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Pharmaceutical care in Europe Latest developments

Pharmaceutical care in Europe Latest developments. Dr. J.W.Foppe van Mil Community Pharmacist Professional Secretary PCNE. Question 1. How far are we in implementing pharmaceutical care by pharmacists in Europe? What are the issues?. Question 2.

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Pharmaceutical care in Europe Latest developments

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  1. Pharmaceutical care in EuropeLatest developments Dr. J.W.Foppe van Mil Community Pharmacist Professional Secretary PCNE

  2. Question 1 • How far are we in implementing pharmaceutical care by pharmacists in Europe? What are the issues?

  3. Question 2 • Have we managed to prove in Europe that pharmaceutical care by pharmacist improves the patients’ outcomes (ECHO model)? • Clinical outcomes • Economical outcomes • Humanistic outcomes • quality of life: = the outcome that matters for the patient • satisfaction

  4. Content • How to assess the status of pharmaceutical care • Latest literature • Status disease-wise • What still needs to be done • Conclusion

  5. How to assess the status of pharmaceutical care • Literature review • Talk to colleagues, be part of PCNE, ESCP and Europharm • Listen to many speakers at conferences • Ask questions…… • Do we then get the answers?

  6. Challenges especially in Europe • Varying health care systems • Different roles of pharmacists • Varying definitions of what constitutes pharmaceutical care • Different terminologies • Inaccessible languages • Example: Farmacia hospitalaria : órgano oficial de expresión científica de la Sociedad Española de Farmacia Hospitalaria in Spanish) • Many national and even local pharmacy practice publications, that are not in Medline or any other database

  7. Recent Issues • Implementation & barriers • Several papers on ethics and legislation • Role of pharmacists vs staff • Relationship with other health-care professionals and with the patient (UK) • Adapting and working with instruments e.g. Beers Criteria for medication reviews

  8. Beers criteria, developments • Beers criteria are an instrument to conduct a comprehensive medication review in the elderly, first published in the US in 1991 • Expert panel identified 19 drugs that should generally be avoided and 11 doses, frequencies, or durations of use of specific drugs that generally should not be exceeded. • Example: certain medicines should not be prescribed to the elderly e.g. short acting benzodiazepines, long acting barbiturates etc. • Instrument not appropriate for use in European countries because of the differences in national drug formularies and prescribing practices and attitudes. • Effectiveness of instrument depends on its setting: must be adapted to time, population, national drug selections.

  9. Beers criteria, adaptations • Update by Beers et al in 1997 (for US) • Update by Flick et al in 2003 (for US) • 2006 Language/culture and medicine adaptation for Portugal (de Olivieira) and France (Larochet) • 2007 Language/culture and medicine adaptations being done for Germany, Poland and the Netherlands • But …. adaptations make international comparisons more difficult.

  10. Publications

  11. Overviews/reviews van Mil JWF. Atención Farmacéutica en Farmacia Comunitaria en Europa, retos y barreras [Pharmaceutical Care in Community Pharmacy in Europe, challenges and barriers]. Pharm Care Esp 2000;2:42-56. Berenguer B, La Casa C, de la Matta MJ, Martin-Calero MJ. Pharmaceutical care: past, present and future. Curr Pharm Des 2004;10(31):3931-3946. Martin-Calero MJ, Machuca M, Murillo MD, Cansino J, Gastelurrutia MA, Faus MJ. Structural process and implementation programs of pharmaceutical care in different countries. Curr Pharm Des 2004;10(31):3969-3985 van Mil JWF, Schulz M. A review of Pharmaceutical Care in Community Pharmacy in Europe. Harvard Health Policy Review2006;7 (1):155-168

  12. Annals series • Series of articles on Community Pharmacy in the world in Annals of Pharmacotherapy • Ongoing series coordinated by people in US, Europe and Australia • Publications from Eastern Europe and Asia still lacking

  13. Focus of Annals publications(1)

  14. Focus of Annals publications(2)

  15. Focus of Annals publications(3)

  16. Activities in the Netherlands Individualised pharmaceutical care 1. Medication surveillance and coaching. 2. Medication analysis based on selections with indicators 3. Disease oriented projects 4. Special instructions at therapy initiation 5. Home care and OTC counselling Supporting activities • Seamless care data transfer • Pharmacotherapy discussions with physicians

  17. Disease oriented Pharmaceutical Care

  18. Asthma • Germany: Community pharmacy-based pharmaceutical care for asthma patients: Positive impact on humanistic and clinical outcomes. Mangiapane et al. Ann.Pharmacother. (2005). • Belgium: Medication use and disease control of asthmatic patients in Flanders: a cross-sectional community pharmacy study: No intervention yet, test of Instrument. Mehuys et al. Respir.Med (2006). • Review: More favourable PC outcomes were associated with use of all elements of PC, independent pharmacies, pharmacist certification, a detailed PC protocol, targeting patients with uncontrolled asthma, and a practice system facilitating innovation PC. McLean et al. Ann Pharmacother (2005) • Other positive data from Denmark (Herborg), Spain (Andrès), Malta (Cordina), N. Ireland(Cordina) and Netherlands (van Mil, Stuurman-Bieze)

  19. Diabetes • Review: Sensitivity of Patient Outcomes to Pharmacist Interventions. Part I: Systematic Review and Meta-Analysis in Diabetes Management. General conclusion: HbA1C levels are sensitive to pharmacist interventions. Machado et al. Ann.Pharmacother. (2007, not only Europe). • Switzerland: Pharmaceutical care model for patients with type 2 diabetes: integration of the community pharmacist into the diabetes team-a pilot study: Reduction in HbA1c and cholesterol values.Wermeille et al. Pharm.World Sci (2004). • Belgium: Medication use and disease management of type 2 diabetic flemish patients: Pharmacist should take a role. Mehuys et al. Pharm World Sci (2007) • Norway: Diabetes care in pharmacy. 30% Of pharmacist involved in diabetes care. Kjome et al. PWS (2007 on-line first.)

  20. Tuberculosis • Turkey: Effect of pharmacist-led patient education on adherence to tuberculosis treatment: Improved adherence. Clark et al. Am.J Health Syst.Pharm. ( 2007)

  21. Hypercholesterolaemia • Spain: Pharmaceutical care in hiperlipemic drug patients. Decrease in the mean values of total cholesterol and triglycerides. Cardo Prats et al. Pharm Care Esp (2001). • Germany: Pharmaceutical care in patients with disturbed lipaemic patterns:Improved lipid profiles, improved compliance. Birnbaum et al. Pharm.Ztg. (2003). • Belgium: Effect of intervention through a pharmaceutical care program on patient adherence with prescribed once-daily atorvastatin: improved compliance and persistence. Vrijens et al. Pharmacoepidemiol.Drug Saf 15 (2):115-121, 2006.

  22. Parkinsons’ disease • UK: Pilot in PhC in community pharmacy of Parkinson patients: Increased compliance. Minors et al. Pharm J (2007): • Scotland: Effect of educational intervention on medication timing in Parkinson's disease: a randomized controlled trial: Improved timing adherence. Grosset KA et al. BMC Neurol. (2007).

  23. Migraine • Denmark: Pharmaceutical Care in borderline Migraine. No clear impact. Soendergaard et al. Scand J Prom Health Care (2006).

  24. Congestive Heart Failure (CHF) • Spain: Post discharge Pharmaceutical care in heart failure: Reductions in readmissions and hospital stay.Lopez Cabezas et al. Farm.Hosp (2006). • UK: Medicines management in Coronary Heart Failure. But: no positive impact. Holland et al, (BMJ 2007).

  25. Over The Counter • In the past there have been many studies in the past in the field of Over The Counter medication. • These studies show a positive impact of counselling on behaviour and satisfaction • In many countries OTC counselling has been implemented in practice, and structured • But…… Counselling is not pharmaceutical care! and there has been no follow-up • Impact of PhC on outcomes in OTC medication remains an important field for study!

  26. Comprehensive Drug Use Review (1) Community • Netherlands: FTOs: Latest report of DGV indicates 808 pharmacotherapy discussion groups in NL, of which more than 50% function optimally. DGV report 2007 • UK: Home-based medication review in a high risk elderly population in primary care--the POLYMED randomised controlled trial: Had only impact on number of medicines (economics?).Lenaghan et al. Age Ageing 2007. • UK: Review in chain pharmacies. Study from University of Nottingham to be published. • Poland: Polypharmacy and potential inappropriateness of pharmacological treatment among community-dwelling elderly patients: it is a frequent problem in Poland, and a project has been started. Rajska-Neumann et al. Arch Gerontol.Geriatr. (Suppl 2007).

  27. Comprehensive Drug Use Review (2) Hospital • France: Implementation of a Canadian Pharmaceutical Care model in a French paediatric department. Many DRPs detected and solved. Proth Labarthe et al. Arch Pediatr (2007). • N. Ireland: Preventing hospital readmissions by medicines management: Rate of, and time to readmission decreased.Scullin et al. J Eval Clin Pract (2007) • Belgium: Improving appropriateness of prescribing in elderly people admitted and discharged in hospital, pilot. Successful: improved appropriateness.Spinewine et al. Ann Pharmacother (2006) J Am Geriatr Soc (2007).

  28. Comprehensive Drug Use Review (3) Nursing homes • UK: Pilot of transfer Fleetwood model for Drug Use Evaluations in nursing homes from the USA. Barrier is seamless access to medical data.Huges C et al. Pharm World Sci (2007) • Netherlands: A study of medication reviews to identify drug-related problems of polypharmacy patients in the Dutch nursing home setting: 3,5 problems per patient found, 1.7 problems solved at follow up. Finkers et al. J Clin Pharm Ther (2007).

  29. Discussion • Non-significant findings are usually not reported. • In case of pharmacist interventions, however, non-significant findings are sometimes reported in especially medical journals (sic!) • Magnitude of the effects of pharmaceutical care interventions also depends on the current state of healthcare: impact of a diabetes intervention will potentially be largest in countries where the diabetes patients are badly regulated.

  30. Conclusion (1) • Disease oriented pharmaceutical care does have a proven effect on intermediate outcomes like adherence and (of course…) patient satisfaction. • Comprehensive medication review has an impact on the appropriateness of the pharmacotherapy, but real effects on the ECHO outcomes have not yet been firmly established. • More insight into the real implementation of pharmaceutical care in Europe is urgently needed

  31. Content • How to assess the status of pharmaceutical care • Latest literature • Status disease-wise • Status of the implementation • What still needs to be done

  32. Conclusion • My personal impression is that pharmacists, and especially their organisations in most countries are still too busy with M&Ms (management and money) • Pharmacists and their associations should realise that the value of the profession to society can not be measured in Euros earned, but in the impact they have on the outcomes that matter to the patient. • The question if pharmacists must provide pharmaceutical care lies behind us: yes we must; please start

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