Abstract
This project enabled us to develop procedures for organizing and running successful pharmacy blood pressure sessions. The knowledge gained from this pilot was used in the multicentred Community Health Awareness Program (CHAP).
Running blood pressure sessions in community pharmacies and using a multidisciplinary approach, including volunteer health educators and support from public health, was a feasible way to raise awareness of cardiovascular health among the older adults who participated in our project.
This pilot project included pharmacist involvement at several stages, from the planning of the blood pressure sessions and development of the documentation forms, to participation in the pilot and feedback after project completion. With its multidisciplinary approach, the pilot showed that it is feasible for a community pharmacist to be involved in research projects that can benefit patient care and enhance their professional roles.
Background
Over the past decade, research into community pharmacy practice has increased in Canada and around the world. 1,2 Pharmacists' knowledge of issues affecting medication compliance, drug interactions, and adverse effects enables them to effectively discuss drug therapy with clients and minimize drug-related problems. Working in community pharmacies makes pharmacists accessible to the general public. It is therefore not surprising that research focusing on health service delivery is being conducted in pharmacies and with pharmacists.
Hypertension is a significant public health concern in Canada, affecting 22% of Canadian adults. It is a modifiable risk factor for cerebrovascular disease, coronary artery disease, congestive heart failure, renal failure, and peripheral vascular disease. 3
Although family physicians routinely monitor and treat hypertension, only 16% of Canadians with hypertension are aware of their condition and are treated and controlled. 4 Reasons for suboptimal blood pressure control in treated patients include poor compliance with medications, drug-induced hypertension, and drug interactions. 5,6 Greater collaboration among pharmacists, physicians, and patients should help optimize drug therapy for hypertension.
Greater collaboration among pharmacists, physicians, and patients should help optimize drug therapy for hypertension
Pharmacists have shown initiative by actively helping patients achieve better blood pressure management and control. 7 Physician-pharmacist collaboration in primary care outpatient teaching sessions has been shown to successfully reduce blood pressure. 8 Many community pharmacies in Canada provide blood pressure measuring devices for self-monitoring by clients. 9 Community pharmacists are in an excellent position to provide a link between patients and family physicians regarding blood pressure control. 9
Community Health Awareness Program
The Community Health Awareness Program (CHAP) began in 1999. The purpose of the CHAP working group was to assess whether an organized community-based program linking family physicians, pharmacists, and public health units could identify and monitor hypertensive patients, provide education, and ensure communication among these partners. This could effectively raise awareness of high blood pressure among patients, pharmacists, and physicians, improve the cardiovascular health of Canadians, and reduce health care costs.
The CHAP team worked with the local health unit and a hospital volunteer organization to recruit and train a group of volunteer health educators to operate the blood pressure sessions in pharmacies, since time and financial restraints did not make it feasible for the pharmacy or public health staff to regularly conduct these sessions during a busy work day. The role of these volunteers was to assist patients with monitoring and documenting their blood pressure, to provide educational handouts (prepared by public health units), and to record cardiovascular risk assessment with each patient.
As the CHAP team worked toward acquiring research funding to evaluate the effectiveness of this intervention in a controlled trial, pilot studies were conducted to further define different components of the program and to determine their feasibility. This report describes the contribution of community pharmacists in a pilot project, conducted in 2002, that explored the management of high blood pressure during and following blood pressure sessions held in a community pharmacy.
Pilot studies
Objectives
The purpose of this CHAP pilot study was to:
Gain feedback about project evaluation forms and develop procedures for organizing and running pharmacy blood pressure sessions.
Estimate patient participation and retention rates.
Methods
This descriptive pilot study involved four pharmacists who participated in a focus group, one of whom volunteered her pharmacy for the pilot, and three family physicians and their patients who met the inclusion criteria and participated in the pilot blood pressure sessions. Pharmacist input and feedback were sought at three distinct times: before, during, and following completion of the community pharmacy blood pressure sessions.
Pharmacist focus group held prior to pilot: A pharmacist focus group dinner was held with four Ottawa community pharmacists. Potential participants were identified through consultation with the chair of the Ottawa-Carleton Pharmacists Association and with several family physicians participating in the project. The objectives of the focus group were to gain feedback from area pharmacists about how to create a realistic, reproducible role for the study pharmacist, to determine the feasibility of pharmacists aiding in physician recruitment, to identify the environment necessary to operate a pharmacy blood pressure session, and to find a suitable pharmacy to host the blood pressure sessions.
Knowledge into practice
Community pharmacists can work with local health service researchers to help design feasible interventions in a community pharmacy to improve health.
Pharmacy-run blood pressure sessions are a feasible approach to improving cardiovascular health, especially if conducted by volunteer health educators, and supported by public health professionals. Subsequent communication to physicians and pharmacists is also an important part of this multidisciplinary approach to improve patient care.
Documentation per patient is important to enable patient follow-up, track resolution of drug-related problems, and to record pharmacist's time.
Community pharmacists are in an excellent position to provide a link between patients and family physicians regarding blood pressure control
Pilot blood pressure sessions: The community pharmacy owner and three area family physicians jointly identified patients with hypertension who could be invited to attend sessions. Ninety-four patients were invited by personalized letter from their family physician to attend at least two of six community pharmacy blood pressure sessions held in the pharmacy during July 2002. Volunteer peer health educators, trained by a public health nurse, helped participants measure and record their blood pressure and pulse using the BPM-100 automated blood pressure measuring device. They also helped participants fill out a cardiovascular risk profile and a health questionnaire during the blood pressure session. The volunteer health educators were students with an interest in heart health and community volunteering. The BPM-100 was chosen for the study because it has been shown to be a reliable and valid blood pressure measuring device. 10,11 The public health nurse was available by telephone during the blood pressure sessions. The blood pressure readings and the cardiovascular risk profiles were forwarded to the family physician and the study pharmacist at the end of the pharmacy sessions. Volunteer health educators were to refer study participants to the pharmacist if they met the following criteria:
High blood pressure, as per the 2001 Canadian Recommendations for the Management of Hypertension Risk Stratification Guide — greater than 140/90 mmHg for patients under 65 years and greater than 160/90 mmHg in patients older than 65 years
Low blood pressure — below 120/80 mmHg
Abnormal pulse rate — high, low, or irregular
In addition to consultation with the pharmacist, one physician wished to be contacted if a patient had a systolic BP greater than 180 mmHg, a diastolic BP greater than 100 mmHg, an irregular pulse, or a pulse greater than 100 beats/min.
During pharmacist referrals, patients were assessed for compliance with medications (through questioning and review of refill frequency), drug-induced hypertension, and drug interactions. Pharmacist assessments, actions, follow-up, and time taken for each component were documented on a standardized documentation form.
Post-pilot feedback sessions: Project staff held two meetings after completion of the blood pressure sessions — one with the pharmacist individually and one with the pilot study team, including the pharmacist, physicians, and the public health nurse — to get feedback and recommendations for future CHAP development.
Results
Pre-pilot pharmacist focus group
The focus group (four pharmacists and two investigators) discussed the following issues and made recommendations.
Proportion of patients seen by the pharmacists: The pharmacist should ideally see all participants of the blood pressure session. However, since this was not feasible during a pharmacist's busy work day, it was decided that referrals to the pharmacist during session times would be limited to patients who had abnormal blood pressure or pulse measurements or were unwell. Blood pressure and cardiovascular risk information for all participants would be forwarded to the pharmacist for review at the end of each session in case the pharmacist wanted to follow up with a patient after the session.
Depth of pharmacist assessment: Pharmacists should assess patients for compliance with medications, drug-induced hypertension, and drug interactions that could limit the effectiveness of antihypertensive medications. They also agreed that, in some circumstances, they could provide a more intensive assessment of the antihypertensive regimen (which they occasionally did with certain family doctors and patients); however, this should not be an expectation of the project.
It was agreed that the impact of the study on time and workload should be closely monitored so that recommendations could be made about possible remuneration of pharmacists' time. They also felt that using a simple documentation form would provide structure for the patient assessment process; capture the pharmacist's actions, interventions, and time taken to complete the assessment; and could be used as a communication tool with the physician.
Training and role of peer health educators: There was initial concern about the role and training of the volunteer health educators who would be taking the blood pressure readings. After a detailed discussion, it was agreed that a copy of their training manual be provided to the pilot pharmacist. The group also felt it important that the pharmacist have an opportunity to meet the volunteer health educators at the start of the session.
Environment: Adequate privacy and space (table and chairs) were identified as essential. One of the participating pharmacists felt her pharmacy met these requirements and volunteered for the pilot.
Physician recruitment: The pharmacist agreed to identify and make first contact with appropriate physicians regarding their interest in participating in the pilot project.
Blood pressure sessions
Attendance: Forty-seven percent (44 of 94) of invited patients attended at least one blood pressure session. Of these 44 patients, 86% (38 of 44) attended two or more sessions. Participants ranged in age from 58 to 93 years, with a mean age of 75 years (SD = 7); 80% (35 of 44) were female. Two-thirds of the patients (66%) were clients of the study pharmacy. There were 92 blood pressure measurements available from the 44 patients. Seventy-three percent of patients were found to have high blood pressure or were taking antihypertensive medications. The majority of patients (88%) stated that they would like to return to a pharmacy blood pressure session within the next six months.
Pharmacist consultations and documentation: Eight patients were referred to the pharmacist during the blood pressure sessions. Two study participants each saw the pharmacist once, while two other study participants were referred to the pharmacist on two separate occasions. Two other referrals were walk-in patients who had requested to have their blood pressure taken. Two additional study participants should have been referred, but they could not see the pharmacist during the clinic time due to other commitments. Four (50%) of the referrals were for high blood pressure and four (50%) were for low blood pressure. The average time taken to complete assessments for study patients was seven minutes. An average of ten minutes was spent on assessments for participants who were not clients of the pharmacy.
Documentation forms for the four study patients indicated that the pharmacist checked medication compliance for three referrals and drug interactions for one referral. Drug-induced hypotension was found for one referral. The pharmacist communicated by phone with the physician on five occasions for these patients.
Several forms were not fully completed and no pharmacist follow-up was recorded.
Post-session feedback
Recommendations from the participating pharmacist included the following:
Limit referrals to the subset of patients meeting definitions for hypertension and include patients with hypotension (establish criteria for volunteer health educators).
Make several modifications to the pharmacist documentation form to make it more user-friendly and to capture future follow-up when patients referred to pharmacist do not have time to stay for the assessment on the day of the session.
Include instructions for completing the pharmacist documentation form and provide examples in study orientation manual.
Provide current information about hypertension, medication compliance assessment, and potential drug interactions, including over-the-counter medications. This could improve the pharmacists' assessment and documentation process.
The purpose of the CHAP working group was to assess whether an organized community-based program could identify and monitor hypertensive patients, provide education, and ensure communication among these partners
La connaissance en pratique
Les pharmaciens communautaires peuvent travailler avec les chercheurs des services de santé locaux, afin d'aider à concevoir des interventions pratiques dans une pharmacie communautaire en vue d'améliorer la santé.
Les séances sur la pression artérielle, animées dans une pharmacie, sont une approche permettant effectivement d'améliorer la santé cardiovasculaire, surtout si elles sont animées par des éducateurs de la santé bénévoles, et s'ils ont l'appui de professionnels de la santé publique pouvant apporter l'aide additionnelle nécessaire. La communication subséquente aux médecins et aux pharmaciens est aussi un élément important de cette approche multidisciplinaire ayant pour objet d'améliorer les soins aux patients.
Une documentation par patient importe pour permettre un suivi, pour surveiller la solution des problèmes liés aux médicaments et pour enregistrer le temps du pharmacien.
The procedures for setting up and running the sessions were judged appropriate by the pharmacist and her staff.
Discussion
This pilot project included pharmacist involvement at several stages. Focus group discussions, completion of documentation forms, and feedback following the pilot all contributed to improving the understanding of how to better implement and evaluate blood pressure sessions in pharmacies.
Support from community pharmacists was evident in their willingness to attend the focus group meeting. The pharmacist who volunteered to host the sessions and pilot the documentation forms was the co-owner of an independent pharmacy. Her participation was vital to the successful outcome of the pilot. Her feedback allowed us to improve our documentation forms, improve the organization of the blood pressure sessions, and estimate an appropriate remuneration for pharmacists. It also gave us an indication of the various degrees of pharmacist involvement that could be feasible in a busy community pharmacy. She stated that she felt her involvement had strengthened her relationship with the physicians in the study and also with her patients.
Almost half of the invited patients attended the blood pressure sessions. Our higher-than-expected response rate was likely due to the patients receiving a personal invitation letter from their family physician. Development of a collaborative approach and utilization of pre-established linkages among family physicians, pharmacists, and public health to implement a community-based program like CHAP shows promise as an intervention to improve heart health. The involvement of public health staff and volunteer health educators reduces the time commitment for pharmacists and pharmacy staff and thus improves the feasibility of the CHAP approach. However, we recognize that only a small number of pharmacists were involved in the focus group, and only one pharmacist was involved in the pilot study. Therefore, further evaluation of feedback provided by a large number of pharmacists is required before a positive impact on heart health can be realized.
The results of this pilot project were included in a submission to the Canadian Institutes of Health Research (CIHR) for funding of the Community Hypertension Assessment Trial (CHAT) — a randomized controlled trial involving family physicians and pharmacists in the Ottawa and Hamilton areas. This trial is nearing completion and the CHAP program has most recently been expanded to the communities of Brockville and Grimsby, where it has been tested on a community-wide level. Expansion of the CHAP program across Ontario is being explored. As the expansion of the program continues, the CHAP team will continue to work with pharmacists to maximize their opportunity to contribute to this worthwhile public health endeavour and to enhance their evolving professional roles.
Footnotes
Acknowledgements:
Thanks to pharmacists Denise Allen, Brian Stowe, Ron Silver, Mark Kearney. In-kind resources were provided by participating volunteers, and health care professionals also volunteered their time. This pilot project was funded in part by Crystaal Pharmaceuticals.
The CHAP working group consists of Chantal Belley, Margaret Black, Kim Canary, Larry W. Chambers, Lisa Dolovich, Tom Elmslie, Barbara Farrell, Manal Guirguis-Younger, Heather L. Hall, Maureen Harmer, Alexandra Hendriks, William Hogg, Janusz Kaczorowski, Tina Karwalajtys, Crystal LaRose, Cheryl Levitt, Pamela Logan, Beatrice McDonough, Robert S. McKelvie, Rolf J. Sebaldt, Constance Sellors, Brenda Szabo, Lehana Thabane, Jennifer Thompson, and Claire Zanetti.