Pharmacist prescribing of cholesterol-lowering drugs leads more patients to reach cholesterol goals: study

September 29, 2016 (Ottawa): When pharmacists help patients reach cholesterol goals — by assessing their risk, prescribing drugs, ordering tests, and explaining results — more than three times as many patients reach their target cholesterol and their cholesterol levels drop farther than for patients given only test results, a pamphlet, and usual care, finds a study published in the September/October 2016 issue of the Canadian Pharmacists Journal.

The study was conducted in Alberta, the only province in Canada that authorizes certified pharmacists to prescribe any needed medications for the patients they see (see Pharmacists rise to challenge of prescribing). In other provinces, pharmacists can prescribe certain medications in certain circumstances (see How is pharmacists’ scope of practice expanding?), but in a more limited fashion.

The study provides strong evidence that allowing pharmacists to prescribe drugs and order lab tests — among other steps in patient care — can lead to positive health outcomes, said the study authors. It is the first study to look at effects of pharmacist care that includes prescribing on cholesterol levels. In previous studies, pharmacists have referred patients to other health care providers, mainly physicians, for medication.

High cholesterol levels are a common problem in Canada. The Canadian Health Measures survey, conducted from 2007 to 2009, found that roughly 36% of all Canadians and 43% of those aged 40 to 59 had unhealthy levels of LDL cholesterol, the unwanted or “bad” type of cholesterol that leads to cardiovascular disease such as heart attacks and strokes. (See Why do so many Canadians have unhealthy levels of cholesterol?)

This study, which started in January 2012 and concluded in mid-2014, tackled the problem of high cholesterol using a treatment and monitoring approach, explained authors Dr. Ross Tsuyuki and Dr. Glen Pearson, both pharmacists and professors of medicine at the University of Alberta.

“The first step is identifying people who have high cholesterol,” said Pearson. “If you can't identify them, it doesn't matter what you try to do. This involves pharmacists being systematic and finding cases.” Ninety-nine patients with high- or moderate-risk cholesterol levels were found and randomly assigned to “usual care” (a test for cholesterol, a pamphlet on cardiovascular disease, and whatever steps the pharmacist and physician would normally take) or to assessment, treatment and monitoring.

The approach included assessment of the patients’ risk and health goals and beliefs, repeated follow-up and testing for cholesterol over six months, prescription of cholesterol-lowering drugs or changes to existing prescriptions (many patients had high cholesterol levels despite taking medication), and information about what the test results meant and how the patients’ risk was changing. “The whole package is important,” emphasized Pearson. “The patient needs to understand the disease — the rationale for treatment, what the benefits are expected to be. It needs to be put into an appropriate context.”

The lower level of cholesterol achieved in the treatment group would be expected to reduce heart attacks, death due to coronary disease, and the need for bypass surgery or angioplasty by 13%, and to reduce stroke by 11%.

Pharmacist involvement is key to these results, said the authors. As front-line primary care professionals, pharmacists see many patients at risk for cardiovascular disease, and often more frequently than physicians do. “Our study doesn't say ‘pharmacists are better than physicians.’ It says we have a different and complementary approach,” said Tsuyuki. Pearson believes that pharmacists have a role in preventive health care. “We are reaching people earlier. If we can treat high cholesterol early, we can prevent problems.”

Since high cholesterol is one of the major public health problems in Canada, it makes sense to have pharmacists identifying and treating the problem, said Tsuyuki. At a recent conference, Tsuyuki asked an audience of US and Canadian cardiologists (physicians specializing in heart disease), “If you were truly serious about public health and wanted to reduce heart disease, why would you not be supportive of having thousands of helping hands — additional primary care providers — supporting you and patients?” He said many of the cardiologists were supportive of the role of pharmacists in prevention of heart disease.

About the Canadian Pharmacists Journal

Established in 1868, the Canadian Pharmacists Journal is the oldest continuously published periodical in Canada. CPJ’s mission is to support pharmacists in optimizing patient care by linking knowledge to practice. CPJ is an official publication of the Canadian Pharmacists Association. CPhA advocates for pharmacists and supports its members to advance the profession and enhance patient outcomes.

To arrange interviews, contact

Dr. Ross Tsuyuki, tel. (780) 492-8526; email ross.tsuyuki@ualberta.ca

Dr. Glen Pearson, tel. (780) 407-2044; email Glen.Pearson@ualberta.ca

Dr. Meagan Rosenthal, tel. (662) 915-2475; email mmrosent@olemiss.edu

For more information, please contact:

Stefi Proulx

Media and Stakeholder Relations Specialist

Canadian Pharmacists Association

sproulx@pharmacists.ca

(613) 523-7877 ext 230

Background

Why do so many Canadians have unhealthy levels of cholesterol?

There are many reasons for the high rate of unhealthy levels of cholesterol among Canadians, said Tsuyuki and Pearson. Patients may not have a physician or may not go to their physician. Even if their doctor has found high cholesterol levels and prescribed medication, patients may not take it as directed.

“This is a condition that doesn't really have any symptoms,” said Tsuyuki. Patients may feel fine and may lack motivation to take action to prevent cardiovascular events that could be years away. Pearson said other studies have shown that achieving an end goal is important for patients. “If you have no symptoms that are perceivably reduced or improved, then people might think, why bother?”

“There is also a lot of misinformation about cholesterol-lowering drugs,” such as concern about side effects, that may lead to poor patient adherence to prescribed drugs, said Tsuyuki.

As well, physicians may prescribe medication, but patients may fail to follow up to ensure they have reached their target for cholesterol.

“Patients have been treated, but are not at goal,” explained Pearson. Some studies estimate that a high percentage of heart attacks and strokes result from “clinical inertia” that leads to under-treatment of risk factors. “Clinical inertia” is when treatment of chronic conditions does not meet targets such as blood sugar control, blood pressure control, and cholesterol lowering. Issues on the part of both physicians and patients have been found to contribute to this problem.

How is pharmacists’ scope of practice expanding?

In recent years, provincial and territorial laws and regulations that set out what pharmacists are permitted to do (“scope of practice”) have been updated in order to meet the health care needs of Canadians. As a result, pharmacists in many provinces and territories can perform some services that were previously restricted to physicians and, in some cases, nurses.

In this study, pharmacists ordered laboratory (blood) tests for patients; they also checked past and current test results; and they prescribed drugs or changed existing prescriptions. Only pharmacists in Alberta currently have the authorization to prescribe any drug — in many other provinces they can prescribe drugs in a collaborative practice setting, for certain common conditions, for smoking cessation or in an emergency. To be authorized to assess patients and start drug therapy, Alberta pharmacists require additional certification.

Canadian pharmacists have added many other services to their repertoire:

Ordering and interpreting lab tests (Alberta, Manitoba, Quebec and Nova Scotia, pending in Saskatchewan, New Brunswick and PEI)

Providing prescription renewals or extensions (all provinces plus Northwest Territories)

Changing drug dosages or formulations (all provinces)

Making therapeutic substitutions (all provinces except Manitoba, Ontario and Quebec)

Administering drugs by injection (all provinces except Quebec, and pending in Saskatchewan)

In Alberta, where this study was conducted, pharmacists have had a widely expanded scope of practice since 2012. For patients with multiple chronic conditions such as diabetes or asthma, and at least one risk factor such as smoking, obesity or addiction, they conduct comprehensive annual care plans that include an assessment, medication history, resolution of drug-related problems and a follow-up and monitoring plan. For patients with at least one chronic condition who take at least four medications, a standard medication management assessment is conducted.

For more information about pharmacists’ scope of practice across Canada, see http://www.pharmacists.ca/index.cfm/pharmacy-in-canada/scope-of-practice-canada/

Pharmacists rise to challenge of prescribing

For many of the pharmacists participating in this study, prescribing was a relatively new part of their practice, as pharmacists in Alberta have been able to prescribe since only 2012.

Co-author Dr. Meagan Rosenthal, an assistant professor of pharmacy administration at the University of Mississippi, says that using their knowledge of medication has always been part of the culture of pharmacists. “What the prescribing component has added to that is that pharmacists don't just recommend to another practitioner. They really have to step it up and take accountability.”

Dr. Tsuyuki agreed: “What changed with prescribing was pharmacists having to take ultimate, final responsibility. It’s an important step along a spectrum of responsibility.”

Dr. Rosenthal said the study team worked with the pharmacists to help them obtain prescribing authority and integrate prescribing into their practice for the long term. “We were also demonstrating how these types of services could be successfully implemented in all practices in a sustainable way, even once the study ended.”

Authority to prescribe needs to go hand-in-hand with other practices traditionally reserved to physicians or nurses. The ability to order tests and see previous test results is crucial to monitoring improvement and adverse events due to medication, for example.

“Without access to the labs, this study would not have been possible,” said Rosenthal. Pearson added that being able to monitor adverse events “made the pharmacists more comfortable” and helped them with the transition to their new role.