Positive benefits of a pharmacist-managed hypertension clinic in Nigeria

doi:10.1016/j.puhe.2004.11.009

Public Health

Volume 119, Issue 9, September 2005, Pages 792-798

https://doi.org/10.1016/j.puhe.2004.11.009 Get rights and content

Summary

Objective

The aim of this study was to determine whether the provision of further practice-based support by pharmacists will bring about improved outcomes for blood pressure (BP) control in middle-aged and elderly Nigerian hypertensive patients managed with combination diuretics (amiloride hydrochloride 5 mg+hydrochlorothiazide 50 mg) and/or methyl dopa at the primary care level.

Design and setting

Patients and method

The study population comprised 51 Nigerian patients with uncomplicated hypertension aged 45 years or more, with a 0.2–3.0-year history of hypertension, registered at the Comprehensive Health Centre, Ife between October 2002 and March 2003. They were invited into the pharmacist-managed hypertension clinic and followed for the study period. Participating pharmacists counselled for current medication, personalized goals of lifestyle modification stressing weight loss and/or increased activity, increased patient awareness by providing relevant education about hypertension and associated/related diseases, adjusted drug therapy to optimize effectiveness and minimize adverse events, utilized treatment schedules that enhanced patients' adherence to therapy, and monitored treatment outcomes between enrolment and return visits. Patient satisfaction and the number of treatment failures within 6 months post enrolment were compared with retrospective data from our earlier study involving physician-managed patients under a similar setting.

Results

Uncontrolled BP reduced from 92 to 36.2% by 10.15±5.02 days after enrolment. Treatment failures were observed at 5.9% of the total return visits (n=184) within 6 months.

Conclusion

Pharmacist-managed hypertension clinics can improve BP control, reduce treatment failure and increase patient satisfaction.

Introduction

A large proportion of hypertensive patients in Nigeria live with untreated or uncontrolled blood pressure (BP), although reductions in elevated BP have been shown to reduce the risk of cardiovascular mortality and morbidity.¹ While there is considerable evidence for the benefit of drug treatment in reducing BP,² published guidelines for the management of hypertensive patients recommend that strategies should be implemented at the primary care level.3, 4 Pharmacy-based programmes are cost effective, can be used to determine the ideal drug and when/how it should be used, and can provide ancillary programmes to support appropriate physician prescribing and optimal patient adherence.⁵

A recent investigation into BP control in hypertensive Nigerian blacks managed with alpha methyldopa and combination diuretics at the primary care level⁶ revealed a treatment gap; only 37.5% of the studied patients had controlled BP after their first treatment, and 10.2 and 4% of the study population needed three and five treatments within 6 months, respectively, to achieve target BP levels. In nearly all cases, diuretic therapy was not individualized and lifestyle modification was not prioritized.⁶ A pharmacist-managed hypertension clinic was therefore set up in the facility as an intervention. We report the benefits of the provision of additional practice-based support by pharmacists at the health centre facility on BP control in this low-income population. This is the first report on this topic in Nigeria.

Section snippets

Methods

This was a 1-year prospective, randomized cohort study of the outpatients of a state comprehensive health centre in South-western Nigeria. Free primary health services including free drugs were provided for all patients. The study population comprised 51 Nigerian patients with uncomplicated hypertension aged 45 years or more, with a 0.2–3-year history of hypertension, registered at the Comprehensive Health Centre, Ife between October 2002 and March 2003. They were invited into the

Results

Fifty-one patients were enrolled in the study; 15 males and 36 females. Of these, 33.3, 43.1 and 19.6% were normal weight, overweight and obese, respectively, and only 3.9% suffered from extreme obesity at enrolment according to ‘Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: the Evidence Report’.⁸ The patients were either non-alcohol drinkers or did so at a frequency and volume that was considered to be inconsequential.¹⁰ About 63%

Discussion

Supposition from the retrospective study of Erhun et al.⁶ showed that hypertensive Nigerian blacks ignore routine check ups and seldom go to clinic except when highly inconvenienced by the disease. This may explain the high level of unchecked BP in patients managed by physicians at the health centre during the years covered by the retrospective study,⁶ and it perhaps explains why a number of the patients enrolled into this study did not attend again after at least one normal BP reading (Fig. 1)

Conclusion

The pharmaceutical service provided by a pharmacist-managed hypertension clinic improved BP control, reduced treatment failures and recorded remarkable patient satisfaction. The impact of this intervention on clinical outcomes such as mortality and morbidity will be the focus of further studies.

Acknowledgements

The authors acknowledge the support of the Medical Officer and clinic staff of the Comprehensive Health Centre, Sabo, Ile-Ife as well as the support of the Hospital Management Board, Osogbo, Osun State, Nigeria.

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Several hours of productivity are lost due to improper management of hypertension. Poor adherence and inadequate care due to weak healthcare systems contribute to the lack of effectiveness of anti-hypertensive therapy. Pharmaceutical care plays a vital role in achieving treatment goals for patients with chronic conditions such as hypertension. This study sought to ascertain the effectiveness of pharmaceutical care services provided at the workplace on adherence and blood pressure control among staff with hypertension. This was a prospective pre-post study conducted at the Kwame Nkrumah University of Science and Technology from September 2019 to September 2020. Staff with confirmed diagnosis of hypertension were offered individualized pharmaceutical care every month for six months. Outcome measures were changes in blood pressure measurement, adherence and the number of pharmaceutical care issues identified and resolved. Forty-three university staff participated in this study. Reductions in mean systolic and diastolic blood pressure and difference in mean adherence scores were statistically significant after 6 months of follow up (p ≤ 0.00). A medical diagnosis of diabetes (p ≤ 0.044) and Body Mass Index (p ≤ 0.038) were associated with control of hypertension. Adherence to medications improved after the follow up period. Participants and pharmacists involved in the study expressed satisfaction with the program's impact. Pharmaceutical care at the workplace can improve medication adherence and blood pressure control among hypertensive patients. Blood pressure control was also better among individuals with normal Body Mass Index or a medical history of diabetes.
Factors hindering hypertension control: perspectives of front-line health professionals in rural Ghana
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Hypertension (HTN) control remains a major public health challenge in sub-Saharan Africa (SSA). Health professionals influence patient adherence and self-management practices for HTN particularly in rural and lower socio-economic communities in SSA. Contextual evidence on the reasons for the suboptimal control of HTN in clinical settings is crucial to improving health delivery practices for HTN and preventing HTN related-complications.
A cross-sectional qualitative study.
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We identified three key themes underlying the poor HTN control. First, health professionals’ barriers included communication difficulties, poor collaboration and referrals among health professionals and limited training on HTN and other non-communicable diseases (NCDs). Secondly, health system–related barriers included limited health personnel, drug shortages, inadequate facilities and equipment and challenges with National Health Insurance (NHIS). The third theme was patient-related barriers including non-adherence, use of traditional treatments, sociocultural factors and lack of appreciation.
A holistic public health approach, which builds upon health professionals’ capacities, harnesses and integrates into existing health policy and systems structures and empowers and collaborates with communities could contribute to improving HTN control in rural settings. Health policymakers need to consider the sociocultural, economic and geographical characteristics in such settings, which influence health service delivery practices in designing and implementing HTN interventions. There is also a need for health policy to integrate NCD training and management of multiple and comorbid conditions into the training curriculum of health training institutions to build health professionals capacity to facilitate the uptake of evidence-based NCD interventions and manage the double burden of diseases.
Patient acceptability of and readiness-to-pay for pharmacy-based health membership plans to improve hypertension outcomes in Lima, Peru
2017, Research in Social and Administrative Pharmacy
Pharmacies have been used to improve population health in Peru and other countries globally, operating as a non-traditional health access point. A pharmacy-based model holds potential to improve patient management of hypertension, a leading risk factor for non-communicable diseases in low- and middle-income countries. The aim of this study was to evaluate patient acceptability of hypertension services and health membership plans, if offered through private pharmacies in the future.
A cross-sectional study was conducted with 347 hypertensive individuals who purchased anti-hypertensive medications in a private pharmacy during the study period (July–October 2012). The study included a brief survey assessing patients' acceptability of and readiness-to-pay for pharmacy-based hypertension management services. Chi-square tests for differences in proportions were used to evaluate whether any demographic characteristics (e.g., binary variables for age, time since diagnosis, and type of medication usually purchased) could identify groups of hypertensive individuals that might be more or less likely to use pharmacy-based services. Multiple logistic regression was used to estimate associations between readiness-to-pay for pharmacy-based health membership plans and patient-level characteristics.
Over 80% of individuals indicated they would be interested in pharmacy-based hypertension services, particularly discounts on anti-hypertensive medications and free blood pressure screenings. Compared to individuals 65 years of age or older, individuals under 65 years were more interested in receiving at least one pharmacy-based service. Another 80% indicated they would be interested in purchasing a monthly health plan through a pharmacy that provided access to hypertension services each month. The vast majority of individuals interested in pharmacy-based services indicated they would pay ≤$3.69 US/month to participate in a monthly health membership plan.
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Point-of-Care Testing for Anemia, Diabetes, and Hypertension: A Pharmacy-Based Model in Lima, Peru
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We developed a multiphase training curriculum for pharmacists and pharmacy technicians to build capacity for identification of risk factors, patient education, point-of-care testing, and referral for abnormal results. We conducted a pre-post evaluation with participants and evaluated results using Student t test for proportions. We conducted point-of-care testing with pharmacy clients and evaluated acceptability by patient characteristics (age, gender, and type of patient) using multiple logistic regression.
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We found that it is both feasible for pharmacies and acceptable to clients to train pharmacy workers to provide point-of-care testing for anemia, diabetes, and hypertension. This innovative approach holds potential to increase early detection of risk factors and bolster disease prevention and management efforts in Peru and other low- and middle-income settings.
Phone-based intervention under nurse guidance after stroke: Concept for lowering blood pressure after stroke in Sub-Saharan Africa
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Over the last 4 decades, rates of stroke occurrence in low- and middle-income countries (LMIC) have roughly doubled, whereas they have substantively decreased in high-income countries. Most of these LMIC are in Sub-Saharan Africa (SSA) where the burden of stroke will probably continue to rise over the next few decades because of an ongoing epidemiologic transition. Moreover, SSA is circumstantially distinct: socioeconomic obstacles, cultural barriers, underdiagnosis, uncoordinated care, and shortage of physicians impede the ability of SSA countries to implement cardiovascular disease prevention among people with diabetes mellitus in a timely and sustainable manner. Reducing the burden of stroke in SSA may necessitate an initial emphasis on high-risk individuals motivated to improve their health, multidisciplinary care coordination initiatives with clinical decision support, evidence-based interventions tailored for cultural relevance, task shifting from physicians to nurses and other health providers, use of novel patient-accessible tools, and a multilevel approach that incorporates individual- and system-level components. This article proposes a theory-based integrated blood pressure (BP) self-management intervention called Phone-based Intervention under Nurse Guidance after Stroke (PINGS) that could be tested among hospitalized stroke patients with poorly controlled hypertension encountered in SSA. PINGS would comprise the implementation of nurse-run BP control clinics and administration of health technology (personalized phone text messaging and home telemonitoring), aimed at boosting patient self-efficacy and intrinsic motivation for sustained adherence to antihypertensive medications.
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Le Programme National Nutrition Santé (PNNS), propose des repères nutritionnels visant à améliorer l’état de santé de la population en agissant sur la nutrition. Le pharmacien, de par ses missions, est à même de relayer des conseils nutritionnels basés sur ces repères pour améliorer l’hygiène de vie de ses patients. L’objectif de ce travail est donc d’élaborer des fiches nutritionnelles, que peuvent exploiter les pharmaciens d’officine pour mieux conseiller leurs patients.
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View full text

Positive benefits of a pharmacist-managed hypertension clinic in Nigeria

Summary

Objective

Design and setting

Patients and method

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

Acknowledgements

Lancet

British hypertension society guidelines for hypertension management : summary

BMJ

Health Survey for England

Disease state management: an overview for the managed care pharmacist

Drug Benefit Trends

Managing hypertension with combination diuretics and methyldopa in Nigerian blacks at the primary care level

Clin Drug Invest

Medical Research Council trial of treatment of hypertension in older adults: principal results

BMJ

Alcohol consumption and blood pressure

N Engl J Med

Pharmacoeconomic evaluation of a pharmacist-managed hypertension clinic

Pharmacotherapy

The effect of clinical pharmacy services on patients with essential hypertension

Circulation

Role effectiveness of a pharmacist in the maintenance of patients with hypertension and congestive heart failure

Contemp Pharm Pract