When does pharmaceutical care impact health outcomes? A comparison of community pharmacy-based studies of pharmaceutical care for patients with asthma

Managing Allergic Rhinitis in the Pharmacy: An ARIA Guide for Implementation in Practice

The paradigm of how we manage allergic rhinitis is shifting with a growing understanding that it is a complex process, requiring a coordinated effort from healthcare providers and patients. Pharmacists are key members of these integrated care pathways resolving medication-related problems, optimizing regimens, improving adherence and recommending therapies while establishing liaisons between patients and physicians. Community pharmacists are the most accessible healthcare professionals to the public and allergic rhinitis is one of the most common diseases managed by pharmacists. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines developed over the past 20 years have improved the care of allergic rhinitis patients through an evidence-based, integrated care approach. In this paper, we propose an integrated approach to allergic rhinitis management in community pharmacy following the 2019 ARIA in the pharmacy guidelines.

Development and psychometrics of a short-form pharmaceutical care-specific measure for quality of life

Background The validated patient-reported outcomes measure of pharmaceutical therapy for quality of life (PROMPT-QoL) contains 43-items, and can be too lengthy for some applications. Objectives To develop a brief version called the PROMPT, and test its psychometric properties. Setting Four public hospitals in Bangkok, Thailand. Method Secondary analysis of three databases used to develop and evaluate the original PROMPT-QoL. Items for the short-form PROMPT were selected based on expert and patient evaluations of content and importance, and lack of redundancy. All domains of the original version are represented in the PROMPT. Main outcome measures Psychometric properties (internal consistency and test-retest reliability, criterion, convergent and discriminant validity, and responsiveness), and indicators of practicality (e.g., administration time, missing data). Results Analyses of the PROMPT and its domain subscales demonstrated good internal consistency and fair-to-excellent test-retest reliability. Correlations between the original and short-form, overall and by domain, were high. Expectations for convergent and discriminant validity were met as correlations between the PROMPT and generic health-related quality of life measures (WHOQoL-BREF domains and summary scores of the SF-12v2) were modest (< 0.40). Based on data from a trial of pharmaceutical care, the PROMPT short-form was very responsive to reductions in medication related problems. Administration time for the PROMPT is estimated to be about 5 min, and across all datasets used, no missing data were found amongst the 16 items of the PROMPT. Conclusion The 16-item PROMPT appears to be a practical, reliable, valid, and responsive instrument to identify patient's drug-related needs and to assess the humanistic impact of patient-centered pharmaceutical care.

Randomized controlled trials covering pharmaceutical care and medicines management: A systematic review of literature

OBJECTIVE

To review the effects of pharmaceutical care on hospitalizations, mortality and clinical outcomes in patients.

METHODS

Systematic searches were conducted in MEDLINE, EMBASE and International Pharmaceutical Abstracts (IPA) databases to identify studies that were published between 2004 and January 2017. Studies included in this review were randomized controlled trials (RCTs) that spanned across both community and hospital settings. Using strict inclusion/exclusion criteria studies were included if they reported level 1 or 2 outcomes in the hierarchy of outcome measure i.e. clinical and surrogate outcomes (e.g. blood pressure (BP) control, blood glucose level, cholesterol BMI). Each study was assessed for quality using the Jadad scoring system.

RESULTS

Fifty-four RCTs were included in the present review. Forty-six of these studies ranked high quality according to the Jadad scoring system. Studies were categorized into their general condition groups. Interventions in patients with diabetes, depression, respiratory disorders, cardiovascular disorders, epilepsy, osteoporosis, and interventions in older adults were identified. In the majority of studies pharmaceutical care was found to lead to significant improvements in clinical outcomes and/or hospitalizations when compared to the non-intervention group. Some conditions had a large number of RCTs, for example for cardiovascular conditions and in diabetes. Statistically significant improvements were seen in the majority of the studies included for both of these conditions, with studies indicating positive clinical outcomes and/or hospitalizations rates. Within the cardiovascular condition, a subset of studies, focusing on cardiac heart failure and coronary heart disease, had more mixed results. In other conditions the number of RCTs conducted was small and the evidence did not show improvements after pharmaceutical care, i.e. in depression, osteoporosis, and epilepsy. The majority of interventions were face to face interactions with patients, whilst a smaller number were conducted via the telephone and one via a web-based system. Patient education was a key component of most interventions, either verbal and/or written. Longitudinal data, post intervention cessation, was not collected in the majority of cases.

CONCLUSIONS

RCTs conducted to evaluate pharmaceutical care appear to be effective in improving patient short-term outcomes for a number of conditions including diabetes and cardiovascular conditions, however, other conditions such as depression are less well researched. Future research should attempt to evaluate the conditions where there is a lack of data, whether the positive effects of pharmaceutical care persist in patient populations after the interventions cease and what the long-term clinical outcomes would be of continued pharmaceutical care.

Improving Asthma Control in the Rural Setting: The BREATHE (Better Respiratory Education and Asthma Treatment in Hinton and Edson) Study

Background:

Overuse of β-agonists is a risk factor for poor control of asthma. Pharmacists can identify high-risk patients through refill information and can then initiate disease-management programs for these patients.

Methods:

The Better Respiratory Education and Asthma Treatment in Hinton and Edson (BREATHE) study was a randomized, controlled trial in high-risk asthma patients. The intervention included an educational program (with focus on development of a written action plan), assessment of asthma therapy, and referral to a respiratory therapist and primary care physician. The primary objective was to determine the effect of this program (initiated by community pharmacists) on asthma control, as measured by the Asthma Control Questionnaire. Secondary objectives included determining the effect of the program on numbers of emergency department visits and hospital admissions, use of inhaled corticosteroids, courses of oral steroids, and lung function. Endpoints were measured at baseline, 2 months, and 6 months.

Results:

A total of 70 patients were randomized (34 to usual care, 36 to the intervention). At 6 months, there was no significant difference in asthma control between the usual care and inter-vention groups (change in ACQ score 0.33 and 0.43 respectively, p = 0.66). There were no significant differences in the secondary endpoints. Generally, pharmacist compliance with the intervention was poor.

Conclusions:

Although no differences were found in asthma control, this model, which uses a multidisciplinary, community-based approach, offers a unique management strategy for rural asthma patients. Can Pharm J 2006;139(4):44–50.

The General Practitioner–Pharmacist Collaboration (GPPC) study: a randomised controlled trial of clinical medication reviews in community pharmacy

Objectives

There are conflicting results in studies of pharmacists undertaking medication reviews for older people. With increasing promotion and funding for ‘medication reviews’ there is a need for them to be standardised, and to determine their effectiveness and the feasibility of providing them from a community pharmacy. The objective was to determine whether involvement of community pharmacists undertaking clinical medication reviews, working with general practitioners, improved medicine-related therapeutic outcomes for patients.

Methods

A randomised controlled trial was carried out in people 65 years and older on five or more prescribed medicines. Community pharmacists undertook a clinical medication review (Comprehensive Pharmaceutical Care) and met with the patient's general practitioner to discuss recommendations about possible medicine changes. The patients were followed-up 3-monthly. The control group received usual care. The main outcome measures were Quality of Life (SF-36) and Medication Appropriateness Index.

Key findings

A total of 498 patients were enrolled in the study. The quality-of-life domains of emotional role and social functioning were significantly reduced in the intervention group compared to the control group. The Medication Appropriateness Index was significantly improved in the intervention group. Only 39% of the 44 pharmacists who agreed to participate in the study provided adequate data, which was a limitation of the study and indicated potential barriers to the generalisability of the study.

Conclusion

Clinical medication reviews in collaboration with general practitioners can have a positive effect on the Medication Appropriateness Index. However, pharmacist withdrawal from the study suggests that community pharmacy may not be an appropriate environment from which to expand clinical medication reviews in primary care.

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.

Partner for Promotion: an innovative advanced community pharmacy practice experience

OBJECTIVES

To implement the Partner for Promotion (PFP) program which was designed to enhance the skills and confidence of students and community pharmacy preceptors to deliver and expand advanced patient care services in community pharmacies and also to assess the program's impact.

DESIGN

A 10-month longitudinal community advanced pharmacy practice experience was implemented that included faculty mentoring of students and preceptors via formal orientation; face-to-face training sessions; online monthly meetings; feedback on service development materials; and a web site offering resources and a discussion board. Pre- and post-APPE surveys of students and preceptors were used to evaluate perceptions of knowledge and skills.

ASSESSMENT

The skills survey results for the first 2 years of the PFP program suggest positive changes occurring from pre- to post-APPE survey in most areas for both students and preceptors. Four of the 7 pharmacies in 2005-2006 and 8 of the 14 pharmacies in 2006-2007 were able to develop an advanced patient care service and begin seeing patients prior to the conclusion of the APPE. As a result of the PFP program from 2005-2007, 14 new experiential sites entered into affiliation agreements with The Ohio State University College of Pharmacy.

CONCLUSION

The PFP program offers an innovative method for community pharmacy faculty members to work with students and preceptors in community pharmacies in developing patient care services.

Pharmaceutical Care for Migraine and Headache Patients: A Community-Based, Randomized Intervention

Background:

Despite the high prevalence of headache and migraine in the general population, many people do not receive adequate medical attention and treatment.

Objective:

To evaluate the effects of pharmaceutical care (defined as intensified structured counseling between patient and pharmacist, including the use of drug databases), for patients with headache or migraine, on both clinical and psychological endpoints.

Methods:

A prospective, randomized, controlled intervention study was conducted using pharmacies in Northern Germany. A total of 112 pharmacies (26% of all pharmacies in the study region) recruited 410 patients with headaches. Pharmacies were randomly assigned to an intervention or control group. Patients were interviewed by telephone prior to the intervention and again after 4 months. Primary endpoints were number of days with headache, number and severity of headaches, self-efficacy, and the patients' perceptions of their health-related quality of life.

Results:

Each pharmacy treated an average of 4.6 patients (total time effort 9 h). The intervention group consisted of 201 patients who received pharmaceutical care, whereas the control group comprised 209 patients who received standard counseling. In both groups, the number of headache attacks and intensity of pain in treated headache attacks did not change significantly between the first and second interviews. However, a statistically significant improvement in mental health and self-efficacy was shown in the intervention group. Intensity of pain in untreated headache attacks and the number of days with headache decreased in both groups. Most participants described this intervention as helpful and effective and 90% reported that they would recommend pharmaceutical care to other patients with headache.

Conclusions:

A short-term pharmaceutical care intervention improved patients' mental health and self-efficacy, although it did not significantly change the number and severity of headaches. The increase in self-efficacy and mental health associated with pharmaceutical care may be instrumental in improving long-term pharmacotherapy of patients with migraine and headache. To fully assess the effects of pharmaceutical care, a longer study may be required.

Patients' understanding of the reasons for starting and discontinuing inhaled corticosteroids

AIM

Although early discontinuation of treatment in new users of inhaled corticosteroids (ICS) has been widely discussed, the reasons for stopping have not been investigated in depth. We aimed to describe reasons for discontinuation from a patient's perspective in relation to their experience of symptoms at the time of the investigation.

METHODS

A cross-sectional study among new users that discontinued ICS use in the Netherlands was performed. Patients were interviewed by telephone, aiming to identify the symptoms for which they were prescribed ICS, the reasons for discontinuing treatment and the respiratory symptoms patients still experienced at the time of the survey. In addition, automated dispensing records of all patients were retrieved.

RESULTS

From 287 eligible patients, 230 (80.1%) were interviewed. Only 22 patients (9.6%) mentioned asthma as the reason for a first ICS prescription. A decrease in symptoms was the main reason for discontinuation (45%). Thirty patients (13%) reported clinically significant residual symptoms. These patients reported more seasonal variation of symptoms and were more often prescribed short-acting beta(2)-agonists.

CONCLUSIONS

The majority of patients mentioned a wide range of symptoms and conditions, other than asthma or chronic obstructive pulmonary disease, as the reason for the start of ICS therapy. Most of these conditions may be expected to be of short duration. Not surprisingly a decrease in symptoms was the main, and justifiable, reason for discontinuing ICS. However, a non-negligible proportion of patients reported residual symptoms that suggest the need of continued ICS use. Physicians and pharmacists could cooperate in identifying those patients for which ICS are really indicated and motivate them to continue the use of ICS.

An innovative approach to integrated medicines management

RATIONALE, AIMS AND OBJECTIVES

To determine whether an increased input by clinical pharmacists at each stage of the patient's hospital journey, from admission through discharge, resulted in an enhanced level of patient care as measured by a number of clinical and economic outcomes.

METHODS

This project was designed to address medicines management issues in patients deemed at risk of drug-related problems. During the project, these latter patients at the time of admission were randomly assigned to an integrated medicines management (IMM) service group (n = 371) or regular hospital care group (n = 391). The IMM service involved comprehensive pharmaceutical care provided by a pharmacy team throughout each of three stages: patient admission, inpatient monitoring and counselling, and patient discharge.

RESULTS

Patients who received the IMM service benefited from a reduced length of hospital stay [by 2 days (P = 0.003; independent samples t-test log(e))]. IMM patients also had a decreased rate of readmission over a 12-month follow-up period (40.8% vs. 49.3%; p = 0.027; Fisher's exact test) and an increased time to readmission [20 days longer (P = 0.0356; log rank test)]. A numbers-needed-to-treat calculation indicated that for approximately every 12 patients receiving the IMM service, one readmission to hospital, within 12 months of discharge, would be prevented. The new service was welcomed by cognate health care professionals.

CONCLUSION

The IMM service proved very effective and can be used as a template to support the implementation of comprehensive pharmaceutical care as a routine service across Northern Ireland and beyond.

Impact of a continuing education program on community pharmacists' interventions and asthma medication use: a pilot study

BACKGROUND

By upgrading the pharmacists' knowledge and skill set through continuing education (CE) programs, they could be better suited to contribute to the enhancement of the management of asthma.

OBJECTIVE

To assess the impact of an asthma CE program provided to community pharmacists on their knowledge, intervention frequency, and the appropriateness of asthma medication use.

METHODS

Community pharmacists were invited to participate in a CE program on asthma. Those who displayed an interest in the program were assigned to either a control or experimental group. Participants in the first group were not offered the CE program until the study was completed; the second group participated in the CE program at the onset of the study period. The knowledge on asthma of both groups of pharmacists was assessed using a questionnaire before the CE program, and the knowledge of the experimental group was reassessed after the CE program. Pharmacists were asked to document their interventions in the study log book over 6 months following the CE program. The appropriateness of asthma medication use was estimated by reviewing the prescription claims for a subgroup of patients covered by Québec's Public Prescription Drug Insurance Plan.

RESULTS

Pharmacists' knowledge improved after the CE program; however, the number of interventions reported during the 6 month period following the program was low and did not differ significantly between the groups, with an average of 3.04 per pharmacy in the experimental group versus 3.26 in the control group. The appropriateness of asthma medication use did not improve once the CE program had been completed.

CONCLUSIONS

Our CE program had little impact on the number of interventions by community pharmacists and the appropriateness of asthma medication use.

Pharmacists' smoking cessation practices: relationship to their knowledge and skills, attitudes, and perceptions of roles

OBJECTIVE

To assess factors associated with pharmacists' practices regarding patients' smoking and smoking cessation.

DESIGN

Cross-sectional analysis.

SETTING

Four Canadian provinces (Ontario, Québec, Saskatchewan, Prince Edward Island).

PARTICIPANTS

Practicing community pharmacists (n = 906; weighted n = 897).

INTERVENTION

Population-based mailed questionnaire survey with 72% response rate.

MAIN OUTCOME MEASURES

Bivariate and multivariate relationships between 12 clinical interventions regarding smoking and smoking cessation and 7 domains: basic pharmacologic knowledge; applied health science knowledge and skills; positive, negative and economic-related attitudes toward smoking cessation; perceptions of pharmacists' roles with patients who smoke: assessing and motivating patients; assisting, referring and following up.

RESULTS

Basic pharmacologic knowledge and applied health science knowledge and skills were independently related to 12 and 10 interventions, respectively. Positive attitudes toward smoking cessation were independently related to 8 interventions. Negative attitudes and economic-related attitudes toward smoking cessation were each independently related to only 1 intervention. Perceptions of pharmacists' roles with respect to "assessing and motivating patients," and "assisting, referring, and following up" were independently related to 8 and 3 interventions, respectively.

CONCLUSION

Initiatives to increase tobacco-related knowledge and skills and enhance positive attitudes and role perceptions with respect to smoking and smoking cessation may promote interventions by community pharmacists with patients who smoke.

Medication therapy management services in North Carolina community pharmacies: current practice patterns and projected demand

OBJECTIVE

To evaluate the types of cognitive services offered and the number of patients being served in community pharmacies, determine the number of pharmacies that plan to offer medication therapy management (MTM) services under the Medicare Part D prescription drug benefit, and assess whether current and expected practices will meet the potential needs of enrollees.

DESIGN

Cross-sectional study.

SETTING

North Carolina in January 2005.

PARTICIPANTS

1,593 community pharmacy managers.

INTERVENTIONS

Survey using a Web-based tool.

MAIN OUTCOME MEASURES

Provision of cognitive services and number of patients for whom services are provided.

RESULTS

A total of 262 (16%) pharmacy managers provided usable responses. Approximately 42% of respondents (n = 110) indicated that they provide some type of cognitive service. Comprehensive MTM services, or services consistent with the professionwide consensus definition, were provided by 31% of respondents (n = 81). Independent pharmacies were more likely to offer some type of service compared with chain pharmacies (58% versus 31%, respectively; P < .001). Pharmacy managers with a doctor of pharmacy degree were less likely than pharmacy managers with a bachelor's degree to offer services in their pharmacies (P = .02), and pharmacies with pharmacists on staff who had received certificate training were more likely to offer cognitive services (P = .03). Of all respondents, 28% (n = 73) indicated that they planned to offer MTM services under the Medicare Part D prescription drug benefit.

CONCLUSION

Comparing these results with those of a 1999 survey of North Carolina pharmacists that used some of the same items, the percentage of community pharmacies that provide cognitive services has increased in the intervening years but remains low. Among the services being offered in 2005, most were focused on patient education and training, coordinating and integrating care, and medication regimen reviews. Implementation of MTM services under the Medicare Part D prescription drug benefit should hasten the development and offering of these services in community pharmacies.

Medication use and disease control of asthmatic patients in Flanders: a cross-sectional community pharmacy study

The aim of this study was to describe medication use and disease management of asthmatic patients and to evaluate the usefulness of the Asthma Control Test (ACT) in community pharmacies. In 54 Flemish community pharmacies 166 asthmatic patients were included in the study. At inclusion, the study persons completed a survey to assess subject characteristics, symptoms and asthma attacks, and peak expiratory flow (PEF) was measured. Furthermore, the actual level of asthma control was assessed by ACT, a clinically validated measure of asthma control. Prescribed medicine data of the patients were 1 year retrospectively analysed from the prescriptions. Mean age of the sample was 36.8 year, 23% were smokers. As maintenance treatment, 63% of the patients used a combination product containing an inhaled corticosteroid and a long-acting beta2-agonist in a single inhaler. According to ACT, 49.1% of the patients were insufficiently controlled. Only 4.9% of the patients had a maximal ACT score of 25, indicating complete asthma control; 46.0% of the study population obtained an ACT score between 20 and 24, meaning that their asthma is well controlled. In contrast, 30.7% of the patients had a score between 15 and 19, indicating uncontrolled asthma. In all, 18.4% obtained ACT scores of less than 15, meaning that their asthma was seriously out of control and necessitating referral to their general practitioner or lung specialist. Importantly, the correlation between the self-perceived level of asthma control and the objective assessment of the asthma control level was poor: 82.3% of the patients believed their asthma to be totally or well controlled, while this was the fact for only 50.9% of the patients. In conclusion, the ACT appears to be a useful tool to determine rapidly and accurately the level of asthma control in patients presenting at community pharmacies.

Community pharmacy-based pharmaceutical care for asthma patients

BACKGROUND

Despite significant progress in asthma drug therapy in recent years, there has been no major change in asthma morbidity and mortality. It is still important to determine whether pharmaceutical care (PC) influences health outcomes.

OBJECTIVE

To evaluate the effectiveness of PC with regard to clinical, humanistic, and economic outcomes in adults with asthma.

METHODS

An intervention study was conducted over 12 months. At baseline, 39 community/retail pharmacies, 84 primary care physicians (general practitioners, internal specialists, chest physicians), and 183 patients (aged 18-65 y) diagnosed with asthma were included. To evaluate economic outcomes, 2 German statutory health insurance funds provided 2 years of claims data for their insured patients (n = 55). A 1:10 matching was carried out to compare the data of this intervention subgroup with those of a control group (n = 550).

RESULTS

Significant improvements were found for all humanistic outcomes (eg, asthma-specific quality of life, self-efficacy, knowledge, medication adherence). In addition, asthma severity, self-reported symptoms, peak expiratory flow, and patients' inhalation technique improved. Increases in forced expiratory volume in 1 second and vital capacity were not significant over time. Evaluation of the insurance claims data revealed a shift toward better adherence to evidence-based therapy.

CONCLUSIONS

The study shows that PC for people with asthma has a positive impact on humanistic and, to some extent, on clinical outcomes. To determine potential economic benefits, future research should focus on patients with more severe asthma.