Participant demographics
Twelve participants were initially invited to participate in this study. Two did not respond, and two could not participate because of time constraints. Consequently, invitations were sent to three additional participants who were available and willing to participate. Thus, 11 individuals were interviewed. Table 1 presents the characteristics of the participants.
Table 1
Characteristics of key informants
Code | Gender | Position |
P1 | Female | Pharmacy lead |
H1 | Female | Manager of health centre |
C1 | Male | Primary care physicians with cardiology privilege |
P2 | Male | Pharmacy lead |
H2 | Female | Manager of health centre |
P3 | Male | Pharmacy lead |
C2 | Male | Primary care physicians with cardiology privilege |
F1 | Female | Physician lead |
H3 | Male | Manager of health centre |
F2 | Female | Physician lead |
P4 | Male | Pharmacy lead |
[insert Table 1 here]
Thematic findings
The themes that emerged during the interviews were mapped according to the CFIR domains and collectively described the feasibility, barriers, and facilitators of implementing the service in primary care. Table 2 displays the CFIR domains and the main constructs derived from the interviews, each with its corresponding definition.
[insert Table 2 here]
Table 2
Main CFIR domains and constructs identified in interviews
Domain | Constructs | Short description* |
Intervention characteristics | Evidence Strength and Quality | Stakeholders’ perceptions of the quality and validity of evidence supporting the belief that the intervention will have desired outcomes. |
Relative advantage | Stakeholders’ perception of the advantage of implementing the intervention versus an alternative solution. |
Complexity | Perceived difficulty of the intervention, reflected by duration, scope, radicalness, disruptiveness, centrality, and intricacy and number of steps required to implement. |
Outer settings | Cosmopolitanism | The degree to which an organization is networked with other external organizations. |
Inner settings | Readiness for implementation | Tangible and immediate indicators of organizational commitment to its decision to implement an intervention. |
Compatibility | The degree of tangible fit between meaning and values attached to the intervention by involved individuals, how those align with individuals’ own norms, values, and perceived risks and needs, and how the intervention fits with existing workflows and systems. |
Networks and Communications | The nature and quality of webs of social networks and the nature and quality of formal and informal communications within an organization. |
Relative priority | Individuals’ shared perception of the importance of the implementation within the organization. |
Characteristics of individuals | Individual Stage of Change | Characterization of the phase an individual is in, as he or she progresses toward skilled, enthusiastic, and sustained use of the intervention. |
Process | Tailoring strategies | Choose and operationalize implementation strategies to address barriers, leverage facilitators, and fit context. |
Engaging | Attracting and involving appropriate individuals in the implementation and use of the intervention through a combined strategy of social marketing, education, role modeling, training, and other similar activities. |
*Adapted from The Consolidated Framework for Implementation Research construct descriptions (22). |
Intervention characteristics
This domain presents key informants’ perceptions of a pharmacist-led anticoagulation service in primary care.
Evidence strength and quality
Most participants were unaware of research evidence supporting the effectiveness of pharmacist-led anticoagulation service in primary care. However, many participants cited positive evidence of pharmacist-led anticoagulation clinic outcomes implemented in the secondary care setting, particularly Hamad Medical Corporation (HMC), the main secondary health care provider in Qatar.
"We know it is available at HMC and already implemented. Personally, I did not work on it, so I have no information about the outcomes, but I'm sure it has a positive impact." P4
“The patients were satisfied with the convenience of walk-in services. Those I have treated at Hamad are doing well.” C1
Many participants emphasized the necessity of specialized clinics, indicating that the current practice of warfarin management in primary care is inefficient. They attributed this inefficiency to three main factors: reluctance of some family physicians to treat patients on warfarin and would prefer to refer them to secondary care; patients primarily visiting primary care for medication refills without having a clear treatment plan; and inconsistent adherence to warfarin dispensing protocols by pharmacists.
“As family physicians, we do not have extensive background knowledge about anticoagulation management; therefore, we often have to refer the patient.” F1
“I always visit pharmacies where the received prescriptions are dispensed as they are, especially those coming from Hamad. Usually, warfarin is not prescribed by family physicians at the PHCC; it is often prescribed by specialized clinics like cardiology at Hamad and family physicians in primary care only refill the prescription without making any modifications.” P4
The participants identified several advantages of the proposed model during the interviews. Many interviewees indicated that the development of a specialized anticoagulation clinic at the PHCC is anticipated to significantly improve patient accessibility to healthcare services and reduce burden on secondary care services.
“This is easier for patients in terms of time and accessibility. Hamad [Secondary care provider] has a limited number of hospitals, whereas there are 31 primary care centers distributed across Qatar. Therefore, it is easier for patients to reach the clinic, which saves time and effort.” P4
Some interviewees emphasized the importance of having a clinical pharmacist available in primary care to address complex issues related to the management of anticoagulation therapy.
“Another important point is that warfarin has a high drug– drug interaction … patients on warfarin are usually on polypharmacy, so their management is complicated in which the pharmacist-led clinic would be beneficial.” P2
Concerning the disadvantages, most interviewees had concerns about increasing the workload on primary care, as they pointed out that they had already grappled with staff shortages, and the staff who would manage the clinic would be mostly released from the regular workflow. Furthermore, two participants doubted the patient’s acceptance of the intervention.
“I cannot see any serious disadvantages of that because it is more beneficial. The only thing is to have a very competent pharmacy team.” C2
“It could be the workload, especially since we have shortages of staff, it could be one of the disadvantages, only this the main thing is the workload.” H2
Complexity
The participants had diverse perspectives on the perceived difficulty of the intervention, considering factors such as the complexity of the intervention itself, integration of the service into the usual workflow, number of steps involved in the clinic execution, and complexity associated with the scope of practice of pharmacists. Many participants agreed that implementing a pharmacist-led anticoagulation model in primary care is a high-risk intervention. Some participants found it relatively easy to integrate and adapt the service to the workflow. Others attributed the complexity of the service to the scope of practice of the clinical pharmacist and primary care.
Regarding the perceived complexity in the number of steps needed for clinic execution, the majority agreed that it would be manageable; however, they recognized that it would still require a significant amount of time.
“There is no legal prohibition preventing pharmacists from prescribing. It depends on the internal policy… It is not complicated as it is a high-risk project, you have to study everything” P1
“It takes time, which is one thing. There are several parties, so things are difficult. I am not saying this is easy; it is difficult but achievable.” C1
Outer settings
This domain presents key informants’ perceptions of the external environment and contextual factors in which the PHCC operates, which have a substantial impact on implementing a pharmacist-led anticoagulation clinic.
Cosmopolitanism
The majority of participants valued their ongoing communication with external organizations, particularly the HMC. They identified HMC as an external organization that has the most significant impact on the development of the clinic. Many participants stressed that the HMC is a central organization whose requirements should be a priority for the clinic to adhere to.
“You have to work with the cardiologist in Hamad to implement one clinic and run a joint clinic; for example, the anticoagulation clinic running in Hamad, which is a pharmacy-led clinic, they can come here, or I know they are doing clinic in a cardiology setup, so they have expertise there like physicians or cardiologists running parallel.” C1
Inner settings
This domain presents key informants’ perceptions of the internal environment and contextual factors of the PHCC that impact the implementation of a pharmacist-led anticoagulation clinic.
Readiness for implementation
In general, all participants acknowledged the critical role of resource allocation in ensuring successful implementation of anticoagulation service. They also acknowledged the presence of skilled and knowledgeable clinical pharmacists capable of running the clinic.
“There are clinical pharmacists here who are very competent and knowledgeable, so some kind of small training may be needed. If you add streamlining to anticoagulation clinics, that is all.” C1
However, the majority expressed concerns about the potential shortage of staff if the pharmacists were drawn from the existing workforce, as they were already grappling with staff shortages. Moreover, some participants identified the need to assign a nurse to the clinic, which poses a challenge due to the existing shortage of nurses.
“A clinical pharmacist will be taken from the available staff, which will lead to a decrease in the number of pharmacy staff.” P2
“Nurses are very limited, the staff shortage, the main problem we face, the staff shortage, both in physicians and nursing departments, which would be a barrier I would say.” C1
Most participants believed that other essential components, such as physical space, INR testing machines, clinical guidelines, and the necessary database, are readily available and should not be an obstacle to the development of the clinic.
“Most clinics are new, so the issue of resources is solved except in the case of some pharmacies as a manpower, but resources, empty clinics, physicians, and INR tests are available.” P3
Compatibility
Most participants believed implementing a pharmacist-led anticoagulation clinic at the PHCC aligned with several corporate goals, including patient safety, patient-centered care, improving health outcomes for patients with chronic diseases, and providing high-quality services. In addition, some participants believed that this intervention was compatible with the values and work processes of the PHCC.
“According to the new operational plan and strategic department, the golden goal was to minimize referrals from primary care to secondary care. It will be an excellent idea to start the clinic at this time...” F2
Networks and communications
There was a consensus among the participants that they had strong internal communication, which may support the implementation.
Relative priority
The participants expressed diverse views on the priority of developing a dedicated anticoagulation clinic within the organization. While some considered the clinic to be of utmost priority, many held the view that there are more critical initiatives to prioritize over the clinic.
“Warfarin is one of the important services, looking from the risk point of view, definitely it has a priority.” C2
Characteristics of individual
This domain describes the characteristics of individuals involved in implementing anticoagulation clinics in primary care, including administrators, and healthcare providers.
Individual stage of change
Many participants displayed a positive attitude toward the proposed model. Furthermore, they expressed the need to progress toward consistent use of the service.
“I am not against such clinics because we have always worked with specialized nurses, nurse-led clinics, and pharmacist-led clinics will be still better.” C1
Most participants shared the perception that implementing the clinic would encounter a high degree of flexibility from the healthcare provider in scheduling appointments and referring their patients to be managed within the clinic. They believed that general practitioners would refer their patients to the clinic without hesitation.
“They were highly coordinated. The referrals were excellent. From previous experience with the clinical pharmacy clinic, once they knew the clinic was operated, the referral increased. I followed all the interventions. I have never faced any refusal to any intervention.” P3
Additionally, they highlighted that patients would accept the concept of the clinic. However, they acknowledged that it might take a short time for patients to fully accept the idea.
“If you see any of the specialized clinics, it is all the specialists who are brought into the community simply because, closer to home, they will be happy. They used to visit this health center there, the family health center. They like the physicians or nurses here; like family, they know everyone here.” C1
Process
This domain emerged throughout the interviews and comprised two main constructs related to the perceptions of stakeholders regarding effective strategies for overcoming implementation challenges, leveraging facilitators, and ultimately ensuring successful implementation.
Tailoring strategies
Most participants emphasized the importance of ensuring the competency of the clinical pharmacist in managing the clinic. In addition, many participants highlighted the need for pharmacists to work under the supervision of a cardiologist.
“The only thing is to have a competent pharmacy team, which is very important. Are people well trained? Do they have proper clinical exposure in addition to their theoretical knowledge of the studies or the courses they have completed?” C2
Many interviewees emphasized the necessity of establishing a clear operational pathway for the clinic.
"Workflow, specifically the operational part, includes factors such as working hours, number of appointments, patient load for each pharmacist, and time spent with each patient. All these factors should be taken into consideration” P1
Some participants emphasized the importance of using clinical practice guidelines for the safe use of anticoagulants in primary care settings. They suggested that the protocol should be established in collaboration with HMC and aligned with the clinical pharmacist’s scope of practice, as determined by the PHCC and Ministry of Health.
“This protocol and policy will define the tasks that can be performed, such as referring the patient back to the doctor and setting the inclusion and exclusion criteria. At the PHCC, it is applicable, but it will be project-based, and you will need physicians and clinical pharmacists who should understand the limitations of the pharmacist in this context.” P4
Effective internal and external communication was frequently highlighted as a key factor by many participants for the successful operation of the clinic.
"In any project or service, communication between patients and the multidisciplinary team is crucial. This enhances workplace communication and benefits both team and patient interaction. Increased transparency with patients is also essential, making communication more effective and important." P3
Engaging
This subtheme outlines the process and strategies for engaging individuals involved in the implementation and adoption of a pharmacist-led anticoagulation clinic in primary care settings to ensure its successful establishment and operation. The participants identified several strategies for engaging patients in the clinic, such as marketing campaigns and direct communication. In addition, some participants emphasized the role of secondary and tertiary care physicians and the proper awareness of engaging patients with the service.
“The first thing we should do is collaborate with Hamad, so the patient from Hamad or physician from Hamad should inform the patient that yes there is a clinic. The same occurs in the cardiology clinic. It was difficult at the beginning because people thought we had a cardiology clinic there, until Hamad convinced their patients that the same physicians from Hamad were covered in the health center.” H1