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News feature: Point-of-care testing in the community: a new role for pharmacists

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The Pharmaceutical Journal Vol 267 No 7162 p256-257
25 August 2001

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News feature

Point-of-care testing in the community: a new role for pharmacists

Diagnostic testing is an area in which many pharmacists will need to become involved if the vision for the future of pharmacy outlined in the NHS plan is realised. Clare Bellingham investigates

POINT-OF-CARE testing in pharmacies has two main functions. The first is in disease screening or risk assessment. A clear distinction should be drawn between screening and diagnosis of disease, which is a role for a general practitioner rather than pharmacist. The second function is in monitoring and management of chronic diseases and medicines used to manage these conditions.

This new role for pharmacists is widely supported by the Government, the Royal Pharmaceutical Society and the National Pharmaceutical Association. Dr Gillian Hawksworth, the Society’s Vice-President, says: “Point-of-care testing is a crucial development area for the future of pharmacy and something that pharmacists should have a role in.” She adds that it will become increasingly important as the area of pharmacogenomics develops.

In an article published in The Journal this week, Dr Tony Moffat, the Society’s chief scientist, describes practical aspects of point-of-care testing and provides evidence to support this role for pharmacy (see related article). The article is a useful source of information for pharmacists wishing to set up diagnostic testing services. But some pharmacists are already doing so.

Management of chronic conditions

Managing chronic conditions is an area in which pharmacists are increasingly becoming involved. By 2004, repeat dispensing will be in operation and a future extension of this is pharmacists acting as supplementary prescribers, altering doses of medication on repeat prescriptions where necessary. In order to do this, pharmacists will need to be able to monitor the patient’s condition.

Dr Hawksworth says that, in repeat dispensing, pharmacists should be able to identify patients who need therapeutic drug monitoring, advise them on the best time of day to have the tests, carry out the testing and then interpret the results. “Pharmacists should then be able to change doses of repeat medication according to the test results,” she said.

This vision can be applied to management of many chronic conditions. Pharmacists could monitor blood pressure and cholesterol levels and adjust doses of antihypertensives and cholesterol-lowering drugs accordingly. Drugs with narrow therapeutic ranges could be monitored and adjusted by pharmacists.

One area in which pharmacists have already been successful in providing long-term management is in running anticoagulation clinics.

Dixon & Hall Ltd in County Durham has been running an anticoagulation clinic since 1994. John Hall explains that the service started as an outreach clinic in a health centre but was moved into the pharmacy with support from GPs. The pharmacy-based clinic is funded by the primary care group.

The pharmacy runs two clinics a week and also provides a domiciliary service. There are 240 patients registered at the clinic and about 70 patients are seen each week. The clinic is situated in a room in the pharmacy with a sink, bench, computer and facilities for disposing of clinical waste and sharps.

At each clinic visit, the patient’s INR (international normalised ratio) is measured and, if necessary, the pharmacist adjusts the dose of anticoagulant within a certain range set out in a standard operating procedure. “If the INR is above 6, then the GP is contacted to discuss what action should be taken, for example, stopping the dose for a few days,” says Mr Hall. Patients’ results are filed in the clinic and the results are sent to their GPs at the end of every month. Results are also logged in the patient’s own records (a Department of Health “yellow book”). The introduction of electronic records would be useful for the service because it would mean that results could be instantly accessible.

Blood sampling is carried out using finger-pricking. Quality control is assessed by facilities provided by the manufacturer of the diagnostic machine. In addition, the clinic is registered with the National External Quality Assurance Scheme (based in Sheffield) and four sets of samples are sent by the scheme for the pharmacy to analyse each year.

Four pharmacists run the clinics and each has undergone a mixture of formal training, using a distance learning package available through Roche Diagnostics, and practical training in the clinic.

“Patient satisfaction surveys are favourable,” Mr Hall says. “Patients prefer to come to a local service and be seen swiftly by the same person, which is possible because each pharmacist involved in the service has set clinic days.”

Mr Hall advises that pharmacists considering setting up such a service should establish funding with a health authority or primary care group/trust and not rely on the possibility of getting private work.

Another approach to pharmacist-led provision of anticoagulation services is operated in Gateshead and South Tyneside. In this service, a pharmacist from the Queen Elizabeth Hospital in Gateshead provides anticoagulation clinics in GP surgeries.

Keith Holden, principal clinical pharmacist, Darlington Memorial hospital, assessed the project when working at Durham and Teesside pharmacy practice unit. He compared the accuracy of pharmacist and GP monitoring in terms of the length of time that the patient was stabilised at their target INR over one year. “Pharmacists were more effective than GPs at targeting the mid-point of the INR ranges,” he says. The service recruits patients who have been treated at the outpatient clinic at the hospital and who have been transferred to their GP for ongoing monitoring. Clinics are based at several general practices but patients belonging to other practices can be referred to one of the clinics.

Blood is taken by finger pricking. Some clinic pharmacists are also trained in venous blood sampling although it is rarely required, Mr Holden says. The service has the backing of the hospital’s haematology department and provision is made for rapid access to its services when high INR readings are found. All pharmacists involved in the clinic have to be vaccinated against hepatitis B (as recommended for any health professional handling bodily fluids).

When first set up three years ago, the service was funded through the local health authority’s primary care development fund. The success of the service has meant that it has expanded to include more patients and it has continued to be funded through the health authority.

Health screening

GEHE Primary Care Services (PCS) has recently completed a pilot diabetes risk assessment service at a Lloydspharmacy in Coventry. The service involved community pharmacists undertaking a structured interview with people to identify those at high risk of developing type II diabetes. People identified as being at risk were then asked to return for a fasting blood glucose test. If the fasting blood glucose level was found to be above a specified value, the person was then referred to their GP.

The pilot ran from March to June this year. A full assessment of the service is currently being undertaken and the response from both patients and local GPs has been positive. A total of 72 people were assessed, 49 were asked to return for a fasting test and 17 were subsequently referred to their GP. Dietary and lifestyle advice was given to each person who underwent an assessment.

Sara Mudhar, professional services manager, GEHE PCS, says that one of the reasons that the service was successful was that it had been based on a standard operating procedure that had been agreed with local GPs and the local diabetes services advisory group. “Pharmacists should link new services with local needs and involve local stakeholders,” she says. The diabetes risk assessment service in Coventry had matched the local needs where type II diabetes had been defined as a health priority. Involving local GPs had meant that they were happy to accept referrals from the service and to promote the service to their patients.

Patients did not have to pay for the service, which was funded by Lloydspharmacy as a pilot study to test the service model. All pharmacists involved in the pilot completed the Centre for Pharmacy Postgraduate Education training package on diabetes and received additional training from GEHE PCS in order to deliver the service.

Meanwhile, in Barking and Havering Health Authority, pharmacists are planning services to target coronary heart disease.

Hemant Patel, local pharmaceutical committees secretary, north east London, says that the service will be offered through 20 community pharmacies in the area. “While services based at GP surgeries are important, there is a population that does not visit surgeries and consequently there are a number of ?walking sick’ who need help. Offering diagnostic testing through pharmacies provides an opportunity for these people to access high quality services,” he says.

The initial assessment will be made using a questionnaire and the pharmacist will then recommend up to five tests — body mass index, blood pressure, cholesterol alone, full lipid profile and blood glucose. Depending on the test results, the pharmacist will then recommend a course of action for the patient. These include giving general advice on preventing coronary heart disease and its symptoms, referring the patient to a dietitian or exercise expert, or referring the patient to their GP for treatment. Test results will also be sent to the patient’s GP if consent is given.

Patients will be identified by pharmacists from computerised patient medication records or over-the-counter purchases, or by patients asking for advice which might be prompted by advertising of the service within the pharmacy.

The health authority is currently considering a bid for funding of the service. Mr Patel said that he hoped it would be in operation later this year.

Support for pharmacy provision of screening services comes from patients, too. Greenlight pharmacy in Euston, London, provides a health screening service. Speaking recently at a meeting to discuss the services Greenlight offers, a patient praised the pharmacy’s coronary heart disease screening service. His reasons for using the service were accessibility — the pharmacy is located close to his place of work and there is no need for an appointment — a good relationship with the pharmacy staff and a feeling of having control over the screening process. “I had been thinking about going to the GP for some time but being able to have several blood pressure tests and a cholesterol test at the pharmacy over the course of a month allowed me time and control over the assessment process,” he explained. “When I did go to the GP, I was able to take the test results with me which resulted in the GP arranging a fast-track cardiac assessment for me.” The patient was found to have coronary artery disease. “Without the pharmacy’s service I would not have gone to the GP yet, but now I know I have coronary disease I can adjust my lifestyle accordingly,” he added.

Why pharmacy?

So what makes pharmacy the ideal place for point-of-care testing? First is accessibility. GP surgeries are overloaded and waiting times for appointments can be up to several weeks. Patients making a spur of the moment decision to have a disease risk assessment may be put off by the wait for an appointment. In addition, pharmacists have access to a wide population, including people who do not consult other health professionals on a regular basis.

Looking to the future and repeat dispensing, allowing pharmacists to carry out diagnostic testing will enable patients to visit the pharmacy for a “one-stop shop” service: having their disease and medication monitored and collecting their repeat prescription that has been adjusted according to the results of the testing.

In order to provide diagnostic testing, pharmacists and pharmacy staff will have to undergo appropriate training about testing techniques and what information should be provided to patients. Pharmacists will also have to address issues such as the need for a separate consultation area for testing and health and safety issues associated with handling bodily fluids. Formulating an effective standard operating procedure will iron out many of these difficulties.

But the recurring problem in pharmacy is funding. How will these services be paid for? Some patients will be willing to pay for health risk assessments but others will not, and few are likely to want to pay for long-term disease management which is currently provided free by GPs. The answer might lie in local pharmaceutical services (LPS), but pharmacists wanting to move the profession forward in this key area will need to make their voice heard within local primary care organisations.

Society guidance

The Royal Pharmaceutical Society is currently revising its guidance on diagnostic testing and health screening. An announcement will appear in The Journal when it becomes available (within the next six months).

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Clare Bellingham is on the staff of The Pharmaceutical Journal

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