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Dr Helen Flint National Lead Medicines Management

Medicines Management Programme Regional Prescribers’ Forum Cork University Maternity Hospital November 7 th 2013. Dr Helen Flint National Lead Medicines Management Office of the Nursing & Midwifery Services Director

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Dr Helen Flint National Lead Medicines Management

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  1. Medicines Management ProgrammeRegional Prescribers’ Forum Cork University Maternity Hospital November 7th 2013 Dr Helen Flint National Lead Medicines Management Office of the Nursing & Midwifery Services Director Clinical Strategy and Programmes Directorate Health Services Executive, Dublin, Ireland

  2. Unsupervised sources of medicines • Over-the-counter medicines • Medicines purchased overseas • Counterfeit medicines. They include products without active ingredients, or with the wrong active ingredients, or with insufficient active ingredients, or with fake packaging. Sometimes they contain substitutes, or are diluted with foreign or toxic bodies, to increase the quantity of the original medicine • Medicines purchased on the Internet

  3. Irish Medicines Board Patient Survey 2011 • Almost three in four of those surveyed claim to read product information (on the leaflet and label) before taking a prescription medicine for the first time • Among those who do not read the product information, the vast majority qualified this by explaining that their GP or pharmacist give them the necessary information • 67% read the product information before taking an over the counter medicine for the first time • One quarter of adults (25%) use the internet as a source of information about medicines. Of the 1 in 4 consumer who do go online 30% are attempting to diagnose health symptoms (self diagnosis) • Half (49%) of those surveyed always seek advice from a healthcare professional– typically a pharmacist – before taking a new over the counter medicine • GPs (68%) and pharmacists (25%) are by far the most trusted sources of medicines advice

  4. Effect of patient payment status • 80% antibiotics prescribed by GPs • Recent study compared GMS with private • GMS 54 years: private 34 years • Antibiotics prescribed at 3,407 consultations • Private patients were 23% more likely to receive a prescription for antibiotics overall • Private patients were more likely to receive a delayed or deferred prescription • In general patient <65 years less likely to receive a prescription • ?private patients present at a later stage or unwillingness to return for a second visit due to cost • Authors suggest patient expectation NMIC, 2011

  5. Non-adherence • “A worldwide problem of striking magnitude” (WHO, 2010) • Improving adherence has become a priority • 30-50% of patients do not take their medication for chronic conditions as prescribed • Cost of non-adherence is a missed opportunity for treatment gain • Unused or unwanted medicines £millions annually • 75% reported a visit to community pharmacy in last 6 months

  6. Medication adherence • Poor adherence and persistence in chronic disease • Poor persistence in prevention of osteoporosis • Medical model does not sit with the theory of concordance • Taking medicines according to the instructions • Unintentional drug misadventure e.g., nebulisers and inhalers • Completing the course of drug therapy • Drug may make the person feel unwell e.g., nausea, dizziness, alteration of bowel habit, frequency of micturation • Drug may not improve the problem • May have problem swallowing • People may share medications • People may confuse medicines

  7. Women who stop taking their prescribed hormone tablets after surgery to treat breast cancer are almost three times more likely to have their cancer reoccur • 1400 Irish women • Up to 30% of women will discontinue hormone treatment, with another 20% not taking as many as one in five of their doses • Early identification of women experiencing side-effects, the availability of effective supportive pharmacologic and psychological care, and the timely switching to alternative hormonal therapies could make a significant impact on patients adhering to their medication, and thereby improve their chances of living longer” • The full paper is available from the British Journal of Cancer at: http://www.nature.com/bjc/journal/vaop/ncurrent/full/bjc2013518a.html  

  8. Key performance indicators • Specific and measurable elements of practice that can be used to assess quality of care • Act as flags or alerts • Capture trends • Inference about quality • Medicines Management pilot Q4 2013

  9. Medicines Reconciliation • The process of obtaining an up-to-date and accurate medication list that has been compared to the most recently available information and has documented any……. • Resulting in: “a complete list of medications, accurately communicated” www.ihi.org 9

  10. Non-pharmacological interventions Patient expectation from Doctors visit is treatment: most commonly a prescription; medicines are regarded as something that will fix the problem Other interventions are non-reimburseable in Ireland Dietary i.e., specialist drinks, probiotics, supplements &C Counselling Breathing re-training Relaxation and teaching coping and adaptation strategies Heat and cold TENS (Transcutaneous Electrical Nerve Stimulation) Behavioral symptoms associated with dementia: range of interventions Acupuncture

  11. Medicines Management Programme: over-arching aim “Our vision is that people everywhere have access to the essential medicines they need; that the medicines are safe, effective and of assured quality; and that they are prescribed and used rationally” Essential Medicines and Pharmaceutical Policies (WHO, 2010)

  12. National Medicines Care Programme • IMPROVE MEDICINES SAFETY • Reduce medicines-related hospital admissions, morbidity and mortality • ENSURE PATIENTS HAVE ACCESS TO THE MEDICINES THEY NEED • Access to medicines based on need and is evidence-based • REDUCE COST • Ensure rational prescribing for the five most expensive drug groups • Introduce systems for switching to equally effective and less expensive alternatives where opportunities arise • IMPROVE MEDICINES ADHERENCE • Ensure patients are on the right medicines • Ensure patients understand the rationale for the medicine choices • Support patients with taking their medicines correctly to improve health and reduce wastage

  13. ‘Preferred’ Medicines Although there are no head-to-head trials, clinical experts do not consider there to be clinically significant difference between the currently authorised agents Guidelines for good medication management would involve selecting the cheaper of two options In line with list of interchangeable drugs in new pharmacy system Open discussions with patient representatives Preserve clinical freedom: exception rather than rule

  14. Preferred Medicines April 2013 Medicines Management Programme identified both the ‘preferred’ statin and PPI for Ireland Traditionally account for @20% expenditure under the GMS scheme PPIs used for the management of various GI conditions for many years No direct comparative efficacy studies: however repeated scientific reviews suggest that any differences in efficacy noted are of negligible clinical relevance The MMP has indicated that lansoprazole should be considered as the PPI of first choice and switching from other PPIs could save over € 23 million per annum

  15. simvastatin is the most cost-effective statin and therefore should be considered as the statin of first choice; An alternative statin should be considered for patients on concomitant medications with a potential to interact with simvastatin and those where simvastatin is contraindicated; Full prescribing information is available on www.medicines.ie/www.imb.ie.

  16. As part of the Preferred Drugs initiative the Medicines Management Programme (MMP) is considering two further drug classes; • selective serotonin re-uptake inhibitors (SSRIs) • serotonin noradrenaline re-uptake inhibitors (SNRIs) These drug classes are being reviewed with the aim of recommending the preferred SSRI and SNRI to prescribers in the first quarter of 2014

  17. The SSRIs being considered for inclusion in the Preferred Drugs initiative are: • citalopram • escitalopram • fluoxetine • fluvoxamine • paroxetine • sertraline These drugs are used for a wide range of conditions including depression, generalised anxiety disorder, panic disorder, etc.

  18. The SNRIs for consideration are: • venlafaxine • Duloxetine • The MMP now invite submissions from stakeholders to inform the selection process which will consider a range of criteria including licensed therapeutic indication(s), clinical outcome data, clinical guidelines, cost, patient factors and prescribing trends in Ireland. • Submissions should be made to: The National Centre for Pharmacoeconomics, St. James’s Hospital, Dublin 8 or info@ncpe.ie 

  19. The Medicines Management programme (MMP) has recently reviewed prescription data from the PCRS database for pregabalin and gabapentin for 2012; There was a steady rise in pregabalin prescribing with a monthly ingredient cost of pregabalin to the PCRS of € 2 to 3 million; this represents a 10-foldincreased cost compared with gabapentin ingredient cost during the same time period.

  20. Pregabalin is licensed in the EU for • the treatment of adult neuropathic pain, • adjunctive therapy in adults with partial seizures (with or without secondary generalisation) and • treatment of generalised anxiety disorder in adults. • The dose range is 150- 600mg/day (given in 2 or 3 divided doses) • Evidence of sub-optimal prescribing In the absence of overwhelming evidence of superiority of one drug over another, the review states it would seem sensible to use the lowest cost agent first

  21. Source of concern with algorithms? Irish health service is not used to working within strict parameters USA: Funding depends on adhering to standards (BTA) UK: Funding directed by NICE which has statutory powers (BTE) The argument is “medicine by numbers” Decisions made clinicians who are used to debating Declarations of interest: Irish infrastructure includes funding by pharmaceutical industry

  22. Target areas for safe, effective and cost-effective prescribing Generic medicines Oral nutritional supplements Proton pump inhibitors (PPIs) Statins Pregabalin (f an average of 10 patients in every practice in NI. were switched from a two twice daily dose of pregabalin to a one twice daily dose (of double the strength) this could save almost £3 million for the health service) New oral anticoagulants HSE Funding of New Medicines (evidence-based) Ace-inhibitors (angiotensin-converting enzyme) ARBs (angiotensin receptor blockers: hypertension, heart failure &C)

  23. New oral anticoagulants 1% adults have atrial fibrillation Dabigatran (pradaxa) rivaroxaban (@Xarelto) apixaban (Eliquis) appear to be at least as efficacious and safe as warfarin No antidote to reverse Patients should have creatinine clearance checked (Lancet Neurol. 2012; 11: 1066-1081) Cost effectiveness

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