International Journal of Clinical Pharmacy (2020) 42:315–320
https://doi.org/10.1007/s11096-020-00985-7
COMMENTARY
Pharmaceutical care services available in Danish community
pharmacies
Bjarke Abrahamsen2 · Alaa Hassan Burghle1 · Charlotte Rossing2
Received: 29 April 2019 / Accepted: 28 January 2020 / Published online: 5 February 2020
© Springer Nature Switzerland AG 2020
Abstract
In recent years, increased longevity of the Danish population has resulted in a growing segment with age-related and chronic
health conditions. This, together with a general increase in the demand on the services of doctors, has augmented the role of
pharmacies in the provision of healthcare services. In Denmark, a variety of pharmacy services has been developed, evalu-
ated and implemented since the introduction of pharmaceutical care. The services are aimed at the person responsible for
administering the medicine e.g. the patient themselves or care workers, thereby supporting medication safety. The services
available have been developed, evaluated and implemented in collaboration between community pharmacies, the Danish
Association of Pharmacies, the Danish College of Pharmacy Practice and international collaborators. In this commentary we
present an overview of the available pharmacy service, the contents of each service, remuneration and the scientific evidence
behind each service. The commentary covers: Inhaler Technique Assessment Service; New Medicines Service; Medication
Review; and Medication Safety in Residential Facilities.
Keywords Community pharmacy · Denmark · Pharmaceutical care · Pharmacy practice · Professional pharmacy services ·
Public health · Rational pharmacotherapy
Impacts on practice Introduction
Pharmaceutical Care, as defined by Hepler and Strand in
• In Denmark, pharmacy services are standardised and 1990, has formed the foundation for professional services
available from all pharmacies throughout the country. available at Danish community pharmacies. Today, patients
This ensures consistency and supports medication safety. without an appointment can walk into their local community
• To further support pharmacy practice, manuals and sup- pharmacy and receive counselling on safe and effective use
porting materials are made available by the Danish Asso- of medication by a trained pharmacist or pharmacy techni-
ciation of Pharmacies in Denmark. Overall, this means cian [1].
that pharmacies around Denmark can provide the same In Denmark, 484 community pharmacies have a monop-
services at consistent standards. oly of practice and serve a population of 5.75 million people.
The location and distribution of community pharmacies are
state-regulated, securing extensive public accessibility with
80.7% of people living within five kilometres of a commu-
nity pharmacy [2]. Staff at the pharmacy consist of pharma-
cists with a 5-year MSc-degree in pharmacy and Pharmacy
technicians holding a three and a half-year Academy Profes-
* Charlotte Rossing sion degree. Pharmacists, like other healthcare profession-
[email protected] als, have electronic access to patients prescribed medication
through the Shared Medication Record. The level of trust
1
Hospital Pharmacy Funen, Odense University Hospital, between pharmacy staff and patients is high, with 83% of
Odense, Denmark
patients reporting satisfaction with advice and counselling
2
Research and Development, Danish College of Pharmacy [3]. Professional pharmacy services available have increased
Practice, Hillerød, Denmark
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316 International Journal of Clinical Pharmacy (2020) 42:315–320
since the millennium and today include: smoking cessation, 31 pharmacies [6, 7]. For the intervention group, signifi-
home delivery, automated dose dispensing, flu vaccination cant effects were found in asthma symptom status, overall
service, medication review, New Medicine Service (two health related quality of life (HRQoL) and asthma-related
different services) and Inhaler Technique Assessment Ser- quality of life. There was a 23% improvement in asthma
vice—with only the two latter being remunerated by the symptom status for intervention patients after twelve
government. months compared with 10% for the control group. The
study also showed positive, although not significant,
effects on knowledge of asthma and medication, num-
Aim ber of reported sick days, number of inhalation errors,
drug use and number of drug therapy problems. During
The aim of this commentary is to summarise the last the study period, the drug therapy regimens changed
25 years’ research in pharmaceutical care in Denmark. This towards consensus guidelines for the intervention group.
is done by reviewing the literature describing research and The study demonstrated that an asthma service delivered
development behind some of the current pharmacy service by the community pharmacy is an effective strategy for
programmes where the benefit for the patients’ safe and improving the quality of drug therapy for asthma patients.
effective use of medicine has been considered greatest versus Two evaluations on the use of ITAS implementation were
considerable barriers to implementation, i.e. resource use; performed. A mystery customer evaluation showed that
Inhaler Technique Assessment Service, New Medicines Ser- pharmacies provided ITAS for 81% of patients using inha-
vice, Medication Review and a programme to build medica- lation devices based on 1579 visits to 320 pharmacies [8].
tion safety in residential facilities. Furthermore, data from three pharmacies and 95 patients
showed that 60% of patients demonstrated suboptimal use
of their inhalation device [9]. The effect of ITAS has been
Inhaler Technique Assessment Service (ITAS) investigated in a Norwegian setting where an identical ser-
vice is available. The evaluation included 405 patients and
The current service is available to new or experienced showed that the percentage of patients demonstrating an
patients using any kind of inhalation device. Since 2005 the optimal inhalation technique increased from 8% at baseline
pharmacies have been remunerated by the government for to 52% when measured again after three months [10].
this service. The service, delivered by either a pharmacist To secure uniformity and quality of the service, the
or pharmacy technician, assesses the patient’s inhalation Association of Danish Pharmacies has since created an
technique by demonstration and teach-back. The service is individual mandatory certification programme.
scheduled to take 10 min and aims to optimise the patient’s
outcome of the treatment.
The development of ITAS was based on results from the
programme, Therapeutic Outcomes Monitoring (TOM) [4]. Safe and effective use of medicines
The 1-year programme was established to improve drug
therapy for asthma patients and developed by researchers Research on safe and effective use of medicines in Den-
from several countries through the Pharmaceutical Care mark has been performed since 2004 developing and test-
Network Europe (PCNE) [5]. The programme involved the ing a comprehensive adherence programme. The results
patients paying monthly visits to their community pharmacy from the programme have been part of the foundation for
where they received individual counselling on adherence, both New Medicines Services and Medication Review.
inhalation technique, therapeutic problems and coping with The background and contents of Safe and Effective Use of
the disease and treatment [6, 7]. The pharmacist recorded Medicine has been described elsewhere [11], but in brief,
the patient’s inhalation technique, peak expiratory flow rate consisted of four sessions with the patient at the commu-
and asthma symptoms. The patient kept a diary, which was nity pharmacy over a period of up to 1 year. The patient
monitored by the pharmacist along with discussion of daily received either a basic service or an extended service.
experiences and challenges with the disease and possible Both services identified drug-related problems and, in col-
solutions. Pharmacies are obliged to provide this service. laboration with the patient, found individualised solutions
to low adherence, lack of knowledge or other identified
Effectiveness of the service problems related to the patient’s medicine. The extended
service was more time-consuming and elaborate, compris-
In Denmark the programme was evaluated in a prospective ing a Medicine Use Review, clinical measurements, patient
controlled multicentre trial involving 500 adult patients narratives and motivational interviewing.
(264 intervention patients and 236 control patients) and
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International Journal of Clinical Pharmacy (2020) 42:315–320 317
Effectiveness of the service Medicine. The first service, Adherence Service for New
Medicine Users, was included in the counselling guidelines
The programme was evaluated in two randomised clinical for Danish community pharmacies in January 2016. The
trials targeting patients with type 2 diabetes and patients service is aimed at patients diagnosed with a new chronic
with hypertension [12, 13]. The study for type 2 diabetes condition having started new medication within the last
included five pharmacies and 205 adult type 2 diabetes six months. The service is provided by pharmacists and
patients (39 basic intervention patients, 41 extended inter- consist of a counselling session and a follow-up by phone
vention patients and 125 control patients) using oral antidia- 2–4 weeks after the initial session. The counselling focuses
betic medicines and managed their medication themselves. on the patient’s new medicine and how the pharmacy can
The intervention group testing the extended service support the patient’s own medicine management by pro-
reported significantly higher improvements for outcome viding knowledge about the treatment, disease and thereby
measures in patient health, well-being, knowledge and sat- boost adherence. The second service, Adherence Service
isfaction [13]. The study targeting hypertensive patients for Patients with Chronic Conditions With Signs of Low
included five pharmacies and 563 adult hypertensive patients Adherence, launched in April 2018, is similar in structure
(120 basic intervention patients, 120 extended intervention to the first, the only difference being that the service is only
patients and 323 control patients). For both the basic and available for patients who already have been in long-term
extended intervention the number of patients with blood treatment for more than 1 year and show signs of low adher-
pressure exceeding recommended by clinical guidelines was ence. Both services are remunerated by the government and
reduced by more than 50% [12]. both services have a combined length of 20 min. Pharmacies
The programme was adjusted further and evaluated in are obliged to provide these services.
two different settings. The first study was designed for adult
hypertensive patients with specific focus on the patient’s Effectiveness of the service
adherence to treatment [14]. The study was designed as a
formative evaluation and was a collaboration between The The service for newly diagnosed patients was evaluated by
Danish Heart Foundation and 26 community pharmacies endpoint questionnaires (n = 56 patients) and semi-struc-
and included 290 adult heart patients. Recruited patients tured interviews (n = 6) [16]. Approximately 85% of patients
received a medication review with focus on adherence and who responded reported being satisfied with the programme.
a follow-up by phone 4–6 weeks after the initial session. The programme helped patients start well using their new
The study showed that patients receiving the intervention medicine; increased their knowledge of the effects; educated
obtained more knowledge about how to take their medica- them on correct use of the medication; gave them a feeling
tion and improved their adherence. For patients experiencing of safety and helped develop good medication intake habits.
side effects of medication, adherence improved significantly.
Another important finding from this study was the recom-
mendation that future studies should implement screening Medication review
of patients to ensure those in most need received the ser-
vice. Finally, the experience and knowledge from Safe and The current Medication Review pharmacy service was
Effective use of Medicine was adapted to design a study launched in 2005 and is offered at the community phar-
targeting ethnic minorities [15]. The study was designed as a macy or as part of a clinical service to nursing homes or
before and after evaluation and involved four municipalities other residential facilities. The review is carried out by a
and five community pharmacies. A total of 82 unemployed pharmacist in collaboration with the patient or nursing staff.
patients of non-western origin receiving social benefits was Data is sourced from the patient’s digital list of prescribed
recruited. The patients received a medication review, patient medication with all other data collected from the patient or
education and follow-up for a total of four sessions. The carer such as actual drug use, over-the-counter drugs, vita-
results showed that several levels of adherence improved mins and minerals and results from blood tests etc. Focus of
significantly over the course of the study (Intentional, self- the review is to optimise the patient’s medical treatment by
regulation, unintentional and intentional, effect-related). identifying and solving drug related problems. Suggestions
are summarised in agreement with the patient and commu-
nicated to the patient’s general practitioner, preferably by the
New medicines services patient. The service is estimated to last 75 min. If relevant,
a follow-up of the review can be offered. The Medication
The New Medicines Service consists of two services. The Review pharmacy service is not remunerated, and phar-
services were founded on the experience from the compre- macies are not obliged to provide this service. However,
hensive compliance programme Safe and Effective Use of in recent years more pharmacies throughout Denmark have
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318 International Journal of Clinical Pharmacy (2020) 42:315–320
established contractual agreements with municipalities to and medicines; quality, safety, communication and coordina-
deliver medication reviews at e.g. nursing homes. To sup- tion; and skills, knowledge and competencies according to
port and secure the uniformity and quality of the service, the national qualification framework for lifelong learning.
the Association of Danish Pharmacies has since created an The educational programme was developed through a
individual mandatory certification programme. task-and-learning analysis based on official guidelines and
The background for the current medication review service interviews with management and staff from residential
is founded on data and experience from several programmes; facilities. The programme consists of a seven-day basic
The Therapeutic Outcome Monitoring programme, Safe and programme for all participants and an additional 2 days
Effective Use of Medicines, and the Pharmaceutical Care for participants whose responsibilities related especially to
model [5–7, 10, 12–14]. medicines. The delivery and cost are agreed between the
pharmacy and the residential facility.
Effectiveness of the service
Effectiveness of the service
A medication review was part of the Therapeutic Outcome
Monitoring (TOM) programme [5, 6] and the comprehensive The educational programme was evaluated using a quantita-
compliance programme Safe and Effective use of Medicines tive baseline and endpoint evaluation based on data from 75
[7, 10]. In the TOM project there was a sharp decline in participants from 14 residential facilities representing five
the number of DRPs [5]. In the Safe and Effective Use of different, rural and urban municipalities [20]. They were
Medicines for ethnic minorities study, there was an 8.4% interviewed about their knowledge, skills and competence
decrease in the number of patients with potential adherence regarding medicines and perceived need of further train-
problems [10]. Also, a large multi-centre study was carried ing. Most of the respondents were social workers (48%)
out in seven European countries testing the pharmaceutical with an average work experience in residential facilities of
care model on elderly patients [17]. The study included 190 10.2 years. Positive effects were reported for improvements
community pharmacies and 2454 home-dwelling patients in staff motivation and confidence, perceived ability to safely
(1290 intervention patients and 1164 control patients) over handle residents’ medication, safety culture, patient empow-
65 years of age using at least four prescription medicines. erment and communication skills.
The study found no overall significant differences between A qualitative study based on ten semi-structured inter-
intervention and control groups for HRQoL or hospitali- views with residential care facility staff members, five semi-
sations, but patients’ satisfaction with the service in gen- structured interviews with residential care facility manag-
eral was significantly increased over time when compared ers and five open-ended questionnaires with community
with the start of the study and the control group. However, pharmacists was carried out to explore the experiences of
the Danish contribution to the study based on data from the staff, managers and community pharmacists [21]. The
28 community pharmacies and 523 patients (254 interven- analysis showed that community pharmacists provide a
tion patients and 269 control patients) reported a significant resource to engage in educational programmes. As educa-
improvement for two domains of the HRQoL and a signifi- tors, the community pharmacists were successful in their
cant reduction in hospitalisation [17]. Another study, based role as experts in medicine. After the project, improved col-
on patient data from the large European multi-centre study, laboration was reported between the residential facilities and
analysed the impact of the pharmaceutical care model on their local community pharmacy.
drug-drug interactions in elderly [18]. Data from six coun-
tries and 1601 elderly patients was included. The study iden-
tified 1324 potential drug-drug interactions corresponding Discussion
to 0.83 interactions per patient.
The pharmacy services described in this commentary have
all been founded on scientific evidence. Research pro-
Building capacity on medication‑safety grammes have been conducted in collaboration between
at residential facilities Danish community pharmacies, the Association of Danish
Pharmacies, The Danish College of Pharmacy Practice and
An educational programme service for staff at residential international collaborators such as Pharmaceutical Care
care facilities to ensure medication safety has been available Network Europe. Barriers and facilitators for implementa-
since 2005 [19]. The programme is delivered by a pharma- tion of pharmacy services have been identified and linked
cist or pharmacist technician at the local community phar- primarily to financial constraint [22]. Remunerated services
macy and is tailored for the specific needs of the residential have a high degree of uptake as pharmacies are obliged to
facility. The programme can cover three main areas; disease provide the services. Medication Review and Educational
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International Journal of Clinical Pharmacy (2020) 42:315–320 319
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