Primary Care Pharmacy March 2001 Vol 2 No 1 p23-24

Journal Club

What is in the medical press?

Clinical governance

Khunti K, Baker R, Ganguli S. Clinical governance for diabetes in primary care: use of practice guidelines and participation in multi-practice audit. Br J Gen Prac 2000;50:877-81.

The authors carried out a postal questionnaire survey of all GPs in three English health districts to determine the factors associated with guideline implementation and audit participation when managing patients with diabetes. Just over 80 per cent of GPs replied, 92 per cent of practices had a diabetes guideline and 51.7 per cent were taking part in an audit of patients with diabetes. However, the guideline in question was implemented more than three years ago by 73.9 per cent of practices.

It was concluded that smaller practices in socioeconomically deprived areas were less likely to implement clinical governance programmes of guideline implementation and audit. This was despite the fact that these practices had disadvantaged patient populations and therefore the greatest need for clinical effectiveness programmes.

Adverse drug reactions

Millar SJ. Consultations owing to adverse drug reactions in a single practice. Br J Gen Prac 2001;51:130-1.

Adverse drug reactions (ADRs) are recognised as a common reason for hospital admission. Data collection from patients attending a single practice over a six-month period showed that this is also a frequent reason for doctor-patient contact in primary care. The incidence of consultations associated with an ADR was found to be 1.7 per cent, although this was thought to be an underestimate. Three groups of drugs were found to be responsible for 50 per cent of reported reactions — antidepressants, antibiotics and non-steroidal anti-inflammatory drugs. Selective serotonin reuptake inhibitors were a particular problem and the authors did not accept that there was a lower incidence of ADRs with these drugs than with tricyclic antidepressants.

Cardiac disease

Morgensen CE, Neldam S, Tikkanen I, Oren S, Viskoper R, Watts RW, et al for the CALM study group. Randomised controlled trial of dual blockade of renin-angiotensin system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: the candesartan and lisinopril microalbuminuria (CALM) study. BMJ 2000;321:1440-4.

This study assessed and compared the effects of candesartan and lisinopril, individually and in combination, on blood pressure and urinary albumin excretion in patients with microalbuminuria, hypertension and type 2 diabetes. Candesartan 16mg daily was found to be as effective as lisinopril 20mg daily. Combination therapy reduced blood pressure by about 8mmHg more than with either component alone. The results indicate that dual blockade of the renin-angiotensin system may be a particularly effective approach for achieving the aggressive blood pressure reduction that is recommended in diabetic patients with evidence of renal disease.

Collaborative Group of the Primary Prevention Project. Low dose aspirin and Vitamin E in people at cardiovascular risk in general practice. Lancet 2001;357:89-95.

A randomised, controlled trial to investigate the effectiveness of low-dose aspirin (100mg/day) and vitamin E (300mg/day) in preventing cardiovascular events in people with one or more of the following — hypertension, hypercholesterolaemia, diabetes, obesity, a family history of premature myocardial infarction — or people who were elderly. Low-dose aspirin had preventive effects and an acceptable safety profile, although severe bleeding was more frequent than in the non-aspirin group. No conclusions with respect to vitamin E could be drawn.

Frijling BD, Spies TH, Lobo CM, Hulscher MEJL, Van Drenth BB, Braspenning JCC, et al. Blood pressure control in hypertensive patients: clinical performance of general practitioners. Br J Gen Prac 2001;51:9-14.

A cross-sectional study carried out between November, 1996, and April, 1997, assessed how well 195 general practitioners (GPs) from the Netherlands were able to control the blood pressure of treated hypertensive patients. The GPs appeared to take action when diastolic blood pressure (DBP) was lower than 100mmHg, despite target levels of lower than 90mmHg. Non-pharmacological intervention, increased prescribing of antihypertensive medicines and follow-up appointments were more common in patients with DBP of greater then or equal to 100mmHg but median performance rates were less than 51 per cent for most recommended actions. Patient and GP characteristics contributed little to clinical performance.

Pharmacy practice and care

A series of five articles published in American Journal of Health-System Pharmacists between September, 1999, and January, 2000, has just come to my attention.

They will be of interest to pharmacists involved in managing change within pharmacy practice and in looking at ways in which to implement the new health plans.

Holland RW, Nimmo CM. Transitions in pharmacy practice, part 1: Beyond pharmaceutical care. Am J Health-Syst Pharm 1999;56:1758-64.

This article provides a background to the series by examining how pharmacy practice has evolved from compounding and distribution to clinical pharmacy and pharmaceutical care. It concludes by proposing a model designed to optimise pharmacy’s contribution to health care.

Nimmo CM, Holland RW. Transitions in pharmacy practice, part 2: Who does what and why. Am J Health-Syst Pharm 1999;56:1981-7.

This article looks at the skills needed by pharmacists to deliver new services, so that pharmacy managers and leaders can estimate the extent of change that may be required when changes in practice are contemplated.

Holland RW, Nimmo CM. Transitions in pharmacy practice, part 3: Effecting change — the three-ring circus. Am J Health-Syst Pharm 1999;56:2235-41.

Part three discusses the essential components for successful implementation of change. If individual pharmacists are to change their practice, the environment must be appropriate, they must have access to learning resources to address any educational needs, and, most importantly, they need to be motivated to change.

Nimmo CM, Holland RW. Transitions in pharmacy practice, part 4. Can a leopard change its spots? Am J Health-Syst Pharm 1999;56:2458-62.

Perhaps the most interesting of the series, this article examines the personal characteristics of pharmacists and how these predispose them to reacting to change in a certain way.

Nimmo CM, Holland RW. Transitions in pharmacy practice, part 5: Walking the tightrope of change. Am J Health-Syst Pharm 2000;57: 64-72.

The final article of the series discusses a leadership model for facilitating change in pharmacy. It describes how managers can help pharmacists adopt new models of practice by guiding them through stages of attitude and value formation.

Letter

Pharmacists working in primary care

From Miss A. Fish, MRPharmS

Madam, — We would like to hear from anyone who has been involved with, or who knows of, studies evaluating the work of pharmacists within primary care medical practices.

Pharmacists at the department of general practice and primary care, University of Aberdeen, are undertaking a systematic review and would like to hear of studies (published or unpublished) conducted in the United Kingdom, United States and Scandinavia.

If readers have any information that could help, they are asked to contact.

Alison Fish
Research Pharmacist
Department of General Practice and Primary Care
University of Aberdeen
Foresterhill Health Centre
Westburn Road
Aberdeen AB25 2AY

E-mail: alison.fish@abdn.ac.uk
Fax: (01224) 840683