Implementation of pharmaceutical care: Important aspects for a lasting service

Silva, Luanna Gabriella Resende da; Mendonça, Thays Santos; Roque Obreli-Neto, Paulo; Pereira, Mariana Linhares; Baldoni, André Oliveira

doi:10.1590/s2175-97902025e23856

Abstract

This is a commentary manuscript, which aims to carry out a critical analysis of the effects of Pharmaceutical Care (PC) without the continuity of the service by healthcare professionals. PC has proven to be a very effective practice for improving pharmacotherapy for medicine users. In Brazil, it is noticeable that in the vast majority of cases, PC is carried out by professionals who are already working within the healthcare systems under the supervision of researchers affiliated with universities, for the purpose of research and data collection. When the research ends there is no continuation of the service, which hinders its continuous implementation and the establishment of a connection with the community. It was observed that after discharge from pharmacotherapeutic monitoring, due to the interruption of the service, there was a deterioration in the clinical and laboratory parameters of individuals with chronic diseases. Therefore, it is clear that PC needs to be implemented not only for research purposes, but also in the “real world”, so that it is long-lasting and permanent with the monitoring of the patients using medication.

Keywords:
Health Systems; Pharmaceutical care; Pharmaceutical Services

Within the Pharmaceutical Care (PC) practice, the pharmacist has the responsibility to guarantee effective and safe pharmacotherapy, in addition to ensuring correct adherence to the treatment. The implementation of this service has demonstrated many benefits for patients and health systems (Apikoglu et al., 2022; Foucault-Fruchard et al., 2020; Lum et al., 2019).

Many studies explain the clinical, economic, and humanistic benefits of PC in Brazil and around the world (Posses et al., 2022; Coradi et al., 2020; Franco, Jesus, Abreu, 2020; Pereira et al., 2018; Hohl et al., 2017; Obreli-Neto et al., 2011). However in Brazil, a large portion of the studies are affiliated with universities with the purpose of research projects (scientific initiation, extension, master’s and doctoral projects) without continuity once data collection concludes (Mendonça et al., 2022; da Silva et al., 2022). Thus, most of the time the services are not permanent, and the results are not long-lasting.

A retrospective cohort study covering post-PC discharge (four years later), found that glycated hemoglobin (HbA1c) levels in the intervention group were maintained (8.5 % vs. 8.0 %, p=0.082), while the control group decreased (9.1 % vs. 8.1 %; p=0.004). However, diastolic blood pressure decreased in the intervention group (80.1 vs 77.2; p=0.004), while in the control group it was maintained (p=0.433) (Pereira et al., 2018). Such results can be explained by the number of antidiabetics used in both groups and the fact that reducing a higher HbA1c (as in the control group) is easier than verifying decreases when HbA1c is more controlled (intervention group). A question that can be asked is: “If PC had actually been implemented, wouldn’t HbA1c levels in the intervention group have decreased more?”

Other studies have shown that the favorable outcome in patients’ health during pharmaceutical consultations was lost with the absence of the research team (where PC is not implemented) (Aquino et al., 2019; Cazarim et al., 2016). A study conducted with patients with type 2 diabetes mellitus found satisfactory results, with a reduction in HbA1c levels after PC. However, 18 months after patients were discharged, an increase in HbA1c levels was observed, similar to pre-intervention levels. This was probably due to the fact that the study was carried out by researchers, without the involvement of service professionals, making continuous PC for patients impossible (Aquino et al., 2019). A similar effect was observed in a study conducted with patients with systemic arterial hypertension, in which it was observed that blood pressure levels reduced during PC, but the values increased significantly with the absence of pharmacotherapeutic monitoring (three years post-discharge) (Cazarim et al., 2016).

Considering that PC is indeed effective in controlling various comorbidities, especially chronic (Mendonça et al., 2022; Wang et al., 2022), it is necessary for the service to be implemented permanently in health systems. It is important that when following implementation protocols, a more individualized approach is used in each location, taking into account its peculiarities (Garcia-Cardenas et al., 2019). To make adaptations to protocols already used, it is important to know the scenario where PC is planned to be implemented, the profile of the local population, as well as the profile of the pharmacist and the multidisciplinary health team. Some points facilitate implementation, others hinder it. Using strengths which facilitate the flow of care, not only for the pharmacist but for the team as a whole is seen as encouraging, both from a clinical and management point of view. The same happens with barriers; devising strategies to overcome them is something that will make implementation happen (Waltering, Schwalbe, Hempel, 2022; Ilardo, Speciale, 2020).

It is known that lasting health results are multifaceted and depend on clinical factors and others that affect or influence the individual’s health in a determinant way (Carrapato, Correia, Garcia, 2017). Therefore, it is important to highlight that in addition to the manager’s support, some barriers need to be overcome to ensure the successful implementation and permanence of the service, such as the need of qualified pharmacists to carry out the service, physical structure, available hours of the pharmacist, among others.

In this way, the pharmacist needs to remain close to the medication users within the community (Dewulf et al., 2009), exercising their clinical duties (Gemmeke et al., 2021). The population and other health professionals need to know the work of the clinical pharmacist and, in this way, patients will arrive both voluntarily and also by referral (Marques et al., 2019). It is also important to highlight that studies that evaluate post-PC discharge are scarce in the literature (Pereira et al., 2018). The permanent implementation of PC is a great alternative to assess how the patients are doing in relation to their pharmacological treatment and continue the care for them and for new patients.

THANKS

Federal University of São João del-Rei (UFSJ), Central-West Dona Lindu campus.

REFERENCES

Apikoglu S, Selcuk A, Ozcan V, Balta E, Turker M, Albayrak OD, et al. The first nationwide implementation of pharmaceutical care practices through a continuing professional development approach for community pharmacists. Int J Clin Pharm. 2022 Dec 14; 44(6): 1223-31.
Aquino JA, Souza TN, Sanches C, Pereira ML, Baldoni AO. What is the effectiveness of post-discharge pharmacotherapeutic empowerment of patients with diabetes? Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019 Mar; 13(2): 1321-3.
Carrapato P, Correia P, Garcia B. Determinante da saúde no Brasil: a procura da equidade na saúde. Saúde soc. 2017; 26(3): 676-689.
Cazarim M de S, de Freitas O, Penaforte TR, Achcar A, Pereira LRL. Impact Assessment of Pharmaceutical Care in the Management of Hypertension and Coronary Risk Factors after Discharge. PLoS One. 2016 Jun 15; 11(6): e0155204.
Coradi A, Figueiredo F, Adami F, Fonseca F, Souto R. Effectiveness on diabetes mellitus treatment through apharmaceutical care in a government program foraccess to medicine: a randomised controlled trial. JAPHAC. 2020; 1(7): 237-49.
da Silva LGR, da Silva Pinto AW, de Queiroz WE, Coelho CC, Blatt CR, Oliveira MG, et al. Deprescribing clonazepam in primary care older patients: a feasibility study. Int J Clin Pharm. 2022 Apr 13; 44(2): 489-98.
Dewulf NLS, dos Santos V, Leira Pereira LR, Troncon LEA. The invisible pharmacist. Am J Pharm Educ. 2009 Jul 10; 73(4): 74.
Foucault-Fruchard L, Bizzoto L, Allemang-Trivalle A, Renoult-Pierre P, Antier D. Compared benefits of educational programs dedicated to diabetic patients with or without community pharmacist involvement. Prim Health Care Res Dev. 2020 Nov 6; 21: e49.
Franco M da CS, Jesus FM, Abreu CR de C. Papel do farmacêutico no controle glicêmico do paciente diabético. Revista JRG de Estudos Acadêmicos. 2020; 3(7): 636-45.
Garcia-Cardenas V, Rossing C, Benrimoj SI. Pharmaceutical Care and Implementation Strategies. In: The Pharmacist Guide to Implementing Pharmaceutical Care. Cham: Springer International Publishing; 2019. p. 203-12.
Gemmeke M, Koster ES, Rodijk EA, Taxis K, Bouvy ML. Community pharmacists’ perceptions on providing fall prevention services: a mixed-methods study. Int J Clin Pharm. 2021 Dec 13; 43(6): 1533-45.
Hohl CM, Partovi N, Ghement I, Wickham ME, McGrail K, Reddekopp LN, et al. Impact of early in-hospital medication review by clinical pharmacists on health services utilization. PLoS One. 2017 Feb 13; 12(2): e0170495.
Ilardo ML, Speciale A. The Community Pharmacist: Perceived Barriers and Patient-Centered Care Communication. Int J Environ Res Public Health. 2020 Jan 15; 17(2): 536.
Lum ZK, Siaw MYL, Lee MJX, Koh Z, Zhang PQ, Eng SK, et al. Impact of pharmaceutical care on mental well-being and perceived health among community-dwelling individuals with type 2 diabetes. Quality of Life Research. 2019 Dec 29; 28(12): 3273-9.
Marques PA, Simão TA, Moriya MM, Dias G, Antunes VM de S, Oliveira CR. Prescrição farmacêutica de medicamentos fitoterápicos. Braz J Nat Sci. 2019 Jan 11; 2(1): 15.
Mendonça TS, Oliveira WN, Belo VS, Silva ES, Pereira ML, Obreli-Neto PR, et al. Clinical and humanistic impact of pharmacotherapeutic follow-up in patients with type 1 diabetes mellitus treated judicially. Diabetol Metab Syndr. 2022 Dec 3; 14(1): 61.
Obreli-Neto PR, Marusic S, De Lyra Júnior DP, Pilger D, Cruciol-Souza JM, Gaeti WP, et al. Effect of a 36-month Pharmaceutical Care Program on the Coronary Heart Disease Risk in Elderly Diabetic and Hypertensive Patients. J Pharm Pharm Sci. 2011 Jun 24; 14(2): 249.
Pereira LB, Guidoni CM, Borges AP de S, Pereira LRL. Avaliação da efetividade do acompanhamento farmacoterapêutico no controle do diabetes mellitus tipo 2 em longo prazo. Clinical & Biomedical Research. 2018; 38(3): 237-44.
Posses CP, Lima EM de, Brasil GA, Cassaro KO dos S, Cruz MM, Rezende AMB, et al. Resultados clínicos e humanísticos em pacientes dislipidêmicos atendidos em farmácia pública antes e após a implantação do Cuidado Farmacêutico. Res Soc Dev. 2022 Jun 13; 11(8): e14411830610.
Waltering I, Schwalbe O, Hempel G. Identification of factors for a successful implementation of medication reviews in community pharmacies: Using Positive Deviance in pharmaceutical care. Int J Clin Pharm. 2022 Feb 6; 44(1): 79-89.
Wang W, Geng L, Sun C, Li H, Wang J. Efficacy of Pharmaceutical Care in Patients with Type 2 Diabetes Mellitus and Hypertension: A Randomized Controlled Trial. Int J Clin Pract. 2022 Mar 24; 2022: 1-6.

FINANCING
This study was funded by the Research Support Foundation of the state of Minas Gerais (Fundação de Amparo à Pesquisa do estado de Minas Gerais - FAPEMIG - APQ-01107-21), by the Coordination for the Improvement of Higher Education Personnel - Brazil (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES - 001), and by the National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq - 304131/2022-9).

Edited by

Associated Editor:
Patricia Melo Aguiar.

Publication Dates

Publication in this collection
31 Jan 2025
Date of issue
2025

History

Received
07 Nov 2023
Accepted
24 June 2024

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] Apikoglu S, Selcuk A, Ozcan V, Balta E, Turker M, Albayrak OD, et al. The first nationwide implementation of pharmaceutical care practices through a continuing professional development approach for community pharmacists. Int J Clin Pharm. 2022 Dec 14; 44(6): 1223-31.

[2] Aquino JA, Souza TN, Sanches C, Pereira ML, Baldoni AO. What is the effectiveness of post-discharge pharmacotherapeutic empowerment of patients with diabetes? Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019 Mar; 13(2): 1321-3.

[3] Carrapato P, Correia P, Garcia B. Determinante da saúde no Brasil: a procura da equidade na saúde. Saúde soc. 2017; 26(3): 676-689.

[4] Cazarim M de S, de Freitas O, Penaforte TR, Achcar A, Pereira LRL. Impact Assessment of Pharmaceutical Care in the Management of Hypertension and Coronary Risk Factors after Discharge. PLoS One. 2016 Jun 15; 11(6): e0155204.

[5] Coradi A, Figueiredo F, Adami F, Fonseca F, Souto R. Effectiveness on diabetes mellitus treatment through apharmaceutical care in a government program foraccess to medicine: a randomised controlled trial. JAPHAC. 2020; 1(7): 237-49.

[6] da Silva LGR, da Silva Pinto AW, de Queiroz WE, Coelho CC, Blatt CR, Oliveira MG, et al. Deprescribing clonazepam in primary care older patients: a feasibility study. Int J Clin Pharm. 2022 Apr 13; 44(2): 489-98.

[7] Dewulf NLS, dos Santos V, Leira Pereira LR, Troncon LEA. The invisible pharmacist. Am J Pharm Educ. 2009 Jul 10; 73(4): 74.

[8] Foucault-Fruchard L, Bizzoto L, Allemang-Trivalle A, Renoult-Pierre P, Antier D. Compared benefits of educational programs dedicated to diabetic patients with or without community pharmacist involvement. Prim Health Care Res Dev. 2020 Nov 6; 21: e49.

[9] Franco M da CS, Jesus FM, Abreu CR de C. Papel do farmacêutico no controle glicêmico do paciente diabético. Revista JRG de Estudos Acadêmicos. 2020; 3(7): 636-45.

[10] Garcia-Cardenas V, Rossing C, Benrimoj SI. Pharmaceutical Care and Implementation Strategies. In: The Pharmacist Guide to Implementing Pharmaceutical Care. Cham: Springer International Publishing; 2019. p. 203-12.

[11] Gemmeke M, Koster ES, Rodijk EA, Taxis K, Bouvy ML. Community pharmacists’ perceptions on providing fall prevention services: a mixed-methods study. Int J Clin Pharm. 2021 Dec 13; 43(6): 1533-45.

[12] Hohl CM, Partovi N, Ghement I, Wickham ME, McGrail K, Reddekopp LN, et al. Impact of early in-hospital medication review by clinical pharmacists on health services utilization. PLoS One. 2017 Feb 13; 12(2): e0170495.

[13] Ilardo ML, Speciale A. The Community Pharmacist: Perceived Barriers and Patient-Centered Care Communication. Int J Environ Res Public Health. 2020 Jan 15; 17(2): 536.

[14] Lum ZK, Siaw MYL, Lee MJX, Koh Z, Zhang PQ, Eng SK, et al. Impact of pharmaceutical care on mental well-being and perceived health among community-dwelling individuals with type 2 diabetes. Quality of Life Research. 2019 Dec 29; 28(12): 3273-9.

[15] Marques PA, Simão TA, Moriya MM, Dias G, Antunes VM de S, Oliveira CR. Prescrição farmacêutica de medicamentos fitoterápicos. Braz J Nat Sci. 2019 Jan 11; 2(1): 15.

[16] Mendonça TS, Oliveira WN, Belo VS, Silva ES, Pereira ML, Obreli-Neto PR, et al. Clinical and humanistic impact of pharmacotherapeutic follow-up in patients with type 1 diabetes mellitus treated judicially. Diabetol Metab Syndr. 2022 Dec 3; 14(1): 61.

[17] Obreli-Neto PR, Marusic S, De Lyra Júnior DP, Pilger D, Cruciol-Souza JM, Gaeti WP, et al. Effect of a 36-month Pharmaceutical Care Program on the Coronary Heart Disease Risk in Elderly Diabetic and Hypertensive Patients. J Pharm Pharm Sci. 2011 Jun 24; 14(2): 249.

[18] Pereira LB, Guidoni CM, Borges AP de S, Pereira LRL. Avaliação da efetividade do acompanhamento farmacoterapêutico no controle do diabetes mellitus tipo 2 em longo prazo. Clinical & Biomedical Research. 2018; 38(3): 237-44.

[19] Posses CP, Lima EM de, Brasil GA, Cassaro KO dos S, Cruz MM, Rezende AMB, et al. Resultados clínicos e humanísticos em pacientes dislipidêmicos atendidos em farmácia pública antes e após a implantação do Cuidado Farmacêutico. Res Soc Dev. 2022 Jun 13; 11(8): e14411830610.

[20] Waltering I, Schwalbe O, Hempel G. Identification of factors for a successful implementation of medication reviews in community pharmacies: Using Positive Deviance in pharmaceutical care. Int J Clin Pharm. 2022 Feb 6; 44(1): 79-89.

[21] Wang W, Geng L, Sun C, Li H, Wang J. Efficacy of Pharmaceutical Care in Patients with Type 2 Diabetes Mellitus and Hypertension: A Randomized Controlled Trial. Int J Clin Pract. 2022 Mar 24; 2022: 1-6.