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Pharmacy and pharmacy practice research in the Netherlands Dr. J.W.F. van Mil Community pharmacist Pharmacy Practice Consultant

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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

Pharmacy in the NetherlandsPharmacy in the Netherlands

28-10-2008 Belfast 2008 4

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

Pharmacist’ educationPharmacist’ education

28-10-2008 Belfast 2008 6

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)

28-10-2008 Belfast 2008 7

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)

28-10-2008 Belfast 2008 8

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

28-10-2008 Belfast 2008 9

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)

28-10-2008 Belfast 2008 10

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

28-10-2008 Belfast 2008 11

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 -

28-10-2008 Belfast 2008 12

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

28-10-2008 Belfast 2008 13

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 <-

28-10-2008 Belfast 2008 14

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

28-10-2008 Belfast 2008 16

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)

28-10-2008 Belfast 2008 17

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)

28-10-2008 Belfast 2008 18

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

28-10-2008 Belfast 2008 19

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

28-10-2008 Belfast 2008 20

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)

22

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

23

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

28-10-2008 Belfast 2008 27

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

Pharmacy and pharmacy practice research in the Netherlands

Dr. J.W.F. van Mil

Community pharmacist

Pharmacy Practice Consultant