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)

Landscape of Lipid Management Following an Acute Coronary Syndrome Event: Survey of Canadian Specialists

Background

Following the occurrence of an acute coronary syndrome (ACS), patients are at high risk for subsequent cardiovascular events. Therapies to lower the level of low-density lipoprotein (LDL) cholesterol remain a pillar in secondary prevention approaches following ACS. Significant variability remains in the application of therapies to lower cholesterol level in clinical practice.

Methods

A cross-sectional, online survey was conducted of 200 cardiovascular and lipid specialists across Canada who routinely care for patients following the occurrence of ACSs. The survey consisted of 50 multiple-choice questions with opportunities for free-text entry exploring knowledge of lipid guidelines and recent clinical trials, and in-hospital and outpatient management of lipids and familial hypercholesterolemia.

Results

A total of 67.5% (n = 135) of participants stated that a lipid panel would routinely be obtained during the first 24 hours of an admission for an ACS, and 68.5% (n = 137) stated that their hospitals had standing orders for statin initiation at ACS presentation. In high-risk patients, the majority (75.5%; n = 151) of participants indicated that they target an LDL cholesterol level of <1.8 mmol/L. However, a subset (22%; n = 44) would target lower LDL cholesterol levels ranging from 0.5 to 1.7 mmol/L. Only 32.0% (n = 64) of participants stated that >70% of their ACS patients were at or below guideline-recommended LDL cholesterol levels. Respondents generally underappreciated the prevalence of familial hypercholesterolemia in both the general population and ACS patients.

Conclusions

There is significant variation in practice patterns involving therapies to lower LDL cholesterol level in the post–ACS onset period. To improve management of lipids in this high-risk population, changes to institutional policies, shared responsibility of lipid management across multiple disciplines, and physician education are required.

Long-term impact of pharmacist intervention in patients with bipolar disorder: extended follow-up to the EMDADER-TAB study

Background

Pharmaceutical care (PC) through the Dader method (DMet) vs. the usual care process (UCP) significantly reduced psychiatric hospitalizations and emergency service consultations during one year of follow-up of outpatients with bipolar I disorder (BD-I). To date, the effect of long-term PC on the use of health services by BD-I patients once pharmacist intervention has ended is unknown.

Objective

To determine whether the effect of PC measured by the decrease in psychiatric hospitalizations and emergency service consultations is maintained one year after pharmacist intervention ceases.

Methods

This was a retrospective analysis of patients who had previously participated in a randomized, controlled, prospective, single-center clinical trial to compare PC (intervention group) vs. UCP (control group) in BD-I patients. Data were collected from November 2012 to March 2014. The primary outcome was the use of health services measured by the number of psychiatric hospitalizations and emergency service consultations. Descriptive statistics, Student's t-test, Kaplan–Meier function, and Log-Rank test were used.

Results

The study included 92 patients: 43 in the intervention group and 49 in the control group. Eleven psychiatric hospitalizations occurred for the intervention group and 19 for the control group. One year after pharmacist intervention ceased, there were no significant differences between the groups in psychiatric hospitalizations (p = 0.261). There were 14 emergency service consultations for the intervention group, and 24 for the control group without significant differences (p = 0.212).

Conclusions

PC through the DMet has no long-term effects on psychiatric hospitalizations and emergency department consultations in patients with BD-I following discontinuation of pharmacist intervention; the effect dissipates when the intervention ceases. Future studies should focus efforts on identifying factors associated with PC that explain why the outcomes derived from this intervention are not maintained in the long term.

Community pharmacists' perspectives on shared decision-making in diabetes management

OBJECTIVES

Shared decision-making (SDM) is an approach where patients and clinicians share evidence and patients are supported to deliberate options resulting in preference-based informed decisions. The aim of this study was to describe community pharmacists' perceptions and awareness of SDM within their provision of general diabetes management [including Ontario's MedsCheck for Diabetes (MCD) programme], and potential challenges of implementing SDM within community pharmacy.

METHODS

This qualitative study used semistructured interviews with a convenience sample of community pharmacists. Data were analysed using thematic analysis.

KEY FINDINGS

We conducted 16 interviews. Six participants were male, and nine were certified diabetes educators. When providing a MCD, participants used aspects of a patient-centred approach focusing on providing education. Variation was evident in participants' description and use of SDM, as well as in their perceived level of training in SDM. Participants also highlighted challenges surrounding implementing a SDM approach in practice.

CONCLUSION

Pharmacists are well positioned to apply SDM within community settings; however, implementation barriers exist. Pharmacists will require additional training as well as perceived patient and physician barriers should be addressed to encourage uptake.

Clinical pharmacist understanding of the 2013 American College of Cardiology/American Heart Association cholesterol guideline

BACKGROUND

Clinical pharmacists are frequently involved in the management of dyslipidemia, yet clinical pharmacists' knowledge, awareness, and the level of agreement with the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol guideline are unknown.

OBJECTIVE

The objective of the study was to examine clinical pharmacists' knowledge, awareness, and the level of agreement with the 2013 ACC/AHA cholesterol guideline.

METHODS

We administered a validated questionnaire via an online survey that was electronically mailed to clinical pharmacists. We compared responses between those in practice for ≤ 10 and those in practice for > 10 years, and according to practice specialty.

RESULTS

The response rate was 11% (314 of 2845). Most respondents were from the Midwestern and Southeastern US, in practice for ≤ 10 years, and practiced in family practice/primary care. Nearly all (92%) respondents had read the guideline and 72% were able to identify the 4 statin benefit groups. Notable knowledge gaps included recalling the 4 outcomes of the 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimator (41.4%), understanding differences between the Framingham Risk Score and the ASCVD risk estimator (33.7%), and monitoring lipids after initiating a statin (41.1%). More knowledge gaps were identified in those practicing for > 10 years and who specialized in internal medicine. The use of the ASCVD risk estimator was high; yet nearly half (44.2%) were concerned whether the ASCVD risk estimator would overestimate 10-year ASCVD risk.

CONCLUSION

Although most clinical pharmacists had read the 2013 ACC/AHA cholesterol guideline, several knowledge gaps were identified, especially among those with more experience and those practicing in internal medicine. Targeted education efforts are needed to address these gaps.

Cholesterol Point-of-Care Testing for Community Pharmacies: A Review of the Current Literature

Objective:

To summarize the literature on cholesterol point-of-care tests (POCTs). This article would serve as a resource to assist community pharmacists in developing cholesterol point-of-care (POC) pharmacy services.

Data Sources:

A literature search was performed in MEDLINE Ovid, PubMed, EMBASE, and Cochrane database using the following medical subject headings (MeSH) terms: point-of-care test, cholesterol, blood chemical analysis, rapid testing, collaborative practice, community pharmacy, and ambulatory care. Additional resources including device manufacturer web sites were summarized to supplement the current literature.

Study Selection and Data Extraction:

All human research articles, review articles, meta-analyses, and abstracts published in English through September 1, 2014, were considered.

Data Synthesis:

A total of 36 articles were applicable for review. Information was divided into the following categories to be summarized: devices, pharmacists’ impact, and operational cost for the pharmacy.

Conclusions:

The current literature suggests that POCTs in community pharmacies assist with patient outcomes by providing screenings and referring patients with dyslipidemia for further evaluation. The majority of studies on cholesterol POC devices focused on accuracy, revealing the need for further studies to develop best practices and practice models with successful reimbursement. Accuracy, device specifications, required supplies, and patient preference should be considered when selecting a POC device for purchase.

Impact of an interactive workshop on community pharmacists' beliefs toward patient care

BACKGROUND

Patient assessment and documentation are less than optimal in pharmacy practice as preparing and dispensing medications is still a major part of community pharmacy practice. Pharmacists' attitudes, specifically self-efficacy and role beliefs, toward practice have been shown to predict practice change.

OBJECTIVE

This study will determine the impact of an interactive workshop on pharmacists' attitudes toward assessment and documentation in routine pharmacy practice. Specific objectives included how (1) pharmacists' role beliefs and self-efficacy toward assessment and documentation change after training and rehearsal and (2) frequently do pharmacists assess patient therapy and document patient care?

SETTING

"Chat, Check and Chart: patient assessment and documentation demystified" workshop Alberta College of Pharmacists Annual General Meeting in Calgary, Canada.

METHODS

This study is pre-post evaluation. Quantitative data on self-efficacy and role beliefs toward assessment and documentation was gathered from a validated written survey. Surveys were completed before and after the intervention. The intervention, an interactive workshop, focused on the use of three tools practice and was designed to support pharmacists in achieving the assessment and documentation required by the Alberta College of Pharmacists Standards for Practice.

MAIN OUTCOME MEASURE

Pharmacists' role beliefs and self-efficacy toward assessment and documentation in patient care.

RESULTS

Of the 61 eligible pharmacists, the response rate was 61 % (37 pharmacists) with complete data. In the past 2 weeks, 54 % of pharmacists were assessing patients and 32.6 % of pharmacists were documenting greater than half the time. Prior to the workshop, pharmacists "agreed" (5.42 ± 1.41) with their role in patient assessment and they were "quite sure" (4.75 ± 1.10) they could assess patients. Pharmacists "agreed" (5.13 ± 0.890) with their overall role in documentation of patient interactions and reported lower self-efficacy (3.88 ± 1.32) for their ability to document patient interactions. After the interactive workshop, there were statistically significant increases in pharmacists' self-efficacy and role beliefs in regards to both patient assessment and documentation (p < 0.05).

CONCLUSION

This brief interactive workshop increased both self-efficacy and role beliefs towards assessment and documentation, indicating these pharmacists are likely to change future practice. Future research will assess practice uptake and implementation.

Lifestyle changes for prehypertension with other cardiovascular risk factors: findings from Thailand

OBJECTIVE

To evaluate a model for community pharmacists to screen and recommend lifestyle changes for patients with prehypertension/hypertension and other elevated modifiable cardiovascular risk factors.

DESIGN

Descriptive, exploratory, nonexperimental study.

SETTING

One accredited community pharmacy in Hat Yai, Thailand, between October 2008 and January 2009.

PARTICIPANTS

Individuals 35 years or older without any previous diagnosis of hypertension and other cardiovascular disease.

INTERVENTION

Measurement of blood pressure, blood glucose, total cholesterol, and body mass index; history taking for smoking and physical exercise; laboratory referral; assessment of readiness to adopt lifestyle changes; and provision of verbal advice and an education pamphlet on cardiovascular risk factors and recommended lifestyle modifications.

MAIN OUTCOME MEASURES

Number of prehypertensive/hypertensive participants, patient return rate at 3-month follow-up, rate of laboratory referral uptake, confirmed glucose intolerance and dyslipidemia, and changes from baseline in blood pressure level.

RESULTS

263 of 400 people eligible for screening were found to have prehypertension or hypertension. Of these patients, 57% returned at 3-month follow-up. Mean (±SE) systolic (6.5 ± 0.89 mm Hg [95% CI 4.7-8.2], P < 0.001) and diastolic (2.2 ± 0.82 [0.54-3.77], P = 0.009) blood pressure were lowered. Compared with baseline (39.3%), the percentage of normotensive participants increased significantly at 3-month follow-up (51.8%; P < 0.001). The overall laboratory referral uptake was 36% (50 of 138). Glucose intolerance was confirmed in 2 of 21 participants. Of the 42 patients accepting laboratory confirmation, total and low-density lipoprotein cholesterol were confirmed to be above the normal range in 100% and 78.6%, respectively. Among these participants, those who returned at follow-up were rescreened for blood glucose and total cholesterol. Both values were found to be in the normal range. Although more participants reported lifestyle changes at 3 months, the smoking rate and amount of physical exercise were not changed.

CONCLUSION

Community pharmacists, through the use of point-of-care testing and referrals for laboratory testing, can detect patients who are at risk of developing or already have hypertension, diabetes, and/or dyslipidemia. Lifestyle advice from pharmacists can have a positive effect on these risk factors.

Diabetes and cardiovascular disease interventions by community pharmacists: a systematic review

OBJECTIVE

To systematically review and assess the quality of studies evaluating community pharmacist interventions for preventing or managing diabetes or cardiovascular disease (CVD) and/or their major risk factors.

DATA SOURCES

A comprehensive literature search was performed using MEDLINE (1950-February 2011), EMBASE (1980-February 2011), International Pharmaceutical Abstracts (1970-February 2011), Cumulative Index to Nursing and Allied Health Literature (1982-June 2007), and Cochrane Central Register of Controlled Trials (1898-February 2011). Search terms included: community pharmacy(ies), community pharmacist(s), cardiovascular, diabetes, and intervention. The grey literature was searched using the ProQuest Dissertations and Theses, Theses Canada, and OAlster databases.

STUDY SELECTION AND DATA EXTRACTION

Articles published in English or French with all study designs were considered for the review. Studies were included if they contained interventions designed to reduce the incidence, risk, or mortality of CVD or diabetes; affect clinical indicators of CVD or diabetes mellitus (including hypertension, dyslipidemia, or hemoglobin A(1c)); and/or improve adherence to treatment strategies. Only studies involving interventions carried out primarily by pharmacists in community pharmacy settings were included. Study quality was assessed using a checklist validated for both randomized and nonrandomized studies.

DATA SYNTHESIS

A total of 4142 studies were initially identified, with 40 meeting our inclusion criteria. Eleven studies were randomized controlled trials, 4 were cluster randomized trials, and 2 studies had randomized before-after designs. The remaining studies were controlled before-after (n = 2), cohort (n = 4), and uncontrolled before-after (n = 17) designs. Interventions focused on diabetes (n = 12), hypertension (n = 9), medication adherence (n = 9), lipids (n = 5), evidence-based medication initiation or optimization (n = 3), risk factor prediction scores (n = 1), and body mass index (n = 1). All studies contained interventions focused at the patient level and the majority of studies (34/40) involved interventions directed at both the physician and patient. No specific intervention emerged as superior, and study quality was generally poor, making it difficult to determine the true effect of the interventions.

CONCLUSIONS

Poor study quality, time-intensive interventions, and unproven clinical significance warrant the need for further high-quality studies of community pharmacist interventions for preventing or managing diabetes or CVD and/or their major risk factors.

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.

PharmacistCARE: description of a pharmacist care service and lessons learned along the way

OBJECTIVE

To describe the PharmacistCARE program, an innovative pharmacy practice model implemented within a self-insured employer and to describe lessons learned by the authors in implementing and maintaining the program.

SETTING

University of Kentucky (UK), March 2003 to present.

PRACTICE DESCRIPTION

A free-standing pharmacist clinic located within an ambulatory care facility owned by UK HealthCare.

PRACTICE INNOVATION

PharmacistCARE, a pharmacist-provided patient care service for UK Health Plan members that includes comprehensive disease and medication therapy management.

MAIN OUTCOME MEASURES

Various lessons learned by the authors during development, implementation, and maintenance of the program.

RESULTS

The program has been recognized by the university as a positive contribution to health plan service enhancement and cost savings and has documented enhanced patient care outcomes.

CONCLUSION

The PharmacistCARE program is a unique pharmacist-provided service delivered in a free-standing pharmacist clinic that enhances health outcomes for adult members in a self-insured employer group.

Control of modifiable risk factors in ischemic stroke outpatients by pharmacist intervention: an equal allocation stratified randomized study

OBJECTIVE

To evaluate the adequacy of management of modifiable risk factors (MRF) in a group of ischemic stroke outpatients and the value of pharmacist intervention in a randomized controlled study in a tertiary referral hospital.

METHODS

160 ischemic stroke outpatients from the same catchment area and with the same financial arrangements for healthcare, went through a 6-month equal allocation stratified randomized study. Routine practice was not altered except for a monthly 1-hour pharmacist-intervention education programme. We evaluated the differences in blood pressure (BP), blood glucose and lipid profiles before and after study. The proportion of patients with adequate management of MRF was studied.

RESULTS

There were no differences in the demographic characteristics, MRF and medications prescribed throughout the study. Before the study, the proportions of adequate control of BP in the control and intervention groups were 43% vs. 40% (P = 0.64), lipid 27% vs. 13% (P = 0.09) and glucose 36% vs. 21% (P = 0.15) . At the end of the study, the corresponding proportions were for BP 43% vs. 83% (P = 0.00), lipid 27% vs. 40% (P = 0.16) and glucose 46% vs. 35% (P = 0.40).

CONCLUSION

Pharmacist intervention was associated with improved BP control but not with the other MRF. Earlier initiation and longer duration of intervention may improve the outcome further, and whether targeting of high-risk subjects may be particularly rewarding is worthy of investigation.

Sensitivity of Patient Outcomes to Pharmacist Interventions. Part III: Systematic Review and Meta-Analysis in Hyperlipidemia Management

Background

Hyperlipidemia increases the risk of cardiovascular diseases, and control is pivotal ror preventing disease complications. Multidisciplinary interventions, including those performed by pharmacists, are important for improving patients’ outcomes.

Objective:

To quantify the impact of pharmacist interventions in enhancing patients’ outcomes.

Methods

TWO reviewers searched International Pharmaceutical Abstracts, MEDLINE, EMBASE, The Cochrane Central Register of Controlled Trials. 3rd Quarter, and Cumulative Index to Nursing and Allied Health Literature (all from inception to July 2007) for pharmacist interventions in hyperlipidemia. Quality was assessed using the Downs-Black scale. Data extracted included the number of patients enrolled; study characteristics; intervention type; and pre- and postintervention measures for low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides, total cholesterol, adherence, and quality of life. A random effects meta-analysis combined data. Heterogeneity of effects was tested using χ5 analysis. Publication bias was assessed using funnel plots and the Begg-Mazumdar statistic.

Results:

Forty-eight studies were found; 23 met inclusion criteria. Study settings included medical clinic/center (n = 12), community pharmacy (n = 8), hospital (n = 2), and patient homes (n = 1). Article quality was good (71% ± 7.0%). Patient education (78%) and medication management (74%) were the most common interventions. Total cholesterol was significantly reduced from baseline (mean ± SD; 34.3 ± 10.3 mg/dL; p < 0.001) and above that for controls (22.0 ± 10.4 mg/dL: p = 0.034). LDL-C was reduced significantly from baseline (32.6 ± 11.3 mg/dL; p = 0.004), but not significantly more than controls (17.5 ± 10.9 mg/dL; p = 0.109). A clinically relevant but not statistically significant reduction in triglycerides was found. No impact on HDL-C levels was found. Patients’ adherence to pharmacotherapeutic regimens and quality of life were considered possibly not sensitive and possibly sensitive to pharmacist interventions, respectively.

Conclusions:

Total cholesterol is sensitive to pharmacist interventions, while LDL-C and triglyceride levels are possibly sensitive to those interventions. Further research is required for these outcomes.