Impacts on practice

  • The support of Medication Use Review starts in local working environments, where managers have to proactively approach and provide more suitable work organization, which will facilitate provision of MUR.

  • Low recognisability of the medication review service has to be approached with the use of comprehensive strategy to get different stakeholders on board with the service.

  • Pharmacy practice should provide opportunities for continuous education of MUR providers on the theoretical level as well as practical approaches based on experience sharing.

Introduction

Since the concept of pharmaceutical care emerged in the 1990s, pharmacists have been exploring new ways to provide the best care for patients [1, 2]. Services provided by pharmacists, using their skills and knowledge to take an active role in contributing to patient health through effective interaction with both patients and other health professionals are generally known as cognitive pharmaceutical services [3, 4]. Cognitive pharmaceutical services encompass different types and models of services, but in the last decade medication review services have been at the forefront as the most discussed and explored services among researchers and pharmacy practitioners [4,5,6,7,8,9]. The Pharmaceutical Care Network Europe (PCNE) officially defines medication review as a structured evaluation of a patient’s medicines with the aim of optimizing their use and improving the patient’s health outcomes. This review entails detecting drug-related problems (DRPs) and recommending interventions [10]. Based on the type of information available to evaluate a patient’s medicines, three types of medication review are proposed: simple (1), intermediate (2a, 2b), and advanced (3) [10, 11]. Two medication review services have been implemented in Slovenia, Medicines Use Review (MUR) and clinical medication review. MUR represents a harmonisation of several activities that were already being performed in Slovenian pharmacies. It is classified as a type 2a review and focuses on the patients and their experiences with medicine use. The aim of the service is to provide adherence support and monitoring as well as to improve proper use of an individual’s medicines and knowledge about them [10, 12]. The service was officially adopted by the Slovene Chamber of Pharmacies in December 2014 as a standard operating procedure for MUR (SOP MUR) [13]. In addition, the definition of the service was included in the renewed Pharmacy Practice Act, which was passed in December 2016 [14]. An educational program was established along with the SOP for MUR to ensure pharmacists’ competencies for MUR provision. The program consists of an entry online examination and a one-day seminar (addressing SOP MUR, communication skills, and role play). Afterwards, each candidate manages five real-life cases under mentorship and undertakes a final examination [15]. The first group of pharmacists (15) were certified in June 2015, after which they implemented the service in their local practices [16]. The current number of certified MUR providers surpasses 100, which means that approximately 10% of Slovenian community pharmacists are eligible to provide the service (data obtained from the Slovene Chamber of Pharmacies).

Implementation of medication review services represents a next step in Slovenian pharmacy practice and its contribution in the transition to more patient-oriented health care and toward achieving better health outcomes. Two approaches can describe changing a system: ISLAGIATT (“it seemed like a good idea at the time”) or implementation research [17, 18]. The nature of ISLAGIATT is intuitive and random, while implementation research emphasizes good knowledge and an understanding that the factors influencing implementation of the services are as important as the evidence for their effectiveness and potential benefits [17,18,19,20]. The main idea is to establish how and why something works in a real-world setting by seeking different stakeholders’ views on it, establishing facilitators and barriers in the translation process and acting or at least following up on them [18, 20]. In order to support the implementation of MUR in the Slovenian health care system in a more systematic and comprehensive way, we performed a set of studies to gain insights on MUR from different stand points (providers, patients, pharmacy owners/founders, etc.), starting with an exploration of the impressions, experiences and views from the first certified MUR providers.

Aim

The aim of our study was to gain insight into the implementation of MUR in Slovenia from the perspectives of the first community pharmacists certified to provide the service in practice.

Ethics approval

The study was part of a larger research project on implementation of MUR in Slovenia. Ethics approval was given by the Republic of Slovenia National Medical Ethics Committee (NMEC) in February 2016 (No. 0120-025/2015-2; KME 55/02/16).

Methods

A focus group was conducted in February 2016, 6 months after the first pharmacists were certified to provide MUR service and started providing MUR in practice.

Selection of participants

In June 2015, 15 community pharmacists were certified in the first round of MUR education course. To make the focus group feasible and to include only one representative per institution we invited 10 of them for which we have also assured they were providing the service in practice after certification. Purposive sampling technique [21] was used with the aim to get an insight into the variation of pharmacists’ views and opinions, considering regional distribution of pharmacies, type of community pharmacy (public pharmaceutical institutions and concessionary, privately owned pharmacies) and personal characteristics [22]. At the end, seven pharmacists attended the discussion, two from concessionary pharmacies. Three pharmacists (2 from public and 1 from concessionary pharmacy) excused themselves due to personal reasons, not related to the study. Pharmacists were invited via email, where the aim and process of the focus group (including audio recording) were explained.

Development of the framework for discussion

Prior to the meeting the framework for discussion was designed to cover three major topics: ensuring competencies for MUR provision, identifying barriers and facilitators in providing MUR in practice and identifying opportunities for future improvement of the service (Appendix). The framework was based on research questions and experiences of the research team: a PhD student researching implementation of cognitive pharmaceutical services in Slovenia, an experienced community pharmacist who is eligible to provide MUR, and a senior researcher with a research background in pharmacy practice and pharmaceutical care with experiences in qualitative methodology and approaches. The latter two have been actively involved in the process of developing the concept of pharmaceutical cognitive services in Slovenia, including all elements of MUR service provision (education, certification and SOP). No other theories, frameworks or models were used in the development of the framework for discussion.

The focus group meeting

The meeting was held at the Faculty of Pharmacy. The discussion was predicted to last 1.5 h, and an audio recording was made, with written consent obtained from all participants before the beginning. The senior researcher moderated the discussion, using predefined open-ended questions or statements, followed by sub-questions if needed. The other two research members assisted as observers and note takers and were not included in the discussion.

Qualitative analysis approach and presentation of results

The recording was transcribed verbatim by one researcher and afterwards the qualitative content-analysis approach was used to elicit meaning from the responses. Qualitative content analysis facilitates contextual meaning in text through the development of emergent themes derived from contextual data, a process is known as coding. Significant themes emerge from similar responses repeated by multiple participants [23]. In current study the inductive approach was applied with following steps taken in QSR International NVivo 11 Pro software [24]. Firstly, the whole verbatim transcript was analysed sentence by sentence, which resulted in the generation of several themes or “free nodes”. Secondly, in the process known as “nesting”, themes (free nodes) were formulated into categories (tree nodes) and further on placed under the main categories, generating three levels of results. The coding process was performed independently by each research team member. Afterwards, we held a research group meeting where we discussed the results, resolved any disagreements and finalized the structure of categories, sub-categories and underlying themes.

For presentation of the results in the international literature we translated generated main and sub-categories as well as participants quotes in English with the use of informal (colloquial) language to reflect the actual type of language used during the discussion. The translation was performed by the research team.

To ensure adequate reporting of the study process and findings, consolidated criteria for reporting qualitative research (COREQ) were followed [25].

Results

Participants characteristics

Seven community pharmacists participated in the focus group, 6 females and one male in the age range 25–40 years. Five of them have been working in community pharmacies, which were part of public pharmaceutical institution and 2 have been employed in concessionary pharmacies. Majority had 5–10 years working experiences, with the least experienced having 2 years of working experiences. Among them 5 finished or were in the process of postgraduate training, mainly specialization to become clinical pharmacists (4) and one with a PhD. All of them were proactive pharmacists, recognized in their working environments, representing regional centres of MUR in Slovenia.

Results of the qualitative content analysis

A total of 364 different themes (free nodes) were derived from the transcript analysis. These themes were organized into 10 tree nodes (sub-categories), which were then grouped into three main categories as presented in Fig. 1.

Fig. 1
figure 1

The mind map represents 10 sub-categories (oval shapes around the circles) and 3 main categories (circles), which were generated in the second and third-level coding (“nesting” process). Each sub-category is in the same format (colouring and borders) as the corresponding main category. Percentages (%) next to the 3 main categories show the proportion of different identified themes (free nodes) included in a category

Full size image

Quality assurance of MUR

More than half of coded themes (54.4%) were categorized as quality assurance items, which addressed pharmacists’ competencies for MUR provision as well as the competencies of other health care workers.

Pharmacotherapy and correct use of medicines

Participants emphasized that the quality of MUR service is based on broad knowledge in pharmacotherapy and correct use of medicines. In their opinion those factors are pharmacists’ key competencies and represent advantages in performing MUR compared with other health care professions.

“We [pharmacists] are the most competent when it comes to the correct use of medicines. I don’t think any other profession has that much knowledge in medicines use.”

Pharmacists 1

“A lot of knowledge in pharmacotherapy is expected, to repeat and to deepen. This is our main tool. It gives you self-confidence.”

Pharmacists 2

Education and competencies

In this regard training for MUR provision had provided them with appropriate directions, especially mentorship was highlighted as a valuable experience.

It was good [the training]. The procedure and systematic approach to the conversation with a patient, how to start, …

Pharmacist 3

The approach was different, which was great. The work on real-life cases with the mentor’s help, someone you could turn to.

Pharmacist 4

As knowledge fades, continuous education is needed to provide quality service. The proposed means of education were advanced pharmacotherapy courses and regular meetings in which practical cases are discussed and experiences can be shared.

“It is good to have somebody you can consult with.”

Pharmacist 1

I miss something like that [workshop]. At least once a year to gather together solving cases… To see how others tackle problems…

Pharmacist 5

Identification of drug related problems and communication

Beside the knowledge, identification of DRPs and appropriate communication with physicians were noted as two elements for quality provision.

“You have to be able to identify [DRPs], react and direct him [the patient] further.”

Pharmacist 2

“In my opinion the key component in communication with the doctors is not to tell them only the problem, but also the solution.

Pharmacist 1

Perceptions of different stakeholders regarding MUR

Marketing approach

A general idea permeating the discussion was the need for appropriate and comprehensive marketing of the service to enhance the recognisability of MUR among other stakeholders—patients, doctors and other health care professions, the pharmacists’ own working environments and payer.

“Comprehensiveness [in approach]; so that the pharmacists, people and doctors would recognise it.”

Pharmacist 5

Patient

Positive patient feedback and satisfaction were reported and presented as encouragement for future work. However, persuading patients to attend MUR is challenging, and this problem needs to be overcome by raising awareness of service among patients and the public. According to participants’ experiences, the best way to raise awareness is to spread satisfied patients’ stories.

“In regard to the patients it is well accepted. After MUR the patient proclaims you for his personal pharmacist. I think this is great!”

Pharmacist 3

“I see the biggest problem in persuading them [patients] to attend MUR – when I present and explain the service, they are excited; but when I want to arrange the meeting they say that they will stop by when they will have the time.”

Pharmacist 6

“They [patients] got recommendation from somebody else who attended MUR. This is the best promotion.”

Pharmacist 4

Other healthcare professions (physicians)

Furthermore, lack of interest among patients relates to low recognisability and acknowledgement of MUR among physicians. Participants felt that it is essential to present MUR systematically as a nationwide service, not just as a local idea.

“Communication with doctors is a problem… and it is transferred to the patients as they trust the doctor above all and they fear what the doctor will say…”

Pharmacist 2

“I believe the service has to be properly presented. They [doctors] see it as a competition, meddling in their work, which MUR is not.”

Pharmacist 4

Fellow pharmacists

Although positive examples were shared, several exposed misunderstandings and a lack of support among fellow pharmacists and management for implementation of MUR in the participants’ work environments.

“Colleagues have great understanding. They don’t bug me or think of MUR as a waste of time. When it’s time for MUR it’s time and they make it possible for me to perform it.”

Pharmacist 1

“At the end of the day the pile of prescription is what counts the most and how much profit you made. And that is a disaster.”

Pharmacist 3

“I think the management is mostly interested in how we will pay for it. For my co-workers I believe they need some time to see things can change.”

Pharmacist 5

Health care payer

Last but not least, recognition of the service by the health care payer was emphasized and linked to recognition and support among other previously mentioned stakeholders. A reimbursed service would mean better conditions for performing MUR, but it goes hand in hand with resolving other issues (e.g., the number of employees, having evidence of benefits of the service).

“If the payer supports us, then also doctors will and we will be performing more.”

Pharmacist 3

To evaluate benefits [of such service]. To produce results.

Pharmacist 2

“I think finances are the key. That you can employ enough pharmacists, some are performing MUR, while others dispense medicines and patients don’t have to wait in line while you talk to one of them for half an hour.”

Pharmacist 7

Management of MUR provision

The management of MUR provision contained statements addressing facilitators and barriers to organizational aspects affecting efficient provision of the service.

Special time for MUR and work organization in the pharmacy

Sufficient time to perform MUR was identified as the main barrier, which could be overcome by suitable work organization and designated times for MUR. Many pharmacists were performing MUR in whole or in part outside their working hours.

“… lack of time. We are understaffed, plus misinterpretation from my co-workers. It looks like I am wasting time by talking to someone for half an hour, like we have a debate class …”

Pharmacist 3

“I wish I would have regular time in which I would perform MUR, a day in a week or couple of hours every day, when I would take the time.”

Pharmacist 5

“Everything, except the conversation [with the patient], in my free time.”

Pharmacist 2

Work organization of other health care professions

Beside work organization in the pharmacy, doctors’ work organization presented a challenge when the service was implemented locally. MUR could lighten doctors’ work load if they would refer the patient to certified pharmacists for in-depth counselling about correct use of medicines.

“Other healthcare workers also have time management issues. I personally presented the new service to a doctor. She was excited, but there was no other effect [patient referrals to MUR] out of it.”

Pharmacist 4

Discussion

Pharmacists reported overall positive experiences with implementation and provision of MUR in practice. In their opinion, quality provision of MUR is based on a high level of knowledge about pharmacotherapy and the use of medicines, which results in identification of DRPs and suggestions for solving them. To achieve and sustain MUR, continuous education, experiences sharing, and good communication are crucial. Since recognisability of MUR among different stakeholders is low, a comprehensive approach to marketing the service is needed for it to become routine and sustainable. In addition to raising recognition, improved work organization and time management have to be established.

Comparison with the existing literature

Several studies exploring MUR services through the eyes of pharmacists have been published [26,27,28,29,30,31,32,33,34,35,36]. Our study identified similar facilitators (e.g. patient satisfaction, extending professional role) and barriers (e.g. lack of time, financing, poor recognition), and it therefore supports the concepts already presented in the cited literature. Given that the Slovenian MUR service was based on the British model and most of the published literature originates from the United Kingdom (UK) or Australia, the similarities are expected. However, research on different implementation research frameworks [20, 37,38,39] has established that “the content” is only one part in the translation process and other factors have to be taken into account. In our case, a different country with a different health care system [40], therefore different pharmacy professional background and development [22], as well as other involved stakeholders explain some divergence from other reports.

The educational programme to gain MUR competency

In contrast to the UK [26, 28, 33, 41, 42], the education course to gain MUR competency (particularly the mentorship system) was well accepted in Slovenia. Participants felt reassured and more confident, knowing they have somebody to consult with if they encounter a problem. Moreover, the idea of regular meetings to share experiences and work on practical cases emerged from positive mentorship experiences. However, participants desired more pharmacotherapy-based course work in the program. Given that pharmacotherapy is perceived as the main tool, competency and confidence builder, the suggestion is understandable. However, it raises the question of how this desire reflects on the image of pharmacist as the expert in the field, and more importantly, how pharmacists perceive the nature of MUR. A similar question was raised in the qualitative research of Khideja 2009 [43] and Connelly [44]. Explaining to patients in a lay manner how to correctly use their medicines may seem like an easy task, but deep pharmacotherapy knowledge may result in using expert jargon that impedes achieving this aim [45, 46]. Therefore, proper communication skills are crucial, however during our discussion, communication skills were mainly addressed with regard to other medical professionals, especially doctors. Communication with patients was only touched on, although the issue of convincing them to attend MUR was established as a major barrier and is a point in favour of adding more communication content to the course. The low expressed need for this content might be explained by participants already being experienced community pharmacists, who talk with patients daily and therefore feel their communication with them is adequate. Furthermore, reasons for low patient attendance rates are broader than solely pharmacists’ motivational and persuading skills [28], anyhow an assessment of this factor was not the objective of our study.

Remuneration of the service

As previously mentioned, implementation of MUR in Slovenia followed the British model. An exception is that MUR is not (yet) a remunerated service in Slovenia. In the eyes of our participants, the lack of remuneration presented a major issue, connected with recognition among all other stakeholders, especially management in their own pharmacies. Financing and money are commonly recognized as facilitators or barriers in the implementation of cognitive pharmaceutical services even though published data supports the reimbursement as one of the steps toward reaching sustainable service [3, 19, 31, 47, 48]. Our study adds to the existing evidence, showing similar challenges are met despite reimbursement being present. The adoption of MUR in UK, for instance, tackled challenges comparable to those identified in our study, including understaffing, unsuitable work organization, low support among co-workers and pressure to fulfil targeted numbers [27, 31, 33]. The only challenge mentioned for the UK and not brought up in our discussion was ensuring privacy [31, 49, 50], which was probably due to legal requirements obligating each pharmacy in Slovenia to have a private consultation area [51]. Although reimbursement and health-care payer were perceived as important factors in raising MURs’ recognition, participants expressed that other points are as much important, especially suitable work organization and establishing evidence of service benefits beforehand. The latter could be corroborated with participants having in mind the example of reimbursement for clinical medication review into primary care in Slovenia in 2016 [52].

Patient satisfaction

The greatest facilitator for MUR providers in our study was patient satisfaction after MUR, and it is not surprising that sharing satisfied “customers” stories was emphasised as an effective marketing strategy. Health care around the developed world is being challenged by increasing demands for medication and the problem of polypharmacy [53]. At the same time adherence to medication is generally low and medication waste is consequently increasing [54]. The concept of a personal pharmacist as expressed in the discussion seems appealing as one part of possible solution [4, 55]. As one participant emphasized: “… we don’t have a job because of the prescriptions. We have to convince them [stakeholders] this is the future. And it is right thing to do.”

Strengths and limitation of the study

Our study was performed with the use of a qualitative technique—specifically, a focus group with semi-structured guided discussion. This format presented participants with a chance to interact with each other and to share or debate opinions expressed and is the main reason we choose it over performing individual interviews. Moreover, a focus group was a more time and money efficient way of gathering qualitative data, especially due to regional spread of involved participants in our study [56]. The approach to address pharmacists’ views first offers a good starting point for exploring the views of other stakeholders in the future. The study supports the importance of implementation research as an essential part of introducing pharmaceutical cognitive services into pharmacy practices. In addition, it shows an example of MUR implementation in a non-British environment, which is rarely found in the literature.

On the other hand, we have only performed one group meeting, which is not a conventional way of conducting a focus group. Participants were purposively selected from among the first certified MUR providers. The small sample size to begin with and additional limitation of participants might place a question mark on achieving data saturation and therefore transferability [57] of study results and conclusions. Nevertheless, we argue that relevance and transferability is still merited as we covered different institutions and regions across Slovenia. More importantly, the included pharmacists were experienced and proactive community pharmacists. They present regional centres from where MUR grows, acting as mentors to new providers and key stakeholders in shaping the future of the service, therefore study findings based on their experiences are a valuable and relevant source.

In addition to the main weakness mentioned above, some other elements of the study could have been improved. Firstly, the debate was in some parts dominated by a few participants; nonetheless, the moderator successfully balanced their dominance by addressing and encouraging others to express their views and experiences or to substantiate what was established. Secondly, we have not returned the transcript and quotes to participants for validation. These might have decreased the level of results credibility [57], although they have been publicly presented as part of a specialist’ thesis of a research team member and therefore externally evaluated. In a way, this could have been an alternative approach for participants to provide feedback in case they would have comments on interpretation.

Conclusion

Participants of the focus panel had positive experiences with the development of competencies and the implementation of the Medication Use Review service in their daily practice in Sloovenia. Several challenges were identified in connection with recognition of the service by patients, physicians and health care payer. To ensure MUR sustainability, these challenges need to be properly addressed and opportunities for continuing professional development must be provided.