How does community pharmacy reduce the GPS workload by helping patients living with diabetes?

Introduction

Diabetes mellitus is a metabolic disorder that affects more than 220 million people worldwide.1 The prevalence of type 2 diabetes is on the rise, leading to higher levels of morbidity, workload, and cost for the National Health Service (NHS).2 In addition, the long-term complications of diabetes can also contribute to higher levels of morbidity and workload for General Practice. Community pharmacists have clinical knowledge which is being utilised to provide a range of services to patients living with long term conditions.3 These include the New Medicines Service (NMS) and the Community Pharmacist Consultation Service (CPCS) that can both support those living with diabetes by helping patients to understand their condition and use their medication correctly, reducing the need for a General Practitioner (GP) appointment. The role of the pharmacist in community pharmacy diabetes management currently has limited research.

Aim

The aim of the study was to explore the role of community pharmacy in helping diabetic patients and thereby decrease the workload of the GP.

Methods

This study targeted community pharmacies in Croydon (n=77) and Kingston Upon Thames (n=34) in greater London, aiming for one response per pharmacy. A survey consisting of 29 questions was crated with a mixture of tick box and free text questions. Community pharmacies were visited in both boroughs, and surveys were distributed and collected. After data collection, quantitative analysis was completed through SPSS and qualitative analysis was using thematic analysis. Ethical approval was granted by Kingston University.

Results

In total, 65 responses were received (59% response rate). Diabetes was found to be the long-term condition that had the greatest number of referrals to the GP (n=30/65; 46%). Referrals were mainly in response to recurrent infections and over the counter sales linked to eyes and feet. Community pharmacies provided an average of 3 advanced services, including NMS (n=63/65; 97%), CPCS (n=61/65; 94%), flu vaccinations (n=59/65; 91%) and hypertension screening (n=24/65; 37%). Some of the key themes when participants were asked about the most common issues identified in an NMS consultation with a diabetic patient, was adherence issues to their medication, lack of knowledge about diabetes and about lifestyle changes, leading to opportunities for community pharmacy-based interventions, and limiting a referral to a GP. Pharmacists felt confident in having intervention conversations and felt knowledgeable about diabetes.

Discussion/Conclusion

Community pharmacies are an essential part of a patient’s diabetic journey, supporting person centred care. This study outlines and establishes a clear role of how community pharmacies can carry out different services for diabetic patients, be able to identify any diabetic complications in the community setting. NMS and CPCS were found to be beneficial services for diabetic patients unlocking the full potential of a community pharmacist. Although a small study in a limited geography, this study highlights that community pharmacists support diabetic patients to manage their condition, thus reducing referrals to GPs and therefore the GP workload. Future studies can be carried out over a larger area to extrapolate findings.

References

1. Ali, M., Schifano, F, Robinson, P, Phillips, G et al. Impact of community pharmacy diabetes monitoring and education programme on diabetes management: a randomized controlled study. Diabet Med, 2012;29(9):326-333.

2. Hindi, A, Schafheutle, E, Jacobs, S. Community pharmacy integration within the primary care pathway for people with long-term conditions: a focus group study of patients’, pharmacists’ and GPs’ experiences and expectations. BMC Fam Pract, 2019;20(1):1-15.

3. Gummerson, I. The new community pharmacy contract: an overview of services in relation to diabetes care. Pract Diabetes, 2005;22(7):250-252.

'Cocooning' the vulnerable - a main pillar of Malta's COVID-19 response

Issue

Early epidemiology established higher risk of morbidity & mortality amongst infected older individuals or those having specific chronic diseases, consuming most hospital care. Also where demand exceeding supply of healthcare, mortality was very high. As an island nation with one central main hospital, not overwhelming the healthcare system whilst avoiding total lockdown was key.

Description

On the 27-03-2020, the Superintendent of Public Health enacted the Protection of Vulnerable Persons Order, specifying that these categories (or subcategories thereof) of persons are to be granted vulnerable status: age >65; pregnant; persons suffering from diabetes; immunosuppressed; cancer; end stage renal failure; respiratory disease; cardiac disease; heart failure. Such persons were entitled to stay at home, to be granted special leave from work, entitled to a monthly allowance by social services. One could go out only to attend to essential or urgent personal matters, e.g. groceries, medicines, medical needs, bank etc. with mitigation measures. Exemptions were only granted to special categories such as healthcare workers, farmers, or headship positions. In addition, the carers & staff of most nursing homes voluntarily decided to isolate themselves inside the homes for periods of 2/3 weeks. Thanks to a very active family support network, offspring, relatives or neighbours ran basic errands for them, or else organised deliveries. This legal status has been lifted on the 5th June 2020.

Results

This status was granted to 126 000 persons, including 14000 employed persons. Only 9 deaths occurred in Malta out of 664 cases in a population of 500000 up till 20th June 2020, with a case fatality rate of 1.35% - one of the lowest in Europe.

Lessons

Protection of vulnerable individuals can be a cornerstone of COVID-19 public health response if mobility is effectively restricted in this subpopulation.

Key messages

Protection of the vulnerable reduces healthcare & mortality burden.

Effective legal & economic support measures, & extensive societal engagement required.

Trends in incidence and predictions of cutaneous melanoma across Europe up to 2015

BACKGROUND

Melanoma is a significant health problem in Caucasian populations. The most recently available data from cancer registries often have a delay of several months up to a few years and they are generally not easily accessible.

OBJECTIVES

To assess recent age- and sex-specific trends in melanoma incidence and make predictions for 2010 and 2015.

METHODS

A retrospective registry-based analysis was performed with data from 29 European cancer registries. Most of them had data available from 1990 up to 2006/7. World-standardized incidence rates (WSR) and the estimated annual percentage change (EAPC) were computed. Predictions were based on linear projection models.

RESULTS

Overall the incidence of melanoma is rapidly rising and will continue to do so. The incidence among women in Europe was generally higher than in men. The highest incidence rates were seen for Northern and north-western countries like the UK, Ireland and the Netherlands. The lowest incidence rates were observed in Portugal and Spain. The incidence overall remained stable in Norway, where, amongst young (25-49 years) Norwegian males rates significantly decreased (EAPC -2.8, 95% CI -3.6; -2.0). Despite a low melanoma incidence among persons above the age of 70, this age group experienced the greatest increase in risk during the study period.

CONCLUSIONS

Incidence rates of melanoma are expected to continue rising. These trends are worrying in terms of disease burden, particularly in eastern European countries.

Basal cell carcinomas without histological confirmation and their treatment: an audit in four European regions

BACKGROUND

Limited data are available on how often basal cell carcinomas (BCCs) are clinically diagnosed without histological confirmation and how they are treated.

OBJECTIVES

Within the framework of the EPIDERM project, an audit was conducted in four European countries to study the occurrence of clinically diagnosed BCCs without histological confirmation and to investigate how these are treated.

METHODS

In the Netherlands, Scotland, Finland and Malta studies were performed within different timeframes. Patients with one or more BCC(s) were selected and the number of clinically diagnosed BCCs without histological confirmation and their treatment was investigated by (manually) reviewing the (electronic) patient records and checking the (hospital) pathology databases to find evidence of histological confirmation.

RESULTS

In the Netherlands, 1089 patients with a first histologically confirmed BCC developed 1974 BCCs of which 1833 (92·9%) were histologically confirmed and 141 (7·1%) were not. A 4-month retrospective study conducted in Scotland selected 294 patients with 344 BCCs; 306 (89·0%) were histologically confirmed and 38 (11·0%) were not. A 3-month prospective study performed at the same centre in Scotland identified 44 patients who developed 58 BCCs; 44 (75·9%) of these were histologically confirmed and 14 (24·1%) were not. In Finland, there were 701 patients who developed 977 BCCs, of which 807 (82·6%) were histologically and 170 (17·4%) nonhistologically confirmed. In Malta, there were 420 patients with 477 BCCs. Only three (0·7%) of them were clinically diagnosed without histological confirmation. In the Netherlands and Finland, clinically diagnosed BCCs without histological confirmation were most often treated with cryotherapy, whereas in Scotland 5% imiquimod cream was the preferred treatment modality.

CONCLUSIONS

Although the frequency of clinically diagnosed BCCs without histological confirmation differed between the four European regions (range 0·7-24·1%), this confirms that the burden of BCC in Europe is underestimated when based on data from pathology and/or cancer registries.

The prevalence and determinants of health care-seeking behavior for fecal incontinence in multiparous United Arab Emirates females

PURPOSE

This study was designed to determine the prevalence and sociodemographics of fecal incontinence in United Arab Emirates females.

METHODS

A representative sample of multiparous United Arab Emirates females aged 20 years or older (N = 450) were randomly selected from the community (n = 225) and health care centers (n = 225). Patients were interviewed about inappropriate stool loss in the past year using a structured and pretested questionnaire.

RESULTS

Fifty-one participants (11.3 percent) admitted fecal incontinence; 26 (5.8 percent) were incontinent to liquid stool and 25 (5.5 percent) to solid stool. Thirty-eight patients (8.4 percent) had double (urinary and fecal) incontinence. Sixty-five patients (14.4 percent) were incontinent to flatus only but not to stools. The association between having fecal incontinence and chronic constipation was significant (P < 0.0001), but there was no significant association with other known risk factors such as age, parity, and previous instrumental delivery, episiotomy, perineal tears, or anorectal operations. Only 21 incontinent patients (41 percent) had sought medical advice. Patients did not seek medical advice because they were embarrassed to consult their physician (64.7 percent), they preferred to discuss the difficulty with friends, assuming that fecal incontinence would resolve spontaneously (47.1 percent) or was normal (31.3 percent), and they chose self-treatment as a result of low expectations for medical care (23.5 percent). Sufferers were bothered by the inability to pray (92.2 percent) and to have sexual intercourse (43.1 percent). Perceived causes of fecal incontinence were paralysis (90.2 percent), old age (80.4 percent), childbirth (23.5 percent), or menopause (19.6 percent).

CONCLUSIONS

Fecal incontinence is common yet underreported by multiparous United Arab Emirates females because of cultural attitudes and inadequate public knowledge.

Measurement-specific quality-of-life satisfaction during the menopause in an Arabian Gulf country

OBJECTIVE

The aim of this study was to use an instrument, the menopause-specific quality-of-life satisfaction questionnaire for the postmenopausal period, in the United Arab Emirates (UAE).

DESIGN

A cross-sectional descriptive study was used to generate menopause symptoms experienced by Arabian Gulf women. Measurement-specific quality-of-life satisfaction questionnaires were used and face-to-face interviews were performed.

SETTING

The study was based in primary health-care clinics in Al Ain City, Sharjah and Dubai Emirates, UAE.

SUBJECTS

A multistage sampling design was used, and a representative sample of 450 UAE females aged 45 years and above were included during January-April 1999.

RESULTS

Of the 450 women living in both urban and rural areas, 390 women agreed to participate (86.7%) and responded to the study. The mean age and standard deviation (SD) of the subjects was 56.5 +/- 6.6 years, and the median age of natural menopause in the present study was 48 years (mean +/- SD 48.4 +/- 3.8). The rate of consanguinous marriages in the sample was found to be 47.2%. The most common disease was found to be diabetes mellitus (10.3%), followed by osteoarthritis (7.7%), hypertension (7.2%) and asthma (6.2%), but the majority of subjects (68.7%) had no specific disease. Out of 29 possible symptoms, the mean number of symptoms was 7.57 (range 0-24). The most frequent symptom was 'aches in the back of the neck or head' at 46.4% followed by 'aches in the muscles/joints' at 34.6%. The least reported symptom was 'facial hair' at 15.9%. Increasing education resulted in more symptoms reported, and increasing parity resulted in fewer symptoms reported. In the present study, it was found that employed women experienced more symptoms and disorders. Of the total sample, 28.5% of the subjects reported no symptoms. In the four domains, 69% reported physical symptoms, 58.7% reported psychosocial symptoms, 40% reported vasomotor symptoms and 37.9% reported sexual symptoms. Spearman's rank correlation coefficient indicated that there is highly statistically significant concordance between the four domains (p < 0.01).

CONCLUSION

The present study showed that menopause-related symptoms in UAE women are fewer and of less severity than in Western women. The postmenopausal women, despite a continued decline in estrogen levels, reported few symptoms as part of a normal life stage, suggesting that they were able to cope with stress.

Diversity in expression of glucose-6-phosphate dehydrogenase deficiency in females

The aims of this study were to determine the prevalence of glucose-6-phosphate dehydrogenase (G6PD) deficiency in the United Arab Emirates (UAE), to describe the different mutations in the population, to determine its prevalence, and to study inheritance patterns in families of G6PD-deficient individuals. All infants born at Tawam Hospital, Al-Ain, UAE from January 1994 to September 1996 were screened at birth for their G6PD status. In addition, those attending well-baby clinics during the period were also screened for the disorder. Families of 40 known G6PD-deficient individuals, selected randomly from the records of three hospitals in the country, were assessed for G6PD deficiency. Where appropriate, this was followed by definition of G6PD mutations. Of 8198 infants, 746 (9.1%), comprising 15% of males and 5% of females tested, were found to be G6PD deficient. A total of 27 families were further assessed: of these, all but one family had the nt563 Mediterranean mutation. In one family, two individuals had the nt202 African mutation. The high manifestation of G6PD deficiency in women may be due to the preferential expression of the G6PD-deficient gene and X-inactivation of the normal gene, and/or to the presence of an 'enhancer' gene that makes the expression of the G6PD deficiency more likely. The high level of consanguinity which, theoretically, should result in a high proportion of homozygotes and consequently a higher proportion of females with the deficiency, was not found to be a significant factor.

The age and symptomatology of natural menopause among United Arab Emirates women

OBJECTIVES

To determine the median age of natural menopause in United Arab Emirates women, the factors affecting that age and the prevalence of climacteric symptoms amongst those women.

METHODS

A population-based survey was conducted on a community sample of United Arab Emirates women who had had natural menopause defined as cessation of menstruation for at least 6 months at the end of reproductive years. A total of 742 women aged 40 years and above were recruited from both urban and rural areas of the country using the multi-stage stratified cluster sampling technique. Data were collected using a structured questionnaire and face to face interviews and included a number of familial, reproductive and life-style variables.

RESULTS

The median age of the menopause in the United Arab Emirates is 48 years (mean = 47.3 +/- 3.29, range 40-59). This is significantly lower than the median age reported from the West (50.3 years). The subject median age of the menopause was significantly related to that of the mother (P < 0.001), older sister (P < 0.001), parity (P < 0.0001) and the previous use of oral contraceptive pills for more than 1 year (P < 0.001). Hot flushes were the commonest feature of the menopause occurring in 45% of women.

CONCLUSION

The age of natural menopause in United Arab Emirates women, as in other developing countries, is less than in Western women and may be influenced by genetic factors, parity and previous use of oral contraceptives. Climacteric symptomatology, however, is similar in the different patient groups.

Consanguinity and the age of menopause in the United Arab Emirates

OBJECTIVE

The study examined the association between some biosocial factors, consanguinity and age at natural menopause in the United Arab Emirates (UAE).

METHOD

A cross-sectional population-based study using a multi-stage sampling design and face-to-face interview.

RESULTS

In a sample of 800 UAE females aged 40 years and above, there were 742 (85.8%) respondents. The median age of natural menopause was 48 years. The bodyweight, parity number, occupation, smoking habits and consanguinity in marriage were the significant variables associated with the age at natural menopause. There were statistically significant differences between women in consanguineous and non-consanguineous marriages with regard to BMI (P < 0.002), occupation (P < 0.008), weight (P < 0.0001), age (P < 0.03), age of menopause (P < 0.005), parity (P < 0.0001), mother's age at menopause (P < 0.007) and sister's age at menopause (P < 0.002).

CONCLUSION

The study showed that among UAE women, consanguinity of marriage, maternal and sister's age at menopause, BMI, parity number and smoking habits significantly influence the natural age of menopause.

Consanguineous marriages in the United Arab Emirates

This study examines the frequency of consanguineous marriage and the coefficient of inbreeding in the United Arab Emirates (UAE). The study was conducted in Al Ain and Dubai cities between October 1994 and March 1995. A sample of 2033 married UAE females aged 15 years and over participated. The degree of consanguinity between each female and her spouse, and the degree of consanguinity between their parents were recorded. The rate of consanguinity in the present generation was high (50.5%) with a coefficient of inbreeding of 0.0222. The commonest type of consanguineous marriage was between first cousins (26.2%). Double first cousin marriages were common (3.5%) compared to other populations. The consanguinity rate in the UAE has increased from 39% to 50.5% in one generation. The level of consanguinity was higher in Al Ain (54.2%) than in Dubai (40%).

A study of possible deleterious effects of consanguinity

The aim of the study was to determine whether consanguineous marriages result in reproductive wastage and an increased incidence of illness in the offspring in a community with a long history of inbreeding and an expected high rate of consanguineous marriage. A representative sample of 2200 women aged > or = 15 years from Dubai and Al Ain, two cities in the United Arab Emirates, representing on the one hand a modern metropolis and on the other a traditional society, were studied. A questionnaire, which included questions on age, parity, gravidity, number of stillbirths, number of abortions, number of children alive, neonatal deaths and specific illnesses in children, was administered by nurses in antenatal and gynaecological clinics in the two cities. The rate of consanguineous marriage was 50.5% and parity, gravidity, ages and number of children were similar in consanguineous and non-consanguineous groups. There was no significant difference in rates of abortion, stillbirth and neonatal death between the two groups. Overall, there was statistically significant higher reproductive wastage in consanguineous couples, but when the category of less than second cousins was excluded from the consanguineous group no difference was found in reproductive wastage between consanguineous and non-consanguineous marriages. Children born to consanguineous unions also had significantly higher incidences of illnesses (37.1%) than those of non-consanguineous unions (29%). The occurrence of malignancies, congenital abnormalities, mental retardation and physical handicap was significantly higher in offspring of consanguineous than non-consanguineous marriages. In conclusion, consanguinity did not result in reproductive wastage, but was found to be an important factor in the causation of specific illnesses in offspring.

Consanguinity and associated socio-demographic factors in the United Arab Emirates

The aim of this study was to explore the association between socio-demographic factors and consanguineous marriages in the United Arab Emirates (UAE). This was a cross-sectional population-based study conducted in the cities of Al Ain and Dubai between October 1994 and March 1995. A multi-stage sampling design was used and a representative total sample of 2,200 UAE females aged 15 years and above were included in this study. Data on 2,033 (85.8%) UAE national families who consented to participate in the study were obtained. The rate of consanguineous marriages in the sample was found to be 50.5% with 95% estimated population confidence limits 49.2-51.8%. The socio-demographic factors considered were: husband's age, wife's age, husband's and wife's educational levels, husband's occupation, wife's occupation, housing conditions, husband's parental kinship, wife's parental kinship, and kinship between the spouses. Consanguinity is more common among women with educated husbands (secondary or university/high) than among women with less educated husbands. The results indicate that the frequency of consanguineous marriages significantly increases when the husband's educational level is higher (p = 0.003). The distribution of relationship between spouses over the two generations of the study group and their parents is presented. The incidence of consanguineous marriages among the parents is 53% and 62% for the women and their husbands, respectively, and the overall incidence is 57%. The parallel patrilateral marriage is obviously the favoured practice when considering the parent's kinship distributions. The results of step-wise multiple logistic regression analysis for the occurrence of consanguineous marriages show that the husband's education and husband's parent's consanguinity status only are significantly associated variables.