Programs led by community pharmacists to improve medication use and patient outcomes have been implemented in different countries with various names . These programs targeted chronic diseases, mainly hypertension, diabetes, dyslipidemia, asthma and COPD . It has been well established that pharmacist-led pharmaceutical care can have a significant positive impact on clinical, humanistic, and economic outcomes [22,23,24].
The Turkish Pharmacists’ Association developed a nationwide practice aiming to realize pharmaceutical care provision of standard quality to patients with NCDs at community pharmacies through a CPD approach. The first modules were about asthma, COPD, diabetes and hypertension.
In our asthma patients, this practice resulted in significant improvement in peak flow rates, need for reliver medication, inhalation technique and ACT scores (p < 0.05). These results were consistent with those reported in the literature. For example, in Australia, pharmacist-led asthma programs improved the patients’ knowledge score (p < 0.01), severity of asthma (from 88 to 53%), quality of life score (p = 0.05) and control of asthma score (p < 0.01) . In France, pharmacists were able to improve asthma patients’ inhaler technique (p < 0.01) and medication adherence (p < 0.001) . Community pharmacist-led pharmaceutical care improved patient outcomes in many cases [21,22,23,24, 27, 28].
In our COPD patients, the pharmacist-led intervention resulted in significant improvement in the need for reliver medication, CAT and inhalation technique scores (p < 0.05). These findings are consistent with the results reported in the literature, where the pharmacist-led intervention significantly improved inhalation scores and medication adherence [29, 30]. Pharmacist-led pharmaceutical care programs for COPD patients improved inhalation scores [mean estimated difference (Δ), 13.5%, medication adherence (Δ, 8.51%) and hospitalization rates (9 vs. 35; rate ratio, 0.28)] in the intervention group compared to the control group in Belgium . Another pharmacist-led intervention for asthma and COPD patients was the improved inhalation technique in Germany, where 78.9% of patients had at least one mistake in inhaler use before the intervention and the number was reduced to 28.3% after the intervention .
In our diabetic patients, HbA1c, blood glucose and LDL levels as well as injection technique and medication knowledge scores were significantly improved by the pharmacist’s intervention (p < 0.05). This finding is similar to the results reported in the literature [23, 32]. In the UK, community pharmacists were able to improve the clinical outcomes of diabetic patients, including HbA1c level (p < 0.001), blood pressure level (p = 0.01), body mass index (p < 0.001) and blood glucose levels (p < 0.001). Moreover, community pharmacists also improved humanistic outcomes, such as diabetes-related quality of life (p = 0.001), diabetes knowledge (p = 0.018), belief about the need for medication (p = 0.004) and reduced concerns regarding medication (p < 0.001) . The pharmacist-led pharmacotherapy follow-up plan for diabetes significantly reduced drug-related problems (intervention group (IG) 1.7 ± 1.2 vs. control group (CG) 3.1 ± 1.2, p < 0.0001), HbA1c (IG 7.9 ± 1.7 vs. CG 8.5 ± 1.9%, p < 0.0001), FBG (IG 154 ± 61.3 vs. CG 168 ± 57.8 mg/dl p = 0.0004), total cholesterol (IG 202 ± 41.5 vs. CG 217 ± 43.5 mg/dl, p = 0.0054) and systolic BP (IG 135 ± 16.4 vs. CG 150 ± 19.9 mmHg, p = 0.0006). Patient knowledge scores (IG 17.9 ± 3.7 vs. CG 11.4 ± 6.7 points, p < 0.0001) were also increased by this program in Spain .
In hypertension patients, medication adherence, blood pressure measurement technique, medication knowledge scores and systolic blood pressure levels improved with the pharmacist’s intervention. This finding is similar to the results reported in the literature, where pharmacist input resulted in improvements in the reduction of blood pressure and medication adherence [22, 35]. A community pharmacist-led intervention resulted in improved adherence to antihypertensive medication (57–64% (CG) vs. 60–74% (IG), p = 0.23) and reduced systolic BP (mean reduction 10 mmHg (IG) vs. 5 mmHg (CG), p = 0.05) in Australia . A community pharmacy-led intervention in patients with diabetes and hypertension was effective in improving BP control (p = 0.021) in the US. .
All these existing pharmacist-led studies demonstrated good practice examples, but our approach is unique because it represents the largest involvement of community pharmacists and their self-demand to contribute more to patient care. Providing well-organized and structured training, intervention and data collection increased the sustainability of our approach.
Despite some legal, technological, and logistical challenges in fully implementing this practice, desirable clinical outcomes were still achieved. The major strength of this practice is that it was the first (and still unique) example of a nationwide practice aiming to realize pharmaceutical care provision of standard quality to patients at community pharmacies. Before this practice, the impact of pharmacists in the community setting was established by the results of local academic studies of various methodologies, where the majority of the pharmacists were students of clinical pharmacy graduate programs. Obtaining similar results with those obtained from academic studies reflects that the pharmacists who were involved in this practice and showed a commitment to follow-up the patients reached success. No incentives were provided to the participating pharmacists, and their services were not reimbursed. Therefore, a large number of pharmacists (n = 6161) involved in and completing the training phase of this practice under voluntary conditions is another success reflecting the high motivational environment created by the TPA.
On the other hand, there are still many areas to improve. Although 6161 pharmacists registered to the portal and fully completed the trainings, only approximately one-fifth of these pharmacists recorded patient data collected on the first encounter with the patient. Although the pharmacists were very familiar with electronic operating systems (as their use has been mandatory since 2010), they were not familiar with the use of electronic systems for clinical purposes, such as documenting patient data for record-keeping and follow-up. They needed some time to become familiar with the website (RE Portal) where they electronically recorded patient information, and thus, not all patient information was always complete. Another drawback was that pharmacists were not used to spending approximately 15–20 min for patient interaction, data collection, assessment and documentation, which occurred on the first encounter with the patient. Therefore, many of them preferred to give the service but did not document it. Although the importance of documentation as an essential process in quality assurance was emphasized during all trainings, it requires repeated practice and time to turn such a practice into a cultural behavior at the workplace. Another concern experienced during this practice involved peer training. The training at the local chambers was provided by the pharmacists who received the 3-day train-the-trainer course. During these training sessions, there was no problem regarding the transfer of the scientific knowledge, but the rationale of data collection seemed to be ‘lost in translation’. Although only the minimum data needed for the provision of the pharmacist’s patient care were to be collected, there were complaints from the pharmacists about the amount of data collection. The aim of data collection, which is the very first step of pharmaceutical care processes, seemed not to be properly understood. Additionally, these complaints might have been partly due to the low software skill levels of some pharmacists. However, another area of improvement was the need for regularly updating the RE Portal to make it more user-friendly. All these challenges will be considered for future modification of the program. One possible solution is involving pharmacy staff who can support pharmacists on such issues.