Pharmaceutical care for patients with chronic conditions

Connecting Pharmacists and Other Health Care Providers (HCPs) towards Drug Therapy Optimization: A Pharmaceutical Care Approach

BACKGROUND

Pharmaceutical care services offered by pharmacists rationalize drug therapy, improve patient quality of life, and save patients' lives. This study was designed to optimize patient drug therapy through pharmaceutical care services offered by a pharmacist in consultation with other health care providers (HCPs) at a tertiary care hospital.

METHODS

This descriptive study was conducted to assess the role and effectiveness of pharmacists in optimizing drug therapy outcomes. The study was carried out at an internal and pulmonary medicine unit of a tertiary care hospital in Srinagar, Jammu and Kashmir, India, with a total of 50 health care providers (HCPs) (24 doctors, 16 nurses, and 10 pharmacists). A total of 182 patients (males and females) of all age groups were recruited into the study over a period of nine months. Patient-specific pharmaceutical care plans initiated by the pharmacist based on drug therapy-related needs and problems were used to address and optimize drug therapy outcomes in consultation with other HCPs.

RESULTS

A total of 388 drug-related problems (DRPs) with an average of 2.29 DRPs per patient were identified, for which 258 pharmaceutical care plans as interventions were proposed, out of which 233 (90.31%) were accepted and implemented. Preassessment and postassessment by HCPs on services rendered by the pharmacist showed a positive change in attitude among HCPs with respect to their endorsement and acceptance of the pharmacist's services in providing direct patient care.

CONCLUSIONS

Pharmaceutical care services offered by pharmacists helped in optimizing drug therapy and patient care.

A Survey of Canadian Pharmacists’ Knowledge and Comfort in the Management of Epilepsy and Antiepileptic Drugs

Background: As antiepileptic drugs (AED) remain the mainstay of epilepsy management, pharmacists have the potential to play an integral role in the management. Objective: The goal of our study was to characterize Canadian pharmacists’ knowledge and comfort in managing epilepsy and AED and identify areas of need for the development of support tools. Methods: An electronic survey was designed and distributed to Canadian pharmacists through professional organizations. The survey consisted of 4 sections, including demographics, knowledge, comfort, and needs assessment around epilepsy management. Results: A total of 605 complete responses were included. Nearly two-thirds of the participants were females (61.6%) and most reported more than 10 years of practice experience (61.6%). For comfort, a majority of the participants responded agree or strongly agree to the statement inquiring about the comfort in checking prescriptions, answering questions about drug interactions, and counseling on AED. Conversely, more than 50% of the participants selected disagree or strongly disagree when asked about their comfort regarding interpreting therapeutic drug monitoring and assisting patients withdraw from AED. For the knowledge section, the overall average score was 57.6% ± 19.1%. Hospital practice, recent graduation, and neurology experience were independent predictors of high scores. Many participants indicated a need for tools addressing newer AED and monitoring of therapy. Conclusion: Although Canadian pharmacists displayed knowledge and comfort in certain aspects of epilepsy management, some clear knowledge and comfort gaps are prevalent. These findings indicate a need for the development of epilepsy educational support tools.

Theoretical model and measurement of shared decision making in web-based pharmaceutical care consultation

Objectives

We aimed to construct a theoretical model and an observer-based measurement of shared decision making (SDM) in web-based pharmaceutical care consultation.

Methods

We first constructed a theoretical model through analysis of SDM models and interviews with 24 key informants. Then, the initial measurement was formulated, and the content was evaluated by 16 key informants alone. A cross-sectional study was executed, where 300 provider-patient encounters were collected at the online platform ‘Good Doctor Website’, for reliability and validity assessment. Content validity was evaluated by appropriateness score, that is the median of 7–9 and without disagreement. Interrater reliability was evaluated by Spearman correlation coefficient using 30 out of 300 samples. Single indicator validity was tested by Pearson correlation analysis, and convergent validity was evaluated by the Multiple Indicators Multiple Causes (MIMIC) model using 300 samples.

Results

Theoretical model constructed included four elements: ‘comprehensive understanding of the patient's condition’, ‘exchanging ideas on medication options’, ‘achieving a medication plan’, and ‘providing decision support’. Measurement constructed included four dimensions and 19 items, and four dimensions were in accordance with four elements of the theoretical model. We found median scores of these dimensions and items were 7–9 and without disagreement, indicating good content validity. Spearman correlation coefficients of 19 items were greater than 0.750, suggesting good interrater reliability. Pearson coefficients between 19 items and their external variables were significant (p < 0.001), and MIMIC model results showed that the R² values of dimensions 1–4 were over 0.5, indicating good single indicator validity and convergent validity.

Conclusions

Characteristics of web-based pharmaceutical care consultation, highlighting the importance of medication history, medication regimen, and detailed medication plan, were observed in the theoretical model. Measurement constructed had good reliability and validity and may be used by health policymakers to improve the quality of pharmaceutical care consultation online.

Interventions to improve adherence to pharmacological therapy for chronic obstructive pulmonary disease (COPD)

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic lung condition characterised by persistent respiratory symptoms and limited lung airflow, dyspnoea and recurrent exacerbations. Suboptimal therapy or non-adherence may result in limited effectiveness of pharmacological treatments and subsequently poor health outcomes.

OBJECTIVES

To determine the efficacy and safety of interventions intended to improve adherence to single or combined pharmacological treatments compared with usual care or interventions that are not intended to improve adherence in people with COPD.

SEARCH METHODS

We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register, CENTRAL, MEDLINE and Embase (search date 1 May 2020). We also searched web-based clinical trial registers.

SELECTION CRITERIA

RCTs included adults with COPD diagnosed by established criteria (e.g. Global Initiative for Obstructive Lung Disease). Interventions included change to pharmacological treatment regimens, adherence aids, education, behavioural or psychological interventions (e.g. cognitive behavioural therapy), communication or follow-up by a health professional (e.g. telephone, text message or face-to-face), multi-component interventions, and interventions to improve inhaler technique.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Working in pairs, four review authors independently selected trials for inclusion, extracted data and assessed risk of bias. We assessed confidence in the evidence for each primary outcome using GRADE. Primary outcomes were adherence, quality of life and hospital service utilisation. Adherence measures included the Adherence among Patients with Chronic Disease questionnaire (APCD). Quality of life measures included the St George's Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT) and Clinical COPD Questionnaire (CCQ).

MAIN RESULTS

We included 14 trials (2191 participants) in the analysis with follow-up ranging from six to 52 weeks. Age ranged from 54 to 75 years, and COPD severity ranged from mild to very severe. Trials were conducted in the USA, Spain, Germany, Japan, Jordan, Northern Ireland, Iran, South Korea, China and Belgium. Risk of bias was high due to lack of blinding. Evidence certainty was downgraded due to imprecision and small participant numbers. Single component interventions Six studies (55 to 212 participants) reported single component interventions including changes to pharmacological treatment (different roflumilast doses or different inhaler types), adherence aids (Bluetooth inhaler reminder device), educational (comprehensive verbal instruction), behavioural or psychological (motivational interview). Change in dose of roflumilast may result in little to no difference in adherence (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.22 to 1.99; studies = 1, participants = 55; low certainty). A Bluetooth inhaler reminder device did not improve adherence, but comprehensive verbal instruction from a health professional did improve mean adherence (prescription refills) (mean difference (MD) 1.00, 95% CI 0.46 to 1.54). Motivational interview improved mean adherence scores on the APCD scale (MD 22.22, 95% CI 8.42 to 36.02). Use of a single inhaler compared to two separate inhalers may have little to no impact on quality of life (SGRQ; MD 0.80, 95% CI -3.12 to 4.72; very low certainty). A Bluetooth inhaler monitoring device may provide a small improvement in quality of life on the CCQ (MD 0.40, 95% CI 0.07 to 0.73; very low certainty). Single inhaler use may have little to no impact on the number of people admitted to hospital compared to two separate inhalers (OR 1.47, 95% CI 0.75 to 2.90; very low certainty). Single component interventions may have little to no impact on the number of people expereincing adverse events (very low certainty evidence from studies of a change in pharmacotherapy or use of adherence aids). A change in pharmacotherapy may have little to no impact on exacerbations or deaths (very low certainty). Multi-component interventions Eight studies (30 to 734 participants) reported multi-component interventions including tailored care package that included adherence support as a key component or included inhaler technique as a component. A multi-component intervention may result in more people adhering to pharmacotherapy compared to control at 40.5 weeks (risk ratio (RR) 1.37, 95% CI 1.18 to 1.59; studies = 4, participants = 446; I² = 0%; low certainty). There may be little to no impact on quality of life (SGRQ, Chronic Respiratory Disease Questionnaire, CAT) (studies = 3; low to very low certainty). Multi-component interventions may help to reduce the number of people admitted to hospital for any cause (OR 0.37, 95% CI 0.22 to 0.63; studies = 2, participants = 877; low certainty), or COPD-related hospitalisations (OR 0.15, 95% CI 0.07 to 0.34; studies = 2, participants = 220; moderate certainty). There may be a small benefit on people experiencing severe exacerbations. There may be little to no effect on adverse events, serious adverse events or deaths, but events were infrequently reported and were rare (low to very certainty).

AUTHORS' CONCLUSIONS

Single component interventions (e.g. education or motivational interviewing provided by a health professional) can help to improve adherence to pharmacotherapy (low to very low certainty). There were slight improvements in quality of life with a Bluetooth inhaler device, but evidence is from one study and very low certainty. Change to pharmacotherapy (e.g. single inhaler instead of two, or different doses of roflumilast) has little impact on hospitalisations or exacerbations (very low certainty). There is no difference in people experiencing adverse events (all-cause or COPD-related), or deaths (very low certainty). Multi-component interventions may improve adherence with education, motivational or behavioural components delivered by health professionals (low certainty). There is little to no impact on quality of life (low to very low certainty). They may help reduce the number of people admitted to hospital overall (specifically pharmacist-led approaches) (low certainty), and fewer people may have COPD-related hospital admissions (moderately certainty). There may be a small reduction in people experiencing severe exacerbations, but evidence is from one study (low certainty). Limited evidence found no difference in people experiencing adverse events, serious adverse events or deaths (low to very low certainty). The evidence presented should be interpreted with caution. Larger studies with more intervention types, especially single interventions, are needed. It is unclear which specific COPD subgroups would benefit, therefore discussions between health professionals and patients may help to determine whether they will help to improve health outcomes.

Pharmacist-led intervention study to improve drug therapy in asthma and COPD patients

BACKGROUND

Pharmacists can play an important role in identifying and instructing pulmonary patients on their inhalation techniques in their patient contacts when dispensing inhalation medication. Pharmacy dispensing data can be used to identify inappropriate drug use in asthma and chronic obstructive pulmonary disease (COPD) patients. Recent studies found beneficial effects of pharmacy care services in improving drug adherence of pulmonary patients. However, large-scale and rigorous evaluations on pharmacist-led interventions in community care settings to enhance evidence-based drug treatment in patients with asthma and COPD seems to be lacking and results from studies on pharmacist-led interventions for pharmacotherapy improvements are inconsistent. This study evaluated the effectiveness of pharmacist-led interventions on suboptimal drug use patterns with asthma or COPD medication with substantial numbers of pharmacies and patients involved.

SETTING

A prospective cohort study in a group of community pharmacies (intervention group) with a matched control group of Dutch community pharmacies was conducted between May 2011 and February 2012. Algorithms on 19 potential problems with asthma or COPD medication in a national dispensing database were used to signal patients to pharmacists of the intervention group (IG).

METHODS

IG pharmacists selected patients for comprehensive care by a structured program. Changes in problems were measured during 10 months in selected and all users of asthma and COPD medication of IG pharmacies and in compared to a control pharmacies (CG) without the structured program. Primary outcome was reduction of oral high dosage corticosteroids or antibiotics (HDT). Secondary outcomes were changes in the persistence of 19 potential problems in the IG compared to CG.

RESULTS

In the 107 IG pharmacies, 3,757 patients were selected for comprehensive care from totally 102,497 asthma or COPD patients and compared with 105,507 patients from 105 CG pharmacies. The mean number of HDT decreased in selected IG patients by an additional 0.54 (95 % CI 0.21-0.86) HDT treatments. From the problems with specific COPD and asthma medication, all problems decreased additionally to the CG within the total asthma or COPD population from the IG. Within the selected IG population the following problems decreased additionally for obsolete medication by 35 % (95 % CI 6-54 %), contra-indicated medication by 61 % (95 % CI 38-75 %) and lower use of powder inhalers in elderly patients by 29 % (95 % CI 13-42 %).

CONCLUSION

Community pharmacists actively providing comprehensive pharmacy care could improve effective treatment in asthma and COPD patients and thereby decrease the number of prescriptions for exacerbations for these patients.

The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma

OBJECTIVE

To assess clinical, humanistic, and economic outcomes of a community-based medication therapy management (MTM) program for 207 adult patients with asthma over 5 years.

DESIGN

Quasi-experimental, longitudinal pre-post study.

SETTING

12 pharmacy locations in Asheville, N.C. PATIENTS/OTHER PARTICIPANTS: Patients with asthma covered by two self-insured health plans; professional educator at Mission Hospitals; 18 certificate-trained community and hospital pharmacists.

INTERVENTIONS

Education by a certified asthma educator; regular long-term follow-up by pharmacists (reimbursed for MTM by health plans) using scheduled consultations, monitoring, and recommendations to physicians.

MAIN OUTCOME MEASURES

Changes in forced expiratory volume in 1 second (FEV1), asthma severity, symptom frequency, the degree to which asthma affected people's lives, presence of an asthma action plan, asthma-related emergency department/hospital events, and changes in asthma-related costs over time.

RESULTS

All objective and subjective measures of asthma control improved and were sustained for as long as 5 years. FEV1 and severity classification improved significantly. The proportion of patients with asthma action plans increased from 63% to 99%. Patients with emergency department visits decreased from 9.9% to 1.3%, and hospitalizations from 4.0% to 1.9%. Spending on asthma medications increased; however, asthma-related medical claims decreased and total asthma-related costs were significantly lower than the projections based on the study population's historical trends. Direct cost savings averaged 725 dollars/patient/year, and indirect cost savings were estimated to be 1230 dollars/patient/year. Indirect costs due to missed/nonproductive workdays decreased from 10.8 days/year to 2.6 days/year. Patients were six times less likely to have an emergency department/hospitalization event after program interventions.

CONCLUSION

Patients with asthma who received education and long-term medication therapy management services achieved and maintained significant improvements and had significantly decreased overall asthma-related costs despite increased medication costs that resulted from increased use.

Development and initial validation of an instrument to measure physician-pharmacist collaboration from the physician perspective

OBJECTIVE

Using a conceptual model of collaborative working relationships between pharmacists and physicians, a measure for physician-pharmacist collaboration from the physician perspective was developed. The measure was analyzed for its factor structure, internal consistency, construct validity, and other psychometric properties.

METHODS

An initial 27-item Physician-Pharmacist Collaboration Instrument (PPCI) was developed to assess seven themes about professional relationships using Likert scales. The PPCI was mailed to a random sample of 1000 primary care physicians. Principal component analysis was used to assess the structure and uncover underlying dimensions of the initial instrument. Items were evaluated for inclusion or exclusion into a refined instrument. Internal consistency was assessed by calculating Alpha coefficients for each identified factor. Convergent validity was assessed using Spearman correlations between the identified factors and a previous measure of collaborative care. After measure refinement, confirmatory factor analysis was used to evaluate the fit of both versions of the instrument.

RESULTS

Three hundred forty usable surveys were returned for a response rate of 34%. Almost 70% of the respondents were male with a mean age of 45.8. A majority were family practice physicians (72.1%) in private practice (67.3%). Three unique factors were identified during principal component analysis and utilized in a confirmatory factor analysis. Both a full and a 14-item reduced model were constructed and tested. Cronbach's alpha for the three factors of the full model ranged from 0.91 to 0.97, while the reliability for the reduced model ranged from 0.86 to 0.96. Comparative fit indexes of 0.97 and 0.98 were obtained, indicating good fit for the models.

CONCLUSIONS

The results indicate good reliability and validity of the refined (14-item) PPCI. This instrument can be useful as a research tool for assessment of the physicians' perspective about a physician-pharmacist relationship. Further research is warranted to examine if the extent of relationship development, as measured with the PPCI, can affect patient care outcomes.

Estado actual de la investigación en atención farmacéutica

OBJECTIVE

A systematic review of studies on pharmaceutical care research from June 1999 to June 2004 was carried out.

METHOD

Medline, Current Contents, Cochrane Library, IDIS, and Teseo were used as data sources. Works were categorized according to evidence levels and recommendation grades in clinical practice guidelines. The JADAD method was used for quality quantification.

RESULTS

In all, 129 references were found; 19.4% (n = 25) were randomized studies; 2.3% (n = 3) had blinded assessors; losses to follow-up were documented in 7.8% (n = 10); 4.7% (n = 6) had a Jadad score= 3; 8.5% (n = 11), 14.7% (n = 19), 5.4% (n = 7), and 20.9% (n = 27) had evidence levels Ia, Ib, IIa, and IIb, respectively; 44.2% (n = 57) and 6.2% (n = 8) had levels III and IV, respectively; 23.3% (n = 30) had a recommendation grade A; 26.4% (n = 34) had a grade B; 44% (n = 55) had C and 6.2% (n = 8) had D. Most common study types included: descriptive (39.5%), trials including patients (32.6%), and reviews (17.8%); 59.5% of reviewed clinical trials were controlled, randomized clinical trials (CRCTs). Studies were double-blind in 7.1% of cases. Discontinuations and exclusions were recorded in 23.8% of cases. Randomization was appropriate in 11.9% of cases; 14.3% of clinical trials had 3 points, and 85.7% of studies were of poor quality.

CONCLUSIONS

Work methodology should be more rigorous. The use of universally accepted methods is needed to enhance the quality of studies (Jadad system, Consort list). The performance of observational, prospective, multicenter investigations allowing the effectiveness and efficiency of pharmaceutical care to be measured would be most beneficial. Works should measure health-related quality of life (SF-36 questionnaire) and patient satisfaction.

Over-the-counter analgesics in older adults: a call for improved labelling and consumer education

The use of analgesics increases with age and on any given day 20-30% of older adults take an analgesic medication. Over-the-counter (OTC) analgesics are generally well tolerated and effective when taken for brief periods of time and at recommended dosages. However, their long-term use, use at inappropriately high doses, or use by persons with contraindications may result in adverse effects, including gastrointestinal haemorrhage, cardiovascular toxicity, renal toxicity and hepatotoxicity. Many OTC drugs are also available through a prescription, for a broader range of indications and for longer durations of use and wider dose ranges, under the assumption that healthcare providers will help patients make safe choices about analgesics. Safe and effective use of medications is one of the greatest challenges faced by healthcare providers in medicine. More than 60% of people cannot identify the active ingredient in their brand of pain reliever. Additionally, about 40% of Americans believe that OTC drugs are too weak to cause any real harm. As a result of a recent US FDA policy, the conversion of prescription to OTC medications will result in a 50% increase of OTC medications. To reduce the risks of potential adverse effects from OTC drug therapy in older adults, we propose that the use of analgesics will be enhanced through the use of patient and healthcare provider education, as well as improved labelling of OTC analgesics. Improved labelling of OTC analgesics may help consumers distinguish common analgesic ingredients in a wide variety of preparations and facilitate informed decisions concerning the use of OTC drugs.

Evaluation of the impact of a pharmaceutical care program in children with asthma

The objective of this study was to evaluate the impact of a pharmaceutical care program on children with asthma. A comprehensive asthma education and monitoring program that includes basic asthma knowledge, symptoms and exacerbation evaluation, pharmacotherapy assessment including inhaler technique, and quality of life measurements was developed and applied in an outpatient paediatric clinic of the Catholic University of Chile. All patients with moderate asthma scheduled for outpatient visits with their internist over a 1-year period were referred for pharmacist intervention. Patients (aged 7-17) with moderate asthma attending the clinic were allocated to the intervention (group A) or control group (group B). Intervention patients were educated on their disease, pharmacotherapy, self-management, and inhalation techniques. The group B were children with their regular treatment for asthma but without pharmaceutical intervention. A paediatric asthma quality of life questionnaire (PAQLQ) was applied to both groups at 0, 2, and 9 weeks to assess the quality of life. Spirometry was done at the beginning and at the completion of the 9-week study. Beta-agonists used by each patient were also recorded. Eleven children (10.0+/-0.7 years) were included in the pharmaceutical care program, and ten children (9.9+/-0.6 years) in group B. For the individual domains of activities (A), emotions (E), and symptoms (S) there was a significant improvement in the children who received pharmaceutical care in comparison with those who did not receive it. The scores of group B did not change during the 9 weeks of follow-up. There were no significant changes in spirometric values in either group.