Characteristics of Australia\'s community pharmacies: National Pharmacy Database Project

June 4, 2017 | Autor: Andrew Joyce | Categoria: Pharmacy Practice
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IJPP 2007, 15: 265–271 © 2007 The Authors Received August 10, 2006 Accepted May 31, 2007 DOI 10.1211/ijpp.15.4.0003 ISSN 0961-7671

Characteristics of Australia’s community pharmacies: National Pharmacy Database Project Constantine G Berbatis, V Bruce Sunderland, Andrew Joyce, Max Bulsara and Christina Mills

Abstract

School of Pharmacy, Curtin University of Technology, Perth, Western Australia Constantine G Berbatis, lecturer V Bruce Sunderland, professor School of Pharmacy and School of Public Health, Curtin University of Technology, Perth, Western Australia Andrew Joyce, lecturer School of Population Health, University of Western Australia, Perth, Western Australia

Objective To report the characteristics of community pharmacies in Australia and analyse them for their association with pharmacists’ consultation time. Setting A large representative sample of community pharmacies in Australia in 2002. Method Questionnaires were mailed by an independent survey group to managers and owners in a national sample of pharmacies stratified into six zones. Questionnaires were returned by 1131 of 1532 pharmacies contacted (73.8%). The data were analysed using the general linear model (GLM) for univariate analysis. Key findings: Male pharmacists comprised 76.3% of pharmacy owners and 39.5% were aged ≥ 51 years. Most pharmacies (81.1%) had one or two pharmacist owners, and 51.3% of pharmacies were members of marketing groups. Medicines accounted for approximately 75% of annual sales and occupied a minority of the average total area of 187.2 m2. Pharmacies opened for an average of 55.5 h per week. Pharmacists spent 18.8% of their time on patient consultation. This was significantly related to pharmacies with forward pharmacy dispensing areas (P < 0.001), which were owner or partner operated (P < 0.002) and had high numbers of customers (P < 0.004). Holding national accreditation status and belonging to a banner group may be additional factors. Conclusions Ownership of community pharmacies in Australia is dominated by pharmacists in contrast to the minority pharmacist ownership in the USA and England. Owners and managers of pharmacies were mainly male and older than other staff. Pharmacists working in pharmacies with a forward dispensing area, designed to facilitate patient consultation, were significantly more likely to provide increased consultation time for patients. Owner- or partner-operated pharmacies, and pharmacies with high numbers of customers were also significantly associated with patient consultation time. The strength of association between membership of marketing groups and national accreditation with consultation time requires more evidence.

Max Bulsara, biostatistician and research fellow School of Population Health, University of Western Australia, Perth, Western Australia Christina Mills, research associate

Correspondence: Mr Constantine G Berbatis, School of Pharmacy, Curtin University of Technology, GPO Box U1987, Perth, Western Australia 6845. E-mail: [email protected] Acknowledgements: This project was funded under the Third Community Pharmacy Agreement Research and Development Grants Program for the project titled ‘Reference database of Australia’s community pharmacies: analysis of national survey’.

Introduction Community pharmacy practice, including the pharmacists and the environment where they work, have changed in many countries from a mainly dispensing function to include a wide range of other services involving medicines and health.1,2 These developments have made it important to research the nature of community pharmacy practice and the factors that influence pharmacies in the provision of more health-related services. In Australia, more than 97% of community pharmacies have, historically, been owned by pharmacists. Since 2002, legislation passed in each state has retained pharmacist ownership but increased the maximum number of pharmacies per pharmacist. Approximately one-half of pharmacies in Australia are members of banner groups whose main purposes are to enhance promotion and purchasing power. In order to evaluate the changes in the structure and processes of community pharmacy practice, it was decided to develop a database which defines and quantifies the components of pharmacy practice.3,4 The National Pharmacy Database Project was conducted in 2002 to provide a reference of the structure and processes in community pharmacy in Australia against which future changes could be monitored.4 National studies of community pharmacy practice in many countries were reviewed in 2002.3,4 Several national studies have been subsequently published. A study of pharmacies in Great Britain was reported in 2001, which resulted from a postal questionnaire sent to a

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random sample of 10% of registered pharmacies of whom 731 (57.9%) responded.5 A number of pharmacy- and pharmacist-related characteristics were reported, some of which were analysed for their influence on selected health services provided in pharmacies. It was found that increased turnover of NHS prescriptions, the use of a private consultation area and pharmacies in smaller pharmacy groups were generally associated with increased likelihood of involvement in extended activities including medication reviews and compliance assessment. This was the first national study to report statistical associations between the characteristics of pharmacies and pharmacists with pharmacy services.5 In 2000 and 2004, two national postal surveys of 4895 and 4622 randomly selected registered pharmacists throughout the USA were performed to investigate the time spent on consultation, business management and drug-management activities.6–9 Usable questionnaires were returned respectively by 2092 and 1564 pharmacists (response rates of 42.7% and 33.8%). The prescription volume and type of pharmacy, whether a large or small chain, supermarket or mass merchandiser, were reported. Hours of operation of pharmacies were similar in the two surveys, but in 2004 the number of technicians and prescriptions dispensed and the equipment facilitating dispensing had all increased. In 2004, 50.1% of pharmacists’ time was consumed in dispensing, 19.4% in consultation, 14.9% in business management and 12.2% in drug-use-management activities.9 The amount of consultation time reported by pharmacists in 2000 and 2004 did not differ according to position, pharmacy type or prescription volume.6–9 In March and April 2000, all 965 registered pharmacies in New Zealand were mailed brief questionnaires, of which 892 pharmacies (92.4%) responded.10 The staff pharmacists’ ages, prescription numbers, staff numbers, opening hours, proximity to medical practitioners and group membership were reported. Most pharmacies were small in size, with two or fewer full-time pharmacist staff. Of the pharmacies surveyed, they were open an average of 52.5 h, 39% belonged to a marketing group, and 61.3% of the turnover generated was from dispensing. A regression analysis of the results revealed that pharmacies with high staff numbers were likely to provide aged care services and testing for screening and monitoring purposes. Pharmacies with large prescription volumes and those in a marketing (banner) group were more likely to provide extended services such as supervised dosing, methadone dispensing and unit dosage packaging. Pharmacies located adjacent to a doctor’s surgery were associated with lower rates of extended service provision.11 In Australia, national surveys of pharmacies have been conducted regularly by government agencies such as the Australian Bureau of Statistics, and by national pharmacy bodies such as the Pharmacy Guild of Australia or the Pharmaceutical Society of Australia.3,4 Regional or state surveys have been routinely performed by state boards of pharmacy for workforce data or other reasons. Surveys of a specific nature have been reported by university research groups or on behalf of national health research bodies such as labour force studies conducted by the Australian Institute of Health and Welfare.12 These latter surveys have usually reported demographic data of pharmacies, with little information on the

nature of and practices in community pharmacies operating within Australia. The aim of this paper was to quantify the characteristics of Australia’s pharmacies relative to their location, size, configuration, group membership, commercial activities, ownership and staff, and to examine which of these factors are associated with the amount of time pharmacists spent on consultation.

Methods This project received ethics approval from the Curtin University Human Research Ethics Committee and was approved by the Australian Government’s Statistical Clearing House and the Pharmacy Guild of Australia.3,4,13 The ethics committee required consent by pharmacies to participate in the study. Participants

The population from which the sample was drawn was all 4824 pharmacies registered in all Australian jurisdictions for the 12 months to December 2001. A power calculation defined that a minimal sample size of 15% or approximately 750 pharmacies was required to meet statistically defined margins of error, with prevalence rates of pharmacy services or pharmacist characteristics set at 1%, a 75% response rate and confidence intervals of 95%.3,4 In order to minimise sampling bias arising from location, and to ensure the relatively low proportions of remote and rural pharmacies were included, stratification was adopted.3,4,14 The PhARIA (the physical and professional remoteness of pharmacies within Australia) system was the basis of stratification.14 The PhARIA classification categorised pharmacies into one of six groups, from 1 ‘highly accessible’, to 6 ‘very remote’. Highly accessible pharmacies accounted for 81% (PhARIA 1) of the total of community pharmacies; hence a random sample of almost 20% was selected. Due to the small number of pharmacies in PhARIA 2 to 6, the total number of pharmacies in these groups was used. The resulting stratified sample totalled 1641 ‘possible’ pharmacies. Materials

The questionnaire was designed according to expert guidelines.15 It was 10 pages in length and included 13 sections and 33 questions, which could be divided into 231 subquestions (Table 1). The mean and median areas in square metres of various sections of community pharmacies were calculated for the number of respondents who provided a response to each item. For example, the number of participants that completed the dispensary area section was 1034 out of 1131. The figure of 1034 was utilised as the denominator for the percentage of pharmacies that had specialist areas. To ensure high levels of content validity, the choice of items was based on an extensive review of the community pharmacy literature and consultation with pharmacy leaders and researchers nationally and internationally, and observations in

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Table 1

Sections comprising the national pharmacy questionnaire 2002

Section A B C D E F G H I J K L M

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Respondent pharmacist details Enhanced pharmacy services paid or unpaid Barriers to and facilitators of enhanced pharmacy services Prescription-related activities in this pharmacy Medication review processes Primary health care including pharmacy (S2) and pharmacist only (S3) medicines Preventive services implemented in this pharmacy Harm-minimisation or harm-reduction activities Complementary therapies including herbal medicines Information facilities and programmes Technologies and health communications Opinion on the use of technical facilities Pharmacy and staff

pharmacies.3,4 Special attention was given to the inclusion of questions relating to Australia’s health priorities and the quality use of medicines. The questions (wording and code frames) were examined and tested by delegates of academic and administrative bodies, and a sample of specialist and practising pharmacists throughout the country (across PhARIA zones 1 to 6). To ensure face validity, a focus group session with pharmacists in PhARIA zones 1 and 2 was conducted to gain practical feedback on the questionnaire. On the basis of their comments various changes were made to the wording of questions. A national panel also commented on the questionnaire and methodology. Pilot testing found the questionnaire took on average 50 min to complete. A website was developed in order to provide participants in the study and other parties interested in the national survey with notices, results and other information.3,4 Procedure

The study was conducted according to national and international standards of best practice.4,15–18 From March to June 2002, articles were published in the major national pharmacy journals and circulated through newsletters produced by the Pharmacy Guild of Australia to efficiently create interest nationwide and awareness of the project and the need for co-operation and high response rates from pharmacies. In June 2002 the school of pharmacy sent a letter to all 1641 pharmacies to explain the survey, request that one owner or manager pharmacist be selected to be the respondent for the pharmacy, and introduce the survey research company based in another university which would implement the survey.3,4 These pharmacies were telephoned by trained interviewers and asked to participate in this study. The pharmacies were asked to provide the name and contact information of an owner or manager pharmacist respondent. The following strategies were implemented to increase the response rate.15,17,18 The respondents were mailed the questionnaire on July 12, 2002, with an individual incentive payment for each respondent pharmacist and a competency credit for each participating pharmacy in the national Quality Care Pharmacy Program (QCPP). A prepaid envelope was

Question

Questionnaire (%)

1 to 6 7 8 and 9 10a to 13c 14a to 14f 15a and 15b

10 6 6 18 10 4

16 to 18 19a and 19b 20 21 22a to 23 24 25a to 33b

6 4 3 3 6 4 20

included in the first and two subsequent mailings posted at approximately 20-day intervals to non-respondents in July and August. This was interspersed and followed up with contact by facsimile and telephone calls to the non-respondents in August and September. The cut-off date for the return of questionnaires was September 16, 2002. The procedure was monitored by a panel of delegates from Australia’s national pharmacy bodies and pharmacy practice researchers.4 The data in questionnaires that were returned by respondent pharmacies were entered into a computer-assisted data entry (CADE) system by trained clerks. The data were validated using double-entry verification. Data-entry error levels were found to be within acceptable levels (P < 0.005); therefore the effects of non-differential information bias would be minimal. Data were extracted from the CADE system and exported to SPSS (Version 11) for analysis. The question on pharmacy areas was not mutually exclusive, hence a separate analysis was conducted for closed counselling/dosing area, unenclosed counselling/dosing area and ‘forward pharmacy’, which is a private unenclosed front-of counter seated area in the pharmacy with a dispensary computer for prescription receipt, counselling for medicines or health and dosing. Data are presented as the mean value (± 95% confidence intervals (CI)). Where appropriate, the median is provided. The total annual turnover of Australia’s pharmacies and the component percentages by category were estimated from the respondent data for pharmacies in each subgroup of turnovers and the product of the weighted sample from PhARIA zone 1 and the total of PhARIA zones 2 to 6 and the total number of pharmacies in all PhARIA zones. The significance of the difference in annual turnovers between pharmacies which were or were not members of banner (promotional) groups was calculated by chi-squared analysis.19 In order to analyse predictors of consultation time, the amount of time a pharmacist(s) spent performing consultation time in a pharmacy was tallied and divided by the total time spent in both consultation and dispensing roles by the same pharmacist(s). The results presented in this paper involved frequency analysis and the general linear model (GLM) for

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univariate analysis, to ascertain associations for providing patient consultation. A separate univariate analysis was performed for each group variable. In the ‘setting of pharmacy’ group, ‘hospital’ was excluded because less than 1% of community pharmacies were located in hospitals. Approximately 20% of respondents filled in the dispensing section times but left the consultation time blank. This question was in the form of a grid response. Other relevant responses were recorded in the grid, and where it was left blank the response was coded as zero. A second analysis was performed omitting the respondents who did not record consultation times. Only pharmacies where the total time of pharmacists was greater than 20 h per week were included. This cut-off figure was based on the operation of some rural pharmacies where there is only part-time service provided.

Results Of the original sample of 1641 ‘possible’ pharmacies, 42 were not contactable and 67 were screened out as the telephone number no longer belonged to the pharmacy or was a duplicate number. The response rate excluded pharmacies duplicated or not contactable. The response rate of 73.8% was based on the 1131 usable questionnaires returned by the 1532 contactable pharmacies. In this study, 1391 pharmacies consented to participate, 141 refused to participate, hence 81.3% (1131/1391) of the consenting pharmacies returned a usable form. The individual response rates were; PhARIA zone 1: 482/611 (78.9%); PhARIA zone 2: 240/278 (86.3%); PhARIA zone 3: 226/276 (81.9%); PhARIA zone 4: 91/110 (82.7%); PhARIA zones 5 and 6: 92/116 (79.3%). Non-respondent pharmacies were not significantly different by PhARIA (P = 0.20). There were significantly more non-responders from PhARIA 1 as a percentage of all non-responders compared to the percentage of respondents from PhARIA 1 relative to all respondents (49.6% to 42.6%: P = 0.04). Of the 260 non-respondent pharmacies, 27% agreed to provide demographic information so that investigators could test for bias. Overall it was found that non-respondents and respondents were not significantly different in terms of staff numbers (P = 0.20), ownership category (P = 0.68) or pharmacy setting (P = 0.78). Ten hospital pharmacies and 13 community pharmacies that were open for less than 20 h per week were excluded from the analysis for consultation time. The majority of community pharmacies were located in a shopping centre or retail precinct, were owner operated, had between 700 and 2100 customers per week, grossed between $AU1 million and $AU3 million in sales a year, and the pharmacy was accredited or nearing accreditation with the national QCPP. More than 97% of pharmacies in Australia were owned by pharmacists, the majority (57.2%) by a single pharmacist owner. Of those in partnerships, the most common number of partners was two (23.9%). The average opening hours per week was 55.5 (95% CI, 54.6 to 56.3).4 Community pharmacy owners comprised 76.3% males and 23.7% females. The ages of owners were 7.7% aged from 21 to 30 years, 22.5% from 31 to 40 years, 30.3% between 41 and 50 years, 24.4% between 51 and 60 years and 15.1% over

61 years. Of the owners, 74.9% held a university bachelors degree reflecting pharmacists who graduated since 1960, and 18.2% of owners had a diploma. Much of the area in Australia’s community pharmacies is used for retail, dispensing and storeroom purposes (Table 2). Less than 18% of the total area was dedicated to prescription and to non-prescription medicines restricted to pharmacies located behind the counter or behind a barrier (schedule area). Enclosed and unenclosed areas for counselling occupied another 5.2% of pharmacies. The forward pharmacy area, which comprised just 2.8% of the area, was reported by 27.3% of pharmacies. The category of ‘other’ areas refers to various small spaces utilised for health-related or cosmetic services and often including associated devices or products (Table 2). Prescription medicines comprised nearly two-thirds of total community pharmacy sales (Table 3). The large majority of these are partially subsidised by the national government’s Pharmaceutical Benefits Scheme (PBS). Most non-PBS prescription medicines are paid for by individuals. Non-prescription medicines in Australia include pharmacy-only (Schedule 2 or S2) and pharmacist-only (Schedule 3 or S3) agents. Prescription and non-prescription medicines accounted for approximately three-quarters of reported annual sales nationally in pharmacies (Table 3).

Table 2 Australia’s pharmacies in 2002: areas of sections in pharmacy, mean (±95% CI), median and percentage of pharmacies with the stated areas Mean area (m2) (±95% CI) Dispensary area Schedule area Forward pharmacy Unenclosed counselling area Enclosed counselling/ dosing area Retail Storeroom, office, other Other Total area of premises

Median (m2)

Percentage

21.0 (20.3–21.7) 12.2 (11.6–12.8) 5.2 (4.8–5.6) 4.4 (4.1–4.7)

20.0 10.0 4.0 4.0

100.0 95.9 27.3 68.8

5.6 (5.2–6.0)

5.0

22.2

90.0 20.0 10.0 160.0

98.0 93.3 17.6 100.0

116.8 (111.5–122.2) 30.7 (28.5–32.9) 18.8 (15.6–22.0) 187.2 (180.0–194.4)

Table 3 Categories of sales in Australia’s community pharmacies in 2002 (n = 1025, 90.7% of respondents)

Prescriptions Non-prescription medicines Herbals, vitamins Medical aids Other sales Total

Percentage of total

Annual sales ($AU billion)a

64.6 13.3 4.8 2.1 15.2 100.0

5.99 1.23 0.46 0.20 1.41 9.29

Indicative exchange rates in 2002: $AU1 = $US0.55 and $AU1 = £UK0.36. a

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December 2007, The International Journal of Pharmacy Practice

Approximately one-half of Australia’s pharmacies belonged to banner groups (Table 4). Pharmacies that were members reported significantly higher sales compared to pharmacies not having group memberships (χ2 (7, 1) = 235.37, P < 0.001 (n = 1096)). The relative time that pharmacists spent on consultation within pharmacies, based on the coding adopted, was 18.8% of the total hours worked by pharmacists in pharmacies (95%CI: 17.5 to 20.1 hours: n = 961) (Table 5). The reported time was probably minimal because blank recordings were assumed in the analysis to represent that pharmacists were not providing consultation services. As a percentage of time worked in the dispensary, single proprietors and pharmacist managers were doing less consultation work proportionally than pharmacists who were partners in partner-operated pharmacies (Table 5). The strength of the association between pharmacy characteristics and the relative time worked by pharmacists in consultation within pharmacies is reflected by the F number and the corresponding P value (Table 6). Consultation time was most strongly associated with pharmacists working in pharmacies with forward pharmacy areas (P < 0.001), in those that were owner or partner operated (P < 0.002), and in pharmacies that reported the highest numbers of customers (P < 0.004). The second analysis, which omitted respondents who did not include a figure for consultation time, revealed

Table 4 Frequency and relative percentage of Australia’s pharmacies with pharmacy banner group membership by annual sales Turnovera ($AU million sales per annum)

Pharmacy group membership, n (%)

Less than 1 1–1.5 1.5–2 2–3 3–4 4–6 6–8 >8 Total

No group

In a group

195 (36.5) 167 (31.3) 91 (17.0) 60 (11.2) 11 (2.1) 9 (1.7) 1 (0.2)

39 (6.9) 120 (21.4) 120 (21.4) 153 (27.2) 84 (14.9) 37 (6.6) 7 (1.2) 2 (0.4) 562 (51.3)

534 (48.7)

Indicative exchange rates in 2002: $AU1 = $US0.55 and $AU1 = £UK0.36

a

Table 5

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QCPP accreditation and group membership were not significant at P < 0.05 (footnote, Table 6).

Discussion Pharmacist-owned or ‘independent’ pharmacies became minorities of all community pharmacies in the USA before 1995 and in England and Wales by 2002.20,21 This compares to Australia where they still exceed 97% of pharmacies. Owner pharmacists comprised an older group of males with far fewer females than reported in other national studies of pharmacists and by Australia’s pharmacy workforce survey.5,6,7,10,12 Average hours of opening were similar to pharmacies in New Zealand and independent pharmacies in the USA.8,10 A majority of pharmacies were members of banner groups, compared to 39% of New Zealand community pharmacies, and these pharmacies had significantly higher turnovers than non-banner-group pharmacies.10 In 2002, 22% of Australia’ community pharmacies had an enclosed counselling area compared to 24% of Great Britain’s pharmacies in 1997–98.5 The percentage of pharmacies with designated consultation areas has increased considerably in Great Britain over the past decade. The counselling areas together with the forward pharmacy, dispensary and non-prescription medicines sections comprised 25.9% of the total area, but generated approximately three-quarters of sales. The percentage of income generated by prescription medicines of around 65% was similar to British and New Zealand figures (Table 4).5,10 These similar proportions of sales must, however, take into account factors such as differences in the national formularies of subsidised medicines and the patient contributions for medicines.5,10 The relative amount of time pharmacists and managers spent on consultation was similar to work patterns reported by community pharmacists in the US, where 19–20% of time was spent on patient consultation.6,9 The consultation time was influenced by various pharmacy characteristics. Pharmacies with forward pharmacy sections had the strongest association with increased patient consultation time, but factors associated with this configuration such as trained staff and concurrent procedures in the pharmacy or their combination may individually or together contribute to the association.22,23 By 1998 more than 100 pharmacies had embraced this model of practice.23 These findings strengthen the evidence that the reorganisation of community pharmacy premises, the management structure and technical staff,

Hours per week in dispensary and patient consultation by proprietors, managers, consultants and other pharmacists Dispensary (hours/week)

Proprietor 1 Proprietor 2 Proprietor 3 Proprietor 4 Manager Consultant Other pharmacists

Patient consultation (hours/week)

n

Mean (± 95%CI)

Median

n

Mean (± 95%CI)

Median

761 204 46 11 309 52 519

30.9 (29.9–31.9) 18.8 (16.8–20.8) 15.9 (11.2–20.6) 2.7 (0–6.2) 32.9 (31.4–34.3) 19.4 (15.1–23.7) 26.9 (24.7–29.1)

31.0 18.0 10.0 0.0 35.0 15.5 20.0

741 198 39 11 304 77 506

8.9 (8.1–9.6) 6.9 (5.7–8.1) 8.3 (4.7–11.9) 0.3 (0–0.7) 8.5 (7.3–9.7) 8.3 (4.8–11.8) 7.5 (6.4–8.6)

5.0 4.0 3.0 0.0 5.0 4.0 2.8

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270 Table 6 group

The International Journal of Pharmacy Practice, December 2007 Mean of relative consultation time for pharmacists (±95% CI) by pharmacy group characteristic and strength of association by pharmacy

Group

n

PhARIA 1 2 3 4 5 6 Setting of pharmacy City suburb or town centre strip Regional shopping centre Neighbourhood shopping centre Isolated: 1 to 9 shops together Medical centre Pharmacy areas Forward area Yes No Unenclosed counselling/dosing area Yes No Enclosed counselling/dosing area Yes No Pharmacy group membership No group In a group QCPP status Not yet registered Partially completed Completed but not accredited Accredited Re-accredited Number of customers 0–700 701–1400 1401–2100 2101–3500 3501+ Turnover of pharmacy ($AUm)
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