Figure 1: Community Pharmacy Diabetes Programme process summary
The winning project in the Diabetes category of the 2005 Guidelines in Practice Awards, led by Shailen Rao, used community pharmacists to help educate and monitor patients |
In 2000, a Primary Care Trust (PCT) baseline audit on the management of more than 2000 patients with diabetes revealed that many were not reaching the PCT/national targets for blood glucose control (HbA1c), blood pressure and cholesterol.
Patient education and increased participation in their self-management, can lead to an improvement in both patients' knowledge and understanding of their disease, and their compliance with prescribed therapy for a number of conditions.
The role of community pharmacists in the management of patients with diabetes has not been widely evaluated. Therefore, the community pharmacy diabetes programme was developed to:
Phase 1 of the programme was launched in 2002 as a pilot involving four community pharmacies within the PCT. The programme was so successful that in May 2004 it was extended to 10 community pharmacies for 18 months. This was phase 2 of the programme. Financial support was provided by the PCT modernisation fund and the medicines management budget.
Pharmacists and support staff from participating pharmacies, attended specialised training covering clinical updates, consultation skills, programme delivery, use of monitoring equipment and case studies, to ensure effective delivery of the diabetes programme. A written protocol, incorporating a 2-way referral process between GPs/diabetes nurse specialists and pharmacists provided a systematic patient-centred approach (Figure 1).
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Figure 1: Community Pharmacy Diabetes Programme process summary
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Targets set for the programme were based upon diabetes management guidelines from Hillingdon PCT and the NSF for Diabetes (Table 1).1
| Table 1: Goals set for the Community Pharmacy Diabetes Programme |
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Self-care
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At least 90% of patients recruited should:
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Monitoring parameters
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At least 90% of patients recruited should:
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Referral
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At least 90% of patients recruited should: |
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| Table 2: Parameter targets | ||
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Target
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Referral | |
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Random blood glucose
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Fasting 4.4-7.8mmpl/l
Postprandial 4.4-0mmol/l |
>10 mmol/l
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HbA1c
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>6.5%, <7.5%
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>7.5%
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Total cholesterol
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<5 mmol/l
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>5 mmol/l
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Blood pressure
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<145/85 mmHg
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>150/90 mm/Hg
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Body mass index (BMI)
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<25 kg/m2
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>30 kg/m2
Male > 102 cm Female > 88 cm |
Community pharmacists were required to recruit patients on medication for diabetes and follow them up nominally at 2, 4 and 6 months post-recruitment, as necessary. Patients completed two validated questionnaires,2,3 to assist pharmacists in identifying and addressing their needs: the Satisfaction with Information about Medicines Scale (SIMS) and the Beliefs about Medicines Questionnaire (BMQ).
Since the Phase 2 launch, 181 patients have been recruited; 59% (n=107), 30% (n=55) and 20% (n=37) have been followed up at 2,4 and 6 months post-recruitment, respectively.
Monitoring parameters were measured at recruitment and follow-up, and were evaluated for change (Table 3).
| Table 3: Comparison of parameters at first and last consultation*+ | ||
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Percentage of patients
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First consultation
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Last consultation
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Random blood glucose
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72
28 |
80
20 |
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HbA1c
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57
43 |
68
32 |
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Total cholesterol
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63
37 |
86
14 |
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BP
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50
50 |
56
44 |
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BMI
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16
84 |
19
81 |
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*Last consultation: 2, 4 or 6 months post-recruitment, depending on how long each patient was followed-up for
+Figures based on paired data |
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Random blood glucose - 81% (n=147) of patients had an initial random blood glucose measurement recorded. Of these patients, 31% (n=46) had a reading above 10 mmol/l. From paired data analysis on 86 patients, 28% (n=24) had a blood glucose level above 10 mmol/l at recruitment; 96% of these (n=23) went on to improve their blood glucose and 63% (n=15) achieved the target.
HbA1c - 83% (n=151) of patients had an initial HbA1c level recorded, of which 37% (n=56) were above the target.
Cholesterol - 85% (n=154) of patients had their initial total cholesterol level measured; 29% (n=44) had a total cholesterol level exceeding 5 mmol/l. From paired data analysis on 63 patients, 37% (n=23) had a total cholesterol level in excess of 5 mmol/l at recruitment, subsequently 74% (n=17) of this cohort reduced their cholesterol and 52% (n=12) went on to achieve the target.
Blood pressure - 95% (n=172) of the patients had an initial BP measurement recorded, 56% (n=96) of which had BP readings above 145/85 mmHg.
BMI - 93% (n=169) of patients had an initial BMI reading recorded; 85% of these (n=143) had a BMI in excess of 25, 41% (n=70) in excess of 30, and 15% (n=25) in excess of 35. From paired data analysis (n=93), 84% (n=78) of patients had a BMI in excess of 25 at recruitment, subsequently 32% (n=25) of these patients went on to reduce their BMI and 6% (n=5) went on to achieve the desired target.
Out of 385 patient consultations 749 problems were identified (Figure 2); 59% of problems (n=444) were identified at recruitment and 24% (n=179), 11% (n=83) and 6% (n=43) at 2, 4 and 6-month follow-ups, respectively. Pharmacists made 959 interventions consisting mostly of verbal advice (72%, n=694) and written information (19%, n=180), to address these needs. The remaining 9% (n=85) were referred to the appropriate healthcare professional for specialist lifestyle advice, weight management, smoking cessation or because of problems with compliance.
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Figure 2: Nature of problems identified by patients*
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| * The remaining 19% included compliance problems, unpleasant side-effects, suspected drug interactions and unsuitable drug dose/regimes |
Patients' satisfaction with information received about their medicines (SIMS)2, n=107, improved significantly as a result of pharmacists' interventions from a mean score of 6.9 pre-intervention to 3.2 post-intervention.
Patients' underlying misinformed beliefs and concerns about their medicines (BMQ)3 for diabetes, n=105, reduced significantly from a mean score of 4.2 pre-intervention to 2.5 post-intervention.
Pharmacists referred 15% (n=28) of patients to their GP; 64% of these referrals were to address a patient's monitoring parameters when outside the target range, 7% were referred because of undesirable side-effects and the remainder for a variety of other reasons, all of which could not be addressed within the community pharmacy, e.g. significant interactions with other medication, additional underlying conditions.
Patient feedback indicated that over 90% of patients:
Additional feedback will be sought from pharmacists, pharmacy staff, GPs, other healthcare professionals and patients at programme completion, in order to evaluate and adapt the programme for future roll-out.
All patients received appropriate advice on diabetes, healthy lifestyle factors, medication for diabetes and self-monitoring and all patients were appropriately referred to their GP for review, as necessary.
The programme recognises and utilises the skills, knowledge and accessibility of community pharmacists. The Community Pharmacy Diabetes Programme is available from local pharmacies without an appointment. It improves patient access to a full diabetes monitoring service with advice from a trained professional, at a time convenient to the patient.
The programme is currently under review and being adapted to incorporate:
The PCT has endorsed the programme and are considering it for wider roll-out across other localities within the PCT and the Strategic Health Authority. In addition, the service delivery model can be adapted to address other therapy areas, e.g. respiratory disorders, to meet the specific needs of a PCO and its locality.
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Guidelines in Practice, 2006, June Volume 9(6) |
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