Abstract
Background: Predicting suicide risk in psychiatric in-patients in order to inform risk management decisions is compromised by the poor predictive validity of the available models.
Aims: This study explored the factors influencing judgements regarding suicide risk in psychiatrists and nurses working in acute psychiatric in-patient units in Scotland.
Method: Clinical judgement analysis. Information used by 12 psychiatrists and 52 nurses to make judgements about suicide risk were analysed over 130 hypothetical cases. Correlations and linear regression analysis were used to examine judgement consistency and information use.
Results: There was agreement between clinicians on the relative but not absolute degree of risk of each patient case. Consistency of judgments was low, particularly amongst nurses. All clinicians rated those with more previous suicide attempts, men, those with shorter admission times, and those who were less compliant and not improving clinically as at greater risk of suicide. Conclusions: Clinicians use cues that have been associated with suicide in traditional predictive models based on epidemiological studies and short term factors that may be particularly relevant to acute psychiatric settings. The inconsistencies observed can be interpreted to cast doubt on the validity of predictions of risk for imminent suicide and the role of such predictions in the assessment process.
Introduction
Psychiatric in-patients are at significantly increased risk of completing suicide in comparison
to the general population in all countries reflecting admission criteria (Eagles et al., 2001;
Powell et al., 2000). Preventing such suicides occurring is therefore a legitimate concern in
acute psychiatric care settings (National Confidential Inquiry, 2006) Despite criticisms of
the current practice in the area suicide risk assessments continue to be a mainstay of such
efforts and predictions of suicide risk are used to inform decisions that are potentially critical
to patient safety such as the level of observation/engagement ordered (National Confidential
Inquiry, 2006).
Clinicians working in acute psychiatric in-patient environment are tasked with assessing
who may be at increased risk of imminently completing suicide over periods of hours, rather
than months. However, the existing models of proven predictive validity are based on large
scale community samples and identify factors that are predictors for suicide over the ‘‘longterm’’
and at a group level. They are unable to accurately predict which individual patients
will commit suicide over the short term (Cassells et al., 2005; Hughes, 1995). In the absence
of tools with proven predictive validity how clinicians use the information available to them
in order to make suicide risk judgements and whether or not a consensus exists between
practitioners over who is at a higher risk are therefore important questions which, are
addressed in this study.
Clinicians are rarely able to accurately describe the clinical information they use
when making decisions (Denig et al., 2002; Harries et al., 2000). Clinical judgement
analysis is a research method that examines the relationship between an individual’s
judgement and the information they use to make that judgement (Harries et al., 1996).
Using linear regression techniques it identifies the relative weight or importance
individuals attach to different information items, without relying on potentially unreliable
self-reports. These ‘‘captured’’ judgement policies can then be compared between
individuals to identify areas of agreement or disagreement (Harries et al., 1996). The
approach has been used successfully within medicine to explore how clinicians use
information to inform their diagnosis of heart failure (Skane´r et al., 2000), and to explain
variation in practice for prescribing decisions (Backlund et al., 2000; Harries et al.,
1996).
This article present the results of a study which used clinical judgement analysis to
explore the factors influencing judgements regarding suicide risk of a group of clinicians
working in acute psychiatric in-patients in Scotland. The study examined the information
cues that clinicians used to inform their judgements of suicide risk, comparing them to
risk factors identified by a review of the literature (Cassells et al., 2005). The study also
considered the reliability of clinicians’ predictions. This study formed part of a larger
study examining the relationship between predictions of suicide risk and decisions
regarding observation/engagement whose results are not reported here and are the focus
of a further paper in preparation. Ethical approval for this study was granted by Lothian
MREC.
Method
The information used by clinicians to make risk judgements was analysed over a series of
hypothetical patient cases. The cases were presented in written form in a booklet.
Hypothetical cases are useful in this context for several reasons. First, it allows us to
study a complex judgement process, associated with a relatively rare outcome, easily.
Second, the correlation between cues across cases can be minimised in order to allow for
identification of the influence of individual cues on each person’s risk of suicide
judgements. Third, it allows for a subset of cases to be repeated within the booklet to
measure the consistency of judgements. Finally, it also allows for direct comparison
between clinicians, and clear measurement of agreement as all clinicians see the same set
of cases.
Participants
All psychiatrists and registered mental health nurses involved in the assessment of suicide
risk in acute psychiatric in-patient settings, in four Primary Care Trusts in Scotland were
invited to take part in the study.
Procedure
On agreeing to take part, participants were sent a data collection booklet, consisting of a
questionnaire and the judgement task. The questionnaire was designed to collect
demographic data on participants, together with details of the environment where they
worked.
The Judgment task
The judgement task consisted of a set of 130 hypothetical cases (scenarios), each defined in
terms of 13 pieces of information, plus 15 cases that had been picked at random and
repeated. An example of a case is shown in Figure 1. Each booklet consisted of the same set
of cases, presented in the same order.
For each case, participants were asked to judge how likely it was that the patient described
in the scenario would try to commit suicide within the next 24 hours. They indicated this on
a 10 cm bar (see bottom of Figure 1) anchored on the left with ‘‘no risk’’ and on the right
with ‘‘very high risk’’. Their judgement of likelihood on this bar was encoded as a rating
between 0 (no risk) and 100 (very high risk). They were also asked to state what observation
level they thought the patient should have as an intervention (on pass, general observation,
constant observation, special observation). These observation levels were those in use in the
majority of Scottish services at the time of the study (Table I) (Scottish Executive, 2002).
Participants returned the completed booklet to the researchers in a prepaid envelope. Only
data from fully completed and returned booklets was analysed.
Case profile
The 13 different potential predictors of successful suicide attempts in acute psychiatric inpatient
populations identified by (Cassells et al., 2005) were used as a basis for the cases.
These factors were a mixture of more traditional ‘‘long term’’ predictors (e.g., psychiatric
diagnosis, previous self harm) and more short term predictors (e.g., changes in clinical state,
comorbid drug or alcohol use).
For each of these predictors, a number of different potential levels of severity related to
suicide risk were developed (Table II). For each of the predictors, at each level, a number of
verbal descriptions were constructed and validated by a panel of experts. The descriptors
were developed following interviews with experienced clinicians. A computer program
(written in visual basic 6 by CH and adapted by DD, based on the cue generation program
used in (Evans et al., 1995), was then used to randomly generate a number of series of 130
scenarios. For each predictor, each level had an equal probability of being included in each
scenario. These sets of scenarios was sampled and re-sampled until, for each set that was
generated, the inter cue correlation was negligible.
To ensure that the final sample of 130 scenarios used in the study had face and content
validity they were selected from those scenarios that represented real in-patient cases with a
distribution designed to mimic the overall in-patient caseload. Scenarios were examined for
face validity by a panel of 4 experts (operationally defined as experienced psychiatrist/mental
health nurse practitioners). Participants were aware that no observation level had been
decided in these cases. Scenarios that did not represent a realistic acute in patient case were
discarded. Caseload distribution was determined via a local survey of the range and
prevalence of diagnoses within in-patient services together with an examination of national
statistics. The final number of scenarios used in the study was based on a ‘‘rule of thumb’’
suggesting that between 5 – 10 scenarios are necessary for every item of information used, to
ensure sufficient variety in the judgements that are made, and to provide stable statistical
estimates of cue weights (Cooksey, 1996; Harries & Harries, 2001).
Analysis
All data were analysed using SPSS (version 12.0). Clinicians’ judgements of likelihood that a
patient would attempt suicide within the next 24 hours, rated as a mark on a bar were
encoded as a rating between 0 (no risk) and 100 (very high risk). To examine the extent to
which clinicians agreed on the relative degree of risk for each case (i.e., if they identified the
same case as being at a higher or lower risk), Pearson’s correlations between risk judgements
by each pair of clinicians was calculated for each of the participants, and the mean
correlation was calculated via Fisher’s z transformation (Fisher, 1921). Agreement between
clinicians’ judgements’ of risk across all cases was measured using Kendall’s W measure of
concordance. Kendall’s W varies from 0 (no agreement) through to 1 (perfect agreement).
(Howell, 1992, pp. 280 – 282).
The reliability of clinician’s risk judgements were also examined by calculating
Spearman’s rho correlation on the two sets of judgments for the 15 cases that were
repeated within the vignette booklet. These 15 and their original equivalents form a test and
retest set of cases. The mean for nurses and for psychiatrists was calculated separately via
Fisher’s z transformation and an independent samples t-test of the mean difference was
used. Finally, an individual’s judgements of risk across the 130 cases were standardized and
regressed onto standardized cue values giving a set of standardized regression coefficients
(their judgement policy). These indicate how the participant used each item of information
to judge suicide risk. Mean differences in the beta-weights attached to information use were
analysed using independent sample t-tests.
Results
Participant characteristics
Twenty eight psychiatrists and 92 nurses consented to take part in the study (from a
potential pool of 88 psychiatrists/269 nurses) with 12 psychiatrists and 51 nurses returning a
completed booklet (53%). The mean age of participating psychiatrists was 39 years (SD 7.9;
range 25 – 53), 50% were male and 50% female. The mean age of participating nurses was
40 years (SD 8; range 20 – 54), 40% were male and 60% female.
Agreement between judgements of suicide risk
There was considerable variation in both psychiatrists’ and nurses’ absolute ratings of the
suicide risk for each individual vignette. On average the range between the lowest and highest
ratings for a vignette was 61.3 for psychiatrists and 78.4 for nurses. The range was over 75 in
15/130 (11.5%) cases judged by psychiatrists, and 79/130 (60.8%) cases judged by nurses.
The extent to which clinicians agreed in terms of the relative degree of risk was calculated by
examining the extent to which their judgements for the vignettes correlated with each other
(a significant correlation would indicate that they agreed on cases that were at greater/lesser
risk than others). The correlation of judgements for each clinician across all 130 cases was
compared to all other clinicians, giving a total of 3294 comparisons. Of these 3060 (92.9%)
were significantly positively correlated (p5.01). Agreement ranged from an r=0.018 to
r=0.733, with a mean correlation of 0.416. Agreement between psychiatrists was slightly
greater (98.5% of comparisons significantly positively correlated, mean correlation 0.486)
than agreement between nurses (92.9% of comparisons significantly positively correlated,
mean correlation 0.412).
Concordance between clinicians was assessed using Kendall’s W. The greatest agreement
was between the psychiatrists (W=.5, n=12), with agreement between the nurses slightly
lower (W=.41, n¼51). Concordance when comparing the judgements of the whole
clinician group was also lower (W=.41, n=63).
Reliability of risk judgements
Of the 12 psychiatrists, 7 (58%) had significant (p5.01) correlations between their risk
predictions on their test and retest cases (mean correlation 0.614, range .158 – .737). Of the
51 nurses 11 (22%) had significant correlations (p5.01) between their risk assessments
(mean correlation 0.479, range 0.024 – 0.844). An independent samples t-test of the mean
difference in Fishers z transformations of consistencies indicated that psychiatrists showed
greater reliability in their judgements than nurses did (t(61)=72.053, n=63, p5.05).
Factors influencing risk judgements
Individual judgement policies, which examined how each clinician used information to
reach their judgement of suicide risk, were calculated. The number of significant cues in a
judgement policy that predicted risk judgements varied between clinicians, ranging from 1
to 6. The average number of cues for both psychiatrists and nurses was 3.7, with a median
of 4. There was substantial variation in the fits of the linear regression models (R2)
between participants. The mean adjusted R2 for psychiatrists was 0.34 (median=0.34,
range .22 – .51) and for nurses 0.28 (median 0.29, range .04 – .51).
There was also some variation in the way clinicians were influenced by cues. Mean
standardized beta-weights for each of the cues for psychiatrists and nurses can be seen in
Figure 2.
Figure 3 indicates the percentage of clinicians who had a particular cue as a significant
predictor within their judgement policy, together with the direction of the weighting.
Both psychiatrists and nurses associated suicidal ideation with increased suicide risk,
although psychiatrists were significantly more influenced by this cue (t(61)=2.103,
n=63, p5.05). Psychiatrists were also significantly more influenced by the patient’s
diagnosis than nurses were (t(61)=5.387, n¼63, p=1.0). The number of previous
suicide attempts, being male, lack of clinical improvement, lack of compliance and
shorter admission times were also associated with higher risk of suicide judgments by
both groups of clinicians.
Three of the cues (insight, adverse events and protective factors) were not significant
predictors at all in psychiatrists’ judgement policies. Two cues (co-morbidity and insight)
were not significant predictors in nurses’ judgement policies. Suicidal ideation and previous
suicide attempts were important factors for the majority of psychiatrists and nurses. For 50%
of the psychiatrists, but only 8% of nurses, diagnosis was also an important predictor.
Clinical improvement, length of admission, gender, compliance and hopelessness were
important predictors for between approximately 20% and 40% of clinicians.
Discussion
Clinicians who took part in this study rated the patient cases represented in the scenarios at
varying degrees of risk, often with very large differences in ratings. A patient case therefore
could have likelihood ratings of completing suicide from one practitioner of 25 and from
another of 100. However, when comparing the relative degrees of risk, there appeared to be
consensus regarding cases that were of relatively higher risk, compared to others. Therefore,
although individual clinicians may have different anchor points on a scale related to what
they consider high or low risk to be, they did appear to agree on who was at higher risk
compared to another patient.
What is perhaps of more concern are the results of the analysis of the reliability of
clinicians risk judgements, across the 15 repeated patient cases. Overall psychiatrists were
more likely to provide roughly similar risk assessments for the same case at two different
time points, than nurses. However, for a significant proportion of psychiatrists (42%) and
the majority of nurses (78%), risk judgements across the same patient case at two different
time points were significantly different. This implies that the predicted risk of suicide in the
same patient, exhibiting the same symptoms and behaviour, seen at two different times by
the same clinician could vary substantially. However, low reliability, agreement and
accuracy is also associated with greater uncertainty in the decision task (Harvey, 1995).
These findings may reflect the inherent complexity associated with the prediction of suicide
in this population. An increased familiarity with the task is however, associated with
increased consistency and given the pre-eminent role ascribed to psychiatrists in the decision
making process in most settings this may explain the greater reliability observed in
psychiatrists’ judgements of risk (Shanteau et al., 2003).
Clinical judgement analysis is a method that examines the relationship between the
judgements’ that individuals make and the information they use to make them. The analysis
of judgement policies of clinicians that took part in this study highlighted variation in the
number of information cues clinicians use to inform their judgements of suicide risk, and
some variation in which cues are used according to professional group.
The psychiatrists in our sample were more likely to use the patients’ diagnosis as a
predictor of the likelihood of suicide than nurses, and appeared to place more significance
or weight on the presence of suicidal ideation as a predictor than nurses. However, what is
evident is the extent to which there is considerable agreement between the two groups on
the relative significance of other factors such as previous suicide attempts, gender, length
of admission, clinical improvement, compliance and hopelessness when assessing suicide
risk. Predictive models derived from epidemiological studies suggest that factors such as
suicidal ideation, previous suicide attempts, diagnosis, gender and length of admission are
long term predictors of successful suicide (Cassells et al., 2005) all of which appear as
factors used by clinicians in this study to inform their risk judgements. However,
clinicians’ judgement policies also included other factors, such as clinical improvement,
and compliance when making such risk judgements. These factors, along with others such
as the degree of insight a patient has into their condition, comorbid substance abuse and
social factors (such as the level of social support an individual receives) (Cassells et al.,
2005) have been identified as dynamic or short term factors linked to increased suicide
risk in psychiatric in-patients. It is still uncertain whether using these more short term
factors increases the accuracy of suicide risk predictions within acute psychiatric inpatients.
It is also unclear whether some short term factors are more significant than
others either generally of for individuals when trying to estimate suicide risk. Clinicians’
use of clinical improvement and compliance as predictors of risk within their judgement
policies imply that these factors may have more clinical utility than other short term
factors. However, whether they are more useful in terms of accurate prediction remains
uncertain.
One of the main methodological issues that needs to be considered when examining
the results of studies that use case vignettes is the transferability of subjects performance
from the judgement task simulated in the vignette to their performance in real task
situations. A number of studies have indicated that clinicians performance on ‘‘paper
cases’’ in clinical judgement analysis studies appears to be no different to that on ‘real
patients (Braspenning & Sergeant, 1994; Denig & Rethans, 1996; Kirwan et al., 1983).
In order to increase the transferability, the case vignettes constructed for this study
were based on both evidence from the research literature on key information that is
deemed to be associated with suicide risk in psychiatric in-patients, and expert validity.
However, it should be recognized that clinicians’ information use was limited to that
presented in the case vignettes. Individuals judgements in reality may be influenced by
elements of the task situation such as the context of the ward environment and resource
issues (such as staff availability), which, were not represented in the vignettes used within
this study.
One way to increase the validity of the judgement task that is carried out is to either base
the case vignettes on real patient cases (Skane´r et al., 1998), or to ask clinicians to carry out
judgements in the clinical setting and analyse the patient case retrospectively. Although
these approaches would overcome the limitations of presenting clinicians with paper-based
vignettes, they would also make it harder to control the information that clinicians receive,
or to directly compare clinicians’ judgments and policies. The combination of risk factors
identified and used in this study would probably rarely be recorded in totality for each
in-patient, and often a combination of a number of risk factors together in one
patient case is rare (Powell et al., 2000). If patients are used in clinical practice, then the
ability of comparing clinicians across the same cases for consistency is also lost.
A further issue that should also be acknowledged when considering the results of this
study is the nature of how risk assessments are made in clinical environments. This study
examined the judgements of individual practitioners when studies have highlighted that
this is often a process involving members of the multidisciplinary team (Bowers et al.,
2000).
The prediction of the likelihood of suicide forms one element of the broader process of
risk assessment and management of suicide risk that in turn forms part of the overall care of
the patient. Prediction of suicide risk is however in and of itself a complex task, evidenced by
the difficulties in producing models in those studies that have attempted to identify risk
factors. The importance of clinicians’ judgements is therefore paramount, as they need to
continually evaluate a variety of different information sources to reach a judgement about an
individual patient. Although there were some differences in how psychiatrists and nurses
used and weighted information regarding patients diagnosis and suicidal ideation to inform
their judgements in this study, overall there was remarkable agreement in the relative use
and weighting of information.
Within acute psychiatric in-patient areas, patients who are judged as being at higher
risk of suicide are often identified as requiring intensive support by means of higher
levels of observation/engagement (Bowers et al., 2000). The relationship between risk
assessments and decisions regarding interventions is therefore potentially critical. It has
been suggested that there is a relationship between risk assessments and the level of
observation a patient is placed upon (Kettles et al., 2004). However, research in other
areas has suggested that a clinicians judgements may not necessarily influence their
treatment decisions with the nature of the relationship between judgements reached and
decisions made varying between clinicians (Poses et al., 1995; Sorum et al., 2002).
Despite the relative agreement with which clinicians in this study identified patients they
considered to be at higher or lower risk, relative to other patients, this may not
necessarily lead to agreement regarding the interventions those patients receive. The
relationship between the risk judgements made by the clinicians in this study and their
subsequent decisions regarding observation level are however the subject of a further
paper currently in preparation.
Overall, psychiatrists and nurses appear to agree on the characteristics of patients who are
considered to be at higher or lower risk of suicide, within acute psychiatric in-patient
environments. They use a mixture of both long term predictive factors and more dynamic
short term factors, to inform these judgements. There are some discrepancies in the
importance that different professional groups attach to the patients diagnosis and level of
suicidal ideation, when making judgements. However, it has been possible from this study to
provide some transparency as to the way in which clinicians use different predictive factors
to inform their judgements regarding imminent suicide risk in acute psychiatric in-patients,
an area under explored to date. The inconsistency in risk judgments observed is significant
and must cast some doubt on the validity of using predictive models based on aggregated
risk factors.
Alternative approaches to risk management focused not on statistical models but rather
the lived experiences of service users may though offer scope for improved patient outcomes
in this area. Such improvements may lie however not in any improved accuracy in the
prediction of suicide risk but instead in terms of a decreased likelihood of suicide both
during and after the in-patient episode. A phenomenological perspective on suicide suggests
that we must seek to understand individuals’ unique reasons for suicide and not committing
suicide at a particular point in time. Central to this perspective is the belief that suicide is an
endpoint in a trajectory following high levels of societal, intra and interpersonal stress which
result in unendurable psychological pain described, compellingly by Shneidman (1993a) as
‘‘psychache’’. In the context of such unbearable distress suicide becomes a compelling and
even attractive means of escape. Risk factors such as suicidal attempts and suicidal thoughts
are expressions of distress which can exist independently or co-exist with underlying
pathology. An understanding of the sources of stress, particularly at an individual level is
therefore necessary because it is the individuals idiosyncratically understood psychological
anguish which is the driving force behind suicide and not simply an aggregated collection of
risk factors (Shneidman, 1993b). Adopting a phenomenological model of suicide prevention
seeks therefore to ascertain in partnership with the service user their reasons for living and
dying (Jobes, 2000, p. 11). These reasons, revisited regularly, form the basis of a care plan
which focuses not on the treatment of the disorder but on addressing explicitly these issues
which the patient gives for wishing to kill themselves as treatment priorities, whilst
maintaining and expanding on the reasons for the patient’s ambiguity about suicide (i.e.,
their reasons for not committing suicide). Practice is focused on changing the balance in
favour of living with suicide seen not as a symptom of a mental illness which can be
addressed via treatment of the supposedly underlying disorder but simply as a coping
strategy ‘‘albeit a limited and problematic one’’ (Jobes, 2000, p. 11). The challenge for
clinicians in such circumstances becomes not how to assess risk accurately but instead how
to engage constructively with the service user in order to enable them to want, and be able,
to ‘‘say yes to life’’ (Degan, 1996, cited by Barker, 2003, p. 97) not just in hospital but after
discharge.
The presence of a collection of risk factors whether static, e.g., diagnosis, history of
previous attempts or more dynamic such a recent history of substance misuse or the loss of a
significant relationship may tell us that the individual falls into a particular risk category. It
cannot reliably predict the choices that individual will make in the short term regarding
suicide. Engaging with the individual patient and their lived experience of that world on an
ongoing basis may however allow us to understand why for some patients at some times
suicide can come to seem their only option. Only by doing so can we then begin to explore
with the patient what they feel might need to change in order for them to decide to choose
life over death.
Conclusion
One interpretation of one of the findings of this study in terms of the inconsistent judgement
by clinicians might be that it lends weight to calls for further training of clinicians. However,
where as in this case there is no valid predictive model in which the relative importance that
should attached by clinicians is known then the question becomes what might such training
be expected to deliver in terms of improving the predictive accuracy of the judgement
reached. Practitioners should be under no illusions regarding the irreducible uncertainties
involved in making short term predictions of suicide risk in in-patient settings no matter the
approach used (Simon, 2006). This does not mean that the present practice of routinely
incorporating consideration of such risk factors into the risk assessment process should be
abandoned. The significant limitations involved in predicting risk based only on such
information must however be acknowledged and greater efforts to incorporate a
phenomenological perspective on suicide risk assessment and management into practice
should be made.
понедельник, 25 февраля 2008 г.
Choosing a course of study and career in pharmacy—student attitudes and intentions across three years at a New Zealand School of Pharmacy
Abstract
Factors influencing undergraduates’ selection of Pharmacy as a course of study, career, study and professional perspectives were evaluated by survey over the years 2004–2006 at Otago University, New Zealand. Altruistic intent emerged as a powerful motivator for choosing pharmacy and entrepreneurial career intentions were prominent. A sizeable though declining number
of students selected pharmacy secondarily to medicine or dentistry. Gender differences were found between intended areas of practice.
Introduction
Graduates from the National School of Pharmacy
(NSP) atOtago University represent just over half of all
Pharmacy graduates educated in New Zealand. In the
year 2006, these students constituted 45% of additions
to the practising register, with other significant
additions being from Auckland University (23%) and
UK/Ireland (21%; Pharmacy Council of New Zealand,
2005a). The motivations, career aspirations and
choices ofNSP studentswill therefore have a significant
influence on the future practice and culture of
Pharmacy both in New Zealand and on the work
overseas that many will pursue. Indirectly, selection
criteria used to admit students to the BPharm course
will also play a role in shaping the next generation of
pharmacists.
Choosing pharmacy as a course of study—demographics
and motivations
The choice by students of any undergraduate degree
involves many factors, including but not limited
to: socioeconomic variables, gender and ethnicity,
academic ability and academic self-concept, career
ambitions, personality, and prior educational attainment
(Van de Werfhorst, Sullivan, & Cheung, 2003;
Reay, Davies, David, & Ball, 2001; Pike, 2006; Porter
& Umbach, 2006; Abowitz, 2006). Recent studies in
the UK have indicated that there are increasing
numbers of women studying pharmacy, with almost
twice as many women as men qualifying as pharmacists
in 2005 (Hassell & Eden, 2006) leading to
pharmacy now being described as a “female-dominated”
profession (Hassell, 2003). The ethnic mix of
pharmacists in the UK is also becoming more diverse,
with around 25% of newly qualified pharmacists now
recorded as being “Asian British” (Hassell & Eden,
2006)—that is to say Indian, Pakistani or Bangladeshi—
compared with 4% of the population (Census,
1991/2001). Black British and Chinese ethnic groups
are also growing in representation (Hassell & Eden,
2006), though there is huge variability in the makeup
of course cohorts around the country (Willis,
Shann, & Hassell, 2006d).
Race or ethnicity has in a different way been shown
to be strongly associated with the pursuit of a
pharmacy degree and career. A US investigation into
whether individuals who had initially expressed an
interest in pharmacy subsequently pursued this field,
found that Hispanic or “other” ethnic group students
were 12 times more likely than White students to
continue with their plans to become pharmacists
(Cline, Mott, & Schommer, 1999). This study found
that those with higher grade point averages and career
commitments were also more likely to apply to study
pharmacy, suggesting that “despite pharmacy’s
uncertain future, it is still able to attract academically
qualified students” (P399). The role of ethnicity,
attitudinal traits and academic factors have been
found to interplay in other ways, for example with
family influence in choice of pharmacy as a career
reported to be particularly strong for non-White
students (Willis, Shann, & Hassell, 2006a).
The strongest motivating factor to study pharmacy
in the UK has recently been found to relate to its being
a science-based course, with other extrinsic and
intrinsic motivators also featuring—namely career
status and prospects, and a desire to help people and
to work with patients (Willis et al., 2006d). In
Australia, extrinsic factors relating to self-employment
and salary, and intrinsic factors relating to a liking for
science, interpersonal aspects and a desire to be socially
useful have all been found to influence students’ choice
of pharmacy as a degree (Roller, 2004). At the graduate
entry level, future employment prospects and a desire
to make a contribution to healthcare feature most
highly as factors influencing decision to study
pharmacy (Davey, Evans, & Stupans, 2006). Consistency
in motivations to study pharmacy across time and
cultures is indicated when it is considered that similar
findings relating to science, salaries and a “desire to
help humanity” were obtained in the US from the
1950s through to the 1970s (Cline et al., 1999; Pratt,
1956; Smith, Gibson, & Mikeal, 1974).
Around 75% of UK pharmacy students initially
chose pharmacy as their first course of study, with white
females most likely to take pharmacy as a first choice
(84%;Willis et al., 2006a). Ethnicity also emerged as a
factor in first degree selection, with almost four times as
many non-White students reporting pharmacy was not
their first choice of degree, compared with White
students. At the NSP, it is said to be “inevitable” that a
portion of undergraduates will not have opted first for
pharmacy, as the majority of students take a common
health sciences first year and subsequently compete for
entry to pharmacy, medicine, dentistry and physiotherapy
courses, for all of which they may apply at the end
of this year (Shaw, 2000).
Selection criteria
Admission to pharmacy at NSP is mostly based on
students obtaining a minimum of an average B grade
(70%) in the common health sciences first year.
A smaller number of students are admitted from
second or subsequent year of study, usually at Otago,
or as “competitive” graduates (of a New Zealand
university within the previous 3 years). An “alternative
applicant” category brings in a few others: those who
may have graduated from a New Zealand university
more than 3 years previously; those who have obtained
degrees, usually in medicine or pharmacy, from an
overseas university; and those who have worked as an
allied health professional (most often a pharmacy
technician or nurse) for 5 years or more. All such
applicants are required to have passed the subjects of
Otago’s common health sciences first year course (or
the equivalents) and to have demonstrated competence
in English. A certain degree of positive
discrimination exists in that students who are Maori
or Pacific Islanders may be brought into the BPharm
programme even if they achieve only an average of
65% or more during their pre-admission year(s). Only
about 1–2 students are admitted in this way each year,
however. Very few applicants for admission are
interviewed—only those applying as “alternative”
candidates and for whom English is not their first
language.
In the UK, A-level grades have been found to show
a small but significant correlation with grades at
pharmacy undergraduate level and thus it has been
argued that both teachers’ estimates of A-level
performance and actual A-level scores remain useful
in selection and forecasting (Foy & Waller, 1987).
A-level biology scores may perhaps be a stronger
predictor of performance in a pharmacy degree, and
English ability at entry level is also important as an
indicator of student success (Sharif, Gifford, Morris,
& Barber, 2003). Given that pharmacy undergraduates
must have the capacity to acquire diverse
scientific knowledge and skills, as well as developing
the knowledge and interpersonal skills of pharmaceutical
care, it is also reasonable to ask whether there
might be other selection criteria also applicable to
undergraduate admissions. With respect to the
contemporary focus of pharmacy practice as one
centred on patient care (Strand, Cipolle, Morley, &
Frakes, 2004), it has been suggested that formal
assessments of self-reported empathy be used in the
admissions processes of pharmacy schools. Similarly,
with reference to the scientific demands of the course,
that critical thinking skills and mathematical ability
should be taken into account, in addition to a range of
other non-academic and affective qualities (Duncan-
Hewitt, 1996).
The use of a variety of aptitude tests for pharmacy
admissions is now commonplace in the US (Chesnut &
Phillips, 2000), for example the Pharmacy College
Admission Test (PCAT; Duncan-Hewitt, 1996;
Chesnut & Phillips, 2000), which incorporates
measures of communication skills, reasoning ability
and chemistry- and biology-specific knowledge (American
Association of Colleges of Pharmacy, 2006).
Currently, no equivalent pharmacy admissions test
exists at the NSP; however, students pursuing entry
into medicine or dentistry from the common health
sciences first year are admitted in part according to
their performance on the UMAT (Undergraduate
Medicine and Health Sciences Admissions Test).
Given the potential relevance of various factors which
may be used in admissions, ranging from interpersonal
relations to problem-solving skills to ethical awareness
(Chesnut & Phillips, 2000), the novel step was taken
in this study to ask students themselves, what they
consider to be important and relevant selection
criteria for the pharmacy degree.
Career aspirations—professional intentions and influences
In the US, a study of eight Pharmacy Schools
indicated that the majority of students (71%) have
career aspirations that are strongly oriented towards
“direct patient care”, although concern is expressed
that this may be at odds with the realities of drug
distribution-based pharmacy likely to be encountered
in the professional workplace (Siracuse, Schondelmeyer,
Hadsall, & Schommer, 2004). This study also
found evidence that the more career-committed of
students will also be those aspiring to work in direct
patient care. Others have found that the “professional
subculture” of students entering pharmacy is comparable
to nursing and medical students as regards
their emphasis on patient care (Horsburgh, Perkins,
Coyle, & Degeling, 2006).
Pharmacy students in the UK apparently possess a
strong expectation that they will work very hard no
matter what pharmacy job they acquire—95% believe
this to be the case—and 80% state they are very
ambitious about their pharmacy career (Willis et al.,
2006a). Diverse factors have been shown to affect the
choice made by students about specific career paths,
including previous work experience, the influence of
sections of the undergraduate syllabus directed
towards pharmacy practice (Siverthorne, Price, Hanning,
Scanlan, & Cantrill, 2003) and practical matters
such as salary and work location, a desire for personal
fulfilment and to help patients (Carvajal & Hardigan,
1999; Carter & Segal, 1989).
As recently as 2000, concern has been expressed
that hospital pharmacy in the UK is said at the
undergraduate level to have an “image problem”,
being considered elitist, badly paid, dull and repetitive
(Hatfield, Marriott, & Harper, 2000). In contrast to
this (or perhaps evidence of a shift in attitude and
intention of students), more UK students stated that
they were at least “certain” that “in 10 years time”
they wanted a career in hospital pharmacy (60%)
compared to any other career option, although
significant interest was shown in community practice
(proprietor, 33%; employed by multiple, 51%),
working abroad (43%) and primary care (37%; Willis
et al., 2006a). Given that more than one option was
permitted in this survey, students do appear to be
hedging their bets to an extent, but these figures at
least suggest an open-mindedness about the practice
sites available to them.
Of those intending to work in the community sector
in the UK, strong entrepreneurial intentions are
evident, with 44% of male students and 28% of female
students saying they are certain they want to own a
pharmacy (Willis et al., 2006a) and pharmacy
ownership reported as the top ambition for students
(Wilson, Jesson, Langley, Hatfield, & Clarke, 2006).
The proportion of these individuals who will attain
their ambitions, given the decline of the independent
pharmacy in Britain, remains to be seen, however.
Consequences of the “feminisation” of pharmacy relate
to the likelihood of women working part time once in
their 30s, and gravitating towards temporary community
work (Hassell, 2003). It has been suggested also
that this feminising shift may at least correlate with
pharmacy itself becoming a more attractive career for
women than men (Gidman & Hassell, 2005).
Attitudes and career intentions in pharmacy have
not been as clearly elucidated in New Zealand.
However, given that currently 2100 (82%) of
pharmacists work in the community sector and 300
pharmacists (10%) in the hospital sector (Pharmacy
Council of New Zealand, 2005b) it could be valuable
to assess students’ perceptions of these and other
career paths.
Aims of this study
This study evaluated factors influencing students’
decisions to study pharmacy and to work as health
professionals, aswell as the characteristics they consider
important for selection to the course and for practising
pharmacy. Also investigated were pharmacy students’
career aspirations and intentions, and the relative
importance and attraction of various professional
activities and incentives. NSP students across three
separate cohorts and years were surveyed to examine
for commonalities and trends in these areas.
Method
This study, approved by the University of Otago
Human Ethics Committee, was developed in December/
January 2002/2003 following a series of interviews
and focus group discussions with current and recently
graduated students. It was piloted in 2003 by a
group of student researchers on that year’s second year
intake, following which a number of minor adjustments
were made to ensure consistency and ease of
analysis. The questionnaire has since then been
administered routinely to each incoming second year
class at the start of their first lecture, in the School of
Pharmacy. This first lecture which introduces students
to the School and pharmacy profession, is attended by
most students, all of whom have just been admitted
into the BPharm programme. The results presented in
this paper relate to the second year students of 2004–
2006.
The (anonymous) questionnaires were distributed
around the lecture theatre before the start of the lecture.
Students were then given 15 min to complete the
surveys and were asked to do so in silence, without
reference to their neighbours. At the end of the allotted
time, class representatives collected the completed
questionnaires and handed them to the academic staff
member present (who was not one of the researchers).
The questionnaire consisted of 24 separate questions,
many of which were subdivided into further
categories of choice. Most questions were multiplechoice,
requiring respondents to rate statements on a
Likert-type scale of 1–5, with 1 being not at all
important/ not at all interested through to 5 as most
important/ very interested. Other questions asked
students to rate order of importance of factors (e.g.
order of priority of factors influencing decision to
study pharmacy) or to make selections from alternatives
(e.g. ethnicity).
The following areas from the survey questionnaire
were analysed for the period 2004–2006:
1. Why do you want to work as a health professional?
(rating scale 1–5, 17 statements)
2. Which three of these factors (statements from
Question 1) were the most important in your
decision? (Please list in order of priority)
3. What, in your opinion, are the most important
attributes that the School of Pharmacy should
consider when selecting people for the Bachelor of
Pharmacy programme? (rating scale 1–5, 12
statements)
4. When you applied for admission to the Health
Sciences, was Pharmacy your first preference?
(yes/no) If not, please state which programmes
were preferred.
5. At this stage in your BPharm programme, do you
want to become a pharmacist? (yes/no)
6. Community pharmacists are involved in many of
the following activities in their day to day work.
Which activities are of most interest to you? (rating
scale 1–5, 11 statements)
7. What aspects of being a pharmacist are most
important to you? (rating scale 1–5, 14 statements)
8. During my working life, I would like . . . (tick as
many phrases as you feel apply [12 statements])
9. If you had to choose a pharmacy career path today, in
what field would it be? (Please tick one [6 options])
Further questions were also asked about gender,
age, ethnicity, language spoken and residency status.
Data were collated and analysed for all student
responses over the 3 years (n = 351) and separately for
each year to examine for trends. Participants’
responses between questions were not linked for the
2005 data, so analyses linking responses from different
questions are only presented for 2004 and 2006.
In addition to reporting descriptive statistics,
participants were forced to rank only three factors in
Question 2. Thus ranking data in Figure 1 represent
the mean number of times participants ranked a factor
as primary importance (3), secondary importance (2),
and tertiary importance (1). A score of 3 would
indicate all participants said a factor was the most
important; conversely a score of 0 indicates a factor
was not ranked in the top 3 by any participant.
Using the two smallest cohorts (2004 and 2006), it
was estimated using G*Power 3 that with 80%power, a
two-tailed pairwise comparison would be able to detect
an effect of d ¼ 0.38. By convention, values of 0.2 and
0.5 are considered to be small and medium respectively,
meaning that where differences were not found,
any real differences are likely to be close to small in size.
Results
A total of 351 students completed the survey (2004,
n ¼ 103; 2005 n ¼ 125; 2006, n ¼ 123) representing
98% of the total of three cohorts. All students in 2005
and 2006 completed the survey; 103 of 110 students
did so in 2004. There was a small level of nonresponse
on some questions, but this appears to be a
student accidentally omitting a question rather than
systematically not responding.
Motivations to study pharmacy
The left-hand panel of Figure 1 shows a strong degree of
consistency between years as to the primary ranked
motivations of students to work as a health professional
(Question 2). By far, the most highly ranked motivation
was a desire to work in a job where they “care for/
help people”, which was twice as highly ranked as
the next highest motivation, an “interest in human
biology”. A job involving interaction with people, a high
salary, a desire to work in the community, a desire to
own a business and a number of other aspects also
featured as important motivators. University publicity,
friends studying in the health sciences, family tradition
and “having high grades but not knowing what else to
do” were the least reported reasons for wanting to work
as a health professional.
The right-hand panel of Figure 1 presents mean
rating data for the same factors. Few trends across the
surveyed years were evident in students’ motivations to
work as a health professional, with the exception of a
desire for a “career in research”. Over the 3 years,
there was an approximately 15% increase in the
importance placed on this factor. It would seem
therefore that students coming into the pharmacy
course are increasingly explicitly considering a research
career at an early stage. It is also interesting to note the
difference in responses between the ranking and rating
data. For example, students were clearly interested in
learning new technology, but it was not a top priority.
Admissions criteria
Figure 2 shows that students rated being a good
communicator with good English (language skills) as
the top attributes that they considered the School
should considerwhen selecting people for the pharmacy
programme. Highmarks in health sciences first year and
in science at schoolwere also highly-rated, aswas having
an “orderly/controlled mind”. Those attributes considered
least important fromthe options presented were
a previous tertiary qualification, being an older student
and high marks in arts subjects at school.
Study and career commitment
A large, but slightly decreasing number of students
opted first for medicine or dentistry on application
from health sciences, with those opting for pharmacy
as their first choice ranging between 38 and 50%.
2006 was the first year of the three that more
students selected pharmacy as their first preference
than did not (50% (CI: 42–59) in 2006, vs. 38%
(CI: 30–47) in 2005 and 46% (CI: 36–56) in 2004).
One notable trend is the decreasing numbers of
students opting for medicine as their first preference,
from 38% (CI: 29–48) of applicants in 2004 to 33%
(CI: 25–41) in 2005 and 24% (17–32) in 2006.
There appeared to be an increasing conviction
among students that they wished to become “a
pharmacist”. In 2004, 82% (CI: 75–90) of students
stated they “want to become a pharmacist”, in 2005
this rose to 89% (CI: 84–95) and 2006 to 98% (CI:
95–100). Of the 3 students in 2006 who said they
did not, one stated they would prefer to go into
research.
Matters of interest and importance in a pharmacy career
There appeared to be a sharp division in interest in
aspects of the role of the community pharmacist,
between the “generic” work of selling products,
arranging staff duties and administration, and health
care-specificwork such as offering health promotionand
compounding drugs. Students rated the eight health
care-specific activities presented as being of similar
interest (each receiving an average rating of around 4 out
of 5) and the three generic items at around 3 out of 5
(Figure 3). Out of the eleven activities presented for
rating, students rated “listening to patients” and
“interviewing people” most highly, suggesting a
particular enthusiasm for the interpersonal aspects of
pharmacy work.
“Reliable employment” and “steady job” were the
highest-rated aspects of being a pharmacist followed
closely by “ability to travel” (Figure 4). A number of
other factors were also rated, including professional
status, a good salary and working in the health sciences
and in the community. The least-rated aspect is
“working in a retail shop”.
Looking at trends evident in Figure 4, there was a
slight decrease in importance placed on the “ability to
travel with my qualification” as an important aspect of
being a pharmacist over the years (though it is still
rated highly), a similar decline in the importance
placed on salary, and a corresponding increase shown
in the importance of “owning my own pharmacy”.
Career aspirations
Looking to the future, an overwhelming majority of
students (87% averaged over 2004–2006) stated that,
during their working life they would like to be able to
live and work outside New Zealand (Figure 5). There
is some evidence of this declining in later years. A high
proportion of students (62%) would like to find work
in New Zealand, however, and only 11% say they want
to move away from New Zealand permanently.
Over two-thirds of students, stated they would like
to own a business at some point during their working
life. Furthermore, when asked separately to indicate
what pharmacy career path they would choose “if they
had to today” the majority chose “owner, community
pharmacy (urban)”. This choice has remained
relatively constant over the years (Figure 6). There
has been a decline in the number of students stating
they would choose a career in hospital pharmacy. Only
small numbers of students each year (around 4%)
indicated they would choose a career as a lecturer or in
public administration.
Undergraduate demographics
New Zealanders of European descent made up the
largest proportion of students at NSP at 39% with
sizeable other groups being ethnic Chinese (19%),
Korean (9%), Taiwanese (7%), Malay (6%), (Fijian)
Indian (6%) and Middle-Eastern (5%), though it is
worth noting that there are 25 separate ethnic
groups/nationalities listed in responses.
The male to female ratio of students studying
pharmacy has been consistent since the mid 1970s, at
about two-thirds female to one-third male students
(64–36%). This contrasts with the university student
profile as a whole, which is 55% female and 45% male.
The majority of students beginning the course are 18
or 19 years old (around 80%), with around 15% aged
20–22, and less than 5% aged 23 or over.
Gender and ethnic differences
Gender differences were found to exist in the career
aspirations of students (Figure 7). Only 2004 and 2006
datawere able to be analysed for effects, and across both
years female students were more likely than males to
indicate that they would choose hospital pharmacy “if
you had to choose a pharmacy career path today”
(females 37% versus males 20%; p = 0.006). There
were no significant differences between male and female
students in their preferences for an urban pharmacy or
rural pharmacy career. However, male students were
twice as likely as female students to opt for research as a
career path (females 13% versus males 31%,
p , 0.001). When asked whether during their working
life students wanted to own a business, 89% of male
students indicated this as a careerambition,with 81%of
females saying they did, though this difference was not
significant.
Students’ ethnicity appeared to be one determinant
of whether they studied pharmacy as a first choice, with
New Zealand/European students far more likely to have
done so than students from other ethnic groups (63%
NZ European versus 37% all “others”; p , 0.001). It
was not possible to separate out different ethnicities in a
fully satisfactory manner because of issues with data
collection (changing census classifications) over the
years of study. Of those students who identified
themselves as “Chinese” (n = 38) or “other” Asian
(n = 42), however, less than half had selected
pharmacy as a first choice (n = 27) and one of the
eleven Taiwanese students (all of whom are Chinese by
ethnicity if not by politics) had done so. Differences by
ethnicity were found in terms of influences of parents.
None of the 2006 New Zealand European students
rated parental influence most highly in their decision to
become a health professional, indeed 70% gave it the
lowest possible rating. Parental influence on non-
European New Zealanders was more evenly spread
with 18% of students rating it as the most important
factor in their decision-making and only 33% rating it
as being least important.
Discussion
Motivations to study pharmacy
We have examined themotivation to study pharmacy in
a novel way, by asking students to rank which three
(of seventeen) factors had most influence upon their
choice, in addition to asking students to rate separately
the importance of the range of factors. This enables a
differentiation between factors that might appear at first
sight similarly salient (ratings), and those thatweremost
important in actually influencing a decision (factors
scored by rank). Using thismethod, themost important
motivation given by students in this study for choosing
pharmacyemerges as an intrinsic, altruisticone: that of a
desire to “care for/ help people”.
These findings are probably more pronounced than
those fromother research in this area but do correspond
with other studies of pharmacy students’ study choices.
These studies have consistently reported high prominence
of motivations to study broadly describable as
altruistic, such as “a desire to help humanity” (Pratt,
1956), aspiring to be “socially useful” (Ferguson,
Roller, & Wertheimer, 1986), a desire to make a
contribution to healthcare (Davey et al., 2006) and “a
desire to help people” (Willis et al., 2006a).
These and the current study’s results might seem to
imply that much of students’ motivation to study
pharmacy is in large part a deferred one, that is to say
directed towards their professional life after graduation;
however, other research has indicated that intrinsic
factors influencing the selection of a pharmacy degree
also relate to the course of study itself. Roller (1993)
found that the most important intrinsic or extrinsic
influences on Australian pharmacy students were that
the course was perceived to be “intellectually satisfying”;
however, students’ belief that pharmacy was
socially useful was also important. Willis et al. (2006d)
in the UK similarly identified the science-based nature
of pharmacy as the primary draw for students, but again
with the desire to help people also strong among
intrinsic factors. The current study did not ask directly
whether the course of study was inherently appealing,
although our finding that the second most important
reason why students selected the coursewas “an interest
in human biology” indirectly indicates this is likely to
have been relevant.
Extrinsic factors of most importance to students in
choosing to study pharmacy relate to a desire to earn a
high salary and to own their own business and, to a
lesser extent the status of the profession. Previous work
has also found that students are motivated to study
pharmacy for financial reward and the opportunity for
self-employment (Roller, 1993, 2004; Willis et al.,
2006d) with the most recent research in this area
claiming pharmacy ownership is the “top ambition for
students” (Wilson et al., 2006). Seston, Shann, Hassell
and Willis (2006) found that just under half of all UK
students report the prospect of ownership as having
some influence in their decision to study pharmacy,
with the effect particularly strong among male students
and ethnicminority students. Crucially, they also found
a strong link between the prospect of owning a
pharmacy as a reason for choosing pharmacy as a
degree, and career intentions after three years of study.
Career intentions and expected benefits
In the current study, there appeared to be an early
explicit intention expressed by students to pursue
a career in pharmacy: 121 of 123 respondents in
2006, stated that they want to become a pharmacist,
a proportion that has increased over the three
surveyed years. This result is striking for its being
obtained at a very early stage in students’ course of
study, where one might reasonably expect some
ambivalence towards the degree (though it should be
noted that students were not given the option of
expressing uncertainty). These high rates of commitment
to a career as a pharmacist may relate to other
findings which indicate pharmacy students are careercommitted
(Willis et al., 2006a) and the finding in this
study, that in 2006 for the first time more students
selected pharmacy than any other health profession as
their first choice of study. In 2004 and 2005, as many
of those surveyed had wished to study medicine as
pharmacy, whereas in 2006 over twice as many
students opted for pharmacy as medicine. Despite
this, large numbers (almost half) of NSP students
would have preferred to follow another profession,
usually dentistry or medicine, as has been noted
previously (Shaw, 2000). The tendency for European
New Zealand students to be more likely than ethnic
minority students to have chosen pharmacy as a first
choice is in keeping with other studies which have
found similar ethnic differences in application
priority. This result is curious though for its being
apparently robust across courses, countries and
cohorts (Ferguson et al., 1986; Willis et al., 2006a),
despite the very different actual mix of ethnicities
studying pharmacy between New Zealand, Australia,
Canada, the US and the UK. It may be of concern to
educators that ethnic minority, foreign-born or
overseas students appear to be those most likely to
be studying pharmacy as a second (or lower) choice,
particularly considering the high, and in many
instances increasing, proportion of these students on
pharmacy courses.
Since over two-thirds of students indicated that they
would like at some point in their working life to own
their own pharmacy, New Zealand students’ entrepreneurial
intentions seem as strong as their UK
counterparts (Seston et al., 2006). Interestingly, there
was a decline in the proportions selecting hospital
pharmacy as a desired career path over the years
surveyed.
With so many students wanting to own their own
pharmacy, the question should be asked to what extent
these ambitions are realisable. In theUK, they may well
not come to fruition “given the steady decline of
independent pharmacies through competition from
multiples over recent years and an economic climate
that is not favourable to small pharmacy business”
(Seston et al., 2006). The potential for proprietorship is
higher in New Zealand, which has a long tradition of
individual ownership. Recent changes in legislation,
however, have enabled pharmacists to have a share in
up to five pharmacies, with the consequence that
groups of pharmacists have banded together to form
some small chains of pharmacies, run by manager
pharmacists rather than owners. It will therefore be
important for educators in New Zealand and elsewhere
to be aware that students’ ambitions for individual
ownership may not remain viable.
That hospital pharmacy sector suffers an “image
problem” (Hatfield et al., 2000) is also not so much an
issue in New Zealand, where anecdotal evidence
suggests that pre-registration hospital placements are
more sought after than community internships. The
tendency for females to be significantly more interested
in hospital work than males found in this current
study is in keeping with UK findings (Willis et al.,
2006b) and findings spanning the US, Canada and
Australia (Ferguson et al., 1986). These findings seem
likely to be borne out by students’ career trajectories in
the UK, where three times as many women as men
work in hospitals (Hassell, 2003).
This well-documented gender difference may relate
to hospital pharmacy offering more flexible hours and
institutional benefits (Cockerill & Tanner, 2001), and
also be related to gender differences in entrepreneurial
ambitions, given the generally lower salaries pertaining
in the sector. Other research looking at UK
pharmacy students’ perceptions of hospital pharmacy
suggests that it is perceived by students to offer poor
salaries but more opportunities to interact with
patients and better career progression (Silverthorne
et al., 2003). However, Hassell (2003) identified
concerns among some UK pharmacists that a “glass
ceiling” exists for female hospital pharmacists,
resulting in them being under-represented in senior
positions in this field. This is not the situation in New
Zealand; however, where, in 2006, almost 70% of the
chief pharmacists working in the country’s main
hospitals were female.
As for student aspirations to pursue a career in
research, New Zealand differs from Europe or the US
in that it has only a small pharmaceutical research
industry and only two Schools of Pharmacy, which
may explain the relatively low numbers of NSP
students interested in this career pathway. Interest in a
research career, though still quite limited, is growing
and may increasingly be considered by students to be a
viable career option.
In the current study, students perceived from an
early stage the associated benefits of a pharmacy
career, foremost among these being reliable employment
and the ability to travel with their qualification.
Aspects such as being a professional, working in the
community and earning a good salary also feature as
important facets of being a pharmacist. These and
other factors—such as undergraduate practice and
work experiences (Silverthorne et al., 2003)—are
likely to play a part in influencing the particular career
trajectories of students. Perhaps contrary to expectations,
Carvajal and Hardigan (1999) have also
suggested that females are more likely than males to
experience job satisfaction from high salary and retail
work. This finding did not emerge in the current study
but would be worthy of future attention.
The diminishing importance given by students to an
ability to travel as pharmacists from 2004 to 2006 may
be a consequence of the recent ending of direct
reciprocal employment agreements between the UK
and New Zealand, which has traditionally been a
popular route for New Zealand pharmacists to engage
in their “overseas experience”. Despite this decline, it
should be noted that almost 90% of students still say
they would like to be able to live and work outside
New Zealand at some point in their lives. This finding
may be particular to New Zealand where it is
especially common for university graduates to travel
and live abroad for a few years, usually within the first
10 years post-registration.
Admissions criteria
When asked to consider what might constitute
appropriate admissions criteria for the BPharm
programme, students report that “being a good
communicator” was more important as a selection
criterion than any other of the hypothetical admissions
criteria presented to them, more so even than high
marks in the health sciences common first year
or school science subjects. Speaking English well was
rated highly, and this aligns with research that has
found English skills to correlate highly with final
pharmacy exam marks for non-native English speakers
(Sharif et al., 2003). Science marks and the critical
thinking/scientific capacity indicator “having an
orderly and controlled mind” also featured highly in
students’ opinion of appropriate admissions criteria.
These results regarding student appraisal of what
might be important admissions criteria taken together
are an interesting indicator of students’ own perceptions
about what constitutes a good pharmacist and a
capacity to do well in the degree course: a combination
of good communication skills and cognitive ability. It
has been argued in the pharmacy education literature
that empathic and other non-traditional measures
should be used in student selection (Duncan-Hewitt,
1996; Wright & Miederhoff, 1999). At the university
where this study was conducted such measures are not
currently used in student selection for pharmacy,
though they are in medicine and dentistry. Whether to
use such measures in pharmacy admissions is likely to
arouse continuing controversy, not least because it is
now possible for students to be coached in how to
perform well in these tests in such a way that may be
construed as “faking” their true attitudes.
Aspects of interest in pharmacy practice
Interpersonal/empathic aspects again emerged as
aspects of being a pharmacist of most interest to
students, with “listening to patients” and “interviewing
people” receiving the highest ratings. There appears
overall to be a pronounced division in opinions of the
two facets of professional pharmacy practice: students
perceive non-patient-centred aspects of work, such as
administration and selling products, to be less attractive
than the range of patient-centred work. This may be a
sign that students are already conceptualising pharmacy
work as comprising two different types of
activity—indirect and direct patient care—and that
they are inherently more interested in the latter. This
result is perhaps not surprising, and matches other
research indicating students aspire more to involvement
in direct patient care than indirect patient care, with the
latter described as being “product-focused” or involved
with “drug distribution” (Siracuse et al., 2004). Such
attitudes on the part of students would seem to be in
keeping with the altruistic, patient-centred motivations
expressed for studying pharmacy in the first place.
The current study’s results may in a positive way be
placed in the context of Davey et al.’s (2006) remark
that “as pharmacy practice continues to emphasise
patient interface it is encouraging to see that a
contribution to health care is of more significance (to
students) than the status of the degree”. A cautionary
note may also be added though, that in light of these
findings it will be important to consider in future
research the extent to which students’ expectations and
aspirations are matched by the realities of the workplace,
where “for many pharmacists, there is a clear
disconnect between what pharmacy leadership says
pharmacists should be doing and the reality faced by
practising pharmacists on a daily basis” (Siracuse et al.,
2004) especially in terms of the administrative and
bureaucratic demands of small business management.
Undergraduate demographics
The approximate 2:1 ratio of female:male students at
the NSP corresponds with what seems now almost to
be becoming an education standard for this increasingly
female-dominated profession (Hassell, 2003).
Whilst registers of practising pharmacists consist at
present of 53% females in the UK and New Zealand
(Hassell, 2003; Pharmacy Council of New Zealand,
2005b) this seems destined to change. There are
implications for workforce supply, as the current UK
register shows a far greater degree of part-time hours
worked by women in their 30s and 40s thanmen of the
same age group, which in part is due to family building
(Willis et al., 2006c). A similar trend towards
feminisation has been observed in other health
professions, including medicine and dentistry, in the
US, the UK and Australasia, where similar consequences
have been predicted as a result.
The student body at the NSP is noteworthy in that it
is very diverse and unique to this pharmacy school.
Whereas, well-represented ethnic minorities in pharmacy
in the UK are “Asian British”, that is to say
British students of Indian, Pakistani and Bangladeshi
origin, in New Zealand the ethnic origin of (mostly
New Zealand-resident) minority students are mostly
represented by Chinese, Taiwanese, Koreans and
Malaysians, with those from Arabic and other backgrounds
also rising in numbers. Given the high
diversity, there is likely to be consequent variability in
the learning behaviours of students that educators
may increasingly need to take into account (Miranda,
Bates, & Duggan, 2002).
Limitations and suggestions for future research
A social desirability effect on the self-report measures
in this study may be pronounced because the survey
asked about explicitly socially desirable factors such as
“desire to care for/help people”. A strength of this
study is the very high response rate (98%) obtained,
largely through our distribution of the survey during
compulsory course elements. Although the questionnaire
used in this study was based in part on surveys
used in previous research into pharmacy student
choices, its reliability and validity were not separately
tested. Indicators of reliability and validity however
include the emergence of dual factors from questions
pertaining to direct and indirect patient care and the
congruence of certain career- and study-related
motivators emerging in separate areas of the survey,
for example in the intention and aspiration to own a
business. It is the authors’ intention to use a followup
questionnaire in longitudinal research with the
cohort surveyed in 2004–2006, which may give
further indications of its validity and reliability.
A particular point for concern for this and similar
studies is the apparently limited extent to which
physicians have accurate retrospective recall of the
causes of their own behaviour in relation to career
choice (Pathman & Agnew, 1993).
Future work might focus on extending knowledge of
intrinsic and extrinsic factors in choice of profession by
placing the choice of pharmacy as a degree and career
against a wider social context. The extent to which
socioeconomic factors and family background influence
students’ decisions might be further considered, for
example. Large-scale work has indicated that “professional”
class background can have a particular
positive effect upon the choice of prestigious degrees
such as medicine and law (Van de Werfhorst et al.,
2003). These authors also presented evidence that
educational systems are institutionally biased towards
students who possess “cultural capital”, which makes it
difficult for working-class students to succeed in the
education system. Furthermore, because of differential
costs and benefits between class backgrounds, professional
career trajectories are less easily attainable for
working-class students. In the health sciences, differences
in career choice have been found between lowand
high income family backgrounds of medical students
(Cooter et al., 2004). It is not known whether such
influences are as important in New Zealand, where
social systems are perhapsmore fluid. Neither has there
been any examination of whether the cost of study—
which ranged in 2006 from US$3300 per annum for
physiotherapy toUS$3850 for pharmacy andUS$7400
for medicine/ dentistry—influences students’ choice of
career. Nevertheless, it is a matter for concern that the
proportion of BPharmstudents who identify asMaori is
well below the proportion of Maori in the general
population (1–2% compared with 12%).
A further limitation of this study is that it was
focussed to a large extent on students’ intentions,
which may vary over their course of study and may
also not manifest in reality. Edwards, Lambert,
Goldacre, & Parkhouse, (1997), for example, reported
that ten years after graduating only two-thirds of
medical students end up working in the field they
intended to during study. It will be of value in future
research therefore to ascertain the extent to which
students follow through with their intentions, which
will better inform the reliability and validity of this and
similar survey tools and, more importantly, to what
extent expectations and aspirations of pharmacy
students are realised in the workplace. This would
have significance for those promoting pharmacy
degrees and admitting students to their courses, as
to what character of advice is most appropriate and
honest to offer to these aspiring professionals.
Summary and conclusions
This study, as well as previous research across a range
of cohorts, courses and countries, offers a generally
consistent view of the motivations of students to study
pharmacy and work as a health professional. Whereas
other research has suggested that altruistic intent may
be similar in importance to other factors, this study’s
results point to a clear prominence for this particular
factor.
Scientific aspects inherent to pharmacy as a course
of study also act as attractors to the subject area and
pharmacy is perceived in favourable terms as offering
good employment prospects with considerable entrepreneurial
potential. A tendency still exists among
many first year pharmacy students to have selected
medicine or dentistry as a first choice, particularly
among ethnic minority students, a tendency which
may be declining but is likely to be to an extent
inevitable, particularly with a system in which all
students take the same first year curriculum. The
picture among the undergraduate cohort, nevertheless,
is of committed individuals who intend to
pursue a pharmacy career. Gender differences
were shown to emerge between aspirations to work
in the different sectors, and in pharmacy
ownership intentions. The perceived value of a
pharmacy “passport”, and intention to travel with it
is very high among NSP students and will see many
working overseas. Students perceived that good
communication and English skills are of greatest
importance when considering potential entrants to the
course, a belief borne out by the literature. Yet the
Pharmacy School’s admissions process does not place
a greater emphasis on this requirement (which is
currently assessed by means of a paper on Effective
Communication, provided by the University’s English
Department) than any of the other papers of the
compulsory health sciences first year course, despite
the fact that many of its students have English as a
second language.
There is some concern about the extent to which
students’ desire and intentions to own a pharmacy
will be realisable in the future and also the extent to
which students’ experience in community pharmacy
after registration will match their expectations and
preferences.
Future focus for research that elucidates the wider
range of factors likely to influence students’ pursuance
of pharmacy, such as that which relates to family, class
or cultural background is suggested. Also of importance
will be work that better investigates the link
between students’ education and ambitions and the
realities of their professional life.
Factors influencing undergraduates’ selection of Pharmacy as a course of study, career, study and professional perspectives were evaluated by survey over the years 2004–2006 at Otago University, New Zealand. Altruistic intent emerged as a powerful motivator for choosing pharmacy and entrepreneurial career intentions were prominent. A sizeable though declining number
of students selected pharmacy secondarily to medicine or dentistry. Gender differences were found between intended areas of practice.
Introduction
Graduates from the National School of Pharmacy
(NSP) atOtago University represent just over half of all
Pharmacy graduates educated in New Zealand. In the
year 2006, these students constituted 45% of additions
to the practising register, with other significant
additions being from Auckland University (23%) and
UK/Ireland (21%; Pharmacy Council of New Zealand,
2005a). The motivations, career aspirations and
choices ofNSP studentswill therefore have a significant
influence on the future practice and culture of
Pharmacy both in New Zealand and on the work
overseas that many will pursue. Indirectly, selection
criteria used to admit students to the BPharm course
will also play a role in shaping the next generation of
pharmacists.
Choosing pharmacy as a course of study—demographics
and motivations
The choice by students of any undergraduate degree
involves many factors, including but not limited
to: socioeconomic variables, gender and ethnicity,
academic ability and academic self-concept, career
ambitions, personality, and prior educational attainment
(Van de Werfhorst, Sullivan, & Cheung, 2003;
Reay, Davies, David, & Ball, 2001; Pike, 2006; Porter
& Umbach, 2006; Abowitz, 2006). Recent studies in
the UK have indicated that there are increasing
numbers of women studying pharmacy, with almost
twice as many women as men qualifying as pharmacists
in 2005 (Hassell & Eden, 2006) leading to
pharmacy now being described as a “female-dominated”
profession (Hassell, 2003). The ethnic mix of
pharmacists in the UK is also becoming more diverse,
with around 25% of newly qualified pharmacists now
recorded as being “Asian British” (Hassell & Eden,
2006)—that is to say Indian, Pakistani or Bangladeshi—
compared with 4% of the population (Census,
1991/2001). Black British and Chinese ethnic groups
are also growing in representation (Hassell & Eden,
2006), though there is huge variability in the makeup
of course cohorts around the country (Willis,
Shann, & Hassell, 2006d).
Race or ethnicity has in a different way been shown
to be strongly associated with the pursuit of a
pharmacy degree and career. A US investigation into
whether individuals who had initially expressed an
interest in pharmacy subsequently pursued this field,
found that Hispanic or “other” ethnic group students
were 12 times more likely than White students to
continue with their plans to become pharmacists
(Cline, Mott, & Schommer, 1999). This study found
that those with higher grade point averages and career
commitments were also more likely to apply to study
pharmacy, suggesting that “despite pharmacy’s
uncertain future, it is still able to attract academically
qualified students” (P399). The role of ethnicity,
attitudinal traits and academic factors have been
found to interplay in other ways, for example with
family influence in choice of pharmacy as a career
reported to be particularly strong for non-White
students (Willis, Shann, & Hassell, 2006a).
The strongest motivating factor to study pharmacy
in the UK has recently been found to relate to its being
a science-based course, with other extrinsic and
intrinsic motivators also featuring—namely career
status and prospects, and a desire to help people and
to work with patients (Willis et al., 2006d). In
Australia, extrinsic factors relating to self-employment
and salary, and intrinsic factors relating to a liking for
science, interpersonal aspects and a desire to be socially
useful have all been found to influence students’ choice
of pharmacy as a degree (Roller, 2004). At the graduate
entry level, future employment prospects and a desire
to make a contribution to healthcare feature most
highly as factors influencing decision to study
pharmacy (Davey, Evans, & Stupans, 2006). Consistency
in motivations to study pharmacy across time and
cultures is indicated when it is considered that similar
findings relating to science, salaries and a “desire to
help humanity” were obtained in the US from the
1950s through to the 1970s (Cline et al., 1999; Pratt,
1956; Smith, Gibson, & Mikeal, 1974).
Around 75% of UK pharmacy students initially
chose pharmacy as their first course of study, with white
females most likely to take pharmacy as a first choice
(84%;Willis et al., 2006a). Ethnicity also emerged as a
factor in first degree selection, with almost four times as
many non-White students reporting pharmacy was not
their first choice of degree, compared with White
students. At the NSP, it is said to be “inevitable” that a
portion of undergraduates will not have opted first for
pharmacy, as the majority of students take a common
health sciences first year and subsequently compete for
entry to pharmacy, medicine, dentistry and physiotherapy
courses, for all of which they may apply at the end
of this year (Shaw, 2000).
Selection criteria
Admission to pharmacy at NSP is mostly based on
students obtaining a minimum of an average B grade
(70%) in the common health sciences first year.
A smaller number of students are admitted from
second or subsequent year of study, usually at Otago,
or as “competitive” graduates (of a New Zealand
university within the previous 3 years). An “alternative
applicant” category brings in a few others: those who
may have graduated from a New Zealand university
more than 3 years previously; those who have obtained
degrees, usually in medicine or pharmacy, from an
overseas university; and those who have worked as an
allied health professional (most often a pharmacy
technician or nurse) for 5 years or more. All such
applicants are required to have passed the subjects of
Otago’s common health sciences first year course (or
the equivalents) and to have demonstrated competence
in English. A certain degree of positive
discrimination exists in that students who are Maori
or Pacific Islanders may be brought into the BPharm
programme even if they achieve only an average of
65% or more during their pre-admission year(s). Only
about 1–2 students are admitted in this way each year,
however. Very few applicants for admission are
interviewed—only those applying as “alternative”
candidates and for whom English is not their first
language.
In the UK, A-level grades have been found to show
a small but significant correlation with grades at
pharmacy undergraduate level and thus it has been
argued that both teachers’ estimates of A-level
performance and actual A-level scores remain useful
in selection and forecasting (Foy & Waller, 1987).
A-level biology scores may perhaps be a stronger
predictor of performance in a pharmacy degree, and
English ability at entry level is also important as an
indicator of student success (Sharif, Gifford, Morris,
& Barber, 2003). Given that pharmacy undergraduates
must have the capacity to acquire diverse
scientific knowledge and skills, as well as developing
the knowledge and interpersonal skills of pharmaceutical
care, it is also reasonable to ask whether there
might be other selection criteria also applicable to
undergraduate admissions. With respect to the
contemporary focus of pharmacy practice as one
centred on patient care (Strand, Cipolle, Morley, &
Frakes, 2004), it has been suggested that formal
assessments of self-reported empathy be used in the
admissions processes of pharmacy schools. Similarly,
with reference to the scientific demands of the course,
that critical thinking skills and mathematical ability
should be taken into account, in addition to a range of
other non-academic and affective qualities (Duncan-
Hewitt, 1996).
The use of a variety of aptitude tests for pharmacy
admissions is now commonplace in the US (Chesnut &
Phillips, 2000), for example the Pharmacy College
Admission Test (PCAT; Duncan-Hewitt, 1996;
Chesnut & Phillips, 2000), which incorporates
measures of communication skills, reasoning ability
and chemistry- and biology-specific knowledge (American
Association of Colleges of Pharmacy, 2006).
Currently, no equivalent pharmacy admissions test
exists at the NSP; however, students pursuing entry
into medicine or dentistry from the common health
sciences first year are admitted in part according to
their performance on the UMAT (Undergraduate
Medicine and Health Sciences Admissions Test).
Given the potential relevance of various factors which
may be used in admissions, ranging from interpersonal
relations to problem-solving skills to ethical awareness
(Chesnut & Phillips, 2000), the novel step was taken
in this study to ask students themselves, what they
consider to be important and relevant selection
criteria for the pharmacy degree.
Career aspirations—professional intentions and influences
In the US, a study of eight Pharmacy Schools
indicated that the majority of students (71%) have
career aspirations that are strongly oriented towards
“direct patient care”, although concern is expressed
that this may be at odds with the realities of drug
distribution-based pharmacy likely to be encountered
in the professional workplace (Siracuse, Schondelmeyer,
Hadsall, & Schommer, 2004). This study also
found evidence that the more career-committed of
students will also be those aspiring to work in direct
patient care. Others have found that the “professional
subculture” of students entering pharmacy is comparable
to nursing and medical students as regards
their emphasis on patient care (Horsburgh, Perkins,
Coyle, & Degeling, 2006).
Pharmacy students in the UK apparently possess a
strong expectation that they will work very hard no
matter what pharmacy job they acquire—95% believe
this to be the case—and 80% state they are very
ambitious about their pharmacy career (Willis et al.,
2006a). Diverse factors have been shown to affect the
choice made by students about specific career paths,
including previous work experience, the influence of
sections of the undergraduate syllabus directed
towards pharmacy practice (Siverthorne, Price, Hanning,
Scanlan, & Cantrill, 2003) and practical matters
such as salary and work location, a desire for personal
fulfilment and to help patients (Carvajal & Hardigan,
1999; Carter & Segal, 1989).
As recently as 2000, concern has been expressed
that hospital pharmacy in the UK is said at the
undergraduate level to have an “image problem”,
being considered elitist, badly paid, dull and repetitive
(Hatfield, Marriott, & Harper, 2000). In contrast to
this (or perhaps evidence of a shift in attitude and
intention of students), more UK students stated that
they were at least “certain” that “in 10 years time”
they wanted a career in hospital pharmacy (60%)
compared to any other career option, although
significant interest was shown in community practice
(proprietor, 33%; employed by multiple, 51%),
working abroad (43%) and primary care (37%; Willis
et al., 2006a). Given that more than one option was
permitted in this survey, students do appear to be
hedging their bets to an extent, but these figures at
least suggest an open-mindedness about the practice
sites available to them.
Of those intending to work in the community sector
in the UK, strong entrepreneurial intentions are
evident, with 44% of male students and 28% of female
students saying they are certain they want to own a
pharmacy (Willis et al., 2006a) and pharmacy
ownership reported as the top ambition for students
(Wilson, Jesson, Langley, Hatfield, & Clarke, 2006).
The proportion of these individuals who will attain
their ambitions, given the decline of the independent
pharmacy in Britain, remains to be seen, however.
Consequences of the “feminisation” of pharmacy relate
to the likelihood of women working part time once in
their 30s, and gravitating towards temporary community
work (Hassell, 2003). It has been suggested also
that this feminising shift may at least correlate with
pharmacy itself becoming a more attractive career for
women than men (Gidman & Hassell, 2005).
Attitudes and career intentions in pharmacy have
not been as clearly elucidated in New Zealand.
However, given that currently 2100 (82%) of
pharmacists work in the community sector and 300
pharmacists (10%) in the hospital sector (Pharmacy
Council of New Zealand, 2005b) it could be valuable
to assess students’ perceptions of these and other
career paths.
Aims of this study
This study evaluated factors influencing students’
decisions to study pharmacy and to work as health
professionals, aswell as the characteristics they consider
important for selection to the course and for practising
pharmacy. Also investigated were pharmacy students’
career aspirations and intentions, and the relative
importance and attraction of various professional
activities and incentives. NSP students across three
separate cohorts and years were surveyed to examine
for commonalities and trends in these areas.
Method
This study, approved by the University of Otago
Human Ethics Committee, was developed in December/
January 2002/2003 following a series of interviews
and focus group discussions with current and recently
graduated students. It was piloted in 2003 by a
group of student researchers on that year’s second year
intake, following which a number of minor adjustments
were made to ensure consistency and ease of
analysis. The questionnaire has since then been
administered routinely to each incoming second year
class at the start of their first lecture, in the School of
Pharmacy. This first lecture which introduces students
to the School and pharmacy profession, is attended by
most students, all of whom have just been admitted
into the BPharm programme. The results presented in
this paper relate to the second year students of 2004–
2006.
The (anonymous) questionnaires were distributed
around the lecture theatre before the start of the lecture.
Students were then given 15 min to complete the
surveys and were asked to do so in silence, without
reference to their neighbours. At the end of the allotted
time, class representatives collected the completed
questionnaires and handed them to the academic staff
member present (who was not one of the researchers).
The questionnaire consisted of 24 separate questions,
many of which were subdivided into further
categories of choice. Most questions were multiplechoice,
requiring respondents to rate statements on a
Likert-type scale of 1–5, with 1 being not at all
important/ not at all interested through to 5 as most
important/ very interested. Other questions asked
students to rate order of importance of factors (e.g.
order of priority of factors influencing decision to
study pharmacy) or to make selections from alternatives
(e.g. ethnicity).
The following areas from the survey questionnaire
were analysed for the period 2004–2006:
1. Why do you want to work as a health professional?
(rating scale 1–5, 17 statements)
2. Which three of these factors (statements from
Question 1) were the most important in your
decision? (Please list in order of priority)
3. What, in your opinion, are the most important
attributes that the School of Pharmacy should
consider when selecting people for the Bachelor of
Pharmacy programme? (rating scale 1–5, 12
statements)
4. When you applied for admission to the Health
Sciences, was Pharmacy your first preference?
(yes/no) If not, please state which programmes
were preferred.
5. At this stage in your BPharm programme, do you
want to become a pharmacist? (yes/no)
6. Community pharmacists are involved in many of
the following activities in their day to day work.
Which activities are of most interest to you? (rating
scale 1–5, 11 statements)
7. What aspects of being a pharmacist are most
important to you? (rating scale 1–5, 14 statements)
8. During my working life, I would like . . . (tick as
many phrases as you feel apply [12 statements])
9. If you had to choose a pharmacy career path today, in
what field would it be? (Please tick one [6 options])
Further questions were also asked about gender,
age, ethnicity, language spoken and residency status.
Data were collated and analysed for all student
responses over the 3 years (n = 351) and separately for
each year to examine for trends. Participants’
responses between questions were not linked for the
2005 data, so analyses linking responses from different
questions are only presented for 2004 and 2006.
In addition to reporting descriptive statistics,
participants were forced to rank only three factors in
Question 2. Thus ranking data in Figure 1 represent
the mean number of times participants ranked a factor
as primary importance (3), secondary importance (2),
and tertiary importance (1). A score of 3 would
indicate all participants said a factor was the most
important; conversely a score of 0 indicates a factor
was not ranked in the top 3 by any participant.
Using the two smallest cohorts (2004 and 2006), it
was estimated using G*Power 3 that with 80%power, a
two-tailed pairwise comparison would be able to detect
an effect of d ¼ 0.38. By convention, values of 0.2 and
0.5 are considered to be small and medium respectively,
meaning that where differences were not found,
any real differences are likely to be close to small in size.
Results
A total of 351 students completed the survey (2004,
n ¼ 103; 2005 n ¼ 125; 2006, n ¼ 123) representing
98% of the total of three cohorts. All students in 2005
and 2006 completed the survey; 103 of 110 students
did so in 2004. There was a small level of nonresponse
on some questions, but this appears to be a
student accidentally omitting a question rather than
systematically not responding.
Motivations to study pharmacy
The left-hand panel of Figure 1 shows a strong degree of
consistency between years as to the primary ranked
motivations of students to work as a health professional
(Question 2). By far, the most highly ranked motivation
was a desire to work in a job where they “care for/
help people”, which was twice as highly ranked as
the next highest motivation, an “interest in human
biology”. A job involving interaction with people, a high
salary, a desire to work in the community, a desire to
own a business and a number of other aspects also
featured as important motivators. University publicity,
friends studying in the health sciences, family tradition
and “having high grades but not knowing what else to
do” were the least reported reasons for wanting to work
as a health professional.
The right-hand panel of Figure 1 presents mean
rating data for the same factors. Few trends across the
surveyed years were evident in students’ motivations to
work as a health professional, with the exception of a
desire for a “career in research”. Over the 3 years,
there was an approximately 15% increase in the
importance placed on this factor. It would seem
therefore that students coming into the pharmacy
course are increasingly explicitly considering a research
career at an early stage. It is also interesting to note the
difference in responses between the ranking and rating
data. For example, students were clearly interested in
learning new technology, but it was not a top priority.
Admissions criteria
Figure 2 shows that students rated being a good
communicator with good English (language skills) as
the top attributes that they considered the School
should considerwhen selecting people for the pharmacy
programme. Highmarks in health sciences first year and
in science at schoolwere also highly-rated, aswas having
an “orderly/controlled mind”. Those attributes considered
least important fromthe options presented were
a previous tertiary qualification, being an older student
and high marks in arts subjects at school.
Study and career commitment
A large, but slightly decreasing number of students
opted first for medicine or dentistry on application
from health sciences, with those opting for pharmacy
as their first choice ranging between 38 and 50%.
2006 was the first year of the three that more
students selected pharmacy as their first preference
than did not (50% (CI: 42–59) in 2006, vs. 38%
(CI: 30–47) in 2005 and 46% (CI: 36–56) in 2004).
One notable trend is the decreasing numbers of
students opting for medicine as their first preference,
from 38% (CI: 29–48) of applicants in 2004 to 33%
(CI: 25–41) in 2005 and 24% (17–32) in 2006.
There appeared to be an increasing conviction
among students that they wished to become “a
pharmacist”. In 2004, 82% (CI: 75–90) of students
stated they “want to become a pharmacist”, in 2005
this rose to 89% (CI: 84–95) and 2006 to 98% (CI:
95–100). Of the 3 students in 2006 who said they
did not, one stated they would prefer to go into
research.
Matters of interest and importance in a pharmacy career
There appeared to be a sharp division in interest in
aspects of the role of the community pharmacist,
between the “generic” work of selling products,
arranging staff duties and administration, and health
care-specificwork such as offering health promotionand
compounding drugs. Students rated the eight health
care-specific activities presented as being of similar
interest (each receiving an average rating of around 4 out
of 5) and the three generic items at around 3 out of 5
(Figure 3). Out of the eleven activities presented for
rating, students rated “listening to patients” and
“interviewing people” most highly, suggesting a
particular enthusiasm for the interpersonal aspects of
pharmacy work.
“Reliable employment” and “steady job” were the
highest-rated aspects of being a pharmacist followed
closely by “ability to travel” (Figure 4). A number of
other factors were also rated, including professional
status, a good salary and working in the health sciences
and in the community. The least-rated aspect is
“working in a retail shop”.
Looking at trends evident in Figure 4, there was a
slight decrease in importance placed on the “ability to
travel with my qualification” as an important aspect of
being a pharmacist over the years (though it is still
rated highly), a similar decline in the importance
placed on salary, and a corresponding increase shown
in the importance of “owning my own pharmacy”.
Career aspirations
Looking to the future, an overwhelming majority of
students (87% averaged over 2004–2006) stated that,
during their working life they would like to be able to
live and work outside New Zealand (Figure 5). There
is some evidence of this declining in later years. A high
proportion of students (62%) would like to find work
in New Zealand, however, and only 11% say they want
to move away from New Zealand permanently.
Over two-thirds of students, stated they would like
to own a business at some point during their working
life. Furthermore, when asked separately to indicate
what pharmacy career path they would choose “if they
had to today” the majority chose “owner, community
pharmacy (urban)”. This choice has remained
relatively constant over the years (Figure 6). There
has been a decline in the number of students stating
they would choose a career in hospital pharmacy. Only
small numbers of students each year (around 4%)
indicated they would choose a career as a lecturer or in
public administration.
Undergraduate demographics
New Zealanders of European descent made up the
largest proportion of students at NSP at 39% with
sizeable other groups being ethnic Chinese (19%),
Korean (9%), Taiwanese (7%), Malay (6%), (Fijian)
Indian (6%) and Middle-Eastern (5%), though it is
worth noting that there are 25 separate ethnic
groups/nationalities listed in responses.
The male to female ratio of students studying
pharmacy has been consistent since the mid 1970s, at
about two-thirds female to one-third male students
(64–36%). This contrasts with the university student
profile as a whole, which is 55% female and 45% male.
The majority of students beginning the course are 18
or 19 years old (around 80%), with around 15% aged
20–22, and less than 5% aged 23 or over.
Gender and ethnic differences
Gender differences were found to exist in the career
aspirations of students (Figure 7). Only 2004 and 2006
datawere able to be analysed for effects, and across both
years female students were more likely than males to
indicate that they would choose hospital pharmacy “if
you had to choose a pharmacy career path today”
(females 37% versus males 20%; p = 0.006). There
were no significant differences between male and female
students in their preferences for an urban pharmacy or
rural pharmacy career. However, male students were
twice as likely as female students to opt for research as a
career path (females 13% versus males 31%,
p , 0.001). When asked whether during their working
life students wanted to own a business, 89% of male
students indicated this as a careerambition,with 81%of
females saying they did, though this difference was not
significant.
Students’ ethnicity appeared to be one determinant
of whether they studied pharmacy as a first choice, with
New Zealand/European students far more likely to have
done so than students from other ethnic groups (63%
NZ European versus 37% all “others”; p , 0.001). It
was not possible to separate out different ethnicities in a
fully satisfactory manner because of issues with data
collection (changing census classifications) over the
years of study. Of those students who identified
themselves as “Chinese” (n = 38) or “other” Asian
(n = 42), however, less than half had selected
pharmacy as a first choice (n = 27) and one of the
eleven Taiwanese students (all of whom are Chinese by
ethnicity if not by politics) had done so. Differences by
ethnicity were found in terms of influences of parents.
None of the 2006 New Zealand European students
rated parental influence most highly in their decision to
become a health professional, indeed 70% gave it the
lowest possible rating. Parental influence on non-
European New Zealanders was more evenly spread
with 18% of students rating it as the most important
factor in their decision-making and only 33% rating it
as being least important.
Discussion
Motivations to study pharmacy
We have examined themotivation to study pharmacy in
a novel way, by asking students to rank which three
(of seventeen) factors had most influence upon their
choice, in addition to asking students to rate separately
the importance of the range of factors. This enables a
differentiation between factors that might appear at first
sight similarly salient (ratings), and those thatweremost
important in actually influencing a decision (factors
scored by rank). Using thismethod, themost important
motivation given by students in this study for choosing
pharmacyemerges as an intrinsic, altruisticone: that of a
desire to “care for/ help people”.
These findings are probably more pronounced than
those fromother research in this area but do correspond
with other studies of pharmacy students’ study choices.
These studies have consistently reported high prominence
of motivations to study broadly describable as
altruistic, such as “a desire to help humanity” (Pratt,
1956), aspiring to be “socially useful” (Ferguson,
Roller, & Wertheimer, 1986), a desire to make a
contribution to healthcare (Davey et al., 2006) and “a
desire to help people” (Willis et al., 2006a).
These and the current study’s results might seem to
imply that much of students’ motivation to study
pharmacy is in large part a deferred one, that is to say
directed towards their professional life after graduation;
however, other research has indicated that intrinsic
factors influencing the selection of a pharmacy degree
also relate to the course of study itself. Roller (1993)
found that the most important intrinsic or extrinsic
influences on Australian pharmacy students were that
the course was perceived to be “intellectually satisfying”;
however, students’ belief that pharmacy was
socially useful was also important. Willis et al. (2006d)
in the UK similarly identified the science-based nature
of pharmacy as the primary draw for students, but again
with the desire to help people also strong among
intrinsic factors. The current study did not ask directly
whether the course of study was inherently appealing,
although our finding that the second most important
reason why students selected the coursewas “an interest
in human biology” indirectly indicates this is likely to
have been relevant.
Extrinsic factors of most importance to students in
choosing to study pharmacy relate to a desire to earn a
high salary and to own their own business and, to a
lesser extent the status of the profession. Previous work
has also found that students are motivated to study
pharmacy for financial reward and the opportunity for
self-employment (Roller, 1993, 2004; Willis et al.,
2006d) with the most recent research in this area
claiming pharmacy ownership is the “top ambition for
students” (Wilson et al., 2006). Seston, Shann, Hassell
and Willis (2006) found that just under half of all UK
students report the prospect of ownership as having
some influence in their decision to study pharmacy,
with the effect particularly strong among male students
and ethnicminority students. Crucially, they also found
a strong link between the prospect of owning a
pharmacy as a reason for choosing pharmacy as a
degree, and career intentions after three years of study.
Career intentions and expected benefits
In the current study, there appeared to be an early
explicit intention expressed by students to pursue
a career in pharmacy: 121 of 123 respondents in
2006, stated that they want to become a pharmacist,
a proportion that has increased over the three
surveyed years. This result is striking for its being
obtained at a very early stage in students’ course of
study, where one might reasonably expect some
ambivalence towards the degree (though it should be
noted that students were not given the option of
expressing uncertainty). These high rates of commitment
to a career as a pharmacist may relate to other
findings which indicate pharmacy students are careercommitted
(Willis et al., 2006a) and the finding in this
study, that in 2006 for the first time more students
selected pharmacy than any other health profession as
their first choice of study. In 2004 and 2005, as many
of those surveyed had wished to study medicine as
pharmacy, whereas in 2006 over twice as many
students opted for pharmacy as medicine. Despite
this, large numbers (almost half) of NSP students
would have preferred to follow another profession,
usually dentistry or medicine, as has been noted
previously (Shaw, 2000). The tendency for European
New Zealand students to be more likely than ethnic
minority students to have chosen pharmacy as a first
choice is in keeping with other studies which have
found similar ethnic differences in application
priority. This result is curious though for its being
apparently robust across courses, countries and
cohorts (Ferguson et al., 1986; Willis et al., 2006a),
despite the very different actual mix of ethnicities
studying pharmacy between New Zealand, Australia,
Canada, the US and the UK. It may be of concern to
educators that ethnic minority, foreign-born or
overseas students appear to be those most likely to
be studying pharmacy as a second (or lower) choice,
particularly considering the high, and in many
instances increasing, proportion of these students on
pharmacy courses.
Since over two-thirds of students indicated that they
would like at some point in their working life to own
their own pharmacy, New Zealand students’ entrepreneurial
intentions seem as strong as their UK
counterparts (Seston et al., 2006). Interestingly, there
was a decline in the proportions selecting hospital
pharmacy as a desired career path over the years
surveyed.
With so many students wanting to own their own
pharmacy, the question should be asked to what extent
these ambitions are realisable. In theUK, they may well
not come to fruition “given the steady decline of
independent pharmacies through competition from
multiples over recent years and an economic climate
that is not favourable to small pharmacy business”
(Seston et al., 2006). The potential for proprietorship is
higher in New Zealand, which has a long tradition of
individual ownership. Recent changes in legislation,
however, have enabled pharmacists to have a share in
up to five pharmacies, with the consequence that
groups of pharmacists have banded together to form
some small chains of pharmacies, run by manager
pharmacists rather than owners. It will therefore be
important for educators in New Zealand and elsewhere
to be aware that students’ ambitions for individual
ownership may not remain viable.
That hospital pharmacy sector suffers an “image
problem” (Hatfield et al., 2000) is also not so much an
issue in New Zealand, where anecdotal evidence
suggests that pre-registration hospital placements are
more sought after than community internships. The
tendency for females to be significantly more interested
in hospital work than males found in this current
study is in keeping with UK findings (Willis et al.,
2006b) and findings spanning the US, Canada and
Australia (Ferguson et al., 1986). These findings seem
likely to be borne out by students’ career trajectories in
the UK, where three times as many women as men
work in hospitals (Hassell, 2003).
This well-documented gender difference may relate
to hospital pharmacy offering more flexible hours and
institutional benefits (Cockerill & Tanner, 2001), and
also be related to gender differences in entrepreneurial
ambitions, given the generally lower salaries pertaining
in the sector. Other research looking at UK
pharmacy students’ perceptions of hospital pharmacy
suggests that it is perceived by students to offer poor
salaries but more opportunities to interact with
patients and better career progression (Silverthorne
et al., 2003). However, Hassell (2003) identified
concerns among some UK pharmacists that a “glass
ceiling” exists for female hospital pharmacists,
resulting in them being under-represented in senior
positions in this field. This is not the situation in New
Zealand; however, where, in 2006, almost 70% of the
chief pharmacists working in the country’s main
hospitals were female.
As for student aspirations to pursue a career in
research, New Zealand differs from Europe or the US
in that it has only a small pharmaceutical research
industry and only two Schools of Pharmacy, which
may explain the relatively low numbers of NSP
students interested in this career pathway. Interest in a
research career, though still quite limited, is growing
and may increasingly be considered by students to be a
viable career option.
In the current study, students perceived from an
early stage the associated benefits of a pharmacy
career, foremost among these being reliable employment
and the ability to travel with their qualification.
Aspects such as being a professional, working in the
community and earning a good salary also feature as
important facets of being a pharmacist. These and
other factors—such as undergraduate practice and
work experiences (Silverthorne et al., 2003)—are
likely to play a part in influencing the particular career
trajectories of students. Perhaps contrary to expectations,
Carvajal and Hardigan (1999) have also
suggested that females are more likely than males to
experience job satisfaction from high salary and retail
work. This finding did not emerge in the current study
but would be worthy of future attention.
The diminishing importance given by students to an
ability to travel as pharmacists from 2004 to 2006 may
be a consequence of the recent ending of direct
reciprocal employment agreements between the UK
and New Zealand, which has traditionally been a
popular route for New Zealand pharmacists to engage
in their “overseas experience”. Despite this decline, it
should be noted that almost 90% of students still say
they would like to be able to live and work outside
New Zealand at some point in their lives. This finding
may be particular to New Zealand where it is
especially common for university graduates to travel
and live abroad for a few years, usually within the first
10 years post-registration.
Admissions criteria
When asked to consider what might constitute
appropriate admissions criteria for the BPharm
programme, students report that “being a good
communicator” was more important as a selection
criterion than any other of the hypothetical admissions
criteria presented to them, more so even than high
marks in the health sciences common first year
or school science subjects. Speaking English well was
rated highly, and this aligns with research that has
found English skills to correlate highly with final
pharmacy exam marks for non-native English speakers
(Sharif et al., 2003). Science marks and the critical
thinking/scientific capacity indicator “having an
orderly and controlled mind” also featured highly in
students’ opinion of appropriate admissions criteria.
These results regarding student appraisal of what
might be important admissions criteria taken together
are an interesting indicator of students’ own perceptions
about what constitutes a good pharmacist and a
capacity to do well in the degree course: a combination
of good communication skills and cognitive ability. It
has been argued in the pharmacy education literature
that empathic and other non-traditional measures
should be used in student selection (Duncan-Hewitt,
1996; Wright & Miederhoff, 1999). At the university
where this study was conducted such measures are not
currently used in student selection for pharmacy,
though they are in medicine and dentistry. Whether to
use such measures in pharmacy admissions is likely to
arouse continuing controversy, not least because it is
now possible for students to be coached in how to
perform well in these tests in such a way that may be
construed as “faking” their true attitudes.
Aspects of interest in pharmacy practice
Interpersonal/empathic aspects again emerged as
aspects of being a pharmacist of most interest to
students, with “listening to patients” and “interviewing
people” receiving the highest ratings. There appears
overall to be a pronounced division in opinions of the
two facets of professional pharmacy practice: students
perceive non-patient-centred aspects of work, such as
administration and selling products, to be less attractive
than the range of patient-centred work. This may be a
sign that students are already conceptualising pharmacy
work as comprising two different types of
activity—indirect and direct patient care—and that
they are inherently more interested in the latter. This
result is perhaps not surprising, and matches other
research indicating students aspire more to involvement
in direct patient care than indirect patient care, with the
latter described as being “product-focused” or involved
with “drug distribution” (Siracuse et al., 2004). Such
attitudes on the part of students would seem to be in
keeping with the altruistic, patient-centred motivations
expressed for studying pharmacy in the first place.
The current study’s results may in a positive way be
placed in the context of Davey et al.’s (2006) remark
that “as pharmacy practice continues to emphasise
patient interface it is encouraging to see that a
contribution to health care is of more significance (to
students) than the status of the degree”. A cautionary
note may also be added though, that in light of these
findings it will be important to consider in future
research the extent to which students’ expectations and
aspirations are matched by the realities of the workplace,
where “for many pharmacists, there is a clear
disconnect between what pharmacy leadership says
pharmacists should be doing and the reality faced by
practising pharmacists on a daily basis” (Siracuse et al.,
2004) especially in terms of the administrative and
bureaucratic demands of small business management.
Undergraduate demographics
The approximate 2:1 ratio of female:male students at
the NSP corresponds with what seems now almost to
be becoming an education standard for this increasingly
female-dominated profession (Hassell, 2003).
Whilst registers of practising pharmacists consist at
present of 53% females in the UK and New Zealand
(Hassell, 2003; Pharmacy Council of New Zealand,
2005b) this seems destined to change. There are
implications for workforce supply, as the current UK
register shows a far greater degree of part-time hours
worked by women in their 30s and 40s thanmen of the
same age group, which in part is due to family building
(Willis et al., 2006c). A similar trend towards
feminisation has been observed in other health
professions, including medicine and dentistry, in the
US, the UK and Australasia, where similar consequences
have been predicted as a result.
The student body at the NSP is noteworthy in that it
is very diverse and unique to this pharmacy school.
Whereas, well-represented ethnic minorities in pharmacy
in the UK are “Asian British”, that is to say
British students of Indian, Pakistani and Bangladeshi
origin, in New Zealand the ethnic origin of (mostly
New Zealand-resident) minority students are mostly
represented by Chinese, Taiwanese, Koreans and
Malaysians, with those from Arabic and other backgrounds
also rising in numbers. Given the high
diversity, there is likely to be consequent variability in
the learning behaviours of students that educators
may increasingly need to take into account (Miranda,
Bates, & Duggan, 2002).
Limitations and suggestions for future research
A social desirability effect on the self-report measures
in this study may be pronounced because the survey
asked about explicitly socially desirable factors such as
“desire to care for/help people”. A strength of this
study is the very high response rate (98%) obtained,
largely through our distribution of the survey during
compulsory course elements. Although the questionnaire
used in this study was based in part on surveys
used in previous research into pharmacy student
choices, its reliability and validity were not separately
tested. Indicators of reliability and validity however
include the emergence of dual factors from questions
pertaining to direct and indirect patient care and the
congruence of certain career- and study-related
motivators emerging in separate areas of the survey,
for example in the intention and aspiration to own a
business. It is the authors’ intention to use a followup
questionnaire in longitudinal research with the
cohort surveyed in 2004–2006, which may give
further indications of its validity and reliability.
A particular point for concern for this and similar
studies is the apparently limited extent to which
physicians have accurate retrospective recall of the
causes of their own behaviour in relation to career
choice (Pathman & Agnew, 1993).
Future work might focus on extending knowledge of
intrinsic and extrinsic factors in choice of profession by
placing the choice of pharmacy as a degree and career
against a wider social context. The extent to which
socioeconomic factors and family background influence
students’ decisions might be further considered, for
example. Large-scale work has indicated that “professional”
class background can have a particular
positive effect upon the choice of prestigious degrees
such as medicine and law (Van de Werfhorst et al.,
2003). These authors also presented evidence that
educational systems are institutionally biased towards
students who possess “cultural capital”, which makes it
difficult for working-class students to succeed in the
education system. Furthermore, because of differential
costs and benefits between class backgrounds, professional
career trajectories are less easily attainable for
working-class students. In the health sciences, differences
in career choice have been found between lowand
high income family backgrounds of medical students
(Cooter et al., 2004). It is not known whether such
influences are as important in New Zealand, where
social systems are perhapsmore fluid. Neither has there
been any examination of whether the cost of study—
which ranged in 2006 from US$3300 per annum for
physiotherapy toUS$3850 for pharmacy andUS$7400
for medicine/ dentistry—influences students’ choice of
career. Nevertheless, it is a matter for concern that the
proportion of BPharmstudents who identify asMaori is
well below the proportion of Maori in the general
population (1–2% compared with 12%).
A further limitation of this study is that it was
focussed to a large extent on students’ intentions,
which may vary over their course of study and may
also not manifest in reality. Edwards, Lambert,
Goldacre, & Parkhouse, (1997), for example, reported
that ten years after graduating only two-thirds of
medical students end up working in the field they
intended to during study. It will be of value in future
research therefore to ascertain the extent to which
students follow through with their intentions, which
will better inform the reliability and validity of this and
similar survey tools and, more importantly, to what
extent expectations and aspirations of pharmacy
students are realised in the workplace. This would
have significance for those promoting pharmacy
degrees and admitting students to their courses, as
to what character of advice is most appropriate and
honest to offer to these aspiring professionals.
Summary and conclusions
This study, as well as previous research across a range
of cohorts, courses and countries, offers a generally
consistent view of the motivations of students to study
pharmacy and work as a health professional. Whereas
other research has suggested that altruistic intent may
be similar in importance to other factors, this study’s
results point to a clear prominence for this particular
factor.
Scientific aspects inherent to pharmacy as a course
of study also act as attractors to the subject area and
pharmacy is perceived in favourable terms as offering
good employment prospects with considerable entrepreneurial
potential. A tendency still exists among
many first year pharmacy students to have selected
medicine or dentistry as a first choice, particularly
among ethnic minority students, a tendency which
may be declining but is likely to be to an extent
inevitable, particularly with a system in which all
students take the same first year curriculum. The
picture among the undergraduate cohort, nevertheless,
is of committed individuals who intend to
pursue a pharmacy career. Gender differences
were shown to emerge between aspirations to work
in the different sectors, and in pharmacy
ownership intentions. The perceived value of a
pharmacy “passport”, and intention to travel with it
is very high among NSP students and will see many
working overseas. Students perceived that good
communication and English skills are of greatest
importance when considering potential entrants to the
course, a belief borne out by the literature. Yet the
Pharmacy School’s admissions process does not place
a greater emphasis on this requirement (which is
currently assessed by means of a paper on Effective
Communication, provided by the University’s English
Department) than any of the other papers of the
compulsory health sciences first year course, despite
the fact that many of its students have English as a
second language.
There is some concern about the extent to which
students’ desire and intentions to own a pharmacy
will be realisable in the future and also the extent to
which students’ experience in community pharmacy
after registration will match their expectations and
preferences.
Future focus for research that elucidates the wider
range of factors likely to influence students’ pursuance
of pharmacy, such as that which relates to family, class
or cultural background is suggested. Also of importance
will be work that better investigates the link
between students’ education and ambitions and the
realities of their professional life.
Additional Antihypertensive Effect of Drugs in Hypertensive Subjects Uncontrolled on Diltiazem Monotherapy: A Randomized Controlled Trial
The purpose of this study was to compare several diltiazem-based antihypertensive drug
combinations and assess the usefulness of home blood pressure monitoring in the evaluation
of the efficacy of combination pharmacotherapy. Sixteen general practitioners
recruited hypertensive subjects uncontrolled on diltiazem monotherapy, who were randomized
to receive eight weeks of add-on therapy with a diuretic (chlorthalidone), a
dihydropyridine calcium antagonist (felodipine), an ACE inhibitor (lisinopril), or an
angiotensin blocker (valsartan). Sitting office and home blood pressure was measured
using electronic devices A&D 767. A total of 211 patients were randomized, and 185
completed the study. Of 52 subjects randomized to felodipine, 15 were withdrawn due to
ankle edema. The additional antihypertensive effect of the second drug was smaller in
18 subjects with a white coat effect (p < 0.01). All combinations produced a significant
decline in office (21.2 ± 14.8 / 7.7 ± 9.7 mmHg) and home (17.1 ± 11.9 / 6.0 ± 7.0) blood
pressure (systolic / diastolic, p < 0.001). There were no differences in the efficacy of the
four combinations assessed using office or home blood pressure monitoring. These data
suggest that diuretics, dihydropyridines, ACE inhibitors, and angiotensin receptor
blockers provide significant additional antihypertensive effects in hypertensive patients
uncontrolled on diltiazem monotherapy. The diltiazem-dihydropyridine combination is
often intolerable because of ankle edema. Home blood pressure monitoring is useful in
the assessment of the efficacy of combination pharmacotherapy and also allows for the
detection of subjects who do not require treatment intensification.
Introduction
There is agreement among hypertension guidelines that diuretics, b-blockers, calcium
antagonists, ACE inhibitors, and angiotensin receptor antagonists are appropriate to be
used as first line treatment in hypertension (1–3). Moreover, it is recognized that in order
to achieve the recommended blood pressure (BP) goals, combination pharmacotherapy is
required in the majority of hypertensive patients (1,2). It is clear, however, that more clinical
research from randomized comparative trials on the efficacy and tolerability of antihypertensive
drug combinations is needed (1).
Non-dihydropyridine calcium antagonists are effective antihypertensive drugs and are
being widely used in clinical practice (4). Outcome trials have shown that these drugs
improve cardiovascular prognosis in hypertensive patients with or without coronary heart
disease (5,6). Some short-term studies have assessed the antihypertensive effects of
combined treatment of non-dihydropyridine calcium antagonists with thiazide diuretics
(7–9) or angiotensin-converting enzyme (ACE) inhibitors (10,11). However, the evidence
on the combination of these drugs with dihydropyridines or angiotensin blockers is very
limited (12,13). In addition, no direct comparison of these combinations in regard to their
antihypertensive efficacy has been reported.
Self-blood pressure monitoring at home is regarded as an important adjunct to office
measurements in hypertensive patients and is being increasingly used in clinical practice
(1,2,14,15). Accumulating evidence suggests that home BP is devoid of the white coat (16)
and the placebo effect (14) and provides highly reproducible BP values (17). Therefore,
home BP has been recently used in several trials to assess the efficacy of antihypertensive
drugs, and it has been suggested that the use of this method instead of the conventional
office measurements can improve the accuracy of antihypertensive drug trials (14,17).
The objectives of this study are to (1) assess the additional antihypertensive effect of a
thiazide diuretic versus a dihydropyridine calcium antagonist, an ACE inhibitor, and an
angiotensin receptor blocker in hypertensive patients uncontrolled on diltiazem monotherapy,
and (2) compare self-home BP measurements with office BP measurements in the
assessment of the antihypertensive effect of combination pharmacotherapy.
Subjects and Methods
Physicians and Patients
Trained general practitioners employed in primary care recruited subjects aged 25–79
years with uncontrolled hypertension after at least four weeks of open monotherapy with
diltiazem at 240 mg o.d. Uncontrolled hypertension was defined as average office BP
greater than 140/90 mmHg for all or 135/85 mmHg for diabetics or subjects under the age
of 65, confirmed on two office visits at least one week apart (3).
Design
Participants were randomized to receive one of the following open add-on therapies for
eight weeks:
1. thiazide diuretic chlorthalidone 12.5 mg o.d.,
2. dihydropyridine calcium antagonist felodipine 5 mg o.d.,
3. ACE inhibitor lisinopril 10 mg o.d., or
4. angiotensin receptor blocker valsartan 80 mg o.d.
Add-on treatment was doubled if office BP remained uncontrolled after four weeks of randomized
combination pharmacotherapy. All antihypertensive drugs were taken in the
morning just after rising from bed. The study protocol was approved by the Quality Assurance
Committee of the Greek Association of General Practitioners. Participants gave
informed consent for study participation.
Exclusion criteria included the following:
• contraindication or known intolerance of diuretics, calcium antagonists, ACE inhibitors,
or angiotensin blockers;
• compelling indication for treatment with a specific antihypertensive drug class;
• nephropathy, coronary heart disease, congestive heart failure, major cardiac, hematological,
or hepatic or pulmonary disease;
• cerebrovascular event in the three months prior to study entry;
• any other clinically significant illness based upon recent medical history, with the
exception of stable diabetes type-2 on diet alone and/or by oral hypoglycemic agents;
• evidence of secondary hypertension;
• systolic BP >200 mmHg and/or diastolic >110 mmHg at any time during the study;
• therapy with any drug likely to influence BP, including diuretics and NSAIDs
(excluding aspirin up to 300 mg per day); and
• clinically important abnormalities of baseline laboratory data.
Measurements
Office BP was measured by general practitioners at trough before randomization and after
four and eight weeks using validated electronic devices A&D 767 (18) (bladder size 12 × 23
cm or 14 × 2 8 cm, where appropriate). Triplicate measurements were taken at each visit
after 5 min sitting rest and 1 min between readings, and the average was used for decision
making (randomization and titration). Home BP was monitored by the patients themselves
on three routine workdays in the week before randomization and after four and eight weeks.
Self-measurements were taken by the patients at home using the same device and cuff as
office measurements (A&D 767). Participants were trained in the conditions of home BP
measurement and the use of the devices and were instructed to perform duplicate morning
(0600–1000 h, before morning drug intake) and evening (1800–2100 h) measurements after
5 min sitting rest and 1 min between recordings. A form was supplied to the patients to
report self-home BP values. The average of all home measurements was used in the analysis.
Physical examination, body weight measurement, and 12-lead ECG were performed
before randomization and after four and eight weeks. Routine hematology and biochemistry
and urine dipstick and microscopy were performed within four weeks prior to study
entry. Depending on the randomized regimen, selected tests were repeated after four and
eight weeks according to current hypertension recommendations (1–3). An assessment of
adverse reactions was performed at each office visit.
Analysis
Taking into account that home BP was used in a four-group parallel design, in order to
have a probability greater than 0.9 (study power) to detect between treatment groups differences
of 10/5 mmHg in systolic/diastolic home BP at p < 0.05, a total of at least 180
subjects with complete data should be studied (estimated standard deviation of differences
for home systolic/diastolic BP = 7/5 mmHg (17); clinically important between periods
difference ≥ 10/5 mmHg in home systolic/diastolic BP; corrected for multiple comparisons).
Paired t-tests were used to assess treatment-induced changes in clinic and home BP
and unpaired t-tests for between-groups comparisons of antihypertensive drug effects. A
Bonferroni’s correction for multiple comparisons was applied where appropriate.
Results
A total of 211 subjects were recruited by 16 general practitioners and randomized. Fifty-four
subjects were randomized to receive add-on chlorthalidone; 52, felodipine; 54, lisinopril; and
51, valsartan. Twenty-six subjects were withdrawn after randomization, of whom 22 (10.4%)
due to adverse drug effects (17 due to ankle edema) and 4 (1.8%) due to missing follow-up
data. Ankle edema was observed in 15 subjects on felodipine (29%), 1 on valsartan (0.5%), 1
on chlorthalidone (0.5%), and none on lisinopril (p < 0.001). Data from the remaining 185 subjects
with complete follow-up were included in the final analysis, of whom 51 (27.6%) were on
chlorthalidone, 36 (19.5%) on felodipine, 50 (27.03%) on lisinopril, and 48 (25.9%) on valsartan.
The mean age of the 185 subjects was 63.9 ± 10.6 years, 80 (43%) were men, the mean
body mass index (BMI) was 28.7 ± 4.6 kg/m2, and 41 (22%) had type-2 diabetes.
Average office BP at randomization was 158.6 ± 13.1 / 86.1 ± 9.4 mmHg (mean ±
SD, systolic / diastolic), whereas average home BP was significantly lower (150.3 ± 13.3 /
83.0 ± 8.6 mmHg; p < 0.001). There was no significant difference among randomized
groups in regard to patients' age, sex, BMI, proportion of diabetics, and baseline office or
home BP (see Table 1). Eighteen subjects (10%) had average home BP <135/85 mmHg at
randomization and where classified as having a white coat effect. After four weeks of
combination pharmacotherapy, the dose of the second drug was doubled in 113 subjects
(61%) because of an uncontrolled office BP. There was no difference among randomized
groups in the proportion of subjects in whom randomized treatment was doubled.
Table 1
Baseline characteristics of participants in the four randomized treatment
groups (mean ± SD)
Thiazide
diuretic
Dihydropyridine
ACE
inhibitor
Angiotensin
blocker All drugs
Subjects 51 36 50 48 181
Age (years) 63.5 ± 9.9 64.7 ± 9.8 62.6 ± 12.9 65.2 ± 8.6 63.9 ± 10.5
BMI (kg/m2) 28.7 ± 4.2 28.2 ± 4.7 28.1 ± 4.7 29.3 ± 4.3 28.6 ± 4.6
Men (%) 24 (47) 15 (42) 20 (40) 21 (44) 80 (44)
Diabetes (%) 16 (31) 5 (15) 8 (49) 12 (47) 41 (22)
Office BP (mmHg)
Systolic 159.6 ± 13.6 160.2 ± 16.0 157.7 ± 11.4 157.7 ± 12.2 158.6 ± 13.1
Diastolic 86.5 ± 9.3 87.1 ± 8.1 86.1 ± 10.5 85.0 ± 9.7 86.1 ± 9.4
Pulse rate 75.2 ± 8.3 77.8 ± 7.9 77.1 ± 10.7 73.2 ± 9.5 75.7 ± 9.4
Home BP (mmHg)
Systolic 148.6 ± 14.1 152.4 ± 14.0 151.2 ± 14.2 149.7 ± 10.9 150.3 ± 13.3
Diastolic 82.7 ± 8.5 83.6 ± 8.6 83.5 ± 8.8 82.0 ± 8.3 83.0 ± 8.6
Pulse rate 72.1 ± 8.1 74.2 ± 7.5 72.4 ± 6.9 70.5 ± 8.9 2.2 ± 7.9
BMI: body mass index; BP: blood pressure.
Significant decline in both office and home BP was achieved during the study (see
Table 2). The additional antihypertensive effect obtained by the second drug was significantly
greater in subjects without compared to those with a white coat effect (Table 2).
This difference in the antihypertensive effect was more pronounced and reached statistical
significance when home BP monitoring was used (average home BP decline 8.0 / 2.8
mmHg systolic / diastolic in subjects with a white coat effect versus 17.1 / 6.0 mmHg in
the others; see Table 2). All drug combinations induced a significant decline (p < 0.001) in
both office and home BP during the study (see Table 3). There were no significant differences
in the additional antihypertensive effects of the four drugs assessed using either
office or home BP monitoring.
Discussion
This study compared the efficacy of four diltiazem-based antihypertensive drug combinations
using office and home BP monitoring. The study showed that a thiazide diuretic, a
dihydropyridine calcium antagonist, an ACE inhibitor, and an angiotensin receptor
blocker provide significant additional antihypertensive effects in hypertensive patients
uncontrolled on diltiazem monotherapy. However, the diltiazem-dihydropyridine combination
was often intolerable because of significant ankle edema. In addition, the study
showed that home BP monitoring is at least as effective as the conventional office measurements
in the assessment of the efficacy of antihypertensive drug combinations and
also allows for the detection of subjects who do not benefit from treatment intensification.
Studies have shown additional antihypertensive effects of diltiazem combined
with hydrochlorthiazide (7–9). Furthermore, several hypertension trials have investigated
the efficacy of combining non-dihydropyridine calcium antagonists with ACE
inhibitors, and fixed dose combinations of these drug classes have been developed
(10,11). However, in regard to the angiotensin blockers, there are no published studies
of the antihypertensive efficacy of these drugs in combination with non-dihydropyridine
calcium antagonists.
The combination of non-dihydropyridine calcium antagonists with dihydropyridines
remains controversial. Receptor binding studies have suggested that this combination
might result in either enhanced or diminished pharmacological effects (12). However, the
evidence from clinical trials on the antihypertensive efficacy and the tolerability of this
combination is very limited (12,13). A small randomized study in hypertensive patients
uncontrolled on nifedipine monotherapy showed significant additional antihypertensive
effects with either diltiazem or verapamil (12). That study provided evidence that the additional
antihypertensive effect is due to a pharmacokinetic interaction between diltiazem
and nifedipine (12). In another randomized comparative study of diltiazem versus nitrendipine
in patients with hypertension and stable angina, an additional antihypertensive
effect without additional side effects was observed in a subgroup of 16 subjects who
received both drugs because of uncontrolled BP on monotherapies (13). In contrast, the
present study showed that the diltiazem-felodipine combination is associated with intolerable
ankle edema in 30% of subjects. This adverse effect might be attributed to the high
dose of calcium antagonist rather than to a drug interaction, given that the incidence of the
calcium antagonist-induced vasodilatory ankle edema is the most common side adverse
effect of these drugs that leads to withdrawal and is clearly dose-dependent (19). It should
be noted that the abovementioned studies that assessed the efficacy of the combination of
non-dihydropyridine calcium antagonists with other antihypertensive drugs have compared
combination therapy with monotherapies, whereas the present study provided a
direct head-to-head comparison of the antihypertensive effect of four non-dihydropyridine
calcium antagonist-based combinations.
In this study, both office and home BP measurements were taken using validated
automated devices. This approach increases the reliability of measurements by preventing
observer bias and the terminal digit preference, which are known to be present using conventional
auscultatory BP measurements (14). Significant additional antihypertensive
effects were detected in this study using either office or home BP measurements (Table 3).
However, the use of home BP monitoring allowed for the detection of a significant white
coat effect in 10% of study participants (16). Recent recommendations suggest that subjects
with the white coat phenomenon do not benefit from treatment intensification
(1,2,14). In line with these recommendations, this study showed that in subjects with a
white coat effect, the magnitude of the decline in home BP was less than half of that
achieved in the rest of study participants (Table 2). It is clear that the implementation of
home BP monitoring in clinical trials aiming to assess the efficacy of antihypertensive
drugs allows for the exclusion of subjects with the white coat effect, thereby increasing the
study power or reducing the number of subjects required (16,17). On the other hand, the
use of home BP in clinical practice is essential for the detection of treated hypertensives
with a white coat effect in order to prevent unnecessary, costly, and potentially harmful
additional pharmacotherapy. These benefits of home BP monitoring are attributed to the
facts that measurements are taken away from the office setting and to the larger number of
readings obtained (14–16).
combinations and assess the usefulness of home blood pressure monitoring in the evaluation
of the efficacy of combination pharmacotherapy. Sixteen general practitioners
recruited hypertensive subjects uncontrolled on diltiazem monotherapy, who were randomized
to receive eight weeks of add-on therapy with a diuretic (chlorthalidone), a
dihydropyridine calcium antagonist (felodipine), an ACE inhibitor (lisinopril), or an
angiotensin blocker (valsartan). Sitting office and home blood pressure was measured
using electronic devices A&D 767. A total of 211 patients were randomized, and 185
completed the study. Of 52 subjects randomized to felodipine, 15 were withdrawn due to
ankle edema. The additional antihypertensive effect of the second drug was smaller in
18 subjects with a white coat effect (p < 0.01). All combinations produced a significant
decline in office (21.2 ± 14.8 / 7.7 ± 9.7 mmHg) and home (17.1 ± 11.9 / 6.0 ± 7.0) blood
pressure (systolic / diastolic, p < 0.001). There were no differences in the efficacy of the
four combinations assessed using office or home blood pressure monitoring. These data
suggest that diuretics, dihydropyridines, ACE inhibitors, and angiotensin receptor
blockers provide significant additional antihypertensive effects in hypertensive patients
uncontrolled on diltiazem monotherapy. The diltiazem-dihydropyridine combination is
often intolerable because of ankle edema. Home blood pressure monitoring is useful in
the assessment of the efficacy of combination pharmacotherapy and also allows for the
detection of subjects who do not require treatment intensification.
Introduction
There is agreement among hypertension guidelines that diuretics, b-blockers, calcium
antagonists, ACE inhibitors, and angiotensin receptor antagonists are appropriate to be
used as first line treatment in hypertension (1–3). Moreover, it is recognized that in order
to achieve the recommended blood pressure (BP) goals, combination pharmacotherapy is
required in the majority of hypertensive patients (1,2). It is clear, however, that more clinical
research from randomized comparative trials on the efficacy and tolerability of antihypertensive
drug combinations is needed (1).
Non-dihydropyridine calcium antagonists are effective antihypertensive drugs and are
being widely used in clinical practice (4). Outcome trials have shown that these drugs
improve cardiovascular prognosis in hypertensive patients with or without coronary heart
disease (5,6). Some short-term studies have assessed the antihypertensive effects of
combined treatment of non-dihydropyridine calcium antagonists with thiazide diuretics
(7–9) or angiotensin-converting enzyme (ACE) inhibitors (10,11). However, the evidence
on the combination of these drugs with dihydropyridines or angiotensin blockers is very
limited (12,13). In addition, no direct comparison of these combinations in regard to their
antihypertensive efficacy has been reported.
Self-blood pressure monitoring at home is regarded as an important adjunct to office
measurements in hypertensive patients and is being increasingly used in clinical practice
(1,2,14,15). Accumulating evidence suggests that home BP is devoid of the white coat (16)
and the placebo effect (14) and provides highly reproducible BP values (17). Therefore,
home BP has been recently used in several trials to assess the efficacy of antihypertensive
drugs, and it has been suggested that the use of this method instead of the conventional
office measurements can improve the accuracy of antihypertensive drug trials (14,17).
The objectives of this study are to (1) assess the additional antihypertensive effect of a
thiazide diuretic versus a dihydropyridine calcium antagonist, an ACE inhibitor, and an
angiotensin receptor blocker in hypertensive patients uncontrolled on diltiazem monotherapy,
and (2) compare self-home BP measurements with office BP measurements in the
assessment of the antihypertensive effect of combination pharmacotherapy.
Subjects and Methods
Physicians and Patients
Trained general practitioners employed in primary care recruited subjects aged 25–79
years with uncontrolled hypertension after at least four weeks of open monotherapy with
diltiazem at 240 mg o.d. Uncontrolled hypertension was defined as average office BP
greater than 140/90 mmHg for all or 135/85 mmHg for diabetics or subjects under the age
of 65, confirmed on two office visits at least one week apart (3).
Design
Participants were randomized to receive one of the following open add-on therapies for
eight weeks:
1. thiazide diuretic chlorthalidone 12.5 mg o.d.,
2. dihydropyridine calcium antagonist felodipine 5 mg o.d.,
3. ACE inhibitor lisinopril 10 mg o.d., or
4. angiotensin receptor blocker valsartan 80 mg o.d.
Add-on treatment was doubled if office BP remained uncontrolled after four weeks of randomized
combination pharmacotherapy. All antihypertensive drugs were taken in the
morning just after rising from bed. The study protocol was approved by the Quality Assurance
Committee of the Greek Association of General Practitioners. Participants gave
informed consent for study participation.
Exclusion criteria included the following:
• contraindication or known intolerance of diuretics, calcium antagonists, ACE inhibitors,
or angiotensin blockers;
• compelling indication for treatment with a specific antihypertensive drug class;
• nephropathy, coronary heart disease, congestive heart failure, major cardiac, hematological,
or hepatic or pulmonary disease;
• cerebrovascular event in the three months prior to study entry;
• any other clinically significant illness based upon recent medical history, with the
exception of stable diabetes type-2 on diet alone and/or by oral hypoglycemic agents;
• evidence of secondary hypertension;
• systolic BP >200 mmHg and/or diastolic >110 mmHg at any time during the study;
• therapy with any drug likely to influence BP, including diuretics and NSAIDs
(excluding aspirin up to 300 mg per day); and
• clinically important abnormalities of baseline laboratory data.
Measurements
Office BP was measured by general practitioners at trough before randomization and after
four and eight weeks using validated electronic devices A&D 767 (18) (bladder size 12 × 23
cm or 14 × 2 8 cm, where appropriate). Triplicate measurements were taken at each visit
after 5 min sitting rest and 1 min between readings, and the average was used for decision
making (randomization and titration). Home BP was monitored by the patients themselves
on three routine workdays in the week before randomization and after four and eight weeks.
Self-measurements were taken by the patients at home using the same device and cuff as
office measurements (A&D 767). Participants were trained in the conditions of home BP
measurement and the use of the devices and were instructed to perform duplicate morning
(0600–1000 h, before morning drug intake) and evening (1800–2100 h) measurements after
5 min sitting rest and 1 min between recordings. A form was supplied to the patients to
report self-home BP values. The average of all home measurements was used in the analysis.
Physical examination, body weight measurement, and 12-lead ECG were performed
before randomization and after four and eight weeks. Routine hematology and biochemistry
and urine dipstick and microscopy were performed within four weeks prior to study
entry. Depending on the randomized regimen, selected tests were repeated after four and
eight weeks according to current hypertension recommendations (1–3). An assessment of
adverse reactions was performed at each office visit.
Analysis
Taking into account that home BP was used in a four-group parallel design, in order to
have a probability greater than 0.9 (study power) to detect between treatment groups differences
of 10/5 mmHg in systolic/diastolic home BP at p < 0.05, a total of at least 180
subjects with complete data should be studied (estimated standard deviation of differences
for home systolic/diastolic BP = 7/5 mmHg (17); clinically important between periods
difference ≥ 10/5 mmHg in home systolic/diastolic BP; corrected for multiple comparisons).
Paired t-tests were used to assess treatment-induced changes in clinic and home BP
and unpaired t-tests for between-groups comparisons of antihypertensive drug effects. A
Bonferroni’s correction for multiple comparisons was applied where appropriate.
Results
A total of 211 subjects were recruited by 16 general practitioners and randomized. Fifty-four
subjects were randomized to receive add-on chlorthalidone; 52, felodipine; 54, lisinopril; and
51, valsartan. Twenty-six subjects were withdrawn after randomization, of whom 22 (10.4%)
due to adverse drug effects (17 due to ankle edema) and 4 (1.8%) due to missing follow-up
data. Ankle edema was observed in 15 subjects on felodipine (29%), 1 on valsartan (0.5%), 1
on chlorthalidone (0.5%), and none on lisinopril (p < 0.001). Data from the remaining 185 subjects
with complete follow-up were included in the final analysis, of whom 51 (27.6%) were on
chlorthalidone, 36 (19.5%) on felodipine, 50 (27.03%) on lisinopril, and 48 (25.9%) on valsartan.
The mean age of the 185 subjects was 63.9 ± 10.6 years, 80 (43%) were men, the mean
body mass index (BMI) was 28.7 ± 4.6 kg/m2, and 41 (22%) had type-2 diabetes.
Average office BP at randomization was 158.6 ± 13.1 / 86.1 ± 9.4 mmHg (mean ±
SD, systolic / diastolic), whereas average home BP was significantly lower (150.3 ± 13.3 /
83.0 ± 8.6 mmHg; p < 0.001). There was no significant difference among randomized
groups in regard to patients' age, sex, BMI, proportion of diabetics, and baseline office or
home BP (see Table 1). Eighteen subjects (10%) had average home BP <135/85 mmHg at
randomization and where classified as having a white coat effect. After four weeks of
combination pharmacotherapy, the dose of the second drug was doubled in 113 subjects
(61%) because of an uncontrolled office BP. There was no difference among randomized
groups in the proportion of subjects in whom randomized treatment was doubled.
Table 1
Baseline characteristics of participants in the four randomized treatment
groups (mean ± SD)
Thiazide
diuretic
Dihydropyridine
ACE
inhibitor
Angiotensin
blocker All drugs
Subjects 51 36 50 48 181
Age (years) 63.5 ± 9.9 64.7 ± 9.8 62.6 ± 12.9 65.2 ± 8.6 63.9 ± 10.5
BMI (kg/m2) 28.7 ± 4.2 28.2 ± 4.7 28.1 ± 4.7 29.3 ± 4.3 28.6 ± 4.6
Men (%) 24 (47) 15 (42) 20 (40) 21 (44) 80 (44)
Diabetes (%) 16 (31) 5 (15) 8 (49) 12 (47) 41 (22)
Office BP (mmHg)
Systolic 159.6 ± 13.6 160.2 ± 16.0 157.7 ± 11.4 157.7 ± 12.2 158.6 ± 13.1
Diastolic 86.5 ± 9.3 87.1 ± 8.1 86.1 ± 10.5 85.0 ± 9.7 86.1 ± 9.4
Pulse rate 75.2 ± 8.3 77.8 ± 7.9 77.1 ± 10.7 73.2 ± 9.5 75.7 ± 9.4
Home BP (mmHg)
Systolic 148.6 ± 14.1 152.4 ± 14.0 151.2 ± 14.2 149.7 ± 10.9 150.3 ± 13.3
Diastolic 82.7 ± 8.5 83.6 ± 8.6 83.5 ± 8.8 82.0 ± 8.3 83.0 ± 8.6
Pulse rate 72.1 ± 8.1 74.2 ± 7.5 72.4 ± 6.9 70.5 ± 8.9 2.2 ± 7.9
BMI: body mass index; BP: blood pressure.
Significant decline in both office and home BP was achieved during the study (see
Table 2). The additional antihypertensive effect obtained by the second drug was significantly
greater in subjects without compared to those with a white coat effect (Table 2).
This difference in the antihypertensive effect was more pronounced and reached statistical
significance when home BP monitoring was used (average home BP decline 8.0 / 2.8
mmHg systolic / diastolic in subjects with a white coat effect versus 17.1 / 6.0 mmHg in
the others; see Table 2). All drug combinations induced a significant decline (p < 0.001) in
both office and home BP during the study (see Table 3). There were no significant differences
in the additional antihypertensive effects of the four drugs assessed using either
office or home BP monitoring.
Discussion
This study compared the efficacy of four diltiazem-based antihypertensive drug combinations
using office and home BP monitoring. The study showed that a thiazide diuretic, a
dihydropyridine calcium antagonist, an ACE inhibitor, and an angiotensin receptor
blocker provide significant additional antihypertensive effects in hypertensive patients
uncontrolled on diltiazem monotherapy. However, the diltiazem-dihydropyridine combination
was often intolerable because of significant ankle edema. In addition, the study
showed that home BP monitoring is at least as effective as the conventional office measurements
in the assessment of the efficacy of antihypertensive drug combinations and
also allows for the detection of subjects who do not benefit from treatment intensification.
Studies have shown additional antihypertensive effects of diltiazem combined
with hydrochlorthiazide (7–9). Furthermore, several hypertension trials have investigated
the efficacy of combining non-dihydropyridine calcium antagonists with ACE
inhibitors, and fixed dose combinations of these drug classes have been developed
(10,11). However, in regard to the angiotensin blockers, there are no published studies
of the antihypertensive efficacy of these drugs in combination with non-dihydropyridine
calcium antagonists.
The combination of non-dihydropyridine calcium antagonists with dihydropyridines
remains controversial. Receptor binding studies have suggested that this combination
might result in either enhanced or diminished pharmacological effects (12). However, the
evidence from clinical trials on the antihypertensive efficacy and the tolerability of this
combination is very limited (12,13). A small randomized study in hypertensive patients
uncontrolled on nifedipine monotherapy showed significant additional antihypertensive
effects with either diltiazem or verapamil (12). That study provided evidence that the additional
antihypertensive effect is due to a pharmacokinetic interaction between diltiazem
and nifedipine (12). In another randomized comparative study of diltiazem versus nitrendipine
in patients with hypertension and stable angina, an additional antihypertensive
effect without additional side effects was observed in a subgroup of 16 subjects who
received both drugs because of uncontrolled BP on monotherapies (13). In contrast, the
present study showed that the diltiazem-felodipine combination is associated with intolerable
ankle edema in 30% of subjects. This adverse effect might be attributed to the high
dose of calcium antagonist rather than to a drug interaction, given that the incidence of the
calcium antagonist-induced vasodilatory ankle edema is the most common side adverse
effect of these drugs that leads to withdrawal and is clearly dose-dependent (19). It should
be noted that the abovementioned studies that assessed the efficacy of the combination of
non-dihydropyridine calcium antagonists with other antihypertensive drugs have compared
combination therapy with monotherapies, whereas the present study provided a
direct head-to-head comparison of the antihypertensive effect of four non-dihydropyridine
calcium antagonist-based combinations.
In this study, both office and home BP measurements were taken using validated
automated devices. This approach increases the reliability of measurements by preventing
observer bias and the terminal digit preference, which are known to be present using conventional
auscultatory BP measurements (14). Significant additional antihypertensive
effects were detected in this study using either office or home BP measurements (Table 3).
However, the use of home BP monitoring allowed for the detection of a significant white
coat effect in 10% of study participants (16). Recent recommendations suggest that subjects
with the white coat phenomenon do not benefit from treatment intensification
(1,2,14). In line with these recommendations, this study showed that in subjects with a
white coat effect, the magnitude of the decline in home BP was less than half of that
achieved in the rest of study participants (Table 2). It is clear that the implementation of
home BP monitoring in clinical trials aiming to assess the efficacy of antihypertensive
drugs allows for the exclusion of subjects with the white coat effect, thereby increasing the
study power or reducing the number of subjects required (16,17). On the other hand, the
use of home BP in clinical practice is essential for the detection of treated hypertensives
with a white coat effect in order to prevent unnecessary, costly, and potentially harmful
additional pharmacotherapy. These benefits of home BP monitoring are attributed to the
facts that measurements are taken away from the office setting and to the larger number of
readings obtained (14–16).
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