Exploring the perspectives and strategies of Ontario community pharmacists to improve routine follow-up for patients with diabetes: A qualitative study

Background

Almost 10% of the Canadian population lives with diabetes. ¹ Diabetes is a chronic disease that causes many potentially debilitating and long-term complications. People living with diabetes are over 3 times more likely to be hospitalized with cardiovascular disease, 12 times more likely to be hospitalized with end-stage renal disease and over 20 times more likely to be hospitalized for nontraumatic lower limb amputations compared to the general population. ¹ Moreover, 50% of people living with diabetes in Canada are not achieving their blood glucose targets, 64% are not achieving blood pressure targets and 43% are not achieving lipid targets. ²

The collaboration of many health care professionals, including pharmacists, can improve diabetes care through the provision of patient education and the planning and implementation of holistic care plans. ³ Community pharmacists are in a unique position to contribute to diabetes management due to their knowledge of and expertise in medication management, ⁴ as well as being broadly accessible in large or small, rural or urban communities in Canada and most countries worldwide.^4,5 Active involvement of a community pharmacist in the management of patients’ chronic diseases, such as diabetes, has been shown to optimize medication management and patient outcomes.^6-8

One opportunity community pharmacists in Ontario have available to facilitate care provision for people with diabetes is through the MedsCheck Diabetes (MCD) program. A MCD service is provided to patients with type 1 or type 2 diabetes and includes a focused medication review with advice, training, monitoring and education on diabetes. ⁹ Anyone with a valid Ontario health card and who has been diagnosed with diabetes is eligible for an MCD. Pharmacists are reimbursed $75 per patient for an initial MCD appointment that can be done annually and $25 per patient for a follow-up appointment. ⁹ There is no limit on the number of follow-up appointments that can be billed. MCD services cannot be conducted over the phone or through videoconferencing, and the follow-up must take place at the same pharmacy that provided the initial service. ¹⁰ The program was designed to promote continuity of care for the patient so that the initial appointment can guide subsequent medication management. A similar medication management program is also in place in Australia. ¹¹

Previous research has demonstrated that only about 2.7% to 4.1% of patients who received an MCD also received follow-up by their community pharmacist through the MCD program. ¹² While literature has broadly examined the community pharmacist’s role in diabetes care, ¹³ there is benefit to increasing the depth of understanding regarding community pharmacists’ roles, barriers and facilitators in conducting follow-up after an initial medication review for a patient with diabetes.

The objective of this study was to explore perspectives of community pharmacists in Ontario on barriers and facilitators to routine monitoring and follow-up of patients with diabetes. This was the first phase of a multiphase study, and the findings reported here were used to help develop an online survey administered to pharmacists across Canada. ¹³

Methods

Study participants included community pharmacists working in Ontario who had a Part A (active) license and experience providing MedsChecks to people with diabetes. Participants were recruited through a convenience sample approach, using existing investigator networks, but there was no existing relationship between the interviewer and the participants.

The interviewer contacted the participants to provide an introduction to the study and set up a time for the interview. Participants were aware that the interviewer was part of the research team and a Doctor of Pharmacy student at the University of Toronto.

One-on-one interviews with community pharmacist participants were conducted using a 5-question semistructured interview guide (Appendix 1, available online at www.cpjournal.ca). Interviews were conducted over the phone and were approximately 30 minutes in length. The interviewer was female and received training and conducted pilot testing with a researcher experienced in qualitative interviewing.

All interviews were audiotaped, transcribed verbatim, deidentified and cleaned. No field notes were taken during the interviews. Interviews were conducted until saturation occurred, when identified responses from interview participants began to repeat and no new themes were emerging from the interviews. ¹⁴

We used a qualitative descriptive content analysis approach, ¹⁵ which is a systematic method of analyzing data to categorize and understand the meaning of trends and patterns in the data based on descriptions and characteristics of the research content itself. Three research team members individually and manually analyzed each interview transcript. The researchers identified themes from each interview and then compared individual findings to triangulate the data collected. ¹⁶ These themes were synthesized into a master document. Common themes were identified and reviewed by the research team over multiple discussions, leading to further refinement of theme and subtheme triangulation. Each quote provided below has an associated number in parentheses denoting the study participant number.

The study was approved by the Research Ethics Boards at the University Health Network and the University of Toronto.

Results

Eight pharmacist participants were interviewed in this study. Participants had a mean age of 44 years old (minimum-maximum, 27-52 years). Four participants practised in independent pharmacies, 2 in banner pharmacies and 2 in franchise pharmacies. No participants dropped out, and each participant was interviewed once.

Three main thematic areas emerged that form the basis of the findings of our study: Design of the MedsCheck Program, Environment of Community Pharmacy and Collaboration and Relationships.

Discussion

This study identifies that there is poor alignment between the specifications of the MCD program and how it can be implemented in the community pharmacy setting. Although community pharmacists report that they often provide routine follow-up to their patients with diabetes, these interactions are inconsistently channeled through the MCD program. Our findings suggest that this is due to the design of the MedsCheck Diabetes program, the community pharmacy environment and the current relationships between pharmacists, patients and physicians. Our findings show that while pharmacists understand and endorse their professional responsibility in providing comprehensive care to patients with diabetes and are equipped with the skills to actively conduct routine follow-up, a number of factors impede the success of the MCD program at this time.

Our research shows that community pharmacy workflow is not always conducive to offering MCD follow-up on an in-person walk-in basis. This may result in missed opportunities for follow-up; for documentation to be rushed, incomplete or of poor quality; and for billing for reimbursement to not occur. As our findings and previous research suggests, coordinating MCD appointments with patients coming into the pharmacy to pick up medication could blend the reliability of scheduled follow-up with the convenience of medication pick-up and integrate clinical services into pharmacy workflow. ¹⁷ Virtual MedsCheck visits, which have been permitted during the COVID-19 pandemic, may also improve the implementation of follow-up visits since the logistical challenge of people travelling to the pharmacy is avoided. ¹⁸

Additionally, a major barrier for pharmacists to conduct follow-up through the MCD program is the extensive documentation required. Pharmacist participants reported not always documenting follow-up activities using MCD-approved forms. This is consistent with other studies that have identified the need to employ automated documentation systems to reduce documentation barriers for MedsCheck services. ¹⁹ This optimization is important because documentation of patient care activities has been shown to be crucial for continuity of care, justifying pharmacist salary and sharing information with other health care providers. ²⁰

Our study respondents felt the community pharmacy business model in Ontario was poorly aligned with the MCD program structure. These findings are consistent with other reports identifying that there is a balance between profitability and patient care experienced by many health care professionals; for example, family physicians and nurse practitioners in Ontario are compensated a standard fee for each service they provide. ²¹ Ontario pharmacists are remunerated for MCD follow-up in a similar way, but the pharmacists interviewed in this study felt that the remuneration from the MCD program was not financially sustainable. ¹⁰ This is consistent with the underlying need for revisions to the pharmacy business model to incorporate broader clinical care, including chronic disease prevention and management.^22,23 Further research in this area would provide insight into alternative pharmacy care models that optimize the balance between patient health outcomes, workflow and profit.

Finally, our study points to the well-identified need to improve patient and physician understanding of the role of community pharmacists in diabetes management and awareness of the MCD program. Many patients are unaware of the services available at their community pharmacy, as well as the pharmacist’s role in their care. ¹³ Lack of awareness among physicians regarding the MCD program may also present a major barrier, as the pharmacist may be unable to make clinical interventions without a physician’s authorization. Therefore, a weak relationship between pharmacists and physicians may have a profound impact on the pharmacist’s ability to follow up with their patients and, in turn, provide recommendations to improve the patient’s therapeutic regimen.^24,25

The MCD program was designed as a tool for pharmacists to provide quality, effective follow-up for patients with diabetes. The MCD program should be a helpful tool, given the critical need for diabetes care.^1,9 However, due to poor alignment between the program, community pharmacy and the broader health care environment, only about 2.7% to 4.1% of MCD patients receive follow-up by community pharmacists through the MCD program. ¹² This study suggests several mechanisms that could support the restructuring of the MCD program and workflow in community pharmacy to better enable pharmacists to conduct continuous and proactive follow-up care for people with diabetes through the MCD program (Table 1).

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Table 1

Barriers and strategies associated with the MedsCheck Diabetes (MCD) program and community pharmacy

Barrier	Strategy
Patient must be physically present for the MCD follow-up	Redesign MCD program to include remuneration through various mediums (e.g., phone, email, video call, in person)
Extensive documentation and time required by the MCD program	Employ automated documentation systems to streamline documentation and retrieval of previously gathered information Invest in pharmacy technicians to allow pharmacists to focus more on clinical service provision
Walk-in model for MCD consultations is inconsistent for workflow and staff	Schedule follow-up appointments in advance Coordinate MCD follow-up appointments with medication pickup Provide patients with a reminder card with the appointment details
Pharmacy software does not have a system to track and follow up with patients	Use systems that can track and set scheduled appointment reminders for follow-up
Patients unaware of services they may be eligible to receive from their pharmacist, as well as clinical skills of the pharmacist	Initiate community education programs regarding the pharmacist’s scope of practice Engage front store staff to promote clinical services
Prescribers unaware of pharmacist scope of practice and the MCD program guidelines	Engaging with prescribers to raise awareness and enhance opportunities for collaboration

Conclusion

This study found that the design of the MedsCheck Diabetes program, the community pharmacy environment and the relationships between pharmacists, patients and prescribers can pose a challenge in the conduct of routine monitoring and follow-up through the MedsCheck Diabetes program. Future research should aim to more closely examine and implement strategies to optimize routine monitoring and follow-up in community pharmacy for patients with diabetes, taking into consideration the themes identified in this study. ■

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