Return to PJ Online Home Page The Pharmaceutical Journal Vol 266 No 7129 p20-22
January 06, 2001

Original Papers

General practitioners’ opinions of educational outreach visits from community pharmacists as a method of providing prescribing information

By Margaret C. Watson, PhD, MRPharmS, and Deborah J. Sharp, MB ChB, FRCGP

AIM • To investigate general practitioner (GP) opinion of educational outreach visits from community pharmacists as a method of providing prescribing advice.

DESIGN • Questionnaire survey of GPs participating in one arm of a randomised controlled trial.

SUBJECTS AND SETTING • 35 GPs from 7 practices in South West England, received 2 one-to-one educational outreach visits from community pharmacists.

OUTCOME MEASURES • GP response to a 20-item questionnaire survey.

RESULTS • A 100% response rate was achieved. Three questionnaires were completed by telephone with the remainder returned by post. 30 (88%) GPs said they benefited from the educational outreach visits and 32 (94%) and 27 (79%) thought they were an acceptable and effective method of providing prescribing information, respectively.

25 respondents (73%) thought that educational outreach visits were a suitable role for community pharmacists and the same proportion said they would accept future visits of this type in order to discuss prescribing issues.

CONCLUSION • Educational outreach visits from community pharmacists were well-received by GPs. General practitioners stated that they benefited from the visits and that they were a suitable role for community pharmacists.

There is growing evidence of the effectiveness of educational outreach visits as a strategy for achieving behavioural change among health professionals.1 Educational outreach (also known as academic detailing) is an example of a behavioural change strategy using an interpersonal setting.2 Individuals or small groups are targeted by an outreach visitor. The principles of educational outreach are reviewed elsewhere.3 Prescribing behaviour in particular has been shown to be susceptible to educational outreach.1 The pharmaceutical industry invests approximately 57 per cent of its promotional expenditure on medical sales representatives whose main activity is outreach visits.4 This investment suggests these visits are effective in achieving behavioural change. There is recognition of the suitability of pharmacists as a source of influence on general practitioner (GP) prescribing behaviour.5-7 However, of the randomised controlled trials that have evaluated the effect of educational outreach visits from pharmacists on prescribing behaviour8-12 none has evaluated outreach visits from community pharmacists. Furthermore, there has been little evaluation of the acceptability of pharmacist visits to prescribers as a method of influencing their behaviour.

This paper reports the results of a questionnaire survey of GPs who received educational outreach visits from community pharmacists as part of a randomised controlled trial.

Method

Randomised controlled trial General practices within the former Avon health authority that used the EMIS computer system (n=51) were invited to participate in a randomised controlled trial. Of these, 20 (39 per cent) were recruited and stratified according to fund-holding status and size (number of GPs). Randomisation was performed using a random numbers table (the full randomisation process is described elsewhere13). Seven practices were randomised to the control group (no intervention), six practices were randomised to the mass media group (and received printed guideline materials), and seven practices were randomised to the educational outreach group.

Every GP (n=35) in each of the seven educational outreach practices was scheduled to receive two one-to-one educational outreach visits from a community pharmacist during the first six months of the study. The visits were to last a maximum of 10 minutes. The purpose of the visits was to promote evidence-based guidelines for the use of non-steroidal anti-inflammatory drugs (NSAIDs) in general practice. The effect of the interventions on NSAID prescribing is reported elsewhere.13,14

A letter describing the study was sent to all community pharmacies (n=200) within the former Avon health authority. Pharmacists interested in providing outreach visits were invited to attend a training event. Of the 37 respondents (18 per cent), six completed 20 hours of training, which included presentation, communication and promotional skills, as well as the theory and development of the prescribing guidelines. Three pharmacists were selected to provide the outreach visits for the study based upon their performance during training and their interpersonal skills. Two of the pharmacists were male employee pharmacists and the third was a female proprietor pharmacist. Details of the duration and timing of the outreach visits were recorded by the pharmacists following each visit.

Questionnaire survey A questionnaire survey was conducted of GPs who received a second cycle educational outreach visit. The purpose of the survey was to evaluate GP opinion of the acceptability and format of outreach visits from community pharmacists as a method of providing prescribing information. The questionnaire was designed for self-completion within five minutes. The questions referred to previous experience of educational outreach visits, the benefit they derived from the study visits, and their extent of agreement with the major guideline recommendations. The survey included questions about the likelihood of future acceptance of visits of this type, the preferred format and duration of visits, and whether the GP would wish to select the pharmacist making the visits. Finally, the GPs were asked whether they thought educational outreach visits were a suitable role for community pharmacists and how useful (using a Likert scale) they rated their personal visits. Most of the 20 questions used a closed format to assist rapid completion. Space was provided following each question to enable respondents to record additional comments or qualifying statements. The questionnaire was not piloted prior to dissemination because there was no suitable population upon which to perform a pilot survey.

The questionnaire was mailed to each GP, or given to them by the pharmacist for completion following their second educational outreach visit. The postal questionnaires were sent within one week of the visit. A covering letter describing the purpose of the survey was included, together with a reply-paid envelope. To enhance the response rate, GPs were informed that all respondents would be entered into a prize draw, the winner of which would receive a case of wine. A second questionnaire was sent to non-responders after one month. Following the second mailing, non-responders were contacted and asked to complete the questionnaire by telephone.

Results

Visit characteristics Of the 35 GPs randomised to receive educational outreach visits, 34 (97 per cent) received a second cycle visit. Of these, 31 (91 per cent) completed and returned the questionnaires by post, with the three remaining questionnaires being administered by the researcher by telephone. Prior to participation in the trial, seven GPs (20 per cent) had received educational visits from community pharmacists.

There was considerable variation in the duration of the visits (Table 1), with significant differences shown between the pharmacists. Although originally scheduled to last a maximum of 10 minutes, the median duration of the first and second cycle visits was 20 minutes and 15 minutes, respectively. One-to-one visits were preferred by 13 GPs (38 per cent) and 14 GPs (41 per cent) would have preferred a group meeting (ie, with all GPs from the practice). Twenty-eight respondents (82 per cent) felt that 10 minutes was sufficient time to discuss a prescribing topic. Lunchtime and morning visits were the preferred times of day for the majority of respondents (>80 per cent).

General practitioner opinion All respondents agreed that the visits were conducted in an acceptable manner and that the pharmacists’ discussion of the guidelines had been clear and precise. Twenty-one responders (62 per cent) enjoyed the educational outreach visits. Thirty GPs (88 per cent) said they benefited from the visits; specific areas of benefit are listed in Table 2. The visits were rated as “acceptable” and “effective” as a method of providing prescribing information by 32 (94 per cent) and 27 (79 per cent) respondents, respectively.

Twenty-five respondents (73 per cent) thought educational outreach visits were a suitable role for community pharmacists as a method of providing prescribing information to GPs. The same number of GPs said they would accept pharmacist visits if offered in the future to discuss prescribing matters, only two (8 per cent) of whom stated that they would wish to select the pharmacist making subsequent visits. Two GPs stated that they would not accept future visits but gave no reason for their decision. Of the seven GPs who gave a “don’t know” response to this question, three qualified their answer by stating that future acceptance of visits would depend upon the topic to be discussed and its relevance to their practice. The GPs were asked to rate educational outreach visits from community pharmacists as a method of providing prescribing information and 10 (29 per cent), 11 (32 per cenet) and nine (26 per cent) rated them as extremely useful, quite useful and useful, respectively.

Additional information A number of GPs expanded upon their responses. One respondent questioned the “cost-effectiveness” of this type of approach while another, asked whether it was “worthwhile” for the pharmacists. Some respondents mentioned that educational outreach visits would not be effective if GPs were already prescribing in the desired manner. It was also suggested that visits could be tailored to an agenda set by GPs and combined with Prescribing Analysis and Cost (PACT) data. Another comment was that visits would be better suited to “problem” practices. Finally, one GP commented that the visits from the pharmacists were “Better than drugs reps”.

Discussion

The results of the questionnaire give an indication of GP opinion of educational outreach visits from community pharmacists as a method of providing information to prescribers. The maximum response rate is likely to have been due to a variety of factors including the use of personalised letters15 and an incentive, as well as brevity and offering telephone completion to non-responders. Although an incentive may increase the cost of administering a questionnaire survey16 these were not prohibitive for this study. Despite the small size of this study, the results can be used to inform future interventions of this type.

Limitations of the questionnaire survey The size of the survey population (n=34) influences the generalisability of the results. However, the practices participating in the randomised controlled trial, including those allocated to the educational outreach group, did not differ significantly from the remaining practices in Avon health authority in terms of size, fund-holding and dispensing status (Table 3).

The respondents were not anonymised in order to conduct the prize-draw and this may have made GPs more likely to give favourable responses. A pilot survey was not performed because the questionnaire was relevant only to GPs who received educational outreach visits during the trial so there was no suitable group with whom piloting could be performed. The reliability15 of the questionnaire was not assessed as it would have required a number of GPs to complete the questionnaire twice within a short period of time. This additional workload could have created ill-feeling towards the trial, therefore, a repeat questionnaire was not disseminated.

There were considerable missing data for question 8 (ie, Please indicate your opinion of each of the guideline recommendations discussed [strongly agree=1, agree=2, disagree=3, strongly disagree=4]). The extent of missing data may provide a negative indication of the content validity of a questionnaire.17 However, it is likely that the extent of missing data with this particular question was due to the layout of the response and coding boxes resulting in confusion among the responders.

The researcher administered three questionnaires by telephone. It is possible that the respondents may have given more favourable answers as a result of this personal contact; however, there are too few data to investigate differences between postal and telephone responses.

The future of educational outreach and community pharmacists Prior to the introduction of primary care groups, most community pharmacist involvement with local prescribers was prompted by prescription queries for individual patients. However, pharmacists (although not necessarily community pharmacists) are now being recruited by primary care groups to provide prescribing advice at a practice population level. This fact is evidenced by the flurry of advertisements in The Pharmaceutical Journal over recent months for roles of this type.

The results of this questionnaire show that the GPs surveyed had a favourable response to community pharmacist visits as a method of providing prescribing information.

ACKNOWLEDGMENTS The authors thank the GPs who took part in the survey and the community pharmacists who made the educational outreach visits. We would also like to thank Dr David Gunnell for his contribution to this study and Dr Christine Bond for her comments on this manuscript. We are very grateful to Ms Viv Josza of E. Merck and Lipha who provided considerable assistance with the pharmacist training programme. MCW was funded by a South and West Regional Research and Development training studentship and the study was funded by a small project grant from the same directorate.

Margaret Watson is a research fellow in the Department of General Practice and Primary Care, University of Aberdeen, Westburn Road, Aberdeen AB25 2AY. Deborah Sharp is professor of primary health care in the division of primary health care at the University of Bristol. Correspondence to Dr Watson (e-mail m.c.watson@abdn.ac.uk)

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