Abstract
It is well established that cardiovascular risk reduction strategies are often not successful in primary care settings1,2 and several organizations suggest that community pharmacists should play a more active role.3,4 As a result, several studies have attempted to examine the benefits of involving community pharmacists in the management of cardiovascular-risk patients. While many have reported positive results, real-world implementation has been minimal at best. In our view, 3 major barriers to widespread implementation of published protocols exist: generalizability, efficiency, and strategic focus.
Generalizability
It has been shown that community pharmacists can influence adherence and/or utilization of recommended cardiovascular medications.5–8 However, protocols that have achieved success have been very labour intensive. For example, in a study by Chabot and colleagues, 8 eligible subjects were identified through a scan of prescription records and then contacted by phone to request participation. Pharmacists measured each individual's blood pressure at every prescription refill, documented the encounter, and made individual recommendations based on their findings. In a descriptive evaluation of a lipid lowering program, 9 pharmacists spent an average of 30 to 60 minutes with each patient on the initial visit and 10 to 30 minutes on subsequent visits that occurred every 3 months. Each visit consisted of a point-of-care cholesterol test and communication of the results to the responsible physician. In a more recent example of a successful pharmacist intervention, 5 pharmacists took blood pressure measurements, provided individualized education every 2 months, and blister-packed all medications for each eligible subject. Similar to the previous studies, the average time required for each patient at the initial visit was 60 minutes, while subsequent visits lasted approximately 30 minutes (every 2 months).
Although these studies provide reproducible, high-quality protocols, the reason they have not been implemented into usual community pharmacy practice is most likely related to the time requirement. These strategies require pharmacists to provide rigorous and frequent care to individual patients in addition to their already full work day. In Saskatchewan, we have already observed the problems with asking pharmacists to perform strategic protocols on top of their existing duties. The recently published PIRR study invited all Saskatchewan pharmacists to take part in a high-quality program to improve cardiovascular medication use. 10 Out of 1100 invitations sent, 61 pharmacists volunteered. Of the 61 volunteers, 20 did not enroll any patients over a period of 2 years.
Blame is often unfairly directed at pharmacists. Community pharmacies are businesses and incorporate “fee-for-service” payment structures based primarily on prescription sales volume rather than activities such as patient counselling or chronic disease management. As this is unlikely to change anytime soon, study protocols must recognize the context and constraints under which community pharmacies are required to operate.
Efficiency
Observational studies suggest nonadherence to cardiovascular medications is rampant in primary care settings.2,11–14 Similarly, the “treatment gap,” where at-risk individuals do not receive recommended medications, appears equally problematic.1,15,16 Although predictors of nonadherence and the treatment gap have been suggested, it is impossible to identify all patients who are at risk for nonadherence. Therefore, support for chronic medication use should ideally be provided to as many people as possible.
Published studies of community pharmacy interventions have demonstrated beneficial effects on cardiovascular risk reduction. However, these initiatives were generally restricted to small numbers of subjects. For example, excellent adherence was reported in an uncontrolled study reported by Bluml and colleagues, but the study population was restricted to approximately 15 patients per participating pharmacy. 9 Similarly, limited success in improving adherence was reported in 7 pharmacies throughout Quebec, with an average of only 13 patients per pharmacy. 7 One of the largest community pharmacy studies on record, the SCRIP study, averaged only 6 subjects in the intervention arm per participating pharmacy. 17
Clearly, there exists a discord between the number of subjects who are at risk for nonadherence or undertreatment and the number who have received support by clinical trial protocols. Because of the overwhelming number of cardiovascular risk patients in North America, community pharmacy programs must attempt to support a greater proportion of this target population if they hope to make an impact on this public health problem.
Strategic focus
We believe that community pharmacy interventions need to alter their strategic focus in order to have a greater impact on cardiovascular risk reduction in the real world. We have identified 3 major areas that should be considered in the design of upcoming protocols:
Sustainability Focus on medication-taking versus prescribing Focus on non-consenting patients
Sustainability
High-quality protocols have not been implemented in real world settings because most community pharmacists are unable to provide such intensive services in everyday practice. Although we wholeheartedly support a movement towards the transformation of typical community pharmacy practice, we do not believe it will occur in the near future. Therefore, we propose that future studies should examine the impact of striving for small changes in significant numbers of patients rather than large changes in only a few. We believe this strategic focus can be better aligned with a community pharmacist's current activities; thus, increasing the likelihood that published protocols are implemented and sustained in the real world.
Practice change by pharmacists must be supported. Pharmacist “adherence” to practice change is likely very similar to patient adherence to chronic medications, in that regular follow-up, reinforcement, and support are needed if change is to be implemented successfully.
Focus on medication-taking versus prescribing
Cardiovascular risk reduction interventions in community pharmacies typically focus on at least 1 of 2 overlapping professional activities: providing patient support or making recommendations to physicians. Patient support activities are usually geared towards improving patient adherence, and the majority of the pharmacist's energy is focused on regular communication and reinforcement to the patient.5,6 Protocols that focus on physician recommendations are generally intended to close the treatment gap by identifying patients who require medication optimization and communicating a recommendation to the physician.10,17 In the latter case, success is defined by evidence that a physician acted on a recommendation by prescribing a drug or laboratory test.
In our view, the majority of community pharmacy practices are better suited to providing patient support activities versus physician recommendations. Lack of access to individual medical information, lack of an existing professional relationship or line of communication, as well as the potential to offend prescribers with unsolicited advice can make the most logical recommendations tenuous. On the other hand, community pharmacy practice has long been recognized for its accessibility to patients and frequent opportunities for patient support activities. However, community pharmacists need strategies to convert regular patient encounters (such as prescription refills) into constructive patient support opportunities.
Focus on non-consenting individuals
We believe that clinical studies of intensive programs exclude a significant number of patients who require ongoing support for medication adherence. In other words, it is unlikely that individuals who provide consent to participate in clinical studies are representative of a sizeable proportion of the nonadherent population in the real world. Therefore, we believe it is important that future protocols attempt to provide support to all clients of a community pharmacy so the intervention can be evaluated in a more representative population.
Summary
Although several successful risk reduction strategies involving community pharmacists have been published, implementation into real-world settings has not occurred due to difficulties in performing protocol-driven activities on a daily basis. New evidence-based strategies are required to further explore the benefits of cardiovascular risk reduction programs that allow for practical implementation in typical community pharmacy settings. By ensuring that adequate support is provided to community pharmacists, we stand to make a greater impact on patients, the health care system, and the practice of community pharmacy.