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An exploration and evaluation of the work processes of accredited pharmacists performing Home Medicines Reviews in the Australian communityMarea Patounas BPharm MPS AACPA
IF49 PhD Student
UHREC Ethics Approval 1400000561
Supervisors:
Prof Lisa NissenDr Esther LauProf Greg KyleMs Debbie RigbyDr Vincent Chan
Outline
• Background
• Significance of PhD project
• Research aims
• Research design & methods
• Results – interviews, national survey
• Research dissemination
2
Learning Objectives
3
After completing this activity pharmacists should be able to:
• Describe a recent systematic review of clinical medication reviews in
Australia
• Explain issues and problems reported by patients about pharmacists
performing Home Medicines Reviews in Australia
• Describe a human factors framework for studying and improving the work
of healthcare professionals and patients – SEIPS 2.0 Model
Superpolypharmacy and the complexity of healthcare
4
Photo courtesy of M Patounas
The term “medication review” encompasses a continuum of processes in
various formats and complexities
5
From: PSA Guidelines to providing Home Medicine Review (HMR) Services. 2011.http://www.psa.org.au/downloads/practice-guidelines/home-medicines-review-services.pdf
Types and locations of Medication Reviews in Australia
Community:
Home Medicines Review
Hospital
Approved Aged Care Facilities
(RMMR)
Community:
MedsCheck, Diabetes
MedsCheck
6
PhD project –
accredited
pharmacists
(APs)
Jokanovic N, Tan EC, van den Bosch D, Kirkpatrick CM, Dooley MJ, Bell JS. Clinical medication review in Australia: A
systematic review. Res Social Adm Pharm. 2016;12(3):384-418. https://www.ncbi.nlm.nih.gov/pubmed/26250049
7
Medication Reviews – what does the literature say?
Problems with HMR pharmacist work processes
• Failure to :
– clearly identify themselves at the start of the home interview
– clearly set the scene with the main purpose of the interview
– have structure within the home interview process
– engage in discussion & address patient needs
– inform the patient of the fact that the HMR Report would be sent to the GP
• Laptop in home interview may not be well perceived by patients Carter SR, Moles R, White L, Chen TF. The impact of patients’ perceptions of the listening skills of the pharmacist on their
willingness to re-use Home Medicines Reviews: a structural equation model. Research in Social and Administrative Pharmacy.
2015;11(2):163-75. https://www.ncbi.nlm.nih.gov/pubmed/?term=The+impact+of+patients%E2%80%99+perceptions+of+the+listening+skills+of+the+pharmacist+on+their+willingness+to+re-use+Home+Medicines+Reviews
8
Ahn J, Park JE, Anthony C, Burke M. Understanding, benefits and difficulties of home medicines review. Australian
Family Physician. 2015;44(4):249-53. https://www.ncbi.nlm.nih.gov/pubmed/?term=Understanding%2C+benefits+and+difficulties+of+home+medicines+review
Extract:
• “Participants who received the shortest reviews felt their HMR was 'a complete waste of time.' (P:3) In their
limited time they felt they simply received no information.
– 'She [the pharmacist] came here, she sat right where you're sitting...and said that's all, have a good day.
And off she went.' (P:3)
• They engaged in no discussion and were given dismissive responses to their questions.
– 'I didn't get any answers. Everything was fine.' (P:4)
• In addition to these pharmacists being brief, they were also described as being inattentive, which added to
the participants' dissatisfaction.
– 'She [the pharmacist] was a bit blasé. Her person was there but like nothing inside. She was empty. Like
a shell...
– It was like she had other places to be and she wanted to get it over and done with.' (P:4) .”
9
Ahn J, Park JE, Anthony C, Burke M. Understanding, benefits and difficulties of home medicines review Australian Family
Physician. 2015;44(4):249-53.
Problems with HMR pharmacist work processes
Problems with HMR Reports
• Majority of HMR Reports unexceptional in format & content
– 13 / 110 (11.8%) particularly good layout, 3 / 110 (2.7%) poor layout
– 7 / 110 (6.4%) remarkably good content, 11 / 110 (10%) poor content
• No mandated guidelines on HMR Report structure
– APs may choose to subscribe to software companies
– E.g. Medscope, MediFlags
10
Sorensen L, Stokes JA, Purdie DM, Woodward M, Elliott R, Roberts MS. Medication reviews in the community: results of a randomized,
controlled effectiveness trial. British Journal of Clinical Pharmacology. 2004;58(6):648-64.
Data analysis techniques
11Ickowicz E, Amer Geriatrics Soc Expert P. Patient‐Centered Care for Older Adults with Multiple Chronic Conditions: A Stepwise
Approach from the American Geriatrics Society. Journal of the American Geriatrics Society. 2012;60(10):1957-68.
A Stepwise Approach from the American Geriatrics Society
Pharmacists in society - changing paradigm (Mossialos et al. Health Policy 2013)
Lim
ite
d fu
nctio
ns Retailing of
productsDispensing
Compounding
Retailing
Ad
ditio
na
l fu
nctio
ns Safety Monitoring
Focus on medication-related adverse events
Co
mp
reh
en
siv
e r
ole Public Health
Role Promotion, Prevention and Disease Management
12
Significance of research
Research Aims
1. What are AP’s work processes in the 3 stages of HMR work system:
I. Pre-interview (preparation)
II. Home interview stage (with the patient)
III. Post-interview stage (collation of findings & recommendations into
a HMR report for the patient’s GP)
2. What time is required to complete a HMR?
– What time is required for the 3 stages of HMR?
13
The stages of HMR process for this research project (Steps 1, 2 and 3)
14
GP
Initiates HMR Referral; &
receives completed HMR
Report; Management Plan
back to APStage 1:
Pre-Interview(Information
gathering)
Stage 2:
Home Interview
Stage 3: Post
Interview (Clinical decision making & HMR
Report preparation)
Collaboration with patient and/or
carer and others linked with
patient's care such as community
pharmacist
Home Medicines Reviews – 3 “Stages”
What do accredited pharmacists do when performing HMRs?
How much time is involved with their HMR work?
How to gather information to answer the research question/s?
1. Perspectives
– Focus Groups, Interviews, Surveys
2. Examine artefacts
– HMR reports, other documents of practice
3. Observe HMR practice in real time
– Non-participatory observation
– Time and motion studies
– Audio recording of patient-pharmacist conversation15
Triangulation
of research
methods
PhD extended Project – multiphase study
Focus Groups
• 2 Focus Groups – uncover broad themes
• 10 accredited pharmacist participants
Interviews
• Semi-structured Interviews – in-depth
• 15 accredited pharmacist participants
Survey
• National e-survey via QUT Key Survey
• 255 accredited pharmacist participants
Artefacts
• Examination of accredited pharmacist artefacts
• HMR Reports
Observation
• Non-participatory observation & audio recording of in-home patient-pharmacist conversation
16
Participants, recruitment & sample size
17
Study Recruitment
Method
Data collection
method
Number of AP
Participants
HMR Practice Location
Focus
Group 1
Purposive,
professional
networks
Face-to-face:
Audio recording &
live scribe
6 Brisbane & North/South
Coast areas
Focus
Group 2
Purposive,
professional
networks
Face-to-face:
Audio recording &
live scribe
4 Brisbane
Semi-
structured
Interviews
Purposive,
professional
networks,
snowball
sampling
Face-to-face (1) &
via phone (14),
with audio recording –
average time 90
mins
15 Brisbane, south-east,
regional & far north
Queensland; &
Regional & remote NSW
Survey Convenience
sampling
Electronic –
QUT Key Survey255 ACT 1% SA 11%
NSW 36% Tas 4%
NT 1% Vic 20%
Qld 17% WA 10%
Data Analysis
18
19
Holden RJ, Carayon P, Gurses AP, Hoonakker P, Hundt AS, Ozok AA, et al. SEIPS 2.0: a human factors framework for studying
and improving the work of healthcare professionals and patients. Ergonomics. 2013;56(11):1669-86.
https://www.ncbi.nlm.nih.gov/pubmed/24088063
What do
accredited
pharmacists
DO?
PhD project –
accredited
pharmacists
(APs)
RESULTS: Quotes: TIME
20
It just depends on how hard
your - how long is a piece of
string?
How hard do you want to look at
the pathology reports? Just from my own personal point of
view, that interests me, so I will sit
there a bit longer.
I probably spent an hour and a half
this afternoon looking and
background medical reading as
well about the patient’s condition,
yeah.
How long is a piece of string?
sometimes it can really blow out,
especially if they have got a lot of
medicines and you have got trouble
getting them back on track
And it is longer if you have got a
carer. The interview takes longer
when there is a carer there.
In some ways what is happening in the
rest of their life can be relevant to what
is happening for them. Hearing about
their social situation --
may be keys to
something else as well.
Quotes – ‘Grouping via Disease vs Working Down the List”
Researcher:
“Do you have a particular order or process by which you interview the patients about
each medicine?
I know you said you mainly go by disease groups. Is there a particular order that you
interview them about each one?”
Participant:
“Not really. I'd probably pick the top guys first, so I'd do diabetes,
cardiovascular and pain. Then I would add in GORD, GIT - but yes, the top three for me would
be cardiovascular, diabetes and pain. That's what - they would be my targets first and then bring the other
two in and see what trickles out.
It depends on the patient. Like if I'm dealing with an MS patient, I'm probably more talking about
continence and that. But I do do a lot of work with recommending other practitioners for things
like continence management and that too. So some patients I will say to them you could visit a
physiotherapist who specialises in continence management or a physiotherapist who specialises in pain
management, I've told her, or whatever. I touch on that with the patient, but I tend to dress that more
firmly in my report to the GP.”21
“GROUPING VIA DISEASE vs WORKING DOWN THE LIST”
Quotes – PERSONAL SAFETY• “There might be weird pictures of guns or horrible stuff and you're kind of like, oh my gosh, and
you're thinking, how the hell am I going to get out of here if I have to? I've had a few things like that.”
• “The Aboriginals, they're always a totally different ballgame for millions of different reasons. It's a miracle that you can do an HMR if they're at home if they turn up, because they can even ring up and do that sort of thing. Generally the home environments are catastrophic, they're distracted, some of them are cognitive impaired, they've got a million people in the house, they're selling drugs in the house. I've been attacked by dogs, all sorts of funny things. You've got somebody else with you as well. Generally I tend not to hear much back from the patient, or the doctor for that reason. There's probably less - whether that's because often you do the HMR and they don't even go back to see the doctor.”
• “A lot of people are bit embarrassed about their house and certainly I've had the cockroaches crawl across me. I've watched mice run across the floor. I've had cats and dogs doing all sorts of -animals jumping on me. So you know and just houses full of smoke and grot, but it's a lot nicer sometimes to actually sit outside. But it can get a bit awkward when they haven't actually got all their medicines out and they're just slowly traipsing back in and out of the house to get the [puffers] and get the extra things out. So you don't get that same thing of being sitting in the kitchen or wherever where you can actually see where the medications are stored.”
22
Quotes: PERSONAL SAFETY
Quotes – MOTIVATION TO BECOME ACCREDITED• “I think it is more the contact with people and the ability to use a lot of those clinical skills that
you learned at uni that you wouldn’t necessarily use in a pharmacy working day-to-day so more
chance to actually use your clinical knowledge.”
• “It seemed like an exciting opportunity. I think I was taken up in the - as P5 said, it was an
exciting time that the role of a pharmacist was potentially going to change. There was an
opportunity and you needed to grab that and do that extra bit of work in order to become
accredited, in order to ride the wave, more or less.
It was get on - you had to take the step to get in there. I think it was just exciting and it is good
when you feel that you are going to be part of that team and striving for really great
outcomes for the patient. Yeah, yeah.”
• “To be challenged clinically and just apply - seeing patients - because I was in a role where I
wasn’t seeing patients. I was working part-time in the community just casually and kept that up.
When I first started at the practice the principal said, ‘P2, I am really enjoying seeing patients. I love
that’. He said, ‘It is good for the soul’, and I thought, it sure is so that’s why I did it. It sounds a bit
idealistic, doesn’t it? “23
Quotes: MOTIVATION TO BECOME ACCREDITED
PERSONAL
SAFETY
COGNITIVE
FRAMEWORK
Concept map – emergent themes Study 1 & 2
PROVIDING
VALUE TO
PATIENT
CARE
PRE-INTERVIEW
HOME
INTERVIEW
POST-
INTERVIEW:
HMR REPORT
TIME
TIME
FEELING
SUCCESSFUL
DESPITE
BARRIERS
“FRAME A
PATIENT
PICTURE”
“PLAYING
SHERLOCK”
PERSON/S
TASKS
TOOLS &
TECHNOLOGY
ORGANISATION
INTERNAL & EXTERNAL
ENVIRONMENT
“GROUPING VIA
DISEASE vs
WORKING
DOWN THE
LIST”
TIMERUM
PROFESSIONAL
FRUSTRATION
Rapport &
trust
GP
MANAGEMENT
PLANFOLLOW-
UP
DRPs
Adherence
Med
Recon
Holden RJ et al. SEIPS 2.0: a human factors
framework for studying and improving the
work of healthcare professionals and
patients. Ergonomics. 2013;56(11):1669-86.
National Survey 2016 (n=255) Respondents’ Demographics
25
24
77
56
67
31
Age of Respondents
20-29 30-39 40-49 50-59 60+
181
74
0Gender of Respondents
Female Male x
26
Decade of Graduation
1950-59 2
1960-69 6
1970-79 35
1980-89 62
1990-99 51
2000-09 84
2010-2015 15
2
6
35
62
51
84
15
0
10
20
30
40
50
60
70
80
90
Nu
mb
er
of
Res
po
nd
ents
Year of BPharm Graduation
National Survey 2016 (n=255) Respondents’ Demographics
27
3
93
3
4529
10
53
26
Location of HMR practice in last year
ACT NSW NT Qld SA Tas Vic WA
National Survey 2016 – Respondents’ Demographics
132
70
69
8
Location of HMR practice in last year
Urban Rural
Regional Remote
Average time required to prepare for HMR:
PRE-INTERVIEW STAGEQUT National Survey - M Patounas n=255
28
119
72
41
15
6
2
0 20 40 60 80 100 120
0-30 mins
30-45 mins
45-60 mins
60-90 mins
90-120 mins
120 mins+
Number of Responses
Tim
e t
o p
rep
are
fo
r a
HM
R
0-30 mins 30-45 mins 45-60 mins 60-90 mins 90-120 mins 120 mins+
119 72 41 15 6 2
Survey Results: TIME to perform HMR
Average time required to perform
HOME INTERVIEW STAGE QUT National Survey - M Patounas n=255
29
5
59
120
65
6
0
0 20 40 60 80 100 120
0-30 mins
30-45 mins
45-60 mins
60-90 mins
90-120 mins
120 mins+
Number of Responses
Tim
e t
o in
terv
iew
pati
en
t d
uri
ng
HM
R
0-30 mins 30-45 mins 45-60 mins 60-90 mins 90-120 mins 120 mins+
5 59 120 65 6 0
Survey Results: TIME to perform HMR
Average time required:
POST-INTERVIEW STAGE
HMR Report preparation & provisionQUT National Survey – M Patounas n=255
30
4
42
102
69
31
7
0 20 40 60 80 100
15-30mins
30-60 mins
1-2 hrs
2-3 hrs
3-6 hrs
6+ hrs
Number of Responses
Tim
e to
pe
rfo
rm P
ost-
Inte
rvie
w S
tag
e o
f H
MR
15-30mins 30-60 mins 1-2 hrs 2-3 hrs 3-6 hrs 6+ hrs
4 42 102 69 31 7
Survey Results: TIME to perform HMR
Survey Responses – Personal Safetyn=255 QUT National Survey – M Patounas
31
Survey Responses –
Signing of Patient Privacy Notification Formn=255 QUT National Survey – M Patounas
32
Survey Responses – Technology and Toolsn=255 QUT National Survey – M Patounas
33
HMR practice: other health professionals contacted apart from doctors255 respondents, 507 responses; Source: QUT National Survey – M Patounas
34
65
18
43
14
166
36
21
92
117
34
0
20
40
60
80
100
120
140
160
180
I don't contactother HPs
Aboriginal andTorres StraitIslander HP
Dietitian Exercisephysiologist
Pharmacist Physiotherapist Podiatrist Practice Nurse Psychologist Social worker Other
Nu
mb
er
or
Re
so
ns
es
Other Health Professionals mainly contacted as part of HMR practice
Expected outcomes of extended PhD project
• Key contributions in knowledge:
– Accounting for HMR work processes from an AP perspective
– Describing thematic domains of APs’ HMR work processes
– Enumerating APs’ time required for the 3 stages of HMR
– Examination of APs’ “artefacts” – HMR Reports
– Observational analysis of home interview
• Essentially:
– Highlighting the contribution & significance of APs’ HMR work processes in healthcare
– Research in pharmacy practice is important for observing pharmacists’ effectiveness
and their contribution to the healthcare system and to patient health outcomes (PSA
Careers Guide 2015)
– “We must be prepared to critically review our practices, to meet changing
service provision contexts, respond to increased public expectations & health
policy directions” (Felicity J Smith. Conducting Your Pharmacy Practice Research Project 2nd ed)
35
Research Dissemination 2017 APSA-ASCEPT
https://eprints.qut.edu.au/115428/
36
APSA Conference 2017Home Medicines Reviews – exploring accredited pharmacists’ work processes
Marea Patounas1, Esther Lau1, Greg Kyle1, Debbie Rigby1, Lisa Nissen1, Vincent Chan2. Faculty of Health, School of Clinical Sciences, QUT1, Brisbane, QLD, Australia; RMIT University2, Melbourne, VIC, Australia.
Introduction. In healthcare, work processes shape patient, professional and organisational outcomes. Little is known about the specific tasks and activities that form the work processes of accredited pharmacists (APs) performing Home Medicines Reviews (HMRs) in Australia.
Aims. To explore APs’ work processes and the time taken to conduct the three stages of HMR: pre-interview (preparation phase); home interview (with the patient); and post-interview (collation of findings and recommendations into a HMR Report for the patient’s General Practitioner).
Methods. Focus groups and semi-structured interviews were conducted with Australian APs. Participants were recruited via professional pharmacy networks and organisations. The sessions were transcribed verbatim and thematically analysed using Leximancer and NVivo 11 software.
Results. There were 10 APs in the focus groups and 15 APs who participated in the semi-structured interviews. Participants for the two focus groups were from southeast Queensland, and interview participants ranged from urban, regional and far north Queensland, to northern regional and western regional New South Wales. The configural work system processes for each stage of HMR were categorised as: person, task, technology, organisation, and internal and external environment factors. The APs focussed on establishing rapport and trust with the patient as a top priority. The majority of APs spent an estimated 4 hours performing a HMR from beginning to end, with the majority of pre-interview, home interview and post-interview stages taking 30-60 minutes, 45-60 minutes and 1.5-2 hours respectively. Most HMR reports were 2-4 pages in length, although this varied depending on whether the AP worked from a home office or if they were a practice pharmacist (integrated into a clinic/practice setting).
Discussion. A detailed account of APs’ HMR tasks and work processes may be of practical value to medical home decision makers, funding bodies, professional organisations, educators and health professionals involved in medication reviews. Further investigation of APs’ work processes and the time taken to conduct HMRs is warranted.
APSA-ASCEPT Conference 2017 Abstract
https://eprints.qut.edu.au/115428/
Lifelong Learning in Pharmacy 2018 Abstract
38
Research Dissemination 2018 LLLP
39
FIP 2018 – HMRs and ADR reporting
FIP 2018 – HMRs and RUM
40
41
APSA Conference Abstract 2016
No of Pages
HMR Report
Response %
1 2%
2 40%
3 36%
4 19%
5 3%
6 <1%
https://eprints.qut.edu.au/101815/
What does HMR success look like to you?
QUT National Survey 2016 (n= 250) – M Patounas
42
Thank You to all the accredited pharmacists and AACP, PSA & SHPA who made this research possible!
https://eprints.qut.edu.au/view/person/Patounas,_Marea.html
Acknowledgments to Tony Hall, Hung Tran & QUT colleagues