09-04-2014 The EuroPharm Forum The European Forum of National - - PDF document

09-04-2014

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Recent developments in pharmaceutical care: Europe and Hungary

Balázs Hankó Vice-president Associate professor, chief pharmacist EuroPharm Forum Semmelweis University, University Pharmacy Department of Pharmacy Administration

45th EQUIP ASSEMBLY MEETING AND OPEN CONFERENCE "INTERPROFESSIONAL MANAGEMENT OF PATIENTS IN FAMILY PRACTICE„ MAY 8-10th, 2014 Ljubljana, Slovenia

The EuroPharm Forum

• The European Forum of National Pharmaceutical

Associations in Europe

• A joint network of national pharmaceutical associations
• Collaborates with the World Health Organization, Regional

Office for Europe

• The first of the Regional Forums of FIP, covering the WHO

Europe Region

• Founded in January 1992

Content

• 1. Society needs and challenges
• 2. Why should pharmacists be involved?
• 3. Pharmaceutical care
• 4. Evidence – pharmacists interventions
• 5. Hungarian examples
• 6. Need for better collaboration

1.1. Society needs

• primary prevention -

Risk factors Total DALY % High income countries Total DALY % middle income countries Tobacco use 10.7 5.4 Alcohol use 6.7 7,6 Overweight and obesity 6.5 3.6 High blood pressure 6.1 5.4 High blood glucose 4.9 3.4 Physical inactivity 4.1 2.7 High cholesterol 3.4 2.5 Total 42.4 30.6 7 leading risk factor causes of DALYs, GLOBAL HEALTH RISKSMortality and burden of disease attributable to selected major risks WHO, 2009

(DALY: Disability adjusted life years)

1.2. Society needs

Undiagnosed chronic diseases – secondary prevention

• Three European cities (Abruzzo,

Italy; Limburg, Belgium; South- west London, UK) 24.4 % of the participants’ blood pressure was higher than 140/901, – 56 % of them were newly diagnosed

• The ratio of undiagnosed diabetic

patients is around 50 %2 – The average prevalence of diabetes is 7-8 % in adults

• 1. J.-M. Ekoé, Paul Zimmet, Dav id Robert Rhy s Williams. The Epidemiology of Diabetes Mellitus: An International Perspectiv e. John Wiley and Sons, 2001. ISBN 047197448X, 9780471974482.
• 2. S. Costanzoa, A. D. Castelnuov oa, F. Zitoa et al. Prev alence, awareness, treatment and control of hy pertension in healthy unrelated male–f emale pairs of European regions: the dietary habit prof ile in European

communities with dif f erent risk of my ocardial inf arction – the impact of migration as a model of gene–env ironment interaction project. Journal of Hy pertension 2008, 26:2303–2311.

1.3.1. Society needs

Drug-related problems

• Increasing OTC consumption, but!

– Inadequate use - overdose

• Irish example - Prevalence of OTC overdoses at ER departments (40 % partly,

24 % total caused by OTCs - 2002 )1 – Interactions

• USA study shows that 50 % of the interactions are caused by OTCs2
• Elderly population
• Polypharmacy in the elderly
• Odds of being hospitalized by ADR are 4 times higher than for younger3

– (16.6 % vs. 4.1 %).

• Use of over-the-counter (OTC) medications by elderly patients is often not

identified (78 % of admitted patients use OTCs)4

• Low health literacy
• Strongest predictor of an individual’s health status5
• Low literacy was significantly associated with misunderstanding6

– 34.7 % could demonstrate the number of pills to be taken daily

• 1. M. Wazaif y , S. Kennedy , C. M. Hughes, J. C. McElnay . Prev alence of ov er-the-counter drug-related ov erdoses at Accident and Emergency departments in Northern Ireland – a retrospectiv e ev aluation Journal of Clinical

Pharmacy and Therapeutics; 2005 30:39-44 2. D. M. Qato, G. C. Alexander, R. M. Conti, M. Johnson, P et al. Use of Prescription and Ov er-the-counter Medications and Dietary Supplements Among Older Adults in the United States. JAMA. 2008;300(24):2867-2878. 3. Hospitalizations caused by adv erse drug reactions: a meta analy sis of observ ational studies. Pharm World Sci 2002; 24(2):46-54.4. Gwenno M Batty et al. The use of ov er- the-counter medication by elderly medical in-patients. Postgrad Med J. 1997; 73:720-722. 5. www.askme3.org 6. Terry C. Dav is, Ruth Parker. To Err Really is Human: Misunderstanding Medication Labels. http://www.iom.edu/Object.File/Master/47/271/Dav is.pdf

• 3. H.J.M. Beijer et al.

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• Pharmaggedon1

– Non-adherence

• Yearly 194,500 patients die in the EU
• Yearly 1.25 billion € lost

– UK

• Estimated medication costs for England due to non-adherence (2004) € 12

million;

• Wastage of medicines accounted for 2.3 % of total medication costs

– Portugal studies

• proportion of medicines wasted ~ 16 %.
• average wastage cost per medicine dispensed was € 4.44,
• Harm survey in the Netherland2
• The Hospital Admission Related to Medication is 41,000/year
• 5.6 % of the unplanned hospital admissions were medication-related,

almost half (46.5 %) of these admissions were potentially preventable

• 1. PGEU policy statement. Targeting Adherence. Outcomes in Europe through community Pharmacists’ intervention.

http://www.pgeu.org/Portals/6/documents/2008/Publications/08.05.13E%20Targeting%20adherence.pdf2. Anne J. Leendertse et al.Frequency of and Risk Factors for Preventable Medication-Related Hospital Admissions in the Netherlands. ARCH INTERN MED/VOL 168 (NO. 17), SEP 22, 2008

1.3.2. Society needs

Drug-related problems

1.4. Difference between efficacy and effectiveness

• Quality gap -
• Can pharmacists take part in interprofessional collaboration by

bridging these gaps, solving these problems?

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• Will society and other professionals

accept this?

• Will society and other professionals

respect this?

• Will society and other professionals

reward this?

• Will pharmacists accept the challenge?

Content

• 1. Society needs and challenges
• 2. Why should pharmacists be involved?
• 3. Pharmaceutical care
• 4. Evidences – pharmacists interventions
• 5. Hungarian examples
• 6. Need for better collaboration
• 400,000 Community

Pharmacists in Europe

• 160,000 Community

Pharmacies in Europe

• 46 million citizens visit a

pharmacy every day

~1300 2014

• 2. Why should

pharmacists be involved?

Lisbon, 11 Nov 2009

• Community pharmacists in Europe are

committed to making a major contribution to improving public health by:

– seeking to ensure that people derive a maximum therapeutic benefit from prescribed medication dispensed in pharmacies – providing high-quality advice to ensure safe and responsible self-care including, where appropriate, self-medication – encouraging healthy lifestyles through effective health promotion and health education strategies

• 2. Why should pharmacists be involved?

Content

• 1. Society needs and challenges
• 2. Why should pharmacists be involved?
• 3. Pharmaceutical care
• 4. Evidences – pharmacists interventions
• 5. Hungarian examples
• 6. Need for better collaboration

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• 3. The pharmacists’ answer is pharmaceutical care
• development in terminology -
• “is the responsible provision of drug therapy for

the purpose of achieving definite outcomes that improve a patient’s quality of life”. (Hepler & Strand, Am J Hosp Pharm. 1990)

• “…..pharmacy practice ….. to promote health, to

prevent disease, and to assess, monitor, initiate, and modify medication use …. within realistic economic expenditures.” (APhA)

• ”responsible provision of pharmacotherapy

……collaborative process that aims to prevent or identify and solve medicinal product and health related problems…” (FIP)

• 3. The pharmacists’ answer is pharmaceutical care
• development in terminology -
• EuroPharm Forum - WHO

– Holistic approach, including:

• Primary and secundary prevention
• Improving prescribing and rational drug use
• Country definitions1

– Differences

• Drug therapy focus – holistic approach

– Hungarian definition

• „The responsible, documented activity of the

pharmacist in collaboration with the doctor, which aims to improve the effectiveness, and efficiency of the drug therapy, and to promote healthy lifestyle, and the right medication use, improve the adherence, and quality of life under quality controlled circumstances” (Act of Medicine)

• 1. J. W. Foppe van Mil, PhD, Martin Schulz. A Review of Pharmaceutical Care in Community Pharmacy in

Europe Harvard Health Policy Review. Vol. 7, No. 1, Spring 2006 1

• 3. The pharmacists’ answer is pharmaceutical care
• development in terminology -

Pharmaceutical care is

• the pharmacist’s contribution…

– multidisciplinary approach is to be desired

• … to the care of individuals…

– targeting individuals

• …in order to optimise medicine use…

– should include patient-centered elements

• and improve health outcomes
• 3. The pharmacists’ answer is pharmaceutical care
• development in terminology -

Content

• 1. Society needs and challenges
• 2. Why should pharmacists be involved?
• 3. Pharmaceutical care
• 4. Evidences – pharmacists’ interventions
• 5. Hungarian examples
• 6. Need for better collaboration
• 4. A guide to evidence

11/05/2014 C ore V alues, EuroPharm Forum 18

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4.1. Evidences – literature review

• The Contribution of Community Pharmacy to Improving

the Public’s Health1

– Literature review (EBM criteria)

• CVD (13 studies: SCRIP plus, PIRR CHAP etc)

– Risk reduction, better disease control, higher satisfaction

• Diabetes care (11 studies: Ashville project,

Machado et al, 2007; Krass et al, 2007, Snella et al 2006)

– significant HbA1c reduction, – better disease control etc.

• Hypertension (Machado et al, 2007)

– Significant blood pressure reduction

• Other

– Obesity, STD, Osteoporosis, Vaccination etc

• 1. The contribution of community pharmacy to improving the public’s health. Literature review and
• update. Claire Anderson

4.2. Evidences – country examples

Source PGEU Annual Report 2013 In Norway (2013) launch

• f a campaign for patients

taking anti-coagulant medication for the first

• time. Outcome: fewer

DRPs. In Spain (2013) conSIGUE project pharmacist led MUR for elderly. Outcome: 30 % reduction of emergency vistis H2

4.3. Evidences – international, national guidelines

Content

• 1. Society needs and challenges
• 2. Why should pharmacists be involved?
• 3. Pharmaceutical care
• 4. Evidences – pharmacists interventions
• 5. Hungarian examples
• 6. Need for better collaboration

5.1. Pharmaceutical Care in Hungary

• Hungarian Chamber of Pharmacists
• Pilot Pharmacy Care Study of Hypertension in Hungary (PIPACH

study)

• Blood pressure sigificantly decreased and patient satisfaction

increased in the intervention group

• Hungarian Society for Pharmaceutical Sciences
• Pharmaceutical care program in headache and in sunburn
• To half of the patients pharmacist suggested a different medication, and

25 %/10 % headache/sunburn of the patients were referred to the GP

• Hungarian Private Pharmacists’ Association
• Diabetes Prevention Program
• 800 community pharmacies; 100 thousand blood-glucose checks
• 23,000 documented interventions, 19 % referal letters to GPs

Diapozitiv 20 H2

Hanbal; 5.5.2014

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• Basic level pharmaceutical care

activities

• Ask your pharmacists
• Dispensing protocols
• Self -medication
• Prescription only

medicines

• Health promotion activities
• Disease specific programs
• Metabolic syndrome,

pharmaceutical care

• Asthma, COPD pharmaceutical

care

5.2. Pharmaceutical Care protocols

• Ministerial decree on pharmacuatical

care

• Pharmacists’ competencies and new

financing methods

• Ministerial guideline on basic level

pharmaceutical care activities

• collaborative development between

pharmacists and GPs

5.3. Developments in regulation and guidelines 5.4. EU funded implementation and guideline development

27/xx

• Health care service quality

accreditation

• inpateint and outpatient care
• Community pharmacy settings

Pharmaceutical care collaborative developments

Content

• 1. Society needs and challenges
• 2. Why should pharmacists be involved?
• 3. Pharmaceutical care
• 4. Evidences – pharmacists interventions
• 5. Hungarian examples
• 6. Need for better collaboration

6.1. Patients are in high risk…

…to prevent this, interprofessional collaboration is needed

• Existing pilot models

– Pharmacotherapy consultation in NL – Quality circles in SW – Home medicines review in AUS – Collaborative Practice Agreements in US

• But not well known area
• Model for working relationships

between pharmacists and physicians1-2

6.2. Research on pharmacists – GPs collaboration

• 1. San Martin-Rodriguez L, Beaulieu MD, D’Amour D, Ferrada-Videla M. The determinants of successful

collaboration: a review of theoretical and empiricalstudies. J Interprof Care 2005 May; 19 Suppl 1: 132-47. 2. McDonough RP, Doucette WR. Dynamics of pharmaceutical care: developing collaborative w orking relationships betw een pharmacists and physicians. J Am Pharm Assoc 2001 Sep-Oct; 41 (5): 682-92.

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6.3. Research on pharmacists – GPs collaboration1

• 1. Ema Paulino et al. Community pharmacists’ and physicians’ inter-professional work: insights from qualitative studies with multiple stakeholders Rev Port Clin Geral 2010;26:590-606

“ (...) I dare say that the majority

• f physicians doesn’t have the

slightest idea of what pharmaceutical care is.” [Phys5:P7]. “shopkeepers”: “They sell medicines as they could be selling shoes.” [Phys2:P7]. “ Have you ever gone to buy a medicine at a pharmacy? Do they give you this big talk? Or just it’s this much, how much was it, hand over x amount, give you a receipt…” [Phys2:P7].

6.4. Research on pharmaceutical care acceptance in Hungary

How much do you agree with the following statments concerning pharmacuetical care?

GPs and specialists median

Totally agree Totally disagree

Patients get more information Useful help for doctors work Effective way of prevention More patients get checked More trust in health care system Enhance adherence Poor patient get more chance for check

• Identified society needs and challenges
• Pharmacists are easiest available
• Development professional background and in

daily pharmacy practice

• But to be more effective:

– harmonization and implementation – better interprofessional (recognition) collaboration needed

Summary

Thank you for your kind attention!