A pilot study evaluating multiple risk factor interventions by community pharmacists to prevent cardiovascular disease: the PAART CVD pilot project

Does Collaboration between General Practitioners and Pharmacists Improve Risk Factors for Cardiovascular Disease and Diabetes? A Systematic Review and Meta-Analysis

Objective

To assess whether inter-professional, bidirectional collaboration between general practitioners (GPs) and pharmacists has an impact on improving cardiovascular risk outcomes among patients in the primary care setting. It also aimed to understand the different types of collaborative care models used.

Study design

Systematic review and Hartung-Knapp-Sidik-Jonkman random effects meta-analyses of randomised control trials (RCTs) in inter-professional bidirectional collaboration between GP and pharmacists assessing a change of patient cardiovascular risk in the primary care setting.

Data sources

MEDLINE, EMBASE, Cochrane, CINAHL and International Pharmaceutical Abstracts, scanned reference lists of relevant studies, hand searched key journals and key papers until August 2021.

Data synthesis

Twenty-eight RCTs were identified. Collaboration was associated with significant reductions in systolic and diastolic blood pressure (23 studies, 5,620 participants) of -6.42 mmHg (95% confidence interval (95%CI) -7.99 to -4.84) and -2.33 mmHg (95%CI -3.76 to -0.91), respectively. Changes in other cardiovascular risk factors included total cholesterol (6 studies, 1,917 participants) -0.26 mmol/L (95%CI -0.49 to -0.03); low-density lipoprotein (8 studies, 1,817 participants) -0.16 mmol/L (95%CI -0.63 to 0.32); high-density lipoprotein (7 studies, 1,525 participants) 0.02 mmol/L (95%CI -0.02 to 0.07). Reduction in haemoglobin A1c (HbA1C) (10 studies, 2,025 participants), body mass index (8 studies, 1,708 participants) and smoking cessation (1 study, 132 participants) was observed with GP-pharmacist collaboration. Meta-analysis was not conducted for these changes. Various models of collaborative care included verbal communication (via phone calls or face to face), and written communication (emails, letters). We found that co-location was associated with positive changes in cardiovascular risk factors.

Conclusion

Although it is clear that collaborative care is ideal compared to usual care, greater details in the description of the collaborative model of care in studies is required for a core comprehensive evaluation of the different models of collaboration.

Implementation factor mapping of a pilot study of point-of-care C-reactive protein testing for respiratory tract infections in community pharmacy

Background

Explicit consideration of implementation factors in community pharmacy service development may facilitate widespread implementation and sustainability.

Objectives

This study involved mapping the methodology for the pilot study of point-of-care C-reactive protein (CRP) testing to support pharmacists' management of respiratory tract infections in Western Australian pharmacies against an implementation factor framework, focussing on the resources and training program provided to participating pharmacy staff.

Methods

Phase 1 involved post hoc mapping of the pilot study methodology against the framework previously described by Garcia-Cardenas et al.; phase 2 was an a priori evaluation of the resources and training program, involving pre-training, post-training, and post-pilot questionnaires administered to pharmacists and pharmacy assistants/interns. A mixed model analysis compared pharmacists' responses at the three time points.

Results

Employment of comprehensive strategies to optimise service feasibility and sustainability was demonstrated across the five domains of ‘professional service’, ‘pharmacy staff’, ‘pharmacy’, ‘local environment’ and ‘system’; further consideration of ‘consumer’ or ‘patient’ factors is needed to address issues such as patient refusal. Study pharmacists (n = 10) and pharmacy assistants/interns (n = 5) reported high levels of satisfaction with the training (100% ‘good’/‘excellent’). Pharmacists reported significantly improved attitudes towards, confidence in, and knowledge about CRP testing and service provision from pre- to post-training (p < 0.05). Positive perceptions were maintained at the post-pilot time point.

Conclusions

Post hoc mapping of implementation factors highlighted potential strengths and deficiencies of the current service model. Systematic, prospective mapping, coupled with strategies to explicitly emphasise the patient perspective, may have value in optimising service implementation or modifying future service delivery models.

Point-of-care C-reactive protein testing to support the management of respiratory tract infections in community pharmacy: A feasibility study

BACKGROUND

Point-of-care (POC) C-reactive protein (CRP) testing is employed in European primary care settings to differentiate viral from bacterial respiratory tract infections (RTIs) the latter, requiring referral for antibiotics. This service has yet to be trialled in Australian community pharmacy to support over-the-counter RTI management.

OBJECTIVES

To evaluate the feasibility, based on clinical and operational outcomes, of POC CRP testing to support Western Australian community pharmacists' management of RTIs.

METHODS

Patients with RTI signs and symptoms were recruited from June-August 2019 at 5 community pharmacies. Trained pharmacists made recommendations based on participants' POC CRP levels and routine clinical assessment. Participants completed questionnaires and telephone follow-ups on Days 3 (by pharmacists) and 5 (by researchers) post-testing. Service provision and uptake were assessed in 3 separate weekly tally sheets.

RESULTS

Clinical outcomes: CRP levels among the 131 participants recruited were: < 5 mg/L (bacterial infection unlikely; n = 60; 45.8%); 5-19 mg/L (bacterial infection possible if suggestive routine assessment; n = 52; 39.7%) and 20-100 mg/L (bacterial infection likely if suggestive routine assessment; n = 19; 14.5%). Pharmacists' management included over-the-counter medicines (131, 100%), self-care advice (125, 95.4%) and immediate general practitioner (GP) referral (15, 11.5%). Sixty-five percent (76/117) of participants had recovered by Day 5. Operational outcomes: The services was provided in 21.2% of eligible RTI presentations, representing a service uptake rate of 28.1%. Post-CRP testing, 50.9% (58/114) of participants had changed perceptions regarding their need for antibiotics, with 14.3% (16/112) subsequently intending to seek a GP prescription. Consumer satisfaction was high (100%) and most participants (93.4%, 123/131) would utilise the service again.

CONCLUSIONS

POC CRP testing was a feasible and well-accepted strategy to facilitate community pharmacy as a triage point for RTI. Consumer confidence in the pharmacists' advice, supported by CRP testing, potentially reduced unnecessary GP visits and antibiotic prescribing.

Development and Evaluation of an Educational Program for Community Pharmacists on Cardiovascular Risk Assessment

Purpose

Cardiovascular disease (CVD) risk assessment is an important strategy for the prevention of CVD. Pharmacists play an important role in CVD risk assessment and management (CVDRAM). Our previous study identified gaps in knowledge among community pharmacists for the provision of CVDRAM services as assessed through patient simulation. Therefore, our objectives were: a) to develop and evaluate an educational program on CVD risk assessment for community pharmacists, b) to assess the knowledge and skills of participating pharmacists in assessing and managing CVD risk before and after enrolling in the educational program and c) to explore pharmacists’ satisfaction and perceived effectiveness of the educational program.

Methods

Using a blended learning instructional approach, the educational program for a subset of 25 community pharmacists recruited from our previous study consisted of two face-to-face workshops, and an online 5-module course on CVD risk factors such as hyperlipidemia, hypertension, diabetes, obesity, and smoking cessation based on principles of adult learning. A repeated measures study design was utilized by measuring participants’ knowledge on pre- and post-questionnaires and an objective structured clinical examination (OSCE) at the conclusion of the educational program was also used to assess its impact on the knowledge and skills of community pharmacists in the provision of CVD risk assessment and management (CVDRAM) services. The knowledge questionnaire was completed by 23 pharmacists while the OSCE was completed by 8 pharmacists. In addition, a survey assessed the pharmacists’ level of satisfaction with the educational program.

Results

At the conclusion of the educational program, the participating pharmacists achieved knowledge and skills for the provision of CVDRAM services. Knowledge scores in relation to CVDRAM significantly improved after the educational program [out of a maximum of 20 points, the median (interquartile range) = 9 (7–9) at pre- vs 12 (12–13) at post-educational program], p<0.001. On the OSCE, the median (interquartile range) scores for Stations 1 and 2 were 66 (63–71) and 71 (67–76), respectively. Out of the 21 pharmacists that completed the satisfaction survey, 71% were very satisfied and 29% were satisfied with the educational program.

Conclusion

The educational program improved pharmacists’ knowledge and skills for the provision of CVDRAM services.

General practitioner and pharmacist collaboration: does this improve risk factors for cardiovascular disease and diabetes? A systematic review protocol

INTRODUCTION

Cardiovascular disease (CVD) remains a major cause of morbidity and premature mortality globally. Despite the availability of low-cost evidence based medicines, there is a significant treatment gap in those with established or at high risk of CVD in the primary care setting. Pharmacist-based interventions have shown to improve patient outcomes for many chronic diseases including CVD. However, there is little synthesised evidence that has examined the effects of collaborative care between general practitioners (GPs) and pharmacists on patients' cardiovascular risk outcomes. This protocol aims to outline the methods employed in a systematic review of current literature to assess whether interprofessional collaboration between GPs and pharmacists has an impact on improving cardiovascular risk outcomes among patients in the primary care setting.

METHODS AND ANALYSIS

Randomised controlled trials (RCTs) will be identified through database searches, scanning reference lists of relevant studies, hand searching of key journals and citation searching of key papers. Two independent reviewers will screen studies against eligibility criteria and extract data using standardised forms. Databases including MEDLINE, EMBASE, Cochrane, CINAHL and International Pharmaceutical Abstracts, will be searched from the beginning of each database until October 2018. Primary outcome includes improvement in cardiovascular risk factors, such as hypertension, due to GP and pharmacist cooperation. Secondary outcome is to describe the different types of GP and pharmacist collaborative models of care. A narrative synthesis of findings will be presented. A meta-analysis will be performed if the data are homogenous.

ETHICS AND DISSEMINATION

This study does not require ethics approval. The results of the systematic review described within this protocol will be disseminated through presentations at relevant conferences and publication in a peer-reviewed journal. The methods will be used to inform future reviews.

PROSPERO REGISTRATION NUMBER

CRD42017055259.

Implementing screening interventions in community pharmacy to promote interprofessional coordination of primary care - A mixed methods evaluation

BACKGROUND

Screening is a critical component of efforts to reduce the population burden of cardiovascular disease (CVD), by facilitating early use of cost-effective prevention and treatment strategies. While international evidence suggests that screening in community pharmacies improves screening access and identifies at-risk individuals, concerns from medical organisations about the absence of interdisciplinary coordination and related lack of continuity of care with general practice have significantly contributed to reluctance from some stakeholders to endorse, and engage with, pharmacy-based screening initiatives. The Cardiovascular Absolute Risk Screening (CARS) study was designed to address these challenges and promote an interprofessional approach to screening for cardiovascular disease risk by pharmacists. This study describes the impact of the CARS implementation model on interdisciplinary coordination and continuity of care.

METHODS

In addition to clinical training, pharmacists at eleven participating pharmacies were provided with implementation training, resources and support to promote interprofessional coordination. Completion of training and pharmacy implementation plans, both of which highlighted GP engagement strategies, were pre-requisites for screening commencement. Using mixed methods approaches, data were analyzed from screening records (n = 388), researcher interviews with patients at 6-10 weeks post-screening (n = 248, 64%), and pharmacist interviews (n = 10).

RESULTS

Screening records suggested that 94% of screened individuals were advised to seek formal GP assessment, and 98% consented to sharing of results. Among interviewed participants, 81% recalled direct pharmacist action to facilitate GP engagement. Among interviewees who had seen their GP already (n = 70), 79% reported that their GP was aware of the results (another 16% were uncertain). Pharmacists reported positive GP feedback stemming from efforts at early engagement, but an absence of ongoing collaboration.

CONCLUSIONS

Use of implementation planning by pharmacists, alongside clinical training, can effectively promote an interdisciplinary coordination focus by pharmacists.

Nutrition Education and Community Pharmacy: A First Exploration of Current Attitudes and Practices in Northern Ireland

Community pharmacist is one of the most prominent and accessible healthcare professions. The community pharmacists’ role in healthcare is evolving, with opportunities being taken to reduce pressure on primary care services. However, the question remains of how well community pharmacists are equipped for this changing role. This was a sequentially designed study using a mix of methods to explore nutrition education among community pharmacists in Northern Ireland. It consisted of two phases. Phase 1 was a cross-sectional exploration to map the attitudes and practice of Northern Ireland (NI) pharmacists towards diet-related health promotion and disease prevention. An online questionnaire with open and closed questions to gain both quantitative and qualitative responses was developed and distributed to community pharmacists practising in NI. A total of 91% considered nutrition important in reducing the global burden of disease. While the majority (89%) believed patients would value nutritional advice from a pharmacist, 74% were not confident in providing advice to a patient with diabetes. From the consensus gained in Phase 1 a nutrition education intervention (Phase 2) for pre-registration pharmacists was developed using the Hardens 10 question system. The training programme was advertised to pre-registration pharmacy students in NI. It was delivered by nutrition experts who have education qualifications. The intervention was evaluated using a before and after questionnaire that assessed knowledge, attitudes, and practice (KAP). Phase 2 did find sustained improvement from the baseline in KAP but there was a decline from immediately post-training to three months post-training. This suggests the need to further embed nutrition education. The education programme was found to be effective for the target population and sets the stage for the development of an implementation strategy for a wider roll-out with evaluation.

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

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

Pharmacy-based alcohol-misuse services: current perspectives

Context

Globally, the use of alcohol is a leading cause of mortality and morbidity. Opportunistic screening and brief interventions (SBIs) have been shown to be effective in reducing alcohol consumption in certain primary care settings and provide a means of reaching some of those who do not seek treatment for alcohol-related problems. Further, community pharmacies have the potential to reach consumers at an early stage of their alcohol use and incorporate intervention and advice into their role in providing medications.

Aim

The purpose of this review was to inform pharmacists and stakeholders of the evidence base for SBI in community pharmacy settings. To date, there has been limited research on the effectiveness of alcohol SBI in community pharmacies, with a systemic review only identifying two randomized trials.

Methods

This narrative review reports on the period 2007–2017, covering feasibility studies, pilot programs, and surveys of consumers and pharmacy staff attitudes relating to alcohol SBI in this setting. Studies were identified via MEDLINE, CINAHL, Google Scholar, and reference lists of relevant publications.

Findings

The findings indicated that the provision of community pharmacy alcohol SBI requires training in communication and intervention skills and in some cases increasing confidence and alcohol-related knowledge. Consumers were generally receptive to the SBI approach but requested private areas for delivery of such.

Conclusion

The high prevalence of “at risk” alcohol use in many countries and the low level of treatment seeking by this group means that novel approaches to engage opportunistically with these people is imperative in reducing alcohol-related harms. However, before committing routine health funding, these novel approaches need rigorous evaluation.

Quasi experimental designs in pharmacist intervention research

Background In the field of pharmacist intervention research it is often difficult to conform to the rigorous requirements of the "true experimental" models, especially the requirement of randomization. When randomization is not feasible, a practice based researcher can choose from a range of "quasi-experimental designs" i.e., non-randomised and at time non controlled. Objective The aim of this article was to provide an overview of quasi-experimental designs, discuss their strengths and weaknesses and to investigate their application in pharmacist intervention research over the previous decade. Results In the literature quasi experimental studies may be classified into five broad categories: quasi-experimental design without control groups; quasi-experimental design that use control groups with no pre-test; quasi-experimental design that use control groups and pre-tests; interrupted time series and stepped wedge designs. Quasi-experimental study design has consistently featured in the evolution of pharmacist intervention research. The most commonly applied of all quasi experimental designs in the practice based research literature are the one group pre-post-test design and the non-equivalent control group design i.e., (untreated control group with dependent pre-tests and post-tests) and have been used to test the impact of pharmacist interventions in general medications management as well as in specific disease states. Conclusion Quasi experimental studies have a role to play as proof of concept, in the pilot phases of interventions when testing different intervention components, especially in complex interventions. They serve to develop an understanding of possible intervention effects: while in isolation they yield weak evidence of clinical efficacy, taken collectively, they help build a body of evidence in support of the value of pharmacist interventions across different practice settings and countries. However, when a traditional RCT is not feasible for logistical and/or ethical reasons researchers should endeavour to use the more robust of the quasi experimental designs.

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

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

Exploring an increased role for Australian community pharmacy in mental health professional service delivery: evaluation of the literature. J Ment Health 2015;25:550-559. [PMID: 26607639 DOI: 10.3109/09638237.2015.1101418]

BACKGROUND

Australian general practitioners primarily treat mental health problems by prescribing medication dispensed by community pharmacists. Pharmacists therefore have regular interactions with mental health consumers and carers.

AIMS

This narrative review explored the potential role of community pharmacy in mental health services.

METHOD

Medline, CINAHL, ProQuest, Emerald, PsycINFO, Science Direct, PubMed, Web of Knowledge and IPA were utilised. The Cochrane Library as well as grey literature and "lay" search engines such as GoogleScholar were also searched.

RESULTS

Four systematic reviews and ten community pharmacy randomised controlled trials were identified. Various relevant reviews outlining the impact of community pharmacy based disease state or medicines management services were also identified.

CONCLUSION

International studies involving professional service interventions for mental health consumers could be contextualised for the Australian setting. Australian studies of pharmacy professional services for chronic physical health conditions provided further guidance for the expansion of community pharmacy mental health professional services.

Community pharmacy interventions for public health priorities: protocol for a systematic review of community pharmacy-delivered smoking, alcohol and weight management interventions

BACKGROUND

Community pharmacists can deliver health care advice at an opportunistic level, related to prescription or non-prescription medicines and as part of focused services designed to reduce specific risks to health. Obesity, smoking and excessive alcohol intake are three of the most significant modifiable risk factors for morbidity and mortality in the UK, and interventions led by community pharmacists, aimed at these three risk factors, have been identified by the government as public health priorities. In 2008, the Department of Health for England stated that 'a sound evidence base that demonstrates how pharmacy delivers effective, high quality and value for money services is needed'; this systematic review aims to respond to this requirement.

METHODS/DESIGN

We will search the databases MEDLINE, Embase, CINAHL, PsycINFO, Social Sciences Citation Index, ASSIA, IBSS, Sociological Abstracts, Scopus and NHS Economic Evaluation Database for studies that have evaluated interventions based on community pharmacies that aim to target weight management, smoking cessation and alcohol misuse. We will include all randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after studies (CBAs) and interrupted time series (ITS) and repeated measures studies. Data from included studies will be extracted by two independent reviewers and will include study details methods, results, intervention implementation/costs and methodological quality. Meta-analysis will be conducted if appropriate; if not, the synthesis will be restricted to a narrative overview of individual studies looking at the same question.

DISCUSSION

The review aims to summarise the evidence base on the effectiveness of community pharmacy interventions on health and health behaviours in relation to weight management, smoking cessation and alcohol misuse. It will also explore if, and how, socio-economic status, gender, ethnicity and age moderate the effect of the interventions and will describe how the interventions included in the review have been organised, implemented and delivered, since context is an important factor governing the success of public health interventions. The findings from this review will have an impact on the commissioning of public health services aiming to promote healthy weight, smoking cessation and prevent excessive alcohol consumption.

SYSTEMATIC REVIEW REGISTRATION

The review has been registered with PROSPERO (registration no. CRD42013005943). Available at: http://www.crd.york.ac.uk/prospero/display_record.asp?ID=CRD42013005943.

Aspirin for cardioprotection and strategies to improve patient adherence

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in North America. Aspirin therapy has proven clinical effectiveness in the prevention and treatment of CVD and is one of the most widely used drugs nationwide. However, despite the medication's popularity and utility, adherence to a proper aspirin regimen is suboptimal, resulting in adverse health outcomes and increased health care costs. Our review outlines current knowledge on aspirin therapy adherence, causes of nonadherence, and strategies available to increase adherence to aspirin and medications in general. We demonstrate that, indeed, aspirin adherence rates are suboptimal, ranging from 72% to 92%, and that a combination of patient- and medication-related factors contribute to nonadherence. A multidimensional approach involving patient education and medication innovations to reduce aspirin side effects is imperative to improving rates of aspirin therapy adherence.

The Cardiovascular Intervention Improvement Telemedicine Study (CITIES): rationale for a tailored behavioral and educational pharmacist-administered intervention for achieving cardiovascular disease risk reduction

BACKGROUND

Hypertension, hyperlipidemia, and diabetes are significant, but often preventable, contributors to cardiovascular disease (CVD) risk. Medication and behavioral nonadherence are significant barriers to successful hypertension, hyperlidemia, and diabetes management. Our objective was to describe the theoretical framework underlying a tailored behavioral and educational pharmacist-administered intervention for achieving CVD risk reduction.

MATERIALS AND METHODS

Adults with poorly controlled hypertension and/or hyperlipidemia were enrolled from three outpatient primary care clinics associated with the Durham Veterans Affairs Medical Center (Durham, NC). Participants were randomly assigned to receive a pharmacist-administered, tailored, 1-year telephone-based intervention or usual care. The goal of the study was to reduce the risk for CVD through a theory-driven intervention to increase medication adherence and improve health behaviors.

RESULTS

Enrollment began in November 2011 and is ongoing. The target sample size is 500 patients.

CONCLUSIONS

The Cardiovascular Intervention Improvement Telemedicine Study (CITIES) intervention has been designed with a strong theoretical underpinning. The theoretical foundation and intervention are designed to encourage patients with multiple comorbidities and poorly controlled CVD risk factors to engage in home-based monitoring and tailored telephone-based interventions. Evidence suggests that clinical pharmacist-administered telephone-based interventions may be efficiently integrated into primary care for patients with poorly controlled CVD risk factors.