Community Pharmacists

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Community Pharmacists

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Title: Improving Medication Use by Older Adults: A Shared Responsibility Author: Ruby Grymonpre Created Date: 4/18/2001 4:50:14 PM Document presentation format – PowerPoint PPT presentation

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Title: Community Pharmacists

1

Community Pharmacists
Provision of Pharmaceutical Care
to the Older Adult
R. Grymonpre
L. Vercaigne
C. Metge
P. Montgomery
University of Manitoba

2
Community Pharmacists Expanded Role

There is strong evidence that clinical pharmacy
services add value to patient care and reduce
health care utilization costs.clinical services
are not widely provided in community pharmacy
settings
The
Clinical Role of the Community Pharmacist.
Office of the Inspector General, USA. January
1990
The judicious use of the professional
qualifications of pharmacists is encouraged
The Rational Use of Drugs by the Elderly A
Strategy for Action. Government of Quebec. 1995
National action to ensure appropriate use of all
medication will require the active participation
of seniors, physicians, pharmacists, nurses,
governments, industry, family members and
caregivers
Federal/Provincial/Territorial Strategy for
Action. Health Canada. June 1996

3
Community Pharmacists Expanded Role

The pharmacist is in an excellent position to
monitor seniors medication use at the point of
dispersal
Optimizing Medication Use in Seniors Receiving
Home Care. Canadian Association Community Care.
August 1997
Pharmacists are perhaps both the most important
and least utilized source of information and
education about medications
Seniors, Diversity Access Medication Use
Hard to Reach Seniors. National Pensioners and
Senior Citizens Federation. May 1997
Pharmacists can play an increasingly important
role as part of the primary health care
teamthis expanded role would allow pharmacists
to consult with physicians and patients, monitor
patients use of drugs, and provide better
information and communication on prescription
drugs.
Building on Values The Future of Health Care in
Canada Final Report. Romanow RJ. (Commissioner)
November 2002

4
Community Pharmacists Expanded Role

Cochrane Review
increased scheduled health services but no
decrease in hospital and ER admissions (1 of 7
studies)
decreased hospital/ER admissions, number of
specialty physician visits, numbers or costs of
drugs, improved appropriateness of drugs (6 of 7
studies)
improvements in targeted condition but no change
in quality of life or incidence of ADR (10 of 13
studies)
improvements in patient adherence (3 of 6
studies)
favorable changes in physician prescribing (9 of
10 studies)
Beney J, Bero L, Bond C. Expanding the roles of
outpatient pharmacists effects on health
services utilisation, costs, and patient outcomes
(Cochrane Review). In The Cochrane Library,
Issue 1, 2004. Chichester, UK John Wiley Sons,
Ltd.

5
Geriatric Pharmaceutical Care
2001 12.5 Canadians 65 years old 2026 20 of
Canadians 65 years old
In Manitoba (1996) 13.6 of population 65
years old 34 of prescriptions
dispensed average of 5 different drugs
6
Geriatric Pharmaceutical Care
Life expectancy, at birth (1997) 75.8 years for
men 81.4 years for women
In one study of older persons, drugs
contributed to 20 of
hospitalizations Grymonpre et al J Am Geriatr
Soc. 1988
7
Community-Based Geriatric Pharmacy Care

6 studies
Positive results
Improved adherence (1)
Excellent physician patient acceptance (81
91) (1) DRIs identified and resolved (2)
More appropriate drug use (1) more drug changes
(1) fewer repeat prescriptions (1) reduced drug
costs (1)
Reduced outpatient visits (1) reduced
hospitalizations and hospital stays reduced
health care costs (1)
Negative results
No difference in SF-36 (1) no difference in
health decline, falls (1)
Poor physician acceptance (28) DRIs identified
but not resolved (1)
No difference in numbers/costs of drug,
medication adherence (1)
no change in health services use (2)

8
Community-Pharmacists Geriatric Pharmaceutical
Care

Bernsten C et al. Drugs Aging 200118(1)63-77
Design randomized (by pharmacy), controlled
Participants 190 sites, 2,454 patients, ? 65
years, ? 4 prescribed meds, oriented x 3,
noninstitutionalized
Intervention pharmaceutical care for 18 months
community pharmacy
Process measures number of medications
changes contacts with GP, GP acceptance
satisfaction cost analysis medication knowledge
adherence
Outcome measures SF-36, hospitalizations,
symptoms (self-reported), patient satisfaction
Results improved satisfaction symptom control,
no difference in other measures

9
Community-Pharmacists Geriatric Pharmaceutical
Care

Sellors J. SMART. Final report. Sept. 2000
Design randomized, controlled
Participants 889 patients, ? 65 years, ? 5
prescribed meds, MMSE25, noninstitutionalized
Intervention pharmaceutical care 24 community
pharmacists
Process measures number and types of
drug-related issues, resolution rate of issues,
physician response, number of daily medications,
medication units, costs, inappropriate drugs,
medication adherence
Outcome measures medication problems
(self-reported), health care utilization and
costs SF-36
Results DRIs identified in 88 of subjects (mean
3.2) 84 physician acceptance 57 MD
implementation no difference in other measures.

10
Community-Based Geriatric Pharmacy Care

Grymonpre RE et al Int J Pharm Pract
20019235-41
Design randomized, controlled
Participants 135 patients, ? 65 years,
noninstitutionalized,
? 2 medications
Intervention pharmaceutical care for 1 year
wellness clinic
Process measures number and types of
drug-related issues, resolution rate of issues,
physician response, number costs of
medications, medication knowledge adherence
Outcome measures symptoms (self-reported)
Results 952 issues identified, 29 resolution
rate positive MD response but 28 acceptance
rate (by survey) no difference in other measures

11
Hypothesis

Community pharmacists
have the necessary skills and knowledge to
improve drug taking behaviour of older adults and
the prescribing habits of physicians, thereby
optimizing disease control and reducing the
amount of drug-related illness in this segment of
the population.

12
Manitoba Pharmaceutical Care Project

Research Questions
Can a workable model of community-based
pharmaceutical care be provided to physicians and
elderly patients?
What is the impact of community pharmacists
practicing pharmaceutical care on
Physician and patient acceptance and
implementation of
recommendations?
Use of medications by older persons?

13
Objectives

To document measures of the patient-focussed
pharmacy care provided
numbers and types of drug-related issues
identified
numbers and types of recommendations made
physician and patient acceptance of
recommendations
endpoints of plans of action
interview and work-up times
level of remuneration
To measure the impact of comprehensive
patient-focussed pharmacy on
medication adherence (primary measure)
numbers and costs of medications

14
Methods Pharmacy Pharmacist Selection

Invitation for participation and application
Selection based on criteria signed contract
demonstrate an understanding of pharmaceutical
care
removed from dispensing activities for 6
hours/week
recruit 1 client/week x 74 weeks
provide pharmaceutical care to patients
agree to training group sessions
complete and submit required documentation
access to confidential area
space equipment for maintaining files
access to library of references

15
Methods Process of CareIntervention

Eligible clients perceived to be at risk
recruited
Intervention Comprehensive patient-focussed
pharmacy care
medication history
develop, implement and document patient care
plans
identification of drug-related issues
intervention (MD /or client)
follow-up
Remuneration provided

16
Methods Process of Care Action Plan

Characterized by a single or multiple
drug-related issue(s) and disease state(s)
Requiring a single or multiple recommendation(s)
Resulting in one desired endpoint
Issues undertreated diabetes, lack of knowledge,
condition requiring monitoring
Recommendations add drug, educate client, refer
to dietician, monitor blood sugars
Acceptance client and MD accepted
recommendations
Endpoint blood sugars normalized

17
Methods Process of Care Endpoint

Dependent on issue(s) identified in plan of
action
health outcome - clinical issue
symptom/measure of disease or side effect BP,
BS, pain, constipation
process endpoint drug issue
no indication, wrong drug, overdose
when not feasible to look at clinical endpoint
(immunization, osteoporosis, stroke
prophylaxis)
education nonadherence
Status of issue at follow-up
partially resolved - positive trend but desired
target not reached

18
Methods Research design

Design prospective, nonrandomized, controlled,
before-after trial, survey and population based
Setting community pharmacies
Study Subjects convenience sample 65 years
old noninstitutionalized willing to provide
signed informed consent taking at least 1
medication
Control Subjects randomly selected from Manitoba
Health database 31 match by age, gender, and
Adjusted Clinical Group

19
Methods Process Measures

Population based measures
medication adherence (primary measure)
numbers and costs of medications
Survey based measures (test only)
interview and work-up times
remuneration
numbers and types of drug-related issues
identified
numbers and types of recommendations made
physician and patient acceptance of
recommendations
endpoints of plans of action

20
Methods Data analysis

Population based data
Required sample size (total) 220
10 change in medication adherence
? 0.10 ? 0.05
std deviation 25 (Annals 1998)
Mixed modeling procedure (SAS)

21
Medication Adherence Cumulative Medication
Acquisition (CMA)

CMA ? days supply in interval
actual number of days in interval

CMA values are only calculated on medications
with 3 or more fills and a prescribed rate
(quantity dispensed ? days supply) of 0.5, 1,
1.5, 2.0, 2.5, 3.0, 3.5, 4.0, 4.5. Using these
criteria, DPIN was determined to be a valid
measure of medication adherence compared to pill
count with 77 concordance McNemars p0.6837

Grymonpre RE et al ABSTRACT Can J Clin Pharm
(in press) 2004
22
Remuneration Pharmacy Consultation
Grymonpre et al J Res Pharm Econ 200111(1)51-61
23
Results Pharmacy recruitment

Total number of pharmacies 11
(selected from 15 applicants)
Total number of test pharmacists 15
Orientation session May 1 2, 1998 (9 hours)
Ongoing one-on-one support with resource
pharmacist and groups sessions.

24
Results Client recruitment

Study duration May 1, 1998 - Jan 31, 2000
Total number of clients evaluated 337
Total number of eligible clients 213 (63)
124 Exclusions
no consent 78
insufficient documentation 46

25
Results Demographic Data
26
Results Drug Benefit Plans
No 3rd party coverage 70/126 (56)
Blue Cross 42/126 (33)
Dept. Veterans Affairs 9/126 (7)
Other 5/126 (4)
Great West Life, Indian Affairs, Assure
27
Results Time required
28
Results Action Plans

211 of 213 clients had ? 1 Action Plan
732 Action Plans were developed
mean of 3.5 ? 1.7 per person
characterized by 945 drug-related issues
involving 1005 recommendations

29
945 Drug-Related Issues
30
Recommendations to physician

Of 1005 recommendations made
499 (50) recommendations involved the MD
114 (23) of 499 recommendations to MD not
made/documented

31
385 recommendations made to MD

dispensing task 12 (3)
change dosing time 11 (3)
refer other hcp 9 (2)
change dose form 8 (2)
encourage adherence 5 (1)
other 27 (7)

start drug 80 (21)
stop drug 61 (16)
switch drug 61 (16)
monitor therapy 54 (14)
decrease dose 29 ( 8)
increase dose 28 ( 7)

32
Physician response

Of 385 recommendations made to MD
physician response to 87 (23) unknown
Of 298 known responses
82 accepted and
4 partially accepted

33
Recommendations to patient

Of 1005 recommendations made
1003 (99.8) recommendations involved patients
89 (9) required recommendations to patients not
made/documented

34
914 recommendations to patient

educate 153 (17)
start drug 127 (14)
monitor 122 (13)
change drug 92 (10)
stop drug 76 (8)
disp.related task 48 (5)
increase dose 43 (5)

compliance aid 43 (5)
decrease dose 41 (4)
nonpharm. advice 38 (4)
change time 34 (4)
enc. adherence 34 (4)
refer to hcp 25 (3)
other 38 (4)

35
Patient response

Of 914 recommendations made to patient
patient response to 142 (16) unknown
Of 772 known responses
90 accepted and
3 partially accepted

36
Endpoints of 732 Plans of Action

Of 732 Plans of Action
Endpoint unknown for 278 (38)
Of 454 documented endpoints, 344 (76) were
resolved or partially resolved.

37
Medication Adherence Pre- versus Post-
Intervention 199 Test vs 506 Control Subjects
P0.0064
38
Number of Different Drugs Pre- versus Post-
Intervention 199 Test vs 506 Control Subjects
P0.0044
39
Annual drug costs Pre- versus Post- Intervention
199 Test vs 506 Control Subjects
P0.0716
40
Summary

Some difficulties with process
target recruitment rate of 1 client/week could
not be met
23 recomm. involving MD not made/documented
9 recomm. involving patient not made/documented
23 of MD responses not determined/documented
16 of patient responses not determined/
documented
38 of endpoints not determined/documented

41
Summary

When process successfully implemented
documented
99 of clients experienced 945 drug-related
issues requiring 1005 recommendations
86 physician acceptance rate
93 patient acceptance rate
positive endpoints achieved for 76 action plans

42
Benefits Health Health Costs

Compared to control subjects, test subjects had
a lower rate of increase in numbers of drugs
(p0.004)
a lower rate of increase in costs of drugs
(p0.07)
greater improvements in medication adherence
(p0.006)

43
Conclusions

The delivery documentation of pharmaceutical
care was challenging required one-on-one
support by a resource pharmacist
Older adults experienced several drug related
issues
Community pharmacists had the necessary skills
and knowledge to identify resolve these issues
which resulted in desired process endpoints and
health outcomes
Community pharmacists providing patient focussed
care reduced numbers and costs of medications and
improved medication adherence

44
Acknowledgements