James C. McElnaySchool of PharmacyThe Queen’s University of Belfast

Pharmaceutical care in community pharmacy

Pharmaceutical carePharmaceutical 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

Outcomes of Pharmaceutical CareOutcomes 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)

H.PyloriH.Pylori eradication eradication

Brit. J. Clin. Pharmacol. (2002) 53,163-171.Brit. J. Clin. Pharmacol. (2002) 53,163-171.

MethodsMethods

• 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

23.7

92.1

010

2030

4050

6070

8090

100

%

Control Intervention

Adherence rateAdherence rate

7273.7

94.7

50

60

70

80

90

100

Pre-study Control Intervention

Era

dica

ti r

ate

(%)

Eradication rateEradication rate

ConclusionsConclusions

• 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

Question

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

Pharmaceutical care of asthma patients

J. Appl. Ther. (1997) 1, 145- 161 Pharmacotherapy (2001) 21, 1196-1203.

Comparison of inhaler scores in controls and in patients receiving education/monitoring intervention * p<0.05

* * *

40

50

6

750

8

90

10100

1 2 3 4 5 6

Assessment period: 1-3 baseline, 4-6 intervention

% I

nhal

er s

core

(±9

5% C

I)

Inhaler scores in control Inhaler scores in patients receiving education

J. Appl. Ther., 1, 145-161 (1997)

Comparison of prophylactic asthma treatments used in the first 6 months and last 6 months of study period

0

10

20

30

40

50%

Intal InhaledSteroids

Oral Steriods

Theophyllines

Medications

FIRST SIX MONTHS

LAST SIX MONTHS

Asthma International Perspective

• Northern Ireland

• Netherlands

• Belgium

• Iceland

• Denmark

• Malta

Conclusion

Positive Impact on:• Health Related Quality of Life

• Inhaler Technique

• Peak Expiratory Flow

• Self-Reported Symptoms

• Pharmacist-patient Relationship

• Hospitalisation?

Question

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

Care of elderly patientsCare 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

Question

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

Individualised smoking cessation programme (PAS)

Pharmacoeconomics (1998) 14,323-333

Addiction (2001) 96, 325-331.

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.

The PAS Smoking Cessation Model

STEP 1

STEP 4

STEP 3

STEP 2

To encourage and motivate clients using the pharmacy to stop smoking

To identify what type of help and support your client’s need to stop smoking

Gaining your client’s commitment to stop smoking

To support and monitor smokers wishing to stop smoking

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

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

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)

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)

Sensitivity Analysis

Sensitivity analysis cost per life year saved per successful intervention*

Uptake rate (50% - 75%) £227.78 - £276.65Throughput rate (10 - 30 patients/yr) £318.09 - £262.97Success rate (5 - 25%) £553.14 - £110.75Natural cessation rate (0 - 2%) £213.20 - £364.04Relapse Rate (0 - 15%) £249.22 - £293.27Fixed costs (£40,000 - £70,000) £265.62 - £288.29Variable costs (£15 - £45 /patient) £159.26 - £394.65Discount rate (3 - 5%) £213.22 - £361.42

cost per life year saved per successful intervention based on a 45 year old male

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

Question

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

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

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

IMM readmission statistics

Time to readmission (days)

4003002001000

Cum

pro

port

ion

of r

eadm

issi

ons

.5

.4

.3

.2

.1

0.0

Normal care

IMM

Influence of medicines management on patient knowledge of medicines

0

20

40

60

80

100

120

1st Major 1st Minor 2nd Major 2nd Minor

Poor product Knowledge

Poor purpose knowledge

Poor dosage knowledge

Poor instruction knowledge

Prescription queries

0

10

20

30

40

50

60

70

Major 1st Minor 1st Major 2nd Minor 2nd

Query Item

Query Condition

Product Discrepancies

Direction Discrepancies

Query Directions

Inadequate Directions

Query Formulation

Query Combination

Prescription queries

Medication storage seen during home visits

0

5

10

15

20

25

30

35

40

45

50

Major 1st Minor 1st Major 2nd Minor 2nd

Inappropriate Containers

Inappropriate Location

Damaged Container

Obsolete Products

Drug reactions / interactions and OTC use

0

5

10

15

20

25

Major 1st Minor 1st Major 2nd Minor 2nd

Adverse Effects

Drug Interactions

OTC Overuse

Inappropriate OTC Use

Adherence issues

0

20

40

60

80

100

120

Major 1st Minor 1st Major 2nd Minor 2nd

Need More Help?

Omitted Dose

Extra Dose

Poor Inhaler Tech

Forgetful

Problem Opening Meds

Problem with Label

Patient understanding / monitoring

0

10

20

30

40

50

60

70

80

90

100

Major 1st Minor 1st Major 2nd Minor 2nd

Poor Understanding of Condition

Poor Understanding of Meds

Unrealistic Expectations of Meds

Poor Monitoring of Condition

Question

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

Behavioural Pharmaceutical Care Scale (BPCS)

N. Ireland 1996 vs 2006

AJHP (1998) 55, 2009-2013.

BPCS Scores 1996 vs. 2006

Respondents’ Scores

1996 2006

Dimension and Domain No. Max Mean + SD Mean + SD

Direct Patient Care Activities 17 85 33.5 14.2 30.6 13.9

Documentation 6 30 10.2 6.2 9.3 5.9

Patient Assessment 6 30 9.3 7.2 6.6 6.4

Therapeutic Plans 2 10 3.4 3.1 3.3 3.2

Record Screening 1 5 4.1 1.5 4.5 1.2

Patient Consultation 1 5 3.4 1.6 3.5 1.5

Verification of Patient

Understanding 1 5 3.6 1.7 3.7 1.7

BPS Scores 1996 vs. 2006

Respondents’ Scores

1996 2006

Dimension and Domain No. Max Mean + SD Mean + SD

Referral and Consultation

Activities

8 40 18.3 5.2 19.8 5.5

BPS Scores 1996 vs. 2006

Respondents’ Scores

1996 2006

Dimension and Domain No. Max Mean + SD Mean + SD

Instrumental Activities 7 35 23.0 3.8 23.8 3.7

Counselling Location 1 5 3.7 0.9 3.8 1.0

Filled prescription validation 1 5 4.7 0.8 4.9 0.4

Informational Support 1 5 3.6 1.2 3.6 1.1

Evaluation of patient satisfaction 1 5 2.0 1.0 1.9 0.9

Competency Improvement 1 5 3.2 0.9 3.6 0.9

Performance Evaluation 1 5 2.1 1.1 2.2 1.0

Provision of Medical Information 1 5 3.8 0.9 3.9 0.8

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)

Translation of Research

Bench → Bedside

Clinical Trials → Policy and Routine PracticeTranslation

Translation

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)

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?