INTRODUCTION:

The profession of pharmacy nowadays is expanding from dispensing medication to evidence-based, patient-centered approach, in which optimizing pharmacologic therapy is the goal. The community pharmacist is the right health care team member to direct and educate patients about their medication ^1–5.

Pharmaceutical care is the new definition of the pharmacist’s role. This implies that the pharmacist will be responsible to perform a patient-focused activity leading to an overall improvement in medication therapy management for that patient⁶. Community pharmacist has an important role in improving patients’ adherence to their medications ⁷. Medication therapy management contributes to resolve serious problems in health care system. This will be achieved by the pharmacist who considers optimizing the pharmacotherapy of his patient to achieve best therapeutic outcomes is his goal^8,9. Many systematic reviews support the extended role of the pharmacist. Medication review led by the pharmacist will lead to various clinical outcomes ¹⁰. A pharmacist-led prescribing review significantly reduced the number of target drugs elderly received ¹¹. Polypharmacy, especially in older people, leads to adverse drug events, hospitalization, and even death^12,13. Adverse drug reactions, in addition to their negative impact on health, have economic cost as they might lead to hospitalization, and in some cases, emergency department visits^14,15. In addition to poor health outcomes associated with adverse drug reactions, non-adherence, underuse of therapeutic dose, drug-drug and drug-disease interactions, and inefficient use of resources are among the major disadvantages of inappropriate prescribing ¹⁶. Potential inappropriate medications (PIMs), another increasing problem, encompass drugs that have risk overweighing benefits in elderly, which in addition to leading to poor quality of life, will increase health care costs ¹⁷. Polypharmacy and increased age are both risk factors for adverse drug effects¹⁸. 20% of the Europeans are elderly with multiple chronic conditions leading them to receive multiple medications, this in turn increases the chance of adverse events and avoidable hospitalization of this category that constitutes 70% of admitted patients due to medication related problems ^18–20. Inadequate monitoring, lack of adherence, drug interactions, are among the major causes of avoidable hospital admissions. As the community pharmacist has adequate information about the medications his patient receives and based on the trust between them, he is the right healthcare member to perform early pharmacotherapeutic analysis and prevent any possible preventable adverse events ²⁰. Pharmacist intervention in Japanese elderly population had led to decreased average drugs taken from 7.2 to 6 drugs. Moreover, polypharmacy (>=6 drugs) decreased from 67.3% to 53.7% after the intervention of the pharmacist. After one month of consulting their pharmacist, 84% of the patients experienced change in the symptoms. According to pharmacotherapy guidelines, 33.4% of received medications need a dosing change ²¹. A cross-sectional study was conducted in nursing homes in Portugal, on elderly patients receiving mainly cardiovascular, digestive, and nervous system medications revealed that 484 drug related problems in total were found, 49.51% for adverse events, 19.11% for increased cost, 14.82% for decreased effectiveness, and 6.16% for unnecessary medication. Cost savings reached € 3,950/year for the sample in the study. This study support the importance of pharmaceutical care services in elderly ¹⁹.

In well developed countries, UK for example, the community pharmacist is able to develop a patient-centered approach by meeting with their patients one to one. Pharmacists were satisfied in respect to patient’s benefit and the kind of service they were offering²². In UAE, conducted studies showed the lack of rational use of medications. Therefore, actions must be taken to enhance appropriate utilization of drugs and reduce the negative impact of polypharmacy ²³.

Evaluating pharmacists’ preparedness and confidence to practice their emerged role, and assessing patients’ acceptance to this service, especially during COVID-19 pandemic circumstances, will shed a light on the opportunities for implementing pharmaceutical care service in UAE community pharmacies. This is an innovative research that will be the first in the region to assess the impact of pharmaceutical care performed by community pharmacists.

AIM AND OBJECTIVES:

This research aims to assess the Impact of a Pharmaceutical Care Program for elderly patients with polypharmacy in selected community pharmacies in Ajman and Sharjah.

Specific Objectives are as follows:

· To identify the various challenges likely to be encountered by community pharmacists while providing pharmaceutical care.

· To assess the impact of pharmacist provided medication use review, counseling, and education in terms of adherence and quality of life.

· To evaluate patients’ response and satisfaction toward the community pharmacists’ services.

MATERIALS AND METHODS:

Study design:

This is a prospective observational intervention study with a pretest-posttest single group design, in which pharmaceutical care service will be performed for selected patients.

The intervention is performed by the community pharmacist. Patients are followed over a period of three months. Due to COVID 19 circumstances, some patients may refuse a face-to-face interview, therefore, the follow up will take place either in the pharmacy, on a one-on-one interview with the patient, on a phone call, or in a zoom meeting with the patient.

Sample selection:

The study will enroll 45 patients, 15 patients for each community pharmacy. The sample is taken from a group of patients easy to contact or to reach by the community pharmacist.

Sampling method:

Convenience sampling is used in reference to similar studies from literature review.

Inclusion criteria:

Selected patients should be elderly, which means their age is greater than or equal to 60 years old, polymedicated, receiving four or more medications, and either Arabic, English, or Urdu speaking. This patient group is more prone to drug related problems as they usually develop multiple chronic conditions and receive different medications.

Study tools:

Three questionnaires are used in the study, Medication Adherence Rating Scale (MARS)²⁴ which is used to assess the patient’s adherence, SF-36 questionnaire²⁵, which is a measure of health status, and quality of life, Patient Satisfaction with Pharmacist Service Questionnaire (PSPSQ-2.0)²⁶. The first two questionnaires (MARS and SF 36) will be filled three times by the recruited patients with the assistance of the pharmacist. First time will be prior to pharmacist intervention (upon signing the consent form), then it will be filled again in the second and third interview after the pharmacist intervention. These two questionnaires are used as quantitative tools to measure the impact of pharmaceutical care service performed by the community pharmacist on patient’s adherence and quality of life. PSPSQ-2 questionnaire will be filled once only at the last interview. It will be used as a quantitative measure of the patient’s satisfaction about the pharmaceutical care service.

These questionnaires are used to provide an accurate quantitative assessment for patients’ adherence, quality of life, and satisfaction with pharmaceutical care service.

Pharmacies selected:

two pharmacies in Ajman Emirate, and one pharmacy in Sharjah Emirate, all in UAE.

Study phases:

This study involves four phases. Phase one is the training phase. Phase two and three are quantitative and aim to assess the impact of pharmaceutical care service on elderly patients with polypharmacy in three selected pharmacies in Ajman and Sharjah. Impact will be assessed through questionnaires. phase three is qualitative and aims to assess the experience of the participating community pharmacists regarding the pharmaceutical care service.

Phase one, training phase:

In this phase, participating community pharmacists will receive training from the research team on how to perform the pharmaceutical care service. This training will be conducted through zoom meeting due to COVID-19 circumstances which make it difficult for regular training sessions. After receiving this training, pharmacists are expected to know clearly what questions they should ask their patients, and what issues to monitor their patients for.

Phase two, baseline evaluation of the study patients:

This phase is quantitative. It involves patient recruitment; this will occur in two specific days of the week to avoid selection bias. It will take place in the pharmacy and will be performed in collaboration between the community pharmacist and the research team.

Upon recruitment, patient will sign a consent form, and then will be asked to fill two questionnaires before performing the pharmacist’s intervention, MARS questionnaire to assess patients’ adherence before pharmacist intervention, and SF-36 questionnaire which is a measure of health status and quality of life.

The pharmacist will ask the patient if he can contact him through a phone call in addition to one-on-one interviews for follow-up. Due to COVID-19 circumstances, many patients, especially elderly avoid going out; therefore, the pharmacist can offer the patient to run the intervention and monitoring through a phone call or a zoom meeting instead of face-to-face meeting. On the patient’s comfort, a convenient timing will be arranged for an interview, a phone call, or a zoom meeting. The patient is asked to bring all his medications (prescribed and non-prescribed) to the interview. In case of a phone call, a caregiver can assist the patient in reading the medications or giving information to the pharmacist, while the patient is still involved.

Phase three, interventional phase:

This phase is quantitative. it will take place in the pharmacy where the community pharmacist will perform the pharmaceutical care service for his patients.

The community pharmacist will interview his patient three times in three consecutive months.

Encounter one (listening to the patient’ story, education of the patient, and building a therapeutic relationship with the patient). This stage involves patient input. The community pharmacist will listen carefully and deeply to the patient’s story and his perception about the illness he is experiencing. He will ask him to explain his medication experience (table 1). The pharmacist at this stage will focus on the parts of the patient’s story he needs to approach and target. The pharmacist should know at the end of this interview the patient’s general attitude and behavior toward taking medication, what the patient knows about his medication and what he understands about them, what exactly he expects from his medications (symptom relief, disease cure, prevention), what fears, worries, or concerns regarding his medication therapy does he have, barriers preventing the patient from taking his medication (religious, forgetfulness, ethical, drug related problems, or any other reasons), and the patient’s medication taking behavior. The pharmacist should address all these areas and influence the patient’s behavior positively toward his medication.

Table 1: Questions asked by the pharmacist to assess patient’s medication experience²⁴

Questions asked by the pharmacist	Information gained from patient’s answer
Generally, how do you evaluate taking medication regularly?	Patient’s attitude toward taking medication. This will enable the pharmacist to influence patient’s belief about his medication.
What are your medications, what are they used for? How should they be taken (dose, frequency, route of administration)?	Patient’s level of understanding of his medications. This will enable the pharmacist to determine the extent and type of education the patient needs.
What do you expect/want from your medications?	Knowing what patient wants enables better service. Patient will have more confidence in his pharmacist.
What are your fears, worries, and concerns regarding your medications? (eg. side effects, confusion about how or why medications are taken)	These concerns have impact on the patient’s behavior toward taking his medications. Addressing these concerns may greatly enhance patient’s adherence.
Are there any barriers from any type influencing your willingness to take your medications?	This also has an impact on patient’s attitude toward medication. Pharmacist can influence this behavior as well.
Are you taking your medications regularly, as prescribed by your physician?	Description of patient’s behavior toward medication. Pharmacist needs this information to make good decisions.

The pharmacist then will educate the patient about his medications, this will be customized based on the condition of each patient, and the medications he receives. In this stage, the pharmacist will ensure the patient knows the name of his medications, fully understands why each medication is being used, the dose and frequency for each medication, how the outcome will be measured (clinical or laboratory outcome), and how the safety will be measured. Pharmacist will encourage the patient to ask questions regarding his medications and will answer these questions comprehensively in a way the patient can understand. Pharmacist will educate his patient on how to deal with side effects if possible. Pharmacist will clarify any vague issue and ensures the patient fully understands his therapy. Moreover, the pharmacist will provide his patient with available educational materials regarding his medications.

For any serious drug related problems, wrong dosing or unnecessary medication, the pharmacist will ask the patient to refer to his primary physician. He will arrange with his patient for the next interview. He will ask him to bring all his medications. If the patient is not willing to come to the pharmacy due to COVID 19 circumstances, they can arrange for a phone call or zoom meeting instead based on the patient comfort.

The pharmacist will call his patient after two weeks from the interview for further follow-up.

Encounter two will take around 15-20 minutes. The pharmacist will review the medication with his patient, either in the pharmacy, through a phone call, or in a zoom meeting. He will ask him about his adherence, compliance, and quality of life. He will assess if the patient’s adherence and quality of life have improved after the first interview. This will be achieved by quantitative measurement through filling MARS questionnaire for adherence, and SF 36 questionnaire for quality of life. Pharmacist will ask the patient if any other problems have emerged. He will encourage his patient to ask questions if he has any. Then he will arrange with his patient for the third (final) interview.

Pharmacist will ask the patient to bring all his medications for the final interview.

Pharmacist will call his patient after two weeks from the interview for further follow-up.

Encounter three will evaluate the impact assessment of the pharmaceutical care service on the patients. The pharmacist will ask the patient about his adherence, compliance, and quality of life. This will be achieved by quantitative measurement through filling MARS questionnaire for adherence, and SF 36 questionnaire for quality of life. He will encourage his patient to ask questions and will ensure his patient fully understands everything regarding his medication and all his questions are clearly answered and explained. The pharmacist will ask the patient to fill three questionnaires, MARS, SF-36, and PSPSQ-2.0 (Patient Satisfaction with Pharmacist Service Questionnaire). The pharmacist will read, explain, or translate the questions (based on the patient’s need).

Phase four, focused group discussion:

This phase is qualitative. A discussion between the participating pharmacists and the research team will take place either on face-to-face interview or through zoom meeting based on COVID 19 updates. Points that will be discussed are the pharmacists’ feedback about their experience in performing the pharmaceutical care service, their confidence when performing it with their patients, their satisfaction level regarding this emerged role, challenges and barriers they faced, and the recommendations they suggest for improving the pharmaceutical care service in UAE.

DISCUSSION:

As the pharmacy profession now is being transferred from being medication-oriented to patient-oriented, the pharmacist became responsible to provide his patient with the maximum efficacy of his medication with proper education and continuous monitoring to ensure minimum or no drug related problems. This practice will in turn have a great impact on patients’ health²⁸. Further, medication error is becoming a big challenge for health care systems worldwide leading to increased cost and mortality²⁹. It is listed by the WHO to be among the top ten killers ³⁰. In a large-scale multicenter study that aimed to evaluate the impact of pharmaceutical care service performed by community pharmacist on elderly patients, results showed significant improvement in intervention patients’ health with reduced costs of therapy. Not only intervention patients were satisfied, but also the community pharmacists were enthusiastic about this new emerged role ³¹. Serving the patients in a fast and effective way is a key performance goal, however, time pressure is considered a main barrier in performing pharmaceutical care service efficiently³². Community pharmacist-led intervention is increasingly contributing to improved patients’ adherence to their medications which will reflect on their therapeutic outcomes. This was concluded from a systematic review of twenty-two studies. The study revealed that the intervention led to improved blood pressure control, cholesterol, COPD, and asthma. However, less significant results were seen in diabetes and depression ³³. It is believed by WHO that community pharmacists are the most reachable health care members. Many cancer patients consult community pharmacists when buying over the counter medication for their cancer related signs and symptoms ³⁴. Elderly patients are more susceptible to comorbidities which will lead them to receive multiple medications, this in turn will increase the risk of adverse drug reactions and drug interactions ³⁵. There is an increased interest in providing elderly with appropriate polypharmacy that will enable them to get the best out of their pharmacotherapy which will reflect on their clinical outcome. However, it’s still not very clear if the pharmacist’s intervention like medication review can significantly optimize the clinical outcome³⁶. Counselling patients was the main service conducted by community pharmacists in UAE. Health Authority of Abu Dhabi (HAAD) added a new definition to the community pharmacist role which will include emerged roles that will lead to optimal health care services in which public health will get the highest attention ³⁷. Although community pharmacists in UAE strongly believed in extended roles of their carriers, such as medication use review and management of chronic conditions, they demonstrated several obstacles. Among these barriers are the patients’ perception and acceptance to pharmaceutical care, in addition to the current restrictive rules. However, training, time, and additional staff are among their requirements³⁸. Community pharmacists should be motivated to participate in medical educational programs that will enrich their knowledge and keep them updated³⁹. Moreover, continuous review of the pharmacists’ activities and their training level must be applied to modern healthcare systems ⁴⁰. In UAE, this will be the first interventional study conducted to assess the impact of pharmaceutical care service performed by community pharmacists, this is considered a strength of this research. Furthermore, the study involves multiple phases in which the pharmacist will evaluate, educate, and intervene efficiently. Although COVID-19 pandemic circumstances are considered as serious barriers to conduct this type of research, zoom meeting and phone calls with patients can become convenient alternatives to the classic one on one interviews. On the other hand, this will open doors to performing pharmaceutical care service in the future through online meetings which might be more convenient for elderly population. However, there are some limitations accompanying this research. UAE has seven emirates, performing this service in Ajman and Sharjah will reflect partial assessment of pharmaceutical service impact. Additionally, duration of the study is three months, which might influence the accuracy and durability of the results. Therefore, more rigorous research in the future to include more community pharmacies over UAE for longer duration is recommended.

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Received on 10.11.2020 Modified on 14.02.2021

Research J. Pharm. and Tech 2022; 15(1):305-310.

DOI: 10.52711/0974-360X.2022.00050