Follow-up in community pharmacy should be routine, not extraordinary

Almost one-third of Canadians have a diagnosis of 1 of the top 5 chronic diseases, including diabetes.¹ It is well accepted that people with chronic diseases benefit from regular long-term use of medications, and maintaining adherence and continuity of care have been identified as priorities for the delivery of quality and effective health care.^2,3 Almost 75% of Canadian pharmacists practise in community pharmacy, and therefore, pharmacists are in a unique position to provide ongoing, longitudinal care and follow-up.^4,5 In fact, people with diabetes will see a pharmacist more often than any other health care provider, but this is one of the chronic diseases in which improvement in follow-up activities is necessary to ensure patients are achieving healthy outcomes.^6,7

Regular monitoring and follow-up is not common in community pharmacy setting

Unfortunately, recent evidence has identified that routine follow-up of people with chronic disease is not happening enough in community pharmacy.⁷

An evaluation of the Ontario-based MedsCheck Diabetes (MCD) medication review program demonstrated that while approximately 50% of people with diabetes received an initial diabetes medication review during the first 3.5 years of the program, only 3.3% had a follow-up billed by pharmacists in that same time frame.⁷ Stated another way, about 97% of patients with diabetes had no follow-up by their pharmacist, despite the remuneration available and almost certainly a clinical need. Furthermore, most (65.2%) received only 1 MCD assessment during this time frame, despite being eligible to receive this review yearly. During the first 7 years of the MedsCheck annual medication review, available for people taking 3 or more chronic medications, only 36% of recipients of an initial assessment had more than 1 review over the 7-year time frame despite being eligible for an annual review.⁸ The results from analyses of both the MCD and MedsCheck annual service uptake and delivery were surprising, especially considering the focus of these services on chronic diseases, the vulnerability of the patient population served and the complexity of the medication regimens the patients were taking. In fact, MCD recipients 66 years of age and older had been dispensed on average 11 unique prescriptions in the previous year, including high-risk medications such as insulin (20.1%), insulin secretagogues (36.2%), anticoagulants (23.3%), narcotics (25.4%), nonsteroidal anti-inflammatory drugs (21.5%) and benzodiazepines (15.5%).⁷ It would be unrealistic to think that all people receiving an initial pharmacist review were meeting their goals of therapy and did not require follow-up. Even if the reported number of follow-up evaluations is conservative because pharmacists chose not to bill for follow-up activities, this number is extraordinarily low and signifies a deficiency in follow-up care provision for people with diabetes. It makes the profession look bad—and even in the best scenario, it reveals clinical incompetency in follow-up.

Regular monitoring and follow-up is critical in chronic disease management

People with chronic diseases benefit from regular follow-up by their health care providers, including their pharmacist. Monitoring and follow-up allow for regular evaluation of effectiveness, safety and adherence to drug therapy and continued assurance that medications are helping a patient reach his or her desired treatment goals and outcomes. It also allows for the identification of new drug therapy problems. The regular communication between pharmacists and patients that occurs during routine monitoring and follow-up, including the documentation of resolved or emerging issues, helps enhance the relationship between the pharmacist and patient.⁹

Regular monitoring and follow-up is helpful in almost all circumstances of chronic disease management

Medication review programs may recommend specific instances in which follow-up evaluation is most beneficial, such as after hospitalization or an emergency department visit.¹⁰ However, patients may benefit from a follow-up evaluation anytime there is a change in drug therapy or a change in their condition. For example, if a pharmacist prescribes or recommends an increase in a patient’s metformin dose because their A1C is not at target, then follow-up allows for an assessment of whether treatment targets are met, the emergence of new side effects or issues related to adherence. All of this information helps determine if further changes in therapy are required. If the pharmacist does not follow up with the patient, this may lead to delays in reaching treatment targets and may contribute to poor adherence due to lack of management of side effects as well as the lost opportunity to provide further education about the medication and disease. Follow-up needs to be proactive, intentional, timely and documented. Waiting until the patient comes into the pharmacy for a refill or for the patient to call with a concern is insufficient.

There is a wealth of evidence in Canada that has demonstrated the value of community pharmacist–based interventions in improving outcomes in chronic diseases such as diabetes.^11-14 In all of these studies, routine monitoring and follow-up by the pharmacist was an essential component of the intervention and may have been a key determinant in the success of the intervention. For example, in a follow-up of the R_xING study, a pharmacist prescribing an intervention for patients with poorly controlled type 2 diabetes who demonstrated improved A1C and cardiovascular risk reduction with regular follow-up, the investigators found that approximately half of the gains in glycemic control and reduction in cardiovascular risk that had been achieved during the study were lost 12 months after the intervention was complete because of a drop off in follow-ups after the study formally ended. This clearly demonstrates the importance of ongoing monitoring and follow-up and resulting course corrections that are needed to maintain positive outcomes in chronic disease.¹⁵

There are many barriers to routine monitoring and follow-up

Research on barriers to disease state management by pharmacists for people with diabetes have identified practice site environment barriers including time constraints and workload, lack of reimbursement, lack of support by the patient’s physician, lack of pharmacy management support and lack of patient knowledge of the pharmacist’s ability.¹⁶ Participants in the Canadian Pharmacy Thought Leadership Summit felt more strongly about the impact that system and workplace-level barriers had on the advancement of the profession of pharmacy as compared with individual and education-level barriers, specifically poor understanding of the scopes of practice/services of pharmacy professionals in the health care system and too many competing priorities in the pharmacy workplace.¹⁷ If these were the same barriers resulting in lack of follow-up in the MCD research, it does not explain why pharmacists were able to overcome these barriers to deliver more than 400,000 initial medication assessments but were unable to provide follow-up evaluations. One explanation may be that the medication review was seen as a 1-time service rather than a tool to be used in ongoing care. By completing the initial assessments and not following up on the interventions, including clinical decisions and education provided, pharmacists are missing a key step in providing optimal patient care. Pharmacists may be following up more frequently than billed, because documentation may be too onerous (or at least perceived to be too onerous).¹⁸ On the other hand, documentation is mandatory, not discretionary, if we are going to be part of the clinical care team as primary health care providers. Although the numbers were low, there were pharmacists who were providing documented follow-up evaluations. A better understanding of how these pharmacists have overcome system and workplace barriers would be incredibly helpful to spread across the profession to encourage the profession to move forward toward the delivery of patient-centred care.

Patients and the profession are losing out

As pharmacists incorporate regular monitoring and follow-up of interventions and recommendations made in day-to-day practice, they will gain confidence and clinical experience that can be applied to other patients, which will allow them to develop expertise in medication management for specific disease states. Like any skill, clinical decision making takes practice, and with follow-up, a pharmacist will learn the outcome of his or her recommendation and then develop a growing collection of experiences that provide the tacit knowledge to aid advanced health care decision making.