Plaque psoriasis is a chronic inflammatory skin condition that is thought to affect up to 3% of the UK population. Though not life threatening, psoriasis is associated with a significant impairment of quality of life and emotional well-being. Most people with plaque psoriasis have a mild to moderate disease that can be managed with topical therapies in primary care. Nevertheless, adherence to topical regimes is often poor and research suggests that many patients want, but rarely receive, sufficient advice on how to use topical therapies. Consequently, people sub optimally manage their condition due to the absence of adequate advice on treatments.
In guidance from NICE it was recommended that healthcare practitioners offer support and information tailored to individual needs so that patients understand “how to use prescribed treatments safely and effectively and how to minimise the risk of side-effects through safe monitoring of medicines”. Given the constraints on time in primary care, who is best placed to provide this support?
In recent years, the role of pharmacists has changed to become more patient-centred. Examples of this include government-funded enhanced roles to support patients, for instance, medicines use reviews, and the new medicine service, both of which are designed to help patients use medicines more effectively. Indeed, a white paper, ‘Pharmacy in England’, lent support to this role by suggesting that “pharmacies expand and improve the range of clinical services they offer to people, in particular, to those with long-term conditions – through routine monitoring, screening and support in making the best use of their medicines”.
The fact that patients regularly visit pharmacies to collect their prescriptions makes them ideally placed to support those with psoriasis.
The perceived lack of support among patients, coupled with pharmacists’ emerging clinical role, provided the impetus to develop a study to explore the extent to which patients might benefit from pharmacists’ support. The Psoriasis and Psoriatic Arthritis Alliance (PAPA) provided a small research grant to fund the study and the research question we asked was: “Is it feasible for community pharmacists to deliver an educational programme designed to help people with psoriasis self-manage as effectively as possible?”
We wanted to ensure that participating pharmacists were familiar with the research process and made it a requirement that all had completed GCP (good clinical practice) training. Pharmacists recruited patients either opportunistically when presenting at the pharmacy with prescriptions for topical treatments for psoriasis, or through a search of the pharmacy medication record system and contacting the patients directly.
The plan was for pharmacists to hold an initial consultation with patients and arrange for a followup appointment after six weeks. This timeframe was felt to be sufficient to see an impact of any advice or information provided. In their consultations, pharmacists used the PEDESI (person-centred dermatology self-care index) tool that involves a series of 10 questions. The tool provides a structure for the consultation, allowing pharmacists to ask the questions, assess the patient’s understanding of their condition and its management, as well as providing the opportunity to offer educational advice to improve their level of knowledge. PEDESI scores range from 0 to 30, with higher scores reflecting an increase in knowledge. In addition, patients selfcompleted a SAPASI (self-administered psoriasis and area severity score) to provide some measure of their disease severity, and the DLQI (dermatology quality of life index) to assess the impact on quality of life. In contrast to the PEDESI scores, both SAPASI and DLQI values increase as disease severity and quality of life worsen. The outcome measures were simply changes in the three tools, PEDESI, SAPASI and DLQI at six weeks. Leaflets produced by PAPPA were available for patients to supplement any verbal advice given to them.
One of the first challenges was to recruit pharmacists. We worked with the clinical research networks (CRNs) to identify pharmacists with an interest in undertaking research, but there were few of them. Finally, we found a group of pharmacists in the South West willing to participate and three in the Humberside area. However, this took a long time and the sponsor was wanting to call a halt to the study since the process took over 16 months.
What we found
Perhaps the most interesting result was that simply offering appropriate advice to patients led to statistically significant improvements in the outcome measures as shown in Figure 1. The take-home message was very clear; transfer of knowledge from pharmacists to patients improved understanding (increased PEDESI scores) and led to significant reductions in disease severity (and thus improved quality of life).
We undertook telephone interviews with 38 of the patients (we were unable to make contact with any of the others) and asked to rate their level of agreement with several statements connected to the pharmacist consultation (see Table 1). The statements used a five item Likert-scale ranging from strongly agree to strongly disagree, and patients were asked to rate their level of agreement to each statement. Note that in Table 1, the penultimate statement has reverse scoring, i.e., a lower score indicating that patients were NOT dissatisfied with the consultation.
What did patients like about the study?
As shown in Figure 2, just over half of the patients stated that they gained a better knowledge and understanding of their condition, and a third appreciated the fact that someone was prepared to talk to them about their condition.
Finally, as shown in Figure 3, responses to the question ‘Do you think your psoriasis improved as a result of the pharmacist’s advice?’ suggested the vast majority believed that the pharmacist’s input had helped their condition.
'The perceived lack of support among patients, coupled with pharmacists’ emerging clinical role, provided the impetus to develop a study'
What did the pharmacists think?
Semi-structured interviews with the pharmacists identified several key themes, perhaps the most important of which was the notion that they saw themselves as team members, caring for those with psoriasis and taking a proactive approach to treatment. This was illustrated by one pharmacist who said: “I took the responsibility to contact their prescriber and gave a few suggestions of emollients that they could prescribe and quantities that I would be expecting them to use. And the local prescribers did what I’d asked them, which was really empowering. And I think they really appreciated it.”
A common thread among interviewees was how little patients appeared to know about their condition and how it should be managed as summed up by one pharmacist.
“A lot of them [patients] had got the creams and didn’t understand how best to use them, in which order, how much, how often, that kind of thing. They don’t understand that you can use it once or twice a day. We gave that education in getting the best out of it [treatment] without having to go back to the GP.”
Putting it all together
What does the study reveal about the role of pharmacists in psoriasis?
The clear message is that they have a potentially important role to play in supporting patients with psoriasis. Most GPs simply don’t have sufficient time with patients, leading to high levels of dissatisfaction for both parties. Nevertheless, ensuring that patients receive appropriate support and advice to allow optimal use of treatments can be delegated to community pharmacists. This has the potential to improve self-care and reduce re-consultation rates. The pharmacists who participated in the study seemed happy to embrace this role and their added value in caring for those with psoriasis should not be underestimated.
1. https://www.gov.uk/government/publications/pharmacy-inengland-building-on-strengths-delivering-the-future [Last accessed June 2017]
Dr Rod Tucker Pharmacist with Special Interest in Dermatology