Cognitive Pharmaceutical Services in Community Pharmacy

Transcription

1 Cognitive Pharmaceutical Services in Community Pharmacy Prof Charlie Benrimoj Professor of Pharmacy Practice & Head of Graduate School of Health CHERE October 2013

2 Overview National and International Context Australian Environment & Research Pharmacy Barometer Implementation and Sustainability Model Piloting of Model International Impact Study (ECHO) in Spain Conclusion

3 International Trends 1975 Early 90 s Late 90 s /13 Traditional pharmacy role as medicine supplier challenged 1 Philosophical shift Pharmaceutical Care 2 Cognitive pharmaceutical services 3 Remuneration for service provision 4 Service integration and business viability 5 1.Business models Market Differentiation 2.Pactice roles Individual Pharmacist Careers 1. Mickeal, R.L. et al, Am J Hosp Pharm, : p Benrimoj, S.I. and A.S. Roberts, Ann Pharmacother, : p Hepler, C. and L.M. Strand, Am J Hosp Pharm, :p Feletto, E. et al, FIP 2008 Congress Abstract (#147) 3. Cipolle, R.J., et al, Pharmaceutical Care Practice. 1998, New York: McGraw Hill.

4 Hierarchical Model of Cognitive Pharmaceutical Services 1. Medicines Information 8 2. Compliance, Adherence and/or Concordance 9 3. Disease Screening Disease Prevention Clinical Intervention or Drug Related Problems Medication Use Reviews Medication Management/Medication Therapy Management a. Home Medication Reviews a. Residential Care Medication Reviews a. Medication reviews with continuance follow up (SFT) 8. Disease State Management for Chronic Conditions Participation in Therapeutic Decisions with Medical Practitioners 18,19 a. In Clinical setting a. In the pharmacy 10. Prescribing 20 a. Supplementary a. Dependent

5 Payers Government Cost savings Quality or rational use of medicines Health Insurers Decrease hospitalisations Prevention Pharmaceutical companies Adherence Direct Patient 5

6 Funding type Capitation funding Fee for service Salaries Pay for performance Performance based Outcomes payment Blended payments Grant payments Episodic or bundled payments Definition Fixed prepayment, per patient, to a healthcare provider to deliver health services to a particular group of patients, over a specified period of time. A system of fees that are related to specific services provided (e.g. visits, treatments, procedures). A fixed payment to a provider per unit of time. Payments are related to defined measures of health outcomes and processes of care rather than number of services provided. Performance is usually measured in terms of process and types of care recommended in evidence based guidelines rather than actual health outcomes. Usually a mix of 1 3 above and possibly 4 as an add on. Focused on providing incentives for quality improvement. A payment proposed to support multidisciplinary clinical services and care coordination. The size of the grant would be linked to the volume of patients enrolled with the primary health care service. These payments are designed to eventually replace fee for service. They involve bundling together the cost of packages of primary health care for enrolled individuals over a course of care or period of time. 1. Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A, Sergison M, Pedersen L (2000). Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians. Cochrane Database of Systematic Reviews 2000, Issue Australian Government Department of Health and Ageing (2009). Element 10: Fiscally sustainable, efficient and cost effective. In: Primary Health Care Reform in Australia: Report to Support Australia s First National Primary Health Care Strategy 3. Smith P C (2008). Formula funding of health services: learning from experience in some developed countries. Discussion Paper 1; World Health Organisation, Geneva. Ref : A. Roberts et al 2012

7 Stages of Services Debate and Defining Services e.g. South America Japan Research Stage e.g. Germany Spain Denmark France Payment secured e.g. UK USA Australia Canada NZ etc. National Implementation

8 Australia: Community Pharmacy Agreements Signed between the Pharmacy Guild and the Commonwealth Government Increasing shift towards cognitive services 2 nd Agreement rd Agreement th Agreement th Agreement th Agreement $4 m $302 M $500 M $660 M :?

9 Funding elements 5 th Agreement Element $m Pharmacy remuneration (includes dispensing fee, pharmacy and wholesaler mark up, extemporaneously prepared and dangerous drug fees, premium fee dispensing incentive, and electronic prescription fee) 13, Programs and Services Additional Programs to support patient services Community Service Obligation Total 15,384.5

10 Funded Professional Programs Practice Payment Incentives (PPI) 2 nd Agreement Residential Medication Reviews Quality Care Pharmacy Program 3 rd Agreement Residential Medication Management Home Medicine Reviews Provision of CMIs Indigenous Programs Rural Programs R&D Quality Care Pharmacy Program 4 th Agreement Residential Medication Management Home Medicine Reviews Provision of CMIs Indigenous Programs Rural Programs R&D Quality Care Pharmacy Program 5 th Agreement Residential Medication Management Reviews Home Medicine Reviews Medscheck Diabetes Indigenous Programs Rural Programs R&D Quality Care Pharmacy Program PPIs for: DAAs Daily Dispensing Clinical Interventions Available Funds $5m $416m $568m $738m

11 Pharmacy Practice Projects/ Programs Three General Types Projects: Define and theoretically design the service, Classify and test & optimise feasibility Projects: Evaluate the impact (ECHO) Program: Implementation & Sustainability

12 Chronology of HMR 95 Chen, TF, Benrimoj S et al. Medication regimen reviews a collaboration between community pharmacists and general medical practitioners. [Report] 97 Chen, TF Benrimoj S et al. Medication regimen reviews a collaborative project between community pharmacists and general medical practitioners. Development, implementation and evaluation of intervention. [Report] 00 Krass, I and Smith, C. "Impact of medication regimen reviews performed by community pharmacists for ambulatory patients through liaison with general medical practitioners." Int J Pharm Pract 8(2): Chen, TF, Benrimoj S et al. A comparative study of two collaborative models for the provision of DMMR. [Report] See also: Roberts, MS and Woodward, M. The domiciliary medication review project. [Report] Gilbert, A and Beilby, J. Quality use of medicines in the community implementation trial. [Report]

13 Barriers and Facilitators Barriers Pharmacist related Attitude e.g. fear of change, lack of self confidence Practice skills e.g. limited communication skills Resource related E.g. lack of management and incentives, lack of protocols and guidelines System related E.g. limited acceptance by other health professionals Academic and education related Knowledge and training Other Lack of mentors and models, lack of vision Facilitators Experiential Remuneration Pharmacist competence Use of protocols Interaction with patient groups Profile within local community Atmosphere of pharmacy Motivation Potential Advertising Proven benefits of service Working as a team Documentation system Communication skills Professional reward Autonomy Roberts A.S., Benrimoj S.I., Chen T.F., Williams K.A., Aslani P. Implementing cognitive services in community pharmacy: a review of facilitators of practice change. I J P P (2006) 14:

14 AUSTRALIA Business and professional facilitators of change in community pharmacy Roberts A, Benrimoj SI, Chen T, Williams K, Aslani P Investigator initiated grant through 3 rd Agreement R&D program Quantification of facilitators of practice change in community pharmacy Roberts A, Benrimoj SI, Chen T, Williams K, Aslani P Investigator initiated grant through 3 rd Agreement R&D program Change management and community pharmacy Dunphy D, Palmer I, Benrimoj SI, and Roberts A Commissioned study through 3 rd Agreement R&D program Policy uptake: incorporated into all professional programs and services in the 4 th Community Pharmacy Agreement SOURCE17. d_projects.asp Building organisational flexibility to promote the implementation of primary care services in community pharmacy Benrimoj SI & Feletto E Investigator initiated grant through 4 rd Agreement R&D program

15 Organisational Flexibility HIGH VARIETY of managerial capabilities STRUCTURAL Emerging trend in pharmacy: increasing the capabilities of pharmacists in specific areas e.g. disease state management Current state of pharmacy in many countries: regulated system, pharmacies doing what they always do STRATEGIC Not generally seen as the trend in pharmacy goal setting & cognitive abilities used to change strategically : discounting model & service model. Existing business model in pharmacy: convenience model larger, taking a supermarket approach LOW STEADY STATE LOW SPEED at which the capabilities can be activated Source: Volberda HW Building the Flexible Firm: How to Remain Competitive. Oxford: Oxford University Press; 1998 OPERATIONAL HIGH

16 Emerging Business Models VIABILITY Dispensing Retail Offering Service Provision Combination Classic Pharmacy Retail Destination Pharmacy Health Solution Pharmacy Networked Pharmacy

17 Needs Assessment: Factors 1 Factor Importance Measure 1 Planning & Performance 2 People & Processes 3 Service Awareness & Infrastructure Improvement Measure More staff are Planning, required Performance & Staff Change with in specialized physical Service Awareness Business knowledge and strategic layout for service planning Define operational Infrastructure provision Financial process resources Aid in increasing to guide to the support provision service customer of awareness services implementation People & Processesof services available Service awareness: increased knowledge of service to customer, customer feedback 1 Feletto E et al Building capacity to implement cognitive pharmaceutical services: quantifying the needs of community pharmacies Res Soc Admin Pharm;

18 Remuneration to individuals Direct employee providing services Professional Service Managers (industry, pharmacy groups and individual pharmacies) Consultant pharmacist Specialisations based on Setting ( e.g. nursing homes, hospital, community)

19 Community Pharmacy Economic Drivers PBS Reform Accelerated Price Reductions and Disclosure Generic substitution Changing remuneration systems Discount models Medicare local reform (local purchasing) Wholesaler Direct Distribution Reduction on wholesalers trading terms Community Pharmacy Agreements Shift from product based to service based Retail Trade trends

20 UTS Pharmacy Barometer Sponsored by Bankwest Objective : Impact on community pharmacy business and professional practice, and on individual community pharmacists.

21 UTS Pharmacy Barometer Wave 1: April (data collected Feb 2012) Confidence Value of Pharmacy Business Opportunities and Challenges Expanded and Accelerated Price Disclosure Wave 2: October (data collected Sept 2012) Services and their provision Wave 3: October (data collected Sept 2013) Finance advice Minor ailments and Pharmacist only (S3)

22 Wave3: 226 Responders

23 Most optimistic UTS PHARMACY BAROMETER INDEX Less optimistic Wave 1 (April 2012) Wave 2 (November 2012) Wave 3 (September 2013) Confidence in the future viability of community pharmacy

24 Expected value of pharmacy in the next 70% year 63% 60% 50% 47% 40% 30% 34% 28% 39% 24% Wave 1 Wave 2 Wave 3 20% 16% 17% 10% 6% 9% 10% 8% 0% Increase Decrease Remain the same Not sure (Answered only by Owners, Owner managers, Pharmacy managers and Pharmacist-incharge; n=200)

25 Average changes in value expected in the next year Expected value of pharmacy will INCREASE in the next year Wave 1 Wave 2 Wave 3 (n=11) Maximum 30% 30% 50% Mean 15% 10% 17% Minimum 2% 0% 2% Expected value of pharmacy will DECREASE in the next year Wave 1 Wave 2 Wave 3 (n=126) Maximum -40% -50% -90% Mean -16% -17% -20% Minimum -5% 0% 0%

26 Where do you see the greatest opportunities for community pharmacy over the next three years? 80% 70% 72% 60% 50% 40% 30% 24% 20% 10% 0% 4% Services Generics Other / Not sure n=226

27 Framework for Implementation of Services in Health (FISH) 27 Moullin, J (2013) et al FIP: Community Pharmacy section

28 Domains and Factors System Local Context Organisation (Pharmacy/Banner Group) Individuals (Owner, service provider, staff) Innovation (Adherence service ) Legislation and policy Standards and Guidelines Remuneration Inter/Intra professional network Government support Demographics Health needs Awareness Network Team structure Network and communication Capacity Culture and Climate, Readiness Leadership Return on investment Knowledge & experience Motivation & Self efficacy Beliefs Identification with organisation Characteristics Evidence Cost Relative advantage Adaptability Complexity Moullin, J (2013) FIP: Community Phar

29 Methodology 1. Exploration 2. Adoption 3a. Implementation 3b. Implementation Initial Full 4. Sustainability Initial Program evaluation Facilitator and owner training evaluations Pharmacist Training evaluation Facilitation evaluation Facilitator & facilitation evaluation Champion evaluation Program evaluation Capacity Acceptability Context Awareness Capacity Acceptability Context Awareness Capacity Acceptability Context Awareness Capacity Acceptability Context Awareness Capacity Acceptability Context Awareness Capacity Acceptability Context Awareness Measures of implementation Stage: Adoption Adoption Decision Stage: Initial implement Initiate service delivery Reach (Number of services delivered) Fidelity Adherence Dose Quality Response Stage: Full implement Delivering to target no. of patients Reach (Number of services delivered) Fidelity Adherence Dose Quality Response Routine integrated delivery Stage: Sustainability Institutional Capacity Acceptable Context Awareness Reach (Number of services delivered) Service benefits Fidelity Adherence Dose Quality Response No. pharmacies registered to program No. pharmacies initiated delivery No. pharmacies delivering to target No. pharmacies

30 Aim Develop a national program for the implementation of Diabetes MedsCheck service which incorporates Roche s resources Objectives 1. To measure the level of implementation of Diabetes MedsCheck after applying the Implementation Program 2. To evaluate the Roche Implementation Program Participants 1. NSW 12 pharmacies (started in May 2013) 2. VIC 6 pharmacies (started in Aug 2013) 3. QLD 7 pharmacies (started in Aug 2013) Source: PAC 2013 Lichin Lim et al 30

31 Level of Implementation in NSW Adoption/ Exploration Initial Implementation Implementation Sustainability Visit 1 Recruitment Participant training Visit 2 Roche TM addressed main barriers and provide strategies Source: PAC 2013 Lichin Lim et al Visit 3 All NSW participants reached initial implementation Visit 4 6 Level of implementation continue to be assessed 241 Diabetes MC were delivered in 11 pharmacies in 2 months (average 11 Diabetes MC per month per pharmacy) 31

32 Reach: Number of Diabetes MedsCheck Delivered NSW VIC QLD Before By Visit 2 By Visit 3 By Visit 4 By Visit 5 Source: PAC 2013 Lichin Lim et al Average number of Diabetes MedsCheck per Pharmacy

33 33

34 Introducción Spanish Study Foro de AF 1 Consigue 2009 to 2012 Consigue 2013 to Defining the service 2. Evaluating Impact Pilot Principal study 3. Implementation Pilot 10 Provinces

35 Methodology Research design quasi experimental, longitudinal cluster randomised with six time points with intervention and comparison group 6 months of SFT (Medication Management review) Guipúzcoa Tenerife Granada Las Palmas

36 Sample characteristics (N=1403) Total GI (n=688) GC (n=715) P value Age (6.53) (6.46) (6.59) Gender ( female); n (%)** 850 (60.9) 409 (60.1) 441 (61.7) Marriage status ; n (%)*** 739 (59.5) 355 (59.8) 384 (59.3) Educational status n (%)**** No level of education 265 (22.6) 149 (27.0) 116 (18.6) Primary 552 (47.0) 239 (43.3) 313 (50.3) Secondary 241 (20.5) 106 (19.2) 135 (21.7) Higher 116 (9.9) 58 (10.5) 46 (9.3) No of medications used (2.44) 7.74 (2.50) 7.39 (2.37) Health problems 4.65 (1.66) 4.96 (1.76) 4.35 (1.49) <0.001 Uncontrolled health problems 1.09 (1.22) 1.46 (1.34) 0.73 (0.97) <0.001 VAS QOL (19.14) (18.55) (19.64) Source:; Dr Daniel Sabater Hernandez UTS post doctoral fellow

37 Uncontrolled health problems Mean(SD) GI GC p value Period (1.34) 0.73 (0.97) <0.001 Period (1.22) 0.68 (0.94) <0.001 Period (1.07) 0.68 (0.91) <0.001 Period (1.01) 0.68 (0.94) Period (1.00) 0.67 (0.94) Period (0.94) 0.69 (0.94) Change (period1 period 6) 0.81 (1.08) 0.05 (0.65) <0.001 p value < Adjusted difference between changes in the number of uncontrolled health problems 0.44 (IC95%: 0.52, 0.35) p<0.001 Changes in number of uncontrolled health problems at the end of the study were compared through an analysis of covariance (ANCOVA) using the patient s group assignment as the primary effect and the baseline number of uncontrolled health problems, age and gender as covariables.

38 Clinical Impact Percentage of uncontrolled health problems Period 1 Period 2 Period 3 Period 4 Period 5 Period 6 GI % (total Health problems) (3415) (3359) (3303) (3273) (3252) (3181) GC % (total Health problems) (3110) (3043) (3018) (3004) (2997) (2982) p value <0.001 < <0.001

39 Difference in Number of Medications 0.5 Patients using 5 to 7 medications 0 initially; mean (SD) 0.5 (GI: 369 vs. GC: 435) GI GC P value 0.02 (0.91) 0.01 (0.82) Patients using 8 to 10 medications initially; mean (SD) 1.5 (GI: 189 vs. GC: 189) 2 Patients using 5 to 7 medications 2.5 initially; mean (SD) (GI: 88 3vs. GC: 63) 0.36 (1.29) 0.25 (1.08) Grupo intervención Grupo comparación 1.20 (1.81) 0.19 (1.39) <0.001

40 Economic Analysis Granada: 324 Guipúzcoa: 525 Meeting inclusion criteria Granada: 290 Guipúzcoa: 467 GI: SFT: 415 GC: 342 Prof. José Jesús Martín Martín

41 Economic Impact SFT Comparison Difference / ICER QALY QALY adjusted Cost , Cost adjusted ICER ICER adjusted Gain one year of quality of life (adjusted) costs (adjusted only for the differences in QALY and costs at baseline study.

42 Economic Impact SFT: Comparison: 0,0122

43 Economic Impact (Map of cost effectiveness)

44 LEVELS AND COVARIANCE MATRIX EACH MULTILEVEL MODELS Dr Tracey Farragher Model Levels Province Pharmacy Pharmacist Patient Covariance Matrix Number of patient s drugs ü ü Unstructured Number of manifested health problems ü ü ü Unstructured Number of uncontrolled manifested health problems ü ü ü Unstructured Number of risk health problems ü ü ü Unstructured Number of uncontrolled risk health problems ü ü Unstructured Quality adjusted life years (QALYs) ü ü ü Unstructured Change in number of ER Visits from baseline to 6 months ü NA Change in number of hospital admissions from baseline to 6 months ü NA

45 Marginal Means predicted from Multilevel mixed effects linear regression model : Intervention v Control (adjusted model) Number of medications Uncontrolled health problems Quality Adjusted Life Years Hospital Admissions ER Visits Dr Tracey Farragher 45

46 Conclusion 1. Future very challenging for Community Pharmacy 2. Current business model highly questionable 3. Develop new markets in service provision 4. Support for the Change Implementation and Sustainability program

47 consigue Impacto (estudio principal) Sample sizes 28 < 65 years 36< 5 med 7 < 65 years y 5 med 1474 patients Pharmacy Total (N) GI (n 1 ) GC(n 2 ) Guipúzcoa Intervention group 715 Comparison group Granada Las Palmas Santa Cruz de Tenerife Total (49.0%) 715 (51.0%) Patients per pharmacy: 7.88 (SD: 2.40); minimum: 1; maximum: 13