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Pharmacist led interventions to improve medication related care of community-dwelling patients

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Naunton, M 2004 , 'Pharmacist led interventions to improve medication related care of community-dwelling patients', PhD thesis, University of Tasmania.

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Abstract

The aim of this thesis was to demonstrate the important roles pharmacists could fulfil in improving the medication management of patients, particularly the elderly. There were three separate parts completed.

Part I
Medication mishaps and adverse events in patients post-discharge from hospital have been well established. The first part of the research evaluated a pharmacist-conducted follow-up at home of elderly patients discharged from hospital. This was a randomised controlled study of 121 "high-risk" medical patients who were assigned to an intervention or control group. A pharmacist visited the intervention patients 5 days post discharge. The pharmacist educated patients on their medications, encouraged compliance, assessed for drug related problems, intervened where appropriate and communicated all relevant findings to community health professionals.
Intervention patients had significantly less medication-related problems at 90 days post-discharge (median 1.0) compared to control patients (median 2.0). In addition, there was an improvement in compliance, and decline in use of non-steroidal anti-inflammatory drugs. Forty-five per cent of control patients had unplanned readmissions to hospital during 90 days following discharge, compared to 28% of the intervention group patients (p = 0.05).
The project demonstrated that a pharmacist-conducted follow-up of "high-risk" elderly patients discharged from home is valuable in identifying and addressing drug-related problems and reducing the risk of readmission to hospital.

Part IIa
There has been much evidence published demonstrating that many women are not investigated for osteoporosis and many with osteoporosis and osteoporotic fractures do not receive adequate treatment. Quantitative heel ultrasound is recognised as a useful method for predicting risk of fracture in elderly women. Rural communities often have difficulties accessing a number of health resources including diagnostic equipment for osteoporosis. The aim of Part Ila of the thesis was to assess the role of a pharmacist, trained in the use of a portable heel ultrasound device, in screening elderly rural women for risk of osteoporosis, and assess whether those found to be at risk seek further help and treatment from their GP following the screening. In addition, the project aimed to increase the women's knowledge on osteoporosis.
Three hundred and forty-five women were recruited from 6 rural community pharmacies and underwent screening. Women were comprehensively educated on risk factors for osteoporosis and completed a calcium intake questionnaire to assess their calcium status. Results were promptly forwarded to each woman's GP and the subjects were followed-up 3 months later to assess outcomes from the screening procedure. Pharmacists and GPs were surveyed to assess their opinion.
Approximately 20% of women were shown to be at high-risk for osteoporosis and 27% of patients at increased risk for fracture. One hundred and ninety-one subjects (55%) were referred to their GP for further assessment. Sixty-eight per cent of women screened discussed their results with their doctor. Eleven per cent of women underwent further investigations and 4% had further investigations planned. Over one-third (30% calcium, 6% bisphosphonate, 6% vitamin D) of women screened commenced medication to treat or prevent osteoporosis. Two thirds of women indicated they had made lifestyle changes (e.g. increased calcium intake and exercise) following the screening. Women's knowledge about osteoporosis increased from a median of 10/17 to 14/17 following the screening.
In conclusion, screening for osteoporosis in community phannacies, particularly rural pharmacies, is a potentially useful method to identify women at risk for future fracture and is a suitable location for the discussion of preventive therapy. The osteoporosis screening was well received by the subjects and pharmacists. General practitioners were generally supportive of the project.

Part llb
Long-term use of oral corticosteroids has been shown to increase the likelihood of sustaining a fracture. Guidelines exist for the prevention of corticosteroid-induced osteoporosis. However, studies have consistently shown that patients prescribed long term oral corticosteroids do not receive adequate preventive therapy against osteoporosis. The aim of Part Ilb of the thesis was to perform a controlled comprehensive educational programme intended to increase the use of preventive therapy against osteoporosis in patients prescribed long-term oral corticosteroids.
The intervention was conducted in southern Tasmania, Australia, using the north of the State as a control area. The target group of all GPs and community pharmacies in southern Tasmania were sent educational material and locally produced guidelines on the prevention of corticosteroid-induced osteoporosis. A pharmacist then visited each GP and community pharmacist, and discussed the material directly with him/her. The community pharmacists were also provided with supplies of educational refrigerator magnets, intended for patients. The outcome of the programme was measured using evaluation feedback from the GPs and pharmacists, and drug utilisation data provided by (i) a series of patients presenting to hospital and taking oral corticosteroids for at least 3 consecutive months and (ii) dispensing of osteoporosis preventive therapy and prednisolone under the Australian Pharmaceutical Benefits and Repatriation Pharmaceutical Benefits Schemes.
The educational programme was very well received by the GPs and pharmacists. Baseline data prior to the intervention demonstrated that only 31% of admitted hospital patients on long-term oral corticosteroids were receiving preventive therapy against osteoporosis. Post-intervention data showed a significant increase to 57% of patients (p < 0.0001). The use of bisphosphonates, calcium and vitamin D increased significantly. Pharmaceutical Benefits and Repatriation Pharmaceutical Benefits Scheme data also indicated a significant (p < 0.01) increase in the dispensing of osteoporosis preventive therapy in the south compared to the north of Tasmania.
A multi-faceted educational programme, incorporating academic detailing of GPs and community pharmacists, advanced the safe use of oral corticosteroid therapy, although there was still scope for improvement in the prevention of corticosteroid induced osteoporosis.
This thesis has shown pharmacists can have a beneficial role in the medication management of community-dwelling patients through several interventions.

Item Type: Thesis - PhD
Authors/Creators:Naunton, M
Keywords: Osteoporosis, Pharmaceutical services, Older people, Adrenocortical hormones
Copyright Information:

Copyright 2004 the author - The University is continuing to endeavour to trace the copyright owner(s) and in the meantime this item has been reproduced here in good faith. We would be pleased to hear from the copyright owner(s).

Additional Information:

Thesis (PhD)--University of Tasmania, 2004. Includes bibliographical references

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