Use of pharmacy services in community-dwelling middle-aged and older adults; findings from The Irish Longitudinal Study on Ageing (TILDA)

Introduction The role of community pharmacists has evolved in recent years with expansion in pharmacy services offered. The extent to which patients utilise such services in community pharmacies in Ireland is unclear. Objective To assess pharmacy services use among adults aged ≥56 years in Ireland, and determine the demographic and clinical factors associated with pharmacy services use. Methods This cross-sectional study included community-dwelling participants in wave 4 of The Irish Longitudinal Study on Ageing (TILDA), aged ≥56 years who were self-respondents. TILDA is a nationally representative cohort study, with wave 4 data collected during 2016. TILDA collects participant demographics and health data, in addition to information on the use of several services when visiting the pharmacy in the last 12 months. Characteristics and pharmacy services use were summarised. Multivariate logistic regression was used to examine the association of demographic and health factors with reporting (i) any pharmacy service use and (ii) requesting medicines advice. Results Among 5782 participants (55.5% female, mean age 68 years), 96.6% (5587) reported visiting a pharmacy in the previous 12 months, and almost one fifth of these (1094) utilised at least one non-dispensing pharmacy service. The most common non-dispensing services reported were requesting advice about medications (786, 13.6%), blood pressure monitoring (184, 3.2%), and vaccination (166, 2.9%). Controlling for other factors, female sex (odds ratio (OR) 1.32, 95% CI 1.14–1.52), third-level education (OR 1.85, 95% CI 1.51–2.27), higher rates of GP visits, private health insurance (OR 1.29, 95% CI 1.07–1.56), higher number of medications, loneliness, and respiratory condition diagnosis (OR 1.42, 95% CI 1.14–1.74) were associated with higher likelihood of utilising pharmacy services. The relationship between these factors and requesting medicines advice was similar. Conclusion A high proportion of middle-aged and older adults visit community pharmacy and a fifth utilise specified pharmacy services. Despite advances in the services offered in pharmacies, medicines advice remains at the core of pharmacists' practice.


Introduction
Community pharmacy has a potentially significant role in expanding access to community-based healthcare while providing enhanced services outside of traditional medication dispensing. In recent years, the role of community pharmacists has evolved globally, with expansion in a wide variety of pharmacy services offered in the community setting, 1 with further developments since the onset of the COVID-19 pandemic. [2][3][4] In Ireland, enhanced or extended community pharmacy services include: interventions focused on smoking cessation, blood pressure monitoring, and inhaled medication adherence. 5 A recent study by Heinrich and Donovan (2022) identified that community pharmacists in Ireland reported confidence and willingness to play a greater role in medication deprescribing, but were limited in their involvement by time constraints while remuneration, interdisciplinary education, and bidirectional communication with prescribers facilitated community pharmacy deprescribing involvement. 6 When considering the extent to which pharmaceutical care is provided by community pharmacists, Ireland had a significantly higher total score than other European countries in the Behavioral Pharmaceutical Care Scale (BPCS), with the highest score for direct patient care activities. 7 These include patient assessment, implementation of therapeutic objectives and monitoring plans, and verifying patient understanding. Furthermore, there was a statistically significant positive relationship between provision of a health service (health screening; patient monitoring; domiciliary visiting; health promotion/education) and higher BPCS scores, suggesting community pharmacists and pharmacies in Ireland may be providing health services in greater number or frequency than other European countries. 7 Exploratory Research in Clinical and Social Pharmacy 10 (2023) 100265 Although community pharmacies in Ireland have expanded enhanced and non-traditional service offerings, little is known about the uptake of pharmacy services in the middle-aged and older population in this setting. As such, the objectives of this study were to 1) assess pharmacy service use among adults aged 50 years and over in Ireland and 2) determine what demographic and clinical factors are associated with pharmacy service use.

Methods
This was a cross-sectional study of community-dwelling participants in wave 4 of The Irish Longitudinal Study on Ageing (TILDA). A nationally representative cohort study focusing on health, social and economic circumstances, TILDA recruited a sample of the population from a geodirectory of households in Ireland with residents 50 years of age and older with a baseline sample size of 8175 participants and a 62% response rate. 8 Individuals younger than 50 years of age and those residing in a nursing home or receiving institutional care were excluded from sampling. Wave 4 data were collected during 2016, and the current analysis included self-respondents (i.e., proxy respondents were omitted), who were all aged ≥56 years. Ethical approval for each wave of data collection was obtained from the Faculty of Health Sciences Research Ethics Committee at Trinity College Dublin, Ireland. All participants provided written informed consent.
Data collection at wave 4 involved a computer-assisted personal interview (CAPI) with a trained interviewer in the participant's home, covering a wide range of questions relating to economic, health and social circumstances, as well as a self-completion questionnaire. As part of the CAPI, TILDA participants were asked if they utilised several named services when visiting their pharmacy in the last 12 months. These included: requesting advice about medication; vaccination; blood pressure (BP) or cholesterol checks; advice on smoking cessation or weight management; and diabetes, asthma, or allergy tests. A full list of pharmacy services included in the CAPI questionnaire is included in Appendix 1; medication dispensing was not asked about as a service.
Factors were identified based on the literature and clinical experience, which could plausibly be associated with pharmacy services use. These included socio-demographic factors, age, sex, and level of educational attainment, classified as no or primary education, secondary education, or third-level (i.e., college-level) education. Healthcare use factors included the level of GP utilization (self-reported number of GP visits in the previous 12 months, divided into groups based on quintile), private health insurance status, and their public health cover entitlement. This was categorised as: those with a medical card (with eligibility based on age and household income, covering a third of the population and two-thirds of those aged ≥65 years, 9 entitling individuals to a range of public health services at low or no cost), a GP visit card (with eligibility based on a higher income threshold, entitling to free GP visits), or neither of these. TILDA participants are asked to report doctor-diagnosed health conditions (based on a list of common conditions, and with the opportunity to provide "other" responses) and medications they take on a regular basis. The latter was used to determine participants with polypharmacy (≥5 medications, excluding supplements) and major polypharmacy (≥10 medications). Reported medications were also used to identify participants taking highrisk medication classes (anticoagulants, NSAIDs, opioids, diuretics, antiplatelets, antimicrobials, insulin and hypoglycemics). 10 Last, within the self-completion questionnaire, participants were asked how often they felt lonely. In Ireland, loneliness has been shown to be positively associated with the number of general practitioner visits 11 ; however, the relationship between loneliness and pharmacy service use in Ireland has not been described.
All study analyses were performed using Stata 17 (StataCorp. 2021. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC). The characteristics of all included participants were described. The prevalence of reported use of any of the above services, as well as the prevalence for each service separately, were summarised among all participants. The relationship between high-risk medication categories and the pharmacy service of requesting advice about medications was assessed using chisquare tests. The relationship between the above characteristics and reporting use of any pharmacy services was assessed using multivariate logistic regression, generating adjusted odds ratios with 95% confidence intervals (CI). A further regression model was fitted with requesting advice about medications as the dependent variable (as the most prevalent service reported). Statistical significance was assumed at p < 0.05.

Results
This study included 5782 participants, 55.5% were female with a mean age of 68 years. A total of 96.6% of participants (5587) reported visiting a pharmacy in the previous 12 months, and almost one fifth of these (1094, 18.9%) utilised at least one specified pharmacy service. A summary of the participants characteristics and a comparison of characteristics between service non-users and users is included in Table 1.
The most common services reported were requesting advice about medications (786, 13.6%), blood pressure monitoring (184, 3.2%), and vaccination (166, 2.9%). A summary of frequency of service use across all participants is included in Fig. 1. Compared to those not using any services, users were a similar age (mean 68 years), but were taking more medications (mean 3.6 versus 2.8), were more often female (64.1% versus 54.2%), had higher educational attainment, and had higher GP visit rates.
Considering the relationship between specific high-risk medications and requesting advice about medications, there were statistically significant associations for anticoagulant, antiplatelet, and NSAID medication use (Fig. 2). Further, the composite for any high risk medication use was associated with requesting advice about medications. Results from Chi-square tests for high risk medication category and requesting advice about medications at the community pharmacy are included in Appendix 2.
Controlling for other factors, the following were associated with a higher likelihood of utilising pharmacy services: female sex (adjusted OR 1.32, 95% CI 1.14-1.52), third-level (i.e., college-level) education (OR Table 1 Descriptive statistics for overall participant demographics and comparison of participants between any pharmacy service non-users and users (n = 5782).  Fig. 3. The relationship between these factors and requesting medicines advice were similar (Appendix 3), and notably taking a highrisk medication was significantly associated (OR 1.24, 95% CI 1.01-1.52).

Discussion
This study identified that nearly one-fifth of individuals who visited a pharmacy in the past 12 months used a non-dispensing pharmacy service. The most common service reported was requesting advice about medications. Service use outside of medication advice was relatively low, with the highest services used being blood pressure monitoring (3.2%) and vaccination (2.9%). Pharmacy services offered in Ireland have not changed substantially since these data were collected, with the exception of expansion into COVID vaccination in 2021.
These findings reflect those in existing community pharmacy literature. First, a number of studies have focused on community pharmacist perspectives on enhanced services, with pharmacists reporting they most frequently provide services considered standard practice while occupying conventional roles within the healthcare system (i.e., medication dispensing). 1,12,13 There is wide variation in pharmacist willingness to provide/provision of pharmacy services across and between countries, 14 with countries like New Zealand effectively scaling select pharmacy services (e.g., provision of trimethoprim for uncomplicated urinary tract infections, 85% of pharmacies surveyed) while other services are less frequently reported (e.g., supply selected oral contraceptives, 44% of pharmacists surveyed). 15 Although pharmacists in other countries report willingness to provide enhanced or expanded pharmacy services, information on the extent of service offering, availability, and uptake is limited. 16,17 Profitability of such services may influence the extent to which pharmacists offer them. With the exception of testing and vaccination, most services asked about in TILDA often do not incur fees for patients (and influenza vaccination is the only service funded by the government).
Further, lack of patient awareness of pharmacy services may contribute to low uptake and repeated use. A systematic review of patient and public perspectives of community pharmacy services in the United Kingdom identified that low public or patient awareness of pharmacy services was a common theme in existing literature, with lack of publicity and exposure to pharmacy services identified as potential explanations. 18 Further, a patient preference study by Janet et al. (2010) included in the systematic review found 28 participants (15.8%) chose a pharmacy providing extended services as their least preferred pharmacy, compared to just one patient who selected the pharmacy as their first choice. 18,19 The review also found patient perceptions of the role of pharmacists and physicians were contributing factors to service use, with a number of facilitators and barriers to service use identified. 18 Newer studies have focused on patient preferences for enhanced services provided in the community pharmacy setting using discrete choice experiments, measuring patient preference with utility. 20,21 A study examining patient preferences for enhanced services in the community pharmacy setting found that services focusing on the provision of prescription drugs for minor ailments, pharmacogenetic testing, and pointof-care testing resulted in negative utility values, suggesting that older patients taking more medications expressed disfavor in the provision of these services and may prefer pharmacies who offer standard pharmacy services. 22 Conversely, a study exploring expanded pharmacy service use in Australia identified that the mean number of pharmacy services that patients felt their community pharmacists should provide was significantly higher for older patients (>55) compared to those who were <25 years of age. 23  Overall, the evidence for patient preference and expectation for pharmacy services is mixed, with these differences potentially explained by a difference in the type of pharmacy services offered and included in the studies and patient-specific characteristics like gender and education level. In addition to service availability, patient awareness, and preferences for pharmacy services, patient-specific factors have been shown to contribute to service use. In this study, patient-specific factors which were positively associated with service use were female sex, third level education, higher rates of GP visits, private health insurance, higher number of medications, loneliness, and a diagnosed respiratory condition. In the existing literature, number of medications are associated with an increase in service use. 24 A study by Picker et al. (2015) found that the prevalence of 30-day hospital readmissions was associated with patients' number of discharge medications, with a larger number of medications increasing risk of readmission. 25 In addition to number of medications, this study found certain categories of high-risk medications were associated with requesting advice about medications specifically. Additionally, a large body of literature has identified multimorbidity, often defined as the coexistence of two or more conditions, as a predictor of increased health service use. 26,27 Multimorbidity has been associated with potentially inappropriate prescribing and polypharmacy (taking 5 or more medications). [28][29][30][31] As such, the results from this study highlight the relationship between multimorbidity, medications, and pharmacy service use, suggesting that patients who may most benefit from pharmacist advice (i.e., patients with multiple conditions, numerous medications, high-risk medications) are utilising community pharmacy services. Finally, higher rates of GP visits were associated with pharmacy service use, suggesting patients may utilise pharmacy services as a complement, rather than a substitute for visiting their GP.
Importantly, loneliness has been identified as a contributing factor to increased health service use among older populations in multiple studies. [32][33][34] Loneliness, recognised as a significant public health issue, has a number of health and economic implications, including increased risk of cardiovascular disease. 34,35 Existing literature has identified community pharmacies as a potential health promotion resource for older individuals experiencing loneliness, assisting patients in identifying community resources (e.g., care managers and elderly day cares) and engaging in social prescribing. 34,36,37 In recent years, the role of community pharmacists in mental health has continued to expand, specifically in the development and provision of mental health first aid. 38,39 While not specifically listed as a pharmacy service in TILDA, community pharmacy training and interventions focused on psychological well-being and mental health may provide older adults in Ireland with essential psychological support and help to decrease physician visits and healthcare costs. 34

Limitations and future research
This study has a number of limitations. First, TILDA focuses on middleaged and older adults (all of whom were 56 years and older at wave 4) in Ireland, limiting the generalisability of the findings to other countries and individuals who fall outside of TILDA inclusion criteria. Additionally, while patients reported a variety of pharmacy service use, information on the range of pharmacy services available in Ireland and the proportion of pharmacies offering each service is relatively limited. 40 Future research should focus on exploring the availability of pharmacy services in Ireland, with specific emphasis on pharmacy services and patient perspectives. Additionally, studies focused on the specific strategies to increase public and patient awareness of existing pharmacy services are needed, emphasising existing facilitators and barriers to enhanced service use. Patients may benefit from studies focusing on the development and implementation of additional pharmacy services addressing loneliness and mental health. Although there is evidence of patient benefit from pharmacist provided medication management and counselling, and that provision of vaccination services may enhance access, these and other services should be evaluated as they are developed further to enhance the evidence base. 41 The data in this study were collected before the onset of the COVID-19 pandemic in 2020. The pandemic spurred expansion in the role of community pharmacists internationally and in Ireland, 2,42 with growth in additional services offered given the reduced access to other healthcare providers. 42,43 This included delivery of COVID-19 vaccination, and the enhanced awareness of such expanded pharmacist roles among the population may have impacted the use of pharmacy services generally since 2020. Change in pharmacy services use could be examined in future research analysing data from TILDA participants collected since the onset of the COVID-19 pandemic.

Conclusions
A high proportion of middle-aged and older adults visit community pharmacy and a fifth utilise specified pharmacy services. Despite expansion in the services offered in pharmacies, standard pharmacy services such as medicines advice remain at the core of pharmacists' practice. Patients on multiple medications or with increased GP visits are more likely to use community pharmacy services, suggesting patients may utilise pharmacy services as a complement, rather than a substitute, to visiting their GP. Community pharmacy services were more often used by people who are lonely, identifying an important opportunity for community pharmacies to develop additional interventions focused on health and social support.

Funding
LTM was supported through a grant from the Health Research Board (grant number ILP-HSR-2019-006). TILDA is supported by Atlantic Philanthropies, the Department of Health, the Health Research Board and Irish Life.

Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.