Abstract
With the increase in life expectancy in Japan, the proportion of older adults requiring medical assistance continues to increase. Hence, the Japanese government proposed the establishment of a community-based integrated care system, aimed at ensuring housing, medical care, long-term care, prevention, and lifestyle support in a comprehensive manner by 2025. To achieve this paradigm shift, pharmacies must collaborate with their respective medical providers. Therefore, we conducted a questionnaire survey to investigate the characteristics of pharmacies with successful regional medical collaborations. An original questionnaire was sent to 1200 randomly sampled pharmacies in Tokyo, of which 350 (29.2%) responded. These were evaluated based on the implementation of regional medical collaboration. The adequacy of a regional medical collaboration system was positively related to the operational structure (e.g., staffing and information sharing within the pharmacy) and the number of hospitals (including clinics) issuing prescriptions. In addition, insufficient personnel and a lack of interaction with other medical providers were identified as major obstacles to implementing regional collaboration. Notably, the geographic distance from medical providers and the type of division of labor with medical providers were not associated with the adequacy of engagement in a regional medical collaboration system. The results of this study suggest that it may be possible to move closer to the realization of a community-based integrated care system through communication with other healthcare professionals and appropriate staffing regardless of the pharmacy’s business form.
INTRODUCTION
According to WHO, the aging rate is defined as the proportion of the population aged 65 years and older. Societies with aging rates exceeding 7, 14, and 21% are called “aging society,” “aged society,” and “super-aged society,” respectively. Aging of the population structure is a common and severe problem worldwide, with the aging rate rising to approximately 9.1% in 2019.1) Especially in Japan, it is remarkably high at 28.4%, categorized as a super-aged society.2) To respond promptly to the ever-increasing needs of the elderly in health, welfare, and social security, it is necessary to rebuild social infrastructures that enable comprehensive support, whether in policy or in practice. The Japanese Ministry of Health, Labour and Welfare (MHLW) proposed the establishment of the community-based integrated care system aimed at ensuring housing, medical care, long-term care, prevention, and lifestyle support in a comprehensive manner by 2025.3) Establishing the community-based integrated care system will not only improve the sustainability of the current health insurance system but also benefit the public in the following ways: (1) Improved safety and efficiency through centralized management of medication information; (2) 24-h response system for emergencies; and (3) Home medication counseling for the very elderly and persons with disabilities, et cetera. Therefore, community pharmacies must play appropriate roles in collaborating with other regional medical providers.3)
The Japan Pharmaceutical Association (JPA) has reported that the national average legal prescription receipt rate in 2023 is 76.6%, approaching 90% in certain areas (e.g., 89.3% in Akita Prefecture).4) This high prescription receipt rate reflects the progress of the separated system of dispensing and prescribing medicines in Japan. However, as a certain percentage of community pharmacies are only engaged in operations centering on medicine dispensing, patients and other professionals have commented that they do not feel the significance and benefits of this separation.5) To realize a patient-oriented system of separation of dispensing and prescribing medicines, the MHLW established a goal for family pharmacists and pharmacies called the “Pharmacy Vision for Patients” on October 23, 2015.
To encourage patient-centered pharmacy choice, the Japanese government has already launched an initiative to collect and publicize information on the state of collaboration among community pharmacies and Pharmacy Functional Information Provision System.6) This system allows patients to obtain approximate information about community pharmacies and helps them choose the one that best fits their lifestyle. However, the items disclosed as functional community pharmacy information do not necessarily cover all the data necessary to judge the establishment of a regional medical collaboration system.7) Indeed, as a public system, the Japanese government collects and discloses only sweeping information related to regional medical collaboration. Therefore, it is not possible to obtain detailed information on the status of the establishment of regional medical collaboration from the disclosed information.7)
The present study was a complementary survey of information not covered by Pharmacy Functional Information Provision System and clarified the characteristics of pharmacies willing to establish a regional medical collaboration system.
MATERIALS AND METHODS
Study Design and Eligible Facility SelectionThe present study was approved by the ethics committee of Tokyo University of Pharmacy and Life Sciences (Approval No. D-2023-001). The candidate facilities were community pharmacies in Tokyo as of July 27, 2022. Tokyo Metropolitan Government’s pharmacy information service “t-Yakkyoku Info” was used to select eligible facilities, and community pharmacies that responded “Yes” to the question “whether they are designated as an insurance pharmacy under the Health Insurance Law” were included in this study.
Based on the “regional medical collaboration system” item (Fig. 1) in the functional information of community pharmacies,8) we evaluated the implementation status of regional medical collaboration of each community pharmacy. Specifically, medical collaboration with other medical providers became necessary, and these items (Fig. 1) which are very important in establishment a regional medical collaboration system, were used to classify the groups into four groups according to the number of implementation of each effort. As a side note, “Others” and “Participation in awareness-raising activities for local residents” were not used for the evaluation because they are not direct indicators for the establishment of a collaborative system among medical providers. However, there is no clear consensus regarding such a classification method. Therefore, we performed a quantitative-scale classification using disclosed public information to evaluate the implementation status of eligible community pharmacies and establish a regional medical collaboration system into four groups (Fig. 1).
Distribution of Questionnaire FormThree hundred community pharmacies from each of the four groups were selected using a random-number generator. The distributed questionnaire (Supplementary Material 1) consisted of questions regarding the status of pharmacy-to-pharmacy and pharmacy-to-medical providers collaboration, in addition to the attributes of each community pharmacy. Questionnaires were sent to community pharmacies on April 1, 2023 and collected by June 30, 2023.
Research consent forms were enclosed along with the questionnaires. Responses to the questionnaire and written research consent were provided by the pharmacy director or their equivalent.
Statistical AnalysisAll statistical calculations and the creation of a random number table were performed using JMP Pro 17.2 (SAS Institute Inc., Cary, NC, U.S.A.) and Microsoft Excel 365 (Microsoft Corp., WA, U.S.A.). First, two-tailed Cochran–Armitage trend tests were performed to examine increasing and decreasing trends in the binary variables. In addition, residual analysis was performed to detect singular values for the multi-matrix. Ordinal logistic regression was used to identify the factors influencing the implementation status of eligible community pharmacies in establishing a regional medical collaboration system. Because the implementation status was on a 4-point scale, three logit models were used. The effects of the variables were presented across three logit models, and comparisons were made for probabilities of being in a group with a favorable implementation status versus being in or below that group. The logit model was constructed considering multicollinearity and was restricted such that the variance inflation factor (VIF) of each explanatory variable did not exceed 3.0. The significance level (α) was set at 5% for all statistical tests.
RESULTS
Results of the QuestionnaireOf the 1200 community pharmacies that sent questionnaires, 350 responded: Group 1 (n = 102), Group 2 (n = 98), Group 3 (n = 67), and Group 4 (n = 83). The response rate was at least 20% in each group.
Figure 2 shows an evaluation of the implementation status of establishing a regional medical collaboration system. “Collection of cases in which medicine-related adverse events were prevented or avoided” was highest in Group 2 and lowest in Group 4. “Implementation of the pharmacist’s duties according to protocols agreed upon with the physician” was the highest in Group 2 and the lowest in Group 3. Also, “standardization of medicines used through collaboration among regional hospitals (including clinics)” was highest in Group 1 and lowest in Group 4. There was a statistically significant association between these items and the implementation status of the establishment of a regional medical collaboration system, which validated our grouping based on publicly available information (p for trend <0.001).
The two items of “collaboration with other medical providers” were highest in Group 1 and lowest in Group 4. There was a statistically significant association between these items and the implementation status of the regional medical collaboration system (p for trend <0.001).
As for the number of community pharmacies with official certifications, the number of “Health Support Pharmacy” and “Regional Collaborative Pharmacy” were highest in Group 1 and lowest in Group 4. There was a statistically significant association between these items and the implementation status of the regional medical collaboration system (p for trend <0.001). On the other hand, community pharmacies that have acquired “Specialized Medical Institution Cooperating Pharmacy” were in only Group 2.
Attributes of Community PharmaciesTable 1 lists the attributes of the participating community pharmacies. Of the “location of the community pharmacy,” the highest proportion of community pharmacies located within the living area was Group 1. In contrast, Group 4 had the highest proportion of community pharmacies located near hospitals. No statistically significant trend was observed in any of the community pharmacies in Groups 1 to 4 (p for trend = 0.4, 0.6). Only two community pharmacies located on hospital grounds were classified in Group 4.
Table 1. Attributes of Community Pharmacy
| Overall (N = 350) | Group 1 (n = 102) | Group 2 (n = 98) | Group 3 (n = 67) | Group 4 (n = 83) |
|---|
| Location of the pharmacy (n = 347) |
| Located within living area | 100 (28.8%) | 31 (30.4%) | 29 (29.6%) | 20 (29.9%) | 20 (24.4%) |
| Located in the vicinity of hospitals | 245 (70.6%) | 70 (68.6%) | 68 (69.4%) | 47 (70.1%) | 60 (73.2%) |
| Located on hospital grounds | 2 (0.6%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 2 (2.4%) |
| Not answered | 3 | 1 | 1 | 0 | 1 |
| Percentage of prescriptions prescribed by fixed hospitals (n = 341) |
| 0–19% | 33 (9.7%) | 6 (6.1%) | 10 (10.5%) | 14 (21.2%) ▲▲ | 3 (3.7%) ▽ |
| 20–39% | 79 (23.2%) | 31 (31.3%) △ | 25 (26.3%) | 15 (22.7%) | 8 (9.9%) ▼ |
| 40–59% | 49 (14.4%) | 16 (16.1%) | 14 (14.8%) | 5 (7.6%) | 14 (17.3%) |
| 60–79% | 98 (28.7%) | 28 (28.3%) | 34 (35.8%) | 15 (22.7%) | 21 (25.9%) |
| 80–100% | 82 (24.0%) | 18 (18.2%) | 12 (12.6%) ▼ | 17 (25.8%) | 35 (43.2%) ▲▲ |
| Not answered | 9 | 3 | 3 | 1 | 2 |
| Number of pharmacists working in community pharmacies (n = 347) |
| 1 pharmacist | 68 (19.6%) | 10 (9.9%) ▼ | 13 (13.4%) | 12 (17.9%) | 33 (40.2%) ▲▲ |
| 2 pharmacists | 99 (28.5%) | 25 (24.8%) | 29 (29.9%) | 17 (25.4%) | 28 (34.1%) |
| 3 pharmacists | 70 (20.2%) | 27 (26.7%) | 19 (19.6%) | 13 (19.4%) | 11 (13.4%) |
| 4 pharmacists | 45 (13.0%) | 17 (16.8%) | 11 (11.3%) | 12 (17.9%) | 5 (6.1%) ▽ |
| 5 pharmacists | 26 (7.5%) | 8 (7.9%) | 11 (11.3%) | 5 (7.5%) | 2 (2.4%) ▽ |
| 6–9 pharmacists | 30 (8.6%) | 9 (8.9%) | 12 (12.4%) | 7 (10.4%) | 2 (2.4%) ▽ |
| >9 pharmacists | 9 (2.6%) | 5 (5.0%) | 2 (2.1%) | 1 (1.5%) | 1 (1.2%) |
| Not answered | 3 | 1 | 1 | 0 | 1 |
| Number of prescriptions filled (n = 348) |
| <501 | 35 (10.1%) | 3 (3.0%) ▼ | 4 (4.1%) ▽ | 7 (10.4%) | 21 (25.6%) ▲▲ |
| 501–1000 | 129 (37.1%) | 34 (34.7%) | 37 (37.7%) | 24 (35.8%) | 34 (41.5%) |
| 1001–1500 | 73 (21.0%) | 26 (26.8%) | 21 (21.4%) | 14 (20.9%) | 12 (14.6%) |
| 1501–2000 | 48 (13.8%) | 17 (17.8%) | 18 (18.4%) | 8 (12.0%) | 5 (6.1%) ▽ |
| 2001–2500 | 27 (7.7%) | 9 (9.9%) | 9 (9.2%) | 3 (4.5%) | 6 (7.3%) |
| >2500 | 36 (10.3%) | 12 (13.8%) | 9 (9.2%) | 11 (16.4%) | 4 (4.9%) |
| Not answered | 2 | 1 | 0 | 0 | 1 |
The implementation status of regional medical collaboration of each community pharmacy was classified into four groups. The association between implementation status to establish a regional medical collaboration system and each variable was evaluated by the Cochran–Armitage trend test. △: Standardized residual (dij) > 1.96, ▲: dij >2.58, ▲▲: dij >3.30. ▽: dij<−1.96, ▼: dij<−2.58, ▼▼: dij<−3.30.
In terms of the “percentage of prescriptions prescribed by fixed hospitals” (average for one month), the average percentage was 60–79%. The most common response was 20–39% in Group 1 and 60–79% in Group 2. On the other hand, community pharmacies that responded 80–100% were the most common in Groups 3 and 4. In terms of the “number of pharmacists working in community pharmacies,” the average was “2 pharmacists”; community pharmacies that answered “3 pharmacists” were the most in Group 1. On the other hand, community pharmacies that answered “2 pharmacists” were the most in Groups 2 and 3, and community pharmacies that answered “1 pharmacist” were the most in Group 4. In terms of the “number of prescriptions filled,” the largest number of community pharmacies answered “501–1000” in all groups.
Collaboration with Other Medical ProvidersTable 2 shows the status of collaboration with other medical providers. There was a statistically significant association between all items requiring collaboration with other medical providers, except community pharmacies, and a positive attitude toward establishing a regional medical collaboration system. Among these items, the implementation rate of items requiring collaboration with other medical providers decreased linearly in Groups 1 to 4, except for “participation in joint training and study sessions held at hospitals or clinics, “recommend visits to other medical providers,” “fee for provision of compliance,” “fee for concurrent guidance at discharge,” “fee for specified medicine management guidance 2,” “fee for inhalation medicine guidance,” and “sharing of events in which it was difficult to deal with patients.” There was no linear decrease in the implementation rate of excluded items in Groups 1 to 4 (participation in joint training and study sessions held at hospitals or clinics, recommended visits to other medical providers, fees for the provision of compliance, fees for concurrent guidance at discharge, fees for specified medicine management guidance 2, fee for inhalation medicine guidance, and sharing of events in which it was difficult to deal with patients).
Table 2. Collaboration with Other Medical Providers
| Overall (N = 350) | Group 1 (n = 102) | Group 2 (n = 98) | Group 3 (n = 67) | Group 4 (n = 83) | P for trend |
|---|
| Collaboration with other medical providers (excluding community pharmacies) |
| Participation in standards for patients and citizens with other medical providers | 30.6% | 54 (52.9%)▲▲ | 32 (32.7%) | 11 (16.4%)▼ | 10 (12.0%)▼▼ | < 0.001 |
| Participation in joint training and study sessions held at hospitals or clinics | 46.0% | 66 (64.7%)▲▲ | 48 (49.0%) | 20 (29.9%)▼ | 27 (32.5%)▼▼ | < 0.001 |
| Recommend visits to other medical providers | 77.7% | 86 (84.3%)△ | 81 (82.7%) | 50 (74.6%) | 55 (66.3%)▼▼ | < 0.001 |
| Preparation of information provision documents describing compliance at the time of admission | 33.7% | 49 (48.0%)▲▲ | 39 (39.8%) | 19 (28.4%) | 11 (13.3%)▼▼ | < 0.001 |
| Calculation of dispensing fees |
| Fee for provision of compliance | 68.0% | 83 (81.4%)▲▲ | 81 (82.7%)▲▲ | 46 (68.7%) | 28 (33.7%)▼▼ | < 0.001 |
| Fee for medication adjustment support | 18.9% | 25 (24.5%)▲▲ | 23 (23.5%)△ | 11 (16.4%) | 7 (8.4%)▼▼ | 0.002 |
| Fee for medicine management guidance after dispensing | 43.7% | 61 (59.8%) | 53 (54.1%) | 24 (35.8%) | 15 (18.1%)▼ | < 0.001 |
| Fee for concurrent guidance at discharge | 5.7% | 11 (10.8%)▲ | 6 (6.1%) | 0 (0.0%)▽ | 3 (3.6%) | < 0.001 |
| Fee for specified medicine management guidance 2*1 | 16.6% | 21 (20.6%) | 27 (27.6%)▲▲ | 4 (6.0%)▼ | 6 (7.2%)▼ | < 0.001 |
| Fee for inhalation medicine guidance | 59.4% | 75 (73.5%)▲▲ | 73 (74.5%)▲▲ | 33 (49.3%)▽ | 27 (32.5%)▼▼ | < 0.001 |
| Monitoring of adverse drug reaction | 56.0% | 69 (67.7%)▲ | 64 (65.3%)△ | 35 (52.2%) | 28 (33.7%)▼▼ | < 0.001 |
| Provision of patient information obtained through patient follow-up to medical provider | 70.0% | 86 (84.3%)▲▲ | 74 (75.5%) | 45 (67.2%) | 40 (48.2%)▼▼ | < 0.001 |
| Sharing of events in which it was difficult to deal with patients | 59.7% | 63 (61.8%) | 65 (66.3%) | 43 (64.2%) | 38 (45.8%)▼ | 0.013 |
| Collaboration with other community pharmacy |
| Participation in events for patients or the public with other community pharmacies | 22.0% | 42 (41.2%)▲▲ | 23 (23.5%) | 5 (7.5%)▼ | 7 (8.4%)▼▼ | < 0.001 |
| Participation in joint training and study sessions with other community pharmacies | 28.0% | 42 (41.2%)▲▲ | 34 (34.7%) | 9 (13.4%)▼ | 13 (15.7%)▼ | < 0.001 |
| Sharing information using information-providing documents | 39.7% | 49 (48.0%)△ | 53 (54.1%)▲▲ | 23 (34.3%) | 14 (16.9%)▼▼ | < 0.001 |
| Provision of information via the medicine profile book | 75.7% | 85 (83.3%)△ | 81 (82.7%) | 41 (61.2%)▼ | 58 (69.9%) | 0.003 |
| Provision of information by other means | 30.9% | 48 (37.3%)△ | 54 (40.8%)△ | 49 (23.9%) | 65 (16.9%)▼▼ | < 0.001 |
| Receipt the medicine from other community pharmacies or make over the medicine to other community pharmacies | 91.1% | 95 (93.1%)△ | 93 (94.9%) | 61 (91.0%) | 70 (84.3%)▼ | 0.001 |
| Number of community pharmacy undertakings related to a regional medical collaboration |
| Calculation of fee for family pharmacist guidance | 60.2% | 85 (83.3%)▲▲ | 77 (78.6%)▲▲ | 40 (59.7%) | 7 (8.4%)▼▼ | < 0.001 |
| Sharing of cases in which medicine-related adverse events were prevented or avoided to medical provider | 50.3% | 66 (64.7%)▲▲ | 66 (67.4%)▲▲ | 28 (41.8%) | 16 (19.3%)▼▼ | < 0.001 |
| How to share patient information within community pharmacy |
| Implementation of case review meeting | 23.7% | 35 (34.3%) ▲ | 23 (23.5%) | 15 (22.4%) | 10 (12.0%)▼ | < 0.001 |
| Oral communication | 85.7% | 95 (93.1%) ▲ | 87 (88.8%) | 61 (91.0%) | 57 (68.7%)▼▼ | < 0.001 |
| Sharing patient information via intranet or other bulletin boards | 32.6% | 39 (38.2%) | 33 (33.7%) | 26 (38.8%) | 16 (19.3%)▼ | 0.020 |
| Sharing through medical history | 90.3% | 99 (97.1%) ▲ | 93 (94.9%) | 59 (88.1%) | 65 (78.3%)▼▼ | < 0.001 |
| Implementation of reporting in accordance with procedures related to adverse reaction reports | 33.1% | 51 (50.0%)▲▲ | 42 (42.9%)△ | 17 (25.4%) | 6 (7.2%)▼▼ | < 0.001 |
| Reporting to medical providers | 51.1% | 69 (67.7%)▲▲ | 60 (61.2%) | 29 (43.3%)▽ | 12 (25.3%)▼▼ | < 0.001 |
| Reporting to marketing authorization holders | 25.7% | 42 (41.2%)▲▲ | 29 (29.6%) | 11 (15.4%)▽ | 8 (9.6%)▼▼ | < 0.001 |
| Reporting to PMDA | 36.3% | 59 (57.8%)▲▲ | 49 (50.0%)▲ | 16 (23.9%)▼ | 3 (3.6%)▼▼ | < 0.001 |
| Reporting to other institutions | 10.3% | 21 (20.6%)▲▲ | 10 (10.2%) | 4 (6.0%) | 1 (1.2%)▼ | < 0.001 |
| Interaction with other medical providers through joint study sessions | 38.0% | 52 (51.0%)▲▲ | 54 (55.1%)▲▲ | 12 (17.9%)▼▼ | 15 (18.1%)▼▼ | < 0.001 |
The implementation status of regional medical collaboration of each community pharmacy was classified into four groups. The association between implementation status to establish a regional medical collaboration system and each variable was evaluated by the Cochran–Armitage trend test. Abbreviation: PMDA, Pharmaceutical and Medical Devices Agency. △: Standardized residual (dij) > 1.96, ▲: dij >2.58, ▲▲: dij >3.30. ▽: dij<−1.96, ▼: dij<−2.58, ▼▼: dij<−3.30. ※1 Specified medicine management guidance 2 is a dispensing fee that can be calculated when administrating antitumor agents and other medicines prescribed to patients who inject antitumor agents is managed and patients’ physical condition and/or supports taking them.
There was a statistically significant association between all items requiring collaboration with community pharmacies and a positive attitude toward the establishment of a regional medical collaboration system (p < 0.05). However, the decrease in the implementation rate of the items required for collaboration was not linear from Groups 1 to 4.
There was a statistically significant association between the implementation rate of undertakings related to regional medical collaboration at community pharmacies and a positive attitude toward the establishment of a regional medical collaboration system (p < 0.05). Among these items, there was a linear decrease from Group 1 to Group 4 in the rates of “calculation of Fee for family pharmacist guidance,” “implementation of reporting in accordance with procedures related to adverse reaction reports” and “adverse drug reaction reports to each organization.” On the other hand, there was a non-linear decrease from Group 1 to Group 4 in the implementation rate of “sharing of cases in which medicine-related adverse events were prevented or avoided to medical provider” and “interaction with other medical providers through joint study sessions.”
In addition, among the methods of sharing patient information within community pharmacies, the implementation rate of “implementation of case review meeting” and “sharing through medical history” decreased linearly from Group 1 to Group 4. However, the decrease in “oral communication” and “sharing patient information via intranet or other bulletin boards” were not linear from Group 1 to Group 4.
Factors to Improve a Regional Medical CollaborationNecessary items were identified for establishing and improving a regional medical collaboration system and were performed in Groups 1 to 4 to confirm which items were greatly influenced.
The results of the ordinal logistic regression analysis (fitting model: p < 0.001, R2 = 0.32) are shown in Table 3. In this model, the items showing a significant positive correlation with the positive attitude toward establishing a medical collaboration system were “collection of cases in which medicine-related adverse events were prevented or avoided,” “calculation of the fee for family pharmacist guidance,” “calculation of the fee for inhaled medicine guidance,” “regional care meetings and/or service collaboration meetings,” and “information sharing with other medical providers through medical information collaboration networks.” Additionally, we evaluated three intercepts in the ordinal logistic regression model: intercept [1] (Group 1 vs. other groups), intercept [2] (Groups 1 and 2 vs. Groups 3 and 4), and intercept [3] (Group 4 vs. other groups). Intercepts [1] and [3] are statistically significant (p = 0.001), except for Intercept [2]. The results for all variables used in this analysis are shown in Supplementary Material 2.
Table 3. Ordinal Logistic Regression Analysis
| Estimate parameters | p-Value | VIF |
|---|
| Intercept [1] | 2.09 | 0.001 | — |
| Intercept [2] | 0.001 | 0.100 | — |
| Intercept [3] | −2.04 | 0.001 | — |
| Collection of cases in which medicine-related adverse events were prevented or avoided | 0.74 | < 0.001 | 2.02 |
| Calculation of fee for family pharmacist guidance | 0.70 | < 0.001 | 1.94 |
| Calculation of fee for inhalation medicine guidance | 0.56 | 0.002 | 1.70 |
| Regional care meetings and/or service collaboration meetings | 0.55 | 0.020 | 2.52 |
| Information sharing with other medical providers through medical information collaboration networks | 0.46 | 0.010 | 2.09 |
Ordinal logistic regression model (Group 1, Group 2, Group 3, and Group 4) with objective variables from Group 1 to Group 4 indicating factors to establish a regional medical collaboration system. Model fit of Ordinal logistic regression (p < 0.0001, R2 value = 0.32, and LOF p > 0.99). Intercept [1] is divided into Group 1 vs. other groups, intercept [2] is divided into Group 2 vs. Group 3, and intercept [3] is divided into Group 4 vs. other groups.
Table 4 shows the results of awareness of the improvement in regional medical collaboration in each group.
Table 4. Current Situation and Problem of a Regional Medical Collaboration
| Overall (N = 350) | Group 1 (n = 102) | Group 2 (n = 98) | Group 3 (n = 67) | Group 4 (n = 83) |
|---|
| Reasons for not implementing measures to improve the regional collaboration (including multiple answers) |
| Only the items included in the pharmacy functional information report are sufficient | 19.4% | 32 (31.4%) | 21 (21.4%) | 11 (16.4%) | 4 (4.8%) |
| Lack of manpower | 47.4% | 39 (38.2%) | 39 (39.8%) | 37 (55.2%) | 51 (61.5%) |
| Facilities other than community pharmacies, such as regional core hospitals, have not established a regional medical collaboration system. | 10.3% | 16 (15.7%) | 9 (9.2%) | 7 (10.5%) | 4 (4.8%) |
| There are few reasonable benefits to implementation related to facility standards, etc. | 12.9% | 5 (4.9%) | 11 (11.2%) | 11 (16.4%) | 18 (21.7%) |
| There are few reasonable benefits to improving pharmacy profitability | 12.0% | 10 (9.8%) | 12 (12.2%) | 7 (10.5%) | 13 (15.7%) |
| No opportunities to collaborate with other medical providers | 32.9% | 20 (19.6%) | 33 (33.8%) | 31 (46.3%) | 31 (37.4%) |
| Opportunities for collaboration with other medical providers, but no experience | 13.4% | 12 (11.8%) | 14 (14.3%) | 10 (14.9%) | 11 (13.3%) |
| Others | 8.0% | 10 (9.8%) | 6 (6.1%) | 4 (6.0%) | 8 (9.6%) |
| Necessary matters perform unique measures to improve a regional medical collaboration (including multiple answers) |
| Increase pharmacists working in community pharmacies | 37.4% | 30 (29.4%) | 36 (36.7%) | 31 (46.3%) | 34 (41.0%) |
| Establishment of a regional medical collaboration system led by organizations other than community pharmacies such as regional core hospitals and pharmacy associations, etc. | 40.6% | 47 (46.1%) | 52 (53.1%) | 25 (37.3%) | 18 (21.7%) |
| Deepening collaboration with community pharmacies and other medical providers | 59.7% | 57 (55.9%) | 68 (69.4%) | 50 (74.6%) | 34 (41.0%) |
| Reasonable benefits over the implementation related to the facility standards, are required | 30.9% | 30 (29.4%) | 31 (31.6%) | 24 (35.8%) | 23 (27.7%) |
| Reasonable benefits to improve community pharmacy profitability are required | 30.9% | 40 (39.2%) | 28 (28.6%) | 21 (31.3%) | 19 (22.9%) |
| No unique measures required | 2.3% | 0 (0.0%) | 2 (2.0%) | 1 (1.5%) | 5 (6.0%) |
| Others | 4.0% | 4 (3.9%) | 5 (5.1%) | 1 (1.5%) | 4 (4.8%) |
The most common reason for not implementing measures to improve regional collaboration within a community pharmacy was “ack of manpower,” followed by “no opportunities to collaborate with other medical providers.”
In order to implement unique measures aimed at improving a regional medical collaboration, the most common necessary matter was “deepening collaboration with community pharmacies and other medical providers,” followed by “establishment of a regional medical collaboration system led by organizations other than community pharmacies such as regional core hospitals and pharmacy associations, etc.” In each group, the most important item for implementing unique measures aimed at improving regional medical collaboration was “deepening collaboration with community pharmacies and other medical providers.” An “increase in pharmacists working in community pharmacies” was common in Group 4. The next necessary item was the “establishment of a regional medical collaboration system led by organizations other than community pharmacies such as regional core hospitals and pharmacy associations, etc.” in Groups 1 to 3, and “reasonable benefits over the implementation related to the facility standards, are required” in Group 4.
DISCUSSION
It is important to establish a collaboration system of regional medical providers, with “family pharmacy and family pharmacist” as one of the core components. Administrative support is essential to establish a collaborative system for regional medical providers to maximize the use of limited resources. Therefore, it is necessary to assess the current status of collaborative systems. Although the Japanese government has publicly collected and disclosed information on community pharmacy functions, it has not been able to fully ascertain the actual status of regional medical collaboration. This study covers information that could not be captured by the current Pharmacy Functional Information Provision System. Furthermore, the implementation status of community pharmacies engaged in regional medical collaboration was evaluated in groups and the actual status of their efforts in the collaboration system was described in detail. These efforts used for classification are considered to be extremely important items for the establishment of a regional medical collaboration system, since collaboration with other medical providers is required.
First, the implementation status groups to establish the regional medical collaboration system, which we predefined before distributing the survey instrument, were assessed based on the following implementation rates: (1) the collection of cases in which medicine-related adverse events were prevented or avoided, (2) the implementation of the pharmacist’s duties according to protocols agreed upon by the physician, and (3) the standardization of medicines used through collaboration among medical providers. All these implementation rates, prime representatives of medical collaboration, were significantly positively correlated with our defined groups of the implementation status of regional medical collaboration. These items were also included in the functional community pharmacy information disclosed by Tokyo Metropolitan Government, and in the questionnaire used in this survey for verification. As a result, the items added for verification were consistent with the public information used to classify the implementation status of regional medical collaboration, suggesting that the response bias was negligible. Thus, the defined group of implementation status is meant to serve as an indicator that reflects the efforts of regional medical collaboration, and the definition of the implementation status is the willingness to establish a regional medical collaboration system.
We then surveyed the form of the community pharmacies, status at the time of obtaining official accreditation, and status of implementation of regional medical collaboration efforts for each classified group (Table 2). Most of the pharmacies that responded were located outside hospitals (99.4%). Of these, 28.8% were independent of specific hospitals. Although the independence of medical providers was not statistically significant (p = 0.19), it was suggested that there was a tendency toward the implementation of regional medical collaboration. Simultaneously, a higher percentage of community pharmacies with less implementation status for collaborating with medical providers were located in the vicinity of hospitals. In addition, the percentage of prescriptions prescribed by fixed hospitals was 20–39%, most common in Group 1, and 80–100%, most common in Group 4, showing a linear decrease from Group 1 to Group 4. In other words, they received prescriptions from various hospitals as they approached Group 1, whereas the closer they were to Group 4, they received prescriptions from the same hospitals, such as a nearby hospital or clinic. This suggests that the closer community pharmacies are to Group 4, the more often they receive prescriptions from patients outside of the community.
In this study, the status of collaboration with other medical providers in each group was clarified by dividing each group according to the “Regional Medical Collaboration System” item (Fig. 1) in the functional information of community pharmacies. As a result, the implementation rate was the highest in Group 1 and the lowest in Group 4. In addition, the implementation rate of each action item showed a significant decreasing trend in Groups 1–4, indicating a correlation between a positive attitude toward the establishment of a regional medical collaboration system and the implementation rate of these items related to a regional medical collaboration system.
In the ordinal logistic regression, the attributes of community pharmacies with detailed information on the state of regional medical collaboration and items indicating the state of collaboration with other medical providers were used as explanatory variables. There were statistically significant differences between Groups 1 and 2, and between Groups 3 and 4, but not between Groups 2 and 3. In other words, there is a clear distinction between Group 1 and the other groups, and Group 4 and the other groups, although there is no difference in the status of the establishment of a regional medical collaboration system between Groups 2 and 3.
Of the estimated parameters for the items used as explanatory variables, the items with the highest values were “collection of cases in which medicine-related adverse events were prevented or avoided,” followed by “calculation of the fee for family pharmacist guidance,” “calculation of the fee for inhalation medicine guidance,” “regional care meetings and/or service collaboration meetings,” and “information sharing with other medical providers through medical information collaboration networks.” A regression equation that included these five items was derived. The results suggest that these five items may trigger the establishment of a regional medical collaboration system. However, of these items, the “collection of cases in which medicine-related adverse events were prevented or avoided” is implemented in many community pharmacies (implementation rate is 64.9%) and it is included in the Community Pharmacy Functional Information report. As stated in the notice by MHLW,9) if the following two points are satisfied, community pharmacies can answer that “collection of cases in which medicine-related adverse events were prevented or avoided” is “Yes.” First, community pharmacies should collect cases of avoiding adverse medicine reactions and should register “near-miss” under the project to promote medical safety measures in community pharmacies, if the relevant information is provided to medical providers. The second was to report events in which prescriptions were changed due to prescription inquiries during the previous year (January 1 to December 31) on the date specified by the Japanese government in the Guidelines for Implementation of Pharmacy Functional Information Provision System,10) which prevented patients from suffering harm to their health or from failing to obtain the intended efficacy of a physician. Article 24 of the Japanese Pharmacist Act specifies the duty of pharmacists to prevent health hazards to patients by changing prescriptions based on prescription inquiries. In other words, community pharmacies that answered “Yes” for “collection of cases in which medicine-related adverse events were prevented or avoided” because of changing prescriptions based on prescription inquiries are included. In light of this point, community pharmacies implementing a “collection of cases in which medicine-related adverse events were prevented or avoided” are not necessarily able to establish a regional medical collaboration system.
On the other hand, since “calculation of fee for inhalation medicine guidance” is required to be reported to hospitals, it was considered to have a function as a tool for collaboration with other medical providers. There are many other types of additional fees for which such collaboration is required; however, statistically significant estimated parameters were not obtained for fees other than those for inhalation medicine guidance. This suggests that the difficulty in calculating fees for inhalation medicine guidance is relatively low among those for which collaboration with other medical providers is required. Accordingly, it was thought that calculating the fee for inhalation medicine guidance would be one of the starting points for establishing regional medical collaboration in community pharmacies where this fee has not been calculated.
With regard to “regional care meetings and/or service collaboration meetings” and “information sharing with other medical providers through medical information collaboration networks,” they identified opportunities to meet other medical providers. Therefore, the fact that there is complimentary relationship among other medical providers is considered a factor that leads to the improvement of a regional medical collaboration system.
In the survey on attitudes toward improving regional medical collaboration, many community pharmacies answered that they could not take measures to improve it because of a lack of manpower or opportunities to collaborate with other medical providers. In addition, the need to deepen collaboration with other medical providers to implement efforts to improve regional medical collaborations became clear. The need for opportunities for collaboration with other medical providers supports the results of the ordinal logistic regression. These results suggest that opportunities to collaborate with medical providers, such as regional core hospitals, are necessary to establish a regional medical collaboration system, and that such opportunities reinforce medical collaboration.
Based on these results, community pharmacies should ideally plan or join study meetings to increase collaborative opportunities with other medical providers. However, it is necessary to hold joint study meetings not only on the community pharmacy side but also with the participation of other medical providers, such as regional core hospitals, pharmacy associations, and other non-community pharmacy organizations. Community pharmacists should actively participate in these meetings.
However, this study has several limitations. First, the pharmacies included in this study were limited to those in Japan, and the generalizability of the applications outside Japan should be given due consideration. Second, in this survey, quantitative evaluation using dispensing fees could not be possible with regard to the establishment status of a regional medical collaboration system. Accordingly, we should evaluate the establishment status of this system by using dispensing fees, and quantitatively evaluate the characteristics of community pharmacies that have established such a system. Third, this study was a macro analysis of community pharmacies and did not consider the influence of individual pharmacy workers. Although this study identified the factors associated with the implementation status of regional medical collaboration in each community pharmacy, it did not reveal the willingness of individual pharmacists to establish such a system. As a future issue, in addition to facility-based surveys, it is necessary to survey pharmacists working in community pharmacies and other medical institutions such as hospitals on their attitudes toward it. Fourth, the model constructed in this study has limitations in terms of the goodness of fit. The R2 value of the ordinal logistic model used in this factor analysis was 0.32; its use as a forecasting equation requires further improvement.
Despite above limitations, this study comprehensively identified the status of the regional medical collaboration system and clarified the characteristics of the pharmacies that have been able to establish such a system. In conclusion, we showed that complimentary communication strengthens regional medical collaboration, including information sharing (such as prescription, patients etc.) between pharmacies and other medical providers.
Acknowledgments
In conducting this survey, we would like to thank the Pharmaceutical Affairs Section, Health and Safety Division, Bureau of Public Health, Tokyo Metropolitan Government for providing information on responses to the community pharmacy functional information report and the Tokyo Metropolitan Government's independent published item report, which were the subject of the survey as of 27 July, 2022.
Conflict of Interest
The authors declare no conflict of interest.
Supplementary Materials
This article contains supplementary materials.
REFERENCES
- 1) United Nations. “World Population Projects 2019 Highlights.”: ‹https://population.un.org/wpp/publications/files/wpp2019_highlights.pdf›, accessed 12 April, 2024.
- 2) Statistics Bureau of Japan. “Japan Statistical Yearbook 2022.”: ‹https://www.stat.go.jp/english/data/nenkan/71nenkan/zenbun/en71/book/html5.html#page=2›, accessed 12 April, 2024.
- 3) Ministry of Health, Labour and Welfare. “Community-based Integrated Care System.”: ‹https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/hukushi_kaigo/kaigo_koureisha/chiiki-houkatsu/›, accessed 12 April, 2024.
- 4) Japan Pharmaceutical Association. “Estimated prescription receipt rate for all insurance (social insurance + national health insurance + older elderly) dispensed in fiscal 2023.”: ‹https://www.nichiyaku.or.jp/assets/uploads/activities/bungyo/s/R3suikei.pdf›, accessed 12 April, 2024.
- 5) Ministry of Health, Labour and Welfare. “Ideal state of pharmacies and pharmacists and the separation of prescription and dispensing (Part 1).”: ‹https://www.mhlw.go.jp/content/11121000/000366641.pdf›, accessed 12 April, 2024.
- 6) Ministry of Health, Labour and Welfare. “The Pharmacy Functional Information Service System.”: ‹https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kenkou_iryou/iyakuhin/kinoujouhou/index.html›, accessed 12 April, 2024.
- 7) Katsuta D, Kamimura M, Kuriya K, et al. Survey on the current status of the regional medical collaboration system and community pharmacy functions in Tokyo. Japanese Journal of Community Pharmacy, 12, 21–37 (2024).
- 8) Tokyo Metropolitan Government. “Pharmacy Functional Information Report.”: ‹https://www.hokeniryo.metro.tokyo.lg.jp/anzen/iyaku/sonota/youshiki_down/yaku_kyoka/kohyo_hokoku.files/r3yousiki.pdf›, accessed 12 April, 2024.
- 9) Ministry of Health, Labour and Welfare. “Points of Attention When Reporting the Concept of the Pharmacy Functional Information Provision System.”: ‹https://www.mhlw.go.jp/content/000792095.pdf›, accessed 12 April, 2024.
- 10) Ministry of Health, Labour and Welfare. “Guidelines for Implementation of the Pharmacy Functional Information Provision System.”: ‹https://www.mhlw.go.jp/seisakunitsuite/bunya/kenkou_iryou/iyakuhin/dl/kinoujouihou0623_2.pdf›, accessed 12 April, 2024.
