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Determining patient preferences of community pharmacy attributes: A systematic review
SCIENCE AND PRACTICE Journal of the American Pharmacists Association xxx (2019) 1e8
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REVIEW
Determining patient preferences of community pharmacy attributes: A systematic review Pranav M. Patel*, Varun Vaidya, Feyikemi Osundina, Djatomah A. Comoe a r t i c l e i n f o
a b s t r a c t
Article history: Received 6 October 2019 Accepted 11 October 2019
Objective: Patient selection of community pharmacy is based on a multitude of factors. With increasing competition and rapidly changing face of pharmacy, identification of these factors is critical for patient satisfaction and financial success. This systematic review summarizes patient preferences for different attributes of community pharmacy. Data sources: Systematic review of peer-reviewed studies conducted on U.S. population, published from 2005 to 2018 in EBSCO, PubMed, and EMBASE, was conducted to identify attributes of community pharmacy that determine patient patronage. Study selection: Studies conducted between 2005 and 2018 on U.S. population that examined attributes in choosing a pharmacy were eligible for this systematic review. Data extraction: Data were independently extracted, assessed, and evaluated by 2 reviewers. Any disagreements were resolved by the third reviewer. Data obtained included year, setting, number of patients, data-collection/evaluation methods, and relevant results and outcomes. Results: Of the 713 papers identified, 10 articles met the inclusion criteria and were included in this systematic review. Majority of the studies used surveys to examine key attributes that influence patients’ selection of a pharmacy. Pharmacist traits like friendly, helpful, trustworthy, professional, competent, caring, knowledgeable, responsive, and approachable are critical attributes that influence a patient’s selection of pharmacy. Convenience (i.e., location, hours of operation, wait time, stock availability) also influenced patients’ selection of pharmacy. Cost and contract with insurance were other important factors. Availability of autorefills appeared consistently in the studies. Medication safety (detecting drug interactions) quality metrics also appeared high among patients’ preferences. Conclusion: The results of this review found that a relationship with a respectful, friendly, competent pharmacist represents important pharmacist-related attributes in the process of pharmacy selection. Important pharmacy-related attributes include cost, convenience, and wait times. Availability of auto-refill service was also a frequently reported attribute in this review. © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
Background The number of dispensed medications in the United States has been steadily increasing.1 In the year 2017, approximately 4 billion prescriptions were filled at a community pharmacy.2 Also, the expenditure for prescription medications increased
Disclosure: The authors declare no relevant conflicts of interest or financial relationships. * Correspondence: Pranav M. Patel, PharmD, MS, Graduate Research Assistant, University of Toledo, 39279 Huron Parkway, Westland, MI 48185. E-mail address: [email protected] (P.M. Patel).
from $324 billion in 2015 to $328 billion in 2016.3 This rise in prescription medication expenditures and increasing demand may be attributed to the growth in incidence of chronic diseases, especially in the elderly population.4 The Affordable Care Act has also fueled the utilization of prescription medications because of expanded coverage, which enabled access to medications.4 The number of community pharmacies in the United States has been increasing as well. The number of community pharmacies has risen from 63,752 to 67,753 from 2007 to 2015, respectively, representing a 6.3% increase during that time.5 These pharmacies cover 92% of the U.S. population within 2
https://doi.org/10.1016/j.japh.2019.10.008 1544-3191/© 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE P.M. Patel et al. / Journal of the American Pharmacists Association xxx (2019) 1e8
Methods Key Points Data sources and search strategy Background: Community pharmacy is a crowded and highly competitive market. Newer models of community pharmacy offer a variety of products and services. Not much is known about patients’ preferences of community pharmacy attributes involved in the decision-making process of choosing a pharmacy. Findings: Staff attributesdfriendly, helpful, trustworthy, competent, knowledgeable. Pharmacy attributesdlocation, hours of operation, wait time, stock availability. Service attributesdauto-refill programs, delivery, medication safety metrics. miles of a pharmacy.5 Over the years, there has been a rejuvenation of community pharmacy in terms of store capacity, clinical and nonclinical services, and other offerings (products or services) to the patients.6 However, this progress in community pharmacy has also led to more competition in this crowded market.7 Higher densities of pharmacies and prescription coverage have helped level the playing field with respect to the role of location and out-of-pocket payments in the pharmacy selection process.7 Additionally, the penetration of mail-order pharmacies into the community pharmacy’s market share creates competition from an external source. Therefore, it is important for community pharmacies to explore patients’ preferences and adjust their models to remain competitive. Apart from staying competitive, considering patient preferences may help community pharmacies transition toward a patient-centered model.8 The traditional models of care often fail to take into account patients’ choices.9 More unified, transdisciplinary evidence-based practice models such as patient-centered models of care, have been embraced by community pharmacists.7 The patientcentered model not only attempts to promote evidencebased medicine, but it also considers individual preferences to achieve patient outcomes.7 As an important player in the healthcare system, there is an increasing need for community pharmacies to identify patients’ preferences and adapt their pharmacy’s services to match those preferences. Previous literature has explored the attributes of pharmacy patronage; however, many of these studies were conducted over twenty years ago.10-12 More recent studies have explored the determinants of choosing mail-order versus community pharmacy.13,14 In light of the lack of relevant recent data on consumer preferences, the aim of this study was to systematically review, summarize, and evaluate the literature to identify patient preferences for different attributes of community pharmacy.
2
Three databasesdEBSCO, PubMed, and EMBASEdwere searched. The following search strategy was used to identify the studies: ( "community pharmac*" OR retail pharmacy OR "Pharmacies and Drug Stores" ) AND ( (consumer-prefer* OR consumer-behavior* OR consumerattitude*) or (patient-prefer* OR patient-behavior* OR patient-attitude*) OR (customer-prefer* OR customerbehavior* OR customer-attitude*) OR consumer-choice* OR patient-choice* OR customer-choice* OR patient-satisfaction ) Eligibility criteria and study selection Studies were included only if they evaluated patient preferences of choosing a pharmacy. This review only included studies conducted between 2005 and 2018 on the U.S. patient population. This time period was chosen because it coincides with the preparatory phase of Medicare Part D rollout in 2006 and reflects current patient preference trends. This review excluded studies conducted on non-U.S. patients because the practice setting, expectations, and scope of practice may not be identical. During the selection process, a preliminary search of the databases with the keyword combination was conducted. Then, each reference title was screened for eligibility according to the inclusion criteria (Figure 1). Next, all included abstracts were screened for potentially eligible studies. Finally, full texts of all included studies were retrieved and screened for eligibility. All articles that met the inclusion criteria and were deemed relevant to the research topic of this review were included. In addition, the reference lists of included studies were searched for more articles. The review was performed by 2 independent reviewers. Any disagreement between these reviewers was resolved by the third reviewer. Data-collection process A standardized data extraction form was developed a priori. Data were extracted from the studies included by 2 independent investigators. Data obtained included author, date of publication, year, study setting, number of patients, patient population, data-collection, evaluation methods, and relevant results and outcomes. Results A search of databases carried out by employing different combinations of the keywords resulted in 713 unique studies. After title and abstract screening, 32 articles were remaining. Of the 32 articles identified for potential inclusion, 10 were included in the review. Studies were excluded because of the following reasons: evaluated patient satisfaction (n ¼ 17), evaluated pharmacist attire and perception of pharmacy quality (n ¼ 2), evaluated determinants of mail-order pharmacy versus community pharmacy (n ¼ 1), and evaluated in
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Identification
Patient preferences of community pharmacy
Records identified through database searching (n = 978 )
Included
Eligibility
Screening
Records after duplicates removed (n = 713 )
Records screened (n = 713 )
Full-text articles assessed for eligibility (n = 32 )
Records excluded (n = 681 )
Full-text articles excluded, with reasons (n = 22 ) n = 17: evaluate patient satisfaction n = 2: evaluate pharmacist attire n = 2: non-United States n = 1: evaluate mail-order versus community pharmacy
Studies included in evidence synthesis (n = 10 )
Figure 1. Flowchart of article selection.
non-U.S. settings (n ¼ 2). Researchers used surveys and focus group studies to collect patient preferences of attributes a desired pharmacy should have and improve. Figure 1 illustrates the steps of the database search and selection process. The available studies are described by their goals, patient population, setting of community pharmacy, year of study, datacollection method, statistical tests, and results in Table 1.
aimed to examine relationships among variables.25,26 This may be used to explain or predict decision-making attributes.25,26 Franic et al.22 employed the determinant attribute approach, which is a marketing tool to determine consumers’ motives or preferences. The determinant attribute approach takes into consideration both the importance and perceived difference of a certain product or service utilizing a survey.22
Data collection and analysis
Patient characteristics
There was substantial variation in methods utilized to identify attributes important in choosing a pharmacy. A majority of the studies used a survey to evaluate patient preferences.14,15,17,19-23 Patterson et al.18 elicited preferences of patients using a discrete choice experiment. Discrete choice experiments measure stated preferences by asking individuals to choose from the options presented.24 Shiyanbola et al.16,17 utilized a qualitative approach (focus group study) to identify themes that determine preferences. Mardanov et al.20 used a survey and structural equation modeling. Structural equation modeling is an advanced multivariate statistical method
There was substantial variation in the characteristics of the patients examined in the eligible studies. Multiple studies represented the preferences of the patients in the Midwest region.14,16,17,19,21 Other regions represented were Georgia,22 Northeastern U.S.,23 and central North Carolina.15 Patterson et al.18 examined responses from a national sample. All of the studies recruited patients from multiple sites except for the study conducted by Patterson et al.,19 which recruited patients getting service from one independent community pharmacy. Dominelli et al.23 evaluated the preferences of consumers who shopped at supermarkets compared to those who shopped at community 3
Result
93
Survey
60
Focus group study; 90 min; divided into 6 groups
Not specified
34 (12 rural; 22 urban)
Semistructured focus group and survey; 60-90 min
Not specified
741
Discrete choice experiment
Latino patients reported being treated with respect and friendliness by pharmacy employees, cheaper medications compared with other pharmacies, and written information in Spanish as factors that are very important when choosing a pharmacy. Other attributes included employees speaking Spanish, availability of interpreter, and fast pace of service. Fewer respondents found location to be an important factor in the pharmacy selection process. Proximity to house, drive-through, short wait times, prescription delivery, medication packaging, convenience store for other shopping, multiple locations (transferability), cost, contracted with insurance, and auto-refills were all reported as factors when choosing a pharmacy. Additionally, relationship with pharmacists and staff was important. Traits of staffdresponsiveness, helpfulness, and friendlinessdwere reported as reasons for choosing a pharmacy. Respondents hesitant to use quality measures to choose a pharmacy but may use to switch pharmacy in certain conditions. These conditions include negative experience with current pharmacy, awareness of quality information, number of pharmacies available, or moving to a new area. Urban patients were more likely to switch pharmacies using quality information than rural patients. Medication safety and providing access to medications were necessary quality measures when choosing and switching pharmacies. After holding location and costs constant, the following attributes were deemed necessary (in order): medication safety, competency, and access (pharmacy hours of operation). Extended hours 7 days a week (8 AM-10 PM) was preferred by respondents over extended hours on weekdays and reduced hours on weekends over reduced hours on weekdays and closed on Sundays.
Patient population, setting, region
Year
Sleath et al.,15 2009
To examine factors that are important in choosing a pharmacy among Latino patients
Self-identified Latinos 18 years or older taking at least 1prescription; 3 central NC counties
Late 2006 eearly 2007
Shiyanbola et al.,16 2016
To examine older adults’ reasons for choosing a pharmacy
Adults 65 and older who filled a prescription at community pharmacy within 90 days before recruitment; study held at community centers and senior residence facilities
MayeJuly 2014
Shiyanbola et al.,17 2015
To describe the use of quality measures in choosing and switching a community pharmacy
Patients with chronic illness and used a community pharmacy to fill their current prescriptions; patients recruited from rural and urban areas in Midwestern state
Patterson et al.,18 2018
To determine patient preferences for community pharmacy attributes
Adults ( 18 years) who filled a prescription at a pharmacy other than mail-order within last 12 months; national sample
Size (n)
P.M. Patel et al. / Journal of the American Pharmacists Association xxx (2019) 1e8
Data-collecting method
Goal
Author(s), year
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Table 1 Summary of included studies
241
Survey
Not specified
332
Survey; structural equation modeling
Grocery store patrons (not necessarily pharmacy patrons) were recruited from 8 grocery store locations in central Ohio
Dec 2005eJan 2006
163
Survey
To identify motivating factors for use of community pharmacies
Residents of Toledo, Ohio (Midwest city)
Not specified
91
Survey
Franic et al.,22 2008
To identify which pharmacy attributes were drivers of pharmacy patronage
Adults at independent, grocery store, chain, and discount store pharmacies in Georgia were recruited
Not specified
175
Survey; determinant attribute analysis
Dominelli et al.,23 2005
To examine the differences in service preferences between chain and grocery patrons
Loyal customers (> $200/week in grocery purchases) were identified from discount card database; 8 supermarket stores in competition from chain pharmacies and other supermarkets in the vicinity
Not specified
917
Survey
To identify the relationship with pharmacy services, patient satisfaction, and pharmacy patronage
Mardanov et al.,20 2013
To test the relationship of pharmacist’s professionalism and helpfulness on consumer loyalty
Lindstrom et al.,21 2007
To assess preferences associated with pharmacy services
HolidayGoodman et al.,14 2007
Random sample generated from prescription and clinical pharmacy service; an independent community pharmacy in Midwestern city that offers MTM, cholesterol screening, immunizations, and other pharmacy services Adults ( 18 years) in Midwest
Respondents most commonly reported professional relationship with staff, convenience, and local pharmacy ownership as patronage motives. Marketing and offering unique services may increase awareness but not enough to bring patients. Pharmacist’s professionalism and willingness to help are associated positively with consumer loyalty. Customers’ willingness to ask for help is contingent to pharmacist's helpfulness and professionalism. Communication and helpfulness help build relationships and in turn customer loyalty. Availability of automatic refills, 24-hour pharmacy within 20 miles of home, 24hour drug information, vaccinations, and urgent care clinics inside pharmacy were most frequently reported preferred services in pharmacy. Among community pharmacy patrons, time delay, high prices, and no opportunity to ask questions were reasons (in rank from 1 to 3) for not using the community pharmacy. Quality and reliability were highly ranked when choosing a community pharmacy. Staff characteristics (competency, reputation, caring, friendliness, knowledge) were prominent in the decision-making of pharmacy selection. Location was important among discount and grocery store patrons; however, staff characteristics were more important. Knowing and trusting the pharmacy staff emerged as a factor that influenced patients’ pharmacy selection. Storage and protection of insurance and prescription information, convenience, and shopping while waiting were also top priorities that patients consider.
Patient preferences of community pharmacy
MayeJuly 2011
Patterson et al.,19 2013
Abbreviations used: MTM, medication therapy management; NC, North Carolina.
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pharmacies, and Lindstrom et al.21 evaluated preferences of patients who shopped at a grocery store. Franic et al.22 was the only study that collected information about patient preferences in the following 4 different community pharmacy settings: grocery, chain, independent, and discount. The researchers also evaluated patient preferences of special populations. Sleath et al.15 evaluated the factors important in choosing a pharmacy among a Latino population. Shiyanbola et al.16 examined the factors associated with choosing a pharmacy among the elderly. In another study, Shiyanbola et al.17 explored the differences in attributes between an urban and rural setting. Pharmacy attributes Figure 2 indicates the attributes considered important for choosing a pharmacy. Although Figure 2 indicates the most frequently reported attributes, it is important to note that the factors cannot be ranked according to the number of mentions in the study, because of the substantial variability in patient population, study setting, and methods employed in evaluating patient preferences. Location and cost repeatedly appeared as determinants of choosing one pharmacy over another.14-16,19,21-23 Whereas the location was a consistent attribute for choosing one pharmacy over another, some studies reported different results. Sleath et al.15 reported that Latinos did not consider the location to be an important factor in choosing a pharmacy. Also, Franic et al.22 reported that location was important among discount and grocery store patrons rather than chain and independent pharmacy patrons. In addition, Patterson et al.18 in their discrete choice experiment held location and cost constant as they identified these as potentially dominating factors in the decision-making process. Short wait times, extended hours of operation (open 7 days a week from 8 AM to 10 PM), ability to shop within the store, and inventory availability were other frequently cited attributes responsible in choice of pharmacy.14-18,23 Availability of drive-through and multiple locations (for transferability) were reported as attributes by the elderly respondents.16 Respondents in the study conducted by Patterson et al.19 reported local pharmacy ownership as a factor in choosing a pharmacy. However, it must be noted that these respondents were recruited from a Midwestern independent pharmacy.19 Insurance acceptance was another determinant that influenced patients’ pharmacy selection. Dominelli et al.23 found that patients would pick pharmacies that accepted their
Relationship Reputation Respectful/Courteous Competence Friendly Prices Quality Metrics Value-Added Services* Convenience/Location Wait Time 0
1
2
3 4 Number of Studies
5
Pharmacy personnel attributes Friendliness, competence, helpfulness, and a cordial relationship repeatedly appeared as determinants of choosing one pharmacy over another.15,16,19,20,22,23 Other traits of personnel that are considered important include trustworthy, professional, competent, caring, knowledgeable, responsive, and approachable.14,16,18,20,22,23 Sleath et al15 reported that Latinos considered being treated with respect, availability of Spanishspeaking staff, or availability of interpreter to be important factors in choosing a pharmacy. Notably, personnel attributes were reported as being more important than pharmacy attributes by a few studies.15,19,22 Service and quality attributes While the attributes related to relationship and convenience were widely examined in all eligible studies, clinical services and quality ratings were thoroughly examined in few studies.16-18,21 Availability of auto-refill service and high ratings on medication safety (detecting drug interactions) were consistently reported as important factors in choosing a pharmacy.16-18,21 Elderly patients reported the availability of prescription delivery and medication packaging as services that would help them choose one pharmacy over another.16 Lindstrom et al.21 reported that patients gave high preference ratings to clinical services like additional education, screening, vaccination, and other chronic disease-related services. Also, the availability of the urgent care clinic inside the pharmacy was a preferred option that was reported.21 The role of utilizing quality metrics was limited to pharmacy switching in certain conditions and not associated with pharmacy selection.17 Shiyanbola et al.17 reported that quality measures such as detecting drug interactions and high-risk medications, among others, played an important role in choosing or switching a pharmacy when there was a negative experience with their current pharmacy. However, patients were hesitant to use these measures in pharmacy selection.17 Notably, urban patients were more likely to use quality information as a determinant compared with rural patients.17 Patterson et al.18 reported that medication safety quality measures (drug-drug interactions) were more important than competency and access when choosing a pharmacy. Overall, only some aspects of clinical services and pharmacy quality metrics were deemed as determinant factors in patients’ pharmacy selection, but they still did not rank as high as pharmacy and personnel attributes.
6
Figure 2. Most frequently reported top attributes in included studies. *Valueadded servicesddelivery, auto-refill, medication packaging, disease state management, vaccination.
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insurance compared to pharmacies that do not. Insurance acceptance was reported as an attribute by elderly patients interviewed in the study conducted by Shiyanbola et al.16 However, among pharmacies that accepted insurance, insurance was no longer a top priority.22 Additionally, patients tend to prefer pharmacies that already have insurance and prescription records on file; this was indicated in Dominelli et al.23 but was not examined further in other studies.
Discussion This review of key attributes that influence patients’ selection of pharmacy in the United States included 10 studies that
SCIENCE AND PRACTICE Patient preferences of community pharmacy
were published from 2005 to 2018. Pharmacist traits like friendly, helpful, trustworthy, professional, competent, caring, knowledgeable, responsive, and approachable are fundamental attributes that influence a patient’s selection, and are sometimes more important than location and cost.15,16,19,20,22,23 Studies have indicated that trust in pharmacists is a driver of patient satisfaction, which in turn leads to loyalty.27 Given the availability of comparable options concerning location and cost (most pharmacies are contracted with major insurance carriers), often the determining factor becomes the cordial relationship with the pharmacy personnel. Consequently, it is crucial to invest in human resource management. For example, recruitment processes should not only look at technical expertise, but also incorporate interpersonal skills and emotional intelligence. The patient experience should be continuously measured to identify any shortcomings and should be addressed accordingly. Workflow processes require continuous quality improvement to deliver high quality service. Training could be provided to the staff to deal with the demands of the service-oriented workflow. Location and cost appeared consistently as factors important in choosing a pharmacy.14-16,19,21-23 This is consistent with research done in the years before this review.10-12 Additionally, short wait times, extended hours of operation (open 7 days a week from 8 AM to 10 PM), ability to shop within the store, and inventory availability were other frequently cited attributes responsible in choice of pharmacy.14-18,23 These attributes indicate the importance of ease of access, multitasking, and quick service in today's fast-paced atmosphere. However, this also presents an opportunity for pharmacies to engage with their customer at places other than from behind the counter. Research has evaluated patient perception of store layout and pharmacist attire and its impact on the patient experience.28-31 Creating an atmosphere that is inviting can affect the patients’ experience and in turn pharmacy loyalty. Community pharmacy has continued to evolve from performing dispensing duties to providing patient-centered care. Future models are being evaluated to expand the role of pharmacies and pharmacists to prescribing, point-of-care testing, screening, and enhanced counseling.32,33 Because of the proliferation of value-added services such as medication synchronization, medication therapy management, diseasespecific programs, or vaccinations, it is essential to assess the patients’ receptiveness of these services. This review reports availability of auto-refill service and high ratings on medication safety as important factors in choosing a pharmacy.16-18,21 This may indicate that patients still perceive pharmacists primarily as medication experts. Foraying into provider roles may be associated with receptiveness as well as reimbursement challenges. There has been conflicting evidence on patient perceptions of and willingness to pay for clinical services provided by pharmacists.34,35 With many pharmacies having in-store clinics, the receptiveness of these clinics and their impact on patient patronage needs to be evaluated to enhance the patient experience. Lessons learned from the experiences in the expansion of pharmacists’ roles in vaccination and providing medication therapy management need to be applied as we transition into provider roles. Publicly available quality metrics are being utilized more frequently across healthcare, especially when choosing health
insurance. Currently, pharmacy-specific quality metrics are not available to the public. However, that may change soon. A few studies in this review have evaluated the association of quality and pharmacy patronage.17,18 These studies indicate that medication safety quality measures were perceived as necessary by the patients.18 Currently, pharmacies are rated based on adherence to chronic medications for blood pressure, hypercholesterolemia, and diabetes. In addition, they are also rated based on the number of elderly patients on high-risk medications. The performance on these parameters is used by health plans to give in-network or out-of-network status to the pharmacies. With the acceptance of insurance being an important factor in choosing a pharmacy, it is critical that pharmacies provide interventions aimed at improving medication adherence for their patients. Hispanic patients have reported cultural and linguistic challenges when seeking medications.36,37 Sleath et al.15 evaluated patient preferences of pharmacy attributes among Latino patients and found that being treated with friendliness, access to medical information in Spanish, and having staff that speaks Spanish are important factors. Additionally, cost was an important factor in this group of patients.15 This is consistent with literature that indicates that lack of insurance served as a barrier in getting healthcare among Spanish-speaking patients.38 Also, their perceived negative attitudes from pharmacy personnel and lack of Spanish-speaking providers affected satisfaction with pharmacy services negatively.36,38 Having access to Spanish-speaking staff and medical information in Spanish can provide a competitive advantage, especially in areas with a higher number of Hispanics. This review has several limitations with respect to generalizability and ranking. Most of these studies were conducted in one region and sometimes in just one pharmacy. This limitation in the geographic area makes it difficult to generalize the results to other parts of the country. A more extensive study, including many states and regions of the country, may be needed to evaluate patients’ preferences of pharmacy attributes. Additionally, although Figure 2 presents the attributes that are important, it must be noted that there was substantial variation in study population, study setting, and study methodology. Some studies were qualitative, because of which, ranking was not ascertained.16,17 Also, one study kept the effects of location and cost constant.18 Hence, the evidence generated in this review cannot be generalized or ranked. Additionally, most participants in these studies were older, Caucasian, and female. Race, gender, and age may be factors that influence preferences of pharmacy attribute. Future studies should further investigate how these factors may play a role in patients’ choices.
Conclusion The results of this review found that a relationship with a respectful, friendly, competent pharmacist represents important pharmacist-related attributes in the process of pharmacy selection. Important pharmacy-related attributes include cost, convenience, and wait times. Availability of auto-refill service was also a frequently reported attribute in this review.
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References 1. National Center for Health Statistics (US). Health, United States, 2014: With Special Feature on Adults Aged 55–64. Hyattsville, MD: National Center for Health Statistics (US); 2015 May. Available at: https://www. ncbi.nlm.nih.gov/books/NBK299348/. Accessed February 19, 2019. 2. Number of retail prescription drugs filled at pharmacies by payer. The Henry J. Kaiser Family Foundation. Available at: https://www.kff.org/health-costs/ state-indicator/total-retail-rx-drugs/. Accessed February 19, 2019. 3. IQVIA. A review of 2016 and outlook to 2021. Available at: https://www. iqvia.com/institute/reports/medicines-use-and-spending-in-the-us-areview-of-2016. Accessed February 19, 2019. 4. Schumock GT, Li EC, Suda KJ, et al. National trends in prescription drug expenditures and projections for 2014. Am J Health Syst Pharm. 2014;71(6):482e499. 5. Qato DM, Zenk S, Wilder J, Harrington R, Gaskin D, Alexander GC. The availability of pharmacies in the United States: 2007e2015. PLOS ONE. 2017;12(8):e0183172. 6. Melton BL, Lai Z. Review of community pharmacy services: what is being performed, and where are the opportunities for improvement? Integr Pharm Res Pract. 2017;6:79e89. 7. Schommer JC, Yusuf AA, Hadsall RS. Market dynamics of community pharmacies in Minnesota, U.S. from 1992 through 2012. Res Social Adm Pharm. 2014;10(1):217e231. 8. Kaldy J. Medical home 101: the pharmacist’s role in this growing patientcentered care model. Consult Pharm. 2010;25(8):468e474. 9. Satterfield JM, Spring B, Brownson RC, et al. Toward a transdisciplinary model of evidence-based practice. Milbank Q. 2009;87(2):368e390. 10. Shannon GW, Cromley EK, Fink 3rd JL. Pharmacy patronage among the elderly: selected racial and geographical patterns. Soc Sci Med. 1985;20(1):85e93. 11. Carrol NV, Gagon JP. Identifying consumer segments in health services markets: an application of conjoint and cluster analyses to the ambulatory care pharmacy market. J Health Care Mark. 1983;3(3):22e34. 12. Schommer JC. The effect of age on pharmacy patronage: is locational convenience a lurking variable? J Pharm Mark Manag. 1994;9(1):33e46. 13. Linton A, Garber M, Fagan NK, Peterson M. Factors associated with choice of pharmacy setting among DoD health care beneficiaries aged 65 years or older. J Manag Care Pharm. 2007;13(8):677e686. 14. Holiday-Goodman M, Darley WK, Lively BT, Siganga W, DeshmukhEstoll HC. Investigation of consumer choice of community, mail order, or internet pharmacies. J Pharm Technol. 2007;23(1):16e22. 15. Sleath B, Blalock SJ, Bender DE, Murray M, Cerna A, Cohen MG. Latino patients’ preferences for medication information and pharmacy services. J Am Pharm Assoc (2003). 2009;49(5):632e636. 16. Shiyanbola OO, Mott DA, Croes KD. The structural and process aspects of pharmacy quality: older adults’ perceptions. Int J Clin Pharm. 2016;38(1): 96e106. 17. Shiyanbola OO, Mort JR. Patients’ perceived value of pharmacy quality measures: a mixed-methods study. BMJ, (Open). 2015;5(1):e006086. 18. Patterson JA, Holdford DA, Harpe SE. Patient preferences for objective quality metrics during community pharmacy selection: a discrete choice experiment. Res Soc Adm Pharm. 2019;15(6):641e649. 19. Patterson BJ, Doucette WR, Urmie JM, McDonough RP. Exploring relationships among pharmacy service use, patronage motives, and patient satisfaction. J Am Pharm Assoc (2003). 2013;53(4):382e389. 20. Mardanov IT, Ricks J. Pharmacist professionalism, helpfulness, and consumer behavior linkage. J Med Mktg. 2013;13(4):221e230. 21. Lindstrom NS, Casper KA, Green TR, Pedersen CA. Designing pharmacy services based on grocery store patron preferences. J Am Pharm Assoc (2003). 2007;47(5):605e612.
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22. Franic DM, Haddock SM, Tucker LT, Wooten N. Pharmacy patronage: identifying key factors in the decision making process using the determinant attribute approach. J Am Pharm Assoc. 2008;48(1):71e85. 23. Dominelli A, Weck Marciniak M, Jarvis J. Service preferences differences between community pharmacy and supermarket pharmacy patrons. Health Mark Q. 2005;23(1):57e79. 24. Viney R, Lancsar E, Louviere J. Discrete choice experiments to measure consumer preferences for health and healthcare. Expert Rev Pharmacoecon Outcomes Res. 2002;2(4):319e326. 25. Glaser DN. A first course in structural equation modeling. 2nd ed. Tenko Raykov and George A. Marcoulides. Mahwah, NJ: Lawrence Erlbaum Associates, Inc., 2006. Structural Equation Modeling: A Multidisciplinary Journal. 2008;15(1):174e181. 26. Buhi ER, Goodson P, Neilands TB. Structural equation modeling: a primer for health behavior researchers. Am J Health Behav. 2007 Jan-Feb;31(1): 74e85. 27. Castaldo S, Grosso M, Mallarini E, Rindone M. The missing path to gain customers loyalty in pharmacy retail: the role of the store in developing satisfaction and trust. Res Social Adm Pharm. 2016;12(5): 699e712. 28. Emmett D, Paul DP, Chandra A, Barrett H. Pharmacy layout: what are consumers' perceptions? J Hosp Mark Public Relat. 2006;17(1):67e77. 29. Bentley JP, Stroup LJ, Wilkin NE, Bouldin AS. Patient evaluations of pharmacist performance with variations in attire and communication levels. J Am Pharm Assoc (2003). 2005;45(5):600e607. 30. Cretton-Scott E, Johnson L, King S. Pharmacist attire and its impact on patient preference. Pharm Pract (Granada). 2011;9(2):66e71. 31. Khanfar NM, Zapantis A, Alkhateeb FM, Clauson KA, Beckey C. Patient attitudes toward community pharmacist attire. J Pharm Pract. 2013;26(4):442e447. 32. Scott A, Bond C, Inch J, Grant A. Preferences of community pharmacists for extended roles in primary care: a survey and discrete choice experiment. Pharmacoeconomics. 2007;25(9):783e792. 33. Whitty JA, Kendall E, Sav A, et al. Preferences for the delivery of community pharmacy services to help manage chronic conditions. Res Social Adm Pharm. 2015;11(2):197e215. 34. Feehan M, Walsh M, Godin J, Sundwall D, Munger MA. Patient preferences for healthcare delivery through community pharmacy settings in the USA: a discrete choice study. J Clin Pharm Ther. 2017;42(6): 738e749. 35. Tootelian DH, Rolston LW, Negrete MJ. Consumer receptiveness to nontraditional roles for community pharmacists. Health Mark Q. 2005;23(1):43e56. 36. Bradshaw M, Tomany-Korman S, Flores G. Language barriers to prescriptions for patients with limited English proficiency: a survey of pharmacies. Pediatrics. 2007;120(2):e225ee235. 37. Flores G. Language barriers to health care in the United States. N Engl J Med. 2006;355(3):229e231. 38. Olenik NL, Gonzalvo JD, Snyder ME, Nash CL, Smith CT. Perceptions of Spanish-speaking clientele of patient care services in a community pharmacy. Res Social Adm Pharm. 2015;11(2):241e252. Pranav M. Patel, PharmD, MS, Research Assistant, University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, OH Varun Vaidya, PhD, Associate Professor, University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, OH Feyikemi Osundina, PharmD, MS, US Oncology Advocacy & Policy Manager, Bristol-Myers Squibb, Lawrenceville Township, NJ Djatomah A. Comoe, PharmD(c), student pharmacist, University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, OH
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REVIEW
Determining patient preferences of community pharmacy attributes: A systematic review Pranav M. Patel*, Varun Vaidya, Feyikemi Osundina, Djatomah A. Comoe a r t i c l e i n f o
a b s t r a c t
Article history: Received 6 October 2019 Accepted 11 October 2019
Objective: Patient selection of community pharmacy is based on a multitude of factors. With increasing competition and rapidly changing face of pharmacy, identification of these factors is critical for patient satisfaction and financial success. This systematic review summarizes patient preferences for different attributes of community pharmacy. Data sources: Systematic review of peer-reviewed studies conducted on U.S. population, published from 2005 to 2018 in EBSCO, PubMed, and EMBASE, was conducted to identify attributes of community pharmacy that determine patient patronage. Study selection: Studies conducted between 2005 and 2018 on U.S. population that examined attributes in choosing a pharmacy were eligible for this systematic review. Data extraction: Data were independently extracted, assessed, and evaluated by 2 reviewers. Any disagreements were resolved by the third reviewer. Data obtained included year, setting, number of patients, data-collection/evaluation methods, and relevant results and outcomes. Results: Of the 713 papers identified, 10 articles met the inclusion criteria and were included in this systematic review. Majority of the studies used surveys to examine key attributes that influence patients’ selection of a pharmacy. Pharmacist traits like friendly, helpful, trustworthy, professional, competent, caring, knowledgeable, responsive, and approachable are critical attributes that influence a patient’s selection of pharmacy. Convenience (i.e., location, hours of operation, wait time, stock availability) also influenced patients’ selection of pharmacy. Cost and contract with insurance were other important factors. Availability of autorefills appeared consistently in the studies. Medication safety (detecting drug interactions) quality metrics also appeared high among patients’ preferences. Conclusion: The results of this review found that a relationship with a respectful, friendly, competent pharmacist represents important pharmacist-related attributes in the process of pharmacy selection. Important pharmacy-related attributes include cost, convenience, and wait times. Availability of auto-refill service was also a frequently reported attribute in this review. © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
Background The number of dispensed medications in the United States has been steadily increasing.1 In the year 2017, approximately 4 billion prescriptions were filled at a community pharmacy.2 Also, the expenditure for prescription medications increased
Disclosure: The authors declare no relevant conflicts of interest or financial relationships. * Correspondence: Pranav M. Patel, PharmD, MS, Graduate Research Assistant, University of Toledo, 39279 Huron Parkway, Westland, MI 48185. E-mail address: [email protected] (P.M. Patel).
from $324 billion in 2015 to $328 billion in 2016.3 This rise in prescription medication expenditures and increasing demand may be attributed to the growth in incidence of chronic diseases, especially in the elderly population.4 The Affordable Care Act has also fueled the utilization of prescription medications because of expanded coverage, which enabled access to medications.4 The number of community pharmacies in the United States has been increasing as well. The number of community pharmacies has risen from 63,752 to 67,753 from 2007 to 2015, respectively, representing a 6.3% increase during that time.5 These pharmacies cover 92% of the U.S. population within 2
https://doi.org/10.1016/j.japh.2019.10.008 1544-3191/© 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE P.M. Patel et al. / Journal of the American Pharmacists Association xxx (2019) 1e8
Methods Key Points Data sources and search strategy Background: Community pharmacy is a crowded and highly competitive market. Newer models of community pharmacy offer a variety of products and services. Not much is known about patients’ preferences of community pharmacy attributes involved in the decision-making process of choosing a pharmacy. Findings: Staff attributesdfriendly, helpful, trustworthy, competent, knowledgeable. Pharmacy attributesdlocation, hours of operation, wait time, stock availability. Service attributesdauto-refill programs, delivery, medication safety metrics. miles of a pharmacy.5 Over the years, there has been a rejuvenation of community pharmacy in terms of store capacity, clinical and nonclinical services, and other offerings (products or services) to the patients.6 However, this progress in community pharmacy has also led to more competition in this crowded market.7 Higher densities of pharmacies and prescription coverage have helped level the playing field with respect to the role of location and out-of-pocket payments in the pharmacy selection process.7 Additionally, the penetration of mail-order pharmacies into the community pharmacy’s market share creates competition from an external source. Therefore, it is important for community pharmacies to explore patients’ preferences and adjust their models to remain competitive. Apart from staying competitive, considering patient preferences may help community pharmacies transition toward a patient-centered model.8 The traditional models of care often fail to take into account patients’ choices.9 More unified, transdisciplinary evidence-based practice models such as patient-centered models of care, have been embraced by community pharmacists.7 The patientcentered model not only attempts to promote evidencebased medicine, but it also considers individual preferences to achieve patient outcomes.7 As an important player in the healthcare system, there is an increasing need for community pharmacies to identify patients’ preferences and adapt their pharmacy’s services to match those preferences. Previous literature has explored the attributes of pharmacy patronage; however, many of these studies were conducted over twenty years ago.10-12 More recent studies have explored the determinants of choosing mail-order versus community pharmacy.13,14 In light of the lack of relevant recent data on consumer preferences, the aim of this study was to systematically review, summarize, and evaluate the literature to identify patient preferences for different attributes of community pharmacy.
2
Three databasesdEBSCO, PubMed, and EMBASEdwere searched. The following search strategy was used to identify the studies: ( "community pharmac*" OR retail pharmacy OR "Pharmacies and Drug Stores" ) AND ( (consumer-prefer* OR consumer-behavior* OR consumerattitude*) or (patient-prefer* OR patient-behavior* OR patient-attitude*) OR (customer-prefer* OR customerbehavior* OR customer-attitude*) OR consumer-choice* OR patient-choice* OR customer-choice* OR patient-satisfaction ) Eligibility criteria and study selection Studies were included only if they evaluated patient preferences of choosing a pharmacy. This review only included studies conducted between 2005 and 2018 on the U.S. patient population. This time period was chosen because it coincides with the preparatory phase of Medicare Part D rollout in 2006 and reflects current patient preference trends. This review excluded studies conducted on non-U.S. patients because the practice setting, expectations, and scope of practice may not be identical. During the selection process, a preliminary search of the databases with the keyword combination was conducted. Then, each reference title was screened for eligibility according to the inclusion criteria (Figure 1). Next, all included abstracts were screened for potentially eligible studies. Finally, full texts of all included studies were retrieved and screened for eligibility. All articles that met the inclusion criteria and were deemed relevant to the research topic of this review were included. In addition, the reference lists of included studies were searched for more articles. The review was performed by 2 independent reviewers. Any disagreement between these reviewers was resolved by the third reviewer. Data-collection process A standardized data extraction form was developed a priori. Data were extracted from the studies included by 2 independent investigators. Data obtained included author, date of publication, year, study setting, number of patients, patient population, data-collection, evaluation methods, and relevant results and outcomes. Results A search of databases carried out by employing different combinations of the keywords resulted in 713 unique studies. After title and abstract screening, 32 articles were remaining. Of the 32 articles identified for potential inclusion, 10 were included in the review. Studies were excluded because of the following reasons: evaluated patient satisfaction (n ¼ 17), evaluated pharmacist attire and perception of pharmacy quality (n ¼ 2), evaluated determinants of mail-order pharmacy versus community pharmacy (n ¼ 1), and evaluated in
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Identification
Patient preferences of community pharmacy
Records identified through database searching (n = 978 )
Included
Eligibility
Screening
Records after duplicates removed (n = 713 )
Records screened (n = 713 )
Full-text articles assessed for eligibility (n = 32 )
Records excluded (n = 681 )
Full-text articles excluded, with reasons (n = 22 ) n = 17: evaluate patient satisfaction n = 2: evaluate pharmacist attire n = 2: non-United States n = 1: evaluate mail-order versus community pharmacy
Studies included in evidence synthesis (n = 10 )
Figure 1. Flowchart of article selection.
non-U.S. settings (n ¼ 2). Researchers used surveys and focus group studies to collect patient preferences of attributes a desired pharmacy should have and improve. Figure 1 illustrates the steps of the database search and selection process. The available studies are described by their goals, patient population, setting of community pharmacy, year of study, datacollection method, statistical tests, and results in Table 1.
aimed to examine relationships among variables.25,26 This may be used to explain or predict decision-making attributes.25,26 Franic et al.22 employed the determinant attribute approach, which is a marketing tool to determine consumers’ motives or preferences. The determinant attribute approach takes into consideration both the importance and perceived difference of a certain product or service utilizing a survey.22
Data collection and analysis
Patient characteristics
There was substantial variation in methods utilized to identify attributes important in choosing a pharmacy. A majority of the studies used a survey to evaluate patient preferences.14,15,17,19-23 Patterson et al.18 elicited preferences of patients using a discrete choice experiment. Discrete choice experiments measure stated preferences by asking individuals to choose from the options presented.24 Shiyanbola et al.16,17 utilized a qualitative approach (focus group study) to identify themes that determine preferences. Mardanov et al.20 used a survey and structural equation modeling. Structural equation modeling is an advanced multivariate statistical method
There was substantial variation in the characteristics of the patients examined in the eligible studies. Multiple studies represented the preferences of the patients in the Midwest region.14,16,17,19,21 Other regions represented were Georgia,22 Northeastern U.S.,23 and central North Carolina.15 Patterson et al.18 examined responses from a national sample. All of the studies recruited patients from multiple sites except for the study conducted by Patterson et al.,19 which recruited patients getting service from one independent community pharmacy. Dominelli et al.23 evaluated the preferences of consumers who shopped at supermarkets compared to those who shopped at community 3
Result
93
Survey
60
Focus group study; 90 min; divided into 6 groups
Not specified
34 (12 rural; 22 urban)
Semistructured focus group and survey; 60-90 min
Not specified
741
Discrete choice experiment
Latino patients reported being treated with respect and friendliness by pharmacy employees, cheaper medications compared with other pharmacies, and written information in Spanish as factors that are very important when choosing a pharmacy. Other attributes included employees speaking Spanish, availability of interpreter, and fast pace of service. Fewer respondents found location to be an important factor in the pharmacy selection process. Proximity to house, drive-through, short wait times, prescription delivery, medication packaging, convenience store for other shopping, multiple locations (transferability), cost, contracted with insurance, and auto-refills were all reported as factors when choosing a pharmacy. Additionally, relationship with pharmacists and staff was important. Traits of staffdresponsiveness, helpfulness, and friendlinessdwere reported as reasons for choosing a pharmacy. Respondents hesitant to use quality measures to choose a pharmacy but may use to switch pharmacy in certain conditions. These conditions include negative experience with current pharmacy, awareness of quality information, number of pharmacies available, or moving to a new area. Urban patients were more likely to switch pharmacies using quality information than rural patients. Medication safety and providing access to medications were necessary quality measures when choosing and switching pharmacies. After holding location and costs constant, the following attributes were deemed necessary (in order): medication safety, competency, and access (pharmacy hours of operation). Extended hours 7 days a week (8 AM-10 PM) was preferred by respondents over extended hours on weekdays and reduced hours on weekends over reduced hours on weekdays and closed on Sundays.
Patient population, setting, region
Year
Sleath et al.,15 2009
To examine factors that are important in choosing a pharmacy among Latino patients
Self-identified Latinos 18 years or older taking at least 1prescription; 3 central NC counties
Late 2006 eearly 2007
Shiyanbola et al.,16 2016
To examine older adults’ reasons for choosing a pharmacy
Adults 65 and older who filled a prescription at community pharmacy within 90 days before recruitment; study held at community centers and senior residence facilities
MayeJuly 2014
Shiyanbola et al.,17 2015
To describe the use of quality measures in choosing and switching a community pharmacy
Patients with chronic illness and used a community pharmacy to fill their current prescriptions; patients recruited from rural and urban areas in Midwestern state
Patterson et al.,18 2018
To determine patient preferences for community pharmacy attributes
Adults ( 18 years) who filled a prescription at a pharmacy other than mail-order within last 12 months; national sample
Size (n)
P.M. Patel et al. / Journal of the American Pharmacists Association xxx (2019) 1e8
Data-collecting method
Goal
Author(s), year
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4
Table 1 Summary of included studies
241
Survey
Not specified
332
Survey; structural equation modeling
Grocery store patrons (not necessarily pharmacy patrons) were recruited from 8 grocery store locations in central Ohio
Dec 2005eJan 2006
163
Survey
To identify motivating factors for use of community pharmacies
Residents of Toledo, Ohio (Midwest city)
Not specified
91
Survey
Franic et al.,22 2008
To identify which pharmacy attributes were drivers of pharmacy patronage
Adults at independent, grocery store, chain, and discount store pharmacies in Georgia were recruited
Not specified
175
Survey; determinant attribute analysis
Dominelli et al.,23 2005
To examine the differences in service preferences between chain and grocery patrons
Loyal customers (> $200/week in grocery purchases) were identified from discount card database; 8 supermarket stores in competition from chain pharmacies and other supermarkets in the vicinity
Not specified
917
Survey
To identify the relationship with pharmacy services, patient satisfaction, and pharmacy patronage
Mardanov et al.,20 2013
To test the relationship of pharmacist’s professionalism and helpfulness on consumer loyalty
Lindstrom et al.,21 2007
To assess preferences associated with pharmacy services
HolidayGoodman et al.,14 2007
Random sample generated from prescription and clinical pharmacy service; an independent community pharmacy in Midwestern city that offers MTM, cholesterol screening, immunizations, and other pharmacy services Adults ( 18 years) in Midwest
Respondents most commonly reported professional relationship with staff, convenience, and local pharmacy ownership as patronage motives. Marketing and offering unique services may increase awareness but not enough to bring patients. Pharmacist’s professionalism and willingness to help are associated positively with consumer loyalty. Customers’ willingness to ask for help is contingent to pharmacist's helpfulness and professionalism. Communication and helpfulness help build relationships and in turn customer loyalty. Availability of automatic refills, 24-hour pharmacy within 20 miles of home, 24hour drug information, vaccinations, and urgent care clinics inside pharmacy were most frequently reported preferred services in pharmacy. Among community pharmacy patrons, time delay, high prices, and no opportunity to ask questions were reasons (in rank from 1 to 3) for not using the community pharmacy. Quality and reliability were highly ranked when choosing a community pharmacy. Staff characteristics (competency, reputation, caring, friendliness, knowledge) were prominent in the decision-making of pharmacy selection. Location was important among discount and grocery store patrons; however, staff characteristics were more important. Knowing and trusting the pharmacy staff emerged as a factor that influenced patients’ pharmacy selection. Storage and protection of insurance and prescription information, convenience, and shopping while waiting were also top priorities that patients consider.
Patient preferences of community pharmacy
MayeJuly 2011
Patterson et al.,19 2013
Abbreviations used: MTM, medication therapy management; NC, North Carolina.
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pharmacies, and Lindstrom et al.21 evaluated preferences of patients who shopped at a grocery store. Franic et al.22 was the only study that collected information about patient preferences in the following 4 different community pharmacy settings: grocery, chain, independent, and discount. The researchers also evaluated patient preferences of special populations. Sleath et al.15 evaluated the factors important in choosing a pharmacy among a Latino population. Shiyanbola et al.16 examined the factors associated with choosing a pharmacy among the elderly. In another study, Shiyanbola et al.17 explored the differences in attributes between an urban and rural setting. Pharmacy attributes Figure 2 indicates the attributes considered important for choosing a pharmacy. Although Figure 2 indicates the most frequently reported attributes, it is important to note that the factors cannot be ranked according to the number of mentions in the study, because of the substantial variability in patient population, study setting, and methods employed in evaluating patient preferences. Location and cost repeatedly appeared as determinants of choosing one pharmacy over another.14-16,19,21-23 Whereas the location was a consistent attribute for choosing one pharmacy over another, some studies reported different results. Sleath et al.15 reported that Latinos did not consider the location to be an important factor in choosing a pharmacy. Also, Franic et al.22 reported that location was important among discount and grocery store patrons rather than chain and independent pharmacy patrons. In addition, Patterson et al.18 in their discrete choice experiment held location and cost constant as they identified these as potentially dominating factors in the decision-making process. Short wait times, extended hours of operation (open 7 days a week from 8 AM to 10 PM), ability to shop within the store, and inventory availability were other frequently cited attributes responsible in choice of pharmacy.14-18,23 Availability of drive-through and multiple locations (for transferability) were reported as attributes by the elderly respondents.16 Respondents in the study conducted by Patterson et al.19 reported local pharmacy ownership as a factor in choosing a pharmacy. However, it must be noted that these respondents were recruited from a Midwestern independent pharmacy.19 Insurance acceptance was another determinant that influenced patients’ pharmacy selection. Dominelli et al.23 found that patients would pick pharmacies that accepted their
Relationship Reputation Respectful/Courteous Competence Friendly Prices Quality Metrics Value-Added Services* Convenience/Location Wait Time 0
1
2
3 4 Number of Studies
5
Pharmacy personnel attributes Friendliness, competence, helpfulness, and a cordial relationship repeatedly appeared as determinants of choosing one pharmacy over another.15,16,19,20,22,23 Other traits of personnel that are considered important include trustworthy, professional, competent, caring, knowledgeable, responsive, and approachable.14,16,18,20,22,23 Sleath et al15 reported that Latinos considered being treated with respect, availability of Spanishspeaking staff, or availability of interpreter to be important factors in choosing a pharmacy. Notably, personnel attributes were reported as being more important than pharmacy attributes by a few studies.15,19,22 Service and quality attributes While the attributes related to relationship and convenience were widely examined in all eligible studies, clinical services and quality ratings were thoroughly examined in few studies.16-18,21 Availability of auto-refill service and high ratings on medication safety (detecting drug interactions) were consistently reported as important factors in choosing a pharmacy.16-18,21 Elderly patients reported the availability of prescription delivery and medication packaging as services that would help them choose one pharmacy over another.16 Lindstrom et al.21 reported that patients gave high preference ratings to clinical services like additional education, screening, vaccination, and other chronic disease-related services. Also, the availability of the urgent care clinic inside the pharmacy was a preferred option that was reported.21 The role of utilizing quality metrics was limited to pharmacy switching in certain conditions and not associated with pharmacy selection.17 Shiyanbola et al.17 reported that quality measures such as detecting drug interactions and high-risk medications, among others, played an important role in choosing or switching a pharmacy when there was a negative experience with their current pharmacy. However, patients were hesitant to use these measures in pharmacy selection.17 Notably, urban patients were more likely to use quality information as a determinant compared with rural patients.17 Patterson et al.18 reported that medication safety quality measures (drug-drug interactions) were more important than competency and access when choosing a pharmacy. Overall, only some aspects of clinical services and pharmacy quality metrics were deemed as determinant factors in patients’ pharmacy selection, but they still did not rank as high as pharmacy and personnel attributes.
6
Figure 2. Most frequently reported top attributes in included studies. *Valueadded servicesddelivery, auto-refill, medication packaging, disease state management, vaccination.
6
insurance compared to pharmacies that do not. Insurance acceptance was reported as an attribute by elderly patients interviewed in the study conducted by Shiyanbola et al.16 However, among pharmacies that accepted insurance, insurance was no longer a top priority.22 Additionally, patients tend to prefer pharmacies that already have insurance and prescription records on file; this was indicated in Dominelli et al.23 but was not examined further in other studies.
Discussion This review of key attributes that influence patients’ selection of pharmacy in the United States included 10 studies that
SCIENCE AND PRACTICE Patient preferences of community pharmacy
were published from 2005 to 2018. Pharmacist traits like friendly, helpful, trustworthy, professional, competent, caring, knowledgeable, responsive, and approachable are fundamental attributes that influence a patient’s selection, and are sometimes more important than location and cost.15,16,19,20,22,23 Studies have indicated that trust in pharmacists is a driver of patient satisfaction, which in turn leads to loyalty.27 Given the availability of comparable options concerning location and cost (most pharmacies are contracted with major insurance carriers), often the determining factor becomes the cordial relationship with the pharmacy personnel. Consequently, it is crucial to invest in human resource management. For example, recruitment processes should not only look at technical expertise, but also incorporate interpersonal skills and emotional intelligence. The patient experience should be continuously measured to identify any shortcomings and should be addressed accordingly. Workflow processes require continuous quality improvement to deliver high quality service. Training could be provided to the staff to deal with the demands of the service-oriented workflow. Location and cost appeared consistently as factors important in choosing a pharmacy.14-16,19,21-23 This is consistent with research done in the years before this review.10-12 Additionally, short wait times, extended hours of operation (open 7 days a week from 8 AM to 10 PM), ability to shop within the store, and inventory availability were other frequently cited attributes responsible in choice of pharmacy.14-18,23 These attributes indicate the importance of ease of access, multitasking, and quick service in today's fast-paced atmosphere. However, this also presents an opportunity for pharmacies to engage with their customer at places other than from behind the counter. Research has evaluated patient perception of store layout and pharmacist attire and its impact on the patient experience.28-31 Creating an atmosphere that is inviting can affect the patients’ experience and in turn pharmacy loyalty. Community pharmacy has continued to evolve from performing dispensing duties to providing patient-centered care. Future models are being evaluated to expand the role of pharmacies and pharmacists to prescribing, point-of-care testing, screening, and enhanced counseling.32,33 Because of the proliferation of value-added services such as medication synchronization, medication therapy management, diseasespecific programs, or vaccinations, it is essential to assess the patients’ receptiveness of these services. This review reports availability of auto-refill service and high ratings on medication safety as important factors in choosing a pharmacy.16-18,21 This may indicate that patients still perceive pharmacists primarily as medication experts. Foraying into provider roles may be associated with receptiveness as well as reimbursement challenges. There has been conflicting evidence on patient perceptions of and willingness to pay for clinical services provided by pharmacists.34,35 With many pharmacies having in-store clinics, the receptiveness of these clinics and their impact on patient patronage needs to be evaluated to enhance the patient experience. Lessons learned from the experiences in the expansion of pharmacists’ roles in vaccination and providing medication therapy management need to be applied as we transition into provider roles. Publicly available quality metrics are being utilized more frequently across healthcare, especially when choosing health
insurance. Currently, pharmacy-specific quality metrics are not available to the public. However, that may change soon. A few studies in this review have evaluated the association of quality and pharmacy patronage.17,18 These studies indicate that medication safety quality measures were perceived as necessary by the patients.18 Currently, pharmacies are rated based on adherence to chronic medications for blood pressure, hypercholesterolemia, and diabetes. In addition, they are also rated based on the number of elderly patients on high-risk medications. The performance on these parameters is used by health plans to give in-network or out-of-network status to the pharmacies. With the acceptance of insurance being an important factor in choosing a pharmacy, it is critical that pharmacies provide interventions aimed at improving medication adherence for their patients. Hispanic patients have reported cultural and linguistic challenges when seeking medications.36,37 Sleath et al.15 evaluated patient preferences of pharmacy attributes among Latino patients and found that being treated with friendliness, access to medical information in Spanish, and having staff that speaks Spanish are important factors. Additionally, cost was an important factor in this group of patients.15 This is consistent with literature that indicates that lack of insurance served as a barrier in getting healthcare among Spanish-speaking patients.38 Also, their perceived negative attitudes from pharmacy personnel and lack of Spanish-speaking providers affected satisfaction with pharmacy services negatively.36,38 Having access to Spanish-speaking staff and medical information in Spanish can provide a competitive advantage, especially in areas with a higher number of Hispanics. This review has several limitations with respect to generalizability and ranking. Most of these studies were conducted in one region and sometimes in just one pharmacy. This limitation in the geographic area makes it difficult to generalize the results to other parts of the country. A more extensive study, including many states and regions of the country, may be needed to evaluate patients’ preferences of pharmacy attributes. Additionally, although Figure 2 presents the attributes that are important, it must be noted that there was substantial variation in study population, study setting, and study methodology. Some studies were qualitative, because of which, ranking was not ascertained.16,17 Also, one study kept the effects of location and cost constant.18 Hence, the evidence generated in this review cannot be generalized or ranked. Additionally, most participants in these studies were older, Caucasian, and female. Race, gender, and age may be factors that influence preferences of pharmacy attribute. Future studies should further investigate how these factors may play a role in patients’ choices.
Conclusion The results of this review found that a relationship with a respectful, friendly, competent pharmacist represents important pharmacist-related attributes in the process of pharmacy selection. Important pharmacy-related attributes include cost, convenience, and wait times. Availability of auto-refill service was also a frequently reported attribute in this review.
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