Submitted by Alexandre Sousa (alexandre.sousa@incqs.fiocruz.br) on 2015-04-09T16:41:54Z No. of bitstreams: 1 Dissertacao-Ana_Maria.pdf: 1466792 bytes, checksum: 7d79b81726ae4b1cef3d0df3f9bae720 (MD5) / Approved for entry into archive by Alexandre Sousa (alexandre.sousa@incqs.fiocruz.br) on 2015-04-09T16:42:05Z (GMT) No. of bitstreams: 1 Dissertacao-Ana_Maria.pdf: 1466792 bytes, checksum: 7d79b81726ae4b1cef3d0df3f9bae720 (MD5) / Approved for entry into archive by Alexandre Sousa (alexandre.sousa@incqs.fiocruz.br) on 2015-04-09T16:42:20Z (GMT) No. of bitstreams: 1 Dissertacao-Ana_Maria.pdf: 1466792 bytes, checksum: 7d79b81726ae4b1cef3d0df3f9bae720 (MD5) / Made available in DSpace on 2015-04-09T16:42:20Z (GMT). No. of bitstreams: 1 Dissertacao-Ana_Maria.pdf: 1466792 bytes, checksum: 7d79b81726ae4b1cef3d0df3f9bae720 (MD5) Previous issue date: 2014 / Fundação Oswaldo Cruz. Instituto Nacional de Controle de Qualidade em Saúde / Os serviços de terapia renal substitutiva (TRS) possuem alta complexidade, o que gera diferentes riscos e requer uma equipe multidisciplinar com capacitação específica. As inspeções nas clinicas de diálise são o principal instrumento utilizado pela Vigilância Sanitária para controlar o risco sanitário. No estado do Rio de Janeiro estão cadastrados na Superintendência de Vigilância Sanitária (SUVISA), em 2013, 89 serviços de diálise, correspondendo ao atendimento de 12.000 pacientes. Neste estudo exploratório foi realizado um levantamento de inadequações sanitárias referentes à atuação do farmacêutico entre 2010 a 2012. O objetivo principal foi identificar as atribuições do farmacêutico nos serviços de diálise e nas inspeções a fim de elaborar um guia para nortear o seu trabalho nessa área. De acordo com os relatórios da Superintendência de Vigilância Sanitária da Secretaria de Estado de Saúde do Estado do Rio de Janeiro, (SES-RJ/SUVISA), o número médio de inadequações na área farmacêutica foi de 1122, 34,4% do total de 3264 observadas nas inspeções nestes serviços. As inadequações foram divididos em seis categorias: a) armazenagem de medicamentos e insumos (29,6%), b) programa de gerenciamento de resíduos (21,4%), c) sistema de distribuição e tratamento de água para hemodiálise (17,5%), d) uso de produtos saneantes (17,5%), e) programa de controle e prevenção de infecção e eventos adversos (8,7%), f) controle de qualidade da água de hemodiálise (6,8%). Quanto ao risco sanitário das inadequações, 53% representam risco moderado, 37% risco elevado e 10% risco baixo. Na avaliação dos serviços de TRS, 88 % foram satisfatórios e o grau de risco foi moderado em 75% e baixo em 13% dos serviços. Apenas 10% tiveram avaliação insatisfatória e grau de risco elevado. Quanto às medidas adotadas, foram expedidos 86 termos de intimação, 82 autos de infração, 8 termos de ajuste de conduta e 4 interdições (2%). A partir dos dados obtidos, concluímos que a ausência de farmacêuticos nos serviços de TRS (2/87) pode ter contribuído para a ocorrência das inadequações; que a sua inclusão nas equipes poderá melhorar a qualidade da terapia oferecida aos pacientes; e que sua presença nas equipes de inspeção é essencial para a detecção e avaliação de irregularidades inerentes a sua área de competência. / Renal substitutive therapy services have high complexity, which generates different risks and requires a multidisciplinary staff with specific capacities. The inspections in clinics of dialysis are the main instruments used by the Health Surveillance Department to control the sanitary risks. In the State of Rio de Janeiro 89 dialysis services related to the treatment of 12.000 patients are registered at the Superintendence of Sanitary Surveillance, in 2013. In this exploratory study, it was conducted a survey of sanitary inadequacies within the pharmacistic´s expertise area, from 2010 to 2012. The main objective was to identify the responsibilities of the pharmacist in the dialysis services and inspections with the aim to elaborate a manual to guide the work conducted by those professionals. According to the reports of Health Surveillance Department /SUVISA - RJ, the average number of inadequacies in the pharmaceutical area was 1122 (34.4%) out of 3264, scattered into six categories: (a) storage of medicines and supplies (29.6%), (b) waste management program (21.4%), (c) distribution and treatment system of water for hemodialysis (17.5%), (d) use of sanitizing products (17.5%), (e) control and prevention program of infection and adverse events (8.7%), (f) quality control of hemodialysis water (6.8%). Regarding the health risks of the inadequacies, 53% represent moderate risk, 37% high risk and 10% low risk. The evaluation of dialysis services indicated that 88% were satisfactory and that the degree of risk was moderate in 75% and low in 13% of the services. Only 10% had unsatisfactory evaluation and high degree of risk. In relation to the measures adopted, it was issued 86 summons, 82 notifications of infraction, 8 conduct adjustment terms and 4 bans (2%). Based on these data, it can be concluded that the absence of pharmacists in the dialysis service (2/87) may have contributed to the occurrence of inadequacies; their participation in the staff can improve the quality of the therapy provided to the patients; and that their presence in the inspection teams is essential for the detection and evaluation of irregularities within their area of competence.

Objetivo: desenvolver sistema de suporte à decisão clínica dos farmacêuticos no manejo de sintomas menores (SM) com medicamentos isentos de prescrição (MIPs). Métodos: Inicialmente, foi realizada uma revisão sistemática, entre janeiro 1980 a agosto de 2010, nas bases de dados Medline/Pubmed, Scopus, Lilacs e Embase. Posteriormente, uma amostra de conveniência de farmacêuticos comunitários (FC) participou de uma entrevista semiestruturada realizada nas farmácias comunitárias de duas grandes redes em Aracaju, no período de Junho a Agosto de 2012. Em seguida, a metodologia do paciente simulado (PS) foi aplicada a mesma amostra de FC com dois casos de SM (1 - mulher adulta com sinusite; 2 - mulher grávida com tosse seca e dor nas costelas). As simulações foram avaliadas de acordo com o instrumento desenvolvido pela Farmacopéia dos Estados Unidos (USP) chamado "Medication Counseling Behavior Guidelines" e validado para o português. No período de fevereiro de 2012 a janeiro de 2014, foi desenvolvido um software para auxiliar o farmacêutico no processo de manejo de SM do trato respiratório com MIPs. Para tanto, 7 farmacêuticos clínicos, juntamente com engenheiros de produção, determinaram o conteúdo dos algoritmos. Resultados: Apenas nove artigos preencheram todos os critérios de inclusão estabelecidos na revisão sistemática. Foi observado que quatro estudos relataram adesão do paciente a orientação do farmacêutico. Participaram da entrevista 40 FC e destes, 62,9% não cursaram na graduação disciplina sobre o manejo de SM. As respostas dos FC sobre sua atitude frente a automedicação, revelou que a depender do tempo da queixa eles indicam um tratamento ou encaminham o paciente ao médico. Foram realizadas 80 simulações que apresentaram um tempo total de atendimento farmacêutico de 91,31 segundos (DP ±68,63). A análise das simulações revelou que 83,3% e 72,5% dos FC recomendaram a visita ao médico para o PS1 e para o PS2, respectivamente. Foi observado que 45% e 17% dos FC revisaram a solicitação do paciente antes da orientação. No processo de desenvolvimento do software, os farmacêuticos especialistas apontaram que os algoritmos deveriam explorar as características dos SM (início, frequência, duração), os tratamentos farmacológicos e não- farmacológicos apropriados e os parâmetros de encaminhamento do paciente ao médico. A versão final do software proporciona a determinação de diagnóstico condizente com o conjunto de sinais e sintomas do paciente, retornando ao farmacêutico uma pequena lista das possíveis enfermidades. Conclusão: O software poderá melhorar as condições de trabalho dos farmacêuticos comunitários, adicionando-lhes maior evidência cientifica no manejo de SM com MIPs.

Orientadores: Priscila Gava Mazzola, Patricia Moriel / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-21T18:32:30Z (GMT). No. of bitstreams: 1 Costa_CarolinedeGodoiRezende_M.pdf: 3126877 bytes, checksum: 97128de773972dad8f95a4242353e863 (MD5) Previous issue date: 2012 / Resumo: Muitos fatores contribuem para a resposta do paciente à terapia antirretroviral (TARV), incluindo adesão, efetividade farmacológica e tolerância. A TARV é complexa e longa, e o risco de falha virológica, comumente associada à resistência antirretroviral, aumenta quando a adesão diminui. Neste contexto, a presença do farmacêutico, como o profissional capaz de orientar o paciente em relação à terapia medicamentosa e realizar o acompanhamento farmacoterapêutico, estimula os pacientes a estarem familiarizados com seus próprios esquemas terapêuticos, tornando mais simples a compreensão da importância do uso correto do medicamento, aumentando a adesão à terapia, efetividade e tolerância. Este trabalho teve como objetivo avaliar a efetividade da Intervenção Farmacêutica (IF) na resolução dos Problemas Farmacoterapêuticos (PFTs) e na melhora dos parâmetros clínicos dos pacientes com HIV/AIDS. Foi realizado um estudo prospectivo controlado intervencionista, com amostra consecutiva e de conveniência com controles de reposição emparelhados segundo gênero e valores iniciais de linfócitos T CD4+. Do total de pacientes selecionados para o estudo (n=143), 57 (39,86%) pacientes foram descontinuados e 86 pacientes finalizaram o estudo de 1 ano, sendo 43 pacientes do controle (GC) e 43 do grupo intervenção (GI). Os pacientes do GI receberam acompanhamento farmacoterapêutico por meio de método próprio baseado no método Pharmacotherapy workup. Durante o período de 1 ano foram realizadas 202 Intervenções ou Orientações Farmacêuticas no GI, com uma redução de 38,43% (p=0,0001) do total de PFTs. O GI apresentou aumento médio da variação de CD4 1,84 vezes maior que o aumento observado GC, com média de 154,66 para o GI e 83,80 para o GC. Apesar da carga viral média final do GI ser maior do que aquela observada no GC (17394,51 e 12921,53 cópias/mL, respectivamente), para o GI foi observada uma redução 3 vezes maior da carga viral do que para o GC: GI variou em média 23517,67 e GC, 6226,51. Os resultados deste estudo indicam que as Intervenções Farmacêuticas proporcionaram redução PFTs principalmente aqueles relacionados às reações adversas e interações medicamentosas, promoveram a adesão, aumentaram a efetividade da terapia antirretroviral, constatada com maior elevação da contagem de CD4 e redução da carga viral em comparação com o grupo controle / Abstract: Many factors contribute to the patient's response to antiretroviral therapy (ARVT), including adhesion, drug effectiveness and tolerance. Antiretroviral therapy is complex and lengthy, and the risk of virologic failure commonly associated with antiretroviral resistance increases when adhesion decreases. In this context, the presence of the pharmacist as a professional capable of guiding the patient in relation to drug therapy and follow up drug use, encourages patients to be familiar with their own therapeutic regimens, making it easier to understand the importance of using correct medicine, increasing adherence to therapy, effectiveness and tolerance. This study aimed to evaluate the effectiveness of pharmaceutical intervention (PI) in solving drug related problems (DRPs) and improvement of HIV/ AIDS patients clinical parameters. We conducted a prospective controlled intervention study, with a consecutive and convenience sampling with replaced controls paired by gender and initial T CD4+ lymphocytes values. Out of the total patients enrolled in the study (n=143), 57 (39,86%) patients were discontinued and 86 patients completed the 1-year study, with 43 patients in the control group (CG) and 43 in the intervention group (IG). Patients from de IG received pharmacotherapeutic follow up through a method developed in this work and some Pharmacotherapy workup method features. Over the period of 1 year were performed 202 interventions or counselling on Pharmaceutical IG, with a decrease of 38.43% (p = 0.0001) of total PFTs. The IG showed a mean improvement variation of 1.84 times CD4 greater than the increase observed CG with an average of 154.66 for IG and 83.80 for CG. Although the final viral load mean of IG found were greater than that observed in the CG (17394.51 and 12921.53 copies / mL, respectively), IG presented a reduction of three times greater than that in the CG: IG had mean range of 23517.67 and CG, 6226.51. The results of this study indicate that pharmacist interventions led to lower DRPs especially those related to adverse reactions and drug interactions, promoted adherence, increased the effectiveness of antiretroviral therapy, verified with greater elevation of CD4 count and viral load reduction compared with the control group / Mestrado / Ciencias Biomedicas / Mestra em Ciências Médicas

Master of Public Health - MPH / Background: Hospital pharmacy practice is an important aspect of healthcare, as drugs are a key component of patient treatment in hospitals. In Lagos state, Nigeria, provision of healthcare services, including drugs, was at one time entirely free but in the face of ever dwindling resources and increasing government responsibility, the health sector has to compete with other sectors for scarce public funds. Therefore, in 2002, a private sector initiative (PSI) in hospital pharmacy was implemented in seven hospitals in Lagos state as an alternative financing system for managing drug procurement and supply to fee-paying patients. Each of these seven hospitals now has two pharmacies, one providing free drugs to certain categories of patients entitled to this service and the second providing services to all other patients. Aim: This study aimed to explore and describe the impact of this private sector initiative on the job satisfaction of the pharmacists working in these hospitals from the viewpoint of the hospital pharmacists and relevant stakeholders, and to suggest ways of improving the job satisfaction of hospital pharmacists in Lagos state. Study Design: The study utilized a qualitative research design to explore the perceptions and experiences of government-employed pharmacists and key stakeholders on the impact of the private sector initiative. Study Population and Sampling: Individual interviews were conducted with three key informants and two focus group discussions were carried out, one with hospital pharmacists from the fee-paying pharmacies and the second with pharmacists from the free pharmacies from the seven hospitals in Lagos state where the private sector initiative was in operation. Data Collection and Analysis: The audio-taped interviews and focus group discussions were transcribed and analysed to identify the key categories and themes raised by the participants. Results: The study found that most pharmacists felt that the PSI has met the main objective for which it was set up, that is, improving availability of drugs in the hospital but there were some attendant factors like inadequate funding of the free health unit, increased workload of the fee-paying unit and poor working conditions, which affect the job satisfaction of pharmacists. The study however showed that the introduction of the PSI has led to improved performance of roles and recognition of the pharmacists and better working relationships between pharmacists and other healthcare workers which have impacted positively on the job satisfaction of pharmacists. Recommendations: The study recommended that the working conditions should be improved and issues of staffing and workloads should be addressed. Also, alternative but effective means of drug financing should be sought to ensure availability of drugs to all categories of patients.

Type 2 diabetes mellitus is a chronic disease of pandemic magnitude, increasingly contributing to the disease burden of countries in the developing world, largely because of the effects of unhealthy lifestyles fuelled by unbridled urbanisation. In certain settings, patients with diabetes are more likely to have a healthcare encounter with a pharmacist than with any other healthcare provider. The overall aim of the study was to investigate the potential of South African community pharmacists to positively influence patient adherence and metabolic control in Type 2 diabetes. The designated primary endpoint was glycated haemoglobin, with the intermediate health outcomes of blood lipids, serum creatinine, blood pressure and body mass index serving as secondary endpoints. Community pharmacists and their associated Type 2 diabetes patients were recruited from areas throughout South Africa using the communication media of various nonstatutory pharmacy organisations. Although 156 pharmacists initially indicated interest in participating in the study, only 28 pharmacists and 153 patients were enrolled prior to baseline data collection. Of these, 16 pharmacists and 57 patients participated in the study for the full twelve months. Baseline clinical and psychosocial data were collected, after which pharmacists and their patients were randomised, nine pharmacists and 34 patients to the intervention group and 8 pharmacists and 27 patients to the control group. The sample size calculation revealed that each group required the participation of a minimum of 35 patients. Control pharmacists were requested to offer standard pharmaceutical care, while the intervention pharmacists were provided with a scope of practice diabetes care plan to guide the diabetes care they were to provide. Data were again collected 12-months postbaseline. At baseline, proportionally more intervention patients (82.4%) than control patients (59.3%) were using only oral anti-diabetes agents (i.e. not in combination with insulin), while insulin usage, either alone or in combination with oral agents was conversely greater in the control group (40.7%) than in the intervention group (17.6%) (Chi-squared test, p=0.013). Approximately half of the patients (53.8% control and 47.1% intervention) reported having their HbA1c levels measured in terms of accepted guidelines. There was no significant difference in HbA1c between the groups at the end of the study (Independent t-test, p=0.514). In the control group, the mean HbA1c increased from 7.3±1.2% to 7.6±1.5%, while for the intervention patients the variable remained almost constant (8.2±2.0% at baseline and 8.2±1.8% at post-baseline). Similarly, there were no significant differences between the groups with regard to any of the designated secondary clinical endpoints. Adherence to medication and self-management recommendations was similarly good for both groups. There were no significant differences between the two groups for any of the other psychosocial variables measured. In conclusion, intervention pharmacists were not able to significantly influence glycaemic control or therapeutic adherence compared to the control pharmacists.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Introduction. Clinical Pharmacy Services (CPS) have been growing worldwide and have positively impacted health outcomes. However, studies that go deep into the steps of CPS implementation in the healthcare networks of the Brazilian healthcare system (SUS) are incipient. Objective. To analyze the implementation and propose strategies for integrating CPS into healthcare networks. Methods. A study was carried out in the Recife city, in three steps, from July 2015 to October 2017. The first step corresponded to a quasi-experimental study (before and after), carried out through the problematization with the Maguerez Arc in order to implement CPS. The second step gathered two qualitative studies, conducted through focus groups and semi-structured interviews, in order to identify barriers, facilitators and strategies that influenced the implementation. The third step included a methodological development study, conducted through semi-structured interviews and a nominal group, to propose and prioritize CPS integration strategies for SUS. Participants in the study were pharmacists, health managers and decision-makers involved in implementation, patients and panel experts. This study was approved by the Research Ethics Committee. Results. We carried out in the first step: i) initial evaluations (before): identified incipient CPS, deficiencies in the structure and work process of pharmacists; ii) planning: 16 brainstorming meetings and a strategic plan; iii) intervention: 22 political-administrative meetings were held with managers and health staff, 768 hours of theoretical-practical training with Mentoring for pharmacists; iv) preliminary evaluation (after): structure indicators presented a statistically significant difference, differently from the work process, and 1,465 pharmaceutical appointments were performed with 842 patients. It was possible to identify changes in the clinical status of the most prevalent diseases among the patients attended by three pharmaceutical appointments. In the second step, two focus groups were held with pharmacists and five interviews with health managers, which identified 43 barriers and 39 facilitators related to the healthcare networks, pharmacists, health team, implementation process and/or patients. In addition, 21 strategies related to pharmacists were identified as necessary for the implementation of CPS. In the third step, interviews were conducted with five managers and seven decision-makers who identified 21 barriers and 20 facilitators. From these results, specialists who composed the nominal group proposed 41 CPS integration strategies and prioritized the following: formalizing CPS; agreeing on care flows and referral protocols; evaluating and publicizing CPS results/benefits; planning and defining CPS; sensitizing the health managers. Conclusion. The analysis of the process identified factors that may have influenced the implementation of CPS, planning of the interventions and their application to reality, as well as in the prioritization of the strategies of integration of these services to SUS. Thus, the results obtained in this thesis can serve as a guide to help pharmacists, managers and decision-makers to plan, implement and integrate CPS in SUS. / Introdução. Serviços Clínicos Farmacêuticos (SCF) tem se expandido mundialmente e tem impactado positivamente nos resultados em saúde. Entretanto, estudos que se aprofundem nas etapas de implementação de SCF nas redes de atenção à saúde do sistema de saúde brasileiro (SUS) são incipientes. Objetivo. Analisar a implementação e propor estratégias para integração de SCF às redes de atenção à saúde. Métodos. Foi realizado estudo na cidade do Recife-PE, em três etapas, de julho/2015 a outubro/2017. A primeira etapa correspondeu a um estudo quasi-experimental (antes e depois), realizado por meio da metodologia da problematização com Arco de Maguerez, a fim de implementar SCF. A segunda etapa compreendeu dois estudos qualitativos, realizados por meio de grupos focais e entrevistas semiestruturadas, com a finalidade de identificar barreiras, facilitadores e estratégias que influenciaram na implementação dos SCF. A terceira etapa compreendeu estudo de desenvolvimento metodológico, realizado por meio de entrevistas semiestruturadas e grupo nominal, para propor e priorizar estratégias de integração de SCF ao SUS. Os participantes do estudo foram farmacêuticos, gestores e decision-makers envolvidos na implementação dos SCF, pacientes e painel de especialistas. Este estudo foi aprovado pelo Comitê de Ética em Pesquisa. Resultados. Na primeira etapa foram realizados: i) diagnóstico situacional (antes): identificou SCF incipientes, carências na estrutura e no processo de trabalho dos farmacêuticos; ii) planejamento: foram realizadas 16 reuniões de brainstorming com diferentes atores e um cronograma de atividades; iii) intervenção: foram realizadas 22 reuniões político-administrativas com gestores e equipe de saúde, 768 horas de treinamento teórico-prático com Mentoring para os farmacêuticos; iv) avaliação preliminar (depois): indicadores de estrutura apresentaram diferença estatística significativa, diferentemente dos indicadores de processo, e foram realizadas 1.465 consultas farmacêuticas com 842 pacientes, impactando em mudanças na situação clínica das doenças mais prevalentes entre pacientes atendidos por três consultas. Na segunda etapa foram realizados dois grupos focais com farmacêuticos e cinco entrevistas com gestores, o que identificou 43 barreiras e 39 facilitadores relacionados à rede de saúde, farmacêuticos, equipe de saúde, processo de implementação e/ou pacientes. Ademais, 21 estratégias relacionadas aos farmacêuticos foram identificadas como necessárias à implementação de SCF. Na terceira etapa foram realizadas entrevistas com cinco gestores e sete decision-makers que identificaram 21 barreiras e 20 facilitadores. A partir destes resultados, especialistas que compuseram o grupo nominal propuseram 41 estratégias para integração de SCF e priorizaram as seguintes: institucionalizar os SCF; pactuar fluxos assistenciais e protocolos de encaminhamentos; avaliar e divulgar os resultados/benefícios dos SCF; planejar e definir SCF; sensibilizar a gestão. Conclusão. A análise do processo identificou fatores que podem ter influenciado na implementação de SCF, planejamento das intervenções e sua aplicação à realidade, bem como na priorização das estratégias de integração desses serviços ao SUS. Assim, os resultados obtidos nesta tese poderão servir como eixos norteadores para que farmacêuticos, gestores e decision-makers planejem, implementem e integrem SCF no SUS. / Aracaju

Background: Interpersonal communication is inherent in a majority of strategies seeking to engage prescriber and pharmacist health care professionals (HCPs) in the reduction and prevention of prescription drug abuse (PDA). However, research on HCP PDA communication behavioral engagement and factors that influence it is limited. Objectives This study quantitatively examined communication behaviors and trait-level communication metrics, and qualitatively described prescription drug abuse-related communication perceptions and behaviors among primary care prescribers and community pharmacists. Methods: Five focus groups (N = 35) were conducted within the Appalachian Research Network (AppNET), a rural primary care practice-based research network (PBRN) in South Central Appalachia between February and October, 2014. Focus groups were structured around the administration of three previously validated trait-level communication survey instruments, and one instrument developed by the investigators to gauge HCP prescription drug abuse communication engagement and perceived communication importance. Using a grounded theory approach, focus group themes were inductively derived and coded independently by study investigators. Member-checking interviews were conducted to validate derived themes. Results: Respondents' trait-level communication self-perceptions indicated low communication apprehension, high self-perceived communication competence, and average willingness to communicate as compared to instrument specific criteria and norms. Significant variation in HCP communication behavior engagement was noted specific to PDA. Two overarching themes were noted for HCP-patient communication: 1) influencers of HCP communication and prescribing/dispensing behaviors, and 2) communication behaviors. Multiple sub-themes were identified within each theme. Similarities were noted in perceptions and behaviors across both prescribers and pharmacists. Conclusions: Despite the perceived importance of engaging in PDA communication, HCPs reported that prescription drug abuse communication is uncomfortable, variable, multifactorial, and often avoided. The themes that emerged from this analysis support the utility of communication science and health behavior theories to better understand and improve PDA communication behaviors of both prescribers and pharmacists, and thereby improve engagement in PDA prevention and treatment.

Background: Patients engaged in evidence-based opioid use disorder (OUD) treatment can obtain prescriptions for buprenorphine containing products from specially trained physicians that are subsequently dispensed by community pharmacists. Despite the involvement of physicians and community pharmacists in buprenorphine prescribing and dispensing, respectively, our understanding of their interactions in this context is limited. Objective: To qualitatively describe the communication and collaborative experiences between Drug Addiction Treatment Act 2000 (DATA)-waivered physicians and community pharmacists from the perspective of the physician. Methods: Ten key informant interviews were conducted with DATA-waivered physicians practicing in Northeast Tennessee. A semi-structured interview guide was used to explore communication and collaborative experiences between the physicians and community pharmacists. Interviews were audio recorded and transcribed verbatim. A coding frame was developed using concepts from the scientific literature and emerging codes from physician interviews. Interviews were coded using NVivo 11, with the data subsequently organized and evaluated for themes. Results: Four themes were identified: (1) mechanics of communication; (2) role specification and expectations; (3) education and understanding; and (4) climate of clinical practice. Physician-pharmacist communication primarily occurred indirectly through patients or staff and perceived challenges to collaboration included; lack of trust, stigma, and fear of regulatory oversight. Physicians also indicated the two professionals may lack clear roles and responsibilities as well as common expectations for treatment plans. Conclusions: Communication between DATA-waivered physicians and community pharmacists is influenced by multiple factors. Further research is warranted to improve physician-community pharmacist collaboration (PCPC) in the context of OUD pharmacotherapy and addiction treatment.

Background: The past three decades have seen a growth in health promotion research and practice, stimulated by the epidemiologic transition of the leading causes of death from infectious to chronic diseases. An estimated 50% of mortality from the 10 leading causes of death is due to behaviour, which suggests individuals can make important contributions to their own health by adopting some health-related behaviours and avoiding others. Motivational interviewing (MI) has emerged as a brief counselling approach for behavioural modification that builds on a patient empowerment perspective by supporting self-esteem and self-efficacy. MI has become increasingly popular in a variety of health care settings as well as non-health care settings. Aims: The overall aim of this thesis is to contribute to improved understanding of the different factors that impact on the learning and practice of MI. The aim of study I was to identify barriers and facilitators to use MI with overweight and obese children in child welfare and school health services. The aim of study II was to identify barriers, facilitators and modifiers to use MI with pharmacy clients in community pharmacies. Methods: Participants in study I were five child welfare centre nurses from the county council and six municipally-employed school health service nurses, all from Östergötland, Sweden. Participants in study II were 15 community pharmacy pharmacists in Östergötland Sweden. Data for both studies were obtained through focus group interviews with the participants, using interview guides containing open-ended questions related to the aims of the studies. Study II also included five individual interviews. Interview data were interpreted from a phenomenological perspective. Results: In study I, important barriers were nurses’ lack of recognition that overweight and obesity among children constitutes a health problem, problem ambivalence among nurses who felt that children’s weight might be a problem although there was no immediate motivation to do anything, and parents who the nurses believed were unmotivated to deal with their children’s weight problem. Facilitators included nurses’ recognition of the advantages of MI, parents who were cooperative and aware of the health problem, and working with obese children rather than those who were overweight. In study II, pharmacists who had previously participated in education that included elements similar to MI felt this facilitated their use of MI. The opportunity to decide on appropriate clients and/or healthrelated behaviours for counselling was also an important facilitator. The pharmacists believed the physical environment of the pharmacies was favourable for MI use, but they experienced time limitations when there were many clients on the premises. They also experienced many difficulties associated with the practical application of MI, including initiating and concluding client conversations. Conclusions: Learning and practicing MI effectively is difficult for many practitioners as it requires a new way of thinking and acting. Practitioners’ use of MI is not effective unless there is recognition that there is an important health-related problem to be solved. Practitioners feel more confident using MI with clients who have health-compromising behaviours and/or risks in which the practitioners feel they have expertise. Possessing considerable MI counselling skills does not compensate for insufficient knowledge about a targeted health-related behaviour and/or risk. Feedback from clients plays an important role for the quality and quantity of practitioners’ MI use.

L’hypothèse de cette thèse est qu’une pratique collaborative médecins de famille-pharmaciens communautaires (PCMP) où le pharmacien fournit des soins pharmaceutiques avancés avec ajustement posologique d’une statine permettrait aux patients avec une dyslipidémie une réduction plus importante de leur LDL et augmenterait le nombre de patients atteignant leurs cibles lipidiques. Dans une étude clinique contrôlée et randomisée en grappe visant à évaluer une PCMP pour des patients ayant une dyslipidémie (l’étude TEAM), une journée de formation basée sur un protocole de traitement et des outils cliniques a été offerte aux pharmaciens PCMP pour les préparer à fournir des soins pharmaceutiques avancés. Les connaissances des pharmaciens sur les dyslipidémies étaient faibles avant la formation mais se sont améliorées après (moyenne de 45,8% à 88,2%; p < 0,0001). Après la formation, les pharmaciens avaient un haut niveau d’habiletés cliniques théoriques et pratiques. Bref, une journée de formation basée sur un protocole de traitement et des outils cliniques était nécessaire et adéquate pour préparer les pharmaciens à fournir des soins pharmaceutiques avancés à des patients ayant une dyslipidémie dans le contexte d’une étude clinique. Dans l’étude TEAM, 15 grappes de médecins et de pharmaciens (PCMP : 8; soins habituels (SH) : 7) ont suivi pendant un an, 225 patients (PCMP : 108; SH : 117) à risque modéré ou élevé de maladie coronarienne qui débutaient ou étaient déjà traités par une monothérapie avec une statine mais qui n’avaient pas atteint les cibles lipidiques. Au départ, par rapport aux patients SH, les patients PCMP avaient un niveau de LDL plus élevé (3,5 mmol/L vs 3,2 mmol/L) et recevaient moins de statine à puissance élevée (11,1 % vs 39,7 %). Après 12 mois, la différence moyenne du changement de LDL entre les groupes était égale à -0,2 mmol/L (IC95%: -0,3 à -0,1) et -0,04 (IC95%: -0,3 à 0,2), sans ajustement et avec ajustement, respectivement. Le risque relatif d’atteindre les cibles lipidiques était 1,10 (IC95%: 0,95 à 1,26) et 1,16 (1,01 à 1,32), sans ajustement et avec ajustement, respectivement. Les patients PCMP ont eu plus de visites avec un professionnel de la santé et d’analyses de laboratoire et étaient plus enclins à rapporter des changements de style de vie. La PCMP a amélioré l’adhésion aux lignes directrices en augmentant la proportion de patients aux cibles lipidiques. Les données intérimaires de l’étude TEAM (PCMP : 100 patients; SH : 67 patients) ont permis d’évaluer les coûts directs annuels du suivi du pharmacien du groupe PCMP (formation, visites, laboratoire), du médecin (visites, laboratoire) et du traitement hypolipémiant. Le suivi du pharmacien a coûté 404,07$/patient, incluant 320,67$ pour former les pharmaciens. Le coût global incrémental était 421,01$/patient. Une pratique collaborative pour des patients ayant une dyslipidémie engendre un coût raisonnable. / The hypothesis was that a family physician-community pharmacist collaborative care (PPCC) model where the pharmacist provides advanced pharmaceutical care including statin dosage adjustment would provide a greater LDL reduction to dyslipidemia patients and increase the number of patients reaching their target lipid levels. . In a cluster randomised controlled trial to evaluate a PPCC model for patients with dyslipidemia (TEAM study), a one-day workshop based on a treatment protocol and specific clinical tools was offered to prepare PPCC pharmacists to provide advanced pharmaceutical care to dyslipidemia patients. Pharmacists knowledge on dyslipidemia was low before the workshop but significantly improved thereafter (overall score from 45,8% to 88,2%; p < 0,0001). After the workshop, pharmacists showed a high level of theoretical and practical skills. Finally, a one-day workshop based on a treatment protocol and clinical tools was necessary and adequate to prepare pharmacists to provide advanced pharmaceutical care to patients with dyslipidemia in the context of a clinical trial. In the TEAM study, 15 clusters of physicians and pharmacists (PPCC: 8; usual care (UC) : 7) followed for 1 year, 225 patients (PPCC: 108; UC:117) at moderate or high risk of coronary heart disease who initiated or were already treated with a statin monotherapy but who did not achieved target lipid levels. At baseline, compared to UC patients, PPCC patients had a higher level of LDL (3.54 mmol/L vs 3.22 mmol/L) and were prescribed less high-potency statin (11,1% vs 39,7%). At 12 months, the crude and adjusted between group-differences in the mean change in LDL-C were equal to -0.2 mmol/L (95%CI: -0.3 to -0.1) and -0.04 (95%CI: -0.3 to 0.2), respectively. The crude and the adjusted relative risk of achieving lipid targets were equal to 1.10 (95%CI: 0.95 to 1.26) and 1.16 (1.01 to 1.32), respectively. PPCC patients had more health-professional visits and laboratory tests, were more likely to have their lipid-lowering treatment changed, and to report lifestyle changes. PPCC improved adherence to treatment-guideline recommendations with higher proportion of patients achieving their target lipid levels. From an interim analysis of the TEAM study (PPCC: 100 patients; UC: 67 patients) the annual direct costs for the pharmacist follow-up in the PPCC group (training, visits, laboratories), physician follow-up (visits, laboratories) and lipid-lowering treatment were evaluated. The cost for the pharmacist follow-up was $404.07/patient, including $320.67 to train pharmacists. The incremental overall cost was $421.01/patient. Finally, a PPCC for patients with dyslipidemia entails a reasonable cost.