6 DISCUSSION
6.2 T HE PROPOSED PATIENT JOURNEY
6.2.1 The patient perspective
6.2.1.1 Pharmaceutical care package
The pharmaceutical care package was designed based upon published evidence regarding the separate elements (i.e. medication review, assessment of falls risk and diet). This was to assure delivery of the best possible health care to patients.
Medication reviews
Medication review outcomes are beneficial for patients. The outcomes in different settings have been presented in literature (6, 72). In a recent meta-analysis, Hatah et. al. concluded that medication reviews have a positive impact on hospitalisation rate, increased adherence and some clinical outcomes, such as low density lipoprotein and blood pressure (72). However, the authors also concluded that medication reviews do not influence mortality risk. Vinks et. al. showed that medication reviews undertaken in community pharmacies may lead to a reduction in drug therapy problems (73). In a study where medication reviews were undertaken in care homes for elderly, Zermansky et. al. showed a reduction in falls, which is important in osteoporosis to avoid fractures (74). A Cochrane review concluded that increased adherence to treatment have larger effect then any treatment itself (1). Despite all the evidence, data in this study suggested medication reviews are not currently delivered to all osteoporosis patients, which emphasises the clear need for such an intervention.
Most of the community pharmacies included in the current study reported they were undertaking medication reviews in general and believed that they could help increase adherence through medication reviews, which is the basis for the CMS. This data supports the feasibility of including a medication review in the pharmaceutical care package.
Assessment of falls risk and the need for calcium and vitamin D supplements
Assessment of falls risk using FTSST and FRASE is also evidence based and the latter following the current Lothian protocol (54, 55). No validated tool was found for assuring sufficient intake of both calcium and vitamin D, but is highlighted as important in the SIGN guidelines and is an important part of osteoporosis treatment (12). The intake of calcium alone could be assessed by using an online calculator from the Centre for Molecular Medicine, which is in accordance with the suggestion from National Osteoporosis Society in the Vitamin D Guidelines (70, 75). This is also a relatively simple task for a community pharmacist which indicates feasibility.
Delivery of the pharmaceutical care package
It seems there is insufficient capacity in all professional services and there is a need for multidisciplinary agreement as to who delivers this service. Almost half of the patients did not report being asked about medicines, falling or diet in primary care (i.e. by GP or practice nurse). Most of the GP respondents agreed that medication reviews and encouraging adherence could be done by a community pharmacist and did not disagree with the pharmacist assessing falls risk and the need for calcium and vitamin D. They had more disagreement with pharmacists administering the denosumab injection. This evidence suggests that there is some appetite to explore and agree a defined new model of shared care.
Despite all the evidence of the pharmaceutical care package being beneficial for patients, it is not currently delivered to all osteoporosis patients. Consequently, there is a clear need for such an intervention. The opportunity to deliver a service which includes these elements was embraced by almost ¾ of the community pharmacy respondents. However, some patients would not be comfortable with a pharmacist asking about falls, diet or the medication, perhaps based on their previous experiences or the relationship. As the wording of the questionnaire item did not clarify if it was questions about falls, diet and medication, or the fact that it is the pharmacist who asks these questions that was perceived as uncomfortable, a conclusion cannot be drawn.
6.2.1.2 Relationship
One reason for the patients’ preference for GP practices is their relationship with the practice and osteoporosis specialist nurse. This was described in the patient interviews and questionnaire comments as an important factor for the preference of venue. A good relationship with the health care professional was explained to be important in Robben et. al. findings in a qualitative study, which investigated the preference for receiving information among frail older adults and their caregivers (76). The authors do not describe if it is the bond and rapport itself, or if it is important that the bond is with a physician or in this study; a nurse. One of the important factors involved in the patient-nurse relationship is trust, and was explained by some patients as the reason for their choice (77). One of the patient interviewees expressed the relationship with the pharmacy as very good and based her preference of receiving treatment in the pharmacy partially on the relationship. As many patients explained the relationship with the pharmacy as good, it can be questioned if the patient-nurse relationship and the trust involved can be translated to the patient-pharmacy relationship. The chi square did indicate that a higher proportion of patients have a good relationship with the nurse compared to the community pharmacy, but a more thorough study should be undertaken to investigate the relationships. This study does not conclude that a higher proportion of patients have a better relationship with the nurse compared to the community pharmacy.
It is important that the patient-pharmacist relationship is good to deliver health care in community pharmacies. For the pharmacist to a build a good relationship with the patients, continuity in the pharmacist who delivers the service to the patient would be important (76). The continuity may also increase the feeling of expertise, which was commented as a reason to prefer the hospital and is a determinant of patient satisfaction (78). The public must be reassured through revalidation of competence for pharmacists to be trusted delivering direct clinical care (79).
Recognition of the existing pharmacist-led services in community pharmacies was believed to be an advantage for the patients to be comfortable with receiving the denosumab injection and osteoporosis care in a community pharmacy. Over one third of the community pharmacies responded that they deliver the contracted pharmaceutical care services and are leaders in the profession prepared to take responsibility for delivery of clinically based services. However, the data did not indicate that prior knowledge of the clinics results in more patients being comfortable with the proposal.
The implementation of CMS may help to build relationships as pharmacists are required to engage with patients in the delivery of pharmaceutical care.
6.2.1.3 Convenience
The anecdotal feedback from patients regarding inconvenience of the current denosumab administration was confirmed in this study. The patients reported a longer travel to the hospital than to their community pharmacy and several patients explained that the travel was time consuming and inconvenient. Convenience was explained by many patients as the reason for preferring primary care (i.e. community pharmacy or GP practice) as the venue of receiving the denosumab injection. Over half of the GPs agreed that denosumab could be administered in their practice and almost ¾ of the pharmacists respondents reported willingness deliver the proposed service. Delivering the service in a community pharmacy is in accordance with the government policy documents and drive which recommends transfer of healthcare to primary care and to be patient centred (4, 31, 32).
One important disadvantage with the proposed pharmacist-led service is that the majority of patients seem to prefer receiving their injections with their GPs. Although more patients answered the pharmacy rather than the hospital, the high number of preferences for the GP practice might question if the proposed pharmacist-led service will be patient centred. The results might have been different if the question asked to rank the preference of venue from 1 – 3. The GPs did not give a clear response on their views regarding delivering the proposed service from the GP practice, which could have been a lack of capacity and remuneration as some comments suggested.