James C. McElnay School of Pharmacy The Queen’s University of Belfast

1. James C. McElnaySchool of PharmacyThe Queen’s University of Belfast Pharmaceutical care in community pharmacy

2. Pharmaceutical care Three main components: • ensure patient is receiving optimal drug therapy (minimise drug related problems) • patient education (illness, medication, healthy lifestyle, treatment goals, need for compliance with medication regimens) • monitoring patient outcomes • self-monitoring plan • monitoring of goal achievement

3. Outcomes of Pharmaceutical Care • cure of a disease (CAP) • elimination or reduction of a patient’s • symptomatology (asthma; diabetes, PUD) • arresting or slowing of a disease process (rheumatoid arthritis; diabetes; CHF; COPD) • preventing a disease or symptomatology (smoking cessation)

4. H.Pylori eradicationBrit. J. Clin. Pharmacol. (2002) 53,163-171.

5. Methods • Study design • Prospective, randomised, controlled clinical trial • Combination therapy used • Lansoprazole, amoxicillin and clarithromycin • Patients • Endoscopy confirmed PUD with H. pylori • Intervention group (n = 38 ) • Control group (n = 38) • Pharmaceutical care intervention • Patient education (disease / need for compliance with treatment) • F/U telephone call midway through therapy

6. Adherence rate

7. Eradication rate

8. Conclusions • H pylori eradication rate and compliance rate were significantly increased • Significant difference between the routine clinical practice and counselling enhanced treatment • Involvement of pharmacist led to improved cost-effectiveness of treatment

9. Question • What percentage of community pharmacists provide robust advice to, and follow-up adherence checking of, patients who are receiving H. pylori eradication therapy?

10. Pharmaceutical care of asthma patients J. Appl. Ther. (1997) 1, 145- 161 Pharmacotherapy (2001) 21, 1196-1203.

11. Comparison of inhaler scores in controls and in patients receiving education/monitoring intervention * p<0.05 * * * 100 1 0 9 0 8 50 7 % Inhaler score (±95% CI) 6 5 0 4 0 1 2 3 4 5 6 Assessment period: 1-3 baseline, 4-6 intervention Inhaler scores in control Inhaler scores in patients receiving education J. Appl. Ther., 1, 145-161 (1997)

12. Comparison of prophylactic asthma treatments used in the first 6 months and last 6 months of study period FIRST SIX MONTHS 50% LAST SIX MONTHS 40 30 20 10 0 Oral Steriods Inhaled Theophyllines Intal Steroids Medications

13. Asthma International Perspective • Northern Ireland • Netherlands • Belgium • Iceland • Denmark • Malta

14. Conclusion Positive Impact on: • Health Related Quality of Life • Inhaler Technique • Peak Expiratory Flow • Self-Reported Symptoms • Pharmacist-patient Relationship • Hospitalisation?

15. Question • What percentage of community pharmacists provide good pharmaceutical care / medicines management to their asthma patients?

16. Care of elderly patients Pharmacotherapy (1999) 19,860-869 Pharm. World Sci. (2003) 25, 218-226 Pharmacoeconomics (2003) 21, 455-465 Clin Drug Invest (2003) 23, 119-128 Brit. J. Clin Pharmacol. (2005) 60, 183 - 193

17. Question • What percentage of community pharmacists provide good pharmaceutical care / medicines management services to all their elderly patients?

18. Individualised smoking cessation programme (PAS)Pharmacoeconomics (1998) 14,323-333Addiction (2001) 96, 325-331.

19. Aim of smoking cessation study The aim of the study was to examine, in a randomised controlled clinical trial, the success of the PAS model as a method of smoking cessation in the community pharmacy setting.

20. The PAS Smoking Cessation Model STEP 4 STEP 3 To support and monitor smokers wishing to stop smoking STEP 2 Gaining your client’s commitment to stop smoking To identify what type of help and support your client’s need to stop smoking STEP 1 To encourage and motivate clients using the pharmacy to stop smoking

21. Intervention subjects (PAS) • Verbal advice and leaflets • Client’s NRT needs and position on the cycle of change assessed • Details of intervention recorded on individual patient file • Return visit at established intervals

22. Control subjects • Normal practice as usually performed in pharmacy (including use of NRT) • Patient profile sheet completed • Contact 3, 6 months and 1 year for feedback on smoking status

23. Outcome Measures • Self reported smoking cessation at 3, 6 and 12 months • Cotinine confirmed smoking cessation at 12 months • Pharmacist views on the service (focus groups)

24. Results • Intervention (PAS) (n=265) • 14.34% smoking abstinence at 1 year (n=38) • Control (ad hoc) (n=219) • 2.74% smoking abstinence at 1 year (n=6) • PAS significantly increases cessation rates (P<0.01)

25. Sensitivity Analysis Sensitivity analysis cost per life year saved per successful intervention* Uptake rate (50% - 75%) £227.78 - £276.65 Throughput rate (10 - 30 patients/yr) £318.09 - £262.97 Success rate (5 - 25%) £553.14 - £110.75 Natural cessation rate (0 - 2%) £213.20 - £364.04 Relapse Rate (0 - 15%) £249.22 - £293.27 Fixed costs (£40,000 - £70,000) £265.62 - £288.29 Variable costs (£15 - £45 /patient) £159.26 - £394.65 Discount rate (3 - 5%) £213.22 - £361.42 cost per life year saved per successful intervention based on a 45 year old male

26. Conclusions • PAS model is much more cost-effective that a number of other disease prevention practices e.g. hyperlipidaemia treatment • A clear case can be made for NHS remuneration of this pharmacy service

27. Question • What percentage of community pharmacists provide robust smoking cessation programmes?

28. Integrated Medicines ManagementJournal of Evaluation in Clinical Practice (2007) 13, 781-788.

29. Integrated Medicines Management (IMM) Healthcare organisations face major challenges including: • Suboptimal prescribing • Poor patient adherence to prescribed medication regimens • Adverse drug reactions and interactions • Medication administration errors • Inadequate communication across the primary/secondary interface

30. IMM readmission statistics

31. Influence of medicines management on patient knowledge of medicines

32. Prescription queries Prescription queries

33. Medication storage seen during home visits

34. Drug reactions / interactions and OTC use

35. Adherence issues

36. Patient understanding / monitoring

37. Question • What percentage of community pharmacists provide robust integrated medicines management services to patients?

38. Behavioural Pharmaceutical Care Scale (BPCS)N. Ireland 1996 vs 2006AJHP (1998) 55, 2009-2013.

39. BPCS Scores 1996 vs. 2006

40. BPS Scores 1996 vs. 2006

41. BPS Scores 1996 vs. 2006

42. BPCS Response Rate 1996 45.5 (n=230) 2006 41.4% (n=213) Mean Scores 1996 74.7 + 19.3 [46.7% of achievable score] 2006 74.1 + 19.2 [46.3% of achievable score] (maximum possible score = 160)

43. Translation of Research Bench → Bedside Clinical Trials → Policy and Routine Practice Translation Translation

44. Community Pharmacy - untapped healthcare resource • Community pharmacists trusted by patients • Highly trained healthcare professionals available without appointment in the High Street • We have run a number of successful initiatives (in collaboration with GPs) via community pharmacies • Care of asthma patients • Repeat dispensing • Smoking cessation • OTC drug abuse • Care of elderly patients • Medicines management • Treatment of URTIs (minor ailment scheme)

45. Questions • Does the responsibility of researchers end when trials are completed and published? • Who is responsible for translating research results into policy and routine practice? • Why is policy often not evidence based, e.g. emergency hormonal contraception and pharmacist prescribing in the UK introduced ahead of robust research? • Do researchers keep pharmacy services negotiators fully informed of research outcomes and is this evidence used in negotiations with payers?