Pharmacists' Perceived Knowledge and Expertise in Selected Pediatric Topics

Abstract

OBJECTIVES

The purpose of this study is to determine pharmacists' perceived knowledge and expertise required to make recommendations regarding selected pediatric topics.

METHODS

A questionnaire was distributed to 400 pharmacists practicing in community, hospital, and home care settings. This instrument explored their perceived knowledge, expertise, and comfort in providing recommendations related to 38 pediatric topics. The impact of responder demographics on differences in perceived knowledge and expertise for each topic were evaluated.

RESULTS

Ninety-five of 400 (24%) questionnaires were returned completed or partially completed. Forty-seven and 36 of responders practiced in the community or inpatient hospital setting, respectively. Seventy percent of responders reported that ≤ 40% of their patients were children. In general, responders believed they had the knowledge and expertise to make recommendations for the frequently occurring conditions or topics but not for the less familiar. Formal pediatric training was the most influential responder characteristic with a larger proportion having training that they believed enables them to have knowledge and expertise to make recommendations. Although less impressive, experience of more than 5 years and a community-based practice were also important factors.

CONCLUSION

Additional training is beneficial in increasing the perceived knowledge and comfort of pharmacists making recommendations regarding pediatric patients.

INTRODUCTION

Determining appropriate medication use in children frequently places health care providers in a quandary. The rapid and varying physiologic development that occurs during childhood causes changes in pharmacokinetic and pharmacodynamic parameters, which complicate dosing recommendations.¹ Young infants and children present additional challenges with drug administration. For the anxious and inexperienced caregiver, giving the correct dose using oral syringes, measuring cups, and droppers may present an arduous task.² Inappropriate dosing may lead to a lack of efficacy or significant toxicity. This scenario was highlighted during an October 2007 joint session of the Food and Drug Administration Center for Drug Evaluation and Research Nonprescription Drugs Advisory Committee and Pediatric Advisory Committee.³ Based on a combination of a lack of supporting clinical efficacy, errors from dosing or administration, and an increase in adverse drug effects reported, this session ended with a rejection of cough and cold medication use in children < 2 years of age. Previously, 14 products that targeted infants were withdrawn from the market. Of interest, several committee members were concerned that withdrawal of these products might lead to more errors as caregivers attempted to use products intended for older children.

For pharmacists within the community setting, American Pharmacists Association President Winnie Landis raised expectations of patient counseling. Her comments during the open public hearing portion of the October 2007 joint session noted “Pharmacists are available to help consumers learn how to appropriately select and use OTC (over-the-counter) products and equally as important, when not to use OTC products.”³ OTC products are not the only concern. Prescription medication for infants and children, used within an institution or provided on hospital discharge, from an ambulatory clinic, or from a pharmacy located within a heath care system or community site, also require provider or caregiver to provide patient counseling. The need for pharmacists' intervention or consult within the hospital inpatient setting has been noted by several studies. One study demonstrated that 5.7% of inpatient pediatric medication orders contained errors and 1.1% of the orders could potentially result in an adverse drug reaction.⁴ A significant proportion of pediatric medical residents, during all years of training, make dosing calculation errors in infants and children.⁵ Medication errors in children and the need for pharmacists to advise both caregivers and providers has been the topic of several publications.^6–10 Regardless of prescription or OTC medications or the practice setting, it is clear pharmacists need to advise caregivers and health care providers on appropriate medication use. To do so will require a basic understanding of infant and childhood conditions and their treatment coupled with willingness to or comfort in advising caregivers. There is a lack of data regarding pharmacists' perceived knowledge of and comfort in making recommendations regarding pediatric topics. The primary objective of this study was to determine pharmacists' perceived knowledge and expertise to make recommendations regarding 38 selected pediatric topics. A secondary outcome was to determine the impact of selected responder demographics on differences in perceived knowledge and expertise.

MATERIALS AND METHODS

Survey

This study was approved by the associated university Human Investigation Committee. A pilot survey was developed by a panel consisting of pharmacists with pediatric experience in both inpatient and outpatient settings and a research design specialist with experience in survey development. The survey consisted of 3 parts. Part 1 consisted of responder demographic data (Table 1). This included age, gender, ethnicity, years as a practicing pharmacists, pediatric training, primary practice setting, approximate percent of their patients that are children, preceptor role during the past 3 years, and parental status. Pediatric training included whether or not they completed a course or rotation in pediatrics while in school or a pediatrics residency or fellowship, or the number of continuing education (CE) credit hours earned on pediatric topics within the past 2 years.

Table 1.

Summary of Responder Demographic Data

Part 2 consisted of 4 sections and used a 5-point Likert scale. For each section, responders were asked to indicate their agreement with the study statements using the scale 1, strongly disagree; 2, disagree; 3, neutral; 4, agree; 5, strongly agree. Section 1 queried the responder's perceived responsibility to provide consultations and evaluated the amount of CE related to pediatric issues that had been taken. Sections 2 to 4 involved 38 topic areas selected by the panel (Table 2). Topic areas included those likely encountered in the ambulatory or inpatient settings. Less frequently occurring conditions were included if the panel believed a pharmacist's consult would be valuable. Also included were topics believed to be of interest to early adolescents or their caregivers. Although additional topics may have been included, limitations in responder time and questionnaire size precluded their inclusion. Responders were asked their agreement with the following statements: Pharmacists have the knowledge and expertise to make recommendations (section 2), I feel comfortable making recommendations (section 3), and I have the knowledge and expertise to make recommendations (section 4).

Table 2.

Questionnaire Topics and Percent Responding Agree or Strongly Agree for Each Topic

Part 3 queried the responders' impression of the study questionnaire. Using the same Likert scale, responders were asked their agreement with the statements: The questions were easy to understand, the format of the questionnaire made it easy to use, and the questionnaire contained knowledge areas that are important in my practice. Additionally, they were asked to comment on the time required to complete the questionnaire, any questions too difficult to understand, questionnaire format, and topic areas. Part 3 was intended to guide changes following a piloting of the survey.

Procedure

The pilot survey was distributed to a convenience sample of 20 pharmacists practicing in community or home care settings within the Detroit, Michigan metropolitan area. It has a Flesch-Kincaid readability score of 11.6 and was considered appropriate for the selected participants. Along with the questionnaire, participants received a cover letter and information sheet. The cover letter invited their participation and documented appropriate university approval. The information sheet explained the study purpose, procedures, benefits, risks, costs, lack of compensation, confidentiality, and voluntary participation. In addition, participants received an addressed stamped envelope to return the completed surveys. To ensure individual responder anonymity, an individual not involved in the study received the completed surveys and removed any personal identifying information from the return envelope before forwarding the questionnaires to the research team. Completed study questionnaires were securely stored and accessible to only study personnel.

Results of the 20 pilot surveys, part 3 responders' impression of the study questionnaire, were reviewed and it was determined that no changes were necessary. The results of the pilot surveys were filed for inclusion in the final analysis. As previously done, the cover letter, information sheet, and an addressed stamped envelope were sent to pharmacists practicing in several sites. Sites selected were involved as university training locations for Doctor of Pharmacy students and were again located within the Detroit, Michigan metropolitan area. They included a free-standing pediatric hospital, 3 primarily adult institutions, and 3 different community pharmacy chains. At each of these hospital or community sites, all pharmacists were given an opportunity to participate. Permission to solicit the pharmacist's participation was first obtained from the hospital or pharmacy management. A total of 400 surveys (including pilot surveys) were distributed. Upon return, an individual not involved in the study removed personal identifying information prior to their being securely stored. Data were only accessible to study personnel at the time of analysis.

Data Analysis

Survey item questions were categorically scaled; as such, data were presented using frequency counts and percentages. Associations between categorically scaled variables were examined using cross-tabulations. Differences in proportions were interpreted using a Fisher exact test. Data are shown as mean ± SD. Differences were considered statistically significant at p≤0.05, two-tailed. All statistical procedures were conducted using SPSS Version 15.0 (SPSS, Inc, Chicago IL).

RESULTS

Responder Demographics

Ninety-five of the 400 (24%) questionnaires were returned. Seventy-seven surveys were fully completed, while 18 were partially completed. Table 1 summarizes the responder demographic data. Most responders were white (87%) and female (65%). The primary practice setting of 47 (49%) and 36 (38%) responders was community and inpatient hospital, respectively. Almost one half (45%) of responders reported that ≤ 20% of their patients were children, while 55 (71%) reported that ≤ 40% of their patient population were children. Only 16 responders (21%) noted that their patient population was 81% to 100% children, which reflects data from the children's hospital. Almost half of responders (47%) reported training in pediatrics, which was described as a residency/fellowship, pediatric didactic course, or pediatric rotation.

Not unexpectedly, responders from the children's hospital (n=16) reported a larger proportion of pediatric training when compared with other respondents (n=79). Thirty-one percent (n=5) of pediatric pharmacists reported they were required to take a didactic course in pediatrics while in pharmacy school, 44% (n=7) noted taking a pediatric elective course, and 68.8% (n=11) reported taking a pediatric rotation. This compared with only 12.7% (n=11), 14% (n=11), and 13.9% (n=11), respectively, of those not employed in a pediatric arena.

Only 2 of the 16 (13%) responders who were employed in a children's hospital completed a pediatric residency and none completed a fellowship. When answering questions about CE, 53% (50/95) agreed or strongly agreed that education in pediatric related areas should be mandatory. Only 12% (11/95) disagreed or strongly disagreed. This is consistent with the 82% (78/95) who agreed or strongly agreed that providing information about pediatric issues is a pharmacist's professional responsibility. Only 2% (2/95) disagreed or strongly disagreed.

Knowledge and Expertise

Table 2 lists the 38 pediatric topic areas, which are ordered by the percent responding agree or strongly agree for each topic within section 4 (i.e., I have the knowledge and expertise to make recommendations regarding the topic). For 10 of 38 topics, > 75% of responders agreed or strongly agreed with this statement. Not surprising, these 10 involved familiar topics such as cough and cold, analgesics, antipyretics, and diaper rash. Similar results were found for these topics within questionnaire sections 2 and 3. For 14 of the 38 topics, less than 50% of responders strongly agreed or agreed they have the knowledge and expertise to make recommendations. These topics, such as enuresis, anorexia/bulimia, terminal illness, cancer, and poisoning, for which the expert panel believed a pharmacists' consult would be of value, may be less familiar, and their input less likely. For 2 topics, dehydration and fluid status and attention deficit hyperactivity disorder (ADHD), > 50% of responders agreed or strongly agreed that pharmacists have the knowledge and expertise to make recommendations. However, < 50% responded they were comfortable with and knowledgeable enough with these topics to make recommendations. Finally, although 64% agreed or strongly agreed that pharmacists have the knowledge and expertise to make recommendations regarding diabetes mellitus, only 42% of responders felt they had the knowledge and expertise to make recommendations.

Impact of Responder Demographics

Responder demographics selected were pediatric training, years as practicing pharmacist, primary practice setting, experiential rotation student preceptor during the past 3 years, and parental status. Table 3 lists the statistically significant differences for the selected demographics among responders agreeing or strongly agreeing they had the knowledge and expertise to make recommendations. Responders with any training (required or elective class, rotation or pediatric residency) were compared with those with no training. Across each of the 38 topics, a greater proportion of responders with training agreed or strongly agreed they have the knowledge and expertise to make recommendations. For responders indicating they have the knowledge and expertise, there was a significantly larger proportion in those with pediatric training for oral contraceptives and birth control (22/26 vs 27/45; p=0.04), teething (31/31 vs 39/48; p=0.01), poisoning (17/25 vs 16/43; p=0.02), cancer (9/26 vs 4/49; p=0.01), and terminal illness (8/27 vs 4/50; p=0.02). Similarly, there was a significantly greater proportion in those with training for dehydration and fluid status, swimmer's ear, food allergies, weight loss and bodybuilding, constipation, enuresis, drug use with lactation, apnea, and nutritional requirements and vitamin supplements.

Table 3.

Significant (p≤ 0.05) Differences Among Responders Agreeing or Strongly Agreeing They Had the Knowledge and Expertise to Make Recommendations

Responders with more than 5 years as a practicing pharmacist were compared with those with less experience. For most topics, responders with > 5 years experience were more likely to strongly agree or agree they possessed the knowledge and expertise to make recommendations. For all responders who indicated they have the knowledge and expertise, a significantly difference was noted for those with more than 5 years of experience for topics including minor burns (56/60 vs 16/22; p=0.02), teething (54/58 vs 16/21; p=0.05), ringworm (51/55 vs 15/21; p=0.02), and eczema (44/53 vs 11/19; p=0.05) (Table 3).

For most topics, responders who practiced in the community setting (n=42) were more likely to report they had the knowledge and expertise to make recommendations than those working in an inpatient hospital (n=28). There was a significant difference between these 2 practice setting for swimmer's ear (41/42 vs 21/28; p=0.01), ringworm (41/42 vs 18/25; p=0.003), acne (39/39 vs 18/27; p=0.01), eczema (32/37 vs 17/27; p=0.04), allergic rhinitis (43/44 vs 23/28; p=0.03), nausea/vomiting/diarrhea (38/39 vs 22/27; p=0.04), skin rashes (40/42 vs 20/26; p=0.05), ear wax removal (40/42 vs 20/26; p=0.05), teething (39/41 vs 22/28; p=0.05), and diaper rash (43/44 vs 24/28; p=0.05). Conversely, significantly more inpatient hospital pharmacists noted they had the knowledge and expertise to make recommendations related to terminal illness (7/29 vs 2/37; p=0.04) and poisoning (17/29 vs 9/28; p=0.05).

Significant differences were found between responders that did or did not serve as a preceptor of student pharmacist in the past 3 years (Table 3). For responders indicating they have the knowledge and expertise to make recommendations, there was a significantly more served as a preceptor for poisoning (18/25 vs 15/42; p=0.01), asthma (25/26 vs 34/45; p=0.05), and substance abuse (11/25 vs 8/43; p=0.05). Likewise, a significantly larger proportion of those with children indicated they had the knowledge and expertise to make recommendations for ADD/ADHD (26/39 vs 10/25; p=0.04) and teething (49/52 vs 21/27; p=0.05).

DISCUSSION

A spokesperson for the American Pharmacists Association suggested pharmacists were available to assist in the selection and use of products intended for children. Survey responders agreed. For the most part, they believe it is their professional responsibility to provide information. The results of our survey indicate that most responders had no formal training in pediatrics, which is consistent with previous publications that noted limited pediatric training for pharmacy students.^11,12 Further, although most responders indicated that CE credits related to pediatric issues should be mandatory, only a relatively few earned CE credits devoted to pediatric topics.

Pharmacists' perceived knowledge and expertise to make recommendations varied with the topics. For commonly occurring conditions, which are most frequently observed in an ambulatory setting, most responders indicated they had the knowledge and expertise to make recommendations. This is not surprising considering almost 50% of responders practiced in a community setting. Although the quality of potential recommendations was not addressed in this study, the frequency of exposure to these topics may result in a greater willingness to engage the patient and provide information. Conversely, conditions such as apnea, pediatric cancer, anorexia/bulimia, and terminal illness in children are observed less frequently in both community and general hospital settings. Those caring for children with these conditions frequently require more support and information from a pharmacist. Unfortunately, responders did not believe they had the knowledge and expertise to make recommendations regarding these conditions. Because most responders had no formal pediatric training and few CE credits are devoted to pediatric topics, we suggest this gap in pharmacists' knowledge be addressed within colleges of pharmacy curriculum and by CE providers. The 4.2 hours of pediatric CE reported in this survey represents a small number of the required hours of credit for most states and is only 14% of the 30 contact hours required in Michigan during a 2-year license cycle. If one considers that 16 responders practiced in the children's hospital, this number of 4.2 hours may be higher than expected within general pharmacy practice.

In 2005, the Pediatric Practice and Research Network of the American College of Clinical Pharmacy issued an opinion that current pediatric curricula are inadequate and must be improved.¹³ That same year, the Pediatric Pharmacy Advocacy Group, in response to the American Society of Health System Pharmacists' Guidelines on Providing Pediatric Pharmacy Services, suggested schools of pharmacy better prepare graduates in the provision of pediatric pharmaceutical care.¹⁴ Our results support the need for enhanced pediatric training. Those with training believed they had the knowledge and expertise to make recommendations, and thus are more likely to engage caregivers or health care providers to a greater extent than responders without training. This occurred for all 38 of the selected topics. For 14 of the topics, the difference in proportion between those trained and untrained in pediatrics was a significant factor in those indicating they possessed the knowledge and expertise. This occurred in several of the less familiar topics (e.g., cancer, terminal illness, apnea) or conditions that may be encountered within both the institutional and community setting. It should be noted that for a number of commonly occurring situations, such as the use of analgesics, antipyretics, treatment of coughs, colds, or head lice, there were no significant differences between trained and untrained responders. Further, and perhaps more meaningful, for those pediatric conditions observed less frequently, current training did not completely prepare pharmacists to make recommendations. The proportions of those with perceived expertise and knowledge, even when there was a significant difference between trained and untrained responders, were small. Results from this survey may be instrumental in focusing educational efforts.

Although not as prominent a factor as training, 2 additional responder characteristics potentially associated with perceived knowledge and expertise were practice experience greater than 5 years and practice in a community site. These characteristics appear to influence perceived knowledge and expertise primarily of common conditions or topics. They appeared to have minimal influence on less common topics where input or advice may be of great value to the caregiver.

Our conclusions are limited by the small number of responders and by those within each demographic category. Although 400 surveys were distributed, the low response rate contributed to this small number. Because similar studies were not available on which to power our primary outcome, no power analysis was performed and we are unaware of the impact of only 95 completed or partially completed questionnaires. We are also not aware if our responders had advanced training in other areas, which may have influenced our results. Further, for convenience we surveyed pharmacists practicing at university-associated student pharmacists training locations. Although not all pharmacists at these locations are involved with students, this may have introduced a selection bias. Had we randomly selected sites, the results may have changed. Additionally, because we surveyed pharmacists within the Detroit, Michigan metropolitan area, our conclusions may be limited to this region. It is possible for pharmacists practicing in other geographic areas to differ in their understanding of pediatric topics. Finally, as previously suggested, perceived knowledge and expertise may be a result of familiarity but does not guarantee the willingness to provide consultation or the accuracy of the recommendation.

CONCLUSION

This study demonstrated that most pharmacists believe it is their responsibility to provide information on pediatric issues. However, although formal pediatric training was shown to impact responder perceived knowledge and expertise to make recommendations, less than half had received formal training and relatively few CE credits involved pediatric issues. We conclude that additional pediatric training is beneficial if pharmacists are to provide meaningful recommendations to caregivers including the selection and use of products intended for children.

Abbreviations

ADHD

attention deficit hyperactivity disorder

CE

continuing education

OTC

over-the-counter