Author: Kevin Peter Mc Namara
Mc Namara, Kevin Peter, 2012 The Feasibility of Implementing Cardiovascular Disease Prevention Programs in Community Pharmacy, Flinders University, School of Medicine
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Cardiovascular disease (CVD) is the greatest contributor to the adult burden of disease in Australia and internationally. Community pharmacists can effectively intervene to reduce CVD risk, but remain underutilised in primary care. The aim of this thesis is to investigate the feasibility of implementing pharmacist-delivered CVD prevention programs into Australian primary care. This thesis presents seven published peer review manuscripts addressing this aim, plus two additional unpublished manuscripts. These identify a rationale for engaging community pharmacists, and provide insights into the feasibility of different intervention models that might reasonably be adopted in practice. Research for the thesis occurred in three phases. Phase One identified rural population needs for additional CVD prevention measures. Randomly selected electoral roll samples (n=3320) from three rural Australian regions were invited to undertake a comprehensive CVD risk assessment and self-report questionnaire. Findings highlighted poor control of key CVD risk factors stemming from widespread failure to diagnose and, if diagnosed, failure to adequately treat. It was also identified that individuals with uncontrolled CVD risk visited community pharmacists regularly, offering opportunities for additional intervention. The second project, examining patients at high risk of diabetes, found that medicines-use guidelines were not appropriately followed if lifestyle intervention could not achieve CVD risk factor targets. This suggests a need for additional medication management interventions. Phase Two developed and tested the feasibility of a community pharmacist intervention for the primary prevention of CVD. This intervention adhered to best practice principles for complex intervention development. The intervention systematically identified and addressed multiple cardiovascular health needs, while also integrating patient-centred care and behavioural change strategies. Seventy patients aged 50-74 years and without known CVD or diabetes were recruited from 10 community pharmacies to receive CVD risk assessment and five pharmacist-delivered counselling sessions. The primary outcome was change in mean estimated five-year risk of CVD. Post-intervention, a relative risk reduction of 25% +/- 8% was achieved, along with significant improvements to several individual risk factors. Clinical benefits and stakeholder feedback suggests this is a feasible model to test via randomised controlled trial (RCT). Phase Three examined the effects of a continuous quality improvement (CQI) program for hypertension management on community pharmacist quality of care. Fifty-five pharmacists from metropolitan and rural Victoria were randomised within strata to one of three groups receiving different levels of CQI support (usual care, guidelines plus written advice, or comprehensive support). Primary outcomes were changes to proportion of treated patients reporting improved blood pressure (BP) management in several areas. Outcomes were inconclusive due to reduced sample at follow up, but suggested no intervention effect. Program adherence by participants was explored as an alternative objective. This identified several features of current practice environments limiting the effectiveness of CQI initiatives. It suggests that initial efforts to deliver voluntary interventions such as health promotion will wane despite goodwill from pharmacists. In conclusion, community pharmacists appear competent to deliver much-needed interventions for CVD prevention, but consistent implementation of effective interventions will require improved professional incentives (e.g. remuneration) and supportive systems for preventative care.
Keywords: hypertension,lipid disorders,epidemiology,public health,knowledge translation,smoking cessation,community pharmacy
Subject: Medicine thesis
Thesis type: Doctor of Philosophy
School: School of Medicine
Supervisor: Professor James A Dunbar