Description

Collaborations between patient, pharmacist, and physician were tight enough that substantive dialogue may result in swift and useful remedies. Throughout the last four decades, scientific progress has resulted in increased survival with decreasing morbidity for a variety of chronic conditions. In the 1970s, the common patient with diabetes, chronic systolic heart failure, and atrial fibrillation would have received a sulfonylurea, digoxin, warfarin, and a diuretic. Today, that patient may be taking two or more diabetes medications, a statin, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, beta-blocker, spironolactone, diuretics, aspirin plus a new oral anticoagulant or warfarin, and possibly digoxin.

Although scientific evidence supports polypharmacy for high-risk patients, it is a breeding ground for drug-drug interactions, patient nonadherence, and management uncertainty. But, as pharmacies and insurers merge, the community is losing one of its most effective advocates for health care delivery and best allies in health care to wholesale commercial reasons. Alberta Vascular Risk Reduction Community Pharmacy Project report on 723 patients at 56 Canadian pharmacy clinics who were randomly assigned to either usual pharmacy care or an intervention by participating pharmacists focused on directing more intensive goal-directed therapy to reduce cardiovascular risk. Case-finding recruiting tactics required the presence of peripheral, cardiac, or cerebrovascular illness, an estimated Framingham risk score of >20%, blood pressure (BP) >140/90 or >130/80 mm Hg if diabetic, and Low-Density Lipoprotein Cholesterol (LDL-C).

The findings further indicate that a pharmacist intervention (compared to standard care) would reduce cardiovascular risk score, LDL-C, HbA1c, systolic and diastolic blood pressures, and smoking at the end of a 3-month experiment. The strategy was extremely simple: pharmacists interacted with treating physicians while advancing drugs and changing diets as needed. They improved in these surrogate outcomes. Diabetes patients lowered their baseline HbA1c levels substantially faster than the standard care group. This was accomplished in a relatively short amount of time with monthly pharmacy visits. That improved management is possible with adequate case discovery and strict attention to goals should serve as a wake-up call. Whether such management must be provided by physicians, pharmacists, nurse practitioners, or other facilitators.

The cost of medical therapy for hypertensive patients with diabetes is significant, particularly for those with renal dysfunction. Eliminating financial incentives for adherence has not been shown to enhance outcomes for patients after a myocardial infarction. Even among heart failure patients who require implanted defibrillators, adherence to guidelines is inadequate. Noncompliance with guideline-directed therapy has been associated to increased morbidity and mortality. The RxEACH study results revealed that there is opportunity for improvement in medical treatment in the trial group, which is not surprising given how many patients are not currently meeting guideline targets for lipids, blood pressure, smoking cessation, or glycaemic management. The findings of this study should prompt more research into the potential public health advantages of larger, longer-term studies.

There was little information provided on compensation or other hurdles to the intervention. That compensation for pharmacist care was covered under an Alberta programme; in the United States, pharmacists are excluded as providers in the Social Security Act, limiting programme implementation and preventing widespread compensation for services provided in collaborative care programmes. Different states establish provider status or broaden the area of practise in a variety of ways, therefore the application of these observations may vary by geography. This study found at least short-term benefits to including community pharmacists into a collaborative care project, but for most patients to benefit from more extensive risk reduction, pharmacists would need to be labelled "providers" under federal laws.

The average high-risk patient sees the physician far less frequently than the pharmacist. Patients in our ageing population who are at risk for drug-drug interactions, medication confusion, or nonadherence may also be limited by visual or other handicaps, such as hearing loss or inability to open containers. The loss of the community pharmacist may deprive these patients of safety and coaching measures. Physicians frequently use "lack of training" as an excuse to limit the pharmacist's scope of practise, but pharmacy school curricula and accreditation standards have evolved into comprehensive medication management and collaborative care in all health care settings. Although the design of these programmes varies greatly, each emphasises the patient-centered care process, with essential components of collaboration, communication, and documentation.