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.

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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

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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

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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

• Apotex Inc.
• CIHR (formerly NHRDP)
• Centre on Aging
• Manitoba Health
• Manitoba Pharmacists
• Manitoba Pharmaceutical Association
• Manitoba Society for Pharmacists
• Jenny Kleine Golden (1972-2002)

45
Acknowledgements

• Ms. Marie Berry (Vimy Park Pharmacy)
• Mrs. Carol Boscow (The Pas Super Thrifty)
• Mrs. Barbara Bromilow (Pharmasave Beasejour)
• Mrs. Donna Campbell (Pharmasave)
• Mr. Bill Cechvala (Vimy Park Pharmacy)
• Mr. Terry Chan (Shoppers Drug Mart)
• Mrs. Wendy Clark (Carman Pharmacy)
• Mrs. Morna Cook (Dixons Pharmacy)
• Ms. Shelley Cowie (Shoppers Drug Mart)
• Ms. Camella Crook (CC PC and Consulting)
• Mr. Quy Doan (Shoppers Drug Mart)
• Mr. Brian Dusik (St. James Pharmacy)
• Mrs. Michele Fontaine (Shoppers Drug Mart)
• Mr. Myles Haverluck (Dauphin Clinic Pharmacy)
• Mr. Warren Hicks (The Pas Super Thrifty Drug
  Mart)
• Mr. Rob Jaska (Medical Centre Pharmacy)

• Mrs. Nadine Karpinski (Shoppers Drug Mart)
• Mr. Darryl Lancaster (Pharmasave)
• Mrs. Tracy Lelong-Young (Prescription Plus
  Pharmacy)
• Mrs. Donna McLeod (Pharmasave)
• Mrs. Nancy Metcalfe (Pfahls Drugs Ltd.)
• Mr. Real Mulaire (St. Pierre Pharmacy)
• Mrs. Lisa Olench (Pharmasave)
• Mrs. Julie Penelton (St. James Pharmacy)
• Mr. Sigfried Pfahl (Pfahls Drugs Ltd.)
• Mr. Don Radley (Pharmasave)
• Mrs. Nancy Remillard (Pharmasave)
• Mr. Jay Rich (Shoppers Drug Mart)
• Mr. Mark Scott (Shoppers Drug Mart)
• Mr. Trevor Shewfelt (Dauphin Clinic Pharmacy)
• Mr. Rolland Villar (Shoppers Drug Mart)
• Mrs. Sonia Wriedt (Pharmasave)