The Pharmaceutical Needs of Patients - Literature review Example

?What are the pharmaceutical needs of patients who have recently been discharged following a stroke or TIA (transient ischaemic attack)? Does medicine support benefit these patients? A Literature Review submitted in part fulfilment of the requirements for the award of an MPharm Honours Degree in Pharmacy February 2013 “I certify that this work has not been accepted in substance for any degree, and is not concurrently being submitted for any degree other than that of the MPharm Honours Degree in Pharmacy. I also declare that this work is my own except where otherwise identified by references and that I have not plagiarised another’s work”. CONTENTS 1: Introduction… 4 2: Overview of Patient Pharmaceutical Needs…………………….. 5 3: Overview of Medicine Support…………………….. 7 4: Research Evaluation…………………….. 7 4.1. Literature Search Process………………………………..………………7. 4.2. Critical Appraisal of Literature…………………………………………..9 5: Summary……………………… 12 6: List of References……………………… 13 1. INTRODUCTION 1.1. Background to the Study Within the UK, it is estimated that 150,000 people experience a stroke every year. Currently there are nearly 1.2 million stroke survivors; almost half of these people have been left with long-term disabilities. Strokes and transient ischemic attacks (abbreviated as TIAs) are acute neurological events, believed to be vascular in origin, caused by cerebral ischemia, as well as cerebral infarction, or cerebral haemorrhage (NHS, 2013). The difference between a stroke and a TIA is that with a stroke, the symptoms normally resolve beyond 24 hours or cause death within 24 hours. TIA’s symptoms typically resolve within minutes or could last a few hours. Initially, both a stroke and TIA are managed immediately in hospital and are then likely to need continued medical treatment and support. Recommended pharmaceutical management post discharge falls into three main drug categories; Antihypertensive, Antithrombotic and Lipid-modifying drugs. 1.2. Research Aim Several studies have been conducted that discuss the potential benefits of these medications and whether or not they aid in the long-term management of patients. The aim of this literature review is to identify whether or not pharmaceutical management of stroke or TIA patients support patients in their recovery and reduces the risk of a secondary attack. 2. OVERVIEW OF PATIENT PHARMACEUTICAL NEEDS While stroke remains one of the major causes of lethal outcomes for Europeans and the key cause of disability among the old, the needs of patients who have experienced a stroke or TIA are of primary concern. Research shows that following the stroke or TIA, patients’ life quality worsens. They typically develop disease related symptoms, which means overall deterioration of physical condition. Their functional health suffers, too, since people who have recently had a stroke or TIA may be restricted in self-care, possibility to return to doing the works they used to perform before the stroke or TIA, as well as mobility. Overall, their functional health weakens (Hohmann, Radziwill, Klotz, and Jacob, 2010). Psychologically, these people may experience some peculiar feelings or emotions, and form subjective opinions about their conditions. Finally, the social dimension of their needs includes changes in perception and need of social, especially family, contacts (Hohmann, Radziwill, Klotz, and Jacob, 2010). It emerges from the available sources that patients with stroke suffer from high blood pressure (concerns patients with all kinds of strokes), high levels of cholesterol (patients who experienced the ischemic stroke), and cognitive impairment (which may even be as severe as the loss of memory). These health conditions are reported to increase the risk of the stroke reoccurrence which may be the cause of death or a severe physical disability (Chambers, O’Carroll, Hamilton, Whittaker, Johnston, Sudlow, and Dennis, 2011). To date, the needs of patients who survived the stroke have been associated with special medical services aimed at reducing or removing the foregoing conditions. In particular, multiple medications are prescribed to lessen the cholesterol level in blood, lowering blood pressure, and diminishing the likelihood of a recurrent stroke (Chambers, O’Carroll, Hamilton, Whittaker, Johnston, Sudlow, and Dennis, 2011). It has been revealed that failure to adhere to medication in the period that follows up the stroke and lasts for 1 year leads to increased risk of mortality and recurring vascular events (Chambers, O’Carroll, Hamilton, Whittaker, Johnston, Sudlow, and Dennis, 2011). Another study identifies stroke patients as high risk patients under the threat of recurrent stroke which is more severe in patients with hypertension, diabetes mellitus, as well as hyper-lipidemia (Chun-Chi, Chiu, Shing-Sheng Wu, Ping-Yi Lee, Yu-Ching Huang, Teng-Yeow Tan, and Ku-Chou Chang, 2008). Hypertension, in its turn, has been found the key modifiable risk factor for people who suffer from cardiovascular diseases, and respectively those who experienced a stroke or TIA. Individuals are diagnosed with hypertension once “the average of two or more diastolic blood pressure (BP) measurements on at least two subsequent visits is more than 90 mm Hg or when the average of multiple systolic BP readings in two or more subsequent visits is consistently more than 140 mm Hg” (Hohmann, Radziwill, Klotz, and Jacob, 2010). Hyper-lipidemia and diabetes mellitus are considered modifiable risk factors, as well. Hyper-lipidemia refers to “abnormal plazma lipid status.” It embraces heightened levels of overall cholesterol, lipoprotein (a), triglyceride, and LDL cholesterol (abbreviation from “low-density lipoprotein”), along with low levels of HDL lipoprotein (abbreviation from “high-density lipoprotein”) (Hohmann, Radziwill, Klotz, and Jacob, 2010). Diabetes mellitus, or DM, refers to a group of diseases related to metabolism. It is a disease with chronic hyperglycemia that is a result of defects found in insulin secretion, insulin action, or even both (Hohmann, Radziwill, Klotz, and Jacob, 2010). Finally, patients may suffer from drug-related problems which come as result of prior medical (pharmaceutical) interventions. In this case, the patient needs to have this condition detected and evaluated by a clinical pharmacist. 3. OVERVIEW OF MEDICINE SUPPORT Based on identified patients’ needs to combat the stroke outcomes, regain normal bodily and psychological functions, and prevent the possible reoccurrence of the stroke or TIA, adherence to medication has been strongly recommended. In particular, the study by O’Carroll, Whittaker, Hamilton, Johnston, Sudlow, and Dennis (2011), on the basis of secondary research, asserts that adherence to post stroke medication therapy is the key determinant of successful treatment. On the contrary, poor adherence to prescribed medications hampers the overall quality of medical interventions and reduces their overall quality (O’Carroll, Whittaker, Hamilton, Johnston, Sudlow, and Dennis, 2011). As for pharmaceutical care of patients with a stroke or TIA, it is generally delivered within three major sections: In hospital (patients are given medications, prescribed by the clinical pharmacist) Seamless care (detailed care plan from the clinical pharmacist, which is related to patient treatment, is passed to the general practitioner, community pharmacist, or to the rehabilitation clinic upon the patient’s discharge) In ambulatory conditions (pharmaceutical care is continued in an ambulatory setting for a lengthy period, e.g. 12 months) (Hohmann, Radziwill, Klotz, and Jacob, 2010). 4. RESEARCH EVALUATION In order to determine whether patients who experienced the stroke or TIA will benefit from pharmaceutical interventions and medicine support upon discharge from the hospital, the critical appraisal of the selected peer-reviewed sources has been conducted. 4.1. Literature Search Process Below one may find tables that represent the medical resources databases with those keywords that were utilized to locate peer-reviewed scholarly articles and peer-reviewed medical journals, which constitute the source base of this literature review. Since post stroke care involves a range of medical activities, most notably diagnostic and therapeutic activities, during the search the focus was maintained on a narrow topic of pharmaceutical needs of patients who survived a stroke or TIA, as well as on effectiveness of the medicines support. The search options were modified to include only the studies published within 5 years: date range between 2008 and 2013. Databases Bio-Med Central PubMed® CINAHL from EBSCO PsycArticles Keywords Post stroke medical treatment Stroke patients Stroke patient needs Adherence to medicines Alternative medicines Rehabilitation Ischemic stroke Discharged from the hospital Adherence TIA Pharmaceutical interventions Drug therapy Effective medicines Randomized study Prevention of recurrent stroke 4.2. Critical Appraisal of Literature Based on the aim of critical evaluation of existing sources on the issue of patient pharmaceutical needs after their discharge following the stroke or TIA, certain criteria were located for objective appraisal. First of all, articles were examined in terms of the relevance of the study objective to the question that is being researched. Next, the data collection and data analysis methods were been considered. Further, the sample was taken into account as one of the key determinants of the study validity. Also, it was checked whether the conclusions are adequately supported by research data. Finally, it has been decided whether the findings are clinically relevant. Before the critical review of the articles selected for the literature review, let it be said that the focus is on two major thematic points: 1) pharmaceutical needs of post stroke patients (discharged from the hospital) and 2) the question whether the medicine support will benefit these patients. The first issue of pharmaceutical needs of post stroke patients who have been discharged from hospital care may be resolved by considering the findings of the study “Health-related quality of life after ischemic stroke: The impact of pharmaceutical interventions on drug therapy (Pharmaceutical Care Concept)” conducted by Hohmann, Radziwill, Klotz, and Jacob (2010). In particular, the study identifies post stroke patient needs in terms of their health condition improvement. Specifically, different levels of patient functioning are included (deterioration of physical condition, restrictions of self-care and movement, psychological distress, loss of memory, and social alienation) (Hohmann, Radziwill, Klotz, and Jacob, 2010). Also, major risk factors for such patients are clarified and described (including diabetes mellitus, hyper-lipidemia, and hypertension). As for the second issue (whether the pharmaceutical support is beneficial for patients discharged from the hospital some time after a stroke), evidence is provided that lengthy adherence to medication will bring positive outcomes and lower the chances of morbidity or recurrent stroke (Hohmann, Radziwill, Klotz, and Jacob, 2010). Now critical evaluation needs to be done to confirm the validity of the research findings published by Hohmann, Radziwill, Klotz, and Jacob (2010). Careful examination has led to the following conclusions. The research is an inferential study that uses statistics and data sample to prove the hypothesis that medicine support benefits stroke patients after they have been discharged from hospital. Study sample of 255 participants was selected on the basis of exclusion criteria and grounded on medical records. No randomization or blinding was possible, which makes up the study’s limitation (Control study without randomization, Type of Evidence 2-a). Another limitation was that some patients dropped within 1 year period. The study is generally unbiased, with the involvement of general practitioners who were not aware of the trial. This means exclusion of bias in data collection. However, the study was funded by external sources. Data measurement has been accurate with complex SPPSS analysis, which speaks in favour of this study’s validity. On balance, the study is valid and its results may be applied to a wider clinical context. It confirms the benefit of pharmaceutical support for the selected group of patients. As for the study by O’Carroll, R., Whittaker, J., Hamilton, B., Johnston, M., Sudlow, C. and Dennis, M. “Predictors of Adherence to Secondary Preventive Medication in Stroke Patients”, it has provided important data that explain high and low levels of adherence to medication among the patients of the given type. The article is based on the premise that medication adherence is inherently beneficial. Therefore, it can inform the current research only partially. In particular, the evidence of the Level 3 (expert opinion, conclusions on the basis of other studies) is in favour of medication use in patients following the stroke. As for the overall study validity, it is limited by the absence of randomization. Yet, the combination of qualitative and quantitative methods, and a large sample make the study quite valid. Next, the study by Chambers, O’Carroll, Hamilton, Whittaker., Johnston, Sudlow, and Dennis “Adherence to medication in stroke survivors: A qualitative comparison of low and high adherer” (2011) aimed at explanation of factors that explain adherence variances in use of medicines among stroke patients. This is a descriptive qualitative study based on patients’ self-reporting and interviews. While it embraces quite a large sample of 180 participants, it does not provide genuine evidence as to our research question. Similarly to the previous study, it only provides an expert opinion and conclusions on the ground of other studies to state that medicine intake has positive outcomes in stroke patients after they discharge from the hospital. Finally, the study by Chun-Chi, Chiu, Shing-Sheng Wu, Ping-Yi Lee, Yu-Ching Huang, Teng-Yeow Tan, and Ku-Chou Chang (2008) directly informs our research question. It provides evidence that pharmacist intervention has value in improvement of health conditions in outpatients who experienced stroke and are subject to hypertension and hyper-lipidemia. The study is highly valid due to its use of randomized control trial. The latter along with carefully chosen methods of data analysis compensates for any limitations (relatively small sample size and relatively short duration). Importantly, the researchers managed to prove that medication intake (i.e. pharmaceutical care) benefits the patients who have high levels of hypertension (improvement of BP control) and hyper-lipidemia (lipid levels reduced). Thus, this study is highly relevant and its findings may be generalized to a bigger population. 4. SUMMARY In summary, the pharmaceutical needs of those patients who experienced a stroke or TIA and discharged from the hospital are dependent on the quality of their conditions. Such patients suffer from a range of impairments including worsened bodily functions, impaired movement ability, loss of memory, and psychological detachment . Besides, they are at the risk of experiencing a recurrent stroke. Two of the four selected studies have provided valid evidence that such patients will benefit from pharmaceutical care throughout 1 year after the stroke. In particular, patients’ morbidity risk reduces, as well as the risk of the recurrent stroke. Moreover, patients with hypertension and hyper-lipidemia significantly improve their risk levels due to medicine support over the same period. 6.LIST OF REFERENCES Adamson, J., Beswick, A., & Ebrahim, S. 2004, Stroke and disability. Journal of Stroke and Cerebrovascular Diseases, 13: 171–177 Hohmann et al. 2010, Health-related quality of life after ischemic stroke: The impact of pharmaceutical interventions on drug therapy (Pharmaceutical Care Concept) Health and Quality of Life Outcomes, 2010, 8:59 Chambers, J., O’Carroll, R., Hamilton,B., Whittaker,J., Johnston, R., Sudlow, C., and Dennis, M. 2011, Adherence to medication in stroke survivors: A qualitative comparison of low and high adherer. British Journal of Health Psychology, 16: 592-609. Chun-Chi, Chiu, Shing-Sheng Wu, Ping-Yi Lee, Yu-Ching Huang, Teng-Yeow Tan, and Ku-Chou Chang 2008, Control of modifiable risk factors in ischemic stroke outpatients by pharmacist intervention: an equal allocation stratified randomized study. Journal of Clinical Pharmacy and Therapeutics, 33: 529-535. Hohmann et al. 2010, Health-related quality of life after ischemic stroke: The impact of pharmaceutical interventions on drug therapy (Pharmaceutical Care Concept) Health and Quality of Life Outcomes, 2010, 8:59 National Health Service 2013, Stroke, viewed 13 Feb 2013, . O’Carroll, R., Whittaker, J., Hamilton, B., Johnston, M., Sudlow, C. and Dennis, M. 2011, Predictors of Adherence to Secondary Preventive Medication in Stroke Patients. Ann Behav Med, 41: 383-390. Read More