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pharmaSuisse
Models for Evidence-based Therapeutic Decision-making and Therapeutic Management
Martine RuggliPharmacist FPHpharmaSuisseSwitzerland
pharmaSuisse
Resume of the expose
2 models :1.Collaboration with physicians to improve
prescription practice• 3 applications implemented in Switzerland :
o Quality circles physicians-pharmacistso Pharmacist consulting in nursing homeso Expertise of prescription profile of the physician.
2.Integrated Networks• Pilot project in e-health
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Level of collaboration between pharmacists and other healthcare professionals
Quality circlesNursing home consulting
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7. Assessment of the results and improvements
1. Prescription data
2. Guidelines and Evidence-based
medecine
3. Analysis of prescription attitudes in comparison with scientific and economic data and search for alternatives in drug market
4. Consensus
5. Application of the consensus
6. Check on the impact of the consensus
First model: collaboration with the physician to improve prescription
practice
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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!
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7. Assessment of the results and improvements
1. Prescription data (benchmarking per physician
and therapeutic class)
2. Guidelines and Evidence-based
medecine
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
5. Application of the consensus
6. Check on the impact of the consensus
Application of the model in physicians - pharmacists quality circles:
Cercles de qualité pharmaSuisse
121.7
130.6
139.0143.4
161.8166.9
169.9173.9
176.8180.7
115.2
126.7130.0
132.6
140.6 138.9 136.8132.4
137.4 138
100.0
110.0
120.0
130.0
140.0
150.0
160.0
170.0
180.0
190.0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Evo
luti
on
du
co
ût
méd
icam
ent
ann
uel
par
pat
ien
t (I
nd
ex)
Groupe Témoin
Fribourg - Pionniers
+15.2%
+10.0%
+2.6%+21.7%
+7.3%
+6.4%
+3.2%
+2.0%
+12.8%
+6.0%
-1.2%
+3.2%
n = 20 médecins
+2.24
+0.4%
+1.8%
-1.5%
+2.3%
-3.2%
Saving in 2009 170’000 € per physician
M. Ruggli, O.Bugnon / 2009Source de données brutes : OFAC (2009)
Economic impact on drug cost: 11 years experience in Fribourg
+1.7%
+3.7%
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•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
"Circle effect": more than just cost saving
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
Quality circles after 11 years…which is the constancy?
Quality circles implemented in nursing homes: pharmacist consulting
Quality circles implemented in nursing homes: pharmacist consulting
-42 nursing homes-2'214 patients-22 pharmacists
- Growth of the drugs cost
- Modification of the Fribourg cantonal health legislation
Dissemination and
implementation of the service
Development of pharmaceutical care services and research in a Swiss canton, Pharm World Sci, 2008
7. Assessment of the results and improvements
1. Prescription data Statistics of drug consumption
in the nursing home
2. Guidelines and Evidence-based
medecine
3. Report of the pharmacist: analysis of prescription and search for alternatives
4. Discussion of the report with all health care professionals of the nursing home and agreement on a consensus
5. Application of the consensus
6. Check on the impact of the consensus
Application of the model in nursing home
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 »
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)
2.2% 2.1% 2.1%
6.7%
9.9%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
N0
5A
A0
2B
C
N0
6A
N0
2
C0
9
A0
6
C0
3
N0
4
B0
1A
A1
0
R0
3
C0
1D
A1
2
J01
N0
6D
N0
5B
M0
1
N0
5C
N0
3A D
GO
4B
D
C0
8
ATC code
Per
cen
tag
e o
f th
e to
tal
ann
ual
d
rug
s' c
ost
s [%
]
1. Need identification2. Interdisciplinary
working group
3. Systematic literatureReview
Investiguer d’autres causes :
- Etat confusionnel aigu- Dépression majeure- Déficit cognitif léger (MCI)
Patient en EMS avec trouble cognitif
Trouble cognitifrépondant aux critères
diagnostiques d’un syndromedémentiel?
non
Critères DSM-IV,ICD-10NINCDS-ADRDA(148;150)
Critères DSM-IV,ICD-10NINDS-AIREN (153;154)
Critères Newcastle,CDLB (149)
Critères NINDS, FTD (151;151)
MCI : mild cognitive impaire ment; FTD : Fronto-temporal dementia; IAChE : Inhibiteur de l’acétylcholinestérase; CBD : dégénérescence cortico-basale; PSP : paralysie supranucléaire progressive;
Démence de typeAlzheimer :
A) Démence légère àmodérée (10<MMSE<20)
- Donépézil (5-10mg/j)- Rivastigmine (6-12mg/j)- Galantamine (16-24mg/j)
B) Démence modérée à sévère (MMSE<14)
- Mémantine (20mg/j)Dans la démence modérée àsévère, la mémantine à un effet léger sur la cognition(132). Bien tolérée, mais sujette à plusieurescontroverses(133;134;135)
Démencesvasculaires :
A) Vasculaire seule
Pas d’indication pour letraitement par un anti-démence
B) Vasculaire mixte avec Alzheimer, légère à modérée
- Donépézil(5-10mg/j) (131)
Données limitées pour la rivastigmine, la galantamine et la Mémantine(126;127;132)
Démence à corpsde Lewy :
Un traitement par anticholinestérase peut être considéré en présence de symptômes comportementaux associés; les preuves sur la fonction cognitive sont faibles (136):
- Rivastigmine(6-12mg/j) (121;135;136)
- Autres IAChEPreuve insuffisantes pour l’utilisation de la mémantine (121)
Démence fronto-temporale :
Aucun traitement n’estactuellement disponible pour ce type de démence
Il existe quelques case reports avec plusieurs molécules dans la littérature mais sans bénéfice notable sur la fonction cognitive (121)
oui
Autres types dedémences
Maladie de Parkinson :
Traitement par un IAChE àconsidérer (des preuves existent pour l’utilisation de la rivastigmine) (130)
Preuves insuffisantes pour l’utilisation de la mémantine (121)
CBD et PSP :
Aucun traitement n’estactuellement disponible pour ce type de démence (121)
4. Treatment algorithms5. Dissemination,education
6. Evaluation
Publications
expertise of the prescription profile of the physician
1. Prescription data (detailed analysis to define the
prescription profile)
2. Guidelines and Evidence-based
medecine
3. Analysis of prescription attitudes in comparison with scientific and economic data
4. Highlight of the possible savings
5. Modification of the prescription if necessary
6. Check on the impact
Application of the model in the expertise of the prescription profile of the physician
pharmaSuisse
•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
Other use of the prescription data of the physician
0
20
40
60
80
100
120
140
160
mean drugcost of
physicians
Dr Med Dr College Dr Long Dr Friend
relative value
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•Analysis of the drug costs
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
pharmaSuisse
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
How can the pharmacist help ?
pharmaSuisse
Physician Cost/patient Price/unit Unit/patientPrescription
frequency (%)
Dr Friend 93 70 134 42.2
Dr Collegue 56 40 141 17
Dr Long 51 32 159 32
Dr FriendCost evolution of analgesics
2007 2008 Difference
31000€ 62575€ 31575€
Dr Michel Buchmann, 08.2009
Fine analysis of the prescription of analgesics
2008
pharmaSuisse
Dr Friend: Top80 Analgesics prescription in 2008
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
Palladon Dafalgan Durogesic Oxycontin Zaldiar
Dr Michel Buchmann, 08.2009
Fine analysis of the prescription of analgesics
hydromorphone Acetaminophen Fentanyl Oxycodon Tramadol + acetaminphen
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Dr Michel Buchmann, 08.2009
Hydromorphone: just for 1 patientThis patient can’t take any other painkiller, using high dose of hydromorphone to be able to control his pain
Cost of 22’223 € in 2008 that the physician can’t be made responsible for
Other saving possible through generics substitution of all fentanyl originals: 2857 €
Fine analysis of the prescription of analgesics
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Dr Michel Buchmann, 08.2009
Same analysis for all the therapeutic classes
• Switch to generics• But especially therapeutics switches towards better evaluated
and less expensive drugs
Example:•ezetimibe => potent statin = saving of 1428 € per year•nevibolol => bisoprolol or metoprolol = saving of 285 €
BUT ALWAYS KEEP IN MIND THAT QUALITY IS THE CENTRAL POINT
Next step: fine analysis of the prescription of all therapeutic classes
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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 specificsituations, not influenced by the prescriber
Dr Friend absolutely satisfies the criteria of the health insurance.
Dr Michel Buchmann, 08.2009
Analysis summary
Letter for the Health Insurance:
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To implement projects: what is important?
• Get recognised• Get paid• These services are new services
that have to be remunerated separately .. Impossible with a margin system …. => Change the remuneration system and pay for services = THAT‘s the KEY
All the projects are realised in ambulatory sectorKeep im mind that politicians want to slow the costs’ growth
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Where do we go?
pharmaSuisse20 avril 2023 29
Integrated care
« specialized » pharmaceutical services
« basic » pharmaceutical services
Consulting in nursing homes
Quality circles physicians - pharmacists
New direction: integrated care
Pharmacist Patient
Pharmacist Physician
Pharmacist Physician
Patient
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Pilot project: collaboration with telemedicine
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Pharmacist specially trained to work with algorithmsfor different diseases
Pilot project: collaboration with telemedicine
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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This contact with Medgate is realised via videoconsultationwhich enables the physician to see the patient
Pilot project: collaboration with telemedicine physicians
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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Future of the profession of pharmacists:
•Think services•Think remuneration system partially
based on fee for services•Organise education
•Add motivation and enthusiasm!
Conclusion
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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