Evaluating the Impact and Patient Experience of a Pharmacist‐Led Osteoporosis Clinic: A Service Evaluation

Osteoporosis is a chronic condition characterised by weakened bones, making them more susceptible to fractures. This condition occurs when bone mineral density and bone mass decrease or when the quality or structure of bone changes, leading to a reduction in bone strength, which in turn increases the risk of disability and mortality (NOGG 2021). Several studies suggest that pharmacists can play a crucial role in osteoporosis management (Elias, Burden, and Cadarette 2011). Evidence indicates that pharmacist interventions enhance osteoporosis care by supporting investigations, treatment, patient education, and therapy adherence (Laird, Benson, and Williams 2023). Additionally, studies have demonstrated that pharmacists can make significant contributions to patient care by working collaboratively in interprofessional teams to provide clinical services that assist patients in managing chronic diseases (Rahayu et al. 2021; RPS 2016). Despite the recognised value of such interventions, pharmacists have historically been underrepresented in clinical roles within the local rheumatology department. Recognising the shortage of rheumatology doctors, as reported by the Worldwide Forum on Rheumatic and Musculoskeletal Diseases (Al Maini et al. 2015), there has been a call for a reassessment of healthcare roles within rheumatology. In response, the Rheumatology department of the Local NHS Trust expanded its multidisciplinary team (MDT) in 2023 to include a pharmacist. A recent service evaluation focussing on patient experience in the local early arthritis clinic showed that most patients had a positive experience with the MDT approach in rheumatology, highlighting the potential for pharmacists in clinical, patient-facing roles (Petford, Jiao, and Sandhu 2024). To better support the rheumatology team and address the waiting list of osteoporosis patients, a new pharmacist-led osteoporosis clinic was established under the supervision of a consultant rheumatologist and a specialist doctor in osteoporosis. Patients referred by general practitioners (GPs) or other clinical specialty teams are initially reviewed and triaged by the consultant, after which appropriate patients are assigned to the pharmacist-led osteoporosis clinic. This study aims to assess the quality of care and patient experience within the context of this pharmacist-led osteoporosis clinic. To assess the quality of care provided by the clinical pharmacist within the context of osteoporosis management. To identify the demographic and clinical characteristics of patients referred to the pharmacist-led osteoporosis clinic. To outline the treatment plans from the clinic. To evaluate patient experiences and clinician perceptions of the pharmacist-led service. Clinical letters from a 3-month period were audited to gather demographic information and treatment plans for patients referred to the pharmacist-led osteoporosis clinic. Patient satisfaction was measured using the validated Client Satisfaction Questionnaire (CSQ) (Pedersen et al. 2023; Matsubara et al. 2013). Following discussions with the local research patient representative, a shorter validated version of the Client Satisfaction Questionnaire (CSQ-3), comprising items 3, 7, and 8 from the CSQ-8, was chosen (Christensen et al. 2020) (see Appendix 1). This shorter version was selected because of concerns raised by the patient representative that a lengthy survey might be inappropriate for patients to complete while awaiting potentially life-altering treatment in the hospital. The aim was to keep the survey as brief as possible to enhance the patient experience. All patients were encouraged to complete the survey anonymously, which was provided before the consultation, and to return it in an opaque envelope to mitigate concerns about giving negative feedback. Team meetings were held with all osteoporosis MDT members, including the consultant rheumatologist, specialist in osteoporosis, clinical nurse specialist, and administrative colleague. Feedback was audio-recorded and transcribed anonymously for qualitative analysis. The audio recordings were deleted after the analysis was completed. As this study is a local service evaluation with limited generalisability and transferability, no ethical approval was required according to the HRA support tool (HRA 2022). Of the 35 patients scheduled for the pharmacist-led osteoporosis clinic, six did not attend (DNAs), resulting in 29 patients being reviewed. The average age of these patients was 77 years. Of the 29 patients, 26 were female and 3 were male. Twenty two patients had a confirmed diagnosis of osteoporosis, and five patients were diagnosed with osteopenia. These diagnoses were based on their medical history and DEXA scan results; however, two patients never had DEXA scan. All patients had their Fracture Risk Assessment Tool (FRAX) scores calculated during their clinic visit. The FRAX score estimates the 10-year probability of fractures, which is linked to the National Osteoporosis Guideline Group (NOGG) recommendation for bone-sparing treatment. For five patients, the FRAX calculation was performed without a T-score because of the lack of a DEXA result. The most common reason for referral to the pharmacist-led clinic was intolerance to oral medication, affecting 15 patients. Additionally, seven patients had sustained fractures while on oral treatment, and other reasons for referral included patients with poor renal function. In terms of clinic outcomes, 17 patients were referred for treatment with zoledronic acid, 5 patients were discharged from the clinic, 4 were referred for DEXA scans, and 1 patient requested a DEXA report from another hospital. Two patients required a renal opinion before being referred for denosumab. All patients had baseline osteoporosis blood tests to exclude secondary causes of bone loss, such as metabolic or endocrine disorders. It was documented that all patients requiring bone-sparing treatment had discussions about their medication options and were provided with treatment leaflets that explained the common side effects and benefits of the medications. Five patients were started on vitamin D and calcium supplements or had changes made to their supplement formulations. Twenty seven patients received lifestyle advice, including recommendations on diet and exercise to support bone health. The CSQ-3 feedback was overwhelmingly positive, with 22 feedback forms received out of the 29 patients reviewed in the clinic. The total scores were 78 for Q1, 88 for Q2, and 87 for Q3. Over 95% felt their needs were met at the clinic, and 100% were mostly or very satisfied with the service, with all willing to return to the same clinic if needed. Patient comments included: ‘really helpful, very polite, wasn't rushed, explained everything, brilliant’, ‘I felt that my needs were met fully and that my concerns were appropriately validated’, ‘explained everything to me in a way I could understand’, and ‘excellent care and information given, understanding of patient care needs’. Clinician feedback was mostly positive, highlighting both strengths and areas for improvement identified by the MDT team. The quality and detail of the pharmacist's consultations were positively commented on. Participant 4 said: ‘I think you do loads of things well. And the detail that you take in your consultations, you cover all the areas that I normally cover in mine.’ (Specialist Doctor in Osteoporosis). Participant 2 acknowledged the pharmacist's effectiveness in educating patients and said: ‘We sit together, and I can hear you with the patients; you seem really good at that.’ (Clinical Nurse Specialist). Participant 5 highlighted the progress in the pharmacist's letter-writing skills, noting that initial letters required editing for length and clarity: ‘When you started, we did have to sit there sometimes and edit bits out or change the way it was… now you don't’ (Osteoporosis Co-ordinator). Multiple participants emphasised the strong rapport the pharmacist has with both patients and colleagues. Participant 2 stated: ‘Well, from a patient perspective, or anybody that has seen you previously, they all say you know how good you are… you've got good rapport with them’. (Clinical Nurse Specialist). Participant 5 also highlighted the pharmacist's positive interactions: ‘They all think that you've got an excellent rapport… with all the patients and staff’. (Osteoporosis Co-ordinator). There were instances where the pharmacist was mistakenly identified as a doctor by patients. Participant 2 noted: ‘I had a patient today who thought you were a doctor again’. (Clinical Nurse Specialist). Participant 1 advised focussing more on common issues rather than all the rare side effects: ‘You don't need to tell them everything there is to know about the drug’. (Consultant Rheumatologist). This study highlights the significant potential role of pharmacists in osteoporosis care. The integration of pharmacists into osteoporosis management has been shown to enhance the patient experience. All patients had consultations regarding their choice of bone-sparing agents and were provided with treatment leaflets, enabling them to make informed decisions. This approach promotes patient-centred care and may support treatment adherence, as evidence indicates that advice from pharmacists on drug management promotes adherence in both rheumatology and other chronic disease settings (Lavielle et al. 2018). Pharmacists are capable of providing a variety of injectable bone-sparing treatments and non-pharmacological advice, indicating a holistic approach to osteoporosis management. The positive patient feedback highlights the effectiveness of pharmacist-led interventions and aligns with previous local rheumatology service evaluations on MDT approaches in early arthritis clinics (Petford, Jiao, and Sandhu 2024). The clinical pharmacist's role in the osteoporosis clinic follows clear protocols, and treatment recommendations are based on calculating FRAX scores and NOGG guidance. Any patients with undifferentiated diagnoses were referred for further investigation, such as bone density scans, and referred back to the supervising doctors. There were instances where pharmacists were mistaken for doctors by patients, despite consistently introducing themselves as pharmacists. This issue was also identified in the local service evaluation (Petford, Jiao, and Sandhu 2024). A further study will be conducted to evaluate the perceptions of patients and clinicians regarding the professional identification of pharmacists working in patient-facing clinical settings. Clinicians have positive perceptions of clinical pharmacists within the osteoporosis service. They appreciate the quality of consultations provided by clinical pharmacists, both in verbal and written communication as well as their ability to form positive relationships with patients and colleagues. Similar positive perceptions of clinical pharmacists are evident in other studies, including those conducted in hospital settings and among general practitioners, who recognise the valuable contributions of pharmacists in these contexts (Hurley et al. 2022; Lee et al. 2023). However, not all patients had the opportunity to receive lifestyle advice. This aligns with evidence indicating that some healthcare professionals face barriers in providing comprehensive counselling to all patients (Hagelsrum et al. 2023). The study's findings are limited by several factors. The small sample size restricts the generalisability of the results, and the retrospective nature of data collection may not capture all interventions made by the pharmacists. Additionally, patient and colleague feedback, while largely positive, may be subject to bias. Patients might provide favourable responses due to perceived expectations or a desire to appear compliant. Similarly, work colleagues may be reluctant to provide negative feedback due to an established rapport. The pharmacist working in the osteoporosis clinic has previous experience in patient-facing roles and holds a postgraduate master's degree in clinical practice. Effective and safe practice in such positions requires pharmacists to be qualified through education, training, and experience, along with appropriate supervision and support from experienced doctors. Moreover, the study does not measure long-term clinical outcomes, which are crucial in assessing the true impact of pharmacist interventions on osteoporosis management. Evidence indicates a positive relationship between patient experience and clinical outcomes, which may indirectly support the effectiveness of pharmacist-led clinics (Doyle, Lennox, and Bell 2013). Future research should include larger sample sizes to provide a more comprehensive understanding of the pharmacist's role. Additionally, evaluating long-term clinical outcomes and patient adherence to therapy would offer insights into the effectiveness of pharmacist-led care. This study demonstrates the valuable role that pharmacists can play in the management of osteoporosis, highlighting their potential to enhance both the quality of care and patient experience within a multidisciplinary team setting. Future studies should aim to include larger sample sizes, evaluate long-term clinical outcomes, and explore patient adherence to therapy. The author takes full responsibility for this article. I would like to express my gratitude to all the co-authors who contributed to our study at the Pharmacy-Led Osteoporosis Clinic as well as to Dr. Holly John, Clinical Lead of the Rheumatology Department, for her invaluable support. I am appreciative of the entire team at the Rheumatology Department of the Trust for their encouragement and assistance throughout this project. I would also like to thank Dr. Gail Parsons, R&D Director, Ruckie Kahlon, Chief Pharmacist, and Steven Shanu, Deputy Chief Pharmacist for their support of my project. I am grateful to my Pharmacy Clinical Trial Team in R&D for their support during my absences from the office and for covering my responsibilities. Additionally, I would like to acknowledge our research patient representative. Julian who kindly listened to my project suggestions and advised me to use a shorter version of the survey. Lastly, I am grateful to my family—my wife Miaomiao, my daughter Anna, and our family dog, Icy, for their support and patience during my commitment to this work. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.