Improved latent tuberculosis therapy completion rates in refugee patients through use of a clinical pharmacist

Characteristics, knowledge, attitude, and practice of pharmacy personnel in supporting tuberculosis treatment: A multicenter cross-sectional study in a high-burden tuberculosis country

BACKGROUND

Positive roles of community pharmacy in tuberculosis (TB) care have been widely reported. However, the actual practice of supporting TB treatment is not optimal yet.

OBJECTIVES

We analyzed the current practice of community pharmacy personnel and its factors in supporting the successful treatment of TB patients in Indonesia, aiming to develop strategies for effective and sustainable TB practice models for the community pharmacy.

METHODS

We performed a cross-sectional survey in 3 areas representing Indonesia's eastern, central, and western parts. Development and validation of the questionnaire were conducted to assess 4 domains, that is, characteristics, knowledge, attitudes, and practice of community pharmacy personnel in supporting the successful treatment of TB patients. Data were collected with purposive convenience sampling using online and offline questionnaires. Descriptive analyses were used to summarize factors in each domain, while binary logistic regression was used to analyze the associated factors of the practice.

RESULTS

Thirty-five questionnaire items indicated a valid instrument, and the study successfully included 844 participants who comprised pharmacists (n = 473, 56%) and pharmacy assistants (n = 371, 44%). Although most of the knowledge items were correctly answered by more than 60% of the participants, items related to TB signs, risk groups, drug regimens, and medicine uses were still less than 60%. This was in line with exposure to updated TB training in only 51% of the participants (n = 426). Most of the participants had a positive attitude toward their professional role (n = 736, 87%), capability (n = 646, 77%), and consequences (n = 655, 78%) in supporting TB treatment. However, this was not aligned with the actual practice of supporting TB treatment, intensively performed by only 1.3% of participants (n = 11). We identified several factors associated with the practice, that is, a pharmacy assistant background (P < 0.05), short working time (P < 0.05), experience in TB training (P < 0.001), and a positive attitude (P < 0.001).

CONCLUSION

This study highlighted a limited number of community pharmacy personnel intensively practicing as TB treatment supporters in Indonesia. An interventional package considering the identified factors is needed to develop effective and sustainable practices in the real world.

Interventions to improve latent and active tuberculosis treatment completion rates in underserved groups in low incidence countries: a scoping review

BACKGROUND

People in underserved groups have higher rates of tuberculosis (TB) and poorer treatment outcomes compared with people with no social risk factors.

OBJECTIVES

This scoping review aimed to identify interventions that improve TB treatment adherence or completion rates.

ELIGIBILITY CRITERIA

Studies of any design focusing on interventions to improve adherence or completion of TB treatment in underserved populations in low incidence countries.

SOURCES OF EVIDENCE

MEDLINE, Embase and Cochrane CENTRAL were searched (January 2015 to December 2023).

CHARTING METHODS

Piloted data extraction forms were used. Findings were tabulated and reported narratively. Formal risk of bias assessment or synthesis was not undertaken.

RESULTS

47 studies were identified. There was substantial heterogeneity in study design, population, intervention components, usual care and definition of completion rates. Most studies were in migrants or refugees, with fewer in populations with other risk factors (eg, homelessness, imprisonment or substance abuse). Based on controlled studies, there was limited evidence to suggest that shorter treatment regimens, video-observed therapy (compared with directly observed therapy), directly observed therapy (compared with self-administered treatment) and approaches that include tailored health or social support beyond TB treatment may lead to improved outcomes. This evidence is mostly observational and subject to confounding. There were no studies in Gypsy, Roma and Traveller populations, or individuals with mental health disorders and only one in sex workers. Barriers to treatment adherence included a lack of knowledge around TB, lack of general health or social support and side effects. Facilitators included health education, trusted relationships between patients and healthcare staff, social support and reduced treatment duration.

CONCLUSIONS

The evidence base is limited, and few controlled studies exist. Further high-quality research in well-defined underserved populations is needed to confirm the limited findings and inform policy and practice in TB management. Further qualitative research should include more people from underserved groups.

Impact of pharmaceutical care interventions in improving clinical outcomes among patients with pulmonary tuberculosis: a systematic review

Background

Pharmacists can play an important role in the fight against tuberculosis (TB) through optimising medication use and safety, promoting adherence to anti-TB drugs, and providing patient education. Limited evidence is available on the effectiveness of pharmacist's interventions on health outcomes in patients with pulmonary TB. This systematic review aims to assess the effectiveness of pharmaceutical care interventions in the management of pulmonary TB.

Methods

English language studies assessing the impact of pharmaceutical care interventions in TB management were searched across three electronic databases (PubMed, Embase, Cochrane), a RCT registry ClinicalTrial.gov, a peer-reviewed journal 'The Lancet Infectious Diseases', and the references of retrieved articles. Interventions delivered by pharmacists alone or as part of multidisciplinary teams were included in the review. Data were extracted using the modified Cochrane EPOC standardised data collection tool. The Cochrane Risk of Bias 2 and the NIH quality assessment tools were used to assess the risk of bias among included studies. Data were synthesised narratively. (PROSPERO Protocol Registration CRD42022325771).

Results

Thirteen studies, including two randomised controlled trials (RCTs) with a total of 3886 patients were included. Many of the included studies had a high risk of bias and lacked cohert reporting of treatment outcomes. The most common pharmaceutical care interventions were education and counselling regarding adverse drug reactions and resolution of drug-related problems. Five studies showed a relatively high TB completion rate yet only one study reached the targeted treatment success goal of (>90%).

Conclusion

The current evidence suggests that pharmaceutical care interventions can potentially improve treatment outcomes among patients with pulmonary TB. However, no definitive conclusion can be drawn given the low methodological quality of the included studies and lack of long-term follow-up data. Well-designed RCTs with careful attention to study methodology, standardised outcomes assessment aligned with the World Health Organization's guidelines are warranted to guide future practice and policy.

Practical Models of Pharmaceutical Care for Improving Tuberculosis Patient Detection and Treatment Outcomes: A Systematic Scoping Review

Decreasing global tuberculosis (TB) notifications indicate problems related to TB patient detection and treatment outcomes. Pharmaceutical care (PC) has potential roles in managing these issues. However, PC practices have not yet become widespread in the real world. This systematic scoping review aimed to identify and analyze the current literature on practical models of pharmaceutical care for improving tuberculosis patient detection and treatment outcomes. We then discussed the present challenges and future considerations for the successful implementation of PC services in TB. A systematic scoping review was performed to identify the practice models of PC in TB. Systematic searches and screening were used to identify relevant articles in the PubMed and Cochrane databases. We then discussed the challenges and recommendations for successful implementation using a framework to improve professional healthcare practice. Our analysis included 14 of 201 eligible articles. We identified that the focuses in the PC of TB are on increasing patient detection (four articles) and improving TB treatment outcomes (ten articles). Practices cover services in the community and hospital settings, such as screening and referring people with presumptive TB, tuberculin test services, collaborative practices for treatment completion, directly observed treatment, the solution of drug-related problems, reporting and managing adverse drug reactions, and medication adherence programs. Although PC services positively increase TB patient detection and treatment outcomes, hidden challenges in the actual practice are analyzed. Several factors should be comprehensively considered in successful implementation, such as guidelines, individual pharmacy personnel, patient, professional interaction, organizational capacity, regulation, incentive, and resource factors. Hence, a collaborative PC program that involves all related stakeholders should be considered to create successful and sustainable PC services in TB.

Barriers and facilitators experienced by migrants and refugees when accessing pharmaceutical care: A scoping review

BACKGROUND

Pharmacists in the community are often among the first health professionals encountered by new arrivals. Their accessibility and the longevity of the relationship gives pharmacy staff unique opportunities to work with migrants and refugees to meet their health needs. While the language, cultural and health literacy barriers that cause poorer health outcomes are well documented in medical literature, there is a need to validate the barriers to accessing pharmaceutical care and to identify facilitators for efficient care in the migrant/refugee patient-pharmacy staff interaction.

OBJECTIVE

The purpose of this scoping review was to investigate the barriers and facilitators that migrant and refugee populations experience when accessing pharmaceutical care in host countries.

METHODS

A comprehensive search of Medline, Emcare on Ovid, CINAHL and SCOPUS databases, guided by the PRISMA-ScR statement, was undertaken to identify the original research published in English between 1990 and December 2021. The studies were screened based on inclusion and exclusion criteria.

RESULTS

A total of 52 articles from around the world were included in this review. The studies revealed that the barriers to migrants and refugees accessing pharmaceutical care are well documented and include language, health literacy, unfamiliarity with health systems, and cultural beliefs and practises. Empirical evidence was less robust for facilitators, but suggested strategies included improvement of communication, medication review, community education and relationship building.

CONCLUSIONS

While barriers experienced are known, there is a lack of evidence for facilitators for provision of pharmaceutical care to refugees and migrants and poor uptake of available tools and resources. There is a need for further research to identify facilitators that are effective in improving access to pharmaceutical care and practical for implementation by pharmacies..

Improving primary health care quality for refugees and asylum seekers: A systematic review of interventional approaches

Background

It has been widely acknowledged that refugees are at risk of poorer health outcomes, spanning mental health and general well‐being. A common point of access to health care for the migrant population is via the primary health care network in the country of resettlement. This review aims to synthesize the evidence of primary health care interventions to improve the quality of health care provided to refugees and asylum seekers.

Methods

A systematic review was undertaken, and 55 articles were included in the final review. The Preferred Reporting Items for Systematic Reviews was used to guide the reporting of the review, and articles were managed using a reference‐management software (Covidence). The findings were analysed using a narrative empirical synthesis. A quality assessment was conducted for all the studies included.

Results

The interventions within the broad primary care setting could be organized into four categories, that is, those that focused on developing the skills of individual refugees/asylum seekers and their families; skills of primary health care workers; system and/or service integration models and structures; and lastly, interventions enhancing communication services. Promoting effective health care delivery for refugees, asylum seekers and their families is a complex challenge faced by primary care professionals, the patients themselves and the communication between them.

Conclusion

This review highlights the innovative interventions in primary care promoting refugee health. Primary care interventions mostly focused on upskilling doctors, with a paucity of research exploring the involvement of other health care members. Further research can explore the involvement of interprofessional team members in providing effective refugee/migrant health.

Patient or Public Contribution

Patient and public involvement was explored in terms of interventions designed to improve health care delivery for the humanitarian migrant population, that is, specifically refugees and asylum seekers.

Initiation and completion of treatment for latent tuberculosis infection in migrants globally: a systematic review and meta-analysis

Background

Latent tuberculosis infection (LTBI) is one of the most prevalent infections globally and can lead to the development of active tuberculosis disease. In many low-burden countries, LTBI is concentrated within migrant populations often because of a higher disease burden in the migrant's country of origin. National programmes consequently focus on screening and treating LTBI in migrants to prevent future tuberculosis cases; however, how effective these programmes are is unclear. We aimed to assess LTBI treatment initiation and outcomes among migrants, and the factors that influence both.

Methods

For this systematic review and meta-analysis, we searched Embase, MEDLINE, and Global Health, and manually searched grey literature from Jan 1, 2000, to April 21, 2020. We included primary research articles reporting on LTBI treatment initiation or completion, or both, in migrants and excluded articles in which data were not stratified by migrant status, or in which the data were related to outcomes before 2000. There were no geographical or language restrictions. All included studies were quality appraised using recognised tools depending on their design, and we assessed the heterogeneity of analyses using I². We extracted data on the numbers of migrants initiating and completing treatment. Our primary outcomes were LTBI treatment initiation and completion in migrants (defined as foreign-born). We used random-effects meta-regression to examine the influence of factors related to these outcomes. The study is registered with PROSPERO (CRD42019140338).

Findings

2199 publications were retrieved screened, after which 39 publications from 13 mostly high-income, low-burden countries were included in our analyses, with treatment initiation and completion data reported for 31 598 migrants positive for LTBI, with not all articles reporting the full pathway from initiation to completion. The pooled estimate for the true proportion of migrants testing positive who initiated treatment was 69% (95% CI 51–84; I²= 99·62%; 4409 of 8764). The pooled estimate for the true proportion of migrants on treatment in datasets, who subsequently completed it was 74% (95% CI = 66–81; I²= 99·19%; 15 516 of 25 629). Where data were provided for the entire treatment pathway, the pooled estimate for the true proportion of migrants who initiated and completed treatment after a positive test was only 52% (95% CI 40–64; I²= 98·90%; 3289 of 6652). Meta-regression showed that LTBI programmes are improving, with more recent reported data (2010–20) associated with better rates of treatment initiation and completion, with multiple complex factors affecting treatment outcomes in migrants.

Interpretation

Although our analysis highlights that LTBI treatment initiation and completion in migrants has improved considerably from 2010–20, there is still room for improvement, with drop out reported along the entire treatment pathway. The delivery of these screening and treatment programmes will require further strengthening if the targets to eradicate tuberculosis in low-incidence countries are to be met, with greater focus needed on engaging migrants more effectively in the clinic and understanding the diverse and unique barriers and facilitators to migrants initiating and completing treatment.

Funding

European Society of Clinical Microbiology and Infectious Diseases, the Rosetrees Trust, the National Institute for Health Research, and the Academy of Medical Sciences.

Role of the Ambulatory Care Clinical Pharmacist in Management of a Refugee Patient Population at a University-Based Refugee Healthcare Clinic

BACKGROUND

The International Family Medicine Clinic (IFMC) at University of Virginia Health System serves refugees and special immigrants in Virginia. The IFMC comprises an interprofessional team including a clinical pharmacist.

METHODS

A retrospective chart review of electronic medical records was performed. Adult refugee patients who attended a scheduled clinical pharmacist visit between October 6, 2015 and December 31, 2016 were included. The primary outcome was to characterize interventions made by a clinical pharmacist. Secondary outcomes included describing chronic disease states experienced by certain refugee populations and the clinical impact of pharmacist interventions in diabetes management.

RESULTS

80 refugee patients attended 275 clinical pharmacist visits. On average, visits lasted 30 min. Numerous patient interventions were made, including initiation of 68 new medications, discontinuation of 49 medications, and 66 medication dose changes. An average A1c reduction of 1.8% (p < 0.001) was noted.

DISCUSSION

The clinical pharmacist can play an important role in refugee healthcare.

Addressing Latent Tuberculosis Infection Treatment Through a Collaborative Care Model With Community Pharmacies and a Health Department

Introduction

The objective of this study was to evaluate a novel collaborative care model using community pharmacies as additional access points for latent tuberculosis infection (LTBI) treatment for patients using combination weekly therapy with isoniazid and rifapentine (3HP) plus directly observed therapy for 12 weeks.

Methods

This prospective pilot study included adult patients diagnosed with LTBI. Patients were eligible for study participation if they spoke English or Spanish and were followed by the New Mexico Department of Health (NM DOH). Patients were excluded if they were pregnant, receiving concomitant HIV antiretroviral therapy, or had contraindications to 3HP due to allergy or drug interactions. Community pharmacy sites included chain, independent, and hospital outpatient pharmacies in Albuquerque and Santa Fe, New Mexico.

Results

A total of 40 patients initiated treatment with 3HP and were included. Most were female (55%) and had a mean age of 46 years (standard deviation, 12.6 y). A total of 75.0% of patients completed LTBI treatment with 3HP in a community pharmacy site. Individuals of Hispanic ethnicity were more likely to complete treatment (76.7% vs 40.0%, P = .04). Most patients (60%; n = 24) reported experiencing an adverse drug event (ADE) with 3HP therapy. Patients who completed treatment were less likely to experience an ADE than patients who discontinued treatment (50.0% vs 90.0%, P = .03). Pharmacists performed 398 LTBI treatment visits (40 initial visits, 358 follow-up visits), saving the NM DOH approximately 143 hours in patient contact time.

Conclusion

High completion rates and safe administration of LTBI treatment can be achieved in the community pharmacy setting.

Using an interprofessional team to provide refugee healthcare in an academic medical centre

Introduction

The International Family Medicine Clinic (IFMC) was established in 2002 by the University of Virginia Department of Family Medicine to provide comprehensive, timely, culturally sensitive and high-quality healthcare to the growing refugee and special immigrant population in Central Virginia, USA.

Methods

The purpose of this paper is to describe the IFMC, with a specific focus on interprofessional roles, interprofessional collaboration, community partnerships and the services and resources available to IFMC patients.

Results

The clinic has served over 3100 refugees from 60 countries in its 16-year history. In 2019, the clinic staff now includes 4 attending physicians, 2 nurse practitioners and 14 residents who have dedicated clinic time to see refugees; a registered nurse care coordinator and a social worker dedicated to the IFMC refugee population; 2 clinical psychologists and doctoral students in clinical psychology; and a clinical pharmacist. The IFMC also provides onsite psychiatric care. A process flow map depicts the interconnectivity of interprofessional team members working together with other specialty care providers within the medical centre and with community partners on behalf of refugee patients through the resettlement process.

Conclusion

Individuals who arrive in the USA as refugees are a particularly vulnerable patient group and often require an interprofessional team approach. The IFMC may serve as a model for other institutions interested in starting a similar interprofessional, refugee-centred medical home.

Screening for tuberculosis in migrants and visitors from high-incidence settings: present and future perspectives

In most settings with a low incidence of tuberculosis (TB), foreign-born people make up the majority of TB cases, but the distribution of the TB risk among different migrant populations is often poorly quantified. In addition, screening practices for TB disease and latent TB infection (LTBI) vary widely. Addressing the risk of TB in international migrants is an essential component of TB prevention and care efforts in low-incidence countries, and strategies to systematically screen for, diagnose, treat and prevent TB among this group contribute to national and global TB elimination goals.This review provides an overview and critical assessment of TB screening practices that are focused on migrants and visitors from high to low TB incidence countries, including pre-migration screening and post-migration follow-up of those deemed to be at an increased risk of developing TB. We focus mainly on migrants who enter the destination country via application for a long-stay visa, as well as asylum seekers and refugees, but briefly consider issues related to short-term visitors and those with long-duration multiple-entry visas. Issues related to the screening of children and screening for LTBI are also explored.