Pharmacists recognise sleep apnea

J Sleep Res. (2015) 24, 167–173

Effectiveness of intervention led by a community pharmacist for improving recognition of sleep apnea in primary care – a cohort study  E N C E P E R R A U D I N 1 , B E R N A R D F L E U R Y 2 and C L EM NATHALIE PELLETIER-FLEURY1 1

Centre de Recherche Médecine, Sciences, Santé, Santé Mentale, Société (CERMES3) INSERM U 988, Villejuif, France and 2Unité de Sommeil, Hôpital Saint Antoine, Hôpitaux Universitaires Est Parisien, Paris, France;

Keywords pharmacy, apnea, screening Correspondence Clémence Perraudin, Centre de Recherche , Santé Mentale, Médecine, Sciences, Sante Société, CNRS UMR 8211, Inserm U988, EHESS, Site CNRS, 7 Rue Guy Môquet, Villejuif Cedex 94801, France. Tel.: +33-149583486; fax: +33-149583485; e-mail: [email protected] Accepted in revised form 20 July 2014; received 15 April 2014 DOI: 10.1111/jsr.12230

SUMMARY

Despite its high prevalence and major public health ramifications, obstructive sleep apnea syndrome (OSAS) remains underdiagnosed. The aim of this study was to determine whether the involvement of a community pharmacist (CP) in the care pathway of a patient at risk of OSAS, through the implementation of a community pharmacist (CP) intervention, was effective, i.e. increased the use of diagnostic tests in this population. We compared a cohort of patients included in a research protocol (exposed to a CP intervention) with patients having the same characteristics taken from a general population database who did not receive the intervention (unexposed group). The aim of the CP intervention was to educate patients about the risk of untreated OSAS, encouraging them to consult their general practitioner, and urging the doctor to continue investigations. We included 782 patients at risk of OSAS, i.e. taking one or more anti-hypertensive drugs, being overweight (body mass index >25) and snoring almost every night (88 in the exposed group and 694 in the unexposed group). After a 6-month followup, the number of patients who underwent an OSAS diagnostic test was significantly higher in the exposed group compared to the unexposed group (22.7 versus 11.4%, P = 0.003). Being exposed to the pharmacist intervention was associated with a higher chance of undergoing a diagnostic test for OSAS, adjusted odds ratio: 2.24 (1.25–4.01). In conclusion, these findings provide arguments for the implementation of a CP OSAS screening intervention in CP routine practice.

INTRODUCTION Obstructive sleep apnea syndrome (OSAS) is a common disease. According to epidemiological studies, the prevalence of OSAS is 5–10% in the general population (Fuhrman et al., 2012; Meslier et al., 2007; Young et al., 2002). The disorder is associated with high morbidity and mortality rates because of cardiovascular diseases and traffic accidents (Giles et al., 2006). When OSAS is left untreated, direct medical costs arise in association with the disease and comorbidities (Smith et al., 2002), as do indirect costs associated with vigilance disorders (i.e. traffic accidents, work accidents, losses in productivity and absenteeism) (Lindberg et al., 2001; Tregear et al., 2010). ª 2014 European Sleep Research Society

OSAS remains largely underdiagnosed. A recent study estimated that only 15% of French patients with evocative symptoms of OSAS were diagnosed (Fuhrman et al., 2012). In the United States, 30–40% of adult patients who visit a primary care physician have a high risk of OSAS, but most patients do not discuss their sleep-related symptoms, and fewer than one-third of high-risk patients have sleep-related symptoms documented in their medical records (Mold et al., 2011). This phenomenon is likely to increase because of difficulties with general practitioner (GP) recruitment and retention in deprived areas (Chapman et al., 2004; Manolakis and Skelton, 2010). In the United States, Canada, Australia and several European countries, the role of the community pharmacist (CP), who traditionally dispenses doctors’ prescriptions, has

167

168

C. Perraudin et al.

changed. Because CPs are easily accessible, they have been developing additional clinical services that integrate the services of and collaborate with other health-care providers, i.e. GPs, nurses, etc. (Anderson, 2000; Santschi et al., 2011; Yuksel et al., 2010). In their daily practice, CPs usually see many patients well known to them, and have access to their medication histories through computerized databases. They are in a privileged position to recognize patients with hypertension at high risk of OSAS and may provide services to help improve OSAS screening (Fuller et al., 2011; Hersberger et al., 2006; Noor et al., 2014; Tran et al., 2009). The World Health Organization has recently stressed the importance of including CPs as active members of multi-disciplinary health-care teams with the aim of improving patients’ health, favoured by their accessibility (WHO, 1997). In France, the ‘Hospital, Patients, Health and Territories’ (HPST) law, adopted in 2009, broadens the role of CPs in providing these services. In this context, our study aimed to assess the feasibility and effectiveness of a CP-led intervention for improving the recognition of OSAS in primary care. We examined whether the involvement of CPs in the care pathway of a patient at risk was effective, i.e. increased the use of diagnostic tests in this population. METHODS We compared a cohort of patients included in a research protocol, exposed to a CP intervention (exposed group), with patients with the same characteristics derived from the ^ te Sante  Protection Sociale [Health Social Protection Enque Survey] (ESPS) (unexposed group). The protocol was approved by a local ethical committee  de Protection des Personnes Ile-de-France V, (Comite number 11838). CP intervention Pharmacists were recruited on a voluntary basis to participate in the research protocol. They were approached during a meeting organized by the Ordre National des Pharmaciens (ONP) in October 2011. Thirty-one pharmacists agreed to participate in five regions of France. For training they all received, by mail, a file containing comprehensive information on OSAS and its risk factors, comorbidities and treatment options. In case of any question regarding OSAS and its management, before and throughout the inclusion period, they were encouraged to contact a sleep specialist by telephone (BF, co-author of the paper). They also received by mail all the documents (leaflets, questionnaires and envelopes) needed to perform the intervention. Volunteer CPs were rewarded €20 per inclusion. Patients at risk of OSAS were recruited at the counter according to the inclusion criteria described below. The recruitment period lasted 3 months, from 1 January to 1 April

2012. Inclusion criteria were: taking one or more antihypertensive drugs, being overweight [body mass index (BMI) ≥ 25] and snoring almost every night. The pretest probability of having OSAS was estimated at 82% in this population (Deutsch et al., 2006; Dingli et al., 2003). Exclusion criteria were: being under OSAS treatment, not having a referent GP, having a long-term illness and not having the capacity to sign an informed consent. CPs were asked to include at least four patients each. Patients were made aware of an OSAS screening campaign currently running in their pharmacy through posters displayed on the window. During visits by regular overweight patients coming to renew their anti-hypertensive prescription, the CP took the opportunity to ask if they snored. The eligible patients were included consecutively. They had to sign an informed consent and data were collected. Anthropometric data were: age (years), gender (male/female) and BMI (kg m2). Sociodemographic characteristics were: level of education (primary/secondary/further education) and employment status (retired/not retired). The medication history of the patients, especially antihypertensive drugs uptake (yes/no), was collected. Evidence has consistently supported the association of OSAS with an increased prevalence of hypertension (Marin et al., 2012). The frequency of snoring was also registered as often or almost every night (yes/no), and an Epworth Sleepiness Scale (ESS) was completed. A detailed brochure, with comments from the CP, was given to patients to inform them about OSAS and its potential consequences if left untreated. The patients could ask any questions. At the end of the interview, given the significant pretest risk of these patients, the pharmacist advised patients to consult their referent GP. A letter to the doctor, signed by the CP, was given to patients. This letter explained that the patient was involved in a protocol (all the data collected were attached to the letter), stressed the need for a GP–CP collaboration and urged the GP to continue investigations for these patients at risk of OSAS. Patients were monitored by the CP for 6 months. The CPs were to call the patients at 1, 3 and 6 months to ask: • if (s)he had consulted his/her GP; • if (s)he had given the letter (and the attached data) to his/ her GP; • if the GP had referred him/her to a sleep specialist for a diagnostic test; and • if (s)he had performed a diagnostic test; if so, what were the test results? The patient was considered to have completed the study: • if the diagnosis of OSAS was confirmed or not after a diagnostic test; • if (s)he had given the letter (and the attached data) to his/ her GP but was not referred to a sleep specialist; • if (s)he had declined to consult the sleep specialist; and • if (s)he had decided not to give the letter (and the attached data) to his/her GP. ª 2014 European Sleep Research Society

A pharmacist-led screening intervention for OSAS Selection of patients in the unexposed group The patients in the unexposed group were selected from the ESPS, which is a panel survey conducted by the French Institute for Research and Information in Health Economics (IRDES) (http://www.irdes.fr/recherche/enquetes/esps-enquete-sur-la-sante-et-la-protection-sociale/actualites.html) every two years. The ESPS is based on a representative sample of the French general population. This survey collects information on individuals’ health status, access to healthcare services, health insurance and economic and social status. The survey combines telephone or face-to-face interviews and self-administered questionnaires. As a first step, households are contacted by telephone to identify a key respondent to answer the core questionnaire, which includes questions regarding the composition and incomes of the household and the educational level of each household member. As a second step, a self-administered health questionnaire, which includes self-reported morbidity assessment through a list of approximately 50 diseases, is sent to each participant. The aim of ESPS is to provide a detailed picture of state of health, health-care utilization and level of health insurance. In 2008, questions concerning sleep disorders were included for people aged 16 years or older. In our study, the unexposed group consisted of all patients derived from the ESPS with our inclusion criteria (see above). They were identified by the following questions:

Figure 1. Flow chart of patients participating in the intervention. ª 2014 European Sleep Research Society

169

• Do you snore (no, rarely, often, almost every night, do not know)? [required answer: often or almost every night]; • What are your height and weight? [required answer: their BMI to be 25 kg m² or more]; • Do you currently have illness or health problem(s)? If yes, have you been treated in the past 12 months? [required answer: hypertension treated]. For eligible patients, age (years), gender (male/female), level of education (primary/secondary/further education), employment status (retired/not retired) and ESS were also collected.

Outcome measures The outcome measure was the proportion of patients who underwent an OSAS diagnostic test. In the unexposed group, in ESPS, they were identified by the following question: ‘have you ever had a sleep recording performed at the hospital or at home?’ [required answer: yes]. The participating CPs also completed a final questionnaire in order to record their characteristics, gender (male/female), length of practice (in years); those of their pharmacy, location (urban/rural area); size (number of people authorized to dispense drugs within the pharmacy); their opinions of the profession and their relationship with GPs (degree of satisfaction); and about the usefulness of the intervention. Throughout the study, regular contacts allowed information

170

C. Perraudin et al.

Table 1 Comparison of patients’ characteristics between exposed and unexposed groups

Characteristics Women Age* (mean  SD in years) BMI* (mean  SD in kg m2) Educational level Primary school Secondary and higher education >Higher education Employment status (retired) Epworth score Higher education Employment status Not retired Retired Epworth score

Effectiveness of intervention led by a community pharmacist for improving recognition of sleep apnea in primary care--a cohort study.

Despite its high prevalence and major public health ramifications, obstructive sleep apnea syndrome (OSAS) remains underdiagnosed. The aim of this stu...
101KB Sizes 0 Downloads 5 Views