Bordet, Julie

Burnand, Bernard

Collet, Tinh-Hai

Eggli, Marc

Peytremann-Bridevaux, Isabelle

Santschi, Valérie

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HINTS & KINKSCommunity-based pharmacies: an opportunity to recruitpatients?Isabelle Peytremann-Bridevaux • Julie Bordet • Vale´rie Santschi •Tinh-Hai Collet • Marc Eggli • Bernard BurnandReceived: 28 November 2011 / Accepted: 7 June 2012 / Published online: 1 July 2012 Swiss School of Public Health 2012Keywords Patients recruitment  Diabetes Pharmacies rolesIntroductionRecruiting representative population groups with a specificdisease is a challenge. In jurisdictions with no existing orno access to a database including individual disease diag-noses (e.g., electronic medical records), there are fewsatisfying strategies. Usually, population health surveys donot provide enough diagnostic information and may notallow recruiting large enough samples to study a specificdisease. Registries or clinical cohorts may exist for specificdiseases, but are often not truly population-based.Recruitment from patients’ associations and physicians’practices may also be selective. In addition, the latter isdifficult to run in busy primary care clinics. Finally, thetype of information and the possibility to access healthinsurances’ databases may preclude their use. For diseasesthat require treatment involving pharmacies regularly, wepropose to recruit patients in community pharmacies; thishas been seldom described (Knoester et al. 2005; VanWieren-de Wijer et al. 2009). In the canton of Vaud,Switzerland (*700,000 residents), we have applied suchan approach to conduct a survey designed to describe thecurrent population of diabetic patients and to assess thequality of their care. This survey was developed within theframework of a regional diabetes program that started inthe summer of 2010 (Hagon-Traub et al. 2010), as one ofmany such programs implemented to tackle the chronicdiseases epidemic (Nolte et al. 2008).The aim of this Hints and Kinks is to present a phar-macy-based approach of recruiting diabetic patients.MethodsTaking into account the clustering of data by pharmacies(40 pharmacies recruiting each 15 patients, intra-classcorrelation 0.05, alpha 0.05, beta 0.2), 600 diabetic patientswere considered enough to get a good precision around ourprimary outcomes (mean HbA1C, mean Physical andMental summary score of the SF-12, % of patients withspecific annual checks).To optimize the representativeness of the sample ofdiabetic patients, we decided to randomly select pharma-cies. Expecting a participation rate of 50 %, we first chose80 pharmacies out of the 254 ones registered in the cantonin April 2011 (130 independent and 124 chain pharmacies).Since we did not reach our 40 target pharmacies, weredrew another sample of 60. After this two-step procedure,56 pharmacies accepted to participate. Both participatingand non-participating pharmacies were asked to fill in abrief questionnaire on their practice characteristics (phar-macy type, pharmacy size and pharmacy location).Reasons for participation refusal were also asked.I. Peytremann-Bridevaux (&)  J. Bordet  V. Santschi B. BurnandInstitute of Social and Preventive Medicine (IUMSP),Lausanne University Hospital, 10 Route de la Corniche,1010 Lausanne, Switzerlande-mail: Isabelle.Peytremann-Bridevaux@chuv.chT.-H. ColletDepartment of Ambulatory Care and Community Medicine,University of Lausanne, Lausanne, SwitzerlandM. EggliService of Endocrinology, Diabetes, and Metabolism,Lausanne University Hospital, Lausanne, SwitzerlandInt J Public Health (2013) 58:319–322DOI 10.1007/s00038-012-0383-8123In September 2011, pharmacists recruited consecutivenon-institutionalized adult diabetic patients (C18 years,type 1 or 2 diabetes, disease duration C12 months) whowere visiting the pharmacy with a prescription for oral anti-diabetic drugs, insulin, glycemic strips or glucose meter.Women with gestational diabetes, patients not residing inthe canton of Vaud, not speaking and understanding Frenchwell enough or presenting obvious cognitive impairmentwere excluded. The latter two eligibility criteria weresubjectively assessed by the pharmacists. Age was recor-ded according to data on the prescription, and diabetesduration was asked to the patient. Physicians did not par-ticipate in the recruitment phase but were asked to fill in ashort questionnaire (clinical and laboratory data), ifpatients did share their contact details.A first letter was sent to all physicians and pharmacists ofthe canton, announcing the study. Another letter explainingthe recruitment process to the randomly selected pharmacieswas then sent. The recruitment was expected to last less than10 min per patient, and pharmacies would receive a CHF 5incentive for each questionnaire returned. Finally, we orga-nized a meeting with pharmacists, to launch the study,answer final questions, and provide all needed documents;those who were not able to attend the meeting were seen inperson during the same week. We contacted pharmacistsweekly during the recruitment period. Since the patients’participation rate was lower than expected (i.e. less than 600questionnaires sent back), the recruitment period wasextended from 4 to 6 weeks. During the final phone call,main reasons for ineligibility, main barriers to recruitment,and main reasons for patients’ refusal were investigated.The protocol was approved by the Canton’s EthicsCommittee of Research on Human Beings.ResultsThe characteristics of participating and non-participatingpharmacies (Table 1) did not differ significantly except forsize of the pharmacy. Lack of time (68 %) and not havingenough diabetic patients (23 %) were the main reasons forrefusing to participate.During the recruitment period, 809 of 1,013 eligiblepatients accepted to receive the questionnaire from apharmacy (Fig. 1); approximately 17 % of approachedpatients (0–52 % depending on pharmacy) were ineligible.Finally, 406 patients returned the paper-questionnaire,leading to an estimated patients’ participation rate of50.2 % (406/809). At the end of the 6-week period, mainreported barriers for recruitment were ineligibility ofpatients (34 %), duration of recruitment period too short(25 %), difficulty to propose the study to patients (25 %),and difficulty to motivate the pharmacy’s team (14 %).DiscussionRecruitment of diabetic patients by pharmacies was feasi-ble and satisfactory. Even if we did not reach our 600targeted patients, this did not modify the precision of ourpoint estimates because we got a larger number of clusters(pharmacies) and our dichotomous outcomes estimates hadbeen conservative. This lower recruitment rate might beexplained both by pharmacy- and patient-related barriers.In fact, more patients than expected were ineligiblebecause they did not master French well enough, possiblypresented cognitive impairment, or were not residing in thecanton. Despite clear recruitment recommendation andfrequent contacts with pharmacists, it remains unclear,however, how eligibility criteria were actually interpretedand applied, and whether patients were truly ineligible orTable 1 Characteristics of randomly selected (n = 140) participat-ing and non-participating pharmacies of the canton of Vaud(Switzerland, 2011)Participatingpharmacies(n = 56)Non-participatingpharmaciesa(n = 47)Allpharmacies(N = 254)Pharmacy typeIndependent 37 (66 %) 29 (62 %) 130 (51 %)Chain (Sunstore,Amavita, Capitol,Pharmacie Plus)17 (30 %) 18 (38 %) 124 (49 %)Other pharmacytype2 (4 %) 0 (0 %) 0 (0 %)Pharmacy locationRural 13 (23 %) 6 (13 %) NAUrban 26 (47 %) 25 (53 %) NASemi-urban 17 (30 %) 16 (34 %) NAPharmacy sizeSmall (\100patients/day)11 (20 %) 19 (40 %) NAMedium (100–200patients/day)24 (43 %) 18 (38 %) NALarge ([200patients/day)21 (38 %) 10 (22 %) NAPharmacist participation inQuality circles 15 (27 %) 8 (17 %) NACurrent chronicdiseasemanagementprograms18 (32 %) 17 (36 %) NAOther non-specifiedprogram6 (11 %) 9 (19 %) NANone 17 (30 %) 13 (28 %) NANA not availablea 37 non-participating pharmacies did not provide informationregarding their practice320 I. Peytremann-Bridevaux et al.123whether pharmacists ‘‘unintentionally applied selectioncriteria’’ (Knoester et al. 2005).One important issue with this type of recruitment is therepresentativeness of such a sample. When comparing oursample to 260 known and treated diabetic patients aged35–75 years, participating in a population-based cohort ofresidents of Lausanne (CoLaus), main town of the cantonof Vaud, we noticed that they were rather similar on a fewcomparable variables (women 41 vs. 33 %, mean age 64vs. 61 years, tertiary level education 25 vs. 20 %, currentsmokers 16 vs. 23 %, overweight and obesity 82 vs. 84 %,in our sample vs. the CoLaus sample, respectively)(P. Marques-Vidal, personal communication). Slight dif-ferences might be accounted for by differences in ageranges of the target population. This shows that in a sameregion, two recruitment strategies led to similar samples ofdiabetic participants. This similarity speaks against a majorrepresentativeness bias. However, both samples includeonly patients willing to participate in studies.We chose this form of recruitment to involve physiciansand pharmacists in the survey procedure, to minimizeselection bias of both participating physicians and patients,to include patients treated by a variety of physicians and tolimit the burden of physicians known to be very busy. Inaddition, our multidisciplinary working group hypothe-sized that pharmacist would be more ready to participate inthe recruitment of patients than physicians. With regard tothe latter reason, Swiss examples of diabetes screeningprojects in community pharmacies were promising (Bovetet al. 2011; Hersberger et al. 2006). Indeed, the recentpharmacy-based screening and awareness campaign fordiabetes and cardiovascular risk factors in the canton ofVaud showed that, in 2010, 78 % of registered pharmaciesagreed to participate, allowing 4,222 individuals to bescreened (Bovet et al. 2011). In that example, however(and others in the literature), pharmacists were activelyparticipating in the intervention. They were not only askedto recruit patients and distribute questionnaires, but wereactually assessing several chronic diseases risk factors andbehaviors.Informing, inciting and training pharmacists to take partin clinical research projects, prolonging and carefullymonitoring the recruitment period, finding incentives toincrease the pharmacists’ and patients’ motivation to par-ticipate could improve the yield of this recruitment method.In fact, participation in an intervention, where pharmacistswould not only recruit patients but be actively involved inpatients care, may be an interesting alternative. It maymatch pharmacists’ interest to be further involved in newroles and help them overcome time constraints.Easing recruitment of patients in primary care settings isneeded. Pharmacy-based recruitment represents a valuableoption that should be further developed and tested, par-ticularly, since there is increasing evidence thatpharmacists may help manage chronic diseases (McLeanet al. 2008; Santschi et al. 2011).Acknowledgments We would like to thank all pharmacies, diabeticpatients and practicing physicians who participated in the study. Wealso thank the partners and members of the working group for theircollaboration. We thank Mrs. Lucienne Boujon for copy editing themanuscript. This study was funded by the Department of PublicHealth of the canton of Vaud. Dr. I. Peytremann-Bridevaux is sup-ported by a grant from the Swiss National Science Foundation[PROSPER N 32333B-123817 and N 32333B-139789].Conflict of interest None of the authors has conflict of interest todeclare.Fig. 1 Recruitment flowdiagram (Canton of Vaud,Switzerland, 2011)Community-based pharmacies 321123ReferencesBovet P, Hirsiger P, Emery F, De Bernardini J, Rossier C, TrebeljahrJ, Hagon-Traub I (2011) Impact and cost of a 2-week commu-nity-based screening and awareness program for diabetes andcardiovascular risk factors in a Swiss canton. Diabetes MetabSyndr Obes 4:213–223Hagon-Traub I, Hirsiger P, Bovet P, Ruiz J, Peytremann-Bridevaux I,Noth C, Hauschild (2010) Programme cantonal Diabe`te,pre´sentation du programme. Lausanne: Service de la Sante´Publique du canton de Vaud. http://www.vd.ch/fileadmin/user_upload/themes/sante_social/services_soins/Diabete/fichiers_pdf/Programme_cantonal.pdfHersberger KE, Botomino A, Mancini M, Bruppacher R (2006)Sequential screening for diabetes—evaluation of a campaign inSwiss community pharmacies. Pharm World Sci 28:171–179Knoester PD, Belister SV, Deckers CLP, Keyser A, Renier WO,Egberts ACG, Hekster YA (2005) Recruitment of a cohort oflamotrigine users through community pharmacists: differencesbetween patients who gave informed consent and those who didnot. Pharmacoepidemiol Drug Saf 14:107–112McLean DL, McAlister FA, Johnson JA, King KM, Makowsky MJ,Jones CA, Tsuyuki RT, SCRIP-HTN Investigators et al (2008) Arandomized trial of the effect of community pharmacist andnurse care on improving blood pressure management in patientswith diabetes mellitus: study of cardiovascular risk interventionby pharmacists-hypertension (SCRIP-HTN). Arch Intern Med168:2355–2361Nolte E, Knai C, McKee M (2008) Managing chronic conditions:experience in eight countries. World Health Organization onbehalf of the European Observatory on Health Systems andPolicies, CopenhagenSantschi V, Chiolero A, Burnand B, Colosimo AL, Paradis G (2011)Impact of pharmacist care in the management of cardiovasculardisease risk factors: a systematic review and meta-analysis ofrandomized trials. Arch Intern Med 171:1441–1453Van Wieren-de Wijer DB, Maitland-van der Zee AH, de Boer A,Stricker BH, Kroon AA, de Leeuw PW, Bozkurt O, Klungel OHet al (2009) Recruitment of participants through communitypharmacies for a pharmacogenetic study of antihypertensivedrug treatment. Pharm World Sci 31:158–164322 I. Peytremann-Bridevaux et al.123

Community-based pharmacies: an opportunity to recruit patients?

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Community-based pharmacies: an opportunity to recruit patients?

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