Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP): a randomized trial design of the effect of a community pharmacist intervention program on serum cholesterol risk

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.

A Systematic Review of Evidence-Based Community Pharmacy Services Aimed at the Prevention of Cardiovascular Disease

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death worldwide and has a substantial impact on people's health and quality of life. CVD also causes an increased use of health care resources and services, representing a significant proportion of health care expenditure. Integrating evidence-based community pharmacy services is seen as an asset to reduce the burden of CVD on individuals and the health care system.

OBJECTIVES

To (a) identify community pharmacy evidence-based services designed to help prevent CVD and (b) provide fundamental information that is needed to assess their potential adaptation to other community pharmacy settings.

METHODS

This review used the DEPICT database, which includes 488 randomized controlled trials (RCT) that address the evaluation of pharmacy services. Articles reviewing these RCTs were identified for the DEPICT database through a systematic search of the following databases: MEDLINE, Scopus, SciELO (Scientific Electronic Library Online), and DOAJ (Directory of Open Access Journals). The DEPICT database was reviewed to identify evidence-based services delivered in the community pharmacy setting with the purpose of preventing CVD. An evidence-based service was defined as a service that has been shown to have a positive effect (compared with usual care) in a high-quality RCT. From each evidence-based service, fundamental information was retrieved to facilitate adaptation to other community pharmacy settings.

RESULTS

From the DEPICT database, 14 evidence-based community pharmacy services that addressed the prevention of CVD were identified. All services, except 1, targeted populations with a mean age above 60 years. Pharmacy services encompassed a wide range of practical applications or techniques that can be classified into 3 groups: activities directed at patients, activities directed at health care professionals, and assessments to gather patient-related information in order to support the previous activities.

CONCLUSIONS

This review provides pharmacy service planners and policymakers with a comprehensive list of evidence-based services that have the potential to be adapted to different settings from which they were originally implemented and evaluated in order to reduce the burden of CVD.

DISCLOSURES

Funding for this review was provided by the University of Technology Sydney Chancellor's Postdoctoral Fellowship awarded to Sabater-Hernández. No other potential conflict of interest was declared. Study concept and design were contributed by Sabater-Hernández, Fernandez-Llimos, Rotta, and Correr. Sabater-Galindo and Sabater-Hernández took the lead in data collection, along with Franco-Trigo and Rotta. Data interpretation was performed by Sabater-Hernández, Durks, and Lopes. The manuscript was written primarily by Sabater-Hernández, along with Hossain, and revised by Fernandez-Llimos, Rotta, and Benrimoj, with assistance from Durks, Sabater-Galindo, Franco-Trigo, and Correr.

A community pharmacy-based cardiovascular risk screening service implemented in Iran

BACKGROUND

Cardiovascular disease is a major health concern around the world.

OBJECTIVE

To assess the outcomes and feasibility of a pharmacy-based cardiovascular screening in an urban referral community pharmacy in Iran.

METHODS

A cross sectional study was conducted in a referral community pharmacy. Subjects aged between 30-75 years without previous diagnose of cardiovascular disease or diabetes were screened. Measurement of all major cardiovascular risk factors, exercise habits, medical conditions, medications, and family history were investigated. Framingham risk score was calculated and high risk individuals were given a clinical summary sheet signed by a clinical pharmacist and were encouraged to follow up with their physician. Subjects were contacted one month after the recruitment period and their adherence to the follow up recommendation was recorded.

RESULTS

Data from 287 participants were analyzed and 146 were referred due to at least one abnormal laboratory test. The results showed 26 patients with cardiovascular disease risk greater than 20%, 32 high systolic blood pressure, 22 high diastolic blood pressures, 50 high total cholesterol levels, 108 low HDL-C levels, and 22 abnormal blood glucose levels. Approximately half of the individuals who received a follow up recommendation had made an appointment with their physician. Overall, 15.9% of the individuals received medications and 15.9% received appropriate advice for risk factor modification. Moreover, 7.5% were under evaluation by a physician.

CONCLUSION

A screening program in a community pharmacy has the potential to identify patients with elevated cardiovascular risk factor. A plan for increased patient adherence to follow up recommendations is required.

Interventions to improve adherence to lipid-lowering medication

BACKGROUND

Lipid-lowering drugs are widely underused, despite strong evidence indicating they improve cardiovascular end points. Poor patient adherence to a medication regimen can affect the success of lipid-lowering treatment.

OBJECTIVES

To assess the effects of interventions aimed at improving adherence to lipid-lowering drugs, focusing on measures of adherence and clinical outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO and CINAHL up to 3 February 2016, and clinical trials registers (ANZCTR and ClinicalTrials.gov) up to 27 July 2016. We applied no language restrictions.

SELECTION CRITERIA

We evaluated randomised controlled trials of adherence-enhancing interventions for lipid-lowering medication in adults in an ambulatory setting with a variety of measurable outcomes, such as adherence to treatment and changes to serum lipid levels. Two teams of review authors independently selected the studies.

DATA COLLECTION AND ANALYSIS

Three review authors extracted and assessed data, following criteria outlined by the Cochrane Handbook for Systematic Reviews of Interventions. We assessed the quality of the evidence using GRADEPro.

MAIN RESULTS

For this updated review, we added 24 new studies meeting the eligibility criteria to the 11 studies from prior updates. We have therefore included 35 studies, randomising 925,171 participants. Seven studies including 11,204 individuals compared adherence rates of those in an intensification of a patient care intervention (e.g. electronic reminders, pharmacist-led interventions, healthcare professional education of patients) versus usual care over the short term (six months or less), and were pooled in a meta-analysis. Participants in the intervention group had better adherence than those receiving usual care (odds ratio (OR) 1.93, 95% confidence interval (CI) 1.29 to 2.88; 7 studies; 11,204 participants; moderate-quality evidence). A separate analysis also showed improvements in long-term adherence rates (more than six months) using intensification of care (OR 2.87, 95% CI 1.91 to 4.29; 3 studies; 663 participants; high-quality evidence). Analyses of the effect on total cholesterol and LDL-cholesterol levels also showed a positive effect of intensified interventions over both short- and long-term follow-up. Over the short term, total cholesterol decreased by a mean of 17.15 mg/dL (95% CI 1.17 to 33.14; 4 studies; 430 participants; low-quality evidence) and LDL-cholesterol decreased by a mean of 19.51 mg/dL (95% CI 8.51 to 30.51; 3 studies; 333 participants; moderate-quality evidence). Over the long term (more than six months) total cholesterol decreased by a mean of 17.57 mg/dL (95% CI 14.95 to 20.19; 2 studies; 127 participants; high-quality evidence). Included studies did not report usable data for health outcome indications, adverse effects or costs/resource use, so we could not pool these outcomes. We assessed each included study for bias using methods described in the Cochrane Handbook for Systematic Reviews of Interventions. In general, the risk of bias assessment revealed a low risk of selection bias, attrition bias, and reporting bias. There was unclear risk of bias relating to blinding for most studies.

AUTHORS' CONCLUSIONS

The evidence in our review demonstrates that intensification of patient care interventions improves short- and long-term medication adherence, as well as total cholesterol and LDL-cholesterol levels. Healthcare systems which can implement team-based intensification of patient care interventions may be successful in improving patient adherence rates to lipid-lowering medicines.

Physician Perceptions of Enhanced Community Pharmacist Care in Cholesterol Management

Objectives:

The Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP) was a randomized controlled trial that demonstrated that community pharmacist intervention improved cholesterol management for patients at high risk for cardiovascular disease. The objective of this sub-study was to describe physician perceptions of the intervention program.

Design:

Surveys were mailed to all physicians contacted as part of the enhanced pharmacist care program within SCRIP. Physician opinions were collected on pharmacist participation in cholesterol management and the impact of the program on patient management and outcomes.

Results:

We received 141 usable surveys from 239 eligible physicians, a response rate of 59%. Of those who responded, 110 (78%) remembered components of the enhanced pharmacist care program, and 77 (55%) were in favour of the pharmacist's recommendations. Of the 110 physicians who recalled the intervention, 27 (25%) agreed that the program improved cholesterol management, and 11 (10%) felt the program had a major effect on patient outcomes; however, only 41 (37%) felt the program was helpful or useful. Written comments reflected opinions that the program duplicates current services and that physicians have reservations about the expanding role of pharmacists. Despite these general comments, similar interventions for other medical conditions were welcomed.

Conclusions:

Physicians had mixed attitudes toward the enhanced pharmacist care program. Despite these opinions, the main results of SCRIP were very positive. Indeed, if the physician opinions of the program had been more positive, the impact might have been even greater. The effectiveness of future programs may be enhanced through improved communication of the program's goals and collaboration of all stakeholders early in the program's implementation.

Pharmacy students screening for pre-diabetes/diabetes with a validated questionnaire in community pharmacies during their experiential rotation in Alberta, Canada

Purpose:

Type 2 diabetes is a major condition impacting morbidity, mortality, and health care costs in Canada. Pharmacists are very accessible and are in an ideal position to promote public health education. The primary goal of this study was to incorporate public health promotion and education into a community pharmacy experiential education rotation for fourth year pharmacy students to screen for the risk of pre-diabetes/diabetes in adults. A secondary goal was to determine the frequency of common risk factors for pre-diabetes/diabetes in adults in the community setting.

Method:

Fourth year pharmacy students were invited to recruit all adults 25 years or older attending community pharmacies to complete a pre-diabetes/diabetes risk assessment questionnaire. If the participants were at risk, the participants were provided education about risk reduction for developing pre-diabetes/diabetes.

Results:

A total of 340 participants completed a risk assessment questionnaire. Over 90% of people approached agreed to complete a risk assessment questionnaire. The common risk factors were overweight (154/45%), hypertension (102/30%), taking medications for hypertension (102/30%), and having symptoms of diabetes (111/33%). The ethnic minorities have 2.56 (confidence interval = 1.48–44.1) times greater odds of having a family history of diabetes compared to non-minority subjects.

Conclusion:

Pharmacy students are able to screen community-based patients for pre-diabetes/diabetes risks. The most common risk factors presented were overweight, hypertension, and taking medications for hypertension.

Pharmacist interventions for obesity: improving treatment adherence and patient outcomes

Obesity is currently a worldwide pandemic, with overweight (body mass index [BMI] ≥25 kg/m2) and obesity (BMI ≥30 kg/m2) estimated at 35% and 12% of the global adult population, respectively. According to data collected from the United States National Health and Nutrition Examination Survey, approximately 68.8% of US adults are overweight or obese. Additionally, a large burden of health care costs can be attributed directly to obesity as well as multiple, potentially preventable, comorbidities such as cancer, cardiovascular disease, and diabetes. As a result, national and international organizations, such as the US Centers for Disease Control and World Health Organization, have made halting the rise of the obesity epidemic a top priority. Pharmacists, commonly considered one of the most trustworthy and accessible health care professionals, are ideally situated to provide counseling for weight and lifestyle management. This review presents examples of pharmacist-led as well as collaborative practices that have been somewhat successful in educating and monitoring patient progress in attaining weight-loss goals. Common barriers and potential solutions to administration of lifestyle counseling and monitoring programs, such as limited pharmacist time and resources, lack of expertise and/or confidence in program administration, and patient perception and awareness, are also discussed.

Community health awareness of diabetes (CHAD): description of a community-wide diabetes awareness demonstration program and its feasibility

OBJECTIVE

This article describes the Community Health Awareness Diabetes (CHAD) program and its feasibility. Developing and testing the feasibility of strategies to detect diabetes in the community is an important primary care issue. The CHAD program was designed to be a feasible and reproducible, low-cost community program to identify high-risk individuals for subsequent diabetes screening by their family doctors.

METHODS

Participants from Grimsby, Ontario, older than age 40, were invited to self-risk-assess for diabetes using a validated questionnaire and 2 near-patient blood tests (capillary blood glucose and glycosylated hemoglobin). Some participants were self-selected, having seen advertising for the program, others were invited by a letter from their family doctor. None of the participants had pre-existing diabetes. Numbers and characteristics of participants, numbers found at risk and satisfaction of participants were examined.

RESULTS

There were 588 participants in CHAD. Of these, the majority had received invitation letters, the majority of participants were seniors and were females, 526 did not have pre-existing diabetes and 16% of participants (n=84 of 526) were identified as being at high risk for diabetes. Participants at high risk of diabetes had significantly more modifiable risk factors, including higher fat, fast food and salt intake, and higher systolic blood pressure. Satisfaction with the program was high.

CONCLUSIONS

The CHAD program was feasible and participants were satisfied with it. Participants had a large number of modifiable risk factors. This program could be repeated in other communities and modified to suit the infrastructure of the area.

Multiple risk factor interventions for primary prevention of coronary heart disease

BACKGROUND

Multiple risk factor interventions using counselling and educational methods assumed to be efficacious and cost-effective in reducing coronary heart disease (CHD) mortality and morbidity and that they should be expanded. Trials examining risk factor changes have cast doubt on the effectiveness of these interventions.

OBJECTIVES

To assess the effects of multiple risk factor interventions for reducing total mortality, fatal and non-fatal events from CHD and cardiovascular risk factors among adults assumed to be without prior clinical evidence CHD..

SEARCH STRATEGY

We updated the original search BY SEARCHING CENTRAL (2006, Issue 2), MEDLINE (2000 to June 2006) and EMBASE (1998 to June 2006), and checking bibliographies.

SELECTION CRITERIA

Randomised controlled trials of more than six months duration using counselling or education to modify more than one cardiovascular risk factor in adults from general populations, occupational groups or specific risk factors (i.e. diabetes, hypertension, hyperlipidaemia, obesity).

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently. We expressed categorical variables as odds ratios (OR) with 95% confidence intervals (CI). Where studies published subsequent follow-up data on mortality and event rates, we updated these data.

MAIN RESULTS

We found 55 trials (163,471 participants) with a median duration of 12 month follow up. Fourteen trials (139,256 participants) with reported clinical event endpoints, the pooled ORs for total and CHD mortality were 1.00 (95% CI 0.96 to 1.05) and 0.99 (95% CI 0.92 to 1.07), respectively. Total mortality and combined fatal and non-fatal cardiovascular events showed benefits from intervention when confined to trials involving people with hypertension (16 trials) and diabetes (5 trials): OR 0.78 (95% CI 0.68 to 0.89) and OR 0.71 (95% CI 0.61 to 0.83), respectively. Net changes (weighted mean differences) in systolic and diastolic blood pressure (53 trials) and blood cholesterol (50 trials) were -2.71 mmHg (95% CI -3.49 to -1.93), -2.13 mmHg (95% CI -2.67 to -1.58 ) and -0.24 mmol/l (95% CI -0.32 to -0.16), respectively. The OR for reduction in smoking prevalence (20 trials) was 0.87 (95% CI 0.75 to 1.00). Marked heterogeneity (I(2) > 85%) for all risk factor analyses was not explained by co-morbidities, allocation concealment, use of antihypertensive or cholesterol-lowering drugs, or by age of trial.

AUTHORS' CONCLUSIONS

Interventions using counselling and education aimed at behaviour change do not reduce total or CHD mortality or clinical events in general populations but may be effective in reducing mortality in high-risk hypertensive and diabetic populations. Risk factor declines were modest but owing to marked unexplained heterogeneity between trials, the pooled estimates are of dubious validity. Evidence suggests that health promotion interventions have limited use in general populations.

Engaging community pharmacists in the primary prevention of cardiovascular disease: protocol for the Pharmacist Assessment of Adherence, Risk and Treatment in Cardiovascular Disease (PAART CVD) pilot study

Background

Cardiovascular disease (CVD) is the leading cause of death globally. Community pharmacist intervention studies have demonstrated clinical effectiveness for improving several leading individual CVD risk factors. Primary prevention strategies increasingly emphasise the need for consideration of overall cardiovascular risk and concurrent management of multiple risk factors. It is therefore important to demonstrate the feasibility of multiple risk factor management by community pharmacists to ensure continued currency of their role.

Methods/Design

This study will be a longitudinal pre- and post-test pilot study with a single cohort of up to 100 patients in ten pharmacies. Patients aged 50-74 years with no history of heart disease or diabetes, and taking antihypertensive or lipid-lowering medicines, will be approached for participation. Assessment of cardiovascular risk, medicines use and health behaviours will be undertaken by a research assistant at baseline and following the intervention (6 months). Validated interview scales will be used where available. Baseline data will be used by accredited medicines management pharmacists to generate a report for the treating community pharmacist. This report will highlight individual patients' overall CVD risk and individual risk factors, as well as identifying modifiable health behaviours for risk improvement and suggesting treatment and behavioural goals. The treating community pharmacist will use this information to finalise and implement a treatment plan in conjunction with the patient and their doctor. Community pharmacists will facilitate patient improvements in lifestyle, medicines adherence, and medicines management over the course of five counselling sessions with monthly intervals. The primary outcome will be the change to average overall cardiovascular risk, assessed using the Framingham risk equation.

Discussion

This study will assess the feasibility of implementing holistic primary CVD prevention programs into community pharmacy, one of the most accessible health services in most developed countries.

Trial registration

Australia and New Zealand Clinical Trial Registry Number: ACTRN12609000677202

A community pharmacist delivered adherence support service for dyslipidaemia

BACKGROUND

Dyslipidaemia is a major risk factor for coronary heart disease. A key issue in management is adherence to therapy. Pharmacists are ideally situated to provide a service to increase medication adherence and optimize health outcomes. This study aimed to evaluate the impact of a community pharmacist-delivered adherence support service on patients' adherence and total cholesterol levels.

METHODS

A repeated measures [baseline (t = 1), post-intervention at 3-monthly intervals (t = 2,3,4)], randomized-controlled study in community pharmacies, with patients on chronic lipid-lowering therapy was conducted. Measures used were Brief Medication Questionnaire, Medication Adherence Report Scale, total cholesterol and pharmacist intervention data sheets. A baseline t-test of cholesterol levels between groups was conducted followed by a repeated-measures analysis of variance.

RESULTS

Seventeen pharmacists recruited 142 patients (97 completions: 49 control, 48 intervention). Most patients missed either the third or last visit, thus data at t = 3 and 4 were combined. Although the intervention group started with a higher cholesterol level (5.1 vs. 4.8 mmol/l), a difference was observed in the drop in cholesterol levels of the intervention group between t = 2 and 3 (F(1,95) = 8.85, P < 0.01), and between the two groups over the study period (F(2,190) = 4.89, P < 0.05). No changes in medicine adherence scores were observed though there was an improvement in participants' exercise and eating habits.

CONCLUSIONS

Patients significantly lowered their cholesterol levels probably as a result of the service delivered by their pharmacists within the short study time frame of ~9 months.

Effect of outpatient pharmacists' non-dispensing roles on patient outcomes and prescribing patterns

BACKGROUND

The roles of pharmacists in patient care have expanded from the traditional tasks of dispensing medications and providing basic medication counseling to working with other health professionals and the public. Multiple reviews have evaluated the impact of pharmacist-provided patient care on health-related outcomes. Prior reviews have primarily focused on in-patient settings. This systematic review focuses on services provided by outpatient pharmacists in community or ambulatory care settings. This is an update of the Cochrane review published in 2000.

OBJECTIVES

To examine the effect of outpatient pharmacists' non-dispensing roles on patient and health professional outcomes.

SEARCH STRATEGY

This review has been split into two phases. For Phase I, we searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (January 1966 through March 2007). For Phase II, we searched MEDLINE/EMBASE (January 1966 through March 2008). The Phase I results are reported in this review; Phase II will be summarized in the next update.

SELECTION CRITERIA

Randomized controlled trials comparing 1. Pharmacist services targeted at patients versus services delivered by other health professionals; 2. Pharmacist services targeted at patients versus the delivery of no comparable service; 3. Pharmacist services targeted at health professionals versus services delivered by other health professionals; 4. Pharmacist services targeted at health professionals versus the delivery of no comparable service.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed studies for inclusion, extracted data, and assessed risk of bias of included studies.

MAIN RESULTS

Forty-three studies were included; 36 studies were pharmacist interventions targeting patients and seven studies were pharmacist interventions targeting health professionals. For comparison 1, the only included study showed a significant improvement in systolic blood pressure for patients receiving medication management from a pharmacist compared to usual care from a physician. For comparison 2, in the five studies evaluating process of care outcomes, pharmacist services reduced the incidence of therapeutic duplication and decreased the total number of medications prescribed. Twenty-nine of 36 studies reported clinical and humanistic outcomes. Pharmacist interventions resulted in improvement in most clinical outcomes, although these improvements were not always statistically significant. Eight studies reported patient quality of life outcomes; three studies showed improvement in at least three subdomains. For comparison 3, no studies were identified meeting the inclusion criteria. For comparison 4, two of seven studies demonstrated a clear statistically significant improvement in prescribing patterns.

AUTHORS' CONCLUSIONS

Only one included study compared pharmacist services with other health professional services, hence we are unable to draw conclusions regarding comparisons 1 and 3. Most included studies supported the role of pharmacists in medication/therapeutic management, patient counseling, and providing health professional education with the goal of improving patient process of care and clinical outcomes, and of educational outreach visits on physician prescribing patterns. There was great heterogeneity in the types of outcomes measured across all studies. Therefore a standardized approach to measure and report clinical, humanistic, and process outcomes for future randomized controlled studies evaluating the impact of outpatient pharmacists is needed. Heterogeneity in study comparison groups, outcomes, and measures makes it challenging to make generalised statements regarding the impact of pharmacists in specific settings, disease states, and patient populations.

Interventions to improve adherence to lipid lowering medication

BACKGROUND

Lipid lowering drugs are still widely underused, despite compelling evidence about their effectiveness in the treatment and prevention of cardiovascular disease. Poor patient adherence to a medication regimen is a major factor in the lack of success in treating hyperlipidaemia. In this updated review we focus on interventions which encourage patients at risk of heart disease or stroke to take lipid lowering medication regularly.

OBJECTIVES

To assess the effects of interventions aimed at improved adherence to lipid lowering drugs, focusing on measures of adherence and clinical outcomes.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE, EMBASE, PsycINFO and CINAHL (March 2008). No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials of adherence-enhancing interventions for lipid lowering medication in adults for both primary and secondary prevention of cardiovascular disease in an ambulatory setting looking at adherence, serum lipid levels, adverse effects and health outcomes. Studies were selected independently by two review authors.

DATA COLLECTION AND ANALYSIS

Data were extracted and assessed by two review authors following criteria outlined by the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Three additional studies were found in the update and, in total, 11 studies were included in this review. The studies included interventions that caused a change in adherence ranging from -3% to 25% (decrease in adherence by 3% to increase in adherence by 25%). Patient re-enforcement and reminding was the most promising category of interventions, investigated in six trials of which four showed improved adherent behaviour of statistical significance (absolute increase: 24%, 9%, 8% and 6%). Other interventions associated with increased adherence were simplification of the drug regimen (absolute increase 11%) and patient information and education (absolute increase 13%). The methodological and analytical quality of some studies was low and results have to be considered with caution.

AUTHORS' CONCLUSIONS

At this stage, reminding patients seems the most promising intervention to increase adherence to lipid lowering drugs. The lack of a gold standard method of measuring adherence is one major barrier in adherence research. More reliable data might be achieved by newer methods of measurement, more consistency in adherence assessment and longer duration of follow up. More recent studies have started using more reliable methods for data collection but follow-up periods remain too short. Increased patient-centredness with emphasis on the patient's perspective and shared decision-making might lead to more conclusive answers when searching for tools to encourage patients to take lipid lowering medication.

Health promotion perceptions among community pharmacists in Nigeria

Objective

To explore the attitudes of Nigerian community pharmacists towards health promotion, to determine the importance pharmacists attach to health promotion behaviours and their perceived involvement in promoting them among their clients.

Methods

We conducted a cross-sectional survey of community pharmacists in two Nigerian cities. Attitudes toward health promotion were assessed using a 24-item instrument. The importance pharmacists attach to healthy behaviours as well as their perceived involvement was assessed using a 23-item standard instrument. Interval data on questionnaire items were gathered on a Likert-type scale, and the demographic characteristics of the respondents were also profiled. Principal factor analysis employed Varimax rotation with Kaiser normalisation. Associations between demographic profile and responses were evaluated using Student's t test and one-way ANOVA.

Results

About 84% of the respondents indicated a favourable attitude towards health promotion. Nearly all the respondents (98%) were interested in health promotion services, and 94% indicated willingness to devote extra time to talk to patients. A majority (93%) reported willingness to retrain on health promotion. Lack of health promotion policy for pharmacists, and negative attitude towards the utilisation of pharmacy technicians were potential barriers. Pharmacists that were studied attached very high importance to 12 of the 23 widely advocated health promotion behaviours, and felt they should be very involved in seven of them. Medication-related counselling, use of condoms, and maintenance of blood pressure were perceived to be top priorities. Rating attitudinal scores, importance of healthy behaviours, and level of involvement were 94.07 ± 20.77, 99.22 ± 21.78, and 93.33 ± 24.01 respectively (range 23 to 115; midpoint 69). Perceived involvement had moderate correlation with the importance attached, r = 0.6488 (P = 0.0008).

Conclusion

There is an indication that the Nigerian community pharmacists in this survey perceived an extended role in health promotion, especially medication-related activities. This is consistent with the philosophy of primary healthcare and pharmaceutical care.

Evaluation of a decision aid and a personal risk profile in community pharmacy for patients considering options to improve cardiovascular health: the OPTIONS pilot study

Objective

In a pilot study, to assess the feasibility and relevance of providing a community pharmacist consultation supplemented by a decision aid (DA) or a personal risk profile (PRP) to patients on lipid-lowering or antihypertensive pharmacotherapy. Preliminary data on the clinical effectiveness of these interventions were collected.

Method

Patients were randomised to DA or PRP and evaluated before, two weeks after, and three months after a pharmacist consultation. No differences were observed between DA and PRP groups; results are reported for all patients combined. The quality of the patients' decision to initiate or maintain lifestyle change and/or pharmacological treatment was evaluated at baseline and two weeks after the consultation by measuring their knowledge, risk perception, decisional conflict and satisfaction with the decision process. The stage of change for various lifestyles and changes in cardiovascular disease (CVD)-risk factors were evaluated at baseline and at three months. Setting Ten community pharmacies.

Key findings

Twenty-six of 42 patients (62%) agreed to participate. Patients reported as excellent or very good the way the information was presented (79%), the amount of information (88%), and the usefulness of the tools (100%). The quality of the patients' decision at baseline was low; one-third of participants correctly estimated their CVD risks and laboratory results, and 54% had high decisional conflict. After the intervention, the satisfaction scores for role in decision making, amount of information provided and pharmacist's attitude were 69%, 81% and 85% respectively, and the proportion of participants with high decisional conflict declined to 25% (P = 0.02). CVD knowledge and risk perception did not change after the intervention. Improvements in low-density lipoprotein cholesterol (LDL)-C, total-C/high-density lipoprotein (HDL)-C ratio, body mass index, and estimated 10-year CVD risk were observed.

Conclusion

Providing pharmacist consultation supplemented by a DA or a PRP in community pharmacies is feasible and relevant. However, it did not improve CVD knowledge or risk perception.

Effect of an educational program (PEGASE) on cardiovascular risk in hypercholesterolaemic patients

BACKGROUND

Many studies have demonstrated a gap between guidelines for the prevention of cardiovascular disease (CVD) and their implementation in clinical practice.

AIM

The PEGASE education program has been devised with an aim to improve the management of patients at high risk of CVD.

METHODS

In a multicentre study carried out from 2001-2004 in France, 96 participating physicians were randomized into a "trained" group, which included 398 "educated" patients, and a "non-trained" group, which included 242 "non-educated" patients. Educated patients received six hospital-based educational sessions, four collective and two individual. Framingham score, smoking, lipid levels, glycaemia, blood pressure, dietary intake and drug compliance, as well as quality of life, were evaluated at baseline (M0) and 6 months (M6). The primary endpoint of the study was the efficacy of the PEGASE program in reducing global CVD risk in high-risk patients.

RESULTS

The Framingham score was calculated for 473 patients. The Framingham score improved significantly at M6 vs M0 in the educated group (13.0 +/- 8.21 vs 13.6 +/- 8.48, d = -0.658, p = 0.016), but not in the non-educated group (12.5 +/- 8.19 vs 12.4 +/- 7.81, d = +0.064, p = 0.836); the mean change between the two groups did not reach significance. Quality of life, LDL-c level and diet scores improved in the "educated" group only.

CONCLUSIONS

The PEGASE education program improved risk factors for CVD, although global assessment by Framingham score was not significantly different between groups. This program, aimed at meeting needs and expectations of patients and physicians, was easily implemented in all hospital centres.

Multiple risk factor interventions for primary prevention of coronary heart disease

BACKGROUND

Primary prevention programmes in many countries attempt to reduce mortality and morbidity due to coronary heart disease (CHD) through risk factor modification. It is widely believed that multiple risk factor intervention using counselling and educational methods is efficacious and cost-effective and should be expanded. Recent trials examining risk factor changes have cast considerable doubt on the effectiveness of these multiple risk factor interventions.

OBJECTIVES

To assess the effects of multiple risk factor intervention for reducing cardiovascular risk factors, total mortality, and mortality from CHD among adults without clinical evidence of established cardiovascular disease.

SEARCH STRATEGY

MEDLINE was searched for the original review to 1995. This was updated by searching the Cochrane Central Register of Controlled Trials on The Cochrane Library Issue 3 2001, MEDLINE (2000 to September 2001) and EMBASE (1998 to September 2001).

SELECTION CRITERIA

Intervention studies using counselling or education to modify more than one cardiovascular risk factor in adults from general populations, occupational groups, or high risk groups. Trials of less than 6 months duration were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted by two reviewers independently. Investigators were contacted to obtain missing information.

MAIN RESULTS

A total of 39 trials were found of which ten reported clinical event data. In the ten trials with clinical event end-points, the pooled odds ratios for total and CHD mortality were 0.96 (95% confidence intervals (CI) 0.92 to 1.01) and 0.96 (95% CI 0.89 to 1.04) respectively. Net changes in systolic and diastolic blood pressure, and blood cholesterol were (weighted mean differences) -3.6 mmHg (95% CI -3.9 to -3.3 mmHg), -2.8 mmHg (95% CI -2.9 to -2.6 mmHg) and -0.07 mMol/l (95% CI -0.8 to -0.06 mMol/l) respectively. Odds of reduction in smoking prevalence was 20% (95% CI 8% to 31%). Statistical heterogeneity between the studies with respect to mortality and risk factor changes was due to trials focusing on hypertensive participants and those using considerable amounts of drug treatment.

AUTHORS' CONCLUSIONS

The pooled effects suggest multiple risk factor intervention has no effect on mortality. However, a small, but potentially important, benefit of treatment (about a 10% reduction in CHD mortality) may have been missed. Risk factor changes were relatively modest, were related to the amount of pharmacological treatment used, and in some cases may have been over-estimated because of regression to the mean effects, lack of intention to treat analyses, habituation to blood pressure measurement, and use of self-reports of smoking. Interventions using personal or family counselling and education with or without pharmacological treatments appear to be more effective at achieving risk factor reduction and consequent reductions in mortality in high risk hypertensive populations. The evidence suggests that such interventions have limited utility in the general population.

Evaluation of Community Pharmacy Service Mix: Evidence from the 2004 National Pharmacist Workforce Study

OBJECTIVES

To describe the mix of pharmacy services being offered in different types of community pharmacy practices and to identify factors associated with a community pharmacy offering pharmacy services.

DESIGN

Cross-sectional study.

SETTING

Community pharmacies (independent, chain, mass merchandiser, and supermarket pharmacies).

PARTICIPANTS

Pharmacists practicing full-time or part-time who worked in community pharmacies and responded to the 2004 National Pharmacist Workforce Survey.

INTERVENTION

Mailed survey from the 2004 National Pharmacist Workforce Survey, which included core content questions for all sampled pharmacists and supplemental surveys that included workplace questions for a selected subsample of pharmacists.

MAIN OUTCOME MEASURES

Type and frequency of pharmacy services being offered in a community pharmacy, including dispensing and product-related services (e.g., specialty compounding), and pharmacist care services (e.g., immunizations, smoking cessation, health screening, medication therapy management, wellness screening, nutritional support, and disease management services).

RESULTS

Four pharmacist care services were reported as being offered at more than 10% of community pharmacy practices: immunizations, smoking cessation, health screening, and diabetes management. The number of pharmacist care services offered at a community pharmacy was positively associated with having at least three pharmacists on duty, innovativeness of the pharmacy, status as an independent pharmacy, and status as a supermarket pharmacy. More than one half of the community pharmacy practices did not offer any of the eight pharmacist care services included in a pharmacy service index.

CONCLUSION

Pharmacy services were reported at relatively few community pharmacies, and were associated with pharmacy innovativeness, pharmacist staffing levels, and pharmacy setting. Some community pharmacies are offering pharmacy services as part of their business strategy, while others are dedicated to dispensing services. Continued study of pharmacy service availability in community pharmacies is needed to improve our understanding of our capacity to deliver such services, including medication therapy management services.

Implementation of a Self-Administered Questionnaire to Identify Patients at Risk for Medication-Related Problems in a Family Health Center

STUDY OBJECTIVE

To determine if a self-administered questionnaire can improve the identification of patients at risk for medication-related problems (MRPs) compared with usual methods of referral to a pharmacist.

DESIGN

Prospective, randomized controlled study.

SETTING

Multiprofessional primary care clinic at a tertiary care teaching hospital.

PATIENTS

One hundred ninety-four ambulatory patients aged 18 years or older who were taking at least two drugs.

MEASUREMENTS AND MAIN RESULTS

Patients completed a five-item, self-administered questionnaire modified from a tool that was previously validated in another population and statistically correlated with the risk of MRPs. Of 194 patients who completed the questionnaire, 89 were randomized to the control group (referral by usual methods) and 105 were referred according to their responses on the questionnaire (intervention group). Primary outcomes were the rate of referral and the number of at-risk patients identified. Referral rates were higher with the questionnaire than with usual methods (20% vs 6%, p=0.003). Of five patients referred by usual methods, one was at risk for MRPs according to questionnaire results. Of 84 patients in the control group who were not referred, 12 (14%) were at risk according to the questionnaire results; this finding suggested that several at-risk patients who were not referred by usual methods might have benefitted from a referral for a pharmacist's assessment.

CONCLUSION

This self-administered medication risk assessment questionnaire effectively complemented the usual practices for identifying and referring patients at risk for MRPs.

Differences by Age and Race/Ethnicity in Knowledge About Hypercholesterolemia

This investigation sought to identify gaps in patients' knowledge about hypercholesterolemia and lipid-lowering therapy in an inner-city US population. Chart reviews and interviews were conducted for drug-treated hypercholesterolemic patients at 3 hospital-based cardiology practices in Bronx, NY. Univariate and multivariate analyses were used to assess whether race/ethnicity, sex, and age were predictors of knowledge. Subjects (n = 467, age 65.3 years) were 55% female, 38% Hispanic, 32% black, and 25% white. Most recognized hypercholesterolemia as a cause of heart disease (88%) and stroke (76%), although older subjects (>70 years) and Hispanic subjects, particularly non-English speakers, were significantly less likely to know about cardiovascular disease risks associated with hypercholesterolemia. Only 14% recalled their recent cholesterol levels, and recall was significantly lower among black, Hispanic, and older subjects. Overall, 31% expected to require lipid-lowering medications indefinitely in the future, while 66% did not know how long they would need to continue using medications. Blacks and Hispanics were significantly less likely to believe that they would need to continue taking medications indefinitely. Achieved lipid levels and self-reported medication adherence were relatively favorable although were unrelated to knowledge levels. In summary, among hypercholesterolemic patients in an urban population, relatively few knew their own cholesterol levels or expected to require medications indefinitely in the future. Older patients, black and Hispanic patients, and non-English speakers were significantly less likely to have accurate knowledge about hypercholesterolemia. Therefore, patient and community education efforts targeted to specific populations may lead to improved management of hypercholesterolemia in inner-city regions.

Impact of a pharmaceutical care program in a community pharmacy on patients with dyslipidemia

BACKGROUND

Inappropriate use of medications is a significant problem in health care today. A possible solution to this problem may be achieved through better control of patients' drug therapy.

OBJECTIVE

To design a pharmaceutical care program for dyslipidemic patients within a community pharmacy setting that provides education in the areas of medication compliance and lifestyle modifications, while emphasizing the importance of achieving cholesterol goals to ensure improvement in quality of life.

METHODS

Patients at an outpatient pharmacy volunteered to be surveyed for 16 weeks. Although both the intervention and control groups were surveyed, the randomly selected intervention group was interviewed more frequently and more comprehensively. Cholesterol, triglycerides, glucose, weight, risk factors, drug-related problems (DRPs), and quality of life were measured via a survey at the onset of the study and continually measured until the study's conclusion.

RESULTS

In the intervention group, 26 DRPs were detected, of which 24 were resolved; in the control group, 26 DRPs were detected, of which 5 were resolved. When comparing initial and final blood cholesterol levels in the intervention group, the mean decrease was 27.0 +/- 41.1 mg/dL (p = 0.0266); in the control group, the average blood cholesterol level decreased by a mean of 1.4 +/- 37.2 mg/dL (p = 0.6624). In the intervention group, the triglyceride level decreased an average of 50.5 +/- 80.3 mg/dL (p = 0.0169), while the control group experienced a mean triglyceride level increase of 29.6 +/- 118.5 mg/dL (p = 0.1435). As a result of the intervention, the quality of life in the intervention group was improved.

CONCLUSIONS

Short-term pharmaceutical care plans developed in a retail pharmacy within the proper setting may contribute to improved blood lipid values, cardiovascular disease risk factors, and patients' quality of life.

Long-Term Impact of a Community Pharmacist Intervention on Cholesterol Levels in Patients at High Risk for Cardiovascular Events: Extended Follow-up of the Second Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP-plus)

STUDY OBJECTIVE

To determine the effect of a community pharmacist intervention in patients at high risk for coronary heart disease on low-density lipoprotein cholesterol (LDL) levels 1 year after completion of the Second Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP- plus ).

METHODS

Patients who completed the original study were invited to make a single return visit to their community pharmacy so that the pharmacist could measure their fasting LDL level using a point-of-care device. The primary outcome was change in LDL level from the 6-month (final) visit to the extended follow-up evaluation.

RESULTS

Of the 359 patients who completed the original 6-month visit, data were collected for 162 (45%) patients. The mean +/- SD LDL level at completion of the original study was 107.9 +/- 33.6 mg/dl (2.79 +/- 0.96 mmol/L) (an increase of 2.7 mg/dl [0.07 mmol/L], 95% confidence interval -19.3-7.3 [-0.5-0.19]). Sixty-one (38%) patients were at the target LDL level (< 96.7 mg/dl [< 2.50 mmol/L]).

CONCLUSION

The LDL reduction was maintained 1 year after completion of the extended follow-up. Since most patients were still not at the target LDL level, this finding suggests that continuing intervention is necessary to help patients reach this target.

Interventions to improve adherence to lipid lowering medication

BACKGROUND

Lipid lowering drugs are still widely underused, despite compelling evidence about their effectiveness in the treatment and prevention of cardiovascular disease. Poor patient adherence to medication regimen is a major factor in the lack of success in treating hyperlipidaemia. In this review we focus on interventions, which encourage patients at risk of heart disease or stroke to take lipid lowering medication regularly.

OBJECTIVES

To assess the effect of interventions aiming at improved adherence to lipid lowering drugs, focusing on measures of adherence and clinical outcomes.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycInfo and CINAHL. Date of most recent search was in February 2003. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials of adherence-enhancing interventions to lipid lowering medication in adults for both primary and secondary prevention of cardiovascular disease in an ambulatory setting.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data independently and assessed studies according to criteria outlined by the Cochrane Reviewers' Handbook.

MAIN RESULTS

The eight studies found contained data on 5943 patients. Interventions could be stratified into four categories : 1. simplification of drug regimen, 2. patient information/education, 3. intensified patient care such as reminding and 4. complex behavioural interventions such as group sessions. Change in adherence ranged from -3% to 25% (decrease in adherence by 3% to increase in adherence by 25%). Three studies reported significantly improved adherence through simplification of drug regimen (category 1), improved patient information/education (category 2) and reminding (category 3). The fact that the successful interventions were evenly spread across the categories, does not suggest any advantage of one particular type of intervention. The methodological and analytical quality was generally low and results have to be considered with caution. Combining data was not appropriate due to the substantial heterogeneity between included randomised controlled trials (RCTs).

REVIEWERS' CONCLUSIONS

At this stage, no specific intervention aimed at improving adherence to lipid lowering drugs can be recommended. The lack of a gold standard method of measuring adherence is one major barrier in adherence research. More reliable data might be achieved by newer methods of measurement, more consistency in adherence assessment and longer duration of follow-up. Increased patient-centredness with emphasis on the patient's perspective and shared-decision-making might lead to more conclusive answers when searching for tools to encourage patients to take lipid lowering medication.

Greater effect of enhanced pharmacist care on cholesterol management in patients with diabetes mellitus: a planned subgroup analysis of the Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP)

STUDY OBJECTIVE

To determine the effect of enhanced pharmacist care on cholesterol management in patients with and without diabetes mellitus.

METHODS

We conducted a planned subgroup analysis of the Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP), a 54-center randomized trial of pharmacist intervention compared with usual care in patients at high risk for cardiovascular events. The patients involved had atherosclerotic disease or diabetes. We compared the effect of pharmacist intervention in patients with and without diabetes. The primary end point was a composite of performing a fasting cholesterol profile, or adding or increasing the dosage of a cholesterol-lowering drug. Secondary end points were individual components of the primary end point and change in 10-year risk for cardiovascular events, using the Framingham risk equation.

RESULTS

Of the 675 patients enrolled in the SCRIP study, 294 (44%) had diabetes. Enhanced pharmacist care had a more beneficial effect on cholesterol management in those with diabetes (odds ratio [OR] 4.8) than without diabetes (OR 2.1), p=0.01. Secondary end points showed similar trends, and reduction in Framingham risk was greater in patients with diabetes than without.

CONCLUSION

Pharmacist intervention for dyslipidemia appears to have a greater impact in patients with diabetes. Results of this substudy suggest that pharmacists should target this patient group for interventions in cholesterol risk management.

Patients' achievement of cholesterol targets: a cross-sectional evaluation

BACKGROUND

Despite incontrovertible evidence for the efficacy of cholesterol lowering, numerous studies suggest that patients are suboptimally treated. This study was conducted to determine the proportion of patients achieving recommended target lipid levels in a relatively unselected group of community-dwelling patients who were prescribed HMG-CoA reductase inhibitors (statins).

METHODS

Community pharmacists identified participants who were receiving an HMG-CoA reductase inhibitor at the same dosage for a minimum of 6 weeks and enrolled them into the study. Participants had an interview to determine cardiovascular risk factors and level of cardiovascular risk as defined by Canadian dyslipidemia guidelines, and a fasting lipid profile was performed using a point-of-care cholesterol assessment device.

RESULTS

During 2000, a total of 404 participants were enrolled from 16 pharmacies. The highest proportion (96%) of participants achieving low-density lipoprotein targets was in the low-risk group, and the proportion progressively decreased as cardiac risk level increased: 80% in the moderate-risk group and 82% in the high-risk group. The very-high-risk group had the lowest proportion (37%) of participants who achieved their target.

CONCLUSIONS

Consistent with other studies, this study found that as cardiac risk increased, the proportion of patients achieving their target cholesterol values decreased, such that those at the greatest risk for cardiovascular disease (who had the most to gain from aggressive lipid-lowering interventions) were least likely to achieve their cholesterol targets. This suggests a need for more-aggressive approaches to the management of cholesterol, particularly in high-risk patients.

Drug therapy management: an empirical report of drug therapy problems, pharmacists' interventions, and results of pharmacists' actions

OBJECTIVES

To determine the number and types of drug therapy problems identified by pharmacists at six community pharmacies, identify the interventions made by these pharmacists in their attempts to resolve drug therapy problems, and determine the results of the pharmacists' actions taken to resolve drug therapy problems.

DESIGN

Retrospective review of patient records from pharmacies.

SETTING

Six community pharmacies that had participated in Project ImPACT: Hyperlipidemia.

PATIENTS

One hundred sixteen patients from Project ImPACT: Hyperlipidemia.

INTERVENTION

Drug therapy problems, pharmacists' interventions, and results of pharmacists' actions were identified and categorized. Drug therapy problems were classified into seven categories, pharmacists' interventions into six categories, and results were categorized into eight types. Frequencies and descriptive statistics were calculated for the measures.

RESULTS

A total of 512 initial drug therapy problems were reported for 116 patients in the 6 pharmacies. In addition to the initial interventions, pharmacists documented another 545 times in which they intervened on the original problems. There were 354 (69.1%) drug therapy problems associated with hyperlipidemia and 158 (30.9%) with other conditions. Overall, most common types of drug therapy problems were needs additional therapy (39.8%) and nonadherence to therapy (31.1%). The most common discretionary pharmacist interventions were patient education and physician communication, which occurred on average 4.63 and 3.30 times during the project period. The most common consequence of a pharmacist intervention was an increase in patient adherence, which was reported for almost half of the patients.

CONCLUSION

Drug therapy management (DTM) for patients with dyslipidemias identified frequent drug therapy problems associated with both hyperlipidemia and other conditions. Pharmacists used interventions that included laboratory testing, patient monitoring, patient education, and physician communication to influence patient adherence and optimize drug therapy. Although further research is needed, the findings of this analysis are promising for the more widespread adoption of a DTM role by community pharmacists.

Third party reimbursement for pharmacist services: why has it been so difficult to obtain and is it really the answer for pharmacy?

OBJECTIVES

To describe three models of how health insurance coverage can develop for health care goods and services and apply them to pharmacist services. Also, to raise readers' awareness of the costs/tradeoffs involved in receiving third party reimbursements of insurance coverage from a health provider perspective.

DATA SOURCES

Insurance theory and literature.

SUMMARY

The three models for developing health insurance coverage are the risk-pooling model, the demand model, and the cost containment model. The risk-pooling model does not apply to coverage for pharmacist services because the cost of such services is not catastrophic and unpredictable. Applying both the demand model and the cost containment model to developing coverage for pharmacist services presents some challenges, but the demand model has been used more successfully to obtain insurance coverage for other health care goods and services. Potential costs and tradeoffs to the health care provider associated with insurance coverage are higher administrative costs, lower reimbursement rates, and loss of professional autonomy.

CONCLUSION

If pharmacists want to increase third party coverage for their services, the best approach may be to increase patient demand for insurance coverage by promoting and charging for pharmacist services. However, pharmacists should seriously consider whether the benefits of such coverage for their services outweigh the costs.

The value of pharmacist involvement in a point-of-care service, walk-in lipid screening program

The leading cause of death in the United States is heart disease. Because an elevated serum cholesterol level is an independent risk factor for development of coronary heart disease (CHD), individuals older than 20 years of age are advised to have their cholesterol level checked every 5 years. Walk-in screening programs are becoming popular as a method of health care delivery. The program at the University of California-Irvine Medical Center administers point-of-care, low-cost lipid profile testing, directly involves patients in their own care, and provides individualized education to patients regarding cardiovascular risk reduction. A total of 301 patients participated in the program between August 1998 and September 2000. Fifty percent of them (150 patients) required intervention; 34% of these (52 patients) were previously undiagnosed. Their mean age was 57 +/- 13 years; 35% were women, 53% had two or more cardiac risk factors, and 5% had CHD. Based on the National Cholesterol Education Program guidelines, 29% had low-density lipoprotein levels above target, 23% had triglyceride levels higher than recommended, and 21% had high-density lipoprotein levels below target. It is our hope that our successful experience with the program will encourage pharmacists to develop similar programs.

Economic impact of community pharmacist intervention in cholesterol risk management: an evaluation of the study of cardiovascular risk intervention by pharmacists

The Study of Cardiovascular Risk Intervention by Pharmacists, a randomized, controlled trial in over 50 community pharmacies in Alberta and Saskatchewan, Canada, demonstrated that a pharmacist intervention program improved cholesterol risk management in patients at high risk for cardiovascular disease. In a substudy, costs and consequences were analyzed to describe the economic impact of the program. Two perspectives were taken: a government-funded health care system and a pharmacy manager. Costs were reported in 1999 Canadian dollars. Incremental costs to a government payor and community pharmacy manager were $6.40/patient and $21.76/patient, respectively, during the 4-month follow-up period. The community pharmacy manager had an initial investment of $683.50. The change in Framingham risk function for the intervention group from baseline also was reported. The 10-year risk of cardiovascular disease decreased from 17.3% to 16.4% (p<0.0001) during the 4 months. The intervention program in this study led to a significant reduction in cardiovascular risk in the intervention group during the 4-month follow-up period. The incremental cost to provide the program appeared minimal from both government and pharmacy manager perspectives. It is hoped that these results could support negotiations for reimbursement of clinical pharmacy services with payors.

Cholesterol risk management: a systematic examination of the gap from evidence to practice

Hypercholesterolemia is a major risk factor for coronary heart disease, and data indicate that aggressive cholesterol reduction decreases mortality and morbidity associated with this disease. Many patients with hypercholesterolemia, however, are not screened, prescribed appropriate lipid-lowering therapy, or treated to target cholesterol levels. Practice patterns are particularly inadequate for those patients at highest risk for having a cardiac event. We performed a literature search to identify studies of practice patterns in the management of patients with hypercholesterolemia with regard to screening, implementing lipid-lowering therapy, and treating to lipid goals. The findings highlight the potential for substantial opportunities to improve patient outcomes. Future studies should evaluate reasons for suboptimal cholesterol management as well as provide steps to improve management.

Practice-based research: lessons from community pharmacist participants

We designed this project to determine community pharmacists' opinions regarding the challenges and motivations of their recent participation in a pharmacy practice-based research study At the conclusion of a randomized, multicenter study, 87 community pharmacist-investigators were sent a questionnaire that explored four areas: motivating factors to participate, barriers to participation, communication tools used by study coordinators, and design issues for future studies. Fifty-eight (67%) completed questionnaires were returned. Key factors motivating participation in the study were desire to improve the profession and opportunity to learn. Time was the greatest barrier to participation. Pharmacy practice-based research has two distinct advantages. First, it translates clinical knowledge into direct application in the community. Second, it provides needed data to demonstrate the value of enhanced pharmacy practice. Thorough understanding of pharmacists' opinions is necessary to optimize the design of future studies.

[Treatment of coronary risk factors by general practitioners in Austria]

Aim of the study was to investigate attitudes and practice of coronary prevention in offices of general practitioners and internists. 67 Austrian physicians took part in a mail survey focussing on hyperlipidemia. 96.6% of participating physicians recommend dietary intervention at least at total cholesterol levels of 250 mg/dl, 98.0% prescribe lipid-lowering drugs at least at total cholesterol levels of 300 mg/dl. At corresponding levels of total/HDL cholesterol ratios and especially at corresponding levels of LDL-cholesterol the proportion was lower. On average 37.9% of physicians spend up to 5 minutes for patients with hyperlipidemia, 10.3% spend more than 15 minutes. The time frame is similar in overweight patients, and bigger in patients with hypertension and diabetes. Dietary therapy is estimated similarly successful in patients with hyperlipidemia and overweight, but estimated more successful in patients with hypertension and diabetes. Drug therapy of hyperlipidemia is estimated more successful than in overweight and diabetes, and worse compared with hypertension. Main measures for improving prevention are more time and specific postgraduate education. The majority of physicians feel that within the last five years quality has improved both in the outpatient and the inpatient care.