An evaluation of a pharmaceutical care model in patients with rheumatological disorders

Abstract

Pharmaceutical care offered to patients with chronic musculoskeletal rheumatic diseases within a multidisciplinary team approach definitely improves patient outcomes and financial constraints on the patients and their families as well as the national health system. There is however an increasing need for the health professionals to offer and continuously upgrade the quality of service offered and pharmaceutical care is no exception. Out of all the rheumatic diseases, rheumatoid arthritis, besides being the commonest form, is also the condition for which the pharmaceutical industry has contributed enormously towards effective but costly drug armamentarium. Achieving remission or at least treatment to target using timely medications individualised according to patients' lifestyle, co-morbidites and disease condition is the core of effective patient management and is why this research focuses on rheumatoid arthritis. The aim of this research was to develop and implement valid instruments which systematically assess pharmacotherapy adherence to evidence based medicine, incorporating these tools within the philosophy of pharmaceutical care models. The main outcome of this research was the development and clinical implementation of medication assessment tool specific to rheumatoid arthritis, RhMAT, providing a quality system loop. Latest evidence based guidelines, recommendations and standards on rheumatoid arthritis and its management as set out by the American College of Rheumatology (ACR), the European League against Rheumatism (EULAR), the British Society for Rheumatology (BSR) and the National

Institute for Health and Care Excellence (NICE) were used to develop the RhMAT. The summary of product characteristics for each drug included in the RhMAT were used as reference for criteria related to pharmacological properties of the respective drugs. The RhMAT was designed in the form of a table which includes the criterion assessed and its cross reference. The RhMA T allows the user to determine whether each criterion tested is being adhered to (Yes) or not (No). If the criterion is not met, the user must determine whether the ''No'' response is justified or not justified. The user can also choose between not applicable or insufficient data to determine an appropriate choice. A general instruction sheet was compiled as a reference guide aiming for standardisation of the correct use of the RhMA T. The RhMA T was validated by an expert panel who assessed applicability of the tool to the practical scenario, presentation, robustness and validity of the criteria provided within the RhMAT. Inter-rater variability tests were conducted and the RhMA T was implemented in a secondary care ambulatory setting. The developed RhMAT consists of 11 separate sections targeting general aspects of rheumatoid arthritis, use of analgesics, methotrexate, su1phasa1azine, hydroxych10roquine, 1eflunomide, parenteral sodium aurothioma1ate, general pre-bio10gic screening, biologic therapy, use of glucocorticoids and remission cases. Following validation by the expert panel the RhMAT was piloted and tested for inter-rater variability and thereafter implemented. The RhMAT was run twice, Phase 1 (at baseline) and Phase 2 (at 12 months +/-3 months) on a total of 78 patients. An adherence rate to the RhMAT was calculated at both phases of the study. The validated Health Assessment Questionnaire (HAQ) and the Medication Compliance questionnaire were used to support the RhMAT in a clinical scenario.

Study findings indicate that locally the total RhMAT adherence rate achieved was 82%, defined as high adherence. At Phase 2, the total adherence rate statistically significantly (p value <0.05) increased to 85% following the pharmacist's intervention. The clinical contribution of the innovative RhMAT was two fold. First the RhMAT is able to detect the adherence rate to evidence based medicine. It is therefore able to show quantitatively the quality of pharmacotherapeutic management offered within a multidisciplinary service. Secondly the RhMAT is able to identify gaps which lead to lack of adherence to evidence based medicine. Together with the clinician and the patient the pharmacist can act on the identified gaps through the RhMA T further improving the quality of service offered. The characteristics demonstrated by the RhMAT were high inter-rater level of agreement (Cohen Kappa value of 0.916) and an application time of 15-20 minutes making it practical in a busy ambulatory care setting.