Models for Evidence-based Therapeutic Decision-making and Therapeutic Management

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• Models for Evidence-based Therapeutic
  Decision-making and Therapeutic Management
• Martine Ruggli
• Pharmacist FPH
• pharmaSuisse
• Switzerland

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Resume of the expose

• 2 models
• Collaboration with physicians to improve
  prescription practice
• 3 applications implemented in Switzerland
• Quality circles physicians-pharmacists
• Pharmacist consulting in nursing homes
• Expertise of prescription profile of the
  physician.
• Integrated Networks
• Pilot project in e-health

Work processContinous quality improvement of
prescription
1. Prescription data (benchmarking per
physician and therapeutic class)
7. Assessment of the results and improvements
2. Education on guidelines, Evidence-based
medecine and pharmacoeconomy.
6. Check on the impact of the consensus
5. Application of the consensus
3. Analysis of prescription attitudes in
comparison with scientific and economic data and
search for alternatives in drug market
4. Consensus of each quality circle
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Level of collaboration between pharmacists and
other healthcare professionals
Quality circles Nursing home consulting
Work processContinous quality improvement of
prescription
1. Prescription data (benchmarking per
physician and therapeutic class)
7. Assessment of the results and improvements
2. Education on guidelines, Evidence-based
medecine and pharmacoeconomy.
6. Check on the impact of the consensus
5. Application of the consensus
3. Analysis of prescription attitudes in
comparison with scientific and economic data and
search for alternatives in drug market
4. Consensus of each quality circle
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First model collaboration with the physician to
improve prescription practice
1. Prescription data
7. Assessment of the results and improvements
2. Guidelines and Evidence-based medecine
6. Check on the impact of the consensus
3. Analysis of prescription attitudes in
comparison with scientific and economic data and
search for alternatives in drug market
5. Application of the consensus
4. Consensus
Work processContinous quality improvement of
prescription
1. Prescription data (benchmarking per
physician and therapeutic class)
7. Assessment of the results and improvements
2. Education on guidelines, Evidence-based
medecine and pharmacoeconomy.
6. Check on the impact of the consensus
5. Application of the consensus
3. Analysis of prescription attitudes in
comparison with scientific and economic data and
search for alternatives in drug market
4. Consensus of each quality circle
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Physicians-Pharmacists Quality Circle
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What is a Physicians-Pharmacists Quality Circle ?

• A stable group of 5-15 GPs and 1-2 pharmacists as
  moderators
• Meeting voluntarily
• Evaluation of the daily prescribing practice
• Working together to continuously improve their
  practice
• This means that
• every participant is active!

Work processContinous quality improvement of
prescription
1. Prescription data (benchmarking per
physician and therapeutic class)
7. Assessment of the results and improvements
2. Education on guidelines, Evidence-based
medecine and pharmacoeconomy.
6. Check on the impact of the consensus
5. Application of the consensus
3. Analysis of prescription attitudes in
comparison with scientific and economic data and
search for alternatives in drug market
4. Consensus of each quality circle
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Application of the model in physicians -
pharmacists quality circles
1. Prescription data (benchmarking per physician
and therapeutic class)
7. Assessment of the results and improvements
2. Guidelines and Evidence-based medecine
6. Check on the impact of the consensus
3. Analysis of prescription attitudes in
comparison with scientific and economic data and
search for alternatives in drug market
5. Application of the consensus
4. Consensus of each quality circle
Work processContinous quality improvement of
prescription
1. Prescription data (benchmarking per
physician and therapeutic class)
7. Assessment of the results and improvements
2. Education on guidelines, Evidence-based
medecine and pharmacoeconomy.
6. Check on the impact of the consensus
5. Application of the consensus
3. Analysis of prescription attitudes in
comparison with scientific and economic data and
search for alternatives in drug market
4. Consensus of each quality circle
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Economic impact on drug cost 11 years
experience in Fribourg
Saving in 2009 ? 170000 per physician
1.7
3.7
M. Ruggli, O.Bugnon / 2009 Source de données
brutes OFAC (2009)
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"Circle effect" more than just cost saving

• More balanced attitude towards marketing
  strategies
• example of aliskiren
• Better awarness of the risk of drugs
• example of rimonabant
• Better use of the suitable drug
• example of fluoroquinolone

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Quality circles after 11 yearswhich is the
constancy?

• A real collaborative practice and not a dream!
• The objectives
• optimize the safety and effectiveness of the
  treatments for the patients.
• more efficient spreading of the pharmacovigilance
  messages
• saving capacity on medicine costs based on
  professional decisions and not on price
  reductions.
• increased resistance of the Healthcare
  professionals against industrial marketing
  activities.
• recognized interdisciplinary education in favor
  of person-centered care.
• BUT it is absolutely necessary to be persistant
  to get results

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Quality circles implemented in nursing homes
pharmacist consulting
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Quality circles implemented in nursing homes
pharmacist consulting

• Growth of the drugs cost

• Modification of the Fribourg cantonal health
  legislation

-42 nursing homes -2'214 patients -22 pharmacists
Dissemination and implementation of the service
Development of pharmaceutical care services and
research in a Swiss canton, Pharm World Sci, 2008
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Application of the model in nursing home
1. Prescription data Statistics of drug
consumption in the nursing home
7. Assessment of the results and improvements
2. Guidelines and Evidence-based medecine
6. Check on the impact of the consensus
3. Report of the pharmacist analysis of
prescription and search for alternatives
5. Application of the consensus
4. Discussion of the report with all health care
professionals of the nursing home and agreement
on a consensus
Work processContinous quality improvement of
prescription
1. Prescription data (benchmarking per
physician and therapeutic class)
7. Assessment of the results and improvements
2. Education on guidelines, Evidence-based
medecine and pharmacoeconomy.
6. Check on the impact of the consensus
5. Application of the consensus
3. Analysis of prescription attitudes in
comparison with scientific and economic data and
search for alternatives in drug market
4. Consensus of each quality circle
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Evaluation of the economic impact of this service
in nursing homes
Medications Implemented since 2002,
pharmaceutical care services have allowed to
decrease the costs in a dramatic way
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Evidence-based practice recommendations in
psychogeriatrics for Elderly
Pharmacological management of 1) cognitive
symptoms of dementia and delirium 2) behavioral
and psychological symptoms of dementia
(depression, sleep disturbances, agitation)
2. Interdisciplinary working group

• Need identification

3. Systematic literature Review
6. Evaluation
5. Dissemination, education
4. Treatment algorithms
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Publications
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expertise of the prescription profile of the
physician
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Application of the model in the expertise of the
prescription profile of the physician
1. Prescription data (detailed analysis to
define the prescription profile)
6. Check on the impact
2. Guidelines and Evidence-based medecine
5. Modification of the prescription if necessary
3. Analysis of prescription attitudes in
comparison with scientific and economic data
4. Highlight of the possible savings
Work processContinous quality improvement of
prescription
1. Prescription data (benchmarking per
physician and therapeutic class)
7. Assessment of the results and improvements
2. Education on guidelines, Evidence-based
medecine and pharmacoeconomy.
6. Check on the impact of the consensus
5. Application of the consensus
3. Analysis of prescription attitudes in
comparison with scientific and economic data and
search for alternatives in drug market
4. Consensus of each quality circle
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Other use of the prescription data of the
physician

• Annual survey from the health insurance to
  determinate the cost of the drugs prescribed by
  physicians during one year.
• If too high (30 more than the mean value) the
  physician gets a warning and has to justify his
  costs

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How can the pharmacist help ?
 Therapeutic classes Cost in 2007 Cost in 2008
Antihypertensive drugs 65395.05 69392.25
Hypercholesterolemia treatment 28753.55 32530.9
Proton pump inhibitors 66699.9 58004.85
NSAID 43014.1 42778.9
Antiasthmatic drugs 37435.85 31818.25
Antidepressant drugs 26372.8 28434.95
Antidiabetics 32007.15 32579.65
Antibiotics 33213.65 37294
Analgesics 44306.6 87606.7
Neuroleptics 49958.45 52487
Anticoagulants 11748.95 10928.05
Calcium channel blocker 12943.5 11836.6
Tranquilizers 21261.35 21164.75
Beta blockers 6095.35 6363.3
Hypnotics 21979.55 18386.4
Diuretics 9066.15 9743.2
Vasodilatators 7814.35 8075.05
Antacids 3838.65 2664.7

• Analysis of the drug costs

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How can the pharmacist help ?

• Cost price volume frequency of prescription
• Parameters needed to understand where is the
  problem
• cost per patient
• price per unit
• number of units par patient
• frequency of prescription

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Fine analysis of the prescription of analgesics
Dr Friend Cost evolution   of analgesics 2007 2008 Difference
Dr Friend Cost evolution   of analgesics      
Dr Friend Cost evolution   of analgesics 31000 62575 31575
2008
 Physician Cost/patient Price/unit Unit/patient Prescription frequency ()
Dr Friend 93 70 134 42.2
Dr Collegue 56 40 141 17
Dr Long 51 32 159 32
Dr Michel Buchmann, 08.2009
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Fine analysis of the prescription of analgesics
Tramadol acetaminphen
hydromorphone
Acetaminophen
Fentanyl
Oxycodon
Dr Michel Buchmann, 08.2009
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Fine analysis of the prescription of analgesics
Hydromorphone just for 1 patient This patient
cant take any other painkiller, using high dose
of hydromorphone to be able to control his pain
Cost of 22223 in 2008 that the physician
cant be made responsible for Other saving
possible through generics substitution of all
fentanyl originals 2857
Dr Michel Buchmann, 08.2009
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Next step fine analysis of the prescription of
all therapeutic classes

• Same analysis for all the therapeutic classes
• Switch to generics
• But especially therapeutics switches towards
  better evaluated and less expensive drugs
• Example
• ezetimibe gt potent statin saving of 1428
  per year
• nevibolol gt bisoprolol or metoprolol saving
  of 285
• BUT ALWAYS KEEP IN MIND THAT QUALITY IS THE
  CENTRAL POINT

Dr Michel Buchmann, 08.2009
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Analysis summary
Letter for the Health Insurance
Based on the data of the quality circle, we
showed that Dr Friend could reduce the drug costs
but only in a small way (3 ). This demonstrates
that these 10 years working in quality circle
carried their fruits Dr Friend is a physician
aware of the drug costs, prescribing the best
evaluated drugs, with the best economical
potential the extra costs are due to
specific situations, not influenced by the
prescriber Dr Friend absolutely satisfies the
criteria of the health insurance.
Dr Michel Buchmann, 08.2009
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To implement projects what is important?
All the projects are realised in ambulatory
sector Keep im mind that politicians want to slow
the costs growth

• Get recognised
• Get paid
• These services are new services that have to be
  remunerated separately .. Impossible with a
  margin system . gt Change the remuneration
  system and pay for services
  THATs the KEY

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Where do we go?
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New direction integrated care
Pharmacist Physician Patient
Integrated care
specialized pharmaceutical services
Pharmacist Physician
Consulting in nursing homes
Quality circles physicians - pharmacists
Pharmacist Patient
basic pharmaceutical services
10/11/13
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Pilot project collaboration with telemedicine
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Pilot project collaboration with telemedicine
Pharmacist specially trained to work with
algorithms for different diseases
If the patient needs a consultation, he is given
the choice of visiting his physician if he has
one or getting the service of a physician from
Medgate, the biggest center for telemedicine of
Switzerland
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Pilot project collaboration with telemedicine
physicians
This contact with Medgate is realised via
videoconsultation which enables the physician to
see the patient
Discussion between physician, patient and
pharmacist about the case and the treatment. If
necessary, the treatment will be prescribed by
the physician and delivered by the pharmacist
directly If the case requires a bigger
intervention, the patient will be oriented to a
physician or an hospital
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Conclusion

• Future of the profession of pharmacists
• Think services
• Think remuneration system partially
• based on fee for services
• Organise education
• Add motivation and enthusiasm!

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Thanks to
Michel Buchmann Dominique Jordan and
pharmaSuisse Olivier Bugnon and Jean-François
Locca, University of Geneva
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Thanks for your attention