Abstract
The adoption of evidence-based clinical practice guidelines has been challenging for the medical community. The adoption of lifestyle medicine–related guidelines may be even more challenging due to enhanced social barriers with behaviors such as exercise and nutrition. Pharmacists are well placed within the community to offer lifestyle medicine care to their patients. The practice of this is reported to be low possibly due to a lack of education in both pharmacy school as well as continuing education for practicing pharmacists. Additionally, examples of best practices for implementing lifestyle medicine guidelines in pharmacy practice are lacking. This article discusses these topics and suggests that national pharmacy organizations become more actively involved in implementing and educating pharmacists in lifestyle medicine.
Most health care professionals understand the importance of evidence-based medicine. Formal training programs are based on the most current information available so that students can use state-of-the-art knowledge when they enter practice. Evidence-based medicine is used by experts to write clinical practice guidelines for chronic diseases such as hypertension, hyperlipidemia and diabetes. However, reports have shown that not all practitioners use clinical practice guidelines when working with their patients. In fact, a study published in 2003 showed that physicians used clinical practice guidelines and other quality health care indicators only 65% of the time in patients with hypertension. 1 Additionally, adherence to quality indicators occurred in only 49% of patients with hyperlipidemia and in only 45% of patients with diabetes. 1 Little information is available on the prevalence of pharmacists and other health care professionals’ use of clinical practice guidelines. However, it can be speculated that the adherence rates are similar to those of physicians.
Most health care professionals understand the importance of evidence-based medicine. Formal training programs are based on the most current information available so that students can use state-of-the-art knowledge when they enter practice
Some research has been published looking at the reasons why practitioners do not always use clinical guidelines in practice. In a report published in JAMA, researchers found the most prevalent reasons for this to be related to awareness, familiarity, and agreement with the published clinical guidelines of any given condition. 2 Other reasons included their lack of belief that the guidelines could be implemented in clinical practice, their lack of confidence in the expected outcomes, and their ability to overcome the inertia of previous practices. 2 Additionally, others have reported that social factors and lack of implementation strategies to be the most significant barriers.
Published literature on this topic is lacking when looking exclusively at lifestyle medicine–related guidelines. Therefore, it is difficult to estimate how frequently health care professionals use lifestyle medicine–related guidelines when working with their patients. However, implementing lifestyle medicine–related guidelines may pose its own set of unique barriers for practitioners. A book published in 2007 by 2 sociologists (Hansen and Easthope), titled Lifestyle in Medicine, discusses the social factors related to health care providers and patients using lifestyle as a means for disease prevention and treatment. 3 In the book, Hansen and Easthope discuss how physicians describe the benefits of a healthy lifestyle with reference to what is desirable in the local culture rather than with reference to reducing risk for disease. Recommendations from health care providers about lifestyle are highly influenced by their own personal experiences with lifestyle factors such as exercise and nutrition rather than clinical guidelines. Additionally, patients and health care providers alike are highly influenced by the consumerism associated with lifestyle. For example, because health care providers are also consumers, they can be influenced by unscientific advertizing, which can then spill over into the advice they give their patients. 3
Pharmacy Practice and Lifestyle Medicine
Pharmacists have long been recognized as highly accessible and trusted health care providers. They have frequent contact with patients who could potentially benefit from lifestyle modification education. Pharmacists are in an ideal position to offer patients information, guidance, and counseling regarding lifestyle changes that can help manage their medical conditions.
When looking at the drugs that are most commonly dispensed in a pharmacy setting, it is easy to see that many of these drugs are used to treat conditions in which lifestyle modifications are recommended for treatment and prevention. A brief look at the top 200 drugs dispensed by prescription count shows that approximately one third of these drugs are prescribed for the medical conditions of hyperlipidemia, hypertension, glycemic control, osteoporosis, or osteoarthritis. The clinical practice guidelines for these conditions clearly recommend 1 or more lifestyle modification strategies for prevention and treatment. Therefore, pharmacists have several opportunities to discuss lifestyle modification strategies with their patients on a daily basis. 4
In one previously reported study, researchers showed that even though patients with dyslipidemia visit the pharmacy more often than the physician’s office, pharmacists offer less information to newly diagnosed dyslipidemia patients about lifestyle changes than do physicians and nurses. 5 This same study also reported that patients with dyslipidemia receive more follow-up lifestyle modification information from their physician and nurse as well as from a dietician, and even the media, compared with information received from their pharmacist to help control dyslipidemia. 5 One reason for the lack of this type of counseling by pharmacists may be inadequate knowledge, skills, and confidence to properly counsel patients on lifestyle changes. These skills can be addressed during the formal education of pharmacy school as well as with lifestyle medicine continuing education programs.
Pharmacy Education and Lifestyle Medicine
A study published in 2007 examined the prevalence of lifestyle modification courses offered to US pharmacy students while in pharmacy school. 6 Of the more than 50% of US pharmacy schools who responded to the survey, only 8% offered a required course to students on a single lifestyle medicine–related topic. Additionally, only 14% offered an elective course in this area. What is more, only 1 pharmacy school in the United States offered a comprehensive lifestyle medicine course to its pharmacy students and this was an elective course. 6 Additional pharmacy schools may now offer lifestyle medicine–related courses to their students, but it can be speculated that overall numbers are still low.
Continuing education (CE) for practicing pharmacists on topics related to lifestyle medicine is also low. Many CE courses on specific disease topics (eg, diabetes, hyperlipidemia, hypertension) may incorporate a portion of the content to lifestyle medicine, but a dedicated focus of CE lifestyle medicine topics is lacking for practicing pharmacists. Continuing education courses on implementing lifestyle medicine into pharmacy practice is also currently lacking and desperately needed for the practice of pharmacy to more widely engage in lifestyle medicine, especially in the community pharmacy setting.
Conclusion
As stated earlier, the most common barriers for practitioners when implementing clinical practice guidelines are related to awareness, familiarity, agreement, self-efficacy, outcome expectancy, and implementation into current practice. These barriers all seem very relevant to the implementation of lifestyle medicine–related guidelines as well. Overcoming these barriers should become a priority for professional organizations to more optimally care for the health of Americans. In pharmacy, these would include the American Pharmacists Association, the American Association for Colleges of Pharmacy, the American College of Clinical Pharmacy, the National Community Pharmacists Association, and others. It is clear that a lack of formal didactic and experiential training exists for student pharmacists as well as CE training for practicing pharmacists. More education on comprehensive lifestyle medicine guidelines is needed as well as examples of best practices for implementing these guidelines into pharmacy practice.