Presenter:Chris Budgen President Pharmaceutical Society of New Zealand inc'

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Presenter Chris Budgen President
Pharmaceutical Society of New Zealand inc.
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New Zealand Health Care strategy Primary Health
Care vision Primary health care services will
focus on better health for a population, and
actively work to reduce health inequalities
between different groups. Primary Health Care
Strategy 13 population health objectives are to
reduce smoking, improve nutrition, reduce
obesity, effects of diabetes, cardiovascular etc.
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Changing Patterns of Health Care Delivery

• Nationally and internationally - why?
• Chronic diseases are a huge burden on the State
• A minority of patients consume the majority of
  resources
• Keeping people well and productive in the
  community is to everyones advantage
• Managing those disease states in a systematic way
  achieves the maximum return

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Whats Been Identified ?

• Different levels of care needed
• 70 to 80 of people with long term conditions can
  care for themselves if given a minimum of
  direction and support from the system
• A standard system or protocol for supporting
  those people would result in maximum benefit for
  minimum effort, i.e. most economical use of State
  resources

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Medicines Why the emphasis?

• Medicines keep people well and functioning in the
  community
• Medicine adverse events are a major disease
• - Top five reasons for entering Secondary Care
  Accidents, Medicines, Cardiovascular, Cancer,
  Respiratory
• High public expectations of medicines rising
  demand
• Limited resources

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Medicines New Zealand New Zealand National
Medicines Policy (Hon. Peter Dunne) The
three areas of focus are - 1/ access to
medicines 2/ quality of medicines and 3/ the
rational use of medicines
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• Pharmacist Services Project
• DHB Pharmacy Advisory Group - Aug 2005
• Value added pharmacy services
• Information services
• Medication review services

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National Framework of Pharmacist Services

• Health Education for provision to patients
• Medicines and Clinical Information Support for
  provision to practitioners (this would include
  the pharmacist facilitator role)
• Medicines Use Review and Adherence Support, a
  four part review, assessing the patients use,
  understanding and adherence to their medication
  regimen.
• Medicines Therapy Assessment, which is a
  comprehensive clinical review of individual
  patients medication as part of a
  multidisciplinary team
• Comprehensive Medicines Management, case based
  active management of changes and (future)
  collaborative prescribing

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Compliance/Concordance/Adherence

• Problems
• - Perversity of human behaviour
• - System related factors
• - Therapy related factors
• - Condition related factors
• Solutions
• - Patient education gains
• - Medication adjustments
• - Calendar packs, compliance packs
• - Unit dose dispensing (bar codes)

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Medicine Use Review and adherence support MUR

• 1/ Ensuring that the patient understands
• Why they are taking the prescribed medication
• How it is going to benefit them
• Side effects they may experience or are
  experiencing
• 2/ Identifying any problems clinical or
  organizational and solving them
• 3/ Ensuring that they take their medication
  correctly at the right time right quantity
• 4/ Improve the health of your patient avoid
  hospitalisation (Gullery Love Report)

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MUR Compliance support

• Process -
• a) Criteria for entry
• Living in the community, chronic condition,
  three or more meds, hospital discharge, high risk
  communications, adherence problems already
  identified.
• b) Identifying patients for MUR
• Problems identified in the pharmacy, family
  concerns, doctor referral, Care Plus,
• c) Assessment
• Assemble patient, documents, medicines then
  interview (interpreter?)
• d) Implementation
• Medicines solutions, compliance aids e.g. trays,
  blister packs, own system?
• Information/education, Yellow Card. Follow-up
  interview.
• e) Report back follow up
• Report to GP, add patient into calendar, follow
  up interviews (2/12months)
• Electronic monitoring and health status
  reporting.

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Case Study1. Poor understanding/beliefs
Family, education, packaging.

• Pacific Island woman, middle-age.
• Diabetic ,cardiovascular meds, illiterate poor
  eyesight
• Metformin cartia- felodipine omeprazole-
  inhibace isosorbide- lipex-cromulux e/drops-
  paracetamol
• Concerned about the amount of medication she was
  taking therefore did not take many.
• Educated her and family on the medication and
  explained diabetes Showed her how to use eye
  drops
• Had brand new meter ( from diabetes NZ ) didnt
  know reason
• Compliance packaging / meter training on going

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Case Study 2. physical impairment, own solutions

• GP requested review on patient - nearly deaf
  almost blind- couldnt understand how he could be
  compliant
• Daughter visits ever night for dinner (cooked by
  Dad!)
• Daughter put tablets into different sized
  Tupperware containers based on dosing
• Perfect system for him needed only education
• Moved his Pholcodine Duphalac to different
  places in the lounge similar bottles, both
  sweet.
• Cough mixture by whiskey bottle
• Laxative on top of cabinet.

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Case Study 3. Warfarin patient- wilful
non-compliance Interdisciplinary support
education weekly med. pack

• Elderly gentleman-lives alone- cardiovascular
  meds including warfarin
• Family concerned - Doesn't like meds, they were
  responsible for his wife's death therefore bad
  for you
• Misses/Forgets meds frequently
• MUR Education, Removed unwanted meds
• Put on weekly trays ( family involved)
• Yellow/Green card given photos of tabs on it
• Anticoag.Clinic fax- doses appntmnt times
• Dose appntmnt times confirmed with weekly
  medication tray pick up.

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Case Study 4. Feeling awful

• Felodipine 10mg mane, Betaloc 95 mane,
  simvastatin 40mg, isosorbide 60mg x2 mane, GTN
  spray prn, bendrofluazide 2.5mg mane, oxazepam
  10mg BD, Combivent inhaler QID.
• Mrs K explained that she felt awful, so tired
  most of the time. By 10 oclock I just want to
  sleep, generally with a stonking headache. I
  feel bloated and awful inside and Im so short of
  breath and my nose is stuffy all of the time.
  Ive got aches pains all over its hard to get
  going in the morning, especially my leg muscles.
  
• She worries about falling asleep at the wheel of
  her car and gets light headed at times especially
  when she rises. She presented a picture of
  desperation over how she felt and wanted to feel
  more like her old self get on with life.

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• a) Tiredness/fatigue
• Metoprolol, felodipine and oxazepam at breakfast
  are a potent combination for fatigue and sleep.
• b) Headache
• Probably caused by 10mg of felodipine plus 2x
  60mg of isosorbide in the morning.
• c) Shortness of breath ankle oedema
• Are these symptoms of CHF, or chronic bronchitis
  related to asthma/COPD, and is the ankle oedema
  diuretic resistance swelling due to felodipine??
  Im working in the dark here.

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• d) Nasal stuffiness
• This could be allergy related although the
  permanent nature of it leads me to suspect the
  peripheral dilation effect of felodipine. She
  tells me that nasal sprays have been ineffective.
  
• e) Muscle aches and pains
• Mrs K puts this down to taking Lipex.
  Myalgia/general malaise is a pretty common side
  effect which people complain of when they go onto
  simvastatin - ( felodipine competitive
  interaction liver enzyme substrate -CYP3A3/4)
  elevates the blood levels of both.
• f) Walking/physical fitness (finally)
• Mrs K likes to go walking for the feeling of
  wellbeing it gives her and of course it is to be
  encouraged. However because of feeling awful,
  SOB and pain in her toe joint, she now avoids
  walking. Restoring that ability would be a
  worthwhile objective, so possible options-

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Where are we at?

• NZ College of Pharmacists
• Accreditation
• Incentives
• Barriers

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Implementation- Opportunities

• If we implement through the national PHO
  agreement we gain
• Access to patient level information through
  enrolled populations
• Linkages to other services such as CarePlus etc.,
  Chronic Disease Management and Health Promotion
• Access to community engagement and community
  governance mechanisms
• Synergy with the PHO Performance Management
  programme
• Coordination and integration of services
• i.e. Interdisciplinary care

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Take home message

• Compliance/ adherence support (MUR) works
• GPs like it
• Patients like it
• Morbidity hospital admissions reduced
• How can you reduce barriers?
• Influence your peers, local pharmacists
• and DHB/PHO staff

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