Qualitative exploration of the experiences of community pharmacists delivering the Diabetes MedsCheck service

Abstract What is known and objective The Diabetes MedsCheck (DMC) pharmacist service improves patient medication use and provides education on diabetes self‐management. The original 2012 program evaluation identified barriers and facilitators in implementation. There are no recent studies exploring pharmacists' experiences with the DMC service. This pilot study may contribute to achieving an optimal diabetes management service in Australia. To explore the experiences of community pharmacists in providing the DMC service. Methods A purposive sampling approach was used to recruit practising Australian community pharmacists from July to December 2019. Inclusion criteria included provision of DMC service for more than 1 year and having delivered the service within 3 months of recruitment. Semi‐structured interviews elicited pharmacists' experience with the DMC service. Results and discussion Twelve interviews of community pharmacist owners, managers and employees (including three who had additional medication review and diabetes qualifications), resulted in four primary themes: benefit of and need for training in diabetes management, challenges of service delivery and implementation, the challenge of patients' diabetes management and the positive effect of DMC on pharmacists' professional satisfaction from the positive impact on patient interactions and diabetes management. Pharmacists highlighted the need for continuous training on diabetes management and patient communication, and a dedicated time and space for service provision for optimal implementation and delivery of DMC. DMC helped to fulfil pharmacists' desires to provide health care. Pharmacists perceived through patient engagement and patient feedback that DMC benefits patient health care. What is new and conclusion Positively, the implementation of the DMC service has promoted engagement with other health professionals while also contributing to pharmacists' professional satisfaction. Patient satisfaction and awareness of the health knowledge that pharmacists provide promotes pharmacist capabilities to the public. To ensure that accessible diabetes care in community pharmacy is optimized for greatest patient care, pharmacists delivering DMC should be supported by provision of contemporary diabetes management training and communication skills. Additional investment in community pharmacy operational set‐up, such as dedicated pharmacist time, dedicated consulting space, upskilling of staff and investment in technology is also required to support optimal delivery of DMC.


| WHAT IS K NOWN AND OBJEC TIVE
It is estimated that 1.8 million Australians have diabetes, including up to half a million who are undiagnosed. 1 Among the many strategies designed to improve diabetes management are pharmacist-led programs. Studies of pharmacists delivering diabetes management programs demonstrate there are clinical and non-clinical benefits to people with diabetes. [2][3][4][5][6] For example, pharmacist-led diabetes management services show improvement in blood glucose levels, glycated haemoglobin (HbA1c, a measure of blood sugar control over the previous 3-4 months), systolic blood pressure, lipid profile, weight, self-care ability, understanding of diabetes management, medication adherence, quality of life and well-being, and economic outcomes. 2,4,[6][7][8] A meta-analysis of intervention outcomes suggests interdisciplinary and patient-centred interventions to be most effective in reducing HbA1c (−0.81%). 5 Consequently, in 2012, the Australian government established the community pharmacist-led Diabetes MedsCheck (DMC) service to improve the quality use of medicines and reduce adverse drug events, by helping people with diabetes understand and manage medicines. 9 The DMC service involves pharmacists providing consultations with the patient to discuss their medicines, with pharmacists providing education on medication, lifestyle and guidance on the correct use of medications and devices. Recommendations are provided to the patient which includes educational material to support medicine use in diabetes.
Pharmacists communicate any actions identified, with the patient's consent, to the patient's physician and other relevant health professionals to ensure continuity of care. The program is continuously funded through the seventh Community Pharmacy Agreement and provides funding to each pharmacy for a maximum of 20 DMC services per pharmacy per month. 10 Eligible patients are those residing in a community setting, who have not have received the service within 12 months and, who are taking either five or more medications, a high-risk medication or who have had a recent significant medical event. 10 Unfortunately, however, only a small proportion of patients with diabetes have accessed the DMC service, which may be due to various factors, such as service delivery and community pharmacy staffing and other resource limitations. 11 A 2012 initial mixed methods evaluation of DMC which involved surveying and interviewing pharmacists, patients and other stakeholders found that patients benefited from the service and that it improved the relationship between pharmacists with patients and other healthcare professionals. 12 Primary barriers in the initial 2012 review of DMC were predominantly logistical issues including the lack of patient privacy, time constraints, lack of staff and management support, distractions from other tasks, need for additional documentation and low remuneration to sustain the service cost; there were also pharmacist-related barriers such as low pharmacist knowledge on diabetes management and lack of motivation and commitment. [12][13][14] Pharmacist experience with DMC has not been recently nor independently explored.
This pilot study aimed to explore the experience of community pharmacists in providing the DMC service and to explore pharmacists' opinions about approaches to optimize delivery.

| ME THODS
The qualitative approach selected for this study was informed by grounded theory. Qualitative thematic analysis using an inductive approach was used to explore pharmacists' experience with the DMC service in community pharmacy. One to one semi-structured interviews (Online Appendix S1) were conducted. Data were audio recorded, transcribed and analysed using the thematic analysis approach described by Braun and Clarke. 15 Open-ended questions were designed to obtain an understanding of participants' experiences, perceptions, opinions, feelings, intentions and knowledge without the limitation of a list of closed questions and responses. 16 The study followed the standards for reporting qualitative research. 17 Ethics approval was obtained from the Tasmanian Human Research Ethics Committee, H0018098.

| Participants
A purposive sampling approach was used combined with snowball sampling. Community pharmacist participants were recruited through advertisement through professional pharmacy organizations and pharmacist special interest group social media pages.
Interested pharmacists were provided with the study information sheet and consent form via email. Only Australian registered community pharmacists practising in Australia, who had provided the DMC service for more than 1 year and had delivered the service at least once within the 3 months prior to being recruited were eligible to participate. The intention was to interview a sample up to 20 participants, as suggested by Green and Thorogood. 18 of contemporary diabetes management training and communication skills. Additional investment in community pharmacy operational set-up, such as dedicated pharmacist time, dedicated consulting space, upskilling of staff and investment in technology is also required to support optimal delivery of DMC.

K E Y W O R D S
community pharmacy, diabetes, patient education, quality use of medicines

| Data collection
Audio-recorded telephone interviews were conducted between July 2019 and December 2019. The following participant demographics were collected: age group, gender, State, remoteness 19 and additional qualifications. A semi-structured interview guide (Online Appendix S1) was prepared based on topics identified from the initial evaluation of the DMC program. 12 The first three piloted interviews with study participants were reviewed by the other researchers (CC and CM) to assess the applicability of the open-ended questions and prompts. No modification was required for the subsequent interviews. All recorded telephone interviews were conducted and transcribed by one female researcher, a community pharmacist and provider of DMC service, with introductory training in qualitative research methods and interviewing for qualitative research (DG). Transcripts were checked by a second researcher for accuracy (CC). The researcher (DG) introduced herself and followed the interview guide to question participants.
Interview times ranged from 15 to 20 min. Prior relationships with participants were not established with many interviewees before the interviews were undertaken. Participants' knowledge of the researcher's goals and motivations were limited to the information provided in the standard information sheet. All participants were offered the opportunity to review their transcripts. No repeat interviews were carried out.

| Analysis
Transcription and familarization with the data were combined with reflection, and questions arising during the initial transcribing process were explored in subsequent interviews where possible. Initial codes were created and grouped into sub-themes. The transcribed data were analysed using QualCoder 1.9 (https://github.com/ccbog el/QualC oder/relea ses/1.9) after interviews were transcribed.
Thematic analysis was conducted through inductive coding and creation of sub-themes. Refinement of codes and sub-themes was then undertaken, and sub-themes were organized into themes. 20 Themes were identified that characterized the key concepts of the findings.

Coding was conducted independently by two authors (DG and CC).
All three authors discussed and revised the final coding, sub-theme and theme wording and structure.

| RE SULTS AND D ISCUSS I ON
Twelve telephone interviews were included in this study. An additional three interviews were scheduled; one did not occur due to conflicts in schedule. The other two interviews occurred but were not included due to audio issues. Of the 12 interviews included, four participants were pharmacy owners, three were pharmacists in charge or managers, and two worked as professional services pharmacists. Most pharmacists worked in metropolitan areas. A slight majority of pharmacists were female (n = 7) and most were between 30 and 39 years old. Four pharmacists had additional qualifications, one being a credentialled diabetes educator. Pharmacists were from four states of Australia, as detailed in Table 1.
Data saturation occurred when the same concepts kept arising in later interviews, with no new themes emerging. The overarching themes identified from the interviews were the importance of pharmacy staff training in diabetes management, challenges in DMC service delivery and implementation, challenges in assisting patients manage their diabetes, and the effect delivering DMC had on pharmacists' personal and professional outlook (Online Appendix S1).

| Benefit of and need for training in diabetes management
Pharmacists were confident in medication management but re-  Pharmacists accredited to deliver medication management reviews believed their additional training helped them perform a more thorough medication discussion during the DMC consultation.
Definitely it does (having the HMR [home medicines review] background helps) I find that maybe it takes me longer because I ask more in-depth questions.

| Challenges of service delivery and implementation
Pharmacists described how they introduced the service to patients and the practicalities, such as time and staffing resources, of implementing the service in community pharmacy.

| Patient engagement
Participants reported that patients who agree to receive the service did not initially believe that they needed a DMC until concerns were identified during the consultation.

| Resources
Participants said DMC delivery increased pharmacist workload and required a change in pharmacy physical and staffing set-up. They said pharmacies with more than one pharmacist working at the same time and a dedicated consulting space were more likely to deliver DMC.
There's always one pharmacist who is able to be in the consult room anytime. We're fortunate that we're in a location that kind of allows us to employ more pharmacists and we kind of make use of it with diabetes and other services.  It feels good as a pharmacist you're like, oh I did something). i13 This is the first study to explore the experiences of Australian community pharmacists in delivering DMC since its roll out in 2012. The findings confirmed traditional barriers (e.g., time shortage, pharmacist shortage, and lack of knowledge and confidence) and facilitators (pharmacist and ancillary staff training). 11,21 Of these facilitators, pharmacists stated training and experience in diabetes management are key enablers in delivering optimal DMCs. Having more than one pharmacist to address the increased workload and an allocated consulting area were also DMC enablers. Pharmacists found DMC especially useful for patients who have limited access to diabetes management support similar to earlier studies. 13,22,23 The findings confirm the essential role of the pharmacist in a multidisciplinary healthcare approach to diabetes management and confirm that the DMC service strengthens the role of the pharmacist beyond the transactional supply of medications. [4][5][6] As with other studies, [24][25][26] pharmacists with additional training in diabetes management were more confident and motivated to provide diabetes-related services such as DMC. Pharmacists who were not accredited to perform medication reviews or upskilled in diabetes management expressed the need for training and they did not present in interviews with the same confidence of diabetes knowledge as those with additional training. The DMC service in Australia, however, does not require pharmacists to undertake additional training. 9 In comparison, MedsCheck for Diabetes in Ontario, Canada requires specific diabetes qualification. 27 Pharmacists expressed the need for training in diabetes education, diabetes management and blood glucose targets. The continuing advancement in treatment recommendations, technology and management in diabetes underlines the need to upskill including in injection techniques and demonstration of injectable devices. 28 Participants also indicated there was a need to improve their communication skills, which may include motivational interviewing, health coaching, patient-centred care and principles of pharmaceutical care. 5,12,25,29 Pharmacists accredited to deliver medication management reviews believed they inherently performed a more thorough discussion of patients' general health and medication management during DMC delivery. This may be because the accreditation process contains training on patientcentred care and GP communication. 30 A similar approach could be adopted for DMC provision.

| Challenges of patient diabetes management
Participants reported that the DMC service increases pharmacists' workload, as similarly identified in a US study. 24  We found pharmacists felt rewarded professionally through patient recognition and appreciation of the role of pharmacists in health care, similar to US community pharmacists delivering diabetes management services. 24 The personalized interaction allowed pharmacists to build rapport, leading, in their opinion, to patients being more willing to ask their pharmacist about concerns which they may not have been comfortable to mention previously.

| WHAT IS NE W AND CON CLUS I ON
A very positive finding is that the implementation of the DMC service has promoted engagement with other health professionals, pharmacist professional satisfaction and reported patient satisfaction and awareness of the health knowledge that pharmacists can provide; these support the findings reported in the 2012 initial review. 12 However, some of the negative aspects remain after 8 years of implementation: the pressure they place on pharmacists' already limited time, the presence of a potential gap in pharmacists' diabetes management knowledge and the potentially insufficient patient privacy in current pharmacy set-ups.
A strength of this study is the diversity of participants representing different roles, practice backgrounds and settings leading to rich discussion. However, a smaller than anticipated number of pharmacists partook in interviews. While we believe the topic was saturated due to repetition of ideas from later participants, we cannot be cer- Delivery of DMC contributes to pharmacists' professional and personal satisfaction, from the benefit they make to patient care.
Pharmacists believe that patients value the additional support their pharmacist provides. To optimize diabetes care in community pharmacy, pharmacists need to be supported through provision of contemporary diabetes management training and communication skills and the provision of dedicated pharmacist time, consulting space, upskilling of their ancillary staff and investment in technology.

ACK N OWLED G EM ENTS
Open access publishing facilitated by University of Tasmania, as part of the Wiley -University of Tasmania agreement via the Council of Australian University Librarians.

CO N FLI C T O F I NTE R E S T
None of the authors report any conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author, CC, upon reasonable request.