Acceptability of pharmacy-based bone density measurement by women and primary healthcare providers

Stakeholders' Acceptability of Pharmacist-Led Screening in Community Pharmacies: A Systematic Review

INTRODUCTION

Community pharmacists are among the most accessible healthcare providers. Community pharmacist-led screening may facilitate the early detection of illnesses/medical risk factors, optimizing health outcomes. However, it is important to assess the acceptability of screening services to ensure uptake by key stakeholders. The aim of this review was to explore the acceptability of community pharmacist-led screening by all stakeholders (i.e., patients, pharmacists, and other healthcare professionals) and identify the methods used to evaluate the acceptability of screening.

METHODS

A systematic search was conducted in Embase, MEDLINE, International Pharmaceutical Abstracts, and Scopus in April 2020 since inception. Studies that explored the acceptability of pharmacist-led screening for any risk factor/medical condition(s) within community pharmacies were included.

RESULTS

A total of 44 studies met the inclusion criteria. A total of 17 studies identified community pharmacies as appropriate screening locations. Seven studies reported that patients were comfortable with participating in pharmacist-led screening. Eight studies explored acceptability from the perspective of medical practitioners and other healthcare professionals, with 6 reporting high recommendation acceptance rates and/or acceptability of pharmacist-led screening. Barriers to pharmacist-led screening included time and privacy constraints, whereas adequate remuneration was considered an important enabler.

DISCUSSION

Community pharmacist-led screening appears to be acceptable to patients, pharmacists, and other healthcare professionals. However, no uniform psychometrically sound measure of acceptability was used consistently across studies, rendering comparisons difficult and showing the need for future research exploring the psychometric properties of acceptability measures. Findings, including barriers and enablers to pharmacist-led screening, are important to consider when providing screening services in community pharmacies.

Point-of-care testing in pharmacies-An evaluation of the service from the lens of resource-based theory of competitive advantage

BACKGROUND

Point-of-care tests (POCTs) are innovative services that are increasingly offered in community pharmacies. Assessments of these services should consider their financial sustainability in addition to their effectiveness if they are to be successful over time in a competitive environment.

OBJECTIVES

The aim of this research was to review and evaluate the POCT practice innovations literature through the lens of the resource-based theory (RBT) of competitive advantage.

DATA SOURCES

Articles describing POCT services were identified systematically through PubMed, exclusively.

STUDY SELECTION

All POCT articles in the review met the following inclusion criteria: (1) articles were published after 1999; (2) interventions were pharmacist-led innovations within a community pharmacy; (3) articles described research studies with results; and (4) articles were published in English, Spanish, or Portuguese.

DATA EXTRACTION

The RBT was operationalized using a strengths, weaknesses, opportunities, threats matrix and a business model canvas, which were employed to extract and analyze data. Articles were assessed according to the degree to which they articulated elements that the RBT needed to assess their financial sustainability in targeted markets.

RESULTS

A total of 36 articles describing POCTs and associated services were included in this review. Most of the studies reported aspects pertaining to the contextual environment of the innovation, value proposition, key activities, partners, and channels of distribution. However, the competitive dimension of the environment, as well as the cost structure and revenue streams, were often neglected in the studies.

CONCLUSIONS

The RBT is a widely tested framework that can be used for planning and reporting POCT practice innovations. On the basis of this framework, pharmacists seem to do a good job in describing how to provide POCT but fall short in explaining how these services are sustainable over time.

Consumer willingness to pay for pharmacy services: An updated review of the literature

BACKGROUND

Quantifying the value of pharmacy services is imperative for the profession as it works to establish an expanded role within evolving health care systems. The literature documents the work that many have contributed toward meeting this goal. To date, however, the preponderance of evidence evaluates the value of pharmacist services to third-party payers; few published studies address the value that consumers place on these services.

OBJECTIVES

In 1999, a review of studies that used the contingent valuation method to value pharmacy services was published. The objective of this manuscript is to provide an update of that review.

METHODS

Relevant studies published in the English language were identified searching MEDLINE, ECONLIT and International Pharmaceutical Abstracts databases from January 1999 to November 2017. Only studies that specifically elicited willingness to pay for a community pharmacist provided service from actual or potential consumers were included.

RESULTS

Thirty-one studies using the contingent valuation method to value pharmacy services were identified using the search strategy outlined. These studies included surveys in different demographic and geographic populations and valuing various pharmacy services.

CONCLUSIONS

Improving the quality of studies using contingent valuation to value pharmacy services will aid the profession in marketing pharmacy services to consumers, and may assist practitioners who wish to implement various pharmacy services in their practice settings. A limited number of studies have been conducted, but the quality of contingent valuation studies valuing pharmacist services is improving. Understanding the pharmacy services that consumers value, and understanding the level of their monetary willingness to pay for those services will be crucial as the profession continues to work toward establishing a sustainable and economically viable role within the evolving health care systems.

Assessment of ovarian failure and osteoporosis in premenopausal breast cancer survivors

Premenopausal women who develop ovarian failure after receiving chemotherapy are at a higher risk of rapid bone loss. Pharmacists have successfully implemented osteoporosis screening programmes in the general population and thus, assessment of breast cancer survivors for ovarian failure and osteopenia could represent a novel focus for oncology pharmacists. Therefore, we conducted a retrospective chart review to determine the adequacy of ovarian failure and osteoporosis assessment and management in premenopausal breast cancer survivors.

Methods and results. The charts of 20 women diagnosed with early stage breast cancer treated with cyclophosphamide over a 4.5-year timespan were included. Their median age was 36.7 years (range 29.8-41). The median cyclophosphamide cumulative dose was 9 g/m2 (range 2.4-14.45), with a median duration of follow-up being 4.62 years. The assessment of ovarian failure mainly occurred by documenting menstrual periods, which has been questioned as a reliable method for assessing ovarian failure. Menses stopped while or shortly after receiving chemotherapy in 11 women. Prior to and during cyclophosphamide administration, osteoporosis screening or counselling was not documented for any patient. After completion of chemotherapy administration, eight patients were counselled regarding osteoporosis and seven women were screened for osteoporosis with a dual X-ray absorptimetry (DXA) scan. Five women had DXA scans indicative of osteopenia according to World Health Organization guidelines.

Conclusions. Improvements are needed in the documentation and potentially also the management of ovarian failure and osteoporosis in premenopausal breast cancer survivors receiving cyclophosphamide-based regimens. This represents a potential opportunity for pharmacists to manage long-term chemotherapy toxicity.

A qualitative study of pharmacy nurse providers of community based post-birth care in Queensland, Australia

Background

Reduced length of hospital stay following childbirth has placed increasing demands on community-based post-birth care services in Australia. Queensland is one of several states in Australia in which nurses are employed privately by pharmacies to provide maternal and child health care, yet little is known about their prevalence, attributes or role. The aims of this paper are to (1) explore the experiences and perspectives of a sample of pharmacy nurses and GPs who provide maternal and child health services in Queensland, Australia (2) describe the professional qualifications of the sample of pharmacy nurses, and (3) describe and analyze the location of pharmacy nurse clinics in relation to publicly provided services.

Methods

As part of a state-wide evaluation of post-birth care in Queensland, Australia, case studies were conducted in six regional and metropolitan areas which included interviews with 47 key informants involved in postnatal care provision. We report on the prevalence of pharmacy nurses in the case study sites, and on the key informant interviews with 19 pharmacy nurses and six General Practitioners (GPs). The interviews were transcribed and analysed thematically.

Results

The prevalence of pharmacy nurses appears to be highest where public services are least well integrated, coordinated and/or accessible. Pharmacy nurses report high levels of demand for their services, which they argue fill a number of gaps in the public provision of maternal and child health care including accessibility, continuity of carer, flexibility and convenient location. The concerns of pharmacy nurses include lack of privacy for consultations, limited capacity for client record keeping and follow up, and little opportunity for professional development, while GPs expressed concerns about inadequate public care and about the lack of regulation of pharmacy based care.

Conclusions

Pharmacy based clinics are a market-driven response to gaps in the public provision of care. Currently there are no minimum standards or qualifications required of pharmacy nurses, no oversight or regulation of their practice, and no formal mechanisms for communicating with other providers of postnatal care. We discuss the implications and possible mechanisms to enhance best-practice care.

Willingness to pay for diagnostic technologies: a review of the contingent valuation literature

OBJECTIVES

To understand how people value information from diagnostic technologies, we reviewed and analyzed published willingness-to-pay (WTP) studies on the topic.

METHODS

We searched PubMed for English-language articles related to WTP for diagnostic laboratory tests published from 1985 through 2011. We characterized methodological differences across studies, examined individual- and technology-level factors associated with WTP, and summarized median WTP values across different diagnostic tests.

RESULTS

We identified 66 relevant WTP studies. Half focused on oncology, while others analyzed infectious diseases (n = 11, 16.1%) and obstetric or gynecological conditions (n = 8, 11.7%), among others. Most laboratory tests included in studies were biological samples/genetic testing (n = 44, 61.1%) or imaging tests (n = 23, 31.9%). Approximately one third of the analyses (n = 20, 30.3%) used discrete-choice questions to elicit WTP values. Higher income, education, disease severity, perceived disease risk, family history, and more accurate tests were in general associated with higher WTP values for diagnostic information. Of the 44 studies with median WTP values available, most reported a median WTP value below $100. The median WTP value for colon or colorectal cancer screening ranged from below $100 to over $1000.

CONCLUSIONS

The contingent valuation literature in diagnostics has grown rapidly, and suggests that many respondents place considerable value on diagnostic information. There exists, however, great variation in studies with respect to the type of technologies and diseases assessed, respondent characteristics, and study methodology. The perceived value of diagnostic technologies is also influenced by the study design and elicitation methods.

The role of community pharmacists in the prevention and management of osteoporosis and the risk of falls: results of a cross-sectional study and qualitative interviews

In a mailed survey and qualitative interviews, it was observed that community pharmacists and public health authorities believe that pharmacists should play a significant role in the prevention and management of osteoporosis and the risk of falls. However, pharmacists acknowledge a wide gap between their ideal and actual levels of involvement.

INTRODUCTION

The aim of this study was to explore perceptions of community pharmacists and public health authorities regarding the role of pharmacists in providing services in relation to osteoporosis and risk of falls and the barriers to providing them.

METHODS

Using a modified five-step version of Dillman's tailored design method, a questionnaire was mailed to a random sample of 1,250 community pharmacists practicing in Montreal (Quebec, Canada) and surrounding areas. A similar questionnaire was sent to public health officers in these regions. Additionally, telephone interviews were conducted with regional and ministry level public health officers.

RESULTS

Of the 1,250 pharmacists contacted, 28 were ineligible. In all, 571 of 1,222 (46.7 %) eligible community pharmacists and all the public health officers returned the questionnaire. Six public health officers (five regional and one at ministry level) were interviewed. Most pharmacists believed they should be involved in screening for osteoporosis (46.6 %) and risk of falls (50.3 %); however, fewer reported actually being involved in such services (17.4 % and 19.2 %, respectively). In their view, the main barriers to providing these services in current practice were lack of time (78.8 %), lack of clinical tools (65.4 %), and lack of coordination with other healthcare professionals (54.5 %). Public health authorities also thought community pharmacists should play a significant role in providing osteoporosis and fall risk services. However, few community pharmacist-mediated activities are in place in the participating regions.

CONCLUSIONS

Although community pharmacists and public health authorities believe pharmacists should play a significant role with regard to osteoporosis and the risk of falls, they acknowledge a wide gap between the ideal and actual levels of pharmacist involvement.

Screening for major diseases in community pharmacies: a systematic review

OBJECTIVES

The aim of this systematic review was to assess the published evidence about the feasibility and acceptability of community pharmacy-based screening for major diseases.

METHOD

Studies published between January 1990 and August 2012 involving community pharmacy-based screening interventions, published in the English language, were identified from electronic databases. Reference lists of included studies were also searched.

KEY FINDINGS

Fifty studies (one randomised controlled trial, two cluster randomised studies, five non-randomised comparative studies and 42 uncontrolled studies) were included. The quality of most of these was assessed as poor. Screening was mostly opportunistic and screening tools included questionnaires or risk assessment forms, medical equipment to make physiological measurements, or a combination of both. Few studies assessed the accuracy of pharmacy-based screening tools. More than half of the screening interventions included an element of patient education. The proportion of screened individuals, identified with disease risk factors or the disease itself, ranged from 4% to 89%. Only 10 studies reported any economic information. Where assessed, patient satisfaction with pharmacy-based screening was high, but individuals who screened positive often did not follow pharmacist advice to seek further medical help.

CONCLUSION

Available evidence suggests that screening for some diseases in community pharmacies is feasible. More studies are needed to compare effectiveness and cost-effectiveness of pharmacy-based screening with screening by other providers. Strategies to improve screening participants' adherence to pharmacist advice also need to be explored. This systematic review will help to inform future studies wishing to develop community pharmacy-based screening interventions.

Women's Attitudes and Health Beliefs toward Osteoporosis Screening in a Community Pharmacy

The aim of this study was to examine women's attitudes and health beliefs towards osteoporosis screening in a community pharmacy setting, utilizing the theoretical framework of Health Belief Model. A nonexperimental, cross-sectional research design, examining a convenience sample of women aged 18 and over, from several New York City senior care centers, a church, and a university campus in New York, was employed to assess the study objectives. Osteoporosis Health Belief Scale questionnaire was used to study the attitudes and health beliefs of participants towards bone mineral density screening in community pharmacy. From the study, it was observed that perceptions of severity and susceptibility towards osteoporosis and subjects' demographic characteristics did not seem to significantly influence the decision to screen in a community pharmacy setting. The perceptions of benefits of community pharmacy-based osteoporosis screening and the perceived barriers were found to be of greater importance in women's decisions to engage in osteoporosis-specific preventive behavior.

Review of services provided by pharmacies that promote healthy living

BACKGROUND

The recognition that community pharmacies have the potential to make a greater contribution to promoting public health has led to a new concept, called the Healthy Living Pharmacy (HLP). These are designed to meet public health needs through a tiered commissioning framework delivering health and well being services through community pharmacy, tailored to local requirements for tackling health inequalities.

AIM

To search the literature for quality evidence to support the inclusion of services in the HLP portfolio and suggest areas where more evidence is required.

METHOD

A systematic review of the research literature covering the period January 1990-August 2011 inclusive, using MEDLINE, EMBASE, Pharmline, NHS Evidence and the Cochrane databases. On-line searching of the grey literature (e.g. conference proceedings) was also carried out. Standard methods of assessing quality were employed.

RESULTS

A total of 377 papers were included. Over time, there was a marked increase in frequency of publications reflecting a growing pharmacy interest in the public healthcare agenda; over a third (35 %) of papers appeared in the last three-year study period. The body of research had a wide geographical basis; contributions were as follows: UK (51.5 %), US (20.4 %), Australia/New Zealand (9.8 %), Europe (7.7 %) and Canada (7.2 %). The topics of contraception, cardiovascular disease prevention, diabetes and smoking cessation accounted for 40 % of included papers. The literature supports the introduction of specific community pharmacy services, targeted at customer groups, both with and without pre-existing diseases. Good evidence exists for smoking cessation, cardiovascular disease prevention, hypertension and diabetes. Some good evidence exists for interventions on asthma and heart failure. The evidence supporting weight management, sexual health, osteoporosis detection, substance abuse and chronic obstructive pulmonary disease is weak and needs development.

CONCLUSION

There is strong evidence for the role of community pharmacy in a range of services, not only aimed at improving general health, but also maintaining the health of those with existing disease. In other areas, the evidence is less strong and further research is required to justify their inclusion in a HLP portfolio.

The impact of pharmacist interventions on osteoporosis management: a systematic review

We completed a systematic review of the literature to examine the impact of pharmacist interventions in improving osteoporosis management. Results from randomized controlled trials suggest that pharmacist interventions may improve bone mineral density testing and calcium intake among patients at high risk for osteoporosis.

INTRODUCTION

Pharmacists play a key role in many healthcare systems by helping patients manage chronic diseases. We completed a systematic review of the literature to identify randomized controlled trials (RCTs) that have examined the impact of pharmacy interventions in narrowing two gaps in osteoporosis management: identifying at-risk individuals and improving adherence to therapy.

METHODS

We searched the electronic databases of EMBASE, HealthStar, International Pharmaceutical Abstracts, MEDLINE, and PubMed from database development to April 2010, examined grey literature, and completed manual searches of reference lists to identify English-language research that examined osteoporosis management interventions within pharmacy practice. Results from RCTs were abstracted and assessed for bias.

RESULTS

We identified 25 studies that examined pharmacist interventions in osteoporosis management: 16 cohort, 5 cross-sectional, 1 historical/ecological control, and 3 RCTs. RCT interventions included osteoporosis educational and counseling programs, screening by pharmacists based on risk factor assessment or bone mineral density testing, and physician contact or recommendations for patients to follow-up with a general practitioner. Results from the three RCTs suggest that pharmacist interventions may improve bone mineral density testing (targeted screening) and calcium intake among patients at high risk for osteoporosis. However, two of the three RCTs had high risk of bias, and no study examined the impact of pharmacist intervention on osteoporosis treatment adherence.

CONCLUSIONS

Data support the potential role for pharmacists to help reduce gaps in osteoporosis management through improved identification of high-risk patients. More research is needed to examine pharmacist interventions on osteoporosis treatment adherence.

Osteoporosis screening preferences of older adults

We aimed to examine older adults' osteoporosis screening test preferences, willingness to travel for screening, and willingness to pay for screening. A survey was mailed to 1830 women and men aged 60 yr or older in Pennsylvania, assessing screening test preference (among dual-energy X-ray absorptiometry [DXA], heel quantitative ultrasound [QUS], and risk-assessment tools), willingness to travel 20 miles for a better screening test, and willingness to pay $100 for a better screening test, as well as socio-demographic and health-related characteristics. Analyses included descriptive statistics and multivariable logistic regression analyses to evaluate association between screening test preference, willingness to travel, willingness to pay, and potential explanatory variables. Surveys were completed by 1268 individuals (69.3%). Most respondents indicated a screening test preference (73.9%) and, of these, 78.1% preferred DXA. 78.8% of the respondents indicated that they may be willing to travel 20 miles for a better test, and 51.2% indicated that they may be willing to pay $100 for a better test. Similar trends were observed in analyses including only individuals who had not had prior osteoporosis testing or diagnosis. Many older individuals would prefer the "best" test for osteoporosis screening, and may be willing to travel or pay more to obtain a better test.

Osteoporosis risk screening for women in a community pharmacy

OBJECTIVES

To describe the development, implementation, and financial aspects of a sustainable osteoporosis screening service in a community pharmacy and report osteoporosis risk factors for women screened during the 48 months in which the screening service was in operation.

SETTING

An independent community pharmacy (Main at Locust Pharmacy Clinic) in Davenport, Iowa, beginning in 1999.

PRACTICE DESCRIPTION

The osteoporosis screening service was provided by a staff pharmacist, a pharmacy resident, or a combination of a pharmacist and a resident. The service included use of the Hologic Sahara Bone Sonometer at the heel and education of the patient. Patient education consisted of a discussion of screening results, an overview of osteoporosis, and recommendations to address risk factors.

PRACTICE INNOVATION

For patients who received osteoporosis screening, an overall cumulative risk score and a cumulative modifiable risk score were calculated. Patients were identified as having high (T-score <or=-1), moderate (-1 < T-score <0), or low (T-score >or=0) risk. An analysis was performed to determine the net financial gain or loss of osteoporosis screening.

INTERVENTION

Osteoporosis screening service.

MAIN OUTCOME MEASURES

T-score, overall cumulative risk score, cumulative modifiable risk score, and net financial gain of service.

RESULTS

A total of 444 women received the osteoporosis screening service during 48 months. More than 90% of the women had an overall cumulative risk score of at least 3, and 83.3% had at least one modifiable risk factor. According to the bone density tests, about 58% of the women were at high risk for osteoporosis and 25.7% were at moderate risk. The service had a net gain if provided by a pharmacist ($4,823.72), a resident ($8,153.72), or a combination of a pharmacist and a resident ($6,488.72).

CONCLUSION

This pharmacy-based osteoporosis screening service effectively identified patients at risk for osteoporosis and was sustainable for 48 months. Other community pharmacies are encouraged to offer similar services.

Improving the quality of clinical care for patients with osteoporosis

Osteoporosis, leading to hip fractures and other fragility fractures, is prevalent in countries with a high life expectancy. Fractures have a high associated societal cost and disease burden. As a result, many countries have established screening guidelines for osteoporosis, especially targeting those at a higher risk. However, primary- and secondary-fracture prevention is currently suboptimal despite existence of effective medications. In addition, adherence to therapy is low. This special report outlines some of these challenges and evaluates different techniques for improving the quality of clinical care for patients with osteoporosis.

Pharmacy- and community-based screenings for diabetes and cardiovascular conditions in high-risk individuals

OBJECTIVE

To assess a model to screen minority, elderly, and at-risk individuals for diabetes, hypertension, and dyslipidemia in pharmacy and non-health care settings.

DESIGN

Multicenter, prospective, observational trial.

SETTING

26 pharmacies and 4 non-health care settings.

PARTICIPANTS

888 individuals with one or more of the following risk factors: first-degree relative with diabetes, age 55 years or older, obesity, previous diagnosis of hypertension, or a previous diagnosis of dyslipidemia.

INTERVENTION

Measurement of plasma glucose, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and blood pressure; risk assessment using a risk factor tool; referral of participants with abnormalities to physicians.

MAIN OUTCOME MEASURES

Adherence with follow-up, physician recommendations, and new diagnoses of diabetes, hypertension, and dyslipidemia.

RESULTS

Pharmacists screened 888 participants in pharmacies and non-health care settings; 794 scored at least 10 on the risk factor tool and received further screenings. Of these, 81% were referred for follow-up for at least one abnormality: 15% glucose, 68% blood pressure, 66% total cholesterol, and 26% HDL-C. For those referred, the mean (+/- SD) fasting plasma glucose concentration was 179 +/- 87 mg/dL, and the random glucose concentration was 234 +/- 90 mg/dL. Of participants completing follow-up, 16% received one or more new diagnoses as follows: diabetes, 8; hypertension, 9; and dyslipidemia, 29. Therapy changed for 42% of participants. Participants who were elderly, of African American and Hispanic race/ethnicity, or those with elevated cholesterol values were at significantly greater risk for elevated glucose levels. Screenings in community pharmacy settings had improved follow-up rates with physicians compared with screenings conducted in non-health care settings.

CONCLUSION

Pharmacists identified individuals with elevated glucose, cholesterol, and blood pressure values through community-based screenings. Pharmacists also identified individuals who could benefit from further control of previously diagnosed hypertension and hyperlipidemia.

Community Pharmacy–Based Implementation and Evaluation of an Osteoporosis Self-Assessment Tool for Asians

OBJECTIVES

To implement an osteoporosis screening and referral program in community pharmacies and evaluate the use of the Osteoporosis Self-Assessment Tool for Asians (OSTA) as the screening instrument.

DESIGN

Uncontrolled study.

SETTING

Three community pharmacies in Bangkok, Thailand.

PATIENTS

51 women aged 50 years or older without prior diagnosis of osteoporosis; three community pharmacists; six hospital-based physicians.

INTERVENTION

OSTA assessment by community pharmacists of the risks of osteoporosis in patients; counseling of patients about diet and exercise; referral of patients at high risk (OSTA index value less than -4) to hospitals where pharmacists had made arrangements in advance; and assessment of satisfaction and opinions of participating patients and physicians.

RESULTS

Of the 51 patients, 32 (62.7%) were categorized as low risk (OSTA index value > -1) and 19 (37.3%) as intermediate risk (OSTA index value range, -4 to -1). The majority of patients (97%) were satisfied with the program and the knowledge gained. Even though no high-risk patients were identified and referred for medical care, all six participating physicians agreed with having risk assessment service in community pharmacies and the prearranged referral system, and five of six physicians believed that OSTA results were valuable in the management of osteoporosis.

CONCLUSION

Community pharmacy-based osteoporosis risk assessment services using OSTA were well accepted by the patients and participating physicians. Public health benefits may result from the provision of osteoporosis risk screening services in community pharmacies in Thailand and other Asian countries.

Osteoporosis assessment strategies for male nursing home residents

OBJECTIVES

Twenty-five to thirty percent of hip fractures occur in men, and nursing home residents have a 5-10-fold greater fracture risk than community-dwellers. Osteoporosis prevalence in men in long-term care, however, is poorly defined. Our objectives were to determine the prevalence of osteoporosis, as assessed by peripheral bone mineral density (BMD), in a group of institutionalized veterans, and to determine how many men with low BMD had received a prior diagnosis of osteoporosis.

METHODS

Subjects were residents in a 740-bed skilled nursing facility (78% men). Male residents (n = 103) competent to give informed consent underwent bilateral calcaneal and forearm BMD by dual-energy X-ray absorptiometry (DXA). Prior osteoporosis documentation was sought in medical records.

RESULTS

Twenty percent of veterans (95% confidence interval (CI) 12-28%) exhibited calcaneal osteoporosis (T-score < -2.5), and 62% (CI 52-72%) were osteoporotic at the forearm. Forearm and calcaneal BMD were correlated (r = 0.678, P < 0.001). BMD of the left and right forearm, and of left and right calcaneus, were highly correlated (r = 0.880, P < 0.001 and r = 0.931, P < 0.001, respectively). Documentation of osteoporosis existed for one of 20 men with calcaneal osteoporosis and four of 59 men with forearm osteoporosis.

CONCLUSIONS

Osteoporosis was prevalent but poorly documented in institutionalized veterans. Discordance in T-scores between forearm and heel was similar to that reported in other studies. The broad range of T-scores among subjects suggests that peripheral BMD measurement may be useful for clinical fracture risk stratification. Correlation among skeletal sites indicates that measuring a single site may be practical.

Osteoporosis Screening and Education in Community Pharmacies Using a Team Approach

STUDY OBJECTIVES

To develop a model for osteoporosis screening and education in community pharmacies using a team approach, compare bone mineral density T-scores between quantitative ultrasound (QUS) and dual-energy x-ray absorptiometry (DXA), and determine patient satisfaction with this pharmacist-provided osteoporosis screening and education program.

DESIGN

Prospective, cross-sectional study.

SETTING

Community pharmacies and outpatient family medicine, internal medicine, and obstetrics and gynecology clinics in Amarillo, Texas.

PATIENTS

Women aged 55 years or older with no previous diagnosis of osteoporosis or osteopenia who had at least one additional risk factor for osteoporosis and had not been screened in the previous 3 years.

INTERVENTION

Patients were referred from family medicine, internal medicine, and obstetrics and gynecology clinics to a community pharmacy. Osteoporosis screening using heel QUS and education regarding disease prevention and treatment were provided by pharmacists. Screening results, recommendations for confirmatory DXA, and potential treatments options were provided to the referring physicians.

MEASUREMENTS AND MAIN RESULTS

A total of 100 patients (mean age 66.2+/-7.9 yrs) were enrolled in the study; three were subsequently excluded. Of the 97 study patients who were screened using QUS, 45 (46%) patients were at moderate risk (T-score<-1 to>-2.5) and nine (9%) were at high risk (T-score<or=-2.5). Of 54 patients recommended for DXA referral, 20 (37%) completed the scan. All 20 were diagnosed with either osteopenia (9 patients [45%]) or osteoporosis (11 patients [55%]). Correlation was moderate between T-scores obtained by QUS and DXA of lumbar vertebrae 1-4 (r=0.45, p=0.026). Counseling regarding risk factors, screening results, smoking cessation, calcium intake, exercise, and caffeine intake was perceived by patients as valuable or highly valuable (medians for all items ranged from 4-5 on a 5-point Likert scale). Of 84 patients assessed (13 were lost to follow-up), 81 (96%) said they would recommend this service to others.

CONCLUSION

Osteoporosis screening and education in community pharmacies are effective in detecting undiagnosed disease and are perceived by patients as highly useful.

Impact of pharmacist-led community bone mineral density screenings

BACKGROUND

Osteoporosis-associated fractures burden both individuals and the overall healthcare system. Bone mineral density (BMD) screening remains the gold standard measure for identifying patients at risk.

OBJECTIVE

To determine the impact of convenient, pharmacist-led BMD screening and counseling sessions on identification and education of patients at risk for or with osteoporosis.

METHODS

Nonpregnant persons >18 years of age were eligible for enrollment in this descriptive study. At an urban retail pharmacy, participants underwent risk factor assessment, peripheral BMD scanning, and personalized counseling. At 3 and 6 months after screening, subjects were questioned by telephone regarding any subsequent primary care provider (PCP) interactions, as well as any behaviors initiated and/or medications modified.

RESULTS

Of the 102 subjects screened, 22.6% and 11.7% were identified as being at medium risk (T score -1.0 to -2.5) and high risk (T score -2.5 or less) for osteoporosis, respectively. By 6 months, 42.5% of the participants reported increasing their dietary intake of calcium, 29.3% began or increased calcium supplements, and 54.9% positively modified smoking status, exercise level, alcohol consumption, or caffeine intake. Additionally, 24 of 52 subjects who had discussed their results with a PCP by 6 months also received a treatment recommendation. Eighty-nine participants reported the community location increased their likelihood of receiving a BMD scan.

CONCLUSIONS

Overall, pharmacist-led BMD screenings that include individualized counseling sessions appear convenient, accessible, and beneficial for patients. With the establishment of clinical benefit of and positive reception to such screenings, pharmacists can now look toward securing consistent reimbursement for this vital pharmaceutical care service.

Regional osteoporosis screening, referral, and monitoring program in community pharmacies: findings from Project ImPACT: Osteoporosis

OBJECTIVE

(1) To identify patients at risk for osteoporosis through community pharmacy-based bone mineral density (BMD) screening, to refer at-risk patients to primary care and/or specialty practice physicians, and to follow-up with at-risk patients; (2) to treat and manage osteopenic and osteoporotic patients referred to the pharmacy for medication therapy management services; and (3) to test a payment methodology for pharmacists who deliver community health management services to a population at risk for or diagnosed with osteoporosis.

DESIGN

Single-cohort observational study.

SETTING

Ukrop's Super Markets, Inc. Grocery and Pharmacy, a 29-store chain with 22 pharmacy locations in Richmond, Virginia.

PARTICIPANTS

Consumers with one or more known risk factors for osteoporosis in Ukrop's customer service area.

INTERVENTION

During the initial phase (health promotion and disease prevention) of the project, pharmacy-based osteoporosis screening with referral and follow-up was provided to consumers who responded to Ukrop's screening promotions. The second phase-provision of collaborative community health management services focused on osteoporosis monitoring and management--is ongoing and includes patients who are at risk for or diagnosed with osteoporosis and are covered by a regional payer.

MAIN OUTCOME MEASURES

Results of screenings; responses of patients and physicians to notifications; and long-term results during collaborative care.

RESULTS

The pharmacists screened 532 patients and were able to contact 305 of these patients for follow-up interviews 3 to 6 months later. The stratification for risk of fracture was 37%, high risk; 33%, moderate risk; and 30%, low risk. A total of 78% of patients indicated that they had no prior knowledge of their risk for future fracture. In the moderate- and high-risk categories, 37% of patients scheduled and completed a physician visit, 19% had a diagnostic scan, and 24% of those patients were initiated on osteoporosis therapy subsequent to the screening. Participating pharmacies received payment for both the osteoporosis screening and the collaborative health management services.

CONCLUSION

Pharmacists can play a useful role in the identification, education, and referral of patients at risk for osteoporosis through pharmacy-based BMD screening. Patients are willing to pay for pharmacy-based osteoporosis screening services. Third-party payers are willing to compensate pharmacists for collaborative community health management services.

Fracture risks for women in long-term care: high prevalence of calcaneal osteoporosis and hypovitaminosis D

STUDY OBJECTIVES

To determine the prevalence of osteoporosis as assessed by peripheral bone mineral density (BMD) in women living in a nursing home, to determine how many women with low BMD had received a diagnosis of osteoporosis, to assess the prevalence of vitamin D deficiency, and to seek reasons for vitamin D deficiency.

DESIGN

Measurement of calcaneal BMD and serum 25-hydroxyvitamin D.

SETTING

Skilled nursing facility.

PATIENTS

Forty-nine women aged 68-100 years.

MEASUREMENTS AND MAIN RESULTS

Bilateral calcaneal BMD was measured by dual-energy x-ray absorptiometry and serum 25-hydroxyvitamin D by radioimmunoassay. Medical records were reviewed to assess osteoporosis risk factors, previous documentation of osteoporosis or malabsorption, and supplemental vitamin D intake. Fifty-nine percent of the 39 women with calcaneal BMD measurements (95% confidence interval [CI] 44-74%) exhibited calcaneal osteoporosis (T score < -2.5). Sixty percent (95% CI 46-74%) had 25-hydroxyvitamin D levels of 20 ng/ml or less, which is associated with secondary hyperparathyroidism; only 4% of women had levels above 30 ng/ml, recently recommended as optimal. Vitamin D status was suboptimal even in most women taking multivitamins. Osteoporosis was documented in the records of 17% of 23 women with calcaneal osteoporosis.

CONCLUSION

Osteoporosis was prevalent but poorly documented in women living in the nursing home. Peripheral BMD measurements have the potential to improve the recognition and management of osteoporosis in women in long-term care facilities. The high prevalence of vitamin D deficiency, even in those taking multivitamins, indicates that practical new approaches for vitamin D repletion in this population are urgently needed.