Pharmacist 's advisory role concerning drugs, poisons and sickroom supplies ranked high by both groups

By G. Joseph Norwood, Attitudes of Rural Jeffrey J. Seibert and Jean P. Gagnon Consumers and Physicians Toward Expanded Roles for Pharmacists

The pharmacy literature has included numerous references to nondispensing roles for the pharmacist over the past several decades .1 However, there have been relatively few attempts to determine the need for the suggested roles as perceived by consumers and physicians: One study, although not focusing on specific roles, indicated that in general, pharmacists tended to view themselves less hi"ghly than consumers. 2 Another study, focused on poverty area consumers' receptivity to various pharmacy roles, demonstrated that poverty area consumers tend to view expanded pharmacy roles more favorably than higher income consumers. 3 A large portion of northeast Iowa is rural with median income below national levels as defined by the Office of Economic Opportunity (OEO). Much of this area has been classified as deficient in physician manpower.4 As in many rural areas of the United States, physicians tend to cluster around the hospitals, leaving many towns with little, if any, physician services. The area is not dissimilar to areas in Colorado, 5 in that " drugstores " tend to be distributed much more evenly than physicians, dentists, and hospitals. Because of this more even distribution, pharmacists are often more accessible than other health care sources. The increased pharmacist accessibility, coupled with the lower median income of the population, led the authors to believe that the area may be ideal for expansion of pharmacist roles. The primary objective of the project was to determine which of the proposed roles for pharmacists would be perceived as most desirable among physicians, pharmacists and consumers in northeast Iowa.

Table I

Seminar and Questionnaire Utilized for Input A nine-county area in northeast Iowa was designated as the target area. The project was explained to physicians and other health professionals in the area at a meeting on October 1, 1973. Pharmacists were informed of the project and the necessity of their support at a meeting on October 11, 19 7 3. Based on their input, it was decided that a conference, focusing on the pharmacist's role in health care delivery, be held in the area on December 2, 1973. Two conference brochures were mailed to each physician in the nine-county area. Eight to ten brochures were mailed to each hospital in the area, with a request that the seminar notice be given to nurses. Similarly, Presented to the Economic and Administrative Sciences Section,

APhA Academy of Pharmaceutical Sciences. APh A Ann ual Meet ing. San Francisco. California. April 22. 1975.

Vol . NS 16, No. 10, October 1976

Consumer Respondents by Age Category

Age Category

Percentage of Respondentsa

18- 25 26 - 35 36 - 50 51-65 66 +

10.5 17.6 26. 5 29.4 16.0

a s am pl e size of 23 8 .

Table II

Consumer Respondents by Educational Level

Educational Level

Percen tage of Respondentsa

Some high school High school graduate Some college work College graduate Some graduate college work Postgradua te or professional Other

7.0 37 .4 23.9 11.3 7. 0 6.5 6.9

a s ampl e size o f 23 0 .

15 brochures were mailed to each pharmacy in the area with a request that they be posted in a place conspicuous to patients entering the pharmacy and that the extra copies be distributed to consumers interested in the health care delivery problems of the area. The seminar's prepared talks were intended to convey the current role of the pharmacist in northeast Iowa, as well as the roles being considered by pharmacy educators and the American Pharmaceutical Association. As a result, participants were able to delineate pharmacist roles which they deemed most pertinent. This was accomplished during small group discussion sessions following the formal seminar program. Inasmuch as the seminar was held the first Sunday after instituting the " No Sunday Gasoline" policy, the attendance was poor, except for pharmacists. Although approximately a quarter of the area pharmacists attended, only two nonpharmacists participated-one nurse and one physician . Therefore, the input from consumers and physicians was obtained by questionnaire. Each of 17 pharmacies in the area consented to assist the investigators by distributing 50 questionnaires to consumers obtaining prescriptions in each pharmacy during June 1974. The questionnaires contained statements describing various roles which have been proposed for pharmacists as well as roles presented at the December 2 seminar. Demographic data as well as data on health care utilization were requested. The respondent was requested to mail the preaddressed, franked envelope upon completion . The same questionnaire was utilized to assess the physicians' reactions to proposed pharmacy roles . The cover letter was modified and the demographic and health utilization questions were deleted. All physicians in the nine-county area were mailed questionnaires.

Pharmacists distributing questionnaires of this nature to patients have the advantage of reaching the consumer while he is well aware of the pharmacist's roles. However, there is the disadvantage of the investigator being unable to accurately determine the percentage return obtained because he is unsure of the number of questionnaires distributed by each pharmacy. Although it was possible for 850 questionnaires to have been distributed, it is likely that many of these were retained on the pharmacy counter. A total of 238 usable questionnaires was returned, giving a minimal response rate of 28 percent. Usable questionnaires were received from 33 of the 99 physicians. giving a response rate of 33 percent. The demographic characteristics of the consumer respondents appear in Tables I and II (above). Most of the consumers are middle-aged or older and have at least a high school education . This relatively high educational level for a low median income area is not atypical for rural Iowa. Seventy percent of the consumer respondents were female. This finding is similar to previous studies which have indicated that most prescription medications are purchased by women . The age distribution of physician respondents appears in Table Ill (page 552). This distribution is similar to the age distribution of physicians in rural areas throughout the state. It is interesting to note that 25 of the physicians were classified as general or family practitioners, three as general surgeons, two as internists, one as a radiologist and one as a psychiatrist. The individual role statements were grouped into four major categories. These categories are discussed in order of decreasing importance as ranked by physician and consumer respondents. The response to each role could range from one to five depending on the desirability of that role as perceived by the respondent. In all cases, mean responses above three indicate that the

551

Table Ill

Physician Respondents by Age Category

Table IV

Consumer and Physician Responses to Roles Concerned with Consultation Regarding Drugs, Poisons and Sickroom Supplies Responses

Age Category

Number of Respondentsa

40 or less 41 - 49 50- 60 61 +

8 10 8 6

Total

32

Consumers Question Number

Role Statement A pharmacist should offe r his services for drug abuse and drug infor mation lectures in his co mmunity. A pharmacist should give drug abuse lectures in his co mmunity. A pharmacist should give drug infor mation lec tures in his community. The pharmacist should advise the patient about his prescription and how it should be taken. The phar macist should assist the physician in the selection of the proper drug therapy. The pharmacist should be able to answer questions concerning nonprescription medicines. The pharmacist's drug record s should be used to deteet any possible drug-drug interactions from previous prescriptions. The pharmacist should supervise drug use and storage in nursing homes and small hospitals. The pharmacist should be able to advise patients requiring sickroom and surgical supplies (e.g., wheelchairs, crutches, ostomy appliances, etc.). A pharmacy should provide availability of surgical and sickroo m supplies for either rent or sale. A pharmacist should be available to provide information for emergency treatment of poisonings. A pharmacist should be able to advise in the proper storage of household substances which may be poisonous.

12. 13. 14.

a De m og raphic data w ere not available on one physic ian responden t.

18. 21.

respondents are favorably disposed toward pharmacists performing that role.

24.

Roles and Economic Reward 20.

Physicians

%Pay

Mean

9.0

4.104

4.ooa

3.828

3.7 88

3.806

3.606

4.14 2

4.182

7.5

% Pay

3.253 20.0

Mean

9.5

3.485

4 .325

4.15 2

4.122

9.5

4.273

3.622

9.5

3.667

Table IV (at right) presents consumer and physician mean responses to roles involving pharmacist consultation pertaining to drugs, poisons and sickroom supplies. All roles in this category are viewed favorably by both consumers and physicians. Advisory roles concerning poisons and sickroom supplies were ranked very high by both groups. Likewise, roles concerned with the drug use process are viewed with considerable favor by both groups. Particularly high rankings were given to functions concerned with advising patients about both prescription and nonprescription medications. Also, there is a strong feeling by both groups that a pharmacist's patient records should be used to detect any possible drug-drug interactions. To obtain a clearer indication of the roles which may prove more economically advantageous for the pharmacists, respondents were requested to designate the roles which they considered to be of sufficient importance that they would pay the pharmacist for their performance. Table IV also lists the percentage of consumers and physicians who indicated they would pay (percent pay) for roles specified in this category. The data confirm that the designated roles would also be financially beneficial for the pharmacists to assume. Consumer and physician rankings of roles in the area of preliminary diagnosis, screening and treatment appear in Table V (at right). It is apparent that the consumer tends to view these roles more favorably than physicians. However, with the exception of administering first aid in emergency situations, the consumer does not strongly favor the pharmacist functioning in any of the roles in this category. Also, with the exception of emergency first aid, it would be difficult for the pharmacist to be financially rewarded for performing these roles. Table VI (page 553) shows consumer and physician reactions to pharmacists providing general health information. Although there was not a preponderance of opinion in either direction by consumers, the physicians viewed all of them negatively. It is evident that neither of the groups considered any of

A dash (- ) indi c ates an i nsufficie nt n u mbe r of respondents c o nsider ed tha t pa rticular ro le wor thy of additio nal financ ial co m pensati o n.

552

Journal of the American Pharmaceutic al Association

17. 23.

25 . 1. 4.



0

0

•••

0.

0

•••

0





•••

••



••

•••

••

••

••

••

••

•••



••••••••••

0

4.060

3.909

27. 6

4. 013

4.000

14.0

4.405

9. 5

3.909

4.39 3

••

0.

0

•••

Grand Mean

••

••



4.455

•••





0

.

0

•••

4.006



••



3.95 2

A dash (-) indicates an insufficient number of resp o ndents considered that particular role worthy of additional financial compensation .

Table V

Consumer and Physician Responses to Roles Involving Preliminary Diagnosis, Screening and Treatment Responses Consumers

Question Number 2. 3. 5.

6.

7.

8.



0

Physicians

Role Statement

% Pay

Mean

A pharmacist should be able to provide first aid on emergency poisonings. A pharmacist should be able to provide first aid for emergencies other than poisonings. A pharmacist should be able to determine if a patient with common skin conditions should see a physician or self-medica te. A pharmacist should be able to detect whether common colds, coughs and hay fever are serious enough that the patient should see a physician or selfmedicate. A pharmacist should be able to screen moderately severe conditions to direct the patient to an appropriate source of treatmen t. A pharmacist should be able to provide periodic screening of patients to detect such diseases as high blood pressure and diabetes that may go undetected. (These patients wo uld then be directed to an appropriate so urce of treatmen t.)

14.0

4.121

3.613

7.5

3.825

3. 061

3.376

2. 594

3.030

2. 688

3.1 20

2.515

2.8 79

2. 182

•••••••••

Grand Mean

••

••

0



•••







•••••••••



0







••

•••••



••



•••••

•••

••



•••••••

3.392

% Pay



••••

•••

Mean

•••••

2. 77 6

Table VI

Table VIII

Consumer and Physician Responses to General Health Information Roles Responses Consumers

Question Number

%Pay

Role Statement

9.

A pharmacist should discuss health conditions with the patient when requested. A pharmacist should discuss health conditions with the patient when the pharmacist considers it desirable. A pharmacist should provide short courses on health matters. The pharmacist should advise the patient about the illness his prescription is treating.

10.

11. 19.

Grand Mean

Mean

Physicians %Pay

Mean

3.326

2.545

3.117

2.303

2.922

2.303

2.884

1.750

3.0622

2.2252

A dash (-) indicates an insufficient number of respondents considered that particular role worthy of additional financial compensation.

Consumer and Physician Responses to Drug Selection, Dosing and Administration Roles

Table VII

Responses Consumers

Question Number

15. 16. 22.

26.

27.

%Pay

Role Statement The pharmacist should be able to administer shots or vaccinations at the pharmacy. The pharmacist should be able to prescribe drugs in an emergency. A pharmacist should be able to fill a prescription with another brand name drug that has a lower cost but is chemically the same drug. The pharmacist should regulate long term drug therapy for proper dosages. This would consist of adjusting the frequency with which prescription medication is taken. The pharmacist should control long term medication by judging when a prescription should or should not be refilled.

Grand Mean

Mean

Physicians %Pay

Mean

2.355

1.656

3.116

2.061

3.738

3.333

Consumer Demographics and Receptivity to Roles The overall receptivity to pharmacy roles

Vol. NS 16, No. 10, October 1976

Patient Age Category (years)

Nb

Patient Mean Response

18 to 25 26 to 35 36 to 50 51 to 65 Over 65.

24 42 62 68 37

3.500 3.667 3.774 4.088 4.027

d.f.

F Value

4,228

2.5789*

a patient mean response by age category. bNumber of respondents. Those not reporting were omitted. *Significant at the 0.05 level.

above right). Receptivity to this role increases with a consumer's age. Although there are some significant differences among consumers of various educational levels regarding pharmacists administering shots or vaccinations, there is no definite pattern. It is apparent that this role is not viewed favorably by any of the consumers. Discussion

9.5%

2.903

2.219

2.937

2.750

3.010

2.404

A dash (-) indicates an insufficient number of respondents considered that particular role worthy of additional financial compensation.

these roles sufficiently significant to merit an economic reward. Likewise, most roles concerning drug selection, dosing and administration were viewed without much enthusiasm by both consumers and physicians. The exception to this trend was generic substitution. The generic substitutiol} role was viewed somewhat positively by physicians as well as consumers (Table VII, above). Although 9.5 percent of the consumers consider the renewal decision sufficiently important that the pharmacist should be rewarded, the mean response was not favorable since only 39 percent of the respondents agreed that the role should be performed.

Question No. 3: "A Pharmacist Should be Able to Provide First Aid for Emergencies Other than Poisoni ngs"a

appears to be independent of demographic characteristics for consumers. The consumer total score for all roles investigated was not significantly different among consumers of different educational levels, sexes, ages and location. The location factor is unrelated whether one considers the distance from the patient's home to the physician's office, the pharmacy or the difference in miles traveled to the physician as opposed to the miles to the pharmacy. Also, there is no significant difference in receptivity to the overall pharmacy roles by patrons of various pharmacies. However, age appears significantly related to the consumer's receptivity to certain specific roles. For example, age is significantly related to a consumer's receptivity to pharmacists providing first aid for emergencies other than poisonings (Table VIII,

The enthusiasm which many spokesmen have for greatly enlarged pharmacy roles is not shared by the rural consumers and physicians responding in this study. This becomes evident when one views the responses to items in the area of preliminary diagnosis, screening and treatment. The lack of enthusiasm among consumers for these functions is similar to the findings of a recently conducted metropolitan study where the pharmacist was considered to be honest ''. . . but not the appropriate party to make diagnostic or therapeutic decisions." All but one of the conference panel members felt that the pharmacist should not prescribe or even recommend over-the-counter products and that a patient should seek a physician for professional care. 6 Although the consumers in this study frequently were located in areas which were relatively inconvenient to physicians as opposed to pharmacists, they still tended to disfavor the pharmacist becoming involved in preliminary diagnosis, screening and treatment roles, even for minor illnesses. Thus, there are indications that the consumer draws a clear distinction regarding the pharmacist's role in drug therapy for relatively simple to moderately severe conditions-he should provide advice and answer questions concerning medicines but he should not select the drug. Even preliminary diagnosing to determine if a patient should

553

Attitudes of Rural Consumers and Physicians Toward Expanded Roles for Pharmacists

see a physician was not greatly favored by patients. It is not surprising to find physicians looking with disfavor upon these activities but it was somewhat startling to find consumers sharing these attitudes. The one exception was emergency treatment. This function was deemed sufficiently important that a few consumers were willing to pay for it. There also was a favorable orientation among physicians for pharmacists providing treatment for emergencies. Perhaps both parties desire the security of having a pharmacist provide first aid when needed. This also may account for older consumers viewing this role as more important than young consumers. Consumers and physicians also drew fairly . distinct lines for pharmacists providing health information. Both parties strongly supported pharmacists providing information to physicians, patients and the community at large whenever that information concerned drugs. However, neither consumers nor physicians viewed the provision of general health and disease information as an activity in which the pharmacist should be engaged. The study indicates that consumers and physicians view the pharmacist's role as comprising primarily the drug spectrum of health care. However, within the drug spectrum, it appears that drug selection, dosing and administration have no support except in the area of selecting chemical equivalents. The relative strong disfavor of shot administration or vaccination roles of the pharmacist also was observed in a study of consumers in urban and rural poverty areas. 7 Thus, within the drug area, consumers and physicians tended to favor primarily those roles concerning the provision of drug information and advice, the supervision of drug storage and the monitoring of drug therapy to prevent drug-drug interactions. Two related areas also emerged as important among consumers and physicians-the pharma-

APhA Academy of Pharmacy Practice Seeks 1977 Smith Award Nominees The APhA Academy of Pharmacy Practice is looking for an outstanding community .pharmacist to be the recipient of its 1977 · Daniel B. Smith A ward. The award, named for the first president of the American Pharmaceutical Association, was established in 1965 to recognize

554

G. Joseph Norwood

G. Joseph Norwood, PhD, is associate professor of pharmacy administration at the University of Iowa college of pharmacy. He received his BS in pharmacy from the Medical College of Virginia and his PhD in pharmacy administration from the University of Mississippi. In addition to having practiced community and hospital pharmacy, Norwood also was a product development pharmacist at A.H. Robins. He is a member of APhA, the APhA Academy of Pharmaceutical Sciences, Iowa Pharmaceutical Association, AACP, Kappa Psi and Rho Chi.

Jeffrey J. Seibert

Jeffrey J. Seibert, BS, is a community pharmacist in Quincy, Illinois. He recently received his BS degree in pharmacy from the University of Iowa college of pharmacy. Seibert has been a member of SAPhA and is a member of the Illinois Pharmaceutical Association.

Jean P. Gagnon

Jean P. Gagnon, PhD, is an associate professor in pharmacy administration at the University of North Carolina school of pharmacy. He was previously an assistant professor at the University of Iowa. He received his BS and MS degrees at the University of Connecticut and his PhD at Ohio State University. One of Gagnon's research interests is delineation of variables affecting trading areas, and defining and costing pharmaceutical services of community pharmacies. Memberships include APhA, the APhA Academy of Pharmaceutical Sciences, AACP and Rho Chi.

cist's role in accidental poisonings, and surgical and sickroom supplies.

References

Conclusion Both consumers and physicians in rural Iowa responding to the questionnaire viewed the pharmacist's advisory role concerning drugs, poisons and sickroom supplies as extremely important. Expansion much beyond these boundaries is viewed with considerable skepticism by both groups. Therefore, it would be most fruitful for pharmacy to concentrate its efforts on its advisory role concerning drugs, poisons, and sickroom supplies before embarking into other areas. e

the achievements of a community pharmacy practitioner who has distinguished himself and the profession of pharmacy, both in the recipient's practice setting and the community. Any community practitioner is eligible for the award, which will be presented during the 1977 APhA Annual Meeting in New York City, May 14-19. Any individual may submit an entry on behalf of any community pharmacist, or a pharmacist may act as his own nominator,

1. Norwood, G.J., "Changes in Pharmacy Practice: Predicted vs. Observed," Am. J. Pharm. Educ., 37, 657-662 (Nov.

1973) 2. Knapp, D.E., Knapp, D.A., and Edwards, J.D., "The Pharmacist as Perceived by Physicians, Patrons and other Pharmacists," JAPhA, NS9, 80-84 (Feb. 1969) 3. Galloway, S.P., and Eby, C.E., "Poverty Area Residents Look at Pharmacy Services," Am. J. Public Health, 61, 2219 (Nov.

1971) 4. Bognanno, M.F., Jeffers, J.F., and Seibert, C.F., Health Manpower Resources: Patterns and Trends (Aug. 4,

1970) 5. Wanderer, J.J., and Smart, G.R., "The Structure of Service Institutions in Rural and Urban Communities of Colorado and Sweden," Rural Sociol., 34, 368-374 (Sept. 1969) 6. Wertheimer, A.l., Manasse, H.R., Jr., and Smith, M.l., "The Characteristics of Pharmaceutical Services: An Examination of Myths and Facts," Drugs in Health Care, 2, 49-56 (Winter

1975) 7. Galloway, S.P. op. cit.

but all entries must be prepared according to official guidelines. Deadline for nominations for the 1977 Daniel B. Smith Award is December 31, 1976. Official award guidelines and nomination forms may be obtained by writing Academy of Pharmacy Practice, American Pharmaceutical Association, 2215 Constitution Avenue, N. W., Washington, DC 20037.

Journal of the American Pharmaceutical Association

Attitudes of rural consumers and physicians toward expanded roles for pharmacists.

Pharmacist 's advisory role concerning drugs, poisons and sickroom supplies ranked high by both groups By G. Joseph Norwood, Attitudes of Rural Jeffr...
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