pharmacy and pharmacy practice research in the netherlands dr. j.w.f. van mil community pharmacist...
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Pharmacy and pharmacy practice research in the Netherlands
Dr. J.W.F. van Mil
Community pharmacist
Pharmacy Practice Consultant
Topics
The NetherlandsPharmacy EducationCommunity pharmacy & care provisionPractice Researchand.. Europe
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Netherlands and Dutch pharmacy
Kingdom, parliamentary democracy, approx.18 million inhabitants. Symbolic role of king/queen
Approx. 1900 community pharmacies serving average of 8100 patients/pharmacy
1 community pharmacy with 1.5 pharmacist and approx 8.5 FTE assistant pharmacists and 3 FTE other staff
35 Emergency pharmacies (24hrs) in bigger citiesApprox. 90 hospital pharmaciesFinancial situation of pharmacies reasonably sound.
Annual turnover approx €2,502,000
Data: SFK Fact & Figures 2008
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Dutch pharmacy education
7 major universities with European style curriculae (4 years: bachelor-master)● 2 Universities (Groningen, Utrecht) focus on pharmacy
practice and educating pharmacists 6 years curriculum -> Pharm D for all pharmacists After 1 years initial choice: community/hospital/research After 4 years final choice
● 1 University (Leiden) focus pharmaceutical product research
● 1 University (Nijmegen) focus patient care2 additional years in practice for licence in community
pharmacy, 3 years for hospital pharmacyTo keep license: obligation to follow postgraduate
education (18h/year, and increasing)
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Community pharmacy
One national association for all pharmacists (KNMP) with a scientific branch, stimulating practice research and care implementation.
KNMP has no legislative power; this is exerted by Dutch Inspectorate for Health Care
30% of pharmacies are quality certified; ongoing process and increasing
Care packages and projects provided by KNMP
Independent community pharmacies have their own organisation (NAPCO)
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Chains
35% of pharmacies in a chain or affiliated on franchise basis
Major chains are owned by 3 major wholesalers
Chains have own care-packages but no obligations (yet) for their pharmacies to participate
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Payment system
Pharmacies are contracted by insurance companies4 large insurance companies, 10 smaller onesInsurance now assigns preferred generic brand(s)Insurance pays dispensing fee + costs of medicines,
subsidised by the stateDispensing fee: New tariff structure approved by the
state since July 2008€ 5.30 Normal prescription€ 2,90 Week-dosing dispensing (Baxter)€ 1.50 First time dispensing fee (supplement)€ 10.60 Dispensing during off hours (supplement)€ 10.60 In-house preparations (supplement)€ 79.40 Complex preparations (sterile, etc. supplement)
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Dutch pharmacy and Care
Hospital and community pharmacists are care-providers by law. Standard automated ‘medication surveillance’ in all pharmacies
since 1980ies (MUR) Cooperation with GPs in so called FTO-groups (meet every 2
months), also called Pharmacotherapeutic Consultations Structured instructions for first time and second time dispensing Standards based care ‘packages’ for
Asthma Cancer
Diabetes Travel advice
Incontinence Polypharmacy / review
OTC First-second time dispensing
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Pharmacy Care standards
Prepared by WINAp, part of Dutch pharmacists association.
Based on Dutch medical treatment standardsStandards to be translated locally into protocols Cancer (incl. pain management) – Incontinence
– Constitutional Eczema – Diabetes - Multiple Sclerosis – Headache –Osteoporosis – Asthma/COPD – Cardiovascular risk management -
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Care initiatives (1, disease oriented)
Local initiatives, uncoordinated but driven by chains or pharmacists association● Advantages: PR for pharmacy, improving image
amongst GPs and patients
● Disadvantages: Small scale and uncoordinated, so no evidence of effect, no proof of savings
● For the time being no (financial) support from payers and not recognised by payers
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Care initiatives (2-epidemiological)
Mostly based on GP-treatment (NHG)standards● Monitoring use of preventers with high use of relievers
in asthma
● Monitoring use of laxatives with opoids
● Monitoring use of calcium and biphosphonates with chronic use of oral corticosteroids
● Monitoring use of gastric protection with NSAIDS etc.. in the elderly >6o
● Monitoring duration of use of anti-depressants
-> All done through epidemiological searches <-
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Current issues
Role of chains in pharmacist organisationRelations with minister and department of healthLimitations in freedom to dispense any brand of genericsLimitations in dispensing within a therapeutic group (e.g .
only simvastatin as a statin)Limitations in dispensing certain therapeutic groups
(benzodiazepines; remuneration ends 31-12-2008)Level of wholesaler discount (currently approx 17%, was
35!)Continuous change in payment structure (‘pharmacists
earn too much’)Level of extra services and careDocumentation of care activities
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Practice research, major leads (1)
Utrecht: ● Role of assistant pharmacists in care provision● Epidemiological translation of drug profiles as starting
point for care provision.● Development of disease oriented pharmaceutical care ● Affiliation with SIR-Leiden● Recent PhDs on:
Initiation, execution and discontinuation of antidepressant therapy (van Geffeb 2008)
Children and Asthma Medication (Zuidgeest 2008) Unintended effects of inhaled corticosteroids (Devries 2007)
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Practice research, major leads (2)
Groningen● Prescribing and pharmaco-epidemiology● Driving and medicines● Medicines in pregnancy and lactation● Development individual care plans
Nijmegen (in medical faculty)● Medication review in the elderly
Amsterdam VU Medical faculty End-of-life Care in general practice in the Netherlands
(Borgstede2006)
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Other research and implementation activities (1)DGV (Dutch Institute for responsible medicine
use)● Supporting materials for medication review● Coaching FTO and implementing medication review
to stimulate optimal prescribing● Training GPs, pharmacists and GP-practice
assistants around optimal prescribing
Leiden (independent)● Stevenshof Institute for practice Research (SIR)● Focus on adherence issues● Repeat prescribing through pharmacists
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Other research and implementation activities (2)KNMP (Royal Dutch pharmacy association)
● Maintaining on-line national medicine database with data to support medication review
● Maintaining national prescribing database where searches can be performed
● On-line support system for pharmacy advice about interactions – contra-indication etc.
● Producing and maintaining pharmaceutical care standards in different field
● Producing and maintaining leaflets to support counselling● Producing and maintaining several databases with patient
information leaflets
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Challenges in practice research
Finding pharmacists and pharmaciesAvailable time in the pharmaciesQuality of documentation
What we do have …Excellent centralised dispensing databasesWell equipped pharmacies and well trained
pharmacists & staffGood counselling and support system
Interesting issues in Europe (1)
Implementation & barriersSeveral papers on ethics and legislation
(especially in Spain)Role of pharmacists vs staffRelationship with other health-care
professionals and with the patient (especially in the UK)
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Interesting issues in Europe (2)
Digital data exchange (inter and intra-professional, seamless care)
Adapting and working with instruments e.g. Beers Criteria for medication review, BPCS questionnaire or DRP classification
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European cooperation
European Society for Clinical Pharmacy● Publication & Education
Europharm Forum● Practice implementation
PCNE● Education & research cooperation
Europe, the PCNE
Pharmaceutical Care Network EuropeSince 1993: Informal network of European researchers
studying outcomes and implementation of pharmaceutical care
Several ongoing and concluded projectsFree DRP-classification Every 2 years a Working Conference with 3-day
workshopsMaintains databases of literature and projectsSee www.pcne.org. For contact: [email protected] Institutional or individual members from all European
countries also welcome
Innovation in Pharmaceutical Care
Research4-7 March 2009, Vimeiro, Portugal
See www.pcne.org
Pharmaceutical Care
Network Europe
6th Working Conference
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Conclusion
Pharmacy in the Netherlands is well-developedPharmacists in the Netherlands have a very
good education and are competent health care practitioners
But Pharmacy Practice research is rather ‘academic’ and not so developed● Lack of time / resources in pharmacies● Only 2 universities teaching pharmacy practice● Lack of funding
More is happening on a European level