Meagen Rosenthal

Are Pharmacists the Ultimate Barrier to Pharmacy Practice Change

for pharmacists to provide “optimal drug therapy outcomes for Canadians through patient-centred care” has been accepted by all Canadian pharmacy organizations. This means a shift from dispensing and technical duties to a particular focus on services that improve patient outcomes. However, practice change of this nature has been discussed for many years, and few programs have been fully successful or sustainable over the long term.

Randomized Trial of the Effect of Pharmacist Prescribing on Improving Blood Pressure in the Community The Alberta Clinical Trial in Optimizing Hypertension (RxACTION)

Background— Hypertension control rates remain suboptimal. Pharmacists’ scope of practice is evolving, and their position in the community may be ideal for improving hypertension care. We aimed to study the impact of pharmacist prescribing on blood pressure (BP) control in community-dwelling patients. Methods and Results— We designed a patient-level, randomized, controlled trial, enrolling adults with above-target BP (as defined by Canadian guidelines) through community pharmacies, hospitals, or primary care teams in 23 communities in Alberta. Intervention group patients received an assessment of BP and cardiovascular risk, education on hypertension, prescribing of antihypertensive medications, laboratory monitoring, and monthly follow-up visits for 6 months (all by their pharmacist). Control group patients received a wallet card for BP recording, written hypertension information, and usual care from their pharmacist and physician. Primary outcome was the change in systolic BP at 6 months. A total of 248 patients (mean age, 64 years; 49% male) were enrolled. Baseline mean±SD systolic/diastolic BP was 150±14/84±11 mm Hg. The intervention group had a mean±SE reduction in systolic BP at 6 months of 18.3±1.2 compared with 11.8±1.9 mm Hg in the control group, an adjusted difference of 6.6±1.9 mm Hg (P=0.0006). The adjusted odds of patients achieving BP targets was 2.32 (95% confidence interval, 1.17–4.15 in favor of the intervention). Conclusions— Pharmacist prescribing for patients with hypertension resulted in a clinically important and statistically significant reduction in BP. Policy makers should consider an expanded role for pharmacists, including prescribing, to address the burden of hypertension. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00878566.

Improving hypertension management through pharmacist prescribing; the rural alberta clinical trial in optimizing hypertension (Rural RxACTION): trial design and methods

BackgroundPatients with hypertension continue to have less than optimal blood pressure control, with nearly one in five Canadian adults having hypertension. Pharmacist prescribing is gaining favor as a potential clinically efficacious and cost-effective means to improve both access and quality of care. With Alberta being the first province in Canada to have independent prescribing by pharmacists, it offers a unique opportunity to evaluate outcomes in patients who are prescribed antihypertensive therapy by pharmacists.MethodsThe study is a randomized controlled trial of enhanced pharmacist care, with the unit of randomization being the patient. Participants will be randomized to enhanced pharmacist care (patient identification, assessment, education, close follow-up, and prescribing/titration of antihypertensive medications) or usual care. Participants are patients in rural Alberta with undiagnosed/uncontrolled blood pressure, as defined by the Canadian Hypertension Education Program. The primary outcome is the change in systolic blood pressure between baseline and 24 weeks in the enhanced-care versus usual-care arms. There are also three substudies running in conjunction with the project examining different remuneration models, investigating patient knowledge, and assessing health-resource utilization amongst patients in each group.DiscussionTo date, one-third of the required sample size has been recruited. There are 15 communities and 17 pharmacists actively screening, recruiting, and following patients. This study will provide high-level evidence regarding pharmacist prescribing.Trial RegistrationClinicaltrials.gov NCT00878566.

A randomized trial of a community-based approach to dyslipidemia management Pharmacist prescribing to achieve cholesterol targets (RxACT Study)

Background: Dyslipidemia is an important risk factor for cardiovascular disease but is suboptimally managed. Pharmacists are accessible primary care professionals and with expanded scopes of practice (including prescribing), could identify and manage patients with dyslipidemia. We sought to evaluate the effect of pharmacist prescribing of dyslipidemia medications on the proportion of participants achieving target LDL-cholesterol (LDL-c) levels. Methods: We conducted a randomized controlled trial in 14 community pharmacies in Alberta, Canada. We enrolled adults with uncontrolled dyslipidemia as defined by the 2009 Canadian Dyslipidemia Guidelines. Intervention was pharmacist-directed dyslipidemia care, including assessment of cardiovascular risk, review of LDL-c, prescribing of medications, health behaviour interventions and follow-up every 6 weeks for 6 months. Usual care patients received their lipid results and a pamphlet on cardiovascular disease and usual care from their physician and pharmacist. Primary outcome was the proportion of participants achieving their target LDL-c (<2 mmol/L or ≥50% reduction) at 6 months between groups. Results: We enrolled 99 patients with a mean (SD) age of 63 (13) years, 49% male and baseline LDL-c of 3.37 mmol/L (0.98). Proportion of patients achieving LDL-c target was 43% intervention versus 18% control (p = 0.007). Adjusted odds of achieving target LDL-c were 3.3 times higher for the intervention group (p = 0.031), who also achieved greater reduction in LDL-c (1.12 mmol/L, SE = 0.112) versus control (0.42 mmol/L, SE = 0.109), for an adjusted mean difference of 0.546 mmol/L (SE = 0.157), p < 0.001. Conclusion: Pharmacist prescribing resulted in >3-fold more patients achieving target LDL-c levels. This could have major public health implications.

Case Finding: The Missing Link in Chronic Disease Management

The practice of pharmacy is moving from dispensing to patient-centred care. One component of this transition for pharmacists is involvement in chronic disease management (CDM). CDM is characterized by interventions designed to prevent or manage one or more chronic conditions using a community-wide, systematic and structured multidisciplinary approach. Indeed, there are numerous trials and a high level of evidence for the efficacy of pharmacist-led CDM. The “missing link” in most CDM programs is identification of patients who could benefit from the intervention. For example, a dyslipidemia program, no matter how elegantly designed, will be useless if pharmacists cannot systematically find those patients who have dyslipidemia. While pharmacists may participate in the traditional screening method approach for CDM, the yield is generally very poor, leading to frustration and poor uptake of clinical pharmacy services (and an unrealized potential for improving patient outcomes). In this paper we discuss strategies to improve CDM through a focused approach — case finding.

Prevalence and Treatment Patterns of Lower Extremity Peripheral Arterial Disease Among Patients at Risk in Ambulatory Health Settings

BACKGROUND Lower extremity peripheral arterial disease (PAD) is underdiagnosed and undertreated in Canada, although data are limited. We sought to measure PAD prevalence and treatment patterns in ambulatory settings. METHODS Five trained undergraduate pharmacy students screened subjects > 50 years of age in 10 community pharmacies and 4 physician offices in northern and central Alberta. We assessed cardiovascular risk factors, cardiovascular disease (CVD), and use of evidence-based therapies; administered the Edinburgh Claudication Questionnaire; and measured the ankle-brachial index (ABI). Patients with definite claudication but ABI > 0.90, or patients with ABI > 1.30 were referred to the study vascular medicine physician for further assessment. PAD was defined as an ABI ≤ 0.90 at the initial community screening or an exercise ABI of ≤ 0.90 and 20% lower than the resting ABI, or toe-brachial index of ≤ 0.70. RESULTS We recruited 361 patients (65.1 ± 9.5 years old, 55% female, 85% white) between July 1 and November 30, 2008. Sixteen subjects had PAD (prevalence 4.4%; 95% confidence interval [CI], 2.3-6.5), and all were previously unaware that they had PAD. Nine patients (2.5%) had PAD only, 7 (1.9%) had both PAD and CVD, 87 (24%) had CVD only, and 259 (72%) had neither PAD nor CVD. Use of antiplatelet agents (44%), angiotensin blockade (56%), or statins (44%) was low in patients with newly diagnosed PAD and without other CVD. CONCLUSIONS About 1 in 20 ambulatory persons > 50 years of age screened had PAD. All cases of PAD that we found were previously undiagnosed, and there was a large treatment gap for those without concomitant CVD.

Pharmacists' perceptions of their practice: a comparison between Alberta and Northern Ireland

Objective  To explore how community pharmacists from Alberta, Canada, and Northern Ireland, UK, describe what a pharmacist does and to compare their responses.

Making MTM implementable and sustainable in community pharmacy: Is it time for a different game plan?

Although the literature has demonstrated positive patient outcomes from medication therapy management (MTM), implementing it in community pharmacy continues to be met with significant barriers. To make MTM implementation more attainable, scalable, and sustainable in community pharmacies, this paper puts out a call for the need to identify the proportion of patients who clinically qualify for various levels of intensity of MTM services. This paper presents three proposed levels of MTM: adherence management (lowest level of MTM intensity), interventions on drug-related problems (mid-level MTM intensity), and disease state management (highest level of intensity). It is hypothesized that the lowest levels of MTM intensity would be sufficient to address medication problems in the vast majority of patients and require fewer MTM skills and resources, while the highest levels of MTM intensity (requiring the most skills and resources) would address medication problems in the smallest number of patients whose medication problems could not resolved with lower-intensity MTM. Future research in this area will involve testing previously designed instruments to determine why patients are not adhering to their medication regimen, following patients who have already had their adherence managed with medication synchronization, and tracking patients who will require higher levels of pharmacy services.

Glycemic control in community-dwelling patients with type 2 diabetes.

Nearly 25% of Canadians have either diabetes or prediabetes, with diabetes-associated health care costs reaching

Stories from the Trenches: Experiences of Alberta Pharmacists in Obtaining Additional Prescribing Authority

12.2 billion in 2010.1 It has been reported that glycemic control in primary care is poor. Harris and colleagues2 conducted a study across the 10 provinces of Canada to assess the quality of care and treatment of type 2 diabetes patients in primary care settings. They reported that almost half of the patients with type 2 diabetes in primary care settings did not achieve their glycemic target (HbA1c ≤7%).2 Poor glycemic control puts diabetes patients at high risk of suffering from diabetes complications.3 Glycemic control testing plays an essential role not only in diabetes diagnosis,4 but it is also considered the first step in diabetes management.2 There are 3 different ways to measure glycemic control: Fasting plasma glucose (FPG) Oral glucose tolerance test (OGTT), in which the blood glucose concentration is measured 2 hours after taking a glucose solution (75 g anhydrous glucose dissolved in water) Glycated hemoglobin (HbA1c) (the 2008 Canadian Diabetes Association Guidelines recommend diabetes patients to have HbA1c ≤7%)4