A cross-sectional survey of enhanced and extended professional services in community pharmacies: A pharmacy perspective

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Research in Social and Administrative Pharmacy journal homepage: www.elsevier.com/locate/rsap

A cross-sectional survey of enhanced and extended professional services in community pharmacies: A pharmacy perspective Tin Fei Sim, Bronwen Wright, Laetitia Hattingh1, Richard Parsons, Bruce Sunderland∗, Petra Czarniak School of Pharmacy and Biomedical Sciences, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, 6102, Australia

ARTICLE INFO

ABSTRACT

Keywords: Community pharmacy Pharmacists Pharmacy services Primary care Remuneration Barriers for delivery Australia

Background: Community pharmacies provide enhanced (within current scope of practice) and extended (requiring additional credentialing) services, for disease state management and primary care. Objectives: To quantify the prevalence and characteristics of extended and enhanced professional services offered by community pharmacies in Western Australia (WA), their frequency of remuneration, facilitators, barriers and factors influencing their provision. Methods: A questionnaire was mailed to a random sample of 421/628 (67.0%) community pharmacies in WA. Data collected included demographic information, provision of extended and enhanced pharmacy services and whether remuneration was received. Facilitators and barriers for offering these services used Likert scale responses to proffered questions. Data were entered into SPSS and descriptive statistics were reported. Logistic regression analyses investigated any factors (pharmacist and pharmacy characteristics) associated with the provision of influenza vaccination, or any of nine selected enhanced services. Results: The response rate was 205/417 (49.2%). Only one-half or less of respondents provided any extended services. Pharmacist-administered influenza vaccinations (94/205, 45.0%) and Home Medicines Reviews (105/ 205, 52.0%) were the most prevalent. Remuneration for extended services was received by > 60% of respondents. Of 18 enhanced services > 80% of pharmacies provided blood pressure monitoring and needle and syringe programs. Over half of the pharmacies (113/205, 55.1%) were banner (franchise) group members. Belonging to a banner group, having a private consultation area and space for a patient to lie down were positively associated with the provision of influenza vaccination and the selected enhanced services. Facilitators for the provision of services included enhancing patient relationships and the role of pharmacists. Major barriers were time constraints and inadequate remuneration. Conclusions: Extended services were limited in scope and provision whilst enhanced services were not uniformly available. Pharmacy organisations should look to increase their scope and provision, including improved government and third-party funding.

Introduction Chronic diseases represent the largest cause of morbidity and mortality across the world.1 Internationally, governments are promoting chronic disease state management at the primary care level.2 Community pharmacies are primary care providers that are ideally situated to offer disease state management services.3 Pharmaceutical services provided in community pharmacies have been divided into those relating to drug therapy and those involving disease state management,

health promotion and primary care.4 These latter services are not directly associated with prescription or non-prescription medicines and are often termed enhanced and/or extended services.4,5 However definitions of enhanced and/or extended services may vary in different countries. Community pharmacies in many countries provide a range of these services including some with remuneration.5 Their provision has been collated through a survey by the International Pharmacy Federation. That survey of 74 countries revealed that: 51 countries provided health promotion initiatives, 39 smoking cessation, 42 diabetes

Corresponding author. E-mail addresses: [email protected] (T.F. Sim), [email protected] (B. Wright), [email protected] (L. Hattingh), [email protected] (R. Parsons), [email protected] (B. Sunderland), [email protected] (P. Czarniak). 1 Currently at School of Pharmacy and Pharmacology, Griffith University, Gold Coast, Queensland 4222, Australia. ∗

https://doi.org/10.1016/j.sapharm.2019.07.001 Received 26 October 2018; Received in revised form 27 June 2019; Accepted 2 July 2019 1551-7411/ © 2019 Elsevier Inc. All rights reserved.

Please cite this article as: Tin Fei Sim, et al., Research in Social and Administrative Pharmacy, https://doi.org/10.1016/j.sapharm.2019.07.001

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management and 24 vaccination. Third party remuneration was seldom available for these services.6 A recent systematic review reported provision of a wide range of these services internationally, with Australia, Canada and a number of other countries particularly involved in their provision.5 Another review of community pharmacy services provided internationally, identified that studies most frequently reported on those providing management of asthma, diabetes, migraine, sleep apnoea, as well as opioid substitution treatment and emergency contraception.7 These services have thus far not been well integrated into community pharmacy practice as is the case for dispensing of medicines and the over-the-counter management of minor ailments. Individual community pharmacies usually provide a limited and inconsistent range of enhanced and extended services. For example, in the United States of America (USA), of eight selected services only immunisation, smoking cessation, diabetes management and health screening were provided by more than 10% of pharmacies.8 In England, Local Authorities commissioned supervised consumption of opioid substitute therapy across 100%; needle and syringe programs in 97% and smoking cessation in 89% of all local authority areas. However the uptake by individual pharmacies was highly variable ranging from 2 to 100%.9 In New Zealand (NZ) a full range of enhanced and extended community pharmacy services was undertaken by less than one-third of respondents. Anticoagulant management, over-the-counter supply of emergency contraception, trimethoprim, sildenafil, and administration of vaccines were the services most commonly reported.10 Another study reported methadone dispensing, needle exchange, smoking cessation, blood pressure measurement, compliance aids and weight management, were being offered by more than one-third of NZ pharmacies. Blood glucose and cholesterol monitoring, asthma management and vaccinations were less frequently provided.11 The terms enhanced and extended pharmacy services are not consistently used. Moullin et al. defines enhanced pharmacy services as the diversity of additional services being developed and remunerated in developed countries.4 Nordin et al. in a recent systematic review used the term extended services which included enhanced services.5 They are referred to as “in-person services” in the USA and enhanced services in England.7,9 Some analysis of these terms has occurred in Australia, within the scope of advanced or extended community pharmacy practice. For this study, enhanced pharmacy services are within the current scope of community pharmacy practice and require no additional specific qualifications or credentialing, although additional training specific to that service may be part of its implementation. Extended services are an extension of the existing scope of community pharmacy practice and require additional credentialing education and qualifications.12 These health-related pharmacy services in Australia, are included within the framework of primary care. Community pharmacy extended and enhanced services form part of the primary care model, especially within the chronic disease management model13 and are a strategic priority of the Australian government.14 Community pharmacists’ involvement with prescriptions for the treatment of chronic diseases places them in a strong position to provide additional professional services appropriate to these patients.15,16 A study of Australian community pharmacy enhanced services in 2002 reported at least one service was offered by 88.8% of pharmacies. Smoking cessation, diabetes, hypertension and asthma care were offered by approximately half of the pharmacies. The main predictors for offering services were pharmacies with high turnovers, those with younger managers or proprietors, those who spent more time on voluntary continuing professional education and the availability of an enclosed counselling space.17,18 Recent community pharmacy contractual agreements between the Pharmacy Guild of Australia and the Australian government [currently the Sixth Community Pharmacy Agreement (6CPA)] have funded the provision of a range of enhanced and extended services embodied

within support program suites such as medication adherence, medication management, rural support programs, Aboriginal and Torres Strait Islander (ATSI) peoples programs and medication reviews.19 These services are important in relation to achieving good prescription medicines outcomes for patients and for disease state monitoring. In addition, they often facilitate important public health outcomes. It has been demonstrated in a recent narrative review that most of these services are effective and some such as home medicines reviews, diabetes and blood pressure interventions improved patient outcomes.20 Since the introduction of the 6CPA suite of professional service arrangements in Australia, no evaluation of their overall provision has been reported. This study therefore aims to quantify the prevalence and characteristics of extended and enhanced professional services offered by community pharmacies in Western Australia (WA), their frequency of remuneration, facilitators, barriers and factors influencing their provision. Methods The study received ethics approval from Curtin University Human Research Ethics Committee: Approval number HRE2017-0036-02 on 8 March 2017. Enhanced services were defined as services implemented in pharmacies that were additional to, or not routinely provided with, prescribed or non-prescribed medicines. Examples included blood pressure monitoring, asthma screening and blood glucose testing. These were identified from literature sources and community pharmacy websites.5,18 Extended services were defined for this study as an extension of the existing scope of practice requiring additional education and training and a demonstration of competence to obtain additional credentialing qualifications.12 Extended services evaluated in this study were:

• Home Medicines Reviews (HMRs) performed by pharmacists ac• •

•

•

credited by the Australian Association of Consultant Pharmacy (AACP) or the Society of Hospital Pharmacists of Australia (SHPA) usually in patients' homes and funded by the Australian government. Residential Medication Management Reviews (RMMRs) performed by similarly accredited pharmacists in residential aged care facilities and funded by the Australian government. Pharmacist administered influenza vaccinations performed by pharmacists after completing an education program established by the Health Department of WA, in pharmacies with facilities that meet the WA Department of Health's Structured Administration and Supply Arrangement (SASA) for vaccine administration and patient care. Funded from patients or a third party payer. Compounding services performed by pharmacists after the completion of a comprehensive compounding course run by the Professional Compounding Chemists of Australia (PCCA) and the establishment of the required facilities as or within a community pharmacy. The Pharmacy Board of Australia regulates this practice.21 Funding is from the patient or a third party payer. Diabetes education performed by pharmacists following the completion of a Graduate Certificate in Diabetes Education and subsequent practice requirements. Credentialed pharmacists receive funding from Medicare (the Australian government agency funding medical and health services) (medical referral is required to access Medicare funding for this service), the patient, or a third party payer.

Influenza vaccinations are also administered by Nurse Practitioners in community pharmacies. They can claim remuneration from Medicare and may have a contractual arrangement with the pharmacy. Although not a pharmacist extended service these data were collected and 2

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reported for comparative purposes.

remuneration was received (Yes or No). Frequency of service provision was requested monthly (since payment is based on a monthly return) for services that involved government payments (6CPA) and for the calendar year 2016 for influenza vaccinations. Services to ATSI peoples were reported as frequencies per month, number of clinics or number of patients. These were rated at none, or the minimum service level < 3, except for DAAs which was < 6 and QUM services per patient were < 11. All were remunerated by the government so remuneration data were not requested in the questionnaire. RAAHS services involved supply of bulk medicines usually by community pharmacies under contract and provision of QUM service support to RAAHS. These medicines are provided free to communities attending RAAHS.24 The questionnaire was printed as a booklet preceded by two pages containing information on the nature and purpose of the study, its objectives, the importance of participation and ethics information.

Aboriginal and Torres Strait Islander (ATSI) peoples services These services were provided from community pharmacies directly to patients under a Closing the Gap (CTG) government initiative and other services to Remote Area Aboriginal Health Services (RAAHS). Community pharmacies could provide a range of services if the prescriber had endorsed the prescription with “CTG”. These include Quality Use of Medicines (QUM) services, Dose Administration Aids (DAAs), medical devices and subsidised transport. Questionnaire A questionnaire was developed based upon previous literature as well as the Australian community pharmacy context.5,17,18 The questionnaire incorporated expert guidance with the aim to achieve high response rates from detailed questions.22,23 It was 17 pages in length and included seven sections with 50 questions. The sections were; Part A: Pharmacist demographic details (10 questions); Part B: Pharmacy demographic details (13 questions); Part C: Enhanced services offered by the pharmacy (9 questions); Part D: Extended services offered by the pharmacy (4 questions); Part E: Services provided to the ATSI peoples (2 questions). Parts C, D and E requested defined service frequencies (Table 1) and in Parts C and D, whether specific remuneration was received. Part F (8 questions): Barriers and facilitators to enhanced and extended services were assessed through five point Likert scales from strongly agree to strongly disagree. These were from proffered statements based on literature sources and/or the experience of the investigators.18 ‘Other (please specify)’ was included to capture any additional opinions. Part G (4 questions): Collaborations with general practitioners (GPs) and other health professionals was as defined frequencies and similar Likert scales. Many questions also included subquestions to explore existing service experience and provision. The respondents also had the opportunity to provide additional written comments at the end of the questionnaire. The questionnaire was developed by the authors and face and content validated by five academic pharmacists, some with current community pharmacy experience. Their feedback was incorporated into the questionnaire. Subsequently, face, content and the frequency interval ranges for each professional service (Table 1) were validated by nine experienced community pharmacists. The validators were selected based upon community pharmacy knowledge and experience and represented a range of community pharmacy sizes and practice focus. Feedback included clarifications, additional factors to be considered for inclusion, that one detailed question was not feasible and was subsequently deleted. They also completed the frequencies with which their pharmacies provided the extended and enhanced services, enabling appropriate ranges of service provision frequency intervals to be defined, that covered the spread of pharmacy sizes and operations. For all services respondents were asked to indicate the average number of patients that received the service, per average week, within defined frequency ranges (Table 1). They were also asked if specific

Questionnaire distribution The sampling frame was 452 metropolitan (Greater Capital City Statistical Area) and 176 regional (rural or remote) community pharmacies obtained from a list provided by the Pharmacy Registration Board of WA.25 A 67.0% random sample of each of the metropolitan and regional pharmacy cohorts was performed using Microsoft Excel.26 This was based upon an a priori expected response rate of 50%, and designed to provide a 95% CI of ± 6.8% in any prevalence estimate and enable regression analysis. The questionnaire (coded to identify non-respondents) was posted to the Pharmacist-in-Charge, with a reply paid envelope, to 303 metropolitan and 118 regional pharmacies on 21 April 2017. Respondents were asked to return the completed questionnaire by 15 May 2017. A reminder was sent to non-responder pharmacies on 31 May 2017, which included the questionnaire and reply paid envelope, with a return date of 19 June 2017. A further one-page advertisement was inserted in local pharmacy professional organisations’ newsletters in early July extending the return date to 24 July 2017. A gift voucher (AUD$ 50) was offered to respondents as a token of appreciation. To receive this, they provided a name and mailing address on a separate form and returned it with the questionnaire. Data analysis Service frequency was analysed as none, limited, or moderate/large. If the service was not offered, it was reported as “none”. If the service was provided for the lowest frequency, (usually < 3 times per week), it was reported as “limited”. “Moderate/large” was any level above ‘limited’. For some services: RMMRs and PCCA compounding the lowest frequency was < 6. For pharmacist-administered influenza vaccinations, fewer than 11 administered during 2016, was the lowest frequency. The median number of vaccinations administered at each pharmacy was estimated as the mid-point of each frequency range identified. The total number administered was estimated as the sum of all these median values.

Table 1 Examples of defined frequency intervals for specific services (frequencies were per average week).

3

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All responses were entered by trained computer data entry clerks into the SPSS version 23 (IBM USA, 2013) followed by analysis using SAS version 9.2 (SAS Institute Inc. Cary, NC, USA, 2008). All data entries were independently audited and corrected where necessary. Simple descriptive statistics were used to summarise demographic information and questionnaire responses. Pharmacies were classified into those which provided at least one extended or enhanced service and those that did not. Chi-square and Student's t-tests were used to compare the provision of services for different demographic and pharmacy profile data. Logistic regression was used to investigate the characteristics associated with the provision of extended or enhanced services. Multiple demographic variables were initially included in the regression model and the final model was reached by a process of backward elimination. Least significant variables were consecutively dropped until all variables remaining in the model were significantly associated with the outcome. A p-value < 0.05 indicated a statistically significant association.

remuneration was received. It is evident that based upon the 205 respondent pharmacies, less than half provided any of these services and few at the moderate/large level. Influenza vaccinations were provided at a moderate/large level by almost half of the respondent pharmacies, while PCCA compounding by less than 10% of pharmacies. Five pharmacies indicated they provided credentialed diabetes education less than three times weekly. The remuneration information in the figure box (Fig. 1) indicated that not all pharmacies charged for these services. The denominator was the total of pharmacies which provided at least some of the relevant service excluding pharmacies where the remuneration question was not answered. Influenza vaccination Almost half of the cohort 94/205 (45.9%) reported providing pharmacist administered influenza vaccinations in 2016. Of this group, 32/205 (15.6%) of respondent pharmacies provided 11 to 50 vaccinations in that year, whereas 3/205 (1.5%) exceeded 1000. Overall, an estimated 17,698 vaccinations were provided by respondent pharmacies during 2016. Remuneration was reported as being received by 69/78 (88.5%) of pharmacies providing this service with 9/78 (11.5%) reporting no remuneration. While remuneration may not have been received from the patients in these cases, it may have been obtained from a private health fund. There were 16/94 (17.0%) who reported providing this service, but left specific remuneration blank. There were 39/205 (19.0%) pharmacies that reported nurse-administered influenza vaccinations in the pharmacy. Overall, 1893 nurse-administered vaccinations were provided in pharmacies in 2016. Of those which provided the information, 18/29 (62.1%) indicated they received remuneration and 11/29 (37.9%) did not receive remuneration. There were 10 provider pharmacies that left specific remuneration blank. Owing to the low level of provision of extended services overall and since almost one-half of the pharmacy respondents provided Influenza vaccination services, the following univariate tables and logistic regression analysis focussed on factors associated with the provision of pharmacist administered influenza vaccinations (Tables 3 and 4). It is evident that mandatory facilities and staff requirements that were essential for the provision of vaccination services, were the primary factors influencing significance in the univariate data (Table 3). Considering the factors independently associated with the provision of vaccinations, banner group membership and pharmacy facility requirements, were the only characteristics associated with delivery of this service (Table 4). Banner group membership results when groups of community pharmacies subscribe to franchise groups. These franchise groups are principally for providing support in areas of group buying, advertising and promotion.

Results Demographic data Of the original sample of 421 community pharmacies, four questionnaires were returned to sender (two metropolitan and one regional) as the pharmacies no longer existed whilst the other was not a community pharmacy). The response rates were 146/300 (48.7%) for metropolitan pharmacies and 59/117 (50.4%) for regional pharmacies which were similar (p = 0.850); giving an overall response rate of 205/ 417 (49.2%) useable questionnaires. Both the pharmacist respondent details and the pharmacy characteristics are provided in Table 2. These data provide a detailed report of community pharmacy practice in WA. A majority of respondents was female 108/205 (52.7%). It is notable that almost two-thirds of the respondent cohort 136/205 (66.4%) was aged 40 years or less and approximately half, born in Australia. Notably almost 90% were first registered in Australia. Few respondent pharmacists worked longer than 50 h per week and most were not accredited to perform HMRs and RMMRs. More than one-quarter of the pharmacies (59/205, 28.8%) opened for business for more than 11 h on weekdays, many also opened for substantial hours on Saturdays. There were 76/205 (37.1%) not opened on Sundays. Approximately half (113/205, 55.1%) of the pharmacies belonged to a banner (marketing/franchise) group. More than twothirds of the pharmacies were located in the metropolitan area. More than half of the pharmacies were within a 5 min walk of a general practice surgery and only a small number were characterised as large pharmacies based on gross turnover. The largest cohort of pharmacies was located within 1 km of another pharmacy. There were 59/205 (28.8%) pharmacies located in regional areas of which 24/59 (40.7%) were in isolated or very isolated locations. Two-thirds of pharmacies had a confidential enclosed counselling area and space for a patient to lie down. A few included the provision of a medical bed. Almost half of the respondent cohort had one pharmacist rostered at any one time. When one pharmacist was rostered: on average 1.68 nonpharmacist staff were also rostered. When 1.1 to 2.0 pharmacists were rostered; the pharmacist to other staff ratio was 1:1.16 and for 2.1–3.0 pharmacists; the pharmacist ratio was 1:1.12 and for 3.1–4 rostered pharmacists it was 1:4.06. Only three of the pharmacies which had more than one pharmacist rostered, employed a pharmacy intern, while 43/97 (44.3%) of pharmacies with one rostered pharmacist did so.

Enhanced services The rate of provision of 18 listed enhanced services per week, by the 205 respondents, is illustrated in Fig. 2. In this figure, the red bar indicates the service was, on average, not provided on a weekly basis. A limited provision (yellow) indicated that the pharmacy provided this service on average < 3 times per week, or for services frequently provided such as blood pressure monitoring, < 6 times per week. Green indicated a moderate to large number were provided on average each week. Only blood pressure monitoring and the needle and syringe program were provided to a moderate/large extent by more than half of the respondent pharmacies and were available in > 80% of respondent pharmacies. Absence from work certificates were provided from

Extended services The average frequency per week of the provision of extended services, with the exception of influenza vaccinations which was based on the 2016 calendar year, is shown in Fig. 1 as well as whether 4

5

*PhAria: Pharmacy Access Remoteness Index. 1:Highly accessible to 6: Very remote.27

Characteristic n (%) Pharmacy Trading Hours Monday to Friday (hr) 8.0 9 (4.4) 8.1–9.0 34 (16.6) 9.1–10.0 55 (26.8) 10.1–11.0 46 (22.4) 11.1–12.0 26 (12.7) 12.1–13.0 21 (10.2) > 13.0 12 (5.9) Missing 1 (0.5) Saturday (hr) ≤3.0) 14 (6.8) 3.1–7.0 43 (21.0) 7.1–8.0 13 (6.4) 8.1–9.0 62 (30.3) 9.1–12.0 44 (21.8) > 12.0 23 (11.2) Missing 1 (0.5) Sunday (hr) < 6.0 99 (49.0) 6.1–9.0 29 (14.1) 9.1–12.0 28 (13.7) > 12 22 (10.9) Missing 1 (0.5) Location Metropolitan 146 (71.2) Regional 59 (28.8) PhArIa* 1 48 (43.8) PhAria 2 3 (66.7) PhAria 3 14 (42.0) PhAria 4 10 (60.0) PhAria 5 19 (73.7) PhAria 6 23 (43.5)

Characteristic n (%) Male 97 (47.3) Female 108 (52.7) Age Group 21–30 50 (24.4) 31–40 86 (42.0) 41–50 32 (15.6) 51–60 24 (11.7) > 60 13 (6.3) Country of Birth Africa 23 (11.2) Asia 21 (10.2) Australia 105 (51.2) China 4 (2.0) Malaysia 30 (14.6) New Zealand 2 (1.0) United Kingdom 7 (3.4) Other 11 (5.4) Missing 2 (1.0) Country of initial qualification Australia 183 (89.3) India 6 (2.9) United kingdom 5 (2.4) New Zealand 4 (2.0) Egypt 4 (2.0) Africa 3 (1.5) Year of Initial Registration in Australia 1960–1969 2 (1.0) 1970–1979 13 (6.3) 1980–1989 20 (9.8) 1990–1999 18 (8.8) 2000–2009 75 (36.6) 2010–2017 75 (36.6) Missing 2 (1.0)

Characteristic n (%) Highest Qualification in Pharmacy Bachelor 174 (84.9) Master (graduate entry) 9 (4.4) Master 16 (7.8) Graduate Certificate 2 (1.0) Graduate Diploma 2 (1.0) Other 2 (1.0) Primary Role in the Pharmacy Sole Proprietor 43 (21.0) Partner Proprietor 46 (22.4) Pharmacy Manager 55 (26.8) Pharmacist in Charge 35 (17.1) Employee Pharmacist 22 (10.7) Consultant Pharmacist 1 (0.5) Other 1 (0.5) Accredited Pharmacist AACP 31 (15.1) SHPA 2 (1.0) Under Training 7 (3.4) Not Accredited 145 (70.7) Missing 20 (9.8) Pharmacy Data n (%) Data n (%) Total Working Hours per Week 0–9 1 (0.5) 10–19 3 (1.5) 20–29 21 (10.2) 30–39 46 (22.4) 40–49 90 (43.9) 50–59 34 (16.6) 60–69 4 (2.0) 70–79 4 (2.0) 90–99 1 (0.5) Missing 1 (0.5)

Pharmacy Data

Pharmacist Data

Table 2 Demographic details of the pharmacist respondents and the respective pharmacy characteristics data (n = 205).

Characteristic n (%) Banner Group Membership Yes 113 (55.1) No 91 (44.4) Left Blank 1 (0.5) Pharmacy Location Small Shopping Centre 77 (37.6) Town Strip Centre 57 (27.8) Medical Centre 32 (15.6) Large Shopping Centre 14 (6.8) Strip of Shops 7 (3.4) Other 18 (8.8) Location with respect to GP Surgery Co-located 12 (5.9) Next Door 44 (21.5) < 5 min walk 75 (26.6) Same shopping centre 20 (9.8) > 5 min walk 54 (26.3) Distance to Closest Pharmacy < 1 km 87 (42.2) 1–2 km 48 (23.4) 2.1–4 km 33 (16.1) 4.1–8 km 11 (5.4) 8.1–20 km 3 (1.5) > 20 km 22 (10.7) Missing 1 (0.5)

Characteristic n (%) Pharmacy Size (Annual Turnover) Small < 1.5 million 78 (38.1) Medium 1.5–3.5 million 89 (43.4) Large > 3.5 million 37 (18.1) Missing 1 (0.5) Robotic Dispensing System Yes 12 (5.9) No 193 (94.1) Automated Drug Administration Aid Machine Installed Yes 7 (3.4) No 19 (96.6) Closed Consultation Room Yes 141 (68.8) No 64 (31.2) Space for Patient to Lie Down Yes 141 (68.8) No 63 (30.7) Missing 1 (0.5) Space Includes a Medical Bed Yes 39 (19.0) No 163 (79.5) Missing 3 (1.5) Semi-confidential area(s) for Consultation Yes 140 (68.3) No 65 (31.7) Average Number of Pharmacists rostered on an Average Day 1 97 (47.3) 1.1–2.0 68 (33.2) 2.1–3.0 31 (15.1) > 3.0 1 (0.5) Missing 1 (0.5)

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Fig. 1. Frequency of provision of extended pharmacy services on average each week by community pharmacies (n = 205). Influenza vaccinations were for the year 2016. The box indicates the proportion of pharmacies that provided the service and reported receiving specific remuneration (HMRs: Home Medicines Reviews RMMRs: Residential Medication Management Reviews).

and “Diabetes MedsChecks” services.

approximately three-quarters of the cohort. Prescription repeat reminders were provided, usually at limited or moderate levels, to patients by 123/205 (60.0%) respondents. Some respondents that offered a service left the remuneration response blank. Only those that completed that section are reported in the remuneration box in Fig. 2. Some level of frequency of remuneration was reported for all services, but of those services that were more often provided, needle and syringe program provision and absence from work certificates were frequently remunerated. It is notable that remuneration frequency was higher for some services that were less frequently provided. After excluding the top four services which were provided frequently, the number of pharmacies that provided the subsequent nine services listed in Fig. 2 (from blood glucose to sleep apnoea) is reported in Table 5. There were 42 (20.5%) pharmacies that provided none of these services whereas one (0.5%) provided all nine. There were 97/ 205 (47.3%) that provided three or more of this group of services per average week. A logistic regression model was used to identify factors associated with the provision of any of these nine services (one or more versus none). All demographic variables were initially tabulated against provision of any of these enhanced services and Chi-Square tests used to assess the significance of possible associations. The younger age group (p = 0.032); belonging to a banner group (p = 0.004); space for a patient to lie down (p = 0.002); medical bed available (p = 0.004); private area available (p = 0.004); and, more than three total staff (p = 0.042) showed significant associations. All variables except the availability of a medical bed (where all pharmacies with one provided at least one of these services) were entered into a logistic regression model. The results of the final model are shown in Table 6. These three variables therefore were independently associated with the provision of enhanced services on average, weekly. The younger age group and more than three staff did not contribute to the model after these three variables were taken into account.

Other enhanced services Community program for opioid pharmacotherapy (CPOP) Approximately one-half of the community pharmacy cohort 103/ 205 (50.2%) offered the CPOP program. There were 602/1024 (58.8%) patients registered with these pharmacies for the program in April 2017 receiving methadone and 422/1024 (41.2%) buprenorphine. Dose administration aids (DAAs) to aged care facilities There were 55/205 (26.8%) respondent pharmacies that reported the provision of DAAs to aged care facilities, of which 45/55 (81.8%) supplied < 2 facilities and 1/55 (1.8%) > 20 facilities. In addition, 23/55 (41.8%) of these pharmacies provided their services to < 11 residents and 9/55 (16.3%) community pharmacy respondents provided to > 100 residents. Aboriginal and Torres Strait Islander (ATSI) peoples The monthly provision of ATSI services is reported in Table 7. It is evident that in WA, seven pharmacies provided more than 100 DAAs per month however overall only a small number of community pharmacies provided any of these services. Facilitators for provision of extended services Respondent views to proffered statements for offering these services (facilitators) were made on Likert scales as reported in Fig. 4. Enhancing the role of pharmacists, improving business sustainability and improving relationships with patients were the main reasons, favoured by respondents. External promoters of these services such as pharmacy organisations or banner groups were not perceived as major drivers and professional esteem and satisfaction aspects were attributes that respondents reported as important. Facilitators for provision of enhanced sevices Facilitators regarding the provision of enhanced services are reported in Fig. 5. Most of the proffered statements were well supported. Enhancing relationships with patients and to enhance the role of pharmacists were two professional esteem issues that rated highly, together with it providing health promotion opportunities which falls into the realm of public health. Promotion by banner groups or professional bodies, did not rate as highly with respect to respondent views.

Government funded enhanced services Enhanced services reported on a per month basis are shown in Fig. 3. Remuneration for these services is available from the Australian Government through the 6CPA. There was a small number of pharmacies not providing all of these services and some with limited frequency. Remuneration is capped by the government for “MedsChecks” 6

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were the lack of return on investment/inadequate remuneration. Time constraints and staff shortages were notable as barriers. There were also barriers regarding opportunities to interact with GPs and having access to medical records. The open question at the end of the questionnaire did not elicit a meaningful narrative suitable for thematic analysis, but mainly social comment of the equivalent of “good luck with the study”.

Table 3 Univariate analyses of factors influencing the provision of pharmacist administered influenza vaccination services in 96 of 205 (46.8%) of community pharmacies in WA. Variable

Number (%)

Gender Male Female Age group 21-40 41 or more Sole Proprietor Yesa Partner Proprietor Yes Pharmacy Manager Yes Pharmacist in charge Yes Employee pharmacist Yes Consultant pharmacist Yes PhAria (rural location) Yes Banner group Yes Pharmacy size Small Medium Large Robotic dispensing system Yes Automated DAA Yes Closed rooms Yes Space for patient to lie down Yes Medical bed available Yes Private area available Yes GPs willing to collaborate (Q46 J) Yes Total staff 1-3 more than 3

38/97 (39.2) 58/108 (53.7) 71/136 (52.2) 25/69 (36.2) 18/43 (41.9) 24/46 (52.2) 36/76 (47.4) 32/64 (50.0) 10/27 (37.0) 4/9 (44.4) 59/205 (28.8) 63/113 (55.8) 28/78 (35.9) 46/89 (51.7) 22/37 (59.5) 6/12 (50.0) 4/7 (57.1) 86/141 (61.0) 89/141 (63.1) 31/39 (79.5) 64/140 (45.7) 72/151 (47.7) 31/84 (36.9) 65/121 (53.7)

p-value 0.037

Discussion

0.030

This is the first comprehensive study of the prevalence of community pharmacy provided non-prescription related professional services in WA. Although performed in WA, these results should reflect a similar situation across all Australian pharmacies. A 67% random sample was adopted to reduce the error level in the data ensuring a higher level of validity and enable regression analysis. A wide range of community pharmacy extended and enhanced services is available to the public in WA. However as found internationally, uptake of these extended and enhanced services by individual pharmacies was variable.5 Of particular note was the moderate uptake level of 6CPA services, where government remuneration was accessible, with only DAAs and clinical interventions showing high uptake. These services however, may cause the least interruption to the established work flow pattern of a community pharmacy. Internationally, Local Authorities in England commissioned several remunerated services which also had limited and variable uptake by individual community pharmacies.9 A somewhat similar situation is reported in NZ, where a revised model of pharmacy practice remuneration has been implemented, with limited uptake beyond the provision of medicines information (88%).10

0.463 0.410 0.906 0.540 0.274 1.000b 0.417 0.005 0.031

0.821 0.708b < 0.001

Extended services

< 0.001

Surprisingly, more than half of the cohort surveyed did not offer extended pharmacy services even when most that did, reported receiving specific remuneration. One year after its introduction in 2015, the pharmacist-administered influenza vaccination service showed a high initial uptake. Its primary aim was to increase the number of people immunised by providing easier access for the community.28 Similar objectives for this service have also been reported in England.29 From a sample of 74 countries a vaccination service was only provided in 24, demonstrating scope for community pharmacy in other countries to provide this service and therefore expand community pharmacy's public health involvement internationally.6 Only HMRs and influenza vaccination showed reasonable prevalence. HMRs were not selected for regression analysis because they were not provided inside the pharmacy and not all accredited pharmacists are community pharmacists. For the provision of influenza vaccination, no pharmacist characteristics were independently associated with its provision, leaving only belonging to a banner group and regulatory requirements essential to providing this service, being associated with provision. A Canadian study in British Columbia reported low rates of pharmacy immunisations overall, with pharmacists having high competiveness traits being twice as likely to provide higher numbers of immunisations.30 Several extended pharmacy services provide consumers medication assistance and chronic disease state monitoring support. Some are also available in other countries but few with third party remuneration.5 Although almost half of the respondent pharmacies provided HMRs, almost all only provided a limited service due to the introduction of a national government remuneration cap.31 RMMRs are performed in registered aged care facilities often by arrangement with a community pharmacy. This service is also funded by the Australian government. Both HMRs and RMMRs can also be performed by accredited pharmacists not directly associated with a community pharmacy; hence these data do not indicate the total numbers performed.

< 0.001 0.639 0.682 0.018

a The number (%) of No responses is available from the difference of the yes responses from 96 pharmacies providing the service, based on 205 pharmacy respondents. b Fisher's Exact Test.

Table 4 Results of the multivariate logistic regression model, showing factors independently associated with the provision of pharmacist-administered influenza vaccinations (in 2016). Variable

Odds Ratio

Banner group No 1 (reference) Yes 2.06 Closed rooms No 1 (reference) Yes 3.39 Space for patient to lie down No 1 (reference) Yes 7.92

95% confidence interval

p-value

1.07–3.96

0.032

1.43–8.05

0.006

3.12–20.11

< 0.001

Barriers for the delivery of enhanced and extended services Barriers to extending the current level of services provision of enhanced as well as extended services encompassed the related themes of staffing/time and remuneration/cost issues (Fig. 6). Major barriers 7

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Fig. 2. Frequency of provision of enhanced pharmacy services on average per week in respondent community pharmacies in WA (n = 205). The rates (percentages) indicate the number of pharmacies where remuneration was reported for that service.

response to the high prevalence of Type 2 diabetes and the resultant high cost of managing patients with serious adverse outcomes and complications from poorly managed Type 2 diabetes.33,34

Table 5 The frequency with which up to nine enhanced services (from blood glucose to sleep apnoea in Fig. 2) were provided by community pharmacies on average each week. Number of services provided

Frequency, n (%)

Cumulative frequency, n (%)

9 8 7 6 5 4 3 2 1 0

1 (0.5) 1 (0.5) 13 (6.3) 15 (7.3) 19 (9.3) 25 (12.2) 23 (11.2) 37 (18.1) 29 (14.2) 42 (20.5)

1 (0.5) 2 (1.0) 15 (7.3) 30 (14.6) 49 (23.9) 74 (36.1) 97 (47.3) 134 (65.4) 163 (79.6) 205 (100.0)

Enhanced services A wide range of enhanced services were provided on average each week across respondent pharmacies, but < 50% of the community pharmacies surveyed provided three of nine less frequently available services. The relationship between provision and remuneration was skewed in that blood pressure monitoring was widely available but only occasionally remunerated. However, sleep apnoea was only provided by 18.5% of pharmacies with 91.7% of those reporting receiving remuneration. Services provided monthly under the 6CPA, with the exception of QUM (annually), were provided by most respondents.19 DAAs are clearly an important service that assist with medication adherence.35,36 The same independently associated characteristics for influenza vaccination were evident for the provision of the nine less commonly provided enhanced services, with only pharmacy characteristics that independently influenced their provision. This would indicate that factors such as pharmacy size or staffing are not factors independently associated with service provision. When comparing the findings with an Australian wide study conducted in 2002, little change is evident in pharmacy settings, however the proportion of pharmacies with enclosed consultation rooms has increased from 23.1 to 68.8%.18 It would appear that the strong uptake of vaccination administration may have influenced this finding as this service requires a space for patients to lie down in case of an emergency. Notably, approximately one-third of pharmacies have no confidential enclosed area for patient consultations that require extra privacy. It is noteworthy that many of the pharmacies are small in terms of turnover, showing little change in the turnover proportions reported 15 years previously.17 The proportion of pharmacies belonging to a banner group has not changed (p = 0.329).17 The level of enhanced pharmacy services reported in this study show some changes over those also reported Australia wide in 2002.18 For example, blood pressure monitoring frequency has doubled from 43.5% to 95.1%, harm minimisation services (needle and syringe program) and methadone dispensing have increased and weight

Table 6 Results of the multivariate logistic regression model, showing variables independently associated with the provision of any one of nine selected enhanced services (weekly). Variable

Odds Ratio

Banner group No 1 (reference) Yes 3.94 Space for patient to lie down No 1 (reference) Yes 3.24 Private area available No 1 (reference) Yes 3.29

95% confidence interval

p-value

1.80–8.64

0.006

1.53–6.83

0.002

1.52–7.12

0.003

Specialised compounding, regulated by the Pharmacy Board of Australia,21 shows moderate/large numbers of compounded medicines dispensed per week. It is similar to that provided in the USA.32 Patients are charged for these extemporaneous preparations and some private health insurance funds cover the cost. Pharmacists in Australia and certain other health professionals can undertake further training to become credentialed diabetes educators. In terms of disease state management there should be scope for expansion of this service in pharmacies in Australia and internationally in 8

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Fig. 3. Enhanced pharmacy services based upon government funding, provided from community pharmacies on average each month (n = 205). The rates (percentage) indicate the number of pharmacies where remuneration was reported. (QUM = Quality use of medicines).

There are however the limitations of self-reported data, particularly when some respondents may consider some information as business confidential. The accuracy with which rates were reported is unknown, however respondents were asked to review their pharmacy records to provide up-to-date information. There is a potential bias if non-respondents were generally not providers of these services. As there are no data available on the characteristics of all pharmacies in WA or Australia, this could not be evaluated. The quality of the services provided was not evaluated but most pharmacies are accredited by the National Quality Care Pharmacy Program (QCPP) to enable them to receive the Pharmacy Practice Incentive Program.37

Table 7 Specific services provided per month to Aboriginal and Torres Strait (ATSI) peoples by community pharmacies under the Closing the Gap scheme. Frequency

Number of pharmacies, n (%)

Dose administration aids (DAAs) 0 135 (65.9) <6 50 (24.4) 6–15 9 (4.4) 16–100 3 (1.5) > 100 7 (3.4) a Blank 1 (0.5) Home Medicine Review Travel Costs 0 196 (95.6) <3 7 (3.4) >3 1 (0.5) Blank 1 (0.5) Quality Use of Medicines (QUMs) Devices 0 189 (92.2) <3 11 (5.4) 3–4 2 (1.0) > 50 2 (1.0) Blank 1 (0.5) Other Services 0 126 (61.5) <3 3 (1.5) 3–50 2 (1.0) Blank 74 (36.1)

Facilitators and barriers to service provision Remuneration may act as a facilitator for service provision and includes those from patients, government remuneration pathways, and third party (e.g. private health funds). Although receiving specific remuneration for these services is reported as generally above 60%, it was not universal. Lack of government remuneration is internationally a major barrier.5 Although some of these services are promoted by pharmacy organisations and/or banner groups, professional satisfaction and patient satisfaction were strong reasons for the establishment of these services. Surprisingly, the impact of banner groups as facilitators was not strongly evident in respondent views, indicating perceived facilitators were at variance with the regression analysis findings. Professional bodies also did not feature strongly as facilitators. Staffing issues, and the related time constraints, and lack of adequate return on investment were perceived as major barriers for the provision of enhanced and extended services, all linked to remuneration. Pharmacists however did not wish to remain in the dispensary and did not consider these services as outside their scope of practice. Few were concerned with them creating difficult working relationships with GPs. These findings have changed since the 2002 Australia wide survey where lack of knowledge or skills, beyond the scope of practice and impaired relationships with GPs were major impediments.18 A global systematic review of extended pharmacy services indicated lack of remuneration, lack of time and lack of collaboration with GPs were barriers frequently reported.5 Findings from this study, in particular the range of services and characteristics of pharmacies as well as remuneration and facilitators and challenges to service provision, provide a valuable reference for

Remote Area Aboriginal Health Services Number of Clinics Serviced 0 181 (88.3) <3 7 (3.4) 3–4 3 (1.5) 5–10 1 (0.5) Blank 13 (6.3) Number of Quality Use of Medicines (QUMs) Services to patients per annum 0 183 (89.3) < 11 2 (1.0) 11–50 1 (0.5) 51–100 1 (0.5) 101–500 2 (1.0) > 500 2 (1.0) Blank 14 (6.8) a

Left blank by the respondent.

management has slightly increased from 30.0% to 41.5%, As the study involved data collection using a voluntary questionnaire that was comprehensive, the response rate was reasonable (205/417; 49.2%). 9

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Fig. 4. Reasons for offering extended services perceived by community pharmacists (n = 205).

service development internationally.

improved and equitable funding fee-for-service options for community pharmacists to provide these services.

Conclusions Funding

The addition of extended services into community pharmacies has increased the range of professional services available, but uptake is still limited, which is concerning when remuneration pathways are well established. Overall a wide range of enhanced services have been established, but only a limited range is available in most pharmacies. The perceived facilitators for extended and enhanced services provision that relate to enhancing patient and professional relationships, are more effectively implemented with banner group support. Barriers were primarily based upon inadequate remuneration and time constraints. Provision of enhanced CTG services to ATSI peoples was limited and further research is needed to identify if greater uptake is needed to better close the gap. The lack of community pharmacist access to funding for many services available to other Australian health practitioners is a serious deficiency. Pharmacy bodies should act to negotiate

This project was funded by a J M O'Hara Research Grant 2017/1, Pharmaceutical Society of Western Australia. Conflicts of interest The authors have no conflict of interest. Author contribution Involved in the study conception, methodology development and questionnaire design and analysis and reviewed the manuscript.

Fig. 5. Facilitators for the provision of enhanced services. 10

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Fig. 6. Barriers towards pharmacies extending the existing level of enhanced or extended pharmacy services.

Appendix A. Supplementary data

16. George J, Zairina E. The potential role of pharmacists in chronic disease screening. Int J Pharm Pract. 2016;24:3–5. 17. Berbatis CG, Sunderland VB, Joyce A, Bulsara M, Mills C. Characteristics of Australia's community pharmacies: national database project. Int J Pharm Pract. 2007;15:265–271. 18. Berbatis CG, Sunderland VB, Joyce A, Bulsara M, Mills C. Enhanced pharmacy services, barriers and facilitators in Australia's community pharmacies: Australia's national pharmacy database project. Int J Pharm Pract. 2007;15:185–191. 19. Community Pharmacy Agreement 6.(6CPA) Pharmacy Guild of Australia. https:// www.guild.org.au/resources/6cpa Accessed 23.02.19. 20. Buss V, Shield A, Kosari S, Naunton M. The impact of clinical services provided by community pharmacies on the Australian healthcare system: a review of the literature. J Pharmaceut Policy Pract. 2018;11:22. 21. Pharmacy Board of Australia. http://www.pharmacyboard.gov.au/CodesGuidelines/FAQ.aspx Accessed 26.04.18. 22. Dillman DA. Mail and Internet Surveys: The Tailored Design Method. second ed. New York: John Wiley and Sons; 2000. 23. Smith F. Research Methods in Pharmacy Practice. London: Pharmaceutical Press; 2002. 24. Guide to Providing Pharmacy Services to Aboriginal and Torres Strait Islander People. Canberra: Pharmaceutical Society of Australia Ltd; 2014. 25. Pharmacy Registration Board of Western Australia. http://www.pharmacyboardwa. com.au/ Accessed 17.04.17. 26. Microsoft Excel. http://www.microsoft.com/Office Accessed 17.04.17. 27. Pharmacy Access/Remoteness Index of Australia. Adelaide: Hugo Centre for the Commonwealth Department of Health. https://www.adelaide.edu.au/hugo-centre/ spatial_data/pharia/Accessed 27.04.18. 28. Hattingh HL, Sim TF, Parsons R, Czarniak P, Vickery A, Ayadurai S. Evaluation of the first pharmacist-administered vaccinations in Western Australia: a mixed-methods study. BMJ Open. 2016;6:e0111948 10,1136/bmjopen-2016-011948. 29. Warner JG, Portlock J, Smith J, Rutter P. Increasing seasonal influenza vaccination uptake using community pharmacies: experience from the Isle of Wight, England. Int J Pharm Pract. 2013;21:364–367. 30. Rosenthal M, Tsao NW, Tsuyuki RT, Marra CA. Identifying relationships between the professional culture of pharmacy, pharmacists' personality traits, and the provision of advanced pharmacy services. Res Soc Adm Pharm. 2016;12:56–67. 31. Pharmacy Guild of Australia. Changes to Community Pharmacy Agreement Programs. https://www.guild.org.au/news-events/news/2014/02/12/changes-tocommunity-pharmacy-agreement-programs Accessed 4.10.18. 32. Professional Compounding Centers of America (PCCA) https://www.pccarx.com/ Accessed 18.02.19. 33. Australian Institute of Health and Welfare 2014 Australia's Health 2014;no.14: Cat No. AUS 178. Canberra AIHW. 34. International Diabetes federation. IDF Diabetes Atlas. Belgium: International Diabetes federation; 2017. 35. Haywood A, Llewelyn V, Robertson S, Mylrea M, Glass B. Dose administration aids; Pharmacists' role in improving patient care. Australas Mark J. 2011;4:183–189. 36. Roberts M, Stokes J. Effectiveness And Cost Effectiveness of Dose Administration Aids (DAAs). Phase 3 Final Report. Canberra: Pharmacy Guild of Australia; 2006. 37. Quality Care Pharmacy Program (QCPP). http://www.qcpp.com/about-qcpp/what-isqcpp Accessed 6.04.18.

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