Laurence A Goldberg
The hospital–primary care continuum was the theme of the third ESCP spring conference on clinical pharmacy held in Portoroz, Slovenia, in May. Plenary sessions and workshops explored the ways in which pharmaceutical services were delivered and considered how they might be improved.
Dr Kathleen Johnson (Associate Professor, Departments of Pharmacy and Pharmaceutical Economics and Policy, University of Southern California, Los Angeles) spoke about a disease management programme in asthma that has reduced costs per patient by 40%. There had also been an improvement in the management of community-acquired pneumonia (CAP).
Disease state management (DSM) is a comprehensive, integrated approach to providing healthcare and reimbursement based on the natural course of a disease, with treatment designed to address the illness by maximising the effectiveness and efficiency of care delivery. The emphasis is on preventing disease and/or managing it aggressively where intervention will have the greatest impact.(1)
Disease management aims to optimise clinical, economic and humanistic outcomes, in contrast to the traditional “component management” approach to the delivery of healthcare and cost control. DSM programmes work best in situations where there are published, evidence-based guidelines for the treatment of a given condition and measurable goals or outcomes. Examples of DSM programmes include: HIV/AIDS, asthma, chronic obstructive pulmonary disease (COPD), congestive heart failure and diabetes (see also Table 1).
In the USA it is not only hospitals that are involved in DSM – the pharmaceutical industry and pharmacy benefit managers (organisations that negotiate prices of pharmaceuticals for hospitals) are also involved. There are several reasons for the growth in DSM programmes in recent years, including pressure from employers who purchase health insurance plans and pressure from policy-makers. The consumer influence is also significant. “Consumers are dissatisfied with managed care that focuses on cost alone,” said Dr Johnson.
Two studies concerned with respiratory disease demonstrated benefits. In one, the impact of clinical pharmacy services on the management of community- acquired pneumonia (CAP) was assessed. This is an important topic in the USA because compliance with treatment guidelines for CAP is now required for accreditation of hospitals by the Joint Commission on Accreditation of Hospital Organizations (JCAHO). The results showed that hospital pharmacists were able to ensure that the correct drug treatment was started and was given promptly, within eight hours of admission. Another study examined the effects of a disease management programme for asthma that involved pharmacists in the assessment and education of patients. More than 200 pharmacists were involved, receiving a payment of $25 (e25.60) per consultation. Healthcare costs per patient were reduced by 40%, and patients’ quality of life improved.
There are few data on the overall impact of DSM programmes. The programmes tend to use selected patients, which might lead to an overestimation of the benefits. Such programmes also fragment care because they focus on a specific disease instead of the whole patient. There is also the risk of a conflict of interest in programmes run by pharmaceutical companies.
In Europe, elements of disease management have been implemented; for example, in France, mandatory treatment guidelines have been introduced in an effort to contain drug costs.(2) Doctors could be fined up to e. 3,000 for failure to comply.
In the Netherlands, electronic networking between doctors and pharmacists is commonplace, generic substitution by pharmacists is encouraged, and quantities of medicines on prescriptions are limited.
In summary, Dr Johnson said that there is little published evidence of activity in the field of disease management among pharmacists, and that closer collaboration between hospital and community pharmacists would be an important step.
Pharmacovigilance is concerned with quality, safety and economics as new information is accumulated under normal conditions of use, explained Dr Noel Wathion of the European Medicines Evaluation Agency (EMEA). Therefore adverse drug reactions (ADRs) that occur during clinical trials do not fall into this category, he emphasised. Pharmacovigilance obligations apply to all authorised medicinal products, irrespective of the marketing authorisation process.
A total of 67 countries currently participate in the WHO programme for drug monitoring, reported Marie Lindquist (Uppsala Monitoring Centre, Sweden), as she described some of the practical problems in the detection and classification of ADRs. In the 40 years since the thalidomide disaster, better regulation of drugs has been achieved and the science of pharmacoepidemiology has been developed along with growth in international cooperation. However, there is still room for improvement in the reporting and use of patient data and in communicating information that is useful for diagnosis and management of ADRs.
According to Ms Lindquist, one of the main difficulties in diagnosing ADRs is the limited education of doctors in this area. The so-called “seven deadly sins” of not reporting are also important factors (see Table 2).
The absence of treatment guidelines for the management and prevention of ADRs is a problem that needs to be solved using a combination of education, information, communication and cooperation. There are also many problems with coding and data transfer. The translation of complex data into structured information and the ability to store and retrieve complex text are key issues. “The challenge is making this available to all centres, not just the rich ones,” said Ms Lindquist. Another issue is the inclusion of patients as partners in this venture, which, she noted, is not always taken into consideration.
International collaboration also brings a host of potential problems. Ms Lindquist suggested that we should learn from each other’s experiences – not reinvent the wheel but fill the gaps. We should also optimise the use of different competencies and resources, so that results can be brought together rather than duplicated. She felt that harmonisation should be about building bridges rather than enforcing standardisation.
Ms Lindquist concluded her talk by reinforcing the point that collaboration and communication are the keys to further progress, and regulatory and IT developments should support the pharmacovigilance process, but not run it.
Hospital and community pharmacists
It is important to ensure the continuity of pharmaceutical care when patients leave hospital, and this requires good communication between hospital and community pharmacists, said Dr Georges Zelger (Chief Pharmacist, Hôpitaux du Nord Vaudois et de la Broye, Yverdon-les-Bains, Switzerland). One good example of community pharmacists delivering pharmaceutical care was a study carried out in Scotland in which the community pharmacists’ input to the multidisciplinary care of patients with type 2 diabetes was evaluated.(3) The results showed significant improvements in haemoglobin A(1c), blood pressure and total cholesterol. Patients’ knowledge about their medications also improved significantly.
A study in the Netherlands revealed the potential for transfer of information from the community pharmacy to the hospital. The researchers had reviewed the hospital medication records (HMRs) of 304 patients and compared them with the community pharmacy records. The results showed that 25% of prescription drugs were not recorded in the HMRs, and 61% of patients had one or more drugs not recorded. The full records were readily available and could easily be sent to the hospital when patients were admitted.
Shorter hospital stays have increased the demand for high-quality services from community pharmacies, said Ms Liisa Eskelinen (Community Pharmacist, Sysmä, Finland). Increasingly, patients are receiving complex treatment at home in a “hospital without walls”, and this often gives rise to practical problems. One such problem is determining who is responsible for drug costs – it could be the hospital, the insurance company or the patients, and sometimes it is necessary for all parties to adopt a flexible attitude, she said.
Finnish community pharmacies are well staffed with highly trained individuals. The average community pharmacy handles 50,000 prescriptions annually and employs six or seven pharmacists in addition to the owner, who holds a Master’s degree. The majority of pharmacy sales (96%) are medicines, and 80% of these are prescription products. It is no longer enough just to dispense, she said; patients need new services near to where they live, and community pharmacists are the experts in drug treatment. It is important to understand that the effectiveness of good clinical pharmacy services could be undermined if patients are in a hurry or worried about their illnesses. It is also important to realise that the doctor might overestimate a patient’s ability to cope with a particular type of treatment.
Considering what makes good practice in community pharmacy, Ms Eskelinen said, “We must make sure that the patient meets a professional when he/she comes into the pharmacy.” There should also be the facility for private discussion. Up-to-date education and training for pharmacy staff is essential – in larger pharmacies it is possible for some individuals to specialise, she added. Pharmacists should also keep in mind that pharmacy is only a part of the overall healthcare system, and they should cultivate good links with other healthcare professionals, including hospital pharmacists. “In Finland, we have much more contact with doctors and nurses than we have with hospital pharmacists ,” she lamented.
Medication counselling by email is a service that has been set up by one community pharmacy in Ljubljana in Slovenia. Mr Bostan Debeljak described how he and his colleague, Ms Irina Korosec, established their website in August 1998 (www.lekarna-lj.si). The site was set up to provide information and advice and is not concerned with the sale of medicines.
Enquiries via the website are very similar to those they receive from patients in the pharmacy or over the telephone. Fifty per cent of enquiries consist of simple questions about product availability, prices or side-effects of medicines. Enquirers are usually advised to visit their local pharmacy for these. Difficult or demanding questions account for 35% of the workload, and these relate to minor health problems or, occasionally, requests from students for help with projects. Fifteen per cent of questions are categorised as “very demanding”, which are time-consuming and “nerves- consuming”, according to Mr Debeljak. This group includes requests for advice about complex treatment, situations where the patient is obviously anxious or distressed, and questions that indicate that the patient is considering an inappropriate use of a medicine or chemical substance. In these cases they try to give an answer as soon as possible, but if the situation is critical the pharmacists recommend immediate referral to a doctor.
One of the major advantages of this scheme is that patient counselling is documented. The main drawback is that it takes time to produce a written reply. Ninety-five per cent of email consultations came from Slovenia; the remainder came from overseas, usually because the enquirer wanted an answer in Slovenian.
In the poster discussion session, Ms Barbara Milliken (United Hospitals, Antrim, UK) described how a team of pharmacy technicians had been trained to educate patients about correct inhaler use. Clinical pharmacists are now able to refer patients to trained technicians for this service. The training programme included one classroom teaching session and a series of supervised patient education sessions.
The results so far show that the average education session took 15 minutes, and technicians recommended a change of inhaler on 20% of occasions. The initiative had been well received by nurses and doctors, and the technicians themselves had found the experience rewarding. Asked if this model might be applicable to other therapeutic areas, Ms Milliken suggested oral anticoagulation as another suitable topic.
- Navarro RP, editor. Managed care pharmacy practice. Gaithersburg, MD: Aspen; 1999. Chapter 16.
- Durand-Zaleski I, Colin C, Blum-Boisgard C. An attempt to save money by using mandatory practice guidelines in France. BMJ 1997;315:943-6.
- Wermeille J, Bennie M, Brown I, et al. Pharmaceutical care model for patients with type 2 diabetes: integration of the community pharmacist into the diabetes team. In press 2002.
WHO Collaborating Centre for International Drug Monitoring
European Society of Clinical Pharmacy
31st European Symposium on Clinical Pharmacy
Innovation in drug therapy and health policy. Patient’s rights and economic constraints
30 October – 2 November 2002