Background In the UK, 6.5% of hospital admissions are attributed to adverse effects of high-risk medicines, including warfarin and non-steroidal anti-inflammatory drugs (NSAIDs). Warfarin and NSAIDs ‘care bundles’ were developed to address this. These services focus on improving care processes and patient outcomes. They focus on medication-specific interactions and patient education, and were piloted in 2017 in 24 pharmacies across four healthcare regions, with intent for national implementation. This study aims to identify barriers and facilitators influencing their successful implementation.

Methods Following a systematic review identifying barriers and facilitators to the national implementation of community pharmacy innovations, a questionnaire was developed and disseminated in June 2017 to pharmacy staff (n=217) in the pilot pharmacies. Multivariate regression analysis was conducted to identify barriers and facilitators influencing successful implementation (determined using a 6-item Likert-scale). Pearsons-Chi Square test was used to identify differences between the bundles.

Results Seventy-four participants (34.1%) responded from 17 pharmacies (70.8%). 73.1% and 72.1% considered the warfarin and NSAIDs bundles successfully implemented respectively. Multivariate regression analysis identified two factors influencing successful implementation of the warfarin bundle (p<0.001, R²=0.752): compatibility of the bundle with pharmacies’ processes; and positive perceptions of patients. For the NSAIDs bundle, four predictors of implementation success (p<0.001, R²=0.633) were identified: pharmacy staff having sufficient knowledge of NSAIDs; perceived incentives involved in bundle delivery; workload of the NSAIDs bundle; and funding. Compared to the NSAIDs bundle, pharmacy staff involved with the warfarin bundle were less likely to agree there were sufficient pharmacy staff (p=0.030), and that they had enough time (p=0.025) and training (p=0.004) to deliver the bundle.

Conclusion The questionnaire successfully identified barriers and facilitators to the implementation of the bundles. Warfarin bundle success factors (compatibility and positive patient perceptions) were unsurprising as previous strategies in Scotland have engaged pharmacies with warfarin counselling, and patients are likely to have experienced some warfarin counselling already. This is not the case for NSAIDs, therefore it is understandable that additional strategic facilitators (incentives and funding) were success factors. Workload associated with the NSAIDs bundle was a risk to successful implementation, potentially explained by the greater number of patients from over-the-counter purchases and prescription supplies. Contextual factors not captured may explain differences (e.g. regional staffing issues may explain why warfarin bundle participants were less likely to think they had sufficient staff and time).