Yacine Sellam examines how pharmacists in Algeria can follow the lead of their US counterparts and play a greater role in patients’ diabetes management.
Noncommunicable diseases are a growing burden in Algeria. The results of a STEPwise survey revealed that, for adults aged between 18 and 69 years, 23.6 percent had high blood pressure, 14.4 percent had diabetes, and 55.6 percent were overweight. In front of these alarming facts and their costly consequences, and with a view to effective upstream action, the Algerian Government has drawn up a 2015-2019 multisectoral national strategic plan for the integrated management of noncommunicable diseases risk factors, as well as guides of good practices for the attention of the healthcare professionals, including a diabetology guide published in 2015. The pharmacist, as an essential actor within the health system, must be part of this strategy advocated by the International Pharmaceutical Federation (FIP), which could also materialize in Algeria since Article 179 of Health Law No. 18-11 stipules that the pharmacist should provide health-related services and participate in information, counseling, monitoring and therapeutic patient education (TPE) for the users.
The TPE of diabetic patients by the pharmacist, does it really work?
Some might wonder if involving the pharmacist in the TPE would be effective or timely. In contrast, a meta-analysis that included 43 studies and a total of 6259 patients with type 2 diabetes (T2D) in 26 different countries, has demonstrated the beneficial effects of pharmacist-led TPE, indistinctly, in the community or hospital configurations. These benefits include lowering blood sugar and blood pressure, extending to weight loss and lowering blood cholesterol levels. These effects are all the more important when the pharmacist provides both TPE and advice on the proper use of drugs (demonstrated in at least 22 different studies).
Does the pharmacist-led TPE adapt to regional specificities?
The benefits of pharmacist intervention in the TPE, both in terms of biological parameters, glycemic self-monitoring and adherence to treatment, as well as lifestyle changes and weight loss, were also found in Arab countries during TPE programs of diabetic patients led by pharmacists. There are currently six such programs: two studies in the United Arab Emirates (involving respectively 234 T2D patients and 165 gestational diabetes cases), two studies in Jordan (for a total of 257 T2D patients), one study in Iraq (123 T2D patients) and finally one study in Sudan (300 T2D patients).
What model for the TPE of diabetic patients at the community pharmacy?
The role of the pharmacist in the TPE is verified, but it should be made compatible with the exercise in the pharmacy, which for its part has the advantage of proximity to patients and the existence of a national network able to serve the cause of a personalized and accessible TPEE.
The pioneering experiment in this field was conducted in the city of Asheville, North Carolina, USA, between 1997 and 2001, which affected 187 diabetic patients, 27 percent of whom were type 1 (T1D) and 73 percent T2D. As an incentive to join the TPE program, patients received a free blood glucose meter (in a country where everything is paid for) and were exempted from co-payment of drug and laboratory costs with their insurer. The results of this project were encouraging in the short and long term. In fact, the proportion of patients whose HbA1c blood glucose level and LDL cholesterol levels were on target improved with each follow-up. In addition, total medical costs decreased from USD 1,200 to 1,872/patient/year, and the average duration of sick leave decreased from 4.1 to 6.6 days/patient/year. The economic productivity gain was estimated at USD 18,000 per patient, per year.
The Asheville project model was driven by insurers. Community pharmacists planned individual appointments with insured patients, during which their blood glucose self-monitoring data were reviewed. These appointments were also used for physical measurements (height, weight, blood pressure, foot and skin examination) and for setting treatment goals. The project was also based on a collaborative program with physicians and local education centres to which patients were referred when needed. This approach was after that gradually extended to the whole of the USA, notably through the IMPACT project which was launched in 2010, and which affected a total of 1,836 patients in 17 different states:
– In Wichita, Kansas, 20 pharmacies from the Dillions chain were involved in the IMPACT project. Face-to-face personal consultations with the pharmacist lasted one to two hours to create deeper confidence, to help the pharmacist discover the root of the patient’s problem, and then to provide education accordingly. Topics discussed included knowledge of diabetes, understanding of prescribed treatment, physical activity, foot exams, and nutrition.
– In Cincinnati, Ohio, there were 15 pharmacies in the Kroger Pharmacy chain. A first visit to the pharmacist was made following an online appointment for a preliminary assessment, while during the second visit the pharmacist started to provide a TPE according to a personalized plan and agreed on short-term goals with the patient. Subsequently, follow-up visits were scheduled, usually every 1 to 3 months, depending on the patient’s ability to self-manage.
Other pharmacy TPE experiments have also been successful elsewhere in the world. In Germany, the GLICEMIA program made it possible to follow 1,092 pre-diabetic patients over a 12-month period thanks to the valuable assistance of 42 pharmacies in Bavaria. The effects in terms of physical activity, weight loss, and improved quality of life were significant. The pharmacist’s intervention consisted of three individual sessions, which started with a discussion on nutrition and physical activity, followed by an assessment of the achievement of the objectives, and finally the setting of new objectives.
In Finland, for example, pharmacists called “Diabetes Focal Points” were trained at 635 pharmacies. In support, TPE material was made available to them, in the form of a collection of short films, which notably addressed the treatment of diabetic foot problems and the administration of insulin. In Canada, standards for therapeutic education for pharmacists have been in place for several years, and a Diabetes Pharmacists Network was created in partnership with the Banting & Best Center at the University of Toronto. The result of this collaboration was the production of training content for pharmacists, accessible online and sanctioned by a certificate.
Conclusions
Today, the “clinical” and economic effectiveness of TPE by the pharmacist is established in several countries, in particular because of the advantages of proximity that the pharmacy-based TPE model presents. However, a multidisciplinary network organization is necessary so that doctors and pharmacists can complement each other, and for patients to be referred for medical consultation each time necessary. In addition, the practices standardization and the certification of pharmacists’ knowledge are also essential to implementing such a strategy.
