(Public Health in The 21st Century Series) Kazuhiko Kotani (Editor) - Hiroshi Okada (Editor) - Community Pharmacy - An International Comparison (2016)

PUBLIC HEALTH IN THE 21ST CENTURY
COMMUNITY PHARMACY
AN INTERNATIONAL COMPARISON
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COMMUNITY PHARMACY
AN INTERNATIONAL COMPARISON
HIROSHI OKADA
AND
KAZUHIKO KOTANI
EDITORS
New York
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CONTENTS
Preface Expectations of community pharmacies

as a key station of community care vii
Hiroshi Okada and Kazuhiko Kotani
Acknowledgments xi
Chapter 1 Community Pharmacy in Japan 1
Hiroshi Okada and
Mitsuko Onda
Chapter 2 Community Pharmacy in United States 11
Khalid M. Kamal
Chapter 3 Community Pharmacy in Canada 25
Ross T. Tsuyuki and
Yazid N. Al Hamarneh
Chapter 4 Community Pharmacy in Australia 39
Timothy F. Chen
Chapter 5 Community Pharmacy in England 53
David Wright and Vicky Abhay
Summary: Role of Communty Pharmacy
Across Five Countries 67
Hiroshi Okada and Kazuhiko Kotani
Appendix Special Message: Community Pharmacy
Practice in Five Countries 71
Denise A. Epp
vi Contents
Contributors 75
Index 77
PREFACE
EXPECTATIONS OF COMMUNITY PHARMACIES AS

A KEY STATION OF COMMUNITY CARE
Hiroshi Okada1,, BEd, MS,

and Kazuhiko Kotani2, MD, PhD
1
Department of Preventive Medicine,
Clinical Research Institute for Endocrine and Metabolic Disease,
National Hospital Organization Kyoto Medical Center, Japan
2Division of Community and Family Medicine,
Jichi Medical University, Japan
The Current Socio-Medical State of Japan
The priority of keeping and enhancing health and quality of life (QOL) is
considered to be high. In many developed countries, the ageing society is
growing. These states are all exhibiting a socio-medical burden, and the
health- and QOL-related issues are a pivotal topic [1]. Compared to other
countries, Japan has the world’s fastest-ageing society with a decreasing
population (shifting the population distribution to a small percentage of
younger people and a large percentage of older people) [1, 2]. According to

Hiroshi Okada, B.Ed, MS: Department of Preventive Medicine, Clinical Research Institute for
Endocrine and Metabolic Disease, National Hospital Organization Kyoto Medical Center,
Japan. Email: okada.hiroshi.28z@kyoto-u.jp.
viii Hiroshi Okada and Kazuhiko Kotani
the Japanese government in 2012, 30% of the population will be over the age
of 65 by 2030 [3]. Making a sustainable health care system for resolving the
health- and QOL-related issues is therefore an urgent need [1, 2].
The Importance of Reformation of Community Care
Based on this need, health care must be reformed. The change of disease
structure (i.e., a decrease of acute curable disease and an increase of chronic
non-communicable disease) is promoting a system of long-term care to
support people with such chronic diseases. [4, 5] New problems are
developing, such as multi-drug uses, poly-pharmacies, and multi-diseases in
older people. [6] Of greater importance is the realization that this long-term
care system in the community where people reside is necessary, leading to a
‘regional comprehensive care system’ that has been proposed to upgrade the
community-based health care model in Japan. [3] This system includes
‘home care,’ where collaboratively team-approached medical care with
multidisciplinary socio-medical resources in the community is a must. [7-9]
Health care is moving to such community-oriented care.
The Highlight to Community Pharmacies
In line with these changes, community pharmacies are a key to this new
era of local patient care. The role of community pharmacies in patient care will
increase with developing pharmacist roles and activities. [10] In Japan, a
campaign for family pharmacies, dubbed “a health station hub,” has been
launched nation-wide. [10]
To date, community pharmacies have developed in many countries with
various roles and activities. From the view of global health, [2] we should
learn from community pharmacies of representative countries through an
international comparison of these roles and services (i.e., the participation in
and/or the conduction of medical examinations/tests, diabetes care,
vaccination, smoking cessation education, medical review, and home care).
This knowledge is crucial and useful for understanding community
pharmacies.
There has been no such documented research like this until now, so this
research has critical value. We would like to share these perspectives of
community pharmacies with readers from the medical field (such as
Preface ix
pharmacists, physicians, public health practitioners, students and researchers

in pharmacy, medicine and public health, home care providers, pharmaceutical
manufacturers). We believe that this research will contribute to a revolution in
community patient care.
REFERENCES
[1] Arai H, Ouchi Y, Yokode M, Ito H, Uematsu H, Eto F, Oshima S, Ota
K, Saito Y, Sasaki H, Tsubota K, Fukuyama H, Honda Y, Iguchi A,
Toba K, Hosoi T, Kita T; Members of Subcommittee for Aging. Toward
the realization of a better aged society: messages from gerontology and
geriatrics. Geriatr Gerontol Int. 2012;12:16-22.
[2] Abe S. Japan's vision for a peaceful and healthier world. Lancet.
2015;386:2367-9.
[3] Terada N. Regional Collaboration in Home Care Services. Japan Med
Assoc J. 2015;58:10-4.
[4] Parker D, Mills S, Abbey J. Effectiveness of interventions that assist
caregivers to support people with dementia living in the community: a
systematic review. Int J Evid Based Healthc. 2008;6:137-72.
[5] Kanda M, Ota E, Fukuda H, Miyauchi S, Gilmour S, Kono Y,
Nakagama E, Murashima S, Shibuya K. Effectiveness of community-
based health services by nurse practitioners: protocol for a systematic
review and meta-analysis. BMJ Open. 2015;5:e006670.
[6] Doos L, Roberts EO, Corp N, Kadam UT. Multi-drug therapy in chronic
condition multimorbidity: a systematic review. Fam Pract. 2014;31:654-
63.
[7] Jaarsma T. Health care professionals in a heart failure team. Eur J Heart
Fail. 2005;7:343-9.
[8] Health Quality Ontario. Community-based care for the management of
type 2 diabetes: an evidence-based analysis. Ont Health Technol Assess
Ser. 2009;9:1-40.
[9] Baqir W, Barrett S, Desai N, Copeland R, Hughes J. A clinico-ethical
framework for multidisciplinary review of medication in nursing homes.
BMJ Qual Improv Rep. 2014;3:pii u203261.w2538.
[10] Saito M. Current Status of Community Pharmacies: Expectations as a
health information hub, the enforcement of revised pharmaceutical and
medical device act, and a new role as stakeholders. Yakugaku Zasshi.
2016;136:245-9.
ACKNOWLEDGMENTS
I would like to give acknowledgement to Dr. Naoki Sakane of the Kyoto

Medical Center, who motivated me throughout this project and to Dr. Takeo
Nakayama of Kyoto University for his sage advice.
Although this book didn’t have any direct support from them, I would like
to thank the Pfizer foundation for the international research grant we received
for our international survey in 2014. In 2015, we traveled to eight cities in four
countries and observed pharmacists in community pharmacies. I would also
like to thank Dr. Kazuhiko Kotani who strongly encouraged me to make this
research project into a book and gave me full support.
I would also like to acknowledge Ms. Kayoko Iwasaki, the president of
Hanshin Dispensing Pharmacy Co., Ltd., and my friend Mr. Hideki Iwasaki.
They truly understood how important this book was to me and offered support
in the publishing of it.
I would like to thank Denise Epp for supporting me with writing and
speaking in English. I couldn’t have done it without your great help.
Also, I want to say a big thank you to my brother Akira Okada and
especially, to my wife Kumiko for her continuous and persistent support.
Hiroshi Okada
In: Community Pharmacy ISBN: 978-1-53610-199-7
Editors: H. Okada and K. Kotani © 2016 Nova Science Publishers, Inc.
Chapter 1
COMMUNITY PHARMACY IN JAPAN

and Mitsuko Onda2,†, MS, PhD
1
2
Associate Professor of Clinical Laboratory of Practical Pharmacy,
Osaka University of Pharmaceutical Sciences, Japan
INTRODUCTION
In Japan, there are 58,000 pharmacies, and 55% of pharmacists work in
community pharmacies, while 19% work in hospital pharmacies [1]. The
overall number of the pharmacists in Japan is 290,000 [2], which means that
Japan has the most pharmacists per population among the developed countries
with 22.7 pharmacists per 10,000 people [3]. The rapid progression of an
aging society in Japan has made it increasingly difficult to secure financial
resources sufficient to maintain the current health insurance, long-term care

†
Mitsuko Onda, MS, PhD: Associate Professor of Clinical Laboratory of Practical Pharmacy,
Osaka University of Pharmaceutical Sciences, Japan. Email: Onda@gly.oups.ac.jp.
2 Hiroshi Okada and Mitsuko Onda
insurance and pension systems. Under these circumstances, the quality of the
pharmacy role has also become an important issue [4].
There has been a drastic change in the medical system over the past 40
years by the Japanese government. Before 1974, there were few pharmacies
which dispensed medicine based on the prescription from the physicians. The
Japanese government promulgated the first medical law in 1874; however, it
was not generally accepted for two reasons. Because the pharmacy education
system was just starting, there was an extremely small number of pharmacists
that existed at that time. The other reason was that only physicians dispensed
traditional medicine. After World War II, the Pharmaceutical Affairs Act of
1954 and other related acts were brought into effect. These laws failed because
the Medical Practitioners Act included a provision that allowed physicians to
dispense drugs to the patient he/she diagnosed, and patients became
accustomed to receiving drugs directly from the physicians. The government’s
policy to promote the system of separation of drug prescribing and dispensing
became clearer in 1974, when it raised the physician’s prescription fee 5 times
in the health insurance system. This became an incentive for physicians to
cooperate with the pharmacists and make the change.
“Bungyo” is a term used in Japan that refers to the separation of drug
prescribing and dispensing. Under the bungyo system, physicians and
pharmacists provide their professional services at their own discretion as
professionals independent of each other. The pharmacy is accredited as a
separate and independent institution.
MEDICATION REVIEW
Japan does not have the same type of medication review as seen in
Western countries. Japanese community pharmacists are required to check
specific matters to collect medication management fees. When the patient
comes to the pharmacy with the prescription, the pharmacist should check
adherence, inquire about leftover medicines from prior prescriptions,
recommend generic drugs, and ask about any medications received from other
clinics or hospitals. Pharmacists have limited time with each patient, but they
can get an additional fee of about USD$3.50 for checking these items. If the
pharmacist consults with the physician about the prescription and makes a
change, an additional fee of about USD$2.80 can be received. Reviewing
medication is another example of how they can collect extra fees. The
government strictly regulates the prices of prescription drugs, so pharmacies
Community Pharmacy in Japan 3
cannot make a profit by just handing out the medications to patients without
checking the matters that will lead to an extra 5% fee [5].
Figure 1. Changes in the Number of Pharmacists.
Figure 2. Bungyo Ratio.

A unique feature in Japanese pharmacy is the medication memo book or

“okusuri-techo” that patients receive for their personal health records.
Pharmacists record the medications in this memo book with each patient visit.
Recently some patients use a smartphone application instead of small memo
book for medication records. Community pharmacists also keep the patient’s
medication history on the pharmacy computer. When a patient comes in to the
pharmacy, the pharmacist checks both records before providing the prescribed
drugs and giving an explanation of the dosage and administration of the
medicine when dispensing. This medication memo book allows the pharmacist
to regularly monitor which medications the patient is taking.
HOME VISITING SERVICE BY PHARMACISTS

Sufficient medical care for elderly patients and the control of these costs is
a common issue shared by many countries. Japan is the most rapidly aging
country among industrialized nations. In October 2014, 26% of the population
was considered elderly, and this rate will rise to 39.9% by 2060 [6]. The
Japanese government has been promoting home healthcare as a national policy
to improve quality of life (QOL) for the elderly and to control inpatient
medical costs associated with the care of elderly patients.
“The home of the patient” was designated “a place of medical care” by the
Medical Service Law revision in 1992. Also, at the time of the dispensing fee
revision in 1994 and the founding of long-term care insurance in 2000, home
visiting service by the pharmacist was officially recognized. Specifically, the
pharmacist who visits a patient home provides the following services.
1. Supply medicines to the patient’s home (which is mainly dispensing

medicine) and sanitary materials
2. Medication history management (check for duplicate medication, drug
interactions, careless administration, etc.)
3. Medication consultation (explanation of the purpose and effect of
medication, instruction and guidance for appropriate medication, etc.)
4. Confirmation of adherence
5. Medication assistance (simplification of usage, change of dosage
form, etc.)
6. Side effects monitoring
7. Prescription proposal to the physician
8. Management and disposal of drugs
9. Sharing of patient information among medical and welfare

professionals
According to the authors’ study, currently in Japan, approximately 30% of

the community pharmacists perform home visiting service. The average
number of pharmacists working in a pharmacy is 2.5, covering 20
prescriptions per day and doing three home visits per month. Most community
pharmacists (61.9%) visit patients’ homes twice a month, spending an average
of 20.6 work minutes there. The target patient of this relevant service has
multiple drug use (on average 8 medications) and is considered to be elderly
(an average of 82 years old).
One objective of this study [7] was to conduct a nationwide, large-scale
survey to shed light on the occurrence of Potentially Inappropriate Medication
(PIM) induced adverse drug events (ADEs) of homebound elderly patients
receiving the pharmacist home visiting service, and to identify the drugs that
cause such ADEs.
The results were as follows:
1. PIMs were prescribed to 48.4% of subjects.

2. ADEs were experienced in 8.0% of patients who were prescribed
PIM, and were mostly related to the central nervous system, which
could potentially lead to more serious conditions.
The outcomes of the home visiting service by pharmacists were as follows

[8]:
1. 29.8% of the patients had improvement in adherence.

2. 41.6% showed a decrease in unused medications.
3. Home-visiting pharmacists found ADEs caused by inappropriate drug
administration in 14.4% of their patients. The results were that 44.2%
of these cases were solved by discontinuing administration of the
suspected drug, 24.5% by reducing the dosage, and 18.3% by
changing drugs, with a total of 88.1% overall improvement.
4. In cases where the pharmacists visited patients more often, there had
been a higher percent of ADEs, so the prescriptions were changed to
solve the problem, adherence improved, and there was a reduction in
unused medications.
5. The average actual work time was longer with patients whose
outcomes improved than with those whose outcomes did not.
The results above show that a higher involvement in homecare by

pharmacists improved outcomes of medication management. Also, the
responses of visiting pharmacists to ADEs were helpful in preventing
potentially serious situations. Therefore, home visits by pharmacists should be
further encouraged.
Immunization
Immunization in pharmacy is not permitted in Japan. It is one of the most

sensitive issues in the medical field, so it will be difficult to make that change
in Japan.
Smoking Cessation
Although the nicotine patch and gum for a smoking cessation can be
purchased in the pharmacy, pharmacists are not involved in it because
smoking cessation service in the pharmacy isn’t presently covered by the
national health insurance system [9]. In some cross sectional surveys, 67% of
community pharmacists are committed to promoting smoking cessation in
their pharmacies with consultation and advice to their patients [10, 11]. The
Japan Society for Tobacco Control trains certified educators to be “Fellows of
the Japan Society for Tobacco Control.” Only 6% of these educators are
pharmacists, and half of them are community pharmacists [11]. Some
universities have established a practical training program for pharmacists to
give smoking cessation instruction to patients [12].
Diabetes
According to an intervention study in community pharmacies, there is no

support program for patients with diabetes by pharmacists in Japan. The
COMPASS project was carried out in Japanese chain pharmacies in cluster
randomized trials [13]. The support provided by the pharmacist within a
limited time of about 3 minutes, by giving a pamphlet and a pedometer, helped
patients with diabetes improve their HbA1c by 0.4% in 6 months [14].
Hypertension
Many of pharmacies in Japan provide free use of an automated

sphygmomanometer and sell home sphygmomanometers. Compared to
Western countries, Japanese have more salt intake with an average of 10
grams a day [15]. Though salt intake is decreasing year by year because of the
health-conscious trend, the elderly people still maintain a high intake of salt. A
research group launched an intervention study called COMPASS-BP, which is
a randomized controlled trial in pharmacies for hypertension patients [16]. In
this study, pharmacists supported patients with hypertension by giving advice
about a healthy lifestyle, such as salt intake reduction or aerobic exercise.
Point-Of-Care Testing (POCT)
The Japanese government changed the law for clinical testing in

pharmacies in 2014, along with strict requirements and conditions [17]. For
example, pharmacies have to provide a separate space for testing, and
pharmacists may never explain the result of the test because that infringes on
physicians’ jobs [18]. There were about 1000 registered pharmacies providing
POCT in 2014 [19].
OTHER SERVICES
Prescriptions with Clinical Test Results
In 2015, the Pharmaceuticals and Medical Devices Agency (PMDA)

reported that 5.1% of Hospitals and Clinics write prescriptions based on
clinical test results [20]. Many of the university hospitals started a system to
collaborate with community pharmacies. These test results do not include
hepatic and kidney function for the metabolism of medicine for patients’
medication, but include HbA1c and cholesterol for patient life style and
disease management. As a result, the quality of pharmacist communication
with physicians significantly improved after starting this system because
community pharmacists could check the prescription drugs based on patient
clinical test results [21].
The Family Pharmacist and Pharmacy Policy
The “family pharmacist and pharmacy” policy was launched by the

Japanese government in 2016. This policy is based on the following three
conditions:
1. The family pharmacist totally manages all the prescribed medicines

for the contracted patient.
2. The family pharmacist is available 24 hours a day for consultation in
the case of an emergency.
3. The family pharmacist can provide medication to the patient in
collaboration with the family physician [22].
This pharmacy service will permit direct monitoring of medications taken

by the patient and improve the QOL through the personalized care of the
pharmacist.
REFERENCES
[1] Japan Pharmaceutical Association. Annual Report 2014. http://www.
nichiyaku.or.jp/e/data/anuual_report2014e.pdf.
[2] The number of pharmacies in Japan: http://www.mhlw.go.jp/toukei/
youran/indexyk_2_4.html.
[3] FIP Global Pharmacy Workforce Report 2012: http://www.fip.org/static/
fipeducation/2012/FIP-Workforce-Report-2012/?page=hr2012#/10.
[4] The number of pharmacists in Japan: http://www.mhlw.go.jp/toukei/
saikin/hw/ishi/14/dl/kekka_3.pdf.
[5] Ministry of Health, Labour and Welfare. http://www.nichiyaku.or.jp/wp-
content/uploads/2016/02/h28023_4.pdf.
[6] Cabinet Office, Government of Japan (final access date: 2016.5.24).
http://www8.cao.go.jp/kourei/whitepaper/w-2015/html/gaiyou/s1_1.html
[7] Mitsuko Onda et al. Identification and prevalence of adverse drug events
caused by potentially inappropriate medication in homebound elderly
patients: a retrospective study using a nationwide survey in Japan. BMJ
Open. 2015 (doi: 10.1136/bmjopen-2015-007581).
[8] Mitsuko Onda et al. Nationwide Study on Relations between Workload
and Outcomes of Home Visiting Service by Community Pharmacists.
Yakugaku Zasshi. 2015 135(5): 519-27.
[9] Japan Pharmaceutical Association. http://www.nichiyaku.or.jp/action/

wp-content/uploads/2012/02/201202kinen_report.pdf.
[10] Hirota Eiji et al. Survery of smoking cessation support at insurance
pharmacies. http://www.nosmoke55.jp/gakkaisi/201302/gakkaisi_13030
6_21.pdf.
[11] Japan society for tobacco control: http://www.jstc.or.jp/.
[12] Saito Moei et al. Establishment of a system for smoking cessation
instruction practice using coginitive-behavioral therapy and a motivation
interview method. Yakugaku Zasshi 2012 132(3) 369-79.
[13] http://www.yobouigaku-kyoto.jp/compass/english/index.html.
[14] Okada Hiroshi et al. Effect of lifestyle intervention performed by
community pharmacists on glycemic control in patients with type 2
diabetes: The community pharmacists assist (Compass) project, a
pragmatic cluster randomized trial. Pharmacy and Pharmacotherapy
2016 7(3). http://www.scirp.org/journal/PaperInformation.aspx?paperID
=64381.
[15] Ministry of Health, Labour and Welfare, National Health and Nutrition
Survey. http://www0.nih.go.jp/eiken/english/research/project_nhns.html.
[16] COMPASS-BP: http://www.yakuji.co.jp/entry38292.html.
[17] Ministry of Health, Labour and Welfare, POCT Guideline.
http://www.kantei.go.jp/jp/singi/tiiki/kokusentoc_wg/hearing_s/150327s
hiryou03-01.pdf#search=‘%E3%80%8C%E6%A4%9C%E4%BD%93
%E6%A4%9C%E6%9F%BB%E5%AE%A4%E3%81%AB%E9%96%
A2%E3%81%99%E3%82%8B%E3%82%AC%E3%82%A4%E3%83%
89%E3%83%A9%E3%82%A4%E3%83%B3%E3%80%8D
[18] Japan Pharmaceutical Association, POCT Guideline. http://www.
nichiyaku.or.jp/action/wp-content/uploads/2015/05/201504kentai_jpa.
pdf.
[19] Ministry of Health, Labour and Welfare, POCT. http://www.mhlw.go.jp/
stf/seisakunitsuite/bunya/0000098580.html.
[20] PMDA: Pharmaceuticals and Medical Devices Agency (PMDA). http://
www.pmda.go.jp/files/000148264.pdf.
[21] New Medical World Weekly. 2015. Oct. 19 No. 3146. https://www.igaku
-shoin.co.jp/nwsppr/pdf/3146.pdf.
[22] Ministry of Health, Labour and Welfare, Family pharmacists/
pharmacies. http://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kenkou_
iryou/iyakuhin/yakkyoku_yakuzai/.
Chapter 2
COMMUNITY PHARMACY IN UNITED STATES
Khalid M. Kamal*, MPharm, PhD

Associate Professor of Pharmacy Administration
Pharmaceutical, Administrative and Social Sciences ,
Duquesne University Mylan School of Pharmacy
INTRODUCTION
Pharmacists play a vital role in the United States (US) health care system.
Together with physicians and other health professionals, pharmacists are well
positioned to provide improved access to quality and cost effective care
through important initiatives such as medication therapy management (MTM),
immunizations, collaborative practice agreements and point-of-care (POC)
testing. Pharmacist roles in these clinical services include medication
monitoring, dose adjustments, screening, regimen changes, recommending
cost-effective medications, and assessing patient outcomes. Most collaborative
agreements require specific record keeping and are governed by state
legislation with regards to registration of services, setting where the service is
provided, and the disease that can be managed [1]. Thirty-six states allow
pharmacist-delivered clinical services in any setting (retail, inpatient) as
outlined in the service protocols, which may be disease focused or provide
specific services such as immunizations or smoking cessation [1]. Twenty-one
states require written service protocols to be submitted to the Board of
*
Email:kamalk@duq.edu.
12 Khalid M. Kamal
Pharmacy or Medicine by pharmacists and physicians (in selected cases) who

are providing these services [1].
POINT-OR-CARE TESTING
Point-of-care (POC) testing involves performing Clinical Laboratory
Improvement Amendments (CLIA)-waived tests outside of a laboratory.
Pharmacists are permitted under federal law to perform POC testing of CLIA-
waived tests and this provides an opportunity for community pharmacies to aid
in disease screening, diagnosis, and patient monitoring. These tests can
improve the prevention and treatment of diseases, which can result in
significant cost savings and improved patient outcomes. Although POC testing
is a departure from the pharmacist’s traditional role, this tool helps expand the
practice of pharmacy and generates new revenue streams for the pharmacy
since pharmacists can charge patients directly or get reimbursed by third party
payers for their testing services.
Point-of-care (POC) testing can be offered at both outpatient and inpatient
settings. The most utilized tests include chronic disease assessment tests
(cholesterol, hemoglobin A1c, liver function tests, and blood glucose) and
infectious disease tests (influenza, group A streptococcus, HIV and hepatitis C
(HCV). The Centers for Disease Control and Prevention (CDC) provides
estimates for undiagnosed cases in the US (7 million with undiagnosed
diabetes; 240,000 with undiagnosed HIV; 800,000 with undiagnosed HCV)
which provides pharmacists with tremendous opportunity to make a positive
impact on patient’s health [2].
For pharmacists to offer these tests, the pharmacy needs to obtain a CLIA
Certificate of Waiver by filing an application with the CDC and Centers for
Medicare and Medicaid Services (CMS), both of whom have collaboratively
produced the final CLIA Quality Systems Laboratory regulations [3]. In
addition to understanding the state regulations, the successful implementation
of the testing services requires the evaluation of resources at the pharmacy
such as personnel, training, and equipment. Additionally, the physical
environment should be clean, with arrangements for proper hazardous waste
disposal and maintaining patient confidentiality [3].
A critical element in the success of the POC testing is the documentation
of the impact of these tests in terms of improved patient outcomes. Evidence is
emerging that demonstrates the economic comparability of POC tests with
laboratory-based assays tests [4]. Some studies have also been conducted to
Community Pharmacy in United States 13
assess the effectiveness of these tests. A hospital-based, outpatient pharmacist-

managed lipid clinic improved LDL-C goal attainment since pharmacists were
able to make therapy adjustments during face-to-face visits with patients [5].
Another study assessing warfarin management showed significant
improvement in patients who were in the therapeutic range with the use of
POC [6]. Having access to immediate test results through POC testing is
associated with the same or better medication adherence compared with
having test results provided by a pathology laboratory [7]. Patient satisfaction
with POC was found to increase as well. In a study of 232 patients, 87.5%
preferred POC testing due to time saved and less pain caused by fingers sticks
compared to venipuncture [8].
IMMUNIZATION
Each year, 42,000 adults and 300 children in the US die from vaccine-
preventable diseases such as influenza, pneumococcal disease, and hepatitis B
or from their complications [9]. The total economic cost to the society of
treating vaccine-preventable diseases among adults and children is substantial,
not counting the value of years of life lost [10, 11]. Vaccines are one of the
most cost-effective preventive measures against certain diseases and
immunization is a key component in the prevention of communicable diseases
[12]. Despite the availability of effective vaccines, they are widely underused
and reasons for underutilization include patient-related barriers such as a lack
of knowledge about the safety and efficacy of vaccines, inadequate access of
rural patients to preventive services, and lack of health insurance coverage.
Provider-related barriers include missed opportunities to immunize, while
clinic-related obstacles include distant location, inadequate staffing, and
inconvenient service hours. Additionally, many immunization initiatives are
not successful because they are not tailored to any specific target audience, or
they simply fail to identify high-risk populations [13]. One possible approach
for improving the delivery of immunizations is to increase the number of sites
where patients can obtain immunizations. Pharmacists play an important role
in improving immunization rates in adults and children. Pharmacists are
considered the most accessible healthcare professionals and are involved in
immunization as advocates, partners, and providers [14]. Data shows that
immunizations administered by pharmacists assist in preventing an estimated
14 million cases of vaccine-preventable diseases and 33,000 cases of death
[15]. The American Pharmacists Association (APhA) established its
14 Khalid M. Kamal
Pharmacy-Based Immunization Delivery program in 1996. The American

Pharmacists Association (APhA) provides a 20-hour program, recognized by
the CDC, that trains pharmacists to provide immunizations [13] and the
National Community Pharmacists Association (NCPA) offers a certificate
program that provides information on setting up a community-based
immunization program [13].
Currently, all 50 states in the US allow pharmacists to administer
vaccinations [16, 17]. However, there is a lot of variability across state laws
and regulations governing pharmacy practice including certification
requirements, type of vaccinations pharmacists can offer, and age of patients
that pharmacists can vaccinate [14, 18]. Pharmacist-provided immunizations
are clinically and economically sound and support the achievement of national
public health goals. Pharmacy-based immunizations, just like other non-
dispensing services (diabetes care, blood pressure clinics), have to be
integrated in the pharmacy workflow. Pharmacists have to work
collaboratively with their patients and their physicians [13]. However, there
are challenges such as reimbursements for immunization services and
recognition of pharmacists as immunization providers. In spite of challenges,
there are numerous studies that support that pharmacist-provided
immunizations are cost effective [19, 20]. Not only are these services cost
effective, but patients also perceived satisfaction with the pharmacist-run
immunization clinic, both in terms of professionalism and access to
vaccination [21].
DIABETES
Diabetes is a group of metabolic disorders characterized by inefficient
utilization of blood glucose in the body due to the body’s inability to produce
any or enough insulin [22]. The three most commonly recognized forms of
diabetes are: (i) Type 1 Diabetes Mellitus (T1DM) or Insulin Dependent
Diabetes Mellitus (IDDM); (ii) Type 2 Diabetes Mellitus (T2DM) or Non-
Insulin Dependent Diabetes Mellitus (NIDDM); and (iii) Gestational Diabetes
[22]. Approximately, 90% of all diabetes cases worldwide are T2DM followed
by 5-10% of T1DM cases. Gestational diabetes is typically seen in females
during pregnancy [22].
In 2012, 29.1 million American adults had T2DM out of which 8.1 million
adults were undiagnosed. Also, 1.25 million children had T1DM [23]. The
incidence of new diabetes cases among people 20 years or older is 7.8 per
1,000 with higher incidences seen in people over the age of 45 years [23].
Uncontrolled diabetes is associated with complications such as blindness,
kidney failure, gangrene, and amputations of the lower limbs and is one of the
primary causes of heart disease and stroke [24]. Hypertension is the most
common co-morbidity associated with diabetes with around 67% of the adults
having comorbid diabetes and hypertension. Given the chronic nature of
diabetes and the associated complications, the economic burden of diabetes on
the US healthcare system was reported to be $245 billion ($176 billion in
direct medical costs and $69 billion in productivity loss) [24].
Diabetes self-management (DSM) is an essential component of diabetes
care and is defined as the ability to manage the symptoms, treatment, and
lifestyle changes inherent in living with a chronic condition. There is a strong
evidence linking DSM with optimal glycemic control, enhanced quality of life
and improved psychosocial functions. The goal of DSM is to improve the
hemoglobin A1c control in individuals with diabetes and bring it closer to the
optimal level (HbA1c ≤ 7). The American Association of Diabetes Educators
(AADE) has summarized evidence-based recommendations for DSM into the
following behaviors: being active, eating healthy, taking medications, blood
glucose monitoring, problem solving (particularly in patients with high or low
blood glucose levels), reducing the risks for diabetes related complications and
modifying psychosocial behaviors to adapt to living with diabetes. In addition,
the American Diabetes Association (ADA) recommends weight loss or energy
restriction, monitoring carbohydrate intake, high fiber intake, limitation of
saturated fat, trans-fat, cholesterol, and sodium and lastly, consumption of fish
twice a week [25]. Diabetes care and management, and clinical preventive care
practices such as annual eye exams, annual foot exams, daily monitoring of
blood glucose, and diabetes self-management education (DSME), help control
diabetes, thereby keeping people with diabetes healthy. The management of
diabetes requires coordinated medical care coupled with patient self-
management to decrease the risk of serious complications such as vascular,
renal, and ophthalmologic morbidities. Pharmacists play an important role in
diabetes care, as they can provide “continuity of care” in between physician
visits, monitor and manage diabetes medication plans, and educate patients on
disease and lifestyle issues. The Asheville Project diabetes program and the
Diabetes 10-city challenge provide growing evidence of the role of pharmacist
in managing diabetes [26].
16 Khalid M. Kamal
HYPERTENSION
Hypertension (HTN), also known as high blood pressure (BP), is among
the most prevalent chronic medical conditions and affects nearly 74.5 million
Americans who are 20 years or older [27]. The worldwide prevalence of HTN
is predicted to be 1.56 billion by the year 2025 [28]. Hypertension is present if
the resting BP is persistently at or above 140/90 mmHg for most adults [29].
In most individuals in the US, HTN remains above the national guidelines and
since high BP does not have any symptoms, these individuals are at an
increasing risk for heart failure, stroke, coronary heart disease, and kidney
failure [30]. Modern lifestyle factors such as lack of exercise, salt-rich diets,
processed and fatty foods, alcohol and smoking contribute to the growing
burden of HTN. The economic burden of HTN on the US healthcare system is
substantial as well. The incremental direct medical expenditures is estimated at
$55 billion [31], with additional $14 to $18 billion expenditures in indirect
costs [32].
The Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation and Treatment of High Blood Pressure (JNC 7)
classifies individuals as Normal hypertension (systolic BP <120 mmHg,
diastolic BP <80 mmHg), Prehypertension (systolic BP 120-139 mmHg and
diastolic BP 80-89 mmHg), Stage I hypertension (systolic BP 140-159 mmHg
and diastolic BP 90-99 mmHg) and Stage II hypertension (systolic BP >160
mmHg and diastolic BP > 100 mmHg). The guideline recommends the use of
thiazide-like diuretics, calcium-channel blockers (CCBs), angiotensin-
converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs),
beta-blockers, or combination therapies as first-line treatment choices in Stage
I and II HTN [33]. In prehypertension, lifestyle modifications are
recommended but if these individuals have comorbid diabetes or kidney
disease, then appropriate drug therapy is recommended.
A care model that is gaining increased attention in recent years is
collaborative or team-based care where patients are managed by two or more
providers from different disciplines (e.g., a physician and pharmacist, or a
physician and nurse). The addition of a pharmacist to the treatment team, in
particular, has been shown to be effective in reducing BP and improving BP
control. Like many chronic diseases, in HTN also, pharmacists play an active
role in the primary prevention, early detection, and management of individuals
with HTN. This provides an excellent opportunity for a multidisciplinary
shared-care approach to screening, diagnosis, management, and follow-up of
patients with hypertension. The pharmacist is better positioned to optimize the
patient’s therapy, thereby positively impacting patient outcomes. Through

pharmacy clinical services, pharmacists have the opportunity to screen
patients, deliver tailored medication regimens, and educate the patients
resulting in better treatment adherence and effective BP control. These clinical
services also score well in patient satisfaction, an important indicator in
keeping the patients engaged in their healthcare. A recent study demonstrated
the benefit of having a pharmacist as an important member in the coordination
of care in patients with HTN. Home BP monitoring is useful in assisting
people lower their BP and researchers utilized telemonitoring devices to send
BP readings to pharmacist who then adjusted the person’s BP medication if
needed. At the end of six months, 72% participants had controlled BP
compared to 45% in high blood pressure under control compared to 45% in
usual care group [34].
SMOKING CESSATION
As per CDC data, nearly 17% (~ 40 million) of US adults aged 18 years or
older smoked cigarettes in 2014. This is lower than the reported 21% smoking
rate in 2005 in this population. Even with the decline in smoking rates in the
US, cigarette smoking continues to be a leading cause of preventable disease
accounting for more than 480,000 deaths every year. Additionally, more than
16 million adults live with a smoking-related disease such as cancer, heart
disease, stroke, lung diseases, diabetes, and chronic obstructive pulmonary
disease (COPD) [35, 36]. What is alarming is that thousands of young
individuals under the age of 18 years smoke their first cigarette with most of
them becoming daily smokers [36]. The economic burden of smoking in the
US is estimated at $300 billion in health costs and lost productivity [37].
Given the substantial social and economic burden of smoking, there is a
need for a comprehensive tobacco control and smoking cessation program that
prevents kids from starting to smoke, facilitates quitting in adult smokers, and
educates the public and policymakers about evidence regarding the
effectiveness of these programs [38]. An important aspect of these programs is
the recognition of a person’s readiness to quit smoking. From a behavioral
perspective, there are five stages that individuals progress through and
recognition of the stage can be very useful in tailoring the smoking
intervention. Precontemplation is the first stage and individuals have no
intention to quit at this stage. In the contemplation stage, individuals begin to
examine their behavior and there is some desire to quit smoking. In the
18 Khalid M. Kamal
preparation stage, people make a commitment to quit and develop a plan to

achieve the same. In the last two stages (action and maintenance), people put
their plan to work and sustain it over time [39]. Once the stage is identified, an
effective approach to produce a behavior change is motivational interviewing.
Motivational interviewing is a patient-centered counseling technique that has
been found to be useful in resolving the ambivalence regarding quitting
tobacco use [40].
Pharmacists are better positioned to promote smoking cessation given
their easy accessibility to the patients. Some pharmacists are now trained as
certified tobacco treatment specialists who can deliver comprehensive tobacco
control and smoking cessation programs including behavioral support. Clinical
practice guidelines for pharmacist-delivered smoking cessation program
recommend the “5 A’s” framework: Ask, Advise, Assess, Assist, and Arrange
[41]. As part of the Assist, pharmacists can also recommend some medications
such as nicotine replacement therapies (nicotine gum, patch, lozenge, nasal
spray, and inhaler), bupropion SR (Wellbutrin SR®) and varenicline
(Chantix®). A systematic literature review examining pharmacist-delivered
tobacco-cessation services conducted from 1980-2006 concluded that
pharmacists can deliver tobacco-cessation interventions and they are effective
in helping smokers to quit [42]. In addition to delivering an effective
intervention, economic evaluations of smoking cessation programs have been
shown that these interventions are cost effective [43]. A number of pharmacy
schools in the US now offer smoking cessation certificate programs that are
designed to train future pharmacists in providing smoking cessation programs.
MEDICATION REVIEW
Medication review is a structured and systematic evaluation of a patient’s
medications with the goal of improving patient’s health outcomes. Pharmacist-
led medication review services are available in United Kingdom (Medicines
Use Review, MUR), United States (Medication Therapy Management, MTM),
Australia (Home Medication Review, HMR), Canada (Meds Check), and New
Zealand (Medicines Use Review, MUR) [44]. A systematic review and meta-
analysis examining the impact of fee-for-service pharmacist-led medication
review on patient outcomes showed that a majority of studies showed
improvement in medication adherence and an overall positive benefits in terms
of patient outcomes including attainment of key clinical biomarkers and
reduced hospitalization [44]. In the US, MTM services are offered to patients
to optimize their outcomes. There are number of services provided as part of

MTM and these services include: pharmacotherapy consults, disease
management coach/support, pharmacogenomics applications, anticoagulation
management, medication safety surveillance, health, wellness, public health,
and immunizations [45].
The Medicare Modernization Act of 2003 requires Medicare Part D
prescription drug plans to include MTM services delivered by a qualified
healthcare professional, including pharmacists. Patients with multiple chronic
conditions (e.g., diabetes, hypertension, and hyperlipidemia) and taking
multiple medications are likely candidates for MTM services [46]. MTM
differs from patient counseling as it is provided independent of dispensing and
generally involves collaboration with patients and providers. Also, MTM can
be delivered face-to-face or by telephone with no consensus on the mode of
delivery [47]. A recent study among many that have been published
demonstrates the positive return on investment on MTM services [48]. Despite
the potential benefits of MTM, there are challenges including reimbursement
from payers and justification of the service for internal stakeholders such as
pharmacy administrators for investment in these services. To meet these
challenges, adequate studies need to be designed that provide evidence linking
the impact of MTMs with positive patient outcomes [47].
HOME MEDICINES REVIEW

Home Medicines Review (HMR) involves an accredited pharmacist, on
referral from the patient’s physician, conducting a comprehensive clinical
review of medications in the patient’s home. The house call is making a
comeback. One of the primary reasons is the ageing population. The world’s
population of 65 years and older is projected to be 1.2 billion in 2025. In the
US, this population is estimated to increase from 40 million in 2010 to 72
million by 2030 [49, 50]. This population also consumes 30% of all
prescription medications [51]. Since polypharmacy and subsequent
medication-related problems are more common in elderly patients, HMR by
pharmacists can help manage their medicines and reduce the risk of adverse
events. These pharmacist reviews result in cost savings due to the
minimization or avoidance of unnecessary physician visits, hospitalizations,
and emergency visits and also have been shown to improve patient’s quality of
life.
20 Khalid M. Kamal
The HMR consists of visits by a pharmacist who analyzes the patient’s

medications, disease, and life style. Based on the pharmacist-patient
interaction, the pharmacist is able to prepare an individualized care plan where
the patient is informed and educated about the disease, medication, and
lifestyle changes. Through regular follow-up visits, the pharmacist is able to
assess patient outcomes and quickly addresses incomplete or failed outcomes.
The pharmacist coordinates the patient care with the patient’s physician and in
doing so encourages a truly patient-centered care. There are instances such as
cultural reasons or pharmacist’s safety concerns inside patient’s home, which
prevent a pharmacist to avoid face-to-face interaction with the patient.
Although HMR is widely practiced in Australia, there are examples of its
implementation in the US under the term “patient centered medical home.” A
study conducted in Southern Illinois University, trained students to conduct an
in-home medication inventory in addition to measuring BP and assessing the
risk of fall in patients. The data collected by the students were reviewed by a
hospital pharmacist for fall risk medications, major drug interactions, or
duplicate therapy and any changes to patient management was made by the
primary care provider. The costs involved in delivering the program are mostly
travel and training, which could be offset by the healthcare cost savings it
results in [52].
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24 Khalid M. Kamal
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Chapter 3
COMMUNITY PHARMACY IN CANADA
Ross T. Tsuyuki, PharmD

and Yazid N. Al Hamarneh, PhD
EPICORE Centre, Department of Medicine,
University of Alberta, Edmonton, AB, Canada
INTRODUCTION
Canada is a large (almost 10 million square kilometers), but relatively
sparsely populated (about 35 million) country. Healthcare is governed by the
Canada Health Act: which espouses “… universal, comprehensive coverage
for medically necessary hospital and physician services.” [1] Although
healthcare is funded federally, it is administered at the level of the 10
provinces and 3 territories, resulting in 13 different health system regulations.
This includes different systems for insurance coverage of medications, and
differences in scope of pharmacy practice and remuneration for clinical
services (see Tables 1 and 2).
Canada has about 40,000 pharmacists and about 10,000 pharmacies. The
main clinical activities performed by pharmacists in primary care (community)
practice in Canada are described below.
Table 1. Pharmacists’ Scope of Practice in Canada
Scope of Practice 1 Province/Territory

BC AB SK MB ON QC NB NS PEI NL NWT YT NU
Prescriptive Independently, for any Schedule X 5 X X X X X X X X X X X
Authority 1 drug
(Schedule 1 In a collaborative practice X 5 5 5 X X   X X X X X
Drugs) 1 setting/agreement
For minor ailments/conditions X   5 X    5  X X X
Initiate 2 For smoking/tobacco cessation X  P 5     5  X X X
In an emergency X    X X    X X X X
Adapt 3/ Independently, for any Schedule X 5 X X X X X X X X X X X
Manage 1 drug 4
Independently, in a collaborative X 5 5 5 X X   X X X X X
practice 4
Make therapeutic substitution    X X X     X X X
Change drug dosage,           X X X
formulation, regimen, etc.
Renew/extend prescription for            X X
continuity of care
Injection Any drug vaccine X    X7 X7  X   X X X
Authority Vaccines 6     X X     X X X
(SC or IM) 1,5 Travel vaccines 6     P X     X X X
Influenza vaccine      X     X X X
Labs Order and interpret lab tests X  P8 9 X  P  P X X X X
Techs Regulated pharmacy technicians     10  X     X X X
1. Scope of activities, regulations, training requirements and/or limitations differ between jurisdictions  Implemented in jurisdiction
Please refer to the pharmacy regulatory authorities for details P Pending legislation,
2. Initiate new prescription drug therapy, not including drugs covered under the Controlled Drugs and regulation or policy for
Substance Act implementation
3. Alter another prescriber’s original/existing /current prescription for drug therapy X Not implemented
4. Pharmacists independently manage Schedule 1 drug therapy under their own authority, unrestricted by
existing/initial prescription(s), drug type, condition, etc
5. Applies only to pharmacists with additional training, certification and/or authorisation through their
regulatory authority
6. Authority to inject may not be inclusive of all vaccines in this category. Please refer to the
jurisdictional regulations
7. For education/demonstration purposes only
8. Ordering by community pharmacists pending health system regulations for pharmacist requisitions to
labs
9. Authority is limited to ordering lab tests
10. Pharmacy technician registration available through the regulatory authority (no official licensing)
BC: British Columbia, AB: Alberta, SK: Saskatchewan, MB: Manitoba, ON: Ontario, QC: Québec, NB:
New Brunswick, NS: Nova Scotia, PEI: Prince Edward Island, NL: Newfoundland and Labrador,
NWT: Northwest Territories, YT: Yukon, NU: Nunavut
Modified from: https://www.pharmacists.ca/pharmacy-in-canada/scope-of-practice-canada/
28 Ross T. Tsuyuki and Yazid N. Al Hamarneh
Table 2. Publicly Funded Pharmacy Services by Province
BC AB SK MB ON QC NB NS PEI NL
Medication        
Review/Assessment ̶
Basic/Standard
Medication    
Specific for Diabetes
Medication   
Advanced/
Comprehensive
Minor Ailments    
Assessment/Prescribing
Smoking Cessation    
Services
Immunization         
Prescription        
Adaptation, Renewals,
Trial Rx,
Refusal to Fill Rx,
Pharmaceutical
Opinion, etc.
Modified from: https://www.pharmacists.ca/pharmacy-in-canada/payment-for-pharmacy-
services/
MEDICATION REVIEWS AND HOME

MEDICATION REVIEWS
Standard medication reviews are one of the services that are publicly
funded in most Jurisdictions across Canada (Table 2). However, more
advanced medication review services such as those specific for diabetes or the
more comprehensive ones are only publicly funded in a limited number of
jurisdictions (Table 2). Medication reviews are meant to go beyond a simple
medication list. As a patient-centered service they should include patient’s
medications and health status assessment, drug therapy problem identification,
care plan development and conducting necessary follow up visits [2].
Canadian pharmacists have welcomed this service [3] as it provided them
with an opportunity to optimize the use of medications, improve (or maintain)
patients’ health outcomes, and reduce healthcare system costs [4].
Community Pharmacy in Canada 29
Evidence: It has been reported that proper medication reviews can help in
resolving drug therapy problems and reduce emergency department visits. [5,
6] Papastergiou and colleagues conducted a study about providing medication
reviews to homebound patients [7]. They reported identifying 1.4 drug therapy
problems per home visit. Non-compliance was the most identified problem
followed by adverse drug reactions and then inadequate treatment. During
those home visits, pharmacists also removed medications that were expired,
not being used or over dosed/double dosed [7]. Henrich and colleagues [3]
reported that medication reviews service was well received by the patients as it
helped them understand their medications and how to use them correctly.
INJECTIONS
Injection of medications by pharmacists in Canada is mostly done by the
subcutaneous or intramuscular routes. Influenza vaccination is permitted all
provinces except Québec and the 3 territories. Pneumococcal vaccinations can
be provided in BC and Alberta [8]. In Alberta, pharmacists can inject via other
routes (e.g., intravenously) and use other types of agents. Indeed, some
pharmacists have also developed travel vaccination services. Papastergiou and
colleagues also recently reported on a novel point of care pilot project to detect
Influenza A and B [9].
The uptake of vaccination by Canadian pharmacists, and acceptance by
patients, has been rapid and high, [10] with suggestions of higher vaccination
rates in the population due to availability through pharmacies.
Evidence: Kwong and colleagues showed an increase of about 518,000
influenza vaccinations in Ontario after pharmacists started to vaccinate [11].
Papastergiou and colleagues have reported on a high degree of patient
satisfaction with pharmacist vaccination [12]. With regards to pharmacy
student vaccination, Cheung and colleagues showed a high (99%) level of
patient satisfaction in 1555 subjects at the University of Alberta [13]. Church
and colleagues showed a number of positive attributes of student vaccination
in Canada and elsewhere, however pointed out that a number of jurisdictions
in Canada do not permit students to vaccinate [14]. Houle and colleagues have
published a review of publicly funded remuneration for administration of
injections - the fees for administration of injections ranged from $CDN7.50 to
$20.00 [8].
SMOKING CESSATION
Smoking cessation services are publicly funded in Alberta, Saskatchewan,
Ontario, and Quebec (Table 2). Pharmacists in most jurisdictions can prescribe
drug therapy for tobacco cessation [4].
The uptake of tobacco cessation services has been high among Canadian
pharmacists as Wong and colleagues reported that the number of pharmacies
providing pharmacy smoking cessation program in Ontario increased from 142
when the service was introduced in 2011 to 1253 in 2013 [15].
Evidence: Jackson and colleagues reported 37.5% self-reported quit rates
among individuals who received community pharmacist intervention, which
consisted of initial assessment, follow up visits and behavioral support over a
6-month period [16]. A study which assessed the impact of the pharmacy
smoking cessation program in Ontario on smoking levels, reported 29% quit
rate over 1 year. Tobacco cessation is also associated with financial benefits as
Budgen and colleagues reported that individuals can save approximately $266
per month if they reduce their cigarette consumption [17].
DIABETES
Pharmacists’ activities in diabetes include provision of blood glucose
measurement services and screening (via glucometers, clinic days) as well as
selling glucometers and other diabetes supplies such as lancets and testing
strips. Pharmacists also provide counseling/education services, conduct follow
up visits and make recommendations/adjustments and prescribe hypoglycemic
medications.
Pharmacists in Canada have identified diabetes as the condition of greatest
interest when it comes to chronic disease management [18]. Many are also
obtaining extra certification in diabetes management and becoming certified
diabetes educators (CDE).
Evidence: On the screening front, Papastergiou and colleagues [19] and Al
Hamarneh and colleagues [20] demonstrated that glycemic control can be
assessed in community pharmacy setting, demonstrating glycemic control
rates of only 42 – 44%. Al Hamarneh and colleagues took this evidence one
step further when they assessed the effect of pharmacists prescribing on
glycemic control in patients with uncontrolled type 2 diabetes - the RxING
Study [21]. They reported a clinical and statistically significant drop in HbA1c
of 1.8% (from 9.1% at baseline to 7.3% at the end of the study) over a 6-
month period.
HYPERTENSION
Pharmacists’ activities in hypertension include provision of blood pressure
measurement services and screening (via kiosks such as PharmaSmart®,
office-style blood pressure measurement, clinic days, and, in some cases, 24
hour ambulatory blood pressure monitoring services), as well as selling blood
pressure monitors. Pharmacists also participate in patient counseling/
education, follow-up of patients, and make recommendations/adjustments and
prescribe antihypertensive medications. The national advocacy body,
Hypertension Canada (www.hypertension.ca) is a strong supporter of the role
of pharmacists in hypertension management, including pharmacist-specific
recommendations in their guidelines and sponsoring yearly pharmacist-
directed practice guidelines published in the Canadian Pharmacists Journal
(www.cpjournal.ca).
Evidence: There is strong evidence supporting the role of Canadian
pharmacists in hypertension management. With regards to screening, one large
pharmacy-grocery chain recently reported on a screening program that
enrolled over 50,000 [22] during the month of February for the past 2 years.
Other trials include the SCRIP-HTN study, a randomized trial of pharmacist-
nurse intervention in 248 patients with diabetes and poorly controlled
hypertension, which showed a further reduction of 6.6/3.4 mmHg in the
intervention group [23]. Simpson and colleagues [24] also showed a
significant reduction in blood pressure in the 260 patient VIP study conducted
in a primary care network setting. Recently, the value of independent
pharmacist prescribing (only available in Alberta at this time) has been
demonstrated in a randomized trial, RxACTION [25]. This trial of 248 patients
with poorly controlled hypertension who had their blood pressure managed by
their pharmacist with prescriptive authority showed a reduction of 6.6/3.2
mmHg [25].
POINT OF CARE AND LABORATORY TESTING

Pharmacists in Canada can order and interpret laboratory tests in Alberta,
Manitoba, Québec and Nova Scotia (Table 1). Point of care testing can be
considered as an alternative when pharmacists do not have access to lab test

results [26]. Canadian pharmacists have used point of care testing to assess
different conditions such as diabetes, influenza, and dyslipidemia.
Evidence: Al Hamarneh and colleagues provided one of the first studies to
validate the benefit of pharmacists ordering lab tests [27]. They reported that
pharmacists screening for chronic kidney disease uncovered a large number of
cases, 40% of which were previously unrecognized [27].
Papastergiou [19] and Al Hamarneh [20] used point of care testing to
assess glycemic control in patients with diabetes who are receiving treatment.
These studies reported that a large number of patients who are receiving
treatment for diabetes are not meeting their treatment targets. Mansell and
colleagues [28] used point of care testing to assess the impact of a pharmacist
education program on glycemic control in patients with diabetes. They
reported that point of care was a reliable method to measure the change in
HbA1c between baseline and the end of the study [28].
COMMON AMBULATORY CONDITIONS

(AKA “MINOR AILMENTS”)
Most provinces have a provision for common ambulatory conditions (also
referred to as “minor ailments” – this term is discouraged in Canada because
of its denigrating connotation) [29]. Generally, this consists of a narrow range
of self-limiting conditions. Saskatchewan has the prototypical program which
allows for prescribing of steroids for diaper dermatitis, nasal steroids for
allergic rhinitis, tinea skin infections, gastric reflux, dysmenorrhea, insect
bites, oral thrush, seasonal allergies, mild acne, oral apthous ulcers,
hemorrhoids, muscle strains and sprains, and bacterial skin infections [30]. A
recent review of the current programs and unanswered questions has been
written by Lee and McCarthy [31].
PRESCRIBING
Prescribing represents a spectrum of activities, from refill authorization to
prescription adaptation to fully independent prescribing. All provinces and the
Northwest Territory permit pharmacists to renew prescriptions (Table 1).
Pharmacists in all provinces can change a drug dosage or formulation and
about half permit therapeutic substitution and prescribing for common

ambulatory conditions (see above). Collaborative agreements that permit
pharmacists to prescribe are available in Saskatchewan. Limited independent
prescribing is permitted in several provinces; Alberta is the only province to
have truly independent prescribing, with about one third of pharmacists having
qualified for this privilege.
Evidence: A number of Canadian-led trials have demonstrated the benefits
of pharmacists’ independent prescribing. The RxING study was a before-after
trial of pharmacist prescribing and follow-up in patients with type 2 diabetes
who were not at their HbA1c target [21]. It showed a significant 1.8%
reduction in HbA1c over 6 months [21]. The RxACTION study was a 248
patient randomized trial of pharmacist prescribing in patients with poorly
controlled hypertension [32]. The primary outcome of systolic blood pressure
reduction was significantly reduced by 6.6mmHg more than in the usual care
group [32]. Similarly, the RxACT study showed a significant reduction in
LDL cholesterol [33]. More recently, the RxEACH study reported a 21%
reduction in risk for major cardiovascular events in 723 patients randomized to
a pharmacist prescribing intervention [34].
REMUNERATION FOR CLINICAL SERVICES

Table 2 outlines publicly funded clinical pharmacy services in Canada.
Most provinces will pay for a medication review, prescription adaptation
(change in dosage or formulation), renewals, trial prescriptions, and refusal to
fill prescriptions. About half of Canadian jurisdictions will cover “minor
ailments” assessment and prescribing and smoking cessation services. Some
private insurers will also remunerate pharmacists for programs such as
cardiovascular risk reduction (e.g., Greenshield). In Alberta, pharmacists with
Additional Prescribing Authorization receive higher fees than those who do
not.
Evidence: Remuneration for clinical services in Canada and abroad has
been recently reviewed by Houle and colleagues. [35]. Tsao and colleagues
surveyed 819 subjects in British Columbia about medication management
services and found that 93% perceived that the medication review improved
their health and determined an average willingness to pay of $24.55 per review
[36].
CONCLUSION
Since the publication of the Blueprint for Pharmacy’s vision statement:
“Optimal drug therapy outcomes for Canadians through patient-centred care,”
[37] the scope of practice for pharmacists (and uptake in the new services) has
been changing very rapidly. Along with this, remuneration is changing to
cover more clinical services. Efforts to support and guide pharmacists in
changing their practice are ongoing [38].
REFERENCES
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[2] Canadian Pharmacists Association. Medication review services
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education-practice-resources/professional-development/medication-
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2016).
[3] Henrich N, Tsao N, Gastonguay L et al. BC medication management
project. Prospectives of pharmacists, patients and physicians. Can
Pharm J. 2015; 148: 90-100.
[4] Canadian Pharmacists Association. A review of pharmacy services in
Canada and the health and economic evidence. 2016. Available from
http://www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-
issues/Pharmacy%20Services%20Report%201.pdf (Accessed April 10,
2016).
[5] Riley K. Enhanced medication management services in the community.
A win-win proposal from an economic, clinical and humanistic
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[6] Wong J, Marr P, Kwan D et al. Identification of inappropriate
medication use in elderly patients with frequent emergency department
visits. Can Pharm J. 2014; 147: 248-256.
[7] Papastergiou J, Zervas J, Li W, Rajan A. Home medication reviews by
community pharmacists: Reaching out to homebound patients. CPJ.
2013; 146: 139-142.
[8] Houle SKD, Grindrod KA, Chatterley T, Tsuyuki RT. Publicly funded
remuneration for the administration of injections by pharmacists: An
international review. Can Pharm J 2013; 146: 353-364.
[9] Papastergiou J, Folkins C, Li W, Young L. Community pharmacy rapid
influenza A and B screening: A novel approach to expedite patient
access to care and improve clinical outcomes. Can Pharm J 2016; 149:
83-89.
[10] Canadian Pharmacists Association. Available from https://www.
pharmacists.ca/news-events/news/pharmacists-play-a-key-role-in-
achieving-higher-immunization-rates-in-canada/, (Accessed April 11,
2016).
[11] Kwong J, Cadarette S, Schneider E, et al. Community pharmacies
providing influenza vaccines in Ontario: A descriptive analysis using
administrative data (abstract). Can Pharm J 2015; 148: S12.
[12] Papastergiou J, Folkins C, Li W, Zervas J. Community pharmacist-
administered influenza immunization improves patient access to
vaccination. Can Pharm J 2014; 147: 359-365.
[13] Cheung W, Tam K, Cheung P, Banh HL. Satisfaction with student
pharmacists administering vaccinations in the University of Alberta
annual influenza campaign. Can Pharm J 2013; 146: 227-232.
[14] Church D, Johnson S, Rama-Wilms L, Schneider E, Waite N, Sharpe JP.
A literature review of the impact of pharmacy students in immunization
initiatives. Can Pharm J online ahead of print 2016. DOI:
10.1177/1715163516641133.
[15] Wong L, Burden AM, Liu YY et al. Initial uptake of the Ontario
Pharmacy Smoking Cessation Program: Descriptive analysis over 2
years. CPJ. 2015; 148: 29-40.
[16] Jackson M, Gaspic-Piskovic M, Cimino S. Description of a Canadian
employer-sponsored smoking cessation program utilizing community
pharmacy–based cognitive services. Can Pharm J 2008; 141: 234-240.
[17] Budgen S, Hamilton K, Shearer B et al. Manitoba pharmacist initiated
smoking cessation pilot project. 2015. Available from
http://www.msp.mb.ca/files/Smoking%20Cessation_Report%20in%20B
rief_Final.pdf (accessed April 10, 2016).
[18] Mah E, Rosenthal M, Tsuyuki RT. Study of Understanding Pharmacists’
Perspectives on Remuneration and Transition toward Chronic Disease
Management (SUPPORT-CDM): results of an Alberta-wide survey of
community pharmacists. Can Pharm J 2009: 142: 136-43.
[19] Papastergiou J, Rajan A, Diamantouros A, et al. HbA1c testing in the

community pharmacy: A new strategy to improve care for patients with
diabetes. Can Pharm J 2012; 145: 165-167.
[20] Al Hamarneh YN, Rosenthal M, Tsuyuki RT. Glycemic Control in
Community-Dwelling Patients with Type 2 Diabetes. Can Pharm J
2012; 145: 68-69.
[21] Al Hamarneh YN, Charrois T, Lewanczuk R, Tsuyuki RT. Pharmacist
intervention for glycaemic control in the community (the RxING study).
BMO Open 2013; 3: e003154.
[22] Diamond S, Tsuyuki R, Kaczorowski J, Syron L, Berg A, Farrell J,
Padwal, Feldman R. Hypertension treatment and control in the
community: A novel program of surveillance for hypertension in a
grocery-pharmacy setting (Abstract). Can Pharm J 2015; 148: S56.
[23] McLean DL, McAlister FA, Johnson JA, et al. A Randomized Trial of
the Effect of Community Pharmacist and Nurse Care on Improving
Blood Pressure Management in Patients With Diabetes Mellitus. Study
of Cardiovascular Risk Intervention by Pharmacists- Hypertension
(SCRIP-HTN). Arch Intern Med 2008; 168: 2355-2361.
[24] Simpson SH, Majumdar SR, Tsuyuki RT, Lewanczuk RZ, Spooner R,
Johnson JA. Effect of Adding Pharmacists to Primary Care Teams on
Blood Pressure Control in Patients With Type 2 Diabetes. A randomized
controlled trial. Diabetes Care 2011; 34: 20-26.
[25] Tsuyuki RT, Houle SKD, Charrois TL, et al. Randomized Trial of the
Effect of Pharmacist Prescribing on Improving Blood Pressure in the
Community. The Alberta Clinical Trial in Optimizing Hypertension
(RxACTION). Circulation 2015; 132: 93-100.
[26] Canadian Pharmacists Association. Available from http://www.
pharmacists.ca/cpha-ca/assets/File/education-practice-resources/
TranslatorSpr16-PharmacistsPointOfCareTesting.pdf (accessed April 10,
2016).
[27] Al Hamarneh YN, Hemmelgarn B, Curtis C, Balint C, Jones CA,
Tsuyuki RT. Community pharmacist targeted screening for chronic
kidney disease. Can Pharm J 2016; 149: 13-17.
[28] Mansell K Evans C, Tran D, Sevany S. The association between self-
monitoring of blood glucose, hemoblobin A1c and testing patterns in
community pharmacies: Results of a pilot study. Can Pharm J 2016;
149: 28-37.
[29] Tsuyuki RT, Davies NM. Self-denigration in pharmacy: Words to banish
from the pharmacy lexicon. Can Pharm J 2014; 147: 133-134.
[30] Pharmacists Association of Saskatchewan, available from

https://www.skpharmacists.ca/patients/faqs/my-pharmacist-can-
prescribe (accessed April 12, 2016).
[31] Lee R, McCarthy L. Canadian “minor ailments” programs: Unanswered
questions. Can Pharm J 2015; 148: 302-304.
[32] Tsuyuki RT, Houle SKD, Charrois TL, Kolber MR, Rosenthal MM,
Lewanczuk R, Campbell NR, Cooney D, McAlister F. Randomized Trial
of the Effect of Pharmacist Prescribing on Improving Blood Pressure in
the Community: The Alberta Clinical Trial in Optimizing Hypertension
(RxACTION). Circulation 2015; 132: 93-100.
[33] Tsuyuki RT, Rosenthal MA, Pearson GJ. Improving Dyslipidemia
Management in the Community: RxACT, a randomized trial of
pharmacist prescribing. Can Pharm J 2016, in press.
[34] Tsuyuki RT, Al Hamarneh YN, Jones CA, Hemmelgarn BR.
Effectiveness of Community Pharmacist Prescribing and Care on
Cardiovascular Risk Reduction: Randomized Controlled RxEACH Trial,
Journal of the American College of Cardiology (2016), doi:
10.1016/j.jacc.2016.03.528.
[35] Houle SKD, Grindrod KA, Chatterley T, Tsuyuki RT. Paying
pharmacists for patient care: A systematic review of remunerated
pharmacy clinical care services. Can Pharm J 2014; 147: 209-232.
[36] Tsao NW, Khakban A, Gastonguay L, Li K, Lynd LD, Marra CA.
Perceptions of British Columbia residents and their willingness to pay
for medication management services provided by pharmacists. Can
Pharm J 2015; 148: 263-273.
[37] Blueprint for Pharmacy, available from https://www.pharmacists.ca/
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[38] Tsuyuki RT, Schindel TJ. Changing pharmacy practice: The leadership
challenge. Can Pharm J 2008; 141: 174-180.
Chapter 4
COMMUNITY PHARMACY IN AUSTRALIA
Timothy F. Chen*, PhD

Associate Professor, Faculty of Pharmacy,
The University of Sydney, Australia
INTRODUCTION
Pharmacists form an integral part of the Australian healthcare system.
They can work in a variety of public and private settings. These include
community pharmacy, hospital pharmacy, residential aged care facilities,
government and non-government organisations and academia. Their roles can
vary and include: the dispensing of prescription medicines, provision of advice
and management of minor illnesses, the provision of cognitive pharmaceutical
services (e.g., Home Medicines Review, Residential Medication Management
Review) and development of health and medicines policy. In addition to the
role of pharmacists in dispensing prescription medicines, over the past decade,
there has been a strong focus on the delivery of professional pharmacy
services, which utilise the pharmacotherapy expertise of pharmacists. This is
significant as it represents a major philosophical shift and paradigm change,
from a focus on the supply of medicines to the provisions of professional
services for patients [1]. This chapter will focus on the roles of community
pharmacists in the delivery of healthcare in Australia.
*
Email: timothy.chen@sydney.edu.au.
40 Timothy F. Chen
Australia has an advanced healthcare system and a highly trained health

workforce. The Australian healthcare system includes a balance of public and
privately owned healthcare entities, with community pharmacies privately
owned. There are approximately 5350 community pharmacies in Australia
(average of one pharmacy for every 4300 persons). Of the 1345 hospitals in
Australia, most are government owned [2]. As of 2014, of the 28,751
registered pharmacists in Australia, 19,792 were working in a clinical capacity
(e.g., community pharmacy, hospital pharmacy, medication management) [3].
Community pharmacists represent approximately 63% of those working in a
clinical capacity and hospital pharmacists 18%.
There are four main pharmacy organisations in Australia, designed to
support pharmacists in different capacities. These are the Pharmaceutical
Society of Australia (https://www.psa.org.au/), Pharmacy Guild of Australia
(http://guild.org.au/), Society of Hospital Pharmacists of Australia
(http://www.shpa.org.au/), and Australian Association of Consultant Pharmacy
(https://www.aacp.com.au/).
 The Pharmaceutical Society of Australia (PSA) is the main

organisation responsible for representing all Australian pharmacists,
and has the vision of improving health through the practice of
pharmacy. The PSA plays a major role in providing educational
support and professional development for pharmacists. It supports
pharmacists working in community pharmacy for them to become the
“Health Destination” for consumers. The PSA is the custodian for the
National Competency Standards Framework for Pharmacists in
Australia, and also publishes key professional practice standards and
guidelines.
 The Pharmacy Guild of Australia (PGA) is the main organisation in
Australia which represents community pharmacy owners. The PGA
fully supports community pharmacy as a model for the appropriate
and efficient dispensing of medicines and for providing medication
management services in order to achieve quality health outcomes. It is
noteworthy that the PGA is the peak body responsible for negotiating
(five year) “Community Pharmacy Agreements” with the Australian
Government. A copy of the current agreement is available at
http://guild.org.au/docs/default-source/public-documents/tab---the-
guild/Community-Pharmacy-Agreements/6cpa---final-24-may-
201558b59133c06d6d6b9691ff000026bd16.pdf?sfvrsn=2.
 The Society of Hospital Pharmacists of Australia (SHPA) is the major
national organisation representing hospital pharmacists. The SHPA
Community Pharmacy in Australia 41
supports hospital pharmacists to achieve excellence in medicines

management via a range of well-established programmes including
continuing professional development, specialty practice (e.g., mental
health, infectious diseases, cancer) and the development and
publication of practice standards for different areas of specialty
practice.
 The Australian Association of Consultant Pharmacy (AACP) is the
major organisation in Australia responsible for accrediting
pharmacists to provide professional services such as medication
review and management (e.g., Home Medicines Review, Residential
Medication Management Review). The AACP is jointly owned by the
Pharmaceutical Society of Australia and the Pharmacy Guild of
Australia.
Achieving the “quality use of medicines” (QUM) is a key feature linking

the major pharmacy organisations in Australia. The quality use of medicines
refers to the judicious, appropriate, safe and efficacious use of medicines. The
quality use of medicines is one of the major tenets of the National Medicines
Policy in Australia. The other major tenets of this policy include “timely
access to medicines that Australians need, at a cost individuals and the
community can afford; medicines meeting appropriate standards of quality,
safety and efficacy; and maintaining a responsible and viable medicines
industry” [4].
DISPENSING PRESCRIPTION MEDICINES:

CLINICAL INTERVENTIONS
A major role for community pharmacists is the dispensing and reviewing
of prescription medicines or “Schedule 4” medicines (Table 1). Currently most
medicines are dispensed manually in the community pharmacy; however,
increasingly high prescription volume pharmacies are using robotic technology
to support the dispensing of medicines. Most of the medicines dispensed by
community pharmacists are listed on the Pharmaceutical Benefits Scheme
(PBS) or the Repatriation Pharmaceutical Benefits Scheme (RPBS). These are
commonwealth government funded co-payment schemes in which patients pay
an initial contribution to the cost of each medicine dispensed ($AUD38.30 for
general patients or $AUD6.20 for concessional patients) and the government
subsidies the remaining cost of the medicine.
42 Timothy F. Chen
Table 1. Schedule of Medicines
Schedule1 Description Some indicative examples

Schedule 2 These medicines are available in beclomethasone nasal spray
Pharmacy community pharmacies. Advice on the 50 mcg; codeine 10 mg /
Medicine use of these medicines may be phenylephrine;
provided by a pharmacist or a dextromethorphan; ibuprofen
pharmacy assistant. 200mg; ketoconazole 1%;
loperamide 2 mg; loratadine;
oxymetazoline;
promethazine; ranitidine 150
mg; terbinafine topical
Schedule 3 These medicines do not require a chloramphenicol eye
Pharmacist prescription but must be stored behind preparations; clotrimazole for
Only Medicine the counter in pharmacies. A vaginal use; codeine 12 mg /
pharmacist must be consulted about combined with other
the use of these medicines. therapeutically active
substances; diclofenac 25
mg; esomeprazole 20 mg;
famciclovir oral; glyceryl
trinitrate; metoclopramide /
paracetamol; naloxone
(opioid abuse); orlistat 120
mg; pseudoephedrine;
salbutamol aerosol 100 mcg;
salbutamol dry powder 200
mcg;
Schedule 4 These medicines must be prescribed A list of the most commonly
Prescription Only by a registered healthcare professional prescribed medicines in
Medicine and dispensed at a pharmacy or Australia is included in Table
(or Prescription hospital. The vast majority of 2.
Animal Remedy) prescriptions come from medical
practitioners and dentists. More
recently, nurse practitioners and
optometrists have also been granted
authority to prescribe medicines within
their scope of practice.
Schedule 8 These medicines must be prescribed alprazolam; amphetamine;
Controlled Drug by a registered healthcare professional buprenorphine; cocaine;
and dispensed at a pharmacy or dexamphetamine; dronabinol
hospital. The prescriber may need a (delta-9-
permit to prescribe these medicines. A tetrahydrocannabinol);
detailed register of these medicines fentanyl; flunitrazepam;
must be kept in the dispensary of the ketamine; methadone;
pharmacy and the medicines must be morphine; oxycodone;
stored in a locked safe.
1
Australia has a national classification system for the scheduling of medicines (and chemicals).
Schedules 2, 3, 4 and 8 are most relevant to pharmacy. The classification system is based on the
level of regulatory control mandated in order to protect public health and safety
Almost 300 million prescriptions are dispensed per annum in Australia

community pharmacies. Most of the medicines dispensed are subsidized by the
commonwealth government (e.g., concessional prescriptions), whilst for a
significant proportion, consumers pay the full cost of the medicines dispensed
(i.e., under co-payment). Detailed information about dispensing statistics is
available from “Australian Statistics on Medicines 2014” available at
https://www.pbs.gov.au/statistics/asm/2014/australian-statistics-on-medicines-
2014.pdf.
There is a considerable difference in the cost of medicines to the
PBS/RPBS with some low volume, high cost medicines accounting for a
significant proportion of total costs (Table 2).
In dispensing medicines for patients, Australian community pharmacists
must ensure that the use of medicines is both safe and appropriate for patients.
At the time of dispensing, community pharmacists are encouraged to work
with their patients and other healthcare professionals to minimize the chance
of actual or potential drug-related problems (DRPs). Specifically, pharmacists
are trained to identify the causes of drug-related problems and to recommend
evidence-based solutions to them.
Example 1: A pharmacist confirms a serious allergy to a prescribed

medicine at the time of dispensing and contacts the prescriber to recommend
an alternative medicine.
Example 2: A pharmacist identifies an excessive starting dose of a

prescribed medicine at the time of dispensing and contacts the prescriber to
recommend an appropriate dose.
Example 3: A pharmacist detects a potential serious drug-drug

interaction at the time of dispensing and contacts the prescriber to discuss
monitoring if the medicines are both used, and or potential alternative
medicines, in order to avoid the drug-drug interaction.
Detecting and resolving drug-related problems is a core responsibility for

community pharmacists and has been recognised accordingly, with the
availability of remuneration for the documentation of clinical interventions.
Whilst different systems for classifying and documenting drug-related
problems or the causes of drug-related problems exist, an aggregated
classification system has been validated for use by healthcare professionals
and researchers [5].
44 Timothy F. Chen
Table 2. Top 10 medicines by prescription volume and cost to

PBS/RPBS [6]
Most commonly dispensed Cost to PBS/RPBS

1 Atorvastatin Rosuvastatin
2 Esomeprazole Adalimumab1
3 Rosuvastatin Esomeprazole
4 Paracetamol Salmeterol and fluticasone
5 Perindopril Atorvastatin
6 Pantoprazole Aflibercept1
7 Amoxycillin Ranibizumab1
8 Cefalexin Rituximab1
9 Metformin hydrochloride Etanercept1
10 Amoxycillin with clavulanic acid Tiotropium bromide
1
Low volume high cost medicines
It is noteworthy that resolving drug-related problems and conducting

clinical interventions at the time of dispensing may serve as a catalyst for a
range of other professional community pharmacy services. These include, but
are not limited to: comprehensive and other medication management services
(e.g., Home Medicines Review, Residential Medication Management Review,
MedsCheck – medicines use review), use of dose administration aids to
facilitate medication taking behaviour, provision of medicine information to
patients (e.g., Consumer Medicines Information) and screening and disease
management services.
MEDICATION MANAGEMENT REVIEW

There are two major government funded programmes in Australia that
involve the provision of medication management services by pharmacists in
collaboration with medical practitioners. These are Home Medicines Review
and Residential Medication Management Review. Both have the goal of
achieving the quality use of medicines.
The Home Medicines Review programme commenced as a government-
funded service in 2001. This service, aims to identify and resolve actual and
potential drug-related problems in order to achieve better outcomes for
patients. The service is delivered by accredited pharmacists in collaboration
with the patient’s general practitioner, following a referral. The Australian
Association of Consultant Pharmacy (described above) and the Society of

Hospital Pharmacists of Australia (described above) are the major
organisations, which manage the post-registration certification for medication
review.
Positive outcomes from Home Medicine Reviews are more likely to occur
if all stakeholders (e.g., pharmacists, general practitioners, patients) recognise
the expert contribution pharmacists can make to optimizing pharmacotherapy.
Hence, in addition to pharmacists having high level technical and clinical
knowledge about optimizing the use of medicines, high-level collaboration and
communication between pharmacists and general practitioners is essential.
Whilst the Home Medicine Review process is unique to Australia, the skills
required by the pharmacist are similar to those required for Medication
Therapy Management in the United States or Clinical Medication Review in
the United Kingdom. In general, Home Medicines Review is designed for
consumers well enough to be living at home (i.e., not residents of residential
aged care facilities), and in this sense is different to the Home Medicines Care
service provided to less mobile consumers in Japan.
The key steps involved in the provision of Home Medicines Review are:
1) Identification of the consumer based on need. The clinical needs

include but are not limited to:
a) discharge from hospital in the previous 4 weeks;
b) significant change to medication regimen in the past 3 months;
c) change in medication condition or abilities (e.g., falls, cognition,
physical function);
d) use of a medicine with a narrow therapeutic index and that
requires therapeutic monitoring;
e) symptoms suggestive of an adverse drug reaction;
f) sub-therapeutic response to pharmacotherapy;
g) non-adherence or problems with managing medication-related
devices;
h) risk of being unable to continue managing own medicines due to
changes in dexterity, confusion or impaired vision.
2) Referral of the patient to their preferred pharmacy or pharmacist by
general practitioner.
3) Pharmacist visits patient at home and obtains a comprehensive
medication history.
4) Pharmacist documents their medication review findings and
recommendations in a report for the general practitioner.
46 Timothy F. Chen
5) General practitioner and patient formulate a medication plan based on

the pharmacist medication review report.
The commonwealth government funded Residential Medication

Management Review program commenced in 1997. This service is designed to
ensure optimal pharmacotherapy for residents living in aged care facilities
(formerly known as nursing homes). More than 250 000 residents live in aged
care facilities across Australia. Each facility is served by an accredited
pharmacist or team of pharmacists who provide medication review services for
residents. Other activities which may be provided by pharmacists in addition
to residential medication management review to support the quality use of
medicines in aged care facilities include: medication advisory committee
activities; provision of education for staff; involvement in continuous
improvement activities [7].
The key steps involved in the provision of Residential Medication
Management Review are:
1) Identification of the resident in the aged care facility, based on need.

The clinical needs are described in step 1 of the Home Medicines
Review process.
2) Referral of the resident to RMMR service provider.
3) Pharmacist gathers resident information from resident, family, next of
kin, aged care facility staff members, and resident’s case notes.
4) Pharmacist documents their medication review findings and
recommendations in a report for the general practitioner and notes that
this has been completed on the medication chart and resident’s case
notes.
5) Potential for face-to-face discussion between the pharmacist and
general practitioner after the review.
DOSE ADMINISTRATION AIDS

Many community pharmacies provide dose administration aids for their
patients. Dose administration aids can be used to support the outcomes of
medication review activities by optimizing adherence to prescribed medicines.
Dose administration aids are devices designed to facilitate medication
management by a patient by re-packing medicines taken on a regular basis
(e.g., tablets, capsules) into either unit-dose packs (one single type of medicine
per compartment) or a multi-dose pack (different types of medicines per

compartment). Dose administration aids may be used when patients are
stabilized on their medication regimen, the dose forms are suitable for re-
packing and when adherence to therapy is judged to be effecting treatment
response. These devices are not suitable for eye/ear drops,
creams/lotions/ointments, respiratory devices, transdermal patches, parenteral
formulations etc.
The types of dose administration aids include relatively basic manually
packed compartmentalized multi-dose plastic boxes which typically cover
periods of one to seven days; multi-dose blister or bubble packs which
typically cover a period of seven days; machine packed unit dose sachets in a
roll, with medicines packed in the chronological order in which they are
intended to be taken; and automated medication dispensing devices which are
generally manually packed.
NON-PRESCRIPTION MEDICINES AND MANAGEMENT

OF MINOR ILLNESSES
Australian community pharmacists have an established role in health

promotion and the management of a broad range of minor illnesses. New
community pharmacies now all include a private consultation room to aid the
delivery of an expanded range of primary care services. The medicines
available under Schedule 3 and Schedule 2 (Table 1), which can be sold in
community pharmacies without a prescription, attest to this. Community
pharmacists have access to purpose designed professional practice standards to
support the delivery of professional services and facilitate the quality use of
medicines. These include:
 Guidance for the provision of Naloxone for the treatment of opioid

overdose
 Guidance for the provision of combination analgesics including
codeine
 Guidance for the provision of famciclovir for treatment of herpes
labialis (cold sores)
 Guidance on use of chloramphenicol for ophthalmic use
 Guidance for the supply of fluconazole for treatment of vaginal
candidiasis
48 Timothy F. Chen
 Guidance for provision of levonorgestrel for emergency contraception

 Guidance for the provision of orlistat for obesity in adults
 Guidance for the provision of prochlorperazine for nausea associated
with migraine
 Guidance for the provision of proton pump inhibitors (PPIs) for the
relief of heartburn and other symptoms of gastro-esophageal reflux
disease
 Beta agonist protocol for bronchospasm
In addition, the Pharmaceutical Society of Australia has produced a wide

range of written materials designed to support pharmacists in counseling
patients about different health conditions and scenarios – demonstrating the
wide scope of practice for Australian community pharmacists (Table 3).
SELECTED OTHER PROFESSIONAL SERVICES

Smoking Cessation
The prevalence of cigarette smoking in Australians aged over 18 years is

now 13.3% (2013), down from an estimate of 35% in 1980. Notwithstanding
this significant downward trend, cigarette smoking still contributes to
significant clinical, social and economic costs and is estimated to kill 15 000
Australians each year [8]. Trained community pharmacists are well placed to
assist in the smoking cessation process as highly trusted and accessible
primary healthcare professionals. Specifically pharmacists must assess
readiness to change (pre-contemplation, contemplation, preparation, action,
maintenance, and relapse), the degree of nicotine dependence and use specific
counseling techniques such as motivational interviewing.
Diabetes Monitoring
The prevalence of diabetes in Australia is high with an estimated 5.4% of

those aged over 18 years with the condition. “Diabetes MedsCheck” is a
remunerated medication use review service provided by community
pharmacists for patients with diabetes. The service involves an interview with
the patient to assess concerns and beliefs about medicines and assess
medication adherence. The service also involves the provision of written

information, the management of drug-related problems, review of clinical
parameters (e.g., HbA1c), assessment of glucometer use, and discussion about
lifestyle factors that may influence diabetes control [9].
Table 3. Examples of written materials developed by Pharmaceutical

Society of Australia
Acne Diabetes type 1 Infant colic Psoriasis

Alcohol Diabetes type 2 Irritable bowel syndrome Red and dry eyes
Alzheimer’s disease Drug overdose Medicines and Relaxation techniques
breastfeeding
Antibiotics Dry mouth Medicines and driving Rheumatoid arthritis
Anxiety Ear problems Meningococcal disease Safer injecting
practices
Asthma Eczema and dermatitis Menopause Scabies
Asthma medicines Epilepsy Menstrual chart Sense in the sun
Back pain Erectile dysfunction Men’s health Shingles
Bladder and urine Exercise and the heart Methadone and Sleeping problems
control buprenorphine
Blood glucose Exercises for Migraine Smoking
monitoring flexibility
Breast awareness and Fat and cholesterol Mouth ulcers Sprains and strains
pap smear
Carer support Fibre and bowel Nappy rash Staying a non-smoker
health
Chicken pox First aid in the home Nicotine replacement The PBS and you
therapy
Childhood Generic medicines Opioids for pain relief Threadworms
immunisation
Children’s pain and Genital herpes Oral contraceptives Thrush
fever
Colds and flu Glaucoma Oral health Tinea
Chronic pain Gout Osteoarthritis Travel health
Cold sores Haemorrhoids Osteoporosis Urinary tract infection
Complementary Hair loss Pain relievers Vaginal discharge
medicines
Constipation Hay fever Pelvic floor exercises Vision impairment
Contact lens care Headache Period problems Vitamins
Contraception Head lice Post-traumatic stress Vomiting and diarrhea
disorder
Coughs Heartburn and Pregnancy and ovulation Warning signs of heart
indigestion attack
Dandruff Help with medicine Preventing falls Weight and health
costs
Depression High blood pressure Prostate problems Wise use of medicines
HIV/AIDS
50 Timothy F. Chen
CONCLUSION
Community pharmacy practice in Australia has undergone significant
change over the past two decades. This has seen community pharmacy move
from a predominantly supply function (dispensing medicines for consumers)
to now include a focus on the delivery of professional pharmacy services for
patients, often in collaboration with other healthcare professionals. The five
year Community Pharmacy Agreements between the Commonwealth
Government and the Pharmacy Profession – in particular the Pharmacy Guild
of Australia - have provided the framework for many of these developments.
Specifically, the Community Pharmacy Agreements have recognised the
importance of practice-based research in informing ways to utilize the
pharmacotherapy expertise of pharmacists. Governments are now far more
aware of the professional contributions made by pharmacists in the delivery of
healthcare. For many involved in community pharmacy, this paradigm change
has been long overdue, in that pharmacists have been a much underutilized
resource in primary healthcare.
There is a significant opportunity for community pharmacists to play an
increasingly more clinical role in the future. But for new professional services
to be considered, implemented, and funded, robust evidence for their value
must be collected [10]. New services may be evaluated from the Government
or health system perspective (often an economic perspective); from a clinician
perspective (often an assessment of clinical outcomes); or from the patient’s
perspective (often includes humanistic measures). In Australia the collection
and interpretation of this evidence has been a result of close collaboration
between community pharmacy clinicians, pharmacy practice academics/
researchers, patients and consumer groups, amongst others.
The dissemination of new professional services may also be aided by the
increased use of technology and robotic dispensing systems, which have the
potential to free up pharmacist’s time. In Australia, there is also strong
recognition and understanding by professional organisations, such as the
Pharmaceutical Society of Australia, to support pharmacy businesses and
community pharmacists delivering new professional services. The support
may include integrated business/financial planning, goal setting, staff training
and responsibilities and promotion activities. This emphasis on practice
change and the science of implementation is crucial to the success of existing
and any new services offered by community pharmacists.
REFERENCES
[1] Chen TF. Pharmacist-Led Home Medicines Review and Residential
Medication Management Review: The Australian Model. Drugs Aging.
[journal article]. 2016;33(3):199-204.
[2] Australian Institute of Health and Welfare. Australia’s Health System.
2014; Available from: http://www.aihw.gov.au/australias-health/2014/
health-system/.
[3] Australian Institute of Health and Welfare. Pharmacy workforce. 2014;
Available from: http://www.aihw.gov.au/workforce/pharmacy/.
[4] National Medicines Policy. Canberra, Australia: The Department of
Health; 6th November 2014; Available from: http://www.health.gov.au/
nationalmedicinespolicy.
[5] Basger BJ, Moles RJ, Chen TF. Development of an aggregated system
for classifying causes of drug-related problems. Ann Pharmacother.
2015 Apr;49(4):405-18.
[6] Australian Statistics on Medicines 2014. 2015; Available from:
https://www.pbs.gov.au/statistics/asm/2014/australian-statistics-on-
medicines-2014.pdf.
[7] Pharmaceutical Society of Australia. Guidelines for pharmacists
providing Residential Medication Management Review (RMMR) and
Quality Use of Medicines (QUM) services2011 24 May 2016]:
Available from: https://www.psa.org.au/download/practice-guidelines/
rmmr-and-qum-services.pdf.
[8] Australilian Government Department of Health. Tobacco key facts and
figures. 2015 [24 May 2016]; Available from: http://www.health.gov.
au/internet/main/publishing.nsf/Content/tobacco-kff.
[9] Pharmaceutical Society of Australia. Guidelines for pharmacists
providing medicines use review (MedsCheck) and diabetes medication
management (Diabetes MedsCheck) services2012.
[10] Chen TF, Hughes CM. Why have a special issue on methods used in
clinical pharmacy practice research? Int J Clin Pharm. 2016;38(3):599-
600.
Chapter 5
COMMUNITY PHARMACY IN ENGLAND
David Wright* and Vicky Abhay

Professor of Pharmacy Practice
School of Pharmacy, University of East Anglia, Norwich, UK
INTRODUCTION
The main funding sources for community pharmacy in England are
through the supply of medicines under a contract with the National Health
Service (Essential services), delivery of nationally funded patient facing
services (Advanced services), delivery of locally funded patient services
(Enhanced services), provision of private healthcare (currently limited within
England) and retail sales. The latter of which reduces year on year as the large
commercial retailers take a greater share of this market.
Essential services such as dispensing and supplying medicines had, in
previous years always constituted the majority of a community pharmacist’s
workload. In 2016 there were over 11,000 registered community pharmacies in
England supplying over one billion prescription items per year. [1] Whilst
there is a nominal patient fee for the supply of medicines in England, 90% of
prescription are supplied exempt from this fee and within the last ten years the
numbers of prescriptions supplied through community pharmacies has
increased by over 50%. [2]
*
PhD, BPharm(Hons). Email: d.j.wright@uea.ac.uk.
54 David Wright and Vicky Abhay
In 2005 the community pharmacist contract was changed to enable the

supply of patient facing services. [3, 4] Nationally funded advanced services
include medicine use reviews (MURs), new medicines service (NMS), stoma
appliance customisation (SAC), appliance use reviews (AUR), and flu
vaccination. [5] With no limits as to their remit there is a wide range of locally
funded enhanced services and these include domiciliary services, chlamydia
testing, emergency hormonal contraception supply, minor ailments treatment,
travel health immunizations, supervised administration, needle exchange and
smoking cessation. [6] Locally commissioned services can be commissioned
by local government which is responsible for the provision of public health
services or clinical commissioning groups which are led by primary care
physicians and consist of conglomerates of medical practices working together
to commission clinical services. This recent distinction in responsibility
between public health service provision and clinical service provision has been
helpful for community pharmacy in England as it has increased their
involvement in public health initiatives as previously the budget for public
health had been held by primary care physicians who were more likely to
provide such services themselves rather than include other healthcare
professionals.
MEDICATION REVIEW
Clinical medication review, defined as ‘a structured evaluation of a
patient’s medicines, aimed at reaching agreement with the patient about drug
therapy, optimizing the impact of medicines, and minimizing the number of
medication-related problems’ [7] by community pharmacists in England is
currently not frequently commissioned and this is probably due to a lack of
evidence to demonstrate meaningful clinical outcomes such as reduced
hospitalisation or mortality which could result from such reviews [7, 8].
A recent study in England involving national community pharmacy
companies and independents found that clinical medication review undertaken
by community pharmacists with patients prescribed four or more medicines
was associated with increased medicine adherence, reduced likelihood of falls
and quality of life. The cost per QALY, which is used by the UK government
to decide which healthcare interventions it can afford was found to range from
£11,885 to £32,466 depending on assumptions and therefore it straddled the
£20,000 to £30,000 threshold for implementation set by the National Institute
of Health and Care Excellence (NICE) [9].
Community Pharmacy in England 55
MEDICINE USE REVIEWS

Medicines use reviews (MURs), defined as ‘a patient-pharmacist
consultation to discuss the patient’s use of medicines and improve their
knowledge about their purpose’ was introduced in 2005 [4] to improve patient
adherence and reduce medicines wastage. The provision of time with the
community pharmacists also provides an opportunity for patients to discuss
any problems they may have and ask any questions that may have arisen since
their medicines were initiated. Additionally the pharmacist can use the time to
provide healthy living advice and signpost patients to relevant services.
Medicines use review may be performed by an accredited pharmacist once
a patient has received two or more medicines from a pharmacy for three
consecutive months and may be repeated on an annual basis. To be accredited
to provide MURs, community pharmacists in England had to complete an
approved training course. Unfortunately disparities in interpretation as to the
purpose of MURs led to differences in accreditation requirements with some
education providers focusing on assessment of competence for clinical review
and others on mainly ensuring that the remunerated process itself was adhered
to. This lack of clarity as to purpose was identified in a large scale survey of
community pharmacists conducted soon after MURs were introduced [10].
The initial reception of medicine use reviews was consequently mixed.
Whilst patients were found to be broadly positive regarding the provision of
MURs [11], primary care physicians were less positive due to duplication of
work which they had already performed, questioning decisions which they had
previously made with careful thought and consideration and due to
pharmacists making clinical recommendations which went beyond the original
remit of the MUR. [12] The lack of access to patient records held in medical
practices by community pharmacists in England provides a partial explanation
for recommendations which have already been implemented or considered by
the patient’s doctor and may be addressed with current government plans to
create a summary care record [13].
Whilst MURs were recognised by community pharmacists as providing an
opportunity to transform their role from the routine process of dispensing to
the provision of direct patient care, they also noted that these new roles were
in addition to the current service delivery and therefore increased pressure
within the current working environment [10, 14]. Lack of collaboration
between community pharmacists and general practitioners in the delivery of
MURs has been identified as a barrier to enhancing the perceived value of
MURs [15]. Additionally in 2015 the UK government responded to the
previously identified lack of competence of community pharmacists in

providing patient consultations [16] and sent out a national training pack to all
pharmacists in an attempt to address this [17].
One of the benefits of the introduction of MURS for community
pharmacies was the requirement for pharmacy premises to meet certain
national standards to ensure that a conversation may occur between a
pharmacist and their patient in a private and confidential environment. In 2013
it was reported that over 90% of community pharmacies had a consultation
room and this was used for the delivery of many advanced and enhanced
services. [18].
Research published in 2016 has shown that patients in England who have
received an MUR when compared with patient who had not received an MUR,
were more likely to be satisfied with information about their medicines and to
report greater adherence [19]. To date however no trials have been undertaken
in England to demonstrate the cost-effectiveness of MURs.
In April 2015 the government announced that in order to maximise the
outcomes from the 400 MURs which each pharmacy premises is remunerated
to provide each year, 70% were to be targeted to patients prescribed high risk
medicine(s) (NSAIDS, anticoagulants and diuretics), patients recently
discharged from hospital who had changes made to their medicine(s) while
they were in hospital and those with respiratory conditions such as asthma and
COPD, patients at risk of or diagnosed with cardiovascular disease and
regularly being prescribed at least four medicines.
PRESCRIPTION INTERVENTION MUR

If a significant adherence problem is identified at any point during the
dispensing process and a patient is prescribed one or more medications, a
prescription intervention MUR may be performed by community pharmacists
in England. Whilst in essence this is an MUR and the community pharmacist
still has to provide a consultation with the patient and complete the same
paperwork, they can perform these on patients who have not received their
medicines from the community pharmacy in the last three months
They can be used for patients who are not within the target population but
cannot be used purely for dose optimisation or synchronisation purposes. An
example of a prescription intervention MUR may be for a visiting patient who
admits to non-adherence to their medicines when receiving counseling from
the pharmacist on their medicine.
HOME MEDICATION REVIEW

Medicine use reviews can be performed by community pharmacists for
housebound patients, if they believe that they would benefit from an MUR
providing they have permission from their local health authority to perform
this off-premises. In practice home MURs are not performed as the relatively
small amount of remuneration received (£28 in 2016) does not warrant the
amount of time taken to travel or the problems created by not having a
pharmacist on the premise to authorise the supply of prescription and
pharmacy only medicines.
Domiciliary visiting services are locally commissioned in England and
these consist of counselling on prescribed medicine, compliance review,
provision of multi-compartment compliance aids, prescription review, and
response to patient queries. In 2008 almost 30% of local primary care
organisations who responded to the survey had commissioned a domiciliary
visiting service by community pharmacists with two thirds of those still in
operation [20].
In 2005 a definitive randomised controlled trial of pharmacists visiting
patients at home in England post hospital discharge found that patients who
had been visited by a pharmacist were more likely to be re-hospitalised [21]
and such a service was highly unlikely to be cost-effective [22]. Consequently
with evidence which was described as counterintuitive it has been difficult to
build an effective argument for such services in England.
NEW MEDICINES SERVICE

Although not a conventional home medication review, a New Medicines
Service was introduced in England as an advanced nationally funded service in
2011 [23]. The service, which is designed to help improve medicines
adherence, is focused on patients who have been newly prescribed treatment
for asthma, COPD, type 2 diabetes, antiplatelet/anticoagulant therapy and
treatment for hypertension [24].
Once a new prescription for a relevant condition is identified the
pharmacist offers to provide medicines related advice to the patient at the point
of supply and again within seven to fourteen days post initiation. The content
of the consultation is prescribed within the service specification and is based
on underpinning health behaviour theory. The follow up consultation, the
content of which is also prescribed, is then undertaken face to face in the

pharmacy or over the telephone at the patient’s home or other location
convenient to themselves.
The NMS was based on a study where two trained pharmacists provided a
theory based telephone intervention to patients newly prescribed treatments for
a chronic condition which was shown to be cost-effective. [25] Following
similar rigorous testing the New Medicine Service was shown to provide a
10% improvement in self-reported adherence over usual care. [26] Whilst GPs
were found to be more receptive to the NMS, the same inter-professional
barriers to effective implementation were identified with the NMS as with
MURs [27].
IMMUNISATIONS
In 2015 the government made the supply of influenza vaccination through
community pharmacies a nationally funded service. Community pharmacies
provide influenza vaccinations to the general public who are considered at
higher risk of contracting influenza or putting those in their care at risk of
contracting the disease and this includes: people aged 65 years and over
(including those becoming age 65 years by 31 March 2016), pregnant women,
and people living in long-stay residential care homes or other long-stay care
facilities.
The provision of influenza vaccinations through community pharmacies in
England has been shown to increase uptake, [28] to increase choice for
patients and to be provided at lower cost than via the traditional route [29].
Unsurprising primary care physicians who traditionally provided the majority
of vaccinations and were remunerated accordingly were less positive about
community pharmacies undertaking this role [29].
SMOKING CESSATION
NHS England first introduced the stop smoking service in 2000 and is one
of the most frequently commissioned enhanced pharmacy services [30]. The
service is divided into two parts with the first, smoking advice cessation
advice element, free to all patients and the second, the provision of nicotine
replacement therapy (NRT), paid for by the patient if they already pay for their
prescribed medicines.
During the consultation patients agree a ‘quit date’ with their adviser, have
their carbon monoxide levels taken and are asked to attend at least two more
consultations with their adviser four weeks and twelve weeks after their last
cigarette.
Pharmacies are compensated for their time, both the provision of products
(patches, sublingual sprays, lozenges, inhalators, Varenicline, Bupropion etc.)
and if a patient is deemed a successful ‘quitter.’
Training is provided free by the local authority and may be undertaken by
any member of the pharmacy team. The NCSCT (National Centre for Smoking
Cessation Training) supports the delivery of the service through training and
assessments of all members of the healthcare professional team and also has a
list of all smoking cessation certified practitioners.
Researchers in the UK have repeatedly demonstrated the effectiveness of
community pharmacy led smoking cessation services [31].
DIABETES
Whilst researchers in England have identified what patients with diabetes
may want from their community pharmacist, [19] have demonstrated that
community pharmacists can effectively screen for type II diabetes [32, 33] and
bespoke services provided by community pharmacists to educate such patients
have demonstrated clinically important reductions in HBA1C, [34] services for
patients with diabetes are not commonly commissioned in England.
HYPERTENSION
Similarly, whilst a role for community pharmacists in supporting primary
care physicians in the management of hypertension has been identified in
England, [35] this service is not frequently commissioned.
POINT-OF-CARE TESTING
With free access to primary care physicians in the UK and testing
provided for free through the National Health Service (NHS) there is a limited
market for point of care tests to be provided by community pharmacists in
England. Individual companies have chosen to provide blood pressure and
diabetes tests for free [36, 37] however the business model underpinning such
decisions is unknown.
Allergy testing has been reported to be provided by a large number of
community pharmacies, [38] largely because this is not routinely provided
under the national health system and more recently a trial to determine
whether coeliac disease can be detected through community pharmacies has
been completed.
OTHERS (ALCOHOL, WEIGHT, PRESCRIBER ETC.)
Brief Alcohol Interventions
Within recent years in England the role of the community pharmacist in

making brief alcohol interventions has been explored. The importance of
privacy for such interventions in community pharmacies has been identified
[39] and researchers via randomised controlled trial have shown no long term
benefits from brief interventions undertaken in this environment. [40] A recent
systematic review identified the need for more research and evidence for brief
alcohol interventions in community pharmacies before they can be adopted.
[41]
Health Checks
The NHS health check service was introduced free of charge in 2009 for
all patients who meet the eligibility criteria (i.e., are between 40 & 74 years of
age, not pregnant, have not received another NHS health check within five
years and have not been pre-diagnosed with medical conditions such as
hypertension and diabetes). Community pharmacy was identified as one
potential provider for this service.
As a locally commissioned enhanced service an NHS health check can be

performed by any trained member of the pharmacy team and takes around
twenty to thirty minutes. It involves an initial weight and height measurement
to calculate the patient’s BMI, a validated blood pressure check, a cholesterol
check and, if deemed necessary, a blood glucose check. A family history is
taken, alongside a patient’s response to certain lifestyle questions. The
pharmacist then talks through the results with the patient, giving them an idea
of where their results lie as compared with targets using Cates plots. There is
also the opportunity to provide relevant counseling and lifestyle hints and also
ensure that the patient has had all questions answered. The pharmacist is
expected to support the patient to identify strategies for reducing blood
pressure, cholesterol and BMI and where appropriate signpost the patient to
their primary care physician.
Research has shown that health checks by community pharmacists
identify the appropriate patients and that patients were positive regarding
receiving this service through this environment [42].
Pharmacist Prescribing
With legislation introduced in both 2003 and 2006 in the UK to allow

pharmacists with accredited additional training to prescribe medicines in the
same manner as doctors [43] there has been limited uptake by community
pharmacists. Whilst there is now evidence to support the use of pharmacist
prescribers for the management of chronic conditions in England [44] the
predominant reason for lack of uptake is the need to access an NHS
prescribing budget which are held by medical practices. With community
pharmacist income partially dependent on the difference in the purchase price
of a medicine and the national tariff price there is a recognised conflict of
interest in being both a prescriber and supplier.
THE FUTURE
In 2016 the UK government decided that it wanted to dramatically change
community pharmacy in England. Within the availability of large scale
dispensing robots and electronic transfer of prescriptions it believes that the
majority of repeat prescriptions, which account for over 80% of all
prescriptions, can be dispensed in centralised supply hubs [45]. Whilst the
dispensed products can still be supplied through community pharmacies, the

government believes that community pharmacy premises and staff can be
better used for the provision of clinical services which are integrated with
those services already provided in primary care. It also believes that the
network of community pharmacies requires rationalisation to ensure that
services are only provided where required and local over provision should be
addressed. A separate fund had been announced to support the testing and
evaluation of new integrated community pharmacy based services.
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contract issued by the Secretary of State for Health. This issue may be
freely reproduced for the purposes of private research and study and
extracts (or indeed, the full report) may be included in professional
journals provided that suitable acknowledgement is made and the
reproduction is not associated with any form of advertising.
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NIHR Journals Library, National Institute for Health Research,
Evaluation, Trials and Studies Coordinating Centre, Alpha House,
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UK.; 2016.
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SUMMARY: ROLE OF COMMUNITY
PHARMACY ACROSS FIVE COUNTRIES

and Kazuhiko Kotani2, MD, PhD
1
2Division of Community and Family Medicine,
Jichi Medical University, Japan
In the not too distant future, the governments of developed countries will
find it impossible to cover medical costs without changing the existing system
due to the aging society. As a solution to this problem, some developed
countries take advantage of community pharmacists to educate their citizens.
The role of the community pharmacist has been expanding in recent years,
especially in Western countries. In this book, we demonstrate and introduce
the roles of the community pharmacist by focusing on each country’s experts.

68 Hiroshi Okada and Kazuhiko Kotani
JAPAN
Due to the growing aging society, the government provides incentives to
pharmacies if they perform domicile services in their community. Most of
their responsibilities are essential services such as dispensing and supplying
medicines. The government provides incentives to pharmacies if they perform
domiciliary services in their community. Recently, the government launched a
new policy called “family pharmacy/pharmacist.”
USA
There are quality and cost effective care services provided by pharmacists
in USA such as Medication Therapy Management (MTM), immunizations,
collaborative practice agreements, and Point-of-Care (POC) testing.
Pharmacists deliver clinical services such as immunizations or smoking
cessation in 36 states. In 21 states, these services require written service
protocols to be submitted by the boards of pharmacy or medicine. Currently,
all 50 states allow pharmacists to administer vaccinations.
CANADA
Community pharmacists play diverse roles for public health in Canada and
are very different between the 10 provinces and 3 territories. Influenza
vaccination by pharmacists is permitted in most areas. Smoking cessation
services are implemented by four provinces. Prevention and screening of life
style diseases such as diabetes or hypertension are also considered part of the
pharmacists’ job in Canada. In addition, they participate in patient counseling
and education about health and life-style in the pharmacies.
AUSTRALIA
Australia has two unique programs by pharmacists called Home
Medicines Review and Residential Medication Management Review. The
Home Medicines Review started in 2001 in order to identify and resolve drug-
related problems. This program is delivered by accredited pharmacists in
Summary 69
collaboration with the patients’ general practitioners. The skills of Home

Medicine Review required by the pharmacist can be compared to the
Medication Therapy Management in the USA or Clinical Medication Review
in the UK. “Diabetes Meds Check” is a medication use review service
provided by community pharmacists for patients with diabetes. This service
includes an interview with the patients about medicines, medication
adherence, provide written information, and resolve drug-related problems.
ENGLAND
There are many pharmaceutical services for patients in England similar to
that of other Commonwealth Nations such as vaccination and medication
reviews. There is a wide range of locally funded services, and these include
domiciliary services, chlamydia testing, emergency hormonal contraception
supply, minor ailments treatment, travel health immunizations, supervised
administration, needle exchange and smoking cessation. Smoking cession was
introduced by the NHS (National Health Services) in 2000. Influenza
vaccination started in community pharmacies as a nationally funded service in
2015. Brief alcohol intervention has begun in England.
In summary, the role of community pharmacy in Japan is distinctly

different from the other representative countries. As this role of community
pharmacy changes and improves, further research will be expected.
APPENDIX – SPECIAL MESSAGE:
COMMUNITY PHARMACY PRACTICE
IN FIVE COUNTRIES
Denise A. Epp
The world is becoming a smaller place, thanks to technology and travel,

but is “global pharmacy” with a common standard in pharmaceutical patient
care really attainable? A comparison of pharmacy practice observed in five
countries to the “Developing pharmacy practice: A focus on patient care”
handbook provided a guideline of how pharmacy practice is developing
around the world. It is undeniable that culture, language, and history affect
pharmacy practice in every country, along with the rate of progress there.
Traveling to these five countries in 2015 was a glimpse into each country’s
unique pharmacy culture and the rate of change in the transition to greater
patient care.
The starting point with this research project was Japanese pharmacy
practice, which could be considered unique because of the slow pace of
change in practice. Many Japanese pharmacists believe that the role of the
pharmacist will eventually change in Japan, following the global trend to
clinical patient-care focus rather than only dispensing, but they continue to
follow the conservative practice they were taught. Specific areas within Japan
focus on developing patient care practice and researching how this can be done
effectively, but the overall tendency seems to remain in the safety of the
pharmacist behind the counter compounding and filling prescriptions. Every
year, the government grants permission for specific pharmacy patient care
72 Denise A. Epp
services, but they are heavily laden with guidelines and instructions. As a
result, many pharmacies across the country remain indifferent to these
changes, although there are some prefectures that are finding ways to expand
their practice. Perhaps the biggest contradiction is that the history of traditional
Japanese medicine (kampo) has always been based on meeting individual
patient’s needs (the basis of patient-centered care).
Our first research trip was to North America in spring of 2015. These
countries have moved relatively quickly towards patient care from a
dispensing-only role for pharmacists. In Canada, several pharmacists
expressed individual ways of reaching out to their patients. One pharmacist
produced a series of pamphlets that not only provided necessary information to
the patient, but also included a section that could be filed in the pharmacy for
future reference when providing care. Another pharmacist focused on the East
Asian culture of his community, educating patients in how to combine
religion, health, and culture for greater quality of life in Canada. The
outpatient pharmacy in the university hospital focused on the needs of the
patients with specific health issues of chronic and life-threatening conditions,
and provided care that extended to the greater geographical area by using
buses to transport medications to rural areas and technology to maintain
regular communication with the patients. As with the American pharmacists,
they were actively involved in research, looking for ways to be more effective
in their patient care.
In the United States, we found it intriguing that the pharmacists were
united about patient care, regardless of being a new graduate or a pharmacist
with years of experience. They all expressed the mutual belief that that the role
of a pharmacist was to serve the patient with education and support to improve
health and quality of life through their pharmacy practice. It seemed that
regardless of remuneration, these pharmacists were focused on improving
health for their patients through physical assessment, counseling,
immunization, testing, and other pharmacy services. The transformation of the
role of pharmacist has been aided in these two countries by the assistance of
technicians, freeing up the pharmacist to do more than dispensing. The
transition of change in North America appears to be on the opposite end of the
scale to Japan, moving quickly towards greater prescribing and even
diagnosing, as the role of the pharmacist expands.
Scotland, England, and Australia were put in the middle of this transition
scale. These countries appear to be moving to greater patient care at a steady
pace with the support of the pharmacist society and government interventions.
What stood out with these countries was the strong desire by pharmacists to
Appendix 73
see greater change in pharmacy practice, but frustration with the hindrances to
change in the health care systems. In Scotland, where there is free universal
healthcare, they face issues regarding the relatively easy access to prescriptive
medicines and the consequences such as drug addiction, for example. Despite
their concerns and frustrations, they remain dedicated to helping patients. We
visited a pharmacy, which provided regular dispensing of methadone, free
needle exchange, smoking cessation services, and provision of some random
prescriptions like shampoo (since all prescriptions are covered under the
national health care). Another pharmacy was involved with medication
reviews in welfare and low-income areas, and leaving the pharmacy to assist
with patient care.
In England, we visited the Royal Society and learned about the
developments of pharmacy practice from an administrative angle. There is
strong government control with prescriptions and pharmacy services that guide
healthcare. Independent prescribing and primary care pharmacy in
collaboration with physicians is moving the role of pharmacy beyond
dispensing only. In Australia, there seemed to be a challenge to the system and
a desire to improve the future of pharmacy practice. The pharmacists were
conflicted between their desire to make changes for patient care and health
policies that had been implemented by the government. Despite the various
barriers, there was a distinct change towards patient care.
Global pharmacy, as observed in these five countries, is moving at
different paces, but definitely gaining momentum towards greater patient care.
REFERENCES
Wiedenmayer, K., Summers, R. S., Mackie, C. A., Gous, A. G. S., Everard,
M., & Tromp, D. 2006. Developing pharmacy practice: A focus on patient
care [handbook]. Netherlands: World Health Organization and
International Pharmaceutical Federation. Available from: http://www.fip.
org/files/fip/publications/DevelopingPharmacyPractice/DevelopingPharm
acyPracticeEN.pdf.
CONTRIBUTORS
Kazuhiko Kotani, MD, PhD

Division of Community and Family Medicine, Jichi Medical University,
Japan
Email: kazukotani@jichi.ac.jp
Hiroshi Okada, B.Ed, MS

Department of Preventive Medicine, Clinical Research Institute for
Endocrine and Metabolic Disease, National Hospital Organization Kyoto
Medical Center, Japan
Email: okada.hiroshi.28z@kyoto-u.jp
Mitsuko Onda, MS, PhD

Associate Professor of Clinical Laboratory of Practical Pharmacy, Osaka
University of Pharmaceutical Sciences, Japan
Email: onda@gly.oups.ac.jp
Khalid M. Kamal, M.Pharm, Ph.D

Associate Professor of Pharmacy Administration
Division of Clinical, Social and Administrative Sciences, Duquesne
University Mylan School of Pharmacy
Email:kamalk@duq.edu
Ross T. Tsuyuki, BSc(Pharm), PharmD, MSc

Professor of Medicine, University of Alberta, Canada
Email: ross.tsuyuki@ualberta.ca
76 Hiroshi Okada and Kazuhiko Kotani
Yazid N. Al Hamarneh, BScPharm, PhD

University of Alberta, Canada
Email: alhamarn@ualberta.ca
Timothy F Chen, PhD

Associate Professor, Faculty of Pharmacy, The University of Sydney,
Australia
Email: timothy.chen@sydney.edu.au
David Wright, PhD, BPharm(Hons)

Professor of Pharmacy Practice
Email: d.j.wright@uea.ac.uk Phone: +441603 592042
Vicky Abhay, MPharm

School of Pharmacy, University of East Anglia
Denise A. Epp, BEd, MSEd

Senior Assistant Professor, Daiichi University of Pharmacy, Japan
Email: depp@daiichi-cps.ac.jp
INDEX
arthritis, 49
A assessment, 12, 28, 30, 33, 49, 50, 55, 72
assets, 34, 36
abuse, 42
asthma, 56, 57
access, 8, 11, 13, 14, 32, 35, 41, 47, 55, 60,
attachment, 66
61, 73
attitudes, 63
accessibility, 18
Australia, v, 18, 20, 39, 40, 41, 42, 43, 44,
accounting, 17, 43
45, 46, 48, 50, 51, 68, 72, 73, 76
accreditation, 55
Australian Association of Consultant
acid, 44
Pharmacy, 40, 41, 45
acne, 32
authority, 26, 31, 42, 57, 59
ADA, 15
avoidance, 19
adaptation, 32, 33
awareness, 49
administrators, 19
adolescents, 23
adults, 13, 14, 16, 17, 48 B
adverse event, 19
advocacy, 31 barriers, 13, 58, 73
aerobic exercise, 7 behaviors, 15
age, vii, 14, 15, 17, 58, 60 benefits, 18, 30, 33, 56, 60
ageing population, 19 biomarkers, 18
aging society, 1, 67 blindness, 15
agonist, 48 blood, 12, 14, 15, 22, 23, 30, 31, 36, 49, 60,
alcohol interventions, 60, 65 61, 65
allergic rhinitis, 32 blood pressure, 14, 22, 23, 31, 49, 60, 61
allergy, 43 BMI, 61
alternative medicine, 43 bowel, 49
ambivalence, 18 breastfeeding, 49
angiotensin receptor blockers, 16 bronchospasm, 48
anticoagulant, 57 business model, 60
anticoagulation, 19, 21 businesses, 50
78 Index
communication, 7, 45, 72
C community, viii, ix, xi, 1, 2, 5, 6, 7, 9, 12,
14, 25, 26, 30, 34, 35, 36, 39, 40, 41, 42,
Cabinet, 8
43, 44, 46, 47, 48, 50, 53, 54, 55, 56, 57,
calcium, 16
58, 59, 60, 61, 63, 64, 65, 66, 67, 68, 69,
cancer, 17, 41
72
candidates, 19
community pharmacy agreements, 40, 50
candidiasis, 47
compliance, 29, 57
carbohydrate, 15
complications, 13, 15
carbon, 59
computer, 4
carbon monoxide, 59
conduction, viii
cardiovascular disease, 56, 65
confidentiality, 12
cardiovascular risk, 33
conflict, 61
care model, viii, 16
conflict of interest, 61
caregivers, ix
consensus, 19
catalyst, 44
consumers, 40, 43, 45, 50
CDC, 12, 14, 17
consumption, 15, 30
CDM, 35
contraceptives, 49
central nervous system, 5
contradiction, 72
certificate, 14, 18
coordination, 17
certification, 14, 21, 26, 30, 45
COPD, 17, 56, 57
challenges, 14, 19
coronary heart disease, 16
channel blocker, 16
cost, 11, 12, 13, 14, 18, 19, 20, 21, 22, 41,
chemicals, 42
43, 44, 54, 56, 57, 58, 62, 64, 67
childhood, 21
cost effectiveness, 64
children, 13, 14
cost saving, 12, 19, 20
chlamydia, 54, 68
counseling, 18, 19, 30, 31, 48, 56, 61, 68, 72
cholesterol, 7, 12, 15, 33, 49, 61
covering, 5
chronic diseases, vii, 16
critical value, viii
chronic kidney disease, 32, 36
culture, 71, 72
chronic obstructive pulmonary disease, 17
cigarette smoking, 17, 48
cities, xi D
citizens, 67
clarity, 55 deaths, 17, 62
classification, 22, 42, 43 dementia, ix
CLIA, 12 Department of Health and Human Services,
clinical interventions, 43, 44 24
cocaine, 42 dermatitis, 32, 49
cognition, 45 detection, 16, 22
cold sore, 47 developed countries, vii, 1, 67
colic, 49 diabetes, viii, ix, 6, 9, 12, 14, 15, 16, 17, 19,
collaboration, 8, 19, 20, 44, 45, 50, 55, 68, 22, 28, 30, 31, 32, 33, 36, 48, 49, 51, 57,
73 59, 60, 64, 65, 68
commercial, 53, 65 diarrhea, 49
common ambulatory conditions, 32, 33 diseases, vii, 12, 13, 23, 41, 68
Index 79
disorder, 49
distribution, vii
F
doctors, 61
face-to-face interaction, 20
DOI, 35
family history, 61
dosage, 4, 5, 26, 32, 33
family physician, 8
dose administration aids, 44, 46, 47
fat, 15
drug addict, 73
federal law, 12
drug addiction, 73
fever, 49
drug interaction, 4, 20, 43
fiber, 15
drug reactions, 29
financial, 1, 30, 50
drug therapy, ix, 16, 26, 28, 29, 30, 34, 54
financial planning, 50
drugs, 2, 4, 5, 26
financial resources, 1
dry eyes, 49
fish, 15
DSM, 15
flexibility, 49
dyslipidemia, 32
funding, 53
dysmenorrhea, 32
E G
gangrene, 15
East Asia, 72
general practitioner, 44, 45, 46, 55, 68
economic evaluation, 18
generic drugs, 2
economics, 23
gerontology, viii
education, viii, 2, 15, 26, 30, 31, 32, 34, 36,
glucose, 12, 14, 15, 30, 36, 49, 61
46, 55, 65, 68, 72
goal attainment, 13
educators, 6, 30
goal setting, 50
eligibility criteria, 60
government intervention, 72
emergency, 8, 19, 26, 29, 34, 48, 54, 68
governments, 67
energy, 15
grants, 71
enforcement, ix
guidance, 4
England, v, 53, 54, 55, 56, 57, 58, 59, 60,
guidelines, 16, 18, 23, 31, 40, 51, 72
61, 62, 63, 64, 65, 66, 68, 72, 73
enhanced service, 54, 56, 61
environment, 55, 56, 60, 61 H
enzyme, 16
enzyme inhibitors, 16 hazardous waste, 12
equipment, 12 health, vii, viii, ix, 1, 2, 4, 6, 7, 11, 12, 13,
evidence, ix, 15, 17, 19, 30, 31, 34, 43, 50, 17, 18, 23, 24, 25, 26, 28, 33, 34, 39, 40,
54, 57, 60, 61 47, 48, 49, 50, 51, 54, 57, 60, 61, 64, 65,
examinations, viii 68, 69, 72, 73
exercise, 16 health care, vii, 11, 64, 73
exercises, 49 health care system, vii, 11, 73
expenditures, 16, 23 health checks, 61
expertise, 39, 50 health condition, 48
extracts, 65 health expenditure, 23
health information, ix
80 Index
health insurance, 1, 2, 6, 13 inhaler, 18

health promotion, 47 initiation, 57
health services, ix injection, 26, 29, 35
health status, 28 insulin, 14
heart attack, 49 intervention, 6, 7, 9, 17, 18, 30, 31, 33, 36,
heart disease, 15, 17 56, 58, 69
heart failure, ix, 16 intravenously, 29
heartburn, 48 investment, 19
height, 61 issues, vii, 6, 15, 34, 72, 73
hemoglobin, 12, 15
hemorrhoids, 32
hepatitis, 12, 13, 20 J
herpes, 47, 49
Japan, v, vii, viii, ix, 1, 2, 4, 5, 6, 7, 8, 9, 45,
herpes labialis, 47
67, 69, 71, 72, 75, 76
high blood pressure, 16, 17, 22
jurisdiction, 26, 28
high-risk populations, 13
justification, 19
history, 4, 45, 71, 72
HIV, 12, 49
HIV/AIDS, 49 K
home medication review, 34, 57
home medicines review, 19, 39, 41, 44, 45, kidney, 7, 15, 16
46, 51, 68 kidney failure, 15, 16
home visiting service, 4, 5 kill, 48
homes, 5, 58
hospitalization, 18
House, 65 L
hub, viii, ix
humanistic perspective, 34 laboratory tests, 31
Hunter, 24 laws, 2, 21
hyperlipidemia, 19 LDL, 13, 33
hypertension, 7, 15, 16, 19, 22, 23, 31, 33, lead, 3, 5, 21
36, 37, 57, 59, 60, 65, 68 leadership, 37
legislation, 11, 26, 61
lens, 49
I lice, 49
lifestyle changes, 15, 20
ibuprofen, 42 light, 5
identification, 28 liver, 12
immunization, 6, 13, 14, 21, 22, 28, 35, 72 liver function tests, 12
incidence, 14 local government, 54
income, 61, 73 long-term care insurance, 2, 4
individuals, 15, 16, 17, 30, 41 lung disease, 17
industry, 41
infection, 49
influenza, 22, 29, 35, 58, 64
influenza vaccine, 35
Index 81
nausea, 48
M negotiating, 40
Netherlands, 73
majority, 18, 42, 53, 58, 61
New Zealand, 18
management, ix, 2, 4, 6, 7, 11, 13, 15, 16,
NHS, 58, 60, 61, 66, 69
19, 20, 21, 23, 24, 30, 31, 33, 34, 37, 39,
nicotine, 6, 18, 48, 58
40, 41, 44, 46, 47, 49, 51, 59, 61, 65, 66
North America, 72
materials, 4, 48, 49
NRT, 59
measurement, 30, 31, 61
nursing, ix, 46
Medicaid, 12
nursing home, ix, 46
medical, vii, viii, ix, 2, 4, 5, 6, 15, 16, 20,
24, 42, 44, 54, 55, 60, 61, 67
medical care, viii, 4, 15 O
Medicare, 12, 19, 24
Medicare Modernization Act, 19 obesity, 48
medication, ix, 2, 4, 6, 7, 8, 11, 13, 15, 17, obstacles, 13
18, 19, 20, 21, 24, 28, 29, 33, 34, 37, 40, opportunities, 13, 20, 23
41, 44, 45, 46, 47, 48, 51, 54, 57, 62, 63, outpatient, 12, 13, 72
64, 68, 73 ovulation, 49
medication review, 2, 18, 24, 28, 29, 33, 34,
41, 45, 46, 54, 57, 62, 63, 64, 68, 73
medicine, viii, 2, 4, 7, 21, 41, 43, 44, 45, 46, P
49, 54, 55, 56, 57, 61, 63, 65, 68, 72
medicine use review, 54, 55, 57, 63 pain, 13, 49, 66
mellitus, 22 pap smear, 49
mental health, 41 participants, 17
messages, viii pathology, 13
meta-analysis, ix, 18, 24, 62 patient care, viii, 20, 37, 55, 71, 72, 73
metabolic, 1, 75 permit, 8, 29, 32, 42
metabolic disorder, 14 pharmaceutical, viii, ix, 39, 68, 71
metabolism, 7 pharmaceutical benefits scheme, 41
methadone, 42, 73 Pharmaceutical Society of Australia, 40, 41,
modifications, 16 48, 49, 50, 51
momentum, 73 pharmacology, 62
morbidity, 15 pharmacotherapy, 19, 39, 45, 46, 50
morphine, 42 Pharmacy Guild of Australia, 40, 41, 50
mortality, 54 physical environment, 12
motivation, 9 physicians, viii, 2, 7, 11, 14, 34, 54, 55, 58,
muscle strain, 32 59, 60, 73
pilot study, 36
PMDA, 7, 9
N point-of-care testing, 7, 21
policy, 2, 8, 27, 39, 41, 67
national community, 54 policymakers, 17
National Health Service, 53, 60, 69 population, vii, 1, 4, 17, 19, 29
national policy, 4 positive regard, 55, 61
82 Index
potential benefits, 19 resources, viii, 12, 34, 36

pregnancy, 14 response, 45, 47, 57, 61
prescribing, 2, 28, 30, 31, 32, 33, 36, 37, 61, retail, 11, 53
72, 73 revenue, 12
prescription drugs, 2, 7 risk, 15, 16, 19, 20, 33, 45, 56, 58, 64, 65
president, xi risk assessment, 64
prevention, 12, 13, 16, 22 risk factors, 65
principles, 24 routes, 29
problem solving, 15 Royal Society, 73
professional development, 34, 40, 41 rural areas, 72
professionalism, 14
professionals, ix, 2, 5, 11, 13, 23, 43, 48, 50,
54 S
profit, 3
safety, 13, 19, 20, 41, 42, 64, 71
project, xi, 6, 9, 29, 34, 35, 71
saturated fat, 15
proton pump inhibitors, 48
school, 18
PSA, 40
science, 50, 63, 64
public health, viii, 14, 19, 23, 42, 54, 63, 64,
scope, 25, 27, 34, 42, 48
65, 66, 68
self-monitoring, 36
publishing, xi, 51
service provider, 46
services, viii, 2, 4, 11, 12, 13, 14, 17, 18, 19,
Q 20, 21, 24, 25, 28, 29, 30, 31, 33, 34, 35,
37, 39, 40, 41, 44, 46, 47, 50, 51, 53, 54,
quality of life, vii, 4, 15, 19, 54, 72 55, 57, 58, 59, 62, 64, 67, 68, 72, 73
questioning, 55 signs, 49
SKD, 35, 36, 37
skin, 32
R smoking, viii, 6, 9, 11, 16, 17, 18, 23, 26,
30, 33, 35, 48, 54, 58, 59, 65, 68, 69, 73
rash, 49
smoking cessation, viii, 6, 9, 11, 17, 18, 23,
rate of change, 71
30, 33, 35, 48, 54, 59, 68, 69, 73
rationalisation, 62
society, vii, viii, 9, 13, 72
reception, 55
Society of Hospital Pharmacists of
recognition, 14, 17, 50
Australia, 40, 45
regulations, 12, 14, 25, 26
sodium, 15
relief, 48, 49
solution, 67
religion, 72
specialists, 18
repatriation pharmaceutical benefits
spending, 5
scheme, 41
sphygmomanometer, 7
reproduction, 65
sprains, 32
requirement, 7, 14, 26, 55, 56
staff members, 46
researchers, viii, 17, 43, 50, 59, 60
staffing, 13
residential, 39, 41, 44, 46, 51, 68
stakeholders, ix, 19, 45, 65
residential medication management review,
state, 11, 12, 14, 22
39, 41, 44, 46, 51, 68
state laws, 14, 22
Index 83
states, vii, 11, 14, 68

steroids, 32
U
stoma, 54
United Kingdom, 18, 45
stress, 49
United States (USA), v, 11, 18, 21, 22, 45,
stroke, 15, 16, 17
67, 68, 72
supplier, 61
universities, 6
surveillance, 19, 36
urine, 49
symptoms, 15, 16, 45, 48
US Department of Health and Human
syndrome, 49
Services, 23
systolic blood pressure, 33
T V
vaccinations, 14, 29, 35, 58, 68

target, 5, 13, 33, 56
vaccine, 13, 26
target population, 56
venipuncture, 13
tariff, 61
virus infection, 20
technician, 26
vision, ix, 34, 40, 45
technology, 41, 50, 71, 72
telephone, 19, 58, 64
testing, 7, 11, 12, 20, 21, 30, 31, 32, 36, 54, W
58, 60, 62, 65, 67, 68, 72
therapy, 9, 11, 13, 17, 20, 24, 29, 47, 49, 57, weight loss, 15
59 weight management, 65
thiazide, 16 welfare, 5, 73
thrush, 32 wellness, 19
tobacco, 9, 17, 18, 23, 26, 30, 51 Western countries, 2, 7, 67
total costs, 43 workflow, 14
training, 6, 12, 20, 21, 26, 50, 55, 56, 59, 61 workforce, 40, 51
transformation, 72 workload, 53
transport, 72 World Health Organization, 73
treatment, 12, 15, 16, 18, 22, 29, 32, 36, 47, World War I, 2
54, 57, 69 worldwide, 14, 16
trial, 7, 9, 21, 31, 33, 36, 37, 57, 60, 63, 64,
65, 66
type 2 diabetes, ix, 9, 30, 33, 57, 64

(Public Health in The 21st Century Series) Kazuhiko Kotani (Editor) - Hiroshi Okada (Editor) - Community Pharmacy - An International Comparison (2016)

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PUBLIC HEALTH IN THE 21ST CENTURY

Additional books in this series can be found on Nova’s website

Additional e-books in this series can be found on Nova’s website

NOTICE TO THE READER

Library of Congress Cataloging-in-Publication Data

ISBN:  H%RRN

Library of Congress Control Number: 2016953548

Published by Nova Science Publishers, Inc. † New York

Preface Expectations of community pharmacies

EXPECTATIONS OF COMMUNITY PHARMACIES AS

Hiroshi Okada1,, BEd, MS,

Jichi Medical University, Japan

The Current Socio-Medical State of Japan

The Importance of Reformation of Community Care

The Highlight to Community Pharmacies

pharmacists, physicians, public health practitioners, students and researchers

I would like to give acknowledgement to Dr. Naoki Sakane of the Kyoto

COMMUNITY PHARMACY IN JAPAN

Hiroshi Okada1,, BEd, MS,

Figure 1. Changes in the Number of Pharmacists.

Figure 2. Bungyo Ratio.

A unique feature in Japanese pharmacy is the medication memo book or

HOME VISITING SERVICE BY PHARMACISTS

1. Supply medicines to the patient’s home (which is mainly dispensing

9. Sharing of patient information among medical and welfare

According to the authors’ study, currently in Japan, approximately 30% of

1. PIMs were prescribed to 48.4% of subjects.

The outcomes of the home visiting service by pharmacists were as follows

1. 29.8% of the patients had improvement in adherence.

The results above show that a higher involvement in homecare by

Immunization in pharmacy is not permitted in Japan. It is one of the most

According to an intervention study in community pharmacies, there is no

Many of pharmacies in Japan provide free use of an automated

Point-Of-Care Testing (POCT)

The Japanese government changed the law for clinical testing in

Prescriptions with Clinical Test Results

In 2015, the Pharmaceuticals and Medical Devices Agency (PMDA)

The Family Pharmacist and Pharmacy Policy

The “family pharmacist and pharmacy” policy was launched by the

1. The family pharmacist totally manages all the prescribed medicines

This pharmacy service will permit direct monitoring of medications taken

[9] Japan Pharmaceutical Association. http://www.nichiyaku.or.jp/action/

COMMUNITY PHARMACY IN UNITED STATES

Khalid M. Kamal*, MPharm, PhD

Pharmacy or Medicine by pharmacists and physicians (in selected cases) who

assess the effectiveness of these tests. A hospital-based, outpatient pharmacist-

Pharmacy-Based Immunization Delivery program in 1996. The American

patient’s therapy, thereby positively impacting patient outcomes. Through

preparation stage, people make a commitment to quit and develop a plan to

to optimize their outcomes. There are number of services provided as part of

HOME MEDICINES REVIEW

The HMR consists of visits by a pharmacist who analyzes the patient’s

[18] Carpenter L. Pharmacist-administered immunizations: Trends in

[44] Hatah E, Braund R, Tordoff J, Dufull S. A systematic review and meta-

COMMUNITY PHARMACY IN CANADA

Ross T. Tsuyuki, PharmD

Scope of Practice 1 Province/Territory

Table 2. Publicly Funded Pharmacy Services by Province

MEDICATION REVIEWS AND HOME

POINT OF CARE AND LABORATORY TESTING

considered as an alternative when pharmacists do not have access to lab test

COMMON AMBULATORY CONDITIONS

about half permit therapeutic substitution and prescribing for common

ISBN: H%RRN