Couzos, S., Smith, D., Buttner, P, and Biros, E. (2020) Integrated pharmacists in ACCHSs- Analysis of the assessment of clinical endpoints in Aboriginal and Torres Strait Islander patients with chronic disease (IPAC Project). External Commissioned Report. Australian Government, Canberra, ACT, Australia.

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Abstract

Objective: To assess the effect of integrated pharmacist interventions on intermediate clinical endpoints in Aboriginal and Torres Strait Islander adults with chronic disease attending Aboriginal Community Controlled Health Services (ACCHSs) compared with usual care (pre-intervention).

Design and participants: The study was a non-randomised, prospective, pre and post quasi-experimental community-based, participatory, and pragmatic trial that integrated a registered pharmacist within an ACCHS located in Queensland, the Northern Territory or Victoria. The intervention comprised non-dispensing medicines-related services, collaborative and coordinated care, including the provision of medication management reviews. Participants were usual patients of the ACCHSs aged 18 years or older with a chronic disease. Participants consented to receive the intervention and were followed for up to 15 months.

Outcome measures: De-identified participant data was electronically extracted from health records. Biomedical outcome measures comprised HbA1c in participants with Type 2 diabetes mellitus (T2DM), and systolic and diastolic blood pressure (SBP and DBP), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (LDL-C), triglycerides (TG), estimated glomerular filtration rate (e-GFR), albumincreatinine ratio (ACR), and absolute primary cardiovascular disease risk (CVD risk) for all participants.

Statistical analysis: The following differences were calculated for paired measurements: (1) for HbA1c and ACR: the differences between the most recent observation in the 12 months prior to enrolment and the final observation during follow-up; (2) for SBP, DBP, TC, LDL-C, HDL-C, TG, ACR: the differences in the mean baseline values (12-month pre-intervention period representing usual care) from the mean follow-up value; (3) for e-GFR: mean annualised e-GFR difference as the most recent e-GFR value 12 months pre-enrolment and at end of study divided by follow-up time between assessments; (4) and for the absolute CVD 5-year risk according to the Framingham risk equation for those not at high risk according to clinical criteria: the difference between assessment at enrolment and at the end of the study.

Differences for all outcome measures except for e-GFR were statistically compared against zero using clusteradjusted (ACCHS) regression analyses techniques. For e-GFR, annualised differences were statistically compared against -3 (ml/min/1.73 m2) a theoretically assumed value, using cluster-adjusted (ACCHS) regression analyses techniques. The effects of participant, health service, and intervention characteristics on differences of outcome measures were examined, including the influence of Home Medicines Review and other comprehensive reviews, using cluster (ACCHS) and length of follow-up time adjusted regression analyses.

Results: Participants (n=1,456) from 18 ACCHSs involving 26 integrated pharmacists were followed-up for a median of 285 (IQR: 219-352) days. At baseline, the mean age of participants within clinical endpoint groups defined by the availability of outcome measures stated above, ranged from 57- 58 years, and most (91-94%) were Aboriginal and/or Torres Strait Islander, 65 to 76% attended health services located in inner and outer regional locations, 59% to 75.4% had T2DM, and 87.5% to 90.2% had co-morbidity. Of the participants with data available for analysis, mean baseline HbA1c was 8.3% (n=539), mean SBP was 133 (n=1,103) with mean DBP of 80 mmHg (n=1,045), dyslipidaemia only pertained to elevated mean triglycerides (2.39 mmol/L, n=730), mean eGFR was consistent with Stage 3A of CKD (49.1 ml/min/1.73m2, n=895), mean ACR levels were consistent with overt albuminuria (57.9 mg/mmol, n=475), mean BMI was 32.4 (n=991), with moderate CVD risk (10% to <15%, n=38).

There was a significant improvement in HbA1c in participants with T2DM, with a 2.8 mmol/mol or 0.3% (unit) reduction (p=0.001, 95% CI -0.4% to -0.1%). Significant reductions in diastolic BP (-0.8mmHg, p=0.008), total cholesterol (-0.15 mmol/L, p<0.001), LDL-C (-0.08 mmol/L, p=0.001), and triglyceride levels (-0.11 mmol/L, p=0.006) were observed for the entire participant collective. The mean calculated absolute 5-year CVD risk was significantly reduced by 1% (95% CI: -1.8% to -0.12%, p=0.027). The mean annual eGFR significantly improved with an increase of 1.9mL/min/1.73m2 (95% CI: 0.1 to 3.7) from baseline (p<0.001). When participants with less than 6-months of follow-up were excluded, the mean annual eGFR decline was -0.2 ml/min/1.73m2 (95% CI:-2.99 to 2.7), significantly less than the predicted decline of -3 (p=0.034, n=720). SBP significantly improved only for younger participants (<57 years, -1.8 mmHg, SD: 12.5, p=0.004).There were no net improvements in HDL-C. ACR stabilised with a mean difference of 3.8 mg/mmol (95%CI: -6.3 to 13.8,p=0.42).No differential impact on clinical endpoints was identified by the type of medication management review (p>0.05).

Conclusion: Integrated pharmacists embedded into usual care in a range of geographical settings, can significantly improve the control of CVD risk factors, glycaemic control in patients with T2DM, and reduce absolute CVD risk in Aboriginal and Torres Strait islander adults with chronic disease. This evaluation supports the integration of non-dispensing pharmacists within ACCHS settings more broadly.

Item ID:	87124
Item Type:	Report (External Commissioned Report)
Keywords:	Medication adherence, diabetes, chronic disease, Aboriginal health, primary health care, pharmacist, pharmacy, integrated care, prevention
Additional Information:	Report to the Pharmaceutical Society of Australia for the IPAC Project. This report is publicly available at the following website: https://www.health.gov.au/resources/publications/integrating-practice-pharmacists-into-aboriginal-community-controlled-health-services-final-report
Funders:	Australian Government Department of Health & Ageing
Projects and Grants:	Pharmacy Trials Program
Date Deposited:	03 Oct 2025 05:04
FoR Codes:	42 HEALTH SCIENCES > 4203 Health services and systems > 420319 Primary health care @ 50% 32 BIOMEDICAL AND CLINICAL SCIENCES > 3214 Pharmacology and pharmaceutical sciences > 321403 Clinical pharmacy and pharmacy practice @ 50%
SEO Codes:	20 HEALTH > 2001 Clinical health > 200105 Treatment of human diseases and conditions @ 100%
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