How pharmacists check the appropriateness of drug therapy? Observations in community pharmacy.

BACKGROUND In Alberta (Canadian province), the Chat Check Chart (CCC) model was developed to help pharmacists understand how patient care standards fit into routine practice. The CCC model outlines a process that covers the following: 1) Chart-asking three prime questions to gather information; 2) Check-perform pharmacotherapy workup by assessing prescription's indication, efficacy, safety and manageability; and 3) Chart-document findings of the pharmacotherapy workup. OBJECTIVES To characterize how pharmacist collect patient information and apply the pharmacotherapy workup when evaluating routine prescriptions in community pharmacy settings. METHODS An observational study with a mixed methods analysis was employed. Participants were surveyed and audio-recorded talking with patients, as well as thinking aloud while evaluating medication therapy. Quantitative analysis was conducted to describe the proportion of time allotted to clinical or technical duties when using the 3 prime questions and pharmacotherapy workup in routine practice. A generic qualitative approach was conducted to describe how the pharmacists evaluated prescriptions and counseled patients. RESULTS Nine pharmacists from five different pharmacy stores participated in this study. Fifteen recordings of consults and 14 think-alouds were eligible for analysis. Pharmacists allotted 16% of their think-aloud on clinical related issues for new and chronic medications, and the remainder on technical dispensing activities. All pharmacists checked if the medication was safe, but fewer than half checked if the prescription was indicated, effective, or useable (i.e., adherence). Pharmacists covered more content areas when checking the appropriateness for new prescriptions in comparison to chronic refills. Four overarching themes arose from the qualitative analysis: missed opportunities, absence of personalized assessments, reliance on routine pharmacist activities, and non-specific questions. CONCLUSIONS Pharmacists gathered insufficient clinical information to assess their patients' medication therapy, as they overly relied on the patients' profiles, asked patients non-specific questions, and missed patient cues. Routine activities appeared to shape practice including a bias against refill prescriptions and a focus on technical dispensing activities.