modernising community pharmacy in scotland- how do we know what the stakeholders want? christine...
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Modernising community
pharmacy in Scotland- how do we know what the stakeholders
want?
Christine BondDepartment of General Practice and Primary Care
and NHS Grampian
Acknowledgements
• Research colleagues– Terry Porteous, Mandy Ryan, Tony Scott, Michela
Tinelli– Phil Hannaford, Sally Wyke
• Funders– Chief Scientist Office, MRC/ESRC, NHS R and D
Traditional NHS contracts
Traditional contracts• Dispensing of prescriptions
– volume driven payment
• Displaying leaflets• Providing opportunistic advice on dispensed medicines
– professional fee
• Locally negotiated services– eg drug misusers, nursing homes, compliance needs
assessment, smoking cessation
• Recognition of other ‘private’ health care roles– Sales of OTC medicines
New UK community pharmacy contracts(Smoking, Health and Social Care (Scotland) Act 2005)
• Scotland (from July 2006)
– Four core services provided by all pharmacies• Minor Ailments (MAS)• Public Health (PHS)• Chronic Medicines Service (CMS)• Acute Medicines Service (AMS)
– Pharmaceutical Care Services Plan – Locally negotiated services based on national
specifications– Performers List
– Supplementary (and Independent) prescribing– OTC sales function still not NHS
New contracts
Drivers for change
Research data
Policy, culture/society change
Practice norms
Drivers for change
Research data
Policy, culture/society change
Practice norms
GP workload
Convenience
Skills mix
Drug budgets
Expectations
Relationships
Drivers for change
Research data
Policy, culture/society change
Practice norms
GP workload
Convenience
Skills mix
Drug budgets
Expectations
Relationships
DCE
New responsibilities for pharmacy
• NHS role in self care and provision of advice and supply of medicines– Community pharmacy led treatment of minor illness
• Chronic medicines review and supply– Medication review– Repeat dispensing– Prescribing pharmacists
• What do pharmacists think?• What do patients think?
DCEs could have informed both of these
Will stakeholders accept new policies? Patients
• DCEs have been used to assess– What patients value in repeat dispensing
• Bond, C.M. , Matheson C., Jones, J., Williams, S. Repeat prescribing study: an evaluation of the role of community pharmacists in controlling and monitoring repeat prescribing, following protocols agreed with the general practitioner.Report to the Grampian Health Board February 1997
– Acceptability of prescribing pharmacist• Tinelli M., Ryan M., Bond C.,Patient preferences for increasing the role of the
pharmacist in the management of drug therapy IJPP 2004 12 (R93)
– Pharmacist role in medication review• Tinelli M., Ryan M., Bond C., Economic evaluation advancement in pharmacy: discrete
choice experiments IJPP 2007 15 A12
– The public’s preferences in self care• Porteous, T., Ryan, M., Bond, C., Hannaford, P. Preferences for self-care or consulting
a health professional in minor illness; a discrete choice experiment BJGP 2006 911-17
Will stakeholders accept new policies? Pharmacists
– Pharmacists’ preferences for contractual changes• Scott. A, Bond, C.M., Inch. J, Grant. A, Preferences of Community Pharmacists for Extended
Roles in Primary Care – A Survey and Discrete Choice Experiment. Pharmacoeconomics 2007;25 (9) 983-792
– Pharmacists’ preferences for different attributes of an electronic data interchange system
• Ubach, C., Bate, A.,Ryan, M., Porteous, T., Bond, C., Robertson, R. Using discrete choice experiments to evaluate alternative electronic prescribing systems.. Int.J.Pharm. Pract 2002; 10:191-200
– Pharmacists’ decision making in OTC advice • Roins S, Benrimoj SI, Carroll PR et al Pharmacists’recommendation of the active
ingredient(s) of non-prescription analgesics for a simple tension and migraine headache JSAP 1998; 15:262-274
Terry Porteous, Christine Bond,
Phil Hannaford, Mandy Ryan,
Sally Wyke
Managing minor illness Factors influencing the choice between self-care and
health professional advice: a discrete choice experiment.
Study design
• Qualitative interviews Aim - To describe what factors influence patients when deciding how to manage minor ailments associated with analgesic use
• Discrete choice experiment Aim - To describe what trade-offs people make when deciding how to manage minor ailments associated with analgesic use
Qualitative interviews
24 interviews across Scotland asking about:
• recent experience and management of symptoms associated with analgesic use.
• reasons for practising self-care and/or consulting health professionals
• opinions on self-care and use of analgesics
Influencing factors • Reasons for practising self-
care • Faster treatment/easier access• Use of complementary treatments • Avoidance of unwanted treatments• Feelings of control/independence• Previous experience of same
symptoms• Advice from friends, relatives or
media• Perception that condition is self-
inflicted• Belief that GP will be of limited
help• Does not want to waste Dr’s time
• Reasons for not practising self-care
• Having to pay for treatments yourself
• No advice from Dr/pharmacist• Chance of missing important
condition• Chance of drug interactions• Chance of making things worse• Belief that nothing can help or
stoicism• Lack of knowledge• Belief that only medical help
will work
The attributesThe “influencing factors”
• Type of management (self-care, GP, pharmacy, practice nurse, complementary, NHS24, do nothing)
• Time to treatment (the time you have to wait for an appointment, travel time and time taken to get any treatment) (0,1,5 hours, 1,2,5 days)
• Cost (travel costs and the cost of any treatment e.g. any consultation fee, over-the-counter medicines, complementary remedies etc.)(£2, £5, £7, £15)
The scenario
Please imagine this situation:
You have a headache and a fever, your bones are aching and your nose feels slightly blocked up. You are still able to do all the things you usually do but are more tired than usual. The symptoms started to appear four days ago, and were slightly worse when you woke up this morning.
A sample question
Option 1 Option 2
Type of management
Self-care GP
Availability 1 hour 2 days
Cost £2 £7
(Tick ONE box only) Option 1 Option 2 Do nothing
Example Which option would you choose?
DCE analysis and results
• DCE administered during November 2005
• Response rate of 57% (326/573)
• Analysed using multinomial logistic regression
• Regression coefficients used to estimate - utility (“preferences” or “satisfaction”) - willingness-to-pay
Overall preferences
For the symptoms presented:• Respondents had a general preference for doing
something (rather than “do nothing”) • Relative preferences for type of management:
Self-care Community pharmacy GP consultation Practice nurse NHS24 Complementary
Decreasing preference
Conditional logit regression analysis
Respondents valued self-care at £22.62 i.e they were prepared to pay up to £22.62 to treat these symptoms by self-care but beyond this price, they would rather “do nothing”.
Willingness to pay
Willingness to pay
They valued other treatment options lesshighly e.g. they wouldpay £17.01 LESS thanthis to treat symptoms using the NHS24 option
Willingness to pay
They were prepared topay £3.69 to reduce thewait to treat symptomsby 1 day
Moving from one “service” to another
Service 1 Service 2
Type of management
Telephone advice from NHS24
Ask for advice in a pharmacy
Wait before treating symptoms
5 hours 1 day
Moving from one “service” to anotherService 1 Service 2
Type of management
Telephone advice from NHS24
β = -1.48
Ask for advice in a pharmacy
β = -0.304
Wait before treating symptoms
5 hours
β = 5/24*-0.321
1 day
β = -0.321
Utility of a service = Constant (1.968) +β (service)
Moving from NHS24 to pharmacy management gives an increase in “utility”
ie β (NHS24) – β (pharmacy) = -1.48 – (-0.304)
= -1.176
Moving from one “service” to anotherService 1 Service 2
Type of management
Telephone advice from NHS24
Ask for advice in a pharmacy
Wait before treating symptoms
5 hours
β = 5/24*-0.321
1 day
β = -0.321
Utility of a service = Constant (1.968) +β (service)
Moving from a wait of 5 hours to 1 day gives a decrease in “utility”
ie β (5 hours) – β (1 day) = -0.067 – (-0.321)
= 0.254
•
Moving from one “service” to anotherService 1 Service 2
Type of management
Telephone advice from NHS24
Ask for advice in a pharmacy
Wait before treating symptoms
5 hours 1 day
Overall difference in “utility” is positive and we can quantify it by WTP
U (service 1) – U (service 2)/ β (cost) = 0.421-1.343/-0.087
= £10.60
Rather than get telephone advice from NHS24 with a 5 hour wait, a respondent would be willing to pay an extra £10.60 to get advicefrom a pharmacy with a wait of 1 day
Conclusions• Self-care was the preferred way of dealing
with these symptoms
• It was highly valued by respondents
• Community pharmacy was the preferred source of professional advice
• DCE allowed quantification of preferences and expressed them by WTP
Assessing what patients liked about pharmacist led medicine management
Tinelli M, Ryan M, Bond C
• Aim: to evaluate the introduction of the Medicines Management Service by community pharmacists for patients with CHD
• Randomised Controlled Trial
• Setting: Nine Health Authorities in England, 50 Community pharmacies, 39 General Practices
• Primary subjects: Patients with CHD
• Intervention: Community Pharmacy face-to-face patient review to include medication and lifestyle advice
• Control: Usual care
The Community Pharmacy Medicines Management Project* The Community Pharmacy Medicines Management Project*
The Community Pharmacy medicines Management Project Evaluation team (C. Bond Principal Investigator) The MEDMAN study: a randomized controlled trial of community pharmacy-led medicines management for patients with coronary heart disease. Family Practice 2007; 24(2):189-200
• Primary outcome measures: appropriate treatment (derived from the NSF), health status (EQ5D and SF36)
• Secondary outcome measures: satisfaction, experiences and attitudes of patients and health care professionals
• Time period: All measures were assessed at baseline and 12 months
• Results: no changes in clinical or QALY outcomes; patients satisfaction higher in the intervention group
• To use a DCE to– Explain the increased satisfaction– Inform a CBA for the community pharmacy-led medicines
management service
The Community Pharmacy Medicines Management ProjectThe Community Pharmacy Medicines Management Project
• Identification of attributes from replies to patient survey• DCE survey questionnaires sent to all patients participating to the trial 2
years after study start (879 intervention; 470 control) • DCE compared three options:
– a novel community pharmacist and general practitioner review of medicines (CPGP)– a GP only medicines review (GP) – the current scenario
• WTP in moving from the current situation to ‘CPGP’ or ‘GP’ were estimated
• Groups compared: – intervention all vs control (TAU) (ITTA)– intervention still receiving the Medman service vs control (TAU) (PPA)
• A priori assumed people who had experienced the service more likely to value it
Use of DCEUse of DCE
Attributes• Advice
– None, only on medicines, only on health/lifestyle, both
• Time (travelling to and in the pharmacy)
– 10,20,30,40 min
• Privacy (in the pharmacy)
• Satisfactory replies to questions– Yes, No
• Chance of receiving most appropriate treatment– Very poor, poor, good, very good
• How much you pay ( medicine + advice+ review+ travel) – £0, £10, £20, £30
Example of DCE choiceMedicines
review by GP and Pharmacist
Medicines review
by GP only
Current situation
ADVICE On medicine & health/lifestyle
No
PRIVATE DISCUSSION Yes No
SATISFACTORY REPLIES Yes No
CHANCE OF APPROPRIATE TREATMENT
Very good Very good
TIME(Travelling to + waiting in the pharmacy)
10 minutes 10 minutes
HOW MUCH YOU HAVE TO PAY (Consultation + medicines + travelling)
£ 10 £ 10
WHICH SERVICE WOULD YOU CHOOSE? (Tick one box only)
Results
• Response rates: Intervention (73%) and Control (67%)
• 44% of intervention still receiving the service, 52% stopped , 4% never
• The preferred option for all groups was the current option
• Controls:– ‘Chance of receiving the best medicine’ and ‘cost’ were most
important
– If moving from the current service would choose the GP only option
Intervention groups
• Intervention all– ‘Advice on medicines’, ‘satisfactory replies’ as well as ‘chance of
receiving the best medicine’ and ‘cost’ were most important
– If moving from the current service would choose the GP only option
• Intervention still receiving the service– ‘Advice on medicines’, ‘satisfactory replies’, ‘chance of receiving
the best medicine’ and ‘cost’ remained most important plus ‘advice on medicines and lifestyle’
– If moving from the current service would choose the combined GP-pharmacist option
Willingness to pay
• Intervention all– Valued their current service at £19.28
• Intervention still receiving the service– Valued their current service at £21.99
– Would pay £50 to move to a GP-pharmacist service
• Control groups – Would pay £17.09 to stay with their current service rather than
move to GP-pharmacist service
Cost benefit analysis for trial
Control Intervention all Intervention still receiving the service
Mean extra benefits per patient (from DCE)
-£17.09 £19.28 £21.99
Mean extra cost per patient
£32.67 £18.16 £18.16
Mean net benefits per patient
£-49.76 £1.12 £3.83
Decision making process Efficient allocation of resources
Outcome measures Results Economic evaluation
Clinical outcome
(Appropriateness of treatment)
NO difference across groups Cost minimisation
Results: increased total NHS costs with the introduction of the service
QALY (EQ5D and SF6D)
NO difference across groups Cost minimisation
Results: increased total NHS costs with the introduction of the service
DCEs Differences across groups: Subjects who experienced the new service valued the input from their pharmacists, and preferred it to any other option
Cost benefit analysis
Results: The increase in intervention costs was partially compensated by increased patients’ valuation for that service
Conclusion
• Patients value the opportunity to have input from both pharmacist and GP
• Extra costs of delivering the pharmacy led medicines management service were partially offset by increased value to patients
• The DCE methodology:– helped understand what patients valued
– quantified value of the service within a CBA
– is useful for use in pharmacy policy decision making
Summary
• DCEs can inform emerging policy and evaluate implemented policy
• Add a dimension not otherwise available
• In pharmacy research has explained what stakeholders want and how it is valued
Thank you for listening