Laurence A Goldberg
HPE Editorial Consultant
More than 650 pharmacists gathered in Vilnius, Lithuania in May 2006 for the 6th ESCP Spring Conference. The conference theme was the role of the pharmacist in chronic disease management.
Pharmacy-based hypertension management
The joint WHO CINDI (Countrywide Integrated Non-communicable Disease Intervention) and Europharm Forum hypertension project has now been in operation for 10 years, Suzete Costa (Task Force Manager – joint WHO CINDI and Europharm forum on pharmacy-based hypertension management) told the audience. This multidisciplinary project is concerned with the development and implementation of a pharmacy-based service model of best practice and tools that contribute to optimal control of hypertension through the active involvement of community pharmacists at various levels.
Guidelines for pharmacy-based management of hypertension were drafted in 1999 and pilot demonstration projects were set up in six countries – Estonia, Latvia, Lithuania, Portugal, Slovenia and Spain. As a result of the pilot projects, three levels of intervention were defined – primary prevention, detection and management of hypertensive patients in treatment – and the final version of the guidelines was drafted.
Primary prevention involves counselling patients with unfavourable cardiovascular disease (CVD) risk profiles. Detection involves screening for CVD risk factors, including hypertension. Management involves monitoring patients who are receiving treatment for hypertension and undertaking blood pressure measurement, identification and reporting of drug-related problems to the patient’s general practitioner (GP), reinforcing compliance, giving advice on medication, counselling on lifestyle issues and providing advice on self-measurement of blood pressure.
A comprehensive protocol complete with sample documents has been produced (see Resource).
Pharmacist-managed lipid clinic
A pharmacy-managed lipid clinic has succeeded in achieving control of blood lipids for a greater proportion of patients than large published studies, according to Todd S Paulsen (University of Nebraska Medical Center, College of Pharmacy). Dr Paulsen described how a lipid clinic was set up at the Veterans Affairs hospital in Grand Island, Nebraska in 1994. It now runs with four clinical pharmacists who have no dispensing role, three pharmacy residents and three or four pharmacy students on monthly rotations. More than 3,500 patients are registered with the clinic and the pharmacists have independent prescriptive authority, which allows them to write prescriptions. Patients are referred to the clinic by their physicians through an electronic process. At the initial clinic visit a pharmacy student takes a full history. A pharmacist then calculates the risks of coronary heart disease and discusses the treatment options with the patients. Treatment is prescribed electronically and sent to the pharmacy for checking and dispensing. Patients are monitored and followed until they reach their blood lipid target, when they are discharged to the care of their GPs.
More than 800 pharmacists in the UK have now completed training to become supplementary prescribers, Fiona Reid (Chairman of the National Pharmacy Cardiovascular Group, Scotland) told the audience. Mrs Reid has been a prescriber herself for the past two years.
Prescribing by pharmacists is intended to improve access to medicines for patients and to reduce the workload of doctors in chronic disease management. Supplementary prescribing is defined as “a voluntary partnership between an independent prescriber (a doctor or a dentist) and a supplementary prescriber (who could be a pharmacist or a nurse) to implement an agreed patient-specific clinical management plan with the patient’s agreement”. The independent prescriber always retains the responsibility for making a diagnosis, but thereafter treatment can be managed by a supplementary prescriber, explained Mrs Reid.
Additional training is required before a pharmacist can register as a supplementary prescriber. This involves 25 days of university-accredited training to provide the underpinning knowledge, including training in therapeutics, care planning, public health and consultation skills. In addition, a minimum of 12 days training in practice under medical supervision is required to demonstrate that the candidate has the required competencies to prescribe in practice.
Essential requirements for supplementary prescribing include the clinical management plan (CMP), communication between the independent and supplementary prescribers and shared access to the patient’s medical records. Mrs Reid works with a CMP for the management of hypertension both for primary prevention of cardiovascular disease and for the treatment of essential hypertension. The plan specifies the drug groups that can be prescribed, the monitoring required and the period for which treatment can be given. This reflects Mrs Reid’s level of experience; a less experienced prescriber might be limited to specific drug products and shorter periods of treatment, she explained. She runs four clinic sessions per week during which she sees 12–14 patients for 15-minute appointments. She now has 450 patients under her care.
The problems that have been encountered in primary care have included:
- Finding sufficient doctors who were willing to act as mentors.
- Lack of IT support.
- Access to medical records.
- Funding problems.
- Competence to handle multiple comorbidities.
- Poor understanding of the scheme by other healthcare professionals and patients.
Another issue has been pharmacists’ confidence in their own ability to prescribe. “Prescribing is a big step – confidence is an issue,” said Mrs Reid.
Feedback from GPs has confirmed that the scheme has allowed more time for them to deal with complex patients. They also said that treatment was quicker and more aggressive when the pharmacist prescribed because they followed treatment guidelines. Feedback from patients indicated that they were very satisfied with the service. One had said, “(She is) more knowledgeable about her subject and committed to her patients.”.
Adherence in HIV patients
Since the introduction of triple therapy, the lifespan of patients with HIV infection has increased considerably and this has made the issue of adherence to treatment more important, explained Hervé Trout (Clinical Pharmacist, Hôpital Lariboisière, Paris). As part of his practice he has developed an inpatient and outpatient therapeutic consultation service for HIV-infected patients.
HIV targets a receptor on CD4 cells. Once inside the cell the virus borrows the tools of replication and multiplies. As many as 10(9) virus particles can be produced daily and CD4 cells are destroyed in the process. Over a period of months or years the CD4 count decreases slowly and viral load remains low. However, reservoirs of HIV are formed in the muscles, genitals and in the central nervous system. When CD4 levels fall to 200/mm(3), treatment with antiviral agents should be started. Intermittent treatment will inevitably lead to viral resistance and treatment failure, warned Dr Trout.
There can be many reasons for nonadherence. These include side-effects such as lipodystrophy and poor understanding of the disease but also complexity of treatment regimens, not feeling ill and fear of the illness. Another aspect is the desire to stay anonymous; taking tablets at meal times or in a shared bedroom draws attention to the sufferer, explained Dr Trout. “The patients need to be aware of the ins and outs of the disease and it is important for the clinical pharmacist to adapt the language to the level of understanding – some of these patients never went to school in their native Africa and cannot read or write,” he added.
A therapeutic education programme is designed for each patient. This identifies the competencies that the patient needs in order to manage his/her treatment effectively. Once the patient’s commitment is gained the programme can start. Dr Trout likened it to an apprenticeship in which the patient is deeply involved; it must make sense to the patient, it must be understandable and the patient must have control over it.
One simple example of this is a diagram to show how 12-hourly doses should be taken, showing that there is a window of six hours during which a missed dose could still be taken. If the six-hour interval is exceeded then the dose must be missed because it will be too close to the next one.
Education is a continuous process and it is essential to get feedback on what the patient has learned. It is also important to move at the patient’s pace. Dr Trout also makes use of reminder charts, pill identification charts and cartoons to explain how the disease is transmitted, as well as a competence chart to record the individual’s progress. The pharmacist must adapt and customise for each patient. The goal of the programme is total independence for the patient, he reminded the audience.
The clinical pharmacist can play an important role in the care of patients with tuberculosis (TB), according to Philip Clark (Clinical Pharmacy Tutor, Yeditepe University, Istanbul).
About three million people die of TB infection each year, making it the second greatest global killer after AIDS. It is estimated that one-third of the world’s population is infected with Mycobacterium tuberculosis. The incidence of the disease is highest in sub-Saharan Africa and the incidence is higher in Eastern Europe than in the West. In Turkey, where Dr Clark works, the annual incidence is 29 cases per 100,000 people.
Factors that have contributed to the global increase in TB include the development of multidrug resistant (MDR) organisms, coinfection with HIV and the inadequacy of preventive programmes. Treatment failure is also an important issue and the reasons for this include nonadherence, inadequate treatment regimens, early termination of treatment and primary resistance.
Treatment for patients with MDR TB needs to be continued for two years and so adherence to treatment becomes critically important. Directly-observed treatment (DOT) and patient education are two ways of improving adherence. A controlled study undertaken in Istanbul assessed the impact of pharmacist-directed patient education on adherence in 114 first-time TB patients. After two months of inpatient treatment, participants were randomised to receive routine care or oral and written education by the pharmacist before discharge. Follow-up and adherence assessments were then conducted one, two and four months postdischarge. Adherence was measured by urine analysis for the presence of isoniazid (INH) metabolites and by tablet counts. The results showed that 80% of the patients who had received the patient education tested positive for INH metabolites compared with 42% of the control group. Patients in the control group also attended fewer follow-up visits.
Patients with TB often have other pharmaceutical care needs, including pain control, respiratory problems, nutrition problems and diabetic control, noted Dr Clark. The most common of these was pain control. Many patients experienced joint pain related to treatment with ethionamide or pyrazinamide. This could usually be controlled with nonsteroidal anti-inflammatory agents, he said.