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Welcome to the May 2012 homepage edition of i2P-Information to Pharmacists. Rollo Manning has been having some time out having staples removed from the site of his open heart surgery.He is now at home recuperating in Darwin, having arrived home last Friday, beating a cold and hasty retreat from Canberra.We all wish him a speedy recovery and hopefully, he will be fit enough to contribute by next month.
This month, Pharmedia discusses the toll that is taken when someone complains about you to an authority without good cause. Well, the good news is that you can now take action to protect yourself if such a complaint is made, and that may even include action for defamation. Read about a recent case involving two doctors, with Mark Coleman drawing on personal experience to illustrate.

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The line between counselling and adherence support

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Dr Linda Bryant (PGDipPharm, MPharm, DPharm(Auck), FACPP, FNZCP, FPSNZ, MCAPA) articles by this author...

Linda is a New Zealand Clinical Advisory Pharmacist working as part of a team with GP's and nurses, in a medication advisory role. New Zealand clinical pharmacists get some encouragement to work independently in a variety of settings not necessarily tied to a community pharmacy. Through her company, Comprehensive Pharmaceutical Solutions, she contracts to Primary Health Organisations, lecturing postgraduate students in Clinical Pharmacy and undertaking evaluations of services. Linda's PhD thesis involved investigation into the barriers of implementing Comprehensive Pharmaceutical Care (clinical medication reviews) in primary care.

I was asked a question by a nurse yesterday that set me thinking. She asked where she could find information on what is expected by way of counselling at the time of dispensing for a prescription. On which website could she find this information – the Pharmaceutical Society or the Ministry of Health?
This set the cat amongst the pigeons somewhat. She liked the attention her mother got as part of the Medicine Use Review service, but wondered whether things may not have got this far if some information and direction had been given at the time of dispensing.
Unfortunately, being asked the question in front of others started a litany of accusations about the extent of counselling that people experienced from their community pharmacist, and even a comment about where counselling did occur because for someone’s family member, the information on fluoxetine was overheard by others in the shop.

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While it is accepted that there is variability in the extent of counseling at the time of dispensing, I did wonder about the question of the border between counseling at the time of dispensing (brief interventions), versus the receipt of a considerably larger payment for providing counseling when the person becomes ‘high risk’. There is also the question of whether a 45 to 60 minute session, with extensive information imparted, is as effective as brief interventions whenever the patient is seen, along with reinforcement. The brief intervention studies in the literature indicate that 4 x 5 minutes sessions are just as effective, if not more so, than one x 20 minutes.

Counseling is a generic term that is usually poorly defined in studies of pharmacist – patient communication. Yet there is often the claim that pharmacists ‘counsel’ patients, and this is an important role with significant effects on health outcomes. There appears, however, to be little clarity regarding what is meant by counseling. Is it the simple instructions given out when medicines are dispensed, saying how to take the medicines? Is it information given about the medicine, including expected adverse effects and benefits? Or is it a more in-depth two-way discussion involving asking and listening and taking into account the patient’s perspective. Questions arise regarding the type and extent of ‘counseling’ required for more complex patients, including those who have been identified as non-compliant.

The type of counseling provided by community pharmacists has been noted to be of the ‘instruction and information giving’ or technical type, rather than being motivational.¹ In this study 62% of patients said they would not consider paying a fee for pharmacists’ counseling, so although 75% of people felt that the pharmacists’ counseling helped them in taking their medicine, they did not value it highly in terms of willingness-to-pay.

Looking at counseling from a different perspective, patients were asked to give a brief description of their experience with newly prescribed medicines on their second presentation.² Of 700 patients who were asked, 154 (22%) had concerns regarding side effects or perceived ineffectiveness of the medicine. While community pharmacists may provide counseling or information when the prescription is first presented, this study suggests that checking with the patient when they present with the second prescription, might identify drug-related problems that could be acted on at this time.

It has been found that time was a barrier to providing primary health care advice.³ In the study population of 394 pharmacies in the USA, the average time spent explaining drug benefits to patients was 33 seconds for pharmacies processing less than 80 scripts/day, 29 seconds for pharmacies dispensing 80 to 110 scripts, and 20 seconds for those processing an average of 167 scripts per day. A similar UK study of advice given by pharmacists found that the average time taken to give advice with a prescription was 27 seconds per prescription and only 3 of 18 pharmacists averaged more than one minute.
Conversely advice about over-the-counter medicines was an average of 111 seconds per item.⁴

Similarly, lack of time (63%), lack of privacy (51%) and lack of reimbursement (13%) ranked highly as
barriers for pharmacists providing patient counseling at the time of dispensing.⁵ Smith et al.⁶ found that time-stressed pharmacists were significantly less likely to perform 12 of 22 counseling behaviours. However, perceived skill and interest in compliance counseling, and job satisfaction also correlated significantly with the extent of counseling.

A word of caution was raised by Salter et al.⁷ who performed discourse analysis of community pharmacist consultations during a domiciliary visit to undertake a medication review in people older than 80 years. This study indicated a potential reduced quality of life due to undermining of the person’s confidence in their self-management. Community pharmacists are usually focused on the brief instruction and information-giving counseling style associated with dispensing, rather than motivational style that may be more appropriate in a clinical consultation. Pharmacists found many opportunities to offer advice, information, and instruction. These advice-giving modes were rarely initiated by the patients and were given despite a no problem response and deliberate displays of competence and knowledge by patients. Advice was often resisted or rejected. Pharmacists may need to take care to adopt the style of counseling appropriate for the patient and the service, rather than risk undermining the patient’s confidence in their medicines and their ability to manage them.

So, what are the contractual requirements for counseling at the time of dispensing in New Zealand? From the Base pharmacy contract:

Provision of essential advice and counseling includes: (i) directions for the safe and effective use of the Pharmaceutical; (ii) the expected outcomes of therapy; (iii) what to do if side-effects occur; (iv) storage requirements of the Pharmaceutical; (v) disposal of unused Pharmaceuticals.

When reviewing the adherence support service (Medicine Use Review), how much of this service should have been done at the time of dispensing? To be of any value to the profession, services have to be affordable and sustainable. Would it not perhaps be better to be clear on verbal advice given at the time of the initial dispensing of a medicine, plus specific follow-up at the second dispensing (or sooner), along with an annual check of any issues occurring. Information may be best provided in the form of brief interventions rather than extended sessions. We need to be clear what is part is the professional dispensing services, and what is specific to adherence support.

If adequate counseling isn’t done at the time of dispensing, then remote / robotic dispensing services would be acceptable.

1. Report S. Patients confirm that medication counseling helps. Am J Hosp Pharm. 1994;51(13):1606, 1608.

2. Hugtenburg JG, Blom AT, Gopie CT, Beckeringh JJ. Communicating with patients the second time they present their prescription at the pharmacy. Discovering patients' drug-related problems. Pharm World Sci. 2004;26(6):328-32.

3. Muirhead G. Where does the time go? Drug Topics 1996:128-140.

4. Savage I. Time for prescription and OTC advice in independent community practice. Pharm Journ 1997;258:873-77.

5. Schommer JC, Wiederholt JB. Pharmacists' perceptions of patients' needs for counseling. American Journal of Hospital Pharmacy. 1994;51(4):478-85.

6. Smith SL, Golin CE, Reif S. Influence of time stress and other variables on counseling by pharmacists about antiretroviral medications. Am J Health-Sys Pharm. 2004;61:1120-9.

7. Salter C, Holland R, Harvey I, Henwood K. "I haven't even phoned my doctor yet." The advice giving role of the pharmacist during consultations for medication review with patients aged 80 or more: qualitative discourse analysis. Bmj 2007;334(7603):1101.

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