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Supplementary Material
Ambulatory Clinical Pharmacy Services to Discharged Patients
The ambulatory service was located inside of a tertiary care university hospital in
Southern Brazil. All discharged patients from the cardiology ward had their clinical records
revised by four cardiovascular pharmacy residents and five PhD & MSc candidates. Two
preceptors were in charge of conducting case discussions and establishing clinical priorities.
This ambulatory served as a pilot experience for the implementation of Clinical Pharmacy
Services in the Brazilian Primary Care Health System [http://www.blog.saude.gov.br/34925ministerio-da-saude-implanta-projeto-piloto-de-clinica-farmaceutica-no-sus.html].
After selecting patients by chart review, phone calls were performed in a weekly basis to
offer the service. All consultations were done on Fridays. Patients who agreed to come were
asked to bring all their current prescriptions, exams and medications (“brown bag with
medications”).
Ambulatory care consultations aimed to identify drug-related problems, according to lab
results, adherence patterns and drug therapy comprehension and other issues such as
identifying adverse reactions. Pharmacists also provided point-of-care assessments (e.g.:
glycemic test and blood pressure). All problems detected were solved by pharmacists,
according to local legal requirements, such as: changing drugs, dosages (directed to
physicians), etc.
Other counseling-related interventions were also performed, but not restricted to the
following:
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Adjustment to patients’ routine;
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Adherence reinforcement;
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Explaining the purposes of each drug prescribed;
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Other individually raised issues.
Many of the included patients knew most of ambulatory pharmacists, once they
provided other services during hospital stay. The aforementioned hospital also works with: daily
inpatients’ medication review, bed-side clinical discussions, patient counseling at discharge
(especially those initiating clopidogrel after coronary stent placement) and medication
reconciliation at ward admission.
Specific Definitions of the Adherence tools used for Data Collection
The definitions of each outcome and tool used in this research are as follows:

“Patients’ Ability to Manage Drug Therapy” assessed patients’ autonomy by indirect
measures, such as checking: a) the need for assistance to use the drugs; b) the need
for reminders and assistance to take the drugs; c) the ability to take medications alone;

MEDTAKE7 was used to assess the ability to use the drugs correctly, by demonstrating
knowledge on: a) identifying the drug and dose correctly; b) describing its indication; c)
describing how the medication is used, such as with food or type of liquids; 4)
describing the dosages used along the day. Every correct answer accounts for 1 point,
so a given prescribed drug can totalize 4 points. All points are converted to a 100 points
scale and represented as percentage;

Medication Adherence Tool 1, the Adherence to Refills and Medication Scale (ARMS) 8,
was developed to assess patients with chronic medical conditions and with low health
literacy. It is based on 12 questions for the patient (or caregiver) during the consultation.
The lowest grade, 12, means the best adherence;

Medication Adherence Tool 2, Beliefs about Medicines Questionnaire (BMQ) 9, was
created to measure one patients beliefs about diseases. This tool can assess patients’
perceptions about drug therapy Needs (N) and other related Concerns about the
treatment (C). The value of (N%/C%) above 1.0 represent good comprehension to
adhere to prescribed therapy.
FIGURES
Figure S1 – Top 15 prescribed drugs.
Notes: Numbers are expressed as percentages.
Table S1 – Number of Controlled Clinical Conditions and Adherence Tools Scores.
Number of Clinical Conditions
6 (1~11)
Controlled Clinical Conditions, %
42.5 (0~100)
Medication Adherence Scores
MEDTAKE Score, average % (sd %)
86.7 (14.3)
ARMS Total Score
15.6 (3.4)
ARMS Taking Score
10.1 (2.0)
ARMS Refill Score
5.6 (2.0)
BMQ Needs Score, average % (sd %)
93.8 (11.6)
BMQ Concerns Score, average % (sd %)
56.1 (16.9)
BMQ Ratio Needs/Concerns
1.85 (0.66)
Notes: Data were reported as average, ranges or sd, unless otherwise stated.
STUDY’S PROTOCOL
Controlled or uncontrolled clinical conditions were defined as follows (criteria to identify drugrelated problems by clinical pharmacists).
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Hypertension (HTN): ambulatory-based blood pressure (BP < 140/90mmHg), or homebased BP (Sys. BP < 130mmHg and Diast. BP < 85mmHg).i
Coronary artery disease: symptoms control (angina, exercise tolerance), HTN, diabetes
and dyslipidemia control.ii
Dyslipidemia: as per cardiovascular risk assessment and lipid profile (e.g.: LDL <
100mg/dL or < 70mg/dL; for patients with atherosclerosis, HDL > 50mg/dL, TG <
150mg/dL.iii
Type 2 Diabetes mellitus: HbA1c < 7%, fasting glucose < 110mg/dL, capillary glucose <
160mg/dL, micro and macrovascular diseases, patients’ glycemic diary.iv
Heart failure: symptoms control (shortness of breath, exercise tolerance, edema),
(hospital readmissions), left ventricle ejection fraction follow up.v
Hypothyroidism: TSH 0.5 to 5 µU/mL, free T4 0.7 to 1.48 ng/dL, symptoms control
(weakness, cold sensation, hair loss, memory and concentration loss, constipation,
weight gain, dyspnea, paresthesia, low hearing, dry skin, cold extremities swollen
extremities, alopecia, bradycardia).vi
Obesity: BMI < 25 kg/m2.vii
Sleep problems: symptoms control (sleep hygiene, sleeping hours, energy during the
day).viii
Atrial Fib / Flutter: symptoms control (palpitations, accelerated/irregular pulse, shortness
of breath, confusion, vertigo, fatigue, exercise tolerance), absence of thromboembolic
events, hospital readmissions, INR vales (2 to 3 in most of cases. Exceptions were
mitral prosthetic valve and antiphospholipid syndrome, where INR should be 2.5 to
3.5).ix
Chronic renal disease: symptoms control (hosp. readmissions, edema, serum Cr, CrCl,
serum urea/BUN, proteinuria, albuminuria, albumin/creatinine ratio > 30 mg/L).x
Psychiatric diseases: symptoms control (anxiety, fatigue, sleep disturbance, mood
alteration, lack of concentration / interest, reduced self-esteem, guilty feelings,
increased or reduced appetite), insomnia, confusion, chest pain, palpitation, sudoresis,
dry mouth, shaking, muscle tension, vertigo, nausea and vomiting.xi, xii
GERD: symptoms control (burning sensation, regurgitation, night time awakening dry
cough).xiii
Arrhythmia: symptoms control (palpitation, syncope), hospital admissions.xiv
Stroke: sequela symptoms control, functional capacity, other co-morbidities control.xv
Peripheral artery occlusive disease: symptoms control (pain, edema, skin alterations or
palpable pulse).xvi
REFERENCES USED IN THE PROTOCOL
[i] VI Diretrizes Brasileiras de Hipertensão. Arq. Bras. Cardiol. 2010;95:Suppl 1. doi:
10.1590/S0066-782X2010001700001.
[ii] IV Diretriz da Sociedade Brasileira de Cardiologia sobre Tratamento do Infarto Agudo do
Miocárdio com Supradesnível do Segmento ST. Arq Bras Cardiol 2009; 93 Suppl. 2:e179-e264.
http://publicacoes.cardiol.br/consenso/2009/diretriz_iam.pdf. Accessed 28 Apr 2014.
[iii] IV Diretriz Brasileira Sobre Dislipidemias e Prevenção da Aterosclerose. Arq. Bras. Cardiol.
2007; 88 Suppl I. doi: 10.1590/S0066-782X2007000700002
[iv] Diretrizes SBD 2014-2015. Métodos para avaliação do controle glicêmico.
http://www.diabetes.org.br/images/Capitulo_Diretrizes_SBD.pdf. Accessed 16 Apr 2014.
[v] Bocchi EA, Marcondes-Braga FG, Bacal F, Ferraz AS, Albuquerque D, Rodrigues D, et al.
Sociedade Brasileira de Cardiologia. Atualização da Diretriz Brasileira de Insuficiência Cardíaca
Crônica. Arq Bras Cardiol. 2012; 98 Suppl 1: 1-33.
[vi] Sociedade brasileira de endocrinologia e metabolismo. Hipotireoidismo: Tratamento 2011.
http://www.projetodiretrizes.org.br/ans/diretrizes/hipotireoidismo-tratamento.pdf4. Accessed 11
Mar 2014.
[vii] Godoy-Matos AF, Oliveira J. Sobrepeso e Obesidade: Diagnóstico. Sociedade Brasileira de
Endocrinologia e Metabologia, 2004.
http://www.projetodiretrizes.org.br/projeto_diretrizes/089.pdf. Accessed 07 Mai 2014.
[viii] Suplemento Distúrbios respiratórios do sono. J Bras Pneumol. 2010; 36 Suppl 2: S1-S61
http://www.jornaldepneumologia.com.br/detalhe_suplemento.asp?id=61. Accessed 23 Apr
2014.
[ix] Zimerman LI, Fenelon G, Martinelli Filho M, Grupi IC, Atié J, Lorga Filho A et al. Sociedade
Brasielira de Cardiologia. Diretrizes Brasileiras de Fibrilaçao Atrial. Arq Bras Cardiol 2009;92
suppl 1):1-39. http://www.publicacoes.cardiol.br/consenso/2009/diretriz_fa_92supl01.pdf.
Accessed 14 Feb 2014.
[x] National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease:
evaluation, classification, and stratification. Am J Kidney Dis. 2002; 39:S1–266.
[xi] Associação Brasileira de Psiquiatria. Transtornos de Ansiedade: Diagnóstico e Tratamento,
2008. http://www.projetodiretrizes.org.br/projeto_diretrizes/099.pdf. Accessed 13 Nov 2013.
[xii] Fleck MP, Berlim MT, Lafer B, Sougey EB, Del Porto JA, Brasil MA et al. Revisão das
diretrizes da Associação Médica Brasileira para o tratamento da depressão (Versão integral).
Revista Brasileira de Psiquiatria, 2009; 31 Suppl I: s7-17.
[xiii] Federação Brasileira de Gastroenterologia. Refluxo Gastroesofágico: Diagnóstico e
Tratamento. Projeto Diretrizes. http://www.projetodiretrizes.org.br/projeto_diretrizes/084.pdf.
Accessed 19 Jun 2014.
[xiv] Levy, S., Olshansky, B. Arrhythmia management for the primary care clinician.
http://www.uptodate.com/contents/arrhythmia-managemnte-for-the-primary-careclinician?source=search=arritmias+tratamento&selectedTitle=2~150. Accessed 20 Fev 2014.
[xv]. Manual de rotinas para atenção ao AVC / Ministério da Saúde, Secretaria de Atenção à
Saúde, Departamento de Atenção Especializada – Brasília: Editora do Ministério da Saúde,
2013. http://www.bvsms.saude.gov.br/bvs/publicacoes/manual_rotinas_para_atencao_ avc.pdf.
Accessed 05 Mar 2014.
[xvi] Sociedade Brasileira de Angiologia e Cirurgia Vascular. Doença arterial obstrutiva
periférica (DAOP). J Vasc Br 2005; 4 Suppl. 4.