Discussion
Around one-third of hospital pharmacists were involved in multidisciplinary TB care, and one-quarter had TB-specific tasks. Most hospital pharmacists were female, young professionals in an early-to-middle career stage, working in a hospital of the highest accreditation with specialty TB polyclinics. Most TB-related CPS was directed at patients, followed by patient support (medication use supervisor) and other healthcare professionals (nurse, physician). TB-related CPS mainly focused on medication safety and adherence. Pharmacists’ views on TB-related CPS implementation factors were generally positive, except for financial incentives. Mid-range career experience, ever-received TB-related training, working in a mediocre accredited hospital and specific assignments to provide TB-related CPS significantly predicted pharmacists’ involvement in multidisciplinary TB care teams.
In Indonesia, CPS implementation and development is still in its early stages,22 especially for TB with a patient-centred multidisciplinary care model. Thus, our finding of the low involvement of pharmacists in this type of care is plausible. A national study showed that young female pharmacists are more likely to engage in patient-centred activities,23 which might be the case for TB care, as we also found a higher proportion of young females (in their 30s) than male pharmacists working in hospitals, that is in line with that study.
Many factors determine the TB care process and outcomes. Non-adherence to treatment is a significant factor causing inadequate drug effectiveness and adverse reactions, leading to drug resistance.24 25 Pharmacist intervention through CPS can address these issues,25–28 but its implementation is challenging18 and requires a comprehensive and collaborative approach focusing on the unique traits of each patient.2 7
Despite the limited number of patients receiving collaborative TB care,9 we found that patients were the most likely to receive CPS, indicating their high involvement with pharmacists, and this could improve TB understanding and the quality of care,29 30 motivating them to adhere to their treatment.31 However, our study did not elaborate on the relationship between greater involvement, better engagement and treatment outcomes.
Drug effectiveness is determined by its bioavailability, predicting TB treatment outcomes,5 which can be maintained and improved by adhering to the medication. Directly observed therapy), or supervised medication administration, is one of the strategies to enhance TB medication adherence. Supervised medication administration by non-healthcare professionals with adequate health education positively influences TB patient outcomes.32 Our findings highlight the role of CPS in supporting non-healthcare professionals, as indicated by the high number of medication-use supervisors receiving CPS.
Aside from the patients themselves, healthcare professionals have a pivotal role in TB treatment initiation and adherence.33 Nurses who clinically manage patients have a higher engagement with patients than pharmacists. Improved knowledge of medication preparation and administration errors of nurses would increase patients’ safety, averting undesirable effects of medication administration.34 While collaborative pharmacist-nurse medication adherence interventions are limited, our study found that nurses were the healthcare professionals who mostly received CPS. Educating patients about TB care and medication by nurses significantly improves adherence and quality of care31; hence, high pharmacist interaction with nurses through CPS can facilitate the transfer of drug-related knowledge that benefits patients.
Physicians, the primary persons responsible for TB patient care, often need to share their duties with pharmacists and nurses,35 but their interactions with pharmacists are slightly different compared with other recipients of CPS. Physicians need pharmacists to be more proactive within their scope of expertise and open communication related to patient care when necessary.10 36 37 Due to this type of interaction, our study found lower physician involvement as a recipient of CPS. However, this does not warrant lower engagement quality because physicians acknowledge pharmacists’ role in patient care.38
The pharmacist’s perceived and actual role is partially defined by their clinical and communication skills, which remain significant obstacles across various disease conditions,10 39–41 as might be the case in TB care. Therefore, despite pharmacists’ positive views and other healthcare professionals’ acknowledgement of their capacity for effective TB care, only a limited number of pharmacists had a specific TB-related CPS assignment or were part of multidisciplinary TB care teams, as seen in this study. Although policies, infrastructure and quality care are in place, this gap persists and suggests that pharmacists’ competencies have not yet been translated into added value in the TB care process.
The TB-related CPS emphasises medication adherence and safety, as per current policies and guidelines,2 7 since poor medication adherence and adverse drug reactions are still prevalent24 32 42 43 and must be addressed. Non-adherence to TB medication negatively affects health outcomes and costs; hence, implementing cost-effective adherence interventions is necessary for successful outcomes.42 We found that adherence monitoring was a top priority in TB-related CPS. Notably, digital adherence technologies (DAT) increasingly support adherence interventions in TB.44 45 Besides monitoring and supporting adherence directly, combining DAT with therapeutic drug monitoring (TDM) could further aid personalised TB care.46 47 The latter, TDM, was not part of the top listed CPS activities in Indonesia; only drug therapy monitoring was more of an activity to ensure safe, effective and rational drug therapy for patients, not specifically assessing blood drug concentration. However, TDM uptake by hospital pharmacists is increasingly acknowledged globally as part of optimal TB drug dosing.48
Regarding medication safety, we found that drug use evaluation is essential for monitoring adverse events and vital to TB care success,49 which indicates CPS activities are done according to the evidence that despite the proven effectiveness and safety of the WHO standard regimen,50 with possible drug resistance occurrence,24 close monitoring of adverse events43 is needed through drug use evaluation.
Regarding healthcare services provided in a regulated setting like a hospital, accreditation status indicates its quality and patient safety, whereas specialised healthcare services are available in a higher accredited hospital.51 A higher level of accreditation does not necessarily predict pharmacist involvement in TB care. The availability of general services also plays a role, as most TB cases are typically less severe3 and preferably managed through general health services.2 We found that a higher accredited hospital may have lesser predictive value for pharmacist involvement in multidisciplinary TB care, especially for moderately accredited hospitals, due to the balance between specialised and general service availability.
Additionally, financial incentives adequacy is essential and may improve professional practice when providing CPS.52 While it is true that providing clinical and non-clinical services is part of the standard services by the pharmacist,53 with an immature professional recognition system,54 augmented by variability in the remunerated service, patient eligibility and fees, making standardised financial incentives difficult, despite growing financial support.55 The inadequacy is stressed by our finding, where perceived financial incentives still lag, even with presumably supportive policies, infrastructure, quality care and self-competence of the pharmacist.
Our study showed that higher working experience is an added value for healthcare professionals, especially for pharmacists involved in TB care, which is best at the mid-range level. We argue that they are technically involved with patient services and can simultaneously manage TB cases. Apart from work experience, competence in TB care is built through technical and managerial knowledge, which can be obtained through education and training.56 Unfortunately, our study showed that most pharmacists had limited TB-specific training; this could undermine the TB care process. Though this study showed fewer pharmacists ever receiving TB-related training, the TB-related training and specific assignment to provide TB-related CPS determine pharmacists’ involvement in multidisciplinary TB care. They are greatly affected by pharmacist competencies through education and training.57
Several strengths and limitations should be noted. A strength was the nationwide survey in Indonesia based on the sampling adequacy and participating pharmacist workforce proportion.23 The survey was extensively validated and reported according to the CHERRIES checklist.
We applied a strict rule on the online survey based on the device identity and idle time to avoid duplicated participation; hence, when the survey was accessed and started but not completed within 24 hours, it could not be reaccessed from the same device (based on cookies) and considered incomplete. While we targeted hospital pharmacists, the announcement was received by all pharmacists within the SIAP. With further filtering questions in the questionnaire, hospital pharmacists’ who provided TB-related CPS as a participant was ensured. A limitation is that it is self-reported and an internet-based survey; hence, it relies on participant access and customary internet use. This could result in some institutions having many hospital pharmacists responding and fewer in other institutions. However, a limited response rate does not necessarily increase the selection bias level,57 though the generalisability of results needs further study.
To further strengthen multidisciplinary TB care, several recommendations can be made. First, hospital pharmacists will benefit from additional TB training. Second, proper financial incentives should be provided. Third, the commitment of the local leaders to encourage and assign CPSs in TB is essentially needed. Finally, more evidence is needed on the added value of hospital pharmacists’ involvement in TB care and the effectiveness of the TB-related CPS itself.