Supply and administration of denosumab for patients with osteoporosis in primary care - a qualitative study to explore the potential for pharmacy practice development

Abstract

BACKGROUND: Denosumab is a medication for postmenopausal osteoporosis delivered as a subcutaneous injection. Within the National Health Service (NHS) Lothian, Scotland, the treatment is currently administered in a hospital setting. Feedback from patients and staff indicate that the drug could most likely be delivered in a community setting, which is in accordance with Scottish Government policy emphasising a need for local patient care. “Shared care”, which is a mixed model where the hospital and General Practitioners (GPs) share patient responsibility, was not approved by NHS Lothian committees. Consequently, other alternatives for local patient care have been explored. One of the ideas has been to involve community pharmacies in a “shared care” model with hospitals, offering the administration of denosumab.

AIM: To investigate the potential for community pharmacists to deliver a pharmaceutical care package for the management of osteoporosis that includes the supply and administration of denosumab, a medication review and an assessment of falls risk and the need for calcium and vitamin D.

METHODS: The current patient journey was defined from literature review and feedback from hospital specialists. The identified pathway formed basis for eleven semi-structured interviews, exploring opinions of three patients, one community pharmacist, one hospital pharmacist, one GP, two nurses and three hospital physicians on the existing patient journey and potential improvements. Information acquired from the interviews informed the design of questionnaires that were distributed to 114 patients, 182 community pharmacies and 500 GPs. Recommendations for a novel pharmaceutical care package as a part of a new patient journey was based on three elements; 1) data collected from the semi-structured interviews, 2) questionnaire responses and 3) the existing legal framework. Finally, the proposed patient journey, including the novel pharmaceutical care package was presented for feedback at the hospital multidisciplinary rheumatology meeting.

RESULTS: From the interviews, 4 main themes and 13 subthemes appeared concerning advantages and disadvantages from different perspectives regarding both current patient journey and the proposed patient journey, including the pharmaceutical care package. Inconvenience for patients with the current journey was acknowledged by the majority of all interviewees. In particular, patients expressed the importance of rapport with health care professionals. The health care professionals expressed opinions about the competence of community pharmacists to deliver the proposed package of care. The response rates for the questionnaires were 80.7 % (patients), 29.7 % (pharmacists) and 6.6 % (GPs). Over two thirds of the patients preferred the GP practice as the venue to receive denosumab based on convenience and trust in the GP and nurse. Almost three quarters of the pharmacist respondents were willing to deliver the package (39/53), but expressed a need for remuneration and training. Almost a third of the GP respondents were positive to the pharmacist administering the injection (10/33). However, almost two thirds (19/33) were willing to administer denosumab in their own practice, for which resourced capacity was mentioned as the main barrier. The pharmacists’ competence and capability in undertaking falls and dietary assessment in addition to medication reviews were acknowledged by all respondents. The proposed pathway of care, including community pharmacy administration of denosumab, was positively received by the current hospital staff.

CONCLUSION: This study indicates that delivery of the proposed pharmaceutical care package in community pharmacies may be feasible. Current challenges for implementation include funding, gaining trust from the public and GPs and appropriate training of community pharmacists. In addition, effective communication systems and clarification of the roles and responsibilities of health personnel involved are crucial elements. Results from this study can inform the design and evaluation of future services.