The format of this conference in Denmark would be unfamiliar to British conference goers. It truly was a working conference with only five plenary lectures over the three-day period. The lectures were designed to give participants a working knowledge of the key issues to consider when developing an outcome measure and an understanding of some of the concepts to be addressed within the workshops. Participants worked in one of six topic areas, all of which centred around the development of instruments to measure the outcomes of pharmaceutical care. All the workshop leaders were experts within their fields and each started off their workshop with a "state of the art" presentation, providing participants with an insight into the types of tools which could be used as outcome measures of pharmaceutical care. Although the experts gave their group an overview of the subject, it was left entirely up to the participants to decide what they wished to achieve within the workshop. The workshop leaders acted as expert resources and tried to ensure that the groups achieved their own aims within the available time. On the last morning of the conference, the workshop leaders reported the progress made within each group to all conference participants, providing an impressive view of all the work that had been done over the three days.
Workshop I was led by Hanne Herborg (Denmark) and Linda McKeigan (Canada). This group worked on the development of a measure of patient satisfaction. Their working definition of patient satisfaction was "the patient's evaluation of the care received", with the aim of comparing pharmaceutical care with traditional pharmacy services delivered in a community pharmacy. The instrument that the group developed had 44 items covering the domains of technical competence, disease management, interpersonal relations, communication, accessibility of the pharmacist and the pharmacy environment. The group also reviewed the place of health status measurement as an outcome measure in pharmaceutical care. They concluded that published studies of pharmaceutical care often used health status measures inappropriately; usually this related to premature evaluation before the pharmaceutical care process was fully implemented and established. It was also emphasised that the pharmaceutical intervention needed to be robust in order to have any impact on health status. They cautioned that inappropriate use of health status measures as an outcome of pharmaceutical care would inevitably demonstrate no benefit.
Workshop II was led by Frank Verheyen and Marion Schaefer (Germany). The aim of this workshop was to develop an instrument which would allow the pharmacist to assess a patient's attitude towards his or her medicines, which in turn could be used to provide individualised patient counseling to improve adherence. The group produced a 46-item instrument which they planned to refine in order to make it more suitable for use in practice. It was suitable for self-completion by the patient and was constructed using attitude statements to which the patients marked their response on a five-point Likert scale. It was felt important to include items which looked at patients' broader attitudes towards their health as well as specifically to medicines, as they were inevitably closely linked. The domains included individual self-perception (for example: "I can contribute to improving my own health"), beliefs about medicines (for example: "I am afraid of becoming dependent on my medicines") and the influence of their environment (for example: "The support of my family help me to cope with my illness"). The group also concluded that, for most patients with chronic conditions, pharmaceutical interventions would be disease specific and therefore assessments of knowlcdgc should also be disease specific.
Workshop III was led by John Urquhart (United States), Ian Sturgess (UK) and James McElnay (UK). This group looked at the current literature on coping strategies and suggested that pharmacists should use tailored intervention strategies for non-compliant patients, according to their coping strategies. However, before considering such an intervention in the practice setting, they proposed to develop a research proposal to test their hypothesis. The development of the proposal would need to take place in several stages. In the first stage, patients would be categorised into groups according to their risk from non-compliance. Examples of patients at high risk were those who had had organ transplants, and those who had congestive cardiac failure or diabetes. At the other end of the spectrum, an example of a low risk group was patients with a minor, self-limiting illness. In the next stage, patients within the chosen group(s) would be categorised according to their degree of compliance, and assessed using a validated questionnaire. Finally, non-compliers would then be categorised according to their coping strategy. The interventions would be tailored to the different subgroups of patients identified.
Workshop IV was led by Hakan Brodin (Sweden) and Fransisco Batel Marques (Portugal). While much had been said about the importance of pharmacists understanding the need for and principles of economic evaluation, the economists in this group also stressed that it was essential for economists to develop an understanding of pharmacy and pharmaceutical care. They stressed that if economists applied their models to pharmacy without an understanding of the realities of pharmacy practice, the evaluations might be flawed. This group concentrated on developing an economic model of pharmaceutical care using patients with asthma as a model.
Workshop V was led by Almut Muller-Jaeger (Germany) and Foppe van Mil (Netherlands). This group set itself the task of developing an instrument capable of screening patients for drug-related problems in any pharmaceutical care setting. A drug-related problem was defined as "an event involving a patient's drug therapy that actually or potentially interferes with the desired health outcome". The group decided to design a questionnaire suitable for self-completion by the patient and to develop a robust coding system. Drug related problems were divided into six broad domains: lack of a necessary drug, an unnecessary drug, an incorrect drug choice, wrong dosage, an adverse drug event and other patient related problems. During the workshop, the participants developed 20 patient-based cases and tested out their coding system and subsequently refined their coding.
Workshop VI was led by Judy Cantrill and Mary Tully (UK). This group aimed to produce an instrument which could be applied to the drug therapy of patients in any care setting in order to assess its appropriateness. The group reviewed six instruments which had already been developed for this purpose and discussed the methods which had been used in their development. Against this background they decided to use a group consensus process to decide on the items for inclusion. This process produced a total of 64 potential items which, through a process of refinement, were subsequently reduced to 18. They covered the domains of indication and drug choice, effectiveness, risks and safety, interactions, practical use and monitoring. The instrument incorporated a review of the appropriateness of the medication by the pharmacist using their professional expertise, combined with a brief interview with the patient to ascertain their view of their medication.
At the end of each workshop, participants decided how they wished to take forward the development of their outcome measures. At the end of the three days the outputs from the workshops were understandably varied, but all had produced a plan for future work. Some groups decided to take their work forward as a collaborative group and develop some international comparative studies; others wished to take the instrument and continue development work in their own countries. Some participants planned to develop their tool for use in routine practice, while others intended to incorporate into research plans for the evaluation of pharmaceutical care interventions.
Pharmaceutical Care Network Europe plans to assimilate all the outputs from the conference into published proceedings. In addition, it will monitor the development of the instruments and report on the progress made in the participating countries.