INTRODUCTIONA health condition which persists for a longer periodand requires long-term treatment where it is also associated with manycomplications can be called as chronic illness. The term chronic is often appliedwhen the course of the disease lasts for more than three months. 1 Chronicillness is the personalexperience of living with the affliction that often accompanies chronicdisease.
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 thechallenges of chronic disease. 3In 2015, according to global burden disease (GBD)totally among 56.4 million deaths worldwide major causes of deaths globallyinclude the following diseases: § Ischaemic heart disease and stroke§ LRTI § COPD§ Trachea and bronchus cancers§ Diabetes mellitus§ Dementia problems§ Diarrheal diseases§ Tuberculosis and§ Road injuriesBurden of disease is calculated by using DALY. Timebased measure comprises of years of life lost over pre-mature mortality andlife years lost as a result of time lived in condition less than full health. When calculated among all the causes of deaths in2015, major causes include chronic diseases like Ischaemic heart disease andstroke, Diabetes, Neurological problems, Infections related to lowerrespiratory tract etc. So there is a need of providing medication informationfor chronic diseases to enhance long-term medication compliance automatically by incorporating behavioural element.
4 Figure 1: Topten causes of death globally in 2015Clinical pharmacy is a health specialty in thepharmacy literature and its actions ultimately lead to accurate use ofmedications on three discrete levels like before, later and during theprescription is written. Clinical pharmacists are capable of preparing regimensand dispensing of investigational product to subjects and monitoring itsPharmacogenecity and toxigenicity effects in clinical trials. They can detectand avoid fatal effects of drugs during their prescription appraisal. As a partof post-prescription analysis, Clinical Pharmacist acts a communicator andmedication counsellor.
5 The key-element of clinical pharmacy is to detect,solve and prevent drug-related problems which deals with choice of drug, dosagecalculation of drugs, adverse effects, interactions, medication adherenceproblems and drug toxic effects. Clinical pharmacists can influence outcomessuch as marker levels for drug use (anti-coagulation levels and B.P), reducedlength of hospital stay, and fewer admissions. 6Sick persons are frequently discharged from thehealth-care settings with the modification to their prior medication regimens.Drug related problems like adverse effects, medication discrepancies andnon-adherence are common during these transitions of care as information givenduring their discharge is brief.
7 Lower adherence to theirmedications is seen in 40% of chronic diseased patients and it leads tosub-therapeutic benefit, reduced QOL, mortality, morbidity. So, patient may bein need of further information. 8Integrated health system which can also be called aspatient care team includes diverse clinicians along with Clinical Pharmacistwho has a prime position to deliver acute, intermediate, long term, home andambulatory care.
9They are intended to continuously provide carewith a goal of improving outcomes, which requires better discerning of specificobstacles directed towards therapy and facilitators of adherence to remedialtherapy and patient experiences across practice settings through appropriateuse of individual health professionals and teams.8 Physicianacquiesce and acts on clinical pharmacist’s suggestion by making interventionto regimen. Majorly clinical pharmacists can assess DRPs in different settingslike hospital multi-disciplinary departments, in nursing homes and in case ofprimary care. Interventions comes under an indirect measure of those effects onpatients. 6 The Clinical Pharmacist is in a highly visible andreadily available position to rule out interacting domains also. Domainsinclude socio-economic factors, health care system services, characteristics ofregimen and disease, patient related factors, physical factors include age,gender etc and to answer patients concerns and enquiries about their medicationsand alternate treatments they may read about or hear from others.
8 Severalinterventions such as drug information to enhance patient’s understanding,reminder, self-monitoring, reinforcement and manual telephone follow-up haveresulted in improved adherence to medications.10 This activeparticipation and interventions by clinical pharmacists in health carepositively influence on clinical practice.6 Participation ofpharmacist in post-admission ward rounds has shown to minimise medication errorsand reduce prescription costs and improved accuracy of medication historydocumentation.11Evidence based medicine has exceedingly broad supportin health services as it provides strong scientific base for practice isdifficult to practice actually.
Clinical pharmacist can fill gaps betweencurrent clinical practice and evidence. Initially clinical pharmacist has tocollect best available evidences form research articles with absolute benefitsand harms. Later clinician’s judgement is important to calculate individualisedrisk profile and prognosis. Finally considering patient’s values andpreferences 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.14In case of evidence based medicine optimising clinicaldecision by evidence from research articles comprising reliable results issignificant. Evidence based pharmacy can improve importance ofclinical pharmacist in hospital by enhancing the relationship betweenpharmacist and patient.
13 Figure – 2: Evidence BasedMedicine Generally meta-analyses studies and systematic reviewsprovide higher evidence.14 Pharmacists should be trained well indeveloping individualised patient care plan and counselling. EBM helps inpreventing polypharmacy and improve compliance (proportion of drugs to whichpatients respond) to geriatric patients. 15Primary care clinical pharmacist should possessupdated knowledge, skills and abilities in support of their profession inclinical practice.16 The concept of 7 star pharmacist is aremarkable aspect in terms of achieving benchmarks in proving high qualitypharmaceutical care even though there is an amendment which adds two newcriteria to that.
This shows that the pharmacist can give his best as aresearcher and an entrepreneur.17 According to WHO pharmacistshould possess seven stars qualifying all the skills like,§ Care-giver§ Decision maker§ Communicator§ Leader§ Manager§ Life-long learner§ TeacherCare giver- Pharmacist should provide care in clinical,analytical, technological or regulatory aspects.Decision maker- Pharmacist plays major role in making decisionsregarding appropriate use of drugs.Communicator- Pharmacist acts as a good communicator for thepatient as well as other health-care professionals. Poor communication has been shown to have adverseeffects on many important outcomes such as patients’ satisfaction and adherenceto treatment or advice.Leader- As a leader the pharmacist is able to make decisions, communicate andmanage accordingly.Manager- Pharmacist can manage human, physical, fiscal resources effectivelyand should be managed comfortably by others too.Life-long learner- Clinical Pharmacist should be updating himselfthroughout his career.
Teacher- Pharmacist also has a role in guiding and training apprenticepharmacists.An ideal Pharmacist must possess all these skillswhich are possible through post-admission patient case analysis and appropriatedischarge care via patient counselling in patients suffering from chronicillness who have to attend for regular follow-ups.18Clinical pharmacist also performs manual follow-upsfor case management process which can be defined as collaborative procedurethat analyses, plans, implements, monitors and calculate options and healthservices required to meet individual needs. Pharmacist performs case managementby using available resources and communications to improve quality of healthcare and cost effective outcomes.
19Patient counselling may be defined as a one – to – oneinteraction between a pharmacist and a patient and/or caregiver. It isinteractive in nature. It should include an assessment of whether or not theinformation was received as intended and that the patient understands how touse the information to improve the probability of positive therapeuticoutcomes.20Patient counselling process includes some steps whichare to be followed during the session. Comprises of 4 steps.Preparing for the counselling session:The appropriate counselling can be achieved by thecomplete knowledge and skill of the counsellor. So the pharmacist should beaware of the patient and his medications to the possible extent.
In thehospital pharmacy settings the information pool may be the patient, hisprescription and a record of previous dispensing for the patient.Opening the session:The pharmacist should introduce himself to the patientand greet him by his name in order to ease the patient. Then the pharmacistassesses the patient’s knowledge about the disease he is suffering from byasking some open-ended questions.
Counselling content:This is the major step for the entire counsellingsession. In this step, the pharmacist explains about the disease, causatives,precautions to prevent recurrence, life style modifications and exclusivelyabout medications in this study. The medication counselling includesinformation like strength and adverse effects of the medications, monitoringparameters, interactions with other drugs, duration and benefits of thetherapy.Closing the session:Before this step assessing the patient’s understandingby asking closed ended questions is significant to assure the quality of thesession. Then the patient is given some time for his further doubts andclarified as such.
At last briefing up the counselling points might be helpfulto the patient. 21Patient counselling is a key competency element of thePharmaceutical Care process which requires direct relationship between apharmacist and an individual patient. Clinical pharmacists provideinterventions based on pharmaceutical care principles. Pharmaceutical care is aprocess where pharmacists support the patients and other health professionalsin designing, introducing and monitoring a pharmacotherapeutic plan whichproduces therapeutic outcomes for patient.Implementation ofpharmaceutical care involves six (6) basic steps which includes establishmentof a professional/therapeutic relationship, collection of patient-specificdata, evaluation of data to identify health and drug related problems,development and implementation of pharmaceutical care plan (pharmacist’sintervention which could be patient – focused intervention or drug – focusedintervention), evaluation of intervention and follow – up and documentation.22One of the major interacting domains associated withadherence in chronic illness patients is satisfaction with information aboutmedicines. So patient’s satisfaction with information provided by clinicalpharmacist can be easily assessed with SIMS questionnaire.
Pharmaceuticalinterventions influences patients’ adherence, optimizes their drug therapy andimproves rational prescribing and care resulting in significant improvements inthe outcomes of their treatment and levels of satisfaction.22Higher satisfaction is associated with exceedingcompliance, improved attendance at follow-ups and better therapeutic outcomes.Generally patient beliefs on seriousness of illness, fear on complications ofillness and treatment efficacy can strongly predict better adherence levels.8 Satisfaction has been reported to improve one’s healthstatus and to analyse the process of health care. Knowing satisfaction wouldfacilitate health care team to understand gaps within health care delivery andunderstand particular needs of the patient.23 Pharmacistscan also have prescribing rights but no published research has compared theeffectiveness of their prescribing with that of GPs.
The hypothesis was thatpharmacist advice (with or without pharmacist prescribing) would lead to betteroutcomes than usual care.24SIMS tool was designed by the R. Horne, director ofcentre for health care research (CHCR) in University of Brighton and theyperformed research work by using SIMS questionnaire during admissions inhospital and OP clinic appointments which was published on 5th June,2001. SIMS tool was developed to examine psychometric properties of SIMSquestionnaire and to assess the belief of the patients on information aboutprescription medicines what they have received. Usually providing leaflet orstandard written information regarding disease and medications doesn’tguarantee the appropriate use of medicines. So there is a provision forinformation which must be tailored to meet individual needs. 25Quality of medication information can be easilyassessed by SIMS tool.
Every item in SIMS questionnaire specify all aspects ofpatient’s medications. SIMS showed a remarkable effect on psychometricindicators and can be considered as a best tool for auditing, research andclinical practice (to plan medical related consultations). The Satisfaction with Information about MedicinesScale (SIMS) provides a valid and reliable tool for assessing how well the needs of the individual patients for medicinesinformation are being met.
25It has been shown to be consistent in patients withcardiac rehabilitation, Asthma, Diabetes, oncology and distinguishes withinlower and higher adherence in Rheumatoid arthritis.8The provision ofwritten information can significantly improve patients’ understanding ofthe rationale, modeof administration and precautions concerning their therapy. Patients withcardiovascular disease often require several drugs and to use them safely andeffectively they require certain basic information.26 The scale hasalso been shown as highly effective across a wide range of conditions andtherapy areas like Endocrinology, Infectious diseases, Anti-coagulationtherapy etc. SIMS (Satisfaction withInformation about Medicines Scale) tool also investigates patients to expressif they acquired whole information regarding prescribed drugs. The measure waswell accepted by patients and showed satisfactory internalconsistency, test-retest reliabilityand criterion related validity.
25Currentlythere is limited resources or research studies available in Indian settings, inrelation to assessment of satisfaction towards the information about allaspects of drug use to patients. Hence, we designed a survey on assessingindividual patients satisfaction on patient counselling (disease and drugspecific), who suffers chronic illness on ambulatory care through the modifiedSIMS (Satisfaction with Information about Medicines Scale) tool. Patient’s medicationdischarge counselling provides an opportunity for pharmacists to improvepatients’ therapeutic outcomes. Patient satisfaction is an important link in betweenmedication adherence and therapeutic outcomes.
It is a commonly used indicatorfor measuring the quality in health care, as well and It affects patientretention and medical malpractice claims. So we have planned to perform thisstudy among rural population of South India.