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Study of the contribution of community pharmacists in screening for diabetes and cardiovascular diseases

par Rondeaux, Sarah
Président du jury Dufrasne, François
Promoteur De Vriese, Carine
Publication Non publié, 2024-07-04

Thèse de doctorat

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IntroductionThe prevalence of non-communicable diseases, such as diabetes and cardiovascular diseases,is increasing globally, posing a significant challenge for individuals, communities, andsocieties worldwide. Addressing this burden requires a multifaceted approach thatencompasses not only primary prevention and early detection but also patient education, aswell as comprehensive care coordination. The pharmacy profession has evolved significantlyin recent decades, shifting from a traditional role of delivering medication to more clinicalactivities. Pharmacists could take a more active role as primary care team members,leveraging their accessibility and expertise, in identifying, counselling, and referring patientswith previously undiagnosed conditions. International evidence has demonstrated thebenefit of pharmacy-led screening services. However, translating the findings into practicecan be challenging due to the variability of regulatory environment and practices betweencountries.Objectives of the thesisThis thesis intends to explore the extent to which community pharmacists can contribute toscreening for diabetes and cardiovascular diseases in Belgium. Through different studies, itaims to gain a deeper understanding of the feasibility of delivering a risk assessment incommunity pharmacies, to gather the perceptions of the stakeholders, as well as thecontextual factors that may facilitate or hinder a successful implementation withincommunity pharmacies of pharmacist-led services of this nature. Furthermore, the researchaims to develop tools that can support pharmacists in providing a diabetes and cardiovasculardisease risk assessment service.MethodsFirstly, to explore the feasibility of offering a risk assessment service for diabetes andcardiovascular diseases in the Brussels Capital Region, three qualitative studies wereconducted with 17 pharmacists, 14 patients and 14 general practitioners. Secondly, a mixedmethod was used following the RE-AIM framework to evaluate the service implementation.The five dimensions, reach, effectiveness, adoption, implementation, and maintenance, wereassessed through focus groups with 16 pharmacists and individual interviews with 20patients. Finally, the development of the tools involved a multistep process using a user-centred approach, including a need assessment phase and a creative design phase, followedby the evaluation of the materials with ten patients. All qualitative interviews and focusgroups were recorded and transcribed ad-verbatims, then coded independently by at leasttwo researchers with the Nvivo software. The quantitative data were collected through a webplatform designed by APB for this pilot project, in which pharmacists recorded patientinformation during the screening. They were analysed descriptively and statistically withExcel.Results and discussionPharmacists are seen as integral members of the healthcare team, with responsibilitiesranging from medication dispensation and management to primary care provision andpatient education. There's a consensus on the potential benefits of integrating pharmacistsinto preventive healthcare, but concerns remain regarding role boundaries and commercialinterests. During the pilot study, a total of 502 patients were enrolled in the screeningprogramme by 32 pharmacies. Of which 376 patients (74,9%) were eligible for the according-to-protocol analysis. 145 patients (38.6%) and 152 patients (40.4%) with low and moderaterisk profiles, respectively, received counselling on managing their determined risk factors.However, 74 patients (19.7%) were established to be at a high risk of developing diabetes andwere referred to a general practitioner for further evaluation. Out of the 297 patients with alow or moderate risk profile for diabetes, 255 patients (85,9%) participated in thecardiovascular disease evaluation. Of these, 223 patients (89.6%) were assessed with a low/moderate cardiovascular risk profile; however, six patients with a score ≥10 (2.4%) and 20patients (8.0%) presenting above threshold high blood pressure or waistline values wereassessed to be at a higher risk and were referred to a general practitioner. This service wasconsidered feasible in practice, but financial and external supports are essential for ensuringthe sustainability of this pharmacist-led service while defining roles and responsibilitiesbetween healthcare professionals. In that regard, additional strategies such asinterprofessional workshops, a facilitated data-sharing platform and communicationcampaigns should be considered to spread awareness of the pharmacists’ new role andpromote collaboration with general practitioners to ensure the follow-up of patients at highrisk. Alongside this research, tools for patient education purposes and awareness campaignswere created. During the development, special attention was paid to the writing style andstructure, with less text and more colourful graphical elements to suit patients with differenthealth literacy and educational levels. Overall, participants were satisfied with the tools,which were considered valuable and relevant. However, adaptations were necessary toensure their understanding and long-term usability. Finally, further studies should evaluatethe effectiveness and monitor the implementation of preventive-related services to providesuitable strategies over time to overcome barriers across different implementation stages.ConclusionConsidering the increased strain on primary care, pharmacists can take a more active role inidentifying, counselling, and referring patients with undiagnosed conditions, guiding at-riskpatients to prevent further disease progression. This thesis demonstrates that withappropriate training, policy support, and increased collaboration with primary care, apharmacy-led screening is feasible in practice and could become an integral part of publichealth strategies for the prevention and early detection of diabetes and cardiovasculardisease. However, financial incentives and remuneration for pharmacists and an extendedlegal framework for the reimbursement of point-of-care testing should be discussed at thepolitical level as they will be critical determinants of the sustainability and larger-scaleimplementation of the risk-assessment service on a national level.