Diabetes Medication Assistance Service Stage 1: impact and sustainability of glycaemic and lipids control in patients with Type 2 diabetes

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.

Awareness campaigns of atrial fibrillation as an opportunity for early detection by pharmacists: an international cross-sectional study

Atrial fibrillation (AF) accounts for up to one third of strokes, one of the lead mortality causes worldwide. The European Society of Cardiology guidelines recommend opportunistic screening as a means to increase the odds of early detection and institution of appropriate treatment according to risk factors identified. However, in most countries there are various barriers to effective uptake of screening, including low awareness. The Atrial Fibrillation Association is a patient association engaged with raising awareness of AF. Establishing a partnership with the International Pharmacists for Anticoagulation Care Taskforce, we set as goals to test a model for raising awareness of AF involving pharmacists globally; and to identify barriers and enablers to its implementation. A cross-sectional study was conducted during the Arrhythmia Alliance World Heart Rhythm Week. Pharmacists from 10 countries invited individuals (≥ 40 years; without anticoagulation therapy of AF) to participate in the awareness campaign. Participants agreeing were engaged in the early detection of AF (EDAF) using pulse palpation. Individuals with rhythm discrepancies were referred and prospectively assessed to have information on the proportion of confirmed diagnosis, leading to estimate the detection rate. Interviews with country coordinators explored barriers and enablers to implementation. The study involved 4193 participants in the awareness campaign and 2762 in the EDAF event (mean age 65.3 ± 13.0), of whom 46.2% individuals were asymptomatic, recruited across 120 sites. Most common CHA₂DS₂-VASc risk factor was hypertension. Among 161 patients referred to physician, feedback was obtained for 32 cases, of whom 12 new arrhythmia diagnoses were confirmed (5 for AF, 2 for atrial flutter), all among elders (≥ 65 years). Qualitative evaluation suggested a local champion to enable pharmacists' success; technology enhanced engagement amongst patients and increased pharmacists' confidence in referring to physicians; interprofessional relationship was crucial in success. This study suggests pharmacists can contribute to greater outreach of awareness campaigns. Effective communication pathways for inter-professional collaboration were suggested enablers to gain full benefits of EDAF.

Compared benefits of educational programs dedicated to diabetic patients with or without community pharmacist involvement

Background:

International guidelines on diabetes control strongly encourage the setting-up of therapeutic educational programs (TEP). However, more than half of the patients fail to control their diabetes a few months post-TEP because of a lack of regular follow-up by medical professionals. The DIAB-CH is a TEP associated with the follow-up of diabetic patients by the community pharmacist.

Aim:

To compare the glycated hemoglobin (HbA1c) and body mass index (BMI) in diabetic patients of Control (neither TEP-H nor community pharmacist intervention), TEP-H (TEP in hospital only) and DIAB-CH (TEP-H plus community pharmacist follow-up) groups.

Methods:

A comparative cohort study design was applied. Patients included in the TEP-H from July 2017 to December 2017 were enrolled in the DIAB-CH group. The TEP-H session was conducted by a multidisciplinary team composed of two diabetologists, two dieticians and seven nurses. The HbA1c level and the BMI (when over 30 kg/m2at M0) of patients in Control (n= 20), TEP-H (n= 20) and DIAB-CH (n= 20) groups were collected at M0, M0 + 6 and M0 + 12 months. First, HbA1c and BMI were compared between M0, M6 and M12 in the three groups with the Friedman test, followed by the Benjamini-Hochberg post-test. Secondly, the HbA1c and BMI of the three groups were compared at M0, M6 and M12 using the Kruskal-Wallis test.

Findings:

While no difference in HbA1c was measured between M0, M6 and M12 in the Control group, Hb1Ac was significantly reduced in both TEP-H and DIAB-CH groups between M0 and M6 (P= 0.0072 andP= 0.0034, respectively), and between M0 and M12 only in the DIAB-CH group (P= 0.0027). In addition, a significant decrease in the difference between the measured HbA1c and the target assigned by diabetologists was observed between M0 and M6 in both TEP-H and DIAB-CH groups (P= 0.0072 andP= 0.0044, respectively) but only for the patients of the DIAB-CH group between M0 and M12 (P= 0.0044). No significant difference (P> 0.05) in BMI between the groups was observed.

Conclusion:

The long-lasting benefit on glycemic control of multidisciplinary group sessions associated with community pharmacist-led educational interventions on self-care for diabetic patients was demonstrated in the present study. There is thus evidence pointing to the effectiveness of a community/hospital care collaboration of professionals on diabetes control in primary care.

Community pharmacy interventions for health promotion: effects on professional practice and health outcomes

BACKGROUND

Community pharmacies are an easily accessible and cost-effective platform for delivering health care worldwide, and the range of services provided has undergone rapid expansion in recent years. Thus, in addition to dispensing medication, pharmacy workers within community pharmacies now give advice on a range of health-promoting behaviours that aim to improve health and to optimise the management of long-term conditions. However, it remains uncertain whether these health-promotion interventions can change the professional practice of pharmacy workers, improve health behaviours and outcomes for pharmacy users and have the potential to address health inequalities.

OBJECTIVES

To assess the effectiveness and safety of health-promotion interventions to change community pharmacy workers' professional practice and improve outcomes for users of community pharmacies.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, six other databases and two trials registers to 6 February 2018. We also conducted reference checking, citation searches and contacted study authors to identify any additional studies.

SELECTION CRITERIA

We included randomised trials of health-promotion interventions in community pharmacies targeted at, or delivered by, pharmacy workers that aimed to improve the health-related behaviour of people attending the pharmacy compared to no treatment, or usual treatment received in the community pharmacy. We excluded interventions where there was no interaction between pharmacy workers and pharmacy users, and those that focused on medication use only.

DATA COLLECTION AND ANALYSIS

We used standard procedures recommended by Cochrane and the Effective Practice and Organisation of Care review group for both data collection and analysis. We compared intervention to no intervention or to usual treatment using standardised mean differences (SMD) and 95% confidence intervals (95% CI) (higher scores represent better outcomes for pharmacy user health-related behaviour and quality of life, and lower scores represent better outcomes for clinical outcomes, costs and adverse events). Interpretation of effect sizes (SMD) was in line with Cochrane recommendations.

MAIN RESULTS

We included 57 randomised trials with 16,220 participants, described in 83 reports. Forty-nine studies were conducted in high-income countries, and eight in middle-income countries. We found no studies that had been conducted in low-income countries. Most interventions were educational, or incorporated skills training. Interventions were directed at pharmacy workers (n = 8), pharmacy users (n = 13), or both (n = 36). The clinical areas most frequently studied were diabetes, hypertension, asthma, and modification of cardiovascular risk. Duration of follow-up of interventions was often unclear. Only five studies gave details about the theoretical basis for the intervention, and studies did not provide sufficient data to comment on health inequalities. The most common sources of bias were lack of protection against contamination - mainly in individually randomised studies - and inadequate blinding of participants. The certainty of the evidence for all outcomes was moderate. We downgraded the certainty because of the heterogeneity across studies and evidence of potential publication bias. Professional practice outcomes We conducted a narrative analysis for pharmacy worker behaviour due to high heterogeneity in the results. Health-promotion interventions probably improve pharmacy workers' behaviour (2944 participants; 9 studies; moderate-certainty evidence) when compared to no intervention. These studies typically assessed behaviour using a simulated patient (mystery shopper) methodology. Pharmacy user outcomes Health-promotion interventions probably lead to a slight improvement in health-related behaviours of pharmacy users when compared to usual treatment (SMD 0.43, 95% CI 0.14 to 0.72; I² = 89%; 10 trials; 2138 participants; moderate-certainty evidence). These interventions probably also lead to a slight improvement in intermediate clinical outcomes, such as levels of cholesterol or glycated haemoglobin, for pharmacy users (SMD -0.43, 95% CI -0.65 to -0.21; I² = 90%; 20 trials; 3971 participants; moderate-certainty evidence). We identified no studies that evaluated the impact of health-promotion interventions on event-based clinical outcomes, such as stroke or myocardial infarction, or the psychological well-being of pharmacy users. Health-promotion interventions probably lead to a slight improvement in quality of life for pharmacy users (SMD 0.29, 95% CI 0.08 to 0.50; I²= 82%; 10 trials, 2687 participants; moderate-certainty evidence). Adverse events No studies reported adverse events for either pharmacy workers or pharmacy users. Costs We found that health-promotion interventions are likely to be cost-effective, based on moderate-certainty evidence from five of seven studies that reported an economic evaluation.

AUTHORS' CONCLUSIONS

Health-promotion interventions in the community pharmacy context probably improve pharmacy workers' behaviour and probably have a slight beneficial effect on health-related behaviour, intermediate clinical outcomes, and quality of life for pharmacy users. Such interventions are likely to be cost-effective and the effects are seen across a range of clinical conditions and health-related behaviours. Nevertheless the magnitude of the effects varies between conditions, and more effective interventions might be developed if greater consideration were given to the theoretical basis of the intervention and mechanisms for effecting behaviour change.

The change in pharmacists’ attitude, confidence and job satisfaction following participation in a novel hypertension support service

Objectives

To demonstrate how the confidence, attitude and job satisfaction of pharmacists who provide interventions and lifestyle support services to patients with hypertension are altered.

Methods

This study was a before-and-after study that used data from 50 pharmacists who participated in the Community Pharmacists Assist for Blood Pressure (COMPASS-BP) study, which was an interventional study that was conducted in Japan to evaluate the effects of lifestyle support services provided to hypertension patients. The pharmacists received 4 h of training before the study was initiated to learn how to quickly provide patients with guidance about diet and exercise and tobacco and alcohol consumption. During the interventional period, each pharmacist provided concise lifestyle guidance to 1–3 hypertension patients. The pharmacists met with the patients a total of 5 times. The parameters that were assessed were the pharmacists’ attitudes towards and confidence in their lifestyle support services, as well as their level of job satisfaction. We verified the scores of each parameter assessed before and after the study, as well as changes in the relationships among the different parameters.

Key findings

Significant increases from baseline to the end of the study were observed for Confidence (P &lt; 0.01), Job satisfaction, including ‘Knowledge’ (P &lt; 0.01), ‘Patient counselling management’ (P = 0.04) and ‘Sense of personal growth’ (P &lt; 0.01). Additionally, path analysis results revealed that after the study, the causal relationship between ‘Knowledge’ and ‘Attitude’ disappeared, and a new causal relationship appeared between ‘Patient counselling and management’ and ‘Attitude’.

Conclusions

Providing lifestyle guidance improved pharmacists’ confidence and attitude. Also, ‘Attitude’ tended to improve as the ‘Patient counselling and management’ score increased.

Pharmacist-Led Self-management Interventions to Improve Diabetes Outcomes. A Systematic Literature Review and Meta-Analysis

Background: Treatment of diabetes requires a strict treatment scheme which demands patient self-management. Pharmacists are in a good position to provide self-management support. This review examines whether pharmacist-led interventions to support self-management in diabetes patients improve clinical and patient-reported outcomes. Methods: This review was conducted according to the PRISMA guidelines. An extended literature search was conducted with the keywords "pharmacist," "diabetes," and "self-management" using the electronic databases Pubmed, Embase, CINAHL, PsycINFO, Web of Science, and the Cochrane Library from the beginning of the database through September 2017. In addition reference lists of systematic reviews and included studies were searched. Eligibility criteria included; self-management intervention tested with an RCT, performed in an ambulatory care setting, led by a pharmacist and reporting at least one clinical- or patient-reported outcome. Primary outcomes were HbA1c (-as this is a clinical parameter for long-term diabetes follow-up), self-management and components of intervention. Secondary outcomes were blood glucose, blood pressure, BMI, lipids, adherence to medication, quality of life, and diabetes knowledge. For the meta-analysis HbA1c values were pooled with a random-effects model in Revman 5.3. Risk of bias was assessed with the Cochrane Risk of Bias tool. Results: Twenty-four studies representing 3,610 patients were included. Pharmacist-led self-management interventions included education on diabetes complications, medication, lifestyle, and teaching of self-management skills. Some studies focused on patient needs through a tailored intervention. No key components for a successful self-management intervention could be identified. Pharmacist-led self-management interventions improve HbA1c levels with a mean of 0.71% (CI -0.91, -0.51; overall effect P < 0.0001) and had a positive effect on blood pressure (SBP -5.20 mm Hg [-7.58; -2.92], DBP -3.51 mmHg [-6.00; -1.01]), BMI (-0.49 kg/m2 [-0.79; -0.19]), lipids (total cholesterol -0.19 mmol/l [-0.33; -0.05], LDL-C mmol/l -0.16 [-0.26; -0.06], HDL-C 0.32 mmol/l [0.02; 0.61]), self-management skill development, and adherence to medication. Conclusion: Pharmacist-led self-management interventions significantly improve HbA1c values in diabetes patients. These results underline the added value of pharmacists in patient-related care. Pharmacists should offer self-management support to diabetes patients in order to improve diabetes outcomes.

The operation of a Research and Development (R&D) program and its significance for practice change in community pharmacy

Background

Community pharmacy practice in Australia is changing and Research and Development (R&D) in community pharmacy plays an important role in contributing to the changes. A range of Cognitive Pharmacy Services (CPS) were developed from R&D programs, yet their implementation has been minimal indicating slow practice change within community pharmacy. Given the vital role of R&D, little is known about the operation and the extent to which it has been effective in supporting practice change in community pharmacy.

Methods

In depth, semi-structured interviews were conducted with 27 key stakeholders in the pharmacy and healthcare system in Australia. All interviews were audio-recorded, transcribed ad verbatim and analysed using an inductive approach.

Results

Participants perceived that the R&D program has played an important role in the advent of CPS. Furthermore, they considered that evidence generated by the R&D projects is a critical influence on policy formulation, funding and implementation of CPS into practice. However, policy decisions and subsequent implementation are also influenced by other factors associated with context and facilitation which in turn foster or inhibit effective Knowledge Translation (KT) in the community pharmacy sector.

Conclusion

While R&D programs have been viewed as essential for supporting changes in community pharmacy practice through development and funding of CPS, the overall impact has been small, as contemporary practice continues to be predominantly a dispensing model. Given the complexity and dynamic nature of the community pharmacy system, stakeholders must take into account the inter-relationship between context, evidence and facilitation for successful KT in community pharmacy practice.

Physicians' and patients' valuation of pharmaceutical care implementation in Poznan (Poland) community pharmacies

Implementation of pharmaceutical care (PC) in Poland is of great importance to patients, who, on the one hand, often follow complex pharmacological treatment regimens recommended by several physicians of different specialties, and, on the other, take up the decision on self-treatment due to availability of OTC medications. The aim of the present study was to assess the opinion of both patients and physicians about implementation of PC service in Polish community pharmacies.

A cross sectional study was carried out from September 2009 to September 2010 by a pharmacist (author of the study) on the basis of an anonymous questionnaire, where demand of physicians (n = 104) and patients (n = 202) for implementation of PC in a community pharmacy was assessed. The study was planned to determine the relationship between implementation of PC, cost and time of this service and patients’ and physicians’ socio-economic information.

Responding patients (85.64%) and physicians (76.92%) unanimously confirmed the need for implementation of PC. Most people convinced of the service implementation were 88.89% of physicians under the age of 35 and all the respondents were over 65 years of age (p = 0.027), just as 93.33% with service lesser than 5 years and 73.68% of respondents working a maximum of 20 years (p = 0.023). Mainly according to 90.00% of physicians with specialty in internal medicine and 92.59% of physicians of the group “Others” (p = 0.012), PC should be implemented in pharmacies. Women more frequently than men reckoned that appointments with a pharmacist should last up to 15 min (p = 0.012). According to 77.78% of the youngest physicians and 83.33% of the oldest ones, appointments should last from 5 to 15 min (p = 0.049), and a similar opinion was shared by 80.77% of physicians without specialty and 77.78% of physicians of the group “Others” (p = 0.0009). According to patients, the mean cost of the visit should be USD 7. Physicians most often assessed the mean cost of the appointment at USD 14.

This study provides new data about implementation of PC in Poland. The increased patients’ and physicians’ willingness to benefit from this service provides pharmacists with opportunities to develop PC in community pharmacies.

Effects of a pharmaceutical care model on medication adherence and glycemic control of people with type 2 diabetes

BACKGROUND

Diabetes mellitus is a lifelong chronic condition that requires self-management. Lifestyle modification and adherence to antidiabetes medications are the major determinants of therapeutic success in the management of diabetes.

PURPOSE

To assess the effects of a pharmaceutical care (PC) model on medication adherence and glycemic levels of people with type 2 diabetes mellitus.

PATIENTS AND METHODS

A total of 241 people with type 2 diabetes were recruited from a major teaching hospital in Malaysia and allocated at random to the control (n=121) or intervention (n=120) groups. Participants in the intervention group received PC from an experienced pharmacist, whereas those in the control group were provided the standard pharmacy service. Medication adherence was assessed using the Malaysian Medication Adherence Scale, and glycemic levels (glycated hemoglobin values and fasting blood glucose [FBG]) of participants were obtained at baseline and after 4, 8, and 12 months.

RESULTS

At baseline, there were no significant differences in demographic data, medication adherence, and glycemic levels between participants in the control and intervention groups. However, statistically significant differences in FBG and glycated hemoglobin values were observed between the control and intervention groups at months 4, 8, and 12 after the provision of PC (median FBG, 9.0 versus 7.2 mmol/L [P<0.001]; median glycated hemoglobin level, 9.1% versus 8.0% [P<0.001] at 12 months). Medication adherence was also significantly associated with the provision of PC, with a higher proportion in the intervention group than in the control group achieving it (75.0% versus 58.7%; P=0.007).

CONCLUSION

The provision of PC has positive effects on medication adherence as well as the glycemic control of people with type 2 diabetes. Therefore, the PC model used in this study should be duplicated in other health care settings for the benefit of more patients with type 2 diabetes.

Experiences of community pharmacists involved in the delivery of a specialist asthma service in Australia

Background

The role of community pharmacists in disease state management has been mooted for some years. Despite a number of trials of disease state management services, there is scant literature into the engagement of, and with, pharmacists in such trials. This paper reports pharmacists’ feedback as providers of a Pharmacy Asthma Management Service (PAMS), a trial coordinated across four academic research centres in Australia in 2009. We also propose recommendations for optimal involvement of pharmacists in academic research.

Methods

Feedback about the pharmacists’ experiences was sought via their participation in either a focus group or telephone interview (for those unable to attend their scheduled focus group) at one of three time points. A semi-structured interview guide focused discussion on the pharmacists’ training to provide the asthma service, their interactions with health professionals and patients as per the service protocol, and the future for this type of service. Focus groups were facilitated by two researchers, and the individual interviews were shared between three researchers, with data transcribed verbatim and analysed manually.

Results

Of 93 pharmacists who provided the PAMS, 25 were involved in a focus group and seven via telephone interview. All pharmacists approached agreed to provide feedback. In general, the pharmacists engaged with both the service and research components, and embraced their roles as innovators in the trial of a new service. Some experienced challenges in the recruitment of patients into the service and the amount of research-related documentation, and collaborative patient-centred relationships with GPs require further attention. Specific service components, such as the spirometry, were well received by the pharmacists and their patients. Professional rewards included satisfaction from their enhanced practice, and pharmacists largely envisaged a future for the service.

Conclusions

The PAMS provided pharmacists an opportunity to become involved in an innovative service delivery model, supported by the researchers, yet trained and empowered to implement the clinical service throughout the trial period and beyond. The balance between support and independence appeared crucial in the pharmacists’ engagement with the trial. Their feedback was overwhelmingly positive, while useful suggestions were identified for future academic trials.

Screening Education And Recognition in Community pHarmacies of Atrial Fibrillation to prevent stroke in an ambulant population aged >=65 years (SEARCH-AF stroke prevention study): a cross-sectional study protocol

BACKGROUND

Atrial fibrillation (AF) is associated with a high risk of stroke and may often be asymptomatic. AF is commonly undiagnosed until patients present with sequelae, such as heart failure and stroke. Stroke secondary to AF is highly preventable with the use of appropriate thromboprophylaxis. Therefore, early identification and appropriate evidence-based management of AF could lead to subsequent stroke prevention. This study aims to determine the feasibility and impact of a community pharmacy-based screening programme focused on identifying undiagnosed AF in people aged 65 years and older.

METHODS AND ANALYSIS

This cross-sectional study of community-based screening to identify undiagnosed AF will evaluate the feasibility of screening for AF using a pulse palpation and handheld single-lead electrocardiograph (ECG) device. 10 community pharmacies will be recruited and trained to implement the screening protocol, targeting a total of 1000 participants. The primary outcome is the proportion of people newly identified with AF at the completion of the screening programme. Secondary outcomes include level of agreement between the pharmacist's and the cardiologist's interpretation of the single-lead ECG; level of agreement between irregular rhythm identified with pulse palpation and with the single-lead ECG. Process outcomes related to sustainability of the screening programme beyond the trial setting, pharmacist knowledge of AF and rate of uptake of referral to full ECG evaluation and cardiology review will also be collected.

ETHICS AND DISSEMINATION

Primary ethics approval was received on 26 March 2012 from Sydney Local Health District Human Research Ethics Committee-Concord Repatriation General Hospital zone. Results will be disseminated via forums including, but not limited to, peer-reviewed publication and presentation at national and international conferences.

CLINICAL TRIALS REGISTRATION NUMBER

ACTRN12612000406808.