Constipation is a problem which has been observed to commonly effect the elderly population, especially those above the age of 60 years, with prevalence rates being about 31%.1 There are currently no national guidelines for the treatment of constipation. Both the NPC and CKS guidelines suggest a stepped approach towards management where first line of treatment is the consideration of dietary/lifestyle modifications.2, 3 Since the use of laxatives is particularly prevalent among the elderly, it is important to tutor elderly on the fact that daily bowel movements and purging are not essential for health; in fact long-term laxative use, besides being associated with high health care costs can also result in adverse effects. 4 Also, long-term constipation can have many health related adverse consequences including haemorrhoids, diverticulae, increased risk for colorectal cancer etc.5, 6
Definition of Local Needs
Currently, NHS Grampian does not offer any services directly aimed at elderly patients suffering from constipation. NHS Grampian, however does have a “healthy topics programme”, one of its topic being nutrition. 7 As part of this, a presentation entitled “healthy eating for older people” is available to raise the awareness regarding the importance of a healthy diet in later life.8 The importance of balanced diet in improving health has become the driver for shaping many policies, ‘Eating For Health: A Diet Action Plan for Scotland’ (1996)9 and the 2003 document ‘Improving Health in Scotland: the Challenge’.10 However a review commissioned by the Food Standards Agency, Scotland in 2006 found that despite these dietary policies there was no significant improvement in intake of high fibre diet over the period, 1996 – 2003/2004. 11 ‘Delivering for Health’ 2005 concluded that there needs to be a shift towards preventive medicine and continuous care in the community by strengthening local services, and providing more support for self-care.
According to the Grampian Health plan, the population of pensionable age group is projected to increase by up to 35% in forthcoming years.12 Thus the Grampian Health plan 07/08 lists the aging population and improving access to treatment as two of its main drivers.13 Bucksburn, an area within the North region of Aberdeen city and within the Grampian Health Board, is known locally to have a high cluster of elderly people. There are currently no similar services aimed at providing lifestyle advice to the >60 years in the Grampian area. Read more at: http://www.essaywriter.co.uk/executive-summary.aspx?id=OajfwkHwUzhwn
The proposed service is to set up a pharmacist run ‘healthy bowel clinic’ in the Bucksburn area of Aberdeen. The service will be piloted initially for 12 months to assess its effectiveness and eventually considered Grampian wide, if successful. The current recommendation for the treatment of short duration constipation2,3, basically, the lifestyle measures such as increasing dietary fibre intake, increasing exercises and increasing fluid intake, would be used as the first line of treatment. The elderly patients would be provided with and counseled on ‘pack’ containing information on diet, exercise, bowel training and adverse effects of long-term laxatives. If the lifestyle modifications fail, then the patients would be prescribed the the most appropriate, safe and effective short term laxative via e-MAS (minor ailments service system), which would also ensure the monitoring of laxative use by the pharmacies. Patients will be made aware about the availability of minor ailments service in the community pharmacy; will be encouraged to consult participating pharmacies instead of their GP; they would be counselled on how to take the medicine appropriately; and how to report adverse drug reactions using yellow card system or to the clinic pharmacists.
These small lifestyle changes would significantly improve the quality of life of the geriatric group. This will reduce the NHS burden of laxative prescription costs in the longer term. This would also encourage consultation with community pharmacy service, before self-medicating and help reducing the number of GPs visits by individuals in the target group by encouraging the elderly to consult the dietary clinic. Read more at: http://www.essaywriter.co.uk/executive-summary.aspx?id=R74k33VQ4AvXr
Implementation and Evaluation Proposals
Four pharmacies in the Bucksburn region of Aberdeen have been chosen to implement this service for a 12-month pilot programme. Patients meeting the inclusion criteria will be invited to make an appointment which will be confirmed by telephone and logged in the appointments book, maintained by the pharmacist. Prior to attending the clinic the pharmacist will obtain a record of the patients’ previous medical history, GP’s contacts details and current drug therapy from the GP. Each pharmacy will host a pharmacist run consultation clinic one day each month between the hours of 10-5pm, in which there would be 12 maximum consultations per day, each appointment being for about half an hour. The clinic will operate from the consultation space in the community pharmacy. Summary sheets will be used to record any actions and/or outcomes that take place during the consultation for each patient and stored with patient records. Follow-up consultations will take place monthly and will be allocated 15 minutes per patient.
An orientation-training programme, delivered by a dietician with experience in health promotion will also be developed for all staff involved. This training will comprise two sessions, the first will include introduction of the service and its purpose and would be designed for all staff that will be involved in signposting for this service. The second session will be designed for the pharmacist recruited to deliver the service and will comprise of a 3-hour session.
In order to develop the service of e-MAS, both the service pharmacist and those managing participating pharmacies will undertake a training programme, which will help them further develop the skills necessary to provide advice and information to elderly people with chronic constipation and prescribe them OTC drugs for constipation, mainly laxatives. This training will be incorporated into their continuing professional development (CPD). Care will be taken at this stage to identify patients whose constipation may be due to underlying more serious condition and who may require referral.
A record of dispensed laxatives will be kept when a product is supplied, using a CP2 form (printed through the pharmacy computer) and the CP1 form which would be completed by hand by the pharmacist and stored as a back up in the event of being unable to print a CP2 form. Details of OTC medicines supplied to patient will be recorded in the patient’s medication record (PMR) and shared GP records will be updated. Finally, the CP1 form will be sent to the practitioner Services Division where the prescription data will be recorded.
Both proxy (stand in outcomes for the long-term outcomes) and longer-term outcomes of the service need to be evaluated. Proxy outcomes measures will include the capacity of the service being utilised along with the percentage of participants relieved from symptoms. The number of participants who do not return for follow-up visits will be recorded. A primary outcome measure will be improvement in the patient reported quality of life. Secondary outcomes will be the frequency of bowel movements, presence or absence of Rome II symptoms, fluid and fibre intake, need for laxative use, etc. Since presently no similar service is available, this service has no current comparator. This service will thus be quantitatively assessed by comparison to baseline measures. This will be assessed using the PAC-SYM QOL questionnaire, monthly during the period of consultation, as well as at 3 and 6 months post commencement of the service. Relapse rates will be monitored for 12 months post recruitment by examining patient records. Longer-term outcomes will be assessed on a yearly basis. The number of elderly enrolled in the MAS scheme in the four pharmacies will be surveyed before and after the scheme.
One specifically trained pharmacist will run the pilot scheme, operating one day per month at four different locations. In order to provide the best professional practice to all patients, this service will engage with clinical governance, comprising of regular audits and clinical risk management and continuing professional development.14
This would include monthly fee of £10 for use of light and heat in the consultation room of each pharmacy for one day per month (ongoing cost), cost of posters and leaflets (1000 leaflets and 100 posters = £179.18), cost of stationary (£108.39, ongoing fees for renewal of stationary @ £10 per month) and cost of the patient packs (150 packs = £721.50).
The Dietician’s cost would be a one time cost, required for providing dietary information for high fibre menus/recipes for the patient pack and would amount to £105. 15
The cost of a community pharmacist will be an ongoing cost and amount to £480 per month.15
Training costs are once off payments. Brief training given by the dietician, to those involved in signposting would amount to £42 + travel fees (£0.40/mile).
In-depth training of service pharmacist would incur a cost of £63 + travel fees (£0.40/mile). Cost of implementing a software package for recording of data will also be accounted for.
The NHS will incur cost for laxatives given on e- MAS.
It is probable that in the long-term this service will reduce prevalence and incidence of constipation resulting in overall reduction in health care costs.