Chronic diseases – such as heart disease, stroke, COPD, and diabetes – are among the most prevalent, costly, and preventable of all health problems. And they’re on the rise in Ireland, in tandem with our ageing population and unhealthy lifestyle choices.
The Institute of Public Health in Ireland (IPH) forecasts a 40% increase in the number of people living with these chronic conditions in the Republic of Ireland by 2020 - that’s more than 1.7 million people - making the prevention and management of chronic diseases the greatest actual and future challenge to our healthcare system.
At present, for many individuals with a chronic disease, care is reactive, sporadic, and usually occurs within the costly hospital system. In fact, chronic diseases account for a massive 80% of all healthcare costs. Both government and individual caregivers recognise that this is unsustainable. The axis of care must shift and a new approach developed that puts chronic disease management programmes in a central position to prevent, treat and delay the onset of complications for those with a chronic condition.
The fact that people with chronic conditions managed by medication have more contact with community pharmacists than any other healthcare professional, places pharmacists in an ideal position to detect early changes in condition and identify at-risk patients well before they reach the hospital revolving door.
“There is so much benefit to be had by involving the pharmacist in the management of a patient’s chronic disease, whether it’s asthma, diabetes or a heart condition. We know these patients, some of them for many, many years; we see them every time they get a prescription filled. There are opportunities for health screening, medicines management, health promotion, and incentive-based self-management. We’re a logical part of the solution,” said Professor Peter Weedle, adjunct Professor of Clinical Practice at the School of Pharmacy, University College Cork (UCC) and a community pharmacist from Mallow, Co Cork with over 25 years’ experience.
“In Ireland, we are clogging up our hospitals with people who have chronic diseases. We knew they had a chronic disease and they were being treated for their chronic disease and yet they end up in hospital because we have failed or they have failed to manage their condition correctly.”
Prof Weedle has long maintained that pharmacists can make a significant impact on critical areas of patient care. He published a paper in the British Journal of Pharmacy Practice in 1983 in which he defined pharmaceutical care. “What we were saying back then was that pharmacists need to start talking about pharmaceutical care; not talking about medicines, not about medicine management or medicine use review, but talking about patients. In the same way you talk about medical care or nursing care, we needed to start talking about pharmaceutical care.”
“That was nearly 30 years ago and not much has changed in the interim, but hopefully, with the establishment last year of the HSE’s new Clinical Care Programmes under the Clinical Strategy and Programmes Directorate (CSPD), led by Dr Barry White, we have an opportunity to explore how pharmaceutical care can fit into and benefit a new integrated approach to acute and chronic disease management,” he said.
A panel of pharmacists with an interest and expertise in chronic diseases was recently selected to participate in the chronic disease CSPD Clinical Care Programmes, which include heart failure, stroke, COPD, asthma, diabetes and care of the elderly.
|Professor Peter Weedle|
Prof Weedle, who was involved in the selection process in his capacity as Chairperson of the National Pharmacy Reference Group (NPFG), remarked: “We got a phenomenal and enthusiastic response from the profession of pharmacy when we looked for expressions of interest to participate in these programmes. Almost immediately we had about 70 or 80 people volunteer to get involved in the various programmes.
“It’s very exciting to see the various experts, be they consultants, GPs, nurses, pharmacists, physiotherapists, dieticians, all meeting together and looking at what are the gold standards for the treatment of any particular chronic disease, and how these complimentary professions can work together. Taking one example, heart failure, there are new and compelling data which suggest that an integrated, collaborative approach to care involving GPs and pharmacists can improve the long-term outcomes for patients. I believe this is a very exciting development for patients and our profession; it’s a natural evolution and a golden opportunity just waiting to be tapped.”
The reality is that people with chronic conditions managed by medication have more contact with community pharmacists than any other healthcare professional. Poor adherence to medicines affects 30-50% of patients and often it is the pharmacist who directly observes this. Consequently, community pharmacists are well placed to monitor the patient’s medication adherence, encourage self-management, and also detect early warning signs and changes in the person’s medical condition.
“In an ideal world, the pharmacist has a role in at least three important areas of chronic disease management. First, pharmacists see a wider group of patients to GPs and hospital doctors and can screen the population widely for undiagnosed chronic disease. Secondly, pharmacist can carry out therapeutic drug monitoring and self-care, checking that the patient’s condition is properly controlled. For example, a patient with diabetes, who is monitoring their blood glucose levels on a daily basis and recording that information, could bring their self-care records into the pharmacy with their prescription for repeating on a monthly basis. Thirdly, because several chronic diseases tend to co-exist in the same patients, pharmacists can help identify important pharmaceutical care issues, with complex drug-drug and drug-disease interactions a growing problem.”
“The pharmacists can chat with the patient, review their records and condition, and if everything is fine the prescription is dispensed. If not, they can be referred back to their GP. But, at the moment, the pharmacist cannot tell if the patient is managing their condition optimally and could be repeating the prescription for six months when in fact the patient really needs to see their doctor to have their treatment reviewed.”
“This is just one example. Specialist training is being developed for pharmacists, who are interested in running clinics for a specific condition, at which patients can be monitored, their medication reviewed, and perhaps running group education sessions. This will be carried out, where possible, in conjunction with the CSPD programmes. It too early to say how the CSPD programmes will work, but the potential is vast,” Prof Weedle stressed.
Effective medical therapy is a key factor in good chronic disease management programmes. Half of all people with chronic conditions fail to take their medicines properly and 10% of hospitalisations may be due to older people’s inability to manage drug therapy.
The rates of non-adherence to prescription medication therapy have remained stagnant over the past three decades and recent research has shown that as many as 40% of patients still do not adhere to their treatment regimens and up to 20% of all new prescriptions go unfilled.
Medication non-adherence is a problem that applies to all chronic diseases, diminishing the ability to treat diabetes, heart disease, cancer, asthma and many other conditions, and resulting in suffering, sub-optimal utilisation of healthcare resources and even death.
“If we want to improve patient adherence to prescription medication, it is clearly imperative that we involve pharmacists as part of a multi-disciplinary approach to patient care. Recent Irish work has shown that non-persistence of vital medicines affects 30% of a well-educated heart failure population and is associated with worse outcome and increased healthcare costs. This highlights the importance of regular, on-going, professional management of adherence issues.”
“We’ve seen situations of medication being returned, unused - not in small carrier bags but in black bin bags - when a patient has died. For example, a few years ago a lady’s family brought back her medicines. We were able to take out a product she received regularly, used in the treatment of osteoporosis, and place all 24 unopened packets in the order in which they had been dispensed. None were missing. She had not taken them in two years yet was still getting the prescription.The cost of those medicines was €1,200. Not only was this money wasted but the patient’s condition was going untreated and unmonitored,” Prof Weedle pointed out.
He maintained that chronic disease management in community pharmacy deals primarily with control and prevention. Medication compliance, monitoring of disease parameters and complications, health education, lifestyle modification advice and identifying situations to seek help from health professionals, are key components in the management of chronic diseases in community pharmacy. A pivotal element in this partnership is pharmacist-led patient self-management.
“I’m a great believer in self care,” said Prof Weedle. “The patient needs to take responsibility for their own health, their own treatment. However, the emerging evidence suggests that regular, on-going professional encouragement and coaching is key. The bottom line is our population is aging and we have to accept the growing chronic disease burden. But having a disease does not mean you cannot live long and well. “
“Provided the patients themselves are coping well, we should get away from this idea that only health professionals can manage their condition. The patients themselves should be taking an active role in controlling their disease and we should be helping, coaching, advising the patient in the management of their own chronic care.”
With the regulatory framework in place, by way of the Pharmacy Act 2007, the role of pharmacy is set to expand exponentially, enhancing pharmacists' responsibilities in the delivery of health care and disease management.
In order to facilitate this pharmacist-led approach and integrate the pharmacist in the multi-disciplinary care of patients with chronic diseases, it may be appropriate to allow pharmacists access to electronic health records, as well as deregulation of more prescription-only medicines to pharmacy-only medicines, as seen recently with the emergency hormonal contraception.
These are all details that will be teased out over the coming months by members of the clinical care programmes for chronic diseases, and their deliberations will have widespread implications for the future training and practice of pharmacy in Ireland.
“This is an ongoing process; there won’t be an official launch date for pharmacy’s involvement in the management of chronic diseases, it will happen gradually. It’s happening now and it’s gathering pace all the time,” said Prof Weedle.
“As the clinical programmes report we will start to see how the national parameters by which we treat a particular disease category – the gold standards - will change and how this will impact on the role of the pharmacist in the management of chronic diseases in the community.”
“I believe when we look back in perhaps two years from now we will see that we’ve implemented a huge range of initiatives in pharmacy in this regard, including possibly legislative change where time-limits on prescriptions are concerned. The potential for pharmacy is huge, as are the benefits for the individual patient and our health service as a whole. These are very exciting times don’t you think?”
On the rise: Chronic diseases in Ireland
High blood pressure
In 2007 nearly 852,000 adults (25.1%) had high blood pressure. By 2020 this is expected to rise to over 1,192,000 people - an additional 341,000 adults (a 40% increase in less than 15 years).
Coronary Heart Disease (CHD)
In 2007 nearly 131,000 adults (3.8%) had ever had a Coronary Heart Disease (CHD, angina and heart attack). By 2020 this is expected to rise to over 195,000 people - an additional 65,000 people (a 50% increase in less than 15 years).
In 2007 almost 59,000 adults (1.7%) have ever had a stroke. By 2020 this is expected to rise to almost 87,000 people – an additional 28,000 adults (an increase of 48% in less than 15 years).
Diabetes (Type 1 and Type 2 combined)
In 2007 nearly 144,000 adults (4.5%) have diabetes (Type 1 and Type 2 combined). By 2020 this is expected to rise to over 233,000 an additional 89,000 adults – (a 62% increase in less than 15 years).
Source: Institute of Public Health in Ireland