Pharmacy Cardiovascular Health Care Model

144 Pages·2007·2.88 MB·English

Third Community Pharmacy Agreement Research & Development
Grants Program
Pharmacy Cardiovascular Health Care Model
Final Report to the Pharmacy Guild of Australia
This research is funded by the Australian Government Department of Health and Ageing
through the Third Community Pharmacy Agreement Research and Development Program
“Community pharmacists are well placed to help patients who have
cardiovascular disease or who are at risk of this.”
Petty D. Drugs and professional interactions: the modern day pharmacist.
Heart 2003; 89 (Suppl 2): 31-2
Chief Researcher:
Professor Gregory Peterson
Lead investigators:
Jeff Hughes
Dr Kay Stewart
Professor Roger Nation
Professor Shane Scott
Assoc Prof Karen Farris
Pharmacy Cardiovascular Health Care Model 2
Co-investigators:
Dr Shane Jackson
Kim Fitzmaurice
Peter Gee
Luke Bereznicki
Project Manager:
Michael Ryan
Contact person for correspondence
Professor Gregory Peterson
Unit for Medication Outcomes Research and Education
School of Pharmacy
University of Tasmania
Locked Bag 83
Hobart Tas 7001
Phone: [phone]
Fax: [phone]
Pharmacy Cardiovascular Health Care Model 3
Table of Contents
Table of Contents .................................................................................................................................................. 3
Index to Figures ..................................................................................................................................................... 6
Index to Tables ...................................................................................................................................................... 9
Abstract ................................................................................................................................................................ 16
Executive Summary ............................................................................................................................................ 16
Acknowledgements.............................................................................................................................................. 30
1.Introduction ...................................................................................................................................................... 31
1.1 Overview of possible roles for community pharmacy .......................................................................... 33
2. Methodology and results................................................................................................................................. 36
2.1 Systematic literature review ................................................................................................................ 36
2.1.1 MEDLINE search terms and criteria ............................................................................................... 38
2.1.2 International Pharmaceutical Abstracts (IPA) search terms and criteria ......................................... 38
2.1.3 Cochrane search terms and criteria ................................................................................................. 39
2.1.4 EMBASE search terms and criteria ................................................................................................. 39
2.1.5 INFORMIT search terms and criteria ............................................................................................. 40
2.1.6 Kinetica search terms and criteria ................................................................................................... 40
2.1.7 Community Pharmacy Research Database (CPRD) search terms and criteria ................................ 41
2.1.8 Summary of database searching ...................................................................................................... 42
2.2 Evaluating quality of research papers ................................................................................................. 45
2.2.1 Overall assessment of evidence ....................................................................................................... 50
2.2.2 Results of the Systematic Review ................................................................................................... 51
2.3 Public survey ....................................................................................................................................... 54
2.3.1 Public Survey Methods ................................................................................................................... 54
2.3.2 Results of the public survey ............................................................................................................ 55
2.3.3 Summary of the results of the public survey ................................................................................... 78
2.4 Survey of peak representative organisations ....................................................................................... 80
2.4.1 National Heart Foundation .............................................................................................................. 82
2.4.2 National Stroke Foundation ............................................................................................................ 85
2.5 Canvassing of Australian community pharmacists and pharmacy organisations to report on their own
CVD activities ................................................................................................................................................... 87
2.5.1 General Public (education, posters etc) ........................................................................................... 88
2.5.2 High-risk groups (screening/ referral) ............................................................................................. 89
2.5.3 Management of existing CVD ......................................................................................................... 89
2.5.4 Summary of self-reported CVD activities: ...................................................................................... 93
3. Developing the Pharmacy Cardiovascular Health Care Model .................................................................. 94
3.1 Draft National Chronic Disease Strategy .......................................................................................... 104
Pharmacy Cardiovascular Health Care Model 4
3.2 Draft National Service Improvement Framework for Heart, Stroke and Vascular Disease .............. 107
3.3 Potential roles for community pharmacists for the ‘General Community’ group ............................. 124
3.4 Potential roles for community pharmacists for the ‘At-Risk’ group .................................................. 125
3.5 Potential roles for community pharmacists for the ‘confirmed CVD’ group .................................... 126
3.6 Additional overarching guidelines .................................................................................................... 128
3.6.1 Education of Pharmacists ............................................................................................................. 128
3.6.2 Relevant Professional Practice Standards ................................................................................. 128
3.6.2 Blood Handling Procedures ...................................................................................................... 130
3.6.3 Ethics and Privacy Guidelines ...................................................................................................... 137
Health Information and the Privacy Act 1988 ................................................................................................ 139
A short guide for the private health sector - December 2001 ......................................................................... 139
4.The Tentative Model ...................................................................................................................................... 145
5. Elements of the Pharmacy Cardiovascular Health Care Model: Public/preventive health promotion 147
5.1 ................................................................................................................................................................... 147
Guiding principles and existing framework .................................................................................................... 147
5.2 Health promotion to prevent development and progression of CVD ................................................. 148
5.2.1 The SNAP Framework .............................................................................................................. 153
5.3 Improving community awareness of their risk factors ....................................................................... 169
5.4 Promote awareness of the early symptoms of acute cardiovascular events ...................................... 171
5.4.1 Chest pain ................................................................................................................................. 171
5.4.2 Stroke ........................................................................................................................................ 181
6.Elements of the Pharmacy Cardiovascular Health Care Model: Continuum of care .............................. 183
6.1 Guiding principles and existing framework ....................................................................................... 183
6.2 Transfer of medication related information and follow-up of patients post-discharge ..................... 184
7. Elements of the Pharmacy Cardiovascular Health Care Model: High-risk patients .............................. 192
7.1 Guiding principles and existing framework ....................................................................................... 192
7.2 Pharmacy-based risk factor screening and referral for assessment .................................................. 193
8. Elements of the Pharmacy Cardiovascular Health Care Model: Compliance with therapy .................. 212
8.1 Guiding principles and existing framework ....................................................................................... 212
8.2 Promoting patient compliance with drugs, diet and exercise ............................................................ 212
8.2.1 Hyperlipidaemia ............................................................................................................................ 216
8.2.2 Hypertension ................................................................................................................................. 225
8.3 Practical strategies to promote compliance in cardiovascular disease ............................................ 226
9.Elements of the Pharmacy Cardiovascular Health Care Model: Medication management and reviews233
9.1 Guiding principles and existing framework ....................................................................................... 233
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9.2 Promoting evidence-based pharmacotherapy of CVD ...................................................................... 234
9.2.1 Heart failure .................................................................................................................................. 245
9.2.2 Atrial fibrillation ........................................................................................................................... 249
9.2.3 Hypertension ................................................................................................................................. 250
9.2.4 Hyperlipidaemia ............................................................................................................................ 252
9.3 Monitoring and educating patients .................................................................................................... 257
9.3.1 Patient education, including participation in cardiac rehabilitation programs .......................... 258
9.3.2 High-risk drugs requiring ongoing monitoring ......................................................................... 261
9.4 Use of information and communications technology solutions to promote QUM in CVD ................ 284
10.Assessment of Opinion on the Model .......................................................................................................... 291
10.1 Input from stakeholders using a modified Delphi Process ................................................................ 291
10.1.1 National Heart Foundation........................................................................................................ 294
10.1.2 The Royal Australian College of General Practitioners ............................................................ 298
10.1.3 National Stroke Foundation ..................................................................................................... 298
10.1.4 Heart Support ........................................................................................................................... 303
11. Conclusions .................................................................................................................................................. 307
12. Recommendations ....................................................................................................................................... 298
13. References .................................................................................................................................................... 315
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Index of Figures
Figure 1 Framework for the potential roles of community pharmacists in alleviating the societal
burden of cardiovascular disease ....................................................................................... 34
Figure 2 “ABC” format to summarise the key principles of an evidence-based approach to the
prevention of CVD. ........................................................................................................... 35
Figure 3 Approach to the conduct of the systematic literature review of pharmacy programs in
cardiovascular disease........................................................................................................ 37
Figure 4 Example screen shot of the comprehensive electronic database of relevant literature ...... 44
Figure 5 Approach to the development of the National Pharmacy Cardiovascular Health Model .. 94
Figure 6 Stages of CVD risk ............................................................................................................ 95
Figure 7 Continuum of chronic disease prevention and care ........................................................... 98
Figure 8 Continuum of chronic disease prevention and care ........................................................ 101
Figure 9 From Pharmacy News, 13 May 2004 .............................................................................. 113
Figure 10 From Pharmacy News, 21 July 2005 ............................................................................... 113
Figure 11 From Pharmacy News, 27 May 2004 .......................................................................... 114
Figure 12 Staged approach to developing the pharmacist-physician collaborative working
relationship ................................................................................................................... 120
Figure 13 Stages of CVD (normal health, elevated risk for CVD, and diagnosed CVD) .............. 122
Figure 14 Possible roles for community pharmacists within the stages of CVD ............................ 123
Figure 15 Lifestyle interventions and drug treatments shown to reduce the risk of cardiovascular
morbidity and/or mortality ............................................................................................... 150
Figure 16 Lifestyle guidelines for preventing cardiovascular events .............................................. 151
Figure 17 Risk factor assessment, targets and monitoring intervals for the prevention of vascular
41
disease ........................................................................................................................... 152
Figure 18 Five step model (5As) for detection, assessment and management of risk factors within
the SNAP Framework ................................................................................................... 154
Figure 19 The National Heart Foundation of Australia’s Heartmoves program. ............................ 159
Figure 20 Excerpt from the patient decision aid “Making Choices: Life Changes to Lower Your Risk
of Heart Disease and Stroke”, developed by the Ottawa Health Research Institute
(http://decisionaid.ohri.ca/decaids.html). ......................................................................... 160
Figure 21 Example of materials for consumers available from the National Heart Foundation of
Australia’s website. .......................................................................................................... 162
Figure 22 Information leaflets for patients with CVD available from the National Heart Foundation
of Australia’s website. ..................................................................................................... 163
Figure 23 Example of general material on prevention of CVD for consumers available from the
National Heart Foundation of Australia’s website. .......................................................... 164
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Figure 24 Educational material available for order through the National Heart Foundation of
Australia’s Heartline ........................................................................................................ 166
Figure 25 Pharmacy Self Care card on exercise and CVD .............................................................. 167
Figure 26 Pharmacy Self Care card on hypertension ....................................................................... 168
Figure 27 Example of educational material on prompt presentation for chest ................................ 179
Figure 28 Excerpt from ‘Heart Attack, available in 10 languages from the National Heart Foundation
of Australia’s website. ..................................................................................................... 180
Figure 29 Excerpt from ‘Transient Ischaemic Attack’, available from the Stroke Foundation’s
website. ............................................................................................................................ 181
Figure 30 Example of an educational poster suitable for display in community pharmacy (from the
Stroke Foundation’s website). ......................................................................................... 182
Figure 31 Deficits in the delivery of care at the hospital-community interface ............................... 184
Figure 32 Pharmacy-based Heart Assessment and Referral Methodology: a program to tackle
coronary heart disease in the Australian community (Pharmacy Guild of
Australia/Government, Third Community Pharmacy Agreement Research and
Development Grants Program. Project ............................................................................ 195
Figure 33 Predictors of poor patient compliance ............................................................................. 216
226
Figure 34 Discontinuation rates with lipid-lowering drug therapy (from Simons et al. ). Dispensing
data six to seven months after initial supply. Values are numbers (percentages) ............ 218
256
Figure 35 Treatment persistence with antihypertensive medications. Data from Jones et al. ..... 226
Figure 36 General strategies to improve compliance with medication ............................................ 227
Figure 37 General approach to enhancing patient compliance with lipid-lowering drug therapy ... 228
Figure 38 Multiple strategies that can improve medication compliance in CVD ............................ 231
Figure 39 Clinical aid outlining appropriate therapy for patients in different CVD risk categories 235
Figure 40 Therapeutic guidelines for preventing cardiovascular events in patients with CVD ...... 237
Figure 41 National Prescribing Service guidelines on drug use in CVD ......................................... 239
Figure 42 Example of media coverage of a published study of management of CHF by members of
the Project Team .............................................................................................................. 247
Figure 43 Underuse of beta-blockers and the pharmacist ................................................................ 256
Figure 44 Suggest content of cardiac rehabilitation programs ........................................................ 260
Figure 45 Pharmacist checklist for patient counselling on warfarin ................................................ 264
Figure 46 One page guide to warfarin treatment ............................................................................. 265
Figure 47 New anticoagulants or better use of existing therapy? .................................................... 267
Figure 48 Need for close monitoring of amiodarone therapy .......................................................... 283
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Figure 49 Decision support box to promote the appropriate use of low-dose aspirin (from
PROMISe2). The pharmacy dispense screen has links to print-friendly secondary
windows providing further information for the pharmacist and an information leaflet for
the patient ......................................................................................................................... 285
Figure 50 Screen shot of automated intervention alert for Low-dose aspirin (from PROMISe2) ... 286
Figure 51 Patient handout for aspirin automatic intervention prompt ............................................. 287
Figure 52 Pharmacist information sheet for aspirin automatic intervention prompt ....................... 288
Figure 53 Example of an intervention from the PROMISe2 study relating to the aspirin alert within
the dispensing software .................................................................................................... 289
Figure 54 Effect of aspirin intervention prompt on the overall intervention rate in different phases of
the PROMISe2 study ....................................................................................................... 289
Figure 55 The response from the National Heart Foundation, providing feedback on the draft Model
......................................................................................................................................... 298
Figure 56 The response from the National Stroke Foundation, providing feedback on the draft Model
......................................................................................................................................... 302
Figure 57 The response from Heart Support, providing feedback on the draft Model .................... 306
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Index of Tables
Table 1 INFORMIT search terms and criteria ................................................................................ 40
Table 2 CPRD search terms and criteria ........................................................................................ 41
Table 3 Source of papers for literature review ............................................................................... 42
Table 4 Information extracted from clinical papers ....................................................................... 45
Table 5 NHMRC levels of evidence classification ........................................................................ 46
Table 6 Checklist for appraising the quality of studies of interventions ........................................ 47
Table 7 Quality of Non-randomised controlled trials (NHMRC) .................................................. 48
Table 8 Definitions of types of outcomes (NHMRC) .................................................................... 49
Table 9 Body of evidence assessment matrix (NHMRC) .............................................................. 50
Table 10 Summary of papers examined, by CVD focus and evidence grade .................................. 52
Table 11 Location of residents completing survey ........................................................................... 56
Table 12 Categories of patients based on future risk of a cardiovascular event .............................. 96
Table 13 Common obstacles to inter-professional collaboration ................................................... 118
Table 14 Collaboration Between Community Pharmacists and Family Physicians: Lessons Learned
from the Seniors Medication Assessment Research Trial ............................................... 119
Table 15 Strategies to Achieve Stage 1: Increasing Pharmacists’ Recognition among Doctors .... 121
Table 16 Strategies to Achieve Stage 2: Relationship Exploration and Trial ................................ 121
Table 17 Strategies to Achieve Stage 3: Expanding the Professional Relationship ....................... 121
Table 18 Common causes of chest pain ......................................................................................... 175
Table 19 Differentiating features with the major causes of chest pain ........................................... 176
Table 20 Counselling Plan for High-Risk Patients ......................................................................... 178
Table 21 Summary of subject details from Pharmacy-based Heart Assessment and Referral
Methodology: a program to tackle coronary heart disease in the Australian community 196
Table 22 Main unit costs for pharmacy-based cardiovascular risk profiling ................................. 198
Table 23 Summary table of benefits, costs and cost-effectiveness of a ......................................... 200
Table 24 Individuals at increased risk of CVD .............................................................................. 205
Table 25 Some roles for the pharmacist in the care of the patient with dyslipidaemia (modified from
Luxford) ........................................................................................................................... 224
Table 26 Examples of conditions which may be under-diagnosed and/or under-treated in the elderly
......................................................................................................................................... 243
Table 27 Some roles of the pharmacist in patients with dyslipidaemia (modified from Luxford) . 253
Table 28 Patient partnership in medicine taking ............................................................................ 258
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Table 29 Specific aims of cardiac rehabilitation programs ............................................................ 259