meeting report
Science meets practice
Evidence-based clinical pharmacy services was the theme for the 2017 ESCP Symposium. Key topics
included pharmacy-managed cardiovascular disease, research design and predatory publishers
Christine Clark PhD
FRPharmS FCPP(Hon)
Laurence Goldberg
FRPharmS
Marcel Bouvy
Claudia Langebrake
Cristin Ryan
Ross Tsuyuki
Over the past five years, community
pharmacists in Canada have participated in
trials that have provided robust evidence of their
effectiveness in improving adherence to treatment.
Furthermore, Canada now has the best-controlled
hypertension in the world – managed by community
pharmacists, Ross Tsuyuki (a pharmacist who holds
the post of Professor of Medicine, University of
Alberta, Canada) told the audience. Pharmacists
in Alberta can prescribe medicines and order
laboratory tests and they put their skills to the test
in a series of controlled trials. First, the RxING
(‘Ring’) study showed that type 2 diabetes was
well controlled when managed by community
pharmacists. Next, the RxACTION (‘Reaction’)
study showed that pharmacist-management of
hypertension was more effective than ‘usual care’. In
fact, the odds of achieving the target blood pressure
were more than doubled in the intervention group.
Finally, the RxACT (‘React’) study showed that in
people with poorly controlled dyslipidaemia, 43%
reached the target low-density lipoprotein
cholesterol (LDL-c) in the intervention group
compared with 18% in the control group. In each
study, community pharmacists provided treatment
according to the evidence-based Canadian
guidelines, emphasised Professor Tsuyuki.
Until this point, the trials had focused on
individual cardiovascular risk factors, but the
RxEACH (‘Reach’) study – involving 56 community
pharmacies – pulled them all together in a
comprehensive, province-wide program. Pharmacists
were able to use a web-based cardiovascular risk
calculator (available from EPICORE, www.epicore.
ualberta.ca/rxeach) during consultations. This displays
risk on a green-amber-red dial and shows how an
individual’s risk can be ‘dialled down’ by modifying
factors such as weight and smoking.
Patients with at least one uncontrolled risk factor
(high blood pressure, LDL cholesterol, haemoglobin
A1c or smoking) were included. Those in the
intervention group received a standardised medication
therapy management consultation and follow up –
something which is already covered by the Canadian
community pharmacy reimbursement scheme. Once
again, treatment was prescribed in accordance with
evidence-based Canadian practice guidelines.
The results showed a 21% relative risk reduction
(RRR) for cardiovascular risk over three months,
linked to improved adherence. Furthermore, of
the 723 patients enrolled, 283 had chronic kidney
disease but in 113 (40%) this had previously been
undiagnosed. This was “a powerful validation
of pharmacists ordering laboratory tests”, said
Professor Tsuyuki.
42 | Issue 90 | 2018 | hospitalpharmacyeurope.com
Management of hypertension by community
pharmacists was associated with better outcomes
and lower costs than the usual (doctor-managed)
care. If implemented throughout Canada, almost
one million life-years and about 15.7 billion
Canadian dollars could be saved. “Even without
the prescribing element the savings could be
substantial”, said Professor Tsuyuki. “Having the
evidence has driven practice”, he concluded.
Atrial fibrillation
Two studies in ten countries have shown that
community pharmacists can effectively diagnose
atrial fibrillation (AF), much of which would
otherwise go undetected. AF is a major risk factor
for strokes and it is estimated that approximately
50% of AF is undiagnosed. Pharmacists were trained
to take the pulse manually and assess symptoms and
risk factors. They were also allowed to use electronic
aids such as the AliveCor™ device that works with
a smart phone and produces a read out equivalent
to a single-lead ECG. However, electronic devices
(for pulse checking) are not universally available,
commented one of the investigators, Filipa Alves
da Costa (Pharmacy, Centre for Interdisciplinary
Research Egas Moniz, Lisbon, Portugal). Whenever
an abnormal rhythm was detected, the patient was
referred to a physician. In total, 2573 patients with
a mean age of 65 years were included. The most
common risk factor was hypertension, followed by
diabetes and peripheral cardiovascular disease. An
irregular pulse was detected in 212 (8.3%) and so far
AF has been confirmed in 35 (1.4%).
Doing the right research
It has been estimated that there are almost $500
billion of avoidable costs associated with non-
adherence, untimely use of medicines, antibiotic
overuse, medication errors, suboptimal generic use
and mismanaged polypharmacy. These are all areas
where good quality pharmacy research conducted
by pharmacists is needed, according to Marcel Bouvy
(Professor of Pharmaceutical Care, University of
Utrecht, The Netherlands).
Poor trial design can lead to misleading results.
Critical factors are patient selection, the nature of
the intervention and choosing the right outcomes.
Studies of the impact of medication review by
pharmacists illustrate the problem – there have
been a number of publications in this area in recent
years but some results appear to be conflicting.
Two studies – the British HOMER and the Spanish
conSIGUE – addressing the impact of medication
review by pharmacists had different findings.
Analysis of the two trials showed that the design