Professional Challenges Facing Pharmacists Working at Public Hospitals in an Iraqi Province: A Qualitative Study

In Iraq, because of the dramatic turnovers facing the country for three decades, pharmacists continue to experience significant professional challenges in both the public and private sectors. The present study aimed to explore the professional challenges and obstacles facing Iraqi pharmacists working in public hospitals. This qualitative study included face-to-face semi-structured interviews with open-ended questions with hospital pharmacists. The participants were selected purposefully (with ≥ 3 years of experience) to work at governmental hospitals in Karbala province between December 2022 and April 2023. The audio-recording interviews were scripted. Thematic analyses were used to generate themes and subthemes from the interviews. Thirty-two pharmacists participated in this study. The study found that there are many challenges facing Iraqi pharmacists in hospitals. Some of which are related to the pharmacists themselves, such as suboptimal competency with an overwhelming number of pharmacists in each hospital, while the others are related to suboptimal organizational conditions, such as inadequate interdisciplinary collaboration, an unfriendly hospital environment as patients' confrontation, unequal task distributions, and inadequate technology and tools. According to the study findings, greater emphasis should be placed on improving multidisciplinary teamwork, pharmacist competency, the pharmacists' role in hospitals and securing the supply of essential medicines. Most participants recommend enhancing quality over quantity of pharmacists in addition to finding areas and horizons to benefit from these large numbers of pharmacists. Keywords: Iraqi pharmacists, hospital pharmacists, challenges, obstacles, Qualitative study.

The Insights of Experienced Pharmacists Regarding the Iraqi health Insurance Program: A Qualitative Study(Conference Paper )#

The aim of study was to explore pharmacist insights toward the impact of prospective implementation of the national health insurance program on patients, providers and Iraqi health system. This was a qualitative study including semi-structured face-to-face (mostly) interviews with experienced pharmacists. The interview guide included open-ended questions about the impact of the national health insurance program on patients and healthcare providers at three levels: quality of services, costs, and frequency of visits. Potential challenges were also discussed. Interviews were conducted in four provinces from March to May 2022. Thematic analysis was used to analyze the interview findings and generate themes and subthemes. The study recruited 21 pharmacists till the saturation point has been reached. Most of the participants were aware of the new health insurance law. Most participants believed that the program can enhance patient health and would increase the income of healthcare providers (HCPs) in the private sector. They also expected that patients would use private-sector services more frequently. Additionally, the implementation of the health insurance can improve the quality of healthcare services and reduce the financial burden regarding private sector fees. The potential challenges of the program include people's resistance to paying a monthly premium, difficulties in claims processing, potential delays in the reimbursement of HCPs, potential patient misuse of the insurance program, and the absence of an electronic system and database. There are not an adequate number of priced and tested medications. The health insurance program has several potential advantages, but at the same time it can face several technical challenges. The program should be well studied before implementing and it needs to be piloted at small scale before national implementation. The electronic system must be implemented by healthcare settings to facilitate transferring of the information/bills to the health authority. It is recommended to hire international team of experts to supervise the management this new system

The Perceptions of General Population About Mental Health Services in Baghdad, Iraq: A Qualitative Study

Background: Access to mental health services remains a challenge in many countries including Iraq, where mental illness is often stigmatized and marginalized. This can lead to negative outcomes such as decreased quality of life and increased morbidity and mortality.  Objectives:  The present study aimed to explore the perceptions of general population in Iraq towards mental health services and identify the challenges facing patient access to these services. Methods: This qualitative study included face-to-face semi-structured interviews with general population in primary health care centers and private pharmacies in Baghdad between (December 2022 through February 2023). Thematic analysis was used to identify recurring themes and sub-themes. Results: Thirty participants were recruited in this study. The study found that the general population in Iraq have negative perceptions towards mental health services. The repeated themes were "public social stigma," "lack of privacy in public healthcare settings," and "lack of psychotherapy sessions in mental health services." The social stigma" was further divided into sub-themes including stigma from family, friends, or co-workers. Lack of privacy indicated there are too many interruptions in the environment of public healthcare settings. Lack of non-pharmacological therapy in mental health services, was expressed as a feeling that only medication therapy was offered, while psychotherapy was not available. Conclusion: The findings suggest that a cultural awareness is needed to reduce the social stigma associated with mental illness and to increase trust in the public mental health services. The results also highlighted the need for improved privacy and culturally-sensitive mental health services. To improve access to mental health services, it is crucial that healthcare providers, social workers, and society work together to promote and destigmatize mental illness

Comparison between Reference Infliximab (Remicade) and its Biosimilar (Remsima) in Patients with Ankylosing Spondylitis: A Field-based Pharmacoeconomic Study

Background: Ankylosing spondylitis is a chronic inflammatory disease that mostly involves the spine and sacroiliac joints. It is associated with a decreased quality of life. Biological medicines such as infliximab and its biosimilar are the mainstay treatments for active ankylosing spondylitis. Objective: The study objective was to conduct a pharmacoeconomic study comparing the cost-effectiveness of the reference infliximab with its biosimilar in ankylosing spondylitis patients visiting public hospitals. Subjects and Method: This is a two-center pharmacoeconomic study performed at two large teaching governmental hospitals in Baghdad, Iraq, which supplied infliximab to outpatients with ankylosing spondylitis. The outcome data were obtained from patient’s medical records and face-to-face interviews with the patients from December 2021 through April 2022. The Independent T-Test was used to measure the differences in areas of utility, and quality of life, between the two infliximab groups. Results: The study recruited 62 patients with ankylosing spondylitis who received infliximab (31 received Remicade, and 31 received Remsima) for at least 12 weeks at two public teaching hospitals. The mean age of the patients was 37.85 years and 83.9% were men. In general, both reference infliximab and its biosimilar were successful in increasing the quality of life. Their importation costs were different from 2019 to 2021. The incremental cost-effectiveness ratio of reference infliximab versus biosimilar was $ 40,909/quality-adjusted life year (QALY) according to 2019 pricing. In contrast, in 2021 reference infliximab (Remicade) was less expensive and yielded slightly better quality of life improvement than biosimilar (Remsima) making Remicade more cost-effective (dominant). Conclusion: Remicade was slightly superior to Remsima in quality of life improvement. However, it was difficult to determine whether the reference or its biosimilar was more cost-effective in 2019 because the health officials did not specify a willingness to pay per quality-adjusted life year. Compared to Remsima, Remicade was more cost-effective in 2021 because it was less expensive and more effective in terms of quality of life improvement

Cost-effectiveness Analysis of Reference Infliximab (Remicade) Compared to its Biosimilar (Remsima) in Iraqi Patients with Rheumatoid Arthritis (Conference Paper )#

The study objective was to conduct Pharmacoeconomics study (cost-effective analysis) between infliximab reference (Remicade) and its biosimilar (Remsima) in patients with rheumatoid arthritis (RA) in Iraqi hospitals. This is a retrospective multicenter pharmacoeconomic analysis conducted at two large teaching governmental hospitals in Baghdad, Iraq which provided infliximab to patients with RA. Data were collected from patient’s medical records and face-to-face interviews with the patients from December 2021 to April 2022. The study included 57 patients with rheumatoid arthritis (RA).  The patients were categorized into two groups according to the type of infliximab they received over 30 weeks: 27 patients received reference infliximab (Remicade) and 30 patients received biosimilar infliximab (Remsima). The two groups had comparable demographic and baseline disease parameters, with a mean age of 49.6 years and a BMI of 30.0. The vast majority of participants were women (82.5%) with low level of formal education (65%). Overall, both infliximab biopharmaceuticals had good effectiveness to reduce the RA disease activity (CDAI) and improve patient quality of life. They both had comparable adverse reactions including UTI, fatigue, and headache. There was no significant difference (P-value >0.05) in disease activity between the two groups according to RA clinical disease activity index (CDAI) score across all three-time measures: before biological therapy, 14 weeks post-therapy and 30 weeks post-therapy. In 2019, Remicade was slightly more effective and provide better quality of life, but costlier ($41,896 per QALY) compared to Remsima. It was not clear whether the reference biologic (Remicade) or its biosimilar (Remsima) was more cost effective. In 2021, Remicade was more cost effective compared to Remsima because Remicade was less expensive and relatively more effective according to CDAI and EQ-5D-5L scores. Registering and purchasing both reference infliximab and its biosimilar was good idea to keep the competition in the price and maintain infliximab for RA patients.

Physician Acceptance of Pharmacist Recommendations about Medication Prescribing Errors in Iraqi Hospitals

The objectives of this study were to measure the incidence and types of medication prescribing errors (MPEs) in Iraqi hospitals, to calculate for the first time the percentage of physician agreement with pharmacist medication regimen review (MRR) recommendations regarding MPEs, and to identify the factors influencing the physician agreement rate with these recommendations. Methods: Fourteen pharmacists (10 females and 4 males) reviewed each hand-written physician order for 1506 patients who were admitted to two public hospitals in Al-Najaf, Iraq during August 2015. The pharmacists identified medication prescribing errors using the Medscape WebMD, LCC phone application as a reference. The pharmacists contacted the physicians (2 females and 34 males) in-person to address MPEs that were identified. Results: The pharmacists identified 78 physician orders containing 99 MPEs with an incidence of 6.57 percent of all the physician orders reviewed. The patients with MPEs were taking 4.8 medications on average. The MPEs included drug-drug interactions (65.7%), incorrect doses (16.2%), unnecessary medications (8.1%), contra-indications (7.1%), incorrect drug duration (2%), and untreated conditions (1%). The physicians implemented 37 (37.4%) pharmacist recommendations. Three factors were significantly related to physician acceptance of pharmacist recommendations. These were physician specialty, pharmacist gender, and patient gender. Pediatricians were less likely (OR= 0.1) to accept pharmacist recommendations compared to internal medicine physicians. Male pharmacists received more positive responses from physicians (OR=7.11) than female pharmacists. Lastly, the recommendations were significantly more likely to be accepted (OR= 3.72) when the patients were females. Conclusions: The incidence of MPEs is higher in Iraqi hospitalized patients than in the U.S. and U.K, but lower than in Brazil, Ethiopia, India, and Croatia. Drug-drug interactions were the most common type of MPEs in hospitals. Physician specialty and pharmacist gender and patient gender significantly influenced physician agreement with the pharmacist comments. Only one-third of the pharmacist recommendations were implemented. Phone drug applications would be helpful for daily hospital pharmacy practice. More pharmacist-physician collaboration is needed to address MPEs. Pharmacist-led MRR can identify and address MPEs to improve patient safety.   Type: Original Researc

Assessment of Academic Resilience and its associated factors among Pharmacy Students in Twelve Countries

Objective Academic resilience, a critical determinant of academic achievement, is affected by various factors. There is a paucity of large-scale international assessments of academic resilience among pharmacy students. Therefore, this study aimed to assess academic resilience among pharmacy students in 12 countries and to evaluate factors associated with their academic resilience levels. Methods A cross-sectional online survey-based study was conducted among randomly selected pharmacy students in 12 countries: Egypt, Türkiye, Indonesia, Pakistan, Bangladesh, Iraq, Jordan, Nigeria, Malaysia, Saudi Arabia, Sudan, and the United Arab Emirates. After pilot testing, the validated 30-item academic resilience scale (ARS) was used for the assessment. The data were collected between November 1, 2022 and April 15, 2023. Descriptive and inferential statistics were performed, as appropriate. Results A total of 3950 were received from the 12 participating countries. The mean age was 21.68 ± 2.62 years. About two-thirds of the responses were from female participants and those studying for Bachelor of Pharmacy degrees. Overall, the findings show moderate academic resilience, which varied across countries. The median (IQR) of the total ARS-30 was 114 (103−124). Females exhibited lower negative affective and emotional response subscale levels than males. There were significant cross-country variations in the ARS-30 and all subscales. The highest overall levels were reported for Sudan, Pakistan, and Nigeria and the lowest were reported for Indonesia and Türkiye. Students in private universities tended to have higher overall ARS levels than public university students. Higher academic performance was significantly associated with ARS levels, whereas those with excellent performance exhibited the highest ARS levels. Students with exercise routines had higher ARS levels than those without exercise routines. Finally, students who were engaged in extracurricular activities had higher ARS levels than those who did not participate in these activities. Conclusion The study offers insights into the factors affecting academic resilience in pharmacy students across several countries. The findings could guide interventions and support activities to improve resilience and academic outcomes

In-depth Assessment of Iraqi physicians' Adherence to Treatment Guidelines for Different Diseases

This file includes the responses of the participating physicians to the interview questions about their expereince with the implementation of treatment guideline in Iraqi public Hospital </p

The Expected Impact of the New Iraqi Health Insurance Program and the Challenges Facing its Implementation: Physicians’ Perspective

Aim of the Study: The aims of study were to explore the physicians' insights toward the impact of prospective implementation of the Iraqi Health Insurance Program (IHIP) on patients, healthcare providers (HCPs) and services and identify the potential challenges facing its implementation. Method: This was a qualitative study including semi-structured face-to-face interviews with specialist physicians from different disciplines (Internal medicine, family medicine, cardiology, orthopedic, oncology, gynecology, general surgery, pediatricians and dentistry). The interview guide included open-ended questions about the impact of the IHIP on patients and HCPs at three levels: quality of services, costs, and frequency of visits. Potential challenges were also discussed. Interviews were conducted in six provinces from April 19th to August 2022. Thematic analysis was used to analyze the interview findings and generate themes and subthemes. Results: The study recruited 26 physicians till the saturation point has been reached. Only sixteen from the participants were aware of the IHIP. Most participants believed that the program could enhance patient health and would increase the income of HCPs in the private sector. They also expected that patients would use private-sector services more frequently. Additionally, the implementation of the health insurance can improve the quality of healthcare services and reduce the financial burden regarding private sector fees. The potential challenges of the program implementation include corruption, provision of comprehensive medical services to insured people, overuse of the plan by the insured patients, convincing non-governmental employees to join the health insurance plan and potential delays in the reimbursement to HCPs. Conclusions: The IHIP has several potential advantages, but at the same time, it can face several technical challenges. Thus, the program should be well studied before being implemented, and it needs to be piloted at a small scale before national implementation. Electronic health system must be adopted to facilitate transferring data to health insurance authority. Hiring international experts to help managing the medical claims is pivotal to avoid delaying in the processing. Finally, the Health Insurance Authority (HIA) needs to raise the awareness of HCPs and people about the national health insurance plan