Jan 16, 2015 - IN TWO TERTIARY HEALTH CARE FACILITIES IN SOUTH ... take responsibility with other health-care professionals to improve ..... 60th IPC.
WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES
Ogbonna et al.
World Journal of Pharmacy and Pharmaceutical
SJIF Impact Factor 2.786
Sciences
Volume 4, Issue 03, 91-100.
Research Article
ISSN 2278 – 4357
PHARMACEUTICAL CARE INTERVENTIONS IN TYPE 2 DIABETES IN TWO TERTIARY HEALTH CARE FACILITIES IN SOUTH EASTERN NIGERIA Ogbonna Brian Onyebuchi1*, Ezenduka Charles Chukwuemeka1, Nduka Sunday Odunke1, Uzodinma Samuel Uchenna1, Orji Chima Ernest1 and Oparah Azuka Cyriacus2 1
*Department of Clinical Pharmacy and Pharmacy Management, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University Awka, Nigeria. 2
Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Benin, Benin City, Nigeria.
Article Received on 21 Dec 2014,
ABSTRACT
Revised on 16 Jan 2015, Accepted on 09 Feb 2015
interventions improve treatment outcomes and reduce the development
Background:
Evidence
has
shown
that
pharmaceutical
care
of complications in Type 2 diabetes. Aim: This study assessed the *Correspondence for
provision of pharmaceutical care among patients with Type 2 diabetes
Author
in two tertiary health care facilities in Nigeria. Methods: A descriptive
Ogbonna Brian
cross-sectional study was carried out on randomly selected clinical
Onyebuchi
pharmacists was carried out using pretested structured questionnaire.
Department of Clinical Pharmacy and Pharmacy
Data on pharmacists’ demographics and responsibilities in the
Management, Faculty of
management of Type 2 diabetes was analyzed using SPSS Version 16
Pharmaceutical Sciences,
and descriptive statistics.. Results: A total of 204 pharmacists with a
Nnamdi Azikiwe
modal age range of 20-30 years, 92(48.94%) took part in the study.
University Awka, Nigeria.
The modal year of practice was 1-10 years, 97 (73.5%). Drug therapy
problems assessment was carried out by 186 (97.4%). Patients’ counseling on selfmonitoring of blood sugar was 191(98.5%). Assessment of patients’ medical history and diabetic complications was significant. Patients knowledge of disease state and expectations from management were the most assessed outcomes. rise to: 185 (94.9%) and 172 (91.1%) respectively.. Conclusion: Study revealed that a good number of respondents carry out pharmaceutical care on patients with Type 2 diabetes Mellitus. However, the level of these
www.wjpps.com
Vol 4, Issue 03, 2015.
91
Ogbonna et al.
World Journal of Pharmacy and Pharmaceutical
Sciences activities was inconsistent with best practice. This underscores the need for a more comprehensive approach, specialization and development of subspecialties. KEYWORDS: Pharmaceutical care, type 2 diabetes, pharmacists, patients, interventions, complications. INTRODUCTION The philosophy of pharmaceutical care as stated by Hepler and Strand rests on four prongs of service: patient-centered care, caring, social need and pharmacists’ responsibility. Pharmacists’ responsibility borders on identifying and meeting patients’ drug related needs in order to prevent immediate and long term complications and improve patients’ outcomes. Achieving treatment goals depend greatly on how well the pharmaceutical care roles are implemented.[1, 2, 3] Type 2 diabetes is a chronic metabolic disorder associated with relative to absolute insulin resistance leading to hyperglycemia when glucose is denied entry into the cells. Morbidity and mortality are usually associated with-long term vascular complications especially in poorly managed patients.[4,
5]
Pharmacists interventions in this disease state
management have been known to greatly improve patients’ clinical, economic and humanistic outcomes.[6, 7] The role of pharmacists in the management of disease state since the advent of pharmaceutical care is evolving and increasingly dynamic. It is a quality improvement process that minimizes cost, eliminates actual and potential drug therapy problems, and improves patients’ quality of life.[8, 9, 10] Pharmacists role in disease state management have been reported over the years from significant reduction in emergency room visit by Watanabe et al,
[11]
to reduction of length of hospitalization,[12] reduction in avoidable adverse drug
reactions,[13] reduction in glycosylated hemoglobin count,[14] and lots more. Their activities in patient education have been known to improve adherence and eliminate medication errors which are vital in achieving therapeutic goals. Patients cannot succeed without pharmaceutical care due to increasing complexity and risk of drug therapy problems at different levels of care. This informs the need for pharmacists to take responsibility with other health-care professionals to improve patients’ outcomes.[15, 16] Pharmaceutical care services vary from simple to moderate and complex operations namely: primary, secondary and tertiary pharmaceutical care services. Tertiary pharmaceutical care involves comprehensive clinical pharmacy services which require complex judgment, sound knowledge and skills in resolving patients’ need.[17, 18, 19] www.wjpps.com
Vol 4, Issue 03, 2015.
92
Ogbonna et al.
World Journal of Pharmacy and Pharmaceutical
Sciences Pharmacists in collaboration with other health care professionals can greatly improve type 2 diabetic patients’ outcomes.[20,
21]
These activities include but not limited to patients
education and counseling on drugs use, disease state management, life-style modifications, prevention of acute and chronic complications, self monitoring of blood glucose and miscellaneous like foot care, eye care, oral care, diet modifications, etc.[22,23,24] This is done in addition to collection and creation of patient specific information base, identification of medication problems, prioritization of lists, creation of treatment goals, development of therapeutic plan, problem solving, documentation, follow-up and making recommendations. All these activities are individualized and targeted towards achieving each patient’s outcome goals.[25, 26, 27] METHODS A cross-sectional survey was carried out among hospital pharmacists who gave their informed consent to participate in the study. Study was carried out between January and September, 2014. Pretested structured questionnaire was administered to the respondents excluding their names to prevent any form of respondents identification and avoid bias.. The questionnaires were self -administered and collected back on agreed dates at designated points at a response rate of 97.0%. Statistical analysis Data was analyzed using descriptive statistics reported as mean ±SD and SPSS version 16. Statistical significance was accepted at p< 0.01 confidence interval. Chi square test of independence was used to test for association between categorical variables. Ethical consideration Ethical approval was obtained from an Institutional Research Review and Ethics Committee of the University Teaching Hospital before commencement of the study. Informed consent was obtained from all pharmacists who took part in the study before administration of the questionnaire. RESULTS A total of 204 hospital pharmacists took part in the study. Baseline characteristics showed that a majority of the respondents 77.9% had just the first degree (B. Pharm) while their modal years of practice were between 1 to 10 years (73.5%). The modal age of the respondents was 20 to 30 years (48.9%). www.wjpps.com
Vol 4, Issue 03, 2015.
93
Ogbonna et al.
World Journal of Pharmacy and Pharmaceutical
Sciences Table 1: Demographics of participants Variables
N±SD(%)
Academic qualification B. Pharm Pharm D M. Pharm FPC Pharm Ph. D Others Years of professional experience 1 – 10 11 – 20 21 – 30 31 – 40 SEX Male Female AGE 20 – 30 31 – 40 41 – 50 51 – 60 >60
(n=204) 159 (77.9%) 16 (7.8%) 23 (11.3%) 6 (2.9%) 0 1 (0.5%) (n=132) 97 (73.5%) 22 (16.7%) 9 (6.8%) 4 (3.0%) (n=204) 90 (44.1%) 114 (55.9%) (n=188) 92±12.88 46±8.42 32±3.50 15±2.61 3±0.8
Table 2: Pharmaceutical Care Role of Pharmacists in Type 2 Diabetes Management p≤ 0.01 VARIABLES YES (%) a Determine if DT correlate with problems being treated 187 (98.42%) Assess patients for DTPsb (n=191) 186 (97.38%) Determine whether DTPs are being treatedc (n=171) 157 (91.81%) Determine if current therapy is appropriated (n=194) 192 (98.97%) Determine if additional therapy is needede (n=176) 168 (95.45%) Determine if the DTPs are caused by the medicinese (n=178) 164 (92.13%) Others 0 2a 2e 2 2a Calculated x; x =0.01, x = 0.01, Expected x ; x = 13.2767, x2e = 13.2767
NO (%) 3 (1.58%) 5 (2.62%) 14 (8.19%) 2 (1.03%) 8 (4.55%) 4 (7.87%) 0
DTP: Drug therapy problems, DT: Drug therapy
www.wjpps.com
Vol 4, Issue 03, 2015.
94
Ogbonna et al.
World Journal of Pharmacy and Pharmaceutical
Sciences Table3. Areas of patient counseling Variables
Yes ±SD
No ±SD
Self-monitoring of blood sugar (n=194) 191±23.42 3±1.2 Weight (BMI) (n=101) 86±10.68 15±3.69 Blood pressure control (n=180) 174±21.10 6±1.47 Feet care and examination (n=147) 114±15.64 33±5.75 Skin care (n=104) 53±7.47 51±10.7 Random blood sugar (n=146) 132±17.21 14±3.19 Fasting blood sugar (n=156) 145±18.70 11±3.49 Medication/insulin use (n=177) 165±19.73 12±3.50 Aspirin use (n=104) 54±6.41 50±10.83 Smoking status (n=141) 100±8.88 41±10.4 Diabetic complications (n=176) 157±18.51 19±7.6 2a 2d 2 2b Calculated x; x =0.1, x = 3.97, Expected x ; x = 13.2767, x2d = 13.2767
Those actually documented ±SD 23±5.82 6±1.6 20±6.10 8±2.73 1±0.4 6±2.4 3±1.2 4±0.98 0 1±0.4 3±1.2
Table 4: Patient assessment VARIABLES YES (%) NO (%) Past/present medical history (n=160) 144 (90.0%) 16 (10.0%) Medication allergy/intolerance (n=130) 94 (72.3%) 36 (27.7%) Hyper/hypoglycemic reactions/episodes (n=127) 103 (81.10%) 24 (18.9%) Glucose monitoring date (n=136) 127 (93.38%) 9 (6.6%) Dietary history (n=156) 143 (91.67%) 13 (8.3%) Drug history (n=173) 158 (91.33%) 15 (8.67%) Exercise history (n=148) 118 (79.73%) 30 (20.27%) Diabetic complications (n=151) 136 (90.1%) 15 (9.9%) Others, specify (n=0) 0 0 2a 2h 2 2a 2d Calculated x; x =0.36, x = 0.085, Expected x ; x = 13.2767, x = 13.2767 Table 5. Patient Treatment Outcome Being Assessed VARIABLES YES (%) NO (%) a Patient knowledge of disease state (n=195) 185 (94.87%) 10 (5.13%) Attitude towards the illnessb (n=173) 151 (87.28%) 22 (12.72%) c Expectations from treatment/management (n=189) 172 (91.01%) 17 (8.99%) Satisfaction with treatmentd (n=177) 159 (89.83%) 18 (10.17%) Physical/emotional/financial well-beinge (n=178) 156 (87.64%) 22 (12.36%) Calculated x; x2a =0.17, x2e = 1.27, Expected x2; x2a = 13.2767, x2d = 13.2767 DISCUSSION The study provided an insight and understanding into pharmacists’ roles in type 2 diabetes pharmaceutical care practice in developing countries. Study suggests that the pharmacists determine varying categories of drug therapy problems which include: determination of the correlation of drug therapy with problems being treated, assessment of drug therapy problems and resolution of drug therapy problems. Others include determination of the appropriateness www.wjpps.com
Vol 4, Issue 03, 2015.
95
Ogbonna et al.
World Journal of Pharmacy and Pharmaceutical
Sciences of drug treatment, need for additional therapy and determination of the causes of drug therapy problems. These support the fact that drug therapy problems form the core of pharmaceutical care. It is in line with Tomechko et al[28] who pointed out five drug- related needs that need to be tackled in order to optimize patients’ therapy. It supports the result obtained by Odili et al[29] where these factors were noted as the key drug therapy problems identified by pharmacists in type 2 diabetic clinic in Benin City, Nigeria. Determination of whether drug therapy correlates with medical problems being treated and the need for additional drug therapy were statistically significant. This suggests the dire need for these interventions in chronic disease states with life threatening complications as obtainable in type 2 diabetes, hypertension and metabolic syndrome. Comfort et al obtained a similar result in northern Nigeria.[30] Patients’ education and counseling forms an integral part of pharmaceutical care in type 2 diabetes. It covers type 2 diabetes care process which includes but not limited to the following: self- monitoring of blood sugar, body weight control, blood pressure control, graded exercise, foot, eye, dental and skin care. Others are medication use, hypoglycemic and hyperglycemic manifestations detection, aspirin use, smoking status, diabetic complications development and assessment of progression for necessary interventions which could halt or slow down the progression. Proper counseling on these factors have been known to significantly improve type 2 diabetes treatment outcomes.[31] This was supported by a work by Bhattacharyya who suggested that type 2 diabetic patients who received pharmaceutical care education on life style modifications, medication use and management of diabetes signs and symptoms through self monitoring showed better treatment outcomes.[7,32,33] However, a good number of respondents did not counsel patients on skin care and aspirin use. This underscores the need for continuous professional training and development in line with global best practices.[34, 35] Patients’ assessment is vital in collection of patients’ data for the creation of patient-specific information database, identification of problems, setting of pharmacotherapeutic goals and development of therapeutic and monitoring plan. These enables proper follow-up of patients which is necessary for achieving treatment success especially in chronic disease states like diabetes
[34]
. Study indicates that the pharmacists carried outpatient assessment through
collection of patients past and present medical history, determination of medication allergy and intolerance, determination of potential and actual hypoglycemic and hyperglycemic www.wjpps.com
Vol 4, Issue 03, 2015.
96
Ogbonna et al.
World Journal of Pharmacy and Pharmaceutical
Sciences reactions and glucose monitoring dates. Other services carried out include review of diet, drug and exercise history. Good monitoring of these parameters correlate well with good quality of life for this category of patients and is consistent with studies by Powell, and Cioffi et al respectively.[36,37] The patients’ treatment outcomes assessed by the respondents were patients’ knowledge of disease state, attitude of patients towards the illness, patients’ expectation of treatment, satisfaction with treatment and assessment of physical, emotional and financial well-being. These borders on clinical, economic and humanistic outcomes which are the three domains of outcome measures in clinical pharmacy and are invaluable in type 2 diabetes disease state management.[38, 39] It forms the basis for patient assessment which is the systematic process of acquiring, analyzing and interpreting subjective and objective patient information to identify, resolve and prevent drug-related and disease related problems.[40] Previous studies showed that pharmaceutical care interventions through assessment of patients’ specific information, expectations of treatment, evaluation of physical, emotional and mental well-being, reduced cardiovascular risk factors known to cause death in type 2 diabetic, leading to significant improvement in health- related quality of life.[41,42] CONCLUSION The advent of pharmaceutical care has led to ever increasing and dynamic roles of pharmacists to evolve and develop through re-professionalization to patient- oriented practice. Studies support the positive impact of pharmacists’ interventions on type 2 diabetes management outcomes. This study examined the roles and interventions of pharmacists in type 2 diabetes management. It underscores the need for speedy implementation of pharmaceutical care in disease state management and will help to minimize associated complications and improve the actualization of patients’ treatment outcomes and goals. It gives an indication of specialization and development of sub- specialties which gives room for more comprehensive care. ACKNOWLEDGEMENTS I am greatly indebted to the hospital management and the pharmacists for their corporation throughout the study. Competing interest The authors declared no conflict of interests. All authors agreed and approved the final manuscript. www.wjpps.com
Vol 4, Issue 03, 2015.
97
Ogbonna et al.
World Journal of Pharmacy and Pharmaceutical
Sciences Authors’ contribution OBO conceived the study, designed, collected data and wrote the manuscript. ECC, OSN, OEC, and USU participated in the study design and data collection while OAC participated in data analysis, interpretation and review of the manuscript. REFERENCES 1. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm, 1990; 47; 533-543. 2. Strand L. Building a practice in pharmaceutical care. Pharm J, 1998; 260: 874-878. 3. Oparah AC. Essentials of pharmaceutical care. Cybex publication, 2010; Ed 1(2): 21-40. 4. Alder AL, Stratton IM, Neil HA, Yudkin JS, Mathew DR, Cull CA, Wright AD, Turner RC, Holman RR. Association of systolic blood pressure with macrovascular and macro vascular complications of type 2 diabetes (UKPDS 36): Prospective observational study, BMJ 2000; 321: 412-19. 5. The hypertension in Diabetes Study Group. Hypertension in Diabetes Study (HDS): II. Increased risk of cardiovascular complications in hypertensive type 2 diabetic patients. J Hypertens, 1993; 11: 319-25. 6. Viberti G, Wheeldon NM. Microalbuminuria reduction with Valsartan in patients with type 2 diabetes mellitus. A blood pressure-independent effect (MARVAL). Circulation, 2002; 106: 672-8. 7. Nadia RAM, Mostafa MK, Naserdeen MG and James CM.. Influence of pharmaceutical care on health outcomes in patients with type 2 diabetes mellitus. Br J of Clin Pharmacol, 2009; 65(1) 547-557. 8. Zitter M. Med Interface 1995; 7:70. 9. Data from the Centers for Medicare and Medicaid Services, National Health Statistics Group, Office of the Actuary, National Health Expenditures, 2000. 10. Navarro RP. In: Navarro RP, ed. Managed Care Pharmacy Practice. Maryland: Aspen, 1999. 11. Watanabe T, Ohta M, Murata M, et al J Clin Pharm Ther, 1998; 23: 303. 12. Dager WE, Branch JM, King JH, et al. Ann Pharmacother, 2000; 34: 567. 13. Leape LL, Cullen DJ, Clapp MD, et al. JAMA, 1999; 282: 267. 14. Grace KA, McPherson MI, Burstein AH, Am J Health-System Pharm, 1998; 55 S27. 15. Strand LM, Morley PC, Cipolle RJ, Ramsey R, Lamsam GD. . Drug-related problems: their structure and function. DICPA Ann Pharmacother,1990; 24: 1093-1097. www.wjpps.com
Vol 4, Issue 03, 2015.
98
Ogbonna et al.
World Journal of Pharmacy and Pharmaceutical
Sciences 16. Hepler C, Grainger-Rousseau. Pharmaceutical care versus traditional drug treatment: is there a difference? “Drugs, 1995; 49: 1-10. 17. Smith WE, Benderev K.. Levels of pharmaceutical care: a theoretical model. Am J Hosp Pharm, 1991; 48: 540-546. 18. Cipolle RJ, Strand LM and Morley PC. Pharmaceutical care practice. McGraw-Hills, 1998;NY; 76-83. 19. Al-Shaqha WM, Zairi M. Pharmaceutical care management: a modern approach to providing seamless and integrated health care. Int J Health Care Quality Assur,2011; 14(7): 282-301. 20. Hawkins D, Bradberry JC, Cziraky MJ, Talbert RL, Bartels DW, Cerveny JD. National Pharmacy Cardiovascular Council treatment guidelines for the management of type 2 diabetes mellitus: towards better patient outcomes and new roles for pharmacists. Pharmacotherapy, 2002; 22(4): 436-44. 21. Shanmugam S, Lini EC, Rajeswari R et al. Impact of pharmaceutical care on quality of life in patients with type 2 diabetes mellitus. JRMS, 2011; Vol 16, Special Issue. Pp, 412413. 22. Kumanan R, Sudha S, Jayaveera KN. Can a pharmacist improve diabetes patient? An overview. RJPBCS, 2010; Vol 1 Issue 3 pp, 55-9. 23. Heidi M, Harper A and Berger et al. Am J Pharm Edu, 1992; 56: 252-8 24. Pharmacy practice changing times, new roles. Chronicle pharmabiz, 13: 12. pp.31. 25. Strand LM, Cipollle RJ, Marley PC. Documenting Clinical Pharmacy Services. Back t basics. Drug Intell. Clin. Pharm, 1988; 22: 63-67. 26. Buerki R. In search of excellence: The First Century of the American Association of Pharmacy. Am J Pharm-Educ, 1999; 63 suppl: 1-210. 27. Winslade NE, Bajcar JM, Bombassao A. Pharmacists’ management of Drug-related Problems: A Tool for Teaching and Providing Pharmaceutical Care. Pharmacotherapy, 1997; 17(4): 805. 28. Tomechho MA, Strand LM, Morley PC, Cipolle RJ. Question and Answer from the pharmaceutical care project in Minnesota. Am Pharm, 1995; NS 35(4): 30-39. 29. Odili VU, Egiebor BO, Oparah AC.Identification of drug therapy problems in patients with diabetes treated in a secondary care facility in Benin City. Nat J Trop Research, 2011; 9(1) 72-81.
www.wjpps.com
Vol 4, Issue 03, 2015.
99
Ogbonna et al.
World Journal of Pharmacy and Pharmaceutical
Sciences 30. Comfort OO, Stieve SG, Temidayo OO, Titus TS. Drug utilization review of anti-diabetic medications and therapeutic outcome in type 2 diabetes in a tertiary hospital in northern Nigeria. West Afr J of Pharm, 2012;23(2): 58-64. 31. Patient counseling in magic spell for better healthcare, scientific abstracts, 2008; p.512, 60th IPC. 32. Bhattacharyya A.. Treatment of type 2 diabetes mellitus. Hospital Pharmacist, 2001;8: 10-16. 33. English GN, Poirier S. Optimizing adherence to pharmaceutical care plans. J Am Pharm Assoc, 2000; 40: 475-85. 34. McDonough RP. Interventions to improve patient pharmaceutical care outcomes. J Am Pharm Assoc, 1996; 536: 453-466. 35. Volume CI, Farris KB, Kassam R, Cox CE, Cave A . Pharmaceutical care research and education project: patient outcomes after provision of pharmaceutical care. J Am Pharm Assoc (Wash), 2001;41(3): 411-420. 36. Powel MF, Bukhart VD, Lamy PP, Diabetic patient compliance as a function of patient counseling. Drug Intell Clin Pharm, 1979; 13(9): 506-11. 37. Cioffi ST, Caron MF, Kalus JS, Hill P, Buckley TE. Glycosylated hemoglobin, cardiovascular and renal outcomes in a pharmacist-managed clinic. Ann Pharmacother, 2004; 38(5): 771-5. 38. Farris KB, Kirking D. Assessing the quality of pharmaceutical care II: Application of the concepts of quality assessment from medical care. Ann Pharmacother, 1993b; 27: 215223. 39. Farris KB, Kirking D.. Assessing the quality of pharmaceutical care I: One perspective of quality. Ann Pharmacother, 1993a; 27: 68-73. 40. Campbell RK.. Role of the pharmacist in diabetes management. Ann J Health-Syst Pharm, 2002; (59): 1, Suppl 9. 41. Arnoldo Z, Maria ARCP, Raquel ST, Rui C, Roberto BB. Pharmaceutical care consultation as a tool to improve health outcomes for patients with type 2 diabetes. Brazilian J Pharm Sci, 2013; 49(1): 85-95. 42. Azubuje MIR, Foppa M, Maranha MFC, Achutia AC. Economic burden of severe cardiovascular diseases in Brazil: an estimate based on secondary data. Arq Bras. Cardiol, 2008; 91: 163-171.
www.wjpps.com
Vol 4, Issue 03, 2015.
100
