pharmacists' reasoning approaches when making medication appropriateness decisions. Results A total of 17 pharmacists participated. Pharmacists were most likely to use analytical clinical reasoning approaches when checking prescriptions and three used no clinical reasoning. When the pharmacists were asked specific questions regarding the decision-making model for pharmacy (i.e., check for indication, efficacy, safety, and adherence), 50% reported using analytical decision-making approaches, with a third of the decisions being made in hindsight. Conclusion The majority of the pharmacists followed an analytical decision-making approach to clinical reasoning. When the pharmacists were asked prompting questions about their medication-related decisions, they employed a combination of intuitive and analytical approaches. The pharmacists had the competency to check for medication appropriateness; though this knowledge was mostly restructured during the process of hindsight reasoning.

Asthma control can be achieved with effective and safe medication use; however, many patients are not controlled. Patients' perceptions of asthma, asthma treatment, and pharmacist roles can impact patient outcomes. The purpose of this study was to explore patients' experiences and patient⁻pharmacist relationships in asthma care. Qualitative Interpretive Description method guided the study. Semi-structured individual interviews were conducted with 11 patients recruited from personal contacts, pharmacies, and asthma clinics. Categories and themes were identified using inductive constant comparison. Themes indicated patients had a personalized common sense approach to asthma management, "go-to" health care provider, and prioritized patient⁻pharmacist relationships. Patients described their illness experiences and asthma control based on personal markers similar to the common sense model of self-regulation. Patients chose a family physician, asthma specialist, respiratory therapist, or pharmacist as an expert resource for asthma management. Patient perceived pharmacists' roles as information provider, adviser, or care provider. Pharmacists who develop a collaborative relationship with their asthma patients are better positioned to provide tailored education and self-management support. Inviting patients to share their perspective could increase patient engagement and uptake of personalised asthma action plans to achieve asthma control.

Objectives: To map the extent, range, and nature of research on the effectiveness, level of use, and perceptions about electronic medication administration records (eMARs) in long-term care facilities (LTCFs) and identify gaps in current knowledge and priority areas for future research., Design: Scoping review of quantitative and qualitative literature., Setting: Literature review., Participants: Original research relating to eMAR in LTCF was eligible for inclusion., Measurements: We systematically searched MEDLINE, CINAHL, Scopus, ProQuest, and the Cochrane Library and performed general and advanced searches of Google to identify grey literature. Two authors independently screened for eligibility of studies. Independent reviewers extracted data regarding country of origin, design, study methods, outcomes studied, and main results in duplicate., Results: We identified 694 articles, of which 34 met inclusion criteria. Studies were published between 2006 and 2016 and were mostly from the United States (n=25). Twenty studies (59%) used quantitative methods, including surveys and analysis of eMAR data; 7 (21%) used qualitative methods, including interviews, focus groups, document review, and observation; and 7 (21%) used mixed methods. Three major research areas were explored: medication and medication administration error rates (n=11), eMAR benefits and challenges (n=19), and eMAR prevalence and uptake (n=15). Evidence linking eMAR use and reductions in medication errors is weak because of suboptimal study design and reporting. The majority of studies were descriptive and documented inconsistent benefits and challenges and low levels of eMAR implementation., Conclusion: Further investigation is required to rigorously evaluate the effect of standalone eMAR systems on medication administration errors and patient safety, the extent of eMAR implementation, pharmacists' perceptions, and cost effectiveness of eMAR systems in LTCF., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Background: The patient care process (PCP) was adopted to move community pharmacy practice from the traditional dispensing role to a more professional level of patient care. However, research has not yet empirically characterized how pharmacists conduct the PCP in community pharmacies., Objectives: This study characterizes how pharmacists employ the PCP when evaluating medication appropriateness in a simulated community pharmacy setting., Methods: A mixed methods analysis was employed to analyze simulated patient-pharmacist interactions (i.e., consultations), and concurrent think-aloud (checking sessions). Transcripts were quantitatively coded for elements of the PCP. A generic qualitative approach was used to explore how pharmacists provided care., Results: Almost all pharmacists checked for medication indication, safety, and manageability at the end of the process when releasing the medication to the patient. Still, most pharmacists gathered insufficient information to fully evaluate medication appropriateness. Six overarching themes described consultations and checking sessions: missed opportunities, the absence of personalized assessments, reliance on routines, nonspecific questions, communication style, and response to patient cues. The quantitative and qualitative findings together created a picture of incomplete assessments which were driven by technical routines and medication-focused communication., Conclusion: Overall, the majority of pharmacists completed most of the patient-care process. Even so, pharmacists did not complete a full assessment of medication appropriateness. Patient care tasks were driven by routines and occurred at the end of the process, whereas the initial patient assessment and prescription check were mainly devoted to technical activities. Pharmacists had opportunities to enhance patient-centered communication by engaging patients in dialogue and recognizing patient emotional cue., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of Conflicting Interests:K. Leblanc has received consulting fees and speaker honouraria from Boehringer Ingelheim, Bayer, Bristol Meyer Squibb/Pfizer Alliance and Servier. W. M. Semchuk, has received consulting fees and speaker honouraria from Boehringer Ingelheim, Bayer, Bristol Meyer Squibb/Pfizer Alliance, Servier and Sanofi. J. Papastergiou has received consutling and speaker honouraria from Bayer and Pfizer. B. Snow has received consulting and speaker honouraria from Bayer. V. Kapoor has received consulting fees from Boehringer Ingelheim and Bayer. L. Mandlsohn and L. M. Guirguis have no conflicts of interest to declare. J. D. Douketis has received consulting fees from Boehringer-Ingelheim, Bayer, Pfizer, Sanofi and Janssen Research and Development. He also receives royalties from The Merck Manual and Up-to-Date. W. H. Geerts has received consulting fees from Jansen Research and partial salary support from a hospital foundation account that has received donations from Sanofi. D. J. Gladstone has no disclosures from July 2016 onwards. Prior, he had received speaking and advisory honouraria from Boehringer Ingelheim, Bayer and Bristol Meyers Squibb/Pfizer Alliance.

Objective: Study objectives were to develop a questionnaire to assess factors influencing pharmacists' adoption of prescribing (i.e., continuing, adapting or initiating therapy), describe use of pre-incentive and mixed mode survey, and establish survey psychometric properties., Methods: Questions were developed based on prior qualitative research and Diffusion of Innovation theory. Expert review, cognitive testing, survey pilot, and main survey were used to test the questionnaire. Six content experts reviewed the questionnaire to establish face and content validity. Ten pharmacists from diverse practice settings were purposefully recruited for a cognitive interview to verify question readability. Content analysis was used to analyze the results. A pre-survey introduction letter with a monetary incentive was mailed via post to 100 (i.e. pilot) and 700 (i.e., main survey) randomly selected pharmacists. This was followed by an e-mail with a personalized link to the online questionnaire, e-mail reminders, and a telephone reminder if required. The psychometric properties of scales were evaluated with an exploratory factor analysis and Cronbach's alpha. Scale responses were described., Results: Engagement of six experts and ten pharmacists clarified definitions (e.g., prescribing), terminology, recall periods, and response options for the 34-item response scale. Fifty-six pharmacists completed the online pilot survey. Based on this data, ambiguous questions and routing issues were addressed. Three hundred and seventy-eight pharmacists completed the online main survey for a response rate of 54.6%. The factors analysis resulted in 27 questions in eight scales: (1) self-efficacy, (2) support from practice environment, (3) support from interprofessional relationship, (4) impact on professionalism, (5) impact on patient care), (6) prescribing beliefs, (7) technical use of electronic health record (EHR) and (8) patient care use of the EHR. Prescribing beliefs and technical use of the EHR scales had low reliability while the remaining six scales had strong evidence for reliability and validity., Conclusion: Through a multi-stage process, a survey instrument was developed to capture pharmacists' perceptions of prescribing influences. This questionnaire may support future research to develop interventions to enhance adoption of prescribing and enhance direct patient care by pharmacists., Competing Interests: CONFLICT OF INTEREST The authors declare that they have no competing interests.

Background: Oral anticoagulant therapy (OAC) to prevent atrial fibrillation (AF)-related strokes remains poorly used. Alternate strategies, such as community pharmacist prescribing of OAC, should be explored., Methods: Approximately 400 pharmacists, half with additional prescribing authority (APA), randomly selected from the Alberta College of Pharmacists, were invited to participate in an online survey over a 6-week period. The survey consisted of demographics, case scenarios assessing appropriateness of OAC (based on the 2014 Canadian Cardiovascular Society AF guidelines) and perceived barriers to prescribing. Regression analysis was performed to determine predictors of knowledge., Results: A total of 35% (139/397) of pharmacists responded to the survey, and 57% of these had APA. Depending on the case scenario, 55% to 92% of pharmacists correctly identified patients eligible for stroke prevention therapy, but only about a half selected the appropriate antithrombotic agent; there was no difference in the knowledge according to APA status. In multivariable analysis, predictors significantly associated with guideline-concordant prescribing were having the pharmacist interact as part of an interprofessional team ( p = 0.04) and direct OAC (DOAC) self-efficacy (confidence in ability to extend, adapt, initiate or alter prescriptions; p = 0.02). Barriers to prescribing OAC for APA pharmacists included a lack of AF and DOAC knowledge and preference for consulting the physician first, but these same pharmacists also identified difficulty in contacting the physician as a major barrier., Interpretation and Conclusion: Community pharmacists can identify patients who would benefit from stroke prevention therapy in AF. However, physician collaboration and further training on AF and guidelines for prescribing OAC are needed., Competing Interests: Statement of Conflicting Interests:There are no conflicts for any of the authors. J. S. Healey has received research grants and speaking fees from Boehringer-Ingelheim, Bayer, Bristol-Meyers-Squibb, Pfizer, Medtronic and St. Jude Medical and is also the medical director of m-Health Solutions. T. J. Bungard has received honoraria from Bayer, Bristol-Myers-Squibb, Pfizer and Boehringer Ingelheim and unrestricted research grants from Bayer, Bristol-Meyers-Squibb and Pfizer.

Background: Community pharmacists are well positioned to identify patients with poorly controlled asthma and trained to optimize asthma therapy. Yet, over 90% of patients with asthma live with uncontrolled disease. We sought to understand the current state of asthma management in practice in Alberta and explore the potential use of the Chat, Check and Chart (CCC) model to enhance pharmacists' care for patients with asthma., Methods: An 18-question survey was used to examine pharmacists' monitoring of asthma control and prior use of the CCC tools. Descriptive statistics were used to characterize the response rate, sample demographics, asthma management and CCC use. Survey validity and reliability were established., Results: One hundred randomly selected pharmacists completed the online survey with a 40% (100/250) response rate. A third of responding pharmacists reported talking to most patients about asthma symptoms and medication, with a greater focus on talking with patients on new prescriptions over those with ongoing therapies. Fewer than 1 in 10 pharmacists routinely talked to most patients about asthma action plans (AAPs). The majority of pharmacists (76%) were familiar with the CCC model, and 83% of those reported that the CCC model influenced their practice anywhere from somewhat (45%) to a great deal (38%). Both scales had good reliability, and factor analysis provided support for scale validity., Conclusions: There was considerable variability in pharmacists' activities in monitoring asthma. Pharmacists rarely used AAPs. The CCC model had a high level of self-reported familiarity, use and influence among pharmacists., Competing Interests: Declaration of Conflicting Interests:The author declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Background: A collaborative patient-pharmacist interaction is fundamental to greater patient satisfaction with pharmacy care and improved medication adherence. Effective pharmacist-patient communication occurs when both pharmacist and patient are able to successfully attend to not only the typical tasks and goals of the interaction but also basic face needs that underlie all social interaction; autonomy, competence or esteem, and fellowship. Addressing face needs occurs through conventional and strategic communication strategies that respond to the emerging needs throughout an interaction. Pharmacist-patient interactions are not just about transfer of information and medications. Both parties assess the situation, the others' intentions within the context of their own goals and this influences how they choose to act throughout the interaction. Face-work Theory provides a framework to understand these interaction processes in pharmacist-patient communication., Objectives: The aim of this study was to determine face needs, threats and the strategic communication strategies used to address these within community pharmacist-patient interactions., Methods: This exploratory descriptive study drew upon principles of ethology to first describe naturally occurring behaviour and then to interpret this behaviour within the context of Face-work theory. Twenty-five audio-recorded community pharmacist-patient interactions were collected and analyzed. The average length of these interactions was 3:67 min with a range of 0.39 s-9:35 min., Results: Multiple face needs for both pharmacist and patient were evident in most interactions. Autonomy, competence and fellowship face needs were negotiated in the following contexts: participative relationships, concordant role expectations, sensitive topics, and negotiating expertise and knowledge. Competence face needs for both parties were the most dominant need found in negotiating role expectations. The most common communication strategies used to support face were solidarity based strategies while indirect and depersonalized questions were commonly employed to mitigate face threat., Implications and Significance: Face-work Theory is a novel approach to understand processes and outcomes of patient-pharmacist interactions in community pharmacies. Linking speech acts with face needs and threats may help to elucidate how pharmacist-patient interactions achieve both task oriented and interpersonal goals., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: To describe pharmacists' self-reported refill monitoring activities and test for demographic and work setting differences that contribute to variation., Methods: This study used a cross-sectional survey design. A 4-contact survey was mailed to 599 community pharmacists randomly selected from a list provided by the state board of pharmacy. Surveys were mailed in June and July 2013. Descriptive statistics and analysis of variance were used to characterize these data., Results: Of the 599 surveys mailed, 269 complete responses were received for a 44.9% response rate. Pharmacists reported reviewing the patient's medication profile for 40% of refills. Of the 29% of refills handed off, pharmacists asked 70% of patients if they had any questions and 23% a specific question about drug therapy. Pharmacists at mass merchandisers and those in smaller towns were least likely to examine the profile, whereas pharmacists working at independent stores, owners, and pharmacists with a BS Pharm degree were most likely to hand off refills to patients. Demographic and work-setting characteristics factors were not associated with the rate of asking specific questions about the patient's drug therapy, although pharmacists with a BS Pharm, at an independent store, or working in the smallest towns were least likely to ask "Any questions?" when handing off the prescription., Conclusion: Pharmacists reported reviewing patient profiles, handing off prescriptions, and asking medication-specific questions to fewer than one-half of patients picking up refills. Pharmacists were more likely to inquire if patients had any questions than to ask specific questions, and other researchers have reported that the former phrasing may inadvertently serve to reduce patient engagement., (Copyright © 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Background: In Alberta (Canadian province), the Chat Check Chart (CCC) model was developed to help pharmacists understand how patient care standards fit into routine practice. The CCC model outlines a process that covers the following: 1) Chart-asking three prime questions to gather information; 2) Check-perform pharmacotherapy workup by assessing prescription's indication, efficacy, safety and manageability; and 3) Chart-document findings of the pharmacotherapy workup., Objectives: To characterize how pharmacist collect patient information and apply the pharmacotherapy workup when evaluating routine prescriptions in community pharmacy settings., Methods: An observational study with a mixed methods analysis was employed. Participants were surveyed and audio-recorded talking with patients, as well as thinking aloud while evaluating medication therapy. Quantitative analysis was conducted to describe the proportion of time allotted to clinical or technical duties when using the 3 prime questions and pharmacotherapy workup in routine practice. A generic qualitative approach was conducted to describe how the pharmacists evaluated prescriptions and counseled patients., Results: Nine pharmacists from five different pharmacy stores participated in this study. Fifteen recordings of consults and 14 think-alouds were eligible for analysis. Pharmacists allotted 16% of their think-aloud on clinical related issues for new and chronic medications, and the remainder on technical dispensing activities. All pharmacists checked if the medication was safe, but fewer than half checked if the prescription was indicated, effective, or useable (i.e., adherence). Pharmacists covered more content areas when checking the appropriateness for new prescriptions in comparison to chronic refills. Four overarching themes arose from the qualitative analysis: missed opportunities, absence of personalized assessments, reliance on routine pharmacist activities, and non-specific questions., Conclusions: Pharmacists gathered insufficient clinical information to assess their patients' medication therapy, as they overly relied on the patients' profiles, asked patients non-specific questions, and missed patient cues. Routine activities appeared to shape practice including a bias against refill prescriptions and a focus on technical dispensing activities., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Results of a survey to characterize pharmacist prescribing in the Canadian province of Alberta are reported., Methods: A cross-sectional survey of a random sample of pharmacists registered with the Alberta College of Pharmacists was conducted. The survey was developed in four stages, with evidence of reliability and construct validity compiled. Analysis of variance and chi-square testing were used to compare prescribing behaviors., Results: Three hundred fifty of 692 invited pharmacists (51%) completed the survey, with 76.9% and 11.1% indicating that they practiced in community and hospital settings, respectively, and 12.0% practicing in a consultant role (i.e., on a primary care team or in a long-term care setting). Overall, 93.4% of the pharmacists had prescribed. The most common practices were renewing prescriptions for continuity of therapy (92.3%), altering doses (74.3%), and substituting a medication due to a shortage (80.6%). Twenty-three pharmacists (6.6%) indicated that they did not prescribe because they were on an interprofessional team, had a consulting role, or preferred to fax physicians to request orders. Pharmacists with additional prescribing authorization (6.3% of the total survey population) were more likely to prescribe to adjust ongoing medications (63.6%) than to initiate a new medication (18.2%)., Conclusion: A survey showed that Alberta pharmacists prescribed in a manner that mirrored their practice environment. Compared with other groups, hospital and consultant pharmacists were more likely to adapt prescriptions, and community pharmacists were more likely to renew medications. Pharmacists in rural areas were prescribing most frequently., (Copyright © 2017 by the American Society of Health-System Pharmacists, Inc. All rights reserved.)

Background: Interactive communication approaches may help to shift pharmacy practice toward more patient-centered care. One example of such an approach is the 3 prime questions (3PQs). Patients' preferences for pharmacists' interactive communication styles were not identified in the literature., Objective: The purpose of this paper was to explore standardized patient (SP) preferences, satisfaction, and perceptions of pharmacists' communication style and changes in pharmacist to standardized patient talk-time ratio., Design: Mixed methods, before and after evaluation., Setting: SPs were hired from the University of Alberta's Standardized Patient Program, Canada., Participants: Twelve SPs and 10 pharmacists., Intervention: SPs were video recorded interacting with the same pharmacists before and after pharmacist training on the 3PQs. SPs participated in an open-ended interview using stimulated recall on videos of their pharmacist encounters., Main Outcome Measures: Explore SP preferences, satisfaction, and perceptions of pharmacists' communication style, in addition to changes in pharmacist to standardized patient talk-time ratio before and after the intervention, Results: Generally SPs were satisfied with pharmacists' interactive communication style post training. Qualitative themes varied with SPs' preference for an interactive approach (58%, i.e., Conversation with Equals, Double Check, and Manageable Information) or traditional approach (33%, i.e., Expected Information, Shouldn't the Pharmacist Know, and Feels Uncomfortable) and improvements in item scores varied by type of prescription. Pharmacists' use of the 3PQs increased patient talk time for scenarios with new chronic and acute medication, though pharmacists still dominated the conversation., Conclusion: Just over half of SPs preferred an interactive communication style, although a third of SPs preferred a communication style that focused on information provision. Patients had more time to talk in some interactive encounters. Pharmacists may need to be aware of patient expectations when using the 3PQs., (Copyright © 2016 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Background: Pharmacists in Canada have been prescribing since 2007. This review aims to explore the volume, array and nature of research activity on Canadian pharmacist prescribing and to identify gaps in the existing literature., Methods: We conducted a scoping review to examine the literature on prescribing by pharmacists in Canada according to methodological trends, research areas and key findings. We searched for peer-reviewed research articles and abstracts in the Ovid MEDLINE, Ovid EMBASE and International Pharmaceutical Abstracts databases without any date limitations. A standardized form was used to extract information., Results: We identified 156 articles; of these, 26 articles and 12 abstracts met inclusion criteria. One-half of the research studies (20) used quantitative methods, including surveys, trials and experimental designs; 11 studies used qualitative methods and 7 used other methods. Research on pharmacist prescribing demonstrated an improvement in patient outcomes (13 studies), varied stakeholder perceptions (10 studies) and factors that influence this practice change (11 studies). Pharmacist prescribing was adopted when pharmacists practised patient-centred care. Stakeholders held contrasting perceptions of pharmacist prescribing., Discussion: Canadian research has demonstrated the benefit of pharmacist prescribing on patient outcomes, which is not present in the international literature. Future research may consider a meta-analysis addressing the impact on patient health. Gaps in research include comparisons between provinces, effects on physicians' services, overall patient safety and access to health care systems and economic implications for society., Conclusion: A growing body of research on pharmacist prescribing has captured the early impact of prescribing on patient outcomes, perceptions of practice and practice change. Opportunities exist for pan-Canadian research that examines the system impact.

Objective: To identify which activities produced a significant improvement in blood pressure control in patients with type 2 diabetes when pharmacists were added to primary care teams., Methods: This prespecified, secondary analysis evaluated medication management data from a randomized controlled trial. The primary outcome was a change in treatment, defined as addition, dosage increase, or switching of an antihypertensive medication during the 1-year study period. The secondary outcome was a change in antihypertensive medication adherence using the medication possession ratio (MPR)., Results: The 200 evaluable trial patients had a mean age of 59 (SD, 11) years, 44% were men, and mean blood pressure was 130 (SD, 16)/74 (SD, 10) mm Hg at baseline. Treatment changes occurred in 45 (42%) of 107 patients in the intervention group and 24 (26%) of 93 patients in the control group (RR, 1.63; 95% CI, 1.08-2.46). Addition of a new medication was the most common type of change, occurring in 34 (32%) patients in the intervention group and 17 (18%) patients in the control group (P = 0.029). Adherence to antihypertensive medication was high at baseline (MPR, 93%). Although medication adherence improved in the intervention group (MPR, 97%) and declined in the control group (MPR, 91%), the difference between groups was not significant (P = 0.21)., Conclusion: The observed improvement in blood pressure control when pharmacists were added to primary care teams was likely achieved through antihypertensive treatment changes and not through improvements in antihypertensive medication adherence.

Objective: In 2007 Alberta, Canada, became the first North American jurisdiction to adopt prescribing legislation for pharmacists. In light of these legislative changes and expanded scope of pharmacy practice, we evaluated what ‘prescribing’ means to pharmacists in Alberta and the application of prescribing in pharmacy practice., Methods: We invited pharmacists to participate in semi-structured telephone interviews using closed and open-ended questions. Pharmacists working in community, hospital or other settings were selected using a mix of random and purposive sampling. Interviews were audiorecorded and transcribed, and data were entered into nVIVO 9 software. Transcriptions were analysed by two investigators using an interpretive description approach to identify themes., Key Findings: Thirty-eight pharmacists were interviewed, of whom 13 had additional (independent) prescribing authorization. Prescribing had a wide breadth of meaning to the pharmacists in our study, which included writing a new prescription and extending an existing prescription, as well as advising on non-prescription medications. Pharmacists described prescribing in terms of the physical act of writing the prescription and as part of the patient care process as well as the legislated definition of pharmacist prescribing. The sense of increased responsibility associated with prescribing was noted by many pharmacists., Conclusion: Prescribing had diverse meanings to pharmacists in our study, and appeared to be context-specific. Understanding the meaning prescribing holds for individual pharmacists is important to explore whether pharmacist's definition of this expanded scope has shaped pharmacists’ enactment of prescribing practice.

Background: Pharmacists worldwide require improved patient-centered communication skills as they transition from a dispensing role to enhanced involvement in patient care. Researchers have studied pharmacist communication through audio and video recordings of patient-pharmacist encounters. A meta-narrative review of research using these recordings will offer insight into the extent of biomedical vs. patient-centered communication in patient-pharmacist exchanges., Objectives: This review aimed to characterize research on patient-pharmacists interactions using audio or video recordings and explore the 1) focus of research questions, 2) study design, 3) data analysis methods, 4) main findings and 5) presence of patient-centered vs. biomedical models of interaction., Methods: Drawing on the principles of meta-narrative systematic review, a literature search was performed to identify studies published in English. No publication date limits were implemented. Key search terms included: "audio recording", "video recording", "communication", "patient counseling", "patient interaction", "discourse analysis", "conversation analysis", "narrative analysis", and "content analysis". The search was conducted in five databases: Medline, Embase, International Pharmaceutical Abstracts (IPA), Web of Science, and Academic Search Complete., Results: Forty-one articles met the inclusion criteria and represent 32 unique collections of patient-pharmacist recordings. The 23 quantitative studies focused on "what" was in the interaction, whereas the 5 qualitative studies characterized specialized pharmacy practice and 13 studies used conversational analysis to describe "how" patients and pharmacists interact. The majority of research described the content of recorded interactions in community pharmacies. Twenty-three studies presented evidence of a biomedical model, whereas 8 studies characterized a patient-centered focus., Conclusions: A developing body of research used recordings to describe the content of patient-pharmacist communication and explore the quality of the interactions, validation of coding tools, impact of an intervention, and patient-pharmacist power asymmetry. Study findings, particularly the identification of biomedical vs. patient-centered communication, were guided by the quantitative, qualitative, or conversational analysis research paradigm., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: In 2007, Alberta became the first Canadian jurisdiction to grant pharmacists a wide range of prescribing privileges. Our objective was to understand what factors influence pharmacists' adoption of prescribing using a model for the Diffusion of Innovations in healthcare services., Methods: Pharmacists participated in semi-structured telephone interviews to discuss their prescribing practices and explore the facilitators and barriers to implementation. Pharmacists working in community, hospital, PCN, or other settings were selected using a mix of random and purposive sampling. Two investigators independently analyzed each transcript using an Interpretive Description approach to identify themes. Analyses were informed by a model explaining the Diffusion of Innovations in health service organizations., Results: Thirty-eight participants were interviewed. Prescribing behaviours varied from non-adoption through to product, disease, and patient focused use of prescribing. Pharmacists' adoption of prescribing was dependent on the innovation itself, adopter, system readiness, and communication and influence. Adopting pharmacists viewed prescribing as a legitimization of previous practice and advantageous to instrumental daily tasks. The complexity of knowledge required for prescribing increased respectively in product, disease and patient focused prescribing scenarios. Individual adopters had higher levels of self-efficacy toward prescribing skills. At a system level, pharmacists who were in practice settings that were patient focused were more likely to adopt advanced prescribing practices, over those in product-focused settings. All pharmacists stated that physician relationships impacted their prescribing behaviours and individual pharmacists' decisions to apply for independent prescribing privileges., Conclusions: Diffusion of Innovations theory was helpful in understanding the multifaceted nature of pharmacists' adoption of prescribing. The characteristics of the prescribing model itself which legitimized prior practices, the model of practice in a pharmacy setting, and relationships with physicians were prominent influences on pharmacists' prescribing behaviours.

Multiple barriers can influence adherence to antihypertensive medications. The aim of this systematic review was to determine what adherence barriers were included in each instrument and to describe the psychometric properties of the identified surveys. Barriers were characterized using the World Health Organization (WHO) Multidimensional Adherence Model with patient, condition, therapy, socioeconomic, and health care system/team-related barriers. Five databases (Medline, Embase, Health and Psychological Instruments, CINHAL, and International Pharmaceutical Abstracts [IPA]) were searched from 1980 to September 2011. Our search identified 1712 citations; 74 articles met inclusion criteria and 51 unique surveys were identified. The Morisky Medication Adherence Scale was the most commonly used survey. Only 20 surveys (39%) have established reliability and validity evidence. According to the WHO Adherence Model domains, patient-related barriers were most commonly addressed, while condition, therapy, and socioeconomic barriers were underrepresented. The complexity of adherence behavior requires robust self-report measurements and the inclusion of barriers relevant to each unique patient population and intervention., (© 2012 Wiley Periodicals, Inc.)

Background: Patient assessment and documentation are less than optimal in pharmacy practice as preparing and dispensing medications is still a major part of community pharmacy practice. Pharmacists' attitudes, specifically self-efficacy and role beliefs, toward practice have been shown to predict practice change., Objective: This study will determine the impact of an interactive workshop on pharmacists' attitudes toward assessment and documentation in routine pharmacy practice. Specific objectives included how (1) pharmacists' role beliefs and self-efficacy toward assessment and documentation change after training and rehearsal and (2) frequently do pharmacists assess patient therapy and document patient care?, Setting: "Chat, Check and Chart: patient assessment and documentation demystified" workshop Alberta College of Pharmacists Annual General Meeting in Calgary, Canada., Methods: This study is pre-post evaluation. Quantitative data on self-efficacy and role beliefs toward assessment and documentation was gathered from a validated written survey. Surveys were completed before and after the intervention. The intervention, an interactive workshop, focused on the use of three tools practice and was designed to support pharmacists in achieving the assessment and documentation required by the Alberta College of Pharmacists Standards for Practice., Main Outcome Measure: Pharmacists' role beliefs and self-efficacy toward assessment and documentation in patient care., Results: Of the 61 eligible pharmacists, the response rate was 61 % (37 pharmacists) with complete data. In the past 2 weeks, 54 % of pharmacists were assessing patients and 32.6 % of pharmacists were documenting greater than half the time. Prior to the workshop, pharmacists "agreed" (5.42 ± 1.41) with their role in patient assessment and they were "quite sure" (4.75 ± 1.10) they could assess patients. Pharmacists "agreed" (5.13 ± 0.890) with their overall role in documentation of patient interactions and reported lower self-efficacy (3.88 ± 1.32) for their ability to document patient interactions. After the interactive workshop, there were statistically significant increases in pharmacists' self-efficacy and role beliefs in regards to both patient assessment and documentation (p < 0.05)., Conclusion: This brief interactive workshop increased both self-efficacy and role beliefs towards assessment and documentation, indicating these pharmacists are likely to change future practice. Future research will assess practice uptake and implementation.

Objective: To explore how pharmacists integrated the Chat, Check and Chart (CCC) tools in community practice and to identify barriers and facilitators to use., Design: Concurrent nested mixed-method study. Open-ended, semi-structured qualitative interviews on tools use and a quantitative survey were completed via telephone., Setting: Community-based pharmacy practice., Participants: 39 community pharmacists consented to interviews 2 months after the CCC training workshop; 22 completed an interview., Intervention: Workshop training on CCC tools and workplace implementation strategies., Main Outcome Measures: Barriers, facilitators and implementation strategies for CCC tools., Results: More pharmacists were implementing or had made patient assessment part of their practice (54%) than documentation of patient care (36%). Integration was facilitated by patient success, collaborative worksite, personal beliefs, and provincial regulations. Lack of routines, patient expectations, reimbursement, and time were familiar barriers. Strategies to overcome these barriers included practicing new habits, using technology, starting small, using physical reminders, and recognizing benefits., Conclusion: Patient care tools for assessment and documentation had both positive and negative effects on patients, pharmacists, and community pharmacies because of demands on time, lack of resources, and limited personal, external, and patient expectations of pharmacists' care. Findings resulted in Alberta College of Pharmacists academic detailing of the CCC tools during onsite pharmacy assessments to help pharmacists meet or exceed provincial practice standards.

Background: Optimal medication management requires an effective relationship between the patient and health care professional. As pharmacists move from the traditional dispensing role to become more actively involved in patient care, factors influencing their relationship with patients need to be identified. A better understanding of these factors will facilitate more effective relationships., Objective: To explore the effect of patient-perceived pharmacist expertise on relationship quality, self-efficacy, patient satisfaction, and relationship commitment., Methods: This was a cross-sectional study conducted in five community pharmacies within the province of Alberta, Canada. A total of 500 patients were asked to complete a set of validated, self-administered questionnaires that measured perceived pharmacist expertise, relationship quality, self-efficacy, patient satisfaction, and relationship commitment. Hierarchical multiple regression was used to examine the associations between variables., Results: A total of 112 surveys were returned. Internal consistency ranged from 0.86-0.92, suggesting good reliability, except for the relationship commitment scale. There was a significant, positive correlation between patient-perceived pharmacist expertise and quality of the relationship (0.78; P < 0.001). There were also significant, positive correlations between perceived expertise and patient satisfaction (0.52; P < 0.001) and relationship commitment (0.47; P < 0.001). These associations remained significant but the magnitude of correlation decreased when relationship quality was taken into account (0.55; P < 0.001 and 0.56; P < 0.001, respectively). On the other hand, there was no significant association between either patient-perceived pharmacist expertise or relationship quality and medication self-efficacy (0.06; P = 0.517 and 0.10; P = 0.292, respectively)., Conclusion: Patient-perceived pharmacist expertise is an independent determinant of relationship quality, patient satisfaction, and relationship commitment. Relationship quality also appears to mediate the effect of perceived expertise on patient satisfaction and relationship commitment.

Objectives: To describe how an electronic health record (EHR) was integrated into community pharmacists' patterns of patient care and to explore factors that are related to the use of medication and laboratory value information from the EHR., Design: Descriptive, exploratory, nonexperimental study., Setting: Edmonton, Canada, between November 2008 and March 2009., Participants: 16 pharmacists, 3 pharmacy technicians, and 2 pharmacy interns from primary care networks, long-term care settings, community independent and chain pharmacies, and grocery store pharmacies., Intervention: Qualitative interviews., Main Outcome Measure: Pharmacists' self-reported use of EHR., Results: Pharmacists in a patient-centered care practice (involving medication therapy management activities) were more likely to adopt the EHR for medication history and laboratory values, whereas pharmacists whose practice was focused on medication dispensing primarily used the EHR for patient demographic and dispensing records. Six general factors influenced the use of EHR: patients, pharmacists, pharmacy, other health professionals (i.e., physicians), EHR, and environment. Access to the medical record versus EHR and timeliness were barriers specific to pharmacists in a patient-centered practice. Factors that affected EHR use for pharmacists with primarily a dispensing practice were role understanding, dispensing versus lab records, valid reasons for using EHR, and fear of legal and disciplinary issues., Conclusion: Many community pharmacists embraced the EHR as a part of practice change, particularly those in patient-centered care practices. Practice type (patient-centered care or dispensing) greatly influenced pharmacists' use of EHR, specifically laboratory values. Because these qualitative findings are exploratory in nature, they may not be generalized beyond the participating pharmacies.

Objective: To characterize pharmacists' experience and explore their beliefs toward an interactive communication technique, the three prime questions (3PQs),where pharmacists ask about patients' understanding of medication's purpose, directions, and monitoring., Methods: Mixed method design. Pharmacists were briefly trained and then integrated the 3PQs into their practice for two weeks. Pharmacists recorded their perceptions of patient interactions, completed a survey addressing self-efficacy and role beliefs toward the 3PQs, and participated in a focus group., Results: Eleven pharmacists participated and the 3PQs were used with 176 patients. Most interactions were under 5min. Pharmacists reported that questions about directions and monitoring were most effective in gathering new information with refills whereas medication purpose question was preferred for new fills. The majority of pharmacists were certain they could use the 3PQs and agreed it was their role. Five themes arose from the qualitative analysis: established communication routines, enhanced patient-pharmacist relationships, good medication history, tailoring of the 3PQs, and impact of pharmacy organization., Conclusion: The 3PQs enabled pharmacists to briefly assess patient medication experiences and tailor education while fostering patient-centered relationships in pharmacy practice., Practice Implications: While the 3PQs may enhance pharmacists' patient assessment; integration may challenge pharmacists' work routine., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Unlabelled: Hypertension is a modifiable risk factor for cardiovascular disease. Despite this, patients often cannot or inaccurately estimate their risk factors., Objectives: IN ORDER TO IMPROVE PHARMACIST INTERVENTIONS, WE SOUGHT TO: 1) find out patients' knowledge about blood pressure (BP) and their self-monitoring behaviors and 2) identify the relationships between these two elements. Specifically, if evaluation of BP control were related to knowledge of one's BP level and self-monitoring habits, and if knowledge of one's target and BP level varied with monitoring habits., Methods: Final year pharmacy students were trained and interviewed patients in community pharmacies as a required exercise in their pharmacy clerkship. Each student recruited a convenience sample of 5-10 patients who were on hypertension medication, and surveyed them regarding their BP targets, recent BP levels as well as monthly and home BP monitoring practices., Results: One third of the 449 patients interviewed were able to report a blood pressure target with 26% reporting a JNC 7 recognized target. Three quarters of patients who reported a blood pressure target were able to report a blood pressure level, with 12% being at their self-reported target. Roughly two thirds of patients perceived their BP to be "about right", and slightly less than a third thought it to be "high". Sixty percent of patients monitor their BP monthly, but less than 50% of patients practice home BP monitoring., Conclusions: This study along with others before it point to the knowledge and self-management gaps in patients with chronic conditions. Furthermore, pharmacy students were able to use a brief intervention to screen patients during routine care. Pharmacists can help improve patient understanding and promote increased self-management through regular BP monitoring.

Objectives: To determine whether pharmacy students who performed Diabetes Checks with patients have greater improvements in attitudes and behaviour regarding monitoring than students who performed a control activity. The Diabetes Check is a brief structured interaction that was designed to facilitate patient-pharmacist conversations about monitoring A1c, blood pressure and cholesterol (diabetes ABCs)., Methods: A randomized controlled trial was conducted where students in the intervention group performed five to ten Diabetes Checks. In the control group, students performed two drug-profile reviews for patients with diabetes. Students completed a pre- and post-assessment of the frequency of monitoring behaviour and attitudes, including self-efficacy, outcome expectancies, role beliefs (counselling role orientation and monitoring role orientation) and mattering. Improvements in behaviours and attitudes were assessed with bivariate and multiple linear regression. The study setting was University of Wisconsin-Madison School of Pharmacy and its affiliated Ambulatory Pharmaceutical Care Clerkship community pharmacies., Key Findings: Of 130 students, 119 (92%) completed surveys at both time points. Students who completed the Diabetes Check intervention had greater improvements in the frequency of monitoring patients' A1c values and in their counselling role orientation than control group students., Conclusions: The Diabetes Check improved pharmacy students' monitoring behaviour and general counselling beliefs. The Diabetes Check is a practical intervention to get patients and pharmacy students working together to monitor diabetes and potentially improve patient health.

Purpose: This research explores predictors of pharmacy students' adoption of one specific behavior, monitoring diabetes ABCs (A1c, blood pressure, and cholesterol) in the community pharmacy. Specifically, this research assessed which student situation and attitudinal factors are predictors of students' intentions and behavior in asking patients about the diabetes targets and goals as per a conceptual model., Methods: Data was drawn from a randomized controlled trial to assess the impact of the diabetes check in pharmacy students during their community pharmacy clerkships. A survey measured students' self-efficacy, outcome expectancies, role beliefs, mattering as well as students' experiences with the Diabetes Check and intentions to routinely monitor diabetes. Stepwise hierarchical multiple linear regression reflected the conceptual model and was used to assess the research questions., Results: Survey response rate was 94% and analysis was performed on a sample of 118 students. In summary, pharmacy students' intentions and monitoring behaviors were predicted by the students' situation and attitudes. Specifically, students' intentions to ask patients about the diabetes ABCs were predicted by pharmacy site counseling, monitoring role beliefs, self-efficacy, and positive outcome expectancies. Mattering predicted intentions, but differently in each study group. Behavior in asking about patients with diabetes about blood pressure and cholesterol was predicted by pharmacy site counseling, self efficacy, and monitoring role beliefs. Students' behavior in asking about A1c was pharmacy site counseling, self efficacy, and monitoring role beliefs in additional to completing the Diabetes Check assignment., Conclusions: Monitoring intentions and behaviors were consistently predicted by pharmacy site counseling, monitoring role beliefs, and self-efficacy and future research investigating the pharmacists' behavior should include these variables. The role of mattering and outcome expectancies in predicting monitoring intentions requires further study.

Background: Pharmacy students in the community setting are ideally situated to help patients monitor chronic diseases; however, their beliefs toward monitoring patients' health are not known., Objectives: Study objectives are to identify relevant survey constructs and survey measures about monitoring beliefs, establish their psychometric properties, and describe students' beliefs about monitoring., Methods: Four constructs that assess pharmacy students' monitoring beliefs were identified through literature review and pilot research: self-efficacy, outcome expectancies, role beliefs, and mattering. Measures of each construct were adapted or developed. The psychometric properties of each scale were evaluated in fourth year pharmacy students. A confirmatory factor analysis (CFA) was used to provide evidence for the factor structure of the scales and validity. Internal consistency reliability was assessed with Cronbach's alpha. Finally, students' responses were described., Results: The response rate was 94% (119 of 127 students). A CFA revealed that a 5-factor model with the elimination of 2 questions was a better fitting model than the originally proposed 4-factor model. Reliability was good for scales except the negative outcome expectancies. Overall, students had positive attitudes toward their monitoring role and were "rather sure" they could routinely monitor., Conclusions: Evidence was provided for the psychometric properties of new measures of monitoring specific self-efficacy, outcome expectancies, and monitoring role orientation, as well as a new measure of general mattering for pharmacy. These instruments have the potential to help pharmacy practice researchers assess pharmacy students' and ultimately pharmacists' beliefs about monitoring.

Objectives: To determine the proportion of patients with diabetes mellitus who knew their personal and target glycosylated hemoglobin (AIC), blood pressure, and low density lipoprotein cholesterol (LDL-C) (ABC) levels and the proportion of patients whose recalled ABC levels were below targets set by the American Diabetes Association (ADA)., Design: Cross-sectional survey., Setting: 35 community and clinic pharmacies in May 2003 through May 2004., Participants: 132 student pharmacists in Ambulatory Pharmaceutical Care Clerkship who recruited a convenience sample of 816 evaluable patients with diabetes., Intervention: Student-administered questionnaires., Main Outcome Measures: Patients' self-reported and target ABC values and comparison of these with recommended ADA guidelines., Results: The greatest number of patients were able to recall their personal blood pressure level (68%), followed by A1C (53%) and LDL-C (23%). Of those who knew their levels, one-half or fewer were within ADA targets for one or more ABCs. Only 1% of patients who were able to provide ABC levels were below all three ADA target values. Patients were most likely to provide an A1C target (43%), followed by blood pressure (35%) and LDL-C (21%)., Conclusions: While almost three-quarters of the patients identified in community pharmacies knew their blood pressure levels, one-half or fewer knew their A1C or LDL-C levels. Fewer than 50% of patients reported even one ABC target number. Pharmacists should take advantage of this educational opportunity by working with patients with diabetes to increase their knowledge of these ABCs.

Objective/background: Aboriginals constitute a substantial portion of the population of Northern Alberta. Determinants such as poverty and education can compound health-care accessibility barriers experienced by Aboriginals compared to non-Aboriginals. A diabetes care enhancement study involved the collection of baseline and follow-up data on Aboriginal and non-Aboriginal patients with known type 2 diabetes in two rural communities in Northern Alberta. Analyses were conducted to determine any demographic or clinical differences existing between Aboriginals and non-Aboriginals., Methods: 394 diabetes patients were recruited from the Peace and Keeweetinok Lakes health regions. 354 self-reported whether or not they were Aboriginal; a total of 94 self-reported being Aboriginal. Baseline and follow-up data were collected through interviews, standardized physical assessments, laboratory testing and self-reporting questionnaires (RAND-12 and HUI3)., Results: Aboriginals were younger, with longer duration of diabetes, more likely to be female, and less likely to have completed high school. At baseline, self-reported health status was uniformly worse, but the differences disappeared with adjustments for sociodemographic confounders, except for perceived mental health status. Aboriginals considered their mental health status to be worse than non-Aboriginals at baseline. Some aspects of health utilization were also different., Discussion: While demographics were different and some utilization differences existed, overall this analysis demonstrates that "Aboriginality" does not contribute to diabetes outcomes when adjusted for appropriate variables.

Objectives: To evaluate a structured patient intervention, the Diabetes Check, in which pharmacy students ask patients with diabetes about 3 clinical targets: A1c, blood pressure, and low-density lipoprotein (LDL) cholesterol (ABC) levels. Specific objectives were to: (1) describe the effect of patients' reactions on pharmacy students; (2) describe pharmacy students' confidence and role beliefs; and (3) determine predictors of pharmacy students' intention to use the Diabetes Check in the future., Methods: After training, pharmacy students were asked to perform 10 diabetes checks and complete an evaluation. Data from the evaluations described pharmacy students' reactions, role beliefs, and confidence. Linear regression was performed to predict intention of using the Diabetes Check in future., Results: One-hundred twenty-eight pharmacy students used the Diabetes Check tool with over 1000 patients. Most pharmacy students were encouraged by patients' reactions (56%). Pharmacy students' perceptions of patients' reaction and pharmacy students' role beliefs about monitoring ABCs significantly predicted pharmacy students' reported intention to use a Diabetes Check (r-squared = 0.52)., Conclusions: Pharmacy students' perceptions of patient reactions and role beliefs about the importance of monitoring predicted their reported intention of performing a Diabetes Check in the future.

Background: There is a need to describe how role theory has been used by researchers to describe various phenomena in pharmacy so as to identify gaps in knowledge and future research priorities., Objective: The primary purpose of this article is to review how role theory has been used in the community pharmacy literature. Secondary objectives are to (1) examine the use of role theory over the evolution of the profession of pharmacy, (2) determine what role theory perspectives have been used, (3) explore the implications of role theory for patient-pharmacist interactions, and (4) explore implications for future pharmacy research using role theory., Methods: A literature search of Web of Knowledge and International Pharmaceutical Abstracts was conducted. Articles were included if they examined some aspect of role theory in community pharmacy and were categorized based on their role theory perspective and "era" of pharmacy in which they were published., Results: Thirty research articles were identified spanning from 1956 to 2004 with the majority (19 studies) using mail surveys. Articles used functionalist (9 studies), organizational (7), functional and organization (4), cognitive (10), and symbolic interactionist (1) perspectives to role theory. The number of articles using role theory has been increasing over time. The functional and symbolic interactionist perspectives provide rich descriptions of the multiple pharmacy roles and allow for a clearer understanding of the barriers affecting actors' experience. Using an organization perspective, role stressors such as role conflict, ambiguity, and overload were found to impact pharmacists' worklife. Cognitive role theory research has clearly shown that pharmacists' and patients' expectations for the encounter shape interaction., Conclusions: The use of role theory informs both researchers and practitioners about the practice of pharmacy and patient interactions. Still, there is much work to be done in role theory and pharmacy research. Experimental designs, longitudinal studies, and qualitative research methodologies may warrant greater use and attention. Role change should be identified as a priority, and research is needed to elucidate what interventions change patients' and pharmacists' expectations of the patient-pharmacist interaction.

Objective: The aim of this study was to examine patient-reported outcomes in a controlled trial of a multifaceted provider-level intervention to improve quality of care for rural patients with type 2 diabetes., Research Design and Methods: We conducted a before/after intervention study with concurrent controls in two rural regions in Alberta, Canada. The intervention consisted of six monthly visits by a multidisciplinary health care team and was primarily directed at primary care providers. Clinical and patient-reported outcomes were assessed after 6 months. Patient-reported outcomes included changes in health-related quality of life (Health Utilities Index Mark 3 [HUI3]), satisfaction with care, lifestyle (Diabetes Lifestyle Form), and adherence to self-care activities. Analysis of covariance was used to assess differences over time between the control and intervention regions., Results: A total of 200 intervention and 172 control subjects were included in this analysis. After adjusting for important clinical and demographic differences, a statistically significant and clinically important improvement in the overall HUI3 score was seen at the 6-month follow-up in the intervention region (0.06 [95% CI 0.02-0.10]) compared with the control region (0.01 [-0.04 to 0.04]) (P = 0.03 for the difference between groups). Satisfaction with general medical care (P < 0.001 between groups) and diabetes care (P < 0.001 between groups) increased among patients in the intervention region compared with the control region. Self-efficacy, attitudes, and beliefs about diabetes control all increased in the intervention region when compared with the control region, but adherence to self-care activities did not., Conclusions: A provider-level intervention directed at improving quality of clinical care for patients with type 2 diabetes also had a favorable impact on overall health-related quality of life, satisfaction with care, and other humanistic outcomes.

Background: There were a reported 2.2 million Canadians living with diabetes mellitus (DM) in 2002, of whom 1.98 million (90.0%) had type 2 DM. In addition, there are approximately 60,000 new cases of type 2 DM diagnosed in Canada each year. However, the research shows that evidence and guidelines for management of hypertension in DM are not always translated into clinical practice. In rural areas, factors affecting implementation of recommendations and/or guidelines are less well understood, although some studies suggest that urban practices provide higher quality of care overall than rural areas., Objective: The goal of this study was to describe the patterns of medication use for hypertension for patients with type 2 DM in rural northern Alberta, Canada. We also tried to identify treatment gaps and opportunities for prescribing antihypertensives relative to the Canadian Diabetes Association's 1998 Clinical Practice Guidelines for the Management of Diabetes in Canada and the Canadian Hypertension Society Recommendations Working Group's 2003 Canadian Recommendations for the Management of Hypertension: Therapy., Methods: This study was conducted at the Institute of Health Economics and the University of Alberta (Edmonton, Alberta, Canada). We collected information from a cohort of patients aged >or =20 years with type 2 DM living in 2 adjacent rural regions of northern Alberta, Canada, at the time of enrollment in a diabetes care quality-improvement program as part of the Diabetes Outreach Van Enhancement (DOVE) study. Treatment gaps were determined by comparing antihypertensive pharmacotherapy with a blood pressure (BP) target of < or =130/< or =85 mm Hg. We used multivariate regression analyses to determine the associations between sociodemographic and clinical characteristics and treatment gaps., Results: A total of 392 patients (229 women, 164 men; mean [SD] age, 62.3 [12.5] years) with type 2 DM were included in this analysis. Patients had a mean (SD) duration of diabetes of 8.3 (8.5) years. A total of 75.8% (297/392) of the study population had hypertension, and most (236/392[60.2%]) were receiving some pharmacotherapy. Treatment gaps were present; 42.7% (n = 67) of patients not receiving pharmacotherapy for hypertension were above the established BP targets. For patients receiving monotherapy, 70% were not at BP targets. For patients receiving dual, triple, and > or =4 medications, 65%, 66%, and 46%, respectively, were not at BP targets. After controlling for systolic blood pressure, male sex (adjusted odds ratio [aOR], 2.17; 95% CI, 1.17-4.03), older age (aOR, 1.80 per decade; 95% CI, 1.51-2.09), lower self-reported physical health (aOR, 0.68; 95% CI, 0.41-0.96), higher body mass index (aOR, 1.05; 95% CI, 1.01-1.10), and past/current smoking (aOR, 1.95; 95% CI, 1.01-3.76) were all significantly associated with a lack of treatment for hypertension., Conclusions: Treatment maps in the management of hypertension exist in these rural Canadian patients with type 2 DM. Cardiovascular risk may be underestimated in these patients, particularly among younger patients and women, and those with multiple non-DM risk factors. These are patient subgroups that should be targeted as opportunities to improve hypertension management at the population level.

Background: Patients with type 2 diabetes mellitus (DM) have a markedly increased risk of cardiovascular morbidity and mortality. Guidelines of both the American and Canadian Diabetes Associations recommend the use of aspirin as antiplatelet therapy for all adults with type 2 DM., Objectives: The aims of this study were to assess the rate of adherence to guidelines for aspirin use in DM patients in rural Canadian communities and to describe the independent correlates of aspirin use in this population., Methods: We collected information from a cohort of patients with type 2 DM living in 2 rural regions of northern Alberta, Canada, at the time of their enrollment in a multidisciplinary outreach program designed to improve their quality of care. Our primary outcome was self-reported use of antiplatelet therapy (aspirin or others). We use multivariate logistic regression analyses to examine the independent association between sociodemographic and clinical characteristics and self-reported use of antiplatelet agents., Results: Among 342 patients included in the study (who were typical of rural Canadian patients with type 2 DM), the mean age was 62.9 years; 149 (44%) were men, 84 (25%) were of indigenous origin, and the median time since diagnosis of DM was 8 years. Despite guideline recommendations, only 23% of the cohort (78 patients) were regularly taking aspirin alone or in combination with a thienopyridine (n = 74 and n = 2, respectively) or a thienopyridine alone (n = 2). The results of them ultivariate analyses showed that the only factors independently associated with the use of antiplatelet therapy were symptomatic coronary artery disease (adjusted odds ratio [AOR], 3.1; 95% CI, 1.1-8.7; P=0.033 ), older age (AOR, 2.0 per 10-year interval; 95% CI, 1.7-2.2; P<0.001 ); and male sex (AOR, 1.9; 95% CI, 1.1-3.5; P=0.026 )., Conclusions: Aspirin is a safe, inexpensive, and readily available therapy that is effective for preventing cardiovascular disease, and patients with type 2 DM are particularly likely to benefit from such preventive therapy. However, we found significant underuse of aspirin therapy among our study population. Aspirin should be included and better promoted as a factor in high-quality, evidence-based DM management.

Objective: Despite good evidence and clinical practice guidelines, studies document that treatment of type 2 diabetes is less than optimal. Lack of resources or limited access may put patients in rural communities at particular risk for suboptimal care., Research Design and Methods: We conducted a prospective, before/after study with concurrent controls to assess the effectiveness of a multidisciplinary diabetes outreach service (intervention) for improving the quality of care for rural patients with type 2 diabetes. Our intervention consisted of six monthly visits by a traveling team of specialist physicians, nurses, dieticians, and a pharmacist. The core of this service was specialist-to-rural primary care physician academic group detailing. Two comparable regions in Northern Alberta were randomly allocated to control or intervention. Data were collected before and 6 months after intervention in a representative volunteer sample. The primary outcome was a 10% improvement in any one of the following: blood pressure, total cholesterol, or HbA(1c)., Results: Our analysis included 200 intervention and 179 control subjects; 14 subjects were at all three primary outcome targets at baseline. The intervention was associated with a trend toward improvement in primary outcome at 6 months (44% intervention vs. 37% control; odds ratio 1.32, 95% CI 0.87-1.99). The intervention was associated with a significant improvement in blood pressure (42% intervention vs. 25% control, P = 0.004); however, there were only small, nonsignificant changes in cholesterol or HbA(1c). The intervention was associated with a significant increase in satisfaction with diabetes care. Multivariate adjustment for baseline differences between intervention and control subjects did not affect any of the main results., Conclusions: A diabetes outreach service has the potential to improve the quality of diabetes care for rural patients. Future studies need to involve longer timelines and larger sample sizes.

The level of compliance with clinical practice guidelines for patients with type 2 diabetes was evaluated in 368 patients from two health regions in rural northern Alberta, Canada. Data were collected from patient interviews, drug histories, physical and laboratory assessments, and a self-report questionnaire to assess clinical status, indicators of diabetes management, and health care utilization. Treatment of three clinical indicators of diabetes--hemoglobin A1c (A1C), blood pressure, and low-density lipoprotein cholesterol (LDL)--has been shown to reduce the morbidity and mortality associated with type 2 diabetes. Mean +/- SD values for this cohort of patients were as follows: A1C 7.25% +/- 1.54%, blood pressure 131.7 +/- 18.2/76.2 +/- 12.7 mm Hg, and LDL 105.2 +/- 32 mg/dl. Despite these results, only 10.4% of the patients met all three recommended targets for control of glycemia: A1C below 7%, blood pressure below 130/85 mm Hg, and LDL below 100 mg/dl. Of patients not at target levels, 14.4%, 27.5%, and 86.7% reported receiving no therapy for hyperglycemia, hypertension, and dyslipidemia, respectively. Of those taking oral hypoglycemic agents who were not at target levels, only 35% were receiving combination therapy. Of patients at or above LDL target levels, 87% were not receiving any therapy. Only 22% of patients were taking aspirin, although this therapy would be recommended for the entire cohort according to clinical practice guidelines. Despite the availability of proved effective therapies, treatment gaps were present for this cohort of patients.

The authors determined the safety and efficacy of recombinant high-dose interleukin-2 administration in patients with brain metastases. This retrospective review included 1,069 patients with metastatic melanoma or renal cell carcinoma who received high-dose interleukin-2 alone or in combination with other immunotherapy or chemotherapy from July 1985-July 2000. All patients were evaluated for both toxicity and response. Only the first exposure to interleukin-2 was considered. Parameters evaluated among the groups included toxicity profiles, reasons for stopping treatment, number of interleukin-2 doses per cycle, and response to therapy. Three patient groups were compared. Group I (n = 27) comprised patients with previously treated brain metastases (surgery or radiation), group 2 (n = 37) comprised patients with untreated brain metastases, and group 3 (n = 1,005) comprised patients without brain metastases. For most comparisons between patients with brain metastases and those without, no significant differences were noted in toxicity profiles or reasons for stopping interleukin-2 therapy. Patients with previously treated brain metastases received fewer interleukin-2 doses per cycle (median, 6.5) than patients with previously untreated brain metastases (median, 7.5) or patients without brain metastases (median, 7.5). Patients with previously treated brain metastases demonstrated an 18.5% overall clinical response to interleukin-2 treatment. However, patients with evaluable (previously untreated) brain metastases had an overall 5.6% response rate, which was less than the 19.8% response rate of patients without brain metastases. Two of thirty-six patients with evaluable brain metastases demonstrated objective regression of intracranial and extracranial disease after receiving interleukin-2. Carefully selected patients with brain metastases can safely receive high-dose interleukin-2, and some can experience a response to treatment at intracranial and extracranial disease sites.