A Consensus-Based Policy Framework on Pharmacist-Led Self-Management Using the Delphi Process ()
1. Introduction
The Hong Kong healthcare system is a dual system. It has a public sector and a private sector. Around 80% of outpatient care and primary care are provided largely by private sector and the bulk of specialist and inpatient secondary and tertiary care are delivered through the public sector. Because of the fragmentation of the current healthcare system and lack of connectivity between inhospital and community health services, many patients with chronic conditions are lack of support after receiving treatment from hospitals. Many patients are not able to manage their own health nor having healthcare professionals to monitor their chronic conditions before the next follow up, which generally takes three to six months. With the growing demand of health services as a result of aging population and advancement of medical technology, the response of the traditional model of health service delivery can no longer meet the needs. To fill the gap between in-hospital and community healthcare services in chronic disease, a new chronic care model needs to be considered.
The Hospital Admission Risk Program (HARP) Chronic Disease Management Guidelines in Australia recommends healthcare professionals using a self-management approach in managing people with chronic diseases with or without complex needs [1]. In the Chronic Care Model, an organizing framework for improving chronic illnesses, self-management is also recognized as one of the elements [2]. It incorporates patient, provider and system level interventions with self-management support as a key component at the patient level. Previous studies have also supported that self-management programs can improve patients’ self-efficacy, self-rated health, cognitive symptom management, exercise behaviors and communication with physicians [3-5].
Self-management in Hong Kong is still developing in an early stage. To choose a health professional qualifying to provide collaborative care to monitor patients’ health conditions in self-management is another challenge. Physicians have the main role in disease diagnosis and management, and nurses also have the training and skills capable to monitor patients’ conditions but it would be costly to have physicians to perform patient self-management and shortage of nursing manpower is an issue in the healthcare system. Community pharmacists in Hong Kong, however, are underutilized. Pharmacist is not the sole dispenser as medical doctors are also allowed to prescribe and dispense drugs. Patients usually receive prescribed medications from private doctors directly or from government hospital/clinic pharmacies after consultation. Pharmacists in hospitals may provide medication counseling to patients but other roles like disease monitoring, health promotion and education are uncommon. Studies have shown that pharmacists are the most accessible healthcare professional to many chronically ill patients [6] and given that they have limited roles, pharmacist can be considered to lead patient self-management.
To establish a policy in self-management of patients with chronic conditions using a pharmacist-led approach, a consensus-based policy framework involving medical doctors, pharmacists, traditional Chinese medicine (TCM) practitioners and dispensers needs to be developed first. Before conducting the Delphi process, we had studied the Thematic Household Survey to understand the use of western and Chinese over-the-counter medication in Hong Kong [7], conducted focus groups to explore the views of medical doctors, pharmacists, TCM practitioners and dispensers on patient self-management and role of pharmacist in self-management [8], and conducted a telephone survey to investigate the views of people over aged 18 on the pharmacist-led approach in self-management [9]. The findings of the focus group and telephone survey served as the base for developing the self-administered questionnaire in the Delphi process. TCM professionals are included in this study because it is a common practice to consult TCM practitioners in our community. Population studies have shown that 13% of 1,507,400 persons who had consulted practitioners in the last 30 days, consulted TCM practitioners [10] and TCM practitioners have been recognized as a medical profession in Hong Kong since 1997.
The objective of this study was to develop a consensus-based policy framework on pharmacist-led selfmanagement using a Delphi panel consisted of medical doctors, pharmacists, TCM practitioners and dispensers.
2. Materials and Methods
2.1. Subjects
A total of 19 participants were invited for participation in the Delphi process. Diminishing returns suggest that Delphi respondent sample size of above 15 participants yields little improvement in reliability [11], therefore, we recruited around five participants from each of the professions. Five physicians, five pharmacists, five TCM practitioners and four TCM dispensers agreed to join. The recruitment was primarily through professional networks. Professional qualifications of participants and working experience were ensured. Inclusion on the panel required participants to meet the following criteria:
1) Current knowledge and understanding of patient selfmanagement and role of pharmacists;
2) Working in primary care and/or pharmacy sectors, including academic, clinical unit, community setting and/ or administration;
3) Commitment to contribute to each Delphi round.
2.2. Instrument
The self-administered Delphi questionnaires were written in both English and Chinese. In round one, the questionnaire composed of 53 statements on 1) patients involvement in self-management; 2) scope covered in patient self-management; 3) patients who may have difficulties in self-management; 4) roles of community pharmacists in self-management and; 5) barriers which may hinder pharmacist-led self-management. The statements were extracted from the focus group discussion [8], telephone survey [9] and expert opinions.
2.3. Procedures
Self-administered questionnaires were sent to the participants by post or email. In round one, participants were requested to rate the validity and clarity of each statement on a 9-point scale. Validity was defined as the extent to which the statement is relevant for the development of patient self-management or the role of community pharmacists in self-management of patients with chronic illness and; clarity was defined as the extent to which the statement was expressed in clear, precise and unambiguous language. A rating of 1 - 3 was categorized as low validity/clarity; 4 - 6 as average validity/clarity and; 7 - 9 as high validity/clarity. Respondents were encouraged to provide feedback on how to improve validity and clarity of the statements, especially those with a rating of 1 - 6. Statements were retained and needed not to be re-rated at round two if 85% or more of the respondents rated 7 - 9 on both validity and clarity, otherwise, the statements were revised at round one following the feedback of the participants or disregarded at round two.
In round two, each participant received a Delphi questionnaire showing his/her responses, the median and distribution of rating of each statement obtained in round one. Participants were asked to re-rate the validity and clarity of the revised statements on a 9-point scale. Same as in round one, a statement was retained if 85% or more of the respondents rated 7 - 9 on both validity and clarity, otherwise the statements were revised in the subsequent rounds or disregarded depending on the feedback of the participants.
2.4. Data Analysis
Descriptive statistics, including median and range of distribution, were used to analyze responses in each round. Subgroup differences in rating between participants of western (physicians and pharmacists) and Chinese (TCM practitioners and dispensers) medicines were analyzed using SPSS (Version 16.0). Chi-square tests were performed to assess differences in ratings (7 - 9 vs 1 - 6) between the two subgroups. The level for statistical signifycance was set at P < 0.05.
2.5. Ethical Consideration
The study protocol was approved by the Joint CUHKNTEC Clinical Research Ethics Committee and was performed in accordance with the World Medical Association’s Declaration of Helsinki.
3. Results
3.1. Round One
In the first round, consensus was achieved on 6 out of 53 statements and there was no significant difference in ratings (7 - 9 vs 1 - 6) between the western medicine and TCM groups. They included two statements on scope of self-management of patients with chronic illness (Medication compliance; Know when to seek help from healthcare providers); two statements on tasks of community pharmacists in pharmacist-led patient self-management (Handling drug problems and side-effects; Providing health product consultation); and two statements on barriers which may hinder community pharmacists to lead patient self-management (Patients’ entire medical records and data are not available for community pharmacists; Liability issues for professional misconduct).
The remaining statements had less than 85% of participants rated them highly on validity and/or clarity. Twenty-one statements were disregarded as the participants commented that these statements were not valid/ relevant in the framework or some of them had similar meaning. Twenty-six statements were kept the same as in round one or revised for reassessment in round two.
3.2. Round Two
Among the 26 statements, three statements were disregarded because less than 85% rated validity and clarity 7 - 9. They were related to scope of self-management of patients with chronic illness (Checking of their own disease; and Aware of own treatment plan) and tasks of community pharmacists in pharmacist-led patient selfmanagement (Checking of patients’ disease condition). Consensus was achieved on the remaining statements as more than 85% of respondents rated them highly on both validity and clarity. Besides, there was no significant difference on ratings between the western and Chinese medicine groups. The consensus-based policy framework on pharmacist-led self-management was, therefore, achieved after two rounds of Delphi process.
The following is a description of the consensus based policy framework (Table 1).
3.3. Self-Management of Patients with Chronic Illness
The four professions agreed that patients with stable chronic illnesses should be involved in self-management. Scope which should be covered in self-management included, medication and follow-up compliance, maintaining of healthy lifestyle, using proper channels to obtain disease information and know when to seek help from healthcare providers. However, the participants also identified numbers of barriers which might limit the ability of chronically ill patients in self-management. These barriers could basically be categorized into socio-demographic factors (old age and low education); mood and social cognition (pessimistic personality, emotional issues, and low perception of health, self-motivation and self-control); lack of disease and health knowledge (lack of health knowledge, not understand own disease, not following healthcare staff’s instructions and incorrectly analyzing disease information) and poor health status.
3.4. Role of Community Pharmacists in Patient Self-Management
Community pharmacists could play an assisting role and they were unable to lead patient self-management. Handling drug related problems and providing health product consultation would be the major tasks of community pharmacists. Other tasks like health promotion, lifestyle modification with the collaboration of physicians and nurses, and referring patients to physicians were also included. The participants agreed that some barriers have to be tackled in order to advocate community pharmacists play a leading role in patient self-management in the future. The pharmacy profession lacked support from the government. Patients’ medical records were not available for community pharmacists to perform effective selfmanagement. Some patients were not familiar with the roles of community pharmacists and the liability for professional misconduct was also a concern.
There were also some self-management activities and role of pharmacists, which were commonly found in patient self-management programs, but consensus were not achieved for these in this study. Other patient self-management activities which can be further considered include, monitoring of disease progress and complications, mental health and emotional support, and family/caregiver support.
Table 1. The consensus based policy framework of self management of patients with chronic illness and role of pharmacists in patient self-management.