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Background: There is an urgent need for health care systems to be more efficient and efficacious. An approach to integrate public and private provider organizations such as community pharmacies and public primary health care (PHC) merits consideration. The objective of this review was to identify the types of integration in health care settings and discuss their applicability to the potential integration of community pharmacy and PHC. Methods: A narrative review using Medline, Scopus and SciELO databases was performed in which terms related to health were combined with terms related to integration. Levels and Types of integration: 14 types of integration were identified (two in breadth, seven as enablers and five in system levels). A model was created which classifies and assigns the types of integration to the different levels of the health system and to the breadth, intensity, and enablers of the integration process. Due to the nature of community pharmacy and PHC system, a horizontal integration at the micro level, supported by meso and macro levels policy, is suggested. The different elements of intensity and enablers can significantly influence the process. Conclusion: The application of principles, concepts and types of integration suggest that it might be feasible and practical to integrate community pharmacies and PHC. However, the conflictive historical context would need to be overcome with appropriate policy and incentives., University of the Basque Country US20/08, Cinfa laboratories for the PhD scholarship

BackgroundImplementation factors are hypothesised to moderate the implementation of innovations. Although individual barriers and facilitators have been identified for the implementation of different evidence-based services in pharmacy, relationships between implementation factors are usually not considered.ObjectivesTo examine how a network of implementation factors and the position of each factor within this network structure influences the implementation of a medication review service in community pharmacy.MethodsA mixed methods approach was used. Medication review with follow-up service was the innovation to be implemented over 12 months in community pharmacies. A network analysis to model relationships between implementation factors was undertaken. Two networks were created.ResultsImplementation factors hindering the service implementation with the highest centrality measures were time, motivation, recruitment, individual identification with the organization and personal characteristics of the pharmacists. Three hundred and sixty-nine different interrelationships between implementation factors were identified. Important causal relationships between implementation factors included: workflow-time; characteristics of the pharmacy-time; personal characteristics of the pharmacists-motivation. Implementation factors facilitating the implementation of the service with highest centrality scores were motivation, individual identification with the organization, beliefs, adaptability, recruitment, external support and leadership. Four hundred and fifty-six different interrelationships were identified. The important causal relationships included: motivation-external support; structure-characteristics of the pharmacy; demographics-location of the pharmacy.ConclusionNetwork analysis has proven to be a useful technique to explore networks of factors moderating the implementation of a pharmacy service. Relationships were complex with most implementation factors being interrelated. Motivation and individual identification with the organisation seemed critical factors in both hindering and facilitating the service implementation. The results can inform the design of implementation programs and tailored strategies to promote faster implementation of innovations in pharmacy.

Pharmacy and pharmaceutical sciences embrace a series of different disciplines. Pharmacy practice has been defined as “the scientific discipline that studies the different aspects of the practice of pharmacy and its impact on health care systems, medicine use, and patient care”. Thus, pharmacy practice studies embrace both clinical pharmacy and social pharmacy elements. Like any other scientific discipline, clinical and social pharmacy practice disseminates research findings using scientific journals. Clinical pharmacy and social pharmacy journal editors have a role in promoting the discipline by enhancing the quality of the articles published. As has occurred in other health care areas (i.e., medicine and nursing), a group of clinical and social pharmacy practice journal editors gathered in Granada, Spain to discuss how journals could contribute to strengthening pharmacy practice as a discipline. The result of that meeting was compiled in these Granada Statements, which comprise 18 recommendations gathered into six topics: the appropriate use of terminology, impactful abstracts, the required peer reviews, journal scattering, more effective and wiser use of journal and article performance metrics, and authors’ selection of the most appropriate pharmacy practice journal to submit their work.

Background Cardiovascular diseases are the leading cause of death. Pharmacist-led medication review with follow-up might be cost-effective preventing cardiovascular diseases. Objective To undertake a cost–utility analysis of the addition of pharmacist-led medication review with follow-up to usual care compared to usual care alone for cardiovascular outpatients. Materials and methods A state-transition microsimulation model was built to project outcomes over a lifetime time horizon. Inputs from a cluster randomized controlled trial conducted in primary health care centers in Chile with full-time pharmacists were used. Probabilities were estimated using patient-level data. Utilities and costs associated with each health state were obtained from the literature, whereas the intervention costs were retrieved from the trial. The public third-party payer perspective was used. Uncertainty was evaluated through one-way and probabilistic sensitivity analyses. Results For the base case analysis, an incremental cost-effectiveness ratio of $963 per quality-adjusted life-year was observed which was considered cost-effective. The results were robust to sensitivity analyses and were driven by decreased cardiovascular events resulting in lower mortality. Conclusions Medication review with follow-up was deemed a cost-effective addition to usual care with low uncertainty.

Background Implementation research has delved into barriers to implementing change and interventions for the implementation of innovation in practice. There remains a gap, however, that fails to connect implementation barriers to the most effective implementation strategies and provide a more tailored approach during implementation. This study aimed to explore barriers for the implementation of professional services in community pharmacies and to predict the effectiveness of facilitation strategies to overcome implementation barriers using machine learning techniques. Methods Six change facilitators facilitated a 2-year change programme aimed at implementing professional services across community pharmacies in Australia. A mixed methods approach was used where barriers were identified by change facilitators during the implementation study. Change facilitators trialled and recorded tailored facilitation strategies delivered to overcome identified barriers. Barriers were coded according to implementation factors derived from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Tailored facilitation strategies were coded into 16 facilitation categories. To predict the effectiveness of these strategies, data mining with random forest was used to provide the highest level of accuracy. A predictive resolution percentage was established for each implementation strategy in relation to the barriers that were resolved by that particular strategy. Results During the 2-year programme, 1131 barriers and facilitation strategies were recorded by change facilitators. The most frequently identified barriers were a ‘lack of ability to plan for change’, ‘lack of internal supporters for the change’, ‘lack of knowledge and experience’, ‘lack of monitoring and feedback’, ‘lack of individual alignment with the change’, ‘undefined change objectives’, ‘lack of objective feedback’ and ‘lack of time’. The random forest algorithm used was able to provide 96.9% prediction accuracy. The strategy category with the highest predicted resolution rate across the most number of implementation barriers was ‘to empower stakeholders to develop objectives and solve problems’. Conclusions Results from this study have provided a better understanding of implementation barriers in community pharmacy and how data-driven approaches can be used to predict the effectiveness of facilitation strategies to overcome implementation barriers. Tailored facilitation strategies such as these can increase the rate of real-time implementation of innovations in healthcare, leading to an industry that can confidently and efficiently adapt to continuous change.

Background Community pharmacies provide an appropriate setting to deliver minor ailment services (MASs). Many community pharmacy services have been developed previously without stakeholder involvement. As a result, implementation of services may fail to produce the expected impact. The aim of this research was to co-design and test the feasibility of an Australian MAS for minor ailment presentations. Methods This study used co-design methodology which included two phases: (1) a focus group with stakeholders to allow the conceptualization of the service and agreement on service elements; (2) a literature review of clinical guidelines and three working meetings with a team of editors and general practitioners for the development of treatment pathways. Following this, a study evaluating the feasibility of the co-designed service was undertaken. The qualitative part of the methodology associated with the feasibility study comprised semi-structured interviews with MAS pharmacists, observation and completion of a tool by change facilitators identifying barriers and facilitators to service delivery. Qualitative data obtained for all phases were analysed using thematic analysis. Results The developed service included the following components: (i) an in-pharmacy consultation between the patient and pharmacist, (ii) treatment pathways accessible to pharmacists on the internet to guide consultations, (iii) existing digital communication systems used by general practice to exchange patient information, (iv) training, and (v) change facilitation. As a result of feasibility testing, twenty-six implementation factors were identified for practice change, with the main change being the simplification of the pharmacist-patient consultation and data collection processes. Conclusions An Australian MAS was generated as a result of co-design, while testing revealed that the co-designed service was feasible. As a result of integrating the views of multiple stakeholders, the designed MAS has been adapted to suit healthcare practices, which may increase the acceptance and impact of MAS when implemented into practice.

Many community pharmacists ideologically support recent changes to their roles in primary healthcare. However, their antithetical resistance towards practice change could have systemic causes (i.e. role stresses), which may account for increased job dissatisfaction, burnout, and job turnover in the profession. Deeper comprehension was sought using a role theory framework. Objective To identify factors leading to role stresses and strain responses for community pharmacists, and to create a framework for community pharmacist role management. Method PubMed, Scopus and Web of Science databases were searched for qualitative studies identifying community pharmacist role stress and strain using scoping review methodology from 1990 to 2019. Content and thematic analysis using the framework method was performed, and themes were reported using thematic synthesis. Results Screening of 10,880 records resulted in 33 studies identified, with 41 factors categorised into four domains: Interpersonal Interactions, Social Setting, Individual Attributes, and Extra-Role. All role stresses were present. Reported role strains suggest role system imbalance. Conclusion Community pharmacists are in a multifactorial transitional environment. Reported role stresses may be a function of past pharmacist roles and increased role expectations, amplified by many requisite interactions and individual pharmacist characteristics. Social science theories were found to be applicable to the community pharmacy setting.

OBJECTIVES To estimate medication noninitiation prevalence in the pediatric population and identify the explanatory factors underlying this behavior. METHODS Observational study of patients ( RESULTS Overall, 1 539 003 new prescriptions were issued to 715 895 children. The overall prevalence of 1-month noninitiation was 9.0% (ranging from 2.6% [oral antibiotics] to 21.5% [proton pump inhibitors]), and the prevalence of 6-month noninitiation was 8.5%. Noninitiation was higher in the youngest and oldest population groups, in children from families with a 0% copayment rate (vulnerable populations) and those with conditions from external causes. Out-of-pocket costs of drugs increased the odds of noninitiation. The odds of noninitiation were lower when the prescription was issued by a pediatrician (compared with a primary or secondary care clinician). CONCLUSIONS The prevalence of noninitiation of medical treatments in pediatrics is high and varies according to patients’ ages and medical groups. Results suggest that there are inequities in access to pharmacologic treatments in this population that must be taken into account by health care planners and providers.

Community pharmacies and pharmacists predominantly operate in a retail environment independently of other health care providers, and they are not often viewed as an integral member of the healthcare team. Thus, they remain overlooked or excluded during integration processes of health care systems. At the same time, there are calls by the profession at national and international levels for community pharmacy to be integrated within primary care systems. The COVID-19 pandemic appears to have further stimulated this desire. When pressing for integration, various terms, such as integration, integrated care, or interprofessional collaboration, are used in an interchangeable manner leading to lack of clarity, ambiguity and confusion for health care policy makers, planners, and other healthcare professionals. The literature was reviewed to identify critical components for community pharmacy to consider for integration. From the five selected articles describing integration of community pharmacies, four different constructs were identified: consensus, connectivity, communication and trust. The integration of community pharmacy into the health system may translate into better access for patients to primary care services, contribute to cost effectiveness, and promulgate the sustainability of the system. However significant political, economic, social, and practice change would be required by all stakeholders. Further research is needed to underpin a consensus for a definition, the type of integration, and the model optimally suited to integrate community pharmacy into primary care. These models, specific and adaptable to each national health care system and political environment, would need to be consensus-based by principal stakeholders to overcome a variety of barriers, including government resistance. Mere calls or demands by the pharmaceutical profession, although laudable, will not be sufficient to overcome the historical, cultural, and economic challenges.

This work was supported by a research grant from the Spanish Society of Community Pharmacy"and the Pharmaceutical Association of Valencia. Neither of these organisations influenced the study design, interpretation of data, writing of the manuscript, nor the decision to submit this manuscript for publication. The Pharmaceutical Association of Valencia assisted with initial selection of study locations and contacting community pharmacies., Background: Minor ailments are “self-limiting conditions which may be diagnosed and managed without a medical intervention”. A cluster randomised controlled trial (cRCT) was designed to evaluate the clinical, humanistic and economic outcomes of a Minor Ailment Service (MAS) in community pharmacy (CP) compared with usual care (UC). Methods: The cRCT was conducted for 6 months from December 2017. The pharmacist-patient intervention consisted of a standardised face-to-face consultation on a web-based program using co-developed protocols, pharmacists’ training, practice change facilitators and patients’ educational material. Patients requesting a non-prescription medication (direct product request) or presenting minor ailments received MAS or UC and were followed-up by telephone 10-days after the consultation. The primary economic outcomes were incremental cost-utility ratio (ICUR) of the service and health related quality of life (HRQoL). Total costs included health system, CPs and patient direct costs: health professionals’ consultation time, medication costs, pharmacists’ training costs, investment of the pharmacy and consultation costs within the 10 days following the initial consultation. The HRQoL was obtained using the EuroQoL 5D-5L at the time of the consultation and at 10-days follow up. A sensitivity analysis was carried out using bootstrapping. There were two sub-group analyses undertaken, for symptom presentation and direct product requests, to evaluate possible differences. Results: A total of 808 patients (323 MAS and 485 UC) were recruited in 27 CPs with 42 pharmacists (20 MAS and 22 UC). 64.7% (n = 523) of patients responded to follow-up after their consultation in CP. MAS patients gained an additional 0.0003 QALYs (p = 0.053). When considering only MAS patients presenting with symptoms, the ICUR was 24,733€/QALY with a 47.4% probability of cost-effectiveness (willingness to pay of 25,000€/QALY). Although when considering patients presenting for a direct product request, MAS was the dominant strategy with a 93.69% probability of cost-effectiveness. Conclusions: Expanding community pharmacists’ scope through MAS may benefit health systems. To be fully cost effective, MAS should not only include consultations arising from symptom presentation but also include an oversight of self-selected products by patients. MAS increase patient safety through the appropriate use of non-prescription medication and through the direct referral of patients to GP., Spanish Society of Community Pharmacy, Pharmaceutical Association of Valencia

© 2019, Springer-Verlag GmbH Germany, part of Springer Nature. Objectives: To evaluate the health economics evidence based on randomized controlled trials of pharmacist-led medication review in pharmacotherapy managed cardiovascular disease risk factors, specifically, hypertension, type-2 diabetes mellitus and dyslipidaemia in ambulatory settings and to provide recommendations for future evaluations. Methods: A systematic review was carried out according to the Cochrane Handbook for Systematic Reviews. PubMed (Medline), Scopus, Web of Science, National Health System Economic Evaluation Database (NHS EED), Cochrane Library, and Econlit were searched and screened by two independent authors. Incremental cost-effectiveness ratio was the main outcome. Risk of bias was assessed with the Effective Practice and Organisation of Care tool by the Cochrane Collaboration. Economic evaluation quality was assessed with the he Consensus Health Economic Criteria list (CHEC list). Results: 5636 records were found, and 174 were retrieved for full-text review yielding 11 articles. Eight articles deemed the intervention as cost effective and two as dominant. Two cost–utility analyses were performed yielding ICERs of $612.7 and $59.8 per QALY. Four articles were considered to perform a high-quality economic evaluation and four had a low risk of bias. Future economic evaluations should consider cost–utility analysis, to describe usual care thoroughly, and use time horizons that capture the effect of cardiovascular disease prevention, a societal perspective and uncertainty analysis. Conclusion: Pharmacist-led medication review has proven to be cost effective in various studies in different settings. Policy decision makers are advised to undertake local economic evaluations reflecting the gaps observed in this systematic review and published literature. If this is not possible, a transferability assessment should be conducted.

Background: Scarcity of prospective medication non-adherence cost measurements for the Australian population with no directly measured estimates makes determining the burden medication non-adherence places on the Australian health care system difficult. This study aims to indirectly estimate the national cost of medication non-adherence in Australia comparing the cost prior to and following a community pharmacy-led intervention. Methods: Retrospective observational study. A de-identified database of dispensing data from 20,335 patients (n=11,257 on rosuvastatin, n=6,797 on irbesartan and n=2,281 on desvenlafaxine) was analyzed and average adherence rate determined through calculation of PDC. Included patients received a pharmacist-led medication adherence intervention and had twelve months dispensing records; six months before and six months after the intervention. The national cost estimate of medication non-adherence in hypertension, dyslipidemia and depression pre- and post-intervention was determined through utilization of disease prevalence and comorbidity, non-adherence rates and per patient disease-specific adherence-related costs. Results: The total national cost of medication non-adherence across three prevalent conditions, hypertension, dyslipidemia and depression was $10.4 billion equating to $517 per adult. Following enrollment in the pharmacist-led intervention medication non-adherence costs per adult decreased $95 saving the Australian health care system and patients $1.9 billion annually. Conclusion: In the absence of a directly measured national cost of medication non-adherence, this estimate demonstrates that pharmacists are ideally placed to improve patient adherence and reduce financial burden placed on the health care system due to non-adherence. Funding of medication adherence programs should be considered by policy and decision makers to ease the current burden and improve patient health outcomes moving forward.

Background An international strategy designed to promote access to primary care is the utilisation of community pharmacy to deliver structured minor ailment services (MASs). An understanding of key implementation features of MASs will support effective service delivery and implementation, promote MAS viability, sustainability and overall improvement. Aim The aim of this study is to explore the views and experiences of a range of stakeholders concerning the implementation of MASs in the United Kingdom. Methods A qualitative approach was used to obtain data. Participants were recruited using purposeful and snowball sampling. Stakeholders from five different regions were included. Using the digital recordings of the interviews, thematic content analysis was undertaken. Results Thirty-three participants agreed to be interviewed. Twenty-nine semi-structured interviews were conducted. Thematic content analysis yielded three major themes, including (1) benefits of MASs, (2) structural challenges associated with MAS design and (3) other implementation factors associated with MAS delivery. Stakeholders recognised the positive impact of the service to improve patient access and care, promote efficiencies, and promote the professional role of the pharmacist. Nevertheless barriers do exist to service delivery and implementation. Stakeholders identified the need to potentially increase the population groups served by MASs, increase the conditions treated and widen their formulary lists. Similarly, marketing strategies needed to be improved to enhance consumer awareness. Stakeholders presented mixed views about whether pharmacists needed to complete clinical training and the need to increase pharmacist's remuneration. In addition the level of healthcare collaboration needed to improve. Conclusion Several concepts emerged from the investigation to facilitate service delivery. Barriers to service implementation had a variable impact on implementation. Service delivery should function to meet all stakeholder needs and can be achieved through stakeholder collaboration. However, improved marketing to promote consumer awareness together with better collaborative processes can potentially improve MAS implementation.

Background Poor medication adherence is associated with adverse health outcomes and higher costs of care. However, inconsistencies in the assessment of adherence are found in the literature. Objective To evaluate the effect of different measures of adherence in the comparative effectiveness of complex interventions to enhance patients' adherence to prescribed medications. Methods A systematic review with network meta-analysis was performed. Electronic searches for relevant pairwise meta-analysis including trials of interventions that aimed to improve medication adherence were performed in PubMed. Data extraction was conducted with eligible trials evaluating short-period adherence follow-up (until 3 months) using any measure of adherence: self-report, pill count, or MEMS (medication event monitoring system). To standardize the results obtained with these different measures, an overall composite measure and an objective composite measure were also calculated. Network meta-analyses for each measure of adherence were built. Rank order and surface under the cumulative ranking curve analyses (SUCRA) were performed. Results Ninety-one trials were included in the network meta-analyses. The five network meta-analyses demonstrated robustness and reliability. Results obtained for all measures of adherence were similar across them and to both composite measures. For both composite measures, interventions comprising economic + technical components were the best option (90% of probability in SUCRA analysis) with statistical superiority against almost all other interventions and against standard care (odds ratio with 95% credibility interval ranging from 0.09 to 0.25 [0.02, 0.98]). Conclusion The use of network meta-analysis was reliable to compare different measures of adherence of complex interventions in short-periods follow-up. Analyses with longer follow-up periods are needed to confirm these results. Different measures of adherence produced similar results. The use of composite measures revealed reliable alternatives to establish a broader and more detailed picture of adherence.

We explore, from the perspective of primary care health professionals, the motivations that lead patients to not initiate prescribed treatments, by developing a qualitative study in Spanish primary care. Six focus groups (N = 46) were conducted with general practitioners, nurse practitioners, social workers and community pharmacists and carried out in primary care (PC) of Barcelona Province, from April to July of 2018. The 46 participants were identified by three general practitioners and two pharmacists. In the interviews, the reasons for non-initiation of PC patients' medication were explored. Triangulated content analysis was performed. Patients' perspective, analysed in a previous study, and professionals' perspective agree on most of the factors that affect non-initiation. New factors were categorized into existent categories, confirming, and supplementing the model developed with patients. Health professionals identified some new factors which were not present in the patients' discourse, such as stigma related to the drug, hidden reasons for consultation, the role of nurses in prescription and support, the role of the pharmacy technician, illiteracy and lack of social support. The professionals confirm and expand on the Theoretical Model of Medication Non-Initiation. Primary care professionals should consider the factors described when prescribing a new medication. Knowledge contributed by the model should guide the design of interventions to improve initiation.

This project was funded and supported by Laboratorios Cinfa., Background Non-adherence to medications continues to be a burden worldwide, with significant negative consequences. Community pharmacist interventions seem to be effective at improving medication adherence. However, more evidence is needed regarding their impact on disease-specific outcomes. The aim was to evaluate the impact of a community pharmacist-led adherence management intervention on adherence and clinical outcomes in patients with hypertension, asthma and chronic obstructive pulmonary disease (COPD). Methods A 6-month cluster randomised controlled trial was conducted in Spanish community pharmacies. Patients suffering from hypertension, asthma and COPD were recruited. Patients in the intervention group received a medication adherence management intervention and the control group received usual care. The intervention was based on theoretical frameworks for changing patient behaviour. Medication adherence, disease-specific outcomes (Asthma Control Questionnaire (ACQ) scores, Clinical COPD Questionnaire (CCQ) scores and blood pressure levels) and disease control were evaluated. A multilevel regression model was used to analyse the data. Results Ninety-eight pharmacies and 1186 patients were recruited, with 1038 patients completing the study. Patients receiving the intervention had an OR of 5.12 (95% CI 3.20 to 8.20, p, Laboratorios Cinfa

Aim: To assess the trial-based cost–effectiveness of medication review with follow-up compared with usual care in primary care. Materials & methods: A cluster randomized controlled trial included patients if they were independent older adults, receiving five or more prescriptions, with moderate or high cardiovascular risk. Costs were estimated from the public healthcare sector perspective, and health benefits were measured as quality-adjusted life years. Both of which were used to calculate the incremental cost–effectiveness ratio. Results: Twelve centers completed the study, six (146 patients) in the intervention group and six (145 patients) in the control group. The base-case analysis showed an incremental cost–effectiveness ratio of US$ (2019) 434.4/quality-adjusted life year (95% CI 64.20–996.03). Conclusion: The intervention was cost-effective in the public primary care setting.

Background Implementation of Professional Pharmacy Services (PPSs) requires a demonstration of the service’s impact (efficacy) and its effectiveness. Several systematic reviews and randomised controlled trials (RCT) have shown the efficacy of PPSs in patient’s outcomes in community pharmacy. There is, however, a need to determine the level of evidence on the effectiveness of PPSs in daily practice by means of pragmatic trials. To identify and analyse pragmatic RCTs that measure the effectiveness of PPSs in clinical, economic and humanistic outcomes in the community pharmacy setting. Methods A systematic search was undertaken in MEDLINE, EMBASE, the Cochrane Library and SCIELO. The search was performed on January 31, 2020. Papers were assessed against the following inclusion criteria (1) The intervention could be defined as a PPS; (2) Undertaken in a community pharmacy setting; (3) Was an original paper; (4) Reported quantitative measures of at least one health outcome indicator (ECHO model); (5) The design was considered as a pragmatic RCT, that is, it fulfilled 3 predefined attributes. External validity was analyzed with PRECIS- 2 tool. Results The search strategy retrieved 1,587 papers. A total of 12 pragmatic RCTs assessing 5 different types of PPSs were included. Nine out of the 12 papers showed positive statistically significant differences in one or more of the primary outcomes (clinical, economic or humanistic) that could be associated with the following PPS: Smoking cessation, Dispensing/Adherence service, Independent prescribing and MTM. No paper reported on cost-effectiveness outcomes. Conclusions There is limited available evidence on the effectiveness of community-based PPS. Pragmatic RCTs to evaluate clinical, humanistic and economic outcomes of PPS are needed.

Cancer is one of the leading causes of death globally and with worldwide increases in life expectancy, the incidence and mortality for most cancers is expected to increase. While surgery and radiation therapy remain the first-line treatment for many cancers, pharmacotherapy has always been an important therapeutic option, especially in the management of locally advanced or metastatic disease. Traditionally, chemotherapy has been the primary pharmacotherapeutic approach used in the treatment of cancer; however, as our knowledge and understanding of cancer pathophysiology have advanced, new treatment options have been developed. Identification of tumor biomarkers and other molecular targets has driven the development of new pharmacotherapeutic options, namely immune- and biological pharmacotherapies, which are now used either in combination with chemotherapy or as monotherapy in the current practice for cancer treatment. In this chapter, we consider and explore the pharmacotherapies currently used worldwide in clinical practice for the treatment of the five most common cancers: lung, female (breast), prostate, colon, and skin.

The AdherenciaMED project was supported by the General Pharmaceutical Council of Spain through funds provided by Cinfa Laboratories. The sponsor did not have any role in the design, methods, protocol of the study, data collection and analysis. The provider pharmacists did not receive any remuneration for their participation in the study., Background: It is necessary to determine the cost utility of adherence interventions in chronic diseases due to humanistic and economic burden of non-adherence. Purpose: To evaluate, alongside a cluster-randomized controlled trial, the cost-utility of a pharmacist-led medication adherence management service (MAMS) compared with usual care in community pharmacies. Materials and Methods: The trial was conducted over six months. Patients with treatments for hypertension, asthma or chronic obstructive pulmonary disease (COPD) were included. Patients in the intervention group (IG) received a MAMS based on a brief complex intervention, whilst patients in the control group (CG) received usual care. The cost–utility analysis adopted a health system perspective. Costs related to medications, healthcare resources and adherence intervention were included. The effectiveness was estimated as quality-adjusted life years (QALYs), using a multiple imputation missing data model. The incremental cost–utility ratio (ICUR) was calculated on the total sample of patients. Results: A total of 1186 patients were enrolled (IG: 633; CG: 553). The total intervention cost was estimated to be €27.33 ± 0.43 per patient for six months. There was no statistically significant difference in total cost of medications and healthcare resources per patient between IG and CG. The values of EQ-5D-5L at 6 months were significantly higher in the IG [IG: 0.881 ± 0.005 vs CG: 0.833 ± 0.006; p = 0.000]. In the base case, the service was more expensive and more effective than usual care, resulting in an ICUR of €1,494.82/QALY. In the complete case, the service resulted in an ICUR of €2,086.30/QALY, positioned between the north-east and south-east quadrants of the cost–utility plane. Using a threshold value of €20,000/QALY gained, there is a 99% probability that the intervention is cost-effective. Conclusion: The medication adherence management service resulted in an improvement in the quality of life of the population with chronic disease, with similar costs compared to usual care. The service is cost-effective., General Pharmaceutical Council of Spain, Randox Laboratories

Aim To evaluate the clinical and humanistic patient outcomes of a community pharmacy (CP) Minor Ailment Service (MAS) compared to usual pharmacist care (UC). Methods A cluster randomised controlled trial was conducted over six months in CP. The pharmacist-patient intervention consisted of a standardised consultation on a web-based program using co-developed protocols pharmacists’ training, practice change facilitators and patients’ educational material. Patients were followed up ten days after initial consultation. Primary outcomes were appropriate medical referral and changes to direct product request. Secondary outcomes were symptom resolution, reconsultation rates for the same ailment and health related quality of life (HRQoL). Results A total of 808 patients were recruited by 27 CP (323 MAS and 485 UC). Patients visiting MAS pharmacies had higher odds for being referred to the general practitioner (OR=2.343, CI95%=[1.146-4.792]); a higher increase in HRQoL (OR=1.026, CI95%=[1.002-1.051]) and higher number of reconsultation (OR=1.833, CI95%=[1.151-2.919]) compared to UC. No significant differences were observed for symptom resolution and modification of treatments with direct product requests. Conclusions Patients with minor ailments are triaged and managed in a safe and effective way in CP, facilitating appropriate self-selection of non-prescription medicines. MAS reinforce pharmacists’ involvement with patient engagement.

Across the globe, pharmacists on the frontline continue to fight COVID-19 and its continuously evolving physical, mental, and economic consequences armed by their knowledge, professionalism, and dedication. Their need for credible scientific evidence to inform their practice has never been more urgent. Despite the exponentially increasing number of publications since the start of the pandemic, questions remain unanswered, and more are created, than have been resolved by the increasing number of publications. A panel of leading journal editors was convened by the International Pharmaceutical Federation (FIP) Pharmacy Practice Research Special Interest Group to discuss the current status of COVID-19 related research, provide their recommendations, and identify focal points for pharmacy practice, social pharmacy, and education research moving forward. Key priorities identified spanned a wide range of topics, reflecting the need for good quality research to inform practice and education. The panel insisted that a foundation in theory and use of rigorous methods should continue forming the basis of inquiry and its resultant papers, regardless of topic area. From assessing the clinical and cost effectiveness of COVID-19 therapies and vaccines to assessing different models of pharmaceutical services and education delivery, these priorities will ensure that our practice is informed by the best quality scientific evidence at this very challenging time.

Background Strategies to improve medication adherence are widespread in the literature; however, their impact is limited in real practice. Few patients persistently engage long-term to improve health outcomes, even when they are aware of the consequences of poor adherence. Despite the potential of mobile phone apps as a tool to manage medication adherence, there is still limited evidence of the impact of these innovative interventions. Real-world evidence can assist in minimizing this evidence gap. Objective The objective of this study was to analyze the impact over time of a previously implemented digital therapeutic mobile app on medication adherence rates in adults with any chronic condition. Methods A retrospective observational study was performed to assess the adherence rates of patients with any chronic condition using Perx Health, a digital therapeutic that uses multiple components within a mobile health app to improve medication adherence. These components include gamification, dosage reminders, incentives, educational components, and social community components. Adherence was measured through mobile direct observation of therapy (MDOT) over 3-month and 6-month time periods. Implementation adherence, defined as the percentage of doses in which the correct dose of a medication was taken, was assessed across the study periods, in addition to timing adherence or percentage of doses taken at the appropriate time (±1 hour). The Friedman test was used to compare differences in adherence rates over time. Results We analyzed 243 and 130 patients who used the app for 3 months and 6 months, respectively. The average age of the 243 patients was 43.8 years (SD 15.5), and 156 (64.2%) were female. The most common medications prescribed were varenicline, rosuvastatin, and cholecalciferol. The median implementation adherence was 96.6% (IQR 82.1%-100%) over 3 months and 96.8% (IQR 87.1%-100%) over 6 months. Nonsignificant differences in adherence rates over time were observed in the 6-month analysis (Fr(2)=4.314, P=.505) and 3-month analysis (Fr(2)=0.635, P=.728). Similarly, the timing adherence analysis revealed stable trends with no significant changes over time. Conclusions Retrospective analysis of users of a medication adherence management mobile app revealed a positive trend in maintaining optimal medication adherence over time. Mobile technology utilizing gamification, dosage reminders, incentives, education, and social community interventions appears to be a promising strategy to manage medication adherence in real practice.

ObjectivePharmacists have been increasing patient-focused care through the implementation and provision of professional services. However, there is a lack of evidence on how to achieve long-term sustainability of the service once it is implemented. A framework identifying the factors affecting the sustainability of professional pharmacy services was developed. The objectives of this study were to explore the experiences of community pharmacists providing professional services to contextualize and assess the applicability in practice of the sustainability framework.MethodsA qualitative study was undertaken across Australia. Community pharmacists were identified using snowball sampling. Data were collected through semistructured interviews. Eighteen interviews were conducted and analyzed using framework methodology in NVivo 12 (QSR International).ResultsA range of major sustainability factors was identified and organized in social, economic, and environmental domains. In the social domain, most of the interviewees stated the importance of motivating staff to increase service promotion and patients' demand. Most of the participants emphasized that having an adequate number of trained staff is required to enhance and maintain services over time. The perceived reluctance of some patients to spend more time than usual at the community pharmacy was another factor highlighted as affecting service sustainability. In the economic domain, the concern about lack of remuneration for service provision was highlighted by most of the interviewees. Having economic support was seen as essential for achieving sustainable services. In the environmental domain, the necessity of government recognition of the pharmacists' role and value to the health care system was identified as a new key sustainability driver.ConclusionThe applicability of the framework for the sustainability of professional services was evaluated in practice. The identified factors will guide pharmacists to maintain implemented services and achieve their sustainability. Future research should focus on designing a tool to measure the sustainability of pharmacy services.

BackgroundCommunity pharmacists are well positioned to support patients’ minor ailments. The objective was to evaluate the clinical and humanistic impact of a minor ailment service (MAS) in community pharmacy compared with usual pharmacist care (UC).MethodsA cluster randomised controlled trial was conducted. Intervention patients received MAS, which included a consultation with the pharmacist. MAS pharmacists were trained in clinical pathways and communication systems mutually agreed with general practitioners and received monthly support. Control patients received UC. All patients were followed up by telephone at 14 days. Clinical and humanistic impact were defined by primary (appropriate referral rate and appropriate non-prescription medicine rate) and secondary outcomes (clinical product-based intervention rate, referral adherence, symptom resolution, reconsultation and EuroQol EQ-5D visual analogue scale (VAS)).ResultsPatients (n=894) were recruited from 30 pharmacies and 82% (n=732) responded to follow-up. Patients receiving MAS were 1.5 times more likely to receive an appropriate referral (relative rate (RR)=1.51; 95% CI 1.07 to 2.11; p=0.018) and were five times more likely to adhere to referral, compared with UC (RR=5.08; 95%CI 2.02 to 12.79; p=0.001). MAS patients (94%) achieved symptom resolution or relief at follow-up, while this was 88% with UC (RR=1.06; 95% CI 1 to 1.13; p=0.035). MAS pharmacists were 1.2 times more likely to recommend an appropriate medicine (RR 1.20, 95% CI 1.1 to 1.3; p=0.000) and were 2.6 times more likely to perform a clinical product-based intervention (RR=2.62, 95% CI 1.28 to 5.38; p=0.009), compared with UC. MAS patients had a greater mean difference in VAS at follow-up (4.08; 95% CI 1.23 to 6.87; p=0.004). No difference in reconsultation was observed (RR=0.98; 95% CI 0.75 to 1.28; p=0.89).ConclusionThe study demonstrates improved clinical and humanistic outcomes with MAS. National implementation is a means to manage minor ailments more effectively in the Australian health system.Trial registration numberACTRN12618000286246.