Research Notes

Physician perceptions of pharmacist-provided medication therapy management: Qualitative analysis Stephanie Harriman McGrath, Margie E. Snyder, Gladys Garcia Dueñas, Janice L. Pringle, Randall B. Smith, and Melissa Somma McGivney

Abstract Objective: To identify physician perceptions of community pharmacist-provided medication therapy management (MTM). Methods: Three focus groups consisting of family and internal medicine physicians were conducted in Pittsburgh, York, and Philadelphia, PA, using a semistructured topic guide to facilitate discussions. Each participant completed an exit survey at session conclusion. Results: 23 physicians participated in one of three focus groups conducted in Pittsburgh (n = 9), York (n = 6), and Philadelphia (n = 8). Participants identified common medication issues in their practices: nonadherence, adverse effects, drug interactions, medication costs, and incomplete patient understanding of the medication regimen. Receipt of a complete patient medication list was reported as the greatest potential benefit of MTM. Participants believed that physicians would be better suited as MTM providers than pharmacists. Concerns identified were the mechanism of pharmacist payment, reimbursement of time spent by physicians to coordinate care, and the training/preparation of the pharmacist. The need for a trusting relationship between a patient’s primary care physician and the pharmacists providing MTM was identified. Conclusion: This study provides information to assist pharmacists when approaching physicians to propose collaboration through MTM. Pharmacists should tell physicians that they will receive an updated patient medication list after each visit and emphasize that direct communication is essential to coordinate care. Keywords: Medication therapy management, collaborative practice, focus groups, pharmacists, physicians. J Am Pharm Assoc. 2010;50:67–71. doi: 10.1331/JAPhA.2010.08186

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he high incidence of preventable adverse drug events in the ambulatory care setting has been broadly described in the literature.1,2 Greater access to pharmacists and enhanced collaboration between prescribers and pharmacists may prevent these events2 and improve health outcomes.3–6 Although evidence supports physician–pharmacist collaborations, this type of coordinated care is not routinely practiced in community settings. Medication therapy management (MTM) services present an opportunity for patients and physicians to work closely with community-based pharmacists.7 Pharmacist-provided MTM core elements include a comprehensive medication therapy review, personal medication record, medication-related action plan, intervention and/or referral, documentation, and collaboration with the patient’s physician to follow-up and address all medication-related needs of the patient.8 Some physicians are unfamiliar with a pharmacist’s role in patient care beyond the provision of a drug product.9–11 To establish collaborative relationships with physicians when providing MTM, pharmacists must understand physician needs related to patient medication regimens and their perceptions of Received December 31, 2008, and in revised form May 23, 2009. Accepted for publication July 1, 2009. Stephanie Harriman McGrath, PharmD, was a community practice resident, School of Pharmacy, University of Pittsburgh, PA, at the time this study was conducted; she is currently Rite Care Clinical Pharmacist, Rite Aid Pharmacy, Pittsburgh, PA. Margie E. Snyder, PharmD, MPH, is Community Practice Research Fellow, School of Pharmacy, University of Pittsburgh, PA. Gladys Garcia Dueñas, PharmD, was a community practice resident, School of Pharmacy, University of Pittsburgh, PA, at the time this study was conducted; she is currently Assistant Professor, Philadelphia College of Pharmacy, University of the Sciences in Philadelphia. Janice L. Pringle, PhD, is Research Assistant Professor; Randall B. Smith, PhD, is Professor and Senior Associate Dean; and Melissa Somma McGivney, PharmD, is Assistant Professor, School of Pharmacy, University of Pittsburgh, PA. Correspondence: Stephanie Harriman McGrath, PharmD, Rite Aid Pharmacy, 900 Mount Royal Blvd., Pittsburgh, PA 15223. Fax: 412-487-6091. E-mail: stephanie.harriman@ gmail.com Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Acknowledgments: To the Pennsylvania Medical Society for organizational support. Also to Shelby Corman, PharmD, for serving as research mentor; Jaqueline Farrell, PharmD, for assisting with data collection; Coleen Kayden, BPharm, and Cynthia A. Sanoski, PharmD, for serving as project mentors during data collection; and Teresa McKaveney for assisting in preparing the manuscript. Funding: American Pharmacists Association Foundation and the National Association of Chain Drug Stores Foundation, Inc. Previous presentations: American Pharmacists Association Annual Meeting, San Diego, CA, March 16, 2008, and 2008 Eastern States Pharmacy Residency Conference, Hershey, PA, April 30, 2008.

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Research Notes

Table 1. Focus group topic guide Main topic Medication needs

Collaboration regarding medication issues

Overview of MTM

Communication of MTM

Facilitator question What proportion of your patient panel takes multiple prescription medications and/or has multiple comorbidities? How does your office communicate with patients about their medication issues and concerns? What are the most significant challenges for you and your office staff when addressing the (medication-related) needs of patients who are taking multiple medications? Have you ever collaborated with another health professional to address your patients’ medication issues? Describe that collaboration or, if no, why not? Provide a description of MTM. Could an MTM service address those medication needs of your patients? What benefits can you see in this MTM service? What concerns do you have regarding this MTM service? What are your thoughts on working with a pharmacist in your office? In the community, outside your office? How would you like a pharmacist to communicate with you about working together? How would you like a pharmacist to communicate with you about your patients?

Abbreviation used: MTM, medication therapy management.

pharmacist-provided MTM.12 This study uses qualitative methods to identify and explore physician perceptions of community pharmacist–provided MTM.

Methods Design

Three physician focus groups were conducted in market research facilities in Pittsburgh, York, and Philadelphia, PA. Geographic locations were chosen to provide a diversity of participants from urban, suburban, and rural locations and were limited by facility location. Facilitators with experience leading focus groups conducted the 2-hour sessions, which were audio recorded and transcribed. The resulting text was analyzed using qualitative methods.13–17 This study was approved by the University of Pittsburgh Institutional Review Board. Participants

Family and internal medicine physicians practicing in outpatient settings in Pennsylvania were eligible for this study. Participants were randomly selected from the Pennsylvania Medical Society membership list and recruited by client service 68 • JAPhA • 50 : 1 • J a n / F e b 2010

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representatives from each market research facility through an initial phone call and/or facsimile and a follow-up phone call. Using a screening tool developed by study investigators, recruiters aimed for 10 to 12 physicians per group, anticipating that 8 to 10 physicians would ultimately participate based on the typical drop-out rate of market research groups. Participants who completed the study were provided a monetary incentive ranging from $175 to $200, as determined by market trends in each geographic area. Focus group script

An MTM-trained pharmacist reviewed the core elements of MTM with each facilitator and provided a semistructured topic guide with literature-derived questions (Table 1)8–12,18,19 and a detailed description of the community pharmacists’ role in MTM. During each session, the facilitator asked participants a series of questions designed to elicit the physicans’ perceived medication-related needs of their patients, determine how those needs are being met, and identify perceived benefits and concerns related to pharmacist-provided MTM. After each focus group session, the research team refined the topic guide for clarity. Qualitative data analysis

The dialogue from each session was transcribed verbatim. Qualitative data analysis was then performed using an iterative coding process, which involves reading the data and identifying repetitive themes.13–17 Coding was conducted by the principal investigator and a coder employed by the University of Pittsburgh Qualitative Data Analysis Program, using the qualitative data management software ATLAS.ti (version 5.2; ATLAS.ti, Berlin). The codebook reflected a combined inductive/ deductive approach to analysis. After coding each transcript, the coders collaboratively refined each code definition to better apply the codes to the next round of coding and eliminate discrepancies. Repeating themes were identified and findings subsequently summarized. Exit survey

After each focus group session, participants completed an anonymous exit survey that identified past and current experience with pharmacists (Table 2). Five close-ended responses described varying levels of involvement in patient care. The preferred method(s) of communication with a pharmacist about an MTM practice and specific patient cases was also queried. A blank space was provided for participants to write in their communication preference. The results were analyzed using descriptive statistics.

Results A total of 23 primary care physicians participated in one of three focus groups conducted in Pittsburgh (n = 9), York (n = 6), and Philadelphia (n = 8). Participant demographic characteristics are summarized in Table 2. The majority of participants were male (83%) family medicine (61%) physicians in private practice (91%). The results of the exit survey are presented in Table 2. Journal of the American Pharmacists Association

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Research Notes

Table 2. Physician demographics and responses to exit survey n Demographic characteristics Gender, No. (%) Men Women Age (years), mean (range) Years in practice, mean Practice specialty, n Family medicine Internal medicine General medicine Current practice setting, n Private practice Nonacademic medical center Unknown Survey responses Experience with pharmacists during postgraduate residency and/or training, No. (%) Received calls/pages from pharmacists regarding patient case Called pharmacist to discuss patient case Pharmacist participated on rounds Current experience with pharmacists, No. (%) Receives call/pages from pharmacists regarding patient case Call pharmacist to discuss patient case Pharmacist participates on rounds Work side-by-side with pharmacist to optimize patient care How would you like a pharmacist to initiate a possible relationship with you?, No. (%) Make an appointment with you Would not participate Regarding a specific patient the pharmacists sees, how would you like to hear about it?, No. (%) Telephone Fax Postal mail Would not participate

Total 23

Pittsburgh, PA 9

York, PA 6

Philadelphia 8

19 (83) 4 (17) NA NA

8 (89) 1 (11) 53 (49–58) 26

5 (83) 1 (17) 51 (41–60) 27

6 (75) 2 (25) 52 (43–61) 22

14 7 1

4 5 0

4 1 1

4 4 0

21 1 1

9 0 0

5 1 0

7 0 1

17 (74) 13 (57) 9 (39)

8 6 4

4 6 3

5 1 2

23 (100) 12 (51) 4 (17) 4 (17)

9 5 1 1

6 5 3 3

8 2 0 0

10 (43) 5 (22)

0 5

5 0

5 0

7 (30) 18 (78) 8 (35) 2 (8)

2 6 1 2

2 6 3 0

3 6 4 0

Abbreviation used: NA, not applicable. Responses are not mutually exclusive.

Of 23 participants, 4 (17%) currently work side-by-side with pharmacists to optimize patient care. The majority of participants would like an appointment with a pharmacist to initiate a relationship; however, five physicians preferred not to participate in such a relationship. The preferred method of communication regarding a specific patient was through facsimile. Thematic analysis results are presented in Table 3. Detailed findings are described below. Patient medication-related needs

Common patient medication-related needs across all focus groups included patient adherence, adverse effects, drug interactions, affordability (of medications), and lack of patient unJournal of the American Pharmacists Association

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derstanding toward medication regimens. Perceived benefits of MTM services

Benefits of MTM were more frequently voiced in the York group compared with the other two groups. The most frequently reported benefit was the complete medication list provided to patient and physician(s). Participants believed that identifying potential medication problems and improving patient adherence to medication regimens were potential benefits. Concerns with MTM

The participants’ primary concern was the belief that physicians are better suited to provide MTM because pharmacists www.japha.org

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Research Notes

Table 3. Physician perceptions of pharmacist-provided MTM Category Physician perceptions Medication-related Patient nonadherence Cost of medications needs Adverse effects Drug interactions Patient understanding of medication regimen Complete medication list is provided to phyBenefits of MTM sician Increased patient adherence to medication regimen Another health provider to catch problems and mistakes Team-based approach to care Primary care physician should provide MTM Concerns with Insurance companies should reimburse MTM physicians for MTM Pharmacist doesn’t know patient well enough MTM requires nonreimbursable time from physician Pharmacists may overstep boundaries Pharmacists need an “all-seeing eye” Payment scheme for pharmacists is needed Software could perform MTM Pharmacists need clinical training Physician and pharmacist must be likePhysician– minded regarding patient care pharmacist Benefits of MTM for physician must be clear communication Pharmacist outside of physician office would hamper communication Physicians would want to hire the pharmacist Pharmacists must establish trusting relationship Physician and pharmacist cannot be competing Physicians need to know who trained the pharmacist Physicians may not understand MTM and would want a standard “script” of the process Abbreviation used: MTM, medication therapy management.

would not know the patient as well and may lack necessary clinical training. One physician provided the following description: “There is benefit; I don’t think anybody is arguing that point. Nobody is arguing the point that [having] somebody sit down and look through medications is not beneficial, of course it’s beneficial. We are questioning very strongly who should be doing it. We feel that we [physicians] should be doing it.” Reimbursement issues repeatedly emerged. Physicians wanted reimbursement for time spent working with pharma70 • JAPhA • 50 : 1 • J a n / F e b 2010

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cists on patient medication issues and questioned how pharmacists would be paid for the service. One physician summarized as follows: “I think a lot of what you’re hearing from us [during the focus group session] is that we feel put upon for our time to begin with and reimbursement is low and we don’t get reimbursement for phone time and a lot of the things we do. This is more time we have to spend for something that’s unreimbursed—it’s frustrating.” Physician–pharmacist communication

Participants felt strongly that pharmacists must clearly communicate the benefit of MTM in order to initiate a collaborative relationship; physicians repeatedly stated that they need a clearer understanding of the mechanics of the program and the impact on the patient’s care. One physician summarized his lack of comprehension of MTM as follows: “Our paranoia is filling in the gaps here, because we don’t know what this looks like. If in other focus groups you would have one of these people [investigators] come in and give a brief description of it or account, or if we would see a video, 5 minutes of what this looked like, I think that might help us in some way critique the situation.” The need for an established, trusting relationship between the pharmacist and physician was repeatedly mentioned. Although MTM can occur in both a community pharmacy and a physician’s office, participants expressed a preference for the model of a pharmacist in a physician’s office. Participants felt that effective physician–pharmacist communication is essential for MTM to be successful and expressed concern that a communication gap could exist if the pharmacist was off site.

Discussion An overwhelming finding across all groups was the lack of understanding of MTM by physician participants. The Pittsburgh group was uniquely negative overall because some participants stated false information regarding MTM and other participants reacted to this misinformation. This response emphasizes a need for clear communication about the mechanics of MTM. In the two other groups, physicians wanted more information about MTM. Despite the verbal and written description of MTM, participants requested a video to help them to visualize the process. Pharmacists must clearly explain and/or demonstrate MTM so that physicians can understand how it may work in their practice. Some participants recognized pharmacists’ ability to meet common medication-related needs, especially aiding patients in medication reconciliation and regimen adherence, and perceived a value for their practice. However, with the exception of one group (York), physician participants did not mention that pharmacists could aid in therapeutic decision making. Similarly, published reports have indicated that physicians perceive a benefit in having “checks and balances” for medication safety.10,19 Although physicians identified some benefits, many participants felt better suited than pharmacists to serve as an MTM provider, similar to results found in the literature.9 As the patient’s primary care provider, participants felt responsible Journal of the American Pharmacists Association

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Research Notes

for the patient’s medications and were reluctant to relinquish that duty to another individual. Participants referred to trusted, hospital-based pharmacist colleagues as “PharmDs” or “clinical pharmacists” and expressed concerns with community-based pharmacists’ clinical training. Community pharmacists can overcome this barrier by discussing their training and patient care expertise with physicians. Demonstrating clinical ability and building trust with physicians is suggested in the literature.18 Physician participants across all groups reported feeling a reimbursement strain. To overcome physician reimbursement concerns, pharmacists must clearly establish that MTM can enhance patient care and enable physicians to see more patients. This finding may support models where both physicians and pharmacists are reimbursed for providing MTM services in a community setting.20

Limitations This study involved primary care physicians from Pennsylvania in the context of its health maintenance organizations, insurance payers, pharmacy law, and medical law; conditions may differ in other states. Participants were in practice on average greater than 20 years. Future research on a broader scope should include generalists and specialists with practices across the country and in various stages of practice. During the first focus group (Pittsburgh), false information regarding MTM from one participant produced reactions by others. As a result, the other facilitators were trained to respond to participant questions with clear, factual information about MTM. Conducting a beta test may have identified some potential problems and prevented some group inconsistencies.

Conclusion These study results reveal that pharmacists must clearly explain MTM and demonstrate their ability to provide medicationrelated patient care. Pharmacists should discuss the physician–pharmacist relationship in person, detail their clinical training, and demonstrate competence. Community pharmacists may propose a defined trial period to meet with patients in the physician’s office. Above all, pharmacists must build a trusting relationship with physicians in order to provide enhanced patient care. References 1. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289:1107–16. 2. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348:1556–64. 3. Bluml BM, McKenney JM, Cziraky MJ. Pharmaceutical care services and results in Project ImPACT: Hyperlipidemia. J Am Pharm Assoc. 2000;40:157–65.

5. Martin OJ, Wu WC, Taveira TH, et al. Multidisciplinary group behavioral and pharmacologic intervention for cardiac risk reduction in diabetes: a pilot study. Diabetes Educ. 2007;33:118–27. 6. Tsuyuki RT, Johnson JA, Teo KK, et al. A randomized trial of the effect of community pharmacist intervention on cholesterol risk management: the Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP). Arch Intern Med. 2002;162:1149–55. 7. Centers for Medicare & Medicaid Services. Medicare Prescription Drug Benefit final rule. 42 CFR Parts 400, 403, 411, 417, and 423 Medicare Program. Accessed at http://a257.g.akamaitech. net/7/257/2422/01jan20051800/edocket.access.gpo.gov/2005/ pdf/05-1321.pdf, October 3, 2007. 8. American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service model (version 2.0). J Am Pharm Assoc. 2008;48:341–53. 9. Smith WE, Ray MD, Shannon DM. Physicians’ expectations of pharmacists. Am J Health Syst Pharm. 2002;59:50–7. 10. Law AV, Ray MD, Knapp KK, et al. Unmet needs in the medication use process: perceptions of physicians, pharmacists, and patients. J Am Pharm Assoc. 2003;43:394–402. 11. Howard M, Trim K, Woodward C, et al. Collaboration between community pharmacists and family physicians: lessons learned from the Seniors Medication Assessment Research Trial. J Am Pharm Assoc. 2003;43:566–72. 12. Brock KA, Doucette WR. Collaborative working relationships between pharmacists and physicians: an exploratory study. J Am Pharm Assoc. 2004;44:358–65. 13. Holland CL. Barriers to physician identification of problem alcohol and drug use: results of statewide focus groups [dissertation]. Pittsburgh, PA: University of Pittsburgh; 2007. 14. Rowan M, Huston P. Qualitative research articles: information for authors and peer reviewers. Can Med Assoc J. 1997;157:1442–6. 15. Starks H, Trinidad SB. Choose your method: a comparison of phenomenology, discourse analysis, and grounded theory. Qual Health Res. 2007;17:1372–80. 16. Draucker CB, Martsoff DS, Ross R, et al. Theoretical sampling and category development in grounded theory. Qual Health Res. 2007;17:1137–48. 17. Ulin PR, Robinson ET, Tolley EE. Qualitative methods in public health: a field guide in qualitative research. San Francisco, CA: Family Health International; 2005. 18. Hirsch JD, Gagnon JP, Camp R. Value of pharmacy services: perceptions of consumers, physicians, and third party prescription plan administrators. Am Pharm. 1990;NS30:20–5. 19. McDonough RP, Doucette WR. Developing collaborative working relationships between pharmacists and physicians. J Am Pharm Assoc. 2001;41:682–92. 20. Chrischilles EA, Carter BL, Lund BC, et al. Evaluation of the Iowa Medicaid pharmaceutical case management program. J Am Pharm Assoc. 2004;44:337–49.

4. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43:173–84.

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