Potential of pharmacists to help reduce the burden of poorly managed cardiovascular risk

Findings From a National Survey of Older US Adults on Patient Willingness to Use Telehealth Services: Cross-Sectional Survey

BACKGROUND

Telehealth (telemedicine and telepharmacy) services increase access to patient services and ensure continuity of care. However, few studies have assessed factors that influence patients' willingness to use telehealth services, and we sought to investigate this.

OBJECTIVE

This study aims to examine respondents' (aged between 45 and 75 years) willingness to use telehealth services (telepharmacy and telemedicine) and the correlates of the willingness to use telehealth services.

METHODS

We administered a cross-sectional national survey of 1045 noninstitutionalized US adults aged between 45 and 75 years in March and April 2021. Multiple logistic regression analyses were used to identify demographic and health service use correlates of self-reported willingness to use telehealth services.

RESULTS

Overall willingness to use telemedicine was high (674/1045, 64.5%). Adults aged 55 years and older were less willing to use telemedicine (aged between 55 and 64 years: odds ratio [OR] 0.61, 95% CI 0.42-0.86; aged 65 years or older: OR 0.33, 95% CI 0.22-0.49) than those younger than 55 years. Those with a regular provider (OR 1.01, 95% CI 1-1.02) and long travel times (OR 1.75, 95% CI 1.03-2.98) were more willing to use telemedicine compared to those without a regular provider and had shorter travel times, respectively. Willingness to use telemedicine services increased from 64.5% (674/1045) to 83% (867/1045) if the service was low-cost or insurance-covered, was with their existing health care provider, or was easy-to-use. Overall willingness to use telepharmacy was 76.7% (801/1045). Adults aged older than 55 years were less willing to use telepharmacy (aged between 55 and 64 years: OR 0.57, 95% CI 0.38-0.86; aged 65 years or older: OR 0.24, 95% CI 0.15-0.37) than those younger than 55 years. Those who rated pharmacy service quality higher were more willing to use telepharmacy (OR 1.06, 95% CI 1.03-1.09) than those who did not.

CONCLUSIONS

Respondents were generally willing to use telehealth (telemedicine and telepharmacy) services, but the likelihood of their being willing to use telehealth decreased as they were older. For those initially unwilling (aged 55 years or older) to use telemedicine services, inexpensive or insurance-covered services were acceptable.

Multicenter Cross-Sectional Study on Perceptions and Roles of Community Pharmacists in the Prevention and Management of Cardiovascular Disorders in Northwest Ethiopia

INTRODUCTION

Community pharmacy professionals are among the initial healthcare providers and could play crucial roles in preventing and managing cardiovascular disorders. This study aimed to assess perceptions and involvements of community pharmacy professionals in the prevention and management of cardiovascular disorders in Gondar city and nearby rural towns, Northwest Ethiopia.

METHODS

A multi-centered cross-sectional survey was conducted on community pharmacy professionals in Gondar city and the nearby rural towns from June to July 2021. Independent sample t-test and one-way ANOVA were used to show mean score differences of pharmacists towards the prevention and management of cardiovascular diseases. A 95% confidence interval with a P-value of < 0.05 in the tests was considered statistically significant.

RESULTS

Of the 223 initial samples, 210 completed the survey and resulted in a 94.2% response rate. The average perception and involvement scores of the community pharmacy professionals towards the prevention and treatment of the cardiovascular syndromes were 4.1 and 3.8, respectively. Numerous professionals (>86%) agreed on weight reductions, alcohol consumption restrictions and physical exercises to decrease cardiovascular risks. Pharmacy professionals recruited from Gondar city had significantly higher mean scores compared with pharmacy professionals involved from rural towns (P < 0.001). A significant difference in mean involvement score was also noted in regarding the numbers of clients serving/day (P = 0.026).

CONCLUSION

Community pharmacy professionals had good perceptions on prevention and management of cardiovascular diseases. However, their level of involvement in measuring weight, blood pressure and glucose level, dispensing equipment for home blood pressure and glucose monitoring and keeping records of patients needs to be encouraged. Professionals might benefit from enhanced training to increase their knowledge and confidence.

Meta-analysis of pharmacist-led and pharmacist-physician intervention on blood pressure control

Effective intervention is a significant component in the improvement of blood pressure control and patient adherence. Blood pressure control includes different self-monitoring techniques, mobile health monitoring, or healthcare professionals’ interventions. This study aims to compare, analyze, and interpret the effectiveness of pharmacist-physician collaboration and pharmacist- led interventions. Meta-analysis was performed using MEDLINE via PubMed, EMBASE, EBSCO, Web of Science, Scopus, and the Cochrane Library databases between 2008-2018. Of the 51 relevant systematic reviews identified, 15 were of sufficient quality and included in the data synthesis. The breakdown of the 15 included 7 (n=2026) pharmacist and 8 pharmacist-physician interventions (n=2361). The impact of pharmacist-physician collaboration and pharmacist-led interventions on Systolic Blood Pressure was –8.22 (–11.01; –5.42) (P<0.01) and –7.68 (–9.30; –6.06) (P=0.35), respectively. On the other hand, similar correlation for Diastolic Blood Pressure for the impact of pharmacist-physician collaboration and pharmacist-led interventions was –3.55 (–4.54; –2.55) (P=0.49) and –2.58 (–3.76; –1.39) (P=0.24), respectively. These results suggest that both interventions are effective for blood pressure control. However, when two meta-analyses were compared, it was found that pharmacist-physician collaboration was more effective than pharmacist-led interventions. This finding highlights the importance of multidisciplinary approaches during blood pressure control procedures. When a holistic view is considered; especially cost-effectiveness, future studies must be diversified to encompass a broader context and impact analysis.

Pharmacy Technicians' Perception About Symptoms and Concerns of Older Patients Visiting Pharmacies: A Cross-Sectional Study

Purpose

Older patients are still not sufficiently integrated into multidisciplinary care concepts including geriatric and palliative care. They do, however, regularly visit pharmacies to fill prescriptions or to buy self-medication. Thus, they have frequent contact with pharmacy technicians (PTs), who are widely involved in counselling in Germany. However, it is not known whether geriatric symptoms are recognized by PTs and to what extent older patients use their pharmacy to address geriatric or palliative concerns. This study aimed to investigate PTs' impression of older patients' symptoms, geriatric and palliative concerns in consultations, as well as multidisciplinary collaboration.

Patients and Methods

We conducted a cross-sectional study in April-May 2019. Using a self-administered questionnaire, PTs were asked about (i) geriatric symptoms, (ii) geriatric and palliative concerns older patients expressed in routine consultations, (iii) supposed reasons for inadequate care, and (iv) PTs' desire for multidisciplinary cooperation.

Results

(i) The 5 most common symptoms the 339 participating PTs recognized in the community pharmacy were pain, insomnia, restricted mobility, eye disorders, and constipation. (ii) The three most frequently addressed non-drug-related geriatric palliative concerns were mental strain, loneliness, and mourning. (iii) As reasons for inadequate patient care, PTs predominantly mentioned patient-related reasons (299 of 518 reasons, 58%). (iv) 85% of the PTs desired closer cooperation with general practitioners, 84% with nursing services and 39% with palliative physicians.

Conclusion

PTs frequently saw older patients visiting the pharmacy who suffer from a variety of symptoms. PTs were additionally confronted with diverse geriatric or palliative concerns. We deduce, first, a need for PT training in geriatric and palliative care. Second, multidisciplinary care concepts and research should include pharmacies because they seem to be a low-threshold contact to older patients, who might need access to adequate care.

Diabetes and cardiovascular disease risk screening model in community pharmacies in a developing primary healthcare system: a feasibility study

OBJECTIVES

This study aimed to develop an evidence-based community pharmacist-delivered screening model for diabetes and cardiovascular disease (CVD), and assess its feasibility to identify and refer patients with elevated risk.

DESIGN

A feasibility study.

SETTING

A purposive sample of 12 community pharmacies in three cities in the United Arab Emirates (UAE).

PARTICIPANTS

Adults 40 years of age and above who have not been previously diagnosed with either diabetes or CVD.

INTERVENTION

Pharmacist screening of adults visiting pharmacies involved history, demographics, anthropometric measurements, blood pressure and point-of-care testing including glycated haemoglobin (HbA1c) levels and lipid panel. Participants with a 10-year CVD risk ≥7.5%, HbA1c level ≥5.7% or American Diabetes Association (ADA) risk score ≥5 points were advised to visit their physician.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were (1) development of UAE pharmacist-delivered screening model, (2) the proportion of screened participants identified as having high CVD risk (atherosclerotic CVD 10-year risk defined as ≥7.5%) and (3) the proportion of participants identified as having elevated blood glucose (high HbA1c level ≥5.7% (38.8 mmol/mol)) or high self-reported diabetes risk (ADA risk score ≥5 points). Secondary outcome is participants' satisfaction with the screening.

RESULTS

The first UAE pharmacist-delivered screening model was developed and implemented. A total of 115 participants were screened, and 92.3% of the entire screening process was completed during a single visit to pharmacy. The mean duration of the complete screening process was 27 min. At-risk individuals (57.4%) were referred to their physicians for further testing, while 94.5% of participants were at least satisfied with their screening experience.

CONCLUSIONS

The community pharmacist-delivered screening of diabetes and CVD risk is feasible in the UAE. The model offers a platform to increase screening capacity within primary care and provides an opportunity for early detection and treatment. However, pathways for the integration of the pharmacist-delivered screening service with physicians in primary care are yet to be explored.

Cardiovascular disease as a leading cause of death: how are pharmacists getting involved?

Cardiovascular diseases (CVDs) are a leading cause of death globally. This article explores the evidence surrounding community pharmacist interventions to reduce cardiovascular events and related mortality and to improve the management of CVD risk factors. We summarize a range of systematic reviews and leading randomized controlled trials and provide critical appraisal. Major observations are that very few trials directly measure clinical outcomes, potentially owing to a range of challenges in this regard. By contrast, there is an extensive, high-quality evidence to suggest that improvements can be achieved for key CVD risk factors such as hypertension, dyslipidemia, tobacco use, and elevated hemoglobin A1c. The heterogeneity of interventions tested and considerable variation of the context under which implementation occurred suggest that caution is warranted in the interpretation of meta-analyses. It is highly important to generate evidence for pharmacist interventions in developing countries where a majority of the global CVD burden will be experienced in the near future. A growing capacity for clinical registry trials and data linkage might allow future research to collect clinical outcomes data more often.

Cardiovascular Disease Risk Assessment in Australian Community Pharmacy

BACKGROUND

Population screening and monitoring of cardiovascular risk is suboptimal in Australian primary care. The role of community pharmacy has increased considerably, but without any policy framework for development. The aim of this study was to explore the nature of community pharmacy-based screening models in Australia, capacity to increase delivery of pharmacy screening, and barriers and enablers to increasing capacity.

METHODS

An online survey weblink was emailed to pharmacy managers at every quality-accredited pharmacy in Australia by the Quality Pharmacy Care Program. The 122-item survey explored the nature of screening services, pharmacy capacity to deliver services, and barriers and enablers to service delivery in considerable detail. Adaptive questioning was used extensively to reduce the participant burden. Pharmacy location details were requested to facilitate geo-coding and removal of duplicate entries. A descriptive analysis of responses was undertaken.

RESULTS

There were 294 valid responses from 4890 emails, a 6% response rate. Most pharmacies (79%) had private counselling areas. Blood pressure assessment was nearly universal (96%), but other common risk factor assessments were offered by a minority. Most did not charge for assessments, and 59% indicated capacity to provide multiple risk factor assessments. Fewer than one in five (19%) reported any formal arrangements with general practice for care coordination. Financial viability was perceived as a key barrier to service expansion, amid concerns of patient willingness to pay. Support from government and non-governmental organisations for their role was seen as necessary.

CONCLUSION

There appears to be a critical mass of pharmacies engaging in evidence-based and professional services. Considerable additional support appears required to optimise performance across the profession.

Intervention fidelity for a complex behaviour change intervention in community pharmacy addressing cardiovascular disease risk

Delivery of cardiovascular disease (CVD) prevention programs by community pharmacists appears effective and enhances health service access. However, their capacity to implement complex behavioural change processes during patient counselling remains largely unexplored. This study aims to determine intervention fidelity by pharmacists for behavioural components of a complex educational intervention for CVD prevention. After receiving training to improve lifestyle and medicines adherence, pharmacists recruited 70 patients aged 50-74 years without established CVD, and taking antihypertensive or lipid lowering therapy. Patients received five counselling sessions, each at monthly intervals. Researchers assessed biomedical and behavioural risk factors at baseline and six months. Pharmacists documented key outcomes from counselling after each session. Most patients (86%) reported suboptimal cardiovascular diets, 41% reported suboptimal medicines adherence, and 39% were physically inactive. Of those advised to complete the intervention, 85% attended all five sessions. Pharmacists achieved patient agreement with most recommended goals for behaviour change, and overwhelmingly translated goals into practical behavioural strategies. Barriers to changing behaviours were regularly documented, and pharmacists reported most behavioural strategies as having had some success. Meaningful improvements to health behaviours were observed post-intervention. Findings support further exploration of pharmacists' potential roles for delivering interventions with complex behaviour change requirements.

The quality of cardiovascular disease prevention in rural primary care

Objective

Design

Setting

Participants

Main outcome measures

Results

Conclusions

Patient engagement strategies used for hypertension and their influence on self-management attributes

BACKGROUND

Several effective methods to facilitate patient self-management of hypertension are available in primary care. These include direct support from community pharmacists and general practice, and the use of home blood pressure (BP) monitoring. The aim of this study is to establish the prevalence of use of key strategies and to determine their independent relationship with patient self-management attributes.

METHODS

A survey of patients with treated hypertension was undertaken in 27 community pharmacies. This established recent use of BP monitoring and advice from health professionals. Patient awareness of BP and targets, appropriateness of BP targets and adherence to anti-hypertensive medications were assessed as indicative self-management outcomes. Predictors of outcomes were determined using binary logistic regression.

RESULTS

Overall, 215 surveys were returned. Two-thirds of patients were aged >65 years, and 45% had conditions warranting tighter BP control (<130/80 mmHg). Almost all patients reported monitoring of their BP in the previous year and 63% could report their most recent BP reading. Just 36% reported knowing a target BP, and 78% of reported targets were within guidelines recommendations. One-fifth (22%) monitored their own BP, and 15% reported non-adherence to medication. Doctors provided the large majority of professional advice. Self-monitoring or documentation of BP readings was independently associated with increased likelihood of BP and target BP being known.

CONCLUSIONS

Regular monitoring of BP does not automatically translate to professional advice. Increased uptake of patient self-monitoring should be promoted as a means of enabling self-management.

Disparities in equity and access for hospitalised atherothrombotic disease

OBJECTIVE

This study of equity and access characterises admissions for coronary, cerebrovascular and peripheral arterial disease by hospital type (rural, tertiary and non-tertiary metropolitan) in a representative Australian population.

METHODS

We conducted a descriptive analysis using data linkage of all residents aged 35-84 years hospitalised in Western Australia with a primary diagnosis for an atherothrombotic event in 2007. We compared sociodemographic and clinical features by atherothrombotic territory and hospital type.

RESULTS

There were 11670 index admissions for atherothrombotic disease in 2007 of which 46% were in tertiary hospitals, 41% were in non-tertiary metropolitan hospitals and 13% were in rural hospitals. Coronary heart disease comprised 72% of admissions, followed by cerebrovascular disease (19%) and peripheral arterial disease (9%). Comparisons of socioeconomic disadvantage reveal that for those admitted to rural hospitals, more than one-third were in the most disadvantaged quintile, compared with one-fifth to any metropolitan hospital.

CONCLUSIONS

Significant differences in demographic characteristics were evident between Western Australian tertiary and non-tertiary hospitals for patients hospitalised for atherothrombotic disease. Notably, the differences among tertiary, non-tertiary metropolitan and rural hospitals were related to socioeconomic disadvantage. This has implications for atherothrombotic healthcare provision and the generalisation of research findings from studies conducted exclusively in the tertiary metropolitan hospitals.

Does the shortage of diabetes specialists in regional and rural Australia matter? Results from Diabetes MILES--Australia

AIM

To investigate differences in access to services and health outcomes between people living with Type 1 (T1DM) and Type 2 (T2DM) diabetes in rural/regional and metropolitan areas.

METHODS

Diabetes MILES--Australia was a national postal/online survey of persons registered with the National Diabetes Services Scheme. Selected variables, including utilisation of health care services and self-care indicators, were analysed for 3338 respondents with T1DM (41%) or T2DM (59%).

RESULTS

Respondents from rural/regional (n=1574, 48%) and metropolitan areas were represented equally (n=1700, 52%). After adjusting for diabetes duration, demographic and socioeconomic variables, rural/regional respondents with T1DM (RR 0.90, 95% CI 0.83-0.97) and T2DM (RR 0.69, 95% CI 0.59-0.81) were less likely to report consulting an endocrinologist during the past 12 months. Rural/regional respondents with T1DM were more than twice as likely to have accessed a community/practice nurse for diabetes care (RR 2.22, 95% CI 1.25-3.93) while those with T2DM were more likely to have accessed a diabetes educator (RR 1.21, 95% CI 1.07-1.36) or dietician (RR 1.17, 95% CI 1.07-1.36). For the T1DM and T2DM groups were no differences between rural/regional and metropolitan respondents in self-reported hypoglycaemic events during past week and the majority of self-care indicators.

CONCLUSIONS

Despite a lack of access to medical specialists, respondents with T1DM and T2DM living in rural/regional areas did not report worse health or self-care indicators. The results suggest that multidisciplinary primary services in rural areas may be providing additional care for people with diabetes, compensating for poor access to specialists.