An exploratory QUALquan comparison of patient‐centeredness priorities in outpatient Care for Patients and Pharmacists

Evidence‐based practice is necessary for improving chronic disease prevention, reduction, and management while simultaneously lowering care costs. Patient‐centeredness encompasses one of three essential and overlapping components of evidence‐based practice, the others being clinical expertise and scientific/research evidence. While patient‐centered care was placed at the center of the Joint Commission of Pharmacy Practitioners Pharmacists' Patient Care Process (PPCP), few studies investigate the concept's meaning in outpatient pharmacist care.

grounded in a holistic, biopsychosocial ethos that respects an individual's preferences, values, and needs as it relates to their health and health care. 8 This extends to factors like patient goals, caregiver expertise, nature of the illness treated, family and friend involvement, access constraints, health-related social needs, and health system integration. 8 The multi-dimensional nature of patient-centeredness has been studied extensively for over 50 years, particularly in the fields of medicine, nursing, and health policy. Pharmacist conceptualizations of patient-centeredness come primarily from medicine, which is characterized by guiding principles for consideration by the clinician to understand the patient's perspective and facilitate desirable clinical outcomes (Table 1; see Data S1 for coding definitions and descriptions Additional information about concepts can be requested from Olson and colleagues). 9,10 Less represented in pharmacist conceptualizations of patient-centeredness are concepts reflecting a health care systems-oriented approach that adjusts the care context to meet the unique needs of the patient. This perspective expands the focus of care from the patient-provider encounter (ie, micro-level) to the level of health systems (ie, meso-level) and considers even more upstream factors like workforce dynamics, accreditation, and payment (ie, macro-level). Filling this conceptual gap is important for

| Design and Data Collection
This study employed a QUALquan approach utilizing a directed content analysis method to enable the data richness necessary for capturing the experiential nature of patient-centeredness necessary to explore the meaning of patient-centeredness in a pharmacy practice context. 16,17 The approach also represents a pre-requisite step for building a theory-informed foundation for meaningful quantitative investigation. Data trustworthiness was also assessed using procedures outlined by Guba and Krefting. 18,19 Data were collected from in-depth, semi-structured phone interviews (interview guide available in Data S2) with adult patients and their pharmacists in the United States 1 to 3 days before a care encounter. All interviews were conducted between January 2019 and January 2020. A care encounter was defined as any prescheduled pharmacy care visit regardless of the specific service delivered. This definition was intentionally broad to match the diversity of pharmacy services and settings applicable to the PPCP. Interview questions were designed to elicit descriptions of care within and surrounding patient-pharmacist encounters, as well as the meaning and components of patient-centered care (eg, pharmacist attitudes or competencies; settings or circumstances where the care services take place).
The development of the interview guide was informed by the patientcenteredness literature, adapting questions from prior seminal research, and refined using cognitive interviewing. 8,[11][12][13][14] All interviews with study participants were conducted by the corresponding author.
Demographic and health-related information was collected to improve the interpretation of the findings. The University of Minnesota's Institutional Review Board (IRB) approved this study (STUDY#00005247).

| Sampling criteria
A target of 10-20 patient and pharmacist study participants was established following Bengtsson's criteria to balance in-depth assessment of each participant's response with a sufficient number of sources for data richness and transferability. 16 Most similar in-depth, qualitative studies in health care enroll between 1 and 30 participants.
The comparatively smaller sample sizes in this area of research reflects the focus on qualitative depth that can then be used to inform quantitative breadth. 16,20 Inclusion criteria for pharmacists were U.S. licensure, actively providing direct patient care, accumulation of at least 10 000 hours of direct patient care consistent with the PPCP (ie, expertise indicator), English speaking, and the provision of two de-identified care plans as evidence of PPCP consistent care. A key informant network of individuals involved in the development or implementation of the PPCP model identified potential pharmacist participants for the study and connected the corresponding author with prospective participants through email. The corresponding author proceeded to recruit these prospective participants as well as assess their eligibility for the study using the criteria described above. A purposive national sampling strategy was employed to include pharmacists in states that allowed modification of drug therapy by pharmacists, and that were representative of four distinct geographic regions (ie, East Coast, Midwest, T A B L E 1 Level of care for 40 seminal patient-centeredness concepts from three health profession fields and their relationships with the pharmacist literature [9][10][11][12][13][14] Health professional field Seminal patient-centeredness concepts

| Content analysis
The frequency of superordinate codes was assumed to reflect perceived importance to patient-centeredness in pharmacist care. Analysis began by merging initial concept codes that were co-applied in 70% of excerpts or more from the Patient-only (n = 162), Pharmacistonly (n = 277), and Composite (N = 439) datasets into superordinate concepts. Mergers were also carried out for concepts with the greater than 70% co-occurrence of excerpts in two of the three datasets.
These mergers reduced artificial inflation or deflation of importance for patient-centeredness elements from overlap between concepts across different fields.
Next, code frequency counts for superordinate concepts were weighted to equalize the magnitude of influence from the Patient-only 13 with a college degree and 2 without; and 14 with health insurance and 1 without. Table 2 shows a complete description of demographic characteristics for both the patient and pharmacist participants including self-perceived health status, number of chronic illnesses, and number of daily medications.

| Content analysis results
Directed content analysis of 439 excerpts (unit of analysis) produced 13 superordinate codes representing the meaning of patient-centeredness in pharmacist care consistent with the PPCP and the literature. 9,10 The applicability and comprehensiveness of the a priori coding scheme were sufficient to avoid adding new inductively generated codes. Table 3 displays the weighting and rank-ordering of the superordinate concepts, revealing similarities and differences in what matters in patient-centeredness from the perspectives of patients and pharmacists.
The top-three superordinate concepts for the Composite and Patient-only datasets were "Care Experience," "Therapeutic Alliance," and "Information, Education, and Communication." The top-three superordinate concepts for the Pharmacist-only dataset were "Care Coordination and Integration," "Care Experience," and "Information, Education, and Communication."  Inter-group differentials for the remaining three superordinate variables of "Therapeutic Alliance," "Care Coordination and Integration," and "Care Experience" revealed noticeable contrasts. "Therapeutic Alli-   (6) 13 (0) 13 (6) Note: "Respect for Patient Preferences, Values, and Needs" concept was also removed from the analysis to increase granularity of the findings given the concept's high co-occurrence with otherwise distinct concepts. a Data weighted so the magnitude of influence from patient study participants matched pharmacists study participants. b "Care Experience" is the superordinate concept for "Context and Time," which was the only initial concept that did not meet the >70% co-occurrence threshold with a superordinate concept across all three datasets (66% patient-only, 90% pharmacist-only, 73% composite).

| DISCUSSION
The directed content analysis identified 13 distinct superordinate concepts that begin to outline the contours of patient-centeredness in outpatient pharmacist practice. The high rate of co-occurrent code applications among the initial 40 seminal concepts produced by this study sample is an initial indication that pharmacy patients, pharmacists, and other health professional groups share congruent meanings of patient-centeredness. Findings also suggest a potential gap in understanding of patient-centeredness in the macro-level of care factors (ie, workforce and policy).
Comparisons revealed high consistency in patient-centeredness priorities between patients and pharmacists, with notable differences for the superordinate concepts of the "Therapeutic Alliance," "Care Coordination and Integration," and "Care Experience." Each of these areas may represent important evidence-based practice factors that are clinically relevant to patient care provided by pharmacists.

| Therapeutic Alliance differences
The weighted results show a higher relative importance expressed by patients for the "Therapeutic Alliance." This finding is intriguing given patient-centeredness is unachievable without a "Therapeutic Alliance" between patient and clinician. Additionally, this study intentionally sampled for pharmacists most likely to exemplify patient-centered care. Alternatively, study pharmacists may have underappreciated the importance of the "Therapeutic Alliance" compared with their patients. This suggests potential room for improvement that if realized, may lead to better patient experience and outcomes. [23][24][25][26][27][28][29] Future research is needed to make such a determination and better understand the presence of a differential for "Therapeutic Alliance" but not a related concept like "Pharmacist as Person." Third, study pharmacists may have undervalued the "Therapeutic Alliance" relative to patients given the superordinate concept's subjective and dynamic nature over time. Patients who have a "Therapeutic Alliance" with their pharmacist may begin to feel better about their health unbeknownst to the pharmacist. Objective or subjective improvement in a patient's health may also occur whether or not a patient's medication regimen changed. 11 Finally, the pharmacist and patient subsamples were very different in terms of age. As seen in Table 1, only one study pharmacist was over the age of 58 years with more than half of the subsample being younger Another important practice-based implication relates to an unsubstantiated misconception of patient-centered care-that it takes too much time. Research suggests more time and costs are saved using a patient-centered care approach with patients who have a therapeutic relationship with their provider. This is because the approach better identifies and supports the fulfillment of priorities and goals that are complex in nature. 8

| Care Coordination and Integration differences
The most frequently coded superordinate concept in the Pharmacistonly dataset was "Care Coordination and Integration" and is not wellrepresented in the pharmacist patient-centeredness literature. 9,10 Patients in the sample ranked this superordinate concept considerably lower than pharmacists. This may indicate a meaningful disconnect where the latter inappropriately overemphasizes the needed level of coordination and integration with other care providers to produce patient-centered care. However, the high level of importance assigned by both groups to the meso-level superordinate concept "Care Experience" (ie, #1 for patients, #2 for pharmacists) suggests an alternative interpretation. "Care Coordination and Integration" might be seen as more important by pharmacists than patients because pharmacists spend large amounts of time in these activities that are not visible to patients, often taking place outside the care encounter. This may also explain why both pharmacists and patients rated macro-level superordinate concepts like "Workforce Developments" and "Health and Social Care Policy" lower in importance-both are less perceptible or modifiable in their care activities. A separate deduction that can be made from the high importance assigned to "Care Coordination and Integration" by pharmacists is the high alignment between patient-centeredness with team-based care approaches. This is consistent with the PPCP's approach to patient care (eg, inclusion of the "collaborate," "communicate," and "document" concepts around the patient-centered care hub) as well as contemporary health care practice and training generally. 15 A fourth potential limitation inherent to directed content analysis was bias from an a priori lens of the 40 patient-centeredness concepts (Table 1). Thus, the study's two coders attempted to inductively generate other concepts that were possibly overshadowed. The first author also conducted a code-recode technique, where the complete data was separately coded 2 weeks apart to assess dependability and confirmability.

| Future research
Operationalized, quantitative field testing of the superordinate concepts in outpatient pharmacist practice is needed to assess for the validity (internal and external), generalizability, and reliability for the findings across populations. This will enable better assessment of how patient-centeredness in pharmacist practice relates to patient These findings could be evaluated by considering care moderators (eg, age, insurance coverage, health status) and mediators (eg, selfefficacy, adherence, trust) through structural equation modeling. A similar approach could then be taken at the meso-and macro-levels of care for patient-centeredness superordinate concepts.

| CONCLUSION
This study identifies 13 distinct elements for understanding patientcenteredness in outpatient pharmacist practice from the perspectives of patients and their pharmacists participating in care consistent with the PPCP. These component concepts may provide useful guidance for pharmacists fulfilling evidence-based practice. Results also suggest high levels of congruence in patient and pharmacist perceived priorities for patient-centeredness, but with some potentially important differences surrounding the valuation of the "Therapeutic Alliance," "Care Coordination and Integration," and "Care Experience" that warrant further investigation. Taken together, this study's findings add clarity for what matters to patients in pharmacist care encounters, identifies key elements for organizing team-based systems to meet the unique needs of each patient, and names upstream factors that can facilitate or prevent patient-centered care. Future research is needed to assess the reproducibility of the findings in other contexts, the reasons behind potential differences in patient and pharmacist care priorities, and an evaluation of their impact. Additional insight in these areas can lay the necessary theoretical groundwork for quantitatively exploring patient-centeredness in a meaningful way.

CONFLICT OF INTEREST
The authors have no conflicts of interest to declare.