The Practice of home healthcare services by Pharmacists in Saudi Arabia

Objectives: To illustrate the practice of home healthcare services by pharmacists in Saudi Arabia. Methods: It analyzes a cross-sectional survey that discussed practice at home health care services in Saudi Arabia. The study comprised respondents’ demographic information about pharmacists and home healthcare pharmacy services implementation and resources used for home healthcare pharmacy services. The


INTRODUCTION
Health care services consist of multiple types: critical, acute, ambulatory, long-term, and home health care. All previous types of care provide Healthcare services directly to the patient through the hospital and primary care centers. [1] One type was home healthcare offers the service at the patient's home. [1,2] Daily, teams visit patients who demand home care, such as elderly patients with chronic conditions or handicapped patients. Each team visits the patients at their homes to provide the services. [2,3] The team consists of physicians, nurses, and an ambulance driver. The team might provide the following services: physical assessment, wound care, vaccinations, laboratory tests, medication therapy, intravenous infusion, respiratory therapy, and nutritional support services. [2,3] In the early morning, the pharmacist prepares and regularly dispenses the medication in bags with appropriate labels to home healthcare nurses. The nurse provides the medications to the patient during the visit. Sometimes the physician writes the prescription, and the caregiver receives the medication from the hospital pharmacy. Few studies worldwide illustrate the pharmacist practice of home care locally or in the Gulf and Arabic countries. [2,[4][5][6][7][8][9][10][11][12][13][14][15] The current cross-sectional study,s aims to investigate home healthcare practice by the pharmacist in Saudi Arabia.

METHODS
The study analyzed a cross-sectional survey that discussed the Pharmacist practice of pharmacy home healthcare services in Saudi Arabia. It selfreported an electronic survey of the pharmacist, including pharmacists from internship to consultant, pharmacist specialties, and Saudi Arabia. All non-pharmacist or students, noncompleted, non-qualified surveys will be excluded from the study. The survey consisted of respondents' demographic information about pharmacists and home healthcare pharmacy services implementation and resources used for home healthcare pharmacy services. [2,[4][5][6][7][8][9][10][11][12][13][14][15] The 5-point Likert response scale system was used with closed-ended questions. According to the previous litterateur with an unlimited population size, the sample was calculated as a cross-sectional study, with a confidence level of 95% with a z score of 1.96 and a margin of error of 5%, a population percentage of 50%, and drop-out rate 10%. As a result, the sample size will equal 380-420 with a power of study of 80%. [16][17][18] The response rate required for the calculated sample size was at least 60-70 % and above . [18,19] The survey was distributed through social media of Whatsapp applications and telegram groups of pharmacists. The reminder message had been sent every 1-2 weeks. The survey was validated through the revision of expert reviewers and pilot testing. Besides, various tests of the reliability of McDonald's ω, Cronbach alpha, Gutmann's λ2, and Gutmann's λ6 were done with the study. The data analysis of the practice of home healthcare services by pharmacists was done through the survey monkey system. Besides, the statistical package of social sciences (SPSS), Jeffery's Amazing Statistics Program (JASP), and Microsoft Excel sheet version 16. It included a description and frequency analysis, good of fitness analysis, and correlation analysis. Besides, inferential analysis of factors affecting home healthcare pharmacy services implementation with linear regression. The STROBE (Strengthening the reporting of observational studies in epidemiology statement: guidelines for reporting observational studies) guided the reporting of the current study. [20,21]

RESULTS
A total number of 393 pharmacists responded to the questionnaire. Of them, more than three-quarters responded from the Central region (303 (77.10%)), with statistically significant differences between the provinces (p=0.000). Most of the responders were from Pharmaceutical Companies (69 (17.56%)), University Hospitals (56 (14.25%)), Community Pharmacy (54 (13.74%)), and Private Hospital (53 (13.49%)), with statistically significant difference between working sites (p=0.000). Males responded less than females (195 (49.74%)) versus 197 (50.26%%)), with statistically non-significant differences between them (p=0.920). Most of the responders were in the age group of 24-35 years (267 (67.94%)) and 36-45 years (121 (30.79%)), with statistically significant differences between all age groups (p=0.000). Most responders held Pharm D (334 (84.99%)). Most of the pharmacists were staff pharmacists (367 (94.34%)), with statistically significant differences between all levels (p=0.000). Most pharmacists had a work experience of 4-6 years (185 (47.07%)), 1-3 years (72 (18.32%)), and 7-9 years (71 (18.07%)), with a statistically significant difference between years of experience (p=0.000). Most pharmacists had worked at Drug Information (239 ((60.81%)), inpatient pharmacy (78 ((53.94%)), and Inventory control (147 ((37.40%)). There was a medium negative correlation between age (years) and gender based on Kendall's tau_b (0.397) and Spearman's rho (0.400) correlation coefficients, with a statistically significant difference between the two factors (p<0.000) ( Tables 1 and 2). The average number of home healthcare prescriptions per responder per day was (17.46), with an estimated total of (6,861) per day, with the highest range of prescriptions (26)(27)(28)(29)(30) and 133 (33.93%) orders per day. Those prescriptions were dispensed to home healthcare (8.34) patients daily per responder, with an estimated total number of home care patients (2,766) daily. The highest number of home care patient range for (16)(17)(18) was 102 (25.95%) patients per responder per day ( Table 3). The average score of the practice of pharmacists about the home healthcare Pharmacy implementations was (4.45). The element "The medication error system is included in home healthcare pharmacy services" obtained the highest score (4.60). The pharmacists believe that "The research on home healthcare pharmacy services" (4.57) and "The cost analysis of home healthcare pharmacy services. In contrast, the lowest score was obtained for the element "The annual plan for home healthcare pharmacy services" (4.29). The score for the element "The pharmaceutical care department provides home healthcare pharmacy activities" was (4.33), for the element "The vision of home healthcare pharmacy services" was (4.34), and the element "Mission of home Healthcare pharmacy services" with a statistically significant difference between the responses (p<0.000). All aspects of the practice of pharmacists about home healthcare Pharmacy implementations were statistically significant between responses (p<0.000) ( Table  4). The most used resources of the home healthcare pharmacy services in practice were Health Practitioners 265 (67.60%) and Drug Bulletin 246 (62.76%). They were followed by the Internet 241 (61.48%) and Scientific literature 212 (54.08%) ( Table 5). The score for single-test reliability analysis of McDonald's ω was 0.985, Cronbach's α was 0.985, Gutmann's was λ2, 0.985, Gutmann's λ6 was 0.993, and Greater Lower Bound was 0.997 with statistically significant (p<0.05).

Factors affecting the home healthcare pharmacy services implementation
Factors affecting the perception were analyzed. We adjusted the significant values using the independent samples Kruskal-Wallis test and the Bonferroni correction for multiple tests. Location, worksite, age (years), gender, experiences, position held, number of homecare prescriptions, and number of homecare patients are all factors in implementing home healthcare pharmacy services. Five locations affected the Home healthcare pharmacy services implementation. There are statistically significant differences between all regions (p=0.000), with the highest score (4.6612) in the central area. Eleven worksites affected the Home healthcare pharmacy services implementation. The Ministry of Health hospital had the lowest scores (3.6092) in implementing Home Healthcare Pharmacy Services, with a statistically significant difference between working sites (p = 0.000) with significance across all sites. There are non-statically significant differences between males and females that affect Home healthcare pharmacy services implementation (p=0.875). The age of the responders did not affect the Home healthcare pharmacy services implementation with a non-statistically significant difference between all age groups (p=0.061). Five levels of work experience affected the Home healthcare pharmacy services implementation. The lowest score (2.0500) was obtained for those with work experience of less than one year, with a statistically significant difference between all levels (p=0.000). Four levels of the position affected the Home healthcare pharmacy services implementation, with the highest score (4.5238) obtained for the pharmacy staff with a statistically significant difference between all levels (p=0.000). The number of home care prescriptions affected Home healthcare pharmacy services implementation. The pharmacist did not know the number of prescriptions, or they can not specify, obtained the lowest scores (2.5495) with a statistically significant difference (p=0.000). The number of home care patients affected the Home healthcare pharmacy services implementation. The number of 4-6 patients daily obtained the lowest scores (2.8292) with a statistically significant difference (p=0.000). The relationship between implementing the home healthcare pharmacy services and factors

Answered question 393
Skipped question 0  such as location, worksite, age (years), and gender. Besides, the years of experience, position held, number of homecare prescriptions, and number of homecare patients. The multiple regression analysis considered perception as the dependent variable and factors affecting it as an expletory variable. There was a medium relationship (R=0.644 with p=0.000) between the home healthcare pharmacy services implementation and its factors. Three out of eight were non-significant differences (p>0.05). However, multiple regression analysis confirmed that one factor (i.e., locations, number of homecare prescriptions) explained 38.3 % and 45.0% of the negative relationship to the variation in perception, with a statistically significant difference (p=0.000) and (p=0.000), respectively. Therefore, the bootstrap model was also confirmed. Furthermore, the relationship was verified by the non-existence of multicollinearity with the location factor with a variance inflation factor (VIF) of 1.249 and 2.832, respectively less than three or five as a sufficient number of VIF (22). [23,24] Besides, three-factor (work site, position held, and the number of home care patients) explained 29.0%, 19.0 %, and 50.7% of the positive relationship to the variation in perception, with a statistically significant difference (p=0.000) (p=0.000) and (p=0.000) respectively. Therefore, the bootstrap model was also confirmed. Furthermore, the relationship was verified by the non-existence of multicollinearity with the three factors (gender, experiences, position held) with a variance inflation factor (VIF) of 1.073, 1.123, and 2.796 respectively less than three or five as a sufficient number of VIF (Table 6). [22][23][24]

DISCUSSION
Home health care is an essential service for most healthcare organizations. [2,4,10] It provides services to geriatric populations or handicapped patients. The home care system can help those types of patients according to their situation and might reduce the cost of health care services and indirect costs for overall societies. [10] The pharmacist can perform various activities for home healthcare patients with medication counseling, prevent drug-related illnesses, and improve patient clinical outcomes by implementing the pharmaceutical care service to home care. [4,9,12,25] The practice level of home care pharmacy is highly demanded to improve pharmacy performance and increase patient satisfaction with the services. The current cross-sectional study with different pharmacist locations, working sites, ages, experiences, and positions; can give practice pictures from different angles, similar to the previous study. [4] The survey was distributed to a calculated number sample which was better than the previous study. [4] The current research assumes the first report estimated the number of prescriptions for the number of home care patents, which was not reported before. [4,10] The study's findings showed the average home care pharmacy practice is appropriate. The significant practice elements were medication errors, possibly answered by pharmacists working in the hospitals because they are very concerned about medication safety-related issues as required by national and international quality standards, [2] which was similar to the previous study. [4] The cost analysis of home care pharmacy that's expected the answers from the pharmacist who works at community pharmacies and private health care organizations. The cost analysis is required to show the benefits of the home care pharmacy services and calculate revenue. Besides, it might need health insurance comparison and coverage. [26] The other system practiced home care pharmacy was research. That is the most common response from respondents who work for pharmaceutical companies. That might be needed for visibility studies in-home care pharmacy-related investments. [27] However, the lowest practice elements were the vision, mission, scope of the services, and annual plan of the home care pharmacy. That's expected because the home care pharmacy is not well developed at most hospitals and healthcare facilities. On the other hand, some elements of home care pharmacy services got good scores, such as home care pharmacy competencies, total quality at the home care pharmacy services, ADR reporting system, and education and training system of home care pharmacy. However, all those elements might be overestimated because they are commonly not found in practice, it might found, and the author might not be aware of them, or the healthcare provider did not publish those services in the home care pharmacy.

Limitations
Despite this, the study had various advantages, including a calculated sample size with high reliability and very informative results. However, the research had various limitations; sample techniques were randomized, and there was a wide range of findings regarding the characteristics of responders. Besides, the results were for a period of time. Therefore, further investigation using the random sampling method is most likely.

CONCLUSION
The home care pharmacy practice was appropriate. Most pharmacists showed medication error prevention and documentation, research in-home care pharmacy, and cost analysis of home care pharmacy services as the highest components in practice. In contrast, the home care pharmacy's vision, mission, and annual plan were the lowest practice elements. Most pharmacists refer to health care practitioners, drug bulletins, and internet platforms as home care pharmacy services resources. Various factors might negatively affect or positively affect the home care pharmacy practice, such as location, working sites, experience, and pharmacist position. Besides, the number of home care patients and related prescriptions. The home care pharmacy should be universal with standardized pharmacy and associated regulations in Saudi Arabia.