WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES Ogbonna et al. SJIF Impact Factor 2.786 Volume 4, Issue 02, 53-62. Research Article ISSN 2278 4357 PHARMACEUTICAL CARE DOCUMENTATION IN TWO TERTIARY HEALTH CARE FACILITIES IN SOUTH EASTERN NIGERIA Ogbonna Brian Onyebuchi *1, Ezenduka Charles Chukwuemeka 1, Enede Udoka 1 and Oparah Azuka Cyriacus 2 1 Department of Clinical Pharmacy and Pharmacy Management, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University Awka, Nigeria 2 Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Benin, Benin City, Nigeria. Article Received on 29 v 2014, Revised on 20 Dec 2014, Accepted on 12 Jan 2015 *Correspondence for Author Ogbonna Brian Onyebuchi Department of Clinical Pharmacy and Pharmacy Management, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University Awka, Nigeria. ABSTRACT Background: Continuity of care cannot be achieved without proper documentation of patient information. Documentation enhances patients follow up and monitoring as they move from one level and state of care to another. Aim: This study was carried out to examine the extent of pharmaceutical care documentation among pharmacists and assess their attitudes towards the practice. Methods: A prospective cross sectional study of randomly selected pharmacists in two tertiary health care facilities in Nigeria was conducted using structured questionnaires to assess pharmaceutical care documentation practices. Data was collected on pharmacists' demographics, attitudes and practices towards pharmaceutical care documentation. The study was conducted between January and September, 2014. Results: A total of 204 pharmacists took part in the study of 90 (44.1%) males and 114(55.9%) females. Out of this population, 138(67.7%) claimed to document pharmaceutical care activities, 65(16.2%) do not carry out documentation while 1(0.5%) document occasionally. The modal years of professional experience were 1-10 years. Standard documentation format was used by 79(40.5%) while 116(59.5%) did not use standard documentation format (n=195). Drug interaction 121(59.3%), unnecessary drug therapy 114(55.9%) and wrong drugs 84(41.2%) were the most documented drug therapy problems, (n=204). Conclusion: Findings suggest inadequate documentation of pharmaceutical care activities by the pharmacists, requiring the www.wjpps.com Vol 4, Issue 02, 2015. 53
need for policy strategies for enhanced pharmaceutical care practices for improved patients quality of life, even though their general perception of its importance is significant. Key words: Pharmaceutical care, documentation, pharmacists, drug therapy, patient care, quality of life INTRODUCTION The principles of evidence-based medicine use patient-specific data, disease and medicationspecific information, ethics, and quality-of-life considerations to improve patients outcomes. Achieving patient-centered, evidence-based monitoring plan for a therapeutic regimen that effectively evaluates achievement of the patient-specific goals for proper interventions depends on the availability of documented information on patients management. Documentation of patients pharmaceutical care activities generates three types of records: patients personalized pharmaceutical care plan, pharmaceutical care patient chart and practice management Report, which could be in manual, electronic form or both. [1,2] Documentation of patients subjective and objective information and pharmacists intervention is at the heart of pharmaceutical care. However, studies in developing countries by Duweijua et al (2001) show that majority of community pharmacists in Ghana do not document their activities. Suleiman et al (2012) reported that only half of the pharmacists population surveyed implemented pharmaceutical care documentation. [3, 4] Oparah et al (2004) also reported lack of fundamental documentation skills and absence of the basic minimum requirements of data needed in pharmaceutical care documentation. [5] Distilling pharmaceutical care interventions into documentation format can help to meet the unique need of pharmacy and help to provide the basis for continuity of care and a platform for interaction with other members of the health care team [6, 7]. Bulajeva (2010) opined that measurement and assessment of practices are the best ways to improve and promote the implementation and practice of pharmaceutical care while Okonta et al (2012) enumerated lack of space, qualified personnel to handle routine technical task and poor remunerations as the key limitations to implementation of pharmaceutical care services. [8,9] This study aimed to evaluate the current documentation status in line with current paradigm shift to pharmaceutical care; to generate information for enhancing pharmaceutical care implementation. www.wjpps.com Vol 4, Issue 02, 2015. 54
METHODS Study area and population The study was carried out in the metropolitan city of Nnewi and Awka in Anambra State, south east Nigeria. The two cities are densely populated with over 850000 and 810000 inhabitants and a tertiary health care facility respectively. They fall within the tropical rain forest belt and the inhabitants are predominantly traders, farmers and civil servants. Nnamdi Azikiwe University Teaching Hospital is a federal teaching hospital with over 500 bed spaces and 2400 work force spread across over 15 clinical and non clinical departments. It is situated at the heart of Nnewi metropolis, one of the commercial nerve centers of south east Nigeria. Anambra State University teaching Hospital is a state tertiary teaching hospital with over 300 bed spaces and situated within the capital territory of the state. Study population and sample size The study populations were registered clinical pharmacists who are staff of the two hospitals used for the study. Sample size was calculated based on the population size with allowance given to take care of those who may not give their informed consent. A total of 206 pharmacists who met the inclusion criteria and gave their informed consent participated in the study, two questionnaires which were not properly filled were dropped, giving rise to a total of 204 properly filled and returned questionnaires. [23] Study design and data collection A prospective, cross-sectional descriptive survey was carried out among hospital pharmacists between January and September, 2014. A pretested structured questionnaire covering demographics and the key areas of pharmaceutical care documentation was administered to randomly selected subjects who gave their informed consent. Respondents name was excluded from the questionnaire to prevent any form of identification. The questionnaires were self administered and collected back on agreed dates at designated points. A total of 210 questionnaires were distributed while 206 were filled and returned, giving a response rate of 97%. Two incorrectly filled questionnaires were dropped giving rise to a total of 204 correctly filled questionnaires. Statistical analysis The Statistical Package for Social Science (SPSS) version 16 was used to analyze the data. Quantitative variables were summarized using descriptive statistics. Categorical data were expressed in percentages while continuous data were expressed in mean and standard www.wjpps.com Vol 4, Issue 02, 2015. 55
deviation. Chi square test of independence was used to test for association between categorical variables. Data were analyzed at 1% significant level and values of p<0.01 were considered statistically significant. Ethical consideration An ethical approval was obtained from the Institutional Research and Ethics Committee of Nnamdi Azikiwe University Teaching Hospital before the commencement of the study. Informed consent was obtained from all pharmacists who took part in the study before administration of the questionnaires. RESULTS Table 1: Demographics of study participants (n=204) Variables Academic qualification B. Pharm Pharm D M. Pharm FPC Pharm Ph. D Years of professional experience 1 10 11 20 21 30 31 40 SEX Male Female AGE 20 30 31 40 41 50 51 60 >60 Table 2: Pharmacists pharmaceutical care activities VARIABLES Documentation of pharmaceutical care activities a response Extent of pharmaceutical care documentation b Always n(%) (n=204) 159 (77.9%) 16 (7.8%) 23 (11.3%) 6 (2.9%) 0 1 (0.5%) (n=132) 97 (73.5%) 22 (16.7%) 9 (6.8%) 4 (3.0%) (n=204) 90 (44.1%) 114 (55.9%) (n=188) 92 (48.9%) 46 (24.5%) 32 (17.0%) 15 (8.0%) 3 (1.6%) n(%) (n=204) 138 (67.7%) 33 (16.2%) 32 (15.7%) 1(0.5%) (n=180) 29 (16.1%) www.wjpps.com Vol 4, Issue 02, 2015. 56
Often Sometimes Rarely Never Method of documentation Paper Computer Computer with software The use of standard documentation format d response Availability of documented reference format e response Willingness to have a format f response Calculated x 2 ; x 2a = 5.52, x 2d =18.21 Expected x 2 ; x 2a =12.8562, x 2d =11.914308 46(25.6%) 55 (30.6%) 26 (14.4%) 24 (13.3%) (n=154) 142 (92.2%) 3(2.0%) 5 (3.3%) 4 (2.6%) (n=195) 79 (40.5%) 60 (30.8%) 56 (28.7%) (n=195) 74 (38.0%) 63 (32.3%) 58 (29.7%) (n=201) 167 (83.1%) 8 (4.0%) 26 (12.9%) Table 3. Documentation of Patient Related and Drug Therapy Problem Variables n (%) Commonly encountered drug therapy problem (n=204) Unnecessary drug therapy 114 (55.9%) Wrong drugs 84 (41.2%) Dose too low 101 (49.5%) Adverse drug reactions 72 (35.3%) Dosage too high 143 (70.1%) Inappropriate compliance 82 (40.2%) Need for additional drugs 38 (18.6%) Drug interaction 121 (59.3%) Inappropriate dosing interval 0 - Documentation of drug therapy problem (n=199) 95 (47.7%) 54 (27.1%) response 48 (24.1%) 2 (1.0%) Other patient related items being documented (n=204) Patient medical history 71 (34.8%) Patient condition 45 (22.1%) Medication error 101 (49.5%) Drug information request 34 (16.7%) Drug interaction 84 (41.2%) www.wjpps.com Vol 4, Issue 02, 2015. 57
Interventions on the listed drug therapy problems Cannot remember Documentation of interventions made response 0 (n=197) 186 (94.4%) 5 (2.5%) 6 (3.0%) (n=198) 102 (51.5%) 47 (23.7%) 49 (24.8%) Calculated x 2 ; x 2b = 12.82, x 2d = 0.28 Expected x 2 ; x 2b = 13.2767, x 2d =13.2767 Table 4. Perceived Importance of Pharmaceutical Care Documentation VARIABLE YES (%) N (%) Improved desired outcome a (n=196) 195 (99.4%) 1 (0.5%) Reimbursement purposes b (n=119) 63 (52.9%) 56 (47.1%) Legal evidence c (n=130) 107 (82.3%) 23 (17.7%) To influence policy d (n=136) 118(86.8%) 18(13.2%) Improve perception e (n=177) 176 (99.4%) 1(0.6%) Increase job satisfaction f (n=186) 180 (96.8%) 6 (3.2%) Improve patient perception g (n=177) 175 (98.9%) 2 (1.1%) Research purposes h (n=162) 153(94.4%) 9 (5.6%) Calculated x 2 ; x 2b = 10.96, x 2d = 0.85 Expected x 2 ; x 2b = 13.2767 x 2d =13.2767 DISCUSSION Pharmaceutical care demands that pharmacists take responsibility rather than merely provide functions. [10] Strand (1998) opined that they have to be able to identify patients drug therapy needs and meet them better than anyone else. [11] Documentation generates information for audit trail and continuity of care. This requires competency which is characterized by strong knowledge, skills, behaviors and values. The population predominantly has the basic B.Pharm qualification and below 30 years of age with less than 11 years practice experience. This is similar to that obtained by Suleiman et al in 2012. [4] This study suggests that a significant number of pharmacists do not document pharmaceutical care activities in their practice and underscores the need for advocacy and continuing education. Only 16.0% of the respondents document their activities always while 13% never documented their activities. This is consistent with the findings of a similar study www.wjpps.com Vol 4, Issue 02, 2015. 58
carried out by Duweijua et al (2001) where 88% of pharmacists kept no record of the services rendered. [3] This undermines the need for continuity of care since no meaningful intervention could be made without audit trail and follow up on patients previous data. This forms the basis for optimization of patients drug therapy to improve outcomes and reduce cost. In the elderly where individualized drug therapy is of immense benefit, it predispose patients to negative health outcomes due to non restricted access to drugs when the previous medications are not known. [12,13] Study shows that documentation is predominantly done in a crude manner since 92.2% was done manually on paper while only 3.3% was carried out using computer and software. This suggests a teething stage in the advent of pharmaceutical care and contrary to what is obtainable in United states where Omnibus Reconciliation Budget Act of 1989 and 1990 mandates documentation of pharmaceutical care activities and stated the [14, 15, 16] minimum required information to be documented. There was no statistically significant difference between those who use standard documentation format and those who do not. This informs the need for enforcement of standard documentation format by the regulatory bodies. A total of 83.1% of the pharmacists are willing to have and adopt a standard documentation format; which shows an indication of their willingness to change. It could be properly harnessed through continuing education, training and retraining. Drug therapy problems (DTPs) which could be actual or potential, forms the core of pharmaceutical care. Studies in United State indicated that1.3 million hospitalizations and 63000 deaths were caused by drug therapy related problems annually. [20] Identification and documentation of DTPs help to prevent adverse drug reactions, save cost and improve patients outcomes. [17] In this study, the pharmacists who document drug therapy problems were statistically significant from those who do not document it. Dosage too high (70.1%), drug interactions (59.3%), inappropriate dosing interval (57.8%), unnecessary drug therapy (55.8%) dosage too low (49.5%) and non adherence (40.2%) were the leading drug therapy problems documented. The finding is consistent with a similar study by Ogbonna et al (2014) where non adherence, unnecessary drug and adverse drug reaction were the leading DTPs documented. [18] This is also consistent with the result obtained by Suleiman et al (2012) where unnecessary drug therapy (17%), non adherence (8.4%) and wrong drug (5.3%) were the highest documented DTPs. [4] There was statistically significant difference between pharmacists who carry out interventions on the documented DTPs and those who do not intervene. Studies have shown enhanced quality of life for patients where interventions was [18, 19] carried out and enhanced profit potential for the pharmacy. www.wjpps.com Vol 4, Issue 02, 2015. 59
The assessment of perceived importance of pharmaceutical care documentation revealed that 99.4% of respondents believe that documentation improved patients desired outcomes. A total of 99.4% believed that it will improve pharmacists perception by other members of the health care team While 96.8% believed it enhances job satisfaction. Findings also show that 94.4% of respondents agreed that pharmaceutical care documentation is good for research purposes. This is a positive development in line with Berger and Grimely trans theoretical model which suggests five stages of voluntary behavioral change namely: precontemplation, contemplation, preparation, action and maintenance. Those with positive perception about the importance of documentation may end up embracing the change. Action oriented strategies [21, 22] like workshops may facilitate the process. There were statistically significant differences to reimbursement purposes and to those who believe that documentation could be used to positively influence good policy framework which will positively impact on patients outcomes and pharmacists remunerations. CONCLUSION The study suggests a gap in pharmaceutical care documentation in majority of the respondents. Most of the respondents do not document while those who document do so without using the standard documentation methods and format. However, majority of the respondents are willing to adopt the standard documentation practice. Evidence calls for enhanced strategies through policy interventions and continuing education to facilitate pharmaceutical care documentation for wholesome implementation of pharmaceutical care for patients improved quality of life. ACKNOWLEDGMENTS We appreciate the support and tireless efforts of pharmacists and management of the two hospitals for their corporations in successful and timely collection of data. COMPETING INTEREST The authors declared no conflict of interests. AUTHORS CONTRIBUTION OBO conceived the study, designed and wrote the manuscript. ECC participated in the study design and data analysis, EU helped in data collection and documentation while OAC participated in data analysis, interpretation and review of the manuscript. All the authors approved the final manuscript. www.wjpps.com Vol 4, Issue 02, 2015. 60
REFERENCES 1. Oparah AC, Essentials of pharmaceutical care. In: Pharmaceutical care concept, Philosophy, Competency and Benefits. 1 st Ed., Lagos; Cybex: 2010; pp. 21-42. 2. Cipolle RJ, Strand LM and Morley PC (1998). Pharmaceutical care practice. McGraw- Hill, NY, 1998; 76-83. 3. Duweijua M, Dodoo A and Palunge-Rhule (2001). Quality of counseling on salbutamol metered dose inhalers in community pharmacies in Kumasi, Ghana. Pharm J., 2001; 20(1): 20-23. 4. Suleiman IA, Eniojukan JF and Eze I (2012). Evaluating pharmaceutical care documentation among pharmacists in Nigeria. West African Journal of Pharmacy. 2012; 23(1) 69-76. 5. Oparah AC (2004). Pharmaceutical care: The Right of the Patient. West Afr J of Pharm, 2004; 18(1): 11-17. 6. Canday B and Yarborough P. (1994). Documenting pharmaceutical care: creating a standard. NCBI Resources, 1994; 1292-1296. 7. Linda MS, Cipolle RJ, Morley PC and Frakes MJ. (2004). The impact of pharmaceutical care practice on the practitioner and the patient in the ambulatory practice setting: twenty five years of experience. Current pharmaceutical design., 2004; Pg 3987-4001. 8. Bulajeva A. (2010). Pharmaceutical care services and quality services in community pharmacies; An international study. Masters thesis, University of Helsinki Division of Social Pharmacy. 2010; pp: 66-67. 9. Okonta J., Eleje O. and Ofoegbu C. (2012). Barriers to Implementation of pharmaceutical care by pharmacists in Nsukka and Enugu metropolis of Enugu state. Journal of Basic and Clinical pharmacy. March 2012-May 2012; 3(2): 295-298. 10. Westfund T, Almarsdottir A, Melinda A (1999). Drug-related problems and pharmacy interventions in community practice. Int J Pharm Pract; 7 impact of pharmaceutical care, 1999; 40-50. 11. Strand L (1998). Building a practice in pharmaceutical care. Pharm J, 1998; 260: 874-878. 12. Nash BD, Koening JB, Chatteron ML. (2000). Why the Elderly Need Individualized Pharmaceutical care. Office of Health Policy and Clinical Outcomes, Thomas Jefferson University. www.wjpps.com Vol 4, Issue 02, 2015. 61
13. Leipzig RM, Cumming RG, Tinatti ME. Drugs and falls in older people: a systematic review and meta-analysis II, Cardiac and analgesic drugs. J AM Geriatrics Society 1999; 47(1): 40-50. 14. Omnibus Budget Reconciliation Act 1990: A Practical Guide to Effecting Pharmaceutical Care. American Pharmaceutical Association, Washington DC 1994. 15. OBRA (1990). Omnibus Reconciliation Act; A practical guide to Effecting Pharmaceutical Care, American Pharmaceutical Association, Washington DC. 16. Omnibus Budget Reconciliation Act 1989. Public Law 101-239. Washington, DC: Government Printing Office, 1989. 17. Smith W. (1988). Excellence in the management of clinical pharmacy services. Am J Hosp Pharm, 1988; 45: 319-325. 18. Ogbonna BO, Ezenduka CC, Oparah CA and Agharah LG. (2014). Drug therapy problems in Patients with type 2 diabetes in a tertiary hospital in Nigeria. Intern J for Inov Research and Dev., 2014; 3 (1): 494-502. 19. Bootman JL. (1986). Application of cost benefit analysis to community pharmacy practice. Can Pharm J, 1986; 119: 295-303. 20. Johnson JA and Bootman JL (1997). Drug related morbidity and mortality and the economic. 21. Berger BA and Grimley D (1997). Pharmacists readiness for rendering pharmaceutical care. A paper presented at the Annual Meeting f the American Pharmaceutical Association. Los Angeles, CA. 22. Prochaska JO, Velicier WF, Rossi JS, Goldstein MG (1994). Stages of change and decisional balance for 12-problem behaviors. Health Psychology, 1994; 13: 39-46. 23. James EB, Joe W and Chadwick CH. (2001). Organizational Research: Determination of appropriate sample size in survey research. Information technology learning and performance Journal, 2001; 19(1): 43-50. www.wjpps.com Vol 4, Issue 02, 2015. 62