Identification of high-risk patients for referral through machine learning assisting the decision making to manage minor ailments in community pharmacies

Background: Data analysis techniques such as machine learning have been used for assisting in triage and the diagnosis of health problems. Nevertheless, it has not been used yet to assist community pharmacists with services such as the Minor Ailment Services These services have been implemented to reduce the burden of primary care consultations in general medical practitioners (GPs) and to allow a better utilization of community pharmacists’ skills. However, there is a need to refer high-risk patients to GPs. Aim: To develop a predictive model for high-risk patients that need referral assisting community pharmacists’ triage through a minor ailment service. Method: An ongoing pragmatic type 3 effectiveness-implementation hybrid study was undertaken at a national level in Spanish community pharmacies since October 2020. Pharmacists recruited patients presenting with minor ailments and followed them 10 days after the consultation. The main outcome measured was appropriate medical referral (in accordance with previously co-designed protocols). Nine machine learning models were tested (three statistical, three black box and three tree models) to assist pharmacists in the detection of high-risk individuals in need of referral. Results: Over 14′000 patients were included in the study. Most patients were female (68.1%). With no previous treatment for the specific minor ailment (68.0%) presented. A percentage of patients had referral criteria (13.8%) however, not all of these patients were referred by the pharmacist to the GP (8.5%). The pharmacists were using their clinical expertise not to refer these patients. The primary prediction model was the radial support vector machine (RSVM) with an accuracy of 0.934 (CI95 = [0.926,0.942]), Cohen’s kappa of 0.630, recall equal to 0.975 and an area under the curve of 0.897. Twenty variables (out of 61 evaluated) were included in the model. radial support vector machine could predict 95.2% of the true negatives and 74.8% of the true positives. When evaluating the performance for the 25 patient’s profiles most frequent in the study, the model was considered appropriate for 56% of them. Conclusion: A RSVM model was obtained to assist in the differentiation of patients that can be managed in community pharmacy from those who are at risk and should be evaluated by GPs. This tool potentially increases patients’ safety by increasing pharmacists’ ability to differentiate minor ailments from other medical conditionsSpanish Society of Clinical, Family and Community Pharmacy and the Pharmaceutical Associations of Valencia, Madrid, Gipuzkoa, Malaga, Castellon and ValladolidUniversity of GranadaOpen access funding by University of Lausanne

An international series on the integration of community pharmacy in primary health care

The interrelationship between governmental policies and objectives in primary health care and community pharmacy/pharmacists' strategic plans are of the outmost importance, having significant professional, economic and practical consequences for the future of the pharmacy profession, research, education and health care. Sharing information of the potential and real impact on current and future practice of community pharmacy/pharmacists, be it in product or service, in primary care would benefit many stakeholders. In order to create and focus professional and scientific debate the journal has commissioned key experts to contribute a series of country case studies. The aim of the series is to promulgate and disseminate country-based information on primary health care and community pharmacy/pharmacist

Strengthening patients’ triage in community pharmacies: A cluster randomised controlled trial to evaluate the clinical impact of a minor ailment service

Background Self-perceived minor ailments might conceal other health conditions if patients are not appropriately assisted by health care professionals. The aim of the study was to evaluate the patient-related outcomes of a community pharmacy Minor Ailment Service (MAS) compared to usual pharmacist care (UC). Methods A cluster randomised controlled trial was conducted over six months in community pharmacy in the province of Valencia (Spain). Patients seeking care or requesting a product for a minor ailments considered in the study (dermatological problems, gastrointestinal disturbance, pain and upper respiratory tract related symptoms) were included. The intervention consisted of a standardised pharmacist-patient consultation guided by a web-based program using co-developed management protocols and patients’ educational material. Patients were followed up by phone ten days later. Primary clinical outcomes were appropriate medical referral and modification of direct product request. Secondary outcomes were symptom resolution and reconsultation rates. Results A total of 808 patients (323 MAS and 485 UC) were recruited in 27 pharmacies of 21 municipalities. Patients visiting MAS pharmacies had higher odds for being referred to a physician (OR = 2.343, CI95% = [1.146–4.792]) and higher reconsultation rates (OR = 1.833, CI95% = [1.151–2.919]) compared to UC. No significant differences between groups were observed for modification of direct product request and symptom resolution. Conclusions The use of management protocols through the MAS strengthened the identification of referral criteria such as red flags in patients suffering minor ailments. These patients with symptoms of minor ailments possibly due to more severe illness were to be referred and evaluated by physicians. Results reinforce that MAS increases safety for those patients consulting in community pharmacy for minor ailments.Spanish Society of Community PharmacyPharmaceutical Association of Valenci

Primary health care policy and vision for community pharmacy and pharmacists in Australia

There is evidence that the Australian Government is embracing a more integrated approach to health, with implementation of initiatives like primary health networks (PHNs) and the Government’s Health Care Homes program. However, integration of community pharmacy into primary health care faces challenges, including the lack of realistic integration in PHNs, and in service and remuneration models from government. Ideally, coordinated multidisciplinary teams working collaboratively in the community setting are needed, where expanding skills are embraced rather than resisted. It appears that community pharmacy is not sufficiently represented at a local level. Current service remuneration models encourage a volume approach. While more complex services and clinical roles, with associated remuneration structures (such as, accredited pharmacists, pharmacists embedded in general practice and residential aged care facilities) promote follow up, collaboration and integration into primary health care, they potentially marginalize community pharmacies. Community pharmacists’ roles have evolved and are being recognized as the medication management experts of the health care team at a less complex level with the delivery of MedChecks, clinical interventions and medication adherence services. More recently, vaccination services have greatly expanded through community pharmacy. Policy documents from professional bodies highlight the need to extend pharmacy services and enhance integration within primary care. The Pharmaceutical Society of Australia’s Pharmacists in 2023 report envisages pharmacists practising to full scope, driving greater efficiencies in the health system. The Pharmacy Guild of Australia’s future vision identifies community pharmacy as health hubs facilitating the provision of cost-effective and integrated health care services to patients. In 2019, the Australian Government announced the development of a Primary Health Care 10-Year Plan which will guide resource allocation for primary health care in Australia. At the same time, the Government has committed to conclude negotiations on the 7th Community Pharmacy Agreement (7CPA) with a focus on allowing pharmacists to practice to full scope and pledges to strengthen the role of primary care by better supporting pharmacists as primary health care providers. The 7CPA and the Government’s 10-year plan will largely shape the practice and viability of community pharmacy. It is essential that both provide a philosophical direction and prioritize integration, remuneration and resources which recognize the professional contribution and competencies of community pharmacy and community pharmacists, the financial implications of service roles and the retention of medicines-supply roles

Piloting the Integration of Non-Dispensing Pharmacists in the Australian General Practice Setting: A Process Evaluation

This process evaluation examined the circumstances affecting implementation, intervention design and situational context of the twelve week pilot phase of a project integrating five pharmacists into twelve general practice sites in Western Sydney. The interventional design included three phases, patient recruitment and selection, the pharmacist consultation and the communication and recording of recommendations. A number of barriers and facilitators affecting implementation were identified. Insight into the situational context of the intervention was gained from examining the differences between individual pharmacists and between practice sites. Conducting a process evaluation in the pilot phase of an integrated care project can allow adjustments to be made to the project procedures to improve the effectiveness and reproducibility of the intervention going forward

Un enfoque holístico e integrado de la implantación de los servicios farmacéutico cognitivos

Community pharmacy is part of the health care system which is currently under economic pressure and facing changes in demands from consumers and government. In response, the pharmacy profession is becoming more patient orientated and implementing cognitive pharmaceutical services (CPS). CPS in various countries has similar objectives with different emphasis, definitions, labels and using different tools. However, they can be classified using a broad hierarchical model based on clinical decision making and the extent of change required (Box 1). The challenges faced by the profession are related the development of a new patient orientated model of pharmacy which affects health care policy, education and research, the evolution of the market, the individual and organisational approaches to change and the implementation of CPS. These issues and previous research conducted in pharmacy practice have been synthesised to provide a platform for change that can guide a holistic and integrated approach to CPS implementation. Implementation can be conceptually framed in six levels: clinical, service provision, community pharmacy, professional organisation, government and stakeholder (Figure 1). Past experience with service implementation has seen the application of programs that include one or two of these levels in practice rather than a holistic approach. A concentric model was developed to illustrate the implementation of CPS and the holistic and integrated approach required to support change. A program (conSIGUE) being conducted in Spain has attempted to integrate all six levels to support the implementation and evaluation of a medication management service (Seguimiento Farmacoterapéutico)La Farmacia Comunitaria forma parte del sistema de salud. Este sistema actualmente se encuentra sometido a presiones económicas y debe afrontar cambios en la demanda tanto de los consumidores como de los gobiernos. La respuesta de la profesión farmacéutica está dirigida a orientar su práctica hacia el paciente y a implantar servicios cognitivos farmacéuticos (CPS). En distintos países estos servicios tiene objetivos similares aunque presentan diferencias en el énfasis de los servicios, en sus definiciones, denominaciones y en la utilización de diferentes herramientas. Sin embargo, todos ellos pueden clasificarse utilizando un amplio modelo jerárquico que se basa en la toma de decisiones clínicas y en la amplitud del cambio requerido. (Box 1). Los retos que debe afrontar la profesión están relacionados con el desarrollo de un nuevo modelo de farmacia orientado al paciente que afecta a las políticas de salud, a la formación e investigación, a la evolución de los mercados, a los abordajes del cambio tanto a nivel individual como organizacional, y a la implantación de CPS. Estos temas y la investigación en práctica farmacéutica que se ha venido realizando con anterioridad han sido sintetizados para proporcionar una plataforma para el cambio que pueda guiar un planteamiento holístico e integrado de implantación de CPS. Conceptualmente la implantación de CPS puede enmarcarse en seis niveles: clínico, provisión de servicios, farmacia comunitaria, organización profesional, gobierno y agentes implicados (Figura 1). La experiencia reciente relacionada con la implantación de servicios ha mostrado la aplicación de programas de implantación que han incluido uno o dos de estos niveles en lugar de haber utilizado un abordaje holístico. Por ello se ha desarrollado un modelo concéntrico para ilustrar la implantación de CPS dentro del planteamiento integrado y holístico necesario para apoyar el cambio En España se ha desarrollado un programa (conSIGUE) que pretende integrar los seis niveles con el objetivo de apoyar la implantación y evaluación de un CPS, el servicio de seguimiento farmacoterapéutico

Opinión de un grupo de expertos sobre facilitadores para la implantación del seguimiento farmacoterapéutico en las farmacias comunitarias españolas

En el contexto de un estudio de investigación sobre priorización de facilitadores para la implantación del Seguimiento Farmacoterapéutico en las farmacias comunitarias españolas, se realizó un grupo focal compuesto por miembros de Foro de Atención Farmacéutica en Farmacia Comunitaria. El objetivo era explorar sus opiniones sobre los facilitadores priorizados en dicho estudio que se habían definido como “Incentivos”, “Campañas externas”, “Experto en SFT” y “Profesionalidad del farmacéutico”. El facilitador prioritario del estudio, denominado “incentivos”, incluye fundamentalmente incentivos económicos, imprescindibles en la implantación y sostenibilidad del Seguimiento Farmacoterapéutico, aunque también hace referencia a otro tipo de incentivo como el reconocimiento profesional.Los participantes estaban de acuerdo con los resultados del estudio, que indican la necesidad de un pago previo para implantar nuevos servicios profesionales. Se considera que este pago queda justificado por los beneficios que la realización del Seguimiento Farmacoterapéutico aporta a la salud del paciente y a la reducción del gasto sanitario derivado de un buen uso de la medicación. Por consiguiente, se plantearon distintos métodos para incentivar económicamente a la farmacia que realiza Seguimiento Farmacoterapéutico. En cuanto al reconocimiento profesional, se consideró como un incentivo la acreditación de la farmacia que realiza SFT y que su provisión tenga relevancia a nivel curricular. Se confirma también como de gran importancia tanto la realización de campañas externas como la existencia de un experto farmacéutico profesional, preparado y acreditado para realizar nuevos SPF

Exploración de las opiniones de agentes implicados sobre la integración entre la farmacia comunitaria y los equipos de atención primaria

Introducción: Dado el aislamiento existente entre los farmacéuticos comunitarios y los miembros de los equipos de atención primaria en nuestro país, se diseñó este estudio para explorar las opiniones de profesionales de la salud de Osakidetza y de farmacia comunitaria, sobre la posibilidad de integración de ambos colectivos.  Método: Se diseñó un estudio cualitativo utilizando el Grupo Focal como método de obtención de información con análisis temático del contenido. La reunión tuvo lugar en el Centro de Salud de Gros (OSI Donostialdea). Participaron diferentes profesionales tanto de Osakidetza (n=6) como de la farmacia comunitaria (n=2). Todo el proceso de la reunión grupal y su informe, se realizó siguiendo los Standards for Reporting Qualitative Research (SRQR).  Resultados: La Farmacia tiene como elementos fuertes su frecuentación, cercanía y facilidad de acceso viéndose como un recurso no suficientemente aprovechado. A pesar de la dificultad conceptual de integrar un colectivo privado con otro público, se entendía la necesidad de acercamiento interprofesional a través de una integración funcional, proceso que por su complejidad será lento y largo. Se debe comenzar con los programas locales ya existentes, proyectos pequeños, con objetivos concretos e indicadores medibles y mejorando la comunicación interprofesional y el conocimiento mutuo. Se analizaron las barreras a superar y los agentes implicados que deberían participar en cualquier proyecto futuro de integración siguiendo un modelo de diseño compartido. Conclusiones: Parece importante integrar funcionalmente la Farmacia comunitaria en Osakidetza – SVS

Community pharmacy and primary health care - Types of integration and their applicability: A narrative review

BACKGROUND: There is an urgent need for health care systems to be more efficient and efficacious. An approach to integrate public and private provider organizations such as community pharmacies and public primary health care (PHC) merits consideration. The objective of this review was to identify the types of integration in health care settings and discuss their applicability to the potential integration of community pharmacy and PHC. METHODS: A narrative review using Medline, Scopus and SciELO databases was performed in which terms related to health were combined with terms related to integration. Levels and Types of integration: 14 types of integration were identified (two in breadth, seven as enablers and five in system levels). A model was created which classifies and assigns the types of integration to the different levels of the health system and to the breadth, intensity, and enablers of the integration process. Due to the nature of community pharmacy and PHC system, a horizontal integration at the micro level, supported by meso and macro levels policy, is suggested. The different elements of intensity and enablers can significantly influence the process. CONCLUSION: The application of principles, concepts and types of integration suggest that it might be feasible and practical to integrate community pharmacies and PHC. However, the conflictive historical context would need to be overcome with appropriate policy and incentives.This research was funded by the University of the Basque Country (US20/08) and Cinfa laboratories for the PhD scholarship

Exploración de las opiniones de agentes implicados sobre la integración entre la farmacia comunitaria y los equipos de atención primaria

Introducción: Dado el aislamiento existente entre los farmacéuticos comunitarios y los miembros de los equipos de atención primaria en nuestro país, se diseñó este estudio para explorar las opiniones de profesionales de la salud de Osakidetza y de farmacia comunitaria, sobre la posibilidad de integración de ambos colectivos.  Método: Se diseñó un estudio cualitativo utilizando el Grupo Focal como método de obtención de información con análisis temático del contenido. La reunión tuvo lugar en el Centro de Salud de Gros (OSI Donostialdea). Participaron diferentes profesionales tanto de Osakidetza (n=6) como de la farmacia comunitaria (n=2). Todo el proceso de la reunión grupal y su informe, se realizó siguiendo los Standards for Reporting Qualitative Research (SRQR).  Resultados: La Farmacia tiene como elementos fuertes su frecuentación, cercanía y facilidad de acceso viéndose como un recurso no suficientemente aprovechado. A pesar de la dificultad conceptual de integrar un colectivo privado con otro público, se entendía la necesidad de acercamiento interprofesional a través de una integración funcional, proceso que por su complejidad será lento y largo. Se debe comenzar con los programas locales ya existentes, proyectos pequeños, con objetivos concretos e indicadores medibles y mejorando la comunicación interprofesional y el conocimiento mutuo. Se analizaron las barreras a superar y los agentes implicados que deberían participar en cualquier proyecto futuro de integración siguiendo un modelo de diseño compartido. Conclusiones: Parece importante integrar funcionalmente la Farmacia comunitaria en Osakidetza – SVS