Last fall, the Canadian Ministry of Health and the Shoppers Drug Mart/Pharmaprix chain of 1,200 pharmacies announced the launch of their Arthritis Screening Program. The program uses pharmacists to help screen for osteoarthritis of the knee (KOA) and to give information on treatments as well as medications. It is the result of research carried out by the Arthritis Research Centre of Canada (ARC) under the auspices of the Canadian Institute of Health Research.
“It has been long established in diabetes and other diseases that pharmacists are in a position to detect problems early, largely because they see patients eight times more often than the family doctor,” says John Esdaile, MD, scientific director for the center. “We wanted to know if pharmacists were a way of detecting KOA earlier than we do now.”
Two Studies
The center completed two studies on the subject as a precursor to the screening program. The first was a pilot study published in 2007.1 The second was a randomized controlled trial that looked at interventions after the pharmacist had completed the screening.2
“In the first study, we basically administered a questionnaire to people 50 years and older who had pain in or around the knee,” says Carlo A. Marra, PharmD, PhD, from ARC and the faculty of Pharmaceutical Sciences at the University of British Columbia in Vancouver. “The pharmacists did a really good job of finding people with KOA who hadn’t been diagnosed before. The care gap appeared to be massive.”
For the follow-up study, the patients were first screened. Seventy-three patients suspected of having arthritis were randomized to the treatment arm. Their current medication regimens were reviewed, and they received suggestions for over-the-counter medication and treatment following the 2008 ACR guidelines. They were also referred to a physiotherapist (PT) for guidance on exercise and weight control. The 66-person control group was given a pamphlet on KOA.
“We found highly significant changes in the pass rate on the Arthritis Foundation’s quality indicators for OA among those receiving treatment,” notes Dr. Esdaile. “In addition, there were significant differences in pain, movement, and function scores on various tools at three and six months. Another look at the data showed this to also be very cost effective, driven by lower medicine costs from the pharmacist consultation as well as fewer visits to physician apparently tied to the use of PTs.”
Pharmacist-Centered Program Useful
The results indicated that pharmacist-centered interventions could be useful in both finding and treating KOA. This led to the wider program currently underway by the Shoppers Drug Mart chain.
The Arthritis Screening Program includes a questionnaire on knee arthritis for initial case findings. A tested, evidence-based review of pain medicines and their major side effects also will be administered. A letter will be sent to their primary care physician to let the doctor know about the diagnosis and results of the review. There will also be an arthritis screening tool available both in the pharmacy and online to help patients self-screen for joint problems.
Although useful for KOA, it appears that similar programs may not be as helpful in changing the course of rheumatoid arthritis (RA) treatment.
“We tried to investigate similar strategies in RA, focusing on those who had been diagnosed but were not yet on disease-modifying antirheumatic drugs [DMARDs],” says Dr. Marra, who is also at the Providence Health Care Research Institute in Vancouver. “In Canada, those not on DMARDs tend to still be treated with steroids and seem very happy because they feel better. It was another level of intervention to convince them to change.”
Concerns Raised
Although expressing support for the general idea, some experts not involved in the research or program had concerns about missing patients with similar symptoms but different diseases.
“There is merit in using pharmacists to screen for OA by asking key questions that could lead to further evaluation,” says Eric Matteson, MD, a rheumatologist with the Mayo Clinic in Rochester, Minn. “I am less sanguine about this program being able to identify a specific kind of arthritis and worry about misidentifying some persons who have rheumatoid, or other inflammatory, arthritis.”
He notes that case finding is only the first step. Strategies like this could be helpful in having people identify themselves as having an arthritic condition, but then they need to see a physician to establish both the exact problem and a tailored solution.
In addition, there are concerns about accurate and complete follow-up in patients who are found by these methods.
“Having pharmacists recommend treatment is not a big concern,” says Janet Pope, MD, MPH, head of the division of rheumatology at Western University in London, Ontario. “But there also needs to be a way to see if a person is improving or needs to see a healthcare professional.”
She also notes that, unlike RA, OA doesn’t have an early-stage intervention that changes the course of the disease.
“Until late in the disease process where joint replacement can give excellent relief in most people, treatment is only symptomatic,” says Dr. Pope. “Pharmacists can have a role at this time using published guidelines.”
References
- Marra CA, Cibere J, Tsuytuki RT, et al. Improving osteoarthritis detection in the community: Pharmacist identification of new, diagnostically confirmed osteoarthritis. Arthritis Rheum. 2007;57:1238-1244.
- Marra CA, Cibere J, Grubisis M, et al. Pharmacist-initiated intervention trial in osteoarthritis: A multidisciplinary intervention for knee osteoarthritis. Arthritis Care Res (Hoboken). 2012;64:1837-1845.
