The pharmacy care plan service: Evaluation and estimate of cost-effectiveness

Evaluation of community pharmacists' knowledge, practice and barriers towards diabetes management in Asir region, Saudi Arabia

RATIONALE, AIMS AND OBJECTIVES

Diabetes mellitus is a global serious health problem that has a clear negative impact on economy. The high prevalence of diabetes worldwide urges for prevention and educational programs. Engagement of community pharmacists in offering various diabetes care services enables delivery of quality of care for patients and could play key role in diabetes management. The current study was designed to assess the knowledge towards diabetes among community pharmacists and to investigate their role in diabetes management through identifying different diabetes care services they provide in Asir region, Saudi Arabia. In addition, possible barriers for providing these services were evaluated.

METHOD

A cross-sectional study was performed using an online self-administered anonymous survey that consisted of 4 domains: demographics, knowledge, practice and barriers related to diabetes management.

RESULTS

A total of 258 pharmacists completed the survey, and one-third of respondents (34.5%) demonstrated good knowledge while 42.2% showed moderate knowledge towards diabetes. Respondents of the age group (30-39) years, males, those with bachelor's degree and those with 5 years or less of experience had higher mean knowledge. Nearly half of the participants had positive practice. The most prominent (75%) services offered by the community pharmacists were counselling on the appropriate administration, handling and storage of insulin and the appropriate time to administer oral antidiabetic drugs. Pharmacists who received training had higher mean practice scores. Lack of time, lack of diabetic patients visiting the pharmacy and low patient expectations regarding pharmacists' role in diabetes care were identified as the most important barriers they encountered.

CONCLUSION

Community pharmacists of Asir region exhibited moderate knowledge and practices regarding diabetes management. Our results support the need for national advanced diabetes training programs targeting community pharmacists for providing quality of care services for diabetic patients Moreover, strategies to overcome the reported barriers are indispensable.

Financial impact of medication reviews by clinical pharmacists to reduce in-hospital adverse drug events: a return-on-investment analysis

BACKGROUND

Adverse drug events contribute to rising health care costs. Clinical pharmacists can reduce their risks by identifying and solving drug-related problems (DRPs) through medication review.

AIM

To develop an economic model to determine whether medication reviews performed by clinical pharmacists could lead to a reduction in health care costs associated with the prevention of potential adverse drug events.

METHOD

Two pharmacists performed medication reviews during ward rounds in an internal medicine setting over one year. Avoided costs were estimated by monetizing five categories of DRPs (improper drug selection, drug interactions, untreated indications, inadequate dosages, and drug use without an indication). An expert panel assessed potential adverse drug events and their probabilities of occurrence for 20 randomly selected DRPs in each category. The costs of adverse drug events were extracted from internal hospital financial data. A partial economic study from a hospital perspective then estimated the annual costs avoided by resolving DRPs identified by 3 part-time clinical pharmacists (0.9 full-time equivalent) from 2019 to 2020. The return on investment (ROI) of medication review was calculated.

RESULTS

The estimated annual avoided costs associated with the potential adverse drug events induced by 676 DRPs detected was € 304,170. The cost of a 0.9 full-time equivalent clinical pharmacist was € 112,408. Extrapolated to 1 full-time equivalent, the annual net savings was € 213,069 or an ROI of 1-1.71. Sensitivity analyses showed that the economic model was robust.

CONCLUSION

This economic model revealed the positive financial impact and favorable return on investment of a medication review intervention performed by clinical pharmacists. These findings should encourage the future deployment of a pharmacist-led adverse drug events prevention program.

Advanced-scope pharmacist roles in medical outpatient clinics: a cost-consequence analysis

BACKGROUND

There is a growing body of evidence that supports the clinical effectiveness of pharmacist roles in outpatient settings. However, limited studies have investigated the economic efficiency of advanced-scope outpatient pharmacist roles, particularly in the Australian setting. Assessing the overall costs and benefits of these outpatient pharmacist roles is needed to ensure service sustainability.

AIMS

To use a cost-consequence approach to evaluate the advanced-scope outpatient pharmacist roles across multiple clinic disciplines from the hospital perspective.

METHODS

A cost-consequence analysis was undertaken using data from a previous clinical-effectiveness study. All outpatient pharmacist consults conducted from 1 June 2019 to 31 May 2020 across 18 clinic disciplines were evaluated. Consequences from the pharmacist services included number of consults conducted, number of medication-related activities and number of resolved recommendations.

RESULTS

The overall cost to the hospital for the outpatient pharmacist service across all clinics was AU$1 991 122, with a potential remuneration of AU$3 895 247. There were 10 059 pharmacist consults undertaken for the 12-month period. Medication-related activities performed by pharmacists primarily included 6438 counselling and education activities and 4307 medication list activities. When the specialist pharmacist roles were added to the outpatient clinics, several health service benefits were also realised.

CONCLUSIONS

The addition of pharmacist roles to outpatient clinics can increase the cost of services; however, they also can increase medication optimisation activities. Future research should examine a societal perspective that includes broader cost and effectiveness outcomes. This study could justify the implementation of advanced-scope outpatient pharmacist roles in other Australian hospitals.

The outcomes of considering goals of care in medication reviews for older adults: a systematic review

INTRODUCTION

This is a systematic review of prescribing, clinical, patient-reported, and health utilization outcomes of goal-directed medication reviews in older adults.

METHODS

A systematic review was conducted using MEDLINE, EMBASE, SCOPUS and CINAHL databases to identify studies examining outcomes of goal-directed medication reviews in humans, with mean/median age ≥ 60 years and in English.

RESULTS

Seventeen out of 743 articles identified were included. Whilst there were inconsistent findings regarding changes in the number of medications between groups or post-intervention in one group (n = 6 studies), studies found reductions in drug-related problems (n = 2) and potential to reduce anticholinergics and sedatives (n = 2). Two out of seven studies investigating clinical outcomes found improvements, such as reduced hospital readmissions and improved depression severity. One study found 75% of patients achieved ≥ 1 goals and another found 43% of goals were achieved at six months. Four out of five studies found significant improvements in patient-reported quality of life between groups (n = 2) or post-intervention in one group (n = 2). Both studies investigating cost-effectiveness reported the intervention was cost-effective.

CONCLUSIONS

There is evidence of positive impact on medication rationalization, quality of life and cost-effectiveness, supporting goal-directed medication reviews. Larger, longitudinal studies, exploring patient-focused outcomes may provide further insights into the ongoing impact of goal-directed medication reviews.

Economic evaluation of pharmacy services: a systematic review of the literature (2016-2020)

BACKGROUND

Economic evaluation is crucial for healthcare decision-makers to select effective interventions. An updated systematic review of the economic evaluation of pharmacy services is required in the current healthcare environment.

AIM

To conduct a systematic review of literature on economic evaluation of pharmacy services.

METHOD

Literature (2016-2020) was searched on PubMed, Web of Sciences, Scopus, ScienceDirect, and SpringerLink. An additional search was conducted in five health economic-related journals. The studies performed an economic analysis describing pharmacy services and settings. The reviewing checklist for economic evaluation was used for quality assessment. The incremental cost-effectiveness ratio and willingness-to-pay threshold were the main measures for cost-effective analysis (CEA) and cost-utility analysis (CUA), while cost-saving, cost-benefit-ratio (CBR), and net benefit were used for cost-minimization analysis (CMA) and cost-benefit analysis (CBA).

RESULTS

Forty-three articles were reviewed. The major practice settings were in the USA (n = 6), the UK (n = 6), Canada (n = 6), and the Netherlands (n = 6). Twelve studies had good quality according to the reviewing checklist. CUA was used most frequently (n = 15), followed by CBA (n = 12). Some inconsistent findings (n = 14) existed among the included studies. Most agreed (n = 29) that pharmacy services economically impact the healthcare system: hospital-based (n = 13), community pharmacy (n = 13), and primary care (n = 3). Pharmacy services were found to be cost-effectiveness or cost-saving among both developed (n = 32) and in developing countries (n = 11).

CONCLUSION

The increased use of economic evaluation of pharmacy services confirms the worth of pharmacy services in improving patients' health outcomes in all settings. Therefore, economic evaluation should be incorporated into developing innovative pharmacy services.

A systematic review of economic evaluations of pharmacist services

BACKGROUND

Challenges to the provision of health care are occurring internationally and are expected to increase in the future, further increasing health spending. As pharmacist roles are evolving and expanding internationally to provide individualised pharmaceutical care it is important to assess the cost-effectiveness of these services.

OBJECTIVES

To systematically synthesise the international literature regarding published economic evaluations of pharmacy services to assess their cost-effectiveness and clinical outcomes.

METHODS

A systematic review of economic evaluations of pharmacy services was conducted in MEDLINE, EMBASE, PubMed, Scopus, Web of Science, CINAHL, IPA and online journals with search functions likely to publish economic evaluations of pharmacy services. Data were extracted regarding the interventions, the time horizon, the outcomes and the incremental cost-effectiveness ratio. Studies' quality of reporting was assessed using the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) statement.

RESULTS

Seventy-five studies were included in the systematic review, including 67 cost-effectiveness analyses, 6 cost-benefit analyses and 2 cost-consequence analyses. Of these, 57 were either dominant or cost-effective using a willingness-to-pay threshold of NZ$46 645 per QALY. A further 11 studies' cost-effectiveness were unable to be evaluated. Interventions considered to be most cost-effective included pharmacist medication reviews, pharmacist adherence strategies and pharmacist management of type 2 diabetes mellitus, hypertension and warfarin/INR monitoring. The quality of reporting of studies differed with no studies reporting all 28 items of the CHEERS statement.

CONCLUSIONS

There is strong economic evidence to support investment in extended pharmacist services, particularly those focussed on long-term chronic health conditions.

Development, Feasibility, Impact and Acceptability of a Community Pharmacy-Based Diabetes Care Plan in a Low-Middle-Income Country

Informed by existing research, mostly from high-income countries, this study aimed to develop and test the feasibility of a community pharmacy person-centred goal-setting intervention for people living with type 2 diabetes in a low-middle-income country-Nigeria. The Medical Research Council (MRC) guidance for developing complex interventions framed the intervention development. Patients participated in monthly community pharmacist consultations over six months. Self-reported and clinical outcome measures were collected at baseline and study completion and analysed in STATA V.14. Twenty pharmacists in 20 pharmacies completed the research and enrolled 104 patients. Of these, 89 patients had complete study data, and 70 patients also completed a post-study evaluation questionnaire. In addition, 15 patients and 10 pharmacists were interviewed. All outcome measures showed statistically significant improvements (p < 0.05). Clinical outcomes (BMI, waist circumference, and fasting plasma glucose) improved significantly. Mean patient activation measure (PAM©), quality of life (EQ-VAS©), and medication adherence improved from baseline to study completion. Eighty-eight per cent of questionnaire respondents were satisfied with the service. Interviews indicated care plan acceptability, patient satisfaction, empowerment, and service enthusiasm. Identified barriers to the consultations included time and technology. This study developed a feasible, effective, well-perceived community pharmacy diabetes care plan in Nigeria.

Cost-effectiveness and cost-utility of hypertension and hyperlipidemia collaborative management between pharmacies and primary care in portugal alongside a trial compared with usual care (USFarmácia®)

Background: There is little experience in the economic evaluation of pharmacy/primary care collaborative health interventions using interprofessional technology-driven communication under real-world conditions. This study aimed to conduct cost-effectiveness and cost-utility analyses of a collaborative care intervention in hypertension and hyperlipidemia management between pharmacies and primary care versus usual (fragmented) care alongside a trial.

Methods: An economic evaluation was conducted alongside a 6-month pragmatic quasi-experimental controlled trial. Data sources included primary care clinical software; pharmacy dispensing software; patient telephone surveys; and published literature. The target population was adult patients on hypertension and/or lipid-lowering medication. The perspective was societal. We collected patient-level data on resource use to estimate trial costs. Effect outcomes included blood pressure (BP) and quality-adjusted life years (QALYs). Bootstrapping was used to estimate uncertainty around the incremental cost-effectiveness and cost-utility ratios. Cost-effectiveness planes and acceptability curves were estimated.

Results: The intervention was not shown to have reasonable levels of cost-effectiveness or cost-utility when compared to usual care as denoted by the levels of uncertainty expressed in wide confidence intervals. The probability of the intervention being cost-effective is 28% at the threshold of €20,000 per QALY gained and 57% at the threshold of €500 per mmHg systolic BP decrease.

Conclusion: Considering the limitations of the trial which affected effectiveness and economic outcomes, our results are not generalizable for community pharmacy and primary care in Portugal. This research offers, however, valuable lessons on methods and strategies that can be used in future economic evaluations of collaborative public health interventions with the potential for reimbursement.

Clinical trial registration:https://www.isrctn.com/ISRCTN13410498, identifier ISRCTN13410498

Pharmacist Interventions for Medication Adherence: Community Guide Economic Reviews for Cardiovascular Disease

INTRODUCTION

Adherence to medications for cardiovascular disease and its risk factors is less than optimal, although greater adherence to medication has been shown to reduce the risk factors for cardiovascular disease. This paper examines the economics of tailored pharmacy interventions to improve medication adherence for cardiovascular disease prevention and management.

METHODS

Literature from inception of databases to May 2019 was searched, yielding 29 studies for cardiovascular disease prevention and 9 studies for cardiovascular disease management. Analyses were done from June 2019 through May 2020. All monetary values are in 2019 U.S. dollars.

RESULTS

The median intervention cost per patient per year was $246 for cardiovascular disease prevention and $292 for cardiovascular disease management. The median change in healthcare cost per person per year due to the intervention was -$355 for cardiovascular disease prevention and -$2,430 for cardiovascular disease management. The median total cost per person per year was -$89 for cardiovascular disease prevention, with a median return on investment of 0.01. The median total cost per person per year for cardiovascular disease management was -$1,080, with a median return on investment of 7.52, and 6 of 7 estimates indicating reduced healthcare cost averted exceeded intervention cost. For cardiovascular disease prevention, the median cost per quality-adjusted life year gained was $11,298. There were no cost effectiveness studies for cardiovascular disease management.

DISCUSSION

The evidence shows that tailored pharmacy-based interventions to improve medication adherence are cost effective for cardiovascular disease prevention. For cardiovascular disease management, healthcare cost averted exceeds the cost of implementation for a favorable return on investment from a healthcare systems perspective.

"A little bit more looking…listening and feeling" A qualitative interview study exploring advanced clinical practice in primary care and community pharmacy

Background Growing demands on healthcare globally, combined with workforce shortages, have led to greater skill mix in healthcare settings. Pharmacists are increasingly moving into complex areas of practice, a move supported by policy and education/training changes. Aim To understand the nature of extended roles for pharmacists practising at an advanced level in primary care and community pharmacy settings, to explore how clinical and physical examination was incorporated into practice and to understand the impact of providing such examination on practice and on patient relationships. Method Telephone interviews (N = 15) were conducted with a purposive sample of pharmacists using clinical and physical examination in their practice in Great Britain. The sample included primary care pharmacists (N = 5), community pharmacists (N = 4), pharmacists working across settings (N = 5) and one working in another primary care setting. Participants were recruited through professional networks, social media and snowballing. Results Primary care pharmacists and community pharmacists were utilising clinical and physical examination skills in their practice. Some community pharmacists were operating locally-commissioned services for low acuity conditions. Incorporating such examinations into practice enabled pharmacists to look at the patient holistically and enhanced pharmacist/patient relationships. Barriers to practise included lack of timely sharing of patient data and perceived reluctance on the part of some pharmacists for advanced practice. Conclusion With growing opportunities to provide patient-focussed care, it remains to be seen whether pharmacists, both in Great Britain and elsewhere, are able to overcome some of the organisational, structural and cultural barriers to advanced practice that currently exist in community pharmacy.

Cost-Utility Analysis of a Medication Adherence Management Service Alongside a Cluster Randomized Control Trial in Community Pharmacy

BACKGROUND

It is necessary to determine the cost utility of adherence interventions in chronic diseases due to humanistic and economic burden of non-adherence.

PURPOSE

To evaluate, alongside a cluster-randomized controlled trial, the cost-utility of a pharmacist-led medication adherence management service (MAMS) compared with usual care in community pharmacies.

MATERIALS AND METHODS

The trial was conducted over six months. Patients with treatments for hypertension, asthma or chronic obstructive pulmonary disease (COPD) were included. Patients in the intervention group (IG) received a MAMS based on a brief complex intervention, whilst patients in the control group (CG) received usual care. The cost-utility analysis adopted a health system perspective. Costs related to medications, healthcare resources and adherence intervention were included. The effectiveness was estimated as quality-adjusted life years (QALYs), using a multiple imputation missing data model. The incremental cost-utility ratio (ICUR) was calculated on the total sample of patients.

RESULTS

A total of 1186 patients were enrolled (IG: 633; CG: 553). The total intervention cost was estimated to be €27.33 ± 0.43 per patient for six months. There was no statistically significant difference in total cost of medications and healthcare resources per patient between IG and CG. The values of EQ-5D-5L at 6 months were significantly higher in the IG [IG: 0.881 ± 0.005 vs CG: 0.833 ± 0.006; p = 0.000]. In the base case, the service was more expensive and more effective than usual care, resulting in an ICUR of €1,494.82/QALY. In the complete case, the service resulted in an ICUR of €2,086.30/QALY, positioned between the north-east and south-east quadrants of the cost-utility plane. Using a threshold value of €20,000/QALY gained, there is a 99% probability that the intervention is cost-effective.

CONCLUSION

The medication adherence management service resulted in an improvement in the quality of life of the population with chronic disease, with similar costs compared to usual care. The service is cost-effective.

A systematic review and meta-analysis of patient activation in people living with chronic conditions

OBJECTIVE

The objectives of this review are to (1) describe the state of the science of patient activation interventions for the self-management of chronic conditions; (2) identify effective intervention elements for improving patient activation; and (3) compare intervention effectiveness across chronic conditions.

METHODS

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). PubMed, CINAHL, and Web of Science databases were searched.

RESULTS

Thirty-two articles published between 2005 and 2019 were identified with intervention elements of self-management, disease management, and education. Meta-analysis of a subset of seven randomized controlled trials (n = 7) that used the 13-item version of the Patient Activation Measure with data collection points at 6 months demonstrated that patient activation did not change significantly in comparison with controls (MD = 0.25, 95 % CI = 0.02-0.47).

CONCLUSION

Most interventions reported significant improvement in patient activation and were linked to tasks such as regular exercise and monitoring glucose. However, the meta-analysis of RCTs did not confirm these findings.

PRACTICE IMPLICATIONS

Patient activation can be assessed and addressed uniformly across all chronic conditions to improve patient engagement in care.

The management of asthma in adult patients in the community pharmacy setting: Literature review

BACKGROUND

Asthma poses a public health concern, with an estimated 235 million people currently living with the condition globally. The provision of evidence-based, patient-centred services for adult asthma patients in community pharmacy which involves collaboration across the multidisciplinary team could improve their asthma control.

OBJECTIVES

A literature review was conducted to examine the evidence of asthma management in community pharmacy setting.

METHODS

Five databases were searched to identify relevant articles published before February 2021. Screening of the potential studies was performed to remove articles that did not comply with the inclusion criteria. Relevant data from all included studies was collected using a data extraction form to ensure consistency throughout the review.

RESULTS

Twenty studies were included in the review; all were conducted in community pharmacy settings in the period of 2001-2020, in different countries. The studies included randomised controlled trials, controlled trials and observational studies. Several successful community pharmacy-based services that were provided to asthma patients to improve their asthma management were highlighted in this review. These interventions consisted of one or more components and included: patient education, inhaler technique improvement, patient counselling, self-management plans, development and provision of asthma action plans and referral to other health care practitioners. None of the studies involved medication or dosage changes by community pharmacy.

CONCLUSIONS

The evidence discussed in this review showed that community pharmacists are well-placed to deliver services to asthma patients and many studies were conducted in the community pharmacy to improve asthma control in adult patients. However, further research could be conducted to explore further opportunities for community pharmacy to enhance asthma patients management of their condition.

Biogenesis of silver nanoparticles to treat cancer, diabetes, and microbial infections: a mechanistic overview

Green synthesis of silver nanoparticles (SNPs) by harnessing the natural abilities of plant secondary metabolites has advantages over routine physical and chemical synthetic approaches due to their one-step experimental setup to reduce and stabilize the bulk silver into SNPs, biocompatible nature, and therapeutic significance. The unique size, shape, and biochemical functional corona of SNPs embellish them with the potential to perform therapeutic actions by adopting various mechanistic approaches including but not limited to the disruption of the electron transport chain, mitochondrial damage, DNA fragmentation, inhibition of ATP synthase activity, disorganization of the cell membrane, suspension of cellular signaling pathways, induction of apoptosis, and inhibition of enzymes activity. This review elaborates the biogenic synthesis of SNPs in redox chemical reactions by using plant secondary metabolites found in plant extracts. In addition, it explains the synergistic influence of physicochemical reaction parameters such as the temperature, pH, the concentration of the AgNO₃, and the ratio of reactants to affect the reaction kinetics, molecular mechanics, enzymatic catalysis, and protein conformations that aid to affect the size, shape, and potential biochemical corona of nanoparticles. This review also provides up-to-date information on the mechanistic actions that embellish the plant-based SNPs, an anticancer, cytotoxic, antidiabetic, antimicrobial, and antioxidant potential. The mechanistic understanding of the therapeutic actions of SNPs will help in precision medicine to develop customized treatment and healthcare approaches for the welfare of the human population. KEY POINTS: • Significance of the biogenic nanoparticles • Biomedical application potential of the plant-based silver nanoparticles • Mechanism of the anticancer, antidiabetic, and antimicrobial actions of the plant-based silver nanoparticles.

Biomedical Potential of Plant-Based Selenium Nanoparticles: A Comprehensive Review on Therapeutic and Mechanistic Aspects

Selenium nanoparticles (SeNPs) have advantages over other nanomaterials because of the promising role of selenium in the stabilization of the immune system and activation of the defense response. The use of SeNPs and their supplements not only have pharmacological significance but also boost and prepare the body's immune system to fight the pathogens. This review summarizes the recent progress in the biogenesis of plant-based SeNPs by using various plant species and the role of secondary metabolites on their biocompatible functioning. Phyto-synthesis of SeNPs results in the synthesis of nanomaterials of various, size, shape and biochemical nature and has advantages over other routine physical and chemical methods because of their biocompatibility, eco-friendly nature and in vivo actions. Unfortunately, the plant-based SeNPs failed to attain considerable attention in the pharmaceutical industry. However, a few studies were performed to explore the therapeutic potential of the SeNPs against various cancer cells, microbial pathogens, viral infections, hepatoprotective actions, diabetic management, and antioxidant approaches. Further, some of the selenium-based drug delivery systems are developed by engineering the SeNPs with the functional ligands to deliver drugs to the targeted sites. This review also provides up-to-date information on the mechanistic actions that the SeNPs adopt to achieve their designated tasks as it may help to develop precision medicine with customized treatment and healthcare for the ailing population.

Supporting patients with long-term conditions in the community: Evaluation of the Greater Manchester Community Pharmacy Care Plan Service

The Greater Manchester Community Pharmacy Care Plan (GMCPCP) service provided tailored care plans to help adults with one or more qualifying long-term condition (hypertension, asthma, diabetes and COPD) to achieve health goals and better self-management of their long-term conditions. The service ran between February and December 2017. The aim of this study was to investigate the impact of the service on patient activation, as measured by the PAM measure (primary outcome). Secondary outcomes included quality of life (EQ-5D-5L, EQ-VAS), medication adherence (MARS-5), NHS resource use and costs, systolic and diastolic blood pressure, HDL cholesterol ratio levels and body mass index (BMI). A before and after design was used, with follow-up at 6-months. A questionnaire was distributed at follow-up and telephone interviews with willing participants were used to investigate patient satisfaction with the service. The study was approved by the University of Manchester Research Ethics Committee. Quantitative data were analysed in SPSS v22 (IBM). A total of 382 patients were recruited to the service; 280 (73%) remained at follow-up. Ten patients were interviewed and 43 completed the questionnaire. A total of 613 goals were set; mean of 1.7 goals per patient. Fifty percent of goals were met at follow-up. There were significant improvements in PAM, EQ-5D-5L and EQ-VAS scores and significant reductions in systolic blood pressure, BMI and HDL cholesterol ratio at follow-up. Mean NHS service use costs were significantly lower at follow-up; with a mean decrease per patient of £236.43 (±SD £968.47). The mean cost per patient for providing the service was £203.10, resulting in potential cost-savings of £33.33 per patient (SD ± 874.65). Questionnaire respondents reported high levels of satisfaction with the service. This study suggests that the service is acceptable to patients and may lead to improvements in health outcomes and allows for modest cost savings. Limitations of the study included the low response rate to the patient questionnaire.

Nanoparticle Delivery Systems in the Treatment of Diabetes Complications

Diabetes mellitus, an incurable metabolic disease, is characterized by changes in the homeostasis of blood sugar levels, being the subcutaneous injection of insulin the first line treatment. This administration route is however associated with limited patient's compliance, due to the risk of pain, discomfort and local infection. Nanoparticles have been proposed as insulin carriers to make possible the administration of the peptide via friendlier pathways without the need of injection, i.e., via oral or nasal routes. Nanoparticles stand for particles in the nanometer range that can be obtained from different materials (e.g., polysaccharides, synthetic polymers, lipid) and are commonly used with the aim to improve the physicochemical stability of the loaded drug and thereby its bioavailability. This review discusses the use of different types of nanoparticles (e.g., polymeric and lipid nanoparticles, liposomes, dendrimers, niosomes, micelles, nanoemulsions and also drug nanosuspensions) for improved delivery of different oral hypoglycemic agents in comparison to conventional therapies.

"It Made a Difference to Me": A Comparative Case Study of Community Pharmacists' Care Planning Services in Primary Health Care

In some jurisdictions, governments and the public look to community pharmacies to provide expanded primary health care services, including care plans with follow-up. Care planning services, covered by the Compensation Plan in Alberta, Canada, require pharmacists to assess an eligible patient's health history, medication history, and drug-related problems to establish goals of treatment, interventions, and monitoring plan. Follow-up assessments are also covered by the Compensation Plan. A comparative case study method facilitated an in-depth investigation of care planning services provided by four community pharmacy sites. Data from 77 interviews, 61 site-specific documents, and 94 h of observation collected over 20 months were analyzed using an iterative constant comparative approach. Using a sociomaterial theoretical framework, the perceived value of care planning services was examined through an investigation of the relationships and interactions between people and information. Patients perceived the value of care planning as related to waiting time to access care and co-creating individualized plans. Physicians and other health care professionals valued collaboration, information sharing, and different perspectives on patient care. Pharmacists valued collaboration with patients and other health care professionals, which renewed their sense of responsibility, increased satisfaction, and gave meaning to their role.