Community Pharmacists Provision of Pharmaceutical Care to the Older Adult R. Grymonpre L. Vercaigne...
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Transcript of Community Pharmacists Provision of Pharmaceutical Care to the Older Adult R. Grymonpre L. Vercaigne...
Community Pharmacists’
Provision of Pharmaceutical Care to the Older Adult
R. GrymonpreL. VercaigneC. MetgeP. Montgomery University of Manitoba
Community Pharmacists’ Expanded Role
“There is strong evidence that clinical pharmacy services add value to patient care and reduce health care utilization costs….clinical services are not widely provided in community pharmacy settings”
The Clinical Role of the Community Pharmacist. Office of the Inspector General, USA. January 1990
“The judicious use of the professional qualifications of pharmacists [is encouraged]”
The Rational Use of Drugs by the Elderly: A Strategy for Action. Government of Quebec. 1995
“National action to ensure appropriate use of all medication will require the active participation of …[seniors, physicians, pharmacists, nurses, governments, industry, family members and caregivers]”
Federal/Provincial/Territorial Strategy for Action. Health Canada. June 1996
Community Pharmacists’ Expanded Role
“The pharmacist is in an excellent position to monitor seniors’ medication use at the point of dispersal”
Optimizing Medication Use in Seniors Receiving Home Care. Canadian Association Community Care. August 1997
“Pharmacists are perhaps both the most important – and least utilized – source of information and education about medications”
Seniors, Diversity & Access: Medication Use & “Hard to Reach” Seniors. National Pensioners and Senior Citizens Federation. May 1997
“Pharmacists can play an increasingly important role as part of the primary health care team……this expanded role would allow pharmacists to consult with physicians and patients, monitor patients’ use of drugs, and provide better information and communication on prescription drugs.”
Building on Values: The Future of Health Care in Canada Final Report. Romanow RJ. (Commissioner) November 2002
Community Pharmacists’ Expanded Role
Cochrane Review: • increased scheduled health services but no decrease in
hospital and ER admissions (1 of 7 studies);• decreased hospital/ER admissions, number of specialty
physician visits, numbers or costs of drugs, improved appropriateness of drugs (6 of 7 studies);
• improvements in targeted condition but no change in quality of life or incidence of ADR (10 of 13 studies);
• improvements in patient adherence (3 of 6 studies)• favorable changes in physician prescribing (9 of 10
studies)
Beney J, Bero L, Bond C. Expanding the roles of outpatient pharmacists: effects on health services utilisation, costs, and patient outcomes (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
Geriatric Pharmaceutical Care
2001: 12.5% Canadians 65+ years old
2026: 20% of Canadians 65+ years old
In Manitoba (1996):13.6% of population 65+ years old
34% of prescriptions dispensed
average of 5 different drugs
Geriatric Pharmaceutical Care
Life expectancy, at birth (1997):75.8 years for men81.4 years for women
In one study of older persons, drugs contributed to 20% of hospitalizationsGrymonpre et al J Am Geriatr Soc. 1988
Community-Based Geriatric Pharmacy Care
6 studies: Positive results:
Improved adherence (1) Excellent physician & patient acceptance (81% & 91%) (1); DRIs
identified and resolved (2) More appropriate drug use (1); more drug changes (1); fewer
repeat prescriptions (1); reduced drug costs (1) Reduced outpatient visits (1); reduced hospitalizations and
hospital stays; reduced health care costs (1) Negative results:
No difference in SF-36 (1); no difference in health decline, falls (1) Poor physician acceptance (28%); DRIs identified but not resolved
(1) No difference in numbers/costs of drug, medication adherence (1) no change in health services use (2)
Community-Pharmacists: Geriatric Pharmaceutical Care
Bernsten C et al. Drugs & Aging 2001;18(1):63-77
Design: randomized (by pharmacy), controlledParticipants: 190 sites, 2,454 patients, 65 years, 4
prescribed meds, oriented x 3, noninstitutionalized Intervention: pharmaceutical care for 18 months;
community pharmacyProcess measures: number of medications & changes;
contacts with GP, GP acceptance & satisfaction; cost analysis; medication knowledge & adherence
Outcome measures: SF-36, hospitalizations, symptoms (self-reported), patient satisfaction
Results: improved satisfaction & symptom control, no difference in other measures
Community-Pharmacists: Geriatric Pharmaceutical Care
Sellors J. SMART. Final report. Sept. 2000
Design: randomized, controlledParticipants: 889 patients, 65 years, 5 prescribed
meds, MMSE≥25, noninstitutionalized Intervention: pharmaceutical care; 24 community
pharmacistsProcess measures: number and types of drug-related issues,
resolution rate of issues, physician response, number of daily medications, medication units, & costs, inappropriate drugs, medication adherence
Outcome measures: medication problems (self-reported), health care utilization and costs; SF-36
Results: DRIs identified in 88% of subjects (mean 3.2); 84% physician acceptance; 57% MD implementation; no difference in other measures.
Community-Based Geriatric Pharmacy Care
Grymonpre RE et al Int J Pharm Pract 2001;9:235-41
Design: randomized, controlled Participants: 135 patients, 65 years, noninstitutionalized,
2 medications Intervention: pharmaceutical care for 1 year; ‘wellness clinic’ Process measures: number and types of drug-related issues,
resolution rate of issues, physician response, number & costs of medications, medication knowledge & adherence
Outcome measures: symptoms (self-reported) Results: 952 issues identified, 29% resolution rate; positive MD
response but 28% acceptance rate (by survey); no difference in other measures
Hypothesis
Community pharmacists have the necessary skills and knowledge to improve drug taking behaviour of older adults
andthe prescribing habits of physicians, therebyoptimizing disease control and reducing theamount of drug-related illness in this segment
ofthe population.
Manitoba Pharmaceutical Care Project
Research Questions:Can a workable model of community-based
pharmaceutical care be provided to physicians and elderly patients?
What is the impact of community pharmacists practicing pharmaceutical care on:• Physician and patient acceptance and implementation of
recommendations?• Use of medications by older persons?
Objectives: To document measures of the patient-focussed pharmacy
care provided: numbers and types of drug-related issues identified;numbers and types of recommendations made;physician and patient acceptance of recommendations;endpoints of plans of action;interview and work-up times; level of remuneration
To measure the impact of comprehensive patient-focussed pharmacy on:medication adherence (primary measure);numbers and costs of medications
Methods: Pharmacy & Pharmacist Selection
Invitation for participation and application Selection based on criteria & signed contract:
demonstrate an understanding of pharmaceutical careremoved from dispensing activities for 6 hours/week recruit 1 client/week x 74 weeksprovide pharmaceutical care to patientsagree to training & group sessionscomplete and submit required documentationaccess to confidential area space & equipment for maintaining filesaccess to library of references
Methods: Process of CareIntervention
Eligible clients perceived to be at risk recruited Intervention: Comprehensive patient-focussed
pharmacy caremedication history develop, implement and document patient
care plans:o identification of drug-related issueso intervention (MD &/or client)o follow-up
Remuneration provided
Methods: Process of Care Action Plan
Characterized by a single or multiple drug-related issue(s) and disease state(s)
Requiring a single or multiple recommendation(s) Resulting in one desired endpointIssues: undertreated diabetes, lack of knowledge, condition
requiring monitoring
Recommendations: add drug, educate client, refer to dietician, monitor blood sugars
Acceptance: client and MD accepted recommendations
Endpoint: blood sugars normalized
Methods: Process of Care Endpoint
Dependent on issue(s) identified in plan of action health outcome - clinical issue
• symptom/measure of disease or side effect: BP, BS, pain, constipation
process endpoint – drug issue• no indication, wrong drug, overdose• when not feasible to look at clinical endpoint
(immunization, osteoporosis, stroke prophylaxis)• education & nonadherence
Status of issue at follow-up ‘partially resolved’ - positive trend but desired target
not reached
Methods: Research design
Design: prospective, nonrandomized, controlled, before-after trial, survey and population based
Setting: community pharmacies Study Subjects: ‘convenience’ sample; 65+
years old; noninstitutionalized; willing to provide signed informed consent; taking at least 1 medication
Control Subjects: randomly selected from Manitoba Health database; 3:1 match by age, gender, and ‘Adjusted Clinical Group’
Methods: Process Measures
Population based measures: medication adherence (primary measure); numbers and costs of medications
Survey based measures (test only): interview and work-up times; remuneration; numbers and types of drug-related issues identified; numbers and types of recommendations made; physician and patient acceptance of recommendations; endpoints of plans of action
Methods: Data analysis
Population based data:Required sample size (total) = 220
10% change in medication adherence
= 0.10 = 0.05 std deviation 25% (Annals 1998)
Mixed modeling procedure (SAS)
Medication Adherence: Cumulative Medication Acquisition (CMA)
CMA* = ‘days supply’ in interval actual number of days in interval
*CMA values are only calculated on medications with 3 or more fills and a ‘prescribed rate’ (quantity dispensed ‘days supply’) of 0.5, 1, 1.5, 2.0, 2.5, 3.0, 3.5, 4.0, 4.5.Using these criteria, DPIN was determined to be a valid measure of medication adherence compared to pill count with 77% concordance & McNemar’s p=0.6837
Grymonpre RE et al [ABSTRACT] Can J Clin Pharm (in press) 2004
Remuneration: Pharmacy Consultation
Grymonpre et al J Res Pharm Econ 2001:11(1):51-61
Results: Pharmacy recruitment
Total number of pharmacies: 11 (selected from 15 applicants)
Total number of test pharmacists: 15Orientation session: May 1 & 2, 1998 (9
hours)Ongoing one-on-one support with
resource pharmacist and groups sessions.
Results: Client recruitment
Study duration: May 1, 1998 - Jan 31, 2000Total number of clients evaluated: 337Total number of eligible clients: 213 (63%)124 Exclusions:
no consent 78 insufficient documentation 46
Results: Demographic Data
Age (n=211) mean sd
77.2 6.5
% Female (n=213) 140 (66%) Prescribed drugs % users (n=213) mean sd (of users)
207 (97%) 6.0 2.9
OTC drugs % users (n = 213) mean sd (of users)
176 (83%) 3.0 2.0
Alternative therapies % users (n = 213) mean sd (of users)
49 (24%) 2.0 1.8
Medical conditions mean sd
213 (100%) 5.8 2.4
Results: Drug Benefit Plans
No 3rd party coverage
70/126 (56%)
Blue Cross 42/126 (33%)
Dept. Veterans Affairs
9/126 (7%)
Other* 5/126 (4%)
*Great West Life, Indian Affairs, Assure
Results: Time required
interview location (n=186) pharmacy home
112 (60%) 74 (40%)
interview time (minutes) mean SD (n=182)
65.4 24.4
work-up/ intervention time mean SD (n=167)
94.1 68.4
remuneration (n=166) mean SD
$78.80 23.30
Results: Action Plans
211 of 213 clients had 1 Action Plan
732 Action Plans were developed mean of 3.5 1.7 per personcharacterized by 945 drug-related
issuesinvolving 1005 recommendations
945 Drug-Related Issues
untreated indication 192 (20%) improper drug storage 32 (3%)
inadequate knowledge 122 (13%) suboptimal regimen 30 (3%)
adverse drug reaction 111 (12%) drug interactions 28 (3%)
monitoring required 91 (10%) drug duplication 18 (2%)
nonadherence 77 (8%) sensory/physical/ cognitive limitation
18 (2%)
primary prevention 57 (6%) subtherapeutic dose 16 (2%)
drug w/o indication 55 (6%) overdose 17 (2%)
improper drug choice 44 (5%) other 37 (4%)
Recommendations to physician
Of 1005 recommendations made:
499 (50%) recommendations involved the MD
114 (23%) of 499 recommendations to MD not made/documented
385 recommendations made to MD:
• start drug 80 (21%)• stop drug 61 (16%) • switch drug 61 (16%)• monitor therapy 54 (14%)• decrease dose 29 ( 8%)• increase dose 28 ( 7%)
• dispensing task 12 (3%) • change dosing time 11
(3%)• refer other hcp 9 (2%)• change dose form 8 (2%)• encourage adherence 5
(1%)• other 27 (7%)
Physician response
Of 385 recommendations made to MD :
physician response to 87 (23%) unknown
Of 298 known responses:• 82% accepted and • 4% partially accepted
Recommendations to patient
Of 1005 recommendations made:
1003 (99.8%) recommendations involved patients
89 (9%) required recommendations to patients not made/documented
914 recommendations to patient
• educate 153 (17%)• start drug 127 (14%)• monitor 122 (13%)• change drug 92 (10%)• stop drug 76 (8%)• disp.related task 48 (5%)• increase dose 43 (5%)
• compliance aid 43 (5%)• decrease dose 41 (4%)• nonpharm. advice 38
(4%)• change time 34 (4%)• enc. adherence 34 (4%)• refer to hcp 25 (3%)• other 38 (4%)
Patient response
Of 914 recommendations made to patient:
patient response to 142 (16%) unknownOf 772 known responses:
• 90% accepted and• 3% partially accepted
Endpoints of 732 Plans of Action
Of 732 Plans of Action:
Endpoint unknown for 278 (38%) Of 454 documented endpoints, 344 (76%)
were resolved or partially resolved.
Medication Adherence: Pre- versus Post- Intervention 199 Test vs 506 Control Subjects
98%
95%
97%
92%
89%
90%
91%
92%
93%
94%
95%
96%
97%
98%
99%
1 year pre-intervention 1 year post- intervention
Control
Test
P=0.0064
Number of Different Drugs: Pre- versus Post- Intervention 199 Test vs 506 Control Subjects
8.6
10.1
9.4
9.8
7.5
8
8.5
9
9.5
10
10.5
1 year pre-intervention 1 year post-intervention
Control
TestP=0.0044
Annual drug costs: Pre- versus Post- Intervention 199 Test vs 506 Control Subjects
$1,005
$1,550
$1,448
$1,685
$1,000
$1,100
$1,200
$1,300
$1,400
$1,500
$1,600
$1,700
$1,800
1 year pre-intervention 1 year post-intervention
Control
Test
P=0.0716
Summary
Some difficulties with process:target recruitment rate of 1 client/week could not be
met23% recomm. involving MD not made/documented 9% recomm. involving patient not made/documented23% of MD responses not determined/documented16% of patient responses not determined/ documented 38% of endpoints not determined/documented
Summary
When process successfully implemented & documented:
99% of clients experienced 945 drug-related issues requiring 1005 recommendations
86% physician acceptance rate 93% patient acceptance rate positive endpoints achieved for 76%
action plans
Benefits: Health & Health Costs
Compared to control subjects, test subjects had:
a lower rate of increase in numbers of drugs (p=0.004)
a lower rate of increase in costs of drugs (p=0.07)
greater improvements in medication adherence (p=0.006)
Conclusions
The delivery & documentation of pharmaceutical care was challenging & required one-on-one support by a resource pharmacist
Older adults experienced several drug related issues Community pharmacists had the necessary skills and
knowledge to identify & resolve these issues which resulted in desired process endpoints and health outcomes
Community pharmacists providing patient focussed care reduced numbers and costs of medications and improved medication adherence
Acknowledgements
Apotex Inc. CIHR (formerly NHRDP)Centre on Aging Manitoba Health Manitoba Pharmacists Manitoba Pharmaceutical AssociationManitoba Society for PharmacistsJenny Kleine Golden (1972-2002)
Acknowledgements
Ms. Marie Berry (Vimy Park Pharmacy) Mrs. Carol Boscow (The Pas Super Thrifty) Mrs. Barbara Bromilow (Pharmasave
Beasejour) Mrs. Donna Campbell (Pharmasave) Mr. Bill Cechvala (Vimy Park Pharmacy) Mr. Terry Chan (Shoppers Drug Mart) Mrs. Wendy Clark (Carman Pharmacy) Mrs. Morna Cook (Dixon’s Pharmacy) Ms. Shelley Cowie (Shoppers Drug Mart) Ms. Camella Crook (C&C PC and Consulting) Mr. Quy Doan (Shoppers Drug Mart) Mr. Brian Dusik (St. James Pharmacy) Mrs. Michele Fontaine (Shoppers Drug Mart) Mr. Myles Haverluck (Dauphin Clinic
Pharmacy) Mr. Warren Hicks (The Pas Super Thrifty Drug
Mart) Mr. Rob Jaska (Medical Centre Pharmacy)
Mrs. Nadine Karpinski (Shoppers Drug Mart)
Mr. Darryl Lancaster (Pharmasave) Mrs. Tracy Lelong-Young (Prescription Plus
Pharmacy) Mrs. Donna McLeod (Pharmasave) Mrs. Nancy Metcalfe (Pfahl’s Drugs Ltd.) Mr. Real Mulaire (St. Pierre Pharmacy) Mrs. Lisa Olench (Pharmasave) Mrs. Julie Penelton (St. James Pharmacy) Mr. Sigfried Pfahl (Pfahl’s Drugs Ltd.) Mr. Don Radley (Pharmasave) Mrs. Nancy Remillard (Pharmasave) Mr. Jay Rich (Shoppers Drug Mart) Mr. Mark Scott (Shoppers Drug Mart) Mr. Trevor Shewfelt (Dauphin Clinic
Pharmacy) Mr. Rolland Villar (Shoppers Drug Mart) Mrs. Sonia Wriedt (Pharmasave)