As roles for community pharmacists continue to expand, helping patients to maintain their cardiovascular health is more important than ever, writes Sheshtyn Paola
Back in mid-2005, pharmacy researchers reached out to more than 500 households across rural, remote and metropolitan Australia.
Their goal was to find out whether Australians saw community pharmacists as service providers in the area of cardiovascular health.
Results published in the Journal of Clinical Pharmacy and Therapeutics in 2010 revealed that while 97% of those surveyed were satisfied with the service provided at their regular pharmacy, just over half (52%) agreed or strongly agreed that pharmacists were capable of providing screening or testing for blood pressure, diabetes and cholesterol.
Slightly less (50.7%) believed pharmacists were capable of testing for diabetes, while a significantly lower 37.6% believed pharmacists were capable of performing cholesterol testing.
Meanwhile about 97% of respondents said they would be likely or very likely to use blood pressure screening provided by their doctor, compared to 58.6% who said they would use the same service at a pharmacy.
In contrast, 90% were willing to seek medicines advice from their pharmacist.
With many people at that time seemingly reticent to trust pharmacists with clinical services beyond medicines advice, researchers were only just testing the waters in investigating what services could be successfully offered within community pharmacies.
More than a decade later…
A lot has changed since those first results were gathered and published.
Professional pharmacy services are continuing to expand every year, as community pharmacies take on greater clinical roles in areas such as cardiovascular disease, smoking cessation, vaccination services, weight management, diabetes and even mental health.
As doctor’s surgeries are increasingly stretched to capacity, more people are heading to their pharmacy for health advice that goes beyond medication counselling.
Sydney pharmacist and proprietor of Balmain Community Pharmacy and Blooms the Chemist Edgecliff, Caroline Diamantis says her pharmacies are staffed with highly trained people who are qualified to test for blood pressure, cholesterol and blood glucose, as well as give advice on lifestyle choices.
“A lot of our pharmacies serve several hundred customers a day and they’re getting all these scripts—it’s a fabulous opportunity to approach customers,” Diamantis tells the AJP.
“We’re trying to actually capture the people that are walking around that don’t think anything’s wrong with them.
“By doing simple tests and simple interviews, just asking a few questions, we can actually determine risk.”
She says if a patient comes in with some warning signs, for example taking blood pressure tablets or mentioning that they’ve gained weight, her pharmacists use the AUSDRISK assessment tool to estimate patients’ risk of developing type 2 diabetes.
They can also conduct a waist measurement, measure blood pressure and discuss lifestyle choices.
“Blood pressure is perhaps the most important predisposing factor to having a cardiovascular event such as a stroke. Diabetes risk complicates it even more. And so we can actually use the information available to us in the pharmacy.
“We talk about BMI, being overweight and being physically inactive—those two often go hand-in-hand—making unhealthy food choices, and even we can do cholesterol testing in the store as well,” says Diamantis.
“It’s just a single finger prick test in the store, we’ve got really good technology these days. We can also counsel people about their smoking and alcohol intake. All of these conversations are easy to have in a quiet part of the shop or in your consulting room.”
Co-proprietors Luke McGrath and John Jones of My Community Pharmacy Shortland in Newcastle, NSW, also offer a wide range of free healthcare services.
These include weight management and diet advice from a qualified expert (Jones practised as a dietitian for 10 years before entering pharmacy), blood pressure monitoring, blood glucose and cholesterol testing.
“A diabetes and heart disease risk screening are provided along with disease state management and lifestyle advice for cardiovascular disease,” McGrath and Jones tell the AJP.
“We also provide smoking cessation advice and products, which are a major risk factor reduction in the management of cardiovascular disease.”
My Community Pharmacy Shortland collaborates with several gyms, personal trainers and physiotherapists in the area, which provide exercise advice and programs to patients that are referred by McGrath and Jones— often at a discounted rate.
They described it as their “holistic approach” to disease management.
“Pharmacists are often the first port of call for anything health related. This means we need to be equipped to deal with different situations at different times, and know when we need to refer someone to a doctor or if it is something that can be dealt with in the pharmacy.”
Pharmacists should also take every opportunity possible to ask patients questions. “There are a million-and-one questions that can be asked to further understand a patient’s situation and better manage their conditions,” say Jones and McGrath.
“This does not have to be directly related to cardiovascular disease but other co-morbidities that can exacerbate these conditions.”
These questions could include:
- How is your blood pressure?
- How is your exercise going?
- Is there anything we can help you with in regard to increasing your activity?
- Can we offer you some more support around taking your medication at the given times?
Going back to the key role of pharmacists—medication advice and counselling—is crucial to the management of cardiovascular disease in the pharmacy. Research also shows this is the area in which pharmacists hold the most trust with patients.
Medication management and compliance is critical in treating and managing cardiovascular disease, say McGrath and Jones.
“Medication plays a major part in managing blood pressure, diabetes and smoking cessation, and compliance is paramount in taking these medications,” they say.
“Our job as a pharmacist is to make this as simple as possible for the patient and to make sure the medications are doing what they are meant to do.”
However medications used in the treatment of cardiovascular disease mainly control the condition and are not a cure, say McGrath and Jones.
Medication compliance “goes hand-in-hand with non-pharmacological measures such as reducing risk factors which would include managing blood pressure, managing diabetes, increasing physical exercise, and quitting smoking.
“These are just as important to a patient’s health and disease management as the medication and often overlooked by pharmacists,” they say.
No turf war
It’s fair to say some GPs have felt increasingly threatened by pharmacists encroaching on their territory.
A few have even urged patients to avoid pharmacy altogether for health checks and screening. Royal Australian College of General Practitioners (RACGP) Victoria chair Dr Cameron Loy recently told the AJP that “the RACGP is concerned the walk-in, quick-stop health checks being advertised by Australian pharmacy chains could fragment patients’ healthcare and put them at serious risk.
“While fast, free advice may sound appealing to many patients, I urge them to consider where they seek medical care and advice,” said Dr Loy.
“GPs work closely with their patients to provide preventive healthcare solutions. This relationship is unique to general practice and cannot be replicated in quick, walk-in appointments.”
Pharmacists aren’t trying to replace doctors in conducting health checks such as cardiovascular disease and diabetes screening, emphasises Diamantis.
“We know doctors do it and we don’t pretend to be doctors,” she says.
“We don’t pretend to take their place—we want to work collegially with them, we want to work hand-in-hand with the doctors to be able to identify those that haven’t considered that they’re just getting older, gaining weight, they’re drinking too much, they’re eating too much, they’re not exercising enough and they’re smoking too much.
“The number of people that we identify of being at a high-risk category and have no idea is huge,” she says.
“They’re the people we target and pharmacy is the perfect place. We are the most accessible people, they’re coming in to get a prescription for whatever it is, it might not even be related to blood pressure—and then they start saying, ‘oh gosh I’ve been so unwell, I’ve been short of breath for the last three months and I don’t know what’s wrong with me’. And that’s again leading conversations.
“The most important message is that we are accessible, very well clinically trained, we understand the impact of lifestyle choices and we have the tools in the store a finger touch away.”
Referring to doctors is “fundamental” to any health checks and screening services that pharmacists may provide, says PSA national president Shane Jackson.
“If you’ve got a patient who’s at risk, the referral pathway is fundamental and a key part of the PSA’s guidelines around screening and risk assessment,” he tells the AJP.
“It’s about getting those people into the healthcare system, leading them to appropriate diagnosis and treatment. Any program for screening or risk assessment must have a referral pathway component.”
Being able to monitor someone’s disease state and effectively communicate this with a doctor is “critical,” say McGrath and Jones.
“This often means bridging the gap between doctors and pharmacists and working collectively in managing a patient’s conditions,” they say.
“All too often there is a disconnect that seems to be so prevalent in other pharmacies in the area.
“Here at My Community Pharmacy Shortland we are lucky enough to have a great rapport with the doctors around the area and often work collectively with these healthcare professionals with the patient as the central focus.”
Pharmacy health checks actually increase referrals to GPs, Diamantis points out.
If one of her patients is found to be at risk of cardiovascular disease or diabetes based on a risk assessment, or presents with a concerning issue such as high blood pressure, Diamantis says: “We alert them straight away that they should see a doctor.
“And if the results are quite scary— in the high bracket—we say look, can you go in today or tomorrow?
“We’re lucky we’ve got a few practices around us where we have good relationships with the doctors.
“It’s most likely we know who their doctor is and we can say, would you like us to ring the secretary and see if we can send you over today or tomorrow first thing? Have you got time for us to do that?”
She says if the patient is in a hurry, her pharmacists will make a note of the patient’s results using Pharmacy Guild software, and make sure they leave with a sheet of important, relevant information as well as a summary of their results—along with a note for their doctor.
“If we can’t organise an appointment straight away, we tell them that we’re at least going to remind them next time they shop with us, we’re going to record their numbers and give them information to take with them as well.
“We are serious about it. When they come in again, if they haven’t been to the doctor, we’ll ask them why; we’ll try and counsel them more about the importance of doing that.”
Diamantis emphasises that doctors’ concerns are unfounded, as pharmacists are providing adjunct rather than replacement services.
“Pharmacists know their place. These are very, very valuable screening tools and I’m excited that more of us are wanting to do this. The next steps are that we are recognised for our clinical knowledge and then paid for it.”
What evidence is there that in-pharmacy services for cardiovascular disease actually make a positive impact?
Here are some studies to read:
- McNamara KP et al. A pilot study evaluating multiple risk factor interventions by community pharmacists to prevent cardiovascular disease: The PAART CVD Pilot Project. Ann Pharmacother. 2012 Feb;46(2):183-191.
- Willis A, Rivers P, Gray LJ, Davies M, Khunti K. The effectiveness of screening for diabetes and cardiovascular disease risk factors in a community pharmacy setting. PLoS One. 2014 Apr 1;9(4):e91157.
- Milosavljevic A, Aspden T, Harrison J. Community pharmacist-led interventions and their impact on patients’ medication adherence and other health outcomes: a systematic review. Int J Pharm Pract. 2018 Jun 21. doi: 10.1111/ijpp.12462. [Epub ahead of print]
- Peterson GM, Fitzmaurice KD, Kruup H, Jackson SL, Rasiah RL. Cardiovascular risk screening program in Australian community pharmacies. Pharm World Sci. 2010 Jun;32(3):373-80.
- Horgan JMP, Blenkinsopp A, McManus RJ. Evaluation of a cardiovascular disease opportunistic risk assessment pilots (‘Heart MOT’ service) in community pharmacies. J Public Health (Oxf). 2010 Mar;32(1):110-6.
- Rohla M, Haberfeld H, Sinzinger H, et al. Systematic screening for cardiovascular risk at pharmacies.Open Heart 2016;3:e000497.
This article was originally published in the August 2018 print issue of the Australian Journal of Pharmacy.