A pharmacist intervention in primary care to improve health outcomes for type 2 diabetes through collaborative medicines management
Creators: name: Pradeep, Geeta
Publisher: name: RMIT University
Year: 2024
Subjects: classificationCode: 321403
subject: Clinical pharmacy and pharmacy practice

description: Medicines are an indispensable part of modern healthcare and pharmacists are widely acknowledged as medicine experts. Consequently, pharmacist oversight on the safety and efficacy of medicine use can have a great impact on patient outcomes. In recent years, the role of pharmacists has evolved to assume direct patient care services not only in retail and hospital settings but also within primary care practices. However in Australia, pharmacy services in primary care or General Practice (GP) setting continue to remain peripheral or external to the primary health care team.
 
Early Australian research in this area has been focused on defining the service role and logistics of pharmacists working in a General practice (GP) setting. There is, however, minimal research assessing the utilization and efficacy of a pharmacist within a GP setting in Australia, to improve disease outcomes for a specific disease or condition.

The aim of this project was to assess the impact of a pharmacist in a GP setting on clinical and humanistic patient outcomes using Type 2 diabetes (T2DM) as the model condition. Given the modern landscape of rising obesity rates and T2DM epidemic with associated insidious co-morbidities and multi-organ complications of T2DM over time, and the crucial role of chronic medication(s) use in T2DM management, the suitability of T2DM as the model chronic disease was unmatched. Additionally, the need for improving individual patients’ self-management skills to become active participants in their own care provided an ideal situation to assess the role of pharmacist intervention in chronic disease management.

This study aimed to evaluate the impact of a pharmacist integrated within a GP practice to provide collaborative medicines management for patients with chronic type 2 diabetes. A suburban GP practice unfamiliar with extended pharmacy services was the chosen study site. A baseline study of 382 active T2DM patients at the practice was conducted as the initial step, to describe the existing systems in place for the management of T2DM at the practice and to identify potential areas for improvement of medicine use. Results of the study identified that while the clinical management at the practice was compliant with recommended guidelines, polypharmacy and inappropriate medicine use were common, thereby compounding the management of T2DM in the ageing cohort. This study provided the background for the design of the pharmacist intervention in the practice.

As this was a novel concept for the practice, interviews and focus groups were used to obtain the views and attitudes of primary stakeholders towards pharmacists and proposed role of the pharmacist in their practice environment to improve quality use of medicines for T2DM. Seventy-four patients completed the semi-structured interviews, four pharmacists and four practice professionals participated in separate focus groups to provide their views. The nature of existing relationship with pharmacists, proximity to the practice, barriers and benefits of collaboration as well as issues around regulation and remuneration for services rendered were explored as themes. All three participant groups agreed that pharmacists help with better communication between patients and their GPs and recognised the importance of the educational role of the pharmacist for both patients as well as practice staff. Many patients envisaged the pharmacy to be a one-stop shop where they could get their medicines as well as advice. Medicines review was identified as the most important role for the practice pharmacist with timely communication of review reports with a pharmacist embedded in the practice identified as the main advantage by both pharmacist and practice participants. The main challenges identified were lack of a defined role for the pharmacist, the absence of a clear pathway to integration and remuneration. The practice considered the pharmacist service as meeting a gap in service while the pharmacist group also felt that their role would complement the GP role at the practice and lead to better health outcomes for patients with T2DM. The findings of this study were used to design and develop a novel GP- pharmacist collaborative medicines model for management of type 2 diabetes at this practice site.

Based on the views expressed by the practice, the decision was made to initiate pharmacist services with provision of home medication review services for patients with T2DM as the main intervention service. The intervention compared changes in clinical parameters namely HbA1C, BP, BMI and cholesterol, Medication Appropriateness Index (MAI) and medication related problems identified and resolved between an intervention group and a control group of patients with T2DM at the practice for 15 months. The study also measured the Quality of Life (QoL) and satisfaction of patients in the intervention group before and after the intervention. Each group had 30 participants. Patients in the intervention group has statistically significant reduction of HbA1C values post intervention compared to patients in the control group. There was a positive trend of reduction in total cholesterol, non-HDL cholesterol and cholesterol ratio from baseline to intervention in the PC group compared to the control group which may have contributed to an improved health outcome, though these differences were not statistically significant. Medication use appropriateness and burden of polypharmacy also improved in intervention group. The GPs at the practice initiated 68.5% of all medication related problems identified. There were no improvements in QoL scores post intervention though there was a trend towards improved scores in some domains attributable to improved self-management skills potentially from the patient education provided by the intervention pharmacist.

As a demonstration project, this study aimed to reflect real-world practice by employing existing services to evaluate the impact of a pharmacist intervention for optimum diabetes management of T2DM in primary care. This research has demonstrated this and posits the need for further large-scale studies.

The GP-pharmacist collaborative medicines management was able to improve the therapeutic outcomes for the patients in this study. Further research should consider the role of the pharmacist in improving clinical inertia and promoting behavioural changes to maintain long term diabetes goals. Additionally, a GP-pharmacist liaison role could improve interprofessional collaboration between pharmacy and GPs, further advancing health outcomes for patients with chronic diseases in the community.