P HARMACEUTICAL CARE

Pharmaceutical care is successfully delivered through several community pharmacy services in Scotland. The services include the Minor Ailment Service, Chronic Medication Scheme (CMS), flu-vaccinations, Acute Medication Service and Public Health Service (e.g. smoking cessation service and sexual health) among others (33, 41).

The current services that can be perceived as most similar to the proposed pharmacist-led osteoporosis service are CMS and flu-vaccinations. The CMS is a free service for people suffering from long-term conditions and includes shared care between GPs and community pharmacists (42). The patient can freely choose and register with the pharmacy where they will receive a pharmaceutical care service based on patients’ needs (42). The community pharmacies in Scotland have been providing influenza vaccinations successfully for some years (43). The pharmacists are trained for the necessary

resuscitation skills and anaphylaxis treatment involved. The vaccinations are undertaken in a private consultation area in the pharmacy. In NHS Lothian, 91 % of the community pharmacies have a private consulting area/room (44). “The Right Medicine”-document states that influenza vaccinations in community pharmacies relieves pressure on GP practices (37). The influenza vaccination is paid for by the patients and costs £12-13 (45, 46). Patients at risk are eligible for vaccinations from the GP practice free of charge.

In addition to the Scottish services mentioned, there are several non-dispensing interventions delivered by community pharmacies internationally. A Cochrane review from 2010 explains services for diseases such as asthma, Chronic Obstructive Pulmonary Disease, depression, diabetes, heart failure, hyperlipidemia and hypertension (47).

These services are evidence from a capability perspective, that a change in service delivery involving community pharmacy is feasible and therefore there is potential to promote such a change within appropriate governance frameworks. Ideas for improvement and change require that existing practices are challenged and new practice ideas are appraised.

1.4.1 Background for a future pharmaceutical care package offered to patients with osteoporosis

Medication reviews

The Right Medicine document recommends regular medication reviews for patients with long-term conditions. A medication review is included in the proposed pharmaceutical care package which will accommodate the Government’s request and have the potential to identify drug therapy problems.

Brief medication reviews are currently delivered by community pharmacists for patients involved in the CMS (42). Some GPs also offer patients a medication review as it is included in the Quality and Outcomes Framework (an incentive scheme for GP practices in the UK) (48). Discussing medicines with the patients and giving information will lead to a focus to optimise adherence. The Scottish Government has expressed that medication reviews would address medication problems and help to reduce falls (37). Casteel et. al. explained a falls prevention program in a community pharmacy which included a medication review. The authors conclude that coordination of care between community pharmacists and prescribers needs to be improved in order to gain the potential benefits (49), but indicates that such an intervention is feasible in the community pharmacy.

Falls assessment

A falls assessment is important because over 90 % of hip fractures are falls related and it is suggested that hip fractures cost the NHS £12,137 each (10). As emphasised earlier, there is an increased risk of morbidity and mortality after a hip fracture (50, 51). There are several assessment tools for use in community and hospital setting (52). In NHS Lothian the falls assessment for inpatients is performed applying a modified version of the St Thomas’s risk assessment tool in falling elderly inpatients (STRATIFY) (53). The SRATIFY tool comprises five questions, and is applied at hospital admission.

In Mid- and West Lothian, the falls assessment for outpatients is performed using another tool, namely the Fall Risk Assessment Scale for the Elderly (FRASE), which includes an eight item questionnaire (54). Each answer yields a score which is summarised into a total score. In addition to a questionnaire, a falls assessment may include a Five-Times-Sit-to-Stand Test (FTSST) where the patient is asked to sit on a 45-cm high chair, stand up and sit down again as quickly as possible without using hands. If the patient uses more than 15 seconds, the patient has an increased risk of recurrent falls (55). In literature, falls assessment by community pharmacists has been described in Fife and Forth Valley, Scotland and Hertfordshire, England, but information of the outcome is lacking (56, 57). However, it indicates that a community pharmacy based falls assessment is feasible.

Assessment of the need for calcium and vitamin D supplements

Sufficient levels of vitamin D and calcium have been shown to reduce bone loss in elderly (58).

Consequently, an assessment of the need for calcium and vitamin D is important in patients suffering from osteoporosis and can be included in a pharmaceutical care package. Philips et. al. illustrated that such an intervention carried out in a community pharmacy did not disrupt workflow or required training (59). Yuksel et. al. compared a community pharmacist intervention with BMD-screening and patient education to no intervention in terms of assessment for calcium and vitamin D intake in a Canadian randomized controlled trial (60). The patient education programme included information about calcium and vitamin D intake, but also risk factors, lifestyle measures, medication and written information. This intervention increased calcium intake in the intervention group (30 % vs 19 %, p=0.011). Intake of vitamin D and quality of life did not change significantly. This indicates that the last part of a future pharmaceutical care package also is feasible

On the basis of the Government drive and patient convenience, this study will explore the potential for community pharmacies to deliver a pharmaceutical care package aimed for osteoporosis patients receiving treatment with denosumab. The proposed pharmacist-led service must be within the framework stated above and will require dialogue and debate. Such a service will expand the

pharmacists’ role in a community pharmacy. It will be a new pharmaceutical care service in this patient population, but there are already pharmaceutical care services being delivered from community pharmacies in Scotland which may indicate that the idea is feasible. The proposed pharmacist-led service is believed to improve health care for the osteoporosis patients.