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Australian Journal of Pharmacy : March 2005
pharmacy practice foundation research patients had a history of medication non- compliance and 5 per cent had stopped their diuretic prior to admission. Six per cent had taken COX-2 inhibitors pre- admission. At discharge (Figure Two), 83 per cent were taking ACE inhibitors or angiotensin receptor blockers (ARBs) and 65 per cent were taking beta-blockers. Of those tak- ing ACE-Is/ARBs, only 27 per cent were on target doses. Fifteen per cent were on target doses of beta-blockers. Twenty per cent had contraindications for beta- blocker use. Fifty per cent of patients were able to be educated regarding the use of flexible diuretic regimens. Documenta- tion of immunisation was poor with only 5 per cent having received pneumococcal vaccination. Fourteen per cent were tak- ing complementary and alternative med- ications (CAM). Given the high medication load and risk of adverse outcomes, QUM is a high priority for HF. While increased numbers of patients are on recommended thera- pies, strategies for up-titration is needed post-hospital discharge. Many patients/carers respond to empowerment strategies such as monitor- ing for flexible dietary regimens and other self-care strategies. When practical expla- nations are provided, confidence with, and knowledge of, medications promotes concordance with the treatment plan and involvement of patients in HF manage- ment promotes QUM outcomes. Disease state management (DSM) The preferred model for chronic disease management has been described as a partnership between patient and health professionals. DSM co-ordinates medical resources for patients across the entire healthcare delivery system53 and is more likely to meet the ongoing needs of patients.48 Moreover, pharmacists have consistently been omitted from the loop.54 There are many examples of positive health outcomes when pharmacists pro- vide DSM services in controlled research situations.56–60 Community pharmacists’ role in CVD Community pharmacists hold a unique position caring for the ambulatory patient. They are readily accessible; pro- vide a non-threatening environment; are able to counsel and supply information or refer when necessary; have established rapport with consumers, often see patients more frequently than other healthcare professionals when filling pre- scriptions; are well-trained in both pre- ventative and therapeutic strategies; and have a holistic approach to the patient’s healthcare needs. Community pharmacists have tradi- tionally been seen as patient advocates. As trained specialists in the provision of safe and effective medication, pharmacists are in an ideal position to complement the clinical activities of other healthcare providers in managing chronic dis- Figure One: Prevalence of co-morbidity per cent (Bennett 2004) 10 20 30 40 50 60 70 80 0 100 20 40 60 80 0 eases,61–66 improving therapeutic out- comes, and resolving drug-related prob- lems. Community pharmacists are well placed to assist GPs in the provision of detection, education and referral systems for individuals at risk of CVD. Importantly, due to their computerised dispensed medication histories, commu- nity pharmacists have the potential to identify medication non-adherence and provide adherence support and monitor- ing services. They are also able to advise regarding the dangers of OTC medications as well as CAMs. A potential future role for com- munity pharmacy could be a QUM mon- itoring role providing information for individual practice as well as regional and national perspectives. Specific activities that pharmacists have or could be involved in • The provision of early intervention and health promotion programs relating to cardiovascular risk factors such as cho- lesterol/triglyceride testing, using point-of-care testing devices, monitor- ing BP and quit smoking programs.67 • The provision of HF self-management education and coaching to help empower the patient.68,69,70 • Monitoring and promoting patient adherence with medication and other components of self-management (for example prescription refills). • Monitoring and documenting key clin- Figure Two: Medication on discharge from hospital (Bennett 2004) 168 ? THE AUSTRALIAN JOURNAL OF PHARMACY VOL. 86 MARCH 2005 Renal impairment Ischaemic heart disease Arrhythmias Arthritis Anaemia Diabetes Thyroid disease Gout Chronic airway limitation Depression Diuretic Beta blocker ACE-I/ARB Warfarin Digoxin Spironolactone Antiplatelet Statin Amiodarone CAM