INTRODUCTION § Diabetes mellitus § Dementia problems § Diarrheal


A health condition which persists for a longer period
and requires long-term treatment where it is also associated with many
complications can be called as chronic illness.  The term chronic is often applied
when the course of the disease lasts for more than three months. 1

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illness is the personal
experience of living with the affliction that often accompanies chronic
disease. 2 The chronic care model (CCM) describes chronic care as
“the prevention and diagnosis, management, and palliation of chronic disease”
and is internationally accepted as the main strategic response to the
challenges of chronic disease. 3

In 2015, according to global burden disease (GBD)
totally among 56.4 million deaths worldwide major causes of deaths globally
include the following diseases:

§  Ischaemic heart disease and stroke



§  Trachea and bronchus cancers

§  Diabetes mellitus

§  Dementia problems

§  Diarrheal diseases

§  Tuberculosis and

§  Road injuries

Burden of disease is calculated by using DALY. Time
based measure comprises of years of life lost over pre-mature mortality and
life years lost as a result of time lived in condition less than full health.

When calculated among all the causes of deaths in
2015, major causes include chronic diseases like Ischaemic heart disease and
stroke, Diabetes, Neurological problems, Infections related to lower
respiratory tract etc. So there is a need of providing medication information
for chronic diseases to enhance long-term medication compliance automatically by incorporating behavioural element. 4


  Figure 1: Top
ten causes of death globally in 2015

Clinical pharmacy is a health specialty in the
pharmacy literature and its actions ultimately lead to accurate use of
medications on three discrete levels like before, later and during the
prescription is written. Clinical pharmacists are capable of preparing regimens
and dispensing of investigational product to subjects and monitoring its
Pharmacogenecity and toxigenicity effects in clinical trials. They can detect
and avoid fatal effects of drugs during their prescription appraisal. As a part
of post-prescription analysis, Clinical Pharmacist acts a communicator and
medication counsellor. 5

The key-element of clinical pharmacy is to detect,
solve and prevent drug-related problems which deals with choice of drug, dosage
calculation of drugs, adverse effects, interactions, medication adherence
problems and drug toxic effects. Clinical pharmacists can influence outcomes
such as marker levels for drug use (anti-coagulation levels and B.P), reduced
length of hospital stay, and fewer admissions. 6

Sick persons are frequently discharged from the
health-care settings with the modification to their prior medication regimens.
Drug related problems like adverse effects, medication discrepancies and
non-adherence are common during these transitions of care as information given
during their discharge is brief. 7 Lower adherence to their
medications is seen in 40% of chronic diseased patients and it leads to
sub-therapeutic benefit, reduced QOL, mortality, morbidity. So, patient may be
in need of further information. 8

Integrated health system which can also be called as
patient care team includes diverse clinicians along with Clinical Pharmacist
who has a prime position to deliver acute, intermediate, long term, home and
ambulatory care.9They are intended to continuously provide care
with a goal of improving outcomes, which requires better discerning of specific
obstacles directed towards therapy and facilitators of adherence to remedial
therapy and patient experiences across practice settings through appropriate
use of individual health professionals and teams.8 Physician
acquiesce and acts on clinical pharmacist’s suggestion by making intervention
to regimen. Majorly clinical pharmacists can assess DRPs in different settings
like hospital multi-disciplinary departments, in nursing homes and in case of
primary care. Interventions comes under an indirect measure of those effects on
patients. 6 

The Clinical Pharmacist is in a highly visible and
readily available position to rule out interacting domains also. Domains
include socio-economic factors, health care system services, characteristics of
regimen and disease, patient related factors, physical factors include age,
gender etc and to answer patients concerns and enquiries about their medications
and alternate treatments they may read about or hear from others.8 Several
interventions such as drug information to enhance patient’s understanding,
reminder, self-monitoring, reinforcement and manual telephone follow-up have
resulted in improved adherence to medications.10 This active
participation and interventions by clinical pharmacists in health care
positively influence on clinical practice.6 Participation of
pharmacist in post-admission ward rounds has shown to minimise medication errors
and reduce prescription costs and improved accuracy of medication history

Evidence based medicine has exceedingly broad support
in health services as it provides strong scientific base for practice is
difficult to practice actually. Clinical pharmacist can fill gaps between
current clinical practice and evidence. Initially clinical pharmacist has to
collect best available evidences form research articles with absolute benefits
and harms. Later clinician’s judgement is important to calculate individualised
risk profile and prognosis. Finally considering patient’s values and
preferences is done to apply evidence to practice.
The pharmacists need to be trained with the skills in patient assessment,
developing patient-specific care plan, patient education and counseling.14

In case of evidence based medicine optimising clinical
decision by evidence from research articles comprising reliable results is
significant. Evidence based pharmacy can improve importance of
clinical pharmacist in hospital by enhancing the relationship between
pharmacist and patient.13


Figure – 2: Evidence Based






Generally meta-analyses studies and systematic reviews
provide higher evidence.14 Pharmacists should be trained well in
developing individualised patient care plan and counselling. EBM helps in
preventing polypharmacy and improve compliance (proportion of drugs to which
patients respond) to geriatric patients. 15

Primary care clinical pharmacist should possess
updated knowledge, skills and abilities in support of their profession in
clinical practice.16 The concept of 7 star pharmacist is a
remarkable aspect in terms of achieving benchmarks in proving high quality
pharmaceutical care even though there is an amendment which adds two new
criteria to that. This shows that the pharmacist can give his best as a
researcher and an entrepreneur.17 According to WHO pharmacist
should possess seven stars qualifying all the skills like,

§  Care-giver

§  Decision maker

§  Communicator

§  Leader

§  Manager

§  Life-long learner

§  Teacher

Care giver- Pharmacist should provide care in clinical,
analytical, technological or regulatory aspects.

Decision maker- Pharmacist plays major role in making decisions
regarding appropriate use of drugs.

Communicator- Pharmacist acts as a good communicator for the
patient as well as other health-care professionals. Poor communication has been shown to have adverse
effects on many important outcomes such as patients’ satisfaction and adherence
to treatment or advice.

Leader- As a leader the pharmacist is able to make decisions, communicate and
manage accordingly.

Manager- Pharmacist can manage human, physical, fiscal resources effectively
and should be managed comfortably by others too.

Life-long learner- Clinical Pharmacist should be updating himself
throughout his career.

Teacher- Pharmacist also has a role in guiding and training apprentice

An ideal Pharmacist must possess all these skills
which are possible through post-admission patient case analysis and appropriate
discharge care via patient counselling in patients suffering from chronic
illness who have to attend for regular follow-ups.18

Clinical pharmacist also performs manual follow-ups
for case management process which can be defined as collaborative procedure
that analyses, plans, implements, monitors and calculate options and health
services required to meet individual needs. Pharmacist performs case management
by using available resources and communications to improve quality of health
care and cost effective outcomes.19

Patient counselling may be defined as a one – to – one
interaction between a pharmacist and a patient and/or caregiver. It is
interactive in nature. It should include an assessment of whether or not the
information was received as intended and that the patient understands how to
use the information to improve the probability of positive therapeutic

Patient counselling process includes some steps which
are to be followed during the session. 
Comprises of 4 steps.

Preparing for the counselling session:

The appropriate counselling can be achieved by the
complete knowledge and skill of the counsellor. So the pharmacist should be
aware of the patient and his medications to the possible extent. In the
hospital pharmacy settings the information pool may be the patient, his
prescription and a record of previous dispensing for the patient.

Opening the session:

The pharmacist should introduce himself to the patient
and greet him by his name in order to ease the patient. Then the pharmacist
assesses the patient’s knowledge about the disease he is suffering from by
asking some open-ended questions.

Counselling content:

This is the major step for the entire counselling
session. In this step, the pharmacist explains about the disease, causatives,
precautions to prevent recurrence, life style modifications and exclusively
about medications in this study. The medication counselling includes
information like strength and adverse effects of the medications, monitoring
parameters, interactions with other drugs, duration and benefits of the

Closing the session:

Before this step assessing the patient’s understanding
by asking closed ended questions is significant to assure the quality of the
session. Then the patient is given some time for his further doubts and
clarified as such. At last briefing up the counselling points might be helpful
to the patient. 21

Patient counselling is a key competency element of the
Pharmaceutical Care process which requires direct relationship between a
pharmacist and an individual patient. Clinical pharmacists provide
interventions based on pharmaceutical care principles. Pharmaceutical care is a
process where pharmacists support the patients and other health professionals
in designing, introducing and monitoring a pharmacotherapeutic plan which
produces therapeutic outcomes for patient.

Implementation of
pharmaceutical care involves six (6) basic steps which includes establishment
of a professional/therapeutic relationship, collection of patient-specific
data, evaluation of data to identify health and drug related problems,
development and implementation of pharmaceutical care plan (pharmacist’s
intervention which could be patient – focused intervention or drug – focused
intervention), evaluation of intervention and follow – up and documentation.22

One of the major interacting domains associated with
adherence in chronic illness patients is satisfaction with information about
medicines. So patient’s satisfaction with information provided by clinical
pharmacist can be easily assessed with SIMS questionnaire. Pharmaceutical
interventions influences patients’ adherence, optimizes their drug therapy and
improves rational prescribing and care resulting in significant improvements in
the outcomes of their treatment and levels of satisfaction.22

Higher satisfaction is associated with exceeding
compliance, improved attendance at follow-ups and better therapeutic outcomes.
Generally patient beliefs on seriousness of illness, fear on complications of
illness and treatment efficacy can strongly predict better adherence levels.8


Satisfaction has been reported to improve one’s health
status and to analyse the process of health care. Knowing satisfaction would
facilitate health care team to understand gaps within health care delivery and
understand particular needs of the patient.23

can also have prescribing rights but no published research has compared the
effectiveness of their prescribing with that of GPs. The hypothesis was that
pharmacist advice (with or without pharmacist prescribing) would lead to better
outcomes than usual care.24

SIMS tool was designed by the R. Horne, director of
centre for health care research (CHCR) in University of Brighton and they
performed research work by using SIMS questionnaire during admissions in
hospital and OP clinic appointments which was published on 5th June,
2001. SIMS tool was developed to examine psychometric properties of SIMS
questionnaire and to assess the belief of the patients on information about
prescription medicines what they have received. Usually providing leaflet or
standard written information regarding disease and medications doesn’t
guarantee the appropriate use of medicines. So there is a provision for
information which must be tailored to meet individual needs. 25

Quality of medication information can be easily
assessed by SIMS tool. Every item in SIMS questionnaire specify all aspects of
patient’s medications. SIMS showed a remarkable effect on psychometric
indicators and can be considered as a best tool for auditing, research and
clinical practice (to plan medical related consultations). 

The Satisfaction with Information about Medicines
Scale (SIMS) provides a valid  and  reliable tool for  assessing how 
well  the needs of the  individual 
patients  for medicines
information are being met. 25

It has been shown to be consistent in patients with
cardiac rehabilitation, Asthma, Diabetes, oncology and distinguishes within
lower and higher adherence in Rheumatoid arthritis.8

The provision of
written information can significantly improve patients’ understanding of

the rationale, mode
of administration and precautions concerning their therapy. Patients with
cardiovascular disease often require several drugs and to use them safely and
effectively they require certain basic information.26

The scale has
also been shown as highly effective across a wide range of conditions and
therapy areas   like   Endocrinology, Infectious diseases, Anti-coagulation
therapy etc.  SIMS (Satisfaction with
Information about Medicines Scale) tool also investigates patients to express
if they acquired whole information regarding prescribed drugs. The measure was
well   accepted by   patients  
and showed satisfactory   internal
consistency, test-retest   reliability
and criterion related validity. 25

there is limited resources or research studies available in Indian settings, in
relation to assessment of satisfaction towards the information about all
aspects of drug use to patients. Hence, we designed a survey on assessing
individual patients satisfaction on patient counselling (disease and drug
specific), who suffers chronic illness on ambulatory care through the modified
SIMS (Satisfaction with Information about Medicines Scale) tool.





Patient’s medication
discharge counselling provides an opportunity for pharmacists to improve
patients’ therapeutic outcomes. Patient satisfaction is an important link in between
medication adherence and therapeutic outcomes. It is a commonly used indicator
for measuring the quality in health care, as well and It affects patient
retention and medical malpractice claims. So we have planned to perform this
study among rural population of South India.