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THE rule of halves applies in Australia. Half of those with high blood pressure are not aware of it, half of those who are aware of it are not at optimal blood pressure levels.
For every Australian known to have diabetes there is another with impaired glucose tolerance who is also at risk of complications. We can and should do better, but how?
We are better than most countries at opportunistic screening for cardiovascular risk factors in general practice and, on average, Australians visit a GP several times a year.
But this disguises the fact that many average Australians never visit a doctor. To reach those with undiagnosed modifiable risk factors we need to cast the net beyond the general practice clinic.
A recent campaign by pharmacies in Portugal to encourage customers to have their blood pressure and cholesterol measured in-store found almost half who participated had a high risk of developing a fatal cardiovascular event in the next 10 years. Could health testing in Australian pharmacies be the way to break the rule of halves?
Pharmacists are trusted as a reliable source of health information. They are trained in health and disease, arguably underutilised and capable of doing far more than labelling medication boxes.
Pharmacies are everywhere in urban and regional settings. Cardiovascular risk evaluation in pharmacies is amenable to guideline-based decision support.
There is no doubt that pharmacy testing could be part of the answer. Many Australian pharmacies already offer blood pressure testing and other services.
Ideally, screening for cardiovascular risk factors should target the right people. It should be cost-effective and provide users with a diagnosis as well as a solution by integrating them with the mainstream health system.
The “right people” are more likely to be disadvantaged, rural and remote dwellers, or employed middle-aged blue-collar men.
But the cost-effectiveness of such a venture depends not just on accurate targeting but the level of screening provided and the outcomes that occur. For example, a simple validated questionnaire such as the AusDrisk, developed in the course of the AusDiab study, provides a high yield of people with previously undiagnosed diabetes.
But there are some worrying aspects of pharmacy testing.
Absolute risk assessment, now recommended for all adult Australians, requires blood pressure and cholesterol testing among other things. The former requires a quiet, familiar setting, with evidence of overdiagnosis of hypertension when done in shopping centres.
Public screening also attracts the “worried well” who may not need testing or may present for screening too often, reducing the efficiency of the service in identifying new cases.
More importantly, the most likely advice a pharmacist will give on identifying an individual apparently at high risk is to “go and see your doctor”.
Our experience is that people respond to this advice in one of three ways. Some follow the recommendation sooner or later, some try their own measures to address the problem whether informed or ill informed, and some deny that a problem exists.
The key to effective risk reduction is to provide an immediate solution. Risk screening without risk reduction can be worse than none at all.
It is feasible, though time consuming, for a pharmacist to provide the counselling on lifestyle and other proven measures for risk reduction and make the follow-up appointments with a GP.
The pharmacist also needs to avoid the temptation to recommend the many products sold in pharmacies that are not evidence-based, will not and cannot achieve the claims to reduce weight, normalise cholesterol, or whatever. In fact, I think these products should be removed from pharmacy shelves, but that is a matter for the regulators.
Regulation is another consideration. It is not easy to provide pathology services out of the laboratory environment and meet regulatory requirements.
Medicolegal issues also need to be taken into account. Risk evaluation is never black or white. Eventually, there will be someone who, soon after being reassured by a healthy result, will die of a heart attack during strenuous exertion.
The Portuguese experience was short-term and went no way towards answering these and many other questions.
We need to break the rule of halves but in a considered manner, not just doing things because we can but because they work.
Pharmacy testing in Australia is worth a trial.
Professor Garry Jennings is the director of the Baker IDI Diabetes and Heart Institute.
Posted 23 July 2012
I support Gary Jennings’s caution about the proposal. Readers may also be interested in considering their views about this proposed study below, in which pharmacists would perform ECGs for asymtpomatic patients and send those ECGs to cardiologists:
“Screening Education And Recognition in Community Pharmacies of Atrial Fibrillation to prevent stroke in an ambulant population aged ≥65 years (SEARCH-AF stroke prevention study): a cross-sectional study protocol”.
The full text is viewable at: http://tiny.cc/qmwngw
The above is a well balanced assessment of the value of pharmacies as places for well person screening for hidden chronic disease states. I support a trial but only if it is known to lead to a more substantial outcome if successful.
It would be the opportunity to leverage a change in the way pharmacies are utilized by government to deliver health services through the establishment of a PharmaCare Agency that is accredited to provide such services and receives a fee for doing it. Like medical practice the base fee would be the minimum remuneration.
And yes they could dispense PBS medicines too.
The present process of granting an Approval Number to EVERY pharmacy that was in business in 1990 with no follow up on efficiency, effectiveness or intent to improve health outcomes has made a mockery of the “approval” process.
For mine ALL pharmacies should have to reapply for an “Approval” that would require them to provide a certain range of services for which they would be paid an amount determined by an INDEPENDENT agency (e.g PharmaCare). The holder of the approved Agency would be required to have studied an additional range of subjects and have obtained some post graduate qualification in order to safely carry out the new responsibilities that are on offer with a PharmaCare Approval.
The days of dispensing PBS as a right must go and responsibility to carry out health promoting functions put in its place.
It might also be the opportunity to consider alternative outlets to be PharmaCare Agencies and break the pharmacist owned monopoly on a pharmacy business. There is no reason why multi purpose health centers, primary health care facilities, GP Super Clinics or Aboriginal health services and other retailers such as supermarkets should not be allowed to bid for a PharmaCare Agency if they meet the criteria.
In this way pharmacists could be fully utilized as a significant contributor to primary health care and not just the ones who put labels on boxes.
The improved income from such a positive change may mean there is not the same incentive to maximize turnover by stocking sham products with no evidence base.
I was not aware of the Portuguese work but certainly know that pharmacists in Australia would welcome a shift in emphasis to a more clinical role. It may not suit the hard nosed profit makers but that is too bad – health of the consumer should always come before pharmacists’ wealth.
It is over 25 years since there was an assessment of the retail pharmacy industry and surely it is timely for something to happen now. It is cruel that consumers are asked to pay $11 in fees for the dispensing of a product that costs $3 – as is the case in a commonly prescribed beta blocker. This would be the time to bring in a fee for service and rid the system of all the individual components of the overall fee with no one really knowing what they are paying for and why.