Cancer patients’ perspectives on participating in a community pharmacy-based hyperglycaemia screening service – A qualitative exploration of enablers and barriers

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Abstract

Background

Patients diagnosed with cancer are often treated with high dose glucocorticosteroids, increasing their risk of developing hyperglycaemia or steroid-induced diabetes, which can be reduced by regular monitoring of blood glucose levels. Community pharmacies can provide easily accessible monitoring services to patients, but may not be convenient or acceptable for people with a cancer diagnosis.

Objectives

To explore patients’ motivations, perceptions of benefits and barriers influencing their decisions to participate in a novel community pharmacy-based hyperglycaemia screening and monitoring program.

Methods

Patients initiated on high-dose-glucocorticosteroids at a quaternary cancer centre, who were meeting risk factor-based inclusion criteria and offered participation in a community-based blood glucose monitoring program, were purposively recruited to semi-structured interviews. Interview transcripts were analysed using content analysis and the Framework Method.

Results

Twenty-four patients participated in the interviews, of whom eighteen enrolled into the monitoring program and six declined participation. Interview analysis identified themes of motivators and barriers which were interpreted within the Health Belief Model. Patients individually balanced perceptions of risk and susceptibility to hyperglycaemia with the illness and treatment burden of a cancer diagnosis and the ability to access the program. Health concerns, accessibility of the community pharmacy, trust in healthcare professionals and altruism of patients (giving back) were identified as enablers to enrol. Barriers were inaccessibility of the community pharmacy, extra burden to deal with monitoring appointments, and initial misunderstandings about the screening and monitoring program.

Conclusion

Ascertaining individual tipping points based on motivators or enablers and barriers with subsequent tailoring of supportive care programs will be more likely to meet patients’ individual needs and may increase the likelihood of delivering appropriate care via community pharmacies.

Introduction

Patients diagnosed with cancer are frequently treated with high dose glucocorticosteroids (HGCS), either to directly reduce tumour size and associated oedema, offset predictable adverse effects of cytotoxic therapies, or to treat immune related adverse effects of immune checkpoint inhibitors. One of the common adverse effects of HGCS is an increase in insulin resistance and subsequent elevation of blood glucose levels (BGL), leading to the development of acute glucocorticoid-induced diabetes and potentially type 2 diabetes (T2D) long-term.1 The risk of developing T2D during HGCS therapy increases by up to 34% for patients with cancer.2, 3, 4 In addition, acute hyperglycaemia impairs immune function and wound healing, which can lead to prolonged stays in hospital and an increase in all-cause mortality.5 Patients commenced on HGCS without a pre-existing diagnosis of diabetes are ideally monitored at least once daily to reduce the risk of developing hyperglycaemia while in hospital.6 A clear follow-up strategy for ongoing monitoring of BGL has to be communicated to patients and outpatient care providers and made accessible in primary care settings, e.g in general practices or community pharmacies, rather than offering outpatient hospital care.

Community pharmacies (CP) provide an easily accessible location for BGL monitoring in many countries, for example, in Australia, the UK, Germany, and the USA. Monitoring of BGL, screening for hyperglycaemia and supporting diabetes care by pharmacists has been shown to contribute to the early detection of T2D, lowering of HbA1C and a reduction in cost of overall care, particularly when established within a multidisciplinary care framework.7, 8, 9, 10, 11

In order to safeguard patients with a cancer diagnosis, who are cared for in a community setting and primary care with prolonged HGCS treatment, from adverse effects a follow-up program was designed by a multidisciplinary team at a quaternary cancer centre in Australia, in collaboration with community pharmacies, a pharmaceutical wholesaler and general practitioners (GP). The ‘Glucocorticoid Induced Diabetes Prevention Program’ (GIDPP) was designed for patients commenced on HGCS and offered regular screening for hyperglycaemia through a CP. Although CP based screening services are acceptable to non-cancer patients little is known about cancer patients' attitudes towards regular attendance of a BGL monitoring service in a CP. Fatigue, morbidity and multiple healthcare appointments associated with a cancer diagnosis and treatment may make it difficult for patients to attend any regular follow-up care.12,13 This qualitative study aimed to identify motivations, enablers and barriers for cancer patients to participate in a CP based BGL screening and monitoring service for the duration of their treatment with HGCS. The overall implementation and feasibility assessment of this novel program will be reported separately, with this report focusing on patients' attitudes and perceptions at the time of their enrolment.

Section snippets

Methods

Approval for this study was granted by the study centre's ethics committee (18/25 L) and patient written consent was obtained. The study adheres to the SRQR standards for the reporting of qualitative research.14

Results

Seventy-five percent of patients (114/153) meeting eligibility criteria consented to enrol in the GIDPP. Not all patients who enrolled in the program consented to interviews and some who provided consent left the hospital before an interview could be conducted, particularly those who had declined participation in the GIDPP. This resulted in a convenience sample of participants, based on their availability and consent to participate in the interviews.

Patients’ carers were present and involved in

Discussion

Community-based health services play an important part in addressing the healthcare needs of patients following acute care received in hospital. Limited knowledge exists about the acceptability of monitoring and support services provided by CP for cancer patients. This qualitative study, conducted at a major cancer treatment and research centre in Australia, provides useful information on patients’ knowledge, concerns and behavioural factors which influenced their perceptions and attitudes

Conclusion

Community pharmacy-based hyperglycaemia and BGL monitoring services were generally acceptable for patients with cancer, although their altruistic attitude to participation in a research study may overestimate the ongoing willingness to attend regular monitoring in a community pharmacy in addition to cancer related appointments. Tailoring supportive care programs to meet the individual needs of patients will increase the overall likelihood of them receiving appropriate care. These findings may

CRediT authorship contribution statement

Antoine Sedrak: Conceptualization, Investigation, Formal analysis, Writing - original draft, Writing - review & editing, Supervision, Project administration. Sarah Glewis: Conceptualization, Investigation, Project administration. Marliese Alexander: Conceptualization, Formal analysis, Writing - review & editing, Supervision. Mr Senthil Lingaratnam: Conceptualization, Resources, Writing - review & editing. Cherie Chiang: Conceptualization, Writing - review & editing. Karen Luetsch:

Acknowledgements

The research team would like to thank the participants in this study.

References (28)

  • K.A. Snella et al.

    Pharmacy-and community-based screenings for diabetes and cardiovascular conditions in high-risk individuals

    J Am Pharmaceut Assoc

    (2006)
  • I. Krass et al.

    Pharmacy diabetes care program: analysis of two screening methods for undiagnosed type 2 diabetes in Australian community pharmacy

    Diabetes Res Clin Pract

    (2007)
  • D.H. Van Raalte et al.

    Steroid diabetes: from mechanism to treatment?

    Neth J Med

    (2014)
  • J. Pilkey et al.

    Corticosteroid-induced diabetes in palliative care

    J Palliat Med

    (2012)
  • J.G. Gonzalez-Gonzalez et al.

    Hyperglycemia related to high-dose glucocorticoid use in noncritically ill patients

    Diabetol Metab Syndrome

    (2013)
  • S-y Lee et al.

    Glucocorticoid-induced diabetes mellitus in patients with lymphoma treated with CHOP chemotherapy

    Support Care Canc

    (2014)
  • R.L. Derr et al.

    Association between hyperglycemia and survival in patients with newly diagnosed glioblastoma

    J Clin Oncol

    (2009)
  • A. Roberts et al.

    Management of hyperglycaemia and steroid (glucocorticoid) therapy: a guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care group

    Diabet Med

    (2018)
  • S. Simoens et al.

    Promoting targeted screening for Type 2 diabetes mellitus: the contribution of community pharmacists

    Diabet Med

    (2005)
  • Y. Wang et al.

    Economic evaluations of pharmacist-managed services in people with diabetes mellitus: a systematic review

    Diabet Med

    (2016)
  • A. Willis et al.

    The effectiveness of screening for diabetes and cardiovascular disease risk factors in a community pharmacy setting

    PloS One

    (2014)
  • G.A. Curt et al.

    Impact of cancer-related fatigue on the lives of patients: new findings from the Fatigue Coalition

    Oncol

    (2000)
  • M. Hofman et al.

    Cancer-related fatigue: the scale of the problem

    Oncol

    (2007)
  • B.C. O'Brien et al.

    Standards for reporting qualitative research: a synthesis of recommendations

    Acad Med

    (2014)
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